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Day 1 – Augmentative and Alternative Communication Strategies for

Individuals with Aphasia* * * * * * * * * * *

Morning: Introduction to AAC Strategies for

People with Aphasia Categories of Communicators

Afternoon Categories of Communicators Cont. Assessment Group Activity

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Day 2 -- Integrated Communication Approaches to Individual and Group

Aphasia Therapy* * * * * * * * * * * * Morning:

Introduction to Integrated Therapy Models Pragmatic Functional Life Participation Supported Conversation Environmental Communication Therapy

Teaching Communicators to Use Communication Skills and Strategies in Meaningful Contexts

Individual Therapy

Afternoon: Aphasia Group Therapy

General Models/Other Models Nebraska-Pittsburgh Model

Wrap-up and Discussion

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I will emphasize treatment mostly for people with….

“global” aphasia symbolic deficits across modalities; cognitive

decreases; severe motor “severe” aphasia with minimal expression

(Severe Broca’s or TMA, some “less” global folks) but better comprehension than group 1

Individuals with a nonlinguistic disorder, such as perseveration or apraxia-of-speech, that interferes with functional communication to

such a degree that they function well below their linguistic ability levels

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The purpose of these talks is….

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Part III: Part III: Assessment and Technique Assessment and Technique

SelectionSelection

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A. Goals of Assessment Identify underlying linguistic, pragmatic and

cognitive-communication Skills With no context – true aphasia impairment (standard

aphasia tests) With context – functional ability Match client skills to appropriate strategies

Assess Communication Needs Assess Desired Participation Level and Activities Utilize a Criterion Assessment

Strategy vs. Maximal Assessment (example).

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B. Cognitive-Linguistic Factors in AAC Strategy Selection

First, analyze the demands of everyday communication situations

What are… The cognitive-linguistic demands of

requesting a blanket (patient in hospital):

The demands of talking about a movie with a friend?

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Discussion – why aren’t AAC strategies always quickly

adopted and used successfully by people with aphasia?

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In aphasia, it’s not as simple as...

Substituting a novel symbol set: for an impaired language system: (“Great, I have mail!)

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Aphasia disrupts the automaticity of information processing and language use in general

And now add...

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Additional Demands Posed by AAC Strategies

Physical Access (often nondominant limb)

Symbol Decoding and Encoding Skills Message Encoding Skills Working Memory Operational Skills for Technology Metacommunicative Ability

To USE strategies in dynamic situations To ID need to use alternative strategy

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AAC SYSTEMS areExternalized

sets of procedures andrepresentations to aidcommunication

- K. Garrett, ‘96

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To think to TURN to an alternative strategy in the right situation and find the right symbols to convey the right message

We’re asking people with aphasia to complete a METACOGNITIVE task when using many AAC strategies– especially those that don’t involve partner support

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Aphasia = disruption of the automaticity of the language/ communication process

+AAC = going outside of one’s own language system to

communicate______________________________

Clinical Challenge = teaching people w/ aphasia to use strategies effectively and naturally

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Cognitive-Linguistic Analysis of:Access Demands

Symbol Skills

Memory Demands

Metacognition

Demands

Call light Y if limb apraxia

No Y – min/mod

Y - min

Yes/No board Y - min Y Y – min Y - min

6-message VOCA to request/tell story

Y - min Y Y - mod Y - mod

Written Choices

No Y - min Yes - episodic

No

Multi-level multisymbol VOCA

Y - min Y - mod Max Max

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What to do…??? 1) Match AAC strategies to

communicators, considering their abilities (cognitive, language, motor, visual) and needs. i.e.,

Don’t expect an emerging (basic choice)communicator to initiate by pointing to a symbol-based VOCA

Don’t ask someone who fits the profile of contextual choice communicator to combine symbols to create a novel sentence

Multimodal, generative communicators will need strategies for spelling, drawing, using word prediction, etc.

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2) Teach strategy use… component by component by modeling strategy use during real

opportunities by embedding use of strategies within

real-life situations as you go

More to come on this approach to communication therapy in Part IV!

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For a more detailed discussion of the cognitive-linguistic demands inherent in AAC and language-based communication activities, see…

Garrett & Kimelman (2000). AAC & Aphasia: Cognitive-linguistic considerations. In Beukelman, Yorkston, & Reichle (Eds.) AAC for Adults with Acquired Disabilities.

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Now, let’s engage in a diagnostic process to help us match appropriate

AAC strategies to specific communicators…

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C. Patient-based Capabilities Assessment

1. Categorical Assessment form (Garrett & Beukelman,

1992/1998; Garrett & Lasker revised 2004) 2. Multimodal Screening tool (Garrett & Lasker rev. 2004):

symbol comprehension/association, use of multiple levels message complexity & symbol sequencing categorization spelling - first letter & whole word

3. Vision Screen 4. Standardized tools (RCBA, WAB subtests)

Assess what you can't see – reading, comprehension Look more carefully at decontextualized performance

5. System Trials (Lasker & Garrett, 2004)

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1. Categorical Assessment Form (Garrett & Beukelman, 1992, 1998;

Garrett & Lasker revised 2004) See handout – Supplementary

Outline and Materials packet p. ___ Will be available on-line at

http://aac.unl.edu OR Beukelman & Mirenda (in press)

AAC Strategies text: Aphasia Chapter (Brookes Publishing Co.)

