1. Presenter: Masoud Rouhizadeh Seminar on Speech and Language Processing for Augmentative and Alternative Communication Class 18: User Issues Papers

2. 1) AAC for adults with acquired neurological conditions: A review, Beukelman et al., 2007, Augmentative and Alternative Communication. 2) The morphology and syntax of individuals who use AAC: Research review and implications for effective practice, Binger & Light, 2008, Augmentative and Alternative Communication. 3) Memory aids as an augmentative and alternative communication strategy for nursing home residents with dementia. Bourgeoiset al, 2001, Augmentative and Alternative Communication.

3. Paper #1: Beukelman et al. AAC for adults with acquired neurological conditions: A review. A review of the state of the science of AAC for adults with acquired neurogenic communication disorders The topics of recent AAC technological advances, acceptance, use, limitations, and future needs of individuals with amyotrophic lateral sclerosis (ALS), traumatic brain injury (TBI), brainstem impairment, severe, chronic aphasia and apraxia of speech, primary progressive aphasia (PPA), and dementia are discussed.

4. Acquired Neurological Conditions Adults with acquired neurological conditions develop their verbal communication and literacy capabilities as typical speakers and writers. Then they gradually or suddenly lose their speech or language capabilities and are required to rely on AAC systems to meet their communication needs. In addition, the impact of their neurological condition on their participation patterns is potentially profound with reduced ability to care for themselves, a reduction or loss of employment, and usually a sudden or gradual restriction of their social networks.

5. 1) Amyotrophic Lateral Sclerosis (ALS) A rapidly progressive neuromuscular disease of unknown cause and no cure. Initial characteristics vary: brainstem symptoms involving speech and swallowing, initial spinal symptoms involving the limbs, or a mix of the two. The decision to use invasive ventilation extends the length of AAC use overall, as well as the duration of time during which AAC technology must be controlled with minimal or no limb or head movement. Artificial nutrition, may extend the length of life and could have an impact on AAC use: individuals spend less time eating, have more energy, and have more time to participate in the social activities of their choice.

6. AAC Acceptance and Use Approximately 95% of people with ALS become unable to speak at some point prior to death. Prior to 1996, approximately 73% of people with ALS used AAC Recently, 96% Those who rejected AAC demonstrated a co-occurring dementia or experienced multiple severe health issues, such as cancer, in addition to ALS; Appropriate timing of referral for AAC assessment and intervention continues to be a most important clinical decision-making issue. Ball, Beukelman, & Pattee recommend that individuals with ALS be referred for AAC assessment when their speaking rate reaches 100 to 125 words per minute on the Sentence Intelligibility Test (the mean is 190 wpm for normal adults)

7. AAC Acceptance and Use (cont.) A database review has documented that family members with non- technical backgrounds typically serve as AAC facilitators. Facilitator roles included mentoring and coaching unfamiliar listeners about how to communicate with the individual, programming messages, caring for equipment, trouble-shooting, and communicating with the AAC interventionist. These primary facilitators preferred hands-on, detailed step-by-step instruction. AAC care-givers reported very positive attitudes toward AAC technology. They reported increased perception of social closeness to the individual with ALS and less difficulty in providing care. Recent data from the Nebraska ALS Database have revealed that individuals with ALS use their technology until within a few weeks of their deaths.

8. Future Research Directions: Access Options A need for technology that can be adjusted to meet a range of motor capability demands. Dynamic touch screens Head-tracking technology Calibration issues for individuals with limited range of movement. Eye-tracking technologies: only effective under ideal situations Eye-tracking technologies that operate effectively and efficiently under a range of lighting conditions and postural conditions are still needed.

9. Future Research Directions: Speech Synthesis Age range of individuals with ALS who use AAC Age of other individuals who reside in long-term care settings with some of these individuals A continuing need for synthesized speech that can be easily understood by elderly people in less than optimal situations As new speech synthesis voices are introduced in speech generating devices (SGD), the effectiveness of these voices in adverse listening situations should be investigated and reported. The impact of the naturalness of synthesized speech on the acceptance and use of SGDs should be studied.

10. Future Research Directions: Access to other Technologies Individuals with ALS present with a range of needs to use their AAC technology to connect them to the outside world. Younger adults with ALS use the Internet to maintain their social networks. First, their generation has been active on the Internet since an early age. Second, their spouses often must be employed and their children are in school, which means there is limited support to maintain social networks. Individuals with ALS continue to use their AAC technology to program computers, do word processing, provide accounting services, or consult over the phone or Internet.

