Augmentative and Alternative Communication Intervention for a Child

with Acquired Aphasia with Convulsive Disorder: A Case Study

Intervention du systeme de communication suppleant et alternatif aupres d'un
enfant atteint d'aphasie acquise et de troubles convulsifs: etude de cas
David McNaughton
Department of Special Education
Pennsylvania State University

Abstract AAC systems for children with severe language disorders and
This paper describes augmentative and alternative communication ongoing seizure activity.
(AAC) assessment and intervention with a young boy diagnosed as
having acquired aphasia complicated by a convulsive disorder. The
case study reviews the child's communication status on referral and Literature Review
provides information on the client's progress during a 12 month
intervention period, A review of the literature is provided, as well as Acquired aphasia with convulsive disorder typically occurs in
a discussion of theoretical and clinical questions regarding the use of otherwise normally developing children between the ages of
AAC systems by children with acquired aphasia. three and seven and is characterized by the loss of receptive
and expressive language ability coincident with generalized
Resume seizure activity and abnormal electrical discharges from one
Cet article deeril!' evaluation et /' intervention de la communication or both temporal lobes (Miller et aI., 1984). Seventy-five
suppleante et alternative (CSA) aupres d' un jeune gar~'on soufJrant. cases of the syndrome have been described since the syn-
selon le diagnostic habli. d' aphasie acquise alaquelle s' ajoutent des drome was first identified by Landau and Kleffner in 1957
troubles convulsifs. Cette hudede cas examine /' etat de /' enfant pour (Van de Sandt-Koendennan, Smit, van Dongen, & van Hest,
ee qui est de la communication apres renvoi aun specialiste etfournit 1984). The cause of the seizure activity and aphasia is often
des renseignements sur /' evolution du dient pendant la periode difficult to identify. A review of case histories by Miller et al.
d'interl'ention de 12 mois. Cet article comporte en outre une revue (1984) suggests that a variety of pathogeneses, including an
de litterature sur le sujet ainsi qu' une discussion des questions active low grade encephalitis (Worster-Drought, 1971), may
cliniques et thtoriques sur /' utilisation des systemes CSA par les be responsible for this disorder.
enfants atleints d' aphasie acquise.
The most significant impact of acquired aphasia with
Acquired aphasia with convulsive disorder is characterized convulsive disorder is on the individual's linguistic abilities.
by the onset of seizures preceding or following the loss of Both expressive and receptive language abilities are severely
previously acquired language (Cooper & Ferry, 1978). While compromised, and these communication problems recur or
there has been some clinical documentation of the case histo- persist beyond six months in 94% of the cases (Miller et al..
ries of children with acquired aphasia with convulsive disor- 1984). Because of their severe comprehension deficits, chil-
der (Deuel & Lenn,1975; Gascon, Victor, Lombros, & dren with this disorder sometimes appear to be deaf; however,
Goodglass, 1973; Mantovani & Landau. 1980; Msall, Sha- the use of audiometric brainstem response testing typically
piro, & Balfour, 1986), little is known about the causes or reveals hearing within nonnal limits (Gascon et aI., 1973).
prognosis for children with this condition (Miller, CampbeIJ, Behavioural abnonnalities (e.g., inattention, refusal to respond,
Chapman, & Weismer, 1984). For those children who do not aggression) are often observed concomitant with the loss of
recover the use of speech. the use of augmentative and alter- communication.
native communication (AAC) systems and strategies is advo-
cated. To date, clinical documentation has focused on the use The recovery of speech and language abilities by these
of AAC systems by children whose seizure activity has been children does not follow a predictable course. While some
brought under control. This paper presents a case study of a clinical investigations have reported that the aphasia sym-
seven year old boy to illustrate the potential usefulness of ptoms were alleviated by the control of the seizure activity

