AAC Resource for Individuals with Aphasia

CAYA, Revised December 2017– Tessa Lowis, Michelle Bunney, Tiffany Visser, Tara Commandeur, Monica Francella

This document is based on the AAC Aphasia Category framework by Garrett and Lasker (2005). The framework differentiates between two types of communicators with Aphasia: 1. Independent communicators: individuals who are able to independently initiate use of different communication strategies. 2. Partner Dependent communicators: Individuals who consistently depend on a partner to manage informational demands and provide communication choices within highly familiar contexts. These five assessment questions help us determine which category best describes the client: 1. Does the person with Aphasia (PWA) use unaided communication strategies (e.g., gestures, writing drawing)? If so, with what degree of cueing? 2. Are partner dependent strategies being used? (e.g. partner writing key words, providing choice of responses)

3. Can the PWA use external stored information/messages on a communication board? The Multi-Modal Communication Screening Task for Persons with Aphasia (MCST-A) can be used to assess this skill. Free download: https://cehs.unl.edu/documents/secd/aac/assessment/picture.pdf (stimulus book), and https://cehs.unl.edu/documents/secd/aac/assessment/score.pdf (score form)

4. Can the PWA access stored messages on a speech generating device? ‘Aphasia -Stored Message Assessment’ pages available in TouchChat through iShare: Go to Public Files > Adult > General Communication > Aphasia-Stored Message Assessment. 5. Can the PWA formulate/generate messages to communicate? These questions may be answered by observing the PWA and a partner in role play situations. Refer to the checklist below to determine which category best matches your client. Use the page for the specific category to guide your assessment and treatment. Consider using Talking Mats to assist with AAC system development (E.g. topic selection). Visit www.talkingmats.com for more information.

AAC-Aphasia Categories of Communicators Checklist Adapted from Garrett, K. & Lasker, J. (2005). Adults with severe aphasia. In D.R. Beukelman and P. Mirenda (Eds.) Augmentative and Alternative Communication: Supporting Children and Adults with Complex Communication Needs, 3rd edition. Baltimore: Brookes Publishing Co. Available at: http://aac.unl.edu.

PARTNER DEPENDENT COMMUNICATORS Communicator Type Skills Challenges Target Skill required for AAC Assessment Ideas Therapy ideas AAC Options – low tech / high tech Emerging Increased Poor comprehension EXPRESSIVE (*Multimodal) 1. Target those skills required for AAC at Low-Tech – Supported Communication this level to maximize life participation. Approach attentiveness to without visual or Ability to use gestures  BDAE -3: Praxis subtest Communicator tangible objects personal context E.g., (e.g., clothing), Inconsistent or Ability to draw  Informal – E.g., draw common  establish reliable yes/no Augmented partner input (with training) personal photos, or nonexistent signal for objects, faces, etc. response: learn to communicate  Gestures reminiscence items “yes” or “no” Ability to point to an object / photo  Object / photo/ symbol selection affirmation with a head nod and  Written key words  Emerging ability to May demonstrate /symbol given an array of choices to: given a verbal cue for a target refusal with a head shake Drawings  make a choice picture / symbol demonstrate emerging awareness of  to choose pictured items in the Specific context supports  direct care  Select a target object / photo/ (nonverbal) daily routine, but is easily context of a functional activity  Premade pages for the partner to  answer question symbol to answer a question acceptance or confused by changes in (e.g. choosing items in grooming use for:   Select a target object / photo/ rejection of a the routine or new assist with identifying direction routine) . Choice of activities symbol to complete a carrier tangible choice events of conversation (topic) . Directing personal and phrase (spoken / written) 2. Communicate affirmation and refusal Looks up when No functional speech or medical care E.g. MCST-A: Section A (e.g. head nod/shake), symbols to greeted gestures . Participation in games RECEPTIVE (*Multimodal)  represent affirmation and refusal) Takes objects and Yes /No questions using personally . Writing letters Reliability of yes / no returns them to relevant or context bound 3. Modeling yes/no responses – gestural . Financial management  thumbs up/down command within questions responses (eg. Head nod/shake) in . Etc.  familiar routines pointing to written cues supported conversation **training partners is key Family scrapbook / visual scenes (low READING / WRITING tech / high tech) to assist with retelling of Word recognition an asset  Picture word matching 4. Focus on Partner Assisted family events Communication / Supported Conversation SYMBOLIC ABILITY  Assess ability to associate meaning Training Simple conversational scripts using Typically limited with objects, photos, picture modality available to client (e.g. personal symbols 5. Increase attention to visual supports (e.g. photos, gestures, eye gaze) PRAGMATIC cards, tic tac toe) Scripts for Social situations  Assess ability to take turn in Boogie board/white board 6. Conversational Group  Greetings conversation

