AAC for aphasia is often associated with independence, leading many people to assume that powered AAC is only appropriate if someone can use it without support. But communication is rarely that simple.
In this blog, Kate Laws, Clinical Manager and Highly Specialist Speech and Language Therapist, and Kate Reader, Highly Specialist Speech and Language Therapist at ATtherapy, challenge some common assumptions around AAC and aphasia. They explore how broadening our understanding of communication, success and support can open up more opportunities for people with aphasia to express themselves, connect with others and participate in meaningful conversations.
Powered AAC for people with aphasia is often viewed as a last resort or dismissed entirely if someone cannot use a device independently. But when we broaden our vision of what AAC success might look like, we open up far more opportunities for people with aphasia.
What is aphasia?
Aphasia is a condition that can make it hard to speak, read, write and understand others. It’s often caused by a stroke or brain injury, and it can affect people differently depending on which part of the brain is damaged. Symptoms may include:
- Being unable to find the right words.
- Speaking very slowly, with long pauses or incomplete sentences.
- Repeating, mixing up or missing out words.
- Making up words or sounds.
- Being unable to understand what others are saying.
- Difficulty reading or writing.
How might AAC use look for people with aphasia?
In 2005, Garrett and Lasker proposed a framework that described two categories of people with aphasia using AAC. They described:
“Independent communicators”: people who can independently take part in conversations through a range of learned strategies.
“Partner-dependent communicators”: people who are unable to learn and implement strategies independently and need a communication partner to support their communication.
Both research and our clinical experience tell us that “partner-dependent communicators” can become successful AAC communicators when appropriate adaptation is made and support is offered. If someone is unable to independently find words on a communication aid, this doesn’t mean AAC has failed or is unsuitable. If a communication partner provides options, or navigates to a page that supports a person with aphasia to express what they want to say, then this is a meaningful communication outcome!
Choosing tools for success
In grid-based AAC systems, an AAC user is expected to move between pages to build up sentences to communicate messages. However, navigating to find a word can be difficult for some people with aphasia.
People with aphasia are often creative communicators, using a range of strategies such as gesture, spoken attempts, singing a melody, drawing or writing a few letters. When adding other AAC tools into this mix, we should aim for a range of tools that support someone to get their message across by building on these existing strengths. Communication often involves a combination of gestures, words on a communication aid and facial expressions working together to convey meaning.
Powered AAC systems can now incorporate:
- Visual scenes: personalized photos surrounded by linked words or phrases. These are particularly useful for people with aphasia to give context and increase the number of turns in a conversation.
- Whiteboards: the person can draw an image with their finger, or write a few letters to give their communication partner a clue. This can be easier than using a pen/pencil.
- Maps: the person can provide a clue by showing the place where something happened.
- Photo albums: these are great conversation starters or ways of reminding someone of a personal story.
- Music and basic news apps: great ways of starting conversations.
In our clinical experience, combining a range of tools can provide more opportunities to initiate and maintain conversations for people with aphasia.
The tools selected for inclusion in an AAC system will be different for each person with aphasia, and the tools themselves often need to be edited and personalized. A ‘one-size-fits-all’ system can be overwhelming, and may not reflect a person’s strengths, needs and communication goals. The AAC systems provided by manufacturers are a starting point, but they work best when personalized to support how that person communicates in everyday life.
Personalizing tools: where to start?
When we are personalizing powered AAC systems, we need to establish:
- What is already working? We don’t need to add AAC features for things a client can already communicate successfully in another way (e.g. through gesture/pointing).
- When is communication breaking down?
- Who do they want to communicate with? In which situations?
In this way, we avoid the mistakes that come with assuming what is important to someone. Therapists often assume, for example, that food choices are important to personalize – we all want to be able to choose what we have for tea, right? Not so for one couple: the wife of a client with aphasia once told us that her husband has never had a say in what he gets for his dinner, so being able to communicate food choices was just not needed! What was important was to be able to joke, to remind his wife that the car insurance was due, to gloat about his football team’s wins and tell his friends what his grandchildren had been up to.
Each person’s life is different, and so their priorities around what is important for them to communicate will be different. Agreeing on goals that are meaningful to someone means that we can adapt systems and create solutions that will be truly useful.
The 'Supports' section in Aphasia Duo 9, which can be personalized.
Personalizing a system isn’t a one-off
Our conversations, interests and priorities change over time, so a system needs to grow with a person. This is why long-term access to Speech and Language Therapy is so important, and why training communication partners in AAC editing is crucial. It is also important to be proactive in looking at new developments in AAC: new features may come online that suit our clients perfectly.
Timing is crucial!
AAC systems can offer different benefits at different points in someone’s journey, so it’s important not to leave consideration of AAC until all other therapy has plateaued. However, learning to use an AAC system takes time and energy, so it’s also important to consider the pressures on the client and their communication partners. A brain injury is a traumatic event for the person and their family, as is adjusting to the new ‘normal’. Is this the right time for everyone? Do the client and their communication partners have the energy and space to take on this new learning now? If now is not the right time, revisiting AAC at later stages in someone’s journey when the situation and demands are different is important.
One-size-fits-one
As AAC specialists, we can use technology to bring meaningful change to our clients with aphasia. But one size does not fit all. We need to use creative approaches, personalized to the client, to support a wide range of people with aphasia to communicate in the ways that work best for them.