Augmentative and Alternative Communication
(AAC) for adults with severe aphasia: where we
stand and how we can go further
B. JACOBS*, R. DREW, B. T. OGLETREE and K. PIERCE
Department of Human Services, Western Carolina University, Cullowhee, USA
Abstract
Purpose: To review literature specific to the use of AAC with
adults who have severe aphasia.
Method: The authors reviewed studies involving AAC interventions
for adults with severe aphasia.
Results: Published data support the use of aided and unaided
AAC with adults with severe aphasia in controlled treatment
contexts. Reported gains in communication typically have not
generalized to everyday settings.
Conclusions: The application of AAC with persons with severe
aphasia must address factors potentially limiting treatment
success outside of training environments.
Introduction
The communicative needs of persons with aphasia are
varied and challenging making the implementation of
meaningful and effective interventions a central priority
of speech-language pathologists charged with their care.
During the past three decades, Augmentative and Alternative
Communication (AAC) has emerged as a treatment
option for many adults with aphasia, specifically
those with severe aphasia. While clinical intuition
suggests that AAC should be both well received and
successful, anecdotal treatment reports have often been
discouraging. This article reviews literature specific to
the application of AAC with adults with severe aphasia.
Published treatment reports are presented from the past
30 years that have included unaided, simple aided, and
more sophisticated aided AAC options. Augmented
output and input devices and strategies are featured.
This review is followed by a discussion of factors contributing
to treatment outcomes. Finally, suggestions for
promoting communicative success through AAC are
provided.
Severe aphasia
Aphasia, the loss of the ability to comprehend and/or
formulate symbolic language, is not an all or none
phenomenon. That is, persons with aphasia can retain
aspects of comprehension and expression, but be unable
to communicate functionally in ways that are acceptable
to themselves or those in their environments. Severe
aphasia refers to a degree of impairment that limits
either comprehension or expression to the extent that,
at least, verbal output is very limited. Obviously, individuals
with severe aphasia would appear to be potential
candidates for AAC.
Early unaided and aided AAC treatment results
Kraat1
examined the results of multiple studies
published during the late 1960s through the 1980s in
which researchers attempted to teach non-speech modes
of communication to individuals with severe aphasia.
Her article reviewed the then prevalent assumption that
AAC techniques offer minimal assistance to adults with
acquired language disorders and discussed future directions
for AAC use with this population.
Kraat’s1
review indicated that the results of studies
during the late 60s and early 70s were encouraging in
that individuals with severe language impairments could
learn alternative means (e.g., signs, symbolic gestures
and written words) of expression and comprehension.
In addition, training signs appeared to facilitate
improved spoken language in some individuals, which
led to training that paired symbolic gestures with speech
production.2 – 7
According to Kraat, early research
suggested that AAC techniques might have important
roles in aphasia treatment.
During the late 70s, the focus of aphasia treatment
shifted from phonology, syntax and semantics to prag*
Author for correspondence; Department of Human Services,
Western Carolina University, Cullowhee, NC 28729,
USA. e-mail: bjacobs@email.wcu.edu
DISABILITY AND REHABILITATION, 2004; VOL. 26, NO. 21/22, 1231–1240
Disability and Rehabilitation ISSN 0963–8288 print/ISSN 1464–5165 online # 2004 Taylor & Francis Ltd
http://www.tandf.co.uk/journals
DOI: 10.1080/09638280412331280244
matics, further encouraging the use of AAC as an
appropriate treatment tool. At the same time, new technologies
such as personal computers and synthetic
speech provided AAC devices that allowed viable
communication alternatives for individuals with apha-
sia.
Kraat’s1
review of new technology in the early 80s
again indicated mostly encouraging results. That is, individuals
with severe aphasia acquired non-speech
communication symbols and mastered the technical
operation of AAC devices. However, doubts about the
functionality of AAC use in this population began to
surface. For example, although many individuals
learned alternative means of communication, the rate
of symbol acquisition was often slow and the vocabulary
acquired was small (less than 100 words). Furthermore,
the non-speech forms acquired were not actively used
outside of the structured contexts in which they were
taught. Other problems observed reflected deficits in
language and cognition that limited success with alternative
modes.
