Health Sciences

School of Human Communication Sciences

Integrating Functional Communication Therapy into Rehabilitation

The Road Home: Integrating Functional Communication Therapy into Rehabilitation

Contents

• Acknowledgements
• Preface
• Introduction
• Part A – Information Section
  • Frameworks
  • Goal Setting
  • Individualised Therapy
  • Communication Partners
  • Group Therapy
  • Approaches to Therapy: Multidisciplinary or Interdisciplinary?
• Part B – Communication Acts
  • Establishing a reliable yes/no response
  • Expressing basic needs & wants
  • Reading signs
  • Taking medications
  • Using greetings & partings
  • Receiving a telephone call
  • Making a telephone call
  • Ordering a taxi
  • Communicating travel destinations
  • Participating in religious acts
  • Participating in a communicative transaction
  • Text messaging
• Appendices

Acknowledgements

The authors would like to thank all those who contributed to the development of this manual.

A special thanks is extended to Donna McNeill-Brown from La Trobe University, as well as Bronwyn Cox and Anna Volkmer from The Royal Melbourne Hospital for their supervision, feedback and support throughout the duration of this project.

The group would also like to thank the numerous clinicians, from Victoria, Tasmania and Queensland, who provided them with extremely valuable ideas, resources and suggestions. Their expertise and clinical reasoning provided a platform for the development of this manual. Finally the authors are in much appreciation to Kate Cutler for her contribution to the graphic design and printing of the manual.

The Road Home: Integrating Functional Communication Therapy into Rehabilitation

This manual addresses the transition from hospital to home for client’s with acquired neurological communicative disorders (ANCD) with a specific focus on language. It is targeted at student Speech Pathologists, Speech Pathology graduates and those re-entering the field of adult neurogenic communication. This manual aims to tackle the emerging area of functional communication in the rehabilitation setting, through addressing both theory and practice of therapy goals.

The content within this manual was informed by the current literature, clinicians currently working in the field and personal experience from clinical placements. The research therefore involved a literature review, interviewing numerous clinicians and utilising clinical experience. There was also intent to interview individual’s with an ANCD, however this was unachievable due to policies and time constraints. One area of concern that has arisen is the issue of copyright. Currently group members are in the process of obtaining permission to use several figures in the manual. This is especially relevant if the project is to be marketed. Furthermore, the issues of ownership and distribution would need to be addressed. At this stage, these figures have not been included in the manual, however, each figure can be obtained through the corresponding references provided.

Preface

This manual addresses the transition from hospital to home for client’s with acquired neurologicalcommunicative disorders (ANCD) with a specific focus on language. It is targeted at student Speech Pathologists, Speech Pathology graduates and those re-entering the field of adult neurogenic communication. This manual aims to tackle the emerging area of functional communication in the rehabilitation setting, through addressing both theory and practice of therapy goals.

The content within this manual was informed by the current literature, clinicians currently working in the field and personal experience from clinical placements. The research therefore involved a literature review, interviewing numerous clinicians and utilising clinical experience. There was also intent to interview individual’s with an ANCD, however this was unachievable due to policies and time constraints.

One area of concern that has arisen is the issue of copyright. Currently group members are in the process of obtaining permission to use several figures in the manual. This is especially relevant if the project is to be marketed. Furthermore, the issues of ownership and distribution would need to be addressed. At this stage, these figures have not been included in the manual, however, each figure can be obtained through the corresponding references provided.

Introduction

Part A

Part A is designed as an informational package that details important features for a successful transition from hospital to home of individual’s with an acquired neurological communicative disorder (ANCD). It is divided into six sections that highlight significant aspects of therapy that facilitate more effective and efficient rehabilitation. Part A aims to detail some of the theoretical considerations of therapy in the rehabilitation setting, providing a background of knowledge for the clinician to develop their clinical skills upon.

Part B

Part B is the practical segment of the manual. It details twelve core functional goals that aim to represent a wide range of communication activities of daily living. It is proposed as a broad set of guidelines to assist clinicians in shaping therapy in the rehabilitation setting. These goals were developed through the literature, looking specifically in the areas of ensuring client safety, expressing needs and wants, reducing social isolation and anxiety, increasing quality of life and re-integration into the community. Input of relevant goals to include was also provided by numerous Speech Pathologists currently working in the rehabilitation setting.

Each goal is accompanied by:

• A brief rationale outlining the importance of the goal and why it is relevant.
• Baseline skills the client is required to possess before beginning to target the specified goal.
• A method of measurability to determine whether the targeted goal is being achieved.
• A general hierarchy of steps the clinicians and client can work through, beginning with the least complex task and moving up the scale.
• An example activity for each step that can be implemented into clinical practice.
• Additional considerations such as client specific deficits or supplementary resources.

It is important to note that Part B does not contain an exhaustive list of goals. Moreover, by following principles of individualised therapy every goal will be not be relevant for every client and not every step within the goals will be appropriate for all clients. However, this manual aims to assist clinicians in targeting functional goals for clients by providing some general guidelines and activities that can be implemented in the clinical setting.

PART A - Information Section

The Road Home: Integrating Functional Communication Therapy into Rehabilitation This section of the manual will focus on the main theoretical frameworks that underlie therapy decisions when preparing client’s with acquired neurological communicative disorders (ANCD) for the transition from hospital to home. The importance of utilising theoretical frameworks coincides with the increasing need to provide evidence-based practice for speech pathology interventions (Fucetola, Tucker, Blank & Corbetta, 2005; Ratner, 2006). Moreover, it is becoming essential that clinicians prove that rehabilitation is purposeful and is making a difference in the everyday life of the client (Lubinski, 2001). Therefore the frameworks will be analysed with a functional focus, which is vital during the transition phase. This section will also include some therapy ideas/ techniques for the different approaches.

International Classification of Functioning, Disability and Health (ICF)

Frameworks

This section of the manual will focus on the main theoretical frameworks that underlie therapy decisions when preparing client’s with acquired neurological communicative disorders (ANCD) for the transition from hospital to home. The importance of utilising theoretical frameworks coincides with the increasing need to provide evidence-based practice for speech pathology interventions (Fucetola, Tucker, Blank & Corbetta, 2005; Ratner, 2006). Moreover, it is becoming essential that clinicians prove that rehabilitation is purposeful and is making a difference in the everyday life of the client (Lubinski, 2001). Therefore the frameworks will be analysed with a functional focus, which is vital during the transition phase. This section will also include some therapy ideas/ techniques for the different approaches.

Adapted from World Health Organization (WHO). (2001). International classification of functioning, disability and health. Geneva: World Health Organization.

What is the ICF model?

The ICF model is a framework specially formulated to address functional health (Ma, Threats & Worrall, 2008). Functional health implies that an individual can carry out their activities of daily living (e.g. dressing, toileting or communicating) and participate in society (e.g. attend school or work). The model can therefore be applied when addressing physical, cognitive and communication skills of a client with a health disorder. The parameters include:

• Body functions and structures: Functions represent physiological and psychological functions of body systems (e.g. mental, pain, respiration, language, hearing etc.) and structures represent anatomical body parts (e.g. nervous system, ear, larynx, heart, lungs etc.). A problem/breakdown is termed an ‘impairment’ (WHO, 2001).
• Activities and participation: Activity represents task/action execution by a client and participation represents involvement in life situations (WHO, 2001).
• Environmental factors: The external world i.e. the physical, social and attitudinal world in which people live. It can have positive (facilitator) or negative (barrier) effects (WHO, 2001).
• Personal factors: The specific features of a client (e.g. gender, age and coping styles) (WHO, 2001).

Example - Aphasia

• Body functions and structures: structure of the brain and mental functions of language (McCormack & Worrall, 2008).
• Activities and participation: Receiving and producing communication (O’Halloran & Larkins, 2008). An activity is concerned with the level of the individual (e.g. unable to write a letter) and participation at a societal level (e.g. unable to work) (AIHW, 2007).
• Environmental factors: Cannot understand signage and communication partners are impatient and lack understanding.
• Personal factors: Highly educated young male, who previously presented as highly confident.

Applying the ICF model to functional therapy

• Research tool: important for strengthening the evidence-base for the practice of functional therapy techniques (Ma et al., 2008).
• Clinical tool: provides guidelines to set and evaluate goals. It is a holistic management approach that encompasses the biopsychosocial aspects of well-being (Cruice, 2008; Threats, 2008).
• Social policy tool: supports advocating for better community resources (Howe, 2008). Educational tool: this international model is recognised by multiple professionals in various fields. This wide application encourages liaisons, communication and understanding with other professionals. The model also seeks to raise awareness amongst the broader community (Ma et al., 2008).
• Additionally the model underpins many language therapy approaches. This client-centred model is functional as it encourages clinicians to tailor therapy to the client (Howe, 2008).

Functional Therapy Ideas

• Conduct therapy in the client’s own environment.
• Ensure the client’s communication partners are educated.
• Ensure the activities conducted are tailored to the client.

Psycholinguistic Assessments of Language Processing in Aphasia (PALPA)

Adapted from Kay, J., Lesser, R. & Coldheart, M. (1992). Psycholinguistic assessments of language processing in aphasia. Sussex: Lawrence Erlbaum Associates.

What is the PALPA model?

It is an approach towards understanding cognitive functions such as recognising, listening, speaking and writing via analysis of presenting impairments (Ellis & Young, 1988). This cognitive neuropsychology approach is based on the treatment principles that the origin and nature of the impairment/s can be identified and then the damaged component’s relationship with connecting processing components is considered (Byng, 1988). The approach is influential in the assessment, investigation, and treatment of word production difficulties in language disorders (Wilshire, 2007).

Functions of the components (Kay, Lesser & Coldheart, 1992; Ellis & Young, 1988):

• Auditory phonological analysis: extracts individual speech sounds from the incoming speech sound wave. Phonological input buffer: temporary storage (working memory) that allows for processing by auditory word recognition systems.
• Phonological/auditory input lexicon: auditory word recognition system. Influenced by frequency. Acoustic-to-sound conversion: individual monitors own speech output by external feedback. Semantic system: semantic representations of all known words. Influenced by imageability. Phonological/speech output lexicon: contains the phonological output form of all words in an individual’s spoken vocabulary.
• Phonological output buffer: considered the phoneme level, where the individual speech sounds are contained.
• Visual object recognition system: storage of familiar visual stimuli.
• Abstract letter identification: identifies, encodes and groups letters in written words. Orthographic input lexicon: identifies strings of letters that form familiar written words. Letter-to-sound rules: unfamiliar words read via a process of dividing a word into letters then translating the visual symbol to a corresponding phoneme. Orthographic output lexicon: stores the spelling of familiar words and makes them available for writing.
• Orthographic output buffer: the grapheme level that contains abstract representations of the letters used in English. Sound-to-letter rules: generates spelling for unfamiliar words via phoneme-grapheme conversion.

Applying the PALPA model to functional therapy

• Although restorative therapy underpins the PALPA model, the model does posit an ability to be combined with functional therapy (Simmons-Mackie, 2001). This can be achieved by implementing drill-based activities in the early stages to ensure the client has progressed to a required level, which then enables functional therapy to take place.
• It is also important that the areas targeted are those that are meaningful to the individual with the ANCD. This is to ensure their full participation (Simmons-Mackie & Damico, 2007).

Functional Therapy Ideas

• Pictures, seen objects – Use photos or objects that belong to the client, rather than meaningless pictures. Base therapy activities around these materials.
• Print – Mobile phone text messaging. Originally establish a grapheme-phoneme relationship, and then persist with tasks using the client’s mobile phone.
• Speech – Train and educate communication partners to use short and simple language.
• Semantic system – Visit common social environments and analyse required vocabulary for that situation. Target words within the environment that have an increased frequency, imageability and concreteness.

Functional Approaches

Life Participation Approach to Aphasia (LPAA)

• Is a “consumer-driven service-delivery approach” that supports client’s with an ANCD to achieve life goals with the focus on re-engaging in life (Chapey, Duchan, Elman, Garcia, Kagan, Lyon & Mackie, 2001, p. 235).
• Re-engagement in life is achieved by strengthening daily participation in activities of the clients choosing (Chapey et al., 2001). Intervention commonly targets environmental factors (Chapey et al., 2001). It uniquely targets the client’s support network. Therefore addressing goals for family, friends and work colleagues (Chapey, et al., 2001). This is vital, given that research suggests a large number of caregivers demonstrate anxiety and depression (McCabe, Lippert, Weiser, Hilditch, Hartridge & Villamere, 2007).
• It produces meaningful outcomes to enhance quality of life. Outcome evaluation is centred on documenting quality of life changes (Chapey et al., 2001). Satisfaction with quality of life is pertinent as it is regarded as the ultimate indicator of rehabilitation efficacy (McCabe et al., 2007).

Therapy Techniques:

• Compensatory strategies – linguistic, gestural, pantomime, drawing, communication aid and environmental resources.
• Clinician acts as a support person.
• Consider all those affected.

Social Approach

• The goal of a social approach is to “promote membership in a communicating society and participation in personally relevant activities” for client’s with an ANCD (Simmons-Mackie, 2001, p. 246).
• It is consistent with the philosophy of the LPAA (Simmons-Mackie, 2001).
• The approach is a shift from traditional, medical model based therapy (Lafond, DeGiovani, Joanette, Ponzio & Sarno, 1993).
• The approach seeks to decrease the long-term problems of chronic communication disorders such as isolation and depression (McCabe et al., 2007; Stalnacke, 2007). The reasoning is that when these problems occur, community reintegration and motivation towards therapy is decreased (Sandin, Cifu & Noll, 1994).

Therapy techniques:

• Conversation therapy, enhanced compensatory strategy training, conversational coaching, group therapy, scaffolded and supported conversations, partner training, resources as supports and counselling and psychological support (Simmons-Mackie, 2001).

Environmental Systems Approach

• Focuses on the client and their communicative environment as “a dynamic and interdependent system” (Lubinski, 2001, p. 269).
• Derived from an environment and family systems theory (Lubinski, 2001).
• Aims to compliment cognitive, linguistic and communicative approaches through increasing physical and social environment functioning (Lubinski, 2001).
• The individual is placed in the core of the system and interacts with their family, external environment, physical environment and sociocultural and economic subsystems (Lubinski, 2001).

Therapy techniques:

• Therapy focuses on the family, sociocultural milieu, lighting and visual cues, acoustic treatment, furniture arrangement and environmental props (Lubinski, 2001).

Conclusion

To achieve functional therapeutic success a combination of clinical judgement and the relevant components of varying approaches can be implemented. The most important concept of functional based therapy is to ensure that the client’s desired goals are being targeted (Wallace, Evans, Arnold & Hux, 2007). Discussing the client’s relevant communicative abilities of daily living is a starting point (Holland, Frattali & Fromm, 1998). The key areas of functional therapy are independence and social integration, caregiver burden, caregiver education, community education, satisfaction with quality of life, productivity and transportation (Mc Cabe etal., 2007; Fraas. Balz & DeGrauw, 2007). Achievement of these goals may require combining traditional restorative approaches with functional therapy approaches or may involve something new and different.

References

Australian Institute of Health and Welfare (AIHW). (2003). ICF Australian user guide. Version 1.0. Canberra: Australian Institute of Health and Welfare.

Bying, S. (1988). Sentence processing deficits: Theory and therapy. Cognitive Neuropsychology, 5(6), 629-676.

Chapey, R., Duchan, J.F., Elman, R.J., Garcia, L.J., Kagan, A., Lyon, J.G., & Simmons-Mackie, N. (2001). Life participation approach to aphasia: A statement of values for the future. In Chapey, R. (Ed.), Language intervention strategies in aphasia and related neurogenic communication disorders(4th ed.) (pp. 235-245). Baltimore; Philadelphia: Lippincott Williams & Wilkins.

Cruice, M. (2008). The contribution and impact of the international classification of functioning, disability and health on quality of life in communication disorders. International Journal of Speech-Language Pathology, 10(1-2), 38-49.

Ellis, A.W., & Young, A.W. (1988). Human cognitive neuropsychology. Hove, England: Erlbaum. Fraas, M., Balz, M., & DeGrauw, W. (2007). Meeting the long-term needs of adults with acquired brain injury through community-based programming. Brain Injury, 21(12), 1267-1281.

Fucetola, R., Tucker, F., Blank, K., & Corbetta, M. (2005). A process for translating evidence-base aphasia treatment into clinical practice. Aphasiology, 19(3), 411-422 .

