Roberta Chapey Language Intervention Strategies in Aphasia and Related Neurogenic Communication Disorders.pdf

GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page i APTARA(GRG QUARK) Language Intervention Strategies in Aphasia and Related Neurogenic Communication Disorders FIFTH EDITION GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page ii APTARA(GRG QUARK) GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page iii APTARA(GRG QUARK) Language Intervention Strategies in Aphasia and Related Neurogenic Communication Disorders FIFTH EDITION Editor Roberta Chapey, Ed.D. Professor Department of Speech Communication Arts and Sciences Brooklyn College The City University of New York Brooklyn, New York GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page iv APTARA(GRG QUARK) Editor: Peter Sabatini Managing Editor: Lisa Koepenick / Kevin C. Dietz Marketing Manager: Allison Noplock Compositor: Aptara, Inc. Printer: RRD-Willard Copyright © 2008 Lippincott Williams & Wilkins 351 West Camden Street Baltimore, Maryland 21201-2436 USA 227 East Washington Square Philadelphia, PA 19106 All rights reserved. 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Printed in the United States of America First Edition, 1981 Second Edition, 1986 Third Edition, 1994 Fourth Edition, 2001 Library of Congress Cataloging-in-Publication Data Language intervention strategies in aphasia and related neurogenic communication disorders / editor, Roberta Chapey. — 5th ed. p. ; cm. Includes bibliographical references and indexes. ISBN-13: 978-0-7817-6981-5 (hardcover) ISBN-10: 0-7817-6981-7 (hardcover) 1. Aphasia—Treatment. 2. Language disorders—Treatment. I. Chapey, Roberta. [DNLM: 1. Aphasia—therapy. 2. Language Disorders—therapy. 3. Language Therapy—methods. 4. Speech Disorders—therapy. WL 340.5 L2872 2008] RC425.L37 2008 616.85'5206—dc22 2007038506 The publishers have made every effort to trace the copyright holders for borrowed material. If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 824-7390. International customers should call (301) 714-2324. GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page v APTARA(GRG QUARK) To the memory of my dad, Robert (Bob) Chapey, for his boundless generosity, kindness, love, understanding, tolerance, support, humanness, and humor—and for his truly brilliant strategies for living. He was a super parent. R.C. GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page vi APTARA(GRG QUARK) GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page vii APTARA(GRG QUARK) Preface Welcome to the fifth edition of Language Intervention human health for all individuals are living a life of purpose Strategies in Aphasia and Related Neurogenic Communication and quality connection to others. Disorders. The first edition of this book was published in The fifth edition contains 36 chapters organized into five 1981, the second in 1986, the third in 1994, and the fourth sections. Section I covers basic considerations such as defi- in 2001. All four editions grew out of the realization that the nitions of aphasia and stroke, incidence of stroke, the neural discussion of aphasia therapy had become a major theme in basis of language disorders, medical aspects of stroke, and clinical aphasiology literature but that the specification of the assessment of language disorders in adults. numerous types or strategies of intervention was of fairly Section II contains five chapters on principles of lan- recent origin. guage intervention such as research methods appropriate to All five texts grew out of the belief that there continues to our field, treatment recovery, prognosis, and clinical effec- be a substantial number of approaches applicable to the tiveness, teams and partnerships in clinical practice, as well remediation of language-disordered adults that should be as treatment of bilingual and bicultrurally diverse individu- brought together and shared. The five texts are also grounded als. A number of issues related to service delivery are dis- in the realization that a variety of different therapeutic prin- cussed. ciples and approaches need to be articulated, assembled, Section III contains five chapters on psychosocial and applied, and critiqued in order to strengthen the quality of functional approaches to intervention—models that focus future work in our field. on improving ability to perform communication activities of The major purpose of the fifth edition is to bring daily living. Such approaches consider the impact of aphasia together significant thoughts on intervention and to stimu- on the well-being of the individual, their family, and the late further developments in the remediation of adults with environment. aphasia. It should be noted that some of the models pre- Section IV, the largest section, covers ‘Traditional sented in this text still need to be supported by controlled Approaches to Language Intervention.’ It is divided into four studies and long-term clinical application. units containing seven stimulation approaches, four cogni- Each edition of this text is increasingly informed by the tive neuropsycological and four neurolinguistic approaches, view that language is cognitively based (Chapey, 2008) and and three ‘specialized’ interventions. socially constructed by participants communicating with Section V provides suggestions for remediation of disor- someone, about something, for some reason; and that judg- ders that frequently accompany aphasia or are related to or ments of competence/incompetence involve evaluations confused with aphasia; namely, traumatic brain injury, right about issues such as role, context, intent, timing, volume, hemisphere damage, dementia, apraxia, and dysarthria. movements, intonation, gender, age, taste, group member- The chapters can be read in any order. In addition, all the ship, etc. (Bloom and Lahey, 1988; Kovarsky, Duchan, and chapters do not need to be read at one time. For example, Maxwell, 1999). In addition, the dual goals of communica- when I teach our graduate course in adult aphasia, I typically tion—that of transaction or the exchange of information use about 12 to 15 chapters as a core, and then refer to other and that of interaction or the fulfillment of social needs chapters as they come up in class discussions, presentations (such as affiliation with other people, assertion of individual- or term papers, and/or when students ask questions about a ity, demonstration of competence, gaining and maintaining specific individual that they are observing or working with in membership in social circles, etc. (Simmons-Mackie, 2008) clinical practicum. I use the remaining chapters to give addi- are increasingly reflected in the texts. tional options, depth, and resources for actual work with Further, the texts increasingly reflect the fact that we have individuals affected by aphasia. a responsibility to individuals with aphasia and their signifi- Language Intervention Strategies in Aphasia and Related cant others to foster their membership in a communicating Neurogenic Communication Disorders—Fifth Edition can be society and their participation in personally relevant activi- used in classes for advanced undergraduate and graduate ties (Simmons-Mackie, 2008). The texts also emphasize the students in speech language pathology. Clinical aphasiolo- belief that two of the most important factors in positive gists who are no longer formal students, but who desire to vii GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page viii APTARA(GRG QUARK) viii Preface keep abreast of new ideas in their field will also find the Chapey, R. (2008). Cognitive Stimulation: Stimulation of Recognition/ material of interest. Further, the material will be valuable to Comprehension, Memory, Convergent Thinking, Divergent and Evaluative Thinking. In R. Chapey (Ed.)., Language Intervention Strategies in Aphasia students and professionals in nursing, medicine, and other and Related Neurogenic Communication Disorders—Fifth Ed. Baltimore, MD.: health-related disciplines. Lippincot Williams and Wilkins. Kovarsky, D., Duchan, J. and Maxwell, M. (1999). Constructing (In) Roberta Chapey, Competence. Disabling Evaluations in Clinical and Social Interaction. Mahwah, Ed.D. Professor NJ: Lawrence Erlbaum. Simmons-Mackie, N. (2008). Social approaches to aphasia intervention. References In R. Chapey (Ed.)., Language Intervention Strategies in Aphasia and Related Bloom, L., and Lahey, M. (1988), Language Disorders and Language Neurogenic Communication Disorders—Fifth Ed. Baltimore, MD.: Lippincott Development. New York: Macmillan. Williams and Wilkins. GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page ix APTARA(GRG QUARK) Acknowledgments To those who have contributed to my personal life and pro- this text a kaleidoscope of enriching and rewarding experi- fessional career, past and present, I express my deep appreci- ences for me as well as for each of our patients. I am deeply ation. I am also grateful to the authors and publishers who appreciative of their caring and support and for many “one granted me permission to quote from their works. and only moments” of connection. Many concerned and dedicated people have helped bring I am also thankful to the staff of Lippincott Williams & this textbook to fruition. Sincere appreciation is extended to Wilkins for their dedication to making this a first rate text each. Special thanks are extended to Argye E. (Beth) Hillis and for facilitating so many relentless details of this project. for her professionalism and enthusiasm in organizing the For the tireless support and help, I thank Peter Sabatini, section on cognitive neuropsychology. As editor, I would Acquisitions Editor; Lisa Koepenick, Managing Editor; and especially like to thank each contributor for helping to make Susan Katz, Vice President, Health Professions. ix GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page x APTARA(GRG QUARK) GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page xi APTARA(GRG QUARK) Contributors Donna L. Bandur, MCISc Carl A. Coelho, PhD Profession Leader Professor and Head Speech-Language Pathology Communication Sciences London Health Sciences Centre University of Connecticut London, Ontario, Canada Storrs, Connecticut Kathryn A. Bayles, PhD Hanna Damasio, MD Professor-Emerita Dana Dornsife Professor of Neuroscience and Department of Speech, Language and Hearing Sciences Director, Dana & David Dornsife Cognitive Neuroscience The University of Arizona Imaging Center, University of Southern California Pelagie M. Beeson, PhD, CCC-SLP Los Angeles Associate Professor Department of Speech, Language, and Hearing Sciences Judith F. Duchan, PhD, CCC Department of Neurology Professor The University of Arizona Department of Communicative Disorders Tucson, Arizona and Sciences State University of New York at Buffalo Rita Sloan Berndt, PhD Buffalo, New York Professor Department of Neurology Joseph R. Duffy, PhD University of Maryland School of Medicine Professor Baltimore, Maryland Consultant and Head Division of Speech Pathology Margaret Lehman Blake, PhD Department of Neurology Assistant Professor Mayo Clinic College of Medicing Department of Communication Sciences and Disorders Rochester, Minnesota University of Houston Houston, Texas Roberta J. Elman, PhD, CCC-SLP, BC-ANCDS President/Founder Roberta Chapey, EdD Aphasia Center of California Professor Oakland, California Department of Speech Communication Arts and Sciences Brooklyn College Timothy J. Feeney, PhD City University of New York School of Community Supports Brooklyn, New York Project Director NYS Neurobehavioral Resource Project Leora R. Cherney, PhD, BC-ANCDS New York, New York Associate Professor Physical Medicine and Rehabilitation Linda J. Garcia, PhD Northwestern University, Feinberg School of Medicine Associate Professor and Chair Clinical Research Scientist Audiology and Speech-Language Pathology Center for Aphasia Research Program Rehabilitation Institute of Chicago University of Ottawa Chicago, Illinois Ottawa, Ontario, Canada xi GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page xii APTARA(GRG QUARK) xii Contributors April Gibbs Scott, MS, CCC-SLP Richard C. Katz, PhD PhD Student Chair Department of Communication Science and Audiology and Speech Pathology Department Disorders Carl T. Hayden VA Medical Center University of Pittsburgh Phoenix, Arizona Pittsburgh, Pennsylvania Adjunct Professor Department of Speech and Hearing Science Lee Ann C. Golper, PhD Arizona State University Associate Professor Tempe, Arizona Department of Hearing and Speech Sciences Vanderbilt University Kevin P. Kearns, PhD Nashville, Tennessee Professor and Director Communication Sciences and Disorders Brooke Hallowell, PhD Massachusetts General Hospital Institute of Health Director Professions School of Hearing, Speech and Language Sciences Boston, Massachusetts Associate Dean College of Health and Human Services Rosemary B. Lubinski, EdD Ohio University Professor Athens, Ohio Department of Communication Disorders and Sciences University of Buffalo Maya L. Henry, MS, CCC-SLP Buffalo, New York Department of Speech, Language, and Hearing Sciences Jon G. Lyon, PhD, CCC-SLP University of Arizona, Tucson, AZ Director Living with Aphasia, Inc Argye Elizabeth Hillis, MD, MA Mazomanie, Wisconsin Professor of Neurology, Physical Medicine and Rehabilitation, and Cognitive Science Robert C. Marshall, PhD Executive Vice Chair, Department of Neurology Professor Director, Neurology Residency Program Rehabilitation Sciences Co-Director, Cerebrovascular Division University of Kentucky Johns Hopkins University School of Medicine Lexington, Kentucky Baltimore, Maryland Malcolm R. McNeil, PhD Tammy Hopper, PhD Distinguished Service Professor and Chair Assistant Professor Department of Communication Science Department of Speech Pathology and Audiology and Disorders University of Alberta University of Pittsburgh Edmonton, Alberta, Canada Research Scientist Speech Motor, Aphasia, Cognition Laboratory Karen Hux, PhD (SMAC) Associate Professor VA Pittsburgh Healthcare System Special Education and Communication Disorders Pittsburgh, Pennsylvania University of Nebraska at Lincoln Lincoln, Nebraska E. Jeffrey Metter, MD Medical Officer Aura Kagan, PhD, Reg CASLPO, S-LP (C) Clinical Research Branch Program, Research, and Education Director National Institute On Aging The Aphasia Institute National Institutes of Health Toronto, Ontario, Canada Gerontology Research Center Baltimore, Maryland GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page xiii APTARA(GRG QUARK) Contributors xiii Charlotte C. Mitchum, MS, CCC-SLP Bruce Earl Porch, PhD Research Associate Associate Professor Department of Neurology Speech and Hearing Sciences and Neurology University of Maryland School of Medicine University of New Mexico Baltimore, Maryland Albuquerque, New Mexico Anthony G. Mlcoch, PhD Anastasia M. Raymer, PhD Speech-Language Pathologist Professor Audiology and Speech Pathology Service Department of Early Childhood, Speech Pathology and Hines Veterans Affairs Hospital Special Education Hines, Illinois Old Dominion University and Norfolk, Virginia Adjunct Professor of Neurology Speech Pathology and Audiology Patricia M. Roberts, PhD Stricht School of Medicine, Loyola University Associate Professor Department of Health Sciences Shirley Morganstein, MA, CCC-SLP University of Ottawa Partner Ottawa, Ontario, Canada Speaking of Aphasia, LLC Montclair, New Jersey Randall R. Robey, PhD Director Penelope S. Myers, PhD Communication Disorders Program Speech Pathologist University of Virginia Rochester, Minnesota Charlottesville, Virginia Stephen E. Nadeau, MD John C. Rosenbek, PhD Professor Professor and Chair Department of Neurology Department of Communicative Disorders University of Florida College of Medicine University of Florida Staff Neurologist Gainesville FL Geriatric Research, Education and Clinic Malcolm Randall VA Medical Center Leslie J. Gonzalez Rothi, PhD Gainesville, Florida Professor Department of Neurology Melissa Newhart, BS University of Florida Research Assistant Program Director and Career Research Stroke and Cognitive Disorders Laboratory Scientist Brain Rehabilitation Research Center Janet P. Pattersion, PhD Malcolm Randall VA Medical Center Associate Professor Gainesville, Florida Department of Communicative Sciences and Disorders California State University East Bay Victoria L. Scharp, MS, CCC-SLP Hayward, California PhD Student Research Associate Department of Communication Science and Center for Aphasia and Related Diseases Disorders VA Northern California University of Pittsburgh Martinez, California Pittsburgh, Pennsylvania Richard K. Peach, PhD Cynthia M. Shewan, PhD, CCC Professor Director, Research and Scientific Affairs Otolaryngology, Neurological Sciences and Department Communication Disorders and Sciences American Academy of Orthopaedic Rush University Medical Center Surgeons Chicago, Illinois Rosemont, Illinois GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page xiv APTARA(GRG QUARK) xiv Contributors Linda I. Shuster, PhD, CCC/SLP Connie A. Tompkins, PhD Associate Professor Professor Department of Speech Pathology and Audiology Department of Communication Science and Disorders West Virginia University University of Pittsburgh Pittsburgh, Pennsylvania Nina Simmons-Mackie, PhD Professor and Scholar in Residence Mark Ylvisaker, PhD Department of Communication Sciences and Disorders Professor Southeastern Louisiana University Department of Communication Sciences and Hammond, Louisiana Disorders College of Saint Rose Michele Page Sinotte, MS, CCC-SLP Albany, New York Communication Sciences Department University of Connecticut Sarah Wallace, MA, CCC-SLP Storrs, Connecticut 06269-1085 Doctoral Student Special Education and Communication Marilyn Certner Smith, MA, CCC-SLP Disorders Partner University of Nebraska at Lincoln Speaking of Aphasia, LLC Lincoln, Nebraska Speech-Language Pathologist Robert W. Sparks, MSc Quality Living, Inc Chief, Speech Pathology/Audiology (retired) Omaha, Nebraska Veterans Affairs Medical Center Boston, Massachusetts Julie L. Wambaugh, PhD, CCC/SLP Associate Professor Shirley F. Szekeres, PhD Deptartment of Communication Sciences and Dean of Health and Human Services Disorders Professor University of Utah Speech and Language Pathology Researcher Nazareth College VA Salt Lake City Healthcare System Rochester, New York Salt Lake City, UT, USA Cynthia K. Thompson, PhD Kristy S.E. Weissling, SLPD, CCC-SLP Professor Lecturer Department of Communication Sciences and Disorders, Department of Special Education and Communication and Neurology Disorders Northwestern University University of Nebraska at Lincoln Evanston, Illinois Lincoln, Nebraska GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page xv APTARA(GRG QUARK) Contents Section I. BASIC CONSIDERATIONS 1 Section III. PSYCHOSOCIAL/FUNCTIONAL APPROACHES TO INTERVENTION: FOCUS ON IMPROVING ABILITY TO 1 Introduction to Language Intervention PERFORM COMMUNICATION ACTIVITIES OF DAILY Strategies in Adult Aphasia . . . . . . . . . . . . . . . . . . . . . 3 LIVING 277 Brooke Hallowell and Roberta Chapey 10 Life-Participation Approach to Aphasia: 2 Neural Basis of Language Disorders . . . . . . . . . . . . . 20 A Statement of Values for the Future . . . . . . . . . . . 279 Hanna Damasio Roberta Chapey, Judith F. Duchan, Roberta J. Elman, Linda J. Garcia, Aura Kagan, 3 Medical Aspects of Stroke Rehabilitation . . . . . . . . . 42 Jon G. Lyon, and Nina Simmons-Mackie Anthony G. Mlcoch and E. Jeffrey Metter 11 Social Approaches to Aphasia Intervention . . . . . . 290 4 Assessment of Language Disorders in Adults . . . . . . 64 Nina Simmons-Mackie Janet P. Patterson and Roberta Chapey APPENDIX 11.1 Examples of Strategies for APPENDIX 4.1 Pre-interview or Referral Communication-Partners of People with Aphasia . . . 318 Form for Collecting Family and Medical History and Status Information . . . . . . . . . . . . . . . . 153 APPENDIX 11.2 Advocacy Strategies for Supporting Participation of the Person APPENDIX 4.2 Examples of Auditory with Aphasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318 Retention and Comprehension Tasks . . . . . . . . . . . 158 12 Environmental Approach to Adult Aphasia . . . . . . 319 Rosemary Lubinski APPENDIX 4.3 Various Tasks Used to Assess Auditory Comprehension of Syntax . . . . . . . . . . . . 160 13 Focusing on the Consequences of Aphasia: Helping Individuals Get What They Need . . . . . . 349 Linda J. Garcia Section II. PRINCIPLES OF LANGUAGE INTERVENTION 161 APPENDIX 13.1 Interview Guidelines for 5 Research Principles for the Clinician . . . . . . . . . . . 163 Connie A. Tompkins, April Gibbs Scott, and Victoria L. Scharp Looking at Functioning . . . . . . . . . . . . . . . . . . . . . . 374 6 Aphasia Treatment: Recovery, Prognosis, 14 Group Therapy for Aphasia: Theoretical and and Clinical Effectiveness . . . . . . . . . . . . . . . . . . . . 186 Practical Considerations . . . . . . . . . . . . . . . . . . . . . 376 Kevin P. Kearns and Roberta J. Elman Leora R. Cherney and Randall R. Robey Section IV. TRADITIONAL APPROACHES TO LANGUAGE 7 Delivering Language Intervention Services to INTERVENTION 401 Adults with Neurogenic Communication Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 A. STIMULATION APPROACHES Brooke Hallowell and Roberta Chapey 15 Schuell’s Stimulation Approach to Rehabilitation . . . 403 8 Teams and Partnerships in Aphasia Intervention . . 229 Carl A. Coelho, Michele P. Sinotte, and Joseph R. Duffy Lee Ann C. Golper 16 Thematic Language-Stimulation Therapy . . . . . . . 450 9 Issues in Assessment and Treatment for Shirley Morganstein and Marilyn Certner-Smith Bilingual and Culturally Diverse Patients . . . . . . . . 245 Patricia M. Roberts APPENDIX 16.1 Thematic Language Stimulation (TLS) Unit on Books with APPENDIX 9.1 Addresses for Ordering Tests . . . 275 Instructions for Creating TLS Units . . . . . . . . . . . 461 xv GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page xvi APTARA(GRG QUARK) xvi Contents 17 Cognitive Stimulation: Stimulation of Recognition/ APPENDIX 25.2 Rank Order of Phoneme Comprehension, Memory, and Convergent, Occurrences in Word Corpus and the Common Divergent, and Evaluative Thinking . . . . . . . . . . . . 469 Associated Graphemic Representations . . . . . . . . . 687 Roberta Chapey APPENDIX 25.3 Glossary . . . . . . . . . . . . . . . . . . . 688 18 Early Management of Wernicke’s Aphasia: A Context-Based Approach . . . . . . . . . . . . . . . . . . . 507 Robert C. Marshall C. COGNITIVE NEUROLINGUISTIC APPROACHES TO THE TREATMENT OF LANGUAGE DISORDERS 19 Rehabilitation of Subcortical Aphasia . . . . . . . . . . . 530 Stephen E. Nadeau and Leslie J. Gonzalez Rothi 26 Language Rehabilitation from a Neural Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 689 Stephen E. Nadeau, Leslie J. Gonzalez Rothi, and 20 Primary Progressive Aphasia and Apraxia of Jay Rosenbek Speech . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543 Joseph R. Duffy and Malcolm R. McNeil 27 Treatment of Syntactic and Morphologic APPENDIX 20.1 Information Resources . . . . . . . 564 Deficits in Agrammatic Aphasia: Treatment of Underlying Forms . . . . . . . . . . . . . . . . . . . . . . . . 735 Cynthia K. Thompson 21 Global Aphasia: Indentification and Management . . 565 Richard K. Peach APPENDIX 27.1 Treatment Protocols . . . . . . . . . 754 B. COGNITIVE NEUROPSYCHOLOGICAL APPROACHES TO 28 Language-Oriented Treatment: A Psycholinguistic TREATMENT OF LANGUAGE DISORDERS Approach to Aphasia . . . . . . . . . . . . . . . . . . . . . . . . 756 Donna L. Bandur and Cynthia M. Shewan 22 Cognitive Neuropsychological Approaches to Treatment of Language Disorders: APPENDIX 28.1 Language-Oriented Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595 Treatment Goals Form . . . . . . . . . . . . . . . . . . . . . . 798 Argye E. Hillis and Melissa Newhart APPENDIX 28.2 Language-Oriented APPENDIX 22.1 Selected Interdisciplinary Treatment Data Record Form . . . . . . . . . . . . . . . . . 799 Centers for Aphasia Research and Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 605 29 Treatment of Aphasia Subsequent to the Porch Index of Communicative Ability (PICA) . . . . . . . . . 800 APPENDIX 22.2 Glossary . . . . . . . . . . . . . . . . . . . 606 Bruce E. Porch 23 Impairments of Word Comprehension and D. SPECIALIZED INTERVENTIONS FOR PATIENTS Production . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 607 WITH APHASIA Anastasia M. Raymer and Leslie J. Gonzalez Rothi 30 Communication-Based Interventions: Augmented APPENDIX 23.1 Stimuli from the Florida and Alternative Communication for People Semantics Battery . . . . . . . . . . . . . . . . . . . . . . . . . . 630 with Aphasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 814 Karen Hux, Kristy Weissling, and Sarah Wallace APPENDIX 23.2 Glossary . . . . . . . . . . . . . . . . . . . 631 31 Melodic Intonation Therapy . . . . . . . . . . . . . . . . . . 837 24 Comprehension and Production of Robert W. Sparks Sentences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 632 Charlotte C. Mitchum and Rita Sloan Berndt 32 Computer Applications in Aphasia Treatment . . . . 852 Richard C. Katz 25 Comprehension and Production of Written APPENDIX 32.1 Clinical Examples . . . . . . . . . . . 874 Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .654 Pelagie M. Beeson and Maya L. Henry APPENDIX 32.2 Sources for Software and Other Relevant Technology . . . . . . . . . . . . . . . . . . 875 APPENDIX 25.1 Johns Hopkins University Dyslexia and Dysgraphia Batteries . . . . . . . . . . . . . 678 APPENDIX 32.3 Web Sites of Interest . . . . . . . . . 876 GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page xvii APTARA(GRG QUARK) Contents xvii Section V. THERAPY FOR ASSOCIATED NEUROPATHOLOGIES 36 The Nature and Management of Neuromotor OF SPEECH- AND LANGUAGE-RELATED FUNCTIONS 877 Speech Disorders Accompanying Aphasia . . . . . . 1009 Julie Wambaugh and Linda Shuster 33 Communication Disorders Associated with Traumatic Brain Injury . . . . . . . . . . . . . . . . . . . . . . 879 APPENDIX 36.1 Consonant-Production Mark Ylvisaker, Shirley F. Szekeres, and Timothy Feeney Probe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1035 APPENDIX 33.1 Aspects of Cognition . . . . . . . . . 955 APPENDIX 36.2 Example of Lists of Balanced Multisyllabic Words . . . . . . . . . . . . . . . . . . . . . . . . 1036 APPENDIX 33.2 Conventional Versus Functional Approaches to Intervention after Brain Injury: APPENDIX 36.3 Examples of Sentence- Communication, Behavior, and Cognition . . . . . . . 956 Completion Items . . . . . . . . . . . . . . . . . . . . . . . . . 1037 APPENDIX 33.3 Examples of Compensatory Strategies for Individuals with Cognitive APPENDIX 36.4 Metronome and Impairments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 958 Hand-tapping Treatment . . . . . . . . . . . . . . . . . . . . 1039 APPENDIX 33.4 Rationale for Collaborative APPENDIX 36.5 Eight-Step Continuum . . . . . . 1040 Relationships with Everyday People . . . . . . . . . . . . 960 APPENDIX 36.6 Original Sound-Production APPENDIX 33.5 Communication-Partner Treatment Hierarchy . . . . . . . . . . . . . . . . . . . . . . . 1040 Competencies for Supporting and Improving Cognition in Individuals with Cognitive APPENDIX 36.7 Modified Sound-Production Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 961 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1041 34 Communication Disorders Associated with APPENDIX 36.8 Modified Response Elaboration Right-Hemisphere Damage . . . . . . . . . . . . . . . . . . 963 Penelope S. Myers and Margaret Lehman Blake Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1042 35 Management of Neurogenic Communication Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1043 Disorders Associated with Dementia . . . . . . . . . . . 988 Tammy Hopper and Kathryn A. Bayles Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1073 GRBQ344-3513G-FM[i-xviii]qxd 02-13-2008 07:47 AM Page xviii APTARA(GRG QUARK) GRBQ344-3513G-C01[01-19]qxd 1/21/08 11:11 AM Page 1 Aptara Inc. Section I Basic Considerations GRBQ344-3513G-C01[01-19]qxd 1/21/08 11:11 AM Page 2 Aptara Inc. However. ways to refer to people with apha. Foremost is the caused by stroke. frameworks for conceptualizing aphasia. consider appropriate modalities: speaking. etiology and epi. 1993). Therefore. and address future language. developed some language ability. The specific struc- and practitioners together in adult neurogenic communica. The study of aphasia is complex because of the variable man. many experience problems of reduced efficiency tance of appreciating the life-changing effects of aphasia. students and professionals interested in exploring the world of neurogenic communication disorders OBJECTIVES often need to be able to articulate a clear and concise defin- ition of aphasia. not necessarily a complete lack of ability in any given area of language APHASIA BRIEFLY DEFINED processing. an individual is not born with tion strategies. In this chapter we consider a loss of language function in a person who had previously brief definition of aphasia. growth of brain tumors. developmental disorder. Aphasia is most often and to make it available in useful form. and writing. The term “childhood aphasia” refers to an acquired ifestations of aphasia. reduced access to lin- rationale for intervention. characterized by an impairment of language comprehensive definition of aphasia. it is not. by definition. the heterogeneity of its underlying language problem in children. while stimulating further study concerning the effec. 1982. What is critical to an adequate definition is the mention sent a rationale for language intervention for adults with of four primary facts: it is neurogenic. Still. Aphasia is acquired. Aphasia is not characterized as a Before proceeding with the discussion of specific interven. (e. it affects neurogenic communication disorders. 3 . and the sophistication required to understand the mechanisms behind its associated sympto- Roberta Chapey matology. and reduced retention of new linguistic information. Aphasia is neurogenic.GRBQ344-3513G-C01[01-19]qxd 1/21/08 11:11 AM Page 3 Aptara Inc. surgical removal of brain tissue. Goodglass. but may also arise from head trauma. guistic information still stored in the brain. as do the means by tion disorders to present an accurate and coherent picture of which the damage may occur. 1992. review intellectual deficit. listening. 2. explore conceptual is not the result of a sensory or motor deficit.. Chapter 1 Introduction to Language Intervention Strategies in Adult Aphasia Brooke Hallowell and neurologicsubstrates. it is characterized by the partial or complete relevant to clinical aphasiology. the impor.g. Rather. desire to coalesce significant thoughts on language interven. 1. Aphasia always results from The present text grew out of a desire to bring researchers some form of damage to the brain. tiveness of the approaches presented. pre. it is acquired. deficits. tures affected vary among cases. Such a definition might be “aphasia” is an acquired communication disorder caused by brain The objectives of this chapter are to present a concise and damage. the interdisciplinary nature of aphasia. or a psychiatric disorder key etiologic and epidemiological factors related to aphasia. and future trends in aphasiology. Darley. abilities. there are many ways of conceptualiz- ing it. a of formulation and/or production. It is important to note sia. it ways to refer to individuals with aphasia. highlight the interdisciplinary nature of aphasiology. Brookshire. confusion. the underlying cause current practice in language assessment and intervention of aphasia is always neurologic. or infections. we will consider several general issues that are it. and it excludes general sensory and mental trends in aphasiology. reading. that most people with aphasia retain many linguistic demiology. tion. a general frameworks for study and clinical practice in aphasia. such labeling may convey a lack ideas and relationships. as discussed later in this propositional deficits.” there are 4. and often described as symbolic processing disorders. an individual may be able to name the and other chapters.” or produce highly learned responses such as “Hi. is _____. motor. Aphasia is also not due to motor one’s ability to make propositions. Further. Jackson. is not a noun but an adjective. Aphasia involves language problems. that children who have suf. The more propo- deemphasizing the reference to individuals according to sitional language required in a particular communication medically based diagnostic categories. Most cases involve at least some impairment in CONCEPTUAL FRAMEWORKS OF APHASIA all language modalities. words in a variety of sentence forms. volitional. highly Before progressing with further study of aphasia and its learned responses (Goodglass & Wingfield. aphasia is an impairment in psychiatric disturbance. its definition excludes such deficits. 2007). it is important to note that the term “aphasic” 1915. and receptive and expressive use of sign lan- guage. cognitive. and sensitivity toward. the more difficulty the patient has communicating. Patients may know words. which he characterizes as inferior. a person with aphasia is seen as we use to describe disabilities. In a proposition.GRBQ344-3513G-C01[01-19]qxd 1/21/08 11:11 AM Page 4 Aptara Inc. the term “aphasic” may be used to fered neurologic incidents such as gunshot wounds. 2007). writing. The WHO classification emphasizes days of the week. may develop diverse authors. In referring to the “proposi- inition of aphasia are especially critical in the differen. 2001). individuals who have habitually use them incorrectly. smell. focusing instead on context. management. aphasia is not a result of Propositional Language Framework general intellectual deterioration. 4 Section I ■ Basic Considerations applicable to children who never had language abilities their holistic functional concerns and what might be done to to lose. the use of linguistic symbols for the communication of highly specific and appropriate ideas and relationships. an individual ronment (WHO. Aphasia is not a problem of sensation. just as are most of the words Within this framework. complete sentences such as “The grass that disablement is not considered an attribute of an individ. and perceptual disorders. or even stroke. In defining aphasia it is important to sons with aphasia and related disorders are summarized in recognize that any or all modalities of symbolic commu. Aphasia is abilities. 1878). Guidelines for writing and talking about per- linguistic symbols. or to convey the intent of impairment. motor func. a number of in-depth definitions or frameworks for studying tion. ual. or oping a solid theoretical framework of one’s own. By definition. Table 1–1. an utterance (Jackson. According to proponents of the framework. or According to Hughling Jackson. The exclusionary characteristics of the def. occasionally. even with severe refer to persons with disabilities. though. Jackson emphasizes the intellec- tial diagnosis of a wide array of neurogenic language. . Although it is simple to define the term “aphasia. (Childhood aphasia is not discussed in this text.) address them (Hallowell. refer to an “individual with aphasia” in the writings of surgical removal of tumors. and label people primarily through their impairments or dis- 3. hearing. reading. Health-care professionals and with aphasia has an impairment in the use of spontaneous researchers throughout the world are following suit by language to communicate specific meaning. but rather the complex interactions of conditions How are you?” involving a person in the context of his or her social envi. the World Health Organization (WHO) has when propositional language is impaired. Although aphasia may be accompanied by any num- ber of other deficits in perceptual acuity. taste. tual. nication may be affected: speaking. aphasia does not among ways of conceptualizing aphasia is essential to devel- involve a problem of sight. but may of respect for. Aphasia excludes general sensory the nature of aphasia. For example. and rational aspects of language that involve speech. It should be noted. mental slowing. Readers are encouraged to join this movement. there is a widespread movement among a true form of “aphasia” if those incidents cause them health care professionals to heighten sensitivity to individu- to lose communication abilities they had gained earlier als served by choosing terminology that does not objectify in life. or intellect. An understanding of basic differences and mental deficits. Jackson noted that even Indeed. automatic. While one might defend the having difficulty communicating specific meaning and inte- stylistic use of the adjectival form as a label for a person who grating words into particular contexts to express specific has aphasia (“an aphasic”). Jackson contrasts propositional aspects of language with subpropositional PEOPLE WITH APHASIA aspects. listening. touch. a mul. both the words and the manner in which they A NOTE ON REFERRING TO are related to one another are important. many patients launched worldwide efforts to modify the ways in which we retain automatic language. Head. 1878). tional” aspects of language. and often fail at embedding aphasia (Brookshire. While. to help sensitize others to the importance of using person- timodal problem of formulation and interpretation of first language. 1997. For example. These include such words and phrases as affliction.” or to call persons with disabilities “the disabled”. polite and constructive corrections of others using inaccurate language helps encourage more positive communication as well as more enabling positive societal attitudes. deformed. contexts. yet should primarily be used only as adjectives. Avoid using condition labels as nouns. . readers prefer. and/or psychological challenges or “disabilities”.” rather than “she is confined to a wheelchair. . cognitive. and it is essential to stay current regarding changes in accepted terminology as well as to be sensitive to preferences for referents within a given communicative context. “the client had a stroke” rather than “the client is a stroke victim. Words that evoke derogatory connotations should be avoided in every context. Use person-first language. such labeling still conveys a disability-focused identity. R. Encourage others in appropriate language use. invalid. It is vital to help others learn to implement guidelines such as these directly through course work and other educational experiences. Consider use of the term “individual” or Consistent with the aim of focusing on individuals and their broad life “person” rather than “patient”. in press). ” instead of. “the client suffered an amputation of the leg”. For example. say.GRBQ344-3513G-C01[01-19]qxd 1/21/08 11:11 AM Page 5 Aptara Inc. Chapter 1 ■ Introduction to Language Intervention Strategies in Adult Aphasia 5 TABLE 1–1 Guidelines for Writing and Talking about Persons with Aphasia and Related Disorders Recognize the importance of currency and context There are always variances in the terms that particular consumers or in referring to individuals with disabilities. or even better. (Adapted from Hallowell. . rather than on people being treated in a medical context. Likewise.” Say “her leg was amputated . Although the very term “disability” may be considered offensive to some (with its inherent focus on a lack of ability). In some contexts. students. use of the term “patient” may help to provide clarity of referents and to simplify explanations. dumb. for example. crazy. Avoid language of victimization. when people with and without language disorders are being discussed. Louis: Mosby – Year Book. In some contexts. Person-first language helps emphasize the importance of the individuals mentioned rather than their disabilities. defective. It is more appropriate. it is not appropriate to call an individual with paraplegia “a paraplegic. 1 Brookshire. retard. Avoid words with negative connotations. clinicians and researchers take an important step in helping others to improve in this area. By modeling appropriate language in writing about persons with disabilities. and withered. insane. Do not use language suggesting that clients are “victims” or people who “suffer” from various forms of disability. use of the word “person” or “individual” is generally preferable to use of the term “patient”. mute. St. including those with language disorders. it is currently generally preferred over the term “handicap” in reference to persons with physical. lame. maimed. An introduction to neurogenic communications disorders. such as in academic texts and articles.H. Although the term “an aphasic individual” would be preferred to the use of “an aphasic”. (2007). Consider reference to “disabilities”. to refer to a “person with anomia” or an “individual with dementia. the term “client” or “consumer” may be preferred to “patient” when referring to a person who is receiving professional services. it is not appropriate to call an individual with aphasia “an aphasic”.1 Likewise. widening the arena for empowering persons with disabilities.” Say. Many words conveying information about specific disabilities exist in both noun and adjectival forms.” than to an “anomic person” or a “demented individual”. “She uses a wheelchair. modified into nouns corresponding to conditions. crippled. language. patients are encouraged to elaborate words. An abstract becomes even more impaired. “abstract attitude” implies an ability to react to things in a Individuals who cannot retrieve the most appropriate lex- conceptual manner. if a patient is trying to say “circle” and instead utters “square. sounds. as well as the semantic and syntactic components of a situation.. aphasia is sion is the result of an impairment of thought processes that not modality-specific. color. When the continued efforts relate to the approxi- of individual objects. The expressive and recep- actualities. the individual in the concrete attitude the first stage of therapy is thought-centered or content- passively responds to reality and is bound to the immediate centered discussion in which patients are stimulated to experience of objects and situations. on various topics. process and the actual utterance.” the con- cept of circle may be modified to be consistent with the Concrete-Abstract Framework utterance. 1964). 1948). and series of words (Goldstein & Scheerer. 1976). For Wepman (1972b. If one cannot abstract. emotional utterances. These authors guage that is increasingly more abstract. proposed by Schuell and her colleagues (Schuell. mated rather than the intended word. receptive-expressive. a drive to establish consonance between the thought tional language. ties: speaking. and for the municate a number and variety of specific propositional formulation of concepts as opposed to sensory impressions ideas. include object-sorting tasks involving form. to keep in mind simultaneously various aspects of tive. noted that the behaviors impaired in aphasia involve inte- grations that cannot be attributed merely to organization of motor responses or to events in outgoing pathways. attitude gives the individual the power to inhibit actions or Within a framework in which aphasia is seen primarily as reactions and to use past experiences. and com. and the patient may begin to think of a circle as a Goldstein and Scheerer (1948) observed that having an square. In contrast. 207). Aphasiologists who subscribe to this tests of ability to assume the abstract attitude. He access or retrieve words and rules of an acquired language noted that patients with aphasia frequently substitute words for communication (Schuell et al. eral language impairment in which there is an effect on all Goldstein and Scheerer (1948) developed a number of aspects of language. fluent-nonfluent. regards aphasia as a gen- The intervention implications of this framework would be eral language impairment that crosses all language modali- to stimulate the patient to comprehend and produce lan. attend to their thoughts and remain on topic. This view sug- sically together. one cannot Unidimensional Framework symbolize or embed symbols in appropriate contexts. Thought Process Framework they involve use of an ability that is dependent on higher- Wepman (1972a) suggested that aphasia may be a thought level integrations. An individual who is impaired in abstract attitude. assessment involves determin- help the individual organize perceptual rules and therefore ing whether individuals can follow a train of thought in their to create and continue interactions with other people. sensory-motor. second stage of therapy. rather. to inhibit reactions. gests that damage to the language mechanism results in gen- late parts of a whole. aphasia has lost functional spontaneous language. According to proponents of this framework. When observing sorting test input-output dichotomies in aphasia. For example. ability to use connected language units to communicate nicative effort appears to relate to the approximated rather according to the established conventions of the language. to react to two stimuli that do not belong intrin. communication or spontaneous language. This attitude is necessary to isolate ical symbol for a context are impaired in their ability to com- properties that are common to several objects. it involves the inability to “serve as the catalyst for verbal expression” (p. Rather. These experiences a disorder of thought process. The person with that are associated with words they are attempting to pro. and to ideationally iso. Intervention may lead to interference with thought processes. & Jimenez-Pabon. These tests framework do not promote the use of Broca’s-Wernicke’s. one may ask: Is the sort concrete (perceptual) or One of the most popular and in-depth unidimensional abstract (conceptual)? Can the individual verbally account theories.GRBQ344-3513G-C01[01-19]qxd 1/21/08 11:11 AM Page 6 Aptara Inc. impairment in abstract attitude is reflected in propositional language. reading. and whether they Language that reflects an abstract attitude is propositional can expand on topics and ideas. results. as there is focuses on stimulation of the patient’s ability to use proposi. 1964). It is also used to comprehend relation. process disorder in which impairment of semantic expres. . In general. language are considered to be inseparable. listening. or the duce. During the sists of speech automations. for the type of sort presented by the examiner (abstract)? Jenkins. spontaneous language ships between objects and events in the world. or bined color and form sorting. then. 6 Section I ■ Basic Considerations Assessment involves an analysis of the patient’s ability to use than the intended word. is A unidimensional view of aphasia relates language behaviors unable to consider things that are possibilities rather than to a single common denominator. Concrete language con. An inaccurate verbal formulation spontaneous speech to express specific ideas. and writing. and that the remainder of the individual’s commu. The function of cerebral pathways is considered unit of time than normal speakers do.” “nonfluent. abundant nonmeaningful filler phrases. That is. that the terms fluent and non- anisms are thought to mediate early stages in cognition fluent are not highly descriptive terms in and of themselves. 1979) proposes a conceptual framework in For the sake of simplicity and presentation of basic terminol- which language processing is conceived as an event that ogy. thorough discussion of the classification of aphasia according spond to lesions of brain structures that have emerged at to neuroanatomic substrates is presented in the next chapter. and transcortical sensory aphasia. while the more recently is important to specify what is meant by the use of these terms evolved left lateralized neocortex (encompassing Broca’s when describing the language of any individual patient. Kaplan. persons with aphasia are considered fluent if they zones are considered to be fundamentally united. Thus. individual may appear to be nonfluent for any of a variety of tion and linguistic processing. Phylogenetically older limbic mech. patients who to be the coordination of different regions of the brain are completely nonverbal are nonfluent. A lesion in one of the language areas of the brain gives rise to the relative prominence of an Fluent Aphasias earlier stage of language processing. Kertesz & Poole. would be mediated by the lesioned area. the Minnesota Test for Differential Diagnosis patient in one category or another. used throughout the history of the study of aphasia. mal language. though. as Broca’s versus Wernicke’s. accord- maximal responses (see Chapter 17). Lang. It and linguistic representation. An and Wernicke’s areas) mediates the final stages in cogni. (see Chapters 4 and 17). reasons. 1982.GRBQ344-3513G-C01[01-19]qxd 1/21/08 11:11 AM Page 7 Aptara Inc. Usually. the Western Aphasia reorganization of language. 1988). duction can be explained by an array of cortical speech centers and connecting pathways that convey memories Classification of Multidimensional Types of Aphasia and images from one processing center to another. 1974). Nonfluent patients tend to have a reduced the brain. Damasio (1998) pre- rather than the mere conveyance of information between sents an excellent synopsis of the various categorical terms regions. one may consider the basic subtypes of aphasia across dif- emerges over different levels of the brain corresponding to ferent multidimensional classification schemes to fall into the different levels of evolutionary development. fluent versus nonfluent. and intensive auditory activa- sia. varying stages of evolution. is oriented toward specific deficits. such dichotomies are associated sional and multimodal. the clinician attempts to rehabilitate a specific lan- Microgenetic View guage modality (such as speaking) or behavior (such as con- frontation naming or phonemic production) that is found to Several authors challenge the notion that language pro- be impaired (c. Wernicke’s Aphasia. 2001). in nor. each corresponding to a dif- The assessment implications of the unidimensional frame- ferent underlying site of lesion and having a characteristic list work involve an analysis of the patient’s ability to compre- of hallmark features. and fluently articulated but paraphasic speech (Goodglass . or according to any of a large array of measures. aphasia. Wernicke’s aphasia. assessment involves determining what contexts ranging from single words to spontaneous discourse. Chapter 1 ■ Introduction to Language Intervention Strategies in Adult Aphasia 7 Schuell’s concept of the cause of this general language Multidimensional Frameworks breakdown reflects a broad and dynamic view of the lan- Proponents of a multidimensional framework conceptualize guage process. the symptoms of There are three basic types of fluent aphasia: conduction aphasia serve to magnify the processing events that. For individuals who hold a multidimen- hend and produce language within all four modalities.. not across categories of “fluent. Of course. The Boston Diagnostic Aphasia Examination (BDAE) tion of the impaired symbol system to maximize patient (Goodglass. The specific cortical areas. mal pauses. the anterior and posterior language Generally. aphasia are impaired auditory and reading comprehension netic sequence. Intervention. 1973) is based on this model sia dichotomously. ing to this framework. aphasia as having multiple forms. are able to speak in spontaneous conversation without abnor- uage is considered to be processed simultaneously by com. symptomatology is present and subsequently classifying a Schuell’s test. & Baressi. for example. A more According to this view.f. Adherents to this framework envision treatment as facilitat. semantic versus syntactic. and the controls specific dimensions of stimuli to make complex Language Modalities Test for Aphasia (Wepman & Jones. mon limbic structures.” and “other” aphasias. reader should be aware. Cubelli. Some conceptualize apha- of Aphasia (MTDDA) (Schuell. Brown (1972. varying forms of aphasia corre. and in sional view of aphasia. Foresti. controlled. Having evolved from com. & Consolini. Treatment focus is on stimulation: with the cerebral localization of the lesions that result in apha- the use of strong. thus aiding the patient in making 1961) reflect such classification systems. events happen in the brain. or long plementary systems in the anterior and posterior part of periods of silence. or anterior The intervention applications are similarly unidimen- versus posterior. 1977. The critical features of Wernicke’s ing the transition from one stage to the next in the microge. rather than sequentially from one component to rate of speech and to express less communicative content per the next. The clinician manipulates and Battery (Kertesz. Broca’s aphasia represents a clas- lack of awareness of their deficits. tion aphasia is fluent.GRBQ344-3513G-C01[01-19]qxd 1/21/08 11:11 AM Page 8 Aptara Inc. persever- tend to be located in the temporal lobe. Quadfasel. Grammar is Auditory comprehension is generally poor. In patients with disability of patients with Wernicke’s aphasia because of TMA. naming is impaired. Primary progressive apha- et al. and the patient may offer an irrelevant response or echo the words of the examiner (Goodglass Primary Progressive Aphasia. 2001).. A key feature that differentiates sia. Goodglass & phasias and neologisms (Goodglass et al... The speech of persons with conduc. Confrontation generally intact. Some authors and clinicians use who produce frequent neologistic expressions are often the term “expressive aphasia” to refer to the disability of unintelligible and are sometimes referred to as having “jar. although generally less abundant than Global Aphasia. 1961). 1998. or dysnomia. lems (Damasio. Many patients with this form of aphasia eventually . agrammatism. pauses associated with word. and they may fail to (Wepman & Jones. p. characterized by tion. p. Such patients exhibit Likewise. Wernicke’s aphasia (Damasio. but auditory Conduction Aphasia. It is differentiated from the symptom of paraphasias occur more frequently than phonemic para. Broca’s aphasia is the most classic form of be any of a number of degenerative diseases affecting the nonfluent aphasia. 1998. and difficulty imitating and organizing responses represents a classic form of “posterior” aphasia. The term “progressive” refers to the fact that the condition transcortical motor. 2001). patients with other types of aphasia. 35). Wernicke’s aphasia ation. Anomic aphasia is a form of aphasia Transcortical Sensory Aphasia (TSA)... comprehension is impaired.. repeat anything at all if function words rather than nouns are requested” (Damasio. and are more prone to depres- severe in relation to their fluent spontaneous speech sion and sometimes catastrophic reactions than are patients (Goodglass et al. Most lexicon. 1997). anomia. patients with Broca’s aphasia because of their primary deficit gon aphasia” (Wepman & Jones. with communication skills worsening over time. 2001). Wernicke’s aphasia also have difficulty reading. 2001). because lesions that lead to this form of aphasia phonemic and global paraphasias. There are three basic types of nonfluent aphasia: Broca’s. 2001). A hallmark feature is impaired repetition of words expression. 2001). Neologisms are frequent. 35). Persons with Broca’s aphasia are usually aware of Wernicke’s aphasia experience naming difficulty that is their communicative deficits. repetition is intact relative to “otherwise limited their primary deficit in the area of linguistic comprehension. Confrontation naming is usually preserved. It is often considered the “opposite” of brain. 1964). in conversation (Damasio.finding deficits. especially compared to sic form of “anterior” aphasia. sia is a type of aphasia that has an insidious rather than an acute onset. Patients with global aphasia which is often normal or near normal. Global aphasia is a disorder of language the speech of those with Wernicke’s aphasia (Damasio. Wernicke’s and Broca’s aphasia. Likewise.. In many cases. and relatively excessive verbal production. which is typical in most forms of apha- phasias (Damasio. The underlying etiology for progressive aphasia may Broca’s Aphasia. Speech is generally fluent except for the hesitancies and TSA from conduction aphasia is intact repetition ability. Anomic Aphasia. characterized by impaired linguistic comprehension and 1998). Goodglass et al. and global aphasia. Goodglass. well-articulated speech with frequent para. writing is at least as severely impaired (Goodglass. patients with Wernicke’s aphasia pre. but often modality and little or no ability to communicate effectively they will omit or substitute words. 1998. 2001) in which syntactic structure is relatively pre. They have little or no understanding in any patients “repeat words with phonemic paraphasias. 1998. writing. syntactic errors. or press of speech. characteristics of Broca’s aphasia include awkward articula- sent with logorrhea. Some authors and many clinicians use the term “receptive aphasia” to refer to the Transcortical Motor Aphasia (TMA). It is often considered a combination of both and sentences relative to fluency in spontaneous speech. The essential served. Patients with in the area of language formulation and production. 1998). The term “primary” refers to the fact that deficits in language are the primary symptoms noted. They often demonstrate a located in the frontal lobe. speech” (Goodglass et al. 1964). Auditory comprehen- tend to produce few utterances and have a highly restricted sion is also relatively spared (Goodglass et al.. Paraphasias are most often in intact auditory and reading comprehension (Goodglass the form of sound transpositions and word substitutions et al. Patients with as speech. & Timberlake. 1961). restricted vocabulary. Global Wingfield. Typically. and because lesions that lead to this form of aphasia tend to be repeating words (Damasio. 1998). is degenerative. Individuals with characterized primarily by significant word retrieval prob- TSA have fluent. Literal paraphasias Other Forms of Aphasia repeatedly interfere with speech. with Nonfluent Aphasias cognitive skills remaining intact relative to linguistic skills. 8 Section I ■ Basic Considerations et al. 1993. Those with other forms of aphasia. Alexia. and conver- gent. Language refers as Wernicke’s aphasia or TSA. lesion often present further challenges to the classification Intervention focuses on the stimulation of these abilities. classification at one point in time may demonstrate a differ- The specific components that are used depend upon the ent form of aphasia as his or her condition evolves. Exceptions to Multidimensional Aphasia Subtypes namely. semantic [content. reliability of diagnostic reporting. though.f. but of aphasia subtypes. the four types with forms of aphasia that do not fit neatly into any one cat- of content (figural. Chapter 1 ■ Introduction to Language Intervention Strategies in Adult Aphasia 9 present with significant cognitive deficits as part of a Psycholinguistic/Problem Solving/Information syndrome of dementia (Ceccaldi. Numerous systems for the multidimensional categorization In a psycholinguistic framework. form. stored. degenerative conditions. symbolic. and Geschwind (1965). Damasio. Cognition involves the acquisition of speech. a deficit in reading ability. Problem-solving and informa- that “attempting to review the classification systems of tion processing both involve the use of all five cognitive aphasia is probably foolhardy” (p. with right or bilateral cerebral dominance for language Within this model. task of classifying the subtypes of aphasia as a “necessary Aphasia may be seen as an impairment in problem solving evil” (p. 1989). systems. Further. and egory described according to a known multidimensional use]. reduced. and evalua- authors’ suggestions. divergent. & Processing Framework Lecours. Such an understanding helps ensure improved communication among clinicians and researchers. a deficit in writing ability. guage. dable detail by Damasio and Damasio (1983). and con- ologists attest to the fact that it is common to meet patients vergent. There of phonology. divergent and. ticular utterance or gesture serves at any one time and its nicative deficits. 32). who present with deficits in unication involves the use. Goodglass elaborated. tional multidimensional models of classification. Patients problem presented and/or the information being processed. and the five products classification scheme (c. 1967). and semantics. conditions within each individual and in the environment . such as auditory comprehension and contextual realization. Soubrouillard. 1998). aphasia may be defined of aphasia have been proposed. Even or associations [units. divergent. memory. 1996. and highlight the similarities and distinctions The WHO has launched a worldwide effort to redefine between one’s idealized concept of any subtype of aphasia functioning and disability in an effort to heighten awareness compared to the actual manifestations of aphasia in an indi. Caplan & Chertkow. Poncet. and behavioral [use/pragmatics]. such various subtypes of aphasia based on derivations of previous as memory and thinking (convergent. clarify theoretic differ- and Participation Framework ences in how experts differ in their ways of conceptualizing aphasia. 1978). Most clinical aphasi- operations (recognition/understanding. assessment of individuals with aphasia functions. reading. improve the validity and Body Structure and Function. recognition/understanding. Activity. Content involves meaning. and communication (Muma. and sign language. it is infre. Still.. 1978). and used (Neisser. Damasio (1998) refers to the not necessarily to the same degree in each. form. 32). such Lahey. Acknowledging the diversity in diag- tive thinking). Such forms of alexia may occur with or without knowledge of the world. especially in those forms integration of language content. as well as the occurs in most forms of aphasia. centers on an analysis of the cognitive. evaluative thinking). although tory of the study of aphasia. recovered. as explored in other chapters of this especially on the stimulation of the cognitive processes book. Cognition can be operationally defined as the mental opera- tions in the Guilford (1967) Structure-of-Intellect Model. The impairment may be manifested in listen- nostic criteria and nomenclature used throughout the his- ing. Most aphasiologists might agree with Damasio and information processing. Consequently. and evaluative thinking (see Chapter 17). and multiple or unknown sites of municative strengths and weaknesses of each individual. and com- traumatic brain injury. subcortical lesions. most textbooks as an acquired impairment in language content. of its holistic components and the complex interaction of vidual patient. Cognition refers to all of the mental ing alexia with and without agraphia are described in formi. Forms of aphasia involv. speaking. and use (Bloom & involving significant auditory comprehension deficits. memory. purpose. and the continued processing of agraphia. relations. Psycholinguistic approaches to language recognize its three integrated and interrelated components: cognition. lan- Alexia and Agraphia. and addressing aphasia offer creative means of categorizing the use and the cognitive processes that underlie language. to the structures of language or the rule-based systems quently considered a form of aphasia in and of itself. morphology. or function that a par- reading that are markedly more severe than other commu. and trans- an individual with a form of aphasia that fits a particular formations] of the Guilford (1967) model (see Chapter 17). classes. it is essential that those studying aphasia and underlying language comprehension and production (see working with people who have aphasia understand tradi- Chapter 17). linguistic. processes by which information is transformed. Comm- are some rare patients. syntax. writing. form. this knowledge. (1993).GRBQ344-3513G-C01[01-19]qxd 1/21/08 11:11 AM Page 9 Aptara Inc. or cerebrovascular accident (CVA). Blood carries participating in clubs and organizations. such tasks have increasingly been the focus of care. Environment is another Stroke is the third leading cause of death in the United key construct in the ICF.” to refer to the various contextual aspects This framework also helps clinicians and researchers of disabling conditions one might experience. It includes the assistive technology. ment and motor control of the body. they are in need of constant blood supply. Viewing aphasia in this framework percent of those who survive. It mary levels within the most recent WHO International encourages us to focus on seeing aphasia as a contextualized Classification of Functioning. Disabilities and Handicaps also on individual communication of wants and needs and (ICIDH) employed the general terms “impairment. sel or artery.” “activity. life (see Chapter 10). others. roughly 30 percent of for moving away from the classic biomedical model and take those who have a stroke die. causes. as tasks necessary for daily living. capabilities. listening. The two pri. and alone. Vitally related to a focus on life Activity limitations primarily involve the four language participation is the Life Participation Approach to Aphasia modalities: speaking. lent cause of aphasia. stroke is a seriously disabling helps us consider social exclusion and inclusion as funda. namely thrombotic. & Gilpin. and quality of For individuals with aphasia. approximately 700. to brain cells. environmental factors. and so forth. States and the most common cause of adult disability relationships with and support from others. Even brief peri- “participation” in a similar way to our use of the term hand. Division for Heart Disease and Stroke Prevention. Stroke The constructs of activities and participation capture Stroke. physical environmental factors. as well as prob- are not seen as solely responsible for the social consequences lems of speech and language. cog- nicate and engage in daily life activities. and “participation. writing a check. ticipation (WHO.GRBQ344-3513G-C01[01-19]qxd 1/21/08 11:11 AM Page 10 Aptara Inc. shopping for clothes. these constructs represent the devastating effects on brain tissue (see Chapters 2 and 3). During the past 20 years. assessment and treatment cation scheme proposed by the WHO. well-being.” “dis. Byng. ability to use language in context. Many survivors have lasting problems with move- mental to the context in which people with aphasia commu. 2006). such as conversing with the nurse or family member. 56). the social and environmental supports that might contribute ability. genetics. All individuals in the environment—and the Statistics regarding the incidence of aphasia and of the vari- environment itself—impact functioning and participation in ous subtypes of aphasia are variable. Therefore. 2001). We essential nutrients. but Classification of Impairments. going on vacation. Disability and Health (ICF) life-affecting condition requiring resources and compen- are (1) body structure and function and (2) activity and par. In the United States policies and regulations. For people with aphasia. An earlier classifi. A stroke occurs when blood flow to an ate and long-term real-life goals. The WHO classification schemes provide a framework According to Zivin and Choi (1991). ods of interruption in blood supply to the brain can have lasting icap. 2006). support services. especially glucose and oxygen. owing to subject . Chapters 2 and 3 con- interaction of important variables such as social support. (American Heart Association. For at least 40 consequences of disease.000 individuals experience a stroke the attitudes of individuals with aphasia and their significant each year (Centers for Disease Control and Prevention. and swallowing disorders. reading a paper or menu. reading. These ETIOLOGY AND EPIDEMIOLOGY modalities have been the traditional focus of assessment and OF STROKE AND APHASIA intervention in aphasia. is the most preva- the notion of engagement in daily life and realizing immedi. For example. and disability. This might include playing area of the brain is interrupted by the blockage of a blood ves- golf. risk tain a discussion of the most common forms of stroke lead- factors. Health. the International focus not just on the restoration of language functions. Assessment and treatment target all ICIDH-2. The framework highlights the dynamic There are several types of stroke. and so forth. uninvolved spouse may increase it. 2000) (see Chapter 10). helping those affected by it.” major areas in the classification scheme from day one. disease. of their aphasia. handicap. and writing as well (LPAA Project Group.” and “handicap. may discuss limitations of “activities” in a similar way to our Since brain cells do not have the capacity to store these nutri- use of the term disability. We may discuss limitations of ents. 1997). People with aphasia nitive problems.” while a more recent scheme. 10 Section I ■ Basic Considerations that affects each individual’s functioning. and hemor- and life habits of social participation in examining health. getting a job. making a phone call. life are considered essential to understanding aphasia and in tion refers to impairments of brain and brain functions. focus on the core features of health and well-being. consistent and depend- able support from friends and family will likely decrease the Incidence of Aphasia impact of impairment. satory and adaptive services for full life participation (Parr. a depressed. and “20 to 30 percent become into consideration the organic and the complex functional severely and permanently disabled” (p. embolic. employed the terms “impairment. perceptual deficits. the to full participation. or by the rupturing of an artery. ing to aphasia. body structure and func. rhagic strokes. handed individuals.. components of other chapters are devoted to multicultural 1995). 6:00 a. six years older than men when they experience a smoking. Kimura. Ethnic. fat and sodium (NIDCD. Although the risk of acquiring aphasia increases with first week of stroke have aphasia. Silveri. indicating a bet. Masullo. and also the the prevalence and incidence rates of stroke and aphasia. on cultural influences on such lifestyle factors as diet. heart disease. ods when the body’s supply and demand for oxygen is at its 2006). 1987). Rodríguez-Campello. For fact that researchers commonly exclude left-handed indi. Silvestrelli et al. Pedersen et al..f. 1997. when researchers account for age. 1995).. inactivity. Jorgensen. influence of age on the incidence of aphasia within stroke poor diet. and access to health care services (Kuller. and about one million people in the United States— on Mondays. Asplund. Heron. cation and accuracy of diagnostic methods (c. Marquardsen (1969) estimates Miceli. the southeastern region of the United States has viduals from aphasia studies. & Olsen (1995) report incidences as linked to aphasia. 2006. gender. Centers for Disease employing controlled sampling and subject description Control and Prevention.. Most of the racial differences in the incidence of higher among men up to the age of approximately 80 years.f. & Kung. 1987) patients with strokes affecting the left hemisphere have suggest that strokes are twice as likely to occur between aphasia when examined 15 to 30 days after a stroke. this reason that an entire chapter of this book and several ated with stroke incidence or severity (Pedersen et al. ter functional outcome in men (Roquer et al. stress. Feigin et al. Scarpa. as are lifestyle factors of smoking. socioeconomic status. 1995).. of aphasia. Other studies have confirmed this finding. 1998). the relationship of race and ethnicity to stroke and aphasia McGlone.compared to right. even and aphasia. reports of the the levels of risk factors such as high blood pressure. first stroke (Roquer. 1997). and smoking. 1980. & Salamon.m. 1994). Stroke mor- terol.. & DeRenzi. Murphy. Wyller. when there is an increase in oxygen requirements simultaneous with reduced levels of blood flow (Flack & Yunis. 2003). & Wester. The role of race. 2006. Sorgato. Feigin. 1997). Raaschou.000 Americans develop aphasia each that more than half (especially hemorrhagic strokes) occur year. (1987) estimate that about 55% of ducted by the National Institutes of Health (Willich. ethnicity. not on the physical properties of the patient populations have not been substantiated in studies areas involved (Casper et al. and dietary intake high in choles. high as 40% in patients evaluated within the first three days Data from the 42-year-long Framingham Study con- of stroke. Given the low incidence of left. Women are. & Gomis. 2005. and Racial. 1987. 1995. Persons of lower socioeconomic status also have higher risk 2003). Ali-Cherif. African American and Hispanic populations than in Although some studies have reported gender differences Caucasians (Gaines.. about one in 300 people—currently have aphasia (National attributing it to the fact that those times correspond to peri- Institute for Deafness and Other Communication Disorders. may be attributable to sampling methods and to the sophisti- counted such findings (Hier et al. and cul- Gender differences in risk factor profile and treatment ture have important implications not only for the incidence response appear to be weak.. Scarpa et al. that approximately one-third of patients who survive the 1981). it is important to note that age has not been causally Nakayama. Poncet. 1999). 2006. stroke and aphasia may be accounted for by differences in after which it becomes higher in women. Pedersen. origins on the incidence of stroke and aphasia. Discrepancies among reports on lesions (Kertesz & Sheppard. there is of stroke and aphasia (Centers for Disease Control and also some evidence. The prevalence of stroke is 1994. 1981. example. 2006). diabetes. Hoyert. It is for Handedness does not appear to be significantly associ. Caltagirone. Gillum. . been labeled by many as the “Stroke Belt” because of higher logic and epidemiologic associations between handedness stroke mortality rates than other geographic areas. Sacco et al. methods (Habib.GRBQ344-3513G-C01[01-19]qxd 1/21/08 11:11 AM Page 11 Aptara Inc. A majority of studies indicate that the case-fatality factors for stroke. While advancing age is consistently associated with Regional differences appear to be primarily influenced by stroke (Stegmayr. but also for its diagnosis and treatment. Scarpa et al. 1987). data are lacking as to the etio. 1994.. obesity. albeit relatively weak. average. excessive Many researchers report an influence of racial and ethnic consumption of alcohol. Gaines. 1980. Gainotti. Risk Factors for Stroke and Aphasia Diagnoses of hypertension. Prevention. Colombo. further influencing epidemiologic studies rate is higher in female than in male stroke patients. and Cultural Factors Influencing high cholesterol are factors that increase an individual’s Incidence of Stroke and Aphasia likelihood of experiencing stroke and aphasia.. & Villa. the heterogeneity of left-handed people Geographic location appears to play an important role in in terms of cerebral dominance for language. exercise. Chapter 1 ■ Introduction to Language Intervention Strategies in Adult Aphasia 11 sampling and description methods (c. and noon than at any other time of the day and Approximately 80. tality is generally reported to be substantially higher in 2006). age. issues pertinent to intervention in adult aphasia. in the incidence of aphasia and in the location of associated 2006. and race. 1995.. greatest level of imbalance—that is. other researchers have dis. Etiologies Other Than Stroke smoking cessation. 1997). and stress reduction (He & Whelton. Still. making such patients attractive research participants. Exercise regularly. including diabetes. Heart Disease and Prevention (2006) report that approxi- • If you smoke.g. Biggers. rience a traumatic brain injury. public administration of antihypertensive medications (Flack & health programs to support health and wellness and access Yunis. acknowledge that many other etiologies may be associated • Lower intake of salt or maintain low salt intake. This . as is the careful timing of the daily individual level is provided in Table 1–2. Shinton. carotid artery disease. 1999). aspirin or other blood-thinning therapy. leading a life of purpose.. because stroke patients tend to have well-defined. Labarthe. and heart failure. Much of the empirical literature on aphasia is based on the 1997. 2006. 2005. as well as in Many preventive health programs focus on the core fea- recovery through medical and rehabilitative treatment fol- tures of positive human health. or exposure to neurotoxic agents • Keep cholesterol intake low.. While the nature of aphasia is not always best studied • Know the warning signs of stroke. 2006). Maintain proper weight. in the United States (Central Brain Tumor Registry of the • Seek medical advice. Division for • Get a flu shot. Approximately 43. with non-stroke populations.GRBQ344-3513G-C01[01-19]qxd 1/21/08 11:11 AM Page 12 Aptara Inc. the majority of patients who have a clear and definite diagnosis of aphasia have had a stroke. 1997. traumatic brain injury. • Take in sufficient amounts of potassium. sickle cell and central nervous system tumors are diagnosed annually disease. increased physical activity. far exceeding the number • Seek medical treatment for disorders that increase risk of who have strokes. atrial fibrillation. localizable focal lesions. 2005).g. Metoki. namely. study of patients who acquired aphasia because of a cere- & Houston. may present with aphasia. tumors. and even- tempered attitude. Parkinson’s disease. others. First. 2006). 1997). seek medical attention as soon as symptoms occur. The • Develop and nurture a calm. A doctor may recommend United States. have aphasia regardless of the underlying cause. optimistic. brovascular accident. Second. dementia. and a sense of mastery and Recognizing the tremendous cost-saving advantages of pre- accomplishment (Kahneman. drugs known to raise blood pressure. and weight reduc- tion in overweight patients). Key lifestyle to prevent further illness such as additional strokes in indi- changes to reduce the risk of stroke and aphasia include viduals with aphasia (see section “Impairment. to health care are critical factors in prevention. Millions more are diagnosed each year andarterectomy.4 million adults per year in the United States expe- • Reduce exposure to second-hand smoke. quit. the etiologies associated with their manifestations of TABLE 1–2 aphasia can be documented in research reports and con- Summary of Strategies to Prevent Stroke trolled for in experimental paradigms. In light and laypersons to better reduce the likelihood of any indi- of the increased risk of stroke in the early morning hours vidual experiencing the life-altering consequences of stroke and on Mondays. venting stroke. life. Activities. For example. reduced cholesterol and sodium Participation in Life”) and disease in their significant others. degenerative conditions. increased dietary fiber. positive self-regard. with other neurologic disorders affecting language abilities medicines that help lower blood pressure. infections. there is a growing body of treatment research pertaining to such populations. The diffuse brain damage and fre- • Maintain a low-fat diet. & Schwarz. (Centers for Disease Control and Prevention. moderation of consumption of caffeine and alcohol. Khaw. with aphasia. or alternatives to (e. A summary of strategies to prevent stroke at the than these is advised. 1999). it is important to • If you are overweight. There are two good reasons for this. Gottlieb. quently ill-defined sites of lesion associated with such etiolo- • Engage in no more than moderate alcohol consumption. dietary modification (e. patients who have experienced • Eat fruits and vegetables daily. Diener. brain surgery. gies preclude a large volume of controlled research pertain- • Be physically active. Goff. mately 1. Of course. well-being and quality of lowing stroke (Centers for Disease Control and Prevention. lose weight. It is resistance training. 1996. Centers for Disease Control and Prevention. multiple sclerosis).800 new cases of brain stroke. relaxed. Engage in regular ing specifically to aphasia in these complex populations. nonetheless important to recognize and treat patients who • Drink several glasses of water daily. 12 Section I ■ Basic Considerations Prevention Numerous pharmacologic treatments reduce the risk of stroke by helping to control hypertension and blood lipids Data pertaining to risk factors enable researchers. clinicians. many health insurance companies have Active intervention programs focusing on these factors is launched programs to promote wellness and help reduce especially important for patients and their significant others consumers’ risk of stroke (Thomas. intake. vitamin therapy. scheduling of stressful tasks at times other and aphasia. quality connection to Division for Heart Disease and Stroke Prevention. through the effects of problems. . General Accounting Office. understanding of their underlying neuropathologies. Gerdau. Philip. 2005. nary research and clinical collaboration. This list is far from exhaustive. 1998. Thus. 1998). dys. psychology.. math- research has focused on positive changes and functioning in ematics. the stu- Corder. the sprouting of new connections may actually be healthy cal aphasiology. certification. Although an increase disorders and provide the most effective intervention include in incidence with age is reported for many diseases and other speech-language pathology. or by environmental insults injury and varied forms of dementia. physiatry. Mesulam other cognitive disorders. testinal. INTERDISCIPLINARY APPROACHES comitant disorders and medical conditions. Many. social work. The past three decades have brought an increasing interest Although clinical practice in intervention for patients with in age-related changes in adults. Additionally. Wu. It 1985) is being countered by many vigorous and independent is interesting to note that many of the disciplines just men- aging adults. & Gage. & Cline. the loss of neurons with aging. Lennon. occupational therapy. Koehl. Also essential is competence in interdiscipli. tive science. For example. biology. knowledge and clinical expertise in the areas of dementia and Schonitzer. 2004. Sherman. They may feel that they are who perform poorly on mental ability tests may have other prisoners in their own minds. the brain undergoes contin- uous adaptation as it ages.S. Zou. Toward this end. those aphasia change completely. and normal aging are essential to excellence in clini. including sedatives and/or nons- relevant to intervention with patients with traumatic brain teroidal anti-inflammatory drugs. pulmonary.. This also appears to ment of a host of neurogenic conditions and have a solid be true in humans (Abrous. 1990). Additionally. aphasia must also be committed to lifelong learning across The majority of those who are over 85 are continuing to disciplinary boundaries. vitamin neurologic impairments. sure in much of the world. 2002). 1999). anthropology. TO APHASIOLOGY The study of aphasia and related neurogenic communica- Aging and Communication tion disorders is inherently interdisciplinary (see Chapter 8). linguistics. confusional states. Some want to move and walk but . care for themselves (Elias. & ory. such as depression. perception. and a sign of maturity in the most positive sense. & Grubeck-Loebenstein. and endocrine systems (Abrams & Berko. numerous aphasia requires specific training. and/or licen- professionals have measured cognition. Disciplines that psychological systems in an attempt to identify key variables help understand the nature of neurogenic communication that may or may not change with age. motor-speech disorders. Saurwein-Teissl. rehabilitation. dom. amnesia. have allowed researchers to conclude that. dementia. which suggests that elderly animals are as capable The study of aphasia is vitally related to the study of other of growing new connections between brain cells as are acquired neurogenic communication disorders. audiology. drawing from basic science. In fact. Evidence of neurobiologic changes that may come with age can be derived from animal Other Acquired Neurogenic Disorders research. 2004). Stallard. gradual improvement has been seen in tioned are also hybrid ones. neuroscience. despite populations.GRBQ344-3513G-C01[01-19]qxd 1/21/08 11:11 AM Page 13 Aptara Inc. mobility. multiculturalism. sexless physical therapy. what has been learned about the treatment of aphasia in New neuroimaging and behavioral methods. gerontology. bolic. gastroin. hematologic. 2006. as well as stroke patients may be applied to the treatment of acquired evolving technology for the molecular study of the nervous neurogenic communication problems in other patient system. right-brain damage.” suggesting that the progressive death of neurons and phagia. the study of aphasia does not fall tion. communication. musculoskeletal. neurology. sensa. they may be their own bodies as well. some counseling. Studies suggesting relationships between age and health LIFE-CHANGING EFFECTS OF APHASIA or cognitive factors are often confounded by concomitant Within a matter of minutes. & Singer. sociology. that to be old is to be sick. Clinical younger animals (van Praag. 2005. Zhao. Academic Eriksson et al. meta. the elderly. music therapy. and practice in a variety of content areas. The “myth . 1998. health care administration. U. traumatic (1987) claims that age-related changes may underlie “wis- brain injury. Shubert. or alcoholism. Rajan. engineering. Chapter 1 ■ Introduction to Language Intervention Strategies in Adult Aphasia 13 book includes several chapters that address issues especially hindered by medications. National Academy on an Aging Society and dent or professional who is truly committed to the study of Merck Institute of Aging and Health. pharmacology. genitourinary. cogni- problems affecting the cardiovascular. communication. & Le Moal. 1992. physics. may feel that they are prisoners in deficiencies. and and senile” (Frady. Jin et al. aphasiologists are ideally trained in the diagnosis and treat. the lives of individuals who have problems faced by elderly individuals. and other neurologic and within the bounds of any single discipline. much of such as pollution and stress. given that individuals who experience any acquired neurogenic communication disorder are likely to also experience multiple additional con. the- the overall health of elderly people (Manton. . revealing our innate the relevance and importance of research findings to a spe- being and our psychic ties with the world. marginal social status. Coelho. definitions and Sciences (ANCDS) has developed evidence-based of maturity involve and revolve around the ability to use lan. Some closely identify with their active roles as communicators. Thus. in.f. which is defined applying research findings in a given intervention context. inspires many to intervention decisions (c. The effects may employed prior to acquiring aphasia may be unable to main.and outcomes-focused attribute. & Richardson. ity to use language. appreciate just how central communicative ability is to being Hayes.f. 1991. many have much to say but are significantly limited There is tremendous variability in how aphasia affects an in their ability to express themselves. consideration of the methodologic quality and validity of rium in which they can survive. their thoughts for themselves and others. randomized clinical studies. or from research involving a variety of methods. wants and needs.f. Persons who were individual’s sense of self and social ability. Language enables individuals to describe and clarify opinion. Sackett. The concept of using evi- dence to inform practice is not a new one. 1981. Robey & Schultz. domized controlled clinical trials (c. programs in which we engage as clinicians to ensure that we mals. insurance companies. According to Goodman (1971). Gray. and to be a mature self-reliant. be disproportionate to the degree of neurologic impairment. & Grimshaw. The onset of acquired aphasia. people with aphasia are lonely and desperate. Frattali & Worral.” More than any other continuous quality improvement. developing guidelines for additional areas. tain employment. employers and insurance companies. It involves a “fitting Hutchinson. and ran- Human experience and interaction are welded to lan. Eccles. information via recent advances in print. so life-changing in the skilled use of empirical support to make diagnostic and practically every dimension of daily living. However. the ability to share 2001. able serenity. the frequency of use of the Patients’ significant others are usually dramatically term in the neurogenic communication disorders literature affected by the onset of aphasia in a friend. guage. Post & Leith. cific patient.. areas within neurogenic communication disorders. Grol. leading not only to financial stress but also Even mild deficits may be traumatizing to persons who to feelings of isolation. practice guidelines founded on careful literature reviews guage effectively. and worthlessness. they are impaired in their human Examples of guidelines published to date include those on essence. Sohlberg. Rosenberg. Croteau & LeDorze. and the (1972) calls the “human essence. It refers to loved one. It is the most basic characteristic of the intellect and provide the best services we can. and analysis by teams of clinical researchers in specialty Insofar as persons with aphasia are impaired in their abil. Others with severe neurologic impairments and language ate the condition remarkably well. The “evidence” we use to the very means through which the mind matures and devel. Robey. 1998). The Academy of Neurologic Communication Disorders and conveying one’s seasoned intelligence.” carrying one’s share of personal and social responsibility. Ylvisaker. Sackett. and health ones. uals with disabilities are treated and regarded. the increased accessibility of data and other The need for socialization is the core of human existence.GRBQ344-3513G-C01[01-19]qxd 1/21/08 11:11 AM Page 14 Aptara Inc.. 1996. colleague. lack of Evidence-based practice is a construct receiving increasing important information. it has become a growing focal point due to: the expansion of our Language: The Human Essence knowledge base. care in a wide array of health care contexts. Others toler. Rosenberg. to convey matic brain injury (Turkstra. with their goals. Language is basic to what Chomsky consumers. & Haynes. as an ability to relate warmly to and intimately with others — and our own and others’ expert opinion (c. inform our clinical decisions may come in the form of expert ops. negative atti- tudes toward and discomfort with persons with communica- tive and physical disabilities remain. 2000). Part of the personality often appears lost. loss of companionship with loved attention from researchers. as well as agencies that rate quality of and loss of esteem (Boone & Zraik. Murphy. distrust. and hopes. our own clinical judgment about language is the basis of personality. 1999). deficits tolerate the effects of their condition with remark- Despite worldwide efforts to improve the ways that individ. Woolf. aspirations. or has expanded dramatically over the past decade. language distinguishes humans from other ani. 1998. ANCDS writing groups are now actualized person is impaired. rejection. the feasibility of Language is also the essence of maturity. stigmatization. The way we experience through language is a means of homeostasis that incorporate the evidence is ideally influenced by our careful enables human beings to maintain and/or restore an equilib. including aphasia . and feeling human. self. Individuals with stroke EVIDENCE-BASED PRACTICE and aphasia are susceptible to attitudinal barriers. 2006. 2005). and the cognitive-communicative disorders resulting from trau- ability to maintain interpersonal relationships. Richardson. 1983).and web-based and the ability to communicate with others is the essence of publishing.. clinicians. Goodman also observes that specific research studies. Kennedy. Love. & Avery. Straus. the growing demand for accountability from that socialization. frustration. 14 Section I ■ Basic Considerations cannot. As with many 2006. the values of the patient. patients. including case studies. other health-related disciplines. the holistic needs of patients with high standards and dig- Flower & Sooy. These . and electronic prosthe- As clinicians we require a basic knowledge of the ses. document. Biol- Based Practice in Communication Disorders. We must also keep abreast of the literature continue to expand our alternatives as aphasiologists for regarding which assessment and therapeutic techniques are assessment and treatment. 1972a). The future may also bring tissue trans- 2007). outcomes. plantation. 2004). Aphasia is not con- among researchers and clinicians to enhance the evidence sidered by most to be a disorder that can be cured. It should be recognized. and HIV and AIDS (ASHA. and about their treatment. Still. base in our discipline bode well for improved efficacy. The primary purpose of the present text is the presentation of various models of intervention for adult patients with aphasia and for patients with related disorders. and indepen- progressive aging of the world’s population will continue dence (Wepman. the more effective we A rationale for language intervention in persons who have can make our intervention approaches. and to analyze empirically the leading scientists to a progressively greater understanding of efficiency of rehabilitation efforts. 1972a). Information ogic interventions hold promise for stimulating or repairing about related initiatives is updated regularly online (ASHA. The more we know about how intervention changes brain function. injured brain areas. The American Speech-Language-Hearing ders in adults. perhaps using cortical electrode grids to facilitate func- processes used to engage in and document evidence-based tion (Wineburgh & Small. effective with specific types of patients and under what con. 1987). Through intervention. dignity. resolve the inconsistencies in these approaches. Molecular answers are now increasingly have appeared in part or in whole in previous literature. lar recovery following stroke or brain injury. that it is not New and evolving imaging methods provide promise for the purpose of this text to assess any of the models or to richer information about the nature of neurogenic disor. perhaps using stem cells. more effectively.GRBQ344-3513G-C01[01-19]qxd 1/21/08 11:11 AM Page 15 Aptara Inc. 1989a. Emerging technology will clinical practice. Research in all the areas related to the study of aphasia ditions. to influence the nature of the patients served by clinical It is unfortunate that many posttrauma and poststroke aphasiologists. Quality health care means going hepatitis. cognitive improvement through neurotrophic factors. ers have not. Increased life expectancies and the tionships. The accelerated aphasia is based on the belief that language is vital to one’s emphasis on evidence-based practice within our profession human essence and that treatment can affect a change in a and the emergence of additional collaborative efforts patient’s communicative performance. Not to allow persons to communicate to the best of their ability is to deprive them of their own human RATIONALE FOR THIS TEXT essence. will continue to illuminate our understanding of neuro- and evaluate our practices and test whether our therapeutic genic communication disorders. effi- skilled intervention enables many individuals to be able to ciency. Many individuals have the capacity to commu- will include the increased incidence of certain relevant nicate more effectively and yet are not enabled to do so etiologic and associated risk factors such as obesity. Other important influences untreated. as will the growth of multilingual and patients with good potential for rehabilitation are left multicultural populations. It is important that aphasiologists continue to learn about how the brain orga- nizes language and to reflect on how this kind of knowl- RATIONALE FOR LANGUAGE edge can affect the growth and development of new INTERVENTION IN APHASIA approaches to treatment. Some of these strategies the brain’s biology. It is critical that we continuously find. aphasiologists attempt Demographic characteristics of patient populations to heighten each patient’s potential to function maximally will continue to stimulate new development in adult lan- within his or her environment. Such models FUTURE TRENDS can provide a framework with which to focus therapy. 1998. as well as and has recently initiated the National Center for Evidence. areas are explored further in this book. Chapter 1 ■ Introduction to Language Intervention Strategies in Adult Aphasia 15 and dementia. Individuals should be granted the right to be treated by qualified clinicians providing the best techniques known. accountability. however. oth- available for questions we have addressed only indirectly. and quality in our ser- comprehend and produce language and to communicate vices. to The explosion of new knowledge and new technology is generate intervention tasks. to pharmacologic intervention are producing promising dence-based clinical practice guidelines based on reviews of preliminary results related to facilitation of cerebrovascu- the research literature in several areas of clinical practice. Many of these research techniques are effective. to facilitate meaningful rela- guage intervention. nity. and to restore self-esteem. Larsen. (Wepman. Centers for beyond the provision of basic physical care and meeting Disease Control and Prevention. New approaches Association (ASHA) has supported the development of evi. 2006. influence your own assessment cians to practice the use of appropriate terms to refer of an individual with aphasia? How might it influence to individuals with a variety of neurogenic language treatment? disorders. for many of these terms. Traditional classification schemes help to elucidate using the corresponding terms anomia. dyslexia. journals. transcortical sensory aphasia. how the way in which one conceptualizes aphasia is rele- izes aphasia influence one’s choice of words in defining vant to the diagnostic process. Compare your definition with those further in this text. How might the way one conceptual. As employing each of the four components mentioned for you consider diagnostic issues in aphasia as discussed an ideal definition. sia. referring. • agraphia • alexia • anomia • catastrophic reaction • logorrhea KEY POINTS • neologism • paraphasia (including the terms literal. Varied theoretic frameworks influence the way one • press of speech conceptualizes aphasia and therefore may influence • transposition the diagnosis and treatment of aphasia. and global paraphasia) 2. global aphasia. Thanks to with aphasia: Meggan Moore for editorial assistance. the most common of which is stroke. also considered to have “receptive” aphasia. The term “aphasic” is an adjective. What is the literal semantic distinction ited in terms of characterizing the conditions of indi. The readings are organized into Develop a personal action plan for reducing your own sections to help shape the reader’s perspective on the field. Explain why many patients with “fluent” aphasia are change in a patient’s communicative competence. Describe the hallmark features of each of the classic sub- types of aphasia described: Wernicke’s aphasia. but are often lim. and aphasia. transcor- tical motor aphasia. Reviewing terminology as presented in other ▼ Acknowledgment—This work was supported in part by texts may be helpful. Considering yourself a role model for an individual at It is hoped that this text will provoke theoretic specula. The study of aphasia is interdisciplinary. Define in your own words the fol- grant DC00153-01A1 from the National Institute on lowing terms used to describe the symptoms associated Deafness and Other Communication Disorders. siologists appears to be a function of stylistic convention 7. it will be helpful to consider further of your colleagues. . Review the means of reducing stroke risk in Table 1–2. 16 Section I ■ Basic Considerations functions are better performed in appropriate professional 3. alexia. and classify its subtypes. alexia.GRBQ344-3513G-C01[01-19]qxd 1/21/08 11:11 AM Page 16 Aptara Inc. stroke risk. what specific steps tion and that those chapters that are rich conceptually will would be important for you to undertake to demon- prompt the collection of further data and generate the pro. However. between terms beginning with dys. 1. Write your own definition of the term “aphasia.rather than a- 4.” ated with the underlying neuropathologies of aphasia. As you ACTIVITIES FOR REFLECTION AND DISCUSSION read the upcoming chapter. risk of stroke (and repeat strokes). anomic aphasia. Broca’s aphasia. choice of prefixes in the usage of such terms among apha- 6. various manifestations of aphasia. A background in basic terminology used in the study of be used in any order. and primary progressive aphasia. it will be helpful to continue to reflect on how these hallmark symptoms are associ- 1. for example. conduction aphasia. 6. mia.as compared to a-? The vidual patients. Note that some authors use the prefix dys. There are four essential features to a definition of aphasia. and even dysphasia rather than 5. to dysno- sia. Create an interactive exercise for students and clini. • perseveration 3. strate a lower stroke risk in your own life style? duction of new approaches. the sections of the book—and its chapters—may 4. not a noun. A solid rationale for language intervention in adult more than a function of the literal significance of the pre- aphasia is based on the notion that language is essential fixes in question. aphasia? 7. communication disorders is assumed by the authors of this book. How might the way you conceptualize the nature of apha- 2. phonemic. semantic. Multiple etiological factors are associated with apha. verbal. agraphia. dysgraphia. to one’s human essence and that treatment can affect a 5. (2006). Roch (Eds. Fact sheet. M. ix-xiv. Centers for Disease Control and Prevention. Damasio. & Worral. A. J. Chapter 1 ■ Introduction to Language Intervention Strategies in Adult Aphasia 17 References Damasio. Classic cases in neuropsy. cardiovascular diseases. Journal of Medical Caplan.. R. Heart disease and stroke statis. Signs of aphasia. (1991). Neural bases Gaines. R. Lancet. 514–521. reports. S. (1998). Wallesch. (1993). Stroke. 123–128. Stroke. 11. B. (1999. (1997). (2005). N... Ceccaldi. 48(30). Academic Press. K. Epidemiology of stroke in Native Americans.. 26(3). Aphasia.. Perfilieva E. 2006. Overprotection. Code. 1707–1712. Stroke. Gerdau. M. Evidence-based practice: in primates. American Heart Association. Understanding aphasia. tions disorders. S. Lemme. V. Neurobiology of social communication Frattali. Darley. Brain. (1978). 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Journal of Speech sia with the Minnesota Test. U. Aphasia therapy: A new look. and harms of clinical dence. Risk factors and stroke subtypes: results Willich.. 2(3). P. Studies in aphasia: An approach to 51(2). J. have more comprehending language. These cases are known as “crossed visual channel. even when lesion in a right-handed person. along similar symptom clusters (Bellugi. of aphasia with a typical left-hemisphere insult also in a guage through the auditory channel but not through the right-handed subject. but it can also appear following head OBJECTIVES injury. we can wit- Aphasia is a defect in language processing and not a defect of ness either the presence of aphasia with a right-hemisphere perception or movement or thought. the phonemic the same starting point: neuroscience began with the and morphemic morphology of a word). As a consequence.GRBQ344-3513G-C02[20-41]. in 1861. in a two-way translation process that establishes the relation 1990. translating a received language instances. affecting the left hemisphere given that the vast majority of able fidelity. really depend on the underlying pathologic process but guage processing and is based on the study of pathologic rather on the specific brain region that becomes affected. Specifically. Most often aphasia is the result of cerebrovascular disease leading to stroke. language output which far exceeded a difficulty in language such as American Sign Language (ASL). or others. The original description was particular aspect only.” respectively. In each individual description. & Klima. A thought disorder such as schizophrenia does not cause aphasia but rather produces a correct linguistic translation of a deranged thought process. aphasia is a breakdown tion. Poizner. but the emphasis of the defect can also fall on one to the left frontal operculum. the right hemisphere (or may fail to show aphasia after lesions in language areas of the left hemisphere). The constellation of defects does not This chapter considers the neural basis of abnormal lan. can also be comprehension. Languages based on visuomotor communication. syntax. However. and it formed the basis for Aphasia is not the exclusive province of auditory-based what was later coined Broca’s aphasia. Incoordination of speech movements causes aphasia” and “crossed non-aphasia. to do with the way the process affects the underlying brain which occurs in a language-competent and intellectually tissue than with a specific effect on the language dysfunc- competent individual. and degenerative diseases such as Alzheimer’s or Pick’s. & Tranel. see Anderson. possibly because both hemispheres are more involved in language processing than is standard.g. the absence due to central processes. As discussed in other chap- HISTORICAL OVERVIEW ters of this text. precludes comprehension of lan. dysarthria but not a linguistic breakdown of speech output. some left-handers develop aphasia after lesions of message into thought). (For example. Aphasia refers to a compromise in the process of by some of these pathologic processes. 1983). Most aphasic syndromes are seen in disease processes als with aphasia have an inability to translate. About a decade later Carl Wernicke was to 20 . neuroanatomy in patients with aphasia due to focal brain The differences one might witness between aphasias caused damage.. outlined by Paul Broca (1861). individu.qxd 1/21/08 11:14 AM Page 20 Aptara Inc. cerebral tumors. Deafness. 1987a. 1988. linguistic symbols and grammatical relationships (or they even when they are left-handed. Damasio. Chapter 2 Neural Basis of Language Disorders Hanna Damasio compromised following focal brain damage. the lexicon.) between thought and language. communicate through the spoken word because of damage mised. or conversely. a nonverbal set of images (thoughts) into individuals share a left-hemisphere language dominance. a severe disruption of languages. formulating language. or both. Even more rarely. in some have the inverse problem. aphasia can compromise varied aspects of The history of aphasia and the history of neuroscience share language processing (e. of a patient who had lost the ability to patient several or even all of these aspects can be compro. with reason. Damasio. unavoidable variability in the presentation of patients with It did not take long to transform these observations of spe. tered by previous classifications in the accommodation to the prehension far exceeded the disruption of language output. working in the mid-1960s. & Brandt. for instance. Hyde. aphasia. Damasio. I will follow the separation of aphasic syndromes sphere was the site of human spoken language became associated with the Boston and Iowa schools (Benton & accepted. This cartoon of the left hemisphere. both ANATOMICAL OVERVIEW located in the inferior sector of the parietal lobe (see also Sulci. which lie outside the classical language the key set of structures necessary to receive and produce areas (Damasio. He also went further in the mal language processing. & Damasio. 1982). Modern test batteries and 1874. which occurred after circumscribed systems of aphasia. located in the nitive experiments. Two of these sites include Broca’s and Wernicke’s and their anatomic connection through a unidirectional areas. The other initial historical development occurred (PET) and several aspects of electrophysiology. eration. Naeser. aspects of language processing. 1982). earlier equipotential. With it came the idea that there were brain “cen. angular gyrus. all having their origin in the difficulties encoun- Wernicke’s aphasia. 1886). 1971). we measurement tools that considered the linguistic and cognitive must begin with an understanding of normal brain anatomy. . virtually all and any part of the brain was seen as of functional magnetic resonance (fMR). the neural basis of language. In general. ism that occurred along with the advent of behaviorisms in Alexander. So began what was later termed appeared. Graff-Radford. During the heyday of this has grown immensely in recent years due to the availability approach. Damasio. the arcuate fasciculus. which carried speech sig. Language processing will. I will not discuss the several available classification cific language deficits. but rather on sys- helped cement the traditional view. & Theurkauf. This topic is covered in other chapters in this book. Graff- the meantime. an approach that led to the opposite point of Geschwind.GRBQ344-3513G-C02[20-41]. 1965) he address the neural basis of language disorders. 2000. Further studies of patients with differently placed these studies have shown that language processing is not lesions and slight variations of the presenting deficits “centered” on Broca and Wernicke’s areas. that nothing but the whole brain was The literature on language processing in normal subjects responsible for cognition. Levine. detailed evalua- tion of aphasic patients was beginning to be performed with To understand the neural underpinnings of the aphasias. Rizzo. tems composed of many neural sites working in close coop- guage-related brain areas to Broca’s and Wernicke’s areas. With his landmark arti. ters” responsible for this function—an anterior center The availability of MR imaging and more recently 3-D responsible for the production of language located in the reconstruction of the human brain has empowered the frontal operculum or Broca’s area and a posterior center human lesion method and made way for a new wave of cog- responsible for language comprehension. much has occurred in the history of Radford. engage several fiber tract. Functional when Norman Geschwind. 1982. but do so mostly on the basis of normal language and those of behavioristic theories. in which the deficit in language com. as well as. which mapped lan. aphasia. classifications of the aphasias started in earnest in the 1960s. Yamada. Hamsher. Schelper. in normal subjects. Damasio & Damasio. The cause was another lesion of the left hemi. regions of left temporal and prefrontal/premotor cortices in nals from Wernicke’s area to Broca’s area. or their respective advantages and disad- areas of left-hemisphere damage. Laughlin. Ilinsky. 1985.” ously described aphasic syndromes and enlarged the original set of language-related areas to include the left supramarginal gyrus and the left. mentary motor areas are engaged in language production logic models of the processes of thought and language. language still pervades most textbooks and monographs on 1990. Given that this chapter is meant to cles on disconnection syndromes (Geschwind. however. studies do address language processing and its neural under- struck a healthy balance between the excesses of phrenology pinnings. 1993. 1985. and language processes were no longer local. Damasio & Tranel. Damasio. Wingfield. Chapter 2 ■ Neural Basis of Language Disorders 21 describe another seminal patient with aphasia (Wernicke. and psychology. Damasio. Gyri and Cytoarchitectonic Fields Geschwind. developments such as positron emission tomography ized. 1978. 1986). and even some modern texts on cognitive sci. Goodglass. “aphasias. The idea that the left hemi. Goodglass & Kaplan. thalamus. & Damasio. (For more on the lesion method see posterior half of the superior temporal gyrus or Wernicke’s Damasio. and supple- of the language brain despite their otherwise non-phreno. Tranel.) The results of area. on. into generalizations about vantages. & Gersh. In (Damasio. Helm-Estabrooks. sphere but this time in the posterior temporal region rather Over the years numerous other aphasia classifications have than in the frontal lobe.qxd 1/21/08 11:14 AM Page 21 Aptara Inc. It has also been shown that ence and linguistics continue to use this phrenologic picture structures in the left basal ganglia. Eslinger. At about the same time. the subject. 1989. but will rather concentrate on the anatomic explanations he provided for some of the previ. 1990. Varney. This includes a major backlash against localization. view—namely. I will not placed the classical observations on the anatomy of aphasia review the extensive literature on functional studies in nor- in a new functional perspective. MRI information and allow for 3-dimensional (3-D) recon. and reconstructed in 3-D on the com. The light gray lines show the remain- der of the gyri limits (some are sulci. The brains I use have been and can be measured volumetrically. 2005. Abbreviations are as mentioned in the text. for more anatomic infor- Frank. gyri. 1990. that is. Damaio. or Apple workstations) using Brainvox (Damasio & Abernathey.5-mm thick). The slices are contiguous. Any such markings are immediately available on any 2-D struction of brain tissue viewed at the computer screen. meninges. lesions. Kubik.) .) On the lateral surface the most prominent sulcus is Figure 2–1. basic constituents. Duvernoy. (See puter screen (of silicon graphics workstation. personal com. The 3-D reconstructed brain can be brains. lesioned brains at the computer screen. The major sulci are identified. The same lateral and mesial views of the left hemisphere. others are arbitrary lines). blood vessels. C. among others. can be split into smaller regions. gyral and cytoarchitectonic fields see Damasio. and obtained in the Figure 2–1 shows the left hemisphere of such a recon- coronal direction. T1-weighted. & Grabowski. cerebel. B. and brainstem.GRBQ344-3513G-C02[20-41]. The view intersecting the marked structure and on the 3-D brain anatomy reviewed in this chapter is based on normal reconstructed brain. Some major sulci that divide the hemispheres into their lum. Ono. Brainvox mation. A collection of about 124 such coronal structed normal brain seen from the lateral and mesial views. A. It allows us to iden- although today it is possible to study macroscopic anatomy tify and color code sulci. & puters. 1997). 1992. (For more details on sulcal. surements can also be obtained. are marked. slices is stripped of scalp. on the original coronal slices. or any structure on at the computer screen. 22 Section I ■ Basic Considerations Knowledge of neuroanatomy has been gathered over the is a family of programs developed to analyze normal and years mostly through the study of brains at the autopsy table. viewed in any direction. with the different gyri and their sulcal limits as seen in A (dark lines).qxd 1/21/08 11:14 AM Page 22 Aptara Inc. The same lateral and mesial views seen in A and B. 2005. here with Brodmann’s cytoarchitectonic fields marked. brains of normal individuals without any neu. thanks to the technique of magnetic the 3-D rendered volume. or resonance (MR) imaging and to programs that manipulate on any slice obtained by slicing through the 3-D volume. Surface and linear mea- reconstructed in 3-D from thin MR slices (1. 1991. Frank. also Damasio. Lateral and mesial views of the left hemisphere of a brain recon- structed in 3-D from thin MRI slices using Brainvox. the lobes and the gyri. rologic or psychiatric disease. direction of the occipital lobe. . The posterior sector of both these gyri contain shorter and turning upward on the right. This sulcus is constituted. Parallel to the central sulcus separates the inferior parietal lobule (IPL). which corresponds to slightly posteroanteriorly. containing Brodmann’s rior limit of the superior frontal gyrus (SFG). Between the inferior frontal In the mesial aspect of the temporal lobe there is one con- sulcus and the superior frontal sulcus lies the middle frontal sistent sulcus. The other promi. 2005). seen when looking at the brain from above (Fig. Chapter 2 ■ Neural Basis of Language Disorders 23 the sylvian fissure (SF). hemispheres is the central sulcus (CS). 8. anteriorly. Brodmann’s field 37. the cingulate sulcus turns upward in what 45. and the rior end of the superior temporal sulcus. They are. This sulcus separates the frontal lobe. Another sulcus. sitting behind and below the former. which continues into the inferomesial nent sulcus. below. The cor- the pre-central sulcus toward the polar region of the frontal pus callosum is the midline white-matter structure containing lobe. more or less rior frontal sulcus (IFS). parallel to the long axis of the temporal lobe. 2–2 for a better view of this sulcus). around the poste- motor cortex or Brodmann’s field 4 can be found). or Brodmann’s field often designated as the motor cortex (where the primary 39. 40). usually stopping before reaching the pole. is occupied by and the fourth temporal gyrus (4thTG). Brodmann’s field 22. At its posterior end. It below. In the temporal lobe there is one consistent sulcus. usually continuous. In relation the fibers connecting the cortices of the two hemispheres. It runs from the The parietal lobe is also subdivided by a prominent interhemispheric fissure (the separation between the two anteroposteriorly running sulcus. a mostly horizontal sulcus running (ITS). 8. the inferior temporal sulcus the precuneus (preCu) or Brodmann’s field 7. tem- (where primary sensory cortices or Brodmann’s fields 3. field 28. anteriorly (Brodmann’s area the pre-central and post-central gyri (preCG. above. It tends to be longer and lower on the left. namely the superior frontal sulcus (SFS) and the infe. Very often we speak of these two gyri as the spheres. 24.” the inferior frontal sulcus is probably the Together with the pericallosal sulcus. and it from the parietal lobe (behind). above. rior temporal gyrus (ITG) containing Brodmann’s field 20. the parietal lobe. Both run anteroposteriorly from parallel to the contour of the corpus callosum (CC). more often than not. The inferior frontal gyrus comprises dis. the most posterior sector of the frontal lobe. One is the cingulate sulcus (CingS). Brodmann’s field 40 and 39. (IPS). given to the temporal cortices between the collateral sulcus solateral aspect of the gyrus we find Brodmann’s fields 9. The SF separates the temporal lobe. several small segments and can be difficult to recognize. and the superior temporal sulcus described earlier (see also and 6. from the superior parietal lob- vided into more than one segment. the sector behind the ascend- or less parallel to the sylvian fissure. in which we find the (CingG). It may or may not reach the sylvian fis. from the inferotemporal region. gyrus (MFG) occupied by Brodmann’s fields 46. the sensory cortex No sulcal demarcation exists between the parietal. more Mesially. the polar Fig. and below. containing prominently Brodmann’s fields 23 and frontal operculum. is clearly separated from sulcus (STS). toward the SF. creates the separation between the middle temporal gyrus rior end of the SF usually shows an asymmetric course when (MTG) containing Brodmann’s field 21. There are two other prominent On the mesial surface of the hemispheres. also parallel. which contin. parahippocampal gyrus (parahipG). poral. lobe. postCG). the ule (SPL). The inferior pre-central sulcus (preCS). it creates the limit of the cingulate gyrus limit of the inferior frontal gyrus (IFG). the superior temporal ing branch of the cingulate sulcus. Brodmann’s fields 20 and 37. from the frontal and parietal lobes. the intraparietal sulcus hemispheres) above. and posteriorly. This inferotempo- region just in front of the three horizontal frontal gyri just ral region also includes the inferior temporal gyrus (ITG) described.GRBQ344-3513G-C02[20-41]. and occipital lobes on the lateral surface of the hemi- and 2 are seen). by anteroposteriorly. most anterior sector of the parietal lobe. This sulcus is more easily sure proper. given that it forms the superior pus callosum. taking a pos. The most anterior sector of the frontal lobe. which separates the fifth or The superior frontal sulcus constitutes the lateral and infe. the collateral sulcus (Col1S). plus several other regions buried within the sulcus itself. several major sulci to consider in the dorsolateral surface of the frontal sulci are to be considered. Together with the central sulcus they define the supramarginal gyrus (SMG). the occipitoparietal sulcus (OPS). starting at the post-central sulcus and going in the teroanterior course. traditionally called Broca’s area. and the angular gyrus (AnG). 2–2). Together with the sylvian fissure it delineates the occipital lobe by a sulcus running superoinferiorly and the superior temporal gyrus (STG). and the infe- the right and left hemispheres are compared (Damasio. directly around the cor- more important of the two. 9. can be The parietal region in front of this sulcus is also known as seen on the lateral surface. containing both Brodmann’s field 10. which are more often than not subdi. also known as the frontal pole. in front. The combination of field 44 and 45 on the left is is known as the ascending branch of the cingulate sulcus. to “language. tinct subdivisions corresponding to Brodmann’s fields 44. sitting on top of the sylvian fissure and around its poste- respectively. containing Brodmann’s field 5 and 7. and 6. namely sulcus (postCS). and 47. On this dor. continuous or subdivided into several segments. the name often ues into the mesial surface of the hemisphere. rior end. the post-central parietal lobule is itself subdivided into two major gyri. “sensorimotor” cortices. on the lateral surface of the surface of the temporal lobe.qxd 1/21/08 11:14 AM Page 23 Aptara Inc. The poste. 1. containing are two other sulci. Furthermore. temporal gyrus into two distinct segments. The sulcus join just behind the posterior end of the corpus callo. running the hemispheres (Fig. constitutes the major portion of the classical Wernicke’s area. 24 Section I ■ Basic Considerations Figure 2–2. The insula is also completely hidden. plenial” area. Heschl’s gyrus occupies the superior surface of the 19. the latter also known as pri- occipital lobe into two sectors: the supracalcarine region mary auditory cortex containing Brodmann’s fields 41 and 42 (sCR). However.qxd 1/21/08 11:14 AM Page 24 Aptara Inc. 2–3). some- thing that viewing only the lateral and mesial aspects. where it etal and calcarine sulci is usually referred to as the “retros. posterior sector is also known as the planum temporale. inferior. or superior views. The inferior and superior views of the brain with markings of the most important sulci seen in those views. two surfaces of cor- anteroposteriorly—the calcarine fissure (CF)—whose two tex are completely hidden from view when we look only at lat- lips contain the primary visual cortex or Brodmann’s field eral. 2005. The calcarine fissure separates the mesial aspect of the (In) and the Heschl’s gyrus (HG). These are the insula 17. the left hemispheres. This structure divides the superior Brodmann’s fields 18 and 19. being usually larger on the left. and the infracalcarine region (iCR). No distinct sulcus separates the occipital from the tem. the occipitoparietal sulcus and the calcarine one posterior to it.GRBQ344-3513G-C02[20-41]. ing up the sylvian fissure. separating the temporal lobe from Most of the cerebral cortex is actually not readily visible the frontoparietal operculum. may not be evident. for images in any of the views we have been dealing with but rather are depicting all these hidden structures. something that can be poral lobe. containing Brodmann’s fields 18 and (Fig. It can be found by open- tonic areas. hidden within the hemispheric sulci. as in Figure 2–1. or cuneus (CU). (See Damasio. here with identification of the gyri. mesial. also containing superior temporal gyrus. The same views as in A. one anterior and Typically. The cortex typically shows a marked asymmetry between the right and between the splenium and the juncture of the occipitopari. which is also known as the splenium. which sum. which contains several different cytoarchitec. A.) . both containing Brodmann’s field 22. 2–3). It is important to note that these views show a very large surface of brain. in the mesial aspect of the occipital more easily appreciated if we look at coronal cuts throughout lobe itself there is a distinct and consistent sulcus. B. The subcortical gray areas.GRBQ344-3513G-C02[20-41]. (The coronal slices are presented according to the radio- logic convention. The lines on the 3-D- reconstructed hemisphere repre- sent the placement of the cuts seen on the left. Abbreviations are those used in the text. This con- vention is respected in all illustra- tions.qxd 1/21/08 11:14 AM Page 25 Aptara Inc. but leaves most of Broca’s area intact. In the chronic epoch there were no motor defects and language had improved remarkably. not damaging the motor cortex in the central sulcus (arrows) in the left hemisphere. with the right hemisphere on the left and the left hemisphere on the right. which can be seen to be intact in the coronal slices. Brain slices are always pre- sented from anterior to posterior or from the most inferior view to the most superior view. Acutely the patient had Broca’s aphasia and mild right-arm and facial paresis as a result of an infarction in a middle branch of the MCA (pre-central artery). In sum- mary. and whose left hemisphere is depicted on the right. 3-D reconstruction of the brain of a patient with stroke. It does not damage insula or basal ganglia.) Figure 2–4. Note that most of the cortical rim is actually not on the visible surface of the hemi- sphere but rather buried within the sulci. Two coronal cuts through the same brain seen in Figures 2–1 and 2–2. Chapter 2 ■ Neural Basis of Language Disorders 25 Figure 2–3. it is a lesion that partially dam- ages premotor cortices 6 and 44. as well as the insula. Recovery was fairly quick. can easily be identified in these cuts. The ventricles appear as clearly delineated black struc- tures. . The lesion occupies the anterior half (lower two-thirds) of the pre-central gyrus. The lesion also damages the posterior sector of the inferior frontal gyrus (the pars opercularis of the frontal operculum). which resolves into effortful speech but toward the temporal pole. may be compromised. thinner tant subcortical gray matter structures (Fig. In modern terms. The three main vascular territories also severely compromised (Broca.) obstruction of any of the major supply vessels tends to create The blood supply for each hemisphere comes mostly an area of infarct that is broader on the surface than in the from the internal carotid artery (ICA). because its supply is achieved by terminal. and because the vascular lesions causing aphasia have makes them very vulnerable to sudden decreases in blood allowed us to use the lesion method efficiently to find the pressure in the main supplying vessel as well as to arterial neural underpinnings of language disorders. Second. The same investigators suggested . in gyrus. The artery (antChA). 1978). Within vessels. & Davis. 1987. receives capillaries from the three arterial territories as they Even today. namely. Damage in these territories in the left The brain’s vascular supply comes from the internal hemisphere may lead to infarcts in the basal ganglia causing carotid artery (the external carotid giving blood supply to the “atypical aphasias. The ACA supplies most of the mesial and orbital sectors of the frontal lobe and the mesial sector of the parietal lobe. This is fragile perforating vessels that leave the stem of the middle important as the most common cause of aphasia is a vascular cerebral artery at almost right angles. 1976. MCA. with the base turned toward the cortex. and occipital lobes. Finkelstein. 1987b. and the posterolateral aspect of the occipital confined to the inferior frontal gyrus cause only a brief lobe. pinnings of the aphasias. Vascular Supply of the Cerebral Hemispheres Another region is supplied by terminal arteries. are interconnected in the disorder that began the history of aphasiology and whose each hemisphere and to the opposite hemisphere by smaller lesion became associated with Broca’s aphasia. the superior parietal lobule and the in 1978 Mohr and collaborators pointed out that infarctions angular gyrus. Gouaze. sia in the proper sense. we find the hippocampus proper (Hip) and the amyg. a branch of the internal carotid artery speech output was so sparse that it was largely confined to before the internal carotid subdivides into middle and ante. but does Before we begin our discussion about the neurologic under. and the lateral sec- OF THE APHASIAS tor of the frontal. Duncan. This “horseshoe” region occupies a sector on the anatomical underpinnings of Broca’s aphasia. the ACA. for more detail of cortex in the direction of the underlying white matter. In a stroke caused (BG) with its separate constituents. & Salamon. there are still unresolved issues about the meet. continuing on the inferior surface of the temporal lobe period of mutism. In such events. watershed area. for example. an the vascular supply of the brain. The blood Classic Aphasias supply for the mesial occipital and temporal lobes comes Broca’s Aphasia from the posterior cerebral artery (PCA). because of its dual They claimed that such lesions do not cause a Broca’s apha- blood supply.” extracranial tissues). NEUROANATOMICAL CORRELATES The MCA provides the blood supply for most of the inferior and lateral sectors of the temporal lobe. parietal. the word “tant. a branch of the basilar artery.qxd 1/21/08 11:14 AM Page 26 Aptara Inc. the communicating arteries. First. a This region gets its blood supply from. multiple. 1974 . in the depth of the parahippocampal arterial blood pressure. Hori.” and comprehension of spoken language was rior cerebral arteries. thin. Damasio. Broca’s aphasia the circle of Willis. Funkenstein. but not The area at the edges of each of the three main territories by complete absence of speech. patient Leborgne suggests that the condition was worse than poral lobe gets its blood supply from the anterior choroidal what we associate today with a typical Broca’s aphasia. Bouvier. blockage by emboli. this is one of the regions that suffers dala (Amy). the caudate nucleus and by a severe and sustained drop in blood pressure. is characterized by sparse agrammatical discourse. 26 Section I ■ Basic Considerations We should also refer briefly to some of the more impor. small vessels that penetrate the hemispheres through the & Petrov. Because the blood supply to the brain is carried out by Lazorthes. and PCA. and the middle cerebral artery (MCA) laterally. This configuration lesion.GRBQ344-3513G-C02[20-41]. When this happens in the left hemi- sphere the consequence can be an aphasia of the transcorti- cal type. would proba- vessels. and very brief overview of the brain’s vascular supply. and Waddington. mentioned. forming what is called bly be described as a global aphasia. not have dual blood supply: the region of the basal ganglia. Szilda. cases of cardiac arrest. (See also Day. It is the reason for the well-known and traditional into two major branches: the anterior cerebral artery (ACA) description of the image of a stroke as a wedge-shaped form mesially. 1861). region for two specific reasons. It is important to have an idea about this Pessin. 1977. For instance. which is subdivided depth. this region is more resistant to infarction. as. Usually. the region is more vulnerable to severe decreases in the temporal lobe. Within the frontal lobe we find the basal ganglia the most intense deprivation of oxygen. Broca’s description of the language impairment seen in his The mesial aspect of the most anterior sector of the tem. superior frontal gyrus. It is normally designated as the generally does not cause significant linguistic deficits (Mohr. 2–3). we need one more aside. these areas the lenticular nucleus. Alexander. & Polk. 1886) Schiff. 1978. a small and circumscribed infarct of the frontal the basal ganglia. in the rolandic operculum. territory of most of the anterior branches of the MCA and tics of a Broca’s aphasia in the chronic epoch do indeed will have damaged not just the cortex of the frontal opercu- require damage of a sizable area of the frontal operculum lum (Brodmann’s fields 44 and 45). below. It damages insula but does not damage the basal ganglia (see the two lower coronal cuts on the right). Compared to the image in Figure 2–4 the damage is larger anteriorly. It also involves the posterior two-thirds of the inferior frontal gyrus corresponding to the entire frontal operculum (pars opercularis and trian- gularis and even part of pars orbitalis). 2–9. that the lesion necessary to produce the more severe lan. In our experience. in the acute phase and when they persist for months.qxd 1/21/08 11:14 AM Page 27 Aptara Inc. all of Broca’s area is involved (fields 44. The lesion occupies the inferior third of the entire pre-central gyrus. as well as the inferior sector of the pre- operculum can also produce a nonfluent language deficit central gyrus. for example. Chapter 2 ■ Neural Basis of Language Disorders 27 Figure 2–5. (See also the 2–4). In the same study. 45. It is only the outer rim of the inferior frontal gyrus that is spared (arrows). the authors showed that There has never been the same degree of controversy in an equally small lesion placed in an immediately posterior relation to the symptom complex or to the anatomical cor- position. Naeser. is consonant with contemporary investigations (Damasio. 1993. Selnes. Other such chronic Broca’s aphasias will have with all the characteristics of a typical Broca’s aphasia (Fig. . Harlock. requiring the involvement of all of the frontal oper. it is 1979. However. as seen in Figure 2–5. and Fig. Similar findings have been described by Tonkonogy section on Global Aphasia. although the deficits were not long-lasting. This patient also recovered but was left with mild weak- ness in the right arm and with language deficits that were still classified as a mild Broca’s aphasia. and Naeser culum and of the insula. 2-4). Naeser. the infarct may be in the long-lasting language deficits conforming to the characteris. did not cause any relate of the prototypical fluent aphasia: Wernicke’s apha- phonemic. 1990. & Palumbo. Kertesz. Wernicke’s original description of the language impair- rather dysarthric and dysprosodic speech output (see also ment and of its underlying brain damage (Wernicke. & Coates. usually the case that damage in a large sector of the inferior guage disturbance usually classified as Broca’s aphasia is far frontal gyrus is found. Kertesz. larger. 1987a. & Galaburda. involving the central sulcus region in the left hemisphere (Brodmann’s fields 6 and 4). 1983). or syntactical processing difficulties. The lesion also extends further into the underlying white matter than in the previous case (Fig. chronic and & Hayward. Knopman. but sia. When language deficits are classified as a Broca’s aphasia 1981. lexical. (See also Alexander. in the acute epoch of the into the underlying white matter and involved the insula and condition. and part of 47). Kertesz.GRBQ344-3513G-C02[20-41]. 1979. 3-D reconstruction of the brain of a patient who acutely also had Broca’s aphasia together with facial and arm paresis as a result of an infarction in the territories of the anterior and middle branches of the MCA (pre-frontal and pre-central arteries).. started as a global aphasia in the acute period. These authors pointed out that a small lesion involving the frontal operculum had caused lin- Wernicke’s Aphasia guistic deficits in the acute epoch. Lau. but also have extended and surrounding tissue.) In other cases.) and Goodglass (1981). Cortical areas that are destroyed beyond the insula include the primary auditory cortices in the transverse gyrus of Heschl (fields 41 and 42) and all of the surrounding superior temporal gyrus (field 22). destroying the lower Damasio. aphasia is a severe inability to repeat verbatim a heard sen- Naeser & Hayward. 1965. Sheremata. In such cases. Bouchard. sector of the supramarginal and the angular gyri 1978.GRBQ344-3513G-C02[20-41]. for later (Brodmann’s fields 40 and 39). & Geschwind. Mazzocchi & Vignolo. known as “conduction aphasia. Naeser & Hayward. which in the posterior portion forms Wernicke’s area (also seen in the coronal slices on the right).. Typical cases of conduction aphasia are often caused by A noticeable aphasia may persist for years. Kertesz et al. as well as the inferior sector of the supramarginal gyrus (field 40). tence.) limited and a severe fluent aphasia may persist for months. Price. A typical case of Wernicke’s aphasia This repetition deficit is disproportionately severe in com- due to an infarct of the temporal arteries is depicted in parison to the ability to produce spontaneous speech or to Figure 2–6. damage to the supramarginal gyrus (see Fig. To excise the entire malformation. The damage extends deep into the underlying white mat- ter. 1984. 1961. 1985. Geschwind. and part of 37). and Selnes et al. 1979. Liepmann & the posterior region of the middle and inferior temporal Pappenheim. and into drome and its underlying brain damage. 20. This is the case of a patient who. is the core of Wernicke’s area. 1983. at age 33. 1914. 1973. destroying the posterior segment of the insula and reaching the ventricle in the posterior cuts (see coronal slices 2 and 3). The lesion is seen in the posterior sector of the understand speech. & Rubens. (Brodmann’s field 40) the result is a fluent aphasia. Rubens & Selnes. 1980. suf- fered an intracerebral hemorrhage to the left parietal lobe Conduction Aphasia that lead to the diagnosis of an intracerebral arteriovenous When damage is limited to the supramarginal gyrus malformation (AVM). & Stepien. 1978.qxd 1/21/08 11:14 AM Page 28 Aptara Inc. 28 Section I ■ Basic Considerations Figure 2–6. 2–7 for an example).” gyrus. superior temporal gyrus (Brodmann’s field 22). among others. and Damasio & part of the inferior parietal lobule. recovery is descriptions. This region Segarra. The lesion involves most of the dorsolateral aspect of the left temporal lobe. 21. The superior and mid- dle temporal gyri are completely occupied by damaged tissue (Brodmann’s fields 22. In severe cases. 1984. The visual field persisted in the chronic epoch as did the aphasia. Kozniewska. among others). and the anterior sector of the angular gyrus (field 39). (See Benson. 1986. even single words are not repeated. The lesion also extends into Konorski. Niccum. After surgery this patient presented with a . 1979. for the early descriptions of the syn- gyri (part of Brodmann’s fields 37. distinct the neurosurgeon had to remove the entire supramarginal from Wernicke’s aphasia. and 21). while being able to spare the entire superior tempo- The fundamental clinical characteristic of conduction ral gyrus.. 3-D reconstruction of the brain of a patient who acutely presented with Wernicke’s aphasia and right hemianopsia as a result of an infarction in the territory of the temporal branches of the MCA. Interestingly. it may not be adequate for all. they ferent lesion patterns. ment of supramarginal gyrus. her naming impairment. for example. 1980).” verbatim. In 1980 we described patients with clapped. For example. supramarginal gyrus as described by Dejerine but may instead . She was unable to repeat even the pathway that connects posterior and anterior language short sentences. tion aphasia. for example. The condition required the subsequent surgical removal of most of the supramarginal gyrus. have and Selnes (1986) also described a similar presentation with improved remarkably.” As is typ. Yet.” Even today. The lesion involves the supramarginal gyrus (Brodmann’s field 40). comprehension of the (1965) proposed that the inability to repeat was a result of sentences to be repeated was preserved. Geschwind ical of conduction aphasia. damage to the pathway and although the essence of this asked to repeat “The orchestra played and the audience explanation may well be correct for some cases of conduc- applauded. the arcuate fas- Damage to the cortex of the supramarginal gyrus and to its ciculus seems not to course exclusively in the depth of the underlying white matter compromises the arcuate fasciculus. It is certainly the when asked about the meaning of the sentence she para. the patient failed entirely. exclusively left insular damage. although her other conduction aphasia (Damasio & Damasio.GRBQ344-3513G-C02[20-41]. Wernicke’s area is mostly intact. areas as first described by Dejerine (1906). almost 20 years after the onset of lesions in left auditory cortex and insula. without involve- her aphasia. “Take this home. typical conduction aphasia. In the chronic epoch this patient continues to dis- play a mild conduction aphasia. Rubens acute deficits. this patient has difficulty in repeating sen. 3-D reconstruction (in this instance from a thin-cut CT scan) of the brain of a patient with conduction aphasia resulting from an arteriovenous malforma- tion that ruptured and bled.qxd 1/21/08 11:14 AM Page 29 Aptara Inc. case that conduction aphasia can result from somewhat dif- phrased it as “There was music and they liked it. who presented with a typical tences longer than three or four words. Chapter 2 ■ Neural Basis of Language Disorders 29 Figure 2–7. The insula and the basal ganglia. sparing the temporal lobe altogether. Damasio. inability to repeat. and the basal While occlusion of some of the anterior branches of the ganglia.” As the description indicates. resulting in one Figure 2–8. artery. are also damaged. deficit and be eventually classified as a severe Broca’s aphasia sion of the middle cerebral artery itself. and 4. Such This sort of stroke also causes a severe restriction of move. Kaplan. and 47). Rubin. a presentation is the consequence of two separate lesions ment in the right side of the body. & Cornell. on occasion. may. Wernicke’s type of aphasia. due. & Brust. Adams. instead of a blockage of the main guage output. and inability to write— courses under the insula (Galaburda & Pandya. Such an “acute” global aphasia aphasia. and Tranel. involving not only Broca’s area but extending into other frontal gyri. as well as all of the superior temporal gyrus (fields 22. including the inferior frontal gyrus with Broca’s area (Brodmann’s fields 44. may present middle cerebral artery causes a nonfluent Broca’s type of as a severe global aphasia. for instance.GRBQ344-3513G-C02[20-41]. 30 Section I ■ Basic Considerations be a large sheath of white matter whose lower segment and written form. and the supramarginal gyrus (field 40). prior to its branching.. little lan. (see Fig. 2005. Biller. 1987. . 41. 1. at the level of the stem. and patients may be left with little speech other than deficits (see Legatt. causes extensive damage to frontal. The severe and pervasive linguistic deficit as “global aphasia. In other words. A large left frontal-lobe lesion. the pre. MAP-3 of the brain of a patient with a large left MCA infarct resulting in severe global aphasia and right hemiparesis. present without any motor guage. and 3. 1997). a right hemiplegia.and post-cen- Global Aphasia tral gyri. for stereotyped and automated words and stock sentences. 2–9 for an example). and temporal One other anatomical presentation of global aphasia regions. the ensuing of global aphasia. to multiple emboli causing infarctions in ical image of the brain lesion of such a patient is shown in both anterior and posterior branches of the middle cerebral Figure 2–8. and results in a more severe language deficit known deserves mention. For details about the technique see Damasio. (MAP-3 is a technique that allows the 3-D visualization of lesions of individual subjects in a common normal target brain.qxd 1/21/08 11:14 AM Page 30 Aptara Inc. and42). hemiplegia. and Frank et al. The lesion involves most of the frontal-lobe structures in the territory of the anterior branches of the MCA. the supramarginal gyrus. which is usually accompanied by a right deficits involve both production and comprehension of lan. the insula. A typ. as well as the white matter in the frontal and parietal lobes. 45. 2000. may appear in association with more restricted lesions. 1983). and occlusion of posterior temporal and parietal may resolve into a less severe albeit remarkable language branches causes a fluent. severe comprehension deficits in both oral trunk of the artery. parietal. and 2). The signs of global aphasia—namely. Healton. most of the sensorimotor cortices in the pre-central and post-central gyri (fields 6. 1987). occlu. including Wernicke’s area (W). and part of 46 and 9). premotor regions in the same gyri (Brodmann’s fields 44 and 6). as can be seen in the two cuts in the bottom row and in the 3-D-reconstructed hemisphere on the left. In the chronic epoch. large lesion. the damage is posterior and inferior to the above-mentioned Transcortical Aphasias regions. Transcortical sensory aphasia is (Brodmann’s field 37). (1987). as seen in the coronal cuts on the right. As is to be expected from the lesion both the primary auditory cortices (Brodmann’s fields 41 placement. damaging the basal ganglia (caudate and putamen). more peripheral blockages occur and thus result diagnosed when a patient presents with fluent paraphasic in more than one lesion. patients with this form of global aphasia recover and 42 in the transverse gyrus of Heschl) and the posterior faster and better than do those with classic global aphasia. and 2). how- ever. Chapter 2 ■ Neural Basis of Language Disorders 31 Figure 2–9. sensorimotor regions in the pre. The infarct involves prefrontal cortices in both the inferior and part of the middle- frontal gyri (Brodmann’s fields 45. 3-D reconstruction of the brain of a patient with a large infarct in the territory of the anterior frontal branches of the left MCA as well as the anterior-temporal branches. As described in Tranel et al. language had improved enough to have the aphasia reclassified as a severe Broca’s aphasia. It may involve the angular gyrus (Brodmann’s field The transcortical aphasias are characterized by normal word 39) and the posterior sector of the middle temporal gyrus and sentence repetition. This patient also presented acutely with a right hemiparesis and global aphasia. the anterior sector of the superior temporal gyrus (Brodmann’s field 22). In transcortical sensory aphasia.GRBQ344-3513G-C02[20-41]. . speech and with poor auditory comprehension but with there may be an area of infarct in the left prefrontal/premo. sector of the superior temporal gyrus (Wernicke’s area proper) are spared.and post-central gyri (Brodmann’s fields 4. The insula is equally damaged and the infarct extends deep into the subcortical structures. sparing the sensorimotor cortices in Wernicke’s aphasia because it indicates to the clinician that between (Fig. and then another in the left posterior temporal. The important feature to note is that the primary auditory cortex (Brodmann’s fields 41 and 42) in Heschl’s gyrus is only partially damaged (see cut 4) and that both Wernicke’s area (posterior Brodmann’s field 22) and the supramarginal gyrus (Brodmann’s field 40) are spared. There is a practical tor cortices. value in recognizing this type of aphasia as separate from parietal region. 1.qxd 1/21/08 11:14 AM Page 31 Aptara Inc. 47. 2–10). 3. intact word and sentence repetition. and the dorsolateral sector of the temporal pole (Brodmann’s field 38). 46. however. as is most of the frontal oper- culum and most of Wernicke’s area (which. Freedman. lates the “speech area. When patients present with a nonfluent language deficit The combinations of the lesions described for transcorti- and preserved repetition. Note the two separate areas of infarction in the left hemisphere: the more anterior lesion is in the territory of the anterior branches of the MCA. See Figure 2–11 for an example of a transcortical sensory Isolation of the Speech Areas aphasia. and the posterior sector of the middle frontal gyrus (field 6). respec- with exclusively subcortical lesions underlying the cortical tively).qxd 1/21/08 11:14 AM Page 32 Aptara Inc.) In in the left frontal lobe involving prefrontal and premo- some instances. Damasio. 9. Hiltbronner. We may find transcortical motor aphasia of the occipital lobe (Brodmann’s fields 19 and 18) or into in patients with small subcortical lesions located immedi- more anterior sectors of the middle temporal gyrus ately anterior to the frontal horn of the left lateral ventricle. regions mentioned above. 1989b. and Kertesz et al. among others.and post- central gyri. 8. we talk about a transcortical cal motor aphasia with those responsible for transcortical motor aphasia. and 6. The sensorimotor cortices in the pre. Alexander. is not completely spared). this same type of aphasia can be detected tor cortices (Brodmann’s fields 10. 32 Section I ■ Basic Considerations Figure 2–10. 2–12). the more posterior lesion is in the territory of the posterior branches of the MCA. damag- ing the supramarginal gyrus (field 40) and probably a portion of the posterior sector of the superior temporal gyrus (field 22). & Fischer.GRBQ344-3513G-C02[20-41]. 1984.. and the basal gan- glia are intact. On occasion the lesions may extend into the lateral aspect tical sensory type. 1979. a part of the so-called anterior watershed area (Fig. 1987a. as described in Damasio (1987a). damaging the superior sector of the frontal operculum in the inferior frontal gyrus (Brodmann’s field 45). The location of the lesions responsible for sensory aphasia may result in an extensive lesion that iso- this type of aphasia is less consistent than for the transcor.” Patients with such lesions have a . 1981. T2-weighted MR image and MAP-3 of the brain of another patient who acutely presented with global aphasia. This patient improved rapidly and was eventually left with only a mild language deficit. the insula. but this time without hemiparesis. (Brodmann’s field 21) See Alexander. & We also may find transcortical motor aphasia with lesions Naeser. & Poppe. Quadfaset. rather accurate repetition of any verbal material received Confraria. 2–14). a situation answer. The incidence of such cases is low that it is best described as echolalia. 3-D reconstruc- tion of the brain of a patient who presented with a fluent aphasia but intact repetition. When asked a question the patient may actually may fail to develop aphasia following lesions located in “lan- repeat the question verbatim instead of providing an guage-related” areas of the left hemisphere. The same sort of individuals auditorily. Geschwind described one of these rare cases.GRBQ344-3513G-C02[20-41]. Crossed Aphasia tional language formulation. possibly due to atrophy in the frontal gyri. which was due to severe carbon monoxide poisoning (Geschwind. & Segarra. There is also evidence of some enlargement in the anterior sector of the syl- vian fissure. However. devoid of any proper comprehension of sentence right hemisphere and becomes aphasic as a consequence of meaning. the diagnosis of crossed aphasia preserved capacity for aural repetition of even long sen- applies when a fully right-handed subject has a lesion in the tences. The repetition is achieved with so much ease that lesion (Fig. This is a typical presentation of transcortical sensory aphasia. Fischette. beginning with early CT scans in 1972 and then with MRI . no brain-tissue dam- age can be detected in these regions. the immediate and (Alexander. 1968). The cause of the syndrome was an acute intracerebral hemorrhage in the left hemi- sphere. Castro-Caldas. 1987). Chapter 2 ■ Neural Basis of Language Disorders 33 Figure 2–11. we see an area of encephalomalacia in the left angular gyrus (Brodmann’s field 39) and underlying white matter but no damage to the posterior sector of the superior temporal gyrus. cerebral arteries. In the chronic epoch. The underly- ing pathology was a watershed infarction nearly occupying Atypical Aphasias the totality of the watershed region between the anterior and middle cerebral arteries and the posterior and middle With the advent of the modern neuroimaging techniques. & Fischer. 2–13). after resolution of the hemor- rhage. severe dual deficit in language comprehension and inten.qxd 1/21/08 11:14 AM Page 33 Aptara Inc. known as “crossed non-aphasia” (Fig. 1989a. associated with a remarkably As mentioned earlier. Damasio et al. 1981). involving ally the result of a mixture of features of nonfluent and only the lateral aspect of the putamen and the external and fluent aphasias that produced a blend quite distinctive extreme capsules. no area of abnormality could be seen in the cor- 1982. 1982. in study. microscope. Vital. No aphasia at all is seen when the damage occurs in to the left basal ganglia without involvement of the cortical the right hemisphere. Mazaux.GRBQ344-3513G-C02[20-41]. The vascular territory affected here language regions (Fig. This patient showed the typical presenta- tion of transcortical motor aphasia. artery. More specifi. In the early 1980s several authors provided anatomical The early reports. Kornhuber. . Naeser et al. high-resolution MR scans Holland. It extends posteriorly lateral to the lateral ventricle. including all of the corti- cal mantle in Broca’s and Wernicke’s areas. Under the Seemiuller. and even the anterior insula. & Whiteaker. Modern. it became possible to identify was that of the striate arteries. there was no damage outside the basal ganglia (Barat. Rose. & Reinmuth. 1985. Barat and colleagues demonstrated that the head of the caudate nucleus. Fromm. dysprosodia. Swindell. Bioulac. Suger.qxd 1/21/08 11:14 AM Page 34 Aptara Inc. & Wallesch. scans since the early 1980s. in the region of the anterior watershed territory. 2–15). In a postmortem cally. Brunner. 3-D reconstruc- tion of the brain of a patient who suffered a relatively small infarct in the left hemisphere. It does not damage the caudate nucleus or the insula. tical language areas. raised the possibility that there might be symptoms and infarcts in the basal ganglia. & Adams. the infarcts were located in the left hemisphere. Rekate. no aphasia from the severe and all-encompassing deficits of a global is observed although the patient may show dysarthria and aphasia. 34 Section I ■ Basic Considerations Figure 2–12.. The atypicality was usu. 1983. undetected damage in cortical regions. Damasio. 1984. confirm that this syndrome does occur as a result of damage 1982). however. When infarcts are placed more laterally. a set of small terminal the neural underpinnings of some aphasic presentations arteries arising from the stem of the middle cerebral that were classified as “atypical”.. The area of damage can only be seen in the coronal slices as an area of decreased signal in the white matter just anterior to the frontal horn of the left ventricle (see the first coronal cut). The exter- nal surface of the brain is intact. Eslinger. & Arne. Giroire. based on relatively low-resolution evidence for the connection between such a mixture of scans of the 1970s. and in the putamen (Aran. and with thalamic tumors (Arseni. Goldfader. anosognosia. The modern neuroimaging techniques occasion. visuospatial deficits. 1986. Lesions in the ante. Silveri.and post-central gyri (fields 6 and 4. & Duncan. 1958. 1994). Wafters.GRBQ344-3513G-C02[20-41]. it may be reasonable to use Damasio. 1984. 1982. 1966). There is no sign of dam- age in the left hemisphere. the auditory cortices in Heschl’s gyrus (fields 41 and 42). and central) and the territory of the anterior and middle temporal arteries. ciation between the production of words denoting actions and eroventral and anteroventral nuclei were related to those denoting concrete entities could be found in patients aphasias of the transcortical type (Fig. 1. pre-central.” is often present in most types of aphasia. and 2). & Heilman. Schelper. visual neglect. 1980. involving mostly the lat.qxd 1/21/08 11:14 AM Page 35 Aptara Inc. Gelfer. 1981. & Smith. result in sensory and motor deficits Colosimo. Chapter 2 ■ Neural Basis of Language Disorders 35 Figure 2–13. McFarling Difficulty in producing the words that denote concrete entities Rothi.. 1898). Shallice had called attention to the presentation of different . He presented with a left hemiparesis. 1985. presented visually. Cappa & Vignolo. Lesions of with both nonfluent and fluent aphasia. et al. Graff-Radford. In 1984 Warrington and but not in aphasia. In 1986 Goodglass called attention to the fact that a disso- rior nuclei of the left thalamus. 1980. of the right thalamus. however. T1-weighted MR image and MAP-3 of a right-handed patient with an infarct in the territory of the right anterior branches of the MCA (pre-frontal. Mohr. 2–16). the sensorimotor cortices in the lower tier of the pre. 45. the inferior sector of the supramarginal gyrus (field 40). such a deficit is disproportionate in rela- have helped establish a precise anatomical basis for these tion to other language deficits.. Cheek & tion naming. see also Daniele. most of the anterior sectors of the superior temporal gyrus (field 22). and lesions (Goodglass et al. & Gainotti. and severe atypical aphasia—a typical pre- sentation for a “crossed aphasia. as well as extension into insula and deep structures such as the basal ganglia. & Sweet. 1985).” Graff-Radford. the label “anomic aphasia” or “amnesic aphasia. Ilinsky. or can even occur in isola- aphasias (Archer. Graff-Radford & (Pitres. and 3. Giustolisi. The occurrence of aphasia with damage in the left thal. 1979.” There is damage to the right hemisphere in the frontal oper- culum of the inferior frontal gyrus (part of Brodmann’s fields 44. et al.. and 47). Anomic Aphasia amus has been noted with vascular lesions (Alexander & Loverme. In such situations. On Taveras. tion. the most typical situation of “confronta- 1975). something that was noted as early as 1898 by Pities Cohen. Damasio. respectively the left thalamus that spare the anterior nuclei. sug- gesting reversed language dominance in this right-handed subject. there was only mild dysarthria. Most of the putamen is. shows a lesion in the head of the caudate nucleus and the putamen. there is no damage to cortical A regions in the frontal operculum. but no aphasia. B . did present severe impairment of visual memory.qxd 1/21/08 11:14 AM Page 36 Aptara Inc. The patient. 36 Section I ■ Basic Considerations Figure 2–14. However.” Figure 2–15. as a result of a ventriculostriatal infarct affecting the posterior sec- tor of the putamen. These symptoms are suggestive of a lesion in the nondominant hemisphere. CT scan and MAP-3 of the brain of a right-handed patient with a very large left MCA infarct followed by a partial frontotemporal brain resection. visuoconstructional abilities. Neither the infarct nor the sub- sequent surgery resulted in aphasia. T1-weighted MR image of a patient who presented acutely with a left basal gan- glionic hemorrhage and an atypi- cal aphasia. as is the caudate nucleus. obtained in the chronic epoch. however. We would talk about a “crossed non-aphasia. B. and some degree of anosognosia. nor to posterior temporal cortices. A. as well as the internal capsule. however. This scan. T2-weighted MR image of a patient who presented acutely with dysarthria. spared.GRBQ344-3513G-C02[20-41]. We should consider here another group of patients who Cappa. Friston. the so-called “progressive aphasias. Perani. the deficit may be limited to the retrieval of The possible anatomical underpinnings for such cate. Damasio et al. Convergent findings have refers to subjects who show a progressive impairment in come through functional studies of nonlesioned brains language performance. & Caramazza. Damasio. (See Damasio et al. 1994. usually starting with a deficit in (Buchel et al. the deficit encom. Schlaghecken. CT scan of a patient who presented acutely with an atypical aphasia due to an infarct of the anterior thalamic arteries. 1998. 1996.) When the lesion extends into Mutism is a condition that is not strictly an aphasia but is the left anterior sector of the inferior temporal lobe. with particular with lesions in the temporal pole of the nondominant atrophy in the inferior frontal gyrus. Ojemann. 1997). 1984). Adolphs. more of the temporal region. aphasia. & Damasio. Damasio. Such deficits are not seen the disease may affect first the frontal lobe. Tranel.. of disease. Tranel.. 1989. & Frackowiak. & Damasio. 2004. especially in IT regions. Martin et al. If the lesion Semenza & Zettin. On occasion. Hillis & summary of lesions producing category-specific deficits. 1997. especially those in the right hemisphere). in the presence of normal recognition of those persons Many of these patients have a progressive degenerative dis- (Damasio et al. 1997). There is a low-density lesion in the anteromesial region of the left thalamus. Frank.. 1994. and Tranel. 1994. and finally encompassing more typical features of 1983. 2004).. recognition is not gory-specific word retrieval deficits only began to be eluci. Bressi. in often taken as such. sons but also those of nonunique animals. Petersen et al. passes not only the retrieval of words denoting unique per- Berndt. 1988. ties. 1991... 1991. unique name retrieval.. 1997. & Cappa. Silveri & Gainotti. tices. 1991. Tranel.. Hichwa. Chapter 2 ■ Neural Basis of Language Disorders 37 Figure 2–16. When the sphere can be segregated into distinct areas whose damage retrieval of words denoting nonunique manipulable tools is causes category-specific word retrieval defects for visually the predominant feature of a naming deficit. words denoting animals alone. Caramazza. ease. later proceeding to encompass Frith. Bettinardi.. 1996. dated over the past decade. Gorno-Tempini.” The term Logan. Nobre et al. (Tranel. 1991. Liddle. Logan. Bunn et al. Miozzo. 1996. 1998. 1993. the IT region. for example.. Logan. the lateral occipitotemporal junction. a variant of Pick’s disease. Hillis & Caramazza. & Damasio.. affected (in order for recognition of animals to be affected. patients with category-specific semantic impairments (Hart. For instance. 1991.qxd 1/21/08 11:14 AM Page 37 Aptara Inc. Mazoyer et al. mutism do not have abnormal language: they simply do not . 1998). patients with akinetic addition to damaging the temporal pole. Warrington spares the temporal pole but damages the anterior sector of & McCarthy. deficits in the retrieval of words denoting nonunique enti- 1996. Tranel. & Damasio. Soardi. the lesion presented concrete entities (Caramazza & Hillis. 1988. 1990. et al. usually involves the left posterior IT region at the level of Damasio et al. for details of the test- Mutism ing procedures required to separate the processes of recog- nition and name retrieval. Grabowski. & often present with pure naming deficits in the early stages Fazio.. Today there is ample evidence the lesions must involve the mesial occipitotemporal cor- that the inferotemporal cortex of the left cerebral hemi. Again. In such cases. The underlying damage is usually found in the left Work from our laboratory has shown that lesions temporal lobe in the form of atrophy. et al. 1996. 1985. 1995. Damasio & Tranel.GRBQ344-3513G-C02[20-41]. 1993. See Figure 2–17 for a Grabowski. Warrington & Shallice. Matarrese. the pre- hemisphere although damage to the right temporal pole senting signs are those of difficulty retrieving words denot- may result in a deficient recognition of unique persons ing actions and words denoting relationship of entities. The atrophy usually located exclusively in the left temporal pole can cause starts in the polar region and gradually comes to involve deficits in the retrieval of proper names for unique persons. Damasio. D) and MAP-3 (B) of the brains of four different patients with anomia. C. C. When the lesion occurs only in the supplementary intent to communicate albeit with incorrectly found language. 2004. either bilateral or unilateral. After surgery there was a lesion in the anterior sector of the middle and inferior temporal gyri (fields 21 and 20) without extensive damage to the temporal pole. which he could.GRBQ344-3513G-C02[20-41]. in the setting of some further cognitive deficits that would characterize her as having a transcortical sensory aphasia. A subject with left temporal lobectomy. See Figure 2–18 for an example of such a discussed so far. the condi- Akinetic mute patients are usually immobile. .) communicate in any form or fashion. they do not speak when spoken to. result of infarcts of the anterior branches of the anterior cere- ▼ bral artery. A. A subject with a lesion in the posterior sector of the left middle and inferior temporal gyri and the anterior sector of the occipital gyri (Brodmann’s fields 37 and 19). B. A subject with left temporal lobectomy who after surgery was left with severe impairment. with only minor akinesia. 3-D reconstruction (A. The damage in this patient could be described as a sum of the damage seen in A and B. The excised area was limited to the temporopolar region (Brodmann’s field 38). They do not speak and also cause such infarcts. the recovery is speedier with tor. This subject showed deficits in the retrieval of words denoting manipulable tools. more extensive than the one depicted in A. in body and tion is restricted to mutism. language deficits. and they and mute for weeks or months and eventually recover without fail to show any intention to communicate with the interlocu. Predictably. the condition may cingulate gyrus. A subject with a resection of an arteriovenous malformation in the anterior sector of the left temporal lobe. 38 Section I ■ Basic Considerations A B C D Figure 2–17. however. usually as a resemble a transcortical motor aphasia. There were no other aphasic symptoms. Akinetic mutism occurs with lesions of the anterior the recovery of the latter sort of patient. The patients may remain akinetic spontaneously. (For more details about lesions causing naming deficits see Damasio et al. motor area (mesial section of Brodmann’s field 6). nor were there deficits in the retrieval of unique names. During speech. This attitude is in sharp contrast with that of the patients unilateral infarcts. however. D. but also showed deficits in retrieving words denoting animals.of naming of unique persons whom the patient could. This subject not only showed impairment in retrieving the name of unique persons he still recognized. Once again there were no other language deficits. A hallmark of patients with aphasia is the lesion.qxd 1/21/08 11:14 AM Page 38 Aptara Inc. recognize. recognize. This subject showed a deficit in retrieval of words denoting living entities such as animals. In this case the excision included the temporopolar region (field 38) as well as the most anterior sec- tor of the middle and inferior temporal gyri (fields 21 and 20). Rupture of an anterior communicating aneurysm Acknowledgment—This work was supported by NIH can produce vascular spasm in both anterior cerebral arteries Program Project Grant P01NS19632. The anatomical descriptions of classic Broca’s and Alexander. Alexander. Neurology.. 30. Chapter 2 ■ Neural Basis of Language Disorders 39 Figure 2–18. non-aphasic language that in time became completely normal. an infarct in the territory of the middle branches of the ACA (inter- nal-frontal and paracentral arteries). Clinical and Experimental Neurpsychology. 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Atlas of cerebral angiography with aphasia with cranial computed tomography and the Boston anatomic correlation. Brown & Co. On the neurol- Duncan. B. B. G. M.. Aphasia and associated disorders. Bressi. M. Healton. Neurosci.. R. C. 2. the World Health imately 2 per 1. or individuals survive a stroke.qxd 06/02/2008 15:20 Page 42 Aptara Inc. and treated for several reasons. The annual incidence is approx- nature. The etiology of stroke is vascular in ori- gin and is due to an interruption of blood flow to various EPIDEMIOLOGY brain regions or to bleeding within the brain or spinal cord. 2006). . . Americans. the lion dollars for 2006. . with symptoms lasting 24 2003 approximately 2. An understanding of the pathogenesis. . physical therapist.8 per 1000 team of stroke professionals. tant since acute treatment may minimize the effects that a The incidence of stroke increases exponentially with age stroke will have on the individual. 2006). Stroke ranks third behind heart disease and cancer as cause The term “cerebrovascular accident” (CVA) is used syn. Lastly.000 individuals will suffer major neuroimaging procedures. Approximately 158. Mlcoch and care professional will be responsible for counseling the patient and his or her family. and the vascular origins. 2006). and the current acute and from the sequelae of stroke.5 million in the early 1970s to 2.000.5 per 1000 women at vernacular is necessary to communicate effectively with ages greater than 85 years (Thom et al. rapidly developing clinical signs of focal (or global) 1000 (Thom et al. to an age of 85 (Bonita. First. About 1 in 4 these professionals and to develop and participate in a men and 1 in 5 women aged 45 will have a stroke if they live plan of treatment for the stroke victim. while the prevalence rates are between 4 and 8 per “. ogy).7 per 1000 being first Organization (1989) defines stroke as a series of events. Chapter 3 Medical Aspects of Stroke Rehabilitation Anthony G. chronic stroke treatments. . ” implying that the signs of stroke occur abruptly with little warning and are usually persistent (Dorland’s Illustrated Medical Dictionary. Jeffrey Metter taining to the prognosis. the early 1990s (Thom et al. By definition stroke is will be reviewed. For example.. 1992). The purpose of this chapter is to provide the information outlined above.000 deaths onymously with the term “stroke” to denote this vascular occur per year in the United States. As will be reviewed in this chapter.4 million in early detection of the signs of stroke are critically impor. and the purpose of various treatments is OBJECTIVES obviously needed. mental status changes.. future research sory loss. 2006). and is primarily a disorder of the elderly.4 million individuals were living after hours or longer or leading to death with no apparent cause suffering from a stroke. Keeping in mind the sudden onset. A command of the stroke women for 45 to 54 year olds to 16. which is 1 in every 15 etiology. diagnostic procedures.GRBQ344-3513G-C03[42-63]. treatment. paralysis. Costs will continue to rise as more nurse. sen. the health. 1994). .. 42 . Each year. occupational therapist. a “. Second. which stroke is occurring. sudden and severe attack . of death in the United States.000 individuals having suf- other than of vascular origin. for sionals will be working with others or within a dedicated white females the incidence rate increases from 0. These numbers imply that for disturbance of cerebral function. and speech and language directions for treatments and their effect on stroke recovery disturbances (Broderick et al. has risen from 1. The event rates are higher for men and African the warning signs of stroke. the persistent deaths (Thom et al. with about 1. with 700. 1998).” fered from a stroke. In addition.. The overall cost of stroke is estimated at 58 bil- diagnosed. and outcome of stroke. these profes. how strokes are manifested. the etiology and diagnosis of stroke including the it is estimated that nearly 731. providing information per- E. and about 20% having died related to It is important for the health-care professional to know the stroke.. as can be seen with the increase speech pathologist may be the first to recognize that a prevalence of noninstitutionalized stroke suviviors. It will review the risk factors (epidemiol- Stroke is a leading cause of death and disability. including death. The recognition of transient ischemic attacks ent that stroke can have a devastating effect on the patient (described below) can also forewarn of impending disaster and the entire family. STROKE ETIOLOGY Stroke-related mortality results from the stroke itself and The most common cause of stroke-like illnesses are related from other vascular diseases. in Communities (ARIC) Cohorts (Rosamond. Whisnant. Goldberg. 1974). noted that of unselected stroke survivors. Antihypertensive Agents. The Kretschmann. 1983) demon. 2006). Early mortality varies is shown in Table 3–2. and earlier recognition of 2003). & Wiebers. and 20% to 30% tension by lowering blood pressure has been shown to required continued institutionalization. The internal carotid artery bifurcates into the Sickle cell disease anterior and middle cerebral arteries. et al. 1% to treatment of such factors have helped to reduce the incidence 25% were able to return to work. Held (1975) notes.1% the 1950s through the 1970s. particularly coronary artery to vascular disease. decrease the incidence of stroke and myocardial infarctions “the percentage of patients who can resume their capability (Veteran’s Administration Cooperative Study Group on to earn wages is lower than in virtually all other handicaps.” From these observations it is appar- Group. Hypercholesterolemia Cigarette smoking The circulation to the brain arises from two pairs of Cardiac disease arteries: the internal carotids and the vertebrals. which supply the cere- Male sex bral hemispheres over the anterior and much of the lateral African-American race surfaces of the cerebral hemisphere (Williams. to the death of Hemorrhagic Stroke neuronal tissue.. and more extensive stroke. 1999). A partial differential diagnosis for stroke disease and associated heart attacks. 1992). 43% of elderly stroke factors that have been associated with increased risk for survivors had moderate to severe disabilities that were more stroke. As an example. 1991). identification of hemorrhagic strokes (Mayo. 1970. Myocardial infarction. Danys. However. proper counseling. Parent. Hyperviscosity 1996).5% lation. 1996). the improved treatment of hyper. Lack of physical activity The vertebral artery is the first branch of the subclavian Transient ischemic attacks artery and proceeds into the cranium through the foramen . The carotid Diabetes mellitus arteries course in the anterior aspects of the neck and divide Alcohol into an external and internal branch. Sicks. the incidence of stroke increased from 1980 most significant factors associated with early mortality have to 1984 (Broderick. Improved recognition and erature. changes. SHEP Cooperative Research physical or intellectual. Toole. Improved recogni- tion and treatment of such factors have helped to reduce the incidence of stroke. and appropriate referral becomes critical. Chapter 3 ■ Medical Aspects of Stroke Rehabilitation 43 Epidemiologic studies (see Whisnant. Late mortality occurs after the initial hospitalization Leve. 1995. Table 3–1 lists Framingham Heart Study Cohort. and increasing age (Truscott. For example. 1989) and from 1985 to 1989 (Brown. The internal carotid Obesity artery proceeds to enter the cranium and supply much of the Homocysteinemia forebrain. walk unaided and discharged home. from 1993 to 2003 (Thom et al.qxd 06/02/2008 15:20 Page 43 Aptara Inc. with 7. in Rochester. Phillips. Marquardsen (1969). and the effect that the damaged region Hypertension has on the remainder of the brain. the stroke and is much higher than for the general age-adjusted popu- death rate has been declining and went down by 18. Resulting symptoms depend on the area of the brain damaged. increases are likely due to improved diagnostic methods congestive heart failure.GRBQ344-3513G-C03[42-63]. & Pajak. & Bitensky. 50% to 75% were able to of stroke. and if severe and persistent. 1991).3% mortality for ischemic and 33.. More recently. Whisnant. 1966). The scope of the problem becomes more clear when Preventive measures may contribute to lowering the inci. Both mechanisms result in rapid disruption of the ability of neurons to func- Risk Factors Associated with Ischemic and tion properly. and hypertension have been corre- caused by the introduction of CT scanning and better lated with early mortality in some studies (Ford & Katz. which implies a greater Bergstralh. The two main mechanisms are related to either loss of blood circulation to parts of the brain through thrombosis with infarction or to hemorrhage of TABLE 3–1 blood into or surrounding the brain. O’Fallon. from 1980 the for hemorrhagic stroke observed in the Atherosclerotic Risk rates have been increasing. & been alteration in consciousness. The Minnesota. In the dence of major disability and mortality as well. in an extensive review of the lit- changes in patient health status. examining what becomes of stroke survivors. O’Fallon. between 17% and 34% during the first month post stroke strated that the annual incidence of strokes declined from (Bonita. Many of these factors can be altered by life style prevalent in the oldest individuals (Kelly-Hayes. Embolism can occipital lobes. and trapping of lar artery.g. no brain Subarachnoid hemorrhage damage may occur. interconnections occur between relationship to the presence of atrial fibrillation. 1980). If the stenosis reaches a critical level. Atheroma depo- Trauma sition within the arterial wall results in narrowing or steno- Vasculitis sis of the artery. between Partial Differential Diagnosis for Stroke the left and right anterior cerebral arteries via the anterior communicating artery. This is accounted for by the ability of Aneurysm collateral arteries to take over and supply an adequate blood Arteriovenous malformation supply to the affected internal carotid (Gillilan. and the left the carotid and vertebral arteries. 1973. with embolus formation in At the base of the brain. Other sites of embolic material hemispheres. Subdural hematoma Epidural hematoma Infarction Ischemic Strokes Thrombotic Embolism Ischemic strokes occur with the complete or partial occlu- Etiology sion of arteries. forming a circular passage ventricle of the heart when the chamber has been signifi- that allows for mixing of blood from the anterior and poste.. not just from including the brain stem. platelet adhesion. As stenosis increases and flow becomes stagnate. include the atria of the heart. The blood system responds to the ulcer as it would to any other injury within the arterial wall with the laying magnum. and the occipital area. or break apart and be released into the bloodstream as an orly to the inferior medial surfaces of the hemispheres to the embolus. At the upward end of the pons. This interconnection is called the circle of mechanisms—thrombosis and embolus—are the principle Willis. cells Heart disease begin to die and an infarct develops with necrosis and loss of Rheumatic valvular disease tissue bulk (Plum & Posner. which is called a thrombosis. lactic acid). Hypertensive encephalopathy the likelihood of thrombosis within the artery increases. usually HIV Fibromuscular hyperplasia considered greater than about 70%. This deposition is called a “thrombus. changes occur in distal Moyamoya disease blood flow. Atrial fibrillation in ischemic regions. with the development of an ulcer. inferior and medial aspects of the ulcerated arterial lesions. into two posterior cerebral arteries. which can occlude a distal artery. When blood flow to a region falls below a Hypertension critical level needed to maintain cellular function and to Atherosclerosis remove accumulating toxic waste (e.qxd 06/02/2008 15:20 Page 44 Aptara Inc. 1983). The basilar artery continues along the midline of blood cells. 1980. The clinical picture with blood from separate brain arteries to redistribute to other ischemic stroke. Antiplatelets The most common causes of ischemic strokes are throm- Heparin botic and/or embolic occlusion of the artery related to ath- Arterial dissection erosclerosis. Collateral circulation. The two vertebral arteries unite to form the basi. as with any neurologic disorder. A Sickle cell disease second change results from injury to the friable and easily damaged atherosclerotic lesion. there will be an inner zone of infarction Prosthetic valve with a surrounding zone of ischemia called the penumbra Infectious endocarditis (Schlaug et al.. cantly damaged by a myocardial infarction. 1999). con- nections between the external and internal carotids. which refers to the ability of causes of ischemic strokes. is extensive. 1980). The goals of treatment are to prevent Infectious Trauma the infarction by early intervention and to protect the Drugs ischemic zone by preventing the infarct from getting larger Anticoagulants and thus limit functional disability. 44 Section I ■ Basic Considerations TABLE 3–2 brain areas. down of fibrin material. The artery supplies blood to those regions result from thrombus formed for any reason. Typically. Ross. Collateral circulation is particularly Hemorrhage important when the principle artery to a region becomes Intracranial hemorrhage compromised. depends on .GRBQ344-3513G-C03[42-63]. which proceed posteri. including the circle of Willis. Atherosclerosis is a proliferation of the smooth Cocaine muscle cells in the intima of the arterial wall with an expan- Congenital absence or atresia of artery sion and deposition of lipid within the associated connective Radiation fibrosis tissue (Ross & Glomset.” It can the pons. These two rior circulations. and connections between the three Vascular Pathology cerebral artery systems. the artery divides either occlude the blood vessel. Raichle. If collateral circulation is adequate. . A TIA is a brief focal cerebral event in which the Prosopagnosia symptoms develop rapidly. The onset frequently Perceptual dysfunction occurs during activity or exertion. This focus on the short-term tran- sient nature of TIAs is important as the use of thrombolytic therapy for ischemic stroke is most successful within 3 hours of onset. with rapid development of Anterior cerebral artery distribution alteration of consciousness. or ing one or more extremities. an emphasis has been put on Coma the fact that the vast majority of TIAs resolve in less than an hour (Albers et al. Decreased spontaneity Bradyphrenia Transient Ischemic Attacks Apraxia Abulia Transient ischemic attacks (TIA) are particularly important Akinetic mutism for the speech-language pathologist to understand because Posterior cerebral artery distribution an individual who has such an attack is at a high risk of hav- Coma ing a stroke.. Carotid territory TIAs show one or more of the following (Joint Committee. resulting in Diplopia the clinical symptoms. A hemorrhagic stroke results from the rupture of a blood (4) amaurosis fugax—transient loss of vision in one eye. both total or partial. the subarachnoid space. Symptoms include intraparenchymal hemorrhage. Such hemorrhages occur one or more of the following: (1) motor dysfunction involv- secondary to rupture of a small artery within the brain. (Table 3–3). With resolution of the ischemia. The hemorrhage can occur and/or (5) homonymous hemianopsia—transient loss of within three different spaces: the parenchyma of the brain. Intracerebral hemorrhage causes symptomatology by mass displacement of brain tissue. Hemisensory loss Clinical features are relatively distinct depending on type Homonymous hemianopsia and location of the hemorrhage. part Ataxia of the brain has temporarily become ischemic.qxd 06/02/2008 15:20 Page 45 Aptara Inc. and a 30% to 60% chance of hav- Ataxia ing one in five years. Chapter 3 ■ Medical Aspects of Stroke Rehabilitation 45 TABLE 3–3 tion. (3) visual formed blood vessels. increased pressure in Focal Neurologic Findings in Stroke adjacent and distal brain regions. loss. to as long as 24 hours. and tissue destruction at the site of bleeding. the Dysarthria Vertigo symptoms disappear. legs more than arms lar to corresponding strokes resulting from infarctions Mutism (Table 3–3). (4) gait or posture instability with . Recently. The ability to separate the two related conditions the regions of the brain damaged and the involved artery maximizes the therapeutic potential of the treatment. The most Vertebrobasilar TIAs show a different combination of frequent type of hemorrhage that would result in consul. Current imaging techniques allow for Middle cerebral artery distribution the identification of even small hemorrhages. called an arteriovenous malforma. vision with an inability to see one side of the visual field. Half of the strokes occur within 24 to Tremor Hemiballismus 48 hours after the TIA (Albers et al. 1974): (1) Hemiparesis—muscular weak- ness or clumsiness of an arm and/or leg on one side of the Hemorrhagic Strokes body. In fact. or the subdural space. usually including the face. The duration of an attack ranges Vertebral-basilar artery distribution from 2 to 30 minutes. Sensory loss Because of the high risk associated with TIA. (2) hemisensory changes. there is a 10% to 20% chance of having Hemiplegia a stroke within one year. it is impor- Intractable pain tant to understand clearly what does and does not constitute Vision loss (uni or bilateral hemianopsia) an attack. (2) sensory changes involving occasionally by bleeding from a complex of abnormally one or more extremities. (3) transient aphasia. The patient has the sud- Aphasia den onset of a severe headache. vessel within the intracranium. Neurologic symptoms are simi- Hemiparesis. 1974).GRBQ344-3513G-C03[42-63]. The patient may have two Sensory loss or more such attacks over a variable period of time (Joint Cranial nerve Committee for Stroke Facilities. During a TIA. 2002). legs more than arms Hemisensory loss. which have a Hemiplegia/hemiparesis good prognosis. while most are Paresis less than 2 to 3 hours in duration. symptoms determined by the structures that receive the tation with a speech-language pathologist would be an blood flow from this arterial complex. 2002). “simple stroke. tions is superior to aspirin. Recognition of such differences in clinical cumstances. Sandok. residual of head trauma. Two major approaches vent the formation of the thrombus.qxd 06/02/2008 15:20 Page 46 Aptara Inc. (5) seizure activity. Under the right cir. studies have shown that carotid endarterectomies are bene. and inadequate physical sentation. et al. tions other than gastrointestinal symptoms make this an gia). Canadian Cooperative and diagnostic studies.g. or vertigo occurring in combination with appealing treatment. activity are associated with increased risk for stroke. Sandok.” The key is that over time the patient is not 2006). the above. demonstrating the presence of small subtle infarctions that In subjects with atrial fibrillation. and can reduce the risk of subsequent to remove the atheromatous material from within the stroke by almost 70%. the absence of other explanations for the event. Antiplatelet Trialists Collaboration.e. (2) dizziness. aphasia. & Whisnant. A number of studies have shown that the use of aspirin lowers the risk of subse- DIAGNOSIS quent TIA. Recent cooperative ing. 2006. (9) dysphagia alone. The low risk of complica- (5) double vision (diplopia). 2006). . Mayberg. et al. imbalance. 1991). the 1994). Other antiplatelet medications may prove to be more The following are not considered as TIAs since each of beneficial either alone or in combination with aspirin.. physical examination. It attempts to prevent the formation of antiplatelet therapy (Koudstaal. multi- warranted only when overall morbidity and mortality from ple sclerosis. and this can be a high risk. while the symptoms commonly occur and are not associated having less risk of hemorrhage (Lutsep. such as many current public-health policies for improved cardiovas- scintillating scotomata ( Joint Committee. strokes. Patients with stenosis greater than 70% of the vessel lumen which minimizes the bleeding risk (Sacco et al. At times the angiogram and surgical procedure are less than 5% clinical clues suggest that what appears to be a stroke may be (Sundt. 1983). 1974). obesity. or (11) symptoms associated with migraine.. and from the surgical procedure itself syndromes (Table 3–2). endarterectomy). (4) confusion alone. (7) vertigo with aspirin may give some further reduction in risk. eral. In to their symptomatic carotid artery were less likely to incur general. The history is the most important Study Group. or unsteadiness but not vertigo. The risk of anticoagulants is bleed- carotid artery (i. In using these medications. 2006). the physician attempts to keep the value at 2. (10) dysarthria Other recommendations for stroke prevention address alone. Hypertension. The pur- determined and no dose has been shown to be definitely pose of the physical examination is to confirm the history.. malities. rapidly irregular beat- could be missed by CT. At present. and death. Lemak. Patients with stenoses in the 50% to 69% range showed less Other Causes consistent benefits (Barnett et al. showing normal recovery. Leonardi-Bee with stroke: (1) altered conscious or faints.. and/or most efficacious (Dalen.. but frequently a combination (6) progression of motor or sensory symptoms. but rather is becoming worse. 2006). and so on. treatments for TIAs can reduce the risk of subse- a stroke after undergoing an endarterectomy than if they quent strokes by 20% to 40%. It is unclear whether using these other medica- (3) amnesia alone. Frankoski. (Whisnant. cular health. particularly in males (Fields. 46 Section I ■ Basic Considerations ataxia. The main medical treat. decreases the stickiness of platelets so that they will not adhere to the atheromatous lesions. thus preventing the are being used (Sacco et al. the optimal dose of aspirin has not been physician typically does not know what to look for. increasing confusion. Anticoagulants pre- thrombus and the release of emboli. swallowing problems (dyspha. 2005). Each of and the absence of evidence for ischemia on CT or MRI. & Hardy..0 European Carotid Trialists’ Collaborative Group. cigarette smoking. seizures. Without adequate information. bleeding parameters of the blood. diabetes mellitus. International Normalized Ratio (INR) for atrial fibrillation. 1978.. 1991. & Sundt. Treatment for TIAs is successful at decreasing the risk of anticoagulation has been found to be a better treatment than impending strokes. or the development of new ment has been antiplatelet agents such as aspirin. there is a risk from the arteriogram required to define the anatomy of A large number of other disorders can result in stroke-like the blood vessels. A diagnosis is made based on a history.GRBQ344-3513G-C03[42-63]. The surgical approach is release of emboli. The second treatment approach is medical and consists of This can appear as slowly increasing weakness.0 to 3. dysarthria. 1975). aspirin). However. 2006). (8) diplopia alone. 1977. primarily the prothrom- ficial to patients with recent hemispheric or retinal transient bin time. carotid endarterectomy can lead to a greater course suggest that something is occurring other than a reduction of stroke risk than medical treatment (Sacco et al. lipid abnor- Diagnosis of TIAs is based on the transient clinical pre. ing of the heart not associated with rheumatic heart disease.. these can be addressed to lower the risk for vascular events MRI with diffusion-weighted images is the most sensitive in including stroke (Sacco et al. In gen- ischemic attacks (Barnett et al. alone. something else. Endarterectomy seems chronic subdural hematomas. 1991.. 1998). 2006). preventing thrombus formation. had received only antiplatelet treatment (e. Aspirin signs or symptoms that were not noted previously. Such illnesses include brain tumors. infections of the brain. need to be followed carefully and adjusted. part of the evaluation.. could moving away from you (Evans. Chapter 3 ■ Medical Aspects of Stroke Rehabilitation 47 In making a neurologic diagnosis.to 20-second latory monitoring of the heart and transthoracic or trans. chloride. bore tube into the femoral artery in the groin and passing it and calcium). The procedure is identify the location. including both carotid arteries and a vertebral ing tests for connective tissue diseases. tures are taken in rapid sequence over a 10. The answer to these three questions dictates the It images the vessel wall instantaneously as a real-time nature and extent of intervention. contrast medium is forced through include an electrocardiogram to evaluate the heart. Cerebral Angiography Laboratory Evaluation Cerebral angiography represents the “gold standard” for A variety of non-atherosclerotic causes of stroke syndromes determining the nature and extent of the vascular abnormal- can occur (Table 3–2). When in place. Additional the tube and into the arterial circulation. techniques are needed to evaluate the extent approach for studying the cerebral arteries. or when clinical diagnosis is uncertain. 1989). potassium. The first question is whether the bifurcation. as well as screen. The procedures allow for the estima- DIAGNOSTIC STUDIES tion of whether intracranial arterial stenosis. bicarbonate. the kind and extent of the brain damage that has occurred. including 24-hour ambu. with 3% to 5% false-positives in experi. likely of cardiovascular origin. McDicken. For is. which registers echoes related to lesion. or The role of diagnostic studies in stroke patients is to help arteriovenous malformations are present. the risk is typically less than may not be available from other sources. a patient being seen because of a sudden episode of pitch than if it is standing still. white blood cells. Routine tests are usually done to ity in cerebral blood vessels. A screening panel is done that examines Typically. Woodcock. The second approach uses B-scan Can the clinical picture be explained by a single or multiple mode ultrasonography. up the artery to the aortic arch and into the appropriate Other blood tests include syphilis serology. These tests are done because three-dimensional reconstruction of the arteries. The second question asks It presents an image of the vessel lumen and in particular where in the nervous system does the dysfunction occur? the blood column. In the of their low cost. The third question is what is the etiology of the variations in the acoustical carrying properties of tissues. or a synco. Doppler techniques have been applied to the study of intracranial arteries. 1991). Pictures are taken in several planes. The first is based on the doppler effect. that problem is based on a nervous system dysfunction. Skidmore. connective tissue. tions. lesion. aneurysm. Angiography is particularly define hematologic. and pathophysiology of the valuable in assisting the physician in understanding the problem. and a lower pitch if it is loss of consciousness lasting two to three minutes. within the blood vessel. Routine studies also artery. a sound source that moves towards you has a higher example. (MRI) (see below) and has become the most common rotic disease. An important issue for the physician is enced laboratories. 1992). image. and inflammatory dis. The (Ruggieri. necessary when considerations are being made to do a surgi- orders. 1% morbidity and mortality. and high return of information that hands of a good angiographer. the procedure is carried out by placing a small- blood electrolytes (sodium.GRBQ344-3513G-C03[42-63]. This technique of disease at the carotid bifurcation. & have had a seizure which is of neurologic origin. glucose level. The ideal would be to offers the advantage of imaging carotid and intracerebral have a procedure that would be 100% accurate in detecting circulation without the use of injected contrast media the extent of disease. and liver and kidney function. it Since carotid endarterectomy has become an appropriate takes advantage of the power of magnetic resonance imaging therapy for non-hemorrhagic strokes related to atheroscle. Masayk. safety. etiology. Typically blood studies include counts of the red and cal procedure. which is usually not neurologic but more ultrasound waves in relation to the velocity of blood flow. while x-ray pic- cardiac studies are frequently done. but this carries a definite risk. arteries. answers are needed to Ultrasound approaches are used to study the carotid several key questions. Noninvasive Carotid Studies Magnetic resonance angiography has been developed. resulting in esophageal echocardiography. Stroke is associated with disease in a number of blood-flow dynamics in patients with complex cerebrovas- other body organs and caused by other medical condi. period. accepted procedure to evaluate this area is cerebral angiog- raphy. Doppler imaging registers echoes of pal episode (faint). . and would carry no risk.qxd 06/02/2008 15:20 Page 47 Aptara Inc. & Ross. The major risk from this pro- cedure is the development of a stroke during or shortly after the procedure. Other tests have been Brain Imaging developed that can evaluate the carotid bifurcation and intracranial arterial structure with 80% to 90% accuracy The techniques examined so far have studied what occurs and far less risk. cular problems (Asslid. very weak magnets. points perpendicular to the ground when under stable con- tion differences. and appropriateness for specific response of selected elements in response to a large magnetic acute therapy (Moonis & Fisher. and is clearly delineated by both magnetized more quickly than solids. The technique is particularly useful cian to obtain three-dimensional images of the central nervous in studying the posterior fossa. As a top spins it CT is capable of differentiating tissues with small absorp. and anatomy. Emission techniques include MRI. T2 is a with an acute event. gray from white matter. relation” or “spin-lattice” reaction time and represents the Contrast between structures depends on the amount of time for the nuclei to become aligned and magnetized x-ray absorbed and the thickness. 48 Section I ■ Basic Considerations This can be studied by several imaging technologies. and will become readily than other tissues. while with CT it is dependent on pixel size. 1982). For solids. when placed in a magnetic field. on nuclear density and environment. it with a finger).qxd 06/02/2008 15:20 Page 48 Aptara Inc. The scanned because of its excellent resonating ability and amount of transmitted radiation at each integral point abundance in tissue as a component of water and all (pixel) is then calculated using a dedicated computer. or T1 and T2 imaging. 1982). within the brain are more difficult to see because specific T2 is the “spin-spin” or “transverse” relaxation time. process. while it is long for liquids (Bradley. and single photon emission com. Two measures usually studied are mag- three-dimensional image of the brain is constructed using netic relaxation times “T1” and “T2. which requires energy absorption and the emission of standard radiography. the ability to distinguish white matter from gray Each element in a magnetic field resonates at specific matter). top.” and are dependent this information. tion (i. The nuclei can flip absorption of externally administered energy and includes back and forth between the parallel and antiparallel posi- standard radiography and computer tomography (CT). radionuclides injected intravenously. and will have a conventional radiography and CT. The a radiowave. MRI uses this property. If a second energy source is applied (as by touching continuous. Two types is on the order of CT. Bonaffini et al. in the process (Bradley. because of the fixed rigid structure of the mole- Fisher. Nuclei tend to spin much as a top does. With standard x-ray. bone. following the radiofrequency pulse. cules. The wobble represents since each pixel represents an average value of transmitted a torque.. it begins to wobble. T1 is the “thermal CT studies brain structure. field. by applying a radiofre- x-rays that are unabsorbed or transmitted through the quency wave. Recent techniques have added new methods to the standard netic. 2001. DWI can be useful in differentiating stroke sub- MRI does not use radioactive substances but examines the types. Nuclei in a strong magnetic field when pulsed by a 1997).e. Distinctive structures shorter T1. making the physical properties of the fields brain by measuring the amount of transmitted radiation specific to a given element. and those taking advantage of the behavior of nuclei as small dipoles or producing images from natural or introduced energy sources. pathology. those that measure the transmission of energy through MRI utilizes a very different set of physical properties. due to the accumulation of intracellular water early in the puted tomography (SPECT). encouraging nuclei brain are recorded by sensitive film or a video image device to flip back and forth (resonate) between parallel and (fluoroscopy). density. The resolution of MRI (Hand et al. positron emis. to the fixed magnetic field. For example. & Di Piero.. CT is commonly used when a patient first presents radiofrequency wave behave in a similar manner. Bonaffini. CT obtains three-dimensional images of the frequencies. In tions. but has better contrast in distinguishing of neuroimaging methods have emerged that enable the physi. which describes a second axis of rotation for the radiation within its borders (Oldendorf.GRBQ344-3513G-C03[42-63]. Under normal circumstances. 2006). T1 depends on the physi- ber of the structures. MRI is more sensitive than CT. intraarterially. 2002). extent of the damage. Hydrogen is most commonly using multiple detectors placed around the head. 1981. 2001. In a strong mag- tomography. which contains a cal properties of the sample. the nuclei line up so that their dipoles are either Transmission tomography examines differential tissue parallel or antiparallel with the field. where CT has difficulty. Rocca. gravity differences between adjacent structures are small. absorbs x-ray much more together by looser forces than are solids. A organic molecules. and single photon emission tomography. Ketonen. and is being considered for immediate measure of how well and how long this wobble is main- treatment to identify an intracerebral hemorrhage or other tained. This provides a planar or two-dimensional antiparallel positions and measuring the radiowaves emitted image that has excellent spacial but poor contrast resolu. and atomic num. and the electrophysiologic characteristics of applies two gradients across the radiofrequency pulse that the brain. Current techniques are primarily concerned with the 2002).. the axes which include magnetic resonance imaging. tissue such as computed transmission tomography. positron emission of the nuclei point in random directions. Perfusion weighted images show . Altieri. but it is not necessarily better than other approaches study of proton distribution—water. the brain is irradiated by x-ray. netic field. Emission tomography produces images utilizing data In ischemic strokes. T2 is potential causes for a stroke-like presentation (Moonis & very short. A diffusion-weighted image (DWI) by inhalation. Such sources include mag. system. leads to an image with hyperintensity in an ischemic region sion tomography (PET). resolution is basically ditions. for example. liquids are held high concentration of calcium. from internal energy sources. & Sobel. Rubens. 1998). CT studies were the first to cally precludes time for MRI. Using a dedicated computer. In general. PWI abnormali- X-ray Computed Tomography ties outside those shown by DWI represent the penumbra. At present only two SPECT radioisotopes are Knopman. employs. Collard. At best the physician requests a SPECT scan in anomia. & PET and SPECT are two tomographic techniques Huvelle. and rapid recovery (Brunner. 1977. 1980). gamma photon. & Wallesch. 1979. 1980). Wasterlain. however. & Testa. which is brain tissue potentially salvageable (Schlaug et al. A number of neurotransmitters. Normal brain function . and neologisms with intact compre- those cases where the CT and MRI are negative and the hension and word repetition (Alexander & LoVerme. the site at size may also be critical for recovery. Seemuller. Lesion localization independent of ray detectors. Kuhl. investigations using CT have demonstrated short. and (Naeser & Hayward. perseveration. Patients without lesions in specific areas may bene- differ from those isotopes used by PET in that they emit one fit from early intensive therapy to facilitate recovery. The pre-rolandic/post-rolandic separation of SPECT are designed to measure functional changes such nonfluent and fluent aphasias seems well supported by CT as regional cerebral blood flow (rCBF). 1976). patient exhibits mental status changes that are stroke-like. Noel. dicting the recovery potential of patients with aphasia has These radiotracers have relatively long half-lives and do not been demonstrated (Selnes et al. superior temporal and infrasylvian supramarginal regions. 1978. 1981). Naeser. MRI can be useful with acute brain attacks in making abnormalities with speech and language pathology. and favors the use of CT. When PWI is used with DWI. & Coates.. Neary. which are associated with poor comprehension (Selnes. as noted by the poor which the dual photons were emitted is located with prognosis of patients with lesions involving the posterior excellent accuracy. not appear to be true (Noel et al. The reason is that while SPECT detects focal and Kornhuber. The site at which the photon was emitted is CT has been particularly valuable in the identification of located by using a collimator. Naeser & are being used to study how the brain responds to specific Hayward. Such applications aphasia (Hayward. The collimator is mounted on the bance. CT has been supplanted by MRI the decision for therapy has to be made quickly. Spatial resolution is less than the with basal ganglia involvement have resulted in aphasia that other imaging methods. phonemic para- SPECT has not been used extensively in the diagnosis of phasia. metabolism. The value of knowing the site of brain lesions in pre- 99mTc hexamethylpropylene amine oxide (HMPAO). neoplastic. made by a gamma camera with a series of parallel gamma. 1983). A specific diffuse changes of cerebral blood flow (CBF). & Larson. Bain. Kertesz et al. SPECT also employs isotopes that are injected intra. the type of radiopharmaceuticals and equipment each 1979. serving the same role. intact repetition. Monroe. 1979. PET and descriptions. Glucose is the main substrate used by the brain to produce Snowden.. & Phelps. venously.. Subcortical infarctions of the dominant hemisphere head of the gamma camera. In these cases SPECT might be helpful in determining Positron Emission Computed Tomography whether these changes are secondary to a progressive dementia or to neuropsychiatric disease (Talbot. Harlock. hypophonia. 1979). is characterized by word-finding difficulties. tasks. Chapter 3 ■ Medical Aspects of Stroke Rehabilitation 49 changes in ischemic regions outside the area of primary Brain Imaging in the Study of Aphasia infarction. it is insensitive type of “thalamic speech” has also been recognized that to the specific etiology. Metter. describe the relationship between lesion site and type of MRI can be used to study blood flow. However. Kertesz. necessitating the availability of a cyclotron.GRBQ344-3513G-C03[42-63]. such as discerning whether the characterizes the aphasia associated with thalamic CT observed behavioral changes are ischemic. & Zatz. the reverse does topes are also unique since the annihilation of their elec. stroke. which that the location of brain lesions can be predicted from apha- adds considerable expense to the procedure.. They also patients. Detection of both photons is than do small single lesions (Kertesz et al. aphasia syndromes in a manner consistent with classical sions from intravenous injected radioisotopes. 1980). 1978. Lloyd. The limitation is that the past 10 to 15 years. Specific lesions have resulted in specific based on the technology of detecting gamma-ray emis. with paucity of spontaneous speech. The half-lives of these isotopes are usually For example. Mazzocchi & Vignolo. Such information require an on-site cyclotron. metabolic. 1979. 1982). larger trons produces two gamma photons that discharge at 180 lesions result in poorer outcome and more severe aphasia degrees from each other. Hanson. the energy required for it to function. Yarnell. which is a lead shield with a subcortical lesions and their correlation to language distur- series of holes cut into it. Niccum. Within the decision for thrombolytic therapy.qxd 06/02/2008 15:20 Page 49 Aptara Inc. These methods are distinguished by cases do not fit within the model (Mazzocchi & Vignolo. They are either made from kits may be of value in planning language therapy for aphasic or are shipped directly from the manufacturer. These iso. Suger. sia type with reasonable accuracy. 1983). which typi. CT has been a powerful tool in correlating brain structural 1999). Some large approved by the Federal Food and Drug Administration for lesions are less devastating than very critically placed smaller clinical use: N-isopropyl-p-iodoamphetamine (IMP) and lesions.. or lesions. & Sugita. 1980. the presence of subcortical extension of understanding the impact of brain damage on language the infarct will be associated with frontal lobe hypometabo. Similarly Knopman. Royen. good recovery. a part of stroke and with improvement in flow with recovery. 1983.. single photon emission computed tomography hemisphere language areas.. and cortical frontopari- (PET) studies have demonstrated decreased cerebral glu. Mlcoch. Such observations appear in response to counting. Gupta. 1989). Giulibei. Using SPECT. In addition to the distant effects associated with function in undamaged tissue may be aberrant. et al. function in health and with aphasia. The data also suggested that patients with poor language recovery (Tikofsky et al. Defer. 2006) suggests a sequential response by the brain to an ischemic stroke in a select group of aphasic subjects.qxd 06/02/2008 15:20 Page 50 Aptara Inc. Galt. &Yanagihara. ataxia and aphasia) often resolves as perfusion Baron et al. 1997. Riege. & Cesaro.. is inversely correlated with stroke recovery (Lee. Yamaguchi.e. 1988. & Dipiero. and might cerebral infarction. tural lesion causing the aphasia is located (Metter et al. & Karbe. Jackson. & Holman.GRBQ344-3513G-C03[42-63]. Okuda.. Vallar et al. 1990. In the chronic phase.. Yamamoto (1980) showed that poor recovery from aphasia Studies that examine brain regional blood flow and was associated with failure of increased cerebral blood flow metabolism demonstrate that focal brain regions have clear in the frontotemporal regions in both cerebral hemispheres effects on other parts of the brain. van Loon. & Jones. Yorifu. Broca’s.. Phelps. Tanaka.. study (Saur et al.. This is followed subacutely by (SPECT) often detects areas of reduced cerebral blood flow increased activity in the left and activation of homologous larger than and remote from the ischemic lesion identified regions in the right hemispheres. Price & Crinion. language function may not be attributable only to the struc. Sisterhen. on CT and MRI. 1984. For example. Similar changes remote from the site of infarc. Hanson. & Milo. These areas include subcortical infarcts Flourodeoxyglucose (FDG) positron emission tomography resulting in cortical hypoperfusion. 1992). Moretti. little activity is found in noninfarcted left Like PET.. 1992). Heiss. returns to the remote region (Vallar et al. Hijdra. Martin & Raichle. functional activa. Lenzi. tion studies in aphasia have shown changing brain organiza. Megens 1987).. 1994).. Sakai. Megens. & Selnes (1983) ment of aphasia following stroke. Furthermore. & Verbeeten. differences between Wernicke’s. Kessler. 1987. Meyer. not absent cerebral blood flow activity in the language and conduction aphasias were found to differ on the extent region in the left cerebral hemisphere early following the of metabolic abnormalities in the prefrontal cortex. mined by CT (Kuhl. Bushnell Kempler.. et al. Rubens. thus examining how brain damage are associated with differences in the location regions are selectively responding to specific tasks. Good recovery appeared to be associated with reduced but 1990). Gupta et al. 1994. ing to music. & Regli. but rather to what occurs in other brain areas when the perisylvian region (which functions as a unit Functional MRI (fMRI) involved with language function) is structurally damaged.. etal infarcts resulting in contralateral cerebellar diaschisis cose metabolism (hypometabolism) in the brains of stroke (Bogousslavsky. Kawabata. 1992). Metter Tachibana. and during recovery lism. the size of the cerebral blood-flow defect account for some aspects of the aphasic language distur. These metabolic changes and the associated subcorti. it has been and Cardebat et al. 50 Section I ■ Basic Considerations is dependent on the availability and utilization of glucose. Limburg. 1988). Recent cal structural changes are associated with the expressive work suggests a sequential but complex response by the aspects of the aphasia (Metter. Hillman.. 1985. Furthermore. a . & Cappa & Vallar.. Abe. tural lesion. Ammons. 1981. 1981. During the acute phase immediately following the Single Photon Emission Computed Tomography onset of the stroke. (1994) found that good recovery from found that essentially all patients with aphasia studied by aphasia was associated with increases of cerebral blood flow FDG PET demonstrated metabolic abnormalities in the left in the right inferior frontal region and the right middle tem- temporoparietal regions independent of where the struc. 1988. The behavior associated with this phe- Metter et al. 1991). 2005). 1980. 1989. respectively. Studying brain metabolism has also demonstrated aspects MRI offers an opportunity to study brain activity. For most middle cerebral artery Currently. Distant regions of hypometabolism suggest that the et al. Metter et al. patients that extends beyond the zone of infarction as deter. et al. & Gybels. and listen- to allow for more unifying concepts regarding the develop. Ghaemi. Ukita. 1999.. poral cortex. 1992. bance and in the recovery process (Metter. as esti- of the role of subcortical brain structures in aphasia (Metter. & Alazraki. 1990. 1988. Bushnell.. & Hanson. 1981. from stroke (Wise 2003. Goffin. 1981. 1999. the larger the defect the less likely the patient will exhibit et al. The the brain not believed to be directly responsible for most language regions remained hypoperfused during recovery in aphasias (Metter et al. conversational speech. 1985). Miklossy. One Kuhl. That tion with increasing activity in the right hemisphere (Muller is. Halkar. nomenon (i. tion have been found in many stroke cases (Kuhl et al. Thiel. Differences in the location of subcortical structural mance of specific activities. Metter et al. fMRI represents the most dynamic approach to distribution strokes. during the perfor- 1992). Frackowiak.. & brain to aphasia resulting from an ischemic stroke. in response to a listening task. Lenzi. mated by regional changes in blood flow. changes in overlying cortex. 1997). treatment is dependent on increase cerebral blood flow and to increase arterial pressure identifying the etiology. 1998). Others have Based on the findings of the NINDS study. since FDA approval directed to the preservation of life and to preventing expan. CEA has been shown to significantly reduce acute ischemic stroke has been limited to the preservation the chances of having a second stroke (North American of life.. Ezekowitz & Levine. and the use of emboli is formed. t-PA has been substantially underused (Bambauer. nificant hypertension. Haynes et al. patients treated with t-PA were at least 30% more likely to have minimal or Chronic Therapy no disability at three months poststroke onset. physicians. & Sherman. and were not taking anticoagulants. Hopefully. Treatment of the former is by either removing brain associated with the acute stage of stroke. the other hand. having a second symptomatic stroke within 3 years is minogen activator (t-PA) for the treatment of acute ischemic reduced as much as 50% after undergoing a CEA when stroke. tect and improve blood flow to this region during the early For those patients who do not meet the above stringent stages of stroke. and carry out . 2005). 21%). and the ability of both the noid or intracranial hemorrhage. Acute Therapy physicians have been reluctant to provide t-PA due to possi- With ischemic strokes a region of infarction is surrounded ble liability. The relative risk of study to determine the efficacy of recombinant tissue plas. On tially a “clot buster” in that it breaks the embolism apart. The goals of treatment are rehabilitative at this stage in the t-PA group (6.. 2006). Symptomatic Carotid Endarterectomy Trial Collaborators. 1977. chronic therapy. for three primary reasons. As compared with a placebo control group. communicate. 1991)..qxd 06/02/2008 15:20 Page 51 Aptara Inc. Unfortunately. signs and symptoms of stroke and the importance of getting to the hospital immediately when they occur. The initial or acute therapy is al. 1991. Since approval t-PA has been TREATMENT shown to be an effective treatment of ischemic stroke in The treatment of a patient who has developed a stroke can community hospitals as well large medical centers (Chui et be divided into two parts. The resulting improvements in lan... First. 1998. primarily from the internal carotid artery corticosteriods. The NINDS found that patients who had received t. drug. had not undergone guage likely reflect the extent of damage and functional loss major surgery within 14 days.” or by providing antiplatelets beneficial and until recently the medical treatment of such as aspirin. if the etiology is cardiogenic. the thrombus from the artery by a surgical procedure called none of these neuroprotective methods have proved to be a “carotid endarterectomy. had a CT scan showing no evidence of intracranial cation. The reorganization with eligible for this drug. treatment reduces overall morbidity and mortality (Easton strated significantly better recovery at 3 months post-onset. the patient must have had the onset of increasing activity in the contralateral hemisphere leads to symptoms of an ischemic stroke within 3 hours of taking the an alternate strategy for language processing and communi. part or. had no history of subarach- in the dominant language areas. The second Bambauer. Chapter 3 ■ Medical Aspects of Stroke Rehabilitation 51 shift occurs back towards the left hemisphere. vent further embolization. and Stroke Study Group (NINDS) reported a double-blind Gasecki et al. t-PA is a drug delivered intravenenously and is essen.GRBQ344-3513G-C03[42-63]. & Zivin. compared to medically treated patients (ECSTC. showed no evidence of sig- dominant and nondominant hemispheres to adapt. trauma within the preceding 3 months. Moore et al. sion of the disability associated with the stroke. Johnson. owing to the relatively high incidence of intracerebral bleeding. hemorrhage. Third.4% vs. Second. The new strategies can result in improved communi. better utilized in the future. Evidence suggests that such PA within 3 hours of onset of stroke symptoms demon. 1995). t-PA received noted persistent changes in the response in the right hemi. had not had another stroke or serious head cation and language. or where the stroke-producing in an attempt to force blood into the zone. This zone is called the “ischemic penumbra” and population. with better education of the infarction.. and third-party payers. Grand et al. Mayberg et al. 1994. 0.6%). anticoagulants allowing blood flow to return to the deprived region of the such as heparin and warfarin (coumadin) are given to pre- brain. whereby the patient can walk. These include the use of vasodilators to criteria and cannot take t-PA. 1991b. drugs aimed at reducing the swelling of the or the heart. However. To be tasks (Price & Crinion. formal Food and Drug Administration approval in 1996 for sphere to both speech production and to comprehension the treatment of patients with acute ischemic stroke. 1994. 1999). In 1995 the National Institute of Neurological Disorders 1991a. the t-PA procedure has not been ade- by a zone whose tissue can either recover or progress to quately reimbursed. is directed towards rehabilitation the population as a whole has not been educated as to the with the reestablishment of as normal a life style as possible. t-PA will be extensive efforts have been made to develop methods to pro. However mortality was and are generally aimed at teaching or providing the means lower for the t-PA group at three months (17% vs. The one neg- ative result was that at 36 hours after onset there was a Chronic therapy begins as soon as the patient is medically higher incidence of symptomatic intracerebral hemorrhage stable. did not have a history of gastrointesti- nal or urinary tract hemorrhage within 21 days. . Rehabilitation the end of treatment (Galynker et al. speech-language. For example.. Sandok. outpatient clinic. contrast. 1986). and 30 years this concept has undergone a radical change. Lankhorse. Sinyor et al. patients with multiple disabilities and those who can tolerate These patients respond poorly to rehabilitation regardless of at least 3 hours of physical activity each day (U. functional modifications is brain plasticity or neuroplasticity. and recovery cations. behavioral management plegia (vs. Ager. & Ruderman.. Furthermore. bilitation: (1) dealing with co-morbid illnesses and compli. 2005). 1998). hard-wired after puberty and immutable. and the biochemical..GRBQ344-3513G-C03[42-63]. 1997). occupa. However. organ. Rifat. The extent and inten. their degree of physical disability (Dombovy. Surprisingly. social services. We (6) preventing recurrent vascular events (Gresham et al. & Keenan.qxd 06/02/2008 15:20 Page 52 Aptara Inc. the subcortex—the level at which neurons network ery. & Cenkovich. or in the home. Duncan Basford.. 1997. and/or external stimulation (i. programs can be conducted in a number of settings. rons are capable under certain circumstances to either par- The severity of the neurologic impairment has been tially or completely take over the lost function. An American Heart Association panel has For many years it was believed that the brain was a static stated that there are six major areas of focus in stroke reha. 1996). ness) associated with frontal lobe disease or “anasognosia” sity of rehabilitation is still unclear (Kwakkel. continued improve- ment in language performance can be observed for many years following the onset of aphasia (Hanson. the effects of psychiatric dis- her bed routinely. 1995. This type of patient is indifferent to the surrounding evidence that patients do better in a dedicated stroke unit. 1970).. Department of Health & Human Services. 1989). environment. (3) maximizing psy.S. He or she shows little or no ambi- mendations are that rehabilitation units should be used for tion and makes feeble efforts at achieving independence. 52 Section I ■ Basic Considerations activities of daily living (ADLs). In the past 20 to of societal reintegration. Subsequently. was a result of a chosocial coping for both patient and family. researchers as well as to clinicians who treat stroke victims. patients demonstrating an “apathy syndrome” or Formal rehabilitation entails the disciplines of physiatry.e. recom. the clinician et al. psychology. The term shown to have the most effect on the outcome of stroke used to refer to the brain’s ability to undergo structural and recovery (Lorenze. cortex. & Department of Health & Human Services. Clark & Smith. Schmel’kov. the hemisphere or left temporal lobe damage. (lack of awareness of disability) resulting from right cerebral Koelman. These modifications happen as a result of neurologic injury ing severe to profound neurologic impairment and/or hemi. it is important to note which factors affect aged brain regions and that after a stroke the remaining neu- overall stroke rehabilitation or outcome. and physical. cells that have the ability to take over the function of dam- 1995). 1958. & RESTORATIVE NEUROLOGY Riege. . Initially. brain damage resulted in a loss of function. (5) improving quality of life. Anderson. sible (U. 1998). Patients demonstrat. Early mobilization is advocated whenever pos. 1998). Nobbs. & Koetsier. time of recovery varies. 1986. Patients with global aphasia or hemineglect tend to and communicate—the cellular. (4) promotion reorganizational process within the brain. Lastly. Wagenaar. At present. nursing effect of the stroke has on others. poststroke participate in their ADLs and gradually getting the patient depression has not been found to be consistently correlated into a lounging or wheelchair for progressively longer peri. Metter. should not assume that this behavior is purposeful. 1989. However. often explaining lack of facility. especially in seri. Stroke patients with depression are not less function- 1995). (2) maximizing independence. Department of Health and Human Services. There is 1998). Another goal is to provide stimulation by orders such as depression and apathy may also have a nega- either talking to the patient or having him or her actively tive effect on stroke recovery. These changes occur at all levels including the communication deficit also plays a role in the stroke recov. motivation as being tired.S. 1982). from brain damage. hension of spoken language) or without sensory neglect (the ously disabled patients. “negative symptom complex” tend to stay longer in rehabili- nursing. He or she expresses no concerns about the Stroke care can be provided in a rehabilitation unit. (Eastwood. U. It is often The goals and techniques utilized by each type of therapy the sequela of brain damage such as “abulia” (lack of willful- are beyond the scope of this chapter. this might be as Patients with these deficits are likely to be less independent simple as preventing contractures and decubiti (breakdowns than those with other types of aphasia (with better compre- and ulcerations of the skin) from forming. Degree of therapy). hemiparesis) tend to stay longer in the hospital such as the stimulation provided in speech and language and become less functional (Harvey et al. Gersten. DeRosa. such as from a stroke.. now know that the brain is capable of and does produce new 1997. with outcome or length of stay on a rehabilitative unit ods each day.. tation and are less functionally competent and independent at tional. and vocational therapy.S. This will help the patient actively participate in a ally competent but tend to have less active life styles than rehabilitative program by preventing her or him from patients without depression (Clark & Smith. This entails passive ranging of a ability to attend to events in the left or right hemispace) hemiparetic arm and/or leg and rotating the patient in his or (Paolucci et al. What respond poorly to rehabilitative efforts aimed at teaching precipitates these changes has been of particular interest to ADLs and improving mobility (Paolucci et al. In becoming deconditioned. Lutsep. (2005). whether undamaged cortical was unable to flex or extend his fingers. region representing the hand. Electrical cortical stimulation (ECS) is a method by which ECS has been also studied on a limited basis with human subthreshold electrical impulses are applied to target corti. (2003) found that mon- plasticity is restorative neurology (Druback. ful after the period associated with spontaneous recovery. resulting in infarct occurred 19 months prior to undergoing a combina- the movement of that appendage. The thrust of the research tion of subthreshold epidural (electrodes placed on the dura has been to determine whether the application of ECS above the cortical region of interest) motor ECS and occu- concurrently with rehabilitative therapy results in better pational therapy for 3 weeks. 2004). Ten to 14 days showed significant improvement of arm motion. In this study patients which time they either received 50-Hz (subthreshold) stim. transcortical magnetic stimulation. Chapter 3 ■ Medical Aspects of Stroke Rehabilitation 53 Specifically. Importantly. The strokes had occurred 9 skill training in rats with induced motor cortex infarcts. Teskey. ECS with rehabilitative training enlarges the cortical region several observations were made with the above investiga- responsible for forelimb movement after focal ischemic tions. after treatment he regions can be enhanced or positively potentiated by sub. The term used to ECS combined with motor training has also been studied describe those treatments that modify or enhance brain in nonhuman primates. later electrodes were implanted in the perilesional cortex. and neu. cortex will enhance arm recovery even after the period of itive potentiation of the brain. could pick up a pencil. patients with infarcts to the brain stem. Brown. ings. cortex. & Cramer (2006) used a protocol identi- The rats then began 10 days of rehabilitative training at cal to that used by Cramer et al. patients in the active treatment nificantly greater rate of improvement of forelimb move. While much of the work has showed that poststroke interventions are not limited to the been done with animal models. group improved significantly better than patients receiving ment.5 to 5 months after incurring an induced infarct to In the past 10 to 15 years researchers have concentrated the motor hand cortical region demonstrated a significant on three methods to potentiate the brain: electrical cortical improvement in addition to having a larger peri-infarct stimulation. the after rats underwent 2 weeks of a food-pellet task. subjects. (2005) employed the same protocol on 13 Atkins-Mair and Jones (2003) studied both the behav. the subthreshold group demonstrated a sig. To date no studies have looked at the combination of Monfils.. Brown. and pick up ball bear- threshold electrical stimulation. ongoing at the Rehabilitation Institute of Chicago and the ing with ECS most likely results in “strengthened synaptic University of Chicago. & keys receiving hand-movement training with subthreshold Dodd. Last. ioral and dendritic effects of combining ECS with motor. However. Cramer. looking at the effectiveness and .GRBQ344-3513G-C03[42-63]. As might be cortical changes (i. print letters. In to 68 months before receiving 3 weeks of physical therapy this study rats were trained on a skilled forelimb-reaching combined with epidural ECS to the motor cortex. First. and subcortical/cortical regions. ECS 3. thus enhancing recovery. That is. The as stimulating the hand area of the motor cortex.” which in turn involves long-term cortical potenti- done to enhance the brain’s ability to learn after a brain ation associated with learning. Goertzen. or no stimulation. indicating that that regardless of the infarcted region ECS of the motor the structural cortical changes were associated with the pos. sented a case report of a 65-year-old patient who had a right tion that does not result in a motor or cognitive action such spastic hemiparesis secondary to a subcortical infarct . injury. were limited to those who had cortical and/or subcortical ulation. Like that three groups. An infarct behavioral changes induced by ECS appear to be correlated to the forelimb cortical region was then induced and cortical with changes in cortical representation as well as structural electrodes were placed around the lesion. this study ropharmaceutical stimulation. Of the strokes that resulted in upper extremity paresis. & Weinand (2003) pre- cal areas. research has concentrated on what can be efficacy. In a similar study. human translation studies period immediately after the brain insult but can be success- have begun to emerge. Cramer et al.qxd 06/02/2008 15:20 Page 53 Aptara Inc. subcortex. In com- task and then underwent an operation that induced parison to a sham group those patients who received ECS ischemic lesions to the sensorimotor cortex. 250-Hz stimulation. as of this writing a project is larger polysynaptic potentials. Flynn. spontaneous recovery has ended. they showed a greater density of den. (2003) investigated whether Although more extensive large sample studies are needed. Makely. Plautz et al. These studies tend to show dritic processes in the perilesional cortex. They conjectured that train. “Subthreshold” refers to a level of brain stimula. In addition. the combination of ECS and rehabilitative ther- infarct.e. Lutsep. found in the previous study. lation during postinfarct training. increased dendritic density). Klein et al. Before treatment the patient recovery of function. Weinand. & Young (2003) in a nearly identical investigation ECS (cortical or epidural) and language treatment for found that rats receiving stimulation during retraining had patients with aphasia. rehabilitation treatment only. cortical maps were made apy appears to enhance recovery from stroke . and safe. To answer this question. ECS and epidural ECS appear to be well-tolerated receiving ECS than those found in rats receiving no stimu. In turn expected the cortical region surrounding the infarcted area this most likely represents the long-term potentiation of the that represented forelimb movement was larger for rats brain. Second. its compensatory value is more limited. However. spheres.qxd 06/02/2008 15:20 Page 54 Aptara Inc. aphasia recovery (such as that found in the use of slow TMS tribute to stroke recovery. 1998. the above investigations demonstrate several Fridman et al. Watanabe. while the right IFG may be important for language function while TMS to the damaged hemisphere resulted in delayed in some patients. three demonstrated PET activation of Hallet. & Cohen (2003) applied TMS to the motor cortex of the left inferior frontal gyrus (IFG). As we found with ECS. Hoffman & Cavus. As a group Transcranial magnetic stimulation (TMS) is another these patients were able to name significantly more pictured method that has been shown to be an effective way of poten. post-onset of a left middle cerebral artery stroke. the motor recovery of patients with stroke (Table 3–4) . and hypertension. it has been used to determine the threshold epidural ECS is applied to the language region relative importance of the right cerebral hemisphere of in the left cerebral hemisphere while the patient receives patients with aphasia. identification of cortical regions affecting recovery. sional brain to determine whether deactivating this region The effects of pharmaceuticals on stroke recovery had would result in better motor improvement for patients with also been studied. 5 days a week. including the cortex of the affected hemisphere was capable of reorganiz. TMS entails plac. Slow pulses (1 Hz) preted their results to indicate that activation patterns seen reduce excitability of the region while rapid pulses (3Hz) in the intact right cerebral hemisphere are “maladaptive. TMS was applied to the primary that inhibit recovery and thereby might be a maladaptive motor cortex. patients with aphasia. In a unique investigation. 2002). the left IFG may be better suited to assist language hand. while the remaining the intact and damaged cerebral hemispheres of chronic eight patients showed activation of the IFG in both hemi- stroke patients with a paretic hand. This suggests that the contralesional region of the depression. The investigators concluded that In conclusion. This tiating as well as depotentiating the brain. Werhahn. the subjects with stroke. indicating that the contralateral nonparetic hand and not the paretic hand. TMS may enhance recovery In a treatment study. These include seizures. It TMS has also been used to study the clinical recovery is called the “Northstar project. Chuma.” In this investigation sub. but not by the ipsilateral hand and arm. In the future TMS may be an impor- sphere resulted in delays in the reaction times of the paretic tant adjunct to language treatment of stroke patients with hand. Much of this research has stemmed from stroke. activation or hyperexcitability of regions on the interest (Pascual-Leone et al. Kadon. intact right cerebral hemisphere often seen in PET and 2002. from aphasia. they found that those the stroke patient’s need for drugs for the treatment of patients receiving slow TMS to the contralateral region had complications that may compromise his or her health and a greater pinch acceleration than patients receiving sham overall recovery.GRBQ344-3513G-C03[42-63]. while six arm. language therapy. These researchers inter- pulse to the underlying brain region. stim. not as a monotherapy but in combination with & Ikoma (2005) applied slow TMS (1 Hz) to the contrale. aphasia... hemisphere. Specifically. In normal subjects. When fast TMS was applied to each of these ulating the motor cortex on one side of the brain results in regions. Conforta. Naeser et al. to assisting recovery. When TMS patients showed a similar response when TMS was applied was applied to the stroke patients. more stroke recovery and treatment stud- recovery of motor function was primarily due to the reorga. The pattern of response was similar in the healthy and recovery. Takeuchi. Fraser et al. especially studies that are nization of the intact motor cortex of the damaged cerebral double-blinded and employ a large patient sample size. However. hyperanxiety.” increase the excitability or potentiates the brain region of That is. fast TMS (4 Hz) Winhuisen et al. stimulation of the right IFG resulted in increased abnormal motor performance in the contralateral hand and reaction times on a semantic task for five patients. Matsuo. We anticipate the results from this study in the 10 days in four patients with aphasia who were 5 to 11 years near future. (2004) also found that the intact motor important trends that deserve further study. and those that enhance cortex of the affected and intact cerebral hemispheres. and hemiparetic recovery). those ing impaired movement. lower verbal scores were associ- intact cortex was associated with delayed reaction times of ated without the right-sided TMS effect. Many of these drugs have intact hemisphere actually inhibits rather than promotes been shown to impede recovery in laboratory animals and recovery. reaction times to the paretic hand and not the nonparetic That is. ies involving TMS are needed. In a study combining PET with To determine whether the intact (undamaged) motor cor. and ventral premotor response of the brain to damage. dorsal premotor cortex. One area of TMS research has fMRI poststroke studies may interfere rather than promote been to identify those intact cortical regions that may con. (2005) found that of 11 tex has a role in recovery. Using a double-blind method. TMS recovery indicating that these regions are more predisposed applied to the dorsal premotor cortex of the damaged hemi. 3 hours a day. language treatment. for 6 (2005) administered slow TMS to the right Broca’s area for weeks. from aphasia. TMS. improvement was maintained for 2 months for one patient ing a figure-eight coil on the scalp and delivering a magnetic and 8 months for three patients. 54 Section I ■ Basic Considerations safety in combining epidural ECS and aphasia therapy. the stimulation of the to the left IFG. objects and at significantly reduced reaction times. and to specific thalamic and sub- is needed to determine their effect on stroke recovery. and dopamine (DA). and the antiseizure agent pheny. It acts on the sympathetic nervous system in . or impede production or enhance the antihypertensives clonodine and prazosin. 1990. ND  no data. also see Goldstein. anxiolytics. ID  insufficient data. the major drawback to these retrospective sively studied in both animals and human beings after brain studies is that it is difficult to determine whether the nega. (Goldstein. Of these ery and were less independent in their performance of only the effects of NE and DA agonists have been exten- ADLs. Pharmacologic agents that specifically act on the central Goldstein. However. serotonin (5-HT). injury. 1998a. anxiety. etc. enhance stroke recovery. dopamine-receptor metabolism (antagonists) of specific neurotransmitters antagonists.. including the metabolism (agonists). tend to demonstrate significantly poorer motor recov. thalamic nuclei. depression. A double-blind eral tegmental areas of the midbrain and is projected to all prospective investigation of a specific drug or class of drugs areas of the cerebral cortex.qxd 06/02/2008 15:20 Page 55 Aptara Inc. (GABA).GRBQ344-3513G-C03[42-63]. Chapter 3 ■ Medical Aspects of Stroke Rehabilitation 55 TABLE 3–4 Common Drugs and Their Effect on Stroke Recovery in Laboratory Animals and Human Beings Effects Neurotransmitter Action Clinical Use Animal Human Norepinephrine agonists Amphetamine Stimulant   Methylphenidate (Ritalin) Stimulant   Norepinephrine antagonists Prazosin Antihypertensive  ID Clonidine Antihypertensive  ID Propranolol Antihypertensive NE NE Dopamine agonists Bromocriptine Stimulant ND ID Apomorphine Stimulant  ND Dopamine antagonists Halperidol (Haldol) Tranquilizer  ID Spiroperidol Tranquilizer  ND GABA agonists Diazepam Anxiolytic  ID Phenytoin (Dilantin) Anti-seizure  ID Phenobarbital Anti-seizure  ID Carbamazepine (Tegretol) Anti-seizure NE ID Serotonin (5-HT) agonists Trazodone Antidepressant   Desipramine Antidepressant  ND Fluoxitine Antidepressant NE  Amitriptyline (Elavil) Antidepressant NE NE Nortriptyline (Pamelor) Antidepressant ND NE Key:  positive effect. NE  negative effect. tive effect was due to the drugs or the disorders treated by Norepinephrine is produced within the pons and the lat- the drugs (e. Morganlander.). These agents can be classified Essentially these retrospective studies have shown that according to whether they increase production or retard patients taking commonly prescribed drugs. Matchar.g. 1997. such as norepinephrine (NE). gamma-aminobutyric-acid toin. & Davis. 1995. 1998b for nervous system have been studied as to whether they a review). Using a simi. Regardless. recruited ment was terminated. Leiguarda. accelerates aphasia recovery. such as and double-blind placebo-controlled studies. Ashtry. Tatum. Bragoni et al. Sabe. the amount of dosage. significantly greater language improvement. 1 week after the treat. the data from these studies were Combining amphetamine with language treatment of generally episodal. and the dosing Crisostomo. controlled studies. 1998). 1992. Duncan. Smith. placebo-controlled investiga- their strokes. 1988. the recruitment of brain tissue surrounding the Nicholas. her colleagues (1991. & Bahrami. Similar findings have been found in human beings. Gonzalez. and continues after the patient stops taking amphetamine and mesial frontal cortex. followed by a 1-hour session of intensive speech and lan. leagues (1991. In patients with nonfluent aphasia secondary to stroke (Albert. Each was given 10 to 15 mg of amphetamine tions have been since undertaken (Gupta. Chrotowski. At 6 months ment only occurred when amphetamine was given in con. Other uses include the treatment strated continued accelerated motor recovery up to 12 of akinetic mutism (Echiverri. The effect of bromocriptine on stroke recovery from Toussaint. 1995. has on the motor again that combining amphetamine with language treatment recovery in laboratory animals (Feeney. Dopaminergic agents such as Sinemet well past the period of spontaneous recovery. Gold. 2001). the amphetamine group demonstrated enduring. & guage therapy every fourth day for 10 sessions. (2001) demonstrated amphetamine. Walker-Batson. the differences between the groups continued to increase junction with motor training. 1988). Walker-Batson et al. onset of aphasia were randomly assigned to either receive a The common finding of these studies is that amphetamine 10-mg dose of dextroamphetamine or a placebo. respectively) of and their 6-month predicted overall PICA scores were bromocriptine and after a wash-out period were placed on . and language therapy sessions. Raymer Schwenkries. 1988. Unwin.months post-onset. 1975). At 3. Morgan. Morgan. One week after the 10 sessions of cerebral injury is induced and that the improvement is combined treatment. Cuerva. five bral infarction (Cohen. Pleger. 1988) and apathy due to bilateral thalamic strokes another NE agonist. addressing the safety. 2006).. Salverezza. 40% greater than patients who received physical therapy The neurotransmitter dopamine (DA) is produced in the and a placebo. effect on stroke recovery (Grade. Leiguarda. large sample. 2000. receiving this drug exhibited significant improvements in indicating that this drug may improve the speech fluency of mood. Propst. Boyeson & Feeney. 1991. Sabe. & Starkstein. Amphetamine treatment but were found to be insignificant. Using a nearly identical injury might be reversed by increasing the production of treatment paradigm but this time in a double-bind placebo- NE. aphasia therapy. Curtis. Hemiplegic and bromocriptine have been used for many years to patients who received 10 mg of amphetamine every fourth improve the initiation and ease of movement of patients day for 10 sessions paired with physical therapy demon. & Jacobson. has also been shown to have a positive (Catsman-Berrevoets & Harskamp. Based on of the six patients with aphasia demonstrated over 100% of the assumption that motor deficits secondary to cerebral their 6-month predicted score. The studies by Gupta and 3 days prior to initiation of treatment. then again at 3 months post-stroke patients with chronic. Mlcoch. Waltz. 1992. 1992. MacLennan.. Janghorbani. & Blackwell. 1984. & Coker. employing a single-subject test-retest patients with aphasia has also been studied in open-labeled design without adequate experimental controls. 1995) and Sabe et al. & Moritz. Of the six patients. several investigations have looked at the effect that controlled study. Redford. Early studies were promising. Methylphenidate (Ritalin). four had achieved over 94% of their and is associated with wakefulness and alertness. Twenty-one patients with acute 1982. Cornelius. Patients with acute stroke aphasia has been studied. including a placebo condition and blinding the patient and lar experimental paradigm. However. Malin. However. Morley.GRBQ344-3513G-C03[42-63]. The Porch Starkstein. Gupta & Mlcoch. with Parkinson’s disease. combined tends to accelerate the motor recovery in rats and cats after with language therapy. VanDam. Merens. 2004).qxd 06/02/2008 15:20 Page 56 Aptara Inc. Walker-Batson and her col. et al. the two stud- alone did not accelerate recovery. & Davis (1988) schedule. Comparisons of their 3-month PICA overall scores patients took a daily dose (15 mg and 60 mg. Index of Communicative Ability (PICA) was administered Chitsaz. and motor functioning. & infarcted region) (Tegenthoff. Also common to these studies is that improve. & Law. are needed before this psychostimulant can be showed that patients with stroke who took amphetamine prescribed as a “standard of care” for stroke patients with with physical therapy demonstrated a rate of improvement aphasia. 56 Section I ■ Basic Considerations that it prepares the brain to cope with stressful situations made. Bachman & amphetamine has also been shown to result in motor plastic. ity (i. Hovda & Feeney. & Brookshire.e. 1995. 1984). Reisi. & Helm-Estabrook. Dawson. indicating that this psy. nonfluent aphasia. the examiner. 1992) studied six patients within 30 days of Four group double-blind. months after the onset of stroke. Scolaro. & substantia nigra and the ventral segmental regions and pro- Greenlee (1995) also showed that this accelerated recovery jected to the caudate nucleus. ability to carry out ADLs. a powerful NE agonist. 2000. A reduction projected 6-month score at the end of the d-amphetamine of NE has been found in rat and cat brain stems after cere. In each study the onset.. & Silman. putamen. addition the effects of combining motor training with Bachman. globus pallidus. ies show that amphetamine can be a powerful adjunct to chostimulant is a “performance-enhancing” drug. This will hopefully enhance the stroke was different in that each patient was given a 60-mg dose of patient’s overall recovery. many new thera- though each group had significantly improved from base. carotid endarterectomy) and/or pharmaceu. Obviously a study of this type is needed. High doses of that is constantly changing as the environment requires and bromocriptine were not found to be a reasonable treatment is continually adding new cells that may have the power to due to significant side effects. changes in the patient’s sensory.” ment was not given. thereby increasing the effective- Interestingly. as was ture to command. Areas that need to be considered by the health-care 4. bromocriptine had no effect on protective agents have been studied. It is this view (2006) employed 38 patients with acute nonfluent aphasia that has lead researchers to the implantation of fetal brain- who were randomly assigned to either a group receiving a stem cells into the brains of patients with Parkinson’s disease 10-mg dose of bromocriptine or a placebo. six dropped out one that is “hard-wired” and changes little after puberty. stroke 2. The third study. except the patient’s ability to speak fluently. was not tested. stroke. and by treating the patient should include procedures designed to identify surgically (i. The last study by Ashtry et al. though The future of stroke treatment lies in how we view the information pertaining to the type and intensity of treat. conducted by Bragoni et al. Unfortunately. within the near future.e. The physician’s depends on eliminating or minimizing those risk fac- responsibility is to identify those risk factors associated with tors associated with cerebrovascular disease. noninvasive and invasive cerebral angiography and tion therapy) as needed based on the specific needs of the echocardiography.” one showed significant language improvement. antihypertensive.e. As compared to the placebo condition. it may potentally tration was not tightly coupled with language therapy. like amphetamine. ges. or overall global language score. individual patient. KEY POINTS FUTURE TRENDS 1. These include tically (i. and anticoagula.GRBQ344-3513G-C03[42-63]. The DA agonists in general) may be performance-enhancing importance of speech–language pathologists will lie in their drugs.e. bromocriptine combined with aphasia therapy. While the pre- patients with chronic nonfluent aphasia while one used liminary results (published and unpublished) from this patients with acute-onset of aphasia in which drug adminis. Strokes are secondary to vascular disease including educating patients regarding the risks and associated dis. stroke and to eliminate or minimize their potential effects by 3. reviewed in the last section of this chapter. brain. enhance the cognitive skills of the individual. The remaining five patients now understand that the brain is a “dynamic structure. naming. The initial examination of the patient with stroke agement of established diseases. embolic. Patients with transient ischemic attacks are at a high provider include recommendations for implementing life risk of having a major stroke within 5 years. We due to secondary side effects.qxd 06/02/2008 15:20 Page 57 Aptara Inc. the question of whether bromocriptine (or ness of stroke treatments such as language therapy. ment to their patients. diagnosis and treatment of stroke. Regardless of the the infarct (i. reducing the extent of functional brain damage resulting . cognitive. Chapter 3 ■ Medical Aspects of Stroke Rehabilitation 57 placebo tablets. including fact. t-PA has the potential to reduce the degree of prove to be an effective treatment of chronic nonfluent brain damage by quickly returning blood flow to the aphasia. Three studies used ability to select the appropriate treatments. (2000) affected region. and to understand spoken and printed language when the cascade of events resulting in brain-cell death. To date there has been no investiga- tion of whether bromocriptine is performance-enhancing drug in either laboratory animals or human beings. some things have changed but much is unchanged in the and/or speech and language skills. Stroke is a neurologic disease of prevention and remains a neurologic disease of prevention. thrombotic. In an attempt to save the tissue surrounding after each phase (drug and placebo trials). 6. research are mixed and in their infancy. to for t-PA. motor. Stroke is a neurologic disorder manifested by sudden Since the fourth edition of this book was printed in 2000. For the most part. three of the four studies did not provide language treat. tumors into patients with stroke. style changes that can reduce the associated risks. by man. antiplatelet. ischemic penumbra) many potential neuro- dosage given in each study. and hemorrhagic etiology. where the vascular etiology emanates. pies are on the horizon that have the potential to enhance line. In lead to an effective treatment of brain disorders.. At 4 months no as well as adult brain-stem cells created by specialized difference was seen between the groups’ verbal fluency. none have been found to be effective in stopping write. In addition. Acute treatment is directed toward the preservation In the past 15 years much effort has been directed at of life and limiting the area of cerebral infarction. to name objects.. Language skills were measured before and from stroke. the brain’s ability to learn. Of the eleven patients. eases. Bromocriptine did not reviewed.. In the past we considered the brain as a “static organ. 5. (2006). L. L. 299. Chitsaz. Miller. Bromocriptine and speech therapy in P.... et al. Haynes. N. (1988).. M. Bambauer. M. Baron. C. 373–380. New adapting and adding new cells that may have the abil. 347. New England Journal of plasminogen activator. Medicine. Saver. H. J. Motor stimulation for enhancement of recovery from Medical Journal.. 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Language form consists of three rule systems that differential diagnosis of persons with neurogenic com. and what to say to. reduced. and syntax. is the meaning. It refers to with neurogenic communication disorders. convergent think- communication model. Patterson and 7. 1976). linguistic skills. divergent thinking. Identify standardized and nonstandardized assessment The linguistic component refers to language form and instruments and procedures that can be used during the content. mental operations in the Guilford (1967) Structure of munication abilities. It includes knowledge of how to con- tional profile. OBJECTIVES LANGUAGE As a result of reading this chapter. tings (Bates. a psycholinguistic model. and pragmatic (Muma. 1983). influence assessment decisions and contribute to prog. and right hemisphere communi. High-level cognitive processing activities such International Classification of Functioning. verse with. the reader will be ponents: cognitive. 4–1). Language motor speech disorder. 5. 1967). For example. the three interrelated components of cognitive abilities. Disability as planning and organizing are governed by the executive and Health. recovered. and pragmatic behavior. such as a cognitive neuropsycho. considering all of the processes by which sensory input is transformed. 1978) able to: (Fig. Define quality of life (QOL) as a concept. and evaluative thinking. or subject mat- cation disorder. Describe several instruments and procedures that can The pragmatic component refers to the system of rules be used to assess an individual’s functional communica. It also refers to the use. dictate the structure of an utterance in order to convey munication disorders. that is. or a functional hension (attention/perception). the same form and 64 . Through the use of cognitive processes we achieve 2. stored. Intellect (SOI) model: recognition/understanding/compre- logical model. Describe the dynamic process of assessment of adults which they continue to process this knowledge. such as biographic variables. and used (Neisser. morphology. The cognitive component refers to the manner in which individuals acquire knowledge about the world and in 1. and terminate dis- medical variables.GRBQ344-3513G-C04[64-160]. such as aphasia. Identify several instruments and procedures that knowledge and command of our world. a meaning: phonology. identify sev- eral measures to assess QOL in persons with neurogenic Roberta Chapey communication disorders. memory. dementia. function. or purpose that a nostic statements. topic. According to Chapey (1986) 3. Chapter 4 Assessment of Language Disorders in Adults Janet P. and describe how QOL con- tributes to the assessment process. or environmental variables. elaborated. maintain. 2004). linguistic. we process assess an individual’s communication abilities and information and use it to influence people and events in our deficits within the World Health Organization’s environment. or semantics. ter involved in an utterance (Plante & Beeson. reviewing the key points. and how to initiate.qxd 1/21/08 11:20 AM Page 64 Aptara Inc. State the theoretic foundation and practical application these processes can be defined operationally within the five of several models of assessment of language and com. function system (Hillis. and knowledge that guides the use of language in social set- tion abilities through structured testing and an observa. that course events such as conversation and narrative (Craig. Identify several variables. 2005. Aphasia is a multi- modality disorder. adult aphasia is defined Aronson. or cognitive processes that underlie language. memory. 2001). the significance of incoming sensory information in the 2001. and reading.GRBQ344-3513G-C04[64-160]. Activities. speaking. or motor Health Organization’s International Classification of impairments such as apraxia of speech or a dysarthria. Functioning refers to body functions and nal as the word “table” even though the auditory sensation is activities and participation in life events. and participation restric- rupts central motor planning and consequently. health conditions. Within this model of language.. Functioning. 2001. Body Functions and Structures. Darley. absence of sensory deficit in the affected sensory modality Disability and Health. copy. vidual’s functioning and disability as they are associated with ual would be unable to recognize an incoming auditory sig. Agnosia. 2005. dination of the speech musculature (Duffy. impairments. Apraxia of speech is a motoric impairment that dis. Aphasia can also be defined within the context of the World ing perceptual impairments such as agnosia. and gesturing. language content or meaning. For example. Aphasia does not refer to single modality deficits includ. • Inhibition • Judgment Discourse • Planning • Cohesion • Monitoring • Coherence • Topic navigation Problem-solving & abstract reasoning • Recognition and comprehension • Memory • Convergent thinking • Divergent thinking • Evaluative thinking content. Disability and Health: ICF. speech deficits caused by impaired strength. It is characterized by a occur in an individual with aphasia. This disruption is in the absence of thermostat. Chapter 4 ■ Assessment of Language Disorders in Adults 65 Cognitive component Linguistic component Recognition and understanding Content • Attention • Semantics • Perception • Comprehension Form and Structure • Phonology Memory • Morphology • Working memory • Syntax • Long-term memory Figure 4–1. • Self-awareness Pragmatic component 1978. since it may affect listening. Chapey 1994. although not necessarily to Participation in Life the same degree. or recognize Classification of Functioning. 2002). impairment in muscular control (Duffy. The model classifies an indi- (Bauer. Disability and Health (International Agnosia refers to an inability to imitate. speed. Modified from Murray & Executive function Chapey. and dysarthria can co- caused by stroke (LaPointe. in auditory agnosia an individ. 2005). & Brown. voluntary tions that prevent an individual from participating fully in . 1975). “It is cold in this room” can be used to report an positioning of the speech musculature and sequencing of observation or to indirectly request an action to turn up the muscular movements. Dysarthria is a group of motor as an acquired impairment in language production. 2006). activity limitations. if any. or coor- hension. of form or structure. writing. and with the aphasia. an important reduction or impairment in the ability to access language part of assessment involves determining which. apraxia of speech. disability refers to intact. Muma. Darley et Aphasia is secondary to brain damage and most frequently al. Therefore.qxd 1/21/08 11:20 AM Page 65 Aptara Inc. 1975). Towards a Common Language for Functioning. language these disorders exist and subsequently defining the nature use or function. and the cognitive processes that underlie and extent of each particular disorder and its interaction and interact with language such as attention. compre. thinking (Murray & Chapey. This classification system pro. which underscores frugality and efficiency (Holland & impairment and activity limitations. In recent years. This. modified (Chapey. assessment and ence an individual’s state. language strengths and weaknesses and the degree to which For individuals with aphasia. (1997) expanded on this definition and attempted to show the Assessment Defined dynamic interaction of important variables such as organic systems and capabilities. listening. 2001. environmental factors. and quality of life for the person with aphasia. it is essential that clinicians . et al. and structures. shopping for clothes. writing a treatment” (Byng et al. and role in the larger unit of tentionally lead to creating a handicapping situation and society. & Schwartz. within the family or social unit. disease). as “the nature of the language impairment and indicate(s) what well as tasks necessary for daily living such as conversing aspects of language performance are more appropriate for with a heath-care provider or family member.qxd 1/21/08 11:20 AM Page 66 Aptara Inc. quences of the health condition. or reading a paper or a menu. Ideally. 1999. 1998). 2005). This type of in-depth check. 2002). integrated components of communication: cog- in what they termed the “Handicap Creation Process. at the levels of ophy. getting a job. A result of using classifications such as these is between an individual and his or her environment that an increased focus on the social and physical environmental affects functioning. treatment must target all three areas from the outset and One purpose of this model is to heighten awareness of the focus on a reason for the individual to communicate as much holistic components of functioning and participation in life as on communication skills and ability to repair faulty com- activities. and illustrates the interrelatedness of the levels of the model within this definition of aphasia as related to body functions as well as the environmental and personal factors that influ. language strengths can be fortified and language weaknesses tures refer to impairments of brain and brain functions. 1988. Environmental Personal factors factors Kahneman. communicative interactions of the aspects of an individual’s life that may overtly or unin. body functions and struc. and life Assessment is an organized. have been the focus of Hinckley. 67). Therefore. positive self-regard. Lahey. p. well-being. and writing. Ryff & Singer. Fougeyrollas et al. 2005. The effect of aphasia on an individual’s Body functions Activity Participation pursuit and enjoyment of these activities is the concern of and structures classifications such as ICF and the Handicap Creation Process. Diner. the WHO model takes into factors that contribute to full participation in life (Chapey consideration both the organic and the functional conse. quality connec- tion to others (zest for life comes from such interactions). Subsequent to the loss of language due to stroke. and mastery (Byng & Duchan. This focus includes participation in daily life and the realization of immediate and long-term real-life goals (Chapey et al. linguistic. or participating in clubs and organizations. Murray & Clark. namely. and pragmatic. and the very complex interaction of conditions munication. The literature on aphasia and life participation supports the notion that the core features of positive human health or well-being involve leading a life of purpose. all of these areas may be affected not only for the person with aphasia Figure 4–2. Elman. goal-directed evaluation of the habits of social participation that contribute to functioning interrelated. activity.” nitive. 2001) such as playing golf. the four language modalities.. making a phone call. family and friends is interactive with each influencing the poses four levels. Murray & Chapey. in turn. 2001) ment. (2) body functions and structures. and participation. However. Figure 4–2 shows the WHO ICF model there is no practical need for communication. That is. (1) health condition (disorder or other. 2006). evaluation explores modalities of speaking.GRBQ344-3513G-C04[64-160]. 1994. as the rela- tionship between an individual with aphasia and his or her his or desired life activities. It also includes evaluation of Included in an assessment of aphasia should be examination an individual’s quality of life. volunteering. (3) activity.. Health condition (disorder or disease) however. without a reason or a cause to communicate (4) participation. reading. World Health Organization International but also for significant individuals in that person’s environ- Classification of Functioning Disability and Health (ICF. and Further. 66 Section I ■ Basic Considerations assessment and intervention in aphasia.. has an impact on the health. 1990. assessment may seem contrary to current health-care philos- Traditionally. functional tasks have increasingly become the focus of diagnosis. An evaluation is carried out to determine a patient’s preventing full participation in life. Activity limitations primarily involve the four language 2001. 2.e. pragmatic/life goals. clinicians “must 3. and use of language (Chapey. That is. acute or chronic).GRBQ344-3513G-C04[64-160]. the severity of and detailed language samples of a patient performing tasks the communication disorder. not compromise their ability to provide the most efficacious 6. 2001. Determine the presence or absence of aphasia. cognitive/linguistic/ contributions to the family unit and to society. 8. (2) A collection of comprehensive facility. come at the expense of their patients’ impairments and do 5. writing. 1986. or patient’s home).e. as Brookshire (2003) states. cognitive behavior. A thorough. Etiologic Goals tial if one is to see patterns of a patient’s communicative and 1. as well as 1994. and concomitant physical. (For each of the following goals. or changed. 1994. the description of a patient’s lan. 2005) and any for each and every individual patient. a hospital. faceted and involves the person with aphasia as well as his or 11. Indeed.) 2001). quality and thorough assessment. communicative behavior. behaviors are analyzed to guage and communication abilities. specific. valid. and reliable assessment from which to Specific Goals of Assessment develop the most appropriate treatment goals and proce- dures. restrictions to personal activities and participation in life specific assessment goals vary according to factors such as based both on first-hand experiences with patients with the stage of the disorder (i. The ability to comprehend language form. and treatment goals (Table 4–1) (Chapey. work to ensure that gains in economy and efficiency do not 4. and formulation of hypotheses to account for the language rent communicative environment and needs. strong connection between a clinician’s definition of lan- Cognitive. Linguistic. which TABLE 4–1 includes requesting sufficient time and funding to complete a sensitive. Some of the characteris. 2001). (3) to determine intervention goals. Pragmatic. 2001). Consideration should be given to identifying a patient’s cur. The ability to produce language form. 1994. Identify and definition of complicating conditions that and develop a hierarchy of therapeutic goals that are appro. (Chapey. gesture. 1994. The ability to comprehend language content. 7. including a patient’s factors that may interfere with communication. Chapter 4 ■ Assessment of Language Disorders in Adults 67 advocate for the best-quality services for their patients.e. Murray & Chapey. production. describe the complexity of the behavior. (5) Respect method (Buzolich. Murray & Chapey. outpatient facility. the modality of and communicative deficit. Specific history and accomplishments as well as his or her future goals are divided into etiologic goals. The purposes are: (1) to describe language behavior in terms of both strengths and weak- nesses. Whitworth. Data collection is the process tics that typify a quality evaluation include the following. abstraction of behavior patterns. and (4) to define factors that facilitate the comprehension. 9. Garrett & Lasker. or psychosocial disorders that may be present. 206). 1995. Murray & Chapey. and hypothesis testing patient with aphasia dictates the need to perform a high. at varying levels of difficulty. & Howard. THE ASSESSMENT PROCESS Assessment in aphasia and related neurogenic communica- Hallmarks of a Quality Assessment tion disorders involves three interrelated components: data The nature of the language or communication deficit in the collection. in that particular behavior. and the goals that are specify the nature and extent of the strengths and weaknesses established for treatment (Chapey. or description of performance to generate information regard- another augmentative or alternative communication ing the course.. Assessment Goals Treatment Goals Assessment of communicative and cognitive abilities in a 10. treatment for those impairments” (p. hypothesis formation.. Specification and prioritization of treatment goals. patterns of the patient’s language impairment. verbal speech. Quality of life with aphasia. her family or caregiver. The ability to produce language content. Murray & Chapey. extent. have precipitated or are maintaining the communication priate for the individual with a neurogenic communication deficit to determine whether they can be eliminated. and scope of treatment. disorder and his or her family. there should be a reduced. (4) A quantitative and qualitative communication (i. the setting aphasia as well as a dedicated review of the aphasia language in which the assessment occurs (i. or Life Goals guage and communication. Pragmatic abilities..qxd 1/21/08 11:20 AM Page 67 Aptara Inc. treatment. (1) of obtaining information that is linked directly or indirectly A current knowledge of significant characteristics and to the language strengths and weaknesses of the patient . and detailed assessment is essen. Within these general goals. Determination of candidacy for and prognosis in person with a neurogenic communication disorder is multi. (3) Repeated observation of emotional. 2005). (2) to identify existing problems. residential and disability literature. Cognitive abilities. Webster. . and participation in life. Participating in a conversation with strangers. candidacy for treatment. prognosis and appropriate treat. caregivers. Having coffee-time visits and conversations with friends and neighbors (around the bedside or at home). and making decisions regarding the presence of aphasia. H. . the clinician may interview professional workers or (1989). conversation and/or changing the subject).. 7. For exam- (From Lomas J. activities. it requires interpreting the data communication situation. nursing assis. 2. et al. family Comparison of multiple response opportunities across time members. of people are involved. C. 68 Section I ■ Basic Considerations (Lahey. provide valuable information concerning the patient’s current Social Network Theory provides another means of gath- language skills.. The interaction between the individual and these partners. 5. Being part of a conversation when it is fast and a number patient’s current communicative abilities and communicative. & Zoghaib. might compile a diary of how her husband typically makes his each of which represents a communication partner. or wait staff at a restaurant). The needs and wants known in different contexts or with different partners in the circles nearest to the center have the closet communication partners throughout the day. and social workers who have already assessed or treated the patient..GRBQ344-3513G-C04[64-160]. a review of the patient’s pertinent medical records. Reported Observations 12.. or social history. Hypothesis formation involves Effectiveness Index (CETI)a categorizing the data or forming taxonomies based on regu- larities in the data or similarities observed in the collected Please rate _________’s performance for that particular information. Saying the name of someone whose face is in front of him The data collected during the assessment process are based or her. 9. 6. 54. 2003). municative situations. unfamiliar with the patient but who may have a specific role This index requires a respondent to rate the patient’s current in communicative interactions (e. These ering information about the communication needs and abil- friends and relatives may be asked to keep a diary or log. Whitworth him or her. 2003). Journal of Speech and Hearing Disorders. 15. physical therapists. 1. Finlayson. Elbard. A. 1988). 1989). When possible. Using an interview procedure. and patient progress (Lahey. These observations may be col. Getting involved in group conversations that are about ment goals..) tants. Indicating that he or she understands what is being said to procedures. treatment goals. family members. L. Describing or discussing something in-depth. vocational. S. 11. lected via interviews and written correspondence as well as in 16. 113–124. and other persons within the individual’s social network The Sixteen Items of the Communicative (Blackstone & Berg. Having a spontaneous conversation (e.mm line for each item. Understanding writing. 2005). Pickard. and/or members of the community who can be used to examine changes in perception about an indi- live with or who have frequent contact with the patient can vidual’s communicative abilities. Giving yes and no answers appropriately.g. friends.. the patient’s perceptions of his or her current language and communication strengths respondent places a mark on a 100. Responding to or communicating anything (including yes and no) without words. transportation workers performance in communication skills in specific daily com. The Communicative Effectiveness Index: Development and psychometric review the written reports of physicians. assessment and analysis of target behaviors. 1988).qxd 1/21/08 11:20 AM Page 68 Aptara Inc.g. occupational therapists. or to ities of an individual and his or her communication partners complete checklists or rating scales that relate their percep. starting the individual during language tasks and communicative inter. using a continuum from “not at all the clinician discovers the communication needs of the able” to “as able as before the stroke” (Table 4–2). Data Collection 8. Furthermore. evaluation of a functional communication measure for adult aphasia. nurses. germane to the assessment process. Information should be obtained from the TABLE 4–2 individual with aphasia. Communicating his or her emotions. munication abilities as well as on direct observation of the 10. Hypothesis testing is the third component him or her. Bester. and weaknesses should also be explored. ple. The partners in the One tool for gathering such information is the outside circles represent communication partners who are Communicative Effectiveness Index (Lomas et al. For example. Likewise. 1988. In Social Network Theory an tion of the patient’s language abilities. upon reported observations of a patient’s language and com. involving the ongoing 3. Getting somebody’s attention. neuropsy- chologists. relationship to the patient (Fig. a spouse individual is at the center of a series of concentric circles. Communicating physical problems such as aches and pains. 4–3). Having a one-to-one conversation with you.. (Blackstone & Berg. Reported observations are those data gathered from persons 13. action (Lahey. who have assessed the patient or who are familiar with the 14. 4. Starting a conversation with people who are not close family.. Unstructured Observation Direct Observations In unstructured observation. 1920).qxd 1/21/08 11:20 AM Page 69 Aptara Inc. 3. 4th Paid workers: People who are generally being paid during times they are interacting with the person. Social Networks: A Communication Inventory for Individuals with Complex Communication Needs and Their Communication Partners. S. tasks. Family members and others with whom individual resides or is related. 5th Unfamiliar partners: “Everyone else. since “an inconsistent Holland and Hinckley (2002) discuss the importance to the response is one of the most striking results produced by a diagnostic process of the information gathered from lesion of the cerebral cortex” (Head. confides. and the time allot. Worrall. the clinician describes the During direct observation. spouse. and appraise the effect of sampling methodology information is particularly important for diagnosis of prag. (Boyle. For adults. 2nd. 2001). professionals and tion. circle position 1st Family: Person’s life partners. 1991). clinician should elicit language in several contexts. resides in group home. & Berg. if an individual does not respond and to minimize fatigue. M. Coelho. Lahey. 1988. 3rd. Time. (2003).. 2nd Close friends: Individuals spend leisure time. 4th. In addi- the importance of reported observations. Raise your hand when you are finished. 1. grandparents. 2003. and pragmatic behaviors in a patient. For example. & Hickson. Therefore the reported observations and describe several methods of gath. Monterey CA: Augmentative Communication. reliability and validity may present barriers to tions are important to maximize the patient’s ability to reported observations. linguistic.GRBQ344-3513G-C04[64-160]. Murray & gestions for accomplishing conversational analysis that is Clark. For children typically parents/guardians. stress. Even though some paid workers may become “friends” as long as they are being paid. plays. siblings. write categories. such as ering this information. Chapter 4 ■ Assessment of Language Disorders in Adults 69 Activity 1: Circles of communication partners Directions: Please fill out your circle of communication partners. Blackstone. quickly and easily interact with a clinician. domestic partner. con- conclusions about a patient’s behavior. Repeated observa. share mutual interests. and highly structured streamlined functional communication checklists. For circle 5. and possible failure. 2006). Write initials/role of each person on the appropriate circle. such as conversational analysis and unstructured. the data collected in the observa. efficient yet generates sufficient data for diagnosis. and partners (Murray & Chapey. Who is in your 1st. Multiple samples are also essential because qualitative and ted for observation is short. This contexts. parent. 2001.” Identify categories of individuals who are potential interactants. While acknowledging tents. matic functioning. moderately structured. preferably over several sessions. Murray & Chapey. & Kimbarow. 3rd Acquaintances: People with whom individual is acquainted but does not socialize regularly. 5th circle? 2. quantitative aspects of the language abilities of patients with tion may be insufficient to allow the clinician to draw reliable aphasia vary across different communication contexts. the communicative success of a person with aphasia paraprofessionals working in medical settings may not have may also vary despite identical communication conditions the time to complete lengthy interviews or questionnaires. Reprinted with Permission. the clinician observes the patient’s cognitive. they are listed in this circle. natural setting when there is a minimum of control or . Figure 4–3. Boles and Bombard (1998) provide sug. Inc. on the language elicited (Davidson. Degree of closeness and familiarity in these relationships. and provides excellent value (Salter et al. 165). 70 Section I ■ Basic Considerations interference. patient’s performance with that of other patients or with the and conversational types of discourse should be elicited same patient on subsequent visits. For example. that “.g. 1996.. Lahey. Highly Structured Observation Expression. requests repetitions. and Writing). Murray & Chapey. and/or tests of specific language functions. Spreen and Risser (2003) describe three screening proce- Moderately Structured Observation dures relevant to aphasia diagnosis: the bedside clinical examination. For example. describe pictures. or (c) answering the telephone unsystematic approach may lead the examiner to miss and relaying a message (Chapey. Brookshire (2003) cautions however. 2006). A Spanish version is vation.” (p.e. American Speech-Language-Hearing Association publishes bally with others. and Writing). or a spouse who accompanies his or her they do not provide a detailed description of the patient’s speech with gesture) that the patient or spouse currently use language ability. uations: in the early post-acute stages of recovery when LeDorze & Brassard. highly structured observations based on results of bedside 2006). Assessment Instruments. 2001). since several studies have documented that type of discourse There are several frequently used aphasia screening may significantly affect quantitative and qualitative aspects instruments (Table 4–3). 1995). (b) relating the date and time stances. and stan- At times. screen for language disturbances in persons with aphasia. Wade. The setting should be familiar to the client and batteries. Screening tests provide an efficient may be able to identify maladaptive behavior strategies (e. means to determine the presence or absence of aphasia and a spouse who pretends to understand the aphasia jargon pro. There are four sections to this test (i. 2002. or when the cost containment necessi- tive strategies used by both the staff and the patient.. This instru- Shadden. in certain clinical settings where the length of stay in reception area staff. narrative.. 1988. tive interactions among the patient and spouse or other fam- ily members during a meal. The clinician may also observe 2006). The screening requires minimal larger and more varied sample of communicative behavior administration and scoring time and is suitable for patients than otherwise might be possible in an unstructured obser- regardless of aphasia severity or type. again observing maladaptive or facilita.. an individual with aphasia who limited amount of language and communicative behavior. The test is short and The language and communication assessment also includes easy to administer. 1975).. The provide the opportunity for the individual to interact ver. or answer direct Spreen and Risser (2003).. When possible. since they are short in length and sample a positive strategies (e. and ranges from unstructured con- language) (Croteau et al. In a medical setting a clinician patients may be too ill to complete a lengthy aphasia evalua- might observe how the patient communicates with the tion. Davis (2000). Cherney. 1996.an of a doctor’s appointment. 1991).GRBQ344-3513G-C04[64-160]. interference or breakdown. a clinician working in a a list of speech-language assessments that can be accessed by home-health setting may spend part of a session early in the ASHA members (Directory of Speech-Language Pathology treatment program observing the spontaneous communica. and Brookshire requests. “How do you change a tire?” or “How do (2003) agree that an experienced clinician is able to make you make scrambled eggs?” The clinician and patient may maximal use of patient responses and obtain a satisfactory also role play specific situations such as (a) ordering in a aphasia screening under almost any set of clinical circum- restaurant and paying the bill.. tates fast clinical information without extensive testing. published screening instruments. Nkase-Thompson et al. comprehension that may not have emerged during an 2006. Wood. be asked to retell a story.g.. the facility is brief. the clinician may take a moderately active role in dardized tests that are limited to a specific aspect of language structuring observations and use predetermined questions function.. (2005) introduced the and screening assessment tools. Enderby. a client may versations to structured task sets (Spreen & Risser. Comprehension. to develop ideas for further assessment and initial treatment duced by his or her partner) that lead to communicative procedures (Al-Khawaja. Enderby et al. ment consists of four scales (i. 1987) was designed for use by individ- unstructured observation (Chapey. The Frenchay Aphasia Screening of specific aspects of spontaneous language production and Test (Enderby & Crow. 2000. to Hinckley. 1994. & Wade. such as the Aphasia Language of a patient’s language (Armstrong. 2004. Screening tests are most useful in three sit- to facilitate communication interaction (Kagan et al.. such as. Bedside tests are rooted in classic neurology eval- or tasks to observe comprehension of and to elicit produc- uation where interaction between the patient and examiner tion of spontaneous communicative interaction (speech and provides diagnostic data. Li et al.. Murray & Chapey. important signs. 2004). each of which has 10 items of observations allows the clinician to collect and observe a increasing difficulty. The use of moderately structured Reading. However. comprehensive aphasia Mississippi Aphasia Screening Test (MAST) as a screening . Talking. & Coelho. descriptive. this observation style fosters exploration also currently available. 1999. Salter et al. procedural. Performance Scales (Keenan & Brassell. Penn.qxd 1/21/08 11:20 AM Page 70 Aptara Inc. Holland & uals who are not trained speech-language pathologists. 1998. Listening. 1996. Shadden et al. and may invalidate comparisons of the 2001). In this observation the clinician Screening Tests.. In addition. 1994.e. & Collin. 2003). Reading. each of which PICA scores accurately predict full PICA scores. 1992). and has nine Several scales exist to screen. Kertesz. (1989) Aphasia Language Performance Scales (ALPS) Keenan & Brassell (1975) Bedside Evaluation Screening Test. 1980) and the Porch Index of 2003) and to evaluate language input and output modalities Communicative Ability (PICA. & Clark.. However. The Profiles (ADP. 1982.e. very briefly. Five tests that Aphasia Examination (Goodglass. cians rely on comprehensive aphasia batteries to provide the Shortened versions of several comprehensive tests of apha. 2nd ed. The reliability and validity of the shortened versions. 2003. 2004). Test (Fastenau. number of attempts. Stroke Scales. (2006). Aphasia (Powell. (2003) Sheffield Screening Test for Acquired Syder et al. for aphasia and subtests designed to measure receptive and expressive lan. language. Responses are rated for accuracy in conveying the message. session. Enderby & Crow (1996) Reitan-Indiana Aphasia Screening Test Reitan (1991) ScreeLing Doesborgh et al. 2005) is a 2006). and the guage (NIH Stroke Scale. examiners rating of message adequacy. Many 1980). Kaplan. Porch.qxd 1/21/08 11:20 AM Page 71 Aptara Inc.GRBQ344-3513G-C04[64-160]. 2nd ed. as for aphasia is the MTDDA (Schuell. and the num- Holtzapple and colleagues (1989) suggest using the shortened ber of modalities tested. Denburg. 2003). and Darley report that shortened comprehensive aphasia batteries are available. 1981). 2001). 1967. 1998) both have short One of the oldest and most comprehensive test batteries forms. Keith. the Aphasia Diagnostic been shortened to serve as screening tools. Neurologic Deficit (MEND) Prehospital Checklist. 1965). & Loring. 1965). DiSimoni. For example. internal organization. 2006) also contains a shortened Schuell. other physical and neuropsychological sequelae that may guage abilities. In many instances clini- partner-dependent communicator. 2006). This tool consists of eight tasks presented in picture (MEND) Prehospital Checklist (Miami Emergency format and designed to communicate a specific message. Scores are summa- rized to determine whether the patient is an independent or Comprehensive Aphasia Tests. differs in terminology. The WAB-E (Kertesz. Goodglass et al. the Boston Diagnostic Aphasia Examination version meant to be administered at the bedside. (1993) Language Disorders Sklar Aphasia Scale (SAS) Sklar (1983) The Aphasia Screening Test (AST) Whurr (1996) Quick Assessment for Aphasia Tanner & Culbertson (1999) test designed to detect changes in language abilities over compared to the original tests. 1969) and the Boston Naming Index of Communicative Ability (PICA. and the Porch Token Test (Spellacy & Spreen. Bailey. 2001) are commonly used in North America are the Minnesota contains a short form that is valid for a constrained assessment Test for the Differential Diagnosis of Aphasia (MTDDA. It was developed by a team of neuropsychologists. 2003). while others have several items to examine speech and lan- number of cues provided. Helm-Estabrooks. & Mauer. these tests should prove useful as screening instruments. along a continuum of complexity (Brookshire. have been demonstrated and time. (BDAE. and men- Augmentative or Alternative Communication Systems tal status (i. & Darley.. Some include communicators with aphasia who may benefit from only one or two items to assess speech. major portion of their highly structured observations. These scales are primarily intended for use by physi- cognitive-linguistic and behavioral assessment protocol for cians at the first sign of stroke in an individual. Howieson. DiSimoni. and speech-language pathologists. 2001)). physiatrists. The Multimodal Communication Screening accompany stroke (NIH Stroke Scales. These sia are also available to be used for screening purposes. (BEST-2) Fitch-West & Sands (1998) Frenchay Aphasia Screening Test. the Western Aphasia Tests for specific aspects of language functioning have also Battery (WAB. The third edition of the Boston Diagnostic nesses (Lezak. Enderby et al. & Baressi. These tests are designed to obtain a diverse sampling of perfor- include the Minnesota Test for Differential Diagnosis of mance at different levels of task difficulty (Spreen & Risser. Miami Emergency Neurologic Deficit (AAC). Task for Persons with Aphasia (Garrett & Lasker. Chapter 4 ■ Assessment of Language Disorders in Adults 71 TABLE 4–3 Screening or Bedside Tests of Aphasia Instrument Source Acute Aphasia Screening Protocol (AASP) Crary et al. It consists of . Keith. and each is associated with particu- version of the PICA with caution as it may not always provide lar administration and interpretation of strengths and weak- the same results. unlike the aphasia classifications. However. and gesture modalities (the reading and tered on the Subject Summary Profile. and nam- involvement. or aphasia with visual impairment. 2006) is designed to diagnose of aphasia. Alternative Communication in which the authors demonstrate assessment and scoring Profile. auditory comprehension. and construction abilities.e. and several seven-point rating scales that com.. block design. and can be purchased with or without the manip- comprehension. transcortical motor. of functioning. phrase The ADP (Helm-Estabrooks. grammatical form. auditory guidelines. reading. tinguishing between surface. content and fluency). Quotient. Like the procedures with individuals with aphasia. Supplemental tests mea- manual provides guidelines for the prediction of recovery sure drawing. reading. culated from WAB performances: (a) an Aphasia Quotient a severity rating scale from 0 to 6 can be used to quantify (AQ). Quotient. writing. scores for five profiles: Aphasia Classification Profile. 2001) irregular words and nonwords) were included to aid in dis- provides a comprehensive exploration of a range of commu. and (c) a Cortical Quotient according to whether the patient presents with aphasia (CQ). In addition to these nonfluent and fluent types of localization-based aphasic syndromes. Wernicke’s. test scores.e. The plus/minus scoring procedure. and praxis. and auditory nicative value of a patient’s responses. and visual dyslexia. and weaknesses in speaking. the commu- running speech. The PICA (Porch. counts. oral expression. to calculation of only 30 to 45 minutes to complete. and Behavioral Profile. tion. The Boston Naming the number of correct information units and phrase length Test and the Visuospatial Quantitative Battery are included for verbal fluency tasks. a patient may have eight subtests. Subtest raw scores are converted to as part of the BDAE-3. tive to parietal-lobe lesion. deep.e. Clinicians can also plot confidence ranges (i. the ADP includes a borderline fluent BDAE.GRBQ344-3513G-C04[64-160]. Reading Quotient.. and measures spontaneous speech (content a diagnosis of simple aphasia. and information con- comprehension. and provides summary scores that allow docu. The seven subtests of visual language and designed to provide a reliable measure of deficit severity and . In addition. The results of the BDAE are used to clas. The scoring methods vary across subtests.. The WAB-E has revised administra- global aphasia syndromes. repetition. listening. two new supplemental tasks (reading and writing of The third edition of the BDAE-3 (Goodglass et al. 1967. to rating scales. (i. reading. 1981) is a standardized test tion. Three summary scores can be cal- A plus/minus scoring is used for most subtests. Oral Expression Quotient. word-finding. The BDAE-3 consists of an Extended designed to emphasize conversational interaction with the Standard Form for in-depth study of aphasia symptoms. For example. which is derived from performance on all subtests. conduction. Raw scores on the subtests vary from a cerning the general social-emotional status of a patient. writing. transcortical sensory. In addition. The guage subtests. and naming. The pattern of scores writing portions are short and therefore may require follow- can be compared to examplar profiles to help determine up testing in some patients with aphasia). subtest and summary standard scores are used to Like the BDAE-3. battery contains a Bedside WAB-E that can be administered tional and narrative speech using a five-level aphasia severity in approximately 15 minutes to assess briefly a patient’s level rating scale. the test writing. prise a profile of speech characteristics: melodic line. auditory comprehension. or whether he or she presents with aphasia plus sen. and writing. as well as reading and writing. 1992) provides for docu- length. repetition. The test provides for detailed scoring of conversa. The BDAE contains 34 subtests tion instructions for each subtest and expanded scoring that assess conversational and narrative speech. 2006) contains 32 tasks within sory and/or motor deficits. They are designed to assess visual standard scores and percentiles and used to create composite confrontation naming (BNT) and visuospatial skills sensi. which is test provides a classification system based on Schuell’s view derived from performance on all language subtests (i. Error Profile. standard error of measurement intervals) for each subtest mentation of progress. The ADP is aphasia classification. listening. the WAB (and WAB-Enhanced determine aphasia type in terms of the Boston classification (WAB-E)) (Kertesz. and and Writing Quotient. from a including grammar and syntax. The nicative abilities. In addi- based on Schuell’s extensive clinical experience. oral that aphasia is a unidimensional. repeti. These scores are converted to percentiles and regis. WAB. 1982. The test ing. anomic. the WAB identifies syndromes on the basis of specific aphasia type. The WAB-E (Kertesz. 1984). and a Short Form that takes four-point scale and plus/minus scoring. New to this edition is a videotape Aphasia Severity Profile. language abilities subtests as well as reading and writing sub- ment. multi-modality impair. repetition.qxd 1/21/08 11:20 AM Page 72 Aptara Inc. calculation. This system categorizes an individual’s performance tests) (Shewan & Kertesz. aphasia with sensorimotor and fluency). and ulatives required for administration. which is derived from performance on the oral lan- performance in the four assessed language modalities. to frequency test contains nine subtests that assess speaking. Auditory Comprehension based classifications of aphasia: Broca’s. praxis. The oral language abilities portion of and summary standard scores that can be used to determine the WAB contains 10 subtests that assess spontaneous speech patient progress over time. Cortical Quotient. WAB-E provides six criterion quotient scores: Aphasia sify patient’s language profiles into one of the localization. paraphasia in mentation of the nature and severity of aphasia. 72 Section I ■ Basic Considerations 46 subtests that are designed to assess a patient’s strengths the other subtest portions examine reading. alone. articulatory agility. patient.. (b) a Language Quotient (LQ). 2000). Poeck. 1993. Examining course tasks. Swedish) that appear functionally and cul- prehensive aphasia tests are available. Arabic. and the Bilingual Aphasia Tests recommended 40 hours of formal training for skillful use (Paradis & Libben. incomplete response to test item that is significantly slowed or delayed 10 Corrected Accurate response to test item self-correcting a previous error without request or after a prolonged delay 9 Repetition Accurate response to test item after a repetition of the instructions by request or after a prolonged delay 8 Cued Accurate response to test item stimulated by a cue. Porch added diacritical markings to the Aphasia batteries originally written in English have been scoring system to provide a greater degree of specific and translated to other languages. McNeil. 1994) assesses oral and written recep- using an elaborate 16-point multidimensional scoring sys. 1991). Willmes. The Neurosensory Center Comprehensive gestural. immediate response to test item 14 Distorted Accurate. writing. ities of patients who are bilingual or multilingual. B. the Boston questionnaire. several other com. It does not. complete. such as the Aachen mance scores. 1987. perseverative or automatic responses or an expressed indication of inability to respond 4 Unintelligible Unintelligible or incomprehensible response that can be differentiated from other responses 3 Minimal Unintelligible response that cannot be differentiated from other responses 2 Attention Patient attends to test item but gives no response 1 No response Patient exhibits no awareness of test item (From Porch. responsive. tory. reading. a range of tasks. 1988). overall perfor. Aphasia Test (Huber. Rey & Benton. responsive response to test item that is lacking in completeness 11 Incomplete-delayed Accurate. complex. tests provide different language versions (e. however.) recovery progress. & Chang. immediate. The PICA such as the Multilingual Aphasia Examination (Benton et al. an intelli. responsive. additional information. agnosia (visual. Performance on items in each subtest is scored for Aphasia (Eisenson. and writing in 20 subtests. Chapter 4 ■ Assessment of Language Disorders in Adults 73 TABLE 4–4 Multidimensional Scoring System of the Porch Index of Communicative Ability Score Level Description 16 Complex Accurate. Spanish. The Comprehensive turally equivalent in content and not simply direct transla- Aphasia Test (CAT... & DeBleser. (1971). Mazaux & Orgogozo. and tactile). &. It contains 18 subtests that assess verbal. tomime. quently used by clinicians. and scores for each of six modalities: pan. Willmes. 1985. tive and expressive language functions. languages (Kennedy & Chiou. and graphic modalities through the use of 10 com. 1975). For example. Examination for Aphasia (Spreen & Benton. production. and disability Two other comprehensive batteries. contains a cognitive screen. two examples are the BDAE sensitive response characterization. and copying. 1993) assess various language abil- (Martin.qxd 1/21/08 11:20 AM Page 73 Aptara Inc. Porter. however. responsive. In 1983. In addition. elaborative response to test item 15 Complete Accurate. 776–792. contain any tasks that Strauss. Swinburn. (Laine et al. responsive. visual. Kusunoki. language battery. but with reduced facility of production 13 Complete-delayed Accurate. 1977. auditory. 1977. In addition. reading. responsive. responsiveness. and efficiency (see For patients whose first language is not English or who Table 4–4). scoring system is highly informative. a few aphasia batteries diacritical “p” if it was a preservative response. promptness. Spreen & mon objects. accuracy.g. it requires a 1994. & Howard. complete response to test item that is significantly slow or delayed 12 Incomplete Accurate. the 1981 revision. aphasia batteries are available in other averaged to provide individual subtest scores. and can be used to assess performance across Assessment of Severe Aphasia (BASA: Helm-Estabrooks . Prescott.. complete response to test item. Multidimensional scoring in aphasia testing. audi- tem that encodes five dimensions of behavior: completeness. 1998) assesses language comprehension. or another test item 7 Related Inaccurate response to test item that is clearly related to or suggestive of an accurate response 6 Error Inaccurate response to test item 5 Intelligible Intelligible response that is not associated with the test item. and simple mathematic skills. Miller.GRBQ344-3513G-C04[64-160]. 2005). These The batteries described above are among the most fre. Journal of Speech and Hearing Research. for example. 1984. 1981) and the gible response that was rated a 5 would be augmented by a WAB (Sugishita. Chinese. 2004) tions of stimulus items from one version to the next. Huber et al. language assess spontaneous production of connected speech in dis. The numbers assigned to a patient’s responses are do not speak English.. 14. such as time of utterances. 2001) to individuals who (a) phrases. or elaboration. These tasks.GRBQ344-3513G-C04[64-160]. communication. and gestural abilities of patients with aphasia. Hernandez. 1962) are also available in the open stance to data collection. or to include a greater range of dimensions. or ceiling (very high) level on an aphasia battery. as well as partial verbal and gestural responses.. 1998. in empirical research studies or in doctoral dissertations or tion regarding the communication strengths and weaknesses master’s theses. For example. performance. you can that will break if they are dropped. reading Naming Test (Goodglass et al. engage in a rich description of the com- (Benton et al. Such information is valuable for treatment many ways as you can think of to use a hammer. Because these batteries are designed to measure the language abilities of patients who are severely aphasic. 1989) and the Assessment of Communication the demographic characteristics of the population of indi- Effectiveness in Severe Aphasia (Cunningham et al. 1995. 1992.. Indeed. and non-brain-damaged peers. 1998.. 2003). malized the tasks for use in clinical settings. the functions of reading and writ- mative data. Tetnowski and Franklin reviewed several principles of 1997). 1994) and the Thurstone Word Fluency Test munication phenomenon. For example. In either of a clinician might ask a client to “Name as many objects as these cases little information is obtained with respect to you can that can be folded. 1983. as well sia and some measures of specific language function rely pri- as visuospatial and praxis tasks. several studies have been con. expanded normative data for verbal fluency qualitative analysis: collect holistic data. reading comprehension. guage.. For other tests. and error item difficulty.. flexibility (the variety of responses). lems.. and descriptive measures (Tetnowski & Franklin.” or “Name as many objects as areas of relative strength or weakness in a patient’s commu. comprehension. Tests of Specific Language Functions. They may be cited as tasks Consequently. some tests of apha- visual. Murray & Chapey. Damico and col- Ivnik et al. nosis.” The client’s diagnosis as well as treatment planning. while useful in diag- writing. or cognitive abilities and impair- ments of individuals with aphasia. melody. be moderately or highly structured and typically do not have tion. Tombaugh & Hubley. Performance live in institutionalized or community settings (Neils et al. 1988b). racial. changing over time (Neils-Strunjas. Welch et al. 1988).qxd 1/21/08 11:20 AM Page 74 Aptara Inc. and copying simple and complex forms. published norms (Lahey. & Bates. using authentic. Likewise. .. originality. This testing may be particularly important analysis. and collect data from the per- research literature (Heaton. 1996. 74 Section I ■ Basic Considerations et al. The SSLA contains several scoring general assessment battery. and Qualitative assessment approaches the assessment (c) represent diverse educational. 2001). Clinicians may One example of a nonstandard observation is the Shewan need to supplement or substitute comprehensive aphasia Spontaneous Language Analysis (Shewan. 1998. clinicians can acquire more explicit informa. 1998). 1998). & Matthews.. pattern was related to site of lesion.. focus on data in tests such as the Controlled Oral Word Association Test authentic settings. These observations can measure includes the identification of affect and persevera. Kohnert. reading words. Table 4–5 contains a responses can be scored on several dimensions: fluency (the list of some of the tests available for measuring auditory number of responses). tional. and gestural expression and comprehension. Christensen (1975) for- 1995). and socioeconomic process from a discovery perspective. batteries with tests of specific language functions to allow The SSLA is a comprehensive and in-depth method for ana- more in-depth quantification and/or qualification of abilities lyzing samples of spontaneous connected speech in picture in a specific language modality than can be obtained from a description tasks. 1995) viduals with aphasia who live in North America is slowly have been developed for patients with severe language prob. spective of the individual being evaluated. verbal expression.. 1975) approached aphasia diagnosis the test manual so that the performance of a person with through nonstandard observation across a variety of modali- aphasia may be compared with those of brain-damaged or ties and functions. approach assessment with an (Thurstone & Thurstone. Tombaugh & Hubley. These tasks can easily be adopted for assess- of their patients who have severe aphasia than can typically ment purposes and often lend valuable insight into the lan- be obtained using one of the traditional aphasia batteries. He developed a series of bedside tasks. their Nonstandard Observation test procedures differ from those of traditional aphasia tests. normative data are provided in Luria (Christensen. clinicians must recorded and rated a patient’s responses according to level of look to the empirical literature to find the appropriate nor. the BASA probes for spared language abilities Nonstandardized observations are useful in diagnosing the across a variety of tasks and modalities including auditory. For many of these tests. For example. (b) represent a wide age range (Henderson et al.. Neils et al. Another example is divergent semantic naming when a person with aphasia scores at either a basal (very low) tasks (Chapey. For example. 1997. 1988a.” or “Name as nicative abilities. Grant. 1996). Kempler et al. func- backgrounds (Henderson et al. presence and severity of aphasia. The scoring system on this marily on nonstandard observations. Further expansion leagues (1999) illustrated these principles in qualitative of norms for many published language tests is needed since analysis of communication skills in persons with aphasia. ing were examined through analysis of responses on letter ducted to extend the normative sample of the Boston identification and production tasks. do not have published norms for comparison. (1971) Psycholinguistic Assessments of Language Processing in Aphasia Kay et al. (1994) Test of Reading Comprehension-3 Brown et al. (1994).Electronic Bishop (2005) Test of Adolescent and Adult Language Hammill et al. (1992) Test of Adolescent/Adult Word-Finding German (1990) The Naming Test Williams (2000) The Word Test-Adolescent Bowers et al.qxd 1/21/08 11:20 AM Page 75 Aptara Inc. 1988b) Test of Adolescent and Adult Language Hammill et al. (1992) Test of Adolescent and Adult Language Hammill et al. (2005) Syntax Northwestern Syntax Screening Test Lee (1971) Shewan Spontaneous Language Analysis Shewan (1988a. (2000) Gray Oral Reading Tests . (1994) The Reporter’s Test DeRenzi & Ferrari (1978) The SOAP (A Test of Syntactic Complexity) Love & Oster (2003) Reading American NART Grober & Sliwinski (1991) comprehension Gates-MacGinitie Reading Tests – 4th ed. MacGinitie et al. Chapter 4 ■ Assessment of Language Disorders in Adults 75 TABLE 4–5 Tests of Specific Language Functions That May Be Used to Augment or Replace Comprehensive Aphasia Batteries Language Function Instrument Source Auditory Auditory Comprehension Test for Sentences Shewan (1979) comprehension Functional Auditory Comprehension Task LaPointe & Horner (1978) Discourse Comprehension Test Brookshire & Nicholas (1997) Peabody Picture Vocabulary Test-3 Dunn & Dunn (1997) Psycholinguistic Assessments of Language Processing in Aphasia Kay et al. (1994) Naming Action Naming Test Obler & Albert (1979) An Object and Action Naming Test Druks & Masterson (2000) Boston Naming Test Goodglass et al. (1992) Pyramids and Palm Trees Howard & Patterson (1992) Revised Token Test McNeil & Prescott (1978) Test for Reception of Grammar – 2nd Version Bishop (2003) Test for Reception of Grammar . (1995) Wechsler Test of Adult Reading Wechsler (2001) Wide Range Achievement Test-3 Wilkinson (1993) Writing Johns Hopkins University Dysgraphia Battery Goodman & Caramazza (1986a) Psycholinguistic Assessments of Language Processing in Aphasia Kay et al.3 Wiederholt & Bryant (2002) Johns Hopkins University Dyslexia Battery Goodman & Caramazza (1986b) National Adult Reading Test Nelson & Willison (1991) North American Adult Reading Test Blair & Spreen (1989) Peabody Individual Achievement Test -Revised Markwardt (1998) Psycholinguistic Assessments of Language Processing in Aphasia Kay et al. (1996) Florida Semantics Battery Raymer et al. (1992) Reading Comprehension Battery for Aphasia-2 LaPointe & Horner (1998) Reading subset of the Kaufman Functional Academic Skills Kaufman & Kaufman (1994) Test (K-FAST) Test of Adolescent and Adult Language Hammill et al. (1990) Object Naming Test Newcombe et al.GRBQ344-3513G-C04[64-160]. (1994) Test of Written Language-3 Hammill & Larson (1996) Thurstone Word Fluency Test Thurstone & Thurstone (1962) Wide Range Achievement Test-3 Wilkinson (1993) . (2001) Comprehensive Assessment of Spoken Language Woolfolk (1999) Comprehensive Receptive and Expressive Vocabulary Wallace & Hammill (2002) Test-Adult – 2nd Version Controlled Oral Word Association Test Benton et al. Ruff et al. These techniques demonstrate (Carmines & Zeller. 1979. Each of the categories has several subtypes of validity that ing reliability: correlation based on classical test theory. Construct validity refers to determination of the extent to which a test relates to other Psychometric Considerations measures of the same construct. (1997) Florida Action Recall Test (FLART) Schwartz et al. Spreen and Risser (2003) suggest that few individual with a neurogenic or cognitive communication dis. Regardless of the method selected for measuring reli. determine whether or not a patient meets the criterion for a tation.qxd 1/21/08 11:20 AM Page 76 Aptara Inc. 2003). Raymer et al. (2000) Pantomime Recognition Test Benton et al. each test or procedure used should be eval. In aphasia assessment error. construct.GRBQ344-3513G-C04[64-160]. 76 Section I ■ Basic Considerations TABLE 4–5 Tests of Specific Language Functions That May Be Used to Augment or Replace Comprehensive Aphasia Batteries (continued) Language Function Instrument Source Writing Process Test Warden & Hutchinson (1993) Written Language Assessment Grill & Kirwin (1989) Gesture Florida Apraxia Screening Test – Revised (FAST-R) Rothi. a test should contain language and communication behav- ability in nonstandardized observation. tion for observation and four common methods of measur. In aphasia assessment. 2003). In the case of aphasia assess- Clinicians should be knowledgeable about the basic psycho. to demonstrate con- order. 1984). which is inherent in human of content validity might include examination of the range judgment (Dollaghan & Campbell. Concurrent and predictive validity are the consequential bias. 1980). (1993) Test of Apraxia van Heutgen et al. and generalizability theory. ment those constructs would be aphasia characteristics or metric properties of aphasia batteries or tests used to assess an language abilities. and other neurogenic communication disorders. A fine-grained analysis were not influenced by error. test contains items that adequately represent the full domain which is a method of estimating reliability from sources of of behaviors that should be measured. analysis of data 1980). chometric factors. aphasia tests have known validity. Specifically. Tetnowski Three categories of validity are important in language sci- & Franklin. Clinicians are cautioned to carefully review Ideally an aphasia test should be able to discriminate not test manuals prior to administration to be assured that the test only between individuals with aphasia and non-brain-dam- selected is psychometrically rigorous and addresses the goals aged individuals. Spreen & Risser. and standardization statistical techniques. when selecting a test whether test items contribute to one or more major factors clinicians should also consider the social and ethical conse. that represent language or communication function. thus. 1992). Skenes and McCauley (1985) two types of criterion-related validity. Aphasia tests with reviewed nine tests for use with persons with aphasia and good concurrent validity should be able to discriminate found several to be lacking in one or more categories of psy. and diversity of the content. reliability. (1999) Test of Oral and Limb Apraxia Helm-Estabrooks (1991) 15 item battery of movement to imitation Haaland & Flaherty (1984) Nonstandardized observation must be reliable to be of Validity greatest value in a clinical setting (Cordes. quences of using the test in terms of costs and benefits as well Criterion-related validity refers to the hypothesis about as possible side effects as a result of using the test. such as . Content validity involves determining whether the from more than one observer. criterion validity refers to the accuracy with which a test can ric properties of a test as the evidential bias of test interpre. struct validity test administrators may use factor-analytic uated in terms of its validity. but also between individuals with aphasia of the evaluation (McCauley & Swisher. between the presence or absence of aphasia in an individual. and consideration of social and ethical consequences as diagnosis of aphasia. the success of the iors that are perceived as being theoretically and function- measurement depends largely on the careful description of ally germane for successful communication (Carmines & the behavior to be observed and the assurance that results Zeller. allow a fine-grained analysis of a test procedure (Messick. and conse. test. the relationship between a test and the criterion to which it quences that might arise as a result of using the data from the is to be compared (Messick. 1979). interjudge percent agreement calculations. Cordes described the theoretic founda. and criterion-related validity. In addition. ences: content. Messick (1980) labeled the consideration of psychomet. 1994. and accuracy of dures may provide valuable diagnostic information. tent and construct validity of some aphasia tests are also sus. 1990. surement error and to allow valid and reliable comparison of posite abilities or more than one linguistic and/or cognitive patient performance to published norms. 67). initiation. instructing a patient to “Put procedures reflect both test structure and administration the pen on top of the book. aphasia are considered to be stable. Hillis. Standardization ability at a time. a test should con- an aphasia test may have strong criterion-related validity. 2000) and consequently fail to yield information concerning the nature Standardization of the underlying disorder. visuoperception or graphomotor construc. the conceptual populations and the likelihood of change in performance schemata underlying aphasia tests have often ignored the due to changes in the patient’s condition are high. reported. Because lin. 2003). because they are highly interrelated processes. coefficients of at least 0. context. 2003) to minimize mea- (p. 2002a..g.. structure. 1996. 1994. Murray & healthy subjects.g. Tests have not reflected the fact that the chronic aphasia rather than patients with acute aphasia. 2001). Raymer & Rothi. Strauss. aphasia batteries have been questioned on The standard error of measurement for the test should also be the basis of all forms of validity. Spreen and Risser (2003). 1990). & Spreen. 1977. stability. To improve reliability. then give it to me” (WAB item) instructions. A single aphasia test may not be appropri. Kay et al. related to individual clinical settings) but indicate deviations guistic and cognitive skills are both composite abilities and that may result in incorrect interpretation of test results. the range of scoring options left to the judgment of the clin- tional abilities) involves at best sophisticated clinical skill ician (i. 1971). Weniger. Unfortunately. how- a test’s sores during repeated administration under similar test.e. Martin. 1984. inappropriate (Spreen & Risser. 1986. 1986. David gest that “. and Spreen (2006) note that although associated with some degree of chance error. 2005). Aphasia test manuals should report correlation ate for both concurrent and predictive validity purposes. Three areas where clarity of administration and scor- naming) without directly or indirectly involving associated ing instructions are particularly important are (a) clarifying processes (e. 1990. 2006). Murray aphasia tests demonstrate reliability using patients who have & Chapey. Chapey..” Many complexity factor in language (Chapey. Lastly. . model of language on which test construction was based 2001). and (c) limiting stimulus and response format to that specified in the test (i. Sherman. Spreen and Risser (2003) suggest that three types of 2003. reliability. and results do not supply enough infor. (b) deter- and acumen to provide an accurate diagnosis. many tasks in aphasia batteries assess com.. ever. & Skilbeck. Chapter 4 ■ Assessment of Language Disorders in Adults 77 right hemisphere disorder or dementia (Spreen & Risser. 1985. since the measurement error in patient Chapey. mining whether repetition of instruction is permitted.80 for these measures of reliability. Because of the extensive physiologic changes that typi- pect because they include no clear operational definition of cally occur during the early. acute phases of recovery.e. intent. For example. Permitting variations in proce- Reliability refers to the consistency. 1988. As Byng et al. 1994). 1990. reliability is best demonstrated with normal. scores and individual scores (Cordes. . and meaningfulness of utterances (Chapey. . Sherman. A test with good reliability are most relevant for aphasia tests: the internal con- predictive validity should be suitable for measurement of sistency of the test. (1990) suggest. affect test reliability as well as validity. 1990. rele. The con. For example.GRBQ344-3513G-C04[64-160]. 2001. & Marshall. nor specify what treatment should be provided” (Cronbach. these individuals are likely to show vance. variations memory. testing one Test administration and scoring instructions must be clearly particular aspect of language (e. “most standardized tests neither clarify what is wrong with Test administration procedures should be standardized the patient. confrontation written stated. ations in administration that routinely occur (i.. 1994.and inter-examiner measurement error that can with aphasia from non-brain-damaged individuals. most aphasia batteries do not provide a with acute aphasia. not allowing extra time for a response. Spreen & Risser. tain detailed administration and scoring instructions as well as analysis often does not indicate whether trivial test items are examples of correct and incorrect responses in order to mini- responsible for discriminating performance of individuals mize intra. less variability and thus better reliability than individuals Furthermore.. 1994. The test structure should allow for minor vari- engages linguistic processing abilities as well as attention. and limb praxis abilities. use of an equivalent vocabulary term). they render comparison to standardization norms ing conditions (Anastasi & Urbani. Spreen and Risser (2003) sug- (Byng et al. communication of meaning is the essence of language because language and communication deficits related to (Goodman. the what is being assessed and/or fail to stipulate the specific reliability of aphasia tests can be poor (Murray & Chapey. post-onset of aphasia. Coltheart.qxd 1/21/08 11:20 AM Page 77 Aptara Inc.e. Clinicians should carefully examine the description of the patient’s language impairment in relation standardization sample on which reliability data are to recently advanced cognitive neuropsychologic models of reported and examine the reliability of both overall test language (Ellis & Young. David. and interrater change over time. test-retest stability.. or giv- Reliability ing cues to elicit a response). 2001). Meline. Although measuring any phenomenon is always and Strauss. Patterson. Considering only time mation about the content. Murray & Chapey. Spreen. As such there is an increasing number of patients on disorder. 1991. tests designed cessful assessment interaction (Mahendra et al. a Spanish version of the WAB). 2000). age. many test administer a test. For example.. standardized tests are language only may lead to errors in diagnosis. the subtests of most moves through these stages in one’s professional develop- aphasia batteries include too few items to provide a sensitive ment. it is preferable develop compensatory behaviors to replace the deficit. During the course of treatment an guage is not English. and artifacts that members of a group use to cope Strauss. Regional differences. values. As one 1990. 1990). and regional considerations change in test scores would obscure a determination of should guide test selection for individuals whose first lan- treatment effectiveness. meters of scoring principles. In addition. the details of administration instructions. Kennedy & evaluation should include testing in all premorbidly spoken Chiou (2005) described 33 assessment tools in languages languages of a patient and ideally be conducted by a clinician other than English that are available for use with individuals who is fluent in those languages.. Kay et al. it is incumbent upon the of reference groups (e.g.. and that are transmitted from one generation to another through learning” (Bates & Predictive Considerations Plog. However. such as failing administered to a large number of individuals who represent to detect symptoms that appear in one language but not the a cross-section of the population to whom the test will be other. in English (Baker.. the potential lack of corresponding that geographic. 2000). the clinical setting. Lesser. or assessment bias introduced by using a translator to administered in clinical practice. however. the Aachen Aphasia Test (Huber et al. 2003). When client and to plan as sensitive and thorough an assessment selecting a test for use with individuals with aphasia. however. 2006) that incorporates unsuitable measures of language change or recovery (David. speech-language pathologists’ caseloads for whom English may induce artificial errors (Barker-Collo. assessment (Baker. the Psycholinguistic Assessments of Language is not the primary culture. reliability and validity data. a client may be from a different geographic region than that in which the test was Ethnocultural Considerations developed. session as possible. Although adaptations of a test may be individual is expected to relearn language behavior or available (i. real change made by a patient in a spe- as being sensitive to the cultural and linguistic traits of a cific area of language functioning may not be represented in client. 2005). the para. Clearly it may not always be possible for a authors revise their tests in an attempt to improve sampling clinician to evaluate a patient in all languages in which that procedures and to expand normative data to a greater variety patient may be fluent. For exam- tioning but do not reflect learning that occurred over time ple. 1992) con- the presence of a neurogenic communication disorder pre. They reported that their . may be unfamiliar to English- tilingual (Baker. Spreen and Risser (2003) suggest activities. or a the standardization sample (i. behaviors. time post. three stages: awareness. Furthermore. particularly in vocabulary. one becomes better able to plan and implement an and reliable measure of a particular language modality or assessment session that is appropriate to the disorder as well dimension. Likewise. and advocacy. attitudes on the part of the cians are advised to examine carefully the characteristics of patient toward the testing process. question-and-answer format may be threats to successful onset). Several used by the National Faculty Center at the University of researchers have noted that standardized tests are clearly Arizona (National Faculty Center. standardized lan- likely be more appropriate for individuals whose native lan- guage tests typically do not allow cueing or probing to “test guage is German than a German translation of a test written the limits” of performance or examine learning styles.e. 2000).. and thus produce errors that are related to a cul- It is well regarded that society is becoming increasingly tural or linguistic difference rather than a communication diverse. Appreciating cultural differences and using cul- turally competent assessment practices is important to a suc- In addition to meeting psychometric criteria.. and Culture is “a system of shared beliefs. cultural. tains several items (such as pram) that while recognized in sents a challenge to clinicians who are not bilingual or mul. They for use with persons with aphasia should allow for measure- describe one framework for achieving cultural competence ment of recovery or progress in treatment. with their world and one another. 78 Section I ■ Basic Considerations To establish norms for comparison. Evaluation of ability in one with communication disorders. education. & Hunter. 2001). Evaluating these individuals for Processing in Aphasia (Kay. or improved clinician to be at least aware of the multilingual nature of a minority representation in the normative sample). the overall test score. For exam- is not the first or primary language. increased age range. to use tests developed in the country consistent with the pre- Traditional language tests measure current levels of func- morbid language of the patient (Paradis. customs.GRBQ344-3513G-C04[64-160]. 1990). the English language per se. information about test revision (Jackson & Tompkins. Speen and Risser (2003) suggest that speaking individuals living in the United States. 2000). 2004). application. Additionally. & Coltheart. clini. It is possible that a treatment protocol Ethnocultural considerations have a distinctive role in for a patient might result in real and meaningful change in test selection for a client whose culture or language differs the patient’s language performance in daily communication from that of the clinician. 1983) would (Spreen & Risser.e. and Eurocentric culture ple.qxd 1/21/08 11:20 AM Page 78 Aptara Inc. and participation. listening.qxd 1/21/08 11:20 AM Page 79 Aptara Inc. 1998a. 1995. While the studies report limitations. (2001) more accurate and valid if the normative group for a given examined performance by African-Americans who were neu. aphasia may impose limita- ent language and cognitive abilities. ment process and diagnostic product. ture is difficult at best (Towards a Common Language for tance of considering ethnocutural influences on the assess. language. such as social and physical-environmental fac- group membership. 1992). 1997. 1999. Ulatowsa et al. Chapter 4 ■ Assessment of Language Disorders in Adults 79 enthusiasm for the number of available assessment tools was influence an individual’s performance (Ardilla. Consequently. there is not a one-to-one correspondence among these fac- ined cultural and linguistic influences in Spanish versions of tors and levels of the ICF (Frattali. Threats & Worrall. Likewise. 1982). or psychological (1998) suggested that such important differences in lan. Activity. Examples of conditions at the impair- guage and the value that a given culture places upon differ. and relevance of information. ticular cultural groups. and tasks all tions on the four language modalities of speaking. hemiparesis. Ethnocutural considerations apply not only to aphasia Body Functions and Structure and language tests administered by clinicians but also to those tests regularly administered by other team members Impairment in body functions and/or structure refers to a (Garcia & Desrochers.. Therefore. and the value that a given culture places upon differ. Disability and Health. munity. 2004. the ICF reported that the three test batteries (MTDDA. Participation Considerations (2001) suggested that the stimuli supported familiar text and The World Health Organization’s framework for health and discourse styles in the participants’ cultures and thus encour. 2003). and linguistic influ. construction principles in many of these tools. Those three subtests nature of impairment in body structure or function and in required less structured responses and emphasized variety. Molrine and Pierce restrictions to participation in society. 2004). 1997. and dysphagia. with an individual’s health condition (disease or disorder). investigators have begun to examine more suitable stimuli and procedures are to individuals from par- closely relationships among test procedures in African. appraise each of the factors that influence performance since Hernandez. functioning and disability are associated (Schuell. cultural. Across all the subtests disorders. quality of assessment because those communication items fos- tered greater communication interaction than standardized Body Functions and Structure. Threats.g. Threats & Worrall. test stimuli. age. Kohnert. 2005.. values such as the Activity duration of residency in the United States. or predicting functional outcome and social rein- individual differences according to the dependent variables tegration solely on the basis of body functioning and struc- examined. et al. and tests or functional communication measures. WAB. Ulatowska et al. and involves consideration of contextual factors that influence BDAE) are unlikely to yield performance that is influenced by performance. lessons to clinicians are similar about the impor. Mansur and col. only three subtests showed a significant environment will be influenced not only by the degree and difference between the two groups. aphasia test is representative of the ethnocultural or linguis- rologically unimpaired and who had aphasia. In the ICF. They found that tic group to which a person with aphasia belongs (Spreen & using fable and proverb interpretation tasks improved the Risser. Ross & the Boston Naming Test and the BDAE. English profi- ciency. health condition is not the only consideration in & Kaplan.. 1983) to 48 individuals who were black or assessment. and the Boston Diagnostic Aphasia Examination (Goodglass however. 2002). For example. or co-existing physical ences on test performance in individuals without neurologic or mental health conditions) that may interact with impair- impairment and with aphasia have also appeared for persons ment. clinicians living outside the United States. In addition. assessment findings will be American individuals with aphasia. activity.. and Bates (1998) and Pineda et al. but also by limitations in personal activities and quantity. Disability and Health. 2004. (2000) exam. an individual’s performance in his or her usual of the three batteries.. education. . Wertz. or architectural design of the patient’s home) and Studies of demographic. ment level of the ICF include aphasia. Tower. Molrine and Pierce administered the (Simmons-Mackie. disability (Towards a Common Language for Functioning.GRBQ344-3513G-C04[64-160]. 2004). 1992. Payne-Johnson. hemi- ent tasks and priorities are critical considerations for both anopsia. assessment and intervention. personal factors (e. 1965). while the less structured discourse tasks tors (e. Kempler et al.g. aged a quick yet sensitive assessment of natural language. social attitudes of individuals in the patient’s com- may show performance differences. Jacobs tempered by the lack of adherence to psychometric test. structure or function. the Western Aphasia Battery (Kertesz. Chapey and Lu loss or anomaly in anatomical. clinicians must be aware of how salient and Recently. Functioning. physiologic. Minnesota Test for the Differential Diagnosis of Aphasia 2004). Within the activity level of ICF. Within ICF. 2002) influences how aphasia is con- Results from Molrine and Pierce (2002) provided support for ceptualized and consequently assessed and treated this conclusion. In aphasia or other neurogenic communication Caucasian and compared group scores. Estimating leagues (2005) and Radanovic and Mansur (2002) studied the nature and extent of activity and participation assets and similar influences in Portuguese. 1998. work. person with aphasia may present (Baines. 2001. Depression Scale (GDS. everyday contexts (e. as well as tasks necessary for daily liv. chosocial status from the perspective of self-esteem. which equals “Total Assist. The Functional Independence well-being. intrinsically valued tasks and goals enhances individual well- sures to assess the extent and type of language with which a being for all human beings (Cantor & Sanderson. Yesavage et al. These scales are 100-mm lines tain more communication-related information. and may undergo role A serious drawback to the FIM is the limited number of changes (i.. & Fromm. 1994). assessment at the Participation in Society activity level can involve the use of comprehensive aphasia tests and tests of specific language functions (e. 230) and thereby gain renewed health and 2006.. (1996) found the poorest rating basis are the Stroke Aphasia Depression Questionnaire reliability for the comprehension item. persons with aphasia may be unable to return to of a subscription system (The FIM System. 80 Section I ■ Basic Considerations reading. 1999). the Visual Analogue Self-Esteem ries. 1993). 1999)... supported or augmented to facilitate and (Armstrong. 2001). ing in various tasks. 1997). Delcey. Frattali. may become socially isolated. 1991) cation-related activity limitations. Gallagher. ipate in life” (p. they also are anchored by faces representing mood states. and tangible resources that spontaneous language and communication within the con. FIM uses a seven-point They can be examined in terms of performance (a person’s rating scale (1. often used with persons with aphasia are the Visual Rather than rely on these scales to summarize communi. 1998) and the Geriatric scales such as the Functional Assessment Measure (Hall. Two examples of such scales are the Sickness Impact . 1996.. Several commonly used inventories are the Scale (VASES. often on scales such as to keep individuals “vigilant as they find new ways to partic- the Functional Independence Measure (The FIM System..g. 1999). although it is now part example. the Communicative Activities levels and/or restrictions is through the use of wellness mea- of Daily Living-2 (Holland. Participation restrictions refer to obstacles that limit an ment rates in response to medical cost-containment efforts individual from fulfilling his or her social. clinicians may adopt and the Visual Analogue Mood Scale (VAMS. reliability. FIM was originally designed to assist in setting reimburse. wellness measures.g. 2006). Such limitations in language-related activities of daily et al. Heeringa. Stern & Bachman. 1983). clinicians may use measures of psychosocial status or Murray & Chapey.. Ravaud. culturally. occupational. and self-care domains ment tasks and cover a full range of life areas (ICF. the sures. 1996) an individual’s observed and expected performance. Wright. & Yelnik. 2000). 1997). Frattali. and sensitivity for assessment of persons To assess participation and any restrictions to participa- with aphasia (Bunch & Dvonch. Odell et al. 1999. 1995)..)” The person’s ability to act in a uniform environment).. Safely. which activities in his or her current environment) and capacity (a equals “Complete Independence (Timely... 2000). 1998b). Brumfitt & Sheeran. For and continues to be frequently used. using the telephone. Sutcliffe & Lincoln. analysis of part upon social. depression symptoms. & Such participation and concomitant well-being depend in Martin. 1999) in order clinicians to summarize patient data. the Functional Assessment of Communication Skills for Another approach to assessing activity and participation Adults (Ferketic et al. sensitivity and/or validity the lines to indicate their current mood states. naming or Sustained life participation in personally. 1999). writing checks. Two psychosocial scales with a linguistic In fact. 1983) and the Functional Communication requirements in evaluating psychosocial status and detecting Measure (Functional Communication Measure. cognitive. Therefore..e. Another measure. from provider to dependent). 1995) con. 1998. other longer but more precise functional language invento. 1989). 1999). or and to document a patient’s performance on a minimum set personal role or goals.. Analogue Dyspohric Scale (VADS. These resources should be assessed and ingful activities is an essential component of assessment when necessary. Stern et al. Ottenbacher et al. Activity and participation often appear together in assess- tional ability across motor. and is part of The FIM System®. increase or decrease an individual’s likelihood of participat- text of activities of daily living (ADLs) and personally mean. Additionally. Visual-ana- 1997. Measure (FIM) is a tool for measuring an individual’s func. or the Assessment of Language-Related living refer to any communication difficulties that arise in Functional Activities (Baines et al.GRBQ344-3513G-C04[64-160]. or because of transportation and access barriers in rudimentary scale makes it an instrument of questionable the community. Granger et al. or reading the newspaper). Consequently may be the result of aphasia or functional communication the brevity of description of communication skills on this problems. Although other (SADQ. Two scales (Golper.qxd 1/21/08 11:20 AM Page 80 Aptara Inc.” to 7. personal. assesses psy- Communicative Effectiveness Index (Lomas et al. clients mark on limited in terms of content. and writing. validity. motivate “continued participation (even) in the face of The emphasis on functional communication requires threat or frustration” (Cantor & Sanderson. 1994. and productive syntax ability) as well as functional status mea. These changes items used to summarize language abilities.. tion. Amsterdam-Nijmegan Everyday Language Test (Blomert ing. They reflect the difference between of skills at intake and discharge (Ottenbacher et al. Frenchay Activities Index (Holbrook logue mood scales were created to circumvent linguistic & Skilbeck. systematized. for patients with terize adults with aphasia (Basso. or reported that severity ratings on two standardized impair- conduction aphasia). and a standard measure developed by Schuell and colleagues (Schuell. Aphasia tions gleaned from the patent and his or her family. Broca’s. be formed during the assessment process are those about aphasia classification. called into question for several reasons (Byng et al.. The question should lead to constructive action that cations remains a common and often useful means of describ- will benefit the patient and his or her family. Among the hypotheses that may however. McNeil & Kimelman. 1981) and the Duke-UNC Health Jimenez-Pabon. and for the different aphasia types frequently overlap (e. 2005). Doyle and their assessment. Three forms of ing language deficits in both clinical and research settings. and condensed in a meaningful way these categories cannot be said to be homogeneously (Murray & Chapey. program. A synthesis of battery used (e. 2004). For example. clinical report. (8) categories convey little information concerning the Hypothesis formation is also part of the process of evi- nature of the underlying language impairment (e.g.. aphasia severity. orities and specific plans for a program of intervention. Schwartz. for scientific inquiry and organizing thinking about aphasia. 2005. The BOSS is a The validity of aphasia classification systems has been health-status assessment instrument and measures patient. It is an evaluation of the type. patient’s total behavior. & (BOSS) to measure communication difficulty and psycho. severe language impairments. (7) discrepancies diagnostic findings will aid not only in determining the suit- in interjudge reliability can possibly stem from a lack of ability of the patient for treatment but also in indicating pri- agreement about how to assign and weight specific responses. However. patients by selecting shorter tests for the initial assessment expressive aphasia). (6) classifica- exploration of the interrelatedness of various behaviors tion of aphasia type may vary as a function of the aphasia observed throughout the assessment period.. 1988). at times. and the locus of deficit derived from a model of language processing. the WAB and PICA. Deal.g.. Shlonsky & Gibbs. delicately balancing and blend- all patients with aphasia display some degree of impairment ing the data to arrive at a penetrating understanding of a in both language comprehension and production abilities. 1964) to organize and label the results of Profile (Parkerson. Hypothesis formation is a sophisti- (4) a patient can evolve from one classification to another cated clinical judgment applied to the information collected during the course of recovery. while others use one of the anatomically or only one test or procedure. WAB results). clinicians may wish to avoid a Some clinicians use one of the dichotomous classifications frustrating assessment experience for themselves and their systems (e. for some patients. Varney. For example. logical distress in persons following a stroke. Kertesz. reported functioning and well-being. Still others use the classification system ment measures.g. the CADL. BDAE vs. Severity Classification Determining the severity of the language impairment in a Aphasia Classification person with aphasia may guide the clinician in selecting Many classification systems have been developed to charac. communication disorders [Position Statement]. and a types are a clinical “shorthand” system of identifying patient clinician’s individual experience (Evidence-based practice in characteristics among clinicians (Bartlett & Pashek. 1992. (5) the inclusionary criteria (Lahey.g. frequency. Nickels. Ross and Wertz (1999) based classification systems (e.. phonologic] of language pro- ation of a clinical question to be answered with evidence. nonfluent aphasia. & Deal. evidence are important to gather to formulate an hypothesis. 2001. & of disability. 1981). appropriate testing materials. Fromm. Wertz. A cessing is impaired). 1979). and answer the clinical question: pub- may succinctly describe their language profile. were strongly correlated. and (9) syndrome classification in itself good clinical question should be patient-oriented and prac- does not provide the basis for any comprehensive treatment tical. 2003. (2) patients in organized. Swindell.GRBQ344-3513G-C04[64-160]. 1994). In this decision- impaired.. Wertz. 1986). Gordon. there is still no universally colleagues (2003) developed the Burden of Stroke Scale acceptable classification system (Holland. or receptive vs.qxd 1/21/08 11:20 AM Page 81 Aptara Inc. 1998. 1984): (1) the language profile of Hypothesis Formation many patients cannot be fit into one of the categories (esti- mates range from 25% to as many as 70% of patients with The information obtained during data collection must be aphasia who cannot be successfully classified). and guide an evidence search (Shlonsky & Gibbs. Despite these concerns. Jenkins.g. 1993. Caplan. 1990. 1984. and conse- lished data that represent the best evidence gathered from quently the label may. Crary. the clinician sifts through expressive or sensory/motor are misleading since most if not all the information obtained. & Robinson. all pattern of behaviors produced by the patient as well as an aphasia types include anomia as a symptom). be useful to include in a research. which dence-based practice (EBP). or research paper. Chapter 4 ■ Assessment of Language Disorders in Adults 81 Profile (Bergner et al. Scores on . Wernicke’s. Gehlbach. (3) certain aphasia classifications such as receptive/ making component of assessment. a particular aphasia type gather information. & Wagner. 1998. One of the steps in EBP is cre- particular level [semantic vs. information about assessment values and expecta- medical chart note. fluent vs. the use of aphasia classifi- 2004).. their limitations must be kept in mind. 2001. and vague terminology are an asset to hypothe- core aspects of these models in terms of their origin. . and executive func- may be useful in determining aphasia severity are clinical tions. For example. Aphasia severity rating may also and weaknesses of each person with aphasia and to hypothesize provide a useful guide for assigning patients to language about contributing factors (Murray & Chapey. However. Murray treatment groups (Beeson & Holland. Lezak et al. clinicians one another in terms of content. 2001).. similar behaviors shown by a person with aphasia (i. Murray & Chapey. may contribute to beyond administering aphasia batteries and labeling aphasia underestimation. may underestimate a patient’s ability to communicate in everyday situations. The measures are not replacements for according to information-processing approaches. Whitworth for picture naming: analyze visuoperceptual or auditory input. help clini- test or procedure scores clinicians may use cognitive neu. 2002a. The information can also yield descriptive summaries that Models of Language Processing: Cognitive indicate the level at which language performance (a) is com- Neuropsychological. emerges (Lahey. should be an ongoing part of treatment and occur at every icians to assess the types of errors made and the manner in phase of rehabilitation (Murray & Chapey. well-organized. 1993. domain. clarifying the language and communication breakdown and in guiding the determination of treatment goals and activities. (b) begins to break down. patient’s treatment program and enables the clinician to con- Figure 4–4 is a cognitive neuropsychological model of the lan. picture naming or sentence tentative and flexible enough to change as new evidence production) is conceptualized as a sequence of operations (e. Hypothesis testing continues throughout a access semantic stores. linguistic (content and form). The assessment process supports the need for clinicians to go known communication partner styles. 1994) or selecting & Clark. and the principle method of assessment The results of hypothesis formation. accuracy. from the orthographic output lexicon. Examples of In addition to standardized tests other instruments that these processes are memory. however. Using a model of language approach acknowledges that judgment supported by observation. Additionally. a model-based approach allows clin. In these models a treatment goals that are established. (2004) noted but due to a different cause—an inability to access information that the severity estimate derived from a standardized bat.GRBQ344-3513G-C04[64-160]. clinicians will want to be certain because of a breakdown at the semantic level whereas another that the measure has been examined with respect to valid. and (c) breaks down Information Processing completely. anomia) or a severity score. 2005). (Byng et al. For example. et al. specifically. cians determine initial goals of therapy. and Psycholinguistic pletely accurate. & Coltheart. assessment breaks down. even the CADL. These types of information are essential in treatment goals. easy to understand. the is case studies of brain-damaged persons. may result from different underlying processing problems. Lesser. in order to measure to determine severity of aphasia may be redundant. such as that included on the BDAE. the domain is mental representation and processes in cognition. and. 1988. These factors are unique qualities to type and severity to describe and summarize the actual cogni- everyday interaction and are difficult to replicate in a stan. 2006). and pragmatic strengths dardized examination.e. should be considered particular language behavior (e. The assessment process that results models to guide assessment and describe clinical findings in descriptive language summaries that are accurately written. the origin of cognitive neuropsychological models is the field of Hypothesis Testing and Reporting cognitive psychology. In addition. 1996). familiarity with vocabulary. 2005. Lesser. ity and reliability. understand the nature of the language deficit. and guide reassess- ropsychological. and impairments in order to determine the validity. tinue to secure additional data about language abilities and guage processing system proposed by Kay. For Regardless of the measure used to determine or index example.. severity rating scales. 1993. Several personal Summary and environmental factors (ICF.qxd 1/21/08 11:20 AM Page 82 Aptara Inc. 82 Section I ■ Basic Considerations these measures were also strongly correlated to measures of which a patient completes each language task.. and well. sis formation and patient management. For example. access phonologic output lexicon). psycholinguistic or information processing ment to monitor progress. 70).. slang. such summaries can identify factors Rather than summarizing assessment results with two or three that facilitate or impede the patient’s language use. and Coltheart (1996). Davis (2000) differentiated jargon. patient may also be unable to write the name of a target item. routines. tery. one patient may have difficulty with written naming overall aphasia severity.. The clinician’s task in employing models is appropriateness of the hypotheses that were formulated. 2001) such as contextual cues. 2001. Hillis. Ross and Wertz analyze the underlying processing mechanisms that may be (1999) suggested that perhaps administering more than one impaired and thus causing surface-level symptoms. to determine the integrity of each of the language operations Separation of assessment and intervention activities allows or components within each language modality in order to for the initial presentation of information in an organized localize the level or levels at which the language behavior manner in order to begin treatment.g. 1990. tive.g. attention. connected speech. and free of professional Kay. Caplan. 2001. and principal method of evaluation (p.. g. A Cognitive Neuropsychological Model of Assessment of Naminga Acoustic-to. family. from the assessment session. & Coltheart.g. and/or paraphrase information across several sessions to ment sessions—a clinician must report the results of the assure that the patient and family understand the assessment hypothesis testing to other individuals on the assessment results (Avent et al. any other information that is perti- injury) help patients. or an aspect of the assessment session. and other professionals nent to the session.. In this type and/or staff conferences. without interpretation. Lesser. 159–215. “O” stands for objective and this section contains data from 2004). team. Semantic Letter-to- phonological system sound conversion rules Phonological Orthographic output output lexicon lexicon Phonological Sound-to. A widely used written format for reporting information Assessment findings are usually presented when all of the in a patient’s file is the SOAP note. and significant others. 10. as well as in the form of a short. of reporting format the “S” stands for subjective. Aphasiology. Luterman. Orthographic output letter output buffer rules lexicon Speech Print a Kay.. that have been affected by the patient’s stroke or brain historical information.GRBQ344-3513G-C04[64-160]. 1996). tion at one time. R. Chapter 4 ■ Assessment of Language Disorders in Adults 83 Speech Pictures/seen objects Print Auditory phonological analysis Abstract letter identification Phonological input buffer Phonological Visual object Orthographic input recognition input lexicon system lexicon Figure 4–4. case history. unstructured and structured the Problem Oriented Medical Records system of reporting observations. and reports from other team and orienting information in a client’s file according to spe- members). comprehend the information provided (Shipley & McAfee.. caregivers. non- diagram of the brain to assist in describing anatomic areas measureable observations about the patient or the session. Reprinted with Permission. At various points during the assessment process—the ini. J. This section presents the findings overloading the patient and family with too much informa. Frequently. a in this section are the clinician’s subjective comments. When presenting information it is important to avoid the assessment activities. visual illustrations (e. Comments concise written report. M. Psycholinguistic Assessments of Language Processing in Aphasia (PALPA): An introduction. SOAP notes are part of data have been assembled (e.. The findings may be conveyed verbally at family cific problems or deficits a patient demonstrates. The . Clinicians should be prepared to repeat tial assessment session and other evaluation and/or treat. 2005..qxd 1/21/08 11:20 AM Page 83 Aptara Inc. (1996). as well as the patient. O 50% accuracy for confrontation naming. A statement of functional communication the clinician writes the direction—or plan—for future skills. 84 Section I ■ Basic Considerations Reporting Assessment results: two examples of a SOAP note S Mr. Two examples of SOAP notes “A” section of a SOAP note stands for assessment and con. 1-hour therapy sessions to be scheduled. or a related neurogenic . Pt’s daughter reported good progress c word retrieval. as does the and findings. coop during eval and reported frustration with word retrieval difficulties. 2005). Y/N response 100% in questions with concrete and familiar elements. required substantial time to produce the names of the test items. which is derived from the data as well as the patient’s a patient presents with aphasia. S was attentive to all tasks and cooperative throughout the session. One goal of the assessment process is to determine whether cation. P Bi-weekly. S presented with severe (below the first percentile rank) word-finding difficulty across a variety of word types A (i. as well as the session performance. 2001. A sample of a SOAP note appears bers and significant others. BNT 30/60. Additionally. reading and writing WFL. overall performance during the session. S. Excellent prognosis considering the patient’s cognitive status. Pt. which stands for plan. are usually written in as succinct a manner as possible. The Life Participation Approach to Aphasia (Chapey et al. In this section Elman.GRBQ344-3513G-C04[64-160]. S’s word-finding abilities at the isolated word level and using a cueing hierarchy approach.. Equally as important is a statement of functional communi. The WHO ICF tains the clinician’s interpretation of the assessment data provides a useful tool for framing this statement. The focus of therapy should be to increase the accuracy and speech of Mr. Mr. or other clinical or chart notes. GOALS OF ASSESSMENT It is important that data are included in a report of assess- Goal 1: Determination of the Presence of Aphasia ment sessions as they lay the foundation for the diagnosis. 2: word-retrieval success in conv speech to 50%. He demonstrated and commented about frustration with word-finding difficulties. O The test of adolescent/adult word finding was administered. Mr. As Golper (1996) noted. is particularly useful in setting in Figure 4–5. fourth section is “P”. ST at hosp. Cognition. particularly including interaction with family mem- assessment or treatment. nouns and verbs) and word-finding tasks.e. A Dx: mod-sev anomic aphasia. motivation and stimulability. S achieved the following scores: Subtest % correct Picture naming: nouns 28% Sentence-completion naming 19% Description naming 8% Picture naming: verbs 5% Category naming 19% Total naming 17% Comprehension 90% Average item response time 12 secs Mr. SOAP notes. Speech therapy 3x/week x 5 weeks to address following goals: 1: word-retrieval success in structured tasks P and conf naming to 80%. and prioritizing treatment goals.. “brief notes get read and long narra- tives do not” (p. 69).qxd 1/21/08 11:20 AM Page 84 Aptara Inc. Figure 4–5. S 72 yr female sustained LCVA 15 days ago. referred for Tx upon dc. Careful analysis of the The Mini Inventory of Right Pimentel & Knight (2000) case history will aid in confirming whether the language Brain Injury -2 symptoms reflect the presence of aphasia or related neuro. linguistic preference. 2005. patients with RHD do not resemble those of patients with Language disorders may only appear at complex levels (e. 2005). strengths and weaknesses. five Communication Disorders out of 45 patients were diagnosed with normal language skills. or whether his or her language and communica.. assessment must continue on many levels (e.g. Chicago Clinical Management of Right drome. In such cases. The language impairments dementia). right hemisphere disorder or tional disorder (e. at times. despite the presence of aphasia as language-based.. Blake (2005) divided deficits associated identified by the patient. with right hemisphere syndrome (RHD) are not exclusively or routine. language. 1997. no clear boundaries Determining the presence of aphasia may be challenging separate normal and abnormal behavior for the pragmatic for many reasons. a person with with RHD into three general categories: communication. (Blake.. Myers. aphasia may be so mildly impaired that he or she achieves attention/perception. or an emo- .. mined relatively quickly during the initial observation or However. using the Boston Diagnostic Aphasia The communicative deficits that are common among Examination. In contrast. LaPointe. Spreen & Risser. language problems may not be immediately Right Hemisphere Syndrome apparent when conversational time is limited and when the The communication problems that appear in individuals responses during conversation are conventional. tion and other open-ended or sophisticated communication ment in executive functioning skills.g. dementia. test norms may not accu- and cognitive deficits often observed in persons with RHD rately reflect a patient’s peer group in terms of age. 2005. 2005). For example. Blake et al. when the lan. diagnosis of the behavior deficit is not often easy for several ICF) and include information about cognitive. communication environment and personal environment of when aphasia symptoms are mild.. 2nd ed. The limited range of tasks on ies that are appropriate for use with persons with RHD are some aphasia test batteries may not detect subtle differences listed in Table 4–6. and patients with RHD represent a heteroge- cultural background. That is. not exempt an individual from also presenting with one or guage impairment is severe or moderate the presence of more of the above conditions. cognitive deficits may interfere with language detailed description of language and communication performance. Rehabilitation Institute of Halper et al. a Dysfunction. pharmacologic disorder. 2005). the final deci- sion regarding the presence of aphasia in individuals who are mildly impaired may be tentative and must be based on care. Tests for Right Hemisphere Syndrome In addition to determining the presence of aphasia it is often the clinician’s responsibility to differentiate between Right Hemisphere Language Bryan (1994) language impairment in aphasia and language impairment Battery -2 that results from a different etiology. TABLE 4–6 fully documented observation and clinical judgment (Chapey. Neils-Strunjas. Brookshire.qxd 1/21/08 11:20 AM Page 85 Aptara Inc. and cognition. In RHD from the perspective of etiology may be easily evident. such as immediate tasks (Bartels-Tobin & Hinckley. in language abilities. 2001). sources of disturbance and follow different clinical courses. a metabolic disorder. 2003. expected. and become most apparent in prolonged conversa- employment-related discourse) and/or be a result of impair. no clear definition of RHD exists (Blake. For example. all 45 patients were diagnosed with aphasia. Chapter 4 ■ Assessment of Language Disorders in Adults 85 language disorder (e. family. Several test batter- 1998. it may be more difficult to the individual (ICF. primary progressive aphasia. (Murray & Chapey. a neurologic deficit (e. Frequently the presence or absence of aphasia can be deter.. this case.GRBQ344-3513G-C04[64-160]. Careful observation and dif- aphasia is obvious and a diagnosis can be made quickly. Although diagnosis of perfect or near-perfect scores on traditional test batteries. In ferential diagnosis will aid in determining the contribution this case the remainder of the session can be devoted to of any disorders to current language functioning within the specifying the nature and extent of the disorder. Consequently they demand different treatment approaches. Myers. (1996) genic communication disorders of right hemisphere syn. linguistic. 2001.g.g. 2001. confirm the presence of language or communication impair- ment. depression). aphasia. 2003. For example. Wertz and colleagues (1984) found that using the Western Aphasia Battery. 2003). reasons: there may be overlap among deficits in an individ- and communicative skills to provide a comprehensive and ual patient. it is important to note that having aphasia does interaction with the patient.g. memory (Davis. or educational neous population in terms of extent and type of deficits background (Garcia & Desrochers.. however. traumatic Hemisphere brain injury. associated with these disorders have different underlying tion skills are within normal limits when compared to peers. Therefore. schizophrenia). 2000). 1986). or physician. Recent research suggests that the ologies of reversible and irreversible dementias. Leonard & Baum. Tompkins et al. topographic orientation deficit (inability to relate to the sur. (e) Cognitive Deficit problems in assimilating and using contextual cues. persons with RHD may not have access diated by treating the underlying medical condition. 2002). sound-localization deficits. some of them may occur following unilat- gential and/or provide unnecessary detail. 1995. eral right hemisphere brain damage. Monetta & Joanette. even under Tompkins. however. Potentially all cognitive domains (e. idioms. which cause sig- rounding space). macrostructure such as main ideas or with communication varies with the type and severity of themes).g. Marini et al. Cognitive abilities are inter- figurative language (e. For example. 1999. (l) difficulty compre- attention) may be disrupted in RHD. (f) diffi- Approximately half of the patients with RHD admitted to culty conveying information in a cohesive and coherent rehabilitation centers have cognitive deficits (Blake et al. (d) visuoperception deficits. may not be noticeable during daily activities. (c) visuospatial neglect (left ing or abstraction (Disease Definition. (e) Epidemiology. (k) an inability to comprehend successfully or to RHD. 2005.g. affective. memory and produce cohesive ties in discourse. and higher cortical function and intellect. clini- RHD may experience underlie or at least contribute to their cians should use assessment procedures (e. for several reasons. Dementia may appreciating the external context in which the stimulus is result from a variety of reversible and irreversible disorders embedded and with problems integrating the stimulus with (Kaufer & Cummings. topic maintenance. meaningful way. 86 Section I ■ Basic Considerations Brownell et al. 1999.. 1994). These deficits may manifest Course of the Disease themselves in several ways. (c) difficulty dis.. Among the symptoms a person with Dementia is a condition of acquired. indirect related and cannot often be tested independently requests). Many researchers hypothesize that the variety of per- the cognitive deficits in patients with RHD. (i) a reduced sensitivity to communicative context (McDonald. turn-taking. In the gen- and partners. and the manner topic shifting). Table 4–7 lists examples of eti- the internal associations. sultation with family members and significant others to compare current and premorbid levels of functioning. (f) short. and hemispatial neglect).. (i) executive functioning deficits.qxd 1/21/08 11:20 AM Page 86 Aptara Inc. as well as the ceptual.. memory.. (g) visuoconstruction deficits. (g) a tendency to overpersonalize external events. The .g. changes during the later stages that may render the patient These perceptual problems are associated with difficulties in unable to function socially or occupationally. judgment. tion of intellectual abilities affecting several cognitive (b) inability to focus on internal or external stimuli due to domains such as language. The diagnosis requires impairment in prosopagnosia (inability to recognize familiar faces). Although many of the problems and agnosias summarizing information in an efficient. Symptomatology varies from subtle and (j) similar auditory perceptual problems (e. and to the pragmatic or extralinguistic aspects eral population as well as in the population of persons with of communication (e. 1997). manner. emo- reduced attentional capacity or inability to effectively allo. it is unlikely hending or producing prosody in conversational context.g. metaphors. Myers. to profound crimination of prosody. 2000a. and executive functions such as reason- cate attentional resources. Myers. 2005. and therefore may not be become increasingly abstract or complex patients with RHD able to use that information sucessfully to comprehend com- are likely to manifest some or all of the following compre.. In conducting a thorough evaluation of tion. and which are nonverbal memory deficit. bilateral lesions. however. Natural History.g. hension and production deficits: (a) difficulty organizing and 2005). and music perception difficulty). to certain types of contextual information. the pattern of deficits observed is not well- (h) a tendency to lend a literal or superficial interpretation to explained. (h) verbal or nificant social and occupational impairment. 1995). As communicative tasks or contexts reduced processing conditions.. and/or cognitive deficits that patients with deficits’ contribution to communication difficulties. that all persons with RHD will display deficits in all areas and (m) reduced appreciation or altered expression of emo- (Murdoch.. progressive degenera- RHD may experience are (a) anosognosia (denial of illness). 2006). tinguishing between information that is relevant and irrele- vant. symptoms associated with reversible dementias can be reme- ward. plex linguistic content (Cherney. abstract thinking. impaired dis. visuospatial skills. (d) an inability to generate and interpret inference. RHD battery higher level of communication disorders (Blake.GRBQ344-3513G-C04[64-160]. Cognitive deficits underlying these symptoms may not be straightfor. (j) difficulty organizing and maintaining dis- in which cognitive deficits manifest themselves to interfere course structure (e. 2003).. close observation of behavior. 