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Part II: Specific AAC-Based Communication Strategies for People with Severe Aphasia

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Title: Part II: Specific AAC-Based Communication Strategies for People with Severe Aphasia


1
Part II Specific AAC-Based Communication
Strategies for People with Severe Aphasia
2
Overview of Categories of Communicators
  • 1) Basic Choice Communicators
  • 2) Controlled Situation Communicators
  • 3) Comprehensive Communicators
  • --------------------------------------------------
    ----
  • 4) Augmented Input Communicators
  • 5) Specific Needs Communicators

3
A. Basic Choice Communicator
  • Characteristics
  • Often prelinguistic, with minimal symbolic
    ability across modalities (reading, writing,
    speech, comprehension, gesture).
  • Sometimes preintentional at the very least,
    seldom initiate
  • Poor aphasia quotients untestable to 10/100.
  • Variable awareness
  • Do sometimes show preference recognition
  • Remind me of children and adults with
    severe-profound developmental disabilities

4
John age 59, AQ .6/100, 7 years post onset,
profound aphasia across modalities,
nonspeaking, severe limb and oral apraxia
5
A. Basic Choice Communicator
  • Treatment Focus
  • develop turn-taking
  • develop choice-making ability
  • develop referential skills
  • develop clear signals for agreement, rejection,
    etc.
  • teach partners to provide appropriate
    opportunities for above

6
A. Basic Choice Communicator
  • Specific Strategies - PWA
  • choose items to meet grooming needs during daily
    routine
  • reference pictures in photo album by pointing OR
    indicating appropriate facial expression when
    participating in dyadic reminiscing activity
  • choose pictured items in context of a functional
    activity (e.g, ordering garden seeds from a
    catalog)

7
Dan Fink (my grandfather) featured in his
reminiscing album. Multi-infarct aphasia and
vascular dementia. Goals to point reference),
recognize, comment appropriately as able
8
A. Basic Choice Communicator
  • Specific Strategies PWA cont.
  • participate in turn-taking within context of
    familiar visual games (e.g., tic-tac-toe, war)
  • consistently signal affirmation (head nod) during
    choice-making activities for preferred items
  • consistently signal rejection (pushing away, head
    shake) during choice-making activities for
    non-preferred items (dental floss, Hitler
    examples)
  • call for assistance with visible, permanent,
    simple call signal/buzzer when appropriate

9
  • Georges own x on 3rd turn

10
Lethargic, minimally responsive patient indicated
a clear rejection signal for the 1st time in
response to this picture
11
Violet learning to signal for assistance
12
A. Basic Choice Communicator
  • Specific Strategies PWA cont
  • (added to handout)
  • Point to others to request turns, or ask for
    additional information
  • Present topic setter to conversational partners
    to learn to initiate a conversation

13
John choosing fast food items (objects first,
then corresponding symbols on VOCA)
14
  • Johns sequentially organized social
    communication wallet. His target behavior hand
    wallet to novel communication partners, then flip
    through it to ask prestored questions, share
    information.
  • Note topic setter message about Twin Towers

15
John asking Sara for more info following HOH
now does spontaneously approximately 30 of the
time
16
A. Basic Choice Communicator
  • Specific Strategies -- Partner
  • Develop contextual routines and opportunities in
    which the individual can utilize the above
    communication skills and increase meaningful
    participation in some life activities.
  • create scrapbook
  • facilitate participation in games

17
Video of John
  • Activity xxxxxx
  • Data derived from a 12 month tx period
  • 1X week individual tx
  • 1X week group tx

18
Changes in Number of Behaviors from Communication
Interview (modified from Schuler, Peck, Willard,
Theimer, 1989)
Percentage of preintentional, intentional, and
intentional/symbolic communication behaviors
(total behaviors rated 14 total of ratings
159 82 intrarater reliability)
19
Changes in target communication behaviors
20
Discussion!!!
21
B. Controlled Situation Communicator
  • Characteristics
  • Emerging symbolic communication skills but
    extremely limited
  • Some automatic and/or stereotypic speech may be
    present (OK, Oh dear)
  • May recognize familiar words, understand meaning
    of simple pictures
  • Good recognition of preferences, familiar
    information

22
B. Controlled Situation Communicator
  • Characteristics
  • Good awareness of daily routine, clock time,
    familiar people
  • Will initiate vocal protests, at times requests
    (but not with language)
  • Show a desire to communicate, but often dont
    initiate questions or comments
  • Low aphasia quotients 5 to 25/100

