Strategic Use in Context: AAC, Supported Conversation, and Group Therapy Interventions for People with Severe Aphasia Kathryn L. Garrett, Ph.D., CCC-SLP Duquesne University, Pittsburgh, PA USA * * * * * * * * * * * * * * * * * * * May 24th and 25th, 2004 Stockholm, Sweden

2 Support provided by: Karolinska Institutet Swedish Aphasia Organization (Afasiförbundet) Swedish Association of Speech Pathologists (SLOF) Inger Gillholm, Conference Coordinator

3 Pittsburgh Pennsylvania Sweden P O N D

4 Pittsburgh, PA

5 Duquesne University

6 My Background Pennsylvania Nebraska Ainsworth – Highway 20, ESU #17 University of Nebraska-Lincoln Madonna Rehabilitation Hospital University of Nebraska-Lincoln Pittsburgh, PA University of Pittsburgh Duquesne University

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8 From Nebraska…

9 To Pittsburgh…

10 …to Stockholm

11 Day 1 – Augmentative and Alternative Communication Strategies for People with Aphasia * * * * * * * * * * * Morning: Part I: Introduction to AAC Strategies for People with Aphasia Part II: Categories of Communicators Afternoon Part II: Categories of Communicators Cont. Part III: Assessment/Cognitive-Linguistic Considerations Group Application Activity

12 Day 2 -- Part IV: 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

13 Part I: Introduction “The context of developing effective communication interventions for people with severe-profound aphasia”

14 Aphasia: an impairment of the ability to use or understand language, usually acquired as a result of stroke or head injury (from NAA definition)

15 A. How many individuals have severe aphasia (U.S.)? 400,000 strokes per year in the U.S. (National Aphasia Association) Of the individuals who survive stroke, approximately 20% (80,000/year) have aphasia (NAA, Wolf, Kannel, & McGee, 1986) 1 in 275 individuals have aphasia Approximately 10-40% of individuals with aphasia demonstrate chronic severe aphasia (Collins, 1986; Poeck et al. 1984)

16 Kauhanen, 1999 Finnish dissertation study on depression and aphasia involving 31 patients 1/3 of all patients with stroke etiologies in the initial subject pool had aphasia 2/3 of the 31 patients with aphasia had moderate-to-severe aphasia initially (~20) However, 74% of this group of 31 did demonstrate significant improvement or resolution of aphasia. No comprehensive studies on incidence of aphasia world-wide.

17 Not only are we concerned with severe-global aphasia... Approximately 70% of all people with aphasia felt that people avoided contact with them because of difficulty with communication (National Aphasia Association Survey, 1987)

18 Steve: age 70, AQ = 30, 2 years post onset, Broca’s-type aphasia, telegraphic speech only

19 How many of you have people with severe, chronic aphasia on your caseloads? How long post onset? What proportion of aphasia cases? Typical management/status at 1 year post? 2 years post?

20 B.Competencies and Challenges in Severe Aphasia People with aphasia have intermittent linguistic/symbolic competence as well as deficits People with aphasia have intermittent nonlinguistic competence (gestures, drawing, writing, intent to communicate)

21 However, competencies and challenges co-occur on a moment- by-moment basis in aphasia, making it difficult to… Predict when breakdowns AND successes will occur “Fix” the problem permanently The “Short Circuit” Model

22 Intermittent, but persistent breakdowns occur at the level of symbolic processing and...during the completion of sequential cognitive-linguistic events  IDEAS “SHORT CIRCUIT” ON THEIR WAY TO A COMMUNICATION TARGET

23 Illustration: Aphasia Hope.org *********

24 They have prior knowledge of how communication works a.k.a. pragmatic knowledge (Holland, 19982; Sarno, 1969) They have a tremendous storehouse of world knowledge derived from a lifetime of experiences vs. developmental vocabulary and topics seen in child language interventions and materials

25 But… They also tend to be frustrated… At the loss of access to communication opportunities With the change in family or social roles With the loss of individualism and independence With the rate of recovery

26 Video - Neil Attempting to have a conversation with Christy, our secretary unfamiliar partner both participants do not have shared, mutual knowledge of possible communication strategies Does this reflect a typical exchange with a nonspeaking person with aphasia (PWA?)