11. Future Research Directions: Facilitator Instruction AAC technology facilitators for individuals with ALS are selected largely because of their availability rather than their technical expertise. Therefore, there is a continuing need for ‘‘just-in-time’’ instruction to support them in their facilitator role(s).

12. 2) Traumatic Brain Injury (TBI) Extensive range of communication disorders: cognitive/linguistic as well as motor speech disorders. 55 – 59% recovered functional natural speech during the middle stage of recovery. Those who were unable: chronic, severe, motor speech or language disorders. Fewer people with relatively preserved cognitive function and severely impaired motor speech now than in previous decades. Given new medical interventions, additional research is needed to predict those with TBI who will and will not recover functional natural speech.

13. AAC Acceptance and Use High level of acceptance of AAC systems Letter-by- letter spelling strategies, Their cognitive limitations interfered with their ability to encode messages Some discontinued AAC use because they had recovered natural speech, lack of funding, and lost the support of an AAC facilitator. None of the participants rejected AAC after receiving it

14. Future Research Directions Reducing the Cognitive Load for Word/Message Prediction and Retrieval Nearly all individuals with TBI prepare messages using letter- by-letter spelling Few reports describing word prediction use Some were able to learn the encoding or prediction strategy None of those taught used the strategy in their everyday communication: It was "too much work" and that they did not "think that way." Need for a means to retrieve words and messages with reduced cognitive demands

15. Future Research Directions Supporting AAC Facilitator Learning It is apparent that an effective AAC facilitator is critical for continued successful use of AAC technology. The use of AAC technology by some respondents was discontinued due to a lack of consistent facilitator support during their transitions to residential settings.

16. Future Research Directions Supporting the use of Residual Natural Speech Individuals with dysarthria as a result of TBI typically wish to use their residual speech to communicate. Commercial speech recognition systems: Instructional strategies are often too difficult Recognition accuracy is relatively low No published reports of individuals with moderate to profound dysarthria who use speech recognition to meet their routine communication needs

17. 3) Brainstem Impairment Brainstem impairment damages the central nervous system structures that control speech production. Individuals with brainstem impairment often experience anarthria, that is, they are unable to speak at all, or experience dysarthria such that their speech is difficult to understand. Reports of natural speech recovery vary from 0 to 25%. Nearly all of these individuals require AAC support soon after the onset of this condition, as most are unable to speak during the acute phase. However, many rely on AAC due to chronic severe motor impairment that may or may not be classified as locked-in syndrome.

18. AAC Acceptance and Use Direct selection: single finger or head movement access Scanning: eyebrow, head, or hand movement Switch access sites: head movements, mouth, fingers, and hands. Assistive technology was used for communication, internet, email, writing, telephone, games, vocational duties, and faxing. Safe-Laser

21. Future Research Directions Motor Learning to Restore Head Movement or Body Movement Individuals with severe brainstem impairment are able to learn head movements, sufficient to access AAC technology, Ongoing research is needed to determine the extent to which motor learning provides sufficient recovery of head movement to allow for the use of conventional head tracking technologies.

22. Future Research Directions Eye-Tracking Technology under Less Than Optimal Conditions proper lighting precise positioning of the technology limited residual head movement precise calibration support

23. Future Research Directions AAC Systems Well-Connected to the World Change in residence, loss of employment, and a shrinking of one’s social network. The Internet provides an opportunity to remain engaged with family, friends, former colleagues, and others with severe disabilities. Additionally, it supports educational, recreational, and volunteer activities

24. 3) Severe, Chronic Aphasia And Apraxia Of Speech Aphasia is an impairment that results from brain injury, usually due to cerebrovascular accident, that may impair language production, language comprehension, or both. Most people acquire aphasia after the age of 60 or 70 years. Approximately one out of 275 elderly adults in the United States has aphasia. Up to 40% of individuals with aphasia have chronic, severe language impairment.

25. AAC Acceptance and Use Acceptance Often, those with severe, chronic aphasia reject AAC secondary for fear of it interfering with, or impeding, the restoration of their natural language system Acceptance and attitude includes their family, friends, and peers. Families often prefer natural speech for their loved ones People less familiar with individuals prefer AAC strategies Both families and peers were uncomfortable with the AAC strategies, because they worried that the implementation of such an approach might impede the return of natural speech. The authenticity of the messages and stories stored in AAC systems is questionable Whether the individual with severe, chronic aphasia actually authored the messages?

