Parents, educators and professionals are often at a loss when presented with a child who is nonverbal or whose speech is unintelligible (unclear) when conversing or communicating. Or if a person is unable to use their voice for whatever other reason unable to communicate.
 Augmentative means to add to someone’s speech. Alternative means to be used instead of speech. (asha.org)
So let’s answer the WHAT, WHO, WHERE, WHEN and WHY AAC!

WHAT?
AAC is an internationally recognized area of clinical and educational practice that attempts to compensate and augment (increase) temporarily or permanently, for those with disabilities who struggle with speech-language production and comprehension in spoken and written modes. 
 
WHO?
A child or person whose speech is not developing within the realm of what is considered typical, or is not likely to develop normal speech due to Autism, Down Syndrome, Cerebral Palsy is a potential candidate for AAC.  AAC can be used for persons who have Aphasia, Traumatic Brain Injury, Multiple Sclerosis or other progressive diseases such as ALS which would affect their communication. AAC has been shown to enhance a child or person’s ability to communicate and have better functional interactions with others.
 
WHERE?
We all have something we want to communicate at any given time.  Using some form of AAC allows for a child or person to directly gain control over the environment, to regulate social encounters and to receive and convey information at all times.  So… AAC EVERY WHERE and ANYTIME!
 
WHEN?
Some people use AAC throughout their life. Others may use AAC only for a short time, such as post-surgery. A child with communication impairment is at risk for Learned Helplessness. Adults often do not expect the child to inform them of his or her needs and wants.  They anticipate and often misinterpret the child's needs and end up doing everything for the child. Having a form or means to communicate can increase a child’s ability to become an independent thinker and communicator, to prevent Learned Helplessness.  So… AAC ALL THE TIME!
 
WHY?
Everyone should be given the right to be able to express their basic wants and needs, and to even express what is in their hearts, no matter the means of communication. Because a person cannot communicate using words, does not mean they have nothing to say.

TYPES of AAC
Here are the different types of AAC:
No-tech to low-tech includes:

• gestures and facial expressions
• writing/drawing
• spelling words by pointing to letters
• using single pictures or visual sentences
• Speech Generating Devices (SGD) which plays messages that you record (up to 6-10 secs) .The user pushes a button with a corresponding picture, and the SGD plays the message.  For e.g. the child can push the button on the device to say “I love you” to mom and dad.

High-tech options include:

• using a communication  app on an iPad or tablet
• Using a keyboard (real or virtual) to type in messages to request, comment and/or share thoughts and ideas.

 
Some people wonder if children need to be a certain age before they can use AAC. Research shows that AAC helps people of all ages (even those younger than 3 years old)! You can use AAC early. There are no thinking skills, test scores, or other milestones that you need to reach before AAC can help (ash.org). AAC communicators often learn how to communicate using low or high tech AAC, in a similar way that children learn to communicate verbally…with continuous exposure and opportunities.
 
 Would AAC Prevent Natural Speech Development?
A child who is unable to communicate effectively is unable to participate meaningfully in many activities, and is at great risk for delays in cognitive, social and emotional development. While it may be appropriate in some cases to continue to focus on speech, it is unfair to leave a child with little or no means of having a way to communicating effectively.
 
Think about a place that you spend the most time and with whom do you communicate?
How do you communicate? If you are unable to communicate using words, how would that change your life and even affect your relationships with others in the world?

​We all have something to say, something to share, something to give to the world. If we are unable to use our voice to do so, some form of AAC is therefore necessary to create a space where a person’s voice can be heard.
 
Sirlon George
Speech Language Pathologist
October 2021

“Dysphagia affects approximately 10% to 33% of adults. It is most commonly seen in the
geriatric population, and in adults who have experienced a stroke or neurodegenerative
diseases such as Alzheimer’s or Parkinson’s Disease.”
https://www.mayoclinicproceedings.org/article/S0025-6196(20)30902-2/fulltext

So what is Dysphagia?
Dysphagia is simply understood as the difficulty in swallowing liquids,
foods, or saliva. When this happens, eating becomes a challenge. Often, dysphagia makes it
difficult to take in enough calories and fluids to nourish the body and can lead to additional
serious medical problems.

