Lasker, Garret, Fox (2007)
Lasker, Garret, Fox (2007)
Lasker, Garret, Fox (2007)
References
Focus on Divisions
Sonya is a 72-year-old retired accountant who had a large, lefthemisphere stroke one week ago. She is currently a patient in an
acute-care hospital. She was unresponsive for three days after
her stroke, but now she seems to recognize her husband and
family members. She produces undifferentiated sounds without
specific words, but she is not able to respond to questions or
communicate her needs. She cannot answer yes/no questions
and seems confused when people talk to her.
Mary Ann is a 56-year-old homemaker who has been
participating for two weeks in speech-language treatment in an
inpatient rehabilitation hospital. Her expressive and receptive
language skills are severely impaired due to aphasia. She attempts to communicate with a few
isolated words ("yeah," "but") and vague gestures. She matches pictures to words with about 70%
accuracy. Her husband is very frustrated when he tries to understand her in conversation.
Hernando is a 62-year-old retired mechanic who lives in an assisted living facility. He had a lefthemisphere stroke four years ago. His pattern of speech is characteristic of moderate Broca's
aphasia with significant apraxia of speech. Conversation with Hernando is difficult because his
communication attempts are fragmented and incomplete. His speech is limited to phrases of one or
two words that often contain paraphasias, and he searches his pockets and wallet for scraps of
information to help him during conversations. At times he tries to write to convey ideas, but
frequently misspells words.
Sonya, Mary Ann, and Hernando represent clients with aphasia who might be seen by speechlanguage pathologists working in intensive care, acute-care hospitals, inpatient and outpatient
rehabilitation hospitals, and assisted living facilities. Aphasia is an acquired language impairment
that occurs typically as a result of left hemisphere stroke. Although traditional speech-language
treatment improves speaking and listening skills for many people with aphasia (Holland, et al.,
1996; Wertz et al., 1981), some individuals live with severe and persistent communication
challenges. Augmentative and alternative communication (AAC) offers specific strategies to help
people with severe aphasia communicate more effectively in their current communication settings,
as they make the transition through care in a hospital, in rehabilitation centers, and at home.
Defining AAC
AAC for people with aphasia goes beyond "talking boxes" and picture boardsit is a
comprehensive collection of communication strategies that provide external support for people who
cannot understand or generate messages on their own (Garrett & Lasker, 2005). A recent ASHA
knowledge and skills document (ASHA, 2002) defines AAC as "a set of procedures and processes
by which an individual's communication skills (i.e., production as well as comprehension) can be
maximized for functional and effective communication" (ASHA, 2002, p. 2).
An AAC treatment approach means focusing on communication and participation rather than on
recovery of speech alone. This type of treatment may feel unfamiliar to clinicians who typically
employ "stimulation" models of aphasia treatment. In this article, we respond to the most common
clinical questions about how to assess and treat these unique clients using an AAC framework. In
addition, we direct clinicians to more detailed resources related to aphasia and AAC.
are referred to Lasker, Garrett, & Fox (2007) for a thorough discussion of the AAC-Aphasia
Assessment protocol. Assessment materials may be downloaded from the AAC Web site.
Emerging/Contextual Communicators
For communicators in acute-care hospital or rehab settings like Sonya, described above, partners
play an important role in supporting effective communication. SLPs may implement several
graphically based strategies with these individuals and their communication partners, but two of the
most powerful conversational tools are Augmented Input (Garrett & Beukelman, 1992, 1998;
Sevcik et al., 1991; Wood et al., 1998) and the Written Choice Conversation Strategy (Garrett &
Beukelman, 1992, 1995; Lasker et al., 1997).
Partner-Dependent Strategy #1: Augmented Comprehension (Input) Techniques
For people with aphasia who have poor comprehension, communication partners can supplement
their spoken language by gesturing, writing key words, or drawing. This set of strategies, called
"augmented input" or "augmented comprehension" strategies, can be implemented whenever the
communicator with aphasia is having difficulty comprehending conversational questions,
comments, or instructions.