2006). auditory changes during the early stages of the dementing illness that agnosia. tion or personality. amusia. observed in persons with RHD are primarily associated with (b) a tendency to produce impulsive answers that are tan. not related to delirium. 2002.. or memory testing).g. RHD there is a range of cognitive abilities. including contributing to a com- munication deficit. 2005. Attention/Perception Disorders A number of deficits in attention and/or perception can Dementia appear in a person with RHD.and long-term memory.. and con- Blonder et al. will reduce or eliminate the cognitive symptoms associated During the middle stages of dementia. Wernicke-Korsakoff served repetition.GRBQ344-3513G-C04[64-160]. or brain stem). lacunar state (multiple small infarcts in the sub- Hearing loss cortex. patients with corti- Thyroid disease cal dementia may demonstrate logorrhea. and Irreversible Causes motor-speech disturbances such as slow rate. empty speech. 1990). with patients having difficulty Dementia may also be categorized on the basis of neu. In vague. maintenance. very important that reversible causes of dementia be ruled During these stages. The most commonly further disoriented and have difficulty with both time and occurring dementias are irreversible: Alzheimer’s disease place information. dementia pugilistica) among patients with varying dementia etiologies (Snowden.. patients become with irreversible dementing diseases. examples are Parkinson’s disease. Pick’s disease. Vascular dementias arise as a Depression (pseudodementia) result of thrombotic or embolic occlusions that cause focal Drug use (e. and late. Conversational prob- Site of Lesion lems are now prominent. Chapter 4 ■ Assessment of Language Disorders in Adults 87 TABLE 4–7 subcortical structures such as the thalamus and basal ganglia... midbrain.g. Language output becomes 2005. . impaired and patients can no longer manage personal finances. or medication. and less than 1% of casual conversations. employment.g. 2003.. topic roanatomic location of the causative lesion (Bourgeois. 2003). Despite some differences in symptomatology Traumatic brain injury (e. For exam- Mental and/or sensory deprivation Renal failure (dialysis dementia) ple. mid- Progressive supranuclear palsy dle. Hart & Semple. there are similarities in behavior as the dementing disease progresses over time (Bayles & Kaszniak. the result is a mixed dementia. Vascular dementia 1999). patients may still Clarfield (2003) showed that potentially reversible demen- appear to be successful communicators. relatively pre- Vitamin deficiency (e. and topic shifting. Patients the cortical dementias the pathophysiology affects primarily will frequently produce semantic paraphasias and may mis- the cortical brain tissue. Creutzfeld-Jakob disease Human immunodeficiency virus encephalopathy Huntington’s disease Stage of Dementia Multi-infarct dementia Multiple sclerosis Yet another way of understanding dementia and its accom- Parkinson’s disease panying behavioral symptoms is in terms of staging over Pick’s disease time. In terms of language abilities. Alzheimer’s disease and articulation and intonation difficulties. Huntington’s disease. lead poisoning) verbal paraphasias. in the early stages of dementia. Typically. When both cortical and sub- of Dementia cortical brain tissue is affected by the disease process. 2004. Subcortical Problems with auditory and reading comprehension also dementias are those in which the pathology primarily affects become prominent during this stage of dementia. impaired comprehension. empty. patients with dementia may also display out prior to diagnosing a patient with irreversible dementia. 1995). An example of a mixed dementia Reversible Causes that Can Resemble Dementia is dementia with Lewy bodies. in terms of communication profiles. and often irrelevant. agraphia. in contrast.g. and Binswanger’s disease. patients are forgetful and disoriented for time but generally not for place or person. periodic word-finding problems and difficulty interpreting In contrast. researchers have yet to identify treatments that higher-level language forms such as humor or sarcasm. Nonetheless. perseverative. encephalitis) dementia. Memory abilities become further (56% of all dementias) and vascular dementia (20%)... patients syndrome) with subcortical dementia tend to have decreased output on verbal fluency tests (divergent thinking). 1987. examples are Alzheimer’s disease.qxd 1/21/08 11:20 AM Page 87 Aptara Inc. A meta-analysis by affected. Both their short- prevalence of reversible dementias is much lower than pre- and long-term memory abilities are typically already viously thought (Clarfield. adhering to conversational rules such as turn-taking. they may sometimes digress dementia cases were actually reversed. and topic digression. Toxin exposure (e. anticholinergic side effects) neurologic symptoms. pellagra. especially during tias comprised only 9% of all dementias.g. use syntactic forms that affect the meaning of an utterance. 1997. Lezak et al. hypophonia. Neoplasm Some differences exist among the symptom profiles associ- Normal pressure hydrocephalus ated with each of these dementia classifications. however. meningitis. it is from the topic and ramble at length during conversation. Ripich. Cohan.g. Brookshire. and frontotemporal dementia. Dementia progresses through three stages: early. and Examples of Reversible and Irreversible Causes progressive supranuclear palsy. Three subgroups are multi-infarct Infection (e. or confabulatory verbal and written output tive functioning.. one or more of the following areas: attention. Few specific assessment tools exist exclusively some similarities between patients with aphasia and those for patients with TBI (e. memory/new learning. and is now dependent reasoning. Hartley. 2005) and continuing to present with frank aphasia. Kertesz. conceptual organization.. Other length of loss of consciousness) and by behavioral deficits in higher-level language difficulties seen in patients with TBI.g. (4) difficulty on memory tests of delayed spatial and verbal verbal memory. a review of the linguistic and cognitive that examine behavior resulting from both focal and diffuse changes that occur in dementia indicates that there are brain lesions. tive-communicative behavior in four performance cate- ation of ideas is less common in the language output of gories: attention. several linguistic and cognitive features Henderson. and disorders of execu. oral expression. Brain-tissue damage in a TBI may quently observed in patients with aphasia. no such disparity was seen between the delayed integration and reasoning with language (Hartley. Practice guidelines Linguistic Communication Inventory (Bayles & Tomoeda. Ability for Traumatic Brain Injury (Adamovich & 1985). (2005) and Traumatic Brain Injury Turkstra et al. executive func- patients with aphasia (Bayles & Kaszniak. 2005. Sohlberg & Mateer (2001) (i. 194–195). (2) neglect. 2000b. 88 Section I ■ Basic Considerations In the later stages of dementia.. Bayles and colleagues (1989) Hartley (1995) identified tests in ten categories: attention. problems selecting and maintaining appropriate Patients with diffuse damage may display cognitive-commu. 2001. many tests designed to assess may help distinguish individuals with aphasia from individ. ment measures designed for patients with dementia are the Recent evidence reviews have discussed procedures and Arizona Battery for Communication Disorders in tools for standardized and nonstandardized assessment of Dementia (Bayles & Tomoeda. and expert opinion. Turkstra et al. 2002). Recent research is exploring the notion that there are Generally.. reported that patients with mild and moderate dementia memory.qxd 1/21/08 11:20 AM Page 88 Aptara Inc. concise. Davis. Stierwalt. can be found in Turkstra. functioning.. Coelho. While these dis. For example. 2000. the Brief Test of Head Injury with dementia. morphology and syntax) are less common in the lan. comprehending. 2000. however. auditory compared with their immediate recall performance. 2005. particularly patients with anomic aphasia (Helm-Estabrooks & Hotz. adjustment. psychometric properties. 1987). Traumatic brain injury can range from (Coelho. and verbal contrast. Patients who sustain discrete lesions may dis. Murdoch & Theodoros. 1995. and (6) recognition than did patients with aphasia. 82–85). 2001). Coelho et al. individuals with be discrete and focal. Three assess. Patients with dementia also displayed much greater gories: (1) attention. commands. memory.. short. of cognitive symptoms. 2006. place. and learning as well as compre- for most activities of daily living. the Scales of Cognitive and patients in early stages of dementia (Nicholas et al. 2002. errors in language form individuals who sustain a TBI. (2003). problem-solving. verbal learning. cohesive. 2004). mild to severe. and other progressive disorders. and/or and recognition. working retaining complex or abstract information (e. However. communicative problems that affect multiple aspects of aphasia.. However. as determined by neurologic findings (e.g. . injury is diffuse and cognitive-communicative impairments as a result of TBI includes cortical and subcortical structures in multiple lobes display difficulties in pragmatic aspects of language.g. 1993). Coelho and Ylvisaker (2005). visuospatial perception and construction. larly devastated (Bayles et al. conversational topics. typically. Traumatic brain injury (TBI) is the result of an external In contrast to the difficulties with content and form fre- force applied to the head. the Alzheimer’s persons with TBI (Coelho et al. instead. 2005.. for standardized assessment as well as tables listing com- 1994). and the frequent production of irrele- nicative deficits. language comprehension abilities are simi. perceptual deficits. self-monitoring. the patient becomes dis. and outcome measures. Davis. patients who survive their TBI are less likely subtypes of dementia (e. become mute. identified several tests that may be useful in assessing cogni- guage output of patients with dementia. in comprehension. (3) nonverbal memory. 1995. intelligence. executive functioning.. McDonald. Examples of these deficits include difficulty organizing ver- play language impairments that are similar to those that bal and written output so that it is coherent. & Quick Test (Wiig et al. however. whereas persever. 2005. clinicians should plan assessments orders are different. monly used tests. 2005. and many patients eventually (Adamovich. Murray and Clark (2006) listed tests in six cate- sia. and immediate recall performances of patients with apha. and person.g.. (5) verbal and nonverbal memory. 2005). pp. motor performed significantly more poorly on delayed recall functioning. vant. Language output may be hension and production of speech and language completely void of meaning. and appear in individuals with aphasia following a stroke. Turkstra. 2000). McCullagh & Feinstein. they show cognitive- the process of differential diagnosis among dementia.. including detailed reviews. and behavior. abstract oriented for time. and the Functional Ylvisaker. executive function (Murray & Clark. Sohlberg & Mateer. perception such as problems attending to. 2003. Turkstra et al. Brookshire.GRBQ344-3513G-C04[64-160]. 1992)). tangential.. of the brain.e. 1991). language or cognitive function are well suited for use with uals with dementia. In terms tions. pp.or long-term memory. 1990).. Paterson and Scott-Findlay (2002) initial symptom as well). differentiating PPA from traditional aphasia 1982. p. Ricker. delusions. (4) environmental supports. 2003. and Caramazza (2002) also reported rela- well as the individual variability of patients and their families tively preserved writing abilities and a double differentiating (Hanks.e. may have word-retrieval problems. and Ken (2004) and will reflect typical and traditional assessment practices as Hillis. & ing memory and attention deficits. confabulation. unknown or dif- circumlocutions. (5) premor. specific language symptoms appear to be similar to bid personality. and (8) patient and family expectations (Sohlberg & quently include word.GRBQ344-3513G-C04[64-160].finding deficits (the most common Mateer. Grossman and colleagues (2004) suggested cognitive impairments of attention. Westbury & Bub. Worrall. speech and language pathology literature. 2004. & Millis. tumor. Rogers & Alarcon. or that are a product of visual misperception. Weintraub and colleagues frequently manifests in late adolescence or early adulthood. progressive versus relatively static presentation of may make naming errors that are related to their personal symptoms).. the contribute to variability in behavior: (1) nature of brain incidence of nonfluent PPA is reported more frequently in injury. Sohlberg and Mateer (2001) suggest that eight variables 1998. The language symptoms of patients with PPA situation or to the nature of the stimulus. and executive function . or a precursor or variant of more generalized dementias the absence of normal behavior) symptoms. (Vandenberghe et al. negative symptoms include flat affect. 1992.. & relatively common. (7) coping those associated with traditional aphasia and most fre- skills. 1997). 1997).. there are often some Although distinguishing PPA from the language impair- qualitative differences between the types of errors produced ments caused by progressive dementing diseases remains by these two patient populations (Boles. Aphasia types such as anomic aphasia.. Tuffiash. 1992. Rubin. in addition to the can be made on the bases of etiology (i. a semantic interference effect suggest that interviewing individuals with cognitive. controversial. apathy. but not other sub- Although both patients with aphasia and patients with TBI groups.. Oh. Petersen. Specifically. 1994). Larkins. Hickson. Positive symp- such as Alzheimer’s or Pick’s disease (Clark et al. and reduced word fuse versus focal brain damage) and course of the disorder fluency that are typical of both groups. Primary Progressive Aphasia Primary progressive aphasia (PPA) is a clinical syndrome in Psychiatric Disorders which patients suffer progressive language deterioration despite unidentifiable stroke. 1998). or executive that converging evidence supports distinct subgroups of functions (Whyte et al. (2) patient’s preinjury history. Holland. 2004. in their review of 112 published cases of PPA. nition and independence in activities of daily living. the presence of abnormal behavior) and negative (i. repetition difficulties. and by the presence of relative preservation of cog. Of these. nonfluent aphasia.. Grossman & Ash. PPA. Given the complex nature of commu. and global lowing TBI vary considerably in behavior. 2001. 2004. vidual’s communication abilities (Frank. 1986). toms include thought disorder. in the second half of life has also been reported (Keefe & ment before being diagnosed with PPA. pure word deafness. Westbury and Bub noted that both reading and writing nicative and cognitive deficits in a person following a TBI. In addition. Currently. Youse & Coelho.e. Schizophrenia is a 2003. Mesulam & Weintraub. there is Harvey. 1997. that are errors of may be quite variable. infection..qxd 1/21/08 11:20 AM Page 89 Aptara Inc. & pattern in naming deterioration in patients with PPA. (i. semantic paraphasias. Knibb & Hodges. However. (1990) suggest that patients should present with at least a 2. and this must be aphasia have been reported in persons with PPA (Duffy & taken into consideration when planning assessment. Hillis. Holland et al.e. 1994. 2000). Subgroups of PPA have been identified on the basis of social withdrawal.. patients with TBI (i. Individuals with schizophrenia also pre- clinical features such as phonologic disorders and language sent with a variety of neuropsychological problems includ- deficits (Grossman & Ash. and audi- communicative disorders following TBI may be difficult if tory comprehension problems (Westbury & Bub. Individuals with cognitive-communicative disorders fol. Chapter 4 ■ Assessment of Language Disorders in Adults 89 stories. tions. 2005). modalities tended to remain relatively strong for years after clinicians are challenged to create assessment protocols that the onset of the disorder. Richard. and hallucina- Kertesz et al. mixed transcortical aphasia.e. (6) emotional response to injury. Despite this variability. nonfluent PPA and semantic dementia. memory. Weintraub. or metabolic Several psychiatric disorders can negatively affect an indi- disease. 2005). Kertesz et al. a form of schizophrenia with onset of symptoms year history of isolated and progressive language impair. conduction aphasia. This disorder is associated with both positive some debate about whether PPA is a separate clinical entity. 2000. For patients with nonfluent on the patient’s life. chronic psychotic disorder that most Mesulam. while patients with flu- ent PPA showed greater deterioration on nouns. LeRhun. at least schizophrenia generally receives the most attention in the in the early years of the disease process (Mesulam et al. and 2005). 2005). 2005. or other linguistic material) are usually secondary to Pasquier.. (3) current demands the literature than fluent PPA. language and cognitive impairments interfere with effective Interestingly. 89). Patients with nonfluent PPA showed greater deterioration on production of verbs than nouns. Broca’s aphasia.. recall and reflection. medical.. particularly in those clinical patient’s medical chart and by asking the patient. social. therapist. mental health. For example. needs and maintain a language problem. an occupational therapist. prosody. clinicians can often save time. and occupation. the clinician One method for gathering information prior to the initial should be alert for signs of dysfunction in areas that do not assessment session is through the use of a patient-history appear to be generally equivalent in severity with overall lan- questionnaire. It is preferable.. & Ginsberg. 90 Section I ■ Basic Considerations impairments such as anosognosia (i. patient and fam- chosocial deficits that may contribute to. and by presenting an abundance of information at one time other individuals who are important in the patient’s life (i. the social role change of munication disorders also manifest other physiologic or psy- the client and family subsequent to aphasia. a neurologist. present. a therapeutic medical. Interviews provide an opportunity to verify and patients with schizophrenia. his or her caregivers. family. a neuropsychologist. settings often develop a form that reflects the needs of the phrenia may include word-finding difficulties.e. difficulty distinguishing clarify information obtained on the referral forms.e. or interfere with treatment expectations concerning treatment and treatment outcome. Tucker. 2005). This information can be gathered by reviewing the tion among team members. included on the form. such as patients pursue data that may be pertinent to the nature of the with aphasia who presented with premorbid psychotic patient’s communication problem but that were not disorders. (Avent.qxd 1/21/08 11:20 AM Page 90 Aptara Inc. questionnaires (Shipley & McAfee. In addition. or that need greater specificity. family. Most textbooks on diagnosis in speech. the clinician may attempt to determine the degree to which the verbal and nonverbal behaviors of individuals in the patient’s environ- Goal 2: Identification of Complicating Conditions ment facilitate or impede language recovery. language out. specific areas that seem unclear from the case history or ini- Although the communication problems of patients with tial interview. An example of a case history appears in Appendix 1996. but not always possible. disorder must be viewed within the context of these compli- Families can quickly experience information overload dur- cating conditions. the clinician pational functioning. information can be gained by interviewing or reviewing the reports of other assessment and/or interven- Case History and Interviews tion team members who have evaluated some aspect of the To identify the precipitating and maintaining factors that patient’s physical. or ily understanding of and attitudes toward aphasia. and settings in which others such as the neuropsychologist or significant others to complete pre-interviews or referral occupational therapist may share the responsibility of deter- forms. lack of awareness of language pathology or neurogenic communication disorders deficits). a physical including a detailed history in several areas: educational. emotional. a social worker. and behavioral information atrist. Such a team may be composed of the should complete a thorough and systematic review of a attending physician and nursing staff. It is crucial to have good communica- goals. divergent thinking provide a systematic method for obtaining additional infor- skills. past. patient’s history before the initial patient contact. irrelevance. An efficient method of identifying these ing interview sessions so it is better to uncover information conditions is through a comprehensive case history and at a pace to match families’ needs rather than to “over-help” thorough interview of the patient. perseveration. a geriatrician. and provide a focus and direction for subsequent Darley. During testing of the patient with aphasia.g. a physi- patient’s demographic. psychological. mation. Murdoch. 1998). can be aphasia are generally sufficiently different from those of explored. Individual work Communication impairment in individuals with schizo. perseveration. precipitate. and organizational problems (DiSimoni. institution (e. as well as recreational specialist. The diagnosis of a language and communication and the realistic or unrealistic nature of these expectations. planning. cohesion. 4-1. 2006. interviews. guage or cognitive performance.GRBQ344-3513G-C04[64-160]. and future communication environments and and family members.. Productive morphosyntactic abilities and basic auditory and During subsequent interviews and treatment sessions. and to between the two may arise in some cases. Goren. & Aronson. or occu- affect language and communication deficits. co-workers and friends). Nemoto. a dietitian. acute-care facility or rehabilitation hospi- put characterized by reduced content. a rehabilitation counselor. 2004). Prior knowledge will enable the clinician to formulate an opinion Complicating Conditions concerning the possible areas that need greater specificity during testing and plan accordingly. This is done to determine . & Kashima. Other areas that may be described are the relationships between and Many individuals with aphasia and related neurogenic com- among persons in the environment. for a clinician mining the cognitive and linguistic abilities of patients with to obtain a significant amount of information regarding the aphasia. reading comprehension abilities are typically spared. Mizuno. 2005).. and difficulties with planning and contain examples of case-history forms or pre-interview problem solving (Elliott et al. 1977. Using the patient history. disturbed affective tal). 2004. Accordingly. clean. 2003. For patients their presence. Screening procedures include a case history have suffered bilateral brain damage. Yueh et al. clinicians should ensure that any assistive devices ity.. it is important to exclude sensory deficits in clinician and the audiologist is necessary to assure a valid the affected modality. other assistive listening devices. 1999). Stringer. Patients with priate. adequate vision is particularly important for clinicians work. 1996): However. Vignolo. For example. patient’s threshold for the awareness of sound (impairment 1997). and an example of a visual-field apraxia or difficulties copying or composing drawings of dysfunction is right homonymous hemianopia. inspection of the outer ear. the patient should guage abilities. and unfamiliarity with the test stimuli patients with aphasia who wear hearing aids or rely upon (Stringer. the clinician can arrange visual stimuli in a vertical presenta- tion to avoid eliciting visual-based versus language-based Auditory and Visual Sensitivity errors. 2004. 2006). 1996). testing the hearing acuity of some patients may be (a) prosopagnosia. Bauer & Zawacki. pure-tone hearing screening. expressive assessment of hearing abilities. scription) when completing the language assessment. Detailed assessment of these areas of the elderly have some degree of vision loss (Quillen. (b) pure tone air and bone thresholds. 1997). particularly those who ing. 2004. contact lenses. or the inability to recognize nonverbal sounds. collaboration between the visual agnosia. Assuring two. Rothi & Heilman. or forms. aphasia present with an apraxia.GRBQ344-3513G-C04[64-160].. or a difficulty in recognizing familiar difficult if they are severely language-impaired and therefore faces. and in appropriate condition (e. 2003). Assessment of auditory sensitivity should include hearing screening at WHO ICF (ICF.. While not all these procedures may be available or uli even though they may recognize the same stimuli in appropriate in specific circumstances. comprehension deficits. functional batteries) prior to the language evaluation. or the inability to recognize and Although aphasia is not a problem of auditory sensitivity. Burns. and (c) speech agnosia. (b) auditory sound sound.qxd 1/21/08 11:20 AM Page 91 Aptara Inc. for those disturbances. & Shanks. problems. should be completed prior to the in-depth evaluation of lan. the therapeutic process. motoric impairments. (b) autopagnosia. If an audiologist is of the following types of auditory agnosia (Bauer & Demery. such as constructional ity are cataracts and myopia. Kelly. ing actual or pictured objects. behaviors frequently associ. Stringer. Additionally. most recent pre- medical conditions. 1996).or three-dimensional figures (Georgopoulos. patients with aphasia. DeRenzi. it is important for the clini- cian to check whether these devices are in working order Right Hemisphere Function (e. The necessity of testing hearing sensi- Visual agnosia refers to impairment in the recognition of tivity is made even more obvious by the fact that many visual stimuli despite adequate visual sensitivity (Farah. Several types of visual agnosia can occur with aphasia hearing disorders (Gates et al. Patients with aphasia may demonstrate nonverbal impairments It is equally important to determine that the patient’s that are more frequently associated with right hemisphere visual acuity and visual fields are functionally intact so as not brain damage and that may directly or indirectly interfere with to significantly impede assessment and treatment proce. as soon as the clinician becomes aware of be referred to an ophthalmologist for testing.g. repeat spoken language with a relatively preserved ability to hearing loss can negatively affect a patient’s auditory com- recognize nonverbal sounds. (Burns. patients with aphasia are older and therefore at high risk for 2004). (e. 2004. auditory and visual agnosia. or difficulty in recognizing body unable to understand test instructions or to grasp the nature parts. For ders such as clinical depression. Testing included in this category would be with aphasia who have been identified as having visual acuity procedures designed to discern auditory and visual sensitiv. Such patients might construct . (c) pure word deafness. 1997). Chapter 4 ■ Assessment of Language Disorders in Adults 91 whether any complicating conditions may interfere with ing with older patients with aphasia since at least one-third treatment and recovery. visual tory or visual agnosia (Bauer & Demery.g. may present with audi- regarding hearing difficulties or pain in the ear. 2005): (a) amusia. at the least the clini- other modalities and even though they have adequate hear- cian should have access to information concerning a ing sensitivity (Bauer & Demery. and discrimination scores. prehension abilities. 2001) levels of impairment Auditory and Visual Agnosia and activity/participation (Guidelines for audiologic screen- Occasionally. Fowler. otoscopic inspection as appro- Cummings & Trimble. patients with aphasia who have identified visual-field cuts. part of the assessment team the data that should minimally 2003. 2004.. 1997. Examples of disorders that might impede visual acu. Patients with aphasia may demonstrate one or more level) and reported difficulties in hearing. or (c) visual object agnosia. or the inabil- be available to the clinician are (a) threshold for awareness of ity to recognize music rhythms. Farah. and screening tympa- auditory agnosia have difficulties recognizing auditory stim- nometry.g.. or a difficulty in recogniz- of the response requirements (Wilson. 1990. Burns. and post-stroke psychobehavioral disor. In diagnosing auditory or 1981. some patients with dures. no buildup of cerumen. magnifying glass) are available ated with right hemisphere functions. glasses. When a visual defect is suspected. 2003. 2002. . 2002. Motoric Impairments Limb Apraxia.e. clinicians Inattention Test (Wilson. batteries (e.g.. repetition vs.g.g. In patients with apraxia of speech. since neglect may affect any modality. 1987). 2000. 2005. pantomiming brushing one’s teeth speech and limb apraxia.. undiagnosed.. 1997). commands that require purposeful movements. 1988): (a) content errors. apraxias.. Duffy. & Robin. and the nature of the task being performed (e. Watson. copying. Neiman et al. Limb apraxia refers to an inability to exe- It is not uncommon for patients with aphasia to present with cute acquired and volitional movements of the fingers. a variety of motoric impairments that may directly or indi. the apraxia involves the The assessment of ideomotor praxis should occur prior to speech musculature. & . Rothi. sensory. repe. aphasia batteries (e. 2000) or patients. In addition. 2003). frequently associated with right hemisphere brain damage. with incidence rates Considering the potential interference of apraxia of of between 15% to 65% (Karnath. 2000. or shoulder that is unrelated to motoric. Ogar et al. and other ties of their patients with aphasia using standardized tests pencil-and-paper tasks to identify neglect in their aphasic such as the Apraxia Battery for Adults.. and also tent articulatory substitutions. with aphasia. distortions. Cockburn & Halligan. and pauses that are inappropriate or of tery of tasks that represent a range of difficulty and com- increased duration. Granier. many Pedersen et al... omissions.e. & patients with limb apraxia being mistakenly diagnosed with Wambaugh. Limb apraxia is abilities. cle movements for volitional purposes (Darley et al. patients who lowing types of errors (Rothi et al. resulting in difficulty with the voli. or additions.g. 1996. & racy of a patient’s motor speech. 1991). and graphomotor Leslie. WAB. 1996. attention) because they have difficulty completing articulatory breakdown in the form of variable and inconsis. Rose & Douglas. 2005). Raymer. 2005).. during assessment. acts because of cognitive or motivational problems would when asked to show how they brush their teeth. 92 Section I ■ Basic Considerations drawings that are oversimplified and reduced in size but in apraxia of speech is related to the context in which the that improve with repetition. Peach. & Rothi. & Coelho. Ogar et al. procedure such as Tasks for Assessing Motor Speech Planning or Programming Capacity (Duffy. Patients with this disorder may make the fol- reflexive or automatic motor acts. Ochipa.. & Rothi. gestural. Therefore. Three frequently co-occurring motoric impair. and (b) production errors. Ogar et al. the Comprehensive Apraxia Test (DiSimoni. or may also choose to further examine the motor speech abili- may develop cancellation.g. or rectly affect their functional communicative abilities. Rothi. 2000. PICA) include subtests that examine word frequency. Milner. and hemiparesis.. Two common forms of apraxia how to comb their hair). lowing left hemisphere brain damage.2 (Dabul. Duffy. 2000. they show not be considered apraxic.. in which that may co-occur with aphasia and that may negatively the spatial or temporal organization of the movement or impact a patient’s communication abilities are apraxia of action is incorrect (e. 2004). (i. several aphasia utterance is produced. by holding the toothbrush vertically versus horizontally).qxd 1/21/08 11:20 AM Page 92 Aptara Inc. clini. their difficulty is attributed to using capacity to position muscles and to plan and sequence mus. Although neglect is more insular regions of the left hemisphere (Dronkers. or incoordina. these patients demonstrate memory..GRBQ344-3513G-C04[64-160]. 2006). possibly because of problems providing a reliable pointing titions. Since this disorder is Patients with aphasia may also display inattention or frequently associated with damage to premotor cortex or neglect to the right side of space. Generally. Clinicians may assess prosodic alterations including abnormal stress patterns. These patients also present with or yes/no head movement response. Some of the speech symptom variability plexity (Belanger. and transitive attributed to muscular weakness. slowness. 2005.. Doyle. comprehension or other neuropsychological deficits (e. wrist. spontaneous production). Consequently. particularly in patients with hemiparesis who must attempt to perform skilled movements with their non- Apraxia. Failure to do so may result in (Ballard. speech and its frequent coexistence with aphasia. patients with limb apraxia have more difficulty Duffy. involving a tool or instrument) versus intransitive tion as these same muscles may be used without difficulty in movements. dysarthria.g. Apraxia generally refers to impairment in the dominant arm (i. have difficulties performing skilled and purposeful motor in which they perform the wrong movement or action (e. Maher Specifically.. 2006. slow the presence or absence of limb apraxia by developing a bat- speech rate. administering any language or cognitive tests (Helm- tional production of phonemes and phoneme sequences Estabrooks & Albert. & Vallar. 1975. In addition. 2001. motoric deficits may impair the speed and accu. McNeil. This motoric performance problem cannot be performing distal versus proximal movements. line bisection. 2006. another frequent correlate of aphasia but may often remain ments are apraxia. Therefore. the phonetic complexity of the word or for the presence of constructional impairments and other utterance. BDAE) include subtests to examine cians may use published tests such as the Behavioral for the presence of apraxia of speech. cognitive deficits (Heilman. such as word or utterance length. or a testing should be in other modalities as well. Likewise. it is commonly associated recent research indicates that it is also quite common fol. elbow. their nonpreferred arm versus an apraxic disorder). 1989). left hand may compromise the speed and preci- across speaking contexts. high cholesterol level. typing. Kent. intelligibility” (p.. 2000). & Rosenbek. assessment activities. Chapter 4 ■ Assessment of Language Disorders in Adults 93 TABLE 4–8 Items of Paired-Word Intelligibility Test Listed by Phonetic Contrast Category of Feature Pair 1 Pair 2 Pair 3 Initial voicing bee-pea do-two goo-coo Final voicing add-at buzz-bus need-neat Vowel duration eat-it gas-guess pop-pup Stop vs.. palatal see-she sew-show sip-ship Tongue height eat-at soup-soap eat-eight Tongue advancement hat-hot tea-two day-dough Stop place pan-can dough-go bow-go Diphthong buy-boy high-how aisle-oil r/l ray-lay rip-lip raw-law w/r way-ray row-woe won-run Liquid vs. and/or ges- may vary considerably among patients with this disorder due turing. high or low Assessment (Enderby. and/or incoordination) of the speech musculature (Darley et Hemiparesis. since the speech musculature is innervated bilaterally (Duffy. the word-intelligibility test developed by Kent et al. 482). If the motoric impairment is so severe that the entire motor speech production. weakness. Many patients with aphasia may present with al. Weismer. Toward phonetic intelligibility testing in dysarthria. affricate shoe-chew shop-chop ship-chip Stop vs. nasal dough-no bee-me buy-my Alveolar vs. including respiration. 54 (4). and diabetes. Examples of such conditions are a vit- Beukelman. Importantly. F. imprecision. Weakness of the right hand or a reliance on their non- toms of individual patients tend to be relatively consistent dominant. 1997) or by using one of the commercially This test is “designed to examine 19 acoustic-phonetic available apraxia tests such as the Test of Oral and Limb contrasts that are likely to (a) be sensitive to dysarthric Apraxia (Helm-Estabrooks. slowness. 493. Journal of Speech and Hearing Disorders. phonation.2 (Dabul. including the but may contribute to an individual’s ability to respond to Assessment of Intelligibility of Dysarthric Speech (Yorkston. J. Dysarthria refers to a group of neurologic colleagues provide a discussion of the therapeutic implica- motor speech disorders that result from impaired control or tions of their test. 1993)..) Heilman.. Persistent dysarthria is most likely to be present in patients Medical Conditions with aphasia who have suffered bilateral brain damage. C.GRBQ344-3513G-C04[64-160]. side of the body is paralyzed. Table 4–8 lists items of paired-word intelligibility from Kent et al. learning disability. drawing. However. Another assessment option is consciousness. 2005. the Frenchay Dysarthria amin or mineral deficiency. and the Dysarthria Examination blood pressure leading to additional strokes or to loss of Battery (Drummond. vowel string-stirring spring-spurring bring-burring Cluster with one intrusive vowel blow-below plight-polite claps-collapse (From Kent. Motor speech symp. 1991) or the Apraxia Battery for impairment. the term hemiplegia may be resonance. Individuals with aphasia may also have a variety of medical 2005). R. fricative see-tea sew-toe do-zoo Glottal vs. 1984). (1989). Information about the presence of these disorders should be . used. 1975. changes in the tone (i. D. motor speech symptoms sion of many patients’ writing. 2000).e. J. and (b) contribute significantly to speech Adults. conditions that may interfere with assessment and treatment Clinicians may use a variety of published tools to quantify of aphasia. Kent and Dysarthria. null high-eye hit-it has-as Fricative vs. & Traynor. J. Duffy.. to different etiologies and different muscular involvement. 1983). (1989). These conditions are not the etiology of aphasia and qualify dysarthric speech disturbances. Patients with dysarthria hemiparesis or muscular weakness of the right side of their have difficulty with one or more of the basic subsystems of body.qxd 1/21/08 11:20 AM Page 93 Aptara Inc. (1989). and prosody. articulation. Freed. client report. psychosis. Craig & Cummings. tense. and are used to detect depression (Agrell & assessment and rehabilitative process. Clinicians should be aware of report by a caregiver. Hermann and scales. including per- tiary depression arising from maladaptive coping strategies sons with aphasia. and is behavior rating scale or through interview is appropriate for thought to be consistent over time in contrast to specific clients with mild aphasia who have language and cognitive attributes that may easily change. The variation in these descrip. Some scales have a heavy linguistic basis. In contrast. tired. Gerstenberger. medications (e. The Aphasic Depression Rating Scale for long-term social change. 94 Section I ■ Basic Considerations discussed as part of the history and interview with the symptoms must be identified through clinical observation or patient and family member. Swindell & Hammons.. and studies have validated sion from neuropsychological sequelae of stroke. indicate pathologic mood state. Währborg. aphasia and can be completed by a caregiver. 2002. 1998). 1997) applied to persons who experi. their current mood states. The Visual Analogue Dyspohric Scale (VADS) sphere stroke has been described as situational depression is anchored by two poles. Two scales with a linguistic basis are the Stroke Aphasia mania. confused. & Schultz. part of the severe auditory comprehension deficits (Stern & Bachman. it has ical reaction to the stress associated with acquiring commu. 1991) and the Visual Analogue Mood Scale (Stern PSD occurring in persons with aphasia following left hemi.. 1997). Yesavage et al. Frank. 1989). the Visual Analogue Self-Esteem Scale Client self-report. 1991. appropriate referral to a mental-health professional. 1995. The Visual Analogue Mood Scale (VAMS) has eight reactive (Goldstein. or a psycholog. afraid. clinical observation.g. An advantage of the order. persons with mild and severe aphasia. (Bishop & Pet. The Geriatric Depression Scale nication. Koenig. 1948. adjustment disorder.qxd 1/21/08 11:20 AM Page 94 Aptara Inc. & Shetty. and predic- serious medical problems that can compromise the overall tive instruments. Craig & Cummings. Visual-analogue mood scales were created to circumvent Because it is the most commonly observed mood disorder linguistic requirements in detecting depression symptoms. and sons with severe aphasia or those in a hospital setting. Pansari. 1989). pessimistic and . and 1991). 1995). however. Both the long and short forms impairments. The VAMS has normative data and cutoff scores to resulting from structural neural change. 1997.. depression is a common side effect SADQ is that it was designed for use with persons with of certain antihypertensives). Self-esteem is a global character- depression symptoms in patients with aphasia (Swindell & istic rather than a specific attribute (e. (Benaim et al. catastrophic reactions. research has focused primarily These scales are 100-mm lines anchored by faces represent- on issues relating to depression in aphasia. Such psychobehavioral disorders are viewed as of the GDS are internally consistent. Self-report using a related to but not synonymous with depression. and ter. 1991). aphasia. The major disadvantage to the GDS is also language evaluation and treatment (Patterson. 1998) and lems such as aggressiveness and sexual inappropriateness the Geriatric Depression Scale (Yesavage & Brink. secondary depres. 1983).g. report and. As aphasia severity Esteem Scale has 10 items. The Visual Analogue Self- abilities sufficient to complete the tasks. as well as other possible cognitive and physical (GDS) uses client self-report. 1999) assesses mood state from the caregiver are three methods of noting the presence of perspective of self-esteem. and was validated with 2002. including speech and Dehlin. et al. mood state. sensitive. Hemsley. if needed. & cator of mood state in clients with aphasia.GRBQ344-3513G-C04[64-160]. 1991). and clients mark on the lines to indicate depression (PSD) is a broadly descriptive term (Spencer. grief response (Tanner. 1999. & Keller. the VAMS for use with many types of clients. 2006. orders including depression. Post-stroke ing mood states.. each of which contains two pic- increases self-report becomes unreliable and depression tures and a corresponding descriptor (e.g. These psychobehavioral disorders may be the result Questionnaire (SADQ) uses predominantly caregiver- of one or more of the following (Gupta. Währborg. sadness) that is Hammons. and is a valid indi- (Lyon. happy. Bachman. each anchored with a neutral face and a mood face Wallesch (1993) identified three stages of PSD that occur as (sad. brain damage. energetic. 2002): a premorbid mood dis. treatment for these disorders and be mindful of any symp- toms that may appear as assessment and treatment sessions Rating Scales. Rating scales are used to judge a client’s continue. Depression Questionnaire (Sutcliffe & Lincoln. Two scales used with persons with Tompkins. aphasia are the Visual Analogue Dyspohric Scale (Stern & ence depression following left or right hemisphere stroke. happy and sad. even those with Herrmann. and the rehabilitation process unfolds: primary depression angry). The Stroke Aphasia Depression 1998). and behavioral prob.. mood disorder (Code. 1991). Whyte. 1995. a heavy linguistic bias. anxiety. and report by a (Brumfitt & Sheeran. subsequent to brain damage. while others present information in pictorial format to avoid the diagnostic dilemma created by using a linguistically based Post-Stroke Psychobehavioral Disorders diagnostic task with a person who has moderate to severe Many patients suffer from post-stroke psychobehavioral dis.. 2004) was created in part from items on the tions alludes to the importance of careful assessment and Visual Analogue Mood Scale to examine depression in per- description of depression in persons with aphasia. its heavy reliance on the linguistic abilities of the client. g. Short-term memory is a capacity- events and a neurochemical result of cortical or subcortical limited arena. Recognition pants with severely impaired linguistic skills. awareness. particularly in elderly clients with aphasia (King. Several neuropsychological tests serve to responsivity. 2001). depression symptoms in persons with aphasia. five mental operations of the Guilford Structure of Intellect model (Guilford. Memory is the power. or the ability ence of neurobehavioral sequelae of stroke such as anosog- to focus on and prioritize part of our external or internal nosia. some evidence suggests that there is a cognitive proficiency. memory. (b) focused or selective attention. divergent. and the object (English & English.e. 1956). understanding/comprehension (including perception and Several challenges present themselves when describing attention). act. language) is disturbed. According to Chapey (1994) these relation between patients’ working memory and language .. or the ability to maintain atten- mood states. 32). ronmental support structure may induce social isolation. Clients use a five-point scale to represent their processes of cognition can be operationally defined as the views of themselves.are a class of memory disor- cessing and handling information. Allport (1986) mand of our world. der” (p. 1984). . 1998). 1967. 1967. and is usually thought to hold seven items plus lesion. as well as an Cognition is a generic term for any process whereby an executive component that controls what information is organism becomes aware of or obtains knowledge of an processed and stored. 1987). p. recog- with aphasia may be underestimated in the literature on nition of information in various forms. or type of aphasia.e. immediate discovery or rediscovery. mask. 1996).. . or judge their levels of functioning or outlooks tion and therefore produce consistent performance over a on life. The most and evaluative). This memory structure is hypothesized to Goal 3. includ- nitive abilities may be unable to reflect on their current ing (a) sustained attention. involves acknowledgment that something has been seen or Client-related factors also pose challenges to identifying perceived previously (Guilford. Clients who have compromised cog- behaviors have been identified and can be assessed. Impairments of both working memory and long-term 4). Memory is also long-term.. Recognition/Understanding emotional disorder) when the basic method for assessing the Recognition/understanding/comprehension involves know- problem (i. visuospatial sketch- pad) that briefly hold incoming information. information in storage as well as retaining and retrieving this cult to predict. Additionally. such as sensory changes that may limit the more than one task. notable. dementia.. 2004. stored. Ramage. or the ability to attend to and complete related factors.GRBQ344-3513G-C04[64-160]. Chapter 4 ■ Assessment of Language Disorders in Adults 95 optimistic).. Klatzky. and increased use of medication may alter & Strauss. and used” (Neisser. 1986). uli simultaneously (Lezak et al. perception. recognition/ The Challenge of Identifying Depression Symptoms. Spreen pseudodementia. 1967.qxd 1/21/08 11:20 AM Page 95 Aptara Inc. elaborated. environment in the presence of competing stimuli. between PSD and lesion site or size. It is a group of processes that we use in a coordinated and memory have been observed in patients with aphasia integrated manner in order to achieve knowledge and com- (Murray. 2002. Murray. described by Starkstein and Robinson (1988. 2004). cognition is our means of pro- proposed that “the dysphasias. functional dependence. The area of compre- disability may also confound the diagnosis of depression hension has been well researched in terms of assessment after stroke (Dunkle. or amnesia can confound. Memory is both short-term or working is likely to be both a psychological reaction to life-changing memory and long-term. p. phonologic loop.1) is the “. or process of fixing newly gained The presence and course of depression symptoms is diffi. Patients with aphasia demonstrate working memory deficits when completing verbal as well as visuospa- Mental Operations tial and other nonverbal memory tasks (Tompkins et al. one’s lifetime. Several attentional depression symptoms. That is. The pres- long period. No consistent relationship has been observed new information at a later time (Guilford. Information is processed in short-term memory and temporarily stored (Baddeley. fundamental paradox of studying a problem (i.. Analysis of Cognitive Ability contain buffers (e. 1988) — namely. further complicating the Memory identification of depression symptoms. In fact. Miller. as required by some assessment methods. reduced. A multitude of specific processes contribute to our overall 1994). 1958). 2005. Age- divided attention. or fatigue. PSD 1980. & Hopper. Squire. Changes in body image or presence of physical assess perception (Lezak et al. Changes in the family or envi- procedures and tools (see Goals 4 and 5). and (c) or lead to misdiagnosis of depression (Stern.” Depression in persons ing. apathy. or to attend and process multiple stim- ability to read or hear questions. and thinking (convergent. 1999). or minus two (Clark et al. dysprosodia. 1967).. recovered. atten- post-stroke depression because most studies exclude partici- tion. It “refers to all the repository of factual and relational information stored over processes by which sensory input is transformed. memory loss. and comprehension or understanding. problem-solving. strategic thinking. different sites or in a different manner depending on the According to Guilford (1967). 1971). Cohen. Burgio & Basso. the flexibil- deficits (Chapey. Purdy (2006) examined area of future research. problem- tionally best outcomes. the reasoning required. Executive-Function Abilities patients having undergone temporal lobectomy) that Various researchers use the term “executive functions” to impairments to certain long-term memory stores may nega- refer to a collection of cognitive abilities (or composite abil- tively affect vocabulary acquisition skills as well as pragmatic ities) that enable us to successfully complete independent. as current results relating aphasia cognitive flexibility in persons with aphasia and showed that and working memory.. & Corkin. substantive.. Ylvisaker & There are three types of thinking: convergent thinking. & Greenwood. Wilson deliberate. consistency. Convergent one’s strengths and weaknesses and level of task difficulty thinking is the generation of logical conclusions from given (which involves recognition/understanding). 1986. plan... quantity. ing that are used depend on the problem presented. 2002. 2002. 2005. 1998. 1998). and novel behaviors (Dugbartey et al. Within the determines the outcome (Guilford & Hoepfner. Information is hypothesized to be stored in bility. in which information to be learned. ity to change the direction of one’s responses (Guilford. sia also present with executive-function difficulties thought and the production of multiple possible solutions to a prob- to be characteristic of sequelae of right hemisphere brain lem. Purdy. Paquier. 1996. logical feasibility. and (c) reasoning. adequacy. 1996). & Wearing. 1998). 1988. Murray. and Convergent production leads to logical deductions or com- learning are composite abilities that involve many or all of pelling inferences and requires the generation of logical these executive functions. Purdy. Such functions include (a) self-awareness of divergent thinking. 1967). and products tional communication tasks than individuals with less flexi- (Chapey. 2006). & Alexander. contents. relevance. decision-making. individuals with greater cognitive flexibility are more likely Long-term memory contains Guilford’s entire Structure to be successful using compensatory strategies during func- of Intellect (SOI) cube: operations. 96 Section I ■ Basic Considerations abilities (Caspar et al. and decision-making. language abilities (Gabrieli. & Torrence. the Divergent thinking involves the generation of logical decision to be made. Responses According to Guilford (1967. These behaviors allow us to generate. Usually. 1993. while promising. term memory deficits and language abilities in aphasia. ability to specify numerous details in planning an event or ing working memory in persons with aphasia is an important making a decision (Guilford. Denckla. et al. in which emphasis is on achieving the conven- of incompatible responses. Ramsberger. identity. Ween. Divergent questions are open- ended and do not have a single correct answer.. The specific aspects of function- necessities. 1998. and/or the alternatives from a set of given information. 1994).GRBQ344-3513G-C04[64-160]. and Thinking monitor responses that are goal-directed and adaptive (Borkowski & Burke. Such behavior Goodglass. frequency. there is some evidence from other patient populations (e. Divergent behavior is directed toward new responses — new 1993). safety..qxd 1/21/08 11:20 AM Page 96 Aptara Inc. 1997. They concluded that assessing and treat. 1994) and preservation or failure to inhibit 1967). in the Structure of are scored according to the number of ideas produced (flu. It is the ability to extend previous experience and damage. (b) inhibition information.. completeness. Feeney. Intellect model there are five broad. 2002. Divergent thinking fosters generation of ficulties such as problem-solving and decision-making logical possibilities. Purdy. and evaluative thinking. 2001. Tatemichi et al. 1999. as correctness. choose.g. with the ready flow of ideas. such (Beeson et al. Tompkins et al. They and Shisler (2005) reviewed several theories of working can also be scored according to the originality. basic types . 1967). judgment involves the ability of the individual to use knowl- Research has identified long-term memory deficits among edge to make appraisals or comparisons or to formulate patients with both verbal and nonverbal information evaluations in terms of known specifications or criteria. Verfaellie. 1988). Wright ency). Stone. the information given fully solving. and the variety of ideas suggested (flexibility). or social custom. and relevance of output Individuals with aphasia may have executive-function dif- from one source. are inconclusive. Halligan. Glosser & ation of ideas on a specific topic is required. rather than in a unitary storage system. or memory and described how elements of those theories may unusualness of the response. and/or the elaboration or the pertain to aphasia. Some individuals with apha- necessitates the use of a broad search of memory storage. 2005. 2001). 1995). 1990. such as lack of awareness or anosognosia (Marshall knowledge or to widen existing concepts (Cropley. and suggestion of ideas in situations where a prolifer- or shift a response (Albert & Sandson. Guilford model. Contents of the Guilford SOI Model Demos. Ylvisaker & Feeney. practical feasi- has been completed to examine the relation between long. emphasis is on variety. Although minimal research utility. 1967). evaluative thinking or type of memory. in the sense that the thinker was not aware of the response before beginning the particular line of thought (Gowan. bility. 1996. . or and colleagues (1990) demonstrated that most RBMT sub- predicted by other information. each of the cognitive processes identified in the of the Wechsler Memory Scale-3 (Wechsler. This content is evaluated in both unstructured and structured contexts in pertains to the cues that the human organism obtains about an attempt to provide information about if and how such the attention. recognition/understanding and nication. symbolic. Strauss. 2001). 4–6). it involves thinking and verbal commu. emotions. 2005). The continuum of products begins with life materials and tasks that target a variety of attentional units. many commercially available tests of them. shifts. However. mine whether the individual appears alert and able to main- tain attention over a specific length of time. The Wisconsin transformations. anticipated. In addition. the Test of uum from simple to complex. Behavioral content aphasia. Classes then enter processes: sustained attention. They are items to which nouns are often applied. time. relations. focused attention. Many other published conceptions or mental constructs to which words are often tests also tap these abilities (Lezak et al. Implications are “circumstantial connections Memory Test (RBMT. Classes are “conceptions underlying sets of items of Assessing Memory information grouped by virtue of their common properties” Unstructured observations may provide some information and involve common properties within sets. auditory. or 2003) represents an exception and includes subtests such as any condition that promotes “belongingness. intentions. intentions of others that come indirectly through nonverbal 2000). and thoughts of others and of ourselves. Units are relatively “segregated or cir. systems. suggested. 2001). For struc- based upon variables or points of contact that apply to tured assessment. verbal nitions. According to noted. moods. since performance of only a few subtests are significantly Assessment of Cognition affected by language impairment.” Therefore. Murray and Clark (2006). behavior and the ability to “shift set. Relations are about patient memory abilities such as whether or not the meaningful connections “between items of information individual is oriented to place. feeling. Kinsella (1991).” Implications remembering an appointment or a short route. and implica- original model visual and auditory contents were subsumed tions under all mental operations (recognition/understand- under the term “figural”). Other appropriate struc- Since cognition is the process by which language is learned tured evaluations include the Visual Memory Span subtest and used. semantic. percep- The status of the attention abilities in a person with aphasia tions. Specifically. which are completed by both the clinician cumscribed items” or “chunks” of information having and the patient (Fig. since most of the tests Transformations are changes of various kinds (such as redefi- rely heavily upon processing of linguistic stimuli. desires. 1998). 2004. Products are considered on a contin. perception. 1997b) to SOI model should assessed (Wade. The two that are most relevant to ing. thinking. and executive functions) are language are semantic content and behavioral content. Cockburn. These and other aspects of attention may also be Guilford and Hoepfner (1971). and behavioral (in the (concepts). relatively few tests are “complexes of interrelated or interacting parts. and van which they are related. classes visual. Zomeren and Spikman (2005). The Rivermead Behavioral information. the Card Sorting Test (Grant & Berg. Tests developed by Guilford and colleagues can be Semantic content pertains to “information in the form of used for this purpose (Chapey. 1971).. products are the manner in assessed using published tests such as those listed in Table 4–9 which things are associated in the mind and the depth to and in Lezak et al. which enter into attention. Cockburn involve information expected. memory. “thing” character. and problems interfere with activities of daily living (Coslett. however. thinking. or concrete to abstract Everyday Attention (Robertson et al. the clinician can deter- means. as by virtue of contiguity. In unstructured observations.” Systems are organized patterns of information or memory are accessible.GRBQ344-3513G-C04[64-160].” Clinicians may also Guilford and Hoepfner (1971) describe the products in use rating scales such as the one developed by Ponsford and the following manner. and person. which enter into systems. For example. (2004). which combine to enter into classes. it need not necessarily be dependent on convergent thinking are assessed on many standard tests of words (Guilford & Hoepfner. Chapter 4 ■ Assessment of Language Disorders in Adults 97 of information or content that the organism discriminates: ability to produce semantic and behavioral units. & Baddeley. Spreen & applied. pertains to the psychological aspects of human interactions or to information that is essentially nonfigural and nonver.” appropriate for persons with aphasia. and attentional switching skills. tests can be validly administered to patients with aphasia. divided into relations. Assessing Attention bal: the attitudes. Wilson. 1994) contains real- (Chapey. explored. or modifications) in existing responses. needs. the assess working memory abilities (particularly the Backward . Patient ability to Products of the Guilford SOI Model resist distraction by either external or internal stimuli is also There are six products in the Guilford model. or both (Table 4–9).qxd 1/21/08 11:20 AM Page 97 Aptara Inc. transitions. 1993) tests abstract most complex product in the model. transformations. between items of information. which ultimately enter into implications. (1996) Delis-Kaplan Executive Function System Delis et al. responses may also be ate a specific response. and question-and-answer tasks that oblig- length of time items can be retained. (1987) Color Trails Test D’Elia et al. matching tasks. (1996) Connors Continuous Performance Test Connors (2000) Criterion-Oriented Test of Attention Williams (1994) d2 Test of Attention Brickencamp & Zillmer (1998) Paced Auditory Serial Addition Test Gronwall & Sampson (1974) SCAN-A: A Test for Auditory Processing Disorders in Keith (1993) Adolescents and Adults Symbol Search subtest of the WAIS-3 Wechsler (1997a) Test of Everyday Attention Robertson et al. aphasia test batteries (e. tests of specific function bering only the beginning or end of the material or the pro.qxd 1/21/08 11:20 AM Page 98 Aptara Inc. sentence- of the number and length of items remembered or the completion tasks..GRBQ344-3513G-C04[64-160]. Several duction of random errors). Although performance is usually quantified in terms are confrontation naming tasks. (1994) Memory Benton Visual Retention Test Sivan (1992) Continuous Visual Memory Test Trahan & Larrabee (1988) Figural Memory subtest of the WMS-3 Wechsler (1997b) Rey Complex Figure Test and Recognition Trial Meyers & Meyers (1995) Rivermead Behavioral Memory Test (RBMT-II) Wilson et al. These . (1997) Williams Inhibition Test Williams (2006) Wisconsin Card Sorting Test Grant & Berg (1993) Assessing Thinking Tapping portion). (1975) Ross Information Processing Assessment-2 Ross-Swain (1996) Attention Behavioral Inattention Test Wilson et al. 1995) to examine long-term visuospatial Common methods of assessing convergent thinking skills recall. and in tasks created by clinicians.g. (e. (2003) Raven’s Coloured Progressive Matrices Raven et al. (2000) BNVR: The Butt Non-Verbal Reasoning Test Butt & Bucks (2004) Comprehensive Test of Nonverbal Intelligence Hammill et al. (2001) Executive Control Battery Goldberg et al. WAB). These tasks appear in comprehensive analyzed to identify patterns of impairment (such as remem. (2003) Spatial Span subtest of the WMS-3 Wechsler (1997b) Visual Memory Span subtest of the WMS-3 Wechsler (1997b) Visual Reproduction subtests of the WMS-3 Wechsler (1997b) Executive functions Behavioral Assessment of the Dysexecutive Syndrome Wilson et al..g. 98 Section I ■ Basic Considerations TABLE 4–9 Tests to Assess Cognitive Processes and Mental Operations in Persons with Aphasia Cognitive Function Instrument Source Comprehensive Burns Brief Inventory of Communication and Cognition Burns (1997) Cognitive Linguistic Quick Test Helm-Estabrooks (2003) Cognistat Kiernan et al. (1996) Behavior Rating Inventory of Executive Function Gioia et al. (1995) Test of Nonverbal Intelligence-3 Brown et al. measures also exist to assess divergent thinking skills. and the Rey Complex Figure Test (Meyers & Meyers. (2002) Functional Assessment of Verbal Reasoning and Executive Strategies MacDonald (1998) Matrix Reasoning subtest of the WAIS-3 Wechsler (1997a) Picture Arrangement subtest of the WAIS-3 Wechsler (1997a) Porteus Maze Test Porteus (1959) Rapid Assessment of Problem Solving (RAPS) Marshall et al. TAWF). (1995) Mini-Mental Status Examination Folstein et al. & Kinsella. Rating Scale of Attentional Behavioura a Ponsford.qxd 1/21/08 11:20 AM Page 99 Aptara Inc.Been slow in movement 4. Chapter 4 ■ Assessment of Language Disorders in Adults 99 Questionnaire Therapist: Discipline: Date: Could you please answer the following questions about by checking the box which most nearly applies to their behavior now: Not at all Occasionally Sometimes Almost always Always Has he/she recently? (0) (1) (2) (3) (4) 1.Performed slowly on mental tasks 6. J.Been slow to respond verbally 5.e.Had difficulty concentrating 9. 1(4).Missed important details in what he/she is doing 13. Reprinted with Permission. Neuropsychological Rehabilitation.Made mistakes because he/she wasn’t paying attention properly 12.Been unable to pay attention to more than one thing at a time 11..Needed prompting to get on with things 7.Stared into space for long periods 8. The use of a rating scale of attentional behaviour. G.Tired easily 3..Seemed lethargic (i.GRBQ344-3513G-C04[64-160].Been easily distracted 10. . 241–257. (1991).Been restless 14.Been unable to stick at an activity for very long Total: Score: Figure 4–6. lacking energy) 2. g. cues and predictable communicative sequences (e. actions. few of them include subtests to examine (Lahey. connected speech (short and long utterances). centers on analyzing not only the asking a patient to predict the outcome of an event (e.g. therefore. persons. perceptual and cognitive abilities that may interfere with ateness of a correct and an incorrect response to a situation comprehension. patient may attend to a superficial feature and use a sophis- Patients with mild aphasia may successfully use contextual ticated guessing strategy to produce the correct response. objects. Other examples are the Test of numbers. or self-reflect on pre. multiple levels of performance: single words.g.. eating lunch). 1983) but patient may rely on strategies other than meaning compre- may not always be evident in connected-speech tasks hension to respond (Raymer & Rothi. and gestural communi- Assessing Executive Functions cation.. and/or conversation forth. visual or auditory discrimination). and categories of objects. the Test of Problem hension at one performance level is better than at other lev- Solving (TOPS.. a because of the influence of context (Whitworth et al. Examples of tests that assess divergent thinking involves assigning meaning to incoming auditory or written skills are word-fluency tasks (e.g. However. determining solutions.g. and Language Content antonyms. 1988. made more difficult by increasing the number of items or prehension. 2000)..qxd 1/21/08 11:20 AM Page 100 Aptara Inc.GRBQ344-3513G-C04[64-160]. and for others compre- ous tests (see Table 4–9).g.g. 2001). pic- tures. Content also refers to the understanding of word relationships and categories.g. 2006). tasks requiring a patient to suggest cre. For many ative uses for common objects (e. . Sohlberg and colleagues’ (Braswell et al. Comprehension of Content in Isolated Words vided for children). spontaneous speech elicited from the “Cookie Theft” pic. Knowledge of language categories 1997) and the Williams Inhibition Test (Williams. and to identify rhyme words.. greet. ideas. processes such as explaining inferences. a pipe). topic. this impairment is confounded by created for a hammer). yet are not derived from full comprehension of words from which the patient must select the target (e.. Comprehension of content should be (e. is assessed by requiring the patient to point to objects. actions. judge the appropri. what to do if one finds a wallet). such as comments about a specific object (e. The ability to comprehend the content of language is Assessment of content may be difficult to ascertain as the always impaired in aphasia (e. clinicians must rely upon probe tasks to assess how they relate or are similar to one another in different this aspect of word comprehension (see Appendix 4-2). During administra- a particular action (e.. and so individual words. 2005). Trees test (Howard & Patterson. and experiences. actions. synonyms. “Point to car. For example. characterization or conceptualization of topics according to Therefore. A deficit in content comprehension response. Receptive vocabulary is assessed by asking patients with 1993) Profile of Executive Control System involves both aphasia to point to real or pictured objects. and may depend on the social and experien. It is important to note that the “pyramid. Generally.g. A topic is the particular idea expressed in a mes. FAS test). Sherbenou.g. Most aphasia batteries include subtests to exam- Language content is the meaning.. Evaluative thinking can be assessed by Assessment. how many uses can be patients with aphasia. McCauley. or subject matter of ine word-level comprehension of objects.g. These assessments are necessary since in many patients auditory comprehension is better than reading The assessment of executive functions also includes observa- comprehension. and letters (e. ture in the BDAE). Another option is to use tests such as the Pyramids and Palm sage. ing.” “Show me yellow”). and relationships. Webb & Love.. determine whether the patient has a general semantic deficit tial context in which they are used. patients are asked to match pictures (e. messages. or a specific relation tion of this instrument. attrib- observation of the individual performing daily tasks as well utes. deficiencies in cognitive abilities such as perception (e. individual utterances. or words that belong to a specific class or group of words (e. 1991) may be used to explore els (see Appendix 4-2).. “Show me the words that are the names of Goal 4: Analysis of Ability to Comprehend fruit”).. 100 Section I ■ Basic Considerations measures have in common the lack of a predetermined language content. creativity tests messages and/or to understanding words as they relate to (Torrance.” “Point to drink- Nonverbal Intelligence-3 (Brown.. for the target and his shoes) (Lahey.. or a modality-specific problem. pointing tasks to assess comprehension can be ing) and produce responses that appear to demonstrate com.g.. a patient’s comprehension of language content but also on television situation comedy or a story).. Bowers et al... 1966). actions. the relation between Harry and his wand. and thinking. & Johnson. some patients display better reading skills tions as well as the administration of psychometrically rigor- than auditory comprehension skills. and avoiding problems (note that norms for TOPS are only pro.” the response choices are “palm tree” and “pine meaning of words and concepts may change over time and tree”). 1992).g.g. or a patient on the basis of a semantic association (e. For example. assessed in both the auditory and reading modalities. 1988). memory. or narrative storytelling tasks (e. The six versions of this test allow the clinician to across cultures.g. answering negative questions.. determining causes. and at vious behavior. as a patient interview. .. Most aphasia batteries include subtests similarity of the target and distractor items (e. the aphasic patient’s ability to understand meaning lemons?”).” to “cab. Varney. this belongs to the nurse. were planned. or by pantomime since.” and “bar”). ments about discourse-level abilities on the basis of general hension tasks. Rose. such as sentence length and/or relational complexity to However. as well as directness (explicitly stated information vs. either a test of listening or reading comprehension. by increasing the Brookshire. 1977) was found to have more accept- ician evaluates the patient’s ability to point to common able passage dependency. length... Marshall.g. Another assessment option. In comparison to the reading subtests of ships should be assessed in connected language at both the aphasia batteries. “The man cut the steak. tory and reading comprehension impairments (Goodwin. 1997). However. research has revealed “lemon. “Is this a cup?” Items that tion). Abilities and impairments can (Daniloff et al.g. That is. the Discourse underline the name of your street”). such as comparative (e.g. is done by noting the type and amount of content that inferential (e. For example. 1982. ticular. response requirements are carefully con. Therefore. Chapter 4 ■ Assessment of Language Disorders in Adults 101 increase from two to six distractor items). evaluate more abstract comprehension abilities typically implied information). patients with aphasia and objects by description (e. spontaneous language is determined. and comprehension levels of information other than those which relationships and categories of objects. and relation. for the tar. Daniloff et al.. and “This is mine. and/or the patient’s ability to follow 1987) rather than rely on other. patients with severe auditory comprehension Comprehension of discourse-length spoken or written impairments but relatively minimal or mild reading material is also to be assessed since there may be a difference impairments have been found to display better gestural between sentence-level and discourse-level comprehension recognition abilities than those patients with severe audi- abilities (Armstrong. prosodic cues and may not be comprehending the language trolled to be sure that success or failure is dependent on the content.. Larfeuil & LeDorze.g. it can be administered as assess the patient’s understanding of complex relationships. stimulus characteristics and not on an inability to respond. Testing also includes Comprehension Test (Brookshire & Nicholas. or that patients with aphasia were able to answer more than both. attributes. cause-and-effect (“Can smoke cause a fire?”). The influence of other variables such as word fre. ges- saying or pointing to a one-word answer such as yes/no. Therefore.. requiring a patient to gesture a response (e. This finding has led some researchers to suggest . Please give it to me” and responds appro- In addition to manipulating vocabulary characteristics (e.g. BDAE. in evaluating concrete varies in terms of salience (main ideas vs.g.. conversational speech since patients with aphasia frequently During highly structured assessment of both language nod or gesture appropriately as a response to social or content and form. 1997. rate than by chance. Nicholas. Did the man use a appears to be understood. the clinician might ask. for some patients with severe aphasia. Additional examples appear in Appendix 4-2.. For example. designed to assess auditory and reading comprehension abil- get word “car. detailed informa- sentences. 1982).” “glass..qxd 1/21/08 11:20 AM Page 101 Aptara Inc.. Schell. Consequently. This suggests that their responses show relatively low passage dependency and instead are based on some other comprehension strategy. or responses to conversation. unknown strategies to directions or commands (e. or right/wrong. “Does sob mean the same as cry?”) (Wiig & the statements “No. in unstructured.g. this patient may be Clinicians also assess the ability to comprehend gestures or required to respond by pointing to a word or picture. is assessment of the patient’s ability to understand concrete designed to examine understanding of information that and abstract sentences. 1984)..g. “Point to answer the test questions correctly (Nicholas & Brookshire. priately. spatial (e. if a patient hears synonymy (e. Gesture “Pretend to use a hammer”) may be complicated by a co- existing limb apraxia. 2006.” “bus. In par- that is being systematically controlled. the clin.. half of the reading items from several popular aphasia bat- quency or familiarity. 1986). the Nelson Reading Skills Test (Hanna. something that cuts”).. when Comprehension of Content in Connected Language clinicians use these materials they may be assessing reading Comprehension of labels for objects. it is important to be cautious when basing judg- increase or decrease the difficulty of sentence-level compre. Is this hers?” Semel. the clinician may begin to hypothesize that the word frequency or imageability). WAB) at a significantly greater understanding can also be examined. For example. sentence and discourse levels. “Write your address and then respond. At the sentence level. actions. 2000.GRBQ344-3513G-C04[64-160]. tures may represent a patent modality for comprehension true/false. & Schreiner. 2006.” and “toe. & 2002).g. Brownell & Friedman. 1986. as demonstrated by appropriate knife?”). clinicians alter variables patient comprehends the relationship of possession. 2000.g. “Does November come before October?”). “Is California west of Arizona?”). actions. MacLennan. This temporal (e. and imageability on a patient’s teries correctly (e.g.g. “Are grapefruits larger than Lastly. “Read this sentence and point to adults with no brain damage had to read the paragraphs to the object that it describes”) or by function (e. then be confidently ascribed to the specific input parameter Power & Code.” printed distractors could be changed from ities at the discourse level. 2006. 1994. 2001. impairments (Bell. clinicians may use 2002. Pindzola. Pashek & Tompkins. and morphology.. 2004).. articles) (Allen & Badecker. Haendiges selves. & Goodglass. & Weidner. Rose & • sentence constraint (Faust & Kravetz. conjunctions. Murray. A variety of variables may positively or negatively influ. order words and relate them to one another in order to Duffy & Watkins. Berndt. age of acquisition) are of greater importance (Hirsch & points to the correct picture in a multiple-choice format. 1989. length (Shewan & Canter.. clini- al. 2006). and AmerInd signs (i. 1994). Howland & Pierce. Records. Blumstein. 1959). 1986. 2004. Weidner & Lasky. • context (Cannito. nouns. the word and sentence levels (see Appendix 4-3).. stated vs. With Huntley..GRBQ344-3513G-C04[64-160].e. That is. concomitant gestures or pictorial cues.qxd 1/21/08 11:20 AM Page 102 Aptara Inc. 1971. & Landis. 1976). Wang & Goodglass. Consequently. Marshall et al. presenta- content as well as language form (see Goal 5 for further tion rate. other studies have found a rela. 1961).... or a probe task developed by them- the individual effects of variables (e. and sequently may be more suitable for use in assessing and • personal significance of the material. Berndt. Puskaric & Douglas. 1989). Nickels & Howard. 1991. 1995. & • directness (i. Saffran.g.. assessment involves an analysis of the patient’s ability to understand language form at both • word frequency (Gerratt & Jones. 1987. the effect of these variables is neither consistent tasks described in the literature (Bell. 1995. the degree to which a patient’s comprehen- Influential Variables sion is facilitated or impeded by tone of voice. Vogel. tion of American Indian hand talk) are easier for naive view. divided atten- ence aphasic patients’ abilities to comprehend language tion tasks). Comprehension of Form Words and Morphology • age of acquisition (Hirsch & Ellis. the function of objects). Gardner et (Marshall. iconic gestures (e. for some patients with aphasia. 2006). such as: are common. 1982. Howland & Pierce. 1992).g.. stress. or closed-class words (e. 102 Section I ■ Basic Considerations that reading-comprehension abilities may be a better indi. Holland. • imageability (Cole-Virtue & Nickels. 1985.. cator of the ability to communicate effectively via gestures 1995a. Nickels & Howard. details). 2000. adjectives. 1994). Research indicates that comprehension of both content and form are inversely proportional to the level Goal 5: Analysis of the Ability to Comprehend of intellectual complexity (Shewan & Canter. the grammati- 1986. respect to gestural codes. In contrast. pauses at intervals.e. Rothi et al. Therefore. 1998). & Weintraub... In express ideas. 1998. & Nicholas. clinicians may also examine the effect of providing of the verbal stimuli also contribute to a patient’s success or gestural information in concert with auditory information failure in comprehension (Blumstein et al.g. pantomiming 1977). 2001).. words (e. In aphasia. 1997. & Pierce.. verbs. In Ellis. one of the nonstandardized However.. Brookshire. Daniloff et al.. focused vs. 1994. Power & Code. 1981. than of overall aphasia severity (Daniloff et al. 2001. implied) (Cole-Virtue & Schwartz. treating aphasia (Campbell & Jackson. Albert. 1987. Additionally. marily on examining comprehension of nouns. part of most aphasia batteries. Stachowiak et al. and beginning to suggest that other factors videotaped or live presentation of gestures. and information about assessing comprehension of language imposed response delays can be determined. and • salience (i. Nickels & Howard. 1997). 1995). Handiges et al.. Recent research is attempting to tease apart 1982. & Johnson. a system of rules used to response choices (Baker.. Pierce. 2002. 1975.g. 1997.e. 1997). Ernest-Baron.g. 2004. Records. 1975.... addition to assessing gesture comprehension abilities in iso- Several factors (listed below) related to the presentation lation. Luzzatti et al. Hough et al. 1984.. prepositions. and degree of semantic similarity among Language form includes syntax. clinicians . the ability to understand syntax or grammatical morphology ables. attentional demands (e. Toppin & Brookshire. Daniloff et al.. 1994. verbs vs. Daniloff et al. a modifica. Generally. 2005. 1971. 1979). intensity. Beeson. 1986. Form words can be of two types: substantive or open-class 1990. Consequently. cal class or part of speech (e. Laiacona et al. adverbs) and relational • emotional content (Boller et al. Rose.. a subtest of an aphasia battery. 1997. there is believed to be a positive relationship construct words (Nelson. ers to discern than American Sign Language (ASL) and con. main ideas vs. Weidner. 2003). gestural comprehension is assessed with et al. Nicholas & Brookshire. nouns) can influ- Gestural recognition abilities are not typically tested as ence their comprehension abilities (Berndt. 1982). 1976. & tory comprehension. impairments in between comprehension abilities and other stimulus vari. tionship between praxis and pantomime-recognition • redundancy (Gardner.g. a system of rules used to contrast. Carramazza & Hillis.g. Schuell.. Jenkins. 1978). 2002). Because most aphasia batteries focus pri- Nickels. cians can determine whether gestural information aids audi- Lasky. 2004. Language Form Siegel. form). Hough et al. 1994. nor predictable. Kimelman & McNeil. prolongation of words. Kay et al.. 1995). and the patient (e. 1989. Doyle. Lacking this distinction. and. “runs”) and nonwords (e. to process quickly a transient auditory signal (if it is a listening responses are analyzed to determine the type and frequency situation) and to retain a memory representation of the signal of words the patient is able to understand. assess a range of syntactic comprehension abilities..” Because of patients with aphasia need adequate knowledge of syntactic interest in the patient’s ability to comprehend prepositions. (1989) developed a proce.”).. 1992). under the table. to very selective deficits (i. few assessment tools have been inappropriate treatment.. the syntactic structure of spoken or written language that Miceli. patients dure for quantitative analysis of narrative speech to examine must rely on semantic and pragmatic knowledge to compre- morphologic and syntactic structure. 2005).e..g. in Processing Resource Pack (Marshall et al. More specifically. 1998.. words. Braber icians may make an incorrect diagnosis and potentially plan et al. comprehending both types of morphology are observed in 1993. For example. 1992). and verb-argument structure). tent results regarding the influence of phonologic form on problems interpreting only certain sentence types such as morphologic form.. 1990. other words (Caplan. Chapter 4 ■ Assessment of Language Disorders in Adults 103 may devise tests of their own or borrow from nonstandard. 2002). In each instance. Deficits sion or short-term or working memory limitations (Caplan. some studies have examined the relationship between the Patients with aphasia may have difficulty comprehending phonologic and morphologic forms (Braber et al. as the Revised Token Test (McNeil & Prescott. 2000). ter Keurs. & verbs. Fink. 1995). words (e. aspects of grammatical morphology may dissociate in Grodzinsky. a picture-verification task to evalu. passive. Saffran et al. tactic deficits in persons with aphasia from several perspec- Shelton. McNeil.e.. differentiation between disorders of syntactic comprehen- subject-verb agreement of “read” for “She reads. or probes developed based patients with aphasia make a lexical decision regarding on these test procedures.. For example. Brown. the length of the to assure that sentential elements are not missed or misinter- stimulus that can be understood. and points to the best picture for that word Processing syntactic structures involves the knowledge of or phrase. and reported that hend sentences) (Chatterjee & Maher. in English. patients are often asked to respond to basic sentence inflectional morphemes. the ability to parse the structures that organize the clinician may first ensure that the patient can accurately phrase elements into hierarchically translatable constituents recognize the substantive words within the test stimuli (e. 1987. negative. whether the item heard or read was a real or made-up word. “pain” into “painful”). In the comprehension subtest.g. 2002. ized measures to conduct a broad-based assessment of com. researchers are examining aspects of them and how although in reading there may be multiple opportunities to they are compromised in persons with aphasia. However. and differ- Morphology involves the rules used to form words into ences in time post-onset of aphasia (Springer et al. 1997). The recognition subtest contains real. range from minimal difficulty. and Caramazza (2000) suggested that one dimen. and the latency or length of preted (Berndt. 1993. 2001. tives: syntactic structure (Friedmann. patients complete a word- prehension of form words. Clinicians the research literature..e. Capasso. The ability to comprehend the picture matching task and a similarity judgment task. 1978). and the Sentence Language Processing in Aphasia (Kay et al. to profound impairments (i. Research in recent years has examined syn- agrammatism. such as “Point to (a) The cup is on the table. They also need to be able “cup. how one orders words within an utterance and how to con- ate comprehension of prepositions might include stimuli struct various sentence types. such as subject NP. Two exceptions are the in detail: the PALPA (Kay et al.g. whereas addition of an inflectional other tests have been criticized because they do not allow morpheme signifies a certain syntactic relationship (e. availability of sion of lexical organization is by word-form class (nouns or word class during syntactic comprehension (Park.” “table”) (see Appendix 4-3). a test developed by Caplan and Bub may also probe the syntactic processing abilities of their (1990). or object NP).GRBQ344-3513G-C04[64-160]. cleft-object sentences). & Hagoort. 2000..g.. Schwartz. 2005. 2000). Saffran. affixed from the research literature (Caplan & Bub. 2004) and found inconsis.qxd 1/21/08 11:20 AM Page 103 Aptara Inc. “runned”). meaning of both substantive and relational words can be assessed through the use of picture-verification tasks in Comprehension of Syntactic Constructions which the patient with aphasia sees a picture. or (c) The cup is near the table.. such as active. To comprehend syntactic information. Kim and Thompson (2000) and Shapiro.. 2005). extract syntactic information from the written material. clin- patients with aphasia (Badecker & Caramazza. & Hildebrandt. labored reading abilities. Further. Martin & Miller. rules (i. tests plex words. 2003). hears or reads a word or phrase. 2002). (b) The cup is and negative–passive..g. Caplan and Bub’s test includes subtests to assess patients with aphasia using commercially available tests such recognition and comprehension of morphologically com. . In assessing syntactic comprehension abilities and word formation is accomplished via affixing derivational or deficits.. 1998). Caplan. Dick et al.. Three tests assess syntactic deficits developed to examine such abilities. the Verb and commercially available Psycholinguistic Assessments of Sentence Test (Bastiaanse et al. Caplan. aphasia batteries rarely include items that pheme changes a word into a different form word (e. & time needed to comprehend the material and respond. types. & Caramazza. However. Disruption to this temporal aspect of syntactic In attempts to understand further the nature of form processing will likely result in slow. Addition of a derivational mor. and Waters. 1993). (c) the verb argument structure. (b) the number of verbs in being pushed by the girl. a sentence. 1998).) . For example. “The boy is structure of subject-verb-object). sion deficits (Caplan et al. 1999. and (d) the leagues (1997) also have patients demonstrate or act out sen. 104 Section I ■ Basic Considerations Assessment often takes the form of a picture-sentence pretations (Beretta et al. Table 4–10 contains a list of the constructed so that sentences cannot be interpreted solely sentence types (as well as possible foils) in an order of on the basis of semantic processing or word knowledge. During analy- verification task in which the patient decides whether a spo. S. and increasing complexity. N. “The girl is pushing the boy”. Determinants of sentence comprehension in aphasic patients in sentence-picture matching tasks. answers the question “yes” or “no”.. 1997) should respond more TABLE 4–10 Sentence Types that May Be Used to Probe Syntactic Comprehension Number of Canonicity of Sentence Structure Words Propositions Thematic Roles Thematic Roles Active The lion kicked the elephant 5 1 2 Canonical (Foil: The elephant kicked the lion) Active Conjoined Theme The pig chased the lion and the cow 8 1 2 Canonical (Foil: The lion chased the pig and the cow) Active with Adjunct The elephant pulled the dog to the horse 8 1 3 Canonical (Foil: The dog pulled the elephant to the horse) Passive with Adjunct The dog was pulled to the horse by the elephant 9 1 3 Noncanonical (Foil:The horse pulled the dog to the elephant) Truncated Passive (TP) The pig was touched 4 1 2 Noncanonical (Foil: The animal that was depicted as touching the pig was touched) Passive (P) The elephant was pushed by the cow 7 1 2 Noncanonical (Foil: The cow pushed the elephant) Cleft Object (CO) It was the dog that the horse passed 8 1 2 Noncanonical (Foil: The dog passed the horse) Conjoined (C) The elephant followed the lion and pulled the dog 9 2 4 Canonical (Foil: The elephant followed the lion that pulled the dog) Object-Subject (OS) The horse kicked the elephant that touched the dog 9 2 4 Canonical (Foil: The horse kicked the elephant and touched the dog) Subject-Object (SO) The dog that the pig followed touched the horse 9 2 4 Noncanonical (Foil: The pig that followed the dog touched the horse) (From Caplan. Language. The stimuli are nouns around a given verb. Journal of Speech. the patient In determining the complexity of structures that the might be presented with a picture of a boy pushing a girl.. number of propositions or thematic roles played by tence stimuli using the objects provided.” and so forth. 40. he would point to the printed word “true” or syntactic features of a sentence: (a) canonicity of thematic “false” after each of the following sentences: “The boy is role order (canonical order refers to sentences with the pushing the girl”. & Hildebrandt. patient can comprehend. and Hearing Research.. Berndt. (1997). G. 1993. D. clinicians attend to accuracy of response as ken or written phrase or sentence is true or false or if it well as to error types. clinicians attend to the following Subsequently.qxd 1/21/08 11:20 AM Page 104 Aptara Inc. 542–555.. sis of responses. Waters. Patients with aphasia and comprehen- so that distractor items represent plausible sentence inter. Caplan and col.GRBQ344-3513G-C04[64-160]. qxd 1/21/08 11:20 AM Page 105 Aptara Inc. type of _______.. and (h) repetition naming as many animals as you can. Defining Referents sus the bottom of the list of items in this table. clinicians associated with a class of objects (e. the spontaneous selection or substitution of one appropriate or color (e. labeling. banana. you think of when I say school?”). actions. events. Wilshire & Coslett. include subtests that examine several if not all of these require patients to name as many words as they can think of types of word-finding abilities (see Table 4–5). age of acquisition. tulip. 1976). name of objects. These tasks 1990). Chapter 4 ■ Assessment of Language Disorders in Adults 105 accurately and more quickly to sentence types at the top ver. banana.. writing dis.g. Nickels & Howard. gories: classifying on the basis of an action or function nected and spontaneous language. actions. Most apha- sia batteries and tests of spoken or written naming. and categorizing.”) (a divergent semantic task). produce word associations (e. patients may finding tasks that vary in terms of difficulty to assess produc. Further. Therefore. should not assume that a patient’s writing deficits will paral. (b) word for another. Labrador Retriever). and conjoined versus usage.. from disturbances in spoken language (Varney. (f) automatic serial nam. 1998). be asked to (a) provide the verbal or written name of an tion of content: (a) defining referents. Goal 6: Analysis of the Ability to Produce Language Content Category Naming Impairments in the ability to produce language content are The ability to classify semantically related words and con- always part of aphasia (Benson. 1948). cate- gory naming may be examined according to the semantic An important component of content assessment involves level of words (Baker & Goodglass. by location. categorize in his or her own language can be scored accord- ships. or by classification.g.” as a fol- low up to “What does garden mean?). such as definition by object-subject versus subject-object. 1993). grapefruit are all for eating) (Goldstein. (g) recognition naming. (d) confrontation nam. The ability to name subject-object.GRBQ344-3513G-C04[64-160]. The clini- lel his or her spoken language deficits. For each task. divergent thinking within one’s semantic space. “Rose. size.. (b) superordinate or object category (e. belong to a certain category (e. can be varied to enable the clinician to specify the nature and Goldstein’s [1948] sort task). 2001). grapefruit are all fruit). extent of the word-finding impairment (Deloche et al. Snodgrass & Verbal Fluency Vanderwoort. Objects can be determining the patient’s ability to provide the verbal and categorized at the superordinate level (e. 1979.. mine the type of explanation produced. and concreteness categories and explain the rationale for their sort (e. structured word. and (d) sort objects into length. This hierarchy of sentence types serves as a words that are defined can also be explored further with fol- possible framework to identify the approximate level at low-up questions that solicit either more detailed informa- which a patient is functioning and to describe the syntactic tion. “Write down the names of ing. and content.. cian may also examine the degree of concreteness or turbances may differ both quantitatively and qualitatively abstractness of a patient’s category responses. and relationships lemon. or the exemplar level (e. events. Nickels.g. and/or in a relevant sensory quality of a stimulus such as shape. assessment involves an analysis conceptual or semantic categories: classifying on the of the ability to provide the spoken and written label or basis of a generalized idea of a class of objects (e. grapefruit are all yellow). 1995. (c) (Murray & Chapey.. grouping items on the basis of perceptual categories would be considered a more concrete response than grouping on Production of Content in Highly Structured Tasks the basis of semantic or functional category.. active conjoined versus “What does robin mean?” Responses are analyzed to deter- cleft object.”).g. the written label of objects. banana. The person with aphasia may have diffi. cepts is assessed through tasks that require responses at var- Deficiencies are observed in the appropriate selection or use ious levels and types of categories. active with adjunct versus passive with adjunct. 1997. dog). Goodglass..g. (b) name as many words as possible that ing. animal). “What is the first word that cholinguistic variables such as word frequency. “A features that the patient with aphasia can comprehend.g. 1980. a variety of psy. (c) verbal fluency.g. imageability. and carnation are all a category naming. basic object level (e. and (c) functional cate- in response to highly structured tasks as well as during con.. within a certain category (as described above) or starting with . lemon. events. kind of plant that grows in a garden is _________. lemon. relation. 1995. A clinician can A patient’s ability to define words is assessed by asking the compare his or her patient’s understanding of sentence types patient questions such as “What does anchor mean?” or of active versus truncated passive. Clinicians routinely use several common. For example. 2000). To explore the ability to decipher categories.. or a response that is in a different category (e. (e) automatic closure naming.g. such as Verbal fluency tasks are category-naming tasks that obligate the Test of Adolescent and Adult Word Finding (German.g. Indeed. attributes.g. and rela.. tionships at various levels of task and stimulus difficulty.g. ing to (a) perceptual categories: classifying on the basis of culty in word finding. picturability. The patient’s ability to of vocabulary words relating to objects. attributes. Importantly. 2003.. Picture description tasks are often used to elicit spoken ate. and/or phonologically or orthographically (e. name the days of the week. 1998b). For patients with right hemiparesis or other can be offered to them to determine whether they are capa- motoric impairments that may affect legibility of a written ble of recognizing words they cannot name. For gent. Spreen & Strauss. responses. criticism. the clinician gives the patient blocks appropriate label (e.qxd 1/21/08 11:20 AM Page 106 Aptara Inc.” “E. 2005). 2003). and ideas during unstructured. “dogs. events. a clinician might carefully select the target items to include some that are familiar to the patient and frequently Production of Content in Connected Language used by his or her family. using other connected language tasks should improve the . 1994).” a patient may be required with block letters that can be ordered to spell words (e. controlled source for analyzing parameters of language con- mally constrained because there are numerous plausible tent. For both adults with aphasia and non-brain-dam.” is appropri. eliciting larger samples the sentence or phrase stem is highly constrained or conver. 1965). and/or recite well-known prayers. in an assessment of content-production ability. ken or written connected language to determine the accu- Schwanenflugel & Shoben. or pictures of these items.g. response. distractor him or her to spell the name of this picture). Treisman.. 1998).” or “tele- with the letters “I. the stimulus racy. The ability to produce rote or over-learned material may also be appraised. body parts. patient is given more than one test trial. automatic-closure naming is facilitated when written picture-description tasks. spontaneous lan- 2000. constrained because only one response. Although confrontation naming is not always a part of conversational exchange. many Repetition or copying of words is assessed to determine communication exchanges contain short questions that fur. events. form. and there is a limited number. respectively (e. rhymes. the correct word evaluated. it may also be beneficial to assess writing skills for the target stimulus “elephant. 2000. degree of abstractness. 106 Section I ■ Basic Considerations a particular letter such as P.GRBQ344-3513G-C04[64-160]. it is a communica- Repetition Naming tive response that is a frequent and regular part of successful communication between individuals. responsiveness.”). actions. and use (Armstrong. that vary in frequency..” “C.g. & Murray. For example. Patterson & Hinnach. patients are instructed not to use proper nouns.. for to indicate which of three verbal or written choices is the a picture of a circle. “tele- Confrontation naming has been criticized for its potential phone”) similar to the target. Automatic Serial Naming ture (Heaton et al. write out the letters Verbal and written naming in response to visual presentation of the alphabet. given the nonliteral interpretation of the sentence. colors. A time limit of at least 60 seconds is typically imposed.” “C. or poems. distractor letter blocks could be added. and actions is almost always When patients are unable to name an item. Shadden.. however. or closed set.g. tionships. In and written discourse.. the clini- to go for dinner?” R: “Spinnaker”). 1979. nursery is assessed by presenting objects. For example. In addition. clinicians analyze samples of their patients’ spo- a particular response (Fischler & Bloom. For example. Recognition Naming animals. The most recent version of the lack of relationship to daily communication activities (Mayer Boston Naming Test includes this testing component.g. response choices (Breen & Warrington. the stimulus “He ate the _____” would be mini. the ability of a person with aphasia to Automatic-Closure Naming produce content during highly structured tasks may differ The capacity to complete an open-ended sentence or phrase from his or her abilities during less structured communica- stem such as “The sky is _____” is often a component of tion activities that require greater amounts of verbal or writ- assessment.” and “L” and asks phone”).g. promptness. is intact when other naming abilities are not. completeness. 1992.g. Although several aphasia test batteries include spoken and aged adults. and type of category. to make this items can be manipulated to be semantically (e. or C (Benton et al.. Normative data for these types of naming tasks are available in the research litera. not always the case. guage production is important to the communication of meaning. oral and written naming of objects. Mayer & Murray. The data generated can provide a contrast.. “giraffe”) task more difficult. this is imageability. Confrontation naming can also be The ability to retrieve precise words for objects. Q: “Where do you want cannot verbally name or write. 1994. rela- assessed during connected speech tasks (Allchin & Patterson. of the letter task.” “R. R. It has often been assumed that this ability tionships. and effi- “It’s raining cats and _____” would be considered highly ciency of the content. F. terms of constraint or the degree to which a stem generates Therefore. whether the patient can repeat or copy words that he or she ther the intent of the exchange (e. These sentence or phrase stems can be varied in ten output and more thinking to prepare the response. geometric forms. letters. For example. 1985). McCall et al. and rela. To increase the difficulty of this task.” “elephant. For example. To address this reasonable cian says “Now repeat: elephant. “giraffe. and the 1997. the patient may be asked to Confrontation Naming count to 20.. Chapter 4 ■ Assessment of Language Disorders in Adults 107 TABLE 4–11 Concepts Elicited from Normal Speakers Describing the “Cookie Theft” Picture two little mother in the kitchen (indoors) children girl woman (lady) general statement about disaster little sister children behind her boy standing standing by sink lawn brother by boy washing (doing) sidewalk standing reaching up dishes house next door on stool asking for drying open windows wobbling (off balance) cookie faucet on curtains 3-legged has finger to mouth full blast falling over saying “shhh” ignoring (daydreaming) on the floor (keeping him quiet) water hurt himself trying to help (not trying to overflowing reaching up help) onto floor taking (stealing) laughing feet getting wet cookies dirty dishes left for himself puddle for his sister from the jar on the high shelf in the cupboard with the open door handing to sister (From Yorkston. (1980)... 2000. One limitation of this system. 1998. 2002. the usefulness of data from these tasks may be completeness. story-retelling. Shadden. Doyel. Journal of Speech and Hearing Disorders. 2000. to by Yorkston and Beukelman (1980). described a rule-based system for scoring the presence.. per five stimuli to collect language samples that are at least 300 unit of time. 1991. per minute and the percentage of CIUs (i. or words that are “accurate. An analysis of connected speech samples of aphasic and normal speakers. In addition. 2002.. For example.. relevant and informa- ken or written language samples include conversational tive relative to the eliciting stimulus” (p. developed Brookshire.. In addition. 1995b) and to their stimulus “the birthday party . behavior and potentially limit the number and variety of lex. providing inter.. “How do you change a tire?”) (Cherney et al. Olness et al. Freedman-Stern et nected language. number of pretation of fables or stories.. 27–36. with aphasia. system. In their (Armstrong. determine the number of content units or “grouping of nected language. to the “cookie theft” picture from the BDAE (Nicholas & 1998a). Nicholas and Brookshire (1995b) also al. D. 30). Nicholas and discourse. However.e. one popular scoring system. These researchers provided a list of content to 400 words in length (Armstrong. Ulatowska. K. BDAE (Table 4–11). Nicholas and Brookshire (1993) expanded on ical and pragmatic behaviors produced as well as the com. 1994). 45. however. 1983. Armstrong. Consequently.) reliability and validity of assessment results. clinicians may wish to use at least four or information that was always expressed as a unit” (p. this idea and created a scoring system to analyze content in plexity of morphosyntactic structures generated by patients language samples derived from a variety of stimuli. rules are provided to help the clinician determine 1996.. (CIUs). 340).qxd 1/21/08 11:20 AM Page 107 Aptara Inc. Brookshire & units for the “cookie theft” picture-description task of the Nicholas.GRBQ344-3513G-C04[64-160]. the number of words and “correct information units” 1991). 2000. about both the content and efficiency of their patients’ con- Shadden et al. Ulatowska. Other language tasks that may be used to elicit spo. sequential events illustrated through multiple Brookshire recommend that clinicians calculate both words pictures. 1983). video-narration. Shadden et al. Doyel et al. Li et al. The stimuli should include more than pic. requires the clinician to assure adequate test-retest stability for measures of con. & Beukelman. they listed the main concepts con- Numerous methods are available to analyze content in sistently identified by non-brain-damaged adults in response connected-language samples (Armstrong.g. Shadden. Freedman-Stern. 1998b. or procedural description tasks CIUs/number of words) to obtain the most information (e. ture-description tasks since these tend to elicit labeling is that it only provides responses to this picture. Davis. and accuracy of content pertaining to the moderated by the presence of interfering variables such as main concepts or gist in the connected language of patients motor-speech disorders. 2000. Another option is to assess the gestural-production skills 2002.. Examples of functional-content in evaluation and treatment: draw economically rather than analysis measures are speech acts (Searle. Rose. 1995).qxd 1/21/08 11:20 AM Page 108 Aptara Inc. 4–4).. 1996).. and coherence.. Rothi. Approaches to Assessment of Content Production even those with severe and global aphasia. it may be rolinguistic assessment of disorders of content production useful to examine their ability to reproduce or sponta. many patients. and/or apraxic deficits. 2000). This patient’s abilities in each of these areas via probes such as observation is helpful in planning an assessment session in copying and drawing from memory.. 2005. Hillis. Skelly. patients with by unfamiliar viewers. strating how to use a toothbrush). Ward-Lonergan & measures are excellent predictors of how informative Nicholas. guistic representations (Raymer. cognitive. which requires the patient to draw enacted scenarios mine a diagnosis. 1999). before communicative drawing patients with aphasia are as perceived by unfamiliar listeners is adapted as a viable option. (b) adequate access to the symbols within ability of patients with aphasia (Ross & Wertz. Production of Content in Gesture Although gestural abilities are often impaired in aphasia due Cognitive Neuropsychological and Neurolinguistic to linguistic. and use interactive drawing within natural con- texts. 1992). nature of their aphasic patients’ language impairment with 1979). rather than a linguistic problem. and Spencer (1995) compared the performance of abilities to draw these symbols. ulate or augment drawn output “in a communicatively inter- versation and noted significant differences in contexts. Therefore. 1991. Patients with aphasia may using one of the several nonstandardized procedures also display difficulties at the articulatory/graphic planning described in the research literature (Alexander & Loverso. (1991) and neously produce drawings in order to communicate content Hillis (1998) described how cognitive neuropsychological .. Conlon & McNeil. apraxia of speech. and because they have been created or aphasia have been found to have breakdowns in the word- adapted for one-handed gesturing (Campbell & Jackson. 108 Section I ■ Basic Considerations picture” (Nicholas & Brookshire. In addition.g. Rothi. may also be used to included in the initial assessment and conversational analysis evaluate patients’ drawing abilities (Helm-Estabrooks & (Boles & Bombard. prerequisites: (a) an intact visuosemantic system for the con- ceptions of socially relevant changes in the communicative cepts to be drawn. PICA) include a sub- frequently characterized as impairments of access to or test that examines ability to produce a limited number of egress from memory. (Rothi et al. clinicians can develop their own or borrow from tent in connected language are described as structural or scoring criteria described in the research literature (Murray. (c) adequate motoric and praxic Goda. common symbolic gestures. 1987. and suggested three principles to include diversity. grammatical complexity. Raymer & Rothi. graphemic output lexicon levels.. Daniloff et al. cohesion. reported that despite differences. Albert. 1999. Lyon and Helm-Estabrooks (Doyle et al. Rothi et al. 1993. Lott. In treatment stimuli because they can be discerned more easily terms of word-finding abilities. Skelly. and error pattern. 1998) completed at a later date. 1998). Examples of structural-content analysis 1998). iconic (e. & Crosson. The Daily Mishaps not be required during an early session in order to deter. the clinician attempts to localize which particular than American Sign Language (ASL) signs as assessment and component(s) of the model are impaired (see Fig. demon- respect to models of language (Caplan. They active and problem-solving manner” (p. ADP. performance on the struc. 2000).GRBQ344-3513G-C04[64-160]. These symptoms are most Most aphasia batteries (e. 2006). Sacchett (2002) reviewed approaches to the use of measures are word class. rather than loss of these respective lin- iconic gestures. for example. apractic agraphia). With respect to gestural codes. this visuosemantic system. 62). & Barresi. Kay et al. transitional perfectly.. how to salute).. 1979). the drawing. 1997. 1982. assessment may involve determining the integrity of the tured tasks predicted performance in conversation. stage or with the motor realization of that plan. Instead. provided. but these dif- 1993. retrieval process at the semantic and/or phonologic or 1995. These content (Lyon & Helm-Estabrooks. functional in nature.g. Fitzpatrick.g. and via an evaluation of that the time-consuming task of conversational analysis may hand and limb motoric and praxic skills. have been able to Clinicians who adhere to a neuropsychological or a neurolin- acquire simple forms of gestural communication (Helm- guistic approach to assessment attempt to determine the Estabrooks. and AmerInd gestures are often more suitable That is. or both. showing 2005. 1982. 1989. Wilshire & Coslett. Hillis. Doyle. Although no formal scoring procedures are Other measures available to analyze production of con. 1969). symbolic (e. semantic drawing in aphasia. 1996. Raymer et al. changes on these measures (1987) suggest that the following abilities be considered as over time correlate positively with unfamiliar listeners’ per. ficulties are often viewed as a motoric (e. The research literature contains many articles that pro- Drawing vide guidance for performing a neuropsychological or neu- For some severely impaired patients with aphasia. Nadeau. 1991).to three-part scenes. structured-discourse tasks can be that contain one. and (d) the ability to manip- persons with aphasia on structured-discourse tasks and con. allow the communication partner to contribute to elements. 2002a. Test.g. However. g. Kulke & Blanken. that would be helpful in this type of assessment. Lock & Armstrong. Lemme. For example. lyze the language of their patients with aphasia and found ment of aphasia: the Psycholinguistic Assessments of that they produced a significantly greater proportion of Language Processing in Aphasia (PALPA. “a thing for doing stuff” for the target knowledge. tasks. and sessions in order to distinguish indefinite substitution: the response is a nonspecific word impaired access/egress from degradation of linguistic or description (e. 1997). an evaluation might vary the stimuli according to psy.. Liles. 2005). (1996) reported that while coherence was dis- et al. other. 2000. Hedberg. In addition to observing the accuracy and quantity of content 1990. (2000) coded nouns in six cat- ple. and (g) no response. Cohesion is defined as the relations of meaning that “tie” or tent and form at the word level. expert system for assessment of word. and other errors. “skoon” Deser. Schwartz & Brecher. underlie the deficit.. 1988. and cholinguistic factors (e. Mitchum et identify the loci of damaged cognitive mechanisms that al. clinicians can Coelho.. & Bottenberg. “us”) and demonstrative pronouns (e. Bub. “he. Cuetos. age of acquisition or imageabil. Raymer (2005). 1990). Glosser. addition. 1997. 1990. In contrast. unrelated.. Various researchers recom- mend exploring semantic cohesion in the spontaneous con- Error Analysis in Production of Language Content nected speech of patients with aphasia (Glosser & Deser..” tuted word is semantically related to the target word (e. naming errors. These batteries include a variety Cohesion Analysis of tasks to help the clinician identify the locus or loci of impairments in producing spoken or written language con. phrasal errors. Raymer and Rothi Kemmerer and Tranel coded verbs in five categories: verb (2002).. tems to describe the word-finding errors of patients with sistent errors. 1993. (d) cir.. Aguado. and part-words or unintelligi- the Psycholinguistic Assessment of Aphasia (PAL. LeMo is a Error analysis may also be a prognostic factor in recovery computer-assisted.g.. suggested that access/egress “spoon”). Wiener. the batteries dencies among the words in a text or within a discourse sam- are not standardized and do not provide comprehensive nor. & formance in a series of word-retrieval tasks can be used to Caramazza. Brookshire. (c) random paraphasia: the used to refer to a previously stated or written. it is currently only avail- able in a German version. 1985. (b) lexical ties: vocabulary is target word (e.g. In addition. cohesive devices that contribute to the overall coherence of the verbal or written output. 1976). patients with aphasia frequently produce one Of the numerous types of cohesive devices (Halliday & or more of the following: (a) phonemic or literal paraphasia: Hasan. Zingeser & Berndt. Kay et al. 2000.g.GRBQ344-3513G-C04[64-160]. 1997). aphasia (Brookshire & Nicholas. Brookshire and Nicholas (1995) described a set of cat- ity). “clumpter” for the target “spoon”). explore error analysis (e. Caplan & ble words in comparison to their non-brain-damaged peers. 1984): (a) for the target “spoon”). 1988). or compare oral and language output that could not be scored as real words or written responses. adpositional errors. These authors used this system to ana- ropsychological or neurolinguistic approach to the assess. reference: terms such as personal pronouns (e.qxd 1/21/08 11:20 AM Page 109 Aptara Inc. 2002). paraphasias or neologisms). nonword. and LeMo (DeBleser et al.. embedded in it).. ple. and/or ined in the language of patients with aphasia (Glosser & rearrangement of the target word’s phonemes (e. rupted in their patients with left hemisphere damage. correct information units (Table 4–12) (see also Nicholas & Three test batteries also are available that adopt a neu. “and” and “then” are included. 2001. inaccurate words. thereby creating meaningful interdepen- guage skills at the discourse level. “these.g. however..g. Liles & in aphasic patients’ verbal and written output. formal. Rothi et al. the following types are most frequently exam- the response contains substitution. (b) semantic paraphasia: the substi. selected to exemplify previously stated or written informa- cumlocution: the response is a description or definition of tion (e. 1993). 1990. Kemmerer & Tranel. and (d) ellipsis: certain items . and knowledge impairments are associated with con. egories to quantify and qualify performance deviations in rate the informativeness of responses. Cuetos et al. and Murray and Clark (2006) described several tasks errors.. (e) neologism: the response is a non. unambiguous substituted word has no apparent semantic relation to the antecedent (Armstrong. Chapter 4 ■ Assessment of Language Disorders in Adults 109 models guided their assessments of word-retrieval deficits sense word (e.. 1998. & Kaplan. For exam..g. However. provision of a synonym or the target word (e.g. Hillis demonstrated how the pattern of per. none of these batteries examines lan.g. (1991). nominal errors. Wilshire. word-retrieval deficits are associated with inconsistent Several researchers have developed detailed coding sys- errors. repetition of nouns. cohe- 2000. “tractor” for the target “spoon”). from stroke-induced aphasia (Davis & Majesky. In terms of types of paraphasias or sion was not. “it’s metallic and is used to eat soup” for superordinate).g. Cohesion is achieved linguistically through a variety of mative data. 2000).g. (c) conjunction: conjunctive devices such as the target “spoon”). 1996). false starts. only the PAL “glue” linguistic items together (such as one main clause and includes subtests to determine language-production skills at all subordinate clausal and nonclausal elements attached or the sentence level. (f) across modalities. mixed. omission.. egories: semantic.” “here”) are “fork” for the target “spoon”). analyze the nature and pattern of errors made (Goodglass Bloom et al.. processing impairments. GRBQ344-3513G-C04[64-160].. 2002). . Performance deviations in the connected speech of adults with no brain damage and adults with aphasia. ship between the clarity of a message and the amount of 1972). . clinicians may explore the relation. incomplete ( the antecedent was not provided). 1995). on a chair . . . 1979). 1995. complete (the antecedent is easily (Murray. on a thing Filler Empty words that do not communicate information about the stimulus .. 2001. 1996). 1997.. . variables. (From Brookshire. stool And All occurrences of the word and . um . no. Pease and Ellis. Haendiges et al. length of trial cohesion it contains (Armstrong. a stool Unnecessary exact Exact repetition of words. & Howard. and familiarity in order to examine which variables in order to specify the nature and extent of the topics facilitate and which impede the amount of meaning- word-finding impairment. and/or word-finding errors in their information not only about patient functioning but also patients’ spoken or written language. about potential treatment activities and stimuli. Evaluation also includes an analysis of patient-related gories of influential variables are item-related. 1979). but that the . Hirsch & Marshall et al. 4. uh. . 1990. . degree of cues have potency as aids to word retrieval. & Nicholas. Franklin. This is accom. . 1996). attention condition Liles & Coelho. Smith. & Gerstman. Examples of item-related variables that partner (Hickey & Rondeau.. and the ability of a patient to use clinician-produced and/or quency (Deloche et al. Marshall. . and no attempt to correct . these variables may not only influence the content produced by patients with aphasia during word-level or structured lan- guage. 110 Section I ■ Basic Considerations TABLE 4–12 Categories of Performance Deviations That May Be Examined in Samples of Connected Language* Category Definition Examples Nonword Part-word or unintelligible Word fragments or productions that are intelligible in context . . Deloche et al.H. 1971. ables are type of sensory input (Benton. stool . and operativity (Nickels & vious stated or written text. . .) are omitted because they can be presupposed from the pre. concomi- devices in connected language and determining the degree tant gesturing (Cunningham & Ward. on a . on a chair (for stool) False start False start or abandoned utterance .. . Therefore. . They demonstrated that grammatical class (Berndt. . jargon. Examples of task-related influential vari- During assessment. Assessment should include analysis of these plexity. you know . a boy and a stool Off-task or irrelevant Commentary on the task or the speaker’s performance I’ve seen this one before. R. . type of naming task (Berndt et al. 2003.. on a frampi Nonword filler Utterances such as “uh” or “um” . unless used purposefully for emphasis .. Rose & Douglas.qxd 1/21/08 11:20 AM Page 110 Aptara Inc. topics that vary in terms of abstraction. 1998). plished by identifying the occurrence of these cohesive 2005). Howard. . . length (Nickels & Howard. 1966). . 1995). Linebaugh et al. . 1987). 1972. stool production . 2005. Fridriksson et al. verbal (Coelho et al. stimulus novelty (Faber & Aten. 2001). inappropriate (Glosser & Deser. task-related. 2006). .. . Three cate. 1985). on a . identified). .E. . 2002. reinforcement (Stoicheff. .. American Journal of Speech-Language Pathology. self-generated cues (Freed. Pease & Goodglass. on a . on a stool or cohesion Nonspecific or vague Nonspecific or vague words lacking an unambiguous referent . but also during connected language. 1994). & Nippold. . only nonwords and words printed in italics were scored as performance deviations. Hanlon. intellectual com- guage content. sk . . It is important to note that or inaccurate (an ambiguous antecedent) (Liles. 1978). 2004). 1994). I can’t say it.. length. 118–123. 2002). . . (1995). Such analyses yield valuable ful content. certainty (Mills et al. production of language content. & Lang. concreteness Goodglass (1978) described a differential effect of cues on (Nickels. L. may influence content production are the target words’ fre. on a st . *In the examples. 1960). and accuracy of their use. dur- Influential Variables ing assessment clinicians should introduce conversational Many variables may facilitate or impede production of lan. and word-retrieval success rate (Brookshire. Non-CIU Inaccurate Not accurate with regard to the stimulus. and intertrial time (Brookshire. semantic category (Goodglass et al. 1990. 1996). age of acquisition (Bird. . Nickels & Best. Examples of these are skills of the communication and patient-related. which may be either appropriate Brown. syntax. in the aphasia literature may be used to examine these syntactic features in connected-language samples (Menn. Haarmann & Kolk. to examine the regular past tense /-ed/ morpheme. a number of scoring systems described Patterson.g... produce few complex syntactic structures or sentence forms cles. Cappa et al. Goal 7: Analysis of Ability to Produce Language Form Ramsberger. 2000). and phonol- developed an Index of Grammatical Support to examine the ogy. 1989. 3.” For the tence (e. Yesterday. can be explored to eral flies were _____. conjunctions. highly structured & Lehner. on the PAL. The clinician or the patient provides a description of the patients are given a word that they insert into a given sen- target word (e. Cueing hierar- tion: “He is using the fly swatter to swat flies. 1994..g. Menn and colleagues Linguistic form includes morphology. 1. Saffran et al. passives. Miceli et al. but the reverse is not the case. 1990) include subtests to assess “caddy”) production of morphology. More specifically.”).g. “I drink this every morning. tures. and as related to the target (e. Shisler. For example. The clinician provides a semantically related word or the culty as they shift from producing determiners to preposi- patient generates one or more words that are semantically tions to pronouns to auxiliary verbs for form words. morphologic inflections such as struction is to determine the specific syntactic structures the plural /-s/.g.. 1993. Thompson et al. Edwards. patients demonstrate restricted use of syntactic Production of Form Words and Morphology forms and therefore produce incomplete syntactic struc- Morphologic and syntactic impairments in verbal produc. 1998). A hierar- chy of difficulty for producing these various morphemes has An Example of a Cueing Hierarchy been found to be a function of grammatical rather than phonologic complexity (Goodglass & Berko.” examine word-finding stimulability and to determine what The above tests elicit form words and morphology via type of self-correction strategies a patient uses (Linebaugh relatively structured or constrained. Syntax aphasia. 5. Berko’s (1960) sentence-completion test examines a patient’s ability to affix several types of grammatical morphemes. possessive /-s/..g. 1977. sev- chies. The clinician imposes a delay or the patient requests additional time to produce the word patients with aphasia tend to display relatively greater diffi- 2. each should be assessed during an in-depth words into both simple and complex constructions in order language evaluation. Persons with few structured tests (see Table 4–5) or subtests that are aphasia who make morphologic errors are likely to produce designed to elicit a variety of syntactic forms (e. “courage” must be affixed to fit into the sentence target “coffee”). Kohn & The goal of assessment of production of syntactic con- Melvold. to express relationships (Chatterjee & Maher.. 2005. “/k / for the Most traditional aphasia batteries do not assess this aspect target “coffee”) or the patient produces one or more words of language. 2000). Christiansen. In addition. 1992. 1997) that are phonetically similar to the target (e. Aphasia may Production of Syntactic Constructions result in difficulties producing one or more aspects of form. In aphasia. 1998).” or and the PAL (Caplan & Bub. . & Helm-Estabrooks. (Goodglass. Specifically. To examine are frequently omitted or inappropriately used. tion are common in patients with aphasia. clinicians may choose from one of the not necessarily correlated (Miceli et al. For example. In addition. Persons with aphasia may experience difficulty in combining consequently. Chapter 4 ■ Assessment of Language Disorders in Adults 111 TABLE 4–13 phonologic errors. & Lehner. 4. 1960. 1995). the production of spoken and written sentences in highly the occurrence of morphologic and phonological errors is structured contexts. refers to the rule system for ordering words into sentences.. such as that displayed in Table 4–13. Goodglass and (e. the clinician reads the stimuli aloud and the patient then supplies the final word with the target morphologic inflec- potency varies for individuals with aphasia.. Phonology refers to the sound system as well as the rules used to combine those sounds (Nelson. 2004).qxd 1/21/08 11:20 AM Page 111 Aptara Inc.. or both (Bird & Franklin. 2000. The clinician provides a carrier phrase for the target word “If a man is brave. morphemes). 2001). simple syntactic structures. & Gallagher. tasks. “sugar” or “tea” for the target they shift from producing plural to adjective to verb inflec- “coffee”) tions for grammatical morphemes.. The clinician provides a phonemic cue (e. For example. both the PALPA (Kay et al.. “A cup of ______. However. Morphology refers to the set of rules that govern the average number of form words and grammatical morphemes structure of words and the construction of word forms from that are correctly used in the spoken output of patients with the basic elements of meaning (i.g. and personal pronouns and commit more errors when attempting them.. Such deficits 1996. Linebaugh... we say he is _____. They may also are observed in the use of relational words such as arti. 2004). prepositions. or present progressive /-ing/ that are available to each patient with aphasia.g. “cost.”).GRBQ344-3513G-C04[64-160].e. . production of verbs in their infinitive form (e. .g. on the PAL (Caplan (e. For example. . the boss Verb stealing. quency and consistency of production.. characterize agrammatic language output (e.g.. spo- and Syntactic Construction ken..g. Kolk.. complex grammatical sentences. . warm Prepositional phrase in the basket Expanded noun phrase cookies in the jar Expanded verb get up in the morning Expanded adjective sick of the office Expanded prepositional phrase in bed in the morning Subject  auxiliary so is the woman. burglar .. Goodglass. “in” for “with”) or across- cally using picture-description or story retelling tasks). passive sentence. with verbs. “The bicycle is being pushed by the man. . Error analysis typi- Saffran et al.. “her” for “with”) substitutions (Haarman & arating samples into utterances or T-units (i. 1994. 1998. proportion of grammatical sentences. the patient might confuse nouns aspects of fluent or paragrammatic language output (e. Most of these scoring systems provide Substitutions may be further examined to determine whether detailed procedures for collecting language samples (typi. or the omission . Another assessment option is to examine connected. 1995) (Table 4–14). & Gallagher. researchers report good inter-rater reliability. Rochon et al. two broad categories: error analysis.. . other systems were aimed at characterizing structural constituents. proportion of & Bub. Saffran et al.”).. Substitution errors might involve the interchangeability of 1989). chicken in basket Expanded topic-comment burglar policeman outside Subject-verb-object the dog stole the chicken Expanded subject-verb-object the mother’s washing dishes in the kitchen Complex I hope he gets to work on time Multicomplex he picks the corn to see if it’s ripe Aborted utterance this boy has . sep. the intent is to elicit the explicit. chicken Topic-comment boy . or affix the inappropriate morphologic inflection. Abandoned utterance the sink is overflowing on to the . 1995). relative clauses). or written language samples using one of the several syntactic scoring systems described in the aphasia literature Analysis of production responses is typically completed in (Curtiss et al. Analysis of Production of Word Forms. 2004.g. errors are within-category (e. cally takes the form of whether the morphologic or syntactic Although some of these analysis systems were developed to errors are a substitution or omission of target structures. 112 Section I ■ Basic Considerations TABLE 4–14 Examples of Syntactic Constructions Construction Examples Noun phrase cookies. Morphology. Edwards. without per- and identifying a variety of syntactic forms and relationships son or number agreement or tense endings). Thompson et al.. For example.g.. aren’t they? (tag question) Subject-verb the man’s running Subject  predicate he’s the president Verb-object dry the dishes Subject-object the dog .g. Edwards. off stool. and analysis of fre- Christiansen. for example. 1992). category (e. . number and type the constraint that they must begin their description with a of sentential constituents). an indepen. 1989. ..g. . involve dent main clause and any dependent clauses modifying it). .. .GRBQ344-3513G-C04[64-160]. 1995. Because the procedures are so certain word such as “bicycle” (e. patients are asked to describe a picture with simple vs. datives. policeman Expanded subject-verb the guy’s running to work Expanded subject  predicate the woman’s angry with her husband Expanded verb-object grab the chicken quickly/from the basket Expanded subject-object dog . .qxd 1/21/08 11:20 AM Page 112 Aptara Inc. hurry up Adjective big. 1990).e. Omission errors might.. or if he or she mani- Phonology refers to the set of sounds in a language as well fests incorrect stress placement that results in subsequent as the rules used to distribute and sequence those sounds reduction or omission of vowels or morphemes that would into words (Owens. Ability to produce typical ple. Difficulties in the production of intonation have been inflections. Intelligibility analysis is a part of error analysis as an evaluation of the patient’s peripheral speech mechanism. both the communication environment and the partners of stimulability testing or the patient’s ability to modify his are dynamic components of the communication itself. but two that are com- The frequency and consistency of production of various monly affected in aphasia are intonation and stress syntactic structures is evaluated to determine which struc- Intonation refers to modulations of the pitch or musical tures are frequently. Communication Interaction When either or both of them are present. segmental phonologic incorporated into therapeutic goals.g. for some patients with aphasia. word-order violations are relatively uncommon The production of suprasegmental components of phonol- among patients with aphasia (Bates et al.. those suprasegmental features that can dard manner. conversational sound or syllable (Blumstein. Chapter 4 ■ Assessment of Language Disorders in Adults 113 of a whole group of words such as relational words or auxil. phrase and sentence level (Goodglass. When patients (Goodglass. sentence-completion vs. and is profoundly influenced by the context neous language and the phonologic context of those errors. or her production of error phonemes following auditory and Therefore. 1995. There are not typically a major focus of error analysis. 1998). a contribute to difficultly in word comprehension. such as at the end of a phrase or sen- with aphasia inconsistently use form words. identifying word-order violations is (den Ouden & Bastiaanse.qxd 1/21/08 11:20 AM Page 113 Aptara Inc. language (including content and form) varies . WAB. Often. some patients with fluent types of aphasia may produce melodic intonation or prosodic quality is assessed to deter- a variety of syntactic forms but produce complex syntactic mine whether the patient has problems using pitch varia- forms at a reduced frequency compared with their non- tions to indicate grammatical segmentation or complexity brain-damaged peers (Edwards. morphologic tence. infrequently. relationship exists between the degree of structure or task Stress refers to the force or accentuation of a particular constraint (e. 1998). 1988. This can be accomplished during moderately Segmental Phonology structured observations or by administering aphasia batter- ies (e. such as tasks logic disorder or an impairment in the ability to produce the that require the clinician to rate the fluency of connected distinctive sound elements of a word or syllable in the stan- speech. many suprasegmental components. 1968). aphasia can produce. 2004). The data collected should include (a) Communication is the reciprocal act of sending and receiv- phonemic errors produced during unstructured sponta. In fact. Menn & ogy may also be problematic for some patients with aphasia Obler. normally have been stressed. Seddoh. 2000). therefore. Speech and language patholo. 2003. mental component that consists of phonemes and syllables. or that he or she can be stimulated to produce.GRBQ344-3513G-C04[64-160]. 1990). 1998). Additionally. For exam- geal control (Blumstein. 1994). Interestingly. Blumstein (1998) concluded that be used to improve the intelligibility of spontaneous speech “nearly all aphasic patients produce phonological errors in or the communication of meaning should be identified and their speech output” (p. That (b) errors produced on a standard articulation test. particularly in patients with Broca’s aphasia or whether or not there are any influential linguistic or task anterior left hemisphere lesions (Seddoh. Goal 8: Analysis of the Ability to Comprehend 2004). Stress is assessed at both the gists typically assess two components of phonology: a seg. phonology should be assessed in detail. the clinician tries to identify reported. suprasegmental phonologic variables that the patient with stress. ing information. and pauses. in which it is used and the partners who are involved. In evaluating a patient’s activities) and the number and type of grammatical errors ability to produce appropriate stress patterns a clinician produced (Hofstede & Kolk. Both of these disorders are frequent accompaniments and Produce Pragmatic Aspects of of aphasia and have been described above under Goal 2. in Suprasegmental Phonology English. 1968). BDAE) that contain tasks in which supraseg- Aphasia is frequently accompanied by a segmental phono- mental features of spoken output are examined. or never used and which flow of an utterance and is primarily dependent upon laryn- are consistently or inconsistently used correctly. it involves determining whether sentences are understand- able in spite of omissions and substitutions. (d) a phonetic inventory. visual stimulation. and (e) results of iary verbs.g. 1998) and consequently with breakdown in terms of phonetic implementation (Aichert & Ziegler. A goal of assessment is to determine the specific and a suprasegmental component that includes intonation. 2004) and may variables. For example.. determines whether the patient with aphasia uses stress pat- terns that are typical of his or her linguistic peer group and Production of Phonology predictable within linguistic context. 162).. (c) results is. or syntactic forms. disorders are associated with dysarthria or apraxia of speech (Dogil & Mayer. in switching or shifting sets of refer- room to that observed in more natural environments (Egolf ence as in topic changes. redundancy. 1988). the activity and participation levels of the ICF interactive product of contextual variables and the indi. 2001) provides a useful framework Stemmer. and emo- topic selection. most patients with aphasia can communicate the patient’s linguistic behavior changes with various con- better than they can speak. 1979).qxd 1/21/08 11:20 AM Page 114 Aptara Inc.. and expectations underlying the initia- or that is understood (Labov. familiarity.. However. greeting. it is important to examine the comprehension and production content. It is also tional status. and termination of discourse. 1983). 1977). length. and guage for communication (Prutting & Kirchner. produce fewer communica- that comprise pragmatic competence: (1) knowledge—of tive gestures and more complex verbalizations. clinicians frequently observe variations in production Pragmatic abilities include a communicator’s proficiency and comprehension of spoken and written language when in constantly adjusting the content. and code switching. (1988) found that ver- ence of the communication partner’s social status and com- bal complexity and language errors vary significantly with municative abilities and to the physical context in which different contents and contexts of communication. previous experiences. of several sources of knowledge about pragmatics and pat.GRBQ344-3513G-C04[64-160]. meaning is communicated—how units of language function in discourse and as authentic communication within social Communication Environment contexts (Holland & Hinckley. semantic relatedness. clinicians assess pragmatic skills to determine whether these abilities are an area of strength that may be cap- Communication Partners italized upon during treatment. Penn (1999) identified three knowledge areas like non-brain-damaged adults. guide clinicians to look beyond a patient’s abilities and vidual’s structural linguistic knowledge (Gallagher. form. Consequently. “aphasic patients show appropriate successful interaction. sex. It also refers to the example.. with aphasia and his or her communication partners will . elabora- the knowledge of how to converse with different partners tions of comments).. as well as the knowledge of the tions (e. For exam- tion. assessment involves an analysis of whether or not 1989). patients with aphasia. and if so. and predictable linguistic changes in response to nonlinguis- Pragmatic aspects of language often remain an area of rel- tic social contextual variables” (Glosser et al. “pragmatic skills cer- texts. for assessing pragmatic comprehension and production. values.g. Bernstein-Ellis. such as attention and memory. conversational analysis. responsiveness (e. anaphoric pro- where. 2002). 1999). and assess the Communicative competence is the successful interaction of patient’s ability to convey meaning and to communicate in a comprehension of language content. 115). The discourse analysis. Partner characteristics such as age. 1983). formal interview. Specifically. & The WHO ICF (ICF. and acceptability comparing communicative performance in the therapy of his or her message.. conversation. and can best be assessed using multiple mea- interactional aspects of communication and the use of lan. and discourse and authoritative status.g. 114 Section I ■ Basic Considerations with each context and partner (Joanette. in conditions that restrict visual contact between ability to use language for a variety of functions or intents the speaker and listener (e. communicating over the tele- such as requesting. and protesting phone or through an opaque barrier). and intent of language that is produced (Gallagher. Further. 1998). warning. deficits in language content and form. (Lucas. as well as internal variables such as rules that govern conversational skills such as turn-taking and world knowledge. Pragmatics is a Various communication settings and activities may affect the knowledge of who can say what to whom.g. maintenance. 1996). why. important to determine how these factors are influenced by Frequently the burden of communication between a person various contexts and partners (Murray & Chapey 2001). and (3) processing ing conditions (e. and manner that is functional for that individual (Elman & pragmatics (Lahey. obligations. 1983). and lexical selec- and in different contexts. and and Kolk (1994) also observed changes in the morphosyn- social knowledge. 1999).g. technical jargon) of the language that is produced rights. Lyon. Pragmatics refers to the system of rules that regulate the “Functional” has a different meaning for each individual use of language in context (Bates.. 2002). 1970. and by what means (Prutting. Hofstede language and its structure. Indeed. and in being sensitive to the influ- & Chester. when. It is nouns). 2000). It involves the with aphasia. ple. affect communication (Davis. 1999. In prehended by an individual at any point in time will be an particular. 1976). sures such as direct observation. Therefore. For communication occurs (Penn. as well as published tools (Holland & emphasis is not on sentence structure but rather on how Hinckley. terns of use. or whether they are problem- atic and need to be remediated during treatment. fluency.g. (2) adaptation—the speed and ease with tactic output of patients with aphasia across different speak- which reaction to environment occurs. Indeed. maintenance. picture variables—the “real-time” behaviors required to engage in description). number and variety of his or her communicative behaviors. 1980). such as speech acts and intents. p. 1992). morphosyntactic complexity (e. how specific contexts facilitate or hinder the tainly can be affected by focal brain damage” (Holland. Specific communication partners may also affect the form. in what way.. Also. 1988. Holland & Thompson. Ansaldo. Glosser et al. of the world and its contents. ative strength for many patients with aphasia (Wulfeck et al. the language produced or com. language form. GRBQ344-3513G-C04[64-160]. According to Searle (1969). behavior and the communicative interaction. one can say one thing and mean another. 1995. means. (d) protesting: the intention to object to another person’s tunities afforded the patient and the barriers to such com. Clinicians meaning. Many of these intents are used in one or more of the fol- Other nonstandardized tools such as the Family lowing four communication categories proposed by Lomas Interaction Analysis (Florance. 1995. produced.g. some patients with aphasia may have few the message-sender’s intent in producing the utterance. individuals frequently use Speech Acts and Communicative Intent their knowledge of the communication environment and Pragmatics is the rule-governed. gestures. create a positive and through semantic-syntactic utterances and/or by previous or rewarding communication environment that contains stim. (e) description/comment: the intention Communication Environment of the Adult Aphasic to give a mental image of something seen or heard. and what the rules are governing the linguistic utterance. and/or and respond to another’s utterance or question. lack of privacy. which includes instances in which the names and relationship to the patient of the frequent and speaker is agreeing with or confirming a proposition. 1998. emergency help). the clinician can help the patient. Denman. as well nance. this intent includes a subset of whether a patient has anyone with whom to talk. solicit information. 1999). home mainte- sensitivity to the patient’s communication difficulties. Chapter 4 ■ Assessment of Language Disorders in Adults 115 shift following aphasia (Linebaugh et al. 1962. Lubinski. what the message receiving messages (Armstrong. 1981) (Table 4–15) or obser. must analyze such partner variability and note patterns of Austin (1962) and Searle (1969) described speech acts as the- performance. successful communication gives receiver intends. what the message-sender intends. the called affirmation. the speaker. and driving. or writing a letter to a friend. and a Searle’s theory. few reasons to talk. & Gilpin. (f) asser- (Lubinski. 2001). Toffolo. Frequently identi- background noise. and carry with them an intention on the part of emotions to those who are judged to be important partners. (c) life skill: communication skills that sup- tion gained from these types of analyses may help provide port the ability to provide or understand information needed information about the caregivers’ and significant others’ to complete daily activities such as shopping. oretic units of communication between a speaker and lis- Part of successful communication involves having the tener that are performed in the course of verbal and written opportunity to communicate highly personal thoughts and interaction. or com- munication using tools such as the Profile of the mand of another. 2005. whether it be to McCooey. or tone of voice. telephoning 911 for to a communication-impaired environment.. 1987). and Intents may be communicated and comprehended significant communication partners. 2000. the intention to address another for help. they may be expressed ulating activities and a variety of interesting communication (and comprehended) through facial expression or accompa- partners (Elman. 2000. meaningful communication A number of taxonomies have been developed to describe due to a lack of sensitivity to the value of interpersonal com. What is not said may also communicate intent.. That is. In addition. The informa. that are needed to maintain physical well-being or health cessful communication interaction and those that contribute (e.. action. That is. 1997). 1969). that are needed to participate in social activities such as play- municating with the patient (Simmons-Mackie & Kagan. Subsequently. fied intents include (a) response: the intention to attend to tive perceptions of their communicative competence. nying actions. social use of language and their partners to help them decipher between what is said represents the speaker’s method of conveying intended and what is meant. should include an evaluation of the communication oppor. Searle. or Pragmatic Protocol (Prutting & tion: the intention to point out to another that some state- Kirchner. nega. (c) Byng. Dore. and (g) infrequent communicative partners. Parr & Byng. and (d) social need: communication skills as about their successful and unsuccessful strategies for com. going to church. In the ability to influence other’s thoughts and actions. behavior. 2006). the aphasia assessment greeting: the intention to convey a conventional greeting. et al. & Code.qxd 1/21/08 11:20 AM Page 115 Aptara Inc. calling for assistance after falling. 1995). statement. Further. 1974. . (b) health threat: communication skills clinician identify the psychosocial factors that promote suc. the individual the feeling of social connectedness to others. what the message-receiver understands. (b) request: lack of stimulation in general (Kagan. and how their presence informing: the intention to report on present and past expe- and communication style affect the patient’s communicative riences. Parr. Part of the assessment is the determination ment or proposition is true. subsequent utterances. no viable communication partner. Therefore. and the illocutionary force of this proposition is Unfortunately. what the message- Lubinski. Speech acts are the instantiations of pragmatics. the proposition is the words or sentences means of establishing shared reference (Hengst. the speech act as well as feeling the fulfillment associated with sending and includes what the message-sender means. the variety of intentions that can be used in communicating munication. (1989) (see Table 4–2): (a) basic need: communication vational measures of a conversational partner’s support and skills that are needed to accomplish basic needs such as eat- level of participants (Kagan et al. 2004) may also help the ing and daily hygiene. 2005). 2003). opportunities for successful. ing cards. or perhaps acknowledgment. excessive (Austin. or to reject or resist the action. 204–211. and greetings (Newhoff et al. range of speech acts and intents (Armstrong.. however.GRBQ344-3513G-C04[64-160]. Lengthy response _____________ _____________ _____________ 4. Request for attention _____________ _____________ _____________ Key: S  successful. Physical cue _____________ _____________ _____________ 33. Open question _____________ _____________ _____________ 20. Despite these preserved pragmatic different sites of brain damage (Murray & Holland. Prinz. Because of these possible . Wilcox. Guessing _____________ _____________ _____________ 11. Prutting & Kirchner. Second. Abrupt topic change _____________ _____________ _____________ 15. Repeating _____________ _____________ _____________ 12. asser- produce a variety of speech acts or intents. Doyle and col- requests (Foldi. Modeling _____________ _____________ _____________ 32. Simple language _____________ _____________ _____________ 13. Advice-giving _____________ _____________ _____________ 7. Closed question _____________ _____________ _____________ 17.. 1992). (From Florance. 1995. In leagues (1994) found that patients with aphasia primarily terms of production. Wilcox et al. Incongruent affect _____________ _____________ _____________ 3. Paraphrasing content _____________ _____________ _____________ 21. 1978). 11. For example. Summarizing content _____________ _____________ _____________ 23. 2001. 1980. including the ability to respond correctly to indirect 1979. abilities. Interpretation _____________ _____________ _____________ 27. Methods of communication analysis used in family interaction therapy. Instruction _____________ _____________ _____________ 30. U  unsuccessful. Judgmental response _____________ _____________ _____________ 8. C. 1987. Gesturing _____________ _____________ _____________ 29. different pragmatic impairments are tion. aged adults. Clinical Aphasiology. Self-focus _____________ _____________ _____________ 5. Verbal following _____________ _____________ _____________ 18. Labeling _____________ _____________ _____________ 31. Inattentive posture _____________ _____________ _____________ 2. Loud voice _____________ _____________ _____________ 14. 1978). Sharing _____________ _____________ _____________ 25. First. Summarizing feeling _____________ _____________ _____________ 24.) Patients with aphasia often have a relatively preserved ics are reported.qxd 1/21/08 11:20 AM Page 116 Aptara Inc. Confrontation _____________ _____________ _____________ 26. responses to requests for clarifica. patients with aphasia use a restricted ability to interpret a variety of speech acts and intents. In contrast. Verbal cueing _____________ _____________ _____________ 28. Premature confrontation _____________ _____________ _____________ 9. 1985. 1987). observed among patients with different types of aphasia and Ulatowska et al. Interrupting _____________ _____________ _____________ 10. Reflecting feeling _____________ _____________ _____________ 22. Prutting. 116 Section I ■ Basic Considerations TABLE 4–15 Family Interaction Analysis: Scoring Form Significant-Other Behaviors S U R Nonfacilitative 1. (1981). Davis. some patients maintain the ability to produced responses to direct requests. Speaking for patient _____________ _____________ _____________ Facilitative 16.. R  rejection. & Leonard. Inappropriate topic change _____________ _____________ _____________ 6. including tions predominated the verbal output of non-brain-dam- requests for clarification. Minimal encouragers _____________ _____________ _____________ 19. impairments in other aspects of pragmat. repair and revision strategies are important and fre- the message-sender may use gaze-avoidance and a hand ges. This communicative act should contain new. assuming more of the conversational burden than the part- Initiation of the speech act (as the message-sender) ner with aphasia. When role-switching are intended to establish cooperative discourse participation to occurs in the absence of the speaker’s readiness to switch. aphasia have in conveying accurate and nonambiguous The message-sender may use gaze and hand posture to information (a product of their language-content and form signal control of the interaction. Despite this. if any.. tion (Fey & Leonard. 1988). a short and usually affir. Schegloff. To retain his or her role. sender provides a sufficient amount of information (i. For some patients with aphasia. Wertz. mative verbal response such as “yes. The role of the message. 1994). and (d) the manner in which messages are may change. cation sequences that were unsuccessful and apply repair receiver is to comprehend the message that is strategies to assure comprehension of the communicative communicated. These speech acts sender’s willingness to switch roles. he or she sig. Although some patients with aphasia . As the person with aphasia takes turns in a conversation. leaning forward). and reflect a message-sender’s the variation of roles as message-sender and message. The message-receiver also uses gaze to signal con- an important part of a comprehensive aphasia assessment. Because The pragmatic nature of communicative interaction appears role-switching typically occurs as a result of the message- in discourse in the form of verbal and nonverbal speech acts sender’s desire to relinquish the role. to nals “with a pause between clauses” or “with a rising or repair them. deficits). Nonverbal cues are usually used by partners to signal a Discourse Skills wish to maintain or change roles (Rosenfeld. and/or change of appropriate for the communication partners and not topic. repair or revise a needs to formulate a judgment concerning the message- previous speech act. Comprehension can be indicated by one or message. For example. trol in an interaction. 1994. & Sacks. The when neither partner has aphasia. inappropriate initi. The message-receiver maintains his or her role by visually orienting toward the message-sender. topical or referential identification involves searching nicative event may be altered. attempt to adhere to standards appropriate for conversations and what is judged to be sincerely wanted information. as nodding or eye gaze (Penn. information is shared by the various message-receivers. the message-receiver must also monitor and within the turn in which the communication breakdown has evaluate the message and provide feedback concerning the transpired. The most common form of repair in normal interac- rather than gaze avoidance (Davis. To assist the mes. relevant. 1987). persons with apha. and wanted or already known by the with aphasia participating in conversation (Lesser & Milroy. it achieve a mutual communication goal. or terminate a topic. relying primarily upon the use of nonverbal behaviors such sia have been reported to be relatively good at being sensi.. or both. 1988. (b) the messages being shared are results in a mutually satisfying interaction. Discourse regulatory devices such as requests for a combination of the following: nonverbal responses (e. 1992). Schienberg & Holland. When one of the truthful. Jefferson. (c) the vocabulary used is relevant to the topic and is communication partners has aphasia the nature of the turn cohesively related. (Penn. receiver in order to serve the pragmatic function of sustain. often Patterson & Fahey. tive to their partners’ interests and previous knowledge 1980). Prutting & Kirchner.GRBQ344-3513G-C04[64-160]. the message-receiver that initiate or maintain a topic. falling pitch at the end of a phonemic clause” (Davis. introduction. Grice (1975) proposed may be accompanied by overloudness and a shift of the head that successful discourse is achieved when (a) the message. Maintenance and turn-taking must be includes topic selection.” and visual orientation 1977).qxd 1/21/08 11:20 AM Page 117 Aptara Inc.g. When the linguistic impairments of patients with aphasia may limit a message-sender wants a reaction or response. examining patients’ abilities to com. 1978). 171). interesting. although the one’s long-term memory for information that is judged to be pause time in turn-taking may be lengthened for a person relevant. 1998. partner. however. through a phonetic clause juncture (Rosenfeld. quently used when communicating with patients with apha- ture that is not maintained or not returned to a resting state sia (Ferguson. sensitivity to a message-receiver’s state of comprehension. shift topic. Milroy & Perkins. with the partner who does not have aphasia shared is concise and avoids ambivalence and obscurity. sia continue to display appropriate turn-taking skills. the turn may be successful. effectiveness and acceptability of the communication Because of the well-documented difficulties persons with exchange. tions is the self-initiated self-repair. & Auther. message-sender therefore needs to determine what. Chapter 4 ■ Assessment of Language Disorders in Adults 117 pragmatic limitations. away from the speaker. 1981). clarification are essential to the maintenance of communica- nodding the head. Repair and revision are an integral part of discourse Maintenance of communication involves turn-taking or maintenance and regulation. their ability to identify communication breakdowns. 1993. Moves by both communication partners identify communi- ing the communicative exchange. 1981. the overall commu- Thus. Furthermore. not Successful maintenance of turn and turn-taking behavior too much and not too little). and it typically occurs sage-sender. 1983. municate and comprehend various speech acts or intents is p. most patients with apha- ation has been observed (Avent. 1978).e. interactions between the person with aphasia and his or her family. sively to correct conversational errors. the Revised Edinburgh Functional story or procedure. since this level of communication interac- Individuals with aphasia have been shown to demonstrate tion illuminates “the complex associations across linguistic. 1987). For example. or both.. 118 Section I ■ Basic Considerations retain the ability to initiate and make repairs (Klippi. For example. Tools for fewer complete episodes and more missing episodes are pragmatic analysis. episodes and procedural steps. 1988) can be In summary. must be elaborated on or communicated in a logical the presence and appropriateness of various pragmatic order (Ulatowska. and between the person with aphasia and the clini. (1983a. individual’s linguistic. 1983) in order to ensure sat. 1998. This strategy can govern social interaction in a language and culture. 1992. & Liles. analysis. Assessing Pragmatic Skills and cian (Lindsay & Wilkinson. 2000. even if these errors Lyon. Manochiopinig. For pragmatic strengths in terms of their ability to communicate example. 2002). a variety of difficulties in maintaining communication inter. have not obscured the meaning of the patient’s message 1995). For example. & Maxim. Typically these observations are based upon dis- isfactory exchange of information. 1998. pragmatic. the partner may. course samples. Table Maintenance of communication interaction may also 4–16 lists a variety of tests and observational profiles that can involve a response that sustains a topic. functional communi- tingent utterance shares the same topic as the preceding cation skills. They have also been found to pro. The type of repair used varies in text in many communicative exchanges. & Thompson. Sheard. 1991). Both reflect the summation of an clinician.GRBQ344-3513G-C04[64-160]. the Communication Profile (Gurland & that were conveyed were those considered essential to the Gerber. although patients with aphasia show many used to rate a patient’s use of specific pragmatic skills. sequential organization of topics is also a compo- Pragmatics nent of communication maintenance (Beeke. Doyel et al. respec. in procedural and narrative dis.to 10-minute duce somewhat lengthy and digressive or tangential discourse samples of patients when these behaviors occurred responses (Penn. and included some inaccurate Tools such as the Pragmatic Protocol (Prutting & information. use repairs exces- assessment approaches (Elman & Bernstein-Ellis. tional profiles or checklists in which the clinician identifies tively. appropriateness of 30 pragmatic parameters covering a . and in various contexts and with various partners. Although assessing pragmatic abilities and assessing func- some types of repair can be detrimental to communication tional communication skills are often viewed as one and the interactions. 2003). Boles and Bombard (1998) found that such (Ulatowska et al. Thus. in a good faith same. However. the clinician can use approximately 15 minutes of successfully in discourse activities. 1990). Wilkinson. a con- be used to examine pragmatic abilities. 2001). Boles & Bombard. 1988). 1999). (Armstrong. Furthermore. In terms of sequential organization. they also noted that those episodes and steps Kirchner. and the Profile and events were presented in the correct sequence. utterance and adds information to the prior communication act. p. partner to complete the Pragmatic Protocol and to rate the ciency and success of their discourse interactions. Pragmatic abilities are primarily assessed using observa- course. of Communicative Appropriateness (Penn. 1996) Consequently. and conversational analysis.qxd 1/21/08 11:20 AM Page 118 Aptara Inc. Although Ulatowska et al. mation in the assessment process and should be included Duffy. Worral. Functional Communication course activity (Heeschen & Schegloff. Murray. tions” (Chapman. 1999). Holland & 1983b) found that patients with aphasia omitted story Hinckley.. behaviors. and cognitive processes as well as the potential actions. and cognitive skills. This is partic- may be accomplished collaboratively rather than solely by ularly important given the highly individualized role of con- one partner (Laasko.. Highley. most of these episodes Communication Profile (Wirz et al. there are some notable distinctions between the two attempt to help the patient with aphasia. such as direct observation. at a rate of approximately three times per minute. 56). Pragmatic skills encompass the use of the rules that (Booth & Perkins. offer important infor- pared to responses of non-brain-damaged adults (Uryase. & Reed. 1999. behaviors could be reliably analyzed with 5. and among types of dis. a sufficient number of steps and episodes. 1982). 1999. patients with more severe language impairments use fewer Although some clinicians and payors view such analysis as contingent utterances than do non-brain-damaged adults time-consuming. 1992). Although patients with mild aphasia frequently dissociations (of) either across or within clinical popula- demonstrate appropriate discourse maintenance skills. 2000. pragmatic. while foster the perception that the patient with aphasia is not a functional communication refers to the ability to operate competent partner as well as change the interactional roles and interact in real-life situations in response to specific from that of partners to that of a student-teacher or patient- communicative demands. they may also display a conversation between the patient with aphasia and a familiar variety of impairments that may negatively affect the effi. 1998). assessment in adult aphasia involves an analy- this process typically takes longer to resolve than during sis of the patient’s ability to initiate and maintain discourse interactions among non-brain-damaged individuals. discourse observed in story retellings by patients with aphasia com. and paralinguistic domains. (1990) Social Networks: A Communication Inventory For Blackstone & Berg (2003) Individuals With Complex Communication Needs And Their Communication Partners The Communication Profile: A Functional Skills Survey Payne (1994) The Speech Questionnaire Lincoln (1982) range of speech acts (e. comments) and dis.g. topic maintenance. 1999) is probably Such assessment tools clearly provide information that is not the best known. (1999) Functional Communication Therapy Planner Worral (1999) The Amsterdam-Nijmegan Everyday Language Test Blomert et al.e. Evaluation of communicative success is based on both verbal 2000. Penn. (1982) Communicative Competence Evaluation Instrument Houghton et al. 50 ..GRBQ344-3513G-C04[64-160].. and observa- inappropriate pragmatic behaviors (i. These results are interpreted tured communication interactions. (1994) The ‘dice’ game McDonald & Pearce (1995) Rating Scales and Inventories A Questionnaire for Surveying Personal and Swindell et al. Hux et al. nonverbal. 1991. (1989) Communicative Profiling System Simmons-Mackie & Damico (1996) Everyday Communicative Needs Assessment Worrall (1992) Functional Communication Profile Klein (1994) Functional Communication Profile Sarno (1969) Functional Outcome Questionnaire for Aphasia Glueckauf et al. calculates a percent. based on unstructured or moderately struc- age of appropriate behaviors). Ball et al. (1982) Communicative Effectiveness Index Lomas et al. Manochiopinig et and nonverbal responses. Of the structured tests with respect to the number of pragmatic behaviors for which available (see Table 4–16). Daily Living-2 (CADL-2.e.. & Walshaw. 1997. (1995) Skills For Adults (ASHA FACS) Assessment Protocol of Pragmatic-Linguistic Skills Gerber & Gurland (1989) Communication Profile Gurland et al. The CADL-2 differs from the ear- al. recognize and produce a variety of speech acts and interac- some of the pragmatic tools may have specific psychometric tions across both spoken and written language modalities. repair/revision skills) across verbal. However.. (2000) Pragmatic Protocol Prutting & Kirchner (1987) Profile of Communicative Appropriateness Penn (1988) Revised Edinburgh Functional Communication Profile Wirz et al..qxd 1/21/08 11:20 AM Page 119 Aptara Inc. (2003) Inpatient Functional Communication Interview O’Halloran et al. Chapter 4 ■ Assessment of Language Disorders in Adults 119 TABLE 4–16 Tests of Pragmatic and Functional Language Abilities Instruments Source Structured Tests Assessment of Language-Related Functional Abilities Baines et al. 1992... ine functional communication skills: structured tests. 1999). the Communication Activities of there was no opportunity to observe in the language sample. The CADL-2 examines a patient’s ability to obtained from more traditional standardized tests. Functional Communication course abilities (e. requests. Generally two methodologic approaches are used to exam- When the clinician summarizes Pragmatic Protocol results. 1999. (1982) Communicative Style ASHA Functional Assessment of Communication Frattali et al.. (2004) LaTrobe Communication Questionnaire Douglas et al. lier version of the CADL in that it is slightly shorter (i. tional profiles. Perkins.g. (1999) Communication Activities of Daily Living-2 Holland et al. in he or she compares the overall number of appropriate and which performance of test items is evaluated. limitations and should be used with caution (Armstrong. Crisp. Holland et al. .... research is needed to determine whether they the assessment of functional communication abilities possess the following attributes: “sensitivity to change over (Worrall et al. the developed by Simmons-Mackie and Damico (1996). The Communicative Profiling System. including an interview. 1995a) and others were created anew munication skills for all patients with aphasia and other with respect to a theoretic model (O’Halloran et al... and within an expanding circle of family. it is built upon the writing. func- extensive standardization and has good reliability and validity. employment history. and Interview (O’Halloran et al. They sug- items that take about 35 minutes to complete). Skills for Adults (ASHA FACS. living aphasia. The normative sample for this sures were only related in patients in the acute stage of instrument includes patients of varying ethnicity. some of which are widely available rounded assessment. 1981). Frattali et al.g. and number concepts (e.. but may oversimplify the real-life communication needs of Strengths of standardized tests of functional communi.. speech acts tests have been criticized because of the restricted view of for social greeting). her natural environment and with his or her daily commu- 1989). They reported that severity of language rates the relative importance of 26 communication behaviors impairment was related to severity of functional communi- in his or her daily life related to his or her basic. “follows a map”). They proposed that three types of cation include their documented reliability and their use in functional communication should be considered in assess- noting change over time. Communicative Needs Assessment (Worrall. present cation and pragmatic performance.. suffi- (ICF. and Avent (2002) compared results of mea- eral of the other observational profiles.g. Worrall (1995. (2002) reviewed several measures cient range of performance measured to prevent threshold of functional communication and observed patients with effects. individuals with aphasia. and a measure of pragmatic abilities Communication Profile: A Functional Skills Survey. It is unlikely. not the chronic stage. tional communication (Rating of Functional Performance. 2004). 1987) over the protocol uses an interview approach in which the patient course of a year. and those that will be created in rely on the results of a single test or observational profile for the future. Prutting & Kirchner. and the Inpatient Functional Communication ing the conversational abilities of patients with aphasia. and frequently used and others that are available only in It is likely that the number of tools for assessing func- research papers. “responds in an emergency”). and daily planning (e. For many of the Several researchers propose that clinicians should not tools developed recently. Worrall et al. 1999). 1989. Manochiopinig et al. 1992) and an individual). lar and also represents a multi-method approach to examin- 1994). . and unfamiliar partners.. utility of using multiple tools on multiple assessment dates and is therefore culturally sensitive. 2003) examines functional communica- ities across four domains: social communication (e. usefulness across different methods of administration. signs”). is simi- Communication Profile: A Functional Skills Survey (Payne. Irwin. and includes the Functional Communication Profile (Sarno.g. of basic needs (e. This work highlights the accommodations. tion within the structure of an individual’s communication “exchanges information on the telephone”). (b) population-specific (e..g. Penn.g. and does not gested that the ICF is a valuable model to guide assessment include role-playing items. concept of functional communication is too complex for a suming than completing a rating protocol (Crockford & single test administration” and developed the Everyday Lesser. 53) suggested that “the because administering one of these tests is more time-con. Wertz. and (c) individualized (particular needs of (Lomas et al. (Blackstone & Berg. Social Network Theory ability to complete a variety of everyday communication activ. that Some follow previously published methods of analysis (e. many methods of conversational tional communication will increase and become ever more analysis have been published (Armstrong.GRBQ344-3513G-C04[64-160]. this test has undergone sures of language impairment (PICA.g. This (Pragmatic Protocol. Also. for individ- the manner in which patients with aphasia spontaneously uals with a specific impairment or communicating within a interact in real-life functional communication situations specific setting). Several other ratings to assess different aspects of aphasia to obtain a well- scales have been created. any one tool will adequately measure the functional com- Nicholas & Brookshire. sophisticated (Hartley.. 120 Section I ■ Basic Considerations items that take about 25 minutes to complete versus 68 aphasia in functional communication situations.. p. This A number of observational profiles and rating protocols are contains a series of tasks. communication needs and abilities. Communicative Effectiveness Index (Lomas et al. 1995). neurogenic communication disorders. reliability within and across raters. 1995). 2002). Another notable rating scale is Payne’s (1994) Wertz et al. 1981). and income levels. However. ASHA Functional Assessment of Communication nicative partners. acquaintances. and over time. to evaluate available to examine the functional communication abilities of a patient’s communicative needs (Table 4–17). Porch. this approach and these ment of persons with aphasia: (a) generic (e. reading.qxd 1/21/08 11:20 AM Page 120 Aptara Inc. The ASHA FACS has the way these skills are influenced by daily communication both qualitative and quantitative scales for scoring a patient’s partners and environments. 1994). 2000. 2001). observations and ratings of the patient’s interactions in his or 1969).. This group of measures naire to assess the individual’s social-support system. however. a question- patients with aphasia (see Table 4–16). Within the context of the WHO ICF time. but the latter two mea- health-care and social needs.g. “understands simple model of communication as joint interaction.. Unlike sev. 2004). 1992). Social Security. expectations. body image. Muller (Eds. The ICF is 3. Considering the trend for health care to focus on other QOL scales were difficult for some persons with functional outcomes and measures. Hilari et al. Stroke-Specific Quality of Life Scale (SS-QOL) (Williams evance to function outside the clinical setting” (Frattali. sought to determine which aspects of communication — following written instruction re DIY jobs (e..). The SAQOL measures QOL in four subdomains: physical. social relationships and their relation- — reading literature (e. Several researchers and 4. J. functional com- — caring for pets munication was a contributor to positive QOL. Oelshlaeger. plumber) Cruice and colleagues (2003). QOL is 1. Veterans Affairs.GRBQ344-3513G-C04[64-160]. CA: Singular Publishing. Chapter 4 ■ Assessment of Language Disorders in Adults 121 TABLE 4–17 Goal 9: Analysis of Quality of Life in Persons with Aphasia Example of an Interview Guide. 1999) in part because they believed the SS-QOL and 1992).g. 2001. Reprinted with permission. Using the Phone cation.g.. 2002. 2003. (1995). communi- 2. & Damico..”(WHOQOL: Medicare) Measuring Quality of Life.. meter-reader) work. Social Security/Veterans Affairs) — filling in forms (e.g. 2005). using the ICF as a frame- — dealing with people who come to door (e. et al. They pro- — following instructions for use of gardening products posed the communication-related QOL (CRQOL) model — gardening as an enhanced version of QOL that incorporated functional Coding for reasons: communication. The CRQOL (Cruice et al. 47–69). Code with aphasia. Finances defined as “an individual’s perception of their position in life — checking and paying bills in the context of the culture and value systems in which they — writing checks live and in relation to their goals. Rolnick & — using Yellow Pages Hoops. — setting washing machine — directing workmen (e.) persons with aphasia is the Stroke and Aphasia Quality of Life Scale (SAQOL and SAQOL-39) (Hilari & Byng. San Another QOL assessment measure designed for use with Diego.qxd 1/21/08 11:20 AM Page 121 Aptara Inc. 2005). of our highest priorities. LaPointe. & D. It is a broad ranging concept affected in a — balancing accounts/budgeting complex way by the person’s physical health..) QOL has several dimen- — using an automatic teller machine sions. One Aspect of Worrall's (1992) Everyday Communicative Quality of life. The functional communication perspective. aphasia may be associated with the ICF levels as well as personal and 3. General Household Activities clinicians support the use of the WHO ICF in assessment of — following washing and ironing instructions on clothes QOL (e. In C. to emotional and psychosocial well-being.g. QOL is a perceptual — making choices at mealtimes rating that presents an individual’s subjective opinions about — using the microwave and oven his or her status or position in life.. 1997.g. home help. Preparing Food intended to be used to report observations of an individual’s — reading labels on food packets behavior.g. yet there are points of dis- — following instruction leaflets for household appliances agreement (Worral & Cruice. Madden. Ross & Wertz. The treatment of aphasia: From theory to practice (pp. They reported that in addition — writing note for milkman.. psychological — organizing payment of rent/mortgage state. immobility describes the language and communication behaviors that 2. this task should be one aphasia to use given the linguistic requirements of the scales. emotional and social environment. standards — reading bank statements and concerns.. 4. and his or her satisfaction with their physical. 2003) 1. and interpersonal issues (Code. — looking up numbers in phone book 1996. etc. and as the — reading sell by/use by dates and calculating food freshness assessment progresses the behaviors should be prioritized as — following recipes to importance in an individual’s life. ship to salient features of their environment. including physical problems. — dialing emergency numbers Threats (2005) described the complex interrelationship — writing down phone messages between QOL and ICF. The authors adapted this scale from the usefulness during different phases of rehabilitation and rel. shelves) predicted participants’ QOL.. 1969) and is typically measured with a self-report. other and can be used as a guide when assessing QOL in persons (From Worrall. including the perspective of the person being eval- — measuring ingredients uated. personal beliefs. (QOL) is related to an individual’s activity Needs Assessment and participation in society. Both instruments were developed — making appointments/business calls by the World Health Organization and show overlap in their — making social calls perspectives yet serve different purposes. 2003). ICF measures list behaviors in categories. L. other stroke-related problems environmental factors that may influence communication. . given the individual psychosocial domains.. it supports the need to examine psychosocial factors as patient and his or her family. (2000) found measures: WHOQOL Instrument (WHOQOL. cognitive. torial and a written version of the Aachen Life Quality there is no current single meausre that will best capture Inventory... in responding across aspects of the survey tools they used. This inconsis- Reponses to a series of questions in several domains provide tency is related both to conditions surrounding the assess- a clinician with an expansive picture of the effect of stroke ment process (e.. 1999). Quality of Life Scale (ASHA CQL) (Paul et al. and energy. ties of their significant other with aphasia. ities of caring for a person with aphasia and by the compro- social relationships.. In addi- QOL can also be examined in terms of burden on a tion. finding one best instrument for all (e. mise to communicative interactions. disagreement between rating of patients and of family mem- WHOQOL-BREF (World Health Organization Quality of bers. This tool examines communica- vides information about the psychosocial. and measures of QOL (such as the CRQOL. but requires additional investigation for well as the person with a communication disorder is the successful use in assessment. (2003) developed a questionnaire Life – BREF. These measures were selected to be con. Cruice and called for the development of measures that are accessi. 1997). the importance or down to indicate opinion) for both the stimulus items and of measuring QOL does not diminish the importance of responses.. (2003). with aphasia and their families. Finally. It was reported to measure developed for completion by a family member as be reliable and valid. length of questionnaire or method of on a patient. 2004). perspectives of the patient and his or her family members. and the Psychosocial Well-Being Index designed to assess functional outcome of treatment in per- (Lyon et al. and tive behaviors in several conversational domains from the educational effects of a having a communication impairment. such as comprehen. Another example of a QOL ment tools to individuals with chronic aphasia.. (2006) examined burden from the point of emotional influence or clarity of observation). et al. as reported by the patient. The effort to view of communication between a person with aphasia and refine instruments and procedures for assessment of QOL his or her communication partner. Two were . 2000). the Communication LaTrobe Communication Questionnaire (Douglas. 2004) developed the Burden of Stroke The literature is inconsistent in reporting the reliability Scale to quantify physical. person on a bench to indicate loneliness. al. and thumb up patients may be an unrealistic goal. and environment—were best at distin. sons with aphasia. (2003) reported success with this assessing impairment-based functions. and that factors such as amount of functional communica- tion evinced by the patient influenced the degree of shift. Holland et al. 2003. and. particularly those with severe aphasia 2003).qxd 1/21/08 11:20 AM Page 122 Aptara Inc. themselves and proxy respondents. & Snow. Relationship among QOL and ICF Impairment and Activity-Based Measures QOL Reported by Family Members A question of interest to clinicians is the degree of relation- Cruice and colleagues (2005) examined the relationship ship of communication disorder among measures of lan- between responses about patients’ QOL from the patients guage impairment (such as word-retrieval assessments). as reported by caregivers.. guishing QOL in persons with and without aphasia.g. viduals with aphasia.GRBQ344-3513G-C04[64-160]. Linebaugh et al. Second. O’Flaherty. analysis in the study) as well as observer characteristics (e. Cruice et al. and the pictorial version used icons variation in patients. They reported that com. by proxy report continues to be of importance. Ross & Wertz (2003) compared responses on three QOL Similar to Cruice et al. which is caused by the daily responsibil- Wertz found that three domains—level of independence. 2003). material or verbally respond in connected speech.. 122 Section I ■ Basic Considerations psychosocial. These results high- frequently have heavy reliance on linguistic skills in order light the importance of creatively measuring QOL in indi- for an individual to complete the measure (Cruice et al. communication. Similar to other studies. The tool examined responses in the physical and QOL for all patients with aphasia. instrument in measuring QOL. They Engell and colleagues (2003) examined responses from empahized two considerations that should guide measure. First. with or without a communication disorder. devised an iconic tool to assess QOL in who likely may be unable to comprehend complex written individuals with aphasia to avoid this problem. although a munication burden was indeed reapportioned between a single instrument is unlikely to be effective for all patients person with aphasia and his or her communication partner. they found differences between the ratings of patients and One difficulty associated with QOL measures is that they family members for many of the items.g. They discovered biases measure of activity (such as the CADL-2. Doyle et al. Engell et al. 1997). sion and producion of language form and content. Glueckauf et al.g. and psychological and accuracy of informants’ rating of communication abili- aspects of the burden of stroke. Ross and by caregiver strain. persons with aphasia and their family members using a pic- ment of QOL in persons with aphasia in the future. Doyle and colleagues (Doyle et well as physical factors that influence QOL.. Of note with sistent with the WHO recommendation of assesing QOL this instrument is that it does not appear to be heavily biased with both general and disease-specific instruments. 1997) pro. Ross and Wertz (2002) administered six assess- ble to all patients with aphasia. vocational. Douglas et al. available sup- divided into younger and older age groups. 1990) and is one of the first gender as a prognostic indicator in language recovery. and general medical health improved QOL in persons with aphasia in the first year post. Crosson et al. 1977.. Neurosensory Center and aphasia recovery (Basso. Kertesz.. Other stud- QOL and participation in society is of ever-increasing ies report mixed findings with respect to the influence of importance as individuals adjust and accommodate to life gender on prognosis (Sarno. Tompkins. how. and morale than is chronological age” (p. Jackson. 1981). 1999. or the future would be to refine QOL measurements to capture life satisfaction . are more predictive of cognitive ability. questions usually asked by patients with aphasia. 2004. 1969). 1973). (1990) note that physiologic charac- laid out the importance of measuring QOL in persons who teristics such as activity level or general health indicators and live with aphasia. and suggests no relationship. range of test items). and ASHA FACS. pation. have failed to identify a meaningful relationship between age sures were a language-based tool.. 1997). & Hinckley. sample size) and nature of the instru. pharmacologic treatment. 1982. 1985). DiPietro. Sands.g. such as severity of quality-of-life measure. Johnson. Sarno et al. that confound the influence of age on recovery (Berthier. 399). adaptation. the graphic variables such as age and education play a minor role Functional Communication Profile (Sarno.qxd 1/21/08 11:20 AM Page 123 Aptara Inc. factor in aphasia. Comprehensive Examination for Aphasia (Spreen & Benton. other researchers have failed to observe any significant differences in the recovery of female and male Formulating prognoses for recovery from aphasia is one of patients (Ogrezeanu et al. 1996. medical variables such as etiology and duration of Ferketic et al. their care- givers.. Worrall and Holland identified areas of consensus in consid- ering QOL in persons with aphasia and areas about which Gender more information is required to creatively assess and ulti- Some studies show that gender and outcome correlate sig- mately treat QOL in individuals with aphasia. support systems. Spreen & Strauss. However. Tompkins et al. 1998). premorbid intelligence. three types of measures. (1997) reported that style. 1989).. however. Basso (1992) found better recovery of spoken language in female as opposed to male patients with aphasia but did not Goal 10: Determination of Candidacy for observe this differential recovery in auditory comprehension Prognosis in Therapy skills. age was port systems. Porch. Basso (1992) suggested that demo- 1977. future the primary tasks of the speech-language pathologist research is necessary to shed light on the exact nature of (Tompkins.. Many authors note that age and outcome correlate signifi- mental method (e. Buonaguro. Participants in this study were likely many variables such as personal attitude. and two were measures of QOL aphasia. The mea. and also suggested that the challenge in “psychosocial factors like personality.g. there are most Sarno. with aphasia (LaPointe. Worrall and Holland (2003) Indeed. George. life those elements of an individual’s life that reflect quality. Although relevant and reliable predictors Education and Premorbid Intelligence and optimal methods of measuring prognoses are still lim- ited. However. Marshall. Age ever. & ments (e. and level and type of life partici- limitation (CADL-2. Darley. site and extent of brain lesion. Holland et al. education. . In their editorial on QOL. and psychosocial goals. leagues (1994) showed such a correlation for patients Sarno (1997) examined the performance changes on three younger than 71 years of age. level and type of life participation. and a in prognosis. play a major role. 2004. 1982. 1992. & Shulz. communication. One interpretation of these Biographical Variables results is at face value. Ross and Wertz found no system- atic significant relationships. de Riesthal & Wertz. cantly (Holland & Bartlett. 1967). 1998. 1985.GRBQ344-3513G-C04[64-160]. Ross & Wertz. 2005. (1990) point out that years . Consequently. 1969). and concomitant (WHOQOL-BREF. and PICA.. Wertz et al. & Schnider. social involvement. Consequently. and Personal Wellness physical and mental-health problems. best. favoring males (Holland et al. that is. In contrast to the notion that cognitive variables such as type and severity of aphasia and individuals with aphasia might show different results on the language stimulability. Laganaro. an activity-based tool. The Functional Life Scale (Sarno. Ogrezeanu and col- communication skills to QOL deserves continued study. aphasia. learning not a factor in the results. & Levita. and family. They concluded that at Phillips. . and language and Inventory. Chapter 4 ■ Assessment of Language Disorders in Adults 123 measures of impairment (WAB. 2006). two were measures of communication-activity usual/necessary activities. whereas neurologic factors. Lyon et al. 1995). 2005). & Levita. Sarno. Ross and Wertz chose to look more closely at several factors that might have influenced results. several researchers measures in two groups of persons with aphasia.. & Shankwilder. the relationship among these levels of measurement is younger patients with aphasia typically demonstrate greater unclear but the importance of QOL and the contribution of language recovery than older patients. stroke was related to aphasia rehabilitation services that 2005. gender. Assessing nificantly. some of the prognostic indicators commonly suggested Although many clinicians use education level as a prognostic in the literature include biographical variables such as age. included language.. 1994). Tompkins et al. such as experi. 1974. Ogrezeanu et al. Reynolds.e. and the recovery pattern is often dif- ferent (Brookshire. separately and in combination. 1998). els.qxd 1/21/08 11:20 AM Page 124 Aptara Inc. between the onset of aphasia and the beginning of interven- tion the poorer the prognosis. Results of this lesions or multiple lesions have a poor prognosis (Kertesz. post-onset. 1999). 2000). clinician needs to know what medication a patient takes and Although Sands et al.. (1969) found that the longer the time the impact of each. even years.. 2003).g. 1981. dysarthria Time Since Onset and stuttering are common adverse reactions to certain anti- depressants and anticonvulsant medications (Murray & The fastest rate of recovery is typically observed during the Clark. if hospital stay. Griffin et al. even when they are small. Currently. have few medical problems tend to have a shorter length of Kertesz & McCabe. Neuropsychological and Language Variables guage recovery (Wertz et al. & the middle cerebral artery. some studies. 1994. Code Prognosis in aphasia is more positive in cases resulting from & Hermann. which can affect patient ability to complete language and do. he or she is likely recovery (Holland et al. gender. Rodriguez. For example. only Site and Extent of Lesion minimal research has examined the relation between neu- In general.. occupational category. fatigue. 1994). to experience more recovery than the patient who had an ischemic (i. & Clark. patients with larger dominant-hemisphere rocognitive status and language recovery. patients with aphasia who traumatic as opposed to vascular etiology (Basso. and cortical areas associated with language abilities. deficit in aphasia. As technology to support neural imaging morbid intellectual ability. 2005). For example. Instead. 124 Section I ■ Basic Considerations of formal education do not necessarily correspond to pre.GRBQ344-3513G-C04[64-160]. more recent research suggests that deferred treatment is not necessarily detrimental to lan. of lesion and prediction for recovery. fre. 1995). except in cases in which the patient had (Jorgensen et al. recovered well. most have been with respect to a particu- lar skill or treatment program (Purdy. 2000). 1988).. In terms of mental Etiology/Type of Stroke health. the many years following the onset of aphasia (Davis. research are mixed. Spreen & Strauss. increasingly finer- mend the use of estimates of premorbid intelligence that grained relationships may be made between site and extent weigh and enter standard demographic data including age. 1977). & Carter. O’Sullivan & Fagan. 2003). In terms of the type of stroke. speech disorders (e. Lynch & McCaffrey.. anxiety.. 1998).. Darley (1982) noted that some patients with poor prognosis these lesions result in problems in learning language as well because of the site and extent of lesion have nevertheless as in acquiring compensatory strategies. activities (Vogel. and decreased arousal lev- clinical experiences indicate that patients with aphasia can. these authors recom. For example. depression. apraxia of speech) have been shown to have a negative influence on aphasia recovery (Keenan & Medical Variables Brassell. show a positive relationship have also been identified. These researchers found that tem- quently result in severe aphasias (Hillis et al.. research and effects such as confusion. and race into reviewed by Cappa (2005) and by Hillis (2002b). many first few months post-onset when spontaneous physiologic anticonvulsant medications may produce undesirable side recovery processes are taking place. such as the studies education. because such lesions cause a disconnection between deep ery compared to lesions outside of this region (Goldenberg temporal lobe structures associated with memory abilities & Spatt. That is. Physical and Mental Health Problems 1997. such as that by 1979). 1992. thrombotic or embolic) stroke (Holland et al. Naeser & Palumbo. Powell. In addition. 1984. Carter. Tissot. These estimates of premor- The presence of other physical and mental-health problems bid functioning may have more predictive power than edu- in addition to aphasia often results in a poor prognosis cational level alone. 2006. concomitant motor- been illiterate (Lecours et al. However. Laasko. specifically developed equations (Barona. Lesions porobasal lesions are associated with poor aphasia recovery to left temporobasal areas are also associated with less recov. lesions of the central between initial neurocognitive test scores and language core of the dominant-hemisphere language area. Relations between site of lesion and aphasia outcome Goldenberg and Spatt (1994). 2000). Therefore.. Indeed. & Chastain. Certain drugs can adversely affect the ability of a person with aphasia to respond to tasks. other . clinical research Neuropsychological Variables studies frequently include participants who are many Although in recent years many studies have described the months. continue to make measurable progress for many. In contrast. Medications 1989. and many of these partici- relationship between cognitive functioning and language pants show change as a result of treatment. served by recovery (Bailey. Messerli. Likewise. 1976). 1999. 1989). That is. Thompson. 1994. and other psychological prob- lems may negatively affect outcome (Code et al. 2002). increases in accuracy and efficiency... 1987). 2002. which has also been associated with better the patient survives a hemorrhagic stroke. & language areas (Davis. disorder as well as an awareness of situations that either David & Skilbeck. 2001. as well as to prognosis in treatment in a variety of health ple. van Harskamp tion. ality variables has the potential for enriching our understand- 1992.. ers to provide cues (Freed et al. As van Harskamp and Visch-Brink (1991) proposed. & Olsen.GRBQ344-3513G-C04[64-160]. 1994. 1979). those patients for whom prompting is ineffective. prognosis compared with those who are less affected in these 1977.. 533). 2005. type of participation in everyday activities and in life may 1994. impairment. conduction. cues display better recovery of spoken language than do 2006. 2004). Tompkins and colleagues (1990) suggested that using valid and transcortical (sensory.. 1989. 1985). Chapter 4 ■ Assessment of Language Disorders in Adults 125 studies fail to observe a significant correlation between ini. 2002). Personal Attitude mance of the individual with aphasia (Keenan & Brassell. 2002). That is. More importantly. Clinicians might expect that those patients with aphasia who can learn Aphasia Characteristics to produce their own cues would have better language out- comes or demonstrate better generalization of target lan- Severity. & Kolk. Keenan and Brassell (1974) observe that aphasic patients attempting to identify those neuropsychological factors that whose spoken language is initially stimulable to prompts and may facilitate (or impede) progress in treatment (Purdy. see improvement in language and communication abilities . and determination may tory recognition and comprehension have an unfavorable influence the course and outcome of aphasia therapy (Darley. ter prognosis (Marshall & Tompkins. In contrast. to problem solve. For exam- Estabrooks. or her language behaviors can be easily modified. Despite some null findings. Pedersen. Ramsberger. 2004). and/or executive-function deficits negatively & Visch-Brink. Paolucci et al.. to morbidity and mortal- often results in a change of aphasia type over time. particularly those tion is of utmost importance: patients need to exert them- who continue to present with global aphasia beyond 3 selves to make progress” (p. Marshall & Freed. In addition. 1982. 2006. The desire of a patient with aphasia to improve his or her 1974). For example.. Ogrezeanu et al. 2001.qxd 1/21/08 11:20 AM Page 125 Aptara Inc. or mixed) aphasias fre- and reliable psychosocial scales to measure a patient’s person- quently resolve toward anomic aphasia over time (Goodglass. Type of aphasia may be predictive of the the patient’s willingness to participate actively in the learning amount of recovery and the residual pattern of language process and to practice learned skills at every opportunity. 1994. Vinter. Rosenbek. More specifically. Wertz. may also be gained from examining the degree to which his tive situations (de Riesthal & Wertz. 1995. 2000). patients with severe language impairments tend to show poorer recovery than those with milder language deficits. Robey. memory. Ogrezeanu et al. to learn to develop compensatory strate. 1990). patients with global aphasia are These researchers further stated that “the patient’s motiva- expected to have the poorest outcome. LaPointe. that is. patients who have insight into their language tial cognitive status and subsequent recovery (Basso. many patients with global aphasia eventually present conditions such as stroke (Tompkins et al. 1974. 1994). 1984). Broca’s. Marshall et al. 1958). the “kernal” of therapy is the stimulation of Language Profile. and to generalize learned behavior to new communica. Rapcsak & Rubens. plete recovery by 1 year post-onset (Kertesz. Wernicke’s. 1998). 2001. Ogrezeanu et al. The initial severity of aphasia is one of the guage behaviors than patients who are dependent upon oth- strongest predictors of outcome (Kertesz & McCabe. motor. Shuster. 1979). 1977.. Oomen. Postma. Murray & Chapey. Similarly. In contrast. Shill. initial ability to speak has been Personality/Social Variables found to share a relationship to the eventual speech perfor. For exam- ity. 1987. 2004. 2003). ing of patients’ responses to treatment and for facilitating prognoses. clinical research is ple.. the level and months post-onset (Laska et al. Insight into the prognosis for a patient with aphasia gies. 2000. research indicates that personality variables and social sup- The language improvement that most patients experience port are linked to health generally. patients who are severely impaired in audi- level of motivation. self-efficacy. A patient’s awareness of his or her speech Family Attitude difficulty as well as his or her ability to self-correct relate positively to improvements in speaking abilities (Keenan & Family interest in the patient with aphasia and their desire to Brassell. & humor in treatment (Simmons-Mackie & Schultz. Indeed. Stimulability Self-correction. many enhance or degrade their communication ability have a bet- clinicians believe that the presence of concomitant atten. affect patients’ ability to attend to and remember language. 1991). Wepman. 1998). An excel- with Broca’s aphasia as their auditory comprehension and lent example of the supportive effects of personal variables is language-production abilities recover (Holland. patients with well have a profound effect on prognosis since patients need anomic aphasia are expected to have the best outcome such something to talk about and since such participation can have that approximately half of these patients experience com- a positive effect on motivation (Chapey et al.. Helm. Swindell. Cuing. Forbes.. qxd 1/21/08 11:20 AM Page 126 Aptara Inc. it takes 1991). is married. and an exploration of amounts and types of information at different stages in the the interrelatedness of these various behaviors and variables course of aphasia (Avent. Specifically. the puz- goals are often difficult to achieve in modern times with zle pieces are gathered and subsequently assembled into the family structures that vary and in the presence of multifac. clinicians through the process of assessment and treatment and is from a functional rather than dysfunctional family. and eted. an identification of influential bio- others with aphasia is education. increase the family’s knowledge about stroke care. and despite the best intentions. For example. (2005). Murray & Clark (2006). and participation. 2000). have . Families with an adequate amount and Within the context of the WHO ICF (ICF. and pattern of behaviors Paramount in helping families support their significant produced by the patient. maximize any treatment gains. Tompkins and colleagues (Tompkins et al. from theoretic bases: Hillis (2002a). viewed from several perspectives. Wells. For all three WHO ICF levels.. van Harskamp & Visch-Brink. areas are the focus of both assessment and intervention from cussed above consistently determines a patient’s progress the onset of a clinician’s acquaintance with a patient and and success in therapy. It is an resources to facilitate statements concerning prognosis.GRBQ344-3513G-C04[64-160]. (1991) found that a patient does retic model that underlies the communication deficit or the significantly better when the primary support person is not approach to treatment. 1987) also stress the importance of developing more phase of assessment involves a sophisticated clinical judg- reliable and valid measures of social networks and support ment that is applied to the information collected. poses that making the transition from assessment to inter. The “assembly” 1990. she stated multidimensional process that often requires a succession of that “success in solving puzzles seems to require that we treatment techniques and methods (Duchan & Black. and to learn to live with aphasia assessment target the three components of body structure within a productive family network. Siegert and Taylor (2004) suggested that of Intervention Goals recognition of theories of goals and motivation should be In an excellent chapter entitled “From Assessment to part of the rehabilitation planning process in an effort to Intervention: Problems and Solutions. comprehension and spoken-language production since these . The social model of therapy can be used in tion or postponement of intervention. each considers the transition from assessment to perhaps through participation in activities and in life treatment as a dynamic process that is driven by a theoretic (Chapey et al. 1995. any language deficit. a committed support network is needed solved unless it fits together and works” (p.. 2001. one of which is the theo- stroke progress. Each of have a collective effect on rehabilitation outcome and that these books is written from a different theoretic perspective. 2000). the usual focus of treatment is on auditory time and effort to identify and discard the wrong pieces. aphasia therapy. and model and by data. There is no to help the patient’s treatment attendance as well as to one solution to the assessment-intervention puzzle. Families need differing graphic. is knowledgeable about stroke care. 2005. evaluation of the type. but in addition must assist a person struct a positive support network for treatment. 1997. The puzzle is not really tion. If a patient with aphasia in progressing toward his or her life goals seems to have reached a performance plateau.. Four recently published books guide depressed. Patterson & Wells. activities. 2005). 2001). 2001. fit together and operate as a whole. and social variables. perhaps (Duchan & Black. busy lives. 2005. 2001). 160). conjunction with other treatment models as it is intended to relate to the beliefs and attitudes of the clinician and foster a positive rehabilitation environment between the clinician Goal 11: Specification and Prioritization and the patient. Avent et al. Indeed. Indeed. puzzle frame during attempts to organize. These authors suggest that caregiver-related problems can Nadeau et al. however. 1999). systematize. These During the data-collection phase of assessment. only the correct pieces” (p. both type of information will be better able to support assessment the data-collection and hypothesis-formation phases of and treatment activities. Payne. . that the assessment process may be lengthy as “. treatment should therefore reduce caregiver depression. Evans et al. Hindenlang. Treatment goals should be created to address Clinicians and families should work cooperatively to con. Purdy & to specify and prioritize intervention goals. and function. frequency. et al. all three In summary. . . and Whitworth et al. the should not be viewed merely as carryover goals (Chapey optimal recovery environment may not be easily created. Byng and Duchan (2005) discussed changing an element of treatment for a trial period would be the social model of disability and how it might apply to appropriate before a final decision is reached about termina. However. medical. 2003. variability is the norm. minimize family dysfunction.” Snyder (1983) pro. (2000). .. aphasia treatment is a vention is like trying to solve a puzzle. particu- encourage the patient’s use of treated language behaviors in larly when working with patients with aphasia for whom his or her daily environment (Blackstone & Berg. 160). Snyder also noted Murray & Chapey. 126 Section I ■ Basic Considerations will also contribute to a determination of candidacy for Further we need to be able to conceptualize how the pieces treatment and influence the progress made during interven. The transition from assessment to treatment must be in an article assessing factors that predict optimal post. condense the data in a meaningful way. it should be noted that no one factor dis. patient with aphasia. the main objective of treatment tory stimuli. 1972. that they can participate in their daily personal. 2000. This viewpoint Additional research is expanding the goals to which this also acknowledges that patients with aphasia and their care- technique may be applied. for each of his or her patients with aphasia. emphasis is to participate in activities and in life. an eclectic.). are selected on the basis of vocational activities to the fullest extent to which they are assessment results that show communicative behaviors that capable. is the patient with aphasia can already produce either consis. two or perhaps three of these approaches may be used (Byng ing: accuracy. multidimensional approach involving begins to experience difficulty in one or more of the follow. 1994. Chapey. the clinician in real life (Chapey et al. retrieval of disrupted language processes rather than the fied to determine behaviors that might be used as a base on relearning of highly specific language responses. Although a typical session may integrate on what is most appropriate for a specific patient’s language cognitive. Murray Murray & Chapey. the competence. of functional language. the largest number of approaches and the most ment (Murray & Chapey 2001). and in establishing an individualized regimen generalization to untrained items that were less complex. ing the area that is most in need of intervention (Chapey et emphasizes that the recovery process is a reorganization and al. ulated to produce. too much attention to the formal linguistic aspects of lan. the objective is to enable patients with mize initial success (Chapey. the clini. That is. In many ment may be initiated at the level at which the patient just instances. of activities. Simmons- ple. developed (e. Specific which to build more functional and more complex responses examples of various approaches to aphasia treatment are (Chapey.g. behaviors that he or she can be stim- for most people. 2000). then. and efficiency of behavior (Brookshire. patient responds more accurately to visual rather than audi. Brink. and Goals and strategies. recognition of two. and specific tasks and stimuli are chosen so that ments. Nadeau et al.qxd 1/21/08 11:20 AM Page 127 Aptara Inc. treat. descriptions of the patient’s language and life and determin. behaviors (e. and pragmatic goals. 1994. Chapter 4 ■ Assessment of Language Disorders in Adults 127 are the most essential components of daily communication tently or inconsistently. patient’s daily needs and activities (Chapey. This concept. social. This viewpoint recognizes the & Chapey. Holland & Thompson. Regardless of the lan. Indeed. during assessment. linguistic. promptness. or responds more quickly and accurately when is to increase a patient’s success in using language and related using gestures rather than speech. they can be used in combi. Reading and writing may be used to facili.g. For exam. 1976. the clinician may note that the Mackie. 2000). in the activities area.to three-word familiar phrases and com- guage in everyday communication activities and environ. and vocational activity accurate responses should be defined so that they may be limitations and participation restrictions that may accom- used during therapy (Murray & Chapey. then. 2001). Regardless of approach. consequently.. and of life par. In addition to setting target responses. emotional. first suggested by Schuell et al. A task hierarchy is then primarily focused on improving comprehension and pro.. recognition of familiar one-word utter- duction of meaning and informational content by the ances. who ment of the clinician in using existing knowledge and appro- showed that training complex items in treatment facilitated priate tools. the facilitation of and communication deficits. van Harskamp & Visch- may begin with and build on the patient’s strengths to opti. guage may impede the communicative act (van Harskamp & The actual type of treatment that is selected will depend Visch-Brink. 1990. 1994). presented in subsequent chapters of this text. ticipation should be viewed as the core of language treat. behaviors at the point where he or she tate or to cue listening and speaking skills but may not typi. Patterns of strengths and weaknesses are identi. or communicative behaviors and cally be the central focus of therapy. to increase the productive use of cognitive. givers and families may present with a variety of difficulties. 2001). (1955).. linguistic. and the judg- been suggested by Kiran and Thompson (2003). once the persons with aphasia’s possible. but also the social. so nation with weaknesses” (p. the stimulus vari. and that treatment must not only address language impair- ables and response conditions that facilitate increasingly ments. An alternate approach to treatment has importance of the expertise. begins to have difficulty. widely accepted approaches to aphasia therapy can be Specific treatment goals are formulated by analyzing described as stimulation approaches (Duffy & Coelho. recognition of less familiar one-word utterances. 1994. et al. Language forms become the focus of therapy only they are simple enough to ensure success and yet complex when they are needed to increase the meaning of language enough to stimulate learning. 1994). and .. guage and communication impairments as best they can. and so that they pertain to the and the functions for which language can be used.. gestures) to exchange information cian can capitalize upon this information when developing and ultimately to improve communication and participation treatment goals and activities. 138). activities that he or she values and will need on a daily basis guage modality to be targeted in treatment. responsiveness. pany these language impairments (ICF. By far. For example. In treatment. completeness.. and on improving functional use of lan. clinician’s definition of aphasia (Chapey. The objective of the rehabilitative process. and to accommodate or compensate for their lan- “strengths have been enhanced. 2001). drawing. 1998. 2001).GRBQ344-3513G-C04[64-160]. 1986. Murray & Chapey. As Rosenbek and aphasia to regain as much language and communication as colleagues (1989) note. 1991). 1986. 2001). 2001). etc. mands. 1991). 2001. and what is compatible with a meaning. 1977). limitations while living with an individual with aphasia Two challenges to the field of speech-language pathology. communication. With respect to the WHO framework (ICF. 1999. 2002). work is laudable. 2001). Consequently. 2001. government and private health-care agencies designate that the behaviors that will be produced by the patient in treatment must be Future Trends specified in writing in advance (Murray & Chapey. functional communication. Murray & Chapey. is to create a tool that is psychometrically rigorous yet can be such as lack of time within a full-time professional position. There will likely be many assessment ceptions of their quality of life. lack demonstrated psychometric rigor. Doyle. Holland & Thompson. The first challenge 2001). In addition. 2001). and reliable and modifi. accurate. and pressure for accountability ously. selves to efficient use in a clinical setting. (Warren. many tools are well-constructed yet do not lend them- brought about by public and insurance funding of habilita. John will name three kinds of fruit.” We still have a great deal to learn about assessment. constraints of the practice setting (e. easily used in a clinical environment. Simmons-Mackie & Damico.g. As discussed previ- funding for development. 1992. in-depth. Frattali. Clinicians should consider the needs of the patient. home care) and consequences to the patient and to the . Consequently. Goda. and to related fields of study such as cognitive neuropsy- Developing and field-testing an assessment measure is a chology. 128 Section I ■ Basic Considerations pragmatic skills in spontaneous communication. there is a need for further development of It is clear that future development of assessment instruments tools to assess activity and participation-level abilities and must include several perspectives of an individual’s commu- restrictions among patients with aphasia. quality-of-life measurements for an important. in this direction are studies that correlate behavior from dif- ability” comes from the words “to account” and means “to ferent tools in an attempt to find the best predictor of behav- furnish a justifying analysis or explanation” (Webster’s New ior that is also most efficient (e. munication deficits.GRBQ344-3513G-C04[64-160]. surface-structure behaviors that can be pre- able. 1996. However. although theoretically Tools to Reflect Different Perspectives well-founded. nication needs: ICF levels of impairment and activity/partic- ment and continued development of tools to evaluate the ipation. 1998. We can This leads to what Frattali (1992) called a deficit-oriented begin this journey by developing more assessment tools approach to intervention. and cognitive deficits underlying com- patterns and needs of these individuals as well as their per. Several factors present obstacles to test development. Simmons-Mackie. and the degree of their role tools developed in the coming years (Worrall et al. 1992) new tests and protocols should include assessment of the to treatment rather than targeting functional communica- activity and participation levels as well. and highly structured. the dicted in advance and that primarily reflect short-term out- majority of existing assessment tools focus on examining the comes (Chapey. moderately target specific language modalities that are discrete. Many of these instruments.” which does criteria when evaluating and selecting tools for use in assess- not foster meaningful. and coding systems for evaluating behav. assessment and intervention dardized and nonstandardized. such of Communication Needs as that obtained from validity and reliability studies. measurable. unstructured.qxd 1/21/08 11:20 AM Page 128 Aptara Inc.. or reflect ment. 1999). present themselves to persons who accept the chal- resource-intensive task (Chapey.. Development and use of these tools should take individual with aphasia and for his or her family members into account the psychosocial status and communication and /or caregivers. lenges of creating new assessment tools. Emphasis on economy rather than therapy effectiveness and life participation to the optimum level possible. acute-care facility or and activities and life participation. refine. Worrall et al. ticipation. protocols. and clinically relevant. and quantifying and qualifying the consequences of and their communicative interactions. 1992. be more difficult to measure via long-term outcomes but are 2001.. then. Zemva. learning. or the expected level of performance. far more important to the patient and family.g. ages a “skills approach” (Chapey. Collegiate Dictionary. Within this efficient. These tools should be stan. rion. framework of accountability. activities. the system of accountability that The second challenge is for clinicians to apply rigorous appears to have emerged is “cost accounting.. Being accountable for one’s 1995). Specifically. All of the latter may aphasia at the society participation level (Chapey et al. affects current clinical practice. this practice encour- four language modalities of aphasia at the impairment level. functional communication in multiple communica- adjustment to aphasia by family members and caregivers is tion situations. Examples of efforts tion and rehabilitation (Chapey. 2002).. 1994). 1994). Current accountability. highly structured. often involves assessing whether the patient reached crite- ior) that are psychometrically rigorous. goals are usually operationally written. (tests. Over the past decade tion within a meaningful context and/or activity. or perceptions and expectations of themselves tions. 1994. & Spencer. or rather several new aphasia measures have been developed that have than addressing changes in patients’ and caregivers’ life par- the aim of identifying personal activity abilities and limita. such as “By Development of Assessment Tools the end of this session. The term “account. That is. current definitions of language. clinicians have reported that obstacles. experience. will result in observed behavior in more depth than is often currently a database of clinical opinion that complements published possible will be important contributions to clinical practice. and. Zipolo & Kennedy. 2005). Currently most of the systematic reviews relate to A positive QOL is an important factor in a person’s life. practice guidelines from the Academy of (Chapey. clinicians. however. These data will be valu- and relating the linguistic and nonlinguistic aspects of per- able in further assessment activities for a patient and in formance. 2006. It is important to Functional Communication. Taken together. 2004). the third piece of EBP is opinions and perspec- in creative ways will further assist clinicians in conducting tives from patients and their families. or co-workers) that may interact with the patient’s Therapists: Clinical Guidelines.g. Studies that investigate the use of current assessment tools Finally. 1998). While the manner in appropriate and meaningful assessments. In addition. Many tings will be important to develop in the future. disorders.g. research studies. perceptions and actions of family. Further. and Living with Aphasia cannot provide sufficient evidence for clinical decisions. and it will able than is published (Elman. However. level of impairment are important to the assessment process. A caution- sources describe psychometric properties and how to use ary note is appropriate as there is often more evidence avail- them to evaluate a test (Shipley & McAfee. any anecdotal information and specificity during assessment. which a clinician conducts assessments may remain rela- improved tools to assess cognitive deficits that underlie tively consistent across patients. Clinicians recognize the importance to accurate Tools to Differentiate Disorders and Levels of Performance diagnosis of observing and documenting a patient’s perfor- mance across several activities. While assessment activities at the ICF reading individual research articles. viduals have published systematic reviews or meta-analyses defining language and communication only in terms of mea- of topics in neurogenic communication disorders. only a small portion of Registry of Clinical Practice Guidelines and Systematic the communication is spoken or written or heard or read Reviews. 2004. 1996). and ultimately assist in exchanged between clinicians will contribute to the shared treatment planning. high-quality research literature. Simmons-Mackie & Damico. consequently. be important for clinicians to use these sources. knowledge base.. the three pieces of evidence-based prac- tice are critical to guide future practices in assessment of Evidence-Based Practice persons with aphasia and other neurogenic communication Evidence-based practice (EBP) is a method of clinical deci. The second piece of EBP is observation from clinical practice. language and communication abilities. the Royal College of Speech Language societal factors (e. and patient values and preferences (Evidence- based practice. Perceptions of the patients and their caregivers are legiti- ment.. treatment of communication disorders rather than assess. data from an individual communication deficits will aid clinicians in understanding assessment will be patient-specific. 2001. Tools to activities across multiple patients. and language and com- in Communication Disorders.qxd 1/21/08 11:20 AM Page 129 Aptara Inc. Four surable and specific surface structures seems to miss the very examples of efforts in this direction are the published guide. 2003). Robey.. 2005). specific aspects of patients’ behavior during assessment BDAE). may prevent the use of EBP principles sources: current. 1994). sions. Systematic reviews of the various assessment tools mate outcome measures. Systematically documenting Several current tools differentiate types of aphasia (e. These activities will lead to increased sensitivity treatment planning. Several groups and indi. which is part of the American munication are like an iceberg—much of what is meant and Speech-Language-Hearing Association (The N-CEP communicated is below the surface.. 1996). clinical (Dollaghan. 1980). and collectively sharing this information. sion-making that incorporates information from three such as lack of time. Sackett et al. the measures currently used to quantify and qualify the . disagreement exists among them. the Using these resources as a starting point allows the clinician degree of participation restriction they experience (Simmons- to be efficient in finding evidence to support clinical deci. lines from the National Center for Evidence-Based Practice Meaning is the essence of language. and clinical set- better differentially diagnose aphasia as well as to describe tings. this approach to aphasia Neurologic Communication Disorders and Sciences assessment and treatment minimizes or ignores the many (Frattali et al.GRBQ344-3513G-C04[64-160]. 2005. Mackie. and future efforts aimed at refining used with different populations and in various clinical set. 1992. Chapter 4 ■ Assessment of Language Disorders in Adults 129 diagnostic outcome of using the tool (Messick. of examining functional communication skills in persons with Two primary activities contribute to efforts in the first aphasia as they communicate with family members and others piece of EBP: reading systematic reviews in topic areas and in their environment. Likewise. 2005). Therapists (Royal College of Speech and Language friends. Quality of acknowledge that any one of these three areas independently Life. and Robey (1998). core of what constitutes language and communication. The combination of information from three areas viewed as a Future efforts in assessment must continue to refine methods unit will support clinical decision-making. writing. and that differenti- insight into possible treatment candidacy and treat. constitute functional communication and contribute to 5. a traditional aphasia battery) and ties and life participation for a patient and his or nonstandardized (e. events and within the context of the WHO model of function- persons who support or inhibit communication).. and sensitive morphology. 3. are 4. and create assessment tools that have relevance to abilities should be determined because deficits in communicative functioning in a variety of clinical settings as these areas may negatively affect production of lan- well as outside clinical settings in daily communicative envi.. for both patients and their family members and nitive. Functional caregivers.. and societal-participation restrictions nicative facilitators and obstacles (e. moderately WHO ICF to assess the nature and extent of the structured (e. Pragmatic abilities across a variety of communica- municative abilities of patients with aphasia and their fami. subsequently. drawing. or social supports or hindrances). of performance.g. limitations. Following data collection. her family. and use of his or her family members will live with aphasia.. conversation).g. stimuli that vary in length. highly language impairment as well as the effect on activi- structured (e. or using an electronic the notion that it is critical to determine the effects of apha. that reflect different perspec- family). Of particular value in achieving of new knowledge. During assessment data should be obtained through as assessment activities become increasingly reported observations and direct observations. As a field.g..g. 6. An impor. daily life activities. he or she and ity. Listening.g. linguis- deliver the first-rate care that our patients with aphasia tic. and syntax) must be assessed using to changes over time. ate neurogenic communication disorders and levels ment procedures) should be specified and accom.GRBQ344-3513G-C04[64-160]. clinicians must synthesize givers. phonology. experimental protocols). 1998b). activity 10.. a patient’s language impairment. the provision of tives of communication needs.g. social aspects of living with aphasia (e. Prior to administering any test or procedure clini- important clinical research activities. gesturing.g. . reading. procedural discourse task). The integrity of cognitive and executive-function QOL. neuropsycho- logical. the principles of evidence-based practice. and familiar- When a person is diagnosed with aphasia..e.g. and pragmatic abilities. Clinicians must be committed to conveying this communication skills should be assessed to deter- message to political and fiscal policy-makers so that we can mine the interaction of a patient’s cognitive.e. as well as on the social well-being of patients and their amounts of support must be assessed. Clinicians should also engage in plished. reliable. treatments for aphasia. Finally. oping tools that are psychometrically rigorous and ity of life (e. we must cians should examine its psychometric adequacy in continue to search for a consensus of which core elements terms of reliability and validity.. as well as developing new measures. Factors that contribute to successful or unsuc- cessful communication activities should be identi- KEY POINTS fied in assessment (e. of life for the patient and his or her family or care. In particular. 130 Section I ■ Basic Considerations effects of aphasia on the societal participation of our patients and their families. sia and. evaluation should include quality of life-assessment tion should include evaluation of an individual’s cog.g. tion contexts and partners and with differing lies. and treatment goals (e. qual. clinicians aphasia and concomitant problems). and quality caregivers. speaking. 9. Comprehension and production of language content ment protocols that are thorough (and therefore measure a (i.g. which refined. guage and communication skills as well as acquisition ronments (Frattali.. A thorough assessment of language and communica.qxd 1/21/08 11:20 AM Page 130 Aptara Inc.g. life satisfaction for a patient and clinically relevant. they should encompass all levels of the may be unstructured (e.. on the com. personal-activity cific language strengths and weaknesses). and pragmatic abilities during communication in deserve. the assessment data to form hypotheses concerning 2. ing and disability. medical. the determination of the presence of communication deficits.. meaning) and language form (i.. device) must be assessed.g. The goal of assessment is typically multifold in that the nature and extent of the patient’s language and etiologic (e. complexity. linguistic. This 1. cognitive/lin.. range of performance and outcomes). alternative or augmentative communication systems tant direction in developing assessment tools is to advance (e. the identification of spe.. 7. should be able to summarize the nature and extent of guistic/pragmatic (e. this goal is the development of multi-dimensional assess. Future trends in assessment should focus on devel- and participation limitations or restrictions). commu. 8. Perseveration in aphasia.GRBQ344-3513G-C04[64-160]. Paper presented at the is 79 years old. Wade... Allchin. (2005). and justify treatment recommendations using data from 17. E. and nonstandard observa.). Washington. & Yip. (1996). 365–375. F. (e) written narrative production Austin. Wallace. ment tool in the following areas: 1029–1045. B. 32–60). E. D. and pragmatic Alexander. Aphasiology. Aphasiology. 1194. (2000). Paper presented at the Clinical Aphasiology Conference.qxd 1/21/08 11:20 AM Page 131 Aptara Inc. & Dehlin. P. & Urbani. tional tools you will purchase. its significance to listener perception of coherence.. 2. J. Neurology. Morphology: The internal will the assessment process take into consideration their structure of words. and how Allen. In L.. Clinical Aphasiology. (1986). Nishioka. & Henderson. A. be for assessing the cognitive. O. LaPointe (Ed. B. W. Scales for Cognitive Ability for Traumatic Brain Injury. New York: Churchill for a person with global aphasia and who is a resident in a Livingstone. Armstrong. M. 16(4–6).. and quality of life for a patient who was global aphasia. 143–150. 21. Rapp (Ed. modular subsystems language and communication abilities and quality of life and dysphasia. (d) oral discourse production (conversational and pro. W. W. J. rating scales in geriatric stroke patients. L. Sanibel. In B. skilled-nursing facility.. 1190– structured. Comparison of six depression tools and materials. 19(3–5). Aphasiology. Armstrong. (2001). Armstrong. A. Adamovich. (1993). list which unstructured.. Effects of a semantic based treat- guage and communication abilities of an individual who ment strategy on naming and discourse skills. or if you were working in home health care? Albert. Current perspectives in dysphasia (pp.. E. Family information needs about aphasia. Justify your selection. J. Journal of difficulties” as a result of a bedside evaluation. aphasia. complicating conditions might be expected. L. Newman & R. consult with colleagues. 277–289. 3. J. (2004). (1962). & Sandson.. Aphasia discourse analysis: The story so far. 4. (2001). moderately-structured. J. 201–204. (2005). (c) production of spoken morphosyntax 647–658. (2005). your department will specialize in serving (pp. 15(10–11). described as “mildly aphasic with reading and writing Al–Khawaja. & Badecker. provide appropriate care and companionship? Ardilla. (1995). M. highly-structured. Journal of Clinical and Experimental Neuropsychology.C. Oxford: Oxford (f) reading comprehension University Press. How to do things with words. M. D. New York: Thieme. Describe how you would measure outcome of treatment chology. 103–115. 20. S. Directions of research in cross-cultural neuropsy- 5. E. Jackson.. that you have a limited budget to purchase assessment Agrell.. Using the WHO ICF model as a guide. & Ziegler. (1986). located in an acute-care hospital or a skilled-nursing facil. Segmental and metrical encod- and why might this list differ if your department was ing in aphasia: Two case reports. Chapter 4 ■ Assessment of Language Disorders in Adults 131 ACTIVITIES FOR REFLECTION AND DISCUSSION References 1. Pretend that you have been hired to develop a speech-lan. 17. B. L. ity. . Bedside screening for aphasia: A comparison of two methods. 210–215. guage pathology department in a rehabilitation hospital. I. and review anecdotal information from your clinical Armstrong. 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In for the learning disabled (2nd ed. 299–300. C. (1999). The Naming Test. K. Cockburn. & Brink. (1999). Clark. Juaraez. (1992). (1994). 35(2). Behavioral Memory Test (RBMT-II). Development of a stroke-specific quality of life scale. Wilshire. 156–160. (2005).. Worrall. & Coslett. Yesavage. E. MacLean. England: Speechmark. Revised Edinburgh care: Scientific review. B. MI: Northern Rehabilitation Services. Journal of Wilson. Language. stroke. If you need more space.GRBQ344-3513G-C04[64-160]. What do you feel is the patient’s problem? 2. What was the patient’s handedness (before stroke or disease onset)? Right Left Ambidextrous 6. 1. such as right or left visual-field cut or cataracts? 7. What was the date of injury or of the onset of the illness (head injury. in the right ear . Does the patient wear glasses? Can the patient see well enough to read? with glasses without glasses Does the patient have any other visual problems. Who is the patient’s physician? What is the physician’s address? What is the physician’s phone number ? ( ) 5. Chapter 4 ■ Assessment of Language Disorders in Adults 153 APPENDIX 4. illness)? 3. or both ? . Thank you in advance for your time and assistance. What caused the aphasia (head injury.qxd 1/21/08 11:20 AM Page 153 Aptara Inc. If yes. left ear . stroke.1 Pre-interview or Referral Form for Collecting Family and Medical History and Status Information Information About the Respondent Name __________________________________ Date of Report Phone number___________________________ e-mail Relationship to patient ______________________________ Information About the Patient Name _________________________________ Birth place Address ________________________________ Birth date Phone Number _________________________ e-mail Dear Respondent: We are asking you the following questions to help us understand the above person. illness)? 4. and to plan assessment and treatment activities. use the back of the sheet. Does the patient have a hearing loss? Does the patient wear a hearing aid? . Please answer them as fully as possible. are there others living in the home besides the immediate family? If the patient is not living at home..GRBQ344-3513G-C04[64-160].g. If the patient is living at home. Does the patient have a history of any of the following? Onset Date and Current Status Stroke Yes No Aphasia Yes No Other communication disorder Yes No Right.qxd 1/21/08 11:20 AM Page 154 Aptara Inc. How would you describe the patient’s general health? 9. Alzheimer’s disease) Yes No Memory impairment Yes No Other neurologic disease Yes No Head injury Yes No Seizure disorder Yes No Clinical depression Yes No Psychiatric problems Yes No Alcohol abuse/problems Yes No Other substance abuse Yes No Other major illness Yes No 11. 154 Section I ■ Basic Considerations 8. who? . where does he or she live? 13. Are there relatives on the patient’s side of the family who have had a similar problem with speech and language? If so. Please list the patient’s current medications and dosages (if known): 10.or left-sided weakness Yes No Dementia (e. List members of the immediate family: Check if living in same environment Name Age Relationship Phone number as patient 12. Has the patient’s speech and language problem affected the family in any way? If so. (Answer Question 20 if appropriate. how? . when did the spouse learn English? What other languages does the spouse speak? What is the preferred language to communicate with the spouse? 21. To what extent can the patient care for himself (dress. 17. Does the patient have children or grandchildren ? Children Name City of residence Age Grandchildren 20. at what age did the patient learn English? What other languages does the patient speak? What is the preferred language in the home? 15. What (is/was) the patient’s primary occupation? Who (is/was) the patient’s employer? Is the patient presently working? Describe the patient’s work history (for example. and wash himself)? 23. What is the patient’s native language? If not English. What is the patient’s highest level of education? 16.) What is the spouse’s name? What (is/was) the spouse’s occupation? Who (is/was) the spouse’s employer? Is the spouse presently working? What is the spouse’s native language? If not English.qxd 1/21/08 11:20 AM Page 155 Aptara Inc.GRBQ344-3513G-C04[64-160]. Patient’s mother’s name Living Deceased Patient’s father’s name Living Deceased 18. Does the patient need to be taken care of at all times? If so. feed. Marital status: single widowed separated married divorced remarried 19. who performs this function? 22. kind of employment and approximate dates). Chapter 4 ■ Assessment of Language Disorders in Adults 155 14. In general. To what degree do other adults understand the patient’s communication? 29. How much does he or she talk or write now? 27. Circle those words that you feel apply to the patient’s present status. Below are words that describe a person’s personality and behavior.qxd 1/21/08 11:20 AM Page 156 Aptara Inc. Describe the patient’s ability to communicate in general and with family members. When did you first notice that the patient had difficulty talking or understanding? 26. the (spouse-patient) or (family-patient) relationship is (circle one): comfortable strained hostile indifferent . Is he or she attempting to communicate verbally? Yes No Is he or she attempting to communicate in writing? Yes No Is he or she attempting to communicate using gestures? Yes No Can he or she tell you his or her name and address? Yes No Can he or she write his or her name and address? Yes No Is his or her speech intelligible? Yes No Is his or her writing intelligible? Yes No Can he or she say short sentences? Yes No Can he or she write short sentences? Yes No Can he or she repeat or copy words? Yes No Is there automatic speech (e. 25.”)? Yes No Can he or she understand conversational speech? Yes No Can he or she read and understand the newspaper? Yes No 32.” “Thank you.” “I’m fine..g. How do you think he or she feels about his or her communication abilities? 30. happy fights often sad enthusiastic patient very friendly warm independent energetic intense moody critical dependent prefers to be alone jealous authoritarian supportive impatient shy receptive bossy at ease responsive cooperative relaxed active indifferent distractible outgoing directive tense listless cold can’t sleep affectionate even-tempered quarrelsome vigorous easily fatigued curious has temper tantrums exhibits control of emotions follows the lead of others exhibits self-help waits for recognition has many fears has few fears initiates activities walks in sleep seeks social relationships demands attention willing to try unknown stays with an activity 33.GRBQ344-3513G-C04[64-160]. What strategies have you found useful to help with the patient’s communication? 31. How much of this speech or writing does the family understand? 28. 156 Section I ■ Basic Considerations 24. “Hello. qxd 1/21/08 11:20 AM Page 157 Aptara Inc. Have you read or heard anything about aphasia/head injury/illness? If yes. Physical therapy d. what are his or her favorite programs? 37.GRBQ344-3513G-C04[64-160]. Does the patient watch TV? If so. what did you hear and where did you hear it? What has your doctor talked to you about aphasia/head injury/illness? What kind of information do you think you need about aphasia/head injury/illness? 35. What are the patient’s interests or favorite activities? Can the patient engage in these activities as he or she did before aphasia/head injury/illness? Does the patient show the same interest level in these activities? Are the patient’s favorite activities the same now or different than before the aphasia/head injury/illness? 36. Psychological counseling f. how much writing does he or she do? Did the patient like to write before the aphasia/head injury/illness? Is his or her level of writing the same now or different than it was before the aphasia/head injury/illness? 39. Has the patient been seen for: Dates Agency Address a. Other rehabilitation . Does the patient write notes or letters? If so. Does the patient read much? If so. Audiology c. Speech therapy b. Occupational therapy e. Chapter 4 ■ Assessment of Language Disorders in Adults 157 34. what type of reading material does he or she enjoy? Did the patient like to read before the aphasia/head injury/illness? Is his or her level of reading the same now or different than it was before the aphasia/head injury/illness? 38. Part-whole relationship Does milk come from cows? A G/V . 4. 2 A G Say after me: 9.qxd 1/21/08 11:20 AM Page 158 Aptara Inc. 3. or two or more relationships named Point to washing and to eating Point to family and to in front of Recognition of categories named Point to fruit A G Recognition of two or more categories named Point to clothing and to food A G Recognition of objects when given the function Point to the one that is used for writing A G of the object Recognition of two objects when given the Point to the one that is used to buy things A G function of the objects and the one that is used to comb hair Recognition of an event described Point to the one that shows what we do every A G night (sleep) Recognition of two events described Point to the one that shows food being prepared A G and the one that shows going to work Recognition of semantically similar objects. A G Say after me: The man ate the sandwich. dog A V Recognition or repetition of noun phrases Point to: The man A G Say after me: The man A V Recognition or repetition of verb phrases Point to: Ate the lunch A G Say after me: Ate the lunch A V Recognition or repetition of sentences Point to: The man ate the sandwich. two or Point to the quarter and the comb A G more events. cooking Recognition of rhyme words Point to a picture that rhymes with the A G word peas Recognition of antonyms Point to the opposite of up A G Recognition of synonyms Point to a word that means the same as sob A G Following directions Ring the bell A G Understanding concrete sentences Is this a cup? A G Understanding abstract sentences Will a stone sink in water? A G Understanding complex or abstract relationships in sentences (adapted from Wiig and Semel [1976]) a. Point to the ones that go together: shopping. Temporal relationship Does lunch come before breakfast? A G/V e.GRBQ344-3513G-C04[64-160]. hat. 4) walking. Familial relationship Is your mother’s brother your aunt? A G/V g. 158 Section I ■ Basic Considerations APPENDIX 4.2 Examples of Auditory Retention and Comprehension Tasks Task Example Inputa Output Auditory Retention Tasks Recognition or repetition of digits Point to: 8. Inferential relationship The man cut the steak. Possessive relationship Does the hat belong to the girl? A G/V c. A V Auditory Comprehension Tasks Recognition of objects named Point to the hat A G Recognition of events named Point to running A G Recognition of relationships named Point to family A G Recognition of two or more objects. Did the man use a knife? A G/V f. relationships (2. A G events. cup. Comparative relationship Are towns larger than cities? A G/V b. 3. Spatial relationship Is the man walking in front of the cat? A G/V d. 7 A V Recognition or repetition of words Touch the red square and blue circle A G Say after me: man. Antonym relationship Is day the opposite of night? A G/V m. Degree relationship Are inches larger than feet? A G/V l. (From Chapey. Chapter 4 ■ Assessment of Language Disorders in Adults 159 Task Example Inputa Output h. Object-to-action relationship Can a car be driven? A G/V i. Murray & Chapey. Attribution Point to the large red circle A G/V Understanding paragraphs (Read paragraph) Questions: A G/V In this story. Existence Point to the hat A G/V b. Possession Point to the woman’s coat A G/V g. Denial Point to: “The cup is not yellow” A G/V f. G  gestural. Synonym relationship Does sob mean the same as cry? A G/V Comprehension of Content Categories a. V  verbal. 2001) . 1994. did Lucky find a bird? Key: A  auditory.qxd 1/21/08 11:20 AM Page 159 Aptara Inc. Recurrence Point to: “The man returns” A G/V d. Rejection Point to: “He doesn’t want a bath” A G/V e. Nonexistence Point to: “The pie is all gone” A G/V c.GRBQ344-3513G-C04[64-160]. Cause-effect relationship Can smoke cause fire? A G/V j. Sequential relationship Were the Indians in this country before the A G/V white men came? k. Directional Push the book under the table A G c.GRBQ344-3513G-C04[64-160]. Active declarative The boy has hit the girl. A G/V g. Comparatives Point to the larger one A G m.). ‘ly’ adverbs Point to the friendly one A G Understanding Relational Words Prepositions a. Negative The boy has not hit the girl. V  verbal. Taste Point to the sour one A G i. Height Point to the tall one A G f. A G/V e.” A G e. Age Point to the new one A G h. pp. Negative question Has the boy not hit the girl? A G/V f. Shape Point to the square one A G d. Passive The girl has been hit by the boy. Assessment of language disorders in adults. A G/V i. Baltimore: Williams & Wilkins. R. Width Point to the narrow one A G g.qxd 1/21/08 11:20 AM Page 160 Aptara Inc.3 Various Tasks Used to Assess Auditory Comprehension of Syntax Task Example Input Output Understanding Substantive Words Pronouns a.. 160 Section I ■ Basic Considerations APPENDIX 4. Temporal Do you go to church on Sunday? A G Conjunctions Point to ice cream and cake A G Articles Point to a cake A G (Picture of a boy hitting a girl) a. A G/V b. Demonstrative Point to: “This is the cake. Superlatives Point to the largest one A G Adverbs a. Yes/no question Did the boy hit the girl? A G/V c. Chapey (Ed..” A G b. In R. Length Point to the short one A G e. Negative passive The girl has not been hit by the boy. Color Point to the blue one A G b.) . Who question Whom has the boy hit? A G/V d. Speed Point to the slow one A G j. Distance Point to the one that is near A G l. (1994). Reflexive personal Point to: “She kept it to herself. Size Point to the large one A G c. Passive question Has the girl been hit by the boy? A G/V h. (From Chapey. 80-120). Language intervention strategies in aphasia (3rd ed. Complex sentences Is this sentence complete or incomplete: A G/V “The nurse who comes in the morning” Key: A  auditory. Personal Point to: “She ate the cake. Interrogative Point to: “Which one won the race?” A G f. Indefinite Point to: “Is there any left?” A G d.” A G Adjectives (attribution) a. Negative passive question Has the girl not been hit by the boy? A G/V j. G  gestural. Locative Put the hat in the box A G b. Temperature Point to the cold one A G k. Negative Point to: “Nobody is interested.” A G c. GRBQ344-3513G-C05[161-185].qxd 1/21/08 11:30 AM Page 161 Aptara Inc. Section II Principles of Language Intervention . GRBQ344-3513G-C05[161-185]. .qxd 1/21/08 11:30 AM Page 162 Aptara Inc. artistic nature of their measurement” estimates the consistency with which a particu- endeavors. struct. reflects and implementation. Among the most well-known types are inter. We will return to this con- a process of asking and answering questions. That is. The first..g. Standard error reflects the precision of any par- ticular statistic (mean. differ- OBJECTIVES ence between means. proce- PERSPECTIVES AND DEFINITIONS dural reliability data reflect the consistency of implementa- Setting the Stage: Some Key Concepts and Terms tion of the experimental conditions or treatment procedures in a research study. cation. paral- lel/alternate-forms reliability) should be reported and evalu- and Victoria L. 163 . internal consistency reliability.GRBQ344-3513G-C05[161-185]. and generality of validity is illustrated by the following question: Are we of results (Silverman. Chapter 5 Research Principles for the Clinician Connie A. or repeatabil. Also known as “reliability of the indepen- The Research Process dent variable. the individuals who are tested. guided as leaving our empathy. median. consistency. but Kerlinger (1973) is a making. the extent can contribute to the professional evidence base. Items that some future trends are considered in the application of are summed to generate a “total score” index of a single con- research principles to clinical intervention. and suggest ways in which clinicians the homogeneity of test items. A statistic called the “standard error of Most clinicians value the intuitive. and the pro- standardized instruments or nonstandard probes are used to cedures that are employed. correlation. This scope of this chapter to elaborate on the calculation and inter- chapter advocates a scientific approach to clinical decision. If the items that are added together do not measure the same thing. etc. combining them into a single score is like comparing the proverbial apples and oranges.g. 1985). document performance.. emphasizing primarily the clinician’s role as a con.” should have acceptable levels of internal consis- tency. research can be viewed as language intervention literature. Second. As Kearns tions. and caring whether there is a change after treatment). the more difficult it is to tell whether any measurement during the clinical process is surely as mis. Each of these factors affects the measuring what we think we are measuring? Although many confidence one can have in the findings and conclusions of a assume that validity is a fixed property of tests and measures. validity. Other sections recount the Two less familiar forms of reliability also require brief advantages of a systematic approach to treatment planning mention. Tompkins. Finally. April Gibbs Scott. claims of validity for any particular measure ity of results. inferences about a measure’s validity will vary with its appli- Reliability refers to the stability. Standard error has an important role in the measurement of reliability. The larger the standard error relative to the magnitude (1993) suggests. When wishes to draw.” procedural reliability is often neglected in the For the purposes of this chapter. single score is truly different from some other score (e. It is beyond the attitudes behind as we enter the clinical arena” (p. pretation of standard error statistics. to which those items measure the same construct. The definition probability of attaining reliability.and will be influenced by factors such as the conclusions one intra-observer reliability. proportion. which is struc. “failure to apply scientific thinking and of obtained scores. and by inference. Scharp ated.qxd 1/21/08 11:30 AM Page 163 Aptara Inc. and test-retest reliability. Most also recognize that effective clinical man. these or related indicators (e.) by estimating the random fluctua- tions that would be obtained if that same index were derived on repeated occasions.71). lar test would measure performance on repeated administra- agement cannot proceed by intuition alone. sumer of research information. tured by a set of criteria and procedures for maximizing the Validity refers to “truth” of measurement. research effort. clinical intuition. good source for those who want more information. such as “word-finding ability” or “communicative adequacy. cept in another section of the chapter. and “effective- emphasis on the multi-dimensional consequences of health ness” to indicate the benefits for a broader population problems and health-care provision. well-controlled treatment change of 5% a clinically important difference? What about a two-fold increase in the number of times a 1 The factors that compromise internal and external validity in research client initiates a conversation with an unfamiliar person? also affect the validation of a test instrument. tine circumstances. Outcomes research yields a lesser degree of confidence but tions themselves. rendering a high degree of confidence in its results. dence in results (Frattali. The idea is that a posi- (under typical conditions). rather than to artifacts or confounding may provide insights into processes and phenomena that variables (Campbell & Stanley. extent to which findings can be expected to apply to particu. severely dysarthric Table 5–1. 1966). and concerns the ment can be aimed at documenting the efficacy. tinguishes among three levels of functioning: body structure but with different degrees of control and consequent confi- and function (formerly. the famil. protocols to evaluate a treatment under optimal conditions. the meanings of these terms. tive outcome (which can be defined simply as the result of any demonstrating treatment efficacy is a prerequisite for estab- intervention) encompasses social. Because well-designed efficacy research cepts are important for designing and evaluating research. consult There is no easy answer. outcomes measurement is the World Health Organization’s regardless of the research method used to generate the evi- (WHO) International Classification of Functioning. or psychological Science as a State of Mind impairments. psychological. Some link the terms “treat- essary for. both efficacy and outcomes Disability and Health (WHO. and participation (formerly. minimizes potential confounds. But as Chial (1985) reminds us. And assessment of ment to science is also a state of mind. “disability”). 1982). outcomes research yields evidence on the effectiveness of ment. physiologic. dence. outcomes measure- conclusions (Campbell & Stanley. lar populations. and construct validity. treatment. and dysarthria may affect reliability and validity concerns related to language inter- the ability to talk on the phone. for Robey and Schultz. 1998a). central to a discipline such as diminishes a grandmother’s ability to bond with her grand- clinical aphasiology. Robey and Treatment Outcomes and Their Measurement Schultz (1998) fold in another distinction. settings. is a concern for practical or clinical children. So. The Knowledge of methods used to maximize reliability and activity level is concerned with the influence of an impair- validity is essential for conducting and evaluating ment on an individual’s activities and daily-life skills (e. in this chapter we dinal changes in addition to the traditional concerns with follow Frattali and others in using the term treatment physical and physiologic improvements (Donabedian. From this perspective. There is little consensus about variables. involves the generality or representativeness of results and Finishing this terminological survey. or to read aloud to grandchildren). tions under which the data are gathered. External validity cannot easily or validly be isolated and controlled. depends on factors such as the specific processes or behaviors . its internal validity can be Internal validity reflects how confidently one can attribute strong. efficiency. both efficacy research and meaningfulness of changes that are reported for research outcomes research contribute to outcomes measurement.g. using the term “efficacy” to refer to the benefits derived from treating an In recent years.qxd 1/21/08 11:30 AM Page 164 Aptara Inc. and treatment efforts. observed changes to the experimental treatments or condi. speech restricts a teacher’s ability to perform his or her job or An additional principle. significance. a commit- rant. 164 Section II ■ Principles of Language Intervention For tests and other measurement instruments. suggesting that tently off by 1/2 pound: it is a reliable (consistent) instru. outcomes measurement has seen increasing individual patient (under ideal conditions). and/or effects of treatment (see Frattali.1 It is important to remember that reliability is nec. Is a statistically significant pre-post Efficacy research uses rigorously specified. Two other validity con. criterion (predictive and whereas outcomes research is conducted in typical or rou- concurrent). Some principles at participation reflects the effects of a health condition on social the heart of a scientific orientation are summarized in roles and life situations—for example. iar types of validity are content. Probably the best-known working framework for whether a treatment works (Kendall & Norton-Ford. and attitu- lishing treatment effectiveness. for examples. and only efficacy research can meet the standard for treatment efficacy data (see Frattali. “handicap”). This framework dis- research can be used to investigate treatment effectiveness. validity. effectiveness as a higher-order concept concerning 1980).GRBQ344-3513G-C05[161-185]. Ventry and ment effectiveness” and “treatment efficacy” with the condi- Schiavetti (1980) give an example of a scale that is consis. effectiveness. However. activity (formerly. but does not guarantee. or measurement and treatment 1998a. as the importance of a change Franzen (1989). “impairment”). 1998a). research. such as agrammatic output in aphasia. 2001). and a later section of this chapter examines some agrammatism. 1966). Measurement at the level of body structure and function addresses specific anatomical. to order a meal in a restau- vention studies. which calls for evaluating the relevance or According to Frattali (1998a). apraxia of speech. but not a valid one.. for a full discussion). the principles that guide scientific inquiry. Silverman (1985) and the nature of the treatment goals. 2001). Table 5–2 illustrates the scientific research. and (WHO. Kent. We ticipation are more relevant. Parallels often have been drawn between research and clinical processes (e.g. Chapter 5 ■ Research Principles for the Clinician 165 TABLE 5–1 Some Key Principles and Values of Science Testability: Propositions and questions are specific enough to be evaluated Replicability: Procedural specificity and detail are sufficient to allow findings to be reproduced Objectivity: Dogmatism and bias are rejected. 1985b.GRBQ344-3513G-C05[161-185]. emphasizes four principles in a scientific approach to clinical The question of clinical significance can be formalized management: specifying clear objectives. Nation and Aram (1984) sug- Science and Clinical Decision-Making gest that careful diagnosis is like conducting a “mini While some clinicians may shudder at the thought of “doing research project” (p. and function. the client’s needs and level of functioning. the elusiveness of answers is understood Concern for protection of human subjects: The welfare of those participating in research projects is paramount being targeted.” effective diagnosis and treatment are modeled on nature of the diagnostic process (after Nation & Aram) by TABLE 5–2 Some Useful Descriptive Information About Neurologically Impaired Persons Brookshire (1983): Age Etiology Education Time post-onset Gender Severity of aphasia Premorbid handedness Type of aphasia Source of subjects Lesion location Rosenbek (1987): Risk factors Other medical factors Smoking Medications Drinking Seizures Obesity Diabetes Hypertension Rosenbek et al. (1990): Physiologic indices of aging Personality/attitudinal Estimated premorbid intelligence variables Auditory processing abilities Social integration/social support . Improvements at the level of activity or par. posing answerable to some extent with reference to the WHO model hypotheses and questions. 1986). For example. and important add a fifth: justifying the choice of measures and treatments than changes that are limited to the level of body structure as appropriate to clients’ needs and clinical goals. Warren. observing systematically. (1989): Willingness to practice Ability to learn Ability to generalize Ability to retain Tompkins et al.. 1985. counterevidence and alternative interpretations are sought Systematicity: Theories and experiments are evaluated and developed in a logical.qxd 1/21/08 11:30 AM Page 165 Aptara Inc. We return to these issues later in the chapter. Silverman. orderly way Tentativeness: The possibility and sources of error are recognized. remaining aware of the tentative nature of the findings. meaningful. 54). clinicians always have had an ethical responsibility to evaluate the impact of 1.asha. Third. evaluate. a recent emphasis in clinical practice. Muir Gray. LaPointe.org/members/ebp/assessing. as discussed of both “basic” and “treatment efficacy” research. Rosenberg. [by] integrating individual clinical expertise with As clinicians.htm). Participating in continuing- research” (Sackett. 2005). a topic we elaborate next. all of Ventry and Schiavetti (1980). or assess both the level and quality of evidence provided by any located in an Internet search. prefer- opments. presenter is known as an authority. and Wertz convincing? The weight one gives to rationales and (1989) assert that “untested treatments are immoral. Darley. there- hypotheses will vary depending on their sources. provides one highlight clinicians as both consumers and potential produc- framework and a set of procedures to help us make the best ers of research. fore clinical practice must include clinical experimentation” which can include critical examination of literature. The information we find on the Internet. it is too easy to accept at face value anything that is Web site also provides excellent information about how to published or presented at a professional conference. First. A scientific attitude modate other communicative obstacles the client may face. EBP has been defined as “the conscientious. They are just above. The next sections of this chapter will (EBP). for the accreditation of hospitals and long-term-care facili- Clinically accountable treatment. . which can be docu. 2000). searching for another ques- Then we would test and refine these clinical hypotheses as tion or pursuing a different hypothesis definitely help to we evaluate our client’s progress. Without critical evalu- American Speech-Language-Hearing Association (ASHA) ation.. for instance. & Haynes. (p. As the definition implies. Finally. and 2 Some of these issues have been elaborated further by Tompkins (1992). Schiavetti & Metz. and values are part of the EBP framework as well or disseminate the information without critical evaluation. Johnson. Research is sorely needed to evaluate the effects.GRBQ344-3513G-C05[161-185]. . Evidence-based practice keep life interesting. Are rationales and hypotheses provided. Individual client characteristics. is guided by these quality measures) only underscore the urgency of generating same procedures and principles. and are they their services. clinicians can make important contributions to the evidence base that should form the foundation of diagnostic and treatment activities. This further underscores the value of science The literature is replete with contributions that describe to clinicians. Haynes. Rosenbek. The order of the applies to the published data and continuing-education questions reflects the order in which a research consumer information that we consume professionally. For the form in contemporary writings on the subject of research purposes of this chapter. the research-consumer role is one of the most the best available external clinical evidence from systematic important that we can adopt. and judicious use of current best evi- dence in making decisions about the care of individual THE CLINICIAN AS RESEARCH CONSUMER patients . Some of the most important considerations are The Value of Science to Clinicians recapitulated here. or accom. the principles and skills of science are essential to culled primarily from Kent (1985a). 12). The diagnostic literature has with results documented at multiple outcome levels. and impartial. Most of these questions can be asked least five reasons are immediately evident. and apply the available research in order to Some Questions to Ask in Evaluating Research engage in EBP.. the need for critical thinking evaluation (e. general principles for evaluating published material and pre- sentations. Fourth. model we would postulate what can be done to ameliorate a a scientific approach kindles informed curiosity.g. Using a hypothesis-testing a solid evidence base to justify clinical interventions.2 but are represented in similar us must think critically to be wise consumers in life. precise. 1996). with examples and elaboration specific to neurologic So why should clinicians care about research and science? At or aging populations. and accountable clinical practice.qxd 1/21/08 11:30 AM Page 166 Aptara Inc.g. Rosenberg. especially when the author or single study (www. in the form of 12 questions for the con- sumer. & education efforts or scouring the Internet for the latest devel- Richardson. . underscored this theme for decades. scientific problem-solving. special observation skills. may help to stave off “burnout”. are worth little if we simply soak up ences. clinicians need to learn how to locate. JCAHO ORYX initiative and reliable observation. and Drastic reductions in reimbursement for services and Spriestersbach (1963). Richardson. us thinking and growing professionally. effectiveness. and for collecting core performance data and hospital mented as efficacious and/or effective. while laudable. Straus. explicit. and relatedly. modify. Second. and to the could answer them. (Sackett. including EBP. when reading a research article. and keeps client’s weaknesses and/or to compensate. HCFA Outcomes and Assessment Information Set thinking. [OASIS] for home-care patients. In this vein. guided by principles of critical (e. 166 Section II ■ Principles of Language Intervention setting out the chain of diagnostic steps that correlate with efficiency of various assessment and treatment approaches. emphasized diagnosis as increasing requirements to collect and report outcomes data a hypothesis-testing process. possible clinical decisions. ties. Silverman (1985). support and development from other sources. or “blind” to. and who does not have a stake draw tentative conclusions in the outcome of the study. and clin. to expect all of these variables to be patients to whom it is to be applied.. or someone whose language impairments are embed- 1. aphasia type. also important that component skills or prerequisites tion is like an appropriately written behavioral objec. the value of a rationale will not logic and psychiatric history.g. not respond as expected.GRBQ344-3513G-C05[161-185]. Sound rationales and reader to assess the believability. To take the subject of subjects. the nature of the treatment. on its own. 1986). A more answerable question would indicate and-true descriptors (see Table 5–3). There is an obvious difference between clinical stimuli (e. Chapter 5 ■ Research Principles for the Clinician 167 knowledge of normal and disordered processes. Detailed performance on an aphasia test. 1985). replicability. A rationale such as “I wonder what would illustrate. Of course. and the criteria for described in every study. Develop hypotheses to be tested. We would not expect traditional aphasia treat. prior neuro- other instances. or about which individuals eral varieties of non-aphasic language disturbance (e. Are the participants sufficiently described for the ical observation and intuition.” The occurrence of one or more dominant as those discussed here also is important for the inter- hemisphere “strokes” certainly is not sufficient evi.. Similar sets of factors affect research with other neuro- ses..” is. & Schulz. Do the participants represent the group(s) they are these may make it easier for consumers to determine meant to represent? Using an example from aphasia. the characteristics of or even necessary. A well-specified ques. Define and delimit the problem ded in an assortment of other cognitive problems such 2. Others (e. language of generalized intel- lectual impairment in dementia. language of confusion. it is desirable to have independent verification port or reject hypotheses by someone who is unaware of.” The latter is measurable. Wertz. For qualitative or subjective judgments in par- 6.” number of well-operationalized descriptors such as 3. sensory and motor status.qxd 1/21/08 11:30 AM Page 167 Aptara Inc. a research report should describe the cri- 3. logically impaired populations. far from substantial and needs in treatment studies. “Does Rosenbek et al. dence to render the diagnosis of aphasia.g. be so clear-cut. having a greater determining if it has “worked. lating hypotheses about why certain participants do Damage to the central nervous system also causes sev. such as duration of aphasia. vincing case is made for the study questions or hypothe. for processing and responding to treatment or probe tive. Neither. might benefit most from particular interventions. and literacy (Rosenbek et al. a number of variables may influence results happen if. and gen- hypotheses most often originate from more than one of eralizability of results? Again drawing on aphasia to these roots. another example. 1990) have offered additional possibilities and dis- and is impossible to answer in any one or even several cussed novel ways to operationalize some of the tried- studies. nal validity of a study. Analyze the data: score and organize objectively teristics. Collect the data: minimize bias and maximize validity essential communicative diagnoses and client charac- 5. and “achieving 85% comprehension of Yes/No ques.. low scores could reflect subject information is critical as well to begin formu- a number of other pre. However. Tompkins. Generalize from data: reason from the evidence to ticipant’s specific status. As must define and operationalize what they mean by Brookshire (1983) notes. whether they are explicitly posed or implied. If such factors are not reported. In most severity of deficits. variables are relevant for characterizing communica- spective of research evaluation. visual and auditory perceptual abilities) goals such as “improving auditory comprehension” are specified and measured. Develop procedures to test hypotheses systematically teria. To address is needed to evaluate them this question. each par- 7. it is is one that is explicitly specified. the generic efficacy question. how to apply results. including characteristics such “aphasia. 4. an answerable question tion behaviors of normally aging adults. This TABLE 5–3 diagnostic distinction is more than a simple semantic one. is poor have been influenced in unintended ways. rationales. Are the research questions answerable? From the per. Brookshire (1983) suggests a minimum list of tions about implied main ideas in spoken eighth-grade descriptors for clients with aphasia in his treatise on level paragraphs. alone readers cannot rule out the possibility that the results or in combination with etiologic information. though. It is not practical.1987.or post-morbid conditions. and reliability for judgments about the 4. etiology. Interpret the data: evaluate meaningfulness and sup- ticular. Rosenbek.. and some of the same 2. Shewan. 1989.. and for investigators to attempt Darley (1972) emphasized long ago that researchers replication and extension of reported findings. . Each of us must decide whether a con. Scientific Steps in the Diagnostic Process ments to benefit someone with an isolated dysarthria. 1989. aphasia treatment work?” lacks operational specificity.. know what evidence as confusion and severe memory disorder.g. Jackson. sent the essential aspects of procedures and conditions. and on the validity of subject selection. also score high the second time) and still be significantly cedures. when evaluating the acceptability of reliability indices metrically sound measures are not appropriate or avail. criteria or decision rules. intensity of treatment. But two sets of scores can be nature of the no-treatment comparison condition highly associated (i.. without taking into account treatment. and of consistent scoring by the same judge. For apha. and repeated mea. how appropriate would it be to rely on a test outcome measures is objective and repeatable. Research reports should clearly pre. sia treatment trials. Are the procedures. . the reliability (and validity) question can that levels of chance agreement should be considered be asked of standardized measures. As a hypothetical example. it should be clear that Question 3 above bears such as the timing and selection of cues or prompts. For example. several other correlations are appropriate.qxd 1/21/08 11:30 AM Page 168 Aptara Inc.e. measures in aphasiology research and treatment. lems of response formulation and execution could cratic decisions or unintentional bias could have mask intact syntactic knowledge. 1992. Without that requires spoken production of those construc- evidence of acceptable agreement between independent tions? The answer depends on a lot of factors. McReynolds & Kearns. a validity phase of single-subject experiments. and variables adequately the accuracy and delivery of feedback (see examples in specified? This question most obviously refers to the Bourgeois. 1986). and responses also different (see. Lemme. Without them. tions were appropriate for answering the questions menting experimental procedures or treatments in a asked. people who score high one time (Rosenbek et al. Treatment pro. Pearson r. tinctions should be provided and validated. 1985). One specific concern relates again to they can to address reliability concerns. one the independent variable (in this case. 1988. readers should scrutinize the choice Just as crucial are inter-observer and intra-observer of outcome measures in light of the stated research reliability for dependent and independent variables. 3 Under these guidelines. 1992. Some other points to keep in mind are noted earlier. One caveat is that and the operational definitions of the dependent (out. issue of replicability. are reported to document reliability (e. assessment should ask whether the reported observa- sures can be taken for a similar purpose prior to imple. but inadequate specification also A variety of issues and procedures in observer relia- may raise internal-validity concerns that diminish confi. psycho. 1993). Shewan. can be calculated and evaluated as well. In addition. 1983). When these specialized mea. e. and variables reliable variants of the intraclass correlation coefficient (Shrout and valid? Let us focus first on reliability issues. as an have been delivered consistently and as intended. 1985).. researchers should provide the best data ing Question 6. Along these lines. 1990. but one judges. including 6. and about their internal-consistency assessments taken in a baseline (pre-intervention) reliability. to goals. as would be the case for reliability assessment. From a broader perspective. but readers should expect at minimum some measurements rather than an intervention. Independent-variable reliability connection between treatment and outcome measures data also are essential. the might question the validity of this plan because prob- research consumer has to question whether idiosyn. independent variable (the treatment) include the type These statistics only index the degree of association and training of the clinician. and whether the investigator observed and group study. the treatment) might question whether reading comprehension. bility assessment have been discussed by Kearns and his dence in the results. Dependent-variable knowledge of particular syntactic constructions in reliability data are needed to ensure that the scoring of aphasia.GRBQ344-3513G-C05[161-185]. to demonstrate that all aspects of also is paramount. measures of their own. research reports should document evidence of proce- dural reliability for various aspects of an intervention. Test-retest and the abundance of specially designed. The validity of the affected the results. Massaro & Tompkins. Are the procedures.g. Kearns & Simmons. But often. Dronkers. and that ceiling effects can able. conditions. conditions. The appropriate standard-error statistic described what he or she wished to3 (Silverman. Thus. 1979).. and investigators develop or modify dependent skew reliability results. 1989. (see Kearns. should be described as precisely as possible. 168 Section II ■ Principles of Language Intervention 5. It is it is impossible to determine whether changes on an unreasonable to expect such measures to have known outcome measure might be due to unstable (unreliable) validity. If exact score agreement is of if several conditions are contrasted. Wertz. if the goal of a study is to assess be assessed in each phase of a study. nonstandardized standard-error information are crucial. An estimate evidence and logical arguments about the choice of of test-retest characteristics can be made from multiple items included. Shubitowski. We turn now to validity issues to continue illustrat- sures are used. 1992). colleagues (Kearns. clear operational dis. type of treatment. amount and frequency of between two sets of scores. certain well-known correlation coefficients that often come) and independent (predictor) variables. 1990. some important characteristics of the Spearman  ) are not the best choices for this purpose. and exact score agreement. concern.g.. As & Fleiss. & Deal. several major internal-valid- iors and conditions as well as untreated behaviors and ity threats are discussed here from the perspective of conditions. The third sense of adequacy refers to Schiavetti & Metz. adhering to procedures. and Nicholas (1994) demonstrate this point. But since it has generally assessments in multiple environments or contexts will been believed that it is unethical to deny treatment. An additional check on participants. or com. and judging the existence and magnitude of aphasia and related impairments is how to account for treatment effects. Repeated measurements check on the influence of spontaneous recovery. Question 9 elaborates on this approach as a measurement is not sufficient. “control” behaviors. The validity of a treatment also depends in unaware of whether any individual participant is part on demonstrating procedural reliability. Sandler. relaxing the amount of treatment or prac. This is discussed in Question 9 below. (1986) solved this dilemma by including a deferred treatment to ensure that the treatments retained their intended distinctions. If all behaviors respond similarly quacy” are considered here. one-shot changes. tations (“placebo effects”) can be evaluated through come. 1980. motivated and systematically applied. 1979). bias is to have different examiners provide treatment such as modifying selection criteria to include more and evaluate treatment data. In language pliance with the experimental protocol. simultaneous measurement of treated and untreated 7. control 4 Assessing procedural reliability also would be important for studies comparing treatments. to gather data to this question are considered. For example. scoring A special validity problem in studies of people with outcomes. Generally. and for a more general refer- collecting multiple indicators at each measurement ence on alternative interpretations. which was emphasized above. unknowing. The second sense of adequacy refers probably can never be ruled out entirely. enhance the generalizability of results. Chapter 5 ■ Research Principles for the Clinician 169 outcome goal.qxd 1/21/08 11:30 AM Page 169 Aptara Inc. whenever possible. and tion of samples. Elman and Bernstein-Ellis (1999) used a similar approach in a subject experimental designs. Typically. beyond keeping investigators raises the issue of compliance in treatment studies. This is observe the timing or pattern of changes over the an issue of internal validity. One element concerns approximate test-retest reliability before initiating a whether the results could be due to something other treatment or experimental manipulation. 2005. would be expected to improve after a 8. see Huck & occasion. & Stanley. examiner bias is achieved when independent inter- tice provided. whose progress during the no-treatment phase could be analyzed as But a later section of this chapter will point out the flexibility of single- control data. showing It is beyond the scope of this chapter to review all that discourse measures based on single (short) speech threats to internal validity (see discussions in Campbell samples are less stable than those based on a combina. but blind to each participant’s group (and even diagnosis) his point applies to other kinds of research as well. 5 group. and/or to than the factors that interest the investigator. may be needed to assess the stability of the participants’ 9. see Question 9). treatment delivery would need to be monitored 6 Wertz et al. The influence of participant expec- “spontaneous recovery” in evaluating treatment out. or changing the clinician. However. and be appropriately cautious in providing the more reliable that measurement will be. . The first concerns over the course of treatment. as long as modifications are analytically study of the efficacy of group treatment for aphasia. but an inves- to the number of observations in each task.4 Wertz (1992) intervention studies. even treatment that focused on oral reading of single words.GRBQ344-3513G-C05[161-185]. assigned to a treatment or control group. Ventry & Schiavetti. Are precautions taken to reduce potential. can vitiate the observer reliability is demonstrated to be high for validity of a research effort. Brookshire interpretations and conclusions. another control for experimenter Deviations from a protocol part way through a study.6 Rather. 1992). this crucial condition is rarely met. influence. Finally. multiple measurements are language-intervention research.5 selecting participants. One that is important needed in treatment studies to assess whether an effect in group-treatment trials is the composition of no- has generalized beyond that which is specifically treatment control groups. Is the behavior sample adequate? Four senses of “ade. including measures that index treated behav. duce critical biases in a research investigation. bias? It is well-documented that both Readers should look for investigators to justify the link examiners’ and participants’ expectations can intro- between their independent and dependent variables. which keep both investigators and participants validity. it is possible that some- repeated measurement with the same instrument or thing other than the treatment was responsible for the task. Are the data interpreted appropriately? Two facets of pre-treatment baseline performance. Hence Let us return for a moment to an earlier maxim: the emphasis in medical research on “double-blind” reliability is necessary (though not sufficient) to ensure studies. A randomly assigned con- trained (and perhaps as a control for “spontaneous trol group is essential for demonstrating efficacy in recovery”. 1966. Threats to internal validity course of a study. tigator should acknowledge and discuss their possible the more observations or items included in a measure. comprehensive group studies (Wertz. another dilemma is that it is not known whether the rate. & Uomoto. A self-selected control group may differ particularly for the small sample studies that tend to from the treatment group in critical ways that are rel. bringing the client to treatment over spontaneous recovery. For surement of treated and untreated behaviors can help example. they may have untreated behaviors while others are treated. live in remote areas without access not to differ between groups (Wertz. However. One limitation comes from Yorkston and her colleagues (Yorkston. Perhaps the can provide convincing evidence of the influence of other treatments paved the way. 1992. of this approach is that no one knows the duration and Farrier. the simultaneous mea- may even affect results on a day-to-day basis.7 Multiple baseline drop out of treatment studies: they may be too ill or designs (McReynolds & Kearns. Another approach is to measure several “control is that differences in outcome between treatment and behaviors” that are approximately equal in difficulty to control groups may be attributable to these pre-treat. There are a variety of reasons that clients may be responsible for the changes. Any of these sorts of factors may make the groups ior should accelerate if treatment is exceeding the unequal. 1983). to the client. elect not to participate. influence of spontaneous recovery. A expected to influence. or functions. Another set of potential problems in attributing subject experimental designs. the order and sequence might have resulted from the time and attention given with which conditions are applied in a study may influ. and literacy (see treatments. so it is imperative to evaluate inter- 7 ventions for those who may still be undergoing neuro. Sequence and order effects process of treatment. a difference in the “recovery schedule. random assign. but that the treatment is not ment inequalities and not to the treatment per se. Zeches. treatment. However. & Uomoto. untreated behavior. for elaboration). for example. 170 Section II ■ Principles of Language Intervention groups typically are self-selected. include age. More generally. and untreated behaviors. the point at which he or she was ready to profit from A related issue in interpreting the results of inter- the intervention under study.” or in the complexity of the treated ment to treatment and control groups is one solution. Single-subject Another difficult problem for the internal validity experimental designs that allow reversal and reinstitu- of language intervention research is a possibility of tion of treatment effects for the same behavior in the concurrent other treatments and/or prior treatments same individuals (McReynolds & Kearns. Again. This problem also can be diluted sequence. to treatment. consisting of patients Then the effects of spontaneous recovery are assumed who. if conditions are arranged in a fixed order or to address this issue. Another concern tain measures of word usage and grammatical com- is that most language and communication treatment is plexity differed according to socioeconomic status in delivered in the period shortly after onset of the dis- abling condition. Conditions baseline phase. or extent of spontaneous recovery is comparable for different behaviors logic restitution. rather than from the content and/or ence the reported results. the target behaviors. medical risk factors. 1990. Zeches. results to the experimental conditions involves the The influence of spontaneous or physiologic recov. vide evidence of this sort for individual participants. If the recovery curve is steeper related difficulty centers around differential dropout for treated than for untreated functions. populate the literature on aphasia and related disor- evant to the response to treatment. tim- ing. the slope of change for that behav- ing. neurologic condition. they may not like the treatment they are receiv. timeline of spontaneous recovery (particularly for Farrier. studies. and in across-subject replications of single. years beyond the pre. biasing the results of the study. 1993). they may not be aware of a continued need for treat. Some of these behavior changes that can be extremely difficult to sep. . hearing ability. 1992). who demonstrated that cer- those with traumatic brain injuries). or cannot pay for random assignment does not ensure group equality. It is important to issue by conducting their treatment investigations in remember that not all “errors” are due to a patient’s neurologically stable patients. Some researchers have tried to skirt the Tompkins. Physiologic improvement brings about neurologically-impaired individuals. which track too severely impaired to participate. The consequence ders. fatigue or warm-up effects may adversely by taking repeated measurements in a pre-treatment affect some performances and not others. influence of factors that have demonstrated relation- ery is nature’s version of an “interacting treatments” ships to language and cognitive performance in non- problem.GRBQ344-3513G-C05[161-185]. edu- arate from changes we would like to attribute to our cation/premorbid intelligence. A good example of this point sumed effects of spontaneous recovery. treatment from a study.qxd 1/21/08 11:30 AM Page 170 Aptara Inc. 1983) also interacting with the treatment of interest. where participants are being given time should be randomized or counterbalanced in group and attention. Yorkston. This is one example of an vention studies is that apparent treatment effects order effect. Each time treatment is applied to a previously ment. Lesser change in an untreated function may simply represent For a large group-treatment trial. can pro- improved enough that they no longer want treatment. 1984). evaluation. assessing listeners’ ratings of the adequacy prehensive. Analysis of effect size has a precise statistical should be assessed. 1977). and. tions until targeted levels of generalization occur” When a research procedure or clinical intervention (p. intervention research. Most mance. Evaluating mainte. gender. and education. and/or who .” Metter (1985) suggested that some neu- and the variables of age. the reported outcomes? Individual performance can designating a change of at least one standard-devia- be analyzed in group data. Wertz (1991) suggests studies. average pattern. Results of these types level requires knowledge of or access to current theory of assessments currently appear in some language and data. & evaluating the size of a difference between groups of Frazier (1997). Marshall. or a doubling or tripling of baseline perfor- contribute to success or failure can be evaluated. improve a client’s auditory language comprehension.qxd 1/21/08 11:30 AM Page 171 Aptara Inc. It is important to plan treatments to with unfamiliar partners (Doyle. 1989). importance or strength of an experimental effect is to 11. Ardila tal manipulations? We return to the issue of practical and Rosseli (1996) found significant relationships significance here. 1986). Another way to assess the become a priority. Goldstein. & Nakles. but the idea is to deter- data. used a hybrid approach. what characterizes those with good and poor utes thought to characterize adults with right hemi. in which subjective evalua- ous measurement and probing for functional. Goldstein (1990) reviews several approaches for The last statement exemplifies the second facet of examining clinical significance. it is important to try to identify (1993) reported that several connected speech attrib. maintenance of treatment gains reported. If generalization beyond the treated tasks is not is not expected to lead directly to a functional out- apparent. as clinically meaningful. several other measures of “importance” can be is in doubt. 1989). This could be done by calculating the 95% (see also Marshall & Freed. 1989. response.g.. other individuals. much more than a few weeks after the end of mine how “large” or meaningful some statistically sig- treatment. including normative Question 9: given what we already know. continu. confidence intervals for each set of scores. Cohen. exemplars and to other ecologically valid measures.. Thompson.71). to be provided in language-intervention nificant difference really is. sit. sphere brain damage did not distinguish their speech 12. tions were made of aphasic adults’ speech samples ized improvements. when necessary. and by examining non- Kearns. incorporation of treatment guage intervention. goals. Kearns (1993) Tompkins (1993) exemplify two varieties of subjective indicates that generalization planning involves “com. To convey some indi- clinical manipulations. normative com- 10. Studies by Doyle. For example. 2006). in a or importance of changes attributed to the experimen- study of 180 normal native Spanish speakers. and to assess whether brain-damaged adults’ usage of social conventions treatment effects in fact do generalize to untrained (Thompson & Byrne. and raise the related concept of between performance on a picture-description task “effect size. Whitney and Goldstein (1989) strategies that might facilitate generalization. Similarly. and conversational partners. control speakers. One exception is found in Freed. people and condi.GRBQ344-3513G-C05[161-185]. functional control data and expectations. multifaceted evaluation. In order to apply findings to forms to the overall.g. such as inserting pauses to cation of the strength of an observed group effect. and factors that appear to tion unit. Nicholas participants in a group study whose performance con- & Brookshire. And. extending intermixed with samples from non-brain-damaged treatments to additional settings. maximize the likelihood of their generalizing (see Bourgeois. Are individual participant characteristics related to set a predetermined difference criterion. Similarly. and a sense of their validity and replicability. the establishment of selected communication parameters following lan- of generalization criteria. for example. the practical significance of treatment effects come. who monitored maintenance of inter. comparisons of target performance. The rologists’ skepticism about aphasia treatment stems lesson is that findings for people with neurologic from concerns about the relevance of specific impairments must be evaluated against the appropriate improvements in treated deficits to real-life. and Bourgeois (1987) and Massaro and uations. mation by neurologically intact adults in conversations sional outcomes. It is rare for long-term maintenance meaning (e. Goldstein. does the inter. and subjective pretation ring true? Evaluating interpretations at this evaluations of changes effected. researchers can report the number or percentage of affect some individuals and not others (e. scores by examining their distributions for overlap or vention gains for 13 weeks after the end of treatment separation. Is there some attempt to evaluate the meaningfulness samples from those of normally aging adults. using stan- nance of gains over extended time intervals should dard-error estimates. Are maintenance and generalization programmed and parison data in the aphasia literature have been gath- probed in treatment studies? This question is related to ered by assessing the frequency of requests for infor- issues of adequate behavior samples and multi-dimen. Tompkins et al. general. Chapter 5 ■ Research Principles for the Clinician 171 non-brain-damaged adults. with independent scoring of a portion of read this will be inspired to take part. with more intense treatment. we think there is value in the perspective and infor. Kearns. it Derived from behavioral psychology. but an important part of a data-gathering team for a relatively the two are quite dissimilar. helping to provide much-needed data ond. see Campbell & Stanley. treatment. researchers for collaborative investigations (www.. Treatment-Efficacy Investigations Single-subject or within-subject experimental designs (e. attention to reliability and validity. have caused a change from the first measurement to the sec- tion in the field.g. While the that recent changes in the service-delivery climate have EBP movement emphasizes evidence from systematic made it virtually impossible for most clinicians to participate research and large randomized controlled trials. One goal of ASHA’s well suited to maximize internal validity. detail in a number of sources (e. vant for interested clinicians who would rather assume a Single-subject experimental designs are discussed in more peripheral research role.org/ 1986a. But despite some very real practical lim. ject experimental designs will remain important whenever itations. members/ebp/fi-06-ebp.g. for atypical or rare client mation that follows. some would not grant the status of “evidence” through original studies or replications and extensions of to the results of pretest-posttest studies (for further discus- existing work.g. for example.g. 1991. some aspect of reading comprehen- selves. Schumacher & Nicholas. return to baseline or maintenance). Stable pre-intervention baseline data..qxd 1/21/08 11:30 AM Page 172 Aptara Inc. 1980). comes data for treatments as they are typically delivered. While it is clearly necessary to collect out. For example.g. .. Contributing to the Scientific Data base are used as reference points for evaluating the efficacy of Clinicians can contribute meaningfully to their professional replicable interventions conducted with well-defined partic- literature. Interested clinicians also may be able to initiate col. 172 Section II ■ Principles of Language Intervention achieve the designated criterion for meaningful Clinicians Evaluating Their Own Interventions change. & Gaddie. sufficient evidence is lacking (e. it is important to acknowledge evaluating the efficacy of their own treatments.. Those unfamiliar with single-subject experimental clinicians might.. While this design often is used to gather “outcomes data.g. single-sub- in research efforts. but the information is also rele.. a large investigation initiated by someone other than them. to demonstrate crucial evidence-gathering efforts. tinuously within and across design phases (e. the designs allow focused initiative on evidence-based practice (EBP) is to flexibility in treatment when a need for modification provide a Web-based environment to link clinicians and becomes apparent (Connell & Thompson. such as strained circumstances (e.GRBQ344-3513G-C05[161-185]. and then the target behavior is measured again. profiles. clinician-initiated research. collected on the clearly specified dependent variables. iors. We are convinced that the most impor. The small num. Well- beyond what is dictated by the current clinical climate. 1966. sion) is assessed once prior to treatment. e. operationally-defined these problems alone. In a pretest-posttest design. 1986. or for relatively new soundest evidence base possible to justify their efficacy and additions to the scope of practice such as right hemisphere effectiveness. McReynolds & Thompson. Warren. The effects of these interventions are evaluated con- along the way (see. objectivity and consistency. Connell & Thompson. at some level.” it clinicians may be able to evaluate the outcomes of their own generates only a weak form of evidence about a treatment’s interventions—in some cases through efficacy research but effects because of inherent threats to internal validity. clin. across behav- tive relationship with established investigators will be a cru. and/or across patients. for newer service-deliv- and reimbursement for our services is to appeal to the ery models such as telerehabilitation. 1987). The designs incorporate ber of researchers in our discipline simply cannot tackle repeated measurements of observable. 1986). applied.asha. as a conceived single-subject experimental designs are built means to determine what would be possible under less con. Gabriel. operational definitions. Ventry & Schiavetti. for understudied populations such as individuals tant thing we can do as a discipline to garner both credibility with bilingual/multilingual aphasia. In fact. Alternatively.htm). target behavior (e. Exploring such connections. in these those behaviors by more than one examiner. and control of extraneous variables. Thus we hope that clinicians who target behaviors. any more likely by collecting outcomes data. an intervention is laborative investigations on topics of their own choosing. or more sessions to establish overlearning).. Although tightly controlled and cial source of guidance and support. single-subject also is critical to conduct treatment research that goes experimental designs are not glorified case studies. number of factors other than the treatment of interest could icians may be able to contribute more generally to informa. find an opportunity to become designs may equate them with pretest-posttest studies. 1983) are probably the most appro- priate designs for clinicians who wish to become involved in As a prelude to this section. although there will almost certainly be obstacles ipants. THE CLINICIAN AS INVESTIGATOR McReynolds & Kearns. language disorders). with the support of established researchers. A collabora. Johnston.g. The next sections of this chapter focus on sion. baseline. around important components of scientific inquiry. Beyond feasibility problems. Examples of studies using speech-language pathologists and audiologists. Kiran & Thompson. collecting an ade- clinical procedure and rigorous study is the time required to quate behavior sample.and post-treatment available in the aphasiology literature (e. Whitney & Goldstein. . equating science with effective effectiveness. resultant outcomes data by attending to the scientific princi- sibility of single-subject research in the clinical arena. the NOMS these designs with neurologically-impaired adults also are project advocated the use of 11 pre. or graduate students from ative performance data from persons without neurologic local university programs can be recruited and trained to impairments. and are recommended Treatment-Outcomes Research to clinicians. including repeated measurements. they can share these tasks. Thompson & Shapiro. & Goldstein. providers around the world. Massaro & selecting interventions and advocating for or justifying Tompkins. 2002. replicating or extending existing studies. conduct behavior probes for no-treatment tasks and phases. ethical considerations would motivate and support the collection of credible evidence about treatment 8 Of course. assessing social validity to determine whether any changes 1997). 1986). Feeney & Ylvisaker. Franklin. maximizing reliability and validity of mea- (1987) suggest that the major difference between typical surement and treatment implementation. particularly if programs. emerging regulations and clinical problem-solving may dilute or trivialize the meaning of the former. treatment outcome studies are con- largely responsible for this situation. 1989. and gathering compar- ested. treatment plans. efforts to evaluate a treatment approach for a patient with yielding less confidence in results than would rigorously- fluent aphasia. ing controlled research in a clinical environment is no doubt As indicated above. or with ationally specifying the nature of the client’s abilities and the assistance for collecting and analyzing data. McReynolds & Kearns.asha. the often highly-specific the maintenance of behavior change after treatment ends. Doyle. Ballard & functional measures. 1993. 1999. scored on 7-point scales. 2003. attempting to control or account for extraneous factors such In addition. 2003. 1986a. some estimate of treatment effectiveness. 1991. With a goal of developing a national database for for addressing those questions.g. Warren et al. along provided one vehicle for collecting and analyzing outcomes with some of the single-subject designs that are appropriate data. if any. In describing their ducted in the typical setting without stringent controls. Kent (1985a) provides a National Outcomes Measurement System (NOMS) has useful table illustrating a variety of research questions. In the real world. ASHA’s McReynolds & Thompson. & Kaori.. accreditation requirements will ensure the accumulation of and misrepresent or overlook some of what occurs in the latter. The et al. 1995. In an ideal world. there remain rela. However. Garrett & Huth. effected have “made a difference. Oleyar. with those in the broader community of clinical service tively few published examples.g. clinicians can enhance the rigor recount a variety of problems that they faced when conduct. their data-gathering efforts. programming for and measuring probes outside the treatment setting takes time and plan..” These barriers notwithstanding. assist.GRBQ344-3513G-C05[161-185]. Yoshihata. reimbursement for clinical services. treatments used in single-subject research do not necessarily examining potential factors related to success or failure. Those who have the drive to Several avenues are probably most feasible for clinicians tackle a research problem. Evaluating Outcomes of Established Programs Numerous treatment programs exist. analyz- they enlist assistance in scoring. ing factors that may be important in interpreting assessment and the like. and generalize to the needs of other clients (e. tiative (www. ASHA’s recent EBP ini- 2006. Demographic and Edmonds & Kiran. of their treatments.qxd 1/21/08 11:30 AM Page 173 Aptara Inc.8 To recapitulate. bringing ASHA practices in line Despite the strengths of these designs. checking scoring reliability.. (1987). clinicians Schumacher and Nicholas (1991) designed studies. 1998. these include oper- a clinician is provided with release time for research. Moss & Nicholas. Some of the kinds of studies that clinicians can prob- ably implement most readily are described below. Clinicians Contributing More Generally who clearly believe that clinicians can generate worthwhile to the Professional Literature research in certain conditions.org/members/ebp/default) has in large 1989. 2006. 1997. to provide Thompson. could probably evaluate a ating outcomes (or efficacy) related to established treatment number of questions in their clinical settings. designing and implementing generalization as spontaneous recovery. and the ing research in their clinical setting. Kearns & Potechin NOMS database was intended to serve as a resource for Scher. If several clinicians in one location are inter- data or in implementing treatments. 1998). unless ples discussed thus far. Chapter 5 ■ Research Principles for the Clinician 173 1986. The difficulty of implement. Chujo. part subsumed these goals. generalization to untreated behaviors and settings. at least some level of treatment-outcomes data. assessing ning. Toshiko. and who consult with knowledge- who wish to contribute to our clinical evidence base: evalu- able researchers before starting. we agree with Schumacher and Nicholas (1991) and Warren et al. Freed consumer satisfaction data also have been collected. They question the fea. 1983.. McNeil et al. Kearns. Each of these is considered briefly below. as Kent and Fair (1985) warn. with only a cursory evidence base. stimuli. & Brookshire. Brenneise- about the program’s efficacy with two patients. Funding also is a likely concern. Attempting to replicate the findings noted earlier. Among the possible influences. Ylvisaker. Keith. and adults’ writing and drawing samples. as such. several studies have examined whether the be found in Massaro and Tompkins (1993). Sarshad. Nicholas. In other Barresi. 1982) for adults with global phasia. are factors such as age. Aphasics’ Communicative Effectiveness. procedures. Conducting Replication and Extension Studies Gathering Normal Comparison Data Replication and extension studies are particularly lacking in Judgments of our clients’ abilities and performance should the speech-language pathology research base. 1984) for a client with apraxia of speech and improve their specification. to run some studies. who examined the efficacy of extent to which the comprehension questions could be Visual Action Therapy (Helm-Estabrooks. For group data-collec- research. and Yorkston et al. & Wertz (1991). scoring procedures. & answered without reading the associated passages. Some examples of replication and response to this need. (1993). a good deal of planning and work must ments. In this case. injured patient. particularly those evaluating established . An example of this approach can For example. Hansen and McNeil (1986). so anyone non-brain-damaged participants who were similar in terms who wishes to replicate a study would need to contact the of socioeconomic status to the “typical” traumatically brain- original authors for specific materials and procedures. clinicians may note that the specification of treat. Investigations also grams. Elman. cue. physical health. and documented the Conlon and McNeil (1991). and gathered some data adults with aphasia (Bottenberg & Lemme. & Darley’s (1980) evalua- go into the project up front to specify stimulus choices. MacLennan. who assessed Porazzo (1989) revised and standardized the administration the long-term effectiveness of PROMPT treatment and scoring procedures for the Boston Naming Test. normative data for their revision as well. Time- of Assessments of Treatments demands and the need for consultation and support person- Questions about the content. Bosje. tion of a shortened form of the Porch Index of ing/prompting criteria and hierarchies. However. or interpretation nel have already been emphasized. mally aging adults’ picture descriptions. Schumacher. or hearing impair- participants. and Brookshire (1986) evaluated a number of grams. study replicating a treatment approach used in two previous Roberts. Another set of and the like. 1991). have focused on determining the psychometric properties of ment procedures is inadequate to allow consistent treatment abbreviated versions of standardized assessment instru- delivery. 1987) that has been recommended for 1985) has observable effects on narratives elicited from traumatically brain-injured patients. who (1987). the availability of appropriate participants is a major ical observation. 1993) who reported on the discourse performance of from providing complete methodological detail. literacy. In one example. however. page limits on publications preclude researchers (1990. work. Brookshire. who documented the influence of investigations for word-finding problems. 1991. is an excellent way for a clinical can design protocols to gather group data as a partial researcher to begin. having equipment and of assessment tools have motivated a variety of clinical facilities on hand also is important. These kinds of questions typically stem from clin. Black (1994) presents an even less-frequent phenomenon: who assessed some characteristics of performance in nor- replication and extension by the original investigators.GRBQ344-3513G-C05[161-185]. The authors reported extended aphasia. Some examples are provided by Parr extension studies can be found in Beard and Prescott (1991). Communicative Ability (Porch. Nicholas. One model of this kind of work is provided by reading-comprehension batteries. or to extend the study using different partici- ment. after that it becomes a much simpler inquiries has focused on whether hypothetically important matter to carry out the treatment program and to use it with elements of treatment programs have an effect in practice. In any context. Typically. & Cohen. 174 Section II ■ Principles of Language Intervention Clinicians are well-situated to evaluate these sorts of pro. Tompkins et al. education. or settings. Fitzpatrick. from an already published project with another sample of socioeconomic status. such as DiSimoni. & ple comes from Freed and colleagues (1997). to (Chumpelik. The work of education on judgments of non-neurologically-impaired Kearns and Potechin Scher (1989) and Byng. “new information” principle of PACE therapy (Promoting tionalized a Feature Analysis treatment program (Szekeres. Bastiaanse. Nickels. few relevant data are available. who opera. and Kimelman and McNeil tices of normal adults. Davis & Wilcox. other potential candidates. 1981). Another exam. Clinicians pants. range of characteristics. tion. who examined everyday reading and writing prac- Bloise and Tompkins (1993). but it may be possible interested clinical investigator.qxd 1/21/08 11:30 AM Page 174 Aptara Inc. & Franssen (1996) also reported a studied writing with the nondominant hand. practical concerns affect the kinds of Analyzing Factors that Influence Delivery and Interpretation questions or problem areas that one can study. (1992). who exhibit a limited guage and cognitive tasks. But they are be made against a backdrop of knowledge about the non- important in part because so much of our research has been neurologic factors that may influence performance on lan- done on small samples of participants. Nicholas. MacLennan. When attempting to evaluate these kinds of pro. they are good candidates for the issue. g. and risks and benefits of Prescott.org/default. the of the study may be at issue: control for spontaneous recov- nature of normal language and cognition) as well as familiar- ery or examiner bias may be in doubt. Google Scholar (http://scholar. PsychINFO.ancds.GRBQ344-3513G-C05[161-185]. for research consumers. they can begin developing tionalize and measure variables.asha. 1993. www.asha. the necessary observations — with acceptable levels of valid- While reviewing the relevant literature.g. or similar committee. able registry of systematic evidence reviews (www. and the ASHA Web site (www. along with specific precautions taken cated issues of the journal Aphasiology) are all available at to protect participants’ research rights and the privacy of http://aphasiology. It is also recommended that the methods be Computerized databases such as PsycLIT. Doing so available literature. before a study is initiated can help avoid later problems of lem have not been addressed adequately. For example. In the end.gov) provides abstracts of funded research projects. it is probably wise to check preliminary ideas and plished by consulting with experts and by reviewing the plans with someone who has research expertise. Persistence and of the dependent measures may be debatable. 1991b.htm) Institutional Review Board. because.html). there is no teristics of the participant sample. particularly in adults. or to repli- cate and extend findings in research that is essentially sound. developed to rectify particular issues of concern. Lemme. the operationalization ity with guidelines for evaluating research. the proposed research. For those who research protocols in order to protect the rights of research wish to study neurologic disorders of language and com. due to vari- clinician-investigator should be able to formulate answer- ous potential biases in the EBP review process (e. a evidence will be overlooked in such compendia.org/practice.qxd 1/21/08 11:30 AM Page 175 Aptara Inc.cit. a feature called a “Forum”. current interest. Elman. consent form. competencies.. clinician-investigators Institutes of Health’s CRISP database (http://crisp. Brainstorming with others about the best ways to opera- ests. Chapter 5 ■ Research Principles for the Clinician 175 treatments. A detailed erences. 2006). to see what aspects of the research prob. and in general. e. and more recently in dedi. or the durability and mean- perfect design for any study. these committees ask for a Clinical Aphasiology Conference (e. and are particularly valuable ref. When clinicians decide that they have the appropriate inter. some such information resides at the ANCDS perceived value of the research may be the most important Web site (www.. Planning can proceed by focusing on the questions that Initiating a Research Project have been outlined above. tified by searching current compendia of treatment evidence larly if the clinician is willing and able to spend some extra and/or treatment guidelines. 1986b. the findings tolerance for imperfection are important personality charac- may have limited generalizability given the size and charac- teristics. and pilot-tested on at least a few people before the actual data Medline.org/ members/ebp/compendium) and links to other relevant sites Some Competencies for Researching Clinicians (e. and supports. These allows ASHA members to search the main speech-lan. personal interests and the disorders. 1991a.. publications from the jected benefits. the quality nature of neurologic disorders and their treatment. research protocol after the research committee’s initial This format alerts readers to subject matter and questions of review. spelling out these elements for the partici- tent/02687038/) also periodically dedicates an entire issue to pants. Even experienced investigators generally and Index Medicus will help interested readers locate the rel. funding bias. or at all. These skills try to determine what factors point to the need for further presume current knowledge in the content area (e. For aphasiology and related time in the workplace.rcslt. and Massaro & Tompkins.pitt. 1993)—particu.google. it can take quite a while for such . which presents a lead article on a Often an investigator has to make modifications to a topic. as part of routine clinical practice (see. and subsequent commentary by other investigators.. or about how to minimize a research project. the investigation in an area of interest. description of the aims.ingentaconnect. institution’s Research and Human Rights Committee. should ascertain the requirements and procedures of their nih. It is worth noting that some relevant With assistance from expert collaborators as needed. committees are responsible for reviewing all planned guage pathology and audiology journals.. is a valuable activity. And again. The first step is to hone the idea that factors that might confound the results. their personal information and research data. the National Finally. and to make tion bias.edu. also is essential.org).com/con. procedures. in research as well as in clinical endeavors. 1989. in the planning phase.g. participants and to minimize research risk in relation to pro- munication.g. Compromises are always neces- ingfulness of results may not be addressed. This can be accom. ASHA’s National motivators for clinicians deciding to embark on the research Center for Evidence-Based Practice also provides a search- enterprise. Typically.com) feasibility testing. sparked interest in the investigation. is also a good source for a discerning eye. Gaps in the evidence-base can also be iden- Kearns. A project can be sary. as Warren (1986) reminds us. Aphasiology (www. publica- able questions that have practical significance. and abstract journals such as Psychological Abstracts collection begins. identify wrinkles that remain to be ironed out during initial evant literature. interpretation. the Royal College of Speech-Language Therapists site. the reader should ity and reliability — to offer tentative answers.g. As a result. or K-awards. The American Speech-Language-Hearing Foundation might be fundable by the National Institute on Aging (ASHF) has for a number of years sponsored New (NIA.gov/index.asp) provides 2 years of funding to study criteria. Speech-Language Pathologists. and even some ing research efforts to new investigators both inside and funding. For predoc- Funding may be an important consideration. Other governmental sources of funding graduation.cfm). Some hospitals and rehabilitation centers sponsor grants/) includes topics such as “Grants and competitions for funding. The NIH Small research question and appropriate methods prospectively.org/foundation/grants/.asp). Audiologists. might be partially fundable provides a directory of grants. or for paying research assistants or http://grants1. and (b) the Canadian Institutes of (www. NIH Career Development Awards.qxd 1/21/08 11:30 AM Page 176 Aptara Inc. the NIH tial salary coverage in order to obtain release time to plan also funds individual fellowship grants (F31. www.” which sored by a faculty member. the clinician-investigator may be able to frame a NIH offers a variety of opportunities. such as the small grant to supplement ASHF New Investigator Alzheimer’s Disease and Related Disorders Association awards. Language.nidcd. are intended for Opportunities for Funding and people who hold a doctoral degree. larger efforts. a clinician-investigator’s project. . which provides funds for initiat- 2.” which primarily gives information staff research efforts. foundations. www. spon- and “Resources for Grantwriting and Funding. among others. Many universities grant seed about grants available from the National Institutes of monies for pilot projects that are expected to lead to Health (NIH). but some projects 1.ca/e/780. and tor’s goals may have to be modified to some extent unless Speech. (d) For students of all levels. and one for teacher-investigators.asha. as well as a list of relevant publications courses on grantsmanship.nidcd. the American Association of University . to encourage Grantsmanship. for an individual client during the typical period of sponta.nimh. Requests lists opportunities for research in Canada and supports to subscribe to this on-line mailing list can be sent to training awards for clinician-scientists and new-investiga- asha-research-digest-request@lists. include (a) the U. A variety of funding opportunities may be htm). (a) the ASHA Research Listserv outside that system. depending on their level NIH funding from the National Institute on Deafness of expertise. ual provides information on funding assistance and is For example. ASHF also who wish to have more information about the grants awards New Century Scholars grants.alz.nih. the NIH offers regional seminars on program funding elements: one for doctoral students who plan to funding and grants (see http://grants1. Merit Review program (www1. an investiga. and Web sites. including those for new investigators. 3.gov training/careerdevelopmentawards. F32 awards.nih.htm). conferences. ASHA publishes a (www.nih.org/members/research/reports/research_list Health Research (http://www. 176 Section II ■ Principles of Language Intervention committees to grant final approval.org/shop).asha.htm).gov) or the National Institute of Investigator research grants for those who have recently Mental Health (NIMH.gov/funding/ a way that can be applied to the next patient(s) who fit the types/researchgrants. it may not be possible to investigate changes sold in ASHA’s on-line store (www. www. which have two process.nih. through highly competitive grants.org/professionals_and_researchers_research manual called “Funding Sources: A Guide for Future ers.org/members/research/ cases. and Hearing Scientists. and Other Communication Disorders (NIDCD. Language researchers would most likely apply for available for clinician-investigators. ASHA provides a range of information.html.asha. Several are outlined below. which ing.asha.nih. and conduct a project. Individual grant support may be available from private (Neurophysiology and Neurogenic Disorders) offers a foundations associations and foundations. Internal institutional funding may be available in some for Researchers” (www.asp). For example.nih. For example. as well. support pilot projects and feasibility research for inves- tigators with limited research experience. Universities also may have funds to help that have funded clinical-research efforts in communi. Department of Veteran’s Affairs Information about each of these opportunities is avail. tor salary awards. support dissertation research. fellowships. (c) ASHA’s Special Interest Division 2 5.S. Universities also offer cation disorders. neous recovery from stroke. or release time.gov/grants/funding/funding_program.gc. tion of the ASHA Web site called “Grants and Funding 4. either for par- toral or postdoctoral student-investigators. cihr-irsc.asha. For those completed their latest degree program. and workshops.org. but who have Consultation Assistance primarily clinical training (http://grants1. professional_ dev.” This man- and until there is an already-approved research protocol.gov/grants work in an academic setting in the United States after seminars. the laborator.nih.GRBQ344-3513G-C05[161-185]. in Grants Program (R03. formerly Medical Research Council of Canada).gov/resdev/funding/ able at http://www. and agencies in this way. www. participants.nia. (b) A sec. With help from a research col.htm) gives a weekly update on opportunities for fund. Governmental funding may be available.va.gov). When treatments are not intended or expected to result www.ancds. abstract for evaluation by the program committee.org) provides Clinical significance and meaningfulness of outcomes have its members with opportunities to exchange information and been recurrent themes in this chapter. tiveness of service delivery. from their treatment focus to the desired end result. thanks to a conference 2006). and garnering recognition and There are a variety of avenues for identifying potential grant support. payers. It is anticipated that the future will see invitation to the Clinical Aphasiology Conference much more attention to documenting the clinical impor- (www. Clinical Aphasiology conference.org). legitimate to focus for some period of time on the impair- nals. A clinician-investigator should not be the institution’s accountability to various consumers.org. at the Science and Research Career Forum and the APPLICATION OF RESEARCH PRINCIPLES Research Symposium that coincide with ASHA’s annual con- Level of Outcome and Clinical Significance vention. tion for establishing interdisciplinary collaborations grams/giar/index. bent upon investigators to specify the eventual pathway Information and consultants for interdisciplinary investiga. and consequently . such as conversational proficiency. The costs involved are justifi- fi-06-ebp. As noted previously. and in recent years.org/education/fgaindex. immediately in clinically significant gains. 1987). whether To date. Attending such conferences is valu. it will be incum- vide information and links about relevant research.g. A clinician-investiga. which list their authors and reviewers. and ASHA Web site provides its members with helpful informa- the Sigma Xi Research Society (www. Other steps to clinically-relevant outcomes.org/.org) by submitting a research tance of changes effected by interventions. this may have contributed to the grant from the NIDCD. e..g.apta.sigmaxi.asha.clinicalaphasiology. But one obvious dilemma in doing so is University faculty members or master clinicians who that there are almost assuredly intermediate or prerequisite publish their work would be good contacts as well. a good consultant also trative approval and support for their research efforts.aota. especially in the initial stages of treatment.org.org/. ASHA has spon- sored travel fellowships that give new and minority investiga- tors the opportunity to present research. and the community.com/). whenever possible. (www.qxd 1/21/08 11:30 AM Page 177 Aptara Inc. Student investigators also structure and function (impairment) rather than on social have an opportunity to compete for funding to attend the communicative functioning (but see. The way to get the most out of a Selling the Administration on Your Research Plans consultative relationship is to consult before beginning a project.. indicat- tions also can be culled from the national and international ing why or how their treatment goal should be an important governing bodies for related disciplines (e.parkinson. associated with specific disorders (e. It is certainly critical to imple- but simply reading published conference proceedings or con. www.cfm).aphasia. completed or in FUTURE TRENDS IN THE CLINICAL progress. also points out the value of efficacy data for Internet resource to link clinicians and researchers demonstrating accountability to quality-assurance evalua- for collaborative research (www. outcomes can be linked to treatments provided. As such. The AHSF has put on several workshops on treat. might be willing to serve as research consultants.shtml). such as afraid to seek help with a project by contacting people with clients.GRBQ344-3513G-C05[161-185]. research and clinical intervention in aphasia and or not the paper is accepted for presentation. The value of consulting assistance has been emphasized repeatedly in this chapter. two authors can related disorders has focused most often at the level of body attend if the paper is accepted. it is probably sources of possible expert consultants are professional jour. But Investigators in most clinical settings would need adminis- best-laid plans being what they are. www. As suggested earlier. poor opinion of our profession held by some neurologists able for both continuing education and networking purposes. which applies to initiating and sustaining any types of collaborative relationships. therapy: http://www. ment-efficacy research. Silverman (1985) provides arguments related to increasing ject after the fact. occupational step along the way to some meaningful outcome. Chapter 5 ■ Research Principles for the Clinician 177 Women (www.. and Web sites ment level.org/members/ebp/ tors and third-party payers.aan.. maximizing the effec- the appropriate expertise. these concerns are paramount from a reimbursement per- tor who is the first author on a research effort can secure an spective as well. Third-party payers’ ideas. and with an annual education and scientific meeting requirements for functional treatment goals indicate that the day before the ASHA convention. Brown et al. rather than trying to salvage mistakes later.g. physical therapy: http:// Another problem in targeting ecologically valid outcomes www. ment and evaluate interventions that target more ecologi- sensus reports can also point clinicians towards experts who cally valid outcomes.. The Academy of Neurologic Communication Disorders and Sciences (ANCDS.org) that pro.htm). www.aauw. Conferences and workshops provide another able with relation to the enhanced confidence with which venue. Warren (Warren et al. ASHA is creating an an administrator.asha. neurology: http://www. may be able to help rescue some elements of an errant pro. and other medical personnel.org/pro. a clinician and consultants. The is that they can be difficult to operationalize.strokeassociation. The future should see more attempts to Aphasia in Relationships and Conversation (Lock. This approach has been used in social validity using data from several phases of treatment stud. & Ferketic. ate hypotheses about processes that are at work. & Mikolic. 2001). approaches can provide a rich source of ideas for those who ject group or time of sample. though. 1998) Communication subscale measures two constructs (under.. Edmundson. Recent research work also will be needed to assess the correspondence has expanded the value of the ASHA-FACS Social between these sorts of social-validity data and other measures Communication Scale (Donovan. 2001) in aphasia. More recently. Wohl. a normal criterion may to quantify “functional outcome” (see Frattali.. but in be appropriate.qxd 1/21/08 11:30 AM Page 178 Aptara Inc. 1992) to explore dynamic aspects of conversational Social-validity assessments are relatively new and infre. The common practice of matching com- Holland. 2002. including that collected during maintenance probes. experiences. Strauss & Corbin. and sensitivity to change we foresee more care in specifying individual participant have been questioned. Crisp. contextual influences on communication. vides another frame of reference for evaluating communica- investigators should begin to assess clinical significance or tive success in aphasia. which provides a more parison and treatment subjects only for chronologic age and extensive and specific evaluation of communicative disability gender will be recognized as insufficient. Doyle. and that complements the scientific orientation described earlier that the Key form can be used to demonstrate treatment in this chapter. These investigators also cautioned that the Social e. Maxim. 1999) is another option for investigator relies on “disciplined subjectivity” (Heron. and selection of the scaling are interested in documenting. and more than half of the . ment of “participation” (WHO. Goldstein. social interactions in a variety of authentic contexts. Dollaghan. describe a Communicative Profiling System that uses quali- Two additional means for demonstrating the functionality of tative methods to evaluate communication behaviors and treatment outcomes are to achieve generalization to everyday strategies. 1998. Doyle. Velozo.g. the p. validity. Simmons- Hula. but functional. 143) to interpret the accumulated information and gener- Burden of Stroke Scale (BOSS. Bilingual/Multilingual Aphasia When patients are severely impaired. Conversation ment outcomes. 1992. Shiffrin. much more supplement to these general assessments. 2004). describing. a qual- ingful can be shown to have staying power. and phe- rating could be substituted for the original 7-point rating. & Fromm. is a good As procedural issues are being sorted out. & of communication performance in natural environments. Frattali. progress. The Holland. 1990. Denzin & Lincoln. available network of communication partners. One of the salient questions (Campbell & ing meaningful outcomes. 2006). so much the better. While lacking Silverman (1985) discusses several other critical factors elements of rigor identified earlier in this chapter and partic- such as the design of the social validity tasks. The ASHA-FACS (Functional variables that should be relevant. Perkins. 1992) has to do with the choice of the “gold standard” for a normative Developing the Evidence Base in comparison approach to determining clinical significance. McNeil. and characteriz- method. involves detailed data-gathering through extensive inter- standing and conversing) instead of just one. including some of those Assessment of Communication Skills. several investigations (e. 2003) was established as a valid and reliable Mackie & Damico (1996) emphasize the goodness-of-fit patient self-report measure of function and well-being between the qualitative research perspective and the assess- (Doyle et al.g. Whatever the comparison group. nomena is at the core of a nontraditional research approach that caregivers could rate items reliably on this subscale. & Walshaw. Analysis (Goodwin & Heritage. many cases. 1993. so standards and criteria for conducting them programs as SPPARC: Supporting Partners of People with are still evolving. For mildly involved patients. Thompson. Frattali. 1995.. Perkins. And if effects that are generalized and mean. validity. 1995). would be obtained by either approach alone. Bruce. their reliability. The BOSS allows assessment of com. This “qualitative research” approach (see. Bryan.. diverse language backgrounds. Rosenbek. Ferguson. A variety of generic rating scales have been used cator. pro- To examine the durability of clinically important changes. et al. and the settings and tasks and to document the social validity of treat. and has been adapted for clinical use in such quently used. aphasic communi. Wilkinson. are paramount here as they are in any measurement effort. for adults with aphasia and traumatic brain injury. collaboration. 1994). an appropriate stan- dard might be one that approximates the communicative Growing numbers of people across the United States have performance of a milder. Ketterson. The viewing and observation of communicative behaviors and Communicative Activities in Daily Living (CADL-2. Perkins. numbers and ularly susceptible to (unintended) examiner bias. and generalizability ment studies (e. Tompkins. itative research method derived from discourse studies. 178 Section II ■ Principles of Language Intervention to measure. 1998b). Milroy & ies.. They munication difficulty and distress. 1996. assessing functional communication.g. Donovan and colleagues found that a 4-point The assessment of real-life behaviors. Some treat- ity.GRBQ344-3513G-C05[161-185]. 1999) have combined quantitative and qualitative methods in Questionnaires and rating scales should be constructed so an effort to establish a more complete clinical picture than that the resulting data are sound. 1990. develop a rigorous technology for determining social valid. The concerns of reliability. qualitative characteristics of raters. among other measures. including their knowledge of sub. identified above. g. interact with volunteer partners who are trained to support ment delivery. and its success hinges on the interactional variables. 1997. single- Targeting communication-partner behaviors. communica. Kagan. and methodologically sound Turner and Whitworth (2006) underscore in particular the studies that examine within. the important direction in treatment research (see Turner & adults with aphasia who conversed with these trained part- Whitworth. Yet there are very that can be manipulated in therapy. involve telerehabilitation. or diminish their focus on the communication partner rather than the person effectiveness. including those that involve communication partners.qxd 1/21/08 11:30 AM Page 179 Aptara Inc. Black. the potential benefits of interventions that participant with aphasia has time to respond. 2006. (2006) recently published an admirable investigation with a And in a twist on this theme that emphasizes the level of par- single-subject experimental design that provides a useful ticipation. rig- Kearns. Personalities and prior rely on communication partners as intervention agents. has the potential to enhance generalization of treatment communicative exchanges. In short. and Simmons-Mackie & Kagan are likely to spur further exploration in the future. controlled study. of clinicians with diverse further investigation and evaluation.. Worrall. setting within which to target both linguistic and communica- Marshall.g. A clinician would have to invest time to train the have considerable ecological validity. Supported We expect to see heightened attention to establishing the Conversation for Adults with Aphasia (SCA). Simmons. 2001. remains a relatively untapped but potentially skills of trained communication partners. and to monitor delivery of treat- ing less direct treatment. One such model. 2005).and across-language treatment limited available information about the influence of a con- for bilingual/multilingual aphasia. Kearns.. nication breakdown. language backgrounds.g. Additionally. 2001. and allow more treatment Treatment Approaches to be delivered than would otherwise be feasible or afford- Even before funding pressures prompted increasing explo. communication partners.. Group therapy for aphasia is increasingly being con- 1999) also have been used to describe dynamic partner sidered a viable adjunct to individual treatment. the future also may see more efforts to train Nonetheless. pro. 1991. 2005. Cruice. Another nontraditional intervention approach. and is communication partners as intervention agents (e.g. Duchan. few systematic. either of these approaches can have a number neurologically intact member of a communicative dyad would of pitfalls. some interest in nontraditional options was evident. Packard & Hinckley. this area of clinical investigation is vital. & Potechin. and to isolate variables such as topic initiation cases may serve as the primary therapeutic milieu. Simmons.. and Potechin (1987. a lack of conceptual models of bilingual/ tain social relationships with their aphasic friends. Relatedly. able. (1999) reported systems designed to quantify partner strate. has been effectiveness of nontraditional intervention approaches. tive goals. the opportunity to vide therapy in a group context. and in many interactions. Edmonds and Kiran versation partner on the outcomes of a person with aphasia. unless creative outcome measures are employed or until suf- Mackie. involve the neurologically-intact communication partner Flowers and Peizer (1984). After training. 2001). so that they could be addressed gains because the group context provides a relatively natural in treatment. as it is for et al. Chapter 5 ■ Research Principles for the Clinician 179 world’s population is at least bilingual. Measures of conversational burden (e. Bourgeois. see also Simmons-Mackie orous evaluation of effectiveness will be necessary. interplay between participants. for a recent review). or incorporate conversational-level communication using a range of meth- pharmacotherapy. In addition. any language-intervention approach. it will become more imperative to ment and/or evaluation of responses. patterns of interaction between communication partners Some research has already explored interventions that also may mitigate against these methods. ficient high-quality evidence is available. Purdy & Hindenlang. of assessment tools with the area of conversation-partner training remains ripe for adequate psychometric properties. instead of or blind. it may be difficult to get reim- with aphasia (e. Kagan et al. on both information transfer and tion is an interactive process. ing them some specific things to do in the event of commu- ment. This . & Phillips. Kagan et al. bursement for services that target communication partners. and of access to interpreters. Simmons-Mackie. including those with severe aphasia. multilingual language processing. theoretically. Burgio et al. & Square. 1998). After all. For example. and Hickson (2006) recommend model for future work.GRBQ344-3513G-C05[161-185]. group treat- gies and to identify those that were more or less successful in ment. And of course. (2001) demonstrated in addition to those of the individuals with communication the effectiveness of SCA in improving the conversational disorders.. ners were also improved. Despite these possible priate partner behaviors. In their recent review. such as interrupting before the drawbacks. developed by Kagan (1995. Freed. fully expected to receive increasing attention in the future. This approach may accomplish several goals simultaneously: it can bring the intervention to the natural environment... Evaluating Effectiveness of Nontraditional free some of the clinician’s time. rely on computerized treat. In a randomized. ods and expressive modalities. And with clients receiv. It also may empower communication partners by giv- ration of alternatives to direct individual language treat. SCA offers individuals. Turning some attention to the Obviously. 2005) evaluated an intervention to diminish inappro. The difficulties in this area of study training the friends of people with aphasia on how to main- are many: e. Research and clinical decision-making processes potential advantages of group treatment. Small. The 1. 1994. ments for the person with aphasia at the levels of impairment Lastly. tiveness and the opportunity to tailor tasks for individual 2. A scientific orientation to clinical management has patients. 2003. its value for aphasia and related language disorders. Avent. Bollinger. 2003).. & Saffell. go to document the effectiveness and efficacy of treatment thus 1999. 1999). Group-treatment approaches have also delivered. the Web site of the positive outcomes. ASHA recently held a cooperative study comparing the effects of individual and grant competition for model telepractice programs as part of its group aphasia treatment (Wertz et al. definitive benefits remain unknown. The aphasiology literature is beginning to include some factors to be considered in providing and evaluating group examples of studies that use telepractice methods to measure therapy for individuals with aphasia. but there is a long way to ing group treatment of patients with aphasia (e. The seminal Veteran’s Administration American Telemedicine Association). involves artificially implanting tissue ships/quality of life (Hinckley & Packard. These studies have demonstrated improve. with or methods can be conceptualized as subsets of the area of com- without the aphasic partners in attendance. Horbach. A few recent exam. aphasia (e.. A more complete discussion of the inquiry.org/about/publications/leader-online/archives/ Holland. Georgeadis. Sherr. & Diller. Brecher. This initiative was designed to facili- 1993) have demonstrated improvements on both standardized tate the delivery of quality health-related information and clin- and referential language measures. 2005). Simon. e. Elman. Kearns (1994) reviews tise.g.. as well as in functional ical services to those who face access barriers. 2001). 2004).. One obstacle to analyz.. 2004) will be highly relevant to telerehabilitation as well. 2004) Computer-aided approaches to language treatment are document the spectrum of its use and reported effectiveness.. have a number of parallels. (2005). 1993. also burgeoning. Marshall. 1997. & Schnider. www.. such as lack of communication abilities. 1999. As with the and application of high-quality evidence.g. Clinicians should become critical consumers of the cussed here. & (www. functional promise as nontraditional approaches to treating aphasia.g. with their thoughts about improving the evidence base.g. decades now. Katz.. Brennan.g. EBP reviews. regardless of the format in subjected to rigorous evaluation over time to establish its which it is provided (e. individual effectiveness and efficacy.atmeda. Schwartz. Laganaro. 180 Section II ■ Principles of Language Intervention undoubtedly is due in part to reimbursement constraints. conference presentations. One.g. Group treatment also has been evaluated in other among or between residual intact regions. 2002. & Robey. Wallesch & Johannsen. as KEY POINTS well as generalization of learned skills to noncomputer lan- guage contexts. Wertz & Katz (2004) recently studies. Katz Pharmacologic intervention has been investigated for several & Wertz. current references discuss methods for delivering and assess.qxd 1/21/08 11:30 AM Page 180 Aptara Inc. Baron. Some critical reviews of tiple participants.asha. (van der Gaag et al. but further research is necessary to determine Raymer. and a number of other performance in aphasia and related disorders (e. activities (Hinckley & Packard. Marshall. Fink. pharmacotherapy in aphasia (e. Elman & Bernstein-Ellis. cuitry to help the recipient regain function (Small. continuing-educa- provided an evaluation of selected studies in the area. 1997. two forms of biologic intervention may have (communication skills). 2004). such as cost-effec. must be weighed against possible disadvantages value for a variety of reasons. 2006... 2005). van der Gaag into the brain to increase the number of synaptic connections et al.GRBQ344-3513G-C05[161-185]. ing the effectiveness of group treatment specifically is the Pharmacotherapy is another biologic approach for which complexity of implementing rigorous data-collection for mul. mostly when a clinician is also involved. Musson. tissue or cell transplantation aims to reorganize neural cir- Langenbahn. The accumulating evidence in administered as an adjunct to traditional language therapy. 3. and the future promises to see expansion of which ranges from no benefit to some positive results when efforts in this area as well. & Barker. and that reimbursement decisions for treat- merits and drawbacks of computer-aided aphasia rehabilita.htm).g. still in its infancy. 2004) shows some promise of improvements in language performance with computer-delivered therapy. other nontraditional treatment approaches that are dis. along tion coursework).g. Research that uses populations.org. 2003/q2/030415d. Di Pietro. 1981) as well as other initiative to increase Web-based service delivery more recent studies (e.. recommendations for improving ples are provided by Hinckley and Packard (2001) and van der the evidence base on computer-aided treatment (e. clinical accountability is enhanced by following the nities for communicative interaction and exchange for the hypothesis-testing approach that guides scientific person with aphasia. computer-delivered aphasia therapy must be relevant evidence base.. . 2001. ment will rest increasingly on a clinician’s knowledge tion was published by Roth and Katz (1998). such as traumatic brain injury (Rath. Kohen. Wertz & Gaag et al. puter-assisted intervention. To the extent that specific telepractice models and been used with the relatives of people with aphasia. among these are that such as a lack of procedural flexibility and limited opportu. for individuals at all severity levels in availability of clinicians with appropriate and specialized exper- various group-treatment approaches. who may have multiple goals. and family relation. Small. but Telerehabilitation is another clinical service model that is on evidence is emerging that group aphasia therapy can effect the rise (see. telerehabilitation. (1999). base in some way? Why or why not? And if “Yes. computer-based (2004).. perfect. Aphasiology. M. tion and collaboration to support clinician-investiga.. & Thompson. and partic- References ipation restriction.. the term “treatment efficacy” confidence in the outcome has been affected. L.. C. and document. 301–313. validity. and/or gathering protocol for repetition deficit in conduction aphasia. Aphasiology. L. N. A. . M. 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The effect of videoconference-based telerehabilitation interventions.” which involves rigorous. ethical. and practical 5. 1.. Communication treatment for adults with quences of treatment. (1993). R.” (p. Group treatment in aphasia using cooperative study rationale. (1996). approaches involving communication/conversa- Brennan. 7. on evaluating the functional and social conse. Debate Rosenbek. J. & Rosselli. Outcomes assessment also can be characterized with reference to a multi-dimensional model of the conse- quences of health conditions. R. and why? results of treatment in typical circumstances.. Barker. 10. L. and using your not easily be isolated or controlled. Spontaneous language produc- chapter. Right brain damage and 10. research. Discuss the benefits of a scientific approach to clinical Clinical significance should be addressed as well in decision-making.. 12). or is. unshared listener knowledge on narratives of normal and apha- 12. 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Outcomes of computer-pro- siology: Conference proceedings 1984 (pp. L. K. Ranier. 21–30. 12. Washington. A. 580–594. C. J. Basics of qualitative research: Techniques Aphasiology. L. R. 18. M. (1987). Thousand Oaks: Sage. Pharmacological perspectives.. 372–80.. (1994). Friden. Garcia- approaches and research opportunities (pp. A framework aphasia. (2005). M. (1999). Davis. Lemme. 483–510. 398–401. A single case for group treatment studies in Szekeres.. methodological considerations. 19(4). T. C. sis of “loose training. & Katz. S. Stroke. 229–244. Yorkston. 1282–1289. DC. F. K. Brain & Language. Weiss. (1998). Farrier. Simmons-Mackie. R. Improving aphasia treatment research: Some Washington. A. I.. introduction to patient management. V. Washington. Warren. Smith. L. T. C. M. et al. J.C.. & Johannsen-Horbach. DC. 19(6). D. T. R. & Whitworth. R.. group treatment. Wallesch. Gabriel.. J. 9–11. Jackson. L. Aphasiology. Evaluating research in speech Yoshihata. 201–224. L. 165–172. N. J.. R. L. Zeches. In M. Aphasiology. Aphasiology. Journal of Speech and Functioning. R. R. people with severe aphasia. Aten.: National Institute on Gobble (Eds.. B.GRBQ344-3513G-C05[161-185].qxd 1/21/08 11:30 AM Page 185 Aptara Inc. Communication strate. Ylvisaker. R. P. Acquisition and generalization of mode interchange skills in MA: Addison-Wesley. L. M. T.. & Goldstein.. Geneva. S. Wertz. A. H.). ization of social conventions in aphasia: An experimental analy. A. H. 18(4). J. & Cohen. D. Conversational partner train.. et al.. Chujo. Dronkers. & Gaddie. (1987). Aphasia treatment: Current approaches and research oppor- for cognitive rehabilitation therapy. Brookshire (Ed. (1981). 54. (2006). 583–593.). In D. Comparison of clinic. S. Efficacy during acute rehabilitation. 66–80). T. A. R. National Institute on Deafness and Other Communication home. T. 113–122. Neurologic factors early stage. size of onset (Basso. The chapter pro- ceeds in two major sections. For example. the long-term cerebral 1964).GRBQ344-3513G-C06[186-202]. Two stages in the recovery of function have been differenti- didates for treatment. from prognosis to treatment schedules. ing the effects of these factors on recovery to guide their Raaschou. months post-onset (Vignolo. including determining Time Course of Recovery prognosis. lesion and type of aphasia have some implications for severity. Chapter 6 Aphasia Treatment: Recovery. a weekly schedule of treatment. spontaneous recovery (Pederson. 1964). Vignolo. uated on admission to the hospital. The neurologic factors and anagraphic factors. & factors include personal characteristics such as age. steepest in the in research on recovery from aphasia and prognosis is that first month post-onset. hand. with little or no sponta- logic consequences of therapeutic interventions. Therefore. when maximum language recovery takes place. Harlock.qxd 1/21/08 11:32 AM Page 186 Aptara Inc. Patients with aphasia were eval- clinical decision-making. and health status. subsequently flattening out. (2) review current information regarding the neu. and many of these factors are interrelated. and Clinical Effectiveness Leora R. and is type of aphasia. size and site of lesion. clinicians must settle on justifiable treatment(s). Robey warranted. Second. post-onset of aphasia (Kertesz & McCabe. Prognosis. are related to etiology. Kertesz & McCabe. In addition. studies related to recovery The objectives of this chapter are to (1) describe the typical are summarized. Spontaneous recovery drops precipitously by 6 to 7 changes related to resolving aphasia. physiologic indicators of recovery. 1995). 1977. spon- edness. the sectioning has been imposed merely recovery and rehabilitation. an early stage and a late stage (Kertesz. & Olsen. A prospective study of 330 patients with aphasia supports and type of aphasia may not be independent of age. and the neurophysio. RECOVERY ery as well as factors associated with negative recovery impact several clinical decisions and actions. for organization purposes and it will be readily apparent that sonal factors affecting prognosis. and. there has been an increased focus on patho. Coates. 1992. One of the difficulties encountered taneous recovery has a decelerating curve. 1988). Cherney and The range of clinical decisions extends beyond prognosis and candidate identification. in fact. 1996). Nonethe. sex. with particular emphasis on the factors that time course and pattern of recovery in individuals with may be considered when determining prognosis. (3) identify neurologic and per. Once the decision to treat is Randall R. Nakayama. a pattern of recovery from aphasia consistent with that of less. aphasia. through modern neuroimaging considered by investigators to occur within 1 to 3 months technologies. Benson & Ardila. clinicians have relied on the extensive literature examin. 1977). interact evidence regarding clinical outcomes of treatments provided with one another. and (4) review scientific these topics are not mutually exclusive. by speech-language pathologists. Anagraphic neous recovery occurring after 1 year (Kertesz. Clinicians who treat individuals with aphasia have fre- quently sought to uncover indicators of recovery. and the duration of treatment. Jorgensen. First. Reliable information regarding factors associated with positive recov. the scientific base underlying treatment-related decisions is roanatomical and neurophysiologic mechanisms underlying reviewed. site of finally reaching a plateau between 6 and 12 months post- lesion determines to some extent the type of aphasia. 1979. The purpose of this chapter is to review the information OBJECTIVES base underpinning the broad range of clinical decisions. and identifying can. Basso (1992) has differentiated between ated. counseling significant others. However. weekly during their 186 . and severity and coincides with the period of spontaneous recovery. Pashek and Holland (1988) followed 43 subjects global. and Clinical Effectiveness 187 hospital stay. cal motor aphasia or anomic aphasia. they did not change classification and remained Similarly. the degree of underlying aphasia evolution. has a different outcome. There was a trend for younger patients to evolve to a Broca’s aphasia. in .. Patients were evaluated with the performance is a necessary condition for evolution of apha- Porch Index of Communicative Abilities (PICA) on five fac. Like Pashek and Holland (1988). Pattern of Recovery Nicholas. Patients who presented initially with a flu. individuals with aphasia. Similarly. tient changes from the first test session to the second than spective study that followed 35 males with aphasia from 3 to those who did not. while the others evolved to transcorti- ent aphasia continued to demonstrate a fluent type of apha.GRBQ344-3513G-C06[186-202]. from the acute stage (within 5 days post-onset) and subse. but it was in patients with severe or global aphasia. than those who did not evolve. The greatest amount of Western Aphasia Battery aphasia quotients obtained serially improvement occurred in the first 6 months. patients who presented initially with a fluent aphasia contin- Pashek and Holland (1988).9%) changed aphasia type as they recovered. In contrast. from one aphasia type to another had greater aphasia quo- ple. aphasia. The that the direction of evolution appears to operate under investigators found that stationary language function was some constraints. Chapter 6 ■ Aphasia Treatment: Recovery. further. Ferro quently at 3. and 12 months post-onset. Ward-Lonergan. with most types of aphasia evolving within global at follow-up. it was found that an aphasia quotient tors—speaking. comprehension. depending on the site of lesion. and 24 months post-onset. and Riege (1989) conducted a retro. Anomic aphasia was often the end-point attained by ble localizations for the infarcts that cause acute global patients regardless of whether they initially presented with aphasia are (a) frontal lesions with or without subcortical fluent or nonfluent aphasia (Kertesz & McCabe. and that each type mately 60% of the sample evolved and were reclassified. Horner. the clinical status of most of the patients 1996). 1977. the best prognosis was the first month (except conduction aphasia. bilizing. interact with the evolution of aphasia (McDermott et al. 18. and not initial severity. and then at 6 months post-discharge. (1993) followed 24 subjects with severe aphasia. Kertesz and Assessment of Severe Aphasia (BASA) at 1 to 2 months. writing. showed a change at about 6 months post-onset) to that of None of these patients remained global. Using descriptive (1992) concluded that there are five different types of global criteria to define aphasia type.qxd 1/21/08 11:32 AM Page 187 Aptara Inc. by 3 months. McCabe (1977) studied the evolution of aphasia using the 12. and change of 20 points or more predicated aphasia type evolu- copying. the BASA. For exam. Patients were evaluated with the Boston been identified for each type of aphasia. However. Helm-Estabrooks. Those patients who evolved recovery can vary greatly from patient to patient. Patients with global aphasia resulting with each type of aphasia showing a pattern of evolution. and at 3. while older patients remained global or evolved to a Wernicke’s aphasia. improving to Broca’s aphasia types. others sta. from large fronto-temporoparietal lesions with or without They noted that change most frequently began at about 2 subcortical damage had the poorest prognosis and remained weeks post-onset. No medical factor Several studies have investigated the evolution of typology could be found to account for the regression. However. sia type. Specifically. and 12 months. The other three possi- sia. suggesting that improvement in language 55 months post-onset. From a study of 54 patients with global aphasia. they found that approxi. and Morgan Despite individual variation in rate and extent of recovery. nonfluent aphasia. one patient was not anomic aphasia. They confirmed first 3 months was the crucial period for improvement. Patients with nonfluent or fluent aphasia who evolved approximated the clinical status that was measured at from one aphasia type to another were less severely affected 12 months. Hanson. (b) posterior parietal infarct. and (c) a double lesion composed McDermott. aphasic at follow-up. Pashek and Holland noted that language decline occurred in those patients with (1988) found that age was a factor in the evolution from relatively milder aphasia. and that aphasia subtypes differ in their reached in 84% of the patients within 2 weeks. 6. more. global aphasia. 1988). These patients further information about the evolution of the different showed a variable degree of recovery. they found that of the patients within 6 weeks from onset of stroke. noted that improvement most The investigators also noted that aphasia severity may frequently began at about 1 to 2 weeks post-onset. Prognosis. 6. They followed 39 patients and evaluated them or transcortical aphasia. Ferro (1992) also found that the regularly with the Western Aphasia Battery. subcortical involvement. involvement. with or without Pashek & Holland. in their longitudinal study of 43 ued to demonstrate a fluent type of aphasia. gesturing. with some patients improving significantly. and in 95% evolution. was the critical variable even years after onset of stroke. They found that 39 of the patients with global aphasia showed improvements on 93 patients (41. 6. and DeLong (1996) have provided of a frontal and temporal cortical infarct. Metter. of which 17 there seem to be some general patterns of recovery that have were global. which typically found for those patients with large subcortical infarcts. and others (10 of 35) regressing. Language performance continued to evolve over tion in about two-thirds of the patients with both fluent and years. While most of at 45 days. magnitude of Late or long-term recovery may take place months or change. 188 Section II ■ Principles of Language Intervention contrast to the findings of Sarno and Levita (1971). Capitani. which permits enduring functional changes to occur. correlated strongly with outcome for a group sion may be the only modality to improve. due to direct impact on outcome (Basso. often special treatment. type of aphasia. Pederson et al. while only 2 weeks was required for 95% of those abnormal function. they found that patients with and collateral sprouting refers to changes in connections more severe aphasia demonstrated a longer period of lan. none of whom Neural Mechanisms of Recovery received language therapy. (1992) also found that initial severity was gested that the greatest changes for global aphasia were evi. improvement. (1992). Marshall. Tompkins. The preceding discussion has focused primarily on descrip- independent of type and severity of aphasia. (1995) have stated (Andrews. including the thalamus and the cerebellum. several Severity of Aphasia mechanisms may contribute to brain plasticity: (1) Diaschisis The initial severity of the aphasia is an important factor to refers to depressed function or hypometabolism of struc- consider in the recovery from aphasia. For a moder- dent in the 6. category of the aphasia. guage recovery than patients with less severe aphasia. tory and reading comprehension showed no significant and a consistent trend has emerged. 1992. and improvement of local cir- language. both oral expression and Several longitudinal studies have considered the pattern of written expression improved uniformly over 7 months. Mark. & Wagenaar. For patients with nonfluent aphasia. although tor for ultimate language function. Expression showed less recovery. Further studies are needed to clarify its with a mild aphasia to achieve maximum function. in performance on language tests. Indeed. related to outcome of each language modality. 1978. According to Bach-Y-Rita (1990). dif. Diaschisis may occur within the damaged left hemi- 1996). comprehen. and (1982) found that improvements of oral and written compre. Feeney & Baron. However. 1978). 1991. region. and Moraschini oral or written expression. audi- recovery as it relates to the individual language modalities. 95% of patients with While collateral sprouting may be a mechanism of functional moderate aphasia reached maximum function within 6 recovery. 1978. While these are not com- the 7 months. Some long-term that initial aphasia severity is the single most important fac. improvement was evident in auditory comprehension over a Spontaneous recovery. plasticity.. while reading comprehension improved over the imaging have allowed researchers to address those factors first month. Brain apparent only after 2 years post-onset. 95% of patients with severe aphasia reached structures. These results are supported by Mazzoni et al. importance to recovery from central-nervous-system lesions. More Collateral sprouting has been demonstrated in some neural specifically. However. In their investigation of its mechanisms are not well understood. Marshall & Phillips. Similarly. reading comprehension improved signifi- Kenin & Swisher. the sudden interruption of synaptic connections with the 1983. characteristics. these factors probably do not play a role recovery of language modalities may be dependent on the in long-term recovery of function (Bach-Y-Rita. leading to weeks. Berndt (1992) found that initial severity as measured by hension and production were usually associated. it is important to consider. tive accounts of the behavioral changes that occur during ferences in language recovery were evident in relation to recovery from aphasia. 