Augmenative and Alternative Communication

Following severe traumatic brain injury, patients present with significant communication challenges that interfere with daily communication needs. Those who sustain a mild or moderate ABI may be more readily able to communicate using natural speech with minor difficulties. On the other hand, those who suffer from a severe ABI may not be able to meet communication needs through speech alone and may benefit from an augmentative or alternative communication strategy (Johannsen-Horbach et al., 1985; Bourgeois et al., 2001; Burke et al., 2004; Fager et al., 2006; De Joode, et al., 2012). Although many individuals post ABI do recover their speech abilities, there are still many who remain unable to speak for extended periods of time (Fager et al., 2006). For this specific group, assessments and AAC intervention may be a continual process. Multiple changes the individual’s level of function may occur over time thus the introduction of new systems (from the simple to the more sophisticated) is needed to allow for effective communication (Fager et al., 2006).

In the AAC domain there are divisions of complexity.  These include easy to make, low tech options (e.g. alphabet boards, picture based communication boards, memory books, reminiscent/conversation books, day planners) and high tech options that include VOCA devices (Voice Output Communication Aid) including Dynavox, McCaw, Message Mate, Big Mack, Voice Pal and Boardmaker. Notably, both low tech and high tech solutions to communication difficulties maybe have access that is either direct (i.e. touching/pointing) or indirect (i.e. switch access or partner assisted scanning). 

Those clinicians working in the area of AAC or Assistive/Enabling Technology are well acquainted with the recent explosion of technology options available. Traditional and most familiar AAC devices and software include, but are not limited to, voice output (VOCA) systems as noted above. Presently clinicians and patients have access to a wider, more universally available set of devices and peripherals including, but not limited to, iPad, Android and Windows based tablets as well as the wide variety of associated apps and software (e.g. Proloquo2go, Talking Tiles). Changes in cost, improved ease of access/availability in mainstream retail, rapid changes in the technology itself and associated applications have resulted in AAC clinical practice that is both invigorating and exhausting.

Presently, we are in the midst of a time of technology growth and changes that is unprecedented.  Consequently, the research in this area is not able to keep pace and we rely on limited or dated studies.  Given the scope and methodology of the ERABI project, reviewing the strongest evidence available, there was an unfortunate gap in evidence to support what is actually being implemented in the practice of front line clinicians.

Difficulties Sustained Post ABI

  • Difficulty with verbal expression
  • Severe dysarthria

Goals of Treatment

  • To allow individuals with severe ABI to efficiently access and communicate effectively via AAC.

Treatment Strategies

  • Assess needs of the individual from access and communication perspectives
  • Determine the best device and method of access for individuals on a 1:1 basis
  • Age and gender must be taken into account when choosing a device
  • Allow time for training and teaching of both patient and communication partners (i.e. Facilitator)

Materials and Devices

  • Non-electronic Communication Boards
  • Alphabet Communication Boards
  • Lexical Communication Board
  • Eye-Gaze Communication Board
  • Communication Board
  • Picture Communication Board
  • Pictograms
  • Sign Language
  • Blissymbol Communication board
  • Synthetic voice
  • Memory Aids

Augmentative and Alternative Communication  (AAC) Treatments

While there is a great deal of discussion around the importance of augmentative and alternative communication devices, there is a paucity in the literature supporting the effectiveness of the programs and devices currently available. In order to understand how these devices work, why they work and the benefits to those who use them, more research is required.

Organizational Word Retrieval Strategies

Burke et al. (2004) studied the use of three organizational word retrieval strategies for adults with ABI who use AAC. These organizational strategies include semantic topic, geographic place and first letter or alphabet. While the subjects retrieved words more accurately when using the alphabet organization strategy, they expressed the preference for use of the semantic topic strategy. Clinicians may consider providing these three strategies for clients using AAC, and assisting with identification of the most beneficial and preferred strategy for the individual client.

Bliss Symbols

Bliss symbols or bliss boards have been available and used for several years now. The use of Blissymbols has been found to be very effective with those who have been diagnosed with aphasia or Broca’s aphasia (Rajaram et al., 2012). There is little in the literature specific to the ABI population.

Picture/Symbol Based Boards

Despite the surge in technology, picture and symbol based boards remain in high use today (e.g. pictograms, Boardmaker). These symbols or pictures may represent a concept, object, activity place or event. Symbols, pictures and boards in general may be used with minimal training and software may be individualized (Bhatnagar et al., 1999). The selection of symbols should be appropriate to the individual’s communicative needs. Picture/symbol software is also available for use on home computers, iPads, and iPhones.

Alphabet Boards

Individuals with dysarthria or who are non-verbal may benefit from an alphabet board. These boards are helpful for spelling single word or short phrase messages. Board sizes may vary depending on the person’s abilities, necessity or access (Bhatnagar and Silverman, 1999).

Further research needs to be conducted regarding AAC and the ABI population. Early and limited studies however, report favorable use of organizational strategies to facilitate word recognition (by the communication partner).


Despite the limited amount of research that has been done, augmentative communication intervention designed to assist with organization, access, and efficiency of AAC use, may be beneficial for individuals with severe ABI.