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This is the final part of the Augmentative/Alternative Communication (AAC) for Aphasia three part series.
Selecting a device
There are oodles of options for AAC and a dizzying number of features. People with aphasia should work with their SLP to identify the processes and devices that will best support them.
SLPs understand what is available and will be able to match the person’s needs with device or system features. “In general, a speech pathologist should be involved in all aspects of assessment,” Gutmann said. “Whether you’re thinking high-tech, low-tech, it doesn’t matter. In aphasia, you can have various profiles of impairment. In general, there are four major language domains that can be affected by aphasia — speaking, understanding, reading and writing. Spoken language subsumes speaking and understanding, and written language subsumes reading and writing.”
To start the process of identifying appropriate AAC, an SLP evaluates the survivor’s communication needs. They identify what the survivor wants to be able to do. They consider information from the survivor’s comprehensive language assessment. The survivor’s other deficits also must be considered:
- Are they in a wheelchair? Do they use a cane?
- What can they carry?
- Are there vision problems?
- Can they swipe a page? Press a home button? Tap an icon?
- If they can’t use their hands, are they willing to use alternate access, like auditory cues?
- Do they need symbols, text or pictures? A combination of those?
- Can they identify communication environments, topics, partners and current modes of communication?
“Once a thorough evaluation is complete, we would consider the various technological options and conduct a process called feature matching, where you match the person and their needs to what each technological option offers,” Gutmann said.
“The research is very clear now that people with aphasia can work with and relate to personally meaningful, highly contextualized photographs much more readily than a grid of symbols arranged according to parts of a sentence — noun, verb, object, adjective,” Gutmann said. “So we would look at the various apps and devices that are available, thinking about what this person wants to be able to accomplish in their everyday communication, and then narrow down the field from all the available AAC apps to things that are more specific, tailored to adults, and that support text, pictures and VSDs, and can be customized.”
Speech generating devices use a variety of components — text, icons, photographs. “That’s part of the assessment process to see how the person relates to and understands those different forms of representation and also how they can use them,” Gutmann said. “Can they put together icons to make a sentence, or can they spell well enough that they’d rather type something, or are they better looking at a picture?
“In the best-case scenario, you might have a system that supports all of those different aspects,” Gutmann continued. “So, if you want to talk about a fishing trip, it’d be great to have a picture of the humongous fish that you caught and whoever was on the trip smiling in the background. They could work together with the speech pathologist to have messages related to that picture programmed and saved so that they can be readily accessed, or a message for a doctor connected to a pain scale or a specific question about a medication or upcoming surgery.”
Learning the system
McKelvey emphasized that any form of AAC is useless without training. “You can’t hand a survivor a speech-generating device or phone app and say, ‘Here, now use this to communicate,’” she said. “That is no more effective than sitting someone in front of a grand piano and saying, ‘Now, play Mozart.’ There has to be training and support involved, and that means the family and caregivers, too. My task is to bring them into this treatment process and show them ways to support their loved one’s comprehension and communication. When I do that, they are a part of the process. It’s when everybody understands the supportive techniques, strategies and systems, it’s much more effective.”
So, go low or go high?
Bottom line, low-tech is usually less expensive and is user friendly for those unaccustomed to tech devices. High-tech is versatile with almost endless capacity to meet diverse needs and can be the preference of those already familiar with devices.
But ultimately, it’s about what is appropriate for the individual. “I have a gentleman who has a little 97-cent flip book that he writes things on to help clarify his message,” McKelvey said. “He’s always flipping through his book to use a word or find something that he discussed earlier in the day. We enhanced it with peel-off tabs, so he could mark conversations with different colors, which made it easier to locate information. Now, that may not work for somebody else, but it definitely worked for him.”
McKelvey added this final thought: “There is no research evidence that says that an individual who uses AAC will never speak or that it will prohibit them in some way from speaking. When we talk about people with aphasia, I talk about it in terms of communication. Depending on when their stroke happened, they may get more actual speech back, but I’m not going to wait for that speech to emerge. Individuals with aphasia need to be able to communicate right now with the abilities that they have. They need to be able to participate in making decisions about their medical care as well as communicate with their family, friends and community members. Communication can’t wait. It’s critical for individuals with aphasia to have a successful way to communicate right now. As they become more adept at using strategies, their communication needs may change and therefore the strategies and systems they use should be modified to meet their current communication needs. Most people with aphasia will use more than one modality to communicate be it gestures, drawing, photographs, speech, communication board or a high-tech device. The most important thing is that the individual communicates wherever they want, with whomever they want, about any topic they choose using the most effective mode of communication they can.”
This information is provided as a resource to our readers. The tips, products or resources listed or linked to have not been reviewed or endorsed by the American Stroke Association.