Published on January 15, 2008
The Fundamentals of AAC: An Approach to AAC Assessment, Treatment and Documentation: The Fundamentals of AAC: An Approach to AAC Assessment, Treatment and Documentation Patricia Ourand, MS, CCC-SLP Susan Fridie, OTR, ATP Lewis Golinker, Esq. March 21, 2003 Communication: Communication “If all my possessions were taken from me with one exception, I would chose to keep the power of communication, for with it I would soon regain all the rest.” Daniel Webster Goals of AAC : Goals of AAC 1 2 3 4 Slide4: communicate self care needs communicate emotional status; engage in social communicative interaction with immediate family members; carry out communicative interactions in the community Primary Medical Diagnosis: Primary Medical Diagnosis Identify and describe primary medical condition ALS (ICD-9 Diagnostic Code 335.20) CVA (ICD-9 436) Traumatic Brain Injury (ICD-9 854) Cerebral Palsy Spastic, congenital, infantile (ICD-9 343.9) Athetoid (ICD-9 333.7) Multiple Sclerosis (ICD-9 340) Communication Diagnosis: Communication Diagnosis 1 2 3 4 Expressive Communication disorder: Expressive Communication disorder Identify and describe the secondary diagnosis (e.g., expressive communication disorder): dysarthria (ICD-9 Diagnostic Code; 784.5) aphasia (ICD-9; 784.3 ) apraxia (ICD-9; 784.69) aphonia (ICD-9; 784.41) Current Communication Impairment: Current Communication Impairment Dysarthria (784.5) % intelligible, speaking rate “Demonstrates mild dysarthria, as evidenced by a speaking rate of 101 wpm and intelligibility of 91% on the Sentence Intelligibility Test 4.5” Prognosis/ rate of improvement vs. decline Current Communication Impairment: Current Communication Impairment aphasia (784.3) Include scores on receptive and expressive language tests Western Aphasia Battery: Overall Aphasia Quotient: 56.4/100; Spontaneous Speech: 4/10(Fluency, Grammatical Competence, and Paraphasias); Auditory Comprehension: 9.3/20; Repetition: 4.4/10; Naming: 5.5/10; Reading and Writing: 14.7/20 Current Communication Impairment: Current Communication Impairment Apraxia (784.69) Apraxia Battery for Adults: Scores consistent with severe to profound apraxia of speech; however, results were confounded in part by the presence of expressive language deficits. Anticipated Course of Impairment: Anticipated Course of Impairment State and describe the expected course “Due to the degenerative nature of ALS, Mr. D’s speech condition is not expected improve, nor is he expected to maintain functional speaking abilities over time. As the progression of this disease continues, Mr. D. will not able to use natural speech to meet communication needs in his daily life, therefore he will require the use of a speech generating device (SGD) throughout the remainder of his life.” Anticipated Course of Impairment: Anticipated Course of Impairment “Given the time post onset and current severity of his apraxia and moderate aphasia, his prognosis for developing functional speech is poor. In addition, his needs cannot be met using natural communication methods (e.g. speech, gestures, writing) or low-technology speaking aids (e.g. communication book). He requires a SGD so he can interact effectively with both familiar and unfamiliar communication partners” Functional Communication Needs:: Functional Communication Needs: 1 2 3 4 Functional Communication Needs:: Functional Communication Needs: Describe the patient’s specific needs. These may include: communicative content (e.g., medical needs, social interaction, family interactions); communication contexts (e.g., face-to-face communication, group, phone); types of partners (e.g., familiar, unfamiliar); and environments (e.g., home, community, work). Functional Communication Needs:: Functional Communication Needs: Examples include: Communication to meet physical needs: communicating on the telephone or to a caregiver in emergency situations and expressing both basic and detailed needs to wife and caregivers. Categories of AAC devices:: Categories of AAC devices: 1 2 3 4 Categories of AAC devices: : Categories of AAC devices: digitized speech: pre-recorded messages, 8 minutes or less recording time pre-recorded messages, more than 8 minutes recording time synthesized speech: spelling, access by physical contact with device synthesized speech, multiple methods of message formulation, multiple methods of device access Assessment Data: Assessment Data 1 2 3 4 Assessment Data: Assessment Data Cognition Language Motor Sensory Assessment Data: Cognition: Assessment Data: Cognition Include a clinical assessment (formal and/or informal) discussing and describing the severity of cognitive impairment, if present. If no impairment is present or suspected, state such. Where available, include a state from the neurologist or primary care physician. Slide21: In a Clinic Note dated 12/02/02, Dr. R notes that “His neurological examination shows that he is awake, alert, and oriented to time, place and person”. Clinician observation and interactions with Mr. M. supports the suggestion that he has no cognitive impairments associated with this disease. He demonstrated the ability to follow complex information (e.g., discussion regarding medical care) and directions related to the discussion of various augmentative techniques and strategies (e.g. word boards, scanning arrays). As