Holland, A.L., Frattali, C., & Fromm, D. (1998). Communicative abilities in daily living (CADL 2). Texas: Proed Publishers Inc.

Howe, T.J. (2008). The ICF contextual factors related to speech-language pathology. International Journal of Speech-Language Pathology, 10(1-2), 27-37.

Kay, J., Lesser, R., & Coldheart, M. (1992). Psycholinguistic assessments of language processing in aphasia. Sussex: Lawrence Erlbaum Associates.

Lafond, D., DeGiovani, R., Joanette, Y., Ponzio, J., & Sarno, M. (Eds.) (1993). Living with aphasia: Psychosocial issues. San Diego, CA: Singular Publishing.

Lubinski, R. (2001). Environmental systems approach to adult aphasia. In Chapey, R. (Ed.), Language intervention strategies in aphasia and related neurogenic communication disorders (4th ed.) (pp. 269-296). Baltimore; Philadelphia: Lippincott Williams & Wilkins.

Ma, E. P.-M., Threats, T.T., & Worrall, L.E. (2008). An introduction to the International Classification of Functioning, Disability and Health (ICF) for speech-language pathology: Its past, present and future. International Journal of Speech-Language Pathology, 10(1-2), 2-8.

McCabe, P., Lippert, C., Weiser, M., Hilditch, M., Hartridge, C., & Villamere, J. (2007). Community reintegration following acquired brain injury. Brain Injury, 21(2), 231-257.

O’Halloran, R., & Larkins, B. (2008). The ICF activities and participation related to speech-language pathology. International Journal of Speech-Language Pathology, 10(1-2), 18-26.

Ratner, N.B. (2006). Evidence-based practice: An examination of its ramifications for the practice of speech-language pathology. Language, Speech and Hearing Services in Schools, 37, 257-267.

Sandin, K., Cifu, D., & Noll, S. (1994). Stroke rehabilitation. Psychological and social implications. Archives of Physical Medicine and Rehabilitation, 75, S52-S55.

Simmons-Mackie, N. (2001). Social approaches to aphasia intervention. In Chapey, R. (Ed.), Language intervention strategies in aphasia and related neurogenic communication disorders (4th ed.) (pp. 246-268). Baltimore; Philadelphia: Lippincott Williams & Wilkins.

Simmons-Mackie, N. N., & Damico, J.S. (2007). Access and social inclusion in aphasia: Interactional principles and applications. Aphasiology, 21(1), 81-97.

Stalnacke, B-M. (2007). Community integration, social support and life satisfaction in relation to symptoms 3 years after mild traumatic brain injury. Brain Injury, 21(9), 933-942.

Threats, T.T. (2008). Use of the ICF for clinical practice in speech-language pathology. International Journal of Speech-Language Pathology, 10(1-2), 50-60.

Wallace, S.E., Evans, K., Arnold, T. & Hux, K., (2007). Functional brain injury rehabilitation: Survivor experiences reported by families and professionals. Brain injury, 21(13), 1371-1384.

Wilshire, C.E. (2007). Cognitive neuropsychological approaches to word production in aphasia: Beyond boxes and arrows. Aphasiology, 22 (10), 1019-1053.

World Health Organization (WHO). (2001). International classification of functioning, disability and health. Geneva: World Health Organization.

Goal Setting

Effective goal setting is an essential component of rehabilitation (Duff, 2004). Previous studies have shown that a client’s involvement in the goal setting process is a strong indicator to the therapy’s effectiveness in ensuring lasting change (Duff, 2004). Individual involvement in goal setting has been found to increase adherence, goal attainment and client satisfaction (Duff, 2004). Furthermore, individual involvement facilitates a sense of power, enabling the client to adequately manage the consequences of their injuries, as well as strongly contributing to greater physical and cognitive gains in therapy (Holliday, 2007).

Setting Functional Communication Goals

Focusing on functional life goals influences a client’s compliance and motivation to succeed in therapy (Nair, 2003). Functional life goals are the desired states that people wish to obtain and maintain or avoid (Nair, 2003). Functional life goals in rehabilitation are generally derived from the client’s pre-morbid status (Nair, 2003). These can be obtained directly from the client or from the client’s relatives or friends (Nair, 2003). Cognitive impairments and lack of insight can interfere with assessment of life goals, inhibiting one’s ability to express their goals to relevant medical staff (Nair, 2003). For neurological patients, it is vital to spend sufficient time in establishing and setting goals (Holliday, 2007). Establishing a reliable yes/no response and requesting clients to make simple choices will assist setting relevant goals for therapy (Nair, 2003). On admission to rehabilitation, it is important to determine what areas of life are the greatest concerns to the client (Nair, 2003). Those areas identified as greatest concern can then be used to formulate a hierarchy of goals to work from.

Success in rehabilitation largely depends on the client’s motivation levels (Nair, 2003). This greatly relies on the consensus between a client’s life goals and goals set by the rehabilitation team (Nair, 2003). For this reason, it is the responsibility of the medical team to tailor goals specifically to the individual’s needs. Communication between the medical team and the client needs to be carried out to ensure the client understands and agrees that goals set in therapy coincide with their life goals (Nair, 2003). It is common for clients to feel unable to express their wants and needs in therapy, and for that reason individualisation is often missed in the therapy setting (Schulman – Green, 2006). However, a study performed by Schulman – Green (2006) found that with increased prompting, all clients expressed very specific, individual goals ranging from walking up stairs to attending a concert. Examples of how to set goals specific to a client’s life goals is further discussed in the “Individualised Therapy” section of the manual. The following table developed from Nair (2003) describes how to set and carry out life goals in rehabilitation:

Figure 1 Rehabilitation programme based on life goals. [ not included in the PDF file]

Nair, K. S. (2003). Life goals: the concept and its relevance to rehabilitation. Clinical Rehabilitation, 17, 199.

Another component to goal setting in rehabilitation is that goals need to be specific and set to an achievable, yet challenging level (Duff, 2004). It is vital to also ensure that goals set in therapy are measurable by an evidence-based scale (Siegert, 2004). An example of a measurable scale is the Australian Therapy Outcome Measures (AusToms) (Perry, 2004). AusToms is a valid and reliable measure that was developed by clinicians for clinicians in establishing baseline measures, intra-and-inter profession comparisons and evaluation of intervention (Perry, 2004). Studies have shown an association between setting measurable goals within onset of skill acquisition, also contributing to the development of positive psychological benefits mediating between task ability and performance (Duff, 2004). Goal proximity and the setting of both short and long term goals have been found to increase performance on task and set lasting, self-regulating behaviour change (Duff, 2004).

Ineffective goal setting and rehabilitation practice does occur, as described in a study by Duff (2004). Such reason for goal non-achievement was predominately caused by staff and/or organisational issues, followed by client issues (Duff, 2004). Another factor for failed goal setting is due to the lack of rapport built between clinician and client (Holliday, 2007). This highlights the importance of effective teamwork in interdisciplinary and multidisciplinary teams, as failure can and does impact on the client’s success in achieving goals (Duff, 2004).

A study performed by Hersh (2007) found that although clients did find therapy useful, they were unable to describe the rationale behind completing individual activities in therapy. Completion and achievement of specific therapy exercises was described as the main reason for improvement in therapy, followed closely by ongoing encouragement to achieve goals (Hersh, 2007). Other participants reported therapy being too theoretical and irrelevant to their individual needs (Hersh, 2007). Functional communication goals in therapy directly assist in the client’s personal needs and pre-morbid status (Siegert, 2003). Furthermore, targeting functional communication allows clarification of the importance of therapy to clients. It is important to recognise that goal setting involves more than simply setting a goal and achieving it through exercises (Siegert, 2003). It is vital to provide clients with accurate descriptions of what the set goal is, and why it is being targeted in therapy, as well as providing appropriate encouragement (Hersh, 2007).

Nair (2003) established a set of guidelines when setting functional goals in therapy.

These are described below:

1. Identification of functional goals.
2. Analysis of functional goals from prognosis, impairment, disability, handicap, available resources and the client’s environment.
3. Assist client’s to cope with loss of life goals and develop attainable goals from unachievable goals identified.
4. Assist client’s to develop realistic expectations about rate of progress to achieve functional goals.
5. Plan and implement a therapy program focused on the client’s functional life goals.
6. Assist client to relate their treatment goals to their overall functional goals.
7. Frequent and consistent reviews to identify any change in functional life goals so suitable adaptations can be made when necessary.

Another guideline that has been advocated for setting goals in rehabilitation is the SMART model (Siegert, 2003). This model states that an ideal goal should be Specific, Measurable, Achievable, Relevant and Time-limited (Siegert, 2003). It also suggests that goal setting is a dynamic process that may require online changes and adjustments during the rehabilitation stay (Siegert, 2003).

Discharge from Rehabilitation

It is important to acknowledge that following completion of rehabilitation therapy, adequate discharge procedures are carried out to ensure client satisfaction and confidence (Hersh, 2007). A study completed by Hersh (2007) on client opinions following the discharge of therapy of clients with aphasia, found clients had unpredictable rationales to timing and reason for discharge. Rationales were generally placed in one of three categories: client related, based on the client’s assessment and progress; therapist related, based on the therapist’s perceptions; and externally imposed influences that were any reasons judged by clients to be out of the therapist’s control (Hersh, 2007).

All rationales described by clients were due to a lack of communication on discharge, causing uncertainty and confusion (Hersh, 2007). These findings have suggested that extra effort and consideration need to be applied on discharge of clients from rehabilitation (Hersh, 2007). This can be achieved through the implementation of the following factors:

• Consistent communication with clients throughout the entire therapy period, regularly discussing progress with the individual.
• Discussion with client of why therapy is ending.
• Consistent communication with clients to encourage them to express any concerns they have with therapy/their progress/feelings associated to discharge.
• Communication and collaboration with the client in setting rehabilitation plan and goals in therapy.

References

Duff, J., Evans, M. J., & Kennedy, P. (2004). Goal planning: A retrospective audit of rehabilitation process and outcome. Clinical Rehabilitation, 18, 275 – 286.

Hersh, D. (2007). How do people with aphasia view their discharge from therapy? Aphasiology, 1 – 20.

Holliday, R. C., Ballinger, C., & Playford, E. D. (2007). Goal setting in neurological rehabilitation: Patients’ perspectives. Disability and Rehabilitation, 29(5), 389 – 394.

Nair, K. S. (2003). Life goals: the concept and its relevance to rehabilitation. Clinical Rehabilitation, 17, 192 – 202.

Perry, A. (2004). Therapy Outcome measures for allied health practitioners in Australia: the AusToms. International Journal for Quality in Health Care, 16, 285 – 291.

Schulman-Green, D. J., Naik, A. D., Bradley, E. H., McCorkle, R., & Bogardus, S. T. J. (2006). Goal setting as a shared decision making strategy among clinicians and their older patients. Patient Education and Counselling.

Siegert, R., & Taylor, W. (2004). Theoretical aspects of goal-setting and motivation in rehabilitation. Disability and Rehabilitation, 26(1), 1 – 8.

Individualised Therapy

There is no one specific manual or set of guidelines, which inform clinicians of the exact steps required in providing therapy for individual’s with an acquired neurological communicative disorder (ANCD). This is because people and their deficits differ so greatly. There are many factors, which need to be taken into account when developing therapy activities for an individual with an ANCD i.e. client’s functional level, type of brain injury (the site and extent of their injury), individual goals, client’s life stage & expectations for discharge e.g. do they require supervision or are they able to return to work. All these key factors differ significantly for individuals, and consequently therapy should be client-centred and focus on meeting the differing needs of each client. This is what is referred to as individualised therapy.

It is often very difficult for individual’s with an ANCD to generalise what has been learnt in therapy and then apply it across different contexts (Ponsford, Sloan & Snow, 1999). Therefore, goals must be practical and focus on activities performed in everyday life (Ponsford, et al., 1999). When developing client-centred therapy activities for an individual, it is critical they are as functional and as relevant to the client as possible (Ponsford, et al., 1999). Impaired self-awareness is a common symptom for individual’s with an ANCD (Noé, Ferri, Caballero & Villodre, 2005). It has been reported that many individual’s with ANCD’s lack insight and have difficulty seeing the relevance of therapy (Ponsford, et al., 1999). Therefore by focusing on everyday living and helping individuals to see the relevance of therapy activities, maximises the likelihood of client participation in therapy (Noé, et al., 2005). Once a clinician has recognised the importance of developing therapy that is individualised, the next step is to implement and conduct the appropriate therapy. So how do clinicians go about shaping therapy that is individualised for their clients? The following information provides a brief recommended overview of important aspects needed to be considered.

Conducting Individualised Therapy

Therapy must be tailored to the individual with an ANCD (Worrall, 1999). Therapy for an individual should be shaped in such a way that the clinician performs therapy activities in the context that is as close as possible to real life (Worrall, 1999). This involves who the client talks with regularly, common communicative environments & frequently used communication aids i.e. telephone (Worrall, 1999).

Individual Goals for Therapy

Before therapy can begin it is important to find out what activities clients took part in pre-morbidly, but now have difficulty with because their impairments are impeding on their participation (i.e. return to work, buy the weekly shopping, pay bills, talk to friends etc.). This information will then be used to form therapy that is individualised and focused on meeting the client’s needs. If a client’s level of insight has been affected, then their aims for therapy will need assistance and input from the clinician and their primary communication partners. Research conducted by Noé et al. (2005) found that improvement in self awareness was associated with participation in cognitive and functional tasks. This highlights the need for therapy to be functional and relevant to the individual. For a more comprehensive look at individual goals for therapy, refer to the “Goal Setting” section.

Communication Partners

The involvement of primary communication partners, who the client regularly talks with or depends on for communication in therapy is both realistic and functional. Rather than basing therapy on improving the client’s communication difficulties by interacting solely with the clinician, the client can interact with the people they will be communicating with on a regular basis. This functional approach to therapy also exposes the communication partners to the therapy process and clinicians are able to model helpful strategies for effective communication (Ponsfor, et al., 1999). Many individual’s with an ANCD need to adjust to different levels of functioning, which may be significantly different to how they previously lived (Marsh & Knight, 1991). Some never return to their pre-morbid functioning and may have lasting and disabling cognitive and psychosocial deficits, which will need assistance for the rest of their lives (Marsh & Knight, 1991). Therefore, it is important that their familiar communication partners are educated in how best to assist with their communication. The importance of communication partners is discussed in more detail in the “Communication Partners” section.

Common Communicative Environments

For therapy to be functional and individualised, it is suggested that one establishes the best context and environment to conduct therapy (Worrall, 1999). Clients can accomplish tasks at home that they cannot otherwise do at hospital and this is why rehabilitation in the home is successful (Worrall, 1999). If conducting therapy in their home is difficult to arrange, then the clinic setting can be created in a way that is as near to real life as possible. This can be arranged by asking the client to invite their communication partners to therapy and bring in any aids. Aids are defined as a prop, which enhances communication (Worrall, 1999). The fact still remains that clients should have more opportunities to practise therapy outside the hospital setting. Finding the right setting to conduct therapy will assist with the successfulness of therapy for an individual with an ANCD. Environments may include home, work, local shopping centres or cafés, schools or train stations. Select environments, which the client commonly spends the majority of their day, as these will most likely be the places where the most communication will occur.

Frequently Used Communication Aids

Communication aids or props are also a functional aspect, which is important to include into therapy (Worrall, 1999). Aids such as telephones, keyboards, books, recipes, telephone bills and bus timetables are some of the props that can be used. It is critical that each aid is relevant to the client. That is, clinics may have phones, however they may be different to the one the person commonly uses at home. Irrespective of the aid, ensure that it is commonly used by the client and it is from their own environment, as individualised therapy is the key (Worrall, 1999). If rehabilitation cannot be accessed in the home, ask the client to bring their communication aids from home into the clinic in an effort to make the environment as close to real life as possible (Worrall, 1999).

Taking into account the above information, an example of individualised and functional therapy would be the following:

Individualised Goal:

To independently buy a coffee at the local café when meeting with friends.

Communication Partner

Exchange occurs with the sales assistant and also in Communication Exchange: primary communication partners i.e. close friend, may aid effective communication.

Communicative Environment:

The person’s favourite café.

Use of Communication Aids:

Aids that assist with communication i.e. menu, gestures/pointing, writing, communication book etc. (Worrall, 1999).

