CD 5672 Week 4 AAC Interventions for Individuals with Acquired Disabilities

1. CD 5672Week 4AAC Interventions for Individuals with Acquired Disabilities Summary of Chapters 15, 16, 17, 18, and 19 In Beukelman, , & Miranda, (2005). Augmentative and alternative communication: Supporting children & adults with complex communication needs (3rd Ed.) Baltimore, MD: Brookes Publishing.

2. Chapter 15 Adults With Acquired Physical Disabilities

3. Model for Intervention • Communication needs can be based on several factors. The three reasons to measure the intervention outcomes are: 1. To consider the outcomes that have and have not been met. 2. To document the effectiveness of the AAC agency and services provided. 3. To measure the effectiveness of the agencies efforts.

4. Acquired Physical Disabilities • Amyotrophic Lateral Sclerosis (ALS) • Multiple Sclerosis • Guillain- Barre Syndrome • Parkinson’s Disease • Brain- Stem Stroke

5. AMYOTHROPHIC LATERAL SCLEROSIS • Average onset is age 56 • ALS affects the motor neurons of the brain and spinal cord, there is an unknown etiology • Persons with ALS maintain their cognitive abilities throughout the prognosis, however, there are changes in cognition with their executive functioning skills. • 14%-39% survive for five years after being diagnosed. • 10% live up to ten years • Median survival rate is 2.2 years • Persons with dementia and ALS will also have more severe problems including severe personality changes and more cognitive breakdowns.

6. Communication Symptoms of ALS • Between 75% and 95% of people with ALS are unable to speak at the time of their deaths. • Depending on the progression and type, speech symptoms can vary • Flaccid-spastic dysarthria are almost universally present at some point • Speech rate may decrease but intelligibility does not until speech rate decreases to less that 100 words per minute

7. Cognitive/Linguistic Skills • People with ALS generally retain cognitive and linguistic function with progression. • 40%-50% of those with ALS experience some degree of dementia. • 25%-35% of those without diagnosed dementia will experience subtle changes in cognition. • Cognitive deficits tend to be more prominent in individuals with dysarthria and pseudobulbar palsy. • Evidence shows that progressive aphasia tends to evolve into individuals with ALS.

8. Motor Skills • Motor control capabilities effect AAC systems • Bulbar ALS • For some time people with this type can usually use a device that they can touch with their fingers or hands. • Spinal ALS • These persons will typically have limb and trunk weakness so they will need a device that involves scanning of some type. During the progression the need to change the device will occur several times.

9. AAC Devices & ALS • Typically persons with ALS are open to AAC systems but it is important to assess their acceptance of the system for best use. • Early introduction to AAC is key. • If implemented after speech is lost, instruction on how to operate a device becomes much more challenging. • An individual may always need facilitator assistance to help maintain the device.

10. Intervention Staging • Each stage relies more and more on AAC than the preceding stage. Stage 1: Minimal to no detectible speech disorder, may be short, purpose of intervention is to monitor speech, educate individuals with ALS, and acceptance of disease. Stage 2: Changes in speech rate due to fatigue, focus intervention on minimizing environmental interference, teaching strategies for establishing conversational topics, making sure listeners are understanding of the message, group conversations.

11. Intervention cont. • Stage 3: decrease in intelligibility, intervention should focus on slowing speech rate to compensate, AAC device needs to be learned and available to resolve communication breakdowns. • Stage 4: AAC devices become the primary source of communication along with residual natural speech. • Stage 5: loss of all functional speech and rely on AAC entirely, ventilators may be used for respiratory support, swallowing difficulties may occur.

12. MULTIPLE SCLEROSIS • MS is a degenerative disease where there is multiple plaques that cause destruction in myelin cells. • Dysarthria is the most common among MS but is not present in all persons. Although there are speech impairments, for most persons, AAC systems are not required. • Aphasia can also be associated with MS causing language impairments at different degrees for different people. • Visual impairment is also affected with MS, often being one of the first symptoms. • Motor control problems vary significantly depending on the person and progression. The limitations of MS that will be acquired must be assessed with visual impairments when assessing for an AAC device. • Since progression is unknown it is hard to locate a device that will work for long periods of time and assessment is difficult for the same reason.

