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
• Parkinsons 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
PARKINSONS 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 BSSs 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.

31

• Angie H refer back to printed ppts for revision
  of this ppt..

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

• Wernickes
• Brocas
• 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 aphasias 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 communicators
  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 Partners 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
51
Primary Progressive Aphasia

• PPA is characterized by a gradual
  regression/deterioration of language skills in
  the absence of other types of cognitive
  impairments or other behavioral disturbances for
  a period of at least two years.
• PPA is the fifth most common type of dementia
• Some individuals with PPA may eventually show
  other cognitive impairments that are more
  consistent with other types of dementia (such as
  Alzheimers disease)
• Symptoms of PPA include
• anomia (problems with naming)
• slow and hesitant speech
• fluent and nonfluent forms exist

52
Early Stage Intervention

• People in early stages of PPA are still able to
  use some speech
• People in the early stages show the most
  difficulty with word finding
• Intervention techniques are similar to techniques
  used for specific needs communicators
• use of booklets or cards that contain specific
  information
• pre-prepared questions that can be used for
  tricky language situations
• gestures for resolving communication breakdown

53
Middle Stage Intervention

• People with PPA in this stage are considered
  generative message or transitional
  communicators
• People in this stage may require AAC for most
  communicative contexts
• Persons in this stage may benefit from drawing in
  order to communicate messages
• Persons in this stage may find the use of maps,
  calendars, floor plans to be helpful for the
  clarification of specific content related to
  their messages
• Persons in this stage may also have problems
  comprehending spoken information and so may
  require some augmented input devices as well as
  devices/strategies for message generation, these
  might include printed key words, photos,
  gestures, etc.

54
Late Stage Intervention

• The communication needs of persons with PPA in
  the late stages are similar to the needs of
  contextual choice communicators in the initial
  phases of this stage
• These individuals need help both to communicate
  and to comprehend information
• As the disease progresses, these persons may
  become emergent communicators. At this time,
  they may require the use of interventions which
  use limited choice making for the communication
  of needs and wants

55
Communication Notebooks

• Communication notebooks are small wallets or
  note-books which contain information that is
  personalized relevant to a persons communication
  needs
• Communication notebooks or wallets may contain
• photos of family members
• if literate, may contain printed info that the
  person may normally forget
• Notebooks should be personalized
• Person with dementia or PPA should help the SLP
  decide what content will be placed in the
  notebook before the disease progresses
• Opportunities for using the note-book and
  updating of content should be a priority
  throughout the course of PPA
• The notebook should be dynamic and adapted as the
  individuals communication needs change

56
Dementia

• Dementia is described as a chronic, acquired
  cognitive impairment
• Diagnosis requires that the cognitive impairments
  involve memory PLUS one other cognitive domain
  which might include attention, language,
  praxia, and frontal lobe functions, Alzheimers
  is the most common form
• Dementia affects
• episodic memory- memory of recent events,
  effected first
• semantic memory- memory for facts and general
  knowledge
• procedural memory- memory for how to do things,
  this type of memory is preserved the longest

57
AAC Recommendations for Dementia

• The primary focus of intervention throughout the
  course of the disease is focus on strengths of
  the individual
• General communication strategies for persons with
  dementia
• Use of memory books (facilitates memory by
  utilizing recognition rather than recall memory)
• Reducing distractions- Persons with dementia may
  process information more easily in distraction
  free environments
• Organize information into manageable chunks
• Provide information in multiple modalities
  (visual, auditory, etc)
• Strategies should address both language
  representation and organization
• Environmental print/photos- when placed on
  commonly used items, may remind person what the
  items are used for
• Use a variety of strategies

58
Huntingtons disease
59
Huntingtons disease

• HD is an inherited autosomal dominant
  degenerative disease.
• Symptoms begin to appear around age 40
• Persons with HD are often unable to speak
  functionally by the end stages of disease
  (Folstein, 1990)
• Primary symptoms include
• spastic/irregular movement of the limbs/face
• emotional problems
• cognitive symptoms progressing to dementia with
  time
• Communication impairments include
• language comprehension deficits including
  high-level processing difficulties
• expressive language deficits