JSLPA VoI.15,No.2,June 1991 iROA Vol.15.N" 2.}uin 1991 35

AAC Intervention for a Child with Acquired Aphasia

with anti-convulsant medication (Deuel & Lenn, 1975), oth- average to superior range with verbal, quantitative, and per-
ers have reported that speech does not always return after the ceptual abilities all equally well developed. Language com-
seizures have been controlled (Msall et al., 1986). To date, prehension was developed to age 7, and expressive language
clinical researchers have been unable to identify those factors was assessed as being at age 6;3.
that best predict recovery (Mantovani & Landau, 1980), al-
though the importance of controlling seizure activity has been Michael's loss of language abilities occurred in two phases.
emphasized (Shoumaker, Bennett, Bray, & Curless, 1974). The first loss occurred after Michael experienced his first
series of seizures in November, 1986. As this initial seizure
Much of the case literature to date has described the activity was brought under control through medication over a
progress of children with acquired aphasia whose seizure one month period, it appeared that his language skills and
activity has been brought under control. A number of clini- speech were slowly returning. This progress was reversed by
cians (Worster-Drought, 1970; Cooper & Ferry, 1978; Chris- a second series of seizures three months later in February,
topher, 1980; Miller et al., 1984; Pearce & Darwish, 1984) 1987, that resulted in severe expressive and receptive apha-
have documented the successful use of AAC techniques (e.g., sia. A tentative medical diagnosis of seizure activity as a
sign language, gestures, communication boards of pictures or result of an active low grade selective encephalitis in the left
words) with children who present with acquired aphasia and a temporal lobe was made. Although the cerebral oedema caused
controlled convulsive disorder. Miller et al. (1984) hypothe- by the encephalitis was arrested with extended cortizone the-
sized that AAC systems enabled these children to make use of rapy, Michael's seizure activity was very difficult to control.
previously acquired linguistic knowledge. Speech and language functioning did not return to pre-seizure
levels, and Michael continued to experience severe and mild
These reports provide evidence of the usefulness of AAC tonic clonic seizures, as well as complex partial seizures. The
with children who have experienced a severe loss of lan- number of seizures experienced by Michael varied widely,
guage; there are limitations, however, in the available litera- from as many as five or six in one day to as few as one a
ture. In the cases described, the children experienced only a week. A single seizure left Michael temporarily disoriented; a
single brief episode of seizure activity or their seizures were series of seizures resulted in extended periods of distractibil-
controlled successfully through medication. At present, there ity and impulsivity. Michael was treated with a number of
is no case literature concerning the use of AAC by children anticonvulsant medications, including Depakene, Dilantin, and
who have undergone a language loss and continue to experi- Mysoline. An EEG revealed multi focal epileptiform activity
ence ongoing seizure activity. As well, detailed information involving frontal, parietal, and temporal regions independently,
regarding the use of the AAC systems as a means of facilitat- as well as a disturbance of background activity. In summary,
ing receptive and expressive communication is unavailable. Michael had a diffuse encephalopathy involving both hemi-
spheres, which made localization of a discrete seizure focus
The following case study reviews the assessment process extremely difficult.
and progress over a twelve month intervention period for a
seven year old boy with acquired aphasia with an ongoing Michael was referred to the Augmentative Communica-
convulsive disorder. The case study documents the clinical tion Service in September, 1987, at the age of 6;7, ten months
investigation of the following issues: after the onset of seizure activity. At the time of the referral,
Michael was typically a very active young boy, unless he was
(I) Would an AAC system support this child in compensat- experiencing a high level of seizure activity. Michael was left
ing for his severe expressive and receptive aphasia and handed, as he was prior to the onset of the seizure activity,
provide him with a functional means of communication? and he demonstrated good fine motor control, with a slight
ataxia at times. Michael performed most activities of daily
(2) Which AAC techniques would best meet his needs? living independently, but he required supervision as his behavi-
our was often impulsive and he did not demonstrate a good
awareness of safety issues (e.g., running out into traffic, touch-
Case Study ing cooking utensils while in use). Michael's vision appeared
to be within normal limits, and no concerns in this area were
Case history expressed by his parents. His hearing abilities were more
difficult to assess and will be discussed in detail below.
Michael had been attending a regular senior kindergarten
class when the seizure activity first started in November, Michael lived at home with his mother and father and
1986, at the age of 5;9. He had no prior history of seizure attended school at a treatment centre for physically disabled
activity. Michael had been assessed formally at age 4;2. At children. His educational program focused on the develop-
that time his general level of cognitive ability was in the high ment of functional life skills (e.g., self care, food preparation,