Kraat1
summarized the findings of studies undertaken
during the late 60s through the 80s as indicating, ‘AAC
techniques currently appear to have a very tenuous place
in aphasia rehabilitation’ (pp. 326). Before abandoning
AAC as an aphasia treatment tool, however, Kraat
suggested a more critical examination of the techniques
that had been applied, how they had been applied, with
whom, and with what expectations. In aphasia, techniques
primarily had been applied in a global way with
the expectation that non-speech forms would replace
speech or restore functional levels of communication.
Minimal attention had been directed towards supplemental
or restricted applications of AAC, such as using
written words to increase comprehension.
Other issues Kraat1
addressed were the appropriateness
of training procedures and the measures used to
evaluate AAC applications. Her review found that the
acquisition of non-speech communication modes typically
did not result in pragmatic use of these alternate
forms in social interactions. This suggests that more
pragmatic and systematic training is required to effect
functional change. Additionally, the measures used to
evaluate the results of AAC applications assumed a
direct relationship between the discrete acquisition of
forms and communicative competence, in spite of
evidence to the contrary. The studies Kraat reviewed
rarely provided structured training protocols for integrating
AAC techniques into natural settings; therefore,
evaluation of the efficacy of such techniques was limited.
A final issue presented by Kraat1
was the minimal
attention to variables within AAC components. The
studies reviewed indicated that AAC techniques were
assigned randomly, rather than in terms of what might
be best suited to the individual with aphasia. They
further indicated a tendency to separate formally-taught
non-speech forms (e.g., gestures, devices) from other
communication strategies used by individuals with
aphasia, such as pointing to objects/actions in the environment
or using residual speech and intonation. Kraat
suggested that when multiple natural and taught modes
are integrated, they are more likely to result in functional
changes. She further suggested that the lack of
attention to vocabulary and language issues in the
studies reviewed might have impacted the success of
acquisition and use of AAC forms.
Kraat1
concluded that some of the new AAC technologies
might be applicable to aphasia rehabilitation and
provided examples that illustrated applications in reading
comprehension, conversational use and self-cuing.
She emphasized, however, that the complex language,
motor and cognitive deficits that have challenged aphasia
rehabilitation efforts in general, ‘will continue to
challenge the new applications and technologies developed
in AAC as well’ (pp. 334).
Recent treatment studies
This section examines issues and suggestions outlined
in Kraat’s1
review to determine if encouraging evidence
to support the use of AAC in adults with aphasia has
been reported in more recent studies. The following
review is not comprehensive, i.e. only those studies
incorporating some degree of experimental control and
addressing treatment efficacy issues are included. Studies
emphasizing unaided means are presented first followed
by those featuring simple and more sophisticated aided
options.
Two studies in the early 1990s8, 9
used unaided AAC
approaches with adults with moderate to severe nonfluent
aphasia. Coelho8
investigated manual sign acquisition
using a single-subject multiple-baseline acrosssettings
design with two participants with aphasia. They
were taught 12 iconic signs representing various food
items. Training was administered in two conditions:
the clinic and a simulated restaurant setting. Results
indicated that participants acquired the use of trained
signs in both settings; however, only one participant
generalized sign use to the natural setting. Maintenance
of sign use was observed for the settings in which training
occurred, but not in the natural setting. Coelho
interpreted these findings as encouraging, but not an
‘endorsement for recommending sign training with all
aphasic patients’ (pp. 216 – 217). He further concluded
B. Jacobs et al.
1232
that observations and family reports indicated that
neither participant increased sign use in daily communication
following treatment.
Conlon and McNeil9
tested the efficacy of Visual
Action Therapy (VAT)10
on the communication skills
of two participants with global aphasia. The objective
of VAT is to train symbolic representation of line
drawings and gestures so that individuals with severe
aphasia can pantomime the associated symbolic
gestures. Separate single-subject multiple baseline
across behaviours experimental designs were used to
examine treatment effects. The results indicated a positive
treatment effect for 46% of trained steps for one
participant and 86% for the other one; however,
generalization from successfully trained steps to
untreated steps was poor for both participants. Additionally,
maintenance of the treated behaviour varied
within steps and across participants. Conlon and
McNeil concluded that, given the poor generalization,
the positive VAT effects were not sufficient to conclude
that this approach is effective in achieving the
programme’s original purpose of establishing ‘symbolic
representation.’
