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WHY use visual communication supports?

People with aphasia benefit from visual supports, also called augmentative and alternative communication (AAC), to help them understand language, express themselves, and support reading and writing. Historically, compensatory strategies, such as AAC visual supports, have only been introduced when restorative strategies have plateaued or are not working. This means that the person might wait a long time to get a communication book and have to tolerate a lot of frustration during this time. AAC should be part of the total aphasia rehabilitation package. If we wait to introduce AAC we are at risk of: increasing frustration due to communication breakdowns; increasing risks of depression and withdrawal from social situations, therefore leading to having a resistance to AAC when it is finally presented because it looks like the person has “failed” to get their speech back and “have” to use AAC.

It is important to remember that AAC may look different in various settings. For example, a relatively ‘simple’ AAC system (such as a pain scale and a choice board) might be used in the acute setting but later as the person is discharged into the community and some spontaneous recovery has occurred, a more ‘complex’ communication book or high-tech device might be put in place. There are many different low-tech AAC systems that just require printing and laminating that you could try. We’d recommend just giving it a go to see what is useful for the person with aphasia and what might need tweaking!

Myths around AAC for people with aphasia

1.  AAC can be provided too soon after an neurological event –This statement assumes that: AAC is a bandage at best and a last resort at worst; AAC will interfere with the return of speech; and that AAC is not part of speech therapy. There is research showing that AAC will not prevent speech from returning and in fact, provides a multimodal communication tool that will if anything aid in speech rehabilitation. This does not mean that you need to have a really complex 100-page communication book on day one, it might just mean that you start with some simple communication boards and then adapt it over time as spontaneous recovery occurs and rehabilitation changes.
2. An individual can be too cognitively impaired to benefit from AAC – There are no prerequisites for using AAC.  Learning to use AAC is just like learning to use language – you need to be taught and practice, practice, practice! The least dangerous assumption states that “in the absence of absolute evidence, it is essential to make the assumption that, if proven to be false, would be least dangerous to the individual”, therefore according to this principal we need to assume that a person is going to be able to learn. Again, this might mean that you have a more simplified communication book or board rather than a hugely complex communication system but you can adapt it and add to it as needed.
3. An individual can be too physically impaired to access AAC – There are lots of different methods to access a communication system and an Occupational Therapist can help with this. If the person is not able to directly access (point with a finger) then they could use partner assisted scanning, eye gaze, stylus, etc.
4. AAC will hinder regaining speech/ If you have some speech, you don’t need AAC – There is a lot of research showing that AAC adds to communication and that it will not hinder speech production. Even if you are able to use some speech, AAC provides a multimodal approach to communication to reduce communication breakdowns and frustration when speech is not quite enough.
5. Symbols look too childish – This is a personal preference. AAC can be created with symbols (which are less visually cluttered and easier to differentiate on the page) or photos (which can be highly personalised and meaningful to the person), so give the individual both options and let them decide.  

Communication books

Communication books are useful because using photos or pictures combined with the written word can support memory and help with word-finding difficulties. Communication books can be grid-based or visual scene-based. There many different types of communication books (e.g. size A4 or A5, number of phrases on the page, photos or symbols, etc), so it is important to get your Speech Therapist to help you find one that works for you. TalkLink have many templates, which you can customise to make it meaningful and functional for the person with aphasia. Remember to try and get the person with aphasia to be as involved as possible with choosing which phrases, photos and pictures go into the communication book. 

Grid displays come in lots of diferent sizes. TalkLink have templates with 4/9/12 symbols per page. Remember to include: personally relevant messages (not just the phrases on the template); maps; personal stories (e.g. when they got married, the birth of a new grandchild, etc); sentences that are phrase-based rather than just single words; and an alphabet for spelling page if they are able to spell out some words (use some initial letter cueing). Remember that it needs to be asthetically pleasing or it won’t get used as adults are embarassed to bring something ugly out with family/friends,let alone a shop assistant.  It is worth the time and effort to include the person with aphasia in the decision-making process. We all know that if we don’t like something, we won’t want to be seen with it.

Visual scene display (VSDs) is a picture that portray events, people, actions, objects and activities against the backgrounds within which they occur or exist. Research about VSDs with people with aphasia shows that it may be more 1) accepted due to it’s appearance 2) easier to use 3) more personalized. VSDs offer a way to (1) capture events in the individual’s life with clear photos without much visual clutter, (2) offer interactants a greater degree of contextual information to support interaction and (3) enable communication partners to participate more actively in the communication process as the scenes are highly personalised. They also shift the focus away from the expression of wants and needs toward social interaction and the exchange of ideas and information.

WHAT are visual communication supports? 