26. AAC Acceptance and Use Low-Technology AAC Date back 30years and include: communication and remnant books, drawing, photography, written words, messages, and written choices The lack of contextualization and personalization of communication books and boards given with aphasia Commercially available communication boards designed to facilitate communication about pain, preferences, and health concerns They deemphasize the importance of communicating to maintain social closeness, transfer new information, and express social etiquette

27. AAC Acceptance and Use High-Technology Interventions Lingraphica

28. AAC Acceptance and Use High-Technology Interventions Talking screen

29. Visual Scene Displays in DynaVox

33. Future Research Directions Technology Commercial computer software, digital photography, and Internet tools Impact of Context on AAC Interface Use Messages are frequently co-constructed with listeners The system must contain navigation strategies that can be easily managed by both system users and their communication partner VSD interface High-Quality Speech Output Integration of Contextually Relevant Information into Traditional Aphasia Interventions Acceptance and Use of AAC for Individuals with Severe, Chronic Aphasia

34. 4) Primary Progressive Aphasia (PPA) PPA is now recognized as a distinct clinical condition resulting in the gradual progression of language impairment in the absence of more widespread cognitive and behavioral disturbances for at least 2 years Rogers et al (2000) A three-stage plan of AAC intervention that relies extensively on low-technology AAC options: Communication notebooks consisting of photos, icons, and collections of remnants that represent an experience or an episode. Usually these items are accompanied by printed names or messages to assist individuals with PPA and their listeners.

35. 5) Dementia Dementia is a condition characterized by acquired, chronic, cognitive impairment that may involve a variety of domains, including executive function, attention, organization, visuospatial function, praxis (movement) or language. 10% of people aged 65 years and 47% of people 85 years and older diagnosed with Alzheimer’s disease (AD), a form of dementia. 4 million people in the US with AD; expected to be 14 million by 2050

36. AAC Acceptance and Use Interventions designed to remind them of temporal or semantic information Computerized memory aids Modifications of the communication partner’s behavior

37. Future Research Directions Lexical representation formats with and without voice output High-tech multi- media system that supports reminiscence interactions

38. Paper #2: Binger & Light, 2008 The morphology and syntax of individuals who use AAC: Research review and implications for effective practice, Binger & Light, 2008, Augmentative and Alternative Communication. A research review of 31 studies pertaining to the morphology and syntax of individuals who use AAC and who had severe speech and physical impairments (SSPI)

39. Introduction Developing grammar skills is a complex part of language development for individuals who use augmentative and alternative communication (AAC) These individuals, many of whom have severe speech and physical impairments (SSPI), rely on AAC devices that typically contain graphic symbols (e.g., line drawings, photo- graphs) and/or traditional orthography. Many individuals who use aided AAC appear to have difficulty mastering grammar skills

40. Paper Goals (a) To provide a systematic, comprehensive review of the literature pertaining to the morphology and syntax of individuals with SSPI (b) To discuss the implications of these findings.

41. Criteria for Inclusion and Exclusion of Studies (a) primary research studies published between 1985 and 2006 (journals and book chapters) (b) studies that reported data pertaining to morphology and/or syntax (c) studies that included either individuals who had congenital SSPI or who did not have disabilities but used aided AAC systems for research purposes. Morphology: the ‘aspect of language concerned with rules governing change in meaning at the intraword level Syntax: ‘organizational rules specifying word order, sentence organization, and word relationships’

42. Review Parameters Age and number of participants Disability type Research design Language and/or cognitive functioning Type of AAC system(s) utilized Aided AAC access methods Results of the study.

43. Receptive Grammar Global measures of receptive grammar Eight studies were conducted and involved 62 different individuals with SSPI Some individuals received receptive grammar scores within the average range for their chronological ages No consistent differences were found between the participants who appeared to be on target with receptive morphology and syntax skills versus those who struggled with these skills with respect to the age of participants, developmental level of participants, AAC systems used, or degree of residual speech Global measures 

45. Receptive morphology 19 children with SSPI (age range 4–17 years) Blockberger & Johnston, (2003): children who used AAC had statistically significantly greater difficulty with the three bound morphemes tested (past tense verbs, possessive’s, and third person singular –s) Redmond and Johnston’s (2001): 3 children also demonstrated difficulties detecting regular past tense verb errors. However, they performed better with other grammatical markers, including aspectual –ing, subject– verb agreement, and irregular past tense verbs.

