aac-rerc.psu.edu_documents_fager_ped_rehab_2010.pdf

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Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach 3 (2010) 269277 269DOI 10.3233/PRM-2010-0142IOS Press

Augmentative and alternative communicationintervention in children with traumatic braininjury and spinal cord injurySusan Fager and Colleen Spellman Institute for Rehabilitation Science and Engineering at Madonna Rehabilitation Hospital, Lincoln, NE, USA

Abstract . Children and youth who sustain a traumatic brain injury (TBI) and/or spinal cord injury (SCI) may have temporary orpermanent disabilities that affect their speech, language and communication abilities. Having a way to communicate can helpreduce childrens confusion and anxiety, as well as enable them to participate more actively in the rehabilitation process and thus,recover from their injuries. In addition, effective communication with family, care staff, peers, teachers and friends is essential tolong-term recovery and positive outcomes for children with TBI and SCI as they are integrated back into their communities. Thisarticle describes how rehabilitation teams can use augmentative and alternative communication (AAC) and assistive technologies(AT) to support the communication of children recovering from TBI and SCI over time.

Keywords: Children, AAC, communication, assistive technology, TBI, SCI

1. Introduction

Children and youth who sustain a severe traumaticbrain injury (TBI) and/or a spinal cord injury (SCI)often experience sequelae that can affect their abilityto communicate effectively. In early phases of recov-ery, many children with TBI and SCI are unable to usetheir speech or gestures for a variety of neurologicaland medical reasons related to their injuries. As a re-sult, they can benet fromaugmentative and alternativecommunication (AAC) interventions that specicallyaddress their ability to communicate basic needs andfeelings to medical personnel and family members aswell as ask and respond to questions. AAC approach-es may include having access to a nurses call signal;strategies to establish a consistent yes no response;techniques that help a child eye point to simple mes-sages; low technologyboardsand books that encourage

Corresponding author: Susan Fager, Institute for RehabilitationScience and Engineering at Madonna Rehabilitation Hospital, 5401South Street, Lincoln, NE 68506, USA. Tel.: +1 402 483 9459; Fax:+1 402 486 8629; E-mail: [email protected].

interaction with family members and staff; communi-cationboardswith pictures or words; and speechgener-ating devices (SGDs) with preprogrammed messages,such as I hurt, Come here, Help me please!, andWhens mom coming?

As children with TBI and SCI recover from theirinjuries, many no longer will need AAC. However,some children face residual motor, speech, languageand cognitive impairments that affect their ability tocommunicate face-to-face, to write and to use main-stream communication technologies (e.g., computers,email, phones, etc.). A few may require AAC and oth-er assistive technologies (AT) throughout their lives toparticipate actively in the rehabilitation process and ul-timately, in their families and communities as adults.Without the ability to communicate effectively, chil-dren with TBI and SCI face insurmountable barriersto education, as well as difculties establishing andmaintaining relationships and taking on preferred so-cial roles.

All AAC interventions aim to support a childs cur-rent communication needs while planning for the fu-ture [3]. However, the course of AAC treatment for

1874-5393/10/$27.50 2010 IOS Press and the authors. All rights reserved


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270 S. Fager and C. Spellman / AAC interventions in children with TBI and SCI

children who sustain TBIs and for those with SCIs is

different due to the nature of their injuries. In addi-tion, the focus of AAC interventions will differ for veryyoung children who are just developing speech andlanguage skills (e.g., 18 month-old with shaken babysyndrome) and for those who were literate and alreadyhad some knowledge of the world prior to their injuries(e.g., 16 year-old injured in a motor vehicle accident).For young children, the AAC team will focus on de-veloping language, literacy, academic, emotional, andsocial skills, as well as ensuring that they have a wayto communicate with family members, rehabilitationstaff and others in their lives. For older children, AAC

interventions often build on residual skills and abilitiesto help remediate speech, language and communica-tion impairments whileproviding compensatory strate-gies that support face-to-faceinteractionsand ultimate-ly communication across distances (phone, email). Inshort, AAC intervention goals often seek both to re-mediate and compensate for injuries while promotinga childs access to social networks and active partic-ipation in family, education, community and leisureactivities [4,18,25].