Once these important aspects have been established, the therapy task itself can be developed. The task in this situation is to buy a coffee. The task will involve a greeting (Hi, how are you?), a request (Can I please have one latté?), money exchange (handing over the correct money and receiving the correct change) and a response (Thank you.). The task itself involves a variety of stages, which will need more detailed focus in therapy. This will be discussed in greater length in the Communication Acts.

Conclusion

The most important aspect of therapy is to establish functional tasks that are relevant for the individual. Therapy needs to be individualised for every client. Therapy activities may vary widely amongst clients, which is what individualised therapy entails. This will ensure the optimum outcome is achieved for the client, which is the ultimate goal in therapy.

References

Marsh, N.V., & Knight, R.G. (1991). Behavioural assessment of social competence following severe head injury. University of Waikato, Hamilton, New Zealand: Psychology Press.

Noé, E., Ferri, J., Caballero, M.C., & Villodre, R. et al. (2005). Self awareness after acquired brain injury; Predictors and rehabilitation. Journal of Neurology. New York. 252(2), 168.

Ponsford, J., Sloan, S., & Snow, P. (1999). Traumatic brain injury – Rehabilitation for everyday adaptive living. East Sussex, UK: Taylor & Francis Group.

Worrall, L. (1999). FCTP: Functional communication therapy planner. Bicester, Oxon: Winslow Press.

Therapy Communication Partners

This section of the manual will focus on the use of communication partners in therapy for individual’s with acquired neurological communicative disorders (ANCD) to facilitate successful transition from hospital to home. The use of communication partners in the rehabilitation setting and the involvement of significant others in therapy will be discussed. The use, positive and negative aspects of communication strategies to facilitate communication partners will also be considered.

Use of Communication Partners in Therapy

An article by Correll, Van Steenbrugge and Scholten (2004) discussed the importance of targeting communication in therapy through social activities with familiar communication partners, as they allow for optimal outcomes. This is achieved through training of skills and compensatory strategies, as well as targeting optimal communication rather than linguistic accuracy (Correll et al., 2004).

Family members are the most commonly used communication partners in therapy, aside from the clinician, because they are usually the person/people the client interacts with most. Using a significant other within the therapy intervention reduces the stress, loneliness and depression that the client and significant other may experience (Correll et al., 2004).

Numerous studies referring to the relationship between quality of life and young adults with traumatic brain injury (TBI) emphasise the importance of involving the client’s larger social network in therapy. A larger social network assists in family and client adjustment to disability and associated challenges (Morton & Wehman, 1995). These studies found that the pre-morbid social relationships clients held, often had deteriorated to the point that they no longer associated with their previous social network, and failed to be involved in any new social networks up to two years post-discharge (Morton & Wehman, 1995). Therefore therapy should consider the use of communication partners from the client’s larger social network.

Involving a variety of communication partners in a client’s therapy is used across the Speech Pathology discipline. For example it is common to involve the parent of a child receiving speech pathology intervention (Wetherby, 2002). Like wise it is common to use a variety of speaking partners in adult stuttering therapy to generalise outcomes from the clinical environment across contexts (Block, Onslow, Packman, Gray & Dacakis, 2005). Therefore the use of a hierarchical system of interacting with different communication partners can increase a client’s ability to communicate in social situations (Block et al., 2005). In turn, this reduces the risk of social isolation, and increases independence.

The following is an example of ten goals using a hierarchical system of communication partners in therapy:

1. Greet a familiar communication partner (e.g. family member).
2. Greet a less familiar communication partner (e.g. acquaintance).
3. Greet an unfamiliar communication partner (e.g. retail assistant).
4. Buy a newspaper.
5. Make a telephone call to a familiar communication partner.
6. Order a coffee.
7. Have a discussion with a familiar communication partner about a pre-morbid hobby.
8. Discuss the weather with an unfamiliar communication.
9. Have a discussion with an unfamiliar communication partner about a pre-morbid hobby.
10. Present a lecture to a group of people.

The goals mentioned above are highly dependant on the client, their wishes, the extent of the communication disorder and the amount of intervention received. Appropriateness of communication partners will differ for each client and goal. Refer to “Individualised Therapy” section for further information.

Use of Familiar and Unfamiliar Communication Partners

Communication partners have been identified in the literature to reduce the social isolation and anxiety that frequently results from an ANCD (Rayner & Marshall, 2003). Furthermore, the inclusion of both familiar and unfamiliar communication partners in intervention utilises the recommendations of the ICF framework and the Social model (refer to “Frameworks” section).

However, Simmons-Mackie, Kearns & Potechin (2005), found that without specific training, the benefits of a communication partner are limited and can be detrimental to therapy outcomes. Therefore, when conducting therapy with communication partners, specific training needs to be implemented. Observation of a therapy session and informational counselling in isolation are insufficient.

Many studies have described the communication between individual’s with an ANCD and their communication partners. Simmons-Mackie et al. (2005) suggest that family members are not always the most effective communication partners, as they find it difficult to adapt to a new style of interaction with their spouse/friend after an ANCD.

There is also evidence in the literature that suggests training of unfamiliar communication partners has a positive effect on communication and reacquisition of communication skills for individual’s with ANCD’s (Ylvisaker, 2006). Furthermore, there is evidence to suggest that the training of unfamiliar communication partners reduces feelings of social isolation in individual’s with an ANCD (Rayner & Marshall, 2003). Therefore, it is important to consider the client’s social environment outside of therapy to maximise their expressive output and so increase their ease of communication within the community (Ylvisaker, 2006).

There are many strategies that can be suggested to a communication partner to facilitate communication. A range of generic positive and negative communication strategies are described in the following table. These can be applied to any therapy goal.

A summary of communication strategies as adapted from Simmons-Mackie & Kagan (1999). Communication Partners

Conclusion

The use of communication partners in therapy has been shown throughout the literature to be best practice. However, it is important to acknowledge that sufficient training and education of strategies for communication partners are implemented. Without this training, therapy may break down and can have detrimental effects on the client’s outcomes, as well as the relationships with their communication partner/s. Once adequate training has been provided, positive functional outcomes can be attained. This results in increased client motivation and a decreased risk of social isolation, depression and anxiety.

References

Block, S., Onslow, M., Packman, A., Gray, B., & Dacakis, G. (2005). Treatment of chronic stuttering: Outcomes of a student training clinic. International Journal of Language and Communication Disorders, 40(4), 455-66.

Correll, A., Van Steenbrugge, W., & Scholten, I. (2004). Communication between severely aphasic adults and partners: An early intervention. Acquiring knowledge in speech, language and hearing pathology, 6(2), 93-6.

Morton, M., & Wehman, P. (1995). Psychosocial and emotional sequelae of individuals with traumatic brain injury: A literature review and recommendations. Brain Injury, 9(1), 81-92.

Rayner, H., & Marshall, J. (2003). Training volunteers as conversation partners for people with aphasia. International Journal of Language & Communication Disorders, 38(2), 149-64.

Simmons-Mackie, N., & Kagan, A. (1999). Communication strategies used by good versus poor speaking partners of individuals with aphasia. Aphasiology, 13(9-11) 807-20.

Simmons-Mackie, N., Kearns, K., & Potechin, G. (2005). Treatment of aphasia through family member training. Aphasiology, 19(6) 583-93.

Wetherby, A. (2002). Communication disorders in infants, toddlers and preschool children. In Shames, G. & Anderson, N. (Eds.) Human communication disorders: An introduction (6th ed.)(pp. 186-217). Boston: Allyn and Bacon.

Ylvisaker, M (2006). Self-Coaching: A Context-Sensitive, Person-Centred Approach to Social Communication after Traumatic Brain Injury. Brain impairment, 7(3), 246-58.

Group Therapy

Group therapy is an important part of the rehabilitation process for individual’s with acquired neurological communicative disorders (ANCD). Group therapy is an effective use of the clinician’s time and resources, has many communication benefits and most importantly facilitates transfer of skills from the rehabilitation setting into the home environment. This section will outline some of the relevant theory as to why group therapy is important, and then focus on considerations of clinical application of group therapy.

Effective use of time/resources

Chapey (2001) suggests that in the context of reductions in reimbursement for clinical services and less time to treat our clients, group therapy approaches are becoming a significant aspect of client management. With increased pressure to cope with the demand for services, group therapy can be an extremely effective use of our health care resources.

Benefits of groups

Although group therapy remains a controversial area, various studies have explored the efficacy of group therapy for individual’s with an ANCD and purported that group intervention is an effective means of treating speech language deficits (Aten, Caligiuri & Holland, 1982; Bloom, 1962; Elman, 2007; Elman & Bernstein-Ellis, 1999; Marshall, 1999; Wertz, Collins, Weiss, Kurtzke, Friden, Porch, West, Davis, Matovitch, Morley & Resurreccion, 1981).

In addition to benefits in speech and language, several studies have found that group therapy resulted in numerous psychological and emotional gains. Participants developed an increased sense of personal destiny and confidence; decreased feelings of hopelessness; a lowered sense of victimisation and anger; and a greater sense of control and empowerment (Armengol, 1999).

The groups were found to provide a sense of belonging to individuals that feel extreme social and emotional isolation; more effective coping strategies; behaviour rehearsal opportunities; and self-monitoring training (Delmonico, Hanley-Peterson & Englander, 1998).

Improved ratings on measures of self esteem, social skills, self awareness, everyday memory and other cognitive skills have also been found in a variety of group programs described in the literature (Tate, 1997; Boake, 1991; Deaton, 1991; Onsworth, Mc Farland & Young, 2000).

Transfer of skills – rehabilitation to home

The group setting provides an important link between individualised treatment and the natural environment. It acts as a forum to facilitate generalisation of skills learnt in individual therapy to a variety of communication partners and contexts (Rollin, 2000).

Establishing A Communication Group In The Rehabilitation Setting

Below are some basic considerations to take into account when establishing a communication group in the rehabilitation setting. These considerations have been developed in consultation with experienced clinicians working in the Metropolitan Melbourne rehabilitation setting. This is by no means an exhaustive list and it is important to note that each clinician will develop their own group in accordance to the needs of their clients and individual professional style.

Goals

Before establishing a communication group the clinician first needs to determine the purpose of the group. This will depend on the clients and the setting, however, it is important to have clear goals to build the group around. For example, is the purpose of the group to encourage social participation and conversation or perhaps transfer of strategies developed in individual therapy? In addition to overall group goals, individual goals should be developed with each group member. It is important that each client is aware of his or her personal goals for the group, both to maximise the effectiveness of the therapy and prevent clients from merely attending rather than participating.

Types of groups

Chapey (2001) describes several different types of groups that can be utilised for client’s with an ANCD. These include:

• Direct therapy groups: focus on specific language processes with structured tasks.This may be useful for clients who have more severe impairments and require additional support to initiate and participate.
• Indirect therapy groups: focus on facilitating language recovery in functional activities with unstructured tasks. For example, visits to a coffee shop where the clients are required to order from the menu or ask the staff a question. The hospital cafe can be a useful and safe environment, as the staff can be educated prior to the session.
• Sociolinguistic groups: focus on facilitating a wider range of communication interactions. These groups can support social interaction and pragmatic function however, be wary that they do not become chat groups. Individual goal setting may counteract this. For example a client could be required to initiate 5 questions to different group members.
• Transition groups: focus on facilitating transition between treatment and discharge. These groups may vary across time and begin with more structured, impairment based tasks and then develop into functional tasks as the client moves towards discharge.
• Support groups: focus on providing education and/or support. This may be for the clients alone, or family members may also wish to participate.

Depending on the needs of the clients, various aspects of the different types of groups can be incorporated. For example, the group can commence following direct therapy principles and then transform into a more indirect approach as clients develop different skills and goals.

Criteria for participation

Exclusion and inclusion criteria of the participants need to be established. Depending on the purpose of the group, different aspects of the clients need to be considered. These may include, but are not limited to severity/type of impairment, age range, cultural influences, gender, aggressive behaviours, and non-English speaking backgrounds. The Speech Pathologist may wish to make this decision alone, however input from the medical and allied health team can assist in this process.

The number of clients participating is also important. Will the numbers be capped; does the group have scope to expand? This will be influenced by the types of clients and group. However, to ensure that each member is receiving adequate support, eight participants may be a maximum to consider.

Facilitator of the group

The Speech Pathologist will obviously be the primary facilitator of the group, but depending on the complexities of the clients, the level of experience of the Speech Pathologist and support available, two clinicians may be preferable. If there is only one Speech Pathologist in the setting other allied health staff can be invaluable. Depending on their availability, Occupational Therapists or allied health assistants could act as a second facilitator.

Evaluation measures

Outcome measures are a vital part of therapy and group therapy is no exception. How will client progress be evaluated? Important aspects to take into account include: at what level will the success be measured - reduction in impairment, increase in participation and/or successful completion of functional tasks. Will the measurement be formal, informal or a combination of both and if there are secondary facilitators, who will be responsible for these different measures?

Some possibilities for evaluation include client reports, for example a participation scale or client questionnaire, as well as data collected by the Speech Pathologist. You may wish to develop a template to facilitate concise and time effective measurement.

Other

There are many smaller logistical considerations when developing a group that will not be discussed in detail in this manual, as they are setting and clinician specific. However, it is worthwhile to mention them briefly. The frequency of the group, length of the sessions and transfer of clients will depend upon the clients. Room bookings, timetabling, required materials (e.g. whiteboards) and documentation of attendance will vary according to the policies of the setting.

References

Armengol, C. G. (1999). A multimodal support group with hispanic traumatic brain injury survivors. Journal of Head Trauma Rehabilitation, 14(3) 233-246.

Aten, J.L., Caligiuri, M.P., & Holland, A. (1982). The efficacy of functional communication therapy for chronic aphasic patients. Journal of Speech and Hearing Disorders, 47, 93-96.

Bloom, L.M. (1962). A rationale for group treatment of aphasic patients. Journal of Speech and Hearing Disorders, 27, 11-16.

Boake, C. (1991). Social skills training following head injury. In J.S. Kreutzer & P.H. Wehman (Eds.), Cognitive rehabilitation for persons with traumatic brain injury. Baltimore: Paul H. Brookes.

Chapey, R. (Ed). (2001). Language intervention strategies in aphasia and related neurogenic communication disorders (4th ed). Philadelphia: Lippincott, Williams and Wilkins.

Deaton, A.V. (1991). Group interventions for cognitive rehabilitation. In J.S. Kreutzer & P.H. Wehman (Eds.), Cognitive rehabilitation for persons with traumatic brain injury. Baltimore: Paul H. Brookes.

Delmonico, R.L., Hanley-Peterson, P., & Englander, J. (1998). Group psychotherapy for persons with traumatic brain injury: Management of frustration and substance abuse. Journal of Head Trauma Rehabilitation, 13(6) 10-22 .

Elman, R. (2007). Group treatment of neurogenic communication disorders: The expert clinician’s approach. San Diego: Plural Publishing.

Elman, R., & Bernstein-Ellis, E. (1999). The efficacy of group communication treatment: Preliminary findings. Seminars in Speech & Language, 20(1), 65-72.

42 The Road Home: Integrating Functional Communication Therapy into Rehabilitation

Marshall, R.C. (1999). Introduction to group treatment for aphasic patients: Decisions and management. Woburn, MA: Butterworth-Heinemann. Ownsworth, T.L., McFarland, K., & Young, R. (2000). Self-awareness and psychosocial functioning following acquired brain injury: An evaluation of a group support programme, Neuropsychological Rehabilitation, 10(5) 465 – 484.

Rollin, W.J. (2004). Counselling individuals with communication disorders. Psychodynamic and family aspects (2nd Ed). Boston: Butterworth-Heinemann.

Tate, R.L. (1997). Beyond one-bun, two-shoe: Recent advances in the psychological rehabilitation of memory disorders after an acquired brain injury. Brain Injury, 11(12), 907 – 918.

Wertz, R.T., Collins, M.H., Weiss, D., Kurtzke, J.F., Friden, T., Porch, B.E., West, J.A., Davis, L., Matovitch, V., Morley, G.K., & Resurreccion, E. (1981). Veterans Administration cooperative study on aphasia: A comparison of individual and group treatment. Journal of Speech and Hearing Research, 24, 580-594.

Approaches To Therapy: Multidisciplinary or Interdisciplinary?

The importance of teamwork to providing therapy in the rehabilitation setting is crucial to optimising client outcomes. There are several approaches to providing therapy to clients, including the multidisciplinary approach and the interdisciplinary approach.

