Cognitive-Linguistic Profiles of Aphasic Communicators Who Use AAC

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Cognitive-Linguistic Profiles of Aphasic
Communicators Who Use AAC

• Joanne P. Lasker, Ph.D.
• Florida State University
• Kathryn L. Garrett, Ph.D.
• Duquesne University

Presentation at the American Speech-Language-Heari
ng Association Convention November 22,
2003 Chicago, IL
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A. Statement of the Problem

• Many people with severe aphasia have unmet
  communication needs.
• Which individuals with chronic aphasia will
  benefit from augmentative and alternative
  communication strategies (AAC)?
• Which type/class of AAC strategies?
• Are there systematic ways of assessing this
  issue?
• Is there a profile of an effective AAC
  communicator?

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B. Cognitive-Linguistic Considerations in AAC

• definition of aphasia
• Language or symbolic deficits across
  modalities
• Intermittency of processing (Brookshire, 1978
  McNeil, 1983)
• more recently we have seen attention to possible
  cognitive aspects of aphasia

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Cognition and Aphasia

• Aspects of cognition related to aphasia may
  include (Purdy, 2001 Hinckley, 2002)
• attention
• memory
• executive function skills
• resource allocation
• pragmatics

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Demands of AAC Techniques

• Think to initiate communication through external
  means -- outside of the communicators own head
  and language system (Garrett Kimelman, 2000)
• Verbal memory for messages
• Spatial memory for message location
• Symbol translation skills -- from icons to
  meanings
• Executive function skills -- to judge which
  method of communication best fits the situation
• Attention and perseverance to complete the
  message transaction

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Resource Allocation

• to balance the cognitive demands of using a novel
  form of communication
• with the pragmatic demands of speaking to a
  communication partner
• And the linguistic demands of encoding messages
• And any other stressors in the communication
  environment
• Balancing
• Noise
• Multiple speakers
• Multiple topics
• Interruptions
• Communication breakdowns

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Challenges with AAC and Aphasia

• Limited information is available re who is and
  is not successful.
• Matching AAC approaches to skills/needs of
  communicator involves many variables.
• Limited knowledge is available about how to
  effectively train people with aphasia to use AAC
  in real-life situations.

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Still More Challenges

• People with aphasia tend to be isolated, and
  therefore have limited social opportunities to
  communicate.
• Message pools selected for AAC systems may not be
  appropriate or meaningful for adults with
  aphasia.
• Negative or ambivalent attitudes toward
  technology may be held by adults with aphasia
  and/or communication partners.

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Recent Research

• Helm-Estabrooks (2002) described a case study of
  a person with aphasia who used a high tech AAC
  system (C-Speak Aphasia Nicholas Elliot).
• Her analysis of the individuals
  cognitive-linguistic profile revealed
• mild-moderate aphasia as measured by the WAB
• relatively strong cognitive skills on specific
  subtests of the Cognitive-Linguistic Quick Test
  (Helm-Estabrooks, 2001)
• Trail Making
• Design Generation
• Mazes

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Testable Hypothesis

• Certain measures of cognition may serve as
  reasonable predictors of an individuals ability
  to use an AAC system to communicate meaningfully.

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C. Our Purpose/Design

• Case study approach.
• generate a cognitive-linguistic and behavioral
  profile of successful AAC users with aphasia
• Independent Communicators
• Partner Dependent Communicators
• Nonusers
• aid in assessment and intervention planning

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Proposed Test Battery

• Western Aphasia Battery (Kertesz, 1982)
• Ravens Coloured Progressive Matrices (Raven,
  Raven, Court, 1998)
• Cognitive-Linguistic Quick Test (Helm-Estabrooks,
  2001)
• Wisconsin Card Sort Task (Kongs, Thompson,
  Iverson, Heaton, 2000)
• Multimodal Communication Screening Task (Garrett,
  1998)
• The Assistive Technology Device Predisposition
  Assessment Consumer Form (adapted from Scherer
  McKee, 1989 by Lasker Bedrosian, 2000 under
  revision)
• Categorical Assessment of Communicators with
  Aphasia (Garrett Beukelman, 1998 under
  revision)

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One ComparisonWAB Writing Task
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Clients Written Responses
MH
JK
RM
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The Multimodal Communication Screening
Video Clip
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(No Transcript)
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Ravens Coloured Progressive Matrices
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Cognitive-Linguistic Quick Test
(Helm-Estabrooks, 2001)

• criterion-referenced test
• relative skills in the areas of
• attention
• memory
• language
• executive function
• visuospatial skills
• does require verbal skills for some tasks (e.g.,
  story retelling)

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CLQT Tasks and Composites

• Personal Facts
• Symbol Cancellation
• Confrontation Naming
• Clock Drawing
• Story Retelling
• Symbol Trails
• Generative Naming
• Design Memory
• Mazes
• Design Generation

• Yield composite scores
• attention
• memory
• executive function
• language
• visuospatial skills

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Trailmaking taskoops not this
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Trail Making Example
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Wisconsin Card Sort Test

• sort cards by
• number
• shape
• color
• rules change after 10 correct sorts

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WCST Example
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Sample questions from the Technology
Predisposition Survey

• I will benefit from using this AAC system.
• This AAC system will help me achieve a goal that
  I have.
• I will feel comfortable using this AAC system in
  public.
• This AAC system will improve the quality of my
  life.
• I will feel comfortable using this AAC system
  around my family.

