ASHA Convention 2010 - Philadelphia
Hieser & Diener
Aphasia and AAC: You Know More than You Think
Gina’s Challenge
Aphasia and AAC:
You Know More than
You Think
ASHA Convention 2010 - Philadelphia - Session 2168
Gina Hieser, MS, CCC-SLP, CBIS
Carle Hospital
Bethany Diener, MS, CCC-SLP
DynaVox Technologies
• AAC specialist within the
hospital system was no
longer available
• Clients for whom tried and
true aphasia therapy
approaches weren’t
meeting communication
needs and wasn’t sure what
steps to take next
Gina’s Goal
Gina’s Journey
• Expand knowledge related
to aphasia and AAC to
meet her client’s
communication needs by
providing the most
complete assessment and
successful intervention for
her clients
• Refine definition and beliefs about AAC and its
benefit to people with aphasia
• Discover whether features of AAC take
advantage of strengths of individuals with
aphasia while meeting communication needs
What Gina found…
Learning Objectives
• Help along the way
• Expand definition of AAC and its benefit to
people with aphasia
• It was a matter of reframing
previous knowledge and
adding a few new pieces.
• Identify three features of AAC that take
advantage of strengths of individuals with
aphasia
• Increase knowledge of techniques including
those for communication partners that would
support the interaction of people with aphasia
• Name three communication partner techniques
that will support the interaction of people with
aphasia
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ASHA Convention 2010 - Philadelphia
Hieser & Diener
Aphasia and AAC: You Know More than You Think
Gina’s Original Definition of AAC
Original Beliefs
• AAC is all about independent expressive
communication and is used as a primary
communication method in place of speech.
• AAC doesn’t match with the strengths and
needs of PWA.
• Light tech AAC is used to meet basic needs (eat,
drink and bathroom) and contains important
single words organized categorically.
• AAC is too complicated for a PWA! They
can’t use it independently.
• PWA and their communication partners
won’t use AAC.
• High tech AAC is a last resort to be presented
only when it is clear that speech will not improve.
• There is so much to learn about AAC in
my already full schedule.
Too much to learn…too little time
Agenda
• Sought supports
• Review questions Gina asked herself
• Share the answers she found
• Reviewed book on AAC
• Beukelman, D., Yorkston, K and
Reichle, J. (1994) Augmentative and
Alternative Communication for Adults
with Acquired Neurologic Disorders.
Baltimore: Paul H. Brookes Publishing
Co.
• Manufacturer representatives
• Other SLPs
• UNL website – Aphasia Assessment
Materials
• DynaVox Implementation Toolkit
• Light and high tech AAC examples
• Therapy resources
• Share first steps to integrating AAC into
assessment and treatment
• Approached by addressing
questions
Questions #1 and #2
• What do individuals with aphasia NEED
and WANT to communicate?
• How can I address those needs using
AAC?
