Sonya is a 72-year-old retired accountant who had a large, left-hemisphere stroke one week ago. She is currently a patient in an acute-care hospital. She was unresponsive for three days after her stroke, but now she seems to recognize her husband and family members. She produces undifferentiated sounds without specific words, but she is not able to respond to questions or communicate her needs. She cannot answer yes/no questions and seems confused when people talk to her.
Mary Ann is a 56-year-old homemaker who has been participating for two weeks in speech-language treatment in an inpatient rehabilitation hospital. Her expressive and receptive language skills are severely impaired due to aphasia. She attempts to communicate with a few isolated words ("yeah," "but") and vague gestures. She matches pictures to words with about 70% accuracy. Her husband is very frustrated when he tries to understand her in conversation.
Hernando is a 62-year-old retired mechanic who lives in an assisted living facility. He had a left-hemisphere stroke four years ago. His pattern of speech is characteristic of moderate Broca's aphasia with significant apraxia of speech. Conversation with Hernando is difficult because his communication attempts are fragmented and incomplete. His speech is limited to phrases of one or two words that often contain paraphasias, and he searches his pockets and wallet for scraps of information to help him during conversations. At times he tries to write to convey ideas, but frequently misspells words.
Sonya, Mary Ann, and Hernando represent clients with aphasia who might be seen by speech-language pathologists working in intensive care, acute-care hospitals, inpatient and outpatient rehabilitation hospitals, and assisted living facilities. Aphasia is an acquired language impairment that occurs typically as a result of left hemisphere stroke. Although traditional speech-language treatment improves speaking and listening skills for many people with aphasia (Holland, et al., 1996; Wertz et al., 1981), some individuals live with severe and persistent communication challenges. Augmentative and alternative communication (AAC) offers specific strategies to help people with severe aphasia communicate more effectively in their current communication settings, as they make the transition through care in a hospital, in rehabilitation centers, and at home.
AAC for people with aphasia goes beyond "talking boxes" and picture boards—it is a comprehensive collection of communication strategies that provide external support for people who cannot understand or generate messages on their own (Garrett & Lasker, 2005). A recent ASHA knowledge and skills document (ASHA, 2002) defines AAC as "a set of procedures and processes by which an individual's communication skills (i.e., production as well as comprehension) can be maximized for functional and effective communication" (ASHA, 2002, p. 2).
An AAC treatment approach means focusing on communication and participation rather than on recovery of speech alone. This type of treatment may feel unfamiliar to clinicians who typically employ "stimulation" models of aphasia treatment. In this article, we respond to the most common clinical questions about how to assess and treat these unique clients using an AAC framework. In addition, we direct clinicians to more detailed resources related to aphasia and AAC.
Classifying AAC Users
AAC strategies are not universally applicable to everyone who has severe aphasia. We have developed a clinically based system for describing the communication behaviors of people with aphasia so that SLPs have a better idea of which AAC strategies to consider in treatment. This clinical taxonomy is shown in Figure 1 and is currently being validated (Garrett & Lasker, 2005).
Communicators who must rely on their conversational partners to manage informational demands and provide communication choices within highly familiar contexts are described as "partner-dependent communicators." Communication partners may need to augment interactions for these individuals by restructuring questions, offering choices, and supplementing auditory input with graphic symbols. Partner-dependent communicators can seldom retrieve symbols (e.g. spoken words, gestures, text, pictorial symbols) or initiate communication on their own.
Individuals whose language and executive function are relatively preserved, but who have a significant apraxia of speech and moderate aphasia, may be candidates for more sophisticated speech-generating devices (SGDs) or strategies. These individuals typically comprehend much of what is said to them with little contextual support. They can initiate communication and convey ideas using a variety of self-selected strategies and modalities. Without focused clinical intervention and implementation of AAC strategies, however, these "independent" communicators may experience frequent communication breakdowns. With treatment, they can learn to use both natural communication strategies (e.g., speech, residual writing, drawing) and AAC strategies (e.g., pointing to elements of a picture to elaborate on a topic, finding messages stored in a communication notebook or SGD, spelling, drawing) to communicate effectively in multiple environments with a variety of communication partners.
One of the purposes of AAC-based intervention is to help people with severe aphasia develop their skills so that they can move from partner-dependence to greater independence. In fact, the taxonomy is defined by a sequence of strategies that help the person progress along the continuum of independence. There is, however, no guarantee that all clients will become independent communicators.
We have developed a clearly delineated set of assessment procedures that includes a complete needs assessment, the Multimodal Communication Screening Test for Aphasia (Garrett & Lasker, 2005; Lasker & Garrett, 2006); the AAC-Aphasia taxonomy; and an AAC systems trial protocol. Readers are referred to Lasker, Garrett, & Fox (2007) for a thorough discussion of the AAC-Aphasia Assessment protocol. Assessment materials may be downloaded from the AAC Web site.
