In adults, two situations often lead to AAC, and they call for very different approaches. After a stroke, aphasia affects language overnight: the aim is to make conversation possible again, with simple supports and help from those around the person. In motor neurone disease (MND), speech weakens little by little: the whole challenge is to plan ahead, before the voice changes.
Aphasia after a stroke: getting conversation back
A language disorder, not an intellectual one
Aphasia affects language itself, not the voice: speaking, finding words, understanding, reading or writing. The person keeps their memories, opinions, sense of humour and judgement. Many people live with aphasia, most often after a stroke. The speech and language therapy assessment guides the choice of tools.
One important difference from children: in adults with aphasia, the small grammatical words (articles, prepositions) are often the hardest. Content words (nouns, verbs, names) and whole sentences are usually more useful to them than a core vocabulary grid (Beukelman and Light, 2020).
Six communicator profiles
Garrett and Lasker (2005) describe people by what they can do with support, rather than by severity. People often move from one profile to another as they recover; the profile is decided with the speech and language therapist.
| Profile | What the person does | Useful supports |
|---|---|---|
| Emergent | Communicates little on purpose; does not yet link pictures to their meaning | Real objects, then photos, within routines |
| Contextual choice | Recognises photos, names, logos; points to get something, without starting a conversation | Written choices, rating scales, yes/no questions |
| Transitional | Can use a support, but needs reminding | Introduction card, personal photo pages |
| Stored message | Finds prepared messages on their own in familiar situations | Pages by situation, practice in real life |
| Generative message | Sometimes builds new messages, inconsistently | Topic books, alphabet, calendars, repair strategies |
| Specific need | Talks enough for social life; gets stuck in particular situations | Scripts for the phone, prepared talks |
Talking with written choices
A very useful technique for family and friends, with a notepad and a thick marker pen:
Ask the questionThe one you would have asked anyway
Write 2 to 4 answersIn a few words, in large dark capitals, plus ‘something else’
Read them outOut loud, pointing to each one
Circle, follow upThe person points to their answer; circle it and follow up so the conversation keeps going
For ‘how many?’ or ‘how much?’, a scale from 1 to 5 works well. People with severe aphasia and very low reading scores answered with more than 90% accuracy when the written choices were part of a real conversation and were read aloud (Garrett, 1995). Watch out for automatic nodding: many people with aphasia nod to keep their place in the conversation, without having understood (see Model, wait, respond).
Choose personal photos and whole sentences
For many adults with aphasia, personal photos work better than drawn symbols. A page built around a photo of a real moment leads to more conversational turns than a standard grid (Brock et al., 2017), especially if both partners look at it together (Hux et al., 2010). Put few symbols on each screen, with few levels (Petroi, Koul and Corwin, 2014). Don’t insist on combining symbols or spelling unless the person shows they can: whole sentences, ready to say, are often more effective.
Start from their life, not just their care
Beukelman and Light report the case of a retired man with aphasia who had been given a board about meals and washing. He withdrew into himself: what he wanted was to go back to volunteering at his church, play with his granddaughter, talk about the budget with his wife and tease his brothers. The words in the tool must come from the roles and wishes the person had before the stroke. As a family, ask yourselves what the person liked to talk about and with whom, which activities they want to take up again, which expressions sound like them and which decisions they want to keep making.
Prepare one page per situation
For people who find prepared messages on their own, build one situation at a time (bakery, pharmacy, bank): a page of 4 to 8 messages in the order of the exchange, from ‘who I am and how I communicate’ to saying thank you, via the request, the details and repair (‘That’s not it, let’s start again’). A home page can show the person’s first name and ‘I’ve had a stroke, I use this tablet to talk’ (see the ‘How to talk to me’ card). In Buddy, a button can say a whole sentence and show a personal photo, and the grid can be set from 1 × 1 to 30 × 30 cells.
Remove the real obstacles
According to Beukelman and Light (2020), the main difficulty is not technical: it is remembering to use the tool at the right moment (one woman never took her books out of her bag), then embarrassment in public, which one man overcame through role play and scripts he had co-written. Teaching repair strategies cut the share of conversational turns spent repairing misunderstandings from 46% to 11% (Garrett et al., 1989).
Motor neurone disease (MND): plan ahead before speech changes
Motor neurone disease (MND), whose most common form is amyotrophic lateral sclerosis (ALS), progressively affects the nerve cells that control the muscles. Between 80 and 95% of people lose functional speech, 60% within 18 months of the first bulbar symptom (Makkonen, 2018). AAC is well accepted (96% in one case series, Ball, 2004) and is used for about two years on average: it is prepared before speech becomes difficult, with the multidisciplinary team and the speech and language therapist.