 Responses  Eye contact 7. Functional role plays to practice using the Mid to High-Tech AAC  Carrier phrases with a choice low tech solutions set up to support LINGUISTIC OPERATIONAL Partner Assisted Communication. None Recommended CONSIDERATIIONS  Assess ability to attend to stimuli Typically limited presented, recall information with 8. Conversation scripts, E.g., greeting and repeated teaching through response sequence informal observation 9. Games to target turn taking COGNTIVE COMPONENT Attends to Environmental supports  Do they respond to environmental 10. Practice copying/ writing the names of provided by partner supports E.g., use of photos objects (select objects that will be used  written supports, pictorial cues, illustrating communication on a daily basis and can be used to assist gesture cues, object cues locations and activities for with directing care etc) scheduling

PARTNER DEPENDENT COMMUNICATORS Communicator Type Skills Challenges Target Skill required for AAC Assessment Ideas Therapy ideas AAC Options – low tech / high tech Contextual Some attempts to Speech or gestures are EXPRESSIVE (*Multimodal) 1. Teach key partners: Low-Tech – Supported Communication communicate via minimally Ability to indicate a choice by  Select a target word given verbal cue  To use augmented input strategies Approach Choice natural modalities comprehensible pointing if visually presented,  Select a target word to answer a when needed Can clearly indicate Generate little Ability to indicate a choice with question given a choice of 3-4 words  Respond to all communication modes Augmented partner input (with training) Communicator  an answer or information on their gesture / vocalization if presented  Select a target word to complete a and interpret communication Gestures  preference by own auditorily carrier phrase (spoken or written attempts Written key words  Drawings pointing to a choice Seldom initiates, even Ability to point to a word given a list   Use tagged yes/no questions Informal observation  To use written choice conversation of by pointing or of choices to make a choice /direct  MCST-A, response to written choice Notebooks for use in supported objects, pictures, or vocalizing care/answer question/assist with technique strategy interactions large print written Poor comprehension of identifying direction of conversation  BDAE – 3, WAB, informal 2. Teach communicators  Strategies: Written choice, rating words decontextual auditory (topic) observations  to reference their topic by pointing, scales to communicate opinion, Can participate in information (e.g., RECEPTIVE (*Multimodal) gesture preferences, and qualitative multi-turn commands, questions  Comprehension of written words, Assess ability to answer personally  Turn taking in conversation with responses and augmented partner conversations given that do not pertain to picture or other visual symbols in relevant yes/no questions gestures, written key words, input partner supported events in the present shared context  Assess ability to provide response drawings and a list of choices  Instruction card for notebook strategies (written and/or personally when written choice technique used  meaning of graphic symbols cover describing strategies choice, tagged yes- relevant information)  BDAE-3, MCST-A  reliable yes/no response (gesture, no questions, Family scrapbook / visual scenes (low READING / WRITING pointing, verbal) augmented tech / high tech) to assist with retelling of Recognize a word in context  Assess ability to match pictures to  how to indicate choice in response to comprehension) family events Read at the word or phrase level in words, and understand written questions Confirms or selects context words/phrases in context  to initiate/ask questions by pointing topics of interest Remnant Communication book Identify the first letter of a word  Assess ability to spell for or through verbalizations, gestures Clearly aware of containing personally relevant communication  To visually attend to partner’s daily routine (e.g., information, photos, mementos  First letter of keyword/word/phrase augmented input tries to get shoes  RCBA, WAB  To confirm whether message Premade pages for the partner to use for: on before therapy) SYMBOLIC ABILITY understood  Social etiquette phrases Augmented partner Understands a symbol can represent  Assess symbolic ability - what level of  To show new partners any instruction  Choice of activities input and support a word or concept representation client can use (i.e. cards provided  Directing personal / medical enhances objects, photos, picture symbols, care comprehension text) 3. Identify preferred/familiar topics  Participation in games