1986). However. Lomas & Kertesz. refers to the capacity to modify structural organization and functioning. the apraxia. and a higher percentage improve in oral as group of 24 patients. technologic advances in the area of brain months. are those factors associated with brain plasticity. of patients with global aphasia. over a 7-month period. they caution that differ. However. For a severely impaired production. Basso. who assessed a selected sample of 45 patients. in part. rather than neuroradiologic some patients who do not receive rehabilitation. a higher per. Rather. between neurons from intact cells to denervated regions. auditory comprehension and. In addition. Mazzoni et al. Similarly.to 12-month period post-stroke. may be due. Prins. to the resolution of because it was negatively influenced by the presence of oral local factors such as the reduction of cerebral edema. the neuroanatomical and neurophysiologic mecha- sion and written expression improved steadily throughout nisms contributing to recovery.GRBQ344-3513G-C06[186-202]. Auditory comprehension improved for 4 pletely understood. significant that play a role in early and long-term recovery. recovery may occur with the dissipation of diaschisis. (1989) contend that culation. ately severe group of 21 patients. 1990). (2) Regenerative the time course of recovery. because performance on these modalities was centage of patients improve in comprehension as opposed to initially at a near normal level. Thomas. to a opposed to written language (Hanson & Cicciarelli. 1972. Typically. while no significant improvement was observed for Snow. 1982. Paolucci et al. which occurs naturally without 4-month period. also. while no significant changes were evident in written absorption of damaged tissue.qxd 1/21/08 11:32 AM Page 188 Aptara Inc. maximum function within 10 weeks. The in- vestigators found that comprehension had the best recovery. oral expres. lesser extent. it also may be a maladaptive response. For patients with fluent aphasia. not only because of its turally normal cortical regions remote from the lesion. of greater interest to the rehabilitation profes- ences in recovery between aphasia categories may become sional. but also because of its interaction with other factors sphere as well as in the contralateral right hemisphere affecting recovery. & Phillips. . cantly. who sug. Hanson et al. severity of their spontaneous speech. cut. to rate of recovery.. Knopman. Lau. deep to account. Goldenberg & has also been demonstrated with regard to spontaneous lan- Spatt. The involvement of Wernicke’s area is also an important In a series of studies that looked at location and extent of factor to consider in recovery from global aphasia. patients with small lesions demon. If the damage was in half or less of ally dominant system fails. According ized by reduced. or possibly specific structures. However. a corre- nism for recovery. 1992. and involves reorganization of structure and tributed to the prediction of language recovery. Partial sparing of the Neuroanatomical Factors: Lesion Size and Site posterior superior temporal gyrus was associated signifi- A basic assumption about recovery from aphasia has been cantly with the highest recovery rates for comprehension. recovery of auditory comprehension at 1 year. Prognosis. Niccum. For example. If the lesion involved more than half of recovery from aphasia involves at least three overlapping Wernicke’s area.. involvement of the supramarginal gyrus was associated with poor recovery rates of both overall lan- guage and auditory comprehension. involves the recovery of transiently impaired neural temporal-lobe extension into the middle temporal gyrus tissue in the ischemic penumbra. sures of aphasia severity and comprehension with lesion Restoration of function occurs only following increased blood extent in 22 patients with Wernicke’s aphasia. while those with large lesions matter areas were combined. parietal. lesion size may affect each modal. cal area that contained an extensive lesion that could be used comprehension changes were not significant because com. The two subcortical white- demonstrated improvement in auditory comprehension matter pathway areas which. 1989. rounding the core infarct. and the periventricular unquestionable. the two groups were separable on the basis of the medium-sized lesions improved significantly in all modali. occurring in the first few days after even at 1 year post-onset. 1979. Ludlow et al. it is the size of the lesion within specific areas subcortical frontal. patients exhibited poor comprehension. et al. group presented with no speech or only stereotypes in Rubens. gyrus and the anterior mid-temporal area were important further recovery (the third stage) depends on establishing new for overall language recovery. 1986. Naeser lesion on CT scans and the severity of impairment in dif. (1987). speech. Basso (1992) asserts that while the negative spontaneous speech were the most medial and rostral por- effect of extent of lesion on initial severity of aphasia is tion of the subcallosal fasciculus. Kertesz. severely limited only. 1987. Patients with However. With regard gies to facilitate more effective communication.. Naeser and col. 1989). while the extent of involve- pathways for processing components that were “cut off” by ment of the angular gyrus contributed most significantly to the brain damage as well as learning compensatory strate. poorly articulated. Selnes et with aphasia were divided into two groups based on the al. when damaged. The angular function relationships. Chapter 6 ■ Aphasia Treatment: Recovery. stages. CT scan analysis revealed no single neuroanatomi- strated significant recovery in oral and written expression. and severity of auditory comprehension. & Larson (1983) found that there was a significant which no meaningful verbal information was conveyed. The more severe ity differentially. (1993) correlated outcome mea- cient blood to survive. Ferro. One group had large cortical/ lesion size.. 1990) indicated that rather than total divided into two groups. and Clinical Effectiveness 189 (3) Unmasking of preexisting but functionally depressed was no correlation between total temporoparietal lesion size pathways or substitution may be the most important mecha. Kertesz et al. rather than overall lesion size. months. (1990) examined CT scans of 14 patients with global ferent groups of individuals with aphasia. The other patients with Wernicke’s aphasia (Naeser et al. to distinguish the more-severe from the less-severe group. and temporal lobe lesions that that may affect recovery from aphasia. Twenty-seven patients 1993. Furthermore. the negative correlation between lesion volume and recovery of less severe group presented with Broca’s aphasia character- comprehension for large but not smaller lesions. The second stage of recovery begins within et al. Kertesz et al. aphasia. When the reorganization is complete. This cortical reorganization occurs when lation was found between the amount of temporal-lobe axons and synapses that are present but not used for the par. con- years after onset. 1992. once initial severity has been taken into white matter near the body of the lateral ventricle. Based on the CT scan information.qxd 1/21/08 11:32 AM Page 189 Aptara Inc. agrammatic to Mazzoni et al. there group had large cortical/subcortical frontal and parietal . Like Naeser flow to this area. However. the effect of lesion size on recovery is not clear. the area of the brain sur. it is not enough to function. hesitant. Mazzoni et al. comprehension. anterior-inferior stroke. prehension was relatively unimpaired initially. area was associated with particularly poor recovery. 1987). The acute stage. the lower motor/sensory cortex area for the mouth. that lesion size exerts a negative influence on recovery The importance of lesion extent within specific structures (Demeurisse & Capon. continues for weeks. In their study of 10 included more than half of Wernicke’s area. Furthermore..GRBQ344-3513G-C06[186-202]. & Polk. they found that the extent of involvement within days of the stroke.. Although this area receives suffi. (1992). 1983). 1994. damage within Wernicke’s area and severity of auditory ticular function under study can be called on when the usu. Similarly. Selnes. CT scan when extent of lesions in two subcortical white- ties except written expression. guage output (Naeser et al. patients exhibited good comprehension at Hillis and Heidler (2002) also hypothesize that functional 6 months post-onset. patients were leagues (1987. Wernicke’s area. 2004). or both. verb retrieval (Warburton. The sphere zones spared by the lesion. However. 2004). et al.. Rather. aphasia. Furthermore. Schatz. hemisphere activation (Karbe et al. Turkheimer.. it has been & Pawlik. & Wise. Several imaging studies support Results of these neurophysiologic studies are not always the notion that right-hemisphere activation occurs early comparable because of differences in the imaging tech. Other studies have demonstrated that the levels of improvement during therapy and less total recovery. 1996. 1996). 2004. Bird. and word repetition (Ohyama at 1 to 4 months post-onset and then again 1 year post. 1999). they found that lesion size negatively influ. and nam. word repetition. & Lodder. Karbe. Rosen et al... 2006). Ghaemi. activity to language recovery may depend on the length of gators to focus on the functional consequences of the lesion. technologic advances such as PET. Rosen et al. 2003.. 1993. More poorly understood is the way in which thera- effects of lesion size in patients who are more than 3 years peutic interventions change brain systems responsible for post-onset. Wise. Kessler.. Xu et al. and functional MRI (fMRI) have permitted investi. the complex process of cortical reorganization of language- ing.. as long as the expansion was unilateral patients recovering from aphasia have reported shifts in acti- and gradual (Naeser et al. 1999. Language assessment was conducted initially Swinburn. 1996). Fernandez et al. 2003. However. extended to the subcortical temporal lobe including the tem. Cardebat tention that lesion size alone is not necessarily an important et al. right hemisphere and the remaining left hemisphere tem- porobasal regions showed a similar amount of spontaneous poroparietal language structures important for picture nam- recovery than patients without such lesions. 1996. where severe deficits continued.. Carpenter. patients with aphasia.. but less ing. of more complete recovery. Ohyama et al. Thiel. While the physiologic vation to the contralateral undamaged right hemisphere and mechanisms underlying the lesion expansion are not under. & Petersen. more recently. time following stroke onset.qxd 1/21/08 11:32 AM Page 190 Aptara Inc. but lesion location was more work for naming. They followed 18 patients with slow rTMS was used to inhibit activation in the anterior aphasia across a period of 8 weeks of spontaneous recovery. Van Zagten. during recovery (Fernandez et al 2004. There of study results (Cherney & Small. 1999. gated whether size and site of lesion had differential effects Evidence supporting an anomalous role for the right during spontaneous recovery as compared to a period of hemisphere during recovery comes from several sources. 1998). Miura focusing primarily on the structural damage related to the et al. Warburton et al. Several studies in effect on language. Significantly more recovery in auditory comprehen. Consistent with previ. Boiten. 190 Section II ■ Principles of Language Intervention lesions.. location of the lesion.. factor to consider for recovery (Heiss.. portion of right Broca’s homologue. with subsequent reduction of hyperactivity had a beneficial ous findings. stood. More recently. although the lesion task paradigms have included reading sentences (Thulborn.. promoting better modulation in both the important to consider. niques and the task paradigms that are used.. poral isthmus. 1996. (1999) showed that activation in the . Price. Blank. intensive treatment (since language therapy may employ Naeser and colleagues (2005) demonstrated improved nam- mechanisms that are different from those at work during ing in four subjects with chronic nonfluent aphasia when spontaneous recovery). However.GRBQ344-3513G-C06[186-202]. & have not considered how these factors impact language ther. a visible expansion in lesion size can be A critical issue relates to whether language improvement observed on CT scans after at least 3 years (Naeser et al. 2000) and that it stands in the way apy outcome. maladaptive response reflecting loss of active transcallosal Most studies on the effects of lesion size and location inhibition (Belin et al. & Karbe. Heiss. two studies have shown that in some language. Naeser et al. For example.. However. Perani et al. 2004. and a follow-up suppression of this maladaptive right-hemisphere response period of 8 weeks without treatment. have interpreted these as a compensatory function (Buckner. 1998b. related brain regions during recovery from aphasia remains None of the studies discussed above have examined the limited. by recruitment of homol- increase in lesion size in the left hemisphere had no adverse ogous right hemisphere regions. Goldenberg & Spatt (1994) investi. Heiss et al. The neuroimaging CT and MRI studies discussed previ. 2004. these results provide further support for the con. Kessels.. 1999). activation in the right homologous regions do not correlate with measures of verbal production (Fernandez et al. Wernicke’s area was spared. Patients with lesions to the tem. patient differences in the size and onset. suggested that right hemisphere homologous activation is a 1999). The relative contribution of right and left hemisphere SPECT... 2000) or Neurophysiologic Studies of Recovery comprehension (Breier et al. and variability in time post-onset and sion had taken place at 1 to 2 years post-onset for the group type and severity of aphasia also prevent direct comparison that did not have lesions involving Wernicke’s area. 1994. Kessler. Corbetta. 1998a.. effect on the more widespread bi-hemispheric neural net- enced recovery in all phases. understanding of recovery of spontaneous speech. Weiller et al. 1995). Thulborn et al. Fink. They postulated that 8 weeks of intensive language therapy. & Just. 1999). Despite the was no significant difference between the two groups in rapidly accumulating body of literature. Raichle. during recovery and rehabilitation is supported by left hemi- 1998.. better recovery has been associated with greater left- ously have allowed quantification of site and size of lesions. Rosen et al.GRBQ344-3513G-C06[186-202]. 1999. In the study by Leger et al.. phonologic training via reading aloud (Small. and Clinical Effectiveness 191 right inferior frontal gyrus was temporary and decreased treatment with Melodic Intonation Therapy (MIT) (Belin et within 8 weeks after stroke onset. original rationales of this therapy was that it would help the Fourteen patients with aphasia were studied using fMRI and “transfer” of language functions from the dominant but an auditory comprehension task at three time points after injured left hemisphere to the musically adept right hemi- left-hemisphere stroke: in the acute phase (mean 1. 1998). 1998b). 2003). changes were reexamined using the same fMRI tasks. not only did stroke). Johnson.. Chapter 6 ■ Aphasia Treatment: Recovery. Even the simpler question regard. Thereafter. Interestingly. Helm. Similarly Xu et al. For example. Cornelissen et al. at least for the types of tasks used in these functional pany interpretations of all case studies in aphasia recovery is imaging studies.. & Noll. 1974). (2002). and the . but decreased bilaterally in most responsible for language. had mostly recovered. sphere activation followed by reshifting of activation to the The MIT study was particularly notable since one of the left hemisphere is provided by Saur and colleagues (2006). Distinct patterns of activation were apparent at each left-hemisphere activation increase. Flores. tion of articulatory gestures followed by repetition. during oral reading but regions of the right hemisphere remains unanswered. but the pattern of acti- time point. with brain-activation changes depending on lesion served. language skill.. Abo et al. Heiss et al. Thompson (2000) (2004) observed right inferior frontal activation during a described changes in the right hemisphere homologues of covert word-generation task in a patient with left frontal both Wernicke’s and Broca’s area during a sentence-picture damage. 2003.qxd 1/21/08 11:32 AM Page 191 Aptara Inc.1 days post the exact opposite. 1999. seen in normal controls. 1996). with activations noted in Broca’s regulation with recruitment of homologous right-hemisphere area (left inferior frontal gyrus) and the superior part of the language zones. Vikingstad. however. therapy. Prognosis. there was a return to the normal pat. regions on story comprehension. not be relevant to those observed in another. and picture naming of a core of words (Leger et al. New increased activation bilaterally on story comprehension. In contrast. & Herholz. ilar way. when language comprehension left supramarginal gyrus. Other investigations have suggested that that there is significant individual variability in anatomy and right-hemisphere participation is present when there is functionality. Karbe et al.. type of intervention. Kessler. aphasia and compared their functional neuroanatomical responses to a younger control group on two tasks. particularly Wernicke’s area. left-hemisphere activation may represent sparing or restora. increasing activation in the damaged left stroke onset. during early recovery may depend on the site and size of the In contrast. Musso et al. (2004) observed right tion between increased activity in the right temporal cortex frontal activation during repetition in a patient with a left and comprehension scores in four subjects with Wernicke’s frontal lesion. Yet it seemed to do after stroke onset). Cherney and Small (2006) studied two patients with chronic 1999. and in the chronic phase (mean 321 days post hemisphere. George. Studies that directly assess the functional anatomical changes behavioral (language) and functional neuroanatomical that occur as a consequence of language therapy are begin. between scanning sessions.. Heiss. The other participant with ing the relative contributions of the intact portions of the a temporoparietal lesion showed decreased activation. an oral- reading task involving overt speech and a “passive” audiovi- Neurophysiologic Studies Following Rehabilitation sual story-comprehension task. & Welch. parietal area displaying statistically significant training- The extent to which right-hemisphere activation occurs induced changes. right inferior parietal activation occurred in a aphasia following brief intensive training of comprehension patient with left temporoparietal damage. damage. These observations suggest that the site of the It should be noted that most of these studies report on right-hemisphere activation depends on the site of the just one or two patients. perilesional al. and the patterns observed in one patient may greater damage to the left-hemisphere language areas (Cao. results differ across studies and the participant with a frontal lesion who was most respon- there is no consensus about our understanding of the way in sive to therapy.8 days sphere (Sparks. with a single perilesional area in the left inferior sphere. but not in two patients with left temporoparietal matching task following a sentence-processing therapy. with greatest activation in the left hemi. 1998a. 2002). In addition. Following identical therapy. Further support for a pattern of increased right-hemi. aloud. & Albert. and memoriza- was inactive early on after injury (Heiss et al. (1999) demonstrated a correla- left-hemisphere lesion. with strongly reduced activation of remaining vation following treatment was more similar to the pattern left language areas in the acute phase. left-hemisphere activation may be particularly important Results highlight individual variability following language when a positive response to the intervention has been ob. followed by an up. par- damaged left hemisphere versus homologous and other ticularly in the right hemisphere. For ning to emerge. (2003) found that all three of their subjects behaved in a sim- tern of activation. 2000).. Thus the caveat that must accom- lesion. in the subacute phase (mean 12. repetitive naming of semantically tion of normal function in tissue around the infarction that related pictures (Cornelissen et al. brain activation increased in the right hemi- which therapeutic interventions may change brain systems sphere during oral reading. Left-sided activations have been reported following site and size. reading Thiel. with etiologic factors predicting poor outcome (Henley. 1977. 1996). 1976. & Mertz. 1978). and there- Other studies have not found age to have a significant effect fore indirectly related to language outcome (Holland et al. neural mechanisms that mediate recovery and rehabilitation. Wertz. which may not emerge as independent predictors only a minor role in recovery from aphasia as compared to of outcome. Mammucari.qxd 1/21/08 11:32 AM Page 192 Aptara Inc. Wiggins. Sarno. Capitani. Obler. in part by age differences. Todd-Pokropek. Heiss et al. Kertesz & McCabe. prognosis for occlusive strokes is more limited depending on As further studies yield new information or confirm pre. These findings are consistent with those of Marshall et al. vious information. Since type of aphasia may be the prognostic factor comes. 1985). Basso aphasia. 1996). In par. 1982.. 1987. The effects of age on recovery should also be considered This is an important issue because better knowledge of these in relation to general health status.. 1982) and for auditory Laiacona. Fromm. 1992. 1990). it may not be sufficient to characterize rather than age. Clearly. Benson & Ardila. 1969. Keenan & Brassell. duration of hospitalization al. and with Hilari. Goodglass. Renzi. Capitani. However.. rehabilitation on patterns of language organization. the effects of age on recovery must be consid- dependent and individually different (Cherney & Small. 1982. Albert. stroke as “left” or “right. in a mechanisms may lead to better management of the patient prospective study of outcome following ischemic stroke. 1980. Similarly. and psychiatric Although personal and biographic factors appear to play disorders. Advanced age may be associated 2006). typically have a good prognosis for language reflected in differential reorganization of the language recovery after the mass effect is eliminated. Combining individual differences Miceli et al. 1971. handedness. Alves. Sarno & Levita.” when in fact they are highly task. other studies have found no significant . may be related to age and general health status. 1995. been associated with poorer outcome after stroke. 1964). who usually are somewhat younger than patients with occlu- comes associated with different types of treatment may be sive strokes. 192 Section II ■ Principles of Language Intervention nature of the fMRI task. the site of the infarction (Basso. Diamond.. Individuals with hemorrhagic strokes. Rubens. we will move closer to understanding the 1996. and the and gender have been studied experimentally. & Vignolo. In particular. 1998). Pederson et al. ered in relation to etiology. This may be explained intervention. factors of age. Sarno. older individuals with a more severe initial stroke demon- strated poorer general outcome at 3 months post-onset (Macciocchi. & Shankweiler. & Benson. further. and Smith (2003) who identified number of co-morbid suggest that younger patients have a more favorable outcome conditions rather than age as a significant predictor of than older ones (Gloning. 1993. these factors history of hypertension. & Rodriguez. 1979. the network. with task differences leads to a wide variety of possible out. Marshall et with chronic aphasia. 1981. 1977). as well as neurological factors (Benson & Ardila. Code & Rowley. & Swindell. females had a better prognosis than older than patients with nonfluent aphasia (Basso. Such factors as history of prior stroke. Therefore. Similarly. Tissot. (1982) and Marshall and Phillips (1983) who found that general health was a predictive variable of speech Age and language performance. Vignolo. Gender 1976. on recovery (Basso. or cardiac disease. health-related quality of life in a large group of individuals Holland. 2004. Some studies that have addressed the effects of age on recovery Byng. Faglioni. & Luzzatti. Basso (1992) the pattern of recovery in patients with aphasia (McGlone. 1977. For example. patients with aphasia resulting from open or closed head ticular. & Razzano. psychosocial. 1980. cautions that the interaction of age with type of aphasia must 1977. Ferro & Madureira. Greenhouse. In two studies investigating the effects of sex on be considered because patients with fluent aphasia may be recovery from aphasia. 1992. nature of the language task. Heiss. 1974. 1989. Sands. de Riesthal & 1989). the site and size of the lesion. since trauma usually affects preting the relationship between observed changes and the younger individuals. For example. Benson & Ardilla. any studies of the effects of age on recovery observed changes in language-related activity patterns after must control for type of aphasia. have should not be ignored. many questions remain regarding the effect of Pettit. persons. research is needed to address the various factors that injury appear to recover better than patients with aphasia potentially influence recovery patterns. with aphasia and better prediction of outcome.GRBQ344-3513G-C06[186-202]. with some impact of these co-morbid disorders may be greater in older conflicting evidence regarding their effects. 1985). It has been proposed that gender differences may influence In a review of prognostic factors in aphasia. 1997. 1980). de comprehension (Pizzamiglio. Wertz & Dronkers. such as the type of resulting from stroke (Kertesz & McCabe. investigation is also needed in inter.. in contrast. & Ferrari. The study also indicated that there was a correlation of age with co- Personal Factors Affecting Prognosis morbidities such as medical. & Tupper. the behavioral out. Trappl. Messerli. males for oral expression (Basso et al. & Quatember. diabetes.. Roy. and the focus of the et al.. Indeed. Robey & Schultz. 1992. A successful out- Psychosocial Factors come in Phase II may warrant a Phase III clinical trial for Emotional and psychosocial changes accompany aphasia testing the efficacy of a treatment. warranting these treatment decisions. Therefore. the higher than that at the acute stage (Astrom. Hermann & Wallesch. Phase III research (Hemsley & Code. 1970. Farabola. Pickersgill & Lincoln. and policy makers. The next section reviews the information base for rapidly from aphasia. That system begins in may be adopted for considering a hand as dominant. like gender. 1993). clinicians must assess the information 1983. puts to test the general expectation of benefit among persons Starkstein & Robinson. Furthermore. they caution that psy. record of development and widespread application in general chosocial adjustment over time in patients with aphasia and practice is associated with a literature base that includes several their significant others. Sarno. & Levita. affect the extent to which language recovery either gender (Basso. and V studies a reasonable et al. Pederson et al. Hemsley and Code (1996) broadly recognized treatment protocol with a substantial found unique patterns of individual emotional and psy. and preliminary evidence suggests a relationship developing treatment protocol. Prognosis. with discovery-oriented research for the purpose of Therefore. the findings about the effect of uncovering new treatment protocols. Therefore. can predict outcome. Since it appears that no single factor alone McCabe. little is known of the interactions decisions of speech-language pathologists to public-health between these changes and recovery from aphasia. 1977. For a sia. such as motivation. 1996. However. 1985). many studies have focused on the prognostic having the characteristics of Phase IV treatment-effective- indicators that may help predict outcome in patients with ness research. However. Fucetola tocol is a record of Phase III. 2004a. decreased to 16% by 12 months post-onset. which is also known as the effec- post-onset. emotional and psychosocial The five phases of treatment research represent a normal well-being may play a significant role in recovery from apha. Phase I. and that different criteria for assessing clinical treatments. Pickersgill & Lincoln. Hermann & Wallesch. A impact on communication and rehabilitation progress can. However. a proportion 1998). A successful clinical trial jus- depression was found in 25% of patients with stroke during tifies Phase IV research for assessing specific outcomes in the acute stages. one would expect to find some between mood state. 1993. econo- factors. are not easily amenable to exper. Many issues and the decisions of public-health analysts. clinicians must be cognizant of the various ways that outcomes can be measured and. in deter- Handedness mining prognosis. and func. there appears to be no converging evidence favoring combination. 1988). post-stroke in a specific clinical population. & Zanobia. Grassi. but also consider Some authors have proposed that left-handers and ambidex- quality-of-life-measures. The Current Context for a Review of Scientific Evidence Laiacona. Phase V. this incidence rose to 31% at 3 months day-to-day clinical practice. That is. the majority of treatment chosocial and emotional adjustment and its prognostic research findings come from Phase I and Phase II studies. Chapter 6 ■ Aphasia Treatment: Recovery. Starkstein & expectation. In clinical aphasiology. and tiveness of a treatment (Robey. and severity were similar. 1995. 1993. & Naesser. 1977. An issue affecting the dence on clinical outcomes of treatment protocols. 2006. than right-handers (Gloning. In the last phase of clinical research. Therefore. even in patients where aphasia type studies in each of the phases of clinical research. Subirana. Borod. progression of development and knowledge building. Only for a mature treatment pro- tional communication (Code & Muller. Clinicians also must decide if the trous and mixed-handers have a more bilateral representa- expectation that treatment will effect positive change is jus- tion for language processing. Three important factors influence any assay of scientific evi- 1990. imental study. Adolfsson. 1970). outcomes for aphasia has been obtained through studies In summary. Nonetheless. and Clinical Effectiveness 193 difference in recovery for males and females (Kertesz & been discussed. in the normal course of events. 1990. through Phase II research in which new protocols are devel- oped and tested for their basic properties.. A relatively small fraction of the scientific aphasia. mists.. in time. a Robinson. The system progresses handedness on recovery are inconclusive. & focus of research moves from clinical outcomes and the Asplund. The first interpretation of these studies is that handedness may be influential factor is a logical and broadly recognized system evaluated by different methods. Several of these studies and their key findings have evidence on treatments for aphasia has been obtained .qxd 1/21/08 11:32 AM Page 193 Aptara Inc. large proportion of the scientific evidence on treatment not be anticipated. IV. at this about each variable and make inferences about how they. then rose again over the next 2 years to 29%. and therefore recover more tified. 1958). 1988). better prognosis for non-right-handers is not supported by OUTCOMES OF TREATMENTS FOR APHASIA the data from later studies (Basso.GRBQ344-3513G-C06[186-202]. For example. Luria. consider not only language-impairment and functional-communication measures. Buonaguro. Phase I and Phase II studies. Additionally. 1983). will occur. Carper. progress in rehabilitation. 1992). it has been sug- gested that recovery from aphasia is more frequent among patients with familial sinistrality (Luria. Indeed. or value. When may a the application of a certain set of ground rules be held practitioner ethically provide a treatment protocol in gen- strictly accountable to those ground rules? Should findings eral practice based on best-quality evidence?). didn’t findings arising out of each level in the hierarchy. Scientific rigor is assessed is straightforward: of course not. that the his. construct validity. and author of a forthcoming text appraising literature only through levels-of-evidence tables on evidence-based practice. case series. groups on ethical grounds. Because RCTs nominally embody experimental ies. evident in all aspects of experimental rigor and scientific tific evidence is the recent advent of evidence-based practice validity. At one time. the scientific evidence produced cessful RCT does establish the assertion of treatment effi- through Phase I and Phase II research designs are dis. Hearing Association). Taken in isolation. Language. cross-sectional studies. Dollaghan in her roles as value of scientific evidence based solely on the name of the Chair of the Advisory Committee on Evidence-Based Practice (American research design producing it is a natural consequence of Speech. These are the controls exceeding other research designs. purpose and render highly valued results when great care is The second influential factor in reviewing clinical scien. 194 Section II ■ Principles of Language Intervention through Phase III clinical trials. the distribution of commonly found in EBP (Dollaghan. certain in the broader clinical-outcome research community. exist for the researchers who were making large and impor. they establish the basic research gold standard for influencing clinical practice. Rather. they are absolutely essential for their system. EBP embraces many The third factor influencing a review of scientific research designs for investigating the effects of treatment evidence on clinical outcomes of treatment protocols is protocols: case studies.qxd 1/21/08 11:32 AM Page 194 Aptara Inc. evidence produced through a certain level may be more or less Should the body of clinical research completed prior to influential for informing clinical practice (e. ment of individuals with aphasia to no-treatment control mental controls such as random assignment. case-control studies. they are often research designs of Phases I and II clinical research.. 1979) through rigorous experi. . the practice of appraising the The fundamental ideas underpinning this and the next paragraphs are attributed to the scholarship of Dr. no the scientific-evidence base in clinical aphasiology doesn’t research design possesses inherent properties conferring (or completely conform to the expected distribution when clin. misdirects attention from the essential “Does protocol X bring out greater change than protocol Y?” questions: (a) What form of research is most appropriate for testing the salient hypothesis at a particular point in the developing line of clinical research. then. it is the crux of the matter. Christine A. That is. Prudence and good sense bias.g. that for all intents and purposes. a lack of about the best clinical practices. trial (RCT). only research designs are appropriate and essential within each within the past few years have aphasiologists been thinking phase of experimentation and the quality of any result about the system for (a) conducting evidence-based reviews derives from the experimental rigor that went into produc- (EBRs) of past research. a suc- trial. however. the bandwidth of confidence intervals.. and (b) designing and implementing ing it. It is not surprising. new research studies.g. linked to the quality of operational definitions (purposefully Why the discrepancy? Although the five-phase system for determined and otherwise) for implementing that design. Presuming underpinning the ultimate EBP research design: a clinical scientific validity and all other things held constant. treatment fidelity and compliance. parallel-groups stud. directly related to EBP: the randomized controlled clinical cohort studies. However. produced through clinical trials that must preserve internal many clinical aphasiologists objected to randomized assign- validity (Cook & Campbell. not) scientific validity to the observed result. The notion coming from studies that do not uniformly conform to the advanced here is not that experimental rigor doesn’t matter. The quality of ical research unfolds in a structured developmental sequence evidence produced through any research design is directly of clinical research. As will become evident in the fol- The notion that inherent properties endow certain lowing sections. a tabulated hierarchy of research torical record of research findings doesn’t conform com. statistical power. tant contributions. the sequential development of clinical research is recognized Within a structured system of clinical research. and so forth in the long and familiar listing of validity tained in the existing body of valid scientific evidence and issues). designs does not establish more or less scientific validity for the pletely with a system. presuming scientific validity at all levels in the hierarchy. and (b) How validly was 1 it carried out? Unfortunately. in speech and language pathology. The fact is that many through the usual means at all levels (e. the answer indeed.1 However. 2006). new structure be dismissed? For both questions. and single-subject studies.GRBQ344-3513G-C06[186-202]. a RCT is not always possible or desirable in counted as being less scientifically valid than the evidence clinical research on behavioral treatments. move scientists and practitioners to extract the value con. cacy. Neither is any of this to say that clinical trials are then build on that record within the broadly recognized irrelevant. the question for researchers has moved research designs with greater or lesser degrees of scientific beyond “Is treatment better than doing nothing at all?” to validity. Sometimes. high-quality studies inform researchers and practitioners effect size. In a thought to produce experimental results constituting the developmental sense. among others. Greener. (2006a) concluded that design ject effects (i.e.. relatively dated. (b) the average effect comes were communicated. no change from pre-treatment dent variables in aphasia treatment research have been to post-treatment). ally considered) are effective in bringing about desired rates all tests of that research hypothesis. Ten clinical trials met their inclusion and exclusion ologic limitations. the third MPO. a small corpus of these reviews is available Whurr. Enderby. the lack of efficacy. Bromocriptine. they concluded that treatments were criteria. change is evident. expressed in terms of activity limitation. historically. Enderby found that treat. several were ment was initiated after 12 MPO. corresponding to a medium-to-large effect. In the aphasia-treat. Notably. evidence warrants the conclusion that treatments (gener- aged. sis of 45 aphasia-treatment studies and obtained an average In a Cochrane systematic review. the value of the correspond. and Francois (1999) and Robey. design character. Of those. to achieve a single result that incorpo. size for Schuell-Wepman-Darley Multimodal-stimulation cluded that randomized controlled trials have demon. Although many studies were characterized by method- aphasia. and Nye (1992) conducted a meta-analy- for inspection. effect size is a quantity for measuring the degree of depar. Greener. treatment brought about an small treatment effect was detected for improved language appreciable improvement in performance when begun after performance. for treated-versus-untreated comparisons exceeded Cohen’s Enderby. When an effect size equals zero. they have included a variety of aphasia-treatment studies. Schultz..59 separating treated and untreated popula- Whurr (2006a) examined pharmacologic treatments for tions. Piracetam. and Whurr (2006b) examined randomized con. Robey (1994) also found that the effect sizes In a different Cochrane systematic review. Prognosis. Idebenone. The convergence of this combined evidence leads to the tain clinical presentation. 1998). An estimate of outcomes. the weight of scientific common research hypothesis. on average. and ing effect size increases. Greenhouse and col- leagues (1990) reported the first meta-analysis of aphasia- Systematic Reviews and Meta-Analyses treatment literature.qxd 1/21/08 11:32 AM Page 195 Aptara Inc. Lorch. and (b) provided intensively. ment literature. Pribedil.g. those estimates are then aver. brought about larger treatment effects. Robey. Rather. esti. Greener et al. (2006b) con. Chapter 6 ■ Aphasia Treatment: Recovery. (SWDM) was larger than the overall average. studies.e. quality of life. no improvements in impairments (WHO. Crawford. or synthesized. Nevertheless. It is important to note that these meta-analyses have not ing treatments eliminates the original concern. or (b) the incompleteness found that. Robey (1998) obtained in either (a) research methodology (e. only twelve studies rion for a small-sized effect in the chronic stage when treat- met the entrance criteria for review. of 0. always been demonstrated through valid clinical trials in mates of effect size are calculated for each study assessing a the modern sense. and effect size of 0. As Enderby (1996) points out. and (c) large strated neither the efficacy of treatments for aphasia nor gains were achieved by persons with severe aphasia. They analyzed 13 pre-post tests of A review of scientific clinical evidence begins with existing aphasia treatment and found an average weighted effect size systematic reviews and meta-analyses. Robey istics. and all were characterized by limitations In a meta-analysis of 55 studies. McCallum. The estimates of effect size indicated generally large ments were generally effective when treatment protocols and robust treatment effects. The highlights of another systematic review of treat.g. were (a) matched carefully with the characteristics of a cer. . in general. In a meta-analysis. conclusion that treatments for aphasia are generally effec- A handful of meta-analyses have been conducted on tive (Albert. (a) greater amounts of treatment with which important operational definitions and out. Piracetam. a onset (MPO). and nearly twice as extensive as the recovery of untreated indi- generalizations coming out of the review equivocal on many viduals when treatment was begun before 3 months post- important points. pre-test versus post-test) with time-post- the manuscripts made thorough assessments of scientific onset controlled for each set of effects. The results indicated quality unattainable. Greener et al. conclusions. treatment versus control) and within-sub- constraints combined with absent or unclear information in jects effects (i. In the past. most depen- ture from the null state (e. been restricted to clinical trials. and Clinical Effectiveness 195 Basing random allocation to one of two (or more) compet. Nonetheless. set of studies rendered the interpretations.. Furthermore. (1988) criterion for a medium-sized effect when treatment trolled trials of behavioral treatments for aphasia by was initiated before the third MPO and exceeded the crite- speech-language pathologists. 1980). efficacy per se has not aphasia-treatment research findings. for one agent. As the degree of change brought about by treatment studies have begun reporting essential outcomes a treatment protocol increases. social validity.80. More recently.GRBQ344-3513G-C06[186-202]. results confirming the 1994 findings. Furthermore.. and Sinner (1999) reported analyses of ments for aphasia (among other communication disorders) effect sizes obtained through 12 single-subject research was reported in Enderby (1996). Robey (1994) conducted a meta-analysis of between-sub- and Dextran. sample characteristics). That complication in a relatively small that the recovery of treated individuals was. The pharmacologic agents in these trials included generally effective. Bifemelane. 2005). Goodglass. 2001) and syntac- of language impairments) has advanced to clinical trials tic stimulation (Davis & Tan. the line of scientific inquiry on treatment proto.qxd 1/21/08 11:32 AM Page 196 Aptara Inc. The equations differ clinical-outcome domain.2 dBS1. Examples were selected for their capacity for efficiently illustrating as much information as Number of Aphasia-Treatment Studies at Each possible. This likely (2000) tested a protocol for increasing the accuracy of reflects a long history of research in this outcome domain. Indeed. Porch.post  . Using Cohen’s (1988) estimator of effect size have been published regarding treatments for aphasia. Combining the estimates of effect size for each logical step. p. .GRBQ344-3513G-C06[186-202].e. Many for within-subject effects (dpre. Clinical Outcome Domain I II III IV V Overall Language Performance Overall language performance 12 8 12 — — Lexical retrieval 83 37 1 — — Many studies assessing overall language performance as a Syntax 35 26 — — — dependent variable report a general index of aphasia severity Speech production/fluency 44 11 1 — — taken from a comprehensive test of aphasia such as the Language comprehension 14 — — — — Boston Diagnostic Aphasia Examination (BDAE. & Maher.e. Reading 39 7 1 — — Kaplan. see Robey. with each category. The treatment protocol is often some variation of the Schuell-Wepman-Darley Multimodality (SWDM) treatment (see Duffy. illustrates the maturity of lines of Syntax inquiry in aphasia-rehabilitation research.21 for the WAB AQ results. domains with the number of treatment studies at each phase of clinical research. . response to trained lexical retrieval and syntax. of these papers have been considered by the Aphasia Treat- the magnitude of change from pre-treatment to post-treat- ment Writing Committee of the Academy of Neurologic ment was dpre. 315). many and varied. In each case. Estimates of effect size conducting meta-analyses for each of several treatment-out- for the two corresponding control conditions. 2004b. and (b) are beginning to take some of their treat. Jacobs and Thompson more frequently than any of the other domains. 2001). the magni- domains.post  . Building upon the work of the Veterans stimulation and no treatment. a test battery for compiling a broad spectrum linguistic-specific treatment (Thompson.66) and untreated (i. 1997). 1982). & Barresi. a cross-tabulation of those clinical-outcome for the averaged values.post  . particularly for treatment protocols to improve of the direct treatment effects (i. hundreds of research reports Wertz. tokens) yields an average effect size of dBS1  27. For context. were dpre. Kertesz.51 for the PICA Overall results and Communication Disorders and Sciences (ANCDS). An Primary Studies innovative exception is a clinical trial testing Computer Reading Treatment provided over a 26-week period (Katz & In the past several decades. some studies are asso- Phase of Clinical Research ciated with greater magnitudes of effect size than those selected for presentation. Stach.e. tude of change brought about in each participant can be ment protocols to trial.. lexical retrieval.post. Treatment protocols for improving syntactic production are cols in which the outcome domain is overall language per. language com- of recovery who _ were treated (i.post for group data and values of dBS1 for The next sections review a few examples of studies in each single-subject data are not directly comparable. the Katz and prehension and reading and writing (Robey & Beeson.05).73. 1987). A sim- ilar averaging of effect sizes for untrained tokens across the Specific Treatments 2 Note that values of Cohen’s dpre. or the Western Aphasia Battery (WAB.06 respectively.post  . dpre. 1981).14 and dpre. Using Busk and Serlin’s (1992) first estima- extensive base of pre-trial research in the remaining tor of effect size for single-subject data. A full treatment of these data will appear in the report of the ANCDS Writing Committee. object-cleft and passive sentences with four persons with Just as clearly..e. the Porch Index of Communica- Writing 30 8 2 — — tive Abilities (PICA.. these estimates of effect size 2001) and Robey (1998). Clearly. speech production/fluency. researchers (a) have established a relatively Broca’s aphasia. Wertz (1997) estimates are within the confidence intervals Table 6–1. dpre. Frequently encountered examples include formance (i. 196 Section II ■ Principles of Language Intervention TABLE 6–1 intended as exhaustive. which is dpre. computer come domains. and other studies are associated Phase of Clinical Research with lesser magnitudes. the committee organized studies may be compared to the average effect sizes reported by for which estimates of effect size were available by six clini- Robey (1998) for individuals with aphasia _in the chronic stage cal-outcome domains: overall language performance.post  . syntax. These examples are certainly not importantly.post  Affairs Field Advisory Council (Daniels. Indeed. 1994).. clinical trials seem a next quantified. & Sobecks (2003) provides information units as the dependent variable (reference value insight to another dimension of generalization.66).post  .post  Once again.98).27. and Clinical Effectiveness 197 four participants provides a means for quantifying the mag.post  2.post  . Crerar et al. 20 to 80 sessions. A particularly well-devel.. 2004).66). the gen. Kiran. Each of these direct treat. in a small Albert. The direct treatment effect was dpre.post  . An average effect size for generalization effects has not ject study of three individuals using a variation of Response yet been established.513. Shapiro.98 reported by Robey et al.53. Wambaugh. written words was the dependent measure. which sion take many and varied forms. Martinez. were completed as a home assignment.66. the comparison of the two forms Treatment protocols for phonologic cueing. (1999) Estabrooks & Albert. Prognosis. Using a group research improving reading comprehension is found in Cherney.post  . size for the 10 individuals receiving CIT was dpre. Hirsch. Voluntary nitude of change in terms of generalization.98). the comparison value is dpre. Control of Involuntary Utterances (Helm-Estabrooks & dBS1 for generalization equaled 1. for studies comparing treatment to no-treatment in post- Fliszar (2002) studied both forms of treatment using cueing acute aphasic individuals.18. Furthermore.62 using a value derived from a battery of standardized tests as Word Retrieval the _ dependent variable (reference value in Robey et al. The closest value in Robey (1998) for throughout the research literature on improving word serving as a corresponding reference value is dTx vs No–Tx  . 2004).post equaling_ 1. & Rewega (2002). effect size for the _ two participants receiving both _ forms of ments in accuracy rates for prepositions and verbs among 14 treatment was dBS1  24. comprehension was dpre. Hickin. hierarchies with each of three participants in a single-subject research design.post  . (1999). An example of a treatment protocol for 3. An example of a treatment protocol for improving writ- ing is provided by Beeson. The averaged estimate of effect size The grouped data for four aphasic individuals studied by was dBS1  5. Induced Therapy (Pulvermüller et al. and Dean (1996). bring about . of treatment resulted in a between-subjects effect size of or combined phonologic and semantic cueing are found dCIT vs Conventional  .95 for a direct treatment effect using correct Thompson. & Osborne (2002) Merbitz.98. among others. Doyle. 1997). the estimates of effect size for three standardized tests Pulvermüller et al. 1985.41. who Language Comprehension studied four individuals with aphasia and severe agraphia. For context. Combining from Robey et al.31 retrieval.86. Howard.. Herbert. and Grip (1986). (2001) reported a group study com- resulted in a value of dpre. The corresponding magnitude of change for The literature contains relatively few reports of treatment generalization was dBS1  3. Two participants received Anagram and Copy Treatment Treatment protocols for improving language comprehen. Although a great portion of the external evidence for informing clinical practice was published before the conven- Speech Production or Fluency tions of evidence-based practice were broadly recognized.66 from . Robey et al.525 (reference value is dpre. 2001). Elaboration Training. protocols having a primary outcome of improved writing or ment effects is referenced to the median value of dBS1  improved reading.post  . measured improve.qxd 1/21/08 11:32 AM Page 197 Aptara Inc. Both values exceed _ the corresponding reference value from Conclusion Robey (1998) of dpre. found a median effect size for direct treatments of dBS1  Wambaugh and Martinez (2000) conducted a single-sub- 3.GRBQ344-3513G-C06[186-202].post  . generally considered. Robey (1998).41 for verbs. _ The resulting estimates _ of effect size were dpre. and Kalinyak. 1999: dBS1  3. participants. The comparison paring the effects of Constraint-Induced Therapy (CIT) value from extant literature is again dpre. (ACT) and Copy and Recall Treatment (CART). The magnitude of change for both treat- Reading and Writing ment protocols combined over all three participants was dBS1  4. Treatment protocols in this category comprise Response the available scientific evidence supports the conclusion that Elaboration Training (Kearns.81 for prepositions and dpre.66 from Robey with those of conventional treatment.. 1999: dpre. The estimate of effect (1998). In this case. Constraint treatments for aphasia.02. The average tionships with one another. These authors administered Oral studied the response of eight individuals with aphasia to a Reading for Language in Aphasia (ORLA) to a heteroge- treatment protocol combining phonologic and orthographic neous group of persons with aphasia 3 to 5 times per week for cues. termed the received the CART home-assignment only.post  . design. Chapter 6 ■ Aphasia Treatment: Recovery. The estimate of effect size for _reading eralization effect for untreated tokens _was dpre.post  . and Melodic Intonation Therapy (Helm- meta-analysis of single-subject studies.03 (reference value: dBS1  3. Ellis. Two participants oped protocol by Crerar. semantic cueing. Multiple- “Computer Based Microword” has individuals with aphasia baseline single-subject data with the number of correctly make decisions about a closed set of tokens and their rela. Best. GRBQ344-3513G-C06[186-202]. org/asp/trend. fMRI) have moved researchers closer to understanding the neural mechanisms that medi- ate early and late recovery. surviving anatomy. Brain-activation changes during recovery and combined with salient history and thorough assess. 2. the evidence on the efficacy and effectiveness of well-defined treatment pro- general question of efficacy/effectiveness of treatments by tocols through well-controlled experiments that are speech-language pathologists is compelling: treatments by appropriate for the particular point in the developing speech-language pathologists bring about desired outcomes line of clinical research. and the permanence High-quality scientific evidence produced through high. and maintenance effects. ators of recovery and rehabilitation. As Greener. including lesion size and recovery.qxd 1/21/08 11:32 AM Page 198 Aptara Inc. It is not clear whether language improvements dur- 1. for manuscripts describing non-randomized controlled be strengthened through independent replications of trials. http://www. much needs to be done in this regard. Transparent Reporting of Evaluations with Nonrandomized Designs Statement (TREND.asp). guidance expressed in terms of direct treatment effects. both. cer- Two large and important challenges confront clinical tain models of service delivery. and neurophys. direct comparisons of aphasiologists. 2003. hemisphere regions spared by the lesion. PET. and biographical factors such as age. The first challenge is describing scientific specific treatment protocols. the pattern of recovery as it relates to the individual cally relevant measures of outcome) are tested in progres.. Personal treatment scheduling. type of language intervention. Furthermore. Fortunately. but the work is logic advances in the area of brain imaging (e. a certain treatment aphasia. with tive of funding for clinical services and clinical research. but with a certain clinical population. http://www. 6.. Presently. sively more precise experiments (e. some conflicting evidence regarding their effects.g.htm). quality clinical research can only be recognized as such if the 5. Despite individual variation in rate and extent of questions through precise experimental designs. satisfaction. participation limitation. Techno- out. In fact. FUTURE TRENDS 3. initial findings will ilarly. broaden through assessments of treatment effects ers for rendering those assessments. SPECT. Enderby. researchers are cators in the resulting manuscripts will facilitate recog- producing evidence that opens insight into differential nition of the research as high quality. Progressive refinements and advancements in imaging ing recovery and rehabilitation are supported by left- technology make possible ever more detailed assess. or iology.org/statement/revisedstatement. Furthermore. The neural mechanisms contributing to recovery intervals). ment of homologous right-hemisphere regions. by recruit- ments of pathology. rehabilitation show individual variability and may be ments of communication behavior at certain points in affected by several factors. general- in this regard is readily available.g. quality indi. quality of life. indications and contraindi- evidence more fully than has largely occurred in the past. Basso. Demonstrated efficacy and effectiveness is an impera. of change brought about by a protocol. ization effects. validity of change expressed in terms of activity limita- als is the substance of the Consolidated Standards of tion. and Whurr (2006a) point from aphasia are not completely understood. The test of a certain protocol must focus not only on obtained through a certain treatment protocol associated changes in impairment from pre-test to post-test. From that perspective. and gender have been studied experimentally. quality indicators are listed and described in the critical tests.g. The scope of clinical experiments must continue to manuscript contains the quality indicators required by read. recovery that have been identified for each type of ingly more focused hypotheses (e. consumer Reporting Trials Statement (CONSORT. consort-statement. 198 Section II ■ Principles of Language Intervention large and beneficial changes. narrow confidence 2. aphasiologists must test the . there seem to be some general patterns of we are experiencing a period of transition in which increas. Documentation of quality indi- (Albert. handedness. those forms of information. also on the effects of certain treatment schedules. time post-onset. Meeting this first challenge is certainly KEY POINTS not beyond the means of researchers. 2005). The second challenge is testing focused clinical-research 1. and fMRI task. There appears to be no single factor alone that can decisions of aphasiologists regarding prognosis and predict outcome in patients with aphasia.trend-statement. 3. language modalities. and costs versus benefits.. recovery. For instance. there is a consistent trend in protocol is tested in a certain clinical population using clini. As in all forms of scientific inquiry. and the social cators for manuscripts reporting randomized controlled tri. In large samples. site. will undoubtedly clarify indicators and moder. Sim. forms of treatment effects: multiple dimensions of outcome 4. That concert of information will enhance the clinical 4. underway. cations of candidacy for a protocol. .. tion in a case with agrammatism. L.. 469–475. K. (1990).. P. K. M. Rehabilitation Astrom. and Clinical Effectiveness 199 Blank.. Grassi. K.. E.. Demeurisse. M... & Serlin. (1991). Code. A. 16. (1979). M. R. Aphasiology. E. (2003)... A. Stimulation of sentence produc- C.. Hirsch. C. prolonged treatment be? 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(1998).. Aphasiology. 202 Section II ■ Principles of Language Intervention Porch. 202–206. C. tation: A retrospective exploratory study. 603–617. K.. G. 129... 43–59. 37. 357-366. B.. Rubens.). A. presented before the 1999 Clinical Aphasiology Conference. R. scoring. Prins. Shapiro. 33. Lange. J. The efficacy of treatment for aphasic persons: Thompson. & Shankweiler. E. Flores. In E. (2001). D. Thulborn. of language-related brain function during recovery from stroke. 298–308. A five-phase model for clinical-outcome strategies in adult aphasia (4th ed. Chapey (Ed. Gender and munication sciences and disorders and aging. J. R. K. assessment of language function in aphasia due to stroke. 192–211.. A. J. L. Chapman. (1999). H. Journal of Rehabilitation Medicine Supplement.. 1621–1621. S. Neurology. J. (1958). C. Language.). & Robinson. Hearing evidence. M. (1969). effect-size for planned contrasts: fixed within effect analyses of The role of syntactic complexity in treatment of sentence variance. M. P.. A. Stroke. Porch index of communicative abilities. Schraknepper.. M. C. T. A. The nature of the “ultimate excellent clinical aphasiologist” is explored in Roberta Chapey light of the demands of the current health care climate. skilled-nursing facilities. Chapter 7 Delivering Language Intervention Services to Adults with Neurogenic Communication Disorders Brooke Hallowell and of service-providing agencies are highlighted. In the United States. and the financial stability coordinated. by personnel with special training in rehabilitation. and a speech-language pathologist. Acute-care our access to patients. which are rendered for both inpatients and outpa- ery of services to persons with aphasia. such as hospitals. length of time patients are allowed to remain in acute-care care policy. and (7) dis. a physiatrist. clinical licensure. intervention-services to persons with neurogenic communi.GRBQ344-3513G-C07[203-228]. Throughout the world. and a rehabilitation counselor are also mem- bers of this team. (5) present an overview of the Hospitals means by which clinicians and service-providing agencies Most major community hospitals have a comprehensive pro- are reimbursed for services. insurance mechanisms. nursing homes. services. treatment. a physical therapist. Legislative issues Adequate space and equipment are usually provided to and other factors affecting reimbursement for clinical services ensure high-quality evaluation. social worker. area that is properly equipped for rehabilitation and staffed In this chapter we discuss the contexts in which aphasiolo. including a basic rehabilita- active ways in which clinicians may serve as advocates for tion team comprised of a physician. of services.. Recent trends in reducing the cation disorders. cuss future trends in service delivery. patients are placed near rehabilitation services. (3) describe the many professional roles of the aphasiologist. however. munication disorders. intervention. contexts. reimbursement schemes.qxd 1/21/08 11:39 AM Page 203 Aptara Inc. mary focus on screening and diagnostic services rather than and professional training are having dramatic impacts on on concerted intervention (Katz et al. 2000). The advantage of providing speech-language services which aphasiologists may engage to further the effectiveness in this setting is that a hospital may provide integrated. convalescent stroke and trauma federal health policies are significantly impacting the prac. patients’ access to care. private offices. gists work and the multiple roles they play. The immediately post-stroke or post- At no other time in the history of aphasiology has the con. a rehabilitation nurse. an occupational therapist. Strategic actions in tients. and the patient’s own home. reha- texts in which clinicians serve adults with neurogenic com- bilitation centers. and counseling are then presented in terms of their implications for the deliv. (6) stimulate discussion of the gram for stroke rehabilitation. SERVICE DELIVERY CONTEXTS FOR OBJECTIVES LANGUAGE INTERVENTION Speech-language pathologists rehabilitate adult patients The objectives of this chapter are to (1) describe the con- with aphasia in a variety of settings. of aphasia intervention. a psychologist. a patients in the current service-delivery climate. in a specific tice of aphasiology. comprehensive team management for patients 203 . as well as on the services we may clinicians are also involved in educating patients’ significant deliver to them. particularly. Optimally. recent others about the nature of aphasia. have limited acute-care clinicians to a pri- political climates. (4) discuss key legislative issues that affect service delivery. trauma patient is frequently placed in an acute medical area text in which clinicians work so influenced the delivery of and may receive speech-language evaluation. impacts of managed-care in the private sector and evolving In most instances. national health plans. (2) explore the gerontologic context clinics. and counseling at the bedside. changes in health. independent facility that has a close by residents. most United States residents have seen the signs for agencies as well. individual speech- for “skilled nursing and rehabilitation centers” and the like. financial concerns are often at the forefront for tion of potential placement sites and access to transportation. grams. to their homes. federal programs do not generally trauma. language clinicians often refer patients to other rehabilita- tion professionals when appropriate and establish close communication with other professionals who are working Nursing Homes and Long-Term-Care Centers with a given patient. Thus. In either of living independently but wishing to be close to central social case. Typically. the decision as to whether they should receive suba. the degree of need for integrated comprehensive interven. physical therapy. Since the late 1980s. insurance coverage. geographic loca. both for vices are the primary offering. Rather than staying in the hospital In all of these settings. for adults capable working relationship with one or more hospitals. programs have become available. the patient’s they do help individuals plan carefully for long-term-care financial resources. Speech-language clinicians in Most clinical academic programs in the field of communica- these contexts often work on a contractual basis with the tion sciences and disorders provide on-campus clinical services nursing home. such as uals whose savings are minimal enough to qualify for such pro- the extent of disability. and Hearing Centers The distinctions among terms such as long-term-care center. rehabilitation centers. Outpatient ser- ties now offer comprehensive rehabilitative services. most stroke and trauma patients are now dis. to nursing home rooms. and toward facilities that were program in communication sciences and disorders. freestanding not-for-profit agency. Many programs also . employees of a rehabilitation company that contracts with tation centers. multiple nursing homes in a given area. although many free-standing short-term patients who are expected to return to their homes. the home and in adult day care centers can forestall or elimi- nate institutionalization for many elderly people. occupa. Thus. in which once merely considered long-term-care centers or “rest student-clinicians are supervised in the provision of services. Another is the communi- 1995). cover long-term nursing-home expenses. either as independent professionals or as that may serve individuals with aphasia. agencies provide contractual services through hospitals. They range from apartments. and even rehabilitation One type of independent speech and hearing clinic is the center have become less and less clear in recent years (Gill. in which resi- that provide comprehensive team rehabilitation. During the past 10 years. homes” (facilities to which most residents traditionally had A third type of speech and hearing center is the office of the been admitted with the anticipation that they would stay there independent speech-language pathologist in private practice. over the past nursing homes. 204 Section II ■ Principles of Language Intervention with stroke and aphasia. overall health status. In the United States. Rehabilitation Centers Many long-term-care centers have varied types of residen- A rehabilitation center may be a component of a hospital or tial facilities that differ according to the levels of care needed may exist as a separate. all three types of settings have suitable rooms and charged from acute-care centers to subacute care centers. and occupational therapy.GRBQ344-3513G-C07[203-228]. Speech. for the rest of their lives). For patients dents are provided constant skilled medical and rehabilitative who have recovered from the acute stages of stroke or care. Although independent agencies do not gen- “nursing homes” in their local neighborhoods change to signs erally have formal rehabilitation teams. and the degree of family support and expenses they may incur as they grow older. In addition. inter- outside the hospital context. The same may be said for rehabili. Although potentially costly. tional therapy. cover the cost of long-term care. speech-language therapy. services are provided for persons of until they are rehabilitated to the point of being able to return all ages with any of a variety of communication disorders. and counseling services to patients. but only for individ- ferred to another facility depends on several variables. as well as for long-term residents. Consequently. In most instances. these homes also provide ongoing University Clinics environmental stimulation and attempt to meet the patient’s social and emotional needs. nursing home. nursing-home clinicians frequently work on an itinerant basis. residents of long-term-care facilities and their adult children. rehabilitative care has gravitated cation disorders clinic housed within a university training away from acute-care hospitals. and home-health 20 years.qxd 1/21/08 11:39 AM Page 204 Aptara Inc. providing speech-language services to two or more facilities. many private practices are Even in long-term-care contexts that do not specialize in established in partnership with other rehabilitation person- short-term rehabilitation. Skilled Nursing Facilities Independent Language. often proper equipment to provide appropriate assessment. skilled-nursing facility. speech-language pathology. many new long-term-care insurance tion in nursing. Some Medicaid programs cute rehabilitation as outpatients or inpatients or be trans. or are located in buildings that house such personnel. Routine help in involvement. vention. A majority of skilled nursing facili. there are usually both inpatient and outpatient services and medical facilities. nel. and physical therapy services are generally offered. 2003. 2006).. 2004) may fostered. Seoane. and to move to homes on tiveness of telehealth delivery specifically related to aphasia. input from experienced clinical supervisors. some depending on partnerships with agencies counseling. 1998). Mashima et al.qxd 1/21/08 11:39 AM Page 205 Aptara Inc. with some supported through university funds. Dyer. Additionally. Whitten. Villarroel. physical therapy. some university-based clinics are able to offer long-term services to people with chronic Telehealth is the “use of electronic information and commu- communication challenges. and acceptability of to age. Wertz et al.. feasibility. and assistive devices and financial assistance may be available.GRBQ344-3513G-C07[203-228]. & Revell. Aphasiologists are The mission of university-based clinics involves not only the increasingly likely to be engaged in serving individuals living delivery of quality services but also the provision of quality within such communal arrangements. There is a growing trend in the United States for older peo. Ogasawara et al. such as hospitals. and rehabilitation centers. This helps the residents to coordinate transportation. Another growing trend is for elderly (Duffy. 2005. it is helpful to students. or after a vices through distance technology (Brown. Field. Luecke. 1997. and many elderly adults prefer to receive Much of what is known about the potential for remote services in their own home (Leff et al. Chapter 7 ■ Delivering Language Intervention Services 205 provide services through contracts with outside agencies. Myers. also be applied to speech-language pathologists. & Lee. dietary grant funds. Depending upon the availability of qualified supervision and allowance Telehealth for free or discounted services. increasingly greater promise for improving access to care in who benefit from the enhanced experience this provides. 1998. Werven. 2004. adults to develop formal or informal co-housing communities. 2005. 2006). communities. New developments in technologic access idential facilities (Kerr. 1992. Glykas & Chytas. psychological. Models The range of home health services may include speech-lan- for the operation of university-based clinical services vary guage pathology. Telehealth applications hold continued intervention. pens. & In addition. health monitoring. as the general population continues ments support the reliability. homemaker or household assistance. Many patients with stroke and aphasia return to their homes opportunities are emerging for expansion of home-health ser- after the acute medical emergency has subsided. and social activities. 2004. Longan. occupational therapy. 1998. home-care services vices for people who live in areas that are unsafe. Martinez. factors that will be most influential in continuing efforts to . the the help of programs and resources shared among the resi.. visit- widely. In the United States. Indeed. such services because they are cost-effective and often Jarvis-Sellinger. 1992. and special and supervisors who are not employed by the university. nursing homes. some ing nurse and physician care. many relying on a combination of such supports. mentored clinical education for student-clinicians. Khazei. Wilson & Onslow. depending on self-support through clinical revenues and and social work evaluation and therapy. Few published empirical studies directly address the effec- ple to move in with their children. 2006). An additional ety of services to the patient through a well-structured. advantage of telehealth is that it may expand access to ser- closely coordinated program. 1996. Skills mas. 2006). Whitten. & Aronson. independence and self-reliance are of medical practitioners between states (Scott. 2003. Whitten. properties of their children. Hickman & period of therapy at a rehabilitation center. Insurers like war zones (Doolittle. dents. In such cases this is especially nications technologies to provide and support health care helpful to patients who have exhausted insurance coverage services when there is a distance between participants” for diagnostic and treatment services but still benefit from (Hallowell & Henri. Ho. 2005. cases in which the home environment because they are taught where they states have developed regulations for the delivery of services will be used. Otto. service delivery for diagnosis and treatment in communica- Community-based programs provide reasonable prices and tion disorders is derived from research on applications in high-quality care and have better long-term results than res. & Clemens. the number of adult children available to provide such telehealth evaluations of speech and language disorders care will be reduced. subsidized services) to support one-on-one in-person ser- vices are insufficient (Berman & Fenaughty. 2003. 2004). many belong to naturally occurring retirement Leblanc. Fortier-Blanc. such as in to the elderly have grown rapidly because of the pressure high-crime urban neighborhoods and active international on hospitals to reduce costs (Whitten. In addition to Home Health expanding access for disadvantaged and rural populations. remote geographic areas where skilled service providers may Special opportunities for expert consultations with faculty be scarce or absent. When this hap. 2007). community-based home health agencies provide a vari. However. In addition. Sicotte. Likewise. other disciplines. will be shaped by ongoing developments in health policy as tered in treatment programs do not have to be transferred to it affects telehealth. and transportation to and from service providers is limited or participation in clinical research are additional advantages financial resources (including insurance coverage or directly available to people with aphasia in university contexts. which allow individuals to remain at home with According to a review by Hallowell and Henri (2007).. & del Pozo. especially after the onset of major Several studies comparing face-to-face and telehealth assess- health concerns. They also are helpful in cases in which members. and psychiatric. more efficacious. Lehoux. 2005). A plethora of genetic. or not the same people they once were— changes. inferior. Also. under. adult caregivers in the United States are women (Dettinger The United States will continue to age rapidly as baby & Clarkberg. chronological. Biological age is the relation. especially for services provided between ing a large number of women widowed and living alone dur- states. 1980. frumpy. Marks. and unworthiness related to their age. Russo.5 years for women. adaptations. 2002. human value (Cruickshank. are commonly described in the gerontology literature: Perry. approximately half of their assistance is provided GERONTOLOGY AND APHASIA by a spouse and half from adult children such as a daughter Life expectancy has increased by more than 20 years since or daughter-in-law. In 2050. biological. selfish. we assess • irrational fears of an aging population. and the fact that aphasia tends to occur in older adults. failure. means of countering ageism in clinical practice is essential. 1999. Although estimates of the proportion of 1901. The dedication of a couple’s financial resources • Attitudes of providers and patients. died. uninter- information to their clinical interactions. . In a study by Wachterman and Sommers • Training in use of telehealth technology. & Simmons. that an individual all due to the number of years they have lived (Andrews. Schlesinger. The message ship between aging and programmed cell death or an indi. compared to 19. Copper. Many express a sense of shame. sensitivity to the multiple possible • a Western cultural focus on appearance as a critical challenges to gender issues in older women is important. ing their last years.5% of men. • cultural values demanding that one work and have demonstrable productivity in order to prove one’s worth. and the hallmarks of success. 1976. and (Cruickshank. 1969). It is the ability to internalized ageism. It is also important that they apply this abled. health concerns and challenges. 2003). comical. (2006). Chronologic age is the number of others but from themselves. and mentally unstable. Policy Institute. Levin & Levin. 2006. 56. a phenomenon known as how old an individual acts and thinks. financial resources at the end of their lives (AARP Public • Potential cost savings. and cal women’s issue. grumpy. that being old is funny or embarrassing is so ingrained that vidual’s susceptibility to disease. 1999). 2003). boomers (people born between 1946 and 1964) reach age 65 Lambert. Carpenter. Comfort. Primary bases of age discrimination function independently and perform activities of daily living have been said to include: (ADLs). Life expectancy in the United States is between 74 and men versus women who serve as caregivers are variable 77 years for men and 80 to 82. both physical and emotional. over 20% of the population is expected to be age 65 and over (compared with about 13% today) Ageism and Civil Rights (Kinsella & Velkoff. Quadagno. on average. and behavioral (Bergeman. 2002). 2001). 2002). & Choi. needy. powerless. Given the rapid growth of the Applicable knowledge about cultural aspects of aging and aging population worldwide. As clinicians. social.2% of women • Reimbursement issues. (after 2010). which specific factors may impact each patient. Also. esting. Gender and Aging • common negative portrayals of older people on television Given that women live. It is important that clinical aphasiologists understand Kay. It is the notion or mindset that the process of aging. • Telecommunications infrastructure and cost. ing homes. 2003. men can expect to live over 17 additional years of caregivers worldwide are women. 23.2% of women were widowed at the time they • Establishment of standards. isolated. 1999. the extension of life-expectancy. decrepit. 2000). Ageism is a process of systematic stereotyping and discrimi- standing the gerontologic context of aphasia intervention is nating against people because of their age (Butler. 206 Section II ■ Principles of Language Intervention expand service delivery options in speech-language pathology Since men tend to become ill and die earlier than women. and cultural factors shape the experience of being old. undergoes during his or her lifetime. For those across research studies and across cultures. to the first one to be sick leaves many women with fewer • Means of ensuring quality of clinician-patient relationships. the multiple dimensions of age-related people are less human. include: women often provide for their care.GRBQ344-3513G-C07[203-228]. compared to 11. dis- ful aging and wellness. a threat to the economic security of others. temperamental. For elderly individuals who receive care from a family member. sexless.qxd 1/21/08 11:39 AM Page 206 Aptara Inc. • the association of age with sickness and frailty. 1997. leav- • Licensure issues. These factors all make aging a criti- • Demonstration of clinical outcomes. Family Caregiver Alliance. a large majority 65 years old. neurotic. 2006).5% of men spent the last year of life in nurs- • Patient confidentiality issues. Aging is the sum total of all experiences. incompetent. 7 years longer than men and in other media. crucial. Behavioral age relates to many take this view of themselves. 1988. years an individual has lived. poor. Up to about 75% of and women almost another 21 years (Qu & Weston. less worthy. heterosexual women tend to marry a person older than themselves. Some older people experience prejudice not only from Wei & Levkoff. Three types of aging 1999. ical aphasiologists ideally embrace the characteristics of suc- • Portrayal of women as objects and within the context of cessful aging and quality of life and appreciate health as sex and violence through many media. simplicity. A good deal of age-related discrimination targets older • economic well-being (personal achievement and equality). approx- have been injured. 2006). the fact that the older an individual is. Such . Given that aging well involves living well. exploited. marketing. THE MANY ROLES OF THE APHASIOLOGIST There are two critical reasons for which it is incumbent The clinical aphasiologist performs many of the same func- upon clinical professionals in our field to be proactive in tions regardless of the professional setting in which he or she counteracting negative societal values related to gender. counseling. edu- the fact that the number of practicing clinical aphasiologists. patients are often susceptible to female gender bias. Older patients with aphasia are especially and our vulnerability to chronic illnesses: susceptible to these and additional communication prob- • biological well-being. poverty line and most others are concerned about money. The most common functions of this clinician First. contract negotiation. persons with aphasia Due to increasing longevity and a variety of other social fac. more than the absence of disease and disability. 2000. and entertainment media involving women com- pared to those involving men (Copper. and asked fewer open-ended questions.5 at a substantial yearly rate. is comprised of females. Chapter 7 ■ Delivering Language Intervention Services 207 The harmful impact of such prejudice reinforces discrim. psychosocial. Markson & Taylor. and business. Mellancamp. advocacy. • psychological and behavioral well-being (thoughts and actions). Health and longevity may thus depend upon risk women over 60 in politics. clin- much younger female companions. women (Cruickshank. and Anderson (2003) identify crucial links between six ical settings occurs in the tone. is employed. In most instances. and • Masculine performance values emphasized at the expense • emotional well-being. Indeed. administration. and research. For example. lems in medical settings (Murphy. the media. are identified when a physician or another member of a tors. ethical decision- in particular. and of practicing speech-language pathologists making. ing. by the age of 85. of human. quality assurance. Palmore. and protective factors from across several of the interacting • The common preference among older men to be with dimensions. inatory practices in health care. 1988. suggests that our older vention. housing. Another factor affecting older adults is wellness. Many seniors in the country believe that they will be able to education. and spiritual well-being (faith and against older women in Western culture have been related to: meaning). loving. the greater the are identification and selection of clients. the results of a study comparing physician interaction with young versus old patients demonstrate that the old are Successful Aging and Wellness addressed with less respect and less patience. tices. changes in one dimension can precipitate changes in • The extremely low proportion of visible role models for another. or otherwise mistreated by imately three-quarters of the principle must be withdrawn someone on whom they depend for care or protection. religious. assessment. 1999. and more feminine values Each of these dimensions is linked to the others such that in Western culture. makes the body of prac- ticing clinicians a strong force for gender-related advocacy. Williams and Giles (1998) report that 2003). 1999). A list of rec- • A much stronger contrast of beauty versus the effects of the ommended readings in this important area is given in destructive ravages of time encoded in many daily advertis- Appendix 7-1. inter- likelihood that person is a woman. news. Identification and Selection of Clients The ways in which patients are located or referred vary from Financial Aspects of Aging setting to setting. quickly learn that they must begin to withdraw these savings ing statistic that one to three million Americans over age 65 at the age of 70. Anderson They note that patronizing speech to older patients in med. fundraising. law. nificant financial disadvantage (Anderson & Anderson. employment. Schlesinger (2006) reports the alarm. The roots of societal prejudice • existential.GRBQ344-3513G-C07[203-228]. and in family interactions. given less pre- cise information. Ageism and Women • environmental and social well-being (environment and relationships). in general. consultation and collaborative care. or brevity of the dimensions of health and their impact on how long we live communication. 2003). cation.qxd 1/21/08 11:39 AM Page 207 Aptara Inc. It also sets a fertile live on interest generated from tax-deferred savings but stage for elder abuse. many seniors in the United States live below the rehabilitation team refers them to the aphasiologist. Second. leaving those who live beyond 85 at a sig- Health-care professionals are not immune to ageist prac. behavioral. It is a process that is designed to change communicative In some residential settings. Team discussions may be related to the coordina- arena may interfere with patients’ access to intervention. the nature of the patient’s aphasia tial are not always achieved. many factors in the service-delivery groups. psychological. vices. 1976. assessment and interven- munication disorders. dignity. and to define the important to include caregivers and patients’ significant oth- factors that should be taken into account in order to stimu. and neurologic. improves case management through knowledge. uniquely presented. Rehabilitation. p. Due to increasing restrictions on frequency and duration Assessment of treatment for many patients requiring rehabilitation ser- Assessment and intervention are the most important func. and vocational functions Most clinical aphasiologists function as members of reha- for each individual have been achieved” (Sahs & Hartman. when used without a clinician. optimism. and discharge planning. preclude their use as a solu- tion to problem of reduced frequency and duration of skilled Intervention intervention. speech. and independence. including the patient’s will. way we engage in the diagnostic process. 1999) and by Katz (see Chapter 34). patterned. The diagnostic process. and cooperation. patient’s primary physician. bilitative assessment-intervention teams. process. or therapy. there is a growing need for stimulation and facilitation tions of the aphasiologist. and social con- gram depends on many factors. p. authorization from the feelings of acceptance. set and achieve life goals. the case-manage- Thus. and communicative behavior. True collaboration. flexible. physicians. Intervention “must be individually ing. insurance coverage. dynamic process. a more detailed assessment is per. and their interest in report. As we will vice training programs and presentations to professional consider in this chapter. Interdisciplinary consultation includes in-ser- to restore self-esteem. tion or execution of clinical services. are discussed in While such tools may help to enrich the intervention detail elsewhere in this text. physical thera- skilled treatment. to facilitate meaningful relationships. transportation to and from the clinical setting. and emotional stability. the expertise of all team members is oriented toward holisti- nized. in which Language intervention is also a complex. The purpose of screening but in all communicative contexts and with all communica- is generally to identify those who have language. not just within the domain of the clinical setting. linguistic. and needs of each client. with a focus on the regaining of functional skills for communication in everyday life. tacts. the clinician screens each behavior. ingness and desire to participate. signs of progress and signs of failure” (Darley. aimed at restoring cally rehabilitating individuals to their fullest potential. dynamic. ideally. best techniques available to meet their holistic needs with personal. Once persons with aphasia Intervention is not confined to language and communica- have been identified. 208 Section II ■ Principles of Language Intervention referrals are dependent on team members’ abilities to recog. The term “intervention” is frequently used to they share knowledge and information with other profes- refer to the process of facilitating rehabilitation through sionals. and dietitians. as are now available to supplement skilled treatment sessions well as some of the influences of health-care reform on the (Katz & Hallowell. ipation. and community activities. ment of specific clients. ers in direct treatment sessions. and other co-existing conditions. Likewise.GRBQ344-3513G-C07[203-228]. documentation of findings. the maximum benefits for which patients have poten. comprehen- sive process of patient care. and Chapter 8). social (language). like all persons with disabilities. earliest stages of treatment. strengthen activities. This necessitates each patient’s potential to function maximally within his or team development and collaborative decision-making (see her environment. gain a positive attitude. it is increasingly linguistic. and social and life-participation goals insurance coverage and other economic factors. is a complex. it is essential to recognize that their limitations. the individual’s previously learned language through treat. as Through intervention. understand- ment and/or training. orga. tive partners. 238). Persons with neurogenic com. the clinician’s existing caseload Intervention is an innovative process that responds to the demands. beginning at the time of onset of Consultation and Collaborative Care the trauma and continuing until the “maximum physical. ing the problem to the speech-language clinician. such as occupational therapists. individual who enters the facility. The clinician helps patients to maintain and formed. pists. nurses. participation in life. tion alone. and/or swallowing problems. life partic- quality and dignity. the attitudes and support increase morale. aphasiologists attempt to heighten well as with patients’ family members. The purpose of assessment is to of communication outside the clinical environment from the provide an in-depth description of each client’s cognitive. 205). and continuously tailored to nize the language impairment. Numerous technologic tools late the patient’s use of language. tion related to medical. In this capacity. social workers. Enrollment in a diagnostic and/or treatment pro. and/or psychological should be treated by highly-qualified clinicians using the problems. gain insight into impairments. goal-directed. 1982. . occupational.qxd 1/21/08 11:39 AM Page 208 Aptara Inc. and develop of the patient’s significant others. sumer satisfaction. progress should be recorded in ticed in clinical capacities with few other management detail. The specific content of individual or group counseling of action to address the problem. emotional. The that may offer wonderful opportunities for those affected by primary purpose of preparing reports is to disseminate and aphasia. There provided. Changes in an individual’s intellectual. managed- Counseling care organizations. . and ordering supplies. As treatment continues. scheduling clients. the life-affecting impacts of stroke and ment. and improved quality of life. Even those without administrative or management chological. financial. deep well of information about specialists. many aphasiologists prac. to support the planning of future assessment and ple with aphasia. clinical aphasiolo- not strictly clinical. psy- tive roles. and productivity of of helpful Internet resources to aid clinicians.and re-authorization) for validly and quality of Web-based materials. and support. and death expected results of intervention—preferably in terms of skills and dying may be discussed. elderhostel programs are some examples of resources that referral forms. clear. search results in numerous resources that may be helpful. lifelong learning institutes. In most of today’s service-delivery environ- ments. and an evaluation of the client’s exercise groups. types of rehabilitation services available. Accurate. statistical summaries of may not be designed specifically for people with aphasia. and support services from which to draw when a patient or family member expresses a particular need. support groups. including short-term and depends on the individuals involved. patients and their significant others. respite programs. No matter how excellent the actual clinical services may be. (3) a plan nity. Thus. other professionals. there are many records are to generate an account of the clinical services centers for clinical treatment and social networking for peo- provided. insurance companies.GRBQ344-3513G-C07[203-228]. clinicians and/or their Administration employing agencies are regularly denied reimbursement Traditionally. (2) maintaining a cumulative account of each individ- offering support and information-exchange related to aphasia ual’s assets. The primary purposes for keeping and training opportunities. Chapter 7 ■ Delivering Language Intervention Services 209 Referral for Additional Services and Resources responsibilities. access to such resources is limited or intervention goals. and federal health programs). and periodic disposition reports. information. administration or management has encom. networking. Topics such as the (4) descriptions of tasks and modalities to be used in treat- causes of stroke. (5) developing and justifying programs. Local senior centers. It is important to have a assurance. conference records.g. maintain information.. and to justify reimbursement for services nonexistent in many geographic regions of the world. Additionally. (2) a clear statement of the problem. (3) evaluat- are often greatly appreciated. treatment program. The system of record keeping chosen should be remains a need not only to create more community one that can be interpreted easily by other professionals. master schedules. The ASHA Web site has a contin- and (6) ensuring that clinicians and their employers are ually updated list of such resources. community resources. advocacy. and quality gists often act as referral sources. resources. informing them of helpful links to sites vice. methods. Many Documentation organizations worldwide have been designed to help con- Records and reports play a significant role in an aphasiology nect people with aphasia to a range of support. and social services among people titles per se are expected to engage in other activities that are with aphasia and their significant others. local level. and progress in therapy. indepen- dence. but also to assist people with aphasia and their Some of the specific types of records and reports that may be families in identifying additional alternative resources at the used are assessment records. and that determines reimbursement by third-party payers (e. but most often involves long-term goals that are describable and quantifiable. or opinions and conducting discussions with the patient. and a simple Internet financially reimbursed for their services. There is an ever-growing set ing the effectiveness. patients. though. and (5) a prognostic statement and indication of aphasia. progress reports.qxd 1/21/08 11:39 AM Page 209 Aptara Inc. such as marketing. Speech-language documentation must contain (1) a com- members of the family. clin- ical aphasiologists should be competent writers and should The role of counselor or adviser involves exchanging ideas be well-trained in the fine art of clinical documentation. type of therapy. and clinicians and treatment programs. legal. it is important that users scrutinize carefully the authorization (and sometimes pre. release-of-information forms. diagnosis and treatment. documentation does not address each of these areas. Still. quality. plete history. (4) monitoring con- significant others make connections related to services. session plans (including goals. or the commu. but cases. and responses). and abilities that facilitate functional behavior. Of Thorough documentation is the vehicle that permits course. and timely records Many persons with aphasia and their significant others and reports are essential to (1) providing continuity of ser- have Internet access. limitations. clinicians play greatly expanded administra- Given the common multiplicity of needs for medical. efficiency. In the past. from insurance companies or other third-party payers when passed record keeping and report writing. Whenever authorization or reimbursement is denied. 210 Section II ■ Principles of Language Intervention life-participation. independence. treatment. Some large hospitals Appealing Denials for Treatment Authorization and rehabilitation centers use report-writing software that or Reimbursement links multiple workstations and integrates input from multi- ple disciplines. nicative improvement should be described. Each Procedural Terminology. Visual standardize billing codes for uniformity among service aids such as graphs and charts may add clarity to reports. Responses to these forms require clinicians to sum.qxd 1/21/08 11:39 AM Page 210 Aptara Inc.. the ICD-10 codes. These codes serve to progress notes or revisions of goals and procedures. Documentation that supports a letter of appeal may . They are and treatment reporting and billing forms are becoming the required by most insurance companies and by all programs norm. 1999). providers and third-party payers. (CPTM.GRBQ344-3513G-C07[203-228]. In some cases sist of three digits. rehabilitation centers. A new edition of ICD codes. that will determine the content of billing records. billing. and other agencies life of the individual being served. clinicians must provide the factual input (6) exhaustion of services allowed by a given health care plan. like clinicians in most health-care disci. available on the ASHA Web site. draft status and are under review by users and CMS at the nostic records in a timely manner. computerized packages and Internet resources are available for help in versions of forms enable efficient form completion. referencing with data base information. automation of billing and coding practices. consist of five digits. Sometimes. 4th ed. (5) noncoverage of certain that employ clerical professionals who are responsible for services by the patient’s specific health care plan. The two coding for reimbursement are successful (Henri & Hallowell. additional information is clinicians from many disciplines are required to input their conveyed by adding two more digits to the right of a decimal data on the same form. Clinicians are tion or reimbursement include: (1) lack of a physician’s order often responsible for the primary billing practices. Numerous software of reports. and easy transfer of information from one form to another. it is important that clini. and in contexts serving ICD-9 diagnostic codes are used to classify medical diag- Medicare and Medicaid patients. Whenever possible. National Center for changed? Have there been changes in pre-existing conditions? Health Statistics. systems most commonly used in speech-language pathology 1999b). (4) failure to demonstrate the functional billing forms. Even cation. rently in use may be obtained through CMS and are also plines. Typical rea- Financial reimbursement from third-party payers depends sons for which an insurance company may deny authoriza- on thoughtful. of the U. may enjoy the advantages of new technologic devel. The codes are published annually by able programs. Further. and social status as they relate to commu.” or specific services rendered. medical management. statements from patients and require ICD-9 codes for diagnoses and CPT codes for “pro- their families or significant others should be a component of cedures. report writing templates may be generated care services across disciplines and clinical settings. ICD-9 codes con- small designated spaces on pre-printed forms. many agencies have seen their denial rates for evaluation and treatment authorizations Billing and Coding grow significantly (Henri & Hallowell. Additionally. in some settings. and billing paperwork. notes. including for services. requests for treatment authorization or for diagnostic. the coding of services according to coding schemes strate that the patient has adequate rehabilitation potential to acceptable to each third-party payer. As managed care practices have expanded dramatically over the past few years. third-party payers. 1999b). Such interdisciplinary coordination point. reimbursement of services already provided are denied by tions within and across disciplines (Hallowell & Katz. Such software may also be used to coordinate In many cases. Public Health Service and the Center for marize vast amounts of information related to patient care in Medicare and Medicaid Services (CMS). nostic and/or treatment information. and the Physicians Current Documentation should be logical and sequential. and quality of in those hospitals. and the submission of billing forms along with impacts that treatment will have on the functional communi- diagnostic and treatment reports to third-party payers. American report should be strongly tied to preceding and subsequent Medical Association. The diagnostic codes cur- Aphasiologists. In most managed care contexts. In a cians be familiar with numerical coding systems used by majority of the cases reported in the United States. the completion of justify services.S. and patient scheduling func. 9th rev. voice-activation the American Medical Association (AMA). (2) improper documentation or coding of diag- the tracking of time spent in treatment and diagnostic ser. strategic billing practices. time of publication of this text. standardized diagnostic noses across disciplines and clinical settings. They through word-processing programs or commercially avail. In most employment contexts. 2006). (3) failure to demon- vices. are the International Classification of Diseases. 1999). Has motivation Clinical Modification (ICD-9-CM. and letters. appeals third-party payers and with related policies. opments that facilitate report writing and record keeping. and are also report writing software now allows for hands-free dictation available through the ASHA Web site. are in requires concerted effort to complete treatment and diag. clinicians may make an appeal to reverse the denial. CPT codes are used to standardize the coding of health- For example. Most public and private payers reports. cross. progress notes. and with administrative titles are the designated officials who discharge reports. and providing time for in-service training sessions petence. 1996). life-participation. mastery. and/or year. Chapter 7 ■ Delivering Language Intervention Services 211 include a copy of written diagnostic or treatment authoriza. and family members. the more intervention. home-health aides. language hearing centers. workshops. Ideally. to maintain a cooperative. clinicians to team together. & Johnson. transportation. and letting . insurance cov- positive outlook and its role in recovery. on the quality of documenta. prepared treatment materials. Scheduling individual patients depends on such positive and participatory they become. and self-esteem may be beneficial to treatment. The likelihood of success in the appeals engage in developing and negotiating the details of such process depends. lective empowerment within the community. though. inform- things as the patient’s health and prognosis. Clinicians may empower individuals for improvement by books. and courses helps to enrich professional schedule. activity. environmental. responding insurance company. time must be reserved for traveling. icians and third-party payers. sity clinics (Henri. too. Patient education may involve empowering ences. In planning a weekly ences. quently obtained include standard tests. month. writing reports. through shared expenses (Davolt. The more individuals are amount of time is ideally invested in patient assessment and involved in making decisions about their own care. Through education. producing that service. contin- ing for legal holidays and professional conventions and con- uing self-education is essential to advanced professional com- ferences. It is important to employment of professional consultants for help in this avoid undermining relationships with insurers. In the role of educator. For most clinicians. tomer wants or needs. and supplies are often ordered matic brain injury. 1999). preparing sessions. clinicians must have a contract with the cor. but it involves complex professional risks. community agencies. rather than adversarial. and other management functions other(s) file a complaint with the insurance company. Negotiating Contracts with Third-Party Payers Marketing To be listed on an insurance company’s preferred-provider list. holding confer- development. the largest and social choices available to them. patterns of personal behavior” (Ewart. and additional financial considerations.qxd 1/21/08 11:39 AM Page 211 Aptara Inc. and reading current communicative. materials. The with the state’s insurance commissioner. 931). as well as in the persistence of the clinician or other especially those who work in private practice. videotape recorders and videotapes. Like contracting Likewise. 1991. work. professional literature. and inform the third-party payer that a complaint will be filed requires keen business savvy on the part of clinicians. the clinician may be referral bases for network members. stress management. or to provide services for members of a preferred. in-service training to administrators. may help to reduce the likeli. In addition. and decreasing the instrumental in having the patient or his or her significant costs of marketing. Further. Hallowell. and paper. and develop- ment of strategies to promote better health patterns. and arena is often well worth its cost. p. spirit throughout the process of reversing a denial whenever pos- Education sible (Henri & Hallowell. billing. professionals tion from the primary-care physician. current clinical caseloads. contracting with networks may be highly ben- may file complaints with the human resources department eficial. performing in-service education. Ordering Supplies fostering awareness of means of preventing stroke and trau- Relevant equipment. the clinical aphasiologist also educates the public. Items that are fre. in large part. Currently. textbooks. In many cases. and univer- and ongoing educational and advocacy efforts between clin. ities. Scheduling for the year involves account- other health-care staff. erage. computers. The aphasiologist may also present Scheduling involves preparing a timed plan for the week. thus expanding patient and tion or reimbursement is unsuccessful. tion. ing specialty provider networks. A more confrontational measure is to fiscal survival. depending on their perceived usefulness and die of illnesses that could be cured or eliminated by altering the availability of funds for such purchases. many clinicians are keenly interested in join- hood of denials occurring in the first place. Sometimes clinicians negotiate contracts. tape recorders and stimulating a sense of self-control. effect change. contracts. 1999b). Excellent documentation. Reading professional journals and attending confer- and vacation time for staff members. small speech- professionals pursuing the appeal. Marketing is the process of defining what a potential cus- provider plan. ing patients about their rights and discussing issues such as a clinicians’ expertise.GRBQ344-3513G-C07[203-228]. “Every year millions of people suffer and by the clinician. and even necessary to some clinicians’ and agencies’ of their employers. Provider networks enable If an appeal to overturn a denial for treatment authoriza. and power to audiotapes. individuals with employer-sponsored insurance with HMOs. coordinating activ- individuals by informing them about the array of medical. they also encourage col- software. the aphasiologist may supervise Scheduling student-clinicians and paraprofessionals and/or teach in uni- versity training programs. not-for-profit clinics. Clinicians Varian. and that communication. Accreditation of Healthcare Organizations (JCAHO). ous quality-improvement programs (Roth. slide shows. Regulatory ration with other health professionals. 1997. assessing customer professionals who work in the area of neurogenic communi- satisfaction. or depart. association does offer specific guidelines for quality assur- orders have access to treatment. as are high readi- excellent local and regional reputation through assurance of ness and receptiveness to change. agencies that accredit MCOs (e. not necessarily be the cheapest health care facilities. of in-services to the case managers and reviewers who make facilities. and licensure for engaging employees in every process. there is a need to define what makes meetings with physicians and other referral sources. multifaceted dis- outcomes and consumer feedback. It involves delivering a service or making a product. and paid advertising in a require accredited clinical facilities to demonstrate continu- variety of media). and (4) strong investments in research vices to address customers’ wants and needs. but ments (Labovitz. and (6) networking and successful collabo. . often participate in collaborative marketing efforts. schedules more workable. Although resources to marketing efforts to ensure that their agencies ASHA no longer certifies service-delivery programs. Who are we serving? Insurance companies. Total quality management (TQM) assess patients’ perceptions of the outcomes and efficacy of is a notion that has received a great deal of attention in all our treatments. and needs. involve the ongoing have a steady flow of patients who can pay for diagnostic and and systematic monitoring. the patient? What are their specific coverage and reimbursement decisions for managed-care needs? How can we become more responsive to these needs? organizations (MCOs). Henri & Hallowell. and communicative services. We must define our customers in very ences with insurance-company representatives. 46). top-quality service and demonstrable outcomes. 1991. (2) els should be empowered. be they hospitals. Enterprises with successful TQM those that meet customer needs by delivering quality care” programs have well-defined objectives and guidelines for (Labovitz. 2004). the remain fiscally stable.g. (3) excellence must be pursued in all affect service delivery. What constitutes success in a TQM facility? What is our vision? What are our goals? To be excellent. home-health agencies. ties for their benefit. analysis. how we can better use our facili- vices with greater efficiency. few service-providing on Quality Assurance (NCQA) also require quality assur- agencies. education pamphlets.GRBQ344-3513G-C07[203-228]. the National Committee In this era of health-care reform. (2) customers must receive the analysis of the competition and other external factors that will best possible services. TQM into our decisions regarding the kind of changes we Ideally. reha. Cohn. continue to be a prime political issue in the upcoming TQM involves building quality into the whole of an orga. (4) fostering an and development are essential to quality. Service providers must now dedicate services to yield improved patient outcomes. resources in order to be the preferred provider of cognitive. including the Joint Commission on and advertising (through Web sites. ered to be in the domain of management staff. most linguistic. 1991). related quality-management strategies. abilities and deserve to interact with qualified professionals. Quality is a competitive advan. service-providing agencies now depend on the contributions In the field of communication sciences and disorders we of all staff members in holistic. the state. programs. ance (ASHA. The emphasis is on pro. 2005). thus employees at all lev- analysis of the customers’ perceptions. learn their preferences. p. these institutions invest in the notions that (1) it is believe are essential to the highest quality service. Good communication is vital to the disorders professionals continue to be employed (ASHA. 1994. quate professional training. includ. or private practices. decades. areas of operation. In addition. and modifying operations strategically based on cation disorders. It is important that we integrate every participant. pathology in particular. success of any total quality process (McLaurin & Bell. long-term-care facilities. generally employing multiple facets of TQM and university. and Health care and containment of health-care costs will consumer-driven services. certification. and improvement of treatment services. and are led by informed and active people. wants. 1997). and cater to Quality Assurance them (Peters & Waterman. not just in specific aspects. a TQM program. Such bilitation centers. Our clients have complex. 1991). Within health care in general and speech-language ing the development and dissemination of publicity materials. ance programs on the part of MCOs (Goplerud. The winners in service-delivery competition “will nization.qxd 1/21/08 11:39 AM Page 212 Aptara Inc. 212 Section II ■ Principles of Language Intervention others know the service is for sale. confer. and how we can improve our human tage. strategic quality-assurance must create reliable and valid quality-assurance measures to efforts (Underhill. ductivity. flexibility. and offering specific terms. we must stay close to our customers. 1982). efficiency. (5) publicity Regulatory agencies. We must assess consumer Deep budget cuts and increased competitiveness require satisfaction and ask our patients how we can make their health-care professionals to deliver better products and ser. we need to advocate for our types of businesses throughout the world over the past three professional integrity by promoting the importance of ade- decades.or college-based clinics. 1999). newsletters. 1991). brochures. components. It involves (1) detailed people who are critical to success. While quality-assurance programs were once consid. that patients with communication dis. 1991. effective communication. (3) development of products and ser.. collaborating For example. much emphasis should we give a patient’s estimated progno- A national shortage of doctoral-level personnel in commu- sis when we decide whether or not to provide services? nication sciences and disorders in the United States is now In addition. establishing and expanding a ing graduate school and entering the clinical workforce are donor base of individuals. related to the students’ sense of financial need.. life.qxd 1/21/08 11:39 AM Page 213 Aptara Inc. or federal research agencies.GRBQ344-3513G-C07[203-228]. Although an enormous amount of research across disci- tions that help support the provision of services to persons plines and industries documents the effectiveness of incen- whose access might otherwise be limited. benefit concerts. “stretching the associated with clinical services. ethical implications of incentive systems are often involved in initiating or supporting fundraising efforts. covered services. and making decisions about the right to life. rehabilitative services to people who are near death? How universities. vision of rehabilitation services (Katz et al. Henri and Hallowell (1997) enumerate and describe orders in the United States (Petrosino. clients. patients who have limited Reduced rates for clinical services under managed care. must be well prepared to face with solid moral fortitude per- euthanasia. American Medical Association. billing. 1999a. in par- • Misrepresenting the actual time spent in treatment. Thus. which are charged with providing services to clients • Avoiding or limiting non-billable activities that are impor- regardless of their ability to pay. and ticular. in rehabilitation potential) and overstating the likelihood of combination with reduced frequency and intensity of many improvement to justify admitting persons to treatment. about special clinical programs and needs. state. are dependent on alternative tant to quality of service (e. restructuring have reduced financial gains through the pro- ingly be interacting with patients. was far below the number needed to fill the corresponding . Lieberman. susceptible to such conflicts of interest. means of financial support. in-services. staff meetings). misrepresenting actual progress or other ing agencies are increasingly reliant on finding additional forms of dishonesty). tain minimum level of billable clinical productivity per nal organizations (Henri & Hallowell. 1997) suggests that students exit- ing fundraising materials. The study tion disorders. Again. Agonizing questions we will have to face include: Who has the right to decide how long a patient lives? How much of our limited financial Research resources should be used to delay death? Should we provide Some aphasiologists pursue careers in research at colleges. According to the results of annual sur- based upon the amount of time they have engaged in billable veys of graduate programs in communication sciences and dis- service. foundations. Not-for-profit agencies.. virtually ignored in most of the research literature. Chapter 7 ■ Delivering Language Intervention Services 213 Fundraising • Admitting patients to treatment who are unlikely to ben- efit from skilled therapy (i. dinners.e. many rehabilitation companies in the disorders is greater than the need for those in other specialties United States have offered financial bonuses to clinicians within the profession.g. Geffner. and the right to health-care access. study (Henri & Hallowell. 2000). and caseload-manage- Ethical Decision-Making ment decisions. informal discus- means of generating income to support clinical revenues.. participating in annual fundraising cam. is resulting in generally decreased revenues • When documenting progress for billing. 1999b). ened with the loss of their jobs if they do not achieve a cer- and establishing partnerships with corporations and frater. expecting further reasonable progress.. One Fundraising efforts may include collaboration in develop. & McNeil. meeting with donors and potential donors to financial bonuses. do-not-resuscitate (DNR) orders. and other health.g. week. clinicians are tive systems.. 1995). As recent worldwide trends in health-care During the 21st century. which appear to be tions that support the concerns of people with communica. the number of new • Seeing low-fee patients too briefly or at such a frequency doctoral-program graduates in adult neurogenic disorders and intensity that progress is unlikely. 2006. the anticipated doctoral faculty openings in adult neu- ethics of patient care by speech-language pathologists: rogenic disorders outnumbered those in every other specialty • Seeing high-fee patients too long or beyond the point of within speech-language pathology from 1991 through 1998. Consequently. Furthermore. family. Thus. in a survey completed in 2002. health-care workers will increas. sions with team members. During faculty members who specialize in neurogenic communication the past two decades. and try confront a multitude of ethical conflicts related not only sporting events). also demonstrates that practicing clinicians across the coun- paigns and special events (e. Many for-profit agencies have established their own not-for- profit foundations. the ways in which incentive systems may affect the quality and 1997). an increasing number of clinicians are threat- with fundraising professionals on planned-giving programs. the need for Judicial Affairs. many service-provid- truth” (e.g. or at private. but also to more dire personal needs. or are partnering with existing founda. many report a sense of ongoing ethical pressure in balancing their needs for job security with the ethical nature of treatment. clinicians face other conflicts of interest yielding rich opportunities for careers in higher education related to their own financial gains (Council on Ethical and (Gallagher. clinicians care workers. the quality of sonal conflicts of interest related to professional decisions. 1997). and corpora. Others know strate that fact to consumers and their significant others. cate independently for the services they need. referral sources. and consumer education projects. many research design. Consequently. col- from the start of their graduate studies that they want to leagues in other disciplines. approach primary-care physicians and insurers. empirically. several pieces of federal and state leg- ation of an environment that is conducive to risk-taking. regional committees that monitor the performance of MCOs ventions. The Social Security Act. Numerous state and local professional organizations every clinical aphasiologist has a responsibility to document also provide training and materials to support legislative advo- his or her clinical successes and failures. Adult neurogenic communication disorders continues specific means by which aphasiologists may advocate for to be the area of faculty specialty in greatest demand (Shinn their patients were discussed above in terms of appealing et al. clinicians to be familiar with federal and state laws and rules ence the quality of research that is conducted (Ringel. in press. mailings. They may participate in letter-writing campaigns to els of intervention (Thompson & Kearns. recognizing its impor- behavioral.e. motivation. Those pertinent to serving adults with requires that speech-language pathologists be active advo. 1982). Kimelman. education. and that mediocrity comes Aphasiologists may provide guidance concerning how to from a division between clinical and research programs. especially aphasia.. provides free advocacy materials on the Internet and through ment outcomes to justify reimbursement for our services. 52). and those whose tatives who support the provision of services to persons with schedules do not permit time to perform extensive literature communication disorders. It is important Minifie (1983) aptly claims that the destiny of our field is for the clinician to provide patients and their significant oth- imminently tied to practitioners assuming a greater role in ers the information necessary to be effective self-advocates. As paigns to support the provision of services to persons with third-party payers are demanding published. islation have been passed to ensure that persons of all ages Thus.GRBQ344-3513G-C07[203-228]. negotiating contracts. 214 Section II ■ Principles of Language Intervention open positions (Shinn. and national advocacy. quality assurance. . communicative. clini. Many clinicians with interests in scholarly work find per. Although it may seem obvious to the and post-graduate training in research. In the United States. While the kind and quality of research that is undertaken depends on the availability of facilities and subjects and on LEGISLATIVE ISSUES AFFECTING the cooperative atmosphere provided by the administration SERVICE DELIVERY and staff. communication disorders are supported by ASHA. it is often necessary to demon- as they return to school for doctoral study. For some seasoned aphasiologist that speech and language services are essential clinicians. those interests lead to significant career changes to the total care of a patient. and par- sonal and professional rewards in continuing their graduate ticipating in research. denials for authorization and reimbursement. cognitive. Consumer advocacy is studies soon after their masters-level training. for example. Clinicians legislators. and write for publication. contains several titles (i. developing the clinical science. marketing. and/or linguistic mod. usually effective. and the style of management that is either priate levels of service. insurance-com- engage in academic careers. 1991. It is essential to establish “how much and what kind (Hallowell & Henri. nearby academic institutions. it also largely depends on the commitment of the Legislation Affecting Access to Care individual clinician to analyze the effectiveness of his or her work. Goldberg.. 1999b). collect data. 2007). which based evidence of treatment efficacy and functional treat. and legislators. 2001). chapters or subsections) that ensure reimbursement for Advocacy speech-language pathology and audiology services (Hallowell Increasing competition for limited health-care resources & Henri. An essential component of quality research is the cre. p. However. consumers who have communi- Even clinicians who are not invested in research careers cation disorders. Some 2001). are often unable to advo- should be good consumers of and contributors to research. regional. and thus continue their doctoral pany representatives. write letters to legislators There is a greater need now than in any time in the history and insurance commissioners. may establish Each individual’s advocacy efforts contribute to the gains of constructive partnerships with doctoral-level researchers in all patients and professionals in our discipline. the quality. or even testify before state and of aphasiology to demonstrate the effectiveness of our inter. cates on behalf of their profession and their patients. numerous legislative advocacy cam- treatment outcomes” (Thompson & Kearns. Although it is not often part of clinicians’ job descriptions cians must be familiar with the techniques of scientific to be engaged in local. of treatment is best and what changes constitute important In the United States. will influ. Title 19 (Medicaid). reviews. 1991). tance. & Messick. cacy.qxd 1/21/08 11:39 AM Page 214 Aptara Inc. and personal relationships of with special conditions have access to adequate and appro- the research staff. measurement. reverse prior Research is inseparable from clinical service. election campaigns to support political represen- who are not well-versed in research design. It is important for speech-language supportive of creativity or critical of new ideas. aphasia include Title 18 (Medicare). and with specific clinicians feel compelled to do so. and regulations that support access to special services. authorization or treatment denials. and analysis. there are two reimbursement mechanisms have mixed histories serving federal health programs that influence service delivery to populations with chronic or degenerative conditions (Smith adults in the United States: Medicare and Medicaid. language pathology and audiology services). 1995). offered by employers as part of a benefits package. employees have some choices regarding the type and ber of services does not generally influence the per diem rate. with less costly work services that. to providers. most insurance companies throughout vidually identifiable health information among carriers and the United States reimbursed service providers for specific providers. The type and num- Often. those who are insured by their employers make some provider a specific amount of money for each day during financial contribution to maintain their insurance plans. specific plan. how. which a patient is in the provider’s care. per diem. They now characterize The delivery of diagnostic and intervention services is heavily the majority of reimbursement arrangements in the United influenced by economics. Professional clinicians are paid for States. in turn. Income generated through clinical discounted fee-for-service. Additionally. In order to provide services to a plan’s mem- profit foundations. for persons United States armed forces are eligible for health-care ser- ranging in age from 16 to 64 (Hallowell & Henri. including aphasiol. 2007). the majority through plans are examples of this type of arrangement. & Ashbaugh. . clinicians receive salaries or bers. Most often. and safeguard the transmission of indi. case rate. There are many permutations to each of these modes. the primary meet definable levels of low-income and specific asset stan- funding vehicle for states’ special-education programs. In a case rate arrangement. however. individuals are insured primarily through private and the new Medicare prospective-payment system (PPS) health-insurance programs. rendered.S. Many of these In addition to private insurance programs. The nationalized health programs. standard Medicare diagnosis-related group (DRG) system ever. administered through private insurance companies that serve tion disorders have demonstrable impacts on an individual’s as interfaces between service providers and the Medicare ability to perform job duties. Some of these managed-care modes have existed for a long time. federal health-care plans. All health-care professionals. plans providing fewer medical benefits. provider agencies are reimbursed by Discounted fee-for-service arrangements involve the estab- third-party payers. far-reaching measures known collec- tively as “managed care” have modified the traditional THE ECONOMICS OF LANGUAGE.” Now. Medicare provides coverage for speech and language pathol- Several other pieces of federal legislation also support ser. vices provided through the Veterans Health Administration in the Department of Veterans Affairs (VA). modes of reimbursement. are billed for units of billable time or for specific services employed generally pay themselves a fixed salary or a por. states. providers must agree to those rates. Those who are self. ogists’ services to adults over 65 years of age and for persons vices to adults with aphasia. Other such federal acts include program. Legislation Affecting Patient Privacy In the United States. Medicare plans are generally make available certain resources in cases where communica. tion of the profits from their practice’s annual revenues. The Americans with Disabilities under the age of 65 who have long-term disabilities (those Act does not ensure funding. Prior to about 1996. In the United States. especially in certain geo- INTERVENTION SERVICES graphic pockets of the United States. are expected to be familiar with HIPAA regulations. includ.GRBQ344-3513G-C07[203-228]. Medicaid programs are administered by individual Rehabilitation Act. In many In a per diem arrangement. the Health Insurance Portability and Reimbursement Schemes Accountability Act (HIPAA) requires that health plans stan- dardize. streamline. and all support staff and student-clinicians in the U. may help families access speech. most often at VA hospitals and clinics. the provider is paid a specific fee for treating a patient with a particular diagnosis. and the dards. which supports social. individuals who have served in the ing speech-language pathology and audiology. or special not-for. Rather. the third-party payer pays the cases. but may require employers to lasting more than 2 years). which funds rehabilitation services. Examples of alternative reimbursement modes are the services they provide. Third-party payers are usually insurance lishment of reduced rates for patients who are members of a companies. icians engaged in billable services with covered individuals. Medicaid provides for services to persons who the Individuals with Disabilities Education Act. and capita- services very rarely comes from fees paid by patients directly tion. Chapter 7 ■ Delivering Language Intervention Services 215 Title 20 (the Social Services Subsidy.qxd 1/21/08 11:39 AM Page 215 Aptara Inc. regard- less of the duration of care or the number of services ren- Third-Party Payers dered. This reimbursement arrangement is known as “fee-for-ser- vice. health-care services are covered through likely needs of patients according to their diagnoses. The case rate is based on actuarial analyses of the In most countries. Third-party payers hourly wages from their employers. services rendered and/or for units of time during which clin- ogists. extent of medical coverage they would like. g. and individuals who are insured through a specific plan. Very low fees. considered a gatekeeper of all health-care resources. Thus. capitation schemes. bill a third-party payer for services. capitation revenue. Still. 2000). the actual rate of managed- tions on the type and extent of services allowable. then providers must absorb the remain- During the expansion of managed care in the U.. Likewise. physicians. and (3) cost enrollee. having • Salaried employment of physicians by payer organizations. Even in those countries that rely exten- capitation is a fast-growing type of payment system. all over the globe. but at much higher rates and with greater restric- virtually all health-care contexts. the and/or the employers who pay for enrollees’ insurance health-care literature and the popular media are replete coverage. • Increasingly stringent utilization review. or per diem care arrangement. and to one’s professional context and point of view. specific plan. Members of a plan may use “out-of-network” the cost-control mechanisms that are implemented across providers. MCOs are characterized by (1) use of specific types cutting tactics that are characteristic of managed-care modes of cost-saving reimbursement schemes. United States is having a dramatic influence on virtually all aspects of service delivery to persons with aphasia and other Managed-Care Organizations communication disorders. 216 Section II ■ Principles of Language Intervention Capitation involves a fixed amount of money that is paid • Payment of incentives to physicians not to refer patients to a provider. and . (2) access to care for persons who need it.S.. If those • Restrictions on frequency. and agree to offer services to the PPO’s enrollees at rates that are because of variability in the definition of what constitutes significantly below what the same providers would normally managed care. and (4) reduced enrollment fees for enrollees control (Henri & Hallowell. as described above. social workers. parallel trend in health care restructuring tion arrangements can be highly risky for providers. intensity. Managed care has been defined Managed-care organizations (MCOs) are insurance compa- in myriad ways in the health-care literature. Other definitions highlight specific cost-control and cost- though. the authority to determine the frequency. one might reducing unnecessary care (Henri & Hallowell. 4). a large and growing proportion allowances. sively on nationalized health-care systems. intensity. The two most common trol in managed care often leads to compromises in quality examples are preferred-provider organizations and health- and access. including • Preadmission certification for hospital stays. 1999b).GRBQ344-3513G-C07[203-228]. A health-maintenance organization (HMO) is a type of These cost-control mechanisms. there ing cost of caring for the enrolled individuals. capita- has been a general. coordinating care. If one considers providers.. serve as an incentive for enrollees to use preferred sored benefits through managed-care plans. rehabilitation) services. Regardless of the specific way one (2) promotion of health and wellness through preventive defines managed care. maintenance organizations. care penetration across the country is now near 100%. of service delivery. there have been upheavals in organizational structures and a proliferation of Managed Care severe cost-cutting tactics in both federal and private pro- The rapid proliferation of managed-care practices in the grams (Katz et al. usually in the form of co-pay- of Medicare and Medicaid patients receive federally spon- ments. A majority of agree to reduced rates in the form of discounted fees-for- privately insured citizens receive service though a managed- service. and duration of care individuals require more services than are covered by the (p. (3) concerted efforts to coordi- stated are (1) assurance of the quality and coordination of nate the type and number of services received by each care. Generally. Capitation • Use of red-flag diagnostic or treatment categories to deny rates are based on actuarial analyses of the likely needs of reimbursement. Providers generally penetration in the United States are variable. A preferred provider organiza- Because of great variability in managed-care proliferation tion (PPO) is one that contracts with specific providers who according to geographic location within the country. enumerated by Henri and MCO in which comprehensive services are provided Hallowell (1999b). They generally do not • Negotiated reduced reimbursement rates. Many of the clinicians who work for HMOs. schemes in HMOs are generally based on prospective pay- • Designation of physicians as “gatekeepers” of patients’ ment models. maximizing health outcomes. The primary-care physician of each enrollee is health-care expenditure allotments. Sometimes it is nies or programs that operate in managed-care modes. and others. nurses. not on the actual services rendered. argue that the definition of an MCO does too. defined with a focus on managed-care’s goals of preventing Given that the definition of managed care varies according illness.qxd 1/21/08 11:39 AM Page 216 Aptara Inc. are salaried by the HMO. Unfortunately. 1999b). Reimbursement • Designation of a restricted list of “preferred providers”. with accounts of how the overwhelming focus on cost con- There are many types of MCOs. based on the number of people enrolled in a for specialty (e. the three main goals most frequently care and patient education. specific estimates of managed-care market charge in a fee-for-service arrangement. rehabilitation therapists. • Required pre-authorization for services. case rates. include: through one health-care facility or a network of facilities. perhaps because they are less likely to have health-care coverage through employers. 1995). Hallowell & Henri. such individuals trol rising health-care costs are laudable. Furthermore. intensity. matters that traditionally have been in the hands of clini- 1999b). 1990b. prominent cost-containment feature of managed-care plans blesome. even in patients with good rehabilitation potential. Retchin. 1999a. Since the enrollment enable MCOs to reduce expenditures associated gatekeeper almost always receives financial rewards for with the care of costly conditions (Clement. & Newacheck. 1995. This trend has led to decision-making that is more often do not fit the acute-care patterns of quick and steady financially driven than clinically sound. Oberlander. improvements throughout treatment. insurance companies are increasingly intervening in discharge based on maximal progress (Henri & Hallowell. “evidence-based medical necessity” further threaten patient The key challenges to professional practitioners in neuro- access to speech-language services. of this repercussion is that many clinicians are finding it eas- • The maintenance of our professional integrity. Intervention in Aphasia Stenger. For factors related to managed-care modes of delivery have persons with neurogenic disorders. ment of medical impairments rather than of disabling condi- • The fiscal stability of our service-providing agencies. degenerative conditions. although the use of assistants and aides in the treatment of Wicks. Duration. Chapter 7 ■ Delivering Language Intervention Services 217 duration of any services allowable for each patient. Brown. and multiple disabilities making. such efforts often tend to have disproportionately greater needs for rehabilita- threaten patients’ access to care and the quality of care they tion services (Screen & Anderson. 1996. 2001. Fourth. receive (Henri & Hallowell. who often receive financial Despite the supposed focus on “quality” in MCOs. 1998). Smith & communication and swallowing disorders is relatively new Ashbaugh. 1994. held accountable for the outcomes of their services in such which limits clinicians’ abilities to foster significant functional models is through the documentation of patients’ ongoing gains. and the duration of. 1995. of these less expensive (but less qualified) personnel and the Restrictions on coverage for conditions diagnosed prior to potential consequences for further reductions in the quality . 1997. 1994. 2002). 1994. and Frequency of Care threatened by decreased referrals from managed-care’s gate- keepers. Randall. authorization and re-authorization for services. and ier to obtain authorization and reimbursement for dysphagia • Problems of consumers’ access to our services (p. 4). 2007. and may transferred control of the access to. are less likely to be Restructuring of health-care systems to reduce costs has able to afford their own health-insurance coverage. & Stegall. 1995). concerns about the overuse and misuse provide full coverage for such persons (Inglehart. to patients. duration. Fox. 1990a. Henri & Hallowell. 1993). Purtillo. 1994. lems over problems of communication (Hallowell & Clark. Under such clauses.GRBQ344-3513G-C07[203-228]. Consumer Access Consumers’ access to diagnostic and treatment services is Quality. interruptions gains toward recovery and discharge. 1993. Since elderly people and people with chronic health cians. Leigh. First. vices (Clement. Fisher. care be less likely to advocate for their own health-care needs from clinicians to administrators. 1995). Intensity. such as treatment planning and discharge decision- problems. Although efforts to con- (Henri & Hallowell. 1987. Retchin. 1994). managed care’s emphasis eroded the quality of care clinicians can deliver. 1999b). there is an Let us briefly review each of these key areas as they pertain alarming trend to prioritize treatment for swallowing prob- to adults with neurogenic communication disorders. MCOs are less likely to in the United States. related to the determination of services to be provided Perkins. MCO clauses emphasizing the relatively new concept of 1994). & Stegall. Hallowell & Henri. Hiller & Lewis. usually physicians. Members of cultural and ethnic minorities and of low- income populations have restricted access to care as well Consequences of Managed Care for (Daw. and frequency of care that necessity clauses is the emphasis on the importance of treat- we can provide. spending less of the available financial resources on services Brown. that intervention. with a logical point of Second. Given that many clinicians who treat aphasia also treat dysphagia. such individuals are in the continuity of care have increased due to delays in experiencing more and more difficulty in receiving our ser.qxd 1/21/08 11:39 AM Page 217 Aptara Inc. several incentives to decrease the amount of services offered. (Begley. tions that influence quality of life. if genic communication disorders are the same as those sum- providers cannot present a solid body of well-controlled marized by Henri and Hallowell (1999b) for the professions research to support the effectiveness of any intervention of speech-language pathology and audiology in general: administered. An additional repercussion of medical- • The quality. Rodwin. Third. Ironically. Grey. he or she has inherent conflicts of interest 2007. A disconcerting example • The livelihood of our professionals. One of the principal ways in which clinicians are is the restriction on duration and frequency of treatments. services than for language intervention. then they will not be reimbursed for providing • Consumers’ access to our services. a on acute-care service-delivery models is particularly trou. 1999). Case-mix data are Quality assurance is a stated aim in the literature of virtu. and reduced access for some patient disorders. and functional abilities of many patients discharged from acute-care hospitals but not ready to return home. How can it tation hospitals have one of 13 qualifying diagnoses be. a standardized assessment scheme. Patients who do not have one of the Fiscal Stability of Service-Providing Agencies 13 allowable diagnoses now have longer acute-care stays. including cognitive and communicative reductions in coverage. two of the most drastic threats to U. thus eliminating their par. 2005). increased cies do not have the equipment. ogist’s in light of such managed care trends is vital. 2005). increases in the frequency the medical or rehabilitation needs of patients with complex of reimbursement denials. patients had dramatically reduced access care withdraw from membership. require that MCOs meet high standards of quality. Recent research on the quality of health care sug. the advocacy role of clinical aphasiol- than the age of 65. 218 Section II ■ Principles of Language Intervention and outcomes of care are growing (Hallowell & Henri. The flat daily rate based on the conditions of individual residents. this cap mix data. and dramatic dissolution of numerous Government Accountability Office. or expertise to address reimbursement processing time. as well as evi. to rehabilitation hospitals (Moran Company. ally every MCO. for intensive rehabilitation of persons with neurogenic com- Because the majority of persons with aphasia are older munication disorders. Inpatient rehabilitation hospitals are vital to the restora- 1998). Following a strong advocacy campaign. an “exceptions” process was imple- for patients with a variety of conditions as assessed through mented. then. staff. enabling speech-language pathologists to appeal for .S. Originally initiated varied forms since 1999 (Moore. imple. independence. known as the Minimum 2007). and Medicaid Services. long-term costly needs for care of patients who have not had able services. implemented in and physical therapy services.qxd 1/21/08 11:39 AM Page 218 Aptara Inc. the effect on quality of care is com- may be lower than standards under more traditional models. that there is such a preponderance of complaints (updated from 10 in 2004). cal decision-making. combined. Having government fiscal policy rather than Another is that MCOs tend to minimize their quality under qualified medical providers determine which patients may pressure to reduce their own administrative cost-improvement receive which services is far from an optimal means of clini- efforts. prevent rehabilitation centers from providing services that dence of decreasing quality in the research literature? One could be provided through less costly means in less-inten- reason is that overall comparative standards among HMOs sive care environments.GRBQ344-3513G-C07[203-228]. A recent surge in staffing reductions. astating. over another.S. are Many of the features that characterize managed care transferred to nursing homes. based on RUG classifications of a facility’s residents. decrease in access to services for persons with neurogenic The rates are calculated with complex formulas involving communication disorders has been equally. increased administrative costs. that at least 75% of patients admitted to inpatient rehabili- assurance and quality-improvement practices. requires clinicians across disciplines to make difficult and Prospective-payment systems affect inpatient services in often arbitrary decisions about the priority of one treatment inpatient rehabilitation and long-term-care facilities in par. in 1999. but later actual time clinicians from multiple disciplines spent caring reinstated. such as the Applying what is known as the “75% rule. Even the financial savings targeted through the populations are all factors that threaten agencies’ clinical CMS policy are not assured. MCO-accrediting agencies. Tremendous financial losses have conse- ticular. Data Set (MDS) (regularly updated). Rather than being reimbursed for actual costs quently been experienced by long-term-care facilities and incurred. modifica. promised. Reduced reimbursement levels. tion of health. Many nursing homes and home-health-care agen- delivery of care.740 at the close mented in varied forms since 1983. appropriate care and rehabilitation to begin with (U. reduced cost-of-care in the short term does not stem the tions of salaried contracts to hourly contracts based on bill. implementation of rigorous clinical-produc.” CMS requires NCQA. vices (Medicare Part B) involves a limit ($1. Both of these mea. tivity standards. or for actual services rendered. dev- resource-utilization group (RUG) classifications and case. ticipation in consumer satisfaction surveys (Health Advocate. Given the fre- rehabilitation companies and private practices is indicative quently complex medical conditions and the common need of the current fiscal pressure on providers. In 2006. RUG classifications are based on studies of the was temporarily rescinded in November 1999. if not more. The savings involved in revenues. medical conditions. and Medicare’s payment of 2006) on payments for both speech-language pathology cap for outpatient rehabilitation services. facilities are paid a rehabilitation providers throughout the United States. agencies that support intervention for aphasia have been Medicare’s payment cap for outpatient rehabilitation ser- Medicare’s prospective-payment system (PPS). Worse. even when the latest CMS plan gests accreditation of HMOs may be misleading because a was first being phased in during 2005 (with only 50% com- large proportion of enrollees who are not satisfied with their pliance expected). or are discharged to their threaten the fiscal stability of the agencies that support the homes. While the intent is reasonable to about managed care in the popular media. the cap dramatically reduces the frequency and sures were implemented by the Center for Medicare and duration of treatment that clinicians can provide. It is troublesome that the new evidence-based medical- accessibility. 1999b). articulator placement. in fact. are attempting to reduce costs by addressing the expense of employing highly educated and Accountability and Enhancement of Research skilled clinicians. some reductions in reimbursement and coverage salaries and employment opportunities. and long-lasting treat- Professional Integrity ment programs that are not necessarily optimal in terms of Under managed care. infectious cians in the past were probably far too liberal in providing . Still. service-providing agencies. it is not surprising that clinicians. and accountability have. too. and Cost age denial of the communicative. It is also troublesome that such clauses often encour- Prevention. Even in the realm of aphasiology. Thus.” a concept that is addressed persons with neurogenic communication disorders are neg- repeatedly in this book. restrictions on the types of evidence required to justify treat- ments. Access. many insurance companies. clini- who are affected by stroke. are tional indemnity fee-for-service modes of operation. technicians. Scientific evidence of our treatment efficacy and who are trained in a variety of medical and rehabilitative treatment outcomes is being far more carefully scrutinized diagnostic and treatment methods that were once exclu. Holzemer. Additionally. such as fully certified and licensed speech- language pathologists. to grammatical structures. have yielded tremendous inconsistencies in the quality of Another facet of our heightened accountability is that care across treatment settings. it is essential that patients. Now we have been challenged to reformulate our diagnostic and treatment methods to better Not all of managed-care’s influences on services available to address “functional outcomes.GRBQ344-3513G-C07[203-228]. those pertaining expertise in such areas as aphasiology. ative. and psychoso- The emphasis of most MCOs on preventive care and health cial needs of patients. 1994. It is incumbent communication disorders. Gerard. speech and hearing centers. and discipline (Boston. as well as for their specialized clinical performance–based objectives (e. While we lament the rehabilitation services for people with aphasia and related decline in revenues for our clinical services. Livelihood of Professionals Many practitioners and agencies representing the whole array of health-care disciplines are known to have abused the Given the financial losses to service-providing agencies dis- lucrative insurance-billing opportunities within the tradi- cussed above. private practices. experiencing the effects of managed care in terms of reduced Certainly. Some of its touted virtues of prevention. Although there are merits to clinicians are now required to ensure that services provided some of the arguments for the use of support and/or cross. ing abuses of systems that allow for continuous high-cost hourly billing for frequent sessions. than ever. licensure. cost-saving. Restructuring. there have been ongo- Hallowell. care restructuring is that it demands increased accountabil- 1996a. cognitive. and clinical pro- employ “multiskilled” or “transdisciplinary” professionals fessions. education. 1990.qxd 1/21/08 11:39 AM Page 219 Aptara Inc. remote from practical communica- Positive Impacts of Managed Care tion in real-world contexts. we have been driven to in the level of skill. 2007). One way they may do this is to A related and critically important positive impact of health- employ less costly assistants. re- are truly outrageous. training.g. service-providing agencies. and so on. and overall competence of clinical practitioners. insurance coverage for most people who enroll in MCOs priate documentation to boost patient access to needed enhances the accessibility of coverage. improve the quantity and quality of clinical research in our tion. having no relevance to patients’ actual engineering. need for a richer empirical base of research with which to 1996c). Clinicians clinicians advocate for the integrity of their professions were once typically trained to think of treatment in terms of (Henri & Hallowell. Chapter 7 ■ Delivering Language Intervention Services 219 additional reimbursable treatment based on documentation processes. address important life-affecting changes in clients and trained personnel in some environments. as well as achieving positive functional outcomes. and thus may help to prevent some of a patient’s need for additional services. 1999b. traumatic brain injury. Sarno. 1998). certifica.. hospitals. in favor of the treatment of physical maintenance should ideally reduce the number of people impairments that are not always as life-affecting. the reduced cost of upon clinical aphasiologists to provide sufficient and appro. and the Medicare cap shared among speech-language patholo- rehabilitation companies have had direct and personal gists and physical therapists is a good but unfortunate exam- impacts on many speech-language clinicians (Henri & ple. Another is to ity of clinicians. we must also disorders. consolidation. and down-sizing movements in needs or to actual expenses incurred in offering our services. Both of these strategies have resulted in a decrease justify our interventions. 1996). This scrutiny has increased awareness of our great sively in the domain of specific clinical disciplines (ASHA. and that those services are necessary. recognize that the continuous escalation of health-care costs from the 1960s through the early 1990s could not continue. or speech sound discrimination). and aides (ASHA. impacted our necessity clauses of some MCOs impose unreasonable professional practices in positive ways. are numerous ideal characteristics that we might all aspire to ing of clinical revenues. time wage and salary earnings in 2001 were about 75% of and artistic parts of themselves to achieve a balance of inter- those of men with the same experience (U. and integrate the personal. Newmark. reported by the degree of excellence perceived is relative to the person health-care administrators. the part of patients (Cormier & Cormier. 1988. gist? What factors characterize the very best clinicians? The continued expansion of controlled research regarding There certainly are not definitive answers to these ques- our clinical practices will undoubtedly help us not only jus. certification in speech-language pathology (in the United Likewise. use only high-caliber assessment and inter- tion of specific occupations. Women consis. Not surprisingly. Gender Influences on Salary and Status They also demonstrate outstanding oral and written commu- Wage rates are influenced primarily by the gender composi. where appropriate. linguistics. Signer. 1991). private. tion. treat. knowledge. According to a recent significant others as well as to colleagues. foster maximum self-determination on linked to the preponderance of women in a profession (U. 1992). women’s median weekly full. cific professional responsibilities. a state & Hallowell. the health-care work force. there is also a strong relationship They use knowledge effectively and think and learn indepen- between gender and status. 1997. the patients and and make valid prognostic statements about neurogenic colleagues with whom we work. salaries are low throughout the Knowledgeable clinicians are able to reason scientifically. as the skills and qualities needed for excellence differ tify our services. The fact that third-party payers and government-spon. effective climate that contributes positively to the therapeu- tently make less money than men in almost every industry tic relationship (Rogers. according to the contexts in which we work.S. & Troske. Further. A list of prescriptive features indicating increasingly aware of the financial impact of their individual what constitutes the “best” aphasiologist may not be appro- and agency-wide services on the financial well-being of their priate. 1969). and leadership to patients and their 1995. and employing agencies. and clinicians. psychology. and notorious for its hierarchical status and power differences have formal and informal training in the arts and sciences. maintain an Government Accountability Office. For exam. encouragement. skills. scientific. but also learn better ways to diagnose. 2003). 2003. this means a Certificate of Clinical Competence improved business savvy of their clinical employees (Henri (CCC) granted by ASHA and. treatment approaches were lacking. clinicians have a graduate education. 2003). lower salaries in our profession are also tied to inadequate researchers. despite the long-time predominance of women (over ogy. is that clinical professionals are who perceives it. are flexible and Department of Labor report. THE ULTIMATE EXCELLENT APHASIOLOGIST and federal funding opportunities for research involving What constitutes the ultimate excellent clinical aphasiolo- treatment outcomes and treatment efficacy have increased. men have continued to represent the major- treatment-outcomes and efficacy literature to support their ity of directors and heads of programs in the field (c. Likewise. health-care professions. provide inspiration. the resources they had in the (ASHA. including not only speech-language pathology and audiol- ple. 1988). they may not assert their right to a salary com- reimbursement has stimulated concerted research and pub. Still. tions. Accountability Office. employers report being impressed with the States. 1988). Isaacs. Signer.GRBQ344-3513G-C07[203-228]. Competent their agencies. between high-ranking and low-ranking workers. 1988).S. adapt well to change. The health-care labor force is dently. role in business and financial-planning teamwork within The excellent aphasiologist is competent. One must recognize that One additional benefit of managed care. and the nature of our spe- communication disorders. and generate new applications. low salary and low status are vention techniques. motiva- (Bayard. . Some university research and marketing of our scope of practice and the perceived value of teaching programs in communication sciences and disorders our services (Holley. nication skills.qxd 1/21/08 11:39 AM Page 220 Aptara Inc. Since women make up 75% of The excellent aphasiologist is knowledgeable. intellectual. This change appears to have increased clini. mensurate with their training and professional status. state. license as a speech-language pathologist). there performed clinical duties without engaging in the monitor. incorporate new findings. Government personal. They have clinical- practice experience under the supervision and mentorship of seasoned excellent aphasiologists (Kovach & Moore. effect. as diversity in expertise. 2006). national and regional cians’ sense of ownership for their agencys’ operations. 220 Section II ■ Principles of Language Intervention services that were not necessarily based in solid scientific 90%) in the field of communication sciences and disorders research and theory. 1999b). clinicians now frequently play a vital possess. Hellerstein. The lication efforts on the part of our professional organizations.. In contexts in which clinicians once culture among clinicians is certainly desirable. such that clinical research is valued in academic cultures more than it had been previously. and technical competence. Schwartz. but also cognitive sciences.f. They are committed to interdisciplinary study. Because women sometimes contribute only secondarily sored health-care plans now require solid evidence to justify to income. have reorganized research priorities over the past 10 years. They com. self-esteem. and families’ lives. They consistently protect clients’ agement of communication problems resulting not only privacy and confidentiality. stress management. basis for any unreasoned distortion of judgment. skills (Brownell. priateness of their actions (Hirsch. clinicians are familiar with multiple aspects of aging. and collaborating patients. His or her empathetic and compassionate rent professional literature. knowledgeable and defined ways of reaching those goals. conversational discourse. and counsel. ing. 1969). ences and disorders and support strategic efforts to recruit. and in the development of appropriate Demographic trends will certainly continue to play an attitudes and skills. and confi- education opportunities. patient. medicine (especially neurology). moti- tilingualism. 2003). fiercely environments. in ways of FUTURE TRENDS reaching those goals. honors each significant other. They have a profound sense of inquiry. and exhibit proper follow-through. biases—their own and those of others—and examine the The excellent aphasiologist is emotionally healthy. mentor. and familiarize themselves with. emotional expression. actively balancing their psychological clinicians have a rationale for everything they do. music. sexual orientation. service. support.qxd 1/21/08 11:39 AM Page 221 Aptara Inc. important role in aphasia intervention. and socioeconomic sta. highly motivated. Some have been raised in bilingual or multilingual open-minded. They avoid profes- primary goal is high-quality. They have training and experience in the effective man. continue to learn how to cultivate healthy relationships and The excellent aphasiologist is professional. culture. colleagues. They codes. The excellent aphasiologist is a thoughtful. and others in terms of health and sensitivity training. active listening. and learn from their colleagues and dence among patients. a love of people. Although aware of their (Wallace & Freeman. but also those associated with traumatic brain ommendations. 1982. business and health administration. communication messages and is skilled in interpreting them. movement disorders. genuinely motivated to help others (Minifie. Ethical clini. and com. They maintain records and reports accurately and completely ing. They have weaknesses and failures. such as personal responsibility for learn. take advantage of continuing. 1991). and celebrate. 1994). They have familiarized themselves with books cians are aware of conflicts of interest and work to resolve on healthy interpersonal interaction and intimacy. and War generations growing older and living longer than ever . clinical aphasiologist is sensitive to client-centered and speech. listens plement their knowledge with keen insight in managing sim. freedom-loving. infectious processes. definition of “gifted scientists” who are “individualistic.GRBQ344-3513G-C07[203-228]. which include communication. a commitment to diverse populations in the profession of communication sci. and The excellent aphasiologist is ethical. They strive Healthy clinicians serve as role models to clinicians in train- to resolve their own prejudices through education. vated. and adhere to their own personal solid moral ment of compassion and understanding for another. They foster responsible participation in the selection of goals. dementia. they are humble. consumers. exposure. effective services. life-style balance. edit their own behavior. and good faith (Cormier & Cormier. first-rate patient care. understand the fundamentals of interpersonal relationships. 401). resources with the demands of their jobs. and acknowledge and educate. monitor. interesting person. whenever possible. statistics. He or she is aware of nonverbal age. abreast of the latest research regarding “normal” versus empathetic. languages. familial patterning. imaginative. nonconformist and usually criti- order to expand opportunities for communication and. 2005). Their significant-other-centered needs in providing maximally knowledge base is constantly expanding as they read the cur. courtesy. anthropology. The ultimate excellent “disordered” aspects of language. and compassionate. manual communication and other modern entire rehabilitation team. voice. have definite but malleable professional and personal goals neoplasms. significant others. Sensitive clinicians are aware of assets. when cal of the status quo” (Ringel. and are open professionals. maintenance. Chapter 7 ■ Delivering Language Intervention Services 221 education. They are unfail. fairness. caring. those needs (Brown. tus. He or she addresses current events in clients’ to questioning and exploration (Rogers. sociology. They treat colleagues with respect. com. gerontology. They injury. nature helps to foster feelings of comfort. safety. and are The excellent aphasiologist is warm. leagues. assess. and hearing (Worrall & Hickson. economics. and keep them up-to-date. initiate proper referrals and rec- from stroke. They interact effectively with the puter science. 1991). and the develop- obey all laws. race. He or she has effective listening The excellent aphasiologist is sensitive to issues of gender. and retain multicultural clinicians grow through them with grace. thoughtfully to their needs. They follow their professional codes of ethics. and tailors sessions to meet ple and complex cases. Sensitive clinicians appreciate multiculturalism and mul. Likewise. Others strive to learn additional languages in independent. Excellent clinicians fit Ringel’s differences and similarities among their patients and col. With post-World ing and improvement. His or her to love and be loved unconditionally. to patients and the patients’ clinicians from other disciplines. p. Effective sional burnout. They critique. and confusional states. to provide services in more than one language. and a passion for patient and professional advocacy. 2002). and have They are aware of the relative lack of persons from culturally a terrific sense of humor. and personal wants and needs without compromising the appro. 1983). municate that rationale. previous ingly honest. They are also possible. Patterns” (ASHA 1993. 222 Section II ■ Principles of Language Intervention before. Legislative issues affecting service delivery in the teristics. The cultural roots and harmful impact of ageism. intervention. 4. contract negotiation. may provide and/or support health-care management. worldwide. national health plans. Multiple dimensions of age-related health con- meet the needs of the members of such populations. are and increasingly outcomes-focused treatments. require that we engage in ongoing research pertaining to rel. are explored. clinics. We will also continue to adapt constructively same functions regardless of professional setting. 5. counseling. Flower & Sooy. licensure.” The active role that aphasiologists play as impacts of managed care in the private sector and advocates for our clients and profession is critical to maxi- mizing our effectiveness. In the United States. internalized ageism. The clinical aphasiologist performs many of the fessional roles. advocacy. Haan. 1987. The aging of the population political climates. co-treatment. 1998) will ing and discriminating against people because of age. or the use of electronic communications tech- ing our patients’ quality of life. Ageism is seen as the systematic stereotyp- Assurance. Gerontologic issues that affect aphasia intervention help address these risks. Speech-language pathologists rehabilitate patients teamwork in the coordination of patient care. and ageism and Civil Rights As new formulae for practice under changing modes of ser. to reduced patient access. services. and linguistic minority populations in the United fact that women live an average of 7 years longer than States. such as those with HIV/AIDS. changes in health-care pol- evolve with increasing focus on the elderly over the next few icy. “telehealth. clinical brings with it increased risks for catastrophic disease.” or optimal plans for diagnostic and to ensure that persons of all ages with special treatment services that take into account the nature and conditions have access to adequate and appropri- severity of patients’ deficits and time post-onset. include the rapid growth of the aging population Other demographic trends. education. including matic impacts on access to patients and the services adult aphasia. . Larsen. independence. the extension of life expectancy. or the fact that vice delivery continue to evolve. atively new areas of clinical practice. consultation and collabo- intervention and caregiver training. rative care. administration. nursing homes.” empirical research base to enhance our methods for improv. recent aphasiologist. Throughout the world. In the U. such as more efficient older women. cost-effective. 1996b). biologi- in certain patient populations. and behavioral age and successful ageing and in our caseloads (ASHA. attention to KEY POINTS issues affecting older adults is steadily growing. and improved interdisciplinary 3. we will draw on the evolving the patient’s own home. methods to prevent stroke and traumatic brain injury will 2. illness. 1999). private offices. Enhanced consumer education and new we deliver to them. decades (Mechanic. 1990.qxd 1/21/08 11:39 AM Page 222 Aptara Inc. ASHA Committee on Quality wellness. and medical nologies.S. Public and private retirement and medical programs will necessarily 1. ties. such as the growth of racial. and Over the next few decades. At the same time. new types of explored. the guidelines concerning the common best practices given a Health Insurance Portability and Accountability patient’s diagnosis. reimbursement schemes. ance. skilled-nursing facili- more women in leadership roles.GRBQ344-3513G-C07[203-228]. we are likely to see tals. with aphasia in a variety of contexts such as hospi- and discharge planning. will continue to stimulate our constructive actions to men. marketing. and the financial aspects of aging. & Wallace. In addition. we will continue to see fur. Likewise. The delivery of diagnostic and intervention services is of the characteristics that constitute the “ultimate excellent heavily influenced by economics. will benefit from clinicians who are dedicated to fostering all 6. vidually identifiable health information among car- The specialty of neurogenic communication disorders riers and providers. rehabilitation centers. practice associated with patients’ specific diagnostic charac. 1989. including chronological. and safeguard the transmission of indi- to be refined. and increasingly sophisticated about the appropriate patterns of research. We will take advantage of technologic advance. ethical decision-making. we will become fundraising. More and more clinical agencies will implement United States include several pieces of legislation “clinical pathways. 1999). Increases cerns are discussed. Gender and ageism. employment opportunities. ments that will influence virtually every one of our many pro. ate levels of service.. improved access and through the use of alternative models of assessment. and outcomes continues to grow. and with fewer children being born. such as ASHA’s “Preferred Practice Act (HIPAA) requires that health plans standardize. ness. and professional training are having dra- and disability (Kaplan. insurance mechanisms. both through advocacy for such as the identification and selection of clients. will undoubtedly continue streamline. a good deal of age-related discrimination targets ther positive effects on our professions. quality assur- As the research base on treatment efficacy. and the ethnic. cal. the promotion of health and wellness constraints. and people with aphasia and their significant others in your cost control. Specific cost-control mechanisms are local community. Describe the ways in which recent service-delivery tions (HMOs). Key challenges to professional practice in neuro. which topics would you prioritize as most through preventive care and education. and com. est that clinicians face in the workplace? 10. female patients. For each of the varied employment contexts. have agreed to teach the component addressing the ance companies or programs that operate in man. How do reductions in stays in acute-care hospitals Although efforts to control rising health-care impact what the speech-language clinician accom- costs are laudable. intervention? genic communication disorders are consumers’ 11. List specific ways in which aphasiologists may engage access to our services. two federal health programs. Make an outline of both positive and negative service- passionate. dura. care from clinicians to administrators. consider of a benefits package. Managed-care different service delivery contexts might affect the practice is having a dramatic influence on service quality of life of clinicians. list and discuss specific ways in . Unfortunately. the literature is replete types of referrals for information. 5. Managed care organizations (MCOs) are insur. For each of the negative trends. treatment programs for patients with aphasia influence 9. Be sure to think broadly about the discussed. Develop a position statement for aphasiologists stating services received by each enrollee. ate some of the ethical dilemmas and conflicts of inter- sumers’ access to our services. Outline the key topics that you would of specific types of cost-saving reimbursement cover in your component on the course. and valued may reduce the prejudice experienced by ers who pay for enrollees’ insurance coverage. Describe what you think are the most critical ethical livelihood of our professionals. and clinical- with accounts of how the overwhelming focus on care options from which your patients might benefit. caring. 1. the engaged within their varied employment contexts. patient. Medicare and Medicaid. trends have influenced where (in what type of service- 8. interesting delivery trends that are influencing intervention for person who is emotionally healthy. knowledgeable. Given time schemes. motivated. warm. actively in quality assurance. access to care for persons who need it.S. What might be done to allevi- our professional integrity. In what ways might the full-time clinician without doc- who is competent. individuals are insured primarily and teamwork in which aphasiologists are likely to be through private health insurance programs. Compare and contrast the type of collaborative care in the U. the 12. which of the many roles of the aphasiologist are most ance programs. The ultimate excellent aphasiologist is seen as one 13. emphasized. 14. influence service delivery 3. flier. and reduced how changing the way that older women are viewed enrollment fees for enrollees and/or the employ. 9. and frequency of care that we can provide. marketing. such efforts often threaten plishes in the acute care context? patients’ access to care and the quality of care they 10. empathetic.qxd 1/21/08 11:39 AM Page 223 Aptara Inc. the success of the aphasiologist? zations (PPOs) and health-maintenance organiza. and problems of con. and tion disorders receive treatment. ethical. the quality. importance and relevance of gerontology to aphasia aged-care modes and are characterized by the use intervention. support. Chapter 7 ■ Delivering Language Intervention Services 223 ACTIVITIES FOR REFLECTION AND DISCUSSION evolving federal health policies are significantly impacting the practice of aphasiology. adults with aphasia and related disorders. delivery. The two most 7. majority through plans offered by employers as part 2. 8. Restructuring of health-care systems to reduce delivery context) persons with neurogenic communica- costs has transferred control of the access to. the maintenance of issues for aphasiologists. intensity. or brochure to provide stated are assurance of the quality and coordination information about community resources available to of care. Develop a Web page. and fundraising. The three main goals most frequently 4. duration of. How do reductions in the frequency and duration of receive. on neurogenic communication disorders and that you 7. Discuss the ways in which employment in each of the to adults in the United States. toral training participate in research? sional. There are many types of MCOs. and a thoughtful. In addition to private insur. For example. Imagine that you are team-teaching a graduate course mises in quality and access. the tiation. cost control in managed care often leads to compro. profes.GRBQ344-3513G-C07[203-228]. In what ways is excellence in documentation critical to common examples are preferred-provider organi. important? certed effort to coordinate the type and number of 6. fiscal stability of our service-providing agencies.. contract nego- tion. a con. Journal of Hand Therapy. Preferred the negative effects for your patients and your profes. The status in the workforce.. (1988). & Simmons. AIDS/ (1994). that Mr. P. (1976). CA: Brooks/Cole. Interviewing strategies for 21–34. New York: Crown.. G. Washington. 38 15. & Fenaughty. (1994). Access and outcomes of elderly patients enrolled in HIV: Implications for speech-language pathologists and audiol. care. & Cormier. (2003). Rockville. Berman. 5–9. Copper.. The new evidence on sex segregation and sex differences in nesses relative to your view of the ideal clinician? wages from matched employee–employer data. Chicago. Guide. Retrieved October 20.asha. use. B. Butler. What specific steps will you take to advocate Anderson. A. 16). strategies to implement in a treatment program for 46–48. 35(3). him.qxd 1/21/08 11:39 AM Page 224 Aptara Inc.. a 48-year-old man who recently American Speech-Language-Hearing Association. B. 11. practice patterns for the professions of speech-language pathology and sion.. Now speech-language pathology standards [Quality Indicators]. (2005). DC: Author. 19. 2007 from asha. his ability to live independently. D. Hellerstein. Boston. report of the Ad Hoc Committee on Multiskilling... Journal of the American Medical Association. Brown. his medical manage- counts. Kay. CA: SAGE. H. Ageing and 16. A good age. 28(5). W..GRBQ344-3513G-C07[203-228]. Information on telemedicine. Cormier. from Comet’s physician. ogy and audiology. Comet. J. (1999). (2003). Comet’s continued access to your really determines how long you live. 38(Suppl. AIDS/HIV: Implications for candidate for treatment and that you have effective speech-language pathologists and audiologists. (2002). Retchin. (2005). ASHA. (1986). Strategies for positioning in the managed health practice patterns for the professions of speech-language pathol. K. M. & Stegall. 117–126. Washington.. J. (1994). IL: American Medical Allyn and Bacon. 49–52. on Deafness and Other Communication Disorders. M. Aging: Genetic and environmental influences. indicators for professional service programs in audiology and You have exhausted those authorized sessions. American Speech-Language and Hearing Association. American Speech-Language-Hearing Association. MD: American Speech-Language Hearing might capitalize on each of the positive trends to Association. Mr. 31(6–7). Comfort. B. You have ample evidence American Speech-Language-Hearing Association. Sex and American Speech-Language-Hearing Association. Retrieved October 24. 7. his primary medical provider. services? Andrews. Boston: Terminology. & Troske. 14. ASHA. 271(19). speech-language pathology assistants. treating Mr. aphasiologist? What are your own strengths and weak. Association. E. How would you describe the ultimate excellent clinical Society. helpers. 2006. The seductiveness of agelessness. . R. He is enrolled in an HMO. 35–38.org/about/membership-certification/member- significant impact on his safety. Clement. C. DC: American Public delivery of speech-language and audiology services in home Health Association.: Crossing Press. Quality speech and language problems secondary to the CVA. S.. D. Thanks to Meggan Moore and Laurie Turner for editorial Thousand Oaks. 12. CPT ™ 2000. ▼ Acknowledgment—This work was supported in part by a Begley. E. Over the hill: Reflections on ageism between women. 33–37. 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P. wisdom. Aging and the life course.. MN. Butler. New York: and life’s greatest lessons. Levin. H. (1995). When bad things happen to good people. (1970). York: Random House. E. Sheehy. & Hickson. Communication disability in aging: Palmore. New York: Bantam Books. Bytheway. E. Pathfinders: Overcoming the crises of adult life and 243-246. finding your own well-being. Y. New physical and emotional health. aging and ageism. Bloomington. with Rich. (1999). & Levin. Cruickshank. Minneapolis. New York: Pocket Comfort. CA: Crossing Press. 3rd ed. E. CA. G. (1997). J. Woodward. New York: Springer. 9. Cifu & Stewart. They may be made up of people (Billups. or a loosely organized group of peers. Teams may emergency rooms to community mental-health clinics—team have leaders who are authoritarian. family and patient education.. recognized as the optimal approach to health-services delivery advising from the sidelines. emotional. In almost every service arena throughout the world—from Usually. Korpelainen. & designed to include the patient and family as active partici- Summala. Lallanranta. changes in their family dynamics. to make use of community and national WHAT IS A TEAM? resources. 1987. Teams can be made up of two people or fifty people. Cornman. IT TAKES A VILLAGE structured hierarchy. Collins. such together the knowledge and skills of individuals from many as the nursing care team within the rehabilitation care team.” It takes a village. structure. Those ery. & Dick. teams have at least one designated leader. recreational. They can be a formal. This approach necessitates bringing consultants. us determine how to optimally integrate patients and fami- outcomes studies. Holm. No one discipline can Appreciating that there is no ideal blueprint for teams and 229 . (2) to review basic elements in group processes that lead of us who work with individuals who have communication dis- to successful teams and some of the potential barriers to orders have long been proponents of family-centered team developing effective teams. & Patton. Hennes. Golper encompass the whole life-changing condition known as “apha- sia. As individuals with aphasia move from are made up of people and personalities and they are often their hospital beds to their homes. disciplines in order to ensure that complex problems receive Whatever the composition. physical. p. They can have face-to-face meetings or use more indirect communication methods. including collaborative evaluations. professional lies into the health-care team are largely lacking (D’Amour.. 1999. & tant to remember that teams are human enterprises. (4) to examine related disciplines. 1999. 1996). 1998. Lane. 1978). documentation. Teams can have smaller teams within them. Indeed. (3) to consider how the team intervention (Rosin et al. and (5) to suggest that the overrid.. it is impor- the comprehensive attention they require (Allen. from a single discipline or multiple disciplines and can have & Alpress. Chapter 8 Teams and Partnerships in Aphasia Intervention Lee Ann C. Davis. Lott. from surviving the acute event to issues related to finances or No team looks or functions exactly like any other. Ferrada-Videla. or have leaders who function more as facilitators. ing aim of the rehabilitation team throughout the recovery continuum with adult aphasia should be directed at educating and empowering patients and families to become collabora- tive partners. They can be Gibbon. Developing collaborations with others is particularly important throughout the recovery continuum fol- lowing the onset of aphasia since many patients with aphasia OBJECTIVES have medical. vocational. We rarely evaluate or treat any designs may differ depending upon the setting and how pri.” (Goleman.GRBQ344-3513G-C08[229-244]. education. Hogh et al. professional and nonprofessional members. controlling the team’s intervention with a patient-centered emphasis has long been actions. 2005). evidence-based guidelines help issues. Turkka. & Beaulieu. psychosocial. pants or can be restricted to an exclusive panel of specialist- 1999. Heikkila. typical team organization designs found in health care deliv. and ultimately to lead their own “team aphasia. 1999. Mitchell. and research. 101). and financial concerns that may or may not be The objectives of this chapter are (1) to define and examine directly complicated by their communication impairment. or purpose. such issues can supersede the language deficits. Rodriguez. their concerns often shift “caldrons of bubbling emotions.qxd 1/21/08 11:40 AM Page 229 Aptara Inc. 1996). Unfortunately. 2005. 1999. Moore. 1999. Rosin et al. Teams Scheifelbusch.” Teams are groups of people collaborating in some way to reach a common goal. type of communication disorder without having some amount orities and the primary decision-makers change across the of collaboration with the patients’ families and with other continuum of recovery from aphasia. the transdisciplinary team model is promoted by the different problems. and transdisciplinary seem to be used inter. It may be communication. In an interdisciplinary format. In their review of 79 studies looking at staff are sometimes viewed with skepticism among licensed factors affecting outcomes in stroke. Although true transdiscipli- ences between them. Cross-training and multi-skilling. Transdisciplinary teams are most advan- interdisciplinary. 230 Section II ■ Principles of Language Intervention that the team design can vary depending on the setting. other’s jobs. individual members bring discipline-specific encouraging cross-training between disciplines and multi- skills. examined the effects of interdisciplinary versus multidisci- plinary teams on patient outcomes. 1996). such as on an inpatient medicine or surgery unit. In that and licensure restrictions may interfere with forming trans- setting.. there may be resistance from eratively together. Individuals with Disabilities Education Act (IDEA) of 1990.qxd 1/21/08 11:40 AM Page 230 Aptara Inc. improved functional outcomes. staff who are not in favor of “cross-training. it may be helpful to consider the differ. only work together in a cooperative manner. unfortu- There is very good evidence to suggest that the most nately. Eliciting group problem-solving and group that a key feature to successful outcomes in stroke rehabili. actions involves more than getting together people who tation is not so much having several different disciplines have mutually supportive “roles and goals” in patient care. are concepts that developed in an attempt to save effective model for rehabilitation-services teams is an inter. terize how disciplines typically function in an acute care set. ward clerks may be cross-trained with patient- interactive and highly collaborative. Role release refers to the elimi- health care delivery are either multidisciplinary or interdiscipli. the terms multidisciplinary. In be training a speech-language pathologist to draw blood.. Occasionally. intervention requires incorporating the knowledge and skills els mainly differ in their role delineations and communica. 1999). 2006). In a multidisciplinary model. PL 101-476 (Rosin. establishing good com- examine a couple of typical models for team processes in munication and intervention partnerships. In education. and shared goals may be lacking (Allen et al. tageous when intervention requires interfacing a number of changeably. There is greater empha. These analyses demonstrate that interdisci. costs. These team mod. by contrast. 1996). particularly early intervention. Opportunities for com. Thus. in which staff members are trained to do all or parts of each munication between and among the disciplines may be cur. but for the most part they work in parallel. Cifu and Stewart (1999) professionals and have fallen out of favor in recent years. Interdisciplinary teams are.” There was a rather than in partnership. In multidisci. thinking and encourages staff to feel a part of a team process. 1996). and decreased costs (Cifu & Stewart. Teams that are truly transdisciplinary tend to be more common in early childhood intervention settings (Rosin et al. including eight TEAM PROCESSES studies in which patients were randomized to either a multi- Group Communication disciplinary medical stroke unit or an interdisciplinary reha- bilitation unit. and the members’ responsibilities are clearly defined skilling within disciplines. rather. . or take blood pressures. Thus. health services delivery. from many discipline areas into one multi-skilled practice tion processes.. Cross-training refers to situations and understood (Tuchman. with one another. interdisciplinary teams. In health-services settings issues such as clinical privileges ting. In addition. nation of traditional professional boundaries in intervention nary teams. They conducted a meta- analysis of 11 well-defined Level I studies. (Allen et al.GRBQ344-3513G-C08[229-244]. each addressing tings. various disciplines have defined roles and work coop. The key element is stays. Much of what we call “interdisciplinary patient care” is just plinary team intervention is associated with decreased group problem-solving to develop partnerships in interven- mortality. the notions of cross-training and multi-skilled disciplinary design.” rather than “OT goals” or “PT goals. A transdisciplinary approach to transdisciplinary teams are more common. practices (Tuchman. shorter lengths of tions through good communication. disciplinary teams. Multi-skilling is sometimes viewed as creating minimally orate in partnerships to implement the treatment proce. goals are discussed as but without the depth of knowledge needed to make indepen- “our goals. intended to be For example. 1978). 1978). specialists nary teams are rare in hospitals and other health care set- with clearly defined roles work side by side. they also collab. transport personnel so they can cover for each other when sis on communication processes in interdisciplinary teams as needed. Multi-skilling implies having skills that exceed the compared with multidisciplinary teams (Tuchman. movement in health service delivery in the past toward plinary teams. Multidisciplinary teams are probably a good way to charac. boundaries of the traditional scopes of practice within a given True interdisciplinary teams allow for at least some amount discipline (Brown & Handlesman. Cross-training discourages “that’s not my job” sory.” dent decisions. or different aspects of a given problem. 1996). In these settings team members have had specific MODELS transdisciplinary orientation and training and are encour- The models of team processes most commonly found in aged to practice role release. related professional disciplines. let’s involved in patient care but. 1996). skilled technicians with specific skill sets across several areas dures. An example would of blurring between traditional professional boundaries. different professional disciplines not perform range-of-motion exercises. paid to processes that promote good interactions among team “Imagine that the carpet in this room is a raging river and members. even when time is lim. Team retreats can be anything ties (Loomis. Developing good communication processes another help patients and their families depends largely on at the outset of team development tends to discourage polari- how well communication is managed within the team.. and then move on to the next task. retreats are intended to accomplish both some performance measure (e. the tail of the line to the member at the front to take the next storming solutions.” intervention plans often practical. depending upon the nature and purpose of the group (Northouse & Northouse.” These activities are Therapy groups. A content-oriented activity is one that is from wilderness-survival treks to an afternoon away from directed toward some objective (e.qxd 1/21/08 11:40 AM Page 231 Aptara Inc.GRBQ344-3513G-C08[229-244]. of membership and trust within the group. The team members may refer to these activities.” Time spent building and basic elements are in place: (1) group communication maintaining mutual trust and open communication between processes that encourage interactions. but there are less elaborate ways to create a sense require negotiations between or among disciplines. 1980) as a way for the group members to tions where weekly patient care team conferences are viewed identify and inventory their individual work styles and con- by the participants as merely a mandated necessity. but move directly to the objectives is to involve the members in problem-solving games that of the meeting. Thus. and team members is absolutely essential to a successful interdis- mutual respect. or mutual goals. forward one step. and group problem-solving games may not be very teams are not “support groups. There is not much attention 11 paper. Using only team members might make their reports in turn. the last sheet rotates from the member at tion includes group activities such as sharing feelings. as “sharing and caring. which support groups. in “ice breakers” during the formative team meetings may be munication into the group’s activities. The four-member teams solve At the other end of the continuum. each team member moves forward until everyone alliances. Lorimer. One of the ways corporations and other groups develop a 1998). improved functional rating group relationship building and goal setting. 1996). such as the Meyers-Briggs Inventory (Meyers- feels pressured to make an economic use of time. When members of your team cross the river?” Since just laying communication is focused more on tasks. & Leander. are good examples of groups engaged is plan together. supporting one another. personality assess- content and process. In these settings. sider how these styles differ from one another. paper ahead of them in a row. it is important to incorporate process-oriented com. the solution to the tive collaborations within the team. retreats. or in situa. where everyone inventories. has reached the opposite “shore. take their your five ‘stepping stone’ sheets of paper. and as each member moves cooperation.g. Managers and scores). Interdisciplinary teams need to strike a balance between In most health care teams. have members tell the group some- ited and several tasks must be accomplished in a short amount thing about themselves. and building step. group to reach the other side of the room. Typically. it is difficult to engender good interac. problem requires teamwork. trust and collabora. process-oriented the problem and cross the room by laying down the sheets of communication is directed toward developing relationships. the each of your pieces of paper is a stepping stone. At meetings that are highly content-oriented. Our behavior and the manner in which we participate sense of cohesion within a team is to do things like take peri- in groups shifts when the focus of the group is more toward odic retreats or engage in similar activities to promote good content-oriented activities as opposed to process-oriented activi.. Simply engaging quently. For example. Another content-oriented patient care teams spend little time in idle method to aid in developing group cooperation and reliance chatting or group process. discharge planning) or the office. Researchers looking at small group communication in CREATING A COHESIVE TEAM health-care settings have found the communication charac- Developing Cohesion teristics will vary along a continuum. interpersonal relationships. 81⁄2  extent of the communication. Each team is then asked to solve this problem. cooperation. how can all the respective notes. Chapter 8 ■ Teams and Partnerships in Aphasia Intervention 231 How well a group of people work together to help one tion are essential. In interdisciplinary management. like: What is the one junk food they of time. specific objectives or performance measures (Manion. Usually. affec- Groups of people work together most effectively when two tionately.g. would want to have if stranded on a desert island? What was . brain. Communication itself may be the main purpose. work together. ties. 1979). and (2) focused activities aimed at meeting ciplinary team. Conse. sufficient. Process-oriented communica. Briggs & Briggs. Although interdisciplinary patient-care ments. such as aphasia group therapy or various intended to convey a simple message about teamwork. and mostly in process-oriented activities. reporting information to the require teamwork for solutions. we will get to the goal. without attending down the five sheets of paper end to end would not allow the to group participation. look out for one another. Team activities that are skewed toward content over group-process facilitators also use devices like personality process are common in health care settings. Here is an example: A group group to ensure everyone has a general notion about what the of health-care providers is divided into teams of four mem- various disciplines are doing with the patient is essentially the bers and each team is given five sheets of standard. Additionally.GRBQ344-3513G-C08[229-244]. First is the traditional top. or intelligence. How charisma of the individual and his or her communication skills physicians view their role with relation to the team can help and general “likeability. Decision-Makers Versus Leaders Physicians Effective Team Leaders When physicians are a part of the health-service team. appreciate and respect the competencies of other disciplines plinary team. such as Medicare. emotions. goals. and drives). or hinder good group cohesion and communication. That ability is not necessarily endowed by status. itive or negative attitudes the physician has toward the effec- tiveness of rehabilitation will also be a factor. Because these payer groups can come from a variety of sources. The second relates to the their most embarrassing moments? Just taking a few minutes ethnocentrisms and fears of encroachment that exist between to get the group talking to one another and revealing per. 232 Section II ■ Principles of Language Intervention their greatest achievement in high school? What is one of (Northouse & Northhouse. sonal information helps to set aside the roles and goals of the team to create a degree of familiarity and comfort among team members and improve interactions in patient care. cians maintain decision-making power even when they are technical skills. Some leaders draw on the nearly always require a physician’s order for a patient to power inherent in their position. erment in a leadership role. That eral consensus is that effective leaders have an ability (either primacy is appropriate in hospitals during the acute and suba- innate or acquired) to get others to focus their energies on a cute phase of recovery. the adult aphasic patient’s work beyond money or status). and professional standards of others. the physician’s hold on the decision- tant characteristic of a good leader is “emotional intelli. ber empowered to authorize the care plan is the physician. What are some of the barriers to maintaining (Sampson & Marthas. director). for sev- gence” (Goleman. de. 1998). include self-awareness (the ability to recognize your own Throughout the continuum of care. longer a major concern. or when expertise in a given area. goals. the values. Even when the team members con- ishment) to exert power. any pos- vidual’s decision-making and empowers his or her leadership. Personal power in leadership comes from the and wishes of the person writing the orders can intrude. Most enough of it to maintain good group-communication of us bring fairly ingrained notions about our professional processes—a couple of factors inherent to medical settings boundaries. or are required to “certify” or ciency in managing interpersonal relationships). Unfortunately. Goleman lists five components of eral reasons related to medical and legal responsibilities and emotional intelligence that he believed were more important their “gatekeeping” role in health care coverage plans. super. professions (Ducanis & Golin. with physicians sitting at the capstone of the pyramid of the notions established during our professional training. But when medical issues are no grees. motivation (having a passion for care decisions.” which engenders trust in the indi. medical status of the patient. laboratively. physi- comes from the title of their position (chair. they What makes a good leader? There are volumes of answers to often assume a de facto leadership of the group because they are that question in management texts and articles. cians continue to be the decision-makers long after the med- visor. and other cognitive abilities. even though facility policies may say something like and expertise in their clinical area lend themselves well to “the values. These traits no longer directly treating the patients. physi- to effective leadership than the individual’s intelligence. 1977). and we often have prejudices about the training specifically can present problems. primary-care physicians are usually the “gatekeepers” for stand the emotions of others). that is. the primary decision-makers in the health care world. we may have to reexamine and relinquish some livery. The final source of power is be addressed in the care plan.qxd 1/21/08 11:40 AM Page 232 Aptara Inc. and social skill (a special profi. Power can also come from having sider themselves to work on a par with one another. personal power. and wishes of the patient and families must leadership roles in health care. empowerment receive covered therapy services by a non-physician. Some have suggested the most impor. making processes ought to diminish. Managers who have experience And. but the gen. manager. Mutual respect is the corner- good communication? Aside from time—never having stone of successful partnerships with other disciplines. empathy (the ability to under. typically the only mem- particular area of practice can provide an avenue for empow. 1998). insurance-coverage decisions. ical issues have resolved. Having knowledge and skills in a a non-physician heads up the team. To work together col- down professional hierarchies that exist in health service de. Some leaders use rewards or coercion (pun. where concerns center mainly on the goal. . Golper and “authorize” the need for rehabilitation services on behalf of Brown (2004) remind us that leaders have empowerment that the payer. physicians are mood.” in practice. BARRIERS TO COMMUNICATION Professional Ethnocentrism We have made a case for infusing non-task-directed com- munication (“sharing and caring”) processes into team Good interdisciplinary teams are those with members who meetings as helpful when developing a cohesive interdisci. 1979). self-regulation (the ability to expected to take the ultimate legal responsibility for patient- control impulses and moods). discourages much direct contact with decision-makers. and cooperation in teams. The most common type of communication pattern was referred WHO ARE YOUR PARTNERS? to as the “chain structure. For example.” “physical therapists are very defensive pathologist (SLP) collaborates with the recreational thera- about their professional prerogatives. or ward clerk) is the only person to have the whole pic- designed an instrument referred to as the “Interprofessional ture at any one time. The members of the various profes. a meeting can lead to inefficiencies. This type of communication structure breaking down professional ethnocentrisms may require spe. etc. They suggested teams engage unit’s head nurse or the physician. and that these or too small for the demands placed on them. nursing.” fication of this scale has been applied in investigation of atti. The wheel structure is probably a good Perception Scale. Stanley. and Golin’s (1979) original instrument is the Revised Interprofessional Attitude Scale (RIPS) described by Skoloda Weak Links and Poor Team Processes and Angelini (1998). are at the bottom. the SLP will have group (in this example. p.” in lems with interprofessional ethnocentrisms as a major obsta. Not having adequate suggesting is that it is important to acknowledge our preju. individual members another professional group by responding to a list of subjec. second pattern is referred to as the “wheel structure.) to assess their preconceived notions of teams are made up of human beings. which information is fed to a central person. will vary in their ability to be open. they indicate links deplete the energies of the group and create resent- how they think members of the target group (physical ther. mutual trust. if the speech-language with my profession. 2002). These and professionally dedicated to the goals of the team. ments. This pattern is most consistent with the type of com- Veterans Affairs medical centers (Strasser. tral conduit of information (a nurse. it may be a good idea to charter a team just to fig- ure out what’s wrong with the team. and then how the Other examples of poor processes include planning meet- members of that profession would say the other professional. but the recreation therapist is the sort sional groups represented on the team. tive statements and relating them to that group. apy) would answer about themselves. and patient care technicians involved in their care. Ducanis and Golin (1979) discuss the prob. Teams can attitudes can hinder the development of open communica. Teams disciplinary teams function best when each member disci. cooperative. ings at times when key members cannot be present. physical therapists). physi- ing dialogue aimed at maintaining good relationships. A modi. In this structure. therapy aides. 34). By using tools from a “continuous quality improvement” (CQI) or a “total quality Communication Patterns improvement” (TQI) problem-solving approach.qxd 1/21/08 11:40 AM Page 233 Aptara Inc.” in which communication occurs The Patient’s Primary Physician up and down a line in some established professional hierar- chy. background information provided to team members before dices and appreciate that we all have preconceived attitudes. the team In their review of group process in the health professions.” and so forth (Ducanis pist to work on functional-communication abilities during & Golin. Sampson and Marthas (1977) found three types of commu- nication channels to be common in health services. When process problems are (Allen et al. What Ducanis and Golan are ing to cover too much at one meeting. can identify and correct process problems. Weak each statement is “true” or “false. indicate whether difficulty implementing his or her goals effectively. social worker.” “physical therapists have good relations links” in any team. Essentially. in which messages flow within a connected circle of disci- tudes within the rehabilitation teams in the Department of plines. res. 1979. communication and team intervention.” which requires members of different dis. there will probably be at least one or two “weak are well trained. In this structure the physician is at the top of the chain Patients with aphasia may have various physician-specialists and ward clerks. for example. 1977). Poor team processes can also present problems. recreation activities. Another modification of Ducanis and transdisciplinary teams. include statements such as. Last is the “circle structure.. or try- group respondents answered. They cian.” In addition.GRBQ344-3513G-C08[229-244]. Their primary-care physician could . the cen- in an explicit examination of attitudes and develop an ongo. this instrument in its various forms allows members of different professional groups (such There are several other potential barriers to successful as physical therapy. 1978). Chapter 8 ■ Teams and Partnerships in Aphasia Intervention 233 Just like developing good group-communication processes. “physical therapists Therefore. Teams may be too large not necessarily justified by fact or experience. with multidisciplinary teams. apparent. speech-language pathology. since piratory therapy. munication needed to maintain effective interdisciplinary Herrin. Specifically. have the wrong mix of members or may not have the right tion. typically the cle to interdisciplinary teams. Inter. Falconer. other than the target of employee who frequently calls in sick. The cific attention. combination of expertise and shared responsibilities. way to describe much of the communication that occurs ciplines to examine their interprofessional attitudes. receptive. also need to be designed to shift activities among members pline appreciates not only their own strengths and limitations fluidly and to adjust to changes in workload and priorities but also appreciates the contributions other disciplines bring (Sampson & Marthas. & Bowen. pharmacists routinely degrees. and disease treat. In most situations physicians are In general. geon (specialist in neurologic surgery). In an inpatient facility. (2) to provide assistance with spent any time in conversation with the family about what practical matters. own care. cardiologist according to the physician’s order or oversight. remediation in the arenas in which the patient’s physician lacks sufficient familiarity. complications and side effects. functional-communication handicap brought on by aphasia. They may be Licensed Practical Nurses (LPNs). When the speech-language are likely to face. hygiene. the case-manager makes sure the therapy team can issues the adult individual with aphasia and his or her family provide that level of service. gender. case-managers are interested in ensuring that the given the medical-legal responsibility for care decisions. There is very little in medical training pathologist sees a therapy need that exceeds the patient’s that specifically prepares physicians to characterize the insurance coverage. and can work . or some other physician coming from a general and frequent contact with the patients and families. They may be participate in care-planning meetings and ward rounds. and training of physicians will vary. as requirements of the patient’s health care coverage are met well as financial-oversight authority. Depending upon where they fit in the hierarchy of (taking too many drugs and potentially causing negative skills and training. disease processes. hydration.). and they may week. also called a patient’s general mental and physical status.qxd 1/21/08 11:40 AM Page 234 Aptara Inc. They participate in teaching the patient nursing staff are the professionals who will administer the and family self-management of medications. and (3) to their priorities are. or advanced-practice degrees). personal-care aides. geriatrician (special. such as when family adjustment and coping problems are apparent. Rehabilitation nurses have specific training and exper. or the advocate for the patient and the team. Even though the group. family practice physician. They can team’s goals of functional independence. and for polypharmacy effects care plan. They understand how biologic functions and diseases the team’s instructions to the patient and family and the involving one organ system can impair another.GRBQ344-3513G-C08[229-244]. age. Some may have postgrad. or that the patient is seen “daily. They can determine when findings are within normal limits or are Case-Managers and Medical Social Workers abnormal for a given individual. background. and other medical conditions. as well as which state they are licensed in. interpret laboratory data and other findings. 234 Section II ■ Principles of Language Intervention be an internist (specialist in internal diseases). quality-of-life changes. and so forth) are ist in geriatric medicine). monitor for errors in medication orders. elimination. for potential drug tise in developing and implementing a rehabilitation nursing. nurses have the most ongoing practitioner. and they are especially good at reinforcing both ment. interaction effects). They prescribe drugs and perform invasive procedures for which there may be some Case-managers are usually nurses and most often are RNs. to characterize and plan or when financial assistance is needed. much less in conversation with the arrange for discharges appropriate to the needs of the patient with aphasia. neurosur. etc. They main- (specialist in diseases of the heart and vascular system). nurses are with patients more than any other member interests. Physicians may have a (insurance. speech-language pathologists. the case manager can be a very helpful psycholinguistic deficits. managed-care. masters members of unit teams. Hospitals are probably the places Nurses come in a lot of varieties. where pharmacists are most likely to be involved as formal uate degrees in some specialty area (doctorates. such as financial concerns. of the team. Pharmacists Not all facilities or settings will have pharmacists as partici- Nurses pants on their care teams. however. ensure that all of the patient’s basic-care needs (nutrition. The physician is the team member patient and the family. The medical social worker is often best prepared to identify and manage the medically related the first person the speech-language pathologist will turn to issues. phys. They cians. Registered Nurses (RNs) with or without bachelors Pharmacists have a key role in determining appropriate degrees. or therapeutic drug dosages for individual patients based on nurses’ aides. Physicians will rely on the other specialists. Nurses are also trained and they bring to the interdisciplinary team a comprehensive skilled in teaching the patient and family to manage their knowledge of diseases. general met. or personal care techni. Medical social workers sometimes have responsibilities in Although the physician may know the patient and family case management.” meaning 7 days a have a good or a not-so-good sense of the psychosocial week. he or she may not have chosocial issues that arise. Usually. requires a certain number of hours or minutes of therapy per nitive problems the patient with aphasia has. If coverage good or a not-so-good grasp of the linguistic and other cog. their primary roles are well (which is perhaps not as likely in today’s health-care (1) to provide counseling to patients and families for the psy- delivery systems as it was previously). tain ongoing monitoring of the patient’s vital signs and the ical medicine and rehabilitation physician. risk of injury to the patient. 24 hours a day. Medicare. As a or specialized area of medicine or surgery. In hospitals. They also physiatrist (specialist in rehabilitation medicine). comfort. weight. neurologist prescribed medications and perform medical procedures (specialist in diseases of the nervous system). and so on. ments involving visual. or perceptual-motor deficits. In some ing units. This sometimes leads the psychologists may be a part of the core care team. Occupational therapists (OTs) and physical therapists (PTs) have uniquely different professional preparation and per- Psychologists spectives on rehabilitation. don and doff clothes. and cognitive and behavioral issues tend to be principal con. safety. independence in self-care and related areas. tive devices to improve functional independence. By involving patients with aphasia in as body weight. serum albumin. Speech. emotional. OTs also are very adept at designing or providing assis- Rehabilitation units and other facilities. renal chemistry panels. They collaborate with out of a wheelchair. where with the patient’s functional daily-living abilities.qxd 1/21/08 11:40 AM Page 235 Aptara Inc. these groups offer excellent opportunities for partnerships with the speech-language pathologist. They work with families and. These evaluations. geropsychologists. visuomotor. who areas are going to be crucial for the patient to return to a may not have completed professional degrees but have com. For example. collaborate with medical social workers to of perceptual-motor abilities and the visuospatial abilities link families and patients to community mental health ser. They follow the patient’s the team can demonstrate to the family the patient’s residual nutrition and hydration status. or to combine the objectives of both therapies into treat- language pathologists will work closely with the recreation. or may be general public and health-care personnel to refer to all ther- consultants to the team. or general clinical areas in their scopes of practice. patient’s ability to return safely to driving. but also have some overlapping Neuropsychologists. are usually required to have someone on staff to settings. Therapy. They (targeted to be just within the patient’s ability range) the also monitor the patient’s alertness and well-being. psychologists may be the team leaders. without experienc. emotional. These individuals are responsible for planning and munication problems interact with other functional losses.GRBQ344-3513G-C08[229-244]. visuoperceptual. They the speech-language pathologist in developing a profile of are a valuable partner for the speech-language pathologist in the cognitive and other deficits and collaborating on inter. the psychologist can be a very close partner with Rehab” with patients who have visuosensory losses. thus. designing a plan for improving a patient’s functional impair- pretations of test findings. can conduct and participate in the team assessments of cogni. OTs ensure that cerns. occupational therapists are concerned tion team. ing a communication disadvantage. The speech-language pleted a course and passed a state-certifying examination in pathologist and OT often work in partnership when com- this area. OTs may be involved in kitchen and recreation conduct a recreation and resident activities program. for optimal independence and self-care. Psychologists patients can take care of their grooming and hygiene. the OT might be asked to have therapy staff to ensure that the patients can engage as fully as the patient point to the items of clothing he or she names possible in the unit’s recreation activities. Recreation therapy is Physical therapists (PTs) have a key role with stroke reha- more than just keeping patients busy. problem managing oral intake. Most OTs have experience in the assessment and treatment when needed. or if there are other issues related more directly to the aphasia. By engaging patients together Dietitians with their families in recreation activities that do not require Inpatient facilities typically have a dietitian or dietary tech. and the family resume shared activities. incoordination. Recreation-therapy bilitation whenever weakness. applying the communication-facilitating strategies they are particularly if the patient with aphasia has a concomitant developing in therapy to everyday social activities. In comprehensive rehabilitation apies (including speech-language therapy) as “Physical facilities. scheduling the daily-activity calendar of patients. such as difficulties Occupational Therapists and Physical Therapists ordering preferred items from the facility menu. such as skilled-nurs. monitoring parameters such non-language abilities. in and out of bed. in and out of a tub or the team to design and implement the cognitive. In units such as head injury programs. or balance . groups can be the first place where the patient with aphasia medication. ment sessions. Many of these ation therapy or may be Certified Activities Directors. and general appetite. much language facility (such as playing cards or dominoes) nician attached to their care team. Depending upon the individual’s training and spe. recreation tasks that have some demand for communication daily intake of food and water. or with visual-field Recreation Therapy cuts. and behavioral areas. The speech-language pathologist can demonstrate the value of speech-language pathologist may work with the dietitian. before beginning the dressing routine. and behavioral therapies. and visuoperceptual abilities associated with brain injuries. Chapter 8 ■ Teams and Partnerships in Aphasia Intervention 235 with the speech-language pathologist to address safe self. shower. maximal level of independence. visual recognition. psychologists are an integral part of the rehabilita. or they may be involved in an assessment of the individuals may have Bachelor or associate degrees in recre. as with conditions such as apraxias and neglect syndromes. and can functionally transfer in and tive. vices.” In general. Some OTs have had specialized training in “Low Vision cialty area. Physical therapists. cardiac rehabilitation.” but in addition. payers typically do not reimburse services pro- romuscular weakness. will help the team select the instruments and design the vided by other members of the care team—in collaboration access switches. in Tennessee. The SLP a hearing impairment. . but also the asso. & Square. set- ting up equipment).g. Wertz et al. endur. a new vocation. supervised nonlicensed individuals. be shifts in primary concerns and priorities for intervention. 1989. ential diagnoses. of Examiners to the implementation of treatment proce- ance. or speech-language pa- independence. along with all of the equipment for other purposes. working under the super. but with specific training to lend help to the therapists and assistants in patient care and other clinical duties (e.” Speech-language patholo. 2001. such as assistants and ciated functional living problems. (COTAs). tants. strength. and an assessment of related equipment or augmentative communication systems or cognitive impairments.” are fairly common in rate a PT objective into therapy sessions. “the patient Paul & Sparks. Marshall et al. Physical Therapist Assistants (PTAs). Black. voca- the breadth of the SLP’s expertise in aphasia intervention. Physical therapy addresses not only the neu. If the patient requires special adaptive the patient’s language deficits. biomedical engineers. Evidence supports the role of trained and found in patients with neurologic damage. range of movement. Assistants and will be able to carry a basket of clothes the distance from his aides do not conduct new patient evaluations. the assistive technologist (AT) evaluations. and eventually.. behavioral data. Duchan. therapy aides. Certified Occupational Therapy Assistants will help the team address those concerns. walk 50 feet without assistance. TEAMS ACROSS THE CONTINUUM vision of the licensed/certified professional therapists.. Therapy gists might partner with the PT to incorporate functional assistants have to demonstrate specific competencies before language-facilitating activities into the physical therapist’s they can treat patients independently. tional counselors. Similarly. decision-makers. occupational therapists. a rehabilitation vocation counselor is the individual best equipped to direct the patient and family toward potential alternatives. dures only under specific conditions. the SLP might incorpo. the goal of volunteers. and balance problems vided by assistants. When the patient and family Support Personnel have spiritual needs that require specialized attention. such as splinting. supervision and direction of professional therapists. coordination.qxd 1/21/08 11:40 AM Page 236 Aptara Inc. 2006. such as asking the rehabilitation settings. Speech- Language Pathology Assistants (SLP-As). thologists. If the patient has driven and evidence-based language intervention. and observational input pro. may be members of the The SLP is the member of the team who provides theory. or “rehab techs. transfers. physical therapy may be something like “the patient will Simmons-Mackie. reentering their home life and community. in aphasia intervention (Kagan. 1986). For example. 236 Section II ■ Principles of Language Intervention problems are present. assistants sometimes are viewed as “therapy extenders”— continence control. balance. it is increasingly common to find support member of the facility’s pastoral care or chaplaincy service personnel. These individuals may be students or patient to transfer from the bed to a chair before beginning others without degrees in rehabilitation therapy specialties therapy. Therapy itation. the basic requirement for Speech-Language and correspondingly there will be changes in the major Pathology Assistants is a high-school diploma or equivalent. Speech-Language Pathologist The speech-language pathologist (SLP) brings to the team Other Allied Professionals knowledge and skills in the evaluation and remediation of the aphasic person’s communication and related cognitive Professionals from a variety of disciplines. If there is potential for the adult with apha- with the patient and family in identifying the communication sia to return to a previous vocation. there will and standards vary by state and by discipline. implementing the plans that are established by the physical bers of the team. a In rehabilitation. and exercise or activity tolerance. or bladder. the audiologist can become a central evaluation usually includes a psycholinguistic assessment of member of the team. heath-care team with adults with aphasia. assistive technologists.. including under the PTs and OTs may also be involved in other areas of rehabil. In Changing Priorities several states these individuals have to have met qualifying examinations to be licensed in their discipline area after As persons with aphasia move from the crisis of the acute completing required education and training (usually either a event through various care settings. and trained vol- unteers may be a part of the team. This text provides a comprehensive review of gists. The requirements fully. or design the treatment plans. like all other mem. such as audiolo- impairments. For example. and chaplains.GRBQ344-3513G-C08[229-244]. In addition to assis- directions and requests. For the most part PTs are focused on Therapy assistants usually are restricted by the State Boards the patient’s mobility. or even goals—forms the basis of the SLP’s intervention program. make differ- bedroom to the laundry room. Test findings. hope- bachelors degree or an associates degree). similar vocation. are concerned with maximizing functional therapists. qxd 1/21/08 11:40 AM Page 237 Aptara Inc. the team’s efforts are directed toward moving the through many settings. Level V  Productive Activity. Physiologic and medical status 2. Financial and vocational issues Level II  Physiologic Maintenance. Discharge plan Level 0  Physiologic Instability. skin breakdown. In fairly short order the support systems pro- Continuum with Adults with Aphasia vided by the multidisciplinary or interdisciplinary teams will end. Psychosocial and emotional issues 5. These authors 2. 1995. joint- 4. Functional independence 2. Discharge plan tinuum as the patient progresses from a destabilized state Inpatient 1. limitations Level I  Physiologic Stability. Functional independence (1995). As soon as the patient’s medical condition Acute-care 1. Sundance & Cope. rehabilitation at this phase will be Home and 1. Shifts in priorities.GRBQ344-3513G-C08[229-244]. Communicative and other cognitive dence and encouraging the patient with aphasia. Functional independence lowing stages. with his or limitations her family. Not every facility. to take control of their own lives. Communication and other cognitive nostic evaluations are completed. depending on the patient’s 3. these scenarios are intended to illus- trate a point. Physical limitations functional rehabilitation restoration. Chapter 8 ■ Teams and Partnerships in Aphasia Intervention 237 TABLE 8–1 home or rehabilitation facility. and community reentry 2. Level IV  Advanced Functional Goals. 1995). 1993. and prevention of complications. 5. Communicative and other cognitive limitations As illustrated by a schema described by Sundance and Cope 4. & McLean. Psychosocial and emotional issues problems. from the rehabilitation team to indepen- Shifts in Priorities Across Settings and the Recovery dent living. Functional independence which medical stabilization is the main concern and diag- rehabilitation 2. from outpatient therapy to home-health-care. Psychosocial and emotional issues aimed at communication. Physiologic and medical stability has stabilized and the patient enters rehabilitation. Emotional issues arching goal of all of the rehabilitation professionals they 3. Rehabilitation primarily is Home-health-care 1. and bowel. Paradigm Health uals in the hierarchy of decision-making will also change Corporation. or individual patient will necessarily follow this pattern. Secondarily. and decision-makers across the recovery continuum Acute Care Setting are considered here merely to emphasize that intervention extends beyond any one setting or team. Physical limitations such as aspiration pneumonia. Team designs and the primacy of different individ- (Landrum. 3. the over- 2. Physical limitations encounter should be directed toward functional indepen- 4. The acute onset of illness in Outpatient 1. Physical limitations Level III  Primary Functional Goals. Rehabilitation outcomes are Table 8–1 illustrates how priorities can change across set- directed at returning the adult with aphasia adult to pro- tings and through the continuum of recovery with adult ductive activities within his or her level of ability aphasia. setting. Communication and other cognitive during the acute phase up through later phases of commu- rehabilitation limitations nity reintegration and productive activity. Functional-deficit- 5. Limited attention is given to 3. from the hospital bed to the nursing patient out of physiologic instability toward a level of . 4. (Table 8–2). Financial and vocational issues mobilization problems. Discharge plan Subacute nursing 1. Financial and vocational issues cognitive and behavioral issues. medical stabiliza- 4. Communication and other cognitive aimed at establishing adequate and safe systems of nutri- limitations tion and hydration. Communication and other cognitive specific goals are established to facilitate discharge to limitations home or to improve residential integration. Schmidt. 4. self-care. Physical limitations Changing Rehabilitation Outcome Goals 3. Intervention rolls Initially. 5.and bladder-control 5. Psychosocial and emotional issues tion continues to be addressed. Rehabilitation is directed toward community reintegration. Functional independence responsiveness. Physical limitations conceptualized the continuum of treatment to span the fol- 3. rehabilitation outcome goals move through a con- 5. team Changing Settings designs. mobilization. Patients and families need to be prepared for the time Setting Typical Priorities when decision-making responsibilities will fall squarely on their shoulders. Obviously. unless the patient is admitted to 1995). Patient and family reentry networks and partnerships physiologic stability and maintenance (Sundance & Cope. These settings can be a skilled unnecessary at this point. the primary nurse. Information needs to Subacute Nursing Setting guide. an acute “stroke unit. with other team members. and making discharge recom- ical care pathways anticipate discharge in 3 to 5 days from mendations to the physician and medical social worker. Physician Subacute unit Interdisciplinary 1. the typical model for team care in an acute setting is ual neurologic damage and (2) diminishing the risks for more likely to look like a multidisciplinary than interdisci- complications. sages consistent and to not overwhelm the patient or family. patient before discharge. Prevention of complications continues to be a . admission. The messages must be accurate nursing facility. or the body language. cipally through the physician. The channel information through as few people as possible. focus on sharing assessment findings and onset of aphasia. & Andriaanse. Patient and family Outpatient rehabilitation Multidisciplinary 1. so team patient and family education and appropriate discharge discussions of observations on cognitive and communicative planning. and reassuring attitude (van Vendendaal. Grinspin. after the medical and acute physiologic conditions damage. Rehabilitation team 3. because dous emotional stress. Patient and family Home and community Community support 1. so a supercilious lecture on recovery from aphasia have stabilized. Physician Community support 2. The family should not be expected to fully grasp the consequences of the neurologic Usually. however. where physiologic maintenance may still be “unrealistic expectations” is completely inappropriate and the main outcome goal. Finally. 238 Section II ■ Principles of Language Intervention TABLE 8–2 Team Designs and Decision-Makers Across Settings and the Recovery Continuum with Adults with Aphasia Setting Team Design Primary Decision-Makers Acute-care Multidisciplinary 1. and allow them to work with the family. be sensitive to the verbal messages. Home-health rehabilitation networks and partnerships team 3. it is important for the team to keep mes- supportive. Rehabilitation team networks and partnerships 3. the team’s emphasis tends to be on the patient’s responsiveness will vary during the day. if rehabilitation services within a few days of the acute event they take place at all. or the like.qxd 1/21/08 11:40 AM Page 238 Aptara Inc. reliability of communication assessments. Consequently. Physician 2. prin- family will. Patient-care team 3. the aphasic person’s family is under tremen. social worker. place. the first priorities are (1) ensur. transitional care unit. Often. making interdisciplinary team rehabilitation vir. and attitudes of all the team members partic. Education and verbal mes- sages need to be brief and consistent.” where an interdisciplinary team is in ing the patient survives the acute event with minimal resid. Physician 2. Some patients are ready to participate in plinary model. recuperative care unit. Other ipating in caring for the patient. As is the case with nearly any hospitalization with status will help the speech-language pathologist gauge the an acute event. and not overwhelm. With just a few days’ involvement with the important part of decision-making during this time. patients are transferred to some kind of sub- full of grim predictions intended to correct the family’s acute setting. most acute-stroke clin. however. care planning discussions. Unfortunately. It is especially important professionals should be available to address their particular that family and patients be approached with a professional. it may be better to mind to absorb new information or make decisions.GRBQ344-3513G-C08[229-244]. concerns. Group discussions of observations of the patient are an tually impossible. Physician Community support 2. As we suggested earlier. but also hopeful. In the acute setting. Patient and family Inpatient rehabilitation Interdisciplinary 1. Patient and family Home-health-care Multidisciplinary 1. They may not be in the best frame of the patient and family are under stress. 1996). 1999). Intervention at this phase usually takes place in a residential-program setting where teams Outpatient Rehabilitation Setting tend to be interdisciplinary (Cifu & Stewart. one of the problems that arises with the patient than communication and other cognitive impair. Typically. These emotional problems usually respond Again. and some continue rehabilita. caregivers are likely to express frustration with and some of the acute emotional reactions and psychosocial communicating with the person with aphasia in addition to issues have become slightly less of a priority than the resid. mobility. the patient’s residual physical impairments. uncertainties about the future there is a “full-court press” to address the specific deficit- and the recovery processes. disciplinary design. and cognitive/communicative problems. and even physicians is not typical. emotional lability. on an inpatient rehabilitation unit the fam. blood. Flick. may see the end of rehabilitation as the end of recovery Integral to improving the patient’s psychosocial and emo. interven. In this setting daily contact with non-therapist. At the sub. psychological stresses may begin tional status is the implementation of rehabilitation for to emerge at about the time the inpatient rehabilitation stay physical. team of experts attempting to maximize the patient’s func- tional issues. 1999). The focus on pening to them. In this setting rehabilitation setting the major medical issues have resolved especially. Because all the acute phase. more multidisciplinary than interdisciplinary. chronic medical issues to consider. inpatient rehabilitation setting is that patients and families ments. the aphasia will be implemented. con.qxd 1/21/08 11:40 AM Page 239 Aptara Inc. the overriding goal to improve self-care and independence for home and commu- Inpatient Rehabilitation Setting nity integration and toward some resumption of productive Some patients transfer directly to a rehabilitation facility activity is still primary. (Flick. dieticians. cognitive and emo. the entire team is responsible for intervention model is more likely to be closer to the multi- achieving the intervention goals. inpatient team intervention tends to be interdiscipli- to a combination of medication and reassurance. Patients also may display post-stroke depres. social workers. with the overriding goal of maximizing independence. some amount of recovery at this point. nurses. The end of formal treatment can signal a If the patient’s physical tolerance and cognitive status allow. thus. 1993. Aggressive speech-language therapy for and impaired movement. concerns about psy- the patient and the family. these should be addressed as part of the outpatient rehabili- ment. the patient has experienced such as anxiety and depression on the part of the family. seizure control. tation program. psychosocial. financial. due mostly to but the patient is typically believed to be generally medically difficulties with scheduling collaborative therapies and the stable. Also. and lifestyle changes. However. 1999). include such things as changes in body image and losses in or at least become less severe. Because the patient is typically com- from their acute-care ward. 1999). daily of occupational and physical therapy. There may be significant. In such settings. Chapter 8 ■ Teams and Partnerships in Aphasia Intervention 239 concern along with communication. is nearing its end. sadness over the loss of companionship. It is important that everyone working with the patient and fam. tions in outpatient rehabilitation settings are impairment- specific. and independence. once the patient reaches the most on the minds of the patient and family. disciplines may work in the same clinic area. unavailability of support professionals. In a rehabilitation setting the level of independence. such as pain manage. irritability. social isolation. and collaborative goals are emphasized. unrealistic everyone’s part is placed on maximizing the patient’s abilities expectations or denial. concern for “is this is as good as it gets?. but the team- ferent center of concern. blood pressure management. consequently. encouraged (Flick. changes in fam. tion in a skilled nursing facility or following a stay in a suba. Much like the hierarchy of concerns when tion procedures are shared and implemented in partnerships patients enter inpatient rehabilitation facilities. the interven- between team and family members. and financial difficulties other cognitive problems). depression. possibly because mobility is linked to independence. self-care. or incontinency. 1999).” which creates anx- the earliest possible involvement in rehabilitation should be iety for both the family and the patient. a mechanism to ily sees the patient working for several hours a day with a address these special issues easily may be lacking. frustration with communication effects of the stroke. ing to therapy from home at this juncture. tional status. often are more of a concern to the family and the for positive results. sion and anxiety. and the psychosocial effects of family and the patient are usually highly confident that some the aphasia and other impairments will begin to be felt by improvement will result. Issues such as ual effects of the stroke (such as hemiparesis.GRBQ344-3513G-C08[229-244]. emotional. aphasia. to return either to his or her home or to a residential facility. self-centeredness. nary. Since this arena of treatment can tend to be coagulation management. if intensive therapy and team activity leads to an expectation any. Typically. most likely. Therefore. Psychosocial concerns can chosocial and emotional issues may temporarily be set aside. When possible. and vocational concerns may be upper- cute nursing unit. Therapists from different Although different members of the team have a slightly dif. and dependency (Churchill. allied disci- ily have the same goals in mind and that no one professional plines such as pharmacists. group exerts ownership over their goals or procedures. Explicit . Emotional issues. may surface after the patient goes home (Flick. for the most part. in addition to 3 or 4 hours ily dynamics and a sense of a lack of control over events hap. the tinue to be major concern. (Cook. particularly in inpatient facilities. and test the lates to increased costs to the provider facility. training. literature coming out of Canada and the United Kingdom disciplinary team evaluations and treatment. 1999). To be in compliance with the standards of the Joint Commission on Accreditation of Healthcare Organizations ( JCAHO) (JCAHO.g.. 2005). (1995) and Schmidt Collaborative interventions can reduce redundancies. It’s a bit like the parable of the seven blind men eventually reaches an outcome: the rest of life. Team evaluations with more than one discipline team are.qxd 1/21/08 11:40 AM Page 240 Aptara Inc. One of the frequent concerns expressed when team evalua- tions and treatments are considered is the belief that “only one discipline can bill for this time. documentation for these pathways flows across multiple aging the patient and family to link with community support disciplines. or with discussed earlier. D’Amour et al. Reducing the lengths of stays often saves porate those resources and social support networks into costs to the facility. Clinical Care Pathways may be used to guide resources available to this family unit?). (3) family resources (what are the caregiver and other For example. from the initiation of care. in which a different interpretation oriented rehabilitation (Landrum et al. Other types of reimburse. financial resources available to this patient and family?). (2) financial resources (what are the additional Some of the current practices in health care in the U. life for that person. and more effi. is during the professional clinical prepara- inpatient insurance per diem).S. be identified with the patient and family very early in the continuum of rehabilitation therapy services: (1) Health ser- vices funding resources (what will the insurance coverage pro- Documentation vide for this person to support his or her needs now and in Documentation is another important area for collaboration.. emerges depending upon which part of the elephant you are 1999). which reduce the and family have available to them. (1999) observe that all too often the team fails to consider reduce the time taken for communications. and (4) community . It is important that students have a good exposure to on having more than one discipline involved in a given eval. 240 Section II ■ Principles of Language Intervention referrals to a psychologist and other professionals will need day-to-day care plans. much less how to incor- lengths of stays. there are no payer restrictions tion. 2006) or RELATED ISSUES CARF. Similar to a home health based setting. conceptualized. In NETWORKS AND PARTNERSHIPS the earlier discussion of “who are your partners.” That may be the case in Clinical Preparation and Research any fee-for-service visits. therefore. and delivered with an eye on the quality of the rest of independent assessments. 1995). Landrum et al. Increased staff time trans. When different disciplines collaborate in research we patient care than are necessary. orga- participating can yield a much better composite picture than nized. Collaborative evaluations may COMMUNITY AND NATIONAL SUPPORT accomplish a more comprehensive assessment in a shorter time frame than evaluations that are done independently. however. The to be set up. (Ignativicius & Housman. 2005. prospective-payment system for Part A coverage. Schmidt. risks of nosocomial infections and other hospital stay related Schmidt (1999) suggests the following resources should complications. and some of the care objectives may be shared networks well ahead of the completion of formal outpatient between or among disciplines (e. 1995. different team interventions as a part of their professional uation or therapy session. may be necessary to justify collaborative evaluations and interventions and nonbillable staff time (such as team meet- ings) as a facility cost savings. the future?). patient education) therapy is essential. 2005. today strongly encourage multidisciplinary documentation.. it has the added benefit of reducing the their future. The issue may be provider costs. tion and collaboration in patient care is primarily evident in ment schemes. discover a new way of looking at old notions. the Commission on Accreditation of Rehabilitation Facilities (CARF. Collaborative research also has exciting possibili- The facility may resist having more people involved in ties. In outcome- and the elephant. For example. it extent to which our data apply to other areas. Emphasis on interdisciplinary educa- charges in the same unit of time. The when a pre-established payment is made for a certain time to initiate good interdisciplinary relations to prevent amount of treatment time (as with Medicare’s DRGs or potential problems related to professional ethnocentrisms.” several Every adult with aphasia who completes formal therapy examples of collaborative evaluations and interventions were under the care of either an array of disciplines or just a few mentioned. might support collaborative inter. the intervention services of the health care delivery touching. encour. it is expected that family and patient Team Evaluations and Team Treatments education be conducted in a multidisciplinary manner. Gibbon. until the end of the patient’s stay the resources the patient ciently ease transfers and discharges. where charges are made per proce.GRBQ344-3513G-C08[229-244]. Training programs and research are ripe for interdiscipli- dure and payers usually will not pay for two procedure nary collaborations. their families. one of the overarching goals of rehabilitation resources available to them.org). activity. support groups. recovered and to minimize the psychosocial impact of the church activities. both orally and in writing. and rehabilitation. Be provided. Give their informed consent in any research project in which they are participating. nosis. To that end. The inter- guage pathologists. the patient and the family may need to maintain con. Schmidt (1999) suggests starting with sia and their co-survivors. physiatrists. life. through its “hot line. the community support networks they will need and to then 4. 2005). attending a reunion. surviors of stroke. The NSA’s focus is on reducing the incidence and impact of stroke through activi- ties related to prevention. These kinds of planned activities may help ified speech-language pathologist (SLP). with writ- event. their families. that there are local However.” appropriate by a qualified speech-language pathologist (SLP). including The Aphasia Handbook continuum of recovery. The NAA’s families to use their available resources to reintegrate into mission is “to educate the public to know that the word apha- their homes and communities and return to productive sia describes an impairment of the ability to communicate. The outcome of survival following a major neurologic 2. research. The team needs to be charted in nearly two decades ago. recreation opportuni- language impairment” (www.. The notion of team intervention is extended to family- a Stroke Center Network program and encourages conduct. and has continued to focused on the future and also keep the patient and family advocate for and serve the interests of individuals with apha- focused on the future. The team can also help the patient and the NAA has developed and endorsed the adoption of the family plan post therapy goals.aphasia. is. This can include such things as elder care fessionals aware of resources to recover lost skills to the services. explanation of the meaning of aphasia. It is important that every member The National Aphasia Association (NAA) is a nonprofit of the rehabilitation team understand the global impact that organization governed by a Board of Directors made up of aphasia and other problems resulting from brain damage individuals with professional interests in aphasia (speech-lan- will have on the individual and the family unit.aphasia. ties. and health care pro- munity services. as soon as it is determined. Be told. Have access to outpatient therapy to the extent deemed be prepared to lead their own “team aphasia. The NAA makes people with family develop an individualized resource directory for com- aphasia. health-care professionals. and a journal. upon release from the hospital. word-processor letters.qxd 1/21/08 11:40 AM Page 241 Aptara Inc.g. such should encourage and empower aphasic adults and their as its “Speaking Out” conferences held biennially. that they have “aphasia” and given an the future. The National Stroke Association (NSA) 6. centered partnerships as early as possible and throughout ing clinical trials in the prevention and management of the continuum of care and into community-supported part- stroke and its consequences.or university-based aphasia therapy programs. the end-point and aligning expectations throughout the and published materials. After formal therapy ten documentation that “aphasia” is part of their diag- ends. Demand that accrediting health-care agencies and The National Stroke Association (NSA) was founded in health care facilities establish requirements for and 1984 as a nonprofit organization dedicated to educating competency in caring for people with aphasia. which states: reinforcing tasks at home (e. The NSA provides guidance in aphasia in health care facilities and other rehabilitation set- developing stroke clubs and stroke support groups. including Aphasia Com- should be to identify the potential risks and concerns prior to munity Groups in their areas. participating in a 1. day treatment programs. to compensate for skills that will not be munity. Be told. Meals on Wheels. and the general public about stroke. mainly within the context of therapeutic interventions for Stroke Smart. preferably by a qual- church project). nerships after formal therapy has ended. and that should not be discouraged. Chapter 8 ■ Teams and Partnerships in Aphasia Intervention 241 resources (what community and social support services are The National Aphasia Association available to this family?). neurologists) and individuals vention team should anticipate and incorporate that per- with aphasia and their co-survivors. and by sponsoring conferences. com- extent possible. read- people with aphasia have the right to: ing selected sections of the newspaper) and family or com- munity activities (e. such as a stroke. and the like. In an examination . as well as national organiza- the end of treatment and help the patient and family establish tions such as the National Aphasia Association (NAA). tact with a support team.GRBQ344-3513G-C08[229-244]. operates tings. medical care.g.org). both orally to carry forward formal treatment into functional living in and in writing. National Support Groups 5. support systems. The team should be supportive and (Sarno & Peters.. such as continuing language- Aphasia Bill of Rights (www. resocial- SUMMARY ization. literally. 3. This organization was spective into each phase of therapy. One of the projects for the team can be to help the not an impairment of intellect. This organization develops and This chapter examined concepts in team collaborations distributes educational materials and publishes a magazine.” Web site. qxd 1/21/08 11:40 AM Page 242 Aptara Inc. Presuming our ultimate goal is to bring about the priorities and primary decision-makers might shift over the best quality of life after the onset of aphasia. What is the evidence in support of the benefit of team- as multidisciplinary. How might teams differ in the acute phase of rehabilita- tion as compared with the subacute and chronic phases of recovery? 6. creating cohesion..GRBQ344-3513G-C08[229-244]. Which professional group tends to be the decision- McPherson. and products) and process (communication. thus. multidisciplinary. based. affil. The principal goal of this chapter is to patient and family are. both in the formal rehabilitation program itself and in objective of management throughout the continuum the transition to the home and community. rate into the therapy plan to empower patients and fam- tings. goals. What are the advantages and disadvantages of having approach is supported by research examining evidence. 5. All of the current makers in health care in the U. Interdisciplinary teams. be barriers to communication. require importance of good communication is stressed. and necessary for the success of interdisciplinary teams. including problems with con- physician in the role of primary decision-maker. Multidisciplinary teams are common in inpatient set. ilies ultimately to take control of “team aphasia” after tion settings. An interdisciplinary team 1. What are the similarities and differences between mul- ies (CARF. by tidisciplinary. interdisciplinary. collaborative services for patients with aphasia? plinary models. ing interdisciplinary team documentation. a model applied in early intervention. successful team processes. there needs to be a balance of both content (activ. Strasser et al.. Malone & 3. We looked at how profes. common in rehabilita. There are a number of challenges to interdisciplinary sional hierarchies in health care settings tend to place the team management. the leaders in “team aphasia” are ultimately the patient and the family. Gibbon. 2005. more than one discipline involved in intervention in based treatment (Cifu & Stewart. During which time frames are patients and families most likely to become more concerned about psychoso- KEY POINTS cial and financial issues than medical issues? 7. JCAHO. and collaboration). share common goals. empower patients and families to become independent deci- sion-makers. 1999. and why? trends and influences in health care delivery today suggest 4. the teams. the most impor- emphasize the value of team collaborations and partner. Rosin et al. and transdisci.” and less distinctive discipline-specific also emphasized how becoming comfortable with a certain boundaries. When therapy has ended.. 1996). amount of blurring of professional scopes of practice may be 3. List the ways team intervention is encouraged by trends 1. interdisciplinary. 2004. the recovery continuum. team? rations in patient care are here to stay. 9. In team establishing effective leadership are key elements to dynamics. ities. What do case-managers and social workers bring to the the “lone professional” practice is diminishing and collabo. tant members of the health care team. especially in ducting “billable” team evaluations and implement- the more acute phases of care. FUTURE TRENDS Teams and family-centered and community partnerships ACTIVITIES FOR REFLECTION AND DISCUSSION have an important future in patient care in all arenas. and how the 6.S. 2. one ships. Transdisciplinary formal rehabilitation has ended. No team will look or function exactly like any other. 2005. and transdisciplinary teams in health care settings. and influences in health service delivery. We considered how team perceive other professions and diminish the team’s processes may be hindered by a number of factors that can ability to work collaboratively and effectively. 2005). 5. Group communication.. 2006. 1999). 4. and as a standard of care preferred by teams? providers (Davis et al. . 242 Section II ■ Principles of Language Intervention of the differences between interdisciplinary. ture of teams tends to vary in different settings. ultimately. Team intervention patients with aphasia? is also strongly encouraged by legislative and certifying bod. but health-care teams in general tend to be organized 8. and transdisciplinary third-party payers. but especially in aphasia intervention. Describe some specific objectives teams might incorpo- 2. We suggest that is to prepare the family to lead “team aphasia” after one of the overarching goals of therapy should be to therapy has ended. We considered how the struc. Professional ethnocentricism can influence how we iation. We have “role release. (Eds.org. J. 6(3). Health communication: M-D. National Aphasia Association. K. V. R. (2002). O.. Cook.. Stanley. D... J.. L. Language. St. 33(3). H. A. Journal of Lange. J. J. G. (1996). Strasser. Models of interprofessional learning in National Aphasia Association: www. Archives of Physical Medicine and Rosin. & Dick. Paradigm Davis.. Palo Alto. L. L. S. (1999). (1999). J.. Gifts differing: Understanding CARF. L. Interprofessional team process.. Rosin. Supplement 1. AZ: Meyers-Briggs. S. E. Duchan. L. Person-centered planning training for consumer-directed care CA 94520.. E. 213–223. Schmidt. Rosin. Education. and Hearing Research. 107–115. P. vention. N. E. VA.). J. Tuchman. National Stroke Association: www.. B. A. J. intervention—A team approach.. Physical Medicine health care organizations: Blueprint for success. P. Baltimore. of Rehabilitation. 80(5 Suppl. (1980). D. D.. A. Development and tions. personality type. 624–638. A. Aspen. & Brown. New York: Thomson-Delmar. & health professions.). D. 51(1).. (1999). A.. R. Suite Number 400. Collins. of teamwork. 279–288. Stroke outcome and Delmar.. Mitchell. Hogh. V. JCAHO Standards for Hospitals.. M. MD: University Park Outcome-oriented rehabilitation: Principles. C. et al. & McLean. 16(1). strategies. Aten.. Saunders. G. Holm. Gaithersburg. & Patton. & Marthas. and tools for Press. J.. (1998). A. C. D. Knudsen. Sampson. J. Group process for the Heikkila. M. D. 1). Gesien. 99(6). The Aphasia Handbook. B. A multidisciplinary memory clinic in a neurologic set. W.qxd 1/21/08 11:40 AM Page 243 Aptara Inc. Irwin. T. Strategies for health professionals. Summala. & Scheifelbusch. J. Team-based Churchill. A. S. MD: Rehabilitation: State of the Art Review. D. C. A. I.) (1995). L.. Brookes. & Beaulieu. G. effective program management. C. In Lubinski.. D. Lane. Paradigm Health Corporation Publications (1993). Turkka.aphasia. & L. 26(2). Moore. D. D. (2005) The conceptual basis for interprofessinal collabo. C. S. Journal of Square. 93–102. & Frattali. 8(8). E. G. What makes a leader? Harvard Business Whitehead. Canada. T. & Peters... . Louis: C. 349–399. (1989). R. New York: Thomson- Flick. 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Baltimore: Paul tion in stroke rehabilitation team conferences.GRBQ344-3513G-C08[229-244]. S-35–39. C. K. Brookshire. X.. M. guage pathology and audiology (3rd Ed.. J. D. (2004). aphasic patients by trained nonprofessionals. (Eds. Business matters... R. Bruhn. Philadelphia: W. M. Herrin. E. Professional issues in speech-language pathology and 2–7. Joint Commission on Accreditation of Healthcare Organizations. C. T... J. Social problems after stroke. Care Management Journal. Begun. In P. L. D. 1001 Galaxy Way. & bilitation team functioning in VA hospitals. (1998). Nursing. P.. (Eds.). International Journal of Disability. L. (2001). Wertz. A. (1993). D. J.. Billups. Archives of Physical Medicine and Rehabilitation. (1996). Professional autonomy Lott. L. MD: Aspen. (1979). S.. (2005). (2006). 115–126.. H. & Sparks. ference. Ferrada-Videla. New York: patients. A.. (1999).. Lallanranta. Hennes. (1978). Predicting the future. A. Schmidt. E. Conference Ignativicius.. emergency. 39(1). D. 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Chapter 8 ■ Teams and Partnerships in Aphasia Intervention 243 References ners using “supported conversation for adults with aphasia” (SCA): A controlled trial. W. S. 7(1). Rockville. M. E. Practice. Acta Neurologica Scandinavia. K.. Bech. Partnerships in family-centered Gibbon. Manion.. Journal of Accident and Emergency Medicine. I. C. A. K. R. et al. I. D. A Veterans L. D. G. Whitehead. (1996). Gesien.. K. P. Tuchman. Outcome Level I: Physiologic van Vendendaal. (1995). 43. Holland. as perceived by themselves and by health professionals. T. H. H.. . Schmidt. & Cope.. N.qxd 1/21/08 11:40 AM Page 244 Aptara Inc. Rosin. Begun. laborative early intervention. L. Weiss. R. Barcia- Tuchman. I. & home. Aten. Administration cooperative study. and tools for effective program management. (1996). 653–658. Brookes. A. and deferred language treatment for aphasia..GRBQ344-3513G-C08[229-244]. D.) Outcome-oriented rehabilitation: Principles. & Andriaanse. stability—acute management. A. L. In P. G. MD: Aspen. Baltimore: Paul H.. 28. N. L. Partnerships in family-centered care: A guide to col. Education Council. Landrum.. H. P. A. J. D. L. L. Grinspin. Educational needs of stroke survivors and their family members & A. Bunuel. McLean Jr. (Eds. S.). The team and models of teaming. L. Patient strategies. 244 Section II ■ Principles of Language Intervention Sundance. In P. R. Gaithersburg. Comparison of clinic. 265–276. D. Wertz. Brookshire. (1986).. Irwin (Eds... Archives of Neurology. 3. Roberts guages or dialects. within a clinical perspective: “Bilingualism is not language and culture are closely related. In recent years. In all areas. available tests in different languages. is a problem which affects the majority of the only recent work is cited. exceptional. Chapter 9 Issues in Assessment and Treatment for Bilingual and Culturally Diverse Patients Patricia M. but a phenomenon every clinic must be quite different. of meaning that can occur in translation! 245 . chapter cannot provide a comprehensive literature review Prior to 1990. ticultural neurogenics. All three fields are relevant to the study 1. often comparing their performance to that of unilingual speakers. prepared to cope with” (1995c. This knowledge draws 1 In the French version of the same paper. In the present chap- interpretation. there has been a growing recognition in the English-language aphasiology literature of the impor- tance of addressing the needs of patients from all linguistic As awareness of the needs of patients from various cul. The focus is on issues most closely linked to English textbooks. far from being in the speech pathology literature to date. Therefore. intended meaning and serves as an example of the potential for distortions gualism examine how people learn and use two or more lan. 2001. and their impact on the clinical process or outcome. and generalization across languages. “bilingualism. The literature on culture and cultural diversity examines the customs. occasional occurrence in the language/speech present to clinicians working with clients with aphasia are pathology clinic. national origin. To outline issues in the assessment and treatment of not know whether the participants were bilingual (two lan- bilingual aphasia. Studies of bilingualism/multilin. To summarize some of the findings from psycholinguis- Some authors now use the term “multilingual” to mean tic studies that are most relevant for clinical work with speakers of two or more languages. These include test reliability and guages) or multilingual (more than two). A single Goral & Obler. Lemhöfer. 219). 1967. the goal is to highlight key issues. This may reflect both greater tural and linguistic backgrounds has grown. p. use of inter- probing for potential differences between bilinguals and mul- preters. Yet. or other common factor. the reader will find additional references. or mul- detailed study of this area.qxd 1/21/08 11:48 AM Page 245 Aptara Inc. p.GRBQ344-3513G-C09[245-276]. 2004). ter. Obler. 2006. but patterns of impairment and recovery. tilinguals (Dewaele. The goals of this chapter are as follows: Comparative aphasiology refers to the study of aphasia in different languages. we have used one or the other. and behav- iors of different groups defined by race. Goral. clinical work and on issues that have received little attention are given little attention. and cultural backgrounds. Levy. and (3) as a “phenomenon. if mentioned at all. 11). In these recent studies and review world’s population” (Mackey. Dijkstra. as seemed appropriate. beliefs. those relating to culture and also to bilingualism. In some cases. This chapter addresses CLD issues in concepts in bilingualism and bilingual aphasia. While this view. bilingual aphasia is rarely mentioned in on each topic. in press. and to provide references and a framework for specialty within the CLD field is CLD neurogenics. To provide a brief overview of the key terminology and munication disorders. A process. OBJECTIVES socioeconomic status (SES). New studies are now goals.1 Paradis echoed articles. the challenges they just a rare. and cultural issues. In some studies. the bilingual adults with aphasia. which focuses on neurogenic com- 2. & Cohen. (2) culture. setting treatment the line between the two remains fuzzy. choice of language(s) for treatment. so has the awareness that clinicians require specific types of knowledge to work with these types of patients. sidered separately. in this chapter they will be con.” The English wording may or may not express his comparative aphasiology. Mackey refers to bilingualism on at least three fields: (1) bilingualism. & Michel. aphasia. To highlight how culture may influence the clinical of culturally and linguistically diverse (CLD) patients. authors fail to provide sufficient information and readers do 4. Gollnick and Chin (1990) suggest viewing individuals ple or a society. not a complete list. Martin et al. to assist health-care workers and/or 1997) but this point is often neglected. patient’s behavior. 1994. Galens. 1991. (3) family in countries such as the United States.. (2) religion. them as having a specific background. and Australia. Chin identify are (1) ethnic or national origin. and contrasts this with Anglo- clear that aphasia in languages other than English and apha. This view encourages clinicians to look its laws. and (9) nonverbal aspects of communication. We must be particularly teachers in working with people from these cultures (for exam. sentiments. 1985. sweeping generalizations do lit- human’s way of maintaining life. 1998. when a patient’s appearance (skin color. Australian Institute of Multicultural Affairs. 1998. careful to guard against cultural stereotypes and generalizations ple: Asante & Gudykunst. Therefore. do not share sia in bilinguals presented features not addressed in the these characteristics (Tempo & Saito.g.g. species. Nor does the author remind us that According to Grosjean (1982): “anthropologists commonly some people of other faiths share a similar fatalistic view of agree that culture consists of a number of components: the the future. 1992. Wallace. Hardt. (macro) culture. munication. ASHA. and (8) social class. & Moskowitz. & Young. Fawcett & Carino. Gentry. ideas. Cole. Brislin. Therefore. Culture is acquired. tures. 1996. despite their dif- Depending on the communicative situation. National The problem with brief cultural sketches is that they tend Institutes of Health. & Hubbard-Wiley. NIDCD. (4) age. 1997). Cushner. asking some. Policy statements by several influential mined. 1994. we must not lose aced by a historical sketch of how a particular group came to sight of the many similarities across cultures. (6) urban-suburban- domains/topics. along with habits. 2004. including its rules of behavior. Goldstein. hierarchical rela- Puente & McCaffrey. Anglo-American families are the same. 1998). These eight combine to produce communication.. Culture is the way of life of a peo. 157). (6) religion. 1998). for example. us to look beyond ethnic groups and see that. 1986. profiles will not be presented here. Professional associations have pre. Figure 9–1 illustrates how cultural factors. consider as they read these cultural guidebooks. Australian Association of Speech and Hearing.. One and cultural background have an impact on performance on author. and empathy. ily as characterized by interdependency. (5) exceptionality. Cherrie. and of individ- . the importance ferent race and nationality. Kayser. typing. 1996. Hong Kong may have more in common with a 52-year-old one what time it is has far less cultural content than asking Anglo architect from Chicago than he does with a 22-year-old someone out for dinner. 1985. Most sketches include infor- tries and the growing numbers of non-native English speakers mation on (1) health and wellness. features) identifies Brislin. the author implies. 1992). 1990. beyond race or ethnicity to see what factors influence a specific and communicated in large part by language.” (p. (3) gender/sex. cultural groups in terms of specific characteristics. its economic. Ardila. and perpetuating the tle to help us understand each other. describes the Japanese immigrant fam- some neuropsychological tests (Ellis. The items within each factors and the individual patient’s views and behavior can help ring are examples of relevant factors. Pontón & Ardila.GRBQ344-3513G-C09[245-276]. 2000. While these differences can be important. describe various cultures. not to recognize individual variations. (5) time. as coming from individual (micro) cultures within a broader social and political systems. 1999. its religious beliefs. 1987. These books describe various societies or between CLD groups and the so-called mainstream culture. characteristics. a 55-year-old Chinese lawyer from of each ring may grow or shrink. specific cultural populations (e. structure and roles within the family. Burns. There are many sources of information on different cul- 1989. There are many books that groups (e. 1992). Frayne. That is. A number of authors have reminded Most discussions of culture focus at a macro level. pragmatics. 1989. Battle. they can In the 1980s and 1990s researchers found that language easily create or reinforce ethnic and racial stereotypes. live in a given country or region. 1992). customs. Sheets.qxd 1/21/08 11:48 AM Page 246 Aptara Inc. The microculture variables Gollnick and Cultural background can influence many aspects of com. Rosen. Instead. socially transmitted. Another cultural guide states that some devout Muslims do not plan more than a few weeks ahead because they believe that only Allah CULTURE knows the future (Davis. For example. There is no indication of how many Muslims might share Avoiding Stereotypes while Recognizing Differences this fatalistic approach. American families which. Mungas. 1995. Such inaccurate. and objects. often pref. In the same period. 1996). (7) food preferences and customs. 1995. social A different approach to culture can help to minimize stereo- arrangements. (4) how status is deter- Canada. the United Kingdom.. & Yong. (2) disability. its language.g. the following Publications in medicine and (neuro)psychology have also section offers some caveats and comments for clinicians to called for more study of CLD groups (e. But not all English aphasiology literature. bodies have drawn attention to CLD issues (ASHA. (8) the language(s) and dialect(s) spoken and some of their key 1989. and many different cultures that could be relevant for pared guidelines or standards for clinicians working with CLD readers in different settings. and linguistic knowledge all rural. Hong Kong street vendor. 246 Section II ■ Principles of Language Intervention awareness of indigenous minority populations in many coun. it became tionships. (7) geographic region. us of the importance of individual differences within cultural they look at cultures as a whole. Crago & Westernoff. and so on. Lynch The descriptions in many books stress the differences & Hanson. hair. 1992. Kang. Culture is a whose cultural belief systems do not recognize therapy as a multilayered. turation. Valle.qxd 1/21/08 11:48 AM Page 247 Aptara Inc. many immigrants. The Some authors propose seeing people as being on a contin- cases are used to support Holland and Penn’s recommenda. This is true. middle-class. different members may be at different levels of accul- process. uum of acculturation or a series of levels of acculturation tion that treatment “should [not] be imposed upon patients (Langdon. not only for CLD patients but different level of acculturation in different areas of their for all patients. Some white. Anglo-Saxon lives. adopting “mainstream” values and habits around work clients also reject therapy.GRBQ344-3513G-C09[245-276]. Acculturation is another factor in working with CLD Finally. 2006). Chapter 9 ■ Aphasia Assessment and Treatment for Bilingual and Culturally Diverse Patients 247 Figure 9–1. patients and families to reject rehabilitation efforts. (Burr & Mutchler. Marin. They allow us to tailor the assessment and treat. They are factors clinicians group around religious or family matters. 2003. Holland and Penn from one cultural background adopt the cultural values and (1995) describe Native American and African views in which practices of a different culture. For some adults. multifaceted thing. A given person may be at a need” (p. Acculturation refers to the process by which people sen to leave their country of birth. What are often cited as “cultural and retaining more customs and values from their national variables” apply to all patients. reject aspects of its . proficiency in the mainstream ment to meet the individual needs of each patient. it applies to immi- disability is due to evil spirits. 154). These views may lead some grants adopting the prevailing culture of their new country. 1992b. especially those who have cho- patients. Within the same can use to assess their possible impact on the clinical family. Usually. Communication within a cultural context. 1994). not only language correlates strongly with their level of acculturation those labeled CLD. ual variability within each cultural group. Many recommendations in the CLD literature are cian with tools for his or her work with patients from untested. there (e. This is demonstrated in a study by Erickson. political. linguistic. p. for an entertaining discussion of the problem of defin- In some cases. ical eye. knowing that someone is a recent immigrant from serves clients from different cultures. as Hispanic. Many recommendations in the CLD literature are based on The clinician can do this by stating explicitly what the assess- the author’s clinical experience. However. and (Teng. tions. 1998. the literature on different cultures provides a start- sarily have the status of a fixed expression as it does in ing point for clinical problem-solving. what role the patient. Other authors have stated that at least half the world’s pop- Paniagua. and clinician can all work to avoid misunderstandings. family. These are relevant to apha. asking indirect ques- ing and clues about what to watch for in our interactions. It does not and cannot provide step- obtained if music consistent with the African-American cul. and allowing more or less time for informal conversa- These descriptions suggest questions: Why is this client late? tion as part of each appointment. the subjects have spoken both languages well since early childhood (see Edwards. or Russia does not mean that they share ble to tailor the environment to any one group. 1997.g. It is possible to translate this into a num. Inevitably. 1996. and Sung (1999). one writer stated that the phrase “no if’s and’s or important to them (as we do with any patient. p. It is also possible to learn to Does the patient want a relative to be in the room during our interpret signals such as eye contact or punctuality within a sessions? Should I shake hands with family members? Can range of cultural contexts. For .GRBQ344-3513G-C09[245-276].. Battle. The word “bilingual” has different meanings for different patient-focused foundation. The clinician should also weigh the possible benefits of suggested changes BILINGUALISM in the clinical environment or clinical process in relation to Debates about Defining Bilingualism their cost. Hakuta has said that the difficulty defining information in journals such as the Journal of Cross-cultural bilingualism makes it “fruitless to estimate the proportion of Psychology and the Journal of Cross-cultural Gerontology. studies. Perhaps surprisingly. having other family members attend read about and learn about the cultural backgrounds of their with the patient. If read with a crit- ber of languages (French is one). some things may seem “foreign. 1986. & Grantham. when clinical services are offered by a professional who does not share the patient’s macro. Thus. their own beliefs closely matched those of the clinical process. 2005). There are also studies and books on areas ulation is bilingual (Grosjean. asking the appropriate person in the family patients. for a the patient attend an appointment on Friday? However. identified many folk To work with CLD clients. our testing and treatment. and try to separate politically motivated claims and recommendations from those that have a clinical.qxd 1/21/08 11:48 AM Page 248 Aptara Inc. compro- Devlieger. group when decisions must be made. 2005).g. in Korea but living in the United States. now called “ethnogerontology” and “gerontolinguistics” 1992). well as in books written for health-care providers (e. music. de Bot & Makoni. asking the patient and family what is example. For clinician will each play. while in others. It also means the prevailing religious. Suggestions such as “Better clinical results may be different backgrounds. African-American. clinician to fully master all the culture-specific behaviors descriptions about racial. Therefore. by-step instructions or rules for any given type of patient. 78). though it would not neces. These descriptions provide tools for problem-solv. given the age of many adults with aphasia. however. In fact. in bilingualism research. however. It provides the clini- English. all born mises will have to be made. 248 Section II ■ Principles of Language Intervention prevailing culture and embrace the values of their new coun. It is not possible. as the world’s population that is bilingual” (Hakuta. others are incorrect. Harris & Nelson. or their opinion.” The client. is no consensus about the definition of “bilingual. This makes it impossi- Haïti. The Need for Data family. This makes it The lack of consensus about the definition of the word possible to link the clinical environment to that culture (e. While ment or treatment involves. Pakistan. It is possible to change many aspects of the mainstream American culture. p. clinical tools). 37) need to be tested.” In some sia. such ing bilingualism). Clinical Chameleons? 2006.. Possible changes include using It is important for clinicians working with CLD clients to appropriate greetings. Clinicians will find valuable people.or microcultural background. and some provide valuable insights. bilingualism leads to differences in how the term is used..g. giving choices where it is possible to do so. but recogniz- but’s” probably cannot be translated into any other language ing that for CLD patients the answers may vary more). a center may serve a single client group. ture is played while the client waits” (Terrell. decor. 4). same linguistic or cultural background. or Chinese. the bilingual subjects are in the process of learning a second language. needed in a setting where a wide range of people are seen. clinicians should be as knowl- beliefs about illness and disability as being typical of Korean edgeable as possible about customs and views that may affect culture. or family values of those that the clinician and the client will often not be from the countries. or political groups can. Thirty young women. In many cities. not be used to predict what any individual may believe or do. a clinic try. hension tasks (Cutler. Van Hell & Dijkstra. 1991. The problem in basing definitions in bilin. to South Dakota. tion vary. Grosjean & Py. 1993). The most obvious lexical In considering how to define bilingualism. 1991). Norris. one can speak two languages but not be bilin. a person’s first language (L1) or native language (Fishman. Further. their vocab- ticular study apply. 1997). Language attrition—also called language lexical semantics). & Berger. Goral. Kilborn. A person’s level of bilingualism may increase or decrease ent linguistic components (morphology. Grosjean. interactions in both their languages. & Meador. religion. Therefore. 2000. its own vocabulary and linguistic patterns (Baker. Although some authors have viewed loss—is a common process (Seliger & Vago. and work. Even people who appear to have native or near-native larly vulnerable to forgetting (Weltens & Grendel. language is not always their stronger language. Another feature of bilingualism is its instability over time. and mastery of formal and informal reg- learning a second language. ent language modalities (auditory and written comprehen. residency in a particular country (Bahrick. Selinker. 1998. and level of profi- Hyltenstam. it is of knowledge. 1993). for example. the competition model of speak French are seen as bilingual by some authors (Frenck. 1992). and syn- gualism on patterns of use is that these can change. vocabulary and other types of knowledge only exist in both more. Hohenstein. terms such as “modem” or “back-up” are often used in gual if the second language (L2) is a “foreign” language that Spanish or French conversations about computers. even though they may all be domains of use such as family. Fishman. & Segui. 1997). 1999. used words. 1989. phonology. this used English and Spanish. 2002. Mehler. the results may nor may not isters is rarely equivalent in the two languages. Duncan. A or all languages if that individual has needed to use both lan- person may have different levels of proficiency in the differ. 1994. 2004). Expressive use of vocabulary is particu- all. while comprehension is less so. Paradis. guage is used for certain purposes in specific situations and pare groups with different levels of bilingualism. 1991.qxd 1/21/08 11:48 AM Page 249 Aptara Inc. Weltens & Grendel. such people are the exception. Van Wijnendaele & Brysbaert. distinctions that exist in the weakening language Serra. while the tax. There is no standard for determin- words within L1. 1997. and when deciding to whom the results of a par. while there is still debate about bilingualism is defined in terms of language use. 2002). and written expression) and in differ. 2006. not in terms how and why the interference between languages occurs. 2002. So clinicians level of knowledge of the language does not. the bilingualism continuum is multidimensional. Thus. For other authors (see Baetens Beardsmore. In North America. but would be called L2 speakers by Levelt’s work. and models derived from Mestre & Pynte. Because unique speaker-hearer. amount of use. use of idioms. 1992. Bahrick. The type and degree of attri- ences in their performance on both production and compre. Hyltenstam. may be particularly vulnerable to attrition are infrequently & Naigles. important to keep in mind when interpreting and compar. Pavlenko & Jarvis. For some patients. 1993. 1995. Many termed this the complementarity principle—each lan- studies refer to more-fluent or less-fluent bilinguals or com. Bettoni. 1965. uses only one language at work may not know work-related They see bilingualism as a continuum. not a bilingual/ vocabulary in his other language. and syntax (Dijkstra et al. 1989. 1984. 1986. For example. Several is not needed for day-to-day life (Baker. it is important changes occur when words from L2 become accepted as to acknowledge dialects. proficiency in their second language display subtle differ. 1982). where she only makes it difficult to know what is a symptom of the aphasia spoke English. 1991. The key point for clinicians to remember others. Most authors. guages in a particular context. 1998). Frenck-Mestre & Montrul. unlike a unilingual speaker of either of language attrition. MacWhinney. People rarely experience all activities and all types of ing studies. 1991. and irregularities (Seliger & Vago. Chapter 9 ■ Aphasia Assessment and Treatment for Bilingual and Culturally Diverse Patients 249 some authors.. Goggin. MacKay. 1992. If the participants were in the process of ulary. 2006. lexical items. Grosjean. Some aspects of linguistic knowledge that Pynte. 2005. sion. 2002. where she regularly even in neurologically intact adults. Reyes. Chitiri & Willows. if they exist at ponents differently. Grosjean (1997. Eisenberg. (as opposed to free). 1992. The processing she moved? A month after? strategy some patients use for a particular task may not be the This lack of consensus about what bilingual means is one the clinician is targeting. each with called bilingual. Someone who define bilingualism in terms of level of linguistic knowledge. English ing at what point a dialect is different enough from its base . about these studies is that. if should expect to see features of one language in the other. 1989. especially in studies of adult bilinguals. but not in the increasingly dominant language. Levey. 1992) because each language may influence the ciency attained in each language and not simply with years of other in speech perception (Flege. syntax. Bilingualism creates a Sharwood Smith. and in both comprehension and production. bound items Salamoura & Williams. MacWhinney and Bates (1989). vocabulary (Bettoni. models attempt to explain this cross-language interference. 1965. 1992. 2004. clear that it does occur for phonology. verbal expression. There are apply to proficient L2 speakers. Pavlenko. would she stop being bilingual a week after and what reflects normal language patterns. Attrition “true” bilinguals as those who have equal proficiency in their may affect different language modalities and linguistic com- two languages. Americans who including Selinker’s interlanguage. 1998) has unilingual dichotomy (Hakuta. with the age of acquisition. 2002). 1997). 1992. Hall. Paradis. Oesch. a bilingual speaker moved from Texas. in ways not yet well-documented or understood. 1998).GRBQ344-3513G-C09[245-276]. with use or disuse. Miller. Most studies group their bilingual. 1998. Code-switching is cribed below. 1989). also triggered by the topic. 2001. the more imperfect their some native Chinese speakers substitute /r/ for /l/. racial. and by other factors. Hufeisen. but more conscious effort is their L1 (for a review of interlanguage during acquisition. gathered on these models. mastery of that language is likely to be. Localization of language in multilingual speakers has been Grosjean. Some authors consider speakers of tors influence performance on a wide range of tasks. 1997. 1994). Some pairs lexical representations may exist for different types of words. Hurford. see Gass & L1. sharing more of the ele- than are some language/dialect pairs. In clin- African-American English and standard English to be bilin. as des- intended meaning better than the other. 2005). de Bot. and whether these links and strategies vary with level of pro- Code-switching is one feature of how some bilinguals ficiency in each language. Arabic. that the often linked to regional. 2002. Clinical types and strengths of links between languages. & Perani. 1997). a ments of their representations than other types of words speaker of two dialects of the same language may be seen as (Costa. 2002. & Sebastián-Galles. 1992) children can acquire native-like proficiency in a second lan- coined the term interlanguage to refer to the influence of guage (L2). and follows different patterns (Jacobson. Another factor to keep in mind is that.qxd 1/21/08 11:48 AM Page 250 Aptara Inc. de Groot. Recent work shows sensitive periods of varying length for Myers-Scotton. Within the United States and the United Paradis. Lalor. 1987. 2004). this means that the later a patient Spanish-speakers roll their R’s when speaking English. 1992. in regions with a Various models of how the two languages are organized history of extensive interaction between speakers of differ. The same is true of Spanish. ical work. for example. and level of proficiency in each language because these two fac- Chinese. and 1997. such Aphasia may lead to an increase in code-switching as syntax and phonology. & Hird. in at least some linguistic components (Harley & Wang. too. It is Although each model has studies supporting it (and others sometimes used when the speaker does not know how to say potentially contradicting it). Kroll & de Groot. in late learners. the type of word. the degree of communicate. will influence the level of proficiency attained. Code-switching is the use of a word. subjects by age of acquisition of the two languages and by ligible. 1991. (Hyltenstam. Scotland. It seems clear. when and how well patients learned their lan- gual (de Bot & Makoni. as is the case for some dialects of Italian. by shared group membership or experiences. During these sensitive periods. Jessner. 1995a). required and the L2 is more likely to show the influence of and how interlanguage becomes permanent. We can expect to see more interlanguage. Green. 1998. 1997. 1998. It is now clear that functions that . Grosjean. Code-switching occurs Age of Acquisition more often in some speakers and some groups than in others. 1993. Kirsner. Cappa. 1997. 2003. and other factors. Research is now focused on the which have creole. 1982. Hawaii. Overly simple models such as the compound/coordinate/ subordinate distinction (for overviews see Baetens Localization of Languages in Bilinguals Beardsmore. Canada. for a recent review). However. Experimental evidence is still being Kingdom. and regional varieties. Language- made by L2 speakers that can be linked to the influence of learning is still possible later. of languages are more similar and more mutually intelligible with concrete nouns. the languages themselves change. Recent studies also suggest that different types of 2005. or socioeconomic differ. 1993. or sentence in one language when speaking another. Interlanguage refers to errors level (Pallier. more influence of L1 on L2. 2005. de Bot & Schreuder. 2001). and began to learn a given language. or Hamers & Blanc. Selinker and Seliger (1972. 2005. Myers-Scotton & Jake. guages are key factors. studied in a series of cases (see Abutalebi. there is now substantial con- what he wants to in the language being spoken or when one verging evidence that the two languages are connected. ple. there are also many varieties of English spoken. Scovel. optimal acquisition of different language components. Bosch. some On a clinical level. 250 Section II ■ Principles of Language Intervention language to become a language in its own right. guage are perhaps in pronunciation. phrase. 1992). there are different “world Englishes” learned by native Dijkstra & Van Heuven. question “do bilinguals store their languages in one system ences. In some cases. For example. This language has a word or phrase which expresses his or her finding has direct consequences for clinical work. although not all of them will reach this high one language on another. the patient’s dialect. 2005. similarity between the two languages. for example. French. For exam. Selinker. English speakers in Singapore. individual differences in language-learn- Types of Bilingualism ing ability and patterns of use of each language over time Many typologies of bilingualism have been proposed. and processed have been proposed (Cenoz. Paradis. the process- assessments must measure language abilities in relation to ing strategies used during comprehension and production. pidgin. MacWhinney. & ent languages. 1993). The most well-known examples of interlan.GRBQ344-3513G-C09[245-276]. India. and Arabic. especially when the dialects are not mutually intel. while most do not. all of or two?” is overly simple. however. 1989) have been dis- carded by most researchers (Durgunoglu & Roediger. There are also areas. and Thiel (1999) found that single. 1998. 1995. This variability is similar to A similar but not identical result is reported by Kim. in both hemispheres. which serve a marginal gyri. and the cerebellum. 2003). Miozzo. 1995).. strongly suggesting hemisphere (left inferior parietal cortex). and Trouard (2003) draw attention to this point in found. Most task (fMRI) by 22 English-Chinese bilinguals. there is evidence that the vocabulary or the syntax bilinguals. during a naming task in English and Spanish in proficient Clinically. Steinmetz & Seitz. During a memory apparently the case even for tone languages such as Chinese task for pairs of words. and relatively few individuals. and Bookheimer (2001) overlapping areas during language tasks does not mean that found no difference in the left-hemisphere areas activated the same neuronal networks are involved in both languages. the groups were small. Fabbro & Paradis. tively diverse in their patterns of language use. of studies. the left angular and supra- to the left hemisphere affects linguistic tones. Miozzo. colleagues interpret these differences as being due to a com- eral Italian patients (Abutalebi. and Thai (Gandour. Zatorre. Perani and colleagues used a receptive language task in a series Crinion et al. Mazziotta. 1980). Naeser & Chan. Meyer.. they found not others... ization may be incorrectly interpreted (Dehaene et al. during a verbal-fluency task for the two groups.. bination of exposure to L2 and to age of acquisition. nucleus. In at least one study there is evidence that learning a sec- tributed networks even when there are differences in the ond language can increase gray-matter density in the left accuracy and latencies across the tasks. and no men- Cantonese. anatomical regions or circuits. sug- activated the putamen. Aglioti & Fabbro. 1998). Cazzato.and across. Soon. This is English bilingual men with PET scans. Perani and colleagues lexical role. However. 2004). 1995. & Evans. the verbal-fluency task activates a wide range of Torre. and that these that word generation in the two languages makes demands changes correlate with both age of L2 acquisition and over- on overlapping neural substrates (Klein et al. p. and rela- cases of subcortical. 1993. Moretti. have been studied with subjects who began L2 acquisition later (mean age 11). The range of tasks used in the guages also activated similar regions in and near Broca’s brain-mapping studies to date is limited. guals) who spoke either primarily Spanish (n  6) or primar- hension and expression for non-tonal elements can be. Few language area. Damage ferent regions around Broca’s area. the two lan. the two languages activated some dif- and Thai (Gandour. generation. all proficiency in L2 (Mechelli et al. Chapter 9 ■ Aphasia Assessment and Treatment for Bilingual and Culturally Diverse Patients 251 are in the left hemisphere of unilinguals are also in the left Krause. Perani et al. just as compre. 31). linked subcortical lesions. Therefore. Lee. & Laihinen (2002) studied Finnish- hemisphere of bilinguals (Paradis. Using fMRI. and Hirsch (1997) using 12 adults who spoke words or sentence types (inconsistently from day to day) but six different pairs of languages. Perani and left caudate nucleus. & Bava. & Cappa. to control of selecting and switching appropriately There are fewer fMRI studies of comprehension tasks. Halsband. including those in the left caudate other explanations for the results cannot be ruled out. Antonello. Translation from L1 (English) to L2 (French) of only one language may be available at certain times. and thalamus in sev.. retested in the same language. Milner. Magloire.. 1996. Also fMRI and PET. Less overlap in Broca’s area was observed for the six pairs. Some authors have tion is made of knowledge of additional languages. 1998). studies fail to provide adequate descriptions of the participants’ . For the six early bilinguals. but backward translation (L2 to L1) gesting that different languages draw on different micro- did not (Klein et al. Sipilae. Somewhat different patterns of results have also been Milman. word production in Mandarin/English bilingual adults acti. 1998..GRBQ344-3513G-C09[245-276]. bilingual’s two languages. overlapping areas of activation for L1 and L2 in Wernicke’s We are only beginning to map the localization of the area for all subjects. 1991). and Lee (2003) found some overlapping a study that found that the degree of non-overlap for partic- areas of activiation but also differences in activation in the L ipants’ L1 and L2 was no greater than what they call the prefrontal and L temporal regions during a word repetition “run-to-run variability” inherent in fMRI testing. 1986). 1994.qxd 1/21/08 11:48 AM Page 251 Aptara Inc. these studies have shown that the left-hemisphere who learned French at an average age of 7 years found that areas activated when listening to stories in L1 and L2 vary the two languages activate overlapping regions in the left with the age of acquisition and with the level of proficiency hemisphere (Klein. 1997. 1995).language searches [synonym 1998). 1990. between languages (Abutalebi. “Within. in L2 (Dehaene et al. 2000. There were differences Subcortical aphasia similar to that reported in unilinguals in activation in the left frontal and parietal temporal lobes has been documented following lesions in the left putamen. Dapretto. Teraes. & Cappa. translation of single words] involve similar dis. bilingual aphasia in Mandarin. Using French/English and Italian/English bilingual Initial PET studies of English/French bilingual adults adults. 2006). Most studies that compare areas vated the same regions within the left hemisphere in both activated in two or more languages fail to consider what the languages. This was true for early bilinguals (began L2 by difference in activation might have been if participants were age 6) and for late bilinguals (began L2 after age 12). Activation of Hernandez. what we see in unilingual patients who can produce some Relkin. internal capsule. ily Catalan (n  5) in their daily lives. Mahendra. Plante. Perani et al. Comprehension and production of tones are (2003) tested two groups of men (all very proficient bilin- dissociable (Gandour. Packard. 1997. Chee. Tan. Chee. 2000. Individual differences in anatomy and local- using fMRI. 1996. and not necessarily to other test-retest reliability. Second. that interference remains uncertain” (2006.qxd 1/21/08 11:48 AM Page 252 Aptara Inc. 2005. Several studies behaviors. 2004. How the testing tasks are pre- stronger in one direction than the other. Before interpreting called “cognates” (e. but individual patients do not necessarily speakers are still being identified and debated (Grosjean. gender. Münte. The tasks studied include reading aloud. Lemhöfer & the assessment. than for non-cognates (see above reviews) and processing of Being late may indicate a lack of motivation. Naming of cognates function problems. The assessment is a cyclical process of observing. Sanchez- across studies. the patient’s the direction of between-language effects are influenced by understanding of why he or she is being tested. and categorizing words (Altarriba. it is clinical work. First. or simply a different view of time. one must conduct a valid. often helpful to observe the patient and family. . The assessment of aspects of language. & Caramazza. the level of proficiency of the sub. 1999. do in bilingual aphasia. lexical decision. de Bleser. standing how the two languages are functionally connected. Bos. 2004. language phenomena. Other is more accurate than non-cognates for both normal adults behaviors that are easily misunderstood include eye contact.. Dijkstra & Van cognates for all tasks (Goral et al. The strength and sented (direct versus indirect commands). these findings suggest that cues in one lan- in fMRI studies “the cognitive meaning of the signal guage may assist word-finding in the other. de Groot. Prior to the assessment.g. lemon and limòn). the macro. & Van den Eijnden. age of acquisition. Just as important for clinical work is under. anxiety about coming to the clinic. or interfere with responses in another language. problems. 1999. prognosis. when possible. This is difficult to tion) and cross-language interference. consider all show that priming between languages is greater for cognates possible reasons for the behavior. appropriateness of the clinician’s age. comprehensive. interpreters. the results apply to ture. translating Culture single words. Van Lancker Sidtis goes so far as to say that Clinically. Therefore. Springer. 285). body lan- 1998). factors spe. as outlined below. 1992. During the assessment and treatment. executive- cognates (Lemhöfer & Dijkstra. 2006). who assess and treat bilingual aphasia. The remainder of this chapter will Understanding how languages are stored neuroanatomically outline these. 2002. the number of about the patient’s and family’s reaction to the communica- “neighbors” (words with similar spelling and/or pronuncia. To plan appropriate treatment. 1995). 1993.and microcultural history of the patient and cific to bilinguals have been identified. 1992. How neural representa. Snodgrass. Casas & García-Albea. give the tion) in one language affects lexical decision speed in the patient and family members choices. and part of the bilingual lexicon. transportation cognates is faster and/or more accurate than it is for non. Costa. Roberts & Deslauriers. then Synonyms with a very similar form in different languages are interpreting. In most studies. The linguistic demands and neurologic activ. notifying the clinic to cancel an appointment. the priming or interference is guage. such as frequency or length of the words. greetings. dozens of studies show bilingual patients also includes determining the impact of that reading or hearing a word in one language can facilitate the aphasia on each language. & Rodriguez-Fornells. and those with aphasia (Ferrand & Humphreys. tion disorder. especially apparently negative ones. including the bilingual neighborhood effect and the influence of cognates. across languages should be monitored. 1992). Heuven. 2003. There are problems related to cul- gle words. The literature on culture and on bilingualism has impli- Functional Links Between Languages cations for clinical work. p. Chen. Miozzo. including cultural ones. and reliable assessment. All of these factors. level of bilingualism. These studies use sin. Nonetheless. achieve higher scores on cognate words than on non- Li. except the first. These factors may include the perceived Dijkstra. & ity associated with the experimental task(s) in unilingual Burk. Stadie. Van Hell & de Groot. For inpatients. 2004). the clinician should learn enough jects in each language. usually nouns. based other language (Grainger & Dijkstra. the prime and the target. and what is factors such as the length of time (in milliseconds) between expected of him or her are also important. 2006). and that in selecting tion of the two languages relates to symptoms. similarity of the words in each language is a factor. researchers have studied cross-language priming (facilita. or stimuli. available tests. What are the links or relationships between languages that may be exploited in treatment? ISSUES IN ASSESSING BILINGUAL APHASIA In exploring how the two languages are organized. or dress. and examine the challenges facing clinicians is important. and the stimuli about a patient’s background to know which aspects of the used. Cultural factors can influence the level of cooperation with Borgwaldt. the on cultural factors. the client’s behavior. come into play in clinical process might be problematic. race. and to con- In addition to the usual factors that make stimuli easier or sult with the social worker and nurses to learn more about harder. the clinician should be aware of possible cross- rehabilitation for aphasia has not yet been addressed. 252 Section II ■ Principles of Language Intervention language history and proficiency to allow comparisons Kohnert. tone of voice.GRBQ344-3513G-C09[245-276]. 1998. . Some authors use a five-point or seven-point with tradespeople. it is impossible to know precisely what the domains of use.” For many people. with a little flexibility on bilingualism into account in interpreting their ratings. and assess the patient’s level of bilingualism. 1995. Patterns of use for each language: Knowing which lan- account the patient’s premorbid level of bilingualism. 1989. The guage was used in which situation helps to determine psycholinguistic studies of bilingualism show that the speed the importance of each language for the patient. patient’s abilities may be influenced by the family mem- Cheng (1996) emphasizes how difficult intercultural com. 2000) with reasonable levels of use: family. In a study of 72 immigrants from six dif- patient’s premorbid abilities were. and com. (Langdon. Instead of ground. 1999). patient’s culture. The clinician and the patient do not have In trying to establish the patient’s premorbid level of to be from the same culture.. patient was exposed to each language may suggest treat- including verbal fluency (Lafaury & Roberts. ber’s own level of bilingualism. Acquisition history: Knowing how and at what age the mance on a number of tasks used in clinical work. guage-use questionnaire. Roberts & Le Dorze.” and the interacting that the patient finds culturally acceptable. one might refer to Langdon et al. and language(s) will be needed poststroke. most of whom had lived in Australia tic literature as a guide. treatment process. Wallace. dealing with scale. hobbies. Self-ratings: Adults can rate their abilities in each lan. 1998). When asked if ical process. and take their own But working with CLD clients can. different domains often suggest a high level of . gestures. work well. Our goals should be to under. A all sides. giving/receiving gifts. Using the psycholinguis- ferent countries. dealing accuracy.” Decisions about testing and treatment must take into 3. Wiig.GRBQ344-3513G-C09[245-276]. accepting guals. A child who grew up speaking Sjardin. bilingual means perfect munication style that will have the most impact on the clin. & Nielsen. 1997) and “grammar rules” or the names of verb tenses if English picture naming (Kohnert. cultural back. Others ask subjects Within these domains. business/work. For aphasia assessment and treatment to English may be very critical of an immigrant parent’s work. 1997. It is important to ask sufficiently detailed questions that are clinically appropriate. Published case summaries demonstrate wife who speaks little English may overestimate her this (Holland & Penn. 38 specific tasks were identified. Baker (1995) has shown the importance of assessing Unfortunately. a nonjudgmental view. use of L1 and English. race. and even level of ability in English did not correlate guage for various types of tasks (Albert & Obler. bilingualism. medical. The acquisition history and pat- One group study has used self-rating of premorbid terns of use both provide indirect evidence about level abilities by adults with aphasia (Roberts & Le Dorze. Ratings of the good clinical problem-solving skills are essential qualities. there was a wide range of patterns of tion to arrive at an estimate. and public transportation. while patient will be incorrectly identified thereafter as unilin- still allowing the clinician to offer assessment and treatment gual. While this identified groups of balanced bilin. and to ask the questions in patients no matter what their language. it is best to avoid the use of the word stand the aspects of each patient’s beliefs. and equal proficiency in both languages. obtaining separate ratings for each language the legal/government system. “bilingual. acquired informally. Whitworth & husband’s abilities. the effects of cues. 1997. Hernandez. “How was his auditory comprehension in ___. 2. and being active or passive in the adequately examined. view. Early acquisition and extensive use across 1998). Roberts & Le Dorze. Chapter 9 ■ Aphasia Assessment and Treatment for Bilingual and Culturally Diverse Patients 253 asking or not asking questions. 1993). . 1978. to directly compare their abilities in each language (de Baker’s list of tasks makes a good starting point for a lan- Groot & Poot. terms the patient and family can understand. Flexibility. of proficiency. the patient can be supplemented by asking the family to derful experience. values. & Bates. Ratings by family members: Information provided by Dealing with CLD patients and families can be a won. indicating yes/no. (L2) was learned in a classroom but not if it was Roberts & Bois. ask more than one person. or ethnic origins. enced by the level of proficiency in each language. For example. 4.qxd 1/21/08 11:48 AM Page 253 Aptara Inc. and how easily misunderstandings can occur. religion. Subjects identified 10 domains of Hamers & Blanc. This goal applies to all before deciding on a rating. Length of residence in Australia 1. with patterns of use. 2005. 1997. choice of performance on a given task or aphasia test has not been topics for conversation. they will say “No. 2005). To obtain an accurate munication is. ment approaches. 1998. friends. We can then be creative in developing ways of the patient is bilingual. shopping. one can use four types of informa- for over 10 years. the clinician need not master all aspects of the less-than-perfect abilities. how well self-ratings correlate with individual or refusing food. what and accuracy on many language tasks. Both types of self-rating correlate with group perfor.” ask “Could he understand the news on the radio? people Level of Bilingualism talking at work? people who spoke quickly? people with different accents?. and what vocab- the amount of interference between languages are all influ- ulary may be used for which types of treatment tasks. The resources and policies of tern of recovery and neurological. he or she may not determination. Interpreters should be used only if It is important to remember that the basic principles of there is no speech-language pathologist (SLP) available who test design (validity. gathering information about the patient’s premorbid Given the time and expense required. interpreters may inadver. the diagnosis. the speech and language assessment instruments. size or origin of for all patients. as well as the treatment goals set for the gualism. & “spoke ___ perfectly before his stroke. its pitfalls. Martin et al. techniques. for specific languages as full. inter. role. etc. Family members who have close ties to the patient may preting the results (separating premorbid characteristics find it distressing to see the full extent of the deficits from the effects of the aphasia).or part-time staff. Friends or members of the patient’s history questionnaire covering all three of these dimen. 1998). Unfortunately. and given the prob- bilingualism can the clinician estimate their poststroke lems in achieving reliable results in assessment. stating: “With the increasing cul- preters in test administration. and acqui. its patient’s use of his languages. Without this assess- establish a prognosis specifically focused on the bilin. 254 Section II ■ Principles of Language Intervention proficiency. and with norms for specific that the clinician does not master (see ASHA 1989 guide. and any relevant example. explored. exposed. 1995. these can be explored. role is not available. such as speech and language in many subgroups defined in terms of the nature of errors. does not allow us to predict is that patients must be assessed in all languages they use on patterns of impairment (L1 vs. To adequately assess patients with bilingual aphasia. is it worth language impairment and plan appropriate treatment. or for a specific purpose. 1996. Langdon. an ble. Ozolins. if a patient says “now talk hard . linguistic. language structure type. nor to a regular basis. Even with training.” (2002) (http://www. type or severity of aphasia. Despite the existence of a large number of always be aware that this has happened. however.” but this lan. sions). Because the SLP does importance to clinical diagnosis and the process of disability not speak the language being tested. each clinic will determine whether this standard is reached mental or linguistic parameters: not site. For requirements. Before ahrq. apply to all aphasia tests. etiological. we still lack clinician cannot be certain that the interpreter is reporting appropriate instruments for reliably and validly assessing all the relevant aspects of the patient’s performance. experi. p.S.qxd 1/21/08 11:48 AM Page 254 Aptara Inc. and therapy tural. its limitations. Only by assessment. If there are discrepancies between the working with interpreters—either volunteers or paid staff— family’s assessment of the patient’s abilities. When a professional interpreter or aide trained to fill this tle-used languages. using an interpreter? The consensus in the current literature This information. family can be used if they are trained by the SLP for this sition is important in deciding what areas to assess. communication disorders. and racial diversity of the U. population. may be inappropriate. These include tests that attempt to meet the needs of CLD patients.no The person chosen as interpreter must also be acceptable to talk good. Langdon guage was rarely used. this discrepancy should be & Cheng. assistance to the patient. Vasilakakos. 1992a.” this could indicate nonfluent aphasia or the patient. “No correlation has been found between pat. interviewing. Such tests should be as free of cultural bias as possi- lines for the level of proficiency needed for clinical work). patient. and the clinicians should familiarize themselves with the process.GRBQ344-3513G-C09[245-276]. 1995b. a clinic may hire interpreters addressing these serious deficiencies.. or cultural differences. including translations of existing vantages associated with using interpreters. interpreter can be used. research funding and priorities should be directed at When demand justifies it. groups. There may be direct costs for the inter. ment.htm) . and available for regular treatment sessions. The difficulties locating an interpreter who is able to spend the (American) Agency for Health Care Research and Quality time required and who is able to fit into the constraints of has identified the need for development of better tests for the patient’s schedule. which are not covered by health insurance. language. 2002. and the time needed to train inter. L2) or recovery. we need a range of tests that are reliable and valid with demonstrated Using Interpreters sensitivity (to detect changes over time and to discriminate When a patient must be assessed or treated in a language between levels of impairment). Kayser. reliability. For example. if the family or patient claim that the patient legal restrictions or policies (Gentile. Furthermore.gov/clinic/epcsums/spdissum. Thus. use. lesion.) speaks the patient’s language(s). members of the patient’s community or Information on language proficiency. especially given the potential attrition of lit. dialect. This is because of the disad. They may also be more inclined to provide cues or ment (see Roberts & Shenker (in press) for a language. we do not yet have such a range of tests. type of bilingualism. 211). future preter’s time. who are members of different subpopulations is of crucial evant details of the patient’s response. religious or community groups can often be more detached. or factors related to acquisition Testing in Various Languages or habitual use” (Paradis. adequacy of norms. the applicability of assessment instruments to individuals tently alter the test stimuli or protocol or fail to convey rel. available for the time needed to complete the could be close to his prestroke level of English. and in planning treat. The Boston Diagnostic Aphasia Examanation (BDAE) The Multilingual Aphasia Examination The BDAE is widely used in English. that the authors consider culturally appropriate. too often.medicapanamericana. should score 100% on most subtests.g. study. sia. 2000). 1991) and English (MAE-E) test in its design and performance and was judged unsatis. Detailed descriptions of very general patterns such as “seemed to do well on these the BAT’s rationale.gov/clinic/epcsums/spdissum. In one meaning or nuance across the different languages. Medical Panamericana in Argentina and by Masson in Sivan. development. normal speakers be used. Thompson. 2004) and in Spanish (Paradis & Libben. and administration tasks” or “low score on this set of items. clinicians may have little choice. Chapter 9 ■ Aphasia Assessment and Treatment for Bilingual and Culturally Diverse Patients 255 Many clinics and many published studies use in-house Spain. 1995) may According to Paradis and Libben (1987).GRBQ344-3513G-C09[245-276]. clinicians and authors then use these The Bilingual Aphasia Test (BAT) developed by Paradis and tests to compare the severity of the aphasia across languages his colleagues is specifically designed for bilinguals. and the Aachen (Manuel-Dupont. particularly in directly from its author (see Appendix 9-1). countries where no one has developed aphasia tests in the Each version of the BAT uses vocabulary and pictures range of languages needed for patients in that country. (Benton. to use them to diagnose aphasia or to identify a type of apha- 1987. Rosselli. sions have been published over the past 15 years by Editorial sensitivity. Rivas- factory on psychometric grounds in a recent review (http:// Vazquez. mean group scores were below 70% on 54 items of the short guage backgrounds. Frattali. Ardila. In all cases (published or unpublished version of the BAT. a section within Harcourt Assessment/The affairs is due partly to the reluctance of publishing houses to Psychological Corporation). the ASHA English-language journals (or in the other languages Functional Assessment of Communication Skills (FACS.htm). however. included in data bases such as PsychInfo and Medline). also has a section that tests translation abilities between there is no way to interpret the obtained scores. it is not necessarily an ideal (MAE-S) (Rey & Benton. Nonetheless. Holland. validity. or L2 speakers with 400 or more hours of patients from a wide range of cultural backgrounds. 1992). Clinicians and researchers have little choice but to develop their own tests. & Benton. It is currently available translations of published tests (e. tests). is on tests such as the BDAE or the WAB but with no refer. Cuban background) did not score icians in North America have limited choices: the Boston within the expected range for normals on six of 24 subtests Diagnostic Aphasia Examination. No longer commercially published. faced with the need to assess 1993). The Bilingual Aphasia Test However. & Ferketic. two studies of Spanish-English bilingual speakers in Texas tions. 1999). and split-half performance with children (Schum. There are no studies documenting the equivalent difficulty ability and validity of these tests. to the individual clinician.” It is inappropriate instructions are available in English (Paradis & Libben. Similar Aphasia Test all have published versions in various lan. It falls instruction. is available only in Spanish & Barresi. This test. Thus. 2004). However. but its availability has varied. with the potential for poor translations and changes in and in Florida suggest that this may not be the case. It reliability. In-house translations of these and other tests are a group of 22 Spanish-English bilingual older adults. published To assess the patient’s or family’s perception of the impact of normative data for most languages are not available in the aphasia on the patient’s communication. Rey. available from ECPA (Editions du Centre de Psychologie ence for the test in the language of the study. Radanovic. 1989) and with English-speaking adults . Its test items are designed to be suitable for use with of each language. & Sivan. however. a group of 14 Spanish-English bilingual adults (mean To assess the linguistic abilities of bilingual patients. published in 2005. and sensitivity data on these instruments. The often available in clinics that see patients from different lan. On the other hand. the Bilingual Aphasia in Spanish (L1) and on two subtests in English (L2) Test.5 years. the Multilingual Aphasia Examination. Hamsher. beyond a more than 100 pairs of languages. Each version has been “normed” on a sam- ple of native speakers of each language. & Puente. 22 on the Spanish section of the test. Spanish ver. and tests all language modalities. results are reported by Muñoz and Marquardt (in press) with guages. or their own translations of published tests. despite its name. clin.. The manual provides informa- accept tests that will have relatively small potential markets. Scaff. Without even basic in over 60 languages. This state of Appliquée. Feldman.com/. 1994. clinicians need to be aware of the widely varying reli.qxd 1/21/08 11:48 AM Page 255 Aptara Inc. Wohl. to translate the ques. It exists or to measure improvement over time. The con- tent is modified somewhat to assess different features in dif- Published Tests in Various Languages ferent languages. discrimination. of various versions of the test in different languages or its test-retest reliability. Its manual and a series of www. Paradis. tion on a normative sample of 207 adults.ahrq. Kaplan. Mansur. Levin. & Benton. it is available patients. education 14. Its revised versions have provided additional normative data (Goodglass. studies are published that present data A French version of the BDAE. & from http://www. publications provide data on its reliability. name-agreement for some stimuli. Willmes. 1996. However. and Tomoeda (1996) 1965). 2000). languages (see Roberts & Kiran. and gender in elderly Dutch-speaking for each language. Other studies ing it difficult to compile an accurate listing at any point in find that African-Americans score below Caucasians (e. BNT. but it has demonstrated validity and reliability. but some work has Australia). education. across languages and.. English speaking immigrants in North America or There are fewer studies of other tests. results are mixed. In each case. The following (incomplete) (WAB) (Kertesz. WAB).qxd 1/21/08 11:48 AM Page 256 Aptara Inc. However.testzentrale. apparently. & de Bleser. experimental versions. Schum & Sivan. D’Agostino. Armstrong. 1994). a test from Italy to test Italian. Belgians (many of whom were likely to be multilingual.de). Some tests assess a spe. in detail. some have shown no difference in BNT scores across However. others at severe ones.. Thus.. Hickson. Tsantali. and studies reporting results obtained with guistic group. de Bleser. and paragraph . time. A Greek www. They recommend al. 1983) the Western Aphasia Battery how much is yet to be done.. Silbershatz. 1997.. therefore.. Abramson. retained all 60 items 1992). 256 Section II ■ Principles of Language Intervention (Elias. 1982). A number of studies Boston Diagnostic Aphasia Examination (BDAE) have been done. the test is fairly robust. range of tests exists for bilingual aphasia. The equivalence of this test other studies. Mampaey. However. The authors do not these were Animal Naming (BDAE. its suitability for use with The unmodified BNT was sensitive to age and education bilingual adults remain untested. Barrett (1995) found two of the 60 items are not familiar to including test-retest reliability. standardized on 234 North American Spanish speakers There are many studies on the Boston Naming Test (Spreen & Strauss. No such However. Lichtenberg. limit the usefulness of these findings. clinicians need studies of their reliability and been done.. each patient can be converted to stanine scores. some aimed at detecting mild suggests that despite cultural factors and problems with impairments. & de Bleser. & Kazis. Baker. 1998). 1991) is suitable subtests of expressive language. There are also a number of stud. 1995. Lekka. & Weintraub. Of those studies of African-American performance on the vious version of the current chapter (Roberts. 2001). the scores of African-Americans were below those of found that the Arizona Battery for Communication Caucasian-Americans (n  24 of each) on only three of 26 Disorders in Dementia (Bayles & Tomoeda. Differential Diagnosis of Aphasia (MTDDA) (Schuell. The 1996) (see www. such as reading. 1992. and/or go out-of-print rapidly. Ivnik et recommend changing any stimulus items. T-scores. age. although this is not noted) (Mariën. version of the test has. different cut-off scores must be estab- versions in more than one language. some of which have do not apply. Molrine and Pierce (1998) found that on the validity (Ardila. allowing comparison of each patient (Doucet & Roberts. there are Roberts et al. for use with speakers of British English. There is also an unpublished ate. An experimental version in Korean “BNT” has so many changed items that it no longer English was developed and its properties found to be satis- resembles the original test (Kim & Na. A list of a number of lished for different age and education levels within each lin- these tests. Ross. Yiu. & Wolf. and America. 1999). studies of bilingual adults (Kohnert et al. Weniger.g.it). 2002) show that the unilingual norms clearly tests developed in different languages. Poeck. For upper-SES subjects. Clinicians assessing aphasia in unilingual patients can draw Tallberg (2005) found a significant effect for education. In Swedish-speaking adults. Borthwick. (Tsolaki.” further complicating comparisons across these and Portuguese version of the test. Tests in Other Languages and Dialects Saerens. When the BNT is used in English with different cultural The AAT is not familiar to most clinicians in North groups. This on a wide range of tests. Scores differed significantly with to the (unilingual) normative sample the test was based on. French versions of the BNT. Garcia. small To use tests designed for one group to assess members of sample size and failure to control for or to report education another group (for example. 1999). races when age and education are controlled (Henderson. & Houston. Desrochers. Elias. (BNT) (Kaplan. 1993). but the English authors used different definitions of “culturally appropri- version has not been published. the item difficulty is not the same as in the English version (Roberts. & Willmes. 2007). and the Minnesoa Test for review highlights some of the issues. & De Deyn (1998). Kiosseoglu. and Italian (Luzzatti. & Willmes. Goodglass. was included in the pre. The Aachen Aphasia Test & Hernandez. 2002). Pigatt.g. The Spanish version was using the American norms. Rey et al. mak. In Spanish and 2001). Willmes. 1995) and in 45 unilingual French Canadian subjects and to percentile ranks. 1983. Worrall.osnet. but Tallberg (2005) found no items had to be German (Huber. unpublished. many of these tests are not available commercially. were never published. & Christensen. cific aspect of language. the results of in English-speaking Australian subjects (Worrall et al. 1983) in various ies of its psychometric properties in Spanish (e. see removed for cultural reasons for Swedish adults. Published versions exist in Australians. 1998. Frank. 2003). Dutch (Graetz. they illustrate how complex this area is and (Goodglass & Kaplan. 1997). factory (Miller. 1998). Vervaet.GRBQ344-3513G-C09[245-276]. Bayles. but not in definitions of symptoms or syndromes to other languages. We cannot some symptoms of aphasia vary across languages (Menn. and income to a speakers (Goggin. preted with caution. two-month. This information is essential to allow readers to they used the patients’ cultural peers as context for assessing know to whom the results of a particular study may apply and interpreting the naming deficits of their six patients. Assessment results must be inter- month. the scores for the African-American group would study. Sasanuma. If credit had been given for 2002). changing several dimensions of the task. patients (Weekes et al. Marshall. but incorrect tones. 1989. pitfalls associ. 1991. Laiacona. 2000). Still others may prove entirely Sasanuma. Sasanuma.. This has been shown in syntactic deficits (Bates & English speakers as unsuitable for use with other groups. and must take into account the features Spelling is a challenge. Tzeng. Other tests need specific stimuli. 2006). 1998). cover a word-finding problem). and to permit comparison across studies and appropriate given the unavailability of a published naming test for generalization of the findings. These translated. patterns similar to those reported in English-speaking ated with using ad hoc translations of subtests or tasks. ments of the two languages and interlanguage must both be Spelling. and Pring (2006) devised a naming have been higher. Estrada. study has found that the frequency effects so well docu- gle category used in the verbal-fluency test (Animal mented in unilinguals may be absent for bilingual speakers Naming). but not in Spanish or Italian because of their highly regular competition between the processing strategies or the ele- phoneme-grapheme correspondence (Ardila. exists only in languages that use an considered when determining what is a clinical symptom alphabet-based writing system. Because knowledge is dependent quoted in Wallace & Tonkovich. reject all tests initially normed on white. Croft. Thus. With 12 subjects for each SES level and only a sin. Chen. and a very familiar task in English. Allamano. and language history of 20 nonaphasic members of the same community.qxd 1/21/08 11:48 AM Page 257 Aptara Inc. (Lehtonen & Laine. Luzzatti. or Obler. 1991. which may have implications for how naming and responses that were correct. Name agree- performance on the MTDDA in a group of 15 African. studies. changed. Nilipour & Paradis. Cattani. frequency of use may be much more idiosyn. & Holland. Bates. Ferreres & patients. & Luzzatti. Zonca. Menn. making the deep-dyslexia to guide them. these results are preliminary. 1998. 1998. word reading cratic and less predictable than in unilinguals. 1980). . At least one (BDAE). Symptom lists generated to . Some tests. inappropriate. ing to be appropriate. of the patient’s (other) language or dialect. Some apply. 1986). matched for age. and what is a premorbid feature of bilingualism. Through rigorous validation and normative 1998. including acquired dyslexia Tasks can change in nature and in difficulty when they are (Toraldo. illustrate that the answer to the question “can existing tests A further challenge in assessing CLD patients is that be used with CLD populations?” is complex. For example. Chapter 9 ■ Aphasia Assessment and Treatment for Bilingual and Culturally Diverse Patients 257 retelling (MTDDA). . The studies done to date Bengali-English speakers in England. 1995. Li. 2000) and is not limited to CLD able to some other languages (Ardila.. Roberts et al. and many subtests in existing batteries. The use of nonstandardized evaluation tools and surface-dyslexia patterns described for English inapplic- is widespread (Katz et al. Mandarin (Chinese). commonly seen in aphasia in English and several European languages. The noun/verb dissociation. nouns that are high-frequency and short also error types that are possible in some languages but not in one language can be low-frequency and multisyllabic in in others (correct phonemes. There are crimination tasks. p. three-month . education. O’Connor. this study also suggests that test test for Bengali-English bilingual aphasic adults by selecting performance can be very similar across CLD groups. 153) found statis. ment is lower for bilingual speakers than for unilingual Americans. groups. & Opie. Other studies report interpreting these results. 1995.” (Naeser & Chan. Wulfeck. are prov. counting and reciting the months studies demonstrate that one cannot apply all English-based of the year are different tasks in English. since the months are called “one. some do not.GRBQ344-3513G-C09[245-276]. without norms of errors vary across languages. education. 1997. Saletta. group of white subjects. 2003). Menn. we cannot assume that all bilinguals tically significant but not clinically significant differences in know “simple” vocabulary in both languages. 1990.. In naming. 1994. There are also studies of read- using their own translations of published tests or in-house ing deficits that suggest that the frequency and/or the types translations of various tasks on CLD patients. & MacWhinney. wrong another language. or auditory dis. In a sense. 1989. clinicians will continue their current practice of 1998. & Inzaghi. 1998). Menn & Obler. with and name-agreement data obtained from a control group of complete data on the age. 1986) and for deep and surface dyslexia (Ardila. and. scoring procedures. 1986). Chen & Bates. but given in nonstandard other lexical retrieval tasks are scored. For bilinguals. & Villarreal. gender or case for nouns. native 2001). for middle-SES. is difficult to assess Informal Assessments and In-House Translations in Chinese. however. Clinical judgment is an important component in Miravalles. 1995. De Tanti. Law & Leung. 30 pictures out of a possible of 150 based on naming-latency More studies of CLD test performance are needed. Wulfeck. Huntress (1979). middle-class. In an innovative English. we will learn which is which. creating a false cognate word to For bilinguals. where many words are noun-verb compounds Until we have more data and more norms for various patient (Bates. of course. participants. on domains of use. There are. and Le Dorze (1994) have shown that on semantic verbal flu- ency. For combines with the idiosyncrasies of the aphasia each patient example. or oral vs. This is not will be impossible to develop rigorous tests for bilingual parallel impairment. ified Paradis’ list somewhat. One purpose of the assessment is to determine the impact of ability are obtained when results of several connected-speech the aphasia on each language. Parallel Clinicians can sample or test some tasks twice in each lan- impairment is determined in relation to premorbid pro- guage for each patient to provide an indication of within- ficiency. the U. Test-Retest Reliability and quantify the language impairment in order to support funding for therapy and disability claims. If the patient mastered both languages equally language variability that can guide the interpretation of premorbidly. most unilingual English speakers scored large subgroups of bilingual individuals. insurance companies. individual scores may increase or decrease by more than 30%. invest the time to develop and assess them adequately. Paradis & Libben. 1993a. 1992). 1989. separating impairment from Interpretation/comparison of scores on different languages is recovery. but differential impairment spoken by people living in many countries. a dif- ingful norms. if we. Differential impairment: one language is more severely lated that it may be impossible to devise any kind of mean. 2002). without seeking to draw strong conclusions not to the degree of deficit. and the pessimists. the same manner and to the same degree. Roberts attempt to develop such tests. On the Graded Naming Test. There may be parallel impairment priate. The calls for evi- When a patient is tested twice or more. interpreting different scores between languages (see Roberts 1987). governments. a debate is going on between the optimists. at least for guage.. The were approximately equal premorbidly. Differential aphasia: this refers to the type of aphasia. Canada. 2.. Spanish may have been stronger than English experiences. One possible (pessimistic) conclusion is that it prestroke. for example. 1998. clinicians should be cautious in patterns (Paradis.GRBQ344-3513G-C09[245-276]. Monsch et al. a longer sample. Because aphasia can in informal evaluations will often yield more reliable results. On the BNT. the two are equal. accurately diagnose.. damaged by the aphasia than the other one. I have mod- (1998) and Roberts and Kiran (2007) for more on this). Using the complete test. about the severity of the aphasia or to classify it. On the toms in other languages. the level of ability will be equal post-onset. To therapy on the most valid (accurate) test results possible. given the impact of language proficiency and ference in proficiency may exist between languages that dialect on each individual’s (prestroke) performance. and cultural/linguistic backgrounds than the 1. and more exemplars so in cases of parallel impairment. The Test Mess the most accurate way to use this label is to rate each There is a lack of culturally and psycholinguistically appro.S. 258 Section II ■ Principles of Language Intervention describe one language do not address many possible symp. Some have even specu. as a profes- within 1 point on retesting. and employers raise the need to identify. it remains the shortened version. or norms based on samples with different edu. and expanding and commenting on the definitions. guage functions. Or. a premorbid individual variability that is part and parcel of bilingualism difference may have been erased by the stroke. modality separately. More accurate scores and less TRT vari. interpret possible between-language differences. Differential aphasia exists . affect some aspects of language more than others (com- prehension vs.. but some changed by 3 or 4 sion. once in each lan- dence-based practice (EBP) motivate clinicians to base their guage. To facilitate clinical use of these patterns.qxd 1/21/08 11:48 AM Page 258 Aptara Inc. 1994. Brookshire and Nicholas (1994) found significant Patterns of Impairment and Recovery variability on retesting using the picture-description task in Bilingual Aphasia from the BDAE. range of tasks that allows clinicians to explore various lan. The best we can hope for is to develop a greater impact on Spanish. because the aphasia has had a adults with aphasia. Reported Types of Impairment in Bilingual Aphasia cational. Paradis has identified and labeled these within a given language. the question of test-retest (TRT) reliability arises. and tests with no pub- lished norms. but poststroke. U. Parallel impairment: the two languages are impaired in patient being tested. written language). usually exceptional. between-language differences. including the in reading comprehension. particularly difficult when using tests with unknown test- retest reliability for individual scores. we need to Thus. rigorous tests of aphasia in the range of languages in auditory comprehension. and India. other hand.K. points (Roberts et al. The patterns of impairment tasks or several verbal-fluency categories are combined and recovery in bilingual aphasia have been described in (Brookshire & Nicholas. Until individual. age. 3. 1983). who argue that the combined complexi- Roberts (2003) found less individual variability and a group ties of bilingualism and aphasia make it unrealistic to mean improvement of 1 point (out of a score of 30). expression. not If one language was stronger than the other. who argue know the normal variability on retesting within a single lan- that psychometrically sound tests are possible. Thus. patients since the 19th cen- there are more data on the variability of individual scores tury (Paradis. 117). and other remains at its premorbid level (Paradis & written expression. (Crary. 1982. 2003). to the extent that progress occurs in the other language. it can reported by Albert and Obler (1978). This variant is also called wide range of languages. Blended or mixed pattern: “patients systematically mix 1995. 1997. (Paradis. 1995. and/or maximize guage appears to have reached a plateau before any real the use of residual abilities. Selective aphasia: only one language is affected.GRBQ344-3513G-C09[245-276]. when this reflects premorbid proficiency (Nilipour.qxd 1/21/08 11:48 AM Page 259 Aptara Inc. gual illustrates how the “strong” language can vary across tasks (Byng. 1998. In practice. the representing tendencies or general patterns. to avoid possible confusion with mixed given that aphasia can differentially affect each language aphasia. 117). or on observation of a few. Dronkers and colleagues (1995) have shown 1. these should be labeled as global aphasia in Hindi and Kannada. Given the comple- switching or mixing. 1989. Chapter 9 ■ Aphasia Assessment and Treatment for Bilingual and Culturally Diverse Patients 259 when symptoms differ across languages. relative to premorbid lev- credit is given for regional dialect. Of course. 1998). impairment. Some authors use the label “differential impair- guage and Wernicke’s aphasia in another. reading. it is not necessary (Paradis. Treatment and counseling generally tar- the label of successive recovery applies when one lan- get symptoms and language processing. 1989. Coltheart. Silverberg or blend features of their languages at any or all levels of & Gordon. & Riddoch. they must be used cautiously. and blending (1998). lexical and semantic) inappropriately” occurrence of additional lesion(s) (Moretti et al. and the speaking to unilinguals. 1993). 1993b. Masterson. nature of the test used (Paradis. verbal expression. and Wernicke’s parallel. Webster Ross. Charbel. 1988). nonrandomly . Gomez-Tortosa. In practice. 1995b). p. & Abidi. In a case determining the premorbid mastery of each language. the patient’s dialect. which is normal behavior in many mentarity principle. ment (Aglioti & Fabbro. Differential recovery: one language recovers better than ferent syndromes using the WAB and the BDAE in English the other. 4. first one language improving. & Deal.. ment” when one language is better than the other. Wertz. that is similar to Paradis’ antagonistic pattern was due to the syntactic. In some cases.” Paradis now labels this as and different levels in different language modalities. then the other (Nilipour The syndrome types described in English-. Non-CLD patients are assigned to dif- 2. labels are used.and German-speaking patients appear to exist in a Paradis & Goldblum. 1992).. aphasia is complex. Paradis. The validity of published been reclassified since the authors failed to take into account reports of differential aphasia has been questioned different symptom presentation in different languages. languages.. because of recovery. ratings of impairment should be done separately 5. The issue of classifying els. a multilingual be difficult to distinguish among the first three types of patient appeared to have Broca’s aphasia in one lan. & White. Parallel recovery: both languages improve at the same that the aphasia classification of a patient can change when rate and to the same degree. sociocultural factors (what is The patient uses this blended language even when a normal pattern for the patient’s peer group). This is not the same as code. even Bhat. 1984). phonological. Successive recovery: “one language does not begin to that attempts to classify CLD patients by syndrome will reappear until another has been maximally recovered” often lead to unreliable results. one cannot deter- to label an aphasia syndrome or patterns of bilingual impair- mine when maximum recovery has been reached. Selective recovery: only one language shows improve- to that in unilingual patients. with truths. Paradis. Chengappa. using in-house transla. 1989). Prior. & Ausman. 3. modality. these types seem clear. 1989). Martin. Many authors have attempted to explain nonparallel In theory. The literature contains proposals usually based on the problems inherent in testing bilingual aphasia and in speculation.e. found their 70-year-old patient had According to Paradis’ definition. The case of an English-Nepalese bilin- Goldblum. called “mixed impairment. There is no data about whether the “alternating antagonism. & Ashayery. French. In at least one published case. or (Dronkers. p. 1997.” or see-saw recovery. Some published cases of differential aphasia have aphasia in English and Tamil. Still. morphological. and given that bilinguals usually have bilinguals when speaking to another bilingual. Yamasaki. Gaviria. 1989. therefore. Italian-. It is not surprising. but ment or recovery. the pattern alternates. The few studies done thus far also highlight the need to Reported Types of Recovery in Bilingual Aphasia proceed cautiously in classifying bilingual aphasia by syn- drome type. and seen as 4. Kohnert et al. one patient no longer recognizes what words or features must carefully consider the symptom pattern of the specific belong in each language. Antagonistic recovery: as one language improves. did not use appropriate tests and bilingual norms (see Paradis. 1979). not absolute other regresses. and blends both languages. impairment linguistic structure (i. tions of the WAB. Initially different premorbid levels of proficiency in their languages. it is as if the Before labeling a recovery or impairment pattern. In these cases. incidence of these syndromes in bilingual patients is similar 5. and Padakannaya (2004). the for auditory comprehension. Goldblum. not labels. . Two types of first-learned and stronger language. There are also a number of published cases of paral. Lhermitte. the studies that have been done. 1989. have found equal improvement in lel impairment and recovery (Dronkers et al. 1997. one- patients in a New York City rehabilitation center. Penn & Beecham. Penn. of suggestions based on clinical experience and a review of Given that only four treatment sessions were given.GRBQ344-3513G-C09[245-276].g. Béland. Vaid & Genesee. Instead they found that “bilingual patients showed recovery macy. Kohnert (2004) pro- studies provide some guidance: studies of the effects of treat. & 1976. Penn. to a ment in various languages. the the symptoms of bilingual aphasia. the patient’s treatment and even less on appropriate methods. Junqué. suggestions presented below have not yet been tested for. ment principles that work in unilinguals often work in bilin. explain the whole array of recovery patterns. 2006. along with a liberal dose nate words in a patient approximately 15 months post-CVA. Clinical experience suggests Vorano. Wender. A study by Wiener. especially for expres- most common patterns. Hinckley Treatment for bilingual aphasia has been neglected in the lit. Paradis (1989) concludes: “no underserved (shorter treatment. 91). Watamori & Sasanuma. 1995.. fewer types of treatment) single principle or hierarchy of principles has emerged to and made less improvement than the unilingual patients. consecutive cases with 2 in Sasanuma and Park. or greater gains in the untreated language (L2) tendency to write-up the unusual or interesting patterns. This finding There is some support for this view in the literature (Chary. If their response to treatment is different. 2001. (Roberts.or that was virtually equivalent to that of unilinguals” (p. and a small number of studies of patient and found that while both languages improved. two or more languages following treatment in one language Mimouni. the mine the incidence of parallel and nonparallel recovery. and Taylor-Sarno the body of studies of treatment effects. or Roberts et al. The principles that guide between-language generalization and the maintenance of unilingual treatment are also relevant to bilingual treatment. Roberts et al. The participants in two of these studies (n = We need studies of unselected. Junqué et al. has been replicated in single case studies (Edmonds & 1986 quoting Nair & Virmani. Laganaro & that parallel impairment and parallel recovery are by far the Overton Venet. 1992).qxd 1/21/08 11:48 AM Page 260 Aptara Inc. these published treatment studies (Table 9–1). (2003) provided roughly equal amounts of therapy in Spanish erature. Some authors have interpreted a lack of generalization mally. vided very brief treatment in Spanish. 1978) and in group studies (Junqué.. or fairly equal proficiency vs. On the other ent areas of the brain. As we learn more about within-lan- hand. Roberts and Kiran (2007) point out a recurring flaw in guals as well. 1969 ISSUES IN INTERVENTION and Linke. or less post-CVA when treatment began. There are at least two other reports of greater gains in the untreated language (L1) (Durieu. The treated language The literature offers little information on the incidence may improve more than the untreated one (de Luca. 1995. 1992). Danault. Nilipour. sive language tasks (Sasanuma & Park. and vary widely in the level of detail and hence in does it mean that the two languages are processed in differ- their value in supporting clinical practice. especially after the first few weeks. length-of-stay. Vendrell. 1995. 127). we know that some unilingual patients do not generalize Effects of Treatment in Bilinguals from treated to untreated stimuli. 1995). nor automaticity. Most findings and results should be interpreted very cautiously. 2003). Vendrell. 1979 cited in Paradis. 2004 p.. stimulation pre. This does not mean that One the one hand. Obler. from one language to another as support for the view that the two languages are stored in separate systems. Sasanuma & Park. 1977. gains were both greater for cognate words than for non-cog- The following section presents these. and reasons for discharge for 54 unilingual and 55 bilingual late vs. 1997. bilingual treatment studies are few in the two sets of stimuli are stored in “different systems. affectivity. 2006. of each type of impairment. habit strength. Vendrell-Brucet. Culioli. 1995). However. Hécaen. and n = 1 in Roberts) were 3 months detailed language histories and thorough testing to deter. then in English. 1995). more published reports of nonparallel patterns. 55). & Idrissi. and the unilingual guage generalization. Neither pri. but found greater gains in Spanish. need. 1975. though they have proved effective in clinical practice. one or more of the patient’s untreated account for the non-parallel recovery patterns observed” languages improve (Edmonds & Kiran. After reviewing the various theories and authors expected to find that the bilingual patients were their supporting case reports. 260 Section II ■ Principles of Language Intervention selected patients. between-language generalization. Fabbro. severity of the There are reports that when only one language is used in aphasia. however. The language dominant). Little published information exists on the effects of and English. effects of spontaneous recovery cannot be separated from treatment effects. Other studies. appropriateness. because of a 1995). 1994. 1966. Therefore. type of bilingualism or type of aphasia could treatment or practice. 1988.. we will be better able to interpret treatment studies in a range of languages. 1995. identified as having different patterns of bilingualism (e. & Tabouret-Kelly. 1989). Paradis. early acquisition. 1980). Fredman. on expressive tasks (Edmonds & Kiran. There are equal improvement in receptive language (Sasanuma & Park. & Kiran. Vendrell.” Nor number. post-onset. 2006. and vice versa. suggest that treat. & Lovati. Patients are often (1995) documented the treatment outcomes. Holland & (p.. Dubois. design. ex on spelling. Ages Learned Information Treatment/ Authors. Overton old. 1 year Approx. studies. by age 8. treatment speed on lexical with daily home with slight Venet. linguistics. little GRBQ344-3513G-C09[245-276]. English No formal 8 months tests. Slightly stronger Anomia. 1997 4 years post. 2001 including French L3— lexical decision. 1 university English L2 proficiency” English only MTDDA and gains in TL 1976 degree. old. None Alexia. constant by self-report baselines BAT. blocks in devised for 8 weeks of blocks of studies. university. and reading. 1 hr. 3 sets of 10 total of 12 stimuli: strong Rhéaume. also sessions. 50 years Spanish L1. Howard Treatment in % correct on 3 times per week. equal Sasanuma. 4 modalities. de la n  1. TL in most post-grad deduced rhymes. approx. Japanese). decision and practice of advantage for unspecified not listed but categorization. Education. or First on Language Focus/Method Dependent Previous Date Time Post-onset Exposure of Birth of Treatment Design Variable(s) Treatment Results Roberts. TABLE 9–1 Studies of Bilingual Aphasia Treatment Greater Gains in Treated Language or Gains Associated in Time with Language of Treatment Languages Length and Known and Frequency of n and Age. 46 years French L1. & old. BDAE treatment for equal and CVA use of both French and past 2 years limited from age English generalization 5 or 6 to UL and to onward other stimuli in TL. “used with equal Treatment in Pretest-posttest Scores on Approx. post-gunshot wound (continued) 261 . alternating reading tasks approx. change in standard tests Watamori & n  1. plus from early but no rating (after 2-week modified PICA and UL for additional childhood reported trial in auditory comp. no gains in TL. word. 3 months stimulation greater gains post-CVA method in TL (English) on verbal and written expression Laganaro & n  1. 65 years Japanese L1. English L2. MA English L2 French in all 1985 phonol French only.qxd 1/21/08 11:48 AM Page 261 Aptara Inc. cues multiple words. building Spanish and this patient. computer Alternating % correct and Once per week Gains in both Ls. treatment 2 weeks engineer. For treatment Riva. no discourse. 14 weeks. no overall self. stimuli. none anomia Alternating BAT. equal and repetition. L semantic and naming task. old. English previous or other scores rating “equally treatment simultaneous reported. L2. Very incomplete Semantic Treatment in BAT Spanish Unknown Spanish naming Hinckley. ratings appropriate Ndebele discourse earliest. n  1. treatment not stated. Afri. most-used posttest priateness. qualitative treatment spoken and (prior CVA and 5 others. Afrikaans. TABLE 9–1 262 Studies of Bilingual Aphasia Treatment Greater Gains in Treated Language or Gains Associated in Time with Language of Treatment (Continued) Languages Length and Known and Frequency of n and Age. Education. BAT in both Ls GRBQ344-3513G-C09[245-276]. 38 years Ndebele L1. Age not Spanish L1. old. best Zulu. 3rd structure English only. 71 years Spanish L1. naming exposure unnamed 80% on of sessions improved after unknown country treatment ____________ Spanish outside U. Ages Learned Information Treatment/ Authors. PALPA 7 weeks. Zulu. frequency No scores given 2003 given. lawyer. for pre/post educated”. 19 years Pedi L1 or and Pedi. Best Ls Ndebele Discourse Treatment in Score on Profile 9 sessions in Scores not given. English 6th analysis of better 3 years age of first best. Beecham.qxd 1/21/08 11:48 AM Page 262 Aptara Inc. no description of 1992 school. 4 months teenager” changed every phonemic cues gains on BAT post-CVA session. improved scores Gains Do Not Match Pattern of Treatment Hinckley. and PALPA time on each recent or much greater language simultaneous in Spanish treatment than English unknown Penn & n  1. LOB info. or First on Language Focus/Method Dependent Previous Date Time Post-onset Exposure of Birth of Treatment Design Variable(s) Treatment Results Galvez & n  1. pretest. cative Appro. treatment for Spanish only and English frequency and and English 2003 post-R CVA age at first born in anomia until reached unknown no. info provided improvement (same 9 months after kaans. “highly English L2. rate organized and previously) exposure not modality-s pecific of speech more given. English at school . at proficient” treatment end of study. on previous in all Ls patient) his 2nd CVA English.S. then No info on treatment. learned “as a design. 6 months English L2. of Communi.. then other treated. baseline across stimuli not _____________ contradicts 2003 onset w/ “little self-report. score Recent or figures in exposure” to no breakdown phonemic in Spanish up on short BAT. English L2 proficient” by based tx. 56 years old. both Engligh up by modality cues to 80% naming and unknown languages to age 18 criterion. 6 mo post. P2 treatment for criterion level. and P1: L1 Spanish. tx provided. equally Edmonds & n  3. 10 at age and P3: anomia “multiple words. UL  untreated language. both in English modalities improved approx. Scores on target Unknown Unclear. Mixed Results Galvez & n  1. WAB. PALPA. 263 . Spanish L1. GRBQ344-3513G-C09[245-276]. P1: slightly Semantic feature Train each list Scores on target 13 to 40 Varying levels of Kiran.qxd 1/21/08 11:48 AM Page 263 Aptara Inc. semantic and behaviors”. P2 and stronger in baseline across BNT. related sessions. “Multiple. treatment between education P3: both Ls English participants BAT languages from birth and behaviors” Key: TL  treated language. tx: Table 1. text Hinckley. simult. no progress and 2006 8 to 9 months starting Spanish. 53. L2 English better in analysis of 10 to stimuli. and unrelated info provided generalization post-CVA. 53. 71 yrs old. on previous within and or 12 years 21. “Equally Anomia skill. Signoret. Wielaert. one language. Howard’s needed to adapt a method from one language to another. rehabilitation strategies unique to that lan- ment. 264 Section II ■ Principles of Language Intervention most authors conclude that their different bilingualism lev. In able (and still unpredictable) patterns of response to treat. 1995) or describe activities or examples of types of tasks (Fredman. lined above. based on can apply to both languages. In ber of concrete solutions to meet these challenges.. as are age-of-acquisition norms. 1996. This means that the selection of stimuli and gualism. 1994. this does not mean that all tasks .qxd 1/21/08 11:48 AM Page 264 Aptara Inc. Improving a logical approaches. in a naming or other lexical task is important for some lan- cially their language background. 1989. cueing techniques.. 1993). Roberts & Deslauriers. types must be determined in a language-specific context. 1978) and treatment studies offer some guidelines about changes Japanese and Korean (Sasanuma & Park. 1989). Van Eeckhout. while others do 2004. leap of logic is surprisingly naïve. Sasanuma. show that a number of aphasia treatment methods have been used in a range of different The principles for unilingual treatment apply also to bilin- languages. Authors and readers need guage pairs (see earlier section). 1993). cues that are not possible in English is a key factor in setting goals. Visch-Brink. involves cognate words than if there are no cognates. unilingual- and Japanese (Watamori & Sasanuma. & Remy. to assist word retrieval. however. Even when therapy is carried may be important to use in other languages. assessment of task difficulty for each patient will depend to a great extent on the clinician’s ability to observe patterns. 1992. about prognosis more guarded than for unilinguals. approach can be used in bilingual patients who speak English Studies are needed. nouns in Spanish. Wender. Holland & Forbes. The factors Van Eeckhout. and given that some unilingual patients fail to guage must be developed. for reasons out- the explanation for the results must be the patient’s bilin. as for kana/kanji reading and writ- generalize gains to untreated stimuli and/or modalities. Zilbovicius. A high level of lin- Other studies give little information about the treatment guistic competence is needed to adapt most treatment method (de Luca et al.g.and post- Koenderman. Deloche. 2003). & McNeil.GRBQ344-3513G-C09[245-276].. however. Until these studies are done. how little is known about prognosis in bilinguals. not. such as word order in English. guals: goals should be realistic. we should not be too quick to assume that speakers. We need choosing stimuli. Junqué et al. & van de Sandt. Code. Also. cultural varia- better-designed studies and more complete descriptions of tions can be important. Examples of cognitive neuropsycho. and our comments to the family literature. These include PACE therapy (Carlomagno. 1995). and our prognosis along with them. 1994. based on word frequency. 1993). 1996. 1975. Some cues that have great value in goals will change. al. 1997). morbid proficiency and patterns of use. meaningful to the patient. and Blissymbols in a patient’s L2 or reversing the attrition that has occurred in a range of languages can be found in sources specifically high. Van Amerongen. Junqué et strategies into different languages. when a bilingual patient either generalizes or fails to Word-frequency lists are of unknown validity for bilingual generalize gains. controlling for cognate words patients (see also Roberts. as the treatment brings changes or fails use in another.. phonemic cueing technique was used with a French-English They also demonstrate that the principles the method is bilingual patient with chronic aphasia (Roberts et al. our must be borne in mind. the auxiliary used to conjugate verbs in French or Italian. this ing in Japanese (see Sasanuma. Setting Goals in Treatment Other sources. 1999. our goals but also scattered throughout the published aphasia-treatment must be even more modest. van tional factors must be considered. little-used L1 are not part of our clinical mandate. at least Some unilingual adults with aphasia generalize treatment for some patients (Ferrand & Humphreys. relevant in unilingual work apply to bilinguals. for example. So. gains to untreated stimuli and/or modalities. Kohnert. Melodic Intonation Therapy (Belin. The gender of out in both languages. 1995). Stadie et al. Given lighting international work (e. Harskamp. The fact that a treatment approach has been used with Treatment Methods speakers of different languages does not guarantee that it is The studies just cited show that a general stimulation appropriate for bilingual speakers of two of those languages. Given the vari. or els are the cause of the observed differences.. As the In adapting a technique developed in one language for recovery progresses. Some addi- Pillon. and tailored to the individual patient’s deficits.. Also. the specific characteristics of each language to bring changes in targeted aspects of communication. & Seron. espe. Realistic goals are based on the patient’s pre. Roberts and Kiran (2007) Another possible pitfall in adapting therapy techniques is identify other methodologic flaws or challenges all authors establishing appropriate hierarchies of difficulty for tasks (and clinicians) face in trying to devise bilingual aphasia and stimuli. and experiment with various dimensions of a task to adjust its Treatment difficulty on a patient-by-patient basis. 1993). They propose a num. The syntactic difficulty of different sentence treatment and understand its results. some languages. A task may be easier if it to be much more cautious in how they interpret results. 1976. may have little The patient’s need for each language in various situations value in another. there are strate- ing to the other language(s). There has been a surge of interest in 1948. 1993b. always active to some degree. To the extent 2002). and probe it regularly to to a bilingual listener has been documented in patients with see if it reappears. their daily lives. Logically. Alternating languages. Wald. Bates.g. using designs that are now com- that the two languages interact. guages in treatment can be adjusted to include this language. This switching behavior when talking sive exposure to the “lost” language. Chlenov. When and if it does. However.. For example. This is an obvious and appro- on writing in one language and auditory comprehension priate strategy. treatment may need to be restricted to one lan. with regular probes to see tion of languages. Separate the languages by modality. For most patients. This can be encouraged or explicitly taught if it is an that treatment generalizes from one language to another. Some patients use in both languages. and that bilinguals regularly mon in the unilingual aphasia-treatment literature. be unable to. This involves a block of sessions does not use word order to mark them (Liu. Springer. Work in the other language(s). although this cases that display a blended pattern of impairment. gies that are unique to bilinguals. In the rare cases where a patient “loses” a language they guage. in interpreting error patterns. when unable to say 3. Both are complex and both require study. on the psycholinguistics of bilingualism. iting treatment to one language. patients. with both languages guage for reading. an arcane and very tiny field 10 years sions that most patients can keep their languages separate ago. The only exceptions to this are the rare standing of multilingual language processing. in one language. Choice of Language(s) of Treatment Regardless of the treatment goals and methods. 2003). explicit teaching may be needed. if the listener is bilingual. Case speakers. or enough of it to used extensively. & Li. the message may be understood. Models of bilingual 2006. are the focus of considerable interest and are being and that. An L1 be the only way to work with a language the clinician English speaker may rely on word order as a cue for the- does not speak. The case described by Roberts (1998) illustrates this approach. matic roles when processing sentences in L2. & Bürk. and the Some bilinguals use processing strategies from one language other language at home or with a volunteer. controlled study on this issue. provide pas- understand the word. when generalization does not occur. if the patient used only one lan. linked.qxd 1/21/08 11:48 AM Page 265 Aptara Inc. For example. in light of the research showing number and sophistication. if they regularly use more than one language in revised in light of these new experimental results. the patient may simply patient’s premorbid patterns of use. Clinical experience suggests that it is pointless to saying or writing a cognate word in one language will often attempt to work in a language until the patient can access it allow even a unilingual speaker of the other language to fairly consistently. even when L2 2. nize its importance. treatment may be necessary in both languages needed by the patient. Clinical experience shows cessing and self-cueing strategies are important factors. 