1 Day 1 – Augmentative and Alternative Communication Strategies for Individuals with Aphasia * * * * * * * * * * * Morning: Introduction to AAC Strategies for People with Aphasia Categories of Communicators Afternoon Categories of Communicators Cont. Assessment Group Activity

2 Day 2 -- Integrated Communication Approaches to Individual and Group Aphasia Therapy * * * * * * * * * * * * Morning: Introduction to Integrated Therapy Models Pragmatic Functional Life Participation Supported Conversation Environmental Communication Therapy Teaching Communicators to Use Communication Skills and Strategies in Meaningful Contexts Individual Therapy Afternoon: Aphasia Group Therapy General Models/Other Models Nebraska-Pittsburgh Model Wrap-up and Discussion

3 I will emphasize treatment mostly for people with…. “global” aphasia symbolic deficits across modalities; cognitive decreases; severe motor “severe” aphasia with minimal expression (Severe Broca’s or TMA, some “less” global folks) but better comprehension than group 1 Individuals with a nonlinguistic disorder, such as perseveration or apraxia-of-speech, that interferes with functional communication to such a degree that they function well below their linguistic ability levels

4 The purpose of these talks is….

5 Part III: Assessment and Technique Selection

6 A. Goals of Assessment Identify underlying linguistic, pragmatic and cognitive-communication Skills With no context – true aphasia impairment (standard aphasia tests) With context – functional ability Match client skills to appropriate strategies Assess Communication Needs Assess Desired Participation Level and Activities Utilize a Criterion Assessment Strategy vs. Maximal Assessment (example).

7 B.Cognitive-Linguistic Factors in AAC Strategy Selection First, analyze the demands of everyday communication situations What are… The cognitive-linguistic demands of requesting a blanket (patient in hospital): The demands of talking about a movie with a friend?

8 Discussion – why aren’t AAC strategies always quickly adopted and used successfully by people with aphasia?

9 In aphasia, it’s not as simple as...  Substituting a novel symbol set:   for an impaired language system:  (“Great, I have mail!)

10 Aphasia disrupts the automaticity of information processing and language use in general And now add...

11 Additional Demands Posed by AAC Strategies l Physical Access (often nondominant limb) l Symbol Decoding and Encoding Skills l Message Encoding Skills l Working Memory l Operational Skills for Technology l Metacommunicative Ability  To USE strategies in dynamic situations  To ID need to use alternative strategy

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13 To think to TURN to an alternative strategy in the right situation and find the right symbols to convey the right message We’re asking people with aphasia to complete a METACOGNITIVE task when using many AAC strategies– especially those that don’t involve partner support

14 Aphasia = disruption of the automaticity of the language/ communication process + AAC = going outside of one’s own language system to communicate ______________________________ Clinical Challenge = teaching people w/ aphasia to use strategies effectively and naturally

15 Cognitive-Linguistic Analysis of: Access Demands Symbol Skills Memory Demands Metacognition Demands Call lightY if limb apraxia NoY – min/mod Y - min Yes/No boardY - minYY – minY - min 6-message VOCA to request/tell story Y - minYY - mod Written Choices NoY - minYes - episodic No Multi-level multisymbol VOCA Y - minY - modMax

16 What to do…??? 1) Match AAC strategies to communicators, considering their abilities (cognitive, language, motor, visual) and needs. i.e., Don’t expect an emerging (basic choice)communicator to initiate by pointing to a symbol-based VOCA Don’t ask someone who fits the profile of contextual choice communicator to combine symbols to create a novel sentence Multimodal, generative communicators will need strategies for spelling, drawing, using word prediction, etc.

17 2) Teach strategy use… component by component by modeling strategy use during real opportunities by embedding use of strategies within real-life situations as you go More to come on this approach to communication therapy in Part IV!

18 For a more detailed discussion of the cognitive- linguistic demands inherent in AAC and language-based communication activities, see… Garrett & Kimelman (2000). AAC & Aphasia: Cognitive-linguistic considerations. In Beukelman, Yorkston, & Reichle (Eds.) AAC for Adults with Acquired Disabilities.

19 Now, let’s engage in a diagnostic process to help us match appropriate AAC strategies to specific communicators…

20 C.Patient-based Capabilities Assessment 1. Categorical Assessment form (Garrett & Beukelman, 1992/1998; Garrett & Lasker revised 2004 ) 2. Multimodal Screening tool (Garrett & Lasker rev. 2004): symbol comprehension/association, use of multiple levels message complexity & symbol sequencing categorization spelling - first letter & whole word 3. Vision Screen 4. Standardized tools (RCBA, WAB subtests) Assess what you can't see – reading, comprehension Look more carefully at decontextualized performance 5.System Trials (Lasker & Garrett, 2004)

21 1.Categorical Assessment Form (Garrett & Beukelman, 1992, 1998; Garrett & Lasker revised 2004) See handout – Supplementary Outline and Materials packet p. ___ Will be available on-line at OR Beukelman & Mirenda (in press) AAC Strategies text: Aphasia Chapter (Brookes Publishing Co.)

