Cognitive-Linguistic Profiles of Aphasic Communicators Who Use AAC

Cognitive-Linguistic Profiles of Aphasic Communicators Who Use AAC

Joanne P. Lasker, Ph.D.

Florida State University

Kathryn L. Garrett, Ph.D.

Duquesne University

Presentation at the American Speech-Language-Hearing Association ConventionNovember 22, 2003

Chicago, IL

A. Statement of the Problem

Many people with severe aphasia have unmet communication needs.

Which individuals with chronic aphasia will benefit from augmentative and alternative communication strategies (AAC)?

Which type/class of AAC strategies? Are there systematic ways of assessing this

issue? Is there a “profile” of an effective AAC

communicator?

B. Cognitive-Linguistic Considerations in AAC

definition of aphasia “Language” or “symbolic deficits” across

modalities Intermittency of processing (Brookshire, 1978;

McNeil, 1983) more recently we have seen attention to

possible cognitive aspects of aphasia

Cognition and Aphasia

Aspects of cognition related to aphasia may include: (Purdy, 2001; Hinckley, 2002) attention memory executive function skills resource allocation pragmatics

Demands of AAC Techniques

Think to initiate communication through external means -- “outside” of the communicator’s own head and language system (Garrett & Kimelman, 2000)

Verbal memory for messages Spatial memory for message location Symbol translation skills -- from icons to meanings Executive function skills -- to judge which method of

communication best fits the situation Attention and perseverance to complete the

message transaction

Resource Allocation to balance the cognitive demands of using a novel form of

communication… …with the pragmatic demands of speaking to a

communication partner And the linguistic demands of encoding messages And any other stressors in the communication environment

Balancing Noise Multiple speakers Multiple topics Interruptions Communication breakdowns

Challenges with AAC and Aphasia Limited information is available re: who is and

is not successful.

“Matching” AAC approaches to skills/needs of communicator involves many variables.

Limited knowledge is available about how to effectively train people with aphasia to use AAC in real-life situations.

Still More Challenges

People with aphasia tend to be isolated, and therefore have limited social opportunities to communicate.

Message pools selected for AAC systems may not be appropriate or meaningful for adults with aphasia.

Negative or ambivalent attitudes toward technology may be held by adults with aphasia and/or communication partners.

Recent Research Helm-Estabrooks (2002) described a case study of a

person with aphasia who used a high tech AAC system (C-Speak Aphasia; Nicholas & Elliot).

Her analysis of the individual’s cognitive-linguistic profile revealed: mild-moderate aphasia as measured by the WAB relatively strong cognitive skills on specific subtests of

the Cognitive-Linguistic Quick Test (Helm-Estabrooks, 2001) Trail Making Design Generation Mazes

Testable Hypothesis

Certain measures of cognition may serve as reasonable predictors of an individual’s ability to use an AAC system to communicate meaningfully.

C. Our Purpose/Design

Case study approach. generate a cognitive-linguistic and behavioral

profile of successful AAC users with aphasia Independent Communicators Partner Dependent Communicators Nonusers

aid in assessment and intervention planning

Proposed Test Battery Western Aphasia Battery (Kertesz, 1982) Raven’s Coloured Progressive Matrices (Raven, Raven, &

Court, 1998) Cognitive-Linguistic Quick Test (Helm-Estabrooks, 2001) Wisconsin Card Sort Task (Kongs, Thompson, Iverson, &

Heaton, 2000) Multimodal Communication Screening Task (Garrett, 1998) The Assistive Technology Device Predisposition Assessment

Consumer Form (adapted from Scherer & McKee, 1989 by Lasker & Bedrosian, 2000; under revision)

Categorical Assessment of Communicators with Aphasia (Garrett & Beukelman, 1998; under revision)

One Comparison:WAB Writing Task

Client’s Written Responses

MHJK

RM

The Multimodal Communication Screening

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MULTIMODAL COMMUNICATION SCREENING TASK FOR PERSONS WITH APHASIA: SCORESHEET (C) 1997, Kathryn L. Garrett see http:// www.aac.unl .edu for pictoral stimuli that accompany this score sheet

CLIENT NAME: DATE: EVALUATOR: INSTRUCTIONS: Show the person with aphasia the booklet containing the symbolized choices. Explain that the pictures, letters, sentences and maplocations can all be used to communicate ideas. Provide examples if necessary. For each item, ask individual “How would you communicate ? You can usethis book or any other way you have to communicate.” Mark + if all concepts were communicated, +/- if some were communicated, and - if no items werecommunicated . Circle concepts that were successfully conveyed. Record cues if provided. Substitute alternate concepts as appropriate.

