Reducing the Cognitive/Linguistic Load of Persons with Aphasia and Traumatic Brain Injury Who Rely on AAC David Beukelman University of Nebraska, Lincoln With support from: AAC-RERC/NIDRR/USDE Technology Transfer Partner Dynavox

AAC: Augmentative and Alternative Communication A range of strategies to support communication for those with unmet communication needs

Aphasia Language limitation due to damage language center in the left (usually) hemisphere –Range of symptoms –Range of severity –Range of recovery –30% do not achieve full recovery –??% with minimal functional verbal expression

Traumatic Brain Injury Range of communication limitations –Motor speech –Cognitive/Linguistic –Combination –Pattern of communication limitations changing as medical interventions improve. –More combined communication limitations

Intervention Strategies Restoration--restore verbal expression Compensation--provide alternatives to natural speech Combined--Integrate AAC and natural speech

Cognitive/Linguistic Limitations Related to AAC Representation of Meaning Navigation through the AAC Interface Formulating Messages Organizing Content

Aphasia: AAC Acceptance & Use Long history of low tech AAC use to support residual verbal expression –Communication books and boards –Drawing –Handwriting –Photography –Remnant books

Aphasia: AAC Acceptance & Use High tech AAC use for specific tasks –Answering phone –Calling for help –Ordering in restaurants and stores –Giving speeches –Saying prayers –Engaging in scripted conversations

Rationale for Using Visual Scene Displays (Aphasia) Make use of preserved skills of people with chronic aphasia –Visual-spatial processing –Retention of information about life experiences (episodic information) –Retention of general world knowledge

Strategy: To incorporate Contextually Relevant Visual Scenes Provide a way to represent meaning Support navigation within an AAC system Serve as a shared platform for co- constructing messages with listener(s) Establish a shared communication space Allow for integration with other types of communication supports

Evaluating Images for Contextual Richness of a Visual Scene Four criteria: –Environmental context (setting, people, objects, and activities) –Interaction with people or the environment –Personal relevancy –Clarity regarding elements key to the implied relationships

Environment: High Interaction: High Personal relevance: High Clarity: High Comment: Satisfies all the elements for being a good contextually-rich picture to support a story

Environment: Absent Interaction: Absent Personal relevance: High Clarity: High Comment: Typical portrait that does not convey any contextual or interaction information

Environment: Absent Interaction: Absent Personal relevance: Absent Clarity: High Comment: Only serves to identify an object; typical of pictures available in stimulus sets

Environment: Interaction: Personal relevance: Clarity:

Environment: Interaction: Personal relevance: Clarity:

Environment Interaction Personal relevance Clarify Good scene? –1a Yes – No

Environment Interaction Personal relevance Clarify Good scene? –1b Yes – No

Environment Interaction Personal relevance Clarify Good scene? –2a Yes – No

Environment Interaction Personal relevance Clarify Good scene? –2b Yes – No

Low Tech Visual Scenes with Text Support

Visual Scene Display (VSD) for Aphasia and TBI

VSD Navigational Strategies (High Tech) Themes Organizational strategy for navigation Color & CONTRAST Learning Memory Pattern recognition Organization “Link Deeper” Continue on same topic

VSD

Three Levels Content Management Strategies 1. People who rely on AAC 2. AAC Facilitator/General Clinician 3. AAC Specialists

VSD with Content Management Functions For Facilitators

VSD Features Drag and drop images from Enter messages from onscreen keyboard Hide and reveal buttons Select from a range of templates Navigate themes Navigate deeper into themes Enter content with requiring detailed programming knowledge

VSD Example

Research Strategy Case Reports and Small N Studies of Clinical Interventions with Current Technology Experimental Studies Preference Message representation Navigation of Interface Usability Evaluations of Technology Revisions

Aphasia: Participant 1 Basic Needs New InformationSocial Closeness

Participant 1 25 themes 105 pages 377 messages 185 pictures

Aphasia: Participant 2 New Information Social Closeness

Message Representation: Preference –N = 8 –Miechelle McKelvey Dissertation Results Summary: Preference –Personally Relevant Pictures: 85% –Non-personally Relevant Pictures: 13% –Iconic Symbols: 3%

Message Representation: Accuracy –N = 8 –Miechelle McKelvey Dissertation Summary Results: Accuracy Personally Relevant Pictures: 98% –Non-personally Relevant Pictures: 55% –Iconic Symbols: 34%

Learning New Themes Strategy: –Series of Small N Studies –Completed during field tests Conclusion: –Instruction/practice on FIRST THEME varied –Minimal instruction/practice on Subsequent Themes after the FIRST THEME was mastered.

Traumatic Brain Injury with Complex Communication Needs (N = 30) Summary from Fager et al. Survey (2006) 32% used low-tech AAC –Regained speech –Lack of Facilitator support –Lack of funding for high-tech AAC 68% used high-tech AAC –Of these, 87% used letter by letter spelling without message retrieval –Minimal use of message retrieval strategies –Remainder used iconic symbols-- TBI before learning to spell Severe cognitive/language issues

VSD with Onscreen Keyboard Option VSD to support episodic message retrieval to support multiple themes to support narrative organization to supplement residual speech Onscreen keyboard with speech synthesis output to support spelled messages

VSD & Onscreen Keyboard with Speech Synthesis

VSD for Severe Cognitive Conditions Subset of People with TBI are unable to communicate through speech and experience such severe cognitive limitations that spelling is not an option for some them. VSD appears to be an option provided that visual issues are managed with large pictures and print. Field Trials Ongoing

Acknowledgements AAC-RERC –Janice Light & Jeff Higginbotham University of Nebraska –Karen Hux, Aimee Dietz, Miechelle McKelvey, Kristy Weissling, Sarah Wallace Madonna Rehabilitation Hospital –Susan Fager Quality Living, Inc. –Liz Anderson