Strategic Use in ContextStrategic Use in Context:: AAC, Supported Conversation, AAC, Supported Conversation,

and Group Therapy Interventions and Group Therapy Interventions

for People with Severe Aphasiafor People with Severe Aphasia

Kathryn L. Garrett, Ph.D., CCC-SLPKathryn L. Garrett, Ph.D., CCC-SLPDuquesne University, Pittsburgh, PA USA

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May 24th and 25th, 2004

Stockholm, Sweden

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Support provided by: Karolinska Institutet Swedish Aphasia Organization

(Afasiförbundet) Swedish Association of Speech Pathologists

(SLOF) Inger Gillholm, Conference Coordinator

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Pittsburgh

Pennsylvania

Sweden

P O N D

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Pittsburgh, PA

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Duquesne University

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My Background Pennsylvania Nebraska

Ainsworth – Highway 20, ESU #17 University of Nebraska-Lincoln Madonna Rehabilitation Hospital University of Nebraska-Lincoln

Pittsburgh, PA University of Pittsburgh Duquesne University

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From Nebraska…

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To Pittsburgh…

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…to Stockholm

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Day 1 – Augmentative and Alternative Communication Strategies for People

with Aphasia* * * * * * * * * * *

Morning: Part I: Introduction to AAC Strategies for

People with Aphasia Part II: Categories of Communicators

Afternoon Part II: Categories of Communicators Cont. Part III: Assessment/Cognitive-Linguistic

Considerations Group Application Activity

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Day 2 -- Part IV: 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

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Part I: Part I: IntroductionIntroduction

“The “The contextcontext of developing of developing effective communication effective communication

interventions for people with interventions for people with severe-profound aphasia”severe-profound aphasia”

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Aphasia: an impairment of the ability to use or understand language, usually acquired as a result of

stroke or head injury (from NAA definition)

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A. How many individuals have severe aphasia (U.S.)?

400,000 strokes per year in the U.S. (National Aphasia Association)

Of the individuals who survive stroke, approximately 20% (80,000/year) have aphasia (NAA, Wolf, Kannel, & McGee, 1986)

1 in 275 individuals have aphasia Approximately 10-40% of individuals with

aphasia demonstrate chronic severe aphasia (Collins, 1986; Poeck et al. 1984)

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Kauhanen, 1999 Finnish dissertation study on depression and

aphasia involving 31 patients 1/3 of all patients with stroke etiologies in the

initial subject pool had aphasia 2/3 of the 31 patients with aphasia had moderate-

to-severe aphasia initially (~20) However, 74% of this group of 31 did demonstrate

significant improvement or resolution of aphasia.

No comprehensive studies on incidence of aphasia world-wide.

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Not only are we concerned with severe-global aphasia... Approximately 70% of all people

with aphasia felt that people avoided contact with them because of difficulty with communication (National Aphasia Association Survey, 1987)

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Steve: age 70, AQ = 30, 2 years post onset, Broca’s-type aphasia, telegraphic speech only

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How many of you have people with severe, chronic aphasia on your caseloads?

How long post onset?

What proportion of aphasia cases?

Typical management/status at 1 year post? 2 years post?

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B. Competencies and Challenges in Severe Aphasia

People with aphasia have intermittent linguistic/symbolic competence as well as deficits

People with aphasia have intermittent nonlinguistic competence (gestures, drawing, writing, intent to communicate)

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However, competencies and challenges co-occur on a moment-by-moment basis in aphasia, making it difficult to… Predict when breakdowns AND

successes will occur “Fix” the problem permanently The “Short Circuit” Model

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Intermittent, but persistent breakdowns occur at the level of symbolic processing and...during the completion of sequential

cognitive-linguistic events

IDEAS “SHORT CIRCUIT” ON THEIR WAY TO A COMMUNICATION TARGET

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Illustration: Aphasia Hope.org

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They have prior knowledge of how communication works a.k.a. pragmatic knowledge (Holland, 19982; Sarno, 1969)

They have a tremendous storehouse of world knowledge derived from a lifetime of experiences vs. developmental vocabulary and

topics seen in child language interventions and materials

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But…

They also tend to be frustrated… At the loss of access to

communication opportunities With the change in family or social

roles With the loss of individualism and

independence With the rate of recovery

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Video - Neil Attempting to have a conversation

with Christy, our secretary unfamiliar partner both participants do not have shared,

mutual knowledge of possible communication strategies

Does this reflect a typical exchange with a nonspeaking person with aphasia (PWA?)