Bellaire et al.11
used an aided AAC non-verbal
approach to examine the acquisition, generalization
and maintenance effects of picture communication
board training. Two participants with severe nonfluent
Broca’s aphasia were trained in clinical and natural
settings. Communication boards were constructed
displaying 15 line drawings of items appropriate for
the natural setting. Bellaire et al. used a multiple-baseline
across behaviours design to evaluate ability to point
to target drawings on the board across all study phases.
Treatment in the clinic setting consisted of training
pointing responses by cues, models, and physical assistance.
If generalization to the natural settings did not
occur, two programmes to promote generalization were
applied. These programmes involved a role-playing
procedure in either the treatment room or the natural
setting. Results indicated acquisition of requesting and
personal information responses for both participants.
Neither participant acquired social responses. Additionally,
generalization to the natural setting did not occur.
Based on the lack of treatment effect for social
responses, Bellaire et al. concluded that ‘picture boards
may not be useful for communicating information that
can be conveyed through undifferentiated responses
such as head nods’ (pp. 225). The authors further
concluded the role-playing procedure was not effective
for achieving generalization and suggested that use of
communication boards might best be trained in functional
natural environments.
Although Bellaire et al.11
, Coelho8
and Conlon and
McNeil9
demonstrated that non-verbal communication
modes can be acquired by individuals with long-term
chronic aphasia, their results did not demonstrate generalization
to functional use outside of treatment settings.
These findings may indicate that non-verbal communication
methods are not embraced by individuals with
aphasia because they seem unnatural. Avent et al.12
evaluated
the effectiveness of two treatment models: a
compensatory (non-verbal) approach that incorporated
written, gestural and drawing modes; and, a restitution
(verbal) approach that incorporated accurate verbal
sentence production. Three participants with mild to
moderate aphasia received both verbal and non-verbal
training to improve descriptions of picture stimuli. A
single-subject alternating-treatments design was used
to assess treatment differences. Verbal treatment was
based on the Texas Aphasia Contrastive Series
(TACS);13
the non-verbal approach was based on
PACE-like treatment.14
A 15-point multidimensional
system based on the Porch Index of Communicative Ability
(PICA)15
was used to score picture descriptions.
Results indicated that none of the participants reached
the accuracy criterion level in either of the treatment
conditions within the 15 sessions administered and each
responded to treatments in unique ways. For example,
comparable improvements were noted in both conditions
for one participant, accuracy was higher in the
verbal condition for one participant and in the nonverbal
condition for the third participant. All participants
improved; however, ‘one type of treatment was
not clearly better’ (pp. 300). Follow up testing 3 months
post-treatment also indicated variable maintenance.
Avent et al. concluded that their results raised questions
about how treatment effectiveness is evaluated. It should
be noted that these investigators provided no data relevant
to functional use of the behaviours trained, again
highlighting the lack of attention to social validity
issues.
Verbal plus gestural training, a form of intersystemic
reorganization wherein an intact gestural modality is
paired with an impaired verbal one,4, 6
has been used
to improve verbal production in adults with severe
aphasia and apraxia of speech.2, 3, 5, 7
These early studies,
as well as more recent ones,16, 17
have documented the
benefits of such training in mildly, moderately, and
severely impaired individuals with aphasia. However,
with the exception of the Raymer and Thompson17
study, these investigations were not carefully controlled.
Raymer and Thompson used a single-subject multiplebaseline
across behaviours design to examine the effect
of verbal plus gestural training on oral naming. One
Adults with severe aphasia
1233
participant with severe nonfluent Broca’s aphasia and
apraxia was trained to produce single words with initial
phonemes chosen based on articulatory stimulability
testing. Words were paired with appropriate unilateral
hand gestures, primarily based on Amer-Ind.18
Results
indicated that repetition of three of four target
phonemes was improved and generalized to untrained
and related phoneme exemplars. An overall increase in
gesture use that facilitated verbal responses was documented;
however, little improvement of oral naming
was demonstrated. Raymer and Thompson concluded
that their findings stood in contrast to the optimism
regarding other similar gestural treatment programmes
for severely impaired individuals with language and
motor speech deficits.