46. Tools and tasks used to assess receptive morphology

47. Receptive syntax Two studies The young adults in Lund (2001) had difficulty with possessives and embedded clauses. Most performed well on items assessing prepositions, negatives, interrogatives, and coordinating conjunctions.

48. Tools and tasks used to assess receptive syntax

49. Expressive Grammar Global measures of expressive grammar: Length of messages Young individuals predominantly produced single-word (or very brief) messages when they used picture-based AAC systems. Some individuals who use aided AAC systems produce utterances containing more than one or two symbols The need to include grammatical markers on AAC devices.

50. Expressive morphology Six studies included a total of 25 individuals Many individuals who use AAC can and do express a wide range of morphemes but many individuals demonstrate morphological errors Kelford Smith et al. (1989) One participant demonstrated at least 90% accuracy for each morpheme type, Two others were below 90% for all but one morpheme type.

51. Expressive syntax Range and complexity of syntactic structures Kelford Smith et al. (1989) 6 individuals used complex and/or compound sentences Only two of the participants relied primarily on simple sentence structures For complex sentences, accuracy levels were all at or above 80% Only one participant obtained 100% accuracy for compound sentences; the remainder ranged from 6 to 91%. In some other studies: the production of grammatically complete simple sentences ranged from 0 to 98% Overall, the expressive syntax findings revealed that many individuals were capable of producing a wide range of syntactic structures, but producing grammatically complete and correct sentences was challenging for many of them

52. Expressive syntax: Word order Word order difficulties have been reported both with individuals with SSPI and with children without disabilities who used aided AAC for research purposes Sutton et al. (2000) found that when adults without disabilities used AAC systems that contained limited grammatical markers, they adjusted the word order of sentences to avoid ambiguity

53. Grammar Intervention Using the participants’ AAC devices to model the intended targets Bruno and Trembath (2006): some of the children demonstrated post-intervention progress with acquiring grammatical structures, although others did not. This indicates that mastering grammatical structures may be quite time-consuming for some individuals.

54. Discussion Many aided AAC users had difficulties with receptive and expressive grammar Few consistent patterns emerged across the studies Individuals with SSPI did tend to use brief, grammatically incomplete messages to communicate. Because message creation via AAC is usually a slow, laborious process for individuals who rely on AAC, using brief utterances may ‘reflect a choice of effective language style, thus suggesting communicative competence, rather than deficits’ Many of the studies in this review presented relatively low levels of evidence. Out of the 31 studies, 20 lacked any type of experimental control and reported only descriptive measures Very few participants

55. Factors that may affect Grammatical Outcomes Intrinsic factors that may affect mastery of grammar include developmental/cognitive level, literacy level, motor capabilities, speech intelligibility, and/or presence of a receptive and/or expressive language disorder. 1) the desire to promote communicative efficiency may help to explain the high rates of single-symbol and telegraphic messages, including the practice of message co-construction; 2) some of the graphic symbols on an aided AAC device may represent multiple concepts for an individual, thus negating the need to use multiple symbols. 3) the input-output asymmetry inherent to most aided AAC interactions: the person using AAC receives input via spoken language but produces messages via multiple communication modes 4) it is likely that an interplay of the factors listed above affects grammar outcomes for many individuals with SSPI.

56. Discussion Implications for Practice Providing clinical services to address grammar skills Assessment Tasks Conducting an appropriate assessment that yields a clear picture of clinical strengths and areas of need Intervention Techniques Models, contingent queries, elicitation questions, recasts/expansions, forced- choice alternative questions, corrections of incorrect forms, and explanations of grammatical rules Many tasks that are used for assessment purposes can also be used in intervention, such as sentence completion tasks

57. Directions for Future Research (a) developing and evaluating assessment tools to accurately and reliably assess receptive and expressive grammar of individuals who use AAC; (b) developing and evaluating intervention techniques designed to teach grammar skills to individuals who use AAC, including those from diverse backgrounds; (c) determining when grammar intervention is and is not appropriate for an individual who uses AAC; (d) investigating the impact that using aided AAC has on grammar acquisition; (e) investigating the role that receptive grammar plays in the acquisition of expressive grammar; (f) investigating the impact of using various types of symbols on the expression of grammatical markers.