My dysphagia training only just began upon completion of my SLT MSc degree and really
reached its peak at my job placement at an acute neuro hospital in Wellington, NZ. At that
hospital, my dysphagia competencies were met after months of dysphagia evaluation and
management to patients with a wide variety of acute and congenital diseases and disorders.
It was, and continues, to be a dimension of my current practice that makes me repeatedly
question myself in a quest to ensure that the most accurate decisions are made for my
patient’s well being and progress. For us Speech-Language Therapists, dysphagia training
occurs each day simultaneous with dysphagia practice. Personally, I have found it to be one
of the most fascinating and complex aspects of my journey as a Speech-Language
Therapist.

The management of patients with swallowing dysfunction is vast and complex. As a
dysphagia practitioner in Trinidad, the need to integrate cultural awareness/expectations,
service availability, disease type variables and medical ethics is integral to ensuring the best
individualised care. Being one of these Speech-Language Therapists who provides such
care to patients locally for the past 9 years, critical thinking has been essential in selecting
diagnostic and intervention options. This has especially been the case in an environment
where we do not always have ready access to instrumental swallow evaluations.

When it comes to diagnosing a patient’s swallowing function, there are two broad best
options to be explored- a clinical/bedside examination and an instrumental examination. I’ll
spend some time explaining what an instrumental swallow examination really is. In an effort
to be succinct, the two broad types of instrumental swallow examinations are the Modified
Barium Swallow study (MBSS)/ Video fluoroscopy study (VFSS) and the Barium Swallow
study (BSS)/ Esophagram. A MBSS/VFSS is used to assess oral (mouth) and pharyngeal
(throat) phases of the swallow. It allows us to look for possible aspiration, penetration of
food/drinks, pooling or residue left over after the swallow and structural abnormalities etc. On
the other hand, BSS/ Esophagram explores the oesophagus. It is entirely different and
usually done for the GI to check for reflux, motility of food and drink etc. Both tests are valid
but useful in different ways and your Speech-Language Therapist will determine which
instrumental evaluation is the best fit for the patient, given their complaint.

Because of the reduced availability and access to the MBSS/VFSS study locally, SLT’s here
more readily use the clinical/ bedside swallowing evaluations. A learning experience for me
after my return to Trinidad was that in order to diagnose a swallow impairment, I did not
need to rely too heavily on either instrumental or clinical examinations and found great
opportunity in what was available in my context of operation. Neither option is superior to the
other but each method provide us with different information. I continue to understand the
benefits of a clinical swallow examination and hope to share some with you in the following
paragraphs.

We must be mindful that “Swallowing difficulties can cause anxiety and / or depression” Eslick, GD., & Tally, N.J. (2008). Dysphagia epidemiology, risk factors and impact on quality of life – a population-based study. Having to now rely primarily on clinical evaluations, I found that it significantly reduced the patient anxieties associated with long waiting times for an MBSS appointment, not to mention, patient discomfort with their physical transfer to and from the radiography lab.

Weeks and even months warded in a hospital can add to patient frustrations. With the clinical swallow evaluation, I have the opportunity to meet the patient and evaluate them in a quicker time frame. Additionally, I am able to glean so much more clinical information at bedside, not to mention, develop a greater rapport with the patient if their communication skills are relatively intact. It is also beneficial to explore the patient’s feeding in a naturalistic scenario: at their home; in their favourite chair; with their chosen companions; when they are relaxed.

On a personal level, clinical evaluations forced me to be more thorough and enhance my own observation skills repertoire, knowing that I may never succeed in getting the patient to a MBSS lab for instrumental verification. While I am occasionally filled with discontent when I am unable to see a patient’s hyoid anterior movement or upper oesophageal sphincter movement or residue in the vallecullae or pyriform sinuses that you gain from an instrumental evaluation, I am comforted in the opportunities to test oral sensory-motor function, sucking in an infant, mastication, bolus control and swallow initiation gained from a thorough clinical evaluation. That being said, Speech-Language Therapists ought to remain mindful of the recommendations they make in the absence of instrumental probes and accept the limitations that may be had.