23
B. Controlled Situation Communicator
  • Treatment Focus
  • Develop use of AAC strategies and tools to allow
    participation in controlled, predictable
    exchanges and routine conversations
  • Teach both patients and partners to participate
    in these exchanges the partner has a huge role!
    (Well see)

24
B. Controlled Situation Communicator
  • Specific Strategies - PWA
  • Learn to call for attention/assistance
  • Learn to introduce self with low or high tech AAC
    strategy (card, VOCA)
  • Communicate familiar and topical conversational
    information by pointing to contextual written
    choices (Written Choice Conversation Strategy)
  • Participate in multi-turn conversations by
    pointing to choices/scales to answer
    conversational questions

25
Dr. D. choosing a topic of discussion
26
(No Transcript)
27
Written Choice ConversationGarrett Beukelman,
1992 1995
  • For people with severely limited verbal
    expression, but good awareness and linguistic
    recognition skills, PARTNERS can increase the
    PWAs participation in social conversations by
  • Providing topic choices
  • Asking open-ended conversational questions
    (sincere questions)
  • Writing potential answers in the form of large
    print word/phrase choices (usually vertical,
    indicate start of phrase with or -)
  • OR graphic scales (see example)
  • Asking the PWA to point to a choice/scale to
    communicate
  • Continuing the conversation by asking a follow-up
    question

28
Written Choice Sample Conversation 1
Friend Can you give me advice on what to make
for the school bake sale tomorrow? PWA Nods
yes Friend Should I take an angel food
cake, brownies, or cookies? writes choices
vertically in notebook   ANGEL FOOD
CAKE   BROWNIES   COOKIES  PWA Points
to brownies Continued
  • example

29
Friend Yes, those always sell fast? circles
brownies. Should I make them from
scratch or get a box mix? writes
choices   SCRATCH BOX
MIX PWA laughs and points to box
mix Friend laughs and circles box mix. Yeah,
its hard to make them as good as Betty Crocker!
30
Friend Pause what do you think about the
kids elementary school? Do you think
theyre getting a good education or a so- so
one? writes a rating scale on the page 
Bad So-So Good ?--------------------------
------------------? 1 2 3
4 5 PWA hesitates, points to
4 Friend circles 4 Yeah, were pretty
happy with the school district. Too bad the
classes are so big, though! PWA nods yes
31
While drawing say and point to locations
Right here in Nebraska? Up to Minnesota to
fish? California, where its warm?
Conversational Question Where have you
traveled?
32
Goals of Written Choice Technique
  • Increase PWAs participation in meaningful social
    conversations
  • Establish social closeness
  • Can also use for communication of
  • Functional needs and wants
  • E.g., Aspirin?
  • Milk of Magnesia?
  • Functional information transfer
  • E.g., Your daughter lives.
    Pennsylvania? New York?

33
Video
  • Neil with daughter OR
  • Steve with his wife Diane

34
Written Choice Conversation Garrett 1993
Dissertation Research
  • Data Three participants with severe aphasia
  • Aphasia Quotients ranging from 11 to 20
  • Nonspeaking or only automatisms or perseverative
    jargon
  • Minimally communicative, few initiations
  • At least 6 mos. post left CVA
  • Ages 66-81

35
Baseline Written Choice
Ave of Turns/Topic 2.5 7.5
Range - of Topics 5-9 1-2
Ave Understandability 15 97
Ave Response Accuracy 93 92

36
(No Transcript)
37
Interpretation of data
  • In 10-minute conversations between a person with
    severe aphasia and a partner trained in the
    provision of sincere, consecutive conversational
    questions and potential answers in the form of
    written choices or scales
  • of turns per topic during NO WRITTEN CHOICES
    was approximately 2-3
  • Fast turnover, short discussions, little content
    exchanged
  • of turns per topic during WRITTEN CHOICES
    ranged from 5 to 11
  • Little to no topic turnover, longer discussions,
    lots of content exchanged

38
  • Other findings
  • Subjects often requested written choices by
    pointing to tablet even in 2nd baseline!
  • Accuracy of written choice responses (as verified
    by significant partner) was between 80 and 90
    for all participants
  • Meaningparticipants could comprehend these
    orally/visually presented contextual choices even
    if reading comprehension scores on formal tests
    were low.
  • Participants were just as accurate when questions
    were in conversational order as when they were
    mixed up/in random order
  • Meaning you could use this technique to ask
    1-shot questions (e.g., How much pain do you
    have?)