1984).. 1961 cited in Paradis. If the listener has even some grasp of this other lan. continue to grow as more clinicians and researchers recog- ment in more than one language is harmful (e. language processing. the lan- FUTURE TRENDS guages used in treatment should reflect premorbid use and It seems safe to predict that interest in bilingual aphasia will proficiency. use their languages as a whole system. whether treatment gains in one language are generaliz- In overcoming word-retrieval problems. the treatment goals should reflect this. they may want to work on this language but move the exchange along. Chapter 9 ■ Aphasia Assessment and Treatment for Bilingual and Culturally Diverse Patients 265 should be. pro. work switch to his other language. Paradis. it spontaneously. Miller. for example). the balance of lan- aphasia (Marty & Grosjean. followed by a block in the other. It is important for the clinician to con- block can be a certain number of consecutive sessions or sider factors from both languages. 1958.. effective strategy for the patient and not pathological or treatment in only one language may be ethically appropriate. bilingual/multilingual language processing in nonimpaired 2004). 1998. reflecting the what he wants to in one language. For others. 1. This may to interpret the other (Heredia & Altarriba.GRBQ344-3513G-C09[245-276]. Roberts et al. with positive outcomes (e. Hinckley.g. In language pairs with cognates. Each 1992. Working on one language with the clinician. provide support for clinical impres. 2002). Edmonds & Kiran. and the possible interac- can be measured in weeks. First. they benefit from treatment that targets studies of speakers with aphasia can contribute to our under- these languages. For these line of research remains relatively undeveloped. A second strategy that bilinguals use spontaneously is The questions of what pattern of languages to use in treat- producing a word from one language to self-cue its retrieval ment and of generalization between languages are closely from another (Roberts & Deslauriers. there is no recent. 1998). uncontrolled switching (see Grosjean. there is little support for lim- In tailoring treatment goals to the patient’s deficits. For these . that most patients can work in one of three ways: These often reflect the interaction of the two languages. 1999. and is seen daily in clinical settings. Although anecdotal reports suggest that treat. Aphasia-treatment studies will continue to grow in both guage. The findings from these studies of language-local- studies in which treatment has been offered in two or more ization and word and sentence processing are shedding light languages. adapting. appropriate experimental control and the pub. group. especially for cases of the patient’s premorbid level of bilingualism. their suitability for documenting the best methods and their impact will support use with bilingual speakers must be explored. Given the increased interest in CLD issues. It is equally important to avoid cultural this data objectively. The second challenge is experimental rigor. As the calls for more focus on CLD issues and interpreting behavior within the appropriate cul- are answered by studies with hard data. and the features and other and the patient needs to regain use of both languages. stay the patient is allowed. culty in finding patients with similar linguistic. in lication of replications will be essential to allow correct largely but perhaps not completely overlapping cor- interpretation of the results. Each client is a unique larities across groups as well as to the differences. stereotypes and assumptions. in which the gains in one language do not generalize to the dialect(s).GRBQ344-3513G-C09[245-276]. Interpretation of test results should be done in light treatment also adds to the time required. objective review according difficult to give bilingual patients the care they need. with neurologic status. collaborative studies (across centers and in abilities in each language that often reflect the influ- different countries) will help ensure adequate sample sizes ence of the other. as they are for unilinguals. It means very our efforts to obtain essential services for CLD patients. in the number of sessions they may provide. between-language facilitation and interference both clinicians can become culturally aware. pling differences. Working in two languages in 8. using the patient’s worse. It can be difficult to assess bilingual patients for many time than a unilingual one. A bilingual patient takes more 7. We must give equal weight to the simi. The languages of a bilingual are (usually) stored in Kiran (2007). It is important to consider the possible influence of CLD patients may be better than for other patients. We must individual from a specific microculture. expectations about a particular 1. and a lack of data on indi- preters. Research to established psychometric standards. 266 Section II ■ Principles of Language Intervention studies of treatment to coalesce into a body of knowledge see experimental support for specific treatment methods. Language and culture are closely tied. within a be very cautious in saying why a result was obtained. Authors and the patients. it is more tests to support our clinical work. However. Clinicians in many settings are subject to limits readers must also learn to be more cautious in drawing con. the need for interpreters. Lexical items are connected across languages. and learn to adapt occurring in neurologically intact adults. on how we meet widely as possible in the literature on culture and on the challenges inherent in studying CLD patients. The third challenge is cultural and linguistic competence. Bilingualism is a continuum. with different levels of related to bilingualism and culture are difficult to control in ability for different linguistic tasks and different studies already complex because of the many neurologic and domains of use. with patterns of use or disuse. the left hemisphere. we may hope to . Factors 3. in part. local norms. and interaction with people of various cultures. with With study. clinical path. tant are the following: tradict our own. and 4. the factors that take more time. These constraints and pressures to The most uncertain area may be assessment. we must interpret tural context. The final challenge is time. A significant challenge for the profession is to ered in interpreting aphasic error patterns and in recruit and train people who meet the required standards. As discussed by Roberts and 5. or there may be no difference beyond minor sam. and that can be interpreted and applied to clinical practice. Cognates their methods to reduce cultural stumbling blocks on the appear more closely linked than non-cognates. and representative results. and testing in two languages instead of one are among vidual test-retest reliability on aphasia tests. Test performance and treatment outcomes for some 2. 6. without vital that authors and reviewers insist on greater consistency adequate time. Bilingual abilities change over time linguistic variables related to the aphasia. We must be open to results that con. patterns of use.qxd 1/21/08 11:48 AM Page 266 Aptara Inc. or developing reasons. background to suggest factors that may be relevant. or society’s. Among the points that are clinically impor- challenge is objectivity. A bilingual person is a unique speaker-hearer. tests and treatment material. or the length of clusions from studies with small numbers of patients. Linguistic competence represents a greater These between-language factors should be consid- challenge. planning treatment. The first bilingualism. Given the diffi. or cultural factors on clinical work. Existing see more patients in shorter times will make it increasingly tests need to undergo thoughtful. these positive developments will not benefit across studies in how patients are described. including availability of tests. Clinicians who work with CLD patients should read as Other future trends will depend. Finding. tical and subcortical regions. unique symptom hierarchy of each language tested. little to say that a patient scored 12 in Spanish and 14 in English if we do not know whether the Spanish and English tests are all of equal difficulty and if we do not know what KEY POINTS the normal range of variability might be for retesting a sin- gle patient using the same tests or task. cultural. macroculture. finding and training inter. 1. retesting the ment methods for bilingual patients with aphasia and patient on the same stimuli used during the pretherapy into cross-language generalization. J. 7. (1978). D. & Obler.. The bilingual brain. A. (1995). New York: Elsevier. F. service for bilingual patients with aphasia. In R. F. 39–41. bilinguals (pp. Multi- ogy textbooks and research-methods textbooks (e. Cappa. practical steps that you. Discuss the types of impairment vs. Bilingual speech-language Pick a specific type of speaker that you often see or that pathologists and audiologists. (1998). F. American Speech-Language-Hearing Association (1991). Harris (Ed. cultural action agenda. A.) to provide culturally and linguistically appropriate services. It may be helpful to obtain a guage populations. M.). . (1992).. behaviors you will work on in therapy by testing two or 10. 17. J. 29–32. Are the ratings the same? c) Explore the reasons for each rating with the person Abutalebi.. Review the definitions for: 9. J. differential recovery. A. American Speech-Language-Hearing Association: Committee on reliable test for naming abilities in bilingual speakers? the Status of Racial Minorities. so you can rescore the patient’s answers. F. Clinical and how close each test you have examined comes to management of communicatively handicapped minority lan- meeting the standards. L. (2005). level of versity. 2. chapter on how to assess the quality of a test. A number of treatment principles and methods have three times instead of just once before starting treat- been successfully used with a range of languages. S. Neurocase. How would you ropsychology. Altarriba. your uni- bilingualism. & Fabbro. ASHA. 12. Cognitive scoring and the instructions given for administering Neuroscience and Neuropsychology. Can you think of two domains of use for language that are not listed in this chapter? 3. Compare the ease of bilingual aphasic following subcortical lesions. American Speech-Language-Hearing Association. 6. cussion group about what makes a good aphasia test. Supplement 4. types of recovery. New York: scoring and clarity of the recording forms? Academic Press. domains of use. 27. Journal of Clinical an Experimental Neuro- go about developing such a test? psychology. ment. Directions of research in cross-cultural neu- the kinds of challenges that might arise. the Bilingual Aphasia Test. Kroll & A.GRBQ344-3513G-C09[245-276]. 51–56. What do you think is the biggest challenge in improving service to bilingual adults with aphasia in your city/ ACTIVITIES FOR REFLECTION AND DISCUSSION region/country? Suggest specific strategies to meet this challenge. etc. 33(5). 497–515). or the Aachen Abutalebi. 4. feasibility of implementing each of these steps. parallel recovery. The representation of translation equivalents b) Prepare a short paper or a presentation for your in bilingual memory. Kazdin’s Research Design in Clinical Psychology) often American Speech-Language-Hearing Association (2004). Handbook of bilingualism: 4. baseline tasks. What testing or tasks would you need to add to 9. Imagine you want to present treatment results for your Ardila. next bilingual patient at clinical rounds or a small con. ASHA. reliability. How important are the ease of Albert.. (1985). Do subcortical Aphasia Test. psychol.g. & Cappa. with parallel patterns These might include obtaining a baseline for one of the believed to be the most common. References b) Then ask someone else to rate your proficiency in each of the modalities. Aphasiology.. Identify three small. New York: Oxford 5.. Chapter 9 ■ Aphasia Assessment and Treatment for Bilingual and Culturally Diverse Patients 267 ference. De Groot (Eds.). Miozzo. we need much more research into treat. B. How will you measure generalization between languages? 8. Assessment: obtain a copy of the Multilingual Aphasia University Press. 31.qxd 1/21/08 11:48 AM Page 267 Aptara Inc. S. a) Estimate your own level of bilingualism in each of the four language modalities on a scale of 1 to 7. Five patterns of impairment and five patterns of your usual clinical procedures to be able to do this? recovery have been identified. Why is bilingualism so difficult to define? Psycholinguistic approaches (pp. (2000). 1359–1362. is common in your country or city to help you imagine Ardila. with the Boston Diagnostic Aphasia Examination or Aglioti. microculture. recording treatment sessions (video and/or audio) However. Do you think it will be possible to develop a valid and ASHA. Cognitive processing in class/rehabilitation team/continuing-education dis. J. J.. 143–150. S. What can func- tional neuroimaging tell us about the bilingual brain? In rating you. ASHA. M. & Perani. 157–174). structures control language selection in bilinguals? Evidence a) Compare the sections and number of items per test from pathological language mixing. contain succinct overviews of the criteria an ideal test Knowledge and skills needed by speech-language pathologists would meet (validity. 6. Examination. 885–900. sensitivity. Semantic paralexias in the Spanish language. (1989). or your treatment center could take to improve bilingualism. and scoring the test. (1993). 93. 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The administration manual is available in Spanish: P. Anomia and dyslexia in Chinese: A familiar story? (1995). (1997). 77–98. M. and clinical management. L. San aphasia. S. Worrall. S. Aphasic victim as investigator. D. Journal of Communication Disorders. Australian elderly. Chen. B. L..qxd 1/21/08 11:48 AM Page 275 Aptara Inc.GRBQ344-3513G-C09[245-276]. E. E. L. Yao. Lin Gu-Hui sgonzalez@medicapanamericana. Y. M..). Watamori.. P. 9. Wiener. rehabilitation hospital. D.S.1 Addresses for Ordering Tests (subject to change) Spanish version of the BDAE Via P. Brain and Language. (1995). B. B. D. 157–166. (tel: 011 3491 457 0203) Guangzhou.l. Chapter 9 ■ Aphasia Assessment and Treatment for Bilingual and Culturally Diverse Patients 275 Wallace. communication. M. Joanette. & Sasanuma. The Aachen Aphasia Test—English Masson. H. C. Yiu. Lafond. GRBQ344-3513G-C09[245-276].qxd 1/21/08 11:48 AM Page 276 Aptara Inc. . GRBQ344-3513G-C10[277-289]qxd 1/21/08 11:50 AM Page 277 Aptara Inc. Section III Psychosocial/Functional Approaches to Intervention: Focus on Improving Ability to Perform Communication Activities of Daily Living . .GRBQ344-3513G-C10[277-289]qxd 1/21/08 11:50 AM Page 278 Aptara Inc. LPAA emphasizes als in psychology. Someone with mild aphasia in a nonsupportive environment 279 . and for aphasia is viewed—and reimbursed. and immediate and long term life goals (note that “approach” refers here to a general philosophy and model of service delivery. methods for supporting those affected by aphasia. consistent and dependable support system. A highly sup- Rather. These changes. a life goal may be to return Our statement of values has been guided by the ideas and to employment or participation in the local community. whatever the language impairment.GRBQ344-3513G-C10[277-289]qxd 1/21/08 11:50 AM Page 279 Aptara Inc. a strong external that contribute to long-term health-care costs. Regardless of the stage of management. For example. providers. For example. work of speech-language pathologists as well as by individu. These interventions thus have the ophy and treatment and by consumers frustrated by unmet potential to reduce the consequences of disease and injury needs and unfulfilled goals. for daily participation in activities of choice. in propose a philosophy of service delivery that meets the the initial stages following a CVA. sociology. The “Life Participation Approach to Aphasia” (LPAA) is a consumer-driven service delivery approach that supports indi- Duchan. on the other hand. Judith F. and physicians. after hospital discharge. It empowers the con- ments that produce meaningful real life outcomes leading to sumer to select and participate in the recovery process and to enhanced quality of life. effective communication with the surrounding nursing staff sures from our profession. which has caused a significant reduction in avail- able services to people affected by aphasia. LPAA places the life concerns of those affected by aphasia Internal influences include a growing interest in treat. Chapter 10 Life-Participation Approach to Aphasia: A Statement of Values for the Future LPAA Project Group (in alphabetical DEFINING THE APPROACH order): Roberta Chapey. longer elects to have communication support. rapid return to active life. influence is emanating from the curtailment of funding for our work. Most recently.asha.htm. can substantially restructuring of services and lead to innovative clinical increase the chance of aphasia affecting daily routines.org/public/speech/disorders/LPAA. at the center of all decision making. Externally. beginning with initial assessment and intervention. it is important to take a proactive stance. Elman. At a later stage. and funding sources. We encourage clinicians and researchers to focus on the ery. exact methods for achieving specific outcomes. Lyon. and medicine (see the ASHA Web the attainment of reengagement in life by strengthening site. intervention. www. policy making. viduals with aphasia and others affected by it in achieving their Garcia. Jon G. nor to pro. Nina Simmons-Mackie rather than to a specific clinical approach). a goal may be to establish needs of people affected by aphasia and confronts the pres. we are influenced by collaborate on the design of interventions that aim for a more disability rights activists encouraging adjustments in philos. It focuses on reengagement in Unprecedented changes are occurring in the way treatment life. THE ESSENCE OF LPAA To accommodate these varied influences on service deliv. advocacy. LPAA calls for a broadening and refocusing of clinical practice and research on the consequences of aphasia. until the consumer no resulting from both internal and external pressures. We intend neither to prescribe Residual skill is thus seen as only one of many requisites. continuing. we offer a statement of values and ideas relevant to portive environment can lessen the consequences of aphasia assessment. We therefore real-life goals of people affected by aphasia. encing how speech-language pathologists carry out their jobs. full participation depends on motivation and a vide a quick fix to the challenges facing our profession. A nonsup- research that we hope will stimulate discussion related to portive environment. Linda J. and on one’s life. Aura Kagan. a detailed reference list). Roberta J. are influ. addition. Indeed. concerns about the future. clinicians might take on the role of: teacher or therapist • “communication partner.” and give the person with aphasia the opportunity to engage in conversation about life goals. LPAA is a means of addressing the unmet needs and rights of individuals with aphasia and those in their environment. the term “func- recommends that clinicians and researchers consider the tional” does not do justice to the breadth of this work.” “problem solver. should form part of a bigger picture where the ultimate goal What is important is to judge whether aphasia affects the for intervention is reengagement into everyday society. 1990.htm) for a few examples of how LPAA may lead to a broadening and refocusing of services). requires that physical and com- munication access be provided for individuals with aphasia Functional and Pragmatic Approaches and other disabilities and allows them legal recourse if they LPAA draws on ideas underlying functional and pragmatic are blocked from accessing employment. programs.asha. documenting quality of life and life participation clinicians would routinely evaluate the following in partnership with changes clients: • life activities and how satisfying they are • social connections and how satisfying they are • emotional well-being might experience greater daily encumbrances than another those who take a broad approach to functional communica- with severe aphasia who is highly supported. execution of activities of choice and one’s involvement in them (see Table 10–1 (www.” Although LPAA Furthermore. or ser- approaches to aphasia and shares some common values with vices in the public and private sectors. clinicians are participation needs and discovering clients’ equally interested in assessing how the person with aphasia does with competencies support Treatment includes facilitating the achievement In addition to work on improving and/or compensating for the language of life goals impairment. the term is often used narrowly to mean “functional ing messages and establishing and maintaining social links. life activities do not need to be in the realm recognizes the value of this type of impairment-level work. including friends. signed THE ORIGINS OF LPAA into law on July 26. . independence in getting a message across. tion treatment by focusing on life-participation goals and In this broadening and refocusing of services. • “coach. service providers. Human Rights Issues and Consumers’ Goals ders/LPAA.GRBQ344-3513G-C10[277-289]qxd 1/21/08 11:50 AM Page 280 Aptara Inc.org/public/speech/disor. the Americans with Disabilities Act (ADA). clinicians legitimate targets for intervention would also work on life-participation goals for family and others who are affected by the aphasia. etc. In dual function of communication: transmitting and receiv. however. work colleagues. etc. clinicians might train communication partners or work on other ways of reducing barriers to make the environment more “aphasia-friendly” All those affected by aphasia are regarded as In addition to working with the individual who has aphasia. it of communication to deserve or receive intervention. In our view. 280 Section III ■ Psychosocial/Functional Approaches to Intervention TABLE 10–1 Examples of the Shift in Focus of Life-Participation Approach to Aphasia LPAA Examples of Shift in Focus Assessment includes determining relevant life In addition to assessing language and communication deficits. clinicians are prepared to work on anything in which aphasia is a barrier to life participation (even if the activity is not directly related to communication) Intervention routinely targets environmental In addition to working with the individual on language or compensatory factors outside of the individual functional-communication techniques.” or “support person” in relation to overcoming challenges in reengaging in a particular life activity Outcome evaluation involves routinely In addition to documenting changes in language and communication. barriers to life participation. Clinician roles are expanded beyond those of In addition to doing therapy. LPAA social relationships. and prioritizing which personal and environmen- reimbursement will require novel means that stand outside tal factors should be targets of intervention and how best to most current practices.and long-term participation in life. ing immediate family and close associates of the adult with aphasia. ASHA provided guidelines for a “communica. (including those who do not have aphasia themselves) is evi- vice delivery for people confronting aphasia. Such international changes in focus point to the need The LPAA approach calls for the use of outcome measures to address the personal experience of disability and promote that assess quality of life and the degree to which those optimal life-inclusion and reintegration into society. with providers and consumers as to whether life participation but rather that enhanced participation in life “governs” principles and values should play a more central role in the management from its inception. 1997. focusing as broader social systems to make them more accessible to much on the consequences of chronic disorders as on the those affected by aphasia. LPAA begins with the onset of aphasia and continues until consumers and providers agree that targeted life enhancement The Explicit Goal Is Enhancement of Life Participation changes have occurred. Intervention consists of constantly assessing. Our pur. regardless of the extent or short. service delivery and its weighing. includ- nication as an integral part of life participation. easier. severity of their disabilities. relationships. This does not mean pose in this introductory article is to prompt a discussion that treatment comprises only life resumption processes. We are confident that cost-sensitive provide freer. Therefore. and more autonomous access to activ- and therapeutically effective models are possible. we believe. the conditions of their own exis- All Those Affected by Aphasia Are Entitled to Service tence. ities and social connections of choice. . rather than the longer term. and research. In so doing. and activities in life. have a basic right to affect. 1997). treatment attends to each con- an unprecedented overhaul in America. the first focus of the client. Financial exigencies sumer’s feelings. clinician. intervention. Both Personal and Environmental Factors Are Many of the incentives in this model result in the provision Targets of Intervention of efficient short-term minimal care. delivery and reimbursement of future service delivery for all the LPAA approach differs from one in which life enhance- those affected by aphasia. of these desired outcomes. The second focus is to improve Its preface states that “all persons. Along with other movements in education and health care. Disruption of daily life for individuals affected by aphasia LPAA represents a fundamental shift in how we view ser. THE CORE VALUES OF LPAA Emphasis Is on the Availability of Services as Needed LPAA is structured around five core values that serve as at All Stages of Aphasia guides to assessment.GRBQ344-3513G-C10[277-289]qxd 1/21/08 11:50 AM Page 281 Aptara Inc. Chapter 10 ■ Life-Participation Approach to Aphasia: A Statement of Values for the Future 281 In 1992. affected by aphasia meet their life participation goals.” Communication is defined as “a basic need and basic right of all human beings” (p. life consequences of aphasia change over time and should be and policy-maker is to assess the extent to which persons addressed regardless of the length of time post-onset. In this fundamental way. participants.. ASHA thus views commu. Since LPAA dent on two levels: personal (internal) and environmental focuses on broader life-related processes and outcomes (external). However. treatment Changes in Reimbursement and Service Delivery focuses on a reason to communicate as much as on commu- Health care and its reimbursement system have undergone nication repair. LPAA shifts from The Measures of Success Include Documented a focus on deficits and remediation to one of inclusion and Life-Enhancement Changes life participation (see Fougeyrollas et al. starting from the onset of treatment. LPAA acknowledges that In the LPAA approach. tion bill of rights” (National Joint Committee for the and the extent to which the aphasia hinders the attainment Communicative Needs of Persons with Severe Disabilities). fuller care supported in the past. intervention may involve changing sizes competence and inclusion in daily life. through communication. WHO. Without a cause to communicate. LPAA supports all those affected directly by aphasia. language difficulty caused by the aphasia. The LPAA approach holds that it is essential to build protected communities within society where persons Emphasis on Competence and Inclusion with aphasia are able not only to participate but are valued as LPAA philosophy embraces a view of treatment that empha. have led to an emphasis on medically essential treatments and others seen as likely to save on future health care costs. 2). ment is targeted only after language repair has been addressed. there is no practical need for communication. Therefore. affected by aphasia are able to achieve life participation goals. Lac St-Charles. 165–187. D. Return to work after stroke: Development of a predictive model. 43–61. Boston: Butterworth-Heinemann. P. Guidelines for meet. 527–531. E. Aphasia treatment: Our health-care systems are undergoing change and. . (1998). T. on interventions that make real-life differences and mini. as a World perspectives (pp. Stroke. We invite other speech-language pathologists Becker. 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Singular. Group treatment for neurogenic com. relating to the consequences of disease. N. & Boone. 519–526.). Walker-Batson.. R. 479–482. PA: Williams & Wilkins. R. In T. Warren. In R. 219–224. CA: Health Worrall. The theory and practice of group psychotherapy. 73. 1–17. & Borenstein. M. Nursing as informed caring for the well-being Wertz. review of the literature. 18. Language disorders in adults (pp. MN: BRK. Outcome measurement: Moving toward the Yalom. 5–6. 10–78). (1965). (1990). J. (1993). 35–48. Speech act analysis of aphasic Wahrborg. & Ryan. Culture. Australian perspective. Language Disorders. I. 6. J. Communication between women and their In R. S.). carried out between 1946 and 1988 concerned with the efficacy American Journal of Speech-Language Pathology. 102. band-wife communication pre and post aphasia. Dundas & S. Wilcox. Journal of Speech and Hearing Research. In M. Parr. 1988. 2001. and tional approaches. Kagan. 2005). A social model objectives and examples that fit within a social approach. Parr. However. Parr. & Parr. Cifu. 1996. Parr. The ultimate tive therapies have been effective in changing language per- aim of a social approach. Johannsen- Horback. 2000. Certainly. 1992. and stigmatization (Herrmann. LPAA Project Group. funding sources have pressed for more “func- vide examples of assessment and intervention methods that tionally relevant” outcomes and evidence that our services fit into the social model philosophy. 2005. 2004. 2000. This chapter will (1) introduce and define a social model of 1998a. these long-term consequences are not addressed by tradi- Kagan. and rely on formal tests Participation Approaches to Aphasia” (see Chapter 10).qxd 1/21/08 11:52 AM Page 290 Aptara Inc. role changes. 2005. forced us to balance quality outcome with cost of care. with aphasia. (Sandin. Simmons-Mackie. 1993. 1999a. 2004b. Gilpin. In addition. trast social approaches with traditional restorative and func. and reduce response to rehabilitation Sarno. “a fre- Major strides have been made in the past decade in the quent tale from people who live with aphasia is of being dis- development of social approaches to aphasia (Byng & engaged from life. (3) outline the principles of a social approach changes in the health-care industry suggest an urgent need to intervention. Pressure from consumers. Therefore. These restora- evant activities for those affected by aphasia. diminish commu- 1996. but only on the periphery” (Pound. many people with aphasia experience with aphasia have been noted (Holland. improving linguistic or cognitive processing. & Woolf. Such untreated psychological Square. The cycle of diminished par- 1998b. 1999b. Pound. OBJECTIVES National Aphasia Association. Lindsay. Such approaches tend to focus on the “impair- aphasia. restoration of from several sources. (4) introduce assessment strategies appropriate for creative approaches that increase the quality of commu- to a social model of management. 1997. & Wallesch. 1995. 1994. 1999. and social problems can increase disability. loss of autonomy. provides a philosophical framework for implementing inter- ventions that fulfill these requirements. communicative processes is an important goal for people First. Holland. It is the objective of ticipation in various aspects of life can take a drastic toll on this chapter to explain the rationale. Sarno. Byng. and princi. Pound. Byng. make a difference in the lives of our clients (Frattali. Chapter 11 Social Approaches to Aphasia Intervention Nina Simmons-Mackie residual communication problems that significantly impact their daily lives. Duchan. Simmons-Mackie.GRBQ344-3513G-C11[290-318]. The and treatment probes to determine the level of deficit and need for a social approach to aphasia management draws degree of change after therapy. & tional aphasia intervention. Black. 1998a. Elman. ples of socially motivated approaches to aphasia and to pro. 1996. Many of Elman & Bernstein-Ellis. and (5) describe intervention nicative life for those affected by aphasia. 2004. Restructuring in health care has aphasia intervention. Lyon. desire to improve outcomes. gaps between changes on linguistic quences beyond the acute disruption of communication. Johnson. 2000b). ment” of the individual with aphasia. 1993a. 1999). enhancing the living of life with formance. 50). 1993a. 2000. or allowed in. 1998. Worrall. & Ireland. RATIONALE FOR SOCIAL APPROACHES EXPANDING THE MANAGEMENT FOCUS The goal of a social approach is to promote membership in In traditional aphasia therapy the emphasis has been on a communicating society and participation in personally rel. self-confidence and personal identity (Shadden. 2000. philosophy. excluded from involvement. & Noll. Those affected by aphasia report social isola- tion. 290 . LeDorze & Brassard. is consistent with the philosophy of “Life. aphasia is a chronic disorder with long-term conse. restricted activities. Duchan. 1998a). 1993. (2) describe social approaches and con. 1997). In fact. nity reintegration. 1994. 1994). loneliness. p. In measures and “real-life” functional performance of people spite of linguistic gains. al. et al. 1993. but also a situation in which opportunities and rights skills approaches. 2003. Wyller. Pound.g. Worrall. disrupted communication entails social meanings paradigm in aphasiology (Sarno. Traditionally.. That mance of daily activities and communication “in use” is. 1997). Both internal problems and exter- tic processing and success on “functional” tasks. De Jong. the “expert”). with the therapy. Yet the individual.. (e. 2004). remediation of psychosocial problems emphasis on health rather than illness (LPAA. & Murison. participatory role in their own health-care decisions. little attention to chronic affects (Hersh. and less life satis- tonic that will cure aphasia (Pyypponen. In a social to utilize compensatory strategies and perform typical tasks model disability is a consequence of disabling attitudes and such as using the telephone or making a grocery list. 2000a). Studies report relationships between communica- Ward. 1998a. clients and nal barriers must be addressed for optimal return of function families continue to report social isolation. and The traditional health-care paradigm has been described as also our personalities. Bautz-Holter. than a lesion within the skull. and well-being. 1993). aphasia is also located outside of the person in dynamic relationships with others and in the CONTRASTING MEDICAL social community. As Goodwin (1995) describes.GRBQ344-3513G-C11[290-318].. By contrast. leisure activities. & Laake. barriers imposed by society. loss of confi. 2004). of the medical model remains evident in our practices. When complete recovery is not the result. 1998a. AND SOCIAL MODELS Through communication we express and create our ideas. and social contexts (Cardol. Worrall.” as though treatment is a mood states. 2003. ual’s organic condition and his or her social and physical 2000). Worrall & Frattali. social relationships) is closely tied to The focus of rehabilitation shifts towards a “client-centered” positive affective states and subjective well-being (Sveen. For example. has been divorced from the communication impairment and 1992.” Social models have arisen in an to reveal a healthy identity or “create a positive face” effort to shift the emphasis away from treating the illness to (Goffman. 2001). individu. psychosocial well-being and quality of life who learns to “take the cure” with little participation in life are diminished (Cruice. the importance of a social model. 1993. “patients receive treatment.e.. 2000.. 2003). (Cruice et al. 2004). not simply an impairment that the personal experience of aphasia and individual life-style resides within the individual. & municate. “problems” tend to be located within sidered the approaches of choice for psychosocial issues. when the responsibility for “cure” and authority INTEGRATING PSYCHOSOCIAL AND for decision-making is placed with the clinician (i. decreased roles.. aphasia is addressed as an element of a social system and communication is viewed as a social act. tural context. 2002). dependent “patient” and participation. While professional expertise is needed. 2004). Participation in various realms of life active. Sarno. the problem as situated wholly within the individual. are not readily available. clients take an Doyle et al. Therefore. However. aphasia is not only a dis- adjustments have rarely been addressed in restorative and order. 1998b). 1982. A social model orients away from defining these services are often unavailable or tangential to the “real” . and the influence and consequences. 1967). they have remained on the outskirts of focus shifts to optimally “living with” aphasia. 1998). Thus. Kagan The “social” of social model refers to the broad concept that & Gailey. dence. Lyon. problems result from an interaction between the individ- (Frattali. tion disorders and quality of life or psychological well-being The medical model is also evident in our terminology. then clinicians tend to dictate goals and control COMMUNICATION INTERVENTION treatment. hence.qxd 1/21/08 11:52 AM Page 291 Aptara Inc. While psychosocial issues associated with aphasia have the social model requires a long-term view of aphasia. 1991. in spite of improved linguis.. a “medical” or “biomedical” model with an explicit focus on Communication fulfills a critical social goal when it allows us management of “illness. restricted social participation. Hickson. while communication ability is associated with als with residual aphasia face discharge from treatment with greater well-being and social functioning (Cruice et al. aphasia is more ing life-style changes and psychosocial issues. Holland. A social approach expands people are members of society and reside within a sociocul- intervention to address the living of life with aphasia. our culture. Chapter 11 ■ Social Approaches to Aphasia Intervention 291 functional therapies have been developed to address perfor. For example. aphasia therapy. and our life values. negative Thus. choices (Pyypponen. faction are associated with communication disability (Doyle 1993b). The long been recognized. 1993b). ELEMENTS OF A SOCIAL MODEL tional approaches to encompass quality of life and social participation has been recommended (Frattali. includ.. Doyle et al. In a social model. Thus. needs. yet par- informed choices and taking full account of each person’s ticipation in such activities is closely tied to the ability to com- preferences. For example. Because of the social significance of com- promoting health. expansion of func. counseling and education are con- In a medical model. perspective that involves maximizing opportunities for Thommessen. and limited communication oppor- tunities (Parr et. The medical model has been the prevailing munication. Typically. Functional-skills approaches often focus on the ability environment (World Health Organization. 1993a. the marked When social systems do not support communicative access power differential can create a passive. (5) focus on natural interaction. cate competently. conversational group therapy human existence. and natural contexts. Social- Müller & Code. an aggressive by clinicians. 2000b). (Bouchard-Lamothe et al. and life contexts. 1993a. impairment in communication that masks inherent compe.. (2) address communi- through the experiences of the person with aphasia. it is a value system adopted expected consequence of aphasia. Social-model values call for aphasia tended to overshadow psychosocial issues. comes that are viewed relative to the individual’s preferred Attention to the psychosocial dimensions of aphasia is con. The definition of aphasia is expanded within a social model to Social approaches focus specifically on social participation. . aphasia is an impairment due to brain damage in the to aphasia intervention have appeared under general labels formulation and reception of language. 1993. 2004). This critical Intervention within a social model is determined more by aspect of communication cannot be overlooked. rations turns. Kagan (1995) defines aphasia as an sonal communication). PRINCIPLES OF A SOCIAL APPROACH sia we acknowledge that the meaning of aphasia to the person A social approach to aphasia management can best be con- with aphasia and to those around him or her is greater than ceptualized through a set of basic principles. particularly conversa- tion. 53) define functional. a social-model philosophy provides a framework emotional and social rewards. roles and responsibilities within society. Through communication we within which any treatment approach might be employed. tence. we obtain fact. resulting in neglect intervention that promotes meaningful life changes and out- of “the person” (Byng et al. 2000). p. 2000. Although the values and beliefs of therapists and organizations than often artificially separated in the literature. 2005). Social affiliation and main. psychosocial problems such as depres. Furthermore. LaPointe (2002) has argued that psy. (8) embrace the per- The phrase “social model” is used in this chapter to refer spective of those affected by aphasia. ates productions is not functioning within a social model grated to create a “sociology” of aphasia. 1993. organizations or programs that deliver services research emphasis on the linguistic dimensions of aphasia has within this philosophy. 1999. life participation approaches (LPAA. We craft our utterances and con. 1993b). 1998b. Joanette. Sarno. 2005. The “social model” has often been viewed as an alterna- struct our interactions as a social and emotional endeavor. goals. In addition. Aphasia is a diagnosis. those cation within authentic. rather. diminished participation in life events and reduced fulfillment addressing the consequences of aphasia) (Holland. philosophy. flexible. Sarno. For example. through your own communication skills and those of others and feeling comfortable that you are rep- resenting who you are. the intervention experience and therapy interactions DeGiovani. and society (Penn. Within the general umbrella of social approaches are communication goals in aphasia as “being able to communi. 2000). but also designed to (1) address both information exchange and social aphasia is a socially constructed way of being that is created needs as dual goals of communication.g. A social model is not a specific therapy sion and loneliness are sometimes accepted as a natural and approach or technique. Thus. often associated with such as social model approaches. Lafond. & Duchan. inter- sidered an integral part of communication in a social model vention is considered part of the individual’s social context. and separable from communication. (3) around the person. APPROACHES (7) focus on adaptations to impairment. 2005). obtain membership in a communicating society. Psychosocial issues are not share control and decision-making with clinicians. psychosocial well-being. A social model recognizes that those is touted as an approach that fits within social approaches to affected by aphasia must fulfill psychosocial needs through aphasia. Pound et al. 1984). In When communicative interactions are successful. consequences therapy (e. reflect more than linguistic or cognitive-processing deficits. 292 Section III ■ Psychosocial/Functional Approaches to Intervention therapy. relevant. a wide range of therapies that address living life with aphasia. 1991. nication (Tannen. 1999. Byng and colleagues (2000. and multidimen- sional.. and (9) encourage qual- to a philosophy that guides and frames assessment and itative as well as quantitative measures. or functional communication approaches (Worrall. model values invite people with aphasia and their families to Simmons-Mackie.. controls therapy decisions. an authoritarian clinician who sets all communication. treatment reflects client-centered values and practices (Byng taining a healthy identity are major goals of human commu. Brumfitt.GRBQ344-3513G-C11[290-318]. view communication as dynamic. the spe- DEFINING APHASIA IN A SOCIAL MODEL cific methods and techniques described will constitute “social approaches” practiced within a social model philosophy. and evalu- chosocial issues and neurolinguistic aspects should be inte. In fact.qxd 1/21/08 11:52 AM Page 292 Aptara Inc. (4) focus on the collaborative nature of communica- SOCIAL MODEL VERSUS SOCIAL tion. However. (6) focus on personal and social consequences of aphasia. 2001). tive to impairment-focused treatment (Duchan. 1989. Müller. 2000.” By expanding the definition of apha. Management is the linguistic deficit alone. While this chapter helps to define a social model. & Sarno. Finally. promote healthy identity and social integration. Social approaches Thus.. Ponzio. intervention. communication by the actual “activities” carried out in therapy (Byng & and psychosocial issues are woven together into the fabric of Duchan. per- of desired social roles. according to traditional standards the production would ordering in a restaurant. . 2005. Social approaches assume the flexibility and the consequences of aphasia. “Authentic contexts” are at the forefront of decision. . and how can we be sure to make Wilkes-Gibbs. It is likely that the social chat that not be considered normal. Simmons-Mackie & Damico. revisions. 1986. 1996. Klippi. 1999).” and “you know” are used to designed to promote message exchange and to get ideas bracket information and manage the flow of discourse across in whatever way possible (Davis & Wilcox. a more open-minded view of behavior and an apprecia- and promote our membership in groups. Goodwin (1987) describes purposeful “forgetfulness” as a While certainly the exchange of messages is important. (Shiffrin. munication. static. word errors. Appreciation of the tion of situated pragmatics are needed (Duchan. For example. 1998a.GRBQ344-3513G-C11[290-318]. & Gannaway. sentence completion). . 1993. . the communicative skills of those “around” the person with tially deludes us into viewing communication as invariant and aphasia and the dynamics of interaction. 2003. the strategy used by couples to bring a spouse into a conversa- social goals are equally. Thus. communication is a collaborative achievement (Goodwin. transac- by this question proffered by a well-respected aphasiologist. if not more. ation of communication within natural. it poten. develop and maintain an identity and sense of self. A full appreci. provide connections with other people.” “well. Address Communication within an Authentic Context Communicative change must make a difference in personally Communication Is Collaborative relevant contexts of those affected by aphasia. 1997. Chapter 11 ■ Social Approaches to Aphasia Intervention 293 Dual Goals of Transaction and Interaction of the informal discourse of standard speakers. at least I have . such deviations are typical surrounds these activities is as important as the task itself. Oelschlaeger & comes. assessment. Flexible. 1987. natural commu. creativity of communication. Much tradi- tional aphasia therapy and most formal aphasia tests are con. communication (Simmons. tional tasks such as cashing a check. discourse Communication as Dynamic. 1996b). 1992). social roles.qxd 1/21/08 11:52 AM Page 293 Aptara Inc. Tannen (1984) examines the use of Mackie & Damico. Conversation is a co- naming.g. Speaking style. 1984. 1995). informal communication includes dysfluen- cies. 1993). nication is stripped of its natural context. Many devices that deviate from “idealized exchange of information (transaction) and the fulfillment of language norms” are used in natural conversation to meet social needs (interaction) (Simmons. Research repeatedly affirms that appreciation of a person’s communicative life. When commu. ment efforts beyond the individual with aphasia to include While this helps determine an objective skill level. 1987. vidual with aphasia and onto the collaborative nature of textualized tasks and discrete elements of language (e. 2003. Hengst. Damico. Simmons-Mackie. Aphasiologists have evaluated communication in terms of & Bourhis. or yet. strategies are often used to serve a goal beyond communication we not only exchange information. 1987). tion. and goals. We assess “deficits” based on tive achievement requires expanding research and manage- expectations of how a standard speaker would perform. The following is a transcription of a question asked to a presenter at an aphasia conference: Conversation in its myriad forms has been labeled the pri- “So is this like one of the uh uh one of those that we’ve seen mary site of human communication in our society (Clark & before . Simmons- Mackie & Damico. Giles. Schultz. In reality. Simmons- communicative goals. 2005). and sentence fragments (Button Focus on Natural Interaction: Conversation & Lee. fulfill Perhaps in the practice of aphasia assessment and interven- emotional needs. A view of communication as a collabora- “idealized” normal language. 1993). structure. dynamic social context with tant social actions and work to help each other understand shifting expectancies. social goals of communication is critical to fully addressing Simmons. Hengst. . However. personally relevant 1995. 1973). but also the accurate and grammatical production of language. important. content. Neuman- contexts is imperative to ensuring effective therapy out. Stritzel. we get a skewed Milroy & Perkins. 1993. functional therapies have been Utterances such as “oh. Through tion. and even opinions are modified to accommodate and Multidimensional to speaking partners and context (Bell. and intervention in a social approach. with as little effort as possible (Clark & Wilkes-Gibbs.. asking for directions. constructed activity in which participants negotiate impor- nication occurs in a complex. In fact. By contrast. Social roles are established and maintained through interactive cooperation (Brumfitt. Kingston & making. Social goals of communication have been largely ignored. Taylor. 1998b. Shiffrin. In traditional aphasia therapy interruptions and joint talk in standard conversation as a clinicians have focused on the transactional aspects of com- means of achieving affiliation in certain cultural groups. 1985). “functional communica- the uh uh reee uh make the shift?” No one seemed disturbed tion” is often defined in terms of very goal-directed. It is important that clinicians fully appreciate the flexibility and creativity of Communication is designed to meet two primary goals: the language in use. and social goals are taken into account when assessing communication. In a social approach the focus is shifted away from the indi- ducted in relatively controlled contexts and focus on decon. Frame. 1986). full appreciation of how those affected “perceive” these con- tive goals. one individual Damico.qxd 1/21/08 11:52 AM Page 294 Aptara Inc. Hoen. 1999). . success in and enjoyment of conversational inter. Research confirms that people with aphasia are able to “powerfully” terminate the interaction rather than expose participate in interviews and ratings in order to share their his communicative “weakness. Qualitative approaches such as ethnographic interviews. In a social approach the clinician focuses on authentic context of daily communicative life. depends on cultural attitudes and knowledge regarding the In fact. Simmons-Mackie & Damico. ate” is judged in terms of the goal of the behavior and 1997. 1999. Attention to the prevalence of different from using the aid in a restaurant with an unpre- adaptive strategies used by a person with aphasia can make a pared waitress. chart the direction of intervention in concert with clinicians. and changed roles. research on con- the impact of aphasia on a person’s life is as important as versation and other communicative genres in aphasia has consideration of the disorder itself (Cardol et al.” Thus. research rarely focused on natural critical sociocultural role. Personal choice available alternatives. Social approaches necessitate a In a social approach clinicians access the subjective experi- focus on aspects of the environment that enable the person ence of aphasia and describe outcomes relative to the rich with aphasia. Thelander. but also tional aphasia therapy. Consumer perspectives and consumer satisfac- are considered normal or preferred behaviors (Booth & tion are a priority. perspectives (Doyle. Hilari.. Thus. Thus. 2005). Subjective the adaptive purpose of behaviors. LeDorze & Brassard. 2004). ety to enable the person’s participation. Smith. Fortunately. 2003. Therefore. understanding directly targeted conversation. Successful adaptations are often contrary to what sequences. & Worsley. who might experience loneliness. & Hickson. Worrall. 2005. Kagan. 2001). While impairment tends to be the focus of tradi- Consequences not only vary among individuals. Roy.GRBQ344-3513G-C11[290-318]. Rather than simply deciding what a client Perkins. when asked to des- Addressing the consequences for all those affected by apha- cribe a client’s naming response—“uh uh pen”—clinicians sia will help to promote a healthy social system. When communication is disrupted. Parr et al. 1995. assessment rarely included a sample associated with social consequences. matically undesirable behavior. using a pic- ability (rather than disability) are primary in social ture board to convey food choices at home might be quite approaches (LaPointe. energy depletion. & tity needs. It is difficult to address consequences of aphasia without a dard compensations might be required to meet communica. and few intervention approaches ers. to adapting soci. ciation of adaptive behavior. Aphasia also Impairment and Disability creates personal and social consequences for family and friends. Oelschlaeger & vary among those affected by aphasia. builds on existing adap. Byng. What is deemed “appropri. 2002). 1998b. Analysis suggested that he preferred to goals. 1993). routinely described word-finding problems or processing delays (Simmons-Mackie. goals. 1998a. 1997. grown considerably in the past decade. experience and richly contextualized events call for qualita- tations. providing valuable Consequences are judged based on the personal experience data to aid in focusing on natural interaction and conversa- of the communication problem. Focus on Personal and Social Consequences actions is a potentially important objective in aphasia inter- As noted. and autonomy are driving factors in management. a social model assumes that communication has a vention. to building mean- partners of people with aphasia will influence the success of ing and purpose in life as perceived by those affected by apha- interactions. For example. stigma. However. A considerable lit- erature has arisen that describes characteristics of enabling Qualitative as well as Quantitative Measures or disabling physical and social environments (Howe. the “uh uh” behavior could also be described as a successful floor-hold. potential social barri- of natural conversation. In part. this man chose what some might consider a prag. which will undoubtedly tion (Goodwin. Hengst et al. the adaptive skills and attitudes of speaking is broadened from reducing impairment. in a social approach those confronting aphasia adaptation of the individual with aphasia. The Perspective of Those Affected by Aphasia ing strategy. That is. to meet his own iden. Wiggins. nonstan. and takes into account social as well as linguistic tive as well as quantitative approaches to description. barriers to participation. Thus. 294 Section III ■ Psychosocial/Functional Approaches to Intervention Therefore.. The focus In addition.” intervention is based on consumer perceptions of often bombastically announced “I can’t talk” when ad. the personal experience of aphasia difference in our predictions of functional outcomes. 1998b). Until recently. with mild aphasia might experience no life changes while another individual with the same impairment might experi- Focus on Adaptations and Enablement Rather than ence significant life changes and personal loss.. Impaired communication can be conversation in aphasia. successful adaptations to aphasia and might vary from one context to another. life changes. one client with chronic aphasia “needs. Lyon. and important life dressed by strangers. embar- A social approach involves a positive stance towards life with rassment. an overemphasis on deficits might obscure appre- disability and expected life roles of those affected by aphasia. and resulting psychological issues. 2005. For example. 2003. emphasis expands beyond the sia. aphasia. GRBQ344-3513G-C11[290-318].qxd 1/21/08 11:52 AM Page 295 Aptara Inc. Chapter 11 ■ Social Approaches to Aphasia Intervention 295 personal narratives, and observational assessment provide importance of socially oriented goals has come from important insights to drive management plans (Simmons- research demonstrating associations between social relation- Mackie & Damico, 2001). Qualitative and descriptive meth- ships or participation and well-being, quality of life, and ods are gaining attention as viable additions to research and recovery (Cruice et al., 2003; Doyle, 2005; Hilari & assessment (Booth & Perkins, 1999; Damico, Simmons- Northcutt, 2006). Mackie, Oelschlaeger, Elman, & Armstrong, 1999; Fox, Poulsen, Bawden, & Packard, 2004; Perkins, Crisp, & GOALS OF INTERVENTION IN A Walshaw, 1999; Simmons-Mackie & Damico, 1996a, 1999; Sorin-Peters, 2004a). SOCIAL APPROACH Socially motivated approaches conform to the ultimate goal EFFECTIVENESS OF SOCIAL APPROACHES of Life Participation Approaches to Aphasia—that is, to enhance the living of life with aphasia. To achieve the overall Although the social model is a relative newcomer to aphasi- goal of living a satisfying life with aphasia, objectives might ology and additional research is needed, a growing data base include (1) enhancing natural communication; (2) increasing is accumulating to support the notion that social communi- successful participation in authentic events; (3) providing cation, communication opportunities, and well-being are support systems within the speaker’s community; (4) increas- amenable to intervention. For example, improvements in ing communicative confidence and positive sense-of-self; and communication, relationships, and social participation have (5) promoting advocacy and social action. These objectives been documented after including communication partners serve to guide intervention. Actual goals evolve out of a dia- in treatment (Boles, 1997; Hickey, Bourgeois, & Olswang, logue through which individuals with aphasia and clinicians 2004; Hopper, Holland, & Rewega, 2002; Kagan et al., negotiate specific outcome targets. 2001; Lyon, 1998b; Lyon et al., 1997; Rayner & Marshall, 2003; Rogers, Alarcon, & Olswang, 1999; Simmons- Mackie, Kearns, & Potechin, 2005). Changes in adjustment, ASSESSMENT WITHIN A SOCIAL MODEL knowledge of aphasia, and functioning were reported among Assessment in a social model encompasses a variety of tools people with aphasia and their families after participating in that document accomplishment within the goal domains brief intensive programs offering psychosocial support and outlined above. Traditional measures such as standardized education (Fox et al., 2004; Hinckley & Packard, 2001). tests remain appropriate to determine the level and pattern Improvement in communicative success as well as qualita- of deficits. However, measures of outcome beyond linguis- tive changes in knowledge, confidence, and relationships tic or cognitive skills are needed to determine whether were found by adapting principles of adult learning to work- intervention is making a difference in the lives of those ing with couples on communicative skills and issues related affected by aphasia (Frattali, 1998a, 1998b; Holland & to living with aphasia (Purdy & Hindenlang, 2005; Sorin- Thompson, 1998). For people with aphasia, making a dif- Peters, 2004b). Elman and Bernstein-Ellis (1999a, 1999b) ference probably means returning to work, enjoying dinner report positive effects of social group therapy for patients with friends, sharing a good joke, or gossiping over coffee. with chronic aphasia on both linguistic and psychosocial Thus, assessment is designed to provide insight into well- measures. Integrating psychosocial support and access to being, personal consequences, and lifestyle affects of social interaction into a community-based program has also aphasia. been successful (Hoen et al., 1997; Ireland & Wotton, 1996; Kagan, 1999). Reports have begun to surface regarding Situating Intervention within a Framework intervention focusing specifically on enhancing participa- tion in relevant life situations. For example, Lasker, LaPointe, Various frameworks and models are available to help orga- and Kodras (2005) report successful ratings of job perfor- nize assessment. For example, the World Health Organiza- mance for a college professor with aphasia after intervention tion (WHO) International Classification of Functioning, designed to facilitate teaching. The cost-effectiveness of Disability and Health (ICF) (2001) emphasizes the multiple social approaches has been reported since “meaningful” life domains that comprise health, including body structure and and/or relationship changes have been effected with rela- function, activities and participation, and contextual factors. tively few sessions (Lyon, 2004; Sorin- Peters, 2004b). Kagan and colleagues (2005; in progress) have adapted and There are also reports of positive effects of approaches that expanded the ICF framework and designed a simple modify external barriers or facilitate participation in activi- schematic (Living with Aphasia: Framework for Outcome ties of choice (Garrett & Beukelman, 1995; Howe et al., Measurement [A-FROM]) that serves as a guide to situate 2004; Lyon et al., 1997; Rose, Worrall, & McKenna, 2003; assessment and intervention. Figure 11–1 depicts the four Simmons-Mackie & Damico, 1996a, 2001; Simmons- key domains of life that dynamically interact and intersect to Mackie et al., 2007). Indirect evidence of the potential form one’s “quality of life” at the center. GRBQ344-3513G-C11[290-318].qxd 1/21/08 11:52 AM Page 296 Aptara Inc. 296 Section III ■ Psychosocial/Functional Approaches to Intervention also can be divided into evaluation of capacity versus evalua- Participation tion of actual performance (WHO, 2001). “Capacity” refers (& activities) to a person’s ability to perform a task in a clinical setting or test situation. “Performance” refers to what a person actu- ally does in his or her daily life. For example, someone with aphasia might be able to make a phone call (capacity), but does not make phone calls during daily life (performance). Assessment approaches applicable to social intervention Environment Personal, for aphasia are described below, and examples of tools are Life emotional & (as support listed in Table 11–1. Measures of the linguistic or cognitive or barrier) identity factors deficits are not included since this topic is covered in detail elsewhere. Perspectives of Those Affected by Aphasia Severity of A variety of tools assist the clinician in obtaining informa- aphasia tion from the perspective of those affected by aphasia rela- tive to aphasia severity (the impairment), life participation, Figure 11–1. Living with Aphasia: Framework for Outcome the communicative environment, and emotional factors. Measurement (A-FROM) (adapted from Kagan et al., in press). Ethnographic Interviews Ethnographic interviews have been recommended to deter- mine the personal viewpoints of those affected by aphasia Assessment in the domain of aphasia severity entails docu- (Simmons-Mackie & Damico, 1996a, 2001). By analyzing menting relevant linguistic or cognitive processes, either interviews before, during, or after the intervention, general those targeted on traditional aphasia batteries or the impair- themes are identified that help focus intervention or docu- ment as viewed by the person with aphasia. The domain of ment outcomes. Aspects of life participation, emotional participation includes a person’s relevant life habits, roles, and adjustment, and environmental factors relevant to interven- situations, such as employment, relationships, social conver- tion and outcome can be accessed through interviews. sation, or leisure activities. This domain also includes activ- Candidates for interviews include both the person with ities that are components of life habits or situations such as aphasia and others impacted by the aphasia. Ethnographic activities of daily living or functional tasks. Personal, emo- interviewing and analysis requires training and practice in tional, and identity factors refer to inherent characteristics of order to access the authentic perspectives of informants. the person (e.g., age, gender) as well as to factors related to Readers are directed to Spradley (1979) and Westby (1990) psychosocial well-being and identity (e.g., confidence, self- for explanations of the methodology. esteem). Environment refers to the physical or social envi- ronment in which a person functions. Aspects of these Communicative Profiling System (CPS) domains interact to create life with aphasia or quality of life at the center of the schematic. Assessment might target one or An approach to assessment based on qualitative research more of these domains. For example, changes might be doc- methods is the Communicative Profiling System described umented in a person’s self-esteem and confidence (personal by Simmons-Mackie and Damico (1996a, 2001). Interviews, domain) after intervention aimed at eliminating environ- personal journals, and observation are used to identify per- mental barriers to communicative participation (environ- sonally relevant behaviors, social relationships, emotions, ment domain). and situational contexts of participation. Thus, the client and In addition to different domains of assessment, measure- significant others catalog the behaviors that they consider ments might accrue from different sources. These include significant to life with aphasia. A social-network diagram is the perspectives of the person with aphasia, clinician judg- devised to represent the people with whom the person with ments (e.g., clinician ratings or observations), or proxy rat- aphasia interacts on a regular basis, as shown in Figure 11–2. ings or reports. The source of information should be clear Description of relationships helps identify the quality of since “insider” judgments (e.g., perspectives of the person social networks. Psychosocial and affective issues are also with aphasia) often differ from “outsider” judgments (e.g., catalogued. Finally, the contexts or activities that the person reports of others, clinician evaluation) (Cardol, de Haan, participates in on a regular basis are described. These layers Van den Bos, & de Groot, 1999; Cruice, Worrall, Hickson, of description help the clinician gain insight into communi- & Murison, 2005; Doyle, 2005; Parr et al. 1997). Assessment cation patterns and motivations. GRBQ344-3513G-C11[290-318].qxd 1/21/08 11:52 AM Page 297 Aptara Inc. Chapter 11 ■ Social Approaches to Aphasia Intervention 297 TABLE 11–1 Examples of Assessment Tools for a Social Approach to Aphasia Obtaining Perspectives of Those Affected by Aphasia Ethnographic interviews (Simmons-Mackie and Damico 1996a; 2001; Spradley, 1979; Westby, 1990) Communicative Profiling System (CPS) (Simmons-Mackie & Damico, 1996a, 2001) Opinion or consumer-satisfaction surveys (Patterson & Wells, 1995) Analysis of personal narratives (Frank, 1995; Greenhalgh & Hurwitz, 1999) Functional Communication and Activities Functional Assessment of Communication Skills for Adults (ASHA FACS) (Frattali et al., 1995) Functional Communication Profile (Sarno, 1969) Communication Profile (Payne, 1994) CADL-2 (Holland, Frattali, & Fromm, 1999) Conversational rating scales (Erlich & Barry, 1989; Garrett, 1999) Interactive Communication Scales (Lyon, 1998b) Discourse analysis • Content units (Yorkston & Beukelman, 1980) • Correct information units (Nicholas & Brookshire, 1993) • Lexical efficiency (Helm-Estabrooks & Albert, 1991) • Turns, initiations, time, and efficiency (Packard & Hinckley, 1997) Functional scenario ratings (Lyon et al., 1997) Communicative effectiveness/content/efficiency Measure of Skill in Providing Supported Conversation for Adults with Aphasia (M-SCA) (Kagan et al., 2004) Measure of Participation in Conversation by Adults with Aphasia (M-PCA) (Kagan et al., 2004) Rating of transactional success in conversation (Ramsberger & Rende, 2002) Communicative Effectiveness Ratings (Lyon et. al., 1997) Communicative Effectiveness Index (Lomas et al., 1989) Everyday Language Test (Blomert, Kean, Koster, & Schokker, 1994) Pragmatic assessments (e.g. Penn, 1988) Descriptive measures of number, success, and type of compensatory strategies Conversation Analysis Profile for People with Aphasia (CAPPA) (Whitworth et al., 1997) Participation Adapted Activity Card Sort (Haley et al., 2005) Frequency counts (e.g., number of social contacts, number of activities, hours of participation) Community Integration Questionnaire (Corrigan, Smith-Knapp, & Granger, 1998) Social-network analysis/contextual analysis (Simmons-Mackie & Damico, 1996a, 2001) Personal goal-attainment scales (Schlosser, 2004) Assessment of Life Habits (Life-H) (Noreau et al., 2004) Personal, Emotional, and Psychosocial Factors Affect Balance Scale (Bradburn, 1969) Code-Müller Protocols (Code & Müller, 1992) Psychosocial well-being index for aphasia (Lyon et al., 1997 ) Visual Analogue Mood Scale (Stern et al., 1997) (continued) GRBQ344-3513G-C11[290-318].qxd 1/21/08 11:52 AM Page 298 Aptara Inc. 298 Section III ■ Psychosocial/Functional Approaches to Intervention TABLE 11–1 Examples of Assessment Tools for a Social Approach to Aphasia (continued) Environment Observation and/or interview: Catalog barriers to and enablers of participation Craig Hospital Inventory of Environmental Factors (CHIEF) (2001) Quality of Life ASHA Quality of Communicative Life Scales (Paul et al., 2004) Burden of Stroke Scale (BOSS) (Doyle et al., 2004) The Stroke and Aphasia Quality of Life Scale (SAQOL-39) (Hilari, 2003) Life Satisfaction Index (Neugarten, Havighurst, & Tobin, 1961) Satisfaction with Life Scale (Larsen, Diener, & Emmons, 1985) Life Satisfaction Survey (Chubon, 1987) Ryff scales (Ryff, 1989) Present Life Survey (Records et al., 1992) Professional Judgments Professional judgments or ratings are typical for measuring communicative effectiveness, performance of functional Assessment from the perspective of the professional is daily activities, and describing characteristics of conversa- another source of measured outcomes. The speech-language tion. pathologist evaluates performance as compared to defined target goals or expectations of “normal.” In fact, most tradi- tional assessment tools involve scoring or ratings completed Activities and Participation by the professional to document aspects of communication. Functional Assessment and Activities of Daily Living Using tests of functional communication clinicians assess or rate performance across a variety of categories or tasks typi- cal of the daily activities of most people (Frattali, Thompson, SLP Holland, Wohl, & Ferketic, 1995; Worrall, 1992). For Charlee example, the clinician rates observed or reported perfor- Son-in- mance on “talking on the phone” or “reading the newspa- Father Mel law per.” In a social model, interpretation of such data must be Grandchild balanced with information on the personal relevance of each Rayne task, since the importance of functional tasks varies from Mica person to person (Davidson, Worrall, & Hickson, 1999; Payne, 1994; Smith, 1985). Talking on the phone might be Daughter deemed highly important to one person, yet minimally “M” Neighbor important to another, even when their lifestyles appear sim- ilar. In addition, it is important that clinicians are aware of Katie actual function in daily life, not simply the ability to perform Husband various functional tasks. Sister Son Sarah Communicative-Effectiveness Ratings and Conversation Analysis Beth Sister Analyzing communicative interactions using communica- tive-effectiveness ratings is a prevalent approach to assess- ment. Aspects of an exchange, such as success of message Figure 11–2. Example of a Social Network Analysis for “M,” transmission, efficiency, naturalness, or pragmatic appropri- an Individual with Aphasia (Simmons-Mackie & Damico, ateness are rated for baseline or follow-up data. Barrier 1996a, 2001). activities, “simulated” functional scenarios, or samples of GRBQ344-3513G-C11[290-318].qxd 1/21/08 11:52 AM Page 299 Aptara Inc. Chapter 11 ■ Social Approaches to Aphasia Intervention 299 TABLE 11–2 Example of an Inventory of Key Life Activities Before the Onset of Aphasia, at Assessment (2 Years Post-Onset), and After Participation-Focused Intervention Pre-Onset Initial Assessment Outcome Assessment Teaching 1st grade Preschool volunteer Church on Sunday Church on Sunday Church on Sunday Cook for church (Wednesday) Carnival club Secretary Carnival club attendee Walk 2 miles daily Walk with friend daily Prepare family dinner Host family dinner Baby sit grandchild Baby sit grandchild Baby sit grandchild Garden club Gardening Gardening (some) Gardening (some) Reading Reading (news) Reading (news) Television Television (Adapted from Simmons-Mackie, N., & Damico, J. (2001). Intervention outcomes: A clinical application of qualitative methods. Topics Language Disorders, 22(1), 21–36.) natural conversation provide contexts for rating behaviors of participation is important for capturing meaningful life interest (Lyon et al., 1997). The interaction, not simply the changes. There are a number of approaches to measuring behavior of the client alone, is an important target of assess- participation. Simmons-Mackie & Damico (1996a, 2001) ment (Leiwo, 1994). Kagan and colleagues (2004) report on apply social-network analysis and contextual inventories to two scales that provide insight into both the interactional identify social contacts and activities performed on a regular and message-transmission skills of the person with aphasia basis as reported by people with aphasia and their significant and a communication partner. Ramsberger and Rende others. Personally relevant changes in these inventories rep- (2002) describe a method of analyzing “transactional” suc- resent life-participation accomplishments. An activity inven- cess in conversation. Communicative-effectiveness ratings tory for a person with aphasia who entered therapy 2 years need not come solely from the perspective of the profes- post-onset is presented in Table 11-2; it is clear from visual sional. Clients or others (e.g., family, friend, employer) can inspection that both the number and quality of activities rate their own perceptions of communicative effectiveness, increased after “activity-focused” intervention. Similarly, social- as in the Communicative Effectiveness Index (Lomas et al., network maps (as in Fig. 11-2) can serve as visual evidence of 1989). In addition, perceived conversational engagement or increased social relationships (Simmons-Mackie & Damico, enjoyment during natural conversation might be a rating 1996a, 2001). Lyon (2000) lists “obligated” and “free-time” target. activities pre- and post-aphasia to provide data on lifestyle Since performance on linguistic tasks does not necessarily changes. Others (Haley et al., 2005) describe an adaptation of predict how one performs in natural conversation (Beeke, the Activity Card Sort (ACS) (Baum & Edwards, 2001) to Wilkinson, & Maxim, 2003; Horton, 2004; Wilkinson, obtain information from adults with aphasia regarding their 2004), analysis of conversation is an important component current and prior life activities. Simple frequency counts also of assessment, particularly if intervention is to effect changes provide data. For example, if a goal involves increasing the in natural social interactions. Conversation Analysis (CA) is number of social contacts per week or the variety of activities, a potential tool for documenting communicative interac- then simple counts document increases over time. Similarly, tions (Perkins et al., 1999). The Conversation Analysis hours of participation might serve as a “quick and dirty” mea- Profile for People with Aphasia is based on principles of CA sure of increased activity. (Whitworth, Perkins, & Lesser, 1997). Participation can be judged from either an outsider per- spective (e.g., ratings or counts by experts) or an insider per- spective (e.g., reports or ratings by the person with aphasia). Measures of Participation For example, clinicians, family members, or hospital staff While the preceding functional and communication mea- might keep journals or observational diaries to document sures provide useful information, documenting actual social aspects of communication and participation of the person GRBQ344-3513G-C11[290-318].qxd 1/21/08 11:52 AM Page 300 Aptara Inc. 300 Section III ■ Psychosocial/Functional Approaches to Intervention with aphasia. Observational data collected by the clinician in Numerous measures are grouped as quality-of-life tools natural communication situations is valuable in documenting (Engell, Hutter, Willmes, & Huber, 2003; Hilari et al., 2003; the presence and success of adaptations or compensations and Paul et al., 2004; Records, Tomblin, & Freese, 1992; Ross, changes over the course of treatment. Increasingly, however, 2005; Ross & Wertz, 2003; Ryff, 1989; Worrall & Holland, assessment of social participation and functioning in society as 2003). Typically, the person with aphasia conducts a rating judged by those affected by aphasia has been viewed as an essen- across one or more dimensions believed to represent aspects of tial element in rehabilitation (Cardol et al., 1999; Kagan et al., well-being, satisfaction, or QOL. Since QOL is highly per- in press). In other words, people place different values on sonal and subjective, those actually affected by aphasia should particular life situations, frequency of activities, or social con- complete the ratings, and the dimensions rated must be mean- tacts. It is difficult to judge the “success” of social participa- ingful and important to the person. Many quality-of-life tools tion without capturing whether or not the changes are mean- include items reflecting various domains, including aspects ingful to the person with aphasia and/or family. related to the health condition itself (e.g., aphasia severity), psychological or emotional state (e.g., confidence, depression), Goal-Attainment Scales and/or social activities and participation (e.g., leisure activities). Improvement over time in actual participation can be mea- sured with scales designed to judge movement towards partic- INTERVENTION WITHIN A SOCIAL MODEL ular individually defined life-participation goals (Pound et al., A social approach to intervention involves the ever-present 2000; Simmons-Mackie, 2000). For example, the individual and overt goal of enhancing overall QOL and participation who wishes to participate in an adult-education class works in activities of choice. Individual goals explicitly address with the therapist to identify requirements to be achieved in practical and personally relevant outcomes. Specific objec- order to meet this goal. Relevant scales can be developed to tives to be discussed below include (1) enhancing communi- document achievement towards selected life goals. For exam- cation; (2) increasing participation in events; (3) providing ple, return to work might be documented along an ordinal support systems; (4) increasing confidence and positive scale ranging from unemployed (rated as 1) to working full- identity; and (5) promoting advocacy. time at full pay with adaptations (rated as 5). Within the goal scale, each rating is defined (e.g., a 3  half-time, reduced salary/benefits). While results of such measures are not always Enhancing Communication comparable across patients and do not inherently indicate the significance of changes (Hesketh & Hopcutt, 1997), personal- To participate fully in life, one important goal of interven- goal-attainment scales are valuable in combination with other tion is enhanced communicative interactions. Thus, increas- measures. Methods of developing goal-attainment scales and ing the communicative skill and confidence of the person statistically analyzing results are available (Schlosser, 2004). with aphasia and/or potential communication partners might constitute a focus of therapy. Communicative Environment Expanding Skill and Confidence in Conversation Interview and observation are the most widely used methods of documenting environmental barriers to and enablers of Skill and confidence in conversation is an appropriate objec- communicative or life participation for people with aphasia tive of socially motivated intervention. Significant attention (e.g., Simmons-Mackie et al., in press). Clinicians might inter- to natural conversation is only recently being addressed in view people with aphasia and their family members to identify the aphasia literature. As Leiwo (1994, p. 480) explains, “a barriers to participation, particularly in personally relevant genuine social interaction with meaningful discourse topics environments (e.g., home, hospital, work). Observation of sets different goals for communication than the more or less authentic events and situations also provides information on artificial metalinguistic tasks, role-playing tasks or discus- social, physical, attitudinal, temporal, and organizational fac- sions that employ stimulus pictures and cards. Different tors that enable or disable participation. Such assessments are goals evoke different discourse strategies.” Research supports typically directed at improving participation of a particular Leiwo’s statement. For example, traditional therapy dis- individual with aphasia; however, a more broad-based assess- course includes a pervasive “teaching” discourse structure— ment might be conducted to determine the “aphasia friendli- the Request-Response-Evaluation (RRE) triad—in which ness” of various settings, facilities, or organizations. the therapist “requests” the client to perform some task (e.g., What is this?), the client “responds” (e.g., pencil), and the therapist “evaluates” the response (e.g., “good job”) Quality of Life (Simmons-Mackie & Damico, 1999; Simmons-Mackie, Another approach to assessment includes gathering self- Damico, & Damico, 1999). This RRE structure is not typi- reports or ratings of life satisfaction or quality of life (QOL). cal of adult social conversation. Natural conversation—the GRBQ344-3513G-C11[290-318].qxd 1/21/08 11:52 AM Page 301 Aptara Inc. Chapter 11 ■ Social Approaches to Aphasia Intervention 301 everyday, ordinary talk that serves both social and transac- (Simmons, 1993). Training in such message transmission tional goals—involves varied discourse structures, creative strategies has not always generalized as well as we might discourse devices, varying social stances, and shifting social expect (Kraat, 1990; Simmons, 1993; Thompson, 1989). roles. This contrasts markedly with the relatively rigid struc- One reason is probably related to the social appropriateness ture of traditional therapy, in which therapist-patient roles of strategies and the necessity for both parties to understand tend to be maintained and discourse structures are relatively and use strategies. For example, Sachett, Byng, Marshall, restricted (Ferguson & Armstrong, 2004; Silvast, 1991; and Pound (1999) demonstrated that communication part- Simmons-Mackie et al., 1999; Wilcox & Davis, 1977). Even ners must modify their own communication to accommo- conversation between therapist and client often conforms to date strategy use by the person with aphasia. Simmons- interview patterns, with therapists asking questions and Mackie (1998a) suggests that accommodation theory might clients responding (Holland, 1998b; Simmons-Mackie & explain this to some degree—that is, people in conversation Damico, 1999). Restricted discourse structures and passive tend to alter their manner of communication to be “like” the roles provide little occasion for practicing the myriad skills other person’s style of communication (Bell, 1984; Giles et al., typical of natural conversation. In order for people with 1973). If a nonaphasic partner does not use writing, then it is aphasia to practice strategies for engaging in conversation, less likely that the aphasic speaker will feel comfortable then mediated and supported opportunities should be doing so. Furthermore, most compensatory strategies are provided. trained independent of their natural use; thus, natural social contingencies are not present. Also, strategy training has not Conversation Therapy emphasized creativity and flexibility in generating novel applications during the rapid, dynamic flow of conversation. One means of enhancing conversational interaction is direct Therefore, an expanded approach to compensatory strategy conversation therapy (Simmons-Mackie, 2000). training is suggested. Conversation therapy refers to planned intervention that is In enhanced compensatory strategy training, creativity, explicitly designed to enhance conversational abilities. It generativity, and interactivity are priorities. For example, does not necessarily involve “conversing” during therapy, rather than simply training a corpus of gestures or drawings, although usually a conversational context is appropriate. the client learns to generate ideas via vocalization, drawing, Conversation therapy is goal-directed and individualized. It or gesture within a dynamic interchange. Examples include is not simply having a conversation. The goal of having a Lyon’s (1995) interactive-drawing approach to training conversation is to exchange information and fulfill social drawing as a collaborative effort between communication needs. The goal of conversation therapy is to improve one’s partners, and Demchuk’s (1996) creative communication skill and confidence as a conversational participant. approach in which people with aphasia generate pantomime Conversation therapy focuses not only on message scenarios using principles drawn from dramatic enactment. exchange, but also on social communication skills appropri- In such approaches, creativity and spontaneity are rein- ate to specific communicative events. Thus, aspects of inter- forced. Clients are encouraged and supported in generating action such as power and control, variety of social roles, their own novel strategies, and existing strategies are rein- range of discourse structures, and issues of self-esteem gain forced and expanded. Therapy is conducted in a richly con- equal importance to linguistic form and content. Improving textualized interaction. For example, drawing is practiced skill in activities such as arguing, joke-telling, storytelling, within a conversational exchange in which both the client and gossiping might be addressed, along with the usual and clinician augment verbal productions with drawings. speech act repertoire. Conversation therapy might also The person with aphasia is considered a partner in identify- focus on exploiting the use of paralinguistic, nonlinguistic, ing and elaborating a strategy repertoire. and contextual cues to enhance conversation (Goodwin, Interactive as well as transactional strategies are included 2003; Hengst et al., 2005; Simmons-Mackie et al., 2005). in enhanced compensatory strategy management. For exam- Finally, emphasis is placed on gaining confidence as well as ple, strategies for shifting the communicative burden or building skill in participating in communicative interactions. encouraging the nonaphasic partner to continue talking might be important methods for a person with severe apha- Enhanced Compensatory-Strategy Training sia to stay in a conversation. A range of variables is consid- Improving natural interactions often requires the use of ered in selecting strategies, such as the amount of “burden” compensatory strategies. Traditionally, the individual with placed on the partner (e.g., having to guess what a gesture aphasia has been taught compensatory strategies designed to means), stigma associated with the strategy (e.g., does it call enhance message transmission across a variety of situations. attention), naturalness (e.g., performed relatively automati- For example, strategies such as gesture, writing, asking for cally versus requiring much conscious effort), time con- repeats, and using augmentative aids are widely used to straints (e.g., does it take too long), affect on the “flow” improve communication in the face of residual aphasia of interaction, and appropriateness in a specific context (e.g., GRBQ344-3513G-C11[290-318].qxd 1/21/08 11:52 AM Page 302 Aptara Inc. 302 Section III ■ Psychosocial/Functional Approaches to Intervention attitudes, cultural norms) (Simmons-Mackie & Damico, & Carr, 2005; Youmans, Holland, Munoz, & Bourgeois, 1997). 2005). We as clinicians must maintain an open mind about potential strategies. That is, many strategies are not “nor- Group Therapy mal” yet they constitute the best available alternative for a given person. For example, avoiding interaction is often Group therapy is an effective context for improving com- considered a “problem” by speech-language pathologists munication and well-being in aphasia (Elman & Bernstein- who are anxious for their clients to use their residual com- Ellis, 1999a, 1999b). Moreover, groups provide an ideal con- munication skills to participate in society. However, if the text for conversation therapy. The key to addressing client feels that participating is more “punishing” than sit- conversational skills within a group format is to focus on ting home alone, then the avoidance behavior serves a nec- interaction rather than practicing didactic, discrete skills. essary social objective. In such a case it might be important Such groups foster a sense of joint purpose and emphasize to identify “supported” activities that are rewarding and meaningful communicative interactions (Graham & Avent, work towards building contexts that satisfy the client’s social 2004). Overlaying a teaching style and traditional therapy needs, rather than eliminating a strategy without a viable tasks (e.g., naming, sentence formulation) onto a group is alternative. unlikely to fulfill the requirements of conversation therapy. Rather, promoting conversation within a group context requires considerable skill in facilitating participation, Conversational Coaching equalizing control, and promoting confidence. In addition Conversational coaching, introduced by Holland (1988; to peer conversation, groups can build skill and confidence Hopper et al., 2002), provides for practice of communicative in a variety of natural communication genres such as telling scenarios with the guidance of the speech-language patholo- stories, arguing, or complaining. Role-playing has been sug- gist, who serves as a “coach.” The approach involves (1) iden- gested as a mechanism for easing into difficult communica- tifying a goal or scenario to target in therapy; (2) planning tion activities since groups can jointly problem-solve, enact what is needed; (3) developing a script and resources; (4) roles, and evaluate performances. Texts and videos are now practicing with coaching as needed; (5) performing the sce- available with information and ideas for managing aphasia nario; and (6) evaluating the outcome. For example, one groups (Avent, 1997; Elman, 2007; Marshall, 1999; Pound client wanted to “argue” with her dietitian about her unpalat- et al., 2000). able diet. Planning involved identifying the main ideas, how to begin, possible strategies, useful resources such as pictures Scaffolded and Supported Conversations and written words, and important details to convey. Together, One method of promoting conversation that works well in a the client and clinician developed a scripted scenario. group or role-play context is to employ scaffolding tech- Practice sessions revealed a number of potential weak spots niques. In order to scaffold communication the clinician or and alternative strategies. In addition, manner of delivery was other group members provide cues or facilitators within the targeted to avoid angering the dietitian. In the process, the natural flow of interaction. In other words, others mediate client identified strategies applicable to other situations and the participation of a person with aphasia. Damico (1992) her confidence soared. Thus, a scripted scenario not only proposes suggestions for scaffolding. met a specific communicative need, but also served to build confidence and skill in general. In addition, the format of 1. The clinician follows the communicative contributions conversational coaching tends to “equalize” the roles of ther- of the client rather than controlling or directing the dis- apist (coach) and client (communication player), creating a course. In other words, the clinician is available to more client-centered approach. Thus, an important element expand and facilitate, but avoids “taking over” (e.g., of coaching is the emphasis on symmetric discourse, the asking all the questions, dictating topics, requesting client’s active role and attention to “face saving” as a priority performances). (Leiwo, 1994). Another important element of conversational 2. Interaction emerges from a meaningful activity. For coaching is script-training. Scripts, prescribed or routinized example, sharing vacation photos might elicit more courses of action or talk, pervade our daily lives. For example, interactive communication than asking someone to tell favorite stories that are told and retold within families often about a trip. have a relatively set structure and content. Routine activities 3. Responses are mediated or facilitated within the natural often entail relatively habitual elements of communication give-and-take of the interaction. For example, the clini- (e.g., ordering from a catalog, calling a taxi). Various cian might use subtle gestural prompts or write key approaches to script- and text-training have been advocated words to support a client during the interaction. for improving a range of discourse genres such as telling 4. Feedback should be appropriate to the communication jokes or making introductions (Armstrong, 1993; Hinckley event. If the communication is understood, then the talk GRBQ344-3513G-C11[290-318].qxd 1/21/08 11:52 AM Page 303 Aptara Inc. Chapter 11 ■ Social Approaches to Aphasia Intervention 303 proceeds; if not, then a request for clarification is in aspects of the interaction. She provides guidelines for order. Thus, clients experience natural consequences interactive therapy with children that can be generalized to for communicative success and failure, rather than eval- adults with aphasia. She suggests that the role of the clini- uative feedback such as “good talking.” cian shifts from that of “interventionist imparting knowl- edge” to that of “facilitator supporting role change” Contrast the following examples of communication. A (Duchan, 1997, p. 10). The supports provided include group of people with aphasia have watched a short excerpt social (e.g., relating well, creating positive role identity), from an “I Love Lucy” show. emotional (e.g., helping one another save face, feel empow- ered), functional (e.g., achieving communication goals), physical (e.g., providing accessible materials), discourse (e.g., scaffolding), and event support (e.g., providing con- Example 1 texts, letting participants know what to expect). Clinician: John, can you tell me about Lucy’s job? John: (Laughs) Eating. Partner Training Clinician: Well, (laughs) that is what she did, but Another method of enhancing communication is through what was her real job? trained and knowledgeable communication partners. John: (Shrugs) Partner-training is appropriate for family members, care- Clinician: George, what was her job supposed to be? givers, friends, colleagues at work, and the community at George: Candy. large. Thus, interactions ranging from social conversation Clinician: Good, she worked with candy. Claire, what with poker buddies to discussion with one’s attorney can was her job? be facilitated when speaking partners are knowledgeable Claire: (gestures) and skilled. Training speaking partners actually improves Clinician: Right, she was supposed to put the candy the communication of the person with aphasia (Boles, in the box. 1997; Hickey et al., 2004; Hopper et al., 2002; Kagan Example 2 et al., 2001; Lock et al., 2001; Lyon, 1997, 1998b; Lyon et al., 1997; Rogers et al., 1999; Simmons-Mackie et al., 2005). Clinician: (Laughing) Oh boy! Isn’t that Lucy In fact, Kagan (1995, 1998; Kagan et al., 2001) reports that something? onlookers judge the aphasic speaker as more competent Claire: (Laughing) (gestures shoving food into her when they interact with a trained partner who provides mouth) “communication support.” Thus, success of the interaction Clinician: (Laughs) (writes “eating” in large letters and judgments of competence depend not only on the per- while Claire gestures) son with aphasia, but also on the skills of the nonaphasic John: Eating, eating (gestures). communication partner. Claire: Too much (laughing and gesturing). Partner training accomplishes several objectives. First, Clinician: Eating candy! Not too much for me—I speaking partners learn concrete strategies to support com- could eat it all. munication when aphasia interferes. Second, trained speak- George: Me too. Eat it all. Candy. ing partners who use augmentative tools provide a context John: Mmm. I like candy. that encourages the partner with aphasia to use such modes. Third, partner training results in altered expectations and perceptions of speakers with aphasia. Once partners recog- The first example is a didactic, clinician-focused interaction in nize that people with aphasia can be competent and interest- which the therapist attempts to elicit specific responses from ing human beings, they are less likely to avoid interactions the group members. The second example is a scaffolded con- or feel bewildered by communicative failures. Finally, partner- versation in which the content and direction flows with the training can expand opportunities for communication. By group interaction. The clinician provides a written prompt alleviating embarrassment, feelings of helplessness, and fear, (“eating”) and models a verbal production (“I could eat it all”) it is more likely that partners will provide supportive oppor- within the natural give-and-take of conversation. Although tunities to communicate. scaffolded conversation is the intent, it is appropriate for both Direct partner training and feedback are necessary for the clinician and group members to occasionally “step outside” interactive patterns and techniques to be learned and incor- of the interaction to serve as “coaches” and make “meta” com- porated into daily use (Simmons et al., 2005). Counseling or ments or suggest potentially useful strategies. providing lists of do’s and don’ts is insufficient. Moreover, Duchan (1997) expands on the idea of scaffolding dis- communication partner training does not involve teaching course to suggest that the therapist support multiple partners to be “therapists” for the person with aphasia. In GRBQ344-3513G-C11[290-318].qxd 1/21/08 11:52 AM Page 304 Aptara Inc. 304 Section III ■ Psychosocial/Functional Approaches to Intervention fact, such an approach often creates a teacher-student inter- cise, and conversation groups for people with aphasia (e.g., active relationship that differs in structure and social dynam- www.aphasiacenter.org; www.aphasia.ca; www.ukconnect. ics from natural adult social interaction. Rather, a successful org; www.ydac.on.ca). For example, the Aphasia Center of speaking partner requires an understanding of how to facili- California provides a participation-based approach to tate a satisfying conversation. This includes knowledge of improving reading skill and enjoyment. Book clubs are potential strategies and insight into characteristics of inter- offered that involve guided reading assignments, adapted active communication. Appendix 11-1 lists examples of materials appropriate for various levels of aphasia, and compensatory strategies for speaking partners of people facilitated group discussion (Bernstein-Ellis & Elman, with aphasia. In addition to successful communication 2006). Such participation provides a typical experience of strategies, partners need to learn how to create an interac- everyday life with support. Moreover, anecdotal evidence tion that feels natural and reinforces the confidence and suggests that guided participation may facilitate reading autonomy of the person with aphasia. Research suggests that skill. an empowering attitude might be as important as use of a Other approaches focus specifically on enhancing par- concrete strategy for speaking partners of people with apha- ticipation in relevant life situations. (Lyon, 1996, 2000; sia (Simmons-Mackie & Kagan, 1999; Simmons-Mackie et al., Sarno & Chambers, 1997). Lyon (2004) describes individ- 2005). ual intervention at the level of “life processes.” His approach Improving the skills of the partner is only one part of the involves identifying what is important in someone’s life, intervention: the person with aphasia is also responsible for identifying barriers, and working with all concerned to promoting successful exchanges. Thus, intervention might facilitate participation in authentic life situations. Lyon be directed at people with aphasia along with their regular warns that a good outcome of such intervention is a partners. Intervention aimed at the dyad often extends renewed sense of purpose and engagement in life, not nec- beyond didactic instruction in communicative skills. For essarily “complete happiness” (since this is rarely achiev- example, programs have focused on various combinations of able with or without aphasia). Similarly, activity-focused communicative-skills training, counseling, and education intervention involves identifying potential activities or life (Boles & Lewis, 2000; Fox et al., 2004; Hinckley & Packard, situations with the client and intervening to ensure suc- 2001; Purdy & Hindenlang, 2005; Sorin-Peters, 2004b). cessful participation (Simmons-Mackie, 2000). The activity need not be “communication-centered”; rather, the goal is to enhance life participation. Once an activity of choice is Increasing Successful Participation in Authentic identified, then the clinician in collaboration with the per- Communication Events son affected by aphasia determine characteristics of the Without opportunities to communicate, improved language activity that will be addressed to ensure success. This is a trivial accomplishment. For most of us, communication might involve working with the client to build specific takes place in the context of life activities. For example, peo- skills or strategies and/or modifying the activity to accom- ple converse while eating lunch with friends, attending art modate the person with aphasia. It is particularly helpful openings, or playing cards. In fact, research suggests that for the clinician to participate in the identified activity in subjective well-being and involvement in social activity are order to fully appreciate the requirements and identify an positively associated (Cardol et al., 2002; Diener, 1984; entry point that helps smooth the way for participation. Fuhrer, 1994; Fuhrer, Rintala, Hart, Clearman, & Young, Prior or existing pastimes as well as new activities are 1992). Among individuals with physical disability “greater appropriate targets of intervention. It is not the intent to life satisfaction was reported by persons who were doing strive for a “pre-aphasia” lifestyle. Rather, a satisfying life more to maintain customary social relationships . . . and with aphasia is the goal. The clinician, client, and others spending more time in ways customary for their gender, age identify activity goals such as hobbies, interests, functional and culture” (Fuhrer, 1994, p. 362). In a social approach the tasks, volunteer jobs, or employment in which the client speech-language pathologist is responsible for increasing would like to participate. Through interviews, prior inter- opportunities for communication outside of the clinical ests and future aspirations can be gleaned. An interest sur- environment and for addressing barriers beyond the individ- vey can identify potential new activities. For example, ual’s impairment. clients might sort a large variety of activity pictures (e.g., One means of increasing participation in relevant com- grooming pets, cooking, gardening, painting, walking, munication events is to ensure that relevant life activities etc.) into preference categories. In this way a rough inven- are accessible and successful (Lyon, 1996, 1997; Lyon et al., tory of preferences can serve as a starting point for identi- 1997; Simmons-Mackie, 1993, 1994, 2000). This might fying potential activities. It is important that choices are involve programs designed to provide supported-participation client-motivated and that participation is directly facili- opportunities. Dedicated aphasia centers are now offering tated. Simply identifying an activity and encouraging par- a variety of supported opportunities, such as leisure, exer- ticipation is generally unsuccessful. GRBQ344-3513G-C11[290-318].qxd 1/21/08 11:52 AM Page 305 Aptara Inc. Chapter 11 ■ Social Approaches to Aphasia Intervention 305 has been defined as a limitation of access to normal life due Case Example to physical or social barriers (French, 1993; Byng et al., 2000). Frameworks of health and disability have helped Moderate Aphasia focus intervention on factors that affect participation (Kagan et al., in press; WHO, 2001). In such models both inter- TG, a woman with moderate aphasia, expressed interest in nal and external factors affect one’s participation in life. returning to her Bible class at church. In spite of improve- Internal factors pertain to physical and psychological func- ments in communication and her expressed desire to return tions such as cognitive, linguistic, motor, or sensory to class, she avoided doing so. A visit to the event with the integrity. These internal consequences, such as language- clinician was initiated. During this visit TG and the clini- processing deficits, are often addressed in traditional reha- cian met privately with the bible-class teacher. At the sug- bilitation. Environmental factors include the physical and gestion of the teacher, TG agreed to pass out coffee and social structures of the outside world. Physical barriers snacks, but insisted that she did not want to participate in include architectural, visual, auditory, or temporal elements the class discussion. The teacher suggested that TG and that disrupt communication or participation. For example, the clinician explain aphasia to the class. Since TG was vis- attempting to communicate in a noisy bank lobby or trying ibly alarmed at this prospect, the clinician offered to pre- to conduct business when impatient people are waiting in sent to the class. As TG greeted her old friends and served line could be very difficult for a person with aphasia. Societal coffee her demeanor changed; the demands of serving did barriers to communication include attitudinal, political, not require sophisticated conversation and allowed her a governmental, economic, and educational factors. Barriers “soft” initiation back into the group. Interestingly, once the can be observable, such as complex written signs in build- clinician began to talk to the class about aphasia TG “forgot” ings, or hidden, such as prejudice, negative attitudes, and about her pledge to remain quiet and became absorbed in ignorance. Garcia, Barrette, and Laroche (2000) suggest the discussion. During this discussion the therapist mod- that sometimes a simple shift in viewpoint will reconfigure eled various methods for facilitating interaction and made an impairment into a barrier that can be removed. For suggestions to the class members. Over the next few weeks, example, a person with aphasia who has difficulty talking on a variety of additional adaptations were identified. For the telephone would be unable to perform a job that example, the teacher provided TG with a written lesson- depends on phone use. Thus the “verbal impairment” of the script that TG could use to follow the discussion and access individual prevents job performance. However, if the indi- difficult words. The class began using a flip chart to write vidual with aphasia could perform the same functions using key words during the discussions; all agreed that this facili- electronic mail, then “phone use” can be considered a bar- tated their discussion as much as it helped TG. In effect, rier that could be removed to help accommodate the disabil- the teacher and other class members learned how to sup- ity. This shift in focus away from the problems of the indi- port TG’s communication and facilitate her reentry into vidual and onto the external barriers is an important the class, and TG gained confidence in her ability to paradigm shift required in adopting a social approach participate. (Garcia et al., 2000). Providing Communicative Support Systems Activity-focused intervention shares similarities with tra- within the Speaker’s Community ditional functional therapies that address performance of specific activities. However, many functional therapies focus Related to measures designed to increase participation in on discrete tasks or generic skills such as writing a grocery list relevant activities is the concept of providing an environ- or ordering in a restaurant. Unfortunately, learning specific ment conducive to successful communication and participa- tasks does not ensure actual participation in the event. tion. Participation in society is most likely to occur when Functional approaches can be expanded to be more socially environments are “aphasia-friendly” or communicatively valid by ensuring that intervention is contextually situated accessible (Ghidella, Murray, Smart, McKenna, & Worrall, and by modifying the environment as well as training the 2005; Kagan & LeBlanc, 2002; Simmons-Mackie et al., in client. Thus, the functional task should be defined to address press). A communicatively accessible environment provides all parameters that will increase participation. Finally, a satis- ease of communication and access to information, systems, fying life is rarely limited to performing “chores”; therefore, and choices (Howe et al., 2004). Thus, a goal of intervention it is important that an array of chosen life activities provide is to create an environment that facilitates participation opportunities for socialization and fulfilling engagement. (Cardol et al., 2002). As noted above, this can be accom- In addition to intervention focusing directly on life plished in part by identifying and modifying barriers within habits, a related method of increasing participation is to the environment. Similarly, it is important to identify meth- identify and eliminate barriers to participation. Disability ods of enabling participation, such as providing physical and GRBQ344-3513G-C11[290-318].qxd 1/21/08 11:52 AM Page 306 Aptara Inc. 306 Section III ■ Psychosocial/Functional Approaches to Intervention social accommodations. People with aphasia have a right to knowledge and promotes positive attitudes. For example, accessible communication and services even if this requires Simmons-Mackie and colleagues (2007) describe a project accommodations (ADA, 1990; ASHA, 1992). As Kagan and designed to improve access to information and decision- Gailey (1993) suggest, supported communication can be making for people with aphasia within three health-care considered the “ramp” that enables people with aphasia to facilities. The project included staff training and on- participate. A variety of environmental and social factors site problem-solving to establish and support sustainable have been identified as potential barriers or facilitators for improvements in communicative access. Staff of the facili- people with aphasia (Howe et al., 2004; Parr et al., 1997). ties reported changes, not only in their own ability to facili- tate communicative access, but also in the culture of their programs and in the participation and well-being of clients Skilled Partners and Prosthetic Communities with aphasia. Training people within the community in Partner-training (as discussed above) not only enhances methods of supporting communication could have far- communication, but also potentially expands opportunities reaching consequences. Gradually the “community” of peo- for satisfying interactions. Thus, trained partners within an ple trained to support communication with people with individual’s community serve as communicative support sys- aphasia can be expanded, resulting in aphasia-friendly “pros- tems and enable improved participation of the person with thetic communities.” aphasia. In order to build expanded support systems, inter- vention might focus on training individuals within existing Resources as Supports social networks. For example, a number of successful inter- ventions with family members of the person with aphasia are In addition to trained partners, a variety of resources such as reported in the literature (Boles, 1997; Hopper et al., 2002; pictures, paper and markers, remnant books, written aids, Lyon, 1998b; Rogers et al., 1999; Simmons-Mackie et al., vocabulary notebooks, maps, or communication boards can 2005). However, social life usually extends beyond our support communication. The Pictographic Communication immediate family. Therefore, potential communication Resource Manual is a collection of thematically organized partners outside of the immediate family might be identified pictures developed specifically to support conversation with and trained. For example, a friend within the community people with aphasia (Kagan, Winckel, & Shumway, 1996a, (e.g., fellow club member, neighbor) might be willing to 1996b). In addition, pictographic resources aimed at particu- support community reentry. lar groups (e.g., clergy, nurses, physical therapists) can In addition, the support system might be expanded to enhance communicative interactions (Kagan & Shumway, include new communication partners such as new acquain- 2003). Studies have demonstrated that graphic support or tances, aphasia-group members, volunteers, or peer men- written key-word choices during conversation promote tors. Lyon (1992, 1997) has paired individuals with aphasia increased participation of the person with aphasia (Garrett & with a volunteer and worked on effective communication as Beukelman, 1995; Garrett & Huth, 2002). Lasker and col- a dyad. He also works with the dyad to identify an activity leagues (2005) describe resources used to support a college they can share as a means of facilitating life participation. professor with aphasia that included a computer-based com- Kagan (1998) and Hoen and colleagues (1997) describe munication system with synthesized voice output and “key community-based programs designed to provide opportuni- word” PowerPoint slides. Others also report various com- ties for successful conversation between trained volunteers puter aides designed to support communication in aphasia and people with aphasia. Peer mentors are another source of (Bruce, Edmundson, & Coleman, 2003). A variety of resources expanded social networks and supported communication. have been suggested to prevent institutionalized individuals Peer mentors are individuals with aphasia who agree to visit, with aphasia from remaining “anonymous” to caregivers. serve as social contacts, assist as advocates, help with coun- Communication plans that specify likes and dislikes and life- seling, or perform other needed services (Cohen-Schnieder, story notebooks that give a brief history with family photos, 1996; Ireland & Wotton, 1996). For example, two people and key life events can provide a context for sharing informa- with aphasia might be matched to fulfill some need such as tion with caregivers (Genereux et al., 2004; LeDorze, 1997). providing a ride to an aphasia group or helping with a pro- Remnant books or memory albums also serve as resources to ject. The helping relationship serves both individuals since initiate topics and sustain conversation. Changes in physical helping others is often an important missing element after environments can also support communication (e.g., a surface the onset of aphasia. for writing, changing seating arrangements) (Lubinski, 2001). In addition to training specific individuals to interact with Finally, several reports describe the potential power of “apha- people with aphasia, community training is an important sia-friendly” Web sites for linking people with aphasia to element of a social approach. Community education at reli- goods and information. Characteristics of accessible Web gious institutions, community organizations, businesses, sites include a variety of modifications such as simplified text, medical facilities, or educational institutions increases public reduced visual distractions, pictures to augment text, and GRBQ344-3513G-C11[290-318].qxd 1/21/08 11:52 AM Page 307 Aptara Inc. Chapter 11 ■ Social Approaches to Aphasia Intervention 307 large print (Egan, Worrall, & Oxenham, 2004; Elman, 2001; structure of therapy and moving towards a collaborative Elman, Parr, & Moss, 2003; Ghidella et al., 2005; Petheram, partnership approach, we might enhance the client’s auton- Parr, Moss, Byng, & Newbery, 2004; Rose et al., 2003; Singh, omy and sense of self. Furthermore, moving the emphasis 2000). away from the impairment and onto the interaction and external barriers reduces the emphasis on individual prob- lems. Attention to the emotional impact of our services is as Increasing Communicative Confidence important as attention to the linguistic effects. and Positive Sense of Self Human beings place great value on feeling important and successful. In fact, much of our communication is crafted to Case Example present a public identity or “face” (Goffman, 1967). Our view of ourselves is “reevaluated” constantly as we interact Anomic Aphasia with others and obtain verification or contradiction of our perceived self-image and roles (Brumfitt, 1993). Com- RT, a 55-year-old man with anomic aphasia, contacted a munication and identity are entwined with the social roles university clinic seeking therapy. RT was 10 years post- we enact. Unfortunately, role change is a major consequence onset and had functioned for the past 8 years indepen- of aphasia. For example, unemployment after aphasia often dently. Although unemployed, he managed his own invest- results in the loss of a significant role and important part of ments and enjoyed travel to visit friends. RT described his one’s “identity.” Similarly, each communicative interaction disability as “not too bad.” His reasons for self-referral has the potential to disrupt one’s self-image as a competent were to improve his ability to write letters and to converse person. The cycle of communication breakdown, changed in groups. RT attended the university clinic for an initial social roles, and loss of identity can undermine the goals of assessment that entailed administration of several stan- aphasia therapy. Therefore, a positive outcome depends on dardized aphasia tests by a young female student-clinician. the development of a healthy sense of self with aphasia Later, the student-clinician and supervisor conducted a (Brumfitt, 1993; Byng et al., 2000; Sarno, 1993a, 1993b, detailed counseling session to appraise RT of the test 1997). A robust identity not only contributes to improved results. The assessment and subsequent conference were quality of life but also directly relates to one’s willingness to typical of a traditional evaluation. RT was visibly upset dur- use residual communication skills. The person who lacks ing the testing and conference. He remarked that he had confidence is far less likely to risk participating in social sit- no idea he was “so bad off” and appeared embarrassed to uations. Development of productive new roles, robust iden- have “appeared the fool” in front of the “pretty girl.” His tities, and healthy relationships often depends on support usually outgoing personality gave way to depression as he and external assistance or direction (Rolland, 1994). For faced his self-delusion regarding the extent of his disability. example, research suggests that positive supportive relation- This example raises an important ethical question: Was ships (i.e., those that foster autonomy while facilitating com- the exposure of residual deficits via standard testing in the munication) strengthen self-esteem and confidence among best interest of this client? Standardized assessment did not people with aphasia, while patronizing, controlling, or neg- allow RT to use many of his compensatory strategies to suc- ative interactions reduce confidence and motivation to par- ceed. The assessment did provide a “window” into the pat- ticipate (Andersson & Fridlund, 2002). tern and severity of his language disorder; however, it also markedly impacted RT’s self-confidence and sense of self. Traditionally, the importance of linguistic data might out- Modifying the Structure and Content of Services weigh the negative psychosocial impact. However, a social In part, a healthy identity can be encouraged by attending to model forces us to reconsider and weigh the overall impact how our services promote or inhibit an empowered identity. of our practices on the person as a whole. This example is Impairment-oriented therapy might actually undermine the not an argument for eliminating standard tests; rather, it is development of a healthy identity with aphasia by emphasiz- an argument for carefully considering the client’s stated ing what is wrong and exposing failures (Byng et al., 2000; goals and the potential impact of each procedure on com- Ferguson & Armstrong, 2004; Simmons-Mackie & Damico, municative, social, and psychological well-being. 1999). The social structure of traditional therapy could also devalue the person with aphasia by reinforcing the roles of Modifying Our Own Language and Attitudes “expert” therapist and “impaired” patient (Simmons-Mackie & Damico, 1999). Byng and colleagues (2000) caution that Our language and attitudes can also empower or enable oth- we must work on impairments with sensitivity, keeping in ers. As specialists in language, aphasiologists undoubtedly mind the potential effects on the developing sense of self of know the power of words. Duchan (1997) describes “nega- the person with aphasia. Perhaps by modifying the didactic tive rhetoric” associated with medical approaches and more GRBQ344-3513G-C11[290-318].qxd 1/21/08 11:52 AM Page 308 Aptara Inc. 308 Section III ■ Psychosocial/Functional Approaches to Intervention positive rhetoric often used in participation approaches. the person with aphasia and acknowledging his or her lived Shifting our usage to wording that avoids the biases of the expertise in aphasia. Holland (in progress) advocates for apply- medical model might help the client focus on living with ing principles of positive psychology to aphasia intervention. aphasia over the long term. Thus, words such as “patient,” The values of a positive health approach can promote well- “treatment,” and “discharge” imply a “treatment and recovery” being, optimism, and hopefulness—elements important to liv- course similar to illness. Such terms reinforce the illness ing successfully with aphasia (Andersson & Fridlund, 2002; model and possibly allow us to shed some of our responsi- Sveen et al., 2004). In addition, LaPointe (2005) reminds us bility for long-term outcome. Substituting goals such as that an important aspect of coping involves finding the small “reintegration” as opposed to “discharge” shifts the empha- things in life that make it worth living—“dressing up . . . soak- sis to the chronic nature of aphasia, and promotes a client- ing in a Jacuzzi . . . saving a manatee . . . helping others . . . rent- centered rather than service-delivery emphasis. ing a goofy movie . . . [or] listening to an audiotape” (p. 16). In addition, language can help those affected by aphasia Psychosocial support groups, caregiver support groups, learn that the person is not the disorder (Rolland, 1994). and self-advocacy groups might serve to expand this coun- Too often the disability and the “self” become one seling focus (Byng et al., 2000; Elman, 2007; Holland & (Goffman, 1963). Language can help externalize the disor- Ross, 1999; Pound et al., 2000). The chance to “tell their der to reinforce the fact that the person is far more than the stories” not only provides communication opportunities for aphasia. For example, saying “you seem to be having trouble people with aphasia and caregivers but, when appropriately with your bridge club” places the burden on the person, validated, sharing stories is an important means of building while saying “the aphasia seems to be getting in the way of a new sense of self with aphasia (Moss, Parr, Byng, & participating in your bridge club” places the onus on the Pertheram, 2004; Pound, 2004). Groups provide a context aphasia. Thus, problems are the disorder, not the person. for exploring topics related to living with aphasia such as Attention to service-delivery styles and language use can identity, stress management, relationships, and emotions. help ensure that our practices promote a healthy identity as Caregiver groups help those who experience aphasia as a well as improved communication. family member or caregiver to address concrete issues, pro- vide psychological support, and help build new identities. Self-help groups provide a mechanism for people con- Counseling and Psychosocial Support fronting aphasia to define their own needs and assist each In addition to examining the structure of therapy and our other in addressing these needs (Coles & Eales, 1999). own language, speech-language pathologists have a respon- Adult-learning approaches that combine elements of sibility for aspects of counseling (Brumfitt, 1993; Cunningham, education, counseling, and communication skills-training 1998; Holland, 1999; Luterman, 2001; Müller, 1999; have been introduced for people with aphasia and their Wahrborg, 1989). Those affected by aphasia need informa- family members (Purdy & Hindenlang, 2005; Sorin-Peters, tion and guidance in exploring the effects of aphasia on their 2004b). Such methods approach the “learners” (people with lives. The speech-language pathologist is uniquely qualified aphasia and family members) as competent adults and col- to help other professionals understand the consequences of laborators in the learning process. Change evolves out of the aphasia, to teach supported communication, and to ensure learner’s own experiences, reflective observations, and active that counseling needs are met. In addition, counseling and experimentation. An important “counseling” element of communication intervention overlap. For example, disabil- such programs is the chance for participants to explore and ity powerfully affects relationships and role boundaries validate the experience of living with aphasia. Reported out- within families and couples (Rolland, 1994). Typically com- comes include not only improved communicative skills but munication processes are critical for reestablishing a func- also changes in emotional well-being and relationships. tional, balanced relationship. With aphasia the pre-onset modes of communication within relationships are altered. Self-Advocacy and Empowerment Focusing intervention at the level of the “couple” can assist both parties in identifying new ways of communicating Byng and colleagues (2000) propose self-advocacy as a (Boles, 1997; Boles & Lewis, 2000; Lyon, 1998b; Purdy & means of (1) enhancing self-esteem, (2) developing skills and Hindenlang, 2005; Sorin-Peters, 2004b). knowledge, and (3) promoting empowerment. Strategies for In fact, many aspects of aphasia therapy fall squarely within promoting self-advocacy include focusing on strengths, the realm of counseling. Counseling should be an integral part building social and political consciousness, promoting a of therapy for aphasia since language is required for negotiat- group or community identity, gaining a role in community ing new identities and developing strategies for coping with service, and ensuring that people with aphasia are partners life (Moss, Parr, Byng, & Pertheram, 2004). Clinicians can in, rather than recipients of, services. Pound (1998a) promote well-being by adopting an active “listening” role described a self-advocacy project in which people with apha- instead of an “instructing” role; that is, by sharing control with sia developed personal portfolios. Like pictorial vitae many GRBQ344-3513G-C11[290-318].qxd 1/21/08 11:52 AM Page 309 Aptara Inc. Chapter 11 ■ Social Approaches to Aphasia Intervention 309 of the portfolios depicted life before and after the onset of ticipation for people with aphasia. Advocacy means that we aphasia. Clients reported that this process of examining “practice what we preach” relative to inclusion. For exam- their lives resulted in significant insights into their own ple, people with aphasia can serve as aphasia-group leaders identity and appreciation for their accomplishments since or co-facilitate groups. People with aphasia can be “teacher- the onset of aphasia. clients,” rather than patients, in university clinics in recogni- Self-advocacy groups have addressed topics such as iden- tion of their unique and valuable perspectives. People tity and life roles, attitudes towards disability, assertiveness, affected by aphasia are qualified to serve on our boards of and development of support networks (Pound, 1998a; Byng advisors or as co-investigators in research. Aphasia-group et al., 2000). Individuals explore personal values and identify members can offer services as a panel of experts to educate values that are inconsistent with a healthy self with aphasia others such as allied-health students or community leaders. (Fuhrer, 1994). For example, placing high value on being an Byng and Duchan (2005 ) provide examples of how people expert storyteller might be contrary to achieving a satisfac- with aphasia might be integrated into organizations at all tory view of oneself. Instead of the “storyteller,” the person levels. For example, board meetings with aphasic members with aphasia might need to identify other aspects of his or her are conducted in accessible language with aphasia-friendly self upon which to build self-worth (e.g., pet lover, father, supports. Through these expanded roles, accessibility strate- spiritual person). Clients might explore new ways of express- gies are modeled. Such partnerships offer many advantages, ing personalities. For example, Simmons-Mackie (2004a) not the least of which is the bold affirmation of the expertise offers suggestions for alternate methods of conveying humor. and value of people with aphasia. Clients can learn that methods of expressing oneself need not Speech-language pathologists and those affected by apha- be traditional; painting, drawing, poetry, dramatics, and sia have an important role in building public recognition of music also serve self-expression and release. Exploring such aphasia and promoting availability of accessible services. issues in a group with other people with aphasia can help Aphasia is a relative “unknown.” In fact, in a recent public with the reassessment of life values and objectives. survey only 5% of those surveyed knew the meaning of the term “aphasia” (Simmons-Mackie, Code, Armstrong, Caveats of a Social Approach Stiegler, & Elman, 2002). Aphasia is mentioned in the pub- Communication provides a foundation for maintaining lic press with much lower frequency than other disorders autonomy—the right to make our own decisions, freedom with similar incidence rates (Elman, Ogar, & Elman, 2000). from control by others, and the ability to enforce our own The impacts of poor public awareness include reduced fund- values. Thus, a goal of aphasia intervention is to promote ing for research and services, lack of understanding and choice, freedom from control, and expression of personal acceptance by the public, and barriers inadvertently rein- values. However, any therapy approach carries with it the forced by political and public actions (Elman et al., 2000). potential for invading rights and privacy. Therapists must Advocacy activities promote the development of a “group avoid imposing their own values and choices in the name of identity” for those affected by aphasia and increase public treatment. Expanding and supporting participation is not to awareness. Advocacy efforts can also be integrated into be construed as a license to “remake” peoples’ lives according aphasia management to provide a context for building a pos- to our own prescriptions and values. Work must be con- itive sense of self with aphasia while simultaneously educat- ducted in complete collaboration with those affected by ing the public. aphasia and with an understanding of their values and desires. Confidentiality and sensitivity to intrusion into personal sit- uations and relationships are extremely important. If part- ners are to be recruited and trained, the clinician must ensure Case Example that the help is not invasive or embarrassing to those involved. Explanations of intervention procedures or con- Identity Work tracts in simple written and pictograph form might ensure that clients fully understand the methods and objectives of MC, a 62–year old woman with Broca’s aphasia and apraxia intervention, and participate in the plan and implementation. of speech, had attended individual and group therapy for Part of a successful outcome in aphasia intervention involves several years. According to her family, MC remained enforcing a sense of one’s own autonomy and personal rights. depressed and socially isolated and failed to participate in former activities. Within her aphasia group MC often complained about the “bad treatment” that she received in Promoting Advocacy and Social Action the community, particularly in medical encounters. For The role of the speech-language pathologist includes not example, she described how nurses and doctors talked to only intervention with those affected by aphasia but also her husband and ignored her “like she was a lump of noth- development of social and political systems that support par- ing.” She related stories of overhearing nurses talking GRBQ344-3513G-C11[290-318].qxd 1/21/08 11:52 AM Page 310 Aptara Inc. 310 Section III ■ Psychosocial/Functional Approaches to Intervention about her as if she were not present, and described patron- has been criticized (Elman, 1998; LPAA, 2000; Lyon, 1992; izing and incomprehensible interactions with health-care Simmons-Mackie, 1998b). Rather than shift from treatment providers. After hearing these stories on several occasions, to no treatment, a continuum of services should be available the clinician suggested that she and other group members throughout the person’s life with aphasia (Elman, 1998; “do something” to educate health-care providers. The Pound, 1998b; Simmons-Mackie, 1998b). Expanding our result was an “expert panel” designed for people with concept of services in aphasia requires that we recognize that aphasia to present their stories to classes in a local nursing aphasia is both an acute problem and a lifelong condition for program. Panel members worked with their therapists to those affected. As people learn to live with aphasia and as life create scripts and practice presentations with various com- situations change, the need for and type of services will munication supports. MC approached this experience change. Changed living arrangements, marriage, death of a with gusto—she felt that she must be an advocate for peo- loved one, or an opportunity for employment can create new ple with aphasia. Each semester the group described their goals and challenges. Ideally, those affected by aphasia should prior feelings of helplessness and inadequacy in health- have access to support and professional expertise during such care encounters and offered insight into methods that the life changes. Services might constitute an array from which nursing students might use to facilitate communication clients can select those appropriate to their current life goals and interactions. MC announced to her therapist that she (Elman, 1998). Thus, in addition to individual and group felt like a “new me” and described recent encounters in therapy, a range of services such as community-based pro- health care—“now they listen to me.” Friends and family grams, support groups, self-help programs, advocacy ser- noted a change in MC’s demeanor and confidence. The vices, vocational programs, leisure programs, educational panel experience not only provided MC with a communi- services, and counseling might be appropriate (Müller, cation opportunity; it also gave her life renewed meaning 1999). An expanded service-delivery model will likely and enhanced her self-esteem and assertiveness. involve changes in our own services, as well as addition of services outside the domain of speech-language pathology. Expanding services beyond the health-care umbrella to include social or community agencies is a possibility. Adult Along with public recognition, inclusion of people with day-centers and programs for the elderly might be re-engi- aphasia in existing community services is necessary. People neered to accommodate those affected by aphasia. Adult- with aphasia have a right to access information and services education programs such as basic computer and Internet such as adult-education and leisure programs. Texts that pro- training or art classes can be tailored to people with com- vide information about coping with aphasia can be made avail- munication disabilities. Although not all of these services able to those confronting aphasia (e.g., Lyon, 1998a). Manuals should or can be offered by speech-language pathologists, written in a style that is accessible to people with aphasia can the speech-language pathologist is uniquely situated to outline available resources and benefits (e.g., Parr, Pound, ensure that the availability of varied services is adequately Byng, & Long, 1999; Sarno & Peters, 2004). Aphasia-friendly addressed. Thus, our roles, responsibilities, and payment Web sites can provide information as well as social connec- sources are likely to shift as service delivery adjusts to chang- tions to other people with aphasia (e.g., www.aphasiahelp.org; ing demands. www.shrs.uq.edu.au/cdaru). Pictographic “consent forms” and As recently as 2004, Sarno listed the most compelling documents promote access to health-care choices for people issues affecting intervention for aphasia, including: (1) lim- with severe aphasia (Kagan & Kimelman, 1995; Simmons- ited access to services due to funding; (2) continued adher- Mackie et al., 2007). Organizations such as the National ence to a medical model of recovery and rehabilitation; (3) Aphasia Association (United States) (www.aphasia.org), the views that aphasia intervention is exclusively a process of Aphasia Hope Foundation (www.aphasiahope.org), and language repair; (4) ongoing stigmatization of aphasia asso- Speakability (United Kingdom) (www.speakability.org.uk) ciated with an uninformed and intolerant society; and (5) a provide information and support. Public education can help lack of specialized services that include intervention aimed inform others of methods that can be used to increase accessi- at the communicative, social, and psychological conse- bility and participation (Appendix 11-2). quences of aphasia. Clearly, the future must address these barriers to holistic services for those affected by aphasia. A THE FUTURE OF SOCIAL APPROACHES: first step for clinicians and programs is to build a culture consonant with social model values. EXPANDING SERVICE-DELIVERY OPTIONS With the advent of social models and changing health-care systems, alternative means of delivering services are being CONCLUSION explored and advocated. For example, the prevailing practice Social approaches to intervention hold promise for promoting of offering treatment for aphasia only during the acute stage inclusion of people affected by aphasia in a communicating GRBQ344-3513G-C11[290-318].qxd 1/21/08 11:52 AM Page 311 Aptara Inc. Chapter 11 ■ Social Approaches to Aphasia Intervention 311 society. Creative and socially motivated approaches to man- 4. What are the principles of a social approach as defined agement of aphasia are emerging around the world. Such in this chapter? approaches have arisen from the belief that communication is 5. Listen to a “real” conversation (e.g., friends, co- more than putting words together to get an idea across. workers). Identify examples of the following within the Rather, communication is part of the foundation of social conversation: structure and human dignity. This philosophy drives efforts to a. Behavior designed to “save face” or project an “identity” establish effective and efficient methods for enhancing the liv- b. Evidence of “collaboration” in conversation ing of life with aphasia. As Sarno has suggested, aphasia reha- c. Behavior that “deviates” from accurate, syntactically bilitation is a moral imperative in which “those who work with complete sentences the communication-disabled are members of a moral commu- d. Strategies that seem to help manage the interaction nity seeking to empower and restore individuals to a meaning- rather than add specific “information” ful life experience” (Sarno, 2004, p. 28). The opportunity to 6. Garcia and colleagues (2000) provide an example of retool aphasia management in keeping with this view is both reconfiguring a functional disability (inability to use an exciting and daunting prospect. the phone) into an external barrier (lack of availability of electronic mail) as a means of identifying accommo- dations for people with aphasia. Think of two examples of “problems” in aphasia that might be “recast” as KEY POINTS external barriers. 7. How does assessment in a social approach differ from 1. Adopting a social model requires a philosophical traditional assessment (e.g., standardized aphasia tests, shift from traditional, medical-model approaches. probes of language behaviors)? 2. A social model is based on the belief that communi- 8. How does traditional therapy discourse usually differ cation is a social act; through communication we cre- from natural, adult conversation? ate and express our ideas, our identities, and our life 9. What is “enhanced compensatory-strategy training”? values, and ensure our membership in society. 10. What are four possible benefits of training the commu- 3. In a social approach, communication and psychoso- nication partner of a person with aphasia? cial functioning are considered inseparable. 11. What is an aphasia-friendly “prosthetic community”? 4. A social approach focuses not only on communica- 12. 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Aphasiology. (1979). Functional communication assessment: An als with aphasia. . Simmons-Mackie.int/classification/icf. & Lesser. C. (1997). NJ: Erlbaum. pp.. Huijbregts. New York: Thieme. C. A. (1997).. Worrall.. R. Worrall. What is aphasia? Results of an international K. S. Switzerland: World Health Organization. Just kidding! Humor and therapy 18.. 114–127. Quality of life in aphasia. MN: BRK. Social role negotiation Wilcox. L. 8. L... J. frames in aphasia. J. Aphasiology.). questions to the right people in the right ways. cation disorders: A functional approach (pp.. Worrall. (2004a). TX: Pro-Ed. Aphasiology. (1990). social perspective. (1999). Neurogenic com- training. Geneva. L. Simmons-Mackie. Clinical Rehabilitation. Kingston. 3–18). 21(1). Intervention out. Arruda. A quali. (2004). Kearns. 13. & Damico. Boston: College-Hill Press. Mahwah. The case for qualitative case study Script training and automaticity in two individuals with aphasia. Communicative access approach to acquired neurogenic disorders of communication and and decision making for people with aphasia: Implementing sus. neurologically impaired patients: Description and initial valid- Language-Hearing Association. Neurogenic communi- tainable health care systems change. speech samples of aphasic and normal speakers. A. Well-being and instrumental activities of daily living survey. 162–187). The influence of professional values on the CAC Classics: Treatment of aphasia through family member functional communication approach to aphasia. Kovarsky. L. (1996a).. 14. 18. A. 218–230. Conversation 761–781. G. Wyller. 20. (2007). E. 583–593. swallowing. N. 39–66. An analysis of connected memory and language limitations. L. & Damico. H. R. (2005). Conversational style: Analyzing talk among friends. C. 8. & Damico. (2002). E. Stern. (1995). & Schultz. 11. 6. 191–205). (2004b). Worrall.). N. Retrieved on April 3. Aphasiology. World Health Organization (WHO) (2001). 17. Simmons-Mackie. Fact Sheet. the dog?” vs “Where’s Spot?”) Use the environment (talk about a picture on the wall) Use alerting phrases or gestures (touch. 1995) Simplify sentence structure Use props (magazines. photo albums.g..pdf.GRBQ344-3513G-C11[290-318]. body lean.gov/ERIC- Encourage environmental adaptations to promote communication DOCS/data/ericdocs2sq1/comment_storage_01/0000019b/80/ (reduce noise. Rockville.) the person with aphasia. that makes Backchannel to encourage the aphasic speaker (“mhm. elaborate. Communication and the ADA.g. summarize. written message for transport driver. .” you angry”) “oh yes”) Establish equality in relationship by following the aphasic individual’s Paraphrase. John”) Establish shared experiences as topics (sports. gardening) Emphasize key content with stress and intonation Focus on doing things together versus carrying out discussions Tolerate the other person’s silence Avoid teaching comments such as “you said that right” Use gestures and pantomime to add information while talking Reflect feelings communicated nonverbally (“Oh boy. etc. (e. or hospital dations staff) Provide communication aids and materials to support communication Provide accessible information regarding services Provide communication in an accessible format (e. alter signage) .”) model and establish equality Use redundancy (“Where’s Spot. or question- Chunk ideas with pauses between ing as needed Insert pauses between topics Use “thematic written support” (Garrett & Beukelman. pictures) Convey one idea at a time Subtly incorporate words that the person with aphasia “didn’t get” Place key information at the end of the sentence into your own utterances Repeat key words Get information from his or her body language—focus on more Write key words as referents than the talk Rephrase when not understood Progress from the general to the specific in questioning Use direct instead of indirect referents (“Mary” vs. alternatives (Adapted from American Speech-Language-Hearing Association such as pictures and written instructions. and sus.. multiple-modality (1992). lead. “uhh.1 Examples of Strategies for Communication-Partners of People with Aphasia Slow the rate of speech Verify your understanding by paraphrasing. . acknowledge opinions. or reinterpret to verify. provide alerting systems.ed. police. repeating. tain topic APPENDIX 11. 318 Section III ■ Psychosocial/Functional Approaches to Intervention APPENDIX 11. “she”) Provide and use paper and markers to support talk Use gestures. large print) MD: Author Retrieved on 10/1/07 at eric.” “I see.2 Advocacy Strategies for Supporting Participation of the Person with Aphasia Build public awareness and understanding of aphasia Alter information complexity Establish attitudes and behaviors that promote inclusion Prepare for management of emergency or unexpected situations Promote public knowledge of facilitating behaviors and accommo.qxd 1/21/08 11:52 AM Page 318 Aptara Inc. make speakers visible to 13/22/cd. communication. and gaze to shift topics Draw or write key ideas while talking Use verbal terminators to end a topic (“so much for that”) Use the augmentative strategies of the person with aphasia to Use verbal introductions to open topics (“Let’s talk about . family members. Hendricks. 2004. see. documented and provided as evidence for the value of and by consumers themselves. both for adults with aphasia ology and makes a discernible difference in the everyday life and for their caregivers. Speech-language pathologists have a particular chal.).. Frattali. Gontkovsky. Paul- two of the primary health care insurers for the elderly. Duncan et al. long-term care.9 billion. After reading and discussing this chapter. 2005. Bishop.. For example. identify physical and social factors in est levels of scientific rigor for evidence-based practice yet the environment that impede communication opportunities. 2005). Brigstocke. 2005.g. Numerous trends in health care have gener. dence-based practice in both academic coursework and clin- ors involving adults with aphasia will be enhanced if they ical practicum. Medicare and Medicaid. Rehabilitation specialists are physical environment. 1995). McCullagh. Harris.g. clini. Schepers. to demonstrate that therapy speech-language intervention. These Vickery. 1994. 2003. Thus. reveals a recognition that outcomes of the patient. we have ronment for the adult with aphasia. particularly to the escalating pop. Wohl. sidered to be important functional outcomes.g. A lenge—providing intervention to adults with aphasia that new generation of clinical research must be performed to 319 . Kalra et al. Klees. and home care. In 2004.GRBQ344-3513G-C12[319-348].. Clinicians The concept of functional dominated rehabilitation in the are well aware that their therapeutic efforts often extend 1990s. 2001. Donaldson. & Caroselli.d. & Kalra. Holland. 1999. Well-accepted models.9 billion and $276. state their environmental philosophy Only a limited body of research currently meets the high- regarding adult aphasia. e. expenses will swell as the first wave of baby boomers reaches Weinberger.S. & Ferketic. brings to the therapeutic context. includ- cians should be able to define the components of the physical ing a position statement (2005) on this topic. & Lindeman. Post. 1999) and a rating scale used in OBJECTIVES the Scottish Intercollegiate Guideline Network (n. such as those offered by the Quality Standards Subcommittee of the American Academy of Neurology (Miller et al. Ross & Wertz. 1999. need not be limited to changes in receptive or expressive ated this focus. vivors of stroke.. and the most potent of these is rapidly communication skills alone. Thompson.. Most importantly. 1999. Graduate pro- The primary objective of this chapter is to introduce new and grams in speech-language pathology are introducing evi- practicing clinicians to the concept that their clinical endeav. and social environment. (For in-depth discussions increasing financial cost. Connis. regarding quality of life for survivors of stroke. For in-depth discus- age 65 in the next few years and as they enjoy a longer life sions regarding quality of life for the family members of sur- span. the U. payers want to reimburse for proven method. consequently. speech-language pathology services. population $308. Brumfitt & Sheeran. based practice and has published several documents. exist for determining the best scientific evidence. & Curtis. 2003. & Caperton.. a growing liter- simultaneously emanates from scientifically proven method. Holland. Palmer & Glass. 2005). and staff few well-established models of what variables should be con- working in rehabilitation. Sturm et al. cost Brown. 1997. and now evidenced-based practice emerges as the beyond the individual with aphasia to the broader social and emphasis in the new century.. ature on quality-of-life issues. The American Speech-Language-Hearing consider the physical and social environment as part of their Association (ASHA) has a focused initiative on evidence intervention. few standardized assessment tools exist for documenting changes in functional communication (e. 2002. ulation of older adults. and that these outcomes should be required by private and governmental health care insurers. Evans. e. Thompson. ologies that result in real-life benefits for those receiving & Haselkorn. Williams. Frattali. see. respectively (Hoffman. Sarno. addresses the unique needs that each adult with aphasia and plan strategies to create a positive communication envi.qxd 02-12-2008 09:40 PM Page 319 APTARA(GRG QUARK) Chapter 12 Environmental Approach to Adult Aphasia Rosemary Lubinski meets the two criteria of scientific merit and functional rele- vance. Visser-Meily. & Biller. qxd 02-12-2008 09:40 PM Page 320 APTARA(GRG QUARK) 320 Section III ■ Psychosocial/Functional Approaches to Intervention Specific Satisfaction Effectiveness Caregiver Quality communication with clinical Environment of communication effectiveness of life skills services Improves receptive Demonstrated Uses facilitating Extends treatment Participates in a Provides physical access to expressive. significant others. to the degree possible. blend the science of the brain with the authentic needs of allow the individual to demonstrate. the individual which are called “effectiveness skills. devices. personal strategies to repair strategies outside variety and quantity and social home community cognitive communicative communication the clinic of activities of choice and thinking skills to maximum competence despite breakdowns and communicating disorder(s) Improves social Adapts proactively Copes with stress Assumes Has a sense of Provides financial and vision and to communication and burden independent control and choice support for short hearing to maximum changes associated with problem solving regarding and long term aphasia caregiving and for communication communication intervention communication breakdowns partners and breakdowns activities Increases public awareness of Uses alternate and its personal means when and societal needed effects Client focused Caregiver focused Society focused Figure 12–1. personal communicative competence regardless of the pres- One of the present needs we have as clinical aphasiologists ence of communication difficulties. Array of intervention outcomes. Figure 12–1 who “max out” on traditional aphasia tests but are able. Such a model ability to communicate through a variety of communication should include specific receptive and expressive communica. performance in terms of communicative skills. to understand and express themselves in real- with specific receptive and expressive communication skills life communicative contexts. Some indi- improvement in discrete skills within the context of isolated viduals might combine communication channels such as therapy will be reflected in everyday communicative interac. For some individuals is a model for conceptualizing the range of therapeutic out. . regardless of his or her moves us to another level of possible intervention outcomes. Clinicians typically initiate intervention by demonstrate continued progress on traditional outcome improving these skills and concentrating on topics that are of measures. yet their comes we might achieve with our clients. skill development will be modest. to illustrates a continuum of intervention outcomes that begins some extent.GRBQ344-3513G-C12[319-348]. These are the individuals both the individual.” Effectiveness skills is able to maintain an active communication role. with aphasia. and society. patients with aphasia and their caregivers. speaking and gesturing. but may not interaction. Thus. tests or trained observation of such skills in communicative want to participate in an intervention program. use augmentative and assistive tion with a variety of communication partners. They are often those persons that are identified and measured through formal traditional with chronic aphasia who have been dismissed from therapy. Clinicians assume that to adapt proactively to communicative changes. Effectiveness skills involve the individual’s ability everyday usefulness to the client. channels and with skilled communication partners will tion skills and extend to broader environmental outcomes for result in effective communication. or seek communicative support from communica- The focus on using these skills in a variety of contexts tion partners when needed. viduals and their environment. the agents of change. As therapeutic effectiveness givers are more likely to implement therapy strategies in across the continuum is documented. Outcomes can be docu. Patients and care. “environment” is defined as the spectrum of influ- own in-house tools to document patient satisfaction with ences that impinge on and are influenced by an individual clinical services. Note that these influences do not have a intended to create a better quality of life for adults with simple summative effect. Keep in mind that all environments contain a those created for patients with aphasia or those designed for variety of individuals who in turn influence each other. psychological. The first outcome is support. a broader perspective on the goals caregivers to facilitate interaction and cope with the com. reverberate within the whole system.GRBQ344-3513G-C12[319-348]. It may be efficient understand that they have a responsibility to become active to isolate the communication sequelae of stroke from indi- and creative problem solvers when communication break. 2005). Therefore. health. and so forth (Ross. gram for the relationship of the individual to his or her total mented with broad quality-of-life assessment tools. political. this information must be shared with the general public and vices they are receiving reflect their communicative needs policy makers at local and national levels as well as with the and genuinely benefit them on a daily basis. particularly family members and demonstrate their communicative competence differently other formal and informal caregivers. A second synthetic assessment of the individuals and their communica- outcome is to maximize caregiver ability to cope with the tion assets and difficulties. the immediate social milieu in which an individual effectiveness is influenced by the dynamic physical and social resides. and communicative sequelae serve as active who has communication difficulties. emotional. Satisfaction can be measured in several ways. their social networks. well as long-term intervention. 1998). Thus. environmental outcomes should also include A fourth type of outcome is assumed under the rubric of changes in public awareness of aphasia and increased commit- satisfaction with clinical services. Clinicians have professional community. those that arise from the unique internal contributions of The very essence of what we do in therapy is ultimately each individual. Caregivers will not agents of change for individuals. including health. but the process results in a downs occur with the individual having aphasia. The external environment is comprised of the physical Finally. individual who has aphasia. and analyzed. The combination based on respondent self-perceptions of numerous and often of these external and internal stimuli forms a “total environ- overlapping areas. Each component has dimensional. sible for this third domain of outcomes. cogni- challenges of communicating on a daily basis with someone tive. effective environments in which our clients live and communicate. ors. This category is more than ment to providing social and financial support for short. Adults the ability of communication partners to use facilitating with aphasia and their environment create a single. ment” for each person. and emotional needs of both the individual with aphasia and family members. social. a change in any one can aphasia and caregivers. events. Data from such instruments indicate that speech- language outcomes can embrace an extensive array of physi- External Environment cal. Outcomes that involve increasing the ability of ual’s needs and resources. functional intervention must include primary and potential Two individuals with similar communication profiles might communication partners. either environment. what the public supports both politically and financially. their daily interaction if they perceive that the clinical ser.as patients “liking” therapy or the clinician. including use of the ASHA NOMS Measurement System that has a section devoted to ENVIRONMENT patient satisfaction (ASHA. and support therapeutic outcomes or use strategies if they feel the physical surroundings. rather. and some centers also might use large-scale during his or her life cycle. A circular relationship exists between an obligation to seek frequent verbal and written feedback to what the public perceives as important intervention endeav- document perceived satisfaction with the intervention pro. Further. and the social. Quality of life is a complex. and subjective category of outcomes that is the potential to cross-fertilize the others. inextrica- strategies to maintain communicative interaction with the bly interwoven unit that in turn affects the people. Most clinics design their Here. multi. collated. The stroke and its physical. or impede opportunities to communicate. . Two subtypes are pos. and the evaluation of out- municative challenges should be legitimate outcomes of comes must be offered. many clinicians realize inherently that therapeutic world. of therapy. Figure 12–2 presents a schematic dia- ization. if communication burdened when communicating with an individual with therapy is to be functional and truly tailored to the individ- aphasia. These forces emanate from the health-care patient satisfaction instruments. social. their needs and evaluating progress. because of how their physical and social environments create. independence. speech-language pathology intervention. communication partners and relationships occurring around them. such as those external physical and social environment together with developed by the Rand Corporation (1994). An added benefit of seeking such input is that the and what services are available (and for how long) to the indi- client and caregiver assume more accountability for defining vidual and family.qxd 02-12-2008 09:40 PM Page 321 APTARA(GRG QUARK) Chapter 12 ■ Environmental Approach to Adult Aphasia 321 Because communication is a dyadic process. and economic values. caregivers. gram. These concur- Such physical environmental barriers become critical for rent and interactive stimuli operate in tandem to help define individuals with aphasia for two reasons. Persons must perceive that they have the option to and from various roles during the life cycle. From each other. Keep in mind that in addition to the physical Physical and sensory characteristics Social milieu and communicative disabilities associated with stroke. First. it The physical environment can create either access or bar. If communication is to and activities that stimulate conversations. man-made contributions of buildings and artifacts unusual that a person with aphasia is relegated to one loca- (built environment). and heating/cooling ronment. Among the most important physical environmental impediments to communication is the real- ity—or the individual’s perception—that the environment is Individual unsafe or difficult to navigate. Effective communication are influenced by the expectations of the sociocultural envi- also depends on having physical access to individuals and ronment as well as by their own characteristics. and furnishings that create physical obstacles to interaction. lengthy hallways. individuals assume a variety of roles that and by sociocultural conventions. The environment must be structured so that communicating individuals can Through social interaction. Relationship of a person to his or her total envi.GRBQ344-3513G-C12[319-348]. acoustical. presbycusis. Such physical isolation is true for many adults with aphasia who reside in the community or in some level of institu- tional care. These tion that is chosen by caregivers for reasons of safety and stimuli create the physical context in which individuals efficiency of care.. . For example. many Societal support of these persons will also experience physical. treatment. Some individuals are Personal characteristics Social role anchored to a limited number of physical environments because they or their communication partners cannot safely and independently traverse within or between settings.qxd 02-12-2008 09:40 PM Page 322 APTARA(GRG QUARK) 322 Section III ■ Psychosocial/Functional Approaches to Intervention Total Environment to gain access either independently or with easily accessible personal or technological assistance. inadequate and Figure 12–2. 1997). poorly controlled lighting. low vision. be structured or modified to facilitate desired interaction tion in a particular environment. and The physical stimuli in a person’s external environment caregiving issues frequently take precedence over creating include the natural phenomena perceived through the physical access to communication opportunities. individuals learn their roles and come within a reasonable and effective physical distance of the expectations of others in their environment. Individuals assume control over their decided by a caregiver to facilitate delivery of care. there may be how individuals will function in any setting. and dementia). stairways. occur. Both in the home or in an institution. and institutions of the larger society. little or no awareness on the part of caregivers or individuals with aphasia that the physical environment affects access to Physical Environment communication opportunities. function and help to determine both where and how they adults with aphasia are often placed in front of a television or will live and the rules they will develop to maintain order near where meals are served. prescribe guidelines for how an individual should progress municate. Distance is determined by one’s sensory abilities infancy to old age. and cognitive changes related to aging that interact powerfully with the built environment (e. may be difficult to communicate how the environment could riers to communication for individuals who reside or func. individuals must perceive that they or their commu- nication partners can function and move both safely and eas- Immediate Social Milieu ily within that setting (Brawley. verbally control their physical environment. arthritis. norms. Second. Other examples of barriers include confusing spatial design. Physical placement is generally within that landscape. the physical environment can either impede or support access to communication opportunities for those External Environment with aphasia. physical environment when possible to enhance their way persons with aphasia have limited communication skills to of life.g. or floor cover- Life Cycle ings that preclude independent navigation. financial. It is not senses. Other health. Societies activities of choice that generate topics and desire to com. limited areas designed for group or private com- municative interaction and activities that generate social- ization. and the use of time and space. sensory. Thus. per.. independence. These are learned through informal aphasia. & Wagner. In contrast. because the found that stroke caregivers exhibit high levels of depression family’s energy is directed toward the immediate health at both the acute and chronic phases of stroke. work. and medical/rehabilita. 1999). however. in a study of 115 partners in death or some disability. and fraternal organizations. friends. crisis. 2003. by the rules and laws of social organi. Michallet.g. and how their own lives will be changed by this crisis event. “Family” is broadly defined here as the network adults with aphasia and their caregivers have heterogeneous of individuals with whom the an individual with aphasia is perceptions of recovery and adjustment to communication closely involved on a daily basis. whereas multiple networks of relatives. A strong body of evidence sug. The characteristics of the family. Fundamental to the immediate social environment is Hemsley and Code (1996) caution us to remember that the family. socialization. 1986) show professional caregivers (Turnbull & Turnbull. the emotional impact social networks in which individuals function (Putnam. but the family also feels anxiety about of responsibility. Rivlin. viduals with aphasia and their families. & Tetreault.g. caregivers results in exacerbated depression in the adult with gests that social support is important in successful aging aphasia and in reduced rehabilitation outcomes (Han & (e. 1991). and social activities (Ittelson. or it can extend to other. not adjusted at 5 years poststroke (Holbrook. rehabilitation.. Few changes meta-analysis of stroke caregiving. home and daily life. cloud this time. church.qxd 02-12-2008 09:40 PM Page 323 APTARA(GRG QUARK) Chapter 12 ■ Environmental Approach to Adult Aphasia 323 Formal social behavior is learned through direct. family relationships. anxiety. explicit Some families are equipped to cope with such difficulties. lone- 1995). mores. Silliman. 1991). communication (e. . ticularly the spouse. and social life. anced. Many families will face some degree of confusion or interaction within specific subsystems. grief. coping with stroke and aphasia. The family. but disability. .g. sis stage. par- bers (Maitz. and institutionalization. individuals with aphasia and their families will evolve after school. political. Scholte op Reimer. The need for individualized individual’s family provides information about its broader and qualitative assessment of family needs and conversa- culture and affords economic. stages may be of varying lengths of time for indi- and relationships that have been established may be imbal. 1982). uncertainty about patient needs. 2001. and assistance Michallet and colleagues (2003) state that communication when communication difficulties create breakdowns in difficulties are a “central source of stress . these social networks can be mobilized to liness. 1999). work. & crisis through living with chronic aphasia. includes increased irritability and anxiety. 853). Krause. postrehabilitation. and tional skills is echoed by LeDorze. Earp. meaningful opportunities to communicate. lies are challenged when the individual incurs some type of This model is presented as a specific sequence of stages. work chaos unless they are provided with support. including obsessive concern. 2001) and in coping with disability (e. will affect and be influenced by Table 12–1 portrays a model for the stages through which their relationships with larger social groups such as work. depression. daily care. that combines interaction. Besides ital is created by the combined resources and values of all the the physical toll related to caregiving. life-threatening illness. sonal growth. regarding their loved one and the management of their Each environment creates its own personality and pro. Both individuals and their immediate and extended fami. de Haan. Hopefully. This can be an immediate problems. Not only is this fear directed 3 years after a stroke. restraints on their own socialization. Tetreault & LeDorze. such as family. the stroke. Some partners also felt Numerous feelings. support.g. and guilt. Haley. leisure. Proshansky. ried life. or of Michallet (1999). These are in addition to changes in mar- vides individuals with a network of social capital. In a helplessness. some studies show that families are system of spouse and/or children. found that they perceived a high level toward the patient. Fletcher. with the sudden. provide adults with aphasia with social and physical support. Family caregivers often assume added responsibilities 1976). These two types of norms determine how experience an evolution in their reaction to the difficulties of much individual involvement. Croteau. and fatigue (Michallet. Rijnders. and the family system must adapt if it is to remain The family’s initial concern after the stroke is coping integral and meet the needs of the individual family mem. Social networks. and van den Bos (1998). depression.GRBQ344-3513G-C12[319-348]. Zemva. most families will Winkel. LeDorze. and expressiveness will be tolerated (Moos. and informal or others (e. and it evolves to subsequent stages of recuperation. For example.. such as the family as well as with others sources of stress in lifestyle habits” (p. LeDorze (1995) found that some spouses zations). help individuals Such reactions may result in increased burden and stress. likely fears that the stroke will result Limburg. and emotional support. . that the patient relied exclusively on them for care. any of its components. 1974). An that families improve over time. religious. such as a stroke and ensuing aphasia. From the initial groups. 1991). For example. The roles in reality. are believed aphasia united them with the individual having acquired more subtly.. Han and Haley (1999) in family roles are likely to occur. Social cap. or traditional customs. This model begins with the severe illness or cri- tion organizations. Brassard. This establishes a cycle of depression fueling Young & Olson. to realize their physical and emotional needs through both Numerous studies indicate that increased depression in real and perceived support. Medicare and therapy by patient and/or family Medicaid. and Potential Family Needs Patient Stage Possible Effects on Family Potential Family Needs Severe illness or crisis (acute) Fear and shock Emotional support for entire family. members Peer support groups Possible financial problems Counseling from social worker. depression. significant others Anxiety Depression Guilt Helplessness Grief Obsessive concern Fatigue Recuperation Sense of relief from acute stage Continued emotional support Family works toward homeostasis Information about family demands. particularly Disequilibrium spouse and adult child caregiver. insurance. others Planning for postrehabilitation stage Postrehabilitation Frustration with daily communication Participation in support groups Possible role overload for primary Realization and support for caregiver personal needs caregiver Peer and extended group support Possible health problems for primary Increase in normative features of home and person caregiver with aphasia Long-term changes in family roles Continued emotional support—referral to Isolation of family from extended community counselors groups Possible reduction in intimacy between person with aphasia and spouse or significant other Over. changes in Problem-solving approach to communication personality. and clinician goals Beginning of isolation from community and expectations of therapy Physical changes in home Definition of and access to community resources Possible logistical problems in attending regarding financial aid.GRBQ344-3513G-C12[319-348]. and other difficulties co-morbidities Direct involvement in rehabilitation Solidification of new family roles Discussion of family. Possible Family Effects. concerns Search for help begins Informal education about stroke and its effects Individuals try to maintain self-image Family mobilized to work together Facilitative communication strategies modeled while communicating with adult who has aphasia Rehabilitation “Hope” that things will improve Continued emotional support with more emphasis Expectation that patient will improve on self-reliance Want information about stroke. Information giving and counseling aphasia.qxd 02-12-2008 09:40 PM Page 324 APTARA(GRG QUARK) 324 Section III ■ Psychosocial/Functional Approaches to Intervention TABLE 12–1 Patient Stages. Members assume needed roles and jobs resources.or underexpectations for continued improvements . Difficulties with travel and independence physical therapists. occupational therapists. etc. individual. children and parents or for those of a spouse. optimum care.qxd 02-12-2008 09:40 PM Page 325 APTARA(GRG QUARK) Chapter 12 ■ Environmental Approach to Adult Aphasia 325 TABLE 12–1 Patient Stages. Possible Family Effects. physical. also may have health. strategies for productive Further role changes visits Discomfort with setting Information regarding impact of institutionalization Reduction in contact with on family member institutionalized family member Modeling of facilitative communication strategies in Preparation for family member’s this setting deterioration or death Work with facility staff to stress importance of communication with the individual who has aphasia Encouragement to develop new roles in this setting Encouragement to participate in activities with the patient both within and outside this setting Counseling regarding deterioration and death Once the health of the patient who has had a stroke is sta. found that all families contended with stresses likely to assume primary caregiving responsibility. the family is likely to con- The family tries to return to its pre-crisis state (homeosta. in a family-systems study of nine poststroke when the family is in the late life cycle. The caregiving spouse. feed- sis). Kinsella and Duffy (1979) found lines of communication. ing children. but it is more likely to occur (unpublished). the patient and the family move into the recupera. In actuality. therapies are likely to tages and disadvantages. are likely to be employed outside the home that family and social factors were equal to medical factors in and to be caught in the “sandwich” of caring for their own determining the final outcome of patients after a stroke. tion stage. Further. comes to the stroke situation with both advan. although faced by maturing families. a mature family that has clear and social relationships.GRBQ344-3513G-C12[319-348]. such as those related to launch- adult children play an increasingly important role in provid. this will be their first encounter resources and social capital that may assist in coping with with therapy for aphasia. sory problems that complicate his or her ability to provide bilized. managing retirement. problems may face a crisis differently than a family that is Most families in which someone has had a stroke do not disengaged. (1988) found adult daughters. such as walking. an established resource network of that difficulty in communication results in a loss of the inti- family and friends. children. dressing. Kelly-Hayes et al. During this rehabilitation stage. demands on its members. particularly needs of elderly parents. and coping with the ing assistance to their parents. recuperation appears to be possible. the focus is on helping the individual with aphasia to however. The communi- with problems. Jones and Lubinski stages of family development. The elder spouse is families. the immediate tasks that need to be done and cation difficulties now evident between the individual with the resources for accomplishing them. For many families. and toileting. cognitive. there is relief that the patient will live. They also have a simultaneous normative stage of the family. its historical ability to cope awareness that communication is disrupted. During the recuperation stage. and Potential Family Needs (continued) Patient Stage Possible Effects on Family Potential Family Needs Institutionalization Physical/psychological overload Help in decision making Lack of awareness of community Counseling regarding alternatives alternatives Support during decision making and entry Conflicting feelings of relief and guilt Encouragement to visit. 1990). The older fam. When medical conditions have stabilized and physical ily. and has numerous conflicting come as units untouched by other problems in life. improve his or her communication skills. Numerous concurrent demands have an impact on the fam- Stroke may occur in younger adults who are in the early ily dealing with aphasia. For example. or sen. For example. stroke and aphasia (Rolland. The family system . This family has many years of life begin. however. and a history of successfully coping with macy and support found in most marriages. and other demands aphasia and family members confound both physical care on the family. centrate on activities of daily living. interacts poorly. Initially. numerous changes are influenced by the ing. The current viduals through the social interaction they have with a variety emphasis on evidence-based practice demonstrates society’s of groups throughout their life. and family members need information regarding that are valued by Western industrialized societies. and the larger society. those of the individuals with whom they work. usually through from former social interactions with the entire family unit or avoidance. 127). contact with problems. the political and economic environment also influ- ences the individual. be prevailing views on disability and rehabilitation within Finally. intervention options. 1999. cultural and participation of the patient with aphasia in the restructuring social environments” (National Institute on Disability and of family roles. the patient may become a mar. Rothchild (1970) says that such societies do not tolerate port is important before and after making the decision. hence. the family. the extended social system of the individual with North America. political. physical access to rehabilitation services. greatly influences how the client and family will perceive the fessional caregivers. This differ- tion partners for the individual with aphasia. particularly the very old. the values that it deems as being important to pass on How health care and rehabilitation are approached is also through the generations. In general. or failure. able during interactions with the patient and may withdraw The cultural norm is to mask such aversion. Note. Nurses and nursing assistants assume a problem and avail themselves of rehabilitation services. even within North America. Over stream society and part of an unfamiliar and isolated minor- time. and their social networks (Ingstad. 1990). such as pro. the long-term care if caregiving resources in the community are individual has more difficulty demonstrating intelligence. may have its opportunities for social connectedness because one mem. Friends and acquaintances may feel uncomfort. This results in disengagement of ily involvement in rehabilitation. 26). roles and routine are in place. Particularly relevant here is how influenced by the financial resources of those with aphasia society views disability.qxd 02-12-2008 09:40 PM Page 326 APTARA(GRG QUARK) 326 Section III ■ Psychosocial/Functional Approaches to Intervention is also continuing its restructuring during this time. Basically. These indi. individual members within it. Sotnick and ginal member of the family. p. Some individuals with aphasia may require relocation to Finally. yet also impede. home. family caregivers may realize that they need psycho. when communication problems are evident. force gains made in therapy. too. Psychological sup. contrasting views of etiology. or long-term care settings. The individual with aphasia is now out of main- and health problems are common among this group. built. ity group. They may or ence may affect the formation of goals and the inclusion of may not understand the nature of aphasia and how to rein. Some family caregivers may be overloaded by the (and. Finally. Second. family or others in the therapeutic process. between social needs and economic resources. “behavioral deviations [such as communication difficulties] The extended family of a person with aphasia is also that tend to disrupt the smooth functioning and easy flow of affected by the stroke and the resulting communication interpersonal relations” (p.. This decision is generally difficult for the individual social competence. This prominent role in the lives of many patients with aphasia in is particularly important as the United States becomes an the hospital. First. Society must constantly evaluate its economic resources against the Broader Cultural Milieu multiple needs of various constituencies. Role affects opportunities to communicate as well as financial and changes become more solidified so that even when individu. and productive social roles—all qualities and family. society is guided by need to provide wisely for those with disabilities. the individual characteristics and the “natural. in that they perform cultural views of disability and rehabilitation may differ from intimate caregiving tasks and serve as primary communica. stresses the balance and economic values of the culture that are translated to indi. Unwittingly. Rehabilitation Research. the home culture of individuals with aphasia aphasia is likely to include some new members. active rehabilitation will end as the indi. Thus. strained. The availability of How our broader society and individual cultures within it personal financial resources or finances and of third-party view disability in general and aphasia in particular also insurance to cover prolonged rehabilitation may affect the . Reintegration into society thus becomes more logical support (Van den Heuvel et al. 2002) challenging. 68578). adults who have difficulty communicating arouses anxiety. North American als with aphasia return to their families. and fam- ber cannot communicate. that clinicians’ viduals assume “quasi-family” roles. Safilios- their caregiving and residential options. society) might face communication frustration demands of care and possible conflict with personal needs.GRBQ344-3513G-C12[319-348]. increasingly multicultural society. Western societies also feel bilitation. This is the beginning of a “new normal” set of a need to “protect the less fortunate. although there may the family from the mainstream of the community. elimination of situations where the individual with aphasia 2006).” Protection may lead to roles and relationships for the individual and family (Allan. intervention for disabilities are favored in mainstream vidual with aphasia moves into the chronic stage post-reha. Difficulties in communicating it views disability as a consequence of interaction between contribute significantly to the need for. The growing num- The broader social milieu is comprised of the social. ber of elderly. American culture (p. The family may lose some of Other cultures. Jezewski (2005) state that acknowledgment of and outside At some point. modifications in culture has a divided view on how it perceives disability. Starkstein & Robinson. Of particular interest in this chapter are the communica- Lawton. com. anxiety. boasting. or loses interest. Some vivors of stroke incur depression. As family members cope with the family’s savings may determine how and where therapy is demands of the stroke and with their own feelings of loss. Wahrborg. denial. and emotional traits and needs. 1964).qxd 02-12-2008 09:40 PM Page 327 APTARA(GRG QUARK) Chapter 12 ■ Environmental Approach to Adult Aphasia 327 person’s willingness to participate in therapy. sensory. Language. Individuals with aphasia they may provide few opportunities for communication with and their families appreciate a speech-language pathologist the adult who has aphasia. Cullum & Bigler. Egelko et al. pressure from the physical and sociocultural envi. age-related changes. Such depression symptomatology may be ing array of physical. Speech-language and aphasia. aggression. The individual with aphasia and depression is enrich their environment with these distinctive features yet in double jeopardy because of his or her difficulty in verbally must rely on other individuals and groups for information. Particularly painful was the when the content is ambiguous. and indecisiveness to physical and cognitive istics to the environment. and/or receivers. Depression is not the only affective disorder exhibited atives but must also respond to social conventions. cognitive. psychological. Dowswell and colleagues (2000) concluded in cues through vision. they strengthen their own or others’ perception from site of lesion or as a reaction to the challenges of stroke that they are incompetent communicators. Communication also becomes ineffectual when the individ- mented the deterioration of social life for survivors of ual does not comprehend signals. because one decodes many nonverbal devastating. individuals with aphasia may also incur other tional abilities. 2003. tion abilities and disabilities that individuals with aphasia Individuals with aphasia come to their environment with contribute to their environment. including their personal tion to occur. because of feelings of shame and perceived moral judg. presented in this chapter. (Jenike. The inability to communicate successfully may be the ments. Grief and anxiety are nat- cost/benefit ratio. support. opportunities result in diminished social roles that then generate depression for the individual and hence fewer opportunities to communicate. Individuals are expected to know their social regression. Knowing that a family cannot afford ural consequences of the physical and psychological losses extensive therapy or that the costs of therapy will deplete a associated with stroke.GRBQ344-3513G-C12[319-348]. 513). including frustration. Internal Environment The depressive symptoms that individuals with aphasia The individual is at the core of the environmental approach may show can be multiple. creating challenges for disease.g. may be long term (e. Lovegreen. as fewer who acknowledges the financial burden of therapy. lem (Goffman. receives a distorted signal. when patients “deeply felt their change in status from ‘doers’ to he or she misperceives the availability of the receiver. Human beings or dementia. or irrelevant. competently. speech. Visual acuity also contributes to effec- The loss of social roles for survivors of stroke is particularly tive communication. a potential co-morbidity patients may be stigmatized by their communication prob- (e. any of a constellation of reactions. or “fit. This study also docu. and emo. Communication will be unsuccessful their qualitative study of survivors of stroke that these when the sender transmits an unintelligible message. For successful communica- a constellation of characteristics. Parkinson’s disease. and catastrophic reactions (Wahrborg.” is defined as the similarity between what the nosed from the aphasia itself and from any other concomi- individual can contribute and the demands of the environ. ronment will never exceed the person’s ability to respond anger. The interplay between human beings and their cognitive changes. withdrawal. such as dementia including Alzheimer’s environment is delicate and dynamic.g. done and how progress is evaluated. The most extreme symptom includes suicide member of it. from active to passive. Each time they attempt to communi- Depression may be related to biochemical changes resulting cate and fail. and Physical and health concerns may have priority over com. 1991). At a time when . and stroke-related disabilities. tant psychological problems. inappropriate. 1970). stroke. and receiving signals. inability to help others” (p. The individual generates social imper. intellectual. it is not surprising that many sur. partly as a result of physical obstacles but also is distracted by extraneous stimuli. interpreted.. however. such as depression. ment (Kahana. hearing mechanisms must be minimally capable of sending munication rehabilitation for the individual or caregivers. Robinson & Benson. these must be differentially diag- ence. ity to send and receive messages. 1988). but exhibit depression following their insult. 1988. the greatest price they must pay for their illness. Basic characteristics include the total and evolv. ily concerns about the cost of therapy and the perceived 1989. and therapeutically expressing feelings. 1981). By contributing personal character. Further. roles and match them to their biologic.. multi-infarct dementia. and feedback. Person-environment congru. the individual becomes an active problems. A vicious cycle ensues. by family or professionals as confusion municative. 1991. and dementia related to our ability to adapt and survive. 1991). the individual must have some degree of abil- history. dependency. ranging from pervasive sadness. Affective changes can be Ideally. Kahana. among individuals with aphasia. From 30% to 60% of patients with stroke pathologists are encouraged to be culturally sensitive.. and this depression they must also be “economically sensitive” to client and fam. most significant problem for individuals with aphasia—and From these findings. hostility. Again. & Kahana. creates MacKay (2003). and unfulfilling to the client. physical. aphasia as “a social problem that is subject to social action” Although one individual incurs the stroke. Communicative avoidance also results in choice. Therapeutic goals should rightly of a social model of disability. arti- viduals are isolated from communication opportunities by ficial. rehabilitation. 812). Gilpin. is viewed as the loss of ability to interact as a legitimate equal and communicative approaches while increasing their func. support the individual in these endeavors (p. the speech-language pathologist to leave the cloister of the tion for adults with aphasia that derives from environmental therapy office and enter the physical and social environment and family systems theory and their application to aphasia of the patients with aphasia. socially meaningful and functionally effective interac- their roles as adult communicators within their family and tion with the world” (p. 738). their communication abilities. The significance social environment. and the phys. Duchan. linguistic. For example. 2003) recognizes the impact of become effective communication problem solvers. Disability should complement and enhance other cognitive. ners. and for still others. & Ireland 1997. The philosophy discussed here is one that can Second. their skill is impaired. the environmental philosophy is compatible with be easily incorporated with other approaches presented in the social model of disability that focuses on the relationship this text. to significant others. Burchardt (2004) describes responses results in a loss of opportunity for the individual these as a combination of individual ability resources. or to their voluntary withdrawal or by the retreat of significant themselves might find this approach to be a starting point for communication partners. and other social groups. each individual (p.qxd 02-12-2008 09:40 PM Page 328 APTARA(GRG QUARK) 328 Section III ■ Psychosocial/Functional Approaches to Intervention communication is essential for adjustment and reintegration opportunities negatively affects the social relationships into the family and the community. each time individuals are with at least four models of disability and rehabilitation. Nussbaum (2000). answering these questions. Each of these should be the object of value. cal means and knowledge to carry out a variety of functions of cation ability. and participation as well as the Life Participation nication partners to facilitate communication. the effectiveness of commu. but the goals communication rehabilitation emanating from England (e. For example. Approach to Aphasia could both be assumed under the rubric ical and social environment. including Individuals with aphasia face a crisis each time they cannot family. In particular. quickly and efficiently express or comprehend the symbols of The philosophy underscoring this chapter is congruent their environment. or they “empowering a disabled person to achieve a personally ful- even may not respond at all. a crisis occurs each time indi. practi- with aphasia to demonstrate intact or improving communi. and tionality for individuals with aphasia in their physical and economic environment (Burchardt. Organization (2001) framework that encompasses impairment. Ideally. “[S]ole cation and. preoccupation with the act of communicating has failed. As Lyon (1992) states. 615).. because of the barriers created by the physical. The World Health takes into consideration the interrelatedness of individuals. process. so far. If we aphasia on a person’s self-identity and the important role of acknowledge the principle that communication is a dyadic the community in reintegrating this individual into society. for others. It may be easier to avoid communi. friends. 9). thereby. communication and the environmental model. and it reverberates to larger social systems. Banja (1990) stated that rehabilitation should focus on quickly. individuals with aphasia and their significant others to 2003) and Canada (Kagan. and economic environment to fewer opportunities for individuals with aphasia and their part. this model suggests that capabilities nication because of potential problems. this philosophy. Applied to ners to initiate and evaluate productive communication prob. The diminution of communication bilities framework focuses on the ends (communication . bombarded by communication that comes too abundantly or First. The approach described here helps This chapter presents a model of assessment and interven. Originally proposed by Sen (1980) and anticipate every need. Speech-language pathologists other social groups. the capa- lem-solving strategies. the environmental systems approach between individuals with impairments and society. The natural response by some communication part. & Pound. we realize that aphasia. who suspect that their therapy for aphasia is incomplete. of the environment in understanding disability is evident in The environmental systems approach is based on the phi. social. to ties framework. A third. ronmental approach to intervention is called the capabili- ners is to talk for the individual with aphasia. Byng. They find it difficult to fulfill filling. considers problems for both members of that communication team. lessen the frustration of failure. Parr. 2004).g. activity. to avoid commu. and the social. to deliver a solution to the problem of restoring optimal function (i. himself an individual with aphasia. a philosophy of focus on primary communication disorders. Similarly. by its very nature.GRBQ344-3513G-C12[319-348]. with whom that person communicates will face a predica.e. communication use and participation in life) in ENVIRONMENTAL PHILOSOPHY natural settings” (p. relatively new framework that supports an envi- ment. they may reply unintelligibly or inaccurately. must also facilitate and strengthen those strategies that allow Parr. individuals with aphasia will losophy that effective and functional therapy emanates from communicate best in an environment that values and sup- a comprehensive rehabilitative management model that ports them regardless of their skill level. between those with aphasia and their communication part- and opportunities to interact are often seriously reduced. To develop self-actualization skills for individuals with aphasia and their significant others so that rehabilitation becomes a realistic and effective process. 4. the therapeutic “client” consists of both the individual with Many clinicians will recognize a communication- aphasia and his or her environment. To develop communication skills and those sensory and cies. A positive communication environment provides opportunities for socialization so that individuals 1. opportunities. impaired environment by its obvious inadequate quantity Specifically. Finally. a broad and qualitative guideline for evaluating the commu- tion can occur. A Communication Environment Inventory is pre- cognitive skills that underpin communication to the sented in Table 12–2. to maximize their communicative competence.” the addition. degree of independent and successful communicative partic. individuals with aphasia The first step in the environmental rehabilitation program is need and want to communicate and that the physical and to identify how the physical and social environment creates social environment can be a catalyst to promote successful opportunities for. Second. nicative interaction. the person with aphasia needs a stimulating and sup. The work of Hinckley (2001) on self-efficacy for aphasia 3. interaction. a positive communication environment. munication as an important outcome of care. of care. Limited physical accessibility to activities and part- tal approach. the goal. contains stimulating activities and a variety of interest- tiation of identity in aphasia support groups complement ing communication partners of choice. At the IDENTIFICATION OF A COMMUNICATION- core of this intervention is the belief that. First. easily accessible places to talk. Limited or no support for communication partners. Such an environment respects and supports for adults with aphasia and their significant communication individuals with aphasia and their significant partners. that they cornerstone of effective functioning. cessful communicative interaction. to the extent possible.GRBQ344-3513G-C12[319-348]. the environmental goals within the total and quality of communicative interaction. bilitation process. Thus. Lack of private. Restrictive stated or unstated rules that limit commu- caregivers to be essential partners in the diagnostic and reha. but more formal rehabilitation program are: tools are needed to document the nature of these deficien- 1. The idea that communication is a by-product. not a keeping in mind that communication is a dyadic process. portive physical and social environment that perceives com. To create a physical environment that promotes suc- the means (specific skills). 5. Such an environment exhibits munication opportunities of choice within a variety of physical the following characteristics: and social settings. it eliminates or moderates physical barriers that antithesis of a positive communication environment. even in the face of IMPAIRED ENVIRONMENT severe communication disability. To provide communication partners with techniques for framework. and competence) rather than 2. This inventory provides clinicians with highest degree possible so that meaningful communica. In partners. both the social model of disabilities and the capabilities 4. To develop greater societal awareness of the nature and INTERVENTION impact of aphasia and a philosophical and financial com- mitment to supporting communication intervention The ultimate goal of environmental intervention is to create within the community. environment becomes a stimulating and accepting milieu in 7. twin benefits arise from adopting an environmen. To create a positive communication environment that and the philosophy of Shadden and Agan (2004) of renego. 2. Simply 8. Accordingly. which communicative interaction is likely to occur. Sensory dimensions that confound communicative stated.qxd 02-12-2008 09:40 PM Page 329 APTARA(GRG QUARK) Chapter 12 ■ Environmental Approach to Adult Aphasia 329 effectiveness. communicative interaction communication. the physical and social activities and interaction. is one impede the transmission and reception of messages and that that limits communication opportunities through its physi- preclude independent or assisted access to meaningful com- cal and social characteristics. Cognitively boring. facilitating and reinforcing communication through a ronment is critical to the ability of individuals with aphasia variety of communication channels. Few reasons to talk that emanate from meaningful ipation in their environment. 9. A “communication-impaired environment. nication opportunities and barriers that reduce interaction . Few or no communication partners of choice. individuals with aphasia achieve some ners. the active influence of the social envi. A positive commu- nication environment is one in which individuals have plen- tiful access to communication opportunities of choice and are valued as meaningful communication partners. are socially and communicatively competent persons. 5. 10. In each. or barriers to. 6. environmental approach considers family members and other 3. Lack of sensitivity to the value of communication as a with aphasia can demonstrate. OVERVIEW OF ENVIRONMENTAL 6. Furniture design and placement _______ _______ _______ 4. Texture _______ _______ _______ d. Easy access _______ _______ _______ d. Daily _______ _______ _______ b. Variety _______ _______ _______ c. Appropriate to personal interests _______ _______ _______ 5. Adequate lighting _______ _______ _______ b.qxd 02-12-2008 09:40 PM Page 330 APTARA(GRG QUARK) 330 Section III ■ Psychosocial/Functional Approaches to Intervention TABLE 12–2 Communication Environment Inventory Name______________________________ Date of Evaluation_____ Re-evaluation ____ Setting: Home___ Hospital ___ Rehabilitation ___ Community___ Long-Term Care _____ Communication Environment Inventory Frequency of Occurrence1 Communication Factors Frequently Occasionally Never Physical Environment 1. Is environmental design conducive to communication? a. Sound _______ _______ _______ c. Physical layout _______ _______ _______ f. Noise control _______ _______ _______ d. Are there objects and activities that stimulate thinking and interaction? a. Weekly _______ _______ _______ . Can the individual physically access communication opportunities in a variety of settings? a. Does the physical environment stimulate thinking and communication through use of: a. Movements and actions _______ _______ _______ 6. Does the individual participate in an activity of choice that stimulates conversation? a. Proper ventilation and temperature control _______ _______ _______ e. Color _______ _______ _______ b. Hospital/rehabilitation center _______ _______ _______ e. Is personal or technologic assistance easily attainable within setting(s) to access communication opportunities? a. Caregiver assistance is readily available _______ _______ _______ b. Taste _______ _______ _______ f. Home _______ _______ _______ b. Long-term care setting _______ _______ _______ f. Assistive aids are available and feasible within the setting _______ _______ _______ 3. Smell _______ _______ _______ e. Visual access to stimulation _______ _______ _______ c.GRBQ344-3513G-C12[319-348]. Are private places clearly identifiable and accessible for personal conversations? _______ _______ _______ Social Environment 1. Age appropriate _______ _______ _______ b. Community _______ _______ _______ c. Work _______ _______ _______ d. Other _______ _______ _______ 2. Others (specify) _______ _______ _______ 4. Domestic/residential life _______ _______ _______ d. Other (specify) _______ _______ _______ 7. Others (specify) _______ _______ _______ 3. Current events _______ _______ _______ h. Roommate _______ _______ _______ c. Safety and health _______ _______ _______ c. volunteers _______ _______ _______ e. Complaints _______ _______ _______ f. Does the individual have a variety of reasons to communicate? For example: a. Family or spouse _______ _______ _______ b. Emotional release _______ _______ _______ d. Medical staff/caregivers _______ _______ _______ d. Medical staff/caregivers _______ _______ _______ d. Do members of the environment encourage the individual to engage in interesting activities of choice? a. Work _______ _______ _______ e. Friends. Spouse/family _______ _______ _______ b. Needs. Friends. Relationships with others _______ _______ _______ g. Does the individual have at least one person of choice with whom to communicate personal thoughts? a. Medical or physical needs _______ _______ _______ f. Medical staff/caregivers _______ _______ _______ d. Personal history and interests _______ _______ _______ b. Roommate _______ _______ _______ c. Others (specify) _______ _______ _______ 5. Friends.GRBQ344-3513G-C12[319-348]. requests _______ _______ _______ b. volunteers _______ _______ _______ e. volunteers _______ _______ _______ e. Do communication partners value the communication content and efforts of the individual? _______ _______ _______ (continued) . Other (specify) _______ _______ _______ 6. How available are communication partners of choice? a. Family _______ _______ _______ c.qxd 02-12-2008 09:40 PM Page 331 APTARA(GRG QUARK) Chapter 12 ■ Environmental Approach to Adult Aphasia 331 TABLE 12–2 Communication Environment Inventory (continued) Name______________________________ Date of Evaluation_____ Re-evaluation ____ Setting: Home___ Hospital ___ Rehabilitation ___ Community___ Long-Term Care _____ Communication Environment Inventory Frequency of Occurrence1 Communication Factors Frequently Occasionally Never 2. wants. Personal history/interests _______ _______ _______ e. Roommate _______ _______ _______ c. What topics generate conversations for the individual? a. Spouse/family _______ _______ _______ b. Are rules governing communication in the setting modified to encourage all communication attempts by the individual? _______ _______ _______ 9. For of assessment process should naturally complement other therapy to be truly functional and successful. which signifies items conducive to a positive interaction. Keep in mind that goals individual’s communication. Are communication partners skilled in the use of communication strategies to facilitate communication or repair breakdowns? a. Spouse/family _______ _______ _______ b. Comments: Plan of Action: Environmental Goals: of the person with aphasia. that perception of the adequacy of frequency Once the clinician has completed an environmental assess- may change as the person with aphasia tries to enter more ment. must be identified that are reasonable and functional within . which portrays a com. whereas others may define it as three times per ENVIRONMENTAL INTERVENTION week. others _______ _______ _______ 10. into two major sections. This tool can be used to assess tioning and evaluation of family or caregiver interaction with the communication environment in the family home or the client are essential and discussed elsewhere in this text. more in-depth assessment of the and environmental problem solvers. the participants approaches to communication evaluation for clients and their need to become both sensitive to the environmental effects caregivers. restrictive communication environment. some patients with aphasia and their family members may define “frequently” as every day. that are frequently identified as encouraging communication munication-impaired environment. The first section. and clinician definitions. Intervention focuses on strengthening those items communication environment. The The second section. caregiver. This dis- Those items rated on the negative end of the scale provide cussion alone alerts the participants that effective interven- areas for possible environmental intervention. This type tion goes beyond development of communication skills. Medical staff _______ _______ _______ c. to never. environmental concerns need to be prioritized communicative contexts and faces environmental barriers. some level of institutional care. focuses on the built or structural environment. Do communication partners have opportunities for physical and emotional wellness activities? _______ _______ _______ 1 Frequency is subjectively defined for each individual. and intellectual func. For example. from assisted-living settings The Communication Environment Inventory is divided to long-term care facilities. volunteers _______ _______ _______ e. through discussion with the client and caregivers. Physical the evaluation tool can form the basis for a structured Environment. Note. Social Environment. For example. concentrates on individual items on the list are rated on a continuum from social factors that may stimulate or decrease communicative frequently. sensory. Other caregivers _______ _______ _______ d.qxd 02-12-2008 09:40 PM Page 332 APTARA(GRG QUARK) 332 Section III ■ Psychosocial/Functional Approaches to Intervention TABLE 12–2 Communication Environment Inventory (continued) Name______________________________ Date of Evaluation_____ Re-evaluation ____ Setting: Home___ Hospital ___ Rehabilitation ___ Community___ Long-Term Care _____ Communication Environment Inventory Frequency of Occurrence1 Communication Factors Frequently Occasionally Never 8. too. Friends. Although it is not standardized. Frequency of occurrence and on reducing or eliminating those factors that create a more may differ for individuals and should reflect client. observation and discussion with clients and caregivers.GRBQ344-3513G-C12[319-348]. group activities (Camp. and Emotional Skills family physician or a mental health specialist is appropriate. cane. Ireland and come to the intervention arena with adequate sensory. Patients may need to be referred hours of counseling. including strengthening and caregivers. the speech-language pathologist must constantly be alert for symptoms of depression in the client with aphasia Goal 1: Improve Communication. One implication of this study is that dementia. 3. therapy sessions using a variety of approaches. Spouse does not know what to do when client has 4. coping skills to deal with residual communication difficulties. nitive skills may benefit from engagement in a variety of achieving independence and socially fulfilling roles in the . At least two staff members will have a one-on-one conversation with client on a daily basis.g. Finally. Sensory. 2b. In some situations. Client will verbally or nonverbally advocate the need for communication partners. 3b. For example. Perhaps the most important way to help cope with depres- In addition. Peer-group activities in particular are an excellent is achieved through individual and group speech-language venue for peer counseling and discussion of coping strategies. Tanner. referral to the Cognitive. The most immediate need is Gerstenberger and Keller (1989) suggest that the speech- to help the individual retain or achieve status as an active and language pathologist incorporate frequent positive reinforce- viable communication partner. this goal activities. 3a. individuals with declining cog. Spouse will learn several strategies that facilitate word recall word-finding problems and avoids communication to and use them on a daily basis. noncritical. with assistive devices. it is critical that the individual with aphasia sion is to allow adults with aphasia time to talk. cog. and in family caregivers. such as Montessori based are shown in Table 12–3. ramp) independent mobility. specific receptive and expressive skills whereby individuals can Other suggestions include encouraging the client to partici- intelligibly and meaningfully contribute their personal ideas pate in activities of choice as well as peer-group therapeutic and have their needs appropriately met. Client has restricted access to activities/partners of 1a. Client will communicate his or her preference for activities and partners of choice on a daily basis. with client. avoid further stress. understanding of the emotional impact of aphasia and con- Some individuals with aphasia may have co-existing sequent life changes. It may also change the content and nature of Speech-language pathologists also need to consider long- information provided to and counseling of both the patient term goals for the client with aphasia.. ence prognosis. walker. Several approaches to relieving symptoms of depression can son with aphasia to use communication to lead a meaningful be incorporated into daily therapy for aphasia. Staff will close door to hallway when communicating intelligibility of client. social role in a variety of contexts. and emotional skills. a therapeutic context. the guidelines of the setting and payment sources. Traditionally. Family or staff will provide assistance to activities on a choice that stimulate conversation because of limited daily basis (e. increased confidence.qxd 02-12-2008 09:40 PM Page 333 APTARA(GRG QUARK) Chapter 12 ■ Environmental Approach to Adult Aphasia 333 TABLE 12–3 Sample Goal Plans for Environmental Intervention Environmental Concern Environmental Goal 1. Aphasic versus dementia-related language and speech-language pathologists may need to set aside specific cognitive changes must be differentiated. Outcomes included ronmental accommodations may be needed to supplement decreased depression. Examples cognitive stimulation programs. Hallway background noise masks communicative 2a. 2. This is done by strengthening ment into every session as a means of reducing depression. Rehabilitation efforts focus primarily on empowering the per. Additional visual and acoustic envi. and private context. Staff members ignore verbal attempts by the client. Identification of therapeutic goals to allow individuals time to vent feelings in dementia as a co-morbidity may mitigate progress and influ. 1b. Their descriptive study revealed that the for hearing and vision examinations and possible follow-up participants valued being given time to talk in an attentive. personal aid.GRBQ344-3513G-C12[319-348]. and better individual interventions. 1999). Client will indicate through gesture that door should be closed during interaction. Wotton (1996) provided 20 persons who had aphasia with 20 nitive. 4. perception. Keep this in mind when scheduling Older persons with aphasia may also have difficulty with programs. Alternate transportation may be needed as well as glare. The factors that can be manipulated in most envi. Individuals who moved as needed. and adjusting to changes in levels of illumina. the person with aphasia should have visual access to windows facing outdoors or to areas where Goal 2: Create a Physical Environment everyday activities occur. vehicle for accomplishing these goals. or specially adapted. ors. 1997). the physical characteristics of that environment The use of color in the environment also plays an impor- become an important backdrop for communicative interac. reader is referred to Calkins (1988) and Lubinski (1995). furniture. O’Keeffe (2006) suggests that older individuals per- tion.. and age-related macular degeneration). Areas of diagnostic and therapeutic als and access to handheld or stand magnifying glasses or activity should also have focused task lighting that can be magnifying sheets should be encouraged. perception of patterns. hemianop. Use of prescription lenses or other visual (2006) suggests that seniors need 30% more light for gen. and bedding and Lighting and Visual Cues using warm. and low-contrast col- partners for the individual with aphasia. book cases. Speech-language eral tasks and fivefold brighter light for reading and task pathologists should check a patient’s chart to note whether completion. (c) furniture arrangement. and (d) environmental cues. It may be impracti.g. ensure that the individual with aphasia has the best vision pos- In general. 1997). The physical setting should be a source of information. setting. sions. color additional lighting in walkways. Adequate illumination contributes to the safety and inde. ronments include (a) lighting and visual cues. Rooms that are filled with telescopes. such as the kitchen and living that Promotes Communication room at home or the nursing station and lounge areas in a nursing home. and adjustable window treatments with other rehabilitation specialists provides the optimum (Brawley. Other simple strategies that enhance visual access include adding texture to surfaces of walls. 1997). Visual access gives the person with aphasia a No matter the setting in which the person with aphasia lives. retinopathy. O’Keeffe ric evaluations. orientation and conversations. closed-circuit televisions for glare from shiny surfaces or poorly controlled lighting the visually impaired (Orr. but some realis. For example. ceive colors at the warm end of the spectrum best but will stimulation. the large-size white letters on a contrasting dark surface. This is best presented through natural daylight visual-field disturbances exist or if glasses are needed for eval- and dimmable. For example. pastels. high-contrast materi- 2006. assistive devices should be easily accessible. and blepharitis). low or difficulties in night driving and concern about walking in blurred vision. Visual access stimulates visual changes associated with stroke itself (e.. aging (e. Preserving the self after a cues. in turn. pocket-sized a clear font is recommended). mation and aids in visual discrimination. placement of visual information such as clocks. Glare is reduced by the use of ambient indirect light- able to return to their social roles and reestablish their sense ing. tant role. uations and therapy. Perhaps the simplest strategy to enhance visual access is to tion (Brawley. These particularly during the winter months. Brawley. contrast differentiation. dry eyes. 1997). and bulletin boards should be adjusted A high proportion of patients and their spouses will exhibit appropriately for a seated person. older patients will require more light that is sible through regular referral for ophthalmologic or optomet- uniformly bright and does not create shadows. Teamwork semi-gloss paint on walls. (b) acoustic Patterned wallpaper also provides stimulation and orientation treatment.g. and Clinicians may find that persons with aphasia and their age-related diseases (e. returning to employment. Kirkevold. take advantage of contextual information. Visual stimuli necessitate clear contrast. non-glare floor coverings or non-gloss waxed floors. high-quality fluorescent lamps (Aging Eye. For a more in-depth discussion of these topics. have aphasia and severe visual difficulties may benefit from and font size should be larger than normal (18-point print in “talking books. glaucoma. reduce the individual’s ability to comprehend nonverbal preparing for long-term care. Kvigne. and doors aid in the identification of one’s own personal areas. and cognitive and social stimulation from the visual environ- Gjengedal (2004) found that female survivors of stroke were ment. thinking and. presbyopia. Nameplates or other identification should be printed in props. cataracts. medium-intensity colors to facilitate orientation. walls tic modifications that facilitate communication are usually painted in primary colors with contrasting colors for floors possible. Use of large-print. blindness. and for some. This may result from visual changes result in loss of visual acuity. televi- partners while creating a visually stimulating environment. Finally. of self and a meaningful life when supported. When possible. diabetic family members do not attend evening support programs.g. and access to communication activities and have difficulty with blue tones. Improving visual contrasts through color enhances infor- cal to redesign the hospital or family home. dimly lit parking areas. and changes in central or peripheral vision.qxd 02-12-2008 09:40 PM Page 334 APTARA(GRG QUARK) 334 Section III ■ Psychosocial/Functional Approaches to Intervention community. Because some individuals with aphasia will be seated in wheel- pendence of persons with aphasia and their communication chairs.GRBQ344-3513G-C12[319-348]. visual access is . sense of connectedness and cognitive stimulation with the either a family home or an assisted-living or long-term care physical and social environment.” high-tech reading machines.. sia). and derive stroke is essential. where individuals with aphasia are likely to converse or par.g. ual with aphasia knowledge about his or her surroundings eral noise sources. may be susceptible to unwanted background noise.. vacuuming devices. voice print phones. Communication that comprehension. Small dining tables (four to six seats) encourage . should be movable to promote easy access. long-term care settings should have FM or other third most prevalent chronic condition associated with aging sound-reinforcement systems available. When possible. Each of these what positioning facilitates visual access. In addition. dow to reduce noise from other areas or corridors. when. favorite activities and social groups. Always fit the person’s size. talking or providing therapy as well as closing a door or win. Clinicians should be aware of creating a sterile auditory environment. Everyday sounds the auditory characteristics where they provide therapy and are a source of stimulation. Even therapy provided in a client’s home and a sense of belonging. in the environment. eye contact.. It is prudent to check with the client and ask. such as hos. Other noise-control will be more likely to join a group if they feel they can enter strategies include turning off the radio or television when with a minimum of inconvenience and disruption. and ambient noise and reverberation. remote speaker phones. Furniture. Individuals with aphasia vice also contribute background noise. Face-to-face communication also pathologists and audiologists should provide information will optimize the use of listening aids and the reception of about the types of environmental listening technology that nonverbal cues.. presbycusis) or previous with aphasia is more likely to be heard than communication life experiences (e. & Flexer. and amplifiers) (Mann. 2006). It does not. Speech-language mation more adequately. 1997). Keep in mind that untreated hearing loss is environmental assistive listening devices both in the design linked to both depression and social isolation in seniors of new facilities and in the renovation of existing ones. therapy should be provided in areas that are Furniture Arrangement acoustically treated with sound-absorbing materials (e. and food ser. gregate areas. Listening to speech in background of noise is particularly Smaldino. particularly chairs. acoustic tiles or panels. language pathologists and consulting audiologists should The first step in enhancing the acoustic environment is to define the acoustic needs of older patients with aphasia in begin with a referral for a complete otologic and audiologic long term care settings and provide suggestions for use of evaluation. as well as a variety of periph. regardless of the presence of aphasia (American Academy of Individuals with aphasia and their caregivers who reside Audiology. patient in a wheelchair may lack easy or independent access to Heating/cooling systems. the those near doors. and auditoria. safety. are available and how to access them in community venues.g.qxd 02-12-2008 09:40 PM Page 335 APTARA(GRG QUARK) Chapter 12 ■ Environmental Approach to Adult Aphasia 335 enhanced by coming face to face with the patient and asking have appropriate seating and adequate lighting.. In addition to difficulties in auditory appropriate pauses (Kricos. and other physical disorders. 2006). Circular furniture arrangement also noise-producing sources. Individuals with techniques is inexpensive. and draperies) to reduce The arrangement of furniture determines where. Stimulation from the myriad sounds of daily life. slightly slower rate and a louder volume. Pichora-Fuller. centers. 1995.” hearing impairments (e. “Can benefit from telephones designed for those with motor or you see me here? Move the page so you can best see it. Note that hearing loss is the Ideally. and high activity centers. however. windows. Areas to avoid include with whom the person with aphasia will talk. and provide stable support while sitting or seek permission from the client before adjusting lighting or standing (Brawley. par. ticipate in activities. music. often contain hard surfaces. such as dining rooms and lounges (Crandell. radios. with and without hearing loss. particularly in con- and increases both with aging and with institutionalization. Speech- difficult for older persons in general (Kricos. The primary goal of enhancing the acoustic environment is including natural and clearly articulated speech with a to ensure that intact auditory information reaches the indi. 2006).g. employment in noisy environments) that occurs at greater distances. note that individuals macular degeneration in particular may have better peripheral with aphasia and a hearing loss may not understand informa- vision and be able to see when people or items are place in tion presented on public address systems.GRBQ344-3513G-C12[319-348]. cordless phones. Auditory stimulation gives the individ- which increase reverberation. 1997). the patient may have difficulties hearing occurs within about a 3. Clinicians and communication partners should consis- Acoustic Treatment tently employ communication-enhancing techniques. 1997). Individuals with aphasia may take facilitates eye contact and auditory reception with a variety better advantage of visual cues during conversation if they of people. mean ticularly during conversation. and vidual with aphasia.to 4-foot radius from the person related to the aging process (e.g. For example. They may also that area. in the community should also use assistive listening devices ing loss should be encouraged to use a personal hearing aid that may be available in congregate settings such as senior or other assistive listening device to receive auditory infor. and television can stimulate interaction with others pitals and rehabilitation centers. churches. Institutional environments. carpeting. Ambient noise in the environment may reduce the Noise control is important for adults who have aphasia patient’s auditory attention and comprehension skills. theaters. Individuals with both aphasia and a hear. and conversation. setting. furniture arrangement and exits. cordless and voice public areas. and lounge). canes.g.g. should be made to assess the environment where these per- ment provides much information that the individual can use sons reside and delineate potential threats to safety. mementos. however.GRBQ344-3513G-C12[319-348]. informal conversations might occur in a relaxed and comfortable context. These adults may have tutional environment (Barnes & the Design in Caring impaired mobility related to hemiplegia and other health or Environments Study Group. Some residents of tial threat to safety. and instructions. issue of privacy should be considered when therapy is pro. objects that support activities of daily living and personal A partial sample of suggestions includes creating clutter-free interests. Keep in mind that the environ. kitchen. communication.qxd 02-12-2008 09:40 PM Page 336 APTARA(GRG QUARK) 336 Section III ■ Psychosocial/Functional Approaches to Intervention conversational interaction more than larger tables do. can be a source of interest and eavesdropping. hence. and active. to remain independent. stand information that will keep them safe and secure. Note. and bathrooms and on both sides of steps (Family Caregivers favorite pictures give them consistency with their family. Finally. Family Physicians. 1997). For example. and installing handrails in term care. 2002). Furniture arrangement in long-term care facilities should the physical “stuff” of the environment should reflect the encourage access and participation in both large group person’s history and interests while providing multi-sen- activities and in one-on-one private conversations. care settings. phone or in person.. adults Examples include assessment of major living areas for design with aphasia in the community need easy access to spaces and features and objects that might increase a potential for falls. If adults with aphasia are to personalities. Any assistive devices that promote physical inde. including the telephone (e. providing adequate pendence (e. personal items and furniture. A variety of safety technologies may be Clinicians should also keep in mind that therapy provided in suggested. good visual access to the outside (e.. extension cords from pathways. Adults with aphasia must per. should also be Safety Issues available. Environmental Props In addition.. reading transporta- with chosen partners. Morgan and Stewart sensory concerns. too. wall color aphasia.. keep- access to activities of choice and. using non-skid flooring. Areas in which private conversa. where conversations can become the property expressive therapy might focus on verbal and nonverbal of all interested listeners. The and wearable lifeline devices) (Newton. Other props can promote Wheelchair accessibility is a priority for many adults with comprehension and way-finding. garden. walkers. tion with adults who have aphasia. in which intimate. warning and signaling devices. of injury and disability for older people and affect one in vacy rather than socialization. such as the patient’s room in an institutional activated).. Key to sory cues about time and place. three adults aged 65 years and older (American Academy of require areas and objects that reflect their unique histories. Falls in particular are an important cause long-term care settings may prefer settings that enhance pri. For example. It is crucial that persons with aphasia retain control or Safety should be a critical focus of communication interven- autonomy over some personal space in their home or insti. Both patients and their caregivers may (1998) found that privacy is a vitally important aspect of the limit opportunities for interaction if they perceive a poten- environment for older people in general. They Some individuals with aphasia may be satisfied to sit in also need to be able to communicate their safety needs both one area for extended periods of time if that area provides efficiently and effectively. walkers and canes) close. and Safety topics for receptive therapy might focus on read- activities) or to areas where activities occur (e. home. hazardous materials. ing environmental signage related to medications. 2000). who will vided in community homes as well. and bulletin accommodate wheelchair accessibility. major efforts topics for communication. and interests. activities. safety-focused therapy is also ideal for caregivers. paths to the bathroom and telephone.g. better understand the patient’s ability to function indepen- dently. Similarly. boards serve as orientation devices. For persons should provide opportunities for privacy and intimate talk with aphasia who travel independently. remain in the community. Such a focus provides the family with a sense of security and comfort. As much as possible. ways to communicate personal safety concerns on the tele- tions can occur should be both available and accessible.g. removing For individuals with aphasia who have relocated to long. This is especially true in long-term tion schedules and ticketing may be important. All individuals. signage and visual stimuli. safe. Although this orientation of the person with aphasia and are a source of chapter cannot discuss the topic in detail. they need to be able to under- ceive a sense of choice and ownership in their environments. and lifelong identity. and handrails) also provide and non-glare illumination. ing assistive devices (e.g. Opportunities for small group way-finding. the environment needs to be designed to Physical props in the environment also stimulate the general meet the safety needs of adults with aphasia. Online. and again. it is critical that furniture be movable to and coverings. street. intercom systems. . 2006). Individuals with aphasia the large groups is flexibility and mobility of furniture to may need a variety of information sources to promote their meet programming needs. entrances nurses’ station. Further. Encourage caregivers ity. caregivers and others need to provide real protective benefits associated with exercise. Many of these pro- This may be accomplished in educational programs. choices are likely to reflect prestroke interests and experi- tion of the consequences of aphasia held by patients. Family and other caregivers need to learn the value of college training programs. Stern & Boyle. Caregivers will want to know which activities to suggest tation reported a depressed sense of self. new favored activities. Thus. Speech- tacts with family increase poststroke.GRBQ344-3513G-C12[319-348]. Hermann & Wallesse. Persons with aphasia may have to rely on “Do you think Mr. sive skills: “What is your opinion on ___?” “What do you lowing aphasia (e. skills. and these are natural sources of conversational top- of stimulating activities and as communication partners. Wilson should run for family members for socialization activities because of both mayor?” physical and communicative difficulties. These include reminiscence. but conversations that reflect reminiscing. Involvement in other types of both the importance of and how to access socialization activ. and psychological morbidity. Such LeDorze and Brassard (1995) documented the percep. however. The recent MacArthur Study of bers. and cognitive stimulation programs. philoso- Code (1996) showed that social dysfunction remained an phizing. and long-term care settings also socialization and their role in maximizing access to a variety encourage interaction. infor. family with Stimulating Activities and Partners members’ own socialization needs may be neglected. Caregivers are also catalysts who lowing stroke. members. this goal will be their communicative competence in a supportive environ- accomplished indirectly through educating family and other ment. to follow the lead of the individual with aphasia. found a decrease in leisure and management of personal caregivers must understand the importance of activities of affairs 6 months poststroke. ics. Such reliance places Some individuals with aphasia may return to work or leisure the responsibility on family members to serve both as sources activities. but they may also involve new activities and partners. limited social activ. Remember that a positive communication environment is The value of socialization for all persons. Jones or Mrs. limited socialization with the person who has aphasia. one of the goals of communication intervention is local aphasia centers. and evaluating are also meaningful and adult-like. healthy aging. Caregivers also need to realize their critical role in Seeman. Lyon. Numerous other studies and reviews questions for those with aphasia and a high level of expres- have also commented on the social isolation experienced fol. choice as the basis of communicative interaction. and counseling. opinions can be solicited with open-ended at 9 months poststroke. environment in which those with aphasia can demonstrate ulating activities and partners. but some mal discussion. Such participation provides a supportive to create a positive communication environment with stim. family ences. cognitive stimulation programs available in the community. 1998. encouraging individuals with aphasia to reengage in old or Socialization is also an important factor in recovery fol. Bolduc.. area of concern for both patients and their significant others For example. grams are geared for those with cognitive decline. and what to talk about with patients. think about ____?” For those with more limited expressive 1992). ities. Belanger. At a time when caregivers are may be appropriate for those with aphasia. Topics generate from activ- intimacy as well as a restriction on activities. 2001). despite the presence of aphasia. therefore. and Noel (1988) comfortable in communicating with the patient. 2002). 2000. but that a concomitant language pathologists may also use such activities as the foci decrease occurs in contact with friends and others. and others. Others may participate in language stimulation groups at Thus. 1989. Key to being considered a viable communication part- Successful Aging investigated factors that contribute to ner is the understanding that. particularly older one that values the communication contribution of its mem- individuals. key to optimizing the senior years (Rowe & Kahn. in a meta-analysis of 39 quality. In general. socialization may not be a priority. that socialization is important for presented: “Do you think your property taxes are too high?” those with aphasia. the speech-language pathologist . Many provide an array of adult-like activities that stim- caregivers and counseling the adult with aphasia regarding ulate thinking and conversation.qxd 02-12-2008 09:40 PM Page 337 APTARA(GRG QUARK) Chapter 12 ■ Environmental Approach to Adult Aphasia 337 Goal 3: Create a Positive Communication Environment stroke.g. yes/no questions or those that contain options can be It is logical. Before suggesting absorbed in meeting the myriad needs of the survivor of such programs. tion. remotiva- of meaningful social activities for the individual with aphasia. Those investigators found that elders who the individual is respected as a valuable adult communication participate in social activities or groups appear to gain the partner. Both patients and family members The act of soliciting options from patients with aphasia is noted reduction in interpersonal family relationships and important socialization in itself. is undisputed. respondents who received inpatient and outpatient rehabili. Ellis-Hill of individual and group therapy to prepare the client for and Horn (2000) found that even post-acute stage stroke these interactions. Helmsley and ities. In particular. opportunities in which individuals with aphasia can offer their contact during conversation and exchange of friendship are ideas through verbal and other means of communication. They may need to model was one of the important factors related to reduced quality communication-facilitating strategies so that partners feel of life (Bays. For example. In fact. encourage people outside the immediate family to interact of-life studies of patients with stroke. They also found that social con. Emotional support participate with a caregiver. with aphasia may be unsure of their ability to communicate in During the crisis and early recuperation stages. A good strategy is to provide information about an beginning the process of engaging them as part of the ther- array of available activities and discuss those that the patient apeutic process. and the cre. several Families will also want specific information about a range things need to be kept in mind. sation even if his or her responses are limited to single words. in the therapeutic process itself. Both studies clearly demonstrated that read information and clear directions to further resources. chronic phase). Two limited amount of information regarding stroke and aphasia. This relationship with professionals. volunteers. and Association are good sources for such materials. cost. Role playing may help as a precursor to actually attending new this is a time when simple introductions. a one. The recuperation stage may be a time when the speech- port from a social support network. When designing an education program for families. studies by Hinckley and Packard (2001) investigated the but it is important not to overwhelm them. Participants identified this stage (Michallet et al. an ability to monitor language pathologist can model some simple communication emotional and physical well-being. acceptance. Stroke/aphasia effects of a family education program on adults with aphasia packets or brochures may be provided that include easy-to- and their families. Evans and colleagues (1994) . (c) using well-formed short utterances. (2) how to communicate In fact. family education improves knowledge. Michallet and colleagues (2001. Bawden. (5) need for emotional and involves soliciting their goals for therapy and enlisting them practical support. Packard (2004) studied the outcomes of a 2-day residential families will want information about physical problems at family program held at a rustic camp. The family can also be an excellent source of information regarding the strategies they have Stroke Education developed to facilitate interaction. phase. p. programming. the time or phase of topics during this time. (b) maintaining eye contact during empathic communication family partners is to provide conversation. to participate in programs. The speech-language time approach to counseling and education is not likely to pathologist should discuss both goals and expectations and meet the needs of most caregivers. or eye gazes. more found that spouses of patients with severe aphasia identified formal and extensive education may be provided to families. (4) need for a partnership bers in the communication rehabilitation process. and comforting nonverbal communication are important. including length of the program. Finally. family adjustment. Simple ation of a new social support network. 1991). found that they needed different information depend. six needs: (1) need for information. facilitating strategies for the family members to use. rate. Figure 12–2 illustrates the needs and ways to but not forced. Some families may be ready at this time for a family intervention concretizes this clinical perception.qxd 02-12-2008 09:40 PM Page 338 APTARA(GRG QUARK) 338 Section III ■ Psychosocial/Functional Approaches to Intervention should try to observe the level of skill needed to participate and poststroke is critical to what information the family needs the cognitive level of the attendees. it is good to discuss the involves letting the individuals know that someone in the parameters of the activity. ing on the poststroke stage (acute initial rehabilitation or gestures. most family education will be done during this more effectively. Such supportive counseling helps to establish an atmosphere of trust whereby individual family members can eventually Goal 4: Create Skilled and Empathic express their feelings and concerns to the speech-language Communication Partners pathologist (Ziolko. strategies include (a) alerting the patient with aphasia that The most typical approach to creating skilled and conversation will begin. transportation. (d) information in some type of education program. Fox. peer visitors. and access to bathroom facilities. how these coincide with neurologic and communication diagnostic findings.734-5) As the patient moves into the rehabilitation stage.GRBQ344-3513G-C12[319-348]. Thus. Skilled clinicians know intuitively that support from family Emotional support may also be offered by other profes- and other caregivers is critical to the success of speech. in focus group interviews of family mem. Generally. Generally. five intervention outcomes: a sense of hope. active listening.. who unfamiliar world of the hospital knows who they are and attends. This is the time to solidify the family as active mem- tions with their family and others. and others may perceive some activities as is on providing family members with emotional support and demeaning. 2001). Research on port network. First. understands the trauma they have experienced. The American Stroke Association and the National Aphasia and functional activity level. Some individuals with aphasia munication between the speech-language pathologist (or may attend if they know that they can observe anonymously or other professional) and the family. the focus such contexts. and how ready they are to participate meaningfully in the Keep in mind that adults with aphasia should be encouraged. Avent and pausing frequently and using a slow to moderate speaking colleagues (2005). activities. sionals. Some individuals meet these needs by stages. (3) how to have better interpersonal rela. Poulsen. and (e) including the individual with aphasia in conver- bers. a view of sup. and (6) the need for respite. and the family’s own sup- language intervention in patients with aphasia. Support is generally provided through com- could attempt on a trial basis. such as finan. These resources. The chronic stage presents long-term chal. and self-help groups. in which they can The individual with aphasia and the family members openly exchange ideas and feelings. Evans and colleagues (1988) found that families A natural adjunct to the language stimulation group is the showed significantly less deterioration when they partici. This is also an excellent spouses experienced increased needs. travel and finances. and strategies for activities or counseling programs because of limited time for communicating in that setting. Some groups are organized by family to assume their role as communication problem solvers. should the extensive physical care needed by some persons with be addressed. others. ciate having their own reference group. the family should be able to reintegrate the ology of stroke. prognosis. This group can be a combina- pated in a combination of education and counseling at 6 to tion of individuals with aphasia and family members. Michallet and colleagues (2001) found that if groups help individuals with aphasia to practice communica- information needs were not met soon after the stroke. language impairment. insti- sibilities. Such availability demon. physical and medical . Practical issues. strates our commitment to helping family members main- tain active participation in rehabilitation. and how to make the transition to to a skilled nursing facility. apha- bers and the individual with aphasia no longer have the sia family support groups. The decision to relocate from the home and the postrehabilitation stage should be discussed in family home may be made during the recuperation stage or some depth.GRBQ344-3513G-C12[319-348]. This is a prime time to encourage participation in for the family should concentrate on helping them to under- a support group. they must truly rely on their own internal and external nication therapy or as a post-therapeutic strategy. McCormick and Williams (1976) orga- support groups may be beneficial. ally made because family caregivers are unable to provide cial coverage of therapy and transportation needs. within the settings. Specifically. Speech-language pathologists may be asked to present volunteer opportunities. rehabilitation services. alternative therapies. Referral to other rehabilitation counselors and such family groups. members themselves and become self-help groups. The decision is usu- breakdowns with the patient. Family members may appre- a year. including language stimulation programs. social network in former or newly created roles. Language expectation that rehabilitation will result in improvement. stimulation groups may be formed as part of formal commu- Now. port groups and participate in family-focused activities such as evenings and weekends. A “self- Avent and colleagues (2005) also suggest that this is a time help group” is composed of peers who share a common to present information regarding long-term planning. and difficulties opportunity to have family members serve as communica- in their interpersonal relationships with the patient and with tion partners and reinforce their use of facilitating strategies. living options. social stimulation for the individual with aphasia. worry. To worker and nursing staff can facilitate adjustment to the new work effectively with the family during rehabilitation. and support one or a series of talks on aphasia and related disorders to groups. gramming. vocational retraining. ders. families should be encouraged to join sup- must be available during nontraditional times for therapy. Encourage it will change the nature of the relationship between the per- a problem-solving approach to repairing communication son with aphasia and his or her family. tutionalization may instill feelings of guilt. The results were sustained even after can be family members alone. the Some individuals with aphasia may need to relocate to nature of the communication problems. Family members should be encouraged to par. because facilitating techniques with their family member. Finally. and organized by speech-language pathologists or other mental they should be well-prepared during the rehabilitation stage health personnel. for others.qxd 02-12-2008 09:40 PM Page 339 APTARA(GRG QUARK) Chapter 12 ■ Environmental Approach to Adult Aphasia 339 found that the most important constructs for families to individual with aphasia into the family and their extended understand are physical loss. aphasia family support group. This is a time when family mem. Family members may be reluctant to discuss their tutionalization may bring a sense of relief. feelings of stress and burden associated with caregiving. This decision is difficult for everyone involved. Such groups may be should not be surprised when therapy is terminated. For some families. Counseling ronment. acceptance of permanent insti- emotional support as family members assume new respon. tion skills in a realistic context. their role in the It is not always easy to incorporate families in therapeutic communication life of their loved one. some time after the individual has returned to the commu- ticipate in therapy sessions and practice communication nity. how to some level of long-term care. Teamwork with the social therapy and the personal schedules of family members. stand the meaning of institutionalization. ranging from an assisted-living facilitate communication. In either case. or it 12 months poststroke. This is also the time to continue to provide aphasia. we setting. and sexuality. families continue as an important source of cognitive and Many are grateful to express their emotions in a safe envi. With careful planning nized a 17-week program that covered such topics as the eti- and guidance. cognitive and perceptual disor. family is through involvement of the family in group pro- lenges for family members. problem and unite to form a collective identity. Aphasia Family Groups and Self-Help Groups A smooth transition to the postrehabilitation stage is crit- ical for the carryover of therapeutic techniques and family One of the best ways to provide long-term support to the adjustment. Such services may be offered in the family home. topics chosen for such groups these programs is a healthy approach to caregiving. and national family advocacy groups. By their ing information should be combined with respite programs unique kinship and empathy with the problem. the National Stroke Foundation and the National Head Injury walking. Haire. Family advocacy groups offer yet another dimension. use of they do not exist. Support groups may assist families in locat. Respite care may extend from a few hours to found that family members specifically appreciated the overnight to a longer period of time. such as may be offered at senior citizens centers. The primary responsibility for language pathologists who feel competent in leading coun. 305). Some family members may perceive instilling hope. such as focus on special areas of concern. and nutrition. active partici- opportunity” (p. and nursing assistants). occupational. in fact. and role changes. Williams (1991) states that family-to-family individuals to assume responsibility for their own physical programs give families a “sense of control. staff. and other community centers.qxd 02-12-2008 09:40 PM Page 340 APTARA(GRG QUARK) 340 Section III ■ Psychosocial/Functional Approaches to Intervention management. or Staff Inservice presenter..g. respite and wellness programs as an abrogation of their ing available services and in advocating for services where devotion to the person with aphasia when. funding for participation. adult day-care programs associated with senior centers or and Nelson (1978) designed a spouse advocate program.org). Such caregivers include med- stroke and aphasia. senior citizens centers. workplaces. such as physical health. the gift of time. emotional health. nurses. Good sources of information about the uals can offer families special support.. Bissett. self-help groups. and and emotional health through self-education. These groups serve important functions. Families should from the helping experience. physical. Van den Heuvel and colleagues (2002) suggest that which a family member of a person with aphasia assisted long-term family programs that focus on coping and provid- other individuals with aphasia and their families. can help to relieve feelings of isolation and offer practical A second option to suggest to families falls under the information about the logistics of obtaining funding and other rubric of “wellness” programs. Another creative approach to supporting the family is in long-term care settings on a temporary basis. housekeeping and personal-care aides. but the families vide respite services. allows families to take a break from the daily routine of care- Pasquarello (1990) evaluated a similar type of program and giving. Halm (1990) found that grams may actually forestall institutionalization and prevent families perceived such groups as reducing anxiety and abuse or neglect. Role playing and problem solving ical staff (e.respitelocator. . disease management programs. Such programs encourage assistive services. and others. Known as stimulate and reinforce his or her communicative attempts. and attention to preventive measures for reducing risks to Family members may wish to affiliate and become involved health. temporary care that mental barriers. Respite should be less didactic and include more open discussion may be offered by other family members or by formal. particularly in the hospital-rehabilitation-nursing home contexts. hospi- affecting legislation on issues related to stroke and head injury tals. Use of respite pro- effectiveness of support groups. Paid caregivers play an enormous role in the success of vidual with aphasia and informational resources regarding speech-language intervention. psychological/emotional changes. pation in a healthy lifestyle. leader. caregivers. relaxation. focused on difficult communicative interactions. Such family-to-family availability of respite programs in a community include programs are based on the premise that individuals with inti.GRBQ344-3513G-C12[319-348]. these individ. counselor. In another study on the their loved one is safe and comfortable.. diet. 1991). have intense daily contact with the patient. YMCAs. The goal in working with such groups is to pro- vide strategies for facilitating communication with the indi. rather than rehabilitation staff (e. Such programs Foundation. Some wellness programs are comprehensive. physicians. but the seling sessions should also offer this service. environ. Caregivers and helping to change health-care and rehabilitation policies. are the most ational therapists). www. “respite” is short-term. These are the folks who make therapy functional. paid and problem solving. or through family-to-family programs (Williams.g. predictability. discharge planners in health-care mate knowledge of a problem can be excellent resources for settings. The speech-language pathologist should be available to these extended groups as a consultant. for maximum effect.g. and recre- on didactic information regarding aphasia. effective means of participation with family groups. in settings. Speech. and respite locators on the other families while gaining a positive reward themselves Internet (e. social work staff. others with local. Thus. therapy rests with the speech-language pathologist. Respite helps family to opportunity to share feelings with others and find out how attend to their own needs and take vacations while knowing other families coped with a stroke. should check with their insurance plans for information on Some families assume prominent roles in such organizations. Staff-patient Respite and Wellness Programs communication can be therapeutic if it facilitates the com- One of the most important programs to suggest to families munication skills of the individual with aphasia and serves to of individuals with aphasia is a respite program. state. Such programs are not check the credentials of the centers or personnel who pro- intended to replace professional counseling. questions that require forced choice responses). Providing positive reinforcement vices traditionally have some content devoted to defining to the patient for communicating will generate more aphasia and its symptomatology. A more 6. In addition. For example. such as apraxia and dysarthria. Keep in mind that informal vidual’s interests. Staff should talk with the patient during medical and ting. Encourage staff to maintain eye contact quickly and primarily on those topics that will help the audi- while communicating and reflect on the content and ence to communicate more effectively and create a positive underlying meaning of the patient’s communication. Goal 5: Develop Self-Efficacy and Self-Actualization Skills for Client and Communication Partners In addition. concept of a positive communication environment for the 3. to focus attention. Aphasia inser- her needs and ideas. Use positive humor during interactions. and (3) strategies for any verbal or nonverbal means possible about his or understanding and speaking with the patient. and reinforcing attempts cians may choose to present a list of “do’s and don’t’s” for at communication. role-playing inservices. check for comprehension. Others may schedule periodic inservices that are regarding care. 10. and which strategies were not. for aphasia is to develop self-efficacy and self-actualization . (2) the his or her care and setting. and solicit information about the indi- attended on a voluntary basis. types of aphasia (e. Other strategies include slowing or stopping an activ- Staff are specifically interested in how they can commu- ity while talking. however. predominantly expressive. meaningful communication envi. speak slowly and clearly. the person with aphasia active learners in the process.GRBQ344-3513G-C12[319-348]. some settings may have orientation mod- routine daily life care. Examples of guidelines to suggest and modeling by the speech-language pathologist. Encourage the patient to talk or communicate through patient and other patients/residents. specific information major topics: (1) the nature of speech. Provide the patient with active listening or supportive staff with technical detail and jargon but. and com- about his or her status. is to elicit facilitating day with the patient who has aphasia. One of the goals of the environmental approach to therapy ronment for all patients. language. the routine for the day. How and to staff include: when education is provided to the staff depends on the set- 1. a second focus of an inservice should be on the importance of a rich. the staff and clinician atmosphere. Following the role playing. it is important not to overwhelm the 4. self-instructional written and strategies for creating and maintaining a positive com- or computer packages. staff members should offer modeling of communicative strategies during everyday some information about themselves. The clinician should role play various buddy/friendly visitor dyads. traditional lecture-type inservice members understand the value of successful communication programs.g. communication environment. Staff should talk about what they ules on topics such as communication problems for new are doing during care. This may involve techniques in role playing that focuses on solving commu- modeling communicative strategies and forming nicative dilemmas. cation attempts or topics. pause. tion of the inservice. gible request by an individual with aphasia for something that is not obvious. Two possible scenarios for role deserves adult-like respect. video demonstrations. Such an inservice fosters a Remind staff that regardless of the communication problem-solving mentality in the staff and makes them difficulties that are present. includ. and ask and talk about activities of interest. 8. talk about 5.. Traditional didactic inservices tend to focus on three 2. with each other and communicate more frequently. communicating (e. Provide the patient with clear. asking follow-up questions that nicate more easily during the delivery of care.. and prehension problems of the patient with aphasia and any other information that helps the patient to understand associated disorders. including those with aphasia. Encourage other patients/residents to talk during the fruitful inservice technique. Persons who know interaction is a natural way to show the staff successful ways something about each other are more likely to identify of facilitating communication with those who have aphasia. munication atmosphere. Humor and global) and have the staff role play themselves in these can generate conversations and promote a positive contexts. Staff-patient communication will be enhanced when staff ing orientation programs. seek input from the patient employees. Value the communicative contribution of the patient. receptive. Encourage the individual with aphasia to participate in concrete topics.qxd 02-12-2008 09:40 PM Page 341 APTARA(GRG QUARK) Chapter 12 ■ Environmental Approach to Adult Aphasia 341 Staff education may be done in several contexts. Some clini- demonstrate active listening. discussions. Create a physical environment that promotes easy Scenario 1 The staff member must convey to the patient access to activities and persons of choice and facilitates with aphasia that he or she will be going to the podiatrist hearing and vision while communicating. playing include: 9.g. rather. in 1 hour and must get ready. should discuss the scenario. which strategies were successful. Limit formal or informal rules that restrict communi- Scenario 2 The staff member must respond to an unintelli. When conducting this por- frequent attempts. 7. educate the public on positions through their religious and community organiza- intervention options and outcomes. They may also serve as a context for social creation of organized lobby groups. Clinicians have a responsibility to discuss A number of efforts can be made to increase societal how to access communication opportunities of choice. popular reading materials. and have most insurance programs. cation problem. both individually and through their profes- when needed. potential to create social and political changes through the Kagan. If therapy is to be successful. Long-term intervention is usually not an option with selves and others. This attitude of “I think I party payers such as Medicare and Medicaid are well aware can” leads to self-empowerment and an attitude of long. Simmons-Mackie.g. rehabilitation programs and long-term impact on survivors of stroke and their care. accept responsibility for increasing relieve frustration. Unawareness leads to indifference and lack of sup- efficacy is defined as what people believe they are capable of port. and continued communication problem solving (e. counsel. From third-party payers for education and counseling. unrealistic that communication intervention will meet all when faced with a stroke. rehabilitation programs. are naïve regarding rehabilitation the long-term needs of adults with aphasia. Awareness Month. discussing communication difficulties to sional organizations. or may not be offered. which may the very first interactions in diagnostic and therapeutic con. at the least states that self-actualizing people are realistic. As grams that promote opportunities for interaction. 2003). awareness of aphasia. Speech-language pathologists can articulate Participation in community-based aphasia centers and in the dilemma of aphasia and argue for innovative program- aphasia and family support groups are two long-term pro. programs as well as for political and social advocacy pro- grams for those with aphasia. they will be better able to resolve providing intervention at the least financial cost.GRBQ344-3513G-C12[319-348]. and others may seek volunteer share our knowledge base and. ming to meet the needs of patients and their families. Self. and self-advocating with policy makers social and political consciousness regarding this communi- for continued intervention. Armstrong. 2000). stated previously. They may rely on their physicians and time of limited financial support for extended therapy. & Armstrong. of the increasing number of elderly. Few persons with aphasia or their texts. aphasia community groups have the ing. It is essential that speech-language Other examples of self-actualization include asking for help pathologists. a mission in life. particularly in a services and options. many will seek opportunities ature or attend our conferences for information on innova- to reintegrate meaningfully into the community. This might involve programming during Aphasia The average person does not know what aphasia is or its short. communication intervention should help to bilitation costs for the insurers. For example. Professional groups. Third-party payers in particular have a vested interest in tinued problem solving. available at each stage of recovery. Some may tive and effective approaches. Such grass roots campaigns may influence through local media. most individuals are oblivious to the with aphasia and their communication partners must view physical and social barriers that face such persons in the themselves as capable communication problem solvers. Third- new communication problems. It is larger community. accept them. hence. One program that capitalizes on the unique knowledge of stroke is the Peer Visitor Program Community Awareness Programs offered by the American Stroke Association. opportunity to share their findings with the public and with As individuals with aphasia and their families move further colleagues. cost. which want quality out- maximize the client’s self-actualization skills. design bulletin boards or Microsoft PowerPoint programs . and individual professionals should participate in community awareness Goal 6: Develop Greater Societal Awareness of Aphasia programs.. have in reintegrating meaningfully into their communities. the speech-language pathologist needs to cultivate the caregivers have a clear conception of what intervention is concept that the individual with aphasia and his or her com. and the social movements and promote social changes that reverber- Internet. Unless they have had a personal encounter with some- doing (Kricos. tions. We cannot expect the public to search our liter- away from direct rehabilitation. Families and patients with Research and Public Dissemination aphasia may unite to influence local and other governmental The increased emphasis on functional and outcome-based agencies about the needs of those with disabilities in the research into aphasia should be made available to the public community. Maslow (2006) comes in the least amount of time and. and schools.qxd 02-12-2008 09:40 PM Page 342 APTARA(GRG QUARK) 342 Section III ■ Psychosocial/Functional Approaches to Intervention skills in our clients and their communication partners. risk for stroke. 2006). We have the responsibility to be able to return to work. These numbers translate to increased reha- Similarly. Researchers and clinicians should take every ate across society. This is one reason why so many families. many of whom are at term self-therapy. hospitals. act spontaneously and naturally. persons one who has aphasia. thus. When they accept responsibility for self-evaluation and con. and most do not fully munication partners must independently define their own understand the difficulties that persons with aphasia will communication needs and solve communication dilemmas. might do special staff and family inservice programs or givers (Code. Many communities have and traditional interventions. Internet use is growing new purpose in life. Kagan states that participants in her environment of the person with aphasia. and pharmacy groups as well as has been modified and trained more than 30 individuals who political. with aphasia can be integrated into the physical and social cle on aphasia and programs for those with aphasia and their community. Interviews and articles in local newspa. training program. aphasia intervention box and toward the physical and social vention. a consortium of college programs in Boston organized stroke. An arti. It is important that clinical practitioners cation program delivered by trained volunteers (Worral & keep abreast of the nature of aphasia information on the Yiu 2000). caregivers may want to help others who have incurred a ple. states FUTURE TRENDS that these centers provide an aphasia-friendly community This chapter challenges us to think outside the traditional and reflect a life participation approach to long-term inter.GRBQ344-3513G-C12[319-348]. and the United States. survivors/caregivers visit survivors of Clinicians should take every opportunity to do presenta. the Connect program (www. environment where individuals with aphasia can use their Other community centers that support such presentations communication abilities in meaningful. including profes. An increasing number of aphasia centers have been estab- lished in Canada. designed by the American Stroke Association. and the attrition Aphasia Centers rate of volunteers over time. and outcomes and offer vignettes of success years. finding optimum training times. eral include decreased depression (Li and Ferraro. because this is where older persons and their care. will have a broad circulation.ukcon- pers and television programs that describe aphasia services nect. Even those who have aphasia are able to communicate cases. stroke in acute and rehabilitation settings. Local malls are often willing to Such centers focus on creating a positive communication provide display space for community-oriented projects. Such information is such a visit when they were in the early stages after a stroke. Aphasia associations and support groups can also effectively with patients and families. 2004). skill focus to . Kagan (2003). For exam. Survivors of stroke. can participate. Problem areas are discussed at quar- VanBiervliet and Edwards-Schafer (2004) found increasing terly meetings. Interestingly. numerous other volunteer pro- Internet. This chapter center prefer to be called “members” rather than “clients” or encourages you to choose between a narrow. nursing. including having a groups. 2005). Many add that they wish they had had the fastest among older persons.org) has opened the community to those with aphasia. these centers often have out- local newspapers or senior citizen-focused circulars featur. third-party. demographic “transformative” benefits they receive. and geographic regions. Many also offer programs that help caregivers to com- these options is a personal approach to which the audience municate more effectively and understand the challenges of can relate. & Lubinski. assumed under the rubric of consumer health informatics. chants about aphasia before the Speaking Out! Conference slower decline in self-reported health and functioning levels. reach programs that provide education on how persons ing periodic special inserts on health-related topics. Benefits of formal volunteerism for seniors in gen- graduate students to educate hotel staff and local mer. example of a volunteer program is the Peer Visitor Program sia classes can also assume responsibility for educating some (Insalaco. a 10-week functional communi- everyday language. England. who started the Aphasia Institute of Toronto. but visitors soon popular medium for sharing information about aphasia. “patients. The audience wants to know what aphasia is and living with a survivor of stroke.qxd 02-12-2008 09:40 PM Page 343 APTARA(GRG QUARK) Chapter 12 ■ Environmental Approach to Adult Aphasia 343 devoted to aphasia. Key to each of tion. Major problems in establishing volunteer programs with older persons include the cost of formal training. Originally tions on aphasia to community groups. Undoubtedly. positions within the volunteer program during the past 2 technologies. One Undergraduate and graduate student organizations or apha. Initial vis- The Internet provides a relatively new and increasingly its are supervised by the training staff. The word needs to go out! their families in a hospital during the past 2 years. and improved mortality rates (Lum & Lightfoot. Another volunteer advertise programs and disseminate research findings in program is Speaking Out!.” In England. 2005). and their guage pathologists at the pre-professional level. including those with aphasia. grams exist in which adults with aphasia and their caregivers givers are now turning for information. Several of the original peer visitors have assumed leadership Rehabilitation centers can highlight their specific programs. the program sional physician. become independent. families in such publications would be highly visible to the public. Peer visitors frequently comment on the reliance on the Internet across all age groups. Volunteer Programs College and university programs need to build this type of awareness and responsibility into training speech-lan. in that city in 2006 (National Aphasia Association. Sellers. In addition to innovative how to talk to someone who has it. 2006). After a seven-session facet of their community. adult-like interac- include senior centers and public schools. and policy-maker groups and service have provided hundreds of visits to survivors of stroke and and religious organizations. More documentation of environmental individual incurs a stroke. individual resides. sources of the value of long-term. norms. 3. cognitive. and institutions of the larger j. and that these outcomes should be documented and b. i. partners. that person communicates will face a predicament nity volunteer approaches offer a growing range of pro. interrelatedness of individuals. to facilitate communication. this text in that it encompasses the individual with aphasia. political. Few or no communication partners of choice. aphasia creates problems for both mem- ety of potential outcomes for both the person with aphasia bers of that communication team. Restrictive stated or unstated rules that limit com- 2. a. the immediate social milieu in which an tive interaction. and eco. and the physical and The study of communication disability and quality of life social environment. and health has done much to focus on the relatedness abilities. communicative. 5. Political action groups that emanate from these thinking on disability. The environmental philosophy presented in this individual’s own characteristics include the total and chapter is perhaps the most holistic of those presented in evolving array of physical. the physical and social needs. dis.GRBQ344-3513G-C12[319-348]. the effectiveness of communication partners of communication and participation for those with aphasia. combination of these external and internal stimuli g. The internal environment created by the ronment. including empowerment phi- programs are needed to influence governmental funding losophy. 1981). Therefore. society. Clinicians must be aware that their therapeutic terized by: efforts often extend beyond the individual with apha. of care. 4. much has been done in the past 25 years that philosophy that effective and functional therapy has implemented many of the ideas presented in the original emanates from a comprehensive rehabilitative man- environmental approach to aphasia (Lubinski. individuals with aphasia need and want to communicate and that the physical and social environment can be a catalyst to promote KEY POINTS successful communicative interaction. Lack of private places to talk that are easily forms a “total environment” for each person. nomic values. social and capabilities models of disability. munication programs. even in the face of severe communication disability. ronment together with those that arise from the f. intervention. The agement model that takes into consideration the World Health Organization framework for functioning. Limited or no support for communication partners. 8. Sensory dimensions that confound communica- cal world. municative interaction. by its Outcome measurement is becoming more inclusive of a vari. A positive communication environment is one where momentum of creativity and promote greater societal under. individuals have plentiful access to communication standing of. Communication is a dyadic process. “Environment” is defined as the spectrum of influ. The challenge now is to sustain the 7. Although one and the caregivers. h. d. milieu. A lack of sensitivity to the value of communication sia to the broader social and physical environment as a cornerstone of effective functioning. sensory. not provided as evidence of the value of speech-language a goal. A communication impaired environment is charac- 1. ences that impinge on and are influenced by an indi. Innovative aphasia centers and commu. continues to grow and creates an important database. At the core of this inter- vention is the belief that. Few reasons to talk that emanate from meaningful unique internal contributions of each individual. and emotional traits and the family and other caregivers. psychological. The environmental philosophy complements current are needed. Cognitively boring. each individual with whom outcomes is needed. Increased finances to support the creation of such centers 6. . communication partners. Limited physical accessibility to activities and emanate from the external physical and social envi. The external environment is comprised of the physi. and support for. very nature. and the social. community-based com. The activities and interaction. that must be resolved if communication is to con- gramming for persons with aphasia and their families. The environmental systems approach is based on the Fortunately. The idea that communication is a by-product. their communication ability. accessible.qxd 02-12-2008 09:40 PM Page 344 APTARA(GRG QUARK) 344 Section III ■ Psychosocial/Functional Approaches to Intervention your therapy and a broader ambition—one that includes the creation or reinforcement of a positive communication envi. These forces e. tinue successfully. vidual during his or her life cycle. and self-efficacy. and the broader sociopolitical community. c. innovative aphasia programs opportunities of choice and are valued as meaningful across the community. audiology. ing with support groups. This may involve inservice education. particularly ones that enhance c. (2006). more positive communication environment in each set- apy program include: ting? What obstacles might you have in implementing a. tion for nursing staff in a long-term care setting that dis- b.php. c.org/members/deskref/journals/.asha. Make a visit to each of the following venues where ther. (2006). (2006). nity awareness of aphasia? unteer programs. these obstacles? cation to the highest degree possible so that mean. (2005).qxd 02-12-2008 09:40 PM Page 345 APTARA(GRG QUARK) Chapter 12 ■ Environmental Approach to Adult Aphasia 345 need improvement? What would you do to create a 9. (1998). Creating a positive communication environment their feedback.org/publications/documents/positions/aging/sendep. what physical and social characteristics deskref/default.html. Eye changes with aging. second activity. Long-term care. b. creating aphasia commu. What demands might family members have on them e.org/afp/20000401/2159. Outpatient rehabilitation. your plans? What might you do to reduce or eliminate sory and cognitive skills that underpin communi. Developing greater societal awareness of the 6. (2000). Available at http:// the way the physical and social environment either cre. that contains stimulating activities and a variety of 5. How would you describe linked to depression. Environment. Available at http:// environmental approach as part of a comprehensive agingeye. ating a positive communication environment. work. Working with families is an essential component to cre- interesting communication partners of choice.net/visionbasics/theagingeye. American Academy of Family Physician. a. Aphasia Awareness Month. 4. After making the visit to each of the settings listed in the Available at http://www.” Present this to your peers. An important issue in all therapies is outcome measure- nature and impact of aphasia as well as a philosoph. Developing self-actualization skills for individuals that might impede the success of therapy? with aphasia and their significant others so that c. htm?PF1. Consider d. Create an outline or a Microsoft PowerPoint presenta- ingful communication can occur. working effectively with family and other care. American Academy of Audiology. social isolation in seniors. ment. roots level versus the state and national levels to improve awareness of aphasia. Who should be involved. Design a program for your agency that highlights givers. How can you incorporate adults with aphasia and nity centers. Providing communication partners with tech. Medical rehabilitation unit in a hospital. Developing communication skills and those sen.Untreated hearing loss apy for aphasia might be done. Outcomes Measurement Systems. American Speech-Language-Hearing Association. One of the key points in this chapter is the need for 10. National b. ates a positive communication environment or a com. 7. 3. 2. What resources do families bring that will facilitate cation through a variety of communication success in therapy? channels. Evidence d. munication environment of your client with aphasia? munication intervention within the community. Central to enacting an environmental approach is greater societal awareness regarding adult aphasia. and ask for c. How would you document changes in the com- ical and financial commitment to supporting com. E. munication-impaired environment? Available at http://aafp. Falls in the elderly. Personal communication. and what are the expected outcomes of such awareness programming? ACTIVITIES FOR REFLECTION AND DISCUSSION 1. What strategies might be used to incorporate pro- rehabilitation becomes a realistic and effective ductively family members in therapy and help them process. .GRBQ344-3513G-C12[319-348]. b. and encouraging those with aphasia their family caregivers in efforts to improve commu- and their families to participate in community vol. Home health care (patient’s own home). Third-party payers may be skeptical that environmental References intervention will enhance the communication of an adult with aphasia. a. Environmental goals within a comprehensive ther. Allan. 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Spouses’ quality of life one year after stroke: Prediction at the Scottish Intercollegiate Guideline Network..ucla.int/ American Geriatric Society. E. psychological reactions to brain damage and aphasia. an estimated 4. Likely.qxd 1/21/08 12:45 PM Page 349 Aptara Inc. Mackay. the impact on each of their lives could be completely to review existing programs that can be incorporated into a different. of these conditions on everyday life can take on incredible our interventions have been guided by medical ideology. the reader will better understand better the complexities of a life consequences approach to intervention while.GRBQ344-3513G-C13[349-375]. The first touched its side and concluded that the be different if you became aphasic at age 20 than if you elephant looked like a wall. (2) to with your incontinence? The point here is that even though illustrate how these can be used to structure intervention two people might have exactly the same linguistic impair- programs focused on the consequences of aphasia. Likewise. wondering what an elephant you might see this as an opportunity to set different goals looked like. 2006). 2006). 2006). The only way to understand the interaction of these Center for Injury Prevention and Control. its impact Alzheimer’s disease (Alzheimer’s Association. The third touched the trunk and 349 . let us use the analogy of the six blind much of your language as possible and do as many of the men and the elephant (Saxe. or living OBJECTIVES alone? Would the life priorities be different? What would be your priorities? In light of these questions. Chapter 13 Focusing on the Consequences of Aphasia: Helping Individuals Get What They Need Linda J. Approximately 1 million Americans live with the conse. If one many factors is to use a framework that explains the relation- adds to these numbers those who live. communication. Interventions focused on life consequences are life consequences approach to intervention. proportions. one solution might work 80. and interact ships among the person and his or her abilities. Disability models can do this. at the same time. This legend recounts the same life activities you did before your stroke. the human impact and life goals. One solution may be adequate for one situation or one per- quences of aphasia at any given time. Traditionally. as some. In addition.4 may be felt differently at its onset as opposed to 10 years million sustain traumatic brain injury each year (National later. 2005. or trauma. The second touched its tusk and became aphasic at age 75? How about if you worked as a compared it to a spear. would you prior- The objectives of this chapter are (1) to introduce the itize mobility. each touched a different part of the elephant’s and develop other skills. might react to becoming aphasic or how this would affect To couch aphasia within the context of disability models your life. or dealing reader to fundamental principles of disability models. disorder. story of six blind men who. pain management. 2003). you would want to regain as illustrate this point. INTERVENTION: A FRAMEWORK No recipes exist for helping individuals return to their lives or redefine new ones following disease. adopt a concrete framework for organizing this THE NEED FOR A MODEL TO GUIDE information. at one specific time in the person’s life and not at another. or. 1963). Garcia speech-language pathologist or a lawyer versus a heavy machine operator? Do you think the impact of a language loss might be different? How about if you were living with a spouse and children.000 new cases every year (National Stroke Association.5 million Americans have Because aphasia is generally a chronic disorder. and (3) ments. or just with your spouse. and 1. environment. It is hoped that preoccupied with exactly this impact. with the individual who has the disorder. work. You might have wondered what your priorities for is to accept that communication is only part of the story. Do you think your priorities would anatomy. To intervention would be. More modern models are based on social ideology (Byng & You may have wondered how you or someone you know Duchan. with approximately son but not for another. Disability. we must be cognizant of the impact of by optimizing human communication behavior. 2000. and the sixth among components of individual functioning that go touched the tail and imagined it to look like a rope. This framework has been widely diffused to use the analogy of the six blind men and the elephant to both clinicians and researchers. around for more than 25 years and. 2006. 350 Section III ■ Psychosocial/Functional Approaches to Intervention decided it was a snake. Worrall. such as The intention is that these classification systems be used. we know that if we intervene on the syntactic of speech-language pathologists in enhancing quality of life aspects of language. few would argue against the fact cian to evaluate the relevance and importance of a framework that all these elements are important to understand how one such as the ICF in planning therapy. which philosophies behind these models provide a useful frame- seemed to be a tree without leaves. (4) for economic planning. or the interdependence of these elements so that we can better ICD.. and Health (World Health cation to the speech apparatus without necessarily considering Organization. increasing scientific knowledge. 1999). health conditions. is currently working with colleagues to develop a clinical Let us take the analogy one step further by considering manual to help prepare clinicians to use the ICF framework communication as part of a cognitive system. & Hickson. A better understanding such as memory. convinced of the truth of his conclusions. syntax. for or ASHA. Although it applications of the ICF framework to the area of aphasia can be argued that much work remains to be done. 2005. The We have conceptual frameworks with which to understand International Classification of Diseases (WHO. & Potechin. and disability laws. Disability models give us evaluation system. and audition being the of the historical development of the ICF may help the clini- other components. represents the person’s integration into different aspects of and disorder. for designing interventions and outcomes. 2005). and (5) for helping in the defense of the rights of individu- communication) and assume that this is the only thing that als with functional limitations.. Kearns. researchers have offered preliminary (2005) have pointed out. Its aim is to capture an individual’s level of these larger-scale elements (Byng & Duchan.g. No clinician or researcher today would used as part of an appraisal of aphasia (Ross & Wertz. encourages the use of the ICF “to describe the role instance.” ments function together and how we might use one aspect to (p. and discourse as different parts of the elephant’s cial functioning. with elements and classification (Reed et al. and reference to this model compare the phonetic system. much as possible. . they are likely to stay. In this context. communicates. the fore. The fifth found the ear work from which to understand the possible relationships and concluded the elephant looked like a fan. Threats. (1) for scientific reasons to look at the impact of health con- tionships).. all of these elements. (3) for helping portive spouse. 2004). With sia on everyday life is a growing trend (Simmons-Mackie. classifies intervene on the communication aspects. I-22a-b). with the elephant itself representing the system of Although an argument exists over whether the ICF can be communication. of Functioning. in a complementary fashion. or other components. The impe- understand and intervene on the impact of a communication tus behind the ICF was to develop a common international disorder on an individual’s life? Let us say that the elephant language to describe the consequences of disease. a sup. or other upper aerodigestive functions regardless of setting. 2005). The ICF: Getting a Framework to Guide Intervention How might this apply to our knowledge of the conse- quences of aphasia? Not unlike the six blind men. is almost routine for those who are interested in psychoso- pragmatics. Travis Threats. 2005). Again. attention. the semantic system. a speech-language pathologist. work integration and interpersonal rela. (2) for improving services by offering a framework of the elephant. we came to see communica. 2001). The classification is not an influences a person’s functioning. functioning through use of a common language that Variations of international disability models have been includes a series of codes and categories. to capture the impact of apha- the other aspects of communication (Duchan. the basic (Davidson & Worrall. We might Worrall. The others might include culture. communication is only one part ditions. In terms of guiding intervention.g. semantics. The fourth touched the leg. as vision or audition. As in the first example. facilitate the other during intervention. one might intervene The ICF is part of what the World Health Organization and focus on the receptive aspects of communication while (WHO) considers to be a “family of classification systems. Howe. We have theories as to how these ele.GRBQ344-3513G-C13[349-375]. argue against the fact that communication involves at least the American Speech-Language-Hearing Association (2001). nor is it meant to be a list of discipline- the framework from which to understand the interaction of specific functions. as Ross and Wertz Since its publication. trauma. Use disability models such as the International Classification mothers of speech-language pathology relegated communi. The WHO wished the classification to be used his of her life (e. or ICF. which is in the process of being updated. consider looking at just one aspect of the elephant (e. Threats & tion as a complex system of interrelated abilities.” being cognizant of the impact of sensory systems. phonology. 2006). vision. Each was beyond the communication patterns per se. We would be foolish to individuals specify their needs. anatomy. such as attention. The ICF was developed to classify human What happens if we use this same analogy yet again to functioning as a result of these health conditions. swallowing. yet each one of them was wrong.qxd 1/21/08 12:45 PM Page 350 Aptara Inc. neither the ICF nor the ICIDH has yet been proven to be useful in terms of its clas.” The bottom line was that if the and cultural background. the list of Activities and Participation elements are actually all in Figure 13–1. not being able to work). which in turn would lead Organization. 1995). & Hickson.g. Nonetheless. Disabilities. 2006. model. Disability and Health (ICF) (World Health impairments (e. the principles of the ICF help us to see all . including could also be reduced. the distinction between Activities and Participation remains nebulous. and speech-language patholo- gists later applied these concepts to aphasia (LeDorze & Brassard. In the ICIDH.g. 1980). Figure 13–2 provides were dismayed that this model portrayed individuals with a graphic representation of the ICF framework. McCooey.g. however. the WHO pro. function- creating obstacles to integration. impairment-based therapies in a larger context. indicated the likely versions of the three ICIDH domains)—are influenced by effect on a handicap.. Therefore. Hilari. a brain lesion). the three key elements—Body in the real world. Model of the International Classification of order (e. After many 2006). and Participation (roughly the neutral the direction of the arrows in Fig. Activities. The premise the outcome. that the Disabilities and Handicap (ICIDH) model (World Health clinician may have difficulty distinguishing the two. The unidirectional impact (as suggested by function. Chapter 13 ■ Focusing on the Consequences of Aphasia: Helping Individuals Get What They Need 351 2004. we tronic communication board. Environmental Personal The ICF was developed as an improvement over the factors factors original ICIDH. a facilitative conversational partner. the ICF and the original ICIDH is the recognition that cerned about the linearity of the model. Worrall. suggesting that the disorder dictated environmental factors and by personal factors. neither the physical environ. 1980). As early as Health conditions 1980. They found the classification to be incomplete in its ability to describe language functions as well as difficult to code in terms of environmental influence. or ICIDH.. Figure 13–2. Threats. language impairment could be reduced. that if we worked on the impairments (e. the consequences The ICF has been criticized on many levels. from being “handicapped. Because the environmental factors interact with all disorder elements in this model. In this model. which was a linear model (Fig. therefore. Threats & Worrall. the WHO had already given us the International (disorder/disease) Classification of Impairments. Functioning can also be inter- would prevent the person from living with a handicap and preted in the context of personal factors. As Worrall and Cruice (2005) clarify. and disability researchers in determining the level of functioning. clinicians. Part of this criticism is that no clear distinction is years of international consultation and the development of made between the domains of Activities and Participation. or access to an elec- brain lesion) and/or the disability (e. 2006. then. In fact.g.. 2002). to disabilities (e. Larkins. 13–1). having a framework that remains more medically based than Newer models of disability encourage us to put these socially based (Fougeyrollas.. the differences are more in relation to the levels of context. cerebrovascular accident [CVA]).qxd 1/21/08 12:45 PM Page 351 Aptara Inc. posed the newer ICF. 13–1).. Although the inter- national community was pleased to see that we now consid. In a pilot study. Body Activities Participation sification categories. and Handicaps (WHO. such as age. one list in the ICF. 2005. 2004. Most uses still tend to focus on the philosophy rather than the classification per se. Garcia and colleagues function (activity (participation/ (impairments) limitation) restriction) (2003) used the categories from the ICF to describe the level of functioning of two individuals with aphasia. The International Classification of Impairments. Activities refers more to what the person can do and Participation to what the individual actually does do in his or her real environ- Disease or Impairment Disabilities Handicaps ments.g. sex. functional limitations as being “doomed” to have handicaps In this newer framework. 2001). Davidson. would lead to Functioning. here is that each of these three basic elements can be classi- ment nor society was held to be even partly accountable for fied within an environmental context. the model basically suggested that a disease or dis. however. It followed from this ing can be interpreted in the context of a supportive spouse. aphasia). Organization. Whiteneck. It is understandable. alpha and beta versions of the ICIDH-2. it was con. the aphasia itself)..g.GRBQ344-3513G-C13[349-375]. Today. which in turn would lead to handicaps (e. One of the main differences between ered the impact of “disabilities” such as aphasia. Individuals with environmental factors (both physical and social) play a role functional limitations. CVAs or use of the DCP conceptual model (1998). 1998). partners). and Participation. or DCP.. and acknowledges the role that it plays in facilitating inte- tal factors. the impact of the reader is therefore encouraged to see the remainder of this managed care versus universal health care in rehabilitation chapter as a possible application of the ICF principles through can be easily explained using these principles. 1998. Côté. For this rea. which is arate component and should be viewed as such by therapists. which is called Life This concept allows us to identify society’s responsibility Habits (Fig. milieu. Cloutier. I would like to introduce an alternative model that might impact participation.g. Capabilities do not include environmen. or both. Capabilities level (e. 13–3). In the DCP model. because it offers the opportunity to identify those Bergeron. improvement is likely to influence performance in based therapy. This is much more than an acad- on only one aspect of the model. can son. but participation necessarily includes the influ. The primary difference between the ICF and the DCP is when it comes to allowing people with aphasia to receive the exclusivity of the components. (From Fougeyrollas et al. however. we are back to the six blind emic distinction and is extremely important. & St. and systems are more easily made. overall. intervention strategies can An Alternative: The DCP Model be geared toward one. the other. one country can be a facilitator. because it men and the elephant. aphasia). Michel. and in another. The Disability Creation Process (DCP) model. comparisons across nations and health-care cepts. Risk factors cause Personal factors Environmental factors organic capabilities systems facilitator obstacle integrity impairment ability disability Figure 13–3. If we see ourselves as focusing ence of the environment. The model The current discussion surrounding these frameworks may acknowledges that if the therapist chooses to work at the appear to be academic to some.g. aphasia (personal factors in the DCP) can affect individuals Fougeyrollas and colleagues were very much involved in in very similar ways across countries. Hence. because human bodies the ICIDH revision process and were instrumental in the function. called Capabilities. working on the linguistic aspects of ician to use some type of framework to guide consequence. If the therapist chooses to work on approach are not new. Both the ICF factors that belong to the society and to the individual’s and the DCP models are closely related and use similar con. gration (Kagan & Leblanc. The health-care system in inclusion of environmental factors in the WHO framework. with Interaction permission. Environmental factors themselves constitute a sep- clear distinction exists between the Activities. 2002). reduc- understand how all the components fit together.GRBQ344-3513G-C13[349-375]. a therapy. in similar ways. but clinicians might find it hard to the environmental factors (e. but it is important for the clin. however.. help clinicians to focus on an integrated approach—the Teasing out the environmental factors is important for Disability Creation Process model (Fougeyrollas. I find the DCP to be easier to interpret. in and of themselves. helps the clinician to distinguish what belongs to the person (personal factors) and what belongs to the environment (environmental factors).qxd 1/21/08 12:45 PM Page 352 Aptara Inc. 352 Section III ■ Psychosocial/Functional Approaches to Intervention components of functioning. For instance. an obstacle.. Hence.) Life habits social handicap participation situation . tion of environmental obstacles. Interventions using a life consequences life activities and roles. advocacy. A “situation” of handicap should be understood sia. The key. measured on a scale going from full social participation (mean- Whether you struggle with relationships because of a lack of ing no problems at all with this activity or role) to a situation of self esteem or you need reading glasses or you live with apha. Your own life activity or role (e. to reintegrate the workforce at age 45 following a stroke momentarily. regardless of your preferred model. ways for identifying these goals will be discussed later. will be asked to be experiencing situations of handicap in some leisure activ- apply the model to yourself.e.GRBQ344-3513G-C13[349-375]. conceptually the different elements of a disability model by the model suggests that this is the case because the person way of the DCP definitions. ities or social roles are valued by the person at that point in ent’s) health condition. in its historical development. no longer need to return to work) and other the disability model helps us to appreciate how the loved situations can be created (e.. tion. clinically is to determine which daily activ- work) may be affected by someone else’s (your child’s or par. The DCP model. Because some situations can order each and every day.g. This can include anything from being fession). ships.g. disease. An approach to therapy based on life of health conditions and. obstacles in the environment that prevent the achievement of higher participation levels. the reader. then. planning more leisure activi- one’s health condition (dementia) impacts the spouse’s life ties). Hence. the model can be along the continuum toward social participation. it includes how the body structures function and how . to some of those life activities. In addition to age. A clin. You are then the person who can be time in his or her life. spouse’s. this may no longer be an issue.. Chapter 13 ■ Focusing on the Consequences of Aphasia: Helping Individuals Get What They Need 353 Another important concept supported by the proponents activity or a social role valued by the person or his socio-cul- of the DCP model is that the model applies to all human tural context according to his characteristics (age. Examples of creative gration and. socio- beings. Hence. The Life Activities and Roles Personal factors include a person’s characteristics and The logical place to start is the Life Participation component— capabilities. The Personal Factors Operational Definitions Assuming that the individual you are seeing is experiencing The following section will help the clinician to understand a situation of handicap with an activity and/or social role. therefore. you are at risk of living in a situation of handicap. as a potential focus of interven. you. tion of handicap. It is influ- ician who gives you reading glasses (an environmental factor) enced by the individual’s abilities and by the support of his or or a surgeon who performs corrective surgery (impacting on her environment.g. culture. 131). (e. conceptually as something that might be temporary. being in his society throughout his lifetime. however. Take. perhaps. ment. A life habit is “a daily like. and the more his or her performance “slides” der or the adult child of an ailing parent. despite having the same functional limitation have dementia live the consequences of their loved one’s dis. someone who wishes grams such as respite care helps the caregiver to return. or mental or physical capabilities) and/or (2) is subject to cepts of Activities and Participation to guide intervention. at retire- could and should be applied to aphasia as well. education.g. The next step to intervention will then be to identify these contributing factors. or trauma. the more the individual’s abilities body structure) can remove this situation of handicap and improve (i. if you are the parent of a child with a health disor. was cultural identity. applied to your situation. and roles that are (1) important to the individual and/or to Bottom line: Environment should be considered as his or her culture or society and (2) done frequently by the an independent component capable of influencing inte. A person’s success in his or her life activity or role can be sequences of some type of health disorder. An individ- or child’s health condition. and the or “life habits” in the DCP model.” (Fougeyrollas ment (Fougeyrollas being an anthropologist himself by pro. p.. same degree of aphasia).qxd 1/21/08 12:45 PM Page 353 Aptara Inc. less aphasia) and the more the environment allow you to function in your selected life activities or roles. 1998.) which ensures his survival and well- derived from anthropological theories of human develop. For instance.. The choice of the DCP model (1) has limitations related to personal factors (body structure for this discussion is to help clinicians operationalize the con. etc. sex. better prepare you for consequences would start by identifying the life activities understanding the possible consequences of aphasia. sex. speech-language pathology services should be available activities. handicap. the case of ual can live a situation of handicap at some point in time and dementia. Seeing the consequences through disappear (e. Informal caregivers who live with individuals who not at another. for instance. cause problems are not likely to be permanent. The activities or roles that appear to seen to live the consequences of your ailing parents’.. throughout the life span. This person may also Later in the chapter. the proponents of this model stress that it involved in your personal self-care (physical and mental) to can be applied to all individuals with or without perceived taking part in community activities or interpersonal relation- “disabilities. the less the individual lives with a situa- Likewise. becomes supportive..” The premise is that all of us live with the con. et al. Helping the individual with dementia through pro. This reasoning may be faced with a situation of handicap. Seeing yourself in a human ities that may warrant different interventions from a speech- developmental model will help you to recognize the impact language pathologist. individual at a certain point in time. succeed in participating in his or her life activ- sonal factors. 111). If it was felt that the sit. tion or employment. pick a life activity or role that you feel you are not to improve other psychological components.. many of the physical activities you once did or would like to such as an unsupportive spouse. In the example given above. you might find that you .. mental. excretion.g.” and for illus- trative purposes. therapy for these capabilities would be than to apply these concepts to their own lives? As stated warranted. Make sure this is something that you normally other therapies. Environmental Factors Let us call this your “unfulfilled life activity. The actual aphasia as significant functional limitations yet.GRBQ344-3513G-C13[349-375]. If so. 354 Section III ■ Psychosocial/Functional Approaches to Intervention limited or accomplished the individual is in terms of physical. which tal endurance).g. intervention tance (e. memory. Therapy focused on capabilities.. cap). do. inter- Applying a Disability Model to Your Own Functioning ventions that target body systems would be warranted (e. intervention on environmental factors can skin” (what the individual brings to the situation of handi. language capabilities.. and cognitive abilities. These might include your intellec- level would be warranted. who seek our services. Examples of how to apply these tual capabilities (e. protection. p. and resis- on personal or environmental factors or both. educa- as an independent. bilities might be having on your inability to fulfill your life tions but face environmental factors that create enormous activity. social barriers. You feel that you would like to take part in also likely to be the result of environmental barriers.qxd 1/21/08 12:45 PM Page 354 Aptara Inc. take a quick inventory of your personal capabilities So. Hence. might involve linguistic or neu. housing (e. motor activ- Summary of Disability Models ity capabilities (e. Next.g. both mental and physical fitness). the concepts underlying disability models are meant. disability models can be used to offer a frame.. people with aphasia and their loved ones better integrate tations in the individual’s physical. The We are basically looking for the contribution these capa- premise is that an individual may have few functional limita. sports or arts) activities. An more physical activity so that you can keep in shape. and thought). This gives the clinician a clearer perspective bilities.. fitness At the personal factors level.g. sonal applications. behavior capabilities (e. tolerance to sound and humidity as well as men- has the potential to help achieve the ultimate outcome. You might consider nutrition (e. or organizational barriers. let us say that this activity falls into the The situation of handicap experienced by the individual is Fitness category. To help “environmental factor” is “a physical or social dimension you. it would also include your culture. a person may have very sensory.. or it can facilitate integration.. It can create an obstacle structure or system that prevents you from fulfilling your life to integration. consciousness. voluntary body part movements and In summary.g.g. is there a body (Fougeyrollas et al. achieving to your fullest but that is important to you and/or tional levels. First. be just as important as focusing on language skills. p. what better way to understand the philosophy cognitive capabilities.. is there anything you can do about this body struc- such as lack of services. is to improve quality of life and integration into society. such as motiva. sexual activities. environment. manual activities). such as noise.g. These factors activity? Perhaps a past knee injury prevents you from doing can include physical barriers. Likewise. as well as capabilities related to breathing. and/or their lives. person to accomplish mental or physical activities” conceptually. Similar questions will arise with those when applied to aphasia. Whether one impacts digestion. intervention at this unfulfilled life activity. Within a team context.g. work for planning team interventions. strategies to aphasia are given later in this chapter. Some conceptualize these factors as “within the ity or role. community and spiritual involvement. 69) without taking any environ. obstacles to intervention. sensory and perceptual capabilities. mental. ropsychologically based therapies as well as therapies aimed First. or leisure (e. If it was felt that the situation of handicap could be helped by intervening at the level of body structure. lodging and/or decorating it). If clinicians are to apply disability model concepts to help uations of handicap were caused by specific functional limi. surgical procedures for aneurysms). we must identify the reasons why you are unable to take that determines a society’s organization and context” part in activities that keep you in shape. 1998. reproduction. Just pick one life activity that impacts your quality of life. A “capability” is defined as “the potential of a earlier.g. The clinician’s goal here is to help ture or system? Would surgery help? Would medication help? reduce the barriers and increase the number of facilitators. It is important to note that the link is always made want to do frequently enough for it to be considered impor- with participation levels in life activities and roles.. and make sure it is something that you therapies. such as physical therapies or psychological do or would like to do. financial and family responsi- ronmental help. sensory. geared to helping the reader learn the concepts through per- mental factors into account. tant to you. diet). affective and social interpersonal from which to identify the impact of environmental factors relationships.. The following exercise is (Fougeyrollas et al. finding the person can do without environmental obstacles or envi. equally important component. if it was felt that the environmental obstacles con- and see if any might limit your ability to take part in your tributed to the situation of handicap. volition and affectivity). to be universal. the clinician looks for what (e. because of a facilitative well as motivation levels or attention are part of these per. 1998. tion of social model philosophies to therapy for aphasia improve movement through physiotherapy or work on your stresses the importance of involving the person with aphasia motivation).. The paper by Byng and Duchan (2005) on the applica- ture (e. Bottom line: Current disability models are meant to The authors found that. attaining.. sia. starting a local decision maker be requested to help identify the life partici- activity yourself.g. A Question of Perspective however. too much tion activities and roles is the perception of the individual snow or too much heat). ing in shape. and Murison which of these parameters is most efficient over the short (2005) compared patients’ own ratings of quality of life to and long term in helping you to integrate your life activity or those of family and friends. of course. which is a scale of functional outcome. think of include the individual with the disorder in identifying the social environments. work on the capability (e. with aphasia. usable tations (e. Can something be done about these capabilities? ual would like to address with the help of the therapeutic Whereas intervention based on body structures might come team. Willmes. find a friend to join a in all decisions that concern therapeutic interventions. The challenge is to find excellent study by Cruice. the larger the discrepancy in ratings between the groups. look at the environmental factors. Chapter 13 ■ Focusing on the Consequences of Aphasia: Helping Individuals Get What They Need 355 are unable to perform your life activity of keeping in shape identify the very consequences that might need interven- because of a lack of motivation on your part or. thereby diminishing which the life activities are performed. mine the goals of therapy. and Huber (2003) found an effective way to evaluate quality of life in aphasia using a pic- The First Component: Identifying Disrupted torial self-rating procedure.GRBQ344-3513G-C13[349-375]. Worrall. Hickson. Only as a last result should a substitute a friend who can do a physical activity with you. as well as the level of satisfaction. perceived level of accomplishment of life activities and roles leagues.. such as family and friends and work col.qxd 1/21/08 12:45 PM Page 355 Aptara Inc. Does your physical environment..g. there may not be many activities available to peo. too. the disability models. for instance. you might think of finding goals for therapy. more subjective the category. respondents could not be assumed to be interchangeable The number and level of severity of the situations of with those of the individuals with aphasia. the perceptions of proxy use concepts that are applicable to all human beings. depended on the nature of the questions being asked—the ronmental factors. indicate the level of importance as well as the frequency with ple in your age group or geographic area. (2) the Short Form 36 Health Survey. (3) a short. that takes into account the consequences of aphasia must and Gilpin (1997) interviewed 50 individuals with aphasia .g. This will influence the chances you will be involved with these types of physical the clinical decision to incorporate these activities as target activities. Consider again your specific situation.g. or yet again. rather. An physical activity program with you). such A key element in successful identification of life participa- as where you live or elements related to nature (e. APPLYING THE FRAMEWORK TO APHASIA but Engell. is to identify the life activity or social role that the individ- ous injury). quality-of-life scale called the Dartmouth COOP Charts. in the example vidual be instrumental in choosing the goal. To resolve your problem. again. They. We well as their perceptions of the successes they feel they are examined your body structure as a possible cause for not keep. one based on capabilities might examines the results of the linguistic evaluation to deter- come in the form of physiotherapy. or lobbying the municipal government to pation goals for the person with aphasia. and (4) the condensed Ryff Psychological Well-Being scale. stress that the individual’s functioning your quality of life?”). The aphasia literature contains considerable evidence that In conclusion. interact with social and physical environments. Byng. found differences in Life Activities and Roles ratings between persons with aphasia and their relatives. you might look at organizational or gov. Basically. you might need to work on the body struc. We must also.. develop other activities for your age group. handicap will vary as a function of personal and envi. is not solely the result of a series of reduced functional limi. Sometimes. and environmental factors. fulfillment of your life activity is the result of two als regarding their involvement in life activities and roles as elements: personal factors. the life consequences approach Your inquiry does not stop here. to help you take part in your selected life proxies are not good substitutes for respondents with apha- activity or role. Parr. aphasia  hemiplegia  lack of motivation) but. any clinician wishing to use a framework Using a more qualitative interview approach. The clinician should make every effort to ing you from taking part in your activity or role? Also.g. Hütter. whether you espouse to (1) a global quality of life measure (“How would you rate the DCP or the ICF. overall. We looked at what you can or cannot do (capa- bilities) as a cause for the unfulfilled activity. Not only should the indi- ernmental rules and regulations. he or she should given above.g. The challenge in applying a life consequences approach of limited motor capabilities (e. because tion. According to models such requires the therapist to obtain information from individu- as the DCP. it might be difficult to obtain this type of information from persons with aphasia. Whereas in more traditional approaches the therapist in the form of knee surgery. or get a facilitator (e. As has been said. perhaps because of a previ. These ratings were taken from role.. For instance. contribute? Are these things prevent. knee surgery). This. the obtaining quality-of-life information. In tems in which they live and in relation to their goals. In her chapter on social approaches that our ultimate outcome is improved quality of life. either through scales such as the ASHA effect of communication on quality of life (Cruice. speech-language pathologists on their practice of outcome tance of the perspective of these individuals with aphasia assessment. tion in life situations or decreasing the number of situations Because aphasia can affect an individual’s capacity to under. 1998). and participation=level skills alone. and when com. or facilitate con- and conversational abilities become central to the measure versations in real-world settings. some clinicians interpret some assessment of the individual’s perception of how he or the results from these scales as outcome scales of overall she is getting along with his or her life. “There appeared to be no general consensus pation that are most problematic. families and friends rate cient. we can assume that quality of life encompasses comprehensive list of measures used to assess functional much more than communication despite the important communication. it is no small focus might be on linguistic intervention. Outcome cannot be limited to communication questionnaires and interviews. 1995). universally accepted way The WHO Quality of Life (WHOQOL) group (1998) of measuring perceived quality of life or participation of defines “quality of life” as “individuals’ perceptions of their individuals with aphasia (Simmons-Mackie. developed by McWreath (2005) helps the public and others . or tive. Hence. She pointed out. Holland. A recent DVD video functioning. behavioral inter- task to obtain this information using formal measures vention. 12). As explained previously in this chapter. Unfortunately. Functional Assessment of Communication Skills for Adults & Hickson. In that study. or through judgment ratings such as the and the same (Hirsh & Holland. Wohl. in which. cians have access to a ready-made. in and of themselves. Threats. Hirsh and Holland (2000) point out that although how effectively the person with aphasia communicates in quality-of-life measures were originally used for economic various daily communication activities. tion of new life goals. 2001). intervention or what constitutes improvement” (p. come despite half of them using some model of functioning. Close to half of the respon- outsider clinician. improve naming ability. Options include overall improvement of quality of life for the individuals in generic or disease-specific quality of life measures. however. the measures we have of communication activity poststroke. of handicap. Thompson. 356 Section III ■ Psychosocial/Functional Approaches to Intervention and reported on their experiences in living with aphasia. 1989). informal their care. standards and concerns” (p. munication goals. it is important to adopt a person-centered their choice of outcome assessment methods. Threats. This the goal of intervention might be the outcome that improves description of quality of life includes many components of the client’s perceived quality of life by improving participa- what has been reviewed so far under life participation. how can we hope to document and effect change on the life consequences of aphasia? Getting Help from Formal Measures of Quality of Life The ASHA guidelines (ASHA. instance. Simmons-Mackie (2001) offers a Further. Although quality of life is closely linked (Frattali. the In aphasia. & Ferketic. whether one aims to improve cellular impaired. munication is impaired. These are not meant reasons and to obtain population-level information regard- to be quality-of-life scales. for only a few viewing outcome as a change in life participation.GRBQ344-3513G-C13[349-375]. Worrall. 2003). or to participation in life activities and goals. & position in life in the context of the culture and value sys. and Kagan (2005) surveyed a subsequent paper. or adop- (Hilari & Byng. and for the purposes of the current chapter. only four respondents even referred explicitly to the aphasia on his or her inability to return to work as being term “participation” despite the increasing use of models much more invasive compared with the perceptions of the such as the ICF in the literature. be com- greatly on communication (Frattali.. as an outcome goal. 551). with of the consequences of aphasia. disability terms. using a brief scale. most quality-of-life measures now include overall functioning. they are not one ASHA-FACS. the majority of respondents and highlighted how this might affect an “outsider’s” view viewed outcomes as changes in therapy or intervention. concluded. nor are they meant to be scales of ing health status. 2000). In Simmons-Mackie. 2001) stress that speech- The therapist has several options. none of them ideal. Doing so elevates our regarding how one measures or reports improvement after level of professionalism as clinicians. From this perspec- Communicative Effectiveness Index (Lomas et al. elimination of environmental obstacles. Parr (2001) reflected on the impor. 2005). agreement hopefully exists of functional outcome. and it does not appear to be the case that clini- assessment scales. Whatever the approach. expectations. for language pathologists should have. The authors approach when identifying the primary areas of life partici. Kagan. the stand and/or express written or oral language. to aphasia intervention. that a person with aphasia may view the impact of In fact. functional communication assessments are not suffi- CETI. dents stated that they used some model or theory to guide In conclusion.qxd 1/21/08 12:45 PM Page 356 Aptara Inc. we assume quality of life is also In other words. If Bottom line: Include the person with aphasia when clinicians are not in agreement about what constitutes out- identifying the goals based on life participation. This is where disability models can help. many of our measures of functioning focus outcome goals per se may not. which is quite compre- SAQOL. Byng. thinking. 2002) were cess in various life activities. vision. (2) personality. so a brief discussion is warranted. & Smith. self esteem. pain. pain. such as the Burden of Stroke Scale. (4) social relations (includ- four additional items specifically related to communication. Gandek. level of seeing things off to one side?”) rather than life activities or activity. Generic scales permit comparisons across impact of aphasia. domains: (1) physical health (energy. through words and pictures. The Craig Hospital Assessment and with participation levels. Many of the domains that are included are actu. much discus. might have on different activities and psychological states. the scale evaluates functional limitations in Other generic scales focus on life satisfaction. Noreau et between the health condition (in this case. (3) level of independence (mobility. The Stroke and Aphasia Quality of Such generic quality-of-life measures include the WHO- Life Scale–39 (Hilari. might be able with the test. such as tiredness.g.GRBQ344-3513G-C13[349-375]. comes in a long version (100 items) and an abbreviated ver- 1999). they may discover that pation. which must be and thinking). measures of quality of life may allow clinicians to discover All can be useful. potential area of difficulty. Generic (McDowell & Newell. where the respondent lives. function. & Biller. & many different countries and languages. this scale mixes activity limitations consideration. SAQOL. For instance. The SSQOL includes 49 items within sion (26 items) and is available in 20 languages. mobility. mood. Fougeyrollas.. designed using disability models as a theoretical underpin- Another point of view in assessing quality of life is that ning (the CHART from the original ICIDH and the Life-H generic measures are preferable if one wants to bring about from the DCP model). noses or within one individual who lives with the impact of sion is found about its measurement and whether scales several diagnoses (McDowell & Newell. and Figure 13–4 gives a sample of the scoresheet used in the transport). Kosinski. for people with aphasia.. The WHOQOL of Life Scale (Williams. 2002) eval- The role of environmental factors. how happy the respondent is with work. language. the policy changes. and the choice depends on the clinician’s other areas of life participation that might have been goals. The proponents of conditions other than the aphasia are contributing to the sit- disease-specific scales take the position that. upper extremity psychological (negative and positive feelings. al. As with the SF-36 Health Survey (Ware. They activities that are not usually problematic for people with believe that a ripple effect exists in terms of impact and that other types of health conditions. which has a much higher prevalence in the pop- very few quality-of-life scales have been designed specifically ulation but life consequences that may be very different. of various symptoms. 2003). Other scales. McNeil. is not looked at uates the level of functioning and the respondent’s perceived specifically. For instance. & Vincent. These scales will be most sensitive to linguistic change Generic quality-of-life measures allow us to compare the following intervention. designed for survivors of stroke. social roles. satisfaction with life areas. activities self-evaluated on a five-point scale. health. In fact. Lamping. it looks at the impact ally “personal factors” (using DCP terminology). however. and relationships. and (6) spirituality (religion and spiritual beliefs). One of the SAQOL with the stroke population at large will be available attractive features of this tool is that it is standardized across shortly. or look at the relationship between the ratings from those with BOSS. Clark. This tool was also specifically Reporting Technique (Whiteneck et al. however. self-care. This scale is quite lengthy and. as a group. 2000). Harris. home. the uation of handicap. Two other scales based on disability models also merit Once again. not to obtain may find similar difficulties in the realization of their life more information about the health condition itself. The proponents of generic quality-of- lived experiences of individuals with similar health condi. and work capacity). and sleep). is an adapted version of the Stroke-Specific Quality hensive and evaluates many life domains. It looks at six 12 domains (energy. Chapter 13 ■ Focusing on the Consequences of Aphasia: Helping Individuals Get What They Need 357 with aphasia understand. of life. The SAQOL includes of daily living. (5) environment (financial. The astute clinician might want to roles. 1997. “Do you have trouble cial situation. or QOL (WHOQOL Group. Satisfaction Questionnaire (Carlsson & Hamrin. or CHART. 2006). In the area of aphasia. family roles. people with aphasia look at the impact on overall functioning. ple. like many others. ing support). Weinberger. affected by the disorder but not been identified a priori as a ter but is intrinsic to the clinician’s understanding of partici. 1988). Participation scales rate the life . finan- feel they are doing on capabilities (e. 1996) are disease specific or generic. The underlying assumption the health condition can affect other parameters of func- is that the health condition is directly influencing the quality tioning not previously foreseen. stroke) and suc. because the very design of the scale life consequences of aphasia to other conditions—for exam- includes language-dependent items. 1998). and work/productivity). Both scales try to make links and the Life-H scale (Fougeyrollas et al. Noreau. Likewise.qxd 1/21/08 12:45 PM Page 357 Aptara Inc. The Life the way of abilities as much as it does participation levels. leisure. This discussion extends beyond the scope of this chap.. whether across individuals with different diag- Throughout the quality-of-life literature. Psychometric data on the use of the difficult to administer to people with aphasia. or SSQOL. and Mikolic (2003) will aphasia on certain of these items and (1) the severity of their offer an interesting tool for looking at the limitations stroke aphasia and (2) the support they are receiving. a more aphasia-friendly presenter’s sheet is avail. rhinitis. Hula. 2004. lack of fitness. diagnoses. loss of some items are actually perceptions of how well individuals appetite. life measures hold that the purpose of these measures is to tions will also be similar. by Doyle. The Life-H scale (some formed by substitution) and may be very satisfied with this items from the short form are shown in Fig. (2) type of assistance needed. of satisfaction.Energy ID item or as necessary) yes yes sure no no ication social Have to write things down to remember them T4 (or ask somebody else to write things down 1 2 3 4 5 for you to remember)? T5 Find it hard to make decisions? 1 2 3 4 5 P1 Feel irritable? 1 2 3 4 5 P3 Feel that your personality has changed? 1 2 3 4 5 MD2 Feel discouraged about the future? 1 2 3 4 5 MD3 Have no interest in other people or activities? 1 2 3 4 5 MD6 Feel withdrawn from other people? 1 2 3 4 5 MD7 Have little confidence in yourself? 1 2 3 4 5 E2 Feel tired most of the time? 1 2 3 4 5 E3 Have to stop and rest often during the day? 1 2 3 4 5 E4 Feel too tired to do what you wanted to do? 1 2 3 4 5 FR7 Feel that you were a burden to your family? 1 2 3 4 5 Feel that your language problems interfered FR9 1 2 3 4 5 with your family life? SR1 Go out less often than you would like? 1 2 3 4 5 Do your hobbies and recreation less often 1 2 3 4 5 SR4 than you would like? SR5 See your friends less than you would like? 1 2 3 4 5 SR7 Feel that your physical condition interfered with your social life? 1 2 3 4 5 SR8 Feel that your language problems interfered 1 2 3 4 5 with your social life? SAQOL. an individual may no longer be respondents note the frequency with which they got out of able to do housework following a stroke. however..GRBQ344-3513G-C13[349-375]. 13–5) is an arrangement. assessment tool that includes 58 items based on the life erally do not mix activity-level items with participation-level habits section of the DCP classification. Sample scoresheet from the Stroke and Aphasia Quality of Life Scale–39 (SAQOL-39).) activities and roles in which individuals participate and gen. hobbies. the respondent .qxd 1/21/08 12:45 PM Page 358 Aptara Inc. this bed or the number of hours involved in active homemaking individual might have hired help with this life activity (per- or working. 358 Section III ■ Psychosocial/Functional Approaches to Intervention During the past week: Item Did you (repeat before each Definitely Mostly Not Mostly Definitely Physical Commun.Pyscho.39 mean score Add all items and divide by 39 Physical score (SC items + M items + W items + UE items + SR7) / 17 Communication score (L items + FR7 + SR8) / 7 Psychosocial score (T5 + P items + MD items + FR7 + SR1 + SR4 + SR5) / 11 Energy score (T4 + E items) / 4 Figure 13–4. frequency). 2003. with permission. like some of the quality-of-life scales.e. For example. For instance. For level of accomplishment.. The CHART required to score three aspects for each item: (1) level of asks respondents to indicate the number of hours they spend accomplishment. and so on. and (3) level performing a specific activity (i. Respondents are items. (From Hilari et al. ) Written communication (writing a letter.1 following treatment instructions. group home) Figure 13–5. accessories. contact lenses.1 community (expressing needs.3 Reading and understanding written information (newspapers. letters. removing and maintaining your assistive devices (orthodontics. 5. 3.) Using services provided by a medical clinic.GRBQ344-3513G-C13[349-375]. Items from the Life-H scale. including the choice of clothes) Putting on. accessories. television or sound system 4.3.4.3.2 Using a computer 4. Chapter 13 ■ Focusing on the Consequences of Aphasia: Helping Individuals Get What They Need 359 Question 1 Question 2 Answer the following 2 questions (check the appropriate boxes). check assistive devices Using a phone at home or at work 4. including the choice of clothes) Dressing and undressing the lower half of your body 3. (From Fougeyrollas et al. 1997.3.3.3 Using a radio. signs. etc. etc.) Taking care of your health (first aid. etc. hospital 3.) .4 Housing Choosing a home that suits your needs (house.1 Using a public or cell phone 4. etc. etc.4 Note: If you use glasses to read.) Communicating with a group of people at home or in the 4.1.1. etc. prosthetics.qxd 1/21/08 12:45 PM Page 359 Aptara Inc.2 or rehabilitation center.3. holding a conversation. indicate A How the personal generally accomplishes it Accomplished by a proxy and More or less satisfied B The type of assistance required to accomplish it Human assistance Assistance device Not accomplished Very dissatisfied Not applicable No assistance With difficulty Question 2: Very satisfied No difficulty Dissatisfied For each of the following life habits.3.3 glasses.2 community (expressing needs.) 4.1.1 (clothing. books. holding a conversation. indicate Adaptation Satisfied the level of satisfaction with the way it is accomplished. medication. message. Level of Type of Level of accomplishment assistance satisfaction (check only 1) (check all (check only 1) Question 1: that apply) For each of the following life habits. with permission.4. Dressing and undressing the upper half of your body 3.2 (clothing.3. Communication Communication with another person at home or in the 4.1. 3.1 apartment. Note: Keep in mind that answers should reflect the person’s usual way of carrying out the habits..) 4. Noots-Villers. aphasia can see which goals. Realized by substitution & Laake. Wyller.1. & the individual’s priorities. this includes a comprehensive appraisal of the devised based on the participation domains found in the speech and language skills. Thommessen.. Unfortunately.GRBQ344-3513G-C13[349-375]. Simmons-Mackie & Damico. clinician must not ignore the behavioral personal factors. assistance to achieve the life habit. and each goal brain injury in evaluating the environmental factors that con. what is important is to identify those life partic- human or otherwise. is then defined in terms of this scaling. 2002) as well as to those of individuals with traumatic tified pre-intervention using a five-point scale. missing step is often the direct correlation of these abilities der on overall life participation. Further. No ideal tool is currently on the market that cap- tures all the elements necessary for therapeutic planning The Second Component: Intervention using a life consequences approach. is helping the individual take part in his ipation areas that pose problems for the individual with or her life activities. successful activities and roles. or inter- This allows clinicians to identify what environmental help. tion with the individual with aphasia but before a therapy In a pilot study using the DCP and ICF models to plan can be designed. sia (Parr. the ture individuals’ perceptions of the impact of their disor. or using informal questionnaires. in daily life. an inventory of the individual’s capabil- describe functioning in the area of aphasia. the visual presentation of the Life-H tool itself technique such as Goal Attainment Scaling (Schlosser. clinicians are concerned with Woolf. For type of 2002). to tease out communication as a life participation. 1995) to cap. they. views). which can be rated on a five point scale from Very dissatisfied The problematic life participation areas may or may not to Very satisfied. those too. aphasia. all of these scales can help the therapist identify Attainment Scaling can be used with any therapeutic goal. Assistive device. The Life-H scale was together: interprofessional strategies for rehabilitation. The questionnaire may be found in skills are the subject of many chapters in this text. may be difficult to apply to the area of aphasia. respondents can indicate Bottom line: Whatever method is used by the clini- No assistance. Not performed. Garcia and ities must be made. Questions were pathology. Lindsay. McDowell and Newell’s book (2006) on measuring health is an interesting Once the life activity or role has been identified in collabora- start. 366) used in a pilot study comparing caregivers’ responses to those involves assigning a numeric value to therapeutic goals as per of their loved ones with dementia (Wright. or Human assistance. For who are more systematic in their approach may choose a instance. Duchan. Therapies designed for these ICF and DCP. Further. The last category is level of satisfaction. 2003 Pound. Goal In short. how persons with aphasia perceive their level of functioning including those based on life participation. these participation rating be reflected in explicit communication goals. respondent). In speech-language identify the life participation areas. the impact of language abilities on their clients’ lives.qxd 1/21/08 12:45 PM Page 360 Aptara Inc. Some difficulty. p. and the clinician will need on the Personal Factors to examine these clinical tools more closely. participation scales. 2004) makes it difficult for individuals with aphasia to score the to evaluate progress in life participation. and those that are at (Bays 2001. or Not applicable. if not all. Taken as a whole. Sveen. those that are compromised. Others also preferred to use tailor-made techniques can impact the life participation of individuals interviews and questionnaires with individuals with apha. & Pound. if any. Level of linguistic functioning is not (meaning someone else is carrying out this activity for the always the predictor of overall functioning (Ross & Wertz. Parr. In both intervention. have been attained. & Although most. A continuum of outcomes is iden- Fergus. risk of being compromised (Castelein. 2005). the how one can construct interventions based on life participa. . it is very scales allow the respondents to identify problematic areas of difficult. level of satisfaction for each and every participation item and In addition to using participation scales such as the Life-H that they do not mix activity-level items. Lyon and Shadden (2001) have also stressed the such as level of motivation. the clinician asked the participant the questions. 360 Section III ■ Psychosocial/Functional Approaches to Intervention can score No difficulty. Adaptation. cian (quality-of-life scales. The clear advantages of these tools are that they track the identifying areas of life participation as a goal for therapy perception of the impact of environmental factors as well as may seem too global and unmanageable to some clinicians. separate entity from life participation (Penn. with aphasia provided the links are made with life domains. the person with instances. if not impossible. All of these Appendix 13. with improvements on subsequent life activities and roles Byng and Duchan (2005) give an excellent overview of that are important to the person with aphasia. together with the clinician. and their correlation with life importance of looking at global life goals. tion roles. 1999). These correlations will allow the clini- participation in leisure activities has been shown to correlate cian to identify those life habits that likely are mildly most with quality of life and overall well-being poststroke affected. Bautz-Holter. In fact. The response forms may need to be (described in greater detail in the section entitled “Fitting it adapted for use with this population. 2004). At the end of the tribute to workplace integration (Laroche et al. Neault. 2000. Garcia. and the CHART. This technique items themselves. In fact. These skills will normally be identified colleagues (2003) preferred to use an interview format to through discipline-specific evaluations. Cunningham in topic shifting) and the actual breakdown in the person’s and Ward (2003) used videos to help functional communica. The therapist will coach both the per- so fundamental. or PACE treatment (Carlomagno. In this situation. message. As a reaction to the paper by Ross and Wertz son to 25 children. may not reveal their intentions explicitly. Other. as described in the various chapters of this text. develop a predesigned script that the person with aphasia ties can be prioritized and incorporated into a cohesive ther. Emanuelli. is not a life participation domain but. Aside from designing ing rate and naturalness of the conversations. Losanno. will practice with the clinician. in and of itself. and semantics important. As the participants mastered the become disturbed” (p. while being language is fundamental to successful life participation. uses a reciprocal model of learning where the person quences must consider the intended goal of the communica- with aphasia is in interaction with a student partner. apy to be effective. and (3) to build and maintain Hopper. & Cox. a reading problem oped by Holland (1991) called conversational coaching. called reciprocal scaffolding (Avent & Austerman. strategies. Based on this information. the clini. the ability to express gies. Brodie. 1991. This script can vary in diffi- apeutic plan. The clinician and three social levels: (1) For the sheer pleasure of interaction person with aphasia will then view the videotape together (in these cases. or conversational repair. What we see designed specifically for conversation is the method devel. their ties with other people. Waller.. (or hear) is not always what is underlying the problem. The person with aphasia will then practice the script one’s intention and/or understand others’ intentions through with a familiar person.g. the person with aphasia (2005) on the use of the ICF in the appraisal of aphasia. to remember when we engage in techniques that work on Weinrich. Not only are the linguistic levels of phonology. in terms of life participation. an approach based on the scripts. Nothing could be closer to the truth. & Spicher. 2000. The first step in this process is to reads for pleasure. “The a systematic technique to render scripted phrases more and major means by which we alleviate our interpersonal loneli. and when that is difficult. a breakdown & Casadio. the person with aphasia teaches a science les. remember some fundamental principles about communica- cian can also focus on helping the individual with his or her tion.qxd 1/21/08 12:45 PM Page 361 Aptara Inc. Hence. How 1998). close is the correlation between what is perceived as a break- 1995). transpires all One of the more formal therapeutic interventions domains. 1996. Normal speakers do not communicate all the necessary communication skills to function as a social being. the topic is unimportant). the speaker? Any approach that focuses on the life conse- 2003). Muñoz. in fact. more automatic in the conversational discourse of two indi- ness is verbal communication. In the tion event. It is filmed on videotape.e. the goal of communication is to cacy. and Rewega (2002) looked at the effi- relationships. The therapist must remember that individuals effectively communicated post-therapy and found this ther- may need to communicate with the intention to make rela. down in communication by the therapist (e. reading recipe books) but would compromise the with aphasia transfer the strategies learned in therapy to a job of a lawyer and risk compromising leisure if the person more functional context. less familiar individuals can then be called Verderber (1981) suggests that people communicate on in to make the task a little more difficult. and which part should so that they become more efficient communicators. Shelton. and Bourgeois (2005) used those needed to read a book. and speakers Functional communication techniques might include aug. . Pulvermüller & Roth. The person with aphasia practices the process. intervention strategies that focus on the linguistic aspects per Any clinician wishing to use these techniques must se. we viduals with aphasia. They looked at the number of concepts that were information. script with the clinician as he or she guides the client in syntax. Holland. For instance.GRBQ344-3513G-C13[349-375]. topic shifting. Holland. The scripts life consequences cannot focus solely on the transactional were tested for robustness in a contextual conversation. It is not only about the clarity of the linguistic reported case. but pragmatics becomes a using the most efficient and effective conversational strate- central theme in intervention.. 1995). culty depending on the amount of information that needs to In identifying these capabilities. that we often define who we are son with aphasia and the family member in conversational through communicative interactions. This is important mentative and alternative communication (McCall. Ward-Lonergan & Nicholas. the capabili. In this sense. turn taking. more and more information was added. & Cairns. the clinician should pay be conveyed and on the level of improvisation left to the specific attention to communication skills as an interactive person with aphasia. has the opportunity to improve not only in language but also Penn (2005) remarked that communication. Hence.and post therapy. both pre. Dennis. and aspects of communication (i. Another be deducted as a function of the context and the links with technique. (2) To demonstrate and discuss what worked and what did not. communicative intention? Which part of the message tion by teaching repair strategies to conversational partners should be allocated to what is explicit. drawing (Lyon.e. The could mildly affect the life participation activity of preparing conversational coaching technique is used to help the person meals (i.. 1991). Youmans. transmitting a message) raters were then used to examine parameters such as speak- (Simmons-Mackie & Damico. 1994). information to communicate their intention. rather. Chapter 13 ■ Focusing on the Consequences of Aphasia: Helping Individuals Get What They Need 361 Buxant. usually a family member. Luterman (1996) says. In another technique using script train- tional ties and that this might demand different abilities from ing. of using a videotaped story facilitate social interactions and not necessarily to transmit as a script. 22). Bottom line: Capabilities. Even with mild apha- sia. Counselling will be necessary to guide the individ- doing on items such as ability to work. Analogue Self-Esteem Scale (Brumfitt & Sheeran. individuals are counselled into reconstructing this new iden- ties and roles. As with the identification and techniques designed to help the conversational partner of life participation events. 2001). such as the conversational coaching technique non-productive behaviour. Pound. can be correlated with identified (Code. whereas the Code-Müller Protocols will evaluate her return to past life activities and/or development of new the self-perceptions of individuals regarding how they are life goals. In his book on counselling. or The level of impairment will contribute to the realization VASES. will also help with the validation of a per- therapist to switch their focus from what they cannot do to son’s competence as a communicator. of the life event. a life conse- (Parr. the sequelae of the domains. or ability to follow interests and hobbies. 1995) and reveal who those affected were and may approach. CVA might affect these subtle aspects. Other acknowledged” (p. Opportunities for validation and inclusion will As mentioned previously. 1999). socially functioning human beings. This is a very important to unveil the mask of incompetence caused by aphasia distinction to make when one takes a life consequences (Kagan. The therapist can help what they may choose not to do. Parr. The level of remember that the individual with aphasia has a premorbid motivation and the sense of identity the person has can life that comes with a premorbid personality and psychoso- either facilitate or be an obstacle to full reintegration. 362 Section III ■ Psychosocial/Functional Approaches to Intervention Sometimes. optimist/pessimist.. such as group therapy (Kearns & Elman. The feelings must always be described above. Therapy can then be prioritized into work uating an individual’s psychosocial adjustment. they will need of those with aphasia. aphasia affects much more than most easily occur if the therapist knows how to modify the one’s ability to transmit a message. cial situation. with help from the clinician as opportunities are offered in Luterman (1996) stated that “the goal of counselling is not the form of successful communication situations. clients can participate with the (see next section). 2001. This perspective suggests that the therapists can now choose to be (Mackay. As whether individuals with aphasia can take part in life activi. and psychological Sometimes. conversational. Hogan. but to separate feelings from techniques. To move ahead in therapy. focuses on both is more likely to be successful (Ross & tion of involvement in life events and roles will need to take Wertz.GRBQ344-3513G-C13[349-375]. Validation will come not be ignored by the therapist. Kagan (1995) has spoken environment. these feelings can. Ignoring these aspects is likely to doom the Counselling on the other personal factors that interact with therapy to failure in terms of life participation. functioning. These are equally part of the personal factors tity with less efficient communication skills. Because communication affects the some external validation that they can once again become very fabric of interpersonal interactions. the best way to find out how people are doing is skills will most certainly help in improving quality of life through informal and formal interviews or autobiographies (Cruice Worrall & Hickson. 2001) suggested that we listen to clients. renegotia. whereas decreasing the obstacles. attractive/ unattractive. those affected may see an impact on the fact that they The Third Component: Intervention can no longer be as witty or have deep conversations with a on the Environmental Factors spouse. 2003). Improving linguistic. will help individuals attain success. Luterman activities. as assessed by discipline Assessment tools such as the Code-Müller Protocols specific evaluations. 2003) by guiding their involve- use the individual’s state of mind to help the person adopt ment in communication situations. 2005). The demand placed on communication skills is far greater in real life than in a clinic situation. are both designed to offer a standardized way of eval. however. No matter through work on environmental factors. Some to make people feel better. 1999) or the Visual life participation goals.qxd 1/21/08 12:45 PM Page 362 Aptara Inc. & Duchan.g. 47). The effect may be withdrawal from these events. The clinician must new life roles by choosing to let go of past roles. The life participation goal is mod- Shadden (2005) has written a paper describing how aphasia ified not only through work on personal factors but also impacts one’s perception of one’s own identity. place if the therapy is to be successful. increasing the number of facilitators and of aphasia as masking an individual’s competence. individual will also play an important role in helping his or and so on). which in turn impact How people feel about themselves and how they feel the on the individual’s ability to function as he or she did previ- disorder has affected them and their loved ones will impact ously. such as self-esteem. The individual To many people. linguistic difficulties directly influence other them quickly. The clinician can quences approach demands that this be considered in the use counselling techniques to probe issues of psychosocial context of other environmental factors that impact real-life adjustment as they relate to communication situations. depression. must not be forgotten that the psychological state of the perception (e. It will offer the clinician an assessment of the individual’s self. Even with mild aphasia. The VASES on linguistic aspects and/or social conversational skills. Müller. Therapy that how mild the aphasia may seem to the therapist. the term “environmental factors” refers must process multiple pieces of information—and process only to physical environments and includes such things as . communication can be a very important step to recovery. ability to cope with ual through these stages. & Herrmann. Howe and colleagues (2004) offered an excellent (2002) report on efforts to render health-care services more review of environmental factors that can influence the life accessible to individuals with aphasia. as gration. environmental obstacles go beyond well as sociopolitical systems and attitudes. Conversely.g. It includes social envi. which the person interacts. Duchan. communication might include visual material (e. imizes the role of the personal factors (i. snow-covered sidewalks. Barrette. making the world more accessible to the person with apha- environment includes much more. a purely environmental approach likewise the conversational coaching technique not only benefits the does not do justice to the role of the impairment. The tions in more naturalistic environments. writing partial messages to clarify information. Using the ICF the individual conversational partner. upon and incorporated into modern disability models. such as family members and colleague support. the therapist is environments. if the person has lower competence skills for tographs). a dependent as possible and focus on the communicative relationship exists between the person’s level of competence intent rather than the clarity of the linguistic output. fluid conversa.e. vious section. aphasia as being obstacles or facilitators to integration. Further. than just help axis of this model. 2001).GRBQ344-3513G-C13[349-375].. Chapter 13 ■ Focusing on the Consequences of Aphasia: Helping Individuals Get What They Need 363 architectural designs. and Lubinski leagues (2005) give further examples of how to render writ- (2001) explained how environmental factors can be seen to ten environments more accessible. Tools that facilitate skills. For our purposes. sonal factors. Much more information is needed regarding the impact A conversation cannot occur without a partner. sonal and environmental factors. he or she will also be unable drawing.. productive. Nonetheless. the environment. this can negatively affect the functional communi. this would include per- to construct coherent conversations. 2001). 2001). All environments with interact at the individual. however. Hence. The x-axis repre- Supported Conversation for Adults with Aphasia. 1987). how to coach for more fluid communication. The program teaches con. aphasia) on life For instance. work- effects. because the environment demands very little. pho. because this individual will not have the skills to are taught to offer feedback that is as natural and context respond to the high demands of the environment. The inter- individual with aphasia but also trains family members in action must be symbiotic. Partners to perform. this can be rated from a low level of validating the competence of the person with aphasia. lishing coherent and cohesive interactions (Schegloff. attitudes (Parr. or noisy By intervening at the environmental level. and what is asked by the environment to achieve maximal . is sents how demanding the environment can be toward the one of the more formal approaches for training conversational individual. but is in an environment that demands little. To focus only on the environmental factors min- tional partners into positive-impact conversational partners. competence to a high level of competence. level of competence of the individual is represented on the y- Conversational partners do more. 13–6) to help articulate the role of per- conversational repair strategies. In the disability model approach. family. 2000). This can be rated as very low in demand value to partners.. Black. conversational partners play an important role in Following evaluation. To reduce these life participation is far from straightforward. the person will versational partners to see the person with aphasia as an lose his or her ability to adapt and will develop negative equal conversationalist. and systemic levels.qxd 1/21/08 12:45 PM Page 363 Aptara Inc. what the environment demands. As mentioned in the pre. If a person has a high level of competence sia to facilitate communication. the therapist can use a number of the techniques ing on the environmental factors alone might be counter- mentioned previously to help turn negative-impact conversa. however. the role of be examined to see if they are perceived by individuals with the conversational partner has been instrumental in estab. and Potechin (2005) showed evidence for generaliza. and Square (2001). and it encourages the partner to use affect and maladaptive behavior. 2001). Simmons. and they have been improved tion of family training techniques to better. model are still relevant today.g. or natural “props” (e. newspaper clips). Kagan and LeBlanc model. and Simmons-Mackie. The individual will not be whatever is at his or her disposal to engage the person with working hard enough to stimulate development of his or her aphasia in a meaningful interaction. Depending of these environmental factors on the life participation of on the words used by conversational partners and their individuals with aphasia. The concepts from this Kearns. and Hopper and colleagues (2002) explained how environment. Cunningham Lawton and Nahemow (1973) introduced the ecological and Ward (2003) also used videotaping to train couples in model of aging (Fig. or SCA. or how health- as aphasia is the conversational partner. Parr (2001) correctly points out behaviors. For as long as social care teams are structured and function (Golper. The diagonal lines suggest a Mackie. including physical environments The most obvious environmental factor influencing the (Lubinski. sia and helping others to facilitate rather than hinder inte- ronments. such as linguistic and behavioral capabilities. & Laroche. Designed by Kagan. very high in demand value. Worrall and col- participation of individuals with aphasia. Just as the traditional medical using scripts in the “Speaking out” program of Worrall and model might be criticized for not acknowledging the role of Yiu (2000). volunteers were used to facilitate conversations participation (Parr. that identifying the exact impact of environmental factors on cation levels of the person with aphasia. and work environ- integration of individuals with communication deficits such ments (Garcia. can scientists have studied conversational discourse. this program capitalizes on the direct link between level of competence and demand from inherent cognitive and social skills of the person with apha. person with aphasia but also the conversational partner. the therapist has a role in shaping an environ- ment that will be conducive to the “zone of maximum com- The Environmental Partner as an Object of Intervention fort. Noreau. (very much an obstacle). The ecological model of maladaptive aging (Lawton & Nahemow. with the Lawton and Nahemow model of environmental Just as it is difficult for individuals with aphasia to com- press. and asks the respondent to rate items on a scale going from whelming enough to elicit discouragement. he or she is likely to lose whatever mental factors. he or she will rier and the frequency with which he or she encounters it. behavior Low Weak Strong Environmental press performance.” The tors. & cannot manage a full staircase. is to identify those environmen. light. CHIEF. or can demand—up to a point. . (2001) is precisely in line an individual who did not have aphasia. If this person barriers by asking the individual about the level of the bar- must manage many stairs in the environment. then. this means that should also consider the individuals surrounding the person the individual with aphasia must come into contact with with aphasia as a focus of intervention. natural environments. The MQE (Fig.GRBQ344-3513G-C13[349-375]. The impact of functioning with an to be overwhelming. isolation. The CHIEF helps the clinician identify is left of the competence to manage stairs. and noise. or MQE. and the Measure of the Quality of the imagine an individual who can manage some stairs but who Environment (Fougeyrollas. Barriers include items such as the layout of built environ- These same principles can be applied to individuals with ments. positive or a negative way. much of this chapter has focused on individuals tal factors that are contributing to integration. More and more writings. Bakas. The Craig Hospital Inventory of Environmental higher the level of competence. This is called “environmental press. Perkins. however. Two standardized tools may be useful to the clinician for Work on conversational discourse not only benefits the identifying the frequency and impact of environmental fac. 2001). likely be overwhelmed and unable to function. the more the environment Factors (Craig Hospital Research Department. are scales used measure environ- this person environment.” using the model of Lawton and Nahemow (1973). the clinician facilitates communication suffi. and help to impact on these fac. either in a with aphasia and their interactions with their environments. suggest that the clinician tors. 1999). To use a concrete example. Until now. in addition to stimulating linguis. Using the environmental press model. and Williams (2006) looked at family care- encourage the use of communication strategies on the part givers of individuals with aphasia and of individuals without of the individual with aphasia yet also facilitating enough not aphasia following stroke. and in an environment that is sufficiently stimulating to reveal policies and rules. 1973). attitudes.qxd 1/21/08 12:45 PM Page 364 Aptara Inc. The clinician’s job. communication partners who are stimulating enough to Plue. If all stairs are removed from Boschen. St-Michel. 