Despite the numerous benefits of a clinical swallow evaluation, we cannot continue to forgo the instrumental swallowing evaluation. The question remains…How do we question the things we think we know? I do believe that we must continue to hold dysphagia evaluations to the highest standards and lobby for our ready ability to provide instrumental rationale for patient swallowing decision-making.
​
It is my hope that I was able to shed some greater light on one aspect of Dysphagia. Perhaps my next Dysphagia article could centre around two aspects that I informally and non-clinically coin “The Jell-O-Syndrome” and “The Thickener-Syndrome”.

Your passionate Dysphagia Practitioner
Nadita Maharaj (Msc SLT)

So your family member has been discharged from the hospital after suffering a stroke, but you notice that your loved one is having trouble communicating. Maybe they are not talking at all, maybe they are speaking in broken sentences, or maybe they are speaking non-sense words or “gibberish” and not seeming to understand what you tell them. When you ask your speech-language pathologist or doctor what is going on, he or she mentions that your loved one has a diagnosis of aphasia.

What does this mean?  Where do we go from here?
How can I possibly support my loved one when they are unable to communicate what they need?
What does the term Aphasia mean?

As per the American Speech-Language Hearing Association (ASHA), aphasia is defined as an acquired neurogenic language disorder resulting from an injury to the brain (stroke or head injury), usually in the left hemisphere of the brain. There are different types of aphasia, but most fall into the general categories of nonfluent aphasia or fluent aphasia, depending on the individual’s language characteristics. Are the person’s phrases slow, laborious, broken and effortful, or does the speech flow freely, but perhaps lack meaning or understanding? Aphasia can affect many areas of communication, including a person’s ability to speak, understand others, write and/or read.  Aphasia is a language-based disorder and does not affect a person’s intelligence, although many people may make that incorrect assumption if the communicator is not able to effectively expressive him/herself.

But, I’m confused, my loved one doesn’t fit into those categories! They aren’t answering yes/no questions correctly, they’re not following commands, their speech is slurred, or they are not talking at all. On top of that, they are coughing when they drink. What is going on?

Aphasia can be confusing and complicated in its presentation because it often co-occurs with other difficulties that may result from a stroke or brain injury, such as cognitive impairment, apraxia of speech (difficulty getting the “message” from the brain to the speech muscles to produce voluntary speech sounds or words) and dysarthria (impairment in the muscles or physical structures required for speech, which may make the speech sound slurred, strained, nasal or breathy).

So, what do I do next? Now my loved one is home with me and feeling frustrated or depressed. I don’t understand and I am starting to feel stressed!

This week I asked several of my recent younger patients with aphasia to describe their struggles and offer suggestions. They are middle aged adults who have suddenly been jolted into a world where they are unable to speak fluently, and in one case she can’t talk at all. Imagine how they must feel. When I asked these brave individuals what they’ve struggled with, some of the things they listed include:

• Feeling frustrated that others are not being patient with them and giving them time to finish talking- others are jumping in and speaking for them
• Difficulty texting or “whatsapping,” leading to a feeling of social isolation
• Feeling scared about worrying about job security. How could a language impairment affect their ability to work?
• Wondering if anyone else is experiencing the same situation

The answer is yes! According to American Speech-Language Hearing Association (2021), 1 in 250 people in society may have aphasia; 15% of individuals under age 65 after their first stroke or 43% of individuals over age 85 after their first stroke.
 
So what should I do? What can I do to help my loved one?

Reach out to a speech-language pathologist as soon as possible for assessment and intervention. A list of all qualified, licensed therapists in Trinidad and Tobago can be found on the “Occupational Therapy and Speech Language Therapy Board TT” Facebook page or the board can be reached at otslpboard@gmail.com. Additionally, the following tips from NHS (2021) will help you communicate with your loved one:

• After speaking, allow the person plenty of time to respond. If a person with aphasia feels rushed or pressured to speak, they may become anxious, which can affect their ability to communicate.
• Use short, uncomplicated sentences, and don't change the topic of conversation too quickly.
• Avoid asking open-ended questions. Closed questions that have a yes or no answer can be better.
• Avoid finishing a person's sentences or correcting any errors in their language. This may cause resentment and frustration for the person with aphasia.
• Keep distractions to a minimum, such as background radio or TV noise.
• Use paper and a pen to write down key words, or draw diagrams or pictures, to help reinforce your message and support their understanding.
• If you don't understand something a person with aphasia is trying to communicate, don't pretend you understand. The person may find this patronising and upsetting.
• Use visual references, such as pointing, gesturing and objects, to support their understanding.
• If they're having difficulty finding the right word, prompt them – ask them to describe the word, think of a similar word, try to visualise it, think of the sound the word starts with, try to write the word, use gestures, or point to an object.