39
Followup study Lasker, Hux, Garrett, Moncrief,
Eischeid (1997)
  • 3 participants
  • 3 modes of presentation
  • Auditory-visual choices
  • Auditory only
  • Visual placement only
  • Outcomes each person differed in terms of BEST
    mode of presentation

40
The point...
  • Assess whether your client benefits from
  • Presenting choices through all modalities
  • Needs auditory choices only
  • Needs a visual reference point only
  • Regardless, it works!

41
Audience Participation Activity
  • Try written choice technique
  • Option A 1 volunteer on overhead
  • Option B with each other

42
B. Controlled Situation Communicator
  • Other Specific Strategies PWA cont.
  • Begin to transition to self-initiated
    communication by
  • locating previous written choice info in response
    to communication need/questions
  • find biographical info in a simple reminiscing
    book or communication notebook)
  • Hand a potential communication partner a tangible
    topic setter to initiate a conversation
  • Game ticket
  • Article from a newspaper
  • Cigar from grandchilds birth

43
John learning to choose between 4 symbolic
(photo) representations of favorite activities
44
Constructed Topic Setter
45
Steve data and Telerounds video Garrett Huth,
2002
  • Increased initiations with topic setter,
    especially for current events vs. personal events
  • Increased message successfulness, but mostly with
    1st vs. 2nd partner, and mostly for current
    events (2nd partner was a good guesser regardless
    of amount of context that was available)
  • Instructional implications.

46
B. Controlled Situation Communicator
  • Specific Strategies PWA cont.
  • Answer predictable questions (e.g.,
    autobiographical, topical) by selecting and
    pointing to pre-stored messages on a simple VOCA
  • Tell simple stories on VOCA - sequentially
    ordered steps

47
Needs/Requests
Storytelling
48
(No Transcript)
49
Digitized Voice Output Devices record messages
by pushing the message square and record button,
then speaking into the device. Adv instant,
real voice Disadv cant create novel messages
50
Examples of Simple Vocas
  • TechSpeak (Assistive Technology, Inc.)
  • Cheap Talk (Great Talking Box Co.)
  • Message Mate (Words)
  • Black Hawk (Wolf)

51
Video - storytelling
  • With sequentially ordered messages on a simple,
    digitized voice VOCA with multiple message
    capacity

52
B. Controlled Situation Communicator
  • Specific Strategies -- Partner
  • Identify interesting conversational topics
  • Learn to generate consecutive, meaningful,
    conversational questions
  • Learn to generate potential/possible answers in
    the form of choices or scales
  • Make effort to interpret message person is trying
    to convey
  • Respond to all modes of communication
  • Suggest to PWA that s/he try to find info in
    Conversation book, etc., to encourage transition
    to comprehensive communicator

53
C. Comprehensive Communicator
  • Characteristics
  • Symbolic (but intermittently successful at
    reading, understanding, speaking, etc.)
  • Frequent efforts to initiate communication
    responses, comments, questions
  • Often use multiple natural modalities to attempt
    to convey message (gestures, writing,
    air-writing, drawing, stereotypic phrases,
    intonation, some semantically specific words or
    short phrases)
  • Communication is fragmented
  • Circumlocutions or topic shifts are common
  • Demonstrate awareness of communication breakdowns

54
C. Comprehensive Communicator
  • Treatment Focus
  • Develop organized means of storing messages,
    vocabulary, and communication support strategies
    in conjunction with PWA
  • Teach integrated/strategic use of multiple
    modalities (natural and AAC) in real life
    communication contexts
  • Develop and teach breakdown resolution strategies

55
C. Comprehensive Communicator
  • Specific Strategies - PWA
  • Initiate introduction of self and communication
    strategies
  • Communicate biographical info by pointing to
    previously stored info in a multi-modal system
    (e.g., communication notebook, combination
    VOCA-writing-gestures)
  • Communicate needs by pointing to previously
    stored messages/symbols, gesturing symbolically
  • Communicate specific info within topics by
    pointing to prestored written or pictured words
    in notebook/VOCA

56
  • Combine symbols to convey novel meanings
  • Spell, write, gesture, draw, pantomime, point to
    messages, use remnants, use natural speech, etc.
  • CLEVER COMMUNICATORS WHO WILL TRY ANYTHING!

57
Multimodal System Examples and Components
  • 1. Multi-modal Communication Notebook

58
Mike J Brocas-type aphasia (AQ 47/100)
59
Cover Explanation Card. Can obtain pre-made
cards from the National Aphasia Association
60
(No Transcript)
61
  • Bus Page
  • Drop me off at the
  • VA Hospital
  • Vets club
  • Duquesne Clinic
  • Kaufmanns downtown
  • When is the next bus?
  • to the South Side
  • to downtown
  • to the stadium
  • It helps if the bus can KNEEL
  • Do I need a transfer?