Abstract Mult. page Target Symbols Meaning? search needed? +/- Cues Comments A. IDENTIFICATION OF NOUNS BY NAME 1. Shoes Pic/word NO NO 2. Open Door Pic/word NO YES (2) 3. Grandchild Pic/word YES YES (3) 4. Need to buy something Pic/word YES YES (3) 5. State of residence (“Nebraska”) Map or 1st letter NO YES (5)

B. 2-SYMBOL COMBINATIONS 6. I've been walking alot and I'm tired. Pic/word YES NO 7. Open the window; it's too hot. Pic/word NO YES (2) 8. I'm glad my grandkids are visiting Pic/word YES YES (3)

C. 3-SYMBOL COMBINATIONS9. I want to buy some toys for my

grandchildren. Pic/word YES YES (3) 10.The kids are coming next week from Pic/word, map,

name of state or city. or 1st letter YES YES (6) 11.I want to eat an expensive meal at Pic/word, map,

name of favorite restaurant tonight. or1st letter YES YES (6)

D. PHRASE LISTS“Pretend you’re at the drugstore//with your grandkids.” F ind the page thatwill help you do this. Then, tell me how you’d say...”

12. I need more aspirin and shampoo. Phrase list NO NO 13.Please fill my prescription for 2 refills

and write down your instructions for me. Phrase list NO NO 14. Tell me about school. How is your ? Phrase list NO NO

15.Do you do your homework? Are your grades good? Phrase list YES YES (2) SUMMARY & INTERPRETATION: Can this person intentionally locate info on multiple pages? Combine concepts? Use symbols abstractly? Use writtenwords, maps, or the 1st letter of a word? Use other modalities? Answer and initiate questions?

Raven’s Coloured Progressive Matrices

Cognitive-Linguistic Quick Test (Helm-Estabrooks, 2001)

criterion-referenced test relative skills in the areas

of: attention memory language executive function visuospatial skills

does require verbal skills for some tasks (e.g., story retelling)

CLQT – Tasks and Composites

Personal Facts Symbol Cancellation Confrontation Naming Clock Drawing Story Retelling Symbol Trails Generative Naming Design Memory Mazes Design Generation

Yield composite scores: attention memory executive function language visuospatial skills

Trailmaking task…oops …not this…

Trail Making Example

Wisconsin Card Sort Test

sort cards by: number shape color

rules change after 10 correct sorts

WCST Example

Sample questions from the “Technology Predisposition Survey”

I will benefit from using this AAC system. This AAC system will help me achieve a goal that I

have. I will feel comfortable using this AAC system in

public. This AAC system will improve the quality of my life. I will feel comfortable using this AAC system around

my family.

Categories of AAC Use

Partner-Dependent Communicators

Emerging Communicators

Contextual Choice Communicators

Augmented Input Communicators

Categories (cont.)

Independent Communicators

Transitional Communicators

Stored Message Communicators

Generative Communicators

D. Case Studies

On to Pennsylvania folks!

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JV -- Emerging Communicator WAB AQ - .6/100 BASA -- 2nd %ile for people

with global aphasia Raven’s -- 0/36 CLQT -- N/A Technology Attitudes

Minimal experience Interested in trying

technology Required specific training to

use symbols to request Max assist to locate

symbolized messages

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AA & RC -- Contextual Choice Communicators

WAB AQ = 9.2 Reading: 11/100 Writing: 10.5/100 Ravens: 15/36 CLQT

Symbol Trails: 1/10 Design Memory: 2/6 Mazes: 0/8 Design Generation: 6/13

Technology Attitudes: Minimal to some computer

experience Willing to learn to operate simple

AAC systems Less willing to use in real-life

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SA - Transitional Communicator

WAB AQ = 93.4 Reading = 80/100 Writing = 71/100 Praxis = 55/60 Block Design = 7/9 Calculation = 24/24 Raven’s = 16/20 Moderate dysarthria Technology Attitudes:

Moderate computer experience

Interested in Palmtop PC-type device because of social acceptability

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GW--Deferred Technology User

WAB = 35 Broca’s profile 1 year post onset Lawyer Computer experience Technology Attitudes --

No interest in learning to use AAC at present

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Florida AAC/Aphasia Clients

Client: MH 52-year old woman left CVA in March, 2001

2 years post 14 years of education right hemiparesis lives with mother who is in frail

health completed assessment phase

of project before relocation diagnosed with moderate

receptive and severe expressive aphasia

limited speech therapy

MH - Results

Instrument

Score

CLQT Atte ntion

mild

CLQT Memory

sev

CLQT Executive Function

mod

CLQT Language

sev

CLQT Visuospatial

mild

Clock Drawing

mild

MH - Results

Instrument

Score

WAB Aphasia Quotient (out of 100)

34.8

WAB Reading (out of 100)

66.5/100

WAB Writing (out of 100)

41.5

WAB Praxis (out of 60)

DNT

Ravens (out of 36)