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Categories of AAC Use
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Categories (cont.)
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D. Case Studies
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On to Pennsylvania folks!
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JV -- Emerging Communicator

• WAB AQ - .6/100
• BASA -- 2nd ile for people with global aphasia
• Ravens -- 0/36
• CLQT -- N/A
• Technology Attitudes
• Minimal experience
• Interested in trying technology
• Required specific training to use symbols to
  request
• Max assist to locate symbolized messages

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AA RC -- Contextual Choice Communicators

• WAB AQ 9.2
• Reading 11/100
• Writing 10.5/100
• Ravens 15/36
• CLQT
• Symbol Trails 1/10
• Design Memory 2/6
• Mazes 0/8
• Design Generation 6/13
• Technology Attitudes
• Minimal to some computer experience
• Willing to learn to operate simple AAC systems
• Less willing to use in real-life

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SA - Transitional Communicator

• WAB AQ 93.4
• Reading 80/100
• Writing 71/100
• Praxis 55/60
• Block Design 7/9
• Calculation 24/24
• Ravens 16/20
• Moderate dysarthria
• Technology Attitudes
• Moderate computer experience
• Interested in Palmtop PC-type device because of
  social acceptability

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GW--Deferred Technology User

• WAB 35
• Brocas profile
• 1 year post onset
• Lawyer
• Computer experience
• Technology Attitudes --
• No interest in learning to use AAC at present

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Florida AAC/Aphasia Clients
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Client MH

• 52-year old woman
• left CVA in March, 2001
• 2 years post
• 14 years of education
• right hemiparesis
• lives with mother who is in frail health
• completed assessment phase of project before
  relocation
• diagnosed with moderate receptive and severe
  expressive aphasia
• limited speech therapy

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MH - Results
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MH - Results
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MH AAC Trials
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MH Strengths Challenges

• Challenges
• emotional issues
• frustration
• sadness
• anxiety
• social isolation
• impaired auditory comprehension
• impaired executive skills
• severity of speech deficit

• Strengths
• reading
• writing
• motivation

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MH Current Status

• relocated after assessment
• currently not receiving any services
• SLP attempting to contact an area SLP to continue
  intervention and device trial

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Client JK

• 53-year-old tenured geography professor
• earned doctorate
• left CVA in 3/2001
• 8 months post at first visit
• employed by university for 21 years (since 1982)
• lives with husband (also a professor) and young
  daughter (5 years old)
• diagnosed with moderate expressive aphasia and
  mild receptive aphasia

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JK - Results
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JK - Results
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JK AAC Trials
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Student Evaluations First Teaching Experience
After Stroke

• It was very interesting to see how Dr. Kodras
  put her sentences together and got her point
  across to the class.
• Topic ---- instructor ---- extremely well versed
  ---- passionate about topic ---- makes all
  difference ----- instructor ----- exceptional.
• I could see that living with aphasia does not
  mean that you have to stop living.

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JK Strengths and Challenges

• Challenges
• communication needs
• impaired executive skills

• Strengths
• reading
• writing
• motivation
• education?
• familiarity with technology
• family support

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JK Current Status

• Participating in intervention to utilize a
  combination of EZ Keys and Key Word Teaching to
  lecture to her graduate classes.
• Continues to use EZ Keys to prepare lectures.
• Continues to negotiate support from department.

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Client RM

• 62-year-old
• education 14 years
• retired airport manager
• left CVA occurred 1995
• diagnosed with moderate aphasia and
  moderate-severe apraxia of speech

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RM - Results
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RM - Results
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RM AAC Trials
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Message Behaviors
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Device Usage - Press Behaviors

• I like a cheeseburger and coke please.

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RM Challenges and Strengths

• Challenges
• poor spelling
• unable to use word-based pages on device
  effectively
• resistant to change of relatively inefficient
  layout of device
• automaticity?
• familiarity?

• Strengths
• positive attitude about everything
• multimodal to the extreme
• willing to use device in public, on phone, as
  email tool

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RM Current Status

• increase and enhance facilitative behaviors on
  device
• category-based word search
• word by word formulation
• decrease non-facilitative behaviors
• inappropriate topic setting
• device navigation
• participating in motor-based learning study to
  increase speech output
• acts as ambassador and community educator

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E. Summing Up

• What did we learn?

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Salient Subtests on CLQT
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Categories of AAC Use
JV
AA and RC
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Categories (cont.)
MH and SA
RM and JK
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E. Summary What did we learn?

• Clinician judgment (via AAC trials)
  differentiated independent from partner-dependent
  communicators.
• Test results verified these judgments.
• Potential suspects for determining outcome
  likely a complex picture. . .
• AQs
• expressive writing task
• attitude toward AAC system
• cognitive tasks on CLQT

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As always

• Further research is warranted
• Your comments are appreciated
• Handouts give us one week to post them on the
  ASHA website