JUN 02 2020

Tip of the Month - June 2020 - AAC and Aphasia

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.