Clinical Scenario
Rico is a seasoned practitioner responsible for (a) providing services to individuals with acquired neurological communication disorders and (b) supervising student clinicians in a bustling urban outpatient rehabilitation center. Currently, Rico has several new clients on his caseload with Broca’s aphasia which may eventually become chronic in nature. Rico typically treats these patients using principles from Constraint Induced Language Therapy (Barthel, Meinzer, Djundja, & Rockstroh, 2008) and Social Participation Models (e.g., Simmons-Mackie, 2008). Last month, Rico started supervising two graduate student externs. The externs have been advocating for the inclusion of augmentative and alternative communication (AAC) strategies as a means to facilitate more difficult social interactions for their clients with aphasia. Rico remembers very little from his AAC course 15 years ago; however, he is concerned about substituting one language system (i.e., natural speech and language) with another language system (i.e., AAC). Moreover, Rico is concerned that AAC may facilitate learned nonuse of spoken language (Pulvermüller & Berthier, 2008). Rico’s students, Rochelle and Cristina, explained that AAC strategies for persons with aphasia (PWA) do not have to replace natural speech. In fact, they stated that data indicate that AAC intervention may enhance natural speech (Dietz, Weissling, Griffith, McKelvey, & Macke, 2014). Moreover, AAC can supplement natural speech when the clients’ words fail them in social contexts.
Rico, realizing he wanted to incorporate new therapies into his repertoire to improve the communication of his patients, decided to take his students’ advice, however; he was unsure about the amount of time required to prepare and implement AAC intervention. Rather than incorporate AAC strategies with all of his clients, he conducted brief interviews with them to determine their level of interest in AAC intervention. Two clients were interested, but one of the caregivers stressed that she wanted her husband to “speak again” and not rely on photographs or graphic symbols to communicate.
Rico’s client, MB, is a 60-year-old male who was referred to the outpatient clinic secondary to surviving a left hemisphere ischemic stroke in August 2015. Results from the diagnostic imaging indicated an infarction volume of 50 cm in the superior middle cerebral artery territory (i.e., Brodmann Area 44, Broca’s area). MB had right hemiparesis and used his left hand for daily living activities. Results from the Western Aphasia Battery–Revised (WAB–R; Kertesz, 2006) standardized assessment confirmed MB’s diagnosis of severe Broca’s aphasia (Aphasia Quotient 31.40). A dynamic assessment was conducted using principles from the Promoting Aphasics’ Communicative Effectiveness (PACE) intervention paradigm. The purpose of the PACE assessment was to determine how well MB performed in a barrier task using several communicative modalities. Specifically, he discussed several pictures with a partner who was blinded to the pictures’ content. Results revealed that MB’s spontaneous natural speech was comprised of approximately 10 words; however, he also used gestures, drawings, and writing to communicate. Finally, Rico conducted a modified activity, Participation Inventory (see Beukelman & Mirenda, 2013), to determine (a) where MB participated socially and (b) how much support was required. Rico noted that MB is a partner-dependent communicator, but he wants to participate with more independence at his local Italian Athletic Club. Given Rico’s limited experience with AAC intervention for PWA, he and his students searched the AAC literature to develop a research question and an appropriate intervention program for MB.