A variety of AAC tools, strategies and techniquesare available that offer communication access, howev-er, successful AAC interventions for children with TBIand SCI also require that medical staff, family mem-bers and ultimately community personnel know how tosupport their use. The needs of these children changeover time so speech-language pathologists, nurses, oc-cupational therapists, physical therapists, physiatrists,pediatricians, and rehabilitation engineersneed to work collaborativelywith the childs family and community-based professionals to establish, maintain and updateeffective communication systems. Ultimately, thesechildren need to return to their homes,schools andcom-munities and, as adults to take on desired social roles.AAC can help them realize these goals. The intent of this article is to describe and provide clinical illustra-tion of the variety of AAC tools, strategies and supportrequired for successful AAC intervention for childrenwith TBI and SCI. Clinical illustrations presented inthis article were exempt from IRB review as they de-scribed every-day clinical interventions and all identi-fying information (e.g., names, specic mechanisms of injury, timelines and locations) were changed to pro-tect the individuals identities. The indexes searchedin preparation of the article included CINAHL andPubMed. This article is not a systematic review of theliterature in pediatric TBI and SCI.

2. Pediatric TBI and AAC

AAC intervention for pediatric patients with TBIand severe communication challenges is an essential,complex, ongoing and dynamic process. AAC is es-sential to support the broad range of communicationneeds of children with TBI who are unable to com-municate effectively. It is complex because of theresidual cognitive decits that often persist and be-cause many children with TBI have co-existing speech,language, visual, and motor control decits [10,11].AAC interventions are ongoing and dynamic [12] be-cause children with TBI experience many changes overtime and undergo multiple transitions. Light and col-leagues [17] described the ongoing, three-year AACintervention of an adolescent who progressed throughseveralAAC systems and ultimately regained function-al speech. DeRuyter and Donoghue [6] described anindividual who used many simple AAC devices anda sophisticated AAC system over a seven-month peri-od. Additional reports describe the recovery of naturalspeech up to 13 years post onset [15,29].

2.1. AAC Assessment and intervention

Assessment tools can help identify and describe the

cognitive, language and motor decits of patients withTBI and can provide a framework for AAC interven-tions. The Pediatric Rancho Scale of Cognitive Func-tioning [26] is based on the RanchosLos Amigos Scaleof Cognitive Functioning [13]. Table 1 describes gen-eral levels of recovery, based on the Pediatric RanchoScale, and gives examples of AAC intervention strate-gies that rehabilitation teams canemployacross thevelevels, as described below.

2.2. Levels V and IV: Shaping responses intocommunication

Pediatric patients at Levels V and IV on the PediatricRancho Scale are often in the PICU, the ICU, acutehospital or acute rehabilitation environment. At LevelV (no response to stimuli) or Level IV (generalized re-sponse to stimuli), AAC interventions focus on identi-fying modalities that children can use to provide con-sistent and reliable responses. For example, staff canuse simple switches, latch-timers and single messagedevices to support early communication (see Table 1for some examples). Because childrens early respons-es may be reexive rather than intentional, the fami-ly and medical/rehabilitation team can also use AAC


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S. Fager and C. Spellman / AAC interventions in children with TBI and SCI 271

Table 1Goals for AAC based on level of consciousness and AAC technology examples

Level of consciousness and goals for AAC AAC technology examplesLevel V No Response to Stimuli

Continue to monitorphysical responses tostimuli (e.g., head turn, hand/leg movement)

Gather information from family on motivating/ meaningful stimuli (e.g. favorite songs, toys, people,etc .)

Level IV Generalized Response to SensoryStimuli

Monitor for consistent/reliability of response modalities

Level III Localized Response to SensoryStimuli

Shape responses into early communica-tion

Use AAC strategies to monitor for cog-nitive changes

1. Simple switches (e.g., Jelly Bean, Big Red andBuddy Button from AbleNet)2. Single message communication devices (e.g. BIG-mack and Step-by-Step communicator from AbleNet)with stimulating music or voices3. Latch-timers (e.g., PowerLink from AbleNet) con-nected to switches- fans, CD players, some toys canbe plugged into latch timer for timed activation

4. Battery interrupters favorite electronic toys canbecome switch activated

Level II Responsive to EnvironmentPatient is following simple requests,

recognizes family, indicating no or fussing,responds to or knows name

Expanding communication to facilitateactive participation

Providing cognitive support to use AACtechnology

1. Digitized speech devices with static displays (e.g.,Talara from Zygo, Talk 8 and Cheap Talk from En-abling Devices)2. Talking photo albums to communicate biographicalinformation3. Step communicators (digitized SGDs that allow forprogramming a sequence of messages)4. Simple/durable text-to-speech SGDs (e.g., Allorafrom Jabbla, LightWriter from Toby Churchill)5. Dynamic display with synthesized speech SGDprogrammed with limited levels so messages are easyto access (e.g., Vmax from DynaVox Mayer-Johnson,C8 from Tobii ATI, ComLink ST3G from FRS, Inc.)