58. Paper #3: Bourgeois et al (2001) Memory aids as an augmentative and alternative communication strategy for nursing home residents with dementia, Bourgeois et al (2001), Augmentative and Alternative Communication. A research review of 31 studies pertaining to the morphology and syntax of individuals who use AAC and who had severe speech and physical impairments (SSPI)

59. Introduction Nursing home residents, often presumed to be incompetent and dependent by their care givers, may be spoken to in stereotyped ways that limit their “chances for a meaningful conversation and convey a sense of declining capability, loss of control, and helplessness”

60. Memory books Linguistically, memory books provide the semantic content in the form of sentences, words, or phrases; pictures; and access to additional semantic information stored in long-term memory. Also, the written/graphic form may serve to bridge the apparent comprehension deficits when directions and questions are delivered verbally. Operationally, memory books capitalize on preserved procedural memory skills, such as reading aloud, page turning In the social domain, memory books capitalize on preserved discourse strategies and a desire to communicate on the part of residents with dementia As a strategic skill, memory aids are, by their very nature, compensatory strategies that compensate for memory loss and help to access stored memories.

62. The Dysfunctional Communication Environment The quality of staff-resident communicative interactions is frequently described as impoverished When there are communication problems in the nursing home environment, there also tend to be problems with staff morale, high rates of staff turnover, and quality of life issues for residents Memory books, wallets, and cards have been shown to improve the conversational abilities of persons with dementia In this study it was hypothesized that nursing aides would improve the quality of their conversational interactions with residents using memory aids by asking fewer questions and decreasing other nonfacilitative behaviors.

63. Method The effect of memory aids on conversations between nursing aides and residents with dementia During 5-minute conversations Nursing home units in seven nursing homes were randomly assigned to treatment and control conditions. Residents in the treatment condition were given 12-page memory books consisting of autobiographical, daily schedule, and problem resolution information. Their assigned nursing aides were trained to use the memory books during care interactions and throughout the day.

64. Measures The duration and quality of verbal interactions between dyads of a resident and their nursing aide during 5-minute conversations were measured pre- and post-treatment Computer-assisted observational techniques: The verbalization of the resident (duration, percentage of time), The verbalization of the nursing aide (duration, percentage of time), Positive and negative statements (frequency), Memory book use (duration, percentage of time). Verbatim transcriptions of videotaped conversations Trained, Novel, Question, Ambiguous, Unintelligible, Perseverative, Error, Other Quality of Life Measure The Geriatric Depression Scale (GDS) N = 66; 33 treatment dyads and 33 control dyads

65. Treatment and control groups Residents in the treatment group were observed using their memory books during conversations 83.2% of the time. Control group residents did not have memory books at any time during the study.

66. Results Changes in Quantity of Nursing and Resident Behavior Significant time × group interactions as a result of the intervention. Residents with memory books significantly increased the number of utterances they used in post-training conversations, compared with control residents.

67. Results Changes in the Quality of Conversational Interactions Residents in both groups had similar changes in individual content categories over time. Data were grouped into informative (novel + trained utterances) and uninformative (ambiguous + perseverative + error + unintelligible utterances) categories The second analysis revealed a significant time × group interaction for informative utterances.

68. Results Effects on Quality of Life There were no significant effects of the intervention on depression ratings over time for either residents or nursing aides. After training, nursing aides rated residents as less depressed than at baseline.

69. Discussion Nursing aides generalized communication skills acquired in the care setting to a conversational situation without additional training. The communication skills training + memory book intervention was effective in changing the quantity and quality of conversational interactions between nursing aides and their residents with dementia. Specific facilitative patterns emerged; nursing aides who reduced their percentage of verbalization time and frequency of questions in response to residents’ use of memory books had more equitable conversations with those residents. Reduced nursing aide verbalizations appeared to encourage increased resident verbalizations, an increased frequency of resident utterances, and lower difference scores on resident and proxy quality of life measures.

70. Future work Future interventions to improve the social and communicative environments in nursing homes should incorporate techniques to teach nursing aides: How to elicit conversations about feelings, emotions, and opinions from residents with dementia and How to respond in ways that promote a higher quality of life for both residents and staff.

71. Thank you.