Communication Needs of PWA
Specific
Needs
Daily Activities
Personal Narratives
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ASHA Convention 2010 - Philadelphia
Hieser & Diener
Aphasia and AAC: You Know More than You Think
Communication Needs of PWA
Communication Needs of PWA
• Specific Needs
• Examples of Specific Needs
• “…people with chronic aphasia or cognitivecommunication impairments have a history of
successful use of AAC strategies and devices
to accomplish some specific communication
tasks.” Dietz et. al., 2007
• Relatively obvious if present
• Often the reason an PWA or partner want
AAC because of the level of importance
• Interacting with others in cultural or social
groups
• Participating in a current events group
• Speaking or praying at family events
• Talking to children on the phone who is far
away
• Interacting with grandchildren
Communication Needs of PWA
Communication Needs of PWA
• Address Specific Needs
• High Tech
• Topical Vocab
Communication Needs of PWA
Communication Needs of PWA
• Examples of Daily Activities
Specific
Needs
Daily Activities
Personal Narratives
•
•
•
•
•
•
Mailing a letter at the post office
Completing banking activities
Chatting while sharing a meal
Talking about current events
Sharing opinions
Checking in for appointments
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ASHA Convention 2010 - Philadelphia
Hieser & Diener
Aphasia and AAC: You Know More than You Think
Communication Needs of PWA
Communication Needs of PWA
• Daily Activities
• Addressing Daily Activities
• Lasker, Garrett & Fox (2007)
• Low Tech
• “Basic communication needs that regulate the
behavior of others to achieve one’s wants, desires,
and preferences”
• “Information critical to performing social roles”
including discussing issues, collaborating in
decision-making, arguing, making up and making
small talk
Communication Needs of PWA
• Topical Boards
Communication Needs of PWA
• High Tech
• Topical Vocab
• My Phrases
Specific
Needs
Daily Activities
Personal Narratives
Communication Needs of PWA
Communication Needs of PWA
• Personal Narratives
• Examples of Personal Narratives
• Stories about us, others we know, or a larger
group of people
•
•
•
•
Why you have a communication impairment
Your child putting on plays in the garage
How your family came to the US in 1848
First Thanksgiving
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ASHA Convention 2010 - Philadelphia
Hieser & Diener
Aphasia and AAC: You Know More than You Think
Communication Needs of PWA
Communication Needs of PWA
• Stuart (2000)
• Addressing Personal Narratives
• “…as individuals age, they often decrease the amount
of actual “doing” while they increase the amount of
“telling” in the form of stories (Coleman, 1986).”
• …appears to meet specific personal needs of older
persons. It provides a unique role of cultural
usefulness (i.e., continuity between past and presentday events [Coleman,1986; McMahon & Rhudick,
1964]), contributes to positive self-esteem, and
fosters coping skills (Blau, 1973; Holahan, 1987).”
Communication Needs of PWA
• Light Tech
• Photo album
• Remnant books
Examples available in:
AAC-RERC webcast (Beukelman, et
al) AAC for Aphasia: A Review of
Visual Scenes Display Project
Communication Needs of PWA
• High Tech
• Photo pages
• VSD (Visual Scene
Display) pages based on
the work of Dr. Beukelman
in Series 5
Based on Low
Tech Visual
Scene Display
Templates at
http://aac.unl.edu
/intervention.html
Communication Needs of PWA
• Resources
http://www.dynavoxtech.com/training/toolkit/
Gina’s New Beliefs
• AAC can meet the communication needs
(specific needs, daily activities, personal
narratives) of PWA.
http://aac.unl.edu/screen/aphasiachecklist.pdf
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ASHA Convention 2010 - Philadelphia
Hieser & Diener
Aphasia and AAC: You Know More than You Think
Question #3
Strengths of PWA and AAC
• Does AAC match the strengths of those
with aphasia? Will it work?
• “When planning an AAC intervention, it is
important to use all the client resources
and to stress the person with aphasia’s
strength’s, rather than weaknesses, to
optimize communication (Garrett &
Beukelman, 1992; Hux et.al., 2001).
Hence, type and severity are insufficient
indicators of how successful an aid might
be…” van de Sandt-Koenderman, 2004
Strengths of PWA and AAC
Recall of Past Events
Strengths of PWA
• Recall of Past Events
Characteristics of AAC
• Utilizes world knowledge
and social repertoire in
organization (particularly
when based on familiar
topics)
• Relate messages to
topics pertinent to the
individual’s needs and
experience
• Utilize familiar symbols or
digital images
Recall of Past Events
Recall of Past Events
•
AAC-RERC webcast (Beukelman,
et al) AAC for Aphasia: A Review
of Visual Scenes Display Project
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ASHA Convention 2010 - Philadelphia
Strengths of PWA and AAC
Strengths of PWA
• Recall of Past Events
• Visual
Processing/Memory
Hieser & Diener
Aphasia and AAC: You Know More than You Think
Visual Processing/Memory
Characteristics of AAC
• Visual media
• Stable and predictable
symbols
• Predictable symbol
locations
• Characteristics of
symbols (e.g., shape,
color) can be used to
teach navigation and
meaning
Strengths of PWA and AAC
Strengths of PWA
• Recall of Past Events
•
• Visual
Processing/Memory
•
• “Cognitive Skills”
•
•
Characteristics of AAC
Part of a multi-modal and
flexible communication
system
Utilizes knowledge of
sequences and scripts
Provides options for
repairing communication
breakdown
Capitalizes and leverages
reading and writing skills
“Cognitive Skills”
• Multi-modal and flexible communication
system
• Speech
• AAC
• Pointing
“Cognitive Skills”
“Cognitive Skills”
• Sequences &
scripts
• Repair & prevent communication
breakdown
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ASHA Convention 2010 - Philadelphia
Hieser & Diener
“Cognitive Skills”
Aphasia and AAC: You Know More than You Think
Gina’s New Beliefs
• Reading & writing skills
• AAC can meet the communication needs
(specific needs, daily activities, personal
narratives) of PWA.