 
I hope this information helps. My recent patients told me their best advice to others is to be kind and have patience.      We are all in this together!
 
Sources:
 
American Speech-Language Hearing Association. (2021). Aphasia. https://www.asha.org/practice-portal/clinical-topics/aphasia/#collapse_1
National Health Service (UK). (2021, March 23). Treatment: Aphasia. NHS. https://www.nhs.uk/conditions/aphasia/treatment/

The Speech-Language-Audiology Association of Trinidad and Tobago (SLAATT) wishes to advise the public to use hearing protection during the carnival period.  Music sound levels are such that exposure will typically cause a gradual hearing loss and or tinnitus (ringing in the ears), as a result of damage to the delicate nerve endings in the inner ear.  Additionally, music sound levels today are higher than in previous years due to advances in stereo equipment.  There is no medical cure to repair these damaged nerve endings which can lead to permanent ringing and or hearing loss.
 
Disposable ear plugs are available at many local pharmacies.  Please read the instructions for insertion carefully.  For proper insertion pull up and back on the ear before inserting the plug into the ear canal.  Cotton, toilet paper etc. are not suitable forms of hearing protection as these items are not dense enough to decrease sound to a safe level.
Enjoy your carnival safely.
 
Natasa Bratt Au.D CCC-A
Doctor of Audiology
36 Ranjit Kumar St.
St. James, Trinidad, W.I.

​One of the most essential skills your child will ever learn is focused listening.
Listening is more than just hearing. Listening is a very intentional process that involves consciously extracting meaning from the sounds we hear.  In order for children to listen well, they must learn to focus their attention, block out distractions/competing noise and make a meaningful connection with the message being communicated. Here are a few ways to help build strong listening skills at home:

• Minimize background noise in the environment (e.g. fans, TV, music, washing machine) or move to a quieter location when conversing with your child.
• Get your child’s attention before expecting him/her to listen to instructions.  Call your child’s name and establish eye contact before giving directions or asking questions.
• Stand close and face your child.  Stand within arm’s length of your child, get down to the child’s eye level and communicate face to face.
• Speak in a clear voice.  Slow down your speech and enunciate words.
• Check for understanding.  Ensure that your child understands what is being said. Observe his/her facial expression or ask your child “what did you hear me say?”  
• Allow your child time to respond to your questions.  Be patient and positive.
• Read a book to your child daily. A simple 10-15 minute read-out-loud activity with your child is powerful. It teaches your child to adopt a physical listening posture and allows them to practice active listening to a story containing rich vocabulary.
• Cook together. Find a simple recipe, read each step of the recipe and follow the directions together.  
• Take a listening walk. Go outside with your child with the intention of discovering sounds in nature: e.g. “Shhhh, what do you hear? What is making that sound?”…. “I hear a bird singing, look it’s a kiskadee!”
• Play sound pattern games.  Clap your hands/ drum on a table in a variety of different rhythmic patterns and let your child repeat each pattern.
• Be encouraging.  Give praise generously. Be positive about your child’s learning and celebrate their progress, even very small steps forward.
• Model good listening as a parent. Be engaged when communicating with your child: remove distractions (e.g. cellphone), maintain eye contact, repeat /discuss the content of your child’s message.

 
If you are concerned with your child’s listening and speaking skills please consult your paediatrician. An assessment with an audiologist and speech language pathologist may be warranted.

For more information, please visit the Speech-Language-Audiology Association of Trinidad and Tobago on Facebook or our website www.slaatt.com. 
 
 
Sources:
Helping Kids with Learning Disabilities Build Listening Skills by Dr. Kari Miller, LA Special Education Examiner, March 11, 2011.
Listening: More than just hearing by Jan Pierce, M.ED. www.kcparent.com

So, you know in your heart that your child may have a speech and language delay or
disorder.  Some of your family supports you, and some think you are just over reacting.
An aunt says that you were just like your kid when you were little and that you grew out
of it on your own. The pediatrician didn’t pick up on anything wrong. What should you
do?