36 JSLPA Vol. 15, No. 2, June 19911 ROA Vat. 15, N" 2.juin 1991
 McNaughton

recognizing and writing his own name) as well as the devel- when it rang. He did not, however, demonstrate the ability to
opment of appropriate leisure activities (e.g., participating in match a familiar sound (e.g., the ring of a telephone) to a
a turn-taking activity using building blocks). He demonstrated picture of that item. The audiological investigation provided
age appropriate skills in a limited number of nonverbal tasks, evidence that the use of speech was insufficient to meet
including independent completion of 100 piece puzzles and Michael's receptive communication needs.
creation of elaborate paper models of houses and planes.
Observation of expressive and receptive language skills
Michael presented as a playful and likable young boy A number of observations of Michael's expressive and recep-
who often tried to initiate interaction with preferred peers and tive language skills were carried out at both Michael's home
adults. He frequently experienced difficulty in making him- and school. Observational techniques were used because Mi-
self understood at these times. He typically managed the chael had difficulty participating in formal testing situations.
interactions by initiating familiar shared activities in which It is unclear whether these difficulties arose from Michael's
the expectations for both Michael and his partner's participa- inability to understand the expectations within the task or
tion were routine and, hence, clearly understood (e.g., a tickl- from a refusal to participate. He typically would not imitate
ing game, tic-tac-toe). targeted behaviours, even when presented within the context
of preferred activities. Therefore, there are no formal assess-
Michael displayed strong likes and dislikes with respect ments of his cognitive status or his language abilities available.
to activities. He would participate within preferred activities
(e.g., food preparation, drawing a picture, playing with con- It was observed that Michael frequently was unable to
struction blocks) for extended periods of time and found it comprehend attempts by communication partners to convey a
difficult to change activities until they were completed to his message to him. Michael responded more accurately if spo-
satisfaction. He typically refused to participate in undesired ken input was augmented with gestures. He recognized com-
activities (e.g., workbook activities, imitation tasks) and ex- mon gestures, such as a shrug of the shoulders, as well as
pressed his disinterest at these times by folding his hands and idiosyncratic gestures from his own expressive gestural reper-
lowering his head or by withdrawing from the activity. toire (described below).

It was noted that Michael attempted to make use of a

Assessment variety of expressive communication modes including speech
approximations, a limited number of gestures, and pointing to
Assessment information was gathered in three phases. First, a pictures and line drawings. When speaking, Michael's voice
detailed investigation of Michael's audiological functioning was often strained and high pitched. He made inconsistent
was carried out. Second. observations in naturally occurring use of approximately 30 speech approximations to request
situations were used to collect information regarding Michael's objects and activities, provide information, and request infor-
receptive and expressive communication skills. Third, dy- mation. These approximations were intelligible to familiar
namic assessment activities (cf. Feuerstein. Rand, & Hoff- partners in context (e.g., "coke" was typically pronounced /ko
man, 1979) were used to investigate Michael's receptive and ka ka ko n. More frequently, his speech was unclear and
expressive communication skills further. These dynamic as- poorly articulated, which resulted in severe comprehension
sessment activities employed teach-test procedures to exam- difficulties for his listeners. Both Michael's parents and the
ine Michael's ability to benefit from intervention approaches. school staff reported frustration in using speech to communi-
cate with Michael.
Investigation of audiological functioning
Michael's audiological status was difficult to assess. Central Michael had developed a repertoire of approximately 15
distraction and reinforcement procedures (CORA) were used idiosyncratic gestures that he used expressively. These ges-
to test Michael's ability to localize pure tones and speech tures tended to be highly transparent: the gesture for "McD-
under headphones. As a result of this testing, Michael's hear- onalds" consisted of drawing an M in the air, and the gesture
ing was assessed as grossly normal and adequate for commu- for "I don't understand" consisted of a shrug of his shoulders
nication. However, Michael demonstrated inconsistency in and a questioning facial expression. He accepted and rejected
his ability to comprehend and process auditory information. items offered to him by making appropriate use of a head
Although he had, on occasion, demonstrated fleeting aware- shake for no and a head nod for yes. Michael was often
ness of voices, he typically did not respond to linguistic infor- unable to make himself understood at both home and school.
mation (Le., the speech of other people) and continued activities
without appearing to hear or recognize adult voices. He had DynamiC assessment
been observed to respond appropriately to some nonlinguistic A review of Michael's existing skills and his outstanding
auditory information: for example, he answered the doorbell communication needs (as identified by his parents and teacher)