• AAC matches the strengths of PWA.
Written Choice
Communication
Technique Garrett, 2004
Question #4
Garrett & Lasker, 2007
• People with aphasia vary so much in
language skills. How can I realistically
provide AAC to support PWA across skill
levels?
• Overall Types of Communicators
Varying Complexity of AAC
Varying Complexity of AAC
• Independent
• Partner Dependent
http://aac.unl.edu/screen/
aphasiachecklist.pdf
Other
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ASHA Convention 2010 - Philadelphia
Hieser & Diener
Aphasia and AAC: You Know More than You Think
Gina’s New Beliefs
Garrett & Lasker, 2007
• AAC can meet the communication needs
of PWA.
• AAC matches the strengths of PWA.
• AAC can be customized to meet the
communication ability level of the
individual.
• Overall Types of Communicators
Co-construction of Interaction
Co-construction of Interaction
• Normal for all
communicators
PWA may not be independent with
AAC …and they don’t have to be!
•
•
•
•
Ask for clarification
Provide words
Prompt for more detail
Share context to
enhance
comprehension and
expression
Co-construction of Interaction
• Independent
• Partner Dependent
• Communication partners are
PARTNERS in the interaction
• Assistance should be provided based
on the NEED of the PWA
• Interaction should focus on
participation and successful
interaction not just skill development
Co-construction of Interaction
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ASHA Convention 2010 - Philadelphia
Hieser & Diener
Co-construction of Interaction
Aphasia and AAC: You Know More than You Think
Co-construction of Interaction
• Re-focus on known communication partner
techniques
• Positive Communication Environment
• Responding to all methods of communication
• Focusing on successful interactions
• Partner Augmented Input (Aided Language
Stimulation)
• Communicating your messages with the individual’s
AAC and speech without expecting imitation
• Scripting
• Chain (hierarchy) of Cues - including pausing
Gina’s New Beliefs
Question #5
• AAC can meet the communication needs
of PWA.
• AAC matches the strengths of PWA.
• AAC can be customized to meet the
communication ability level of the
individual.
• Communication is co-constructed no
matter the communication methods being
used.
• Will PWA and their communication
partners use AAC in real-life?