There are many different types of visual systems which may help – ideas are listed below.  It is important to remember that learning a new way of communicating can be difficult for a person with aphasia, so any visual system must be functional, useful and must be used every day. Visuals displayed in this document can be found on the TalkLink website or by emailing your local TalkLink office with a request for a certain communication support.

Shopping lists – could be handwritten or printed pictures.  You could laminate the visual shopping list and circle (with a white board marker) the items you need to get from the supermarket and then wipe the circle off when you place each item in the trolley to visually show that you have got that item.	Menu boards – you could use Velcro or BlueTack to change the date and food options each day. The menu could also be written on a white board with the page number for a recipe book as a reminder of how to cook that meal.
Yes/No visuals – sometimes people may say “yes” when they mean “no”.  Using a visual where a person can point to the visual of yes or no can reduce inaccuracy – these can be printed with pictures or handwritten on a piece of paper or white board.	Phone lists - laminate a list with photos and name of important people and their phone number in large font right next to the phone – family members, medical professionals, friends, caregivers.
Identification card – print a few of these and store them in a pocket, wallet, tied to walker/walking stick or attached to lanyard. The card can be shown to explain which communication strategies can help, how to contact in an emergency, and a bit of information about aphasia.	Daily Planner – it can be confusing remembering what day it is and what is happening that week. This can help to reduce anxiety about what is happening next or around forgetting important activities/appointments.  See Tip of the Month on Visual Timetables for more info.
Cueing boards – you could ask the person “what topic are you taking about?” and then “when did it happen” and then “could you tell me what letter the word starts with?”	Continuum lines – a scale to indicate how someone is feeling or the complexity of a task.  You ask them a question and then they can point to a place on the line to show how they feel about that question.
Topic cuing boards – when the person with aphasia is struggling to express themselves, ask them to cue you into what topic they are talking about before you start guessing. For example, if the person indicated they were talking about family, the conversation partner could then ask yes/no questions relating to family members to find out the intended message.	Communication boards – if the person is not keen to use a communication book, communication boards can be used for a range of specific activities where remembering and naming specific items may be challenging such as gardening group (names of seeds, gardening tools, seasons, etc), book club, cooking, watching TV, ordering at a café, etc.  TalkLink can email resources or they can be downloaded from the website.
Talking Mats – This is a commercially available resource that is a visual aid for decision-making and sharing opinions during conversations.  It is interactive and uses three sets of picture communication supports - 1) a topic (meal times, activities that are important to you, etc), 2) visual options (pictures or photos or hand drawn images of each of the options) and 3) a visual scale (yes, no, maybe/don’t know) – and a space on which to display them – this could be a white board or a carpet square or large piece of paper.  After you have finished talking about that topic you can take a photo of the board as a record of the conversation. The individual with APHASIA is shown each topic one by one and asked whether they ‘like’ that activity or ‘would like to do’ that activity, etc.  They place the visual under ‘yes’, ‘no’ or ‘maybe/not sure’. https://talklink.org.nz/talking-mats-courses	Pain board / something’s wrong board – pain and illness can be difficult to identify and discuss verbally, so having a board with the most common issues, a rating scale to indicate how bad the pain is and some options for what to do about the pain can be helpful.

Other ideas:

·         Large print calendar or diary to keep track of the day, as well as appointments and events – keep this in a very visible place like the front of the fridge.

·         Labels and signs - on doors or objects, e.g. place a label and photo on each door in a retirement village so that you know who lives where, or labels on the linen cupboard shelves to sort towels, sheets, etc.

·         White board or paper & pen - to write lists or write down instructions so that the person can refer back to them if they forget what they are doing half way through an activity. 

·         Memory book – sometimes called “This is your life book” or “All about me book”. See below section.

·         Memory wallet – like a memory book but a smaller version.

·         Photo albums and reminiscence (generic) photos.

·         Communication passport – Here is a link on the TalkLink website how to create a communication passport and a template you could fill in. 

Free or cheap apps to support communication 

Google Maps or Apple Maps for showing places - sometimes visually showing a person the place you are talking about is easier than trying to name the place or describe it.