JSLPA Vol. 15. No. 2. June 1991/ ROA Vo!. 15. N' 2.juin 1991 37
AAC Intervention for a Child with Acquired Aphasia

led to a decision to use dynamic assessment activities to Augmentative communication system selection
address two primary questions: (l) to identify a means to Due to Michael's relatively good fine motor skills (as demon-
improve Michael's comprehension so as to permit his eonsis- strated within art activities) and his demonstrated competen-
tent understanding of one step instructions in familiar con- cies with previous, informal applications of AAC techniques,
texts; and (2) to provide Michael with a means to request both a gestural system and/or a graphic communication dis-
objects and activities and convey basic information. Dynamic play appeared to be a possible means of augmenting Michael's
assessment activities were initiated to investigate the use of communication skills. During the assessment activities, signs
traditional speech therapy and additional AAC techniques as for "more" and "drink" were introduced within the context of
a means to improve Michael's ability to communicate. motivating activities. Michael ignored attempts to encourage
gestural imitation and physically resisted graduated guidance.
A speech-language pathologist worked with Michael in Although Michael had independently developed a number of
order to determine his potential for recovery of speech. Mi- gestures as representations for objects and activities (e.g ..
chael demonstrated limited participation and lack of progress drawing a grid in the air to request a game of tic-tac-toe),
during these sessions. He typically would not imitate targeted assessment activities revealed that Michael only made use of
behaviours, even when presented within the context of pre- gestures that he had developed himself. Michael would not
ferred activities. As well, Michael frequently made use of imitate or make use of new signs, regardless of whether the
speech approximations that were unintelligible even to famil- signs were visually similar to the referent (e.g., drink) or more
iar partners. abstract in nature (e.g., more). It was unclear whether this was
a personal preference on Michael's part or reflected his in-
During AAC assessment activities, evidence was found ability to understand the representational meaning of the new
of Michael's ability to both understand and make use of AAC signs to which he was introduced.
techniques based on visual representations (e.g., pantomime,
line drawings, and photographs) in situations in which he did Michael was, however, more accepting of an individual-
not respond to or make use of speech. As an example, on one ized graphic communication display (Mirenda, 1985) that
occasion Michael was verbally asked "Are you tired?," to was developed for him. This display contained approximately
which he gave no response. When this same question was 75 photographs and Picture Communication Symbols (Mayer-
accompanied by an appropriate gesture for tired, Michael Johnson, 1984,1985) that were organized in a mUlti-page
nodded his head yes and went to lie down. menu folder. In creating the communication display, the aug-
mentative communication consultant interviewed Michael's
Michael demonstrated the ability to match photographs parents and the educational team in order to determine what
and line drawings of people and objects to their concrete vocabulary Michael might want to communicate (e.g., fa-
referents. Although he demonstrated the ability to match pic- vourite toys, preferred food items, familiar people), as well as
tures of 2 different examples of categorically similar items vocabulary that could be used to convey information to Mi-
(e.g.,2 different cars), he was unable to categorize objects or chael (e.g., upcoming events, specific work activities). The
pictures based on their function (e.g., a spoon and a fork). vocabulary selected was made up predominantly of nouns be-
Michael demonstrated some understanding of how pictures cause it was anticipated that Michael would make use of these
could be used to communicate simple concepts: for example, basic concepts first; some verbs and adjectives were also
when shown a photograph of his mother, he typically re- included. The vocabulary was organized into themes (e.g.,
sponded by getting ready for her arrival. Michael's responses people, toys, T.V. shows) to facilitate retrieval by Michael for
to pictures were not always consistent. At those times when his expressive use of the display and by staff to use in com-
Michael did not respond to instructions given using pictures munication with Michael to support his comprehension of
(e.g., when told it was time for his workbook activities), it instructions.
was unclear whether his lack of response was due to a lack of
understanding, a lack of compliance, or difficulty switching Michael appeared to understand the use of the picture
focus and relating to new topics introduced by a partner. The communication display when it was used to convey simple
communication partner's use of alternate modes of communi- information to him. He also demonstrated the ability to make
cation (e.g., showing Michael his workbook) was not always limited functional use of this display as an expressive means
responded to consistently. Michael also made expressive use of communication. Michael displayed these competencies both
of line drawings: He spontaneously pointed to a line drawing in a clinical setting and within interaction in the natural envi-
of a grapefruit at snack time, when that food item was out of ronment. It was therefore decided that the picture communi-
view, to request this preferred food item. It appeared that cation display, in combination with his existing vocabulary of
MichaeJ's participation in communicative interaction improved signs and gestures, would be used both to augment receptive
when he and his communication partners made use of AAC communication and to support his expressive communication
techniques. (e.g., as a means to request objects and activities that were not

