As part of my curriculum for the CDIS 530: Alternative and Augmentative Communication course that requires me to observe an individual using an alternative and augmentative mode of communication, I got an opportunity to observe a friend’s mother who has been diagnosed with severe Broca’s aphasia. I chose Mrs. K. for observation, as she is non-verbal and communicates her needs by a variety of methods. The observation took place at Mrs. K’s home, on a couple of occasions- once during a family get-together and the other time in the presence of a Speech Pathologist (private practitioner) who comes every week to provide remediation services to Mrs. K at her home.
Mrs. K is a 58 year old housewife, who suffered from a cerebral vascular accident about three years ago. She is from a bilingual family; the languages spoken at home are predominantly Urdu and English. According to Mrs. K’s son, she herself is more proficient in Urdu, although she does understand English. Prior to the occurrence of cerebral vascular accident in May 2008, she was in good health and used to live alone in India, however after the occurrence of the stroke she has had to migrate to USA and has moved in with her son and his wife and their child 1 year of age. Cerebral vascular accident occurred in May 2008, without any overt cause, after the stroke Mrs. K was hospitalized for about a week and then discharged. The cerebral vascular accident and the resulting Boca’s aphasia has severely impacted Mrs. K’s life, as she had to migrate to a new country and is now living with her son and his family. She hardly ever leaves her home, and when she does, she is accompanied with a family member. The family member helps in communicating Mrs. K’s needs to her communicative partner. However, the family members too sometimes need to guess what Mrs. K may be trying to say.
According to Mrs. K’s son, a speech pathologist had worked with Mrs. K in India, initially after the stroke, and had attempted to introduce her to a communication board in addition to other oro-motor exercises. Mrs. K resisted the attempt to use communication board and only worked on some oro-motor exercises as she thought it may result in speech. The previous speech therapist focused the remediation program on introducing Mrs. K to a communication board and some functional gestures as well for example gestures for come, eat, and drink. Mrs. K’s son had to discontinue her speech therapy in India, as they had to move back to US and also due to continued resistance of Mrs. K towards both the communication board and the oro-motor exercises recommended by the speech pathologist. He feels, his mother is more open to using alternative and assistive communication system now, as she “has realized that speech may not be possible” and is now seeing a speech pathologist again. The speech pathologist comes to Mrs. K’s house every week. The speech pathologist, Ms. C, is also a bilingual and knows Hindi and English. Hindi is pretty similar to Urdu linguistically.
As per the medical reports, Mrs. K’s hearing is within normal limits. She wears bi-focal glasses for visual correction. She also uses a walking cane when walking, and needs assistance in getting up, after sitting for a long period of time.
Prior to cerebral vascular accident, Mrs. K could comprehend and express herself both Urdu and English. Currently, Mrs. K’s appears to comprehend both Urdu and English, however, the instruction in both language have to be simple and mostly one step commands such as “pass me the book” she experiences difficulty in following two or more step commands such as “Pass me the book and paper after writing your name on it.” Mrs. K is only able to vocalize “haan” which means yes in Urdu and “nai” which means no in Urdu, spontaneously with meaning. She is also able to use gestures for “come”, “eat” and drink. She points to self to indicate “I, me, mine” and points to other to indicate “you, yours” She is aware of the days of the week, the month and year, as she keeps track of the day and the month by ticking of the day on the calendar in her room. Ms. C, the current speech therapist had administered Western Aphasia Battery and the results indicate fair auditory verbal comprehension (about 85%) but severely limited speech output secondary to Broca’s aphasia and verbal apraxia. However, the speech pathologist cautioned that these test result have to accepted knowing that Western Aphasia Battery is a standardized test normed for speakers of Standard American English. Ms. C mentioned that Mrs. K’s writing ability is better than speaking ability and Mrs. K can occasionally write a desired word. She also is able to read familiar words in two to three word sequences. Mrs. K gross motor movements are accurate; however, she has tremors in the hands when performing fine motor movements such as turning pages in a book. Currently, Mrs. K’s communication needs are restricted to familiar people and family members.