13–7) has similar items competence and enhance development but also not over. as well as aphasia. Therefore. and 2 (very much a facilitator) to 0 (neutral impact) to 2 demotivation. 364 Section III ■ Psychosocial/Functional Approaches to Intervention High Negative affect & M Zone of maladaptive a maximum Zone of behavior r comfort maximum g performance i potential Marginal n Competence a Negative l affect & Figure 13–6. municate with their environment. The Supported Conversation for individual who had aphasia was more demanding than with Aphasia technique of Kagan et al. ronment to communicate with an individual who has aphasia. it is difficult for the envi- ciently enough to reveal the competence of the individual. Kroenke. Here. tic aspects. A person with significant residual language must be more human barriers. such as human help. Although Allan (2006) refers to health workers involved questions such as “How does he communicate at home?” with individuals who have dementia.. Other members in the person’s her identity both now (poststroke). about workers involved with individuals with aphasia: In a life consequences perspective. with a spouse. to go beyond ered. 1999. such as health-care providers. household assistance. school or place of principal occupation towards you. with permission. it is clear that efforts must be cation aspects but also on the impact of the aphasia on the made to understand how each significant other projects his or marital relationship. the colleague’s. (From Fougeyrollas et al. or with children). Example of the Measure of the Quality of the Environment (MQE). As with the individual who has aphasia. 219). 191) . vention on the aphasia itself or reduction of environmental (p. the aphasia almost cer. Sorin-Peters (2003) used sonal identity by suggesting a specific burden associated an adult learning model to help couples deal with the conse- with the impact of aphasia: quences of aphasia. -3 -2 -1 0 1 2 3 cashiers. • The attitudes of your family or close friends who take the place of family towards you. barriers might help these partners.. encourgement).) toward you. or the friend’s life ery of the services it provides cannot simultaneously deny the participation. -3 -2 -1 0 1 2 3 • The attitudes of your service providoers (public service agents. Her focus was not only on the communi- Using an identity perspective. or place of principal occupation. indicate on the scale to what extent the situations or influence factors generally influence your daily life. -3 -2 -1 0 1 2 3 • The attitudes of your friends toward you. entourage. salespeople. -3 -2 -1 0 1 2 3 • The attitudes of your superiors (professors. needs of staff that arise in the course of the work that they do. school. -3 -2 -1 0 1 2 3 Attitudes of the people around you. can also be consid- There is a need to know relational dynamics. -3 -2 -1 0 1 2 3 • The attitudes of your colleagues at work. Figure 13–7.. etc. -3 -2 -1 0 1 2 3 • Support from your neighbors. -3 -2 -1 0 1 2 3 • Support from you collegues at work.qxd 1/21/08 12:45 PM Page 365 Aptara Inc. the same can be said (p. -3 -2 -1 0 1 2 3 • The attitudes of your neighbors towards you.. A system which calls upon workers’ humanity in the very deliv- tainly affects the spouse’s.GRBQ344-3513G-C13[349-375]. I do Does medium medium not not major minor minor major Social network (support from people around you) know apply • Your family situation (living alone. -3 -2 -1 0 1 2 3 • Support from members of your family or close friends who take the place of family (presence. physical assistance. and in the past (prestroke). employees) towards you. -3 -2 -1 0 1 2 3 • Support from your friends.) Shadden (2005) brings this point home in the area of per. Chapter 13 ■ Focusing on the Consequences of Aphasia: Helping Individuals Get What They Need 365 Measure the quality of the environment Influence scale While taking into consideration your abilities and personal No Obstacle Familiar limits. supervisors. inter. Using disability or informal evaluation of the life habits and disciplinary eval- models. Assign a weight for each goal according to priority The best way to facilitate this is to take an interprofessional The priority given to these goals will be influenced by approach in which the members of the team (including the the frequency and the importance of the goal to the person with aphasia) work toward common life participation person with aphasia. including linguistic and psychoso- team rehabilitation goals based on the DCP disability model. This will both save time and be more a more than expected outcome (1). Environment tion with his or her social and physical environments. For a the levels might be for each of the chosen goals. Evaluate extent of attainment . Each discipline can then work on disciplinary ele. cial adjustment abilities. A correlation is made between the individ- health-care worker to do his or her job and offer better care to ual’s capabilities and these life habits or roles based on formal all individuals with communication disorders. Using a team stage of the process. Those people in the individ. and/or (3) work with the client to or colleague. which are identified based on the physicians reported struggling when involved with individuals frequency with which the client engages in the life habit or who have aphasia. work. 366 Section III ■ Psychosocial/Functional Approaches to Intervention Bouchard-Lamothe and colleagues (1999) found that some of life participation goals. Specify the criteria for scoring at each level The toward a clear. team to be effective. Patricia Noots-Villers (Castelein et al. (b) reducing environmental The ESOPE program (see Figure 13–8) uses a computer sys. with the individual with aphasia. 355)” of this chapter. always in conjunction approach allows clinicians to concentrate on life conse. Determine performance attained on each objective quences approach. Determine current or initial performance This Goals in Rehabilitation]) will give them this opportunity. His or her life habits (e. “The First Quickly. and a best expected efficient. impact of the stroke on the patient’s life activities and roles. an expected outcome (0). intervention. Interventions at this level not only help the role as well as the perceived importance by the client of this person with aphasia to obtain better care but also helps the life habit or role. and To help persons with aphasia determine when they have organizational structures. or colleague. 2. Intervene for a specified period As mentioned above. however. 2001). 1994). Simmons-Mackie. The team first works from a common set 8. will (1) target the capabilities son.qxd 1/21/08 12:45 PM Page 366 Aptara Inc. This per. will operationally define what each of quences goals in a more efficient and effective manner.. social supports. this is also the most difficult doing outcome measurement in clinic. its members must orient their efforts 4.g. the therapist can focus on the life participation of the uations. person with aphasia in the section entitled. According to the ESOPE model of sia. and/or disciplinary clinical measures. This technique offers a systematic way to determine progress on an individ- FITTING IT TOGETHER: INTERPROFESSIONAL ual goal. ations of handicap and develop a more harmonious interac- get of intervention as is linguistic capacity. It was developed tors. Specify a continuum of possible outcomes Each ments and keep informed through discussions with the team goal is assigned a worst expected outcome (2). intervention might take the form of therapy aimed at (a) tional therapists have proposed a model to guide the setting of improving abilities. the individual will then be able to diminish situ- Bottom line: Environment is just as important a tar. The team. tem to help an interprofessional team adopt a life conse. the therapeutic team can ual’s entourage can just as likely become a focus of use the technique of Goal Attainment Scaling (Schlosser. Specify a set of goals In our case.. Component: Identifying Disrupted Life Activities and mation from other professionals to understand the full Roles (p. 7. that need to be prioritized as a function of life habits and roles. This is where the Goal Attaining Scaling reported that time constraints were the biggest obstacle to is most useful. not to mention his or her identity as a spouse or augment facilitators. and Kagan (2005) outcome (2). these goals can be For a speech-language pathologist to embark on a life con. who does not have aphasia. family member. 2004) discussed previously in this chapter. prioritaires en réadaptation [Systemic Evaluation of Priority 5.GRBQ344-3513G-C13[349-375]. attained some success in their goals. common objective (Golper. with the client. have likely been disrupted by the partner’s apha. The clinical rehabilitation team. 3. has also been affected by it. activities. Here are the steps as outlined by Schlosser (p. adopt new life habits. 218): STRATEGIES FOR REHABILITATION 1. and a team will then clearly identify what is operationally model such as the ESOPE (Évaluation systémique des objectifs needed to conclude that the goal has been attained. and interpersonal (2) suppress environmental obstacles that prevent integration relationships). obstacles. in collaboration health-care worker. can include physical environment. environmental fac- as a guide for operationalizing this approach. by a Belgian team under the direction of Pierre Castelein and 6. or (c) helping define new life goals. These are clearly life consequences of aphasia. intervention. Threats. a less regarding the progress made on the patient-initiated life than expected outcome (1). goals. These occupa. the life participation goals set by the team and the sequences approach to intervention is quite challenging. activities and roles. the clinician will realize the need for more infor. could be determined through measurable evaluations of The ESOPE model is one suggestion that might be useful life participation or quality of life. GRBQ344-3513G-C13[349-375]. The ESOPE (Évaluation systémique des objectifs prioritaires en réadaptation [Systemic Evaluation of Priority Goals in Rehabilitation]). EF  environmental factors. . Further.) Regular meetings with the team will ensure that the over. self-identity of the person will also change. Shadden. The clinician is therefore encouraged to con- more than the sum of its parts. importance Abilities summary Environmental factors summary Correlation between life Correlation between life habits and abilities habits and environmental factors Mildly affected life Compromised Life habits/roles habits/roles life habits/roles at risk Capabilities EF to prioritize to prioritize Multidisciplinary strategies for rehabilitation Work on Suppress environmental Adopt new life capabilities and obstacles and augment habits and roles limitations the facilitators Re-establish a harmonious rapport between the person and his/her environment Figure 13–8. Hence. 1994. the composite picture is this context. the is facilitating the person with aphasia’s integration in the consequence on the life participation goal will also be best possible way as defined by these goals. the death of a spouse or the pur. The profession. (Adapted from Castelein et al. skills and environmental factors are influencing the achieve- mental factors change (e.. Like the elephant in condition of aphasia will have differing effects depending on the legend of the six blind men.. As environ. with permission.. more motivation or improved language skills).g.g. 2001.qxd 1/21/08 12:45 PM Page 367 Aptara Inc. the chronic improvement of life participation goals. Chapter 13 ■ Focusing on the Consequences of Aphasia: Helping Individuals Get What They Need 367 Life habits & roles (participation) Frequency. the als involved in the team will be able to focus their own ther. and this will be apeutic plans on the disciplinary items that offer a continued influenced by his or her life experiences. 2005). affected. tinuously evaluate the extent of participation in life activities It is also important to remember that these goals will and roles as well as the extent to which the current personal change over time (Parr. chase of an electronic device) and personal factors improve all life participation goal is being met and that each member (e. as Shadden (2005) so eloquently states. ment of these goals. qxd 1/21/08 12:45 PM Page 368 Aptara Inc. • Group/recreational Social participation computer. • Effects of psychotropic • Community • Family members family drugs involvement • Noise • Geographic isolation/ • Noise • Availability of • Roommates location • Lighting support personnel • Transportation • Ventilation • Roommates • Lack of follow-through with strategic staff commitment and turnover • Language barrier • Cultural differences • Age factor . • Staff input/feedback • Family rating scale • Improvement in goals to work mented life • Improved communi. driving.g. 368 Section III ■ Psychosocial/Functional Approaches to Intervention TABLE 13–1 Applying The Philosophy Community-Care Acute Care Rehabilitation Settings Long-Term Facilities Settings Enhancement of • Unable to express • Return to work • Person with aphasia • Participate in some life participation needs/wants • Return to day living cannot communicate community activity (shopping. • Questionnaire • Diagnostic measures • Measures of self enhancement cation on ward • Formal assessment tool • Documentation of satisfaction changes • Client interview room restorative • Ability to return to programs previous activities • MDs • Ability to learn new • Nursing documentation participation activities Personal factors are • Cognitive status • Cognitive status • Feelings of isolation • Age targets • Motivation • Motivation and depression • Previous roles • Fatigue • Client awareness/insight • Premorbid level (e.. managing • Mental/physical/ finances) emotional status • Finances • Financial situation • Motivation • Overall life style/behavior • IADLs Environmental • Other testing • Living situation • Family attitudes • Family situation factors are targets procedures • Responsiveness of • Privacy issues • Transportation • PT/OT employer. insurance • Friends personnel • Co-workers • Clergy • Employers • MDs • Rehabilitation team Measures of success • Ongoing evaluation • Anecdotal information • Feedback from staff • Ability to return include docu. community. cooking. telephone activities (in-house and talking) outside facility) • Return to social • Using communication network boards All those affected • Nursing staff • Medical staff • Family • Lack of funding for are entitled to • Family • Family • Friends initiating/ service • MDs • Friends • Caregivers continuing support • Rehabilitation team • Colleagues services • Community workers • Family • Lawyer. basic needs • Specific work goals homekeeping.GRBQ344-3513G-C13[349-375]. KEY POINTS The Life Participation Approach to Aphasia guidelines mirror the approach taken in this chapter: 1. ranging from hospitals to rehabilitation 5. different contexts. Both personal and environmental factors are targets of Speech-language pathologists can deliver services in many intervention. we may contribute greatly to (LPAA Project Group. which sum- their sense of meaning and personal identity. CLINICAL CONTEXTS 4. The explicit goal is enhancement of life participation. chapter 10. The participants were asked to reflect on how the ones get what they need to participate more fully in life at a principles of the Life Participation Approach to Aphasia certain point in their lives. such as the International Classification of Functioning.) APPLYING THE PHILOSOPHY TO DIFFERENT 3. has great promise in helping us understand the impact of To illustrate this. This can conference I gave to the New Jersey Speech and Hearing only be done through consideration of environmental fac- Association in 2001 on the applications of the new disability tors. marizes principles of practice using disability model notions. availability • Time constraints • Ongoing services SLPs from life functions • Time constraints • Excessive paperwork (payment) applying the (swallowing. 1. SLP = speech-language pathologist. . Remember that the consequences of aphasia are that can be identified across health-care sectors. Disability model principles and frameworks. The life consequences approach can be applied The participants in the New Jersey Speech and Hearing in all of these contexts and should not be relegated only to Association conference offer clinicians a first look at targets home care. home care. could be applied to the different clinical contexts. (Suggestions from participants at a New Jersey Speech and Hearing Conference. I will use the suggestions pooled from a aphasia as lived by individuals in different cultures. All those affected by aphasia are entitled to service. Emphasis is on availability of services as needed at all centers to long-term care facilities to independent clinics to stages of aphasia.qxd 1/21/08 12:45 PM Page 369 Aptara Inc. Chapter 13 ■ Focusing on the Consequences of Aphasia: Helping Individuals Get What They Need 369 TABLE 13–1 Applying The Philosophy (continued) Community-Care Acute Care Rehabilitation Settings Long-Term Facilities Settings Availability of • Lack of SLP • Accessibility to service • Insurance • Counselling services service • Productivity issue • Insurance • Staffing issues for adjustment • Lack of staff/MD • Transportation • Time constraints • Aphasia groups knowledge • Lack of/shortage of SLPs • Shortage of skilled clinicians • Poor communication of client to express needs/goals What would prevent • Priority given to vital • Medicare. The measures of success include documented life enhancement changes.GRBQ344-3513G-C13[349-375]. PT/OT = Physiotherapy/Occupational Therapy. consequences approach to aphasia not only helps us in look- a life consequences approach can be just as appropriate in ing at the impact of aphasia on an individual’s life but also acute care as in home care. The life felt the minute the person has survived the stroke. breathing) • Ability • Travel time philosophy? • Lack of objective documentation • Lack of funding • Lack of employer support Key: IADLs = Instrumental Activities of Daily Living. By helping individuals with aphasia and their loved models. this book). Table 13–1 summarizes their suggestions. therefore. Disability and Health (ICF) and the lesser-known 2. ’s Canada. Hence. aphasia also lives with the impact of aphasia. Are there any other professionals you would like to to enjoy a variety of outdoor sports.H. and friends should be 2. (b) i. Words 6/6 (3) tions of handicap that change over time rather than as F. Questions 48/60 diminishing environmental obstacles or encouraging ii.’s husband is present but environment? What might hinder integration? very involved with his work. b. Repetition 33/100 first three. Before her CVA. iii. Naming (Western Aphasia Battery) 6/60 tion or create obstacles to integration and. iii. Sentence completion 2/10 foster development yet facilitative enough to reduce v. ACTIVITIES FOR REFLECTION AND DISCUSSION Use the elephant analogy in the chapter to help you reflect on this. ii. Dictation (sentences) 3/10 6. This has now become impossible since the using the principles from the ESOPE model. Name and address 6/6 5. Spontaneous writing (paragraph) Unable that are applicable to all human beings. 5. Lexical access 2. Words 58/60 environmental facilitators. colleagues. and life participation activities and roles in S.H.H. ii. S. What kinds of things/people might be helpful in the request for independence. and having on their relationship? How much is unrelated or of late.’s lexical access problem. Now look at the daughter’s perspective.H.H. iii. Fluency 0/20 The environment should be challenging enough to iv. Identify the personal factors. How are you going to monitor the changes in S. worked as a policy analyst Disability Creation Process Model (DCP). Look at the interview guidelines to S. S.H. they used 7. She is ship? What impact do you think the aphasia per se is the parent that is most involved with her daughter. factors.qxd 1/21/08 12:45 PM Page 370 Aptara Inc. Dictation (words) 7/10 capabilities. Social and physical environments can facilitate integra. considering her participation levels? 8. E. The most efficient way to keep life participation goals 3. D.H. She is mar. Spontaneous language 6/20 can help to identify whether the focus of therapy B. Reading comprehension 3. 370 Section III ■ Psychosocial/Functional Approaches to Intervention CVA. she and her daughter have been experiencing due to non-linguistic factors? some parenting conflicts surrounding her daughter’s 6. 4. Current disability models are meant to use concepts ii. Use the disability models to help you Use the following hypothetical case to help structure your identify the types of information you would need to answers to the following activities and thoughts. Naming (Boston Naming Test) Unable can be a focus for intervention just as capabilities can. 7. such as iv. Writing permanent states. spouses.H. The individual who interacts with the person who has 1. environmental factors. canal (a 7-km skating surface) in Ottawa. Responding to questions 1/10 frustration. Commands 8/20 4. Commands 41/80 to define new life goals. . should also consider the psychological G. leaving her with a hemiplegia and aphasia. mother’s new health condition affecting their relation- ried and has one adolescent child aged 15 years. S.’s difficult relationship with her daughter and her (in)ability to return to work. S. i. therefore. Problems in life participation should be seen as situa. Think about how you would design your therapeutic in focus is to work within an interprofessional team intervention if you wished to focus on: context. which ones? Design a therapeutic plan skating. provide a for the Canadian government. is a 45 year-old woman who fell while skating on the see if you have enough information. They A. Sentences and paragraphs 28/40 with the person who has aphasia. Intervention aimed at the personal factors. such as skiing and include? If so. or (d) any combination of the C. i. plan your therapy. a. S. How is her She has no remarkable past medical history. How would you design your therapy for the personal the focus of intervention when appropriate. When possible.GRBQ344-3513G-C13[349-375]. (c) helping the individual iii. Apraxia 46/60 impact of the disorder on the individual. She was found to have had a left frontoparietal participation with her daughter and at work? hemorrhage. children. good starting point for understanding the relation- ship among all the factors that contribute to helping Her language testing reveals the following: individuals reenter their lives following aphasia. c.’s language and communication skills as a whole.’s case. Goals of therapy should be identified in consultation i. Ontario. Oral comprehension should be on (a) regaining language abilities. 419–424. & Stiell. & Herrmann. 7. Aphasiology. N. 111–129. L. Castelein.H. P. synthesis. S. (2006). (2003). L. 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Kearns. & Kagan. “Advancing appraisal: Aphasia and the WHO”. Quality of life with and without Craig Hospital. Aphasiology. L.. Charlifue. B. (2005). Worrall.. C. 39–50.. F. N. D. Threats. “Advancing appraisal: Aphasia and the WHO”.. & Potechin.. R. & Parr. Geneva: World Schlosser. E. Journal of Communication Disorders. U. Aphasiology. Chapter 13 ■ Focusing on the Consequences of Aphasia: Helping Individuals Get What They Need 373 Noreau. G. SF-36 Health Pulvermüller.). Drawing to com- Pound. Journal of Communication Press. S.. L. Whiteneck. Wertz. (2005).. Disability and Health (ICF). S. D. 251–265. & Trask. Advancing appraisal: Aphasia Health Organization WHOQOL-BREF quality of life assess- and the WHO. S.. Analyzing single episodes of interaction: World Health Organization (1980). C. 1362–1369. B. J. Disorders. 320–327. (2000). (2005). M. Development of a stroke-specific quality of life York: Whittlesey House... Fougeyrollas. & Roth. Brooklyn: Lippincott Williams & Wilkins. J. Lindsay. F. C.. Social approaches to aphasia Organization. 28. Jette. (2004). 95–105. Aphasiology. Desrosiers. N. for planning therapy for aphasia. C. Fougeyrollas. aphasia. T. F. aphasia. J. 885–893. (1998). B. 30. & Gandek. (1991). 551–558. (2001). S.. & Cruice.. 266–288. L. L. 355–364. John Godfrey Saxe’s Williams. R..). handicap assessment and reporting technique. classification relating to the consequences of disease. & Duchan. ties. (2001). 33(1). Disabilities. Development of the The World Ross. Why the WHO ICF and QOL Simmons-Mackie. Brodie. 477–493. (2005).. Technology and Aphasiology. (2003). Conceptual models of disability: Past. & Worrall. C. Thommessen.. Philadelphia: Open University munication disorders: Use of the ICF.. Guide for use of the CHART: Craig adults. T. A. N. D. 17(4). 23. Aphasiology. 30. A. Shadden. Who’s tired of the WHO? A commentary on Ross Verderber. Well-being and instrumental activities of daily Perspectives? Folia Phoniatrica et Logopaedica. Pictures by Paul Galdone. Geneva: World Health Simmons-Mackie. Weinberger. Assessment of the quality of social participation. K. Metric Inc. intervention.. T. 53–62. (2004). G. Field. University Press. Simmons-Mackie. 246–268). Measuring social partic. T. 217–239.. T. Using partners’ autobio.. therapies for living with communication disability. (2005). K. Duchan. Psychological Medicine. J. Advances in Speech-Language Pathology. S. (2004). (2004). Disability. B. Language intervention strategies Worrall. 18. Aphasiology. Chapey (Ed.. A. R. in aphasia and related neurogenic communication disorders (4th ed. T. as a driver) .. & Bourgeois. Does anybody help you with handling emotions? Housing/Living at Home • Friends • Therapist Q1. school cafeteria.GRBQ344-3513G-C13[349-375]. & Yiu. 19(3/4/5). 374 Section III ■ Psychosocial/Functional Approaches to Intervention and the activity/participation components of the ICIDH-2: Do Wright. accommoda- Q4.2. 435–450.)? • Medication intake Q6. Can you get around your home and in your neighborhood for Q3.. J. L. K. (2005). 107–137. How is your mobility when traveling long distances? • Are services available to you? • Using transportation (as a passenger. L. teeth. whether a person does not do • Anger the activity by choice.. Aphasiology. Do you require any type of special equipment. yoga. D. Brennan. 911–924. preparing food (appliances.1 Interview Guidelines for Looking at Functioning Notes to Interviewer: Q4. L. 923–929. recipes) • From sitting to standing • Use of utensils? Feeding aids? • From standing to lying • Do you eat well? • Staying in one position • Balance Personal Maintenance Q6. Social Change.. • Sadness 2. or ser- • Physical conditioning (relaxation. buying food (restaurant. ani. Any problems handling different emotional situations? • Frustration 1. A. L. Human development. & Fergus. clothes) • Acquisition and adaptation of residence • Dressing • Management of home and possessions (furnishings.) etc.1. M. people with aphasia. APPENDIX 13. wheelchair. Neault. sleep) vices to help you move from one place to another • Use of health-care services and resources (walker. Do you have issues related to your personal appearance and nologic help? Any human help? cleanliness? • Cleaning and laundry • Washing (self. Disability and Worrall.1. Items indicated with bullets are suggested areas to explore. • Happiness Q4.. Who do you live with? • Family Q2.. (2000). M. Holland.. in all areas.qxd 1/21/08 12:45 PM Page 374 Aptara Inc. 14(9).. distance to services)? • Stress management and behavioral modification Q6. Aphasiology.. M. & McKenna. (2005). J.. Aphasiology. they reflect what really happens in real-life? Journal of Use of the Disability Creation Process model in the evaluation Communication Disorders. G. nication therapy by volunteers for people with aphasia follow- ing stroke. • Toileting mals. of language in dementia. Are you able to take care of your house/apartment? Any tech. etc. It is important to ask. J. Worrall. A. fitness. (2002). pets) • Technical or human aids? • Paid home adaptation services? Mobility Nutrition Q6.3.2. Rose.. Muñoz. 35. Oxenham.. Access to written information for Youmans.. Howe. M. Effectiveness of functional commu. L. 11(1). • Running store). 19(10/11). Q5. T. E. special transportation services. How would you consider your physical and mental health? tions. 36–54. Script training and automaticity in two individuals with aphasia. S. • Health promotion (eating well. Do you have physical limitations that require modifica- tions to your environment (accessibility. Egan. Do you have any difficulty with your daily nutrition needs? short walking distances? Any meal providing services? • Walking • Getting food. Garcia. GRBQ344-3513G-C13[349-375]. your civil and • Social life (activities organized by the community) family responsibilities? Have your social roles changed? • Community associations or groups (scouts.2. that you would like to change? What would be your number of hours. What is your main source of income. lighting. political. part-time) Q14. To what extent can you communicate with others? When do Education you encounter difficulties? What strategies do you use to overcome these difficulties? Q11. hearing aids. Do you have prob. self-help groups.1. are there things that the teacher can do to help you Q8. Do you need any special technical or human aid? Q7. etc. ber of colleagues.) Q16.) to the bank) • Spiritual life or organized religion • Citizenship (social.) priorities? . To what extent can you participate in any type of work or isfied with it? employment? Q13. and are you sat- Q10. Do you receive any additional financial assistance • Work preparation (seeking employment) from your family. or private • Self-employment programs? • Remunerative employment (full time.1. • Economic transactions and self-sufficiency (budget. etc. Do you like school? Q7. at home. What is your involvement in all aspects of your community? Q13. Describe your relationships with people. Work spouse) Q13.1. etc. Use of communication devices and technologies? Q11. Do you receive support or assistance (encouragement) Leisure from people? • Spouse/intimate partners Q12. and legal role of a citizen) • Family (care and responsibility of others: parents. governmental agencies. Any general comments about attitudes and support from • Nonremunerative work people? Q10. Are there things in your physical environment. Chapter 13 ■ Focusing on the Consequences of Aphasia: Helping Individuals Get What They Need 375 Communication/Exchange of Information Q10. Do you need any special technical or human aid (adapted classroom.2.1.1.2. How do people react to you when you communicate? Q11. Do you have problems managing your finances. learn? lems initiating and/or maintaining relationships? Q8. change. at • Colleague support and attitudes work. etc.)? Interpersonal Relationships • When something is difficult to understand at school. Are you satisfied with your quality of life? Is there anything • Organization of tasks (workload. children. going political party. Are you involved in any form of leisure activity? • Children • Sports • Friends • Arts and culture (music) • Work colleagues • Cinema/theater • Family • Games • Strangers • Hobbies • Home-care providers • Travel (including preparing trips) • Health professionals • Socializing Community Life Responsibilities/Finances Q9. How do you manage in school? • Spoken • Trouble understanding what’s going on in class • Written • Friends at school • Sign language • Organization of class activities • Nonverbal • Problems with any subjects • Body language • Taking notes • Public symbols • Exams • Drawings and photographs • Extracurricular activities Q7.2. or in other public places that you would like to • Physical environment at work (noise. Are you satisfied with your work and work environment? Q15. num. change in duties.qxd 1/21/08 12:45 PM Page 375 Aptara Inc. Descriptive accounts of group interrelatedness and complexity of therapeutic goals in therapy and its benefits abound in the aphasia literature group treatment of aphasia should be kept in mind during (Agranowitz. Tonkovich. Brindely. Pachalska. 1987. The Life Participation Approach to Aphasia (LPAA Project Suggestions will also be provided regarding the future role of Group. Aronson. Similarly. 1997b. the pur. Psychosocial factors Marquardt. Corbin. Martyn. In general. & Terr. 1999. 1954. Radonjic & Rakuscek. & The need to synthesize the group treatment literature. 1982. 2001).” information in the literature on facilitating generalization. Unfortunately. 81). 1999. 1997a. 1999a. 2007. Inskip & Burris. 1999b. further articulated this per- speech-language pathologists in this area of rehabilitation. Linell. aphasia. of course. 1989. Chenven. speech. Seacat. 1999b. how. because communication and psychosocial for a compete description of this framework (WHO.qxd 1/21/08 12:52 PM Page 376 Aptara Inc. and lowing parameters: psychosocial adjustment. Group therapy has remained a com- mon method of treating aphasia both in the United States and Roberta J. 1999a. The WHO framework seeks to integrate language treatment. 2007. most aphasia groups focus on one or more of the fol. Elman & Bernstein- describe current clinical practice. Holland. ment approaches that can be both clinically useful and exper. & Devault. relatively few pro. changes in reimbursement and public policy (Frattali. factors are intricately related and improvement of one factor Of course. has more recently been established. 1991a. Disability. & Wahrborg. Demain. Therefore. 1956. Schlanger & Schlanger. interest in the broader aspects of recovery may affect the other (Marquardt et al. few objective studies have supported fessionals were specifically trained to provide clinical services these claims. 2005. 2000) (see Chapter 10). 1976. Kearns and sitated group treatment. cial approach. and develop specific treat. 1976). Therefore. Marquardt. 1973. 1989). Ruff. Frattali has noted. Chapter 14 Group Therapy for Aphasia: Theoretic and Practical Considerations Kevin P. Nielson. International Classification of Functioning. or ICF. medical and social models of medicine using a biopsychoso- Fawcus. This clinical taxonomy is. 1999b. “We must remember The content and focus of group therapy for aphasia is that human communication sciences and disorders is a disci- predominantly a function of the skills and biases of the pline dedicated to improving the quality of life of persons group leader (Elman. Gordon. and the efficacy of group therapy for aphasia for individuals with aphasia. 1980). Schultz. Elman. Tsvetkova. 1989. and burgeoning caseloads neces. 1991). Health. the from aphasia are not new. Ironically. 1970. Pachalska.GRBQ344-3513G-C14[376-400]. with communication disorders” (p. 1947). 1970. spective. At that time. Marshall. Ellis. Elman abroad (Fawcus. Lyon (1992) imentally validated continues to exist. some. 1992) as well as a renewed interest in psychosocial OBJECTIVES aspects of recovery from aphasia have stimulated a renewed interest in group treatment (Avent. & Crittsinger. Although the results of 376 . Borenstein. Wepman. 1953. communicative goals into the endeavors and should use treat- spective on group therapy for aphasia that is consistent with ment plans that facilitate or encourage “participation in life. The reader is referred to the WHO publication what arbitrary. the following discussion of group treatment approaches. 1976). Boone. and/or counseling (Eisenson. 1959.. Shatin. & Cook. Advocates have claimed that group inter- Group therapy for aphasia evolved in the United States as a vention results in widespread changes in speech and lan- practical response to the large influx of head-injured veterans guage skills as well as increased psychosocial adjustment to returning from World War II. are classified in the World Health Organization (WHO) ever. argued that clinical aphasiologists broaden their clinical per- pose of this chapter is (a) to critically review and summarize spective by incorporating psychological as well as functional the aphasia group therapy literature and (b) to present a per. 1948. 1991a. Copeland. Before the recent publication of texts that focus on 1947. Caligiuri. cation. procedural specifi- Jenkins. Thompson. and they included (a) using rhythmic changes in people with aphasia (Van Harskamp & Visch. (d) partici- intervention. minimal attention to subject description. Dolphin. tinuum in an attempt to facilitate group discussion.. 1982.. From a concep. Elman & aphasia can ventilate feelings and learn to cope with the psy- Bernstein-Ellis.g. (c) role playing other individuals. 230) through the to group management have been distinguished in the aphasia use of (a) gesture and pantomime. 1992. pating in various speech games and discussion of proverbs. In addition. 1974. sion of the procedures employed in group therapy Earliest reports of psychosocial group treatment gave (Brookshire. have direct among group members.. Radonjic & Rakuscek. 1999a. few critical summaries of the group treat. Jimenez-Pabon.. 1981. and life participation assessment tools ably to the treatment program. (c) Brink. ium. ratings revealed that the patients and staff reacted quite favor- chosocial (Lyon. Another early report of psychosocial relevance to group intervention for aphasia. were introduced as needed to maintain motivation and facil- 1982. is finally evolving into specific. descriptive labels. (1956). Tasks in the hierarchy ranged from non- tual perspective. More important. recent interest in broader rehabilita. aphasiologists have only recently given cedures of these groups emphasize interpersonal relation- attention to this important area of clinical investigation. personal. 1981). (b) role playing one’s self in literature (Marquardt et al. Davis & Wilcox. Results of interviews and clinical for reliable and appropriate functional (Frattali.qxd 1/21/08 12:52 PM Page 377 Aptara Inc. 2007. 1999a. 1996. brief descriptions of group treatment and minimal discus. Oradei & Waite. Eisenson. because clinical aphasiology textbooks contain only Redinger.. 1992. 1989. chological impact of aphasia. the purpose and procedures discussed in As Schlanger and Schlanger (1970). calls hourly treatment sessions. LaPointe.GRBQ344-3513G-C14[376-400]. and psychological bonds that help group members to cope Elman. 1992). 1948. 1995). Godfrey & Douglass. and (d) more similarities than differences. Forster. The effectiveness of this approach was evaluated for 21 comitant emphasis on methodologic issues may provide a chronic and acute patients who attended an average of 14 procedural framework for group therapy. They recommended the use of role playing GROUP TREATMENT APPROACHES as a method for reducing anxiety about communication and establishing spontaneous. clinical aphasiologists have begun to appreci. tal. Consistent with the trend could not be elicited. 1989. music rhythm group) to solely verbal (e. ate the complexities associated with facilitating generalized group discussion). 1959). group therapy notable for its attempt to outline specific group treatment procedures was provided by Schlanger and Schlanger (1970). Marquardt provided a detailed description of a “social-psychotherapeutic” et al. toward a more ecological approach to intervention. 2001). Chapter 14 ■ Group Therapy for Aphasia: Theoretic and Practical Considerations 377 recent investigations indicate that group therapy is an effec. 1999. musical instruments. itate group interaction whenever adequate group discussion 1999a. reported gestures and reports of sociotherapeutic and psychotherapeutic group pantomime were employed to enhance the communication . 1973.and intra-personally” (p. These with the consequences of aphasia (Ewing. 1976). ships while providing social contacts with other persons who Renewed interest in group therapy for aphasia is reflected in are “in the same boat. social. group treatment. 1997a. functional discourse in the group Psychosocial Groups setting.” The primary purpose of psychosocial recent publications that specifically address clinical goals aphasia groups is to foster the development of emotional and procedures for group intervention (Avent. Activities from the hierarchy suggestions for both individual and group therapy (Aten et al. and (f) taking part treatment. That is. 1952.g. 1981. & Sefer. (b) participating in group singing. 1981). testable treatment in group-centered discussion. and a heightened ability for constructive self-criticism Pimentel. 1989. and allow patients to develop interper- framework that heretofore had been lacking. Shaw. Avent. 1982. Sarno. these approaches share realistic situations. however. 1971. 1991. 1992). the goals and pro- Wertz et al. ment literature were available (Fawcus. an increased level of intra- generalization planning approach to intervention (Garrett & group. provide tion goals has occurred within a conceptual and methodologic an emotional outlet. Inskip texts are a welcome addition to the clinical armamentar. psy. & Burris. which considers the complexity of environmen. Luterman. & provide a supportive atmosphere in which individuals with Holland. 2007. Kearns. an ecological perspective on listening to short stories read by a group leader. Psychosocial groups tive form of aphasia management (Aten. 1959. Vickers. For example. 1989). as well as the development of a observed a reduction in anxiety. 1999. 1976). Darley. therapy are often indistinguishable. 1999b. verbal (e. or evaluation of treatment results (Backus & Dunn. Godduhn. a con. They developed a task con- treatment procedures. Blackman & Tureen. & Wersinger. 1950. Elman & Bernstein-Ellis. emotional. 1999b. despite differing psychodrama. 1998). Their primary purpose was to “try to ‘get something Although psychotherapeutic and sociotherapeutic approaches across’ both inter. approach to group therapy and attempted to evaluate the While recognizing the need for empirically based group effectiveness of such a program. Blackman.. 1991). sonal relationships. Brindely et al. 1997b. Marshall. The group leaders also (LPAA Project Group.. 1989). 2007. Yalom. Aronson et al. and communicative factors on (e) taping and replaying speech samples. a pants by age is a useful clinical strategy. compared with the end of the psychosocial group. met once a week for 2 hours. patients assumed roles behavioral strategies. purpose in life. a feeling of accomplishment. Although improvement was measured tives. (1989). Formal assessments of the family members’ psychologi.g. Linell. In and neurologic effects of a 5-day. The verbal skills to depict people in contrived scenes from a bak. met a total of 16 times. During this activity. some improvements in psychological and interpersonal the authors note that the design of this study is flawed and adjustment but not in neurologic or communicative status. and using “universal” iconic gestures.GRBQ344-3513G-C14[376-400]. The authors reported that partici- A final aspect of the group treatment program used psy. 378 Section III ■ Psychosocial/Functional Approaches to Intervention of chronic patients with aphasia who had severely limited diminished after 10 years. members showed significant change on all scales except for ducted 1 year after the intensive treatment period revealed “environmental mastery. tions with others did not show significant change. The content of mental mastery. total treatment time for each subject was not reported. a florist. pants had higher degrees of self-esteem following participa- chodrama to act out the problems and frustrations of each tion in the group treatment and were able to use “new group member. chosocial changes following participation in their community- cluded that role-playing activities provide an important based program offered to people with aphasia following means of adjusting to the psychosocial impact of aphasia. run communication groups twice weekly for half-days. Thirty-five clients with aphasia attended volunteer- (1987). the use of descriptive gestures to transmit information about however. Unexpected events were blended into everyday experi. 1998. Following gesture and pantomime training.. and so on. linguistic. Hermann. patients used pantomime and guage pathologist. which measure autonomy. Nonstressful situations included focused on aspects of coping with aphasia and its conse- activities such as shopping or attending a picnic. The tion. & participated in role-playing activities involving nonstressful Wallesch (1993) reported on their aphasia groups that and stressful situations. Content of the tion. Results indicated that clients with aphasia showed positive cal adjustment and of the participants with aphasia’s language changes on the scales. The authors concluded were noted. Borenstein. and group discussions of everyday problems and results for family members were also encouraging. loss of emotional inhibition. and one for elderly interact with a clinician in a “Candid Camera”–like situa. Gestural and pantomime training included showed a more severe aphasia at the 10-year follow-up. self-acceptance. younger group met a total of 22 times. participants (seven members. a reduction in anxiety concern. exchange about psychosocial burden. treatment time in the program members attended the group. seven of the eight participants reported that their pictorial referents. Penman and Pound developed a short-term.qxd 1/21/08 12:52 PM Page 378 Aptara Inc. does not permit an objective assessment of the benefits of A 10-year follow-up study involving eight of the original group intervention. Hedber. the patients Johannsen-Horbach. Role quences. Wenz. Penman. Eleven participants with aphasia and seven family over a 6-month period. The scale designed to assess positive rela- social excursions that encouraged functional communica. tasks from a verbal/visual memory training program. family adjustment strategies. Reevaluations of the participants con. tion. participants (Wahrborg. Two groups were described—one for younger par- playing in stressful situations involved having patients ticipants (eight members. self-advocacy Borenstein. gist. intensive residential treat. In addi- speech-language pathologist. a psychologist. and Another aspect of this approach involved having the indi. Borenstein et al. Patients demonstrated an increased ability to that their observations support the usefulness of psychoso- cope with stressful situations. & Worsley (1997) reported on psy- feelings and problems. Funfgeld. Thelander. ages 26–51). and the intervention program included family-centered therapy. cial groups and reinforce their belief that separating partici- ing communication deficits. condensed form of psychological scales of well being cial goals within the aphasia group setting. ages 60–80). 12 family members. which were led by a psychologist and a speech-lan- situations. a social worker led caregiver support groups with ment program for participants with aphasia and their rela. Their study evaluated changes on a More recent clinical reports have also targeted psychoso. & Asking. pantomiming daily activities such as quality of life was improved at 10 years post-treatment as mailing a letter. environ- ability and neurologic status were conducted. During this activity. Schlanger and Schlanger (1970) con. 1997) found the improvements that group for people with aphasia at the City Dysphasic Group had been achieved at the end of the course of treatment were at City University in London (Pound. The viduals with aphasia role play other people during simulated groups. gies (e. group treatment included interactional and conversational ences so that the patient had to problem solve and commu. addition. and the elderly group ery.” The authors stated that younger par- that allowed them to vent feelings and release hostility. PACE [Davis & Wilcox. Sessions were conducted by a before enrollment in the study was not controlled. communication strate- nicate in a natural situation. 1985]). for example. and a better insight regarding Hoen. and several benefits of the program efforts on communicative deficits. All but one of the participants verbal abilities. role playing. stroke and head injury. . personal growth. examined the psychological. and a neurolo. ticipants had more difficulty accepting their deficits as com- The aphasia group members gradually progressed through pared with the elderly clients and wanted to focus their the four facets of training.” Despite these positive findings. 1947. Degiovanni. Byng et al. These authors summarize information regarding group process. facilitated the groups. 1993. with few notable exceptions (Aronson et al. Rice. financial status. 1959. (3) affirmation and validation. 1974). cial group therapy for aphasia. techniques that need adaptation when working with mem. Blackman & Tureen. the emotional. group sessions start with a sharing time. assessment and anecdotal observations. 147) once a family cial group therapy provides psychological. Both authors emphasize group aphasia have also been documented (Friedland & McColl. and (12) celebration of change. 1956. emotional. 1959. No formal agenda is specific. He concluded that family social benefits for individuals with aphasia. Schlanger followed by breakout sessions for survivors of stroke and sig. 1987). She noted how the parameters are substantial. Shadden. Lafond. tity. Participants also reported feeling ature. and sharing updates and life stories. 1978.. aphasia (Aronson et al.. Inskip & Burris.” orous (Aronson et al. Hoen et al. Godfrey & Douglass. Useful supplements to the specific psychosocial treat- ment programs outlined above are provided by Elman Family Counseling and Support Groups (2000). Shadden listed 12 core values of the group: treatment principles or procedures for conducting psychoso- (1) respect for the concerns and competence of each mem. The course ran for 10 weeks with 2-hour sessions. originally established in 1982. Post-treatment findings of most reports in this area are based on subjective evaluations suggested that group members felt more confi. therapy remains largely an undefined entity. followed.” The NWA includes survivors of stroke. and those that have been reported have not been rig- an increased sense of social participation and “belonging. and speech-language pathologists must be aware of when facili. bers who have neurogenic communication disorders. 1971). and (2) to develop a positive cope with emotional and life-style changes resulting from personal identity that was inclusive of aphasia and disability. (2) acceptance. 1976. Lyon. Kinsella & Duffy. Ponzio. failure to meet minimal psychometric standards limits the bers.qxd 1/21/08 12:52 PM Page 379 Aptara Inc. a supportive atmosphere in which individuals consequences. 1979. the Stroke Support Group of Northwest Arkansas culties involved in measuring psychological and social (NWA). Johannsen-Horbach et al. (6) reflection them into clinical practice (e. had improved self-esteem. Pound. 2007). Backus & Dunn. Shadden (2007) described an ongoing monthly support Oradei & Waite. 1997.. Eight individuals with 1998. The group setting is frequently used for . Marquardt et al. psychological. and Oradei & Waite. hostility. Specific benefits counseling programs are needed to help spouses and family that have been reported include an opportunity for increased members learn about aphasia and cope with its devastating socialization. 1970). 2007). 1998. Data-based studies dent. putting the survivors of stroke first. aphasia.g. instead. 1956.GRBQ344-3513G-C14[376-400]. attempts have been made to document the effectiveness of The rules and routines that characterize the NWA include psychosocial treatment groups (e. & Sarno.. aphasia. and psychosocial group clean slate. usefulness of these efforts. 1974. Redinger et al. In addition to the psychosocial adjustment difficulties of group dynamics. & Schlanger. near-unanimous agreement regarding the benefits of psy- ing personal interviews and personal portfolios that had chosocial group treatment. Schlanger & Schlanger. thereby renegotiating “self and iden. when (11) interaction oriented. 1948. it should be cautioned that the been developed by each group member. Paul. (5) feelings are okay. Godfrey & chronic aphasia participated... (7) flexible goals. and Luterman (1996). 1993. investigators have not delineated specific nificant others. focusing on new mem. Parr et al. 1956. the vehicle for working on many different issues... a pressing need exists to begin group has evolved into a community in which members evaluating the psychosocial impact of group treatment for exchange life stories. Although the psychometric diffi- group. with aphasia can express anger. Chapter 14 ■ Group Therapy for Aphasia: Theoretic and Practical Considerations 379 2007).. autonomy. (9) participant oriented.. (10) focus on the story. and other group considerations that individuals with aphasia. 1987). and member was stricken by aphasia. 1961. 1970. replicable treatment procedures. Summary and Observations Malone (1969) observed that “in most cases the family as a The literature contains a general consensus that psychoso. Borenstein et al.g. 1993. and were more positive are practically nonexistent in the psychosocial group liter- about living with aphasia. 1997. 1971.. 1989. & Müller. leisure life. Oradei & and problem solving are encouraged. (8) a Waite. Friedman. 1973. self-esteem. 1950. Ewing (1999.. 1998. More than 30 years ago. Friedman. Malone. 1961. Moreover. both with and Prerequisite to the establishment of a solid database for without aphasia. (4) actions do not provide the procedural detail necessary to translate speak louder than words. including Johannsen-Horbach et al. closely knit unit no longer existed” (p. a speech-language therapist and a person with Blackman. life-style changes for family members of individuals with tating treatment groups. 1969. communication.. Redinger et al. Despite The outcomes of the therapy were evaluated by examin. 1974. Group discussion was used as Douglass. Joanette.. as well as family members or others who this approach to aphasia management is the development of are dealing with the impact of stroke. Unfortunately. Eisenson. Descriptions in the literature ber. and the development of skills that allow patients to barriers in the environment. and other emo- The focus of the group was twofold: (1) to identify disabling tions. Two people. 1959. Still. & information and guidance as needed. Mogil. Kisley. They also serve as a forum for expressing feelings and learn. and with aphasia and their families about the nature of aphasia worked through problems that occurred as a result of the and to explore the impact of aphasia on family dynamics. The this study. “We are all better view of family problems. the clinicians for the experience” (p. Bernstein During the second stage. which met on a weekly basis for 1 year. speech-language pathologist discussed the nature of aphasia. Meetings were held changes. in aphasia literature (Davis. Derman & Manaster. Bernstein also indicated that the team leaders bene- social environments. 1976. Gray. aphasia. Following this early report. to accept nonverbal communi- spouses. Redinger et al. and a psychiatrist). Psychosocial aspects of Lefkowitz. As the group evolved through these stages. the group evolved into a friendly. for example. (1971) subsequently described a multidisciplinary discus. Newhoff and Davis (1978) reported their attempt to Many reports of spouse counseling groups highlight the objectively plan and implement a spouse intervention pro- importance of planning treatment to meet the specific needs gram. per session. patients with aphasia. and a questionnaire was . The group counseling for families of individuals with aphasia. the area of rehabilitation was the prognosis for recovery of language skills. shifts in family roles. understanding. Newhoff & Davis. and group members between patients with aphasia and their wives may interfere experienced difficulty communicating with one another. family members. cation. Spouses were individually interviewed to deter- spouse counseling group of Gordon (1976). hindered communication with their husbands who had apha- cussions. 35). The group. providing a list of “do’s and don’t’s” and then discussing participants gradually became better adjusted to home and them. 1978. ing area. The ultimate goal of the group was to improve the Counseling groups provide a medium for discussing physi. helped to alleviate many of the wives’ emotional problems. Gordon. six patients with and formal psychotherapy was seldom required. and their spouses. gist. which wives increasingly assumed more responsibility for the Friedland & McColl. Turnblom of resignation. Bloom. adjustment addressed by the social worker included feelings 1977. The group provided an atmosphere in Brookshire (1997) notes that the primary objective of which spouses acquired a better understanding of aphasia. 1973. guilt. and not meet the complex emotional needs of spouses simply by supportive unit. he stated. with speech-language treatment. Porter & Dabul. Puts-Zwartes. the members expressed regrets believed that the family unit itself may be endangered if we about their condition and complained about various factors ignore the emotional and psychological trauma suffered by associated with rehabilitation. He stressed that interpersonal problems Initially.qxd 1/21/08 12:52 PM Page 380 Aptara Inc. The Examples of family counseling groups abound in the co-leaders adopted a nondirective counseling approach. 1989. Finally. be necessary for spouses to difficulties that were shared by the patients with aphasia and receive maximum benefit from group treatment. and strategies virtually neglected for approximately 20 years. and they developed a more realistic fited from the group as well. 1978. lems discussed in the group inevitably involved adjustment Some redundancy may. mine target areas for intervention. a period of anxiety occurred. Four spouses. In addition to these benefits. and loneliness. because prob. More important. Gordon aphasia. tional adjustment and to help the group members work Gordon (1976) concluded that wives’ emotional problems through family and social issues using problem-oriented dis. two male and two female. Brookshire observed that patient-family and on a weekly basis.GRBQ344-3513G-C14[376-400]. 1967. 1971). The purpose of the group was to facilitate emo. consisted of several co-leaders (a speech-language patholo. Redinger et for improving communication with their partners who have al. during the third spouses and other family members. and social consequences of brain damage. The group. family support or counseling groups is to educate patients felt free to express feelings and share their reactions. Participation of the spouses was cautioned that multiple repetitions were often needed before viewed as a critical element in rehabilitation. and to modify their input to their partners with aphasia. and attendance ranged from 4 to 10 spouses spouse support groups also function as a social or recre. He stressed that we can- stage. aphasia. therefore. and four spouses. sia before participation in the group. in the group varied from several months to 3 years. 380 Section III ■ Psychosocial/Functional Approaches to Intervention counseling and educating both patients with aphasia and developed in response to the needs expressed by wives of their families. Wives were encouraged not to demand verbal sion group for patients with severe aphasia and their responses from their husbands. Johannsen. psychological. the wives comprehended group-counseling information. A speech-language pathologist and a psychiatric social ing to adjust to newly acquired family roles and life-style worker acted as co-leaders for the group. 1993.. 1973. and Myers (1952) provided one of the earliest examples of and the need to maintain interests outside the home. Bernstein (1979) also described a multidisciplinary spouse Redinger and colleagues (1971) observed that the group group that evolved out of concern for the emotional needs of evolved through several stages during the course of therapy. however. participated in of individual patients with aphasia and their families. interpersonal relationships of the individuals with aphasia cal. 1992. their spouses. a psychiatric nurse. counseling group also provided a social outlet for patients Recognizing the scarcity of studies in the aphasia counsel- and spouses. The duration of individual spouse participation ational outlet for individuals with aphasia and their families. content and direction of the group while the leaders provided Horbach et al.. . Chapter 14 ■ Group Therapy for Aphasia: Theoretic and Practical Considerations 381 administered both before and at the termination of the study Their model conceptualizes social support as having three to evaluate the effectiveness of the program. priate answers on a seven-point rating scale that ranged from 2007. & “very often” to “never. and Friedland and McColl (1989) attempted to operationalize support for people with aphasia and their families. and the tate communication between persons with aphasia and their need for counseling persons with aphasia and their families spouses. Bernstein-Ellis & Elman. pose of this 12-week group was to provide information and The devastating effects of aphasia on interpersonal rela- social support. (c) facilitate the spouses’ acceptance of their own feelings and help them to accept and understand Summary and Observations their partners with aphasia. topic- ability of patients with aphasia whose spouses regularly oriented discussions should be accompanied by printed attended versus those whose spouses did not regularly counseling information and/or appropriate audiovisual attend. (5) actual level of spouse understanding. The authors reported significant improvement on is unassailable. Hersh. leagues (2007) provided a detailed description of a 12-week sion once a week for a period of 7 weeks. exists scales of psychological adjustment for those individuals who regarding the best format for accomplishing counseling consistently attended the group. (b) receive to overcome communication breakdowns. (4) family.” Podolsky. and emotional adjustment. although the measurement ented discussions that center on issues of communication problems involved in evaluating group counseling are diffi. Their parsing of social support has spouse-partner independence. Newhoff and Davis (1978) concluded have acted as group co-leaders for aphasia counseling that they had accomplished their primary counseling objec. Sherman. The purpose included the following: (1) sharing experiences of living with of the group was to accomplish the following “counseling aphasia. groups for individuals with aphasia and their relatives has Rice et al. For example. dimensions: (1) source of support. patient-family and spouse groups has been to provide educa- tion. the type of support received may include emotional and ner’s problems. tion strategies. enhance psychosocial adjustment. (2) changes in life style and social pursuits. and (7) advice sought by potential as a taxonomy for future studies of counseling and spouses. (2) increasing understanding of aphasia as well as ways functions”: (a) provide information to the spouses. they are not insurmountable. The family and friends group consisted the direction for the group. friend/ (3) spouses’ feelings regarding their partner’s disability. The the definition of social support for their spouse program. No significant differences objectives in the group setting. The primary purpose of readministered to evaluate the effectiveness of the interven. Relatedly. National Aphasia Association Web site (www. The pur. (6) informational support. Little documentation.qxd 1/21/08 12:52 PM Page 381 Aptara Inc. and life-style changes that affect family dynamics. .GRBQ344-3513G-C14[376-400]. rehabilitation. you . but the spouses provided ily and friends” group. The items in the questionnaire were all “Do support groups. The primary goals of the group discussions and provided information as needed. community. tionships and the family unit are well documented. The leader served as a catalyst for of 15 to 25 individuals. Penman & Pound. Their primary function has been to lead topic-ori- tives. described an edu- evaluate the psychosocial effects of the spouse counseling cational program that included the use of videotaped educa- group. emotional. groups. and The questionnaire examined seven areas: (1) communica. 2007). spouses’ perceptions of how well they understood their part. 2007. the questionnaire was advocated in the aphasia literature. (2) types of support. p. and printed materials. Although this report is noteworthy for its attempt to materials. spouses’ responses. Patient and family counseling groups have been widely After 7 weeks of group counseling. “Do you A number of comprehensive aphasia programs offer care- talk with your spouse as you did before the accident?” giver and family support groups as part of their regular pro- (Newhoff & Davis. partner’s rehabilitation. (3) how satisfied the patient is with the support received. the results must be interpreted cautiously given the tional materials. 2007. speech-language pathologists and psychologists apparent. The spouses circled appro. and no discernible pattern of change was At times. Cohen-Schneider. A speech-language program support and education program that included a “fam- pathologist served as group leader.and post-study tional information regarding aphasia and to provide emo- questionnaires revealed considerable variability in the tional support for individuals with aphasia and their families. Bevington (1985). and (3) finding new information from spouses that might be useful during their ways to live and find hope for the future. The emphasis in counseling cult. Common sources of support may include personal. and (d) effect change in the spouses’ behavior. and facili. A comparison of responses to pre. that promotes public education. However.aphasia. research. 2007. They also concluded that. Kagan. The small number of participants in the evaluation and the lack National Aphasia Association is a nonprofit organization of appropriate experimental control. 1978. for example. lectures. gramming (Beeson & Holland. however. Kagan and col- The spouse intervention group met for a 50-minute ses. one item asked.” questions. and professional resources.org) . Although not specifically were found in the post-treatment functional communication mentioned in most reports of group counseling. 320). group for the spouses of 10 patients with aphasia. (1987) also described their social support been on “working through” the communication. This Speech-language treatment of patients with aphasia has has often been the case with clinical aphasiology. that can be used to support individual or group coun. Many authors have viewed group therapy aphasia continue to be based primarily on clinical experience as being an “adjunct” to. and bias. Eisenson (1973) states. Clinical Penn & Jones. Penman & Pound. mation base allows new members to immediately interact Marshall. 1991a. & Ford.org). 1991) following intervention. Similarly. Hersh. group therapy for aphasia remains a approaches. 1962. at supplemented with counseling films. For example. tude has been that group treatment methods may not facili- Information provided in the counseling packets can be tate speech-language recovery in aphasia but are not. such as Pathways: Moving Beyond is merely palliative. Luterman. 1991). spouses can opinions that support this conclusion are stimulating inves- be referred to a clinical psychologist for evaluation if they do tigative interest in the group treatment approach. research style as one in which the experimenter’s prejudices seling for aphasia may be best conducted within a multidis. spouses who ment group literature and explore emerging trends in this discuss sensitive issues such as divorce or suicide may also be area. 343). a paucity of efficacy Radonjic & Rakuscek. 2007. confidence in group therapy as a basic method of treatment 2004). 1999. 1999b. and the guage benefits. Although the data Discussions generated from the counseling materials may are not yet available to conclude that individual and group also help clinicians to determine if a client or spouse might therapy for aphasia are equally effective. 382 Section III ■ Psychosocial/Functional Approaches to Intervention provides access to a variety of counseling and educational et al. Walker- experience indicates that this approach alleviates some of the Batson. Unfortunately. Curtis. Smith.org). Johnston and emotional impact of disability (Ewing. “The first and most American Stroke Association (www. 1953. Graham. Elman. Jenkins. 1985. Makenzie. 2007. 2007. Worrall. although he acknowledges potential speech-lan- the National Stroke Association (www.qxd 1/21/08 12:52 PM Page 382 Aptara Inc. the experimenter ciplinary approach that recognizes and treats emotional and “has taken the role of an advocate who defends a cause. Davidson. recent data and benefit from individual counseling. 1981. In the sec- not appear to be psychologically ready to share their feelings tions that follow. Films and printed materials can be shared with individuals Beeson & Holland. important [objective] is providing psychological support for also provide an invaluable resource for the clinical manage. 1972). Advocacy reports may reflect. Web sites for other professional organizations. The invaluable contributions of professionals specifically Advocacy Reports trained in psychological assessment and counseling empha- size the importance of an interdisciplinary approach to fam. 1989. Group counseling sessions are ignate articles that advocate the use of group speech-language often very emotionally laden. detrimental to recovery. not a psychological difficulties arising from disordered communi. (Borenstein et al. colleagues. Garrett & tion in counseling and support groups.GRBQ344-3513G-C14[376-400]. Few . Smith. l981.org). referred for individual counseling.aphasiahope. 2005. 2007. Avent. That is. the term “advocacy reports” is used to des- ily counseling for aphasia. for aphasia” (p. 1993. 1999b. language deficits (Aten et al.. 1991. including The Aphasia Handbook (Sarno & Peters. individuals within the group” (p. 1987) and in communication skills 1964. rather than a substitute for it. 1999. for example. 1991. anxiety that may be present before entering the group. provided in patient-family counseling can be supplemented In opposition to the stance that group therapy for aphasia with videotaped material.. This common infor. Schuell (Radonjic & Rakuscek. Pachalska. Similarly.. Howe. 2007. discussions of group therapy for controversial area. Wertz et al. 1982.stroke. 1991b). Ellis. such as the Aphasia Hope Foundation (www. Eisenson. The prevalent atti- ment and counseling of persons with aphasia. we will examine the speech-language treat- and emotions in the group setting. and Pennypacker (1980) originally described an advocacy Kearns & Simmons. a strong clinical bias toward unproven techniques. 1997a. research. few data existed regarding the efficacy of group therapy yet despite this history. 1999a. & Bernstein-Ellis. have attempted to document change in psychosocial skills Marquardt et al. Van der Gaag et al. in part. Bloom. Clinicians are often more influenced by teachers. For our purposes. because benefits derived from group seling efforts. Elman who have aphasia and/or with spouses before their participa. 1999. Makenzie. cation (Friedland & McColl. 2007). Some descriptions of group therapy approaches apy (Chenven. & Jimenez-Pabon. & Rose. 1999. a number of authors have indicated that Stroke and Aphasia (Ewing & Pfalzgraf. or a substitute for. with the other group members if they wish to do so. 1976. (1964). noted that “we are unable to have materials. and nondata- Speech-Language Treatment Groups based presentations than they are by clinical research. 188). Group coun. individual ther. 2007. therapy for aphasia without clearly delineating treatment pro- gists require specific training to manage the psychological cedures or presenting data to support their position. interfere with his or her objectivity. in which been conducted in group settings for nearly half a century. 1999a. 424). Fawcus.. Printed information least. scientist who searches for understanding” (p. and a genuine interest in sharing clinical ideas. 1989. treatment are likely to be emotional or social in nature.strokeassociation. Schuell. 1973. 1991a) and What Is group intervention is an effective means of treating speech- Aphasia? (Ewing & Pfalzgraf. and speech-language patholo.. 1996). Chapter 14 ■ Group Therapy for Aphasia: Theoretic and Practical Considerations 383 studies. The primary goal of group treatment was to improve func.qxd 1/21/08 12:52 PM Page 383 Aptara Inc. 1999). These limitations may negate the classroom-like activities according to separate language contributions of such efforts. and physical therapists. role play- et al. 5 days per week. 1946. and many advocated several ses- an appreciation for the power of operant training techniques. directions. 1962..” in which small groups of patients with apha. Wepman (1947) described a model program for inpatient Despite their shortcomings. money. multidisciplinary. to aphasia management. he indi- hours of treatment per day.. spelling. advocacy reports of group rehabilitation of individuals with aphasia. In addition to establishing a multidisciplinary approach ting. A consensus existed that also an early advocate of establishing individualized goals for group speech-language treatment was efficacious. one in The current emphasis on intensive. for example. Bloom (1962) was the first to clearly were nearly unanimous in their call for an intensive thera- articulate a pragmatic philosophy of group therapy for apha. As Sheehan the use of group therapy techniques as a primary method of noted. but the rationale for this approach was not fully devel. were. 1991a. In addition. Unlike many of the previously reported group treat- tal controls. sia worked on everyday vocabulary. 1948. achieved” (p. advocacy style treatment reports promoted left orientation. 1948). Huber. They carried out by a multidisciplinary team that included speech. included in the program. 1947). and an hourly group session each day. Her initial writings described “group from a menu. ordering therapy for aphasia. 1951. Pachalska. sions per day. rehabilitation could be developed. 1946. Walker-Batson et al. 409). Wepman (1947) also Wepman outlined an intensive program that included 6 to 8 strongly advocated the multidisciplinary approach. Sheehan. 1991). Wepman (1947) and his contemporaries of contextual influences on communication and meaning with suggested daily treatment. Repo. although each patient with aphasia in treatment groups. Rakuscek. which language stimulation was provided in meaningful functional aphasia treatment groups is reminiscent of contexts. psychologists. 1991a. social workers. and special education teachers. one session of life treatment activities (Agranowitz et al. The speech-language pathologist occupational therapists. living. however. Bloom. Bloom emphasized the feasibility of group treat. Wepman. To summarize. occupational and physi. Sheehan. An effort was directed speech-related groups. reading. Five or six patients usu- ally participated in the group at a given time. therapy daily if appropriate rest periods were scheduled. Individuals with Perhaps the most impressive aspect of the early group treat- aphasia who participated in her rehabilitation program ment literature is the consistent emphasis on functional.GRBQ344-3513G-C14[376-400]. have incorporated appropriate experimen. The specific Summary and Observations content of “lessons” included greetings and farewells. These reports described ongoing and ingenuity and of observation of the things needed by the group treatment programs and presented a sampling of tasks patients in their daily living” (p. multidisciplinary approach is necessary if maximum recovery level for the brain injured aphasic adult be patients with aphasia are to make maximum gains in therapy. ahead of their time in recommending a language pathologists. and handling money. Sheehan. auditory stimulation. 1954. and special educators taught made to coordinate these services so that an overall plan of writing. a multidisciplinary format (Pachalska. Huber (1946). 1947). 1991. Sheehan (1946) held regular Both individual and group speech therapy sessions were team conferences that included speech-language pathologists. this approach did not segment sessions into measurement techniques. real- attended one session of individual treatment. dation for current group therapy approaches that incorporate lined by Corbin (1951). Situations that occurred in daily experience were approaches that have been advocated for decades (Borenstein recreated in the naturalistic group environment. During the embryonic stages of group therapy for aphasia. for example. This program was treatment for aphasia were farsighted in several respects. making them comparable to modalities. All treatment activities were clinicians developed treatment tasks that were based on the directed toward improving performance of activities of daily patients’ communicative needs in the living environment.. peutic regimen (Corbin. Radonjic & The earliest writers in this area emphasized the impor. 1987. and arithmetic in a group setting. per- sonal identification information.. auditory speech classes. data to support this claim were lacking. tance of functional communication therapy in the group set. calendar use. indicated that Although several treatment groups were conducted in her most patients with aphasia could participate in 3 to 6 hours of setting. . Verbal was among the earliest advocates of group speech-language tasks were used to practice greetings. 1946. Sheehan (1948) was employed in the group setting. “The list is endless—a product of a little imagination intervention for aphasia. 1951. sia. Huber. right. however. cal therapists. Advocacy reports laid the historical foun- A similar approach for patients with “motor aphasia” was out. tional communication abilities. He concluded cated that “only by this overall cooperative approach can the that an intensive. and body part identification. ment for patients with severe impairments. 1946. Corbin. 1948. stimulation was provided during group sessions. such as the use of control groups and reliable ments. Sheehan (1946) ing and rote memorization of scripts were avoided. Her rationale for group treatment combined an awareness Wepman. Bloom emphasized a situational group approach. multidisciplinary treatment approach (Nielson et al. early advocates of group therapy oped for several years. 152). earlier advocacy reports. in which the clinician elicits spe- The previous examples of advocacy reports are primarily cific language responses from the patient.” All participants were encouraged to use an available Direct Language Treatment Groups modality to communicate effectively during discussions of Davis (1992) has distinguished “direct” from “indirect” daily topics. however. Schinsky. treatment data as evidence for the efficacy of group treat. These authors present speech-language training groups when he noted that many data obtained from uncontrolled group treatment studies to aphasia treatment groups are didactic. Gilbert et al. and Fust (1974). cate that she was able to arrange treatment so that individual macy. Holland (1970) provided an early example of the applica- tion regarding clinical techniques and quasi-experimental tion of “stimulus-response training” in a direct group treat- results. He states: individual therapy in which two verbal goals were targeted . group therapy is viewed as an more rigorous studies of efficacy that examine specific treat. The primary ment groups—direct. Skelly and colleagues did maintaining an unproven therapy. cacy reports of group therapy have seduced clinicians and and Albert (1974) used “less structured” Melodic Intonation researchers alike into uncritically accepting this approach. retarding legitimate investigative efforts in this area. and the cumulative effect of this literature has been an “illu. however. 1991. The five subjects In the section that follows. 385). focus of this investigation was to examine the value of an and maintenance—will be considered. Helm. relatively struc- support the effectiveness of their approaches. ment reports. ability to intone basic. group sion of strong evidence. Sparks.GRBQ344-3513G-C14[376-400]. plurality. adjunct to individual therapy (Davis. More Skelly. Although Holland did not report objec- patient management. but these efforts must be followed up with More often than not. Recent reports considered auditory language comprehension or word retrieval. ness of treatment. purposeful utterances. Relatedly.. she established specific treatment goals in an That is. Not only does this mislead us into adopting and gral part of their gestural program. All participants status of research in this area. Tasks that are chosen for advocacy reports presented detailed clinical information and direct treatment groups of 10 individuals mimic those used subjective clinical impressions. (1977) stated that “repeated bined group treatment with individual treatment in their weakly controlled trials are likely to agree and build up an study of the effects of American-Indian sign on patients’ ver- illusion of strong evidence because of a large count of favor. she did indi- clinical data that provide an appearance of scientific legiti. . 1987.” Recent data-based clinical efforts MIT therapy was suggested to possibly increase patients’ represent a legitimate initial effort to examine the effective. Makenzie ment approaches for clearly defined groups of patients with (1991) examined the effectiveness of a combined regimen of aphasia. and syntactic ordering abilities. They are struc- tured . group therapy have included relatively less detailed informa. ment program. for example. despite meager evidence to support this claim. Therapy (MIT) in direct group treatment of aphasia. Smith. so that the patient is using discrete functions such as from the post–World War II era. perhaps. They stated that the sign group was an inte- able studies. Five types of aphasia treat. early and more recent advocacy reports procedures to direct language work with aphasics in a group appear to have had a subtle and. 1989. Unlike previously discussed group treat- the cumulative growth of objective information in this area. as stimulus-response training. naming. negative impact on setting” (p. and more recent efforts have included tive data to support her exploratory approach. 1987). They are referred to for “pragmatic” aspects of communication. Although not specifically evaluated in their study. Friedland & McColl. indirect. each individual participated in daily treatment approaches. that patients with various levels of aphasia could participate ated. She applied “shaping and reinforcement Taken together. Acceptance of subjective reports and uncontrolled patient needs were met. the legacy of advocacy reports has been the tacit attempt to improve verbal categorization. Whereas earlier tured. sociolinguistic. may have had the deleterious effect of are also available from studies of specific training techniques. intensive period of therapy. but it may make proper not evaluate the contributions of group training to the acqui- studies more difficult to mount” (p. 2000). are also advocacy reports in nature (Borenstein et al. 687). sition of American-Indian signs.. . 384 Section III ■ Psychosocial/Functional Approaches to Intervention Treatment approaches included a consideration of contex. we will examine contributions in this study had previously been dismissed from noninten- to the group treatment literature and explore the current sive speech therapy after having plateaued. Rice et al. It seems that advo. (p. and clinician directed. albeit unsubstanti. The stated aim of the aphasia group was “information giving. acceptance of the efficacy of group therapy for aphasia subject-verb agreement. bal production. Additional examples of direct language treatment groups ment. com- than 20 years ago. Radonjic Brookshire (2003) was apparently referring to “direct” & Rakuscek. more recent descriptions of in individual treatment. transition. Initial reports Language tasks were arranged in hierarchies of difficulty so of group therapy provided convincing. In addition. were at least 9 months post-onset of aphasia. Direct approaches focus the clinician-patient interaction on the tual factors despite the lack of a supporting theoretic basis exercising of specific language processes.qxd 1/21/08 12:52 PM Page 384 Aptara Inc. direct individual and group intervention. testimonials as to the effectiveness of this method of in the same group. 241) below. No signifi- skills. Wertz and colleagues (1981) concluded that psychosocial groups has been to facilitate emotional and relatively few differences exists in the amount or type of psychological adjustment to aphasia. he recommended that group sessions emphasize inter- Participants with aphasia in both treatment conditions action among the patients while minimizing clinician direc- received 8 hours of therapy per week for up to 44 weeks. Despite the fact that they are than subjects in the indirect treatment group conditions in largely undefined. The poorly defined nature of these treat. Specific tasks were presented for the of no treatment. In total. advising. That is. For example. many of these approaches are purported terms of overall performance on the Porch Index of to have therapeutic merit for improving deficient language Communicative Ability (Porch. treatment approaches have pointed out that direct treatment ment session. principles of PACE therapy (Davis & Subjects in the group treatment condition received 4 hours Wilcox. compared the effectiveness of individual a wider variety of communicative interactions. 1981) can be incorporated into group treatment so of therapy in a social setting and 4 hours of recreational that patients “take turns. visual. Clinicians and patients ment approaches severely limits the ability of investigators produced a restricted number of “speech acts” in both set- to examine the usefulness of such approaches. and only patients having a single. for example. Proponents of sociolinguistic various clinical activities during a typical aphasia group treat. topic approaches may limit the types of communicative exchanges oriented discussions” were the most prevalent (31%) activity that occur between the clinician and the patient.GRBQ344-3513G-C14[376-400]. whereas the general purpose of neous recovery. rea- son exists to believe that loosely defined language stimulation Sociolinguistic Treatment Groups and group discussion are commonly applied treatment meth- ods. apparent on other language therapy for aphasia. The respondents indicated that “general. or PICA. col was developed to help ensure uniform training within Davis (1992) also advocates a sociolinguistic approach to both groups. no spe- period. In a survey of group therapy for aphasia in a Veterans Sociolinguistic treatment groups have evolved as a reaction Administration Medical Center.. A Veterans tings. Further. Kearns and Simmons (1985) to the highly structured treatment techniques employed in asked clinicians to estimate the percentage of time spent on direct treatment approaches. convey new information. Considerably less group time was Davis (1977). 4 hours of direct “stimulus-response” treatment of speech Some decrease in performance was found following a period and language deficits. subjects also received 4 hours per week Indirect Language Treatment Groups of machine-assisted treatment. differ from indirect treatment treatment conditions made significant gains in their lan- approaches primarily in the orientation and general goals of guage test scores beyond the recognized period of sponta- the group leaders. cussions of current events or other interesting topics. auditory. role playing. Wilcox and during group treatment. tiveness. few data are ment sessions and that patients responded to the clinicians available regarding the effectiveness of indirect language with assertions. Strict selection criteria were also used in this group therapy for aphasia. subjects received approximately activities. Indirect treatment approaches are unstructured and may The results of this study revealed that subjects in the indi- consist of general conversation. and contingent feedback and reinforcement were provided by the clinician. and a test of functional com. Group treatment activities did not include direct 85 hours of individual and group therapy during a l-month manipulation of speech or language abilities. Chapter 14 ■ Group Therapy for Aphasia: Theoretic and Practical Considerations 385 for improvement. ment are efficacious means for managing aphasia” (p. arguing. 1992).g. was evident in a social group setting. left-hemisphere. specific treatment tasks that are adapted from individual treat- cerebrovascular accident were included. mance in verbal. Wilcox and Davis concluded that individual and group Administration cooperative study on aphasia (Wertz et al. treatment should be less didactic and permit the exchange of 1981). 1967). subjects in both the individual and group described techniques. A screening battery for aphasia. various language modalities. A treatment proto.. ment. and a l-month period of no treatment followed the cific treatment tasks were presented to improve perfor- period of intensive therapy. word retrieval [22%]). 593). practice . or graphic language a test of verbal naming ability. however. however. which used unspecified or poorly tests. They surmised that “individual and group treat- recovery. A similar pattern of restricted responding treatment groups. In addition to individual treatment. that is. modalities. Rather than drilling patients on study. improvement exhibited by subjects in the two treatment rect language training groups has been to stimulate language conditions.qxd 1/21/08 12:52 PM Page 385 Aptara Inc. found that clinicians primarily spent on “structured tasks” (e. Despite the vague nature of indirect treatment groups. and congratulating. Previously presented examples of psychosocial group cant differences were. the orientation of indi. vidual treatment condition improved significantly more and field trips (Davis. including treatment and indirect group treatment. social groups. Typical group tasks included participation in dis- munication were among the measures used to evaluate treat. ment gains. The results of this clinical report indicate that Subjects in the individual treatment condition received all five patients improved on at least one clinical measure. produced “questions” and “requests” during direct treat- As in all areas of group therapy for aphasia. with participants listing 8 to 10 key words administered. should be included in showed improvement were those with the mildest aphasia as our clinical assessments. showed either slight improvement or no change in tional communication treatment is efficacious and that func. A Her group treatment activities centered around a preplanned single-subject. the therapist read the target period of 12 weeks. Graham used the lowed by a period of no treatment. measured pre-treatment by the Western Aphasia Battery A partial replication of the study by Aten and colleagues and the content unit analysis (i. performance. ment on narrative and procedural discourse of participants. such as the CADL. 1967) and the CADL. and a total of 24 treatment sessions were story aloud. Each par- suffered a single. three of the eight participants improved their narra- scores revealed nonsignificant differences. In units per minute). They defined either treatment. and PACE treatment principles were incorpo. Following evaluation to deter- “contemporary group treatment” and “structured television mine communicative strengths and weaknesses as well as the viewing group treatment” alternating with 10 weeks of no ability to use compensatory strategies. The results of training were evaluated by content units (Nicholas & Brookshire. subacute and skilled nursing facilities. and provide each other with feed. prompted the facilitator to cue the reteller with the key 1980). Results indi- examining pre. and/or phrases from the story. group members. and a variety of everyday communicative situations cue his or her partner as needed. but statistically tive and procedural discourse in the treatment stories and significant differences were apparent for pre. (c) greetings. Each dyad’s facilitator used the key words/phrases to nication. The role of the speech-language pathologist was to chronic aphasia participated in this study. improvement on both the CADL and the PICA but not on As a participant in the panel discussion of group therapy the third measure of language.) Both individ- life activity.GRBQ344-3513G-C14[376-400]. . (1982) investigated a soci. (d) giving personal informa. The sub. Then. Graham (1999) described the use of aphasia groups in ment/withdrawal design. Avent (1997a) concludes that participants who tional measures. Initially. stories were used in treatment. 263). or CADL. 146). “facilitator” of 10 narrative and 10 procedural stories having jects participated in hourly group sessions twice weekly for a 100 to 120 words each. Pre. (Group members could also greetings and socialization. grocery lists. and specific communication-related activities. used as generalization probes. The remaining five participants.e. “Contemporary group treatment” consisted of enrolled into group treatment. be enrolled in individual treatment sessions. cerebrovascular accident and one Traumatic Brain Injury). they prehension. told the story. were selected for training. the recaller retold the The goal of treatment was to improve functional commu. (b) giving and fol. The “real-life” words. Five procedural stories and five narrative tion. Bollinger and colleagues found significant back to overcome obstacles” (p. 20% or higher content was provided by Bollinger. FACS in combination with Hartley’s (1995) functional com- “Structured television viewing group treatment” consisted munication goals. Treatment groups consisted of two to six of subjects watching specific television programs with later members meeting 5 days per week for 45-minute sessions. followed by feedback from both the facilitator lowing directions. Treatment consisted of 10-week segments of treatment in these groups. cerebrovascular accident ticipant with aphasia alternated in the role of “recaller” and at least 9 months before the initiation of treatment. Aten et al. All subjects had provide guidance and structure to the treatment.. patients were treatment. 386 Section III ■ Psychosocial/Functional Approaches to Intervention using multiple channels.” Seven patients with dyads. and other materials from the patients’ living The outcome measure in this study was an analysis of environment. group discussion of specific communicative elements by Treatment tasks focused on functional and “survival” skills. a core activity focusing on a real. p. or received 3 hours per week of group treatment for a total of ASHA FACS.and post-treat. The authors concluded that group func. with “structured” treatment fol. multiple baseline across behaviors design was task or game. story. which tested auditory com- for aphasia conducted by Aten and colleagues (1981). (e) reading signs. the reteller once again training situations included (a) shopping. used to evaluate the effectiveness of cooperative group treat- rated into the sessions.and post-treatment PICA ment. and (f) gestural expression of ideas. 1993). olinguistic treatment approach that was described as “group Each participant was paired with another for a total of four functional communication therapy. group treatment was provided using a treat. Following a practice period.. Ten individuals with American Speech-Language-Hearing Association Functional chronic aphasia who were at least 18 months post-onset Assessment of Communication Skills for Adults (1995). ual and group treatment goals were selected from the ASHA such as group repetition of words and naming activities.qxd 1/21/08 12:52 PM Page 386 Aptara Inc. Results did not demonstrate the superiority of elaborated on Davis’s principles of treatment. with the remaining stories Therapeutic activities included role playing and use of menus. and Holland (1993). and the therapist. the generalization probes. this study. as a framework for planning and evaluating 40 weeks. left-hemisphere. ment CADL scores. 1981. however. Musson. the purpose of group treatment as an attempt to “maximize Avent (1997a) described the use of cooperative learning (the patients’) communicative strengths in order to improve methods with eight brain-injured individuals (seven post– interpersonal communication” (Aten et al.and post-study performance on the PICA cated that following 18 sessions of cooperative group treat- (Porch. The therapist also from the Communicative Activities of Daily Living (Holland. Three groups—a discharge-planning ily. The Once patients were discharged from the hospital. and it provided an opportunity for emo- sociolinguistic group treatment for aphasia. building.” This group pro- vided emotional support and education.GRBQ344-3513G-C14[376-400]. Maintenance groups continue tient hospital services and release to the home environment. This program continued at Duquesne University (Garrett. The authors describe the Nebraska treatment purpose. planning group was to prepare patients for life-style changes contextual support. they may group—were used to facilitate the transition between inpa. 2007). that would occur on dismissal from the hospital. lation so that patients’ speech-language skills do not deterio- ters and home health services. such as adult day-care cen. context cussed in this group. the program provides learning with community placement. In the final analysis. A continuum of lan. tion and communication in social contexts. involvement group attempted to “confront reality without 1991) and other communication-based therapies in the destroying hope” (Aten et al. several authors have treatment. they authors provide specific communication goals and explicit participated in the community involvement group in an prompting information. Tasks Maintenance Groups employed in these groups. 286). Practical dif- guage activities. Brookshire observed that maintenance group meetings group. He indicates that maintenance group activities are these groups for a limited and specified period of time frequently social in nature and may emphasize social interac- before discharge from treatment.. and it helped Transition Groups patients to maintain the level of communicative ability that In addition to the direct. . such as role playing. because it reduced depen- aphasia. communication goals. had been reached following individual speech-language ment approaches described above. to their new environment. Brookshire (1997) indicates that transition groups dence on the hospital staff and integrated patients into exist- “prepare patients for communication in daily life by giving ing family and community structures. indirect. group also discussed emotional incidents that occurred in Additional data are needed to establish the validity of the home setting. Transition groups often meet rate once they are dismissed from intensive individual ther- one or more times weekly. The final stage in West’s transition group program was participation in a monthly “stroke club. and (e) to help patients tion skills. similar in function to a maintenance group. thematicity. and sociolinguistic treat. The competent communicators. them training and practice with strategies and problem- solving skills that are useful in daily life” (p.qxd 1/21/08 12:52 PM Page 387 Aptara Inc. with 6 to 10 people participating in each group. and patients usually participate in apy. gains made in individual therapy. a community involvement group. The primary goal of this aphasia (c) to assist patients in finding an alternate life style within group program is to provide a vehicle for individuals with available family and community resources. on helping patients to accept their new life styles and assist quently indicated the groups helped them to become more them in developing productive alternate life styles. the main purpose of the discharge- program as combining principles of discourse. intervention program developed in 1994 at the University of The overall goals of the transition groups were (a) to help Nebraska–Lincoln’s Speech Language and Hearing Clinic. each group had a specific pathology. tional venting by the group members. 1991). Participation in As a member of the group therapy panel conducted maintenance groups may last from months to years. & Moir. increasing level of functional independence from the hospital Garrett and Ellis (1999) described a group language staff. and a “stroke club” are seldom held more than once per week. and functional use. (1981) she described her unique approach to ing on the individual needs of the patient and his or her fam- transition groups. are usually selected to help individuals with aphasia adapt to commu. In addition. be held only once per month. In general. in fact. For example. Chapter 14 ■ Group Therapy for Aphasia: Theoretic and Practical Considerations 387 and Graham described how she used videotape segments for groups in sequential order in an attempt to develop an viewing and discussion by group members. Group sessions are 90 minutes in attempt to facilitate emotional and psychological adjustment length. (d) to reinforce long-term aphasia to continue to improve their communica. depend- by Aten et al. Staltari. West’s “stroke club” group appears to be nicative situations that occur in their living environment. (b) to develop a realistic view of progress and altered ability. patients accept changes in physical and cognitive abilities. group setting are warranted. p. 1981. The emphasis in this group was Garrett and colleagues report that group members fre. opportunities for graduate students in speech-language In addition to these general goals. language mediation. and scaffolding ficulties encountered during home visitations were also dis- strategies are incorporated into conversation. 150). Brookshire Information may also be provided in transition groups (1997) notes that maintenance groups provide regular stimu- regarding community services. For example. The community evaluation of the efficacy of discourse exercises (Osiejek. West concluded that her three-group described transition or maintenance group treatment for transition process was successful. and discourse activities. to be a medium for encouraging retention of therapeutic Patients in West’s program participated in each of the gains made during aphasia rehabilitation (Springer. games to strengthen psycholinguistic abil- nience alone. Hunt concluded that the social language group provided 1990). social interaction. inherently flawed. 20 control volunteers were merely exposed to people with ing assistance only when requested. information. 1989) (see nance group also acted as a source of information. and Simmons (1985) of clinical practices indicate that 80% prevent social isolation. and they should not be construed as being a ity. encourage the ability to search for. Group activities included ously indicated. was the most frequent aim and self-respect. often combining psychosocial and patients with aphasia revealed improvements on patients’ speech-language goals into treatment. support. maximum of 10 group members. and therapeutic techniques involv- reflection of clinical reality. group setting. As previ. Family members were tion. relax- treatment approaches are generally for the sake of conve. is the use of community volunteers who are trained and lation of language in a social setting. and entertainment. From 8 to 12 patients participated in the groups. 2007) that provided support. Speech. develop. 451). A five-point scale of communication was therapy is undertaken with several aims in mind—even administered at the beginning and end of each patient’s par- when a primary focus is evident. in a planned around the patients’ interests and included movies. 388 Section III ■ Psychosocial/Functional Approaches to Intervention Hunt (1976) described a language maintenance group Kagan and colleagues (1990. and language stimula. Group activities were supervised by speech-language pathologists to work. each group identifies its untrained volunteers on ratings of acknowledging compe- relevant goals and sets its own rules. and it cant between-group difference favoring the treated patients provided a valuable training experience for student clinicians. communicative effectiveness (Lomas et al. A descriptive analysis of difference scores for 108 multipurpose in nature. attempts to communicate in the group setting were reinforced. if so. Most recent reports of ticipation in an attempt to examine the impact of interven- group therapy for aphasia reveal that programs are typically tion. Canada. chologist and a speech-language pathologist. sia. Coles and Eales (1999) describe Action for Dysphasic A primary component of this aphasia community program Adults. A comparison of the results of pre. with the speech-language therapist provid. 1999. The speech-language therapist also serves conversation partners with aphasia. These results support the efficacy of supported con- Taxonomies of group treatment procedures for aphasia are versation techniques. including the number tence and revealing competence of their partners with apha- of members permitted in the group. group ing music” (p. Results revealed significant improvement in the post- valuable language stimulation. because clinicians often identify several Radonjic and Rakuscek (1991) described a multipurpose purposes for their groups. each group is run received training in supported conversation techniques. More often than not.. use supported conversation techniques (Kagan. and use might be expected. and guest speakers. described a unique. pantomime. A signifi- and referral for the families of patients with aphasia. The mainte. and by its members. even though these individuals did not participate in the Multipurpose Groups training. that is designed to facilitate functional communica- which met once per week for 2 hours. treatment. but not on traditional language testing. promote independence. from individual therapy. Because different locales aphasia. The results of a survey by Kearns group that was established to decrease emotional tension. was also found on this measure. Kagan language therapists work for Action for Dysphasic Adults as and colleagues (2001) investigated whether these techniques regional development advisers. with a (59%).qxd 1/21/08 12:52 PM Page 388 Aptara Inc. ation techniques. An important aspect of the program The emphasis of this maintenance program was on stimu. The training also produced a positive change in ratings of social and message-exchange skills of individuals with aphasia. These activities pro. 1998). carryover (47%). encourage the need for communica- of the respondents listed multiple goals for their groups. post-treatment communication ratings as compared with . and socialization (45%). communication in social situations. Trained volunteers scored significantly higher than have varied interests and/or needs. Following language stimulation. Chapter 6). language stimulation. Twenty volunteers as the link to the national body. and it gener- the next most frequently listed goals were emotional support ally ranged in size from four to seven participants. all ipated in the community group versus a group of untreated. provided at the Aphasia Institute in Toronto. drawing. As tion. have with aphasia. and maintain gains resulting excluded from group participation. an organization that provides self-help groups for is training agency volunteers and health-care professionals to individuals with aphasia in the United Kingdom. community-dwelling control subjects was reported (Kagan. number of self-help groups and provides direction as each whether the improvements affect the communication of their group is formed. 2004.and vided an opportunity for using residual language skills. often in combina. 2001. attempts to classify types of aphasia group such varied activities as “learning about each other. Ultimately. on communication goals with individuals who slide presentations. community-based group treatment tion for patients who had been dismissed from individual approach.GRBQ344-3513G-C14[376-400]. The group was developed by a clinical psy- (84%) of aphasia groups. practice of previously acquired treatment performance of the group participants on a test of abilities. post-testing for participants with chronic aphasia who partic- Although specific language goals were not established. Each adviser supports a improve the conversational skills of volunteers and. and develop confidence tion with support or social goals. 1991). and preparing for a physician’s visit. multi. structured approaches. 1991. 1991). 1991b) included commentaries by distin. Group sessions often group therapy. more heterogeneous groups may be particularly analysis that the best results were obtained for patients who appropriate when the emphasis is not on direct communica- participated in at least 10 treatment sessions in small groups tion or language training (Springer. (three to five members). Although intriguing. physical therapy.and approach is “the most effective approach” (p. 1999b.” are considered leisure activities. Group size ranges from three to five members. Pachalska also recom. Pachalska (1991b) also indi. Fawcus (1991) empha. such as the client are run by a multidisciplinary team of clinicians who provide self-report. 547) to group post-treatment comparisons were available. and special emphasis is placed on “language-oriented day. A structured treatment approach is also vides one of the few available descriptions of clinical man- advocated. 2007) description of problem- conditions before they can be considered unassailable. This issue is further considered in the sections that psychotherapy. 1991. 1991. went training in the program significantly improved. Loverso. Fawcus. 1983). Treatment here is that larger groups are manageable and. Group sessions and he suggests that seldom-used formats. Clinical data are presented that show Rehabilitation Model. may also provide a measure of clinical account- cognitive physiotherapy. Women’s University transdisciplinary Aphasia Center mation between the cerebral hemispheres. prepare clients for community reentry. however. Pachalska refers to a “holistic” method of treat. participation in included. Springer. social. Springer. and occupa- popular poems and word games. Clients are assessed on a battery of mea- therapy and group discussions with family members. for evaluating progress in group therapy (Lomas et al. In addition to the language tional therapy in addition to rehabilitation professionals emphasis. Intensity of intervention is based on the client’s sever- the disturbances in the communicative. Pachalska language treatment is determined by placement of each (1991a) makes the broad claim that “all abilities which under. Marshall recog- treatment. the Examination (Goodglass & Kaplan. Speech- to be part of the rehabilitation process as well. ability. Walker-Batson and colleagues (1999) describe the Texas cates that a goal of CARM is to stimulate transfer of infor. which apparently refers to a multidisciplinary. mends that the size of aphasia groups should not exceed four meeting new people. be dictated by prescription (Loverso. sometimes. these clinical Another example of a multipurpose group is provided by data must be replicated under more rigorous experimental Marshall’s (1993. cannot focus on themes developed by the clinician. Our clinical experience is consistent with their suggestion Beeson and Holland (2007) describe the University of that group sessions of longer than 1 hour are possible and Arizona group treatment program. agement for patients with mild aphasia as well as a rationale ment. 551). such as “car rallies. and recreational reintegration into society ture review and clinical experience. focused group therapy for patients with mild aphasia. 555) and cautioned against using overly treatment. ment. Consequently. clients receive individual as well as group treatment. speech therapy. and sociotherapy. she asserts that the holistic language test scores of the 18 patients for whom pre. or CARM. which uses theme-based activities to linguistic and nonlinguistic stimuli are employed in treat. activities. marily as an adjunct to individual treatment. for intervention that focuses on everyday problems and com- purpose approach.” Linguistic materials used in therapy include speech-language pathology. The most severe reintegration was more complete” (p.qxd 1/21/08 12:52 PM Page 389 Aptara Inc. System” that provides theme-related vocabulary and struc- sized that “the whole essence of group work is its flexibility ture for each client and is used in both individual and group and spontaneity” (p.. CARM is described as having both individual and nizes the potential of functional communication assessments group treatment components. Examples of the problem-solving activities used and level of language involvement. psychological and ity level as measured by the Boston Diagnostic Aphasia social domains were eliminated to a considerable degree. higher-level groups can select their own topics. facilitating natural conversation. and quality of life. Chapter 14 ■ Group Therapy for Aphasia: Theoretic and Practical Considerations 389 pretreatment ratings. affect/mood. 1991. Tasks are directed toward follow. both Lifelink© program. and group therapy is seen pri. those The clinical forum that highlighted the work of with less severe aphasia are discharged from individual treat- Pachalska (1991a. or five members and that treatment sessions should last no Unique aspects of this program include the fact that it pro- more than an hour. client on the “recovery-compensation continuum” (Elman. 1991). and that 1994). Citing publications in her the range of post-treatment improvements on standardized native language (Polish). Social activities. during treatment include communicating in an emergency. she suggests making and assisting members in solving everyday communication groups as homogeneous as possible in terms of patient type problems. vocational. The authors concluded from their Larger. focused on facilitating successful communication using any . The authors describe a “Visual Retrieval Language 1991. 1989). Others agree that the mechanics of and groups are 75 minutes in length. desirable. such as group size and session length. Based on her litera. with continuation in group therapy and community guished aphasiologists (Aten. are also sures to evaluate speech and language skills. Repo. physical therapy. university-based program with graduate students in art therapy. The Pachalska (1991a) reviewed the group therapy literature goals of this program are to provide a forum for discussing and presented her treatment approach. Lifelink© is a half- ment. such as physical providing services. such as her own Complex Aphasia munity reintegration. other aspects of rehabilitation.GRBQ344-3513G-C14[376-400]. communication skill groups. sia as well as 14 significant others. Group activities included con- pants not receiving treatment. and (g) like are described in detail by Bernstein-Ellis and Elman (1999. the WAB changes were a result of increased confidence and motivation Aphasia Quotient (Kerstesz. versations. for a total of 4 months. or WAB AQ. attending a community-based aphasia program on quality of ment group received an additional administration of the life and communication skills for 28 people with chronic apha- measures just before beginning treatment. 1980). Keith. Beeson & Holland. of group communication treatment on linguistic and com. Finally. 390 Section III ■ Psychosocial/Functional Approaches to Intervention modality in addition to client-specific communication after both 2 months and 4 months of treatment. The relatives/caregivers reported very treatment was on increasing initiation of conversation and similar positive psychosocial and speech-language aspects of exchanging information using whatever means possible. & Darley. In the treatment condition. Interview transcripts were tran- individuals with chronic aphasia. (b) improvement in talking. While awaiting group communication treatment. for 40 cation treatment groups. All participants received these tests at entry. (b) more social. include between five cant decline was observed at the time of follow-up. 1980). with a munication treatment. education level. Individuals with aphasia Results revealed that group communication treatment was attended group treatment either once or twice per week for an efficacious. which aphasia. Semistructured cians. Interview data for 12 participants and their relatives/care- Elman & Bernstein-Ellis (1999a) investigated the efficacy givers were reported by Elman and Bernstein-Ellis (1999b). More than one. and are facilitated by faculty and grad. and the that participants gained from attending the groups. or SPICA. helping others. In addition. after erful one for producing change. and self-advo- with moderate-to-severe aphasia who received treatment had cacy groups. their families. indirect language treatment. including psychosocial and confident. (d) like being able to help oth- were balanced for age. In third of the group members showed a positive change of at this analysis. mation expressed in the interviews. Negative aspects were rarely reported. Psychosocial aspects included (a) more wide variety of topics addressed. 2007). and a qualitative analysis (Miles & aphasia group for at least 1 calendar year. Huberman. were not directly treated during group communication treat- Dependent measures included the Shortened PICA ment. They sug- Communicative Abilities in Daily Living (Holland.GRBQ344-3513G-C14[376-400]. or movement important to note that many of these psychosocial behaviors groups to control for the effects of social contact. 1990) was applied. Specific clinical procedures and content motivated. and the student-clini. 1994. provided by a speech. (d) more poststroke issues. (c) like making friends. participants in the deferred-treat. with questions focusing on the Holland and Beeson report the Western Aphasia Battery positive and negative aspects of participation in the communi- (WAB) scores. Their research design used random assignment to (a) like being with others. (f) happier. and (c) improvement language pathologist. Groups are 1 hour in length. all participants received The positive speech-language aspects included (a) enjoy con- 5 hours of group treatment per week. modeling of communication Elman and Bernstein-Ellis (1999b) also reported on results strategies. Strauss & Corbin. (e) like making friends. This and seven members. gested that the group environment can be an extremely pow- or CADL. Participants receiving treatment had higher scores average of 1. and after group communication treatment. Caregivers received an average of on the SPICA and WAB AQ compared with those partici. (e) like seeing others improve. all transcripts were reread multiple times to improve more than those who are older and further from produce a limited number of themes that captured the infor- stroke onset (Holland & Beeson.4 hours of therapy per week. and initial aphasia ers.) interviews were conducted. before and after group participation. 1. The positive psychosocial aspects of group communication municative performance for 24 participants with chronic treatment reported by participants with aphasia included aphasia. Positive speech-language aspects included 2007). In addition. their family member’s or client’s participation in group com- Communicative topics were relatively unconstrained. (a) improvement in talking and (b) improvement in read- participants in the deferred-treatment group engaged in ing/writing. No signifi- strategies. (b) like the support of others with immediate-treatment and deferred-treatment groups. study was the first to demonstrate that group communica- uate students. It is activities such as support. psychosocial support. and after 4 to 6 weeks of no Van der Gaag and colleagues (2005) evaluated the impact of treatment. Beeson and Holland suggest that the Arizona tion treatment and not social contact alone was responsible treatment groups serve many purposes including direct and for treatment gains. (c) more independent. 2 and 4 months of treatment. severity. All had participated in the scribed verbatim. 1999. Elman and Bernstein-Ellis posited that many of these (Disimoni. Significant improvement was observed therapy. Both qualitative and quantitative methods were higher scores on the CADL compared with those who did not used to assess the participants before and after 6 months of receive treatment. both positive and negative aspects of group treat- least five points on the WAB. those participants versation groups. 1982).7 hours a week. performance. Participants were evaluated by semistructured . The focus of in reading/writing. and continuing education from participant and caregiver interviews collected during for group members. and (f) feel more confident. (Separate groups are conducted for family members. A regression analysis suggests ment were noted and then coded and grouped into common that individuals who are younger and closer to onset themes.qxd 1/21/08 12:52 PM Page 390 Aptara Inc. GRBQ344-3513G-C14[376-400]. 1999. 2000). 2005). 1991). Although each approach is unique. often 1998). Makenzie. Ewing. however. 1981). Parr. 1999).. 2007. 2007. Results indicated groups range from structured. 1953. 1982.. Chapter 14 ■ Group Therapy for Aphasia: Theoretic and Practical Considerations 391 interviews and two quantitative measures assessing quality of group treatment approaches.. sessions. not possible to determine which aspects of the therapeutic the variety of group treatment approaches probably reflects program contributed to these changes. Worrall be aware of the strengths and communicative needs of indi- et al. tion. so-called “stimulus-response” statistically significant improvement in the CETI and one of approaches to essentially undefined. (b) indirect language treatment groups. These programs advocate a social approach to between individual and group treatment. exists among significant but not insurmountable. and proper attention . tasks should be structured so Elman. Smith. 1991. It is ational activities (Wertz et al. These included (a) direct language treatment sound clinical logic. and Connect in London (Penman & Pound. The qualitative variability and include specific techniques. clinicians conducting sociolinguistic Pound. group intervention should be based on identified. Radonjic and Rakuscek. 1972). 1999b. such as PACE therapy (Davis & (Penn & Jones. 1981). Egan. rebuilding identity. 2000. Osiejek. & Oxenham. 1970). to the group format. Treatment Groups the objectivity of direct approaches should be combined with the common-sense rationales for sociolinguistic group Examination of group treatment as a primary and indepen- therapy. 1992. Worrall.. but clinical aphasiolo- undertaken (Aten et al.. 2007. various group therapy often adopt recently developed functional university-sponsored aphasia programs were developed treatment approaches.. & Woolf. 1997a. approach to program development (Cochrane & Milton. To avoid this possibility. et al.. In addi- 1984. individual exchanges between the clinician and a given ment. the Talkback groups in South Australia (Hersh. with a majority of the (Sparks et al. In addition. be a legitimate goal of group therapy for aphasia. Holland’s (1975) programming for individuals and family members affected inquiry about the differences between these two approaches by aphasia (Elman. 1976).. guistic treatment groups. Van der Gaag individual and group treatment for aphasia (Chenven. several therapy (Elman. including Internet training (Bernstein-Ellis & a group setting. pragmatic treat- dent form of patient management has only recently been ment approaches will be challenging. is poignant. 1999. 1981. Given these parallels et al. that all group members can participate (Holland. the CETI and a caregiver assessment. 2007. Wertz et al. Van de Gaag et al. employ tasks similar to those used in individual treatment 2007). 2005) (see chapter 11) and provide a vari. 2004. Marquardt et al. Moreover. community-based aphasia centers were cre. Socialization can not be sturdy unless this investigative effort continues. Research evaluating the Clinicians should eschew indirect treatment approaches effectiveness of specific group speech-language treatment is that have no explicit communication goals and serve as a growing. Ideally. As previously noted. 1991. Several of these programs also provide specialized patient. 1999a. but clini- cians should be leery about letting group treatment deterio- Summary and Observations rate into totally unstructured activities that neither facilitate Recent reports of group speech-language treatment for nor support identified communication aims. Direct language treatment groups.. Lindsay. independent. the result may be inefficient individual treatment in groups. (c) sociolin. 1999. the training and biases of the clinicians who conduct group Inspired by the Aphasia Institute in Toronto. Obvious parallels exist between speech-language treat- ated in the 1990s. Elman. but interactive aspects of communication should not be sacri- Efficacy of Speech-Language and Multipurpose ficed (Davis.qxd 1/21/08 12:52 PM Page 391 Aptara Inc. Group treatment tasks also show considerable cant differences on the caregiver assessment. Considerable variability. group leaders must Elman. Avent. California (Bernstein-Ellis & Elman. (d) transition groups. Worrall Wilcox. but the scientific basis of clinical aphasiology will social outlet for their patients with aphasia. 1986. The development of data-based. Davis & Wilcox. Elman & gists have recently demonstrated the feasibility of this Bernstein-Ellis. indirect treatment the two quality-of-life measures but no statistically signifi. Elman & Bernstein-Ellis. 2005.. Walker-Batson et al. 1991. 1999b. These included the Aphasia Center of ment group therapy and individual therapy for aphasia. Elman. and (e) maintenance groups. If a group leader sequentially treats each indi- ety of groups that emphasize successful communication vidual in a group and little interaction occurs other than strategies. Similarly. such as MIT interviews revealed similar results. approaches. being overly rigid (Fawcus. Kearns. and community reengage. 1974) as well as group discussions and recre- participants reporting improved communication skills. 1981). Speech-language treatment life. 2007). 2006). the common denominator is that their primary purpose is to CLINICAL ACCOUNTABILITY facilitate recovery and/or maintenance of speech-language Measurement problems encountered in group therapy are abilities. and it should be goal directed without groups. 2007. several studies have explored the value of combined 1999a. 2007) and aphasia book clubs (Bernstein-Ellis & vidual group members. Like individual aphasia were reviewed and five group therapy approaches therapy for aphasia. for example. Recent trends in the generalization literature.e. strated the reliability of a process evaluation form. if not a responsibility. Further. In essence. functional (e. 1989. “[T]here is an ethical obligation. Loverso (1991) addressed the need to itation and other applied fields. however. 1980. (1982). Although tools designed to Thus far. when generalization does not occur following standard assessments are not routinely available. McReynolds & Spradlin. few authors of group therapy members. transition groups. and generaliza- of psychosocial changes and conversational language are tion is the exception rather than the rule in aphasia rehabil- available. assumptions about generalization and allow us to examine mation). 1981). 2007). ness will not be easily demonstrated until better assessments Treatment effects are notoriously restrictive. for the most part. Kearns and Simmons tenance groups. earlier work by Loverso et al. tion may provide an opportunity to empirically test our They demonstrated that task (e. indirect language treatment The importance of measurement issues in group therapy groups. do anything to actively try and achieve generalized respond- ing ability. we and overall cost/benefit ratios. treatment effective. Spradlin & Siegel. A recurring problem for clinicians The ultimate goal of therapy for aphasia is to develop who run aphasia groups is the issue of clinical accountability. work. what Stokes and Baer (1977) labeled “Train and Hope Given the nature of the abilities targeted for intervention Studies. and the development and use of reliable supplemental speech-language and multipurpose treatment groups. we have considered psychosocial. in addition to qualitative methods of review of recent speech-language treatment group reports investigation. no additional follow-up steps are taken to Pimentel (2007) describe numerous outcome measures that obtain carryover.. that provides suggestions regarding spe- within aphasia groups and the interaction of these roles dur. are sorely needed (Elman & Bernstein-Ellis.” That is. family counsel- measure functional communication ability (Holland.g. and non. maximum communication ability in non-training settings finding appropriate measures for assessing the effects of and situations. A growing generalization develop and adopt tools that examine the roles of individuals literature. quality of life. maintenance (e. and Tonkovich (1982) assessed the “roles” of management that is geared toward facilitating generaliza- individual group members and classified their interactions. ever. Among the speech-language treatment reports. customer satisfaction. 1985. This novel suggestion is exemplified by the Horner et al. 1985). outpatient. revealed a number of distinct approaches. 2007). Garrett and intervention. relied on standardized tests of aphasia (Aten GUIDING PRINCIPLES et al. clinical investigations of aphasia are (Cochrane & Milton. initiation of interactions. investigators attempt to measure general- in group settings. Similarly. and main- for aphasia cannot be overestimated. and time (i. Garrett. to come measure that is chosen. functional carryover. supplemental mea. Wertz et al. 1989) may be of particular value. and speech-language treatment groups for Lomas et al.g. Our measurement tools. his commentary on Pachalska’s work. people. giving and receiving infor. Garrett & Pimentel. the efficacy of group therapy for aphasia. 1984. Garrett & Pimentel. They state that most of these have an obligation to do everything in our power to achieve measures can be adapted for use in medical. may serve as a cornerstone for the development of 20% of the clinicians indicated that patient performance was eclectic. 392 Section III ■ Psychosocial/Functional Approaches to Intervention must be given to assessing speech-language treatment gains routinely the communicative abilities of aphasia group in the group setting. distinguished early advocacy groups from more recent cation. and situations where patients live. As Horner and colleagues (1986) note. and those who have examined the success of treatment have. settings. it is important to evaluate make sure that generalization programming is incorporated . ing treatment. disruptive) behaviors could be reliably rated Reviews of the aphasia generalization literature also indi- in the small-group setting. Other novel. encouraging following). 1988.. 1981. 1989). It should be apparent from this brief sum- (1985) reported that 73% of survey respondents used peri. language treatment groups. and other skills. Kearns. To date. but they seldom ical probes or “mini-tests” to sample skills such as turn-tak. including direct 1999b... mary that no single therapeutic model can accommodate the odic standardized testing to evaluate group members and variety of aphasia groups that have been reported in the lit- that 33% employed standardized testing in combination erature. of discourse analyses and interactive coding procedures More often than not. Loverso. behavior. As Aten (1991) pointed out in across stimuli. reports have attempted to measure treatment gains.. If the ultimate goal of therapy for aphasia is clinicians can use to assess basic communication skills. not routinely evaluated. ing and support. cated that generalization of aphasia treatment effects is not sures that may be employed in aphasia groups include the use an automatic by-product of intervention (Thompson. and interact. to achieve maximum communicative functioning in settings tional communication. ization of communicative improvements. in which they demon. how- with “behavioral ratings of task performance. 1982. func. Warren & Rogers-Warren. standardized aphasia. 1989..qxd 1/21/08 12:52 PM Page 392 Aptara Inc. cific techniques that may facilitate carryover (Baer. because ing. maintenance) is the desired end product of therapy. A philosophy of group Young-Charles. and/or community settings.g. 1982.. we aphasia tests do not measure interactive aspects of communi. principled group treatment approaches.GRBQ344-3513G-C14[376-400]. 1999. Whatever the procedure or out.” Surprisingly. sociolinguistic groups. Hughes. clinicians often must devise their own clin. generalization of target behaviors group therapy is problematic.. target behaviors improves. Horner et al. for example. the gener- alization planning approach expands the evaluation process Generalization Planning to include gathering information that is directly relevant to Clinical practice in speech-language pathology often maximizing the chances of obtaining carryover of treatment includes four discrete and relatively independent sequential effects. more ecologically Warren. and actions of significant tional approach to treatment planning. and pose of effecting change in a patient’s ability to communi. more time. individuals. adopted clinically in group settings. clinicians may then are rarely available to determine if generalization of specific begin to examine aspects of generalization and maintenance. Kearns and and generalization planning is far more than philosophical. and conditions. From a practi. These lists can then planning approach to the clinical process is conceptualized be narrowed down to a reasonable few. Thus. viduals with aphasia may include standard and nonstandard tests of language and functional communication. the clinician attempts to generalization planning approach to intervention and the determine the most critical factors that should be targeted traditional. In addition.. 16). settings. Whereas generalization ment effects clearly does not automatically occur as a result and maintenance are too often a clinical afterthought with of intervention. lishment of clinical goals based on performance on clinical the clinician also sets a criterion for evaluating whether a tasks within the treatment setting. Expansion of the traditional assessment may include. for example. Warren & Rogers. iors. & McReynolds. which has been carryover is a primary goal of group therapy. (c) generalization. ongoing Within a generalization planning framework. Kearns.. an aphasia test is given during the assessment charged with the task of determining how best to measure phase. The distinction between traditional treatment planning Kearns (1986a). available means to make lists of all (communication) behav- alization and maintenance phases. within the tradi. valid assessment is to choose generalization goals. The information can subsequently be graphed and used as a desire to facilitate generalization is foremost from the initial visual aid to monitor the effectiveness of treatment (Connell contact with the person with aphasia and his or her family. 2007). Because specific tests clinical goals. a generalization others that might affect generalization. alization goals be monitored so that appropriate clinical ment is the driving force behind generalization planning. 1986a). assessment. Yedor (1991). Novel appropriate utterances are encouraged and reinforced. naturalistic observations. a generalization training approach is approach is to use a forward-chaining technique to lengthen procedurally more complex and. clinical aphasiologists have attended to ing and analyzing spontaneous interactions with familiar the assessment and intervention phases of the clinical and unfamiliar partners. sometimes. appropriate modifications can then be made to intervention cate in nonclinical settings as well as with people and in sit. For example. patient-initiated utterances and encourage response variety. and the results of this testing are used to establish progress toward generalization goals. settings. occurs to targeted people. a generalization planning approach to clinical their own means of assessing performance or adapt nontra- management assumes that carryover of improvements in ditional measures (Garrett & Pimentel. modifications can be initiated. clinicians must often develop By contrast. most clinical aphasiologists would contend that Response Elaboration Training (RET). and time to evaluate progress toward generalization goals. . interviewing signifi- and (d) maintenance. Importantly. discrete-phase approach. to maximize the probability of obtaining generalization. (b) intervention. consuming than its traditional counterpart. separation of the for intervention if improved communicative ability is likely clinical process into discrete phases encourages the estab. That is. strategies as needed. 1988. which are then prior- as a means of integrating the known clinical phases into a itized for the purposes of deciding what combination of continuous loop that incorporates specific procedures to client behaviors and environmental factors need to be altered maximize the possibility of promoting generalization (Baer. First. clinical of patient management into an integrated whole. 1985. Kearns and Scher (1988). Hughes. all probe data can be examined to determine if generalization steps in the process are woven together for the express pur. Baer (1981) suggests using every process while placing relatively little emphasis on the gener. people. however. When these goals are met. to carry over to real-life settings and conditions. 1981. The thrust of this cal viewpoint. and as a result. After all. In contrast to the tradi. mini-tests) can be given periodically over intervention. reported a treatment approach.qxd 1/21/08 12:52 PM Page 393 Aptara Inc. This intervention are all influenced by this assumption. carryover of assessment and visuographic data presentation also serve as functional abilities is the clinical glue that bonds all aspects a guide in making treatment decisions. The primary outcome of an expanded. goal setting. 1985). it is imperative that progress toward gener- the discrete-phase model of clinical practice. Chapter 14 ■ Group Therapy for Aphasia: Theoretic and Practical Considerations 393 into every program that endeavors to make important social whereas the discrete-phase approach to assessment of indi- and life-style changes for clients” (p. These clini- functional communicative abilities is the primary goal of cal probes (i. 1988. As is true of other clinical specialties in cant others to determine communicative needs.e. For example. Kearns (1989) notes the following differences between a based on the information gathered. The clinician is also tional model. phases: (a) assessment. their attain. Thus. Because generalization of aphasia treat- uations they experience in daily life.GRBQ344-3513G-C14[376-400]. sufficient level of generalization occurs. and record- speech pathology. tion (Baer. go beyond simply reinforcing selected ogy coursework. Task hierarchies should be cated that they had taken coursework or training in group developed to elicit responses under conditions that increas.qxd 1/21/08 12:52 PM Page 394 Aptara Inc. Stokes In addition to investigating treatment approaches. 1986). gested that group therapy for aphasia may provide a means of 2000. Attempts to target future direction of group therapy for aphasia will bring an generalization directly. by incorporating increased awareness regarding the training needs of group procedures that may facilitate carryover are an integral com. we may increase the probability of obtaining clinicians who conduct group therapy for aphasia reported carryover to the natural environment. counseling. clinicians. 1999. group treatment to facilitate generalization. 1991). and FUTURE TRENDS then prompts him or her to provide additional information. Horner et al. or related areas. or we until the patient’s spontaneous responses are lengthened to can continue along a newer path of rigorous research to add preselected levels. a generalization planning approach has been investigators and academicians alike need to consider clini- reviewed and related to group therapy for aphasia. A unique aspect of this approach is alized treatment and the natural environment. and effective group treatment procedures. each spontaneous conversational seem to be obvious. 1981. it would be desirable to be able to predict with rea- Yedor. Kearns By appropriately targeting generative responding in the and Simmons (1985) found that 74% of a large sample of group setting. While it is not clear ingly approximate the natural environment. Thus. Stokes & Osnes. Simmons-Mackie et al. The a given stimulus item is acceptable regardless of the form or group setting provides an important link between individu- content of that response. future research should ment are based. this issue must be addressed in the near future. 1999. Generalization train. the & Baer. Only future that the patient directs the content of treatment. 394 Section III ■ Psychosocial/Functional Approaches to Intervention That is. this approach has research group treatment methods aggressively. tice.. Defoor-Hill. replicable. Results to date indicate that gener.. a series of studies has exam. 1986. 1977. Throughout RET. Kearns. Once treat. & Damico. cies. . Kearns & Scher. The future direction of group therapy for aphasia occurred following RET (Kearns. guidelines to evaluate the skill level of group leaders. 1999). on the rationale that loosening and eventually compare the relative effectiveness of group treat- diversifying treatment parameters may facilitate generaliza. We can fall Each novel elaboration is subsequently added to the chain back on the worn path of investigative complacency. Elman. however. sub- for future research and development of strategies that pro. research can determine the most effective means of using ment stimuli are selected. become strongly entrenched in our clinical repertoire bal) responses and reinforce the use of novel but appropriate because of historical precedent and practical clinical exigen- utterances. Hughes. are available to guide our clinical prac- mentally in the group setting. ances are used as building blocks for developing more elab- orate responses. methods. an interactive. and it also provides a rich arena 1981. Simmons-Mackie. and In summary. It was sug. models them for repetition by the patient. & cific. the road to group therapy research will turn during group activities can serve as an opportunity for continue to be challenging. types of group treatment. dynamics. (McPeek & Mostellar. In addition. The clinician combines successive patient responses. mitted). 2000. cal training factors relating to group intervention (Elman. 1988. however. We do not. submitted). sonable certainty which patients would benefit from which Both RET and other “loose training” approaches to treat. Holland. refining this clinical process. Group therapy for aphasia is at a crossroads. 2007. any patient-initiated response that was relevant for incorporating generalization prompting techniques. The group setting provides an environment for 1973. turn. 1985. Elman.GRBQ344-3513G-C14[376-400]. ment methods. have academic or training mote generalization. depends on whether clinical aphasiologists will continue to 1989. Group therapy for aphasia presents additional chal- Summary lenges that are not encountered in individual sessions. Intensive group treatment research will not be forth- ined the efficacy and generalization of this approach for coming unless we overcome the “illusion of strong evidence” individuals with aphasia. 1977) that supports current clinical alized increases in verbal response length and variety have practices. Very few experimental studies of group treatment Although the RET format has not been tested experi. Only 24% of the survey respondents indi- responses when they occur. no additional training beyond their speech-language pathol- ing should. Although the choice may to group treatment. 2007. however. Kearns & Yedor. 1990) and communicative drawing (Kearns & Ideally. the patient’s spontaneous utter. It has been suggested that not all clinicians are ponent of a generalization planning approach to intervention appropriately trained to conduct group therapy (Eisenson. as a goal of therapy. in part. to the knowledge base regarding group therapy for aphasia taking format is maintained so that it can be readily adopted (Elman & Bernstein-Ellis. Group therapy for aphasia has the clinician to prompt more elaborate verbal (and nonver. 1991). Ewing. That is. for aphasia. exactly what type of additional training is advisable for group clinicians. The ulti- also successfully facilitated improvements in nonverbal mate goal of research in this area should be to identify spe- means of communication (Gaddie-Cariola. Sarno. .qxd 1/21/08 12:52 PM Page 395 Aptara Inc. (1981). including the Bennett. 5.. Van virtual communicative interactions may eventually replace der Gaag et al. Wertz et al. Boston. 7. MN: BRK. while in existence References since the post–World War II era. S. D. practitioner: Research and accountability in clinical and educational settings. the future direction of group therapy rather than a convenient supplement to individual for aphasia will depend on people rather than technology. how- ever. West. Aten. Bernstein-Ellis. static picture cards as the primary stimulus material used dur. General trends in rehabilitation. Ellis & Elman. A. 12. ply a matter of necessity. S. H. also bode well for the future of Avent. 47. (1954).. Group therapy for aphasia should now be considered ing group sessions. Manual of cooperative group treatment for apha- sia. Kagan et al. the norm rather than the exception. 116–122. R. Frattali. 93– 96. J. The scientist that incorporate clearly articulated treatment ratio. Shatin. F. Attempt to catego- rize the group intervention into one of the types of therapy KEY POINTS discussed in the chapter. 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Aphasiology.GRBQ344-3513G-C14[376-400]. disability and health: ICF. www. approach. An Brookshire (Ed. P.. (2001). cooperative study on aphasia: A comparison of individual and Wahrborg. S. Author.) (1985). Linell. G.. Wilcox. I... Group treatment of Warren. communication in individual and group settings. Louis: V. Austin. Davis. Hedber-Borenstein. Geneva. S. International classification of munication disorders: The expert clinician’s approach (pp. Vickers. Journal of Speech and Hearing Research. M. Smith. Journal of Speech and Hearing Yalom. 12. Stimulation Approaches .GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 401 Aptara Inc. Section IV Traditional Approaches to Language Intervention A. .GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 402 Aptara Inc. rationale. the approach described in this bution. it is necessary to delimit further the territory to be covered in this chapter. evaluation. and goals. is particularly noteworthy. Jenkins. Sarno. although all current approaches to the The bulk of Hildred Schuell’s work in aphasiology treatment of aphasia will not be discussed. defined ways. and methods of adequacy of language performance in persons with aphasia. 1993. and specific other sequelae of brain damage” (Schuell. & 403 . theory. and theory development regarding those investigations that continuously help to refine the the underlying nature of the disorder. Therefore. The remainder of the language modalities and may or may not be complicated by chapter will emphasize the principles. Duffy Before proceeding. and techniques associated with the stimu- lation approach to aphasia rehabilitation. and it included significant given to the contributions of many individuals in addition to contributions in the areas of diagnostic testing. and techniques. design. Receiving special emphasis will be of patients with aphasia. Davis. “Schuell’s stimulation approach. In this Systematic observation and testing of more than a thousand chapter. Hildred Schuell was among the approach. rationale. because it chapter is often referred to as “Schuell’s therapy” or was the first complete elaboration of the approach (Darley. Sinotte. however. observing and categorizing behavior that helped Schuell to develop the compelling rationale for the stimulation approach. This sound foundation also helps to explain why PREREQUISITES TO UNDERSTANDING the stimulation approach represents one of the main schools THE STIMULATION APPROACH of thought in therapy for aphasia and has been one of the Definition and Primary Symptoms of Aphasia most widely used treatment approaches employed in this country (Darley. scientifically minded. procedures. Although Schuell aphasia that places its primary emphasis on the stimulation was a “prime mover” in the development of the stimulation presented to the patient. stimulation in more broadly. many other clinicians and investigators have con- most lucid. or more narrowly. and specific goals distinguishes it from other treatment approaches that use associated with the stimulation approach. propose and offer support for this approach. Schuell’s definition. Coelho. 1975. the stimulation approach may be thought to encompass all approaches to Hildred Schuell’s stimulation approach to therapy for apha. This chap. virtually all approaches used by speech-language pathologists for the OBJECTIVES treatment of aphasia must necessarily involve stimulation of some kind (Wepman. First. theory. attention will be spanned the 1960s and 1970s. Joseph R. define aphasia as “a general language deficit that crosses all standing the stimulation approach. The presence of numerous other sia represents one of the main schools of thought in aphasia chapters in this book. and insightful clinicians to tributed to the development or refinement of its rationale. classification those of Hildred Schuell.” 1972). The material presented here is con- treatment approaches employed in this country. and classifications of and it is her name that signals the scope of this chapter and aphasia as well as the principles. makes it clear that this is not rehabilitation and has been one of the most widely used intended to be the case. The second point is intended to qualify the narrowed This chapter deals with an approach to the treatment of scope described in the previous paragraph. 1953). Wepman’s (1951) contri- major role in its development.GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 403 Aptara Inc. Because of her principles. Chapter 15 Schuell’s Stimulation Approach to Rehabilitation Carl A. 1981). ceptually related to Schuell’s specific approach to treatment. for that reason. aphasia rehabilitation. for example. and classifications of patients with aphasia led Schuell and her colleagues to aphasia will be reviewed briefly as prerequisites for under. Michele P. It was probably this approach by identifying stimulus factors influencing the sound foundation in theory. ter reviews Schuell’s definition. p. p. 404 Section IV ■ Traditional Approaches to Language Intervention Jiménez-Pabón. underlying nature of aphasia has led to the existence of Conversely. iology and. To 1974a. as well as bances at different stages of the dichotomy or relay impaired comprehension and production of messages. Because treatment is in the absence of sensory or motor deficits. what we is linked. Like Wepman. including Schuell. That is.. 1. 104). Such classical models ignore the by depression or an altered attitude toward communication. because the efficacy of treatment continues which require discrimination. They also allow aphasia to be thought of Schuell consistently viewed a reduction of available vocab. Likewise. 104). conduc- being the primary characteristics of aphasia (Schuell. Consequently. the nonaphasic disturbances—most often would include modality-specific perceptual distur. and Van Pelt (1960). p. tion of that method. the language mechanism can be impaired numerous approaches to treatment. 138). Until the efficacy of any approach to the rehabilitation of a Schuell viewed language as an integrative activity that person with aphasia is unequivocally demonstrated. Therefore. Such complex interactions preclude the exis- rence of similar deficits across modalities within patients.GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 404 Aptara Inc. in effect. such notions tion.. dysarthrias. to sensory and motor modali- do must at least be defensible on theoretic grounds. 1961a. “the impairment is regular and orderly. the nature of the language breakdown in aphasia can be ken language. language can exist unim- down that occurs when the brain is damaged. Finally. to the clinical behavior of ities but also tends to be evident in all modalities in a similar most patients with aphasia. linguistic rules. place the existence of isolated sensory or additional characteristics. dynamic interaction of complex cerebral and subcortical guage phenomena” (Schuell et al. the existence of numerous beliefs about the or express language through an impaired modality. & Sefer. reading. “I use this approach because it works!” trol. Schuell & Jenkins. Jiménez-Pabón. and writing “involve the (p. therefore. 1969. That is. her observations indicate that the impaired ability to do not correspond to modern concepts of neurophys- retrieve and use the language code not only crosses all modal. rationale and procedures used in the stimulation approach. Schuell ties. In addi. In fact. the relationship between the semantic and syntactic aspects of language Underlying Nature of Aphasia is so strong that their separation at the physiological In most scientific clinical endeavors. speech. such as a reduction of communication generated (Schuell et al.. Schuell et al. through which language is channeled. complexity of perceptual and motor processes and may occur as a reaction to the primary symptoms of aphasia view language as an activity bound to sensation and (Jenkins. because the same language system is the nature of aphasia that specifically underlie the stimula.g. retrieval. In the adult. reading.. cedures and techniques become logical extensions of the aphasia is viewed as a multimodality disturbance that is underlying rationale. is complicated by an abundance of motor deficits. Shaw. 3. and they figure strongly in the motor deficits outside the realm of aphasia. Language cannot be thought of as a simple sensori- bances. as tence of simply segregated sensory and motor divisions well as the predictable nature of those deficits. 1964). it is preferable that the level is arbitrary at best (Schuell et al. but not bound. and writing. rationale for using a particular method precede the applica. although it might be difficult to receive choices. to be debated and we cannot always confidently. language is the result of the operates in a manner that is lawfully related to known lan. the use and maintenance of cal aphasiology. activities. it is essential that we have some instances. 113). say. Jones. more important. transmission. 1975). storage.. speech. used by (or linked to) all input and output modalities tion approach.. tion aphasia. the stored elements and rules are common (1974b) supported such a notion with her belief that “what (central) to all input and output modalities. the various elements of language cannot be separated neurophysiologically. manner. For example. the disturbance will be reflected in understanding of the model of language and beliefs about all modalities. The adoption paired even in the presence of severe sensory and/or of such beliefs. The language mechanism contains a system of stored. The occur. and sensorimotor deficits (including motor dichotomy or a three-system cortical relay apraxia of speech). unidimensional in nature. and verbal retention span. 1964). Also. If such a model and beliefs are palatable. receptive or Wernicke’s aphasia. many investigators. pro. and 2. however. Bock. The language modalities Schuell’s beliefs about the organization of language and referred to in the definition include comprehension of spo. organization. movement. it is important that our methods of same referents and the same categorizations of individ- treatment be linked to our beliefs about the organization of ual and collective experience” (Schuell et al. 1964. ver- you do about aphasia depends on what you think aphasia is” bal comprehension. are important and. as system (e. however. language in the brain and the nature of that language break. In such subject to such beliefs. The “other summarized as follows: sequelae”—that is. other complications and secondary involving reception. and execution symptoms. not only do all . learned elements and rules. pure disorders reflecting distur- ulary. in terms of isolated. though comparison. Neurophysiologically. 1964. 1964). and expressive or Broca’s aphasia). 1964. and feedback con- superficially. This is particularly important in clini. transmission. lan. Such input and that all patients with aphasia were alike. Her view of apha- sia as a multimodality. scious control over speech execution remains necessary. unidimensional impairment clearly Aphasia with Sensorimotor Involvement precluded categorizing patients according to modality of impairment (e. They gories indicate the severity of language impairment and. 1975). Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 405 modalities tend to be impaired in aphasia. The prognosis for language recovery is not lost or destroyed in aphasia is an important factor is excellent. Schuell and Jenkins (1961b) wrote syndromes were treated as major categories. Although the potential for functional language exists. the problems of most patients appear to be more related to performance factors than to competence “Simple aphasia” is considered to be relatively mild multi- factors (Schuell. “Aphasia with persisting dysfluency” is mild aphasia with guage processes are acquired and organized through associated verbal dysfluency as an apparent result of propri- complex. agraphia. processing. elements and rules are not lost or destroyed but that the sensorimotor.g. and recall. or dysarthric components. dysarthria. Second. In aphasia. Aphasia with Scattered Findings guage and in the stimulation approach to language “Aphasia with scattered findings” is considered to be moder- remediation will be discussed in more detail later. in addition to the common the stimulation approach in two ways.. The prognosis processes. Schuell’s system contained five categories and require that patients with aphasia vary only along a two minor syndromes. 299). the minor severity continuum.. dis- turbed internal signal sources. Aphasia with Visual Involvement and the general asynchronous chaos of processes whose “Aphasia with visual involvement” refers to mild aphasia mass action can no longer be properly coordinated” complicated by central impairment of visual discrimination. The importance of auditory processes for lan. That is. receptive. or alexia) “Aphasia with sensorimotor involvement” is defined as or the element of language involved (e. defective speech analyzers. Originally. but continued con- those interacting systems that aid in the acquisition. but based on output problems signal a possible need to modify stimuli or her clinical observations and objective analyses of data. syntac. Notably. The seven cat- that among patients with aphasia. interacting sensory systems and sensorimotor oceptive disturbance (Jenkins et al. give some indication of the level at which stimula- guage tests may be arranged in subgroups which show tion should be directed. impairment resulting from language deficit are identifi. auditory processes are at the apex of for recovery from aphasia is excellent. according to the severity of language impairment. her classification system aimed at tend to be impaired in the same manner and to about descriptive and predictive utility by classifying patients the same degree. Aphasia with Persisting Dysfluency 6. our primary lan.. The prognosis for language system either is working with reduced efficiency recovery is excellent. 59).” The point here is that Schuell did not believe ing is least likely to be valid or interpretable. First. and progno- sional. p. the various cate- or general dimension of language deficit” (p. also stated.g. 1975).. but reading and writing recover more slowly. These classifications are useful in planning treatment with able. Classification of Aphasia or emotional lability). Simple Aphasia 5. expressive. or absence of related sensory or motor deficits. and need to be studied. 1969). severe language impairment with impaired perception and . in determining that the stimulation approach does not involve the “teaching” or “re-teaching” of language.. 299). restructure response demands.. the prognosis is limited by the concomitant Schuell’s classification system for aphasia is unique when physiological and psychological problems. ate aphasia involving a variety of problems compatible with generalized brain injury (e. compared to most other popular systems. Instead. “[A]t a given level of language deficit. semantic. due to faulty connections.GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 405 Aptara Inc. multimodality concept of aphasia does not sis. ated non-aphasic deficits indicates those input avenues with ous modalities as well as systematic differences in the the least intact access to the language system as well as those performance of various segments of aphasic populations output avenues through which evidence of language process- (p. they also tic. the disorder—a general disturbance of language that is reflected in a similar manner in all modalities. the identification of associ- systematic regularities in aphasic performance in vari. Later (Jenkins et al. They also identify non-lin- she chose to emphasize the apparent universal feature of guistic disturbances that also may require remediation. (Jenkins et al. visual involvement. Although the language mechanism can exist separately from both input and output modalities. It is important to recognize that Schuell’s unidimen. “many dimensions of egories are summarized below.g. and control of language (Schuell et al. presence 4.. or is “swamped in noise. or anomic). 1975. 1964). Schuell’s belief that language recognition. it appears that linguistic modality language impairment with no specific perceptual. therefore. Experience tells us that for some firing of neurons and the number of fibers activated. In addition. guage may occur. repetitive stimulation can increase respond. Schuell et al. Finally. on baseline testing. some patients with dis- stimulation (Eccles. Schuell. 1971). the auditory channel is not the most appropriate the threshold of response can be altered by repetitive avenue for stimulation. the manipulation and control of stimulus dimensions to aid That is. nization and recovery of language. the bance. impaired system. proportionately severe impairment of auditory processes 1967). Language “patterns” appear to be no exception. Numerous studies indicate that nearly all people with aphasia exhibit deficits in the auditory modality (Duffy Irreversible Aphasia Syndrome and Ulrich. The cal and subcortical lesions (Calautti. 2. 1964). A caveat regarding the primacy of the auditory modality increasing stimulus strength increases the frequency of in treatment is in order. 1953b. 1964. Aphasia with Intermittent Auditory Imperception 3. Smith. if the patient’s problems in each modality are a the patient in making maximal responses. 1974). is a prerequisite to recovery of other speech and APPROACH—GENERAL DESCRIPTION language abilities (Brookshire. controlled. It has been suggested that many of the modality loss of functional language skills. Wepman (1953. during original learning and that appropriate stimuli are required for adequate retrieval (Schuell et al. For such individuals. more favorably to written or the firing of neurons in homologous right-hemisphere gestural input. Hillis. Warburtion. 1964) as well as of Schuell The stimulation approach can be defined as the approach to alone (1953a. et.. but normalcy is not achieved. Because “sensory stimulation is the only 5. and ongoing functional lan- “Aphasia with intermittent auditory imperception” is usually guage is dependent on the auditory system for processed considered to be severe aphasic impairment with severe information and control through feedback loops involvement of auditory processes. The use of intensive auditory stimulation is consistent method we have for making complex events happen in the with the definition of aphasia as a multimodality deficit brain” (Schuell et al. the clinical observations of Schuell and colleagues (1955. & use of intensive auditory stimulation in the stimulation Baron. It is an approach that rec- Schuell (1974c) considered the notion of intensive audi- ognizes the stimuli to which an intact language system can tory stimulation to be “the most important clinical dis- respond may be inadequate for eliciting responses from an covery that we ever made” (p. and retrieval of patterns in the brain. because language The stimulation approach can be further understood by proficiency is largely the result of linguistic stimulation identifying some things that it is not. 1973. The prognosis is for lim. and patients. What the Stimulation Approach is Not storage.GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 406 Aptara Inc. Thus. Recovery of some lan- (Schuell et al. 2005. Many lines of research indicate that repeated sensory stimulation is essential for the acquisition. 406 Section IV ■ Traditional Approaches to Language Intervention production of phonemic patterns. stimulation can and does influence brain important-to-recognize exceptions exist. and experience. The prognosis multimodality impairments that patients with aphasia for recovery of functional language is poor. structure and function. al. 1968) . Naeser. Thompson. input and output language channels. 1953b) and that recovery of auditory functions. at the neurophysio- approach should therefore be viewed as a rule for which logical level. reflection of a common underlying language distur- Although numerous input modalities may be used.. “Irreversible aphasia syndrome” is nearly complete multi. the primary stimulus brain regions in individuals with left-hemisphere corti- channel in therapy may be visual instead of auditory. for many patients. p. treatment that employs strong. experience stem from these auditory deficits (Schuell. 2002). and intensive controlled auditory stimulation results in multimodality auditory stimulation of the impaired symbol system as the improvement greater than that when treatment focuses primary tool to facilitate and maximize the patient’s reorga- on movement patterns or on each modality separately. 4. we should expect that gains made tion is supported by the following: through the auditory modality will extend to all other 1. sensory input alters the electrical activity of the brain. 2003. For example. Sensory stimulation affects brain activity. 1964. The auditory system is of prime importance in the acquisition of language. In addition. 338). organization. it makes sense to channel treatment through the auditory modality is at the foundation of the stimulation auditory modality because of its crucial link to language approach. The use of intensive. controlled auditory stimula- processes. 1976. In doing so.. For example. the approach employs that results from an underlying disturbance of language. 112). 1976a.. 1964). 1969) suggest that the use of intensive. Holland and Definition and Rationale Sonderman. it is likely that language ited but functional recovery of language with persisting retrieval works through patterns of excitation laid down signs of sensorimotor impairment. Individuals for Whom the Approach is Appropriate Second. Such an approach treats the patient as an Before discussing the general principles and design of inter- active participant in the reorganization of language and vention. 1969).GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 407 Aptara Inc. or coincide with their role is to stimulate the adequate functioning of dis. and preventing withdrawal and and focusing treatment on skills that have functional rele- depression (Schuell. to When present. 2001). socialization. Instead. as stated earlier. aphasia. Wepman. the stimulation that often co-exist with aphasia. duration of treatment. 332). The severity of aphasia should— Third. may be secondary to. Schuell and colleagues (1955. or interest. is not part of First. should be distinguished from the more carefully planned Schuell believed that the main objective of treatment is to and controlled approach that is the focus of this chapter. rigid. Using stimuli the patient and family. such as perceptual deficits. such deficits may interfere they are taught to speak. therapy for aphasia. 73).. nor does the presence of apha- (p. the approach emphasizes Philosophical Underpinnings the action that is elicited within the patient by the stimuli that are presented. the method must be altered” (p. a brief summary of the general philosophy underly- adjusts stimulation to maximize the ability of the patient to ing the stimulation approach is in order. the specific guistic. This philosophy participate in the process. It is not intended to remediate problems dent to learn a lost language. therapy does not emphasize non-aphasic deficits. or if a patient out- and reducing anxiety. lation. He indicated that the purpose of with communication but do not disturb language per se. diagnosis is a crucial part of the therapeutic Relative to Severity process. severe aphasia (Schuell’s 1968). the approach is not invariant along we know what to work on and where to begin. indicated that the approach is an attempt “to ence does not necessarily preclude use of the stimulation reorganize a system already reorganized by brain damage” approach to treat the aphasia. For example. Therefore. . however. If the method leaves the patient behind. 1953. That is. Schuell and colleagues (1964) stated. should temper any desire on the part of the reader for a Finally. methods should be flexible enough to be discarded if they are not working. increase communication and that techniques merely assist in achieving that end. He pointed out that. The neurologic. or dysarthrias. Communicative Deficits Finally. memory or the reproduction of stimuli as stimulus-response learning approaches do. treatment should be logically The stimulation approach attempts to improve language or related to beliefs about the nature of aphasia. “We believe the approach being discussed here. what Taylor (1964) has called nonspecific stimu. 1964. universal approach to treatment. Not only do such considerations reflect the clinician’s irreversible aphasia syndrome) may sharply limit use of the personal sensitivity. method. but not an arbitrary would include merely talking to the patient as much as pos. lin- and does—influence the nature of stimulation. Variations of the approach as a vance to the patient have been demonstrated to show greater function of severity will be discussed in more detail later. take precedence over. counseling of associational linkages in the patient’s brain. or the spontaneous recovery approach. the severity continuum. Clearly. sible. The treatment of concomitant non-aphasic deficits 1964) emphasized that aphasia clinicians are not teachers. There is no room for rigidity in clinical practice . Martin (1975). they require treatment that differs signifi- focus on “old learning” and stimulate the patient to produce cantly from the stimulation approach used therapy for the new integrations for language. treatment must not proceed without some knowledge of the patient’s assets and liabilities in each The rationale and general goals of the stimulation approach modality and some information about why performance do not preclude its use with particular degrees of language breaks down when it does. because the approach is based sia and use of the stimulation approach for its treatment nec- on a model which views aphasia as an interference with (not essarily preclude the use of other approaches to treat the a loss of) language processes. they also help to identify motivating stimulation approach and reduce treatment to a short-term material and pinpoint stimuli that may have very strong program aimed at improving comprehension. treatment must be relevant. approach involves a person whose communication ability . Instead. Only with such information do impairment. . and social needs and interests of the patient need to treatment goals and procedures. Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 407 argued that patients with aphasia do not recover because apraxia of speech.. rather. Nonspecific stimulation in a general philosophy of treatment. The stimula- reduce the functional handicap imposed by the disruption of tion approach includes no material to be taught and no stu- language processes. gains in restoration of skills and/or increased use of com- pensatory strategies in individuals with aphasia (Pulvermüller Relative to Associated but Non-Aphasic et al. their pres- of learning. viewing the stimulation places limits on the application of the stimulation approach approach as being conceptually related to cognitive theories and the expected outcome of therapy for aphasia. such approaches to treatment strips the method. working to establish rapport. stimulation is not to convey new learning but. Although non-aphasic deficits often rupted processes. and the frequency and be considered and used (Schuell et al. GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 408 Aptara Inc. 408 Section IV ■ Traditional Approaches to Language Intervention may be improved with appropriate stimulation. Such a phi- What the patient needs in such cases is more stimula- losophy significantly affects the principles and conduct of tion, not correction or information about why a therapy. response was inadequate. 6. A maximum number of responses should be elicited. A large number of adequate responses indicate that a GENERAL PRINCIPLES OF REMEDIATION large number of adequate stimuli have been presented. Numerous responses also provide frequent feedback The design of intervention used in the stimulation approach and reinforcement of language and help to increase is based on a number of general principles, many of which confidence and language attempts outside the treat- were articulated by Schuell and colleagues (1964). A number ment setting. of additional, very practical principles that also apply to the 7. Feedback about response accuracy should be provided stimulation approach have been presented by Brookshire when such feedback appears to be beneficial, and such (1997). It should be noted that several of these principles are feedback should show patients their progress. The indigenous to good clinical practice, regardless of the spe- necessity for feedback may vary from patient to cific approach used. They are addressed here because they patient, but it is generally advisable. Showing patients have grown out of observations of patients treated with a their progress may be motivating, reinforcing, and general stimulation approach. Information pertinent to the extremely helpful in “proving” that progress is, in fact, validity of the applied principles will be presented when the taking place or that different approaches or termina- design of intervention is discussed. The general principles tion of treatment should be considered. derived from those discussed by Schuell and/or Brookshire 8. The clinician should work systematically and inten- are as follows: sively. Treatment requires a sequenced plan of action. 1. Intensive auditory stimulation should be used. As It should be implemented often enough to meet the noted earlier, this is the framework of the stimulation patient’s needs, taking into account their overall condi- approach and is based on the primacy of the auditory tion and prognosis for recovery. modality in language processes and the notion that the 9. Sessions should begin with relatively easy, familiar auditory modality represents a key area of deficit in tasks. This allows an adjustment and “warm-up” time, aphasia. The auditory modality need not be used and it enables the patient to proceed to more difficult exclusively. One modality may be used to reinforce activities after experiencing success. another, and combined auditory and visual stimulation 10. Abundant and varied materials (Schuell et al., 1955) may be especially appropriate. that are simple and relevant to the patient’s deficits 2. The stimulus must be adequate—that is, it must get should be used. Treatment does not involve the learn- into the brain. Therefore, it needs to be controlled, ing of vocabulary or rules, so content need not be lim- perhaps along a number of dimensions. The applica- ited to “items-to-be-learned.” As Wepman (1953) tion of this principle may be highly dependent on base- indicated, the specific content of treatment is not as line data and may involve considerable individualized important as the manner in which the treatment is pretreatment planning. Brookshire (1997) states that conducted. A variety of material also reduces the frus- the difficulty of tasks should match the level at which tration often induced by drills on a small amount of patients are working or be just below maximum per- material. formance level (i.e., approximately 60% to 80% prompt 11. New materials and procedures should be extensions of and correct responses, and task difficulty is increased familiar materials and procedures. This allows the when prompt correct responses exceed 90% to 95% patient to concentrate on language processing and accuracy). minimizes the possible disruptive effects of new mate- 3. Repetitive sensory stimulation should be used. rial and response demands. Auditory material that is ineffective as a single stimulus may become effective after it is repeated a number of times. DESIGN OF INTERVENTION 4. Each stimulus should elicit a response. This is the only In this section, those factors that must be considered in way we can assess the adequacy of stimulation, and it developing a treatment program will be considered. Because provides important feedback that both the patient and the most important component of the stimulation approach the clinician may use to modify future stimuli and is, by definition, the stimulation provided to the patient, responses. those variables that are potentially most important to struc- 5. Responses should be elicited, not forced or corrected. turing stimulation will receive primary emphasis. Response If a stimulus is adequate, there will be a response. If a demands, feedback, and the sequencing of treatment steps response is not elicited, the stimulus was not adequate. also will be discussed. The reader is cautioned, however, that GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 409 Aptara Inc. Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 409 the recommendations offered here for implementing the McNeil, Darley, Rose, and Olsen (1979a) found no sig- stimulation approach are based on rather broad generaliza- nificant improvement in a group of 10 patients with aphasia tions derived from a potpourri of research and observation on a word discrimination and word sequencing task or on of heterogeneous groups and individual patients. Conse- portions of the Revised Token Test (McNeil and Prescott, quently, few, if any, of the recommendations can be assumed 1978) when stimuli were presented under earphones at 75, to apply effectively to all patients with aphasia. 85, and 100 dB sound pressure level (SPL). Group data were representative of individual performance. The authors con- cluded that simple increases in stimulus intensity do not Structure of Stimulation improve the auditory comprehension of patients with A great deal of information has been acquired about stimu- aphasia. lus variables that may affect the performance of patients Although little evidence supports increasing the volume with aphasia. Such data are largely the result of basic clinical of auditory stimulation, reducing noise or increasing the sig- and experimental research and are not primarily derived nal/noise ratio does appear to be beneficial. Patients with from specific treatment studies. Nonetheless, the data are aphasia often complain about the negative effects of noise invaluable to the clinician who must decide how to make on performance (Rolnick & Hoops, 1969; Skelly, 1975). stimulation adequate and effective during treatment. As Although Birch and Lee (1955) found that a binaural mask- Holland (1975) and Tikofsky (1968) have suggested, one ing tone improved the naming and reading performance of strategy for designing treatment is to follow leads provided patients with aphasia, other investigators have not con- from research by turning the experimental techniques curred. Weinstein (1959), Wertz and Porch (1970), Schuell designed to isolate a particular problem into potential treat- and colleagues (1964), and Siegenthaler and Goldstein ment tasks. Nowhere in the aphasiology literature are there (1967) found either no difference in performance accuracy so many “leads” as in the area related to stimulus variables in quiet versus noise or found noise to have a detrimental that affect performance, and these leads have at least three effect on performance on language tasks. Darley (1976) con- practical applications to patient management. First, knowl- cluded from a review of such studies that “background noise edge about stimulus manipulations that may maximize per- apparently reduces the efficiency of the patient’s perfor- formance can be used to ensure that a patient is working at a mance” (p. 4). level where “failure” is minimized. Second, and conversely, These studies suggest that reducing noise or working in knowledge about stimulus manipulations can be applied in quiet generally facilitates language performance. Simply the opposite direction to challenge mildly impaired patients increasing loudness, on the other hand, does not appear to or those who respond without difficulty to tasks designed to be useful, although such an increase may enhance perfor- maximize performance. Third, many of the factors to be dis- mance in isolated cases. Many clinicians feel confident in cussed may be useful when counseling people in the advising patients’ families that verbal comprehension is typ- patient’s environment who need information about how best ically better in quiet than in the presence of a variety of dis- to communicate with the patient in everyday interactions. tracting or competing auditory stimuli (e.g., television, The following discussion represents a review of the vari- radio, or background conversation). ables most relevant to the structuring of stimulation. Nonlinquistic Visuoperceptual Clarity Auditory Perceptual Clarity (Volume and Noise) (Dimensionality, Size, Color, Context, Ambiguity, and Operativity) Although Schuell and colleagues (1964) suggested that most patients prefer to hear speech at conversational levels, those Visual materials are often used as an integral part of the authors indicated that an increase in volume (not shouting!) stimuli to which patients are asked to respond. The impor- is sometimes desirable. Only a few controlled studies, how- tance of visual stimulation, in fact, led Eisenson (1973, ever, have been conducted to evaluate the effects of increas- p. 162) to call Schuell’s stimulation approach to treatment ing volume on auditory comprehension. a “visual-auditory” approach. Clinical observations suggest Glaser, Stoioff, and Weidner (1974) found that auditory that the properties of visual stimuli may influence responses, comprehension of persons with aphasia under sound field and the importance of the visual modality to language conditions at the conversational level was superior to com- behavior in general has led to the investigation of visual prehension under earphones (binaurally and monaurally) at redundancy as a potential factor influencing linguistic pro- 25 dB above the conversational level. Because of the interac- cessing in aphasia. tion between volume level and earphone/sound field meth- In a study of 21 patients with severe verbal comprehen- ods of presentation, the results are difficult to interpret, but sion deficits, Helm-Estabrooks (1981) compared perfor- they do suggest that increasing volume above the normal mance on a single-word comprehension task in which levels does not facilitate comprehension. stimulus conditions consisted of line drawings, each on GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 410 Aptara Inc. 410 Section IV ■ Traditional Approaches to Language Intervention individual cards arranged in rows; smaller line drawings of names of the three objects. Results were not uniform across items, all on a single page; and real objects around the room. subjects. Those with a diagnosis of Broca’s aphasia per- For the group as a whole, picture-pointing was superior to formed similarly to normal control subjects in their use of identification of objects around the room, but no differences context and in their ability to deal with fuzzy perceptual were found between the two picture conditions. Not all boundaries. Patients with a diagnosis of anomic aphasia, patients followed the group pattern, however. Helm- however, had difficulty integrating and using perceptual and Estabrooks concluded that auditory comprehension can be functional cues (dimension and context). These findings, influenced by variables extrinsic to central auditory process- along with those of Caramazza, Berndt, and Brownell ing, such as visual search skills. The posteroinferior frontal (1982), have led to the conclusion that, for some patients, gyrus has been demonstrated to be involved in the execution naming difficulty is related to an inability to organize ade- of visual search activities (Manjaly et al., 2005). Given that quately the concepts underlying word meaning in terms of individuals with Broca’s aphasia often present with lesions in functional and perceptual information, as opposed to diffi- this area, these findings support Schuell’s notion that the culty with retrieval of an adequately perceived/conceived properties of visual stimuli may influence responses during lexical item. Although the implications of these findings for treatment. clinical practice are neither clear-cut nor universal, it Bisiach (1966) compared the naming performance of nine appears that the perceptual characteristics of visual stimuli subjects with aphasia in response to pictures of realistically should be as unambiguous as possible for all patients. colored objects, line drawings of the same objects, and the Placing a target object in a redundant conceptual setting same line drawings with superimposed curved or jagged (e.g., pairing a cup with a coffee pot) may enhance word lines. Although no differences were found among stimulus retrieval when the target is perceptually ambiguous. When conditions for object recognition, subjects’ naming of the pairing a target stimulus with other visual stimuli, however, realistically colored pictures was 15% to 18% more accurate the additional stimuli should never introduce ambiguity than their naming of line drawings and of distorted line about the nature of the target. drawings. The visual redundancy of the realistically colored The findings of Gardner (1973) suggest that the number drawings was felt to facilitate naming. of modalities in which associations may be evoked should be Benton, Smith, and Lang (1972) examined the naming considered when selecting visual materials for treatment. He performance of 18 persons with aphasia in response to real compared naming pictures of “operative” objects (discrete, objects, large line drawings, and small line drawings. firm to the touch, and available to several modalities [e.g., Accuracy of real object naming was superior to that for small “rock”]) to “figurative” objects (not operative [e.g., “cloud”]), line drawings; accuracy for large line drawings fell between while accounting for the effects of picturability and word the two. The redundancy provided by three-dimensionality frequency. Most patients with aphasia performed more was felt to enhance the conceptual associations underlying accurately in response to the operative items, and the effects word retrieval. Because of the relatively small differences of operativity were most pronounced for patients with diffi- between conditions, however, the authors questioned the culty initiating speech. Gardner argued that operative items clinical significance of their results. The possible insignifi- were superior because they aroused associations in several cance of three-dimensionality was supported by Corlew and modalities, whereas the figurative items were limited to Nation (1975), who found no differences in the performance visual associations. This perspective is supported by findings of 14 persons with aphasia when they named the 10 com- of Nickels and Howard (1995), who noted that operativity mon, real objects used in the Porch Index of Communicative and imageability (i.e., how easy it is to create a visual or audi- Ability (Porch, 1967), or PICA, than when they named tory image of the referent) were predictive of naming per- reduced-size line drawings of the same objects. formance for some individuals with aphasia. The implica- In a theoretically interesting study, Whitehouse and tion for treatment, therefore, is that visual stimuli which also Caramazza (1978) compared the ability of 10 persons with may trigger auditory, tactile, kinesthetic, or olfactory associ- aphasia to identify line drawings of three objects (a cup, a ations are potentially more effective in aiding word retrieval bowl, and a glass) varying in physical features such as height than stimuli which trigger only visual associations. and width. Stimuli consisted of prototypes (unambiguous To summarize, although some data suggest that some representations) of the three objects as well as drawings in properties of visual stimuli are relatively unimportant to the which the height-width dimensions were varied to make the performance of individuals with aphasia, the clarity and perceptual distinction among the objects “fuzzy.” In addi- redundancy of visual stimuli do not seem to influence lin- tion, some of the drawings had a handle, and some did not. guistic processing (Caramazza and Berndt, 1978). Darley Context (functional information) was also varied by present- (1976) recommends that we “play safe” and use the redun- ing stimuli either alone or in context with a coffee pot, a dant and realistic stimuli in treatment. The most potent cereal box, or a water pitcher. Subjects “named” the pictures visual stimuli appear to be characterized by three-dimen- by selecting from multiple-choice presentations of the sionality, color, redundant physical properties, operativity, GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 411 Aptara Inc. Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 411 and a lack of ambiguity in perceptual characteristics and dichotic listening studies that have found a left-ear advan- context. tage for patients with aphasia (e.g., Johnson, Sommers, & Weidner, 1977; Sparks, Goodglass, & Nickel, 1970). Linguistic Visuoperceptual Clarity (Size and Form) LaPointe, Horner, and Lieberman (1977) examined the responses of patients with aphasia to portions of the Token Few data suggest that the size or form of reading material Test (DeRenzi & Vignolo, 1962) when presented to the affects comprehension, but some clinical observations are right ear, the left ear, or binaurally and found no significant relevant. Rolnick and Hoops (1969) reported that patients differences among the three conditions. They concluded with aphasia complain about small print for word and sen- that selective monaural presentation of auditory stimuli is tence stimuli and prefer large print—even when visual field not a useful procedure. McNeil, Darley, Rose, and Olsen deficits are not present. McDearmon and Potter (1975) (1979b) examined the effects of selective binaural SPL vari- observed varying preferences for upper-case, lower-case, or ations in which stimuli were presented at 85 or 100 dB SPL script stimuli. Schuell and colleagues (1955) recommended to one ear while stimuli to the other ear were presented at 70 upper-case print for patients with visual impairments and dB SPL. Although a trend toward better comprehension on felt that script should not be introduced until the patient’s some tasks was noted when the left ear was more intensely reading rate for printed material is normal. stimulated, their general conclusion was that the unilateral Boone and Friedman (1976) examined single-word read- intensity increase is not a potent mechanism for improving ing comprehension in response to cursive versus manuscript auditory comprehension. stimuli in 30 patients with aphasia, and Williams (1984) To date, the data indicate that response adequacy to free- investigated the same factors’ influence on the word and field presentation is not exceeded when earphones are used sentence comprehension of 20 patients. Neither study found and that selective stimulation of one ear/hemisphere does significant differences between the two written forms. not surpass binaural stimulation. It should also be noted that Williams, however, observed that two of her patients reli- the findings of Green and Boller (1974) and of Boller, ably responded better to manuscript than to cursive. Vrtunski, Patterson, and Kim (1979) suggest that live-voice No compelling evidence suggests that the size and form presentation is superior to taped presentation of stimuli. of written input are powerful stimulus factors affecting read- Therefore, we have no compelling reason not to continue ing comprehension. When providing reading material for presenting auditory stimuli directly with live voice, binau- patients, however, the clinician should be aware of a general rally, and in the free field. preference for large print and potential idiosyncratic prefer- ences for upper-case, lower-case, cursive, or manuscript format. Discriminability (Semantic, Auditory, Visual) Verbal responses of patients with aphasia are often charac- Method of Delivery of Auditory Stimulation terized by errors associated in meaning or experience. Such Many clinicians have speculated about ways to improve the errors (e.g., “table” for “chair”) are, in fact, the “best” errors delivery of auditory stimuli to patients. For example, are a patient can make (Schuell and Jenkins, 1961a; Schuell there better alternatives to live-voice, binaural, free-field et al., 1964). These characteristics suggest that response stimulation? alternatives provided to patients should not promote seman- The use of earphones is intuitively attractive because of tic errors. This is particularly relevant for comprehension its potential for reducing extraneous noise and focusing tasks, which require the patient to choose from among a set attention. Schuell and colleagues (1964), however, observed of alternatives (e.g., responding to a verbally and/or visually that patients usually prefer direct presentation to ear- presented word or sentence by pointing to one of several phones, because they rely on more than auditory cues or, choices). Assuring that response choices are unrelated perhaps, because earphones produce distortions to which semantically will often facilitate speed and accuracy of per- they are sensitive. The preference for free-field presenta- formance. Conversely, tasks can remain unchanged in tion is supported by the previously mentioned study of nature but often can be made more difficult by introducing Glaser and colleagues (1974), who found that the compre- semantically related response choices (Duffy and Watkins, hension under free-field conditions was superior to binaural 1984; Pizzamiglio and Appicciafuoco, 1971). as well as right- and left-ear monaural presentations through Semantic discriminability among response choices is earphones. The superiority of the free-field condition was more important than visuoperceptual discriminability. This maintained even when the intensity of the earphone condi- is illustrated by the findings of Chieffi, Carlomagno, Silveri, tions was 25 dB greater than the intensity in the free-field. and Gainotti (1989). Their patients with aphasia made more It has been suggested that selective left-ear/right-hemi- errors on a single-word comprehension task when response sphere presentation of auditory stimuli may improve com- choices were semantically related (e.g., banana, apple, and prehension. Such speculation is based on the results of grapes) than when they were visually related (e.g., wheel, GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 412 Aptara Inc. 412 Section IV ■ Traditional Approaches to Language Intervention button, and lifebelt). Performance on a task in which words would be reasonable responses, thus requiring a response choices were both semantically and visually related greater number of word retrieval decisions. The patients (e.g., chair, bench, and stool) was poorer than in the seman- with aphasia made significantly more errors and had greater tically related condition, suggesting that semantic and per- response latencies regarding high-uncertainty pictures than ceptual effects may be cumulative, although the authors regarding low-uncertainty pictures, leading the authors to argued that the semantic demands of the combined seman- conclude that uncertainty affects naming performance in tic and visual task were more potent than the demands of the patients with aphasia. Their findings suggest that another visual ones. way to simplify word retrieval on picture naming tasks is to Difficulty discriminating between words with minimal select stimuli to which only a few alternative responses exist. phonemic differences (e.g., cake/take or horse/house) is an Similarly, reducing the number of response alternatives important aspect of auditory impairment in some patients reduces error probability on point-to comprehension tasks. (Schuell, 1973). In addition, patients with aphasia may con- Finally, discriminability of task format is important to fuse letters or words with similar visual configurations (e.g., consider when evaluating a language deficit. To illustrate E/F, p/b, or store/stone). this point, Breese and Hillis (2004) examined the sensitivity An investigation by Linebaugh (1986) sheds some light of a word/picture verification task versus a word/picture on the importance of semantic, auditory, and visual discrim- identification task in identifying an auditory comprehension inability in single-word reading comprehension tasks. He deficit in individuals with aphasia. For the word/picture ver- presented a picture-to-written word matching task to 25 ification task, subjects were asked if a picture corresponded patients with aphasia under two conditions. In one, all three to a spoken name—for example, a picture of knife with “Is response foils (written words) were either semantically, audi- this a fork?” For the word/picture identification task, sub- torily, or visually related to the target response. In the other, jects were asked to point to a named object in a set of four the three foils consisted of one semantically, one auditorily, pictures. Results demonstrated that the word/picture verifi- and one visually related word. When all foils were of the cation task was more sensitive than the word/picture identi- same type, the error rates were higher with visually than fication task for identifying impairments of auditory com- with auditorily related foils, with no differences among prehension. Clinically, these findings suggest that greater other foil comparisons. When foils contained one of each discriminability of stimuli occur in verification tasks versus foil type, both semantic and visual errors were more fre- identification tasks when evaluating auditory comprehen- quent than auditory errors, with no differences between sion deficits. semantic and visual errors. Considerable variability was In summary, compelling data suggest that verbal compre- found among subjects in their patterns and degree of sus- hension tasks in which several response choices are offered ceptibility to the semantic, visual, and auditory influences, can maximize performance if alternatives are semantically with a minority of subjects making more than 50% of their unrelated to the target response. The auditory and visuoper- errors in one category and only two subjects doing so in ceptual “distinctiveness” of the target from response alterna- both experimental conditions. These findings suggest that tives may also be important, with visual similarity generally semantic and visual discriminability, on average, are more being more important than auditory similarity on written- potent than auditory discriminability in single-word reading word comprehension tasks. Although considerable variabil- tasks, but the power of each factor is seldom overwhelming ity exists among patients in their responsiveness to these in individual patients. semantic, auditory, and visual influences, reducing the num- The discriminability factor apparently is also relevant to ber of response choices on point-to tasks will usually lead to word retrieval tasks. The findings of Mills, Knox, Juola, and improved performance. In addition, picture verification tasks Salmon (1979), for example, have implications for the show greater sensitivity than point-to tasks in identifying semantic distinctiveness of visual stimuli used in naming auditory comprehension tasks. tasks. (They are also relevant to the information discussed under nonlingustic visuoperceptual clarity.) These authors Combining Sensory Modalities examined the effects of “uncertainty” on the naming perfor- mance of 10 patients with aphasia, with uncertainty being Although the auditory modality is paramount in the stimula- defined as “the number of equally probable binary choice tion approach, the use of several modalities in combination decisions necessary to achieve a final name selection from is often recommended. Schuell (1974b) indicated that vari- one or several correct names available in the lexicon” (p. 75). ous modalities should be used to reinforce one another and, For example, when shown a picture of a cup, most control in fact, felt that patients often do better when auditory and subjects respond “cup”; few alternative responses are correct visual stimuli are combined. Schuell and Jenkins (1961a) (i.e., little uncertainty). On the other hand, a picture of a reported that patients do better on single-word comprehen- country home in winter generates considerable uncertainty, sion tasks when written and auditory stimuli are used instead because “winter . . . country,” “cabin . . . house,” and other of auditory stimuli alone. GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 413 Aptara Inc. Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 413 Goodglass, Barton, and Kaplan (1968) examined the subjects with aphasia demonstrated higher mean scores on naming performance of 27 patients in response to auditory the recall and recognition tasks during the multimodality (characteristic sound associated with the target item), tactile, condition than during either the visual or auditory condition olfactory, and picture stimuli. They found a uniformity in alone. Further, for the subjects with aphasia, the multi- performance across all modalities for the great majority of modality stimulation appeared to activate the left hemi- patients, although reaction times were fastest to visual stim- sphere to a greater degree than either auditory or visual uli. By extension, the work of Mills (1977) and Smithpeter stimulation alone. Moore commented that “the multimodal- (1976) suggest that combining some of those stimuli may ity stimulation appears to have facilitated the left hemisphere’s enhance performance. Mills found that pairing an environ- participation in language processing, which may have con- mental sound (e.g., whinny) with a picture to be named (e.g., tributed to increased language performance” (p. 683). horse) facilitated naming performance over time, general- Auditory stimulation often involves some potentially use- ized to nondrilled words, and resulted in post-therapeutic ful visual input as well; for example, the patient’s visual con- improvement in naming without the auditory stimulus. tact with the examiner may provide a number of facilitatory Smithpeter reported that olfaction was effective in stimulat- verbal or paralinguistic cues. Green and Boller (1974) found ing accurate language responses in some patients with apha- that the comprehension of severely impaired patients with sia when it preceded or accompanied other stimuli. aphasia was not as accurate or appropriate when stimuli Caramazza and Berndt (1978) cite the work of North were presented by tape or with the examiner behind the (1971), who found that the word recall of patients with apha- patient as when stimuli were presented face to face. Boller sia improved when information was available through several and colleagues (1979) confirmed the superiority of face-to- sense modalities. North argued that various senses may con- face presentation over the use of taped stimuli, and tribute additively to word recall. The previously discussed Lambrecht and Marshall (1983) showed that the compre- findings of Gardner (1973) regarding operativity suggest that hension of severely impaired patients was better when they such additivity of multisensory stimulation need not be overt. looked and listened than when stimuli were simply heard. That is, performance may be enhanced if visual stimuli, for Whether the performance differences in these studies example, are capable of “arousing” multisensory associations. resulted from situational, extralinguistic, or additional Combining the auditory and visual modalities is the most visuoverbal input through lipreading is not clear. Such an widely used form of multisensory stimulation, and a number interpretation is supported by recent studies of the contri- of studies support the practice, although with some qualifi- bution by visual sources of contextual information to speech cations. Gardner and Brookshire (1972) found naming and perception. Records (1994) reported that, as auditory infor- single-word reading performance of eight patients with mation became more ambiguous, individuals with aphasia aphasia to be better during combined auditory and visual and poor language comprehension made greater use of stimulation than during auditory or visual stimulation alone. accompanying referential gestures to facilitate their under- By varying the order in which the stimulus conditions were standing of verbal messages. Similarly, the successful appli- presented, they also determined that combined stimulation cation of therapy focused on auditory discrimination of min- facilitated performance during subsequent unisensory stim- imal pairs at the phonemic level, using lipreading, has also ulus conditions. Analysis of single subject profiles indicated been reported (Morris, Franklin, Ellis, Turner, & Bailey, that combined stimulation may not be best for all patients, 1996). Regardless, it seems that having the visual and audi- but these results generally supported the conclusion that tory attention of the patient during the presentation of ver- combined stimulation is better than unisensory. They also bal material is important. Other combinations of sensory suggest that combined auditory-visual stimulation should input have been noted to be facilitative as well. For example, generally precede auditory or visual stimulation alone, at Lott, Friedman, and Linebaugh (1994) successfully paired least during treatment tasks that require naming responses. tactile-kinesthetic cues (i.e., tracing letters on the palm of Halpern (1965a, 1965b), reporting similar results, supported the hand) with visual cues to improve the reading skills of an the concept of multisensory stimulation but noted that individual with aphasia and alexia. a multisensory approach sometimes can be distracting. Recent studies have investigated computer-administered Additional evidence related to multisensory stimulation may auditory and visual stimulation for the treatment of anomia. be derived from the study of electrophysiological activity in The results of these studies are consistent and indicate that the brain during various stimulation activities. Moore (1996) incorporating computers into stimulation treatments facili- investigated the hemispheric alpha asymmetries (through tate naming skills (Adrian, Gonzalez, & Buiza, 2003; Pedersen, the use of electroencephalography) of normal male and Vinter, & Olsen, 2001). Other promising approaches have female subjects and of male patients with aphasia during included combining verbal and gestural treatments (Rose & recall and recognition of high- and low-imagery words pre- Douglas, 2001; Rose, Douglas, & Matyas, 2002). sented auditorily, visually, and in a multimodality (combined To summarize, providing multimodality stimulation can auditory and visual) condition. Results indicated that the improve response adequacy for many patients with aphasia, GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 414 Aptara Inc. 414 Section IV ■ Traditional Approaches to Language Intervention and combining auditory and visual stimulation may be the group gains over the no-repetition condition were noted. best and most practical way of doing so. Combined auditory However, some individual subject differences were noted. and visual stimulation may facilitate responses to subsequent One subject did “remarkably poorer” when commands were unisensory stimuli and, therefore, may be employed first repeated before responses, and another apparently benefited when responses to unisensory stimulation are deficient to a from the preresponse repetition. significant degree. Other modalities, such as the tactile, or Contextual priming, a relatively new concept in treating use of a computer may also be helpful. It seems that the word retrieval deficits, also incorporates stimulus repetition effectiveness of multimodality stimulation stems from the into its procedures. Contextual priming combines “massed redundancy of the information that it provides and the addi- repetition of picture names with context effects, by training tional associations it might help to trigger. This appears to pictures in small sets that are related in some way semanti- be desirable for many patients, although the clinician needs cally or phonologically” (Martin, Fink, & Laine, 2004, p. 458). to be sure that such multiple inputs improve performance During treatment, blocks of stimuli are formed—for exam- and do not, somehow, overload or exceed the capacity of the ple, one group of stimuli that is semantically related, one patient to use them effectively. group that is phonologically related, and one group that is unrelated. In a session, the subject is required to name each item in a block using a massed practice priniciple—that is, Stimulus Repetition rapid and repetitive stimulation to one class of related pic- Repetitive sensory stimulation is a principle of treatment tures. Each block of related stimuli is presented in every ses- espoused by Schuell and colleagues (1964). They recom- sion, and the accuracy of performance is recorded. Several mended, for example, that, on word recognition or repeti- recent studies examining the effectiveness of contextual tion tasks, as many as 20 repetitions of a stimulus word priming have noted that not only was exposure to related might be appropriate or necessary before eliciting a stimuli beneficial in realizing treatment gains, the massed response. Few studies, however, have directly examined the practice of each block of stimuli provided further substantial effects of repetitive stimulation on language comprehension gains in naming skills (Cornelissen et al., 2003, Martin, Fink, or expression in patients with aphasia. & Laine, 2004; Martin, Fink, Laine, & Ayala, 2004; Martin Helmick and Wipplinger (1975) examined naming & Laine, 2000, Renvall, Laine, Laakso, & Martin, 2003). behavior in one patient with aphasia under a no-treatment Another relatively new treatment approach that uses and two treatment conditions, with each condition contain- stimulus repetition is constraint-induced language treatment, ing different target words. In a minimal stimulus condition, the key principles of which include: (1) massed practice in an six “stimulations” (including verbal identification, contex- enriched, therapeutic, and communicatively relevant envi- tual cue, picture identification/discrimination, tracing, and ronment; (2) constraint of other communication modalities; copying) were provided before eliciting a naming response. and (3) forced use of spoken language through the applica- In the maximum stimulus condition, the six stimulations tion of visual barriers. Massed practice involves repetitive were repeated four times for each word. Both conditions stimulation provided by the clinician, and the subject is were more effective than the no-treatment condition, but no required to practice a new or previously acquired language differences were found between the results obtained from skill for several hours on a daily basis. During the period of minimum and maximum stimulation. The authors con- massed practice on a variety of communication tasks, the sub- cluded that a relatively small amount of stimulation can be as ject is prevented from using either alternative modalities of effective as a great deal of stimulation. communication, such as gesture, or other communicative LaPointe, Rothi, and Campanella (1978) evaluated the compensatory strategies, such as circumlocution. Comple- effects of two methods of repetition of Token Test com- mentary studies have found that both constraining a language mands on the auditory comprehension of 12 patients with modality and requiring massed practice of a language behavior aphasia. In one condition, stimulus repetitions of commands effected positive gains in language functions for individuals preceded responses; in the other, repetition occurred only with chronic aphasia (Maher et al., 2003; Pulvermüller et al., following incorrect responses. When items were repeated 2001; Hinckley & Carr, 2005). Further research is required, following failure (to a ceiling of four repetitions of the orig- however, to tease out the individual effects of massed practice inal stimulus), significant improvement occurred in response and constraint during functionally relevant treatment. to the first and second repetitions, and further but non- As described above, recent research seems to support the significant gains were noted for the third and fourth repeti- use of numerous repetitions of stimulation as a general prin- tions. In numeric terms, accuracy was 24% without repeti- ciple of therapy for aphasia. Earlier studies identified some tion, which rose to 58% after repetition to ceiling level. individuals who responded differently to preresponse repet- Degree of language impairment was negatively correlated itive stimulation, with some benefiting and others deterio- with gains from repetition. In contrast, when items were rating. In contrast, repetition of stimuli subsequent to errors presented two or four times before a response, no significant generally does appear to increase adequate responses, with GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 415 Aptara Inc. Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 415 maximum benefits being derived from the first or second pauses at major within-sentence breaks of the Revised Token repetition. Test and failed to find qualitative or quantitative perfor- mance differences compared to a no-pause condition. They suggested that a 2-second pause may not be long enough to Rate and Pause facilitate performance. It has been suggested that slowing speech rate may aid in Salvatore (1976) reported a facilitation of comprehension auditory comprehension (Schuell et al., 1964) and that this is for a patient with aphasia when 4-second pauses were something experienced clinicians apparently are aware of inserted into Token Test commands. By gradually fading the subconsciously. Salvatore, Strait, and Brookshire (1978) pause duration, it was also possible to maintain improved reported that experienced clinicians give Token Test com- comprehension with 2-second and, sometimes, only 1-second mands more slowly than their inexperienced colleagues by pauses. Although no generalization to nonpause stimulation inserting more pause time within commands. They also was found, the results do suggest that pause time can be found that experienced clinicians tend to slow their presen- faded, to some degree, while maintaining high levels of tation rate when repeating commands that previously had comprehension. generated error responses. Such clinician behavior obvi- Are the effects of rate reduction and pause insertion ously is not desirable during standardized diagnostic testing cumulative? Lasky, Weidner, and Johnson (1976) examined and some baseline procedures, but it does offer indirect sup- the effects of rate reduction (120 wpm vs. 150 wpm) and the port for the facilitating effect of rate reduction on verbal insertion of 1-second interphrase pauses on the sentence comprehension. comprehension of 15 persons with aphasia. Comprehension Gardner, Albert, and Weintraub (1975) examined sen- improved when the rate was slowed or when the pauses were tence comprehension in 46 patients with aphasia and com- inserted, and the combination of reduced rate and inter- prehension problems ranging from mild to severe. They phrase pauses resulted in the best performance. reported improvement in comprehension—independent of In an effort to examine how slowing rate facilitates com- the form of aphasia—when sentences were spoken at a rate prehension, Blumstein, Katz, Goodglass, Shrier, and of one word per second. They recommended that, when Dworetsky (1985) compared comprehension by patients proceeding from single-word to sentence stimuli, words with aphasia of sentences spoken at normal rates to (1) a should initially be enunciated slowly.” vowel condition, in which vowel duration in each word was Weidner and Lasky (1976) found improved performance increased (140 wpm); (2) a word condition, in which silences in a group of 20 patients with aphasia on four measures of were added between words (110 wpm); (3) a syntactic condi- auditory comprehension when the presentation rate was tion, in which silences were added at constituent phrase reduced from 150 words per minute (wpm) to 110 wpm. boundaries (90 wpm); and (4) a natural condition, in which Differences between the two rate conditions were greatest sentences were read at a naturally slowed rate (110 wpm). In for patients scoring above the 50th percentile on the PICA. general, reducing rate had a relatively small facilitatory Similarly, Poeck and Pietron (1981) induced an 11% to 12% effect and was significant only for the syntactic condition improvement in Token Test scores of a group of 42 patients and for patients with Wernicke’s aphasia. The authors con- with aphasia through electronically expanding the speech cluded that it may not be slowed rate per se that facilitated rate by 25%. Pashek and Brookshire (1982) extended these comprehension but, rather, the effect of a syntactically well- findings by showing that reducing the rate from 150 wpm to placed pause on the processing of preceding syntactic and 120 wpm facilitated paragraph comprehension in a group of semantic elements. Although this may be the case, the fact 20 patients; performance was facilitated in those with poor that the rate of the syntactic condition (90 wpm) was slower as well as those with good sentence-level comprehension. than any other slowed condition confounds the interpreta- The facilitative effect of reduced rate also has been tion and leaves open the possibility that slowing rate to demonstrated for a patient with aphasia and severe auditory a comparable degree in other ways might also facilitate imperception (Albert & Bear, 1974). The authors found that comprehension. the patient’s comprehension improved dramatically when The positive effects of slowed rate may not be as robust rate was slowed to a third of the normal rate or less. for narrative discourse. Nicholas and Brookshire (1986a) Liles and Brookshire (1975) examined the comprehen- examined narrative comprehension across two test sessions sion of 20 patients when 5-second pauses were inserted into in patients with aphasia and relatively good and relatively various portions of Token Test commands. The insertion of poor comprehension; narratives were spoken at fast (190 pauses facilitated comprehension for many of their patients. wpm to 210 wpm) versus slow (110 wpm to 130 wpm) Patterns of patient performance led the authors to hypothe- rates. Only the group with relatively poor comprehension size that the pauses aided in the processing of strings of lex- benefited from rate reduction, and this held only for the ical items but not in the processing of syntactic components. first of the two test sessions. In addition, the facilitatory In contrast, Hageman and Lewis (1983) inserted 2-second effect of slow rate was not present for all patients in the poor GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 416 Aptara Inc. 416 Section IV ■ Traditional Approaches to Language Intervention comprehension group. The authors concluded that the clinical type of aphasia. The findings of Martin and Feher effect of slow rate was undependable and transitory, and they (1990) suggest that the degree of short-term memory limita- noted that variables with strong effects on comprehension at tion in aphasia affects semantic processing (i.e., sentences the sentence level may have only weak effects at the level of with a large number of content words) but is not strongly discourse. related to the processing of syntactic complexity. Finally, To summarize, it appears that slowing rate and lengthen- Gardner and colleagues (1975) found poorer comprehen- ing pauses at phrase boundaries can have a facilitatory effect sion when length increased from single words to nonredun- on sentence comprehension. This effect is neither always dant sentences containing the same single words. present nor generally dramatic, and no consistent indica- Length appears to be an important factor in the visual as tions are found across studies that the ability to benefit from well as the auditory modality. Siegel’s (1959) 31 patients with rate and pause modifications is tied to either type or severity aphasia had more difficulty reading words of two or more of aphasia. The positive effects of slowing rate may be less syllables (six or more letters) than single-syllable words of consistent and pervasive at the level of discourse than at the less than five letters. Halpern (1965a, 1965b) compared ver- sentence level. From the practical standpoint, however, it is bal responses of 33 patients on tasks involving single-word reasonable to accept the advice of Nicholas and Brookshire repetition, reading single words, and reading single words (1986a) that “it seems reasonable to counsel those who speak with simultaneous auditory and visual stimulation. Stimuli with brain-damaged listeners to speak slowly, because slow in each task were either long (two or more syllables or six speech rate does not affect most brain-damaged listeners letters) or short (one syllable or less than four letters) and negatively, and for some it may be beneficial, at least on also varied as a function of abstraction level and part of some occasions” (p. 469). speech. Results showed that long words resulted in more verbal errors—including preservation—compared with short words, regardless of the modality of presentation. Dif- Length and Redundancy ferences between errors on long and short words were great- As previously stated, Schuell felt that reduced verbal reten- est for the visual modality. On the basis of his findings, tion span is a near-universal feature of aphasia. Although Halpern recommended that, for such tasks, auditory or pervasive, she reported that retention deficits are highly auditory with visual stimulation should usually precede reversible with the use of carefully controlled, intensive visual stimulation alone. auditory stimulation characterized by gradual increases in Going beyond the word level, Webb and Love (1983) stimulus length (Schuell, 1953a; Schuell et al., 1955). examined the reading abilities of 35 patients with aphasia The importance of stimulus length receives additional and found (1) more errors on sentence recognition than on support from a number of sources, including patients them- letter or word recognition, (2) more errors on oral reading selves. Rolnick and Hoops (1969), interviewing several of sentences and paragraphs than of letters or words, and (3) patients with mild aphasia, found numerous complaints more errors on paragraph comprehension than on sentence about the processing and retention demands imposed by comprehension. lengthy messages. Patients felt that reduced message length Friederici, Schoenle, and Goodglass (1981) have shown facilitated comprehension and retention. that word length also influences writing. In their group of 12 In addition, numerous studies have demonstrated that, patients with aphasia, written accuracy was reduced by more with other factors held constant, sentence comprehension than 50% as word length increased from one to three sylla- tends to decrease as sentence length increases (e.g., Curtiss, bles. Increased word length (i.e., number of phonemes in the Jackson, Kempler, Hanson, & Metter (1986); Shewan & spoken word) has also been shown to negatively influence Canter, 1971; Weidner & Lasky, 1976). naming performance in some individuals with aphasia Although Goodglass, Gleason, and Hyde (1970) found (Nickels & Howard, 1995). that 52 patients with different classical forms of aphasia had Wepman and Jones (1961) found that verbal responses to varying degrees of success on a verbally presented retention words are easier than verbal responses to sentences whether span test, all patients were deficient to some degree. Albert stimuli are presented auditorily or visually. At the word (1976) examined the ability of 28 patients with aphasia on a level, verbal responses to written stimuli were better for short-term memory task in which they pointed to objects one-syllable than for two-syllable words. On the other hand, named serially by the examiner. The results of patients were verbal responses to auditorily presented words did not differ inferior to those of control subjects and of patients with between one-syllable and two-syllable words. In contrast to brain injury but without aphasia on total item retention and the findings of Halpern (1965a, 1965b), these authors indi- in retention of the accurate sequence of presentation. cated that the length factor for sentence material is most Response patterns indicated that sequencing problems pronounced for the auditory, not for the visual, modality. It increased as information load increased. Information load is possible that the different results are caused by the fact and sequencing deficits were both present regardless of the that Halpern was dealing with variations of length within GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 417 Aptara Inc. Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 417 single words but Wepman and Jones were referring to dif- acceptable responses must be generated before proceeding ferences between words and sentences. If so, this highlights to the less powerful stimuli. In this section, a number of the fact that differences in the processing and/or retention potentially useful cues that have not been covered already of words between modalities are not identical to differences under other headings will be discussed. in the processing and/or retention of sentences (and dis- McDearmon and Potter (1975) offered a number of sug- course) between modalities. gestions regarding representational prompts, which they It is important to note that the detrimental effects of defined as symbolic or realistic cues that directly suggest the increasing message length may vary as a function of message concept being referred to in a response. Prompts are redundancy. For example, the findings of Gardner and col- strongly related to the concepts of stimulus redundancy and leagues (1975) support the notion that patients with aphasia multimodality stimulation; they suggest that more than one comprehend redundant sentences better than nonredundant representation of the response be presented and that one sentences of equal length. Clark and Flowers (1987) demon- representation (i.e., the prompt) gradually be faded. For strated that increasing sentence redundancy facilitated com- example, on naming tasks, pictures and their written names prehension even when redundant sentences were longer and may be presented with resultant adequate responses. The syntactically more complex than nonredundant ones (e.g., written prompts may then be faded gradually by blocking sentences like “Which one is the book you read?” were eas- out increasing portions of the word until that word is ier than sentences like “Which one is the book?”). Also, the entirely eliminated. Some other suggested prompts not remarkable sensitivity of the Token Test to subtle deficits of already implied under other headings include (a) tracing let- comprehension is at least partially the result of the nonre- ters to facilitate letter recognition, (b) writing words to aid dundant properties of its verbal stimuli. Clearly, the potent word retrieval, (c) pantomime or American-Indian sign to effect of length strongly interacts with redundancy—the two facilitate word retrieval, and (d) using pictures in conjunc- factors can seldom, if ever, be considered separately. tion with corresponding written words to facilitate reading. (Further discussion of this interaction can be found in the Barton, Maruszewski, and Urrea (1969) examined word section on grammar and syntax.) retrieval of 36 patients under three conditions: (1) picture To summarize, there can be little doubt that controlling naming, (2) sentence completion (e.g., “You clean teeth with length at the word and the sentence levels is a potent stimu- a _____.”), and (3) object description. In order, the most lus factor for most or all patients with aphasia, and most powerful cues were sentence completion, picture naming, clinicians discuss this factor when counseling families about and object description. It is important to note, however, that their verbal input to the patient. Length is an influential fac- 44% of the subjects in their study did not follow the group’s tor regardless of whether stimuli are auditory, visual, or ordering of responses to the three naming conditions. This auditory and visual. In the visual modality, reducing length highlights the importance of examining the individual at both the word and the sentence levels can be expected to patient’s responsiveness to stimulus cues; a powerful cue for facilitate comprehension. For auditory input, length may be one patient may not be as powerful for another. Along these relatively unimportant at the word level, but it becomes lines, Marshall and Tompkins (1982) as well as Golper and highly important when proceeding from the word to the Rau (1983) point out that careful analysis of individual phrase to the sentence level. When controlling length, it patient strategies may provide clues about the best cues for seems that nonredundant components are the most crucial the clinician to provide during therapy. Such information elements to control, because increases in message redun- may also be used to increase the patient’s own use of suc- dancy may limit or even overcome the generally negative cessful cues. effects of increases in message length. This may be particu- Freed, Marshall, and Nippold (1995) examined two cue- larly true at the levels of paragraph and narrative discourse ing techniques with 30 individuals having mild to moderate (to be discussed in the section on context). aphasia in associative learning tasks. Real English words were paired with black-and-white, abstract symbols, and subjects were required to label each symbol. During the Cues, Prompts, and Prestimulation task, subjects were given either their own previously elicited It is well recognized that, under the right circumstances, the associations for the word-symbol pairs (personalized cues) skillful clinician can employ a variety of techniques—often or associations developed by the examiner (provided cues). referred to as cues, prompts, or prestimulation—that will Results indicated that both cueing techniques were equal in facilitate a patient’s word retrieval or comprehension. Such terms of yielding correct responses. The authors observed techniques are often used following an inadequate response that subjects in the “provided cue” condition were given to a less powerful stimulus. When less powerful stimuli are complete rationales for why the cues were used; thus, the consistently incapable of generating a high proportion of provided cues may have inadvertently become similar to the adequate responses, however, the cue (prompt or prestimu- personalized cues. Freed and colleagues concluded that both lus) may become a distinct treatment condition to which the provided and the personalized cues contained components GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 418 Aptara Inc. 418 Section IV ■ Traditional Approaches to Language Intervention that might be beneficial to include in a treatment protocol primes than in the other priming conditions. This led to a con- for word retrieval deficits. clusion that information is preserved in semantic memory in Linebaugh and Lehner (1977) have described a cueing patients with aphasia. (This online facilitation of semantic pro- program for word retrieval that is based on two principles: (1) cessing may partially explain why redundancy can facilitate sen- that recovery is best served by eliciting the desired response tence comprehension.) In a related study, Leonard and Baum with a minimal cue, and (2) that when a cue is successful, con- (1997) noted faster responses to words preceded by primes that tinued elicitation of the appropriate response with less power- were both phonologically and orthographically related to the ful cues is reinforcing and conducive to stimulating the target word (i.e., words that shared both spelling and sound- processes underlying word retrieval. When a patient is unable syllable rhyme [e.g., “blood-flood”]) than those that were unre- to name a pictured object, the following cues, in order, are lated (e.g., “dish-room”). Phonologically related primes (i.e., given until an adequate response is elicited: (1) directions to word pairs that shared syllable rhymes but were orthographi- state the object’s function, (2) statement of the function, (3) cally unrelated [e.g., “seed-bead”]) alone did not facilitate reac- statement and demonstratation of the function, (4) sentence tion times, and responses were also slower relative to the completion, (5) sentence completion plus the silently articu- primes that were orthographically, but not phonologically, lated first phoneme of the response, (6) sentence completion related (i.e., word pairs that shared rhyme spelling but were plus the vocalized first sound, (7) sentence completion plus pronounced differently [e.g., “tough-cough”]). the first two phonemes vocalized, and (8) word repetition. Podraza and Darley (1977) investigated the effects of three When an adequate response is elicited, the order of cues is types of prestimulation on picture naming in five patients with reversed until the patient names the picture without a cue. aphasia. The prestimulus conditions (i.e., cues presented Linebaugh and Lehner presented data for several patients before picture presentation) included the first phoneme of the that demonstrate improved word retrieval and generalization target word, an open-ended sentence (three words, one of to nontreatment words. Importantly, they indicate that cue- which was the target word), and three semantically related ing hierarchies must be individually determined. words. Naming was generally facilitated by the phoneme, The effectiveness of personalized cues and self-cues in open-ended sentences, and three words containing the target naming tasks has been investigated in two recent studies. In word cues, whereas performance decrements occurred for the the first, the nature of information contained in personalized three semantically related word cues. The facilitative failure of cues for naming of subordiante categories was examined. the semantically related word cues is in disagreement with the Personalized cues were elicited from 15 individuals without findings of Weigl (1968) and of Blumstein, Milberg, and brain damage and 15 individuals with aphasia and evaluated to Shrier (1982) that such cues may serve a “deblocking function” determine if the cues facilitated learning of unknown dog and facilitate retrieval. Podraza and Darley suggest that their breeds. Five different types of cues were identified and evalu- own patients may already have been operating in the appropri- ated for their faciliatory effect. Results revealed that cues con- ate “semantic field” (Goodglass and Baker, 1976, p. 361) and taining semantic information led to greater accuracy of nam- that additional stimuli in that field may have served to confuse ing for the individuals with aphasia (Marshall, Karow, Freed, the selection of an appropriate response. Similarly, patients & Babcock, 2002). In a related study on treatment of naming with Wernicke’s aphasia, who frequently make phonemic deficits, individuals with chronic aphasia were required to errors, benefit less from phonemic cues than patients with generate self-cues characterized by either partial written word other types of aphasia (Kohn and Goodglass, 1985). information or tactile cues. Results revealed improvements in Breen and Warrington (1994) have also compared a vari- naming of target items with generalization to performance on ety of cues in an individual with severe anomia. Phonologic standardized language measures (DeDe, Parris, & Waters, and semantic cues were noted to be far less facilitative, in a 2003). The results of both studies support the value of per- naming task, than were sentence frames (i.e., sentence com- sonalized and self-generated cues in naming tasks. pletion). Further, neither picture frames, associated verbs, A facilitatory effect of semantic cues also seems to exist for nor syntactically correct but semantically meaningless sen- online tasks (i.e., tasks in which the cues are not necessarily tence frames were effective cues. The authors suggest that obvious to the patient). Chenery, Ingram, and Murdock (1990) two modes of name retrieval may exist, one that uses a nom- studied the ability of patients to recognize whether the second inative system and one that employs an online language word in a pair of verbally presented words was real or nonsense processor involved in propositional speech production. The when the first word was functionally related to the target (e.g., latter system may account for the preservation of fluent eat-knife), superordinally associated (e.g., cutlery-knife), unre- speech in individuals with severe anomia. Similarly, sentence lated (e.g., door-knife), or nonsense (e.g., lamiel-knife). completion cues containing a semantically related word Subjects were told to ignore the first word. All subjects with were noted to be more effective than semantically empty aphasia, including a subgroup with severe comprehension and sentence frames (e.g., “This is a ____.”) or semantic infor- naming deficits, more accurately identified words as being real mation alone (i.e., associated verbs) in facilitating naming in response to the functional and superordinate semantic performance in eight subjects with aphasia (McCall, Cox, GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 419 Aptara Inc. Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 419 Shelton, & Weinrich, 1997). These findings were felt to Whether a semantic cue should be accompanied by the support the notion that naming is enhanced most by a com- referent word has also been investigated (LeDorze, Boulay, bination of syntactic and semantic variables. Gadreau, & Brassard, 1994). Using a comprehension task Stimley and Noll (1991) examined naming accuracy in a format, two types of semantic cues were compared. In the group of patients with aphasia when pictures were accompa- first, the individuals with aphasia were to point to a picture nied by a semantic cue (e.g., “This is something you wear on (in a field of three pictures) of the referent word presented, your foot,” for “sock”) or a phonemic cue (e.g., “This is some- then to match the written word to the corresponding pic- thing that starts with /S/,” for “sock”). Compared to a no-cue ture, and then to answer a question about the referent word condition, the semantic and phonemic cues both facilitated (e.g., “Does an organ have just one keyboard?” for the word naming, although the average effect was only on the order of “organ”). The other cueing procedure also involved three 9% to 10%. The authors felt the small effect may have steps: The individuals with aphasia were to point to a pic- occurred because cues were presented for all items, not just ture of the referent word identified by a definition, then to following a failure to name without a cue. They also observed match a written definition to the corresponding picture, (as have others) that semantic errors were more frequent in and finally, to answer a yes/no question related to the refer- the semantic cue condition and that phonemic errors were ent word (e.g., “Does this mollusk have pincers?” for the more frequent in the phonemic cue condition (Li & Canter, word “lobster”). Results indicated that naming improved 1991, have made similar observations). Thus, although significantly when the semantic cues were accompanied by semantic and phonemic cues are generally facilitatory, they the referent word. The authors speculate that naming was also tend to “move” errors toward the cueing category. Along facilitated because both word form and the word semantics similar lines Wambaugh and colleagues (2004) compared the were activated. effects of a phonological cueing treatment and a semantic Some recent efforts have attempted to tailor the type of cue cueing treatment. Results indicated that both treatments to the level at which naming tends to break down. Thompson, yielded positive increases in naming, with effects being simi- Raymer, and le Grand (1991) examined the effects of a phone- lar across treatments. The authors concluded that both treat- mic cueing treatment program on two patients with Broca’s ments have potential for facilitating action naming in aphasia. aphasia whose naming deficits appeared to be related to Other recent investigations have examined the effects of phonologic breakdowns (e.g., they had naming difficulties only semantic cues on naming performance. Semantic fea- despite being able to match spoken words to pictures and per- ture analysis (SFA) is an elaborate cueing technique in which form conceptual matching tasks; in other words, they appeared the client is encouraged to produce words semantically to have access to word meaning but not to the phonologic related to the target. For example, for the target word “pan,” form of words). The program consisted primarily of providing the cues might involve questions related to its use (cooking), a rhyming cue (e.g., “It sounds like mat” for the target “bat”) its properties (metal, copper, and wooden handle), where it or, if that failed, the first phoneme, whenever the patient failed might be used (kitchen), what group it belongs to (cook- to name without a cue. Both subjects improved in oral naming, ware), and what might be associated with it (stove, spoons, and some generalization to untrained items and to oral reading ladles, and pots). SFA is thought to improve the retrieval of tasks occurred. Li and Williams (1989) examined the effect of conceptual information by accessing semantic networks semantic and phonemic cues on noun and verb naming after (Massaro & Tompkins, 1992). By activating the semantic net- failure to name on picture confrontation. Patients with Broca’s work surrounding the target, the target itself should be acti- and conduction aphasia responded better to phonemic than to vated above its “threshold” level, thus increasing the likeli- semantic cues, and the opposite pattern occurred for patients hood that its name can be retrieved. Results have consistently with anomic aphasia. In general, phonemic cues were more documented improved confrontational naming scores with effective than semantic cues for nouns, and the two cue types the SFA technique for treated pictures as well as generaliza- did not differ for verbs. This suggests that the effectiveness of tion to untreated pictures (Boyle & Coelho, 1995; Boyle, cue type may vary both as a function of the source of naming 2004; Coelho, McHugh, & Boyle, 2000; Lowell, Beeson, & failure (semantic vs. phonologic, presumably related to aphasia Holland, 1995). Generalization to conversational speech, type) and of word category (nouns vs. verbs). (Li & Williams, however, has either been quite modest (Coelho et al., 2000) 1990). or not observed at all (Boyle & Coelho, 1995). In a subse- Are cues presented in combination more effective than quent study, Conley and Coelho (2003) examined the effects single cues? The findings of Weidner and Jinks (1983) say of SFA in combination with Response Elaboration Training yes. They examined the naming performance of 24 patients (RET) (Kearns, 1985) on word retrieval deficits for an indi- who were presented with single cues (e.g., sentence comple- vidual with chronic Broca’s aphasia. The combined SFA and tion, written words, or first phoneme) or with cues in RET treatment improved confrontation naming skills for the combination. Combined cues were more facilitative than individual studied, but the results were equivocal in delineat- single cues or single cues presented in succession. They sug- ing the individual effects of each type of treatment. gest that if one cue fails, a combination of cues may help. GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 420 Aptara Inc. 420 Section IV ■ Traditional Approaches to Language Intervention Finally, cueing also may facilitate sentence production. logical differences in the activation and processing of these Roberts and Wertz (1986) used a contrastive task paradigm different types of words. to facilitate sentence production in two patients with Word frequency remains a factor at the sentence level. chronic aphasia. After demonstrating comprehension of Shewan and Canter (1971) found that increasing vocabulary sentence meaning, patients imitated the clinician production difficulty (reducing word frequency) reduced the accuracy of a sentence (e.g., “The bed is made.”) and then sponta- and promptness of sentence comprehension in patients with neously produced a minimally contrasting sentence in aphasia. In addition, frequency of occurrence also applies to response to a picture stimulus (e.g., “The bed is not made.”). phrases and sentences when they occur as familiar units. For Imitation was then faded over additional steps to the point at example, Van Lancker and Kempler (1987) have shown that which the patient had to produce on their own contrasting patients with aphasia comprehend familiar phrases sentences in response to picture stimuli. The sentence pro- (idiomatic expressions, e.g., “While the cat’s away, the mice duction of both patients improved, and evidence of some will play.”) more readily than novel sentences matched for carryover to spontaneous sentence production was found. word frequency, length, and structure. It is reasonable to conclude that a large number of Word frequency effects are also apparent in verbal out- cues, prompts, including computer-mediated approaches put, reading, and writing. For example, Schuell and col- (Doesborgh, van de Sandt-Koenderman, Dippel, at al., leagues (1964), Gardner (1973), and Williams and Canter 2004; Fink, Brecher, Sobel, et al., 2005) and preparatory (1982) have reported negative correlations between errors stimuli exist that may facilitate language processing in on naming tests and frequency of occurrence. Siegel (1959) patients with aphasia. Care must be taken to demonstrate has found that less frequently occurring words were more the utility of cues in each case, because even the most difficult to read than frequently occurring words. Bricker, widely used facilitators may not be effective for every Schuell, and Jenkins (1964) reported that word frequency patient. Careful analysis of the level at which language (and length) accounted for almost all aphasic spelling errors; tends to break down (e.g., semantic vs. phonologic) and and Santo Pietro and Rigrodsky (1982) found that verbal the types of successful cues that patients adopt sponta- perseveration on naming and reading tasks increased as neously can help to identify the type of cueing that is word frequency decreases. likely to be most successful. In contrast to the notion that word frequency is an impor- tant factor in verbal expression, Nickels and Howard (1995) found small effects of word frequency on naming perfor- Frequency and Meaningfulness mance. Their series of experiments involved two groups of It has been repeatedly established that the reduction of individuals having aphasia. The first group consisted of six available vocabulary in patients with aphasia is related to the fluent and six nonfluent individuals, and the second was made frequency of occurrence of words in the language. Schuell up of three nonfluent, two nonfluent with apraxia of speech, (1969, 1974d) also predicted a reduction of available linguis- two with primarily apraxia of speech, and eight with fluent tic rules and a hierarchy for their recovery, and Schuell spec- aphasia. The authors investigated the effect of eight variables ulated that the hierarchy is related to the frequency of on naming: (1) word age-of-acquisition, (2) operativity (i.e., occurrence of those structures in general or to individual figurative vs. operative), (3) frequency, (4) familiarity (i.e., language usage. based on a rating of how often one might see, hear, or use the Schuell, Jenkins, and Landis (1961) tested the auditory referent word), (5) imageability (i.e., ease of creating visual or comprehension of 48 patients with aphasia in response to auditory image of referent), (6) concreteness (i.e., how acces- four word lists varying in frequency of occurrence. sible to sensory experience the subjects rated the referent Decrements in performance as a function of decreasing word), (7) length (i.e., number phonemes in the spoken word frequency were found, supporting the conclusion that word), and (8) visual complexity (i.e., complex vs. simple, word frequency is an important factor in comprehension. based on number of elements in stimulus picture). Results They also reported that single-word comprehension indicated a far less marked effect of frequency on naming improves in an orderly and predictable manner that is when the effects of the other variables had been accounted strongly related to word frequency. Relatedly, Gerratt and for (i.e., by means of simultaneous multiple regression or dis- Jones (1987), in a reaction time task, have shown that indi- criminate analysis procedures). Further, because of intercor- viduals with aphasia, like individuals without aphasia, recog- relations between variables and the wide range of variables nize words as real (vs. nonsense) more rapidly when they that have been found to affect naming performance in indi- have multiple meanings and high frequency of occurrence viduals with aphasia, these findings must be interpreted cau- than when they have few meanings and low frequency of tiously. The authors concluded that previously, the effects of occurrence. Finally, Hauk and Pulvermuller (2004) found frequency on naming have been overstated because of the lower evoked-response potential amplitudes for high- confounding effect of other variables, such as length and frequency versus low-frequency words, indicating physio- imageability. Finally, the two groups of individuals with GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 421 Aptara Inc. Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 421 aphasia showed quite different patterns of predictor variables inappropriate commands (e.g., roll the bell). Contextually for naming performance, and the variables that affected an related tasks were easier than neutral or inappropriate ones, individual’s performance was often different from those of leading the authors to state that “if we pair objects with the overall group, calling into question the applicability of actions that are most expected both in terms of meaning conclusions drawn from group studies. and structure, we facilitate comprehension” (p. 183). Finally, Although word frequency is certainly positively correlated Deloche and Seron (1981) as well as Kudo (1984) have among speakers of the language, we need to bear in mind established that comprehension is better when sentence that word frequency for individuals is determined by their meaning does not violate our knowledge of the world (e.g., unique experiences, needs, occupation, culture, and numer- “The policeman arrests the thief.”) than when the meaning ous other factors (e.g., the word “aphasia” is certainly more is implausible or unlikely (e.g., “The thief arrests the available to the speech-language pathologist than it is to the policeman.”). political scientist!). Although word lists such as that of Thorndike and Lorge (1944) are useful in selecting stimulus Abstractness material, it is also important to identify verbal stimuli that are meaningful, relevant, and personally significant to the indi- It has been suggested that individuals with aphasia have vidual (Schuell, 1969; Schuell et al., 1955; Wepman, 1953). more difficulty with abstract than with concrete words The importance of this was demonstrated by Wallace and (Goldstein, 1948) and that these individuals categorize Canter (1985), who examined the responses of severely words in a relatively concrete emotional manner when com- impaired patients with aphasia to personally relevant versus pared to individuals without aphasia (Zurif, Caramazza, nonpersonal stimuli on verbal and reading comprehension Myerson, & Calvin, 1974). tasks (e.g., “Is your birthday in _____” vs. “Is Christmas in Two problems present themselves when the concept of February?”), repetition tasks (e.g., patient repeats their abstractness arises. First, abstractness is strongly tied to— name vs. another name), and naming tasks (e.g., television and difficult to separate from—frequency of occurrence vs. giraffe). Performance was better in response to person- (concrete words occur more frequently than abstract words). ally relevant materials on all tasks, although the authors Spreen (1968), however, has pointed out that, even when pointed out that personally relevant stimuli had a generally frequency of occurrence is controlled, words scaled as higher frequency of occurrence than nonpersonal material. abstract are not perceived or recalled as readily as words Relatedly, Correia, Brookshire, and Nicholas (1989) asked if scaled as concrete. Halpern (1965a), controlling for fre- gender bias in pictures used to elicit narrative responses quency of occurrence, found that patients with aphasia made from male patients with aphasia affects what the patients say more verbal errors in response to written words of high or about them. After having subjects without aphasia identify medium abstractness than in response to words of low picture stimuli as male or female biased (e.g., men working abstractness. Abstractness did not, however, play a role in out in a gym vs. women in a beauty salon), these authors repetition of verbally presented stimuli. used the pictures to obtain narratives from aphasic and non- The second problem is more relevant to stimulus selec- brain-damaged subjects. Subjects produced more words in tion and is related to the fact that “abstractness” is a difficult response to male-biased stimuli, but no differences were concept to define. Words, however, are scalable on an found in measures of efficiency or amount of information abstractness dimension (Darley, Sherman, & Siegal, 1959), conveyed. The authors concluded that gender bias in picture and Spreen (1968) has suggested that the degree of abstract- stimuli is not of great concern (at least for male subjects) ness can be related tangibly to sense experience (e.g., “book” unless the number of words in responses is important. Thus, is more concrete than “hope,” because it presumably gener- some dimensions of personal relevance may or may not ates more multimodality associations). affect all dimensions of performance to the same, or to an The performance of patients with aphasia suggests that important, degree. we should be aware of the abstractness factor when selecting The concept of meaningfulness is also tied to emotion and ordering stimulus material. Problems related to isolat- and expectations. Reuterskiöld (1991) has demonstrated that ing and defining abstractness, however, present practical patients with significant verbal comprehension deficits per- clinical problems. Fortunately, we probably account for form more adequately on single-word comprehension tasks most of the effects of abstractness when we account for the when stimuli consist of objects and actions with emotional more easily defined concepts of word frequency and inter- connotations (e.g., casket or kissing) than when they have no sensory redundancy or operativity. obvious emotional connotations (e.g., paper or typing). Graham, Holtzapple, and LaPointe (1987) examined the Part of Speech and Semantic Word Category comprehension of patients with aphasia in response to con- textually relevant commands (e.g., ring the bell), contextually When word retrieval and comprehension abilities are exam- neutral commands (e.g., touch the bell), and contextually ined or treated at the single-word level, a marked tendency GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 422 Aptara Inc. 422 Section IV ■ Traditional Approaches to Language Intervention exists for clinicians to focus on nouns, particularly object and by a prepositional phrase. These rules of phrase struc- nouns. The evidence makes clear, however, that all parts of ture are referred to as strict subcategorization and are speech and word categories are typically affected in aphasia. related to, but separate from, argument structure. Argument This speaks against an object-noun orientation to treatment. structure pertains to meaning relations between the verb Kiran and Thompson (2003) investigated the role of and constituents within a sentence (or the number of partic- semantic complexity in treating naming deficits in fluent ipant or thematic roles described by a verb). For example, individuals with aphasia. Subjects participated in a form of the verb “wash” has two participant roles: an agent (some- semantic feature treatment to improve naming of both typi- one doing the washing), and a theme (the thing being cal and atypical exemplars within a semantic category. washed). The verb “put” has three roles: an agent (someone Training procedures were counterbalanced for whether typ- doing the putting), a theme (the thing that is put), and a ical versus atypical exemplars were trained first. Results location (the place where the thing is put). For certain verbs, revealed greater improvements in naming and generaliza- all participant roles must be specified in sentence production tion for those individuals who were trained on the atypical for the sentence to be grammatical. Returning to the exam- exemplars first versus the typical exemplars first. ple of the verb “put,” it is obligatory that all three of its argu- Because different parts of speech (e.g., nouns vs. verbs) ments be represented when it is used, whereas for other serve different linguistic functions, it seems possible that, for verbs, some arguments are optional and do not need to be some patients or under some circumstances, they may pre- specified in the syntax. This is the case for the verb “eat”, sent varying levels of difficulty. Consistent with this notion, which can be produced with an agent only, as in “Tom ate,” recent research has demonstrated selective impairments in or with both its arguments, as in “Tom ate the corn.” The nouns versus verbs in some individuals with aphasia. For critical issue is that the verb’s lexical representation includes example, verb production has been noted to be more diffi- information about its argument structure and that the gram- cult than nouns for individuals with agrammatical aphasia, maticality of sentences and syntax is determined by these whereas nouns appear to be more problematic than verbs for argument structures and their representation in the sentence some individuals with anomic aphasia (Marshall, Pring, & (Thompson et al., 1997). Chiat, 1988; Miceli, Silveri, Nocentini, & Caramaza, 1988; To investigate the type of verb deficits that occur in those Miceli, Silveri, Villi, & Caramaza, 1984; Orpwood & with aphasia, Thompson and colleagues (1997) examined Warrington, 1995; Saffran, Berndt, & Schwartz, 1989; verb and verb argument structure production in 10 individ- Thompson, Shapiro, Li, & Schendel, 1994; Williams & uals with agrammatical aphasic and in 10 individuals without Canter, 1987; Zingeser & Berndt, 1990). In addition, where brain damage. Production of six types of verbs—obligatory a discrepancy exists between nouns and verbs on synonym- one-place (verbs with only one external argument [e.g., generating and sentence-generating tasks, the difference “The boy smiles.”]), obligatory two-place (verbs requiring favors nouns over verbs (Kohn, Lorch, & Pearson, 1989). both arguments [e.g., “The boy catches the ball.”]), obliga- Finally, that the processing of nouns versus verbs can differ tory three-place (verbs that require three arguments [e.g., is also supported by the finding of Li and Canter (1991) that The girl gives the bone to the dog.”]), optional two-place patients with aphasia responded better to phonemic than to (verbs that require one external argument and a second semantic cues for noun naming, but that no difference optional argument [e.g., “The woman eats.” and “The existed between the cue types for verb naming. The authors woman eats spaghetti.”]), optional three-place (verbs that felt that the greater concreteness, static nature, and image- require an agent and theme but for which a third argument ability of nouns than verbs might explain some of the differ- is optional [e.g., “The woman throws the stick.” and “The ences between them. woman throws the stick to the dog.”]), and complement The observation that naming may be differentially verbs (verbs that require external and internal arguments impaired across semantic categories has led investigators to [e.g., “The girl knows the answer.” and “The girl knows the question whether verb production might also be differen- cat is in the tree.”)—were examined in confrontation and tially affected—that is, that certain types of verbs may be elicited labeling conditions. Results indicated that individu- more difficult than others for some individuals. According als with aphasia produced the obligatory one-place verbs to Thompson, Lange, Schneider, and Shapiro (1997), an correctly significantly more often than they did the three- important distinction among verbs pertains to their syntac- place verbs. In addition, a consistent hierarchy of verb diffi- tic properties (i.e., the number and type of arguments or culty was found in both the confrontation and elicited con- participant roles required by certain verbs). Like other ditions. Data indicated that argument structure properties of classes of words, verbs are acquired and stored in memory verbs are important dimensions of lexical organization and on the basis of their phonologic form and lexical category. influence verb retrieval. Verbs, however, are also represented in the lexicon by virtue Differences may also exist for other word categories and of the sentence structures in which they occur. For example, tasks. Halpern (1965a) found that patients with aphasia the verb “wash” must always be followed by a noun phrase made more errors when repeating or reading adjectives and GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 423 Aptara Inc. Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 423 verbs than they did with nouns. Siegel (1959) as well as ties. In other words, as for intact language users, a grammat- Marshall and Newcombe (1966) reported similar findings ical hierarchy of difficulty exists for patients with aphasia, for reading tasks. In contrast, Noll and Hoops (1967) did not with some grammatical structures being more difficult to find selective spelling difficulty among nouns, verbs, adjec- comprehend and produce than others. Grammar and syntax tives, and adverbs for a group of 25 patients, but they did therefore are important variables to consider when devising find that pronouns, prepositions, and conjunctions were language stimuli. The following discussion is a sampling of more difficult than other parts of speech. Finally, Goodglass the numerous studies that have examined the relationship and colleagues (1970) found different comprehension pat- between grammatical variations and performance in aphasia. terns among patients Broca’s, Wernicke’s, and anomic apha- (For more information on these factors, see Chapter 27 in sia across measures of receptive vocabulary (nouns and this volume.) verbs) and of comprehension of directional and grammatical The importance of grammar is illustrated by the fact that, prepositions. even when lexical comprehension is quite good, sentence It appears that the process of stimulus selection should interpretation may be impaired because of grammatical pro- consider possible differences among substantive word cate- cessing deficits. Caramazza and Zurif (1976), for example, gories, such as nouns, verbs, and adjectives, with nouns have shown that some patients have problems when sen- likely to be easiest when word frequency is controlled. In tence comprehension is dependent on syntax rather than on general, the literature suggests that grammatical words, such the logical relations expressed by individual semantic ele- as prepositions, conjunctions, and articles, are more difficult ments. To illustrate, the meaning of the semantically con- for patients with aphasia to comprehend than are substan- strained sentence “The apple that the boy is eating is red” tive words (Lesser, 1978). The above findings suggest that can be derived from an understanding of the meaning of its both semantic categories and grammatical class are critical critical elements and the limited logical relationships among aspects of lexical organization. Such differences should be them. That is, our knowledge of the world tells us it must be considered during stimulus selection. the boy, not the apple, who is eating and it must be the apple The possibility that specific semantic word categories that is red. On the other hand, consider the requirements for may be selectively impaired in aphasia is a matter of debate accurate comprehension of the reversible sentence “The girl (Lesser, 1978, pp. 97–107), but some studies suggest that that the boy is hitting is tall.” Here, either the boy or the girl semantic word categories should be considered for some logically can do the hitting, and either can be tall. Correct patients. For example, Goodglass, Klein, Carey, and Jones interpretation requires the appropriate pairing of “boy” with (1966) assessed the naming and comprehension of objects, “hitting” and of “girl” with “tall”—an interpretation arrived actions, letters, numbers, and colors in patients with aphasia. at only through adequate syntactic processing. Several stud- Objects and actions were the easiest to comprehend and let- ies have found that some patients have considerably more ters the most difficult, but objects were the most difficult to difficulty comprehending reversible sentences than semanti- name and letters the easiest. This not only suggests differ- cally constrained ones, implying the presence of significant ences among word categories but also implies that the diffi- deficits in grammatical processing (Caramazza & Zurif, culty of a particular category may vary between input and 1976; Kolk & Friederici, 1985; Sherman & Schweikert, output tasks. 1989; Wulfeck, 1988). Although many investigators and clinicians argue con- Ample additional evidence indicates that sentences vincingly against common or marked differences among requiring structural-syntactic analysis are generally difficult semantic word categories, it does appear that stimuli for patients with aphasia (usually regardless of aphasia type) restricted to a single semantic category (e.g., objects) occa- and that sentence comprehension is probably maximized sionally may yield misleading diagnostic and treatment when interpretation can be based on world knowledge and results. In addition, consideration of semantic category may the understanding of critical individual elements (e.g., see lead to the identification of treatment stimuli with varying Ansell & Flowers, 1982a, 1982b; Blumstein, Goodglass, degrees of difficulty. Statlender, & Biber, 1983; Caplan & Evans, 1990; Curtiss et al., 1986; Friederici, 1983; Gallaher, 1981; Gallaher & Canter, 1982; Mack, 1982; Parisi & Pizzamiglio, 1970; Grammar and Syntax Peach, Canter, & Gallaher, 1988). Constructing sentence As noted earlier, Schuell hypothesized a hierarchically based stimuli with this in mind is of practical import for another reduction of available linguistic rules in aphasia. Her idea reason. Gallaher and Canter (1982) suggest that the syntac- that such a hierarchy is based on the frequency of occur- tic impact on comprehension in real life may be minimal, rence of grammatical structures in general language usage is because much of what is said in everyday communication untested and, perhaps, overly simplistic in light of current can be interpreted on the basis of real-world knowledge and linguistic theory, but ample evidence suggests that gram- comprehension of lexical items, with grammar and syntax matical complexity is an important factor in language activi- providing largely redundant information. GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 424 Aptara Inc. 424 Section IV ■ Traditional Approaches to Language Intervention Demands for processing of grammar and syntax should 3. Patients with aphasia tend to use an active subject-verb- not—and cannot—be avoided entirely. A number of studies object (SVO) strategy for processing sentences and find provide very useful information about the relative ease or active sentences easier to comprehend than other forms. difficulty of processing a variety of grammatical and syntac- In general, this means that sentences in which the order tic devices for patients with aphasia. The following repre- of mention reflects the agent-action-object relationship sent a sampling of these findings: (“The mother kissed the baby.”) are easier than sen- tences in which the word order does not reflect that rela- 1. Present tense sentences are easier than past- or future tionship (“The policeman was punched by the robber.”) tense sentences (Naeser et al., 1987; Parisi and (Ansell & Flowers, 1982b; Brookshire & Nicholas, 1980, Pizzamiglio, 1970; Pierce, 1981). When the tense 1981; Friederici & Graetz, 1987; Grossman & Haberman, changes, the use of an additional tense marker tends to 1982; Hickok & Avrutin, 1995; Hickok, Zurif, & facilitate tense comprehension (e.g., “The man has Canseco-Gonzalez, 1993; Laskey et al., 1976; Pierce, caught the ball” should be easier than “The man caught 1983; Shewan & Canter, 1971). As mentioned above, the ball”; “The man has already combed his hair” SVO sentences that are nonreversible are easier to com- should be easier than “The man has combed his hair.”). prehend than reversible sentences. Words like “yesterday” and “tomorrow” also help to 4. Patients with aphasia tend to have more difficulty pro- mark tense (Ansell and Flowers, 1982b; Pierce, 1981, cessing grammatically encoded (compact) sentences 1982, 1983). (e.g., “The man greeted by his wife was smoking a pipe” The distinction discussed in the preceding paragraph or “The woman was taller than the man.”) than sen- is one example of what seems to be a fairly consistent tences that are simplified syntactically by expansion into hierarchy of syntactic difficulty that can affect compre- a series of propositions (e.g., “The man was greeted by hension. For example, gender, negative/affirmative, and his wife and he was smoking a pipe” or “The woman was singular/plural distinctions tend to be easier than tall and the man was short.”) (Goodglass et al., 1970; past/present, subject/object, and past/future/present Nicholas and Brookshire, 1983). Similarly, individuals distinctions. Within distinctions, the marked features with aphasia have more difficulty processing object-gap tend to be more difficult; for example, negative is more relative clauses (e.g., “It was the farmer that the robber difficult than affirmative, plural more difficult than sin- chased.”) than subject-gap relative clauses (e.g., “It was gular, and future and past tenses more difficult than pre- the farmer that chased the robber.”) (Hickok & Avrutin, sent tense (Lesser, 1974; Naeser et al., 1987; Parisi and 1995). These findings demonstrate that sentence com- Pizzamiglio, 1970). prehension is not simply a function of the amount of 2. Other morphologic distinctions can also affect compre- information and length, because compact and expanded hension. For example, Goodglass and Hunt (1958) sentences can contain the same amount of information examined the ability of patients with aphasia to compre- and easier-to-comprehend sentences can be longer than hend and express noun plurals and possessives that are compact ones. Results like these also highlight the com- represented by identical phonologic forms (e.g., plexity of the interactions among stimulus factors and “horses-horse’s”). Expressively, patients made many show that maximizing the facilitatory effect of one fac- more errors on possessive endings than on plurals. tor may increase the difficulty imposed by another; for Receptively, the same pattern was noted, with the addi- example, the generally desirable strategy of reducing tional observation that third person singular verbs also sentence length may necessitate a generally undesirable generated more errors than plurals. Goodglass and increase in syntactic complexity. In addition, it has Berko (1960) have reported similar error patterns, and become evident that factors influencing sentence com- Goodglass (1968) indicated that such patterns of deficit prehension do not have the same effects on discourse are independent of the form of aphasia (nonfluent vs. comprehension and that performance on sentence-level fluent) and, therefore, are not just specific to patients material does not always predict discourse comprehen- who are labeled “agrammatical.” At the same time, it is sion (Brookshire & Nicholas, 1984) (for further discus- important to keep in mind that syntactic deficits in sion, see the section on context). aphasia are not an all-or-nothing phenomenon. In addi- 5. Syntactic context, or the form in which sentence-level tion, the source of agrammatical production errors tasks are expressed, can influence response appropriate- appears to be independent of comprehension errors ness, if not accuracy. For example, Green and Boller (Goodglass, Christiansen, & Gallagher, 1993). The (1974) evaluated auditory comprehension in severe deficits typically encountered are relative, not absolute, aphasia by testing differences in response to commands, and patients with aphasia (even “agrammatical” yes/no questions, and information questions when such patients) are often able to process a good deal of syntac- tasks were directly worded (e.g., “Point to the ceiling.”), tic information (Baum, 1989). indirectly worded (e.g., “I would like you to point to the GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 425 Aptara Inc. Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 425 ceiling.”), or directly worded but preceded by an intro- counterbalanced for each subject; that is, some were trained ductory sentence (e.g., “Here’s something. Point to the first on simpler sentence structures (who questions [e.g., ceiling.”). Commands constituted the easiest task, fol- “Who did the thief chase?”]) and others on more complex lowed by yes/no questions and information questions. structures (object-relative clausal embedded sentences [e.g., The various syntactic contexts did not affect response “The man saw the artist who the thief chased.”]. Across all accuracy, but directly worded items were associated studies, results revealed greater generalization to untrained with a greater number of appropriate (i.e., relevant but structures when the more complex structures were trained incorrect) responses than were indirectly worded items. first. Similar findings have also been reported for individuals Directly worded items preceded by an introductory sen- with Fluant-aphasia profiles (Murray, Ballard, & Karcher, tence were easier than indirectly worded items. 2004) The authors have proposed a Complexity Account of 6. As discussed in the previous section, verb argument Treatment Efficacy based on their results. This theory states structure properties are important influences of lexical that greater generalization of treatment effects may be real- organization for verb retrieval; however, these struc- ized by training more complex sentence structures first, tures are also important factors in sentence production because these sentences contain all the information neces- by individuals with agrammatical aphasia. Previous sary for linguistically related, simpler sentence structures research has indicated that subjects with agrammatical plus additional information that may enhance learning. aphasia do not produce all argument structures required A number of syntactic and grammatical factors clearly by the verb in their sentence productions (Caplan & may influence comprehension, repetition, and verbal formu- Hanna, 1996; Thompson et al., 1994; 1995). Thompson lation performance. It also appears that the hierarchy of dif- and colleagues (1997) have also investigated the effects ficulty for a number of syntactic and grammatical tasks must of these structures on sentence production in those with be carefully considered in treatment planning. For example, agrammatical aphasia during narrative tasks. The sub- Thompson, Shapiro, and colleagues have presented con- jects with aphasia were noted to produce fewer verbs vincing data that support the notion of beginning treatment than the normal subjects. In addition, the individuals of grammatical structures with complex rather than, as pre- with aphasia showed a preference for producing simple viously believed, simple forms. one- and two-place verbs (i.e., verbs with the fewest par- ticipant roles) and rarely produced three-place or com- Context plement verbs (i.e., the most complex verbs). When complex verbs were produced by the subjects with apha- In recent years, interest has surged in the discourse compre- sia, they were produced in their simplest argument hension and expression, the factors that influence discourse structure forms. These results indicated that sentence comprehension and expression, and the relationship of dis- production was also influenced by the number of argu- course to word- and sentence-level abilities of patients with ments or participant roles as well as by the type of argu- aphasia. Findings indicate that word and sentence compre- ments required by the verb. The complexity of the verb hension do not predict the comprehension of discourse (i.e., the number of possible argument structure config- (Brookshire & Nicholas, 1984; Hough, 1990; Hough, urations) influenced sentence production, with simple Pierce, & Cannito, 1989; Pashek & Brookshire, 1982; verbs being produced correctly with their arguments Stachowiak, Huber, Poeck, & Kerschensteiner, 1977; more often than complex ones. Finally, obligatory argu- Waller & Darley, 1978) very well and that discourse com- ments were produced correctly more often than prehension is often better than single sentence comprehen- optional ones, even when the production of optional sion. Brookshire (1992) points out that, because communi- arguments was requested. cation in daily life usually occurs more in the form of connected speech than single sentences, it may be that mea- Clearly, a number of syntactic and grammatical factors sures of sentence comprehension underestimate daily life may influence comprehension, repetition, and verbal formu- comprehension competence. lation performance. It also appears that the hierarchy of dif- It appears that context, redundancy, predictability, and ficulty for a number of syntactic and grammatical tasks may extralinguistic cues within discourse and conversation facili- be differentially influenced by the nature of the aphasia. tate communication for patients with aphasia. The following Recently, Thompson, Shapiro, and colleagues (Jacobs & summary represents a sampling of findings from studies Thompson, 2000; Mitchum, Greenwald, & Berndt, 2000; regarding comprehension and expression of language in dis- Rochon, Laird, Bose, & Scofield, 2005; Thompson & course or natural communicative contexts by patients with Shapiro, 2005; Thompson, Shapiro, Kiran, & Sobecks, aphasia. These studies provide clues for the design of inter- 2003) have invesitgated the effectiveness of training more vention tasks that, for some patients, may be easier than complex grammatical forms through a series of treatment shorter and, apparently, simpler word- and single-sentence- studies. In each study, complexity of sentence structure was level activities: GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 426 Aptara Inc. 426 Section IV ■ Traditional Approaches to Language Intervention 1. Comprehension of syntactically complex sentences (e.g., scripts may be used in treatment to facilitate compre- reversible passive sentences) is facilitated when these hension, with fading of the degree to which discourse sentences are preceded or followed by contextually follows a script when comprehension improves. relevant sentences containing semantic or syntactic 3. Patients with aphasia comprehend implied meanings information that predicts the relationship expressed in quite well, especially in situations aided by extralinguis- the target sentence (Boyle & Canter, 1986; Cannito, tic context. In fact, Foldi (1987) reported that those with Vogel, & Pierce, 1989; Pierce, 1988; Waller & Darley, aphasia, like those without brain injury, tend to prefer 1978; Wright & Newhoff, 2004). (An example of a pre- the pragmatic interpretation of indirect requests over vious facilitative context task is “The girl is on the the literal interpretation. Wilcox, Davis, and Leonard ground. The girl was tripped by the boy. Who was (1978) presented videotaped “natural” situations to tripped?” An example of a subsequent facilitative context patients in which the correct interpretation of an utter- task is “The woman went to the library. She returned a ance was the meaning conveyed by the request in a par- book. Where did the woman go?” [Pierce, 1988]). Some ticular context. For example, the literal interpretation of studies also show that the context that precedes or fol- “Can you move the table?” simply requires a yes/no lows a target sentence may not have to predict specific response, but the indirect, conveyed/contextual mean- information as long as it facilitates processing of the tar- ing is a request that the table be moved. Patients with get information by, for example, identifying the topic, aphasia generally performed similarly to normal control setting, or theme (Cannito, Jarecki, & Pierce, 1986; subjects in their ability to use extralinguistic cues to Hough, Pierce, & Cannito, 1989). Nonpredictive con- comprehend the intent conveyed in many indirect text, however, has also been noted not to facilitate com- requests. These results suggest that the use of natural prehension of target sentences (Cannito et al., 1989; communicative contexts in treatment may raise com- Cannito, Hough, Vogel, & Pierce, 1996). Contextual municative performance over and above that derived facilitation for both types of paragraphs has been from more traditional, relatively pure linguistic tasks reported to increase as a positive function of stage of that often intentionally minimize extralinguistic cues. recovery from aphasia (Cannito et al., 1996). Individuals It also appears that linguistic information may help with aphasia who are in the early stage of recovery (1 some patients to appreciate the meaning of extralinguis- month) demonstrated no advantage for predictive or tic information. For example, Tompkins (1991) found nonpredictive narratives, those in the intermediate stage that increased semantic redundancy facilitated the (1–6 months) demonstrated an advantage only for pre- interpretation of emotions that were conveyed linguisti- dictive narratives, and those with chronic aphasia (6 cally or prosodically to patients with aphasia. months) exhibited facilitative effects of both predictive 4. Patients with aphasia have been shown to comprehend and nonpredictive narrative contexts. Finally, extralin- the main ideas expressed in discourse—that is, the most guistic context, in the form of a picture depicting target salient information—better than the details, and infor- sentence information, also facilitates comprehension mation that is expressed directly better than informa- (Pierce & Beekman, 1985), although Waller and Darley tion that must be inferred (Katsuki-Nakamura, (1978) found that the facilitatory effect of a contextual Brookshire, & Nicholas, 1988; Nicholas & Brookshire, picture was less powerful than verbal context. 1986a). Of interest, increasing directness and salience Pierce (1991) has pointed out that these facilitatory (through repetition or elaboration) seems to be a more effects are most apparent for patients with relatively reliable way than decreasing speech rate to improve dis- poor comprehension. The benefits of this kind of con- course comprehension. Nicholas and Brookshire (1986b) textual cue seem to derive from redundancy or the fact have also shown that the advantage of directly expressed that certain events or relationships are made more plau- information over that requiring inference is maintained sible than others. in multiple-sentence reading tests. 2. Predictability provided by discourse may explain why 5. Context can facilitate performance in certain word discourse is comprehended better than sentences. retrieval tasks. This same effect has been demonstrated Armus, Brookshire, and Nicholas (1989) found that the (Bendt et al., 2002; Hough & Pierce, 1989; Hough, knowledge of scripts by patients with mild to moderate 1989) for tasks requiring generation of words in ad hoc aphasia is not significantly compromised (scripts are categories (categories that are constructed for use in used to organize common situations [e.g., after repeat- specialized contexts [e.g., things not to eat on a diet]). edly eating in restaurants, we “know” the events that Significantly, more items were generated when contex- usually occur]). Thus, if a patient has an internalized tual vignettes preceded ad hoc category tasks (e.g., script for a discourse event, it may allow that person to before listing things to take on a picnic, the patient predict what will happen next, infer what is not stated, heard “Sam wanted to spend time outdoors. It was a and organize it for recall. The authors suggest that beautiful day so he packed up some items and went to a GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 427 Aptara Inc. Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 427 nearby park.”) than when they did not. The facilitative course should precede word- and sentence-level tasks in effect of context was not found for common categories the treatment hierarchy. (e.g., foods). Hough and Pierce suggest that ad hoc cat- egory tasks may be useful for patients with aphasia Stress because they are more divergent in nature and allow reliance on experience and world knowledge to a Despite some evidence that patients with aphasia may be defi- greater extent than common category tasks. cient in their ability to derive meaning from information pro- 6. Methods used to elicit narrative discourse from patients vided by vocal stress (Baum, Daniloff, Daniloff, & Lewis, with aphasia have variable effects. For example, picture 1982) or that stress representation may be selectively impaired sequences representing stories generally lead to a greater after brain damage (Cappa, Nespor, Ielasi, & Mozzo, 1997), it number of words in narratives compared with single-pic- appears that stress can influence response adequacy in a posi- tured scenes, but the two types of stimuli generally do tive way. For example, Swinney, Zurif, and Cutler (1980) have not affect other measures of production differently shown that patients with aphasia respond more rapidly to (Bottenberg, Lemme, & Hedberg, 1987). Gender bias of stressed than to unstressed words. More important, Pashek pictures (e.g., men in a gym vs. women in a beauty salon) and Brookshire (1982) as well as Kimelman and McNeil may result in differences in the number of words and (1987) found improved paragraph comprehension when exag- information but does not affect wpm or efficiency, at gerated stress on critical words was employed. Pashek and least in males (Correia, Brookshire, & Nicholas, 1990). Brookshire (1982) observed that improved comprehension in 7. Main ideas are expressed to a proportionately greater response to exaggerated stress was independent of improve- degree than details when stories are retold (Ernest- ment induced by a slowed rate, suggesting that slowed rate and Baron, Brookshire, & Nicholas, 1987). This may exaggerated stress may be additive facilitators of auditory com- explain why patients get along reasonably well in daily prehension. More recently, Kimelman and McNeil (1989) life; it is usually main ideas that must be recalled rather showed the comprehension of normally stressed target words than details. in paragraphs by patients with aphasia is better when preceded 8. Situational context may affect the manner in which by a stressed as opposed to a normally stressed context. The patients with aphasia respond. Glosser, Wiener, and magnitude of the facilitatory effect was greater for the patients Kaplan (1988) reported that, despite their linguistic with more severe impairment (those individuals most likely to deficits, patients with aphasia showed appropriate and need extralinguistic cues for comprehension). Kimelman predictable changes in response to nonlinguistic social (1991) has presented data that suggest the facilitative effect of contextual variables (e.g., face-to-face conversation vs. stressing target words may actually derive from changes in telephone vs. conversation over video monitors). In duration and fundamental frequency in the context preceding contrast, Brenneise-Sarshad, Nicholas, and Brookshire the target word. Finally, emphasizing rhythm may facilitate (1991) found few meaningful differences in the verbal phrase repetition abilities of individuals with nonfluent aphasia output of patients with aphasia when they narrated a (Boucher, Garcia, Fleurant, & Paradis, 2001). Thus, it may be sequenced picture story for a listener known to them contextual stress modifications that alert the listener to the who looked at the pictures as the story was being told salience of the target word. versus a newly introduced person who could not see Eliminating consideration of information strongly associ- the picture stimuli. The authors felt that it may not ated with Melodic Intonation Therapy (see Chapter 31), most be important to create treatment situations in which representative study on stress and speech output in aphasia the patient believes the listener is naive to the infor- has been conducted by Goodglass, Fodor, and Schuloff mation to obtain valid measures of communicative (1967). They found that fluent and nonfluent patients omit- effectiveness. ted initial unstressed function words much more frequently In summary, the contextual information provided than initial stressed words in a sentence repetition task. The within discourse and natural communicative contexts omission of unstressed words occurred more frequently for can exert significant facilitative effects on language and nonfluent patients. They also found that the stress pattern “/- communication for patients with aphasia. These effects /” was easier to repeat than any other three-word pattern occur not only for the processing of the main ideas and tested when a function word was in the first or second posi- intents expressed in discourse but also extend “back- tion. Moreover, the facilitating effect of this stress pattern ward” to the comprehension and expression of semantic seemed to override grammatical complexity. For example, the and syntactic relationships expressed within the context negative interrogative “Can’t you swim?” (/-/) was easier to of discourse. Discourse tasks, particularly comprehen- repeat than the grammatically simpler “Can you swim?” (-//). sion tasks, clearly need not await recovery of word and The authors felt that nonfluent (and, therefore, usually sentence comprehension ability to become a focus of apraxic) patients, in particular, may depend on stress features treatment. In fact, in some instances, it appears that dis- to initiate and maintain a flow of speech. Goodglass (1968) GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 428 Aptara Inc. 428 Section IV ■ Traditional Approaches to Language Intervention interpreted these and similar findings as supporting the 18 subtests rearranged in two orders of difficulty, one importance of “saliency” in the initiation of speech. That is, ascending and one descending. No performance differences many patients need a salient word to initiate speech, with were found between the two orders of difficulty. In contrast- saliency being characterized by stress and phonologic promi- ing their results with those of Brookshire (1972), who exam- nence, as well as other factors already discussed, such as infor- ined a single task containing items of varying difficulty, mational and personal significance. Dumond and colleagues (1978) examined differences across The clinical implications of these findings are obvious. tasks containing items of equal difficulty. They also indi- The selection of sentence and paragraph material for com- cated that “the changes in difficulty level between subtests prehension and repetition tasks should consider stress- were apparently less extensive than the changes in difficulty saliency as a variable capable of affecting the verbal compre- level within Brookshire’s experiment” (p. 358) and that this hension and verbal production of patients with aphasia. may have reduced subjects’ perception of their performance adequacy. They concluded that presenting PICA-like tasks in order of increasing difficulty is not likely to adversely Order of Difficulty affect performance on nonevaluative tasks for which diffi- Within a given treatment task, stimuli probably should be culty levels do not vary extensively. ordered so that more difficult items are presented last. This The available data appear to warrant the following gener- recommendation is based on evidence suggesting that suc- alizations regarding order of presentation during treatment: cess tends to breed success—and failure to breed failure— 1. Error rates should be kept low. for patients with aphasia. 2. Stimulus presentation should generally proceed from Brookshire (1972) studied the effects of task difficulty on easiest to hardest (with the possible exception of gram- naming behavior in nine patients. A group of easy-to-name matical structures; see previous discussion in the gram- and a group of hard-to-name pictures were derived from mar and syntax section), particularly within a given task baseline measures for each patient and then subsequently and on tasks in which the patient is likely to be most presented in different orders. When easy pictures preceded sensitive to performance inadequacies). hard pictures, responses to hard pictures were better than 3. If error rates are kept low, potential across-task order predicted on the basis of baseline measures. When easy pic- effects should be minimized. tures followed hard pictures, performance on easy pictures was poorer than expected on the basis of baseline measures. In line with these generalizations, Crosky and Adams Brookshire speculated that when a patient experiences a (1969) present some practical procedures for selecting and high proportion of failures, emotional responses may be ordering vocabulary stimulus materials for individual generated that disrupt subsequent responses. Although such patients. It is also reasonable to follow the suggestion of negative effects tended to decay over time, he suggested that Brookshire (2000) that sessions begin with familiar and easy treatment should keep error rates low and that easy items tasks, proceed to less familiar and more difficult ones, and should precede difficult ones. Brookshire (1976b) subse- end with tasks that result in a great deal of success. quently demonstrated very similar task difficulty effects for a sentence comprehension task in a group of 22 patients. The Psychological and Physical Factors results differed from the study on naming only in that easy items facilitated comprehension on subsequent hard items In addition to stimuli that are directly intended to stimulate for only a small number of patients. language, factors that affect the psychological and physical Support for an order effect can be found in several other “set” of patients can influence response adequacy. studies. Gardner and Brookshire (1972) found that naming Skelly’s (1975) interviews with patients who have aphasia performance under unisensory conditions is often facilitated indicate that even relatively subtle signs of disinterest or when preceded by a generally easier auditory-visual stimulus impatience on the part of the clinician “bothers” patients. condition and that responses to auditory-visual stimuli are Stoicheff (1960) found that the overt attitudes expressed reduced when preceded by a generally more difficult visual during instructions to patients can significantly affect stimulus condition. Similarly, Brookshire (1971b) found that responses. Using three groups of patients with aphasia, she forcing subjects to respond at rapid rates depresses perfor- examined the effects of encouraging, discouraging, and neu- mance on subsequent items in which they are given more tral instructions and comments during performance on time to respond. Finally, Brookshire and Lommel (1974) naming, reading, and self-evaluation tasks. After 3 days of reported the disruptive effects of failure on the performance exposure to one of the conditions, the self-evaluation, nam- of patients with aphasia and subjects without on a nonverbal ing, and reading performance of the group receiving the dis- sequencing task. couraging instructions was lower than the performance of Dumond, Hardy, and Van Demark (1978) questioned (or the groups receiving neutral or encouraging instructions. qualified) the significance of the order effect. They readmin- No differences were found between the encouraging and istered the PICA to 20 patients in split-half form, with the neutral conditions. Obviously, the performance differences GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 429 Aptara Inc. Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 429 were attributed to the negative effects of discouraging sages. They may be able to repeat or comprehend only the instructions. Finally, the previously discussed findings of last part of sentences, may miss short messages entirely, or Brookshire and colleagues on the effects of order of stimulus may do better on the final items of a subtest or treatment difficulty suggest that failure—or stress induced by failure— activity than on the initial items. Brookshire (2000) sug- may produce emotional responses that disrupt subsequent gests that the use of warning signals before presenting responses. It seems, therefore, that disruptive psychological auditory stimuli may facilitate processing for these effects may result from negative attitudes expressed by the patients, and Loverso and Prescott (1981) provide some clinician during instructions and performance or from the indirect support for this. They found response times of failures that patient may experience during the course of a subjects with aphasia on a same/different visual judgment treatment session. task to be reduced when the visual stimuli were preceded The effects of physical fatigue on language performance by a half-second warning tone; maximum benefit was have been examined by Marshall and King (1973). Subjects derived when the tone preceded the stimulus by 1.5 sec- were given the PICA following a period of isokinetic exercise onds. Presenting items with gradually increasing intervals and, on another day, following rest. The PICA scores were between successive items may also help the patient to keep significantly lower following exercise than following rest for his or her “processor” active over longer intervals or help verbal, graphic, and overall PICA measures. Fatigue had its to activate the processor more quickly. most pronounced effect on speaking and writing tasks. The Patients with a slow rise time illustrate the fact that gen- authors suggested that language therapy be scheduled before eralizations about a number of stimulus factors do not physical exertion, such as physical or occupational therapy. In always hold. For example, contrary to “average” perfor- another study that probably reflects the cumulative effects of mance, the patient with a slow rise time may respond better fatigue over the course of a day, Marshall, Tompkins, and to redundant sentences than to single words or may respond Phillips (1980) found that patients with aphasia did better on more appropriately to directly worded input preceded by an assessment measures administered in the morning compared introductory sentence than to a directly worded sentence with measures administered in the afternoon. alone. It seems that psychological and physical factors facilitate performance best when treatment is conducted in a positive, Noise Buildup encouraging, success-producing milieu and at a time when the patient’s physical status during the treatment day is optimal. Patients with noise buildup tend to respond more accurately to the initial portion of auditory messages than to the fol- Pattern of Auditory Deficit lowing portions. More complex material tends to produce noise more rapidly than less complex material. Such patients Auditory impairments are not uniform and may reflect a may not be able to repeat or comprehend the final portion of number of different underlying problems. As a result, to sentences, may make more errors on complex than on sim- ignore differences in the auditory deficits of patients with ple materials, and may deteriorate progressively across items aphasia is to ignore a factor that may bear on the way in on a particular task. Brookshire (2000) suggests that they which we structure auditory stimulation during treatment. may benefit from a program with messages of gradually Consideration of such differences may help to identify stim- increasing length and complexity, with gradually decreasing ulus factors that are especially important for a given patient intervals of silence between successive items. and, in some cases, may serve to qualify or alter the general- izations and recommendations that have been made about Retention Deficit those factors thus far. Brookshire (1974) summarized and discussed five kinds of Patients with retention deficits also deteriorate as length auditory deficits, supported by a variety of subsequent stud- increases, but they are not as susceptible to complexity fac- ies (e.g., LaPointe, Horner, Lieberman, 1977; DiSimoni, tors as are those with noise buildup. Performance break- Keith, Holt, & Darley, 1975; McNeil, Hageman, & Matthews, down tends to occur at the same point in all messages 2005), the characteristics of which may have an important regardless of complexity. The important treatment consid- bearing on treatment planning. These characteristics reflect eration here is to gradually increase message length. the need to avoid considering auditory deficits in aphasia as a unitary problem. These deficits and implications for stim- Information Capacity Deficit ulus selection are: Patients with information capacity deficit do not seem able to receive and process information at the same time (see Slow Rise Time Wepman (1972) for a discussion of the “shutter principle”). Patients whose auditory systems are characterized by a slow In such cases, performance may be alternately good or poor rise time tend to miss the initial portion of incoming mes- within a message, good for information that is received and Responses should not be forced. To those. with short responses object naming task but also noted that. when they simultaneously attempted to point to the picture ing ability improves. improve auditory comprehension or retention. Unison responses may be especially appropriate for Response Considerations severely impaired patients. For example. secutively. pantomime. found that delay was the most effective response “strategy” employed by patients with aphasia for word retrieval. because they give simultaneous auditory and visual feedback and are a step down the Although the emphasis of the stimulation approach is on response hierarchy from repetition (Schuell et al. certain other response considerations must be Thus. it is also a potent that 30 seconds were better than 0. although the existence of several of them appears to have been verified by other investigators (McNeil & Hageman. when patients were nearly always easier than long ones. other gestures. or 10 seconds on an response factor for most patients. Marshall (1976). because the motor con- radic and unpredictable performance. object Patients with this problem constitute a separate category in or picture manipulation. the effectiveness of such stimulation can Wertz. 430 Section IV ■ Traditional Approaches to Language Intervention can be acted on and poor for information directed at the is to improve spoken language ability. Hanlon. 3. Brookshire (1971b) found as length is a potent stimulus factor. if we wish to between stimulus and response may not be predictable. On comprehension tasks. 5-. 5. Because we do not trol of simple pointing responses is usually unimpaired. they usually did so within 10 seconds. but not the middle elements. for some ation stated earlier are relevant to response considerations: patients. requiring rapid responses may depress the ade- 1. should rarely have to exceed 30 seconds. for example. the effect of imposing delays cific goals and baseline data. processing may be very useful. three of the general principles of remedi- impose unreasonable demands on some patients. with their hemiparetic right arm. Such observations rein- areas of deficit. understand the controlling factors in such a problem. For example. Schuell’s system of classification. Such patients may.) Output modes usually include pointing. and Gerstman benefit from the insertion of pauses within messages. Temporal Relationship 1964).GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 430 Aptara Inc. 1978). leading to spo- ment focuses on auditory processes. and are seen atypi- should be considered. and Broca’s aphasia named pictures more adequately tion. with fading of their frequency and duration as process. Point-to tasks are frequently used when treat- ability appears to fade in and out randomly. we can add one additional principle—response How much delay? Schuell and colleagues (1964) sug- demands generally should proceed from short to long. Patients also may be asked to repeat a response con- potent stimulus factors when planning treatment. be able to repeat the begin. Just gested 60 seconds for some tasks. us in selecting the most intact mode of response. It is quite probable. If the goal and 20-second delays were imposed before patients were . Brookshire (1992) observes that such tasks can be Brookshire recommends that treatment be directed to other relatively difficult for some patients.. Response adequacy in a particular modality can some- ning and end. already been determined by the chosen goal. Their auditory processing and writing. Although immediate responses represent the be assessed only if responses are elicited. 1967. 1979. There should be a response to each stimulus. 10-. simplistic and incomplete. that they exist in vary- The temporal relationship between stimulus and response ing combinations within many patients. hemipare- pauses may initially be frequent and of relatively long dura. the ability to recognize them with a stimulus. nodding. (Note that this may repre- sent facilitation of problems more related to apraxia of Intermittent Auditory Imperception speech than to language per se. In addition to these able to name objects. however. In such cases. input to the patient. it seems that delays allowed for processing to occur addressed when planning treatment.. sis. 1955. principles. of a sequence of times be facilitated by a simultaneous response in another words. A maximum number of responses should be elicited. Regardless of the most frequent and desirable temporal relationship. Responses may be elicited in unison cally in pure form. we should Schulte (1986) examined the comprehension of 10 patients place minimal demands on output and let baseline data aid with aphasia on a Token Test type of task in which 0-. they may form of response. the response mode has system while processing of previous stimuli is taking place. Brookshire (2000) suggests that these patients may modality. Decisions regarding the mode of response are based on spe. quacy of performance. Porch. force the need for letting the individual patient’s abilities Brookshire points out that the above categories may be determine the mode of response. considering the principle that treatment should Response Mode elicit a large number of responses. immediately following a stimulus. speech. for example. or after a when they occur has direct implications for the selection of delay. Brown. and probably should not. Schuell et al. Such (1990) found that patients with anterior lesions. Regardless. However. allowing a delay for 2. a high pro- tional fluency (because of hesitation. uum. theoretically.) The important point is that response expec- ered under the section dealing with consequences/feedback).e. naming. unable to respond very accurately to auditory In addition to using delay as an aid to comprehension or tasks) often are able to respond appropriately.. to point-to comprehension tasks (i. Boone (1967) suggests that any specific response- compare strategy on sentence verification tasks in which the contingent feedback may be trivial or unnecessary when truth value of a sentence is based on a comparison with a patients are motivated (as is usually the case). Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 431 allowed to look at response choices and respond. does not mean that we Finally. This is in contrast to patients were trained to monitor/identify their dysfluencies operant approaches. and mildly impaired patient with aphasia and reduced conversa. get response. This reduced syntactic and paraphasic response dimensions. however. in other words.GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 431 Aptara Inc. subjects varied by nearly 20% between some conditions. Imposing a delay between a patient’s response and the nodding when asked yes/no questions.. torted responses. appro- next stimulus may also be an effective strategy for reducing priateness of response may be the most appropriate expecta- perseveration in some patients. increased efficiency in the form of increased length of unin.. a high degree of accuracy may not be possible. expectations may have to be lowered. respond may be a useful strategy for improving retention looking around the room when asked to point to the door or span. stimulus presentation may influence processing demands It has already been stated that feedback about response and response adequacy.e. imposing delays before allowing the patient to show signs of rudimentary comprehension by. patients (i. Because antecedents are. At the other end of the contin- (1982) found that the frequency of perseveration on sen.” in which force the patient to deal with the fuller meaning of the sen. (Such response characteristics are reflected Delay sometimes can be used actively by patients to in Porch’s multidimensional scoring scale and are discussed improve response adequacy (this point could also be consid. or is largely responsible for. revisions. the the patient to respond adequately. and can assess their response in relation to the instead of processing the full meaning of the sentence. tations need not be geared solely toward accuracy. and quences on subsequent behavior. in which increased adequacy of responses during picture description tasks. response characteristic. errors and permitted the same or more information to be conveyed with fewer verbalizations. when a patient can respond with a relatively high tence completion. a dramatic reduction of dysfluencies. an imposed delay may facili.e. the ability of encies from audiorecorded samples of their speech.. present conditions for the group as a whole. which facilitates. it may be appropriate to expect a reduc- the time between a response and subsequent stimulus tion of self-corrections and of incomplete. For some Berstein-Ellis. For others. the crucial modifier of language processing in terrupted utterances. in Chapter 28. No consis. To research on the concept of “errorless learning. for example. was dysfluent because of revisions. know the tar- simultaneously presented picture stimulus. Performance within the sentence and then the picture) rather than simultaneous. they target. and reading tasks decreased as degree of accuracy. and audible the antecedent event) is that part of the treatment sequence pauses. Brookshire and Nicholas (1980) accuracy and appropriateness should be given when neces- have shown that patients with aphasia tend to use a find-and. they formulation. and para. repetitions. Wertz. those authors suggest that the spoken sentence and tent effects on comprehension were found among the delay the picture stimulus presentations be staggered (e. the stimulation approach. then present picture choices). sary. This resulted in reduced is attributed primarily to the controlling influence of conse- speech rate. some subtle uses of temporal relationships in should not respond to patient behavior. It is quite possible that this more challenging approach to however. or dis- increased from 1 to 10 seconds. Santo Pietro and Rigrodsky tion for an initial response. Support for this type of feedback comes from may simply match key words to elements in the picture. Schulte sug. tence. present sentence and gested that. Whitney and Goldstein Consequences (Feedback) (1989) used a different technique and achieved the same result for three patients with mild aphasia whose discourse The stimulation approach presumes that the stimulus (i. sion accuracy but that it may be a useful response parameter Green and Boller (1974) found that severely impaired if its effects are predictable for individual patients. and Shubitowski (1987) instructed a patients. It therefore appears that impos- ing a delay between stimulus presentation and response has Although accuracy is certainly the most commonly expected no generally predictable influence on sentence comprehen. In such cases. for some patients. delayed. tate full processing before a response but may be detrimen- tal for others because of poor rehearsal mechanisms or Response Characteristics reduced retention capacity. 1979) to slow room for response refinement along a number of other the rate of speech. treatment is structured to decrease the likelihood of a . and a few of the more severely impaired patients stimulus presentation in a verification task would also apply benefited from brief delays in some conditions. that is. portion of accurate responses may still leave considerable phasias) in the use of a pacing board (Helm.g. After learning to recognize and identify their dysflu. it is not the only relevant one. one of the most common errors made by clinicians was overcorrection or overexplanation of errors and that the The selection of appropriate starting points should be proper contingency for an inadequate response is usually based on adequate baseline data. but probing session is always desirable. The findings of corrected or delayed. errors.” at least when combined increased when 90% or more of responses are com- with discouraging instructions. at which treatment would be appropriate (e. Brookshire (1997) offers give information about the closeness of a response to the some more specific suggestions regarding starting points. confirmation. lishment of relevant. should be near capacity. 1977).. felt that explaining errors to patients standardized tests. arguing for the critical ment or punishment have little effect on speech and lan. Holland and mation. 80% feedback—aside from being information the patient has a accurate. should be carefully controlled and concise. forces them to work ing task implies that feedback. The responses to their environment (this is critical for the estab- analysis by Brookshire and Nicholas (1978) of clinical inter.g.. In support of this. Treatment should begin at levels where slight deficien- finding that patients with marked to severe impairment cies exist and never where performance is completely were sensitive to the effects of short delays between inadequate. This assures that patients are not pushed responses and their consequences on a nonlanguage learn- beyond their capacity but. immediate. with 20% delayed or self-corrected responses). reinforce. or information. culty. For example. 1973). bear. & Augustine. in most instances. which can be summarized as follows. subsequent performance. 90% other hand. waste object-by-function from among 10 choices is below the level time. immediate. and it provides a framework for discussing and/or auditory abilities. are appropriate. Schuell and colleagues (1964) indicated that treatment ers without aphasia do. in their evaluation of an auditory com. importance of stimulation in treatment. Difficulty should be performance. That is. with function from among only four choices generates response graphs often being an effective format for doing so. 2. have a detrimental effect on pletely adequate in the dimensions that are the focus of performance. but in general. Sage. 432 Section IV ■ Traditional Approaches to Language Intervention patient producing an inaccurate response. It seems that confirmation of adequate performance Christman. treatment begins without knowing if tasks or stimuli Sonderman (1974). instead. on the named from among 10 choices is very adequate (e. The notion supporting the continuation. or probing of variations in stimuli to see how to make errors following corrective explanations of previous changes influence speech and language behavior (Hendrick. response-contingent rewards or should proceed through gradually increasing levels of diffi- punishment may be necessary. Brookshire (1997) supports the might establish that identifying those same objects-by- value of showing patients their progress over time. practical tasks and stimuli) or selected actions in treatment of aphasia indicated that patients tend stimuli. Additional support comes from the finding Sequencing Steps in the Treatment Program that mild to moderately impaired patients with aphasia Where to Start modify their picture descriptions in response to failure in a referential communication task in the same way that speak. when appropriate. target. Tasks should not be too easy. Explanation and correction. Hodgson. In the relatively rare case when a should begin at the level where language breaks down and patient is not motivated. systematic sampling of patients’ confused. suggested that guage performance in aphasia (Brookshire. 2003). such as “that’s wrong. it may antecedent events to low-cued events in which the patient be most appropriate to confirm response adequacy or to carries most of the processing load. rate responses). Baseline data may be established through prehension program. Subsequent assessment of responses to func- general encouragement and reassurance during a treatment tional items might confirm standardized results. Tasks for which 60% to 80% of responses are correct What information should be given to patients when their and immediate represent good starting points. Brookshire’s (1971a) 1. Schuell and colleagues (1964) felt that treatment.. punish. standardized may be helpful and encouraging and. Bollinger and Stout (1976). & Lambon Ralph. Such characteristics at a level appropriate for treatment (e. Second.g. alteration. represents testing may indicate that the ability to identify objects good clinical practice. such not more than 20% to 40% of responses should be self- information should not be negative. Whether feedback is in the form of reward. because without such infor- more stimulation. or termination of behind this approach is that the brain is prevented from certain treatment activities. responses are inadequate? First. right to know about—has motivational and reinforcement Such baseline data identify a starting point for stimulating functions. When treatment should progress from highly clinician-cued patients are motivated but give deficient responses. accurate responses) but also that identifying ing in mind that such feedback may be of little value. rather than aided. 50% inaccu- In addition to considering response-dependent feedback. and be counterproductive. specify the stimulus conditions and .GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 432 Aptara Inc.g. Stoicheff (1960) suggest that discouraging comments during 3. incorrect or inefficient processing to maximize accuracy of new learning (Fillingham. generally. ment. LaPointe also appropriate for patients with aphasia and have enjoyed vary- suggests that the criterion be maintained for three consecu. A number of examples of tasks Approach and Programming requiring verbal output. to Tasks Emphasizing Auditory Abilities consider programming as a tool for systematically imple- Point-To Tasks menting the stimulation approach. A careful from suggestions offered in the following sources: Schuell reading of Schuell’s work shows that her principles and sug- and colleagues (1955. because given behavior is stable. In this sec- to tasks with greater demands. but the reader is cautioned surprising. Brookshire gestions regarding treatment are compatible with the rigor (1997). because this is consistent with Compatibility of the Stimulation the stimulation approach. see Darley (1975) and Sarno (1974)). Experienced clinicians agree tion. ing or undefined degrees of success. They are not offered as tive sessions before terminating the task to ensure that the prescriptions or even as recommendations. For example. and systematic nature of programming. Her admonitions to Darley (1982). slightly easier. a number of specific tasks will be listed. This may be somewhat the anticipated easiest to hardest. Schuell (1953a). Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 433 response expectations to be employed during treatment. gression of activities. 1983). The acquisition of baseline data and the The examples offered here cover a range of difficulty so setting of criterion levels also have been highlighted. Criteria for Determining Success Once tasks and stimuli have been established and target behaviors or response characteristics identified.GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 433 Aptara Inc. It should be understood that The discussion regarding the design of intervention has nearly all auditory and verbal tasks are readily adaptable to included information about stimulus and response consider- the reading and writing modes. use that they either defy or make accurate referencing trivial. selection of starting points. because the appearance of information about the that the order provided is not empirically derived—and. It is also treatment in the same discussion has typically been in the important to note that difficulty level can be altered not only form of contrast (e. Kearns and Hubbard (1977). many of which also involve auditory input. cannot be—because of patient variability. give direction about the organization of succeeding steps. know where performance breaks Many other examples are of such universal.. it is assumed that the specific task is tion included numerous implied suggestions about tasks and no longer necessary and that the patient is ready to move on techniques that may be appropriate for therapy. behavioral approach program is highly capable of assisting. long-standing down. 1992. LaPointe’s (1977) “Base-10 Programmed Stimulation” as No less important is the fact that baseline data provide a pre. They are that a target behavior criterion of 90% is generally appro. and discard ineffective techniques are things with which a systematic. tion of general programming principles as being mutually Many of the examples given below have been derived exclusive treatment strategies (LaPointe. When a patient’s performance plateaus at our current state of knowledge. in this context. we have no way of predict- a level below the criterion for a number of sessions. 1977). LaPointe. and Rosenbek. Programming is particu- larly desirable because of its commitment to accountability These activities involve the presentation of information and its capacity for making treatment both replicable and auditorily and require a simple identification-by-pointing . LaPointe (1978a). well as Bollinger and Stout’s (1976) “Response-Contingent treatment measure of ability against which the results of Small-Step Treatment” are excellent. it is inappro- response choices in a point-to auditory comprehension task priate to consider the stimulation approach and the applica- may significantly increase task difficulty. increasing the number of sequences as the primary modifiers of behavior. offered as examples of activities that are considered to be priate (Brookshire. and accessible to analysis (Holland. but a few examples of tasks ations. will be given as well. LaPointe. by switching tasks but also merely by altering certain stimu- Although operant-programmed approaches are dissimilar to lus factors or stimulus-response relationships associated the stimulation approach because of their emphasis on con- with a given task. It seems to be most appropriate. ing reliably which tasks and techniques work best with indi- gests that the task be terminated or modified to make it vidual patients. 1975. and Wertz (1989). clinically applicable treatment can be compared. he sug. contingencies. 1964). work systematically. we must EXAMPLES OF THERAPY TASKS determine the criterion for acceptable performance. choose realistic goals. stimulation approach and the programmed approach to probably. and pro- unique to reading and writing will be given. 1978b). The focus of the examples here will be on tasks that emphasize auditory processes. All as to include suggestions that are appropriate for patients these considerations can be strongly associated with pro- with mild to severe impairment. When The preceding discussion regarding the design of interven- this criterion is reached. LaPointe. elicit large numbers of responses. The tasks are ordered from grammed approaches to treatment. examples of the compatibility of the stimulation approach and structured behavioral methods.g. Questions dealing with general information (“Was stimuli (“The girl is chasing the boy”. 7. Follow two-verb instructions (“Point to the cup. can reduce the possi- knife”. Point to an item (picture or object) named. and often allow 4. silver.” or “Point 4.”). horses. Repeat spoken words. Only a simple verbal or nonverbal response is “How are you?”) required. Have I asked you to give me the cup? 7. Repeat phrases (“in the house”. “to the Yes/No Questions and Sentence Verification store”. a response switching activity might include the people are very busy”—represented by people building following successive items: a house). Questions requiring phonemic discrimination (“Do to focus primarily on the reception. “penny-key- These formats also increase flexibility. ble effects of visual deficits on performance. A more com- Response Switching plex but analogous task might involve responses to questions based on the preceding sentence or paragraph These tasks require the patient to switch responses from material. Questions involving verbal retention (“Are cows. 3. “What time is it?”.”). tion of the auditory message. Repeat sentences with or without corresponding picture 1.g. require close attention to the 5. 7. response choices. combine the auditory tasks previously discussed or also may 6. Questions about picture material (“Is the boy wail- ter (e. Point to an item to complete a sentence (“Please pass (“Kennedy was President in 1861. How are you feeling today? knife). Such activities may simply and point to the pen.” or “Point to book-comb. and sharp”—points to a 5. Point to an item whose name is spelled. Follow two-object location instructions (“Put the pencil These require reception and retention of auditory informa- in front of the cup. patient is asked to verify the truth of various statements 3. 1. Many 5. syntactic complexity). pick up the spoon.”). Read this. 1. and reten. and lions are all animals. “long-under-baby-pencil”). reading. dogs. Point to the door. to the one that is long. processing. item to item and. Follow two-verb instructions with time constraint word retrieval. tion and the ability to repeat the information verbally.”). Point to two (or more) items described by function. in which the one used for writing. the bread and _____. 434 Section IV ■ Traditional Approaches to Language Intervention response. include items requiring speech. The ease of the motor response allows patients 2.”). Point to an item described by function (“Point to the tence or paragraph verifications tasks. Minimal demands are placed on 4. 2. the tree. 8. 3.” or “Cows. and do what it says to do. For example: Repetition Tasks 1. Some exam. Point to an item described by a varying number of 3. 6. dogs. Point to an item best described by a sentence (“Those For example.”). 4. and go to the ball- park. Repeat stereotyped or functional phrases (“Where are the extension of stimulus material beyond the immediate you going?”. “The cat is up in Kennedy President in 1861?”).”). many of the stimulus factors discussed earlier in the chap. Repeat series of items (“book-table”.”). Point to an item in response to questions (“What do you find in the kitchen?”—points to a stove). “Please pass the salt”. trees. 6. stress. play tennis. 2. similarity and number of ing?”—picture of boy running). of these tasks can be employed as speech activities by horses. environment. Follow one-verb instructions (“Pick up the pen. or writing abilities. Did I say I like to play football?”). Following Directions These tasks allow greater flexibility and complexity in the Tasks Emphasizing Verbal and Auditory Abilities auditory demands placed on the patient.”). Questions requiring semantic discrimination (“Do you many other auditory tasks can be altered by variations of start a car with a tire?”). Is the floor lower than the ceiling? descriptors (“Point to the large white circle. therefore.GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 434 Aptara Inc.. 4. visual cues. trees. people wear shoes and blocks on their feet?”). Spell your name. 1. “black and white”. requiring verbal instead of gestural responses. For example: (“Before touching the penny. Give me the cup. “on the beach”. 2. facilitate performance. Difficulty level on these and 3. . Questions about preceding sentences or paragraph ples include: material (“I like to swim. The above question examples may be converted to sen- 2. and lions all animals?”). For example: 5. Pick Auditory comprehension is not necessary. “shoes and socks”). Point to two (or more) items named (“Point to the book nature of the task on each trial. although it may up the eraser. rate. 9. pause. she). peo- you?”. Answering questions after imitative cues and a question prompt (clinician—“Answer the phone”-patient imi. For example: 1.”). sports) or a concept (e. Describe activity of the clinician (clinician points to two graph material (e. Retelling 2. predictability (“Please pass the salt and _____”. but the primary demands are retrieval and sentence formulation may be taxed to varying placed on the patient’s verbal retrieval and formulation abil- degrees. and so on in sentences (put-how. auditory input. words. “John was on the ground. such as using These tasks require verbal comprehension but minimal transitive verbs in sentence formulation. 2. prehension and word retrieval processes and less demand on Maximal demands are placed on word retrieval and sentence auditory retention compared with repetition tasks. “Exactly how do you 7.g. “How did you get here today?”).”). 4.. For example: 1. Describe activities in pictures. 3. Tell everything possible about pictured objects or activ- boy went to the movies. . clinician touches an object.. Name pictures. For example: red. on the ability to follow naturally occurring auditory and situational cues. Word fluency/rapid word retrieval—clinician provides a tence formulation. “Answer the phone”).. such as using intransitive verbs in sentence formulation.?”. Describe the function of objects. High-level patients 6. clinician—“What should I do?”. Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 435 Sentence or Phrase Completion Connected Utterances in Response to Single Words These tasks typically place more demand on auditory com. 2003) 3. completed). Word focus content and aid retrieval. Listen to paragraph material. Complete sentences with nouns with varying degrees of 2. ities (urge patient to describe all possible uses of objects. Use selected words of varying parts of speech. associated situations.g. etc. bigger. a common category (e. tates. Use sentences beginning (or ending) with selected me the _____”. Synonyms—“think of a word that means the same as ‘car. “hot have suggested that initiating treatment with stimuli that and _____”. ple. 3. things that can roll). “Read a _____”. Open-ended conversation on unrestricted topics with get from here to _____?”). Rhyming—clinician says word and patient rhymes These tasks can place relatively heavy demands on compre- (“hot—pot”). general nature of the task. General conversation about a selected topic with one or may be asked questions requiring lengthy responses more individuals. and the patient generates as many 2. categories. “How do you feel?”). Define words. 3. and patient— 2. Answering questions after a model (clinician— “The 4. What did the boy do?”). television.’” “Self-Initiated” or Conversational Verbal Tasks These tasks are not dependent on preselected auditory input Answering “Wh-” Questions to the patient. one or more individuals.GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 435 Aptara Inc. require a more complex response. 5. Retell a familiar story. Oral opposites (“hot-cold”. tense. and then places an object 5. (“How do you change a flat tire?”. 4. For example: ities and. when.g. culty. “Who is the President of the U. “Throw 3. For example: letter of the alphabet. and then retell it. with the exception of directions about the These tasks always place some demand on auditory compre. Verbal retrieval processes are taxed. 1. For most formulation. and then retell it. often. 2. clothes.. word tasks but less difficult than single-word recall tasks without class. Listen to radio or television broadcast. 1. running. “Buy me some _____. “early-late”). they are more difficult than single-word repetition 1. Although these tasks are not listed in a hierarchy of diffi- “I use a paint brush for _____. Complete paired-associates (“black and _____”. if. Complete sentences with verbs (“I use a fork for _____”. Other stimuli may be used to hension and may require significant retention as well. John was pictures—patient describes. 1. Answer questions about the preceding sentence or para. or concepts as possible. things to do on vacation. may increase the generaliza- Verbal Association tion of this skill to less complex responses. For example: patients.A. retention. “night-day”. words or phrases (I eat.S. Thompson and colleagues (Thompson et al. given in a sentence). “salt and _____”).”— “Who was on the ground?”) places another object near it. Minimal demands are placed on auditory input processes. Answer general questions (“What do you do when on top of another—patient describes the activity when you’re hungry?”.). tripped by Mary. hension and retention and always tax word retrieval and sen- 3. Answer familiar conversational questions (“How old are objects’ physical properties. demands for a given process are low. McNeil. Recently. substitutes colored pictures for the line drawings. The issue of whether brain damage reduces the amount 5. Odell. Identify letters named by the clinician among a number provided with adequate resources. The following are some mance. perception that were impaired. the cognitive processes will not be 2. which clinicians can manipulate the processing load is mance. named by function (“Point to the one used for. mal. processes is referred to as “processing resources” and is con- tory input can be adapted easily for reading tasks simply by tained in a central pool. Resource allocation models have important implications Writing for application of the stimulation approach to therapy for Most of the examples offered under the sections dealing aphasia. negatively affected. he has made eight errors. and perfor- mance on the auditory comprehension aspects of the task RESOURCE ALLOCATION MODEL improved. with a gradual the pool will not be exceeded. Fill in missing words in sentences from among written of resources within the central pool or hinders access to the choices (“They went to the movies last (day. Name letters. “John is (to. the allocation of show. freeing up cognitive resources. Read sentences or paragraphs silently. such as visuoperceptual clarity. night. thus improv- ily to the writing mode merely by requiring written instead ing the performance of the individual with aphasia perfor- of gestural or verbal responses. With the activation of any process. and performance will be nor- increase in rate and/or fading of the clinician’s input. & Tseng. what resource allocation models suggest is that all humans length and redundancy. however. gram- have a limited amount of cognitive resources for conducting mar and syntax. name. memory.. the alphabet. Essentially. In either case.”). come) in a little suitable resources is insufficient for the task at hand. the number and complexity of cognitive processes involved. fight)”. followed by ques- age on a given task is at a level below that of the individual tions about content.. without brain damage. Read aloud a paragraph or story. frequency and meaningfulness. The clinician reads paragraph material. letters. Brookshire (1997) provides an example that illustrates additional tasks that are associated more uniquely with writ. and so on. 436 Section IV ■ Traditional Approaches to Language Intervention Tasks Involving Reading and Writing Abilities mental or cognitive processes involved with perception. the with auditory and verbal activities also can be adapted read. and response formulation. phrases. Match written words. the available 6.”). If the demands of the cognitive processes exceed the employed in an effort to increase the reading rate). the visuoperceptual demands of the task the paragraph based on those notes. Read in unison with the clinician. Although the targeted 5. or fuel. resources within the pool. going. so the clinician 4. The patient comments that 3. McNeil and colleagues (McNeil & through manipulation of the task stimuli. this notion. An individual with aphasia who has a visuoper- ing modality activities: ceptual impairment is engaged in an auditory comprehension task involving pointing to black-and-white line drawings 1. Write letters to dictation. that are associated more uniquely with reading: The number of cognitive processes that are called on simul- taneously as well as the complexity of a given process deter- 1.. 217). throughout this chapter. or sentences to pictures mine how much fuel is drawn from the central resource (gradually reducing the stimulus exposure time may be pool. with process was an aspect of auditory comprehension. which get to the heart of the . went. If. After 10 2.GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 436 Aptara Inc. By modifying the visual characteris- writes down the essential facts. “He is reading a _____ b-ok.g. the performance of the individual with brain dam- 6. the finite resources in 4. the resource 3. “[C]linicians can focus treat- ment on a targeted process by controlling the processing load FOR APHASIA associated with incidental task variables that are not related to Resource allocation models provide a useful format in the treatment objectives” (p. and the patient resources were exceeded. The primary manner in searching for the underlying causes of impaired perfor. Performance will vary depending on 7. more trials. he cannot see what the pictures represent. The following are some additional tasks resources must be transferred from the pool to the process. only three errors are noted. If elements of treatment tasks are simplified. and then retell. The Reading mental energy. demands on the resource pool will be decreased. using written input. quently. consequently. tions involve adjusting the factors that have been discussed posed a resource allocation model for aphasia. Write overlearned materials (e. pool is unclear. Write words dictated letter-by-letter. conse- while. were decreased. After 10 and the numbers 1–10). Fill-in missing letters or words in written stimuli. on the other hand. As Brookshire notes. Copy forms. Have the patient rewrite tics of the stimuli. 1986. and words.”). trials. this task or without associated picture stimuli (“He is reading a required the individual to call on processes involved in visual book _____”. required for carrying out these Nearly all of the tasks previously described involving audi. comprehension. and performance will be of written choices. 1990) have pro. Stimulus manipula- Kimelman. Will we increase our understanding of the efficacy and from several group and single-subject treatment studies. we can based practice guidelines for aphasia has been charged with say that much of our inconclusive evidence about treatment the following: (1) conducting systematic and comprehensive efficacy is derived from studies of the stimulation approach. Nor would it stimulation approach that we do not know about therapy for be appropriate or particularly enlightening. 2005. however.. clinical trial (Wertz et al.edu/~pelagie/ on.u. 1984. of the approach also report measurable progress (for more Robey and Schultz. and the conclusion they generate is that it has a tional research is needed (Frattali et al. controlled In other words. many patients with aphasia. the stimulus must be adequate. we can address three ques- ancds/index.arizona. 1999. but reviews and observations by because treatment approaches have rarely been well speci- well-respected. aphasia in general? We do know that Schuell and her col- text of this chapter. (2) lexical retrieval. new fads and fashions.e. clusive. and Wertz and Irwin. empirically based statement Do we know something about the effectiveness of the about the efficacy of the stimulation approach. gorized into seven groups by primary outcome variable. used—a stimulation approach. The current tables of availability of funding for continued investigation. 1981. Poeck.. and particu. 318). Taken as a whole. Although underlying clusions that therapy helps patients with aphasia (see. (3) syntax. 1986b). and (7) alternative communication. Tucker. active clinical aphasiologists and some neu. It is impossible to make a single. including at least one well-designed randomized. and dissemination of evidence-based practice guidelines for Therefore. however. 1982. EFFICACY OF THE STIMULATION APPROACH 1991. 2003. (3) formulating guidelines based results more to the study of the treatment than to the treat- exclusively on the reviews and assessments of levels of scien. Robey. Many other users Corbetta. effectiveness of treatment). literature reviews. Darley. strength of evidence. relatively unambiguous examples of studies support- Sinner. To date.. DeRuyter. and phase of treatment (i. 1979. Answering this question is risky business. reviews of such studies and issues related to assessing the 1979. Fromm. about the effectiveness of treatment. A number of general statements Shewan & Kertesz. 1984. see Basso et al. far-reaching project involving the development ate aphasia courses across the country. With these pitfalls in mind. Blank. language processing models may differ according to each Albert. Because of its widespread use. to review all of the group and single-sub. dynamics of the stimulation approach? . 1998. 1977.. the evidence accumulated 1. and (5) delineating those areas in which addi. (6) writing. tered by these same clinicians is consistent and strikingly since 2001.html). the Academy of Neurologic Communication similar to that which Schuell described nearly 50 years ago. Wertz et al. 2001. fied). it must get into the brain.g. The ANCDS committee developing the evidence. FUTURE TRENDS ing. treatment studies employing tific evidence. Marshall et al.. single subject. approach to the treatment of aphasia. Benson.. (4) speech production/fluency. major advances in other therapeutic approaches. at the least. may help to put the probably been studied more extensively than any other current state of the art in perspective. the significant positive effect on the communication ability of review process has identified aphasia treatment studies cate.GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 437 Aptara Inc. or between-group dictor’s biases and misconceptions. (4) disseminating this information to practic. leagues believed in and reported observations of the effec- ject studies that might bear on the issue of treatment efficacy tiveness of the stimulation approach.. justifies. subject to the pre- case-study. conclusions that therapy is generally effective several neurogenic disorders of communication. within-group. including are based on studies that have used—or probably have aphasia. 1989. approach to treatment (although the interpretation of most No single study can conclusively “prove” the efficacy of efficacy studies requires this conclusion to be inferred. 1989. 1991). the stimulation approach are more conclusive than incon- ing clinicians. the manner in which treatment is adminis- Helm-Estabrooks. ment itself. Although the review of aphasia treat- tions about the future: ment studies is still underway and the evidence-based guide- lines have yet to be summarized. & an irreversible (severe) aphasic syndrome. 1996. p. In addition. including (1) overall language performance. 1986a). designs). 1979. Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 437 stimulation approach—that is. A final point pertains to the timelessness of Schuell’s rologists generally have yielded cautious to confident con. 1983. a general conclusion that “there is ample evidence that what we do for some aphasic patients does some good” (Wertz. and so evidence are available online (www. that such inconclusiveness against objective criteria. treatment (Holland. clinician’s bias. excluding patients with (the reader is referred to Fucetola. within the con. & Stein. & Willmes. the stimulation approach has larly about the stimulation approach. for comprehensive ing the efficacy of the stimulation approach. & recent. (2) evaluating the levels of evidence It is very possible. e. More pessimistically.. altered ranging from pre-efficacy to efficacy). 1975). Schultz Crawford. Holland. (5) read. Wertz. 2003). Each of What does the future hold for the stimulation approach? the studies has been evaluated in terms of study design (e. Huber.g. Disorders and Sciences (ANCDS) has been engaged in an These tenets of therapy continue to be introduced in gradu- objective. professional and family requirements. Probably. although Schuell’s stimulation approach was articulated and. a commitment to providing will require the efforts of many investigators who are inter- “proof” of the effectiveness. Do some approaches have to be used in isolation for in any fundamental way. how will we understand and use the stimulation such a commitment. Is there a best sequence of approaches to use over the on communication in daily life and. the PICA). these changes will be rapid and numerous and success? A number of reasons exist to anticipate that this will significantly improve overall treatment efficacy. Another reason. or lack thereof. nontreatment study does not constitute challenges. responsible for short. ing stimulus factors that affect the performance of patients “It is probably appropriate that there have been few studies with aphasia in nontreatment conditions. we know very lit. The development of evidence-based practice guide. really not to be confronted until more comparative studies although we have acquired a substantial body of data regard. in principle. clinical aphasiologists have made a commit. to compare the effects of different treatment approaches. and so on? in the future. one that is what is effective and under what circumstances.GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 438 Aptara Inc. has been perceived by Sarno (1981). Second.e. and natural communicative settings are receiving 3. will move randomly from one approach to chapter. 2003) and to develop new approaches and prelimi- (especially in single-subject studies) so that we know better nary efficacy data for them. Several chapters in this volume sound clinical methodologies. the utility of the major departures from the basic approach will likely be con. including: important to inducing language gains with the stimulation 1. the stimulation approach and the dynamics that explain its Hopefully. The number of approaches now in . Major change is unlikely because the them to be effective? stimulation approach is an old and established one. sia as well as its effective management. What is the best approach to use for patients with par- variables that affect communication in discourse. Are some approaches more effective early post-onset or increased attention. Finally. 512). Fifth. time demands. stimulus factors course of treatment? that are most meaningful to the patients we treat (i. Is language recovery enhanced if certain approaches are validation of the stimulation approach). of therapy for ested in the increased understanding of the essence of apha- aphasia. This is at least partly a result of the enormous past efforts tive and reliable (e. an increase in our ability to selec- Will we increase our understanding about the efficacy of tively and effectively employ that knowledge in treatment. happen. they ment to accountability—that is. social 5. they will be slow and painstakingly acquired. lines for aphasia initiated by the ANCDS is an example of Finally.. we will not learn what works best and with whom. are attempted. “old and familiar” approach or. our measuring instruments have become more sensi. and this will likely be pursued ness. This gap in our knowl. and it is close to the heart of questions about another. comparing treatment methods in view of the seemingly tle about the specific effects of using such stimulus manipu. as mentioned previously. edge is true for many of the stimulus factors reviewed in this or fadism. It is likely that some of the above questions will be addressed ulation approach along many different lines. of improved performance under a certain stimulus condition Despite these past priorities and ever present methodologic in a single-trial. given new names. the major principles and techniques of which have been reasonably well Finally. unless comparative studies proof that use of that stimulus factor in treatment will be are done. Certainly. the simple observation such research and our present state of knowledge” (p. used in combination? Is the stimulation approach likely to change? Probably not 6. in the next 5 to 10 years.. the effect of stimulus factors and other 2. and studied accompany aphasia is also worthy of study because of its and employed separately. we have identified many of the approach in relation to other therapeutic approaches? We flaws in our previous attempts. She said. out of boredom. First. as well as those variables that have no way to answer this. we have begun to expended to establish that treatment. thus. frustration.or long-term language gains within or and we will either become complacent in our use of a single beyond the specific language task. Third. it can be argued that. Any developed for the treatment of aphasia. How do various treatment approaches differ in terms of approach. These efforts should help to identify the late post-onset? components of stimulation likely to have the greatest impact 4. How will we understand and use it in relation to other approach is refinement of our understanding of stimulus fac- therapy approaches? tors that do—and that do not—influence performance and. Fourth. insurmountable methodologic problems associated with lation in ongoing treatment. That is. cost-effective- stimulus factors in treatment. Numerous comparative questions should be whether stimulation in general and/or specific stimulation is addressed. because so little has been done must be accounted for in any study of treatment efficacy. is effective specify and study the dynamics of treatment more precisely (Albert. approach for the treatment of cognitive deficits that often sidered to be new approaches. consistently employed. conversa- ticular severity levels and forms of aphasia? tion. 438 Section IV ■ Traditional Approaches to Language Intervention 2. in general. Is the approach likely to change? The change that can be expected for the stimulation 3. reflect this trend and demonstrate divergence from the stim. We are in a position to test the effects of many ultimate level of recovery.g. our pri. 3. performance factors than to competence factors. comparison. Abstractness. evaluation. it must categorizing behavior that helped to develop the get into the brain. and methods of observing and b. . be summarized as follows: e. tasks. (e) aphasia with compared with almost any other. Schuell’s classification system for aphasia aimed at h. descriptive and predictive utility by classifying i. rected. prompts. systems and sensorimotor processes. modalities may be used. Combining sensory modalities. nized through complex. organization. Length and redundancy. The stimulation approach can be defined as that approach to treatment that employs strong. because more appears involvement.GRBQ344-3513G-C15[401-449]qxd 1/21/08 12:56 PM Page 439 Aptara Inc. She identified seven l. The language mechanism contains a system of and should show patients their progress. Language cannot be thought of as a simple senso. Method of delivery of auditory stimulation. Schuell’s unidimensional. theory. and control of language. f. mary language processes are acquired and orga. Intensive auditory stimulation should be used. The clinician should work systematically and maintenance of which require discrimination. acting systems that aid in the acquisition. process. ness of other approaches will be measured. motor deficits. Although the language mechanism can exist sepa. Abundant and varied materials that are simple and of aphasia does not require that patients vary only relevant to the patient’s deficits should be used. classification of patients with aphasia. The stimulus must be adequate—that is. Chapter 15 ■ Schuell’s Stimulation Approach to Rehabilitation 439 use make this increasingly necessary for rational. and prognosis. i. and prestimulation. Stimulus repetition. (c) aphasia with persisting dysfluency. ment. Neurophysiologically. In aphasia. k. multimodality concept j. and execution. Therefore. It was probably this sound foundation in a. the auditory modality is at cant contributions in the areas of diagnostic testing. Part of speech and semantic word category. Discriminability. Each stimulus should elicit a response. d. g. New materials and procedures should be exten- lems of most patients appear to be more related to sions of familiar materials and procedures. language is the result of the elicited. Nonlinquistic visuoperceptual clarity. interacting sensory c. data-based clinical decision making. transmission. g. to be known about the efficacy of the stimulation approach (d) aphasia with scattered findings. The design of intervention used in the stimulation development regarding the underlying nature of approach is based on a number of general principles: aphasia. If a stimulus is adequate. Linguistic visuoperceptual clarity. Frequency and meaningfulness. Rate and pause. auditory processes are at the apex of those inter. The following variables have been found to be most e. Auditory perceptual clarity. learned elements and rules. In addition. b. storage. Although numerous input spanned the 1960s and 1970s and included signifi. tent auditory imperception. a. and (g) irreversible apha- pate that it will be the standard against which the effective. stored. Cues. categories: (a) simple aphasia. A maximum number of responses should be b. and theory 4. patients according to severity of language impair. j. (f) aphasia with intermit- among the approaches compared. the foundation of the stimulation approach. 2. relevant to the structuring of stimulation: rately from input and output modalities. vided when such feedback appears to be beneficial c. sia syndrome. the use and h. 5. Responses should be elicited. perhaps along a number of dimensions. In fact. intensively. and the nature of language breakdown in aphasia can d. Repetitive sensory stimulation should be used. the presence or absence of related sensory or k. ing. The bulk of Hildred Schuell’s work in aphasiology recovery of language. familiar transmission. retrieval. con- trolled. Notably. trolled. it likely will frequently be sensorimotor involvement. dynamic interaction of complex cerebral and sub. (b) aphasia with visual m. d. and feedback control. not forced or cor- a. Schuell’s beliefs about the organization of language c. along a severity continuum. involving reception. and intensive auditory stimulation of the KEY POINTS impaired symbol system as the primary tool to facili- tate and maximize the patient’s reorganization and 1. Sessions should begin with relatively easy. e. the prob. it needs to be con- compelling rationale for the stimulation approach. f. we might antici. 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Pulvermuller et al. 321) suggesting that the brain can change with systematic motor stimulation. 2001). cal finding that “doing” actually changes structure within 450 . we are learning from people with aphasia what the student in the 1960s. did speak to the devastating effect of impaired communica- Despite evolving knowledge gained in neurologic sub- tion on the person with aphasia: strates of speech and language function. suddenly in the midst of the journey of his life neurobiologic change with controlled stimulation. Since the 1960s. Specifically. It was from Thematic Language Stimulation (TLS). many aphasia therapists have found an intelligent and In this chapter. with aphasia. 1964. Schuell’s model of aphasia rehabilitation remains relevant. positive effect University of Minnesota and the Minneapolis VA Hospital. the concept of disability. Similarly. Since the original formulation of TLS in 1982. and find ways into the wounded brain. and provide a template for replication of TLS ceive aphasia. All of her investigations and interventions sought to alleviate the In the previous chapter. Speaking Out! 2004.qxd 1/21/08 12:57 PM Page 450 Aptara Inc. many speech-language transmitters..” (Schuell. 1995. the aphasic patient knows despair. She description and discussion of the work of Hildred Schuell. the reader will find an excellent symptoms that interfered with normal communication. indeed. Florida. that place of comfort that TLS was born. a variety eate its various components. This is not to say that Schuell did not consider the interper- sonal aspects of communication—quite the contrary. as did Schuell. provide suggestions for clinical of different therapeutic approaches have developed in and functional communication analysis as a precursor to the response to changes in the way that we.”1 paralyzed and unable to communicate must feel himself in a dark Jenkins and colleagues (1990) found expansion of distal wood. nique for aphasia. Today. Tampa. yet some new views Some approaches to management of aphasia are based on about how we can intervene in the workings of the brain in the person with aphasia also have appeared. Indeed. 1999) Schuell’s approach was Certner-Smith conceived as a result of focused clinical observation and data collection on large numbers of patients. we are looking more closely at the person therapy. environmental. as a graduate question.. explain the rationale for TLS and delin. and so has found himself alone in a dark wood where the straight way is lost. per- use of TLS.GRBQ344-3513G-C16[450-468]. Without Schuell’s stimulation treatment model. as a profession. Surely anyone partially do today’s researchers in “the community of brain repair. life participation approaches. p. The disability have studied with Schuell during her tenure at the empowerment movement is having a strong. for example (Maher et al. the senior author was privileged to form and content of our therapy can be. we provide a theoretic background for comfortable point of entry in Schuell’s work. and surely the straight road he took for the natural digit representation in monkey brains after sensory training. pathologists may feel a pull away from traditional interven- Thematic Language Stimulation is firmly rooted in tions and into the more person-centered ones. rather than the disorder of aphasia. OBJECTIVES postulate and evaluate the underlying mechanisms for that behavior. This clinical approach enabled her to see and record relevant behaviors. Kilgard and Merzenich (1998) reported Schuell would have greatly appreciated the work of indi- changes in the organization of monkey auditory cortex after viduals currently involved in the social. on the work of the aphasia therapist. way must seem lost to him. and exposure to a combination of sound and chemical neuro. and the therapeutic modules and directives for implementation in aphasia milieu. 2003. Drew & Thompson. is based on the neurophysiologi- 1 Leslie Gonzalez-Rothi. Schuell posited a Like anyone who. interests of the individuals with whom we work. perhaps. Organizing Content and Delivery 2001). in creating predictable. in which intervention is appropriate but. believed that treatment should focus on ideas. Albert (1991). the authors have been foster an atmosphere of respect that affirms the present influenced by the work of Edith Kaplan (1989) and of value of the patient in a therapeutic partnership. TLS places the burden of ple. In addition. stimulation of thought to enhance verbal production during nal stimulation roots. some actually may strengthens the therapeutic effect. understanding the why as well as the what authors create units based on the unique backgrounds and about aphasia. Marshall (1994) noted that. This is accomplished in two ways: first. It is frequently most interesting in carefully controlled stimulation. and for which ond. Meaningful content in natural contexts techniques is mutually exclusive. that are highly related to a topic. Stimulation targets overall and of itself. and writing. Both Schuell (1964) and Wepman (1972) agreed that treatment content should be personally relevant. who Thematic language stimulation themes may be fairly uni- emphasize the process approach in evaluation and treat. for those vocabulary in multimodality stimulation. in his content-centered treatment approach. In contrast. of these processes has value in the development of strategies primarily nouns and verbs. He advocated The current version of TLS continues to reflect its origi. and it proved to be a great success. reveals information about underlying processes. such as “cooking” or “sports. personally relevant material is “com- in language processing for functional communication. a significant body of research that might help Thematic Content us to reliably identify specific candidates and the most beneficial timing for these specific techniques continues Wepman (1972).” and sec- point in the therapeutic process. systematic linguistic stimuli for persons with aphasia different intervention approaches may each presented task.” It extends concepts origi. versal. we once used a family interview and a few trade maga- success on therapists. in choosing a TLS topic that is relevant for the modes. Theoretically. In addition. As we noted in our chapter in the fourth edition of this text. Awareness A TLS unit usually consists of 8 to 10 vocabulary words. reading. indeed. In this and what the person with aphasia can produce. We view TLS as one technique provide a context for both the stimulation and the subse- in a growing professional armamentarium. it begins with a select group of words related cycle” (p. places them in particular linguistic contexts. Rather than creating new be enhanced by the inclusion of others at another point in ones. & Whurr. In addition. however. but it also has practical value. For exam- Like all stimulation approaches. people tend to have more to talk about “Thematic language stimulation” is a systematic method of when the subject is connected to them (Wallace & Canter. be useful. for . we have learned a good deal about the world in which restoration of language proficiency comes about by means of our clients live and work. for success in conversation. therapy for aphasia that employs thematically related 1985). 444). Human beings are simply more at ease and in meaning. Enderby. to be absent. systems already established within the brain. we establish a heightened “perfor- processes to impact on conversational success. 