Kathryn L. Garrett, Ph.D., CCC-SLP Duquesne University, Pittsburgh, PA USA

1. 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 * * * * * * * * * * * * * * * * * * * March 6th & 7th, 2003 Newcastle-upon-Tyne, England, UK

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

3. 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

4. Emphasis mostly on 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

5. The purpose of these talks is….

6. Part III: Assessment and Technique Selection

7. A. Goals of Assessment! • Identify underlying language and communication skills • With no context – true aphasia impairment (standard aphasia tests) • With context – functional ability • Match client skills to appropriate strategies • Criterion vs. Maximal Dx

8. B. AAC Strategy/Device Selection: Cognitive-Linguistic Considerations • What are… • The cognitive-linguistic demands of requesting a blanket (patient in hospital): • The demands of talking about a movie with a friend?

9. In aphasia, it’s not as simple as... • Substituting a novel symbol set:* J • 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 • Physical Access (often nondominant limb) • Novel Symbol Translation Skills • Message Encoding Skills • Working Memory • Operational Skills for Technology • Metacommunicative Ability • To USE strategies in dynamic situations • To ID need to use alternative strategy

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. Group Analysis of:

16. What to do…??? • 1) Match AAC strategies to communicators, considering their abilities (cognitive, language, motor, visual) and needs • i.e., don’t expect a basic choice communicator to initiate by pointing to a symbol-based VOCA • Don’t ask someone who fits the profile of controlled situation communicator to combine symbols to create a novel sentence • Etc. 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!

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

19. 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.

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

21. C. Patient-based Capabilities Assessment • Garrett & Beukelman's (1992) Categorical Assessment form (see attached) • Multimodal Screening tool : symbol comprehension/association, use of multiple levels, message complexity & symbol sequencing (attached) • Spelling/Writing screening (First letter, whole word, generative writing) • Standardized tools (RCBA, WAB subtests) • Assess what you can't see – reading, comprehension • Look more carefully at decontextualized performance • System Trials

22. 1. Categorical Form • Pp.** and **– handout • Available from Garrett & Beukelman AAC Medical Setting (1992) chapter • OR Beukelman & Mirenda (1998) Aphasia Chapter

23. The goal: • Differentiate between who requires: • Partner support/prelinguistic • Partner support/emerging linguistic skills and intentionality • Self-initiated communication • Simple symbol systems • Complex symbol systems • Special adaptations for specific environments

24. 2. Multimodal Communication Screening Test: Score form p. 35 or on-line at http://aac.unl.edu

25. The goal: • Differentiate between who can: • Use simple symbol systems to request • Symbols represented on multiple levels to request, describe. • Manipulate symbols to communicate alternate meanings • Switch between multiple modalities

26. 3. Spelling screening • P. 34 and 35 of handout • Conduct as part of multimodal symbol assessment OR • Use 1st letter/whole word spelling inventory – especially if the individual is indicating they would like to use a regular computer for most AAC needs

27. 4. Vision screening

28. Video Illustration • Individual participating in multimodal assessment • Additional clips if time

29. D. Partner-based 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)

30. E. Communication Needs and Context Assessment • 1. Needs assessment – see form p. 36 • 2. Identify Environments and Potential Participation Activities • 3. Topics • 4. Messages and Vocabulary

31. 1. NEEDS ASSESSMENT

32. 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.

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

34. Part IV: Integrated Therapy Approaches

35. The issue… • How do we enable people with aphasia to participate once again in meaningful life activities? • Teach communicators to use AACandnatural communication strategies in a purposeful and understandable manner?

36. My hypotheses re: limited intervention outcomes in this population: * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * • Individuals with severe aphasia are the least likely clients to generalize communication targets that are taught: • in de-contextualized contexts • as “products” (e.g., sounds, symbols, words, gestures) vs. communication acts • Opportunities to use both AAC strategies and practiced speech targets must be embedded into contextual communication activities

37. This is not an entirely new philosophy • Let’s discuss some of the current therapy models that provide support for delivering therapy in a more integrated manner.

38. A. Introduction to Wholistic Therapy Approaches • 1. Pragmatic Approach • 2. Functional Therapy Approach • 3. Life Participation Approach • 4. Supported Conversation • 5. Environmental CommunicationTherapy

39. The “granola” approaches….

40. 1. Pragmatic Therapy ApproachPromoting Aphasic’s Communicative Effectiveness (PACE) • a. History: • Albyn Davis and Jeanne Wilcox promoted this approach in the 1980’s. • Thought that goal of tx was to improve patient’s ability to communicate in natural conversations. • However, felt that tx approaches to date had not corresponded with this goal. • Felt area of pragmatics (just emerging at that time) supported this alternative approach.

41. b. Description: • a formalized structure of interaction between the clinician and patient that incorporates elements of face-to-face conversation. Clinician and patient take turns sending new information to each other.

42. c. Research Basis: • Philosophical work of Searle, etc. • Child pragmatics research (important to focus on USE of language, not just the FORM) • Some efficacy studies exist comparing pragmatic tx to other tx approaches…

43. d. Populations: • all communicators with aphasia; however, must have some expressive ability and awareness of interactions.

44. e. Principles: • 1) The clinician and patient participate equally as senders and receivers of messages • 2There is an exchange of new info – this is done by keeping the sender’s message out of view of the receiver (pictures face down) • 3) Free choice of channels: (any modality at any moment – whatever works)

45. 4) natural feedback – the clinician’s feedback is based FIRST on communicative adequacy of the message. Only then may clinician provide feedback on the form of the message. Also, provide feedback in a sequence from general to specific. • 5) Emphasis is on the communication of meaning within a naturalistic context.

46. f. Selecting Treatment Stimuli: • 1) Choose pictures that depict specific relationships – for “barrier” communication tasks. Can buy some picture kits for this (see PACE kit, my pics) • 2) Design roleplays.

47. Sample P.A.C.E. Stimulus Pictures (Edelman, 1985).

48. g. Implementing the Treatment Task • see principles. • KG/student Demo • h. Feedback is supposed to be naturalistic (based on content) rather than direct correction of form. • i. Progress – see scoring system on your handout.

49. j. Summary of this approach: • Differs significantly from conventional stimulation approach: • Communication target is NOT predetermined • Clinician is not in total control of output • Focus is on the adequate communication of intent/meaning • Elicits initiations as well as responses • 5-point scoring system can apply to verbal AND nonverbal behavior (see handout) • In terms of clinical implementation, is MORE structured than the general participation philosophy

50. 2. Functional Approach • a. History: - 1980’s and 1990’s. • Systems theory took hold; rehab dollars became tighter. • b. Description: • Any activity that seeks to improve the patient’s reception, processing, and use of information pertaining to daily activities, social interaction, and expression of current physical and psychological needs. • Some consider it “task-focused”