13. The 5 classes of MS • Relapse and remitting- a person will have symptoms and fully recover. • Chronic progressive- the symptoms progress over time becoming more severe. • Combined relapse/remitting with chronic progressive- degeneration of capabilities with times of remittance. • Benign- typical life span with little progression and typical functioning. 5. Malignant- rapid deterioration of the cognitive, cerebellar, and pyramidal systems that leads to death in a short amount of time.

14. Intervention Staging Stage 1: No detectible Speech Disorder, intervention should include education about progression Stage 2: Slight changes to speech, unstable volume, and speech intervention is not recommended yet. Stage 3: Dysarthria appears and effects intelligible speech, intervention is not required but recommended to teach breakdown resolution strategies.

15. Intervention Staging cont. Stage 4: Experiencing significant reduction in intelligibility, intervention includes speaking in optimal listening conditions, alphabet boards are commonly used during this stage. Stage 5: Limited functional speech, rely on AAC device for communication, implement yes/no communication systems with caregivers, individualized interventions are necessary.

16. GUILLAIN-BARRE SYNDROME • GBS is a degenerative disease that is characterized by progressive destruction and regeneration of myelin sheaths in the peripheral nervous axons. • Paralysis begins in legs and moves upwards. • Paralysis lasts from one to three weeks and the myelin sheath regenerates and muscle strength slowly returns, starting with the head. • 80% fully recover.

17. Communication Disorders • Flaccid dysarthria • Anarthria (complete loss of speech) • Severe paralysis requires ventilator support • Language and cognition is usually unaffected.

18. Intervention Stages Stage 1: monitor progression so AAC can be provided when appropriate Stage 2: respiratory support and AAC intervention is needed, develop yes/ no system Stage 3: continue to use low-tech AAC devices Stage 4: regain speech with reduced intelligibility and loudness, continued respiratory support Stage 5: residual weakness, occasionally dysarthria

19. PARKINSON’S DISEASE • PD is caused by a loss of neurons in the basil ganglia and brain stem. This causes many motor problems for the person. • Persons with PD typically have the ability to spell words out for a device, but can have training to help with memory and learning difficulties. • Sensory skills are left unchanged. • Side effects of L-dopa can interfere with AAC approaches • Motor symptoms include: resting tremor, rigidity, reduction of movement (paucity), and impaired postural reflexes

20. Communication Symptoms • Dysarthria and dementia • Speech symptoms include reduced pitch, volume, increased rate, reduced intensity, imprecise articulation • No natural course of symptoms • Gradually become increasingly difficult to understand

21. Motor Skills • AAC interventions should be aware of their progressive motor impairments and create the device accordingly • Due to reduced ROM and speech, AAC devices need to have a smaller display, size, and keyguard for excessive movement • Lack of fine motor control will limit AAC options

22. Assess Constraints • Due to slow progression, people with PD may be hesitant to use an AAC device because at the time of onset, they can speak • People with PD have older peers and who could have a poorer hearing, which would cause a communication barrier • People with PD blame the communicaiton partner for not being understood

23. Intervention Stages Stage 1: no speech difficulties, education and acceptance of family, peers, and person diagnosed Stage 2: reduce volume, speech intervention recommended, portable speech amplification systems may improve communication Stage 3: reduced intelligibility, reduced loudness, increased rate, important to have frequent communication partners to become more familiar to speech

24. Intervention Stages cont. Stage 4: no functional natural speech, AAC boards can include pace setting boards, alphabet supplementation to control speaking rate. Stage 5: loss of all functional speech, overall motor control and cognitive impairments, AAC devices are difficult to implement and intervention is very individualized.

25. BRAIN STEM STROKE • BSS is caused by lack of circulation around the brainstem often causing dysarthria or anarthria. • Persons with BSS’s communication symptoms differ considerably depending on the level of disruption and dysarthria. • Tactile impairments typically occur with BSS • Vision problems may or may not be affected; eye problems may be affected if the stroke is high in the brain stem.