Use of AAC Outside of Therapy
Fear regarding Effect on Speech
Production
• Impacted by:
• Fear of regression
or plateau in
speech production
• Embarrassment
• Fear of technology
• Quality of support
and teaching
techniques
• Presentation of AAC after everything else
has been tried = last resort
• “The introduction of AAC principles into
aphasia treatment should not be assigned
to the final stages of rehabilitation, but
rather be incorporated throughout the
rehabilitation process.” Ansel & Weinrich,
2002
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ASHA Convention 2010 - Philadelphia
Hieser & Diener
Aphasia and AAC: You Know More than You Think
Fear regarding Effect on Speech
Production
Fears regarding Effect on Speech
Production
• AAC techniques in aphasia treatment can
offer:
• “AAC Myths Revealed”
• A compensatory means of communication in
lieu of spoken language
• A facilitation technique for re-acquisition of
spoken language skills
• An associative link to enable spoken
language to take place
• Kraat, 1990
Embarrassment and Fear of
Technology
Embarrassment and Fear of
Technology
• Address communication needs
• Address communication needs
Use of AAC Outside of Therapy
Embarrassment and Fear of
Technology
• Fear of impact on speech production
• Benefits of AAC to PWA and others
• Address communication needs
• Address benefits to PWA and others
• Maintenance or return to former social roles
• Increase interaction among family and other
important relationships
• Enhance participation or return to participation
in activities
• Decrease frustration
• Increase empowerment and self-sufficiency
decreasing reliance on partners
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ASHA Convention 2010 - Philadelphia
Hieser & Diener
Aphasia and AAC: You Know More than You Think
Embarrassment and Fear of
Technology
Use of AAC Outside of Therapy
• Benefits of AAC to PWA and others
• Fear of impact on speech production
• Accomplishing functional therapy outcomes
• Improve medical care and decrease medical
issues (Bartlett, 2008)
• Address communication needs
• Address benefits to PWA and others
• Effective support and teaching techniques
Effective Support and Teaching
Techniques
Effective Support and Teaching
Techniques
• Prepare yourself
• “When you plant lettuce, if it does not grow
well, you don't blame the lettuce. You look
into the reasons it is not doing well. It may
need fertilizer, or more water, or less sun.
You never blame the lettuce.” Thich Nhat
Hanh
• Know what vocabulary is available
• Know the organization
• Partner Augmented Input/Aided
Language Stimulation
• Use in real communicative
situations, not just role play
Gina’s Changed Definition
Gina’s Goal
• Expand knowledge related
to aphasia and AAC to
meet her client’s
communication needs by
providing the most
complete assessment and
successful intervention for
her clients
Old Definition
New Definition
•
• AAC is a part of a multimodal, co-constructed
communication system
• AAC addresses both
receptive and expressive
language as well as
compensatory and
remediation needs.
• AAC tools and techniques
can be utilized throughout
the rehabilitation process.
•
•
AAC is all about independent
expressive communication and
is used as a primary
communication method in
place of speech.
Light tech AAC is used to meet
basic needs (eat, drink and
bathroom) and contains
important single words
organized categorically.
High tech AAC is a last resort
to be presented only when it is
clear that speech will not
improve.
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ASHA Convention 2010 - Philadelphia
Hieser & Diener
Aphasia and AAC: You Know More than You Think
Gina’s New Beliefs
Current Goal
• AAC can meet the communication needs of
PWA.
• AAC matches the strengths of PWA.
• AAC can be customized to meet the
communication ability level of the individual.
• Communication is co-constructed no matter
the communication methods being used.
• PWA and their communication partners will
use AAC if presented in a manageable way.
• There are supports to help individuals learn
AAC.
• Integrate AAC (light to high tech) into all
aspects of practice to meet her client’s
communication needs
AAC - Integrated into Assessment
• First steps
• Use AAC (e.g., personal photos, visual
scenes) to observe skills in context
• Use AAC to increase participation in goal
setting
• Identify functional communication needs
AAC - Integrated in Intervention
AAC - Communication Partner Training
• First step - Introduce early to enhance
remediation as well as provide a means of
compensation and participation
• First steps
•
•
•
•
•
•
Scales
Multiple choice
Topical communication boards
Written choice
Keyboards (especially with word prediction)
High tech to work on skills (e.g., naming,
comprehension) using the same system they could
potentially use for communication
• Expand your knowledge of AAC
• Comfort with technology
• Contents of AAC
• Increase knowledge of
techniques (self and others)
• Positive Communication
Environment
• Partner Augmented Input
• Scripting
• Chain of Cues (including pausing)
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ASHA Convention 2010 - Philadelphia
Available Supports
• Beukelman, Garrett & Yorkston, (2007),
Augmentative Communication Strategies for
Adults with Acute or Chronic Medical Conditions
• UNL website – Aphasia Assessment Materials
• Manufacturer websites including:
• DynaVox Implementation Toolkit
• Voice for Living blog
• Manufacturer consultants
Hieser & Diener
Aphasia and AAC: You Know More than You Think
AAC Journeys
• Nelson
• Wade
• Gary
• Devices
• Aphasia Solutions Guide (from DynaVox consultant)
• Other SLPs
Summary – Beukelman, 2005
Summary – Beukelman, 2005
• “What really makes these people unique
is that they have this life of historical
information and knowledge of people
and former roles, and that usually is all
retained. Yet, they must try to face
going forward in their lives with this
limited communication…
• …So it isn’t just putting a few needs, and
wants, and greetings on their system and
calling it a day, it’s trying to give them the
content that they need to maintain their
social network and to recapture some
social roles…(because for some) for
the rest of their lives, they will be living
with aphasia and need some way to
compensate for that.”