Level I Oriented to Self and SurroundingsComplete formal AAC assessment

Develop implementation plan forlong-term AAC recommendations

Identify and prepare communicationadvocate(s)

Provide cognitive support as needed touse AAC technology

1. Text-to-speech devices2. Dynamic display SGDs with synthesized speech

and expanded levels of information, e.g., alphabetpage to spell, pages of pre-programmed messages forcontext-specic communication3. Small, portable SGDs for patients with limitedambulatory or visual issues (e.g., Say-it! Sam fromWords+, Proloquo2go App on iPod Touch, PersonaMobile by Zygo)

technologies to encourage more consistent responses.Families provide valuable input about the kinds of mu-sic, games and favorite toys a child nds motivating,and the team can use these items to evoke physical re-sponses fromthe child. For example, if a family identi-

ed the battery-operated toy Elmo from Sesame Street,the rehabilitation team might present Elmo singing aSesame Street song and then observe to see if (and how)the child responds. If the child begins to turn her headwhen Elmo sings, the team might attach a switch witha battery interrupter to the toy and ask the child to hitthe button and play the Elmo song. In doing so, theteam can learn several things. For example, the teammay note that the child is able to follow commands, in-dicating cognitive recovery. The team may also beginto consider alternative access methods for a child withsevere physical impairments, noting, for example, that

head movement may become a reliable way to operatean AAC device or computer in the future.

2.3. Middle Levels III and II: Increasing ability tocommunicate with staff, family and friends and supporting active participation in treatment

Pediatric patients at Levels III (localized responseto sensory stimuli) and II (responsive to environment)become more engaged in their rehabilitation programsas they recover some cognitive, language and physicalabilities. Naturalspeech recovery is likely to occur dur-ing this phaseand long-term decits that affect commu-nication becomemoreapparent (e.g., dysarthria, aprax-ia, aphasia, attention, initiation, memory, vision, spas-ticity). Dongilli and colleagues [7] and Ladtkow andCulp [16] reported natural speech recovery in adultsafter TBI at these stages of recovery, and continued re-


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liance on AAC strategies and technologies is typically

due to persistent motor speech and/or severe cognitive-language decits resulting from the injury [12].

AAC interventions at these levels typically focus onusing a childs most consistent and reliable response to(1) communicate messages, (2) encourage active par-ticipation in the rehabilitation process and (3) increaseinteractions with family and staff. AAC interventionsalways take into account the childs developmental lev-el and interests. Table 1 gives some examples of AACtechnologies employed during Levels III and II. Forexample, Jessica was admitted to the hospital at 18-months with shaken baby syndrome. At Level II, she

began responding to her parents by smiling and laugh-ing, and she alsobegan tomanipulatetoyswith her non-paralyzedhand when staff placeda toywithinher intacteld of vision. However, shedidnot exhibit anyspeechor imitative vocal behaviors, and her speech-languagepathologist noted a severe verbal apraxia. Nursingstaff and family members reported that Jessica seemedfrustrated by her inability to express herself. Prior toher injury, she could name over 30 objects (toys, pets,favorite cartoon characters) and was beginning to puttwo word sentences together ( Momma bye-bye, Daddyhome ).

AAC interventions included the introduction of asingle-message speech generating device (SGD) thatenabled the staff and family members to record a mes-sage that Jessica could then speak during her dailyactivities ( e.g., more , bye-bye , turn page ). Because thedevice selected was colorful, large and easy to access,Jessica was able to press the button despite her up-per extremity spasticity and signicant visual eld cut.Within a month,shewas alsoableto use anSGD withaneight-location overlay that staff had programmed withwords she used prior to her injury (e.g., mommy, daddy,more, bottle, book, bye-bye ). Staff also designed addi-

tional overlays to encourage language development soshe could construct two-word combinations( e.g., morecrackers ). Jessica began to express herself at a devel-opmentally appropriate level when her communicationpartners gave her cues because she had residual mem-ory decits. For example, initially, she did not recallhow to use her AAC system from session to sessionso staff needed to reintroduce it each time; but afterseveral months, Jessica began to search for her SGDto communicate. Like many children with TBI at thislevel, she was able to learn procedures and strategieswith repetition and support [30].

