Cognitive-Linguistic Profiles of Aphasic Communicators Who Use AAC Joanne P. Lasker, Ph.D. Florida State University Kathryn L. Garrett, Ph.D. Duquesne University Presentation at the American Speech-Language-Hearing Association Convention November 22, 2003 Chicago, IL

A. Statement of the Problem Many people with severe aphasia have unmet communication needs. Which individuals with chronic aphasia will benefit from augmentative and alternative communication strategies (AAC)? Which type/class of AAC strategies? Are there systematic ways of assessing this issue? Is there a “profile” of an effective AAC communicator?

B. Cognitive-Linguistic Considerations in AAC definition of aphasia “Language” or “symbolic deficits” across modalities Intermittency of processing (Brookshire, 1978; McNeil, 1983) more recently we have seen attention to possible cognitive aspects of aphasia

Cognition and Aphasia Aspects of cognition related to aphasia may include: (Purdy, 2001; Hinckley, 2002) attention memory executive function skills resource allocation pragmatics

Demands of AAC Techniques Think to initiate communication through external means -- “outside” of the communicator’s own head and language system (Garrett & Kimelman, 2000) Verbal memory for messages Spatial memory for message location Symbol translation skills -- from icons to meanings Executive function skills -- to judge which method of communication best fits the situation Attention and perseverance to complete the message transaction

Resource Allocation to balance the cognitive demands of using a novel form of communication… …with the pragmatic demands of speaking to a communication partner And the linguistic demands of encoding messages And any other stressors in the communication environment Balancing Noise Multiple speakers Multiple topics Interruptions Communication breakdowns

Challenges with AAC and Aphasia Limited information is available re: who is and is not successful. “Matching” AAC approaches to skills/needs of communicator involves many variables. Limited knowledge is available about how to effectively train people with aphasia to use AAC in real-life situations.

Still More Challenges People with aphasia tend to be isolated, and therefore have limited social opportunities to communicate. Message pools selected for AAC systems may not be appropriate or meaningful for adults with aphasia. Negative or ambivalent attitudes toward technology may be held by adults with aphasia and/or communication partners.

Recent Research Helm-Estabrooks (2002) described a case study of a person with aphasia who used a high tech AAC system (C-Speak Aphasia; Nicholas & Elliot). Her analysis of the individual’s cognitive-linguistic profile revealed: mild-moderate aphasia as measured by the WAB relatively strong cognitive skills on specific subtests of the Cognitive-Linguistic Quick Test (Helm-Estabrooks, 2001) Trail Making Design Generation Mazes

Testable Hypothesis Certain measures of cognition may serve as reasonable predictors of an individual’s ability to use an AAC system to communicate meaningfully.

C.Our Purpose/Design Case study approach. generate a cognitive-linguistic and behavioral profile of successful AAC users with aphasia Independent Communicators Partner Dependent Communicators Nonusers aid in assessment and intervention planning

Proposed Test Battery Western Aphasia Battery (Kertesz, 1982) Raven’s Coloured Progressive Matrices (Raven, Raven, & Court, 1998) Cognitive-Linguistic Quick Test (Helm-Estabrooks, 2001) Wisconsin Card Sort Task (Kongs, Thompson, Iverson, & Heaton, 2000) Multimodal Communication Screening Task (Garrett, 1998) The Assistive Technology Device Predisposition Assessment Consumer Form (adapted from Scherer & McKee, 1989 by Lasker & Bedrosian, 2000; under revision) Categorical Assessment of Communicators with Aphasia (Garrett & Beukelman, 1998; under revision)

One Comparison: WAB Writing Task

Client’s Written Responses MHJK RM

The Multimodal Communication Screening Video Clip

Raven’s Coloured Progressive Matrices

Cognitive-Linguistic Quick Test (Helm-Estabrooks, 2001) criterion-referenced test relative skills in the areas of: attention memory language executive function visuospatial skills does require verbal skills for some tasks (e.g., story retelling)

CLQT – Tasks and Composites Personal Facts Symbol Cancellation Confrontation Naming Clock Drawing Story Retelling Symbol Trails Generative Naming Design Memory Mazes Design Generation Yield composite scores: attention memory executive function language visuospatial skills

Trailmaking task…oops … not this…

Trail Making Example

Wisconsin Card Sort Test sort cards by: number shape color rules change after 10 correct sorts

WCST Example

Sample questions from the “Technology Predisposition Survey” I will benefit from using this AAC system. This AAC system will help me achieve a goal that I have. I will feel comfortable using this AAC system in public. This AAC system will improve the quality of my life. I will feel comfortable using this AAC system around my family.