The communication partner first identifies that the communicator has misunderstood after carefully
observing the person's blank facial expression, ambiguous head nods, or incorrect responses. The
partner then reiterates the message while simultaneously using one or more augmented input
strategies. The partner may point to the item being discussed; gesture symbolically (e.g., throwing
hand over shoulder to indicate "away from here"); pantomime an event; show photographs,
drawings, or other diagrams; or write key words and topics.
Partner-Dependent Strategy #2: Written-Choice Conversation
This technique requires the facilitator to generate written key-word choices that relate to a
conversational topic. The person with severe aphasia participates by pointing to the choices, thereby
making his or her opinions and preferences known. Partners can ask basic social or medical
questions (e.g., "Who visited this weekendyour husband, daughter, a friend, or no one?" or "What
do you needblanket, pain medicine, or TV?").
Questions also can be highly specific, particularly if they pertain to personal memories, beloved
hobbies, or detailed knowledge associated with a past career. When facilitators present a sequence
of related questions, interactions lengthen and communicators can discuss topics in greater depth
than when the strategy is not used (Garrett, 1993). Variants of the written-choice conversation
approach include presenting choices in the form of points on a rating scale or locations on a map.
Transitional Communicators
A person such as Mary Ann may best be classified as a transitional communicator according to the
AAC-Aphasia taxonomy. Like many other people with aphasia who may be in the rehabilitation
stage of recovery, she demonstrates improved awareness, comprehension, automatic speech, and
desire to communicate.
Transitional communicators, however, have significant speech-language production deficits (e.g.,
apraxia of speech, anomia, encoding breakdowns) that mask their desire and ability to converse. In
addition, they may not yet have the cognitive ability to initiate use of communication systems
inefficient, but they are persistent communicators who will try anything to convey their message.
With independent communicators like Hernando, the following AAC strategies can be effective.
Independent Strategy #1: Stored Message Retrieval Strategies
Communicators first can learn to access symbolized pre-stored messages within simple, scripted
routines such as calling for assistance over the telephone with an SGD. Supported by a
communication card, wallet, or SGD, they can practice introducing themselves to others in a group.
When asked a question in conversation, they can learn to search for responses from previously
answered written choice questions, a simplified communication notebook, or a single display on an
SGD containing life stories symbolized with photographs.
Independent Strategy #2: Multimodal Communication
Some people with severe aphasia who can spell and/or combine symbols (pictures, text, and
orthography) learn to navigate with relative ease through pages on a dynamic display SGD to
initiate conversation, ask and answer conversational questions, explain or clarify, share novel ideas,
and conduct transactions in the community. Most independent communicators need instruction and
support with spelling, including abbreviations and the use of a word-prediction tool on an SGD.
They benefit from practicing how to combine symbols, letters, stored messages, and other unaided
communication modalities to convey their ideas in a specific community situation; role-playing is
often a tool to practice these skills.
Although independent communicators may not use voice-output systems exclusively, producing a
spoken message with an SGD can get attention, convey specific information, or facilitate phone
communication. The "final" AAC system may consist of an SGD in combination with a variety of
other communication tools, including the client's residual natural speech, use of unaided strategies,
a communication notebook, and other remnants, such as ticket stubs or a list of family members'
names and contacts. (For more information about considerations for selecting an SGD for clients
with aphasia and funding options, see the sidebar on p. 11 for links to Web-exclusive material on
those topics.)
Information about device selection, Medicare SGD/AAC funding, Frequently Asked Questions
Information about SGD fast facts, funding programs, general resources, and AAC Report Coach
Information about Medicare funding and links to other ASHA resources
Information and materials on AAC-Aphasia assessment
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Focus on Divisions
ASHA specal interest divisions offer their affiliates exclusive e-mail lists and Web forums, the
opportunity to earn CEUs through self-study of peer-reviewed Internet publications, and other
benefits. Special Interest Division 2, Neurophysiology and Neurogenic Speech and Language
Disorders, facilitates the highest level of professional practice provided to individuals with
neurogenic communication disorders, and promotes, interprets, and disseminates information that is
relevant to neurogenic communication disorders. Division 12, Augmentative and Alternative
Communication, promotes continuing education on AAC, advocates for AAC clinical service
needs, and advocates for personnel preparation in the area of AAC.
For more information about the special interest divisions, visit ASHA's Special Interest Divisions
Web site.