Questions
• Thank you for coming
• Please download the handout from the
ASHA website for complete references
and resources
• Feel free to contact us
• [email protected]
• [email protected]
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ASHA Convention 2010 - Philadelphia
Hieser & Diener
Aphasia and AAC: You Know More than You Think
Aphasia and AAC:
You Know More than You Think
ASHA—Philadelphia—November 2010
References
Ansel, B. & Weinrich, M. (2002) Computerized Approached to Communication
Retraining
After Stroke. Current Atherosclerosis Reports, 4, 291-295.
Bartlett, G., Blais, R., Tamblyn, R., Clermont, R., & MacGibbon, B. (2008). Impact of
patient communication problems on the risk of preventable adverse events in acute
care settings. Canadian Medical Association Journal, 178 (12). Retrieved December 4,
2009 from http://www.cmaj.ca/cgi/reprint/178/12/1555.pdf
Beukelman, D. et al Webcast (2005): AAC for Aphasia: A Review of Visual Scenes
Display Project. www.aac-rerc.com
Beukelman, D., Yorkston, K and Reichle, J. (1994) Augmentative and Alternative
Communication for Adults with Acquired Neurologic Disorders. Baltimore: Paul H.
Brookes Publishing Co.
Dietz, A., McKelvey, M., Beukelman, D., Weissling, K., & Hux, K. (2007). Visual scene
displays: Case reports. Pittsburgh, PA: Dynavox DV-5 Manual. Downloaded from:
http://www.dynavoxtech.com/training/toolkit/details.aspx?id=376
Garrett, K. (2004). Aphasia - AAC Resources: Strategic Use in Context: AAC,
Supported Conversation and Group Therapy Interventions for People with Severe
Aphasia. Strategic Use in Context Handout Files retrieved on January 19, 2009 from
http://www.redthreadfamily.org/kg/index.htm
Garrett, K. & Lasker, J. (2005). Adults with severe aphasia. In D.R. Beukelman and P.
Mirenda (Eds.) Augmentative and Alternative Communication: Supporting Children and
Adults with Complex Communication Needs, 3rd edition. Baltimore: Brookes
Publishing Co.
Garrett, K. & Lasker, J. (2007) AAC and Severe Aphasia-Enhancing Communication
Across the Continuum of Recovery. Neurophysiology and Neurogenic Speech and
Language Disorders 17, 6-15.
www.dynavoxtech.com www.mayer-johnson.com
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ASHA Convention 2010 - Philadelphia
Hieser & Diener
Aphasia and AAC: You Know More than You Think
Garrett, K. & Lasker, J. (2007) AAC-Aphasia Categories of Communicators Checklist.
Downloaded August 2010 from http://aac.unl.edu/screen/aphasiachecklist.pdf
Hahn, T.N. (date not known) Lettuce quote. Downloaded August 2010 from http://
thinkexist.com/quotes/thich_nhat_hanh/3.html
Kraat, A. (1990) Augmentative and alternative communication: Does it have a future in
aphasia
rehabilitation? Aphasiology, 4:4, 321-338.