• Google Calendar or Apple Calendar for reminders of appointments and recurring events, e.g. “caregiver coming in 15 minutes”, “do your Multimodal Communication Therapy practice now”, “take your blood pressure medication (blue bottle) now – 1 pill”, “start getting ready to go out to your hair appointment – Driving Miss Daisy will be here in 30 minutes”.
• Built-in Photo Gallery app - have different folders within the app with pictures to support communication, e.g. folder of photos of family members, folder of caregivers pictures, photos of most recent trip, photos of medical professionals. Most built-in Photo apps allow you to click on the photo and then click “edit” and write the name of the person directly onto the photo, or the name of the place, etc.
• Talking photo apps – allows you to share memories. They allow you to record a sentence on each page of the story and add a photo. Then the person can look though them and remember special events and memories in their life. e.g. Little Story Creator, Pictello, Book Creator, All About Me Storybook, Talk’n Photos, Click n Talk
• Built-in Timer app - set alarms throughout the day for reminders, e.g. 8am everyday “take medication”, 9pm everyday “have a shower and get ready for bed”, 6pm on Tuesdays “put the rubbish out on the road for collection” etc.
• Visual time table app – if a text-based reminder on the Timer or standard calendar app is confusing, then adding a picture can help.  e.g. Visual Schedule Planner,  PictureRoutines, Symbol Calendar AAC Pro, What's Next (Visual Prompts)
• Built-in text to speech on a mobile phone – This setting allows the person to press and hold text on the screen and then it will read the text out to them so they only have to listen rather than read it. Check the TalkLink website for a Tip of the Month on how to do this on Apple and Android phones – or call your local office.
• SpeakText Free is an app that will read any text or webpage if you are having difficulty with reading
• Built-in Notes app - use the whiteboard feature to handwrite or draw something and then you can save the image into your gallery to view later or send in an email, Facebook/WhatsApp message or post it on Facebook.
• Speakme – is a white board app that will then read out the handwriting as a reminder or what was written
• Simple recipe app or blog - Having pictures or a short video accompany each step of a recipe can be helpful for maintaining independence during cooking. These apps/websites includes simple recipes and have sequenced visual supports you can print and laminate to go with each instruction.  Accessiblechef, Tasty app or SideChef
• Use video calling through FaceTime, Skype, Facebook messenger, WhatsApp, etc, to connect face-to-face with video allows for use of facial expressions, gestures and visual supports, such as holding up your communication book to the camera to show the other person what you are talking about.
• Use Pinterest to create communication boards by visually bookmarking favorite movies, travel destinations, recipes, or unique interests. These can be used as topic prompts during conversations.
• Listen to audio books or podcasts rather than try to read them by using Audible (paid), your local library audio book app, Apple Podcast app, etc.  Alternatively, you can pair audiobooks with e-books so you can listen and read at the same time using Amazon’s WhisperSync.
• Meditation has been shown to potentially increase language recovery, decrease anxiety/stress/depression associated with having a language disorder, try HeadSpace (free with in-app purchases) or free meditations on YouTube
• A simple white board/drawing app can be used to draw pictures to support communication, e.g. Simple Draw on Android or built in Notes app on Apple
• TalkPath News (free news source that reads the daily news to adults with aphasia/and language loss): TalkPath News for Apple, TalkPath News for Android devices
• Big Launcher (for Android phones) - replaces the home screen with this app and increases the size of the buttons and text and reduces the amount of navigation/remembering where apps are on the phone

Multimodal communication therapy 

There are lots of different ways of communicating, such as speaking, writing, drawing or using a communication system. Multimodal communication therapy is an effective programme to support communication.  For more info see this Tip of the Month. 

Scripting therapy 

A script is a predictable sequence of sentences. A script can be a story that the person with aphasia tells, also known as a monologue. A script can also be between two people, such as ordering food in a restaurant. In either of those cases, the words the person with aphasia will use are easy to predict. Teaching scripts can improve topic content, speaking rate and can increase communication across a variety of situations and listeners. It can also increase confidence and maintain independence. Scripts can be taught verbally or using a communication book.

• Have the family and the person with aphasia pay attention to routines and phrases used in everyday life. Ask a family member to write them down. Now you will have a list of what is important to the person’s everyday life, and these phrases can be used as scripts to practice. Scripts and Multimodal Communication Therapy can be used together to practice as many different methods of communication as possible. Remember to introduce a communication book as early as possible after a stroke so the person and their communication partners can familiarize themselves as much as 

Memory book 

A memory book is an external cognitive aid meant to assist with cognitive deficits, specifically memory and perhaps executive function.  Most of the time it is used by an individual with memory loss alone and is not accessed by other people.  Memory books differ from communication books because a communication book is an external communication aid, which is used between two people for the purpose of sharing a message. Pictures or written text in the communication book are a reference point between the individual with aphasia and his/her communication partner. A memory book is a SELF-reference tool to orient an individual to what they have done in the past (e.g., retrospective memories) or things they need to do in the future (e.g., prospective memory). A communication book is a “community” reference that aids communication.

·         A memory book is a connection to the present and a bridge to the past.  This contains information about the individual’s life, history, hobbies, family, friends, holidays, etc. 