60
AAC Strategies for HD

• Speech may or may not be so impaired that it
  requires AAC, dependent on stage of disease and
  individual variation
• Literature review suggests limited success with
  high-tech AAC for persons with HD, as reported by
  Beukelman (2003)
• Text suggests low-tech AAC strategies that focus
  on schedules and choice-making early in the
  course of disease
• Other suggestions include training communication
  partners to cue/prompt persons using AAC
  consistently
• Linguistic and cognitive supplementation is also
  recommended (such as to-do lists, note-books
  describing daily activities)

61
Chapter 18Traumatic Brain Injury
62
TBI

• Until the mid-1990s, patients with TBI only used
  AAC devices if they experienced severe,
  persistent anarthria or dysarthria.
• Intervention with an AAC device is delayed until
  the communication disorder stabilizes after the
  injury.
• Intervention focuses on short-term needs instead
  of long-term so the patient can communicate if
  he/she is in a rehabilitation program.

63
Prevalence Etiology

• Many temporary or permanent brain injuries go
  unreported because the patient may only lose
  consciousness for a short time and do not go to
  the emergency room
• 1 in 6 reported TBI cases are unable to return to
  school or work
• People at risk between ages of 15-24 years and
  older than 75 years
• Most common cause is motor vehicle accidents
• Second most common cause is fire arms

64
Cognitive/ Linguistic Communication Disorders

• Impairments in three areas
• cognitive impairments
• language disorders
• communication disorders as a result of damage to
  the motor control networks
• The communication disorder can change greatly
  over the period of recovery

65
Natural Ability Interventions

• SLPs are not able to predict if the patient will
  have natural speech recovery
• Topic Supplementation
• Alphabet Supplementation
• Portable Voice Amplification

66
Topic Supplementation

• If the patients speech is slightly intelligible,
  a communication device that provides context or a
  topic may be helpful.

67
Alphabet Supplementation

• Used for patients with dysarthria
• The first letter of each word is pointed to on an
  alphabet board while saying the word
• Allows the listener to focus on words that begin
  with the letter

68
Portable Voice Amplification

• Some patients with dysarthria speech is very
  quiet, therefore a portable speech amplifier may
  be used

69
Assessment Intervention

• Early Stage (Levels I, II, and III)
• Assessment
• Very difficult to assess because the patient may
  not be able to stay awake or pay attention for a
  long period of time.
• Very little formal assessment is used during this
  stage
• The team documents changes and observations of
  the patients responses
• Gradually the person is able to differentiate
  between two or more people or object-good sign of
  development of yes/no responses
• Intervention
• The first goal is to have the person awake and
  responding to simple commands consistently.

70
Assessment Intervention cont.

• Middle Stage (Levels IV and V)
• Assessment
• The patient will begin to specify his/her basic
  needs
• May have a difficult time accepting the AAC
  intervention at this time because of agitation
  and poor awareness of his/her communication
  deficits
• At this time assessment is used to determine what
  the individual can do to help achieve
  communication goals
• This assessment is informal and nonstandardized
• Seating and positioning is the main concern at
  this point
• This is important to determine if the patient can
  use direct selection or scanning options.
• AAC Intervention
• One or two major communication goals should be
  chosen at this time
• The devices include nonelectronic alphabet
  boards, pictures, word boards, yes/no techniques,
  and dependent scanning
• Communication partners are important at this stage

71
Assessment Intervention cont.

• Late Stages (Levels VI, VII, and VII)
• Assessment
• Most individuals at this point have regained the
  cognitive capability to be a natural speaker
• Those who cannot speak- due to motor control
  disorders or severe specific language disorders
• AAC Intervention
• May have a difficult time learning new
  information
• Natural speech usually has already come back
  before this stage
• AAC techniques in this stage are used for
  patients who have physical or cognitive
  impairments.
• The most important skill to regain is reading and
  spelling

72
Chapter 19AAC in Intensive and Acute Medical
Settings
73
Intensive Acute Medical Settings

• Acute and intensive medical units serve a wide
  range of individuals who are unable to
  communicate, either temporarily or permanently.
• Communication problems in these settings often
  occur as a result of primary medical conditions
  such as traumatic brain injury, stroke,
  oral-laryngeal cancer, etc. or as a side effect
  of interventions such as surgery, intubation,
  and/or tracheostomy.
• People in acute settings need to communicate
  regularly with hospital staff in order to
  participate in their own care, as well as with
  family members.

