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Identify your client’s AAC needs early so you can get them on a waitlist for an expanded level AAC clinic in a responsible, timely, and safe fashion. Expanded level clinics provide assessment and prescription of AAC systems, as well as access to funding from the Assistive Devices Program of Ontario (ADP).
Consider where to refer your client based on their location and the closest AAC clinic’s mandates – you can view a list of Ontario AAC Clinics designated by the ADP on the Centralized Equipment Pool’s website: https://web.cepp.org/about/
No Tech #
Partner Supported Conversation #
Augmenting the environment and communication partner’s awareness and response strategies is often the first step in exploring Augmentative and Alternative Communication (AAC).
Augmenting the environment includes turning on lights so you can see your communication partner better, turning off sources of noise, facing your communication partner head on.
Augmenting your partner’s expectation and response strategy is about educating household members of how to help the patient with their communication strategies.
For more information, see the Facilitating Functional Communication article.
Low Tech #
Low-Tech AAC consists of communication tools that do not rely on electronics or a power source to operate effectively. Depending on a client’s communication goals for a particular environment, they may benefit from a communication and/or alphabet board, or a larger communication book.
ID Cards #
Wallet sized cards can be a good option for patients to quickly communicate common phrases, such as:
- “I have a medical condition that affects my speech”
- “I use a computer to speak due to a medical condition, please give me a second to respond”
Communication Boards, Alphabet Boards, and Communication Books #
There are different ways of accessing communication aids: pointing with a finger or pointer, spelling out letters or numbers, or Partner-Assisted Scanning – consider what is most efficient and functional for the client. Customizing low tech aids (e.g. with personalized messages) will increase the client’s motivation and efficiency of use. Consider smaller grid size, picture/symbol support, and aphasia-friendly format for clients with language or cognitive impairment.
Be sure to consider the client’s cultural and linguistic background and preferences – low tech communication aids should accommodate to the client’s primary or preferred language to enable functional communication with clients’ family and community. See the following link to a webpage from Widgit with sample critical care communication charts that are available for download in various languages: https://www.widgit.com/products/health/covid19-communication-chart.htm
High Tech #
Many clients with ALS are good candidates for high-tech AAC, though it is considered wise to always pair it with a low-tech option should technology fail/run out of battery. Clients who are interested in preparing for the future and have good intelligibility may be considered candidates for voice or message banking (see below).
Speech Generating Device #
Speech generating devices (SGDs) are high-tech AAC that will ‘speak out’ messages selected by the client. Consider your client’s goals and current level of functioning to determine the appropriate AAC intervention.
Text-to-speech apps are a portable, cost-effective, and efficient strategy for clients who are not experiencing issues with access. This method essentially turns your phone into an SGD (see Speech Assistant AAC handouts for Android and iOS).
Referral to an expanded level clinic is appropriate to obtain a prescription for a dedicated SGD, writing aid, or integrated device. Early education about AAC is encouraged, as well as anticipation of AAC needs to ensure timely assessment. Reduced speaking rate has been shown to be a predictor of rapid decline in speech intelligibility.
Integrated Device #
Integrated devices may be recommended for individuals who have difficulty with hand function in addition to speech impairment. Integrated devices are both speech generating devices and computers that provide access to email, the internet, accessible apps like ‘Netflix’ and ‘Facebook,’ and other typical computer features using alternative access options, such as headmouse, eye gaze, and switch scanning.
Voice Banking / Message Banking #
Voice Banking is the process of recording a large sample of a person’s natural speech, and converting it to a Personalized Synthetic Voice using an online software. This voice can be loaded onto a Speech Generating Device (SGD), as needed.
Message Banking is the process of recording selected messages that can be loaded, and played back in full, on a SGD. Both options allow an individual to continue communication in their ‘own voice’ even after their natural speech has changed.
SLP speech and voice assessment will be needed to determine if the client is a candidate for either or both of these processes; if not, family members can complete a Voice or Message Bank on behalf of the client.
Voice Amplifiers #
Voice amplifiers may be beneficial for clients who have little to no dysarthria, but reduced vocal volume. However, this may not be a long-term solution; these devices will amplify any impairment in the speech signal and may not improve speech intelligibility. Additionally, access to ADP funding for voice amplifiers may prevent the client from acquiring further funding for an SGD or integrated device if they experience further speech changes.
Writing Aids #
Writing aids include alternative computer access methods for individuals who have physical limitations that affect their ability to use a regular keyboard and/or mouse. Referral to an expanded level clinic is appropriate to obtain a prescription for a writing aids system.
Speech recognition software may be beneficial for clients without speech/voice impairment, but have difficulty with writing or computer access. SLP speech/voice assessment is required prior to recommending this strategy, and OT assessment is required to assess physical function.
Education should be provided to ensure clients maintain vocal hygiene while using speech recognition, and are aware that this may not be a long term solution if they experience speech impairment as the disease progresses.
Sources and Further Reading #
- Assistive Devices Program (Ministry of Health of Ontario), Communication Aids,https://www.ontario.ca/page/communication-aids
- Individual Authorizer Home Study Guide, Centralized Equipment Pool (CEP), https://web.cepp.org/continuing-education/
- Yorkston, K., Miller, R., Strand, E., & Britton, D. (2013). Management of Speech and Swallowing in Degenerative Diseases. 3rd edn (Austin, TX: PRO-ED).