Bulbar onset or spinal onset
- Bulbar onset: speech and swallowing are affected first, sometimes quickly, while the person can still walk. A hand-held phone or tablet is used at first; eye gaze comes later.
- Spinal onset: the arms and legs are affected first. Help with writing and computer access often comes before help with conversation.
When to ask for an AAC assessment
Speaking rate drops before intelligibility, which then falls quickly, often within a few months. Benchmarks (Ball et al., 2002, 2007): refer for an assessment when the rate nears 125 words per minute (compared with about 190 usually), or when sentence intelligibility drops below 90%. Rate can be measured even over the phone.
Follow-up has three phases (Ball, Beukelman and Bardach, 2007): monitor speech and record the voice; set up tools suited to current and future abilities; adapt access, positioning and messages as needs change.
Preserving the voice: voice banking and message banking
Two different processes, both to be done before the voice changes:
Voice bankingAbout 4 to 6 hours of speech, in short sessions, to get a synthetic voice that sounds like the person’s own and can say anything
Message bankingChosen phrases (‘I love you’, favourite expressions, a laugh), played back exactly as they were recorded
On iPhone and iPad, Apple’s Personal Voice feature can create a voice in English, and Android has no built-in equivalent. In Buddy, you can record your own voice on each button: message banking directly in the tool. Buddy also accepts a voice from an ElevenLabs voice bank, with an internet connection.
Which messages to prepare
People with MND have ranked their own needs (Fried-Oken et al., 2006). The essentials: calling for help, giving instructions to carers, discussing important matters (especially health), staying in touch and expressing feelings. Instructions and staying in touch are the most frequent uses (Rau et al., 2004), but humour and stories matter too.
If the person can type, prepare whole messages for three reasons: timing (‘Wait, I haven’t finished’, ‘Lift my feet before you push the wheelchair’), speed (long, frequent sentences) and fatigue (a set of messages for the evening). The rest is typed, with word prediction.
Adapt access, keep the vocabulary
As the disease progresses, access moves from touch to a switch, then often to eye gaze (the eyes are usually spared), then to partner-assisted methods. Keep the same vocabulary at every stage if you can. Eye gaze and its no-tech alternatives are covered in Access: positioning, switches, eye gaze. Buddy is used by touch or with a switch (row then cell scanning), without eye gaze; its open OBZ format lets you export the vocabulary to compatible software (check the import with the publisher).
Always a no-tech plan B
For a flat battery, the bathroom or lying down (where eye-gaze cameras work poorly), plan for:
- a reliable yes/no signal, which holds up under fatigue and is known to everyone around the person;
- partner-assisted scanning: the partner says the letters, the person signals. An alphabet in groups that start with a vowel (A to D, E to H, I to N, O to T, U to Z) is easy to remember; Jean-Dominique Bauby, for his part, dictated his book with the letters ordered by frequency;
- a paper version of the same vocabulary: in Buddy, every board can be printed.
Prepare those around them, right to the end
In one case series, 96% of communication helpers were family members, most often with no technical training (Ball, 2005). Families need at least 5 hours of training and support when problems arise (Linse, 2018). Cognitive or behavioural changes, in a minority of people (Murphy, 2016), sometimes mean the tools need adapting. In the last weeks, families often go back to no-tech methods: keep messages that allow decisions to be made right to the end. Patient association: MND Association.
Frequently asked questions
Should you wait until rehabilitation is over before offering AAC after a stroke?
No. Simple tools (written choices, photos, a clear yes/no) can be used from the first weeks, alongside speech and language therapy.
How can you help a family member with aphasia day to day?
Reduce noise, use short sentences, write down key words, offer choices, allow time and check that you have understood.
Pictalk Buddy brings together AAC boards, a visual schedule, guided sequences and notebooks, with the same symbols, on Android, iOS, the web and the watch. A pay-what-you-want app, developed by a non-profit association. Discover Buddy
Sources
- Beukelman, D. R. & Light, J. C. (2020). Augmentative & Alternative Communication (5th ed.). Paul H. Brookes, chapters 14 (contribution by L. Ball and A. Nordness) and 15 (contribution by K. Garrett, J. Lasker and J. King Fischer).
- Studies cited from this book: Garrett & Lasker (2005); Garrett (1995); Garrett et al. (1989); Brock et al. (2017); Hux et al. (2010); Petroi, Koul & Corwin (2014); Makkonen (2018); Ball (2004, 2005); Ball et al. (2002, 2007); Ball, Beukelman & Bardach (2007); Fried-Oken et al. (2006); Rau et al. (2004); Linse (2018); Murphy (2016).