22 The goal: Differentiate between people who require: Partner support/prelinguistic Partner support/emerging linguistic skills and intentionality Communicators who can learn to access prestored messages Self-initiated communicators Simple symbol systems Complex symbol systems/Generative communicators Special adaptations for specific environments

23 2. Multimodal Communication Screening Test: Score form p. _____or on-line at

24 Task 1: Symbol identification

25 Task 2: Categorization

26 Task 3: Combine Concepts

27 Task 4: Locate phrases on an environmentally-organized vocabulary page

28 Task 5: Communicate info locations by pointing on a map

29 Task 6: Communicate complex information by locating and sequencing symbols on Multiple Levels (pages)

30 Task 7: Storytelling

31 Task 8: Spell to convey novel information Important to assess in communicators who have potential ability to spell or write/i.e., generative communicators

32 Video example: Multimodal Screening Test in action

33 3. Vision screening

34 4. Standardized tests To assess impairment in decontextualized situations “Assess what you can’t see!” Reading (e.g., RCBA, Discourse Comprehension Test) Auditory Comprehension (WAB, Token) We’re beginning to use Cognitive Tests too – we’ll let you know which ones are useful Cognitive-Linguistic Quick Test Raven’s Progressive Coloured Matrices Wisconsin Card Sort Test

35 5. Systems/Strategy Trials Give it a whirl! (within contextualized activities, of course!)

36 Systems Trials (Lasker & Garrett, © 2004) Level A - Partner Dependent Task: Conversation Topics: 1)Autobiographical Info 2)Education about the Stroke 3)Goals in Therapy Strategies: Try written choice conversation Look at symbol skills

37 Systems Trials (Lasker & Garrett, © 2004) Level B - Single Message Users Task: Role Play Topic: Requesting coffee/tea Strategies: Model single message VOCA use in simulated role play with a ‘clerk’ -- “Small latte, please” Then ask communicator to try this with minimal to no cues.

38 Systems Trials (Lasker & Garrett, © 2004) Level C - Stored Message Users - 1 level Task: Role Play Topic: Getting a Haircut/Planning a Trip Strategies: Model VOCA use in simulated role play with a ‘clerk’. Communicate multiple messages (“haircut please”; shampoo; 1 inch”) from single level. Then ask communicator to try this with minimal to no cues.

39 Systems Trials (Lasker & Garrett, © 2004) Level D - Stored Message Users levels Task: Role Play Topic: Getting a Haircut/Planning a Trip Strategies: Model VOCA use in simulated role play with a ‘clerk’. Communicate multiple messages (“haircut please”; shampoo; 1 inch”) from level with basic messages and numbers level. Then ask communicator to try this with minimal to no cues.

40 Systems Trials (Lasker & Garrett, © 2004) Level E - Generative Communicator levels+ speech & gestures Task: Role Play Topic: Getting a Haircut/Planning a Trip Strategies: Model integrated VOCA and speech/gesture use in simulated role play with a ‘clerk’. Communicate multiple messages (“haircut please”; shampoo; 1 inch”) from level with basic messages and numbers level. Then ask communicator to try this with minimal to no cues.

41 Systems Trials (Lasker & Garrett, © 2004) Level F - Generative Communicator - Hi tech multi-level system etc. Task: Role Play Topic: Getting a Haircut/Planning a Trip Strategies: Model integrated VOCA and speech/gesture/ writing use in simulated role play with a ‘clerk’. Communicate multiple messages (“haircut please”; shampoo; 1 inch”) from level with basic messages and numbers level. Then ask communicator to try this with minimal to no cues.

42 Video Illustration Mary in a simulated “video store” role play

43 D.Partner Skills Assessment 1.Assess their literacy (informally) 2.Assess their vision and hearing skills 3.Assess their ability to anticipate and provide opportunities (by watching them interact, trying strategies) 4. Assess presence of non-facilitative communication skills Finishing sentences Guessing too quickly Asking just yes/no questions

44 E. Communication Needs and Context Assessment 1.Needs assessment – see form p. ___ 2.Identify Environments and Potential Participation Activities 3.Topics 4.Messages and Vocabulary

45 1. NEEDS ASSESSMENT

46 2.Topics/Vocabulary/Message Inventory See materials from Garrett, K., & Beukelman, D. (1992) AAC in the Medical Setting. K. Yorkston, Ed. Communication Skill Builders. See phrases from new book by Barbara Collier “See what we say – messages for adults”. Brookes Publishing company.

47 Comment Nice to invite families to complete this info gradually but steadily – especially during acute/early phase of recovery.