The Approaches

A multidisciplinary approach is when professionals from varying disciplines work independently of one another to represent their own discipline (Davies, 2007). Team members work parallel alongside each other, but focus primarily on their own discipline. The client’s medical file is the primary means of communication amongst health care professionals (CAPC, 2008). In a multidisciplinary team, there is selected time spent discussing clients with all team members present. However, the ability to transfer skills and work collaboratively with allied health professionals is minimal. Currently, the multidisciplinary approach is commonly used by health care professionals in inpatient rehabilitation (The Medical Journal of Australia, 2003).

An interdisciplinary approach involves professionals from several disciplines working together and using formal channels of communication to share information and discuss results (Davies, 2007). There is possibility for an overlap in roles, however, this approach provides the client with multiple resources and a multi-skilled practitioner (The Medical Journal of Australia, 2003). This coexistence and transfer of skills enables team members to “cover each other’s weaknesses and maximize each other’s strengths” (The Medical Journal of Australia, 2003, para. 8). Furthermore, team members can facilitate the implementation of goals unique to every discipline (The Medical Journal of Australia, 2003). In this approach, team members meet on a regular basis to discuss the needs of the client and to establish intervention strategies accordingly (CAPC, 2008). Goals for the client are set collaboratively to avoid group conflict regarding recommendations, timelines and goals (The Medical Journal of Australia, 2003).

Barriers to Service Delivery

Often time restraints do not permit professionals to see clients simultaneously, and logistically this can be challenging (Resource Centre on Ageing, 2008). Therefore, aspects of the multidisciplinary approach (as opposed to an interdisciplinary approach) remain the most widely used in the rehabilitation setting (Gardner, 2007). Instead, there should be flexibility in service delivery to support each client’s individual needs. Therefore, the focus should be on optimising the overall outcome for the client through best practice, as demonstrated by the interdisciplinary approach. However, funding is supplied to professions as a separate entity for specific purposes and does not support an interdisciplinary approach (Gardner, 2007). Also, for the interdisciplinary approach to be effective, there must be adequate communication amongst team members and minimal team conflict (The Medical Journal of Australia, 2003).

Human service organisations, the Government and funding bodies do acknowledge that there is a need for a holistic and collaborative approach in health care service delivery (Gardner, 2007). The Medical Journal of Australia (2003) identified the interdisciplinary team approach as an effective model to be used in rehabilitation, however, it is currently not widely implemented across health care services.

A Resource for Allied Health Professionals

Informal interviews were conducted with qualified Speech Pathologists currently working in the inpatient rehabilitation setting. This was to gain an understanding of what is required to improve outcome measures for individual’s with an acquired neurological communicative disorders (ANCD). Feedback given by some Speech Pathologists indicated that there is a lack of information provided to allied health professionals in regards to communicating with individual’s with ANCD’s and the role of a Speech Pathologist.

Education about Speech Pathology for allied health professionals can be conducted in a variety of ways. Each rehabilitation facility conducts professional development differently. It must be acknowledged that most services do provide the opportunity for professionals to transfer their skills to other professions in a limited capacity. However, it was expressed that this was not adequate for allied heath professionals to develop a true understanding of communicating with individual’s with ANCD’s.

It is believed that through gaining a better understanding of communication, health care professions will be able to:

• Communicate more effectively with clients.
• Gain a better understanding of the client’s difficulties.
• Understand the emotional and behavioural deficits that may be present.
• Develop a greater understanding of the role of a Speech Pathologist.
• Develop knowledge of communication strategies.
• Improve liaisons with other health professionals e.g. referrals.
• Improve therapy outcomes through enhanced communication with clients.

Attached at the end of this section is a brochure that can be provided to allied health professionals to assist their service delivery. The brochure aims to provide basic strategies to improve the communication between the clinician and the client. It is hoped that it will not only assist allied health professionals, but will indirectly benefit clients, which is the ultimate objective.

References

Centre to Advance Palliative Care (CAPC) (2008). Interdisciplinary care. Retrieved September 1, 2008 from http://64.85.16.230/educate/content.html

Davies, S. (2007). Team around the child: Working together in early childhood. New South Wales: Oxford University Press.

Gardner, F. (2007). Interdisciplinary professional practice: Current issues and prospects. Melbourne: Oxford University Press.

The Medical Journal of Australia (2003). Team working: Palliative care as a model of interdisciplinary practice. Retrieved August 25, 2008 from http://www.mja.com.au/public/issues/179_06_150903/cra10363_fm.html

Resource Centre on Ageing. (2008). The interdisciplinary team: Improving the care of our elders. Retrieved September 5, 2008 from http://socrates.berkeley.edu/~aging/HMS298.htm

Speech Pathology: Communication

• Speech Pathologists assist individuals with difficulties in:
• Swallowing
• Speech
• Language
• Non-verbal Communication
• Cognition (including memory)

Speech Pathologists commonly treat individuals with:

• Dysphagia (swallowing)
• Aphasia (planning of speech)
• Apraxia (programming of speech)
• Dysarthria (execution of speech)
• Cognitive deficits (including attention, memory, reasoning)

If you have any further enquiries regarding these conditions, contact the Speech Pathologist working in your facility.

General tips for communicating with individuals with acquired neurological communicative disorders

• Try to establish a routine with the client so they know what to expect and to minimise stress.
• Minimise distractions during your therapy sessions to keep the client on task.
• Be aware that attention often declines with fatigue.
• Involve the client in all conversations and allow them adequate time to participate.
• Talk directly to the client.
• Focus on what the individual is doing well.

To assist communication for a client with memory difficulties

• If necessary, write down the main points of conversation (visual aid).
• Convey only small amounts of information at a time.
• Recap the main points of your conversation and/or therapy.
• Draw diagrams to help represent important aspects of conversation.
• Keep dialogue simple and concise.

To assist communication for a client with difficulties in understanding

• Reduce background noise.
• Gain the client’s attention and establish eye contact.
• Use short and simple sentences.
• You may need to talk at a slower rate.
• Use repetition and re phrase if appropriate.
• Use gestures in conjunction with speech.
• Use other means of communication such as drawing, writing, communication books, gestures, facial expression etc…
• Use props such as photos, maps, diagrams, pictures, symbols etc…
• Use expression, as the tone of your voice can assist understanding of the message.
• Use terms familiar to the client.
• Allow extra time for the client to process information.
• Emphasise key words or main points.
• Establish a topic first, so the client can follow the conversation more readily.
• Always check that the person has understood what was said to them.

Speech Pathology: Communication

To assist communication for a client who has difficulty expressing their message

• Be aware of any motor speech problems the client may have and encourage them to communicate regardless of errors they may produce.
• Refrain from correcting speech errors, however sometimes it may be helpful to predict the word the client wants to say. Ask for their permission to do so first.
• Acknowledge if you are having difficulty understanding the client. Always clarify what you don’t understand - it may be helpful to repeat what the client has said back to them and ask if it is correct. They are able to respond with a yes/no.
• Acknowledge the client’s difficulties and frustrations (e.g. use statements such as “I know this must be really frustrating for you”).
• Listen to what the client is trying to communicate (don’t dismiss anything the client is trying to tell you).
• Allow extra time for the client to communicate their message.
• Make use of the client’s strengths (e.g. they may have difficulties speaking but are able to write).

Considerations for communicating with individuals with acquired neurological communicative disorder

• It is important to realise that every client presents differently.
• Not all tips apply to every client.
• Establish which techniques are most effective for each client and apply. If unsure, discuss with the Speech Pathologist.
• There may be times when the client is having difficulty coping, both physically and emotionally. Be aware of the client’s needs and adjust accordingly.
• Try not to assume that a client is being lazy or uncooperative. Sometimes the client will be unable to communicate something they have been able to pre-morbidly.
• Remember that communicating can be exhausting for clients, so try not to overload the client during therapy.
• If communication becomes too difficult and the client is fatigued, stop and try again later.

References

• Brain injury organization of America
• National Aphasia Association New York
• National Institute on Deafness and Other Communication Disorders
• Peninsula Health palliative care service
• Speech Pathology Australia
• The stroke and aphasia handbook
• University of British Columbia School of Nursing

Developed by Jacqueline Bonney, Lucy Bransgrove, Shelley Coy, Lauren Cutler, Hayley Dell’oro and Mikayla Moroney (4th Year Student Speech Pathologists)

Part B - Communication Acts

Establishing a reliable yes/no response

Goal

To be able to communicate a reliable yes/no response in a variety of contexts using speech or gesture.

Rationale

Being able to communicate with a yes/no response is the most basic form of expression (Beukelman & Mirenda, 2005). The right to communicate is a fundamental and inclusive human right (Right to Communicate Group, 2002). It is therefore important for a client to have a reliable yes/no response to be able to express their basic needs and wants (Adler & Towne, 1981).

Baseline Skills

• Low cognitive ability
• Sufficient memory skills for learning
• Low receptive language skills
• Adequate hearing
• Intact vision

Measurability

Measurability for steps 1 and 2 is successful completion of the activity, as judged by the clinician. The clinician should ensure that the client understands the task. For all remaining steps, the client will progress to the next level of the hierarchy after achieving 90% or more success on the preceding step. Assessment to include ten trials for the criterion to be measured from. These achievements could be graphed and then used as a motivating tool for the client. Achievement of this goal will be considered when the client can express a reliable yes/no response through speech or gesture. This measure may require input from other allied health professionals (e.g. Physiotherapists, Occupational Therapists, etc…) and the client’s significant others to ensure the response is consistent and reliable. Establishing a reliable yes/no response Establishing a reliable yes/no response

Steps to Achieving Goal

1. Observe client’s interaction
   Activity: Observe the client interacting with a significant other or medical staff. Check if the client can maintain attention and arousal. Consider the client’s distractibility, preservation, fatigue, response time and emotional state.
2. Discussion with significant others and staff
   The clinician will discuss the importance of establishing a reliable yes/no response with the client’s communication partners and in what forms it may present. The clinician will explain the basic steps required to meeting the goal.
3. Understanding basic one stage commands
   Activity: Have the client respond to basic one stage commands (e.g. their name, “look at me”, “close your eyes”, “squeeze my hand” etc…). Use tactile, visual and verbal cues to demonstrate command if required.
4. Establish a non-verbal yes/no response
   Activity: Direct the client to nod their head to indicate “yes” and to shake their head to indicate “no” for answers to simple questions. Provide visual, tactile and verbal prompts where required. A non-verbal yes/no response may also take the form of thumbs up/down, eyes gaze up/down, eye blinks, finger movements, hand squeezes or an Augmentative and Alternative Communication (AAC) yes/no. Establish one non-verbal yes/no response only to avoid ambiguity.
5. Consolidate non-verbal yes/no response
   Activity: Implement a task that requires the client to answer a series of true/false questions. Questions may include “Is your name _____?”, “Is the current year ___?”, “Is _____ your hometown?”, “Are you married?”. Questions initially targeted should be concrete, have high frequency and imageability. Provide visual, tactile and verbal prompts where required. Introduce more abstract questions if the client achieves criterion for initial questions.
6. Establish a verbal yes/no response
   Activity: The task requires the client to verbalise a yes/no response following the clinician’s model. Use cued articulation, tactile cues and visual cues to facilitate place and manner of sound/word production. Target sounds in isolation if the client is experiencing difficulty producing yes/no at a word level.
7. Consolidate verbal yes/no response
   Activity: Repeat step 5, whereby the client is asked a series of yes/no questions. Initially encourage the client to use their verbal yes/no response simultaneously with their non-verbal yes/no response. Then finally encourage them to use their verbal yes/no response in isolation.

Considerations

• Consider the client’s primary mode of expression and implement AAC/non-verbal as required.
• Note the client’s non-verbal yes/no response may be unique; ensure that the response is consistent before assuming that they are communicating.
• If the client presents with dyspraxia the type of their non-verbal yes/no response will need to be considered. Work within the client’s abilities, acknowledging their presenting deficits. This also applies to their verbal yes/no response.

References

Adler & Towne (1981). Looking out/looking in: Interpersonal communication. New York: Holt, Rinehart and Winston.

Beukelman, D., & Mirenda, P. (2005). Augmentative & alternative communication: Supporting children and adults with complex communication needs (3rd ed.). Baltimore: Paul. H. Brookes Publishing Co.

Right to Communicate Group. (2002). The right to communicate organization. http://www.righttocommunicate.org/

Expressing basic needs & wants

Goal

To be able to express basic needs and wants in a short, simple sentence.

Rationale

Being able to express basic needs and wants is an important skill for a person to be able to communicate (Shames & Anderson, 2002). Communication is one of the basic rights in humanity and therefore should be a priority for therapy (Shames & Anderson, 2002). By expressing requests, the client is more likely to have their needs and wants met, rather than them being incorrectly interpreted or ignored (Shames & Anderson, 2002).

Baseline Skills

• Moderate cognitive ability
• Sufficient memory skills for learning
• Low receptive language skills
• Ability to self monitor
• Adequate hearing
• Intact vision

Measurability

Once the goal of “establishing a reliable yes/no response” has been achieved, a further goal of expressing needs and wants can be targeted.

Measurability for steps 1 and 2 is successful completion of the activity, as judged by the clinician. The clinician should ensure that the client understands the task. Basic yes/no comprehension questions can be used to measure this. For all remaining steps, the client will progress to the next level of the hierarchy after achieving 90% or more success on the preceding step. Assessment to include ten trials for the criterion to be measured from. These achievements could be graphed and then used as a motivating tool for the client.

Achievement of this goal will be considered when the client can consistently express short, simple sentences regarding their basic needs and wants. Expressing basic needs & wants Expressing basic needs & wants

Steps to Achieving Goal

1. Client to comprehend the concept of needs and wants
   Activity: Discuss the importance of being able to express basic needs and wants. Use visual/pictorial props of basic needs and wants (e.g. toilet, drink, food, pain etc…) relevant to the individual. Verbalise the words individually and have the client point to the corresponding prop to demonstrate their understanding. Use tactile and verbal cues where required.
2. Provide client with an AAC aid representing basic needs and wants
   Activity: Practise using the aid with the client (aid may take form in communication book, board, box full of real objects etc…). Ensure that the aid is specific to the individual and contains items/pictures that are representative of them (e.g. pictures of family members).
3. Recognition of corresponding picture/word relationship
   Activity: Begin with basic pictures of common items (use the 4 pictures from step 1). Have the client match the picture with its written/verbal form (e.g. ask the client to match the picture of food to its written/verbal form of “food”).
4. Establish expression of single words
   Activity: Show the client single item pictures and ask them to label the item. The clinician may use hierarchical verbal cues to assist the client to verbally label. For example “What’s this?”, “Describe what you can see”, “It rhymes with mood”, “It starts with f”, “It is spelt f-o-o-d”, “It is food”. Expressing basic needs & wants 56 The Road Home: Integrating Functional Communication Therapy into Rehabilitation
5. Establish expression of phrases with clinician
   Activity: Practise using the two words want and need and distinguish the meaning of each. Then team the key words with an item (e.g. want food, need medicine). Then practise using other single words to team with the key words e.g. more, no, later, etc… Then complete a discrimination of antonyms task (e.g. show pictures of a person asking for more food and no more food. Verbalise one of the stimuli and have the client choose the correct one). Drill tasks of the client producing the correct phrase would then follow. Provide the client with a phrase, which they are required to fill in the gap with a target word (e.g. no more ___ = no more drink). Then ask the client to repeat the completed phrase. The client will later be required to spontaneously produce a request phrase. Throughout these tasks visual, verbal and semantic prompting may be required.
6. Establish expression of phrases with a familiar communication partner
   Activity: Clinician to be present. The communication partner will be advised prior to the session of the tasks and expectations. Practise using the two words want and need and distinguish the meaning of each. Then team the key words with an item (e.g. want food, need medicine). Then practise using other single words to team with the key words e.g. more, now, later, etc… Then complete a discrimination of antonyms task (e.g. show pictures of a person asking for more food and no more food. Verbalise one of the stimuli and have the client choose the correct one). Drill tasks of the client producing the correct phrase would then follow. Provide the client with a phrase, which they are required to fill in the gap with a target word (e.g. no more ___ = no more drink). Then ask the client to repeat the completed phrase. The client will later be required to spontaneously produce a request phrase. Throughout these tasks visual, verbal and semantic prompting may be required. Expressing basic needs & wants 57 The Road Home: Integrating Functional Communication Therapy into Rehabilitation
7. Establish expressive phrases with an unfamiliar communication partner
   Activity: Clinician to be present. The communication partner will be advised prior to the session of the tasks and expectations. Practise using the two words want and need and distinguish the meaning of each. Then team the key words with an item (e.g. want food, need medicine). Then practise using other single words to team with the key words e.g. more, now, later, etc… Then complete a discrimination of antonyms task (e.g. show pictures of a person asking for more food and no more food. Verbalise one of the stimuli and have the client choose the correct one). Drill tasks of the client producing the correct phrase would then follow. Provide the client with a phrase, which they are required to fill in the gap with a target word (e.g. no more ___ = no more drink). Then ask the client to repeat the completed phrase. The client will later be required to spontaneously produce a request phrase. Throughout these tasks visual, verbal and semantic prompting may be required.
8. Establish expression of sentences with clinician
   Activity: Practise using common sentences that express basic needs and wants of the client. Fill in the gaps task to be completed (e.g. I ____ more ____ = I want more food). Then ask the client to repeat the completed sentence. The client will later be required to spontaneously produce a request sentence. Props can be provided to assist the client in planning a request sentence (e.g. providing a cup as a stimulus may prompt the client to express a sentence about drinking). Throughout these tasks visual, verbal and semantic prompting may be required.
9. Establish expressive sentences with a familiar communication partner
   Activity: Clinician to be present. The communication partner will be advised prior to the session of the tasks and expectations. Practise using common sentences that express basic needs and wants of the client. Fill in the gaps task to be completed (e.g. I ____ more ____ = I want more food). Then ask the client to repeat the completed sentence. The client will later be required to spontaneously produce a request sentence. Props can be provided to assist the client in planning a request sentence (e.g. providing a cup as a stimulus may prompt the client to express a sentence about drinking). Throughout these tasks visual, verbal and semantic prompting may be required. Expressing basic needs & wants 58 The Road Home: Integrating Functional Communication Therapy into Rehabilitation
10. Establish expressive sentences with an unfamiliar communication partner
    Activity: Clinician to be present. The communication partner will be advised prior to the session of the tasks and expectations. Practise using common sentences that express basic needs and wants of the client. Fill in the gaps task to be completed (e.g. I ____ more ____ = I want more food). Then ask the client to repeat the completed sentence. The client will later be required to spontaneously produce a request sentence. Props can be provided to assist the client in planning a request sentence (e.g. providing a cup as a stimulus may prompt the client to express a sentence about drinking). Throughout these tasks visual, verbal and semantic prompting may be required.