2.4. Level II and Level I: Supporting transitions and

recommending AAC strategies and technologies for use at home and in the community

Aspediatricpatients transition fromLevel II (respon-sive to environment) to Level I (oriented to self and sur-roundings), they often move from an acute rehabilita-tion facility to an outpatientsetting, their home or a carefacility. Before discharge, therefore, AAC teams oftenconduct a formal AAC assessment and provide long-term recommendations for AAC strategies and tech-nologies that will enable children to be integrated suc-cessfully back into community environments. Table 1illustrates the types of AAC technologiesand strategiesemployed at Levels II and I.

For children who continue to use AAC and AT whenthey return to their communities, the rehabilitationteam will identify a long-term communication advo-cate. This person, often a family member, collaborateswith rehabilitation staff to prepare the childs educa-tionalstaff,extended familyandothercaregiversto sup-port communication across environments [9]. Havinga link between the rehabilitation team and communi-ty professionals is essential because most teachers andcommunity-based clinicians need support to managethecognitive andphysical decits often associated with

TBI. For example, McKenzie, a 12 year-old with a se-vere TBI secondary to a car accident, was quadriplegicwith severe spasticity and no upper extremity control.She also had corticalblindness and signicant commu-nication and cognitive impairments. As she recovered,McKenzie used a variety of AAC systems (e.g., thumbsup/down for yes no, two single message SGDs tocommunicate choices, and a auditory scanning devicethat enabled her to access four messages so she couldparticipate in structured activities). Prior to discharge,the rehabilitation team conducted a formal SGD eval-uation and recommended a dynamic display SGD withsynthesized and digitized speech output that McKenziecould access via a head switch mounted to the side of the wheelchair headrest. Using auditory scanning, shecould create and retrieve messages. Because she hadbeen literate prior to her injury and could still spell, thestaff set up her device with an alphabet page as wellas several pages with pre-programmed messages con-taining basic/urgent care needs, jokes and social com-ments. Her familyand friends learned to use tactile andverbalprompts to help her participate in conversationalexchanges. Even so, due to residual cognitive decits,McKenzie had difculty initiating conversations andremembering where pre-stored messages were in her


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device although when prompted, she would respond.

She could also initiate questions and engage in con-versations over multiple turns. Over time, she beganto participate in meaningful, social interactions, oftenspelling out two-to-three word novel phrases using herSGD with the alphabet page.

McKenzie transitioned to a regional care facility thatspecialized in working with young people with TBIwhile her parents were preparing their home to accom-modate her wheelchair, The acute rehabilitation teamhad identied McKenzies aunt as her AAC advocatebecause she participated actively in earlier phases of McKenzies recovery and knew how to charge, set-upand do basic trouble-shooting of her SGD, as well ascould customize and program new messages into thesystem. The care facility staff met with McKenziesaunt weekly and learned how to support McKenziesuse of the SGD. Specic training objectives also in-cludedmaintenance and basic trouble-shooting, set up,switch-placement and programming new messages foruse in specic and motivating activities. Staff alsolearned how to modify the placement of McKenziesswitch when she became fatigued or her spasticity in-creased. Additionally, McKenzies school staff (spe-cial education coordinator, speech-language patholo-gist, occupational therapist, and one of her regularclassroom teachers) visited McKenzie to help preparefor her return home. They wanted to learn how tosupport her in school, given her physical and cognitivelimitations.

2.5. AAC themes in TBI

When working with pediatric patients with TBI,three AAC themes emerge.

1. Recovery from TBI is dynamic and takes placeover time. In early stages of recovery, most chil-dren with TBI have physical, speech, languageand cognitive decits that affect their communi-cation skills. Depending on the nature and sever-ity of their injuries, however, most recover func-tional speech. For those with life-long residualspeech, language and communication decits, re-habilitation teams often need to maintain contactto employ AAC interventions that can supportand monitor a childs changing communicationabilities and needs over time.