 TASP, MCST-A, subtests from the  Writing letters 4. Identify key partners, and assess current  Financial management, Etc. BDAE-3, WAB, AAC Evaluation Genie conversational supports used by key

PRAGMATIC partners Social competence - Initiating  Informal observation Boogie board/white board conversation 5. Target conversational exchange Ability to confirm comprehension or  Assess informally in conversation; (greetings), sharing personal and Mid to High-Tech

signal lack of comprehension through role play breakdowns and repair biographical information Single message button, step-by-step for gesture or verbalization sequences  Teach client to initiate greetings, introductions LINGUISTIC OPERATIONAL CONSIDERATIION communication Ability to locate vocabulary in  Assess ability to categorize iPad: Supported use of Communication 6. Anticipation shelves (calendar boxes), communication book and/or level of vocabulary (ex. TASP –Categorization Apps communicator learns to associate an support required with navigation Subtest, AAC Evaluation Genie,  TouchChat Communication MCST-A) object with an activity  Sort objects or pictures cards into Journey Aphasia with COGNTIVE COMPONENT different buckets/piles (animals, customized/simplified page set Awareness of daily routines and  Assess informally (e.g. family foods, transportation, etc) schedules interview)  Sounding Board app Ability to navigate between pages in 7. Category Therappy App a system

PARTNER DEPENDENT COMMUNICATORS Communicator Type Skills Challenges Target Skill required for AAC Assessment Ideas Therapy ideas AAC Options – low tech / high tech Transitional Can access Requires constant EXPRESSIVE (*Multimodal) 1. Group language therapy Low-Tech – Supported holophrastic cueing to think to Ability to respond to questions by  Ability to categorize (context-based ‘world’ Communication Approach Communicator messages on a access stored gesture/symbols/text  Determine word class ability (noun, verb etc) news/social chat) with access board or device messages Ability to categorize personally relevant  Picture Description tasks that range in to various AAC supports Wallet communication book with cues Requires constant information complexity from N+V, N + Adj, Prep +N, V+O, organized categorically but with

Can shift cueing to use Ability to link two items with a model (noun + N+V+O, done with different supports/devices, 2. Partner training- Partner less vocabulary than a book