27 C. Traditional Therapy Models in Severe Aphasia Emphasis on speech “Stimulation” approaches Decontextualized vs. Contextual Therapy

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29 Outcomes for our patients with severe aphasia…. Survey

30 What happens to people with severe aphasia in the traditional treatment phase? The perception is that recovery of “speech and language” isn’t enough to justify continued tx –- particularly when agencies are under time constraints to achieve functional and visible change. Therefore patients are quickly discharged (U.S. only?) OR, even if direct therapy is somewhat successful, people with aphasia simply don’t learn to use “piecemeal” words and phrases outside of rote, clinical contexts.

31 D. Alternative (Contextual) Therapy Approaches 1.Pragmatic Approaches 2.Functional Approaches 3.Supported Conversation Approaches (Kagan, 1998) 4. Augmentative and Alternative Communication (AAC) approaches

32 a. Definitions of Augmentative and Alternative Communication (AAC) An area of clinical practice that attempts to COMPENSATE for the impairment and disability patterns of individuals with severe expressive communication disorders (paraphrased from ASHA, 1989) AAC interventions are often MULTIMODAL in nature (i.e., involve the individual’s full communication capabilities, including any residual speech, vocalizations, gestures, signs, and aided communication strategies)

33 b.Candidacy for AAC Strategies in Aphasia: 1) those persons who find speech inadequate or inefficient in certain instances, or... 2) those persons who do not regain sufficient natural speech for communication of basic needs (after Hux, Beukelman, & Garrett, 1994). Inclusive vs. Restrictive Candidacy Criteria

34 c. Early AAC interventions in severe aphasia -- results and analysis Symbol/Modality replacement approaches Amerind (Skelly) VIC (Weinrich & Steele) Blissymbols

35 Very few communicators learned to use symbols (i.e., a replacement for speech) in a generalized manner outside of brief, structured clinical tasks Large repositories of alternate symbols were not accessed Kraat (paraphrased): “….it is if people with aphasia cannot think to turn outside of themselves to use these alternate symbols…”

36 My theories…. PWA have a reduced cognitive-linguistic resources to learn a new symbolic language code Overlay of aphasia and neurologic damage interferes with PWAs’ ability to consciously communicate through novel modalities (without being specifically taught to do so) It is not as simple as giving someone a replacement device for their “damaged speech system” Stories from the past……

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38 Dr. D - video with replacement AAC system (optional) Analysis

39 d.Useful AAC Principles Utilize the Participation Model (Beukelman & Mirenda, 1998) vs. the Medical “Fix it” model Decrease the emphasis on viewing therapy’s goal as strengthening the subskills of communication (e.g., motor movements, the ability to repeat words, ability to follow commands) PARTICIPATION Instead, ask “How can we increase this person’s PARTICIPATION in meaningful adult activities?”

40 Emphasize the communication of meaning and intent Capitalize on the residual strengths of the individual Provide communication opportunities

41 Include communication partners in the intervention View communication as a multimodal process, a package of “whatever works” strategies including AAC techniques, technology, and natural speech

42 View the goal of communication as more than conveying needs and wants (e.g., more than asking for a blanket) Light (1988) Needs and Wants Information Transfer Social Closeness Social Etiquette

43 What does this mean for us? Many persons with aphasia, regardless of severity, can increase their participation in meaningful communication activities despite insufficiency of natural speech Examples: saying a prayer at Thanksgiving dinner, introducing self at cocktail party, answering conversational questions about an election, ordering pizza on the phone

44 Dr. D. and his family discussing the Boston Celtics and recent economic downturns