2. The cognitive-linguistic challenges associatedwith TBI make AAC interventions particularlychallenging for rehabilitation staff, as well as for

families, friends and school personnel. Because

of the complex nature of the residual disabilitiescaused by TBI, collaboration among rehabilita-tion specialists, family members and community-based professionals is essential. Family mem-bers, friends and school personnel rarely knowhow to manage the severe memory, attentionand/or initiation decits that can affect long-termcommunication and learning outcomes of thesechildren.

3. There is a need to plan carefully for transitions.Children with TBI are likely to experience manytransitions over their lifetimes. While researchdescribing these transitions in children is not

available, reports of the experiences of adultswith TBI describe multiple transitions. Pennaand colleagues [22] noted that adults with TBIundergo a signicant number of residence tran-sitions particularly in the rst year following injury and Fager [9] described the different tran-sitions (acute care hospital, outpatient rehabili-tation, skilled nursing facility, home with adultdaycare services, and eventually assisted living)for an adult with severe TBI over a decade. Shedocumentedsignicantchanges in cognitiveabil-ities, as well as turnover of communication part-ners and support staff.

3. Pediatric SCI and AAC

Pediatric patients with SCI often have intact cogni-tive skills and severe physical disabilities that can in-terfere with their ability to speak during the acute hos-pital and rehabilitation phases of recovery. In addition,they often have signicant medical complications andmay be left with severe neurological impairments thatmake it difcult, if not impossible, for them to write,access a computer or participate in the gaming, onlineand remote social networking activities embraced by

todays youth (e.g., texting, email). A subgroup mayalso present with a concomitant TBI. For them, AACtreatment must reect guidelines that take into accountboth SCI and TBI.

Aswith TBI, AAC interventionfor childrenwith SCIis developmentally based and directed to the individ-uals special needs [27]. Initially, AAC interventionstypically focus on ensuring face-to-face communica-tion when speech is unavailable or very difcult; how-ever, over the long term, enabling children to write andengage in educational, recreational and pre-vocationalactivities using computers and other mainstream tech-nologies becomes the focus.


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Table 2Associated barriers to communication based on level of SCI and AAC/assistive technology examples to address these barriers

Level of spinalcord injury

Communication barriers AAC and assistive technology examples

High Tetraplegia:C1-C4 SCI

Vent dependent, requires use of one-way valve for oral communicationUnable to utilize upper extremi-ties for manipulation of AAC de-vices, computer keyboards, com-puter mouse

Speech options: Eye tracking technology (e.g., EyeMax by Dynavox Mayer-Johnson, ComLink En-ableEyes by FRS, TobiiC12 with CEye by Tobii ATI),head tracking technology (e.g., HeadMouse Extremeby Origin Instruments, AccuPoint by Invotek, Inc.,TrackerPro by Madentec)Computer options: Voice recognition software (e.g.,Dragon NaturallySpeaking by Nuance), eye trackingtechnology, head tracking technologyPhone options: Voice activated Bluetooth options(BlueAnt by BlueAnt Wireless), Ameriphone RC200voice or switch activated phone, Skype

Low Tetraplegia:C5-C8

Limited access to computers mouseand keyboard secondary to impairedproximal and distal upper extremitymotor function impacting commu-nication and learning.Limited ability to manipulate phonefor answering calls, dialing, texting.

Computer access options:1.Voice recognition software2. Head tracking technology3. Other assistive technologies: universal cuff withstylus, hand typers, trackball or joystick mouse,switch-adapted mouse, large button keyboard, key-guard4. Onscreen keyboard (e.g., Click-N-Type by LakeSoftware, SofType from Origin Instruments)Phone options: Modication of cell phones, universalcuff with stylus, cell phone applications (Vlingo-voiceactivated smart phone control), Bluetooth headsets

3.1. AAC assessment and intervention

The ASIA standard neurological classication of SCI from the American Spinal Injury Association andInternationalMedical Society of Paraplegia [1] is a toolthat rehabilitation teams frequently use to assess pa-tients with SCI because it identies the level of injuryand associated decits at each level. It can help guidethe rehabilitation teams clinical decision-making pro-cess for AAC interventions. As shown in Table 2, chil-dren with high tetraplegia (C1-C4 SCI) have limitedhead control and are often ventilator dependent. Theymay require eye, head, and/or voice control of AACdevices and mainstream technologies to communicate.While switch scanning is an option for some, it requireshigher-level cognitive abilities, endurance, and vigi-lance that maybe inappropriate for very young childrenand those who are medically fragile [14,19,23,28].