Environmentally inventoried vocabulary
62
Timeline to Organize Autobiographical Storytelling
63
Preconstructed outline map to communicate
familiar place names (vs. say North Platte)
64
C. Comprehensive Communicator
  • Specific Strategies PWA cont.
  • Communicate novel info (not stored in advance) by
    writing, gesturing, drawing, pointing to first
    letter, using semantic association strategies
  • Communicate locations by pointing to areas on a
    map
  • Ask questions with key word, enhanced intonation
    and gesturing (e.g., Vacation.you?)

65
Sample of natural drawing writing paper pen
66
(No Transcript)
67
It was over
68
C. Comprehensive Communicator
  • Specific Strategies PWA cont.
  • Establish topics with graphic topic setters
    (card, tangible)
  • Organize and access memorabilia, scraps of info,
    appointment cards
  • Switch between communication modes as needed to
    maintain conversation
  • Combine symbols or words to create novel
    sentences

69
Other corresponding notebook components
  • Alphabet
  • Map
  • Environmentally-inventoried phrases for
    particular situations
  • Lists family, phone numbers, place names,
    medications, etc.
  • Categories of words
  • Calendars
  • Number pages

70
C. Comprehensive Communicator
  • Specific Strategies PWA cont.
  • Provide additional information/shift to new
    strategy during communication breakdowns
  • Signal partner that s/he has understood/not
    understood
  • Manage conversational dynamics/make decisions
    about whether to continue/quit

71
Slide with breakdown phrases
72
Modality Instruction Card
73
Video Mike J.
  • Comprehensive Communicator
  • Pre-intervention (with wife)
  • Post Intervention (with Marcie)

74
Mike Js Comprehensive Communicator
DataGarrett, Beukelman Low (1989)
Measure Pre-AAC Post AAC
Turns 51 88
Initiations 12 42
Initiations 24 47
Ave Turns Per Breakdown Sequence 15 4
of Turns spent on resolving Communication Breakdowns 46 11
75
  • 2. Multi-level VOCA more advanced communicators
    can use these systems to combine symbols and
    create novel messages, to access a large number
    of messages, and/or to spell with or without
    prediction.

76
Multiscreen AAC Device - Dynavox
77
C-Speak Aphasia(Nicholas Elliot available
through Mayer Johnson. Computer-based software
combine with Speaking Dynamically software)

78
Talk Boards(Dundee University available
through Mayer Johnson. Also requires Speaking
Dynamically Pro)

79
Enkidu Portable Impact Devices with
Spelling/Prediction/Phrases
80
Vanguard (PRC) with Minspeak software
JTIME Lets get the mail now!
81
Other brands
  • Talking Screen (words) install on laptop
  • Lingraphica (now marketed as a language training
    tool similar to C-Speak Aphasia)

82
Video Illustration
  • Don/Ron
  • Dr. A
  • Comments on Technology
  • What proportion of the population of adults with
    aphasia can use high technology
  • Independently?
  • For specific purposes?
  • With assistance?

83
A few communicators with aphasia do not need high
tech AAC speech supports.
  • Rather, they benefit from adaptive word
    processing programs for writing enhancement and
    support
  • CoWriter word choices and prediction
  • Spelling assistance/spell checker
  • Video Dr. A
  • Article by Hux (see reference list)

84
C. Comprehensive Communicator
  • Specific Strategies - Partners
  • Assist in compiling vocabulary
  • Interpret and guess at appropriate moments in
    conversations
  • Encourage PWA to try another modality
  • Encourage use of conversational control
    strategies

85
D. Augmented Input Communicator
  • Characteristics
  • Poor comprehension in contextual situations
  • Often nod as if understanding (but dont!)
  • Have difficulty with topic shifts
  • May speak well (transcortical sensory, etc.)
  • Or may have limited speech (e.g., severe
    aphasia)

86
D. Augmented Input Communicator
  • Treatment Focus
  • Develop ability to comprehend key points in a
    conversation given augmented input (partners
    gestures, written key words, referential cues,
    drawings)
  • Develop clients ability to signal comprehension
    breakdowns

87
Sequential Description of Augmented Input
Strategy
  • 1. Partner identifies that PWA has misunderstood
    (blank expression, nodding ambiguously, looks
    away, answers incorrectly)
  • 2. Partner then supplements the most difficult,
    or the most important concepts, by
  • A) writing key words on paper
  • B) gesturing symbolically
  • C) gesturing deictically
  • D) pantomiming
  • 3. Rechecks PWAs comprehension (Got it?)