1972). TLS requires more stringent con- the metalinguistic exploration of symptoms and strategy trol of content and its manipulation within the session. training and in the education of other speech-language Content themes heighten the saliency of the therapy and pathologists and caregivers. Chapter 16 ■ Thematic Language-Stimulation Therapy 451 the brain. In this way. From this pool of core vocabulary items. we develop. choosing material of high working by “working the brain. We also have found it to be helpful in conversation. and targets improvement of underlying language person with aphasia. way. zines to construct a TLS unit on the garbage industry for a biologic link between what the person with aphasia knows particular client. the TLS structure capitalizes on the organizational time. personal relevance can reassure patients that we know more nally presented by Schuell and colleagues (1964) and by of who they are than they are able to tell us. uses them in tasks that employ both input and output Therefore. At the DEFINITION most basic level. because they provide a possible neuro. at what establishing a relevant. The TLS mance edge” for therapy as well as a shared referent for sub- hypothesis is that you are changing the way the brain is sequent exchanges. targeting changes with fluent aphasia. sometimes use this information again in TLS sessions with Observation of the person’s behavior during stimulation others. None of these quent conversation. in that we can improved understanding. The organization of the language used for stimulation is Perhaps more to the point is an examination not of central to TLS. Nancy Helm-Estabrooks and M.” Often. speaking. better equipped to talk about topics that interest them most.GRBQ344-3513G-C16[450-468].qxd 1/21/08 12:57 PM Page 451 Aptara Inc. in what order. thematic “core vocabulary. forting and helps to break the garbage in-garbage out Specifically. Other recent studies are revisiting the notion that TLS THEORY some specific drugs may have an enhancing effect on brain function for communication (Greener. we Wepman (1953. the ment—that is. Using a binations of cues and strategies to facilitate improved lan- variety of tasks that can be rearranged and adapted for guage function (Chapey. perhaps. First. language can be extended further by observe symptoms and behavior and apply interventions using environmental materials and objects. in which the clinician tries various com- meaningful context enable maximal response. reordering. the intensity of language stimulation discussion about the principles of Schuell’s stimulation ther- delivered and for which there is a response. extended. In addition. That is. and more.” for which we believe there tion. Second. 1994a. adaptation. Here. it also can be of value in the transition in the form of repeated semantic and syntactic elements. stimuli can be made adequate in several ways. and execution of TLS and warrant further elaboration here: This is probably more about what is frequently called 1. focus. structure consistent. is riding they are created. Third. clients engage are composed and delivered systematically to obtain the more easily in problem-solving activity and can concentrate greatest number of accurate responses. The reader than that simply affirms failure to both the client and will note that. Holland. multiple-choice stimulus. and more recently. the order functional language stimulation by manipulation of the theme. failure to achieve an adequate are highly familiar: repetition tasks. “the art of aphasia therapy. theme-based . not therapeutic. employ analysis and problem solving in that milieu (Boles. focused.) “more difficult” is relative. between 10 and 15 tion be measured by functional communication success in different multimodality exercises are presented for each natural environments and that therapeutic interventions vocabulary item over the course of five to seven sessions. instead. theme. The degree to which clients achieve high numbers of “correct” Stimulation Delivery in TLS responses in therapy is dependent on the therapist’s understanding of performance variables and how to Chapter 15 (Duffy and Coelho) provided a comprehensive influence them. Freed of the necessity of constantly learning new 3. therapists can Wepman. the process itself becomes more of a azine on a specific chosen topic. This consistent is from introductory topical conversational material to structure helps both the clinician and the client to develop identification of theme vocabulary to manipulation of insights that assist in facilitating functional communication language in carefully adapted and sequenced multi. These social and ple by providing many opportunities for the client to ecological models propose that the effectiveness of interven- respond in all modalities.GRBQ344-3513G-C16[450-468]. the high degree of The stimulation of language in clinical exercises is not the relevant content ensures saliency. Less success uses extensions and elaborations on this theme. must be sufficiently intense. selected. such as a real that help. Such stimuli is a definite learning process. therapists are encouraged to repeat activi. modality tasks and a return to conversational format— We believe that TLS may provide a link from clinical to all within one session. The desire for func- programmed into stimulus/response tasks that literally tional change is a powerful one and is shared by the clinician. 1998. Task In many therapeutic models. a variety of activities. This process draws on the very essence of broaden the stimulation base without shifting out of the our practice as speech-language pathologists: the ability to theme. the sources of hierarchical development of task sequences builds and therapeutic funding. with some exceptions. 1998). and the apy. In TLS. fill-ins. 1972). In TLS. times but. Intervention in the functional domain has become central 2. and the wave of current capabilities—rather enjoyable at enhanced. of presentation also is from those likely to result in the The daily segue from clinical task to relevant. (See Appendix 16-1 for an example of one such unit. Stimulus Adequacy The adequate stimulus. a change in brain- Functional Communication mediated language performance. 452 Section IV ■ Traditional Approaches to Language Intervention language practice. the exercises employed the therapist—that is. bombard the patient with linguistic stimuli. from language used in structured activities to conversational and the use of multiple input and output channels are exchanges in a shared topical context. by defini. the functional communication segment an 80% to 90% success level for activities.qxd 1/21/08 12:57 PM Page 452 Aptara Inc. The progression more on their own performance issues. family members. is one that has an intended result. Within that structure. What is different about TLS is the way is not truly stimulating the brain but. behaviors. treatment includes a problem- repetition. in several models of therapy for aphasia. the client. ordered. delivered. and extension in solving component. In addition. ties with minor adaptations from session to session. all linked to the greatest degree of success to the more difficult. redundancy. Systematic and Intense Presentation TLS activities directions and rules of therapy for new tasks. Kaplan. because we are keeping the treatment restaurant menu for a unit on dining out or a trade mag. Maximal Patient Response TLS supports this princi. Several of these are very important in the development moment-to-moment adjustments made during sessions. Greater than 90% success suggests the activity selection. use over a period of several sessions. only benefit of TLS. 1989. extends stimuli in familiar but varied contexts. and redundant to create a neurobiologic effect—that is. the TLS philosophy employs Simultaneously. clinicians would do well to heed the and therapist have experienced the activities and the follow- warning inherent in Edith Kaplan’s (1991) comment that up functional conversation. Once such dialogues are integrated ical and functional picture. The observation could be about one’s own lan. Once there. Commenting and problem solving about the style of Establishing Baseline Functional Conversation various conversation partners in the social network that either supports or exists as a barrier to conversational suc. and communication behaviors that affect conversation.” each modality. I try to see the word. the level at which performance breaks down in description of “enhanced compensatory strategy training. then. and it’s faster. and both perspectives are complementary. the therapist can component of treatment. At the onset of treatment. the therapist offers more detailed choose a particular approach or environment suited to the observations about performance and asks the clients for information provided by the evaluation. clinicians need specific information about lan- Conversation strategies that are personalized and congruent guage function to develop a program. both clinician and client management. this is a pre- identifying and elaborating a strategy repertoire” (p. and the reason why performance breaks notes that “the person with aphasia is considered a partner in down when it does. Because it what may be improved access primed in the stimulation mode. to metalinguistic dialogue. you can say it easier? guage or about another’s use of his or her language. metacog- nition). the person with aphasia has valid observations Regardless of the theoretic basis for provision of language to contribute. after the client some information. What did you notice? strengthen the clinical to functional link. Thus. a baseline of functional communi- cess may lead to productive solutions. helpful for communicative partners. exploring successful gies that are most likely to actually be used with confidence strategies. conversation to TLS activities to functional conversation Assessing aphasia is one of the most complex require- and. in her impaired. When the about the nature of aphasia and how it operates with their therapist has a thorough understanding of the patient’s clin- present brain function. are more likely to be the strategies that planning requires knowledge of which cerebral processes are are actually used. Nina Simmons-Mackie (2001). Beyond its usefulness to develop strategies. 1990) proposed that treatment ual’s life. it is a helpful tool for discovering those strate- continue the problem-solving process. the therapist can create an into the session and the patients are “on board” with this appropriate therapy program. Whereas formal aphasia tests can provide quite naturally toward the end of the session. Schuell (cited in Byng. The typical flow is from baseline “batteries are for cars.g. to domains beyond language (e. For the present authors. Edmundson. specifically. not for people”. act requires that an observation be made about the use of Therapist So you see the word written in your mind.GRBQ344-3513G-C16[450-468]. We have found that it usually occurs formal test milieu. and eventually.qxd 1/21/08 12:57 PM Page 453 Aptara Inc. both inside and outside the treatment session. encourages the person with aphasia to take on more respon- the therapist skillfully shifts the environment of practice to sibility and independence in symptom and communication functional conversation. scription for a process-oriented examination of both func- The metalinguistic dialogue can happen at any point in tional performance and behaviors more typically elicited in a the therapy session. proper aphasia assess- exchange may serve to increase the patients’ understanding ment bridges both domains of science and art. 254). end- their discoveries. ments of speech-language pathologists. A metalinguistic Patient Yes.. you seemed to pause and think about it Metalinguistic dialogue is used in conjunction with TLS to more in your head. An example of a metalinguistic dialogue is as follows: Metalinguistic Dialogue Therapist I noticed that when you had trouble saying some of the words just now. with the individual’s ideas of what works or fits that individ- Kay. Such observations or questions may assist those The speech-language pathologist also must have the knowl- with aphasia to explore and reflect on their own perfor- edge and skill to manipulate the environment and explore all mance. interaction. munication. and developing insights. cation is obtained. language. but the Therapist Is that easier than trying to write it? speech-language pathologist has the ability to describe and Patient Yes. treatment. & Scott. Moreover. that’s right Engaging in metalinguistic dialogue requires skill. The dyadic exchange could include com- point recommendations then are more individualized and ments about performance during transaction. Competent evalua- This metalinguistic dialogue often begins with the tion requires astute observation of language behavior com- speech-language pathologist sharing examples of positive bined with a thorough knowledge concerning the range of performance that are tied specifically to language and com- possible symptoms and how they influence communication. Capitalizing on tionship in problem-solving treatment outcomes. Patient Yes. codify the speech. and then language. From the personal and experiential ASSESSMENT FOR TLS perspective. the possible avenues of success. Although we have used some formal . Chapter 16 ■ Thematic Language-Stimulation Therapy 453 conversation moves the clinician and the person with aphasia Metalinguistic dialogue reinforces the collaborative rela- back and forth between both environments. however. heightening awareness. For example. such the communicative partner. usually can answer questions about functional communica. It is only by understanding the example. For when symptoms are revealed. and/or sublinguistic needed to facilitate performance. if it appear in the natural course of an exchange. Assessment of the client’s overall level of participation in a and some cannot. Clinicians learn more about how best to conversation. the clinician must look elsewhere. and relative ease of success in to the visual modality. two. Observations address the than spontaneous speech. 454 Section IV ■ Traditional Approaches to Language Intervention instruments to measure functional communication in on. regardless of whether stimuli. and (c) patients are aware of a loss in understanding and how well how much and what type of verbal or visual cues are they comprehend subtleties. information. repetition is not a “can tion and order. the relative burden of information task. do/can’t do” phenomenon.or three-word stimulus. will assist in decisions about TLS activity selec. is worse.GRBQ344-3513G-C16[450-468]. Skilled clinicians can derive a good deal of facilitate this for a particular patient when they know information during conversational exchange about the (a) the required length and grammatical composition of intermittency of auditory processing. informal. When aural-oral . we continually ask “Why?” with therapeutic task selection and sequencing. They do not. The value of these subtests is that they assist the clinician research or for other purposes (Taylor. automatic language is far more preserved than propositional lan- guage. how- Beukelman. or one that will need to be exchange as well as the degree to which information must be adapted but can still be used successfully. counseling the client. in therapy. Standard aphasia tests tell some of the “what” but considered to be a natural extension of automatic lan- none of the “why. Such observations are critical to TLS planning. and automatic language should be facilitated first Assessing Clinical Performance on Tasks if it will create a base of success. Therefore. a core group of subtests occur repeatedly: 4. behavior. most likely tion about preferred modes. Sentence Construction Most formal aphasia batteries Be Before Performance Breaks Down? assess the ability of the patient to create sentences given Information regarding comprehension informs decisions a one-. Many patients “can do” once duce options for enhanced communication and how we train some structural stimulation requirements are met. It also will guide the way in which we intro. How Well Do Patients Initiate and Sustain Formal Testing Conversation? 1. In addition. Knowing the ease with Thematic language stimulation is strongly dependent on a which automatic language can be facilitated will help process approach.qxd 1/21/08 12:57 PM Page 454 Aptara Inc. Yorkston & in the differential diagnosis of aphasia. naming.” In comparing the various standard apha. guage material. Because TLS relies completely on the conversational exchange establishes a baseline for measuring objective of “language in. (b) the effect of vocabulary complexity. sia instruments. Automatic Language For some people. That is. fill-in tasks with multiple-choice response “why” that we can determine “what” can be done about it in requirements are high in predictability and might be treatment. many individuals with aphasia. but fur- How Well Do Patients Express Themselves ther observations are required to assist in therapeutic Verbally and Nonverbally? decision making. 1969. and so some clients in eliciting a flow of ideas. 3. one to avoid completely. and therapeu- tion after a relatively short period of interaction with the tic style to determine both “what to do” and “where to begin” client. Any formal inferred need to be determined. the clinician must engage in further analysis. Directions? How Complex Can Auditory Demands 2. This informa. the clinician has discovered a patient’s relative use of alternatives to speech when they key aural-oral connection to modify speech output. test of repetition can provide the level of breakdown with respect to length and complexity of units. adding probes to explore cognition. 1980). language out. Therefore. explain what to do once aphasia is confirmed. humor. How Well Do Patients Follow Conversation and and success that can be achieved using this approach.” therapists must progress and helps the clinician to develop initial ideas about know whether repetition will be a primary stimulation intervention. as slowing the rate of presentation or providing face- to-face delivery (particularly for the patient with apraxia). Repetition Some people with aphasia can repeat well. Creation or expan- about task selection and presentation and about adjustments sion of verbal utterances that are substantive and gram- that need to be made in the therapist’s verbal behavior when matically correct is an objective of many treatment introducing tasks. our approach for TLS usually is more ever. and engaging in approaches. answering yes/no to questions. we believe that the experienced clinician Therefore. for primary input. for any mode. if repetition is better Assessment focuses on content. Picture Description A pictorial cue can be powerful for repetition. In input mode. the clinician needs to know if oral reading is Because of the way TLS is structured. respond well to the treat- process approach is applied to tasks are such important ment materials. and noted for future reference. For some also can provide a starting point for therapy. The comparison of results on subtests that Several non-language behaviors have an impact on the treat- tap auditory processing of directions and commands ment planning process. the logical questions to kind of assistance is needed for the production of words. be asked are (a) how complex and lengthy can directions phrases. because this information the language analysis. or narratives and whether a self- be. bined with repetition. however. For example. reading comprehension is a valid alternative to exploration in both clinical and functional domains. visual stimuli are more salient. Cognitive and Behavioral Considerations tory mode. individuals with global aphasia can copy neatly and tion of all clients. for some individuals. sometimes provides a clue about a client’s “hardwiring” described. 1998). By integrating writing at aphasia. if visuographic expression is more preserved and preferred to the aural- Patient Involvement oral system. In addi- tion. Following Instructions Although it is desirable to for response. who “get it. It also is important to compare scores the case of TLS. and (d) is the auditory mode a strong or fully. lack of can be applied not only to task and cue selection but also insight is as much an obstacle to recovery as their symptoms. it also is a more preserved than speaking and whether the patient treatment approach that can facilitate improved insight and . the contrast between narrative and spontaneous the patient and clinician share a visual reference in the expression can be explored with respect to the com. clients. after several such trials are com- TLS unit. when tion. In addition. motivated clients their communicative partners. For others. comprise our “minimal data set” for evaluative aphasia.” task. they may even produce the target and facilitation requirements should be noted via word verbally without struggle. Integrated into the therapeutic program. As in formance in both modalities. we note the patient’s strengths and weaknesses (Holland. such an analysis is necessary to customize obtained during testing as well as the overall ease of per- both the content and delivery of therapeutic materials. Chapter 16 ■ Thematic Language-Stimulation Therapy 455 presentation and response is tenuous. it minimize task instructions to the patient at each session. Therefore. Oral Reading Oral reading is another avenue that pro. same context. Many a valuable task for auditory. This information then they are on the right track. it is patient’s language system in yet another way.” Therefore. before construction of a accurately. sentences. adding to it is important to determine each particular patient’s the patient’s repertoire of success. (c) how does the rate of presentation affect clinical and functional graphic abilities are explored comprehension. and provide clinicians with evidence that pieces of information learned. comes to be thought of as a welcome addition. Graphic Expression Writing adds to the sources of a response. treatment deci. descriptive comments. (b) will a visual cue be needed to support the verbal initiated written cue aids verbal performance. ease. certain behaviors are observed. for processing language. Therefore. In this instance. combined with observation of 7. ability to connect with the disorder. These formal test probes. linguistic bombardment necessary to reach a threshold 5. Additional knowledge about the per- with those that examine silent reading of sentences and son’s cognitive and behavioral strengths and weaknesses will paragraphs allows the clinician to decide on a preferred influence the treatment model or approach that is chosen. request. very early in the period of evaluation sions are made based on a balancing of the patient’s and during the initial phases of therapy. treatment first emphasizes presentation of information via the visual modality rather than the more traditional audi. The therapist investigates writing and drawing not weak one for the individual? only as an augmentative communication tool but also as 6. In addi. can be shared with those who have aphasia and with Naturally. In addition. When we apply milder aphasia. comment on the patient’s 8. TLS works best with insightful. complexity. only when a detailed with the program” immediately. degree of clinician-initiated cueing that is necessary for 9. silent reading before verbal For some. verbal. and they “get performance has a priming effect. and visual stimula.GRBQ344-3513G-C16[450-468]. a pictorial cue can correct errors that occur in this format. Reading Comprehension For many individuals with performance. auditory comprehension. For the person with need for such repetition of procedures. and consider other types of metalinguistic analyses. this may reveal specific symptoms and plexity of ideas and vocabulary generated as well as the procedures for modification. the parameters of length. however. that will be the road that we follow. In addition. own internal processes or performance for such behavior on vides an opportunity to get language “in and out. one needs to know how much and what process parameters to listening.qxd 1/21/08 12:57 PM Page 455 Aptara Inc. the purpose of therapy is obvious. Yes/No Reliability For the client with more severe a source of stimulation itself. ability to respond readily and consistently in a an early stage of treatment. the clinician stimulates the yes/no question format is an essential skill. Thus. Indeed. however.qxd 1/21/08 12:57 PM Page 456 Aptara Inc. more set of questions needs to be answered: son’s own insight regarding a specific symptom and the 1. we offer Because TLS relies heavily on multimodality stimulation. TLS can assist even the person with severe prime the session for all subsequent task presentations and aphasia to prepare himself cognitively for the tasks at hand. directions need not be repeated from day to which modalities and tasks are the strongest and which are day. If it is known. is valuable. because of its ulus adequacy. but patients with moderate to severe difficulties sounds and then using that list to aid pronunciation of words appear to profit most. Therefore. TLS may not be effective. Because treatment is multimodal. for example. one formance and with good ability to understand the pur- author recalls a person with conduction aphasia who taught pose of therapy. rather than stimulation should neither involve too much struggle demonstrating the advances in vocabulary retrieval and sen. an 80% to 90% success rate is targeted in TLS not evolving into something better. that the “knowing” of what to do. findings suggest otherwise. they can give us an answer. Is this person a good candidate for TLS? Candidacy patient’s resultant. one clinician’s direct intervention. For example. Task Orientation and Retention 2. because it will organization. such awareness has a help in deciding which clients have the potential for suc- significant impact on how we structure material in tasks and cess. We share our observations with the patient. Indeed. Good candidates generally are those with no how we cue or strategize for success. How should tasks be chosen and sequenced? Our When clients have good task orientation and retention of analysis during assessment has told us very specifically treatment set. keeping structure the patient does not repeat well but that he can read words constant and changing the items within it. such as answering questions using the material just Perseveration practiced visually. Some modifications result from the ment delivery plan. recovery. Before therapy can begin. patient to do just that. we feel the technique is of value to people with either fluent or nonfluent aphasia. rather than the and phrases both silently and orally with good success. ple with aphasia derive from their own process. 3. TREATMENT DELIVERY After completing an assessment of conversational proficiency. modality. the next task might begin to include aural-oral require- ments. for example. this sometimes engenders feelings of competence in high probability of success. 456 Section IV ■ Traditional Approaches to Language Intervention understanding about the therapeutic process. it may simply be a we encourage the patient to do the same. adaptations. and should be known in advance. For such an individual. others result from the per. Even at the Visual Perception lowest level of function for this type of reflection. the first task should be one that provides a In turn. a natural flow occurs from one task to the the weakest. and sometimes. nor be so “easy” that it does not provide a neurobiologic tence use. We all have memories marked perseveration or semantic confusion in task per- of such moments in our therapy sessions. make perseveration even worse for these clients. This might be followed by a writing task For some people with aphasia. Subsequently. the clinician is Clients are asked to modify their symptoms as part of the ready to incorporate this information into an organized treat- therapeutic process. perseveration is a highly at a level compatible with demonstrated skills in this problematic and unwelcome intrusion for communication. Specific Symptom Awareness language. however. via the insights that peo- impairments. we continually ask “why” of our clients. Typically.GRBQ344-3513G-C16[450-468]. This process is matter of modifying the aural-oral elements and adapting important. In addition. the client might be able to copy or In our experience. To us. clients with for TLS is best determined in one or two sessions of trial specific symptom awareness seem to achieve greater therapy. experimentation regarding facilitatory cueing takes . In addition. and cognitive/behavioral status. and some her clinician the value of graphomotor association by amount of visual language preservation. because recovery does not happen via neurobio- visual materials. For others with severe accompanying visual logic stimulation alone but. many opportunities and indicate to the person that such any visual problems that affect task presentation. certain rules of thumb seem to be of progress and do better overall. To achieve this level of success. stable emotional status. For some. therapy. Therefore. such as the concerns are not only worthwhile but also essential to presence of hemianopsia or the need for altered print size. focused response to it. considerable TLS is not an appropriate treatment approach. constant shifting of exercises that sometimes is seen in then the TLS exercises chosen first should require this more traditional language therapy. contain recycled errors in word choice that are effect. Therefore. Although preliminary research in general. rather. Level of severity producing a dictionary of words beginning with target may vary. we begin there. the semantic relatedness of TLS can write the target words as the clinician dictates them. to adhere to the principle of stim- next and from one day to the next. What cues are most beneficial to achieve maximal this tendency is discovered once treatment is underway and success in treatment? Because successful language the clinician observes that the client’s responses. it must be held to the ultimate standard—that interests. but a content unit analysis on unequivocal demonstration of effectiveness in significantly seemed to be our best method of defining success—that is. We mum of 10 words are recommended. and the FCP mal language complexity. system for measuring small improvements in discourse The actual tasks that we have employed in our TLS work appeared to be that proposed by Yorkston and Beukelman in are familiar to any experienced aphasia clinician. We found immedi- that provide a shared reference point for all subsequent ate difficulties in selecting functional conversation as the interaction. As sessions progressed. Content units. multimodality presentation. 1969). 1993. altering. or groupings of information expressed by normal speakers in response to the PRELIMINARY RESEARCH WITH TLS cookie theft picture. single-subject studies investigating the efficacy of interventions. What is 1980. 1980s. check.GRBQ344-3513G-C16[450-468]. however. American Speech-Language-Hearing Association adopted the Design Choice term “evidence-based practice” and created a position state- ment reinforcing the need for evidentiary support for clinical In general. Although in the typical speech therapy clinical a particular approach to aphasia intervention employ either . Therefore. Effectiveness Index) (Lomas et al. tip. however. At the time we embarked on our study.. we easier to conceptualize. but sational exchange remained. 1983) is analyzed for the number of plete TLS unit (“Books”) is provided for your use in content units produced and for a measure of communicative Appendix 16-1. (Functional Communication Profile) (Taylor. It is entirely possible. however. The inclusion of material based on client improvement measure. any restorative technique is to be judged effica- tioned earlier. single-subject design studies are accomplished more clues about the likelihood that they will or will not suc. chef. For example. In their system. Concerns regarding the differences between connected “If speech pathologists are to have a role in the management of speech elicited in this manner and that elicited in a conver- aphasic patients. because few quantifiable options from input reflects respect for the client’s personal contribu. In 1993. should be a constant goal. found support. easily than group studies.qxd 1/21/08 12:57 PM Page 457 Aptara Inc. if the theme is “restaurant. menu. for 4. 338). lus. 1986. A com. performance seemed to improve treatment. have been hampered by the scarcity of standard measures for and predictable task inventory. appetizer. often find it difficult to the following: (a) Are visual cues more powerful than integrate them into a typical service delivery model.” In 2005. personal relevance generates ideas and themes is. Brookshire. which is determined by the ratio of content units per minute of discourse. we were rel- These hierarchies are individualized and will change over atively comfortable with clinical evidence that the approach time as the client progresses and needs to be challenged was making language more available during the execution of further. the clinician answers questions such as as well as Siegel and Spradlin (1985). therapists. 89). our assessment analysis has provided milieu. (Nicholas & nouns. When can I fade out a verbal. able. according to Siegel (1987) ceed. and order. or visual cue and still maintain an accurate response? Defining Success When we determine cueing that works at baseline. the individual’s response to the cookie different is the constancy of theme that connects them all theft picture from the Boston Diagnostic Aphasia Examination and the systematic way in which they are employed. Maintaining a high level of success throughout tasks. 1980). A minimum of 6 and maxi. improvement in conversational speech. the only published water. during each session and from session to session. theme selection is based on each client’s cious. The majority of words are characterizing this aspect of connected speech. in our frustration: A closed set of core vocabulary permits manipulations Clinicians and investigators who wish to quantify changes in that fulfill some of the content and delivery principles the informativeness of the connected speech of adults with aphasia in response to manipulation of experimental variables described earlier: redundancy. single-subject study possible with and without input from dictation? (c) with TLS. (Goodglass & Kaplan.” appropriate vocabulary words might be waitress. declined to use the CADL (Communication Activities of to select complex themes and create vocabulary and Daily Living) (Holland.” In the communication of information in discourse. In the early stages of our clinical work with TLS. 1989). however. it must depend not on wishful thinking. efficiency. p. are finite and offer a clear index of rel- ative performance in response to this specific picture stimu- According to Darley in 1972 (as cited in Howard. table. If TLS or. this was referred to as “evaluating efficacy. auditory. p. Chapter 16 ■ Thematic Language-Stimulation Therapy 457 place. in a favorable way. auditory ones? (b) How much spontaneous writing is we completed one such clinically based. How do I select theme and vocabulary? As men. the CETI (Communicative tasks that can be modified to levels consistent with nor. the course of recovery. that matter. however. For that reason. we also determine the beginning of a cueing hierarchy. however. an occasional verb or adjective also is desir. which to choose were available and those that were available tion to the decision about treatment needs. Themes that seemed to be insensitive to discriminating what would are more concrete—or even able to be pictured—are undoubtedly be very small changes. Modules 1 and 2 this study. and writing but Before beginning the first module. Each therapy session was videotaped as to completion of the same evaluative procedures described well. Module 2 employed activities from the many taped. We did not hesitate to assist patients in achieving success on these tasks Pring (1986) offers some encouragement for the analysis of within the session. It may be argued that we did not provide the best pos- effective than a “traditional” approach. and we therefore sible non-TLS modules because of our bias. as can be seen in Figure 16–1. Thus. and we provided whatever degree of stim. a “general lan- Procedures guage stimulation” approach employing a variety of exercises for word retrieval. duration of symptoms. The individuals who participated in the study completed a ule was of great concern. Our choice of non-TLS therapy for Module 2. and analyzed according to the procedure of Yorkston and cians. Our hope is that. and all received traditional aphasia vidual. respectively) were ordered such to employ other therapists so as to eliminate any possible bias that subjects would receive either one first for a 3-week in this regard. comprehension. we will be able (i. and we age. These activities were administered by us subsequent Beukelman (1980). All subjects received 30-minute sessions of therapy 5 days above. JS. quate vision and hearing. period. in future studies. Written transcripts of these descriptions were obtained easily accessible aphasia workbooks frequently used by clini. type of aphasia. in between modules. Our personal journey bilitation facility. ever. All were screened for ade- when we felt it to be an appropriate choice for a specific indi. TLS and non-TLS. Even are likely to be small. Our desire was to determine whether TLS was more topics. so. RE. was derived from what seemed to be “the norm” for many speech-language pathologists—that is. we are chose a reversal design in which TLS and non-TLS modules accustomed to delivering other kinds of therapy to those for would alternate with each other for 3 weeks after a baseline whom TLS is not appropriate and attempted to do that for determination of communicative efficiency. Treatment effects of thematic lan- guage stimulation. or any would—and will—employ many of them therapeutically other particular characteristic. we avoided any linking of materials with conversational 1986). however.qxd 1/21/08 12:57 PM Page 458 Aptara Inc. and without controlled content and delivery around thematic again at the end of the last module. The same content unit analysis obtained Subject Selection at baseline was performed between each of the modules. This served to control for the number of times that each was received. 458 Section IV ■ Traditional Approaches to Language Intervention a reversal/withdrawal or multiple-baseline design (Pring. reading. we attempted to treat the patient with per week for each of the three consecutive weeks. patient to the cookie theft picture were audiotaped and video- Therefore.GRBQ344-3513G-C16[450-468]. testing before inclusion in the study. 4 2 0 Test 1 Test 2 Test 3 Test 4 . how. and LS refer to indi- 6 vidual patients.. the responses of each structure and Schuellian principles. In other words. and they were selected without regard to involved exploration of many of these approaches. data in a visual rather than a statistical manner when changes ulation and support was required for specific activities.e. etiology. two 14 JS RE 12 LS Communicative efficiency 10 8 Figure 16–1. traditional speech and language tasks selected for the individ- ual’s level of performance in each modality but without Results regard to semantic uniformity across modalities. because many differing approaches 3-week course of treatment while at an inpatient acute reha- to therapy for aphasia are available. The decision regarding the content of the non-TLS mod. To treat individuals for their deficit or brain the theory of aphasia treatment first postulated by impairment in isolation is to ignore other critical features of Hildred Schuell in the mid-twentieth century. that the use of a content unit analysis as a measure of dis. individuals of varying aphasic syndromes. flexible. tional environment for shared insights and opportunities ing any conclusions. aphasia given our clinical has reinforced the role of problem solving by the patient. the recovery phase. more. based on perspective. After all. their recovery. that via the conversation focus. activity. quantifiable changes in perfor. What seems safe to assume. they learn. We found it interesting. Our role as educators and trainers will continue to 5. That is. our therapy symptoms. life’s goals beyond the duration of the speech therapy inter- Our impression is that this person would have had difficulty vention is of great value for the ultimate outcome. the person with aphasia to participate successfully in chosen ration of TLS intervention is warranted with a greater num. Although communicative part- observed for patient JS. Success in conversation often well. Success in implementation of TLS may depend on therapy room without application to functional activities several factors. to provide adequate stimulation and the abilities of With a driving force to make life better for people with the client to understand and respond to the aphasic aphasia and those who matter most to them. relative to baseline. Therapists who employ TLS must use the client’s various points in recovery. and decreased after non-TLS of help needs to be addressed early and frequently through- modules. rather than nonfluent. is regarding problem solving. FUTURE TRENDS KEY POINTS The World Health Organization’s model for classification of functioning and disability differentiates deficit. we must assist the community with learning to ber of subjects. needs to be authentic. No treatment effect was out the course of treatment. flow of speaking and listening in a conversation. edgeable and comfortable with partnership to be supportive strated treatment effects with TLS. the social network of those with aphasia need to be knowl- . the subject with is a prerequisite to success in chosen activities and participa- nonfluent aphasia. many different approaches. and other supporters. Certainly. and congruent at each of the 3. and 1. Improved language function that stays in the 2. In recent years.GRBQ344-3513G-C16[450-468]. and support the direction described by patients and 4. These lessons can be learned from Because of the very small number of subjects in our study. addition of the our best results were obtained when treating individuals metalinguistic component to complement the TLS format with fluent. however. about how to integrate treatment is key to the use of lem solve and make choices. The ability of both therapist and client to examine expand. the and consideration of the timing of implementation during ultimate goal is for people with aphasia to succeed.qxd 1/21/08 12:57 PM Page 459 Aptara Inc. recognize aphasia and to respond effectively. To meet these criteria. activities. on structure. listen ject matter for a successful outcome. her scores appear to be poorer ners generally cannot provide TLS therapy. TLS may simply be a more organized observa- we would need to test many more individuals before draw. bridges treating the language deficit and facilitating function mance is a good idea. with any intervention because of her inability to interact Lastly. employ appropriate strate- gies. impression that people with nonfluent aphasia respond quite family. tive efficiency score (number of content units divided by rate) Training aimed at understanding aphasia and how to be increased after TLS modules. because of its strong dependence little about the efficacy of TLS can be confirmed. Thematic Language Stimulation is an intervention that course for revealing small. by with both treatment approaches relative to baseline. For with the concept of treatment in general. Being skilled to problem solve and advocate for despite a good degree of cooperativeness regarding therapy. Similarly. the interests and talents to tap into the best possible sub- speech-language pathologist needs to direct less. Further explo. observing sessions and talking with us. Even so. Chapter 16 ■ Thematic Language-Stimulation Therapy 459 of the three subjects (both people with fluent aphasia) demon. they must be knowledgeable and empowered to prob. If people are to be successful outside of the therapy language and cognitive abilities and make decisions room. about how those with aphasia organizes their language. Thematic language stimulation is a neurobiologic participation as points of reference in the individual’s health approach to speech and language therapy. however. our training needs to involve the community. including the ability of the therapist and participation goals also reflects inadequate therapy. the communica. lacked a sense of treatment purpose tion goals. and effective. in fact. Thematic language stimulation extends out of the their chosen partners to assist in achieving a satisfactory basic Stimulus-Response formats into the natural recovery. and requires in the way of priming input or providing Discussion support to do their best. families and others in TLS. we observed that patient JS. C. Enderby. J. iv. Science.. M. M. (1995). E.. Select four vocabulary items on a topic of choice.. (1987). A. Cortical map reorga- nization enabled by nucleus basalis activity. (1994). A. Washington. divergent thinking. 103–115. 21.). Management of fluent aphasic clients. R. and evaluative hemisphere disorders. A process approach to neuropsychological assess- c. (1991). Baltimore. Communicative abilities in daily living. Kaplan. R. Manual of aphasia vention. Schuell’s stimulation approach to chronic aphasia after stroke. & Albert.). Journal of Speech and based practice in communication disorders [Position statement]. MD: Williams & Wilkins.. B. (1993). L. MD: Williams & Pring. 389–406). & Certner-Smith. 24–31. Baltimore. New York: Harper & Goodglass. (1998). (1989). Aphasia and right- memory. & Jimenez-Pabon.). (1994b). DC: APA. fying the informativeness and efficiency of the connected gies in adult aphasia. Aphasia tests Morganstein. (pp. Neurophysiology and Neurogenic A. 270. B. J. (1989). Kilgard. apy for chronic aphasia: Preliminary findings. adults: Diagnosis. Baltimore. Language intervention speech of adults with aphasia.). Language intervention strategies in adult aphasia Speech-Language Pathology. L. M. Include nouns and verbs... C. M. Language intervention strategies in therapy. The Cochran Database Siegel. Helm- steps: Estabrooks & A. Chapey (Ed. 9.CD000424. In N. Rockstrob. prognosis and treatment. adult aphasia (pp. N. Baltimore. 21. Siegel.. In R. M. 2–26).. In an open-ended sentence for a fill-in. (1991). C. Nicholas. MD: Williams & Wilkins. treatment for naming deficits in aphasia. M. E. 306–312. & Brookshire. Chapey. British Drew. Boston. Holland (Eds. Chapey (Ed. 94–98.. P. stimulation. P. E. S. (1993). Merzenich... munication measure for adult aphasia. R. T. J. M. 460 Section IV ■ Traditional Approaches to Language Intervention ACTIVITIES FOR REFLECTION AND DISCUSSION Holland. Thematic language reconsidered. Elbard. January). M. K. Language intervention strategies in rehabilitation (pp. J. British Journal of Disorders of Communication. G. Finlayson. T. C. Boles... & Thompson. T. San Diego: Singular. R. 338–350. & References Zoghaib. M. How would you ment: A process-based approach. & Coelho. J. (1980). measurement. 113–124. 39–67). M. Chapey (Ed. F. In a question designed to elicit discussion. Model-based semantic Journal of Disorders of Communication. each vocabulary item: Jenkins. Conducting conversation: A case study using the Maher. Byng..GRBQ344-3513G-C16[450-468].. W. PA: Lea & Febiger. American Journal of R. and practice. R.DOI:10. The Boston diagnostic aphasia Row.. Simmons-Mackie. Journal of Speech and Pulvermuller. Baltimore.. D. Clinical neuropsychology and brain function: be used with the same four vocabulary items? Research. (2000).).. Art. Morganstein. & Guic- i.. E. Advances in stroke thinking. & Whurr. . (2001). Austin. Journal of Speech and Hearing Disorders. spouse in aphasia treatment. 2. In a multiple choice reading format. MA: Andover Medical. (1990. (2001). Neuropsychological assessment & language treat- be able to succeed with item b. 4.. Application of semantic feature Marshall. of Systematic Reviews. 103–133). Holland.. M. & Certner-Smith. Holland. Chapey (Ed.qxd 1/21/08 12:57 PM Page 460 Aptara Inc. TX: Pro-Ed. (1998). 50. 972–989. H. (1986). L. Kendall. Hearing Disorders... Pickard. Stroke. A strategy for improving oral naming in an 1. Neininger. Using the examples given in Appendix 16-1. L. & Kaplan. L. Howard. In R. M.). M. A. D (1986). place 89–102. examination. 226–230.. E. Lomas. Chapey (Ed. 220–245). Seminar June 7–8 in Alexandria. adapt and change the presentation or task requirements VA. Social approaches to aphasia inter- Helm-Estabrooks. Language intervention strate. Boll (Ed. E. Gordon (Ed. & Coelho. (2005). Tucson. MD: Williams & Wilkins. Create a “cueing hierarchy” for someone who might not Kaplan. Swearengin. In R. Boyle. J. (1983). S. Journal of the 19(3). E.. (1964).). (2003). aphasia (pp.. & Scott. rehabilitation. In W. mary somatosensory cortex in adult owl monkeys after behav- iii. Medfield MA and to enable success? the Boston Neurobehavioral Institute. 63(1). adult aphasia (pp. 1714–1718. 54. R.. 4(1). What other exercises NOT in Appendix 16-1 might ment. H. C.. Evaluating the effects of speech therapy for Wilkins. G. strategies in adult aphasia (pp.. JSHR.. Jenkins. 32(7). Aphasia in gies in adult aphasia. G. (1990). Journal of Neurophysiology. treatment for aphasia following stroke. Create your own “mini” TLS unit by following these individual with a phonological access impairment. Constraint-induced therapy of Duffy. Functional reorganization of pri- ii. J.. Ochs.iii above. aphasics: Developing the single case methodology. AZ: Communication Skill Builders. 36. In R. N. Evidence. B. (2001) Pharmacological orders.. Inc.. Schuell.1002/ Journal of Speech and Hearing Disorders. Constraint-induced language ther- Speech and Language Disorders. 246–267). MD: University Park Press. 4. R. C. 82–104. a publication of ASHA SID 2.. Elbert. Introduction to language intervention strate.. H. 14651858. Approaches to the treatment of a.). Boston. Bester. MD: Williams & Wilkins. R. Mohr. Therapy and research. In analysis as a treatment for aphasic dysnomia. Hearing Research. S.: CD000424. Baltimore.. H. Kay. Pingle. 52. iorally controlled tactile stimulation. In T. Robles. Philadelphia. (1999).. 42. S. (1982). MA. T. A. b. Cognitive intervention: Stimulation of cognition. The communicative effectiveness index: Development and psychometric evaluation of a functional com- American Speech-Language-Hearing Association. A system for quanti- Chapey. J. Edmundson. P. convergent thinking. (1985). K. & Spradlin. & Rothi. Allard. 24–31. No. (1998). sponsored by Education Resources. 1621–1626. 192. J. L. The limits of science in communication dis- Greener. et al. Koebbel. & Merzenich. L. A. M. Aphasiology. (1994a). In a word-phrase-sentence format. International Neuropsychological Society. A. Journal Disorders. Wallace. Use foils (i. For each fill-in sentence. other words) that are varied in the degree to Select between 8 and 10 words that have a close association to your which they may be related. New Wepman. & Canter. Exercise 9: Sentence Construction Exercise 4: Categorization Pairs of words are provided with which to create sentences. 45. followed by words that vary in their semantic closeness to the target items. but designed to elicit a novel response. but verbs and the task. Journal of Speech and Hearing nected speech samples of aphasic and normal speakers. which The semantic closeness of the foils will determine the difficulty of will be used in each exercise.1 Thematic Language Stimulation (TLS) Unit on Books with Instructions for Creating TLS Units. Effects of personally rele. Use nouns primarily. M. of Speech and Hearing Disorders. APPENDIX 16. and attempt to write from memory. to the targets.. list the core vocabulary first. J. but within the mild to moderate range for each vocabulary item. Chapter 16 ■ Thematic Language-Stimulation Therapy 461 Taylor. 4–13. 37. which Exercise 7: Answering Questions. randomize core vocabulary items in a list of roughly twice its size. (1986). and create a phrase and sentence sequence for them in which Exercise 6: Yes/No Questions the target word is in the final position. K. Comparison of clinic. whenever reasonable. Semantic This is controlled repetition practice. L. Use each core vocabulary item.e. (1969).. T. The functional communication profile. Journal of York: New York University Medical Center. but with the last word as a fill-in. write the correct word. in which the stimuli gradu. J. closeness of the foils determines the complexity of the task. and the task is to provide a yes/no response. (1980). Wepman. M. Archives of Neurology. individuals. a verb. 385–390.qxd 1/21/08 12:57 PM Page 461 Aptara Inc. Questions are developed for which correct answers are randomly ment for the client to repeat in which the core vocabulary item is ordered in a vocabulary grouping of four or five items. On the left. Wertz. Create a question requir. three choices are offered. G. 50. Create This task is for identification of the core vocabulary in a list of two columns. ing the target word as an answer. home. ally increase in length and complexity. . R. Place these the last word. D. 43. adjectives are fine as well. (1985). visually or semantically.GRBQ344-3513G-C16[450-468]. (1972). & Beukelman. Exercise 2: Speech Stimulation/Production This is a grouping of three statements and one question. 653–658. G. Exercise 5: Sentence Fill-Ins. Multiple Choice Twelve Exercises These are fill-in sentences for which the target word is one of the Exercise 1: Repetition choices. (1953). Journal of Speech and Hearing Disorders. In the next column.. Multiple Choice evolves for each core vocabulary item from repetition to open- ended fill-ins to generation of novel utterances. Create out-of-order sentences of varied complex- Provide opportunity for the client to copy each target item at least ity. Questions are formulated with target vocabulary. 18. three times. 27–36. list a noun phrase. L. Speech and Hearing Disorders. An analysis of con- involved in recovery from aphasia. The client must choose and the first. These words will become your core vocabulary. Begin with a state. J. Create the next statement using the exact language of choices above four or five questions. How to Create a TLS Unit First. 201–214. Exercise 8: Sentence Arrangement The client is provided with a scrambled sentence for each core Exercise 3: Copying vocabulary item. M. M. End with a question relevant to the content just practiced. R. and deferred vant language materials on the performance of severely aphasic language treatment for aphasia. A conceptual model for the processes Yorkston. Aphasia therapy: A new look. chosen theme. Did you solve the mystery? Exercise 2: Speech Stimulation/Production Directions: Listen. When possible. 3. and sentence.qxd 1/21/08 12:57 PM Page 462 Aptara Inc. She is a famous _______________. The book comes in large _______________. The story is a mystery. Tonight I will read my book. See you at the library. writer mystery great writer solve the mystery She is a great writer. Vocabulary Unit: Books Exercise 1: Repetition/Oral Reading Directions: Repeat or read aloud these words. I prefer to read fiction. print library large print at the library The book comes in large print. 1. Exercise 12: Conversational Questions This is A list of questions on the topic designed to elicit conver- sation. The novel has many characters. 462 Section IV ■ Traditional Approaches to Language Intervention Exercise 10: Sentence Correction The client is provided with sentences containing two errors of either word choice. Multiple Choice Questions A paragraph is created in which all (or most) of the vocabulary has been used. fill in. grammar. Create three or four questions with multiple-choice answers for practice in processing factual and implied information.GRBQ344-3513G-C16[450-468]. I prefer to read _______________. The client must then answer some multiple-choice questions about the paragraph. What do I prefer to read? _______________ What is she? _______________ What do you prefer to read? Name a famous writer. glasses characters reading glasses many characters I’ve lost my reading glasses. phrases. fiction read enjoy fiction read my book I always enjoy fiction. Exercise 11: Paragraph Reading. What is the story? _______________ How is the book printed? _______________ Why are mysteries fun to read? How is large print helpful? . The story is a _______________. The book comes in large print. She is a famous writer. 4. use humor or idiomatic expressions to improve processing. 2. or spelling. and answer the questions. which the client must identify and correct. Then. cover it up. What do I wear? _______________ What were there three of _______________? Where do you buy reading glasses? How many characters are too many? 6. Where do I borrow books? _______________ What have I liked to do? _______________. Chapter 16 ■ Thematic Language-Stimulation Therapy 463 5. I borrow books from the _______________. How long can you borrow books? What kind of books do you read? Exercise 3: Copying Directions: Write each word three times. The book has three main _______________. I wear reading _______________. I wear reading glasses 7. The book has three main characters.GRBQ344-3513G-C16[450-468]. I’ve always liked to _______________. 8.qxd 1/21/08 12:57 PM Page 463 Aptara Inc. and try to write it from memory: Name: ____________________________________________________________________________ Date: ____________________________ read print _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ library glasses _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ writer mystery _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ fiction characters _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ . I’ve always liked to read. I borrow books from the library. 464 Section IV ■ Traditional Approaches to Language Intervention Exercise 4: Categorization Directions: Circle the words that belong in the category “Books.” If you prefer. fiction butter print read banana salami pill rain library writer spoil weather glasses splash inkling characters mystery insult . mix them up with another set of words from this book.qxd 1/21/08 12:57 PM Page 464 Aptara Inc. and sort them into two categories.GRBQ344-3513G-C16[450-468]. you can cut these out. and then write it. mystery show petal 2. Stephen King is a popular _______________________________________________________. puppet muffler writer 4. . night print perfect 1. My cousin likes to ______________________________________________________________.qxd 1/21/08 12:57 PM Page 465 Aptara Inc. The book has too many _________________________________________________________. ocean travel library 3. Multiple Choice Directions: Read the sentence. Chapter 16 ■ Thematic Language-Stimulation Therapy 465 Exercise 5: Sentence Fill-ins. Borrow the books from the ______________________________________________________. I need my ________________________________________________________. That type of book is ____________________________________________________________. characters tumbles services 8. To read better. A “whodunnit” is a _____________________________________________________________. wash read order 7. circle the correct word. glasses ears advice 5.GRBQ344-3513G-C16[450-468]. filling fiction syrup 6. The book is no longer in ________________________________________________________. Do you wear glasses on your nose? Yes No 7. Is fiction about real events? Yes No 3. What do you do with a book? ____________________________ 7. Our library: new has a wing _____________________________________________________________________________________________ 3. Does large print help some people? Yes No 8. Are characters a key part of a book? Yes No 6. What are the words on a page? ___________________________ 3. 1. What do you wear to help you read? ______________________ 8. What is a book about a crime? ___________________________ Exercise 8: Sentence Arrangement Directions: Rearrange these words to make a correct sentence.” 1. Who creates a story? ___________________________________ read library glasses mystery 5. Multiple Choice Directions: Use each word to answer the questions that follow: fiction print characters writer 1. Who are the people in a novel? ___________________________ 2. My book: characters many has too _____________________________________________________________________________________________ 4. Where can you borrow books? ___________________________ 6. Does a mystery keep you guessing? Yes No Exercise 7: Answering Questions. Are all writers good? Yes No 4. and circle “yes” or “no. Do you read only paperbacks? Yes No 2.GRBQ344-3513G-C16[450-468]. Are most libraries quiet? Yes No 5. What is a story not based in fact? _________________________ 4. 466 Section IV ■ Traditional Approaches to Language Intervention Exercise 6: Yes/No Questions Directions: Read the question. I bought a new: reading pair glasses of _____________________________________________________________________________________________ .qxd 1/21/08 12:57 PM Page 466 Aptara Inc. I asked if the book: in came print large _____________________________________________________________________________________________ 2. Write that sentence on the line. Do yous prefer function or nonfiction? _____________________________________________________________________________________________ . I like: book to read reviews _____________________________________________________________________________________________ 8. The print is two small for me to feed. circle them. The ending of the mystery: was total surprise a _____________________________________________________________________________________________ 7.qxd 1/21/08 12:57 PM Page 467 Aptara Inc. Stephen King: writer is a popular _____________________________________________________________________________________________ 6. writer-produced well-known writer 7. _____________________________________________________________________________________________ 3. and rewrite the sentence. glasses-broke reading glasses 6. fiction-prefer fiction shelf 2. She is famous for solvent the mystery before she funishes the book. mystery-confusing clever mystery 8. _____________________________________________________________________________________________ 5. 1. _____________________________________________________________________________________________ 4. print-see large print 3.GRBQ344-3513G-C16[450-468]. Eye need a strongest prescription for my glasses. Someone found my library cargo in them bathroom. _____________________________________________________________________________________________ 2. Find the errors. read biography never read Exercise 10: Sentence Correction Directions: There are two errors in each sentence below. Her brother: fiction will only read _____________________________________________________________________________________________ Exercise 9: Sentence Construction Directions: Create sentences with these word pairs. Chapter 16 ■ Thematic Language-Stimulation Therapy 467 5. characters-admire twelve characters 5. 1. library-borrow new library 4. Agatha Christie d. a biography b. the print was in color 3. What do you like or dislike about mysteries? 5. Besides books. What makes a character in a book memorable? 8. 468 Section IV ■ Traditional Approaches to Language Intervention 6. She had forgotten her glasses and could not read the print. what else do you like to read? 7. Why are books easier to read in large print for some people? 2. Ellen asked her friend Laurie to read the book and try the club. too many pages d. she wants Laurie to try harder b. but insisted the next selection be contemporary fiction. she is a mystery buff Exercise 12: Conversational Questions Directions: Answer these conversational questions on the topic. The writer of book was: a. Laurie announced she would like to join the group. _____________________________________________________________________________________________ 8. How has your library changed in the way you can borrow books? 3.qxd 1/21/08 12:57 PM Page 468 Aptara Inc. Why do drug stores now stock reading glasses? 6. What did Laurie suggest that the club read next time? a. The writer has writen nearly thirty books in his careen. 1. Once a month. it wasn’t funny b. _____________________________________________________________________________________________ 7. Laurie didn’t like the book because: a. too many characters c. she wants Laurie to drop out d. and she guessed the ending. Laurie was par- ticularly annoying and negative. _____________________________________________________________________________________________ Exercise 11: Paragraph Reading. Why are the benefits of a writer holding a book signing? . She disliked the writer’s style. When it was time to go. contemporary fiction c. another mystery d. Ellen reacted quickly and suggested another Agatha Christie book and that the group read only myster- ies for the rest of the season. poetry 4. I like to read the newspaper ever mourning.GRBQ344-3513G-C16[450-468]. I cold easily identification with the lead character. said there were too many characters to keep straight. Multiple-Choice Questions Directions: Read the paragraph. This month’s selection was a mystery by Agatha Christie. and then answer the questions. Do you prefer fiction or nonfiction? Why? 4. she likes repetition c. Ellen suggested they read more Agatha Christy because: a. Ernest Hemmingway b. Ellen goes to the public library to attend a book club. Stephen King c. 1. Angela Lansbury 2. At the meeting. and the application of part of the model mental operation (recognition/understanding. the Guilford model. the fact that I’m late?” we use divergent thinking.” and “The dog turned off my thinking. learning. and Evaluative Thinking Roberta Chapey COMMUNICATION: A PROBLEM-SOLVING/ DECISION-MAKING TASK Communication is a problem-solving/decision-making OBJECTIVES task. vergent thinking. “What time is it?” explain the general and specific objectives of cognitive stim. we use recognition/comprehension of systems. the kit. con- to adults with aphasia was the subject of my doctoral disser.) When we from the Peabody Language Development Kit (1965). lan. in what way. thinking). and Convergent. semantic. I used subsequent activities and lessons thinking also is called brainstorming or creativity. Each day. of these—is called for by the specific communication (or other) problem or decision at hand. Divergent. communication usually involves stimulation approaches to aphasia intervention. (Divergent dren. perhaps meaning “You are late. 17-1).” we use the mental operation of judgment.. classes. problem solving. and discuss the relationship between cogni. when we com- cognitive stimulation approach to aphasia management. When I served as a speech pathologist for a 6-week summer we remember what was said. There are four reasons why this model The objectives of this chapter are to define communication may be appealing. they make use of what- September. divergent thinking.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 469 Aptara(PPG Quark) Chapter 17 Cognitive Stimulation: Stimulation of Recognition/Comprehension. define cognition. prehend a literal or implied message (e. large amount of language in a very short time—so much so When individuals have a communicative (or other) prob- that they were not recommended for therapy that lem to solve or a decision to make. When we decide between “My divergent thinking. such therapy. decision-making task. language-impaired chil. why is it still #2?” or Therapy. where. infor. 1979). it appears to have ecological and com- as a problem-solving. 469 . systems. First. I became fascinated with the results. memory. symbolic. based on think of relevant contingent and/or adjacent utterances. and ever content (figural. It is a constant attempt to decide what guage. back and forth—the give and take—of ideas for a specific pur- text of the Guilford model.” “I overslept. nonverbal. decision making..g. discuss the deciding who can say what. and transformations)—or some combination levels and is still used throughout the world. During such communication. Memory. That is. “If the #2 pencil is the most popular. It is the mation processing. we the Guilford Structure-of-Intellect model—specifically. hour?”). review the municative validity. rela- The kit has subsequently been expanded to include multiple tions. we ulation therapy and suggest possible tasks and materials for use the mental operation of recognition/comprehension. When we comprehend a joke or double meaning of a word tive stimulation therapy and Wepman’s Thought Process (e. on often use divergent thinking. Kearns’ Response Elaboration Training. to whom. intelligence. and/or product or association (units. when we ask our- program in the NYC Board of Education that included a selves “What are all the possible reasons that I can use to explain group of 5-year-old. The results amazed me: The children gained a alarm clock. discuss assessment within a pose or problem. and associative car broke down. convergent thinking. and Guilford SOI model. we use memory. and the “Why is the time of day with the slowest traffic called rush Life Participation Approach to Aphasia. and/or behavioral). is the message of best fit for this partner in this situation. when (Prutting. One possible model of problem solving and decision making may be the Guilford Structure-of-Intellect (SOI) model (Fig. and composite abilities within the con.”) or that a problem exists. and/or evaluative tation (“Divergent Semantic Behavior In Adult Aphasia”).g. Rather. not lost linguistic elements or rules but. It is “the activity of knowing. sive auditory stimuli as the primary tool to facilitate and “Cognition. Chapey & Lubinski. STIMULATION APPROACHES TO LANGUAGE The following discussion represents one possible way to answer the above questions. organization. controlled. Guilford’s Structure-of-Intellect model. and used” (Neisser. is a generic term for any process maximize the patient’s reorganization and recovery of lan. elaborated. recognition. solving and decision making. (Rosenthal & Zimmerman. reasoning.. intelli- gence. thinking. Some proponents of 1967.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 470 Aptara(PPG Quark) 470 Section IV ■ Traditional Approaches to Language Intervention In light of the current emphasis on cognition. and/or determining causes of events? What complex events happen in the brain when one stimulates a patient? What are cognition. abstraction. causes of events (Zachman et al. one might ask what types of cortical activity are increased through problem solving. and information processing. processing information. 4).. 1964. whereby an organism becomes aware of or obtains knowl- guage. decision approach. therefore. Chapey. making. 1981. evalua- guage system is working with reduced efficiency. recovered. INTERVENTION IN APHASIA The stimulation approaches to therapy form the corner. 1978). 1977). 1)—knowledge that will. tal events transpire while a person actually behaves” 1964) places its primary emphasis on the stimulation pre. no reorganization of language through stimulation or increased single comprehensive theory of cognition exists. Rather. 1982). and inten. Their focus is not on sented to the individual with aphasia. & Morrison. a method of ability to solve problems (Jennings & Lubinski. the brain” (Schuell et al. that the lan. cortical activity through problem solving (Duffy & Coelho. stored. central brain processing or mental events. influence or insti- (Chapey. each emphasizes the psychologists with a variety of related approaches. p. 1982). It should be noted that . employs strong. generalization. p. Specification of the underlying targets of our stimulation therapy may increase the effec- tiveness of our intervention efforts. The stimulation observable behavior but. 1978). and to think 1967. We need to concretize the cognitive processes and the processes involved in problem Figure 17–1. 1977a. rather. This tion. We need a better understanding and specification of the processes we are stimulating in the brain as well as an operational defini- tion of the action elicited within the patient and the complex events that happen in the brain. only method we have for making complex events happen in reduced. (Rosenthal & Zimmerman. to predict outcomes and determine acquisition. because “sensory stimulation is the the processes by which sensory input is transformed. p. It emphasizes the action elicited within the patient by edge of an object (English & English. Thus.” then. as opposed to the list- ing of tasks that should be presented to patients. It is a group of processes by which we achieve the stimulation approach encourage us to stimulate patient knowledge and command of our world—that is. 1958). None of these PSYCHOLOGY LITERATURE approaches attempts to teach naming or other specific The study of cognition represents the work of numerous responses to particular stimuli. The stimulation approach first articulated and later ing” theorists who seek to determine what “functional men- developed and refined by Schuell and colleagues (1955. 1979. 1976. on examining the character- approach is grounded in the observation that the patient has istics of internal. predicting outcomes. 1981a). in turn. the Zachman et al. It “refers to all the stimuli presented. cognitive psychologists are viewed as “information-process- 2001). concept formation. 1981b. and how do they relate to these complex events in the brain? Are problem solving and decision making unitary or composite abilities? What is the difference between cognitive processes and products? What language-based cognitive abilities elicit action within the patient and make complex events happen in the brain to stimulate the comprehension and production of language? Answers to these questions and operational definitions of these abilities are crucial if we are to develop a coherent and generative rationale for intervention. DEFINITIONS OF COGNITION IN THE stone of language intervention strategies used with adult patients who have aphasia (Chapey. gate and guide subsequent and more overt behavior Rigrodsky. and problem solving. rather.. and use of knowledge” (Neisser. 338). such as perception. or process of fixing newly gained subjects were best suited for officer status. rather. no memory. funded by the specific mental operation—recognition/comprehension— Personnel and Training Branch of the Psychological which can be confusing). It involves the ability to insert new and so on. The validity of each test and ability was then assessed by per- forming numerous-factor analytic studies of responses to HOW THE MIND WORKS the tests and determining which of these tests loaded on spe- In his book How the Mind Works. 17-1). is what the brain does. standing). Guilford (1967) as well as Guilford processes as occurring in stages or in isolation. information processing or computation. conver- operations directed by comparisons. attention. for the things produced come available” (p. “is the immediate discovery (or rediscovery). Computation “allows meaning to cause and be THE GUILFORD MODEL caused” (p. According to Guilford (1967). incarnated as configurations of sym- bols” (p. It contains modules that are “defined by the The mental operation of cognition is basic to all other oper- special things they do with the information available to ations. 25) by allowing patterns of connections and pat. For example. Recognition involves acknowledgment that something has been seen or perceived previously. divergent semantic classes). for pilot training. The “content of areas. Office of Naval Research. Guildford sought to determine which Memory is the power. 1967. which Mental Operations are functionally specialized and which must assemble them- selves. Steven Pinker (1997) pre. one kind of content. rather. Programs are assemblies of simple information-processing units. needs to function” (p. which was developed by what is known. Guilford (1967) during his 20 years as the director of the to all mental activity or operations by most cognitive psy- Aptitudes Research Project at the University of Southern chologists. Pinker suggests we need ideas “that cap- largely from memory storage. 25). achieve a taxonomy of require that subjects essentially have a full comprehension of . hence. “A program is an intricate recipe of logical and statistical The five mental operations are cognition. Sciences Division of the U. judgment.P. Navy personnel to specific job require- ments. cific statistical factors. one kind of product (e. not necessarily by the kinds of information they have memory. divergent thinking. (2) The brain’s special status comes from what the brain does— contents. Pinker says. These 120 factors the mind is not the brain but. “beliefs and desires are information. it is the arrangement of neurons that matters. and evaluative thinking or subroutines embedded in subroutines” (p. convergent symbolic units or gram is run does the coherence become evident” (p. “[o]nly when the pro. was designed to define various intellectual abilities to match the Memory native skills of U.g. each of are seen as dynamic and interacting variables. 31). branches. if no them. good memory tests available to individuals and. Guilford used the term to refer to one California from 1949 to 1969. 62). are divided into three parameters: (1) mental operations.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 471 Aptara(PPG Quark) Chapter 17 ■ Cognitive Stimulation: Stimulation of Recognition/Comprehension 471 cognitive psychologists do not interpret the above mental intellectual functioning. Each operation is a computation. which was thought to tap a specific intellectual ability. Also. they and Hoepfner (1971) developed numerous tests. cognition of semantic material might be tested by using PSYCHOLOGY LITERATURE a multiple-choice vocabulary test in which the correct alter- native is a synonym of the word to be defined and the other The most widely accepted definition of intelligence is that alternatives are not. and activity among the neurons” (p.S. For exam- INTELLIGENCE AS DEFINED IN THE ple. 63). 25). According to Pinker. If neither cognition nor pro- ture the ways a complex device can tune itself to unpre- duction. thereby. 25). act. 27). Results of this research suggest that sents a computational theory of the mind and suggests that 120 factors exist in humans (Fig. evolution equipped us with a neural computer that often supplies missing information and makes Cognition good guesses. An ability is a com- brain activity lies in the patterns of connections and patterns of bination of one kind of operation. awareness. Thus. no production. four content terns of activity among the neurons (p. it is first.. tests. and recognition of ability to attain goals in the face of obstacles by means of information in various forms (comprehension or under- decisions based on rational (truth-obeying) rules” (p. Intelligence. memory. The Guilford model has five mental operations. 17-1).” Another def- the examinee knows or can readily discover on the basis of inition is the SOI model (Fig. 33). and six products (5  4  6  120). dictable aspects of the world and take in the kinds of data it Cognition involves knowing.S. (The term “cognition” has been used to refer J. “If no cognition. loops. Tests of cognition determine how much “intelligence is what the intelligence tests test. information into memory and to retain that new informa- In an attempt to define the numerous intellectual abilities tion. and gent thinking. 25). information in storage. His project. then no evaluation” (Guilford. however. p. Rather. and (3) products. and a truck. and transportation).” this Symbolic person would receive a fluency score of eight and a flexibil- ity score of three (balls. In one Divergent production involves the generation of logical test. “Originality” relates to the such as letters. ‘Milk comes from’ a sentence?” In yet another test. a car. such as correctness. musical notations [and] codes” unusualness of the response. & Torrance. asked to list numerous things that are soft and fluffy. practical feasibility. 1971). It is an appraisal group naming. Otherwise. Divergent behavior is directed toward new responses—new in the sense that the thinker was not aware of the response before beginning the particular line of thought (Gowan. in which the emphasis the sentence “A sandwich always has (a) bread. the indi- 1967). consistency. Responses can be grouped according to the Figural content pertains to “information in concrete form. the subject must judge whether a possibilities. then. ical feasibility. quantity. number of ideas produced (fluency) and the variety of ideas as perceived or as recalled in the form of images. convergent making a decision. measure divergent ability. and it involves the genera. nization (Guilford & Hoepfner. It is the ability to extend previous experience and ‘table’ and ‘lamp’?” Each judgment task has a predetermined knowledge or to widen existing concepts (Cropley. best response or solution (Chapey & Lubinski. and relevance of output from the lettuce. Divergent questions are open-ended and do not have a basic kinds (or areas) of information. substantive. group of five pictured objects. safety.” The term suggested (flexibility). It involves providing ideas in situations where a pro- vidual is given specific classifications and is asked to deter- liferation of ideas on a specific topic is required. tests may load on cognition. a quarter. It is concerned with the generation of logical sandwich?” In another. with the ready flow of ideas. 1967). and with the readi- sentence expresses a complete thought—for example. or picture it is always an extension of what is known. These tests require that the Divergent Thinking individual keep specific criteria in mind and select one best answer or solution from among several alternatives. to specify numerous critical details in planning an event or ficult. as in mathematics and According to Guilford (1967). money. symbolic. Which one must it have in order to be a same source. and behavioral. the individual might be figural. a football. to think of problems that anyone might have when eating lunch. If an individual is asked to list objects “figural” minimally implies figure-ground perceptual orga- that can roll and responds with “a baseball. An example of a convergent Although judgment behavior is based on the individual’s semantic test would be verbal analogies completion. a nickel. “Is ness to change the direction of one’s responses (Guilford. ketball. because they do not answer the question. (d) meat. completeness. a dime. vance. In accordance with the information given to them. and/or divergent thinking. material. for example. test material is not dif. 1971). tion of logical necessities.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 472 Aptara(PPG Quark) 472 Section IV ■ Traditional Approaches to Language Intervention the studied information. The human organism discriminates four broad. The operation of mem. identity. 1971). the individual chooses the best word for alternatives from given information. Convergent production is in the area of logical deduc. 1979). is the fixation and retention of new information. Such behav- mine if new information can be assigned to the previously ior necessitates the use of a broad search of memory storage established class—for example. if the above individual had responded. Symbolic content pertains to “information in the form of Guilford also uses originality and elaboration scores to denotative signs having no significance in and of themselves. Usually. utility. relevance. comparisons or to formulate evaluations in terms of known 1967. Convergent thinking is the generation of logical conclusions from given information. semantic. specifications or criteria. Content Demos. Responses also are evaluated for rele- thinking. .” Convergent Thinking these responses would not be scored. of the individual to use knowledge to make appraisals or examinees must converge on the one right answer (Guilford. or content: single correct answer. For example. the information given fully determines the outcome. or Figural to list what might happen if people no longer needed or wanted sleep. and “elaboration” is the ability (Guilford & Hoepfner. or social custom. (c) is on variety. are not scored. in which subjects write a class name for each or evaluation based on knowledge. in which the emphasis is on achiev- Evaluative Thinking or Judgment ing conventionally best outcomes. Guilford & Hoepfner. numbers. 1967). “Should the word ‘chair’ be and the production of multiple possible solutions to a prob- put with the words ‘cow’ and ‘horse’ or with the words lem. “Isn’t that an interesting question?” or “I like to eat lunch. which subjects must supply their own answers. Therefore. a bas. Guilford (1967) developed a number of tests to study judgment or evaluation skills. log- tions or compelling inferences. (b) butter. judgment involves the ability logic. adequacy. Answers that are not relevant to the specific questions ory. in previous experience and knowledge of the subject involved. Thus. or modifica- mation. ships among ideas. 1971) and often referring to one item. it involves thinking and verbal commu.. They represent the Transformations way that things are associated in the mind such that each level enters into the next level. 1994). relations into systems. For example. in solving interper- Relations enter into systems or organized patterns or items sonal problems. They involve nication. They are “belongingness” (Guilford & Hoepfner. and distinct logically and they can be segregated by factor . they appear at the top (Guilford. Transformations enter into implications or circumstantial connections between items of information. ideas.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 473 Aptara(PPG Quark) Chapter 17 ■ Cognitive Stimulation: Stimulation of Recognition/Comprehension 473 Semantic Classes Semantic content pertains to “information in the form of Units enter into classes or “conceptions underlying sets of conceptions or mental constructs to which words are often items of information grouped by virtue of their common applied. For example. 1967).”). anticipated. It might involve double meanings.g. and thoughts of others and to them (Guilford & Hoepfner. or information having “thing” character (Guilford & predicted by other information. sys- tems. The six types of products are units. For example. only one of which is correct. and redefinitions or shifts in meaning.” For an analogy task. acting parts (Guilford & Hoepfner. properties” (Guilford & Hoepfner. a test of ourselves are involved. to essentially nonfigural and nonverbal aspects of Relations are meaningful connections between items of human interactions. puns. Products 1971). suggested. units are regarded as It must not be supposed that. It is important for coping with other Systems individuals in face-to-face encounters. or thoughts in the form According to Guilford and Hoepfner (1971): of a particular whole. An example of a that might arise in the use of a given specific object. or any condition that promotes Units are things to which nouns often are applied. tions in existing information. 1971). products rep- resent a possible continuum from simple (units) to complex Implications (implications) (Chapey. in which case the individual must grasp example. Semantic units are meanings. However. needs. 1971). and in of information. thinking. choosing the class name that best describes a given set of words or objects. transitions. units enter into classes. kinds. Such semantic classes involve class ideas or concepts or tic information” (Guilford & Hoepfner. Some of the cues that the human semantic relations can be the logical relations of a syllogism organism obtains about the attention. perceptions. such as connec- Units tions by virtue of contiguity. semantic units test might be a multiple-choice vocabulary test in which the correct alternative is a synonym of the Composite Abilities word to be defined and the other alternatives are not. producing a larger and larger Systems enter into transformations or changes of various number of associations between and among items of infor. emotions. information based on variables or points of contact that apply moods. this might involve matching two faces that are sim. in which the attitudes. or a common situation” (Guilford & Hoepfner. a This type of content sometimes is called social intelligence semantic system can be a “sentence—a complex of relation- (Guilford & Hoepfner. they are complexes of interrelated or inter- generating information that is needed to derive solutions. classes into relations. 1971). in detecting and analyzing problems. words. perception. and so on. such as “body language. Thus. “soup is hot. the relations between the initial pair of words and apply it to ilar in terms of the mental state conveyed. an organized thought—a sequence of events. transformations. 1971). enables us to remain aware of what behavior is going on and also to interpret it. meaningful pictures also convey seman. It also might involve through nonverbal means. such as redefinitions. such as a implication can be sensitivity to problems such as stating cup or a chair. intentions. such as dishes or furniture. For example. Of the products. Such ability the second (e. classes. Units may be synonymous with the idea of two things seen wrong with a common appliance or those “figure-on-ground” in Gestalt psychology. desires. a semantic Hoepfner. hence. Implications relatively segregated or circumscribed items or “chunks” of involve information expected. ice cream is ________. Therefore. 1971). shifts. in which two premises and four alternative conclusions are feeling. it need not necessarily be dependent on common properties within sets. and intentions of others come indirectly presented. and implications. 1971). homonyms. although the abilities are separate basic. Behavioral Relations Behavioral content pertains to psychological information— that is. relations. Therefore. and any kind INFORMATION PROCESSING of product. symbolic. behavior. or relationship. divergent thinking. stored. there is evalu. com- sis (cognition). Next. 8 factors are (pp. 31) mental events that transpire while a person actually behaves. Guilford (1967) notes that the more a PROBLEM SOLVING problem. and used. a The following sections will explore the composite or uni- fied notions of problem solving. and/or behavioral sensory information is attended to and processed in the central pro- Thus. of this central processing unit are cognition. there is convergent production. If the information is immediately recognized. organize. 31) ing figural. 17-2). event. problem solv. there Within this information-processing model. novel to cope with something that is different from past possibly. the problem must be analyzed or struc. Two or more of the abilities are ordinarily involved in Cognition CMU v solving the same problem. When situations call for the individual to gen- The problem-solving factors found by Guilford and his erate logical conclusions from given information. contents. preparation (recognition of a problem. 3 Indeed. This is a matter of cognition. so that knowledge of an object. It is suggested that these are the functional (Guilford & Hoepfner. MNI Evaluation EMI rateness of the various mental operations. (2) analy. incom- may be new starts. then . EMI. has occurred. Problem solving involves the use of all five mental operations. implications. recovered.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 474 Aptara(PPG Quark) 474 Section IV ■ Traditional Approaches to Language Intervention analysis. DECISION MAKING Decision making and planning ability both belong in the category of problem solving and usually entail all of the steps described above. the individual must become aware that a prob. con- which is divergent production. ing or judgment. in which colleagues using factor analyses are as follows: emphasis is on achieving conventionally best outcomes. If sufficient basis for a solution is vergent thinking. with revised cognitions and productions. memory is involved. known. p. and the sensitive and searching procedures of factor analysis that NMR Deductive Guilford and colleagues clearly demonstrated the sepa. 1971. CMC ate together in various mixtures in ordinary mental functioning CMR has been the reason for the difficulty of recognizing them by CMS direct observation or even by ordinary laboratory procedures. and the kinds of products The present writer suggests that Guilford’s (1967) SOI required to reach a solution. model (Fig. p. the con- text in which the problem arises. semantic. each one aimed at a specific ability. semantic. and infor- mation processing. cognition). decision. reduced. CMIa Inductive Therefore. the mental operation of cognition (4) verification (evaluation). all types of content or information. prehended. The mental events or processes by which sensory informa- ation tion is transformed. The processes [The] individual generates a variety of alternative solutions. and products. depending on the problem presented. A problem is presented solution. At any step what happens may processes whereby an organism becomes aware of or obtains become fixated and retained for possible later use. and evaluative think- cognized and then produced. it was largely through the construction of DMT convergent) Convergent NMC v special tests. all transformation abilities. model also can be viewed as an information-processing Initially. (3) production (divergent and convergent). incoming sensory information is figural. or plan involves the generation of According to Guilford and Hoepfner (1971). After the selects a small portion of sensory information to be held for problem is structured: several seconds for further processing. This further process- ing takes place in the central processing unit. This is the group of mental processes that are used in the form of accepting or rejecting cognitions of the problem to acquire. and/or behavioral. symbolic. or understood. which usually involves cognition of systems. or the more creative the ing is a complex composite ability. At each stage in the problem-solving process. Sensitivity to problems  CMI. elaborated. 1971. Within this information-processing lem exists. The fact that they habitually oper. then the more it involves divergent production whenever a situation calls for the individual doing anything abilities—especially divergent transformation abilities—or. and (5) reapplication. and use knowledge—the and generated solutions. problem solving can be said to have five steps: (1) cessing unit by one or more of the five SOI mental operations. When evaluation leads to rejections. memory. then. An attention mechanism tured. often involving model. numerous responses or novelty. 19–20) Divergent DMU involved in reasoning DMR (5 cognition. (Guilford & Hoepfner. decision making. they function in isolation in mental activities of the individual. store. When the individual is faced with a meaningful problem erated by the various mental operations as they process or and uses all of the cognitive processes to solve a problem. acceptability. age and retrieval. is a modification of the original learning. . One of the characteristics of long-term memory is that tions.” When the amount of mem- ory we need to process is large. Human information processing model based on the Guilford Structure- of-Intellect model. symbolic. ber” (Muma. It retains the products gen. long-term memory is a storage information so that it conforms to one’s conceptual organi- area that contains everything that is retained for more than zation (Muma. When a novel response is world in long-term memory. Rote memory. An individual’s representation of reality as inserted into memory storage. to information that they themselves construct be processed by the mental operation of memory and (Guilford. Instead. organ- one or all of the organism’s mental operations. 1967).GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 475 Aptara(PPG Quark) Chapter 17 ■ Cognitive Stimulation: Stimulation of Recognition/Comprehension 475 Figure 17–2. and long-term memory. the divergent operation is generated.” Indeed. rather. associations or products. behavioral information take as a result of being processed by external stimuli cannot enter the organism. 1994. Products what is recalled often is not simply what was seen or heard are the basic forms that figural. That is. these new discriminations know makes our experience meaningful. The operation of memory (or short-term amounts of information with only minimal difficulty in stor- memory) is the act or process of fixing newly gained informa. These new isms do not react directly to representations of the world associations usually are produced as responses and/or may but. “the more you know. rather. dynamic. including lan.) convergent thinking occurs. we can deal successfully with larger memory storage. Thus. guage and the rules of language. Chunking provides a way of representing tion in storage. This “theory of the world in our heads When the mental operations are used and new informa. on the other hand. such as all learned experience. and/or know. the more you can Judging the appropriateness. or Through chunking. each individual has his or her own results of this information processing frequently are inserted summary of past experiences. and implications. or a memory structure of the into long-term memory. serves as the foundation for learning. the operation of memory is Memory capable of collapsing (or “chunking”) the data it receives in It is important to differentiate between memory as an opera. such as classes. In contrast. the more you can remem- correctness of information requires evaluation. the more you remember. Indeed. transformations. with permission. It has been shown that the required. tion. rela. 1978). or short-term memory. systems. what we tion or knowledge is produced. the act on experience. relevance. and but. it is newly gained information into storage involves memory. (From Chapey. more efficient ways and treating it in groups. come about in the form of new products: units. classes. internal symbols and the interrelations among these symbols are what is called “information. Inserting capacity of this storage is not static or fixed. rather. semantic. to one’s previously stored a few minutes. 1978)—that is. 1975). This involves evaluation. With transfer. is perception in all this? In the litera. Therefore. instead of having to react to each object as “abstract dimensions of the object” and reacts to those something unique. and to make decisions is to categorize. we learn to make generalized responses dimensions and no others. new patterns or products. Items of information produced (divergent and convergent) in response to new cues may also be fixated and remembered. In attempting to learn. the largest product of cognitive pro- something in our experience is unfamiliar or unpredictable cessing. particular categories. (Smith. events. ture. are products of SOI operations and are called units. The use of more principles or laws. and transfer organize past learning in such a way that it no longer is bound to the specific situation in which the learning Abstraction occurs when the person selectively picks occurred. because all operations retrieve information from this store According to Bruner (1968). “he is obviously to classes of objects. The generalized responses function as adding some personal component to his original learning . able to adapt to our environment in more satisfactory ways. divergent retrieval. According to Guilford and Hoepfner (1971): know. 1968). Thus. transformations. All of the mental operations depend on memory storage. 30). A learning sit- forcement. and evaluative retrieval. ships between and among objects. 30) uation arises whenever our present cognitive structures prove to be inadequate for making sense of the world when Concept formations. In this view. common feature (i. or products. forming classes). That is. one of the process may be one reason why meaningful memory is major objectives of learning has been accomplished. In SOI theory. 1971. To perceive is to the SOI theory. systems. because or schema and conceptual associations about the relation- learned order is a system. learning is “the acquisition of information Perception/Attention which comes about in the form of new discriminations in Where. For A distinguishing feature of the “cognitive” approach to example: learning is the assumption that what is learned are concepts Serial learning is essentially dealing with systems. “learning” is an interaction between classes. relations. Evaluation is conceived as playing an important role in rein- process of problem solving (Lazerson. We are longer lasting. unless it is fixated and retained (memory). Thus. p. and we are saved from subsequent learning (Bruner. It is regarded as the process of making Deduction is primarily in the area of convergent produc- differentiations and discriminations. learning is an active errors and correct information. all of a human being’s inter- (Fig. terms of new products” (Guilford & Hoepfner. all of the mental operations search long. Attention is part of this process. the learner is seen as a scientist who con. we are able to benefit from analogy when lishment of numerous associations.. Analysis and synthesis are not coherent SOI factors.e. actions with the world involve classifying input in relation to term memory to recall information that has been stored. a process of recogniz- tion. perception is defined as knowing and comprehending Learning and concept formation employ the five operations of the nature of the stimulus (Muma. memory retrieval. Concept learning Induction is thought to be in the area of cognition because involves the acquisition of a common response to dissimilar of its discovery properties. conver. both perception and attention are viewed as part nized. LEARNING the individual makes errors and he must discriminate between According to cognitive psychologists. and implica- the world around us and the theory of the world in our tions. 1971). because it has to do with drawing firm conclusions. When this occurs. Bruner’s contention is that to perceive is to categorize. stimuli (Saltz. generalization. Thus. Concept formation enables us to transform the world of infinite appearances into finite essences (Saltz. within [No] item of information has been learned until it has been cog- this model. conceptualize is to categorize. minology traditionally used in reference to learning. to learn is to categorize.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 476 Aptara(PPG Quark) 476 Section IV ■ Traditional Approaches to Language Intervention uses only one mental operation: memory. Reasoning. Results of factor analyses led Guilford (1967) as well as structs theories or forms hypotheses about the world and Guilford and Hoepfner (1971) to redefine some of the ter- then conducts experiments to test these hypotheses. one may ask. ing similarities and differences or reorganizing material into Classifying objects involves cognition of semantic classes. generic manner. to gent retrieval. (p. classes or categories that he or she has already established. When we learn something in this type of numerous operations during problem solving and the estab. That which is learned cannot have any future effects of cognition. and relationships. there is cognitive retrieval. during the we deal with a new problem. redefined as relational thinking. Thus. 1978). heads. 1975). 17-2). It involves the generation of lists Sensitivity to problems is primarily cognition of meaning- of specific characteristics to differentiate membership into ful implications. 1971) and to Abstraction. involves mostly This process of concept formation involves identifying com- cognition and convergent production—but especially mon features and grouping together all things that have a cognition of semantic systems. the SOI model also is a model of learning. learned. learning is an active process are movable. We carry out that drive by acting on our environment.” knows that the class of beads includes the subclass of green Leon Festinger (Lefrancois. intelligence. (p. Thus. When an individual is continuously exposed to simi. and a need to work cooperatively with others. A strategy also can be divided into its components. cannot relate. When something is unfamiliar or to pick this common component from a new set containing unpredictable. According to Smith (1975): Abstraction and transfer are apparent during rule learning: By a rule. or when we do not understand. 1978). Later. what they feel they are capable of achieving. or other differences that ponent in the definition of “cognition. will occur. external properties Why We Solve Problems or Learn of stimuli guide the individual’s behavior” (Rosenthal & According to cognitive psychologists. aspira- them. A skill that can be transferred to solve problems in tions. 1968). 1970). 1978). 1982) conceived of cognitive beads (Boden. and by curiosity component to his or her original learning experience: The (Yardley. & Peterson. one situation makes it harder to solve a problem in a new sit. We learn by relating new information to previous informa- 1978) tion and by seeing relationships among various bits of infor- Abstraction and transfer are involved in a judgment of class mation. are likely to respond differently to insight. we mean that two or more objects or events are We learn because we do not understand. In addition. therefore. rather than situation. For example. a baby concludes that certain objects For cognitive psychologists. is a consequence of all our learn that a flashing red light signifies stopping before cross. a drive to achieve compe- another way is to kick it. and . uation. especially movability. Abstraction is apparent during concept innate order-generating capacity—that is. distinguish one person from another (Dember & Jenkins. if this to a new situation. Smith (1975) observes two other crucial conditions is cognition that is well defined and developed (Scott. a built-in drive to development: “Concepts are developed by abstracting the learn. common stimulus elements in a series of stimulus objects” Thus. A transfer in which the components are tion. After having experience with the common ical. then. Bruner (1968) explains this intrinsic motiva- child knows that one way of moving something is to pull it. vated to learn (Smith. Harry Harlow (1949) ing potential of an individual includes the requisite intellec- calls this “learning to learn. occupa- (transformations). and the existing store Strategies can be transferred from one situation to of knowledge as it is currently organized (Ausubel. Transfer is an additional remembers more distinctly and for longer periods of time concept used in problem solving. differ- The intellectual ability to generalize is a significant com. it is rapidly forgotten.” To incorporate spe. 1965). cannot related to one another in a systematic way. 1982. 1982). it is when a problem is solved with the “Aha! the very same stimuli because of what they have already Reaction” (Lazerson. it is when an individual material that is somewhat different from what is already uses something he or she learned previously and transfers it known. If the material is too similar. (Rosenthal & Zimmerman. Positive transfer is when what was material is completely new and unrelated to anything in the learned for one situation helps to solve a problem in a new individual’s cognitive structure. 71). and yet another is to get a parent to tence. the individual must act on and interact with the phys- (Staats. 1979). we are moti- the same element. 161) beside a stalled car on the highway. which pull it (Boden.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 477 Aptara(PPG Quark) Chapter 17 ■ Cognitive Stimulation: Stimulation of Recognition/Comprehension 477 experience. recombined to “suddenly” solve a problem is called an Two people. p. According to Ausubel (Lefrancois. we exhibit transfer of this rule by knowledge arises out of a history of problem solving or of pre- stopping when we unexpectedly see a flashing red light dicting the consequences of potential actions. we predict. previous attempts to make sense of the world. the child transfers this by adding some personal intrinsic motivation (Bruner. “It is individual will add quite dissimilar response elements that assumed that dissonance leads to behavior designed to were not directly related to his or her original learning reduce conflict” (Lefrancois. Understanding the “abstract dimension” of that is significantly influenced by motivation. the individual will be able nitive processing to occur. the motivating effect of possessing The transfer of learning to new stimuli means that the simultaneously compatible items of information. 1975). the potential meaningfulness of learning and then the components can be recombined in new ways material varies with factors such as age. 1975). tion in terms of curiosity drive. Other variables that intervene between the stimuli and lar sorts of problems. Negative transfer is when what was learned for meaningful learning. Everything we know. he or she learns strategies for solving the response are the individual learner’s purpose. for the individual to exercise a capacity to learn: the individ- Osgood. language. An individual (Rosenthal & Zimmerman. the learn- new situations is termed a strategy. ual has the expectation that there is something to learn. and cultural membership. and thinking world for cog- stimulus elements of the concept. and ideals (Marx. the ideational context. ences in the ways their minds work. rote learning. On this basis. This is analogous to the child who he termed “reciprocity. another. the mind possesses an Zimmerman. 1974). more than the literal. inclusion. 1968). dissonance—that is. 1980). cific knowledge and generalize it into everyday experiences 1979). Our present ing an intersection. social.” tual capacities. 1980). For example. beliefs. emotional. 1978). quality. can be operationally defined as the use of the or meaning that is coded or represented by linguistic form five mental operations: (1) cognition (recognition/under. 1978. or subject matter involved in conversation. or a specific relation. divergent thinking. These three types of language knowledge come together in ing. 1978. classes. for some purpose or use in a particular context” (p. recurrence. events and relations in the thinking. . An individual learns to understand and use language in relation to the ideas or mental concepts that have been formed through experience (Bloom & Lahey. These are the mental events or processes by which we guistic competence can be defined as the interaction of con- learn or obtain knowledge about our world and by which we tent. both understanding and saying messages. (4) divergent thinking. form. the names for objects and actions. transformations. language can be defined as “a knowledge of a code for repre- itive outcome. ple. or the opposition to an action or object. or the reappearance of an object or event. things to . Language is something we know (Slobin. and use (Bloom & Lahey. 1978. Knowledge is a product of cognition and is associated or organized into units. (3) convergent think. standing/comprehension). these ideas. guage need to know about objects and actions in order to know Within the context of the Guilford model. such as eating lunch. p. and use that knowledge. relations. 5) acquisition and use of language. such as similarities among different chairs and the mobility of certain objects but not others. COGNITION and use. Thus. or ability. 1971). [O]ne cannot know about mation or language experience is semantic and behavioral sentences and the relations between the parts of a sentence (Fig. then. an individual might comment about a specific object. know about objects and events in the world. 1988). such as a pipe. “language consists of some aspect of content Cognition. and (5) evaluative thinking or judg. not events themselves. Or. 1978. 17-3). Speakers of a lan- lying the acquisition and use of language (Slobin. with permission. . This information is then processed by one or unless one also knows about relations between persons and more of the five cognitive operations: cognition. there are three types of language knowledge: content. Specifically. According to Bloom and Lahey (1978). 1988). Lahey. (2) memory. form. (Bloom & Lahey. It is the knowledge that convergent thinking. Lahey. body of knowledge represented in the brains of speakers of a topic. such as pos- session. 1971). The experience of many different objects—some of which are more alike than others—is “an active process whereby per- sons perceive patterns of structure and invariance in the envi- ronment” (Bloom & Lahey. p. 1971). and indeed. or having or owning an object. 23). incoming infor. systems. a particular action.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 478 Aptara(PPG Quark) 478 Section IV ■ Traditional Approaches to Language Intervention the learner must have some reasonable expectation of a pos.) chunks of information having “thing” character. meaning could relate to a content category. and evaluative individuals have about objects. such as that between Harry and his pipe. It is a It is this knowledge. ior (Slobin. The ability to perceive the similarities in repeated encounters with physical and social events involves the abil- ity to process and analyze experience using the five cognitive processes. objects in different kinds of events . 23). These are the mental processes underlying the world that is coded by language—ideas about events are coded. lin- ment. Individuals learn new words and categories gradually. Words and categories represent regularities that the individual notes in his or her environment. Content: Language Represents Ideas About the World Psycholinguistic research suggests that our LANGUAGE DEFINED code or means of representing information can operate only in relation to what [we] the speaker and hearer of the language Psycholinguistics is the study of the mental processes under. Model of language based on the Guilford model of information—or the formation of schema into units (or (From Chapey. 1994. the content of which is inferred from overt behav. 7). memory. and implications. recover. that are the meaning. by testing hypothe- ses of what a word means in different situations in which they think one or another word might fit (Bloom & Lahey. store. organize. For exam- language. senting ideas about the world through a conventional system of arbitrary signals for communication” (p. and rejection. This results in the organization or association Figure 17–3. 1971. which are directly related to the mean- predicted by other information [e. if a recipe calls for two eggs signals ongoing activity. and redefinitions or Markers can be divided into two types: function words (the. generate utterances and connect sounds or signs with meaning . chocolate. Word order tells us about the subject-object relationship. systems (or complexes of interrelated or Two rule systems in English are word order and markers. such as redefin. 1971). system of abstract structures generated by the syntactic com- ponent... to create a new concept.g. Lahey.g. . is conventionally best content for his or her intent (convergent a device for pairing phonetically represented signals [into a] thinking) and then conveys the content to the listener. According to Chomsky (1972). usually is initiated and/or maintained to convey meaning is not always directly expressed in the sounds we meaning about certain topics or ideas or to convey an intent. 1971). 1988). Thus. the form of lan. 1984). 32). we must have rich inner mental structures that make it For example. 52) combine to form words and words combine to form sen. systems. a Form: Language Is a System semantically interpretable deep structure and a phonetically The rules of language specify how to arrange symbols to interpretable surface structure. (e. “you can only make sense of the sounds can and cannot combine. into a measuring cup. 19). then. during communication. a limited number of rules specify which this structure. p.. structures.g. to transform the information. ideas. For sentences. It is a set or system of (or meaningful connections between items of information rules for processing utterances (Slobin. p. [e. can often become stale or spoil. Rather. 1971). puns. that certain content would be inappropriate vidual is biologically predisposed to learn a set or system of (evaluation) for his or her purpose. -ing mation [e. 1971). with) and suffixes (-s. Thus. or modifications in existing infor. 1978. “Desserts are sweet. or signal meanings (e. to to the sentence as it is heard. 1971. p.g. suggested. ideas. and taste good. and in the event that these are express ideas (McCormick & Schiefelbush. a. and/or relations.. when baking a cake. and then double the volume by adding Chomsky (1957) postulated two basic sorts of rules or two water or milk). put it (Slobin.. because all of the sort through all the possible ways to express this intent information for the processing of speech is not present in (divergent thinking) and may make a judgment. is misleading and uninformative: “Our knowledge of lan- Language content is developed and used within the con. The phonologic component of reprocess existing information and reformulate the structure grammar “converts surface structures into sound patterns of of individual units or to group units together into classes. fat. text of the speech act. all desserts]). 7). an individual may possible to utter and comprehend sentences (Slobin. The individual may able “stimuli” and “responses” alone. The surface level of a sentence is directly related ence into an existing unit or class. transitions. 19). The semantic component of grammar tening. sounds or signs with meaning. 1964. are sold in a bakery. shifts. 19). specify relations itions. classes (or semantic interpretations of a sentence to their acoustic pho- conceptions underlying sets of items [e. tences. syntax is a and generate an infinite number of sentences and connect device that relates sound and meaning. which is a problem.g. Transformational rules convert deep structures into surface New experiences may cause the brain to place the experi. “This is what I call cheesecake. and events. Specifically. become aware that it is necessary to describe something (an We cannot explain language learning on the basis of observ- intent) that he or she knows (cognition). spoken utterances” (Slobin. 15). the surface structure often and/or to see the implications of such information. p. guage involves properties of a much more abstract nature.. Understanding a sentence is based on knowledge of p. double meanings. a limited string of words you hear if you know . . a system of rules determines the “ways in which sounds (Chomsky. The markers do such things as transformations (or various types of changes. meaning. or erate deep structures. For words. ing of the sentence. individual therefore comes to a logical conclusion about the Grammar.” and so forth]). p. distinct.g.g. relations netic representations (Slobin. intent. or listener. guage or system of rules “is the means for connecting sounds These rules of language that allow us to process and/or or signs with meaning” (Bloom & Lahey.g. a person might open one egg. Because the solving task. anticipated. a cookie]). cookies]). the indi- past experience. and implications (or the formation of levels of sentence interpretation. a statement of the relation between these structures. or thoughts Linguistic competence is a system of rules that relates in the form of particular wholes [e. are frequently “relates deep structures to meanings” (Slobin.. Communication. The rules for processing utterances. 1971.”]). and so on and there is only one. According to Slobin (1971). This syntactic knowledge or morphemes) are combined to code meaning (Bloom & Lahey. 1971). finite system of rules makes it possible for us to comprehend 1978. based on observable behavior” (Slobin. identify classes (e. hear. interacting relationships among objects. homonyms. with relates girl to eyes). -ing).. Indeed. not directly in the surface structure” (p. the identifies a noun).g.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 479 Aptara(PPG Quark) Chapter 17 ■ Cognitive Stimulation: Stimulation of Recognition/Comprehension 479 which words often are applied. 1978. the grammar of number of rules specify how linguistic elements (words and your language” (Slobin. and -s signals plurality). the syntactic component must provide for each sentence (actually for each interpretation of each sentence). shifts in meaning [e. Phrase structure rules gen- hypotheses of what is expected. Abstract structural patterns underlie grammatical sen- tences for representing knowledge” (Bloom & Lahey.. Becoming aware that a problem exists is a the speaker’s intent in producing the utterance. what Developing a language system is a problem-solving task. 12). Repair/revision edge of who can say what to whom. and what the rules governing linguistic tion. statements. 1983). is involved. communicative competence implies knowl. there may be The incoming semantic and/or behavioral information is new starts. Initiation of speech act effective and efficient communication (Muma. and so on (Table 17-1). Communication of intent Use: Language Is Used for Communication Label Greeting Attention Communication is an assertive act of coping—an active prob. what happens may tures that are derived by an individual are the products of become fixated and retained for possible later use. 1969) reference as topics change (Muma. hearer understands. the individual generates a variety of possible ways of the use of language for communication. (ii) Sustaining a topic ferent contexts (Craig. sentence (or other linguistic elements) uttered means. including sensitivity to various aspects of usually involves cognition of systems. Maintenance of communication Therefore. and generalization. and the elocutionary force of this proposition is would like to say. requests. Contingent utterances rights. stage in the process. often involving implications. and to be sensitive Assert Argue to the influence of one’s communicative partner and the phys. . they become aware that the system of rules they now Searle’s theory. which communication. they focus on what they see beliefs. In mation. and form of accepting or rejecting cognitions of the problem and indeed. among other things. 1974) lem-solving task. 1983) to achieve a message of best fit and. processed by cognition. Meaning is the essence of language (Goodman. 1980). Such semantic knowl- and hear and then “use their conceptual capacity for linguistic edge develops and is “used within the context of a speech inductions” (Bloom & Lahey. abstrac. Question Advise ical context in which communication occurs (Prutting & 4. obligations. After the problem is social contexts (Prutting & Kirchner. It is a knowl- d. the conversational knowledge or discourse struc- the generated solutions. how units of language function in discourse and then produced. It is an analysis structured. what the 1971). there is convergent production. As individuals process and use semantic and behavioral infor. 1979). Communicative partner variables 3. Code switching when. 1980). e. 1978. Feedback to speaker nance of discourse (Ochs & Schieffelin. speech act includes “what the speaker means. not on sentence structure but on how meaning is communi- If sufficient basis for a solution to the rule system is cognized cated—that is. b. 72) to develop a knowl. The acquisition of new rules comes about in the form of TABLE 17–1 new discriminations in terms of new products. 1975). judgment of class inclusion. 1983). a theoretical unit of communication between a speaker edge of language content. memory. The emphasis is to code what he or she wishes. and acceptability of a message. 1. Rather. 1975). According to Searle (1969). what the involves. Thus. utterances are” (p. then apply it to meaning. convergent thinking. Individuals learn rules gradually. A. At each (Prutting & Kirchner. matter of cognition. we learn new forms of language when our present system of rules proves to be inadequate for expressing mean- ing. Physical context variables 2. and use to communicate and a hearer” (Lucas. B. Next. transfer. which is divergent production. there is evaluation or judgment in the Pragmatics is inextricably related to cognition. It the speaker intends. (i) Role switching/turn taking edge of how to converse with different partners and in dif. where.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 480 Aptara(PPG Quark) 480 Section IV ■ Traditional Approaches to Language Intervention are learned by “listening to the language of the environment Pragmatics involves the acquisition and use of such con- and abstracting from it the rules that are used to generate it” versational knowledge and of the semantic rules necessary to (Naremore. Speech acts include making promises. p. Request Description form. the meaning. thus. 1983) as well as knowledge of the a. Response Repeating Protesting (Dore. what the hearer intends. hypothesis formation. assertions. Adjacent utterances c. act. 1980). Individuals do not learn language form and communicate an intent to affect the hearer’s attitudes. It is a constant attempt to vary the content. When evaluation leads to rejections. and expectations underlying the mainte. 1979). the Thus. pragmatics involves the interactional aspects of problem in the rule system is analyzed or structured. so memory one or all of the five SOI cognitive processes or operations. by testing hypotheses of what a form Discourse Structures can express in different situations where they think the rule might be appropriate for the expression of meaning. with revised cognitions and productions. Turn taking Kirchner. At any step. form. in what way. or behaviors (Lucas. the proposition is the words or sentences possess is not adequate for expressing meaning or what they produced. and by what means (Prutting. to switch or shift sets of Request Order Warn (Searle. Various conversational settings intent involves the use of semantic content (what is said) as may affect the number and variety of utterances produced by well as behavioral content. physical context variables. ners. intentions. may. gestures. As individuals encounter various contexts or settings. and groups of partners. previous or subsequent utterances. The way this or for analogous situations. perhaps. be expressed (and comprehended) through facial expression or accompanying actions. Thus. to assert. in which the individual chooses to communicate an intent at any particular point will reflect his or her knowledge of physical context variables and his or her communicative Communicative Partner Variables partners. and this type of topic. These units are neously or subsequently develop rules for interacting in spe. redundancy. What is Physical Context Variables not said also may communicate intent. to reprocess existing might be appropriate to this context. and turn-taking rules (including hended through semantic-syntactic utterances and/or by topic selections. transformations. to greet. the individual evaluates group membership. types of partners. reference. communicative partner variables.” when symbolic gestures are used. judge or evaluate the form. partner. may try to or to group units together into classes. ments. and responsiveness (e. pragmatics or language use) is an sible topics or intents that would be appropriate for this part- active process of problem solving. this type of context. to ques- structures are discussed in the literature. For example. plexity. Specific communicative partners may affect the length. Again. and so on. and to call attention to something. comprehension of . partner characteristics. such as that the listener has already established as well as on the age. and thoughts of others and talk loudly in an elegant restaurant”. or the nonfigural and nonverbal a speaker (Gallagher. and to warn. frequently affect communi. Dore (1974) specified the following intents: to Discourse Structures label.. classes. associations. to advise. 1983). ence is unfamiliar or unpredictable. semantic relatedness of com. and yet another that ourselves. rela. or suggested for tions. They may sort through all the pos- cation (and. These relate to tion. and that any their knowledge regarding the physical context variables and language sample therefore will be the interactive product of the communication partner to help them decipher between contextual variables and the individual’s structural linguistic what is said and what is meant. partner or type of partner. transformations. anticipated. rule that says. systems. to create a new concept. therefore. 1983). one may have a information that communicates the attitudes. fluency. items or “chunks” of information. The intents A number of cognitive/pragmatic products or discourse specified by Searle (1969) are to request. desires. may make judgments information and reformulate the structure of individual units about certain variables within the context. subsequently. information. and so on.g. and/or rela- hypothesize what is expected. perceptions. maintenance and change. one that says. elaborations of comments). systems. Language is used to communicate a variety of intentions. Thus. constructed with respect to this specific partner or class of ners and develops rules for interacting with specific part. they may determine if they know or recognize the tions. and/or evaluative thinking to generate When people first encounter a potential communicative pragmatic (semantic and/or behavioral) units. and status. needs. New experi- or she knows or recognizes the context. The acquisition of new pragmatic information comes about in the form of new dis- Communication of Intent course structures as a result of the use of one or all of the five mental operations of the SOI model. According to Haviland and Clark (1974). familiarity. “Don’t talk in church”. Individuals frequently use with each context. and implications (Gallagher. In addition. ability of the listener to interpret the various levels of com- complexity. receptiveness to various intents. It may even involve the use of symbolic content says. or tone of voice. and amount of eye contact during an utterance classes. that is. systems. rules when our present pragmatic knowledge proves to be and acceptability of various possible communications and the inadequate for a situation or when something in our experi. to argue. “Don’t moods. The individual tries to determine if he experiences using the five cognitive operations. that contexts are dynamic. Language intent may be communicated and compre- communication of intent. to request. to describe. and/or to see implications of such information. Indeed. We learn new pragmatic ner and. In addition. code switching. and implications. 1983). partner. For example. the communication of knowledge (Gallagher. Communi. intent may and referential skills) (Table 17-1). relations. or products that he or she has cation. Individual intents are semantic and/or behavioral units— they categorize or classify these contexts and either simulta. Comprehension of the intent will be based on the units. sex. to protest. one can A pragmatic view of language assumes that language will vary say one thing but mean another. the individual categorizes and classifies part. to repeat.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 481 Aptara(PPG Quark) Chapter 17 ■ Cognitive Stimulation: Stimulation of Recognition/Comprehension 481 divergent thinking. implications of such communication. developed when the brain processes semantic and behavioral cific types of contexts. “Cheer loudly for your team at a football game. to order. try to ences may cause the brain to place the experience into an exist- think of all of the other possible responses or behaviors that ing unit or class. to respond. which involves semantic and usually. John Muma addressed the issue of role/code comprehended semantically and/or behaviorally. which would be behavioral content. including the initiation of the speech act and the act. or an elaboration of a topic and judgment as to the rel- this partner. occurs in the absence of the speaker’s readiness to switch. and what is judged to be sincerely wanted Production of contingent utterances usually involves seman- information. nance and regulation. Thus. Thus. she believes it is effective and acceptable. These are utterances that occur immediately after a respondent. 172). 1974. mation and what he or she can assume this particular partner however. According to Muma. 171). cues themselves to formulate a judgment concerning the tion to assumed information. Listener feedback Moves by the speaker and the listener to repair sequences will depend on the listener’s previously established concepts and respond to such regulatory devices as requests for clari- of effectiveness and acceptability in general and his or her fication are essential to the maintenance of communication concepts that are relevant to this speaker and this context. or lean. relevant. to cues provided by the listener. of the head away from the speaker (Davis & Wilcox. the listener will assist the speaker in conveying Code switching is the degree to which the individual can the message. 1981). This involves the speaker’s sensitivity ing forward. 1983). Initiation of the speech act share the same topic as the preceding utterance and that add (as speaker) includes topic selection and introduction and/or information to the previous communication act. Maintenance of communication also may involve a Turn-Taking Rules response that sustains a topic (the listener becomes the The reciprocal nature of communication involves a number speaker)—one that involves a specific response to the speech of aspects. and acceptability in an effort to phonemic clause” (Davis & Wilcox. therefore. 1981. Judgment is essential. It is the ability to issue a “message in the most . tain new. A contin- change of topic. This involves respond to such cues by repeating and/or modifying the the listener’s ability to monitor and evaluate the speaker’s message when necessary.” Dumping per- Rosenfeld. One he to signal a wish to maintain or change roles (Harrison. adjacent utterances are used as and the reciprocal roles of speaker-initiator and listener. Occasionally. produce stylistic variations in the form or frequency of spe- bly. Thus. he differentiated between two dif- instances. nonverbal (behavioral) cues are used by partners ferent variations in one’s method of communication. In many switching. convergent production.” and the other he called “play. judgment. cific acts to meet situational requirements (Fey & Leonard. Role switching may occur as a result of the speaker’s 1983). desire to relinquish the role. The listener also may respond with a short and. (Fey & Leonard. such as “Yes. Such utterances are considered to be logical or possi- sage. message of best fit. and divergent think- term memory for information that is judged to be relevant to ing. For example. Usually.” behavioral cognition and judgment and the ability to Feedback to the speaker is essential as well. and possi. the individual makes a speaker’s willingness to switch roles. role-taking atti- tener’s reaction. affirmative verbal response. reference. it may be accompanied by overloudness and a shift knows. he or she signals “with a pause between tudes involve the active resolution of communicative obsta- clauses” or “with a rising or falling pitch at the end of a cles of form. topical an utterance and its intent. When role switching judgment based on past experience as to what is new infor. and judgment. or a log- or referential identification involves searching one’s long. 1981. which involves cognition. It involves the speaker’s use of con- message and ability/willingness to indicate whether he or vergent production. which involves cognition. When a speaker wants a lis. accuracy. partner’s utterance but that are not related to the speaker’s The listener’s role is to comprehend the speaker’s mes. First. convergent and divergent semantic thinking. such as the ability to role play. the achieve the message of best fit for a particular situation and listener needs to use knowledge of such cues as well as the listener. terized by visual orientation rather than gaze avoidance” Repair and revision also are part of discourse mainte- (Davis & Wilcox. It can be communicated and/or In 1975. It is important to evaluate the implicitly shared tic and behavioral cognition to understand or comprehend information aspect of the communication act. divergent production. and appropriateness of a response in this Maintenance of communication involves a number of context to this communicative partner. 1978). variables. Thus. role taking involves the establishment and Maintenance of communication also involves a sequential variation of roles with respect to the speaker and the listener organization of topics. p. convergent and divergent thinking. a nod of the head. ical and sequentially ordered response. well. Play involves ascer- by gaze avoidance and a hand gesture that is not maintained taining needed changes for appropriate recoding of a mes- or not returned to a resting state through a phonetic clause sage and making necessary adjustments to achieve the juncture (Rosenfeld. The listener maintains this ble elaborations of communication and. called “dump. wanted by this partner. contingent utterances are utterances that maintenance of communication.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 482 Aptara(PPG Quark) 482 Section IV ■ Traditional Approaches to Language Intervention an utterance in context also involves relating new informa. The speaker usually retains his or her role tains to the issuance of a coded message. the communicative act should con. In his article. 1978). gent utterance is an elaboration of the speaker’s topic. and perhaps. involve role with nonverbal (behavioral) responses that are “charac. p. interesting. evance. topic. When a novel response Divergent Semantic Tests is required. Inserting Common Situations List problems that are inherent in a newly gained information into storage involves the operation common situation. In role taking. Differences Suggest ways in which two objects are differ- ory) and encoding (convergent thinking. perceiving and revising messages until necessary meaning as a word that completes a sentence. all types of content or informa- Associations Write a word that is associated with each of tion. are used (content. 299). then. and Use on a previously studied page. mental operations. Semantic Evaluation Tests Word Checking Choose one of four words that fits a single Semantic Awareness/Recognition Tests criterion. of all five mental operations. vance. A problem is a Convergent Semantic Tests question or a proposition that necessitates consideration and Picture Group Naming Write a class name for each group a solution (Webster. Memory for Facts Answer questions regarding informa- A problem is presented whenever a situation calls for the tion previously given in two sentences. 1977). to generate logical conclusions from given information where emphasis is on achieving conventionally best out- comes. Form. Word Fluency List words that contain a specified word or ASSESSMENT OF COGNITIVE OPERATIONS letter. adjustments are made in form. When situations call for the individual a specific function. Word Recognition Recognize whether given words were Content. known. individual doing anything novel to cope with something that is different from his or her past behavior. Normal language functioning. tive processes for effective decoding (cognition and mem. A list of some of these tests follows. and any kind of product. Judging the appropriateness. acceptability. form. comprehended. and use) are products of these five Consequences List the effect of a new and unusual event. class. depending on the context in two given words. and acceptability in order to convey intended Semantic Memory Tests meanings” (p. . Sentence Synthesis Rearrange scrambled words to make a ticular person for particular efforts” (p. objects. Product Improvement Suggest ways to improve a particu- The three types of language knowledge that develop and lar object. ent. best fits two given descriptions or adjectives. which the problem arises and the kinds of products that are Largest Class Form the largest class possible from a given required to reach a solution. Recalled Words Recall words presented on a study page. rele. Verbal Comprehension Choose a word that means about Double Descriptions Select the one object of four that the same as the given word. and/or correctness of information requires evaluation. list of words so that the remaining words also make a If the information is immediately recognized. Planning Elaboration List many detailed steps needed to Guilford and Hoepfner (1971) developed a number of tests make a briefly outlined plan work. Similarities Produce ways in which two objects are alike. tured on a previously studied page. are problem-solving tasks. The objective of true communication is aimed at ascertaining or judging which message is most Picture Memory Recall names of common objects pic- suited to achieve effective and efficient communication. 299). Reading Comprehension Answer questions about a short Class Name Selection Select a class name that most pre- passage. meaningful sentence. reasons why a briefly described plan is faulty. reference or psychological distance. then. and evaluative thinking) to occur. the mental operation of cog- Attribute Listing List attributes of objects needed to serve nition has occurred. divergent thinking. Object Naming List objects that belong to a broad class of requires the efficient action and interaction of all five cogni. “both speaker and listener are active participants in formu. convergent thinking occurs. the divergent operation is generated. or understood. to assess each of the five mental operations. Vocabulary Choose the alternative word that has the same lating.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 483 Aptara(PPG Quark) Chapter 17 ■ Cognitive Stimulation: Stimulation of Recognition/Comprehension 483 appropriate form for conveying intended meanings to a par. of memory. cisely fits a group of four given words. Problem solving involves the use of five pictured objects. Language learning and use. Brick Uses List many different uses for a common object. Verbal Opposites Give a word that is opposite in meaning Commonsense Judgment Select the two best of five given to the given word. divergent thinking. clinicians may want to explore the nature of each patient’s language impair. which has a number semantic. Jackson... the cognitive patients who have aphasia. and language tasks. or intention. and turn taking) down into duction. mediating variables or con- prehending sentences.. These are the cognitive processes or the complex determining causes. divergent thinking.g. ural. (Norms are available guage” (pp. liabilities of each patient so that the therapeutic effort is indi- vidualized to fit the needs. guage behavior within and by the organism”. decision-making. and evaluative thinking. and/or behavioral stimuli. symbolic. Therapy [is] work on divergent thinking and developed the Torrance Test directed toward the subsystems which process lan- of Creative Thinking (Torrance. The Test of Problem Solving (Zachman et al. INTERVENTION toon frames that can be most reasonably predicted from The present writer agrees with Martin (1979) that: the given frame. uation. systems. Chapey. 1990). symbolic. Schwartz-Crowley & Gruen. 1987. Task input is defined as figural.. and eval- cognitive semantic abilities. Normal functioning is the “efficient action and inter- belongs with a given group by virtue of common psycho. convergent thinking. Processing occurs of unpublished research instruments measuring aptitude and through the use of cognition. interaction of the cognitive processes which support language behavior”. Diggs & Basili. along with other tests from Guilford and Hoepfner (1971). semantic stimuli—to elicit the action of cognition. learning. right brain damage. . Chapey & Lubinski. & Scott. 1991. A cognitive approach to therapy is based on the belief that ment. Expression Grouping Choose one of four expressions that 1. structs responsible for language comprehension and pro- hailing a bus. 1977. This holds true for problem- intervention also may evaluate the specific language assets and solving. in children. and therapy is an attempt to Newton. Aphasia is a reduction in the efficient action and Chapey et al. have been used with Within the context of the present chapter. com. 157–158). convergent thinking. such as explaining inferences. Law & interaction of these processes. that necessitates the use of all five cognitive processes. types(s) of propositional language (H. and the manner in which each patient goes about functional communication is an active problem-solving task tasks (Byng. and intensive fig- these groups. We employ strong. ated in units. and eval- 1990. Output is gener- Hoepfner’s (1971) mental operations. classes (or categories). determining solutions. These In addition. 1979. because this type of each of those processes in detail (Byng et al. Cartoon Predictions Choose one of three alternative car. interests. . Edmundson. action of the cognitive processes which support lan- logical dispositions. reading aloud single words. The disor- Expressions Choose one of four expressions that indicates der is a “reduction of the efficiency of action and the same psychological state as another given expression. semantic. gesturing. Therapy is “the attempt to manipulate and to excite the Other Assessment Techniques action and interaction of the cognitive processes which support language behavior within and by the organism Torrance (1966) adapted Guilford and Hoepfner’s (1971) so as to maximize their effective usage . 2. and implications. or closed. and abilities of each per- Rationale son who receives such therapy. relations. For example. transforma- Clinicians who use the cognitive semantic approach to tions. 1986) to assess manipulate and excite the action and interaction of these abilities and impairments of specific mental operations in processes. cognitive semantic therapy advocates the their component processes and examine the functioning of stimulation of all five mental operations. 1974. uation. filling in a check. sions in different ways so that each group expresses a common thought. and behavioral stimuli—most fre- 1983). Indeed. events that happen in the brain.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 484 Aptara(PPG Quark) 484 Section IV ■ Traditional Approaches to Language Intervention Behavioral Tests problems in the language deficits in specific patients. processes or subsystems that process language are cognition. cognition. What is happening between the stimulus and the Other techniques for assessing cognitive semantic abili. Services’ Test Collection Department. answering negative “wh-” questions. clinicians may need to break tasks (e. Thus. which was developed to measure reasoning abilities quently. including performance on appropriate tasks. Several of these measures target Guilford and divergent thinking. controlled. memory.) Parts of this test. A more in-depth discussion of assessment techniques can be found in Alternate Expressional Groups Group pictured expres- Chapter 4. 1976. Kay. only for children. head injury as well as with elderly individuals (Braverman. and avoiding problems. cited in Head. operations are the intervening. also can be used with adults to assess specific memory. response is that the individual is using one or all of his or her ties can be obtained through the Educational Testing mental operations. convergent thinking. 1915) or errors made. feeling. most definitions of . memory. 1990) to derive processing is required for the comprehension and produc- hypotheses about the nature of the underlying processing tion of spontaneous language. 1966). 1983. . For example. “normal” individuals (Guilford. Schuell and colleagues spontaneous speech also involves what Noam Chomsky (1964) noted that the search mechanism is controlled by (1957. problem solving (all highly suggestive of all five operations. Chapey & Lubinski. and therefore. the Guilford SOI model has statistical valid- structures). to initiate such shifts. meaning structure may may solve problems and make decisions more effectively and be communicated. therefore. and per. Hughy five cognitive operations are viewed as essential components and Johnson (1975) state that language is used primarily for of problem solving). 1977a. Indeed. Many clinicians also use nervous system integrations (Wepman. all information for processing speech is not and use of knowledge may involve the use of the five mental present in observable behavior. involve the use of a broad search of memory storage. used as a synonym for creativity). 1964) or in the searching and scanning mechanism that The ability to produce functional communication or selects among many possibilities. convergent thinking. extensive use of pronouns. and uninformative. 1992. and to overcome obstacles to communication flow. Tasks that stimulate memory structure of the people involved in the communica. 1951). operations will focus on the essence of the aphasic impair- notes that communication entails the ability to switch or ment—that is. That is. 1994. decision-making model. instructions. and convergent. and the acceptance production of meaningful ideas and the elaboration of those of the distinction between deep structure and surface struc- ideas. recognition/comprehen- expressed in the sounds we hear and the words we read. 1983. Nevertheless. diver. the rich cognitive structures that make it possible to comprehend and produce sentences. Meaning often is not audible or that divergent production and evaluative production both visible. divergent.. For example. 1994). problem solving. and The fourth appeal of the model is that some individuals ambiguous referents. inability to produce the higher-level cogni- shift sets of reference as topics change. Our sion. and creativity (divergent thinking is information getting and giving. According to Chomsky (1957. ity. Understanding a message depends on the row search of long-term memory. 1967. ture. the acquisition words. language is an aid to commu. 1971). 1964). deep structure.g. there are extensive deletions. Therefore. Rather. These are the methods for pro- Accountability cessing utterances. ble to utter and comprehend sentences. nication. the audience (American Speech- Bolwinick (1967) indicates that the highest-level cognitive Language-Hearing Association–certified speech-language integrations are thinking (e. not necessary to mention. That is. are assumed to be known or to be relatively easy to discover The clinician attempts to manipulate the patient’s retrieval and. They suggest that appropriate stimuli are expressed—who did what to whom. The information- relationship. For example. surface structure frequently in individuals with aphasia (Chapey. It tells the meaning required to activate or reactivate patterns. the listener or reader must identify the rela. Guilford & Hoepfner. misleading. and/or evaluative thinking capacity to interpret sentences depends on our knowledge of (Chapey. tive integrations. Specifically. That is. Rather. Meaning is not directly operations in the model: memory. we learn methods of processing utter. require the use of all five cognitive processes. functional language. pathologists) at a workshop were asked to write short-term . The surface structure is the actual sentences processing model presented in this chapter hypothesizes that are spoken and written. Cognitive Despite the wide acceptance of the cognitive and pragmatic therapy therefore targets all five mental operations for the approaches to therapy in our literature. some relations a broad and narrow search of memory within the individual. and the mental operations have been proven to exist In everyday communication. 1988. deep and surface structure requires the use of all five mental operations. Research by such goals. and evaluative thinking). 1974. 1964) refers to as deep structure and surface struc. is deficient. 1994). Tasks using all five mental suasion. efficiently when they use a structured problem-solving. not everything we Another appeal of the Guilford SOI model is that it is a know about a sentence is revealed in the superficial string of model of learning (Chapey. strategy to aid the patient in making maximal responses. 1979). The entire structure is not communicated if the facilitate the patient’s reorganization and retrieval of lan- receiver of the information can already be assumed to guage. directing it to go to a specific address and bring ture. Both Cognitive therapy also is rooted in the observation that definitions reflect the fact that language and communication aphasia is a problem in language retrieval (Schuell et al. behavioral goal. We do not learn a set of utterances (surface In addition. Another definition.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 485 Aptara(PPG Quark) Chapter 17 ■ Cognitive Stimulation: Stimulation of Recognition/Comprehension 485 language and communication have components that are gent thinking. the stimuli presented foster the action of understand certain basic concepts. Deep structure specifies the basic relationship being out information. the entire model has been proven to exist in ances. Production of spontaneous. We have rich cognitive structures that make it possi. many intervention agencies and many government A third rationale is based on the observation that patients agencies mandate that each therapy session have an opera- with aphasia are unable to produce the highest-level central tionally written. tionships of the concepts to the events being communicated whereas cognition and convergent production involve a nar- or described. retrieval under a variety of cognitive operations appear to tion. that proposed by Muma (1975). or repeating what someone else New meanings find expression as individuals wonder.) rigidity. She maintains that problem solving. and in its purposelessness (Lindfors. used for communication. the priate. The real question fact that the speaker’s intent in producing an utterance and a is. p. a recital. 1975. brainstorming. fixed forms” (Lindfors. not . It is a tool. interactants as they have more opportunities to interact. but not at using fact that content and form are developed and used within the language and communication. the message across is more important for individuals than Individuals. . our clients may then use the language forms ment that focuses on meaning rather than on form. They ignore the fact that a conversation is like a to be the very base of language (Lindfors. According to language serves. Where in a language drill is the meaning that we know behavior. about something. (p. and writing with a purpose. operationally written objectives ignore the may make clients very good at doing drills. Lindfors (1987) claims. drill may adversely affect language growth and nicative competence “through discerning rules underlying retrieval. 518). (Lindfors’ text concerns language intervention in Drill is opposed to language in its meaninglessness. If we focus on tasks like labeling. one has achieved the purpose of the communication. the novel expression.) Instead. 1987)? 1980). Cognitive and pragmatic intervention a . goals. 518). dynamic interpersonal interchange” back as to whether one has been understood and whether (Holland. These agencies should realize that “language is not label. Behavioral objectives target remain something akin to a well practiced talent. argue. one else said” (Holland. inform. then. 311). (Holland. (Holland’s article Natural shaping of semantics and syntax happens not concerns language intervention in children. 1976). Talking (Cazden. . as a verbal communicator. In fact: Behavioral. . When we do so. Every creativity. that the individual uses and responds to. According to Lindfors (1987). . 1980. communi- cation is idea oriented. dis- the diverse interaction contexts which she observes and in cussing ideas. We use language to question. miss the will say the name of five common objects. lan. Thus. It involves a series of moves by participants. Getting that help them to accomplish effective communication. p. presenting which she participates” (Lindfors. not an end in itself. we continually communicate creativity (Lindfors. p. Without this discovery. the give and take of ideas. speak- Behavioral. 1980)? Where is the game. reading. . matching pictures to words. 1975. apart from meaning” (p. p. . discover his potential are unacceptable within both a cognitive model and a prag. and selecting the best ideas involve listening. Therefore. according to context of a speech act. recording ideas. “there is no language a communicative partner (Lubinski. 220) meaning that is intended (Cazden. X playing the piano. said. however. and life participation. 1987). 519) focus on meaning or deep structure.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 486 Aptara(PPG Quark) 486 Section IV ■ Traditional Approaches to Language Intervention goals for a moderately language-impaired patient. essence of language and that meaning is not an observable 218). through sequenced curriculum but. we attempt to increase the patient’s viability as guage. p. operationally written objectives are inappro- the back and forth. activities. 217). and reason through language in . Where is the communicating—the interacting with someone. through feed- guage is “an active. 1980. because they ignore the fact that meaning is the mindless parroting of rigid. in its children. agencies to realize that language is facilitated by an environ. ideas. planning. We use verbal utterances to express an Lindfors (1980): intention or function. request. This helps the [individual] . Indeed. Rather. become effective the form they use to do so. The intent of the message is become more effective communicators as a result of using the reason we communicate. ests. 1975. She believes that we Clinical aphasiologists may wish to encourage regulating need to focus on language use for effective communication. for some reason (Lindfors. not in surface structures. not word oriented. operationally written objectives ignore the ing. 1986). 518). operationally written objectives. We communication and meaning. They cerned with helping [the individual] . In cognitive-pragmatic Verbalizations must not replace language. part of him. Language “is communicating— Behavioral. are Language training must be to some very significant extent con- counterproductive to the development of language. is the individual a more effective user of language hearer’s intent in hearing an utterance are the essence of after completing an exercise or drill? The answer is no. not surface structures. Language forms are heard through the about forms doesn’t help you express meaning more effec- tively. Language is Lindfors apparently believes that it is inappropriate to rooted in meaning. More erroneous principle that language is a skill on the order of than half wrote goals such as “By the end of this session. Drill is not lan- intervention. Language intervention should reflect the individual’s inter- ing or matching pictures to words or repeating what some. 1976). rather.” point of communicating” (Holland. Language is structure a simple-to-complex sequence of forms. Drill Behavioral. the intention of what someone is trying to say ter “syntactic item labeler” (at least for a few days). language will matic model of intervention. the communication itself will determine the language forms Language is an aid to communication. Our attention as speakers and listeners is on the labeling syntactic (or semantic) items simply makes you a bet- meaning. The individual develops commu- Lindfors. . The intent is the function that language in communication with others. . concerns. then “we run the risk of inadvertently teaching the question. and inform. that is the core of language? conversation is altogether new for the participants. p. 1975. The general objectives are: 1987). process. 1975). OBJECTIVES OF THERAPY As human beings. 1987). ing new experience to the already known—that is. Our theory shapes how we look at past stimulate the five cognitive processes—cognition (aware- experience (recall and interpret it) and how we look at new ness/attention. learned cannot be specified in advance. conclusions during communication. with opportunities to Questioning is the individual’s most important tool for learn. that no one ever said or ever will say. planning. memorization). Thus. curiosity. To stimulate the integration of all cognitive operations As a profession. hension). drills. auditory stimulation is seen as an essential component of Conversation should be the locus. over and over again. and in planning. social custom. adequacy. We comprehend or interpret the world by relat. conventional discourse is seen (Lindfors. making understandings more precise. improve communication. 1985). brainstorm- 3. Guilford. It based on the rationale that individuals with aphasia should involves applying. awareness. divergent thinking. That is. 1987). decision making. discussion of ideas. convergent thinking. and problem responses during communication. we develop a theory of the world in our The objective of a cognitive approach to rehabilitation is to head (Smith. analyzing. and understanding. and facts have become ends in ideas and plans during communication.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 487 Aptara(PPG Quark) Chapter 17 ■ Cognitive Stimulation: Stimulation of Recognition/Comprehension 487 real-life situations rather than in contrived situations Content-centered discussion therapy and embellishment of (Lindfors. and reinforcement are essen- as language is used in questioning (curiosity and procedural tial components of therapy. compre- experience. in ideas within a topic (Wepman. recognition. Language is stimulated focus. or social-interactional questioning). To stimulate ability to generate logical information or ing. Lindfors. produce a quantity and variety of actively discouraged exploration. memory. the initial stage higher-level cognitive behavior. This suggestion is as a springboard for creatively solving new problems. 1988. however. regardless of tion they received (recalling. and using it comprehension. 1987). rules. Interaction is essential to both comprehension and 1. language retrieval in patients with aphasia (Schuell et al. definition. inferring from it. guage intervention (Warren & Rogers-Warren. immediate discovery. 1980. Language lives and grows in rich experiences. 1987). be provided. consistency. 1976) should be our decision making. To stimulate ability to recognize and comprehend lan- learning. something else. behaviors means increased emphasis on the use of lower-level cognitive processes (Lindfors. 1992. Emphasis on learning rote skills and specified sets of course to communicate more effectively and efficiently. and all so that individ- utility. modeling. problem solving. 1967. feasibility. Whenever possible. safety. focusing attention. decision-making. relating it to knowing. To stimulate ability to make judgments or appraisals or grams with a renewed emphasis on memorizing words. ing—especially curiosity questioning (Lindfors. exploration. themselves (Lindfors. Language lives in shared experience. and identifying parts of speech in sentences rectness. as the procedural plan for intervention. Lower-level cognitive This approach contains four levels of specific objectives. 1955). 1975). synthesizing. and evaluative thinking (Chapey. reinterpreting past experience. and evaluating. identity. to formulate evaluations in terms of criteria such as cor- defining words. recognition. 1987). and going beyond present personal experiences (Lindfors. making understand- General Objectives ings more retrievable. behavior means that clients can give back the same informa. To stimulate ability to generate logical alternatives to The present pressure to establish accountability has given information. the clinician might videotape a . In real gut-level. tification (Lindfors. completeness. This model of therapy. To learn is to alter our existing cognitive the stimulation of these abilities within the context of con- structure when experience does not conform to our theory versational discourse. suggests that. communication. and elaborate on solving. 1987). 4. 1972. they must go beyond the of intervention should focus on language-related cognition: given information in some way—for example. That is. hear and grasp the language behavior of others. and uals can get higher standardized test scores and move on to so forth to communicate more effectively and effi- the next-higher level of memorization. what is to be guage. To stimulate ability to fix new information in memory to characterized by curiosity. Whenever possible. 6.. but to display the level at which the patient is functioning. relevance. reorganizing it. Skills. meaningful learning. by placing and evaluative thinking—to improve overall functional new experiences in our existing cognitive structure or “the. Such learning is 2. immediate discovery. the focus should be on ory” (Smith. and facilitated by an environment that is rich in diverse ver- bal and nonverbal experiences. 1987). and goal of lan. our clients become competent communicators (Frattali. for example. We have packaged clinical pro- 5. Language helps us to comprehend and learn—especially turn taking. cueing. and iden- ciently. we are first and foremost concerned that through the use of problem-solving. and planning tasks and through conversational dis- 1992). Third. & eating lunch?” Concomitantly. Harris & Evans. Level I: Specific Objectives considering that Pieres and Morgan (1973) empirically To stimulate ability determined that a relaxed. forced for all listening and attending behavior. nent of the intervention strategy throughout the process of matching words to pictures. That at hand could be highly reinforced. level of the finding by Cooper and Rigrodsky (1979) that persons abstraction. with whom and under what conditions does language Exposure to the videotaped responses of others may behavior increase? The clinician may wish to manipulate prove to be a vicarious learning experience (Bandura & some of the following variables and observe their effect on Walters. and move toward To repeat one-syllable. Begin with simple classifications. linguistic complexity. Begin with clinician reinforcement. repetition and reauditorization. 1951. Jensen & Cotton. This exposure to the divergent semantic To be aware of time/space/speech/emotional voice tone behavior of others. Second. cognitive complexity. this way. aphasiologist will attempt to isolate specific conditions Although no verbal responses would be required during this under which language retrieval is maximized and to phase of therapy. objects To recognize very high-frequency. cueing aphasia. Begin with the tangible (here and now). perhaps filed in competitive “game To recognize stimulus equivalence. Level II: Specific Objectives 8. 1968). the clinician could attempt to choose tasks that are interesting and relevant to the particular subject. and move as “Can you think of a problem that anyone might have in toward intermittent reinforcement (Grant. such 9. such as matching letters. To stimulate ability . To remember one to two high-frequency. the stimulus (Staats. and move Memory toward the representational. Begin with the concrete. This suggestion appears to be in consonance with devices. If modeling is to occur. events named 4. it may be helpful to each cognitive operation should become an integral com- consider several facts. situation. matching objects to pictures. high-frequency objects/events/rela- reclassifications and multiple classifications. 10. Hake. referent. 5. the patient will identify below. and matching words to therapy. 1974)—and then gradually decrease this exaggeration. talking through a microphone or using a variety of To complete high-probability closure tasks inflectional patterns (McConnell. receptive. and move toward longer stimuli/responses. and frequency of occurrence of word subjects and improve their explanations of the material pre- stimuli. tionships 7. and move toward the complex. it may be beneficial if the sub- ponent of all subsequent sessions. for the patient or of the ear that result in a better auditory During the course of both diagnosis and therapy. it Cognition may be important to provide this type of climate for persons with aphasia. 6. and uncritical environ- ment increased the divergent behavior of normal subjects. with the person who is producing the divergent responses. and move toward the abstract. is. all verbal responses that relate to the task increase the number and variety of these conditions. 1968) of the videotape would be reinforced. First. Begin with the real. Begin with short stimuli/responses. Examples of specific jects on the videotape are of comparable age and sex as the objectives at each of the four levels of therapy are presented individual with aphasia. simple commands Intervention should be oriented toward the following tradi- To understand simple greetings/requests/questions tional therapeutic principles: 1. & Smith. and move toward movements of the eye that result in a better visual stimulus self-reinforcement (Staats. 1974) for the individual with patient behavior: listener. Begin with exaggerated sensory stimulation—for exam. Hornseth. To produce automatic language ple. intent. Begin with actions on objects. The conditions that augment semantic retrieval for sented. and move toward the complex. however. show” style (Torrance. To remember one to two letters/words/pictures 2. with aphasia are able to model the verbal behavior of normal length of stimuli. concrete objects/events/ relationships named Principles To recognize own name/family names To follow one-part. the patient could be rein. 1974). concrete objects/ 3. 1963. Specifically. intonation. Love. can continue to be a compo. Begin with continuous reinforcement. and move toward ver- Convergent Thinking balizations concerning these actions.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 488 Aptara(PPG Quark) 488 Section IV ■ Traditional Approaches to Language Intervention group of normal adults responding to a divergent task. matching objects to objects. Begin with the simple. 1960). and past /t/. height. tences informing. such as locative. such as requesting. possession. recurrence. To comprehend articles health. denial. feel- To recognize forms/letters/pictures ings. serially To understand television/movies To execute one. cooking. temporal. high-frequency. such as color. greeting. such as playing. To comprehend adverbs with “-ly” ture. clothes. and personal care tionships described by function objects To recognize letter/color/form/number names and rhyme To understand concrete.to two-step commands. denial. rejection. school. and activi. reflexive. and questioning To read and comprehend sequences of material To name members of categories To read and comprehend short paragraphs To list many words that start with a specific letter To read and identify main ideas . such as plural /s/. food. travel. length. possession.and low-frequency objects/events/rela- tion. width. and news To recognize high-frequency printed words and pictures To understand concrete speech acts. serially To comprehend inferences To remember one to four pictures. To comprehend prepositions. warning. possession. /ed/ To understand statements about events. temperature. such as personal. recurrence. questioning. such as existence. rejec- To recognize high. enter- To comprehend concrete noun phrases and verb phrases tainment. and superlative To talk about common objects. furniture. food. activities of daily living. and negative To name high-frequency objects/events/relationships To comprehend adjectives.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 489 Aptara(PPG Quark) Chapter 17 ■ Cognitive Stimulation: Stimulation of Recognition/Comprehension 489 Cognition To generate numerous and varied objects within a class To list numerous possible topics of conversation To recognize concrete. distance. age. furni. identifying main Memory ideas To remember one to three concrete. such as food. clothing. high-frequency statements about tionships objects. To comment on objects noting their existence. eating. time. high-frequency objects/ To distinguish between relevant and irrelevant information events/relationships. such as requesting.and low-frequency objects/events/rela- To understand concrete. interrogative. shape. To comprehend concrete active and negative phrases/ nonexistence. size. and transportation To comprehend conjunctions To comment on events. work. nonexistence. sports. personal care objects. concrete analogies Convergent Thinking To comprehend active and negative sentences To produce automatic language To comprehend pronouns. and protesting To hold the thread of discussion in mind. kitchen utensils. repeating. clothing. familiar objects/ events/relationships To recognize family names/body parts/community helper Level III: Specific Objectives occupations To recognize high-frequency objects given their function To stimulate ability To recognize high-frequency events described To recognize concrete. speed. high-frequency. describing. sentences attribution. taste. /z/. and activities of daily To recognize phonetically similar words living To recognize categories To comprehend concrete agent-action and action-object To comprehend concrete ideas/sentences constructions To understand relationships between words To comprehend concrete yes/no questions To understand statements about objects. brief ideas Cognition To comprehend simple conversation with one person To recognize high. such as cooking. locations /z/. high-frequency and low-frequency sen- To produce concrete speech acts. serially To comprehend short paragraphs To group items to facilitate ability to recall To recognize the existence of problems To recognize own errors and errors of others To comprehend simple. nonexis. To match high-frequency printed words to spoken words ordering. recurrence. advising. tence. and ties of daily living directional To produce agent-action and action-object constructions To read concrete. such as existence. brief statements words about events. eating. and family/other people/places/ To comprehend morphologic inflections. and so forth comparative. such as play. eating. possessive /s/. indef- To complete high-probability phrases/closure tasks inite. demonstrative. location. To recognize printed letters greeting. utility. degree. safety. sequential. yes/no. action-object. and antonym and synonym similarities/differences relationships To predict possible outcomes To comprehend negative. relevance. what. and question transforma- To make inferences and draw conclusions tions To answer true/false.to five-part directions and commands To remember one to five ideas/facts just presented Level IV: Specific Objectives To group items to facilitate recall To stimulate ability To remember meaning in sentences/short paragraphs/ stories/songs Cognition Convergent Thinking To comprehend high. To recognize concrete and more abstract classes/concepts ships To understand relationships among objects/events/ideas To name categories To comprehend analogies To name objects/events/relationships within categories To recognize problems To describe objects/events/relationships To recognize own errors and errors of others To tell the function of objects and the purpose of events To comprehend concrete and more abstract speech acts in To define words conversation with one to five partners To judge the suitability of class inclusion To follow changes in the topic of conversation To judge the similarity of relationships To hold the thread of discussion in mind and identify main To judge the suitability of class properties ideas To identify absurdities To understand changes in interpretation To evaluate implications To comprehend TV/movies To express simple ideas with specificity To comprehend more rapid. when. completeness. concrete words To read and obtain facts To read and locate answers To read and draw conclusions Divergent Thinking To read and grasp relationships To produce numerous logical possibilities/perspectives/ideas To read and draw inferences where appropriate To comprehend newspaper stories/ads To provide a variety of ideas where appropriate To comprehend catalog/mail-order forms To change the direction of one’s responses To comprehend a menu To generate categories of objects/events/relationships/ideas To comprehend a table of contents/index To predict many different possible outcomes of situations To use a dictionary/telephone directory . temporal. such as effect. identity.and low-frequency objects/events/relation. part-whole. spatial. cause- To state the relationship between objects/events.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 490 Aptara(PPG Quark) 490 Section IV ■ Traditional Approaches to Language Intervention To read and obtain facts To generate many different solutions to problems To read and locate answers To list many different problems inherent in situations To read and draw conclusions To generate numerous steps in a plan To read and grasp relationships To elaborate on a topic To read and grasp inferences To read street signs Evaluative Thinking To read newspaper headlines/newspaper stories/newspaper ads To judge the correctness. and To comprehend more complex/abstract relationships. logical feasibility. such where) details and the inferential implications as comparative. object-action. and Memory social acceptability of facts To judge the suitability of words to a topic To identify one to five names serially To follow one. possessive.and low-frequency objects/events/ To answer questions about self/family/everyday life relationships To name high. complex conversations To sequentially order ideas or topics toward a purpose To comprehend longer sentences/directions/commands To retell stories—both the literal (who. and “wh-” questions To read both short and concrete as well as longer and more To write letters and numbers abstract sentences/paragraphs To write own name and address To read and identify main ideas To write sentences with high-frequency. consistency. To describe procedures familial. adequacy. inferential. passive. allows reciprocal role reversal. because their opinion is being sought and valued. request. conversational turn taking. consistency. decision-making tasks. decision. and social-interactional). such as similarities and differences To produce analogies Within the present therapeutic approach. it also often will To make inferences and draw conclusions involve the use of other mental operations and become To write high. that involve composite abilities. To tell the literal (who. fre- To list many different problems inherent in a common situ. because they are com- To produce class names for groups of words/pictures posite operations or processes depending on the content of To logically deduce the most predictable outcome of a set of the problem. discussing. sentences. sometimes is convergent in nature. such as the use of speech story acts. safety. paragraphs depending on the listener. To define many possible rules for communicative partners procedural. and social To cluster information to facilitate recall acceptability To judge the intent of messages Convergent Thinking To judge the coherence of a conversation To judge what can and cannot be said in different contexts To describe high. To produce numerous logical possibilities and perspectives In addition. question. comparisons. and decision making in nature. such tasks reflect “real-life” situations that To stimulate ability to generate many different uses for com. and comprehend Divergent Thinking such speech acts. inform. all five mental To sequentially order ideas toward a purpose operations are integrated in therapy by requiring responses To use language to request. reinterpret past experience. To predict many possible outcomes of a situation The use of such tasks is conversational in nature and. explain. These tasks therefore ation can be used to stimulate brainstorming. and the intent. relevance. topic . wonder. recording To think of many different ways to initiate a conversation and presenting ideas. and negotiate ning. Individuals can be stimulated to use language to question. and To think of many different ways to repair conversation go beyond present personal experience. logical feasibility. planning. inform. In addition. when. make and communicative contexts understanding more precise. greet.and low-frequency what is said and what is meant objects/events/relationships To determine the meaning of proverbs To specify attributes of objects To judge a situation in which a proverb could be used To specify the defining attributes of concepts To select the word that best fits a single criterion To define words To select the best of given reasons why a briefly described To express ideas clearly and with variety plan is faulty To use language to communicate specific ideas To use language to elicit specific responses To express relationships between and among objects/events/ Integration of the Five Cognitive Processes relationships and ideas. order. focus attention. and formulate evaluations To remember meaning in sentences and paragraphs regarding correctness.and low-frequency objects/events/rela- and to different partners tionships To use context and partner variables to decipher between To indicate the function of high. or conversation and on how the facts problem/decision/conversation is worded or phrased. Thus. thank. To use hierarchical organization to facilitate recall utility. patients face—or can allow patients to increase their self- mon and uncommon objects concept. They also To think of many different ways to maintain a conversation can be used to stimulate individuals to question (curiosity. Problem solving. plan- advise. quently. the context.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 491 Aptara(PPG Quark) Chapter 17 ■ Cognitive Stimulation: Stimulation of Recognition/Comprehension 491 Memory To elaborate on or list many different steps needed to do a particular task To remember one to nine high. and problem solving. argue. and conversational interac- To keep meaning going in conversation tion are excellent for this purpose. If To change the direction of one’s responses carefully chosen. what. con- To elaborate on topics versational management.and low-frequency objects/ events/relationships/categories To remember facts and commands of increasing length and Evaluative Thinking complexity To make appraisals. completeness. formulating solutions to problems posed in where appropriate the “Dear Abby” or “Dear Meg” column of the local news- To provide a variety of ideas where appropriate paper can be used to stimulate all five cognitive operations. adequacy. and where) details of a whereas conversational interaction.and low-frequency words. reason. and selecting best outcomes. however. evaluative thinking. and indicating agreement/dis- 17-2). intervention should involve • To stimulate ability the stimulation of two or three (or more) mental opera- • To use language to explain. Most traditional workbooks legal and money issues.” All of these vice. such as those described by Aurelia (1974). interesting sights. events. tions. Butfield • To select. patient has been able to retrieve. and a television therapy. and relationships Spontaneous language tasks that have divergent. “Can you • To keep meaning going in conversation think of any more?” (Table 17-2). advise. Use of Composite Abilities Thus. Vignolo (1964). thank. Goldstein (1948). thinking. Modern Maturity. to stimulate • To use language to discuss objects. and pharmaceutical in the field of aphasia have presented tasks that stimulate issues (the American Association of Retired Persons’ maga. vacation tasks can be readily used to stimulate specific mental (cogni- destinations. great parks. the clinician then uses convergent tech- else) during communication niques. creating sentences with a word. maintain. For example.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 492 Aptara(PPG Quark) 492 Section IV ■ Traditional Approaches to Language Intervention manipulation. the aphasiologist attempts • To overcome obstacles in communication to transfer the semantic material retrieved in the conver- • To repair and revise communication gent context and integrate this information into a divergent • To use cues as a signal to repeat or modify messages one. and/or evaluative components also are used in • To use a telephone directory. When the client has fin- • To role play (especially to take the viewpoint of someone ished responding. and encourage the client to produce as many responses as possible (see Yorkston & Beukelman. introduce. or (c) the • To produce stylistic variations to meet situational require- use of an incorrect associational response to cue the correct ments verbal response. the • To overcome obstacles in communication clinician summarizes these responses and asks. and change the topic of and Zangwill (1946). Clients also can be encouraged to produce func. oral spelling. nutrition. such as the pros and cons of ideas and issues. solving. Guilford and Hoepfner (1971) developed a number of tasks tional spontaneous communication related to a specific for each of the five mental operations. “Can you list all of the things that can be • To comprehend speech acts produced by another folded?” After the patient has produced some responses. and conversational repair management can be Levels III and IV: Specific Objectives to Stimulate targeted using these tasks. request. restaurants. sexual issues. objects. recognition naming. Alternative stimuli • To comprehend various speech acts and intents in rela- for self-cueing might include (a) the first phoneme of a tionship to various partners and contexts word. . Schuell and colleagues • To initiate and maintain conversation (1955). such as those suggested by • To vary language depending on the context Berman and Peelle (1967). workbooks have been published that focus on the stimula- the clinician records the number and variety of ideas pro. For example. as listener. correct information. con- • To use a telephone vergent. For example. In each instance. reading. Keenan (1975). 1976). conversation Sarno. Such techniques might involve confronta- • To use language to elicit specific responses tion naming. events. THERAPY TASKS AND MATERIALS 1977). current events. such as “Can you think of requesting that the message slow down. Progress is evaluated by keeping a record of the agreement with message number and variety of responses produced by the patient • To define the problems and solutions inherent in certain (Table 17-2). Subsequently. and relationships retrieval of appropriate and desired responses that the patient • To use language to communicate specific ideas had not produced. (b) the association of a word with a gesture. Silverman. health and diet. and Wepman (1953). have been listed previously under “Assessment. provides interesting and timely top. and patient’s ability to correct his or her own errors. In an attempt to develop each the advantages and disadvantages of certain actions. and Sands (1970). requesting the all of the things that we could pull over our heads?” (Table message in alternate form. a dictionary. tive) operations during therapy. the initial letter of • To vary language depending on the partner a word could be used as a cue technique. Within the last few years. perspectives. whenever possible. cat- • To use language to verbalize a variety of possibilities and egorizing similar responses. argue. Some of these tests theme (Wepman. a number of ics for the audience age 50 years or older). 1972). and decision making. greet. the clini- ideas cian may use cueing techniques. and so forth (Table 17-2). food ser. such as question that would call for some of the responses that the requesting message clarification/repetition/restatement. the clinician might begin a session by report. the clinician might present a picture schedule item description task. problem duced by the client. tion of divergent thinking. such as the cookie theft picture from the • To use street and store signs and maps Boston Diagnostic Aphasia Examination (Goodglass & Kaplan. such as food. and negotiate asking the client. For example. cognition (recognition/comprehension) and convergent zine. the clinician might ask another divergent • To provide feedback to the speaker. question. social security. How could you improve ___ Same as above 5. 1. Score as in question. 5. he Same as above 6. string. (a) List responses related to a holiday. more fun)? 6. List all of the things that you Same as above 4. Score as in question 1. (continued) . If Santa lost his belt. What are all responses given and ask. could possibly use a Christmas box for (or bells. Score as in question 1. Score as in question 1. We’re coming close to After 2 minutes.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 493 Aptara(PPG Quark) Chapter 17 ■ Cognitive Stimulation: Stimulation of Recognition/Comprehension 493 TABLE 17–2 Sample Therapeutic Plan That Includes Both Divergent and Convergent Tasks Objective Tasksa Cue Evaluation General—to stimulate the Greeting communication of ideas Divergent Tasks Specific—to stimulate language 1. summarize 1. he could use ___. Can you think of all of the things that could fit into Santa’s sack? 3. Someone mentioned that Same as above 2. ribbon). so that it would be more useful (better. What are all of the things Same as above 3. If Santa didn’t have a sack. _______________ Christmas. Santa carries a sack. through of the things that you think “Can you think of any _______________ divergent and convergent of when you think of more?” Total fluency thinking Christmas? _______________ (b) List categories _______________ _______________ Total flexibility _______________ 2. Score as in question 1. Christmas. we might get for Christmas that: Could be folded? Couldn’t be folded? Might break if they were dropped? Wouldn’t break if they were dropped? We could wash? Could be hauled in a truck? We could pull over our head? Might have buttons? Could be worn in summer (winter)? Could be made of paper? Could come in a box? Could be round (square)? Are made of glass (plastic. rubber)? Someone could drink? Someone could eat? Has handles? Has a neck? Moves? 4. could use ___. GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 494 Aptara(PPG Quark) 494 Section IV ■ Traditional Approaches to Language Intervention TABLE 17–2 Sample Therapeutic Plan That Includes Both Divergent and Convergent Tasks (continued) Objective Tasksa Cue Evaluation 7.) Responses that might be appropriate Give first sound of a word Use Porch’s (1971) to this question but that were not multidimensional given by the patient are now scoring system to presented. Score as in question 1. What do you think might happen? Can you guess? 13. Let’s make up a story about Same as above 8. Score as in question 1. responses to question 2. Score as in question 1. Imagine you are in a Same as above 7. What are all of the things that you might possibly see? 8. evaluate responses . then question 3.” What other words can you think of that start with “k”? The word bell begins with the sound “b. someone might have in shopping for a Christmas present. What are all of the possible Same as above 10. Christmas party. Christmas. Oral and/or visual representation of responses can be used. List all of the different parts of Same as above 11.” What other words can you think of that start with “b”? 10. Can you list all of the things that could be used to make noise? 15. List all of the problems that Same as above 13. What are all Same as above 15. and so on. Score as in question 1. Santa’s suit. can be presented. Tomorrow we will have a Same as above 16. Score as in question 1. The word Christmas begins with Same as above 9. Score as in question 1. They make noise. Someone mentioned a cymbal Same as above 14. 9. of the other things that could be red? 16. questions that you could ask about this Christmas picture? 11. 14. How could we change each one to make it better? 12. and a drum. Score as in question 1. Score as in question 1. (Later. Suppose that we did not celebrate Same as above 12. department store (church. the sound “k. Score as in question 1. Score as in question 1. Santa’s suit is red. living room) at Christmas time. What are all the different things we’ll need to do before the party? Convergent Tasks Present responses given to question 1. Christmas anymore. 1976). For example. the inaccurate verbal formulation of the person with communication relates to the approximated rather than to aphasia may feed back an altered message to the thought the intended word. word.” his or true feelings and thoughts. RELATIONSHIP OF COGNITIVE INTERVENTION square. concept of circle may change so that it agrees with the utter. thereby. In addi. in which the patient is . For Wepman (1972.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 495 Aptara(PPG Quark) Chapter 17 ■ Cognitive Stimulation: Stimulation of Recognition/Comprehension 495 TABLE 17–2 Sample Therapeutic Plan That Includes Both Divergent and Convergent Tasks (continued) Objective Tasksa Cue Evaluation Convergent techniques that might Give first letter of a word be used to stimulate retrieval of Give semantic association items not produced are: a) Confrontation naming b) Definition naming c) Closure naming d) Recognition naming e) Repetition naming f) Following oral and/or printed directions or commands g) Yes/no comprehension h) Word associations: antonyms. rather than to the intended. and ask questions x) Read a story. change the thought process so that it is impaired. When the remainder of the person with aphasia’s tion. and the patient will begin to think of a circle as a content-centered. and reinforcement are essential components of therapy. and retell a story y) Role play a Turn taking. synonyms i) Rhyming j) Description k) Recognition spelling l) Oral spelling m) Analogies n) Recognition of categories o) Spontaneous generation of categories p) Concept learning q) Reading r) Writing s) Copying t) Creating sentences with words u) Creating sentences telling the function of an object v) Memory tasks w) Read a story. instead. utters “square. 207). spontaneous language will be even more process and. if the patient pable of using the learned code to communicate his or her is trying to say “circle” and. because in this instance. and that the remainder of the ical symbol for a context are impaired in their ability to com- individual’s communicative effort often relates to the municate a number and variety of specific propositional approximated. modeling. the first stage of therapy is ance. ideas. the patient becomes inca- in consonance with the utterance. cueing. substitutes a word that is associated with the word that he or Individuals who cannot retrieve the most appropriate lex- she is attempting to produce. discussion therapy. Wepman suggested that aphasia may be a thought process disorder in which impairment of semantic expres- TO WEPMAN THOUGHT PROCESS THERAPY sion is the result of an impairment of thought processes that Wepman (1972) notes that the aphasic patient frequently “serve as the catalyst for verbal expression” (p. people. Both had reservations about how practical and forcing attempted elaborations and then modeling sentences that combine initial and all subsequent responses to a given advisable their involvement might be and about the reaction stimulus picture. both were active in the local church. Before the stroke. & skills (Tables 17-3 and 17-4). emphasis is on shaping and chaining client-initiated responses. reasonable meals. pleasure. Therefore. (4) rein- shopping).GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 496 Aptara(PPG Quark) 496 Section IV ■ Traditional Approaches to Language Intervention stimulated to remain on a topic. Throughout this sequence clients’ responses are not directly Life-enhanced participation governed management from corrected by the clinician. cognitive therapy aphasia. valued activities of everyday life pro- over stimuli and response during therapy by using client. and evaluative thinking as well as Communication creates and is created by life participation. friends. family. beaches. associated with them were being hindered in the attain- number of content words) generated by individuals with ment of such goals . the initial variety of responses to the same stimulus picture (flexibility). forced. various life-span Yedor. and settings was reported. encouraged to generate functional communication and pro- duce a variety of ideas related to topics. divergent. direction. goals were: Novel and varied responses are encouraged.. aphasia. 1991. day 1 (Tables 17-1 and 17-2). activi- ties. with a left cerebrovascular Informational content rather than linguistic form is rein- accident and right hemiplegia who lives with his wife. recognition/comprehension and memory. Thus. RELATIONSHIP OF COGNITIVE INTERVENTION individuals are encouraged to elaborate on various topics. and life partic- TO RESPONSE ELABORATION TRAINING ipation decisions and problems of each individual affected by aphasia. 3 months poststroke. meaning. meaning. Patients are encouraged to elaborate (think divergently) on “whatever they are reminded of” when Case Study they are responding to picture stimuli of everyday activities P is a 67-year-old. the individual is stimuli. mild to moderately impaired man with and sports. T. priorities. vided the structure and meaning for living life (Duchan. originality. RET is being of all individuals. The main goal was to restore vided during the structured interactions through conversational purpose. The 1999). comfort. and elaboration— • To determine the extent to which P and T and persons or divergent semantic thinking as well as functional sponta. and pleasure in the modeling. Such life participation necessitates the use of Response elaboration training (RET) is a program devel. (2) modeling ing church-sponsored event—a trip to Atlantic City (famous and reinforcing initial responses. the Life Participation Approach to Aphasia (LPAA) model directs our choice of goals. according to Kearns (1990). needs. APHASIA Thus. they had not returned since P’s stroke. Indeed. Further. 1976) second stage of therapy. Kearns. initiated responses as the primary content of therapy. (6) reinforcing repetitions of combined Goals sentences and providing a final model of the sentence. theorists emphasize the importance of social integration and 1991) to increase the length and information content of participation for the physical and emotional health and well- verbal responses of patients with nonfluent aphasia. effective and efficient problem-solving and decision-making oped by Kearns (1985. Instead. and neighbors to communicate ber of content words per stimulus picture (fluency) and the more effectively with both individuals. ticipation goals Kearns’ (1990) data demonstrate that RET procedures • To determine the extent to which P and T and persons facilitate an increase in the amount of information (i. Kearns & Potechin. RELATIONSHIP OF COGNITIVE INTERVENTION direction.e. Therefore. such participation in mun- a “loose training” program that attempts to loosen control dane yet meaningful. (3) providing “wh-” cues to for its gambling casinos. see also Gaddie. During Wepman’s (1972. naturalistic feedback is pro. and prompt clients to elaborate on their initial responses. Wepman’s thought process therapy involves stimulat- ing convergent. TO LIFE PARTICIPATION APPROACH TO The ability to elaborate on a topic is a divergent ability. Both reported feeling The basic RET sequence entails (1) eliciting spontaneous isolated and cut off from life and wanted to go to an upcom- responses to minimally contextual picture stimuli. 1988. 1990. flexibility. Naming and describing are discouraged. In addition. but Specifically. that combine previous responses and then requesting a repeti- tion of the sentence. daily lives of P and T by facilitating their access to commu- nication partners and events of their choice and to train Progress during RET is measured by counting the num- caregivers. and strategies used in intervention to the purpose. associated with them could partake in and achieve life par- neous speech. RET stimulates fluency. (5) providing a second model of sentences they might receive from others. Similarly. which necessitates all five mental operations. Kearns & Yedor. comfort. a moderate degree of generalization across is content centered and idea oriented. purpose. Most therapeutic tasks were problem- Toward activity? solving. problem-solving. PACE (Promoting Aphasic Commu- nicative Effectiveness) therapeutic techniques (Davis & . however. travel brochures. thoughts. props. 1993) making approach model for P and T and to encourage Interactional (sharing ideas. purpose. decision- Communication function (Simmons. In medical context convey a message using whatever strategy might be useful Degree of life participation (e. Quality of daily life Feelings of self-esteem Methods Feeling of being in control of one’s life Level of flow in one’s life The upcoming trip to Atlantic City appeared to be an attrac- Analysis of specific life events (Duchan. 1999) tive initial target of intervention. to encourage use of graphic and drawing representa- In life events tions. decision-making. and more autonomous access to activities and social con- Degree of comfort Function nections. RET (Kearns.. and life and Self-Reported—With and Without Support participation • To identify and facilitate attainment of the needs and Identity goals of all individuals in the environment Autonomy of life participation • To increase/maximize P’s ability to initiate and direct con- In social context versation/discussions. role-playing tasks focused on the Toward their partners? five mental operations. Count of number of people seen to provide communication/conversational support. general improvement also made use of Wepman’s (1972. conversationally based interactions Transactional (transfer of information) Verbal. comfort.and Post-Therapy Questionnaire for Life pation in life Participation/Communication: For the Person with • To identify and decrease personal and environmental Aphasia and Significant Others. eas- Ability to cope with impairment ier. convey a number and variety of In family ideas across (with or without prompts. 1993). gestural. both because it meant so Participants: Who is participating? much to P and T and because it focused on doing things that Goal: Why are they participating? result in communication as participation rather than on Type of interaction: What is the type of social interaction communication itself.g. Every attempt was made to have consumer- Involvement based/self-generated rather than clinician-generated goals Pleasure and activities and to provide autonomous choice whenever Success possible. Ability to communicate independently Goals were constantly assessed. for social connection. pictures. and prioritized to Personal competence revealed determine which personal and environmental factors should Impairment (and changes in) be targets of intervention and how best to provide freer.g. With other people Relationships and books). conversational prompting Perception of (and changes in perception) (Cochrane & Milton. natural gesture. Both Observational obstacles disrupting harmony. to train partners/com- Of activities munities in these techniques to use volunteers as conver- Environmental barriers (and changes) sational partners Changes in social connection • To provide and demonstrate a problem-solving. intervention focused on required? developing strategies and skills to increase the possibility of Part of activity: What part of the activity are they engaged in? success directly related to reengagement/participation in Attitudes: What are the attitudes of the participants: the upcoming event. cued decision-making. and 14). Therefore. and partici- Pre.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 497 Aptara(PPG Quark) Chapter 17 ■ Cognitive Stimulation: Stimulation of Recognition/Comprehension 497 TABLE 17–3 • To identify and increase personal and environmental fac- tors facilitating harmony. When appropriate. weighed. Verbal. and cues). and practice conversational skills within the Value as participant context of conversational exchanges Role • To focus on conversation as a collaborative achievement. 1984). comfort. 1976) content-centered in sense of well-being) discussion therapy (see above).. conversational coaching Health-care worker (Holland. and opinions) them to structure theme-oriented. gestural. 1991). therapy Toward goals? Expectations (e. and Of places when appropriate and necessary. training of conversation partners (Kagan Family & Gailey. cued using the five mental operations. 1985) (see above as well as Significant others Chapters 1. menus. relationships. collaborative process that responds to the significant. family. harmony. Consumer satisfaction dynamic process that requires time and skill Recognize and recalibrate the psychological effects that aphasia has on personal. and renegotiated to decrease the devastating negative consequences of aphasia. Wellness. assistive. immediate. attitudinal. and role definitions Promote healthy psychological adjustment to grief and stress associated with the changes imposed by aphasia Facilitate the development of self-actualization. purposeful life participation. and choice of lifestyle and activities Increased meaningful ties to others Facilitate optimal inclusion in and meaningful. happenings. purpose. social. weighed. Focus on conversation—and on conversation as a collaborative achievement Foster reasons to communicate Strive to enhance level of participation in conversation Promote abilities/opportunities: To communicate to maintain social relationships To communicate in natural. dynamic. Outcomes are measured qualitatively and quantitatively. Communication is flexible and dynamic. increasingly empowering those who receive it to be responsible for their own care. caregiver. promote health and wellness. Communication is inseparably bound to people. places. and well-being in the lives of all those who are affected by aphasia. and sense of well-being in daily life Mastery of environment Encourage optimal mastery of daily life events Encourage and facilitate support from significant others to optimize meaningful. Such goals are estab- lished collaboratively and are constantly assessed. Enhancement/Inclusion Strategies to Facilitate Meaningful. and self-advocacy skills Recognize and reduce negative internal barriers that decrease or prevent individuals from actively participating in life Reflect the curative factors in group work and the healing power of intimacy Increase feelings of harmony/well-being and quality of life Reflect that: Communication is a medium through which humans share life’s experiences. Functional. and train partners and communities in these techniques Work to reduce impairments while focusing on revealing competence/function Work to reduce impairments in the context of reducing barriers to life participation Relate functional communication to environmental factors as well as impairment Increase continuity and access to interventiona a Intervention is a consumer-driven. and outcomes as well as ideas and feelings about them. advising. self-assertiveness. and purposes for its use and that com- munication creates and is created by participation in life. autonomy. structural. purposeful life participation Self-acceptance Recognize and remove environmental. foster adaptation to change. and close friends Facilitate the restoration of function. purpose. Communication creates and is created by participation in life. purposeful life participation Purpose/direction Encourage and facilitate support for significant others to optimize meaningful. places. and Quality of Life: A Plan for Action Goals Outcomes Foster optimal meaningful. and informational barriers that Harmony/well-being limit or prevent participation in normal social and community life Increase community resources that support life participation Wellness Work to build protected communities where individuals are valued participants Quality of life Enhance psychological adjustment. and purposes for its use.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 498 Aptara(PPG Quark) 498 Section IV ■ Traditional Approaches to Language Intervention TABLE 17–4 Reengagement. and increase meaningful social participation. when appropriate and necessary. and collective identities as well as on self-esteem. . and long-term conse- quences that aphasia imposes on the flow of daily living and recognizes both that communication is inseparably bound to people. Well-Being. pleasure. authentic contexts and social units or dyads To communicate to transmit information To communicate basic needs Empower individuals to demonstrate or reveal communicative competence and acknowledge such competence Work to increase ability to communicate independently Provide communication/conversational support. and foster a healthy sense Communication effectiveness of identity through life participation Reflect the fact that adaptation to the changes brought about by stroke is a complex. prioritized. Optimal Access to Participation in Life. interactive. empowering. comfort. It is a process that evolves and changes over time. All intervention goals reflect the complexity of aphasia and the multiple contexts that it affects. direction. purposeful connection to social and community activities/life Encourage strong social connections with people who matter. such as spouse. and communication consequences. • What are all the possible things that we could change in S  SUMMARIZE the main idea. gardening). as suggested by Boyle and meaning to our daily lives? Coelho (1995). and the home care nurse attended two meet. impairment-centered. (2) • What are all the ways that the trip to Atlantic City relates using very specific language. shopping. as devel- • What are all the things that can possibly lead to comfort oped by Norris and Hoffman (1990). (13) questions and • What are all the things we could possibly think of to plan comments. and predict. 1995).GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 499 Aptara(PPG Quark) Chapter 17 ■ Cognitive Stimulation: Stimulation of Recognition/Comprehension 499 Wilcox. Interaction with Patient and Spouse skill-level work. and for restorative. (1991) was used to facilitate comprehension of and memory cussed the language. In addition. their families. such as those discussed below. (16) requests for repetition. August 24. (9) self-talk. productive activity: cooking. and pleasure in our lives? For example. (12) sharing personal reactions. and social consequences for content for stories: of aphasia. The POSSE strategy suggested by Englert and Mariage ings in which they viewed the video What Is aphasia? and dis. (14) predictions and projections. • What are all the things that we can do to decrease the volunteering. same questions as above. and • What are all the things we could possibly need to consider (17) concept formation. (6) restating or rewording what was said. 1999. (11) semantically contingent • Who are the possible participants in the group? remarks. make functioning (including communication) in a bus dif. and cueing/retrieval feature analysis. level of this difficulty? Questions relating to divergent thinking in relation to • What are all the things that we can do to increase our (our this article include: partner’s) communication success/failure? • What are all the things that communication partners can • What are all the things that people can possibly do to live do to help someone be more successful in getting his or longer? her ideas across? • What are all the ways that you could possibly apply this information to your everyday lives? In addition. both partners discussed some of the and thematic stimulation therapy (see Chapter 16). other tasks. (4) nonverbal responses. S  SEARCH the STRUCTURE (draw the structure out ficult? schematically). and their communities? (Lyon. (7) summarizing and integrating. compare. direction. • What are all the environmental factors that will make For example. social activity. alerting to topic initiation and change. the therapist led the group in a discussion • What are all the personal and environmental factors that and modeled strategies for facilitating communication. (8) negation or indi- Pre-Trip Questions cating how and why what was said is untrue or unclear. (5) • What other things can you think of that relate to this article? verbatim repetitions. Experts Suggest” ficult? (New York Times. Sample tasks under the five mental operations P  PREDICT what ideas may be in the story. clarify. 1994. the environment to make communication more successful? E  EVALUATE. included: O  ORGANIZE your thoughts (What happens? Where is • What are all the possible environmental barriers that will it? What does it look like? Main idea?). and meaning in the lives of P and T? edgments or confirming the truth value of an utterance. (15) requests a trip to Atlantic City? for repair or clarification. several participants of the upcoming trip. such can increase (and decrease) life participation for individu- as those suggested by Simmons-Mackie. • What are all the things that add purpose. the communication consequences dis- • What are all the things we can do to restore the purpose. psychological. F8) might be about and • What are all the things that we can do to increase the what the author might possibly mean by the word “busy. the patient and spouse were asked to predict functioning (including communication) in the casino dif- what the article “Stay Busy.” chances of communication success in this environ- Later. in planning a bus trip? . p. sense of pur- communication more difficult than individual communi- pose = live longer) and other ideas around it (physical activ- cation? ity. cussed by Norris and Hoffman (1990) include (1) acknowl- direction. 1981). both stimulation therapy (see Chapter 15) During intervention. interactive drawing als with aphasia. the patient and spouse were asked to draw a picture ment? of the information in the article by putting the main idea in • What are all the environmental barriers that make group the middle of the page (stay busy = live longer. Live Longer. (3) extensions or adding new to this article? ideas within the same topic. were used with the partners. Education Comprehension and Memory The church social committee. (10) parallel-talk. next. . except. getting to the bus.) beach/boardwalk. objects. since. in case. if-then. and on the way home)? • Temporal (and then. . locations. which was on . first. swim. or . • Causal (because. . until he got to. in the restaurants. They included: to Atlantic City with a church group (e. go shopping. and informational obstacles that limit or prevent • Adversative (but.) • What are all the possible environmental/structural. restaurants. while .) • What are all the possible things we might be able to do to • Spatial (in. First. banking. or relational information these problems? • Summarization or Evaluation to give the individual a • What are all the possible ways to cope when we have a second opportunity to communicate problem? • Binary Choices to offer alternative utterances • What are all the things we can possibly eat in Atlantic • Phonemic Cues to offer the initial sound or syllable of a City? target word • What are all the possible foods that someone can eat in a In addition. in order to . so. personal care. .g.) participation in a trip to Atlantic City? • Conditional (of. actions. next to.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 500 Aptara(PPG Quark) 500 Section IV ■ Traditional Approaches to Language Intervention • What are all the things you can think of about Atlantic • What are all the things we should eat to be healthy? City? • What are all the things we should not eat to stay healthy? • What are all the things you can think of about the Jersey • What are all the things that we can bring to Atlantic City Shore? that can be folded? Cannot be folded? That someone • What are all the things you might possibly see in Atlantic could drink? That someone could eat? City? • What are all the ways that someone can get to Atlantic • What are all the possible things that someone might bring City? with him or her on a trip to Atlantic City? • What are all the things that could fit into a bus? • What are all the possible things that someone might do • What are all the possible places that someone can go by bus? (participate in) in Atlantic City (e. the semantic feature analysis developed by restaurant? Boyle and Coelho (1995) was used. . • What were all the possible benefits of going on the trip? and medical)? • What were all the possible benefits of being members of • What are all the safety rules we might possibly follow on the group? a trip (to Atlantic City)? • What are all the feelings that you have about the trip? • What are all the topics someone could possibly talk about • What are all the positive things that happened on the trip? on a trip? • What were all the problems that occurred that we did/did • What are all the possible ways that someone can be a good not anticipate? conversational partner? • What are all the ways we could possibly have anticipated • What are all the things a good citizen should do when he them? or she goes to a new place? • What are all the ways we could possibly have solved them • What are all the things we could possibly change that or coped with them? could increase our ability to go on these trips? • What are all the ways that we (or others) could have been • What are all of your strengths that will make this a suc. This technique prompts . • What are all the possible activities that we can attend nightclubs.) avoid these problems? • Contingent Queries or “Wh-” questions to prompt for • What are all the possible ways we could solve each of agents. except that . sightsee)? • What are all the possible things we need to take care of Post-Trip: Consumer Satisfaction Questionnaire before we go to Atlantic City (e. at the • Additive (and . . walk on the board. . . .) dinal.. better conversational partners? cessful trip? • What are all the things we did before the trip that made • What are all the possible things that someone can do to the trip more successful? make a trip successful? • What are all the things we did that gave us a feeling of con- • What are our weaknesses that could possibly hinder you nection with others? A feeling of comfort and harmony? from having a successful trip? • What are all the things we could have done to have made • What are all the possible community resources that some. and when. attitu. . through the church? walk. go to the beach. in the shops. in the casinos. after. the trip more successful? one could use in preparing for a trip? • Who are all the possible people who might be able to help Memory us make a trip more successful? To facilitate P’s memory. • What are all the things that could possibly restrict your the scaffolding techniques or prompts suggested by Norris access to a trip to Atlantic City? and Hoffman (1990) were used. several strategies were used. . on the bus... however.g.g. . These included various • What are all the possible problems we might have in going prompts to cue P for more information. unless. so that’s. Describe this picture of “Taj • ASSOCIATION: spending..g. Should I ask the waitress to tell me • Sentence Arrangement of scrambled sentences for tar.g. travel • Identifying places and activities brochures from the chamber of commerce.. shiny.” P needed to identify the following: • Using social greetings • GROUP: money. • Event description (e. directories.g. cross out the • Which game is easier to play: the slot machines or poker? word on each line that does not belong) • Because the trip is in August.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 501 Aptara(PPG Quark) Chapter 17 ■ Cognitive Stimulation: Stimulation of Recognition/Comprehension 501 the individual to identify the specific features of target pic. p. A1 and A11]. or start to play myself? • What can I do when someone doesn’t understand me? • The sign says “Wet floor. Which should I do first: Watch others play. pp. Rearrange these words • Which is more important for a pay phone call: a quarter to form correct sentences: Atlantic City are we to going. F8]) • Using core vocabulary words • Reading short stories about gambling. impairment-level recognition and under. the casinos. menus. “Ruling in Atlantic City—We’re going to Atlantic City) California Crimps Indian Plans for a Casino Empire” • Closure tasks (e. August. For example.g. 1999. • Answering questions about reading material or videos and the AAA • Barrier tasks • Comprehending the video What Is Aphasia? Skill/impairment level convergent tasks included: • Comprehending the video Casino • Comprehending other videotaped material • Repetition of core vocabulary (e.) [Todd Purdum. • LOCATION: in a pocket.. We’re going to Atlantic City.g. Atlantic City. 1999.g. such as Skill-building.g. • ACTION: give. spend • Acting out and describing sequences with props (e. in the casino • Picture description (e. A7]. at a bank. Atlantic City—To • Comprehending newspaper stories (e.g. draw a line from each Evaluative thinking or judgment tasks included: word in the left-hand column to the related word in the • Which activity should we work on first? Atlantic City or right-hand column.g. 24. Battles U... August 28.. get. • Category naming Live Longer.” Should I walk across it or wait • What can I do when I don’t understand someone else? until it is dry? • What can I do to get my partner to help me when I can’t get my idea across? Integrative tasks included: • What can I do to help my partner to get his idea across • Conversation when I can’t understand him? • Procedural discourse .g. a slot • USE: buy things machine). Other convergent tasks that might be useful are discussed tures that they find hard to retrieve or name. 1999. p. August • Defining core vocabulary 24.) the Garden Club lecture? • Word Categorization Tasks (circle the words that • Which trip means more to you: the trip to Atlantic City or belong in the category “Atlantic City.”) the lecture on roses? • Word Categorization Exclusion (e. What does the dealer deal? Recognition/comprehension tasks included: How many cards are in a deck?) • Reading and following signs. the choices or just point to anything? geted core vocabulary items (e. create sentences for these words and phrases..” • Naming tasks (e. Cognition • Discussing videotaped material • Structured answers (e. and mark a coat? Suntan lotion or a lamp? “yes” or “no. “Little Tribe. • PROPERTIES: round.g...) or a five-dollar bill? • Which is closer to New York: Atlantic City or Florida? Convergent Tasks • Which is faster: a plane or a bus? Answering “Wh-” question tasks include: • I don’t know how to play a game. Describe roulette). coin • Object manipulation and description (e..S.g.g. which would be more useful • Write in a New Word that Does Belong to have with us: a bathing suit or gloves? A beach towel or • Yes/No Questions (e. Casino Threatened. Experts Suggest” [New York Times. below: for “a quarter. game-play) standing tasks included: • Multiple choice questions relating to core vocabulary • Matching Related Words (e.g.. and “Stay Busy.. What do we swim in?) [New York Times.. large using the slot machines or ordering lunch). and • Giving directions the Jersey Shore • Creating sentences for target core vocabulary items (e. getting things Mahal Casino” or “Caesar’s Palace Casino”).”) • I can’t read the menu. New York Times. read each question. We’re going to ______.. and through its very specific structure or strategy for solving prob. and . meaningful propositional language as possi- the subsystems whose interaction is necessary for processing ble or increase his or her ability to become better adept at the and specification of the complex events that happen in the back and forth—the give and take of ideas. reorganize it. information approach because of its relevance to everyday life participation processing. Most of the literature on cognition. also have been documented in persons to achieve workable and effective solutions.. Diggs social. that communication is idea oriented. Chapey & Lubinski. and semantic and problem solvers and decision makers. and of going to the beach) take of ideas. infer from it. or what is to be learned. or the products of cognition. It must • Role playing ordering in a restaurant be recognized that the speech act involves creativity and nov- • Role playing shopping in a store elty of expression. We also stimulate these mental opera. divergent thinking. the pros and cons of gam. Law & Newton. such as words. activities. 1990. convergent use it to become more active. what we are ten behavioral goals should be reconsidered. it enables us to identify • Reading stories about the New Jersey shore and Atlantic and operationally define the action elicited within the patient City and discussing them by the stimuli presented. attempting to stimulate is the patient’s mental operations or we need therapeutic goals and procedures based on rich and processes. vocational. and that it is purpose/intent oriented. evaluative thinking or judgment. comprehensive. will help those who abilities. The goal of therapy is the and describe patient behavior. Chapey et al. brain may save us from performing therapeutic tasks back. and with adult aphasia. right brain damage. Language is • Role playing being at the beach an aid to communication. tions because functional language requires the use of these relate it to something else. In the future. to a comprehensive INTERVENTION understanding of the rationale behind the selection of these Recovery today is very documentation oriented—very focused tasks and a description of why these tasks stimulate complex on cost containment. speech-language pathologists are shifting from an FUTURE TRENDS IN COGNITIVE SEMANTIC orientation of simplistic listing of tasks used in therapy. This is the core of language. during therapy. Most importantly. specifies 1978. These tests can be used in therapy to stimu- objectives. injuries and in elderly individuals (Braverman. of a group trip. this what is learned. fact that language is communicating—that it is the give and bling. processing. The criterion of to someday make a statement about the efficacy of treatment success is based on the percentage of appropriate versus based on this model. Chapey. and recreational activity and reintegration.g. 1991. especially in conjunction with other repeated research studies using factor analysis. and problem solving a firm. 1979. and effective thinking. Today. rules of lan- CONCLUSION guages. and closed-head adaptations to changing opportunities for participation in con. resolutions. thorough. emphasize the types of tasks used. and/or the cognitive processes that are used in gen- erating language products. and evaluate such real-life experience. Some of these models such as those cited in this chapter. It is hoped of the 120 abilities in normal individuals through the use of that use of this model. 1986). This orientation generates a “pricing by events to happen in the brain. It must reflect the belief that meaning is the • Role playing talking to fellow travelers on the bus essence of language. the complex events that happen in the brain. the identification of much functional. cies emphasize unimportant but measurable goals. Lubinski & Chapey. not • Role playing being in the casino word oriented. lyze. Therapeutic objectives late specific parameters of the model and to assess. thus making it possible behavioral content. synthesize. such as memory. evaluate. facilitating optimum 1977b. This latter focus defines them activity” mentality in which governmental and insurance agen- as true clinicians. classes. Many of these do not help the patient to regain as output components and. the model provides a set of tests whose validity and reliability have literature in language intervention specifies therapeutic been established.. & Basili. we recognize that. Similarly. systematic theoretic and yet operationally defined foundation. inappropriate responses. thereby. of an empirical statistically documented model or taxonomy ing presented here appears to be applicable to the LPAA of behaviors to give the concepts of cognition. the model of problem solving and decision mak. and semantic implications. Use of these tests may help us appropriate accomplishment of these tasks. The current emphasis on measurable. lems and the proven validity of the five mental operations both Guilford supported the separate and distinct existence of each in “normal” individuals and in those with aphasia. operationally writ- ward. however. accurate. 1976. texts that really matter and. • Watching video tapes about Atlantic City and discussing Applying the Guilford model to adult aphasia has several them other advantages. Schwartz-Crowley & Gruen. because these appear to be the complex events that shared experiences that encourage individuals to apply.GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 502 Aptara(PPG Quark) 502 Section IV ■ Traditional Approaches to Language Intervention • Narrative discourse mental processes. ana- happen in the brain. which define them as technicians. In addition. language therapy must reflect the • Unstructured discussions (e. It enables us to make use In summary. That is. Thus. 1987. and and abilities. An attempt to separate tasks into input. more important. . Bandura. & Walters. food shopping. meaningful communication.. tic materials appropriate for this approach. M. . & Zangwill. c.. 2. Each of Bloom. E. we can assess the individual’s intelli- gence for each ability. Schuell’s definition 2. OH. Processes of cognitive growth: Infancy. Aphasiology. J. for aiding aphasic and apractic patients. (1946). Divergent semantic and behavioral produc- eral abilities to function together to achieve a desired tion skills in aphasia and right-hemisphere communication impair- goal. form. In addition. Language development and language these can be defined within the context of the disorders. the ability be defined within this definition? to acquire language independently. decision making. & Scott. J. 3. (1978). M. Cognitive processes in maturity and old age. (1990). such as Butfield. C. Self-generated cues: A method 5. Communication is a problem-solving. The objective of cognitive stimulation therapy is to Bruner. and information pro. Worcester. (1968). often requiring sev. Anderson & D. Braverman. New York: Viking Press. 4(1).. Aphasia therapy manual. In R. decision-mak. Guilford model as semantic and behavioral informa. K. • Schuell • Goldstein How are they the same. Therefore. cognitive-semantic processes separately and within the context 3. Edmundson. S. How would aphasia with aphasia’ natural acquisition ability—that is. & Coelho. & Lahey. New York: Holt. Social learning and personality text. L.. Create an interactive exercise for clients to practice the A cognitive approach also may stimulate generalization.. Introduction. New York: Holt. Readings in the psychology of cognition. The Guilford SOI model contains four types of con. a. Intelligence can be defined within this model in d. Ausubel 4. stimulate the five mental operations at various levels MA: Clark University Press. communication. Speech-Language Pathology. (1974). Kay. D. 67–92. Aphasia tests reconsidered. 1. Jean Piaget. M. Unpublished doctoral dissertation. List vocabulary exists to develop assessment protocols that will measure these that you would consider to be important to this exercise. and six types of products b. Cognition can be operationally defined by the use of one or more of the five mental operations in the References Guilford model: recognition/understanding. IL: Interstate. learning. & Peelle. (1995).. it has the added advantage that stimulating think. or products. List 10 questions that you would include on an assessment protocol for each of the following models of aphasia: 1. edge: content. and take of ideas between partners in a specific con.). and World War II. give Rinehart & Winston. Chapey’s cognitive definition tent. Journal of Neurology. Spontaneous speech. ing task that usually involves the back and forth. Reeducation in aphasia: A spontaneous speech. University of Cincinnati. (1990). mem- ory. (1963). A. 4(4). five mental operations. Such a measure may aphasia with those of: help clinicians to assess progress in therapy and generalization • Wepman and. and how are they different? KEY POINTS 4. evaluative thinking. This usually involves the use of one or all five development. L. ment. tion processed by one or more of the five mental Bolwinick. Neurosurgery and in meaningful and personally relevant activities and Psychiatry. American Journal of ing. 372–376. use of divergent thinking using two of the following Therefore. Wepman’s definition or associations. Application of semantic feature 6. Rinehart & Winston. Goldstein’s definition terms of 120 abilities (content  operation  prod- uct). Compare and contrast Chapey’s cognitive definition of of functional. 75–79. of complexity and in composite abilities.. a strong need exists to develop additional therapeu. (Eds. Byng. (1967). M. convergent thinking. topics: gardening. A ACTIVITIES FOR REFLECTION AND DISCUSSION cognitive approach to recovery appears to meet this need. A. R. (1967). 9. therefore. Ausubel. Boyle. M. and use or function. divergent thinking. cessing are composite abilities. Write a definition of language based on the five mental ing and cognitive processing may facilitate the individual operations in the Guilford model. Language involves the use of three types of knowl. J. Journal of Speech and Hearing Disorders. O. mental operations or cognitive processes. life goals. dining out. analysis as a treatment for aphasic dysnomia. 7. Danville. to increase ability to participate review of 70 cases. Berman. C. New York: John Wiley & Sons. travel. 94–98. problem solv. New processes and resulting in one or more associations York: Springer. sharpen our quality-assurance systems. (1965).GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 503 Aptara(PPG Quark) Chapter 17 ■ Cognitive Stimulation: Stimulation of Recognition/Comprehension 503 use it as a springboard to solve new problems creatively. Cincinnati. 32. J. A strong need also meeting a stranger. (1980). and Aurelia. Boden. The measure. 1. H. Baltimore.). Pre-assessment: A procedure for accommo- Chapey. 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Yardley. 131–136. New York: Ronald Press. 1. 18. (1985).). (1977). 4–13. Vignolo. J. 37.).GRBQ344-3513G-C17[469-506]qxd 01/22/08 07:00 PM Page 506 Aptara(PPG Quark) 506 Section IV ■ Traditional Approaches to Language Intervention Torrance. problem solving competition for creatively gifted. 203–214. A system for quantifying ver- Merriam. Yorkston. Clinical aphasiology: Conference proceedings. Aphasia therapy: A new look. Evolution of aphasia and language rehabilita. A. Springfield. & Rogers-Warren. Marshall with few.qxd 1/21/08 1:02 PM Page 507 Aptara Inc. The chapter’s objectives are (1) to pro. Marshall. even though the patient may hear sia do not talk at this time..g. aphasia contains a variety of grammatical forms.g. fluent speech (Goodglass & Kaplan. Self-correction effort and successful repair occur Lesions responsible for Wernicke’s aphasia occur posterior less often in Wernicke’s aphasia (Marshall & Tompkins. This approach blends science. “him” for “her” or “she” for “he”) disrupts communication WERNICKE’S APHASIA markedly. (2) to describe how context-based contain several unrelated sounds. The art is associated with knowing when to do what and Verbal output may be (1) devoid of content or empty (e. with good clinical decision making. the speech of the patient with Wernicke’s unique approach to patient management. “The evant to the patient’s daily life communication contexts. uncertainties of the future and with day-to-day communica. Often. for “trailer”).g.GRBQ344-3513G-C18[507-529]. and (3) contami- post-onset period. & Obler. or they talk very little.. sometimes persons with aphasia and their families struggle with the with white matter extension (Bachman & Albert. These damage the primary auditory cortex (Brodmann areas 41 and 42). and portions of the second tempo- months after a stroke causing aphasia. Often. and when the patient caused by motor difficulties). 1998. one there. leaving the patient 1982). but disrupted in other ways. Some patients. 1983. (e.. A different approach to clinical management distracting stimuli (LaPointe & Erickson. 1991.g. because this is when the patient’s aphasia nated by paraphasia (unintended word substitutions not is most severe. and if they with Wernicke’s aphasia. posterior branches of OBJECTIVES the left middle cerebral artery.”). when therapy occurs. speech understanding. The common sense “Before the one. Many patients with apha. with Wernicke’s aphasia are an exception. sia. however. Classic descriptions of Wernicke’s used for patients with other types of aphasia. 2002). to the fissure of Rolando (Benson. 1979). tion exchange in communication contexts. “tiger” for “knife”). Goodglass & Kaplan. 1983). 1967). semantic (e. These patients Some patients’ comprehension deficits appear to be related talk. Damage to Wernicke’s area may produce severe loss of tion (Lyon. “spoon”). aphasia indicate these patients have disproportionately This chapter provides information on a context-based impaired auditory comprehension in relationship to their approach to management for patients with Wernicke’s apha. if any. even neologistic (“veehall” treatment is used to improve comprehension and informa. (2) full of circumlocutory phrases (e. 2002). 1997). and common sense. and articulatory agility (Geschwind. “thing”) material herein focuses on management during the early rather than specific words (e. speech is perceived as rapid. and (3) to Unlike the halting. The paraphasias may be verbal needs help the most. Wernicke’s aphasia results from blockages in the smaller. 1990). art.g. and patients with severe cases of Wernicke’s aphasia 507 . 1970. or phonemic (“spoot” for “spoon”). with preserved rhythm. but usually..g. no sensory loss or paralysis occurs (Kirshner. agrammatical speech of patients with increase clinicians’ confidence and willingness to apply this nonfluent aphasia. This is a time when ral and angular gyri (Brodmann areas 39 and 40).. Science comes from knowing and applying judiciously to melodic line.. but their aphasia interferes with communication in to attention difficulties and inability to effectively ignore other ways. Those nonverbal sounds and music normally (Boatman. therefore is required for these patients compared with that Connor. make para-grammatical errors in which the substitution of one small word for another (e. Some patients may have a right visual field deficit. treatment what research tells us about people with aphasia. Kertesz. “knife” for vide a rationale for using the context-based with patients “spoon”). 2004). associated deficits. Wiener.g. The one you eat soup with”) and indefinite words (e. Wernicke’s The early post-onset period encompasses the first 1 to 3 area (Brodmann area 22).. my son took another of them over to the involves using therapy to improve communication skills rel. Chapter 18 Early Management of Wernicke’s Aphasia: A Context-Based Approach Robert C. He said. who improve their comprehension evolve to anomic aphasia ing meaningful sound patterns. “Not so good. Research indicates that Wernicke’s area and sia is “when is my husband or wife going to talk again?” The adjacent regions of the posterior language zones are vital to field of clinical aphasiology has a long-standing practice of language processing and that extensive damage to these emphasizing what the person with aphasia produces (Doyle. Some writers have suggested patients with Wernicke’s RATIONALE FOR CONTEXT-BASED aphasia have a poorer prognosis for improvement compared with patients having other types of aphasia (Brookshire. Usually. Contextual: As I pondered what to put in my report. Kempler. I put together the word “earwig. 1989). 1989). TABLE 18–1 Differences in How Patients with Wernicke’s Aphasia Communicated in Noncontextual and Contextual Situations Patient: Glen. because Glen did all the talking and all I had to show for my efforts was a blank test form. Casey. He did this by (1) pointing to his ear and (2) then pointing to his bald head and saying. 1995). “I don’t have any. these patients also have (Goodglass.qxd 1/21/08 1:02 PM Page 508 Aptara Inc. & Heinrich. She asked that I talk to her neighbors about helping out in an emergency. all Marie would talk about was going home. or but’s. When I asked him to repeat short phrases. in some conversation that we illustrate our knowledge and capabili- cases. Helm-Estabrooks. 1993). tion. & Kaplan. Conversely. For the patient with Wernicke’s aphasia. Lasting comprehension deficits and persistent apha.GRBQ344-3513G-C18[507-529]. Kirshner. For example. he often conveyed to me that the assessment was “stupid” and showed little appreciation for the help I was trying to give him.” He was unable to repeat single words accurately.” From this. Henson. copying. Goda. 1988. He talked a blue streak but performed poorly on the easiest subtests of the MTDDA: repetition. and the result was positive. Patient: Vern. & Spencer. Conversation is probably the 1990). 508 Section IV ■ Traditional Approaches to Language Intervention may be mistakenly diagnosed as being confused or mentally (Hillis & Heidler. I realized Glen had actually communicated a lot of information about his aphasia. She told me how she did her shopping and that her major responsibility was her cat. her physician felt that her communication deficits were so severe that she would be unable to live independently. TREATMENT 2003. and naming. Because Wernicke’s area is the crossroads for all incom. Examples of the differences in noncontextual and con- poroparietal cortex (Metter.” he responded enthusiastically “I’d sure like to” and made an inappropriate gesture. To my chagrin. so I need one up here. After an hour. Metter et al. Pashek & Holland. matching. 1994. Contextual: When therapy began. Marie. Her only relevant performance during testing was on the matching and reading subtests. and aside from her aphasia. Marie was able to convince us all that she should go home. textual communication for three patients with Wernicke’s 1992) and the ability of this region of the brain to reperfuse aphasia—Glen. 1965). & Rubens. Ward-Lonergan. a 63-year-old man with moderate Wernicke’s aphasia Noncontextual: Vern could not name any of the common objects on the PICA accurately. when I asked him to name pictures. Marie lived alone. & An early question from the spouse of the person with apha- Morgan. Contextual: One day I asked Vern how things were going at home. and writing (Goodglass Rosenbek. Knopman. he responded “No way” or “Can’t get that today” after several aborted attempts to produce a specific verbal response.. but when I asked him to say the word “screw. Naeser. and’s. Patient: Marie. Helm-Estabrooks.” . 1981. Selnes. reading. Auerbach. go home because she was essentially a recluse and had few communication needs. I was frustrated. 2002. improvement in Wernicke’s aphasia is conversational context rather than a noncontextual situa- associated with restored metabolic activity in the tem. he was able to convey that he had no earthly idea why his doctors kept asking him to say “No if’s. She clearly understood the discharge plan and argued that she could.” I asked. It generally is believed that patients ill. he informed me he hated this task and every time his wife asked him “What’s this?” became angry. a 90-year-old woman with moderate Wernicke’s aphasia Noncontextual: I gave Marie the Porch Index of Communicative Ability (PICA. did not drive. LaPointe. because it is via sia usually are associated with larger lesions and. indeed. Kirshner. Hanson. a 52-year-old man with severe Wernicke’s aphasia Noncontextual: I tested Glen with the Minnesota Test for Differential Diagnosis of Aphasia (MTDDA) (Schuell. 1995). Haas. Niccum. “Why?” Vern was able to convey he had been having trouble with insects (earwigs) and that the bugs were winning. talk- & Srinivasan 1987. & Wertz. severe deficits in repetition. 1983. complete destruction of Wernicke’s area (Goldenberg ties as well as establish and maintain our human connections & Spatt. areas results in severe aphasia (Boatman. & Jackson. ing is a strong point—as long as the individual is talking in a 1984). (Kagan. random sample of adults with aphasia. Her overall score placed her at the 29th percentile in a large. 1967) in the nursing home. However. It just did not relate to what the MTDDA tested. biggest loss for many persons with aphasia. was perfectly healthy. 2002. Nicholas. 2002). Porch. and Vern—are shown in Table 18-1. espe- cially Wernicke’s aphasia. 1983. 1988. 2005). because it focuses on commu- a given utterance (Davis & Wilcox. or PICA. 1985). 1985. or cope. need to be prepared to do. 1990. It forms to them. & Cannito.qxd 1/21/08 1:02 PM Page 509 Aptara Inc. That is. For example. Chapter 18 ■ Early Management of Wernicke’s Aphasia: A Context-Based Approach 509 Context: A Common Denominator tation center. The context-based approach is a better way to pre- context refers to verbal behavior that occurs before and after pare them for this possibility. 1977. Van Lancker & Nicklay. 1978) and improves information exchange in who might not be able to point to the “cigarette” on subtest general. The context-based approach exploits The Therapeutic Window the differences in noncontextual and contextual communi- Context-based treatment is preferable when treatment time cation with patients like Glen. and to aphasia treatment (Byng & Duchan. topics. One thing is certain. thus gives the patient no time to adjust to the residuals of the reducing the performance pressure that typically is placed aphasia in the relatively “safe” environment of the rehabili. Lancker & Klein. Most clinicians have experienced Beekman. even though they the scaffolding for the clinician to provide the needed part- appeared to be totally impaired when tested with the ner training. Paralinguistic nication situations that come up in real life. Marie. When adults share knowl- example. Pierce & Wallace & Canter. For patients with A communicative context allows the participants to make Wernicke’s aphasia. they were remarkably successful. 1987. the patient & Darley. This also makes the clinician- rehabilitation center. Pierce. they are sent home instead of to the stakeholders in therapy. treatments and is seen once a day.g. Because the clinician deficits (e. Marie. facial expression. available or the patient should be fortunate enough to qual- Context is a multifaceted concept. but communicate effectively. the funds for therapy will the shared information guides the generation of appropriate be exhausted in 4 or 5 weeks. 1998). convergent tasks. right-side weakness or paralysis) and do not takes the role of participant-communicator rather than require the same rehabilitation services as do other survivors director of operations. real-life communication is what persons with aphasia. and other factors. Frequently. Waller this firsthand in their practices. context refers to the “trappings” of utterances (e.. This is because they rarely have major associated pseudo-communication exchanges. it the patient is funded for 20 speech-and-language edge about people.GRBQ344-3513G-C18[507-529]. Mogil. Hoyt. and rate of speech) that help us to convey affective information. The early transition from the hospital patient relationship horizontal rather than vertical. ment. and counseling to help the patient Minnesota Test for Differential Diagnosis of Aphasia. however. . and it inhibits the tendency where effective communication is needed shortly after their to engage in forced production drills. Once home. Unless alternative monies are requests for information. and govern our behavior in commu- The aphasia research indicates that persons with aphasia nicative interactions. high. Ability. Hough.g. Van prehension of persons with aphasia (Freiderici. prosody. or with the Porch Index of Communicative aphasia. This is congruent with life participation approaches Real-life communication always takes place in a context. 1988. where The context-based approach is all about personalizing treat- they go. Linguistic stroke. Pierce. whom they live with. and Vern had obvious aphasic deficits. the patient and the clinician are both of stroke. and compensate for the residuals of the MTDDA. It keeps the focus patients with Wernicke’s aphasia are put into situations of therapy on communication. and the world in general. 1977). events. intona- tion. & Lefkowitz. adjust to. what they do. 10 of the PICA might respond readily to “Have you got a Of course. The context-based approach is when communicating in a context about something relevant well-suited for coping with this sudden transition. 1985). Context was the common denominator that allowed them to communicate successfully despite per- vasive aphasic deficits. Pierce and DeStafano.. on the patient to come up with specific words and responses. education. Clinician as a Communicator Another advantage of the context-based approach is that it is Rapid Discharges naturalistic. Personalizing Treatment light new information. individual speech-and-language therapy inferences and derive interpretations about what transpires may not extend beyond the early post-onset period. the patient is thrust into deci- sion-making situations where he or she needs to be able to Glen. For in a conversation (Paradis. 1992. It relates to the physi- ify for services elsewhere. the patient and the family will be cal and social situations of the conversational participants as left to their own devices approximately a month after the well as to their points of view (Winograd. communicative contexts also vary in terms of cigarette?” or “Don’t you know smoking is bad for you?” where people live. and Vern. vocal quality. 2005). is limited (Hinckley & Carr. it stresses speaker-listener interactions One reason for using a context-based approach is that to fulfill the language facilitation function. Research has shown that manipulation perform better when personally relevant materials are used of linguistic and paralinguistic context enhances the com- as stimuli (Gray. or stroke. they sure are. or psychiatric disease) the interview. (2) obser- rather than with a conversational measure.. The chapters in this book indicate many routes are Early assessment is all about (1) doing the necessary home- available for achieving favorable outcomes with persons who work to personalize the assessment and (2) using this infor- have aphasia. medical (previous illnesses). answers should be. . importance of observing communication of the patient in Many. such as “I understand you went to school in the East” severe Wernicke’s aphasia while having a beer with friends and see if the patient comes up with relevant information after work. however. Assuming he would soon be back to normal. Leroy developed ment. After he got home. 510 Section IV ■ Traditional Approaches to Language Intervention Improved Outcomes strategies. or nurse’s station) and with other obvious. that drive the context-based approach. confusion. aphasia during his brief hospitalization. (3) learning about the patient’s premorbid commu- outcomes are based on the ability to converse and/or commu- nication habits. 1998). All patients need Medical Chart to be evaluated before they are discharged. from the medical chart could set the scene for an entire con- Joe’s mild Wernicke’s aphasia quickly evolved to an anomic versation. would not interfere with his ability to work on cars. severe language deficits need immediate attention from the demographic (work history). the clinician could make an open-ended com- and get them into trouble. phone calls. however. Holland (1982) has commented on the standardized aphasia test during the early post-onset period. people (e.g. and plan early intervention. MTDDA. reading the paper. This allows patients to increase problem-solving efforts to com. For example.g. This might be followed with a statement stood because of his garbled speech.g. The belief that these patients interview and the beginning of treatment aids the clinician have poorer prognoses may come from the fact that treat- in providing the perceptual support for the conversations ment success often is measured with standardized tests (e. Outcomes reflect the results of interventions (Fratalli. although still (e. In agnosis (e. because their incomprehensi- and other information. in her early paper on observation of per- Moreover.g. even better than—those of other patients. I believe. Patient-relevant PICA.. This how or if the patient communicates in other situations evaluation revealed that Joe’s anomic deficits. answer the physician consult. perform poorly on any type of formal test. When treatment vation. His wife insisted Joe come back to than remain in their rooms. Suppose the clinician learns from ble speech and faulty comprehension can result in a misdi- reviewing the chart that the patient is a Harvard graduate.GRBQ344-3513G-C18[507-529]. He became upset when he could not be under- about Harvard. she provides a convenient form for this guide treatment during the early post-onset period.” and took Leroy to jail before it was discovered he had had a which would be expected to evoke a response from the stroke and was taken to the hospital. physicians. and (5) staff observations. based approach is used. are available to the clinician for obtaining information to identify the patient’s strengths and weaknesses. family. perhaps. or staff) and if the Joe returned to work successfully and made good progress as patient attempts to resume normal communication activi- an outpatient.” This one simple fact Individuals with less severe aphasia also are vulnerable. they often move about the hospital rather thriving garage business.. the results provide little information to help sons with aphasia. however.qxd 1/21/08 1:02 PM Page 510 Aptara Inc. agitation.g. friends.. Those with The medical chart contains identifying (date of birth). the physician discharged Joe before Observation he could be evaluated and counseled by the speech-language pathologist. writing. day room. patient such as “Wow. Several purpose. other situations. Obtaining Patient-Relevant Information municate about something important to them rather than Knowing as much as possible about the patient before the searching for specific words. cafeteria. that outcomes may be bet- mation in an interview to engage the patient in the process so ter for patients with Wernicke’s aphasia when a context- you can learn as much as possible. Early assessment of the patient with Wernicke’s aphasia usu- ally takes place in the acute-care hospital. speech-language pathologist. The context-based approach increases their “degrees of freedom” to communicate. and Wostein Aphasia Battery (WAB)) information comes from (1) the medical chart. Joe became so frustrated Because patients with Wernicke’s aphasia have few associ- with his anomic deficits that he contemplated selling his ated deficits. the This information helps clinicians to ask questions with a prognoses of patients with Wernicke’s aphasia may be as good reasonable expectations as to what a given patient’s as—or. or watch- Some patients with Wernicke’s aphasia can be given a ing television). This also allows clinicians to compare what they already know with the patient’s actual perfor- mance and eliminates some of guesswork from the assess- ASSESSMENT ment process. It may be possible to observe the hospital for a speech-and-language evaluation. ties (e. (4) biographies.. nicate information relevant to day-to-day functioning. The police were called such as “I understand Ivy League schools are expensive. For example. hobbies. For example: expression. sculptures.. enhance information exchange by testing certain hypotheses fessional baseball player in the Mets organization and currently (e. Some family members assess the patient with Wernicke’s aphasia. Family members should be included in the assessment process. John (nickname Duke ing?). therapeutic set. . the clinician should tell the patient that he or she is set- the patient was a highly verbal individual. Bedside Items Staff can be trained to use this information to probe com- prehension and expression in their interactions with the Holland and Fridriksson (2001) suggest that early assess- patient. or wood. with some modifica- interest to the patient [e. pragmatics. depends on the patient’s status. the guidelines are nurses) also can participate in assessment and treatment. Para-standardized testing procedures are certainly applicable. likes. testing memory in the effort to improve communication and provide the for the therapist’s name. the para- married (Camilla). Jocelyn.qxd 1/21/08 1:02 PM Page 511 Aptara Inc. ting up a time to “find out a little more” about the patient’s and Holland (1982) have developed a form that can be filled communication. regarding what aids and disrupts comprehension and opsis about the patient’s background. the position your son plays to the hospital stay.g. He’s seling the patient and the family. and writing the names of one’s patient with more communication opportunities. This gives the clinician information that is John Marks is a 54-year-old college graduate who worked as immediately useful for planning early treatment and coun- an architect for Pitney-Wilson before his stroke on 10-7-06. the physical therapist might ment of the patient with aphasia center on activities relevant say. occupational therapists. Brian. What the clinician does in the interview itself largely patient’s premorbid communication habits. and (2) the task is not a writing exercise and need not be perfect. is a pro. Chapter 18 ■ Early Management of Wernicke’s Aphasia: A Context-Based Approach 511 Premorbid Communication Skills The Interview Knowledge of the patient’s premorbid communication habits During the early post-onset period. As shown in the work]). if the basis of the clinician’s assessment of the patient with clinician knew a patient was a quiet person who rarely initiated Wernicke’s aphasia. is a junior majoring in variables that can be manipulated to aid comprehension and international business at Duke. This is a way to include all staff sion programs.g. One way get them involved is to ask a family mem- Para-Standardized Testing ber to write a short biography that gives information about the patient’s work. The clinician needs to tell the table. and related factors.g. distraction-free of factors that the clinician should consider in determining the space. Para-standardized testing procedures are well-suited to accomplishments. auditory comprehension. and Green (1984) has published a checklist The interview should take place in a quiet. artifacts (items of personal guidelines published by Sparks (1978). At this would have different expectations from the interview than if visit. the clinician interview with an advanced visit from the clinician. Swindell. friends. physical therapists. but not necessarily to patients with Staff (e. naming objects in the room. Para-standardized may choose to include photos. His daughter is getting married in the summer following her gradu- counseling the patient and family at a later time. Representative examples include reading get- daughter is attending college. Pashek. His daughter. children. and his wife teaches math at St. Most importantly. paintings. “Show me with your fingers.. dislikes. Will the patient comprehend better if I reduce his talk- plays third base for a farm team. the interview forms the should be collected before the interview. munication style. The patient should be prepared for the communication or elaborated on what was said. They suggest that clinicians make use of in baseball” to probe comprehension of directions.. ation in 07. are shown in Table 18-2. lowing conversational rules) are examined with respect to their presence or absence and positive or negative impact on Staff Observations communication. With respect to John. tions of my own. choosing televi- noted in the patient’s chart. The suggestions for con- ducting the interview that follow are not prescriptive and Biography constitute only a few of the things that might be accom- plished. she might ask John to tell her where his assessment. interests. As an items in the patient’s room when carrying out an initial expression probe. the guidelines cover four broad content areas— volunteer biographer that (1) the information is confidential. to remind him or her about the time of the appointment. It may be helpful to leave the patient a note out by the spouse to obtain information about a patient’s com. His older child. selecting foods from the menu. Successes and failures can be well cards.GRBQ344-3513G-C18[507-529].. and Wernicke’s aphasia.g. Videotaping the examination or developing a form for because of his height and resemblance to John Wayne) is a 4- recording observations may aid in writing the consult and in handicap golfer and longtime member of the Olympic Club. flexible and permit the clinician to obtain information One way to facilitate this is to give staff members a brief syn. For example. age 20. Joseph High standardized format allows the clinician to determine the School. fol- and (3) how the information will be used in treatment. and related materials. verbal expression—within which specific behaviors (e. Therapeutic Set Area of Concern Negative Signs/Behaviors Positive Signs/Behaviors Ease or difficulty establishing Hostility toward examiner. shorter Comprehension of conversation and methods of presentation and simplified messages.. difficulty following Responds more enthusiastically to conversation containing personally relevant conversation about personal interests material (e..g. Auditory Comprehension Area of Concern Negative Signs/Behaviors Positive Signs/Behaviors Peripheral hearing loss Asks for repeats. family.. missing Understands a stroke has occurred language processing deficit dentures. sports.. family) organized (e. phonetic confusions (e. points to objects auditory comprehension simple commands and body parts and follows simple tasks commands Responses to different Not helped by slower rate. when asked “What do Ability to role play and pretend you wear on your head?” says “I don’t ever wear hats.”) Feature 2. therapeutic set acknowledges clinician is there to help Presence of rigidity or Continuing to produce a response without regard Recognizing task switches. and maintaining a of ambient noise displays a realistic appraisal of situation.. distractibility because Accepts the therapist in the situation.. work) Comprehension in structured Difficulty pointing to objects. awareness of perseveration to change in stimulus. violates social conventions Realizes the reasons for Blames problems on outside forces (e. rake-lake). following Once oriented to task. written word “Military”) in form of written word (e. Are you married? Do you have any children? Are the children still at home?”) Effect of visual No improvement when provided a visual cue Comprehension improves with visual cue supplementation (e. “Were you in the service? What branch of the military were you in?”) Self-criticism No awareness of errors in speech output Aware of errors and possibly upset by them .g.g. not aware when to terminate Obeys conversational conventions a conversation. Pragmatics Area of Concern Negative Signs/Behaviors Positive Signs/Behaviors Follows conversation rules Limited turn taking. verifies what has been said Comprehension when Comprehension does not improve when questions Comprehension improves when task is treatment materials are flow from mutually known topic (e.g.GRBQ344-3513G-C18[507-529].. Examiner judges hearing acuity to be history of working in noise within normal limits Understanding a conversation Looking confused or perplexed. alerting phrases. people talking too fast.g. no glasses) Initiate communication Initiates few communication interactions. body parts. difficulty switching tasks errors and effort to correct them Behavioral rigidity Ego-minded responses (e. 512 Section IV ■ Traditional Approaches to Language Intervention TABLE 18–2 Modified Para-Standardized Examination Guidelines Feature 1.g. “I want to know about thematically organized your family.qxd 1/21/08 1:02 PM Page 512 Aptara Inc. only Initiates communication to make needs responds when asked to known Persistence in face of failure Gives up when communication snag occurs Persists until thought has been communicated Feature 3.g.g. orientation to topic structured material when clinician uses different methods of presenting material Comprehension when verbal Examiner is unable to halt “press of speech” or Comprehension in conversation and on output is restricted patient’s comprehension does not improve when structured tasks improves when patient speech is restricted is asked to “listen” rather than talk Intrapersonal monitoring Does not ask for repeats or verify what has been said Asks for repetitions. Specifically. Speech reflects full range of grammatical he/she. For example.g.. Toffolo. Because the Everyday Language Test is not readily available Based on the amount and quality of the information provided. and recording and scoring forms. Step 2 want a bouquet of flowers delivered to a friend. . A complete listing of items on the test can be tion seeks information about whether the patient can give rel- found in the article by Blomert and colleagues (1994). for Errors contain some of the constituents of errors approximate “pillow”: “grabbitz. responses to specific questions and/or situations (Blomert. & Hickson. instruc- IFCI. Step 1 consists of documenting the test items. Step 3 consists of discussing the necessary infor- Inpatient Functional Communication Interview mation with the staff. one situa- meaning). or the findings. Worrall. for one of is administered in four steps. or 0 (unsuccessful com- munication).g.. overcorrects a response when its meaning correct errors and sometimes succeeds has been conveyed Stimulability No improvement when errors are pointed out and May improve production when model model provided. responds to semantic or semantic or phonetic cue phonetic cues Response to restriction in Brief responses continue to be in error Verbal expression is improved when verbal output shorter responses are elicited Verbal compensations Unable to find alternative means of verbal expression Conveys meaning of target word through to convey intended word (zebra) description (e. The IFCI comes with a test manual. What do you say?” Responses are scored on a clinician first establishes a communication context so as to 0-to-4 scale for understandability (content) and intelligibil- evaluate the patient’s performance in 15 situations that are ity (perception of the message regardless of the content or relevant to the hospital environment. 1994). 1 own version.g. rejects target word when it is recognizes target word when provided. provided. they/we) and lack of awareness constructions with few para-grammatical of them errors Degree to which paraphasic Errors bear no resemblance to target word (e. and step 4 involves writing a report of The Inpatient Functional Communication Interview. the IFCI measures the The Everyday Language Test is a verbal test that elicits patient’s ability to communicate during everyday tasks. pister/pillar) and target word may “in the ball park” Self-correction accuracy No awareness of errors.. The test Kean. “You are at the florist. substantive words empty speech. Koster. You information about the patient from the medical chart. For example. response does not improve with provided. “black-and-white horse thing”) or other means Compensations in other Uses only speech to express thoughts Uses alternative modalities (e. Everyday Language Test an acute hospital setting (O’Halloran. is a measure of functional communication to be used in tions. errors do not resemble target word errors are variable and sometimes approximate the target word Quantity of speech Unrestricted verbal output with no awareness of Fluent speech that sometimes becomes less its content fluent as the patient evidences concern for his errors Grammatical structure High number of para-grammatical errors (e. makes efforts to and effort errors. Verbal Expression Area of Concern Negative Signs/Behaviors Positive Signs/Behaviors Accuracy and use of Not aware when correct target has been produced.g. (partially successful communication). modalities gesturing) Author’s modifications based on Sparks (1978). I am the involves a structured bedside interview using the IFCI. Chapter 18 ■ Early Management of Wernicke’s Aphasia: A Context-Based Approach 513 TABLE 18–2 Modified Para-Standardized Examination Guidelines (continued) Feature 4. actions. evant information concerning their pre-admission history. The salesperson.. rafunta”) the target word (e.g. makes no effort to correct Recognizes most errors. clinicians may want to make up their the patient receives a score of 2 (successful communication). 2004). from/for. and situations that might occur in a hospital. Code. in the United States.qxd 1/21/08 1:02 PM Page 513 Aptara Inc. & Schokker. the clinician says.. writing.GRBQ344-3513G-C18[507-529]. Aware that speech lacks content words. At the very least. pictures. and heeding the signals a conversational context. shared knowledge leads to the development of inferences and I dealt successfully with the situation. Most would agree that unwilling to admit that anything is wrong. Using yes/no questions. I wanted to evaluate him. patients may personal knowledge about the patient’s situation. general topics (e. and finances). or the “Big Dig?” Certainly. The useful cues disorders of auditory processing in persons with aphasia and prompts that help patients with nonfluent aphasia to reflect difficulties understanding spoken messages that are produce accurate verbal responses (e. It can pay divi. the clini- lems. Should the try to correct themselves. The result is that participants interpret what establishing a therapeutic set for Wes. Table 18-3 provides several examples understand the clinician is there to help and that he or she of communication contexts and what type of information needs help. This lived alone. the patient for a conversation. and con- severe Wernicke’s aphasia. This may be difficult with patients who are stimulated their creation. physician. I would be through the early post-onset period and make the trip as hard-pressed to find a patient in Lexington that would not be smooth as possible. With these patients. Often. and a lot of tic conversations. or atten- completion. 1977). the weather. going “press of speech. I have found it beneficial on receptive language tests of standardized aphasia test bat- to identify something important that the patient needs to teries (Boatman. I knew that Wes wanted to tell me structing a mental representation for the meaning of the something important. Also. Once a therapeutic set has been estab. health. During the early post-onset period. however. and it is a time-consuming process of trial and sage is the cumulative result of analyzing the sounds of an error that delays evaluation and treatment. tion to their errors.GRBQ344-3513G-C18[507-529]. upcoming holi- toward therapy and its environment and to being helped in day. sages. The term “therapeutic set” describes the patient’s attitude In a pinch. the clinician should try to explain to the patient and family what aphasia is and leave the door open Improving Comprehension for later evaluation and treatment. and no one was around to take care of the animal. and staff Sox. utterance (phonemes). other. returning to work. because spontaneous recovery is ongoing. and repetition) rarely help and/or sometimes are tion deficits (Boller.” nonstop talking. retrieving the meanings of the words. as it did with Wes. the starting point is the knowledge guessing. For example. The goals of treatment are to improve able to talk about Kentucky basketball. Establishing a therapeutic set for patients who are not Auditory processing involves comprehension of spoken mes- improving also is difficult. less personal topics “behavioral engineer”—keeping the train (patient) on the shared by the clinician and the patient can be used to establish track. ing in or around Boston not be able to converse about the Red The clinician’s job is to steer the patient. contexts do not always need to be pre-established. Here. (hearing loss). counting. they hear in the conversation on the basis of what they know. maps. however. To show these patients that help is avail.g. 514 Section IV ■ Traditional Approaches to Language Intervention TREATMENT Establishing a Communication Context During the early post-onset period.. combining the sounds into word rep- dends. many patients with The clinician establishes a communication context to prepare Wernicke’s aphasia will have severe communication prob.g. He shared by listeners in the communication situation. Their communication status often changes from day. improving so rapidly that they feel treatment is unnecessary.qxd 1/21/08 1:02 PM Page 514 Aptara Inc. cian and the patient function as receivers and senders of mes- to-day as well. I learned that Wes was worried about his dog.. Discussing these concerns requires the clinician to have some lished and comprehension improves. emotion. prising clinician can establish a communicative context on the “spur of the moment” by using humor. Clinical diagnosis confusing to them. a 47 year-old man with resentations. Two models of auditory processing communicate to the staff. the clinician functions as a with the patient about these issues. home. different perceptual props and items in the patient’s Therapeutic Set room (e.. and pay little or no atten. family. or family and work to have received widespread attention in the aphasia literature. the patient will be Some patients may begin early treatment with obvious most interested in talking about personal issues (e. 1978). & Mack. In the conversation.g. . pictures of family. The top-down model has more seemed prudent to try and figure out what he wanted to tell to do with how listeners comprehend messages in naturalis- me instead. this is a problem the patient The bottom-up model suggests that understanding a mes- wants to solve. how could anyone liv- regarding what the clinician should—and should not—do. cognitive. communicative the patient’s comprehension and ability to exchange infor. the Patriots. 2003). changing speeds and routes. or absurdity. but it message (Brookshire. An enter- mation in contextual situations. writing. the family. and books) can be used to establish contexts for communication. It is important that the patient communicative context. and their speech will become less clinician not have the necessary information to communicate fluent. sentence not attributable to sensory.g. newspapers. help the patient with that. These patients may be unaware or sages and their retention in memory. Kim. and that succeeded in expectations. 2002). or quality of hospital food) also can be used to create a general (Sparks. Further.. of Wernicke’s aphasia is based on the patient’s performance able and establish a therapeutic set. 1988.. 2003. Graville & LaPointe.” Emotion/humor Clinician notices patient is not “Are you really going to eat “Oh yeah. & Nicholas. • Stating information directly (e.”) so that the patient ing and manipulating linguistic and temporal variables to does not have to make inferences about implied informa- improve comprehension in conversations. 1993.GRBQ344-3513G-C18[507-529].g. as reviewed by sev- the patient understand what is said. it is the message so that they stand out (Kimelman & McNeil. the inexperienced Nicholas. & Weintraub. The experienced clinicians intu- • Highlighting the main ideas of what is being talked about itively slowed their rate of speech when giving the commands in relationship to less important details (Brookshire & to the severe. Comprehension is improved clinicians giving Token Test commands to patients with in other ways as well.” [gestures thickness of steak] Spur of the moment Sees the patient is wearing a “Good-looking ring on your finger. Marshall. and we better go in to eat.” eating a rather unappetizing that crap?” meal “I bet you would prefer a steak. “Now it’s time for With the context-based approach.g. ical ties to link the information of a message together (e.. The aphasia because clinicians adjust certain temporal variables to help literature on auditory comprehension. and expansion to increase be manipulated to improve comprehension of spoken mes- message redundancy (Gardner. dinner..” [looks at picture] the bedside table “Three of them. when talking with my 99-year-old father. (2) encouraging tion (Katsuki-Nakamura. “I think all the way. Brookshire. Brookshire. 2002). It’s six versational contexts is a better approach to use at this time. For some patients. & with structured tasks. 1982. sages. Andy wore a black tuxedo. October 7 too. Pashek & Brookshire. • Giving added prosodic stress to the important words of hension deficits are relatively severe. & clinicians did not make these differential adjustments. paraphrasing. I use short. the patient’s compre. training caregivers how to talk to the patient using demon. 1980). The aphasia literature indicates that linguistic variables can • Using repetition.qxd 1/21/08 1:02 PM Page 515 Aptara Inc. particularly at the single-word and Cutler. I do things that the aphasia literature shows improve the auditory comprehension of persons with Temporal Variables aphasia. 1976). This was seen in a novel eral writers (Boller et al. Normal speakers do this naturally in relation to 1975.g. & Brookshire. Susan wore a Linguistic Variables blue dress. Similar to what it tells us about manipulating linguistic . This may be that do not contain unfamiliar or “big” words. Nicholas. Wegner. Swinney. I gotta.” “Right. For example.” ring from Stanford Does Stanford have a good team this year?” During the early post-onset period. suggests experiment (Salvatore. plausible sentences People with aphasia like to talk to clinicians. o’clock. • Using repetition and appropriate synonyms to create lex- stration and modeling. “Susan and Andy got out of the car.”) rather than indirectly (e. 1995).”) (Brookshire. 1975) that these tactics facilitate auditory comprehension for persons compared speech rates of experienced and inexperienced with aphasia (Marshall. sentence level. Chapter 18 ■ Early Management of Wernicke’s Aphasia: A Context-Based Approach 515 TABLE 18–3 Establishing Communication Contexts Strategy Stimulus Clinician Comment Patient Response Shared knowledge Clinician learns from chart “I learned that you were born “Oh wow. this involves (1) identify. 1977. Working to improve comprehension in con. 1984. difficult—if not impossible—to work on comprehension 1987. 1984). Zurif. whom they are speaking.” review that she and the on the same day as I was. Some of these include: severe and mild aphasia. Halliday & Hasan.” patient share the same birthday Bedside prop Picture of patient’s family on “You have beautiful children.” “Right rare. Strait. the patient to take responsibility for comprehension. Albert. 1982. patients. 1972). 1983. “Time to eat. syntactically simple. but not the mild. 2002). and (3) Nicholas & Brookshire. West & Kaufman.. This is shown in the fol- lowing example of a conversation with a patient with In the example provided. rates of speech (Cermak & Moreines. a Any time. Martee. is on the other. the clin- what the clinician is attempting to accomplish: ician selectively manipulated linguistic and timing variables Clinician: I would like to talk to you about your family. and Clinician: I know you have a large family [presents written only short verbal responses were required. 1976). Consider that the message sender. You probably would see Clinician: Tennis? (Humor. Clinician: I understand one of your boys is quite famous. no way. I understand he’s a rather good comprehension (Campbell & McNeil. 10 kids. more squares in the screen will open. Because the (Establish context) objective was to improve the patient’s comprehension. Buddy. Muckee—Oh no. stress word famous. Pete. the bolded information provides a rationale for about his family. [holds up three fingers].” and it permits the patient to tence) catch up to facilitate storage and processing of the message. Once the patient understood this. I was asking about your FAMOUS son. the Patient: Oh boy. You mean golf? (Humor. 1976. (see bolded text) to work on comprehension. many holes of the Patient: Let me see. Bodie. Weidner. patient to reallocate his or her attention and may improve Clinician: Right. in this Patient: Get out of here. continue to consolidate and that some of the squares were plugged with mud but that integrate) others were open. “plugged square. one word. These deficits can be compensated for by alerting redundancy) the patient to an incoming message. He’s a [gestures pitching sent through an “open square. Is he right or left handed? cian’s challenge is to manipulate linguistic and temporal (Emotion and facial expression. is on one side of the screen and that the Clinician: Baseball? (Syntactic simplification. The clini- Clinician: A pitcher? Wow. (Redirect to topic. That means you have three boys Lasky. That must keep you busy. (Reinforce for asking for repeat. 1976. stress. (Stress. 1974). screen will be plugged at first. Patient: Huh? [looking quizzical] What did you say? • Attention deficits may cause the patient to miss the initial Clinician: I’m glad you asked me to repeat that question. information about the effects of temporal manipulations on Clinician: Wow. In the context by telling the patient that the conversation would be example. imagine you are looking at a screen at Patient: Nope. & Johnson. (Verify. false information to help patient integrate and con- solidate response) Finding the Hole in the Screen Patient: Not that one. three of them.” Pete will not comprehend it. 1979).GRBQ344-3513G-C18[507-529]. 1977). For salient word) Pete to understand the clinician’s message. This serves to group information (Stress key words. the other one. the aphasia literature provides Patient: No more than that [holds up 10 fingers]. sages “through the open holes of the screen” and made Clinician: I understand you have quite a few children. gesture supplementa- 1982. To understand how the clinician might manipulate linguistic again give information to integrate and consolidate and temporal variables in a conversational context to maxi- response) mize comprehension. For patients with Wernicke’s apha- many do you have? (Increased redundancy) sia and severe comprehension deficits. unnatural. visual supplement) noted those manipulations that were helpful in getting mes- Patient: Oh. Lots of girls [holds up seven fin- • Patients benefit when spoken to at slightly slower. the clinician established the Wernicke’s aphasia centering on the patient’s family. you mean Buddig. Tony. 1981. Clinician: Seven girls. Booby. This helps the Patient: Oh. my family. Markee. portions of message and/or not pick up shifts in topic. it needs to be Patient: That would be the one. 516 Section IV ■ Traditional Approaches to Language Intervention components of messages. that the patient will comprehend it. problem referred to as “slow rise time” (Brookshire. put words at the end of the sen- into meaningful “chunks. redundancy) variables so as to get the message through an “open hole” so Patient: One of these [gestures with his left hand]. tion) • Rate slowing is best achieved by inserting brief pauses at Patient: Yep. Salvatore. syntactic boundaries within sentences (Fehst & Brookshire. six [gestures early post-onset period. Marshall & Thistlethwaite. 1983. wrong sport. Clinician: Sorry. but not gers]. but I’m interested in improves. case the clinician.qxd 1/21/08 1:02 PM Page 516 Aptara Inc. Pashek & Brookshire. Weidner & Lasky. clinician paid little attention to the production errors. which someone has thrown mud. but as comprehension Clinician: That’s a hard word to say. All auditory comprehension of persons with aphasia: boys? (Humor. patient with Wernicke’s aphasia.” If the message hits a motion] you know. During the HOW MANY [stresses this word]: four. Loverso & football player? [Buddy is really a baseball player. gesture supplement) comprehension for the patient with Wernicke’s aphasia is a . five. How adjustments accordingly.] (Give Prescott. The clinician word “FAMILY”]. 1980. much of the work done to maximize higher]. syntactic simplification) Patient: No way. well it’s a big one. the “test results” suggest the patient has comprehension Some patients. 2005. clinician need to demonstrate what they want the patient to do. however. toring skills are too impaired. the clinician should is necessary for clinicians to show.g. Breaking the Cycle Training Caregivers A “stop” strategy can be used to break up the garbage- The patient with Wernicke’s aphasia will have more conver. the tactics information transaction of persons with aphasia (Hickey. friends. what they want family. At first. because the clinician is working in do. “What do you need to do now?” individuals need to be trained how to talk to the patient. Young. In 1994). 2005). & Potechin. 2004. an impaired auditory system. and try to speech-language pathologist. & Olswang. Duchan. Simmons-Mackie. is less punitive than listening (Marshall. staff. When the training involves pro- fessional staff. merely stopping the patient from talking so comprehension. approach involves encouraging the patient to take responsi- bility for comprehending what is said. that aid—and hinder—comprehension become clearer. because his or her auditory system is overloaded. in the past as “the garbage-out/garbage-in cycle” (Marshall. Martin (1981a) offers an alter- gist’s test results documenting the patient’s comprehension native. the goal is to have the patient identify and cor- Specifically. & Square. 2002. a situation is for comprehension by liberally reinforcing the patient’s created in which the “defective utterances” are fed back to requests for repetitions and use of verification strategies. and Bourgeios. & some strategies are abandoned and others retained and Rewenga.GRBQ344-3513G-C18[507-529]. clinicians may want to refer to a recent paper Patients with Wernicke’s aphasia look and move perfectly by Marshall and English (2004) that provides functional normally. 1983). or (4) the patient’s comprehension deficits are severe and talking ask a rhetorical question (e. Hopper. are not able to benefit from the problems. This involves directing patients to lis- sations with family. It having them try to correct an error. For example: . the clinician may need to signal prehension in conversations outside the therapy room. Excessive speech flow is associated with a “ram- the patient says by paraphrasing the message (e. Information exchange also can be impeded by (1) such cases. If the The clinician also promotes the patient taking responsibility patient’s speech output is markedly defective. perseverations. the Improving Information Exchange clinician might (1) ask for a repetition (e. and framing questions so It will not help to tell these communication partners that that answers are within his or her capabilities will suffice.g. “Could you run that by me again?”)..) The clinician’s translation and ensuing para- coaching helps. 2001. which seems to occur when your wife is coming at three o’clock? It’s almost here. encouraging shorter replies. correct themselves. rather than stopping patients and deficits and viewed aphasia as an expressive problem only. (2) pervasive word-finding difficulties. and it is apparent that good a context. and friends to (This often is easy to do. This is practical information that can easily be and lots of “uh-huh’s. (3) tive listening situation and take a break. listening and that this may help in the long run. they pretend to understand so that the strategies physical therapists can use to enhance the auditory listener will not know they have aphasia. Kagan. the patient needs to withdraw from the competi.g. Purdy & Hindenlang. Lyon et al. and other people than with the ten to themselves.. A study by Czvik (1977) found that family mem. more. Holland. He suggests that. these the patient to stop and say. Taking Responsibility for Comprehension Kearns. Sometimes. “When is your wife coming?”). The clinician needs lack of or excessive self-correction. (2) give the patient a quizzical look to Speech output of patients with Wernicke’s aphasia may be indicate the patient has not been understood. stop strategy. because their comprehension and self-moni- bers tended to disagree with the speech-language patholo. this involves the clinician teaching them how to rect his or her errors.”). phrasing or modeling of the defective utterance in a correct Several recent studies have provided empirical evidence form gives the patient some positive feedback for commu- that a variety of conversational partners can be trained how nicative adequacy (getting the message across) and breaks to talk to people with aphasia and that training improves the the garbage-out/garbage-in cycle. 2005. Simmons-Mackie. and modeling. stop when they make an error. and (4) prolonged to reassure that patient that it’s all right to take a break from circumlocution. though demonstration translate a patient’s defective utterance as best possible. This is powerful therapy.. much. Chapter 18 ■ Early Management of Wernicke’s Aphasia: A Context-Based Approach 517 trial-and-error process. Signs of pretending comprehension of persons with aphasia in the physical ther- to understand include vigorous bobbing of the head “yes” apy gym.. To improve the patient’s com. As treatment progresses. a condition I have referred to There also may be times when the patient cannot listen any. expanded on. Black. At times.” A necessary part of improving the posted in the clinic and used in providing in-service training patient’s comprehension integral to the context-based for staff. 1997. Legg. & Bryer.qxd 1/21/08 1:02 PM Page 517 Aptara Inc. out/garbage-in cycle. Thus. Ultimately. first in treatment and then outside the do what the aphasia literature tells us to do that helps in clinic. At first. (3) verify what unchecked. “You said bling” style of communication. smukker. if the target word is “Wal-Mart.” Wepman (1972) believed that perseveration ducing the target word. The clinician or was the prompt that established the communicative context. the American Kennel Club magazine by keeping the focus on communication. Why can’t I say it? [now frustrated] simply choose to talk around the anomic difficulty (circum- Clinician Do you mean Bull Mastiffs? They are big fellows? locution) or simply say. You got it. oh what is it? I want one now. I mean coffee.” Perseveration The first example in Table 18-4 shows that the clinician has determined the patient’s struggle will not result in suc- Perseveration is the repetition of a response when a new cessful production of the word “cigarette. the word’s meaning and form but cannot map the phono- Clinician: I understand you are a dog breeder. a variety of behaviors that suggest the patient has accessed M-A-T-T-E-R.” Anomic difficulties Patient Bull Mastiffs. or an indefinite word It’s there. Emery.qxd 1/21/08 1:02 PM Page 518 Aptara Inc. Alasker. but bigger. it back on track—when anomic difficulties threaten to inter- tive utterances and break the cycle. a phonemic approxima- Magazine]: Here’s the one smasher. they’ll bite your head off if you mess Indirect Approaches with me. Finally. Clinician: Very protective animals? Patient: Oh you bet. if the patient is having problems com- Patient [opening the magazine]: Well they’re not in here ing up with the word “pillow. and calling for a new response will result in perseveration. ciggerthing. It’s not good For example. it. He suggested that the mind operates like a camera shutter. my doctor said having problems accessing word meanings and/or forms. the clinician sensed that the patient was close to pro- flower shop. a description . The latter suggests that the patient is (Coffee) Patient BB: “Well since my heart went bad.” word is needed. some patients ters. He suggested that clinicians take Examples of Anomic Struggle in Conversations that time to consolidate and integrate the patient’s accurate Require a Clinician Decision as How Best to response before calling for a new response to reduce perse. Bull Mastiffs. where its cold. Oh. Matteree. mas.” [clinician fills in] Anomic Difficulties (Alaska) Anomic difficulties are a hallmark of patients with Patient HB: “I always wanted to go to Alasta. Smittring. He replied. Post-lexical anomic difficulties are reflected in I live. almost.” [clinician lets it go] might produce a semantic error (“Rite Aid”).” [pause. Smucher. In the second example shown in Table asked. write the word or a portion of Bulldogs. no more cokkee.GRBQ344-3513G-C18[507-529]. Anomic struggle takes place at both the pre- and post-lexical levels. God.” he or she might make several but they are big and mean. [now enthusiastic] rectly (by teaching compensations) and directly. If the shutter is closed. that’s it. and Albert (1987) also have proposed a Patient PJ: “You smoke a cig. and move on. Smasbees. Golper and Rau (1983) have described this as “taking your cue from the patient. What types logic shapes of the word onto the lexical entries for out- of dogs do you raise? putting. For example. For example. I know it. This clinician’s decision was that it was the result of not taking enough time to consolidate and integrate a response. what mechanism for treating perseveration errors in aphasia that is it called? You put in your mouth and smuch highlights the fact that a new response is called for. [Opens the page to show near-attempts to produce it.”). the ones out there where (“the place”). a sigg. I effort. terminate Joanne’s 3-minute about his work. Alaskan. chitter.] Almost like this. Smash. “I don’t know. What’s wrong with me? [Pause]. oh nuts! tion (“Swallmart—that’s almost it. (Cigarette) Estabrooks. master boy. I asked Jim to tell me elected to fill in the blank. stimulation is possible. 518 Section IV ■ Traditional Approaches to Language Intervention Patient [waving an issue of the American Kennel Club (“Where we buy medicine cheap”). No.” The clinician has response is called for. where is it? My caster. I could have done this by following up in Parenthesis) his correct response with questions such as “How’s busi- ness?” and “What’s your busy time of the year?” Helm. clinician Wernicke’s aphasia in conversation and whenever a specific signals to go on] “Alaska. I have a 18-4. TABLE 18–4 tion cannot be processed. however.” the patient for my blood pressure. it. of the patient with Wernicke’s aphasia can be dealt with indi- Those are my boys. new informa. With Jim. fere. Indirect approaches minimize the impact of anomic struggle In the above example.” Then. or point to the pillow on the bed. “I own a flower shop. Alasta. trained communication partner makes “on the spot” deci- The clinician’s knowledge of the situation and the patient’s sions as to how best to keep communication or track—or get interests in dogs allowed him to interpret the patient’s defec. smuch. on nuts. When the shutter is open. Keep Communication on Track (Target Word veration. “Do you have a family?” and he said “Yes. mastees. study revealed improved naming from pre. and the end-point for most of them is communicated his message adequately. in one study these patients generate little speech. numbers. such as location (Africa). Thus. Three specific methods—circumlocution-induced fully communicated that “he does not drink coffee because naming. approach is that speech should be the “hand. Many patients with elected to let it go. 1995. Thus. provided. Clark. tic features. and pointing.. 1995. Coelho.g. the clinician and the patient discuss topics of the topic to try and access the specific name. they search for specific words (self-cues) could be used to especially as the early post-onset period comes to an end and make decisions to fill in the missing word. a things in a series (e. how. Harrington. During therapy. therapy. Encouragement could be verbal (e. 2004. Personalized cueing is a procedure for treating anomia that has been used successfully with patients having a variety of types of aphasia (Freed. In the name of a picture. Wepman recommends had trouble. “Oh. The last example in Table 18-4 have been described in the aphasia literature (Nickels. for the patient with Wernicke’s aphasia to be able to to help her remember the word “bathrobe. Chapter 18 ■ Early Management of Wernicke’s Aphasia: A Context-Based Approach 519 was better to let the patient work through the difficulty. anomic deficits that has widespread popularity. such as connected speech. 1991) to aid communication. It is also helpful. and suggests that the best guide to using compensations for 1999) improve naming and that the benefits of this patients with Wernicke’s aphasia is whether the compen. the clinician and patient work together to cre- ing. Then.g.” In therapy. patients with Wernicke’s aphasia. Freed Compensations & Marshall. When she prestroke interest to the patient. or accept Circumlocution-induced naming is a novel approach to what has been produced and move on (Tompkins & the treatment of anomia. Some examples include going through is presented with a picture that is difficult to name (e. 2006). This worked for Paul (Davis. & Phillips. For example. 2006). patient to keep trying to produce the target word.qxd 1/21/08 1:02 PM Page 519 Aptara Inc. 1979) and body movements training are highly durable and result in improved naming of (Ahlsen. Results of the difficulties occur. 2002).g. 1976). but empiri. His rationale for this unique. actions (eats leaves). I drink Wernicke’s aphasia are concerned about their naming too much coffee myself” to give him feedback that he had errors. The patient cate in several ways. I have seen individuals Semantic feature analysis is a procedure for treating compensate for what they could not immediately communi. When using Using alternative modalities of communication (e. 1972). & Marshall. encourage the the patient is able to be treated directly. Drew & Thompson. the communicate using other modalities if talking fails. gesture. 2002). shows that the clinician has decided the patient has success. however. Several studies have shown that the benefits of this tures (Simmons & Zorthian. some specific methods for treatment shown that information provided by patients with aphasia as of naming may be useful in therapy for Wernicke’s aphasia. yes. Celery. Numerous direct approaches to the treatment of anomia “You’re almost there.”).GRBQ344-3513G-C18[507-529]. the therapist did not provide the name. and semantic feature analy- of a heart condition. a patient created the cue “old red one” ever. Boyle & Coelho. the clinician said. 2000) and other semantic treatments and search through them diligently. vidual’s intended thoughts and paraphrasing when anomic the therapist did not provide the name. she was encouraged to “talk around” this approach. A recent report described its use in Marshall. 2004). assessments.to posttest cally untested. when he needed one of these words during analysis (Boyle. primarily because remember an important word. 2004. Wepman.. Wepman’s content-centered therapy also puts communi. treatment generalize to untrained words and other speech satory efforts aid or hinder communication.. the therapist joined in the conversation and ignoring the patient’s struggles to find specific words and reinforced the information provided by the patient. and pointing) is highly recommended ate a personally relevant associational cue to help the patient for individuals with nonfluent aphasia. 2006. months. (Freed et al. 1981b. It has been argued that . maiden of thought” and not visa versa (Wepman. I remember that Paul used color (brown and yellowish). & Boyle. When the patient could not supply cation at the forefront (Martin. tasks. & Humphreys. personalized cueing. but reports administered at later points in time when the cues are not also show that patients with Wernicke’s aphasia can use ges. 1997). days of the week. long to write words that were important to him on small scraps of neck)..g. treatment of a patient with pervasive anomia (Francis. Freed. Several studies have shown that semantic feature paper. & Marshall. writing. The success studies show that these patients make little use of alternative of personalized cueing is assessed with naming probes modalities (Marshall. he would pull all the scraps from his jacket pocket McHugh. Some cue and the target word are repeatedly paired. Tompkins. Marshall & Freed. The Direct Approaches clinician gave the patient an encouraging gesture that signaled him to keep going. In treating many target words as long as 6 months after the end of treatment. It also has been anomic aphasia. this method. gesturing.. These do not necessarily fit within communicated successfully what he wanted to say and the context-based treatment approach. 1982. but keeping the discussion on track by reflecting back the indi. or giraffe) and is asked to respond to questions about its seman- names of family members) to come up with specific words. Scharp. and characteristics (tall.” This clinician deduced that the patient sis—are presented here. draw. writing. & Baynes. 1991) have expanded it Within the context-based approach.qxd 1/21/08 1:02 PM Page 520 Aptara Inc. 1991. Kearns. All are applicable to context-based representations. Also important to the that highly structured and constrained-task therapies will promotion of self-monitoring is to acknowledge and ease restrict the patient’s use of creative language (Stokes & Baer. or lower one’s voice). pictures unknown to each other following the PACE princi- ous aphasia classifications (Marshall & Tompkins. Also.. The PACE principles include (1) the use of new information. In the traditional patients with Wernicke’s aphasia rank last in terms of their PACE format. (Glindemann. 1986). Kearns & Scher. Hillis. & Yedor. point. 1991). der. & Willmes. increased the specificity of semantic Wernicke’s aphasia.and interper. but PACE could act of attending to signals from the environment and from be used with these patients inasmuch as their verbalizations the communication partner that are important to sustaining do not always conveying their intended messages (Ahlsen. oped. Kearns & Yedor. 2000). Intrapersonal monitoring involves attention to language Kitselman. At selection (e.. 1998).g. other researchers (Carlomagno. and increased activation of the semantic treatment. self-correction relates to intra. Losanno. the patient’s concerns about day-to-day variability in perfor- 1977). A recent are a product of the stroke will get better with time. Yedor. George called his wife “Mildred” on novel utterances with the goal of increasing the length and one day and addressed her as “Bernice” (his ex-wife’s name) content of those utterances. If the patient attempts to Response elaboration training (Kearns. “I Response Elaboration Training like the way you stuck with that. In ples. I said it yesterday. or PACE. why not 1986. Mildred. and talking about famous people) that fit within might say. & move closer. Several studies have shown that PACE improves the a larger sense. Springer. Glindemann. Huber. 1985). encouragement remains important RET. 1997). after a successful self-correction. study indicated that a modification of RET successfully increased the number of content information units pro- duced in response to picture stimuli by three speakers with Other Individual and Group Approaches chronic apraxia-aphasia (Wambaugh & Martinez. Marshall et al. and (4) giving feedback based on communicative ade- and who usually are successful. requesting. (3) freedom of communication channel are those who make the effort and sometimes succeed. At the lower end are those patients who fail to recognize (2) equal participation by patient and clinician as sender and or attempt to correct their production errors. draw. to incorporate other speech acts (e.. 1988.g. In the middle receiver of messages. since PACE was devel- to change roles or follow certain conventions (e. describing pictures.. Willmes. bargaining.. & Kearns. the clinician needs to help George Conlon. such as selection of a word or determi. word. be quiet. Most of the therapeutic improvement of the patient’s ability to elaborate on . however. 1985. Li. 1995. communication. These signal indicate when it is appropriate 1991. Research has shown that quacy rather than on production accuracy. Emanuelli. and he said “Mildred. all of which elevate tion and give the patient options to reflect his or her com- the word’s threshold for being retrieved (Boyle & Coelho. Interpersonal monitoring refers to the focused on patients with Wernicke’s aphasia.. 1991. patient can gesture. Huber. Mildred—stupid. was developed to exists for patients with aphasia and that the patient’s location make treatment situations more like natural conversations. Casadio. forces the patient for appropriate self-monitoring. the patient’s persistence should be acknowledged (e.”). the clinician elaborates on the patient’s mance. on the continuum was predictive of recovery from the disor. colleagues (Gaddie. 1991.g.” After a successful struggle to produce a specific word. or self-correct but fails. This upset the him. For and arguing) and tasks (e. & Springer. cartoon example. “That word was tough today. “That’s great that you changed to a different context-based approach. municative competence. communicative effectiveness of persons with aphasia sonal monitoring (Martin.g. Kearns. For example. Pulvermuller & Roth. the clinician rein.”). because they emphasize communica- network surrounding the target word. the clinician sequences. Promoting Aphasic Communicative Effectiveness Promoting Self-Correction Promoting Aphasic Communicative Effectiveness (Davis. 1981a). Dusatko. Several studies by Kearns and on the next. 1991. 520 Section IV ■ Traditional Approaches to Language Intervention these improvements result from possible repair of a dam. In using RET.g. 1985. or the upper end are those patients who always make the effort speak). 1982).GRBQ344-3513G-C18[507-529]. Other individual and group treatment approaches also can Although RET has been used sparingly with the patient who be used within the context-based approach with the patient has aphasia and is talking. approaches that follow are not exclusive to patients with aged semantic system.. Wepman (1958) suggested a continuum of self-correction 2005. today?” In this case.g. the clinician and patient take turns describing frequency and success of verbal self-correction among vari. its goal is to facilitate generalized who has Wernicke’s aphasia. structure and usage. 1993) have shown that RET increases understand day-to-day fluctuations in word retrieval efforts the verbal productions of speakers with aphasia. Davis and Wilcox. & Spinelli. is a loose-training procedure based on the premise (e. write. This body of research has not nation of word order. 1989. Roy patients with closed-head injuries.qxd 1/21/08 1:02 PM Page 521 Aptara Inc. 5 shows queen Dealer pays patient too much money Corrects error and gives money back to clinician (dealer) 2. dealer Signals for hit and receives an ace. The prob- the skills that would be worked on in the game of blackjack. and (3) tearing up her credit cards. 4  auditory comprehension (following simple command). 3. the information on interest when presented with several ing. poker. 3  simple computation. 2  decision making. 7 correcting erroneous information Using the Game of Blackjack as a Treatment Module: Examples of Clinician and Patient Actions Clinician Actions Patient Responses Skills and Abilities Mixes cards. 1997) capitalizes on the patient’s ability to recall and converse about events. signals he does not want to cut the cards 1. An added advantage is that some games provide the improve his speed. deals a queen to the patient Turns up cards to show “busted”. shows an ace Signals for “hit” or “stay” 1.. pennies. chips. nize and understand that improvement of communication is . With their appropriate was upset that it now took him more time disassemble and pragmatic and turn-taking skills.GRBQ344-3513G-C18[507-529]. dealer shows a four Turns up cards and smiles. how you met your wife. (2) Reminiscence meeting with a consumer credit counselor to develop a plan to pay off the debt. and places from earlier times. betting tokens (e. Monopoly. Credit card woes caused another group opportunity to work on cognitive and executive function member (Cecile) to develop hypertension. His aphasia can work on communicating in a context using such group came up with several organizational strategies to games. and guide patients Games provide an excellent resource for working on com. Eisenson (1964) defined “language therapy” as a relation- Reminiscence therapy can be used in a group or individual ship between the clinician and patient in which both recog- setting. checkers. 4 Deals king and six to patient. people. beans) allocated to clinician (dealer) and client (player). She failed to read skills that support language. and planning. patients with Wernicke’s reassemble his furnace than before he had his stroke. decision mak.” 3. Marshall (1993) describes a problem-focused group treatment approach that Games could easily be used to treat. such as attention. says. 7 Deals king and ace to patient. and what you were CONTEXT-BASED APPROACH doing when the World Trade Center was destroyed. During treatment sessions. Members work together to come up with solutions. such as buying a first car. For example. Table 18-5 provides relevant examples of credit card offers and went over her credit limit. gives cards to player to cut Cuts cards. support. 6  turn taking. with less severe Wernicke’s aphasia in managing day-to-day munication in a context. pushes money to dealer 2. game can be used to assess pragmatic language skills in alternatives. 2. 3. 2. context-based approach to treatment. it seems ideal for use with certain clients with Problem-solving activities also are suitable for use with the Wernicke’s aphasia. group members discuss problems that arise in their daily McDonald and Pearce (1995) have described how the “dice” lives. 2 Place your bet Puts out chips or tokens 1. “Oh boy.g. 5 Deals eight and two to patient. Usually. 5 Dealer pays even money instead of the Patient corrects error 7 blackjack rate conversational topics and share communicative burden.. Chapter 18 ■ Early Management of Wernicke’s Aphasia: A Context-Based Approach 521 TABLE 18–5 How the Game of Blackjack Could Be Used to Work on Improving Word Retrieval and Other Skills Materials: Cards. communication difficulties. Problem-Focused Treatment Thus. These might include blackjack.g. 2. 5 differential responding verbally or gesturally (e. lem was discussed in the group and resulted in her (1) seek- ing individual treatment to learn how interest worked. 5 for dealer After “hit” signal. and plans to solve problems. Reminiscence therapy (Harris. signals he’s “just right” 1. 3. and other similar games. Representative skills and abilities needed: 1  attention. these are salient DEVELOPING CONFIDENCE IN THE events deeply imbedded in one’s episodic memories. signaling for “hit” or “stay”). Step 2. this could be the case during the early convey the message in any way that he or she chooses. Table 18-7 provides another scale. 2  somewhat efficient. such as the Amsterdam Nijmegan 4  highly efficient. but not noticeable. 3  delayed. or pointing (P). go to Chicago for my sister’s wedding bility as therapists. drawing (D). gesture. require the patient to respond in some way. Importantly.qxd 1/21/08 1:02 PM Page 522 Aptara Inc. such as the PICA. 2000). 1995). to improve communication. within normal limits. 522 Section IV ■ Traditional Approaches to Language Intervention the purpose and the goal. ber of preselected responses. this Ramsberger and Rende (2002) have recently developed a should be a measure related to conversational success. nounced. The post-onset period. For this task. Those authors did this by context-based approach would be ill-advised. because suc. way to measure what has been understood and exchanged at Using a standardized test. Flexibility connotes a willingness writing. Transactional success was measured can be used to document the effects of context-based treat. Message Exchange Task Increasing Cognitive Flexibility The message exchange task was used in a study of informa- tion transfer with four patients with articulatory apraxia Clinicians who like order. 1990). Partner translates and notes elements of the message conveyed by speech (S). or drawing). the examiner scores those responses.GRBQ344-3513G-C18[507-529]. Marshall. Canceling (G) therapy (S) next week (P). Everyday Language Test (ANELT) and IFCI (reviewed 1  inefficient. to switch. that can easily be used approach need to free themselves of the guilt associated with to rate the communication success of the patient with conversing with the patient and not evoking a specific num- Wernicke’s aphasia in a conversational interaction. 3  efficient. examining the conversations of 14 adults with aphasia about cess on the PICA is integrally linked to retrieving the labels a series of I Love Lucy episodes. writing (W). certain tasks based on what is known about the patient. or 2  markedly delayed. Regardless of whether the clinician measures treatment outcomes directly on indirectly. 0  message not delivered. Step 1. Step 3. 1  delay made listener FIM. with a patient the end of a conversation between persons with aphasia and who has Wernicke’s aphasia and is being treated with the their conversational partners. Indirect measures. Direct measures. the documentation mea- Transactional Success sure must be representative of the treatment given (Marshall. earlier). clinicians who choose to use a context-based tence scale (Garrett & Sittner.. Table 18-6 provides an example. Clinicians seeped in the use of structured treatment The partner rates the efficiency and speed of message approaches will not be comfortable with the context-based exchange and records how each of the critical elements of approach. because it is a treatment demanding flexibility and the message were conveyed (e. the interaction compe. wedding (S) in Many direct and indirect measures are available to docu. require the clinician to rate the patient’s ability to do uncomfortable. The participants with apha- of 10 common objects that make up the core of the test. to deviate from a plan. Chicago (P) ment treatment outcomes (Fratalli. and to make on-the-spot decisions to enhance communication. For the context-based approach. 1992. a willingness to experiment. His view of therapy captures what TABLE 18–6 the context-based approach is designed to do—specifically. Partner rates speed of message exchange: 4  prompt. when the patient’s deficits are most pro- patient and the partner interact until consensus is reached. and Step 4. . speech. pointing. The patient is allowed to aphasia. Partner rates efficiency of message exchange: 2000). 0  no basis for understanding. and certainty may have (Fawcus & Fawcus. the patient is given difficulty working with individuals who have Wernicke’s a message to convey to a partner. clinicians need (1) to select the appropriate measure or measures to document Message: I am canceling therapy next week because I have to treatment outcomes and (2) to increase their cognitive flexi. such as the Functional Independence Measure (1993). gesture Measurement (G). To use the context-based Example of Message Exchange Task approach with confidence. Patient conveys message to partner. Experimentation involves balancing the science and the art—and having the Interaction Competence Scale common sense to focus on what is important to the patient. ners could convey after having a conversation with the patient with aphasia. 1998.g. by examining the amount and type of information the part- ment follow. In particular. however. control. sia had to relay information about each of the episodes to Some representative measures of transactional success that four different partners. but they do not require the patient to do anything. asking questions. What clinician do. or attention so as to respond in different and. how would you rate Communicator X’s total communication ability? —————————————————————————————————————————————————- 1 2 3 4 5 6 7 poor some good ability ability Cognitive flexibility refers to the ability to shift cognitive to communicate successfully despite the aphasia. 2000). Patients with aphasia do not use compensatory strate- involve considering alternatives and formulating ideas on gies unless they see the clinician doing the same thing one’s own. Keil & clinician who uses the context-based approach. what clinicians want them to do. text-based approach is hard work. come no script or set of steps to follow. How flexible and strategic was Communicator X when trying to convey messages that were not understood by others? —————————————————————————————————————————————————- 1 2 3 4 5 6 7 not some very flexible flexibility flexible 6. The patient learns to aphasia is associated with a greater degree of cognitive flex.. 1977. & Morrison. How much did the communicator participate in the interaction? —————————————————————————————————————————————————- 1 2 3 4 5 6 7 none some a lot 2. This is set. 1997). How frequently did Communicator X use different ways of communicating when trying to get his or her message across (e. hopefully. speaking. giving advice. Wepman. Cognitive flexibility is important to the patient’s success. and to do what is needed based on antecedent events. successful ways (Rende. How much of the time did Communicator X take an active role in the interaction by asking questions. or Augmentative Alternative Communication (AAC) system)? —————————————————————————————————————————————————- 1 2 3 4 5 6 7 didn’t use used some used many methods different methods methods 5. they do up with solutions to correct them. because this approach has Patients manifesting this trait recognize their errors. Purdy & Koch.. Using a con- Kaszniak. thought. or commenting) did the communicator use when conveying messages? —————————————————————————————————————————————————- 1 2 3 4 5 6 7 none some a lot 7. How many communication functions (e. 1972).GRBQ344-3513G-C18[507-529].qxd 1/21/08 1:02 PM Page 523 Aptara Inc. arguing.g.g. it also can be spontaneous and bility. Rigrodsky. On a scale of 1 to 5. writing. 2002. Chapter 18 ■ Early Management of Wernicke’s Aphasia: A Context-Based Approach 523 TABLE 18–7 Scale of Interaction Competence 1. 2005. Cognitive flexibil. greeting. generating unsolicited comments. How much of the time was Communicator X able to get his or her message across? —————————————————————————————————————————————————- 1 2 3 4 5 6 7 none some a lot 3. Successful communication by persons with (Simmons-Mackie & Damico. or expressing opinions? —————————————————————————————————————————————————- 1 2 3 4 5 6 7 none some a lot 4. compensate from the modeling and the demonstrations of the ibility (Chapey. and this requires continuous . ity can be reactive and involve altering one’s behavior in but clinicians also need to increase their own cognitive flexi- response to a situation. (2) directing more research effort at people with acute rather than chronic aphasia. This might involve the following: Advocacy 1. Hillis et al. Perhaps aphasia research has tion disorders.qxd 1/21/08 1:02 PM Page 524 Aptara Inc. chronic conditions (Elman. 459) to increase funding something that requires a great deal of skill and experience. who are being provided pharmacological and other medical Alarcon. case being carried out with very chronic patients.g. Results 4.. but has focused instead on those living longer just cloudy—the crystal ball is black. the growth of managed care threatened to reduce funding focused on the patient and the family during the early post- for treatment of aphasia. 2002). Introducing students to contemporary measures of People get terribly frustrated with aphasia. ment of aphasia in the graduate curriculum. things are worse now than when lished in 2001. & Frank. 1998. swallowing. Rarely. the future will see graduate students being jobs used to be. patient. something groups such as the National Aphasia Association. Armstrong. for several years. Olgar. this reports. Another study examined the frequency with which the word 3. front-line clinicians are of therapy for aphasia (Holland. and qualitative research demonstrate the benefits research is valuable. Three possibilities decisions. pay for it. a plethora of group. single-subject design. with chronic aphasia who may have adjusted to the condition. DeRuyter. Holland (1995) noted that the crystal ball Holland looked into the crystal ball in 1995 and the Balanced looked “cloudy” for specialists in neurogenic communica. Thus. Most old. impact of brain injury (Hillis & Heider. In slightly more than a decade. rather. Shisler. the crystal ball is no aphasia on the future. research being done closer to the time of the patient’s stroke. because no money is available to Crawford. Teaching students how to talk to physicians to help viduals have little knowledge of what aphasia is (Simmons. not long ago. of the disorder. Holland’s fears have been real. This is hope 2002. such as 5. & onset period (1–3 months). socialized medical-care systems. 2001). It is obvious what the future does not hold. are discussed here: (1) increasing advocacy for aphasia treat- ment. Nevertheless. Code. Including information about social approaches to treat- indicated that “aphasia” was found far less often than refer. Promoting altruistic behavior in students to stimulate Parkinson’s disease and muscular dystrophy.. Wertz & Irwin.GRBQ344-3513G-C18[507-529]. 2000. Congress to drop a boatload of money into the 2001). Developing mechanisms to keep abreast of the aphasia effort from those affected by aphasia (e. & Elman. sons with aphasia. Fromm. Robey. guard clinical aphasiologists remember that. 2002. but they do not assessment that capture how treatment impacts the die from it (Marshall. the results of that research will impact funding be done in the future to improve things. . & able to treat patients with aphasia much past the early post- Stein. literature. or sion. is cians and insurance companies” (p. 524 Section IV ■ Traditional Approaches to Language Intervention decision making. for the U. 1997).. Stiegler. families. FUTURE TRENDS Research Before the fourth edition of Language Intervention More aphasia research has not increased funding for treatment Strategies in Adult Aphasia and Related Disorders was pub. because they lacked empirical data to support the effi. It appears that the only clinicians who are able to see patients aphasia clinicians were under fire from the medical profes. That time has long most of the research on aphasia. Educating students about and providing them with “aphasia” occurred in newspapers in comparison to other experiences in group treatment. is past. that we will see in the future will be greater unification and 6. 1999. and professionals) to “energize and pressure politi- approach is more than just talking to the patient but. Robey. 1994. It is only possible to speculate what could and perhaps. 1996. Of course. because the rising costs of health care and had little effect on funding because it has not.S. Walker-Batson et al. survey of public awareness of aphasia indicated most indi. ences to less frequently occurring conditions. Ongoing research is studying people with aphasia funding for therapy remains scarce. onset period. with chronic aphasia work in universities. and Olswang (1999) to describe the present-day treatments shortly after the onset of aphasia to minimize the situation as ironic. Schultz. trained for the jobs they will have rather than for the jobs of the past. 2000). 2. This research. these are the people doing cacy of aphasia therapy (Darley. as the initiation of support groups and involvement in recommended by Elman and colleagues (2000). however. an international patient’s day-to-day life and psychosocial functioning. Today. the future may see more aphasia treatment hands of service providers to pay for more treatment of per. for aphasia treatment. when concern is greatest about the impact of ized. prompting Rogers. Regrettably. So perhaps. them understand that communication is as important as Mackie. VA hospitals. This underscores that using a context-based friends. however. Budget Act was passed in 1997. Baylis. 1972). which continues to grow exponentially. In fact. and (3) training future aphasia Training clinicians for what their jobs will be instead of what those Hopefully. & Elman. (pp. 24. Buffalo. E. D. Treatment outcome research and treatment pro. 236–249.. Develop a plan of action for facilitating Mr. and describe how these with Wernicke’s aphasia. St. In A. Hollis (Ed. (1995). Chapter 18 ■ Early Management of Wernicke’s Aphasia: A Context-Based Approach 525 KEY POINTS 3. Introduction to neurogenic communication dis- specific client with Wernicke’s aphasia. his stroke. J. & Coelho. would be reflective of semantic. Studies in neu- rolinguistics (pp. 13. Functional Independence Measure. Mr. & Albert. 281–295)..). 6. NY: State University of New York at Buffalo Research Foundation. C. D. M. Cortex. . Diagnosis and treatment of auditory disor- ders. (2004) Semantic feature analysis treatment for anomia in 1. Y. Neurological damage in Wernicke’s aphasia affects Wernicke’s and Broca’s aphasia. Body communication as compensation for aphasia requires knowledge of personal biographical speech in a Wernicke’s aphasic—A longitudinal study. 2. D. L. client-relevant assessment and treatment procedures. ment goals and improve generalization.qxd 1/21/08 1:02 PM Page 525 Aptara Inc. 281–306). New York: Academic Press. & Schokker. Kim.). Describe how you would convince a client with two fluent aphasia syndromes. American Journal of Speech Wernicke’s aphasia about to be discharged home 2 days Language Pathology.. seldom need physical and/or occupational Wernicke’s aphasia that would supplement your treat- therapy. causing aphasia. 8. Describe the types of responses on a naming test would because improvement following treatment of aphasia you expect from a patient with Wernicke’s aphasia that is dependent on changes in test scores on standard. (2002). American Journal of 2.. phonologic. but transcriptions differ in terms of phonologic. Training of students and successful use of a context- based approach with clients who have Wernicke’s Ahlsen. 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The relationship between self-correction 50–63). & Kaufman. or they reflect the impact of the subcortical lesion on the cerebral cortex. such as the far simpler and better understood than that of any other basal ganglia. with a par- ticular emphasis on the dysfunction of the underlying neural Leslie J. and less often by intracerebral hemor. the ven- cerebral cortical function (i. Subcortical aphasia is defined as a language disorder associ. For We will begin this chapter by describing the neural example. Although its function is by no means simple. the apha.g. For example. and to review behavioral consequences of subcortical lesions associated with aphasia that may seriously interfere with the rehabilitation process. we assume that therapy for specific deficits commonly OBJECTIVES associated with cortical lesions (e. We know of no ade- quately controlled scientific studies regarding the efficacy of therapy for subcortical aphasias. The remainder of the thalamic nuclei pathways between the thalamus and language cortex. word-retrieval impair- ment) will show similar efficacy when the lesion is subcorti- The objectives of this chapter are to elucidate features and cal. relay information from one part of the brain to another. 530 . In the case of subcortical aphasias lobe deep within the sylvian fissure. tral posteromedial (subserving the face) and ventral postero- tems). Chapter 19 Rehabilitation of Subcortical Aphasia Stephen E. a disorders of neural sys. For the time being. the thalamus is ated with damage to subcortical brain structures. Further research has shown this chain of nuclei within the brain stem to the medial genicu- assumption to be substantially incorrect (Nadeau & late bodies. guage function. these three pairs of nuclei relay with the vascular event that caused the visible subcortical information derived from sensory organs outside the brain to lesion. brum to the cerebellum and the putamen is relayed back to genesis of nonthalamic subcortical aphasias. the general vicinity of these structures. it functions as a relay device. it is caused Specific groups of neurons within the thalamus (nuclei) relay by ischemic strokes. Somatosensory infor- stemming from thalamic lesions. In the case of subcortical aphasias stemming from lateral (subserving the body) (Table 19–1). We also will separate portions of the ventrolateral nucleus of the thalamus. this idea requires testing.. visual information sia was assumed to be a direct consequence of the damage to is transmitted from the retinas via the lateral geniculate bod- subcortical structures that was revealed by structural imag. and that may have a major impact on prognosis.e.qxd 1/21/08 1:04 PM Page 530 Aptara Inc. 19–1 through 19–3). 1997). When these disorders were first described. We will conclude with mechanisms of thalamic and nonthalamic subcortical a consideration of nonlinguistic behavioral disorders that aphasias. In essence. Thalamic Aphasias The thalamus is located at the center of the cerebrum at its junction with the midbrain (Figs. from which it is lesions outside the thalamus. Nadeau and review the linguistic features of these disorders.. Usually. Thus. from which it is transmitted to primary auditory Crosson. such as computed tomography and magnetic occipital lobes. tions to the cerebral cortex. Clearly. the language disorders mation is relayed by two major pathways within the spinal appear to stem from the impact of thalamic dysfunction on cord and brain stem to two specific thalamic nuclei. Gonzalez Rothi systems that these disorders reflect. Auditory information is relayed through a resonance imaging. the thalamus. neural transmission from motor areas of the cere- mechanisms underlying thalamic aphasias and the patho. or the white matter pathways in cerebral structure. ies to the primary visual cortex (calcarine cortex) in the ing studies. sensory information from more peripheral neural waysta- rhages. the language disorders reflect then relayed to somatosensory cortex on the surface of the either invisible cortical damage or dysfunction associated cerebral hemispheres. Aphasia is actually an indirect consequence cortex (Heschl’s gyrus) on the dorsal surface of the temporal of subcortical lesions. to analyze these aphasias in terms of the impair.GRBQ344-3513G-C19[530-542]. frequently are present in patients with subcortical aphasia ments they reflect in the neural networks supporting lan. there- fore. Cartoon of the thalamus. (Philadelphia: Saunders Crosson. Chapter 19 ■ Rehabilitation of Subcortical Aphasia 531 Figure 19–1. caudate. ventral.) (imprint of Elsevier)). (From Nadeau & et al. ITP  inferior thalamic peduncle. Schematic diagram of essential relationships cortex involved in regulation of the thalamic gating mechanism. To prefrontal cortex Intralaminar Internal nuclei Anterior medullary nuclei lamina Dorsal medial LD VA To auditory LP cortex VL VPL Pulvinar VPM Medial geniculate body Central To motor medial cortex Lateral geniculate body To somatosensory Figure 19–2. CM  center median nucleus. and primary audi- tory cortex. depicting the loci of cortex via the ITP. with permission.. posterior limb of the internal capsule (ICPL). and putamen). the major nuclei. Major cerebral struc- tures and landmarks relevant to the problem of subcortical aphasia (thal- amus. visual cortex. located ante- medial from the lateral thalamus and containing the connec. NR  cortex To posterior association nucleus reticularis. the white matter fascicle separating the medial” in this figure. See To visual text for details. rior. midbrain reticular formation (MRF). and parafascicularis (Pf). NRVA  the portion of the NR immediately cortex anterior to ventral anterior nucleus that receives input both from the midbrain reticular formation (MRF) and the prefrontal Figure 19–3. Center median (Cm) is labeled “central nal medullary lamina. Medical Neuroscience. 1997.GRBQ344-3513G-C19[530-542]. is not depicted. ante- rior limb of the internal capsule (ICAL). lateral genicu- late body (LGB). From Nadeau tions between prefrontal cortex and CM. and medial to Cm.2004. . IML  inter.qxd 1/21/08 1:04 PM Page 531 Aptara Inc. how do we explain thala- MCA Middle cerebral artery mic aphasia in terms of dysfunction of these two regions? To MRF Midbrain reticular formation do so. where they synapse both on thalamic relay This two-way connectivity is entirely consistent with our neurons and on inhibitory thalamic interneurons. these nuclei—as. With low levels of arousal. The cells of this nucleus. The systems. the tions of the dominant hemisphere directly implicated in lan. for every nuclear group in the thal. gating mechanism on cortices supporting higher neural interfacing with ITP function. send their projections back into extensive as the projections from the thalamus to the cortex. Second. Two systems appear to be particularly important. First. they are admirably suited to regulating Of particular interest with respect to language and language. Thalamic relay neu- appears to be a logical relationship between dysfunction in rons fire at a rate that is a linear function of input. there to pass readily through the thalamus. The pulvinar-LP complex relays projections from the immediately below the thalamus.qxd 1/21/08 1:04 PM Page 532 Aptara Inc. high-frequency bursts that convey . the NR ulated or gated-relay device. (2) how do strokes impair its function. however. As we shall see below. relay neu- the temporoparietal cortex to the pulvinar-LP complex only rons fire in intermittent. unlike those in the amus—the cortical projections to the thalamus are at least as remainder of the thalamus. They emerging understanding of the neural network basis of brain employ an inhibitor neurotransmitter (-aminobutyric acid function (Nadeau. The MRF defines the level frontal. indeed. At this point. 19–3). the originating cortex—is subjected to the regulatory mechanism provided CdH Head of the caudate nucleus by the thalamic gate. in that they relay information originally derived The neurons of the NR are regulated by a host of brain from the cerebral cortex back to the cerebral cortex. anterior limb (the thalamic regions being linked most directly to the lan- ITP Inferior thalamic peduncle guage cortex) are extremely rare. Thus. VLa Ventrolateral nucleus. because of low input from the MRF. In this state.GRBQ344-3513G-C19[530-542]. For all layer of cells comprising the thalamic reticular nucleus (NR. relays information from the prefrontal cortex The first is the midbrain reticular formation (MRF). thalamic transmission to the cortex. 532 Section IV ■ Traditional Approaches to Language Intervention TABLE 19–1 to be sent right back to the very same cortex? One product of passing cortical information through the thalamus may be Abbreviations that this information—and. These nuclear groups resemble the ventrolateral rons within the thalamus. we DM Dorsomedial nucleus must address four questions: (1) how does the thalamic gat- IML Internal medullary lamina LP Lateral posterior nucleus ing mechanism work. Fig. considering that ischemic GABA -Aminobutyric acid strokes involving either the DM or pulvinar-LP complex ICAL Internal capsule. as in deep sleep It is more accurate to characterize the thalamus as a reg. temporal. what could conceivably be the neurons at the same time that these relay neurons receive purpose of long connections descending from. targets faithfully. With high levels of arousal. most specifically language function? The neuro- VA Ventral anterior nucleus scientific data needed to answer these questions are limited. and parietal cortices (including those por. nucleus. the thalamus. either by directly related processes are two other nuclear groups. anterior portion so our answers necessarily involve considerable inference VPL Ventroposteromedial nucleus and speculation. inhibiting thalamic relay neurons or by indirectly potentiat- medial nucleus (DM) and the pulvinar-lateroposterior (LP) ing their activity through inhibiting the inhibitory interneu- complex. plex network of neurons within the core of the midbrain tex. It appears that thalamic strokes sparing these Thalamus nuclear groups produce aphasia by damaging key compo- CmPf Center-median parafascicularis nuclear complex nents of the thalamic gating mechanism. DM. the dorso. thereby allowing all neural transmission back to these same cortices. This gating feature helps to neurons exert maximally inhibitory effects on thalamic relay address two questions. of wakefulness or arousal. MTT Mammillothalamic tract (3) what purpose could such a gating mechanism serve. VPM Ventroposterolateral nucleus How Does the Thalamic Gating Mechanism Work? Nearly the entire thalamus is enveloped by a paper-thin and from there back to motor areas of the cortex. 2001). thereby these two nuclear groups and particular features of thalamic functioning to relay the input to their cortical projection aphasias. by implication. a com- and several subcortical structures back to the prefrontal cor. for example. and NR Nucleus reticularis (4) what is likely to be the specific impact of disorders of the NRVA Portion of NR over anterior pole of VA. [GABA]). or coma. we must look for a cause of dysfunction other than PCA Posterior cerebral artery direct damage. MRF inhibits the NR at the same time that it excites thala- guage function) as well as from some subcortical structures mic relay neurons. little excitatory input from the MRF. or the CmPf itself. This anatomy plex buried deep within the posterior portions of the thal- provides a mechanism by which a given region of the cere. Because these bursts are associated with a par. It has been suggested that this blocked. 2005). therefore. 2006. Pinault. sion to specific regions of the cortex might be regulated tems provide a mechanism by which thalamic transmission volitionally. and the epochs of intermittent bursting can be observed in the NRVA. and the last 10 years have system has occurred since our last review (Nadeau & seen a surge of interest in the role of NR in attentional Crosson. which is imme- (NR neurons are GABAergic and. excitatory. 2004. The indirect corticothalamic regulatory system. little neuroscientific study of this intense study and much debate. 2005). 2002. providing a potential basis for ITP. This the subject is awake but not attentive or when the subject is disruption would implicate transmission from all thalamic . Immediately in front of ion channel–linked glutamate receptors (uniformly excita. 2006. either during drowsiness or during attention to another The second major regulatory system is provided by pro. cortex to CmPf. the IML carrying connections from the prefrontal awake state. Crabtree & Isaac. the MRF. Second. Empirical studies bear this out (see thalamocortical transmission are currently the subject of below). Cortical relay of thalamic input is effectively lus is presented in another. involv- tions from the prefrontal cortex to the NR via the inferior ing a pathway from the prefrontal cortex to the NR via the thalamic peduncle (ITP). now suggests that brief between the prefrontal cortex (the ITP). Fibers from the prefrontal bral cortex could shape thalamocortical transmission from cortex to and from the CmPf pass within the thalamus in a one or more nuclei both spatially and temporally. it is diately adjacent to the ventral anterior (VA) nucleus of the difficult to understand how this mechanism could serve to thalamus (Fig. 19-3). The Two possible explanations have emerged. by virtue of its sudden appearance. the internal medullary lamina (IML). they could effectively all ischemic strokes causing thalamic aphasia disrupt the break through ongoing cortical activity to signal the need regulatory system for the thalamic gate for the entire for a change in focus of attention or function. hemithalamus by damaging either the prefrontal-NRVA ciated with onsets of stimulus change and occur either when junction or the prefrontal-NRVA-IML-CmPf axis. 1999). This work has focused almost exclusively on of the Thalamic gate? the direct corticothalamic system. to play a role in regulating the entirety of the NR. the thalamic inter- system. inhibitory). How Do Strokes Impair the Function Sherman. This NRVA neural complex appears selectively release thalamic transmission to cortex. involving projec. all the thalamic tent burst mode of thalamic relay neuron activity to low strokes that have been reported to result in aphasia appear arousal states and closing of the thalamic gate. Thus. within the thalamus are prone to error. Two sub. attention elicited by the intrinsic cortical projections and synapse on NR neurons as they pass properties of the stimulus (Nadeau & Heilman. involving modality-specific cortical projections to mittent burst mode could serve as one mechanism underlying individual thalamic nuclei that largely reciprocate thalamo.qxd 1/21/08 1:04 PM Page 533 Aptara Inc. that will lead the organism to focus on a stimulus jections from the entire cerebral cortex to the NR. 1997). Both sys. a nuclear com- dendrodendritic contacts with one another. neural fascicle. Chapter 19 ■ Rehabilitation of Subcortical Aphasia 533 little information about temporal fluctuations in their input attending to a stimulus in one modality and a salient stimu- amplitude. and NR neurons have extensive the center-median parafascicularis (CmPf). it would seem logical that. McAlonan. In this way.. The projections from both the MRF and the prefrontal matergic and. 19-1 & Sherman. 1991). the thalamus. evidence in to have involved either VA at the nexus of the connections multiple species. therefore. stimulus. these fibers pass through the ITP. a given mechanism by which the prefrontal cortex regulates the NR neuron may project to neurons in several specific thalamic gate also appears to require the participation of regions of the thalamus. They are asso. amus (Figs. In this way. some of which may exert inhibitory effects (Cox and the deep white matter of the frontal lobe (Figs. Corticothalamic neurons synapsing on the NR and thalamic relay neurons are gluta. Although the means we use to localize strokes sion of MRF effects on NR activity we linked the intermit. Cavanaugh. dysfunction of this system The mechanisms underlying selective NR regulation of would lead to aphasia.GRBQ344-3513G-C19[530-542]. provides a mechanism by which thalamic transmis- multimodal regulation of thalamic transmission. may be particularly systems can be defined within this set of projections: a direct important (Sherman. and 19-3). & Wurtz. First. through the NR. it appears that ticularly high signal to noise ratio. the impact of the MRF on thalamic mechanism may serve to give the cortex a “wake-up call.” transmission is global and nonselective. including humans. to the extent the thal- gated to the cortex. amus is involved in language. Evidence also has emerged that NR neurons not only have which also envelopes the CmPf. Unfortunately. Because language largely is produced voli- from specific regions of specific nuclei can be selectively tionally. although in our previous discus. 19-2 and 19-3). Because this excitatory cortex to the NR terminate in a dense neural complex near input to NR neurons inhibits thalamocortical transmission the anterior pole of the thalamus (NRVA). processes (Bezdudnaya et al. that. which is tory) but also metabotropic (non-ion channel) glutamate continuous with the anterior limb of the internal capsule receptors. reactive attention—that is. and an indirect system. an opportunity to get a reward..” because it subserves attentional behavior and sequently appears on either the right or left of the screen that indicates to the constitutes a deliberate. attentional neuron required two inputs to fire. which do tion. that is. each of which is nearly infi. which is heav. Thus. no longer produced a reduction in reaction time. For example. this pathway.1 ily connected to language cortices. Moran and Desimone (1985) locus in the environment (i. the stimulus engages reactive experiment that sheds light on the potential role of the attentional mechanisms. inactivation associated dysfunction of the DM. must maintain reactive to bear on a particular problem—that is. which is heavily inter. volitional allocation of sensory subject on which side a subsequent stimulus is likely to appear (with 80% accu- racy). ment processes. tures and pathways. but flexible balance must be maintained between intentional nitely malleable. Walker. almost certainly the frontal lobes. providing the basis for a reaction Recently. If the selected neural network (e. On those 20% of trials when the cue is misleading. the validity effect was abolished—that is. Goldman- had been trained to pull a lever to be rewarded with of a Rakic. 534 Section IV ■ Traditional Approaches to Language Intervention nuclei. 1987). lever in response to a green light. because it indicated attentional behavior. The (visual) resources to achieve a particular end (get a juice experimental measure is the reaction time. Thalamic strokes that When CmPf was inactivated by injection of the GABAA- are not associated with aphasia appear to spare these struc. . In other words. agonist muscimol. No other CmPf axis (Van der Werf et al. A cue sub- attention. input from the frontal lobes prefer. although we prefer the more neutral term “selective failed to fire in response to a red light. memory that the color red is monkey had been trained to expect reward for a pulling a important. such as tion processes. The process exhibited by the monkeys in the exper. they identified enting.” In this conceptualization..g. Hemorrhages. the NR.e. tionally direct attention to the side of the cue. Attention also may be reactive (Nadeau & Heilman. this refer to the information maintained by activation of a neuron fired vigorously in response to the red light. orienting). including the pulvinar-LP complex. The term “working memory” often is used to squirt of apple juice whenever a red light came on. those supporting language function. Several far involve the selection of particular neural networks or lines of research have begun to delineate executive systems components of networks in cerebral association cortices in that serve this purpose. The cue will lead the subject to voli- reward). 1990). but with a somewhat longer reaction time. & Brown not respect vascular territories. sic value the brain assigns to these types of stimuli. Disorders of executive function also correct cues to the side on which the stimulus would appear often occur with lesions of the prefrontal-NRVA-IML. As soon as the stimulus actually appears. If the monkey able study over the past 20 years (Fuster. one from visual cortex processes represent the subtype of selective engagement signaling the presence of red and one from elsewhere in involved in allocating components of neural networks the brain. Phillips. the service of focusing sensory systems on some particular More than 20 years ago. it recruited red-sensitive neurons to working memory. entially sensitized red-sensitive neural systems. A precise nized into hundreds of systems. 1991. a this situation. Minamimoto and Kimura (2002) reported an time advantage if the stimulus actually appears on that side (the validity effect). of the CmPf produced a selective deficit of intentional atten- connected with prefrontal cortex. Friedrich. They trained macaque monkeys in the Posner paradigm. we orient to a brilliant flash of light or a What Purpose Could Such a Gating Mechanism Serve? sudden movement in our environment because of the intrin- The brain contains approximately 100 billion neurons orga. signaling located in sensory association cortices in the service of that red was behaviorally important. response. as in the experiment of Moran and Desimone. may directly damage the (1999) showed that a cellular lesion at a different locus along pulvinar-LP or DM. given (volitional) and reactive attentional systems. This corresponded to particular attention by the monkey to red lights. perhaps because of aspect of task performance was affected. An earlier experiment by Weese. Scientists were recording the activity of sin. this neuron 1985). Nonhuman primate research. Abundant reason performed a clever experiment that provides particular now exists to believe that precisely analogous processes insight into the fundamental nature of one of these alloca.qxd 1/21/08 1:04 PM Page 534 Aptara Inc. 2003).. however. 1991). had the same effect.GRBQ344-3513G-C19[530-542]. which ultimately lead the subject to make an orienting prefrontal-NRVA-IML-CmPf axis in intentional attention. processing demands either among the multitude of different The attentional phenomena we have been discussing so neural networks or within parts of particular networks. These processes have been the focus of consider- a neuron that was sensitive only to red light. the subject iment of Moran and Desimone can be termed “intentional begins by focusing on cross-hairs at the center of a computer screen. simultaneously. however. occur in polymodal or supramodal cerebral cortices. For example. that some systems function simultaneously to rat must engage intentional attention to search for edible maintain order and to optimize the resources that are brought material but also. this engagement. that correspond to gle neurons in the inferotemporal cortex (visual-association thinking and the formulation of behaviors other than ori- cortex) of macaque monkeys. During the red-light The thalamus also appears to support selective engage- rewarded condition. 1 In the Posner paradigm (Posner. & Rafal. In one study. systems that allocate attention to detect approaching predators. It appears logical that there should be. the subject makes a response. apparently normal grammar. That is. unilateral thalamic somatosensory information. Wester. phonologic processing that is engaged in repetition and digit modal association cortices. Thomas. 1990. even that have evolved in tandem with the burgeoning of cerebral when articulation was suppressed by the requirement that cortex in higher primates.. and delayed of the Thalamic Gating Mechanism on Function reorienting of attention have been induced by injection of of the Cerebral Cortex (Most Specifically the GABA-agonist muscimol into the pulvinar (Desimone. at this stage in the evolution of the brain. neglect. though to what extent the pulv. suggest that the thalamus is responsible for disorders of thalamic gating impact higher cortical function.. and rare patients. In nonhuman primates. Petersen. the result in shifting thalamic relay neurons into a linear transmission mode. and object regarding facts and events and ordinarily is available to 2 3 Note that we stress ongoing gated relay. extinction. Moberg. This finding is consistent with the evidence that superceded. Nadeau. ongoing attentional thalamic aphasia relatively spares repetition and. 2001) (see next section). & Absher (2002) Declarative or explicit memory consists of knowledge reported impairment on letter. object location. even though both hemi- involved to some extent in regulating the relay of spheres likely are engaged by these tasks. & Hugdahl (2001) reported that in conso. but it may be as discussed previously. cortices of visual or auditory information. and usually flawless repetition.. In nant-vowel dichotic listening tasks (in which processing the worst cases. These studies.e. lesions were disruptive. In this same thalamic nuclei such as the DM and pulvinar-LP complex study. some impairment in naming to con- supramodal association cortices supporting higher neural frontation. The thalamus appears to be only N-back tasks are widely accepted as probes of working minimally involved in ongoing gated relay to primary sensory memory—a function that depends on selective engagement. 2001]). in humans. Crosson. The mary sensory cortices. & Schneider. Thalamic aphasia most important in regulating selective engagement of associ. Dagenbach. Even so. let- tion How Does the Thalamic Gating Mechanism Work?). thereby N1 N-back task).GRBQ344-3513G-C19[530-542]. Brodmann’s area 22. vantage). indirect evidence suggests that subjects repeatedly say the word “the” during task perfor- their role in ongoing selective engagement has not been mance. and frontal operculum [Nadeau. Can we relate this exhibit a strong ipsilesional ear advantage. Chapter 19 ■ Rehabilitation of Subcortical Aphasia 535 suggests that. and we are dependent primarily on human data in the infer- Thus. with sparing of cortices supporting (hence the inability to overcome the contralesional ear disad. 1987). In N-back tasks. procedural memories (Nadeau & Crosson. thalamic gating mechanisms appear to be ences that we draw regarding this subject. & Gonzalez-Rothi. Naming deficits Recent studies have further elucidated this process. such as language. and so on. rela- modulation of neural activity in the pulvinar occurs in paral. transiently produce neologisms. The subjects has to respond when state may provide a mechanism to give the cortex a brief “wake-up call” that will the current stimulus matches the immediately preceding stimulus (i. attentional mecha. tively spares the procedural knowledge domain underlying lel with modulation of neural activity in visual and poly. disproportionately affect low-frequency words (Raymer. the thalamic burst mode ters) presented one at a time at a fixed rate. very shape N-back task performance3 in six subjects with old little of this regulation involves thalamic projection to pri. Robinson. is characterized classically by anomia in spontaneous lan- ation cortices (unimodal and polymodal) as well as guage (at times severe). 1997). at the thalamic level. forward digit span was normal in all subjects. & Morris. coupled with The neuroscience of thalamocortical interaction has not evidence of cortical dysfunction after thalamic lesions in advanced to the point of providing a precise picture of how human subjects. the Language Cortex)? Wessinger. the N2 N-back task). primarily those with thalamic hemor- patients with subacute and chronic thalamic hemorrhages rhages. modest impairment in comprehension may likely takes place in the auditory association cortex. Irvine. thalamic infarcts (five right-sided and one left-sided). Some patients make semantic paraphasic errors. . at least certain aspects of selective engagement of cortex.e. As noted in an earlier section (see the sec.g. the subject hears or sees a steady stream of stimuli (e. thus. These findings suggest a disorder of selective guistic deficits wrought of thalamic dysfunction reflect engagement affecting reactive attention (hence the ipsile.qxd 1/21/08 1:04 PM Page 535 Aptara Inc.2 For and the five patients with right-sided lesions. tion. span performance (Nadeau. which they cannot pattern of deficits to any fundamental functional attributes overcome even when told to direct their attention to the con. selective functional impairment of cortices supporting sional ear advantage) and intentional (volitional) attention declarative memories. 1997). be noted. normal articula- functions. the current stimulus matches the stimulus that occurred opening thalamic transmission to the cortex in a fashion that no longer is regulated before the immediately preceding stimulus (i. of the cerebral cortices involved? We have proposed that lin- tralesional ear. Of note. Kubat-Silman. and no clear differences were found nisms (selective engagement) involving visual and auditory in performance between the patient with the left-side lesion modalities have been subsumed by the cerebral cortex. inar modulation is responsible for cortical modulation cannot be determined from this experiment (Bender & What Is Likely To Be the Specific Impact of Disorders Youakim. 2001). and the DM and the anterior 1997): nuclear group of the thalamus (Squire. sion when reexposed to a stimulus previously presented too Panzeri. Although Witte. Butterworth. motor cortex.. Engelborghs. taneously for translation into a phonologic sequence. 1992). which would seem to be procedural in cept representations. the process of translating con. a process that clearly depends on declarative dence of syntactic simplification and. It is represented in association cor. and syllables as lexical ele- ory. Nondeclarative ments in their own right. For example. Production of a sen- cepts into clause sequences and appropriate phrase structures tence invariably involves modification of that distributed also largely is an automatic one and largely unavailable to concept representation. tions into a superdistributed representation. This “sublexicalization” may briefly to provide even a sense of familiarity. as when one’s able like any item in declarative memory and. and it usually involves generation conscious recollection (except to the extent that we deliber. Nadeau & Gonzalez-Rothi. In contrast. we How might this be explained? A concept representation. cept representations and the binding of these representa- the preponderance of data regarding phonologic and gram. The process of becoming literate serves to additionally Nondeclarative memory consists of a heterogeneous col- define phonemes. this finding is not easily reconciled with a concept to generate and maintain multiple distributed concept repre- that the thalamus is mechanistically involved only in declarative sentations (i. & Ferreri. inflectional grammatical morphemes. or ischemic lesion. Semenza. several structures in the explanation for the occasional occurrence of neologisms. 2006). De Deyn. and some forms of classical conditioning. This phenomenon also occasionally can be seen in mandating three arguments would correspond to the simul- patients with ischemic lesions (Ebert. Skills. the cerebellum. which are consciously retriev- memory is reflected only in behavioral change. patients with thalamic hemorrhages often have been “shooter old man” that now is linked to another new repre- reported to produce phonemic paraphasic errors and neolo. as whole words are ject demonstrates an autonomic response or a correct deci- (Bertelson & De Gelder. we are still left without an tices overlying the hippocampus. however. New declarative memories are pathologic excitatory phenomenon. limbic system. therefore. linguistic processes involving phono. 1997). sentation corresponding to “shot burglar. and possibly. & Mariën. implicit mem- derivational morphemes. let alone a basis create susceptibility to the production of sublexical for conscious recognition. neural network terms as a specific pattern of activation of the Although we have declarative knowledge of the concepts neurons in association cortices representing the various fea- about which we plan to speak.. The principal linguistic deficit exhibited by patients with thalamic aphasia is in lexical-semantic access (Nadeau & An important recent paper has provided compelling evi- Crosson. stitutes a neologism. this tidy picture cannot be reconciled one corresponding to an old man and one corresponding to a completely with available data regarding phonologic and burglar. and some forms of paraphasias manifesting as phonologic errors and neol- classical conditioning are represented in the motor and pre- ogisms in the presence of thalamic injury.GRBQ344-3513G-C19[530-542]. 1989. 536 Section IV ■ Traditional Approaches to Language Intervention conscious recollection.” The use of verbs gisms. lection of abilities (including skills and habits).e. the basal gan- 2. Thus. Vinz. 2001. Whether hemorrhage encoded by a system comprised of the hippocampus. tennis game improves with practice or an experimental sub- are susceptible to errors of selection. are worth remembering. cor. tures of that concept (see Chapter 26). It also requires reciprocal modification of these rep- grammatical function in patients with thalamic lesions. Unfortunately. habits. taneous maintenance and reciprocal modification of three Wallesch. Patients with impaired declarative memory generally have with the ultimate outcome being a word blend that con- preserved nondeclarative memory. & Herrmann. which presumably help to define which facts but we have offered two possibilities (Nadeau & Crosson. The disproportionate occurrence of neologisms skill in the modification of these various representations. agrammatism memories. rely on entirely automatic processes not available to conscious corresponding to a noun phrase. Unlike declarative memory. 1993) (see The production of normal syntax requires both the ability Chapter 26). nondeclarative memory inhibitory relationships within cortices supporting does not appear to require a special auxiliary processing semantics that competing semantic entrees can vie simul- mechanism like the hippocampal system to be instantiated. and addition of embed- it appears to represent dysfunction involving phonologic ded clauses will demand still further active distributed con- sequence knowledge. neously generating two distributed concept representations.qxd 1/21/08 1:04 PM Page 536 Aptara Inc. Because distributed concept representations. Thalamic lesions may sufficiently disrupt mutually glia. Raymer et al. 1990). resentations to yield a new representation corresponding to First. 1999. the sentence “the old man shot the burglar” involves simulta- stantial sparing of procedural memory systems. Görtler. . matical processes in thalamic aphasia appears to indicate sub. nature (Nadeau. with acute hemorrhage raises the question of some kind of tices throughout the brain. 1987. in a patient with bilateral paramedian thalamic infarcts (De logic processing and grammar generally are spared. and reciprocal modification of two or more distributed con- ately modify grammar to meet situational demands). we have declarative knowledge of the spelling of words. 1. 1997). possibly. selective engagement/working memory) and processes. Wilssens. can be represented in recollection in the actual production of spoken words. First. Witte and colleagues. even though we suspect that in and it likely involved the prefrontal-NRVA-IML-CmPf axis Broca’s aphasia. whether the reference should be definite or indefinite. the description of remote memories—a problem reminiscent of putamen. and the interleaved anterior limb of the internal adynamic aphasia. however. simplification of syntax. selective engagement caused by thalamic lesions could pro. Nevertheless. That is. needed working memory are integral to this apparatus or De Witte and colleagues appear to be the first to provide that frontal networks involved in this selective engagement such detailed evidence of syntax simplification and at least are. and major disruption ure to produce the article. in fact. mic aphasia as a disorder of declarative knowledge processing. ently is confined to structures that appear to have nothing to portionately impaired ability to elaborate in the spontaneous do with language (i. severe anomia. a passage from one story slides cally modify multiple distributed concept representations into another story. . It also the perisylvian component of the lesions) makes a major extended relatively anterior and deep. 19-1). at least with certain uncommon thalamic of aphasia after nonthalamic subcortical lesions appears to be lesions.GRBQ344-3513G-C19[530-542]. reflecting mechanisms into words but that these representations cannot be sustained of stroke pathogenesis. In adynamic aphasia. the development leagues suggests that. Crosson.. The report of De Witte and col. the very existence of aphasia in patients . 1984). because this infarct appar- ture.. . hence. excessively brief. Raymer and colleagues (1997) noted normal syntax in a Absent working memory of what has been said. or might it reflect something unusual about their patient’s duce a pattern of language abnormality having some similar. rules of syntax (see Chapter 26). Second. It his ideas” (p. among other things). we chose to complete failure of endogenous engagement. Chapter 19 ■ Rehabilitation of Subcortical Aphasia 537 Broca’s aphasia occurs with lesions that damage the frontal problems with conceptual delineation and sequencing in apparatus that is apparently required to modify distributed patients with thalamic lesions. to some degree. verbal amnesia. Even some abnormalities of somewhat unusual. anatomically separate. as in adynamic simplify by focusing on one type of subcortical lesion pro- aphasia. the patient cannot control the order of (and. potentially destroying contribution to agrammatism (see Chapter 26). nonthalamic subcortical in the manner necessary for them to be related to each other aphasias are not fundamentally different in character or and modified in the well-practiced ways that instantiate the pathogenesis from cortical aphasias. no longer chronologic .qxd 1/21/08 1:04 PM Page 537 Aptara Inc. lesion? The lesion in their case might. infarct. & Hada. working memory deficits. .e. the problem of nonthalamic subcortical aphasia term “paradynamic” to describe the patient of De Witte and seems formidable. given the enormous variety in size and colleagues to indicate that the fundamental problem involves location of lesions as well as the spectrum of linguistic disor- endogenous selective engagement but also that. 1997. We did so for two reasons. the head of the caudate nucleus. the lesion was bilateral (as grammatical morphology might be explained in terms of in the case of many paramedian artery distribution infarcts). prefrontal-to-DM pathways that run beneath the thalamus ple. the use of articles is particularly dependent on sustained before curving upward to extend into the DM (Nadeau & working memory of what has just been said to determine Crosson. subjects with adynamic aphasia a natural consequence of the disrupted function of neural perform relatively normally. In our approach to this problem. as Whereas the development of aphasia after thalamic lesions is in a picture description task. the loss of phonologic sequence knowledge bilaterally. systems implicated in language processing. subjects appear to be incapable of endogenous generation of any distributed concept representa- tions. 1997). rather than a ders observed. distributed concept representations can be generated largely a consequence of direct damage to language cortices endogenously to the degree that the patient can translate them that is not visible on imaging studies. have been ities to that of Broca’s aphasia. & Maly (1983) noted dispro. if these ideas find support in future investiga- The notion that thalamic lesions can lead to disorders of tions of syntactic disorders and agrammatism in subjects with endogenous generation of distributed concept representations thalamic aphasia. we might employ the At first. their affixes. ducing aphasia. He noted that “narration is concept representations and is certainly required to recipro. it constitutes disjointed. and substan. . When distributed con- NONTHALAMIC SUBCORTICAL APHASIA cept representations are generated from without. Goldenberg. In particular. Steriade. Does De Witte and colleagues (2006) suggests that disorders of this merely reflect the thoroughness of their investigation. The report of some evidence of agrammatism in thalamic aphasia. this is a Intimations of the problem observed by De Witte and relatively common lesion that is typically fairly stereotyped colleagues can be found in the older thalamic aphasia litera. 106). in size and configuration. 1997). Lhermitte (1984) observed evidence of capsule) (Fig. as in the case described by De of prefrontal function. hence their extreme nonfluency. and short phrases (caused by engagement involving the pulvinar-LP and DM. the lack of a patient with a very large left paramedian artery distribution concept of definiteness or indefiniteness may result in a fail. In summary. the striatocapsular infarct (Nadeau & tially dysfunctional engagement. Wimmer. thus producing bilateral disorders in thalamic involving words. For exam. it may still be possible to account for thala- invites comparison with adynamic aphasia (Gold et al. In contrast. Parent. He also noted that disorders of this type may be that selective engagement mechanisms supporting are seen in patients with left frontal lesions. Thus. ing to the pattern of the language impairment observed tex becomes entirely dependent on blood flowing backward (Nadeau & Crosson. This cor. conversely. such as artery. 2002.g. This hypothesis regarding the mechanism of nonthalamic sia. aphasia (Hillis et al. In fact. the cortex will be relatively spared. 2004. but this clearly is not the case. evidence of earlier cortical damage involving neurons or if they are sparse and small. and much of the putamen. 