Schneider et al.19
used Raymer and Thompson’s17
verbal plus gestural treatment sequence for another
population of adults with aphasia, i.e. primary progressive
aphasia (PPA). Schneider et al.19
examined the effect
of treatment on oral production of simple sentences
(noun + verb + noun). One participant with a 21
2 year
history of non-fluent progressive language decline was
trained to use three verb tenses (present progressive,
past and future) for four verbs in a sentence production
task using a matrix training procedure. A single-subject
multiple-baseline across behaviours design documented
treatment and generalization effects within and across
language matrices. Line drawings were used to elicit
the target verb tenses in a simple sentence structure.
Gestures that depicted noun, verb, and tense markers
in the drawings were selected from Amer-Ind18
and
taught prior to training sentence production. A reversal
component was introduced during treatment as a
measure of control, i.e., gestural response was discontinued
and only a verbal response was required. Results
indicated improved production of grammatical
sentences using trained verb tenses and generalization
to untrained verbs within tense. Paired verbal plus
gestural responses resulted in higher accuracy levels than
verbal responses alone, and follow up testing 3 months
after training indicated that gestural responses were
maintained for all verb tenses while verbal responses
declined for two tenses. In addition, comparison of
pre-post treatment narrative language samples suggested
that, while some linguistic behaviours declined in a
manner expected in PPA, the percentage of simple
sentences increased. Schneider et al. concluded that
‘treatment was effective in maintaining specific linguistic
behaviours despite the degenerative language decline
ensuing from primary progressive aphasia’ (pp. 312).
Two strategies currently used to facilitate interactive
communication for adults with acquired severe aphasia
are communication aids and conversational partner
training.20 – 23
Garrett and Beukelman’s21
investigation
of Written Choice Strategy (WCS) used a technique they
developed24
to assist partners’ conversations with individuals
with global aphasia. The technique involves partners
introducing a topic of mutual interest and initiating
a conversation with a question before orally reading
written choices and encouraging individuals to point
to a choice. Following pointing responses, partners
provided reinforcement based on the response intent
and content. Follow-up questions and written choice
supports continue to be provided until topics are
exhausted. This technique focuses on the exchange of
meaning, rather than the form, of the communication
act and provides an alternative non-speech modality.
It also expands beyond the individual with impairment
to include communication partners.
Garrett and Beukelman21
used an ABAB’B singlesubject
reversal design to measure the effects of three
types of partner support during conversations: (1) no
support (baseline); (2) thematically structured written
choice support; and, (3) non-thematic written choice
support. During each condition, communication mode,
quantity (number of exchanges and topics), comprehensibility
and accuracy of information transfer between the
partner (Garrett) and a participant with chronic severe
aphasia were tallied. The results of this study indicated
that the participant’s number of conversational
exchanges per topic and comprehensible responses were
higher with written choice support. Likewise, the participant’s
wife judged his comprehensible responses to
be proportionally more accurate when he answered
questions with written choices. Although the participant
continued to communicate through other channels (e.g.,
yes/no and gestural responses), his preference was for
written choice communication when it was available.
Garrett and Beukelman concluded that ‘the written
choice technique supported the transfer of information
between the partner and the aphasic communicator,
which in turn allowed conversational exchanges to
extend beyond the minimum number mandated by the
experimental procedures’ (pp. 247). They also suggested
that this technique would be useful in non-conversational
situations (e.g., rapid exchanges between nurses
and patients regarding medical needs). Despite the
restriction of choices and dependence on structured
rules, Garrett and Beukelman felt that written choice
communication might provide increased communicative
quality for individuals with limited communication
options.
Lasker et al.22
used an alternating treatment design to
investigate specific components of Garrett and BeukelB.
Jacobs et al.
1234
man’s21
WCS. They examined the relative contributions
of two WCS components, written and spoken words, by
measuring response accuracy in different presentation
modes. The participants in the Lasker et al. study (three
adults with severe aphasia) responded to questions
under three conditions: auditory-only format (choices
were spoken); visual-only format (written choices were
not read aloud); and, standard WCS (simultaneous
auditory and visual format). The results indicated different
response accuracy patterns for participants across
presentation modes. Two participants responded
equally to all modes, although their response accuracies
differed. In contrast, the third participant needed both
written and auditory cues for optimal performance.