For communicators in acute-care hospital or rehab settings like Sonya, described above, partners play an important role in supporting effective communication. SLPs may implement several graphically based strategies with these individuals and their communication partners, but two of the most powerful conversational tools are Augmented Input (Garrett & Beukelman, 1992, 1998; Sevcik et al., 1991; Wood et al., 1998) and the Written Choice Conversation Strategy (Garrett & Beukelman, 1992, 1995; Lasker et al., 1997).
Partner-Dependent Strategy #1: Augmented Comprehension (Input) Techniques
For people with aphasia who have poor comprehension, communication partners can supplement their spoken language by gesturing, writing key words, or drawing. This set of strategies, called "augmented input" or "augmented comprehension" strategies, can be implemented whenever the communicator with aphasia is having difficulty comprehending conversational questions, comments, or instructions.
The communication partner first identifies that the communicator has misunderstood after carefully observing the person's blank facial expression, ambiguous head nods, or incorrect responses. The partner then reiterates the message while simultaneously using one or more augmented input strategies. The partner may point to the item being discussed; gesture symbolically (e.g., throwing hand over shoulder to indicate "away from here"); pantomime an event; show photographs, drawings, or other diagrams; or write key words and topics.
Partner-Dependent Strategy #2: Written-Choice Conversation
This technique requires the facilitator to generate written key-word choices that relate to a conversational topic. The person with severe aphasia participates by pointing to the choices, thereby making his or her opinions and preferences known. Partners can ask basic social or medical questions (e.g., "Who visited this weekend—your husband, daughter, a friend, or no one?" or "What do you need—blanket, pain medicine, or TV?").
Questions also can be highly specific, particularly if they pertain to personal memories, beloved hobbies, or detailed knowledge associated with a past career. When facilitators present a sequence of related questions, interactions lengthen and communicators can discuss topics in greater depth than when the strategy is not used (Garrett, 1993). Variants of the written-choice conversation approach include presenting choices in the form of points on a rating scale or locations on a map.
A person such as Mary Ann may best be classified as a transitional communicator according to the AAC-Aphasia taxonomy. Like many other people with aphasia who may be in the rehabilitation stage of recovery, she demonstrates improved awareness, comprehension, automatic speech, and desire to communicate.
Transitional communicators, however, have significant speech-language production deficits (e.g., apraxia of speech, anomia, encoding breakdowns) that mask their desire and ability to converse. In addition, they may not yet have the cognitive ability to initiate use of communication systems containing previously stored, symbolized messages. A number of transitional communication strategies that minimize linguistic demands can help people like Mary Ann initiate communication, including stored message retrieval, remnants and topic-setters (Garrett & Huth, 2002; Ho et al., 2005), and storytelling (Stuart, 2000).
Transitional Strategy #1: Stored Message Retrieval
To promote initiation and symbol use, individuals can practice accessing a small selection of stored messages on either low-tech, picture-text communication boards or SGDs to gain the attention of a listener ("Can you help me with this?"), explain their communication disability ("I have aphasia, please give me time to answer you"), ask simple questions ("When is my husband coming?"), provide specific answers ("I have two children who are both physicians"), or comments ("I don't like this TV show"). Practice should occur in highly contextual situations using authentic communication scenarios (e.g., conversation groups, role plays of talking with a doctor).
Transitional Strategy #2: Topic Initiation
For topic initiation training, the clinician first collaborates with the family member to identify a graphic symbol or remnant that is personally relevant to the individual. The symbol can be a souvenir, family reunion photo, headline and photo from a newspaper, or menu from a favorite restaurant. An SGD capable of storing a single digitized message can be programmed with a favorite or trademark phrase such as "Go ‘Noles!" for the diehard football fan. Communication partners are cued to pose questions, such as "What's new?" The person with aphasia is then encouraged to show the remnant or activate the SGD to begin an interaction.
Transitional Strategy #3: Storytelling
People with aphasia can use communication boards, books, or symbol sequences on an SGD to tell simple stories that are personally relevant. Communicators learn to activate messages on a board or device using a left-to-right symbol sequence. The cognitive demands are minimal; the person with aphasia does not need to search for a symbol from a complex array. Most importantly, this approach offers rich opportunities for communication output and participation. Mary Ann, described at the outset of this piece, recounted the humorous story of her first date with her husband of 35 years to aphasia group members on Valentine's Day.