27

Wisconsin Card Sort

1 category

MH – AAC Trials

Communication Task

How much assistance for

success? unaided low-tech strategy use

mod

stored information system

mod (single hits only)

preformulated di gitized messages

min

multiple levels digitized messages

min

dynamic display

mod

augmented writing

max

MH – Strengths & Challenges

Challenges emotional issues:

frustration sadness anxiety

social isolation impaired auditory

comprehension impaired executive skills severity of speech deficit

Strengths reading writing motivation

MH – Current Status

relocated after assessment currently not receiving any services SLP attempting to contact an area SLP to

continue intervention and device trial

Client: JK

53-year-old tenured geography professor

earned doctorate left CVA in 3/2001

8 months post at first visit employed by university for 21

years (since 1982) lives with husband (also a

professor) and young daughter (5 years old)

diagnosed with moderate expressive aphasia and mild receptive aphasia

JK - Results

Instrument

Score

WAB Aphasia Quotient (out of 100)

79.1

WAB Reading (out of 100)

80

WAB Writing (out of 100)

75

WAB Praxis(out of 60)

55

Ravens (out of 36)

29

Wisconsin Card Sort

5 categor ies

JK - Results

Instrument

Score

CLQT Atte ntion

mild

CLQT Memory

mild

CLQT Executive Function

mild

CLQT Language

mild

CLQT Visuospatial

mild

Clock Drawing

mild

JK – AAC Trials

Communication Task

How much assistance for

success? unaided low-tech strategy use

independent

stored information system

independent (uses speech)

preformulated di gitized messages

independent

multiple levels digitized messages

independent

dynamic display

min

augmented writing

min (for technology support only )

Student Evaluations: First Teaching Experience After Stroke

“It was very interesting to see how Dr. Kodras put her sentences together and got her point across to the class.”

“Topic ---- instructor ---- extremely well versed ---- passionate about topic ---- makes all difference ----- instructor ----- exceptional.”

“I could see that living with aphasia does not mean that you have to stop living.”

JK – Strengths and Challenges

Challenges communication needs impaired executive skills

Strengths reading writing motivation education? familiarity with technology family support

JK – Current Status

Participating in intervention to utilize a combination of EZ Keys and “Key Word Teaching” to lecture to her graduate classes.

Continues to use EZ Keys to prepare lectures.

Continues to negotiate support from department.

Client: RM

62-year-old education: 14 years retired airport manager left CVA occurred 1995 diagnosed with moderate

aphasia and moderate-severe apraxia of speech

RM - Results

Instrument

Score

WAB Aphasia Quotient (out of 100)

55.4

WAB Reading (out of 100)

75

WAB Writing (out of 100)

78

WAB Praxis(out of 60)

58

Ravens (out of 36)

29

Wisconsin Card Sort

2 categor ies

RM - Results

Instrument

Score

CLQT Atte ntion

WNL

CLQT Memory

sev

CLQT Executive Function

WNL

CLQT Language

sev

CLQT Visuospatial

WNL

Clock Drawing

WNL

RM – AAC Trials

Communication Task

How much assistance for

success? unaided low-tech strategy use

independent

stored information system

independent (uses speech)

preformulated di gitized messages

independent

multiple levels digitized messages

independent

dynamic display

independent

augmented writing

mod (spelling

difficulties )

Message Behaviors

Message RM’s Behavior Production Partner

Behavior

General manger

Rod spells and uses word prediction and

word morphology pop-up

Device speaks. Partner reauditorizes.

Ja Rod spells. Attempts

before spelling (unintelligible) .

Partner predicts.

Pensacola Rod spells and uses

word prediction .

Rod attempts after spelling

(unintelligible).

Partner responds.

London Rod spells and uses

word pr ediction . No spoken production.

Partner reads message and

responds.

Device Usage - “Press Behaviors”

“I like a cheeseburger and coke please.”

Press Type Number

Navigation 10

Phrase Retrieval 0

Word Retrieval 6

Spelling 4

Word Prediction 0

Total Time 65

seconds

RM – Challenges and Strengths

Challenges poor spelling unable to use word-

based pages on device effectively

resistant to change of relatively inefficient layout of device automaticity? familiarity?

Strengths positive attitude about

everything multimodal to the

extreme willing to use device in

public, on phone, as email tool

RM – Current Status

increase and enhance facilitative behaviors on device category-based word search word by word formulation

decrease non-facilitative behaviors inappropriate topic setting device navigation

participating in motor-based learning study to increase speech output

acts as ambassador and community educator

E. Summing Up

What did we learn?

“Salient” Subtests on CLQT

Symbol Trails Design Memory Mazes Design Generation0123456789

10111213

CLQT Subtests

CC MH RM JK

Categories of AAC Use

Partner-Dependent Communicators

Emerging Communicators

Contextual Choice Communicators

Augmented Input Communicators

JV

AA and RC

Categories (cont.)

Independent Communicators

Transitional Communicators

Stored Message Communicators

Generative Communicators

MH and SA

RM and JK

E. Summary: What did we learn?

Clinician judgment (via AAC trials) differentiated independent from partner-dependent communicators. Test results verified these judgments.

Potential “suspects” for determining outcome – likely a complex picture. . . AQ’s expressive writing task attitude toward AAC system cognitive tasks on CLQT

As always…

Further research is warranted

Your comments are appreciated

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