Remember that you are your child’s mother, father or primary care provider. You know
your child better than anyone else. You need to trust your gut instinct and take the leap
to go find help for your child. As a mother, you want your child to have the best chance
at succeeding in life, to do better and to go further than you have gone with your life. In
order for a child to reach his or her potential, that child may need support to help ensure
basic skills are developing as they should. A child may struggle for the rest of his or her
life in relationships and education if basic communication, speech and/or language skills
are not in place.

First, talk to your child’s day-care provider or teacher at school. Teachers spend 3-8
hours a day with your child 5 days a week. They know your child quite well. A good
teacher who is interested in the success of your child will share concerns regarding
speech and language development, academic and social struggles, as well as areas of
strength.

You can also talk to your doctor about your concerns. He or she can refer you to a
registered Speech-Language Pathologist, an Audiologist, Psychologist or
Developmental Pediatrician. Social Workers can provide support as well. If there are
any questions, go search out the answers. It is always better to be safe than sorry.
Early intervention leads to the best success rates. No child is too young to receive and
benefit from therapy. There is no need to wait until the child has another birthday to see if he or she will
outgrow the problem. Let a professional suggest a plan of action based on results
from the screening or assessment.

A complete evaluation by a registered Speech-Language Pathologist will identify your
child’s weaknesses as well as his or her strengths. An individualized program will be
developed for your child, and long term goals with short term objectives will be set.
Through therapy in the office and follow-up exercises to be done in the home, progress
should be seen within 3-6 months. However, therapy may continue for at least a year or
more, until everyone is satisfied with the child’s development.

Just because your child may have a delay or a disorder, does not mean all hope is lost.  Many
children return to developing on track with support from a registered Speech-Language
Pathologist. All children will make improvements with therapy in the office and following
home programs, once the needed support is provided. Some children may need extra
support in the school setting. The teachers and remedial teacher can work with the
Speech-Language Pathologist to provide adjustments in homework and testing if
needed. Some children benefit most from the use of an aide in the classroom. More
and more children are succeeding in typical schools with the support of an aide.

As with many things in your child’s life, you become the advocate for your child to make
sure his or her voice is heard. To make sure his or her rights are protected. To make
sure that your child has the same opportunities as others to learn and excel. But brace
yourself, this will be a continuous job. It will feel at times like you are hitting wall after
wall. But realize that you are not alone. There are other parents facing similar
challenges who can offer advice, encouraging words or even just an understanding
look. There are professionals who can offer the knowledge and how toʼs to help. And
there are some parent support groups available that bring parents together in a safe
environment to laugh, share triumphs and tribulations and de-stress.
​
Go out there and fight for your child. You are your child’s protector and he or she needs
your voice and your actions. Your child needs you to make the first step and
acknowledge if a problem exists. Your child needs you to seek the help of a professional
and identify the problem. Your child needs your support through the therapy and daily
triumphs and struggles. Your child needs you to continue to love him or her regardless
of the outcome. Do the best for your child. Do what is right for your child. Love your
child.

What are speech and language?
Speech and language are tools that humans use to communicate or share thoughts, ideas, and emotions. Language is the set of rules, shared by the individuals who are communicating, that allows them to exchange those thoughts, ideas, or emotions. Speech is talking, one way that a language can be expressed. Language may also be expressed through writing, signing, pictures or even gestures in the case of people who may have had a brain injury and may depend upon eye blinks or mouth movements to communicate.

While there are many languages in the world, each includes its own set of rules  and speech sounds or, in the case of sign language, word formation, sentence formation(syntax), word and sentence meaning (semantics, intonation and rhythm of speech(prosody) and effective use of language (pragmatics).

How do speech and language normally develop?
The most intensive period of speech and language development for humans is during the first three years of life.  This is a period when the brain is developing and maturing. These skills appear to develop best in a world that is rich with sounds, sights, and consistent exposure to the speech and language of others.