Children with low tetraplegia (C5-T1 SCI) demon-strate limited proximal and distal upper extremity con-trol. If tted with splints that support their arm andhand, some are able to use specially adapted mouseoptions (e.g., joystick mouse, switch-adapted mouse,trackball mouse), large button or light touch keyboardsand switches to control technology. These children arealso candidates for head tracking and voice control of AAC devices, options that can offset the fatigue and

physical effort involved in using their upper extremi-ties. A multi-modal access method to AAC technolo-

gy and computers may include voice control to dictatetext, hand control of the cursor with an adaptive mouseto perform other computer functions (e.g., open pro-grams) and an adaptive keyboard to correct errors thatare generated while dictating text which can be moreefcient and less frustrating than using voice controlalone. Table 2 provides examples of appropriate accessoptions to AAC and mainstream technologies.

3.2. Supporting face-to-face communication

For children with high tetraplegia, being dependenton mechanical ventilation is frightening especially forthose who are unable to tolerate a talking valve [21].Also, children with lower levels of injury can experi-ence reduced respiratory controland be unable to speak as they are being weaned from a ventilator [2]. For anyreason, providing a way to communicate is essentialto recovery and a sense of well-being. AAC strategiesand technologies can enable these children to interactwith direct care staff, participate in their rehabilitationprocess, and maintain relationships with family andfriends.

Pediatric rehabilitation teams may use a range of AACstrategiesand technologiesto support face-to-face


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communication in children with SCI. Some examples

include low tech communication boards used with eyegaze or eye pointing, partner-dependent scanning, anelectro larynx with intra-oral adaptor and a laser lightpointing to a target message or letter on a communica-tionboard [2,3]. Introducing AACand AT technologiesearly in the recovery process, particularly for childrenwith high tetraplegia, begins to familiarize them withapproaches they may need to rely on more extensivelythroughout their lives, even after their speech returns.

Forexample, Jared, a 17-year-oldhigh school senior,sustained a SCI at the C2 level in a skiing accident. Inaddition to his injuries, he developed pneumonia and asevere coccyx wound that lengthened his hospital stay.He was unable to tolerate a one-way speaking valvedue to the severity of his pneumonia and decreasedoxygenation during valve trials. Although Jared hadminimal head movement, he was able to control a headtracker to access his home laptop computer and couldspell out messages he then spoke aloud using speechsynthesis software. He used this AAC system to indi-cate his medical needs to caregivers and later reportedthat having the ability to communicate helped alleviatesome of the anxiety he experienced due to his condi-tion and extended hospitalization. When Jared coulduse a talking valve, his AAC program focused on com-

puter access to meet written and social communicationneeds. Once his wound had healed and he returnedhome, Jared completed his GED and enrolled in onlineclasses at the local community college using his AACsystem.

3.3. Supporting written communication and educational goals

At the time of their injury, some pediatric patientswith SCI are pre-literate, others are developing literacyskills, and others have highly developed literacy skills.Most children with tetraplegia require the use of assis-tive technologies to supportwritten communicationbe-cause their injuries preclude them from using a penciland/or typing on a traditional computer keyboard. Infact, in a report describing the educational participationof children with spinal cord injury, 89% of the chil-dren with tetraplegia relied on AAC to support writtencommunication needs [8].

For example, Max, a 6-year-old boy who suffereda C6 SCI after an All Terrain Vehicle accident, wasreading age-appropriate sightwordsand developing hisability to write single words prior to his injury. For-mal testing revealed that Max had no residual cogni-

tive or language impairments; however, he faced sig-

nicant barriers to his continued development of age-appropriate reading and writing skills, as well as hisability to learn and do math, social studies, science,play games, use a cell phone, etc. Max needed waysto access text and write, calculate, draw, play computergames, and so on. He learned to access a computer us-ing a large button keyboard, joystick mouse, and adap-tivehand-typers (cuffs with an attachedstylus that t onthe ulnar side of the hand and allowed him to presskeyson a keyboard). These technologies supported writ-ing and computer access; and as a result, he was ableto continue with his schoolwork and keep up with hisclassmates. After returning home during the summerand participating in an intense home tutoring program,he joined his classmates in the fall and performed atgrade level in all his classes. Essential to Maxs fu-ture educational success and development, as well ashis future employment, is his ability to write, calcu-late and perhaps even draw using a variety of assistivetechnologies that support communication.

