Augmentative and Alternative Communication (AAC)
Why would someone with MG need AAC?
MG is associated with flaccid dysarthria, resulting in speech that is slurred and nasalized, which can affect intelligibility. In addition, those with MG experience fatigue of voluntary muscles that can fluctuate throughout the day. AAC would be beneficial to increase intelligibility and promote effective communication.
Some people experience generalized MG, which affects the upper limbs, hands, and lower limbs. Additional considerations may be needed for those with generalized MG.
MG is associated with flaccid dysarthria, resulting in speech that is slurred and nasalized, which can affect intelligibility. In addition, those with MG experience fatigue of voluntary muscles that can fluctuate throughout the day. AAC would be beneficial to increase intelligibility and promote effective communication.
Some people experience generalized MG, which affects the upper limbs, hands, and lower limbs. Additional considerations may be needed for those with generalized MG.
Assessment for AAC
Obtain Case History
Identify Client Needs
Current Functioning
Positioning and Seating
Muscles required for truncal support may be affected; therefore, positioning and seating will need to be considered when selecting a device. Collaboration between the speech-language pathologist (SLP) and the occupational therapist (OT) will ensure optimal selection of an appropriate AAC device.
Motor Capabilities
Individuals with MG may experience different levels and areas of muscle weakness. These should be taken into consideration when choosing an AAC device. There are switches available to select items using the head, fingers, neck, knee, etc. In addition, the user may want to chose a device with scanning capabilities for times when they are fatigued, as this requires minimal motor effort.
Cognitive/Linguistic Capabilities
For individuals with MG with intact cognition and linguistic capabilities, AAC can incorporate written words, phrases and a keyboard to allow for unlimited message production. In addition, some AAC devices include internet capabilities allowing the user to email, write and use the web. For those with cognitive delays, there are low tech systems that use pictures and a static display which increase ease of use and are less taxing on working memory.
Literacy Skills
There are low and high tech AAC devices available depending upon an individuals needs. For children and those with emerging literacy skills, a low-tech device may be more beneficial and easier to use. For individuals who are capable of reading and writing, there are high tech AAC devices available that require the ability to categorize, offer word prediction, set phrases and typing capabilities.
Sensory/Perceptual Skills
Vision and hearing of AAC users needs to be assessed. A vision assessment includes assessment of visual acuity, as well as oculomotor functioning. For those with typical vision, average size symbols are appropriate. For those with vision problems, larger symbols and text would be more beneficial. A classic symptom of MG is drooping eyelids. For people affected by this form of muscle weakness eye tracker AAC capabilities would not be appropriate. Special considerations need to be taken into account for selecting AAC that is accessible when clients are experiencing muscle weakness, especially toward the end of the day when fatigue may increase. Auditory feedback and automatic scanning may be beneficial when vision is compromised by drooping eyelids. Hearing should also be assessed, as this will impact the loudness of the device output, as well as the type of feedback.
Potential Barriers
Opportunity Barriers
A knowledge barrier may occur if either the individual with MG, facilitator, or other personnel displays a lack of knowledge about the AAC device. This may include knowledge about intervention options, technologies, or instructional strategies. A skill barrier may occur if the facilitator has difficulty implementing AAC techniques or strategies despite having extensive knowledge about the device. An attitude barrier may occur if any individual (e.g., client with MG, parents, co-workers, supervisors, professionals, peers, general public, etc.) holds an attitude or belief that may impact the use of the device. For example, device abandonment may occur if the individual with MG believes that using the device will make them look or sound different from their peers, or if a parent believes that the individual is capable of effectively communicating without the device. These types of opportunity barriers can be modified with in-services, workshops, handouts, technical assistance, "hands-on" practice, and modeling appropriate practice to allow the user and other involved individuals more comfort and confidence when operating the device.