There is increasing evidence suggesting that there are “critical periods” for speech and language development in infants and young children. This means that the developing brain is best able to absorb a language, any language, during this period. The ability to learn a language will be more difficult, and perhaps less efficient or effective, if these critical periods are allowed to pass without early exposure to a language. The beginning signs of communication occur during the first few days of life when an infant learns that a cry will bring food, comfort, and companionship. The newborn also begins to recognize important sounds in his or her environment. The sound of a parent or voice can be one important sound. As they grow, infants begin to sort out the speech sounds or building blocks that compose the words of their language. Research has shown that by six months of age, most children recognize the basic sounds of their native language.

As the speech mechanism (jaw, lips, and tongue) and voice mature, an infant is able to make controlled sound. This begins in the first few months of life with “cooing,” a quiet, pleasant, repetitive vocalization. By six months of age, an infant usually babbles or produces repetitive syllables such as “ba, ba, ba” or “da, da, da.” Babbling soon turns into a type of nonsense speech (jargon) that often has the tone and cadence of human speech but does not contain real words. By the end of their first year, most children have mastered the ability to say a few simple words. Children are most likely unaware of the meaning of their first words, but soon learn the power of those words as others respond to them.
By eighteen months of age, most children can say eight to ten words. By age two, most are putting words together in crude sentences such as “more milk.” During this period, children rapidly learn that words symbolize or represent objects, actions, and thoughts. At this age they also engage in pretend play. At ages three, four, and five, a child’s vocabulary rapidly increases, and he or she begins to master the rules of language.

What are speech and language developmental milestones?
Children vary in their development of speech and language. There is, however, a natural progression or “timetable” for mastery of these skills for each language. The milestones are identifiable skills that can serve as a guide to normal development. Typically, simple skills need to be reached before the more complex skills can be learned. There is a general age and time when most children pass through these periods. These milestones help doctors and other health professionals determine when a child may need extra help to learn to speak or to use language.

How do you know if your child is reaching the milestones?     
Informally, parents often know their child is not speaking/communicating like other children the same age. If in any way concerned, parents should consult with their paediatrician for guidance.                  

What should I do if my child's speech or language appears to be delayed?

You should talk to your family doctor if you have any concerns about your child’s speech or language development. Your doctor may decide to refer you to a Speech-Language Pathologist/Therapist/Clinician, a health professional trained to evaluate and treat people who have speech, language, voice or swallowing disorders (including hearing impairment) that affect their ability to communicate. The Speech-Language Pathologist will talk to you about your child’s communication and general development. He or she will also evaluate your child with special speech and language tests. A hearing test may be included in the evaluation because a hearing problem can affect speech and language development.

Speech-language pathologists/therapist/clinicians assess, diagnose, treat, and help to prevent disorders related to speech, language, cognitive-communication, voice, swallowing, and fluency. They work with:

• people who cannot make speech sounds, or cannot make them clearly
• those with fluency problems, such as stuttering
• people with voice quality problems, such as inappropriate pitch or harsh voice
• people who have problems understanding and producing language
• those who wish to improve their communication skills by modifying an accent
• those with cognitive communication impairments, such as attention, memory, and problem solving disorders
• people who have problems eating and swallowing difficulties.

​Speech-Language Pathologists/Therapists/Clinicians develop an individualized plan of care, tailored to each patient's needs. For individuals with little or no speech capability, speech-language pathologists may select augmentative or alternative communication methods, including automated devices and sign language, and teach their use. They teach patients how to make sounds, improve their voices, or increase their oral or written language skills to communicate more effectively. They also teach individuals how to strengthen muscles or use compensatory strategies to swallow without choking or inhaling food or liquid.

Speech-Language Pathologists often work as part of a team, which may include teachers, Physicians, Audiologists, Psychologists, Social Workers, Rehabilitation Counselors and others. Speech-Language Pathologists in schools collaborate with teachers, special educators, interpreters, other school personnel, and parents to develop and implement individual or group programs, provide counseling, and support classroom activities.

There are currently 28 Speech-Language Pathologists/Therapists/Clinicians licensed to practice in Trinidad and Tobago, under the Council for Professions Related to Medicine. Many are members of the Speech-Language-Audiology Association of Trinidad and Tobago (SLAATT).

For more information, please visit the Speech-Language-Audiology Association of Trinidad and Tobago on Facebook or our website www.slaatt.com.