Her responses in the standard WCS mode were superior
to responses in the other two modes. Based on the finding
that all participants answered questions in the standard
WCS condition with an average of 87% accuracy,
Lasker et al. concluded that their results confirm that
simultaneous auditory and visual components of WCS
evoke mostly accurate responses from individuals with
severe aphasia. The authors cautioned, however, that
‘specific components of Written Choice may be crucial
to the accurate performances of certain users’ (pp. 115).
Fox, Sohlberg and Fried-Oken20
used an alternating
treatment single subject design to examine ‘the benefit
of conversational topic choice for promoting use of
communication aids designed to communicate opinions
or to describe events’ (pp. 193). Fox et al. tested whether
choice of topic improved use of symbol-based aids with
familiar and unfamiliar partners in the clinical environment
and with family and friends in the natural environment.
Choice was made from topics judged to be of
equal value to three participants with severe Broca’s
aphasia. Quantitative data on selected variables (e.g.,
number of non-ambiguous symbols used to respond to
questions and to comment) were obtained under two
conditions: choice and nonchoice topic communication
aid training. Generalization to natural environments
was assessed by having each participant’s primary
conversational partner rate their satisfaction with
conversations.
Fox et al.20
developed communication aid vocabularies
for topics that consisted of personal photos,
coloured magazine photos, and/or Boardmaker computer
line drawings with key word labels; these pictures
were displayed on pages in a binder. Participants
received communication aid training designed to teach
use of these aids in conversations about choice/
nonchoice topics. Conversation partner training,
provided to promote generalization, involved watching
an instructional video that encouraged pointing to
pictures in the binder when conversing with the participant,
allowing adequate response time, and confirming
understanding of messages. Partners also were encouraged
to take the aid into natural environments to model
use for less familiar partners.
The results of the Fox et al.20
study indicated that,
although all participants showed improved use of
nonambiguous symbols in communication aid training,
only the youngest one with more recent onset of aphasia
benefited most from topic choice in the clinical environment.
This benefit did not generalize to natural environments
where he used his nonchoice aid more than his
choice aid. This participant also showed the greatest
potential to use his choice and nonchoice topic aids with
partners in multiple natural environments. Conversation
partners reported high levels of satisfaction with natural
environment conversations. Fox et al. concluded that
their results ‘illustrate some of the difficulties inherent
in capturing the effects of a dynamic concept such as
choice in a complex and lengthy procedure such as
communication aid training’ (pp. 187). They further
concluded that their study confirmed similar challenges
with natural environment generalization reflected in
previous research8, 11, 25, 26
and suggested that other variables
(e.g., topic preference) were more relevant to
communication aid use than the ability to use nonambiguous
symbols and topic choice.
Lyon et al.23
took a different approach to training
communication partners. They attempted to enhance
communication and well-being in settings where adults
with aphasia and their caregivers live and interact. The
approach emphasized ‘communication with a naı¨ve
normal adult while concurrently strengthening a more
active, self-determined, and controlled role in daily life’
(pp. 695). Treatment involved community volunteers
(Communication Partners), rather than caregivers; partners
were paired with adults with aphasia and trained to
act as their liaisons for bridging clinical and real-life
pursuits.
During the initial 6-week period of this study, a clinician
suggested a number of communication strategies
that the partner could use with the adult with aphasia
including letting them try to say the message first,
encouraging use of gestures or drawing following
unclear spoken messages, and moving from general to
specific questions to clarify messages. The partner and
the adult with aphasia practiced implementing these
and other strategies in the clinical setting as the clinician
observed and provided further suggestions. During the
subsequent 14 weeks, pairs engaged in weekly activities
selected by the adult with aphasia. A session with the
clinician in the clinical setting each week during this
Adults with severe aphasia
1235
phase served as a review of the previous week’s activity
and planning time for the outside activity the following
week. Only the adults with aphasia and the communication
partners participated in the outside activities.