Access Barriers
A current communication barrier may occur if the individual with MG competent in the operational and social aspects of communication. This means that the individual may not be able to operate the device correctly due to motor problems and may not currently be able to socially communicate. Another access barrier that needs to be assessed is the potential to use and/or increase speech. The SLP should determine if AAC is necessary to augment existing but insufficient speech or to replace speech altogether. Since dysarthria often occurs with MG, it is likely that AAC will be necessary to augment existing speech. The SLP should also assess the individual's effectiveness of speech for communicative interactions. Environmental adaptations may also be necessary to accommodate those with generalized MG as they have limited use of their limbs and will need to have easier access to their device. This can be done by altering physical spaces, locations, and structures. The potential to utilize AAC systems or devices also needs to be thoroughly evaluated. If the individual with MG and their family's preferences and attitudes are not considered in the AAC assessment process, the device will likely be abandoned. It is important for the SLP to assess these access barriers to ensure that the selected device is an appropriate fit for the individual with MG.
Consider interventions for today and interventions for tomorrow:
For the client with MG, interventions for today need to be accurate, efficient, and non-fatiguing. The latter is especially important because those with MG tend to fatigue as the day progresses and use of their AAC device should not fatigue them further. Intervention for today should also match their current linguistic, cognitive, sensory, and motor skills to promote optimal use of the device. Additionally, it should require minimum training so that the individual may begin to use the device as soon as appropriate.
Interventions for tomorrow require some planning ahead. This means that the SLP should be knowledgeable about any skills that may change in the individual with MG, such as visual or motor skills. This may affect the type of device that is selected, so that it will still be functional for the user if their condition progresses or worsens. Symbol knowledge, pragmatic skills, and literacy skills also need to be considered however these should remain intact as those with MG only experience weakness in their voluntary muscles; their cognitive skills do not decline.
Identify Client Needs
- Specific daily activities
- Environments: home, school, work, etc.
- Peer's participation patterns
- Individual's participation patterns: independent, gestural assistance, physical assistance, etc.
- Identify strengths and abilities
Current Functioning
Positioning and Seating
Muscles required for truncal support may be affected; therefore, positioning and seating will need to be considered when selecting a device. Collaboration between the speech-language pathologist (SLP) and the occupational therapist (OT) will ensure optimal selection of an appropriate AAC device.
Motor Capabilities
Individuals with MG may experience different levels and areas of muscle weakness. These should be taken into consideration when choosing an AAC device. There are switches available to select items using the head, fingers, neck, knee, etc. In addition, the user may want to chose a device with scanning capabilities for times when they are fatigued, as this requires minimal motor effort.
Cognitive/Linguistic Capabilities
For individuals with MG with intact cognition and linguistic capabilities, AAC can incorporate written words, phrases and a keyboard to allow for unlimited message production. In addition, some AAC devices include internet capabilities allowing the user to email, write and use the web. For those with cognitive delays, there are low tech systems that use pictures and a static display which increase ease of use and are less taxing on working memory.
Literacy Skills
There are low and high tech AAC devices available depending upon an individuals needs. For children and those with emerging literacy skills, a low-tech device may be more beneficial and easier to use. For individuals who are capable of reading and writing, there are high tech AAC devices available that require the ability to categorize, offer word prediction, set phrases and typing capabilities.
Sensory/Perceptual Skills
Vision and hearing of AAC users needs to be assessed. A vision assessment includes assessment of visual acuity, as well as oculomotor functioning. For those with typical vision, average size symbols are appropriate. For those with vision problems, larger symbols and text would be more beneficial. A classic symptom of MG is drooping eyelids. For people affected by this form of muscle weakness eye tracker AAC capabilities would not be appropriate. Special considerations need to be taken into account for selecting AAC that is accessible when clients are experiencing muscle weakness, especially toward the end of the day when fatigue may increase. Auditory feedback and automatic scanning may be beneficial when vision is compromised by drooping eyelids. Hearing should also be assessed, as this will impact the loudness of the device output, as well as the type of feedback.