Considerations

• Implementation of an AAC device may be required if the client has limited or impaired speech output.
• Also if the client presents with an oral dyspraxia or dysarthria consider whether they will be able to express their needs and wants verbally.

References

Shames, G. H., & Anderson, N. B. (Eds.) (2002). Human communication disorders: An introduction (6th ed.) Boston: Allyn and Bacon.

Reading signs

Goal

To be able to read one word written and picture signs found across a variety of contexts.

Rationale

Signs containing both writing and symbols are used in all environments (Beukelman & Mirenda, 2005). They are used to assist in person safety and inform and instruct everyday processes (Beukelman & Mirenda, 2005). An individual with an acquired neurological communicative disorder (ANCD) therefore needs to be able comprehend all written signs and symbols that are common in their everyday living environments.

Baseline Skills

• Moderate cognitive ability
• Sufficient memory skills for learning
• Moderate receptive language skills
• Moderate expressive output (either verbal or using AAC)
• Moderate literacy skills
• Adequate hearing
• Intact vision

Measurability

Present the client with a series of signs. The types of signs would range from single picture/symbol signs to written signs and should be taken from a range of contexts relevant to the client’s lifestyle. The number of signs correctly identified out of ten, are then measured as the baseline. Assessment of the baseline signs is then to occur on a weekly basis to measure the client’s progress. These achievements could be graphed and then used as a motivating tool for the client.

Measurability for step 1 is successful completion of the activity, as judged by the clinician. The clinician should ensure that the client understands the task. Basic yes/no comprehension questions can be used to measure this. The client will progress to the next level of the hierarchy for all other steps after achieving 90% or more success on the preceding step. A baseline of ten attempts can be used to measure criterion, as described above.

Steps in Achieving Goal

1. Client to comprehend the concept of signs and why they are vital to individual safety
   Activity: Use picture cues and created scenarios (e.g. if there is a fire in a building, you need to understand what the EXIT sign is, and its importance to your safety) to describe how signs are used in everyday life.
2. Develop an individualised set of signs for the client
   Activity: Based on feedback from the client and significant others, develop an individual set of signs/symbols that they come across in their everyday lives. For example, if the client travels interstate by plane for work, they need to understand the signs on an airplane (i.e. seatbelt, no smoking and exit signs) or the signs found at their local shopping centre (i.e. toilets, food court and information desk).
3. Identification of picture signs when presented with a binomial choice
   Activity: The clinician provides a verbal description of a sign. The client is provided with two sign picture options to pick from based on the description given. Clinician is to provide verbal, tactile and visual prompting where required.
4. Identification of picture signs when presented with three choices
   Activity: The clinician provides a verbal description of a sign. The client is provided with three sign picture options to pick from based on the description given. Clinician is to provide verbal, tactile and visual prompting where required.
5. Identification of one word written sign when presented with a binomial choice
   Activity: The clinician provides a verbal description of a sign. The client is then provided with two sign written options to pick from based on the description given. Clinician is to provide verbal, tactile and visual prompting where required.
6. Identification of one word written sign when presented with three choices Activity: The clinician provides a verbal description of a sign. The client is provided with three sign written options to pick from based on the description given. Clinician is to provide verbal, tactile and visual prompting where required.
7. Identification of sign when presented with multiple options
   Activity: Clinician to combine both picture and single written word signs. The clinician then provides a verbal description of one sign out of a presented six. The client is provided with the six signs options to pick from based on the description given. Clinician is to provide verbal, tactile and visual prompting where required.
8. Client to describe meaning when presented with a sign
   Activity: Clinician to present a sign to the client and request the client to describe what the sign means. Clinician to prompt using hierarchical verbal cues where required.
9. Community visit for exposure to signs in context with clinician
   Activity: Take the client into the community (e.g. shopping centre, around the hospital, etc…) to describe where you will find learned signs. Ensure the community context is relevant to the individual’s needs and wants. Request the client to describe the meaning of the signs identified in the community. Provide verbal, tactile and visual prompting where required.
10. Community visit for exposure to signs in context with familiar communication partner
    Activity: The client is required to identify signs that they have learned in the therapy setting to their familiar communication partner. The communication partner is to then request the client to describe the meaning of the signs identified in the community (e.g. shopping centres, around the hospital, etc…). Verbal cues/prompts should be provided from the communication partner when required by the client (clinician to therefore educate prior to the session).
11. Individual to go into community to read signs in context
    Activity: Individual to independently go into the community (e.g. shopping centre, doctors office, etc…) and focus on identifying signs learnt in therapy. Following the trip, the client is required to provide feedback to the clinician on what signs they saw, where they saw them and what each sign meant. Clinician is to provide adequate reinforcement and support to the client. Should the client require online support whilst in the community, they can contact the clinician via telephone (refer to other relevant communication acts).

Considerations

• If the client is unable to read words then focus on picture signs only.
• Ensure the signs and words are big enough for the client to see.
• If the client experiences difficulties with increasing stimuli, decrease individualised sign list and focus on two/three signs at a time.
• If the client is unable to express the meaning of signs verbally, utilise AAC devices so that the client can express them self accurately and adequately.
• It is vital that this task is relevant to the individual’s lifestyle. Use signs that the client will encounter in their activities of daily living. Also prioritise the signs that ensure client safety. Therefore it may be beneficial to liaise with other allied health professionals i.e. an Occupational Therapist.

References

Beukelman, D., & Mirenda, P. (2005). Augmentative & Alternative Communication: Supporting Children and Adults with Complex Communication Needs (3rd ed.). Baltimore: Paul. H. Brookes Publishing Co.

Taking medications

Goal

To be able to follow written/pictorial instructions when taking medications.

Rationale

Upon returning to home from hospital many clients are taking one or more medications to control their present or previous medical conditions (National Stroke Foundation, 2007). For the client with an acquired neurological communicative disorder (ANCD) the task of safely managing their medications can become difficult due to their language and cognitive deficits (Worrall, 2000). It is essential that the client be able to read and interpret certain materials e.g. time symbols and numbers. Therefore this goal is crucial as the client’s safety can be compromised by incorrect consumption of medications.

Baseline Skills

• Moderate cognitive ability
• Sufficient memory skills for learning
• Moderate receptive language skills
• Low literacy skills
• Adequate hearing
• Intact vision
• Dexterity to manipulate medications/packaging

Measurability

This goal could continue on from the “reading signs” goal.

Measurability for steps 1 to 4 is successful completion of the activity, as judged by the clinician. The clinician should ensure that the client understands the task. Basic yes/no comprehension questions can be used to measure this where applicable. For all remaining steps, the client will progress to the next level of the hierarchy after achieving 90% or more success on the preceding step. A baseline of ten attempts can be used to measure criterion. These achievements could be graphed and then used as a motivating tool for the client. Achievement of this goal will be considered when the client can demonstrate to the clinician the correct tablet/time of medication consumption. This measure will therefore require input from other health professionals (e.g. Doctors, Pharmacists, Nurses and Occupational Therapists) and the client’s caregiver/s.

Steps to Achieving Goal

1. Collect necessary medication information
   With the client’s permission the clinician should ascertain what medications and the correct dosage the client currently requires. This could involve liaising with the client’s Doctor, Pharmacist or nursing staff.
2. Discussion with client regarding the appropriate method of receiving their medications
   This discussion will address issues such as, if the client only has 1 or 2 tablets they may wish for their medications to remain in their original packaging (bottle/box). Alternatively they may like a caregiver to pack their medications into a pill organiser (daily/weekly) or they may wish for the pharmacy to pack their medications in a Webster-pak. A Webster-pak is an easy to use and individually tailored prescription dispenser, which securely seals medications within a particular time referenced compartment. This decision will impact on the course of therapy.
3. Client and caregiver education
   The clinician should educate the client and their caregiver of risks for each option (discussed above) and personal risks associated to the client’s deficits. This will require research on the clinician’s behalf so that they are knowledgeable about the prescribed medications. In this instance the clinician could liaise with Doctors, Nurses, or preferably a Pharmacist.
4. Organise packaging
   Assist the client to contact the appropriate source (caregiver or pharmacy) to arrange for the selected packaging. Refer to other communication acts regarding phone calls and conversation depending on the selected method of informing.
5. Target comprehension of the written days of the week
   Activity: Have the client verbalise/write the 7 days of the week, prompt if needed. Prompting could include verbalising or writing the beginning letter or the use of semantic cueing e.g. “it’s just another manic …”. Then work on putting the days in the correct order. Explore how the full name of the day is shortened (e.g. Tuesday = Tues) then put the shortened versions in order. Utilise calendars and diaries. Have the client discuss what they will be doing each day of the week. Taking medications
6. Target comprehension of pictorial times of the day
   Activity: Base therapy around the pictures that the medication packs use to symbolise morning, lunch and night. Discuss with the client what each picture represents, then have them tell you back. Have the client discuss why the picture would, for example represent night. Have the client correctly sequence the pictures. Quiz the client on what the pictures mean. Discuss what medications are to be taken at specific times of the day.
7. Target comprehension of written times of the day
   Activity: Pair the names e.g. morning, lunch and night with the corresponding picture. Remove the picture and have the client correctly sequence the words. Quiz the client about what the words mean. Introduce am and pm descriptions. Discuss what medications are to be taken at specific times of the day.
8. Reading/understanding numerals 0-9
   Activity: Put the numbers in order and discuss their shapes. If this task is extremely difficult focus on the number/dosage specific to the client. Quiz the client on the numbers; have them name the presented number. Have the client find particular numbers mixed with letters/numbers.
9. Understanding dosage
   Activity: Have a bucket of smarties (or a non-edible item) and tell the client an amount they are to take out e.g. say “3” and they should select 3 smarties. Give the client a handful of smarties and have them count how many are there.
10. Progress to application of the real task
    Activity: Arrange for smarties to be packaged and trial scenarios of medication consumption. Considerations regarding size of smarties, sugar levels and swallowing impairments apply. Liaise with the nursing staff if administering the actual medication.
11. Strategies for remembering that the medications have been taken
    Activity: Have the client keep a diary, make a mark on a calendar or have a daily checklist.

Considerations

• The mode of packaging that the client selects will alter the therapy options. Clinical judgement will therefore be required to select the appropriate steps.
• If the client has physical impairments that make it difficult/impossible to take their medications liaise with an Occupational Therapist and a Physiotherapist. Impairments may affect dexterity with packaging and/or medications.
• If the client is deemed unsafe to take medications or there is some concern regarding their consumption, ensure that services are provided or that the client’s caregiver is fully informed. This may lead to the client taking the medication with a specified level of supervision.
• It is also important to consider whether the client has any swallowing difficulties, as dysphagia will impact on the form in which the medication is delivered. This issue will therefore require further liaising with the Pharmacist or Doctor, as they are aware of alternative forms, alternative routes and the effect of taking the medications with or without food.
• Liquid medications have not been discussed within this goal and should therefore be considered separately. However, some steps will still apply.
• Hospitals have different policies regarding medication training and clients self-medicating. The Speech Pathologist will therefore need to be aware of the practice/policies within their setting.

References

National Stroke Foundation. (2007). Medications after a stroke. Retrieved September 29, 2008, from http://www.strokefoundation.com.au/component/option,com_docman/Itemid,0/task,doc_view/gid,15/

Worrall, L. (2000). FCTP: Functional communication therapy planner. Bicester: Winslow.

Using greetings & partings

Goal

To be able to use greetings/partings with a variety of communication partners in a variety of contexts.

Rationale

For client’s with acquired neurological communicative disorders (ANCD) greetings and partings remain an important means of connecting with others. Although individual’s with ANCD’s are often, like anyone, apprehensive about initiating conversations, they are more likely to attempt such interactions if they have access to greeting phrases similar to those used pre-morbidly (Chapey, 2001).

Baseline skills

• Moderate cognitive ability
• Sufficient memory skills for learning
• Moderate receptive language skills
• Low expressive output (either verbal or using AAC)
• Adequate hearing

Measurability

Measurability for steps 1 to 4 is successful completion of the activity as judged by the clinician. The clinician should ensure the client understands the task. Basic yes/no comprehension questions can be used to measure this. Successful completion of all other steps can be measured by the client independently using greetings/partings with 90% accuracy. A baseline of ten attempts can be used to measure criterion. The measurability of this step may depend on the client. It may not be realistic for the client to use greetings/partings independently, therefore the measurability may include “with minimal prompting” etc. Results may be graphed and then used as a motivating tool for the client.