74
Causes of Communication Disorders in Acute
Medical Settings

• CD in acute medical settings can occur as a
  result of both primary causes and secondary
  causes
• Respiratory support often interferes with
  communication processes and a personas ability
  to speak.
• Primary Causes- those directly related to an
  individuals illness or condition
• Secondary Causes- those related to an
  individuals need for temporary respiratory
  support

75
Endotracheal Intubation

• Designed to transport air from a ventilator to an
  individuals respiratory system.
• Endotracheal tubes are usually passed in
  emergency situations through the persons mouth,
  pharynx, and larynx into the trachea.
• Oral intubation interferes with communication in
  several ways.
• First, because the endotracheal tube passes
  through the oral cavity, it is impossible to
  articulate speech accurately.
• Second, because the endotracheal tube passes
  between the vocal folds, which are located in the
  larynx, it is impossible to produce sound.

76
Tracheostomy

• A tracheostomy is another way to transport air
  from a ventilator to an individuals respiratory
  system.
• It is a surgical opening from the front wall of
  the lower neck into the trachea.
• An individual with a tracheostomy tube who
  depends on a ventilator has limited natural
  speech because air passes from the ventilator
  through the tube, rather than through the oral
  cavity and past the vocal folds.
• Air passes in and out of the trachea via the
  tracheostomy tube, bypassing the vocal folds so
  that no phonation is possible and messages must
  be mouthed.

77
AAC Service Delivery in Acute Medical Settings

• The core AAC team generally includes a
  speech-language pathologist, a physical
  therapist, and an occupational therapist who are
  employed by the hospital.

78
Establishing an AAC Program

• The following equipment and materials should form
  the basis for AAC interventions in acute medical
  settings
• a lightweight neck-type electrolarynx
• an oral-type electrolarynx
• materials to construct alphabet boards, word
  boards, and picture boards
• several magic slates
• a portable mounting system on wheels to hold
  cardboard message boards or eye-pointing displays

79
Barriers and Supports

• AAC teams must deal with a number of practice or
  knowledge barriers including
• Medical teams that do not refer individuals for
  AAC services
• Personnel who prefer not to be burdened with
  additional work in an already busy workplace
• Speech-language pathologists and other
  professionals who are not familiar with
  conducting AAC interventions in these settings.

80
Screening

• The AAC team should conduct a preliminary
  screening as the first step of an assessment to
  determine whether the individual is an
  appropriate candidate for a more complete
  evaluation.
• The individual must be able to follow simple
  directions and have some way of indicating yes
  and no.
• Individuals who successfully complete preliminary
  screening tasks undergo a more extensive
  assessment of their capabilities.

81
People with Sufficient Oral-Motor Control for
Speech

• The first step in evaluation should be assessment
  of oral-motor capabilities.
• If these are adequate to support speech,
  assessors should explore oral communication
  options.
• If oral-motor control is inadequate, assessors
  must explore other communication options.
• People that may not have the motor control
  necessary to produce voicing will need one of two
  types of electrolarynx often serves as an
  effective intervention device.
• A neck-type electrolarynx is positioned against
  the exterior neck wall and vibrates the air
  column within the vocal tract.
• An oral-type electrolarynx delivers sound into
  the oral cavity through a tube or catheter.
• The oral-type electrolarynx is useful for
  individuals who cant use a neck-type due to
  extensive tissue damage, swelling, or surgical
  tenderness in the neck area or because they must
  wear cervical collars that obscure their necks

82
Individuals with Insufficient Oral-Motor Control
for Speech

• Writing Options
• handwriting
• self construction of communication book
• magic slate so they can erase messages
• Options for People who cannot write
• pointing with hands, eyes, or head to use direct
  selection
• alphabet board
• small typing system (individuals in an acute
  setting are unlikely to have the time or
  motivation to use an encoding strategy)
• voice output if possible ( voice banking for
  children)
• Options for People who Cannot use Direct
  Selection
• scanning options dependent and independent

83
Access Constraints

• Funding Fortunately, the same resources that are
  responsible for hospitalization fees usually fund
  all medicare-related services, including AAC
  services.
• Instruction of Listeners The short-term acute
  medical environment imposes quite extensive
  learning constraints.
• First, individuals are very ill and under a
  considerable amount of stress.
• Second, many professionals and others interact
  with these individuals over the course of their
  stay.
• The most effective AAC interventions are those
  that require minimal listener training.
  Individuals and their medical teams tend not to
  use complicated AAC systems in short-term acute
  medical environments