38 JSLPA Vo!. 15, No. 2. June 1991 ! ROA Vol. 15. N° 2.juin1991
 McNaughton

present within the immediate environment and to provide Michael also was making appropriate, but sporadic, use
information ). of his picture communication display as an expressive means
of communication. He made appropriate use of the communi-
cation display to request items not immediately available to
Intervention him and for which he did not have a speech approximation
(e.g .. to request a hamburger at McDonalds, to request a visit
Training approaches to a friend). In using the display, Michael pointed to a single
The AAC system was introduced within the natural environ- picture representing a noun to request objects and activities
ment rather than in an isolated clinical setting, so as to teach and provide information. He typically did not make use of the
Michael functional skills in the environment in which they pictures that represented verbs. Although he imitated the fa-
would be used (Nietupski, Scheutz, & Ockwood, 1980; Brook- cial expressions used to represent emotions (e.g., the smiling
shire, 1987; Holland, 1983). The provision of motivating op- face used to represent happy), he did not make use of this
portunities for Michael to develop his ability to comprehend picture vocabulary in a meaningful way to convey his emo-
messages, to request objects and activities, and to provide tional state.
information, were discussed with Michael's educational staff
and family. For example, a food preparation activity was devel- Although Michael was making some appropriate and
oped in which the picture communication display was used to spontaneous use of the communication display, in many situ-
instruct Michael as to the steps involved in making a fruit ations he preferred to obtain items independently or to vocal-
salad. Snack time was used as an opportunity for Michael to ize or make speech approximations and point if the item was
request preferred food items. Opportunities to provide infor- available in the environment. While this was often a success-
mation were difficult to establish, as Michael typically was ful communication technique and was recognized and en-
most interested in participating in an activity rather than com- couraged by communication partners, at times the speech
municating within an interaction. However, it was observed approximations were unintelligible and communication break-
that Michael would vocalize in an excited manner at the end downs occurred.
of the day when his parents came to pick him up. Classroom
staff were encouraged to provide Michael with an item (e.g., A trial training period was instigated to determine whether
a completed art activity, a photograph of the day's activities) through repeated practice, in a clinical setting, Michael could
which Michael could use as a shared referent to facilitate be encouraged to make more frequent and generalized use of
communication when he interacted with his parents at these the vocabulary in his communication display as a precursor to
times. Michael's parents and the educational team added conveying more sophisticated communicative concepts (e.g .•
vocabulary to the display as Michael developed new interests requesting information, providing clarification when his speech
and needs. was not understood). The trial training procedures involved a
traditional approach to teaching communication display use
(Collins, 1986) in which the student receives multiple oppor-
Progress tunities within a structured situation to request items using the
augmentative system. During these sessions, the use of the
Thirteen Months Post-onset communication display as a means to request desired objects
Thirteen months post-onset (three months following the ini- was modelled for Michael, and then Michael was encouraged
tial intervention), it was observed that Michael's comprehen- to use his communication display to ask for preferred items
sion was facilitated by the use of gestural input from his that were hidden from view. At first, Michael made some use
partners and that he was continuing to make expressive use of of the display in these training situations. As the training
the gestures in his repertoire. Receptively, Michael clearly continued, however, he quickly became frustrated by the ex-
demonstrated understanding of some of the picture vocabul- pectation that he use his communication display in situations
ary presented to him using the picture communication display. in which he felt he could obtain the desired item more effi-
The use of the communication display allowed Michael's part- ciently using an alternate mode (e.g., obtaining the item inde-
ners to convey basic concepts to Michael that were un- pendently, pointing to where the object was hidden, and making
successfully communicated by speech or gesture. At the same use of a word approximation for "please"). Due to the fact
time, Michael, either did not understand or ignored other that Michael was not making the desired progress and in fact
instructions conveyed using the picture communication dis- seemed to dislike the expectations that were being placed
play. It was unclear whether these inconsistencies were due to upon him, the trial training period was discontinued after five
the ongoing seizure activity (and the accompanying medica- sessions.
tion), Michael's difficulty with the pictorial representation of
an activity, or Michael's incomplete understanding of how the While Michael was being resistant to the use of his com-
communication display could be used to interact with others. munication display within the structured training activities, it