Potential Barriers
Opportunity Barriers
A knowledge barrier may occur if either the individual with MG, facilitator, or other personnel displays a lack of knowledge about the AAC device. This may include knowledge about intervention options, technologies, or instructional strategies. A skill barrier may occur if the facilitator has difficulty implementing AAC techniques or strategies despite having extensive knowledge about the device. An attitude barrier may occur if any individual (e.g., client with MG, parents, co-workers, supervisors, professionals, peers, general public, etc.) holds an attitude or belief that may impact the use of the device. For example, device abandonment may occur if the individual with MG believes that using the device will make them look or sound different from their peers, or if a parent believes that the individual is capable of effectively communicating without the device. These types of opportunity barriers can be modified with in-services, workshops, handouts, technical assistance, "hands-on" practice, and modeling appropriate practice to allow the user and other involved individuals more comfort and confidence when operating the device.
Access Barriers
A current communication barrier may occur if the individual with MG competent in the operational and social aspects of communication. This means that the individual may not be able to operate the device correctly due to motor problems and may not currently be able to socially communicate. Another access barrier that needs to be assessed is the potential to use and/or increase speech. The SLP should determine if AAC is necessary to augment existing but insufficient speech or to replace speech altogether. Since dysarthria often occurs with MG, it is likely that AAC will be necessary to augment existing speech. The SLP should also assess the individual's effectiveness of speech for communicative interactions. Environmental adaptations may also be necessary to accommodate those with generalized MG as they have limited use of their limbs and will need to have easier access to their device. This can be done by altering physical spaces, locations, and structures. The potential to utilize AAC systems or devices also needs to be thoroughly evaluated. If the individual with MG and their family's preferences and attitudes are not considered in the AAC assessment process, the device will likely be abandoned. It is important for the SLP to assess these access barriers to ensure that the selected device is an appropriate fit for the individual with MG.
Consider interventions for today and interventions for tomorrow:
For the client with MG, interventions for today need to be accurate, efficient, and non-fatiguing. The latter is especially important because those with MG tend to fatigue as the day progresses and use of their AAC device should not fatigue them further. Intervention for today should also match their current linguistic, cognitive, sensory, and motor skills to promote optimal use of the device. Additionally, it should require minimum training so that the individual may begin to use the device as soon as appropriate.
Interventions for tomorrow require some planning ahead. This means that the SLP should be knowledgeable about any skills that may change in the individual with MG, such as visual or motor skills. This may affect the type of device that is selected, so that it will still be functional for the user if their condition progresses or worsens. Symbol knowledge, pragmatic skills, and literacy skills also need to be considered however these should remain intact as those with MG only experience weakness in their voluntary muscles; their cognitive skills do not decline.
Potential AAC Types & Devices
Device Organization
Note: Characteristics listed in the above chart were determined based on a typical person with MG. These device characteristics may vary, depending on the user's MG severity and their preferences. To determine device organization for each AAC user, the SLP will need to assess the user's capabilities.
Possible Devices to Trial
Possible Devices to Trial
digitized or synthesized speech - auditory or visual scanning - 12.1 inch display - 6 lbs. 5 oz.
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synthesized speech - auditory or visual scanning - 5 inch display - 1 lb. 7 oz.
*Although this device does not have digitized speech capabilities, it is a smaller size, which the user may prefer. |
digitized or synthesized speech - switch access capabilities - 9.7 inch display - 0.96 lbs.
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digitized speech - visual scanning - 9 x 12 inch display - 1 lb. 7 oz.
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References
Scheer-Cohen, A. (2015). Alternative access [PowerPoint slides]. Retrieved from http://www.cc.csusm.edu
Scheer-Cohen, A. (2015). Assessment of specific capabilities [PowerPoint slides]. Retrieved from http://www.cc.csusm.edu
Scheer-Cohen, A. (2015). Principles of assessment [PowerPoint slides]. Retrieved from http://www.cc.csusm.edu
Scheer-Cohen, A. (2015). Alternative access [PowerPoint slides]. Retrieved from http://www.cc.csusm.edu
Scheer-Cohen, A. (2015). Assessment of specific capabilities [PowerPoint slides]. Retrieved from http://www.cc.csusm.edu
Scheer-Cohen, A. (2015). Principles of assessment [PowerPoint slides]. Retrieved from http://www.cc.csusm.edu