Steps to Achieving Goal

1. Discussion with client regarding importance of greetings/partings
   Activity: Client and clinician to discuss social role of greetings/partings, the impact these have on conversation and people’s perception of the individual.
2. Develop non-verbal greetings/partings e.g. smile, personal space, handshakes, eye contact etc…
   Activity: Client and clinician to develop a list of non-verbal greetings/partings and categorise these into ‘appropriate’ and ‘inappropriate’. A table with two columns, one with a tick the other with a cross, can be drawn up as a visual aid. Video footage of both appropriate and inappropriate greetings/partings can be shown to the client to illustrate others reactions. If the client experiences confusion regarding the difference between ‘appropriate’ and ‘inappropriate’ non-verbal greetings, focus on the ‘appropriate’ greetings in isolation. Therefore the task could simply target a list of appropriate greetings for different situations.
3. Turn taking
   Activity: Client and clinician to look through the newspaper/magazine together, taking turns to describe pictures/articles (this can be in single word utterances). If the client is non-verbal the client and clinician can take turns completing any joint activity e.g. a puzzle, games such as connect 4 etc… A true/false quiz is another example of a verbal turn taking task that can be used. The clinician is required to ask a true/false question, the client is then required to wait for the question to be asked and then to respond when it is their turn. A rationale for turn taking and its importance in conversation should be given to the client so the task is relevant and the client can maintain motivation.
4. Develop generic greeting/parting appropriate for the client
   Activity: Client and clinician together discuss preferred scripted greeting/parting. Initially the client should be encouraged to independently develop a personal greeting/parting. If this is unrealistic for the client, the clinician can provide a list of possible greetings/partings and the client can choose one from this list. The developed greeting/parting should be appropriate for the client in terms of age/ gender/cultural background etc… For example an 85 year old man may not use the greeting “What’s up?”.
5. Practise use of greeting/parting with clinician in the clinical setting
   Activity: Client and clinician to take turns using scripted greeting/parting with each other. This activity can begin with full verbal prompting from the clinician (i.e. “say hello”) then gradually reduce prompts until client is greeting/parting independently.
6. Practise use of greeting/parting with familiar communication partner in the clinical setting
   Activity: Client to nominate a familiar communication partner/s to participate in the task. Client, clinician and familiar communication partner to discuss importance of greetings/partings and the client’s developed greeting/parting. Client, clinician and familiar communication partner to take turns greeting/parting each other.
7. Practise use of greeting/parting with familiar communication partners in a variety of contexts
   Activity: To facilitate transfer of this skill, encourage the client to use greetings/partings outside the clinical setting, for example, when walking the halls of the hospitals, in the hospital cafe and/or in other allied health sessions. Allied health staff can be extremely valuable in transferring the targeted skill/s. If they are briefed as to the client’s task and scripted greeting/parting they can increase the client’s chance to practise tenfold. This task can initially be completed with full support from the clinician. For example the client and clinician can go for a tour around the hospital greeting familiar communication partners. The clinician can provide a full verbal model and then reduce prompting.
8. Practise use of greeting/parting with unfamiliar communication partner
   Activity: Clinician and client to tour hospital together using greetings/partings with a host of unfamiliar communication partners. As with the above activity, the clinician can provide a full verbal model and then reduce prompting. It may be helpful to draw the client’s attention to people’s positive reactions about their greetings/ partings. This will motivate the client and reinforce the activity. Using greetings & partings

Considerations

• If the client is unable to produce verbal output AAC can be used. The same hierarchy of steps applies. However, the client will use their preferred method of AAC to greet/part. This may be a communication board/book, a greetings/partings card, a verbal output device etc…
• Depending on the client, the use of names in greetings/partings can be encouraged. This will be impacted on the client’s skill base, whether the client used names in greetings/partings pre-morbidly etc…

References

Chapey, R. (Ed). (2001). Language intervention strategies in aphasia and related neurogenic communication disorders (4th ed). Philadelphia: Lippincott, Williams and Wilkins.

Receiving a telephone call

Goal

To be able to receive a telephone call.

Rationale

For client’s with acquired neurological communicative disorders (ANCD), the continuation of hobbies and pre-morbid activities is an important means of reducing social isolation (Rochette, Bravo, Desrosiers, St. Cyr-Tribble & Bourget, 2007). For a client to be able to answer the telephone and effectively have a short conversation with a familiar communication partner is a highly important goal in relation to decreasing social isolation and continuing some form of communication with the client’s pre-morbid social network.

Baseline Skills

Moderate cognitive ability
Sufficient memory skills for learning
Moderate receptive language skills
Moderate expressive language skills
Appropriate Pragmatic skills
Adequate hearing
Dexterity to manipulate telephone

Measurability

This goal could continue on from the “usings greetings and partings” goal. Measurability for steps 1 and 2 is successful completion of the activity as judged by the clinician. The clinician should ensure the client understands the task. Basic yes/no comprehension questions can be used to measure this. For all remaining steps, the client will progress to the next level of the hierarchy after achieving 90% or more success on the preceding step. A baseline of ten attempts can be used to measure criterion. These achievements could be graphed and then used as a motivating tool for the client.

Achievement of the goal would be considered once the client can successfully participate in receiving a telephone call. An outcome measurement scale, like the Australian Therapy Outcome Measurement Scale: Speech Pathology (AusTOMS) could also be used to uncover improved independence and socialisation that has been achieved via this goal (Perry & Skeat, 2004).

Steps to Achieving Goal

1. Speech Pathologist to liaise with other allied health staff
   Other allied health staff (e.g. Physiotherapists, Occupational Therapists, etc…) could assist in the client achieving goals related to successfully completing this task, which are outside the scope of communication i.e. dexterity and manipulation.
2. Discussion of required dialogue
   Activity: Discuss how to appropriately answer the telephone (e.g. answer the telephone with a generic verbal greeting). This could lead to the production of a script, which is based on the common requirements for answering a telephone call.
3. Practise turn-taking skills with clinician
   Activity: Utilise the script developed in the previous step. Provide the client with 6 opportunities for turn taking in a conversation. Provide verbal, visual and tactile prompting where required. Also provide the client with positive feedback regarding their performance.
4. Practise on two telephones in the same room
   Activity: Client to practise receiving telephone calls from the clinician in the therapy setting. Clinician to provide maximal prompting. Gradually progress so that the client is required to answer the telephone with minimal prompting and the use of a script, then decrease prompting or remove script and finally have the client use spontaneous speech for approximately 6 turns in a conversation.
5. Client to receive a telephone call with the introduction of a physical barrier The reasoning for this step is to remove visual cues and assist the client in developing skills such as asking for repetition and clarification.
   Activity: The client will role-play receiving a telephone call from the clinician, who is positioned in the same room behind a physical barrier. The client will be required to greet appropriately and converse with the clinician on the telephone for approximately 6 turns. Provide verbal, visual and tactile prompting where required. Also provide the client with positive feedback regarding their performance. Receiving a telephone call
6. Client to receive a telephone call from a familiar communication partner
   Activity: Prior to this activity the communication partner will be informed of the required dialogue and areas of importance. The client is required to answer the telephone with prompting and the use of a script, then decrease prompting or remove script. Clinician to provide verbal, visual and tactile prompting where required. Finally have the client converse independently for approximately 6 turns in a conversation.
7. Client to receive a telephone call from an unfamiliar communication partner
   Activity: Prior to this activity the communication partner will be informed of the required dialogue and areas of importance. The client is required to answer the telephone with prompting and the use of a script, then decrease prompting or remove script. Clinician to provide verbal, visual and tactile prompting where required. Finally have the client converse independently for approximately 6 turns in a conversation.
8. Unexpected/unplanned telephone call from clinician
   Activity: The clinician can contact the client, unexpectedly, to monitor progress and provide them with feedback regarding their ability to receive a telephone call.

Considerations

It is worthy to note that this goal is the initial step of receiving a telephone call. Further therapy may target taking a message for a received a telephone call. Refer to and liaise with an audiologist if the client has hearing difficulties that are impeding on their ability to fulfil this goal. Telstra also offer services to assist with hearing difficulties (Telstra, n.d.). If the client is unable to complete the task without prompting create a written or pictographic reminder of the necessary information required in exchange for them to keep next to their telephone.

References

Perry, A., & Skeat, J. (2004). AusTOMS for Speech Pathology: Australian Therapy Outcome Measures. Melbourne: La Trobe University.

Rochette, A., Bravo, G., Desrosiers, J., St. Cyr-Tribble, D., & Bourget, A. (2007). Adaptation process, participation and depression over six months in first-stroke individuals and spouses. Clinical Rehabilitation, 21, 554-562.

Making a telephone call

Goal

To be able to make a telephone call to a familiar communication partner.

Rationale

It has been purported that community reintegration involves social relationships with others, independence and activities to fill one’s time (McColl, Carlson, Johnston, Minnes, Shue, Davies, & Karlovits, 1998). The ability to not only receive, but also make a telephone call can facilitate each of these aspects of community reintegration. With a familiar communication partner the telephone can enable an individual to reduce social isolation by maintaining family and friendship networks.

Baseline Skills

High cognitive ability
Sufficient memory skills for learning
Moderate receptive language skills
Moderate expressive output (either verbal or using AAC)
Appropriate Pragmatic skills
Adequate hearing
Intact vision
Dexterity to manipulate telephone

Measurability

This goal could continue on from the “receiving a telephone call” goal. Measurability for step 1 is successful completion of the activity as judged by the clinician. The clinician should ensure the client understands the task. Basic yes/no comprehension questions can be used to measure this. Successful completion of all other steps can be measured as the client making 5 successful phone calls independently per task. The client will progress to the next level of the hierarchy for all other steps after achieving 90% or more success on the preceding step. Results may be graphed and used as a motivating tool for the client.

Steps to Achieving Goal

1. Discussion with client regarding their reasons for using the telephone Activity: Client and clinician to discuss the client’s reason for using the telephone at home. For example, will it be to call grandchildren overseas once a month or a daughter who lives down the road every day?

2. Practise a face-to-face interaction Activity: Using the client’s primary mode of expression, the client and clinician can practise a basic face-to-face interaction that simulates a social conversation. If the client does not have appropriate turn taking skills they will need to be established during this point in the hierarchy (refer to “using greetings and partings” goal).

3. Reading/understanding numerals 0-9 Activity: Begin with tasks such as putting the numbers in order and discuss their shapes. Quiz the client on the numbers; have them name the presented number. Have client find particular numbers mixed with letters/numbers. Activity: Then practice using a telephone. For example the clinician could say a number and the client has to find the number on the telephone. Verbalise or give a written number sequence for the client to dial in. Increase length of the number sequence.

4. Practise a telephone call on two telephones in the same room Activity: Clinician and client to simulate a social telephone call in a clinic room using two telephones. It is preferable for the client to use the telephone that he/she will be using at home. The clinician can provide verbal and visual prompting to complete this task.

5. Introduce a physical barrier Activity: Clinician and client to simulate a social telephone call in a clinic room, as in the task above. However, introducing a barrier will remove visual cues and assist the client in developing skills such as asking for repetition and clarification.

81 The Road Home: Integrating Functional Communication Therapy into Rehabilitation

6. Practise a telephone call in different rooms Activity: This task is as above, however the client and clinician will be in different rooms furthering the physical barrier. To facilitate this task the clinician can be in the room with the client while another communication partner (e.g. another Speech Pathologist, allied health assistant or significant other) is in another clinic room receiving the telephone call. This enables the clinician to provide online support and feedback to the client.

7. Practise an external telephone call to a familiar communication partner Activity: The client will make a telephone call to a familiar communication partner. Initially the communication partner will be fully briefed and the clinician will provide maximal prompting and assistance. This will gradually be reduced until the client can perform this task independently.

Considerations

If the client is unable to communicate expressively through verbal output, but has intact typing ability they can utilise the National Relay Service ‘type and listen’ tool. This encompasses the client typing their message to the relay officer, the relay officer reading the message to the person receiving the call, then the receiver speaking directly to the client (Social Change Online, 2008). Any fine motor control impairment/s should be considered as they may impact on the ability for the client to successfully complete this goal. If necessary liaise with a Physiotherapist and/or and Occupational Therapist.

If the client has difficulty initiating conversation a variety of supports can be used to build this skill, such as:

Scripting: providing the client with a script for the telephone call. For example if the client wanted to enquire about a shops opening hours the clinician and client could develop and practise a script for the conversation. Using structured and familiar topics. For example in social conversations the communication partners could be instructed to develop the conversation surrounding structured familiar topics to the client e.g. family, friends, hobbies etc… Limit time of calls. The phone calls could begin as short phone calls designed for a brief greeting with a familiar communication partner, for example 30 seconds. Then gradually extend the time of the call.

References

McColl, M., Carlson, P., Johnston, J., Minnes, P., Shue, K., Davies, D., & Karlovits, T. (1998). The definition of community integration: Perspectives of people with brain injuries. Brain Injury, 12(1), 15 — 30.

Social Change Online. (2008). National relay service: Call options: Type and listen. Retrieved September 1, 2008, from http://www.relayservice.com.au/topics/2061.html

Ordering a taxi

Goal

To be able to order a taxi.

Rationale

Having means of transport is crucial to one’s independence (Turner, Fleming, Cornwell, Worrall, Ownsworth, Haines, Kendall & Chenoweth, 2007). Most individual’s who have an acquired neurological communicative disorder (ANCD) are required to forfeit their licence due to the level of risk associated with their brain impairment (Austroads, 2006). Therefore the options for independent transport become limited, especially for those who live where there is no or minimal access to public transport. This means that the individual with the ANCD has to become competent and confident to order a taxi, as they desire, to ensure that they can reintegrate and participate in society (McCabe, Lippert, Weiser, Hilditch, Hartridge, & Villamere, 2007).

Baseline Skills

Moderate cognitive ability
Sufficient memory skills for learning
Moderate receptive language skills
Moderate expressive output (either verbal or using AAC)
Low literacy skills
Appropriate Pragmatic skills
Adequate hearing
Intact vision
Dexterity to manipulate telephone

Measurability

This goal could continue on from goals such as “making a telephone call” and “using greetings and partings”. Measurability for steps 1 and 2 is successful completion of the activity as judged by the clinician. The clinician should ensure the client understands the task. Basic yes/no comprehension questions can be used to measure this. For all remaining steps, the client will progress to the next level of the hierarchy after achieving 90% or more success on the preceding step. A baseline of ten attempts can be used to measure criterion. These achievements could be graphed and then used as a motivating tool for the client.

Achievement of this goal would be considered once the client can order a taxi to attend the social outing they desire. A quality of life scale could also be used to uncover improved independence and socialisation that has been achieved via this goal. Living with Aphasia: Framework for Outcome Measurement (A-FROM) (Kagan, Simmons-Mackie, Rowland, Huijbretgts, Shumway, McEwen, Threats & Sharp, 2008) is an example of a possible measurement tool.

Steps to Achieving Goal

1. Speech Pathologist to liaise with other allied health staff
   Other staff (e.g. an Occupational Therapist and/or a Social Worker) could assist with uncovering information regarding if there is a specific company/body that offers taxi discounts to individuals with disabilities.
2. Client to recognise the need for a taxi
   Activity: Client to brainstorm scenarios with the clinician for circumstances that the client would require a taxi e.g. to go grocery shopping.
3. Reading/understanding numerals 0-9 Activity: Begin with tasks such as putting the numbers in order and discussing their shapes. Quiz the client on the numbers; have them name the presented number. Have the client find particular numbers mixed with letters/numbers. Dictate and have the client write the spoken number.
   Activity: Then practise using a telephone. The clinician could say a number and then the client has to find the number on the telephone. Verbalise or give a written number sequence for the client to dial. Gradually increase the length of the number sequence.
4. Orientation to time Consider using digital clocks before analogue clocks, as digital clocks may be easier to read than analogue for some clients. Although trial both to find which one suits the client.
   Activity: Have the client state the activities of their normal day. Give the client a daily planner sheet/diary (specifies each hour in a day) and have them put their activities in a time sequence from morning to night. Later ask the client what time of the day did they complete an activity e.g. “brush their teeth”. Another task is to have the clinician spontaneously request the time during a therapy session, prompting the client to provide the correct time according to their preferred clock.
5. Orientation to place
   Activity: Have the client discuss their home address and common places where they would gather. If the client is unable to recall these refer to a significant other for the answers, then target therapy on these destinations. Conduct numerous activities based around their address and the address of 5 of their most common destinations. For example, have the client match the address and description of the destinations. Providing a script for the client to refer to during the task can be used as a prompting aid.
6. Discussion of required dialogue The clinician needs to discuss with the client what information would be required in the conversation exchange. This not only gives the client more confidence in what they are doing, but also ensures that the vocabulary approximates the client’s personal communicative style. Address turn-taking skills and pragmatics (refer to “using greetings and partings” goal for further information).
   Activity: Discuss what the client needs to tell the operator. This could lead to the production of a script, which is based on the common requirements for booking a taxi. Utilise the 5 WH framework when formulating the script i.e. prompt client about who, what, when, where and why.
7. Face-to-face role-play with clinician
   Activity: The clinician and client will role-play face-to-face the dialogue for ordering a taxi. Feedback will be given after the task and include what the client did well, what information they neglected to include, pragmatics, turn-taking, time to communicate etc…
8. Over the telephone role-play with the clinician
   Activity: The clinician and client will role-play over the telephone the dialogue for ordering a taxi. Feedback will be given after the task and include what the client did well, what information they neglected to include, pragmatics, turn-taking, time to communicate etc…
9. Record the assumed operator dialogue for home practise
   Activity: The client can play the tape recording of the operator dialogue, which would include pauses for the client to practise their responses.
10. Face-to face role-play with a familiar communication partner
    Activity: A familiar communication partner and the client will role-play face-to-face the dialogue for ordering a taxi. Prior to the activity the communication partner will be informed of the required dialogue and areas of importance. The clinician will be present to provide visual and verbal prompting, although it is suggested that prompting be gradually decreased until the client can complete the task independently. The clinician will provide feedback after the task, once they have consulted with the communication partner. Feedback will include what the client did well, what information they neglected to include, pragmatics, turn-taking, time to communicate etc…
11. Over the telephone role-play with a familiar communication partner
    Activity: A familiar communication partner and the client will role-play over the telephone the dialogue for ordering a taxi. Prior to the activity the communication partner will be informed of the required dialogue and areas of importance. The clinician will be present to provide visual and verbal prompting, although it is suggested that prompting be gradually decreased until the client can complete the task independently. The clinician will provide feedback after the task, once they have consulted with the communication partner. Feedback will include what the client did well, what information they neglected to include, pragmatics, turn-taking, time to communicate etc…
12. Face-to-face role-play with an unfamiliar communication partner The clinician, with the client’s permission should recruit a person, who is unknown to the client, to role-play the scenario.
    Activity: An unfamiliar communication partner and the client will role-play face-to face the dialogue for ordering a taxi. Prior to the activity the communication partner will be informed of the required dialogue and areas of importance. The clinician will be present to provide visual and verbal prompting, although it is suggested that prompting be gradually decreased until the client can complete the task independently. The clinician will provide feedback after the task, once they have consulted with the communication partner. Feedback will include what the client did well, what information they neglected to include, pragmatics, turn-taking, time to communicate etc…
13. Over the telephone role-play with an unfamiliar communication partner The clinician, with the client’s permission should recruit a person, who is unknown to the client, to role-play the scenario.
    Activity: An unfamiliar communication partner and the client will role-play over the telephone the dialogue for ordering a taxi. Prior to the activity the communication partner will be informed of the required dialogue and areas of importance. The clinician will be present to provide visual and verbal prompting, although it is suggested that prompting be gradually decreased until the client can complete the task independently. The clinician will provide feedback after the task, once they have consulted with the communication partner. Feedback will include what the client did well, what information they neglected to include, pragmatics, turn-taking, time to communicate etc…
14. Client calls the taxi company with the script and clinician present for prompting
    Activity: Client will dial the number and arrange a taxi booking. The clinician will be present and will provide feedback after completion of the task. Feedback will include what the client did well, what information they neglected to include, pragmatics, turn-taking, time to communicate etc…
15. Client calls the taxi company without script and/or clinician present
    Activity: Once the task is complete the client will be required to provide feedback about their performance to the clinician.
16. Client orders a taxi independently
17. Strategies for remembering the booking
    Activity: Encourage the client to use a daily planner or calendar. If they have a device such as a mobile phone, explore the option of a visual/auditory reminder note.