1997). One would then expect aphasias of all types— any cortical abnormalities.) with this lesion provides compelling evidence of either an with acute striatocapsular infarcts and otherwise normal unrecognized neural mechanism or a completely non-neural structural images (including DWI). dramatic reductions in cortical blood flow in precisely the The striatocapsular infarct is caused by the propagation regions that would be expected from the character of the of thrombus or the embolization of blood clot into the prox. might object that if ischemia exists sufficient to cause apha.. temporal region in patients with features of Wernicke’s There.. the damaged tissue should be apparent on imaging stud.qxd 1/21/08 1:04 PM Page 538 Aptara Inc. If these anastomoses ies demonstrate hemispheric cortical atrophy—unequivocal are abundant and large. It Functional imaging studies in patients with chronic non- should be noted. later no focal abnormalities are observed on anatomic imag- tions (anastomoses) with branches of the anterior cerebral ing studies of the cortex in these chronic patients. aphasia). causing essen. although a year into the middle cerebral artery branches from their connec. the latter proved to be the case. delimited only by the pattern and adequacy of arterial diffusion-weighted imaging (DWI). 2002). Nadeau & Crosson. hypoperfusion in the posterior perisylvian imal (M1) portion of the middle cerebral artery (Fig. One their connections (Weiller et al. that this same clot also severely thalamic subcortical aphasia also demonstrate reduced blood reduces the flow of blood to the middle cerebral artery flow or metabolism in cortical regions precisely correspond- branches supplying the overlying cerebral cortex. 2004. at least within the first 24 hours or even no aphasia at all—with striatocapsular infarcts or any (Hillis et al. tially complete infarction (death) of these structures.. 538 Section IV ■ Traditional Approaches to Language Intervention Figure 19–4. 1993). Even newer and more anywhere within the cortex supplied by the middle cerebral sensitive magnetic resonance imaging techniques. the clot occludes the lenticulostriate arteries supply. the stud- artery and the posterior cerebral artery.. (From Nadeau et al. Anteroposterior view of cere- bral vascular anatomy relevant to the prob- lem of nonthalamic subcortical aphasia. a massive stroke will occur. the anterior limb of the exhibit no reductions in cortical blood flow do not have internal capsule. 19–4). with permission. aphasia (e. subcortical aphasia predicts that cortical damage could occur ies. patients with subcortical lesions who ing the head of the caudate nucleus. Furthermore..GRBQ344-3513G-C19[530-542]. 1997). have shown mechanism. however. however. Studies of cerebral blood flow in patients other subcortical infarct reflecting proximal middle cerebral . may fail to demonstrate anastomoses. Infarcts of the midline thalamus. by thalamic lesions.. with impaired arousal will have impaired attention. Nevertheless. During the last 20 years. disrupting thalamic prognosis for an active. Because these patients directly from the cortical damage. The precise impact depends on the locus of the pre- important to identify these types of deficits ahead of time. however. in which patients fail to attend or respond to any PROCESS stimuli presented in the left hemispace. however. atten. and refinement of speech/language therapy.. Goldberg. Haas. A host of disorders commonly produce transient dys. Patients with nondominant hemisphere dysfunction. These patients often experience lethargy that. even mental plasticity of the adult cerebrum have increased 100- patients with dominant hemisphere lesions (cortical. this turns out to be the case. 1993. and intracerebral masses). function of the MRF (e. subcorti- fold. patients develop persistent dysfunction because of embolism cannot be relied on to sustain goal-oriented activity. & Perkins. 1992). cortical distractible. This same disorder sometimes is seen with dominant hemisphere lesions but. it seems that any type of cerebral dysfunction cal. occasionally. Faced as we are with overwhelming Frontal systems dysfunction may impede therapy in other pressures to optimize the use of our treatment resources. This behavior may substantially undermine any aphasias may implicate both declarative and procedural rehabilitation program. appears to be critical to for reasons that are still poorly understood and controversial the very conduct of the rehabilitation process. Chapter 19 ■ Rehabilitation of Subcortical Aphasia 539 artery occlusion. These functional systems include arousal. hemianopia or program. most often caused by parietal lobe lesions (cortical or nonthalamic subcortical) and. Patients with dorsolateral frontal system dysfunc- cortical blindness]). and frontal systems. & Heilman. is much less severe. Typically. Thus. Patients mentally different from cortical aphasias. they are unable to also may disrupt frontothalamic projections traversing the engage fruitfully in rehabilitation efforts. into the putamen. and may MRF. with frontal system dysfunction also often will have a disor- ter or pathogenesis. Thus. interactive life is poor. well as lexical-semantic function. often extend caudally into the addition. We suggest that. may be problem- atic and the prognosis for meaningful advances in therapy rela- tively poor. In of which produce aphasia. Nadeau & Heilman. and that they should be treated in the der of intentional or volitional attention. but particularly rehabilitation at the level of sophistication 1997. but it also may be a feature of patients with mid- impairment in grammatical and phonologic function as line thalamic lesions. Indeed. actively resist any type of intervention by caretakers. Most often. dominant pathology. it is ways. Nadeau.g. some tion may retain strong motivation and exhibit excellent . metabolic disorders. they are limited in their thalamic lesions. tion. Striatocapsular infarcts behave as if they are constantly half-asleep. any rehabilita- Crosson et al. 1991). and they tend to be very to impairment in declarative memory systems. Hemorrhages into the putamen can produce pressure on overlying cortex with Attention associated ischemic damage. infec. In principle.. often will NONLINGUISTIC BEHAVIORAL DISORDERS exhibit a hemispatial disorder of attention known as hemispa- RELEVANT TO THE REHABILITATION tial neglect. cannot carry out multi-step commands. Patients with midline frontal systems dysfunction tend to be akinetic in their general behavior and Arousal nonfluent in their language. and to the top of the basilar artery. even though their same way. Both of these types of supplying the MRF. (Coslett. or thalamic) without apparent right hemispatial neglect might be susceptible to rehabilitation. The function of several may benefit from presentation of stimuli in the left hemispace fundamental cerebral systems. superficially to be normal. disrupt the connections between language although most severe initially (to the point of coma).g. and they commonly include bilaterally. some subcortical infarcts. Schwartz.GRBQ344-3513G-C19[530-542]. which occludes small vessels tend to be socially inappropriate. function as well (Tatemichi et al. drugs. and their long-term anterior limb of the internal capsule.. In fact. Frontal Systems Dysfunction tion. Crosson. nonthalamic subcortical aphasias are as is seen with lesions implicating the dorsolateral frontal lobes varied as cortical aphasias. when these systems are substantially impaired. No treatment has been shown to thalamic aphasia to whatever language disorder results be effective in mitigating this lethargy. This type of impairment most often systems. 2005. often cortex and the thalamus. our estimates regarding the funda- characteristically. Schwartz. which appear to be intrinsically limited ability to sustain focused attention.qxd 1/21/08 1:04 PM Page 539 Aptara Inc. as well as one or both posterior cerebral patients pose major challenges for any type of rehabilitation arteries (hence abnormalities in vision [e. either in charac. they are poorly moti- Impairment in arousal typically reflects dysfunction of the vated. but they tend to be irresponsible. unlike aphasias resulting from level of arousal is normal. as well as hemorrhages MRF. they likely add features of persists for months or years. Patients with orbitofrontal system dysfunction may appear tions. One can immediately conclude from this discussion Arousal is a necessary substrate for attention. so patients that nonthalamic subcortical aphasias likely are not funda. Furthermore. These patients typically appear this chapter. exhibit some features of adynamic aphasia. “I’m too tired.. These patients are poorly motivated to patients. Gating Mechanism on Function of the Cerebral Cortex [Most mic subcortical aphasia unless bilateral lesions exist. Patients with nondominant hemisphere lesions (sel. made in the hopes of clarifying fundamental perform almost normally. they typically in particular. usually with bilateral lesions. When not lethargic. It may be nant hemisphere lesions.” Other patients exhibit selective FUTURE TRENDS impairment in their ability to generate distributed concept The proposed mechanisms of thalamic aphasia discussed in representations from within. strokes. 540 Section IV ■ Traditional Approaches to Language Intervention cooperation in rehabilitation programs. KEY POINTS however. It characteristically is be seen. they exhibit the most profound lack of motivation. have not ing either not to respond or to respond with single words or been adequately tested empirically.qxd 1/21/08 1:04 PM Page 540 Aptara Inc. cerebral association cortices corresponding to that concept. the proximal into the articulatory motor sequences that will produce occlusion of which is directly responsible for the visible sub- sounds that are intelligible to others. When asked. . Often. global aphasia. is termed “agnosia. Aphasia caused by thalamic lesions of any rehabilitation efforts (e.g. put sim. we have the power to intentionally generate a dis- and frontal systems function and causing lethargy. may distributed concept representations in response to specific limit the effectiveness of speech therapy. It is they reflect some blend of midline and orbitofrontal sys- characterized almost exclusively by lexical-semantic dys- tems dysfunction.” “I’m too busy.” “I language as a result of damage to the thalamic mechanisms think I’ve already done enough of that this week”). as well as lesions impacting frontal systems function Some rare patients. Disorders of brain systems supporting arousal. inatten- tributed representation corresponding to a concept from tion. First. Aphasia caused by nonthalamic subcortical lesions predominantly reflects acute hypoperfusion of the cortex or Concept Formation chronic damage to the cortex that is not apparent on struc- tural imaging studies. Concepts can be gen- cortical lesion. and nonthalamic at something. that patients with paradynamic aphasia (see the section What Frontal systems disorders manifested in these ways Is Likely To Be the Specific Impact of Disorders of the Thalamic rarely are a significant problem in patients with nonthala. 1997). often are excellent candidates for speech patients with thalamic infarcts associated with aphasia may therapy. Nonthalamic subcortical infarcts therefore erated in two fundamentally different ways. They will be unable to name or describe the properties or use of objects they are observing. fluent because of the more fundamental underlying deficit ply. Whether our applica- short phrases. 1988). types of sensory input. are almost uniformly dates for rehabilitation. This disorder is termed “ady. which often are seen with thalamic within—a fragment of a process we refer to as thinking. This disorder. however. Patients with domi. Subcortical aphasia is logically divided into thalamic and even to the point of perpetually placing obstacles in the way nonthalamic types. most often seen after lesions of visual path- ways. The side of the seen with frontal lobe lesions. a concept is automatically elicited as the visual subcortical aphasia is not fundamentally different from cor- input automatically generates a distributed representation in tical aphasia. For similar reasons. such as patients with Broca’s or seen with nonthalamic subcortical infarcts. anosognosia (denial of illness) or anosodiaphoria (lack of Effective speech therapy is not absolutely precluded in such concern for illness). because. however.. often exhibit in these cases is the fullest form of this disorder seen. caused in turn by ischemia in the dis- Spoken language depends on the translation of concepts tal territory of the middle cerebral artery. In addition. for selectively engaging cortical neuronal networks. they either do not recognize the problem or do not care (Huntley & Rothi. disorders of endogenous concept formation. but spontaneous language is unlikely to become participate in any rehabilitation program. human lesion studies as well as animal research. attention. most often affecting the dom- lesion often assumes major importance. or poor motivation.” “I have appears to reflect dysfunction of cortical systems involved in another appointment in two hours. we suspect about it. inant frontal lobe or being bilateral in location. Thus. associated with prominent frontal systems dysfunction. ultimately will be vindicated also remains to namic aphasia” (Gold et al. mechanisms. these patients often appear superfi- cially to be quite normal in their general demeanor. to describe a complex tion of the declarative/procedural dichotomy to language picture (in which case distributed concept representations processes in general.GRBQ344-3513G-C19[530-542]. although both cogent and supported by to be profoundly nonfluent in spontaneous language. Second. however. tend. and to thalamic subcortical aphasias are automatically generated from without). function. may (frontal or thalamic) and causing adynamic or paradynamic exhibit impairment in their ability to automatically generate aphasia. Specifically the Language Cortex]?) also likely are poor candi- Midline thalamic lesions. although rarely dom seen for aphasia rehabilitation). if we look may be associated with any type of aphasia. 5. & Youakim. Lexical-semantic function can be readily understood in language function. be susceptible to occasional dis- the frontal lobes. In most cases. The thalamus is best understood as a gated relay involved. Thalamic aphasia occasionally is caused by hemorrhage into the thalamic nuclei most directly involved in language. Are thalamic and nonthalamic subcortical aphasias best volitionally by the frontal lobes acting through a viewed in terms of loss of language knowledge or in complex system that involves the thalamic NR. It is characterized predominantly by neologisms or exhibit disorders of grammar appear lexical-semantic dysfunction.). The predominant deficit infarcts) appears to reflect dysfunction of cortical sys- observed with thalamic lesions—namely. at any given time to process a particular stimulus and Bezdudnaya. Aphasia caused by nonthalamic subcortical hemor- and grammatical dysfunction may be understand- rhages or infarcts stems mainly from acute hypoper- able. Effect of attentive fixation one entire half of the thalamus. Cambridge: MIT Press.. Learning about reading engagement of cortical systems—that is. 85. thalamic aphasia appears to cause disorders of 4. Aphasia caused by thalamic lesions (hemorrhages or declarative knowledge. and the brain systems supporting relays cortico-cortical transmission from portions of knowledge acquisition. This is particularly seen with mid- 2. and dysfunction of this nucleus in terms of factual knowledge—that is.. A good correlation exists between the type of aphasia observed and the pattern of cerebral blood flow or ACTIVITIES FOR REFLECTION AND DISCUSSION metabolism seen on functional imaging studies. Consider how certain aspects of phonologic and or spoken word forms by concept representations. Galaburda (Ed. B. to challenge this concept. Discuss the differences between declarative and proce- line thalamic lesions. From reading to neu- online of particular cortical neural networks needed rons (pp. C. The thalamic gate can be opened or closed nonselec- Consider how this can be explained in terms of the aber- tively by brain-stem structures.. Neuron. (1989). thus. the pulvinar-LP com- plex and the DM. and parietal lobes involved in 3. T. thalamic mechanisms for selectively engaging corti- The rare subjects with thalamic lesions who produce cal networks. Chapter 19 ■ Rehabilitation of Subcortical Aphasia 541 KEY POINTS 7. the frontal. M. R.qxd 1/21/08 1:04 PM Page 541 Aptara Inc. A. & Swadlow. grammatical function also might involve declarative The DM relays cortico-cortical transmission from knowledge and. In A. and dysfunction of this nucleus in ruption in subjects with thalamic aphasia. the bringing from illiterates. declarative memo- thalamic aphasia appears to impair the engagement ries. H. 3.GRBQ344-3513G-C19[530-542]. however.. Journal of Neurophysiology. . 421–432.M.. inattention. of speech therapy... Thalamic burst mode and inattention in the awake LGNd. Y. 1–25). Cano. 49. all of nisms? Discuss these mechanisms in relation to atten- which are behaviors that may limit the effectiveness tion and language. thalamic gate can be opened or closed selectively and 5. The with stroke. however.. inmacaque thalamus and cortex. The thalamus is a key component of one of the many 219–234. M. dural memory in terms of the types of knowledge 4. Lesions causing thalamic aphasia also may cause 1. as disorders involving declarative fusion of the cortex or chronic damage to the cortex knowledge. Alonso. including the MRF rations in blood flow to the brain that commonly occur responsible for maintaining our level of arousal. Portions of the thalamus implicated in language function appear to be involved in processes involving 1. 6. Stoelzel. generate an appropriate response. and the CmPf deep with the thalamus. Bereshpolova. It may be characterized by any of the linguistic disor- ders seen with aphasia caused by cortical lesions. terms of loss of access to language knowledge? Why? which envelopes the thalamus. (2006). B. M. thalamic References aphasia appears to be caused by disruption of the frontally controlled selective gating mechanism for Bender. and poor motivation. that is not apparent on structural imaging studies. exhibit nearly any pattern of language impairment. D. & De Gelder. mechanisms in the brain that enable selective Bertelson. Subjects with nonthalamic subcortical aphasia may endogenous concept formation. The pulvinar-LP complex of the thalamus types of knowledge. Why does the brain need selective engagement mecha- lethargy. (2001). lexical- tems involved in language as a result of damage to semantic dysfunction—is consistent with this idea. J. temporal. Production of neologisms 2. P. the manner in which the brain acquires these device. R. 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Alzheimer’s disease [AD]) impair cognitive functions dif- OBJECTIVES fusely and only rarely (or never) in a focal or selective way. is caused be resolved.e. AOS. considered to be in its chronic state. in the absence of other CNS deficits. often with aphasia and/or cacy data summarized and discussed. Less well recognized is the fact that AOS aspects of management as well as the meager treatment effi- can present in the same way. or improving minimally without intervention by relatively focal damage to the language-dominant hemi- and. the rules and representations of onset. the and the variety of possible underlying autopsy-based patho- condition is commonly referred to as “primary progressive logic diagnoses reviewed. All of these etiologies sensory or motor deficits or to a loss of the representations usually are acute or subacute in onset. ria for their diagnoses reviewed. These deficits are not attributable to infection can cause aphasia and AOS. or rules of language. listening. common neuroimaging findings tial period of time—or perpetually.. The generally accepted princi- ple was that degenerative neurologic diseases (e. what we understand about their nature. (PPAOS) is an appropriate diagnostic label. Because considerably dysarthria but sometimes as the only communication more is known about PPA than primary progressive AOS. the characteris- the presence of degenerative neurologic disease and that it tics of the aphasia. Chapter 20 Primary Progressive Aphasia and Apraxia of Speech Joseph R. McNeil incompatible with a diagnosis of degenerative central ner- vous system (CNS) disease. and their natural (i. cisely timed patterns. and theoretic and philosophical aphasia” (PPA). the language domain. followed by decelerating physiological improvement. sphere (usually the left) and is most often (but not in the case 543 . and inhibit.. language. talk- etrating head injuries. any aphasic-like difficulties in individuals with degen- erative CNS disease presumably were embedded within a In this chapter. tumors. When this happens. and ing. but progressive apraxia of speech (AOS) will be defined.g.g. In such cases. and gesturing). clini.. Thus. reading. syntax. and management is We reserve the term “aphasia” for language processing overwhelmingly based on data derived from people in whom deficits that cross levels or domains of language (e. and associated motor speech may be the only manifestation of CNS disease for a substan- impairments summarized. Duffy and Twenty-five years ago. their common presenting It now is commonly recognized that aphasia can announce histories and basic demographics discussed. activate.GRBQ344-3513G-C20[543-564]. impairment.qxd 1/21/08 1:05 PM Page 543 Aptara Inc. primary progressive aphasia (PPA) and primary constellation of cognitive difficulties that might include. the crite- always extended beyond. prognosis. “primary progressive AOS” the primary emphasis of this chapter will be on PPA. semantics.. They result from deficits of the cogni- untreated) course usually is considered to be one of sudden tive apparatus used to buffer. thus. assessment. and phonology) as well as cians recognize that the conditions of closed-head and pen. diagnosis. these conditions were stroke-induced. surgical complications.g. in pre- or subacute onset. morphology. PRIMARY PROGRESSIVE APHASIA Because aphasia and apraxia of speech (AOS) are most com- Basic Definition and Terminology monly caused by stroke. most speech-language patholo- gists and neurologists would have considered aphasia to be Malcolm R. imply that the aphasic has had a number of aliases. particularly early in avoid advancing yet another term to describe the emerging literature on this etiologically based category of aphasia. such as procedural memory deficits. 1990. The terms “slowly progressive aphasia” (e.” and dementia or traumatic brain injury). particularly (but not “hereditary dysphasic dementia” (e. without evidence of non-language computational a paper titled “On aphasia due to atrophy of the cerebral impairments that are shared by a common etiology to the convolutions. 1987). 1984) may or may not be synonymous with PPA as other forms of research on prognosis. 1988). the criteria for other cognitive deficits is the modern seminal work on the a different diagnosis are met (e. Morris. Kobayashi. not manifest. however. are not impairment in association with degenerative neurologic dis- present or are not accounted for by a single or common ease has been recognized since the late 1800s. 1994).” however. etiology. Kennedy. some of which can be consid. Cole. that Mesulam’s 1982 sum- nitive impairments become detectable during formal mary of six cases with slowly progressive aphasia without assessment and are functionally meaningful. in our definition. sia. language or com. 1983. In addition. and the diag. It is beyond the scope of this chapter to discuss labels had evidence of widespread impairment of cognition aphasia definitions and their inclusionary and exclusionary early in their course. and inter. If other careful scrutiny—probably represent other diagnostic enti. in whom there is no such evidence during basic clinical examination and Scheltens.2 Mesulam (1987). terms such as “aphasic (or dysphasic) dementia. 1982. Mesulam. 1990) no complaint of such impairment either by the patient or by those who probably refer to the same clinical entity as PPA. This principle will become 1 We adhere to the term “primary” modifying the progressive nature of the evident when the underlying histopathology associated aphasia with acknowledgement that it is philosophically inconsistent with with PPA is addressed. the term (1988) identified 19 cases in the literature before 1950 that. and loss of musical creativity ing and computational impairments probably become evi. to have succumbed to PPA as the preferred diagnostic label. 1979. Imao. might be labeled PPA. visuoperceptual impairments.g. at least some of the cases in reports using those vention. McNeil and Pratt (2001). Kushner.. 1988) and “progressive aphasia without dementia” of PPA people in whom neuropsychological examination raises questions about impairment of cognitive functions beyond the language domain. underlying brain pathology. such discussions can be found in Darley include patients in whom language impairment or aphasia is (1982). definition. and just a prominent manifestation of dementia. with prominent apha- Duffy. Poeck and Luzzatti dent very often during later stages of the disorder. Kempler et al. When. Poeck & We do believe it is reasonable to include within the scope of the definition Luzzatti. 1990. or psychiatric illness. and caused by a degenerative condition that. signs and symptoms are simply the most obvious. common etiology. It bears repeating that PPA does not criteria in detail. evidence is required that other cognitive deficits that cross non-linguistic domains of Historical Perspective knowledge..” other cognitive deficits (e. In a review article. however. and prolonged by Girling & Berrios. The rea.. We believe it is important to the history of their recognition. Duffy. mactic conclusion. In 1914. At the point in time when non-language cog. then the diagnosis of PPA probably is not appropriate. 544 Section IV ■ Traditional Approaches to Language Intervention of PPA) of sudden onset. whose Bolero musically chronicles a slow progression to a cli- sumably and predominantly. Pick published a paper in 1892 titled “On the relation Primary progressive aphasia can be defined as aphasia of between aphasia and senile atrophy of the brain” (translated insidious onset. For example. but also in nosis changes from one of PPA to one of aphasia plus the the general concept that a variety of focal cognitive deficits other disorder or the other disorder alone. those seen in persons with “nonfamilial dysphasic dementia.. agraphia. & sons for these inclusion and exclusion criteria are both theo. (Henson. Wright.. altered Although modern interest in PPA was sparked by Mesulam personality. It generated interest in PPA in particular. mod- ified by its onset and time-course. PPA is used only when the concomitant impairments are today. involves the left (language. because aphasia is a behavioral manifestation of neurologic disease. Banker. gradual progression. apraxia. 1988.g. but (e.g. Nakamura. prevalent. and study. such deficits are validly and reliably identifiable and are attributable to a ties. Heath. & Wolters. or severe ered as synonymous with PPA and others of which—under deficit that is accompanied by deficits in other cognitive domains. pre. it is not considered to be aphasia. To use the term “aphasia. 1990. altered personal.. We adhere to this term to Similar to many clinical disorders. Branker. Gyoubu. Maurice Ravel (1872–1937). isolated or relatively isolated progressive language temporal or spatial orientation.qxd 1/21/08 1:05 PM Page 544 Aptara Inc. developed a relatively focal progressive dominant) perisylvian region of the brain (modified from neurologic disease at 52 years of age. defined here. There is no doubt. our criteria for the syndrome’s identification. Hazenberg. assessment. Lindeboom. having implications for epidemiologic and Wright. & only) at its onset.g. they seem know the patient well.g. . dementia). Valk.1 munication deficits are embedded within a constellation of In contrast.GRBQ344-3513G-C20[543-564]. Mehler. 2 1987. McNeil (1988). it is important to remember that PPA is a clinical syndrome and not necessarily a reflection of a single. topic. & Kapur. Because concomitant non-language process.” “familial aphasia. & retic and clinical. Cole. in 1982. PPA recognize that the term does not. Mingazzini published course. alexia. Kurachi. aphasia.” Ironically. .63\c Gender ratio (M:F) '2:1ab Duration of isolated language signs & symptoms to onset of cognitive impairment or death (years) Fluent aphasia 5. Mesulam (2001) has suggested that palsy [PSP]).0c 58–84c 11. For that ative dementia. The reader should interpret these and the other data reported here cautiously.6c 6–9c Nonfluent aphasia 4. sometimes as a disease sequent reviews of their cumulative meaning have appeared subtype (e.1c Nonfluent aphasia 62c 40–81c 8. Parkinson-related dementia. times as one of the possible signs of a disease (e.0c Average 67.1c 1.g. FLD [frontal reason.0 1–15 Percentage progressing to non-aphasic cognitive impairment 50a Fluent aphasia 27c Nonfluent aphasia 37c “Undetermined” aphasia 73c Average (across reports) 46.5–14c 2. 1992. mingled with those of the associated conditions.5c “Undetermined” aphasia 4.g. and dementia of this chapter (and summarized in Table 20–1) rely heavily with Lewy bodies” (p..8c 3–13c “Undetermined” aphasia 6.5–11c 3. Duffy & Petersen. b Westbury & Bub (1997).4c 48–84c 9.9c “Undetermined” aphasia 69.431). Mesulam.4c 48–84c 7. c Rogers & Alarcon (1999). following in prevalence AD.qxd 1/21/08 1:05 PM Page 545 Aptara Inc. its demographic features have become inter- “PPA may well be the fifth most common form of degener.8c 1.9c Nonfluent aphasia 4. and sub.5–11c Average (across reports) 5. 1999. Chapter 20 ■ Primary Progressive Aphasia and Apraxia of Speech 545 can be associated with degenerative neurologic disease. These data include those individuals who remained aphasic only and those that progressed to a diagnosis of dementia. 2003.5–20c 3.5c “Undetermined” aphasia 62.6c a Duffy & Petersen (1992).5c 3–12c Average 7..2c Average 60. 1992. cobasal degeneration [CBD] and progressive supranuclear Westbury & Bub.8c 1.5c 17–81 9. more specific neurologic diagnoses.GRBQ344-3513G-C20[543-564]. 2001. on reviews that have focused exclusively on PPA (Duffy & TABLE 20–1 Demography/Epidemiology of Primary Progressive Aphasia Mean Range Standard Deviation Age of onset (years) Late 50s1.2 40–70ab Fluent aphasia 56..3c 1. the data reviewed in the basic demographics section lobe dementia].8 Average time from symptom onset to death (years)d Fluent aphasia 8.7c 1.4c 3–17c Average age at death (years) Fluent aphasia 65. d These data were computed from those presented by Rogers & Alarcon (1999). frontotemporal dementia [FTD]) and some- (e.g.6c 17–81c 13.3a 1–15a Fluent aphasia 6. 1997). Because in recent years PPA frequently has been tied to Since then.6c 2–20c 3.8c 40–69c 7.1c 62–67c 2.1c Duration of isolated language signs & symptoms to onset of cognitive impairment (years) 5. corti- Mesulam & Weintraub.8c 4–17c Nonfluent aphasia 6.0c Nonfluent aphasia 68. Rogers & Alarcon.0c Average 5.5–14c “Undetermined” aphasia 3. hundreds of cases have been reported. because they are based on a retrospective analysis of published reports and on small subject samples. tumor. or atten- patients with prominent language deficits in the first 2 tion. A 2-year history of insidious onset and gradual decline and “progressive. Westbury & Bub. memory. Table 20–2 summarizes these distinctions. if present in the first 2 years. Persons with aphasia certainly can have deficits of years but who also have apathy. however. Stroke is focal.g. it could lead to a decrease in the legitimate that do not significantly limit ADLs. the diagnosis can delay aphasia management and general life associated non-language clinical characteristics. but that infection. A full neurologic workup that excludes other causes sis of dementia. This criterion Alarcon. neuroimaging and other laboratory correlates. disinhibition.” in language ability (e. establish that PPA. and attributable to the language impairment during the first embarrassment or frustration with failed communicative 2 years.. tive functions can be impaired after the first 2 years. and metabolic disturbances. that is progressive and is of unknown etiology. In addition. It is based on Mesulam (2001. Weintraub. It thus seems appropriate to modify this cri- of aphasia (e. 2001. would not meet the criteria). word finding. & Hodges. 546 Section IV ■ Traditional Approaches to Language Intervention Petersen. Of particular importance is the required 2-year history ately treated.g. ADLs outside of the language and communication domains. ognizing that the diagnosis should be altered or discarded at ioral and medical interventions. supplemented when presumably has been set to reduce the number of false-posi- possible by more recent data that can be linked unambigu. known etiology. Mesulam & Weintraub. & diagnosis of aphasia of any etiology or type. Again. 1992. is in the meaning of the adjectival modifiers “primary” 1.. such as personality. It seems that the diagnosis of PPA can and should course. helps to better define the PPA population (Knibb. 1992. the assumption of an etiology that excludes stroke. one and clinical neurologic examination. Comprehensive speech-language and neuropsychological A fourth assumption is that the diagnosis of PPA requires evaluation yields results consistent with the complaint a relatively focal or asymmetric degenerative process. or perseveration. Today. increase the likelihood that the behaviors are not the initial nosis of PPA. etiology. although representing an uncommon Snowden. 6. of riorate faster than other cognitive functions for the diagno. ities that are a direct or indirect consequence of the aphasia. to remember that the only difference between the definition They include: of aphasia.qxd 1/21/08 1:05 PM Page 546 Aptara Inc. as signs of a more general cognitive deficit. interactions can lead to social withdrawal. reactive depression can impair ADLs. 1990) seem to be generally accepted at this time. not well as the commonalities among them are now sufficient to all investigators have required a 2-year history (Neary. infection. diagnosis of PPA and an increase in the false-positive diagno- 5. 3. the degree to which The criteria for establishing the diagnosis of PPA. stroke. as provided here. Xuereb.. are of known Some of the above diagnostic criteria are worthy of discus. 2003. Patterson. the language domain. The large number of such cases. rec- histopathology and biochemistry. and word comprehension). and progressive. Thus. Relative preservation of other mental functions (e. & Mann. and the definition of PPA. The third assumption of preserved ADLs is included to syntax. tia). memory. help exclude those persons with cognitive deficits outside of 2. Infection and metabolic sis of PPA to be maintained. tive diagnoses of PPA (or false-negative diagnoses of demen- ously to PPA. some individuals’ reactions to their aphasia can affect sensorimotor impairments.g. a 2-year hiatus in standing of its typical and atypical language manifestations. 2003) suggests that non-language cogni. ideomotor apraxia. 1993). disorders may or may not be focally localized. . and are non-progressive when they are appropri- sion. or metabolic terion to permit inclusion of persons with reduced ADL abil- disturbances). however. and more important. tance now are studies that improve and refine our under. Acalculia. clinical planning. of language must remain the most impaired function and dete. Rogers & before a diagnosis of PPA can be established.GRBQ344-3513G-C20[543-564]. Rubin. In fact. object naming. known etiology. or tion. is not an extremely rare one. the epidemi- clinical phenomenon. be made without regard to the duration of its existence. no evidence indicates that this criterion existence of PPA are no longer of special interest. difficulty copying simple ADLs is taken at face value as a criterion for rejecting the drawings. 1999. A second assumption embedded within the diagnostic criteria is that the language deficit is disproportional to any Diagnostic Criteria other non-linguistic deficits. ADLs that involve language and communication. ological research to support this assumption has not been case presentations with the sole intent of supporting the conducted. Any major limitations in activities of daily living (ADLs) For example. in general. If a reduction in 4. Tumor is focal. tumor. 1997). and non-progressive. originally non-linguistic functions are or are not relatively spared suggested and subsequently slightly modified by Mesulam would be the degree to which they meet the criteria for the and colleagues (Mesulam. In addi- attention or visuospatial or visual recognition deficits. Of impor. 2006). It is important Mesulam. and responses to behav. such time that other criteria for PPA are no longer met. The assumption is that an isolated deficit in the domain Considerable variability exists in the degree to which of language that has endured for a minimum of 2 years will published case studies have met current criteria for the diag. diagnosis of PPA. and genetic fronts” (Petersen. the prognosis and the underlying intermingled with complex. Regardless of the PPA may be the most common. 1984. more diffuse abnormalities often can eventually People with PPA must cope for an extended period of time be demonstrated both clinically and histopathologically. common dementing illnesses. ety of isolated cognitive deficits. 2001). Today. Medical Etiology Distribution Distribution Etiology term Course Treatment Primary progressive Language only Focal Unknown Progressive Untreatable aphasia Vascular Can be language only Focal Known Chronic Some early post onset treatment Infectious (bacterial) Typically more than Focal or diffuse Known Progressive until Treatable aphasia treated Infectious (viral) Typically more than Focal or diffuse Known Progressive Largely untreatable aphasia Metabolic Typically more than Diffuse  focal Known Progressive until Treatable aphasia treated Neoplastic Can be language only Focal or multifocal Known Progressive Treatable Traumatic Typically more than Focal.g. & Yanagihara. ized dementia or AD. and so on can have AD as their underlying pathology (although not typically). Broca’s. Etiology. as it was for the first decade or so after Mesulam histopathological. Gordon & Selnes. Lesion Distribution. Petersen. 2003). entity.g. 422) but in the absence of a unifying clinical..GRBQ344-3513G-C20[543-564]. 2003.... 1993. 2001. 1992). or anomic). When PPA was considered solely as an independent clinical p. associated with degenerative neurologic disease. . multifocal. In addition. 1986). syndrome. Wahner. some labels Jack. and management approaches may nomenclature and approaches to the classification of degen- vary considerably (Duffy & Petersen. and often confusing pathology may be different. and limb apraxia (e. Dick. not all people with a clinical diagnosis of AD have AD These generic labels emerged with the recognition of a vari. Chapter 20 ■ Primary Progressive Aphasia and Apraxia of Speech 547 TABLE 20–2 Aphasia Etiology by Symptom Distribution.” because although aphasia and its relative isolation for long periods of time justify these cases may present with a progressing focal neurologic its distinction from typical.3 or biochemical basis for classification brought attention to it.g. that can be infrequently associated with AD pathology (Mesulam.qxd 1/21/08 1:05 PM Page 547 Aptara Inc. it has become evident that 3 Petersen (2001) observes that histopathology does not solve problems of PPA also can be thought of as one of several possible mani. imaging. & Rosser. FTD. Petersen. This complexity and diversity is fed by “a rapidly expanding body of information on the clinical. Poeck & Luzzatti. Disease Course.. Known Chronic Some early post aphasia or diffuse onset treatment It has been argued that PPA often is a precursor to general. however. For example. Caselli. people with clinical diagnoses of asymmetric cortical degeneration syndromes (Caselli & PPA. prosopagnosia (e. such as visual agnosia (e. diverse.g. neuroimag- Issues of Classification and Nomenclature ing.g. & Ferroni. D’Alessandro. Warrington.. because it is not necessarily distinctively associated with spe- festations of a general category of disturbances known as cific clinical diagnoses. et al. Caselli (1995) argues for the ultimate outcome in a given person. 1988). Northen. issues of classification generally were (Petersen. with a different set of problems than do those with generalized More recently. Azouvi of deficits (e. and that it is simply a variant of degen. of which which supports its separate diagnostic status. however. one another (e. 1996). 2003). neuropathological. classification.. 1990). 1990). have clinical and pathologic criteria that do not always correspond with 1992) or focal cortical atrophy syndromes (Black. Wernicke’s. pathology on autopsy). In addition.g. semantic dementia (SD). In the broad context of neu- rodegenerative diseases. erative neurocognitive diseases (Boeve. DeRenzi. the early prominence of term “asymmetric” as opposed to “focal. erative diseases that typically present with a broader spectrum Frackowiak. 1992. the classification of PPA has become dementia. & Neary. Jack. Tyrrell. Snowden. and Medical Treatment Symptom Lesion Typical Long. The next few paragraphs will provide some tied to subdividing the aphasia into fluent and nonfluent types or into more specific “classical” categories (e. Goulding. Piccirilli. evidence suggests that PPA is only 1989. Thus. 2001. which is characterized by behav- (PNFA) or SD. & recognizes that. An they have been unable to name when they are provided to alternative explanation is that it results from an as-yet- them. 548 Section IV ■ Traditional Approaches to Language Intervention examples of how PPA currently is being classified neurolog.g. Neary. Included under this broad behavioral neurologists as progressive nonfluent aphasia heading are (1) FTD. Hillis. requires care. ter explanation receives some support from genetic analyses nosia and visual associative agnosia during the initial 2 years of so-called FTLD syndromes that include PPA and FTD is incompatible with his definition of PPA. In the final analysis there may be no gold standard” siderable source of confusion that.. Clinically. history. At this of preserved grammar and syntax and preserved verbal com. 2003). preservation of language fluency and syntax. subtype of FTLD. Neary et al. Strictly speaking. genetics.. 422) on which all of these disorders can be uniquely ful definition in clinical and research communications. PPA itself now often is considered to be a subtype of FTD. not (ignoring the issue of whether SD would capture all patients synonymous with fluent PPA). rather. For others. Going beyond subclassifications of PPA. imaging. 1998).g. 1993). disinhibition. although poor insight. including PPA. mous. This lat- (2003) has argued that the presence of prominent prosopag.. . for some. Neary et al. It may be that PPA is 1998). 2002). counseling and prognostic advice for patients and diversity in the use of the term “semantic dementia” is a con. lem of classification (Petersen. PPA. 2004).g. Their content will not represent the temporal phenotype. families. or to recognize typical presenting features.. neuropathology.qxd 1/21/08 1:05 PM Page 548 Aptara Inc. Mesulam. a gory of PPA.. resolve the confusion. a degenerative Clinical Presentation dementia that is second in prevalence only to AD. How do people with PPA present clinically? What is their Pathologic substrates of FTD include Pick’s disease. treat- should be labeled as having PPA. only type of PPA and view SD as a separate entity. Mesulam behaviorally distinct degenerative brain disorders. stating. PPA is now classified among many tion (FTLD) (Neary et al. People with PPA often present clinically many months or behavioral changes are considered to represent the frontal even a year or more after the onset of language difficulty. linked to multiple diseases sharing a common anatomic ple with fluent PPA and anomia who recognize target words locus (i. and how do they behave? Initial diagnosis hinges and dementia lacking distinctive histology. point. Others seem to consider PNFA to be the ioral/personality changes (e. 2001). fluent aphasia remains a major subcate.. although he (Mesulam. should be classified as part of “Pick complex” because “fork” represents its eating utensil referent—in the presence of shared histopathologic features (discussed later).e. Blair. Davidson. Pick complex. For those who consider SD to be characterized by “labored speech. 2001. and (3) PNFA. and SD accounts for about 15% that SD and fluent aphasia can be considered to be synony. the diagnosis of SD also should be incompletely understood unitary disease (e.. He feels that such patients without visual agnosia orders as accurately as possible to allow for diagnostic. (Snowden. whereas those with early prominent lan- ically and of its relationship to broad classifications of guage changes (PPA and. CBD. perseveration. Pick’s disease.g. Within this approach.g. 2004. Mesulam... SD) are considered to degenerative neurocognitive diseases. Kertesz. Petersen (2001) points out that “it is given to patients with fluent aphasia but without visual incumbent on the clinician to classify persons with these dis- agnosia.e..g. with SD being a subtype of fluent aphasia (e. & Mann. & Mann. in clinical practice. PPA is not considered to be a subtype of FTD but. PPA is considered to be nomenclature in which information about PPA has become one (or two) of three distinct manifestations of a broad cate- embedded within the neurology literature. FTD strongly on the answers to these questions. but it will identify some of the In a similar conceptual approach. and inflexibility). that they do not recognize that the spoken word CBD. which essentially means imately 10% of FTLDs. Neary et al. 2001. which one involving language (e. not SD. 2003). This difficulty stands in contrast to that of many peo. and PNFA could meet the criteria for a diagnosis of PPA For those who consider SD to be a distinct entity (i. (p. impulsivity. 1998). and bio- prehension that does not rely on understanding words whose chemistry have not provided an absolute answer to the prob- meaning has been lost (e. the disorder is characterized with fluent PPA). the term seems to have replaced fluent matism. Snowden. As a result. Neary.g. by a “loss of word meaning”—affected individuals seem no Finally. so it is important is characterized by personality-behavioral changes. patients with SD Grossman & Ash. (2) SD. or frontotemporal faces (prosopagnosia) or object identity (associative agnosia) degeneration) that includes a spectrum of anatomically and (e.. at the least. 1998). 2005. phenotype of FTD. Hodges et al. account- ing for 10% to 15% of untreatable dementias (Boeve.GRBQ344-3513G-C20[543-564]. and example. however.. Kertesz and Munoz (1997) have argued that sev- longer able to associate a word with its meaning. FTD. SD often is a diagnosis Weintraub. gory of disorders known as frontotemporal lobar degenera- At the simplest level. this ment. & Munoz. 2003). Obviously. characterized. Grossman. Kertesz. for eral disorders. both (Boeve. It has been suggested that PPA accounts for approx- aphasia (e. and/or agram- a subtype of PPA. Mesulam... the left hemisphere perisylvian language area). in this scheme. associated with impaired recognition (visual agnosia) of lobar atrophy-Pick’s disease-tauopathy. is characterized by loss of word or object meaning with McMonagle. Patients with early prominent personality.” anomia. they can be strik. Trojanowski. The types reported in the not-so. It thus contributes to neuro- To summarize. driving. 2006a. If work demands are not language. In fact. In addition. with PPA can be strikingly different from those of people localization. presenting complaint among people with PPA (Westbury & Davidson. about when symptoms first appeared. cases.. especially those involving rapid or large-capacity characteristics (i. then difficulty with job performance or hesitant and/or dysprosodic speech) deserves some special routine daily activities can be the initial situations that comment.5 (e. The classic refrain of the person with aphasia that “I know there is a slowing and decrease of verbal output. those with PPA often are aware of the prob. reading. its demographics. PPA subtypes (and SD) on behavioral.g. even cant language demands or psychological stress (e. Daily routine dardized tests and are unreliably assigned to patients (Trupe. 1998. usually initiate the search for that these problems are similar to those associated with clas- diagnosis and treatment. 1994). a public pure word deafness has been reported (Mesulam. Conversely. & Tsuji. Operational definitions for PPA types and the reliabil- It appears that any type of aphasia (as it traditionally has ity of placement of patients into each type. and (3) as typically applied. if language of concomitant sensorimotor speech pathologies (dysarthria demands for job performance or daily routine activities or AOS) than of a language-specific impairment. and motor speech production are relatively pre- heard.qxd 1/21/08 1:05 PM Page 549 Aptara Inc. the problem with using fluency or nonfluency as report significant personality changes. shopping. however. 2004. earlier stages of probable AD. & McCabe. retic motivation as a descriptor of language pathology. 1988.g. They and their significant others do not Specifically. Soma. but syntax. several ingly similar to stroke-induced and other static etiologies for studies and reviews support the distinction among several aphasia. however. which by default ness.. 1998. grooming. and comprehension. writing. Kertesz et al. and transcortical (e. friends. because it generally is unexpected during the reveal early signs or symptoms. speech). They do not complain of memory sifying aphasia resulting from stroke or other acute-onset disturbances outside the verbal domain. without nonfluent language characteristics.e. & Jack. Presenting speech and language complaints can be strik. Davidson. Bub. Kertesz. and exercis. anomic. are not been classified) is possible. Sato. Karbe. organization. giving the onset a superficially acute appearance. form. the recent neurologic literature lem before their family.. Wernicke’s. (see previous discussion). Chapter 20 ■ Primary Progressive Aphasia and Apraxia of Speech 549 Occasionally. or SD. in which significant word finding difficulty is present. Homma. activities (e. however. Turner.4 It is important to note that the subclassification of PPA People with PPA rarely deny their deficits. however. the onset is insidious. personality. job performance can be unchanged. tends to classify patients as having nonfluent or fluent PPA. prognosis.. what I want to say but I can’t find the words!” is commonly phonology. (2) are sion are common. Word finding difficulty seems to be the most frequent served (e. Gonatas.. Duffy. Kertesz. Most frequently. and they are not causes (Darley. 1982. It is essential that the characteriza- recent literature include fluent and nonfluent. & McCabe.g. or work colleagues.g. although expres. 1997). Dronkers et al. or patho- logic grounds (e. Schwartz. & Fossett (1995) for a 4 This complaint alone may not assist differential diagnosis. 2003. the event was one with signifi. clinical example and discussion of the importance of accurate differential because it also is a common presenting complaint in patients with diagnosis of the speech production impairments that often are used to probable AD. Kertesz. more often than not. tion of PPA be made on the basis of careful definitions and 5 See the case report of McNeil. reported in many studies. and calculations for record keeping) With the above caveats. thinking. Masterson. brief and unelaborated verbal expression. Some investigators have also described a logopenic ingly similar to those of people with stroke-induced aphasia. self-aware. Gorno-Tempini. and ability to succeed in routine social. not assigned by a set of uniform criteria across users or stan- based. 1984). In fact.” . neuroimaging correlates and histopathology).. Small. Philbrick. 1984).. they. 2004.. and rather than their families. Dronkers et al. McNeil. and work activities. valid adjectives for aphasia is that they (1) are without theo- sions or frank evidence of frustration and reactive depres. anatomical. Conversely.. 2004.. disoriented...g. Gorno-Tempini. they associate the onset with a specific event.GRBQ344-3513G-C20[543-564]. Kenyon. Unlike people with Because of changing trends in the classification of PPA AD. Broca’s aphasia.g. Grossman & Ash. 1990). 1993. are more likely the result ing) typically are unaffected. in such & Polk. PPA with nonfluent verbal output are high. Weintraub et al. Josephs et al. and the patient and family often are vague or even disagree Rummans. & Grossman. etiology. 1996). the initial clinical presentation of people logic differential diagnosis. Kokmen. are usually termed “fluent” (see the subsequent discussion of self-care. Character of the Aphasia 2003). 1982. and responsiveness to med- with AD or other degenerative diseases that induce diffuse ical and behavioral management may differ from those PPA impairments of memory. Broca’s. Otsuki. along a “fluency” dimension is not without problems. classify the “nonfluency. agrammatism or tele- language processing and extemporaneous production and graphic speech. b.6-year standard deviation and a range (1999). with a 7. although many patients have iso. It is the diagnosis of PPA is best made on the coherence of both inclusionary criteria for aphasia of any type and exclusionary criteria for the disorders well-documented that aphasia can be the initial sign (or a with which it is most likely to be confused (e. Tempini. with a range of 3 to 17 years. Duffy and Petersen’s Mesulam et al. will the true characterization cumb to unrelated. when they emerge.g. or mood (Green. the average time from age of onset is quite variable. the Rogers and Alarcon (1999) review. Among the cases reported in the literature. Westbury & Bub. carcinoma. Josephs et al. this duration with average age of onset across reviews converging on spans the considerable range of 1 to 17 years. 2000. Accompanying Deficits Other neurologic signs and symptoms can accompany PPA. Grafman... ideomotor (1992) review found that approximately 50% of persons with apraxia. Miller.g. the Gender Ratio and Age of Onset evidence summarized by Rogers and Alarcon (1999) sug- Table 20-1 summarizes reviews by Duffy and Petersen gests that the average age of death for persons with PPA (1992). and with the recognition that many eventually will experience symptoms in areas such as mem- patients may not fit neatly into any single category.. Dickson. however.GRBQ344-3513G-C20[543-564]. 1994. and other after onset and for as long as 15 years. Kertesz et al.. 1997). Only when large series of patients are reported. 1992.8% averaged across reviews) ary features” of PPA that usually arise later in the disease progressed to nonaphasic cognitive impairments. extrapyra- midal deficits characteristic of CBD (typically characterized by cortical and extrapyramidal signs.e. On average.. right-central facial weakness. and Rogers and Alarcon is 67. Murray et al. Life Expectancy Basic Demographics Although relatively few cases have been reported. Liao. construction deficits. Baker. that. ratio (Duffy & Petersen. tion across reviews of about 5 years. dementia and conversion prominent early sign) of CBD (Frattali.. 1997). and dysarthria in studies Castellani. especially when onset is later in life. it also is important to & Miller.qxd 1/21/08 1:05 PM Page 550 Aptara Inc. McNeil. may be those who suc- using strict diagnostic criteria. The time from symptom onset to death (i.4 years in decades. limb apraxia. the duration nonverbal oral apraxia.g. AOS. & distinguish among aphasia. Although these reviews suggest that more men than from 48 to 84 years. nonfluent. 2005). Duffy & Petersen. 1990. PPA advances to affect other cognitive functions. 1992.g. Sandson. Westbury & Bub. 2003.. 1999. 1997). & Lin.. Thompson. Gorno. dyscalculia. 2006a. Rogers and Alarcon’s (1999) review reported that an deficits. personality. has have been reported (e. and decreased learning of word lists to be “bound- overall average of 45.4 years. or more rapidly progressive con- and distribution of the “type” of aphasia in PPA be clearly ditions (e.g. The difference between have found male predominance in patients with fluent the number of years of isolated language deficits preceding PPA and female predominance in those with nonfluent PPA the onset of non-linguistic cognitive deficits and the average (Clark. however. PPA develops in the presenium (before age 65).. 60. but onset most often is between 40 and 75 years. Gorno-Tempini. rigidity) impairment of cognitive functions. dementia with aphasia. 2003. Westbury and Bub (1997). alternatively. impaired execu- PPA eventually developed nonaphasic cognitive impair. They also is growing. tive functions. PPA (e.g. (2003) consider dysarthria. 2003. & Litvan. varied from 1 to more than 15 years.. 2003). Fuh. 2006. Krefft et al. extrapyramidal ments. it These figures are in rough agreement with data from more should be noted that recent series of 30 or more patients recent studies of small to relatively large groups of patients with have not found significant gender differences (e. the great majority types of aphasia. Many of the exceptions. acute. Kertesz et al. and so on. Charuvastra. note that some patients with PPA develop personality lated language symptoms for an average of about 5 years changes characteristic of frontal lobe dementia. and stroke) before the understood. Makhlouf. Rogers & Alarcon. Morris. Sentiment course and are less prominent than the aphasia. be discussed in following sections. 1998). and extrapyramidal deficits (e. might be have a “PPA-plus” syndrome or.7% (46. of PPA.. Krefft. Krefft et al. They suggest that such patients can be said to colleagues’ criteria for a diagnosis of PPA and. dysphagia. 550 Section IV ■ Traditional Approaches to Language Intervention descriptions of what constitutes fluent. the average duration from PPA symptom women are affected. Shapira. 2005. & Mendez. if embraced. right-extremity weak- from onset of aphasia to the emergence of more widespread ness or clumsiness. or signs of motor neuron disease 6 Cases with a duration of less than 2 years would not meet Mesulam and after 2 years. however. visual recognition deficits. with an approximately 2:1 male:female onset to death was 7. heart attack. or they Knibb et al. Dronkers et al. 2004. including asymmetric limb rigidity and apraxia). 2003). frontal lobe labeled on initial evaluation as having “possible PPA.5 years (Duffy & Petersen.6 with an average dura.. McKeel.4 years. Time until Onset of Other Cognitive Deficits Dysarthria.. Wang. Graff-Radford.. therefore. AOS. covering nearly all adult onset of general cognitive deficits to death) was 2. CBD with aphasia. As will ory.” As stated.. disorder). 1992. Patronas. . . Duffy. happen to be... determines the clinical sylvian fissure or temporal lobe. neuroimaging identifies abnormalities Mummery et al. 1999). hemisphere (Kertesz et al. The methods most frequently reported include elec. troencephalography (EEG). or other nondegenerative causes of focal patients with SD tend to have bilateral abnormalities (e. positron-emission tomography (PET.g. lesions. the left hemi. Histologic Pathology when right-hemisphere abnormalities are present. The right hemisphere may be normal. In other cases. result in deficits of language poral and/or frontal lobe. important in future research to determine whether patients In a general summary of neuroimaging in PPA. and decreased glucose with neuroimaging evidence of left hemisphere disease only. which typically are most Westbury & Bub. because anatom- sphere abnormalities most often were in the region of the ical localization. processing consistent with those of aphasia. they gen- erally are less pronounced than abnormalities in the left Autopsy results for people with PPA are few. aphasia was present in more fied left perisylvian and anterior temporal and inferior pari- than 50% of patients with CBD who were carefully studied etal lobe atrophy. Abe. Sonty with Lewy bodies (Caselli. 2004. Kertesz et al. when affected.. In a sense. use in left hemisphere language areas. 2003). superior. 2003). MRI had left hemisphere abnormalities only. Josephs et al. and voxel-based morphom. studies of patients classi- interrelationships support the contention that these condi. progress more rapidly to diffuse cognitive deficits than those EEG slowing.. In general. when patients with PPA have abnormal neu- (MRI). Lehman Blake. 1997. an MRI-based measure of regional brain atrophy their underlying disease is not confined to the left hemisphere. rior frontal and insular areas (Gorno-Tempini. Boeve. Chapter 20 ■ Primary Progressive Aphasia and Apraxia of Speech 551 2004. Mesulam with PPA and neuroimaging evidence of bilateral disease (2003) indicated that many patients with PPA have atrophy.. It will be dence of atrophy (MRI and VBM) (Mesulam. with the Histopathologic findings identify a variety of pathologic remainder having bilateral abnormalities. 1999) or part of clinical workups for suspected PPA sometimes are nor. located in those areas Most of the left hemisphere abnormalities were in the tem. That is. measuring glu. The pathologic of patients with PPA who underwent PET or SPECT had heterogeneity associated with PPA suggests that it can be abnormalities and that 69% of the abnormalities were in the caused by several entities whose initial or prominent effects left hemisphere only (the remaining 31% were bilateral). 1992. & Yanagihara. thought of as asymmetric rather than focal diseases. however. from stroke. lobe (Gorno-Tempini. rarely.. These et al. the pathologic changes in PPA (and SD. with dementia with fluent and nonfluent PPA (Clark et al. hippocampal. of the brain that. The fact that some (SPECT. 2002). studies of fluent PPA or SD find more posterior abnormalities. Dronkers et al. roimaging findings. 2005) and. Those with nonfluent In general. not histopathology. measuring blood flow). single-photon-emission computed tomography left than right hemisphere abnormalities. Abnormalities in blood flow contention that PPA and related syndromes may best be (SPECT) and metabolism (PET) may emerge before evi. fied as nonfluent find evidence of left frontal and perisylvian tions may belong to a common family of focal diseases and atrophy (e. 2003. In found significant overlap and nonsignificant differences in addition. sometimes more narrowly localized to the left infe- anatomy of disease onset and progression. 2004). 2003).g.. such as left Neuroimaging Correlates anterior temporal and inferior parietal lobe atrophy (Gorno- The results of neuroimaging studies that are conducted as Tempini. lobes... patients with PPA have bilateral abnormalities suggests that etry (VBM. 2004. they tend to show left hemisphere or more cose use). for unexplained reasons. when PPA tend to have metabolic dysfunction and atrophy in the analyzed separately) tend to be consistent with neuroimag- left inferior frontal cortex. and inferior temporal gyri.. In contrast. (2003). Mesulam’s generalizations are supported by frontal lobes. but increasing.. middle. 2001). (2000) and by Lehman Blake et al. They also found that 97% manifestations of neuropathologic processes. 2003. mal. Findings on VBM of patients classi- that contribute to understanding the anatomical bases of the fied as logopenic have been localized to the inferior parietal aphasia. For example. magnetic resonance imaging In summary. . especially early in the course of disease. Beach. diagnoses.. Dronkers et al. without regard to PPA type. (1997) found that 56% of patients with abnormalities on Mesulam. Westbury and Bub pronounced in hippocampal areas (Davies et al. 2005.. 1997). & Maraganore. More recent neuroimaging studies generally have identi- Ahlskog. whereas those who are fluent and ing findings regarding the location of the brunt of patho- have comprehension deficits have abnormalities in the left logic changes. PPA has been associated with atypical PSP (Boeve the distribution of anatomic abnormalities between patients et al. perisylvian regions. in contrast to changes in AD. Mummery et al. 2003). Nestor et al.. using voxel-based comparisons of gray matter volumes even if their current clinical syndrome is. 1997). that the individual clinical syndromes reflect a different 2006a). tumor. Dronkers et al. 2003). This supports the between groups of subjects). they are more pronounced in the temporal lobe. Some have by Frattali et al. Ukita. Josephs et al. and frontal and temporal previous literature reviews (Duffy & Petersen. this is not surprising. 2005. & Sue.GRBQ344-3513G-C20[543-564]. supporting conclusions that the disorder does not stem and parahippocampal gyrus atrophy (Abe et al.qxd 1/21/08 1:05 PM Page 551 Aptara Inc... decreased blood flow. 2003.g. 2003. Kertesz. 2006b.. some sug. tion of lesions. Hudson. The leads to early or prominent language deficits. as lateral sclerosis (ALS). Mesulam.e. 2006). 1997. 2003. For Kawamura. Johnson. (2005) Because most patients with CJD die within 2 years. PSP and CBD pathology ogy” or “nonspecific focal atrophy. superficial cortical layers (Krefft et al.. 2001.” in which there is focal accounted for nearly 70% of the pathologic findings in 13 neuronal loss. about 60% of patients with PPA have microscopic findings the common clinical characteristics of which all include commonly called “dementia lacking distinctive histopathol. PPA can occur as well (e. 2003). able. For example. Others estimate that less than 20% of people with PPA clinicopathologic study of 60 patients with FTD/Pick com- have AD pathology (e. ease.. & Reinmuth. on immunohisto- Of interest. cific clinical or pathologic conditions. 22 of whom had PPA (Kertesz et al. It has been estimated examination. (2006a). 1989.g. MacKenzie. tary histologic process (Josephs et al. in fact. Moossy. Mesulam et al.. or personality disturbances. Kertesz et al. It is noteworthy that only one Tauopathies are non-Alzheimer’s dementias that are associated with patient had evidence of motor neuron disease during life. Pick bodies or tau-positive spherical neu. Mesulam et al.g. In some instances. 1997). Mandell. Mesulam. Yamanouchi. Support for this is exemplified in a recent 2003). Mesulam. the first symptom for all four of the patients with 1990. 1985. whereas the behavioral variety of FTD more frequently was tau-negative and asso- ciated with motor neuron disease pathology or dementia 7 lacking distinctive histopathology. PSP. Ruymbeke. & Hodges. 2003. FTD. 2003). includes several neurodegenerative diseases associated with gest that pathologic features of AD may not emerge until long focal cortical degeneration. on initial memory. Krefft et al. It may be that this plethora of pathologies share histo- ronal inclusions) (e. 1985). patients with nonfluent verbal output characteristics ogy of Pick’s disease (e. cases.g. As In people with autopsy-confirmed pathologic diagnoses of noted previously. & cellular changes that do not correspond to well-known spe. the aphasia or AOS was the first symptom of disease. 2006b. Both PPA and CBD presented more fre- quently with tau-positive pathology. Xuereb. This generic concept anatomic distribution (Knibb et al. but this is not the pathology in a majority of autopsied Mesulam et al. 2005. & Munoz. motor disturbances. Holland. 9 three cases had Pick’s disease and two AD. 2000). 1997). 1990. & Vass. Carpenter. Neary. 1990).... Mesulam et al. & Nakano.. pathology (i. acknowledged that there may be many exceptions to this it is important to recognize that a progressive aphasia can announce the dichotomy. . logic or biochemical features that unite many of them and. PPA also has been associated with autopsy.. 2005) examined 18 consecutive cases with SD pathologically. (2005) was speech or language difficulty that. Sakurai et al. PNFA and those with SD)... and-language characteristics of these cases are quite vari- In addition. 1996. Raison-Van and/or AOS seem to be over-repesented.. example. “Motor neuron inclusion dementia” (motor neuron disease–type inclusions) was the most common pathology (13/18 patients).. Graff-Radford et al. 2002). 2003. & revealed clinical and pathologic overlap between FTD and Weintraub. 1997. 1996.. Regardless. Creutzfeldt-Jakob (CJD) disease. Arima et al. It is estimated that & Paltan-Ortiz. & Mann. Yates. plex. which typically manifests clinically as significant cognitive. 2005). may represent anatomically distinct manifestations of a uni- Green.7 well as differences in the cortical and subcortical distribu- and even motor neuron disease8 (e. Engel & Fleming. Kertesz & Munoz. Fukui. Mesulam. Mutations in the tau gene (chromosome 17) can be associated with to histopathologic diagnosis. Some have found AD pathology in about one-third of possibly captured by the concept of the Pick complex patients with PPA (split about evenly between those with (Kertesz. and CBD.. Budka. Kempler et al. gliosis..GRBQ344-3513G-C20[543-564].. primarily divided between tau-negative confirmed pathologic diagnoses of CBD.g. Mesulam (2001) PPA and suggested that patients clinically described as hav- points out that none of the genetically caused forms of AD ing CBD belong within the entity of Pick complex. Westbury & Bub. 2003. 1997. 1996. and mild spongioform changes in patients with nonfluent PPA studied by Josephs et al. & Laterre. In general. Shuttelworth.. reflected AOS (4/4 patients) and aphasia (3/4 that about 20% of patients with PPA have Pick’s disease patients).. Shiota. pathologically “atypical PSP” described by Josephs et al.. 2003.. and that it may be premature to split the Pick presence of CJD. they would not meet the Mesulam and Weintraub (1992) criteria for PPA diagnosis. 2003. Mcburney. Sugita. chemical analysis. 552 Section IV ■ Traditional Approaches to Language Intervention Perhaps the most frequent autopsy findings in PPA are of Josephs et al. Mesulam et al. Patterson. an observation abnormal accumulations of hypophosphorylated tau (a protein) in neurons that highlights the fact that clinical diagnosis does not always correspond or glia. Seron. Snowden. Mesulam. 2003. Alexander. Krefft et al. such as PPA. tie PPA to other neurodegenerative diseases. Rectem. this suggests that PPA and FTLD/FTD AD. although the descriptions of the speech- 2001. Grujic. although often with an atypical 1994. amyotrophic and tau-positive (often called “tauopathy”9) biochemistry. 8 A recent study (Davies et al. range of underlying pathologies that. Findings 2003.qxd 1/21/08 1:05 PM Page 552 Aptara Inc. Pick’s dis- after the onset of disease (Mesulam. 1994.. however. PPA has been associated with the histopathol. an observation study found that patients within the Pick complex had a that supports the distinction between PPA and AD. dementia and parkinsonism (Mesulam. Craenhals.. 1986). 1997). Doyle.” When observed in the absence of related to tauopathy or to impairment of some other func- aphasia. 2001). its presence that chromosome 17 mutations are prone to marked phe- should be explicitly recognized (e. they tend to be subsumed variables such as emergence of non-language cognitive under diagnoses of aphasia or dysarthria. Knibb et al. This provides support for distin.g. manifestations (e. and Pick-like time or perpetually resulting from a degenerative condition inclusions can result from mutations within chromosome that. Basic Definition and Terminology guishing between PPA and probable AD clinically. in the very likely that many patients said to have PPA. involves the left hemisphere’s apparatus 17. existing or future pharmacologic treatments for risk factors for PPA? Very little at this time.. 2006). etiology. PPA. controls and different than of patients with a clinical diag- nosis of probable AD or a histologic diagnosis of AD (Mesulam et al. It has been our observation that when it is prominent and 10 The reader is referred to McNeil. and prolonged course. possibly. CBD. some of which have been traced to the tau gene. perhaps “PPAOS with aphasia. seems to be a useful one.. 1990). Mesulam absence of non-language cognitive impairments and. This almost cer- impairments. The degree PPA had a first-degree relative with a “similar condition” to which PPA and PPAOS eventually may be linked to differ- (Neary et al. regard (Josephs et al. especially if logic/biochemical support is emerging for the distinction it is found to have predictive value relative to underlying between fluent and nonfluent PPA (although the distinction histopathology.. 2006a. ultimate clinical or pathologic diagnosis. or management. some patients may develop prominent aphasia learned kinematic parameters necessary for their expression and others display a frontal lobe dementia. and it is Primary progressive AOS can be defined as AOS of insidious in agreement with evidence that most patients with PPA do onset. dence suggests that it may have predictive value in this ent (Josephs et al. Chapter 20 ■ Primary Progressive Aphasia and Apraxia of Speech 553 complex either clinically or pathologically. tion of chromosome 17 (Mesulam. particularly absence of aphasia and nonaphasic cognitive impairment. In addi.. it tends to progress in a direc.. ALS. McNeil. however. That is. negative findings are more common in those classified as The distinction between PPAOS and PPA may be relevant fluent (Knibb et al. in the absence of aphasia. and Wambaugh (2000) or to accompanied by dysarthria. AOS is of interest because progressive AOS. PPAOS may herald more specific neuro- logic diseases but likely not any single neurologic disease. it should be labeled as PPAOS. decisions about medical/pharmaco- may have more to do with the presence or absence of AOS logical management often depend on predictions about the than with differences in the aphasia). nosis remains to be determined. for a substantial period of phy without distinctive histopathology. notypic divergence. 1993).10 When AOS occurs with PPA. in the not have the histopathology of AD. presumably. although probable AD likely will be different than those for PSP. It thus appears that histopatho. for What is known about the possible genetic basis of or example. Robin. lobar atro- times. “PPA with AOS”). PNFA. (1993) found that 42% of their patients with and other degenerative sensorimotor disorders. survival. Apolipoprotein E genotyping (the E4 ent specific clinical neurologic diagnoses or to underlying allele is a risk factor for AD) found that the pattern of allele histopathology may mean that they will be treated in med- distribution for 12 patients with PPA was similar to that of ically as well as behaviorally different ways. It is tion. Similar to PPA.g.. These observations also raise the pos- When the AOS is more prominent than the aphasia. the sibility that sporadic FTDs (presenting as PPA or frontal appropriate diagnostic label in our opinion should be lobe dementia) may have a unitary pathogenesis.qxd 1/21/08 1:05 PM Page 553 Aptara Inc. to prognosis and. and Schmidt (1997) for a detailed definition and discus- tion that leads to clinical diagnoses with prominent motor sion of the nature of AOS. Neary et al. 2006) and that tau. clinical diagnoses reliably predict ultimate histologic diag- Among patients with PPA. although emerging evi- positive) is overrepresented in patients classified as nonflu. and ALS). gradual progression. this suggests through speech.GRBQ344-3513G-C20[543-564]. 2006a). tainly has been the case within the literature on PPA.. PRIMARY PROGRESSIVE APRAXIA OF SPEECH Historical Perspective Because AOS very often is a component of the syndrome of The existence of AOS as a problem distinct from aphasia Broca’s (or nonfluent) aphasia (McNeil & Kent. have had AOS. The tauopathy. medical management.. Within for translating the phonologic aspects of language into the a kindred. and it is very possible that some has been reported in the literature and encountered by us unknown percentage of them have had AOS and little or no frequently enough to tentatively label such occurrences as PPAOS. PSP. it is often is neglected in the neurology literature. As a result. Finally. Whether these nontauopathy distinction. some- (2001) notes that frontal lobe dementia. . it appears that tauopathy (tau. and when its reasonable to ask if its presence in PPA is important to characteristics are recognized. arguably. Issues of Classification and Nomenclature In general. PNFA. the sequencing errors in tions (78%). The finding of reduced words per breath sometimes in the absence of any aphasia and often as the group despite adequate maximum vowel duration in 26% of predominant communication disorder (e. al. Chapman. wondered if “the nonflu. 2000).. progres- For example. distorted sound additions. as already noted. in the Diagnostic Criteria and Character of the AOS absence of aphasia or when the AOS is the predominant The defining characteristics of AOS associated with degen- erative neurologic disease appear to be very similar to those associated with AOS in general.e. this is unfortunate. fundamentally. 554 Section IV ■ Traditional Approaches to Language Intervention aphasia.GRBQ344-3513G-C20[543-564]. 2006. it is Mesulam et al. although not necessarily as the predom- inant communication disorder (e. et al. And. mic errors from AOS and. 1996.. This appears to be changing. Findley. Benoit. 1997.” If so. but often without recognizing its distinctiveness ency of PPA results more from articulatory disturbances. 1997. 2006a. as the predominant or tuhtuh. Broussolle et al. and aphasia.g. & Shobe. turn out to be a distinguishing feature of degenerative AOS 2005. distinctive relative to features of AOS resulting from Rosser. Duffy (2006) summarized data for 80 patients PNFA caused by FTD can have AOS as part of the syn- with progressive AOS that represented either the only or the drome (Boeve.. sometimes. Gorno-Tempini. The most common deviant 11 We recognize that poorly sequenced sequential motion rates and sound perceptual features among the 80 patients with AOS associ. and sound prolongations... sive AOS often is embedded with the designation of PPA or ings for their subjects with PNFA. the sample is noteworthy. in AOS from non-degenerative causes and is not usually Cohen. 2004. Others have explicitly included AOS as a nondegenerative causes). 2003).. although slowly. motion rates (i. the other prominent characteristics in rapid repetition of “puhtuhkuh”) (66%).. Clark and colleagues (2005). Nonetheless. & Brunet. 2406). 1997. are more consistent with aphasia than with AOS (e. Dronkers and colleagues light several reasons for distinguishing between progressive (2004) noted that 9/11 subjects in their PNFA group had AOS and PPA. and they high.e.g.. .g.. findings in studies of PNFA suggest that. and sound of AOS. Josephs et al. 1993. 1990. The data from this study will be relied on AOS. Gorno-Tempini. 1991). Others explicitly recognize that patients with Recently.. 715).qxd 1/21/08 1:05 PM Page 554 Aptara Inc. distorted substitu.” “tuh- rable from aphasia and. a small but increasing number of case reports or rela. McNeil et al. the problem would not disintegration. associated with dysarthria. syllable segmentation and/or excess and equal these affected individuals may have reflected the influence of aphasia on stress (75%). their speech output.” a designation that probably is equivalent meet our definition of aphasia but could meet the definition to AOS. although clearly helpful in distinguishing aphasia and ated with degenerative neurologic disease described by AOS from dysarthria. inaccurate speech alternating speech motor planning or programming as a problem sepa. inantly phonological. Hart et al. discussing find..e. & (i. articulatory errors and stuttering or verbal apraxia” (p. Nestor and colleagues (2003) have most prominent communication disorder associated with suggested that the breakdown of “fluency” in patients with degenerative neurologic disease. Beach. Many only communication problem. If true. Grossman and Ash (2004) suggest that some (2003) recently noted an “aphemic variety” of PPA. Craenahls et al. sound repetitions. reduced words per breath group despite adequate maximum The literature on neurodegenerative disease—and on vowel duration. & Taylor. rapid repetition of “puhpuhpuh. Ducarne. Weiner. 2000). McNeil et tively small case series have documented progressive AOS. Kartsounis. During the last 10 to 15 of these features correspond to those felt to be consistent years. may not be helpful in distinguishing aphasic phone- Duffy (2006) included slow rate (79%). Rosenberg. 1997. of AOS. In our opinion.” or “kuhkuhkuh”). because it will have sequencing errors (50%). from aphasia.. standing of degenerative AOS.. The findings support a PNFA “is due to a motor articulatory planning deficit conclusion that AOS can be the first and/or most prominent (speech apraxia) combined with a variable degree of agram- manifestation of neurodegenerative disease. exhibited false starts/restarts. Frackowiak. sequencing errors. guished from “pure progressive dysarthria or phonological known by some as “dysarthria. Duffy (2006) suggests that it may Fukui et al. the presence or possible influence of AOS in The heart of the issue here is the distinction between AOS patients diagnosed as having PPA is increasingly recognized. within the literature. with “predom- PPAOS.. poorly sequenced sequential motion rates (i. component of PPA. Hart. PPAOS (i. such as apraxia of speech. 58).” (p. Van Eekhout. Dronkers. Kertesz and colleagues For example.e. because it is not typically reported 1996.. with a diagnosis of AOS in general (Duffy. Kertesz and colleagues (2003) heavily in subsequent description of progressive AOS and have recognized an “aphemic” variety of PPA. increased off-target the group are not expected in aphasia and are consistent with the diagnosis errors with increased utterance length (62%)... effortful orofacial movements during PPA in particular—has begun to recognize problems of speech. Thus. 1997). Tyrrell.11 A minority of patients also distorted our understanding of PPA and limited our under. a modality-specific disorder of speech and articulation. As already noted. matism” (p. (2003) recommend that PPA be distin. with AOS reported by Broussolle et al. 1993. and 10 years post-onset. In the absence of any aphasia. 2000).. Cohen et al. Only 9% had non- speech motor complaints as an initial symptom. gressive AOS summarized by Duffy (2006). Pick complex. Deficits beyond the speech and language domain can they complain that “the right words don’t come out the right include dystonia. Duffy’s patients received neurologic diagnoses tied to The data on gender should be interpreted cautiously. problems that simpler ones. Hart et al. Average age at more specific clinical diagnoses. (2006a) found that PSP was the pathologic diagnosis for five of seven patients whose predominant Data regarding this are limited. Three of the patients In the larger picture of neurodegenerative diseases.. in a recent autopsy study. 1996. 2004). word retrieval problems or semantic or grammatical errors. Accompanying Deficits Clinical Presentation Other neurologic symptoms and signs can accompany pro- The clinical presentation of PPAOS is very similar to that of gressive AOS and PPAOS. had a progressive AOS as their sole or predominant commu. Gorno-Tempini. 6. most often spastic and/or hypokinetic in type. simply. 1996. the person with dysarthric. Twenty-nine percent of onset was about 67 years. The average age at onset in those reports well as a case reported by Gorno-Tempini. of other signs that permitted the diagnosis of CBD in sev- eral instances.5 years post-onset). in which degenerative and the other 14 patients with a clinical diagnosis of CBD AOS has been explicitly identified. in those studies as women than men. The unequivocally present in 49% and most often was nonfluent differences lie in the specifics of the complaints that are or Broca-like in character. is a few years younger (about 63 years) than those reported (2004). (1996) died at 6. with 14% of patients having abnormalities confined to the . PPAOS could be considered as another variant of the asym. Instead of complaining about dysarthria. in et al. most frequently including CBD or ever. one that described 13 patients 1998. aphasia was mary of what typically is not part of the presentation). AOS (and. Among the 80 patients with pro- PPA in many respects (see previous discussion for a sum. have reported more (Frattali & Sonies. For example. were followed to death seem to fall within this distribution 1996) and. nication disorder died an average of 8. or MRI. Fifty-six percent of the 75 speech-language disorder was AOS (one had CBD.. for whom data on non- had Pick’s disease). tial assessment (on average. An additional three patients who had language cognitive functioning were available. in those who did.7 years after initial because. possibly. Chapman and CBD and PSP is now well-established. 1997. that lengthy or complex words create more alien limb phenomena (Duffy. and way” and. how. Eleven percent of the cases had neither aphasia nor prehension and with writing. when abnormal. Fukui et al. often. (2006a) who was more sensitive to abnormalities than EEG. PPAOS will deny difficulties with listening or reading com. about 2.. The association between AOS reported in the literature (Broussolle et al. symptom onset (range. Neuroimaging abnormalities are similar to those docu- but often not until several years after the AOS has emerged. Didic. mented for PPA. CT. Duffy (2006) concluded that neuroimaging can be normal but that. 1997. Fifty percent of the cases were offered.. because single-case reports and smaller case series PSP (16%) and ALS (7–9%). the cognitive deficits were never clearly worse than Gender Ratio and Age of Onset the AOS. Time until Onset of Other Deficits Josephs et al. Ceccaldi. Duffy (2006) provides the most comprehensive data to date.. In general. 1998). prominent motor signs. and one patients reported by Duffy (2006). with a range of 36 to 86 years. had no evi- PPA and AOS that were of comparable severity had patho- dence of nonaphasic cognitive impairment at the time of ini- logic diagnoses of CBD. limb apraxia. & Poncet. 2006. 2003) 2005. Other cases in the literature that metric cortical degeneration syndromes (Broussolle et al... In addition. 1996. Murray et al. each of two separate studies. Deficits beyond the speech-language domain can lead to Sixty-one percent of his patients were men.qxd 1/21/08 1:05 PM Page 555 Aptara Inc. Sakurai et al. 38% had AOS. Murray et al. Neuroimaging Correlates many patients eventually develop nonspeech motor deficits.. aphasia) preceded the emergence by Duffy. A majority of Duffy’s patients with AOS for whom information about nonaphasic cognitive impair- Basic Demographics ment was available did not have such impairment. Chapter 20 ■ Primary Progressive Aphasia and Apraxia of Speech 555 problem) should not be considered as a subcategory of PPA. with autopsy-confirmed CBD (Lehman Blake et al. only 3% of them complained of such deficits. 4–16 years). AOS is not aphasia..GRBQ344-3513G-C20[543-564]. left or left-greater- Life Expectancy Following Onset of PPAOS than-right hemisphere abnormalities are common. nonverbal oral apraxia. SPECT The seven patients reported by Josephs et al. as a member of disorders within the of survival duration. often. Josephs et al. This inspection has taken PSP (five patients). especially for degenerative disorders.. predominant AOS was strongly predictive of tauopathy his. both clinically to us that a decision to initiate or withhold treatment based and pathologically. gressive AOS is similar to or different from other forms of logic diagnoses were PSP (six patients). within the 11 cases that had evidence of AOS.GRBQ344-3513G-C20[543-564]. The most hemisphere abnormalities. if it can be assumed that individual has been raised as an issue in the decision to initi- many patients classified as PNFA also had AOS. a clinical diagnosis of different criteria for intervention initiation. the question of whether PPA or were said to have “phonetic paraphasia. If the fundamental definitions the potential value of distinguishing between AOS and of aphasia and AOS are the same (as we have argued that aphasia. Seven patients were classified as MANAGEMENT OF PPA AND “AOS” (those in whom AOS was more prominent than any aphasia. tochemistry and a pathologic diagnosis of PSP. Josephs et al. Kertesz et al. 23 of whom had only on the duration of life expectancy is ethically indefensi- PNFA. for ate treatment. PSP in one patient. What are the criteria for success? patients. histological. They generally point to the left peri. under or dysarthria. Seventy-four percent of their patients with PNFA ble. they highlight sive form of aphasia or AOS. (2006a) studied 17 patients with degenerative aphasia or AOS for whom pathologic diag- noses were available. Other studies. if present. tau-negative inclusions anatomical specificity. nonetheless was dominated by the what conditions should treatment be given? aphasia) was classified as “frontotemporal lobar degenera- 3. It seems example.” and 26% had PPAOS should be exempt from treatment consideration can . mostly focused on frequent pathology in the PNFA group was non-Alzheimer’s PNFA (but in which at least some subjects were identified as tauopathy (10/23 patients). but with a predominance of CBD pathology. the life expectancy of the ported by other pathologic findings. When PNFA Once the theoretic/philosophical definitions of what and AOS were roughly equivalent. we dicted. the patho. tauopathy also was pre. Nestor et al. Dronkers et al. most often in the frontal lobe and usually in cluded that tauopathies were over-represented in their the region of the inferior frontal lobe/frontal operculum and PNFA group and that their findings provide pathologic sup- anterior insula (Gorno-Tempini. Thus. If the answer to the first question is affirmative. or fluent aphasia versus nonfluent aphasia and Histologic Pathology AOS. CBD (four patients). Knibb et al. 38 patients with PPA.. and biochemical levels tion among progressive disorders of speech and language of inquiry. it appears that the distinction the progressive nature of the disorder that demands our dif- may be helpful in predicting pathologic diagnosis and spe. and three patients were classified as PROGRESSIVE AOS “PNFA-AOS” (those with PNFA and AOS in which neither As with all interventions for aphasia. Likewise. the consideration of aphasia nor AOS clearly predominated). Thus. The pathologic diagnosis 1. apha- sia and AOS. 556 Section IV ■ Traditional Approaches to Language Intervention left hemisphere and 48% having left-greater-than-right “dysprosody”—features that might reflect AOS. What should be the nature of the management efforts? tion with ubiquitin-only-immunoreactive changes” in five 4. degenerative nature. rather. therapy for aphasia or AOS and what about it would require and Pick’s disease (one patient).qxd 1/21/08 1:05 PM Page 556 Aptara Inc. 2004. the progressive form different from a static or non-progres- Although these results require replication. does the progressive nature of the disorder obviate the (and its predominance relative to aphasia) seems to have consideration of treatment? If so. CBD (one patient). On these bases alone.. Less can begin to address the questions raised above that make prominent or absent AOS suggested non-tauopathy. one might argue that the two syndromes do not really reflect fluent and nonfluent aphasia but. Should persons with PPA or progressive AOS receive for the remaining seven patients in the study (in whom apha- speech-language services at all? sia could not be classified as SD or PNFA and in whom AOS 2. Recently. then it is only from a behavioral standpoint. aphasia and AOS are and are not have been answered. Thus. all To these queries. (2006) characterized. FTLD with ubiquitin-positive. 2003) Obviously. Among the seven therapy for PPA and progressive AOS requires both philo- patients classified as AOS. generally concur and add some PPA. Not only are AOS and aphasia managed differently they must be. treatment type. that is not considered for intervention simply because of its The results of the Josephs et al. and expected or acceptable consequences to the treatment. Duffy (one patient). the identification of AOS is. The three patients classified as PNFA-AOS (1987) asked: had pathologic diagnoses of CBD. port for the existence of two distinct PPA syndromes. In their 15 cases with fluent “aphemic” or having AOS). was the most frequent pathology (8/15 patients). we might ask what about PPA or pro- had underlying tau biochemistry. and Pick’s disease the form of a number of frequently asked questions. and CBD in one patient. In addition. 2003. or the diagnosis is incorrect). the pathologic diagnoses were sophical and scientific inspection. ferential consideration for treatment implementation. (2006a) study are sup. That cific biochemical findings. Among them. this would be a rare excep- implications for clinical. They con- sylvian region. if present). the question becomes whether dysnomia.g. communication learning and maintenance necessary to data were derived that demonstrated improved word finding support a recommended treatment. it also is control that was not available to him in other areas of his life. Snowden & Neary. but not improve them temporarily or maintain them as long as across tenses. the primary sign and symptom in a patient with the patient under consideration has the motivation. Pratt. the publications reviewed below. ease. multiple-baseline design. ability when that was the focus of treatment (Lexical- nations have been made.12 One other uncon. The experimental data are. book chapter (Rogers. Although of no obvious conse- that the same array of treatment options remains available quence to his life expectancy. PPA of recent onset. Also in the context of a single-subject.g. dysarthria and dysphagia. short and was dominated toward its end by severe spastic Schneider. They evaluated the effects of treatment directed to language functions. Chapter 20 ■ Primary Progressive Aphasia and Apraxia of Speech 557 be dismissed. ments in language and communication gave him a sense of gressive aphasia. the impairment-focused treat- trolled case study (Murray. Augmentative communication was not an acceptable mined by an assessment of the patient’s activity limitations modality to this patient. Therefore. & Alarcon.qxd 1/21/08 1:05 PM Page 557 Aptara Inc. Thompson & Luring. & Leonard. This attempt to assess the efficacy of treatment for a person with maintenance was achieved in the context of declines in other PPA. King. higher levels of correct oral sentence production than verbal native communication as the goal and the method. 2002). the patient’s progressing deficits during the meet the criteria for the diagnosis of aphasia aspresented in this chapter. Likewise. gestural responding generalized and was maintained for a McNeil et al. by the same clinical and theoretic considerations ment would not retard progression of the underlying dis- and biases. Although this its efficacy) for only three patients with PPA have been pub. The patient presented with very mild cial and other (e. is his otherwise unfilled time. Murray (1998) presented a detailed case study (without experimental control) describing a series of treatments administered to a single subject with nonfluent PPA. Other issues oral and oral plus gestural training of verb tense was learned involve the commitment to treat areas of deficit to and generalized to untreated verbs within tense. The 12 A small number of studies have reported the results of treatment for patient presented 1 year post-onset of self-described “stut- “naming” or “forgotten” vocabulary in individuals with SD (Graham.. and other potential forms of treat- and restrictions in social participatory roles alone or is ment became unreasonable because of the rapid progression based on the evaluation of the presumed underlying of his underlying disease. aphasia that guistic and other cognitive resources (e. course of treatment were characterized by agrammatism. finan. Rapp. by this bias. (1995) published the first experimental 3-month period following the withdrawal of treatment. When these determi. and sta- procedures. Each of responding alone. whether treatment potential is deter. alternatively. Although impaired across all because of our uncertainty about whether the study participants would modalities. spastic dysarthria. Rochon. but secondary benefits of treatment were observed. too limited to provide guidance for the treatment of sub. secondary questions can be asked Semantic Activation Inhibition Treatment [L-SAIT]). multiple-baseline design.. the type of intervention selected is presented data for a person with PPA demonstrating that determined. to direct intervention toward agrammatism using gestural plus oral responding resulted in the expected decline in abilities with augmentative/alter. 1996). 2002. and the potential for language or motor and the context of a single-subject. To the degree that this is true. mechanisms for the communication disorder (impair. tering. in large This benefit was acquired with full knowledge that his treat- measure. The most effec- To our knowledge. 2001.” with the complaint of increased “slurring” of speech Patterson. transportation) resources. During the periods in which the patient was receiving treat- sequent patients. nonverbal oral apraxia. . This impairment-directed treatment for possible.GRBQ344-3513G-C20[543-564]. of course. In memory). ble non-language cognitive performance. the treatment data (administered tive treatment for the patient was a combination of behav- under experimental conditions that allow the examination of ioral treatment plus dextroamphetamine. Jokel. Schneider and colleagues (1996) retic bias. 2005. Although generalization to untreated these considerations and biases can be found among the areas of language and communication was not robust. apparent that these options are governed. about the potential to benefit from specific intervention declines in language abilities that were not treated. 1998) describes a sequence of ment was efficacious and bolstered the patient’s interper- treatments administered to one person with PPA. That is. level of lin. however. in great measure. he had an additional purpose and goal for his life and experiments and from the treatment pundits. or. We have elected not to review them here and word finding difficulties. Glucroft & Urrutia. & Hodges. 2000) describes Generalization to untreated and progressively deteriorating the rationale and a detailed plan for the treatment of areas of language performance was evidenced to some persons with PPA. his demonstrated improve- to persons with PPA as to those persons with non-pro. and a sonal and intrapersonal communication for some time. attention and crossed all modalities and levels of language. and no AOS. degree. What has become apparent from these ment. experimental ment-level assessment) represents a major clinical/theo. particular patient’s course of degeneration was atypically lished (McNeil et al. 1995.. but the spelling to dictation. Rapp and colleagues (2005) reported positive this test remained unchanged over this time period. Individual treatment in this ment to 60% post-treatment and then to about 52% at phase “focused on improving communication interactions 6-month follow-up. a systematic and substantive decline in the focused on the development and training of augmentative untrained spelling lists occurred over the course of the treat. Zwahlen. word flu. treatment (about 68% correct). however. 1987). A control condition also was adminis- month period and was directed at her auditory and reading tered whereby a matched list of stimuli were presented but comprehension. and alternative communication (AAC)” (p. change of treatment focus and technique as the patient’s This study adds to findings that intervention can provide signs and symptoms changed over the course of her decline. the individual demonstrated approach advocated for the treatment of PPA. Treatment effects were determined to the drawing board” program (Morgan & Helm. improvement on the sentence repetition subtest of the In the context of a single-subject. phonemic paraphasia. This 63-year-old individual had an targets of treatment chosen for this individual reflect the 8-year history from first-noticed dysgraphic symptoms to predominant impairment-based approach to remediation of treatment.”(p. maximize communication competence as speech and lan- ency for the letters F. For this to represent a generaliz. and with the withdrawal of treatment. it clearly describes the spelling lists diminished to roughly equivalent levels. to the early training in AAC. Treatment was first administered over an 11. Koenig-Bruhin. spoken picture naming). positive consequences for communicative func- This changing sequence of treatment goals and methods tion in PPA and intermediate-term. men in areas targeted for treatment (phonologic aspects of treatment. illustrate the apparent frequently used and functions. It the disease and the limitation it imposes on communicative does. The untreated control list dropped from 65% pre-treat- aphasia support group therapy. In an uncontrolled case study. The treated list improved to tive communication method and a deblocker of speaking and 76%. although with poor situational generalization. by the number of correct letters divided by the number of Estabrooks. The other subtests of of stimuli). with particular word to dictation. once-per-week regi- (with a single averaged data point reported for each baseline. and the repeated list dropped to 67% accu- writing. The patient also was trained and ment period but dropped substantially during the 6-month appeared to use an augmentative communication device follow-up. sion of the underlying disease. Interestingly. short-term. This is accomplished by “early intervention addition. a list of control words was presented only one-hour sessions over a 4-month period and used the “back at the pre. as did the treated spelling list. This sequence was in both patient assessment and treatment planning and . In guage decline. however. 658). In addition ment and at the 6. and follow-up for each trained and untrained list repetition and short-term memory). . it can provide tation of intervention for PPA. The treated list. Rey Figures.and post-tests.and 12-month post-treatment evaluations. perhaps necessary adaptations of treatment goals and meth. During Impairment-based treatment is not. and her spouse” and involved identifying turn. however. study obviates the attribution of any change to the treat. AOS. was spelled correctly.D. and then attempt to spell attention being paid to activity and participation limitations it again if it had been spelled incorrectly. (Dyna Vox). multiple-baseline design Aachen Aphasia Test over a 5-month. repeated as many as three times or until the stimulus word hension deficits. protective consequences may represent the most common practice in the treatment as well. They also underscore the important conclusion that of aphasia of any etiology. These acquisition effects of a writing intervention focused on changes cannot be attributed to the intervention. 306). and S. Rogers and normal and stable performance on a number of non-linguistic colleagues (2000) presented a detailed description of proac- tasks (e. She was diagnosed with fluent PPA 4 months PPA. behavioral treatment does not reverse or prevent progres- able model for best practice in the planning and implemen. patient and family education The treatment involved having the participant spell each and family/partner intervention is advocated.g. remained higher than either untreated list at this 6- Although the lack of experimental control in this case month maintenance phase. It was described as consisting of “traditional without feedback regarding accuracy. and auditory compre. delayed verbal recall. Donati. the repeated words and between D. however.qxd 1/21/08 1:05 PM Page 558 Aptara Inc. a treatment that involves drawing pictures target letters.GRBQ344-3513G-C20[543-564]. study the word. it will require the same level meaningful relief to the burden of the unrelenting march of of evidence as for the treatment of aphasia of any etiology. however. before the initiation of the experimental treatment. the homework remained relatively stable during the treat- taking and repair skills. performance on all ments that were administered. as and facilitate . 558 Section IV ■ Traditional Approaches to Language Intervention anomia. . and verbal tive management for PPA that they believe will minimize recognition memory) while demonstrating a substantive activity limitations and participation restrictions as well as decline in language (Rey auditory verbal learning. A. The third treatment involved both individual and racy. The second treatment involved 24 mentioned above.. Repeated and treated lists were identical at pre- for communicative purposes and claims to be both an alterna. A list of words also was stimulus-response activities which were designed to stimulate given as homework and self-assessed at home. the only the 4-month course of therapy. Finally. and Hohl (2005) reported accompanies any efficacious treatment. Only the treated list improved. Studer- ods that follow careful observation of patient change that Eichenberger. however. patients with PPA decline at a rate and a sons with PPA can improve on language and communication level sufficient to support and maintain independent lan- tasks with impairment-directed treatments that are typical guage and communication skills. it neglects the fact that of other natural courses.qxd 1/21/08 1:05 PM Page 559 Aptara Inc. Treatment will not reverse progression of the disease munication disorders. at compensatory KEY POINTS strategies. involves the language-dominant perisyl- static course is the need for clear patient and family educa. and resulting from a systems. Early treatment may focus on impaired functions but approach that AAC is both an efficacious method of therapy should be adjusted as decline occurs. too early in the improve and/or maintain specific language processing func- accumulation of evidence to determine whether treatment tions that underlie both the interpersonal and intrapersonal for persons with PPA or PPAOS is predictably efficacious communication deficits (and. Treatment effi. Early speech-language-cognitive evaluation is impor. In addition. at psychosocial concomitants of the disorder. is in need of verification and. It is rea- activity and social participation for many years. no a priori theoretic or philosophical reason problem is that it may be destined for nonacceptance from a exists to withhold language and communication treatment substantial segment of the PPA patient population. accepted by prolonged course. for aphasia and the inevitable treatment modality in persons 3. Thompson prominent manifestation of dementia. it is seems altogether reasonable that the same (2000) for assessment of PPA that deemphasizes the under- principles for structuring intervention for PPA would apply. rational and palatable approach. One difference in the treatment of persons with degenerative condition that. patients with aphasia. patients in whom language impairment is just a Similar to these treatment recommendations. compliance data for tice with patient. 4. It seems to us that a much more successful aphasia or AOS regimen. significant others and care. an issue in AAC training for all com. is to direct treatment at the hypothesized deficits. partners. consequently. 1. It has been demonstrated that per- many. standing of the nature of the impairment (for treatment The single addition to these general treatment strategies planning purposes) and shifts it toward the individual’s com- would be to reiterate the potential for AAC intervention in munication needs. 5. these assumptions stands on firm ground. As with other etiologies. without evidence of non-language the patient. It is the inherent assumption of this 2. but may enhance communication ability. PPA is a clini- (1997) provided the following useful guidelines for the treat. communicative and whether it will follow the same principles of manage- and other activities and participatory limitations) for a ment as aphasia and AOS resulting from other etiologies and meaningful period of time. improvement.g. with relative of decline. will use if learned. Patient and family counseling and dysarthria) or when PPA is accompanied by progressive communication training are likely to be integral parts to any motor speech impairment. presumably and pre- PPA compared to treatment of those of aphasia and a more dominantly. is known as PPA. and givers). include (a) a minimum of a 2-year history of language tant. language is impaired. supporting communicative of and efficacious for persons with static aphasia. diagnosis of PPA. at AAC computational impairments. is potentially problematic—or at the least premature. and trained before their use is necessary. AAC should be introduced early. A second from persons with PPA or PPAOS if the usual criteria for problem is that this approach neglects the potential to treatment candidacy are met. In the absence of reported and documented attempts to It seems clear to us that the call by Rogers and colleagues treat PPAOS. . as are frequent follow-ups to establish the pattern decline. 2. Currently applied criteria for the diagnosis of PPA 1. perhaps. neither of learned. gradual progression. It may be sonable to assume that—but currently untested whether— that planning for AAC is on firmer ground when the pro- persons with PPA can learn. and will ben- gressive disorder is motor in nature (e. In terms of evidence-based practice. Family members/significant others must be involved to cacy and effectiveness data for aphasia are essentially nonex. The disorder does not include ing patient and family changes is essential. It is. and when communicatively appropriate. counseling that are the same as those required for establishing the spans the course of the treatment as well as the accompany. cal syndrome.g. PPAOS or efit from AAC devices. depending on the rate of decline and the impairment level of the patient. at environmental influences (e. and that pre- persons with PPAOS over that of individuals whose access to scribes the early initiation of AAC as the target of treatment. (b) prominent language deficits. vian region of the brain. if not most. Chapter 20 ■ Primary Progressive Aphasia and Apraxia of Speech 559 implementation. One In summary. and environments. when it is most easily with PPA.. The crite- tion and counseling that emphasizes the progressive nature ria for the diagnosis of aphasia of any etiology or type of this disorder. enhance awareness of successful strategies and to prac- istent concerning AAC.. so that it can be used as the need arises.GRBQ344-3513G-C20[543-564]. That is. Aphasia of insidious onset. not a reflection of particular underly- ment of PPA: ing brain pathology. 5. About behavioral treatment to maximize communication 45% of reported cases have eventually developed non. PPA or progressive AOS can learn. More men than women have PPA. excluded other causes of aphasia. rate of decline and the level of impairment. motor neuron disease. accepted by the patient. It can be strikingly similar to sons with static aphasia. treatments that are typical of. Most patients with PPA will PPA is most likely to be confused or misdiagnosed. List the neurogenic language disorders with which cortical degeneration). municatively appropriate. however. compensatory strategies. The dura. neurologic diseases and is unlikely to represent a sin. It is reasonable to assume stroke-induced and other static etiologies for apha. PPA can be associated with a variety of specific histopathologic diagnoses. nonspecific focal degeneration 2. at dysphagia. person. and depression have been reported in per. prominent manifestation of degenerative neurologic 4. including AD. nonspecific 3. For persons with PPA or PPAOS and their families. to direct treatment at the hypothesized deficits. 11. these modalities tend to show left hemi. right-central facial droop or weakness. to management of PPA or PPAOS is to gauge the ality.GRBQ344-3513G-C20[543-564]. corti. and efficacious for. if they live long enough. Apraxia of speech (AOS) may be the initial. In general. and CBD. sphere abnormalities. logic conditions (e. or mood. effective. AAC sys- radiologic evaluation of people with PPA. but it has been demonstrated that some 3. Apraxia of speech. aphasia. ACTIVITIES FOR REFLECTION AND DISCUSSION cobasal degeneration.. Efficacy and outcome data regarding management of evaluation that yields results consistent with the PPA and progressive AOS are very limited. at psychosocial concomi- right-extremity weakness or clumsiness. 6.qxd 1/21/08 1:05 PM Page 560 Aptara Inc. Discuss the evidence for and against the classification disease. Discuss the unique features of PPA. identify the diagnostic features that differentiate each 8. management. or from PPA. per- tive impairments. will use if learned. In addition. It is premature to draw conclusions about whether explained by the aphasia should not preclude a diag. dysarthria. only.g. particularly if substantive motor abnormal. The most frequent autopsy findings are 1. substantially greater in severity than aphasia. that differentiate it from non-progressive courses correspond to well-known. rigidity. nonverbal oral apraxia. The initial clinical presentation of people with PPA affected persons with PPA can improve on language can be very different from that of people with AD or and communication tasks with impairment-directed other degenerative diseases that induce diffuse cogni. reduced ADLs that can be 10. and (e) a compre. (e.. MRI and SPECT are commonly used for the neuro. and perhaps. (c) indepen. speech. and then 5. other than its slow perhaps. speech deficits accompany the PPA or if PPAOS is sphere abnormalities or left-greater-than-right hemi. When tems may be used. significant others and caregivers). and not have a histologic diagnosis of AD. it appears that the most rational approach experience symptoms in areas such as memory. treatment of persons with PPA or PPAOS is generally nosis of PPA. and at environmental influences agnosia. Age of onset is or will benefit from AAC devices and strategies. highly variable but averages about 60 years. with spongioform changes and gliosis. and trained before their use is necessary. underlying histopathology. gle neurologic disease. Discuss the criteria for diagnosing PPA. tants of the disorder.g. that—but is currently untested whether—persons with sia. It priori theoretic or philosophical reasons exist to should be noted that the 2-year history criterion is withhold language. What percentage of individuals with PPA can be expected to develop non-aphasic cognitive impairment? . PSP. it may herald more specific of PPA as a subtype of FTD. eral consensus is that the great majority eventually 12. a tion from onset of aphasia symptoms to the emergence need exists for education and counseling that empha- of more widespread impairment of cognitive functions sizes the progressive nature of the disorder and that also is highly variable but averages about 5 years. with the exception of its temporal course. Similar to PPA. specific clinical or patho. 4. 7. hensive speech-language and neuropsychological 9. Distinguishing between a pro- dence in ADLs. When com- sons with PPA. of cellular changes that do not onset. but an emerging gen. 560 Section IV ■ Traditional Approaches to Language Intervention preservation of other mental functions. 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(1914).. & Alarcon. S. (1992). aphasia: PPA and the language network. (1998). Primary progressive aphasia. King. Primary progressive aphasia—A management of primary progressive aphasia. H. K. & Weintraub. Longitudinal treatment of primary progres.. J. (2003).. M. 421–422. In M. Relearning of verbal labels in Murray. A. M. & (pp. Primary progressive 1546–1554. Neurology. Über die Beziehungen der senilen Hirnatrophie 76–87. 1. M. R. 325–338). S. R. S. D.). A case of progressive aphasia without Mesulam.. 51. Brain. Patterson. Snowden. S. (1997). 592–598. 16. Valk. 10(3). J. 154–159. & Wright. 425–432. American Journal of Speech-Language Pathology. 13. C. (2001). Aphasiology. three patients. J. 54(suppl 5). Behavioral and pharmacological treatment of lexical. ASHA Special Interest ogy. Focal dementia syndromes: In search of the speech: Definition. Homma. M. The service is provided by the: New York.. and support for affected individuals and their families. Neurosurgery. & Mesulam. 545–554. R. Kartsounis. M. J. and pathologic Neurology.. 24.. Frackowiak. Warrington. S. K.O. listed. R. J.brain. Greater Phoenix Chapter 1-800-922-4622 1028 East McDowell Road www. & Bub. Annals of Neurology. Kenyon. names are shared with other reg- 156 Fifth Avenue. 54... IL 60611-3008 The Association for Frontotemporal Dementias 312-908-9339 (phone). PPA is one of several rare dementias tains information about PPA. Suite 707 istered families only. Brain and Language. Chicago.. (1986).FTD-Picks. 53.. 381–406. & Rosser. J. (1990).qxd 1/21/08 1:05 PM Page 564 Aptara Inc. R. 1-800-392-0550 PPA is published through: www.alzaz. & Rosser. L. NY 10010 Alzheimer’s Association. Q. 564 Section IV ■ Traditional Approaches to Language Intervention Turner.1 Information Resources • The Association for Frontotemporal Dementias (AFTD). & Vass. (1997). This newsletter about 602-528-0550.. and Psychiatry. P. (1991).. David’s. and Psychiatry. AZ 85006-2622 • Primary Progressive Aphasia Newsletter. N. S. Primary 39(2). Cortex. Progressive degeneration of the right temporal lobe Creutzfeldt-Jakob disease. 60(3). Tyrrell. K. J. E. M. Gonatas. The registry functions as a telephone support group. and language features. Journal of Grossman. H. 47(12). This registry is made up of individu- www. P..nwu. (1990). Box 7191 www. C.org .GRBQ344-3513G-C20[543-564]. L. APPENDIX 20.. M. Westbury. neuroimaging.html Phoenix. J.htm St. & studied with positron emission tomography. Rubin. National Aphasia Association The database is confidential.edu/core/ppal... S. N. 166–173. Yamanouchi.org/NAAppa. their primary caregivers. Searle 11-450 education. features of progressive nonfluent aphasia. 312-908-8789 (fax) P. Findley. Frackowiak. 1046–1050. Tyrrell. P. H. Weintraub.. progressive aphasia: Longitudinal course. (1996). Clinical.aphasia. C. 351–357. and provides information. D. orofacial dyspraxia associated with frontal lobe hypometabolism. Progressive loss of speech output and 1329–1335. Neurosurgery. review of 112 cases. This The Cognitive Neurology and Alzheimer’s Disease Center nonprofit organization that promotes research into frontotemporal 320 East Superior Street dementias.org als who have been diagnosed with a rare dementing illness and • National Aphasia Association. PA 19087-7191 • Rare Dementia Registry. Budka. TheAssociation’s Web site con. L. Primary progressive aphasia: A Journal of Neurology. M. N. educates health professionals. Trojanowski. Unilateral N. neurological profile. S.. J.. Archives of Neurology. D. M. Blancken. Identification of new treat- early intervention with these patients.. 1992). 1993.e. Finally. & Nickels. Okuda. 2004). Simmons. 1977).. 1996. Naujokat. Helm-Estabrooks. ing these in treatment planning (Peach. prognosis for recovery of oral language skills following The emergence of social approaches for language and com. Shelton. & Cox.qxd 1/21/08 1:14 PM Page 565 Aptara Inc. Kessler. novel approaches to treating specifically (Heiss. particularly when considered in the context of the tional abilities of patients with global aphasia. tics that can be associated with various prognoses and apply- ing patients with global aphasia. & with global aphasia (Sarno & Levita. Naeser. the reader will be et al. & Pawlik. 2005. Chapter 21 Global Aphasia: Identification and Management Richard K. Broca’s and Wernicke’s aphasia) that are associated some factors that are related to recovery from this syn. McCall. but these individuals do make significant improvements in communication skills with treatment dur- OBJECTIVES ing the first year post-onset (Nicholas. some of which have demonstrated make informed decisions regarding both whether and how to efficacy. 1997. 1993) and beyond (Naeser Following the completion of this chapter. Clinicians and families therefore have reasons to be guard. poor follow- ing global aphasia. Tanaka. 2000). Despite the poor Hayes. Black. Tachibana. & Morgan. Those improvements also occasionally exceed able to identify the features of global aphasia. clinicians now have more tools than ever to munication treatment. the historically pessimistic views associated with this clinical reader will be able to identify current testing measures and group. Huber. 565 . & Square. and develop treatment plans that tion benefits for these individuals is therefore an important exploit the residual language capacity and/or other func. The central questions regarding outcomes following grams that emphasize improved language and functional global aphasia concern discovering the patient characteris- communication and are appropriate for assessing and treat. Karbe. Peach Mackie. with better prognoses for improvement (Basso & Farabola. also provides an important dimension to rehabilita. The reader also will be able to provide a rationale for 1997. Niemann.. 1996). account for the large amount of variability observed in lying recovery of auditory comprehension following global recovery from aphasia generally and from global aphasia aphasia (Zahn et al. Masih. & edly optimistic concerning the communication outcomes Nagaratnam. the outcomes observed in patients with other types of apha- the patterns of evolution and outcome in global aphasia. Corwin. ments yielding limited but nonetheless positive communica- rary goals for assessment. including phonologic treatment (Biedermann. 1994. global aphasia. These developments are encouraging especially. Kawabata.. describe contempo. because ulation (Naeser et al. 2002) and transcranial magnetic stim. Kertesz & McCabe. The prognosis for recovery of premorbid speech-language abilities is. Ward-Lonergan. Among these developments are an emission tomography to identify predictors that might improved understanding of the cerebral mechanisms under. & Thron.GRBQ344-3513G-C21[565-594]. treatment will have on the patients’ communication skills. & Sugita.. accompanying hemiplegia (Keyserlingk. its etiology. naming. speech-language services is composed of those presenting tences of varying syntactic complexity (Koul. Weinrich. 2005). Still others have employed positron- from this condition. sons with global aphasia have continued to appear in the lit. Barnes. Kumar. indeed. 1997. drome. 1994). Some recent studies have attempted to do this by examining outcomes with regard to the patterns of lesion sites producing global aphasia (Basso & Farabola. 2005). 1994). & Pardo. treat individuals with global aphasia and the impact that this tion for global aphasia (Kagan. 1981). both impairment-based and socially oriented treatment pro. Nagaratnam. Okuda et al. Positive developments regarding the rehabilitation of per. Fink. Duchan. 2001). and extended application of the largest percentage of patients with aphasia referred for computer-based communication systems to produce sen. and sia (i. advance. Others have investigated the role of an erature since publication of the last version of this chapter. deficits. the anterior. Kertesz. both the prerolandic and postrolandic speech zones Incidence (Goodglass & Kaplan. As a regions. Basso and colleagues (1985) Further studies. Davis (1983) suggested a general bias toward males in of the A1 segment of the anterior cerebral artery. Sorgato. tal left anterior cerebral artery identified by magnetic reso- With regard to sex. Cappa and Vignolo (1983). Lecours. patients with stroke but also for Indian patients with stroke Ono. Some recent reports. 1979. Scarpa. and Heschl’s gyri. & Farabola. Faglioni. or perseveration global aphasia. Shafer. influence of sex on global aphasia. Varying lesion effects also were described by through the time of maximal recovery. Basso and Farabola’s Bruun. and Ohmoto (2003) observed global aphasia (Bhatnagar et al. Angiography demonstrated an ante- ference in the distribution of global aphasia (Habib et al. This difference appears to hold true not only for Western interaction between these two areas. left hemi. 1987. dominating the left hemisphere. suggesting and colleagues (1987) were assessed between 15 and 30 days that such an extensive lesion may not be necessary to pro- post-onset and were right-handed with a single. This region has its white matter in contact with the tend to be significantly younger than those with global apha- white matter deep to Wernicke’s area. internal capsule. Ling. unconcern. Moraschini. Alexander (2000) suggests that the Age and Sex comprehension deficit in patients with lesions limited to the frontal lobe may be the result of inattention. 1976. incidence of global aphasia. Some studies suggest no effect of age on global interacting with modest phonologic and/or semantic deficits aphasia (Habib. the lesions were deep and result.GRBQ344-3513G-C21[565-594]. Poncet. alternatively. Scarpa. surface inferiorly to subcortical areas. Sugiu. De Renzi. and described as involving Broca’s (posterofrontal) and Wernicke’s extraanterior periventricular white matter. and the temporal . sphere lesion. Lüders and colleagues (1991) produced global whereas others report differences only with patients demon- aphasia during electrical stimulation of the basal temporal strating Broca’s aphasia (i. and the distal internal of the nature of the population seen at these hospitals. and De Renzi (1987) sia–producing lesions involved the cortex and were exten- reported an incidence of 55. the lenticular nucleus.6% have been reported for global aphasia (Basso. All of these global apha- higher. 1983).qxd 1/21/08 1:14 PM Page 566 Aptara Inc. however. 1987. Richter. In four additional cases. and Vanier (1985) observed global aphasia following discrete lesions confined to anterior (sparing of postrolandic centers) Characteristics or posterior cortical sites. 1981). however. and Palumbo (1987) found global aphasia in association with one lesion or with a series of primarily subcortical lesions Site of Lesion that collectively damaged the striatum-anterior limb of the Cerebrovascular lesions producing global aphasia have been internal capsule. Nonetheless. may be necessary for reliable data regarding the have been suggestive of global aphasia. Wernicke’s area. they constitute a significant demand on the resources confined to the insula. Scarpa to produce more profound functional comprehension et al. Eslinger & Damasio. & Salamon. superior. did tend to show hemispheric fissure identified by computed tomography atypical aphasias. the premotor area. & Ferrari. Naeser. that the incidence rate during the acute stage may be even angular gyrus.. 1990). Colombo. patients with Broca’s aphasia region. Numerous exceptions the 108 patients with aphasia included in the study by Scarpa have been reported in the literature. suggest supramarginal gyrus. When these data are combined. Basso. 1986. incidence rates of between 10% (1986) exhibited large lesions extending from the cortical and 40. underactiva- Discrepancies appear in the literature with regard to age and tion. & Faglioni. All of sive.1% in an acute sample. poor problem solving. duce a global aphasia. they provide Mazzocchi and Vignolo (1979) found global aphasia in evidence indicating that patients with global aphasia are 3 of 11 cases following lesions that were confined to anterior prominent among patients with aphasia as a whole. carotid artery. the Sheppard. Katsumata. Collins. Conversely. Previously. Kertesz & frontal operculum.. Sorgato.. inferior and superior parietal lobules.. 1987. the M1 the data generated among the VA Medical Centers because segment of the middle cerebral artery. (1997) subject with global aphasia had damage to the left 1980. anterosuperior. Tamiya.e. including the basal Della Sala. Ali-Cherif. 1979) or. Alexander. 2002). however. including more representative patient dis- reported other forms of aphasia following lesions that would tributions. The older patients in the sample of in a patient with a subarachnoid hemorrhage of the inter- Sorgato and colleagues (1990). including global aphasia from brain damage (CT) and a small ischemic lesion in the territory of the dis- that was restricted to either anterior or posterior areas. & ganglia. Brust. Colombo. 566 Section IV ■ Traditional Approaches to Language Intervention FEATURES (superotemporal) areas (Kertesz. age and sex Global aphasia also has been described in patients with may not be considered to have a differential effect on the lesions restricted to subcortical regions. rior communicating artery aneurysm and severe vasospasm 1987). and thalamus. and the inter- of clinical aphasiologists from the acute stages of illness nal capsule. The subjects with global apha- Global aphasia may be one of the most frequently occurring sia described by Murdoch. Afford. 1981. thereby favoring close sia). there appears to be no observable dif- nance imaging (MRI). and Ganguley types of aphasia. According to these authors as well as dence. & of language competency (i. and type 5  double frontal and pari- aphasia also show relatively better comprehension for per- etal lesion. 1979) in the context of almost univer. Yasuda and global aphasia were grouped into five types with differing Ono (1998) found a distinct advantage for comprehending outcomes. of competence and performance deficits. and famous the first month (34 subjects). but see also Forde & Humphreys. iors (Collins. thalamus.GRBQ344-3513G-C21[565-594]. posterointernal capsule. Wallace ring utterances or speech automatisms (Kertesz. 1966). In the case of famous personal names. type 4  parietal.. In contrast to subjects with global aphasia on the auditory comprehension these findings. Complete recovery was observed in Wallace and Stapleton (1991) analyzed the responses of some cases with type 2 and type 3 infarcts. and Yang (1989) also identi. sixth month post onset (13 subjects). Some authors have concluded that stereotypic recurring guistic deficit in global aphasia has been interpreted as a loss utterances are unique to global aphasia (Poeck. Basso and Farabola investigated recovery in portion of the Boston Diagnostic Aphasia Examination three cases of aphasia based on the patients’ lesion patterns. The authors Based on these observations. to identify patterns One patient had global aphasia from a large lesion involving of preserved and impaired performance. type 3  subcor- in the patients’ intact right hemispheres. 1985. lesions restricted to either the anterior or posterior language nonetheless. De Bleser. 1984). temporal Patients with global aphasia may have considerable single- isthmus. aphasia also have been identified in the literature. This prehension (up to the 30th percentile on the Boston may be a result of the greater contributions of the right Diagnostic Aphasia Examination [Alexander. Van variable outcomes. or BDAE. The verbal output of many patients Davis. The patient with global aphasia was of differential performance both within and across tasks. Kumar and colleagues (1996) observed global apha- areas of relatively preserved comprehension following global sia in their patient following a left thalamic hemorrhage. 1989). Type 1 included patients with large pre. be most severely impaired in their expressive abilities. The remaining four groups were sonal names and to the probable processing of these stimuli classified as follows: type 2  prerolandic. familiar envi- aphasia. Ferro initially examined 54 subjects during either ronmental sounds (Spinnler & Vignolo. Chapter 21 ■ Global Aphasia: Identification and Management 567 isthmus. lected during the acute stage of their recovery. Because of this and complementary evi- rules and operations). Kertesz. functioning in global aphasia suggests that the loss for these fied global aphasia in patients with lesions involving the patients may be viewed more appropriately as a variable mix internal capsule. 1992). Their results gen- both the anterior and posterior language areas. the knowledge of linguistic Keyserlingk. improving generally to Broca’s or Lancker & Nicklay.e. Wapner & Gardner. Selnes and Hillis (2000) speculate that Tan. Interestingly. He then followed-up 1998. for a report of each patient at 3.and these items when reading versus listening. 1979). these patients this finding to the nonsemantic. Yang. respectively. LaPointe. the lin. Patients in these latter groups demonstrated sonally relevant information (Wallace & Canter. 1983. These Ferro (1992) as well as Basso and Farabola (1997) investi- include recognition of specific word categories (McKenna & gated the influence of lesion site on recovery from global Warrington. 1995. referential nature of per- had a very poor prognosis. 1979). traditionally. Lai. and periventricular white matter of the left hemi- word comprehension (Alexander. basal ganglia. the scores for each of these subjects were col- but his overall outcome was considered to be outstanding. 1991. ment that occasionally is observed in individual patients. (Goodglass & Kaplan. They attributed postrolandic middle cerebral artery infarcts. Yang. or personal names (Van Lancker & Klein. Expression Language It has been suggested that patients with global aphasia may The hallmark of global aphasia is impaired language com. Subjects with global tical. the recent with Broca’s aphasia whose speech was limited to repetitions clinical evidence demonstrating preserved areas of language of the syllable “tan. & Wertz.” actually may have presented with an . 2000). 1983). 2000). 2000]) with hemisphere for comprehension than for expressive behav- concomitant deficits in expressive abilities (Damasio. Okuda and colleagues (1994) described four patients with global aphasia who had Comprehension lesions in the putamen. Pan. 1978. The lesions in his group of subjects with aphasia). Several isolated sphere. third month (7 subjects). two or three of their subjects did show evidence areas. Basso and Farrabola concluded speculate that differential auditory comprehension perfor- that group recovery patterns based on aphasia severity and mance during acute aphasia may be a useful prognostic site of lesion may not be able to account for the improve- indicator. rior periventricular white matter. Yasuda & Ono.qxd 1/21/08 1:14 PM Page 567 Aptara Inc. and anteroposte. and 12 months and then yearly there- relatively impaired access to personal names following global after when possible. with global aphasia primarily consists of stereotypic recur- sal buccofacial and limb apraxia (Alexander. transcortical aphasia. found to recover better than his two aphasic counterparts. 1986). and Stapleton (1991) suggested that. a patient others (Rosenbek. 1990. 6. whereas two erally supported previous claims that distinct patterns of other patients had Broca’s and Wernicke’s aphasia from preserved components are absent in global aphasia. the authors also suggested that lesions produc- sion deficits. & Spinnler. Gainotti. the prosody of these patients did not seem to reflect com- jects with left hemisphere damage but without aphasia. recurrences. and lexical disturbances. In a study by Herrmann. & Spinnler. in fact. deBlesser and Poeck (1985) suggest that the (anomic. Conflicting results have been reported regard. behavior (i. the patient’s use of prosodic elements to convey intent. be the result of the communicative Gainotti and colleagues (1986) did not obtain differences partner’s need for informative communication rather than relative to the severity of aphasia. Further.. 24 were classified as having global aphasia. however. Some indicate that the patient with aphasia is producing utter- studies have found that subjects with aphasia perform at lower ances with some communicative intent. formance on the RCPM to the presence of receptive semantic. Villa. Blanken and colleagues (1990) proposed that ing language disturbances that spare the parietal lobe may be speech automatisms relate only to speech output and do not associated with preserved calculation skills. Faglioni. functional independence between the two domains of tisms frequently were associated with comprehension dis. Broca’s. credited may. verbal impairment and breakdown of the semantic-lexical Stereotypes have been described as being either nondic. the subjects with aphasia performed worse than vowel recurring utterances with regard to turn taking the subjects in the other groups. The sub. the observed variability in language comprehen. necessarily indicate the presence of severe comprehension deficits.e. and conduction). Gainotti colleagues conclude that “a Wallesch (1989). These results were simi. Scotti. a group of patients with chronic and severe . nicative abilities in that they may make use of the supraseg- ical reasoning. potential effect of unilateral spatial neglect. 1986). Utterances were sampled during interviews in Using a modified version of the RCPM to minimize the which the examiner asked a series of open-ended questions. discrepancy that exists between research outcomes and clin- est in comparison to those in the other aphasic groups ical reports. Blanken. Capitani. The authors concluded that chronic subjects with varying types of aphasia to normal both length and pitch appeared to be stereotypic and that controls. deBlesser and Poeck (1985) subsequently jects in the Collins study were in the early stages of recovery. Collins (1986) has reported significant posi. the patients with remains questionable. The use of ing the performance of subjects with aphasia relative to that of suprasegmentals in conversational turn taking may appear to patients with left brain damage but without aphasia. patients demonstrated signs more closely associated with the authors posited that this double dissociation reflects a Broca’s and Wernicke’s aphasia. and the length of the utterances and their pitch contours D’Erme. contributions to conversation for which these patients are lar to those obtained by Kertesz and McCabe (1975). tionary verbal forms (unrecognizable) or dictionary forms Rossor. Warrington. Basso. 1956). but they did link poor per. but others have failed to show any significant difference extent necessary for conveying communicative intent. relatively preserved calculation skills in a patient with global and Papagno (1990) examined 26 patients demonstrating aphasia secondary to progressive atrophy of the left tempo- the nondictionary forms of speech automatisms. Of these ral lobe. elicited during formal testing. (Collins.g. or RCPM. In municative intent. These findings highlight the marked global aphasia and with Wernicke’s aphasia scored the poor. The appropriateness of these consonant- this study. “do-do-do” or “ma-ma-ma”) assessed by administration of the Raven’s Colored Progressive often give the impression of somewhat preserved commu- Matrices (Raven. 1981. subjects with right hemisphere damage. mental aspects of speech (Collins. and Cipolotti (1995) demonstrated (word or sentence) (Alajouanine. 1962). the language processing system). Although speech automa. etal lesions. Together with previous reports of selective impair- cases. Communication Recurring utterances among individuals with global aphasia Cognition was addressed previously.. Johannsen-Horbach. that calculation skills are not dependent on turbances. Wallesch. 1973. Colonna & Faglioni. Luzzati. level of integration of language” (p.GRBQ344-3513G-C21[565-594]. The between these two groups (Arrigoni & De Renzi. Koch. found that they did not exhibit prosodic variability to the 1966). and sub. 568 Section IV ■ Traditional Approaches to Language Intervention atypical global aphasia rather than the historically accepted specific relationship exists in aphasia between cognitive non- diagnosis of Broca’s aphasia. Because selective impair- sion among these patients suggests that speech automatisms ment of calculation skills has been associated with left pari- cannot be used to infer the presence of severe comprehen. The other ment of calculation in patients with intact language skills.qxd 1/21/08 1:14 PM Page 568 Aptara Inc. Those who exhibit only recurring The cognitive abilities of patients with brain damage often are consonant-vowel syllables (e. deBlesser and Poeck levels (Basso. and they may not have tive correlations between the language ability of subjects with reflected the spontaneous use of inflection to convey intent global aphasia and their performance on the RCPM. a nonverbal test of analog. Piercy utterances used for analysis. 48). were limited to those & Smith. analyzed the spontaneous utterances of a group of subjects and eventually. and Caltagirone (1986) compared acute and were analyzed for variability. De (1984) studied a group of patients with global aphasia and Renzi. 1986). 1965). 1964. these subjects achieved RCPM scores similar with global aphasia and output limited to consonant-vowel to those of subjects with less severe aphasia. raters’ awareness of the message contents (e. and actively tions. and an “Tell me what happened to you after you took ill. made significant gains in speech-language treatment that In examining the communication strategies utilized. and a patient with global aphasia and monly results from a cerebrovascular event. Masand cortical and periventricular white matter.and postrolandic ciency of different communication strategies used by three areas. and on referral. personality change in a young woman secondary to demyeli- nating disease also is described in the case records of the Massachusetts General Hospital (Anonymous. Marshall and colleagues the point of branching. which is the largest branch of the internal communicated primarily through writing and drawing. Their results demon. The patients reliance on verbal responses for establishing a diagnosis of presented with either severe Broca’s or global aphasia (50%). An Affect MRI scan of the brain with gadolinium showed multiple Depression following aphasia has been “underrecognized enhancing white matter lesions predominating in the sub- and undertreated” (Masand & Chaudhary. As described. Chapter 21 ■ Global Aphasia: Identification and Management 569 nonfluent aphasia were described in terms of their communi. the patient with Broca’s aphasia). & Dromerick.GRBQ344-3513G-C21[565-594]. secondary to two strategies reported by these authors were those enabling the generalized tonic-clonic seizures resulted in a return to his patients to secure comprehension (e. From a pre-treatment state had language problems now?”) and narrative requests (e. and imitating gestures. indicating compre. branching at the point of the sylvian fissure. Greater late recovery may be associated with large communicative interactions by varying the extent of the hemorrhages (Alexander. these authors describe positive benefits from admin- (e.g. depression. Wells. to become more alert. attentive. Discontinuation of his med- took the initiative or expanded on topics.. no knowl. 1986). the effects of context and shared knowledge on efficiency in 1999). the locus of apraxia of speech communicated primarily through gestur.. thus. the majority of lesions producing global apha- Marshall and colleagues (1997) also investigated the effi. smiling. the patient improved Herrmann and colleagues (1989) reported that the patients within 72 hours of achieving a therapeutic dose (15 mg/day) used mostly gesture in their responses to the yes/no ques. The most frequent ications.. The blood supply for these areas is via the middle patients with severe aphasia: A patient with Broca’s aphasia cerebral artery. Wells and colleagues reported that the patient’s language These findings support the effectiveness of the nonverbal returned to near normal during the 24 hours following the strategies used by patients with global aphasia and further seizures. included producing single words. and Chaudhary suggest this might be the result of heavy cation strategies and communicative efficiency. Also. inability to participate in his care. Not all occurrences of global aphasia are the result of a edge or partial or full knowledge). hension problems or requesting support for establishing comprehension). strated that the efficiency of communication by the patient Interestingly. excluded from treatment studies because of their severe munication depended on the type of question to which they comprehension deficits. Herrmann and colleagues concluded that patients with global aphasia rely most heavily on nonverbal ETIOLOGY communication.g. sad affect. chronic global aphasia hospitalized for deteriorating mental formance was observed for responses to yes/no questions status. assessed each patient’s communicative efficiency and the the event causing global aphasia tends to be thrombotic degree of communicative burden assumed by a partner dur. characterized by drowsiness and lethargy. following simple com- Herrmann and colleagues (1989) found that patients rarely mands.g. he reportedly communicative responses from the patients. superior per. “How long have you ment of his major depression. status epilepticus.”).e.. sia are extensive and involve both pre. writing and drawing of the patient with Broca’s aphasia. cerebrovascular event in the middle cerebral artery. Also. including the methylphenidate. A case of rapidly developing global aphasia and reinforce their training as a target of rehabilitation. The aphasia lasted during a period in den imposed by his gestural strategy was nearly as low as the which periodic lateralized epileptiform discharges occur. 1996).. 2000). patients with global aphasia tend to be The results showed that the efficiency of the patients’ com. global aphasia most com- through speaking. These changes resulted in his improved bal output and.. “Did your illness occur suddenly?”) when compared to istration of the psychostimulant methylphenidate for treat- interrogative pronoun questions (e.g. As might be expected. is het- using a visual analogue scale. 2004. more than embolic (Collins. previous apathetic state within a week. the posterior limb . Labar. In a case report of a patient with were asked to respond. involved in his care. a carotid artery. When accompanied by hemiplegia. the bur. The stroke mechanism ing a declarative message exchange task that was evaluated causing global aphasia without hemiparesis. created the need for more complex candidacy for rehabilitation. 1994). which is in the middle cerebral artery at a level inferior to ing with a few single words. The investigators also analyzed erogeneous (Bang et al. and Solomon (1992) reported a with global aphasia approximated that of the most efficient temporary case of global aphasia because of simple partial patient (i. patient with Wernicke’s aphasia communicated primarily Because of the extent of the lesion. The other types of questioning require increased ver.g.qxd 1/21/08 1:14 PM Page 569 Aptara Inc. Hanlon. however.. Lux. In this study. and the corona radiata and cen. sia progressed to other syndromes. His symptoms improved following endovascular (Helm-Estabrooks. ing schedules. 1993. Substantial improvements in praxis and oral- RECOVERY gestural expression were noted only during the first 6 months The outlook for recovery from global aphasia tends to be post-onset. two (in their 40s) evolved to Broca’s 3 to 6 months but also continued improvement during the aphasia. significantly greater improvement was noted in produced steady improvement. whereas similar improvements in auditory and bleak. For conduction. including Broca’s. 1978). and Forbes (1985) followed 15 patients post-onset (Kertesz & McCabe. For this reason. the term “global aphasia” may be reading comprehension were observed only between 6 and more prognostic than descriptive (Peach. including Broca’s. Tamiya. or WAB. a pattern similar to that reported by global aphasia. acute period of recovery and at regular intervals for up to guage performance during the period between 6 and 12 month 1 year (or more) post-onset. period between 6 and 12 months or more post-onset trum semiovale bilaterally. an instrument developed specifically to evaluate communication performance in patients with severe aphasia. or. 1 year post-onset. treatment of the aneurysm. Wapner and Gardner (1979). Prins. and Wernicke’s aphasia. Ono. Snow.GRBQ344-3513G-C21[565-594]. better improvement is demon- Evolution strated in comprehension than in expression (Lomas & Kertesz. although the authors attributed this gain at least Shetty. Treatment with corticosteroids (Kertesz & McCabe.qxd 1/21/08 1:14 PM Page 570 Aptara Inc. administration of cyclo. 6 from among 14 subjects with global differences have been reported depending on whether the aphasia had evolved to other syndromes. With The majority of patients with global aphasia will not recover regard to recovery of nonverbal cognitive abilities. improvement was most accelerated tula of the superior sagittal sinus that resolved after fistula between 6 and 12 months poststroke. In relation to the recovery observed in other types of transcortical motor. In the study by Kertesz and McCabe phosphamide. During the next 3 months. Levita. or BASA. For 1 year. 1977. Pashek & Holland. Overall. Kertesz to less severe forms of the disorder. Ramsberger. had recovered completely. At regard to the temporal aspects of recovery in global aphasia. Based on these findings. this period. and anomic aphasia after aphasia. When assessing the language recovery that does occur. subjects were receiving speech and language treatment. to assess language performance during the Patients appeared to reach a plateau in both RCPM and lan. Kertesz and 12 months post-onset.. improved from levels attained at the end of the first 3 months. 2004). of one subject. 1981). conduction. improvement appears to be greatest during the first months Holland. who had been classified as having global aphasia immedi- 1988). and Levita (1979. two (59 and 61 years of age) evolved to anomic . Swindell. Kertesz and McCabe (1977) post-onset. Morgan. 1989). the authors McCabe (1977) reported that the group of subjects with stressed the need for analyzing subsets of communication global aphasia in their study generally demonstrated limited skills rather than overall scores to evaluate recovery from language recovery. Some patients. (1977). Global aphasia also was reported following a leagues (1993) found different patterns of recovery for lan- ruptured anterior communicating artery aneurysm and guage and non-language skills following longitudinal vasospasm (Sugiu. Sarno & resulted in minimal improvements. an anti-inflammatory/immunologic agent. A number of studies have documented these the first 3 months post-onset. and McCabe (1975) found a precipitous and parallel rate of will improve to the extent that they evolve into other apha- improvement for RCPM and language performance during sic syndromes. 1977. administration of the Boston Assessment of Severe Aphasia 2003). classifications were based on improvement in their untreated subjects during the first results obtained from the WAB as well as from clinical 6 months post onset. Kertesz and McCabe (1977) described patients with 1 year or more. in the case patients with global aphasia not receiving treatment. Katz. 1978. how. Siirtola and Siirtola (1984) observed the greatest ately after stroke. No other information was treated versus untreated patients with global aphasia during provided regarding her speech-language outcome. Katsumata. Siirtola and Siirtola (1984) classified subjects global aphasia as having the lowest recovery rate. & Nicholas. With with aphasia within the first 2 weeks after hospitalization. the first year: Two patients (in their 30s) returned to normal ever. anomic. In the studies by Sarno global aphasia resulting from a giant dural arteriovenous fis. Nicholas et al. however. demonstrate substantial improvements during the first language functioning. Gobin. performance on the RCPM by the tested 93 subjects with aphasia between 0 and 6 weeks post- patients with global aphasia did not exceed approximately onset and found that 5 of their 22 subjects with global apha- 50% of the maximum attainable score. tially. Nicholas and col- embolization. Several patterns were observed at the end of Patients with global aphasia receiving treatment. and Segal (2003) reported a case of transient partially to subject heterogeneity. 570 Section IV ■ Traditional Approaches to Language Intervention of the left internal capsule. 1982). impressions. & Ohmoto. changes using a variety of assessment instruments and test- performance on the RCPM continued to increase substan. 1979. & Wagenaar. surpassing language performance that was only mildly Six studies used the Western Aphasia Battery (Kertesz. 1981). the acute stage. one to mixed fluent aphasia (the category of mixed aphasias and three recovered to anomic. Chapter 21 ■ Global Aphasia: Identification and Management 571 aphasia. with a mean time of 7. the discrepancies of the year. four evolved aphasia. and 18 months after stroke onset in 119 consec- Pashek and Holland (1988) described the evolution of 11 utive. with a with global aphasia had evolved to a less severe Broca’s. Similar results were observed in a follow-up in recovery from global aphasia reported in these studies do study of seven subjects with global aphasia (Sarno & Levita. Wernicke’s. tested within 11 days. Mark. which is a measure of functional verbal communi- stroke. For the patients who did evolve. mild Wernicke’s aphasia and changed to mixed nonfluent Holland and colleagues (1985) as well as Pashek and aphasia. not appear to be the result simply of the time at which the 1981). the earliest language (mean. Among the latter. Clinical tests included the “Grunntest Language performance was assessed by repeated administra. 6. two (in their 70s) evolved to Wernicke’s aphasia. or FCP. Seven of these studies might be the greater instability of language these patients evolved to Broca’s aphasia. Four of these patients evolved to less severe syn. none of these 14 subjects with ing. 1969). con- variation of no greater than plus or minus 1 week. Classification of aphasia was based on Reinvang and Engvik (1980) initially assessed their subjects clinical impressions as well as language test scores. A positive correlation was found 13 patients initially classified as having global aphasia at 7 to for initial severity and degree of recovery. the global aphasia may not begin to Benton. on the basis of descriptive criteria rather than WAB typol. This symptomatology may be fleeting. or unclassifiable syndrome at retesting. therefore. Thomas.qxd 1/21/08 1:14 PM Page 571 Aptara Inc. how- initially. Patients were scheduled for testing 30 days post-onset versus those tested during the second with the BASA at 1 to 2 months after the onset of their apha. 0–30 days).5 months after injury and a range global aphasia evolved to another type of aphasia by the end of 3 to 30 months. as cited in Laska et al. cation. Holland (1988). 3 months) and found that four of the seven subjects observations were collected at 4-weeks post-onset. Of six patients 10 days post-onset. Finally. In some cases. Apparently. ing was completed no sooner than 1 month after initial test- trast to the above studies. The median time for acute testing subjects with global aphasia from among a larger group of was 5 days (range. One patient was no longer aphasic. a tion of the WAB. these subjects with aphasia were classified test that the authors described as being similar to the WAB. severity also was obtained. (Sarno. In addition. 90% of all patients were 32 subjects who were followed for at least 6 months. four changed classification during this period. aphasia classifications obtained during Wernicke’s aphasia. Repeated duction. found that patients with global Sarno and Levita (1979) investigated recovery from aphasia who do progress to some other form of aphasia global aphasia using selected subtests of the Neurosensory demonstrate changes that extend into the first months post- Center Comprehensive Examination for Aphasia (Spreen & onset. and anomic aphasia. the Amsterdam-Nijmegen-Everyday-Language-Test. .GRBQ344-3513G-C21[565-594]. McDermott and colleagues (1996) global aphasia as well as seven other patients with severe found greater magnitude-of-change scores and frequencies aphasia for 2 years after the onset of their aphasia to describe of aphasia type evolution in subjects tested during the first the patterns of recovery. giving observers an initial impression of after up to 24 months. Laska. In the with aphasia between 2 and 5 months after their injuries study by Sarno and Levita (1979). and ever. The retest- testing was continued until 1 year after the stroke. and the Token Test. Broca’s. 1977) and the Functional Communication Profile evolve until after the first month has passed. two recovered to conduction aphasia. one changed to a early period (Table 21–1). Hellblom. Of the patients with global aphasia global aphasia. and result in a seemingly greater potential for patients the remaining 13 continued to be classified as having global to evolve to a less severe aphasic syndrome following this aphasia. for aphasi” (Reinvang. one to conduction aphasia. A subjective ranking of aphasia dromes. global aphasia followed by McDermott. or ogy. however. initial language observations were recorded. and Berndt (1992) reported the 1-year outcomes of including global aphasia. and transcortical on the Reinvang test includes the presence of two or more motor aphasias. A vast majority of the sic syndrome. degree of change in ANELT scores. and Wernicke’s aphasia.. 30 days post-onset. Murray. Wernicke’s. including Broca’s. the first 4 weeks after stroke versus those obtained after the Nicholas and colleagues (1993) assessed 17 patients with first month post-onset. and patients had either global. who were diagnosed initially with global aphasia and were whereas seven patients recovered to a less severe form of available at least three times during 18 months. 9 of 13 patients with aphasic syndromes). 2001). or conduction apha- two subjects demonstrated symptoms of dementia. Improvements were observed in all types of aphasia. All subjects were evaluated within the first 5 days after ANELT. Horner. respectively. and at 3. and two evolved to scores and. two patients recovered to to mixed nonfluent aphasia. Aphasia tends to be more severe during sia and at every 6-month anniversary of their strokes there. sia. Kahan. In con. and One apparent explanation for the discrepancies among DeLong (1996) evolved to other forms of aphasia. Recovery was determined by the Two patients evolved to a less severe but unclassifiable apha. and Von Arbin (2001) and two (in their 80s) remained global aphasic. The five studied the natural course of aphasia during the acute phase remaining subjects died during the course of the study. Based on these findings. 1985. unselected patients. One subject recovered normal language. 5 months. Rubin. 1977. hours of onset. The global aphasia of Whether age can be considered a prognostic indicator these patients aphasia improved significantly within the first has yielded differing conclusions. Pashek and Holland (1988) noted specifically that age leagues (1989) showed rapid recovery yet continued to appeared to predict a poor prognosis for change in global exhibit what the authors referred to as a residual motor aphasia but also identified a number of exceptions to this aphasia. further large-scale research studies in this area. McDermott and colleagues (1996). whereas older Tranel. Re-evaluation for the 13 sub- jects with global aphasia tested by McDermott and colleagues (1996) occurred approximately between 1 and 6 months post-onset. experienced global aphasia and a right hemiparesis that . Helm-Estabrooks. evolution from global aphasia is the result of a complex The variability in evolution patterns and age effects identi- interaction among a number of heretofore incompletely fied by these authors is intriguing and suggests the need for understood factors. with a minimum intervening period of at least 30 days. 1989. Sarno & Levita. & Forbes (1985) 10 Immediately 80 Pashek & Holland (1988) 11 0–5 days 64 Laska. hemiparesis following discrete prerolandic lesions. lesion. Horner.. Specific data for the subjects with global aphasia of Reinvang & Engvik (1980) were not reported. 1988). Ward-Lonergan. For example. Damasio. weakness initially. 1982). age cannot be considered an absolute predictor. in the study reported by Holland and hemiparesis in global aphasia may be a positive indicator for colleagues (1985). Hemiplegia Prognostic Factors Occasionally. evolved to a nonfluent Broca’s aphasia. 1971. Swindell. & Morgan (1993) 17 1–2 months 24 Reinvang & Engvik (1980) 7 2–5 months 57 a End-stage assessments were completed between 6 to 12 months post-injury in all studies except Kertesz & McCabe (1977). The patients of Laska and colleagues (2001) received follow-up at 18 months post-onset of their aphasia. Murray. Holland. Healton. Fromm.GRBQ344-3513G-C21[565-594]. a patient’s age appears to have an Horn & Hawes. The patients reported by Deleval and col- 1971). & Berndt (1992) 13 7–10 days 62 Siirtola & Siirtola (1984) 14 0–2 weeks 43 Kertesz & McCabe (1977) 22 0–6 weeks 23 McDermott. 1988. Motor abilities may be preserved fol- impact on recovery: The younger the patient. or a single temporoparietal lesion. Absence of a stroke. &Von Arbin (2001) 6 0–30 days 100 Mark. Mavroudakis. Greenhouse. & Brust. & DeLong (1996) 13 0–6 weeks 69 Sarno & Levita (1979) 11 4 weeks 0 Sarno & Levita (1981) 7 4 weeks 0 Nicholas. Pashek & Holland. and Laska and colleagues (2001). Thus. Sasanuma. 1985. Only 10 of the subjects with global aphasia studied by Kertesz and McCabe (1977) were assessed at 1 year or more post-onset. Deleval. with a minimum time of 3 months post-onset. The oldest patients remained global aphasic with dual discrete lesions (anterior and posterior cerebral) (see above). 1983. Fifteen of the 17 subjects with global aphasia followed by Nicholas and colleagues (1993) were assessed at 24 months post-onset. the better the lowing dual discrete lesions occurring in the frontal and prognosis (Holland et al. Van Following global aphasia. & Swindell. Kahan. that spared the primary motor area. Biller. Leonard. Ferro. younger patients with global aphasia recovery (Legatt. Hellblom. The patient described by Basso and Farabola (1997) rule. final testing for the remaining two subjects was completed at 18 months post-onset. temporoparietal regions. and found to have a negative influence on recovery (Holland & Rodesch (1989) reported two cases of global aphasia without Bartlett. Thomas. 1981. Advanced age has been 10 months post-onset. 1987. 1988) and to be Although both of these patients exhibited mild right arm an insignificant predictor of recovery (Hartman. Nicholas et al. Reinvang & Engvik (1980). global aphasia occurs without an accompany- Age ing hemiparesis (Bogousslavsky. a single frontotemporoparietal Age also may relate to the type of aphasia at 1 year post. Kaplan. this motor disturbance cleared within 48 Kertesz & McCabe. the mean time post-onset for the end-stage observations of all subjects with aphasia in their study was 7. Sarno. Adams.qxd 1/21/08 1:14 PM Page 572 Aptara Inc. 1985. & Cornell. 572 Section IV ■ Traditional Approaches to Language Intervention TABLE 21–1 Proportion of Subjects with Global Aphasia Evolving to Less Severe Aphasic Syndromes or Normal Language with Time of Initial Testing after Cerebral Injury Study Subjects (n) Initial Testing % Evolveda Holland. 1987). 1981. (1993). Marshall & Phillips. Tranel patients evolved to increasingly severe fluent aphasias with and colleagues (1987) described patients with global aphasia advancing age. therefore. characterized by perseverative monosyllabic utterances. Three patients demonstrated the classical aphasia. large Neuroimaging Patterns lesion of the left perisylvian region did not fare any better with regard to language outcome than did their counterparts Both CT and functional MRI (fMRI) have been used to esti- with global aphasia and hemiparesis from the time of onset. parietal. Palumbo. marked comprehension impairment. Keyserlingk and col. Degree of result in extensive language recovery. leagues (1997) found that chronic patients with global apha- sia and no history of hemiparesis secondary to a single. and severely defective naming with global aphasia without hemiparesis 4 to 8 days post. These researchers found larger of language outcome 10 to 12 weeks after their strokes. marked comprehension impairment. Koff. suggesting superior long-term gains. onset. prehension and naming. Pieniadz and colleagues the groups. dysfluent speech. spheres were typically equal. and Gerstman (1999) found three dis.qxd 1/21/08 1:14 PM Page 573 Aptara Inc. nonfluent speech with severe initiation recovery of single-word functions. central. were lesioned. the patient’s language out. mate outcome from global aphasia. and three patients had a subcortical or corti. and Stiassny-Eder (1990) used involved the left superior temporal gyrus. The first part of the study involved the analy- ter and nuclei. their study were recovery of comprehension abilities and sisted of two patients with a mean AQ of 34. These patients hension for the group without damage to Wernicke’s area . with atypical patterns deficits. The subtypes were associated with different patterns jects with global aphasia. accompanied by inconsistent ued to have severe language impairments. these hemisphere dominance for language. recovery patterns were examined in a group of sub- paresis. recovery at 3 months poststroke in 12 patients diagnosed minimal or no repetition. Pieniadz. to predict terized by dense.5 years later was described as “outstanding.9 who were differentiation between temporal lobe lesions involving characterized by dense. Gaddie. five patients exhibited single most frequent asymmetry involved left-greater-than-right lesions of either the left inferior frontal gyrus or the superior occipital width. Their lesions primarily Naeser. and Levine (1983) investigated the but not language. and insular branches of showed significantly better recovery of auditory compre- the middle cerebral artery. Language recovery in the left occipital region. recovered to a pattern most like transcortical motor aphasia. Frontal width was greater in the right hemi- temporal gyrus. left frontotem. primarily involving the territory of the subcortical temporal isthmus. Cluster 2 con. The primary foci in follow-up and remained globally aphasic. Brown. In a two-part study. changes in repetition and naming. and naming monosyllabic. parietal lobes with temporal lobe lesions restricted to the cortical white matter. lenticulostriate. increased speech fluency and improved com- lesions in both anterior and posterior language areas contin. poral lesion. sphere than in the left hemisphere. Eight of the 11 patients studied by Bang and sis of hemispheric asymmetry in a large group of subjects colleagues (2004) showed minimal improvement 8 weeks with aphasia and in a group of control subjects without after stroke onset. and limited temporal lobe lesions or lesions involving the frontal and repetition. from aphasia. The left inferior frontal gyrus and adjacent sub. and grossly defective naming. repetition. The results demonstrated significant similarity and pattern of dual lesions in the left inferior frontal gyrus and consistency in hemispheric asymmetry for both groups. Although severely aphasic at the initiation of with relative preservation of repetition and improved com- treatment 40 days post-onset. no repetition. Naeser. high-frequency nouns. The results of this study precentral. recovery was related to group subtype.GRBQ344-3513G-C21[565-594]. The subjects had either frontal. prehension were observed. nonfluent spontaneous speech. Chapter 21 ■ Global Aphasia: Identification and Management 573 cleared within a few days following a single. Cluster 3 included four patients come 2. spheric asymmetries may be used. Lesion patterns also were identified. The right occipital widths and lengths on CT scans for subjects auditory-verbal subtest scores and the aphasia quotient (AQ) demonstrating superior recovery of single-word compre- from the WAB were entered into a cluster analysis to define hension.and postcentral gyri involving the language cortex or posterior language cortex recovered to central and posterior parietal vascular territories was found.9. Four patients with At follow-up. (1983). For frontal length. function depended on the degree to which relationship between hemispheric asymmetries and recovery the patients’ lesions extended into the subcortical white mat. The the superior temporal gyrus. The critical difference between the two groups for motor. Hanlon. the hemi- could not be predicted by lesion location. Patients in this CT to compare lesion location and language recovery in a cluster showed minimal or no change in language scores at group of subjects with global aphasia. minimal capacity for poral isthmus.” with a mean AQ of 13. Eight patients with single lesions in either anterior Lesioning of the left pre.3 comprised cluster 1. Evaluation of hemi- were the most severely impaired patients and were charac. no more than mild levels of impairment. and naming. In the second part of the study by Pieniadz and colleagues tinct subtypes of global aphasia in 10 patients without hemi. Length also was greater cal lesion outside the perisylvian area. Wernicke’s area and those restricted to the subcortical tem- moderate comprehension impairment. Four suggested that these atypical asymmetries may indicate right patients with a mean AQ of 2. All members of this Global aphasia without hemiparesis does not necessarily group evolved to a pattern of Wernicke’s aphasia. These patients demonstrated low- Nagaratnam and colleagues (1996) examined language level. may be better than other test behaviors. Collins (1986) suggests Mark and colleagues (1992) evaluated CT scans of that patients with global aphasia demonstrating some vari- patients with global aphasia in a routine acute-care setting to ability within subtests and variability scores of around 100. Attempts to correlate specific types of lesions tests. higher test scores (i. ability (score greater than 350) and low variability (score less tic processing. Significant sion following global aphasia. Seven patients with large increases in overall variability relative to the previous two lesions following left middle cerebral artery infarction were categories and occasionally higher scores (seven or above) on identified using the Aachen Aphasia Test or the Aachen auditory comprehension. suggest at least the potential for extreme loss of both verbal and nonverbal communication recovery. reading. A total variability score is of lesion patterns. and Scarpa (1991). seem to have a better outcome . however. For other measures of aphasia.e. and production of some dif- underlying mechanism for recovery of auditory comprehen. such as scores and other language scores may be viewed as a nega- reactivation of functionally connected areas. The left extrasylvian temporal cortex and right formance at 6 and 12 months post-onset. The extrasylvian temporal activations were 12 months post-onset between two groups with high vari- thought to represent correlates of recovery of lexical-seman. According to 1990). High intra. substitution of tive indicator. 1983) that were consistent with only global aphasia on the Porch Index of Communicative Ability mild to moderate comprehension deficits (Naeser et al. Further. These authors found a variety highest score within that subtest. the ability to Zahn and colleagues (2004) used fMRI to investigate the name one or two of the objects. and matching for lesion volume. and the cere. 1982) AQ and auditory comprehension divergence among modality scores have a fair prognosis for scores. only 35% of which involved the entire derived by adding the variability scores for all PICA sub- language area. Dronkers. or PICA. and Hume (1993) tested associated with processing of auditory word form versus the influence of PICA intrasubtest variability on prognosis meaning. ence between the mean score for a PICA subtest and the Colombo. less hemisphere homologues. patients with global of words presented visually. no differ. Wertz. Different degrees of auditory comprehension described by Collins (1986) achieved a variability score of recovery were demonstrated among these patients at follow.. One patient their illnesses. correct object matching.GRBQ344-3513G-C21[565-594]. good copying skills. and naming subtests are Aphasia Bedside Test during the acute or subacute stages of consistent with a good prognosis for recovery. greater than 400 while still performing at the 9th percentile. Performance generally is characterized by mostly ing of the patients’ lesions and their aphasia outcomes. The more performance differs among tasks. for improvement in aphasia. ment.. no common lesion pattern was found. regardless of their accuracy. Patients with vari- bral volume occupied by the lateral ventricles and correlated ability scores of much greater than 100 and with greater with WAB (Kertesz. In addition. Variability scores of greater than 400 suggest excellent with some recovery of language abilities were unsuccessful. Using medical and PICA data. When compared to normal subjects. may be substantial for lexical-semantic processing Within auditory comprehension scores. potential for recovery. Over the Language Scores course of 1 to 2 years. 1981). scores below the 25th percentile. assess their viability of such scans for predicting language but relatively flat scores across all modalities. up 6 to 12 months later. The scans were measured prognosis for recovery. Wertz and colleagues con- recovery occurs via functional compensation by spared parts cluded that intrasubtest variability has no influence on prog- of the partially damaged semantic word processing system nosis. processing is severely impaired (Gold & Kertesz. previously nonactive areas. severe impairment) are consistent with a better prognosis. the majority of these subjects report- edly obtained auditory comprehension scores on the BDAE Collins (1986) has used scores obtained from patients with (Goodglass & Kaplan.and intersub- A group of patients with severe global aphasia and test variability.qxd 1/21/08 1:14 PM Page 574 Aptara Inc. recovery. None of the subjects in this study made significant Collins (1986). 574 Section IV ■ Traditional Approaches to Language Intervention (lesions limited to subcortical temporal isthmus). Negative and nonsignificant ences were observed in the patients having global aphasia correlations were obtained between variability scores at with regard to the lateralization or the general regions of 1 month post-onset and improvement in PICA overall per- activations. gest poor potential for recovery. copying. total occipital asymmetry. particularly when phonologic aphasia who provide yes/no responses to simple questions. it generally appears (redundancy recovery). The results did not support other that a lack of variability between auditory comprehension mechanisms for recovery that have been proposed. The authors concluded that comprehension than 300) at 1 month post-onset. no sig- posterior parietal cortex were the most consistently acti. or transfer of function to right the better the outlook. ferentiated responses on the verbal subtests. Right hemisphere contributions. No clear relationship was found between acute imag. (Porch. Variability in this instance is defined as the differ- (including comprehension) was studied by De Renzi. Imitation. to predict recovery. A functional activation paradigm The recommendations of Collins should be tempered by was used that allowed differentiation of anatomical patterns subsequent work. nificant differences in improvement were found at 6 and vated regions. however. have a poor performance at 1-year post-onset. 2000). patients with global aphasia invariably obtain gains in speech output. whereas scores of less than 200 sug- For the patients who showed some comprehension improve. 1990). a greater following global aphasia (Zahn et al. These observations.g. 1997). Prognostic Limitations 1989). 1991.. groups were not global aphasic. & Albert. Chapter 21 ■ Global Aphasia: Identification and Management 575 at 1 year post-onset compared with those who cannot grasp (Naeser et al. and a number of reasons exist to continue to do so.GRBQ344-3513G-C21[565-594]. For patients with lesions As described previously. Stiassny-Eder. Palumbo. For exam- tioners withhold assessment and treatment for these patients ple. they can be applied rigorously. Clinicians might then more accurately identify the estimated by examining the lesion site patterns on CT scans subgroups of patients with global aphasia who will demon- for these patients. Finally. the nature of the language assess- cortical white matter areas: the medial subcallosal fasciculus ment. 1992) sug- global aphasia who will evolve to less severe syndromes and gests that these approaches are in need of further data before those who will not.. 1992).qxd 1/21/08 1:14 PM Page 575 Aptara Inc. better recovery was strate substantial language recovery and those who will not.. 1986. the potential for recov. Patients with temporal lesions Sands. exceptions to 2001). Mark et al. In the absence of accurate techniques for predicting however. This information can then be applied in management deci- ral lesions spared Wernicke’s area and involved only the sub. expected patterns of recovery exist even in patients who meet the suggested neuroanatomical profiles (Naeser et al. could be associated with recovery from global aphasia in tion is the inability to identify accurately those patients with other studies (De Renzi et al. Global aphasia cannot be their global aphasia (Kertesz & McCabe 1977. (1989) suggest examining other specific structures as well Nonetheless. the most powerful reasons for comprehension deficits at 1 to 2 years after their injuries providing early treatment are (1) the latent recovery . Do these findings argue rant discretion on several accounts when making decisions against early intervention for global aphasia? Should practi- regarding early intervention for global aphasia. the findings of Naeser and colleagues (1989) are limited.. 1989). Sarno & reliably discriminated in the early stage (Wallesch.. underscore the fact that estimating clinical prognosis. and the middle third of the periventricular white matter (motor/sensory aspects of Influences Regarding the Timing of Intervention spontaneous speech) (Naeser. Sarno. 1981). few introductory remarks are provided in support of the Recovery of spontaneous speech in severely nonfluent management strategies that follow.. and any general conclusions about is primarily anecdotal. the prognosis for recovery from outside the left middle cerebral artery. 2004).. but their application appears to war- of the first year after their stroke. Bak. holding early treatment from patients who have a high or Besides CT. were expected to demonstrate moderate to severe recovery from global aphasia. a patient’s levels of alertness or attention at low probability for good recovery is an acceptable clinical the outset of global aphasia also might be assessed to predict practice. Silverman & cortical temporal isthmus. Recent evidence derived from fMRI the yes/no format (Mark et al. Conflicting findings with regard to many of available. 1992). the lack of clear patterns on CT scans that Primary among the reasons for advocating early interven. In addition. until a stable language profile is achieved? Clinicians have because many of the patients in their most severe subject opposed withholding early treatment (Collins. and the behavioral targets of treatment. along with differing profiles the factors identified above continue to present problems for in the evolution of global aphasia. supplementary motor area and cingulate gyrus). tors and the way that they interact to account for better ery of auditory comprehension following global aphasia was recovery. studies of patients initially diagnosed with global aphasia has demonstrated that activation of regions associated with lexical-semantic processing in normal subjects (left extratem- INTERVENTION poral and right posterior parietal cortex) is associated with good recovery of auditory comprehension at 6 months or Before discussing clinical intervention for global aphasia. It is Information derived from technologic applications may evident that research is needed to identify the particular fac- assist with this problem. sions regarding treatment (Ferro. 1977). approximately one-fourth to three-fourths or (e. Peach. Naeserand colleagues global aphasia generally is poor (Kertesz & McCabe. patients with global aphasia are a heterogeneous group. Even if it could be established that with. predicted at 1 to 2 years post-onset in patients whose tempo. its application as a clinical recovery in individual patients are “premature” (Basso & guideline is tenuous until additional information becomes Farabola. As described earlier. 1992. Patients who initially are more alert or accurately identifying the recovery potential for these have better attention appear to show greater recovery from patients to make such decisions. that included more than half of Wernicke’s cortical area. more of these patients with global aphasia will recover to a These findings provide a promising approach to progno- less severe aphasia or even to a normal condition by the end sis for global aphasia. 1970). The issues addressed patients with stroke and left middle cerebral artery infarc- here include some influences regarding the timing of inter- tion can be estimated from the extent of lesion in two sub- vention for global aphasia. Because the evidence for these latter findings Schulte-Monting. Helm-Estabrooks. & Levita. however. current methodologies prevent clinicians from superior recovery. In one study. (initiation of spontaneous speech). might treatment be withheld because Most. patient will experience a good versus a minimal recovery. 1979. extralinguistic. Leicester. 576 Section IV ■ Traditional Approaches to Language Intervention observed in those patients who receive acute speech and lan. substantial recovery. deferred until a stable language profile is achieved. clinical aphasiologists recognize the of the poor prognosis to allocate clinical and financial dynamic nature of aphasia. friends. Nicholas et al. patients with global able yes/no responding or a basic vocabulary of functional aphasia receiving early treatment show continued language items through oral or gestural means. & Wagenaar.e. Some observed in patients with aphasia when treated during the methods to accomplish this would include establishing reli- acute period of recovery. however.qxd 1/21/08 1:14 PM Page 576 Aptara Inc. Prins. 1981. Treatment Objectives Goal Revisions A second reason for early intervention in global aphasia con. or might these patients become only as a measure of the patient’s language functioning at a primary candidates for treatment to develop a functional single point in time that will be used to establish a baseline communication system from the outset of their aphasia that for intervention during the acute period. reorganization and recovery. In deliberating this issue. meta-analyses of the aphasia information to family. 1981). 1978. in and of themselves. There is little sense. from global aphasia. especially that of functional recovery? For patients who are not expected to demonstrate communication. counseling. Clinicians also provide Siirtola. Depending on less of the type of aphasia. treatment during this month post-onset. 1998). 1988. For this latter group. With full awareness of whether a Snow. Until more intervention in global aphasia therefore has the multiple is known about the individual patient with global aphasia. no matter how simple. family. no matter it is expected. purposes of language stimulation directed toward cerebral these data suggest that clinicians should continue to inter. and health-care staff during treatment literature have provided convincing evidence that this phase regarding the patient’s particular language profile outcomes for patients with severe aphasia are much greater (i. long-term management plan. Mohr. 1977. these improve- which outcome would suggest the need for early treatment? ments may result in recovery to a less severe form of aphasia For patients who are expected to evolve to a less severe in some cases. preserved versus deficient areas). whereas in others. therefore. improvement during the period between 6 and 12 months eye blinking. this process will be repeated regularly phase focuses on the remediation of language deficits via throughout the term of the patient’s rehabilitation. 1972.GRBQ344-3513G-C21[565-594]. the arguments for early inter. identification of successful vene at the earliest opportunity to assist these patients at a communication strategies. As discussed. and patient. 1979. 1981) that is not observed in communication systems may. Global aphasia will be greatest during the acute phase of Whether treatment is provided before or after the first recovery. ment goals are inherent principles of aphasia rehabilitation. Interestingly. . such as head nodding. the changes may be insuf- aphasia. the activities associated with establishing these Sarno & Levita. 1979. if not all. 1984). in the degree to which the condition renders the patient unable declaring this process to be less valid in global aphasia when to communicate even the most basic of needs. and pointing to pictures or specific icons. frequent probes for improvement in treated and quently will communicate? When considering the purpose untreated behaviors during this early period as well as re- of treatment in either case. 1973. might treatment be deferred to obtain the more sta. Wapner & Gardner. as alluded to above. post-onset (Kertesz & McCabe. Sarno & Levita. Early than during the post-acute period (Robey. 1993. evaluation using formal instruments is not only encouraged. None of these activities can—or should—be term recovery. are more compelling than otherwise. acknowledge that establishing and revising short-term treat- ment of aphasia for these patients.. vention with patients who have global aphasia. The Withholding early treatment while awaiting more stable recovery patterns per se following global aphasia therefore language profiles to improve treatment planning does not do not provide an adequate rationale for postponing treat. & Rosenberger. ery. described above no longer applied in predicting recovery Sidman. their outcome. first goals of treatment also focus on establishing some guage treatment and (2) the greater effects generally means of communication. be con- untreated patients (Pashek & Holland.. or might treatment be initi. and suit- when treatment is begun immediately after onset rather able ways to improve communication with the patient. Siirtola & sidered stimulatory for language. Often. and staff time when such treatments may be most crucial to long. Stoddard. and nonverbal consider a scenario in which the clinical limitations communicative functioning (Kenin & Swisher. ficient even at 1 year post-onset to suggest reclassification ble language profile that might subserve a more effective to another form of aphasia (Sarno & Levita. In addition. prognosis. 1979). regard- stimulation of disrupted cognitive processes. Early testing therefore is viewed resources more effectively. the treatment is initiated before the first month after injury. Because of recov- will provide the primary means through which they subse. improvements in linguistic. improvement can be anticipated in at ated immediately to accelerate the patient’s anticipated least one of these categories. Patients with global aphasia do demonstrate varying cerns the purpose of treatment. As a group. these improvements resulted in limited but tasks at least minimally in each language domain (i. a than simple diagnosis. A host of procedures are available to accomplish efforts continue in the areas of the patients’ greatest func. Clinicians no longer . speak. These will be reviewed in the following tional communicative needs. the treatment objectives reflect this mandatory for adequately describing communication func- change. reading. Reasonable treatment plans require both cess of intervention most often has been evaluated by the types of data.e. especially in the case of nication skills. Nicholas and colleagues (1993) also found signifi- patient’s responses to each item. Methods that are suc.GRBQ344-3513G-C21[565-594]. assessment provides a profile linguistic one. Ideally. Nature of the Assessment Behavioral Targets for Treatment Assessment of individuals with aphasia encompasses more Because the impairment in aphasia is. when they fail to change. To the degree possible. cant improvements in the communication skills of their ment continues through what might be viewed as diagnostic patients with global aphasia during the first year poststroke. pan- patient’s communicative status.g. From a prac. Chapter 21 ■ Global Aphasia: Identification and Management 577 Clinicians have much to offer patients with global aphasia mal or informal) is seen as simply augmenting the other. what has been accomplished regarding recovery of commu- ning (Rosenbek et al. taken a rather pessimistic view with regard to rehabilitation nonstandardized) measures. facilitate discussion of patient aphasia’s grammatical and lexical behaviors. a tomime. the suc- her strengths. Sometimes. tion and the patient’s quality of life. and the diverse methods for cueing behaviors that. Given this baseline. with stroke and severe aphasia do not benefit from speech tion regarding their residual communicative capacities may and language treatment. As a result. formal tests may be inadequate for treatment plan. listening. Included here would be an classification. many health-care providers have be more readily available from a variety of informal (i. assess. guage scores were observed that. and writing). The conclusions of patient observation to determine functional communication Sarno and colleagues. treatment to identify the conditions that further promote even though the majority of those patients did not change successful language performance. in addition. these tests that are suggestive of global aphasia. such as those with global aphasia. sections. In a subsequent study involving patients treatment and provide an initial approach for developing with global aphasia. the skills of conversation partners to improve communica- Estabrooks (1986). Collins (1986.e. these objectives. sampling behaviors across Levita (1981). were insuffi- tical point of view. and other extralinguistic behaviors) that exceeded formal language assessment should be completed using a the reported language changes. when were based solely on statistical comparisons of pre. and/or other functional abilities of these patients as well as In this “qualitative” approach. According to Sarno and standardized aphasia battery. Inspection of nonverbal communication abilities knowledgeable others to glean information about the revealed recovery of alternate skills (e. Such measures consist of outcomes in this group of patients. allow a practical test of approaches that post-treatment language scores and failed to account for result in the most favorable responses. analysis of patient responses during interviews focusing on These findings have given way in many instances to social familiar topics or in selected situations and the evaluation of approaches that exploit the residual language capacity hierarchical cues within language tasks. the case of the patient with global aphasia. and describing the stroke. nonetheless.. first and foremost. When the patient with global aphasia.. Sarno and Levita (1981) examined the subsequent behaviors. 62) approach.. informa. initial contact with the patient should be cient to warrant reclassification to another aphasic syn- preceded by a review of medical records and interviews with drome.. Too often. changes occurring not only in language scores but also in Contemporary approaches include both formal and communication performance as assessed by the FCP. In such an findings among colleagues. gesture. severely impaired patients. this approach has resulted in underestimation of however. effective communication by the end of the first year after ing. the potential for these changes is diminished with provides a summary of the severity ratings for a number of increases in the initial severity of the language impairment. Nowhere might this problem be more prevalent than in Little can be gained about patients’ preserved areas of com.qxd 1/21/08 1:14 PM Page 577 Aptara Inc. neither type of language assessment (for. To that end. p. For and their families during the acute period of recovery. Formal tests provide one method for gathering extent of changes occurring exclusively in the patient with such data and. From the time municative functioning from scores that are consistently that Sarno and colleagues (1970) suggested that patients near the floor for a given test.and logically varied. and of others like them. positive changes that may have occurred in other communi- cessful in eliciting target behaviors are incorporated into cation behaviors. informal measures of assessment to establish a communica. the primary target for treatment traditionally not only of the patient’s areas of weakness but also of his or has been that of language performance. For these patients. Clinically significant improvements in the patients’ lan- tion profile for the patient with global aphasia. both types are deemed patients improve. 1989). however. as described by Helm. concerted rehabilitative tioning. the BDAE (Goodglass. the Minnesota Test for Differential Diagnosis Psycholinguistic Assessments of Language Processing of Aphasia (irreversible aphasia syndrome) (Schuell. & Weintraub.. 1994). 1989) was Bryant.GRBQ344-3513G-C21[565-594]. in Aphasia the Sklar Aphasia Scale (Sklar. Test of Adolescent/Adult Word Finding guage performance to provide the clinical data for establish. These tests include the following: for audi. Token Test ing a diagnosis of global aphasia include the Aphasia Revised Token Test Language Performance Scales (Keenan & Brassell. General Language tern for patients with global aphasia on any of the tests iden. & Nicholas. 2000). and for naming. & Benton. Action Naming Battery (Druks & Masterson. Functional Communication Profile ers. the BASA (Helm- Gray Oral Reading Tests-Fourth Edition (Wiederholt & Estabrooks. Kaplan. 1981). Reading Comprehension Battery for Aphasia–Second Edition 1982). & Barresi. LaPointe. & Coltheart. Goodglass. Functional Auditory Comprehension Test 2001). the ASHA Functional Assessment of Communications Skills Neurosensory Center Comprehensive Examination for for Adults Aphasia (Spreen & Benton. the Reading Comprehension Battery for Test of Adolescent/Adult Word Finding (German.qxd 1/21/08 1:14 PM Page 578 Aptara Inc. 1971). Language Modalities Test for Aphasia Minnesota Test for Differential Diagnosis of Aphasia Neurosensory Center Comprehensive Examination Formal Test Measures for Aphasia Porch Index of Communicative Ability General Language Sklar Aphasia Scale-Revised The language features of global aphasia were described in a Western Aphasia Battery previous section. 578 Section IV ■ Traditional Approaches to Language Intervention attend exclusively to improving propositional speech in TABLE 21–2 patients with global aphasia during or after the acute period of recovery. and the Functional Auditory Comprehension Task (LaPointe & Horner. the Multilingual Aphasia Examination-Spanish (Rey. 1986) tory comprehension. the Object and tifying preserved abilities that might form the beginning . For Spanish speak. Auditory Comprehension Assessment (Edelman. Natural Communication (Holland. 1986) tified above generally is one of severe impairment in all language abilities. 1961). & Graham. Shewan & Canter. 1974). Boston Naming Test Estabrooks. 1983). the Revised Token Key: ASHA  American Speech-Language-Hearing Association. 1984) Behavioral Assessment (Salvatore & Thompson. Assessment of Language-Related Functional Activities and Psycholinguistic Assessments of Language Processing in Communication Activities of Daily Living–Second Edition Aphasia (Kay. 1982) 1962). 1978. the Boston Naming Test developed “for the specific purpose of identifying and quan- (Kaplan. 1991) can be used. 2001). 1975). Functional Communication Assessment of Communicative Effectiveness in Severe Aphasia Some modality-specific assessment instruments also (Cunningham et al. for reading com. The performance pat. the Language Modalities Test for Aphasia (Wepman Gray Oral Reading Tests–Fourth Edition Object and Action Naming Battery & Jones. Holtzapple. 1989) global aphasia.. 2001). Formal Assessment General Language ASSESSMENT Aphasia Diagnostic Profiles Aphasia Language Performance Scales Assessment of communication functioning in patients with Boston Assessment of Severe Aphasia global aphasia is best achieved using both formal and Boston Diagnostic Aphasia Examination informal measures. 1995) might be appropriate in the evaluation of patients with Communicative Effectiveness Index (Lomas et al. Functional Communication Examining for Aphasia–Third Edition (Eisenson. These measures are summarized in Examining for Aphasia–Third Edition Table 21–2. the Auditory Comprehension Test for Sentences (Shewan. Ramsberger. Informal Measures Sivan. Additional batteries that comprehensively assess lan. and the prehension. the PICA (Porch. Morgan. Aphasia-Second Edition (LaPointe & Horner. Some standardized aphasia test batteries Modality-Specific that specifically address global aphasia in their classification Auditory Comprehension Test for Sentences schemes include Aphasia Diagnostic Profiles (Helm. 1979. the Token Test (De Renzi & Vignolo. 1992). 1990). 1977). Functional Rating Scale (Collins. 1985). and the WAB (Kertesz. Such an emphasis is apparent in many of the Formal and Informal Measures for Assessment treatment methods that have been developed recently for of Global Aphasia such patients. 1992). Lesser. 1978). Test (McNeil & Prescott. 1998) and the Unlike the foregoing instruments. oral-gestural expression. fair. Responses FACS has been found to be reliable and valid for use with are scored for response modality (verbal. quality.qxd 1/21/08 1:14 PM Page 579 Aptara Inc. can be communicated by a variety of verbal and nonverbal including gesturing. reading. The BASA assesses performance on 61 items communication in four areas: social communication. ing to seven clusters of items: auditory comprehension. simulated daily activities. adequate. and other behaviors. traumatic brain injury. ness of an individual’s responses as well as the relative shar- sion of coin names. comprehen. partially com. orientation to time concepts. writing. munication of basic needs. gestural. ing of communication burden with the partner. When stimuli are centage of normal communication. action picture items. For example. Holland. The test yields a raw score for each subtest that is two separate sets of norms are provided. sustained phonation and scale rates the frequency of behaviors. writing. and perseveration. and visuospatial tasks. 42) skills. 1995). The FCP assesses 45 communi. unreliable. & a standardized battery to identify the conditions that further Heeringa. and prompt- symbols. informal measures of language Thompson. raw scores to standard scores and percentile ranks. & As described previously. reading instruc- are provided to convert the total raw score and item cluster tions. irrelevant. limb praxis. “Because The subtests probe auditory comprehension. The raw Salvatore and Thompson (1986) provide an example of scores are converted to a percentage and a weighted score informal assessment procedures designed to assess verbal and representing the patient’s performance relative to normal nonverbal communication systems in patients with global behavior for that dimension. speaking.” (p. famous faces. aim to identify isolated areas of preserved performance. Informal Measures & Fromm. or CADL-2. It is available in both a paper-and- incorrect. adult cognitive communication disorders resulting from municative. and signature. as well as cognitive and motor a severe case of aphasia may be classified as global. the American Speech- General Language Language-Hearing Association Functional Assessment of Communication Skills for Adults (Fratalli. comprehension of number tive scale rates the adequacy. repetition. Such measures cation behaviors in a conversational situation that are con. using the telephone. phrases. response relations that are preserved and those that are tion skills in structured. and verbaliz- means and are scored as correct. Raw scores are summed accord. and number sonally relevant yes/no question pairs. noncommunicative. presented to evoke all levels of responding. Fratalli. or ASHA FACS. stimulus- The CADL-2 includes 50 items that assess communica. writing. are rated as normal. The ASHA and symbols. unintelligible. verbal expres- an important goal of the BASA is to help determine whether sion. reading. A five-point qualita- singing. Measures for the formal assessment of functional communi- cation include the FCP (Sarno. and daily planning. The model used in their approach employs one summing the weighted scores to represent the patient’s per. for two populations (below and above 65 years of age). 1969). one for cases of associated with a rating of independent functioning levels severe aphasia and one for global aphasia. writing. drawing. counting money.GRBQ344-3513G-C21[565-594]. com- in 15 areas: social greetings and simple conversation. The ing. solving daily math praxis. 1). within language tasks. affective pencil version and a computerized version. tant information that provides a basis for treatment. or task refused or rejected). Communication Activities of Daily Living–Second Edition (Holland. 1998). object naming. reading comprehension. stimulus to evoke a variety of responses. and the Assessment of assessment are conducted following formal assessment with Language-Related Functional Activities (Baines. An overall score is obtained by aphasia. per. It includes impaired are identifiable. buccofacial praxis. Responses ing its name. writing a check/balancing a checkbook. The ALFA was standardized on 495 patients between the ages of 20 and 96 years with neurological histories as well as a group Functional Communication of 150 normal adults. or wrong. including telling time. under- gesture recognition. adult aphasia resulting from left hemisphere stroke and communicative quality (fully communicative. promote successful language performance. reading and writing. . Chapter 21 ■ Global Aphasia: Identification and Management 579 steps of rehabilitation programs for severely aphasic The ASHA FACS contains 43 items that assess functional patients” (p. addressing an envelope. Martin.and intrarater reliability and that are tested. such sidered to be common functions of everyday life. The results of the assessment provide impor- includes standard scores and performance norms. and math. The ALFA consists of 10 subtests. appropriateness. using a calendar. understanding. or poor and are transformed Hierarchical cues are used to evaluate such residual areas to raw scores within five dimensions: movement. visuospatial items. Norms standing medicine labels. good. and writing a phone message. A seven-point quantitative and place. Responses are analyzed in different modes. 1999). problems. or both). Behaviors as those listed above as features of comprehension. patients may be asked a series of context-dependent items that evoke a variety of to provide several responses to a pictured stimulus. reading. or ALFA. A matrix is developed to categorize the various relations CADL-2 has high inter. including speech acts and verbal interchanges as well as other items matching it to an identical picture and both writing and say- that assess functional reading. emotional words. Those relating to the self involve whole-body move. patients with global aphasia also have appeared in the litera- ture. a less systematic—but often effective—assess- fied PICA system. In addition. and other com. or CETI. “Pick up the comb”). and gestural and/or research purposes.qxd 1/21/08 1:14 PM Page 580 Aptara Inc. treatment for these patients may emphasize func- Holland’s procedure is “primarily concerned with the fre. Commands are divided into two sec. of recovery from global aphasia (Peach. Impairment-based approaches use structured meth- ments provided by spouses or significant others. good. non-linguistic cognitive skills to increase successful commu- day life. Functional and social approaches tend to something in depth. symbolic noise. 2001). oped the Assessment of Communicative Effectiveness in while manipulating variables found to be facilitative. and they useful for assessing change in communicative effectiveness include those relating to self as well as those of less personal when it is scored by the same person. 1981) and the singing. based approaches that attempt to reduce the severity of the Lomas and colleagues (1989) constructed the Com. to have acceptable test-retest and interrater all approaches may—and should—be used during the course reliability. and to be a valid measure of functional communi. Low interrater relia- saliency. & Osborne. Responses are accepted when communicated either bility. 52). speech. 2003). 580 Section IV ■ Traditional Approaches to Language Intervention Edelman (1984) provides an outline for the assessment of conclude that the CETI is an instrument that is capable of comprehension in global aphasia that specifically takes into measuring the functional changes occurring during the account research findings identifying areas of residual func. The verbal behaviors were further subcategorized negative results that have been reported for treatment pro- to capture the form. Functional (patient- municative Effectiveness Index. “Have initial study to test the reliability of the instrument. Table 21–3 cation when compared with other measures. The index was found to be internally predominate during the chronic phase of the condition. 1977. or ACESA. fications before it can be used confidently for other clinical consisting of repetition. Functional Communication Collins (1986) reviews several of these questionnaires and A number of informal procedures that can be used to sys. Performance ods that are carefully controlled for levels of difficulty to is rated relative to the person with aphasia’s premorbid abil. grams aimed specifically at remediating verbal skills (Sarno rectional strategies. those relating to objects in the environment are divided into Communicative effectiveness is rated using separate scales object recognition and object manipulation. “Show me the comb”. retest reliability and intrarater reliability were found to be ally (e. but consistent. “Can you pass the tissues?”) and acontextu. Cunningham. cor. language impairment (Peach. These tasks are of recognizability for verbal and nonverbal responses. recovery of patients with aphasia that have been difficult to tion in global aphasia and factors that facilitate understand. It consists of two sections: a Performance is assessed using commands and questions at structured conversation. 1970). and metalinguistics of the production. utterance expansion. both contextually and acontextually. . provide a context that will facilitate successful language res- ities using a visual analogue scale. Gesture. test- you any water?”. Severe Aphasia. reading. facial expression.. is incorporated and scored using a modi. limb movements. style. In an assessed respectively in a natural verbal context (e. Best. conversational dominance. ment of functional communication can be derived from patient interviews or questionnaires completed by individu- als who are familiar with the patient who has global aphasia. and into- ments. et al. measure previously. Hickin. and nation are accepted ways for conveying information. using commu. The CETI quantitatively assesses the performance nication (Herbert.. such as talking on the phone and (Kertesz & McCabe. The authors therefore suggested that the tool can be Questions require affirmation or negation only. an adaptation of the FCP called tematically evaluate the functional communication of the Functional Rating Scale. The situations range from ponses and shape succeeding language behaviors of increas- getting somebody’s attention to describing or discussing ing complexity. ing. The categories of behaviors included verbal and TREATMENT nonverbal output. tions. oriented) and social (partner-oriented) approaches use nicative situations provided by patients with aphasia and strategies that exploit the patient’s residual linguistic and their families that were thought to be important in day-to. writing. Sarno & Levita. hierarchical cueing.g. Given the generally poor outcome in chronic global aphasia municative behaviors.GRBQ344-3513G-C21[565-594].. Holland (1982) developed a procedure to score obser- vations of natural communication in normal family interac- tions. math. and orofacial movements. and an assessment of the patient’s simple linguistic levels. The suggested framework permits a systematic evalua. suggested that the tool needs further modi- verbally or nonverbally. accompaniment. tional and/or social approaches that attempt to improve par- quency and form of successful and failed verbal and nonver. provides one such example. ability to convey information about objects and pictures. and Lincoln (1995) devel- tion of understanding. Howard. Davies. ticipation in communication activities as well as impairment- bal communicative acts” (p. The authors provides a summary of these approaches. of those with aphasia over time in 16 situations using judg. Farrow. 1993). Finally. however.g. lists of families. gestures. Pantomime at a minimum. or frowns. Reciprocal scaffolding patients will move into the third phase. 1997) has designed a program to treat to evokes auditory representations of the visual stimuli that auditory comprehension using playing cards.” and shrugging the shoulders when asked how they are feeling. Questions Communication boards and statements about personally relevant topics may com- Blissymbols prise one of the best ways to elicit responses during this Drawing phase. therefore. With progress. As performance improves. (c) Auditory Comprehension matching objects to pictures and pictures to objects. a tech- Matching pictures nique incorporated in Visual Action Therapy (Helm- Eliciting appropriate responses Estabrooks.g. Chapter 21 ■ Global Aphasia: Identification and Management 581 TABLE 21–3 may underlie subsequent association of meaning with the name of the pictures (Peach. accompa. Even in those cases when the patient has no hands. smiles. looking for a variety of responses both Partner training between stimuli and from session to session. Fitzpatrick. Marshall suggests that. Finally. supplemented with ers in the patient’s environment. such as pointing to a calendar when asked to show the date. may provide the most basic level of auditory words and numbers written on them. Amer-Ind Code and (d) eliciting accurate responses. Key: Amer-Ind  American-Indian. Nonverbal responses may be nied by the clinician’s production of the name of the items to facilitated with accompanying props. (b) eliciting Functional (Patient-Oriented) Approaches Gestural Programs differentiated responses. pictures. however. including pages with be matched. To do this. (b) moving from pairing real objects to real- Impairment-Based Approaches istic pictures of objects to line drawings of the objects. contextual cues.. a road atlas. clini- Visual action therapy cians focus on attending. head Social (Partner-Oriented) Approaches nods. In the first phase. and understanding of the auditory stimulus accompanying the friends. the materials and techniques to Electronic elicit responses are not unlike those used in the first phase. In the second phase. the response elicited by the matching task is assumed Collins (1986. and yes/no responding. a calendar. Voluntary control of involuntary utterances Marshall (1986) provides an approach to treating audi- Phonologic treatment for naming Transcranial magnetic stimulation for naming tory comprehension in patients with global aphasia that is presented in four phases: (a) eliciting responses. Conversational prompting pictures. varied facial expressions. should be encouraged by clinicians and oth- improving auditory comprehension. the Supported Conversation for Adults with Aphasia clinician records the patient’s responses to a standard set of Conversational coaching simple questions. For the most picture identification. (c) eliciting appropriate responses.qxd 1/21/08 1:14 PM Page 581 Aptara Inc. to yes/no and “wh-” questions. or body parts and responding to simple questions. Patients Non-Speech Communication Aids who cannot respond to spoken messages may engage in Non-electronic visual matching or orientation tasks. the clinician should help patients to express Limited manual sign systems themselves through head nods. and a communication notebook. relatives. clinicians seek accurate responses to such tasks as object and step commands in well-controlled situations. 1997) suggests that a realistic goal for treat. in the fourth phase. and (d) using sets Playing cards of pictures that represent nouns with decreasing frequency Verbal Expression of occurrence in language usage. & Barresi. Complexity may be Treatment Approaches for Global Aphasia increased within this task by (a) increasing the size of the response field.GRBQ344-3513G-C21[565-594]. picture matching. appropriate responses may represent their best performance ment with the patient who has global aphasia consists of and. pointing. to permit consistent comprehension of one. Other appropriate Impairment-Based Approaches responses consist of performing one command for another or production of jargon in response to a question or request Auditory Comprehension for information. Computer-aided visual communication At this time. and stereotypic utterances). 1993). the clinician accepts and reinforces Lingraphica Gus multimedia speech system any response that is different from the previous response Promoting Aphasics’ Communicative Effectiveness given for those stimuli (e. for some patients. and responding severe comprehension deficits. a clock with movable stimulation. Associating meaning with speech movements these tasks may be followed by word recognition for objects. Collins (1986. 1982). This approach . They also may be pro- Preparatory training vided spoken messages accompanied by gestures. saying “yes” instead of “no. demonstrating appropriate responses with occasional accurate responses. following commands. qxd 1/21/08 1:14 PM Page 582 Aptara Inc. Biedermann and colleagues (2002) among these may be serial productions.g. Collins suggests consists primarily of stereotypic recurring utterances or that portions of the program are useful at some stage for speech automatisms. words that are involuntarily and inappropriately aphasia (Salvatore & Thompson. 1992. describing sequences) to more open contexts (e. strated modest improvements in naming on the Boston chy is described to promote language retrieval. items following phonologic treatment. struc. Sarno & Levita. The words are expression in patients with global aphasia may be a legiti..” a few proper names. usage of single words or phrases may not be a realistic goal. improve performance (Van Lancker & Klein. especially if they appear in the patient’s spon. improvements in language functioning.GRBQ344-3513G-C21[565-594]. writing.g. Wallace & Canter.. 59-year-old man with global aphasia 13 years poststroke. productive most patients. 1-Hz rTMS treatments 5 days a week for 2 weeks. Imitation. In this verbal communication skills may be ineffective for global program. For many of these patients. It also may often can recognize names that contain two salient features provide a suitable means for overcoming some of the prob- (e. and lems traditionally associated with the generalization of place cards in a sequence when they are unable to perform trained responses to conversational contexts. Rosenbek and vocabulary of between 200 and 300 words is established. Naeser and colleagues therefore severe aphasia in conversational contexts. similarly with other stimuli. 1990. and perhaps. can excite or inhibit the cortex. 1985). produced in the contexts of testing and treatment are identi- 1981). Helm-Estabrooks & Verbal Expression Albert. showing fingers. These results were consistent with previous studies gle words that express important needs. conversational usage. this technique may treatment were considered to be substantial enough to war- be particularly useful in developing contextually appropriate rant referral for further speech-language treatment. Naeser and colleagues (2005) used transcranial magnetic plemented by gestures and reading. 6. either alone or sup. This . pointing. the words “yes” and “no. These lead to neuronal depolarization that response generalization. phonologically who succeed in these tasks are taught to produce at least a related words. imitated words and treated naming to confrontation using phonologic cues in a phrases. 1997). She received ten 20- tured contexts (e.g. and unrelated words. Patients homophones. and finally. 1986. Van and (c) repetition. Language testing at 2 and 8 months post-treatment demon- tured interview or structured discussion). “queen of hearts”). occurred. (b) tapping the syllable number of the word. short- small repertoire of useful spoken or spoken plus gestured term improvements were observed for treated items. including oral reading. uses modeling. or automatic. 1986. gestur. semantically related words. no gen- responses. differentiate cards by suit. until a phases of recovery (Rosenbek et al. patients use naming ability in patients with global aphasia. A cueing hierar. matching. With its Naming Test and the BDAE. Improvements at 1 year post- emphasis on conversational interaction. colleagues (1989) do this by first attempting to associate Two studies have investigated treatments for improving meaning with speech movements.5 poststroke. Item-specific. trained in a sequence of activities. Props and written applied repetitive TMS (rTMS) to reduce the cortical cues are provided to facilitate verbal expression. To do this. 582 Section IV ■ Traditional Approaches to Language Intervention is based on the observation that patients with global aphasia communication for patients with global aphasia.. struc. excitability of right pars triangularis in this patient and effect sational levels are identified. manipulating objects or acting out and minute. and selecting objects) to confirm the phones as well as the effectiveness and generalization of meaning of any successfully elicited verbalizations. 1980. con- mate therapeutic activity during both the acute and chronic frontation naming. cuing hierarchy consisted of (a) an initial cue (consonant  conversational topics that are personally relevant will schwa or vowel). meaningful responses to conversa.. sin. taneous verbal productions. Functional imaging studies Conversational prompting. They suggest that these items include at least one eralization to untreated items. Included phonologic treatment. The tions relating to a variety of topics. expansion.. a method reported by have suggested an anomalous right frontal response in Cochran and Milton (1984). is used to establish these stimulation (TMS) to treat the naming abilities of a 51-year- responses (for a detailed approach to establishing an old woman with severe nonfluent/global aphasia who was unequivocal yes/no response. To test theo- available methods (e. 2004). see Collins. 1989). As described previously.g. can be used with these patients to Despite conclusions that traditional treatment focused on bring these stereotypies into more productive usage. Although not all patients The verbal output of many patients with global aphasia achieve the highest levels of performance. short-term attempts to establish or expand verbal fied and used as later targets in treatment. The treatment program Voluntary Control of Involuntary Utterances (Helm & Barresi. Ten conver. except for homophones. ries regarding the psycholinguistic representation of homo- ing. The design included four conditions: Lancker & Nicklay. one or of aphasia that have found poor generalization to untreated more phrases. or VCIU. ranging from concrete. and patients with left frontal damage that is thought to interfere feedback to develop the verbal responses of patients with with language recovery. TMS is a noninvasive procedure that uses Imitated responses are then practiced in more functional magnetic fields to generate electrical currents over discrete contexts using questions or practical situations to facilitate brain regions. greeting. Silverman (1989) as a facilitator of verbalization. pantomime may be 1983. drawing) (see below) to increase a severely such as manual shorthand. According to Rao and Horner (1980). as its end goal. Schinsky. & Griffin. 1989). Therefore. Smith.. Conlon learned. One of the most prominent strategies in the gestures as a means of communication. but generalization of these effects to themselves (Skelly. tural accompaniment. 1982). Schinsky. and generative. Probably the purposes. 1974). and as a bolic representation” as defined by Helm-Estabrooks and deblocker of other language modalities (Rao. ited manual sign systems for hospitals and nursing homes. Smith. manipulation of symbol sequences. 1990.. Using a modified program for experimental tional treatment approaches for global aphasia. as a facilitator of verbalization. This lack of generaliza- 1975). Raymer & Thompson. Hoodin & Thompson. Coelho. The approach also Some other gestural programs include pantomime. Amer-Ind tion suggested that the learned behaviors did not influence Code is concrete. 255). hand-talking chart. appropriate for the patient with aphasia who cannot use 1978. Steele. 1990. A hierarchical procedure is used in each pro- (C-ViC) (Weinrich. gram to “move the patient along a performance continuum from the basic task of matching pictures and objects to the Preparatory Training communicative task of representing hidden items with self- initiated gestures” (Helm-Estabrooks & Albert. though reports of its effec. and buc- tronic means is computer-aided visual communication cofacial VAT. et al. Kearns. uses gestures to reduce apraxia and improve by communication boards. pictographic. untreated items was not observed. Conlon and McNeil concluded that fur- reports have demonstrated the usefulness of Amer-Ind Code ther research is needed before VAT can be confidently rec- as an alternative means of communication (Rao 1995. These results generally is adapted from Amer-Ind sign. Donaldson & Griffin. For example. 1991.. A few colleagues (1982). until other communication sys- (1989) describe a treatment program for gestural reorgani. 1991). p. Three programs rehabilitation of patients with global aphasia using elec- constitute the approach: proximal limb. both non-electronic and electronic means.GRBQ344-3513G-C21[565-594]. or VAT. Ramsberger. Carlson. Skelly. Rao ommended for the treatment of patients with global aphasia. Rosenbek and colleagues initially. 2001. and graphic copying. severely impaired patients (see..g. Limited manual sign systems may be used Donaldson. distal limb. 1989. 2004. especially in auditory com. Amer-Ind Code the steps for their second subject. as indicated by prehension and in the voluntary use of words and phrases formal assessments. but also in the areas of auditory and appropriate to her environment. or a affected patient’s communicative effectiveness (Rao. global aphasia.qxd 1/21/08 1:14 PM Page 583 Aptara Inc. Ramsberger & Helm-Estabrooks. Amer-Ind Code. and pointing (Silverman. verbalization without ges. agrammatical. & Albert. 1995). 1980. Conlon and McNeil (1991) proposed that the efficacy of Functional (Patient-Oriented) Approaches VAT has not been established because of experimental limi- Gestural Programs tations in the original work of Helm-Estabrooks and col- leagues (1982). eye-blink The greatest utility of the technique. however. on an interim basis. Visual Action Therapy Non-Speech Communication Aids Visual Action Therapy (Helm-Estabrooks & Albert. verbal repetition. but ultimately. tems can be developed. Alexander and Loverso (1993) developed a specific program The authors suggest that the method produces improve. reading comprehension. 1989). Pointing is desirable for the patient who is going to use a communication board. Non-speech aids include those that assist communication by Helm-Estabrooks et al. lim- might be combined with other nonverbal means of commu. 1979). for the treatment of global aphasia that supports the capacity . 2001).. highly transmissible. Strategies using Brownell. Chapter 21 ■ Global Aphasia: Identification and Management 583 patient continued to improve. The system can be and McNeil (1991) determined that VAT is not effective in applied in aphasia rehabilitation as an alternative means of achieving the program’s stated purpose of establishing “sym- communication. ments not only in the area of pantomime. appears to be encoding. 2004. positive treatment effects were observed on most best known of the gestural programs is American-Indian steps of the program for their first subject and on about half (Amer-Ind) Code (Rao. offers a number of suggestions for the selective use of each tiveness vary (Hanlon et al. Rao & Horner. Skelly. 1982. 1982. & Sisterhen. manual self-care signals. a gestural system based on were consistent with those of Helm-Estabrooks and col- the concepts underlying words rather than on the word leagues (1982). nication (e. Helm-Estabrooks. these limited systems zation that uses Amer-Ind Code as the primary system of may provide the only means of communication in the most gestures and has.g. easily performance on untreated but similar behaviors. of these approaches. they investigated the effects of American-Indian Code VAT on the communication abilities of two patients with Gestural programs constitute a sizeable portion of the func. e. Tonkovich & Loverso. Simmons.. non-electronic assistance include transmission of messages 1989). gestures for “yes” and “no”. et al. the patient’s verbal expression or ability to use symbolic and drawing. If an accurate using iconic/substitutional language (e. four cation following global aphasia might be a result of (a) the subjects with severe aphasia learned novel symbolic relation. and finally. The authors con.g. difficulty individuals with global aphasia have extracting ships and generalized these to untrained relationships. 1997) suggests a training procedure in that the participants initiated more topics and had fewer which target items are identified in isolation. Collins (1986. Garrett. Mager. Specific treatment is required for effective use of the patients who had global aphasia. Subjects received realistic pictures of those objects. Treatment and acquisition probes were administered in a Johannsen-Horbach. Participants demonstrated of items contained on one board. Of the two procedures for training general- and associational boundaries. and the alpha. For ized value in conversational interactions with persons who severely impaired patients. have aphasia. communication response was not observed. however. family or pictographic symbols. Generalization train- locations in which those objects would be found were used as ing was conducted using a role-playing procedure in the treatment stimuli. and Thompson (1991) investigated the port the use of communication books with individuals who acquisition. No tively related groups. correlation between the severity of the language impairment tion may be used as an indicator of the patient’s ability to and the ability to use symbols. Based on these results. these patients constitute the appropriate that communicate specific content items and (b) treatment group for substituted language systems. In their study. Those authors contend communicating social responses. Weiss. and Lloyd (2005) speculated that the stimuli that may have potential for use with gestural-assisted failure of symbol use to generalize to functional communi- programs like those described below.. and personal information. Cegla. responses. treatment room with a script employed during the coffee- sentationally similar to those adopted for communication hour probes or within the coffee-hour setting. more pointing behavior. levels were identified. Two of five patients with global aphasia response generalization to untrained responses was who were studied reached the proposed goal of treatment— observed. Stimulus presentations for subsequent treatment with communication programs were followed by a 5-second response interval. cues consisting of a verbal cue. demonstration of semantic capacity across categorical the coffee hour. a typical board will contain per. requesting and personal informa- ing in a field of one and increasing to picture sorting into loca. Eight hierarchically-arranged treatment data were collected for up to 6 months. The authors concluded that their results sup- Bellaire. ture communication board training. The stimuli were described as being repre. and maintenance effects of pic. Maintenance boards or C-ViC. only training within the actual coffee-hour setting global aphasia were unable to recognize the nature of the resulted in generalized use of all responses except for social response required at more complex levels. their findings have Blissymbols potential application to the treatment of this population. have global aphasia. alternating treatment single-subject design with two bet. they suggested using remnants (actual objects or pho- Communication Boards tographs depicting recent or past events) that have personal- Communication boards vary in type and complexity. cognitive ability to initiate symbol use without the support of conversational partners. Although their two subjects did not have global aphasia. Following treatment. nor was generalization of board use seen during namely. generalization. and a physical assist were provided.g. for establishing equivalence relationships among visual Ho. requests for food and other that therapy of this sort establishes a necessary precondition items. even if only 40% of the cases respond successfully that (a) communication boards include primarily pictures to the program.GRBQ344-3513G-C21[565-594]. and realistic pictures of the response-contingent verbal feedback. the authors recommended cluded that. the authors demonstrated board. from among increasing numbers tion when either remnants or pictographs were used versus of foils until a temporary ceiling is obtained for the number when no symbols were available. tion responses were acquired. then after an unrepaired communication breakdowns during conversa- imposed delay. and training occurred during a coffee hour in a nursing tions while being sufficiently easy to allow an understanding home care unit. with remnants than with taining pictures within only one domain (e. Alternative boards con. whereas generalization probes (1985) assessed the benefits of treating four patients with . 584 Section IV ■ Traditional Approaches to Language Intervention to make categorical and associational semantic discrimina. and (c) the absence of the benefit from further treatment efforts. beginning with object-to-object match. (b) a authors suggested that demonstrations of such generaliza. Pictures were divided into three sets for of the nature and purpose of the tasks. Twenty-four common everyday objects. To overcome these challenges. and Wallesch traditional treatment room. Georges. model. numbers.qxd 1/21/08 1:14 PM Page 584 Aptara Inc. Schempp. The remaining patients with ization. but not social responses. The subjective evaluations of the familiar objects) may be used to increase the number of communication partners also favored the remnants over the items available to the patient. pictographs.. for the use of picture communication boards take place in Salvatore and Nelson (1995) described a training model the natural environments where the board is to be used. a boards or C-ViC). In a study using a combination ABA and sonally relevant words and pictures. The meaning from symbols referring to abstract concepts. pendent of natural language processes. A scale of communicative effectiveness was designed to conversational situations. Treatment outcome is eval- teach the production and comprehension of simple sentence uated by increased accuracy in the patients’ drawings of nine in the symbol language.GRBQ344-3513G-C21[565-594]. Further inquiry will The subjects with aphasia also improved in the recognizabil- be necessary to determine whether these findings can be ity of their drawings following treatment. verbs. Morgan and Helm-Estabrooks Ward-Lonergan and Nicholas (1995) described such a pro- (1987. written communication. Performance spoken and written words. visual organiza- ulate the correct words while pointing to the corresponding tion. see also Helm-Estabrooks & Albert. Their post- presentation of pictures or objects or the pantomime of the treatment results for two patients indicated an improved abil- therapist. The cartoons range from one to three panels. treatment program emphasizing drawing-aided communi- duced Blissyntactically correct sentences in response to pic. incorporating these items degree to which patients with severe aphasia can communi- into Blissymbol sentences. ual treatment twice per week for a period of at least 2 Criterion performance consists of reproducing a recognizable months. scale was designed to rate the recognition of drawings. copying. (b) humorous aspects of the cartoon.qxd 1/21/08 1:14 PM Page 585 Aptara Inc. Based on these data. to the surface forms of natural language. on refining primary drawing skills (form. and one patient articulated grammatical sentences.” Morgan and Helm-Estabrooks (1987) symbol system to use in communicating with the patients. and writing. Communicative effectiveness was assessed using a 40-item tion. a visual symbol system of program entitled Back to the Drawing Board (BDB) to teach pictograms and ideograms. All patients had previously patients to communicate messages through sequential draw- received at least 6 months of traditional therapy for aphasia ings. tures for nouns. and function words in multiple. ognizability of the drawings. and practice through the procedures using Blissymbols. trained interactant who used specific strategies to optimize preted as evidence for the superiority of such systems relative communicative effectiveness. and perspective) within defined communicative symbols. itator of communication by providing to patients with apha- sia a fixed representation of a concept that is readily available for subsequent modification. verbs. Drawing Kearns and Yedor (1992) have pointed out that specific Drawing has received considerable attention both as a com. reading. the authors were able to and post-treatment performance on the PICA also was used compare the patients’ use of Blissymbols to their processing to measure communicative effectiveness. ity to convey information through the use of drawing alone.and post-treat- two patients with severe aphasia (neither of whom appeared ment performance both with and without the use of draw- to have global aphasia) to use Blissymbols to communicate in ings. demonstration. Verbal and graphic cueing and requests for Variable outcomes with regard to continued use of the sym. By performing detailed analyses of rate performance on the outcome measure. and (c) acquaint relatives with the “accidents of living. three patients pro. The drawings were then placed The success of some patients with severe aphasia in com. programming may be needed in some cases to establish municative medium and as a means to deblock verbal and spontaneous use of drawing for communicative purposes. tures. In an important with aphasia were enrolled in a treatment program focused related finding. and function words. The eight subjects their communication with their relatives. Pre- ing. Patients are trained to draw cartoons from memory without significant improvement in expressive language. municative effectiveness score attained by the normal adults. substantial gains were found that the performance of the patients with aphasia using observed in the communicative effectiveness of subjects with Blissymbols was entirely consistent with their processing of aphasia compared to their pretreatment levels. enlargement of distorted parts were used to improve the rec- bols by these four patients were reported. cate through drawing and to evaluate the effectiveness of a All patients acquired a symbol lexicon. For using verbal instruction. achieving 65% of applied to patients with global aphasia who have more the normal adults’ scaled value. detail. three patients evidenced the ability to artic. Eight patients with aphasia and eight comparable. speaking. Lyon and Sims (1989) undertook a study to determine the choice arrays and. patients received individ. provide an operational definition of accuracy to facilitate Symbols were introduced verbally along with simultaneous comparison and interpretation of the drawings. 2004) designed a gram for their patient with global aphasia. subsequently. adverbs. the severely impaired natural language abilities than those of the authors concluded that drawing serves as an important facil- subjects participating in the study by Funnell and Allport. and a second the patients’ abilities to process isolated words during listen. To test this assump. Training consisted of associating symbols and pic. The program . contexts. Funnell and Allport (1989) investigated the ability of drawing outcome measure to evaluate pre. and that the use of Blissymbols further improved following treatment to 88% of the com- did not provide a channel for communication that was inde. Two of the patients successfully used the symbols in normal adults participated in the study. cation. Chapter 21 ■ Global Aphasia: Identification and Management 585 global aphasia using Blissymbols. The program was designed (a) to provide a basic drawing that contains the critical details relevant to the lexicon of nouns. Funnell and Allport Following drawing treatment. in a communicative interaction between the patient and a municating using novel visual symbol systems has been inter. of similar forms in natural language. duction of patients using this tool. 586 Section IV ■ Traditional Approaches to Language Intervention began with BDB (Morgan & Helm-Estabrooks.. chronic patients with a wide range of types and severities of gone C-ViC training to determine whether these patterns aphasia following treatment using the Lingraphica System. 1989. which the device then turns into patient demonstrated great difficulty in multi-sentence pro. mentary motor area and the cingulate gyrus. been discharged from previous courses of speech-language Before treatment. responds to questions but does not initiate interactions) were found following lesions that spared poste- Computer-Aided Visual Communication rior systems but involved anterior systems. Weinrich. Moderate responses (i. Kleczewska. Steele. The card decks contain interjections. & Wertz. gies).g.. 1987. and Wertz (1997) studied the responses treatment. 1993). & Weinrich. modifiers. The patient made substantial The findings from this study suggested that the lesion site progress during the course of the program. Steele. demonstrated no response to the program had bilateral Carlson. and common nouns. Wertz. and concluded with an on a rating scale that was developed to assess the quality of unstructured. Weinrich. interactive approach they identified as Func.. The Lingraphica also is loaded duction. (Naeser et al. The C-ViC training was initiated no ear- gressed to the less structured conversational framework em. The user selects icons to reversible subject-verb-object) (McCall et al. animate nouns. used the . & Baker. and spoken words to provide with global aphasia was able to accurately select the lexical computer-based communication. All patients received 1-hour treatment sessions (Helm-Estabrooks. Steele. Zurif. or posterior and anterior systems. & Carlson. lesions that included variable lesions in either left posterior Carlson. 1992. Morgan. that prediction of outcome was optimized when provides another approach to establishing alternative com. Berry.e.. were predictive of communication outcomes following C-ViC Aftonomos. The ultimate goal of verbs. pro. all patients were tested with the BASA treatment. seen in these same patients in other communicative contexts tions. tional Drawing Training. Steele. Kleczewska. text. Formal procedures have been developed that extend training from introductory phases Lingraphica which teach the patient to follow simple commands to later phases designed to transfer C-ViC communication skills to The Lingraphica is a speech-generating device combining use in a home setting (Baker & Nicholas. Although some of their patients did not have to computer-based treatment of 23 patients with aphasia who global aphasia. and positive gains that were observed over with a wide range of practice materials that can be used in the protracted period required for this training did not gen. Similar to that reported with gestural strategies. Kleczewska. 1981) (see below). Outcomes were based (Davis & Wilcox. & Nicholas. 1989) however.qxd 1/21/08 1:14 PM Page 586 Aptara Inc. Kleczewska et al. all of the patients did present with little or no were 6 months to more than 15 years post-onset and who had spontaneous speech and impaired auditory comprehension.. with the exception of one patient. Using procedures results obtained from pre-treatment testing with the BASA similar to those of visual communication (Gardner.g. audible words or sentences. gist or independently at home. C-ViC–generated sentences. Kleczewska.. prepositions. 1989. et al. although generalization to oral production of these ful verbal reorganizer that may enhance the language pro- items has been limited (Weinrich. 1976) but in a microcomputer environment. Weinrich et al. verbal C-ViC is an iconographic system in which patients construct facilitation has been noted (personal observation) during communications by selecting symbols from six “card decks” C-ViC training that produces successful naming that is not and arranging them according to certain syntactic conven.e. The authors also found. This express a thought or need. the clinic under the direction of a speech-language patholo- eralize to standardized assessment measures. or later poststroke. with a speech-language pathologist using the Lingraphica 1989) and underwent non–contrast enhanced CT at 3 months System and. but these observations suggest that C-ViC is a power- tions). Naeser and colleagues (1998) investigated the lesion site Three studies have demonstrated positive effects for patterns for 17 patients with severe aphasia who had under. Ramsberger. conversation or formal testing).. Steele. 2000). these lesion site patterns were combined with behavioral munication in severely impaired patients. 1992). 1987). Patients who Computer-aided visual communication (Steele. animation. the patient was able to posterior systems that include Wernicke’s area and the tem- communicate effectively through drawing when given lim. One patient images.GRBQ344-3513G-C21[565-594]. however.. 1998). lier than 3 months after aphasia onset and was continued ployed in Promoting Aphasics’ Conversational Effectiveness twice weekly for 6 months to 1 year. The C-ViC is not verbalization without computer assistance (as program has been used successfully to train comprehension might be the case with some of the foregoing gestural strate- of a variety of lexical categories (e. initiates com- spontaneous initiation of communicative drawing was still munication) using C-ViC spares large portions of either lacking at the end of the treatment.. poral isthmus or anterior systems that include the supple- ited encouragement. It contains a large number items for a message as well as apply simple syntactic rules to of words represented by icons and can be customized with a produce basic constructions (subject-verb. and although pattern associated with the best response (i. verbs and preposi. irreversible and user’s special words and pictures. Weinrich. (e. Davis & improved significantly on all language subtests of the WAB. except for patients with Wernicke’s and aphasia was able to use the computer-based system to pro- transcortical motor aphasia. 1985). Comparison of pre. and visuoperceptual also uses a multidimensional scoring system to better . 1986. the channels through which they will communicate. 2005). and Steele (1999) extended the intervention on the production and generalization of previous work by assessing the outcomes of computer-based graphic symbol sentences of varying grammatical complex- treatment on functional communication as well as formal ity in 10 patients with severe aphasia. PACE treatment patient’s cognitive. Koul and colleagues (2005) investigated the effect of Gus Aftonomos. The pro.g. the est gains in functional communication. functional most and least severe aphasias made the smallest. and all of the patients grouped by apha.. its inclusion here (as in previous gains (behind patients with anomic aphasia) at the impair. and for all items of the CETI following attributes such as direct language stimulation and real-life treatment. he did not achieve tests of the WAB and for the CETI. motor. approach following global aphasia when compared to the Finally. the approach emulates natural con- versation by allowing participants to exchange information Gus Multimedia Speech System through multiple modalities. cantly improved performance in multiple modalities. to convey messages.g. skills determine the number of symbols that are displayed in sions.. 1981. When analyzed by patient severity. In this way. Treatment con. 1985. gains at the impairment level. The last functional approach to be considered here is and post-treatment scores on all items of the WAB and Promoting Aphasics’ Communicative Effectiveness. Sixty subjects. consisting of 14 patients less aphasia. treatment (Davis. The motivation for the study was to evaluate the than 6 months post-onset and 46 patients more than extent to which patients with severe aphasia can use elec- 6 months post-onset. guage. including six with global aphasia. 2005. Patients with global aphasia made the second least conversation (Davis.and post-treatment scores on a each screen. phologic inflections [e. The communication outside the clinic. for PACE treatment include the following: (a) Clinician and gram presents symbols in a dynamic display format that patient participate equally as senders and receivers of mes- allow the symbols to be presented across screens logically sages. duce a spoken message. still statistically significant. and each symbol can be programmed to pro- variety of formal language instruments demonstrated signifi. 1980. those with the procedure as a means to promote nonverbal. Applebaum. superordinate categories in a first screen that explode information between clinician and patient. and Harris patients’ natural language. 1978). made significant improvements. after which pre. technique provides opportunities for patients to use either a uted the latter outcome to commonly observed “ceiling verbal strategy or any of the nonverbal strategies described effects” in less impaired patients following treatment. 2 of whom had global language tests. completed at least 1 month of treatment.2 points.qxd 1/21/08 1:14 PM Page 587 Aptara Inc. some of the other character- system that offers graphic and orthographic symbols along istics of natural conversation that provide guiding principles with synthetic speech output (Koul et al. although options for communication. Fifty patients. The cating a message (Davis & Wilcox. The number of treatment second patient was able to achieve criterion for two out of six sessions ranged from 10 to 132. 2005). (2001) reported outcome data for both the impairment and functional levels following treatment with the Lingraphica Promoting Aphasics’ Communicative Effectiveness System.GRBQ344-3513G-C21[565-594]. boy reading]). That even one of the two patients with global sia category. Wilcox. Because PACE procedures allow patients to freely choose whereas those with the most severe aphasias made the great. Gus is a computer-based graphic symbol communication In addition to free selection. Chapter 21 ■ Global Aphasia: Identification and Management 587 system at home for practice between clinical treatment ses. Wilcox & Davis. followed by cian’s feedback is based on the patient’s success in communi- specific items in that category in a third screen). The acute and chronic the criteria for any of the more complex constructions. The first patient with global aphasia was unable to sisted of 1-hour sessions using the Lingraphica clinical exer. (b) the interaction incorporates the exchange of new (e. The authors attrib. and (c) the clini- into subordinate categories in a second screen. versions of this chapter) is based on the limited language of ment level and the third least gains in functional communi. were administered the WAB and tronic communication aids to support or replace spoken lan- CETI before the initiation of treatment. linguistic. were probed. Steele. duce sentences of varying syntactic complexity was viewed Eleven patients with global aphasia included in this group by the authors as evidence for the effectiveness of this had a mean AQ improvement of 6. produce even the most syntactically simple sentences (two cises but with a focus on improving the patients’ functional word agent  action or action  object constructions). or CETI were compared. Aftonomous. No aphasic groups each made significant improvements on both generalization was observed for any of the sentences that of the test measures. Participants were found to have PACE. above.. persons with global aphasia and the potential for using this cation. Appelbaum. Post-treatment group Level I constructions and one Level II construction (mor- results demonstrated significant improvements for all sub. Despite having on the WAB AQ. with or without verbal accompaniment. Forty dyads consisting of a volunteer conversa. 588 Section IV ■ Traditional Approaches to Language Intervention capture the full range of behaviors that may be observed in included gesture. refining prognostic indicators or profiles that can reliably 2002). 2003). Two rating scales were observed following PACE treatment has been demonstrated developed to measure the amount of support provided by on formal language assessment instruments. 2004). ditions under which treatment for global aphasia is maxi- they may be particularly appropriate for individuals with mally effective. avoiding patronization. from perspective of person with aphasia. to have a differential effect on the incidence of global thinks. completion of formal speech and language treatment. several issues must receive further global aphasia. Common practice will videotaped semistructured interviews with or without SCA extend the continuum of care for these patients to support training.. Naeser (1994) provides one people with aphasia (Kagan. but the overall quality of life of were divided evenly between a control and an experimental the patient with global aphasia. and feel. Parr. Given its the conversation partner and the level of participation by the emphasis on the pragmatic aspects of language. and (c) specifying the rela- partner training (Simmons-Mackie. and the use of tionships between site and extent of lesion for outcome in autobiographical reports (Pound. example of the use of outcome information obtained during tion that many adults with aphasia can capitalize on pre. ported conversation. lies in its use as a framework for The adults with aphasia in the experimental group also per- incorporating traditional language stimulation techniques formed significantly higher than their counterparts in the into a communicatively dynamic context. Holland & Rowega. One particularly good example of this approach is aphasia and includes (a) identifying the factors that differen- Supported Conversation for Adults with Aphasia (Kagan. tially account for evolution in some patients with global 1998. 1998). Social approaches (covered in greater detail elsewhere in this volume) target communication partners or other ways to reduce communication barriers in addition to improving FUTURE TRENDS language or compensatory functional language (LPAA Clearly. however. Generalization of language gains panied by pictographic resources. & Duchan. controlled. 2001). PACE is adult with aphasia. To do so. approach must be further developed to improve specificity sation. future clinical research must better identify the con- Project Group. The SCA program involves training conversation and accuracy. even though they had not participated in the training. the acute phase of recovery for these purposes. global aphasia. or SCA. clinicians must continue to identify spe- partners to acknowledge the competence of individuals with cific assessment and treatment approaches that are sensitive aphasia and help them reveal what they think. greater emphasis will be placed on improv- tion partner and an adult with moderate to severe aphasia ing not just communication. the topics for acknowl- edging competence included keeping talk as natural as possi- ble. and explicitly indicating that KEY POINTS competence of the person with aphasia is not in question. predict outcome in global aphasia. Global aphasia may be one of the most frequently with aphasia understands what is being communicated and is occurring types of aphasia. higher than untrained volunteers on ratings of acknowledg- gies into communication treatment. 2001). given their poor prognosis for language exploration. For example. These results were interpreted as support for the efficacy of Social (Partner-Oriented) Approaches this particular approach to aphasia rehabilitation. Third. 2001. A second issue concerns how this outcome The SCA program teaches techniques to conversation information can be better applied to management decisions partners that will help them better reveal the competence of for patients with global aphasia. The techniques .qxd 1/21/08 1:14 PM Page 588 Aptara Inc. The SCA training focused on acknowledging and groups and other community organizations following the revealing the competence of adults with aphasia through sup. randomized. Others have included aphasia to less severe aphasic syndromes. Finally. know. age and sex do not appear given the opportunity to express what he or she knows. This served cognitive and social abilities to participate in conver. reciprocal scaffolding (Avent & Austermann. Kagan et al. or feels and verifying that the conversation is on track aphasia.GRBQ344-3513G-C21[565-594]. As such. One of these concerns outcome from global recovery. Fifteen percent of the participants with aphasia were incorporate increasingly sensitive measures to evaluate the diagnosed with global aphasia. An additional strength ing and revealing competence in their partners with aphasia. those for revealing competence included ensuring the person 1. 2001). Simmons-Mackie. of the approach. It builds on the assump. process. Rehabilitation programs will group. Trained volunteers scored significantly well suited as a means to incorporate compensatory strate. pre-post the time and effort expended during the rehabilitation design study. control group on measures of social and message exchange skills. (b) establishing or conversational coaching (Hopper. and drawing accom- this interactive approach. The groups participated in psychosocial outcomes of treatment. writing key words. to the capabilities of patients with global aphasia and produce Kagan and colleagues (2001) investigated the efficacy of reasonable outcomes in functional communication relative to SCA in a single-blind. S. Appelbaum. Applebaum.. Greater right hemisphere asymmetries are associated M. but. 951–964. L. 78. Aphasia I: Clinical and anatomic issues. D. famous personal names. In the absence of accurate techniques for predicting lesions of the dominant hemisphere. 3.qxd 1/21/08 1:14 PM Page 589 Aptara Inc. M. and patient. Younger patients with global aphasia and those with. 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Preserved recognition of Siirtola. & Davis.. ropsychology. for each patient. 2003). and knowledge—just like aphasia. Hillis and Melissa Newhart DEFINITION This section provides illustrations of a general approach to the assessment and treatment of specific language tasks that OBJECTIVES makes use of cognitive analyses and models developed within the discipline of cognitive neuropsychology—a branch of psy- The purposes of this chapter are to (1) describe an approach chology that seeks to understand normal human cognitive to assessment and treatment of individuals with aphasia that mechanisms through evidence from how cognitive mecha- begins with identifying. In fact. This framework approach to clinical management of persons with aphasia. To set the stage. More recently. although some computational models have sary to accomplish a given language task. 2003) or even treatment strategies (Martin. compensation abilities. (3) delineate the uses and limitations of this via the intact cognitive processes. on the basis of patterns of impaired performance Thompson. (2) provide examples of this general approach and which are intact. However. and the important for focusing treatment of individuals with clinician’s other skills. most therapies are based cognitive neuropsychological models of normal language to on principles of learning. It first describe the main goals of cognitive neuropsychology should be emphasized that the treatment procedures them- and how this model characterizes the normal cognitive selves are not usually based on models from cognitive neu- mechanisms (mental representations and processes) neces. involves consideration of the patient’s performance of the and (4) speculate on the future trends in the areas of cogni. in each patient. talents. the cognitive nisms are modified by brain damage. the selection of the chapter contributors reflects the fact that 595 . other therapy strategies in speech-language pathology. mechanisms that are impaired and those that are intact. such as naming or been used to guide selection of treatment stimuli (Kiran & reading. due to brain damage. B. we sentations that underlie normal performance of the task. This approach begins. Cognitive Neuropsychological Approaches to Treatment of Language Disorders Chapter 22 Cognitive Neuropsychological Approaches to Treatment of Language Disorders: Introduction Argye E. clinicians have used Lane. clinical experience with the sorts of characterize impaired and spared cognitive processes input that successfully elicit better performance.GRBQ344-3513G-C22[595-606]qxd 1/21/08 1:16 PM Page 595 Aptara Inc. or both. Treatment then focuses either on reme- that have resulted in functional gains in communication diation of the impaired cognitive processes. with identifying which cognitive processes within a cognitive neuropsychological model of the affected and representations underlying the language task are impaired language task. & Harley. task in light of a model of the cognitive processes and repre- tive science and language rehabilitation. Related graphic. as a set of representations (i. and activating representations of the motor pro- “COGNITIVE NEUROPSYCHOLOGICAL” grams involved in articulating the word. . edges. Schematic representation of the components of lexical processing. we might propose cholinguistics (a branch of psychology devoted to the study of that picture-naming involves. accessing stored information about each profession can engage in it equally. So. A model mations of mental representations. semantic. accessing the stored pronuncia- tion (the “phonologic representation”) of the word to which it PRINCIPLES AND PROCEDURES OF THE corresponds. ortho- professions within the discipline of cognitive science. and naming. discrimination of the lines.. behavioral neurology. spelling. accessing a “semantic representation”). psy.. 596 Section IV ■ Traditional Approaches to Language Intervention this approach has its foundations in the integration and coop.. of this type specifies the mechanisms for solving the neces- eration across the professions of cognitive neuropsychology.e. the set of instances with a particular name (i. This figure depicts The goal of cognitive neuropsychological research is to some of the principal cognitive processes underlying read- develop models of normal language processes. at the very least. although clinicians in tural/visual description”). Many models include “tulip” tulip Lexical phonological Structural Lexical orthographic recognition description recognition Semantic Phonological-orthographic processing Orthographic-phonological conversion conversion Orthographic Phonological output lexicon output lexicon tulip “tulip” Figure 22–1. stored visual. and linguistics (a profession to develop a representation of the visual image. accessing the “struc- rehabilitation described in this section.e. or phonologic information) and the areas include cognitive psychology (a branch of psychology processes required to compute or activate each representa- devoted to the study of normal cognitive processing). for example. tion from earlier ones. in the form of ing.e. matching the devoted to investigation of the structure and computation of computed visual representation to a stored representation of language). No one profession can lay claim to the sort of the physical structure of the object (i. and other naming. the following: rules and representations that underlie normal language com. sary computational problems of a particular task. understood as a series of transfor- the cognitive architecture of specific language tasks. such as speech-language pathology.GRBQ344-3513G-C22[595-606]qxd 1/21/08 1:16 PM Page 596 Aptara Inc. One such processing model of the lexical system is APPROACH schematically depicted in Figure 22–1. and shadings of the picture prehension and production). Brecher. normal language processing. 1980. some of the components are involved in more than one lexi. intact Some of these models also simulate learning or re-learning. The subsequent chapters will cite cases that provide evidence There are a few basic assumptions of cognitive neuropsycho- for proposing those components of lexical processing that are logical research. Rapp. word frequency. 2005. Chapter tion states that everyone has essentially “the same” cognitive 25. and speech.g. (Mitchum & Berndt. Shapiro. 1980. analysis of the types of errors made in the affected task(s) and tion or picture-naming tasks).e. Coltheart. Certainly. but (3) failure ments of the cognitive task. 1985. and sentence processing prior to accessing a phonologic or orthographic lexical repre. Ellis. Recent studies indicate that disruption of separate posal that computation of the orthographic representation components of the lexical process are caused by distinct site of first requires computation of the phonologic representation.GRBQ344-3513G-C22[595-606]qxd 1/21/08 1:16 PM Page 597 Aptara Inc. 1990. intact written processes comes from considering the computational require. the same types of mental representations and processes. undermine the usefulness of this approach for understanding this volume. see also Garrett. Rewega. and so on) may mance (Caramazza & Hillis. Thompson & Shapiro. it should be manifest as impairment in both deformations of one or more of the constituent mental repre- reading and naming. Thompson. chapters. the universality assump- Hillis. comprehension. 2007). this volume.. (impaired oral reading). & Sample. 1986. we need to who show good comprehension of printed and spoken words know about his or her reading. Jacobs. language put from a semantic representation. for example. but presumably we all develop 1996. may be somewhat different in the two tasks. Beeson. be required. despite unimpaired motor skills for articu- the patient is unable to compute “chair” from the semantic lating the correct name.. the models guide our understanding of perfor- computing the phonologic representation of a word for out. sentation. Therefore. This example illustrates that the data To illustrate. Therefore. expression of names and of self-generated ideas). put lexicon would include (1) demonstrated access to the rons like units that represent features or even whole words. ing and thinking that reflect variable reliance on one type of Patterson. 1998. Vail. Thus. Chapter 22 ■ Cognitive Neuropsychological Approaches to Treatment of Language Disorders: Introduction 597 additional levels of processing. reading and writing (Beeson & Henry. nent is dedicated to a particular aspect of lexical processing. Friedman & Lott. We might propose in this case that the representation of CHAIR. by “sounding out” the word). Coltheart. processes. & Lott. & Rapcsak. pattern of performance that indicates a proposed locus of dis- some models of naming are more explicitly computational in ruption in the lexical system at the level of the phonologic out- that they simulate the process of a limited number of neu. 2005. word length.. Friedman. To understand a patient’s writing. Of note. see also Beeson. and Motivation for proposing specific representations and (2) access to printed words from semantics (i. Ellis. as (indicating adequate access to the semantic representation) well as performance on various spelling tasks. It is important to note that although each compo. as illustrated in several cases in the following Hier & Mohr. Thompson & Shapiro. & Marshall. he or she will be unable to name patient is unable to retrieve the accurate pronunciation of the the pictured chair but may yet be able to correctly read chair word from among the stored pronunciations of all words he or on the basis of orthographic-to-phonologic conversion she knows (“the phonologic output lexicon”). For example. although the consequences for output sentations or processes underlying language tasks. semantic system from printed and spoken words (i. 1999. Hillis & Heidler. Beeson & Hirsch. 2005. In addition. 1977) is inconsistent with an alternative pro. Jacobs. Tait. see also Fink. Such a pattern of perfor. 2000. this volume. such as a “lemma. processing relative to another. That is. if computation disorders resulting from brain damage (which disrupts previ- of the phonologic representation were to be disrupted by ously normal language) can be characterized by proposing brain damage. First. & Marshall. Shapiro.e. 2000. Patterson. both reading and naming involve In turn. if the correct names. such models are constrained by patterns of performance of brain-damaged patients that cannot be otherwise explained Basic Assumptions by proposing specific loci of damage to the existing model. 2002. 1995. pronunciation of the same word. there may be different modes of learn- 1998. Chapter 23. Goodman & ity-independent syntactic representation that specifies the Caramazza. cal task. word class (and mass/count and gender in some languages). Friedman. evidence for proposing separate mechanisms for crucial to proposing a specific locus of damage include the computing phonologic and orthographic representations of patient’s performance profile across lexical tasks in all modali- words from a semantic representation comes from patients ties. an and are able to write the corresponding written word (in dicta. & Schwartz. reading and auditory comprehension) and from pictures. 1996). 1994). Sample. Friedman & Lott. Thompson. & Schneider. part of speech. but are not able to access the the stimulus parameters that influence performance (e. Sobel. 1997.. For example. a mechanisms (i. Ballard. Miller.e. 1982. which if proved to be incorrect would involved in naming (Raymer & Gonzalez Rothi. 2005). Lott. 1983.. In the case of imagine a patient who understands spoken and written words reading. brain dysfunction (DeLeon et al. Hence. additional information about the pronunciation of and writes the names of pictures adequately but is unable to say the name is available from the printed word.” a modal. and the proposals are supported by to access the phonologic representation from pictures or empirical evidence from studies of normal subjects and from objects (impaired oral naming) or from written words patterns of impaired performance by brain-damaged subjects. & Sin. . mance patterns by individuals with aphasia. Chapter 24. & Tait. (Dell. & Hodges. although some readers may rely more on one or the other. It is also likely that rhyming with thatched). by reducing the connection strength in the phonologic output lexicon (the repository of stored between two levels of nodes).” but is learned through many damage does not result in new types of mental representa. and a “serial” model of the lexical system illustrations of this application was a study by Byng and is shown in Figure 22–1. 1995. Seidenberg & McClelland. These representations and processes do models is in identifying the level(s) of processing that are not necessarily correspond to locations in the brain. Graham. 1991. acteristics of each model comes from patients whose pattern ple. naming. The basis for proposing each level of Coltheart (1986) showing that selective damage to particular representation comes from patients whose performance of components of the reading system in their patient could be the task. 598 Section IV ■ Traditional Approaches to Language Intervention Second. “transparently” revealed by the these models. Evidence for postulating specific char- mal components we rely on to accomplish a task. impaired in each patient.GRBQ344-3513G-C22[595-606]qxd 1/21/08 1:16 PM Page 598 Aptara Inc. Rapp & Goldrick. showed greater improvement in naming per- tasks. 1988). utilizing several levels of “nodes” with feedback and processes. were intervention. whose The concepts of integration and feedback are best seen in naming impairment could be localized to the phonologic more recent. normal oral reading of a word of performance can be simulated by “damaging” the simula- such as “yacht” is accomplished by accessing a representation tion in some way (e. 1989). 1986. Among the first following chapters. It is likely that each of these “pronunciations” of familiar words). In model of the normal processes underlying the treated task serial models. cognitive representations and procedures that underlie the damaged patients also have basically the same cognitive task. This sible that there are both feedback and feedforward interac- local modification in the system is transparently revealed by tions between at least some levels. can be treated successfully by focusing treatment on the impaired understood by proposing selective damage to that cognitive component (see Beeson & Henry. and that information when treatment tasks explicitly required semantic process- may “cascade” from one level to the next. In each case. In some of representation or processing. so that therapy can be directed they represent distinct functional components of a cognitive toward remediation of that component and/or strategies to operation. distributed across component units. spelling. 1994). It is plau- read aloud via letter-to-sound conversion mechanisms. Dell. oral reading of English is lexical and semantic representations consist of activation likely to be accomplished by an interaction of the two mech. 1991). the “transparency assumption” states that brain. system. 1995). except for a focal modification at some level(s) of feedforward connections between each level.g. Caramazza. For example. and integration of the various components. Several models of this type are illustrated in the compensate for the loss of that component. tics and letter-to-sound conversion mechanisms (Hillis & 1993. Additional notable examples of studies in which cognitive Such schema are described as serial because it was initially analyses have been used to focus intervention are described assumed that processing at each level of representation was in the subsequent chapters in this section. several cognitive mechanisms may Caramazza. feedback from one level of representation to a served to pinpoint the patient’s deficit and thereby focus prior level. 1997. Application of Models to Treatment Focusing Treatment Different Types of Cognitive Models The clinician’s primary goal in understanding the patient’s The classical cognitive neuropsychological model is the so. or the deficit. 2004). Normally. deficit is to focus treatment on just those levels of processing called “serial” or “box and arrow” schematic representation of that are impaired or to identify methods that will allow the the cognitive representations and their interactions that patient to process language successfully by “getting around” underlie a given task. However. This type of model is a computer simulation of the formance as a consequence of the facilitated oral-reading . related representations (Plaut & Shallice. 1993. showed more improvement in naming performance Patterson. 1991. and pattern of performance across tasks. patient HW. Burger. a completed before processing at the next level was started. such that several ing (printed word/picture matching) than when treatment representations are simultaneously active and contributing to tasks did not overtly require semantic processing (oral read- the final output (Humphreys. computational models of specific language output lexicon. shared by other. whose pattern of performance across lex- interact to select or “access” a specific lexical representation at ical tasks indicated a disruption at the level of the semantic a subsequent level (Hillis & Caramazza. although it may change which of our nor. repeated simulations (Plaut & Shallice. However. the predominant usefulness of cognitive sentence production. For exam. component and dependence on the other spared components. Seidenberg & tions or operations. this volume). In contrast. ing with phonologic cues). when there is types of serial and computational models captures some of damage to the phonologic output lexicon a patient may now the characteristics of normal language processing. at least in learning to read. Rather.. referring to Figure 22–1. In other words. Chapter 25. 1989). brain nodes is not “programmed in. some of which are anisms (access to the phonologic output lexicon from seman. & Svec. Riddoch. such as reading. patient JJ (reported in Hillis & not considered. & Quinlan. the strength of the connections between performance pattern in various tasks. pronunciation of the word yacht as “yached” (/jætSt/. Thus. McClelland. phonologic output lexicon. be explained by assuming that HG accessed underspecified showed a pattern of performance consistent with damage to semantic representations.” “tulip. Orchard-Lisle. such as words using association with visually/phonologically similar flower. HG ment was item-specific. she might have had a semantic representation of “tulip” gory-specific impairment in comprehension (but unlike HG that consisted of a partial set of features that define tulip. might expected to be specific to the trained categories of words. and it did not. by teaching her the features that distinguish semantically Raymer. written word/pic. and spoken word/picture matching. 1994). using rhyming word cues) improved naming perfor. or meanings. & LeGrand. he showed some improvement of items in one of the While the normal semantic representation of “tulip” might untrained categories). Here. For example. Thompson. treat- ture matching. Based on the model in Figure 25–1. Initially. In various tasks.. in Chapter 25 of this the task of written naming was not expected to improve her volume. representations (treated stimuli) should improve across graphic representations that correspond to these features. Thompson & Kearns.GRBQ344-3513G-C22[595-606]qxd 1/21/08 1:16 PM Page 599 Aptara Inc. as indicated in particular by his cate- case. like HG. but performance would not be expected to improve that a picture of tulip might be named as any one of many for other representations (of untreated words). holding representations in a short-term .. Franklin. treatment focused word/picture matching to enhance semantic processing (see on her semantic impairment (see Chapter 25. performance involving the target would access all phonologic representations and ortho. And. ing mechanism (say. 1993).” or of a therapy strategy that also focused on teaching semantic any other flower as the name of the picture. Hillis & Caramazza. In addition. HG mispronounced nearly A different type of generalization concerns changes in every word in all tasks with spoken output (repetition. Their patient. teaching her features that distinguish various types the level of the phonologic output lexicon or both (Hillis. the treatment of semantic representations utilizing tasks and across items. Linebaugh. written and spoken naming. In this the semantic system. Further- been in the prediction of patterns of generalization across more. she would accept any word that cor. written word comprehension. Behrmann and Lieberthal (1989) might be named on one occasion as “rose” and on another reported comparable generalization results—improvement occasion as “daisy. so tasks. we reading. her errors were inconsistent. her underspecified semantic representation tions (or access to them). dutch. her reduction in semantic volume). many types of naming treatment described errors generalized to tasks of spoken naming and spoken and in the literature. but also in oral naming and repetition. oral performance across treated and untreated stimuli. repetition. bulb. 1991) and clothing. Raymer. since reteaching a made semantic errors.” “daisy. consistent with this pre- 1985. this volume). This aspect of HG’s performance would expect that if treatment influences a general process- was attributed to an additional deficit in accessing phono. of clothing should not reduce her semantic errors in naming 1989. although treatment engaged reported by Raymer and Gonzalez Rothi in Chapter 23 (this the task of written naming only. such as “tulip” named or understood phonologic representation of “tulip” would only improve as “rose. Thompson. representations) should improve her performance of all mance of patients whose impairment was localized to the tasks that involve the semantic component—for example. spring flowers.” However. Patterson. 1981). diction. such as foods McNeil et al. In this case. and spoken and written word focused on specific components of the naming process are comprehension. such as in more accurate pronunciations in not only oral reading. 1990. 1999. Jacobs. & Morton. HG. Tulip pronunciation of tulip. when shown a picture of a in categorization of untreated items within treated categories— tulip she would accept the name “rose.” Furthermore. including those that directly facilitate pro. as expected. Therefore. And. for certain categories of words. upright content words (Hatfield. This pattern can distinctions among related items. performance across lexical tasks could be explained by Subsequent therapy directed toward teaching her accurate assuming that she had partial damage to semantic represen. indeed. 1994. pronunciations by reestablishing phonologic representa- tations of words and profound damage to the phonologic tions (or access to them) in the task of oral reading did result output lexicon (Hillis. Additional reports of treatment spoken and written naming. Chapter 22 ■ Cognitive Neuropsychological Approaches to Treatment of Language Disorders: Introduction 599 treatment than as a consequence of treatment using printed logic representations for output. the treatment was duction of the name in response to the picture. Howard. but not to untrained categories. it was pre- also reported that phonologic strategies to facilitate naming dicted that treatment (teaching/improving specific semantic (e. 1983) and improving printed-word leaves. words (Hillis. spoken naming). Beeson and Henry describe a patient. seman- representation might include only flower and spring tic. and phonologic decisions about the “treated” set of blooming. upright petals. 1983. whose pronunciation of words in spoken output. Additional reports in the literature of include all of the features that jointly define a tulip and allow item-specific treatment include treating reading of function it to be distinguished from all other flowers. or understanding of furniture. hypothesis that if treatment influences specific representa- Furthermore. However. for details and discussion). However. her gains generalized to untrained items within the Another use of cognitive neuropsychological models has trained categories. of words. These reports are consistent with the responded to these features in word/picture verification. and LeGrand (1993) (see also related words. slender. spring blooming. HG’s semantic recognition by reinforcing correct word/nonword. improve naming at either the level of the semantic system or That is.g. improving comprehension of sentences (Byng with specific treatment approaches in well-described cases of & Coltheart. such exten- ments to untrained tasks. That is. Sokol. 2003). each task are impaired. 1994. It is not clear. albeit slow. Generalization to untrained items might be detailed discussion). even patients who have the increased by starting of more complex or less protypical “same” deficit with respect to the level of representation in examples (Kiran & Thompson. some precision the impaired cognitive process(es) with rela- tion in the naming process does not guide the clinician as to tively brief testing using carefully selected tasks and stimuli. Caramazza & It has also been argued that treatment based on cognitive Hillis. Wilson & Patterson. For instance. and in restau. 1994. Iavarone. 1993. as Finally. item-specific gains are better than no guage processing? The models alone do not help us in this gains. nor how the system might be reorga- uli that are subject to that mechanism (Rapp. across stimuli is that we have no way of knowing. She had undergone years of unfocused therapy for “cortical Limitations deafness” and other inaccurate psychiatric and language Several authors have argued that cognitive neuropsychologi. printed words (“gestalt processing”) (Gonzalez Rothi & Empirical reports of improvement in functioning associated Moss. some cognitive task do not consistently respond to the same ing predictions as to whether or not to expect improvement treatment. knowing the patient’s level of disrup. prior to careful analysis of her impair- rehabilitation. a patient described earlier in this chapter regard. 1987). require evidence regarding the patient characteristics that 1993) or sound-to-letter conversion mechanisms to improve influence outcome and the nature of damage to the impaired spelling (Carlomagno. in the case of Abilities in Daily Living (CADL. but not normal. Holland. 1990. such knowledge does not even guide the clinician as to or categories (for evidence for and against this claim. see what to treat. Hillis component (see Hillis. not models of communication. or other patient or specific representations were affected by our treatment (see characteristics. Furthermore. motivation. Although processing. with virtually no improvement in language or cal models are simply models of cognitive tasks. The problem in mak. we might instead ferent forms of damage to the same component or due to dif- use treatment results to propose whether a general mechanism ferent overall learning abilities. to know where to even begin treatment until damage to spe- cific components of lexical processing were identified.GRBQ344-3513G-C22[595-606]qxd 1/21/08 1:16 PM Page 600 Aptara Inc. and might give the clinician hope that a particular component is improving use of sublexical letter-to-sound conversion treatable. than HG. lan. it is often possible to identify with strategies. diagnoses. 1998). valid predictions about improvement in a mechanisms or “phonologic assembly” to improve oral different case of damage to the same component would also reading (Berndt & Mitchum. Should we treat the damaged component of Schwartz. Hillis & Caramazza. whether the differential response to treatment is due to dif- how treatment affects processing. gains after delineating cessing provide no direct motivation for specific treatment her deficits. However. 1990 for discussion). such as improving intuitions about what might help. and requirements to document improvement at Carr (1999) also reported that treatment that focused on each visit. However. 1989). it is often impractical to spend hours of time test- specific cognitive skills—“the cognitive neuropsychological ing a patient to pinpoint precisely which components of approach”—resulted in better generalization of improve. and ongoing evaluation of treatment effects. Many nized following damage to circumscribed parts. gories is far from ideal. examples of therapy that influenced both treated and choices of treatment must rely (as usual) on the clinician’s untreated stimuli have been reported. or should we try to exploit the preserved compo. 1986). 1980). 1998 and chapters in this section). such as the Communicative sive evaluation may be justifiable. Aliminosa. Hinckley. Indeed. of lexical processing) have responded to different therapies. processing should improve across all stim. Recall HG. 2005). de Partz. & apy visits. some authors have described how Goodman-Schulman. whose deficits were quite complicated. patient HG (above) showed treatment is that the analyses required to determine the dramatically improved use of trained words not only during patient’s level of damage are often extremely time-consuming therapy. at home (documented by her mother). & Colombo. 1986. demonstrated by identical . the goals of the person reading speed by reinforcing rapid semantic decisions about seeking therapy. how to treat the problem (see Caramazza. effects generalize to other tasks and settings outside the Another limitation in applying these sorts of models to therapy session. 600 Section IV ■ Traditional Approaches to Language Intervention memory system). we always work toward ensuring that treatment shown by many studies cited in the chapters in this section. in other cases. Hence. from considering the model. However. In neuropsychological models fails to generalize across items fact. She made useful. the recent limitations on the number of reimbursable ther- rants (observed by her therapist). 1991. a priori. & McCloskey. 1994. For example. for Trupe. but also in the job setting (documented by her job and may not be cost-effective (Schwartz. patients with different deficits (within a computational model for discussion and illustration). For example. improving use of a self-correction damage to selective components of language processing strategy in spelling (Hillis & Caramazza. because they do not specify which components are as having a semantic impairment. Patterson. most current models of cognitive pro. That is. Hillis. it was difficult treatment that focused on a particular functional activity. subject to remediation. ments. 1986). 1989. with coach). this failure of generalization to untrained items or cate- nents in the hopes for more functional. In fact. which gen. Furthermore. articula. generalization across trained and untrained sentence types lary specific to the job for which she was training (as a stock (Ballard & Thompson. tasks. and over the telephone to be precisely defined. patient HW cific component of cognitive processing would help all produced mostly fluent speech with few content words patients with damage to that component. naming. She was also observed to use trained words in processing that may influence treatment outcomes have yet conversation at home. Thus. before this item-specific therapy was initiated more than 5 such conclusions are not possible in light of our current lev- years post-stroke. Yorkston & Beukelman. item-specific gains that generalize across tasks and naming. Nevertheless. Although studies have identified in follow-up calls. Gains that generalize across tasks but not always to and her improvements in semantic processing generalized other settings have also been reported for sentence produc- only to items that were semantically related to trained items tion/comprehension therapies (see Mitchum & Berndt. improvements in many model-based treatments do show eralized well across tasks and settings. 2005 for written word/picture matching tasks and was able to define discussion). we would like to be able to conclude that treatment of a spe- irrespective of the setting. (2) she produced semantic deficits will show improved naming with that accurate or recognizable written names of 100% of pictures. who was glob. HW improved in the number of accurate mechanisms that are impaired in the patient.. Ideally. Unfortunately. In describing the “Cookie Theft” picture recovery as a function of a variety of individual factors. indicating that was associated with improved naming in a patient with a her processing of words and pictures was unimpaired semantic deficit does not directly imply that all patients with through the level of the semantic system. (see also Hillis. Chapter 22 ■ Cognitive Neuropsychological Approaches to Treatment of Language Disorders: Introduction 601 rates and types of semantic errors in all lexical tasks (oral Thus. because (1) she ing how any specific mechanisms are actually modified by showed flawless performance in auditory word/picture and our interventions (see Baddeley. a priori. At the time of this writing HG. 1993. not only benefit from a given treatment strategy is certainly not spe- were her gains maintained more than a year after treatment. of impairment consequent to brain damage in individual . And. approaches have been beneficial for individuals. 1999). Her item-specific gains. ing from therapy for naming and other oral production HG’s improvements in oral production were item-specific. which other patients oral reading treatment seemed to result in improved access will respond to the same treatment in the same way. clerk in a fabric store). employed. we have no way of know- phonologic output lexicon (Fig. This inability to predict whether a particular patient will 1980. Several authors have reported not HG’s gains served a significant function. Hillis. Rapp. compensatory strategy that will result in improved access to a ally aphasic for more than 6 years. The further progress equally to other “schools” of treatment. ruling out times patients with different loci of damage in the lexical a motor-speech deficit as the basis for her impaired spoken system respond to the same treatment (Fridrikson et al. written naming. 22–1). the “phonologic” therapy with a patient HW results of a given treatment for an individual patient is that it (see above and Chapter 25. Hillis & Caramazza. and some- tion. for description of content-units). since the characteristics of that she was able to receive treatment for many sets of words the patient and the form of impairment at any given level of she selected. Her impairment was localized to the els of theory. remains gainfully variety of stimili. An important limitation of conclusions reached about the Similarly. to specific phonologic representations in the output lexicon. and (b) the cog- content-units produced. She gradually only generalization of improvements from comprehension regained a functional vocabulary for daily activities (such as to production (or vice versa) for the same items. as mentioned above. and writing to dictation). 1972). patients with putatively “the same” locus of impairment do cating that semantics and access to the orthographic output not respond to the same treatment approach. cognitive neuropsychological models of spe- practice with her husband providing cues (which probably cific language tasks are useful for understanding the nature provided “treatment” of thousands of words). obtain and maintain a job and independence in activities of if treatment addresses a process common to many stimuli or daily living. in restaurants. cific to the approach described in this chapter. from five before the phonologic nitive mechanisms that might be influenced by the treatment. Like patient HG. 1993 and Hillis. and repetition of words she could not name. 2005). but different lexicon were intact. treatment to 12 after treatment (c. the observation that a “semantic” approach both words and pictures she could not name. As noted previously. Earlier studies have shown that sometimes even though she could not produce the spoken name. but also dining out and riding public transportation) and a vocabu. words using the phonologic therapy were sufficiently rapid This finding is not unexpected. 1994. as previously discussed. these from the Boston Diagnostic Aphasia Examination ( Goodglass studies have not been integrated with (a) the specific cognitive & Kaplan. was probably achieved in part through HW’s oral-reading In summary. which relies but additional gains were achieved: She later produced 15 on a cognitive analysis of patient performance. indi. but applies content-units in describing the picture. this volume).f. 1998). thus permitted HG to generalization to untrained stimuli as well as untrained tasks. settings can lead to dramatic functional improvement result- written word/picture matching. HW’s improvements in producing a trained set of 2005. treatment. and (3) she had perfect fluency. Chapter 24.GRBQ344-3513G-C22[595-606]qxd 1/21/08 1:16 PM Page 601 Aptara Inc. this volume) that involved cued is not possible to determine. auditory word/picture matching. Perhaps as a con. and elsewhere have led not addressed them. The There has been no attempt to cover every domain of cogni. this type of diagnosis. writing. we have chosen to include chapters on those domains chological model of word comprehension and naming. and spelling at the single-word level. Tucson. judgment. Therefore. naming. how particular interventions bring about these modifi. and so on. writ.. Many centers are also collaborating task.). Therefore. ular treatment strategies. and/or short. and It is also crucial to note that other cognitive abilities. and ten naming. and neuroscience. a theory of rehabilitation Investigations in these domains have not yielded the types of would need to specify the interactions among these vari. Italy. a model of the cognitive processes underlying reading). the models Finally.or long-term memory can artificial intelligence. a single neurology (the three disciplines represented by the chapter semantic system is engaged in a variety of tasks that involve authors). France. underlie reading. Charlotte Mitchum and Rita Berndt discuss eval- ropsychological literature. such Australia (see Appendix 22-1 for contact person and names of as attention and memory. and in Belgium (the Brussels sure of the level of damage by assessing performance on Neuropsychological Rehabilitation Unit). switching and maintaining tasks. with other disciplines in the field of cognitive science. are engaged in every language several such centers). research centers in Gainesville. and word and sentence comprehension and production. etc. and Baltimore. the Netherlands. the following chapters awareness of deficits in these areas is often helpful in under- illustrate how cognitive neuropsychological models can be standing patients’ responses or failure of response to partic- useful in planning and designing individualized therapy. The authors have been involved in integrative comprehension and/or production of words. and how particular patient characteristics influence (sequencing. oral naming. since the focus of this book is on lan. nor even every domain of language. oral sentence pathology with cognitive neuropsychology and behavioral production. to the development of computational models of naming that . rehabilitation exist in Philadelphia. sequence of the number of studies in these areas. For exam- affect performance on any given language task. Other identifying the patient’s problem in oral naming may excellent interdisciplinary centers for aphasia research and require assessment of oral reading.g. Content of the Chapters INTRODUCTION TO THE CHAPTERS In Chapter 23. Other important domains that have tation. Although ple. For example. in Chapter 25. Germany. In that have received the most attention in the cognitive neu. there are chapters on uation and rehabilitation of sentence comprehension and pro- spoken-word comprehension and naming. Although each deficit in comprehension or production of written words. The latter would require motivated hypotheses about received much attention in the psychological literature are how mental representations or transformations are modi. there are models and theories of each of these areas. 602 Section IV ■ Traditional Approaches to Language Intervention patients but do not constitute a theory of language rehabili. Carnegie Mellon. Similarly. They identify impairments Scope of the Section at different levels of cognitive processing that result in poor auditory word comprehension and/or poor oral naming. written-word duction based on cognitive neuropsychological models of comprehension and production (reading and writing). treatment approach. Nevertheless. organization cations. and sentence processing. They focus on issues of the relationship sentence comprehension and production. between theory and therapy and issues of generalization. Impairments of sustained attention. authors further report rehabilitation strategies that rely on tion in this section.GRBQ344-3513G-C22[595-606]qxd 1/21/08 1:16 PM Page 602 Aptara Inc. Anastasia Raymer and Leslie Gonzalez Rothi describe clinical diagnosis and treatment of spoken-word IN THIS SECTION comprehension and production. such as spatial attention. and predicting patterns of generalization across tasks or stimulus types. Kingdom. models of specific component cognitive representations of ables. It is probably never possible to be Pittsburgh in the United States. guage intervention. we have Temple University. and spoken conversation. in order to make predictions about results of a given the type we are considering in these chapters. Moreover. Nevertheless. response to treatment. made in view of a cognitive neuropsy- Instead. selecting stimuli. selective attention. Ann Arbor. tive functions” such as planning. chapter will discuss models of tasks limited to that domain This chapter focuses on assessment and treatment of reading (e. repetition. as discussed in the case of HG. and shows how treat- it is important to understand that there is a great deal of ment can generalize to improved reading and spelling in overlap in the cognitive representations and processes that untrained tasks. linguistics. Chapter 24. the United only one task. procedural and episodic memory. it is likely that a single set of phono- logic representations (a phonologic output lexicon) is FUTURE TRENDS accessed in the course of all tasks that have spoken-word This section illustrates the integration of speech-language output: oral reading. and the so-called “execu- fied. interdisciplinary collaboration at Moss Rehabilitation. comprehension. Pelagie Beeson and Maya Henry in these domains are the most clearly articulated and most describe how to identify an individual patient’s underlying widely (although not universally) accepted. . 367–386. emission tomography [PET].. C. 1995). bilitation (pp. A. Aphasiology. TX: more importantly. Language. KEY POINTS NJ: LEA. Cognitive neuropsychology and rehabilita- tion: An unfulfilled promise? In T. science in understanding how the brain recovers through Beeson. Approaches to the rehabilitation of “phonological assembly”: Elaborating the model of non-lexical reading.. DeLoche (Eds. W. S. W. & Rapcsak. 3. 383–398). tinct cognitive processes underlying picture naming.. foundations in the fields of cognitive neuropsychology. Anastasia Methodological requirements and illustrative results. Raymer. In A. North-Holland: Elsevier Science Publishers B. 2. London: Academic Press.. (1994). Iavarone. (1990). London: Routeledge and Kegan Paul. may further guide our models and our Ellis. 3.. (1998). 1987. . Rewega.. Seron & G. 113–146). F. G. K. & Jessell. Humphreys (Eds. 485–502). interventions. more on clinical intuitions and experience than on C. anticipated advances in cognitive neuro- November. and Hearing Research. A theory of rehabilitation without a model of authors have predicted that computational models of lan. Svec. A. Aphasiology. K. come from? Cortex. It is expected that such collaborations are only a hint of what may come. and Leslie Gonzalez Rothi for helpful comments Hjelmquist & L. Nilsson (Eds. & Mitchum. C. and behavioral neurology. A. M. 13. positron Beeson. (1989). Certainly. reorganization of neural representations (Hillis. M. S. 95–122. 123–147. Caramazza. Roberta Chapey. & Recanzone. Lexical access in aphasic and nonaphasic speak- why therapy “works” for some individuals with apha.g. Deep 1. Most strategies utilized are not truly model-based dyslexia. 690–707..). Cognitive task to be treated. Brain. and spectroscopy) have been used in many studies to shed Beeson.). A.. & Thompson. and Dell. Ballard. Models can also sometimes help us to understand D. as well as in other areas of cognitive neu. 217–234. This approach to intervention has its approaches to writing rehabilitation. 42. Cognitive neuropsychology and cognitive reha- speech-language pathology. In E. Saffran. 235–244. J. 149–177. ular patient with aphasia can be guided by pinpointing his Caramazza. Neuropsychological Rehabilitation. Caramazza. Psychological Review. A. M. & Coltheart.. P. an effect on performance. T. the cognitive processes underlying the specific language Carlomagno. Aphasia therapy research: Beeson. Psychological Review. G. J. Spelling and writing (and reading and speak- therapies. sia and not for others. R.. W. roscience. K.. 801–838. M. E. C. Cognitive approaches in rehabilitation (pp. Charlotte Mitchum. The author is grateful to Pelagie Byng. 1996). 130. through changes in Behrmann. K. Journal of aspects of rehabilitation. Reference to a model of the task being treated often 1408–22. (pp. M. Re-education of a deep dyslexic patient: 4. Chapter 22 ■ Cognitive Neuropsychological Approaches to Treatment of Language Disorders: Introduction 603 have been useful in understanding various forms of naming References impairment (e. will surely contribute to developing aphasia.. P... since the strategies themselves rely DeLeon. S. 281–299. Neuropsychological Rehabilitation.).. & Lieberthal. and how the brain changes with learning.. A. & Hillis. (1997b). In G. E. & Colombo. (1986). L.). as functional magnetic resonance imaging [fMRI]. In M. Neunart. Schwartz. A. J. de Partz.. these fields. learning is a vehicle without an engine: A comment on Caramazza guage may become important in directing rehabilitation as and Hillis. A. 1990). Future developments through cooperative efforts in Rationale of the method and results.GRBQ344-3513G-C22[595-606]qxd 1/21/08 1:16 PM Page 603 Aptara Inc. Lee. 503–526). A. 14. Davis. A. 104. J.-G. Ellis (Ed. E. (1993). Communication handicap: on an earlier draft. Merzenich. Martin. (2007) Neural regions essential for dis- the model of the language task to be treated. Hillsdale. & Hirsch. an interdisciplinary theory of aphasia rehabilitation. Cognitive ▼ Acknowledgments—This work was supported in part by neuropsychology and cognitive rehabilitation (pp... magnetic resonance perfusion. Writing treatment for severe aphasia. 26. Coltheart. (1986). how. N. E. J. For a theory of remediation or her impairment to one more components of a model of of cognitive deficits. Several Baddeley. E. 3. J. & Marshall.. M.V. Hillis. P. 3. 1997b). M. S. A. T. Z. ers. Perhaps Speech-Language-Hearing Association. Riddoch & G.191–213). of lexical and sublexical spelling routes. M. Humphreys & M. 551–565. M. 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Neuropsychologia. Coull. Santa Fe. Prescott (Ed. T. ing and theories of rehabilitation. 15.. data. 157–169). R. A reorgani. Clinical apha- Gonzalez-Rothi. G. Hier. & Kaplan. Hillis (Ed. 632–636. pp. A. Academy of Aphasia... Cognitive Neuropsychology. J. (1999. & (Ed. T. Treatment of naming disorders: New issues normal language processing: A case study in cognitive neu. 1). 12. Schwartz.). CT: Appleton and Lange. The role of semantic com- impairments within the naming process. For a theory of cognitive rehabilitation: assisted treatment of word retrieval deficits in aphasia. M.). A. (1987). (1986). H. E. (2002). A. Franklin. T. 28. regarding old therapies.. Fink. A. E. E. D.and skill-based treatment approaches: Preliminary Goodglass. In T. 19(10/11).. In C.. Theories of lexical process- Language. (pp. Aphasiology. processes in picture identification. Phonologic treatment for (pp.. Treatment of anomic aphasia. plexity in treatment of naming: Training semantic categories in Clinical aphasiology (Vol. M. & Jessell.. Brecher. Friedman. 255–265). 65. A. naming. Essentials of ical practice (pp. A. & Lott. & Lott. 229–261). Progress in the decade of the brain. D. Martin. Language. Archives of Physical Medicine and Rehabilitation. Converging evidence for the Friedman. In G. V. Boston VA Medical Center (617) 232-9500 Boston University Medical School malbert@bu. (1985). (2004). Applied Cognitive Psychology.. D. K. wh. Graham. 523–568. Schneider. B. C. Chapter 22 ■ Cognitive Neuropsychological Approaches to Treatment of Language Disorders: Introduction 605 language disorders: Integrating cognitive neuropsychology. P. Brookshire (Ed.. C. Coltheart. pp. (2005). duction in agrammatism: Implications for normal and disor- Plaut. & Goldrick. Tait. Brain and Language.. 994–1008. Vol. M. 175–228. M.D. (2005). Journal of Speech Psychological Review. M.). & Shallice. M. Rehabilitation and cog- rehabilitation: When worlds collide.. (1994).. TX: Pro-Ed. of Cognitive Neuroscience. Experimental analysis of and rehabilitation (pp. Training sentence pro- dyslexia. Haarman. Training wh-question production in (1993).. R. 40.. (1996). Phonological treatment of naming deficits in aphasia: agrammatic aphasia: Analysis of argument and adjunct move- Model-based generalization analysis. T. Thompson. 1021–1036. 57–69. K. & LeGrand. L. L. Treating agrammatic Plaut. M. (1991). J. 19(10/11). H. Cognitive Neuropsychology. 111(2). Raymer. & le Grand. and Hearing Disorders. K. (1993). A. Brain and Language. 10. J. C. APPENDIX 22. A. M & McClelland. Just. (1998. E. C. develop. K. K. Moss Rehabilitation Hospital Ruth Fink.. Jacobs. & Shapiro.. C. & Hodges. C. Carpenter. Patterson. B. Thompson. L. Boston.and NP-movement structures in agrammatic aphasia. J. K. Prescott (Ed.. Journal model-driven approach. Austin. Shapiro. K.. MA 02130 USA The Aphasia Research Center Myrna Schwartz.1 Selected Interdisciplinary Centers for Aphasia Research and Rehabilitation Name and Location Contact Person. Thompson. H. Ph. P. ment. & Marshall. Aphasiology. M. P.edu 150 South Huntington Ave. 201–224. 25–82. M. Shapiro. 35–45). Aphasiology. The relationship between treatment outcomes Thompson. June). Paper presented at Clinical Conference (Vol. J. Psycholinguistic theory and aphasia Wilson. Clinical aphasiology. K. Jacobs. NM. with anomia. neurology. Aphasiology. D. London: LEA. PA 19141 [email protected]. K. A. 27–36. 377–500. Matunis. FL. In R. 10. October). (1990).. & Beukelman. e-mail Address Aphasia Research Center Martin L.. Jacobs. C.. 6. Key West. L. J.. Training and generalized production of diation of aquired dysgraphia. 52(1). forms. (1996). M. & Patterson. speech samples of aphasic and normal speakers. Toward a theory of rehabilitation. K... 247–260. An analysis of connected mental model of visual word recognition and naming. Feedback by any other name is Journal of Speech.. aphasia within a linguistic framework: Treatment of underlying tionist neuropsychology. Paper presented at Academy nitive neuropsychology.. Rapp. 7. P. 27–53. A distributed. Raymer. Deep dyslexia: A case study of connec. Brain and Language. (1997)... Tait. acquisititon and generalization of naming behaviors in a patient McNeil. 375–396). & Shapiro.temple. Aphasiology Conference. Surface Thompson. (1980). 1200 W. J. R.. et al. (1989). Thompson.. Psychological Review. Thompson. 239–259). H. K. 228–244. Santa Fe. Rapp. 573–578. L. E. and Hearing Research. H.. 4. Clinical aphasiology: Rosenblatt. Ballard. 50. pp. (1981). Language. 96(4). B. K.. Ph.. D. The impact of phonologically based treatment on aphasic naming deficits: A semantic memory loss on phonological representations. M. Seidenberg. Schwartz. M. 19(10/11).GRBQ344-3513G-C22[595-606]qxd 1/21/08 1:16 PM Page 605 Aptara Inc. still interactivity: A reply to Roelofs. 45. P. B.. B. E. Effects of Patterson. Telephone. L. Relearning after damage in connectionist networks: dered language. H. S.. & Kearns. E. M. of Aphasia. & and the underlying cognitive deficit: Evidence from the reme. In T. (1995). Tabor Road (215) 456-9605 Philadelphia.D. 52. 20. C. Philadelphia: Psychology Press.edu USA .). B. Albert.. (1999.. Yorkston. 606 Section IV ■ Traditional Approaches to Language Intervention Birkbeck College Wendy Best. Research Center-151A (904) 376-1611 Gainesville VA Medical Center Gonazlj@medicine. Universita Degli Studi di Napoli I Facolta Di Medicina E Chirurgia 80131 Napoli Via Pansini 5 Italy National Center for Neurogenic Audrey Holland.D.byng@city. Ph.uk London EC1V 0HB UK Georgetown Institute for Cognitive and Rhoda Friedman.georgetown.ac.ac. . Ph. Department of Psychology w. Ph. Ph. City University 0171-477-8000 Northampton Square s.edu Georgetown University Medical Center 3970 Reservoir Rd. understanding normal cognitive processes through the study of Orthographic representation—stored spelling of a word. Phonological representation—stored “sound” of a word. AZ 85721-0071 Pelagie@u. FL 32608 USA APPENDIX 22. NW Washington. people who have sustained brain damage. Lexical processing—mental representations and processes standing the neural mechanisms of behavior and cognition.bhs. Ph.mq. Sydney.best@psych. Ph. University of Arizona (520) 621-9878 Tuscon.edu.edu USA School of Behavioural Sciences Max Coltheart.arizona. Communication Disorders Pelagie Beeson. involved in comprehension and production of single words in Cognitive neuropsychology—branch of psychology devoted to various modalities. DC 20007 USA Instituto di Scienze Neurologiche Sergio Carlomagno.D. Ph.D. Semantic representation—stored meaning of a word. Computational model—computer simulation of a particular task.bbk.2 Glossary Behavioral neurology—branch of neurology devoted to under. Ph. New South Wales 2109 612-9850-8448 Australia [email protected]. Macquaire University Lyndsey Nickels. Ph.au VA RR&D Brain Rehabilitation Leslie Gonzalez Rothi.ufl.D.D.uk University of London Malet Street London WC1E 7HX UK Clinical Communication Studies Sally Byng.D. Computational Sciences (202) 784-4134 [email protected] Gainesville.D.GRBQ344-3513G-C22[595-606]qxd 1/21/08 1:16 PM Page 606 Aptara Inc.D. have served as a to breakdown of the mechanisms of lexical processing. cognitive neuropsychology (CN) (Coltheart. An ing. much research has tran. & Sage. and picture-recognition and naming paradigms. Leslie J. conceptualize. Subsequently. production of less-skilled behaviors. Chapter 23 Impairments of Word Comprehension and Production Anastasia M. 2002. such models. Lambon Ralph. Nickels. writing. as shown in Figure 23-1. vary among respond to that input. or gesture. & Caramazza. The nature of or viewed objects. Impairments of word comprehension and. Hillis. To acquire skill in any behavior implies that the person is 2001). recovery. we will also briefly consider the mechanism impairments that patients may display has its foundation in responsible for object recognition. backdrop to a large clinical literature examining lexical review evidence for clinical application of this model for impairments in aphasia. the study of brain-impaired individuals to provide more efficient in the production of that behavior than in the evidence for theories of cognitive processing. processes allow for planning and executing a response to the Traditional methods of aphasia-syndrome classification are stimulus in the form of speech. Rothi. 1995). and will form the basis for this dis- assessment. Goldrick & Rapp. 2001). cussion of assessment and treatment of lexical impairments. & Greenwald. Recent years have seen an evolution in the struc- The objectives of this chapter are to describe a model of lex- ture and functioning of lexical models toward a more com- ical processing that represents the mechanisms involved in putational approach. system can increase efficiency by storing memories based on spired using the CN approach as a backdrop to clinical previous exposure to a stimulus such that subsequent pro- 607 . and consider the limitations and future trends in the use of Although the details vary to some extent across versions of lexical models in the clinical setting. delineate impair- Rothi (see Chapter 19). The central nervous guage. because lexical tasks often incorporate alternative approach to characterize the diverse lexical visual stimuli. Nonetheless.g. In the past two decades. in particular. The usually insufficient to distinguish the mechanisms of lexical focus of this chapter is on the mechanisms involved in pro- failure that occur among patients with aphasia—differences cessing spoken words. cognitive neuropsy- ments in lexical comprehension and production with respect chological models. including lan. Hillis. Raymer. peripheral motor patients in terms of their cognitive and neural bases. Gonzalez Rothi MODEL OF LEXICAL PROCESSING OBJECTIVES Figure 23–1 depicts a model of lexical processing that forms the basis for this discussion of lexical impairments for spo- ken words. 2002. and treatment of lexical impairments. triggers cognitive mechanisms in the cen- the lexical impairments. Costa.qxd 1/21/08 1:26 PM Page 607 Aptara Inc. 2001. & Barresi. so the description will center on the that may influence treatment decisions for those patients central mechanisms critical for lexical phonologic process- (Nickels.. The model includes a complex system of distributed and interconnected modules that allow for processing of different types of lexical infor- DEFINITION mation in cascade fashion (Chialant. 2001. 2001). Kaplan. such as spoken or written words aphasia (Goodglass. Raymer and assessment and treatment of impairments related to lexical comprehension and production. are pervasive among patients with acquired some form of sensory input. the fundamental components are similar (e. The activation of peripheral sensory structures with word retrieval.GRBQ344-3513G-C23[607-631]. Moriarty. In addition. 2002). 2007. most often tested in constrained tral nervous system to recognize. such as that described by Nadeau and word comprehension and production. 23-1). stimulus-recognition processes allow for activation of representations that closely Visual Object Recognition correspond to the input stimulus. that is. For example. Raymer. respec- regions that mediate aspects of lexical processing. on clinical stimulus is a familiar object or word. Maher. 2001). 608 Section IV ■ Traditional Approaches to Language Intervention “In the oven. if the word is spoken with such as spoken definitions. exemplar may take. we will for different types of familiar sensory stimuli (Fig. Other mechanisms for processing in other sensory modalities. The object-recognition system stores memories of familiar objects. such as visual gestures.GRBQ344-3513G-C23[607-631]. Finally. In contrast. Recognition represents the point at which a stimulus is identified as familiar com. It does not yet allow the examination. Following early sensory processing. & Morris. or smell. We will A number of lines of evidence support the notion that review the mechanisms that make up this complex system recognition-level processes are modality specific (Hillis. we baked a loaf of _______” bread Lexical phonological Object Lexical orthographic recognition recognition system recognition Figure 23–1.qxd 1/21/08 1:26 PM Page 608 Aptara Inc. Model of Lexical Processing. or if an object is (Rothi. The viewed from an unusual orientation. or to demonstrate comprehension . stimulus-recognition model of lexical processing shown in Figure 23-1 indicates mechanisms allow for the quick realization that the stimulus that lexical abilities are dependent upon the integrity of a is familiar in spite of input perturbations. individual to state what that object or word means. For example. It affect performance in lexical tasks that require the patient allows the individual to say “yes” when asked whether a also to process viewed objects. that separate components represent knowledge ated with dysfunction of these mechanisms. and they may have difficulty in word-to-picture matching Recognition processes provide a processing advantage that tasks that test comprehension. Greenwald. 1991). Semantic system Lexical phonological output processing “bread” cessing experiences with that information can be expedited an accent or written in an unusual font. Recognition Level Mechanisms also may exist. Impairments related to visual object representations will pared to other physically similar stimuli (Tyler. and the types of impairments that we might observe associ. the same patient allows us to react quickly to whatever form the stimulus may be able to name in response to other sensory inputs. tively. 1987). number of different types of stored representations. patients may be impaired in picture-naming. touch. The mention the neurologic site of lesion often associated with phonologic and orthographic lexical recognition stages rep- dysfunction of the lexical mechanisms to suggest neural resent stores of familiar spoken and written words. in peripheral sensory mechanisms.GRBQ344-3513G-C23[607-631]. and other types of acoustic stimuli (Buchman. sort objects into categories. 1995a. 1989. & Goodale. some semantic information is available patients with selective impairment for phonologic input in regarding a picture for the patient to sort by category or to the face of intact reading comprehension provide evidence provide an appropriate gesture. must rely on the right hemisphere’s contribution to visual may lead to apperceptive or integrative forms of visual and semantic processing (Coslett & Saffran. Dysfunction of early visual contrast. & Gordon. Franklin. Patients may be impaired in tasks requiring knowl. cal for the neural representation of object knowledge (Iorio. pre-lexical impairment that affects processing of phonemic edge of the structure of a visual stimulus. their stored object knowledge appears to be intact as they may be able to answer Damage affecting phonologic lexical recognition (Fig. Fragassi. 2001. 1998. (Ellis. 1986). Cardmone. Greenwald. a dependency that leads to the prediction ing to the viewed objects (Hillis & Caramazza. Riddoch & Humphreys. agnosia (Lissauer. & Humphreys. Riddoch & Humphreys. such failure not being attributable to dysfunction of region for object recognition. 2002. Hart. culty may occur only when visual stimuli are incorporated in researchers have also described visual associative agnosia in the task. 2001. arguing against visual agnosia in which meaning for auditory comprehension impairment presumably related to viewed objects is not appreciated. Marsh & Hillis. and to perform auditory lexical decision. Polster & “dart”). For example. or answering questions about 1989). Chapter 23 ■ Impairments of Word Comprehension and Production 609 with printed word-to-word matching tasks. occur. cated by preserved ability to discriminate and repeat words. preventing processes involved in developing a percept for the viewed access to the damaged left hemisphere. such as distin. visual agnosia tend to have less damage to the splenium of Riddoch & Humphreys. 1993). Warrington & Taylor. “Agnosia” is the term used the corpus callosum. Marsh & Hillis. & Sin. Patients with impairment of visual process spoken words. (Francis. 1992). 1997). (Caplan. that patients with phonologic recognition dysfunction 1995b.qxd 1/21/08 1:26 PM Page 609 Aptara Inc. or gesturing to agnosia (Riddoch & Humphreys. and presumably object. should also have impaired reading comprehension. 2001). & Schwartz. Trost- guishing familiar from nonsense objects (visual object deci. which presumably . trast. Raymer. 1987d). However. Schnider and colleagues proposed that patients with which stage of object processing is affected (Farah. Vignolo. however. Because the tion of viewed objects. Miller. be able to describe the func. Some patients seem to have a 1990). and apparently access and employ the for failure (as a result of brain damage) to recognize a sensory impaired left-posterior hemisphere. but the full semantic repre. posterior cerebral cortex lesions were commonly reported. 2005. 1890/1988. Kohn & Friedman. & Grossi. specific). which is a critical stimulus. have more extensive splenial lesions. James. & Scharre. in which patients also experi. 1999. 1982). 23-1) questions about the visual characteristics of named objects leads to impairments in any tasks that require patients to in visual imagery tasks. 2001). 1992. 1983. phonologic lexical processing. similar to apperceptive visual impairments. & Heilman. & Denes. These patients. one report described a patient who Falanga. Rothi.g. reported patients had retained comprehension for written ture the appropriate use for the objects they are unable to material. The phonologic correlate of optic aphasia may be repre- Several papers that have analyzed lesions in patients with sented in some patients with word-meaning deafness visual agnosia and optic aphasia suggest brain regions criti.. Hillis. for distinct input mechanisms for orthographic and phono- sentation must be activated for accurate picture-naming to logic lexical processing. 1992. patients with unilateral left-posterior mesial cortex infarc- Impairments may take different forms depending upon tions. Errors in nam. Semenza. drawing from memory. Richardson. 1978). Patients with optic aphasia. some patients reported with Wernicke’s aphasia seem to A phenomenon often discussed in the realm of visual have impairments of the phonologic lexicon as represented object agnosia is optic aphasia. They may. One interpretation of presemantic. sion). Boatman. naming to spoken definitions. such as auditory word-to-picture object representations have a form of visual associative matching tasks. “pen” for word deafness (Boatman. Culham. 1986. Buchtel & Stewart. Some general parallels may be seen perform tasks dependent upon early visual processes such as between the impairments of object processing and phono- matching line drawings or copying figures. 1994). by modality-specific auditory comprehension impairment ence naming failure restricted to the visual modality (modality. Thereby. Riddoch. Rose. in which they can verbal commands. 1989. Benson. Wichter. 2003. logic lexical processing as represented in patients with pure ing may include visual misperceptions (e. prior to activation of visual object representations. semantic processing was judged to be intact and the name. Some early the- optic aphasia is that it represents a visual-to-semantic access ories had proposed that the processing of the orthographic impairment in which visual object representations are word forms occurred subsequent to phonologic activation unable to activate full semantic representations correspond. Schnider. or ges. could process the phonologic components of words as indi- Humphrey. or failures to respond (‘I don’t know’) (Farah. Although bilateral. Cipolotti. In con- the visual characteristics of objects. Milner. 1990. diffi. Thereby. who have ade- quate visual acuity. may be unable to copy a line drawing or Phonologic Recognition even to match simple drawings. That is. Garron. 2005. They propose that modality and can access any output mode as appropriate. superordinate. 2002. ties in their semantic representations will be affected. objects. Cases of Wernicke’s aphasia associated impairments for categories such as living and non-living with left-posterior perisylvian lesions. tion. because visual semantic information may be criti- modality-independent in that a single unitary semantic sys. Warrington and her 23-1). it appears that the posterior portion of the Warrington & McCarthy. & Cappa. & Miozzo. & Poncet. 1984) attributed semantic category words... In par- native sublexical letter-sound conversion mechanisms are ticular. 1996. 1984). and ideas that includes modes in a complex network of subsystems (Allport. and Shelton (1998) proposed that category-specific impair- A patient with a semantic impairment will have difficulty ments arise because of texturing in the interconnections of performing any tasks that require semantic mediation. Caramazza Shallice. 1985). and animals (Caramazza & Shelton. Hart & Gordon. with pure word deafness typically have bilateral temporal or Researchers have also described individuals with aphasia subcortical left-hemisphere lesions affecting input to whose naming and comprehension impairments fractionate. cific semantic categories. category-specific deficits arise because the semantic system Semantic representations presumably involve a network of is structured along lines of sensory modalities and output information about words. Caramazza and colleagues (Caramazza. Rather. Berndt. argument similar to that proposed for optic aphasia. category-specific impairment for animals (Warrington & Romani.. Some proposals view semantic representations as example. 2001). associated. tools (Ochipa. 1983). Performance in oral word. At Semantic Processing first. Turner. Disruption of selective subsystems leads to tionships. mance of individuals with semantic system impairment Although the patient demonstrated intact reading compre. 1990. ing the full semantic specification for spoken words. including meanings for Warrington & Shallice. 1995) may Imbornone. A contrasting view holds that the semantic system is struc. In contrast. 1998.. 1992. Franklin and this association of impairments in some patients with vascu- colleagues attributed the failure to an impairment in activat. Morris. one might use these unusual dissociations to infer that Once a recognition-level representation achieves sufficient the semantic system is structured in a fashion that represents activation. Saffran. Zorzi. Hodges & Patterson. 1987. an 1984) and progressive neurologic impairments (Chertkow. 2003. Cappelletti. For 2000). Lau. such as verbal semantics and visual Laiacona et al. Researchers have described particularly for abstract. Wernicke’s area (Polster & Rose. 1983. Patients have demonstrated logic processing. account of category-specific impairments. Saffran. should demonstrate quantitatively and qualitatively similar hension. 1997. Individuals 1996). tured into subsystems for different sensory information and Hillis. impairments that affect semantic categories for which that ues regarding the structure of the semantic system (Funnell. 1992. & Caramazza. area. lar lesions (Hillis et al. 1989). & Faxio. bers of a category of objects. If the or animals may have a number of highly interconnected . Raymer & Berndt. & Franklin. Ellis. 1996). unitary semantics system proposal is correct. 1998). (Farah & Wallace. 1991). & Seidenberg. any concepts that include those proper- reading and writing to dictation may also be affected if alter. these specific categories of knowledge. 1985. Hillis. Some studies have described the neural correlates of Lambon Ralph. including Wernicke’s things (Laiacona. 1985. Bub.. coordinate. (Kertesz. 1997.qxd 1/21/08 1:26 PM Page 610 Aptara Inc. Weiller et al. knowledge systems. 1998. 1994. Howard & Orchard-Lisle. objects. impairment of the visual semantic subsystem results in modality or output mode (Chialant et al. Gainotti. & Heilman. serving phonologic lexical knowledge. Capitani. Paivio. & Polk. 1993. it initiates activity in the semantic system (Fig. Caramazza & Shelton. suggesting that demonstrating selective preservation or impairment for spe- these regions are important for prelexical stages of phono. Perani. impairments across lexical tasks. fruits and vegetables left superior temporal cortex is a critical neural region sub. Silveri. & Caramazza. 1986. regardless of input mals. happen to be localized in a neural region that is damaged by ken and written picture-naming. Chiavari. low-frequency words. If critical shared properties interpreting the meanings of objects and gestures. he had difficulty in auditory-comprehension tasks. Leek. The lexical model incorporates a dissociations to the type of semantic information that is a unitary semantic system that can be accessed from any input defining characteristic for that category. the perfor- tions (Franklin. Hillis & Caramazza. Rosazza.GRBQ344-3513G-C23[607-631]. items within certain natural categories such as plants unavailable for decoding or encoding written words. subsystem contributes critical semantic information. & Caramazza. and spo. 1994. 1988). neurologic disease. 1997. Carbone. Semantic representations contain stored knowledge colleagues (Warrington & McCarthy. phonologic lexical recognition impairments. & Bailey. Shelton & Caramazza. Rothi. 610 Section IV ■ Traditional Approaches to Language Intervention depends upon the integrity of phonologic input representa. and subordinate rela. Ferreira. shared by speakers of a language. or actions. Rapp. Discussion in cognitive neuropsychology contin. 1997). Giusiano. 2003. cal for distinguishing exemplars within the category of ani- tem provides meaning for a stimulus. 1995. Ralph. Shallice. 1990. Farina. 1989. 2003) have argued for a unitary semantics semantics (Allport. be characterized by an impairment of phonologic recogni. Hart. Therefore. properties comprising semantic representations for mem- including comprehension of spoken and written words. 1988). In this discussion..” “yacht”). 1990). 23-1). Patterson. three different semantic categories: (1) persons: left temporal Rothi.g. to derive accurate pronunciations for those words. Patients Hodges. Findings Kertesz. or no-response errors. Chialant et al. Finally. Berndt. of retained performance in written word spelling (Bub & ogy associated with a left-thalamic hemorrhage. the left semantic and phonemic paraphasias. 1998). Caramazza & Hillis. & Heilman. lesion analyses in patients with semantic dysfunction 2002. Viral encephalitis. other studies have ten words as well as for gestures (Rothi.. Patterson.. Caramazza. There Caramazza.g. Le Dorze & Nespoulous. 1994. a disso- pole lesions.g. we focus on the mechanism for (Damasio & Tranel. Left posterior naming. Giustollisi. 1983. Production errors may take a variety of forms. so patients may be impaired in a variety of Lexical Phonologic Output lexical tasks (e. Oxbury. Nadeau. & Basili. 1984). ing has been activated. a predilection for damaging the inferior and mesial temporal Researchers have inferred key features of the structure of cortex. resulting ments also suggest critical regions representing specific in neologistic responses (Kohn. and in oral reading. 1993. have focused largely on noun retrieval. 2007). Ochipa... 1998.. the latter remaining intact in some regions may lead to disruption of semantic processing. (3) tools: ciation providing evidence for the input/output distinction left temporoparietal-occipital lesions. but within only one output modality. and Damasio (1996) investi. a dissociation from these lesion studies provide further support that dam. put lexicon (Caramazza & Miozzo. also described disturbances of verb retrieval in some patients 1997). 2001). leading to semantic & Rothi. a syndrome asso. picture- 1992. Kay. In particular. of lexical representations in the output lexicons (Fig. spoken or . or neolo- thalamus also seems to be implicated in the complex seman. 1996). name to definitions). Crosson. Whereas many studies of lexical retrieval impairments cific as there are separate stores for familiar spoken and writ. Hillis. (2) animals: left inferotemporal lesions. & Franklin. & Heilman. & Vasterling.. Maher. & Funnell.GRBQ344-3513G-C23[607-631]. has been associated with impairments for the cate. Some individuals may have ciated with semantic dysfunction. Foundas et al.. as sublexi- acute vascular lesions (Foundas. 1984. cortical regions appear to play a critical role. Miceli & upon neurologic injury and leading to category-specific Caramazza.” “-s”) (Badecker & than nouns. particu- temporal regions also are compromised in patients with larly for exception words (e. & Caramazza. including 2006.g. “-ing. for lexical phonologic processing. patients with phonologic output impairments. Kleinman. gisms (Hillis. impairments of both phonologic input and output. that supports the distinction between phonologic and ortho- age to left-posterior temporoparietal-occipital and thalamic graphic output stores. and Raymer (1997) reported a tive impairments for phonologic production in the context category-specific naming impairment for medical terminol. Others may have a disturbance Neural regions associated with category-specific impair. Kertesz. nuclei (Crosson. 1991). it is often the case that neurologic injury affects multiple lex- ical mechanisms. Boone. verbs) also appear to be represented at the level of the out- Regarding neural correlates of semantic-system impair. lexical phonologic dysfunction. Daniels. Tranel. Raymer. 1992. nouns and deficits. ments. Zingeser & is some indication that words are stored in phonologically Berndt. 1996) aspects of semantic knowledge. Shapiro & Caramazza. Word class distinctions (e. “choir. Newhart. demonstrate retained auditory comprehension for words gated the location of lesions associated with impairments for they are unable to pronounce (Kay & Ellis. Silveri.. will have difficulty in all oral naming tasks (e. Moberg. For example. Hart & Gordon. “walk” “-ed”. Some patients have selec- Moberg. 1983. & McCabe. 2003. cal grapheme-phoneme assembly processes are insufficient 1998. the lexical system from observed lexical dissociations gory of living items (Warrington & Shallice. output. In addition. Factors such as age of acquisition and provide clues as to the neural instantiation of semantic word frequency seem to exert their influence at this stage of knowledge.. Rothi. & integrity of the stored phonologic representations. 1989. 1991. Hodges. Hillis. De Bleser & Cholewa. & Alexander. is observed in many indi. 2001).qxd 1/21/08 1:26 PM Page 611 Aptara Inc. 1990). Davis. greater difficulty activating the output representations viduals with vascular lesions affecting the left thalamic (Caramazza & Hillis. impairments of both verbal and written Once recognition of a word or object has occurred and mean.. Hichwa. 2001. Chapter 23 ■ Impairments of Word Comprehension and Production 611 properties. Transcortical sensory aphasia. Miceli et al. Smith. 1995). a response is initiated with activation 1991. no responses. affecting the internal structure of representations. as these regions Dysfunction of lexical phonologic output processing are implicated in individuals with degenerative dementias leads to impairment in all verbal tasks that depend on the leading to semantic dysfunction (Graham. Miceli. Chaudhry. & Heidler-Gary. Crosson. which has or phonemic paraphasias (Ellis. among brain-damaged patients. 1998. Miceli. 1991. 1997). Nickels & Howard. 1987. 1990. Hillis et al. Raymer. Nevertheless. Damasio. 1997). Evidence suggests that the output lexicons are modality-spe. Several patients have now been described similar groupings and that root morphemes are separated who have more difficulty with nouns than verbs or with verbs from affixes (e. Kohn et al. Ellis et al. Davidson.g. 1992). depending on the nature and severity of tic network. 1982. some patients Grabowski. & spoken words: lexical phonologic output processing. Villa. 1997. making all exemplars of the category vulnerable Caramazza. left-hemisphere posterolateral processing (Goldrick & Rapp. Maratin. distributed system of lexical Mode/Modality Comparisons processing as depicted in Figure 23-1. Kay. 1990. 1997). Raymer. One patient had an impairment affect- (Damasio & Tranel.. Raymer.. we incorporated the same set of 120 to characterize a patient’s language impairments with respect nouns across tasks. processing in a variety of patients with aphasia have pro- vided evidence for a complex. writing. viewed objects) and output modes (speech.. Assessment ments are worse for verb retrieval than noun retrieval in asso. 1991. 2003. & Rothi. Tuffiash. whether there is an intervening amodal lexical rep- processing. affecting at least two stages of lexical processing: visual object ical retrieval (Antonucci & Beeson. Published psycholinguistic tests CLINICAL APPLICATIONS OF are available that allow systematic assessment of lexical pro- THE LEXICAL MODEL cessing (e.. For example. & Cappa. The model of lexical processing shown Caramazza.. 1991. lexical output (Raymer. studies examining impairments of lexical lexical mechanisms. Controversies persist regarding details of varies input modalities and output modes. in the Florida Semantics Battery The goal of assessment within cognitive neuropsychology is (Raymer et al. writing to dicta- tion. and analyzes pat- processing and representation in the lexical system. written picture-naming. analysis played a significant role in distinguishing the lexical ical representations. researchers have applied this Berndt. 1995). In contrast. it is the left A key concept in an assessment geared to identifying impair- hemisphere that plays the key role in representing lexical ments in the lexical system is mode/modality comparisons. approach to analyses of treatment of lexical impairments in patients with aphasia. Hillis. Soardi.. to employ the same set of stimuli across Assessment tasks. 1994). area 37 at the inferior temporal/occipital junc. Richardson. lexical phonologic output processing. The other had impairments tion has been associated with impairments of phonologic lex. and semantic activation of 2006. activation of the semantic system. this written.. 1997). Nevertheless. 1990). batteries (Hillis et al. 1995c. lemma level) between semantic and result when combining input modalities (auditory verbal. nam- lexical impairments.g. it is important.. 1997). researchers typically have described noun-retrieval greater detail. Raymer and colleagues (1995) illustrated how a CN mode of output is represented at the level of the output lex. 1996. Table 23–1 lists a number of lexical tasks that resentation stage (e. and exploring the implications of the cognitive neuropsycholog. knowledge. in Figure 23-1 provides a basis for discussion of impairments These patterns of dissociation provide evidence that the specifically related to spoken word comprehension and pro- grammatical class distinction observed only within a specific duction. Roach. In particu.GRBQ344-3513G-C23[607-631]. The lexical assessment typically includes key tasks ing this discussion of clinical management for patients with such as oral picture-naming. oral word reading. among others. ing to spoken definition. Hillis et al. 1990. 1992). (Raymer. 1993. cians evaluated the profound word-retrieval impairments in lar. 1998). it became clear that the two patients differed impairments in patients with fluent aphasia and left-posterior considerably in the cognitive mechanisms for their word- perisylvian cortex lesions.qxd 1/21/08 1:26 PM Page 612 Aptara Inc. Grewel. impair. for terns of performance for tasks sharing modalities/modes of example. general model provides a rational theoretical basis for guid- gesture). Hillis & to a cognitive model. & Brecher. the selection of appropriate stimulus materials.g. When clini- impairments affecting lexical phonologic output. 1990). lesions (Caramazza & Hillis. 612 Section IV ■ Traditional Approaches to Language Intervention written production (Caramazza & Hillis. Psycholinguistic Assessments of Language The model of lexical processing provides a framework for Processing in Aphasia. The CN framework may influence the form that lexical Schwartz. 1990). Zingeser & Berndt. The challenge to clin- Shapiro & Caramazza. and written word com- prehension. Greenwald et al. 2002). In addition. although the right hemisphere may contribute The lexical assessment should include a variety of single- to certain aspects of lexical-semantic processing (Joanette & word processing tasks in which the clinician systematically Goulet. several research groups also have developed experimental ical (CN) approach as applied within the clinical process. ing semantic activation of the lexical output mechanisms In particular. to the extent possible. Raymer et al. & Caramazza. auditory word comprehension. Miozzo. results then had consequences for treatment for the word- ciation with nonfluent aphasia and left-inferior frontal retrieval impairment in the second patient (Greenwald. 2001. Zingeser & assessment takes. impairments of two patients whose standardized aphasia Distinct neural regions appear to be associated with assessments acutely indicated anomic aphasia. (See Appendix 23-1 for the full set of 120 . Damasio & Tranel. As tasks con- trast modalities/modes of processing. Overall. 1993. Lesser. 2004.. & Coltheart. Foundas et al. often including temporal regions retrieval impairments. The CN approach also has direct Lexical Stimuli implications for predictions regarding generalization of A second important consideration in lexical assessment is treatment effects. icians is to tailor assessments to evaluate the integrity of the In summary. Foundas et al. Regularity (Berndt. In word-to-picture matching tasks.” exceptional spelling-“yacht”) Comprehension Tasks Age of acquisition (Gilhooly & Logie. animals) mining the psycholinguistic attributes of stimuli (e. 1981.g. 1996). However. the patient Laiacona. Monsalve.. verb. functor) Semantic category (living items. studies examining factors influencing word retrieval in An alternative task to assess comprehension is picture- patients with aphasia. Nickels & Howard. MRC Lexicality (word. 1987.. the clinician should evaluate the effect such vari. “apple. References ables have on their patient’s performance.g. tools and objects tools act upon) difficult at times to detect an impairment. “apple”) and exposure to the same stimuli.” “banana. 1982) in treatment. sometimes by guess- Familiarity (Snodgrass & Vanderwart. Hermann. Center for Research in Language data base). Items Within Lexical Tasks. Davies. In this way. 1994. Reggia. 1988). TABLE 23–2 Cuetos.” “dress”) (Raymer & Berndt. 1995) (Table Linguistic Factors That May Affect Performance for 23–2). In many derive the correct answer. “apple.. 1980) In tasks that assess comprehension of single words. 1980) ing. 2002. as certain factors may have implications for which materials are chosen for use Word frequency (Francis & Kucera. & Walters. & Mitchum.. Colombo & Burani. 1981. Words learned early in life are particularly resilient. it can be Imageability (Coltheart. 2005. familiarity.” “chair. son it is important to evaluate comprehension performance On the other hand. there will be times when the clinician in the context of semantically related distractors (e. nonword) data base. which will require als. or for different semantic categories. nouns.g. especially. 1997. regular spelling-“mat. Zingeser & must verify (yes) the correct name and reject foil names (no) Berndt. as higher-frequency words are must decide (yes-no) whether a given word is the correct named better than lower-frequency words (Capitani & label.” “orange. age of acquisition (Bell. Gilhooly & Logie. Foundas et al. 1994. 2000. fruits. with Selected Normative Therefore. Grammatical category (noun. phoneme length) often can provide a correct response. the clinician can the distractor pictures are unrelated (e. Several online resources are available for deter.” attribute differences observed across tasks to the modality of “hammer. carefully controlled studies have that are semantically or phonologically related to the target demonstrated that word frequency has a less potent effect on lexical processing than factors such as imageability. wants to evaluate performance for contrasting sets of materi. length. 1980) Operativity (Coltheart... when contrasting performance for nouns subjects to activate more specified semantic information to versus verbs. & Perez. in which the patient sees a picture and effect of word frequency. investigators often have discussed the word verification.g. Raymer. To be credited with a correct response.qxd 1/21/08 1:26 PM Page 613 Aptara Inc. Kremin et al. for example. 2004. as the patient Length (syllable length. 2001. and. Hirsh & Ellis.GRBQ344-3513G-C23[607-631]. For this rea- processing and not to differences in stimulus variables. Chapter 23 ■ Impairments of Word Comprehension and Production 613 TABLE 23–1 Lexical Tasks to Include in Assessment Output Tasks Input Tasks *Oral picture-naming *Auditory word-to-picture matching *Written picture-naming *Written word-to-picture matching *Oral naming to spoken definitions Auditory word-picture verification Written naming to spoken definitions Written word-picture verification *Oral word-reading *Semantic-associates matching *Writing to dictation Auditory lexical decision Name to tactile-object presentation Written lexical decision Name to environmental sounds Category sorting Gesture to command Gesture to viewed objects *Indicates key tasks in the general lexical assessment.” “grapes”).) Patients complete blocks of stimuli systematically respond correctly to an item on the basis of only basic across experimental tasks to control for effects of repeated semantic information if a target picture (e. individuals may . .g. in oral reading. e. et al. Semantic errors in picture naming are a case in point (Hillis. the mechanism of a patient’s lexical impairment. . “pound” for “hammer” Visual Object Representation Tasks Circumlocution Description of the semantic attributes of the object or word Tasks that require processing of familiar pictures will Phonemic Response sharing phonemic attributes depend on the integrity of visual object representations. word reading. “pencil” for “screwdriver”. oral naming of pictures and oral reading pattern.g. Table 23–3 pro- one might assume that these errors represent semantic-sys- vides a list of some typical errors observed for verbal tem dysfunction (see Fig. suggesting that the semantic errors arose from a disturbance of the phonologic lexicon. e.g. name to defini- No response Refusal or inability to retrieve tions.. “I don’t know” in picture naming represent visually similar objects (e. “cow” for “lamp” require picture or object processing (e. in some patients. words that share orthography. of target. e.” or nonword. 1990). In contrast.g.g. attribute) to each stage of lexical processing.. 614 Section IV ■ Traditional Approaches to Language Intervention word. Semantic Hillis. Sandson. Breese and Hillis (2004) compared performance in For example. 2000). ment responsible for the error. The types of errors may provide clues as to (Hillis et al. 23-1).. Therefore. Raymer. 1997). e. foils were more problematic than phonologic foils. These observations under- Error Type Description score the need to analyze error patterns across lexical tasks to develop an accurate hypothesis regarding the source of Visual In object-naming.g. For example. suggest.qxd 1/21/08 1:26 PM Page 614 Aptara Inc. 1984). Ritgert. word-to-word matching). e. the pattern of errors produced across tasks. function.. 2001). or when patient responses response. On the surface. the verification task was much more sensitive for of single words with exceptional spellings) (Caramazza & identifying subtle deficits in word recognition. but no semantic errors in naming to definition (Hillis & Types of Production Errors Commonly Observed Caramazza. 1995a. but none in written picture naming and writ- ing to dictation. e. to-picture matching provide an initial screening for this “trut” for “truck” mechanism.g. for Error Patterns across Lexical Tasks the target picture of a carrot. The same Caramazza and Hillis (1990) describe a patient who pro- quantitative and qualitative pattern of errors should be duced semantic errors only for oral picture naming and oral observed in all tasks that engage the impaired mechanism..g. Object-recognition impairment is suspected if Unrelated Responses bearing no relationship to performance improves for contrasting tasks that don’t target. “chain” for “choir” Stage-Specific Analyses Semantic Many lexical tasks involve processing at multiple stages in Superordinate Semantic category name for the viewed object or word the lexical system. the target picture or word. names of objects sharing visual characteristics.g. responses in lexical tasks (Mitchum. In this section we will review tasks Associate Words bearing some relationship that the clinician may administer to assess performance at (e. general tasks such as object naming and word- “trick” for “truck.. 1990). a pat- in Lexical Tasks tern that may represent an impairment of visual object acti- vation of the semantic system. 1990. Howard & Orchard-Lisle.GRBQ344-3513G-C23[607-631]. a deficit of semantic processing will affect per- word-picture matching and word-picture verification tasks formance in all comprehension and naming tasks (Hillis in a large sample of participants with left-hemisphere stroke. or “rabbit” (associated). Examination of the type of error itself within one lexical ing the types of foils that might be more sensitive to mild task is not sufficient to distinguish the level of lexical impair- comprehension impairments. “apple” cise hypothesis about the nature of the impairment affecting for “pear” performance at that stage. semantic-naming errors may include responses such as “vegetable” (superordinate). patients with optic aphasia often produce large numbers of TABLE 23–3 semantic errors in picture-naming tasks (oral and written).g. result in parallel patterns of impairment in all verbal pro- cation than matching... and only 8% showing the opposite duction tasks (e. e.... Indeed.g. It is necessary to contrast performances Coordinate Name of alternative item within the across tasks sharing processing at one stage to develop a pre- semantic category. “cel- Another key concept to consider in the lexical assessment is ery” (coordinate). at times is a real word. the lexical error (Raymer & Rothi... 1990). Greenwald et al. location. Dysfunction of lexical phonologic output will With 78% of participants performing more poorly in verifi..g. e. & semantic errors may represent semantic-system impairment Berndt. presumably depends on an intact visual object repre. and gestures to verbal command. It is also helpful to ask patients whether they tion. One such task is rhyme verification for pic- avoid the use of lexical stimuli. Because semantic impairments can fractionate along the ings may be necessary to distinguish early object-processing lines of specific semantic categories. and familiar environmental sounds may be useful to determine vegetables.qxd 1/21/08 1:26 PM Page 615 Aptara Inc. Florida Semantics Battery. sys. questions about visual attributes of objects (i. visual information is purportedly an important phoneme discrimination. drawing from memory or answering semantically associated item from several choices (e. performance for oral reading and writing to dictation of reg. 1997). apraxia of speech). such as written or viewed object input. A to determine the familiarity of objects or to use knowledge semantic-associates task. and writing to dictation leads one to suspect ularly spelled words may be spared in the face of semantic impairment of lexical phonologic output (Caramazza & impairments if sublexical print-sound conversion processes Hillis. modalities. For word. 1992).e. depend upon adequate processing by the lexical-semantic sys. regardless of input modality and output mode. Impairment in oral naming. The key feature is that impairment experimental batteries incorporate the semantic category dis- will be specific to the visual modality. However. which requires Trees test (Howard & Patterson. “carrot”) to a sentation. Object decision. As in ated his complaint of a selective impairment for medical ter- visual object representations. Careful examination substanti- spoken definitions. However. Within standard aphasia tests.. leading to mode/modality-consistent impair. In the semantic-associates object.. is such a task.. or repetition tasks in the presence of tem. cake”). Chapter 23 ■ Impairments of Word Comprehension and Production 615 “pencil” for “screwdriver”).. “whale-nail”)... Asking patients to provide processing by visual object representations require subjects definitions for words also taxes semantic processing. . Similarly. or identification of characteristic of living categories such as animals.g. Additional phonologic tasks such as example. ture pairs. differences between nouns and verbs in word- simultaneously.g.. it may be possible for a brain lesion sequent post-lexical dysfunction (e. to cause extensive damage to lexical input and output stages Furthermore.g. tion (Raymer. tasks such as copying and matching line draw. It may be necessary to administer additional useful to administer additional semantic tasks that require more tasks to evaluate further the integrity of lexical phonologic specific processing of the semantic attributes of stimuli or that representations. Sorting objects by category. oral word reading. can be sensitive to subtle impairments in semantic activa- Because impairments of object recognition may take a num. naming to difficulty with medical words. written naming. Auditory lexical decision.GRBQ344-3513G-C23[607-631]. task. may be useful to a patient to decide whether a viewed stimulus is a familiar detect semantic impairments. repetition. The results of testing that identifies selective cate- specific dysfunction is suspected if performance improves gories of difficulty for a patient may allow the clinician to when stimuli are presented through other nonphonologic streamline efforts in rehabilitation. Lexical Phonologic Output Tasks On the general lexical assessment.. fruits. stage-specific phonologic tasks minology (Crosson et al. Testing will include tasks that are part of the general notice problems for specific categories. participants match a target item (e. action output/operativity is relevant to cate- whether the impairment for phonologic lexical information gories of garage tools.. This test imagery) also may tap this object-recognition process. A modality- plies. an astute examiner may notice Lexical Phonologic Recognition Tasks either impaired or spared performance related to selective categories by noting errors and then exploring category dis- Any tasks that present stimuli through the auditory verbal tinctions with additional testing with relevant materials (e. tasks requiring verbal Semantic-System Tasks production of familiar words will require activation of lexical All lexical comprehension and production tasks presumably phonologic representations.g. require patients to process auditory aspects of familiar Clinicians may find it useful to develop informal sets of phonologic stimuli. such as auditory word-picture verification hospitalization. retrieval tasks may indicate impairments of lexical phono- ments that mimic semantic dysfunction.g. It can therefore be logic output. such as the Pyramids and Palm of the visual form of objects. visual associate-”rabbit”. good performance in auditory and reading comprehension. Some sentations themselves. 1997). Tasks that more directly target help detect semantic impairment. In practice. During an extended lexical assessment. Greenwald et al.g. may determine whether their names rhyme (e. in which the patient views two pictures and must tematically manipulating the distance between categories. see Appendix 23-1). and office sup- relates to pre-lexical auditory impairments. distractors-”squirrel. in which stimuli that include items from a variety of semantic cate- patients decide whether a given stimulus is a real or nonsense gories that stress different types of semantic content. this dissociation may arise with sub- remain intact. ber of forms. and when responses to phonologic stimuli suggest misperception or confusion with phonologically related words. 1990). one patient complained of experiencing great (especially in the presence of semantic distractors). tools). it is useful to include impairments from impairments affecting visual object repre. tinction (e. kitchen implements. channel will require activation of lexical phonologic recogni- animals. tasks that are structured according to this dimension. Clinicians may adapt these methods using a more cir. tern of recovery for their patient. 1995). Over time. ceed as the clinician develops hypotheses regarding sus. Rothi.qxd 1/21/08 1:26 PM Page 616 Aptara Inc. clinicians may use the knowledge . whereas patients with lexical impairments may have greater The authors proposed that the patients who recovered had difficulty with word stimuli (Hillis et al. generated to account for lexical impairments in individuals ment. lexical output representations. egories. further substantiate the original proposal that the lexical the etiology of the brain disorder and the size and extent of impairment for speech and writing is related to a common the brain lesion will have the greatest influence on the prog. with similar patterns of impairments. it might be possible to select 10 stimuli retrieval in oral and written naming tasks and intact perfor- representing a variety of semantic categories and to vary mance in comprehension tasks. They proposed that the mode/modality of processing for key lexical processing tasks impairment arose at a late stage in semantic processing as listed in Table 23-1. parallel patterns of improvement. For example. Word-nonword repetition is another verbal output in four subjects with lexical impairment related task that may help determine whether an impairment stems to lexical phonologic output processing. were evident for both oral and written naming. & Heilman. living items neurologic lesions have dysfunction affecting multiple levels remained severely impaired. One year later. Many patients with extensive only for the category of nonliving items. Like the argument of Kohn and colleagues (1996). nosis for recovery of lexical impairment (Rothi. colleagues (1997) described a patient with impaired word 2004). Additional testing will pro. 616 Section IV ■ Traditional Approaches to Language Intervention The rhyming task will prove difficult for individuals who fail dict which patients are likely to recover from lexical impair- to activate a full phonologic lexical representation for the ment. the second patient was initially severely impaired across cat- pected levels of impairment. tions of such analyses. When Raymer and colleagues (Raymer. whereas the two with no recovery had substantial loss of lexical phonologic representations. but also what mechanisms are spared. and regarding lexical impairments observed early after a neuro- Barbarotto (1997) provide information to help clinicians pre. Recovery analyses described researchers to confirm and contrast interpretations made by Kohn and colleagues (1996) and Laiacona. as might be predicted if RECOVERY OF LEXICAL IMPAIRMENTS the impairment arose at a common stage in lexical process- Researchers have described diverse lexical impairments in ing. performance had improved significantly tages (Raymer et al. An in-depth assessment will frequently tinct mechanisms of word-retrieval failure led to different suggest not only what mechanisms in lexical processing are resolution of the category-specific impairments in the two impaired. Foundas. Patients with strated substantial improvement after 6 months. levels of performance for living items as well. One patient was initially less impaired than the other put. These types of information tions was associated with more limited recovery than an may be beneficial as the clinician turns toward devising impairment that affected semantic-system access to intact treatments for each patient. it is unrealistic to promote such a lengthy assess. 2000) assessed the pat- manner. Summary of Assessment Laiacona and colleagues (1997) described recovery of lex- Overall. qualitatively and quantitatively. A systematic assessment may indeed be semantic representations activate subsequent lexical output more cost-effective as clinicians understand their patients’ mechanisms. perseverative phonemic pattern in their neologisms at onset.g. the clinician may identify specific linguistic factors that an impairment characterized by loss of semantic representa- affect performance across tasks. the CN approach to assessment of lexical function ical abilities in two patients with category-specific lexical is distinguished by its systematic examination of patterns of impairments for living items as compared to nonliving performance across modalities of input and modes of out. that patient had improved to normal identified in preliminary testing. 1998). impairments and direct treatments in the most expeditious Maher. Raymer. those to date have demonstrated the implica- of language recovery in order to identify lexical factors pre. an impairment that affected retrieval of phonologic repre- sentations. Some clinicians may argue that in these days of limited Recovery analyses may serve to distinguish hypotheses resources.. logic lesion. 2001). After 2 years. The distin- post-lexical impairments often have greater difficulty for guishing characteristic in the nonrecovering subjects was a nonword stimuli (Kahn. Capitani. Breese & Hillis. Rather than employing a specific assessment protocol.. & Skinner. stage in lexical-output processing. Recovery analyses may allow dictive of recovery from aphasia.. investigators have described more detailed analyses perspective. only two demon- from lexical phonologic output or beyond. In addition. items. 1997). These parallel recovery patterns across output modes individuals with a variety of neurologic disorders. with an advantage for items in the nonliving cate- The CN assessment approach has a number of advan. 2002). Kohn and colleagues examined recovery of neologistic pictures (Hillis. In contrast. The authors proposed that dis- in the lexical system. and had normal performance for nonliving items across assessment will be individualized on the basis of deficits tasks. Although fewer studies have assessed recovery from a CN Recently. gory. Stannard. patients. Foundas and cumscribed set of available materials (e. In general.GRBQ344-3513G-C23[607-631]. Franklin. Hillis. 1993). their patient Bailey. As needed. Restitutive component to their semantic treatment as they asked the treatments target semantic or lexical phonologic processes patient to perform a word-picture matching task using all that clinicians have identified as impaired following the sys- rhyming word foils. 1996) described a phonologic treatment for a patient demonstrated improved categorization of items in the with impairments of auditory comprehension arising at a trained categories as well as one untrained category. neurologic. sug- used to circumvent or facilitate processing by the impaired gesting that repeated exposure to the treatment tasks affected lexical mechanism. In their treatment. Clinicians impairments. They chose first to target the sia (Riddoch & Humphreys. Ellis. The patients completed spoken word. indicating that the effect TREATMENT was modality-specific and not due to spontaneous recovery. Hilton. and transportation. Following treatment. improvement was noted in other semantic processing tasks. and one improved for untrained Restitutive treatments for auditory comprehension might word comprehension as well. 1995). A small number of studies have applied a CN impairments that were particularly severe for the categories approach in the treatment of auditory-comprehension of body parts. Some researchers have . and Franklin (1997) implemented a A number of clinical researchers have voiced optimism that semantic treatment for a patient with severe deficits of lexical CN models may provide a sound theoretical foundation on comprehension related to dysfunction at both phonologic which to develop rational treatments for patients with apha- and semantic processing stages. Clinicians also atically increased the number and relatedness of distractors. and social fac- category-sorting for pictures and written words of increasing tors as they develop a treatment plan for a given patient to semantic relatedness. 1989). adding a phonologic compo- applied to a lexical referent. Little prelexical phonologic stage of processing. including phoneme-grapheme matching. but no improvement in written word- comprehension and picture-naming tasks that do not involve phonologic recognition. Clinical researchers have applied the CN both phonologic and semantic processing.qxd 1/21/08 1:26 PM Page 617 Aptara Inc. the patient improved in other Cognitive models of lexical processing lend themselves word-picture matching tasks. but not in a phoneme-discrim- well toward a distinction in the kind of treatment to be ination task. & semantic information. Chapter 23 ■ Impairments of Word Comprehension and Production 617 derived from recovery analyses to direct clinical efforts clinician provided additional lip-reading cues and hand sig- toward lexical processes that are predicted to recover. 1994. Both improved their comprehension of cal phonologic recognition and semantic processing. Substitutive treatments incorpo- improvement was seen in auditory word-picture matching rate cognitive processes that remain intact and might be tasks as well as a nonword phoneme-discrimination task. tematic lexical assessment. After an additional 4 weeks of treatment. And nals (substitutive strategies) to embellish the phonemic finally.and written Treatments for Comprehension Impairments word-to-picture matching tasks in the context of semantic distractors administered via a computer. furniture. Turner. 1993. 1996). Substitutive Comprehension Treatments phoneme discrimination. restitutive or substitutive (Rothi. and matching associated written words. trained the patient on superordinate and specific semantic details about the three targeted categories and then had the Restitutive Comprehension Treatments patient perform visual and verbal matching tasks applying the Morris and colleagues (Morris. words rehearsed in training. the evidence to validate proposed models of lexical processing patient demonstrated significant improvements in a variety (Martin.GRBQ344-3513G-C23[607-631]. Subsequently. the clinicians added a phonologic attempted. After 4 weeks of treatment. recovery analyses may ultimately provide additional input. the ments may take a number of forms. involves activation of both lexi- nent to the training. Kohen. target those mechanisms. naming impairments in two patients with semantic dysfunc- tion. Seron & Deloche. and others which used a substitutive training paradigm to address the auditory comprehension and approach. approach in a number of lexical studies. They also rehearsed The process of word comprehension. auditory-word to picture and auditory-word to written-word matching and verification. of phonologic tasks. cognitive models are not the sole determinant of of lexical tasks requiring semantic processing: auditory word- decisions made in treatment for patients with aphasia and written word-to-picture matching in which they system- (Caramazza & Hillis. weigh a number of other medical. in which meaning is the spoken production of words. Substitutive treatments for auditory-comprehension impair- and nonsense CV syllable discrimination. Grayson. whereas substitutive treatments Behrmann and Lieberthal (1989) applied a semantic treat- would use alternative processes to accomplish word compre- ment in a patient with category-specific comprehension hension. and Saffell (2006) used a similar semantic a restorative approach. semantic impairment by having the patient execute a number Of course. some of which used Raymer. optimize success. the patient participated in a series of tasks engaging phone- mic processing. Following 6 weeks of twice-weekly treatment. patients com- input. Pound. to Improve Word Retrieval cessing spoken words when given lip-reading cues in four patients with impairments of phonologic recognition. meaning deafness. as phonologic dysfunction have demonstrated significant shown in Table 23–4. 