26. Communication/Linguistic and Sensory/ Perceptual Skills • If the stroke only involves the brain stem, no cognitive or language impairment is expected. • If the stroke affects more than the brain stem, cognitive or language impairments may occur. • Usually no cognitive impairments

27. Motor Skills • Usually experience problems with limbs. • Difficulty controlling speech mechanisms which would effect articulation and intelligibility. • Research shows eye or head pointing as the alternative access mode is successful as an AAC system.

28. Intervention Stages • Since BSS not degenerative, the stages go from worse to better in terms of therapy Stage 1: provide early communication system so they can at least answer yes/no questions Phase 1- Initial choice making Phase 2- Pointing Phase 3- Multipurpose Electronic AAC device Stage 2: develop voluntary control of respiratory, vocal, velopharyngeal, and articulatory systems while continuing to use AAC systems

29. Intervention Stages Stage 3: intervention focuses on intelligibility with goals of meeting all communication needs through natural speech Stage 4: no need for AAC device, goal of intervention is to speak as natural as possible by learning appropriate breath groups and stress patterns Stage 5: no detectable speech disorder, very uncommon

30. Locked- in- Syndrome (LIS) • Similar to BSS • A basilar artery stroke, tumor, or trauma that results in damage to the upper pons and occasionally the midbrain causes a conscious quadraplegic state that limits voluntary movements to vertical eye movements and sometimes eye blinks. • Average survival rate of 85% is 5 years, ranging from 2 to 18. • Low and high-tech AAC devices can be implemented.

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32. Chapter 16Adults with Severe Aphasia

33. Aphasia • “Aphasia is an impairment of the ability to interpret and formulate language” (Garrett & Lasker, 2005, p. 467). • Reduced abilities in speaking, auditory comprehension, reading, writing, and gestural communication • Approximately 1 out of every 275 adults in the United States have aphasia (Garrett & Lasker, 2005). • Most commonly results from Cerebral Vascular Accident (CVA) • Other etiologies include: brain injury related to accidents, tumors, or neurologic illnesses

34. Subtypes of Aphasia • Wernicke’s • Broca’s • Transcortical • Anomic • Global

35. Treatment Approaches • Traditional treatment involves assisting people with aphasia to speak more effectively, comprehend more fully, and write with fewer errors • Participation Model focuses on interventions that enhance the person with aphasia’s ability to actively participate in life activities that are important to them – Patients are encouraged to use natural communication modalities and AAC

36. Functions of Communiation • Analyze the purposes of communication prior to designing AAC interventions • Consider the four general functional categories: expression of basic needs and wants, information transfer, social closeness, and social etiquette

37. Partner Dependent Communicators • These communicators will always be dependent on their conversational partners for informational demands and communication choices within familiar contexts • Emerging Communicator • Contextual Choice Communicator • Transitional Communicator

38. Emerging Communicator • Characteristics • Profound cognitive-linguistic disorder across modalities • Extreme difficulties speaking, using symbols, and responding to conversational input • Seldom communicate purposefully or use nonverbal signs, such as pointing or nodding • Intervention Strategies for Emerging Communicators • May initially benefit from contextual activities that elicit referential skills • Low-tech AAC devices can be used to help the emerging communicator comprehend and control their environment • Treatment is focused on foundational communication skills: turn-taking, choice-making ability with tangible objects or photographs, referential skills, and clear signals of agreement or rejection • Conversation partner training should focus on how to provide choice-making opportunities throughout daily routines and reinforce communicator’s responses

39. Contextual Choice Communicator • Characteristics • More capable than emerging communicators, but do not initiate or add to conversations on their own – socially isolated • Can participate in conversations when provided written or pictorial choices on a turn-by-turn basis • May benefit from Augmented Input Techniques • Intervention Strategies for Contextual Choice Communicator • AAC interventions should be embedded within conversations about familiar topics • Primary expressive goal is to teach the communicator to consistently reference what he or she is talking about, understand the meaning of graphic symbols, make choices to answer questions, and begin to ask questions by pointing

40. Strategies for Contextual Choice • Written Choice Conversation – the facilitator generates written key words that are pertinent to a conversational topic. Reponses can be general or specific. • Yes/No Responses to a Partner’s Tagged Questions – Partners add the phrase “yes or no” at the end of their questions coupled with the corresponding head nod or shake. • Asking Questions – May need additional interventions to initiate conversations, such as hand-over-hand assistance to point or gesture toward something or someone to ask questions • Augmented Comprehension (Input) Techniques – especially for the communicator with aphasia who also has auditory processing difficulties: after the communication partner identifies that the person with aphasia has misunderstood, partner reiterates the message while simultaneously pointing to the item being discussed, showing photographs, writing key words or phrases, etc.