A combination of standardized tests of language,
communication or well-being, non-standardized investigator-constructed
questionnaires, and informal
measures (SLPs’ subjective ratings of outcomes and
tallies of activities) were used to measure the effects of
training for 10 treated pairs. As predicted by Lyons et
al.,23
results indicated that pre-post treatment differences
on standardized tests did not approach statistical significance
due to the lack of sensitivity and specificity of
standardized measures for revealing treatment gains.
SLPs’ subjective evaluations of outcomes as having been
met, not met, or exceeded, varied across pairs. One-third
of the pairs fell into each of the three categories.
However, SLPs’ tallies of the number of activities
initiated during treatment, sustained after treatment
ended, and begun following treatment indicated that
nine of 10 pairs established activities that were sustained
and eight of nine added activities following treatment.
The investigator-constructed questionnaires indicated
significant gains in well-being and communication for
all participants, i.e., adults with aphasia, partners, and
caregivers. Lyon et al. concluded that, ‘This consensus
illustrated the potential value of Communication Partners
in merging clinical and real-life therapies and, as
importantly, fostering reciprocal and simultaneous
repair of both communication and self’ (pp. 702).
All of the studies reviewed thus far have used unaided
or low-tech aided AAC approaches to treatment of
adults with aphasia. The studies reviewed in this final
section have incorporated high-tech AAC devices into
their treatment.27 – 35
According to Koul and Harding,27
‘Computer-based graphic symbol communication
systems are one of the most recent additions to the
current repertoire of AAC options’ (pp. 11), and a
number of software programs and/or dedicated devices
are currently available for individuals with little or no
functional speech.
Murray’s29
longitudinal study of a participant with a
4-year history of non-fluent primary progressive aphasia
(PPA) used different treatment approaches over a 21
2
year period. At the beginning of this period, Back-tothe-Drawing
Board (BDB)36
was implemented to capitalize
on intact right-hemisphere functions. This
programme taught the participant to draw a series of
uncaptioned cartoons that increased from five singlepanel
to three triple-panel cartoons. The results of the
BDB programme indicated that post-treatment drawings
depicted main events more accurately and reflected
greater detail and clarity than pre-treatment drawings.
Despite positive treatment effect, little spontaneous use
of drawing in communication interactions outside the
therapy room was observed. Four months post BDB
treatment, however, the participant began to augment
written messages with drawing.
Murray29
adopted a dyadic, functional treatment
approach subsequent to the BDB program, and introduced
an electronic AAC device—a Dyna Vox. Symbols
for messages were selected and programmed in the Dyna
Vox with preselected functional vocabulary. A variety of
role-play activities were used to foster the use of the
device, as well as conversations between the participant
and familiar and unfamiliar partners. Although the
conversations were to encourage use of the Dyna Vox,
the participant was also encouraged to use a variety of
modalities (e.g., drawing, writing, gesturing). The results
of training indicated that the participant adapted to the
AAC device quickly and demonstrated improved
message accuracy length and response latency.
However, the participant and her spouse reported minimal
use of the Dyna Vox outside the home or clinic,
likely due to portability issues. Based on the results of
post-treatment functional communication assessments,
Murray concluded that the variety of treatments helped
the participant to retain ‘relatively effective and independent
functional communication, despite the progressive
decline in her linguistic abilities’ (pp. 668).
Another AAC system (TalksBac) was specifically
developed for adults with nonfluent aphasia using a
portable computer with a built-in speech synthesizer.
TalksBac provides predictive access to a personalized
database of sentences and stories. Waller et al.31
trained
four participants with nonfluent aphasia and their caregivers
to use the TalksBac system over a 9-month period.
The participants’ pre-post treatment communication
skills were assessed with a battery of tests.
Conversational abilities with and without the system
also were compared to determine whether TalksBac
allowed better participation in conversations. The
results of the post-treatment assessments indicated little
change in underlying comprehension and expression
when compared to the pre-treatment assessments.
Analysis of the videotaped conversations indicated that
abilities improved when using the system for two of
three participants (the fourth was not able to carry out
conversations using TalksBac independently). Waller
et al. concluded that the conversational abilities of one
participant were not enhanced by the system because
he had developed his own nonverbal strategies that were
more effective. The authors further concluded that
‘TalksBac has the potential to augment the communicaB.
Jacobs et al.
1236
tion abilities of adults with nonfluent aphasia who have
not been able to develop their own compensatory strategies’
(pp. 46).
