Augmentative and alternative communication (AAC) methods are a crucial component of assessment and intervention for adults with severe traumatic brain injury (TBI). These individuals face long-term transitions in recovering their natural speech, cognitive/language status, and physical abilities as well as in moving to different placements or living situations. AAC methods and strategies are often used at all stages or levels of recovery. As a patient's skills improve, AAC methods and interventions are modified to accommodate and support these transitions, making intervention an ongoing and dynamic process (Wallace, 2010; Fager, Doyle, & Karantounis, 2007; Fager, 2005; Doyle, Kennedy, Jausalaitis, & Phillips 2000).
A Framework for AAC Assessment and Intervention
We propose a general framework to consider in AAC assessment and intervention decisions for individuals with TBI. This framework includes three groups of patients with TBI who can benefit from AAC methods, techniques, and strategies: emergent communicators, transitional communicators, and long-term augmentative communicators. These groups follow TBI classification systems that are based on the level of cognitive functioning (The Rancho Los Amigos Levels of Cognitive Functioning I – VIII; Hagen, 1984); the stage of recovery (early, middle, and late) and purpose of rehabilitation (stimulation, structure, and compensation; Ylvisaker & Szekeres, 1998).
Within this framework, patients may demonstrate similar skills or behaviors but may be at different stages in the rehabilitation process. For example, a patient demonstrating behaviors typical of an emergent communicator may have recently sustained an injury and may receive rehabilitation as an acute-care inpatient. However, another patient with similar behaviors may be several months post-injury and may live in a sub-acute or long-term care facility. The same AAC methods and intervention goals apply to both patients, with some modifications.
Emergent communicators are unable to speak due to their cognitive, and in some cases, their respiratory (e.g., tracheostomy) or medical status (e.g., paretic vocal fold due to traumatic intubation). As alertness and cognition improve, natural speech may re-emerge, although this emergence usually occurs during the middle stage of recovery (Dongilli, Hakel, & Beukelman, 1992; Ladtkow & Culp, 1992). Speaking valves may be considered to facilitate voicing as patients progress to smaller, deflated, or cuffless tracheostomy tubes. Cognition and language remain severely impaired and patients also may have severe motor and vision deficits.
For this group, AAC is used for ongoing cognitive and language assessment and to communicate basic wants and needs in structured interactions with trained partners. For those in acute rehabilitation, AAC may be temporary; methods will change as cognition, language, and motor skills improve. The majority of emergent communicators use unaided or low-technology AAC approaches. Due to the severity of the cognitive impairment, AAC methods are simple and use natural motor movements, if possible (DeRuyter & Kennedy, 1991).
Examples of AAC systems and strategies for emergent communicators include:
- Yes/no response system (first consider head nods, then less concrete methods such as pointing to yes/no cards, hand or finger movements, eye movements, eye blinks, etc.).
- Object choices (e.g., intervention tasks, clothing, and food items, if appropriate).
- Simple communication boards with two or three pictures (e.g., family members, activity choices, treatment task-specific boards).
- Single-message voice output devices to communicate yes/no or to request an item or activity within a structured context.
Suggested goals for emergent communicators include developing consistent motor responses, increasing attention, establishing a consistent yes/no response system, following directions, and making choices.
Transitional communicators may be recovering natural speech, but present with severe dysarthria or a voice disorder and need AAC to participate in the rehabilitation process and to convey wants and needs. Transitional communicators typically are in the early or middle stages of recovery and may participate in inpatient or outpatient rehabilitation. Continued improvements in their cognition, language, and motor skills require frequent AAC system re-design and upgrades to accommodate these changes. For instance, as a patient's attention and memory skills improve, the number of messages on a communication board may be increased.
The majority of transitional communicators use unaided or low-technology AAC approaches, including picture or word communication boards and writing or alphabet boards. Some patients, particularly those functioning at level VI and above, may benefit from opportunities to try speech-generating devices (SGDs) in structured interactions. AAC for transitional communicators consists of temporary solutions that help patients participate in cognitive activities and routine/structured interactions.
Examples of AAC systems and strategies for transitional communicators include:
- Writing or using an alphabet board to supplement speech. Writing is considered first because it is familiar and more automatic than pointing to letters. If writing is not an option because of motor impairment, then an alphabet board is considered. Most individuals will need cues to initiate use of these systems.
- Low-tech alphabet or communication boards accessed by looking or gazing at messages with the eyes or using eye-safe laser pointers for those with severe motor impairment.
- Low-tech communication boards and books.
- Digitized, static-display SGDs for individuals with significant cognitive/language deficits and whose spelling has yet to re-emerge to a functional level. These devices have a single display or overlay with messages prerecorded by the speech-language pathologist or caregiver.
- Text-to-speech SGDs for individuals with functional spelling. Letters, words, or sentences are “spoken” as the individual types. Spelling and syntax errors may occur due to impulsivity, perseveration, and poor self-monitoring.
- Dynamic-display SGDs may be tried with individuals who have the attention, organization, and memory skills to navigate between displays or screens. One screen may have the alphabet for generating messages and another screen may contain preprogrammed words or phrases. The SLP may reduce the number of screens or simplify the navigation strategies to accommodate the individual's cognitive and language deficits.
Suggested goals for transitional communicators include increasing reliability of yes/no responses, increasing ability to convey wants and needs, increasing initiation of and participation in routine and familiar tasks, and teaching caregivers how to provide appropriate structure for communication.
Long-Term Augmentative Communicators
Long-term augmentative communicators typically are unable to use natural speech for communication due to severe dysarthria and may continue to have mild to severe cognitive and/or language impairments that affect long-term AAC recommendations. These individuals need to use AAC for functional communication. They are typically in the middle or late stages of recovery and may participate in outpatient or community-based rehabilitation. Some may return to home, school, or supported-employment settings. Ongoing recovery may occur, but at a much slower rate. AAC devices and strategies augment natural speech or serve as an alternative to natural speech. AAC evaluations are conducted and long-term recommendations are made at this stage.
AAC interventions include a variety of low- and high-tech options to facilitate communication in various contexts with different partners. Although the AAC systems recommended for long-term augmentative communicators are similar to those for transitional communicators, the purposes, expectations, and goals for AAC use differ.
For example, a long-term augmentative communicator may have a spelling-based text-to-speech SGD purchased through insurance that he or she is learning to use with new caregivers at home and with teachers at school; the transitional communicator may try a similar SGD to communicate in structured interactions with the SLP and a trained, familiar caregiver at home.
Options that are less costly than SGDs include communication software for commercially available devices, such as the iPad and iPod touch by Apple®, or netbooks. Although the design and “look” of these devices may appeal to many patients and their families, their usefulness as functional communication tools is limited by the residual motor and visual impairments exhibited by many patients with TBI. These devices may be appropriate for conveying some basic needs but don't have the features of a traditional SGD. For instance, SGDs are more durable, have louder built-in speakers for text-to-speech output, and can accommodate different access methods required by some individuals with TBI.
Suggested goals for long-term augmentative communicators include increasing use of AAC within functional contexts; increasing participation in school, work, and community; increasing the ability to identify and use the most effective communication strategy in various contexts; and learning to self-monitor and repair communication breakdowns. Other goals include training staff and family to support and cue the patient to optimize communication.
Individuals with TBI benefit from AAC intervention at all stages of recovery and within various contexts or environments. Given the differences in level of recovery, severity of deficits, and the living environment, the AAC intervention framework provided here may help guide SLPs in the decision-making and functional implementation of AAC for individuals with TBI.