41. Transitional Communicators • Characteristics • Have strategies to convey their message when they are unable to speak, such as search through their communication notebooks or gesturing. • Biggest challenge is communicating successfully in spontaneous conversations without contextual cues • Intervention Strategies for Transitional Communicators • Focus is on initiating conversations with as little cueing as possible • Storytelling can be used as a content-rich communication activity

42. Independent Communicator • Can comprehend most of what is said to them without contextual support; use both natural speech and augmented strategies • Stored Message Communicators • Generative Message Communicators • Specific Need Communicators

43. Stored Message Communicators • Characteristics • Can independently locate messages that have been stored in their AAC systems, without prompting in familiar settings • Seldom generate novel information in unusual topics (AAC skills too limited to participate independently in free-form conversations) • Intervention Strategies for Stored Message Communicators • Therapists and family members should work together to store an inventory of messages for specific situations. • Intervention sessions outside of the therapy room, in naturalistic settings, may be helpful to evaluate the effectiveness of message content, etc.

44. Generative Message Communicator • Characteristics • Maintain independent lifestyles • Preserved skills may include drawing, gestures, pantomiming, first-letter-of-word spelling, word writing, and pointing to words or symbols • Communication skills are often fragmented or inconsistent and require some AAC intervention • Intervention Strategies for Generative Communicators • Focus on participation patterns, clarifying communication needs, identify topics of interest, and teach the individual to manage a variety of AAC strategies • Teach the generative message communicator when to use the various AAC strategies – often overlooked

45. Specific Need Communicator • Characteristics • These communicators only need AAC in certain situations for specificity, clarity, or efficiency • Often live independent lifestyles • Intervention Strategies for Specific-Need Communicators • Analyze the requirements of the specific communication task and contrast those requirements with the communicators current skills • May benefit from situation training (role play)

46. Assessment • Evaluate communication needs, linguistic and cognitive competencies • Assess communication needs in real-life contexts • Assess Specific Capabilities • Linguistic Skills • AAC-Related Skills • Nonverbal Communication Skills • Motor Skills

47. Assessment cont. • Sensory Skills • Perceptual Skills • Pragmatic Skills • Experiential Skills • Cognitive Skills • Assess Constraints • Partner Skills

48. Demands of Potential AAC Strategies • Motoric • Writing, pointing, access to digitally stored messages • Cognitive • Must memorize symbols (if used) – more novel than words • Numeric coding • Layers of arrays or boards – remember to look on each and the steps to transition between, as well as where things are located without having it represented in front of them • Spelling • Operational skills • Turning the device on/off, comprehending synthesized speech, using flowchart menus, keyboarding, charging the device • Metacognitive • Using speech and writing, knowing when to use other strategies • Knowing when to rephrase a message as opposed to repeating • Repairing communication breakdowns with various AAC strategies • Linguistic • Syntax & word-retrieval

49. Intervention Issues • The following may affect success of an AAC intervention. This is not an exhaustive list: • The individual's or family's continued desire to work on speech • Difficulty with acceptance of AAC alternatives • Premature discontinuation of treatment • Poor matching between AAC system features and communicator's capabilities • Limited availability of personalized messages • Lack of practice in contextual situations • Lack of available communication partners for partner-supported communicators • An inadequate support network to assist in message development for generative communicators • Lack of communication opportunities because needs are anticipated by others • Clinicians can work with the communicator and family members about their hesitations using a device • Emphasis on conversation partner training should occur early in an individual's recovery • Schedule routine follow-up visits each week, if possible

50. Chapter 17Primary Progressive Aphasia