Reducing the Cognitive/Linguistic Load of Persons with Aphasia and Traumatic

Brain Injury Who Rely on AAC

David Beukelman

University of Nebraska, Lincoln

With support from:

AAC-RERC/NIDRR/USDE

Technology Transfer Partner

Dynavox

AAC: Augmentative and Alternative Communication

• A range of strategies to support communication for those with unmet communication needs

Aphasia

• Language limitation due to damage language center in the left (usually) hemisphere – Range of symptoms– Range of severity– Range of recovery– 30% do not achieve full recovery– ??% with minimal functional verbal expression

Traumatic Brain Injury

• Range of communication limitations– Motor speech– Cognitive/Linguistic– Combination

– Pattern of communication limitations changing as medical interventions improve.

– More combined communication limitations

Intervention Strategies

• Restoration--restore verbal expression

• Compensation--provide alternatives to natural speech

• Combined--Integrate AAC and natural speech

Cognitive/Linguistic Limitations Related to AAC

• Representation of Meaning

• Navigation through the AAC Interface

• Formulating Messages

• Organizing Content

Aphasia: AAC Acceptance & Use

• Long history of low tech AAC use to support residual verbal expression– Communication books and boards– Drawing– Handwriting– Photography– Remnant books

Aphasia: AAC Acceptance & Use

• High tech AAC use for specific tasks– Answering phone– Calling for help– Ordering in restaurants and stores– Giving speeches– Saying prayers– Engaging in scripted conversations

Rationale for Using Visual Scene Displays (Aphasia)

• Make use of preserved skills of people with chronic aphasia– Visual-spatial processing– Retention of information about life

experiences (episodic information)– Retention of general world knowledge

Strategy: To incorporate Contextually Relevant Visual Scenes

• Provide a way to represent meaning

• Support navigation within an AAC system

• Serve as a shared platform for co-constructing messages with listener(s)

• Establish a shared communication space

• Allow for integration with other types of communication supports

Evaluating Images for Contextual Richness of a Visual Scene

Four criteria:– Environmental context (setting, people,

objects, and activities)– Interaction with people or the environment– Personal relevancy– Clarity regarding elements key to the implied

relationships

Environment: HighInteraction: HighPersonal relevance: High Clarity: HighComment: Satisfies all the elements for being a good contextually-rich picture to support a story

Environment: AbsentInteraction: Absent Personal relevance: High Clarity: HighComment: Typical portrait that does not convey any contextual or interaction information

Environment: Absent

Interaction: Absent

Personal relevance: Absent

Clarity: High

Comment: Only serves to identify an

object; typical of pictures available in stimulus sets

Environment:

Interaction:

Personal relevance:

Clarity:

Environment:

Interaction:

Personal relevance:

Clarity:

• Environment• Interaction• Personal relevance• Clarify

• Good scene?– 1a Yes– No

• Environment• Interaction• Personal relevance• Clarify

• Good scene?– 1b Yes– No

• Environment• Interaction• Personal relevance• Clarify

• Good scene?– 2a Yes– No

• Environment• Interaction• Personal relevance• Clarify

• Good scene?– 2b Yes– No

Low Tech Visual Scenes with Text Support

http:aac.unl.edu

Visual Scene Display (VSD) for Aphasia and TBI

VSD Navigational Strategies (High Tech)

Themes• Organizational strategy for • navigation

Color & CONTRAST• Learning • Memory• Pattern recognition• Organization

“Link Deeper”• Continue on same topic

VSD

Three Levels Content Management Strategies

• 1. People who rely on AAC

• 2. AAC Facilitator/General Clinician

• 3. AAC Specialists

VSD with Content Management Functions For Facilitators

VSD Features

• Drag and drop images from• Enter messages from onscreen keyboard• Hide and reveal buttons• Select from a range of templates• Navigate themes• Navigate deeper into themes• Enter content with requiring detailed

programming knowledge

VSD Example

VSD Example

VSD Example

Research Strategy

Case Reports and Small N Studies of Clinical Interventions with Current Technology

Experimental Studies PreferenceMessage representationNavigation of Interface

Usability Evaluations of Technology Revisions

Aphasia: Participant 1

0

10

20

30

40

50

60

70

80

90

Per

cent

Tim

e U

sed VSD

Low Tech

Vocalizations

Gestures

Writing

Basic Needs New Information Social Closeness

Participant 1

25 themes

105 pages

377 messages

185 pictures

Aphasia: Participant 2

0

10

20

30

40

50

60

70

80

90

Perc

en

t Tim

e U

sed VSD

Low Tech

Vocalizations

Gestures

Writing

Basic Needs New Information Social Closeness

Message Representation: Preference

– N = 8– Miechelle McKelvey Dissertation

Results Summary: Preference– Personally Relevant Pictures: 85%– Non-personally Relevant Pictures: 13%– Iconic Symbols: 3%

Message Representation: Accuracy

– N = 8– Miechelle McKelvey Dissertation

Summary Results: AccuracyPersonally Relevant Pictures: 98%

– Non-personally Relevant Pictures: 55%– Iconic Symbols: 34%

Learning New Themes

• Strategy:– Series of Small N Studies – Completed during field tests

• Conclusion: – Instruction/practice on FIRST THEME varied– Minimal instruction/practice on Subsequent

Themes after the FIRST THEME was mastered.

Traumatic Brain Injury with Complex Communication Needs (N = 30)

• Summary from Fager et al. Survey (2006)• 32% used low-tech AAC

– Regained speech– Lack of Facilitator support– Lack of funding for high-tech AAC

• 68% used high-tech AAC– Of these, 87% used letter by letter spelling without message

retrieval– Minimal use of message retrieval strategies– Remainder used iconic symbols--

• TBI before learning to spell• Severe cognitive/language issues

VSD with Onscreen Keyboard Option

VSD

to support episodic message retrieval

to support multiple themes

to support narrative organization

to supplement residual speech

Onscreen keyboard with speech synthesis output to support spelled messages

VSD & Onscreen Keyboard with Speech Synthesis

VSD for Severe Cognitive Conditions

• Subset of People with TBI are unable to communicate through speech and experience such severe cognitive limitations that spelling is not an option for some them.

• VSD appears to be an option provided that visual issues are managed with large pictures and print.

• Field Trials Ongoing

Acknowledgements

• AAC-RERC– Janice Light & Jeff Higginbotham

• University of Nebraska– Karen Hux, Aimee Dietz, Miechelle McKelvey, Kristy Weissling, Sarah Wallace

• Madonna Rehabilitation Hospital– Susan Fager

• Quality Living, Inc.– Liz Anderson