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C. Traditional Therapy Models in Severe Aphasia

Emphasis on speech “Stimulation” approaches Decontextualized vs. Contextual

Therapy

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Outcomes for our patients with severe aphasia….

Survey

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What happens to people with severe aphasia in the

traditional treatment phase? The perception is that recovery of “speech

and language” isn’t enough to justify continued tx –- particularly when agencies are under time constraints to achieve functional and visible change. Therefore patients are quickly discharged (U.S. only?)

OR, even if direct therapy is somewhat successful, people with aphasia simply don’t learn to use “piecemeal” words and phrases outside of rote, clinical contexts.

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D. Alternative (Contextual) Therapy Approaches

1. Pragmatic Approaches 2. Functional Approaches 3. Supported Conversation

Approaches (Kagan, 1998) 4. Augmentative and Alternative

Communication (AAC) approaches

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a. Definitions of Augmentative and Alternative Communication (AAC)

An area of clinical practice that attempts to COMPENSATE for the impairment and disability patterns of individuals with severe expressive communication disorders (paraphrased from ASHA, 1989)

AAC interventions are often MULTIMODAL in nature (i.e., involve the individual’s full communication capabilities, including any residual speech, vocalizations, gestures, signs, and aided communication strategies)

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b. Candidacy for AAC Strategies in Aphasia:

1) those persons who find speech inadequate or inefficient in certain instances, or ...

2) those persons who do not regain sufficient natural speech for communication of basic needs (after Hux, Beukelman, & Garrett, 1994).

Inclusive vs. Restrictive Candidacy Criteria

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c. Early AAC interventions in severe aphasia -- results and analysis

Symbol/Modality replacement approaches Amerind (Skelly) VIC (Weinrich & Steele) Blissymbols

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Very few communicators learned to use symbols (i.e., a replacement for speech) in a generalized manner outside of brief, structured clinical tasks

Large repositories of alternate symbols were not accessed

Kraat (paraphrased): “….it is if people with aphasia cannot think to turn outside of themselves to use these alternate symbols…”

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My theories…. PWA have a reduced cognitive-linguistic

resources to learn a new symbolic language code Overlay of aphasia and neurologic damage

interferes with PWAs’ ability to consciously communicate through novel modalities (without being specifically taught to do so)

It is not as simple as giving someone a replacement device for their “damaged speech system”

Stories from the past……

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Dr. D - video with replacement AAC system

(optional) Analysis

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d. Useful AAC Principles Utilize the Participation Model

(Beukelman & Mirenda, 1998) vs. the Medical “Fix it” model Decrease the emphasis on viewing therapy’s goal

as strengthening the subskills of communication (e.g., motor movements, the ability to repeat words, ability to follow commands)

Instead, ask “How can we increase this person’s PARTICIPATIONPARTICIPATION in meaningful adult activities?”

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Emphasize the communication of meaning and intent

Capitalize on the residual strengths of the individual

Provide communication opportunities

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Include communication partners in the intervention

View communication as a multimodal process, a package of “whatever works” strategies including AAC techniques, technology, and natural speech

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View the goal of communication as more than conveying needs and wants (e.g., more than asking for a blanket) Light (1988)

• Needs and Wants

• Information Transfer

• Social Closeness

• Social Etiquette

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What does this mean for us? Many persons with aphasia,

regardless of severity, can increase their participation in meaningful communication activities despite insufficiency of natural speech

Examples: saying a prayer at Thanksgiving dinner, introducing self at cocktail party, answering conversational questions about an

election, ordering pizza on the phone

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Dr. D. and his family discussing the Boston Celtics and recent economic downturns