modalities with alternate modes of verb or noun+ adjective) “What’s wrong picture?”, picture description Assisted Communication (with focus on modeling/cueing Introduction card cues communication Ability to use a higher level of response to yes / within barrier task with visual supports) Can initiate a Unable to repair  no questions (i.e., something else / you are on Assess ability to identify letters, and recognize Communication book with or partial message conversation the right track / you are on the wrong track) common sight words 3. Conversational turns (basic without basic Core Vocab; on occasion and breakdowns Ability to point to / write the first letter of a word  WAB, “What’s wrong picture?” level script training?) categorically organized in specific independently for first letter cueing  TASP, AAC Genie contexts, but Does not initiate RECEPTIVE (*Multimodal) 4. ORLA (introductory level) Communication board with single symbol to convey a whole requires support questions, but may Comprehend basic verbal and/or written  Auditory comprehension of sentences with and to communicate a initiate requests for 5. Possibly Constraint Induced message information without visual cue complete physical needs or Language Therapy (e.g.,  Ability to follow 1-3 step directions Tangible topic setters (objects, message comment without produce S + V or V + O with  Ability to identify time and use functionally photos, remnants) Can request by cues cueing) o Day of the week /Time of day/Season pointing or Uses mostly o Yesterday / today / tomorrow 6. Practice ‘sentences’ using Boogie board/white board vocalizing automatic speech, if  Ability to direct finances communication board or book Can greet or any o Identify word/symbol/photo for specific produce gestural – modeling support bank, cheque book, money Mid to High-Tech or spoken word READING / WRITING 7. Introduce self with low or high responses in Recognize personally relevant text  Reading comprehension – picture/word Static displays: Go Talk 9 tech AAC strategy automatic social matching, phrase/picture matching, sight words iPad/tablet: Supported use of conversation Ability to write a single word to:  Ability to copy/write/type the names of objects 8. Practice answering predictable Communication Apps  direct care (select objects that will be used on a daily basis questions (e.g.  TouchChat  answer question and can be used to assist with directing care etc) autobiographical, topical) by Communication Journey  assist with identifying direction of  WAB, APAR, CADL, RBCA searching for and selecting Aphasia conversation (topic)  prestored messages on a TouchChat – Aphasia SYMBOLIC ABILITY  Determine visual discrimination in fields of 2, 4, Navigation ring layout Speech Generating Device Recognize personally relevant symbols /photos 6 + (available in iShare-Public  TASP, AAC Evaluation Genie, or informally with (SGD) Files-Adult-General symbols or other visual supports Communication) 9. Practice telling simple stories PRAGMATIC  Sounding board app Signal communication partner to initiate  Observation by activating sequential communication messages on an SGD. Signal a communication breakdown Take turns in conversation Shift modalities LINGUISTIC OPERATIONAL CONSIDERATIIONS Working memory  Observation Level of cueing required (phonemic, word lists, drawing, gesture, symbols) Navigation ability - Number of levels on a display COGNITIVE COMPONENT Memory and attention sufficient for  Assess Attention/ Memory/ Sequencing/ Social navigational pathways Communication AAC-Aphasia Categories of Communicators Checklist Adapted from Garrett, K. & Lasker, J. (2005). Adults with severe aphasia. In D.R. Beukelman and P. Mirenda (Eds.) Augmentative and Alternative Communication: Supporting Children and Adults with Complex Communication Needs, 3rd edition. Baltimore: Brookes Publishing Co. Available at: http://aac.unl.edu.

Independent Communicators Communicator Type Skills Challenges Target Skill required for AAC Assessment Ideas Therapy ideas AAC Options – low tech / high tech Stored Initiates May require support to EXPRESSIVE (*Multimodal) 1. ORLA (transition to phrase and sentence Low-Tech communication effectively complete a Communicative intent (motivation to  Can they combine 2-3 symbols with level). May be able to manage Message without support communication communicate a message) support? ‘homework’ Communication book/board Independently message Compositional ability  Informal observation (are they  with or without Core Vocabulary to Communicator locates messages Attempts to utilize Categorization ability motivated to communicate?) 2. Constraint Induced Language Therapy work on sentence composition  that have been alternate modalities to  TASP, AAC Evaluation Genie (e.g., S + V + O) categorically organized pages with

stored in advance augment unintelligible symbols and a label/phrase RECEPTIVE (*Multimodal) 3. Practice sentences with visual supports in by others speech are not always Comprehension of verbal information  Informally: following commands, the form of text or symbols Wallet-communication book with key May occasionally effective following a conversation vocab for daily contexts produce Attempts to clarify or  WAB, TASP (understanding 4. Conversational scripts (personally meaningful spoken elaborate stored directions) relevant, contextually rich vocabulary to Boogie board/white board words or phrases, messages are usually READING/ WRITING support utilization). Use communication May occasionally unsuccessful Ability to read at the word /phrase /  Assess Reading Comprehension: book/board/system to assist (with communicate Cannot independently sentence level complexity, comprehension of text cueing) Mid to High-Tech portions of ideas by spell or combine words Ability to supplement message with with/without a symbol writing or using to generate novel 5. Response Elaboration Training (ERT) Static displays i.e. Go Talk 9 writing occasionally.  phrase/sentence-word matching symbolic gestures messages  RCBA, WAB, BDAE-3 6. Melodic Intonation Training (MIT) iPad/tablet: Supported use of Aware of SYMBOL Communication Apps communication Symbolic knowledge – size, word  informally, with symbols or other 7. Communication Group breakdowns but  TouchChat Communication classes (nouns, verbs, etc.) visual supports Journey Aphasia unable to repair  Determine how many symbols/words successfully  TouchChat app w/ Wordpower 20- the client can manage per page (e.g., 42 6, 8, 12, 24 +)  Compass Stroke and Brain injury  TASP, AAC Evaluation Genie persona page set by Tobii- PRAGMATICS Dynavox Signal topic of conversation  Observation (https://www.mytobiidynavox.co Signal communication breakdown m/support/downloads) and need for assistance to repair it o Customize/simplify lay-outs so LINGUISTIC OPERATIONAL that there are not too many CONSIDERATIIONS levels/pages Ability to locate stored phrases (in  Ability to learn and remember the appropriate category) navigational patterns to find stored Ability to navigate levels of a device phrases (2/3 levels) Ability to navigate a communication book (through colour coding or words /symbols on tabs)