The computer-based visual input communication (CVIC)
software is another iconographic system that was
specifically designed as an alternative mode of communication
for adults with chronic severe aphasia. Shelton,
Weinrich, and colleagues have investigated the efficacy
of C-VIC in a number of recent studies28, 30, 32 – 35
and
found that individuals with severe aphasia can access,
manipulate, and combine graphic symbols following
rules specific to the C-VIC software system. For example,
Weinrich et al.32, 33
trained two participants with
severe aphasia to comprehend and produce locative
prepositional phrases and reversible subject-verb-object
(S-V-O) sentences in English and C-VIC according to a
defined treatment protocol (refer to 37 for details). The
results indicated that the participants comprehended
word order in C-VIC S-V-O sentences better than they
were able to assign symbol order during sentence
production. Their results also demonstrated improved
verbal production, a finding that is consistent with the
long-held notion that training graphic symbols improves
speech production.4
In a similar study focused on verb
tense morphology, Weinrich et al.34
also found that three
participants with severe expressive aphasia demonstrated
improvements in comprehension and verbal production
of correct verb tense morphology following C-VIC training.
In contrast, McCall et al.28
found improvements
specific to C-VIC training, but no improvement to natural
language. Similarly, Weinrich et al.35
found that single
S-V-O sentence production did not generalize to multisentence
C-VIC or verbal production.
While the C-VIC studies documented encouraging
results in terms of the participants’ abilities to access,
manipulate, and combine graphic symbols, Shelton et
al.30
reported little evidence that the individuals trained
on C-VIC used the system to interact with family
members. This finding is consistent with Garrett and
Beukelman’s24
observation that replacing natural
language with an AAC device may not enhance functional
communication skills and that effective AAC
intervention requires involvement of communication
partners.
Koul and Harding27
evaluated whether results
obtained with C-VIC could be replicated with a different
software program. This programme, referred to as TS,
was designed to offer graphic symbols with synthetic
voice output, as either a dedicated device or stand-alone
software that turns a microcomputer into an electronic
communication device. The TS program was used to
train five participants with severe or global aphasia.
Koul and Harding27
employed a single-subject multiple-baseline
across behaviours design to assess the effects
of training on symbol identification. The second treatment
phase was non-experimental, i.e. no baseline data
were collected; instead, the percentage of correct
sentences produced was documented to assess symbol
production. Prior to treatment phase one, participants
were taught the mechanics of the computer and TS
program. A structured hierarchical protocol followed
that progressed from easy to more difficult tasks. The
results of symbol identification training indicated that
all participants identified noun symbols better than verb
symbols and symbol combinations. Results of the symbol
production task were comparable to the identification
task in that the most frequently observed error on the
production task was omission or incorrect verb symbol
selection. Koul and Harding concluded their results
‘essentially replicate the results obtained in several
previous studies with C-VIC’ (pp. 19). They further
concluded that the evidence from several studies of CVIC
and their study of TS indicated that individuals
with chronic severe aphasia demonstrate superior performance
on computer-based graphic symbol systems as
compared to their spokenorsign-based language abilities.
Finally, Koul and Harding pointed out that, although
these AAC systems can be effective tools in aphasia
intervention, little evidence is available relative to their
functional use in everyday communicative interactions.
Where do we stand?
A primary purpose of this article is to draw conclusions
specific to the state and effectiveness of AAC treatment
for persons with severe aphasia. The preceding
review provides a confusing, yet intriguing point for
consideration. That is, although positive AAC treatment
effects have been reported for this population, they have
occurred in controlled environments and, in most cases,
failed to generalize to everyday settings.
One can only speculate as to why individuals with
aphasia might not be successful AAC users in natural
settings post treatment. Could it be that researchers
and practitioners have failed to extend and support
training in real world contexts? In our review, only the
Lyon’s et al.23
study provided a structured extension of
a treatment protocol into the everyday settings of
persons with aphasia. Although their unique use of
communication partners as trainers failed to generate
traditionally measurable treatment effects, participants
reported increased perceptions of success and well being.