well, during this evaluation, T. was able to ask cognitively intact questions, requiring age appropriate cognition. Based on the observations of this clinician, Mr. M. appears to possess the cognitive skills necessary to effectively use a speech-generating device to communicate and achieve functional communication goals. Assessment Data: Cognition: Assessment Data: Cognition If deficits have been identified, describe the patient’s cognitive abilities. As an example, for an individual with a TBI, the clinician may indicate a level of cognitive functioning using the Rancho Levels of Cognitive functioning. Assessment Data: Cognition: Assessment Data: Cognition Describe attention, memory, problem-solving skills Note how these skills relate to the individual’s ability to develop communication competence utilizing an ACD/SGD. Assessment Data: Cognition: Assessment Data: Cognition Using less formal clinical observations, indicate the patient’s ability to attend to evaluation tasks or comment on his/her ability to learn device operations and recall locations of programmed messages. Other examples, include indicates regarding the patient’s ability to use strategies to expedite message production (e.g., simplify words, use abbreviations). Slide25: Be sure to include a statement that the patient has the cognitive abilities to use a SGD to communicate effectively and achieve functional communication goals. Assessment Data: Language: Assessment Data: Language Include clinical indications (formal and informal) describing the severity of language impairment. If no impairment state that as well. Using formal and informal clinical indicators describe receptive language abilities. Assessment Data: Language: Assessment Data: Language This may include results from subtests from standardized tests or informal specifics re: yes/no reliability, following directions, comprehending conversation, and/or the ability to recognize and comprehend symbols (e.g., objects, photos, line drawings, written words). Assessment Data: Language: Assessment Data: Language Describe the symbolic skills of the individual. Be sure to rule in/out: concrete pictures abstract symbols photographs letters Assessment Data: Language: Assessment Data: Language Discuss the patient’s competency or ability to develop functional language skills, addressing form, content, use Sample: Sample “At the time of this evaluation, his speech patterns are extremely difficult for others to understand secondary to his severe receptive and expressive aphasia, and apraxia (e.g., limited accuracy with oral motor skills). Intelligibility is judged to be less than 5-10% for familiar and unfamiliar listeners alike. Per observation from this clinician and other staff, Edward is able to imitate 1-2 word responses. His attempts to spell to functionally communicate want and needs to familiar and unfamiliar listeners is not adequate at this time”. Assessment Data: Language: Assessment Data: Language Does the individual possess the linguistic capacity to formulate language: Single-hit messages independently carrier phrases + typing letter-by-letter message generation Slide32: The clinician may also find it appropriate to describe the individual’s pragmatic skills (e.g., initiation, turn taking, providing partner’s with feedback). As appropriate, address, discuss and/or describe the patient’s ability to: use symbols to represent and retrieve language (e.g., photo, line drawings, and written words) locate target messages by searching or navigating through multiple displays associate, categorize and sequence symbols combine symbols (e.g., single words/pictures) to generate language Slide33: Informal observations from this clinician reveal that Mrs. P. is a willing and able communicator. She attempts to initiate communications and responses appropriately, however is only able to produce gestures. Her use of gestures is still very basic, secondary to some degree of receptive aphasia and possible limb apraxia. Pragmatic skills are evident in conversation. During this assessment, Mrs. P. was able to recognize concrete and abstract pictures with 92% accuracy. This activity included picture identification from a choice of 6, 12, 24 and 54. Her accuracy was consistent with increased complexity of the screen. In a SLP Note dated 04/02/02, Jane Doe, MA, CCC-SLP noted, “Patient able to read target words aloud: 9. Produced words “yes”, bathroom”, “up”. Produced functional communication gestures”. A previous note dated 03/29/02 reveals the patient was “able to imitate articulation position given picture”. Slide34: Informal observations from this clinician reveal that Mr. M. is a weak communicator. He demonstrates difficulty initiating communications and responds appropriately. During this assessment, he was able to recognize and point to pictures of common objects (e.g., house, TV, family, baby, care, sailboat, cards, coffee, bottle, gas pump, airplane, drinks, feelings, sick, cat, toys, book, sandwich and cheeseburger) with 70% (23/30) accuracy. Slide35: His performance was best on concrete picture items (e.g., baby, and gas pump), as opposed to more generic items (e.g., feelings and toys). With practice and cueing, his performance increased. His syntax and semantics are not intact. He was not able to recognize alphanumeric or use written communication functionally.