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The goal: Differentiate between people who require:

Partner support/prelinguistic Partner support/emerging linguistic skills and

intentionality Communicators who can learn to access

prestored messages Self-initiated communicators

Simple symbol systems Complex symbol systems/Generative communicators

Special adaptations for specific environments

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2. Multimodal Communication Screening Test: Score form

p. _____or on-line at http://aac.unl.eduAppendix B. MULTIMODAL COMMUNICATION SCREENING TASK FOR PERSONS WITH APHASIA: SCORESHEET

(C) 1997, Kathryn L. Garrett CLIENT NAME: DATE: EVALUATOR: INSTRUCTIONS: Show the person with aphasia the booklet containing the symbolized choices. Explain that the pictures, letters, sentences and map locations can all be used to communicate ideas. Provide examples if necessary. For each item, ask individual “How would you communicate ? You can use this book or any other way you have to communicate.” Mark + if all concepts were communicated, +/- if some were communicated, and - if no items were communicated. Circle concepts that were successfully conveyed. Record cues if provided. Substitute alternate concepts as appropriate. Abstract Mult. page Target Symbols Meaning? search needed? +/- Cues Comments A. IDENTIFICATION OF NOUNS BY NAME 1. Shoes Pic/word NO NO 2. Open Door Pic/word NO YES (2) 3. Grandchild Pic/word YES YES (3) 4. Need to buy something Pic/word YES YES (3) 5. State of residence (“Nebraska”) Map or 1st letter NO YES (5) B. 2-SYMBOL COMBINATIONS 6. I've been walking alot and I'm tired. Pic/word YES NO 7. Open the window; it's too hot. Pic/word NO YES (2) 8. I'm glad my grandkids are visiting Pic/word YES YES (3) C. 3-SYMBOL COMBINATIONS 9. I want to buy some toys for my grandchildren. Pic/word YES YES (3) 10. The kids are coming next week from Pic/word, map, name of state or city. or 1st letter YES YES (6) 11. I want to eat an expensive meal at Pic/word, map, name of favorite restaurant tonight. or1st letter YES YES (6) D. PHRASE LISTS

“Pretend you’re at the drugstore//with your grandkids.” Find the page that will help you do this. Then, tell me how you’d say...”

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Task 1: Symbol identification

sleep eatQuickTime™ and a

Graphics decompressorare needed to see this picture.

s h oes l ig h t

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Task 2: CategorizationCategory A: Fruit Category B:

Tr ansportationCategory C:Celebrations

Category D: W eather

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

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Task 3: Combine ConceptsChildren Calendar

Money Toys

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Task 4: Locate phrases on an environmentally-organized

vocabulary pageHow’s school?

How are……..• your grades? A

B C+• your friends?• your sports?• Do you do your

homework?• What’s your

favorite class?• Do you have a…

-boyfriend?

-girlfriend?

What do you wantfor…..

• Your b ir th day?• Chan ukah/C hrist m as ?• __________________-- - ---- - ---- - ---- - ---- - ---- - ---- --• Money $$$?• A b ig gi ft?• A to y?• A hu g?• Soc ks !! Hah hah .

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Task 5: Communicate info locations by pointing on a map

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Task 6: Communicate complex information by locating and

sequencing symbols on Multiple Levels (pages)

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Task 7: Storytelling

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Task 8: Spell to convey novel information

Important to assess in communicators who have potential ability to spell or write/i.e., generative communicators

A B C D EF G H I JK L M N OP Q R S T UV W X Y Z

1 2 3 4 56 7 8 9 0

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Video example:Multimodal Screening Test in action

QuickTime™ and aYUV420 codec decompressor

are needed to see this picture.

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3. Vision screening

Figure 16.11 Word Scanning/Cancellation Task for Vision Screening Name: Date: Circle the word "good" each time you see it. Read left to right.

good ------------------------------------------------------------------------------ breath good take moth home good bye one good good bee shine good good baby house shirt good see nose good good hope fine good show tired pies seem good ------------------------------------------------------------------------------ good table shine carpet good good team paste good glue time girl gone good good born shout socks pick tone glow glow good point there see good pass

------------------------------------------------------------------------------ good table shine carpet good good team paste good glue time girl gone good good born shout socks pick tone glow

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4. Standardized tests To assess impairment in

decontextualized situations “Assess what you can’t see!” Reading (e.g., RCBA, Discourse

Comprehension Test) Auditory Comprehension (WAB, Token) We’re beginning to use Cognitive Tests too

– we’ll let you know which ones are useful Cognitive-Linguistic Quick Test Raven’s Progressive Coloured Matrices Wisconsin Card Sort Test

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5. Systems/Strategy Trials Give it a whirl! (within contextualized

activities, of course!)