COGNTIVE COMPONENT Memory and attention sufficient  Assess Attention/ Memory/ for navigational pathways Sequencing/ Social Communication

Independent Communicators Communicator Type Skills Challenges Target Skill required for AAC Assessment Ideas Therapy ideas AAC Options – low tech / high tech Generative Independently May require training to EXPRESSION 1. Role play demanding situation for Low-Tech combines a variety learn when to use AAC Ability to code-switch between  Informal: ability to communicate in communication Message of modalities strategies effectively modalities, and use a variety of unexpected situations Tabulated communication book with core Communicator and/or message May require more time means to get message across  WAB: Spontaneous Speech/AAC use 2. Practice using AAC in real-life contexts, and fringe vocabulary components to to complete  WAB: Picture Description task with a new person or new situation create new communication COMPREHENSION Boogie board/white board messages attempts Ability to understand conversation  Informal: ability to follow 3. Role play – the communication partner Independently May require training on between 2+ people, conversation in small group purposely sabotages the conversation to Mid to High-tech: navigates to the use of voice-output Ability to understand questions that  WAB: Auditory Verbal create a breakdown. multiple locations device or other are out of context Comprehension iPad/tablet: Supported use of in a communication symbolic  WAB: Sequential Commands 4. Teach skills for repair: request for Communication Apps system to retrieve communication mode READING / WRITING repetition, rephrasing, addition of  TouchChat Communication appropriate Communication Recognize items through whole-word  APAR: phonological or whole-word context/gestures. Journey Aphasia messages breakdowns continue or phonological strategies reader, RCBA, WAB, BDAE-3  TouchCHat w/ Wordpower20+  May utilize several in highly demanding PRAGMATICS 5. Identifying correct vs incorrect sentence TouchCHat w/ iEssence structure (verbally? using device?)  Predictable App steps to produce a or unfamiliar Communicating in unfamiliar or  Informal: observe ability to  Verbally App single message communication stressful situations recognize/repair breakdowns  Compass Stroke and Brain (e.g., symbol contexts Reliable recognition of breakdowns injury persona page set by sequences, word and repair of breakdowns prediction, spells Tobii-Dynavox series of letters) SYMBOL (https://www.mytobiidynavox Uses stored Able to use variety of symbol  Informal: Able to identify new .com/support/downloads) messages types/sizes symbols on a display independently in  TASP: Symbolic level predictable LINGUISTIC OPERATIONAL CONSIDERATIIONS situations when Ability to navigate multi-level layout rapid Ability to link 5+ items independently Informal: Picture Description task (N+ communication is Ability to link items in grammatical V+O, Adj + N+V etc) needed order, but not necessarily including TASP: Sentence Construction Can sometimes grammatical morphemes AAC Genie: Picture Description communicate by Ability to use categories MCTS-A drawing schematics, maps, objects Recognizes errors and breakdowns and is sometimes successful at repair COGNTIVE COMPONENT Memory and attention sufficient  Assess Attention/ Memory/ for navigational pathways Sequencing/ Social Communication

Independent Communicators Communicator Type Skills Challenges Target Skill required for AAC Assessment Ideas Therapy ideas AAC Options – low tech / high tech Specific Need Has indicated a May require emotional EXPRESSION 1. Identify specific situations and specific Low-Tech need to perform and linguistic support Manages communication effectively  Identify specific desired participation messages. Communicator a specific to participate fully in in most situations using context/communication need Augmented input as needed: communication unfamiliar situations speech/gestures/writing  Assess requirements of specific 2. Develop a script for that situation. If  Written Choice Conversation task more as a communicator communication task and unable to verbalize the script move to a  Communication boards/books efficiently with aphasia communicator’s ability to manage basic stored message device.  Lists/wallet size cards for specific