JSLPA Vo!. 15. No, 2. June 1991 / R()A \'of. 15 .f\;" 2. j/lill 1991 39
AAC Intervention for a Child with Acquired Aphasia

was reported that he was continuing to make use of the com- remediated all of Michael's severe communication difficul-
munication display in more familiar natural settings. After a ties, they helped to compensate for the severe restriction of
careful review of Michael's demonstrated competencies, the his speaking abilities and provided a valuable means of aug-
following conclusions were reached. Michael was most likely mented input during communicative interactions.
to make use of his communication skills (speech approxima-
tions, pointing, gestures, pictures) when the following criteria
were satisfied: (I) there were motivating opportunities for Summary of Findings and Future
participation within familiar routines; and (2) Michael's use Directions
of what he considered the most effective means of communi-
cation was recognized and accepted. When these criteria were Michael's selective use of augmentative communication tech-
satisfied, Michael typically would participate to the best of niques raises a number of interesting issues concerning the
his abilities and sometimes successfully conveyed a novel assessment-intervention process with children with acquired
message to his communication partner. For example, after an aphasia with convulsive disorder. Although previous case his-
outing with a teacher's aide, he told his Mother about their tories have documented the use of AAC systems with chil-
trip to McDonalds by making a gesture for McDonalds and dren with a controlled seizure disorder, this case is unique in
then pointing to a picture of the toy car he had received. that the AAC system was introduced even though the subject
When these criteria for participation were not met, Michael was experiencing a high level of seizure activity. Miller et al.
typically would withdraw from the interaction. For example, () 984) have suggested that children who display aphasia with
during the trial training session, when Michael's selected a controlled convulsive disorder may be able to make use of
mode of communication was ignored, he would refuse to an AAC system in a manner that reflects their previous lin-
participate. Michael's intervention program therefore was modi- guistic knowledge. This was not observed with Michael, who,
fied to emphasize the development of motivating opportuni- perhaps because of ongoing seizure activity and other uni-
ties for communication within familiar functional activities. dentified factors. was only able to make use of the AAC
At these times, staff modeled the use of the communication system to communicate simple needs and wants, and provide
display and gestures as effective means of communication. basic information. The use of AAC systems, however, did
They were also encouraged to accept whatever mode of com- enable Michael to understand and express concepts that were
munication was used by MichaeL If the mode of communica- not successfully conveyed through speech. Although the prog-
tion chosen by Michael (e.g., unintelligible speech nosis for sophisticated use of an AAC system probably would
approximation) was unclear, Michael was encouraged to clar- have been improved by successful management of the seizure
ify his message using his communication display. activity, this case provides evidence that important interven-
tion work can take place even though the seizure activity is
Twenty-two Month Post-onset ongoing.
Twenty months post-onset (twelve months following the ini-
tial intervention) Michael continued to make use of AAC As to the issue of which AAC technique is best for
strategies. He was observed to make expressive use of ap- children with acquired aphasia with convulsive disorder, the
proximately 70 of the 180 picture vocabulary items available answer may be that no one technique is best, but that a
to him and continued to make use of approximately 15 ges- combination of modes should be considered (Vanderheiden &
tures to request objects and activities and provide informa- Lloyd, 1986). Research to date has focused on the use of a
tion. Michael typically used his display to initiate messages. single mode of AAC and may in fact have ignored the pres-
He did not use it to clarify when a spoken message was ence of communicative behaviours that were being expressed
unintelligible, rather he persisted in using his speech approxi- by alternate modes.
mation. Michael's communication partners' use of gestures
and of approximately 85 picture vocabulary items as aug- While Michael's case provides some interesting insights
mented input facilitated Michael's participation in a variety into the use of augmentative and alternative communication
of classroom and home activities. systems by children with acquired aphasia with convulsive
disorder, there is a need for more detailed case studies to
Michael's ability to participate in communicative inter- document the effectiveness of AAC system use in facilitating
actions varied on a day to day basis with his physical and the clinical progress of these children. It is anticipated that by
medical status. Ongoing seizure activity during the 12 months developing a better understanding of the language and neuro-
of intervention reported here had a negative impact on Michael's logical dysfunctions experienced by these children, we will
cognitive and linguistic abilities; in spite of ongoing speech be better equipped to offer effective communication interven-
and language therapy, progressively fewer spoken vocabulary tion in the future.
items were heard during the 12 month period. While the use
of a picture communication display and gestures by no means