One application for storytelling in conversation is Visual Scenes technology (Dietz et al., 2006; McKelvey et al., 2007). A personally relevant, contextual photograph of an event or gathering is displayed (e.g., reunion, favorite musician) accompanied by printed comments ("I actually met BB King once!") or questions ("Do you like blues music?"). The photograph and text symbols represent whole messages. Low-technology starter visual scenes (templates and manual) are available on the AAC Web site. Visual scenes templates are also available on the DynaVox Series 5 devices.
Long-Term AAC Approaches
AAC-oriented treatment for individuals like Hernando begins with a thorough needs assessment to determine appropriate communication goals and identify message topics. For example, a needs assessment may indicate that a communicator wishes to resume conducting bank transactions independently or to participate in a weekly card game. Independent communicators like Hernando are able to initiate communication, recognize and categorize picture symbols, and comprehend familiar written words and phrases. They may attempt novel utterances by using incomplete spelling or writing and symbolic gestures. In general, their communication is fragmented and inefficient, but they are persistent communicators who will try anything to convey their message. With independent communicators like Hernando, the following AAC strategies can be effective.
Independent Strategy #1: Stored Message Retrieval Strategies
Communicators first can learn to access symbolized pre-stored messages within simple, scripted routines such as calling for assistance over the telephone with an SGD. Supported by a communication card, wallet, or SGD, they can practice introducing themselves to others in a group. When asked a question in conversation, they can learn to search for responses from previously answered written choice questions, a simplified communication notebook, or a single display on an SGD containing life stories symbolized with photographs.
Independent Strategy #2: Multimodal Communication
Some people with severe aphasia who can spell and/or combine symbols (pictures, text, and orthography) learn to navigate with relative ease through pages on a dynamic display SGD to initiate conversation, ask and answer conversational questions, explain or clarify, share novel ideas, and conduct transactions in the community. Most independent communicators need instruction and support with spelling, including abbreviations and the use of a word-prediction tool on an SGD. They benefit from practicing how to combine symbols, letters, stored messages, and other unaided communication modalities to convey their ideas in a specific community situation; role-playing is often a tool to practice these skills.
Although independent communicators may not use voice-output systems exclusively, producing a spoken message with an SGD can get attention, convey specific information, or facilitate phone communication. The "final" AAC system may consist of an SGD in combination with a variety of other communication tools, including the client's residual natural speech, use of unaided strategies, a communication notebook, and other remnants, such as ticket stubs or a list of family members' names and contacts. (For more information about considerations for selecting an SGD for clients with aphasia and funding options, see the sidebar on p. 11 for links to Web-exclusive material on those topics.)
Evidence for AAC Use
The documentation of effective AAC device use in "real-life" settings by people with aphasia continues to evolve. King and Hux (1995) reported on a client with aphasia who used a talking word-processor program to improve the quality of his written production. Some studies have described ongoing AAC interventions with clients presenting with primary progressive aphasia (Cress & King, 1999; Murray, 1998). A few studies have described AAC technology that has been successful in improving conversations and daily interactions for people with chronic aphasia (Waller et al., 1998; Lasker & Bedrosian, 2001; van de Sandt-Koenderman et al., 2004; Lasker et al., 2005; McKelvey et al., 2007).
Encouraging AAC Use
Sometimes clients and family are reluctant to use AAC strategies because they view these as "giving
up" on speech recovery. It is difficult for clinicians to alter fundamental attitudes and perceptions held by clients and families, but we can educate them about the powerful communication potential offered by partner-dependent conversation strategies, natural strategy use (e.g. gesture, drawing, writing), and voice-output devices. We occasionally can alter negative attitudes toward "artificial" communication by describing AAC strategies and devices as a means of practicing functional speech as well as providing communication support (Weinrich et al., 1995).
Clinicians also can refer to the growing body of literature on the functional use of voice-output technology in combination with natural speech to re-engage in important life activities (Lasker et al., 2005; Lasker et al., in press). Often acceptance is influenced by when and how AAC approaches are introduced to clients. We tend to avoid introducing complex SGDs at the earliest stages of aphasia recovery. After some time has elapsed, clients and families often are able to think more realistically about how AAC strategies might help accomplish particular communication goals.
Throughout the health care continuum, a variety of AAC-oriented treatment strategies can enhance communication and participation for people living with severe aphasia, provided SLPs have matched the skills and capabilities of the users carefully with appropriate strategies. In addition, these strategies help clients participate more effectively in their own rehabilitation. We invite SLPs to review other resources on this topic and to broaden the scope of therapeutic intervention for people with aphasia to include partner-supported, transitional, and independent AAC techniques.
Author's note: This article is adapted from Garrett, K. L., & Lasker, J. P. (2007). AAC and severe aphasia: Enhancing communication across the continuum of recovery. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 17, 6–15.