Considerations

• If the client is unable to achieve this goal through verbal output, alternatively a TTY service or an AAC verbal output device may be utilised. TTY is a service that allows communication by text (Telstra, n.d.). If neither of these options are deemed appropriate for the client then the option to order over the internet remains. However, note that these options require high level literacy skills.
• If ordering over the telephone and online are both non-viable options, then strategies need to be put into place to enable the client to still have the opportunity to visit the community. Arrangements then need to be made between the client and the taxi company for a possible permanent booking. Although not as flexible as would be desired for full independence, this would still allow for the client to sustain contact outside of their home.
• Refer to and liaise with an audiologist if the client has hearing difficulties that are impeding on their ability to fulfil this goal. Telstra also offer services to assist individuals with hearing difficulties (Telstra, n.d.).
• If therapy tasks are unsuccessful with achieving adequate use of numerals, then alternative options need to be considered. These could include programming the number into the client’s telephone (e.g. the phonebook or speed dial) and providing them with instructions and rehearsal to access. Another strategy is to provide the client with the skills to request help from others and have the communication partner dial the required number.
• If the client is unable to complete the task without prompting create a written or pictographic reminder of the necessary information required in the conversation exchange for them to keep next to their telephone.
• Any physical impairment/s should be considered as they may impact on the type of taxi or services. If necessary liaise with a Physiotherapist and/or and Occupational Therapist.
• Following on from the previous consideration, if a client requires a maxi taxi due to using a wheelchair, their availability needs to be considered. This may have a negative effect on achievement of the goal, as there are commonly limited maxi taxis available.
• Post a brain injury the standard time a client is not allowed to drive is 6 months. Therefore after 6 months if the client is making substantial progress in multiple domains of recovery, it may be appropriate to refer them to their Physician, medical team or an Occupational Therapist for a driving assessment.

References

Austroads. (2006). Assessing fitness to drive. Sydney: Author. Kagan, A., Simmons-Mackie, N., Rowland, A., Huijbretgts, M., Shumway, E., McEwen, S., Threats, T., & Sharp, S. (2008). Counting what counts: A framework for capturing real-life outcomes of aphasia intervention. Aphasiology, 22 (3), 258-80.

McCabe, P., Lippert, C., Weiser, M., Hilditch, M., Hartridge, C., & Villamere, J. (2007). Community reintegration following acquired brain injury. Brain Injury, 21(2), 231-257.

Telstra (n.d). Disability services. Retrieved September 29, 2008, from http://www.telstra.com.au/disability/catalogue/additional.html

Turner, B., Fleming, J., Cornwell, P., Worrall, L., Ownsworth, T., Haines, T., Kendall, M., & Chenoweth, L. (2007). A qualitative study of the transition from hospital to home for individuals with acquired brain injury and their family caregivers. Brain Injury, 21(11), 1119-1130.

Communicating travel destinations

Goal

To be able to accurately communicate a travel destination to a taxi driver.

Rationale

Individual’s with an acquired neurological communicative disorder (ANCD) often experience many other disabilities post their neurological incident (e.g. physical disability and cognitive deficits) that affect general reaction time. As a result, many individual’s who have an ANCD are required to forfeit their licence due to the level of risk associated with their impairment (Austroads, 2006). Therefore, individuals are required to utilise an alternate transportation option. Achievement of this goal will assist the individual to increase community participation and decrease social isolation.

Baseline Skills

• Moderate cognitive ability
• Sufficient memory skills for learning
• Moderate receptive language skills
• Moderate expressive output (either verbal or using AAC)
• Moderate literacy skills
• Intact vision

Measurability

Once the goal of “ordering a taxi” has been achieved, a further goal of communicating the travel destination to the taxi driver should be targeted. Measurability for step 1 is successful completion of the activity as judged by the clinician. The clinician should ensure the client understands the task. Basic yes/no comprehension questions can be used to measure this. For all remaining steps, the client will progress to the next level of the hierarchy after achieving 90% or more success on the preceding step. For the baseline measure the client will be required to convey a correct address/travel destination to an unfamiliar communication partner on 10 occasions. The number of responses correct out of the 10 attempts during the task can then be used as a baseline measure for the client. The client will be required to complete baseline task with a new communication partner on a weekly basis to measure their progress. Results from the weekly task could be graphed and then used as a motivating tool for the client.

Steps to Achieving Goal

1. Client to comprehend what an address is and their address Activity: The task will include a picture aid describing what an address is and its association to a house. Presentation of a flash card with the client’s address written on it will be shown to them.

2. Client to express known address to clinician with maximal prompting Activity: Implement drill tasks to develop the client’s comprehension of their address. Then progress with drill tasks involving the clinician asking “what is your address?”. Maximal prompting may include providing them with a lead in sentence for giving their address, prompting with the flash card that contains their address or verbal prompts.

3. Client to express known address to clinician with minimal prompting Activity: Role-play the scenario of getting into a taxi. The clinician is to request the client’s address and prompt the client to express their address.

4. Client to express known address to clinician independently Activity: Role-play the scenario of getting into a taxi. The clinician is to have their back turned to the client (who is sitting in the back seat of the taxi) and request the client to express their address.

5. Client to express known address to a familiar communication partner Activity: Request a family member or friend to attend the session to participate in this activity. Implement a drill activity that requires the familiar communication partner to request the client to express their address.

6. Client to express known address to unfamiliar communication partner Activity: Invite another Speech Pathologist/colleague unfamiliar to the client to attend the session and participate in the activity. Implement a drill activity requiring the unfamiliar communication partner to request the client to express their address. Communicating travel destinations

7. Client to express their address to a taxi driver with clinician present Activity: Clinician should adequately brief the client of the task and their expectations of the client. The task involves the client to independently order a taxi and greet the taxi driver on arrival (refer to other relevant communication acts). The client is then required to express the address to the taxi driver, with the clinician providing prompting where required.

8. Client to express their address to a taxi driver with a familiar communication partner present Activity: The task involves the client to independently order a taxi and greet the taxi driver on arrival (refer to other relevant communication acts). The client is then required to express the address to the taxi driver, with the familiar communication partner providing prompting where required.

9. Client to express their address to a taxi driver with an unfamiliar communication partner present Activity: The task involves the client to independently order the taxi and greet the taxi driver on arrival (refer to other relevant communication acts). The client is then required to express the address to the taxi driver, with the unfamiliar communication partner providing prompting where required.

10. Client to express their address to a taxi driver independently Activity: The client should contact the clinician following completion of the task for a debrief.

11. Other destinations Once the client has developed the ability to express their own address, destination addresses can be targeted using a similar hierarchy as above. Prioritise the destinations by targeting the 5 most common destinations the client visits (e.g. doctors, recreational facilities, significant other’s homes, etc…). Communicating travel destinations

Considerations

If the client is non-verbal, then integrate the use of AAC.

If the client presents with memory deficits, then introduce the permanent use of flash cards to assist the client when expressing their address.

Consider the client’s mobility. Is the client able to independently or with minimal assistance walk from their house to the taxi and get in? If the answer is no, then liaise with a Physiotherapist and/or Occupational Therapist to assist in achieving adequate mobility. Refer to ‘Talking Taxis’ program, developed by the Maribyrnong City Council to assist in communication between taxi drivers and passengers. The program features specific communication tools such as picture boards and personal journey cards, etc… These tools have been found to benefit passengers, particularly those with a disability (Legge, 2008).

References

Austroads. (2006). Assessing fitness to drive. Sydney: Author.

Legge, J. (2008). Passengers will have easier journeys after ‘Talking Taxis’ launch. Retrieved October 7, 2008, from http://www.maribyrnong.vic.gov.au/Page/page.asp?Page_Id=3770&h=0.

Participating in religious acts

Goal

To be able to participate in a religious act through the use of automated speech.

Rationale

For client’s with acquired neurological communicative disorders (ANCD) the continuation of hobbies and pre-morbid activities is an important means of reducing social isolation (Rochette, Bravo, Desrosiers, St. Cyr-Tribble & Bourget, 2007). Religious activities and worship are important for the psychological well-being of many older adults. Therefore, this goal is an important consideration for functional therapy (Chapey, 2001). Because many prayers and religious mantras have an automatic speech component, targeting this aspect allows those clients with less spontaneous speech to still be able to participate in their religious practices.

Baseline Skills

• Moderate cognitive ability
• Sufficient memory skills for learning
• Moderate receptive language skills
• Moderate expressive output (either verbal or using AAC)
• Low literacy skills
• Adequate hearing
• Intact vision

Measurability

Measurability for steps 1 and 2 is successful completion of the activity as judged by the clinician. The clinician should ensure the client understands the task. Basic yes/no comprehension questions can be used to measure this. For all remaining steps, the client will progress to the next level of the hierarchy after achieving 90% or more success on the preceding step. A baseline of ten attempts can be used to measure criterion. These achievements could be graphed and then used as a motivating tool for the client.

Achievement of this goal would be considered once the client can recite the chosen prayer or religious mantra in the context of a religious service. A quality of life scale could also be used to uncover improved independence, spiritual satisfaction and socialisation that have been achieved via this goal. An outcome measurement scale, like the Australian Therapy Outcome Measurement Scale: Speech Pathology (AusTOMS) could also be used to uncover improved independence and socialisation that has been achieved via this goal (Perry & Skeat, 2004).

Steps to Achieving Goal

1. Discussion regarding client’s pre-morbid religion and religious practices
Activity: Discussion with the client, their significant others and their religious leader to uncover the type of religion, level of devoutness and the prayer(s)/mantra(s) the client wishes to focus on in therapy.

2. Clinician to research religion and religious acts
Activity: The clinician should research the beliefs and specific prayer(s)/mantra(s) within the religion that the client desires to regain (e.g. Hail Mary is a prayer specific to the Catholic religion). This may involve liasing with religious leaders/priests.

3. Client to practise reciting the prayer(s)/mantra(s) with clinician
Activity: Initially, the client and clinician should recite the prayer(s)/mantra(s) in chorus. Commence with breaking the prayer(s)/mantra(s) into smaller components, and then later combine the components together. Written and visual prompting should be provided when required. Gradually decrease the amount of prompting as the task progresses. Finally have the client recite the prayer independently. Additional prompting can include the introduction of the matching music (if appropriate). The clinician could also record themselves reciting the prayer(s)/ mantra(s) and provide this to the client. The recording can then be used as an aid for the client to listen to for practice beyond the therapy session. This allows for the client to self evaluate and monitor their own performance in comparison to the prerecorded prayer(s)/mantra(s).

4. Client to recite the prayer(s)/mantra(s) with familiar communication partner/s
Activity: Have the client and the communication partner recite the prayer(s)/mantra(s) in chorus in the clinical setting. Written and visual prompting to be provided where required. Then progress to the client and communication partner reciting the prayer(s)/mantra(s) in context (i.e. in a religious building, not during religious service hours). The hospital chapel may be an appropriate setting for practise while the client remains in hospital. The next progression is for the client to recite the prayer(s)/ mantra(s) with a small group of familiar communication partners in a religious building/hospital chapel.

5. Client to recite the prayer(s)/mantra(s) with unfamiliar communication partner/s
Activity: Have the client and the communication partner recite the prayer(s)/mantra(s) in chorus in the clinical setting. Written and visual prompting to be provided where required. Then progress to the client and communication partner reciting the prayer(s)/mantra(s) in context (i.e. in a religious building, not during religious service hours). The hospital chapel may be an appropriate setting for practise while the client remains in hospital. The next progression is for the client to recite the prayer(s)/ mantra(s) with a small group of unfamiliar communication partners in a religious institution. Finally the client should recite the prayer(s)/mantra(s) in context during a religious service (e.g. “Our Father” in a Catholic church service).

Considerations

May need to consider dexterity if the specified religion utilise a religious prop whilst reciting the prayer(s)/mantra(s) (e.g. Hail Mary can be recited using Rosary Beads in the Catholic religion) Therefore, liaise with an Occupational Therapist.

References

Chapey, R. (Ed). (2001). Language intervention strategies in aphasia and related neurogenic communication disorders (4th Ed). Philadelphia: Lippincott, Williams and Wilkins.

Perry, A., & Skeat, J. (2004). AusTOMS for Speech Pathology: Australian Therapy Outcome Measures. Melbourne: La Trobe University.

Rochette, A., Bravo, G., Desrosiers, J., St. Cyr-Tribble, D., & Bourget, A. (2007). Adaptation process, participation and depression over six months in first-stroke individuals and spouses. Clinical Rehabilitation, 21, 554-562.

Participating in a communicative transaction

Goal

To be able to participate in a simple communicative transaction i.e. purchase a coffee, with an unfamiliar communication partner.

Rationale

Extensive literature research has shown that an individual with an acquired neurological communicative disorder (ANCD) is at risk for social isolation, depression and anxiety (Stalnacke, 2007). Therefore, the aim of this goal is to assist with increasing the client’s participation in life events, optimising their independence and improving their self-esteem in order to improve quality of life (Wallace, Evans, Arnold & Hux, 2007; Cruice, 2008). If the client is able to purchase an item, whether through verbal or non-verbal means, it will assist with their social functioning and overall ability to function independently.

Baseline Skills

• High cognitive ability
• Sufficient memory skills for learning
• High receptive language skills
• Moderate expressive output (either verbal or using AAC)
• High Pragmatic skills
• Ability to self monitor
• Adequate hearing

Measurability

This goal could continue on from the “using greetings and partings” goal. Measurability for step 1 is successful completion of the activity as judged by the clinician. The clinician should ensure the client understands the task. Basic yes/no comprehension questions can be used to measure this. For all remaining steps, the client will progress to the next level of the hierarchy after achieving 90% or more success on the preceding step. A baseline of ten attempts can be used to measure criterion. These achievements could be graphed and then used as a motivating tool for the client.

Achievement of this goal will be considered when the client can demonstrate to the clinician successful participation in a simple communicative transaction with an unfamiliar communication partner.