In specific COMPREHENSION situations (eg. Grocery shopping, 3. Identify level of cueing needed bank transactions, medical appts) contexts or life Ability to select a target response  Determine minimum size of button  Partner-training on question-asking situations, from an array of choices. for choices 4. Teach use of tool/strategy for specific selectively uses and conversation strategies  Determine maximum # of items per context through role play

AAC page. Scaffolded writing supports (E.g. email, 5. Provide opportunities to use the AAC systems/strategie PRAGMATICS letters, greeting cards) system developed for each specific s to communicate Demonstrates awareness of situations  Assess whether communicator needs  Multiple choice letter format component. messages where AAC is needed partner support to utilize AAC  Blank letter format  Practice with situational questions May fall into strategy  List of phrases and role play for the specific situation either LINGUISTIC OPERATIONAL CONSIDERATIIONS  Cue cards  Accompany to the specific situation independent or Ability to navigate to the target  Determine how many layers can be dependent overlay for the specific situation on a managed to navigate to the target to model / cue. Boogie board/white board classifications dynamic screen. i.e., how many hits? 6. Identify key partners who can assist with Ability to navigate to the target area  Determine whether label or picture or identifying specific needs and developing for a specific situation on a sliding label/picture combination is needed message inventory Mid to High-tech: screen (iPad). to locate target area. Ability to select the target wallet size  Determine how many choices are 7. Involve partner for support if needed Basic stored message device, i.e. Go Talk 9 card to present in a specific situation. managed.  Create page overlays for specific  Determine whether label or picture or context, i.e. phone conversation label/picture combination is needed  Train partners to ask questions that to assist with selecting the target allow for a response available on the wallet card for a specific situation overlay

COGNITIVE COMPONENT iPad/tablet: Supported use of Memory and attention sufficient  Assess Attention/ Memory/ Communication Apps for navigational pathways Sequencing/ Social Communication  TouchChat Communication Journey Aphasia (with pages made to convey a sequence of messages i.e. as required during community transaction or phone call)  Compass Stroke and Brain injury persona page set by Tobii-Dynavox (https://www.mytobiidynavox.com/ support/downloads) o simplify layouts to minimize levels/pages

References

1. J.P. Lasker, K. L, Garrett, & L.E. Fox (2007). Severe Aphasia. In D.R. Beukelman, K.L. Garrett, & K. M. Yorkston, Augmentative Communication Strategies for Adults with acute or Chronic Medical Conditions, (p. 163-206). Baltimore, Maryland: Paul H. Brooks Publishing.

2. K.L. Garrett & J. P. Lasker (2013). Adults with Severe Aphasia and Apraxia of Speech. In D.R. Beukelman & P. Mirenda, Augmentative and Alternative Communication – Supporting Children and Adults with Complex Communication Needs, (p. 405-445). Baltimore, Maryland: Paul H. Brooks Publishing.

3. K.L. Garrett & D.R. Beukelman (1992). Augmentative Communication Approaches for Persons with Severe Aphasia. In K. M. Yorkston, Augmentative Communication in the Medical Setting, (p. 245- 338). Austin, Texas: Pro-Ed.

4. K.L, Garrett, & J. Lasker. The Multimodal Communication Screening Task for Persons with Aphasia, MCST-A, 2005. https://cehs.unl.edu/documents/secd/aac/assessment/picture.pdf (stimulus book), https://cehs.unl.edu/documents/secd/aac/assessment/score.pdf (score form)

5. H. Goodglass, E. Kaplan, B. Barresi. Boston Diagnostic Aphasia Examination – 3rd Edition, 2000.

6. T. Iacono, & L. Cupples. Assessment of Phonological Awareness and Reading (APAR), Version 1.14, 200-2002. http://www.elr.com.au/apar/

7. A. Holland, C. Fratali, D. Fromm (1999). Communication Activities of Daily Living (CADL)

8. L. Cherney. Oral Reading for Language in Aphasia with virtual therapist (ORLA). http://www.bltek.com/virtual-teacher-side-menu/orla.html