Seminar on Speech and Language Processing for
Augmentative and Alternative Communication
Class 18: User Issues Papers
Presenter:
Masoud Rouhizadeh
 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.
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.
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.
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.
AAC Acceptance and Use
 Approximately 95% of people with ALS become unable to speak at
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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)
AAC Acceptance and Use (cont.)
 A database review has documented that family members with non
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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.
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.
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.
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.
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).
2) Traumatic Brain Injury (TBI)
 Extensive range of communication disorders: cognitive/linguistic
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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.
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
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
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.
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
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.
AAC Acceptance and Use
 Direct selection: single finger or head movement
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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
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.
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
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
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.
AAC Acceptance and Use
Acceptance
 Often, those with severe, chronic aphasia reject AAC secondary
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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?
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
AAC Acceptance and Use
High-Technology Interventions
 Lingraphica
AAC Acceptance and Use
High-Technology Interventions
 Talking screen
Visual Scene Displays in DynaVox
Visual Scene Displays in DynaVox
Visual Scene Displays in DynaVox
Visual Scene Displays in DynaVox
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
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.
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
AAC Acceptance and Use
 Interventions designed to remind them of temporal or
semantic information
 Computerized memory aids
 Modifications of the communication partner’s
behavior
Future Research Directions
 Lexical representation formats with and without voice
output
 High-tech multi- media system that supports
reminiscence interactions
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)
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
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.
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’
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.
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 
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.
Tools and tasks used to assess receptive
morphology
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.
Tools and tasks used to assess receptive
syntax
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.
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.
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
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
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.
Discussion
 Many aided AAC users had difficulties with receptive and
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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
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.
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
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.
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)
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”
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.
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.
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.
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:
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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
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.
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.
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.
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.
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.
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.
Thank you.