Steps to Achieving Goal

1. Outline the required dialogue Activity: Therapy should initially involve developing a list of the key aspects required to achieve the task. This will ensure the client is well informed and educated about the process of a communicative transaction. For this particular goal, purchasing a coffee will be used as an example.
   

   Key aspects and examples

   Key Aspects	Example
   Simple Greeting:	“Hi, how are you?” or in response to a question, “I’m well thank you.”
   Request: (verbal/non-verbal)	“May I please have 1 cappuccino and 1 muffin?” Communication aids to be considered.
   Response to questions: (verbal/non-verbal)	If asked, “Would you like the muffin heated?” or “Any sugar in the coffee?” or “Any thing else?” Client responds accordingly.They may wish to purchase another item. Props may be used to assist with communication i.e. nods, finger pointing etc.
   Exchange of money:
   Receive correct change:
   Answer further questions:	If asked, “Where are you sitting?” Client responds accordingly.

2. Focus on key aspects of the dialogue Each key aspect mentioned in the table above involves different language skills. Therefore, therapy activities should target these language skills. For greetings, requests and responses refer to the relevant communication acts. Activity: Exchange of money. The concept of money and its use must firstly be explained and understood. This includes understanding the value of coins/notes. Picture cards of food items with their prices attached e.g. an apple $0.70, could be used. Present these to the client along with real coins and notes. If the client has insufficient mathematical skills then strategies to assist them will need to be implemented i.e. a calculator. Place a picture card in front of the client and ask them to give you the correct amount of money. Provide verbal, visual and tactile prompting as required.
   Activity: Receive correct change. Use the same picture cards as previously mentioned. Firstly, give the client some money i.e. $10.00 and instruct them to purchase an item from the picture cards. Upon selection, the client will write its price on a piece of paper. They must then calculate what change they should receive from $10.00 using simple mathematics or a calculator. Following transfer of money, the clinician will give the client change and they are then required to determine if the change is correct. As a step up to this task, the clinician may include some responses that are incorrect, to further challenge the client. Provide verbal, visual and tactile prompting as required.
3. Role-play using the client’s primary mode of expression
   Activity: The clinician can play the role of the seller whilst the client practises purchasing an item. Have the client use the dialogue developed in step 1 as a script for the communicative transaction. If verbal communication is unachievable, ensure that communication occurs through nonverbal means e.g. communication books, gestures or writing.
4. Develop the client’s self-monitoring skills
   Activity: A video camera can be used to film role-play in a therapy session. Then show the video to assist with the development of the client’s self-monitoring skills. Assist the client to reflect on their performance by asking them to make suggestions on what improvements they could make. The client could also practise this technique independently.
5. Introduce a barrier
   Activity: Continue to practise role-playing by removing all visual cues and to assist the client in developing skills, such as asking for repetition and clarification. A simple script, outlining the key aspects of the communicative transaction process may be required for prompting.
6. Role-play with a familiar communication partner
   Activity: Have the client practise the communicative transaction with a familiar communication partner. The clinician can initially provide maximal prompting to the client, but should decrease prompting when success is achieved. If the communication partner is the client’s primary communication partner, then the clinician should educate them about providing appropriate feedback and prompting to the client.
7. Role-play with an unfamiliar communication partner
   Activity: Organise another Speech Pathologist or an allied health assistant, unknown the client, to act as the seller. Have the client practise purchasing a coffee from the unfamiliar communication partner. Provide verbal, visual and tactile prompting as required.
8. Role-play in the café
   Activity: Sit down with the client in the hospital café. Allow the client to rehearse and practise their communicative transaction at the table, before proceeding to the counter. Only progress once the client feels comfortable with the task and minimal prompts from the clinician are required. This may require a number of practises at rehearsing the communicative transaction.
9. Participate in a communicative transaction with an unfamiliar communication partner in a café with clinician present
   Activity: Sit down in the hospital café and allow the individual to rehearse the communicative transaction prior to approaching the register. Then approach the counter together when the client is ready. Some clients may rely heavily on their communication partners, whilst others may only require minimal assistance. This will affect the level of briefing the unfamiliar communication partner requires prior to the task. Practising this task repetitively may be necessary to achieve satisfaction and success.
10. Independently participate in a simple communicative transaction with an unfamiliar communication partner in a café
    The client will approach the counter and purchase the desired item with no assistance from the clinician. Clinician to debrief with the client at the conclusion of the task. Some clients may be able to achieve this task without assistance from their communication partner. However, others may require minimal prompting to complete the transaction. Therefore overall outcome of this communicative transaction will be different for each client.

Considerations

If the client is unable to verbally communicate, appropriate alternative methods will be implemented i.e. AAC devices, gesture, menus etc…

References

Stalnacke, B-M. (2007). Community integration, social support and life satisfaction in relation to symptoms 3 years after mild traumatic brain injury. Brain Injury, 21(9), 933-942.

Wallace, S.E., Evans, K., Arnold, T., & Hux, K. (2007). Functional brain injury rehabilitation: Survivor experiences reported by families and professionals. Brain injury, 21(13), 1371-1384.

Worrall, L. (2000). FCTP: Functional communication therapy planner. Bicester: Winslow.

Text Messaging

Goal

To be able to write a text message on a mobile phone to a familiar communication partner.

Rationale

According to the Australian Institute of Health and Welfare, traumatic brain injury rates are amongst the highest for youths to young adults (Helps, Henley & Harrison, 2008). In 2007, The Australian Bureau of Statistics reported that the second most common method used for communicating with friends and family was the use of the mobile phone Short Message Service (SMS). Mobile phone use was also found to be extremely predominant amongst younger age groups (Australian Bureau of Statistics, 2007). Considering the evidence suggests that a large number of individual’s with an acquired neurological communicative disorder (ANCD) are young and that mobile phone texting is most commonly used by youth, this goal is an important inclusion. This is because SMS is a means of communicating with significant others and relationships are important to a person’s well-being. The ability to write a text message on a mobile phone will assist those with an ANCD to maintain important links with those they are close to (Australian Bureau of Statistics, 2007).

Baseline Skills

• High cognitive ability
• Sufficient memory skills for learning
• High receptive language skills
• Moderate expressive output (either verbal or using AAC)
• Moderate literacy skills
• Ability to self monitor and correct
• Intact vision
• Dexterity to manipulate mobile phone

Measurability

Measurability for step 1 is successful completion of the activity as judged by the clinician. The clinician should ensure the client understands the task. Basic yes/no comprehension questions can be used to measure this. For all remaining steps, the client will progress to the next level of the hierarchy after achieving 90% or more success on the preceding step. A baseline of ten attempts can be used to measure criterion. These achievements could be graphed and then used as a motivating tool for the client.

Achievement of this goal will be considered when the client can demonstrate to the clinician successful ability to write a text message on a mobile phone to a familiar communication partner.

Steps to Achieving Goal

1. Discuss the importance of texting
   Activity: Discuss with the client the purpose of texting i.e. as a means of communicating and helping to maintain social links, as well as whom texting occurs with i.e. family and friends. It is recommended to use a photo of their mobile phone to assist their understanding.
2. Orientation/navigation of the client’s mobile phone
   Activity: Have a picture of the client’s mobile phone and discuss its basic functions for texting i.e. symbols, letters and numbers. Allow the client to experiment with their phone. Liaise with the Occupational Therapist and/or Physiotherapist if necessary. Once orientation is complete, place cards, which have examples of the symbols and other important functions in front of the client. Then conduct a simple matching game where the clinician chooses a card and the client has to locate the correct symbol on their mobile phone.
3. Recognising numerals 0-9
   Activity: Begin with tasks such as putting the numbers in order and discussing their shapes. Then quiz the client on the numbers e.g. have them name the presented number. Then have them locate the number on their phone.
4. Grapheme recognition
   Present all graphemes (a-z) on flash cards in order and discuss shapes and phoneme relationships. Also note that reciting the alphabet is an automated process and so assess whether this is intact. Quiz the client on the graphemes in a random order. Then present the client with a target word (high frequency and imageability) and request they spell the word using the grapheme flash cards. Continue to provide single words until they can achieve this with minimal prompting from the clinician.
5. Discuss and formulate a message
   Activity: Before the client is able to write their intended text message, they must show they have an understanding, as well as the ability to formulate a message. If they communicate verbally, ask them to provide an example of a short message to a friend i.e. Do you want to go to the movies? Utilise AAC devices if the client is nonverbal. The client will progress once the clinician is confident that their messages are easily understood and formulated in a clear format with minimal prompting required. It is also important to discuss with the client their preference regarding the use of predictive texting or non-predictive texting.
6. Write a single word text message
   Activity: The client will be required to type a single word on their mobile phone i.e. hello, with maximal prompting from the clinician. Continue to focus on this step by requesting the client to type a range of other single words. Only progress once the client is able to complete this activity with minimum prompting from the clinician.
7. Write a simple text message
   Activity: The clinician will provide maximal prompting to the client as they write a text message to a familiar communication partner. Ensure that the message is a simple sentence i.e. Do you want to meet for lunch? As the client demonstrates achievement, decrease prompting until they can complete the activity independently or with minimal prompting from the clinician.
8. Send a simple text message
   Activity: Once a text message has been written, assist the client to send the message to a familiar communication partner. The client is required to locate the number of the recipient through a list of numbers stored in the phone’s memory. Alternatively, have the phone number written clearly on a piece of paper in front of them so they can copy it into their phone. Practise typing in the person’s number until the client is able to do so with minimal prompting from the clinician.
9. Increase the length and complexity of the message
   Activity: The client will be required to write a text message, which is longer and includes more detail. Utilise the 5 WH framework when formulating the message i.e. prompt client about who, what, when, where and why. Continue to work on this step until the client can complete it independently or with minimal prompting and cues from the clinician.

Considerations

This goal is not recommended for clients who are 65 years+ and/or those who did not use texting as a regular means of communicating pre-morbidly.

References

Australian Bureau of Statistics (2007). General social survey: Summary results. Australia, Canberra: Australian Bureau of Statistics.

Helps, Y., Henley, G., & Harrison, J.E. (2008). Hospital separations due to traumatic brain injury, Australia 2004–05. Injury research and statistics series number 45. Australia, Adelaide: Australian Institute of Health and Welfare.

Appendix

Useful resources for clinicians and clients working with acquired neurological communicative disorders.

Texts

Chapey, R. (Ed). (2001). Language intervention strategies in aphasia and related neurogenic communication disorders (4th Ed). Philadelphia: Lippincott, Williams and Wilkins.

Elman, R. (2007). Group treatment of neurogenic communication disorders: The expert clinician’s approach. San Diego: Plural Publishing.

Parr, S. (2004). The stroke and aphasia handbook. London: Connect Press.

Perry, A., & Skeat, J. (2004). AusTOMS for Speech Pathology: Australian Therapy Outcome Measures. Melbourne: La Trobe University.

Sloan, S., Mackey, J., & Chamberlain, S. (2006). Communicate with confidence. Australia: Skilled Life Press.

Journal Articles

Doig, E., Fleming, J., & Tooth, L. (2001). Patterns of community integration 2-5 years post-discharge from brain injury rehabilitation. Brain Injury, 15(9), 747 — 762.

Hersh, D. (2007). How do people with aphasia view their discharge from therapy? Aphasiology, 1 – 20.

Holliday, R. C., Ballinger, C., & Playford, E. D. (2007). Goal setting in neurological rehabilitation: Patients’ perspectives. Disability and Rehabilitation, 29(5), 389 – 394.

Howe, T.J., Worrall, L.E., & Hickson, L.M.H. (2007). Interviews with people with aphasia: Environmental factors that influence their community participation. Aphasiology, 1-29.

McCabe, P., Lippert, C., Weiser, M., Hilditch, M., Hartridge, C., & Villamere, J. (2007). Community reintegration following acquired brain injury. Brain Injury, 21(2), 231-257.

McColl, M., Carlson, P., Johnston, J., Minnes, P., Shue, K., Davies, D., & Karlovits, T. (1998). The definition of community integration: perspectives of people with brain injuries. Brain Injury, 12(1), 15 — 30.

Rayner, H., & Marshall, J. (2003). Training volunteers as conversation partners for people with aphasia. International Journal of Language & Communication Disorders, 38(2), 149-64.

Siegert, R., & Taylor, W. (2004). Theoretical aspects of goal-setting and motivation in rehabilitation. Disability and Rehabilitation, 26(1), 1 – 8.

Simmons-Mackie, N., Kearns, K., & Potechin, G. (2005). Treatment of aphasia through family member training. Aphasiology, 19(6), 583-93.

Simmons-Mackie, N., & Kagan, A. (1999). Communication strategies used by `good’ versus `poor’ speaking partners of individuals with aphasia. Aphasiology, 13(9-11) 807-20.

Turner, B., Fleming, J., Cornwell, P., Worrall, L., Ownsworth, T., Haines, T., Kendall, M., & Chenoweth, L. (2007). A qualitative study of the transition from hospital to home for individuals with acquired brain injury and their family caregivers. Brain Injury, 21(11), 1119-1130.

Websites

Brain Injury Association of America. (2008). Welcome to the Brain Injury Association of America (BIAA’s) new website. http://www.biausa.org/

Legge, J. (2008). Passengers will have easier journeys after ‘Talking Taxis’ launch. http://www.maribyrnong.vic.gov.au/Page/page.asp?Page_Id=3770&h=0.

National Aphasia Association. (2008). Welcome to the National Aphasia Association. http://www.aphasia.org/

National Institute on Deafness and Other Communication Disorders. (2008). National Institute on Deafness and Other Communication Disorders (NIDOC). http://www.nidcd.nih.gov/

Speech pathology Australia. (2008). Speech pathology Australia. http://www.speechpathologyaustralia.org.au/

Telstra. (2008). Additional products - Disability services – Telstra. http://www.telstra.com.au/disability/catalogue/additional.html

The Pharmacy Guild of Australia. (2008). The pharmacy guild of Australia. http://www.guild.org.au/

Aphasia friendly websites

Communication Disability in Ageing Research Unit (CDARU). (2001). Queensland University Aphasia Groups. www.shrs.uq.edu.au/cdaru/aphasiagroups

Connect Communication Disability Network. (2008). UK Connect – Home. www.ukconnect.org

Parr, S., Newbery, J., Moss, B., & Long, B. (2002). Aphasiahelp.org – for people with aphasia. www.aphasiahelp.org

Talkback Association for Aphasia Inc. (2008). Talkback Association for Aphasia Inc., Supporting people with aphasia. http://aphasia.asn.au/aphasiafriendly/index.htm

The Stroke Association. (2008). The Stroke Association – Welcome to the Stroke Association. http://www.stroke.org.uk/index.html

Functional Assessment Tools

Frattali, C.M., Thompson, C.K., Holland, A.L., Wohl, C.B., & Ferketic, M.M. (1995). American Speech-Language-Hearing Association Functional Assessment of Communication Skills for Adults. Rockville, MD: ASHA.

Holland, A.L., Frattali, C.M., & Fromm, D. (1999). Communication Activities of Daily Living (2nd Ed.). Austin, TX: Pro-Ed.

Lomas, J., Pickard, L., Bester, S., Elbard, H., Finlayson, A., & Zoghaib, C. (1989). The Communicative Effectiveness Index: Development and psychometric evaluation of functional communication measure for adult aphasia. Journal of Speech and Hearing Disorders, 54, 113-124.

Porch, B.E. (1981). Porch Index of Communicative Ability. (Vol.2) Administration, Scoring and Interpretation (3rd Ed.). Palo Alto, CA: Consulting Psychologists Press.

Sarno, M.T. (1969). The functional communication profile: manual of directions. New York: New York University Medical Center, Institute of Rehabilitation Medicine.

Worrall, L. (2000). FCTP: Functional communication therapy planner. Bicester: Winslow.

This resource will be useful for student Speech Pathologists, Speech Pathology graduates and those re-entering the field of rehabilitation for individual’s with acquired neurological communicative disorders. The therapy resource manual specifically focuses on language, addressing the transition from hospital to home. This manual aims to provide functional ideas for targeting the essential communication acts required for the client returning home.

This package was created by Jacqueline Bonney, Lucy Bransgrove, Shelley Coy, Lauren Cutler, Hayley Dell’Oro and Mikayla Moroney (4th Year student Speech Pathologists, at La Trobe University) under the supervision of Donna McNeill-Brown, Bronwyn Cox and Anna Volkmer.