Another plausible explanation for limited generalization
of treatment effects could be the acceptance of
Adults with severe aphasia
1237
AAC by users and those around them. In a recent report
of AAC intervention with an ‘ideal’ candidate with
aphasia, Lasker and Bedrosian38
note their subject’s
reluctance to use AAC post a period of successful training
in a clinical setting. These investigators suggest that
AAC acceptance and use is a complex factor in treatment
success involving myriad factors, including readiness,
treatment methods, and outcome measures.
A factor related to AAC acceptance is the conceptualization
of socially valid treatment outcomes. For example,
is the common therapy goal of simple device or
system use meaningful to the user and his or her communicative
partners outside of traditional training venues?
The earlier review noted a shift away from discrete form
related goals to more pragmatically appropriate objectives
in the 1970s and 80s. This move reflected an attempt
to generate meaningful AAC outcomes for persons with
severe aphasia. Since that time, however, one must question
how well we have established and measured
outcomes that are socially valid.
To conduct socially valid treatment we must discover
what is significant to consumers of therapeutic
services.39, 40
Schwartz and Baer41
noted that ‘consumers’
can be categorized according to their involvement with
intervention efforts. The following four types of consumers
have been identified: direct, indirect, immediate
community, and extended community.
Direct consumers are the individuals receiving
services. In contrast, indirect consumers are persons
who are significantly affected by changes in direct consumers.
For example, an indirect consumer may be a
family member or close friend. Consumers in the
immediate community have regular contact with direct
consumers yet may not be strongly affected by changes
targeted through treatments. For example, a church or
club leader may be an immediate community consumer
for many children. Finally, consumers in the extended
community are persons who have no regular contact
with direct consumers. For example, a waiter in a
restaurant or a person passing by on the street could
serve this role. Extended community consumers, then,
may be thought of as unfamiliar interactive partners.
An obvious impediment to socially valid goal setting
is the need to assess the consumers mentioned above.
Simply stated, this takes time and is difficult. Browder42
discussed the importance of including family members
and others. Schlosser43
reported a series of means by
which several investigators in the field of AAC have
assessed one or more consumer groups specific to
setting goals. For example, direct, indirect, and
immediate community consumers have been evaluated
through discussion, problem solving, and other subjective
methods. Schlosser proposed that immediate and
extended community consumers could also be assessed
through social comparisons (e.g., in this case comparing
characteristics of successful and unsuccessful
AAC users). The same method has also been used by
Colton and Sheridan.39
Finally, could the lack of treatment gains in natural
settings for persons with severe aphasia be related to a
failure to adequately control the myriad factors complicating
communicative success for all AAC users? For
example, the ease of use of a system, its portability
and cosmetic appeal, the saliency of vocabulary selected,
and countless other factors, all impact users’ success
with AAC. One can question the degree to which these
system variables and other consumer variables (e.g.,
knowledge of and attitudes toward technology) have
been controlled.
Can we go further?
It is our opinion that AAC applications with persons
with severe aphasia are at a critical juncture. We must be
open to new ideas and changes if there is to be an
increased probability of meaningful treatment success
in the future. What, then, are recommended avenues
of pursuit with this population?
First, training studies must employ careful measures
to control for system and user variables that might
impact findings. These include, but are not limited to,
ease of system/device use, vocabulary selection, and user
knowledge. Second, training paradigms must be
designed that systematically extend treatment to natural
contexts. This appears to be a major shortcoming of
studies conducted to date. Obviously, treating outside
of controlled environments introduces potentially
compromising risks to intervention (e.g., multiple trainers
and training contexts). In our opinion, the
increased opportunity for treatment success outweighs
these risks. Third, investigators must carefully examine
their methods, goals, and outcome measures to determine
their social validity. The work of Schlosser43
provides a helpful guideline for using the various participants
of AAC to help address this critical need. Finally,
subjects must be selected that present a significant
‘buy in’ to treatment. Participants buy in clearly includes
motivation and partner/environmental support. Some
effort to measure these variables prior to intervention
would make treatment findings more interpretable.
In closing, there continues to be an intuitive fit
between AAC and persons with severe aphasia. Validating
this fit will largely depend upon the ability of
researchers and/or clinicians to discover and make use
B. Jacobs et al.
1238
of the variables and strategies that affect acquisition,
retention, and most importantly, communicative use in
naturally occurring environments.
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