Lasker J., Garrett, K. & Fox, L. (2007) Severe Aphasia. In D. Beukelman, K. Garrett &
K. Yorkston, K. (Eds) Augmentative Communication Strategies for Adults with Acute or
Chronic Medical Conditions. (pp. 163-206) Baltimore: Brooks Publishing Co.
Stuart, S. (2000). Understanding the story telling of older adults for AAC system
design. Augmentative Alternative Communication. 16:1, 1-12.
van de Sandt-Koenderman, M. (2004) High-tech AAC and aphasia: Widening
horizons?, Aphasiology, 18: 3, 245 — 263
Visual scene display templates. Downloaded August 2010 from http://aac.unl.edu/
intervention.html.
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www.dynavoxtech.com www.mayer-johnson.com
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ASHA Convention 2010 - Philadelphia
Hieser & Diener
Aphasia and AAC: You Know More than You Think
Aphasia and AAC:
You Know More than You Think
ASHA—Philadelphia—November 2010
Resources
Note: Instructions for downloading resources from the Implementation Toolkit are on
the next page.
Communication Needs
• Aphasia Needs Assessment—http://aac.unl.edu/screen/aphasiachecklist.pdf
•
•
AAC Needs Assessment—Handout—Implementation Toolkit
Low Tech Visual Scene Display Templates—http://aac.unl.edu/intervention.html
Strengths of PWA
• Aphasia and AAC Overview—Video—Implementation Toolkit
• Aphasia Solutions Guide—DynaVox Representative
Varying Complexity of AAC
• AAC– Aphasia Categories of Communicators Checklist—http://aac.unl.edu/screen/
aphasiachecklist.pdf
• InterAACt Framework Guide—Handout—Implementation Toolkit
Co-construction of Interaction
• Low Tech Visual Scene Display Templates—http://aac.unl.edu/intervention.html
• Positive Communication Environment—Video and Handouts—Implementation Toolkit
• Partner Augmented Input—Video and Handouts—Implementation Toolkit
• Scripting—Video, Handouts and Scripts—Implementation Toolkit
• Chain of Cues—Video and Handouts—Implementation Toolkit
• Communication Partner Strategies for People with Aphasia—Video– Implementation Toolkit
Use of AAC Outside of Therapy
• Myths—AAC will Keep Someone from Talking—Implementation Toolkit
• Myths—Too Soon after Neurological Evening—Implementation Toolkit
• Personal Narratives—Video and Handouts—Implementation Toolkit
• Article-at–a-Glance—Impact of Patient Communication on Risk of Preventable Adverse Effects in
Acute Care—Implementation Toolkit
• Interacting with InterAACt—Video—Implementation Toolkit
• Learning Quickfires, Learning My Phrases, Learning Common Constructions, Learning Core—
Implementation Toolkit
• Functional vs. Therapeutic—Handout—Implementation Toolkit
Implementing in Your Setting
• Aphasia Needs Assessment—http://aac.unl.edu/screen/aphasiachecklist.pdf
• AAC Needs Assessment—Handout—Implementation Toolkit
• Aphasia Solutions Guide—DynaVox Representative
• Communication Partner Techniques Training Plans—Overview, Curricula, Videos—Implementation
Toolkit
• Interacting with InterAACt—Video—Implementation Toolkit
• Voice for Living Blog—www.voiceforliving.com
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www.dynavoxtech.com www.mayer-johnson.com
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ASHA Convention 2010 - Philadelphia
Hieser & Diener
Aphasia and AAC: You Know More than You Think
Downloading Resources from the
Implementation Toolkit
1. Go to www.dynavoxtech.com
2. Select “Training”
3. Select “Implementation Toolkit”
4. Type the resource name (or a portion of the name) into the KEYWORD
SEARCH.
5. Click on the resource you want to view or download.
Note: If you have not already setup a user name and password on the
DynaVox website, you will need to do so in order to download.
4
www.dynavoxtech.com www.mayer-johnson.com
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