88
Me using his notebook computer in reverse to
augment Dr. Ds comprehension of a discussion
about politics.
89
D. Augmented Input Communicator
  • Specific Strategies -- PWA
  • Carry notebook with blank pages and instructions
    for partners
  • Demonstrate increased reliability and accuracy of
    answers/comments given partners augmented input
  • Advanced strategy Signal breakdowns in
    comprehension hand notebook to partner, ask
    what? with exaggerated, quizzical facial
    expression
  • Specifically teach this skill in role-playing
    situations

90
Sample instruction card
  • Hello. I had a stroke. Sometimes Im not able
    to understand you. Can you
  • Watch my face if I look confused, I probably
    didnt understand you.
  • Signal topic changes like this
  • Now, Id like to talk about something elselike
    baseball. Did you watch the Pirates game this
    weekend?
  • For key words or concepts, it helps if you
  • Gesture swing bat for baseball, for example
  • Write down the words in large print
  • PIRATES???
  • Draw

91
D. Augmented Input Communicator
  • Specific Strategies -- Partner
  • Identify behaviors that signal breakdowns in
    comprehension
  • Use gestures to signal key concepts
  • Write down key words to signal concepts/topic
    changes
  • Use exaggerated referential communication style
  • Signal upcoming topic shifts

92
Video clip
93
Discussion
94
E. Specific Need Communicator
  • Characteristics
  • May be a member of any of the above categories
  • May be able to speak/communicate intelligibly
    except in certain situations required
    specificity, clarity, or efficiency (e.g.,
    returning an item while shopping).
  • Note this category is NOT based on internal
    linguistic/communicative competence but on NEED

95
Examples of Specific Needs
  • Remembering and recording grocery needs while at
    the store
  • Taking phone messages
  • Stating phone number or other numbers aloud
  • Communicating bets at the race track
  • Getting a specific style of haircut at a new
    hairdressers
  • Saying I love you or another emotional
    expression via natural voice in a controlled
    manner (e.g., via VOCA)
  • Writing thank you notes

96
E. Specific Need Communicator
  • Treatment Focus
  • Develop highly specific AAC mini-interventions to
    increase participation in important life
    activities
  • family rituals/activities
  • communicating needs in the community
  • writing supports
  • telephone assists

97
E. Specific Need Communicator
  • EXAMPLES of Specific Strategies -- PWA
  • Learn to utilize single message VOCAs to
    communicate info by telephone, in community
    situations (e.g., I have aphasia give me time
    to communicate) or to participate in ritual
    (prayer)
  • Refer to phrase card to place bets at the race
    track, explain upcoming bus stop, place bridge
    bets
  • Learn to use writing supports to generate real
    letters, cards

98
Groceries Request List Marys story
99
Numbers page with printed out numerical words to
assist an individual with severe semantic
paraphasias (especially for numbers) to
communicate numerical info by telephone
100
Sample Cloze Letter Format  1) , 199 Dear
2) , 3) ! How 4) ? I am 5) . This
month we 6) . We really 7) .   So, tell
me about 8) . I hope you are 9) .
Please 10) .  11) , X _
101
List of Word and Phrase Choices Jan Feb March Ap
ril May June July Aug Sept Oct Nov Dec   1 2
3 4 5 6 7 8 9 10 11 12 13
14 15 16 17 18 19 20 21 22
23 24 25 26 27 28 29 30
31 -----------------------------------------------
--------------------------------------------------
------ 2. (Names of family members/friends go
here) --------------------------------------------
--------------------------------------------------
--------- 3. Hello! Hi! Howdy! Greetings! ------
--------------------------------------------------
----------------------------------------------- 4.
...are you? ...is it going? ...is your
family? ------------------------------------------
--------------------------------------------------
----------- 5. fine OK pretty good terrific a
little tired -------------------------------------
--------------------------------------------------
----------------
102
Elaines letter copied onto script
Elaines letter using script as a reference
103
Stories about Augmented Writers.
104
Note.
  • The nature of AAC-type interventions to meet
    specific needs is only limited by the teams
    creativity!

105
E. Specific Need Communicator
  • Specific Strategies -- Partners
  • Identify specific situations and specific
    messages
  • Provide opportunities to use system components

106
Video if time
  • Grace on telephone with husband

107
Audience Participation Activity
  • Select a case packet
  • Identify the type of communicator
  • Identify client strategies
  • Identify partner strategies
  • Select someone to report on decisions
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