·         It can be used to 1) refocus the individual during word-finding difficulties or times of frustration, 2) to initiate conversations about their life and interests, 3) to enhance self-esteem, 4) as a security tool when they are in an unfamiliar place (such as the hospital).

·         Communication partners could ask the individual about 1) things they feel proud of in their life, 2) people who are important to them, 3) favourite memories, 4) hobbies, 5) places they have travelled, etc.  If the individual does not respond to these questions, flip through the book and read the annotations and comment on items included in the book to initiate conversation.

·         A memory book can be created on paper using Microsoft Word or by handwriting next to photos in a scrapbook. It is best to keep the pages simple and uncluttered by having only the photos and some short and simple statements on each page. Memory books could also include remnant such as papers, or materials that remind someone of an event or experience. Ticket stubs, maps, seeds, dried flowers, etc can all serve as memories of special events.  These items provide a visual and tactile way of sharing information and connecting with others.  

·         Here are some templates – Personal Life History, Life Story Book and All About Me Book.

·         It could be created on the computer or an app.  Book Creator, Pictello or All About Me are useful apps for creating memory books, electronic ‘talking’ photo albums and for sharing personal information/stories/memories with others.   

WHEN should I use visual communication supports?

It is important to use them throughout the day.  You may use a range of different supports (from the above list) during different times of the day. Use them to 1) warn the individual of what is going to happen (visual time table or calendar or diary), 2) to reduce anxiety about what is going to happen (visual time table or calendar or diary), 3) to reduce anxiety about word-finding difficulties (memory book, communication passport, visual scenes, photo albums) and 4) to enjoy conversation (memory book, visual scenes, calendar, talking photo books). 

WHERE should I keep the visual communication supports?

All of the visuals can be used at home, in residential care, at the shops and in other community locations. It is useful to stick the visual up where you would most commonly talk about that person/event/activity, e.g. have a visual timetable on the fridge (pictured beside), a shopping list on the pantry door, memory book and photo album on the coffee table or bedside table, identification card in their wallet or placed in their pocket each morning, pain board beside the bed or in the bathroom, photos of people by the telephone, etc. If it is available, it will get used whereas, if you have to walk to a different room to find the communication support, you probably won’t use it. 

HOW should I use visual communication supports?

·         Use them in natural everyday conversations to add to your verbal communication. You don’t stop talking when you use a visual communication support.  The visual, added to your verbal communication, can increase the individuals understanding and memory recall.

·         Be consistent in using the communication supports each and every day. 

·         Ensure that everyone communicating with the individual with aphasia knows how to use the communication supports so that there is consistency.  The focus is on maintaining communication as much as possible and compensating for any weakness, so use the person’s personal priorities when setting goals, deciding what visual or therapy programmes to use and making plans for the future. Here is a list of 100 examples of really functional long term goals.

Tips for creating visuals for someone with aphasia

Make sure that you:

·         Have lots of white space around words and pictures

·         Use less visually complex symbols or photos, i.e. make sure that people stand in front of a plain white background when you are taking photos to add to their communication book  

·         Large standard fonts (Arial size 14/16 or above is good) (even when people don’t have a visual impairment)

·         Use simplified syntax and vocabulary, i.e. don’t use multisyllabic long words

·         Add visuals/pictures/photos to all text to support comprehension 

Tips for communicating with a person with aphasia

How you talk to a person with aphasia is just as important as the visual cues you use. Tips for caregivers and communication partners:

·         Reduce background noise from TV or radio

·         Ask simple questions – only ask one question at a time, then wait for an answer before asking another

·         Give the person extra time to respond – count to 10 after you ask a question or make a comment before saying anything more

·         Speak in short, concrete sentences, i.e. don’t use metaphors. But don’t use baby talk or talk down.

·         Respond immediately to communication attempts

·         Maintain eye contact and try to sit or stand at the person’s eye level rather than hovering above them 

·         Redirect the person from frustrating problems to things such as photo albums, memory books or other activities

·         Rephrase the conversation so far, to keep a topic focused when a person is confused

·         Avoid quizzing for the ‘right answer’

·         Encourage and validate the use of any communication techniques, even if they weren’t used quite the way you were expecting

·         Instead of filling in a word, ask if they want help or prompt them to use a visual support

References:

research by Sarah Wallace https://www.duq.edu/academics/faculty/sarah-wallace

https://honeycombspeechtherapy.com/script-training/

http://tdvox.web-downloads.s3.amazonaws.com/MyTobiiDynavox/td-myths-adult-too-soon.pdf

Created by Jessamy Bell (TalkLink Speech Language Therapist) April 2020 

To download this Tip of the Month as a PDF, please click here