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Systems Trials(Lasker & Garrett, © 2004)

Level A - Partner Dependent Task: Conversation Topics:

1) Autobiographical Info 2) Education about the Stroke 3) Goals in Therapy

Strategies: Try written choice conversation Look at symbol skills

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Systems Trials(Lasker & Garrett, © 2004)

Level B - Single Message Users Task: Role Play Topic: Requesting coffee/tea Strategies:

Model single message VOCA use in simulated role play with a ‘clerk’ -- “Small latte, please”

Then ask communicator to try this with minimal to no cues.

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Systems Trials(Lasker & Garrett, © 2004)

Level C - Stored Message Users - 1 level Task: Role Play Topic: Getting a Haircut/Planning a

Trip Strategies:

Model VOCA use in simulated role play with a ‘clerk’ . Communicate multiple messages (“haircut please”; shampoo; 1 inch”) from single level.

Then ask communicator to try this with minimal to no cues.

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Systems Trials(Lasker & Garrett, © 2004)

Level D - Stored Message Users - 2-3 levels Task: Role Play Topic: Getting a Haircut/Planning a

Trip Strategies:

Model VOCA use in simulated role play with a ‘clerk’ . Communicate multiple messages (“haircut please”; shampoo; 1 inch”) from level with basic messages and numbers level.

Then ask communicator to try this with minimal to no cues.

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Systems Trials(Lasker & Garrett, © 2004)

Level E - Generative Communicator - 2-3 levels + speech & gestures Task: Role Play Topic: Getting a Haircut/Planning a

Trip Strategies:

Model integrated VOCA and speech/gesture use in simulated role play with a ‘clerk’ . Communicate multiple messages (“haircut please”; shampoo; 1 inch”) from level with basic messages and numbers level.

Then ask communicator to try this with minimal to no cues.

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Systems Trials(Lasker & Garrett, © 2004)

Level F - Generative Communicator - Hi tech multi-level system etc. Task: Role Play Topic: Getting a Haircut/Planning a

Trip Strategies:

Model integrated VOCA and speech/gesture/ writing use in simulated role play with a ‘clerk’ . Communicate multiple messages (“haircut please”; shampoo; 1 inch”) from level with basic messages and numbers level.

Then ask communicator to try this with minimal to no cues.

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Video Illustration Mary in a simulated “video store”

role play

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D. Partner Skills Assessment

1. Assess their literacy (informally) 2. Assess their vision and hearing skills 3. Assess their ability to anticipate

and provide opportunities (by watching them interact, trying strategies)

4. Assess presence of non-facilitative communication skills

Finishing sentences Guessing too quickly Asking just yes/no questions

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E. Communication Needs and Context Assessment

1. Needs assessment – see form p. ___

2. Identify Environments and Potential Participation

Activities 3. Topics 4. Messages and Vocabulary

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APHASIA NEEDS ASSESSMENT (C) 1997, Kathryn L. Garrett & David R. Beukelman

CLIENT: INTERVIEWER: DATE: Poorly So-So Well HOW ARE THINGS GOING FOR YOU? 1 2 3 4 5 HOW WELL ARE YOU COMMUNICATING? 1 2 3 4 5 WHICH SITUATIONS GIVE YOU THE MOST TROUBLE•? (Mark with an X) phone conversations with family discussions about personal business conversing with friends bank, pharmacy, travel agent, bus driver, etc. restaurants doctor work giving directions understanding others other: DO YOU DO MOST OF THE COMMUNICATING FOR YOURSELF? YES NO IF YOU ANSWERED “NO”, WHO DOES? DO YOU USE ANY OTHER STRATEGIES YES NO TO COMMUNICATE? IF SO, WHAT STRATEGIES? WHICH COMMUNICATION SKILLS WOULD YOU MOST LIKE TO IMPROVE? IN WHICH SITUATIONS? Poorly So-So Well HOW WELL DO YOU READ? 1 2 3 4 5 WHAT KINDS OF THINGS WOULD YOU LIKE TO READ? Poorly So-So Well HOW WELL DO YOU WRITE? 1 2 3 4 5 WHAT KINDS OF THINGS WOULD YOU LIKE TO WRITE?

1. NEEDS ASSESSMENT

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2.Topics/Vocabulary/Message Inventory

See materials from Garrett, K., & Beukelman, D. (1992) AAC in the Medical Setting. K. Yorkston, Ed. Communication Skill Builders.

See phrases from new book by Barbara Collier “See what we say – messages for adults”. Brookes Publishing company.

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Comment Nice to invite families to complete

this info gradually but steadily – especially during acute/early phase of recovery.