Categories of AAC Use

Categories (cont.)

D. Case Studies

On to Pennsylvania folks!

JV -- Emerging Communicator WAB AQ -.6/100 BASA -- 2nd %ile for people with global aphasia Raven’s -- 0/36 CLQT -- N/A Technology Attitudes Minimal experience Interested in trying technology Required specific training to use symbols to request Max assist to locate symbolized messages

AA & RC -- Contextual Choice Communicators WAB AQ = 9.2 Reading: 11/100 Writing: 10.5/100 Ravens: 15/36 CLQT Symbol Trails: 1/10 Design Memory: 2/6 Mazes: 0/8 Design Generation: 6/13 Technology Attitudes: Minimal to some computer experience Willing to learn to operate simple AAC systems Less willing to use in real- life

SA - Transitional Communicator WAB AQ = 93.4 Reading = 80/100 Writing = 71/100 Praxis = 55/60 Block Design = 7/9 Calculation = 24/24 Raven’s = 16/20 Moderate dysarthria Technology Attitudes: Moderate computer experience Interested in Palmtop PC- type device because of social acceptability

GW--Deferred Technology User WAB = 35 Broca’s profile 1 year post onset Lawyer Computer experience Technology Attitudes -- No interest in learning to use AAC at present

Florida AAC/Aphasia Clients

Client: MH 52-year old woman left CVA in March, years post 14 years of education right hemiparesis lives with mother who is in frail health completed assessment phase of project before relocation diagnosed with moderate receptive and severe expressive aphasia limited speech therapy

MH - Results

MH – AAC Trials

MH – Strengths & Challenges Challenges emotional issues: frustration sadness anxiety social isolation impaired auditory comprehension impaired executive skills severity of speech deficit Strengths reading writing motivation

MH – Current Status relocated after assessment currently not receiving any services SLP attempting to contact an area SLP to continue intervention and device trial

Client: JK 53-year-old tenured geography professor earned doctorate left CVA in 3/ months post at first visit employed by university for 21 years (since 1982) lives with husband (also a professor) and young daughter (5 years old) diagnosed with moderate expressive aphasia and mild receptive aphasia

JK - Results

JK – AAC Trials

Student Evaluations: First Teaching Experience After Stroke “It was very interesting to see how Dr. Kodras put her sentences together and got her point across to the class.” “Topic ---- instructor ---- extremely well versed ---- passionate about topic ---- makes all difference instructor exceptional.” “I could see that living with aphasia does not mean that you have to stop living.”

JK – Strengths and Challenges Challenges communication needs impaired executive skills Strengths reading writing motivation education? familiarity with technology family support

JK – Current Status Participating in intervention to utilize a combination of EZ Keys and “Key Word Teaching” to lecture to her graduate classes. Continues to use EZ Keys to prepare lectures. Continues to negotiate support from department.

Client: RM 62-year-old education: 14 years retired airport manager left CVA occurred 1995 diagnosed with moderate aphasia and moderate- severe apraxia of speech

RM - Results

RM – AAC Trials

Message Behaviors

Device Usage - “Press Behaviors” “I like a cheeseburger and coke please.”

RM – Challenges and Strengths Challenges poor spelling unable to use word- based pages on device effectively resistant to change of relatively inefficient layout of device automaticity? familiarity? Strengths positive attitude about everything multimodal to the extreme willing to use device in public, on phone, as tool

RM – Current Status increase and enhance facilitative behaviors on device category-based word search word by word formulation decrease non-facilitative behaviors inappropriate topic setting device navigation participating in motor-based learning study to increase speech output acts as ambassador and community educator

E. Summing Up What did we learn?

“Salient” Subtests on CLQT

Categories of AAC Use JV AA and RC

Categories (cont.) MH and SA RM and JK

E.Summary: What did we learn? Clinician judgment (via AAC trials) differentiated independent from partner- dependent communicators. Test results verified these judgments. Potential “suspects” for determining outcome – likely a complex picture... AQ’s expressive writing task attitude toward AAC system cognitive tasks on CLQT

As always… Further research is warranted Your comments are appreciated Handouts: give us one week to post them on the ASHA website