Ms. C has taken approximately 6 therapy sessions with Mrs. K, which included assessment session; currently her goal is to improve Mrs. K’s functional communication skills. The speech pathologist is using a variety of techniques to improve Mrs. K’s functional communication skills. The techniques include both aided and unaided symbols sets and systems. Mrs. K uses a small bell to gain people’s attention. The speech therapist has introduced some common gestures from American Sign Language such as sit, more, finished in addition to previously learnt come, eat and drink. The speech therapist chose American Sign Language mostly because as Mrs. K is now residing in USA it may be more beneficial for Mrs. K to know American Sign Language. The other reason for choosing American Sign Language was Mrs. K’s use of gesture has proved to be effective so far. Mrs. K is also learning to fingerspell her name, address and telephone number of her son. In addition to the ASL, the therapist has introduced Mrs. K to low tech communication system, which consists of double pocket size communication book, available form Mayer and Johnson Company and a small notebook. Mrs. K carries a small pocket book with her, so that she may write down the target word, if the need arises and if the target word is not in the communication book. This notebook is attached to the double pocket communication book with Velcro. The double pocket size communication book available from Mayer and Johnson Company looks like a wallet and is easy to carry and use and it also provides for a larger vocabulary than a word board which was introduced to Mrs. K by the previous speech therapist.
The initial core vocabulary, which comprised of names of family members and friends, basic human needs and wants such as hungry, thirsty, restroom were selected by clinician in consultation with Mrs. K’s son. However, later Mrs. K would sometimes indicate what words she wanted on her communication device either by writing it down or by pointing to the unwanted symbol or picture and verbalizing “Haan” for yes and “Nai” for no. According to the speech therapist, Mrs. K also chose the black white symbols with words written on top over color coded symbols. The vocabulary is categorized according to the context. The expanded vocabulary was chosen using ecological inventory wherein an analysis of communicative opportunities and demands was done by family members and the clinician. These vocabulary items were either later confirmed or rejected by Mrs. K after a trial period of one week. The symbols used are PCS symbols available from Boardmaker.
The lexicon on the double pocket size communication book is categorized under the headings of people such as family members and friends and places such as home, mosque, grocery store. A single page in double pocket sized communication book for Mrs. K can accommodate about 24 lexicon items.
Mrs. K directly selects the lexicon items using her right index finger. Although there are slight tremors in her hand she is consistent in choosing the right picture, and is also consistent in turning to the desired vocabulary page depending on the context.
I observed Mrs. K producing quite a few two word phrases and a some three word sentences spontaneously to communicate, for example she asked me if I had eaten food by pointing to “you + eat”, she also asked me if I liked the food by pointing to “food+ nice+ sign for ?” Her son also noted that there has been an increase in communication attempts ever since she has started using pocket communication book.
The clinician was hopeful that Mrs. K will soon transition to using more 3 word sentences spontaneously to communicate with other. However, the clinician also raised her concern about the limitation of double pocket size communication book, once Mrs. K’s communication needs and lexicon expands. The clinician wants to explore some high tech communication devices such as Dynavox or Minspeak, but is restricted due to funding issues. As Mrs. K is a recent migrant, she does not have a health care insurance coverage, and her son’s health insurance does not cover Mrs. K. The clinician also noted that, currently Mrs. K communication needs are limited so she is not using her alternative and augmentative communication extensively, which may be insufficient to promote usage of AAC system in other contexts and situation. On the positive side Mrs. K is communicating spontaneously after a long time and her son reports that she seems cheerful now that she has stared communicating.
Overall, the observation was a great learning experience. I learnt firsthand trying to communicate with other using a limited vocabulary and the door of communication that opens when using an alternative and augmentative communication system. I also learned that no system of communication is better than the other, each has its own strength and weakness, and it’s our goal to promote overall functional communication so that an individual using an augmentative and alternative systems can be truly integrated into the society.