3.4. Supporting social participation and pre-vocational activities

Access to assistive and mainstream technologies not

only facilitates participation in education, but also hasimplications for future employment as children tran-sition into adulthood. Assistive and mainstream tech-nologies that can help individuals with SCI achievegainful employment and participate actively in theirfamilies and communities are now available at mod-est cost. In addition, these technologies provide ac-cess to life-long learning, recreational activities and so-cial networking opportunities. Specically, computersare described as great equalizers for individuals withSCI [20].

Social participation in the current technological ageincludes more than face-to-face communication. So-cial participation has expanded with the popularity of social networking sites (e.g., Facebook and MySpace),video web-based communication (e.g., Skype) and in-stant communication and messaging (e.g., Twitter).Advances in the eld of AAC have allowed individ-uals with the most severe injuries to engage in thesesocial communicationactivities. For example, Crystal,a 10-year-old who sustained a C1 SCI due to a fall,had no head/neck control and her only consistent ac-cess method to computerized technology was througheye tracking. Using an ERICA eye gaze system fromDynaVox Mayer-Johnson, Crystal was able to email


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and text her friends and family daily, communicate via

her Facebook account, and engage in online gamingprograms with her friends and siblings. This technol-ogy also allowed her to communicate with her schoolfriends while she was still undergoing acute rehabili-tation. Additionally, Crystals friends began to under-stand that while her impairments were severe, she wasessentially the same person with the same interests,humor, goals, and expectations as before her injury.Maintaining social networks is an essential componentto emotional adjustment for children with SCI [8].

3.5. AT/AAC themes in SCI

When working with pediatricpatientswith SCI, threeAAC themes emerge.

1. For those with high tetraplegia, AAC strategiesand technologies may facilitate face-to-face aswell as distant and written communication needs,depending on the developmental level of thechild. Introducing AAC technology early, whenface-to-face communication support is needed,helps these children become familiar with tech-nology theymay need to rely on after their naturalspeech has recovered.

2. Return to their homes and educational environ-ments is a primarygoal for children with tetraple-gia. Many of these children return to schoolwithin an average of 62 days post discharge [24].Development of written communication skills isan essential component to successful education-al completion and future vocational opportuni-ties [20].

3. Having access to written and electronic commu-nication provides an opportunityfor childrenwithSCI to engage in social networks through email,texting, and social networking sites. Some of these children face a life time of potential med-

ical complications [5], so an ability to maintainand develop new social connections via electron-ic media allow them to stay connected to friends,familyandinformationwhen their medical condi-tions require them to be house or hospital-bound.

4. Conclusion

Communication is essential for the development of cognitive, language, social, and emotional skills. Chil-dren with TBI and SCI have physical and/or cognitive-language decits that may interfere with typical ways

of communicating. However,AAC strategiesand tech-

nologies can support their varied and ongoing commu-nication needs across environments and over time. Amyriad of technology options are currently availablethat not only address face-to-face interactions, but al-so distant social networking, educational, leisure andemployment needs.

AAC interventions in medical settings address thecommunication of basic medical needs and facilitate achilds recovery and engagement in the rehabilitationprocess. For those who continue to need communi-cation supports, AAC technologies increase the likeli-hoodthat children with TBI andSCIwill make success-ful transitions to their homes, schools and communitiesand as adults, can take on desired social roles.

Acknowledgements

The preparation of this manuscript was supported inpart by the Rehabilitation Engineering Research Cen-ter on Communication Enhancement (AAC-RERC)funded under grant #H133E080011 from the Nation-al Institute on Disability and Rehabilitation Research(NIDRR) in the U.S. Department of Educations Ofceof Special Education and Rehabilitative Services (OS-ERS) and Madonna Rehabilitation Hospital. The au-thors would like to thank the patients, families, mem-bers of the spinal cord injury team, and members of thetraumatic brain injury team at Madonna RehabilitationHospital.

Conict of interest

The authors report no conicts of interest.

References

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