40 JSLPA Vo!. 15, No. 2, June 1991 i ROA Vol. 15. N° 2,juin 1991
 McNaughton

Acknowledgements Holland, AL., Swindell, e.S., & Fromm, D. (1983). A model treat-
For the purpose of this case study, a pseudonym has been ment for the acutely aphasic patient. Proceedings of the Clinical
used to insure confidentiality. This case study presents work Aphasiology Conference, Minneapolis, MN, BRK Publishers, 44-51.
carried out while the author was an employee of the Augmen- Mantovani, J.F., & Landau, W.M. (1980). Acquired aphasia with
tative Communication Service (ACS) of the Hugh MacMillan convulsive disorder: course and prognosis. Neurology, 30, 524-529.
Rehabilitation Centre, Toronto, ON. The author gratefully Mayer-Johnson, R. (1984). The Picture Communication Symbols.
acknowledges the input and suggestions provided by Janice Solana Beach, CA: Mayer-Johnson.
Light of Pennsylvania State University, the staff at ACS, and
Mayer-Johnson, R. (1985). The Picture Communication Symbols -
Luigi Girolametto of the Toronto Hospital for Sick Children.
Book 11. Solana Beach, CA: Mayer-Johnson.
The author especially wishes to thank Michael's parents and
the members of Michael's medical and educational team at Miller, J., Campbell,T., Chapman, R., & Weismer, S. (1984). Lan-
the Hugh MacMiIlan Centre School for their contributions to guage behavior in acquired aphasia. In A Holland (Ed.), Language
the work described in this article. Disorders in Children, (pp. 57-99). San Diego, CA: College Hill
Press.

Address all correspondence to: Mirenda, P. (1985). Designing pictorial communication systems for
David McNaughton physically able-bodied students with severe handicaps. Augmenta-
Department of Special Education tive and Alternative Communication, I, 58-64,
Pennsylvania State University Msall, M., Shapiro, B., & Balfour, P., (1986). Acquired epileptic
State College, Pennsylvania aphasia. Clinical Pediatrics, 25, 248-251.
USA 16802 Nietupski, J., Scheutz, G., & Ockwood, L. (1980), The delivery of
communication therapy services to severely handicapped students: A
plan for change. Journal of the Association of the Severely Handi-
capped, 5 (I), 13-23.
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