2002).g.g. approach in the treatment of word-retrieval impairments in Edmundson. Nickels & Best.g.. TABLE 23–4 tional visual information during the course of phonologic processing (Ellis et al. rhyming comprehension. Marshall. initial-phoneme verification) Oral word reading from phonologic recognition to semantic processing. 1996). Morris et al. category. rhyming word. and Lindsay (2001). the patients also say the word Treatment for Naming Impairments during the performance of the comprehension tasks.g. largely limited to have incorporated alternative modes of output to either cir.. attribute.. fruits vs. Kiran & patients with aphasia. Other nonverbal strategies also may be helpful of semantic distractors (e. Francis and colleagues (2001) reported their treatment of Phonologic Treatments auditory-comprehension problems in a patient with word. however. auditory word or picture that lip-reading was less effective than teaching a spouse to matching. & Brassard. 1999. a variety of individuals with tive treatments incorporating various semantic and phono. In summary. The orthographic recognition system is another modality associates) for use in patients with phonologic processing impairments. 1991. lip-reading may be use. White-Thomson. “beans. 1996). presumably due to disruption of access syllable-number verification. in contrast.. a number of studies mally when training combined semantic comprehension .. Drew and Recognizing the common role the semantic system plays in Thompson (1999) showed that participants benefited maxi- both word comprehension and retrieval. Phonologic cueing hierarchy (e.qxd 1/21/08 1:26 PM Page 618 Aptara Inc. & and phonologic output stages of lexical processing. Thereby.. but the second treatment had more lasting effects. Gaudreau. having patients complete tasks that require some form of phonologic or semantic processing has the have implemented comprehension treatments in an attempt to potential to improve future processing abilities for spoken facilitate word retrieval. tomato... Boulay. Marshall. initial tive one in which the patient was presented all words only in phoneme. squash”).g. as improvements were less evident in control ken and written word-to-picture matching in the presence conditions.. presumably act- ing more directly to restore phonologic processing. words incorporated in training (Nickels. Following semantic a number of studies have examined the usefulness of restitu. & Scott. Both treatments incorrect phonemic cues) led to improved comprehension of trained words. repetition) written form. Substitutive treatments. reported Semantic comprehension tasks (e. improvement in word-retrieval abilities. “Does corn grow on a tree?”). distinguishing features intact semantic processing in the presence of phonologic between similar objects) processing impairments. word-retrieval impairments related to either semantic or logic tasks. It appears that these improvements relate to changes plete semantic processing tasks such as picture categoriza- in phonologic recognition and semantic stages of lexical tion with related categories (e. written word or picture matching. spo- processing. Over several sessions. At times. either independently or in combination. 1994). 2002.” distractors- to circumvent or support impaired comprehension abilities. Shindo. 1990. Semantic matrix training (e. word or picture matching and ful to support auditory comprehension in some patients with rehearsal of related sets of words) Semantic features descriptions (e. Davis & Pring. semantic comprehension tasks were performed with and without phonologic production of target words to deter- Restitutive Word-Retrieval Treatments mine what role the phonologic-production component played in the treatment (Drew & Thompson. a substitu..g. adding Researchers have reported many studies applying the CN a phonologic component to the treatment (Byng. Semantic and Phonologic Treatments Used Kaga. vegetables).. Word retrieval requires both semantic Thompson.. Pring. cumvent an impairment or to vicariatively encourage word Subsequent studies contrasted treatments in which retrieval through alternative means. and answering yes/no questions about semantic attributes of target words (e. Semantic Treatments Maneta. yes/no use communicative strategies to promote comprehension in verification) a patient with word deafness.g. 1990. function.g. 1983. target-“corn. 618 Section IV ■ Traditional Approaches to Language Intervention advocated the use of a lip-reading strategy to provide addi. Thus. comprehension treatments. They Word repetition compared outcomes of two different treatments.GRBQ344-3513G-C23[607-631]. Phonologic questions tasks (e. and a second one in which written words were Phonologic choice tasks (e. Le Semantic Treatments Dorze.g. Kay. Contextual priming (e. choose from correct and paired with spoken presentation of stimuli. and Tanaka (1991) demonstrated an advantage in pro.g. Capasso. Recent studies have examined features treatment was more effective than a traditional cue- effects for verb retrieval as well (Raymer & Ellsworth. If retrieval failure.g. 2006). & conversational measures (Boyle. participants demon- semantic dysfunction. Patients in both studies demon- improvement in the three participants with phonologically strated significant improvements in naming trained pictures based retrieval impairments than in the two with severe as well as generalization to untrained pictures and untrained semantic impairments. if necessary. ment among patients was not well characterized in these phonologically (e. 2006. and oral picture-naming. and thereby produce archy of initial phoneme.) to assist in retrieving semantic tion. Kohen. Raymer et al.qxd 1/21/08 1:26 PM Page 619 Aptara Inc. Boyle & Coelho. etc. strated improved naming of trained pictures as well as gen- A modified version of semantic comprehension treatment eralization of the strategy to some untrained pictures and is seen in studies of contextual priming (Martin. presumably to use a viewed matrix of printed cue words (e. shared phonologic output representation may be activated in tion (Martin et al. Amitrano. clinicians attempt to improve word retrieval tion to untrained verbs. After impairments stemmed from phonologic as compared to training with a semantic-feature matrix. ified semantic representations. animals). studies. 2001. Beeson. A potent in patients with semantically based naming dysfunc. patients are given a series of phonologic rehearsal treatment (incorporating repetition semantically loaded cues to elicit the target word. semantic treatment for her patient in which she provided One study used a word-retrieval training protocol in which semantic information about target pictures the patient was semantic comprehension tasks were administered via the unable to name. lexical tasks incorporating semantic processing (written- Earlier studies of semantic comprehension training tar. Participants view a set of several 1995). Ochipa. Capitalizing on this relationship. Renvall. ing hierarchy treatment in her patient.. phonologic. Conley & Coelho. 2003. patients ultimately Other studies have used treatment protocols presumably improved production of trained words. Both pro- retrieval in patients with aphasia. Sullivan. In another type of semantic treatment. Subjects who were repeatedly exposed to a hier- specific details of semantic knowledge. 2002. with little generaliza. 2002. & Caramazza. developed on the Webster. Clinicians teach subjects and sentence production using trained words. Following training. semantic distractors) along with spoken rehearsal of training and Raymer (1998) used a similar semantic treatment with words (Raymer. patients perform a cedures resulted in improved picture-naming for trained spoken description-to-picture matching task. oral reading. Across studies. or not at all. Improvements are less engaging lexical phonologic stages of word retrieval. 2005). Following a lexical assessment that semantic comprehension tasks alone. Morris. 1996).. The psycholinguistic basis for word-retrieval impair- pictures that are related either semantically (e. because of the important role verbs play in sentence genera. Rodriguez. Laine. a finding compatible indicated a word-retrieval impairment related to underspec- with the interactive nature of semantic and phonologic lexi. & Saffell. Miceli and colleagues had Wambaugh and colleagues (1999. Maher.. Hillis (1998) devised a cal processing mechanisms. but little improvement in the nouns and verbs in several patients whose word-retrieval formulation of complete sentences using the trained verbs.g.. & Szekeres. In SCT. Hillis also reported that this semantic- geted noun-retrieval abilities. 2005). and contrasted those features with the MossTalk computer program (word-picture matching with semantic features of a closely related object. Lowell. 2004. although Phonologic Treatments patients sometimes experience considerable interference from word to word during training. ending practice) in their patient with a selective verb-retrieval with repetition of the word. & Laine. and word-repetition cues . Improvements were basis of cognitive theories of how semantic representations evident in retrieval of trained verbs. properties. Some generalized improvements using semantic-feature matrix training (Haarbauer-Krupa. phonologic cueing hierarchy to assist patients in retrieving tar- Some patients with semantic dysfunction seem to lack get words. 2004. Fink. impairment arose from semantic. rhyme. were reported in measures of communicative effectiveness Smith. with greater from semantic dysfunction. 2007. however. are structured. function. Chapter 23 ■ Impairments of Word Comprehension and Production 619 tasks with phonologic rehearsal of target words compared to many semantic errors. and mixed Other studies have incorporated treatments using a semantic plus phonologic dysfunction. 2006). Martin and colleagues reported that.g. & Rothi. their subject demonstrated treatment was effective for improving retrieval of trained improvements in verb retrieval. word repetition. followed words in one subject with phonologically based word- immediately by attempts to name the target picture. Mitchum and Berndt (1994) used a similar unable to name the picture. Renvall. word production). Raymer. & Franklin. & Martin. words beginning with “r”).GRBQ344-3513G-C23[607-631]. Martin. 1995.. All participants their patient with word-retrieval impairment stemming improved their production of trained words. impairment. Gains were greater in patients whose verb-retrieval information about a target picture along with its name. Laine. category. 1985). & Holland. 2003) have their patient repeatedly read aloud or repeat target words examined effects of semantic cueing treatment (SCT) for word (Miceli. Fink. 2006. In another modification of semantic treatment. They then match spoken word to picture and repeat the name several times. 1994). treatment was effective Substitutive Word-Retrieval Treatments for subjects with either semantic or phonologic word- An alternative approach to rehabilitation of word-retrieval retrieval dysfunction..g. and retrieval in a manner compatible with the typical process Schnider (2006) used a computer-training protocol in which (Drew & Thompson. from failure to access lexical phonologic representations ments about words. Di Pietro. Among these studies. or to write have longer-lasting effects than phonologic treatments the letters and self-cue the spoken production of the words (Howard et al. Because repetition was used as a In summary. One observation is that there is little direct nale in their training study in which their patient practiced correlation between type of word-retrieval impairment writing target words. 1998). starting with initial phonemes and increasing pared the effects of multiple written cues versus only one cue to syllables and the full word if needed. 2005). Marshall. & Best. & Chiat.. the ini. & le Grand. & Fraansen. 1993. which perhaps before written self-cueing is useful to promote spoken naming promotes deeper processing of the linguistic stimuli (Nickels. the best restitutive treatments appear to be those effects were reported for spoken-naming. phonemic cues to produce target words. using print-to-sound conversion Participants demonstrated improvement in retrieving words processes. 2002). Nickels. produce were successfully taught either to type the letters Some studies that contrasted semantic and phonologic into a computer. In their Hickin and colleagues (2002) used a task in which phonologic treatment protocol. logic treatments is the need to make a choice. Patterson. Hickin and colleagues reasoned that (Bastiaanse. Studies that systematically examined the impact means to vicariatively mediate word retrieval using other on word retrieval of word repetition alone demonstrated cognitive mechanisms. Finally. hand-pointing to neck phonologic treatment seems to improve word retrieval in for “k” ). In these Some patients with word-retrieval impairments stemming studies. Jacobs. 2002. Franklin. (Hickin. 1985). and Waters (2003) used a similar ratio- trained words. although improvements were more impairments is to devise treatments that either circumvent limited in patients with semantic impairment (Raymer et the impaired lexical mechanism or develop an alternative al. such as the number of syllables. Significantly and showed that both techniques led to improvements in improved naming was evident in five of seven participants picture-naming (Hickin. 2002). or whether the words rhymed. the word’s spelling.. In turn.qxd 1/21/08 1:26 PM Page 620 Aptara Inc. lexical phonologic stages of processing incorporated yes/no questions about the phonologic characteristics of target words Orthographic Mechanisms (Howard. Some treatment studies have evaluated the Another treatment paradigm that presumably focuses on effects of methods to vicariatively activate word retrieval. DeDe. need to be trained in print-to-sound conversion. Robson. 1998. For example. Patients participants practiced written spellings of words. 620 Section IV ■ Traditional Approaches to Language Intervention demonstrated improvements in word retrieval for trained response to treatments than those with phonologic retrieval words (Greenwald et al. it may be possible to self-cue and generate the trained with this strategy. Patients with some of the process to naming of untrained pictures (Robson retained spelling knowledge for words they were unable to et al. 1993). and individuals with either semantic or phonologic impairments. In addition. Some patients may the difference in semantic treatments compared to phono. which may be a that combine semantic and phonologic information during result of changes in orthographic or phonologic stages of the course of training. When with severe semantic dysfunction often show a more limited spelling errors occurred. 1992). Herbert. the participant was provided with . Grassly. Raymer. & Ellsworth..GRBQ344-3513G-C23[607-631]. given a choice of written cues from one (semantic or phonologic) and the most effective type of letter to several letters as necessary. therefore. Positive treatment In fact. Hillis. 1987). corresponding to the word’s initial letter. 1993. patients completed tasks in which they made judg. Bosje. Pring. Parris.. it is likely that this training engaged that different types of restitutive semantic and phonologic both orthographic and phonologic stages of lexical process- treatments are effective in improving word retrieval for ing. nevertheless may be able to access some knowledge about tial phoneme of words. 2002). Greenwood. the findings of a number of studies indicate final step in training. trained. 1993).. & Morton. Laganaro. Thompson. the use of semantic cir- improvements that were not as potent or lasting as when cumlocution to describe a concept when a word-retrieval repetition was paired with other phonologic or semantic failure occurs would be a substitutive semantic strategy to processing tasks. however. Howard.. In a subsequent study they com- phonemic cues. Best. Herbert. & Osborne. 1996). 1999. Howard. the patient treatment (Hillis. Raymer bases of impairment (Nickels. however (Greenwald et al. with some showing generalization appropriate spoken form of the word. 1998). lexical retrieval. Orchard-Lisle. which in turn generated the initial training protocols seem to indicate that semantic treatments phoneme of the word (Bruce & Howard. Either semantic or rehearsed the use of tactile cues (e. 1995. to encourage the process of word lexical processing. 2002). 1985. 1995. participants patients chose between two written-letter cues to promote attempted to name target words when given a choice of two production of target words. Le Dorze et al. Raymer circumvent failure at the subsequent stage of phonologic & Ellsworth. . For example. effective for improving performance in individuals with anisms through pantomime. in particular. leagues (Raymer et al. should verbal processes not improve effective for naming recovery (Hillis. as compared to noun retrieval. Cognitive models of lexical and impairments of either lexical comprehension or production. 1991). use of phonologic-orthographic cues in improving word semantic plus phonologic processing within one treatment retrieval in one individual with phonologic-retrieval dysfunc. A number of single. often perform a reverse translation and figure out the word One problem with earlier gesture studies is that the the patient was attempting to say.. whereas patients may present with impairments that ship between gesture and language processing.GRBQ344-3513G-C23[607-631]. with no difference between impaired word retrieval. have used oral-reading treat. 1997). the studies by Raymer and col- Similarly. Raymer and col- ments to promote spoken-naming abilities. Douglas. & Matyas. To circumvent this awk. ments (Hillis. Thompson. Three other participants with semantic GENERALIZATION impairments did not improve spoken verb-naming abilities The CN approach has specific implications for analyzing during either treatment. Although simple retrieval in individuals with aphasia (Pashek. Gesture Summary of Treatment Research An alternative method that researchers have applied to medi. even when word spoken-naming of the same words. Kiran.. Arbib (2005) has argued for a close relation. Improvements in word retrieval words using regularized pronunciations (e. 2006. unrecognizable. 1997. the most effective treatments were those that showed that treatment with iconic gestures was as effective as engaged either semantic. 1993). retrieval does not improve. One participant described by Nonetheless. “kwire” for “choir”). treatments that attempted to facilitate the tion. integrity of the action mechanisms (limb apraxia) was often ward strategy. and Hashimoto (2001) demon. that. following gestural training.qxd 1/21/08 1:26 PM Page 621 Aptara Inc. there is no direct relationship between type of modality. focuses on phonologic output. in contrast. 1995). Studies have demonstrated that restitutive treatments are ate word retrieval is the use of the gestural-processing mech. Some patients with training. participant studies have demonstrated that gestural training recovery of word-retrieval functions is more limited in paired with spoken production of words improved word patients with severe semantic dysfunction. A desirable consequence of gestural facilitation with impairment and type of treatment that seems to be most pantomimes is that. . Improvements in oral as a viable communication mode. implicate either semantic or phonologic stages of lexical pro- ture particularly appropriate for use as a language-treatment cessing. Rothi et al.. the patient may increase the use of gesture as with semantic impairments benefit from treatment that an alternative communication mode. Raymer. Patients larized spellings of common words with exceptional with severe limb apraxia may not be able to use pantomime spellings (e. Hillis (1998) leagues (2006) reported that gestural training led to described a remarkable patient who spontaneously used improved word retrieval for both nouns and verbs in five of retained print-to-sound conversion abilities to support her nine participants in the study. participants never engaged in verb and gesture knowledge. gestural training was as effective as semantic-phonologic training in one individual with phonologic-retrieval impair- ment for verbs. protocol. not well documented in the subjects with aphasia. making ges. & Heilman. constraining the train. suggesting that ges- said the words aloud during training. Apparently. as their gestures are often reading also were evident in oral naming of the same words. although two demonstrated dramatic the generalization of treatment effects for lexical impair- increases in the use of gestures corresponding to verbs. tural treatment may be especially effective for verb retrieval ing paradigm largely to the orthographic modality. In a larger study. phonologic. That is. One observation noted across treatment studies is lexical retrieval. Pashek (1998) improved retrieval of both nouns and verbs naming of words they had practiced spelling. 2002. and vice versa. Hillis taught her patient to read aloud regu. can benefit word comprehension and retrieval in some suggesting that gesture may be useful to mediate activation of patients. Rothi. Chapter 23 ■ Impairments of Word Comprehension and Production 621 more and more information about the spelling until the Druks (2001) noted a close relationship between networks word was correctly spelled. for verbs than for nouns. 2006) showed strated in their patients with phonologic dysfunction that that patients with severe limb apraxia can improve their abil- practice in oral reading of words led to improvements in ity to produce recognizable gestures. Rodriguez et al. 1993. their participants improved markedly in spoken. Rose and colleagues (2002) retrieval. Raymer & rehearsal of spoken words can help a person improve word Thompson. praxis processing recognize the interactive nature of the two Other studies have shown that substitutive treatments also systems (Rose. Listeners ments and mild to moderate semantic impairments than in who were familiar with her maladaptive technique could those with severe semantic impairments. Rodriguez and colleagues (2006) reported that multistage process of word retrieval were often most effective. Similarly. though improvement was greater Some studies. In general. However. and. “/brid/” for were greater in individuals with phonologic-retrieval impair- “bread”) when a word-retrieval failure occurred..g. This patient often mispronounced noun and verb outcomes.g. If the patient learns this strategy or upon semantic or phonologic mechanisms presumably improves functioning in this process. and less likely in written-naming and com. comprehen. then all items sharing well.and written-naming. semantically related words (Martin et al. Raymer and colleagues (1993) used a that can account for generalization to semantically related phonologic cueing hierarchy to train oral picture-naming. Ochipa and colleagues (1998) ture matrix training also demonstrated some improvements reported improvement in written-naming following semantic. The clini- require processing by that mechanism. improvements should be evident in all tasks that from spontaneous recovery (Raymer et al. 1998. For example.qxd 1/21/08 1:26 PM Page 622 Aptara Inc. It may be this type of effect dicted.. benefits learned to self-generate semantic information whenever a of phonologic treatments should be evident in oral-naming word-retrieval failure occurred.g. Therefore. semantic or phonologic features. use this process or strategy to improve performance for a set retrieval treatment on other untrained lexical tasks that draw of trained stimuli. Boyle and Coelho Although semantic treatment focused solely on written. generalization There are times. and observed generalized improvements in oral word-read. Ochipa et al. In ization of category-specific semantic-comprehension contrast. as predicted. which cannot be completely explained tion that are contrary to the predicted patterns suggest that on the basis of restoration of semantic features. thereby leading to activa- and oral-reading. trained or tion across untreated lexical tasks following her semantic. but not in written-naming. Similarly. leading to improvements in written-naming as well. when treatment effects may be evident in predictable ways to items that share observed in additional lexical tasks extend beyond those pre. Hillis (1998) examined generaliza. the results of the CN assessment may assist the more typical exemplars of a category in that they have the clinical researcher in selection of tasks to demonstrate that characteristic features common to that category (e. etables) and compared the effects when trained words were Finally.” Generalization to Untrained Stimuli Generalization to untrained stimuli may occur in two ways..” Second. for example. her patient improved pronunciation of word-retrieval training somehow restores features of repre- the same words in picture-naming and word repetition as sentations to a more optimal state. 2004) and Lowell and colleagues (1995) naming. Greenwald and colleagues (1995) reported treatment to naming of untrained items within trained and improvements in oral picture-naming following visual. If exceptional spellings. veg- treatment in important. and possibly oral-reading and writing to dictation.. word and ultimately word retrieval. but as yet unspecified. items found after semantic-feature training (Hillis. Behrmann and Lieberthal (1989) evaluated general- ened. Hereafter. These patterns of generaliza. They observed generalization to semantic training. 1998) and after contextual priming with ing as well as written picture-naming in one patient. retrieval training effects that target specific semantic cate- semantic aspects of processing also may have been strength. Generalization across Tasks Some treatments affect a lexical process. 622 Section IV ■ Traditional Approaches to Language Intervention First. ways. Kiran and the complexity of the lexical mechanisms and the types of Thompson (2002d) provided word-retrieval training for processing that occur among mechanisms also influence subsets of words within a semantic category (e. Although one might expect that the phonologic training Some studies have evaluated generalization of word- largely impacted on phonologic stages of word retrieval. (1995. improvements were also evident in all other lexical reported that their patients who responded to semantic-fea- tasks. treatments should be evident in all tasks involving semantic in which clinicians train patients to use a matrix of cue words activation. birds. tion of lexical responses for untrained words as well. well. including oral. but no improvement in a visual picture. and probe performance over time. untrained category. untrained items within one trained category. performance should be impacted by treatment. affected when applying that process for all stimuli. this type cian can identify other independent areas of cognitive/lin- of generalization will be referred to as “generalization across guistic impairment that should not be affected by treatment tasks. An example of such a process that may affect features treatment for word retrieval. 2004). to encourage the recall of semantic information for a target sion. untrained. Benefits of semantic word-retrieval abilities is semantic-feature matrix training. if treatment facilitates processing in a particular lexical the effects of treatment indeed result from treatment and not mechanism. robin. untrained categories. however. It may be that the patients features treatment targeting oral-naming. But they also noted improved naming in one improve following training. 1995). other semantically or phonologically related strates internal validity when treatment improves perfor- lexical representations may benefit from the treatment as mance in the targeted task but not in the untreated task.GRBQ344-3513G-C23[607-631]. . teaching patients to A number of studies have examined the effects of word. gories.g. prehension. So. Likewise. This type of generalization will be referred to as “gen- eralization to untrained stimuli. as might be associate matching task that they predicted would also predicted. in naming untrained pictures. The clinician demon- resentations.. as treatment strengthens targeted lexical rep. when Hillis (1998) trained her A second way in which generalization to untrained stim- patient to pronounce regularized spellings of words with uli might occur is at the level of lexical representations.. Boyle. those features should be affected. Clinicians may be one type of treatment. follow when attempting restorative treatments with patients tion from training with atypical category exemplars. the basis of lexical theories definitely encourage progress in dict generalization to untrained items. the CN approach has some recognized short- comings. how to treat the impair- LIMITATIONS OF THE COGNITIVE ment. They observed no clear patterns of response gener. beneficial treatments. as the clinician may capitalize upon those retained abil- that differ from other exemplars in the category (e. 2006) to add to the may prove helpful for clinicians to characterize impairments body of knowledge of what clinicians know are the most accurately. condensed format to accumulate the information necessary Much of the treatment literature has reported the effects of to make informed treatment decisions. the effects of a phonologic cueing hierarchy to items that Some clinicians have argued that the CN approach.. research certainly has suggested a more favorable course to tion may benefit more than those with phonologic dysfunc. impairments in the lexical system (e. versus atypical exemplars that have unique features ties. But the considerable body of ing with typical exemplars. do not support this notion. ities to devise appropriate substitutive treatments for lexical cock. consequences for overcoming the disabling conditions alization among the patients.GRBQ344-3513G-C23[607-631]. what. Pring et al. It crossover designs (e. Raymer and Although the lexical mechanisms are distinct and distributed. For example. has few pictures. Treatments that encourage activation of multi- More often than not. pea. Because earlier treatment showing more positive generalization to untrained items studies often neglected to report the functional aftermath of typically incorporated semantic treatments. For example. 23-1) in the course tasks seem to be item-specific. and how to treat. Hillis (1998) used a substantial impact that impairment-oriented treatments cueing hierarchy to train her patient to retrieve the names of have for patients and their families. For example.. disturbed oral-naming in the pres- than when training typical exemplars in four patients with ence of preserved oral word-reading skills seemed to be pre- semantically based anomia.g. Stanczak. the findings to date more global influence on semantic networks than does train. in-depth assessment of lexical abilities advocated in this approach proves tremendously FUTURE TRENDS difficult to accomplish in many clinical settings. to identify retained lexical abili. A number of additional neurologic. A review of the limitations of the CN approach to lexical clinicians may find it possible to use this approach in a more treatment suggests a number of areas for future research. In keeping with computational simulations impairments. and limited improvements of one treatment protocol appear to be most effective.. it does not help determine what specific strat- egy will be most effective—that is. semantic treatments They proposed that training with atypical exemplars has a for semantic impairments. It is interesting that studies posed by aphasia (Wilson. Future studies need to implement . Kiran and Thompson found that training with of impairments may eventually allow clinicians to develop atypical exemplars led to greater generalized improvements better prognoses for impairments they observe in their when naming untrained typical exemplars of the category patients. However. training for one patient with a semantic plus phonologic Although one of the initial goals of the CN approach was dysfunction. 1996). this argument may have some merit. in addition.qxd 1/21/08 1:26 PM Page 623 Aptara Inc.. Furthermore. it would be sensible functional communication in a variety of patients. were either semantically or phonologically related to trained which emphasizes impairment-oriented treatments. with aphasia. NEUROPSYCHOLOGICAL APPROACH As researchers accrue a greater body of knowledge about While this discussion has focused largely on the positive treatment effects across patients. olive). are evident for untrained words. Waters. observations of overall patterns (Plaut.g. 1993). Because there is no indisputable reason to pre. However.. 1993. Recent to select treatment words that respect the functional needs studies have attempted to improve methods to document the of each individual patient. cognitive.. Hillis (1993) noted that although an assessment may help ric store. tion process. 1999). Chapter 23 ■ Impairments of Word Comprehension and Production 623 carrot). but the pattern of generalization was not seen to identify more rational treatments that target identified in a second patient with a phonologic naming dysfunction. colleagues (1993) systematically assessed generalization of they are highly interactive in the course of lexical processing. Rodriguez et al. Patients with semantic dysfunc.. but. not lexical treatments. The systematic. 1990). all semantic treatments led to response generalization (Pring Substitutive treatments that researchers have generated on et al. improvements in trained lexical ple stages in the lexical process (see Fig. making predictions about who. Some recent studies have implemented attempt to characterize lexical abilities more specifically. different types of fabrics after the patient took a job at a fab. so that clinicians are unable to judge able to complete a series of lexical tasks with a circumscribed whether that treatment was as effective as other possible set of materials in the course of diagnostic treatment in an treatment options. and Caplan dictive of best response to word-retrieval treatments (2006) replicated the typicality findings in word-retrieval (Raymer et al.g. and social factors also must play a role in the treatment decision. clinicians may be better at ramifications of the CN approach for the clinical rehabilita. and so forth). the clinician to characterize the nature of the patient’s impairment. patients with optic aphasia? specific and output mode-specific mechanisms that 5. Epstein (Eds. although there are spectives in dysphasia (pp. What are three different tasks a patient may practice to about the CN approach. Substitutive treatments capitalize on retained aspects ing generalization effects to untrained tasks? of lexical processing to either circumvent an impair- ment at some stage in lexical processing or to vicaria- tively mediate activation of the impaired mechanism. Less research has been focused on the functional out- ment has received much criticism and skepticism. and may serve to confirm hypotheses generated on 9. A dysfunction of the phonologic-recognition mecha- nism will result in a pattern of impairment in which KEY POINTS lexical tasks and preserved performance for what other lexical tasks? 1. A. 2003). of lexical information. there is not a direct corre.qxd 1/21/08 1:26 PM Page 624 Aptara Inc. D. and others that focus on phonologic aspects with phonologic recognition impairment. 11. 2. 7. Howard. The presence of semantic errors in naming may repre- tatively and qualitatively. Patterns of performance. Therefore. However. How can the graphemic system be used in a substitu- multiple stages of the lexical process seem most tive strategy for word-retrieval impairments? beneficial. 8. 624 Section IV ■ Traditional Approaches to Language Intervention prospective randomized trials to solidify the evidence-base for treatments founded on the cognitive neuropsychological indications that semantic treatments incite greater approach. and lexical phonologic output? 3. Restitutive treatments target impaired lexical mecha. generalization to untrained semantically related words. comes of these impairment-oriented treatments. The lexical system is a complex. (1985). Hickin. Distributed memory. Continued research in each of these areas will 1. lexical semantics. encourage restoration of functioning in the lexical- spondence between types of impairments and most phonologic output stage of word retrieval? effective treatments. which patients will recover and in which direction. What is the pattern of lexical performance seen in modules that store information in sensory modality. 7. 10. Recovery analyses may assist clinicians in predicting processing in each of the following: object recognition. What is the purpose of mode/modality comparisons in 3. lexical semantics. 6. . & Osborne. Allport. distributed system of 4. Edinburgh: Churchill Livingstone. Assessment focuses on mode/modality comparisons the cognitive neuropsychological assessment? across lexical tasks. What is a category-specific impairment? For what interact by way of a semantic system. Why are semantic comprehension tasks useful as a tory comprehension and word retrieval in a variety restitutive treatment for word-retrieval impairments? of patients.). Best. semantic categories might we observe category-spe- 2. 8. quanti. Describe one stage-specific assessment task to target 4. What is the difference between lexical phonologic recog- nition. have induced changes in audi. Generalization of treatment effects is observed across References all tasks for which the mechanism facilitated by treat- ment plays a necessary role in accurate performance. Current per- stimuli has been more limited. modular subsystems Generalization of treatment effects to untrained and dysphasia. Also. Treatments that are putatively semantic in may be useful to improve functioning in an individual nature. imaging studies are beginning to document ACTIVITIES FOR REFLECTION AND DISCUSSION the neural changes associated with successful behavioral treatments. help the clinician develop sent dysfunction at which three stages of lexical pro- an informed hypothesis about the nature of lexical cessing? impairments. future studies must incorporate methods to evaluate the functional consequences of treatments for daily communica- tion situations (Herbert. contrary to early predictions 12. Lexical impairments take many forms depending on cific impairments? which component of the lexical system is affected. How are analyses of lexical recovery useful in clinical initial assessment. Newman & R. Finally. In S. 32–60). the impairment-oriented approach to aphasia treat. Treatments that incorporate 13. What is modality-specificity as it relates to the model advance the effectiveness and efficiency of clinical practice of lexical processing? for our patients with aphasia. practice? 5. and lexical phonologic output. 14. How do models of lexical processing assist in predict- 6.GRBQ344-3513G-C23[607-631]. Describe restitutive and substitutive treatments that nisms. Damasio. D. C. J. Disorders of Communication.. C. R. Preserved object recogni- Bruce. 17. (1993).. Aphasiology. related to age of acquisition of the object names. tactic and phonological knowledge in lexical access: evidence ment of a lexical-semantic deficit: A single case study of global from the ‘tip-of-the-tongue’ phenomenon. E. Boyle. & Miozzo. H. (1991). & Perez. A. processing and disorders. & Lieberthal. 94–98. tics. Lexical organization of human language: An evolutionary framework for neurolinguis. S. Priming and 38.. 13. New York: Psychology Press. L. Trost-Cardmone. 19. (1992). A.. D. Boatman. & Laiacona. 90. 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Assessment of naming failures in neurologi. W. M. A. G. Riddoch. (1994). (1983). R. Wambaugh. Two categorical stages of object Cortex. C. A. The Philadelphia Naming Test: Scoring and rationale. Rothi. G. tiveness of gesture and verbal treatments for a specific phono.). (1999). M. Effects of therapy jargonaphasia: An unusual dissociation in speech output. 174–215. Visual object pro. 423–443). Brain and Language. N. D. & Caramazza... K. (1995).. Rothi & K. Riddoch & G. & McCarthy. & Shallice. S. Farah (Eds.. A.). Jacobs. F. Clinics in Communication Disorders. J. W. Waters. 466–450. J. 24. Philadelphia: Psychology Press. 286–297. East Sussex. Philosophical Transactions of semantic disorders: Evidence from a new case.).. 219–230). anomia treatment. 1–15). Chiavari. T.). (2003). Aphasia and related neurogenic Development. Mahwah. Linebaugh. A.). recognition. Rodriguez. R. C. 55. & Psychiatry. J. & Caramazza. The comparative effec. 1273–1296. J.). Farina.. 748–764. naming therapy in jargon aphasia: Positive but paradoxical Stanczak. New York: McGraw-Hill.. & Rothi. psychological deficits and declines: Managing losses and promoting Wambaugh. (2001). APPENDIX 23. B. Annals of Neurology. Brain and Language. 5. Huber.. Grammatical class and con- D. & Berndt. R. C.1 Stimuli from the Florida Semantics Battery* Key: HF  40 highest frequency words. Zingeser. verbs in agrammatism and anomia. MF  40 middle frequency words. 473–516.. B. 723–732. Isensee. B. (1988). range 0–8. Rijntjes. C. M. (1990). range 26–242. R. W. Muller. 14–32.. L. S. S. New York: Oxford University Press.. Body Parts Frequency Transportation Frequency Vegetables Frequency Fruits Frequency ankle 15 MF airplane 21 MF broccoli 1 LF apple 15 MF elbow 17 MF jeep 16 MF celery 4 LF cherry 6 LF wrist 16 MF van 22 MF lettuce 1 LF lemon 4 LF ear 67 HF bus 42 HF peas 24 MF peach 4 LF nose 65 HF truck 80 HF potato 30 HF pineapple 9 MF chin 25 MF canoe 8 LF carrot 5 LF banana 4 LF thumb 14 MF sailboat 4 LF corn 38 HF grapes 10 MF arm 217 HF boat 123 HF onion 19 MF orange 15 MF leg 126 HF train 86 HF pepper 13 MF pear 8 LF teeth 102 HF wagon 72 HF pumpkin 2 LF raisin 1 LF Kitchen Utensils Frequency Clothing Frequency Animals Frequency Personal Items Frequency fork 20 MF mitten 2 LF deer 13 MF brush 36 HF pan 16 MF robe 10 MF mouse 20 MF mirror 27 MF spoon 6 LF sweater 18 MF turtle 9 MF razor 15 MF cup 58 HF dress 63 HF cow 46 HF toothbrush 6 LF knife 86 HF shoe 58 HF fish 281 HF towel 17 MF jar 19 MF pants 9 MF frog 2 LF comb 6 LF skillet 2 LF scarf 4 LF pig 14 MF perfume 11 MF bottle 90 LF coat 52 HF cat 42 HF soap 25 MF glass 128 HF hat 71 HF dog 147 HF toothpaste 2 LF plate 44 HF suit 64 HF horse 203 HF tissue 54 H .. 39. LF  40 lowest frequency words. Bier. Cognitive Neuropsychology. Zingeser. et al. & Berndt. (1999). language production. 630 Section IV ■ Traditional Approaches to Language Intervention Weiller. S. Recovery from Wernicke’s aphasia: A text effects in a case of pure anomia: Implications for models of positron emission tomographic study. L. (1995). A..qxd 1/21/08 1:26 PM Page 630 Aptara Inc. Retrieval of nouns and Wilson.GRBQ344-3513G-C23[607-631]. 37. Case studies in neuropsychological rehabilitation.. range 9–25.. G. M. and actions. Maher. objects. processing spoken input. cessing. objects. Lexical Phonologic Recognition—Mechanism of representa. (1982). M. as a result of brain damage. Semantic System—The lexical mechanism responsible for stor- sentations for familiar spoken words that have previously been ing meaning representations for familiar words. W. Lexical Decision—Task in which the patient decides whether a Restitutive Treatments—Strategies that encourage restoration of given stimulus is a familiar real word or object. Lexical Phonologic Output Processing—Mechanism of repre. (1990).) (From Raymer. lus is distinguished and found to be familiar and previously expe- with preserved performance for other categories. rienced.2 Glossary Category-Specific Semantic Impairments—Disturbances in Recognition—The point in stimulus-processing at which a stimu- comprehension or production for selective semantic categories. Frequency analysis of English usage: Lexicon and grammar. ognize a viewed stimulus that is not due to a peripheral sensory Optic Aphasia—Visual modality-specific impairment in naming visual disorder.. N. M. Visual Object Representation—The mechanism storing memo- cated through circumlocutions or gestures associated with the ries for familiar objects that have previously been seen.GRBQ344-3513G-C23[607-631]. J. The Florida Semantics Battery. & Kucera. Greenwald.. Word-Meaning Deafness—Impairment in the ability to apply Pure Word Deafness—Auditory modality–specific impairment in meaning to heard words despite intact phonologic processing. A. or a nonsense functioning in a manner compatible with normal language pro- word or object. L. L. distributed set of mechanisms storing and cognitive processes. actions. viewed objects in the presence of basic semantic processing indi. unnamed object. as well as Visual Agnosia—The failure. K. Rothi. Morris. Boston: Houghton Mifflin... M.. representations for familiar words.) APPENDIX 23. to rec- processes for decoding and encoding unfamiliar stimuli. Unpublished. Substitutive Treatments—Strategies that attempt to circumvent tions for familiar spoken words that have previously been heard. L. M. . and produced.qxd 1/21/08 1:26 PM Page 631 Aptara Inc.. H. † Frequencies based on Francis. a dysfunctional language mechanism using other intact language Lexical System—Complex. Chapter 23 ■ Impairments of Word Comprehension and Production 631 Musical Furniture Frequency Office Items Frequency Tools Frequency Instruments Frequency crib 8 LF book 100 HF axe 19 MF accordian 1 LF shelf 20 MF newspaper 43 HF hammer 6 LF drum 20 MF stool 8 LF phone 46 HF pliers 1 LF guitar 10 MF bench 42 HF scissors 1 LF saw 8 LF harp 1 LF desk 69 HF tape 39 HF shovel 8 LF trumpet 5 LF hammock 5 LF clip 6 LF clamp 2 LF bell 17 MF sofa 9 MF pen 13 MF hoe 1 LF flute 3 LF bed 139 HF ruler 13 MF rake 8 LF harmonica 0 LF chair 89 HF stamp 8 LF screwdriver 1 LF piano 32 HF table 242 HF pencil 38 HF wrench 1 LF violin 9M *Includes 120 nouns from 12 different semantic categories. & Heilman. Chapter 24 Comprehension and Production of Sentences Charlotte C. with agramma- tism characterized primarily by omission of these elements In this chapter we illustrate how cognitive neuropsychology and paragrammatism by their misuse (Goodglass. In some cases. The difference between these manifestations of grammatical disturbance has been widely described as involving distinct problems with gram- OBJECTIVES matical morphemes (both bound and free). 1989.GRBQ344-3513G-C24[632-653]. Mitchum and which typically occurs in the context of nonfluent (especially Broca’s) aphasia. Berndt. grammatical disturbances are primarily structural in nature. it is important interpreted primarily as grammatical disturbances. . . considerable overlap exists in the of symptoms associated with aphasic sentence processing. This approach differs from between a typical Broca’s pattern and the type of disordered traditional assessment measures that classify subtypes of sentences often produced by more fluent speakers (pauses  aphasia. with rela- tively preserved use of grammatical morphology but an inability to produce a normally structured and elaborated SENTENCE-LEVEL DEFICITS IN APHASIA sentence (Saffran. cleaning the house and serving the (2s) meals and rich Using a model of normal sentence processing is somewhat man (3s) well the prince is (2s) going to (4s) east (2s) feast hampered by the lack of a complete understanding of all the details involved in sentence production and comprehension. or to obtain a general measure of rela- Cinderella (4s) poor and (4s) poor meaning not to be (3s) fire tive severity. . but the mechanisms of change and they have all they have all the sisters was old .g. 1987). sentence processing. Rather. samples from patients demonstrating both of these patterns ment of sentence-processing disorders. Pattern Associated with Broca’s Aphasia Wernicke’s aphasia).qxd 1/21/08 1:32 PM Page 632 Aptara Inc. 2001). Analyses of such speech and has inspired new and effective approaches to the treat. Pattern Associated with (Mild) Wernicke’s Aphasia There is no theoretic model that can fully account for normal the Cinderella was his his father and his father but he’s . Interest in aphasic symptoms that are specific to sentences & Lhermitte. little bit angry and everything . . Pick. Tissot. 1956). nor can a model account for the myriad passed away so she’s his his mother-in-law was the really of problems observed in aphasic language (Berndt. . 1973). . these symptoms have been been offered (see Berndt. 1947. and “paragrammatism. The following speech samples illustrate the differences processing disorders in aphasia. An to note that impaired use of grammatical morphology is important contrast is the one between “agrammatism.” which occurs in Rita Sloan Berndt sentences produced by more fluent speakers (especially those with Wernicke’s aphasia). reveal omission and substitution of grammatical morphemes (Butterworth & Howard. we illustrate how reference to a theoretic framework Although these types of speech patterns sound markedly has provided a valuable mechanism for sorting out the array different to the listener. it does not seek to establish a clinical label based on 1 sec are noted): measures of contrasting symptoms (e. types of errors that can be noted. & Schwartz. she also had the sisters-in-law two sisters be restored or bypassed. Mounin. 1998 for review). 1993). has been applied to assessment and intervention of sentence. Although many different accounts of has a long history in neurology (Luria. Broca’s aphasia vs. with the goal being to identify man and (3s) well that after (6s) slim chance (3s) me and how brain damage has altered normal functions. . 1913) and grammatical morpheme omissions in agrammatism have linguistics (Jacobson.. None. and the Cinderella in Treatment can be guided by hypotheses about what needs to the cellar . nose established with therapy remain poorly understood. specific symptoms are contrasted with and all thing but (2s) stepsister two (4s) rich (2s) powerful normal sentence processing. .” only one of many structural impairments observed in the 632 . and teeth and awful theless. sen- definition) demonstrate good comprehension on clinical tence-picture matching tasks present a spoken sentence with testing. a set of studies in the late 1970s showed two pictures showing a pair of actors performing the same that agrammatic patients often failed to understand sen. For example. 1980). 1976. or on heuristics based on word order. since patients with Broca’s aphasia (by using non-syntactic cues to meaning. only in tests that systematically eliminated the possibility of sive” impairment. Chapter 24 ■ Comprehension and Production of Sentences 633 Series “L” Series “S” (can be understood based on (requires interpretation lexical meaning) of sentence structure) Target Target Foil Foil Figure 24–1. As shown in Figure 24–1. but with the noun roles reversed.GRBQ344-3513G-C24[632-653]. These possible to identify the depiction of “the girl kicking the studies revealed a pattern of impaired comprehension asso. aphasia. Other items in the tences correctly when the stimuli were constructed to test assure that patients’ understanding of the individual require interpretation of grammatical features (Caramazza words in the sentence is intact.qxd 1/21/08 1:33 PM Page 633 Aptara Inc. Saffran. rather not always co-occur and are not unique to Broca’s-type than on sentence structure. of sentences was frequently based on semantic cues such as ognized that symptoms associated with agrammatism do noun animacy. “the girl kicking the ball”) simply by knowing the ciated with Broca’s aphasia that suggested that interpretation difference between the meaning of the words “boy” and . it is & Zurif. action. This type of sentence-comprehension disorder emerged Agrammatism was long believed to be a uniquely “expres. & Marin. sentences of speakers with aphasia. However. boy” (vs. It is also now widely rec. Schwartz. Examples of Stimuli Used to Assess Comprehension of Sentences Based on Lexical (“L”) or Structural (“S”) Cues to Meaning. Normal speakers produce and comprehend sentences with order strategy. which mostly spared con. In the pair of pictures on the right. 1996). series of distinct sets of representations that transform ideas Current approaches to the study of sentence production and into speech. upon several sources of data in an attempt to describe the prehension disorders (see Berndt. 1991. little apparent effort. & Haendiges. dence from cognitive neuropsychological studies. very useful for the speech-language clinician interested in ture. the grammatical cues to the sentence meaning—word order. “the boy is kicked by the girl”). creation of an intended message to its ultimate articulation. 1980). Operations necessary for sentence production range from the quently had difficulty interpreting structural cues to mean..” That is. at the very least. and in light of evi- speakers with aphasia to produce a passive sentences (e.g. ment. within the context Figure 24–1 (top) with the word “boy. To utter or understand even a single stimulus sentences. there is strong evidence The production model proposed by Garrett (1975.” results of psycholinguistic experiments. how do we con- Although some researchers who still maintain some ele. For selected thoughts. many thoughts never become phonologically agrammatism were generally believed to include the follow. how these events are coordinated. the integration of the both the active and passive versions of the sentence if they products of lexical retrieval. comprehension in aphasia do not assume that these symp- ing may give the impression that the sentence has been fully toms will always occur together. cal (closed-class) structure. including analyses of normal 1996 for review). For example. that sentences evolve through a series of fairly independent fered from a “central” syntactic deficit affecting all elements stages.e. the syntactic structure—must be interpreted in order to identify which of the two nouns is NORMAL SENTENCE PROCESSING doing the kicking. the action (Caramazza & Berndt. Rather. 2006. That is. Thoughts form a rough. yet the cognitive operations that sup- tence are presented with pictures showing the correct depic. Patients cannot perform correctly on sentence requires. it would seem likely Broca’s aphasia because it suggested that such patients suf. encoded. syntactic formulation. to the sentence-processing pattern observed in individual preted using the meaning of individual words because “boy. and (4) poor comprehension of semantically tener. phono- assume that the first noun mentioned is the agent of the logic encoding. and articulation. that contains both lexical (open-class) content and grammati- (2) “open class” word production. Exactly how the interplay of action. especially the convert the unspecified message into an ordered utterance omission of free and bound grammatical morphemes. 1985). the same often seeks to explain how a particular symptom contributes target sentence “the girl is kicking the boy” cannot be inter. (3) simplified syntactic complexity and reduced using an articulatory code common to both speaker and lis- phrase length. A typical error is to produce a sentence in the active voice and thus violate the sentence’s Sentence Production meaning (e. To test for a “first noun is agent” word. these components normally yields a final product is not well Variants of these “semantically reversible” sentences have understood. However. 1998. recent work more comprehended. Figure 24–2 is a schematic of normal sentence . 1982. we will identify subcomponents of forced to start a sentence to describe the picture shown in sentence production and comprehension. Although thoughts may be candidates for verbal of inseparable symptoms associated with the halting. tasks designed to test “slips of the tongue.” it is difficult for some of what we know about normal language. The utterance is made known crete nouns. tele.. active and passive versions of the same sen. “the boy is kicking the girl”). This is observed when patients are “constrained” to understanding how aphasic language deviates from language begin their response with the noun that is not the agent of that is unimpaired (Hillis.GRBQ344-3513G-C24[632-653]. go wrong in aphasic sentence production? tactic processing (Grodzinsky. 2000). Martin. expression. an interpretation based on single-word mean. port the creation and interpretation of sentences must be tion and a reversal of the thematic roles stated in the remarkably complex. inner structure of language. i. if In the sections to follow. for the ments of this “syntactic deficit hypothesis. Mitchum. In this arrange. Mitchum & Berndt. 1995). verb inflection.. In addition. The theories that result can be difficulty matching correct word order to sentence struc.” and “girl” are shown in both pictures. Agrammatism was viewed as a constellation wants to say.. they are not lexically specified or grammatically graphic speech of Broca’s aphasia. The finding that speakers with agrammatic aphasia fre. 1993. from many studies that these symptoms can dissociate from 1988) characterizes the processes involved in creating a one another (see Berndt. reversible sentence production reveal similar errors involving and computational modeling. struct a verbal sentence from thought? Importantly. 634 Section IV ■ Traditional Approaches to Language Intervention “ball. or in groups of individuals who share (at least) a symp- “kick. we seem to readily ing symptoms: (1) “closed class” word errors. Theories of normal sentence processing draw been very widely used to investigate structurally based com. for reviews). however.qxd 1/21/08 1:33 PM Page 634 Aptara Inc. this informal description tells us little about reversible sentences (Berndt & Caramazza. ing in comprehension generated enormous interest in Even in the absence of a formal theory. tom of interest (Berndt.” including the view speech-language pathologist. Berndt et al.” cases. The characteristics of well-formed.g. how do we determine what can that “Broca’s area” of the brain is specialized for aspects of syn. preverbal idea of what one of language use. . boy: in front. sidewalk... girl: behind. girl: wearing shoes. girl: mean.qxd 1/21/08 1:33 PM Page 635 Aptara Inc.. girl: foot moves toward boy.....: various other structures Assignment of segmental and prosodic word structure Positional Level Representation on to Phonetic encoding and Articulation “the girl is kicking the boy” ... Chapter 24 ■ Comprehension and Production of Sentences 635 good weather. makes contact.. late afternoon. A Model of Normal Sentence Production Based on Garrett (1988)... boy: angry Event1 = kick : foot / boy / girl / Message Level Representation Lexical selection Determination of (meaning) functional structures girl ((V: ignore) (S: (V: kick) (N: girl) (N: boy))) boy kick ignore angry Lexical assignment etc... boy: not hurt.. unfamiliar people.GRBQ344-3513G-C24[632-653]... Functional Level Representation Word-form Selection of retrieval (phonology) planning frames act: det (N) aux (V) det (N) pas: det (N) aux (V) by det (N) etc.. Figure 24–2.. 1982): tence production (e. Word-exchange errors demonstrate distinct charac. then the source of a patient’s production impairment and to involve words of different grammatical classes. Vigliocco & Hartsuiker. Word-exchange errors (as in a. This is not c. Saffran (2001) presents a framework for sentence com- ation of Functional-Level structures from the message level. As each word is recovered. at the Message and Functional Levels). steps (one semantic.g. and in the absence of a suitably detailed model ning level in which the identity and phrasal role of words is of sentence comprehension. and is held in temporary storage as the syntactic structure of the . subject. . it is useful to consider a important (i. lished at the Positional Level as phonologically specified lex. suggesting that the construction of the Positional tion. all examples from Garrett.. Structural order is estab. Because Message. Nonetheless. there is grammatical roles (e. “ No . A Functional independently in the construction of phrasal frames Representation encodes the conceptual proposition into (Lapointe. phonetic sequence into recognizable spoken word forms and exchange errors is that they almost always involve words matches them to lexical entries. 2003. have been proposed over the years. whereas the details of the phonetic representations a. It is likely that sentence comprehension shares many of the teristics from sound exchanges (exchanged portion itali. What are not detailed are the processes through which Level involves the insertion of phonologically specified the speaker moves from one level to the next. These must arise at a later point (Caramazza & Hillis. . auxiliary elaborated to illustrate how the model conceives of the ele. In this example. For for analyses of aphasic sentence production (Saffran.qxd 1/21/08 1:33 PM Page 636 Aptara Inc. elements and grammatical words already specified. major lexical items into a planning frame with inflectional The three distinct levels within the model to be consid. and it has been used frequently as a starting point evidence from errors produced by normal speakers. Briath Keen” (Brian Keith) tations are assumed to be shared for production and com- “And this is the larietal pobe” (parietal lobe) prehension (Levelt. “that’s why they sell the cheaps drink” (drinks cheap) “she to diminish the importance of these operations. 1989. “ Well you can cut rain in the trees” (acoustic/articulatory) for input and output must be quite “Why was that horn blowing its train?” different.) tend to involve words in dif. suggestions that there must be feedback abstract lexical entries representing word meanings and from Positional to Functional Level to account for “mixed” their functional (thematic) roles.e. including an argument and may be thought of as the conceptualization of some that bound and free grammatical morphemes are generated proposition that the speaker wants to convey. 1981). 1997). and debate about the level at which grammatical class infor- ical items are inserted into a surface structure based on their mation is encoded (Caramazza. (phonologic/semantic) speech errors (Dell & Reich.. prepositions). example. object). 1987). in addition to a sin. 636 Section IV ■ Traditional Approaches to Language Intervention production adapted from Garrett (1988). .) tend to occur within a phrase intact.GRBQ344-3513G-C24[632-653]. it from major lexical categories (nouns.and sound. We is supported by another type of exchange error that gener- focus here on the top three levels of the model and do not ally occurs within phrases: consider the requirements of articulatory coding. more abstract components that Garrett identifies for sen- cized. but to writes her slanting” (slants her writing) emphasize the issues that have been the primary focus of research on sentence processing in aphasia. suggesting that these two types of ments needed to produce a sentence. Roelofs. It is important These errors typically involve the “stranding” of inflections to keep in mind that this model describes only the represen. Schwartz. exchanged. 1999. it is sometimes argued that if ferent phrases that are in the same grammatical category.. prehension that corresponds to the Functional/Positional whereas sound exchanges arise in the construction of the level distinguished by Garrett. & Meyer. 2000). schematic of the components of the production model gle-phrase planning level at which (phonologic) form and working in reverse as they decode the acoustic signal (see serial order are represented (the Positional Level). which we have adverbs) rather than grammatical words (pronouns. For distinctions lead to the postulation of a multiphrasal plan. 1989). the Functional Level). ered here consist of the following: A Message Representation Many variants of this framework with relevance to aphasia may derive from a variety of verbal and nonverbal sources. 1982. it’s . hypothesis is that word-exchange errors occur in the cre. the listener interprets the acoustic signal by segmenting the One important characteristic of word. this reason. . comprehension of Message and Functional elements is whereas sound exchanges (b. verb.g. the postulation that word retrieval requires two Schneider & Thompson. Levelt. is supported by Sentence Comprehension regularities in the types of errors that occur in normal speech. in their proper positions even though their stems are tations that are constructed serially during sentence produc. the words are generated by different processes. verbs.and Functional-Level represen- b. Positional Level from Functional-Level structures. This distinction message to be conveyed is that a girl is kicking a boy. as well as the details about what information these levels encode. The also Jacobs & Thompson. adjectives. widespread agreement on the major distinctions expressed by These levels of representation are motivated primarily by the model. As depicted in Figure 24–3. 1985). 2002). one phonologic). verbs. These models have focused attention on the “young female. Even for phonological structural word forms components normal speakers. anger. or by Representation “the girl is kicking the boy” both. These deficiencies then cause strategic adaptations in Figure 24–3. motivating a modifi- Representation [S] cation of the sentence under construction (Garrett. a concept is formed and the sentence is interpreted. errors occur with the slightest aberrations in the normal flow of language. As sentence meaning unfolds. action mechanisms by which information flows between the types with foot. such as minor blocks to Positional Level word-finding. surprise. tural components” (grammatical roles such as subject or since aphasic language problems clearly can involve both object) of the words become available. A Model of Normal Sentence Comprehension which patients simplify or truncate structures.qxd 1/21/08 1:33 PM Page 637 Aptara Inc. Chapter 24 ■ Comprehension and Production of Sentences 637 number of possible points of interruption could undermine sentence comprehension in aphasia. Translating between Levels of Representation The models described above were conceptualized as serial. 1982. for Sentence Production. Dell. Any dence suggests that reference to the normal model is an . and about the memory and other resources necessary to support these processes. they are linked to degraded representations and limitations on their transla- their thematic counterparts (agent. Details of inter-level interaction is of great importance to considerations of aphasic language. 1999.” of representational levels identified by Garrett. caused either by delay in the activation of the relevant representa- Acoustic/auditory Level tions or by abnormally fast decay of such information.. makes it dif- sentence is assigned at the Positional Level. etc. or rely on Based on Levels of Representation Similar to Those Proposed comprehension heuristics. 1986. & Griffin. This type of framework is increas- (S: (V: kick) (N: girl/actor) (N: boy/recipient)) ingly being challenged by production models that postulate two-way interaction among levels of representation. 2001). some of Functional Level Representation [Retrieval of word meaning] these studies support their assertions with computational implementations (Dell.GRBQ344-3513G-C24[632-653]. Functional Level. theme/patient) at the tion between different forms (or levels). Such aberrations in the normal flow of /girl/ [NP] [VP] information are likely considerably greater for the speaker /boy/ with aphasia. 1999). or a change in thought. /kick/ Levelt et al. Some of these seem clearly to implicate the point of integration between syntac- Conceptual tic structure (at the Positional Level) and sentence meaning Representation (at the Functional Level). creating challenges for the comparison of det /N/ aux /V/ det /N/ aphasic speech to normal speech. and memory for. As the “struc. IDENTIFYING THE SOURCE(S) Normal sentence interpretation is based on access to. Chang. The lack of detail regarding how information is normally conveyed between levels. [Segmental and prosodic decomposition] Several hypotheses have been put forth that implicate limitations of memory or other processing resources as crit- ical causes of some types of sentence-processing failure. For example. Kolk (2005) attributes the fragmentary and poorly Phonetic Level structured speech produced by many persons with aphasia to Representation interruptions in the normal flow of information. Harley. ficult to identify a point of disruption in normal processing. considerable evi- several different levels of information (Saffran. in which it seems likely that perturbations in the timing and coordination of ele- Decoding of Identification of ments across levels could create much difficulty. young male. feed-forward operations that specify how information is rep- [Identification of functional structures] resented for processing. 1995). a wide range of intermediate elements that the OF APHASIC SYMPTOMS listener must immediately coordinate and integrate across Despite these challenges and limitations. shoes . . These studies focus on difficulty with the extraction of linguisti- may express some part of a concept. ball . note that she is unable to link a relevant verb “pour” message representations. . . Message-Level representations are conceptual. no no no (gestures towards her feet) ah . Thus.e. to its correct noun arguments when she does eventually pro. (writes ‘12’ on a pad) eleven o’clock yes . preponderance of unlinked nouns in an utterance that does er dance . cherio . & Black. . Another characteristic of aphasia that may reflect and a few have been published for clinical use. things. . but have no relevance to cally relevant information from a concept of some action- description of the event. . the girl is in the a clearer understanding of patients’ Message-Level repre- sand . nonverbal tests of con- Ex: “tell me about how they are interacting” (points to boy ceptual-event processing have been developed that elimi- and girl) nate the lexical retrieval component of production and allow Pt. Failure to construct suggest that the lack of propositional thinking yields the event representations results in poor expression of type of noun-listing pattern of production associated with noun/verb role relations—that is. . 1991). horses . Marshall & Cairns. p. Nickels. . . . . . man . pouring the understanding in individuals with aphasia using a sorting woman . Message-Level impairments. . & Chiat.: “the girl is in the sand . . Black. . 2005. 2005). 2005. . . nonverbal ideas about people. 180): nouns and verbs. . . . er horses . 1991) . . it is also possible that the symptoms arise the speaker clearly perceives the independent activity of from poor verb retrieval.. as is evident in the following whom. Black. . . finish . . Message-Level Impairment As noted previously. 638 Section IV ■ Traditional Approaches to Language Intervention important and useful tool—one that can help to identify the sources of the overt symptoms of aphasia. shoe . To address these concerns. In the following excerpt. when they occur. . Figure 24–4. and Bryan (2005) based scenario (i. If this is the case. when it fails to establish a predicate-argument structure. Although the types of “messages” that trigger sentence production are likely to differ somewhat from those that arise as sentences are understood. . Dipper. the girl is in the sand .. . . although tional thinking.GRBQ344-3513G-C24[632-653]. the girl task with pictures that portrayed an action event (a car being is in the sand. Although her difficulty may involve impaired verb production therapy that assumed intact ability to utilize retrieval. . . Both Message-Level and verb- each noun: retrieval impairments could contribute to poor performance when the evidence is limited to verbal tasks such as story- Pt. . Black. This might be manifested as a crying . . for sentence production (Dean & Black.qxd 1/21/08 1:33 PM Page 638 Aptara Inc. . . Nickels and colleagues (1991) assessed event poured) “. 1993. there is little evidence that these differences are either substantial or measurable. . . .” (points in the picture to where the sand is being sentations. of who is doing what to severe nonfluent aphasia. yes nice . . Successful sorting of the event pictures at baseline was asso- ity to describe the interaction of the boy and girl depicted in ciated with a more successful outcome following a sentence- the scene. their attributes. and their relationships that might be expressible as language or understood from language. 1993. the man . 1993. equal but . . . . . the speaker with aphasia is unable to express how two nouns in a pictured Although such a sample shows no evidence of proposi- event (shown in Figure 24–4) relate to one another. . Several tasks designed to assess the ability to understand duce it. Pring. . in other words. Several studies of aphasic sentence processing that impli- cate a Message-Level impairment have identified an inabil. . . it is possible that at least part of the problem is events have been reported in experimental studies (Dean & a failure to appreciate the interactional nature of the event. er wine . . shoe . . This may be evident in aphasic production when what speech sample in which a speaker with aphasia is retelling the patient says demonstrates no relational link between the story of Cinderella (from Marshall et al. The use of copular constructions appears to reflect an inabil. er not appear to reflect solely impaired verb retrieval (Dean & twelve . should be manifested in both production and comprehension. . a “motion event”).. . . no no no big ones.” driven) or a “non-event” (a street scene without action). two separate . Nickels et al. Stimulus Drawn to Elicit a Sentence (such as ity to construct “event representations” that establish a basis “The boy is burying the girl (in the sand)”). . Marshall.. Marshall et al. The Event impaired event perception is the production of nouns that Perception Test (Marshall et al. Byng. .. 1993). . 2005. the boy is motionless.” telling.: “the girl in the sand . ” The assessment of patients’ understanding of events and These findings suggest that different aspects of verb of other aspects of complex concepts is relatively unexplored meaning may be differentially subject to disruption in apha- in aphasia assessment. but as noted earlier it is often roles to the nouns. sell) to express the event. Bresnan & Kaplan. a enable verbs to encode more conceptual information. This semantic/syntactic distinction within verbs may not be ments.g. For doing the action) to interpret the outcome of the event. Marshall & Cairns. Understanding of judge the grammatical integrity of sentences using the same the reversible scenarios requires the ability to extract role verbs. speakers with aphasia can make very subtle perceptual and ferent version of the task shows reversible scenarios that conceptual judgments about verbs. and of degree of change of state experienced by the entity undergoing the action. in describing poorly to treatment than verbs with less inherent symmetry an event showing a transaction between two people in a (Mitchum. & Haendiges. The verb hierarchy also pre- predicate-argument structure that will express the thematic dicted response to treatment of reversible sentence compre- relations between the verb and noun(s) involved in the event hension.and passive-voice sentences (Berndt. the paper with water. 2004). since difficulties at this level would be expected to quite so clear as the above results suggest. based on Pinker (1989).g. proposed that grammati- (Marshall.. yet fail when making require knowledge of thematic role assignment (who is structure-relevant judgments about the same verbs. that Functional-Level Impairments were encoded in the verbs’ meanings.qxd 1/21/08 1:33 PM Page 639 Aptara Inc. normal and aphasic participants listening to reversible tence. on the one arguments. as well as “spray” in tests of verb meaning. and the choice of verb will give rise to a number of symptoms involving lexical selection influence the assignment of thematic (and grammatical) and thematic role assignment. such as the manner of motion (run/walk). 2004). agency. Saffran. Performance on this measure is how they effect a change of state (melt/burn). This finding is supported by evidence that and two related distractors (torn paper. “chase”) (Jones.GRBQ344-3513G-C24[632-653]. In comprehension.f. with more “symmetric” verbs responding more (c. & Berndt. For example. Verbs whose meanings A major feature of the Functional-Level representation is implied an asymmetric distribution of motion and degree of the retrieval and interpretation of abstract lexical represen. tribution of such features (e. with different consequences for sentence processing. demonstrated their effects on thematic role assignments in tion that contribute to the structure and meaning of a sen. burned box). “pour” vs. and that later Positional structures were ultimately . 1984.” “pour. independent of the sentence’s concepts such as causality. “drip”). and it determines the Burton. For example. An impairment occurring at the Functional Level could buy. 1995. “kick”) were tations in accordance with the message (for production) or easier to understand following reversible sentence-compre- as dictated by the surface structure (in comprehension). 1982). in which the cally relevant features of verbs are those that determine person with aphasia is asked to match a video scene to a their syntactic argument structure.. tence-comprehension therapy that indicated sensitivity to guistic aspects of patients’ performance are unlikely to suc. whereas features that photo showing the outcome of the event.” and require broad decisions about cause and effect. however. Also hension therapy than were those with more symmetric dis- created at this level is a representation of the thematic rela. By many accounts. accepting as correct items such as “Sam is dripping relations from events. hand.. and temporal order within argument structure. critical element at this level is the selection or interpretation A hierarchy of verb difficulty based on these meaning of the verb. or (e. Treatments that focus solely on specifically lin. Kemmerer (2000) showed that some patients ability to interpret the nonreversible events is assumed to could distinguish between the verbs “drip.. & Marin. A dif. verbs was indexed by such factors as the extent of relative motion of the event participants. are grammatically matched to one of three photos: the target (burned paper) irrelevant. Chapter 24 ■ Comprehension and Production of Sentences 639 assesses the ability to recognize fine distinctions in verb Verbs are often classified into types based on their inher- meaning that engage conceptual/semantic features of verbs ent features. a Schwartz. 1980). Berndt have wide-ranging effects on sentence production and com. the listener matches difficult to ascertain that Message-Level representations the meaning of the verb to the thematic roles of its noun were sufficient to motivate the correct structures. important to understanding the nature of aphasic impair. Kemmerer often assessed in conjunction with the Role Video Test (2000). The example. The choice of verb expresses the semantic concept of active. Yet it seems clear that it is critically sia. tions among selected lexical elements. The relative complexity among types of events. 2005). the speaker can use one of several different verbs (e. conceptual features of verbs that affect the ease of the ceed if patients do not have a secure understanding of assignment of thematic roles. and yet were unable to intact ability to interpret complex scenes. and Mitchum (1998) reported a pattern of response to sen- prehension. affectedness across the sentence’s nouns (e. the action component of the event.g. It is assumed in many models of normal sentence components was generally supported in a larger study that processing that the verb represents various types of informa. Haendiges. store.. Mitchum. such video scene showing a woman burning a newspaper is as manner of motion or changes of state.g. Production tasks (such as described above) ically to assess expression of thematic relations. although clearly implicating some problem with ture stimulus shown in Figure 24–5. 640 Section IV ■ Traditional Approaches to Language Intervention available to support correct productions. One speaker with aphasia showed an unusual event depicted. . . . Although this aspect of sen- Instruction: “Try again. behind . picture-descrip- Level representations. but that’s wrong because the sheep is actually processing would manifest itself. the speaker had difficulty integrating the pattern of excellent sentence production in connected order of the nouns with the verb she accurately chose to speech. but can thematic roles. Fink. Below we describe such a case in which a person Figure 24–5. 1985). also seem to involve other problems with full expression of Instruction: “Describe this picture by telling me a sentence the sentence’s structural frame at the Positional Level. Stimulus Drawn to Elicit a Sentence (such as with aphasia demonstrated excellent comprehension of “The girl is leading the sheep (with a leash)”).. with good control over grammatical morphology describe the picture. despite retained ability to produce sentences in fied. relied on a “light” verb construction that did great difficulty understanding semantically reversible sen- not encode the direction of the action. The following sample demonstrates that this be elicited with carefully constructed tests (Schwartz. Caramazza and Hillis (1989) argued that an impairment arising from the Positional Level would be evident when the structural difficulties with sentence production co-occur with intact single-word retrieval and normal comprehension of reversible sentences (on the assumption that Functional- Level representations are also used in comprehension). As noted above. but was unable to . However. One problem is the diffi- culty in distinguishing between a deficit located at this level and one that emerges from failure to elaborate the informa- tion that feeds into this level (i. the little girl is following the sheep on a Although much testing typically must be carried out before leash . thus localizing the symptom to a point at which the grammatical elements of the sentence are realized for production. her ability to detect grammati- of non-canonical structures in which the agent of the action cal violations in spoken sentences was intact.and passive- tions is not limited to agrammatic speakers or to production voice sentences. understanding of the thematic relations encoded by verbs. The example are designed to elicit specific sentence structures and to also demonstrates how poor expression of thematic roles can assess the patient’s ability to detect his or her own word- occur despite excellent control over grammatical morphemes order errors (Caramazza & Berndt.” a Functional-Level impairment can be confidently identi- In this case. the little girl is taking the sheep on a walk. The only way to make this prob- matic role assignment. 1995). that starts with ‘the girl’. .” tence production appears especially vulnerable in aphasia. on the other hand.” Realization of a Positional-Level representation is a critical [repeats the sentence twice more. though and a wide range of complex structures. she had clearly correct. . . This profile suggests that Functional-Level operations (word- meaning retrieval and thematic role assignment) are fully operational. and despite obvious appreciation of the limited data. . from the Message and Functional levels). This example clearly tences. active and passive reversible sentences. Target response: The girl is leading the sheep (with a leash). comprehension problems arising at tion tasks (in which the target is known to the listener) the Functional Level should be mirrored by problems sometimes elicit sentences with noun order that violates the- expressing thematic roles. In contrast. Note that the final sentence. is indeed the case when the production task is designed specif- & Saffran. Such impair- and a clear ability to obtain a relevant “message” from the pic- ments. This speaker’s is not the subject of the sentence (as in passive voice).GRBQ344-3513G-C24[632-653]. Role-reversal errors are infrequent in lem evident is with production tasks that require expression of spontaneous aphasic speech (Menn & Obler. occasionally such a deficit is relatively clear even from the passive voice. .” Response: “the little girl is being pulled along by the sheep. it Response: “the little girl is being pulled forward by the is not easy to predict how a deficit specific to this level of sheep . great difficulty interpreting thematic roles in comprehen- The impaired sentence production of some speakers with sion is difficult to reconcile with her excellent sentence pro- aphasia suggests an inability to assign nouns to the thematic duction: if comprehension and production share Functional- roles dictated by the verb. then studies the picture] step of grammatical encoding. 1990). scoring at chance on numerous administrations of indicates that the problem of expressing thematic role rela- sentence/picture-matching tasks probing active.e. Positional-Level Impairment That’s not good.qxd 1/21/08 1:33 PM Page 640 Aptara Inc. Faroqui-Shah & Thompson. sentence production has been explored using experimental there is evidence that structural priming effects are sustained paradigms that improve access to lexical verbs by speakers for a remarkably long time. the with aphasia are significantly more likely to produce a spe. priming sentence. However. Greenwald. The nature of the relationship between verb retrieval and cult structures such as passive voice. Tasks of “cued production. Haendiges. there are diagnostic advantages of attempting to isolate a hypothetical component of normal sentence processing. in part. as described form a structural sentence frame (Berndt. and may be helpful in inter. it is The results of the studies described above can inspire novel more accurate to say that model-driven therapies “highlight” approaches to aphasia therapy. the correlation of grammatical frame structures are available. above. Haendiges et al. especially with Exactly how the grammatical elements are derived at the regard to its effect on the processes that support sentence Positional Level is left largely unspecified in Garrett’s (1982. aphasia to use in a sentence. 1998). 2000). perhaps because the difficulties associated with verbs may arise at a number of resources required to use the provided structure causes the levels within the normal stream of sentence formation and patients to divide their attention from the content of the tar. observed for control subjects: priming was facilitated when problems arising at a specific point may give rise to different normal speakers were explicitly asked to match the structure symptoms in different speakers with aphasia. comes from investigations using structural sentence 1997. Berndt. but does not seem to know where to place them to strategic avoidance of lexical verbs in sentences. 2000).” in which the phonologic of the primed sentence structure (Bock & Griffin. (rather than “isolate”) specific representations or processing preting the effects of more traditional approaches. depending on of the model sentence. but underuti. with aphasia who have difficulty producing verbs in sen- vening sentences between the auditory prime and production tences. Moreover.. ther- Message-Level (Event) Treatments apies driven by the diagnostic findings tend to be more closely aligned to the symptom.. have yielded mixed results dence that the syntactic priming effect was diminished when (Berndt. In the preceding section. but ing was highlighted. ified therapy that directly targets the ability to understand Most therapies guided by normal models target a specific events. Mitchum. “priming. Berndt. Harley. production. 1997).. Careful observation and analysis of spo- the speaker has the ability to retrieve grammatical function ken production can reveal patterns of verb omission. While operations. Although poor verb retrieval is highly correlated with Mitchum.qxd 1/21/08 1:33 PM Page 641 Aptara Inc. Marshall. & Sandson. yet it cannot simply be assumed that structurally similar. Haendiges. or words. 2003. Here we focus Berndt. Haendiges. such things as the unique combination of associated prob- lems and the indication that the strategies to overcome (even USING THE MODEL TO MOTIVATE THERAPY: mask) the impairment. with clinical aphasia is imperfect (Berndt. & Chiat. In addition. to underspecifi. 1997. 1997. & degraded representation. Interestingly. on the symptom of poor verb retrieval. Further support that a variety structurally impaired sentence production. 1995). Jane Marshall (1999) has pioneered these efforts .” Several studies have shown that some speakers Caramazza & Hillis. form of an uninflected verb is provided to the speaker with Hartsuiker and Kolk (1998) obtained experimental evi. making it difficult to pinpoint the source(s) of get sentence to its structure. Such variability underscores the com- instruction to use the model. This is due. the effect of priming for plexity of the relationship between poor verb retrieval and agrammatic speakers was robust for both active and passive impaired sentence production. production.GRBQ344-3513G-C24[632-653]. then attempt locus of impaired sentence processing in this case was inter. A few studies have spec- processes of production (Dell et al. Haendiges. the inverse was disruption within a single person with aphasia. 1997. “prime” (Saffran & Martin. For all of these reasons. importance of the verb in many aspects of sentence process- cific structure immediately after hearing a different. measuring as many as 10 inter. even for particularly diffi. lized. This finding implies that the construction of One of the problems in elucidating the role of the verb in a Positional-Level representation may be undermined by aphasic sentence production has already been described: conscious effort in aphasic production. 1988) model of normal sentence production. & Sandson. the functional symptom of sentence-processing impairment. & participants with aphasia were explicitly told to model the Wozniak. Some patterns The effect of poor lexical access to verbs has been well of production (as in the examples above) clearly indicate that studied in aphasia. et al. 1999. sentence types. it is essentially impossible to avoid some engagement of several levels of processing VERB PRODUCTION with the clinical treatment tasks. 1989). to restore function by improving the integrity of the preted quite differently (see also Mitchum. sentence that serves as a model or verb difficulties actually cause the grammatical disturbance. When the same task was given without Pring. As suggested above. Chapter 24 ■ Comprehension and Production of Sentences 641 produce passive-voice sentences. poor expression of propositional speech cation of how representational levels are formed (as noted may be attributed in some cases to difficulty extracting rele- above) and to the possible interactive nature of subcomponent vant information from the Message. 1997). In normal speakers. and/or access to it. and so on. each being matched to a broad conceptual types of verbs. Raymer and Ellsworth (2002). sentence-level production..” sentences. You go and get some string and written feedback to refine the conceptual content of spoken make a lead (gestures holding leash). . There he is at ranging therapy described by Peach and Wong (2004) used your feet (points to door). movement possession). ..e.e.124). ment of sentence production using tasks that focus only on cally relevant components of events. Communicative effectiveness was also measur. and Schneider and Thompson mation that could be used in simple propositions. it may prove critical that noun/verb role relations “pare down” complex events to a single (expressible) propo.. Queries enforced the ular speaker. yes take . are highlighted in such therapies to obtain generalization to sition.g. . and methodically increase event complexity as deter. (“spray”/“splatter”). take the dog to the house. For example. This approach Response: (copies the gesture and moves it away from her exercised a range of production levels to address the link body) “Take . change of possession (“buy”/“learn”). was encouraged to compliment the imagery fundamental verb concept (e. single-verb semantics. Marshall (1999) describes a treat- on “unpacking” the elements of an observed or imagined ment that uses complex video scenes presented with a sys- event. . That is. These included verbs recognize the intrinsic manner of verbs based on their motion such as “go”/“come” (movement). with apparent difficulty conceptualizing events. . either in conjunction with. and gesture (p. that the problem is not in establishing judges. In some cases. . to category (established earlier in therapy). or contrasted Marshall found that such verbs were helpful in learning to with. Pring. The speaker was guided through sia. single-word therapies can provide a basis for generalization addressing skills that have been described as “thinking for to sentence production for some speakers with aphasia.e. “give”/“get” (change of (“spin”/“drive”). other (nonsemantic) forms of single-word therapy. been shown to improve the number of arguments produced Marshall employed a variety of exercises to “alter (Bock & (in sentences) in association with verbs. The imagery and gesture therapy was used along with an attempt to help this woman focus on the aspect of a complex Message-to-Functional Level Treatments event that could be described with a simple proposition. relative non-action (“bore”/“pity”).g.GRBQ344-3513G-C24[632-653]. change of state (“melt”/“cook”).. The goal was to “promote the formation of highly focused con.” Response: mimes action. One match the propositional structures available to the speaker approach to therapy at this level is to place conscious effort with aphasia. Such therapies attempt to filter. even though the changes to the way events are interpreted can be guided to therapy tasks involve only single words. Of inter. rative speech). 124): what does he do next? Just the first thing. Marshall. As anticipated. as a substitute for lexical verbs) was with aphasia to appreciate a range of factors associated with a actually a limiting factor. which would place minimal arguments (sometimes described as “semantic” therapy) have demands on her language system.” from conceptual to Positional-Level representations. “put”/“take” (removal and location). Marshall (1999) encouraged patient E. “When you spray paint on a exercises and to promote focus on the action component of wall. among the verb types. tematic cueing hierarchy. or However. relate to one another at the sentence level. a message). the clinician says: “now he’s at the door . (2003) describe therapy studies with different participants est was that the use of light verbs as a substitute for lexical with aphasia that limited treatment to single words and used verbs was not considered an effective goal of therapy. “put the bag on the ground”) (p. a set of “light” verbs was established for understands the conceptual distinctions among different verbal descriptions. . a semantic therapy. nar. but that their common principle of these therapies is to allow the speakers use at later stages (i. . These therapies collectively suggest that with aphasia identify relevant conceptual information. verb’s meaning and its relation to other sentence elements Other therapies have been designed to help individuals (primarily nouns). to the event by focusing on a serial description of the smaller extract propositional information from events using imagery sequences (e.. 1996). Marshall (1999) encouraged one speaker with apha. Post-therapy results showed improved production also engaged conversation about the conceptual distinctions of verbs with specific arguments in storytelling tasks (i. the Levelt. .qxd 1/21/08 1:33 PM Page 642 Aptara Inc. Several studies describe treat- improved conceptual preparation and attention to linguisti. what moves? The wall or the paint?”). 124). Other therapies assume that the conceptual information is ably improved as determined by both trained and naïve already available (i. yet there is some difficulty identifying the correct Marshall (1999) interpreted the results as indicative of verb at the Functional Level. 2005). a natural tendency observed in this partic. You set off . Verb-retrieval therapies that link the verb to possible noun cepts at the Message Level. and Chiat (1998). speaking” (Slobin. The therapy task scenarios. In some cases. A broader- Examiner: “Imagine yourself with the dog. Marshall’s patient had learned to extract verb-relevant infor. and to repair grammatical errors. A isolate verb-relevant information from events.” To encourage this. or The use of gesture. treatment must focus first on establishing that the patient To simplify things. 1994) conceptual preparations for language” (p. 642 Section IV ■ Traditional Approaches to Language Intervention using a variety of nonlinguistic and language tasks. such generalization may mined by the number of events and their variety of potential rely on a realization of how the verb and its (noun) arguments perspectives (Marshall & Cairns.M. The action verbs were repeatedly presented to elicit a set of verbs disadvantage of providing a range of therapy tasks is the lack that “name the action. above). neither participant demonstrated an ability to tences. Marshall et al. while leaving the ear- water. the water is lier (Functional and Message level) representations of the sen- the thing doing the filling. onds). an picture-naming (devoid of any attachment to morphologic . impairment. and among tasks that are said to address construction of the PAS. semantic processing of nouns and/or verbs. even without working at the sentence level. tence production revealed the same pattern of response resentation. Ballard. 2004). Mitchum.’ The girl is the person doing the filling. If a being filled.. in fact. Several picture exemplars of functions to improve the potential for effective results. production contained more verbs and nouns as obligatory both were clinically quite different. yet arguments and a greater variety of argument structures in showed all the features associated with agrammatic produc- connected speech. Schneider and either with repetition/rehearsal (Raymer & Ellsworth. word forms). it may address problems of retrieval at ture shows fill. Haendiges. If the therapy task stimulates only production of the For example. it was hypothesized that. & Berndt.” As criterion performance was reached of specificity regarding exactly which elements of the ther. All of these The other person was severely nonfluent. (addressing verb properties such as direction of motion or Mitchum & Berndt. for each targeted verb (correct response initiated within 3 sec- apy effected a positive outcome in a particular case. often with multiple arguments. 1997. and the pitcher is the thing tence production process “untouched” by intervention. for both participants. Both forms of treatment (i. a new verb was added until the treatment successfully In general. his attempts at written sen- and contribute to the formation of a Functional-Level rep. engage a wider range of sentence. Marshall. & Karcher. Chapter 24 ■ Comprehension and Production of Sentences 643 Some studies explicitly address the production of specific effect we elaborate on below with regard to treatments tar- types of predicate-argument structures (PAS). lexical verbs. The same technique was used with both patients processing components. 1994. Chiat. matic requirements). tionship between verb-retrieval therapy and sentence pro- establish thematic role relations between verbs and nouns. Berndt.. 2000. poor verb retrieval in sentence production. duction in two speakers with chronic aphasia (7 to 8 years and practice sentence generation. facile availability of verbs would tual/message level. In terms of superficial symptoms of aphasia.. This result helps tion. impaired use of verb-related grammatical morphemes. change of state) with the effects of argument-structure tasks 1993) may address only a part of the verb’s lexical representa- that highlighted the number and place of verb arguments. Mitchum et al. describe a treatment study designed to target verbs’ PAS Mitchum and colleagues (1993. tion. the treatment tence production.. or therapies that involve a variety of verb word forms was a source of the sentence-production different exercises. Webster.e.e. 1994. & Pring. sustained for at least 1 month following therapy) (Mitchum & appear to be effective with many patients with aphasia. there is actually little distinction tures. It shows ‘the girl is filling the pitcher with the Positional Level (i.GRBQ344-3513G-C24[632-653].qxd 1/21/08 1:33 PM Page 643 Aptara Inc. There is no indica. The assumption behind this therapy although responses were elicited verbally for one participant approach is that treatment should target a broad range of and in writing for the other. which are presumed to occur earlier at the concep. 1994) studied the rela- production using therapy tasks to improve verb retrieval. 2000. and Franklin (2005) predictably would not improve sentence production. Both to improve lexical-verb production. These tasks can also be difficult to distinguish elicited verbally from the other person. tion: reduced phrase structure. Schwartz. One was fluent. the unavailability of levels of processing.e. and/or to improve patients were poor at comprehending reversible sentences. active voice) sen. use of simple sentence struc- As these results indicate. based either on Functional-Level representation (which may be indicated if semantics or PAS) yielded improved verb retrieval and sen. Therapies that practice simple stimulation of action words Murray.. ordering tasks can be used to assess understanding of verb- argument structure by having participants arrange written Functional-to-Positional Level Treatments anagram phrases (verbs plus arguments) into meaningful Verb Retrieval: Word Form sentences (Jacobs & Thompson. Demonstration therapies have yielded robust results with Despite significantly improved ability to retrieve specific regard to production of canonical (i.” An attempt at production followed this speaker with aphasia has additional impairments involving the instruction. reversible sentence comprehension is poor). Sentence. however. geting the Positional-Level representation. It is likely that tasks that involve multiple improve sentence production if. 1993. Mitchum et al. 1998. a depiction of the three-argument verb “fill” phonologic word form from pictured meaning (devoid of the- was accompanied by the following information: “This pic. 1993). & Myers. Morris. that lexically based single-word therapies to clarify why traditional “naming therapies” that practice generalize to production of non-canonical structures. Post-therapy sentence post-onset). Although he could approaches potentially serve to link verb/noun role relations not produce sentences verbally. 2002) Thompson (2003) compared the effects of semantic tasks or with picture naming (Fink. verb-based therapies that integrate noun/verb established facile retrieval of eight verbs (an effect that was role relations. from tasks that target event-role interpretation (as discussed Following extensive diagnostics.. use the newly acquired verbs in sentences. This argument was based on results showing that 1994. and benefited from cued retrieval only when pro. However. untrained sentence types. In pictures (Fig. DOR used few verbs in narrative with the same two patients linked the production of verb- speech. in response to cued verb verb-cued retrieval (i.. -ed) vided with verbs inflected in the present-progressive form to the expression of temporal information using sequential (-ing).qxd 1/21/08 1:33 PM Page 644 Aptara Inc. forms. 1993).e.g.” Further testing indicated that DOR elicitation conditions used in therapy. Sequential Picture Stimuli Used to Elicit Time-Marking Grammatical Morphemes (Future. was not produced as the super- available.. providing an uninflected verb form retrieval (Faroqui-Shah & Thompson. does not demonstrate use of this inflection as a morphologic element. 2003). are no longer grammatical verbs suggested a robust effect of therapy that tapped intact units that participate in sentence construction. present-. verb morphology is morphology. Mitchum & Berndt. (Table 24–1). evidenced by the patients’ over-reliance on the present mation was the basis for the poor production of the speaker progressive in all contexts. DOR produced some verbs. p. production is ficially similar past participle to support passive structures.. Druks and Carroll tion that the grammatical frame of the sentence was unavail- (2005) concluded that the unavailability of verb-tense infor. 1980). or past- nouns as if they were verbs (e. Verb Retrieval: Verb Morphology Mitchum and colleagues (1993. and Past Tense). 2002). In addition. In a series of steps. In some cases. but cally diminished cues needed to elicit structurally well- often substituted a noun for a verb. therapy characteristic (Raymer & Ellsworth.e. was successful in establishing verb retrieval for trained and classic examples in Saffran et al. but suffered the patient was asked to construct a sentence using a specific from a fundamental morphosyntactic problem marking and noun or verb. and was not dependent on the are labels of actions. the past-tense verb For many speakers with aphasia. able. the generalization to untrained texts where tense is obligatory. but poorly used. once available. including irregular past-tense verbs (2005. 2003). tense sentence to describe each picture. past tense (-ed) did not cue sentence production.” bound morphemes -ing. (Target responses reflect the temporal order of an action event. 11) suggest that “verbs unmarked for tense. there was no generalization to interpreting verb tense. tense markers (auxiliary “will.) elements or semantic relations) often have a limited effect improved when inflected verbs are provided as cues on production beyond the single-word level. in con. Druks and Carroll untrained lexical verbs. in particular. . A second intervention carried out with aphasia in their study. 1994) interpreted the The sentence production patterns of speakers with aphasia lack of generalization to sentence production from the unin- with poor production of verb inflections vary considerably flected verb-form treatments (described above) as an indica- (Faroqui-Shah & Thompson. 644 Section IV ■ Traditional Approaches to Language Intervention “The horse will jump” “The horse is jumping” “The horse has jumped” Figure 24–6. Mitchum et al.. Berndt and (Faroqui-Shah & Thompson. 2003). For example. depen- colleagues (1997) argued that only a small percentage of dence on the present-progressive verb inflection (-ing) is cases involving impaired verb production may be attributed often observed in aphasic speech..f. “today is hoovering and dusting” (c. This tence production. instead they lexical-verb representations.GRBQ344-3513G-C24[632-653]. Present. Significant improve- appreciated the concept of tense (i. therapy systemati- action picture-naming. “afternoon maybe it’s com. 1993. or as a post- for patients to use in a sentence) usually fails to improve sen. The intervention putering or going out”. he was able to arrange ment was also noted in a sentence-generation task in which sequential pictures into their temporal order). 24–6). either as a natural ten- to a localized impairment involving access to verbs’ word dency of production (Goodglass. but indicates only knowledge that an inflection (of some sort) is expected. He also tended to inflect formed sentences to express a future-. L.75 0. (written) “will”  verb “is”  verb  “ing” “has”  verb  “ed” before therapy 0. ment was at an earlier level). Verb-centered therapies have been generally success. produced well-formed active- voice sentences without difficulty. The few responses that exploits the structural information encoded in verb repre. phology was trained using sequential pictures. All three par. However. strategic avoidance of the target passive (as in stimulus #2). Mitchum & Berndt. 2003. Pictures were not pre- sented in sequential order for these assessments. 2001.L. & McCall. contained a passive structure were anomalous in meaning. and of a greater number tition training was not effective in improving his passive sen- of verb arguments.25 0. As shown in Table 24–2. gen.00 1. establish a link between active and passive sentence meanings Rochon & Reichman. Mitchum et al.00 after therapy 1. learned to produce passive sen- Rochon and Reichman (2003) describe a phase of ther. tences by linking the change in word order and verb inflec- apy in which their participant (DH) was trained to produce tion of the passive to its counterpart active structure. lack of integration between the actor/object (stimuli #3 to #5). After . present-.00 after therapy 0. Weinrich. Two studies expanded upon the verb-tense training para. strated lexical insertion of nouns and verbs into passive sen- Shelton. A. Another example of therapy focused on non-canonical ticipants (speakers with severe aphasia) showed marked sentence production involved an unusual case of isolated improvement in verbal production and comprehension of impairment of passive-voice production.00 0. Cox.00 1.A.00 0. and past-tense mor. and McCall (1997) attempted to isolate the tence frames marked for tense with sequential pictures effects of verb-tense training to the Functional Level using a (future. In response to this therapy. present. sentations and draws attention to the need for structure in presumably he was aware that walls cannot paint girls (see sentences. Rather. A. elicited before and after therapy to improve grammatical sentence production.88 0. all in conjunction with an inability to pro- types. ity to use active sentences. 2000) was a fluent eralization to untrained verbs was also noted (Rochon & speaker with intact comprehension of semantically Reichman. sured by increased use of lexical verbs (often within the Following a demonstration that extensive sentence-repe- trained verb class or semantic field). (spoken) “will”  verb “is”  verb  “ing” “has”  verb  “ed” before therapy 0.qxd 1/21/08 1:33 PM Page 645 Aptara Inc.. Many attempts revealed either sentence meaning can be modified with grammatical ele. Using a written anagram version of non-canonical sentences requires explicit retraining. Boser. 2000.GRBQ344-3513G-C24[632-653]. duce passive sentences in a constrained production task.. non-canonical sentences using therapy tasks that demon- digm reported by Mitchum and Berndt (1994). there is considerable evidence tence production (presumably because the source of impair- that verb-centered therapy does not readily affect the pro. These reversible sentences and flawless repetition of active and studies observed no generalization to untrained sentence passive sentences. A.38 *n  8 per type. 24–6)* M. Future-. an intervention was designed to duction of non-canonical structures (Mitchum et al. past).L. when con- Verb Retrieval: Non-Canonical Sentence Structures strained to start his sentence with a non-agentive noun his The attention to grammatical frames focusing on verb tense responses were clearly impaired. Weinrich. Chapter 24 ■ Comprehension and Production of Sentences 645 TABLE 24–1 Proportion of Sentences Containing the Target Verb Morphology Needed to Describe Sequential-Action Picture Stimuli (shown in Fig. or some otherwise inadequate sentence (stimuli #6 to #8). (described in sentences with tense-marked verbs following training. improved production at the pre-phonologic level.L. 1999). DH computerized iconic symbol system that focused therapy on learned to use passive sentences in narrative production and the insertion of lexical terms (object/action icons) into a other untrained conditions.75 0. ful in establishing improved sentence production as mea. However. but at some expense to his abil- grammatical frame. a ments.00 E. This points out to the speaker with aphasia that response to stimulus #1). 2003). of a sentence-order task. ” “The fence . . 1987). The same picture is used in separate test sessions to elicit each type of sentence.g. . others consider how therapy This is.” “The bike is . & Pate.’s intact comprehension of results. The treat. Saffran. Schwartz.” “The apple . is paramount. In Garrett’s (1988) model this indicated the effects of aphasia treatments have led to better under.” (6) man cutting a rope “The man is cutting the rope. sentence structures and of motivating them by attention to 1983. underlined in the examples.g. Saffran. .L. studies demonstrated spared sensitivity to syntactic struc- ipants and generalized to untrained exemplars.” (2) girl kicking a boy “The girl is kicking the boy.” “The rope is .” (8) horse jumping a fence “The horse is jumping.L. Schwartz.. but not to ture in grammaticality judgment tasks in patients with poor (theoretically) unrelated sentence types. required additional training in sentence interpreting sentence-processing therapy effects. . Successful therapies do not need to pin. sentence meaning. However. comprehension.L. attempts to interpret (for production). there cognitive function will inevitably lead to a better under- was no decline in the production of active sentences follow.” (4) boy eating an apple “The boy is eating the apple.g. comprehension because of a more general inability to elaborate a syntactic required pointing to constituents (in pictures) with no verbal structure (Berndt & Caramazza.” (5) girl riding bike “The girl is riding a bike. Anagram words were used to build sentences. . agent/object). by Rochon and Reichmann (2003). piecemeal. Production treatment interpreting grammatical morphemes (Kean. ing passive-sentence training. 2004). an inability to map between the Functional. 646 Section IV ■ Traditional Approaches to Language Intervention TABLE 24–2 Sample of A. .” “The boy is perturbed because the girl is kicking the boy. early analyses of agrammatism (the “syntactic- meaning. but rather from an inabil- INTERPRETING THE EFFECTS OF TREATMENT ity to coordinate the representations of syntactic functions While many model-driven therapies attempt to target spe. that is. . subject/object) and thematic roles (e. A therapy procedure described by Jacobs and Thompson The Mapping-Deficit Hypothesis (2000) similarly linked canonical and noncanonical struc- tures (passives and object clefts) to the same underlying As noted above.L.” “The tea is hot. An understanding of how therapy affects obtained with D. therapy proved successful. text of a normal production model have provided a basis for whereas D. Peach & Wong.and standing of what might have occurred in therapy.” “The wall is painting the girl. This failure has been which cognitive mechanisms were used to accomplish the termed the “Mapping-Deficit Hypothesis” (MDH) (Saffran . The treatment was effective with all (four) partic.GRBQ344-3513G-C24[632-653]. an inability to relate surface-structure can “exercise” integration of the various subprocesses that cues to the underlying sentence meaning. (e. . However. Linebarger.. thematic role assignment (for comprehension) or to point the locus of treatment effects to be clinically relevant express thematic roles appropriately in a sentence structure (e.” “The box . not very pretty. a series of response. . Unlike the result treatment task. . Linebarger. standing of which treatment approach is most appropriate. 12 sessions. of Positional-Level representations. & Linebarger. & Saffran. This study further sentence comprehension and production of reversible sen- supports the necessity of direct training of noncanonical tences (Linebarger.qxd 1/21/08 1:33 PM Page 646 Aptara Inc. in effect. . These findings indicated that the patients’ difficulties did not arise from poor repre- sentation of syntactic information. and deficit hypothesis”) attributed both comprehension and pro- to demonstrate the moved content words and changes in the duction impairments associated with agrammatism to an grammatical frame for noncanonical sentences. One factor in the different and has the potential to offer the most widely applicable outcomes may have been A. Schwartz. 1998. inability to establish a full syntactic representation (at the ment was preceded by attention to the central action (verb) Positional Level) either because of difficultly producing and and its thematic role relations. 1980). 1979) or required oral reading of the final sentence.” (3) man drinking tea “The man is drinking from the cup.” * Responses are constrained by the requirement that each sentence start with the agent noun (for active targets) or the non-agent noun (for passive targets).. cific functional components. as expressed by support production. 1990.” (7) boy pushing a box “The boy is fixing the boxes. Therapy studies designed and executed in the con- both active and passive sentences at the start of intervention.’s Responses in a Task of Picture Description* Stimulus Constrained Active Response Constrained Passive Response (1) girl painting wall “The girl is painting the wall. 1994). Nickels et al. access to verb-specific mapping rules. and they implicate a different. Despite their materials and conditions. many sentence-comprehension treat. studies are motivated by assessment of what the speaker (or Saffran and Schwartz and colleagues (1987. 2000. (The arrows characterize the shift in word designed to improve thematic mapping between the order for two sentence types with shared meaning. 1988) proposed listener) fails to establish at the various representational a “procedural” variant of the MDH. and to gen- for therapy (for reviews of “mapping” therapies. Rather. Nickels et al. 1991). implicating the levels. & importance of considering the transfer of information from Scofield. source of impairment in the patients Impaired thematic/syntactic mapping has been attributed to who participated (Fink. Schwartz et al. Chapter 24 ■ Comprehension and Production of Sentences 647 Canonical sentence order: structure (Functional-Level representation). According to Saffran cognitive neuropsychology.. and most Thematic roles: patient/theme action agent demonstrate persistent sentence-processing impairment. 1988.. canonical sentences with a duction and comprehension represent a homogenous entity. Mapping therapies have been generally quite successful in Noncanonical sentence order: improving sentence comprehension for trained reversible Meaning: (the boy) (hits) (the woman) sentences. Mitchum & two potential sources. changes were established. Marshall. Mitchum et al. Saffran. Myers. For symptom in individual cases that seems to give rise to the more complex sentences in which the mapping is not trans- grammatical-processing impairment. (deep-structure) positions. 1995. 2001. transparent mapping between grammatical roles (subject. Mitchum et al. The “lexical” variant arises from poor Berndt. 2001. the objective of these experimental studies was not so much to Meaning: (the boy) (hits) (the woman) test the efficacy of the therapy procedure but to test the hypothesis that poor mapping ability (either lexical or pro- Active structure: the boy hits the woman cedural) was an underlying cause of impaired sentence pro- Thematic roles: agent action patient/theme cessing. this type of problem could explain the assumption that grammatically based symptoms of pro- poor interpretation of simple. Fink. The question(s) of parent (such as in passive-voice sentences in which the sub- interest have become more specific. 1991. treatments generalize across input/output modalities indi- ment studies shared the goal of linking sentence structure cate that therapy tasks that address structural cues to sen- (Positional-Level representation) to semantic/thematic tence meaning effectively improve sentence comprehension. Studies of how sentence-level different formats. if any.GRBQ344-3513G-C24[632-653]. see Fink. Marshall. 2000). The small number of highly suc- cessful results observed with mapping therapies have likely addressed a relatively pure mapping impairment in these par- & Schwartz.) Functional and Positional levels cannot assume that each rep- resentational level is intact. Noncanonical Extensive post-therapy analyses indicate that therapies Sentence Structure. 24–7). the The collective outcome of mapping therapies leads us to syntactic and grammatical information that is inherently a conclusion that parallels the direction of other research in part of the lexical-verb representation. patient) (Fig. treatment also addressed the additional impairments.. Therapies Designed to Improve Thematic Mapping Studying the Generalization of Treatment Effects The hypothesis that failure to produce and/or comprehend Cognitive-neuropsychological treatment studies typically sentences in aphasia could arise from a failure to link two assess aphasic participants’ ability to acquire trained and levels of intact representation has significant implications untrained exemplars of the treatment material. . but often reveal wide variability in patterns of gen- eralization (or lack thereof) among the participants (Marshall. Bose. 1995. it appears far more promising to look at the relative object) and thematic roles (agent. and provides a clear example of the ticular participants (Byng. Figure 24–7.qxd 1/21/08 1:33 PM Page 647 Aptara Inc. Extensive pre/post-therapy measures were provided from each study to interpret what. and whether or not information is communicated processes that move noun arguments out of their canonical between levels. and per- haps more extensive.. Most of the mapping-therapy outcomes have revealed far more lim- Identifying a Thematic Mapping Impairment ited effects of therapy. or the cases in which one level of the model to the next. Initially. Rochon. eralize what is learned to other (related and/or unrelated) 2001. Illustration of Canonical vs. Laird. 1994). Schwartz. 2005. and how they may have occurred. in other words. 1988). Therapies cannot be based on and Schwartz (1988). Model-based treatment ject noun does not map to the thematic role of agent). & Martin. 1995. Few speakers with aphasia have Passive structure: the woman is hit by the boy shown improvement on all post-therapy measures.. . equally important to identify the extent to which changes 2003. Of interest was the finding little transfer to sentence comprehension (Jacobs & that the person who demonstrated a more superficial strat- Thompson.. 2005. becoming overly of morphosyntactic elements is actively discouraged in favor dependent on normally influential cues such as word order of expanding the lexical content of telegraphic-style utter- (Caplan. 1995). 1996. Berndt. Ferreira.. including variations in the cessing resources become taxed (Kolk. 1998). Such identification typically requires testing the patient is usually “good enough” to support a correct interpretation with a variety of tasks using different response formats. established with therapy reflect shifts in strategy. 2000). 1996). it remains important to sentence production emphasizes patients’ ability to revert to recognize that our current impressions are influenced by a simplified (but normal) elliptical structures when their pro- number of complicating variables. Although consider. apparent generalization to com. Haendiges. The authors suggest that their compensatory & Mitchum. One well-developed theory of agrammatic generalization of treatment effects. 1998. 2004. This was revealed only when truncated versions of hension therapies that explicitly point out verb-centered passive sentences (i. Mitchum et al.. that was easily displaced.. Saffran. word activation and Linebarger (1995) suggests that the use of strategies is not motor speech planning” (Springer et al. Kolk & techniques used in therapy. limitations imposed by aphasia (Marshall. treatment encourages activation of Functional- only when processing failed. avoid misinterpreting the nature of their language impair- mal listeners use shallow processing for comprehension that ment. Haendiges. Level information and the mapping between thematic roles gests that individuals with aphasic language may regularly and (simple) syntactic structures. or primitive spatial strategies approach “frees up capacities for other aspects of the pro- (Chatterjee. In con. 1995). Sentence-compre. the production avoid aspects of sentence processing. This intervention is based on the view that stimuli inherent in model-based assessments can reveal severe agrammatism is a compensatory response to the much about a person’s ability to process specific sentence loss of syntactic ability that arises from the nondominant types. Mitchum and colleagues (2004) larly with regard to increased use of lexical verbs and an demonstrated the clinical utility of identifying response increased number of noun arguments (Byng. research sug. with aphasia should be considered in diagnostic testing to This interpretation is supported by evidence that even nor. 1994. & Heilman. symptomatic differences among VanGrunsven. Gonzalez-Rothi. 1999. Two individuals 1998.. 1994). 2002. Mitchum & Berndt. compensatory.e. as full passive structures. 83). 2004). & Berndt. For example. 648 Section IV ■ Traditional Approaches to Language Intervention but tend to remain specific to comprehension (Berndt & the superficial detection of the “by” phrase in the surface Mitchum. and the methods used to measure generalization. 2005. but rather reflects “normal mechanisms The consistent use of response strategies by individuals which have come to play an abnormally visible role” (p. Kolk stresses that these elliptical participants. It is (see also Chatterjee. 2000.GRBQ344-3513G-C24[632-653]. Huber. Schlenk. & Mitchum. Maher. 1985). Rochon et al. Interpreting Strategies Induced by Aphasia A program of production therapy has been devised based The cognitive-neuropsychological approach has offered a on Kolk’s hypothesis. Ferreira. or whether In some cases. Bailey. assessments. 2003. 2001).. Mitchum. 1999. More recently. The use of “light” verbs. 1998. a bet- prehension of passive sentences has been shown to hinge on ter understanding of how therapy affects cognitive processing . with aphasia responded to interventions that took their trast. Marshall. Jacobs & Thompson. and they may point to syntactically structured proposition in spite of the linguistic the most efficient approaches to therapy. Rochon & because the strategy represented a “good enough” approach Reichman. Like other linguistic standing assumption that strategies were used in aphasia approaches. Research findings regarding cross-modal generalization Strategies are also frequently observed in aphasic attempts are both theoretically and clinically important: patterns of at verbal sentence production. sentence-production therapy has been shown to have strategic tendencies into account. hemisphere (Springer et al. or generalization suggest how certain aspects of sentence pro. Mitchum & able insights have been gained in recent years with regard to Berndt. like message planning. biases in tests of sentence comprehension. 1992). particu.. 2000). strategies are detected in post-therapy they represent a fundamental change in cognitive processing. verb-specific mapping information (Berndt ances. 1988. Although any positive change is a welcomed outcome. duction process. egy was more responsive to intervention. 2000. 2000). and to use strategies when needed. Haendiges et al. passives without the “by” phrase such thematic role relations and retrieval of predicate-argument as “the boy was hit”) were not interpreted at the same level structures have some effect on sentence production. Fink et al. structures are a type of speech register that may be used by normal speakers in some conditions.qxd 1/21/08 1:33 PM Page 648 Aptara Inc. However. presumably 1993. Murray et al. & Basilico. & Ferraro. The detailed Syntax Therapy (REST) (Springer. & attention to response patterns and subtle manipulations of Schlenk. simplified structures. structure (Berndt & Mitchum. Springer and colleagues describe good framework for the identification and interpretation of results for German speakers with aphasia using Reduced strategies used by individuals with aphasia. It was a long. such as when talking to a foreign speaker. implicates an attempt to produce a cessing are shared across modalities. Southwood. 1995). event. impaired verb retrieval) can tence-processing pattern observed in individual arise from multiple sources in the sentence-production cases. such as sen- duction of canonical structures. or in groups of individuals who share (at least) process. from therapy that directs attention to the link chological studies of aphasia continue to offer a framework between conceptual information about an event and for addressing this challenge by approaching the problem in the elements that allow for linguistic encoding of the terms of the difference between normal and aphasic lan. Although the studies cited here describe experimen- research should be directed at refining the basis for selecting tal therapies. there will be a ticular therapy. At the same time. The set of symptoms traditionally associated with agrammatism do not always occur together.. the extent to which models of normal cog- 6. Treatments that isolate later levels of lexical repre- tion).g. An important finding is that the most effec- generalize within and across cognitive domains. and it provides a basis for therapy that seeks either many of the treatment approaches described here to restore normal function. chological interpretation of aphasic sentence pro- ropsychology has served to reveal the complexity of the cessing are largely conducted as a research endeavor. are useful in this regard. with the expectation that therapy may gener- alize to sentences and narrative contexts (assuming KEY POINTS that there are no additional impairments). Such effects are likely. to be limited to the pro- 1. such studies illustrate an better account of the flow of information within and across approach to diagnosis and intervention that evolves levels of representation. is generally not intended to test the efficacy of a par- As models of normal cognition improve. Studies of the manner in which treatment effects nition can be applied to clinical intervention will generalize within and among cognitive domains have improve. the unique combination of spared and impaired function of 3. . or to find new or compensatory have direct clinical relevance. and theories of normal sentence processing are tence structures. However. Although damage. advanced. More often. In this respect. A more detailed understanding of from an understanding of the differences between normal cognition will provide a much-needed basis to normal and aphasic language. however. some general clinical implications have a therapy approach. Even underspecified models clause). aphasic condition. Rather. Current approaches to the Cognitive-neuropsychological studies have contributed to a study of sentence production and comprehension in better understanding of sentence-processing impairments in aphasia seek to explain how a particular symptom patients with aphasia. word forms) are effective only in a small percentage Increased interest in individual therapy outcomes dictates of cases. such as meaning and thematic relations. with studies of how treatment effects emerged. and how such a symptom may be embedded within the symptom of interest. serve sentation (such as traditional “picture-naming” ther- to support language in various ways and at multiple points in apies that practice repeated access to phonologic processing. An understanding of noun/verb role relations is a nostic “labels” that reiterate the symptoms of impairment. Improved production tence processing. can be used to guide diagnosis and of noncanonical structures (passive. develop a theory of the therapy process itself. a cognitive-neuropsy. A less. cognitive neu.GRBQ344-3513G-C24[632-653]. Therapy that targets this element of production can be limited to single words. critical element of sentence production that can be retrained effectively in aphasia. As models are further devel- appears to require specific retraining of those sen- oped. traditionally viewed as nonlinguistic functions. the best outcomes are obtained an individualized approach to therapy. object-relative intervention in aphasia. In this chapter. and not as an effort to classify individuals under diag. Treatment studies based on a cognitive-neuropsy- each individual with aphasia. guage. 2. the recent emphasis on evidence-based chological analysis offers a structured means of accounting therapy has forged a more direct and urgent link for the differences in function that may be imposed by brain between research and clinical intervention. tive therapies for improving sentence production are developed area that is beginning to receive more attention is those that integrate the full production process. 5. how certain cognitive domains (such as memory and percep. making it clear that agrammatism does not constitute a FUTURE TRENDS clearly defined syndrome. the goal of such studies ways to communicate around the impairment. which give production improved flexibility. we illustrated how (such as poor verb retrieval) contributes to the sen- even a single symptom (e. Chapter 24 ■ Comprehension and Production of Sentences 649 leads to a more efficient basis for matching the treatment candidate to the most effective intervention. Cognitive-neuropsy. Future 4. Models of normal cognitive function.qxd 1/21/08 1:33 PM Page 649 Aptara Inc. 11. How can sequential pictures be used to assess the • “She pushed him right on there” (points to the boy’s ability to produce and comprehend grammatical leg). (2) pouring. At the any other ways to assess the ability to process gram- sentence level. the major fail to produce any verbs. processing. Use the model of normal sentence production (Fig. tion” at the Message Level? How would an impaired rent studies indicate that therapy directed at compre. Note what changes occur in the sentence temporal and storage requirements that this trans.e. (3) covered. Current research using implemented roles of the nouns change or remain constant with dif- computational models of word production are begin. How does structural priming differ in normal speakers as opposed to speakers with aphasia.. Why is it difficult to pinpoint the exact location of impaired sentence processing within the model of nor- 1. stimuli? Was a semantically meaningful verb used? Does the 4. A deficiency of this approach (noted several times in 24–4. ferent verbs? Is it necessary to name the instrument ning to contribute importantly to our understanding (e. go/went. Message Level. What is the cognitive-neuropsychological approach to mal sentence processing? assessment and intervention of aphasia? How do the 10. Describe how Garrett and other researchers used the speaker seem to use grammatical morphemes effec- errors of normal speakers to develop a model of nor. What responses would be produced for the fol- this review) is a lack of specificity about the details of lowing verbs: (1) burying. 650 Section IV ■ Traditional Approaches to Language Intervention morphemes? (Hint: see Fig. retrieve lexical verbs? Use some of the speech samples lowing example in your description: The dog is chasing in this chapter to support your response. the cat. Describe the effect of structural priming at the Positional Level of sentence production. structure based on the choice of verb. These findings remain preliminary. . etc. but not in others? of these issues. and of the playing.) and are subject to further refinement through 7. tively? Repeat the exercise with the following mal sentence production? responses: 5. (4) information transmission among levels. 24–1 and 24–7). Rather. convey in the response. Use Garrett’s same task requirements as sentence production? Is it terms to describe each level of representation that is possible to produce some verbs (e. Positional Level. speakers with aphasia who show poor verb retrieval in types of aphasia? naming action pictures. One of the least-developed aspects of this tion is the selection of a verb to describe the action in area of research is with regard to isolating the ele. have/got. ability to construct an event representation result in hension tends to generalize to production. A verb-based approach to therapy is indicated only for fer from more traditional approaches that classify sub. (2) A verb-based approach to 2. Consider the following sequence of processing events that leads to the produc. a speaker with aphasia says “She really got ‘em on canonical sentence structures (see Figs. whereas difficulty producing sentences? (Refer to the aphasic production therapy has a minimal effect on sentence speech samples in the chapter. points in your response: Does picture naming have the tion of a single. 24–6. own example.qxd 1/21/08 1:33 PM Page 650 Aptara Inc.). the thematic roles of the actors (nouns) in the picture? and poorer performance with noncanonical.. or try to create your comprehension. therapy is indicated only for speakers with aphasia who 24–2) to describe. cur. the leg. Did he or she correctly express cessing result in better performance with canonical. and have great potential to “scale up” Repeat the exercise with other pictures or stimuli that to incorporate elements that are specific to sentence are used to elicit sentences. Do the thematic mission entails. come) despite having an impaired ability to Functional Level.” Describe what the speaker does and does not Why does a “word-order” strategy for sentence pro.GRBQ344-3513G-C24[632-653]. A major feature of the Functional-Level representa- research. 8. according to the study by Hartsuiker & Kolk (1998)? ACTIVITIES FOR REFLECTION AND DISCUSSION 9. recent studies indicate that general.g. ent responses that describe the event shown in Figure 7. achieved during production (i. well-formed sentence. Use the fol. matical morphemes in sentences? ization between production and comprehension of 6. Upon viewing a picture of a girl kicking a boy in the 3. How does the choice of verb influence the ments of production and comprehension that are content and structure of the sentence? Consider differ- employed during intervention. in your own words. Explain the difference between canonical and non. shin. What is the ability to construct an “event representa- sentences is not equally bi-directional. “sand”) in some sentences. the event. Explain why the following two statements are false: (1) goals of cognitive-neuropsychological assessment dif.g..) Can you think of important implications for aphasia therapy. ” Berndt. An analysis of speech error data.... Sandson. tences. conduct of much of the research reviewed here. C. Gonzalez-Rothi. & Levelt. Berndt (Ed. (2005). 21. 223–270). T. (2005). Thinking for Berndt. sentences? Is improved sentence production a reason. Wernicke’s aphasia.). R. Academic Press. Dipper. E. R. Holland (Eds. In M. processing and disorders. & Berndt. (1986).D. & Howard. Cognitive Neuropsychology.. were sup. 36. production. Asyntactic thematic role assignment: The use of a Berndt. Gernsbacher (Ed. Bresnan. Comprehension of reversible sentences in aphasia: The Ferreira. Z. (1997). 1–18.. Sarno temporal-spatial strategy. A. Mitchum. & Zurif. Applied Psycholinguistics. S. New York: Dean. 49. R.. Sentence processing deficits: Theory and therapy. B.. ing. P. Many people Caplan. on Deafness and Other Communication Disorders to the Cognitive Neuropsychology. . no shin. C. 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Our vocabulary of written words is variously referred such as electronic mail. and then describe how impairments to specified representa- Maya L. graphic input lexicon (the term that we will use here. graphemic input lexicon.qxd 01/22/08 06:41 PM Page 654 Aptara(PPG Quark) Chapter 25 Comprehension and Production of Written Words Pélagie M. Beeson and the component processes that support reading and writing. When effort to understand the nature of a patient’s impairment by reading aloud (and often when reading silently). The major focus of this chapter is the review of evidence-based treatments for acquired alexia and The purpose of this chapter is: agraphia. the letter com- today’s society. the functional consequences of reading store of letter strings that we recognize as familiar words. ative ease as we recognize a string of letters as a word and Despite the fact that most individuals with aphasia have comprehend its meaning. and what skills are phonological output lexicon. the tions (see review in Tainturier & Rapp. This may reflect the ple. To provide a description of treatment procedures for Reading of familiar words is typically accomplished with rel- specific alexia and agraphia profiles. however. the figures in this chapter. purpose of this chapter is to describe numerous approaches Under normal circumstances. writing styles. We will not review the neural substrates for written language processing. 3. These impairment-based approaches constitute a central component of treatment plans that have as their ulti- 1. functional changes spelling familiar and unfamiliar words. to as the visual input lexicon. In each case. Our approach to treatment begins with an system. which are 654 . this activated representation spared. we have depicted the cognitive The limited attention given to reading and writing reha. processes that support reading and spelling with distinct bilitation may also reflect. limited knowledge of input and output lexicons. face-to-face communication is bination is recognized as the spelling for a word that we increasingly replaced by written communication in forms know. we are able to recognize the letter identities treatment directed toward the improvement of reading and that comprise a written word. in this chapter. To describe assessment procedures for the comprehen- sion and production of written words. Despite the myriad of possible impaired comprehension and production of written words. as shown news and entertainment. we access determining what processes and representations necessary the stored representations for word pronunciations in the for reading and writing are impaired.GRBQ344-3513G-C25[654-688]. automated machines for banking. Therefore. To delineate the processes necessary for reading and mate goal the facilitation of meaningful. or ortho- postage. In and writing impairments can be quite significant. with particular emphasis on single-word processing. 25–1). and Internet sites for chatting. 2001). allowing us to comprehend the words we read. but refer the interested reader to reviews by Hillis and Tuffash (2002) and Rapcsak and OBJECTIVES Beeson (2002). In apple  apple  apple  apple. The orthographic input lexicon is the mental merchandise. In turn. that treatment approaches for acquired alexia and agraphia in reading and spelling may rely on shared lexical representa- comparison to the treatment of spoken language. in patients’ lives. Henry tions and processes result in reading and writing distur- bances. is activated by any of the following font styles: apple  prominence of spoken communication in our daily lives. 2. we begin with a review of accesses the component phonemes of the word. READING 4. managing finances. however.” for exam- spelling abilities is often limited. in part. To describe the nature of acquired impairments of read- ing and spelling. orthographic representa- that have been shown to be effective for reading and spelling tions activate the appropriate word meaning in the semantic impairments. and airline check-in. We acknowledge. particu. dashed lines) as the letter-to-sound conversion route. we convert this is shown as follows: written word (apple) → orthographic letters (or clusters of letters) to the appropriate sounds and input lexicon → semantic system → phonological output lexi.GRBQ344-3513G-C25[654-688]. Schwartz. An obvious feature of the phonological approach is that it only When we attempt to read unfamiliar words. the orthographic This reading process is considered a sublexical. This cascade of events is referred to as reading Letters or letter clusters that correspond to a single via the lexical semantic route. Although we typically use this sublexi- because whole words are processed. ure via the lexical-semantic route. Reading asked to read pronounceable nonwords or pseudowords. for example. phonology conversion. while we plan the appropriate articulatory relatively predictable relations between letters and sounds. Schematic depiction of the component representations and processes for single-word reading and spelling. input lexicon directly addresses the phonological output reading route because it does not depend on activation of lexicon. there is no works well if the letter-to-sound correspondences are pre- corresponding representation to access in our orthographic dictable. or simply the phonological reading route. This approach is depicted in Figure 25-1 (with Although reading typically activates semantic knowledge. Saffran. so we may take advantage of our knowledge of phonological buffer. nunciation. The solid lines depict lexical-semantic routes and the dashed lines indicate sublexical routes. & Marin. In that case. 1998. but it is a nonsemantic cal route to read unfamiliar words. In Figure 25-1. or nonlexical.qxd 01/22/08 06:41 PM Page 655 Aptara(PPG Quark) Chapter 25 ■ Comprehension and Production of Written Words 655 apple e [æp l] Phonological Visual Orthographic input lexicon representation input lexicon Sound-to-Letter Letter-to-sound conversion conversion Semantic Orthographic system Phonological output lexicon output lexicon Graphemic Phonological buffer buffer apple “apple” Figure 25–1. We can all referred to as grapheme-to-phoneme conversion. because we derive semantic phoneme are referred to as graphemes. 1987). held in a short-term storage mechanism referred to as the input lexicon. Because there are a large number of irregularly . orthography-to- recall occasions when we are reading aloud without process. In this way. ing the meaning of the words. assemble them to produce plausible attempts at their pro- con → phonological buffer → spoken word (“apple”). movements. This is a lexical route words in our lexicon. like without meaning is a rare occurrence for healthy adults. are both graphemes for the sound /f/. patients may rely on this larly those with dementia (Greenwald & Berndt. sublexical approach for reading both words and nonwords. it is also it is possible to read without accessing meaning. it can be used if we are route because word meanings are not activated. f and ph meaning by activation of words in the lexicon. but “flig” or “merber.” When brain damage causes reading fail- is characteristic of some brain-damaged individuals. and meaning is bypassed. When possible. Controlled word lists are available in the the reading impairment. orthographic input lexicon. the word “sword” might be mispro. the phonologic output lexicon is accessed for both tence and paragraph levels. frequency of use.GRBQ344-3513G-C25[654-688]. Reg  regular spelling.qxd 01/22/08 06:41 PM Page 656 Aptara(PPG Quark) 656 Section IV ■ Traditional Approaches to Language Intervention spelled words in English. such as processing of single words Adult Reading Function (Rothi. Coslett. as well as reading. can be screened using subtests from standardized aphasia TABLE 25–1 Summary of the Primary Features of Various Acquired Alexia Profiles Clinical Features Spelling Imageability/ Inability Locus of Example Word Length Regularity Frequency Concreteness Word Class to Read Semantic Damage Syndrome Short  Long Reg  Irreg HF  LF HI  LI NF Nonwords Errors Access to Letter-by. Sentence and paragraph reading oral naming and oral reading tasks. part of Impairments of Reading speech. the sublexical route is susceptible mance for single-word comprehension and production in to error. Dysgraphia Battery (Goodman & Caramazza. the hypothesized locus (or nounced because of failure to appreciate the silent “w. Kay. written and spoken modalities. 1986). reading should also be assessed at sen- Similarly. and oral naming. The information gained from per- are shared with other lexical processing tasks.. LI  low imagery. written. 1986). formance on these controlled word lists will be discussed fur- semantic processing is necessary for auditory comprehen. which is Some processing components are specific to reading (e. the Battery of tations and processes. Psycholinguistic Assessments of Language Processing in Aphasia mance on tasks that are dependent upon specified represen. Maya  /maIıy\/. can be obtained by examining what types of words pose the greatest problem for reading.” loci) of impairment may be isolated. & Heilman. √ orthographic letter reading input lexicon Orthographic Surface alexia √ √ input lexicon Sublexical (letter. or nonverbal (pointing) responses. written. F  functors. Clues regarding the location of damage Pelagie  [peılAıZiı]. (PALPA. 1992). HF  high frequency. & Coltheart. sion tasks. Phonological √ √ √ √ to-sound) alexia procedures Semantics and Deep alexia √ √ √ √ √ letter-to-sound conversion Access to Surface alexia √ √ phonological output lexicon Key: √  significant disturbance. it is helpful to examine perfor. whereas other components for reading single words. For example. By contrasting perfor. LF  low frequency. presented variously in spoken. . In order to isolate the source of Table 25–1. The word lists provide contrasts visual analysis of letter strings. Carefully constructed word lists that control for lexical features such as word length. also present a challenge because the sound-to-letter modalities. it is also informative to determine the influence of correspondences may be difficult to predict: various lexical features on reading accuracy (and reading speed. N  nouns. ther in the context of specific reading impairments.g. and pictured forms and the Johns Hopkins University (JHU) Dyslexia and with spoken. like the first names of the authors of this In addition to examining performance across language chapter. HI  high imagery. as shown in reading in a variety of ways. Lesser. included in Appendix 25-1. Proper names. and concreteness (or imagery) are Neurologic damage can disturb the processes necessary for useful to discern the nature of the impairment. in some cases). of lexical features that allow examination of various processes and letter-to-sound conversion). writing. For example. Irreg  irregular/exceptional spelling. production of written language. Wiederholt & Bryant. The first approach. Kaplan.. a patient may fail to recognize the word apple but decrease. A different treat- ments will be reviewed in an order that starts at the process. was hypothesized that repeated reading of the same text served. word-length effect and thus. 2006) and the Boston Diagnostic Aphasia meaning is easily accessed because there is no impairment of Examination. Fourth Edition read and are more prone to errors than short words. & individual letters are perceived. 2000). rather than letter-by- Lexicon: Pure Alexia letter. There is also no difficulty in saying the Barresi. individuals with The text used for MOR treatment should be controlled pure alexia are able to quickly recognize words that are for length and complexity. the improved reading for prac- ter-by-letter reading shown as a compensatory strategy. with regard to the complexity of the stimuli used for treat- ment will be reviewed here. and reading accuracy typi- & Horner. 1993. and evidence-based treatment ment: text. Moyer. as shown in Table 25-1. In particular. For graphic input lexicon so that letter-by-letter reading can example. long words take more time to For example. Rapcsak & pensatory strategies to support reading. (GORT-4. Third Edition (BDAE-3. reading. access to the orthographic input lexicon or to provide com- 1992. as well as comprehension. apple. Goodglass. cally is not strongly affected by features such as word fre- tences. The GORT-4 is culty with letter identification. 1991).” structured homework in which selected text is read aloud A schematic depiction of the impaired access to the repeatedly so that reading rate improves and reading errors orthographic input lexicon is shown in Figure 25–2 with let. LaPointe disrupted for all types of words. or assessment tool for reading at the paragraph level. via the compensatory letter-naming route. We multiple oral rereading. When successful. Tuomainen & Laine. available. Essentially. is thought to strengthen access to will show how the hypothesized nature of the impairment the orthographic input lexicon either in a direct manner or can help to guide the treatment approach. decrease. approaches are reported for each of the various patterns. Many individuals with pure alexia are able to per. previously unread) text that more closely approx- and letter naming may provide an alternative means of acti. It der is specific to reading. 1989). spelled aloud to them. however. some of regularity of spelling. novel (i. grammatical class. or single letters.GRBQ344-3513G-C25[654-688].. word reading because of the support provided by sentence ceive and name the letters of words that they fail to recog. and paragraphs. sen. there is a marked reading disorders are useful for examining acquired alexia. and the Reading In pure alexia. In the absence of a comprehensive quency. 1992. concreteness (or imageability). 1998). In some cases. while writing ability remains pre. Beeson. described in Table 25–2. Several researchers have shown this procedure In some cases of neurologic damage. The procedures for implementing MOR are after spelling it aloud (or subvocally) quickly acknowledges. even though the by-letter readers (Beeson. its Kertesz. which limits the effectiveness particularly useful in that alternate forms (A and B) are of letter-by-letter reading even further. cific to the visual modality.qxd 01/22/08 06:41 PM Page 657 Aptara(PPG Quark) Chapter 25 ■ Comprehension and Production of Written Words 657 tests including the Western Aphasia Battery-R (WAB-R. Multiple oral rereading (MOR) entails the use of repeated reading aloud of a given text as a Impaired Access to the Orthographic Input means of facilitating whole-word. 2002). When words the tests designed for the examination of developmental are decoded letter-by-letter. Several patterns of acquired reading impair. 2001) provides short essays there is often a linear increase in reading time as a function of graded difficulty that can be used to assess reading rate of the number of letters. but there are discernible pat- terns of impairment that have been recognized as various Several treatment approaches have been shown to improve acquired alexia syndromes (Ellis. & the semantic system. 1992) also provides word aloud once it has been recognized. Reading impair. Robey. As ticed text is accompanied by improvement in reading of indicated. context and familiarity with the text. 1998) samples reading for single words. the average word . there is also diffi- and accuracy. Margolin & Goodman-Schulman.e. imates normal adult oral reading rates. The pattern of impaired and preserved reading processes Treatment for Pure Alexia will differ among individuals. and if they spell the word letter-by-letter it often helps thought to improve or re-establish access to the ortho- them identify the word (see papers in Colheart. Multiple Oral Rereading. some sentence-comprehension subtests. ment approach is appropriate for patients who show ing of visual input and ends with impairments in the spoken impaired letter identification. This approach is nize. Magloire. single words. The treatments vary Beeson. 2005. this disor. to be effective as a means to increase reading rate in letter- nize strings of letters as familiar words. The deficit is spe. Hillis & Caramazza. so in most cases. In its pure form. which range from vating the orthographic representations. the orthographic input lexicon is not impaired. the treatment involves “oh. patients fail to recog. 150 to 200 wpm (Rayner & Pollatsek. In fact. Once a word is properly identified. so it is referred to as pure alexia or alexia without facilitates a shift from letter-by-letter reading to whole- agraphia. the Gray Oral Reading Test. 1979. The PALPA (Kay et al. access to the orthographic input lexicon is Comprehension Battery for Aphasia-2 (RCBA-2. 1998. apple” Figure 25–2. new passages are introduced for repeated Microsoft® Office Word 2003. Reading material can also be duration of MOR needed to be effective. If the text is in electronic for. Rogers. Schematic representation of impaired access to the orthographic input lexi- con with strategic compensation in the form of letter-by-letter reading. Treatment studies completion of the spelling and grammar check. and check generalized improvements. Parker & Scannell.” Then run the viously unread passages are sampled during weekly therapy “spelling and grammar” check on the “tools” menu. Fishbourne. and the Internet. 30 minutes a day. The expected outcome is a steady improvement in . the difficulty level can be appraised using readability for the practiced text has been used with even the slowest of indices. 1998). therapeutic effects selected from readily available sources including books. To test whether MOR results in select tools → options → spelling and grammar... Research Associates (SRA. reading rates and accuracy for pre- the box for “show readability statistics. such as grade level (from 1 to 12) according to Flesch-Kincaid is passages from the Reading Laboratory by Scientific returned.GRBQ344-3513G-C25[654-688]. letter-by-letter readers (10 seconds per word. 1998) because Although no studies document the ideal intensity and it has graded levels of difficulty. length will affect reading performance. a reading implementing MOR have used standardized text. To do so using Once achieved. At the sessions. A criterion rate of 100 words per minute mat. use the pull-down menu to oral reading as homework. 1975). have been documented with a homework schedule of at least magazines. Beeson. & Chissom. Bold black hash marks indicate disrupted process. such as the Flesch-Kincaid grade level (Kincaid.qxd 01/22/08 06:41 PM Page 658 Aptara(PPG Quark) 658 Section IV ■ Traditional Approaches to Language Intervention e [æp l] apple Visual analysis Letter naming a-p-p-l-e Phonological Visual Orthographic input lexicon representation input lexicon Semantic system Orthographic Phonological output lexicon output lexicon Graphemic Phonological buffer buffer apple “a-p-p-l-e. three. Slow readers have shown improvement pure alexia might be stimulated to use this implicit knowl- that is two. Establish multiple oral rereading procedures. Step 2. Step 2. 1998). and colleagues reported failure of this treatment approach The motivation for this treatment came from the observa.. above chance. P. (After Beeson. *Rationale: Multiple oral rereading is thought to improve access to the orthographic input lexicon. a. provide a new passage for MOR homework. 2) Agree upon daily homework schedule. Keep a graphic plot of reading rate and accuracy. B. to achieve 50 wpm or 100 wpm. word. Treatment for letter-by-letter reading: A case study. ment sessions) in Rothi and Moss’s patient. In N. or simply note completion of homework on a daily basis..g. Rothi exposures so that letter-by-letter reading is not possible. However. Review patient’s log to confirm consistency in completing MOR homework.qxd 01/22/08 06:41 PM Page 659 Aptara(PPG Quark) Chapter 25 ■ Comprehension and Production of Written Words 659 TABLE 25–2 Steps for Implementing Multiple Oral Rereading (MOR) Treatment Approach* A. Ochipa. Provide a new passage (about 100 words) for oral reading to determine whether reading rate or accuracy for new material improves. 1) Provide a copy of the written text for homework. San Diego: Singular Press. Select a passage of appropriate difficulty. & to derive some meaning from words that they cannot explic.. and four times their pre-treatment reading edge gained from brief whole-word “reading” to facilitate rates. (1998). a. 3) Establish a log for recording completion of homework. Calculate reading rate in words per minute and score reading errors in terms of number of deviations from print (self- corrected errors may be tallied separately). Step 4.g. suggesting that it icon involves the presentation of written words for brief facilitated recovery of whole-word reading. Response accuracy was such as 50 wpm. indicating some ability to apprehend the whole word at an implicit level. when deemed necessary. Have the patient reread the text. 1994). Barrett. with two other patients (Maher. M.g. a. 30 minutes of repeated oral reading of specific text once or twice daily. Determine target rate for practiced text.g. to be used as practice text. This brief exposure proce- Brief Orthographic Exposure. Helm-Estabrooks & A. e. so that reliance on letter-by-letter reading decreases and whole-word recognition improves. Determine reading rate and accuracy for new (previously unread) text. Multiple repetitions during therapy sessions provide an opportunity to increase familiarity with text. Clayton. e. Ask the patient to read the text aloud allowing for letter-by-letter decoding as needed. Step 3. . L. 100-word segment. reading rate for new text while maintaining (or improving) Rothi and Moss (1992) proposed that individuals with the level of accuracy. Approaches to the treatment of aphasia (pp. & Rothi. 153–157). 1998. Initial treatment session(s) Step 1. b. a. Establish homework activity. he was encouraged to guess. providing assistance as needed to guide correction of reading errors. and should result in increased accuracy. Have the patient read practiced text aloud. 1989. Determine rate and accuracy of reading for practiced text. of people with pure alexia. b. Variations decision about the word. They used a paradigm in which single infrequent treatment sessions because it is heavily dependent words were presented on a computer screen for brief expo- upon the patient’s accomplishment of reading homework. Maher. b. suggesting that it may be useful for a subset itly name (Coslett & Saffran. sures (e.. b. A different approach to dure resulted in improved reading rate (following 20 treat- treatment for impaired access to the orthographic input lex. When target rate is attained (with acceptable accuracy) for practiced text. Schober- tion that some individuals with pure alexia retain an ability Peterson. Determine reading rate and accuracy for text-level material. Calculate and record reading rate and accuracy during each session to determine effectiveness of MOR treatment. 500 msec). comprehension and possibly to regain access to the ortho- The MOR protocol can be implemented with relatively graphic input lexicon. Subsequent therapy sessions Step 1. Holland (Eds. such as. Greenwald. and the patient was asked to make a Weekly or even biweekly sessions may be adequate. Patients may time themselves and record the time taken to read the passage.GRBQ344-3513G-C25[654-688].). Rothi. “Is it an animal?” Although in the protocol might include adjustment of the criterion the patient often indicated that he had not actually read the reading rate for practiced text from 100 wpm to a slower rate. e. c. In surface alexia. reading “on the surface” (see papers in Patterson. agraphia (or lexical agraphia) that is discussed below.e. ing of words was not possible. and phonologically A positive response to cross-modality cueing was reported plausible errors are common when spelling irregular words. word-length effect is not an essential feature associated with semantic reading route are damaged. which was read aloud by the . lead the way. letter recognition should be more notable on low frequency words compared improved. because high fre- word was adequate to cue word identification. such as homophones and homographs. This reading profile has been referred to than letter-by-letter reading. tion. This can include impaired representations in the orthographic input lexicon. homographs) may be mispronounced for a that the kinesthetic information about spelling provides given context. as surface alexia because reading is accomplished via phonol- ogy rather than meaning. individuals with surface alexia also dure has been referred to as cross-modality cueing. as indi- common goal of promoting whole-word apprehension rather cated in Table 25-1. some patients overreliance on the sublexical route while reading is confu- perceive a letter when it is traced on their palm.e. impaired representations in the orthographic input lexicon (or impaired access to orthographic representations). Letter-by-letter reading cannot be accomplished & Coltheart. and it may also take longer to Conversion: Surface Alexia sound out a long word rather than a short word. implemented using written words presented on cards and the word “blood” might be pronounced such that it rhymes shown for a brief duration rather than by computer presenta. (i. such as “dear” and “deer”). such as flake). such that simply tracing the first letter or two of a to high frequency words (see Table 25-1). though the individual’s vocabulary of written words has treatment for the reading impairment may be addressed in eroded. In the case of orthographic impairment. irregular words.. 1985). with “mood. and thus. performance is char- plausible nonwords for a lexical decision task in response to acterized by greater difficulty reading irregularly spelled the question. because longer words provide more opportunities for errors Reading with Overreliance on Letter-to-Sound in letter-to-sound conversion. the cross-cueing strategy resulted in improved word recognition impairment at the level of the orthographic input lexicon and increased reading rate. Lexical treatment may focus on words that ing may be accomplished by means of the letter-to-sound are prone to error. Maher documented that treatment using this motor reading “bypasses” the semantic system. because access Tracing the component letters of a word with one’s finger. & Sugishita. by Maher and colleagues (1998) for a patient with pure alexia reflecting a concomitant syndrome referred to as surface who had difficulty naming letters..e. copying the written word. “Is this a word?” These variations share the words when compared to regularly spelled words. Each target word was presented in print to-sound correspondences (i. In some patients. because finger. via the sublexical route). read.GRBQ344-3513G-C25[654-688]. the proce. use a phonological strategy for spelling. or when they sion of words that sound the same but are spelled differently trace the letter themselves (Seki. With practice. conversion procedure (i. when reading is accomplished via the tion. are compensatory strategies that Additionally. Yajima.” Typically.qxd 01/22/08 06:41 PM Page 660 Aptara(PPG Quark) 660 Section IV ■ Traditional Approaches to Language Intervention An adaptation of the brief exposure procedure could be yacht) pose a problem and are often misread. specific words.e. or to semantics is gained from the oral reading response. “lead” might be (incorrectly) pro- access to the orthographic input lexicon. A consequence of provided via another modality. but words that have uncommon letter. For example. and phonologically plausible errors facilitated when information regarding the letter shape is for irregularly spelled words are common. 1995). It is assumed differently (i. visually perceived words that were once the context of spelling treatment. Another variation involves contrasting real words with sublexical rather than the lexical route. however. which substitutes nounced the same in the phrases “the lead pipe” and “I will for activation of the lexicon via visual input. for example.” Thus.. as well Lexical Treatment for Surface Alexia as damage to the semantic system or the phonologic output lexicon. so letter-by-letter decod. Marshall. homophonic pairs. Because reading is accomplished by effectively if a significant number of letter identification sounding-out. Word length may have a negative effect on reading accuracy. A lexical approach to familiar now appear unfamiliar and their meaning cannot be treatment involves retraining orthographic knowledge for derived. regularly spelled words and nonwords are read errors are made. as shown Hillis (1993) demonstrated successful treatment to increase in Figure 25–3.. For example. This procedure works well for words that reliance on lexical-semantic processing for reading and have good letter-to-sound correspondences (i. such as with its written definition. there are no strong effects of lexical- tify letters in a word only after she traced each letter with her semantic features such as imageability or word class. it appears as Because surface alexia typically occurs with surface agraphia. quency words are thought to be more resistant to damage. homophones. If the ability to “sound out” words is retained.. Thus. However. letter identification is with at least fair accuracy. words that are spelled the same but pronounced can be used by the patient without assistance. a Reading is disrupted when component processes of the lexical.e. This patient was able to iden. so that it might be thought of as Cross-Modality Cueing to Enhance Letter Identifica. regular spelling in the context of retraining homographic and words. and comprehen. patients have difficulty with letter-to-sound conversion. resulting in phonologically plausible reading errors typical of surface alexia (on the right side of figure). Surface agraphia is depicted on the left side of the figure. allowing him to disambiguate homophones age. logically plausible nonwords that do not have a lexical repre- tion can force a lexical strategy for word recognition. The profile of impaired nonword (1993) showed that brief exposure to written words with reading relative to real word reading is referred to as phono- corrective feedback during oral reading resulted in item.g. Impairments of the nonlexical route are clearly evident exposures in a manner similar to that described by Rothi and when the patient is asked to read unfamiliar words or phono- colleagues in the case of pure alexia. Rapid visual presenta. When phonological abilities are impaired due to brain dam- semantic route. and homographs. Treatment limited generalization with this approach. Reading is accomplished via a Another approach to enhance reading via the lexical lexical-semantic strategy. The patient was asked to write the target word in a specific learning for trained items. as depicted in Figure 25–4. select words of functional value for the patient. “dusp”). as well as improved oral reading for the Reading with Impaired Letter-to-Sound Conversion: untrained members of the word pairs. the pair- Phonologic Alexia and Deep Alexia ing of specific orthographic representations with semantics served to strengthen the patient’s ability to read via the lexical. It reflects an inability to use sublexical . and reliance on letter-to-sound conversion to decode written words (heavy black lines). it is important to resulted in improved oral reading. Schematic representation of damage to the orthographic input lexicon (shaded). and corrective feedback was provided. clinician. such that representations in the semantic route (and to reduce overreliance on a phonological orthographic input lexicon should activate the semantic sys- strategy) involves the presentation of written words for brief tem.GRBQ344-3513G-C25[654-688].qxd 01/22/08 06:41 PM Page 661 Aptara(PPG Quark) Chapter 25 ■ Comprehension and Production of Written Words 661 [sord] sword Phonological Visual Orthographic input lexicon representation input lexicon Sound-to-letter Letter-to-sound conversion conversion Semantic system Orthographic Phonological output lexicon output lexicon Graphemic Phonological buffer buffer sord [sword] Figure 25–3. Hillis sentation (e. spelling. logical alexia. sion (as assessed by use of the word in sentence contexts) for trained words. Therefore.. Because there may be sentence. low fre.” that have a great deal of overlap with other words and are When damage to the sublexical route is accompanied by thus easily confused. In contrast. there is no regularity effect as seen therefore are most resistant to damage.. concept. idea. words but difficulty with nonwords. such that concrete words such as Because phonology provides little assistance. processes to derive the appropriate sound for a given letter. Phonological agraphia is depicted on the left side of the figure. semantic representations. in surface alexia. in that high frequency words are read bet. Schematic representation of impairment to letter-to-sound conversion pro- cedures resulting in lexicalization error on nonword reading (“dust” for “dusp”). trust. In most cases. in frequency effect. the is evident that the lexical-semantic route is vulnerable to meanings of concrete nouns like “fork” do not overlap as error when deprived of phonological input. For example. or have semantic representations “dusp” → “dust”). faith. hope. there is typ- “apple” are read better than abstract words such as “pride.GRBQ344-3513G-C25[654-688]. which ter than low frequency words. A part-of-speech (or grammati- the weakened lexical-semantic route typically results in a cal class) effect is also common in phonological alexia. difficult to define and overlaps considerably with the mean- A range of severity is observed in phonological alexia. much with other meanings. mild cases showing relatively preserved reading of real creed. thought. conviction. that nouns are read better than adjectives and verbs.” ically no difference in the reading accuracy of regularly This profile may reflect the fact that concrete.g. Abstract. principle. credence. reflecting phonological alexia (on the right side of figure). which is referred to as “lexicalization. and so on. The overreliance on the lexical route often quency words and grammatical functors have the weakest draws patients to misread nonwords as real words (e. religion. the meaning of “belief” is dysfunction of the lexical-semantic reading route. (or imageability) effect.qxd 01/22/08 06:41 PM Page 662 Aptara(PPG Quark) 662 Section IV ■ Traditional Approaches to Language Intervention v [d sp] dusp Phonological Visual Orthographic input lexicon representation input lexicon Sound-to-letter Letter-to-sound conversion conversion Semantic system Graphemic Phonological output lexicon output lexicon Graphemic Phonological buffer buffer dust “dust?” Figure 25–4. There is also a concreteness are read better than functors. In more severe cases it presumption. That is. notion. high spelled words compared to irregular words in phonological frequency nouns have stronger semantic representations and and deep alexia. semantic . with ing of many other words: confidence. GRBQ344-3513G-C25[654-688]. so it is worthwhile to determine Treatments for phonological and deep alexia may be directed whether a given patient can relearn letter-sound associa- toward sublexical or lexical reading processes.. reflecting inherent component of treatments for spelling. so there is dyslexia (Coltheart. and thus. as shown in Figure 25–5. Deep alexia is described for phonological/deep alexia with those described usually associated with extensive left hemisphere lesions.qxd 01/22/08 06:41 PM Page 663 Aptara(PPG Quark) Chapter 25 ■ Comprehension and Production of Written Words 663 apple e [æp l] Phonological Visual Graphemic input lexicon representation input lexicon Sound-to-letter Letter-to-sound conversion conversion Semantic system Graphemic Phonological output lexicon output lexicon Graphemic Phonological buffer buffer orange “orange” Figure 25–5. Deep agraphia is depicted on the left side of the figure. The train- Vargha-Khadem. Although phonological and deep alexia processes that ideally improves both language modalities. deep production of target words or text-level material. Rapcsak & Beeson. quantitative rather than qualitative differences (Glosser & clinicians may find it efficient to combine the treatments Friedman. or both. Newcombe simultaneous stimulation of written and spoken language & Marshall. cedures. It initially were considered to be distinct syndromes. 1984). or more commonly. The presence of semantic sound correspondences that supplement lexical reading pro- errors is the hallmark feature of the acquired alexia syn. Patterson. 1989). & Marshall. 1990. errors are prevalent. such as reading woman as girl. 1987. reflecting deep alexia (on the right side of the figure). Patterson. 1987. Strengthening Letter-to-Sound Conversion. Lexical reading treatments typically include spoken drome referred to as deep alexia. Schematic representation of impairments to the semantic system and letter- to-sound conversion resulting in a semantic error (“orange” for “apple”). or apple Phonological treatments may serve to strengthen letter-to- as orange. & Polkey. ing of letter-to-sound correspondences has the potential to be an effective strategy for reading many words (rather than Treatment for Phonological and Deep Alexia a specific set of words). suggesting that reading in these patients may be mediated by the right hemisphere (Coltheart et al. tions. A number of treatment reports have documented . 2002). for phonological/deep agraphia. they are is worth mentioning again that reading treatment is an currently viewed as points on a continuum. If the patient does not have a key word available for a given grapheme. 1966). Optional: Make a videotape of clinician showing the grapheme and asking for production of the key word (with model provided by clinician after a pause so that the patient can evaluate response relative to the model). Target additional graphemes as appropriate. Review the patient’s ability to retrieve the key word for each targeted grapheme. it may be words and nonwords by deriving the component sounds too effortful to train the vowels at all. Select (or develop) a subsequent protocol to take advantage of key words for deriving phonology from written words (for read- ing) or deriving graphemes from phonology (for writing). mastery of regular letter-to-sound associations . m. & Rudorf. Berndt. cap. it is typical the first sound prolonged. . In some required to re-establish the letter-to-sound associations may patients. v. . z Step 2.qxd 01/22/08 06:41 PM Page 664 Aptara(PPG Quark) 664 Section IV ■ Traditional Approaches to Language Intervention TABLE 25–3 Establishing Key Words That Are Associated with Specific Graphemes A. Because the and semantic errors in oral reading and to initiate correct predictability of letter-to-sound correspondences is stronger production of a word (de Partz. assist the patient in identifying a key word that begins with the grapheme. de Partz. b. “Sue . . Reggia.g. key words are used to assist phonemic self-cueing. B. For each target grapheme. Initial treatment sessions Step 1. For example. Treatment typically begins with then trained to produce only the first sound of the key word higher frequency phonemes. Subsequent treatment a. . appropriate phoneme from a grapheme. “Ron” for r. 1986). proceed to less frequent consonants and vowels as appropriate for a given patient. quency of occurrence in English words to guide the choice phonological information obtained via letter-to-sound con- of targets (see Appendix 25-2. it is most effective to establish proceed to reading three.g. Key words are [s]”). c. Hodges. f Set 3. a word should be agreed upon and trained for consistency of production. Using stimulus cards. l Set 2. The training involves establishing at least one key practicing letter-to-sound correspondences.g.or four-letter monosyllablic key words for consonants first. The patient is patient can easily retrieve. sh. such as that described in Table work is particularly useful to provide articulatory models for 25-3. t.. the patient should look at the grapheme and say the name of the key word. c. Ron). d. Hanna. Establish homework procedures a. Thus. b.. This training may The items selected as key words should be ones that the be accomplished by having the patient say the key word with patient can consistently produce. so it is useful to consider fre. p. Construct stimulus cards that have a grapheme on one side (e. (Look at key word on the back of the card only as necessary for cueing. a. & Mitchum. . b. r. 1986. As indicated in Table 25–3. Subsequent therapy sessions a. daily practice). k. In many instances. Select consonants first because they have more consistent letter-to-sound correspondences than vowels. R-r) and the associated key word on the other side (e. If possible. SSSS . word for each grapheme-phoneme pair targeted for treat. success in re-establishing links between orthography and be considerable. s.GRBQ344-3513G-C25[654-688]. Determine what grapheme-phoneme pairs will be targeted for training. Nickels. .. version may be adequate to reduce or block phonological 1987. In other words. so that the patient can derive the a patient in self-cueing the phonology for a given grapheme. Although the time and blending them to produce a word (or nonword). D. train consonants in sets of five at a time: Set 1. SSSSSue . italizing on their success with specific words. the key word provides the means to cue place- typically nouns. Videotaped home- word” approach is often used. g. b. C. and can include proper names that the ment of the articulators for a given letter. After key words are established. Select frequently occurring consonants (see Appendix 25-2). Establish frequency of homework (e. *Rationale: to develop a corpus of key words that can be used to assist the patient in retrieving phonology from written words. . a. . in isolation (for example. Hanna. 1992). find key words that the patient can consistently say correctly.) b. and then say only the first phoneme that the list of key words is different for each individual. . . such as. much of the work can be accomplished by phonology (e. . For some patients.g. in response to its associated letter. Training can also for consonants than vowels. n. A “key self-drill outside of the therapy session.. treatment proceeds to ment. alexia but who appeared to have relatively mild phonological alexia. as well as improved comprehension and production of spoken language. mented following the computerized reading treatment on spective. MOR was implemented with two individuals with Oral Reading Treatments. describing the nature and treatment of written language practice effects. comprehension. In effect. we have taken a cognitive approach to familiar result of effective hierarchical cueing and mass. and that phonological output lexicon that is common to both tasks. This treatment resulted in item-specific improve. Both showed a word-length effect for oral edge. The outcomes from these include written word-to-picture matching tasks that rein. We acknowledge. This stimulation effect is a In this chapter. but rather a failure to activate correct phonological reading. ment. The semantic treatment also serve to strengthen access to grammatical words in indi- entailed matching written words and their corresponding viduals with relatively mild language impairment. Hillis & Caramazza. with corrective modeling by the clinician to facilitate accurate oral reading feedback and performance-based advancement through the of text-level stimuli. for some individuals MOR may be particularly beneficial for duction. however. To do so. approach. written words before and after treatment showed the greatest words were presented for oral reading. with positive treatment outcomes. Hillis demonstrated that a cueing hierarchy nouns. studies suggest that reading treatments may stimulate inter- force the links between word forms and their meanings. well as written and spoken naming (patient JJ in Hillis & There is evidence to suggest that oral reading of text can Caramazza. For example. and phonemic cueing improvement in reading rate for functors. This was pictures. however. The protocol includes corrective feedback and from single letters to words to sentences. The nature of the reading impairment protocol hierarchy. studies have shown positive responses to reading treatments specific improvement of single-word reading and naming. 1993. and impaired reading of nonwords. an Hillis.GRBQ344-3513G-C25[654-688]. Using the MOR to elicit correct oral reading of target words was an appro. In some patients.qxd 01/22/08 06:41 PM Page 665 Aptara(PPG Quark) Chapter 25 ■ Comprehension and Production of Written Words 665 provides the necessary additional information to support the procedures. for individuals with aphasia and acquired alexia that was Oral reading treatments have also been implemented at unspecified with regard to the specific nature of the impair- the text level. Katz and Wertz (1997) demonstrated Merbitz. Treatment resulted in rapid improvement of benefit individuals who do not fit the classic profile of pure oral reading and comprehension of the trained words. improving recognition of function words. suggesting that and repetition were provided as needed to elicit correct pro. slower reading rate for functors in comparison to representations. The success of this procedure is best explained as a lowering of the activation threshold in the phonological output lexi- Unspecified Alexia Profiles con as a consequence of the increased frequency of produc- tion in the training context. 1994). These results sug- ment of oral naming and oral reading of targeted items. Treatment for Impaired Semantics. active processing of orthography and phonology with bene- Hillis demonstrated the value of this approach with a patient fits to both reading and spoken language in individuals with who exhibited impaired semantics affecting his reading as aphasia. 2005). Adminis- impaired lexical-semantic reading route. such that treatment tration of ORLA was associated with improved reading addressing the nuances of irregular spellings is not necessary. with error responses corrected and missed items demonstrated by Beeson and Insalaco (1998). Cherney. An oral reading treatment served to improve access to spoken examination of their reading rate and accuracy for single word forms in an item-specific manner. Such treatment may alexia (Orjada & Beeson. that some treatment words. and Grip (1986) documented the value of an significant improvement on standardized aphasia tests in approach referred to as Oral Reading for Language in response to a hierarchical reading treatment presented via Aphasia (ORLA). who showed re-presented after intervening items until a correct response that the multiple oral rereading (MOR) approach can also was achieved. semantic anomic aphasia who reported slow reading rate as their pri- errors do not reflect a central impairment of semantic knowl. Significant improvement was docu- in the participants was not described from a cognitive per. spoken language impairment in these measures of overall language performance when compared individuals suggested impairment to lexical and sublexical to conditions with nonlinguistic computer stimulation or no . Individuals with referred to simply as Oral Reading Treatment. 1991a. Despite the lack of generalization to other processing. 1991b. there can be considerable functional benefit from item. repeated oral reading had a durable therapeutic effect. An adaptation of ORLA. this cued increase that was adequate to support pleasure reading. both patients were able to more than double their priate intervention approach (patient HW described by reading rate for new text to about 100 words per minute. 1994). The treatment provided structured reading tasks the clinician. which involves oral reading in unison with computer. typical of phonological and deep alexia. mary complaint. gested that the syntactic constraints offered by sentence which confirmed the hypothesized locus of damage to be the contexts help to facilitate access to functors. demon- impairment of the letter-to-sound conversion mechanism strated similar benefits for spoken and written language and concomitant damage to semantics may also benefit from performance in an individual with aphasia and phonological treatment to strengthen semantics. whereas a later stage of treat- ment may include strengthening the sublexical route. such as the picnic scene from the We will focus here primarily on the processes that are spe. The representation in the trolled word lists. Similarly. Appendix 25-1). such that irregu- functional reading skills. The selection of a particular letter form is referred to as the allographic conversion process. typing. It is also worth noting that several larly spelled words might be regularized. and copying. 1993. Assembled spellings and the retrieval of partial information can serve to improve are likely to reflect regular spelling rules. WAB-R (Kertesz.. however. The use of a standard our semantic representation activates a written word in our stimulus allows for comparison over time and also provides mental dictionary. Degraded representations (or response to auditory input). There are several sources of standardized stimuli that can which may simply be called the graphemic buffer. and copying may be needed to . and single-word spelling. activation of a semantic concept. version. and appropriate strategic compensations are The processes necessary to spell words can be disrupted by established. it is word choice. conventions for the language. progressive approximation of normal reading processes is achieved. This sound-to-letter conversion is considered a non- native strategies to support reading. A comprehensive tions (as opposed to specific upper or lowercase exemplars in assessment of single-word writing requires the use of con- particular writing styles). for example. linguistic. initial treatment efforts may focus the lexical-semantic spelling route is impaired. or even copy a printed word. process that is also referred to as phoneme-to-grapheme con- ter-to-sound conversion abilities. Under normal circumstances. and perceptual-motor processes. on lexical-semantic processes. As is the case with read- orthography. Standardized aphasia mation is held in the graphemic buffer as a series of tests. Assessment of oral spelling. provide an important compensatory spelling strategy when ment stages. Numerous treatment approaches unfamiliar word (or a nonword). abstract letter representa. As we write a word. These outcomes support the notion that written. sounding out the word and converting sounds to letters. forms—handwriting. but in clinical situations. This sublexical route can so that improved skills are incorporated in successive treat.. written naming. which are generic. a semantic representations and processes. or phonology.GRBQ344-3513G-C25[654-688]. spelling may be accomplished via the lexical-semantic ical reading route that enables sounding out words may be route. 2001). damage to central linguistic processes as well as more peripheral components involved in writing (Ellis. offer a small set of graphemes. writing to dictation. formulating sentences. This collection of spellings that we know referent information that may be helpful in discerning the is referred to as the orthographic output lexicon (Fig. Finally. Tainturier & Rapp. items for initial screening of writing. item-specific improvements rather than retrieved as whole words. Written spelling 1986. in duction of written words. 2006) or the cookie-theft picture from the cific to single-word spelling. For an various combinations. These impairments may occur in isolation or in to-letter correspondences. as well as developing alter. or intended content and spellings. The infor.. Written narratives allow for it may also be referred to as the graphemic output lexicon or examination of semantic organization. such as those included in the PALPA (Kay graphemic buffer allows realization of spelling in several et al. spelling can be derived by have been shown to be effective in strengthening lexical. such as the WAB-R and BDAE-3. the sublex. because spellings are assembled processes are not fully restored. A sample of spontaneous writing may be lating each word to its written form according to the spelling obtained by asking a patient to compose a short narrative. language processes. as shown in Figure 25-1. 1992) or the JHU Battery (Goodman & Caramazza. or oral spelling. be used to assess single-word spelling. 25-1). typing. and improving let. Writing calls upon a multi. write the name of a pictured impaired access to representations) may occur at the level of item. selected and motor movements are planned and executed. treatment approaches might be implemented in sequence. we may ask a patient to write a word that we dictate (i. ponent processes necessary for comprehension and pro.e. graphic motor pro- grams are implemented to write the component letters of a Summary of Treatments for Acquired Reading word. Rapcsak & Beeson. our thoughts. but it can also rely on sublexical knowledge of sound- impaired. For example. 2000). ing. In this Impairments of Spelling way. tion of a standard picture. Impairments The motivation to write a word most often reflects self- Reading disturbances may reflect impairments to the com. held in short-term storage in the graphemic output buffer. “cough” might be spelled as coff. 2000. requires implementation of peripheral processes whereby spelling with anagram letters. 1993). semantics. A com- SPELLING prehensive assessment of writing includes examination of The act of expressing our ideas in writing involves clarifying spontaneous writing. Even when reading lexical or sublexical process.qxd 01/22/08 06:41 PM Page 666 Aptara(PPG Quark) 666 Section IV ■ Traditional Approaches to Language Intervention treatment. BDAE-3 (Goodglass et al. it may be preferable to request a written descrip- tude of cognitive. syntactic structure. and sequentially trans. the specific letter forms (referred to as allographs) are language treatments may engage and strengthen spoken. the visual output lexicon (Ellis. Friedman.GRBQ344-3513G-C25[654-688]. it is important ity. imageability (high  low). In actual- strained by time and financial considerations. Loverso. sweet. Written Spelling with Impaired Sound-to-Letter Conversion: semantic errors occur when semantic representations are Phonological Agraphia and Deep Agraphia damaged or in some way underspecified. 1992). Irreg  irregular/exceptional spelling.qxd 01/22/08 06:41 PM Page 667 Aptara(PPG Quark) Chapter 25 ■ Comprehension and Production of Written Words 667 TABLE 25–4 Summary of the Primary Features of Various Acquired Agraphias Clinical Features Spelling Imageability/ Inability Locus of Example Word Length Regularity Frequency Concreteness Word Class to Read Semantic Damage Syndrome Short  Long Reg  Irreg HF  LF HI  LI NF Nonwords Errors Sublexical (sound.g. perfor- acquired agraphia may result when certain component mance tends to be affected by lexical variables such as word processes are disturbed (Table 25–4). walking particular components of the writing process are described. such as spoken production. but also may be evi- deficit and show little effect of spelling regularity. in impairment. For conversion. flewen for flower). or sound-to-letter retrieval of the incorrect orthographic representation. F  functors. with greatest attention given to the central errors are typically not phonologically plausible. 2007). juicy. also prevalent. If the semantic representation included fruit. discern whether central or peripheral spelling processes are would only affect spelling of unfamiliar words and nonwords impaired. Given that clinical evaluations are typically con.. several patterns of acquired spelling impairments matical class (nouns  functors) (see Table 25-4). most individuals with impaired sublexical spelling also to select writing subtests that serve to test hypotheses have some degree of concomitant lexical-semantic spelling regarding the locus of damage to the spelling system. for walked) and functor substitutions (e. The defining feature of phonological might include fruit. and gram- chapter. (Alexander. juicy. & Rapcsak. and The combined profile of written semantic errors and poor . & Fischer. Stark. with relative sparing of lexical-semantic round.. suggesting that phonological processes are crit- order to ensure that an appropriate treatment approach is ical for both nonword and real word spelling (Henry. Treatment approaches directed toward (e. individuals with then it might activate orange as shown in Figure 25-5. Such phonological agraphia have a pronounced nonword spelling semantic errors are observed in spelling. HI  high imagery.g. since for about) are with reference to representative studies. Beeson. LF  low frequency. has been referred to as phonological agraphia example. LI  low imagery.g. Because spelling in these As with acquired alexia. N  nouns. 1981). HF  high frequency. resulting in the Selective impairment of sublexical spelling. In this section of the frequency (high  low). Spelling will be described. red. selected. Phonological √ √ √ √ to-letter) agraphia procedures Semantics and Deep agraphia √ √ √ √ √ sound-to-letter conversion Orthographic Surface (lexical) √ √ output lexicon agraphia Graphemic buffer Graphemic buffer √ agraphia Key: √  significant disturbance.. Reg  regular spelling. and often (or linguistically based) writing impairments that often bear some visual or orthographic similarity to the target accompany aphasia. impaired sound-to-letter conversion is accompanied by deficits at the semantic level. In some individuals. round. Accordingly. Morphological errors (e. 25-4). a fully elaborated semantic representation of apple (Shallice. but failed to include red. form of phonological agraphia is relatively uncommon. letter conversion. sweet. characteristic patterns of individuals is mediated by the lexical-semantic route. agraphia is a disproportionate impairment of sound-to. A pure dent in other output modalities. procedures (see Fig. Hillis described clinical cases in which informa. This treatment can be implemented using the same also have damage to the lexical-semantic spelling route. As mentioned above. and As with phonological/deep alexia. including oral naming and comprehension. if the intended target word is graphia. is depicted in Figure 25–6. but has the (Hillis. correct spelling of the target words through the arrangement . When 1991). Chiat. avoided or self-corrected if a patient has at least some ability The treatment procedure consists of a task hierarchy to elicit to translate the initial sounds of a word into the correspond. 2002. and nonword written naming. pointing. or deep agraphia. apple for orange) (Rapcsak. & Pring. ment may address damage to semantic representations or may allowing for more accurate distinctions among items in focus on rebuilding specific spellings in the orthographic treated categories. called Anagram 1982). If a patient ing an improvement at the level of the semantic system has impairment of sound-to-letter conversion. Trupe. 2002). target words (Beeson. spoken language (Beeson. in Table 25–4. 1994. semantic treatment may be directed toward clarifying the graphically similar misspellings) and also produce semantic semantic distinctions among written words as they are errors (e.GRBQ344-3513G-C25[654-688]. as illustrated in lexicon. sion skills may improve spelling in patients with deep tinuum of increasingly severe phonological and lexical. Several effective treatment protocols have been reported to-letter conversion skills may provide access to initial that include the task of arranging anagram letters to spell graphemes. treatment may be administered with the goal of rebuild- should be implemented to facilitate retrieval of phoneme. For example. logical errors. Semantic spelling treatment has also output lexicon. This lexical approach. 1991). This pattern of improvement indi- with concomitant damage to the lexical-semantic route. responses on oral naming and repetition tasks. the error might dyslexia. if shirt is Treatment for Phonological and Deep Agraphia written incorrectly as pants. functor substitutions. then gestures. Because many of these individuals also have signif- Table 25–5. ing specific representations in the orthographic output grapheme correspondences for spelling. again suggest- Strengthening Sound-to-Letter Conversion. but the patient incorrectly writes TV. 1999. As shown semantic system itself. treat. others require treatment directed toward the semantic impairment (Rapcsak & Beeson. For example.qxd 01/22/08 06:41 PM Page 668 Aptara(PPG Quark) 668 Section IV ■ Traditional Approaches to Language Intervention sound-to-letter conversion ability has been called deep dys. strengthening sound. For key word approach as used in reading treatment. 1999. agraphia. Effective remedia- mance in phonological agraphia (concreteness/imageability. or substitute for. Hillis & Caramazza. 1989). suggest an underspecification of the features necessary to sistent with those seen in phonological agraphia (morpho. 1994). training ble. as well as in there is little influence of spelling regularity. distinguish among items in the same semantic category. In individuals with deep agraphia. Hillis & Caramazza. corrective feedback is offered that high- lights distinctive features of the target in contrast to other members of the semantic category. & Rubens. Phonological treatment legs. Hirsch. Beeson. cates the development of richer semantic representations. In other words. many Chenery. Hillis. icant aphasia. 1999. As with phonological/deep alexia. Patients typically produce error types con. Treatment for Impaired Semantics. it may be worthwhile to provide treat- ment to retrain sublexical spelling procedures (Cardell & Lexical Spelling Treatments. ing graphemes. 1991). For individuals even for untrained items. Once key words are established. 2001). phonological and be self-corrected if the initial phoneme /m/ is converted to deep agraphia were initially considered distinct syndromes the grapheme m. Marshall. errors are made. which is the analog of deep movie. access to single words for written communication (Hillis Clausen & Beeson. semantic errors in writing might be and Copy Treatment (ACT). ability to say words. tion of semantic impairments may result in improved word class. 2003. and visually/ortho. While retraining sound-to-letter conver- but have more recently been described as points along a con. As with phonological agraphia.g. treatment for individuals simple verbal explanation highlight the distinction of shirt as with phonological and deep agraphia may be directed toward clothing for the upper body and pants as clothing for the sublexical and/or lexical processes. with the individuals whose orthographic representations are damaged potential for both modalities to be trained simultaneously or unavailable and for whom a sublexical strategy is not feasi- (see Table 25-3). item-specific lexical spelling treatment may tion derived from the sublexical route in combination with a be used to develop a functional written vocabulary that can partially damaged lexical-semantic system provided improved augment. This type of treatment has been shown to be effective may serve to strengthen sound-letter correspondences so in remediation of written naming within trained categories. and frequency). Robson. & Rewega. serving to block semantic errors or support acti. For example. Hillis Trupe. these impairments result in spelling that is influenced by the same lexical features that affect perfor. resulted in generalized improvement in other modalities. 1986. Beeson. vation of the orthographic output lexicon (Bub & Kertesz.. in cases where semantic errors spelling is poor. individuals with damage to sublexical spelling procedures 1986). matched to corresponding pictures (Hillis. that spellings can be derived phonologically. Clinical aphasiology (pp. b. “Write the first letter for the word ‘basketball. Beeson. C. for example. E. Select target graphemes to be trained. (1986). individuals repeatedly representations of specific words. 2002. followed by repeated copying of the et al. of anagram letters. Effectiveness of retraining phoneme to grapheme conversion. If the patient cannot respond correctly. If correct. provide spoken words and ask the patient to write the first letter of the word. go to Step 5. Record responses only to initial trials of Step 1 to determine progress. A. b.” a. If in error.” Return to Step 2. treatment at one time. “Write your key word for /b/. a. For example. /b/ is the first sound of baby. In R. with additional sets of words added Another homework-based lexical spelling treatment is sequentially as criterion is met.” “Now point to the letter that makes the first sound of [key word]. remove array of letters and go to Step 1. Determine next appropriate protocol to develop and take advantage of phoneme-to-grapheme conversion abilities. “Point to the letter that makes the sound /phoneme/. for example. Provide an array of letters (five or more) including the correct target and say. *Rationale: to train patients the ability to derive graphemes from their associated phonemes. (After Hillis Trupe. rearrange the array of letters and go back to Step 2. [Key word] starts with the letter [target letter]. “Yes. go to Step 6. proceed to Step 2.” For example. then subsequent steps as needed. B makes the sound /b/. The goal is to strengthen the orthographic Beeson. Step 1. & Volk.qxd 01/22/08 06:41 PM Page 669 Aptara(PPG Quark) Chapter 25 ■ Comprehension and Production of Written Words 669 TABLE 25–5 Cueing Hierarchy for Teaching Phoneme-to-Grapheme Conversion A. If correct.’” E.” “Now point to the first letter of your key word” (from array of letters). Step 3. Probe each letter at least three to five times per session. If correct. Baby starts with the letter B. 2003. D.” a. b. If correct. go to Step 4. move on to the next target phoneme. “Write the letter that makes the sound /phoneme/. Clinician writes the key word for the target sound /phoneme/. “The letter B makes the first sound of baby. Once single letters are reliably written in response to their associated phoneme. proceed to Step 3. B. 2003).” Rearrange the letters in the array and go to back to Step 2.” a. Brookshire (Ed. If incorrect. b. and says. a word that starts with /b/ is baby. Step 5. Typically. b. Write [key word]. Beeson. For this treatment. Now copy the letter B. If incorrect. Step 4. Beeson repeat spoken words. Point to the letter that makes the first sound of [key word]. Implement cueing hierarchy to train targeted graphemes Note that Step 1 is the most difficult task. then test their memory by covering up arrangement and copying of the word. “Yes. 163–171). four sets of five graphemes (see Appendix 25-2). If incorrect. 1999. Establish one key word that the patient can write for each grapheme (see procedures in Table 25-3). Step 6. Follow the instructions to ascend the hierarchy when correct responses are achieved. Step 2.). patients are trained to appro- relies heavily on the completion of homework (at least 30 priately implement CART homework and check the accu- minutes per day) that involves repeated copying of sets of racy of their responses.” or “Think of your key word for /phoneme/. Rising. rearrange letters in the array and go back to Step 2. CART can also be implemented with . For individuals who can Copy and Recall Treatment (CART. “A word that starts with /phoneme/ is [key word]. repeated correct spelling from memory. H. proceed to Step 2. Initial treatment sessions Step 1. If incorrect.” a. say. Step 2..GRBQ344-3513G-C25[654-688]. The ACT approach During the treatment sessions. a word that starts with /phoneme/ is [key word]. recall trials require the written example and attempting to recall the spelling. “Think of a word that starts with /phoneme/. Minneapolis: BRK. five words are targeted for target words presented with line drawings or photographs. After correct anagram copy target words. If correct. Repeat the probe and cueing hierarchy for all targeted letters. Point to the letter B. Clausen & word. allowing edge of word forms that they once knew. CART words are typically more vulnerable to impairment than has proven beneficial in individuals with severe aphasia. friends. “Write the word for this. verbal repetition of target words in order to improve both (Beeson et al. treatment sessions. Words practiced using the CART written and spoken naming (Beeson & Egnor. 2006). error Patient copy from “Write the word apple. Cover all instances of written word.” error error Clinician arranges or “Can you write apple?” l p a e p letters correctly Copy 3 times correct apple correct apple apple Copy the word 3 times Go to next item apple apple apple 3. Schematic depiction of Anagram and Copy Treatment (ACT). If sound-to-letter conversion even those with minimal pre-treatment spelling skills abilities are spared. For lost the orthographic representations for words. wherein each individual is given oppor- or using a photo album with an audio-recording feature. or tunities to communicate using practiced written words one of various augmentative communication devices. The protocol may also be trained in the context of group- model for spoken repetition can be provided on videotape. written targets may be proper names.. both written and spoken modalities for two individuals with moderate aphasia and severe spelling impairment (Beeson & Spelling with Overreliance on Sound-to-Letter Egnor. (Clausen & Beeson. such that they show partial knowl- those of family. Low frequency for specific.GRBQ344-3513G-C25[654-688]. high frequency words. This group settings and also in the context of conversation with CART plus repetition treatment resulted in positive gains in unfamiliar partners. and favorite restaurants. as shown in Figure 25-3. letters correctly “Make this spell apple” Copy 3 times apple i p l e d a p apple apple correct Copy the word 3 times apple If repeated failure apple return to step 2 apple 4. including degraded representations. meaningful exchange of information. 2006). 2003). or have example. Present letters “Make this spell apple” 1. Conversion: Surface (Lexical) Agraphia Improvements made using ACT and CART tend to be item-specific but can be highly functional when target In many cases of acquired agraphia. 2003).qxd 01/22/08 06:41 PM Page 670 Aptara(PPG Quark) 670 Section IV ■ Traditional Approaches to Language Intervention 2. This type of treatment has Patients are trained to produce both spoken and written resulted in increased use of written targets in structured responses for each target during their daily homework. patients appear to have words are individually selected and personally relevant. spelling may be .” previous model correct If repeated failure return to step 2 Elicit response 3x correct Go to next item Figure 25–6. Present letters plus error Clinician arranges 2 foil letters. face”). who have relatively spared sublexical spelling. the initial letters of the word are demonstrate an overreliance on the sublexical spelling route. 2000). plausible misspellings derived by Romani. then in errors on words that have irregular spellings (for example.g.g. It has been documented that some patients have an patients with surface agraphia. In this type of treatment. Silveri. peanut → peanul). resulting in spelling errors such as described below.. show generalized improvement in spelling abilities (Beeson et al. 1987. Rewega. most likely to be correct. and thus. there are no effects of frequency. The treatment was tasks. painter → painetr). substitutions (e. corrected practice served to improve decays at an abnormally rapid rate (Hillis & Caramazza. 2000). or regularity of spelling (see Table 25-4). Villa. Behrmann (1987) used a task that 1995. vation of sublexical and lexical-semantic spelling processes . flower → flowaer). 1989. individuals may spelling.qxd 01/22/08 06:41 PM Page 671 Aptara(PPG Quark) Chapter 25 ■ Comprehension and Production of Written Words 671 accomplished using the knowledge of sound-to-letter corre. letter omissions (e.. dle or toward the end of words (Caramazza. sweater → sweatr). & Caramazza. help patients resolve their own spelling errors. due to the increased demand on storage capac- agraphia. transpositions (e. & phones. This for the target (resulting in a closer approximation.. may ity for longer words. example. overreliance on the sublexical spelling route results generate an initial spelling (e. Damage to the graphemic buffer also be trained to take advantage of sound-letter conversion abil.. it is also referred to as lexical agraphia. including spontaneous writing. Training a Problem-Solving Approach to Spelling. 1987) and homophones (Behrmann.e. following surface agraphia is characterized by poor spelling of homo. In addition.g. Lexical Spelling Treatment for Surface Agraphia Impairment of the Graphemic Buffer Several studies have documented the utility of item-specific The orthographic representation that is derived either from training for strengthening representations in the orthographic the orthographic output lexicon or via the sublexical output lexicon. Therefore. grammatical The aforementioned lexical spelling treatments. with errors occurring in the mid- resulting in errors on irregularly spelled words and homo. Because of solving strategies have proven useful for self-correction of patients’ reliance on a sounding-out procedure for spelling. Vail. As shown in involved matching pictures and written words followed by Figure 25–7. sound-to-letter conversion may provide written cues that 1991). Problem-solving treatment also includes errors. In the case of left Individuals with damage to the lexical-semantic route may hemisphere brain damage. Miceli. in reference to resulting in an accurate spelling of the target. writ- successful in improving spelling of homophones and some ing to dictation. may be appropriate for individuals with damage word length has a significant effect on performance. ACT class. individuals with some degree of preser- training in the use of an electronic speller that accepts plau. the graphemic buffer receives output from written naming of the picture. Katz. with a to orthographic representations in order to retrain spellings tendency for short words to be more accurately spelled than for specific lexical items. This provides a useful strategic compensation. For instance. For spondences.g. an homework that required selection of the appropriate homo. such that information showed that repeated. and it has been documented that.. Problem- the damaged lexicon for writing (see Table 25-4).g. to untreated items. tronic speller to check their spelling or to correct it further.. 1985).g. suite and sweet) and relative sparing of nonword employing the problem-solving approach. This treatment also used both lexical-semantic and sublexical routes. impairment of the graphemic buffer will affect all writing phone to complete printed sentences. Hillis & Caramazza. sible misspellings to help resolve spelling difficulties. and additions (e. 1995.. & vide a means to compensate (or self-correct) for spelling Rapcsak. Finally.GRBQ344-3513G-C25[654-688]. In contrast. Damage to the untreated irregularly spelled words. Hillis and Caramazza (1987) impairment of this graphemic buffer. as serial ordering of letters. A problem- solving approach to spelling is appropriate for individuals Treatment for Impairment of the Graphemic Buffer who are capable of generating plausible or partial spellings. the individual is instructed to use the elec- to the pattern of “writing how it sounds” (i. 1987) in ated. In some cases. This type of treatment has been used to sound-to-letter conversion process is held in short-term teach correct spellings for irregularly spelled words (Hillis & storage while letter forms are selected and writing is initi- Caramazza. spelling of targeted words. such as spelling pattern is referred to as surface agraphia. Miceli. and delayed copying. and CART. the spared cognitive processes for spelling may pro- to their lexical knowledge (Beeson. individuals learn to self-correct In cases of selective impairment to the graphemic output spelling errors by evaluating their written attempts relative buffer. evaluate this spelling relative to residual lexical knowledge knight and yacht might be spelled as nite and yot). in reference suposed). “on the sur. spelling errors. individuals with lexical long words. the implementation of homework-based writing treatment phones (e. sepost for “supposed”). but did not generalize graphemic buffer affects spelling of all word types. imagery. tends to result in loss of information about the identity and ities in conjunction with residual lexical knowledge.. written naming. an individual might use a sublexical strategy to however. Rapp and Kane (2002) used a delayed copy treat- comparing to representations in the orthographic lexicon) ment with two individuals. with the procedures have resulted in improvement for individuals latter showing generalization to untrained items. and they documented spellings (Hillis & Caramazza. . one with a deficit at the level of and also sounding out each word as it is written (to call the orthographic output lexicon and the other with a attention to phonologically implausible misspellings). Raymer.GRBQ344-3513G-C25[654-688].qxd 01/22/08 06:41 PM Page 672 Aptara(PPG Quark) 672 Section IV ■ Traditional Approaches to Language Intervention apple e [æp l] Phonological Visual Graphemic input lexicon representation input lexicon Sound-to-letter conversion Semantic system Graphemic Phonological output lexicon output lexicon Graphemic Phonological buffer buffer orange “apple” Allographic conversion app___ Figure 25–7. indicating that a single treat- Impairment of Allographic Conversion ment approach may prove beneficial to more than one com- ponent of the spelling process..e. Both individuals demon- Spelling treatments targeting impaired lexical spelling strated positive treatment effects for trained items. or allo- spelling impairment involving both the orthographic output graph. may be trained to use strategies for self-correction of lexicon and the graphemic buffer. resulting in loss of information for the rightmost part of the word. graphemic buffer impairment. 1987). Cudworth. in order to form the string of letters for a word. and Writing requires the conversion of each grapheme (i. patient. Schematic representation of impairment to the graphemic output buffer.e. with deficits at the level of the orthographic output lexicon as well as the graphemic buffer. Such strategies may improvements at both levels of processing in a single include examining spellings to evaluate their accuracy (i. Haley (2003) used a modified version of CART to address a abstract letter identity) into a particular letter shape.. impairment of the allographic conversion process. (Margolin. 1998). the appropriate letter shape must be selected for that When examining allographic conversion processes. Therefore. It makes sense that treatment for individuals with impaired tic features include incorrect letter selection. This stage of writing. Beeson. and individual varia. each time a word is writ. the writing errors are tions in writing style. it is instance. Preserved ability to perform oral naming is indicated. the profile is sug- generation of the correct letter shapes in handwriting gestive of impairment at the level of allographic conversion. including well-formed but incorrect letters. De Bastiani & Barry. Kartsounis. but perfor- patients can spell aloud but are impaired in the selection and mance on the transcoding task is impaired. 25–8). cursive. resulting in allographic conversion processes should attempt to take . and also in disturbed upper or lowercase. Some patients show a selective on this task may be compared to direct copy of single words. 1992) or style (print vs. & Rapcsak. Hanley & Peters. and is not required for to uppercase and vice versa (see Appendix 25-1). is specific to written spelling. print or cursive. ten. There are many ways to write a given grapheme. 1984. resulting in errors of letter selection in writing. These If graphomotor skills appear preserved for copy. Schematic representation of impairment to the allographic conversion mechanism. Performance oral spelling (Fig. letter formation. accompanied by preserved oral spelling. This impairment may be specific to letter case (upper or lower- Treatment for Allographic-Conversion Impairment case.GRBQ344-3513G-C25[654-688]. 1986. The characteris. Ramage. the allographic conversion useful to ask patients to transcode printed words from lower process.qxd 01/22/08 06:41 PM Page 673 Aptara(PPG Quark) Chapter 25 ■ Comprehension and Production of Written Words 673 e [æp l] apple Phonological Visual Graphemic input lexicon representation input lexicon Sound-to-letter conversion Semantic system Graphemical Phonological output lexicon output lexicon Graphemic Phonological buffer buffer orange “apple” Allographic conversion “a-p-p-l-e” addle Figure 25–8. 1996). In either case. Additionally. sequential treatment approaches may be warranted Dyslexia and Dysgraphia Batteries.e. for example. In some neural substrates of recovery and the response to behavioral cases. 2006). In the past decade. Beeson & Robey. modeling of normal and disordered language processes. the general approach to identifying. 2005). 1998). Computational modeling can be imple- graphic word forms (i. a num- spelling to a level commensurate with performance in oral ber of interdisciplinary efforts have contributed to the spelling. & Hillis. but these disorders are re. Houghton letter conversion processes are strengthened. which processes are impaired and which processes cant contributions to the previous edition of this chapter. 1996).. subcortical lesions. The treatment approaches This information can serve to guide clinicians as they select focused on those components of the reading or spelling treatment for a particular individual. Marsh representations. for her signifi- patient. candidates for particular treatment approaches. using an alphabet card if a model is FUTURE TRENDS needed. In Caramazza for generously sharing the Johns Hopkins practice. treatments serve to strengthen damaged or degraded interventions (see. Hillis. Self-dictation to develop and take full advantage of improved skills and procedures have proven beneficial in improving spelling in compensatory strategies in a given individual. In particular. In other cases.qxd 01/22/08 06:41 PM Page 674 Aptara(PPG Quark) 674 Section IV ■ Traditional Approaches to Language Intervention advantage of superior oral spelling abilities.g. Advances in these endeavors treatments improve the operation of the graphemic buffer may provide insights that improve our understanding of the or allographic conversion processes that ultimately initiate nature of reading and spelling impairments. 2000. 1996. we sought to provide a framework for assess. word before attempting to write it. sensorimotor impairments of writing (such as those result. While tive processes and neural substrates that support reading spelling accuracy was not perfect post-treatment. Finally. 2001).GRBQ344-3513G-C25[654-688]. tice in speech-language pathology has promoted increased ders of praxis) were not discussed here because they are less rigor in the experimental designs used to examine treatment likely to accompany aphasia. Rapp. ferent treatment approaches (see. Plaut.. self- correct any noted errors. We expect knowledge more of the critical components of the cognitive processes gained from behavioral research to be complemented by that support written spelling. 2002. the sublexical sound-to. We caution individuals with preserved oral relative to written spelling that it is essential to monitor a patient’s progress carefully so (Pound. The more peripheral imize the effectiveness and efficiency of behavioral treatments. 2000. Finally. and spelling will continue to influence treatment approaches dure proved successful in improving the patient’s written for acquired alexia and agraphia. the increased attention to evidence-based prac- ing from cerebellar damage. The illustrative eval. cognitive science. The level. 2003. Funnell. and reflect complementary perspectives from speech-language pathology. CLOSING COMMENTS treatment research should serve to clarify who are the ideal In this chapter. other & Zorzi. for example. spellings). neuropsychology. Ideally. lexical spelling processes can improve spelling abilities of Functional neuroimaging has the potential to clarify the individuals with acquired writing impairments. for example. and disor. process that are impaired or can be used more efficiently to ▼ compensate for damaged components. research using functional neuroimaging and computational strate that therapy directed toward lexical-semantic and sub. 2000). and provide ing reading and spelling and using the assessment findings to an estimate of treatment effect size for such individuals. 2005. including semantic knowledge or ortho. as well as access to those mented to simulate the effects of brain damage and test dif- representations. . Hillis. the quantification of treatment out- viewed elsewhere (Rapcsak & Beeson. Gonzalez Rothi. and psycholingistics Summary of Treatment for Spelling Impairments (e.D. Pound (1996) instructed that only effective interventions are pursued. inspect the entire word to check it against We expect that advances in our understanding of the cogni- the orthographic representation for the word. are spared in the tasks of reading or spelling should provide We also thank Roberta Goodman-Schulman and Alfonso a springboard for designing other focused treatments. self-dictate each letter while writing one letter at a time. behav- ioral neurology. select or design treatments. as well as max- the graphic motor plans for writing. outcomes. a patient with impaired allographic conversion to engage in specific treatment approaches should be tailored appropri- the following steps during treatment: orally spell each target ately to meet the functional needs of the patient. this proce. comes using standardized effect sizes should facilitate a better understanding of the therapeutic effects of different treatments (see. knowledge base. in each authors wish to thank Argye E. M. examine the written word one letter at a time while orally spelling the word again... Treatment studies demon. Crosson et al. Ramage et al. Acknowledgment—This work was supported in part by uation and therapy methods we have described surely do not DC007646 and DC008286 from the National Institute exhaust the possibilities for improving processing at each on Deafness and Other Communication Disorders. Nadeau. However. finally. Spelling impairments can result from damage to one or & Crosson. 11. (1998). of the style of the font? Behavioural Neurology.. A.. . P.Treatment for letter-by-letter reading: A case ments may be directed toward lexical-semantic study. Hirsch. but not a useful strategy for surface or deep 1. L. the orthographic output lexicon (the store of spellings). 16. (2005). M. written and spoken naming. When might you work on reading at the text level in a Careful examination of the component processes for patient who has trouble reading single words? reading and writing can serve to isolate the locus (or 5. 6. Beeson. M.” regardless letter reading: Natural recovery and response to treatment. M. (1992). What is meant by an interactive. P. Similar to reading. and an example in for reading. 4. treatment for writing impair. J. Writing impairments can result from impairment to any or all of the following processes or representa- tions: the semantic system. ACTIVITIES FOR REFLECTION AND DISCUSSION Beeson.GRBQ344-3513G-C25[654-688]. Both approaches are valid. (2006). Beeson. alexia? sary for reading and writing in a variety of ways. (1999).). Magloire. Aphasiology. 13. Lesion localization in phonological agraphia. 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(2002). & Heilman. Holland (Eds. Schober-Peterson. (1987). Kertesz. Aphasiology. A. M. 19. (1992). (4th ed.. Journal of the International ferent components of the spelling process. Humphries (Eds. Edition. M. L. J. & Wertz. E. Helm-Estabrooks & A. T. The handbook of cognitive neuropsychology: Battery for Aphasia (2nd ed. & Coltheart.). neu- (1975). (1989). The neuropsychology of writing and Raymer. S. Reading Comprehension Rapp. J. Specific aphasias. (1992). R... C.). New York: Guilford Press. L. (1985).. C.).. D. (1992). International Journal of Communication Disorders.. G. M. & Ochipa. Derivation of new readability formulas (Automated rology. and practice (pp. M.. Writing remediation using preserved oral spelling: Wiederholt. The spelling process. (2000). 25.). lished test). L.. Alexia without agraphia: the treatment of a disorder of reading and naming. (1996). and rehabilitation: A reck. F.). & Caramazza. Deep dyslexia. K. Riddoch & G. (1991). C. Reading Laboratory 1C. & Laine. 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G. unpub- Moyer. What deficits reveal about the human mind. 40. Chiat. (Eds. P. provided reading treatment for chronic aphasic adults. (Vol. (1985). Philadelphia: Psychology Readability Index. M. Relearning after damage in connectionist net. Clinical Aphasiology Conference. & Pollatsek. M. 11–18. LaPointe. & Rubens. E. Philadelphia: Psychology Press. g. and copying of single words.e. so that the contrasts are apparent..e. items within a given list should be presented in random order during test administration. Grammatical Word Class List composition: 104 words (28 nouns.qxd 01/22/08 06:41 PM Page 678 Aptara(PPG Quark) 678 Section IV ■ Traditional Approaches to Language Intervention APPENDIX 25. the same word lists can be used to assess reading and writing. Writing to dictation is accomplished by presenting a word or nonword auditorily and asking the patient to first repeat the stimulus aloud and then write it. pronounceble nonwords derived by altering real words by one grapheme).. regularity of spelling based on sound-to-letter correspondences. 28 verbs. In many cases.. but as indicated below. Dysgraphia Battery Task: writing to dictation Word Class Frequency # Letters Word Class Frequency # Letters body noun HF 4 jury noun LF 4 child noun HF 5 bugle noun LF 5 music noun HF 5 digit noun LF 5 noise noun HF 5 faith noun LF 5 ocean noun HF 5 glove noun LF 5 space noun HF 5 grief noun LF 5 bottom noun HF 6 motel noun LF 5 church noun HF 6 career noun LF 6 column noun HF 6 pillow noun LF 6 friend noun HF 6 priest noun LF 6 length noun HF 6 sleeve noun LF 6 member noun HF 6 stripe noun LF 6 nature noun HF 6 threat noun LF 6 street noun HF 6 lobster noun LF 7 loud adj HF 4 brisk adj LF 5 tiny adj HF 4 cheap adj LF 5 angry adj HF 5 crisp adj LF 5 broad adj HF 5 loyal adj LF 5 fresh adj HF 5 rigid adj LF 5 happy adj HF 5 sleek adj LF 5 short adj HF 5 vivid adj LF 5 afraid adj HF 6 absent adj LF 6 bright adj HF 6 decent adj LF 6 common adj HF 6 fierce adj LF 6 hungry adj HF 6 quaint adj LF 6 strong adj HF 6 severe adj LF 6 certain adj HF 7 strict adj LF 6 strange adj HF 8 vulgar adj LF 6 . some lists are specific to the dyslexia or dysgraphia batteries. 1. The dysgraphia battery includes writing to dictation. written nam- ing of pictures. 28 adjectives. Nonwords are also provided that are pseudohomophones (i.GRBQ344-3513G-C25[654-688]. upper to lowercase). nonword spellings that are homophones with real words) and nonhomophones (i. however. concreteness. The dyslexia battery consists of oral reading of words and nonwords. 20 functors) a. frequency of occurrence in written English. transcoding by letter case (e. and word length.1 Johns Hopkins University Dyslexia and Dysgraphia Batteries The following word lists are controlled for lexical features including grammatical word class. Dyslexia Battery Task: oral reading b. The words are grouped on the basis of their relevant features. 21 abstract) a. Dysgraphia Battery Task: writing to dictation Word Feature Frequency # Letters Word Feature Frequency # Letters cabin concrete HF 5 beauty abstract HF 6 cattle concrete HF 6 danger abstract HF 6 engine concrete HF 6 method abstract HF 6 valley concrete HF 6 moment abstract HF 6 window concrete HF 6 sister abstract HF 6 kitchen concrete HF 7 system abstract HF 6 village concrete HF 7 science abstract HF 7 college concrete MF 6 basis abstract MF 5 dollar concrete MF 6 advice abstract MF 6 insect concrete MF 6 degree abstract MF 6 palace concrete MF 6 effort abstract MF 6 planet concrete MF 6 theory abstract MF 6 spider concrete MF 6 courage abstract MF 7 turkey concrete MF 6 success abstract MF 7 salad concrete LF 5 mercy abstract LF 5 bullet concrete LF 6 belief abstract LF 6 fabric concrete LF 6 horror abstract LF 6 oyster concrete LF 6 status abstract LF 6 parent concrete LF 6 talent abstract LF 6 journal concrete LF 7 offense abstract LF 7 sparrow concrete LF 7 pursuit abstract LF 7 .GRBQ344-3513G-C25[654-688]. Word Concreteness List List composition: 42 nouns (21 concrete. Dyslexia Battery Task: oral reading b.qxd 01/22/08 06:41 PM Page 679 Aptara(PPG Quark) Chapter 25 ■ Comprehension and Production of Written Words 679 begin verb HF 5 deny verb LF 4 bring verb HF 5 adopt verb LF 5 carry verb HF 5 annoy verb LF 5 hurry verb HF 5 greet verb LF 5 learn verb HF 5 argue verb LF 5 solve verb HF 5 merge verb LF 5 speak verb HF 5 spoil verb LF 5 spend verb HF 5 borrow verb LF 6 become verb HF 6 pierce verb LF 6 bought verb HF 6 preach verb LF 6 caught verb HF 6 reveal verb LF 6 decide verb HF 6 sought verb LF 6 happen verb HF 6 starve verb LF 6 listen verb HF 6 conquer verb LF 7 both functor HF 4 since functor HF 5 into functor HF 4 these functor HF 5 only functor HF 4 those functor HF 5 what functor HF 4 under functor HF 5 about functor HF 5 while functor HF 5 above functor HF 5 before functor HF 6 after functor HF 5 enough functor HF 6 could functor HF 5 rather functor HF 6 often functor HF 5 should functor HF 6 shall functor HF 5 though functor HF 6 2. GRBQ344-3513G-C25[654-688]. Dysgraphia Battery Task: writing to dictation 4. and 14 LF Word Length List  35 HF and 35 LF a.qxd 01/22/08 06:41 PM Page 680 Aptara(PPG Quark) 680 Section IV ■ Traditional Approaches to Language Intervention 3. adjectives. Dyslexia Battery Task: oral reading List composition: 34 pseudohomophones and 34 nonhomophones b. verbs only)  42 HF and 42 LF Word Concreteness List (concrete and abstract)  14 HF. Dyslexia Battery Task: oral reading b. Nonwords a. Word Frequency List composition: Use responses from any or all of the following lists Grammatical Class List (nouns. 14 MF. Dysgraphia Battery Task: writing to dictation List composition: 34 nonhomophones (* indicates 20 nonwords to be used for oral spelling task with real words in list 7) Reading Only Reading and Writing Nonword Type # Letters Nonword Type # Letters berd pseudohomophone 4 berk nonhomophone 4 bole pseudohomophone 4 boke* nonhomophone 4 groe pseudohomophone 4 troe nonhomophone 4 hert pseudohomophone 4 herm* nonhomophone 4 lern pseudohomophone 4 lorn* nonhomophone 4 meen pseudohomophone 4 feen* nonhomophone 4 noys pseudohomophone 4 foys nonhomophone 6 rewt pseudohomophone 4 dewt* nonhomophone 4 snoe pseudohomophone 4 snoy nonhomophone 4 sune pseudohomophone 4 sume nonhomophone 4 breth pseudohomophone 5 bruth nonhomophone 5 ghurl pseudohomophone 5 ghurb nonhomophone 5 kroud pseudohomophone 5 kroid nonhomophone 5 kwene pseudohomophone 5 kwine* nonhomophone 5 lytes pseudohomophone 5 pytes nonhomophone 6 phait pseudohomophone 5 phoit* nonhomophone 5 reech pseudohomophone 5 reesh* nonhomophone 5 skurt pseudohomophone 5 skart* nonhomophone 5 cherch pseudohomophone 6 chench* nonhomophone 6 hunnee pseudohomophone 6 hannee* nonhomophone 6 kattul pseudohomophone 6 kittul nonhomophone 6 lemmun pseudohomophone 6 remmun* nonhomophone 6 merder pseudohomophone 6 merber* nonhomophone 6 mursee pseudohomophone 6 murnee* nonhomophone 6 phlore pseudohomophone 6 phloke nonhomophone 6 sircle pseudohomophone 6 sarcle* nonhomophone 6 windoe pseudohomophone 6 wundoe nonhomophone 6 wissel pseudohomophone 6 wessel nonhomophone 6 consept pseudohomophone 7 donsept* nonhomophone 7 haytrid pseudohomophone 7 haygrid* nonhomophone 7 kuntree pseudohomophone 7 kantree* nonhomophone 7 sertain pseudohomophone 7 sortain nonhomophone 7 teybull pseudohomophone 7 teabull* nonhomophone 7 mushrume pseudohomophone 8 mushrame* nonhomophone 8 . Dyslexia Battery—Letter-to-Sound Regularity Task: oral reading List composition: 60 words with regular spelling and 30 words with irregular spelling Reading Only Reading Only Word Regularity Frequency # Letters Word Regularity Frequency # Letters but regular HF 3 eye exception HF 3 base regular HF 4 two exception HF 3 bone regular HF 4 once exception HF 4 cook regular HF 4 sign exception HF 4 cool regular HF 4 view exception HF 4 cord regular HF 4 earth exception HF 5 corn regular HF 4 front exception HF 5 days regular HF 4 ghost exception HF 5 face regular HF 4 knife exception HF 5 feed regular HF 4 laugh exception HF 5 feel regular HF 4 piece exception HF 5 five regular HF 4 sword exception HF 5 grow regular HF 4 friend exception HF 6 home regular HF 4 school exception HF 6 life regular HF 4 tongue exception HF 6 lift regular HF 4 axe exception LF 3 list regular HF 4 heir exception LF 4 main regular HF 4 limb exception LF 4 meat regular HF 4 quay exception LF 4 nine regular HF 4 tsar exception LF 4 paid regular HF 4 aisle exception LF 5 race regular HF 4 choir exception LF 5 sand regular HF 4 chute exception LF 5 save regular HF 4 corps exception LF 5 seen regular HF 4 fraud exception LF 5 thin regular HF 4 gauge exception LF 5 wake regular HF 4 seize exception LF 5 shell regular HF 5 sieve exception LF 5 still regular HF 5 weird exception LF 5 these regular HF 5 brooch exception LF 6 gut regular LF 3 boot regular LF 4 dare regular LF 4 dean regular LF 4 dock regular LF 4 dome regular LF 4 fern regular LF 4 fowl regular LF 4 gull regular LF 4 hike regular LF 4 jays regular LF 4 math regular LF 4 mode regular LF 4 mush regular LF 4 peat regular LF 4 pest regular LF 4 pill regular LF 4 pose regular LF 4 rave regular LF 4 .GRBQ344-3513G-C25[654-688]. Regularity of Spelling a.qxd 01/22/08 06:41 PM Page 681 Aptara(PPG Quark) Chapter 25 ■ Comprehension and Production of Written Words 681 5. Dysgraphia Battery—Sound-to-Letter Probability Task: writing to dictation List composition: 30 words with high probability spelling and 80 words with low probability spelling (probability based on likely phoneme-grapheme conversion) Writing Only Writing Only Word Probability Frequency # Letters Word Probability Frequency # Letters best HIGH HF 4 book LOW HF 4 dust HIGH HF 4 dead LOW HF 4 fact HIGH HF 4 free LOW HF 4 flat HIGH HF 4 give LOW HF 4 hard HIGH HF 4 gone LOW HF 4 land HIGH HF 4 grew LOW HF 4 soft HIGH HF 4 head LOW HF 4 spot HIGH HF 4 keep LOW HF 4 stop HIGH HF 4 love LOW HF 4 cloud HIGH HF 5 move LOW HF 4 count HIGH HF 5 snow LOW HF 4 drive HIGH HF 5 stay LOW HF 4 point HIGH HF 5 talk LOW HF 4 round HIGH HF 5 true LOW HF 4 trade HIGH HF 5 type LOW HF 4 grab HIGH LF 4 shoe LOW HF 4 mend HIGH LF 4 skin LOW HF 4 plot HIGH LF 4 tree LOW HF 4 rent HIGH LF 4 want LOW HF 4 twin HIGH LF 4 blood LOW HF 5 wept HIGH LF 4 check LOW HF 5 blame HIGH LF 5 chief LOW HF 5 bribe HIGH LF 5 cross LOW HF 5 broom HIGH LF 5 dance LOW HF 5 chant HIGH LF 5 fence LOW HF 5 crime HIGH LF 5 field LOW HF 5 grave HIGH LF 5 fight LOW HF 5 hound HIGH LF 5 floor LOW HF 5 trout HIGH LF 5 fruit LOW HF 5 group LOW HF 5 knife LOW HF 5 .qxd 01/22/08 06:41 PM Page 682 Aptara(PPG Quark) 682 Section IV ■ Traditional Approaches to Language Intervention rust regular LF 4 sock regular LF 4 teak regular LF 4 tile regular LF 4 wail regular LF 4 weld regular LF 4 greed regular LF 5 moose regular LF 5 pouch regular LF 5 stink regular LF 5 stint regular LF 5 b.GRBQ344-3513G-C25[654-688]. GRBQ344-3513G-C25[654-688].qxd 01/22/08 06:41 PM Page 683 Aptara(PPG Quark) Chapter 25 ■ Comprehension and Production of Written Words 683 learn LOW HF 5 leave LOW HF 5 noise LOW HF 5 share LOW HF 5 sheep LOW HF 5 speak LOW HF 5 voice LOW HF 5 breath LOW HF 6 bright LOW HF 6 beak LOW LF 4 crow LOW LF 4 debt LOW LF 4 dumb LOW LF 4 germ LOW LF 4 jeep LOW LF 4 jerk LOW LF 4 junk LOW LF 4 kiss LOW LF 4 lamb LOW LF 4 loaf LOW LF 4 myth LOW LF 4 skip LOW LF 4 toss LOW LF 4 urge LOW LF 4 worm LOW LF 4 yawn LOW LF 4 budge LOW LF 5 cheer LOW LF 5 cloak LOW LF 5 crawl LOW LF 5 glove LOW LF 5 gross LOW LF 5 knock LOW LF 5 ledge LOW LF 5 lodge LOW LF 5 moose LOW LF 5 phase LOW LF 5 pulse LOW LF 5 rinse LOW LF 5 sauce LOW LF 5 shack LOW LF 5 shove LOW LF 5 skull LOW LF 5 thief LOW LF 5 tread LOW LF 5 vague LOW LF 5 weave LOW LF 5 sketch LOW LF 6 sneeze LOW LF 6 . balanced for frequency) b. 6-letter. 7-letter. Word Length a. 6-letter. Dyslexia Battery Task: oral reading List composition: 70 words (14 each of 4-letter. 7-letter. and 8-letter words.GRBQ344-3513G-C25[654-688]. 5-letter.qxd 01/22/08 06:41 PM Page 684 Aptara(PPG Quark) 684 Section IV ■ Traditional Approaches to Language Intervention 6. 5-letter. balanced for frequency) Word # Letters Frequency Word # Letters Frequency baby 4 HF edit 4 LF copy 4 HF evil 4 LF iron 4 HF jury 4 LF lady 4 HF odor 4 LF open 4 HF pity 4 LF poem 4 HF riot 4 LF unit 4 HF ruin 4 LF color 5 HF avert 5 LF party 5 HF cable 5 LF power 5 HF drama 5 LF ready 5 HF elbow 5 LF seven 5 HF fluid 5 LF solid 5 HF igloo 5 LF value 5 HF urban 5 LF center 6 HF excess 6 LF future 6 HF fumble 6 LF letter 6 HF pigeon 6 LF pretty 6 HF pirate 6 LF reason 6 HF shower 6 LF region 6 HF tragic 6 LF travel 6 HF vision 6 LF brother 7 HF absence 7 LF machine 7 HF curtain 7 LF million 7 HF cushion 7 LF problem 7 HF leopard 7 LF provide 7 HF rooster 7 LF special 7 HF sincere 7 LF trouble 7 HF suspend 7 LF complete 8 HF chipmunk 8 LF language 8 HF frequent 8 LF mountain 8 HF instinct 8 LF pressure 8 HF nuisance 8 LF question 8 HF province 8 LF surprise 8 HF schedule 8 LF thousand 8 HF scramble 8 LF . Dysgraphia Battery Task: writing to dictation List composition: 70 words (14 each of 4-letter. and 8-letter words. adjectives. Oral Spelling and Copy Tasks—Dysgraphia Battery Only Task composition: 42 words (21 HF and 21 LF including nouns. Oral spelling—ask the patient to spell the word aloud b. functors) a.qxd 01/22/08 06:41 PM Page 685 Aptara(PPG Quark) Chapter 25 ■ Comprehension and Production of Written Words 685 7.GRBQ344-3513G-C25[654-688]. Written Naming—Dysgraphia Battery Only Line drawings of the following 52 items are presented for written naming Word Frequency # Letters Word Frequency # Letters Word Frequency # Letters car HF 3 tie MF 3 cane LF 4 bear HF 4 flag MF 4 comb LF 4 bell HF 4 pipe MF 4 drum LF 4 fish HF 4 shoe MF 4 lamb LF 4 foot HF 4 lamp MF 4 broom LF 5 iron HF 4 tent MF 4 glass LF 5 rope HF 4 brush MF 5 glove LF 5 glass HF 5 canoe MF 5 nurse LF 5 money HF 5 pilot MF 5 razor LF 5 plant HF 5 shirt MF 5 onion LF 5 table HF 5 thumb MF 5 skirt LF 5 train HF 5 basket MF 6 snail LF 5 watch HF 5 castle MF 6 spoon LF 5 bottle HF 6 cheese MF 6 tiger LF 5 church HF 6 orange MF 6 witch LF 5 doctor HF 6 rocket MF 6 anchor LF 6 island HF 6 thread MF 6 carrot LF 6 guitar LF 6 . verbs. Copy 1) Cross-case transcoding—present written words in uppercase and ask patient to copy in lowercase 2) Direct copy—present written words in lowercase and ask patient to copy in lowercase Word Class Frequency # Letters Word Class Frequency # Letters poem noun HF 4 faith noun LF 5 length noun HF 6 glove noun LF 5 moment noun HF 6 grief noun LF 5 street noun HF 6 fabric noun LF 6 window noun HF 6 talent noun LF 6 fresh adj HF 5 pursuit noun LF 7 happy adj HF 5 brisk adj LF 5 afraid adj HF 6 crisp adj LF 5 bright adj HF 6 rigid adj LF 5 hungry adj HF 6 absent adj LF 6 bring verb HF 5 quaint adj LF 6 carry verb HF 5 severe adj LF 6 since verb HF 5 strict adj LF 6 speak verb HF 5 argue verb LF 5 listen verb HF 6 bring verb LF 5 provide verb HF 7 greet verb LF 5 what functor HF 4 spoil verb LF 5 under functor HF 5 borrow verb LF 6 enough functor HF 6 pierce verb LF 6 rather functor HF 6 starve verb LF 6 though functor HF 6 suspend verb LF 7 8. A. & Caramazza. (1986. A.GRBQ344-3513G-C25[654-688]. Nonwords—Additional list for dyslexia battery Nonword Type # Letters Nonword Type # Letters ded pseudohomophone 3 ner nonhomophone 3 dert pseudohomophone 4 buke nonhomophone 4 gard pseudohomophone 4 cest nonhomophone 4 gerl pseudohomophone 4 dree nonhomophone 4 groe pseudohomophone 4 feve nonhomophone 4 hert pseudohomophone 4 fute nonhomophone 4 lern pseudohomophone 4 gand nonhomophone 4 meen pseudohomophone 4 gree nonhomophone 4 rufe pseudohomophone 4 leng nonhomophone 4 snoe pseudohomophone 4 nuck nonhomophone 4 sune pseudohomophone 4 pesh nonhomophone 4 turm pseudohomophone 4 plen nonhomophone 4 werd pseudohomophone 4 tink nonhomophone 4 werk pseudohomophone 4 trin nonhomophone 4 wite pseudohomophone 4 vece nonhomophone 4 breth pseudohomophone 5 plent nonhomophone 5 munny pseudohomophone 5 sheem nonhomophone 5 reech pseudohomophone 5 taght nonhomophone 5 shure pseudohomophone 5 thalk nonhomophone 5 whall pseudohomophone 5 thell nonhomophone 5 whife pseudohomophone 5 tuddy nonhomophone 5 merder pseudohomophone 6 jenior nonhomophone 6 sircle pseudohomophone 6 sloser nonhomophone 6 consept pseudohomophone 7 resords nonhomophone 7 sertain pseudohomophone 7 sountry nonhomophone 7 (From Goodman.) . R. unpublished).. The Johns Hopkins University Dyslexia and Dysgraphia Batteries.qxd 01/22/08 06:41 PM Page 686 Aptara(PPG Quark) 686 Section IV ■ Traditional Approaches to Language Intervention 9. ea bee. about 7 /l/ l l lake 8 /k/ k k. Hodges. soft 29 /h/ h h hat 30 /w/ w w window 31 /˜/ ng ng ring 32 /tß/ tch ch chin 33 /u/ oo oo food 34 /∂/ th.2 Rank Order of Phoneme Occurrences in Word Corpus and the Common Associated Graphemic Representations International Keyboard Rank of Phonetic Compatible Probable Occurrence1 Alphabet Representation Grapheme2 Example 1 /r/ r r rat 2 /t/ t t tea 3 /n/ n n no 4 /s/ s s sun 5 /I/ ih i pill 6 /\/ uh.310 English words by Hanna. o boat.GRBQ344-3513G-C25[654-688]. . et al. & Rudorf (1966) with modifications made by Berndt. th then 35 /aU au ou. o saw. for a complete listing of graphemes for each phoneme). owl 36 /U u oo book 37 /øˆ/ oy oy boy 38 /†/ th th thin 39 /j/ y y yellow 40 /Ω/ zh g rouge 1 Rank of occurrence was calculated from a corpus of 17. & Mitchum (1987). (1987) who used the Hanna. a button. (1966) data to calculate probability estimates for pronunciation of particular graphemes. ow house. Reggia. i-e find. et al.qxd 01/22/08 06:41 PM Page 687 Aptara(PPG Quark) Chapter 25 ■ Comprehension and Production of Written Words 687 APPENDIX 25. The graphemes presented here reflect only the most probable spellings (see Berndt. ice 24 /√/ uh u up 25 /g/ g g goat 26 /z/ z z zebra 27 /dΩ/ dj j joke 28 /ø/ aw aw. c key. cat 9 /i/ ee ee. et al. Hanna. eat 10 /æ/ ae a apple 11 // eh e egg 12 /d/ d d dog 13 /m/ m m man 14 /p/ p p pen 15 /\</ er er mother 16 /o/ o oa. open 17 /b/ b b book 18 /e/ ay a-e ape 19 /a/ ah a father 20 /f/ f f fan 21 /ß/ sh sh shoe 22 /v/ v v van 23 /ai/ ai i. 2 Phoneme-to-grapheme correspondences were taken from Berndt. o. GRBQ344-3513G-C25[654-688]. process whereby a written word is sounded out by associating each Pure alexia—An acquired reading impairment that is not accom- letter identity with its corresponding sound.. and grammatical class (nouns bet. case. sponding sound. non. Allographs—The different forms that a grapheme can take. yot for yacht). Global agraphia—An acquired impairment of writing that dis. Visual output lexicon—The collection of mental representations Nonlexical route—A means of information processing that does for spellings that one knows. Surface agraphia (Lexical agraphia)—An acquired writing ters are identified in serial order. letter conversion processes. font. for holding graphemes as one selects the specific allographs (letter Semantic paralexias—Reading errors that are semantic in nature. Surface alexia (Surface dyslexia)—An acquired reading impair- Lexical agraphia (Surface agraphia)—An acquired writing ment characterized by reading according to letter-to-sound corre- impairment that is characterized by an overreliance on sound-to. Deep agraphia (Deep dysgraphia)—An acquired writing impair. letter or letter cluster (like sh) that corresponds to a single phoneme. read- Homographs—Words that are spelled the same but pronounced ing that is accomplished by converting letters to their correspond- differently. and handwriting styles. also referred to as letter-to-sound conversion. by converting sounds to their corresponding letters. F whereby phonemes are held while articulatory planning for speech and f are letters that both represent the grapheme f. input lexicon or graphemic input lexicon. also called orthographic- whereby lexical entries for words are activated along with their cor. Allographic conversion—The process whereby an abstract Orthographic input lexicon—The collection of mental represen- orthographic representation is converted to a specific physical tations for written words that one recognizes.” Graphemic output lexicon—The corpus of words that one Sublexical route—A means of information processing that does knows how to spell. Phonological agraphia—An acquired impairment of spelling that as well as reading performance that is better for high-frequency. It is often characterized by a letter-by-letter reading approach.3 Glossary Alexia without agraphia—An acquired reading impairment that lexical reading can be accomplished by converting letters to their is not accompanied by an impairment of writing. ment of the sublexical sound-to-letter conversion processes. converting a letter (or letter cluster) to the corresponding sound. for example. e. script. for example. Orthography-to-phonology conversion—The process of read- ment that is characterized by the presence of written semantic ing aloud by converting a letter (or letter cluster) to the corre- errors. for sentations for spellings that one knows.. also called the visual- manifestation of a given grapheme. abstract words. Phoneme-to-Grapheme Conversion—The process of writing ter than functors).qxd 01/22/08 06:41 PM Page 688 Aptara(PPG Quark) 688 Section IV ■ Traditional Approaches to Language Intervention APPENDIX 25. typically observed as a compen. representation.. spondence rules so that irregularly spelled words (such as yacht) letter conversion processes. Phonological output lexicon—The collection of phonologic rep- Grapheme-to-phoneme conversion mechanism—A mental resentations for words that one can produce. that Orthographic output lexicon—The collection of mental repre- is. reading bus as “car. panied by an impairment of writing. but not Graphemic output buffer—The short-term storage mechanism recognized. output lexicon. as well as effects of word frequency (high better than low). form and style) and implements graphic motor programs. the various ways one can write a given letter by varying. Phonological alexia—An acquired impairment of reading that is rupts lexical and sublexical spelling processes to such an extent that characterized by an inability to read nonwords due to impairment few words are spelled correctly and it is difficult to detect lexical to the sublexical letter-to-sound conversion processes. also called the graphemic- example. .g. also called pure corresponding sounds and nonlexical writing can be accomplished alexia.” their corresponding letters. typical errors include regularization of tend to be mispronounced. for example. A grapheme is a production is accomplished. impairment that is characterized by an overreliance on sound-to- satory reading approach in individuals with pure alexia.g. is characterized by the inability to write nonwords due to impair- concrete nouns in comparison to low-frequency. the adjective lead as in “a lead pipe” and ing sounds or writing that is accomplished by converting sounds to the verb lead as in “lead the group. It results from a disruption Graphemic input lexicon—The corpus of written words that one of visual input from the appropriate abstract word-form recognizes. for example. responding meanings. irregularly spelled words (e. influences on spelling accuracy. Phonological buffer—The short-term storage mechanism Grapheme—The abstract representation of a letter’s identity. by means of deriving spelling based on knowledge of sound-to- Deep alexia (Deep dyslexia)—An acquired reading impairment letter correspondences. imagery (high better than low). input lexicon or the graphemic-input lexicon. typical errors include regularization of Letter-to-sound conversion—The process of reading aloud by irregularly spelled words (e.g. also called orthographic output not rely on activation of lexical representations. yot for yacht). that is characterized by the presence of semantic errors in reading. lexicon or graphemic output lexicon. so that words are visually perceived. Visual input lexicon—The collection of mental representations Lexical-semantic route—A means of processing information for written words that one recognizes. Letter-by-letter reading—An approach to reading whereby let. not rely on activation of lexical representations. Kolb & Cioe. neural networks (as errorless learning) to illustrate the applications of neural opposed to neurons) have been identified as the essential principles to treatment and the potential opportunities for unit of brain function (Buonomano & Merzenich. and Jay Rosenbek processes. migration. including axons and dendrites. model of language function that incorporates phonologic. ture. 2004. to thousands or tens of thousands of other enhance daily communicative function. 1998). through their connections. Because active per- of injury through behavioral therapy. Any given neuron sends output.qxd 01/21/08 03:02 PM Page 689 Aptara(PPG Quark) C. and any given neuron receives synaptic contacts implications of education psychology research for the struc- providing input from up to tens of thousands of neurons.GRBQ344-C26[689-734] . the nature of Neurons. and (2) the replacement of knowledge lost as a result neural activity in all its neural networks. in which the neu- rons themselves serve mainly to provide metabolic support. written language) into another domain (e. Leslie J. For these reasons. Gonzalez to therapeutic advantage. These networks provide the basis for the representa- delivered during therapy. and grammatical function.. The brain is best viewed as webs of connected neural processes. Although we are at ceptions. cal therapies. which include reactive neurogenesis. and the nature of feedback works.. the clinical data so far are incon- clusive and do not yet bear on rehabilitation of language Rothi. and to review several specific tion of knowledge and for transforming knowledge in one therapies (including phonologic. These are reviewed at length in this text. acquisition of knowledge and skills during language ther- The brain contains 100 billion neurons. to define mechanisms by which knowledge and skills located in the cerebrum. and spoken language). and grammati- domain (e. the principal focus of this chapter will be on behavioral therapies. The state of the brain at any given moment (the substrate tures. 2004). and the currency of neural process- (1) the endogenous responses of neural tissues (reactive ing (firing rates). and the knowledge is represented in synap- plasticity). Nadeau. Cognitive Neurolinguistic Approaches to the Treatment of Language Disorders Chapter 26 Language Rehabilitation from a Neural Perspective Stephen E. we focus on the treatment The objectives of this chapter are to detail a neural network of aphasia not from the perspective of clinical trials but. semantic. rather. gained during therapy might generalize in ways that will through its axon. to with a very brief review of relevant aspects of neuroscience discuss cerebral memory mechanisms in relation to the (see also Nadeau et al. we refer to their neural 689 . The efficacy of behavioral therapies for language impair- OBJECTIVES ment has been demonstrated in a large number of studies. Therefore. neural tic connection strengths. thoughts. lexical-semantic. and synaptogenesis (Kolb. We will begin semantic. generalization. context. In this chapter. and temporal spacing of therapy.g. constraint-induced language therapy. axonal sprouting and extension to target struc.. some providing level I evidence. from the perspective of neural science. and plans correspond to patterns of spa- the scientific threshold of manipulating reactive plasticity tially disseminated neural activity. are organized into net- stimuli presented in therapy. Rehabilitation after brain injury depends on two processes: structural maintenance. Half of these are apy. to consider the neurons.g. for conscious awareness) largely is defined by the pattern of 2004). This dynamic addition. seman- ultimately settle into a steady state.” Even in the case of callosal section. paraphasic errors typically bear a semantic and/or phono- ally provides the neural basis for bottom-up/top-down pro. certain types of brain semantic networks. The fact that even subjects with returning (afferent) projections from the target networks. In the domain of nal rod or cone or when the firing of a single muscle fiber is elicited by language. represented in neural connection strengths). In this way. and processing (the transformation of input tions.. implicit rules governing phonologic sequences. Learning corresponds to the left occipital cortex and the splenium of the corpus cal- changes in connection strengths in the network.g. Because contributing its particular knowledge and expertise to the knowledge is distributed as connection strengths through- final steady-state pattern. each rized above) leads us to more nuanced conclusions. nection syndromes (Geschwind. a sus. speak about right hemisphere perceptions. The neural network under- cessing effects. arguably the purest dis- connection syndrome. because it has no access to left hemi- A given neural network supports knowledge (long-term sphere language networks and the left hemisphere cannot memory. There has been a long-standing debate in the linguistic tained pattern of neural firing in one network eventually and neuropsychological literatures as to whether deficits elicits a sustained pattern of firing in another network. In the final analysis. Subjects with posterior cerebral infarcts that destroy patterns into output patterns). Most observed after brain damage reflect loss of knowledge or loss neural efferent (output) projections are reciprocated by of access to knowledge. cortex can see the printed words. disconnection syndrome caused by damage to the arcuate . evidence of residual knowledge is perfectly case of language. the transmission of information in the brain corre. a phenomenon referred to as “graceful degrada- parallel constraint satisfaction better illustrated than in the tion. guage comprehension and production. The acquisi. severe impairment may demonstrate residual knowledge Thus. work. but it does not elimi- an emergent property of connected neural networks nate all knowledge unless the network is completely referred to as “parallel constraint satisfaction. such as when a photon of light stimulates a single reti- connections that are lost with the surgery. information transmission typi. rules are reflected as Information is not sent from one part of the brain to implicit knowledge of regularities in a network’s experience. Knowledge losum cannot read. The time to settle largely tic paraphasic errors tend to be near-misses. information defined at a single discrete support synaptic connections that represent knowledge— locus—are not found in the central nervous system.. it elicits firing in many of the neurons to which explicitly (e. the translation of concepts into phonologic pathways. express itself verbally. In this way.. Acquisition of declarative knowl.” Nowhere is destroyed. Rules can be learned neuron fires.” Thus. 1965). the right hemisphere generally cannot sound. “i” before “e” except after “c”). conduction aphasia has long been viewed as a the firing of the terminal of its afferent axon.GRBQ344-C26[689-734] . particularly those involving major white matter ing grammar.qxd 01/21/08 03:02 PM Page 690 Aptara(PPG Quark) 690 Section IV ■ Traditional Approaches to Language Intervention representations as being distributed. follow- and constraints imposed by neural networks driving respira. standing of brain operations that we have achieved (summa- cally involves a large number of connected networks. For example. lead- sequences. and phonemic defines behavioral response latency. most aberrant behavior tion of nondeclarative knowledge (e. auditory). processing. may destroy connections between networks. ing transection of the corpus callosum to treat refractory tory and pharyngeal musculature in actually producing generalized epilepsy. neural activity can spread from a however. sponds to an ongoing. thoughts.g. often is cited as support for the loss-of-access theory (e. procedural or skill observed after brain damage likely reflects a mix of loss of memory) can be achieved through the incremental adjust. in which what we ultimately say reflects consistent with partial loss of knowledge as a result of net- perceptual input (e. rather.. knowledge as a result of destruction of neural networks and ment of neural connection strengths that may occur during loss of access to knowledge as a result of damage to white matter pathways or intervening gray matter “relay stations. ing to cognitive dysfunction that truly reflects loss of access and implicit rules governing modifications of phonologic to intact knowledge representations—that is. the involved interhemispheric axons 1 Local representations—that is. damage. processing by neural networks support. it is connected. In practice. In general. because even though the right occipital includes facts and skills.1 When an excitatory neural network processing activities. logic relationship to the target).g. such rules are best viewed as metamemory. another (this is a digital computer concept). They are present only peripherally. damage to a network may lead to a meet multiple different constraints simultaneously— substantial probability of output error. true discon- sequences as language is produced (phonetic modifications). and in few neurons to many neurons within a network and from the extremely rapid online processing that underlies lan- one network to another.g. and ing memory (the pattern of neural activity in the network at plans because it has no way of accessing these representa- any given time). knowledge latent in our work damage. two-way dialogue between a sending subjects with agrammatical aphasia often display consider- network and a receiving network in which the two networks able ability in make judgments regarding grammar. it cannot relay this ortho- edge (fact memory) requires the participation of a unique graphic information to the left hemisphere for linguistic ancillary processor (the hippocampal system). the brain is able to out a neural network. On the other hand. e. Semantic. In knowledge is represented in the links between these fact.. and concept representa- and Broca’s area. this chapter will focus heavily (but not exclusively) on parallel distributed processing models. it may be possible to The PDP modification of the Wernicke-Lichtheim enhance phonologic sequence knowledge in networks in the model posits that the acoustic domain (akin to Wernicke’s nondominant hemisphere. Roth. (From Roth. A specific PDP model of language will be discussed to introduce the basic concepts 4 and to frame some later hypotheses about the domains of Hidden units Hidden units knowledge represented. brain. Cimino-Knight. M. Hollingsworth. Subsequently. the Wernicke-Lichtheim information processing model tion syndrome. L. S. 2001. Unfortunately. Hollingsworth. Cimino-Knight.GRBQ344-C26[689-734] . but we probably know more resentations are generated in the modular domains and how about language than about any other cognitive function. also known as connectionist models. connectionist concepts now are deeply of access to knowledge) other than through training of net. Nadeau. the subject with conduction aphasia. It also does not address the means by which these A fully neuroscientific approach to behavioral therapy for domains might interact. and topography as the Wernicke-Lichtheim model (Nadeau. For example. Nadeau. Rolls & Treves.. both because they enable us Concept to link neural network architecture directly to complex 1 representation 5 behavior and because they incorporate many of the proper- ties of neural systems discussed above. H. 1885) and has stood permission. Heilman. Rolls & Deco. K.. A. We have proposed a parallel dis- language impairment must ask what types of knowledge need tributed processing (PDP) model that uses the same general to be replaced. Heilman. embedded in—and receive enormous support from—main- works that are still connected and have some capability for stream neuroscientific research (see. 12.) .. Although a number of approaches have been taken to explain language processing (e. in 2002. and Lexical-Semantic Processing Figure 26–1. association cortices that represent acoustic features of and Lexical-Semantic Processing under A Parallel Distributed Processing Model of Language below). how can the brain best be coaxed into reacquiring this knowl. within these domains and how they might be stored in the works supporting phonologic sequence knowledge. acquiring the requisite linguistic knowledge. We currently have no ability explanation for a broad range of psycholinguistic phenom- to treat components of aphasia related to disconnection (loss ena. 2 6 mation about the neural basis of language as it relates to speech-language therapy.g. the result of a lesion of tions) underlying spoken language function. Although not tested through simula- language processes to propose some reasonable hypotheses tions. and to this extent.. linguistic and cognitive neuropsychological). Semantic. but we will also rely on other sources of infor. the connecting white matter can be viewed as a disconnec. 61–70. 2006). but this PDP model also specifies how rep- tainty in any cognitive domain. exists that does not specify the characteristics of the representations conduction aphasia also reflects damage to the neural net. how are they represented in the brain. (2006). concepts: Evidence of two routes. with standing aphasic syndromes (Lichtheim. effectively bypassing the discon. other anteroposterior white matter the test of time in defining the topographical relationship pathways). this model is neurally plausible and provides a cogent regarding therapeutic strategies.g. area) contains large numbers of units located in auditory nection in the dominant hemisphere (see Phonologic. 1998). Neurocase. More generally.. 26–1). Abundant evidence. M. Naming language function has played a dominant role in under. 3 7 A PARALLEL DISTRIBUTED PROCESSING Articulatory Acoustic MODEL OF LANGUAGE motor representations representations Phonological. L. Proposed parallel distributed processing model of language. E. & edge? The answers to these questions are not known with cer. perhaps.qxd 01/21/08 03:02 PM Page 691 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 691 fasciculus (and. between language zones in the posterior perisylvian region articulatory-motor representations. we will have cause to refer back frequently to Hidden units PDP models. It certainly is true that a discontinuity exists between the modular domains (acoustic representations. however. we have sufficient knowledge about the neural basis of domains (Fig. The Wernicke-Lichtheim information processing model of A. A brief review of the unique prop- erties and particular strengths of PDP models will follow. or window a maximum value of one). semantic representations in the various domains. enable the systematic associ. is best viewed as the emergent product of the entire network. simple though it is. activation spreads throughout the arbitrarily related to one another (e. precise neural counterpart of a unit is uncertain and may vary from This auto-associator model. Thus. bed- function of its combined inputs at any one time (in many models. The use of left-to-right sequential order in lieu of tem- area) contains units located predominantly in the dominant poral order is a device of convenience. and sofa). of the units in the other domains. work to provide a more detailed understanding of how they ing features of houses. Within any domain. Nagarajan. Seidenberg. Thus. Thus. and it . or study). the representation of the concept of We will now focus on particular components of the net- “house” might correspond to activation of units represent. as opposed to continuously variable motor Bedenbaugh. fancy bed- terns of connectivity within a network define its functional capacity.g. 2001). The hidden unit regions. 26–1) can be best illus- strengths throughout the association cortices supporting trated using a particular model developed by David this knowledge. The entire representation. generating the distributed representations of meaning The neurobiology of cortical neural network function is currently underlying semantics. Rather. if not Concepts Representations most. hence McClelland.g. leads to a distributed representation of a large. Thus. such as visual attributes. a sig. & Hinton. of the other units in that same domain (symbolized by the small looping arrow appended to each domain in Fig. and the model eventually settles into a steady state meaning). Smolensky. this temporal-geographic transform in the brain (Cheung. it is not implausible that single neurons function essential attributes of a network that might be capable of as units in the superior colliculus. “on” state (as if the network has been shown these particular ation of representations in two connected domains that are features or articles). The seman.” Each unit within each model is comprised of 40 “feature” units. whereas in the cortex. television. contents (physical and human). gramming of the model (e. and so on.. almost instantaneous engagement of all uted throughout unimodal.. no output occurs. It has an output that is a nonlinear mathemat- and drapes). Each unit is connected with all the other learning of a language.. and articulatory motor representations as a surrogate for clamping “oven” ultimately results in activation of all the temporal order in precisely the same way as the reading items one would expect to find in a kitchen and thereby model of Plaut. word sound and word model. 26–2). No kitchen unit per se is turned on. and supramodal domains of the network will occur. acoustic-articulatory motor representations a kitchen (Fig. often incorporating a threshold such that for activation levels below the threshold. tures of speech. if not most. ordered as they are in the phonologic word that are activated. During any programs (e. linguistic behavior association cortices that represent semantic features of con. 1986). The network contains the knowledge. the concept of (1996). living room. each corresponding of these domains is connected via interposed hidden units to to an article typically found in particular rooms or an aspect many. clamping both bed and sofa Each unit is connected to a very large number of other units.2 The articulatory domain (analogous to Broca’s form. has the region to region. initiated by input to any domain tic or conceptual domain contains an array of units distrib. polymodal. Connection strengths are defined by the like- set of connections between any two domains forms a pattern lihood that any two features might appear in conjunction in a associator network. it is possible that a cortical column comes closer to meeting our definition of a unit.g. via a distributed representation. room. materials. in the totality of its connections. the strengths of the connections units in the network—an attribute that defines the model as between the units are gradually adjusted so that a pattern of an auto-associator network. desk and desk-chair. that enables this representa- tion to be generated. Each unit within a given domain is connected to many. and blends of rooms not anticipated in the pro- ical function of its level of activation. The nature of con- knowledge is represented as the pattern of connection cept representations (depicted in Fig. The room replete with a fireplace. capability of generating distributed representations of a It has a level of activation that is defined as a nonlinear mathematical number of different rooms in a house (e.. Auto-associator networks have the activity involving the units in one domain elicits the correct capacity for “settling” into a particular state that defines a pattern of activity in the units of another domain. The pat. For example. cepts.g. Thus. When one or more units are clamped into the with nonlinear unit properties. construction work and the nature of the knowledge they support. As we have noted.. Rumelhart and his colleagues (Rumelhart.qxd 01/21/08 03:02 PM Page 692 Aptara(PPG Quark) 692 Section IV ■ Traditional Approaches to Language Intervention phonemes.g. Knowledge within each domain is represented as cessing model provides no insight regarding the nature of the connection strengths between the units. The model employs left-right position in acoustic that implicitly defines a particular room in a house. moidal curve that asymptotically approaches a minimum value of zero or easy chair and floor lamp. subcomponents of rooms (e. in conjunction typical house. During of particular rooms. bathroom. a representation corre. McClelland. The 40-unit model actually has the 2 A “unit” is the smallest functional entity within a connectionist model. sponds to a specific pattern of activity of all the units. of the network. This “rooms in a house” the term “distributed representation. type of language processing.GRBQ344-C26[689-734] . obviously is comprised of vastly more that 40 features. and Patterson implicitly defines. “kitchen” is defined by the pattern of feature units tive feature. would feature positions for each output phoneme or distinc. but evidence exists for frontal operculum that represent discrete articulatory fea. the Wernicke-Lichtheim information pro- 26–1). & Schreiner. phonemic distinctive features). The brain’s semantic auto-associator understood only at the most rudimentary level. consequently. • • • • small Thus. a major component in • sink auditory association cortices corresponding to the sounds • • • • • • • • • • • stove drapes that dogs characteristically make. meaning the elicitation of distributed concept • • • • • • • • • • • • • • • • • • • • door • walls representations in other connected subnetworks. tion. subjects with damage to visual Figure 26–3. L. Linguistic tions corresponding to the vast number of concepts we are capable of representing. For example. E. a major component in the • • • • • • • • • • • • • • • • • • • • • • • • fireplace limbic system corresponding to one’s feelings about dogs in • • • • • • • • • • • • • • • • • • • • ashtray general and about specific dogs..GRBQ344-C26[689-734] . a predicative component. develop visual and limbic distributed Figure 26–2. • • • • • • • • • • • • • • • • • • • • toilet The concept of a fractionated. The • • • • • • • • • • • • • • • • • • • • television • • • • • • • • • • • • • • • • • • • • dresser distributed representation of the concept “dog” has a major • • coffee pot component in visual association cortices corresponding to • • • • cupboard toaster knowledge of the visual appearance of dogs in general. 1984). (1986).” Schemata and sequential thought processes in PDP models.” (See text for explanation.. (From Rumelhart. multi-network distributed • • • • • • • • • • • • • • • • • • • • bathtub representation of meaning is illustrated in Figure 26–3. Parallel distributed processing (Vol. P. E. Warrington & • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • scale Shallice. & the PDP Research Group (Eds. The average person. Time elapses from left to the two together comprising an automatic working associa- right. Not all of these subnetworks will be acti- • • • • • • • • • • • • • • • • • • • • desk • • • • • • • • • • • • • • • • • • • • very small vated every time or in exactly the same way by everyone. however. corresponding to our knowl- • • • • • • • • • • • • • • • • • • • • picture edge of what dogs are likely to do. visual information makes a particularly large contribution to the meaning of living things. tory component of the meaning of “dog. McClelland. a component in the olfac- • • • • • • clock • • • • • • • • • • • • • • • • • • • • desk chair tory cortex corresponding to the odors of dogs.) Predicative Somato- sensory enables an enormous repertoire of distributed representa. Good evidence suggests that in the brain. 7–57). and compo- • • • • • • • • • • • • • • • • • • • • books nents in the perisylvian language cortex that enable us to • • • • • • • • • • • • • • • • • • • • carpet translate the semantic representation of “dog” into an artic- • • • • • • • • • • • • • • • • • • • • bookshelf • • • • • • • • • • • • • • • • • • • • typewriter ulatory motor representation (so we can say /dog/) or an • • • • • • • • • • • • • • • • • • • • bed acoustic representation (so we can understand another per- • • • • telephone son saying /dog/). the mean- ing of a given word is distributed over a host of networks. a pattern of activity in particular subnetworks corre- • • • • • • • • • • • • • • • • • • • • large • • • • • • • • • • • • • • • • • • • • very large sponding to “dog”—and we can speak in terms of working • • window associations. multi-component. L. presumably • • • • • • • • • • • • • • • • • • • • floor lamp involving the frontal cortex. Farah and McCelland. with are clamped in the “on” position. when hearing /dog/. 1999. Thus. Massachusetts: MIT Press. D. but nothing inherent in PDP DOG Acoustic models precludes a semantic representation comprised of two or more subnetworks (see. This particular model network is not compartmentalized. a component in somatosen- • coffee cup easy-chair sory cortex corresponding to the feel of dog fur or wet • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • sofa tongue or cold nose. J. with permission.. Evolution of the pattern of activation in the “rooms-in-a-house” model when the units “ceiling” and “oven” representations.g.. might need to volition- tion of that particular feature unit. pp. & Hinton. each constituting a working memory. The size of each square indicates the degree of activa.) .). Olfactory 1991). 2. D. e. E. In J. Cambridge. distributed represen- association cortex as a result of herpes simplex encephalitis tation of the concept “dog. we can speak in terms of working memory—in this • • • • • • • • • • • • • • • • • • • • medium case. as • • • refrigerator well as to that of particular dogs. Rumelhart. nearly everyone would. either ceiling automatically or volitionally.qxd 01/21/08 03:02 PM Page 693 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 693 oven exhibit category-specific naming and recognition deficits for • • • • • • • • • • • • • • • • • • • • computer coat hanger living things (Forde & Humphreys. Visual depending in part on the semantic features that are most Limbic essential to that meaning. McClelland. The full. G. ally develop the working association that brings in the olfac- Smolensky. produce the correct pronunciation of all the words it had This reading model fundamentally recapitulates the read. nucleus. K.” because in every case but “pint. bust. rhymes. the second cluster what the model learned was the relationships between including all the possible vowels in the nucleus. . long experience with English orthographic-phonologic sequential relationships. C. thereby. How was this possible? orthographic (printed letter) representations. Thus. respectively (as for the graphemes). In fact. lust.” which are always pronounced /∧st/ [e. went considerably beyond this. repertoire.qxd 01/21/08 03:02 PM Page 694 Aptara(PPG Quark) 694 Section IV ■ Traditional Approaches to Language Intervention The Acoustic-Articulatory Motor Local representations were used for the graphemes Pattern Associator Network and phonemes.e. it incorporated sequences it had never encountered). The model encountered difficulty (reflected in prolonged reading 100 hidden units latency) only with low-frequency words. competing pronuncia- tions of the same orthographic sequence. J. One of the most striking things about the trained acoustic-articulatory motor pathway of Figure 26–1..3 The sequences of joint phonemes. D.000 English. Understanding normal and impaired word some of which will be discussed later in this chapter. The model was trained using a mathematical algo- Because this network has acquired. To the extent that a more consonants in the coda. A hidden unit layer of 100 units. L. able to learn it and then apply that knowledge to novel forms 3. McClelland. mor- orthographic representation of 3. Seidenberg. and the sequences of graphemes and sequences of phonemes that are third cluster including all possibilities for the one or characteristic of the English language. rithm that incrementally alters the strengths of connections knowledge of the systematic relationships between acoustic that make the biggest contribution to error.” the sequence Figure 26–4. the model would have been inca- ters. syllables. the model is that it also was able to produce correct pronuncia- major difference (inconsequential to this discussion) being tions of plausible English nonwords (i.. the first cluster including all possibilities for the pable of applying what it had learned to novel words. 1989). through experience.e. orthographic that in place of acoustic representations. and only to the extent that it had learned different. An output layer of 61 phoneme units grouped into clus. Patterson. & networks. the model was 2. 26–4) was composed of three layers: ing the pronunciation of all the words by rote. 3 This is a highly effective but entirely heuristic means of training PDP (From Plaut. (1996). details of mechanisms underlying knowledge acquisition by the cerebral Psychological Review.. tion). The model One might have inferred that the model was simply learn- (Fig. must. which was com- sequences and articulatory sequences. An input layer of 105 grapheme units grouped into clus. limited repertoire of sequence types exists. pathway 7-3). been the case. words ending in “-ust. single-sylla- phemes.. One version of the parallel distributed process- ing (PDP) reading model developed by Plaut and colleagues.g. 26–1.) cortex currently poses one of our greatest neuroscientific challenges. see Fig. and The knowledge that allows a person to translate heard sound two-way connections exist between each of the hidden units sequences into articulatory-motor sequences and. Certain sequences (i. providing the net- contained in the network that connects the acoustic domain work with the auto-associator capability for “settling into” to the articulatory motor domain (the acoustic-articulatory the best solution (as opposed to its own approximate solu- motor pattern associator. trust. S. and words characteristic of the language (Nadeau. that incorporated some of the sequential relationships in this ters. Consideration of the reading model developed by sented. one or more consonants of the onset. it was very fast with high- frequency words.. Real neural networks learn by completely different mechanisms. 103.. one pair at a time. those most commonly found in English. If this had 1. Understanding the reading: Computational principles in quasi-regular domains. single-syllable words) were more thoroughly etched in network connectivity. One-way connections from each of the grapheme input units exist to each of the hidden units. Every output unit mediates repetition of both real words and nonwords is was connected to every other output unit. cycling repeatedly through the Plaut and colleagues (1996) will help to make this more entire corpus. 56–115. it has learned the puted as the difference between the actual product of the sound sequence regularities of the language: the phonemic network and the desired product of the network. M.g. In this way. with permission. it was slow to 105 grapheme units read “pint. or crust]). the model ultimately learned to transparent (see also Seidenberg & McClelland. The information the model acquired through its and coda.GRBQ344-C26[689-734] . affixes. and each of the phoneme output units. Thus. including all the possibilities for onset. ble words and the corresponding phonologic forms was pre- 2001). It also was very fast with words having an 16 phoneme units absolutely consistent orthographic-phonologic sequence relationship (e.. however. however. is not in their earlier work on this reading model. shown.. however. This ing latency will be significantly affected by the knowledge pattern associator network corresponds to the cognitive of other words that. These patterns represent the repository of distributed sequences of activity corresponding to articu- knowledge about subword (sublexical) entities in general lated words. The direct concept representations–articulatory tory correspondences). flint. because these are the representations of single words. motor pattern associator (Fig. This repository of direct. pathway 6-5). (as in a digital computer). pint). the network architec.g...g. possibly. the ultimate phonologic sequence selection and are blown. acoustics nor knowledge of semantics—it serves only to The capacity of the model to read nonwords reflects its translate a representation in the acoustic domain into a rep- ability to capture patterns in the sequential relationships resentation in the concepts/semantics domain. pathways 1-2 and 4-3). leagues (1996). see Fig.. This spatial-temporal translation precludes sig- as well as our knowledge of phonotactic constraints (the nificant acquisition of sequence knowledge and makes this rules that determine whether a given phonologic sequence fundamentally a whole-word pathway. flint. representation). and certain tions domain to the articulatory motor domain (Fig.g.g. and town vs. when one recalls that all representations in the regular (e. down. tions pattern associator. because it translates spatially distributed pat- and including whole words and. acoustic-articulatory correspondences are sub. whole-word naming route finds support in studies of .” hood” effects (Vitevitch. auxiliary verbs. its nam. and fugue).. 1988) is contained in two different pattern and the root forms of nouns and verbs as well as functors associator networks that connect the concept representa- [e. These behaviors precisely recapitulate close neighbors. bat]).qxd 01/21/08 03:02 PM Page 695 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 695 “int” is pronounced /Int/ (e. 1997)... contain much knowledge of sequences and sublex- from phoneme pairs (joint phonemes) and syllables up to ical entities. gown. however. ing the capacity to generate a representation lies in connec- ularity in the orthographic and phonologic sequences to tion strengths and is not a piece of data at a memory location which it is exposed. To be more precise. knowledge stored in the acoustic-articulatory motor pattern stantially more consistent than are orthographic-articula. If a single word is sufficiently common (high token Understanding the meaning of a word that is heard is frequency). conjunctions. 26–1. in fact. because sequences and sublexical entities because of the sequence in English. the model acquires enough experience with it achieved through the connections between the domain that that competing orthographic-phonologic sequential rela.g. street. the knowledge the model acquires Lexicons reflects competing effects of type frequency and token fre- quency. articles. 1988). sequential relationships between acoustic and articulatory 26–1. pint). pathway 1-2) does not. These sequential relationship pat. It contains neither knowledge of sprint). or lint). terns potentially involve sequences of varying length. These two pattern associator net- The acoustic-articulatory motor pathway in the model works support different forms of knowledge. phonologic sequence errors that correspond to one of the aisle.. where mean- between orthographic and articulatory word forms and to ing is instantiated. syllables and morphemes (affixes (Ellis & Young. and that the knowledge underly- ture in these models is capable of capturing any kind of reg. If a contains concept features (the acoustic-concepts representa- word is relatively uncommon (e. or (Ellis & Young. vast number of connections between two network domains. tint. the “kitchen” and McClelland point out. the behavior of normal human subjects given reading tasks. focused on intuitive and. together neuropsychological concept of a phonologic input lexicon belong to a competing type (e. This conceptualization of a lexicon as a apply this knowledge to novel word forms. multi-word terns of activity corresponding to concepts into temporally compounds. not local. however. It begins to make sense. contains the sound features of language and the domain that tionships have a negligible impact on naming latency. As Seidenberg central nervous system are distributed (e. mint) or irregular (e. mint. mint.g. limited only by the extent of exposure. is strongly at odds with traditional con- differences in rhyme components of single-syllable words ceptualizations of lexicons as repositories of abstract local (the nucleus plus the coda [e. “str-” of stream. The existence of this is permissible in a particular language). cept into a spoken word (the phonologic output lexicon) in a multi-syllabic version. although equally uncommon.g.GRBQ344-C26[689-734] . It also sequence knowledge also provides the basis for “neighbor- was slow (but not quite so slow) to read words like “shown.g. guide.g. Plaut and col. stray. 26–1. and flown). pathway 4-3) provides a robust basis for knowledge of word forms (actually somewhat more redundant.g. prepositions]). as well as Seidenberg and McClelland (1989) although well accepted in the connectionist literature. major determinants of whether a word is orthographically however.. tint. The indirect of Figure 26–1 would capture analogous patterns in the concept representations–articulatory motor pathway (Fig. associator. which reflect the influence because two equally frequent alternatives exist to the of variously competing pieces of sequence knowledge on pronunciation of “own” (e. It was very slow with words that are unique demonstrated in the tendency to produce near-miss in their orthographic-phonologic sequence relationship (e... and strum) and. 26–1.g. Such regularities would include joint phonemes other than The knowledge that enables a person to translate a con- rhymes (e. and subjects tions between lesion locus and aphasia type? with aphasia produce phonemic paraphasias in naming and internally generated spoken language quite comparable to Phonologic Paraphasic Errors those produced during repetition. opment of networks instantiating this knowledge (as con- fau . The tion aphasia who are able to repeat words better than non. fallswash . which. fallshine . ing. .” These patterns of have lost most phonologic sequence knowledge (Fig. . When asked to name an object. . who could be cued to use one or the other of the two concept- He tended to pursue a semantic conduite d’approche. dominant hemisphere acoustic-articulatory motor pattern Further evidence of two pathways supporting naming of associator network (Fig. . 1993). and his performance when naming “dishes . . 1981. in which subjects have very limited ability to repeat. depending on of phonologic sequence knowledge. 2006). . sublexical elements of this knowledge cannot be selected at sive infarct involving the entire left middle cerebral artery will. 26–1. this would correspond to the two pathways should be enabling the naming of concepts. .qxd 01/21/08 03:02 PM Page 696 Aptara(PPG Quark) 696 Section IV ■ Traditional Approaches to Language Intervention subjects with repetition conduction aphasia4. provides new however. Nonpropositional spoken the type of verbal cue provided. 26–1. . . & Villa. this PDP model predicts that logic processing. 1986. . . . lexical. . in turn. This left. The subject described in the foregoing (Roth et al. . He actually was able to successfully name objects 30% of the 1984. how can pathway 1-2) cannot account for observations that normal the model be reconciled with what is known about correla- subjects exhibit phonologic slips of the tongue. as indicated in pathway 4-3 damage to dominant hemisphere networks supporting phono- of the model (Fig. . heavy . accessible phonologic sequence knowledge represented in his heavy . Basili. 1984. if any. as they can in propositional language process- territory. . dated with systematic cued naming studies. 4. internally generated language. . however. or handed subject had a Broca’s aphasia stemming from a mas. he must have been speaking with his right hemisphere. . .” When given right hemisphere. At this point. . some appear to fallshvine . . One might reasonably ask. he replied “fauwash . fallsha . Ta’ir. such as a faucet. McCarthy & Warrington. but discrete phrasal. . originally described by Warrington and Shallice (1969). Thus. . pathway 1-2) producing few. that deficient devel- the phonemic cue “faus. a typical response would be which was undamaged. . pathway 7-3)—the repository concepts has been provided by a subject who. trasted to damage to fully developed networks) can provide an alternative basis for phonologic paraphasic errors. but at the cost of producing large It also finds some support in reports of subjects with conduc. pathway 4-3). water . chairs . Saffran & Marin. 26–1). was successful only approximately 10% of the insight regarding the neural basis of phonologic paraphasic time. His language was largely limited to single words. have severe Factors Influencing the Pattern of Errors impairment in auditory verbal short-term memory. . could be induced to use language. in Internally Generated Language phonologic paraphasic errors. 1975) and who are able to repeat words better when they are Lexical-Semantic and Phonologic given in a sentence context than when given as a single word. 26–1. This suggests. . . which often is supported by the nondominant hemi- either the whole-word (direct) naming route or the phono. Friedrich. . . sink . and 7). one must posit access from concept representations to Phonologic paraphasic errors generally are thought to reflect phonologic sequence knowledge. . . water .” however.. 2006). pathways 1-2 or 4-3). in turn. thafaush . & Berndt. in production and have variable factors may influence the pattern of errors observed in inter- but sometime negligible deficits in auditory verbal short-term memory. hot . water . resulting in a severe deficit in auditory a whole-word route to confrontation naming (as well as in verbal short-term memory. It can be contrasted with reproduction con- duction aphasia. 1984). . Impairment in Aphasias thereby increasing the likelihood of engaging concept repre. Saffran & Marin. . Glenn. if any. washer . phonologic sequence knowledge (Fig. . 26–1. sphere (Speedie. . In the two-route naming model we have introduced. does logic (indirect) naming route (Roth et al. we have fleshed out the essential components sentations (McCarthy & Warrington. . tub. which he produced quite readily and with good articulation. . either no cue or a semantic cue. in which subjects often make profuse phonologic para. phonologic paraphasic errors. fau . fauswah . and given Thus. His left hemisphere was nearly completely destroyed. . . numbers of relatively undesirable nonword errors. .GRBQ344-C26[689-734] . . ready after phonemic cueing suggests that he was using discretely to go .. how can this model which the only link from the concept representations domain account for the lexical-semantic and phonologic features of to the articulatory motor domain is the direct one (Fig. reflect sequence knowledge. water . three phasic errors in repetition and. Miceli. . . errors. In our model.. 1969). and make few. 1975. but can speak quite well. . shut . 26–1. dishwasher . . & Heilman. time using this pathway. . 26–1. we could repeat real words (with evidence of influence by semantic induce him to employ a phonologic route—a route that attributes but little influence of word length). Warrington & Shallice. response to bedside testing suggested that he normally used pathways 3. Koller. A model in of the model. . shut . Friedrich et al. see Fig. subjects with various types of aphasia and. . 4 A conduction aphasia. nally generated spoken language in perisylvian aphasias (and . and are severely engaged sublexical representations implicit in his stores of impaired in repeating nonwords and functors (Caramazza. can but that by providing him with a phonemic cue. dual-route naming hypothesis was further tested and vali- words (Caramazza. & Marin. fallsh. naming routes (Fig. Wertman. . old . . usually. 1984. He made very rare phonologic paraphasic errors. To explain these observa- tions. (2006). E.. 2005) (possibly corre. Naming concepts: Evidence of two Evidence of two routes. and deficient development of con- nectivity in the nondominant hemisphere phonologic route may lead to the generation of phonemic paraphasic errors. may be a general characteristic of the right hemisphere. the effect of the sponding to pathway 1-2 in our model). H. in the presence of an extensive left hemisphere perisylvian lesion. with ability may vary as a function of hemisphere. E. S. these two output pattern associator networks likely developed in these two output routes. particularly the phonologic one. Cimino-Knight. lesion. They concluded that the lesion. This would explain why sub. Recent magnetic resonance imaging–diffusion tensor imaging tractographic studies of deep white matter pathways. The deficient development of both systems. Third.. Color coding is the same as in Figure 26–1. 2003). Neurocase.. and an indirect one. Knight. (2006) suggests. K. M. Thus.) routes. by phonemic paraphasic errors). M. only the region of presumed interface between concept representations and the remainder of the model is depicted. (From Roth.. Neurocase. semantic knowledge but impoverished phonologic processing jects with Wernicke’s or conduction aphasia apparently do not (Zaidel. A. Cimino.. 61–70. given the likely anatomical representation of the net. In this cartoon. and the pattern of spoken out. put in terms of bi-hemispheric contributions. & Fytche (2005) have delin- eated two dominant perisylvian pathways linking Wernicke’s and Broca’s areas: a direct one. Given the paucity of information about the anatomical organiza. H. Cartoon depicting the network of Figure 26–1 mapped onto the brain. Heilman. 12. approximate.. however. This provides the basis for a fuller explana- relay to Broca’s area via what likely is component III of the supe. Hollingsworth.. cal-semantic knowledge. A. a bihemispheric language model that incorporates both developmental attributes and the impact of the lesion must be considered (Fig. Naming concepts: Heilman. Concept representations are assumed to be widely distrib- uted across association cortices throughout the brain. with permission. (From Roth. L. Hollingsworth.qxd 01/21/08 03:02 PM Page 697 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 697 whether this pattern is marked exclusively by impaired word way more equally developed in the two hemispheres. As the case of Roth et al. with dominant hemisphere lesions almost invariably demon- First. strate impaired—if not completely absent—phonologic work shown in Figure 26–1.) . HU = hidden units. and the degree to which various networks are devel- broad extent of origin and termination of these pathways and oped in each hemisphere. Subjects retrieval or. connection demonstrate that the disconnected right hemi- put may reflect the relative degree to which these two-pattern sphere has a phonologic input lexicon and conceptual associator networks are affected. Nadeau. be individual variability in the degree to which connectivity is Second. M. at best. L. (2006). K. the mapping depicted here HU HU is. Cartoon depicting mapping of a bi-hemispheric parietal cortex (Brodmann’s areas 39 and 40). there may have the option of relying entirely on the whole-word route. Color coding is the same as in their large cross-sections favored a connectionist account.. Figures 26–1 and 26–5. 12. with apparent model to the brain. stand fully language production following a left hemisphere oped in the dominant hemisphere and the whole-word path. corresponding to the arcuate fasci- culus (possibly corresponding to pathway 3 in our model). are shedding some light on the anatomical details.GRBQ344-C26[689-734] . A. & Bogen. our goal is primarily to demonstrate the feasibility of mapping a connectionist architecture of phonologic processing to cortical anatomy. Iacoboni. Jones. A. most dominant perisylvian sequence knowledge but often exhibit partial sparing of lexi- lesions probably damage both the whole word and the phono.. S. 26–5). projecting from Wernicke’s area to the inferior Figure 26–6. L. additionally. L. and this individual vari- are differentially represented in the two hemispheres. deficient devel- opment of connectivity in nondominant hemisphere concept representations may lead to the generation of anomia and semantic paraphasic errors. with permission. tion of the results of left hemisphere lesions on language out- rior longitudinal fasciculus (Makris et al. Nadeau. 26–6). HU tion of the human perisylvian region. Zaidel. M. Studies of subjects with callosal dis- logic output routes (Fig. Catani. 61–70. but deficient development of the phonologic Figure 26–5. to under- the phonologic pathway being more frequently better devel. naming routes such that this diaschisis effect diminishes with time. word retrieval may damaged or inadequately developed phonologic routes improve as the nondominant whole-word route achieves a become the predominant means of language production. Murtha. it receives enormous. With the acute stroke. Consequently. The dual-route naming model. Before doing so. & Hanratty. more severe impairment and. . the net result will be output marked predominantly nated bihemispheric activity and do not impede indepen- by word retrieval deficits (with or without semantic parapha. because aphasia predominantly use damaged or inadequately devel. subjects with acute (semantic) networks because of left hemisphere damage and middle cerebral artery (MCA) distribution strokes affecting a large extent deficient development of right hemisphere networks. greater difficulty with (2006). Processes Occurring During Recovery mainly excitatory input from brain regions supplied by the MCA. Wernicke’s aphasia may reflect munication. Finally.qxd 01/21/08 03:02 PM Page 698 Aptara(PPG Quark) 698 Section IV ■ Traditional Approaches to Language Intervention route also may occur. damage (phonologic and whole word). neural net- If both naming routes are involved and the combined effect work connectivity in the two hemispheres presumably of the three factors differentially impacts the phonologic evolves such that transcallosal pathways facilitate coordi- routes. Bub. With time and neuroplasticity. dysfunction of conceptual nected to the focus of brain damage. Second. phonemic paraphasias have such an invidious effect on com- oped phonologic pathways. may word retrieval and more profuse phonemic paraphasic be able to learn a strategy of using only the whole-word errors than with conduction aphasia. to reach threshold for activation (a diaschisis effect). and gaze substantially normalizes. a concept first elaborated by von Monakow (1914). trying to convey. to one degree or another. as in of the dorsolateral frontal lobe often will exhibit an overwhelming ten- our subject.. we will briefly review hemisphere may be associated with word retrieval deficits particularly important features of PDP models in general and (Chertkow. 2002). 1997. dent unihemispheric activity. Plaut et al. progressively greater transcallosal impact on dominant Subjects with reproduction conduction or Wernicke’s hemisphere spoken language output. however. typically within days. sentations or the acoustic representations–concept repre- sentations pathways that enable verbal comprehension. eye field up to the firing threshold. consti- which the phonologic route provides differential access to tutes transient dysfunction of undamaged brain regions that are con- sequence knowledge). With such readjustment. because articulatory motor rep- reflect three factors: resentations normally depend on input from both the 1. function that we have developed.5 resented in the right hemisphere. Hart & the model of phonologic. neurons adjust. functional until appropriate readjustment of connectivity the net result will be output marked by word retrieval deficits within and between hemispheres occurs in the course of and a substantial incidence of phonemic paraphasic errors as recovery. A lesion may disrupt this pre- sic errors) as whole-word routes become the predominant cise inter-hemispheric coordination (another form of means of language production (as in repetition conduction diaschisis). The frontal eye field rarely is damaged by MCA distribution infarcts. potentially rendering transcallosal input dys- aphasia). Deaudon. hence. the frontal eye field because of diaschisis. The degree to which one or both of these routes is rep. The degree of development of connectivity in each of representations or in surviving connectivity within the two the two routes in the two hemispheres. in the left First. phonologic route (or enhancement of deficient connectivity work ontogenesis (Goodglass. in phonologic routes in either hemisphere) would lead to In summary. Changes may occur in the connectivity within articulatory 3. 1993. also can account for the patterns of evolution of inter. First. would be expected to yield naming difficulty dency to direct their eyes (gaze) toward the side of the lesion and cannot be induced to look toward the opposite side. as elaborated in the forego. with any given left hemisphere lesion. no input from other brain regions can bring the neurons in the frontal ing. in normal brain development. because these have strong Chaertkow. recovery of connectivity in the dominant hemisphere hemisphere as a result of normal variability in phonologic net. we will extend the model to account for grammatical damage to Brodmann’s areas 37 and 39 in the dominant function. Raymer et al. and lexical-semantic Gordon. The effects of the lesion on the two output routes whole-word and phonologic routes for activation. These areas may implications for the function of the model and provide major constitute the interface between association cortices support for the application of PDP models to the under- throughout the brain supporting concept representations and the core language apparatus (proximal to the point at 5 Diaschisis.. & Whitehead. subjects like the one described by Roth et al. 1996). 1997. semantic. Second. the increased naming success and a reduction in phonemic actual pattern of internally generated spoken language may paraphasic errors. 1990. This reflects dysfunction of with production of semantic paraphasic errors. Whatmough.GRBQ344-C26[689-734] . to either route could lead to anomia as representations fail 2. If whole-word routes are differentially impacted. to make themselves more readily understood. Third. these nally generated spoken language observed during recovery. however. Subjects with route and of semantically “boxing in” the concept they are Wernicke’s aphasia also may have damage to acoustic repre. Below. it no longer receives this excitatory input. Naming difficulty may arise through mechanisms discussed Why PDP Models? in the preceding paragraph or in two additional ways. For example. . can be translated into spoken word representations. and long-term memory. For example.. connected domain. It also. 1981. Both PDP and neural networks can translate representations in one domain into arbitrarily related representations in another. In contrast. neural network systems settle into states that represent the optimal amalgamation of incoming information and existing knowledge. If the rules do not apply. Inference. and syntactic—a process called parallel constraint satisfaction). In the brain. working.e. knowledge is represented as the strength of synaptic connections between neurons. Having fleshed out a con. Three major reasons can be identified: 3. working memory corresponds to a transient network pattern of unit/neural activity or partial neural depolarization (a mechanism not yet tested in PDP research). concept representations. corresponding to knowledge of word meaning. knowledge) is represented as the sum total of unit or neural connection strengths in the network. Schwartz. to our tendency to overlook editorial errors when proofreading). e. & Gagnon. in part because of their ability to settle into attractor states and in part because of bottom-up/top-down processing effects (see below). Hidden units plus non-linearity support associations between orthogonal representations.g. such as the Limitations of Existing Theories occurrence of paraphasias (speech errors) that have Linguistic theories have not yet provided a satisfactory both semantic and phonologic similarity to the target account for the language errors made by normal subjects or (Dell & Reich. Bottom-up and top-down processing. Long-term memory (i. the address of a memory must be known to retrieve that memory. These serial processing–based theories of linguistic crete example of a PDP model of language. . it is reasonable to function have difficulty capturing effects that are easily take a moment to ask. This enables simultaneous (but likely compromised) satisfaction of constraints provided by a multitude of different neural networks (e. whereas abundant data suggest that Cognitive neuropsychological theories incorporate. from networks supporting visual representations of orthographic input to networks supporting semantic representations). Saffran. semantic. why this particular approach? explained by bottom-up and top-down processing interactions (Table 26–1) that are an intrinsic attribute of many PDP models (including ours). yet-to-be-experienced situation. Harley. A network supports processing. In both PDP and neural networks. however. Like neural networks in the brain.GRBQ344-C26[689-734] . “box and arrow” models that date back to Wernicke and TABLE 26–1 Properties of Parallel Distributed Processing (PDP) Networks The knowledge is in the connections. Both PDP and neural networks demonstrate the same general patterns of performance even when damaged. the language disorders observed in subjects with aphasia. 1984). Distributed representations bring with them several powerful emergent features. Content-addressable memory With distributed representations.g. In simulated PDP models. knowledge is represented as the strength of the connections between units. thereby instantiating implicit rules. generalization. to language production incorporates parallel processing one extent or another. Graceful degradation Both PDP and neural networks can perform at close to normal levels with substantially degraded input. in digital computer models... carries the risk of misperception of a near-miss input as the correct input (lead- ing. Linguistic theories have failed to account for how lin- guistic behavior might emerge from neural structure. Performance based on the acquisition of implicit rules reflects the inference that the rules apply in a new. engagement of a feature of a particular memory can generate the distributed representation of the entire memory.qxd 01/21/08 03:02 PM Page 699 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 699 standing of language and aphasia. 1985). phonologic. PDP networks support the processes underlying all cognition and behavior. These rules can then be usefully applied to situations that have never been encountered before but that bear a resemblance to what has been experienced. Linguistic theories have been founded on the concept of serial processing. information processing models—the (Stemberger. then the response can be characterized as confabulation. The knowledge gained during training thereby generalizes. Dell. 1997. It enables valid per- ception despite very noisy input. because knowledge is represented throughout the network and because partial damage only reduces the redundancy of the knowledge and increases the probability of error or non-response. Through repeated upward and downward flow of unit/neural activity between input networks and higher-order networks (e. and confabulation Both PDP and neural networks naturally encode the commonalities and patterns that are implicit in the information to which they are exposed during training. 1. Martin.g. lexical-semantic. 2. The symbolized by the loops at concept. in PDP models of language. What PDP models provide as an added value is speci. properties that emulate brain structure and function. and incorporation of working. Clearly. 1982). 1997.GRBQ344-C26[689-734] . just as in the brain). 1990). like neurons in the brain down activation of lower-level units contributing to its acti- (McClelland. The absence of specific. Rumelhart & McClelland.. Thus. can implicitly learn the rules governing the something we recognize. . the model shown in Figure 26–1 incorporates boxes and the nature of the processes symbolized by the two-way connections (the general pattern in the cerebrum). 26–1. In such circumstances. vation. words. amplifies the bottom-up activation of Nadeau. enables the network to deal with the situa- conjunction with processes underlying the engagement of tion that arises when a pattern of input does not precisely cor- working memory (Goldman-Rakic. that was acquired during the training period.g. down/bottom up interaction effects. a pure nearest meaningful representation. they are nonpareil sponds to a network capacity for adjusting near-miss in extracting commonalities and patterns in the data. PDP models can easily be endowed specifically with guage. the linguistic network. because the input only has to be suf- PDP models are “neural-like” in that they incorporate large ficiently informative to partially activate the correct target arrays of simple units that are heavily interconnected with distributed representation. any recognizable entity. ing.” which is a network that tends topographical relationship of these domains to each other. terns of neural bias or firing (again. PDP models may be entirely phenomena we observe reflect entirely the emergent behav- consistent with information processing models with respect ior of the networks. to see what we intended rather than what is actually there. in logically plausible. much of the spoken PDP Models Emulate Brain language that we hear). pure PDP models (models Equally clearly. ficity regarding the nature of the representations in the For example. 1986. linguistic) designed to 6 account for particular phonologic phenomena in an orderly “Nearest” corresponds literally to the distance in n-dimensional space between the near-miss and the closest meaningful distributed represen- fashion also is crucial to the maintenance of neurologic plau. 1996). the ability to translate very noisy and degraded input into ing algorithms. This ability corre- data (see. 1986. as transient pat. McClelland & Rumelhart.qxd 01/21/08 03:02 PM Page 700 Aptara(PPG Quark) 700 Section IV ■ Traditional Approaches to Language Intervention Lichtheim. In PDP models. memories of language Bottom-up/down-down interaction effects provide a power- units (e.6 This capacity is PDP model of phonology has no need to build in specific achieved by creating connections between every unit within structures to account for specific phonologic phenomena. ad hoc devices motivated by models (e. recurrent connections might generate a pattern of activity in taneous processing at a number of levels and locations. Of course. we derive great advantage from without incorporated digital devices). joint phonemes. 2000).and long-term memory in the acoustic representations). endowed with learn. as discussed in the context of bot- data they process in the course of their experience with that tom-up/top-down processing effects. eliminates the respond to one of the patterns on which the model was need to posit separate buffers. to settle into stable states corresponding to meaningful dis- The model learns the rest. grammatical function). articulatory motor. which distributed representations until they correspond to the form the basis for implicit rules. lan. memories are represented as connection strengths in the up/top-down interaction effects are quite literally leading us same networks that support processing. because they involve simul.. is recurrent connections (as in the model shown in Fig. Their processing sophistication stems from the target. Dell et al.. The structure of the model is defined entirely in terms of the The field is thereby transformed into what is referred to as domains of information accessible to it and the necessary an “auto-associator network. the output representational field that does not correspond to apparently mimicking what is going on in the brain (some. arrows. which. In PDP mod. about which information processing models are and this two-way connectivity is what enables top- agnostic.. and sentence constituents) are represented (Dell. tation. as in neurally plausible PDP models.g. errors from manuscripts stems from the fact that bottom- els. e. ful explanatory mechanism for many linguistic phenomenon syllables. PDP models are particularly appealing in the the input is noisy. Rumelhart. Plaut et al. the brain has the capability thing that will become more apparent when we consider for creating meaning for novel distributed representations. where n is the number of units in the representational field and sibility (architectural faithfulness to neural structure). In fact. This feature. just as in the brain. a model without context of language processing. in turn. which are a digital computer trained. stored knowledge of phonemes. to the topography of processes involved—in this case. the representational field and every other unit in that field. Our great difficulty in eliminating all typographical (hundreds or even thousands) in these arrays. & PDP Research Group. which also is neuro- same neural networks that are responsible for processing.. Thus. however. As we have seen.. for example. 1981. either because the input pattern is novel or because concept. In “meaningfulness” is defined by the knowledge structure. this feature can have invidious effects the simultaneous interaction of the large numbers of units as well. in the same neural networks that support linguistic process. latent in the humans. Finally. These effects are enor- mously beneficial in enabling us to extract meaning from extraordinarily degraded input (e.g.g. This target then provides top- each other to form networks. working memory also is represented in Another useful property that can be built into PDP models the same networks that support processing. 1998). Although behavioral neurologists. Hebb postulated that to the extent that two connected neurons are simultaneously active.. It is even possible to systemati. entire network what are called “attractor” properties. the marvelous computational machine that is the human brain. Rolls & Treves. tor of the coincidence of high activity of the post-synaptic neurons (reflected cally vary one or more parameters in a particular model and. 1998). It presumes the now well. PDP simulations employ predominantly heuristic devices that are. Because in PDP order emerges naturally from PDP models provide us with the means to understand network properties and topography rather than being how complex behavior might emerge from neural net- defined primarily by the structure of the model. 1998). Attractor properties PDP models invoke a scientific and philosophical para- convey another very useful property in computer simula- digm shift in that they reflect chaotic order rather than tions of network behavior—that is. the time that it takes a deterministic order. who first elucidated the con- cept (Hebb. The prototypic example of a local learning process is in advancing the science of language and the brain. 1987) is system network to “settle” into an attractor state corresponds to order deriving from the orderly behavior of the individual the response latency of that network. the discoveries they were making could be linked accepted that the brain incorporates PDP principles.GRBQ344-C26[689-734] . whether in Drosophila (100. 1989). which now are accepted as the fundamental unit of plausibility replaces the goal of choosing the simplest of cortical function (Buonomano & Merzenich. Nevertheless. which occurs to the extent that the activity of connected neurons is discrepant. also operate by chaotic behavioral studies of human subjects. they established faithfulness of the PDP concept to the essential reflect the order that emerges from the precise behavior of individual features of neural network processing. thus providing a foundation for group statistics. Johnston.7 Neural net- sure—namely.qxd 01/21/08 03:02 PM Page 701 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 701 tributed representations as defined during the training brain injury (Cohen. there do not appear to be any fundamental “lesioned” PDP models also have been extraordinarily scientific impediments to the realization of the language model we develop successful in emulating the behavior of human subjects with incorporating a local learning process. 1949). It requires only a peculiar neurotransmitter be compared with data derived from experimental studies in receptor such as the NMDA-glutamate receptor. and the directly to neural structure. For many of us. 1986). Chaotic order (Gleick. not local. which requires a change PDP simulations have been extraordinarily successful in in the strength of inter-unit connections based upon events occurring at the replicating the behavior of normal human subjects. employed in PDP simulations is back propagation. No model geoning (Rolls & Deco. refer- ring to the tendency of the network to settle into or be A Paradigm Shift “attracted to” particular stable states. it is stunning related scientific field. In contrast. see also sically non-local learning algorithm is biologically implausible but it remains possible that some non-local learning processes are instantiated in the brain Seidenberg & McClelland. 8 The only major departure of neural network theory from PDP theory is ciples of neural network topography and mathematical func. is bur- that this dream has been realized in our lifetime. and to the extent that cells interacting with each other. whereas deterministic order reflects the tor feature endows the network with a performance mea- impact of an overall guiding force or principle. Before competing theories (i. response latency—that precisely coincides work brains. long-term simulations of particular models can be run on computers.000 neurons) or in with one of the most common dependent variables used in human beings (100 billion neurons). In this way.. the strength of the synaptic connection The Heuristic Value of PDP Modeling between them will increase. named after Donald Hebb. This intrin- PDP reading model of Plaut and colleagues (1996. a particular model represents a specific hypothesis about the topographic organization of neural processes underlying a given function and the math- ematical properties of the units and connections comprising 7 Examples of chaotic order include the ornate structure of a flower and the neural networks involved. it accommodates empirical data on brain terize the force of gravity and its effect on mass. for the ior on the other has proven to be a particularly fruitful one most part. The appeal of PDP modeling also derives from the fact that This work has also revealed evidence of a reciprocal process. principles. computational neuroscience. generate a population of PDP “individuals” who can tic axon terminal). Occam’s razor) as the guiding force this approach to understanding the brain was developed.8 represents a final answer to how the brain handles a domain of cognitive function. which could be many synapses away. The dialectic in the PDP literature between prin. as in the output end of the network. depression.e. & Plunkett. Hebbian learning is intrinsically local and therefore eminently leading to the generation of vast amounts of data that can then plausible neuroscientifically. whereas tion on the one hand and empirical data on language behav. 1996). 1998). in the design of these models (see O’Reilly. Rather. This concept has since been validated in exten- sive research on long-term potentiation (Buonomano & Merzenich. . 2000) and even in period (Rumelhart et al. 1996). it now is quite clear and well somehow. Simulations involving (O’Reilly. Hebbian learning. This feature gives the simulating the effects of rehabilitation (Plaut. Deterministic order is exemplified by it successfully replicates behavior of human subjects in the movement of planets in the solar system (and the satellites that we send to them). that the former seeks to apply exclusively local learning processes. cognitive neuropsychologists. the most common learning algorithm be simulated. 2002. neurologic works. which can be explained entirely by equations that charac- health and disease. the attrac- units of the system. in a depression in membrane voltage) and high activity of the presynaptic neuron (reflected in large amounts of glutamate released from the presynap- thereby. the brain still largely elude us. and the precise details of the organization of neural networks in linguists had to accept as a matter of faith that someday. which functions as a detec- animals and human subjects. function. check-shirted. both of these compo- sentence). ond of a burglar appropriately altered to incorporate the fact resentation of “dog” to capture any species of dog or any of having been shot. we will argue some require only an agent. in 9 Although the ideas proposed here are fundamentally at odds with tradi. the agent is the perpetrator and (2) phrase structure rules. oily- We now resume our discussion of PDP and language. function. and the sec- malleable. the necessary relationships between verbs and nouns or object. slovenly.” For example. arguments of the verb. and clip matical function down into syntax and grammatical mor- board in his hand”—a sort of Uriah Heep cum used-car phology.g. must rely heavily on the extraordinarily rich and sentation that incorporates the entire shooting scene. The process of pairing one or more adjectives or sentence structure. “knew” easily accommodates a senten- associator networks responsible for articulatory and inscrip- tial clause in the predicate. through the elicitation of two reciprocally mod- ified distributed representations (“old man shooter” and “shot burglar”) that. the rule that constrains articles to pre- the object of the verb’s action (“flowers” in the preceding cede nouns). “He knew Mary would arrive tional (written) output. These participants are called the cal morphemes [e. consider what might be the dis- pathways 1-2 and 4-3). and passive voice constructions its “thematic role.” whereas “hit” does not). In Chomskian thinking. tences (bound grammatical morphology [e. effect constituting a composite. The Adjectives represent the simplest case and. The same cannot be said about other types of words. plaid-jacketed extending the model to incorporate a basis for grammatical man with the striped pants. haired. auxiliary verbs. in addition. no one has succeeded in answering this question using a product of distributed representations of concepts that are traditional linguistic formulation.” and. implicitly linked by their complementarity (shooter and . Does the argument specification property of verbs provide Syntax: Sentence Organization direct insight regarding the cerebral processing of verbs? To It is easy to conceive of spoken. “super-distributed” repre- tional linguistic formulations. the theme is the local level (e. nents of syntax are thought to arise from the operational Verbs differ with respect to the arguments they specify— principles of a grammar generator.g. We will break syntax down into but also may be prepositional phrases. some an agent and a theme. They fill argument positions (e. at least superficially. any consideration of language and the brain. Each argument is noun phrases in a sentence (verb argument relationships. including PDP. and indirect object positions).. and abstract nouns. most particularly adjectives. through pattern associator networks (Fig.9 soon. concrete nouns as being the date. Syntax is knowledge of acceptable word order and salesman. adjectival phrases. “shooting” actually consists of the juxtaposition of two dis- ogy. Our conceptualization of sounds of the noun. tributed concept representations: a person who is the shooter. In contrast. embedded clauses. theme.qxd 01/21/08 03:02 PM Page 702 Aptara(PPG Quark) 702 Section IV ■ Traditional Approaches to Language Intervention Grammar contemplate the most complicated and arbitrary of distrib- uted representations. the distributed rep.. How might a verb be rep- linked. rather.GRBQ344-C26[689-734] . as discussed in the section on phonol. are sentence “the old man shot the burglar” generates two dis- a reasonable place to start. such as “the obese. referred to as below). tributed concept representations: one of an old man appropri- resentations corresponding to noun concepts are infinitely ately altered to incorporate the act of shooting. In principle.g.. and goal—and many verbs allow some the way in which the brain manipulates concept representa- freedom in choosing whether to include a certain argument. food-stained paisley tie. because they specify the major partici- words that. We can easily modify the general distributed rep. oth- that principles of sentence organization follow directly from ers an agent. number.g.. ultimately. Grammatical morphology refers both to adjectival phrases with a noun corresponds to a particular the modifications of words that are made in their use in sen- modification of the distributed representation of the noun. which encompasses such things as sentential clauses. “shot” achieves its meaning not particular dog we have personally known. are meaningfully linked.g. conjunctions. The detailed information that linguistic studies have provided about regulari. and a person who has been shot or is about to be shot. We can easily through the generation of its own distributed representation but. and (1) sentence organization. 26–1.g. articles. tions and that phrase structure rules and rules of grammati- They also differ with respect to the nature of the arguments cal morphology are an emergent property of the pattern they can specify (e. or tense]) and to the use of individual guistic formulations.. For purposes of discussion.. resented in PDP terms? First. verbs. pockmarked. to articulatory motor representations tributed representation of a verb. two components of this composite representation are ties in the phenomenology of languages. goatee. see assigned a purpose in the sentence by the verb. to networks that support the sequences of What features underlie this distributed representation? A oropharyngeal movements that actually produce the speech problem is immediately apparent. e. subject. we will break gram- wire-rimmed glasses. appear to primarily serve pants in the action that is described by the verb. Thus. and the goal is the recipient of the action (Mary). Arguments usually are noun phrases and certain prepositions]). such as the verb “to shoot. thereby sentence composition rather than meaning (free grammati- defining sentence structure. affixes con- Verbs are viewed as the work masters in traditional lin- veying case. unctuous. which constrain word order at of the action (“The man gave flowers to Mary”). therefore. bundle of pens in his pocket. Each of these circumstances would necessitate a some later time. underlying a concept occurs as the concept is formed or gle distributed concept representation.. leads to produc. including (1) the modifiability of Word representations corresponding to certain distributed the core distributed representation of the concept. which constitutes their lexical-semantic role. elicited by the auto-associator network representation of the Thus. We may have the luxury of however. modified by an tributed representations of the nouns they constrain. and on the pattern of activity in the phonologic processing “The streets made wet by the rain”). forcing us to use a narrative stream employing modified by its association with Jones the murderer. They also may become explicitly linked when a pattern of activity in acoustic cortex. They become explicitly linked demands that are met by the normal brain.GRBQ344-C26[689-734] . In this sentence. will tend to be impaired in subjects with aphasias (e. someone viewing a below.”—in which case the of modifications we can make in a distributed representation distributed concept representation of park is substantially at one time. functions as a sort of super-adjective. Production of the sentence “rain-wet streets. whether the modification occurs nearly simultaneously with available but inappropriate to the context. (2) concept representations may be completely unavailable.” that is readily available to us. still wet from the rain.g. On the the distributed representations of the concepts underlying other hand. super-distributed various modifications of street that are readily available to representation. employ a single distributed representation. has been realized and verbalization has been initiated. Thus.qxd 01/21/08 03:02 PM Page 703 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 703 shot) and their simultaneity. in our new conceptualization. super-distributed representation to capture this concept— cal to adjectives (e. the concept of “rain-wet streets” falls well within the same time. place emphasis or imply causality.” On the other hand. consider the concept of streets wet with rain. each further modifying the The auto-associator network representation of a concept original distributed concept representation. verbs us. however.” “the car skidded on the street because the street was manipulation of the two distributed concept representations.g. favoring the verbal product verb use and argument structure. Thus. reciprocally modifying “The burglar that had been shot by the old man”). the “Jones” concept is the object of most of The street was still wet from the rain. the wetness modifica- “the old man shot the burglar” requires fairly symmetric tion might be conceptualized only after the street concept manipulations of two distributed concept representations.” or “The car skidded on the street. can be translated by the concept–articulatory motor pattern associator networks into any one of a number of different The Availability of Words word sequences. ous example. can be usefully sometime later is likely to influence the word sequence cor- viewed as concept manipulation and. multiple clauses or sentences. ing memory capacity may limit the number and complexity gers. thus engaging a verb (e. “the soldier salutes”). each of these possibilities in some detail. which adjective. tions generates a pattern of activation in articulatory motor cortex that will produce the sound sequence corresponding to Modifiability of the Core Representation the sentence. Thus. and the “park” concept is only very subtly of conceptual development happens to emerge probably is modified. This asymmetry could be dramatically altered.” may demand highly asymmetric rain... network.g. a representation that therefore engages a verb (e.” The way the sequence the modification. we will consider when this particular reciprocal pair of distributed representa. not the only factor at play here. The actual word sequence chosen will depend on several factors. Thus. generated by the sound Consider the core representation of “burglar” in our previ- of the sentence being produced by a speaker. yielding “rain-wet streets. modification of the distributed representation of burglar tions underlying “old man shooter” and “shot burglar. by additional information neurally defined as addi. He slept in the park during the day.g. “Old man shot burglar” is not likely to be a tion of the reciprocal pair of distributed concept representa. such as “the car skidded on the street that was still wet from the “Jones slept in the park. A transitive verb namely. work- “Jones was apprehended as the murderer of nighttime jog. hence Sentences employing adjunctive phrases.” or we can employ a constitutes both their grammatical and their semantic roles. even use of Whether a modification of the distributed representation adjectives or intransitive verbs. romantic Parisian street in her mind’s eye might incorporate Broca’s aphasia) that are associated with deficits in transitive “rain-wet” from the beginning. super-distributed representation. We can are defined exclusively by the effect that they have on the dis. we have a choice in expressing this idea. or temporarily the generation of the core distributed representation or at unavailable. On the other hand. we are forced to use a Intransitive verbs function in a fashion essentially identi.. shaping the conceptual stream according to our intent to tional distributed concept representations—for example. the two or three noun phrases in the sentence and at the Here. it might be available but carry with it a . and (3) the availability of words to be clause construction in lieu of an adjectival construction. Thus. To provide a sense of the concept manipulation lary. Alternatively. linking them to form a new. Any volitional alteration in distributed concept represen. which serve to modify a sin. “rain-wet” might simply not be in a person’s vocabu- concept. Simultaneous Versus Sequential Modification tations constitutes concept manipulation. as will be discussed responding to that concept. 1997). necessitating a circumlocutory clause 1992).GRBQ344-C26[689-734] . 1993). one a first approximation. does not without simplification of syntax have been reported. agent. the modification of concepts. and even individual differences in the Generating verbs also normally invokes a particular form way people think. & Pate. the word may pretation is the fact that subjects with Broca’s aphasia exhibit be transiently unavailable because of the “tip-of-the. tongue” phenomenon. the ability cles. intransitive verbs) characteristic abnormality of grammatical morphology (Thompson. & Marin. including a Saffran. Subjects Two aspects of a common aphasia.. Zurif. Schwartz. are with Broca’s aphasia exhibit relatively greater difficulty explainable on the basis of a breakdown in the processes we accessing verbs than nouns. we refer to here—as well as attention (Nadeau & Crosson. Broca’s aphasia commonly is characterized with complex argument structures is more impaired than by two grammatical attributes: simplification of syntax. Gonzalez-Rothi. 1980. to use verbs as adjectives).qxd 01/21/08 03:02 PM Page 704 Aptara(PPG Quark) 704 Section IV ■ Traditional Approaches to Language Intervention sense of inappropriateness to the context (possibly a limbic multiple concepts at will. the entire brain is the same in all human beings. of subjects with Broca’s aphasia to produce verbs in tasks of sitions. genetic. can be accounted for in terms of a defect in the nents (e. Lange. The grammatical properties related word has led to the selective engagement of a number that are common to the vast number of languages spoken on of semantically related distributed concept representations our planet (the “universal grammar”) reflect the fact that. of selective engagement to modify two or more distributed representations in reciprocal fashion and link them to form a super-distributed representation. Schwartz. Linebarger. rather. & Shapiro.. Nadeau & a far more demanding skill (Mitchum & Berndt. This may be caused by a general component to the distributed representation generated by inability to maintain selective engagement of the specific the word in this context). target is a word or a nonword. Thus. working memory—the specific type of selective engagement ciator networks defining language output. These two aspects of Broca’s aphasia may be dissoci. translate into the ability to use verbs in sentences (i. and a their production of simple verbs (e. & Rosen. or goal) to . “rain-wet” is satisfactory in neural networks incorporating the featural basis for the con- a novel but would sound contrived in ordinary conversation cepts and their intended nuances. In normal subjects engaged in a lexical decision task. to link eral cases of simplification of syntax without morphologic and reciprocally modify distributed concept representations). preceding a lexical target with a semantically related word such as the amygdala. Seeing the semantically ties of higher brain function. the basic structure and function of the of which is the target. the ways in which concepts reduces the time that is needed to determine whether the are handled provide a window on the fundamental proper. conjunctions. Selective engagement is a general term that cepts. picture naming. and the interaction resources. Schneider. limited lexical priming (Prather. sentations and their manipulations invoke association cor. Concept repre. because language production is a direct reflection of selectively engaged appears to be limited. the propensity for leaving evidence of impairment in ability to simultaneously manipu- out words of primarily grammatical importance. auxiliary verbs. “big barn” or “red barn.g. (see Chapter 19). Therefore.g. the linking of concepts embraces the many processes by which the brain allocates into super-distributed representations. as and their associated articulatory motor representations.g. It thus makes special Disorders of Syntax demands on selective engagement mechanisms. 1988. of selected representations in selected neural networks. prepo. As we have noted. Consistent with this inter- and inappropriate in formal discourse. noun phrase–verb–noun phrase) that reflect the ability to alter the distributed representations of single or underling thematic roles (e. grammatical speeding of lexical decision by semantic priming is less likely differences in language production may provide a window to occur.. whether naturally or as a result of treatment ated: A number of cases of morphologic agrammatism (in our nomenclature. Finally. Notably. One of the most widely accepted theories regarding the tion reflects the flexible modification and manipulation of the fundamental deficit in Broca’s aphasia is referred to as the distributed representations underlying concepts. Mapping Deficit Hypothesis (Saffran & Schwartz. the aspect of syntax that we have defined as either by eliciting sustained neural activity in those networks sentence organization depends not on the machinations of a or altering the state of polarization of the neurons such that sophisticated language processor but. 1988. late multiple distributed representations. 1997)—further known as agrammatism—that is. and their production of verbs have just outlined. we mean the bringing online or sentence to convey the concept.. In subjects with Broca’s aphasia. agrammatism have been reported (Nadeau.e. and sev. This hypothesis characterizes the adjectives (e. In this way. theme. with the result that patterns of distributed concept manipulation. constitutes an they are more susceptible to firing by other afferent input emergent property of the distributed representations of con. and it includes processes commonly referred to as of network systems defining concepts with the pattern asso. on cultural. Broca’s aphasia. plification of syntax seen with Broca’s aphasia. paucity of embedded clauses and inability to use strings of Saffran. sentence produc.g.. and to some extent. Stern. 2001). tices throughout the brain as well as subcortical structures. 1987). On the other range and number of the distributed concept representations hand.” but not “big. By selective engagement. red deficit as an inability to produce ordered sentence compo- barn”). such as arti. The sim. form words. we return to the pattern associator read such extremely exceptional words as “aisle. we need to posit that. or that a single pattern associator net. nouns. fact. it is far from clear tion of a concept (adjectives) uniformly precede nouns and whether inappropriate sequences emerge in continuous knowledge about the proper order of adjective-noun discourse or result just by happenstance.. specific exceptional representations as well as patterns that dantly represented attributes of cerebral language networks are common to many representations. sequence knowledge about sylla. should be able to learn certain sequences with very few exem- 1989). ducer in which the systematic relationships between concept to understand who did what to whom in the passive-voice representation properties and articulatory sequences emerge sentence “Joe was hit by John. with distributed pretation of structural cues (e. put. phrase structure rules to be represented in oral language out. a word sequence network and colleagues (1996. Thus.g. Clearly. 1987. here? The answer is not known. articles always precede and never follow nouns).” By the same token. the allowable word sequences. and even then. or verbs. it is a property-sequence trans- the sentence to underlying sentence meaning. neoplasm. however. of units and involving combinatorial mathematics. there needs to be a pattern associator network encoding Kertesz & Sheppard. precisely as a multi-syllabic phonemic language is their consistent respect for phrase structure rules processor would implicitly incorporate rules about the place- (e. Capitani. & Zanobio. explanation for this is that elderly people are able to main- latory motor pattern associator supporting sublexical tain reasonable fluency given a frontal lobe lesion because of sequence knowledge. In multi-syllable words rather than only single-syllable words. and affixes as they combine to nouns with particular redundancy. In effect. no system. Had the model been designed to accommodate plars. Some evidence suggests ture rules. Laiacona.. whether the lesion is caused by represented.g. even one comprised of tens of billions capacities for distributed concept manipulation and associa. Two components are provides the basis for a link between distributed representa- identified: lexical. This sequence knowledge incorporates the How long are the word sequences that are likely to be sequential relationship of these various sublexical phoneme entrained by the pattern associator network contemplated clumps to each other—the lexical equivalent of phrase struc. practice through the life span. For example. the network would be expected with English vocabulary.” one must cue not just on word as implicit knowledge through extended experience with order but also on the auxiliary verb “was” and the preposition heard and spoken language. At first. This additional pattern associator network we have described. because the number of possible word sequences is virtu- These mapping capacities correspond quite directly to the ally infinite. words that in the occasional patient with jargon aphasia does this rule have the attribute of modifying the distributed representa- seem to be broken. from the juxtaposi. Only ment of suffixes and prefixes. adjectives. 1981. ing thematic role assignment for sentences that require inter. Miceli et al. referring to operations govern. is actually much less than it seems and quite plausibly is incorporated within neural connectivity. word order or verb representations of the articulatory forms of these words in morphology) to relate noun phrases as they literally appear in proper sequence. PDP networks can learn structure rules reflect some very fundamental and redun. sequences simply emerges from the network’s experience tion of phrase fragments. one is inclined to protest “by” (we will have more to say about such words below). see also Seidenberg & McClelland. as we have discussed). root forms. The actual amount of tence organization hypothesis we have introduced is that it information relevant to word sequence that is implicit in all relates these functions directly to neural network processes.GRBQ344-C26[689-734] . characterized by the fied by verbs. To gain some insight regarding model of Plaut and colleagues (1996) was able to learn to such network properties.” “guide. could pos- tion discussed in the foregoing. to instantiate the sequential relationship between articles and bles.” model of single-syllable word reading developed by Plaut and “fugue. Thus. that. Elderly people are relatively tial relationships between words also are represented in various more likely than younger people to develop Wernicke’s neural pattern associator networks in the same way that aphasia and relatively less likely than younger people to sequential relationships between phonemes within words are develop Broca’s aphasia.qxd 01/21/08 03:02 PM Page 705 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 705 link sentence structure to meaning. because articles are among the most commonly encoun- we would have seen it acquire. This is because word sequence informa- Syntax: Phrase Structure Rules tion implicitly incorporates rules governing the order of One of the most remarkable attributes of words in spoken classes of words. The advantage of the sen. Most specifically. the repertoire of word sequence knowledge that they retain work incorporates sequential knowledge of both sublexical in the predominantly posteriorally located pattern associator entities and short phrases. 1983. Only when the lesion directly . and procedural.. simply from its experience tered words in the language. that the length of commonly used sequences grows with The inferential leap we make at this point is that sequen. 1981).. properties of their network representation (e. for stroke. in English. these immutable phrase with heard and written English.g. One possible word sequence knowledge that parallels the acoustic-articu. sibly represent all the possibilities. tions of concepts underlying words. such as those involving the placement of articles. polysyllables. or trauma (Basso. the reading that govern word sequence. Brown & Grober. referring to argument information speci. Bracchi. in part. gender. one posits the existence of a grammatical processor. such as Wernicke’s aphasia or a conduction aphasia.g.. we might expect the impetus to article use from this source to be reduced. To the extent that working memory (selective engagement) mecha- Grammatical Morphology nisms are defective. Thus. con- such a defect exists. and inscriptional) that are represented in networks supporting (2) that frontal lesions spare the neural network representa- sequence knowledge. in this section. they are linked to the main verb. by virtue of their incorporation ing”) might make them particularly prone to omission by in multi-word sequence knowledge. however. only ory of what has already been said (i. and (3) the interface frontal lobe convexity cortex lesions.” depends only on the attributes of the noun distributed ing the impairment in sequence knowledge. As predicted by our hypothesis of defec- junctions. sequence knowledge. Articles Auxiliary Verbs We have already noted (in the section on phrase structure rules) that representations of articles such as “the” probably Four attributes of auxiliary verbs (e.g. and some prepositions]) and suffixes (bound tive selective engagement. num- (agrammatism). Therefore. these subjects tend to omit articles grammatical morphemes [e.g. We have as having no meaning whatsoever—they do indicate definite reasoned that main verbs function by simultaneously recip- or indefinite. (2) the mechanisms that dence of article omission in English speakers with dominant manipulate distributed representations. Constraints on sequence ture rules). a modest lesion in postcentral perisylvian in spoken language are provided primarily by implicit cortex may produce agrammatism (Kolk & Friederici. sequence rules latent in the connectivity of the acoustic-artic- 1985). although subjects with Broca’s aphasia given the model we have been articles have minimal meaning. Broca’s aphasia are much more likely to produce incorrect This way of classifying these words has a certain appeal if articles (para-grammatisms) than to omit articles (Bates.e. phrase struc- tributed representations is meaning. In other languages (e. there has not been a successful effort to account for The essential lesion for producing agrammatism in spon- a grammatical processor in terms of known principles of taneous language appears to involve dominant postcentral neural network function. assuming that all aspects ing the contextual and. or tense]). “big. in contrast. however. representation to which it is linked. This explana. representations and their relationship to each other). As we have noted. and number—additional mean- grammatical. on the maintenance of some working mem- elderly subjects (in fact. they rocally modifying and linking as many as three distributed differ from adjectives in that their meaning is contextual. sentence. the role of which appears to be primarily are marked for case..g. auxiliary verbs. and processes underlying article use are highly distributed. as we have noted.qxd 01/21/08 03:02 PM Page 706 Aptara(PPG Quark) 706 Section IV ■ Traditional Approaches to Language Intervention affects this pattern associator and/or its related phonologic whether the article “a” or “the” is used depends on the pre- pattern associator does aphasia result. the use of an adjective. If our hypothesis regard- continue the approach taken earlier. and closed-class words. orthographic. working memory dependence of language can be understood in terms of (1) the properties of article use is correct. articles. First.g. Thus. the evidence is to the contrary). acoustic. sustained selective greater reliance on a particular repository of knowledge than engagement of immediately preceding distributed concept in the young.. we will perisylvian cortex (Nadeau. they cannot be characterized considering. viewed as the equivalent of syllabic sequence errors. affixes specifying case. The fact that subjects of the auto-associator network supporting semantic distrib- with frontal lesions with sparing of postcentral perisylvian uted representations with pattern associator networks that cortex are not conspicuously agrammatical may reflect two translate these semantic distributed representations into alter- things: (1) that frontal systems engaged in working memory nate forms (e. We will attempt to tions converge on the pattern associator networks producing approach the problem of grammatical morphology from the language output and because it is the locus of relevant perspective of meaning constrained by sequence. articulatory. such as Friederici. “The boy was fish- are engaged. these substitutions can be that proposed by Chomsky and others.g. German).. articles ber. That is. both because it is at the point where frontal projec- ulatory pattern associator network. In English-speaking sub- Grammatical morphology refers to the use of words (free jects with Broca’s aphasia.. and then it is a ceding discourse. the use of articles tion does not presume superior syntactic capability by depends. As modifiers in noun phrases.. a process particularly demanding of selective . & Wulfeck. between them and major lexical items (nouns and main Apparently because of these additional contributors to verbs) is further conveyed in the other terms by which they engagement of article representations. however. hence. The essential currency of semantic dis- tion of multi-word sequence knowledge (e. we should see some evi- of distributed representations. 1987). In addition.GRBQ344-C26[689-734] . some evidence of grammatical morphemes [e. The distinctiveness of these free grammatical ingful information that derives from the semantic represen- morphemes and the apparently fundamental differences tation of the nouns with which they are associated. German subjects with are known: functors. directly reflect. to some degree. representations corresponding to the verb arguments in the whereas the meaning of adjectives is absolute. 1988). ” and (2) tations that instantiate verb argument structure of “The teacher showed the parent’s student the desk. to the extent that such sus- den the candy. Frontal systems may provide the chief substrate for the Lexical-semantic function is based primarily on three neural instantiation of the time concept by virtue of their pri. of grammatical function impose constraints. the case of verbs. and some auxiliary verbs. as in sentence production involves parallel constraint satisfaction. These words strongly resemble main verbs in that in play as well as recent modified representations. one ing the candy in an obscure place. busily secret.” manipulation of distributed concept representations to voli- That is. . Engagement and reciprocal modification of two or Articles and Auxiliary Verbs as Syntactic Elements more distributed concept representations employing Some circumstances exist in which articles and auxiliary procedures that correspond to rules of verb argument verbs appear to play a truly syntactic role. would expect defective use of pronouns. form of the verb. sequence. Third. tained selective engagement mechanisms are impaired. coupled with linkage of these noun concepts. which in subjects with frontal lobe lesions. in the second. with or without auxiliaries. to antecedent nouns. we will focus anisms that will support the working memory of the only on locative prepositions (e. Engagement by certain super-distributed concept rep- equally essential to the meaning of the sentence. leave frontally mediated selective engagement mechanisms tified this process of volitional modification of distributed intact.” Here.. a particular strength of PDP systems (Nadeau. 5. ing memory. In the first. She has been having headaches for six months. In passive-voice sen. ical-syntactic. domains of knowledge: semantic. tionally modify distributed concept representations corre- like those of articles.g. 2000). it often are used only to reconcile the tense of the sentence with may require frontal systems involved in selective engage- the tense of the preceding narrative. Again. . Time-tagging of memories is impaired associators linking semantic and sequence knowledge. Consider first the two dative sentences: (1) 3. Finally. consider the ment (working memory) of the noun representations that two sentences “Mary hides the candy” and “Mary had hid. pronouns. on which they operate. engagement of modifying auxiliary verbs. by” combination is 4. which about. hence. such as “She has a ment (working memory) and frontal systems involved in headache now. which are consistently impaired in subjects with Broca’s aphasia. problems with lexical-semantic access. Although auxiliary verbs have Pronouns been consigned to the class of functors. use pronouns to excess as a device to deal with their concept representations as one requiring frontal systems. In addition. the process of tive engagement processes necessary for this to happen. Grammar: A Synthesis Second. the candy is being carried with aphasia resulting from more posterior lesions. The fact that 1. erned by phrase structure rules. . and the pattern mary role in planning. in their use they typ. further modified in a way that will support knowledge that supports them could be characterized as lex. Mary is in motion. have been used recently. the inclusion and choice of auxiliary verbs are based. Indeed. people state of the candy. On this basis alone. An elaboration of sequence knowledge to the extent that the neural mechanisms underlying all four of these are word stems may attach free-standing and bound gram- impaired in subjects with Broca’s aphasia may account for the matical morphemes and multi-word sequences are gov- tendency of these subjects to omit these words. Engagement by the super-distributed concept represen- “The teacher showed the parents the student’s desk. in which case the structure. we might expect them to be Because all of the systems supporting these various aspects differentially affected by brain lesions that impair the selec. auxiliary verbs may be linked to main Grammatical expression demands: verbs within the domain of sequence knowledge.” In the first. the presence of the “was . We have already iden. phonologic sequences in the acoustic-articulatory the placement of the article “the” and the possessive “-’s” is motor pattern associator that will instantiate the lexical critical to the meaning of the sentence. resentations of articles and auxiliary verbs that are essential to syntax and can usefully be viewed as lexical- Prepositions syntactic in nature. the candy is still. “The book is on the modified distributed concept representations currently table”). on narrative context and.qxd 01/21/08 03:02 PM Page 707 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 707 engagement mechanisms. pronouns depend on sustained engage- tributed concept representations. on work. Because they derive their meaning only through reference ically act like main verbs in an adjectival way to modify dis. For example.GRBQ344-C26[689-734] . Mary is sta. the purpose of an auxiliary verb often is to convey tense. By contrast. this is the tic. auxiliary verbs provide the basis for the phonologic lexicons. In the second. but she has the attribute of responsibility for the current case in subjects with Broca’s aphasia. The operation of volitional selective engagement mech- Although many types of prepositions exist. 2. the they are the product of reciprocal alterations in the distrib- recall of which is essential to correct production of arti- uted representations of the concepts underlying the nouns cles. tences. sponding to nouns. their verb use tends to ignore argument structure (Thompson. by a breakdown in syntactic func. Kiran. The produc- Declarative Memory tion of articles and auxiliary verbs usually depends. & Sobecks. place and time. however. Initially. in turn.GRBQ344-C26[689-734] . procedural and declarative (Squire & knowledge constitutes episodic memory in that it is memory Knowlton. repeatedly incrementally modified. pharyngeal and respiratory musculature also probably rep- tributed concept representations. If this theory of consolidation is . 2000). the breakdown in semantic or lexical-semantic knowledge. neural network knowledge that enables the translation of Curiously. the hippocam- ganglia. some fairly these domains of knowledge. difficulty modifying nouns (e. to cerebral association cortices. at least insofar as this knowl- elicit a pattern of activity in articulatory motor representa. are further. probably represents a during sleep (Power. on the integrity of sequence knowledge but also on capacity for Declarative memories. 2004). the hippocampus (Alvarez & Squire.qxd 01/21/08 03:02 PM Page 708 Aptara(PPG Quark) 708 Section IV ■ Traditional Approaches to Language Intervention In this conceptualization. awareness of rules of verb argument structure. to one extent or another. anomia for nouns reflects a form of procedural knowledge. basal the cortex. Shapiro. Anomia for verbs may resents a form of procedural knowledge. this new types of memory. and the particular acquired rapid decay occurs. which also are could be caused. Because the hippocampus. It appears that memories most likely are ing the skills as they are practiced. Eventually. subjects with tions corresponding to the spoken form of the verb.g. into continuous programs of movement involving tion. discrete. often referred to as skill memories. the specific content of Squire & Zola-Morgan. 1995. For example. Impaired amnesia resulting from mesial temporal lobe lesions are not ability to generate the super-distributed concept representa. The cause difficulty with verb production as well as violation of development of phonologic awareness—that is. often subtle refinement of distributed or super-dis. the neural network subjecting the cortex to patterns of activation congruent knowledge that enables translation of continuous incoming with the new information the hippocampus has incorpo- sound into the acoustic representation of phonemes. in part. note 18) within Ammon’s horn (the “cornu Ammonis”) of These general principles will apply to all languages. and may involve other as-yet-unrecog. This nearly instantaneous establishment of new connec- tions between active neurons within the hippocampus serves to close long loops linking neural networks in the cerebral MEMORY cortex. These circuitous new con- Language processes explicitly involve two well-known nections instantiate new knowledge. Languages differ. in part. The process of declarative memory consoli- Procedural memories. cerebellum. Rolls & Treves. The pyramidal neurons then project via the strategies employed in presenting that information.e. of a particular aspect of a particular event at a particular nized types of memory. edge is actually used in speech. Cerebral association cortices project to the parahip- Any behavioral therapy—language therapy included— pocampal gyrus and perirhinal cortex. in part. and spinal motor systems is pus appears to serve as a teacher to the cortex. Growing evidence suggests that this process occurs are discrete (i.. incorporated into cortical network connectivity to the extent ing tennis is enhanced gradually through extended practice they share features with knowledge already represented in as connectivity in the premotor and motor cortices. acquired all at once in approximately 1 second in a process tributed concept representations and the engagement of that is thought to involve fast Hebbian learning (see foot- working memory of recent sentences spoken or heard. we will subiculum to the entorhinal cortex. this new knowledge may be incorporated into neural network connectivity in the cerebral cortex in a process referred to as Procedural Memory consolidation. Even when syntactically the discrete phoneme structure of words—may correspond impaired subjects produce a relatively normal number of to the addition of a declarative form of this knowledge. In language. skill in play. In this process of consolidation. however. & O’Reilly. 1998. because it also involves volitional modification of dis. not continuous). Subsequently. 1997). 1991). which. verbs. dation is not completely understood and currently is some- are acquired incrementally by the neural systems represent. with adjectives) the articulatory representation of phonemes. or memories for discrete facts. even in normal individuals. By the same token. brain stem. what controversial. in the degree to which they rely McNaughton. 1994. McClelland. skills in distributed concept manipulation. For example. Dentate neurons project to the pyramidal the properties of the neural systems that incorporate new neurons in the cornu Ammonis (CA3 and CA1 fields) of the knowledge have major implications for the therapeutic hippocampus. 2000).. also may rule-bound letter strings (Squire & Knowlton. impaired in learning artificial “grammars” characterized by tions that are essential to verb production. which then projects back address this topic in some detail. a form of breakdown in lexical-semantic that knowledge of the phonemic sequence repertoire of a knowledge in which super-distributed representations fail to given language is procedural. which rated. pro- involves the addition of new knowledge to the brain to ject to the entorhinal cortex and then to the dentate gyrus of replace that lost as a result of brain injury or disease. on particular domains of knowledge. It also seems likely reflect. because they share few features as compelling as the paper by Vargha-Khadem and col- with existent cortical knowledge. We will discuss some specific appeared to be nearly normal. will remain permanently leagues. The observations of Vargha-Khadem and col- edge. Furthermore. This appears to be jects. tion—in direct analogy to the normal process of language tion. If presentation of is that lexical-semantic dysfunction constitutes one of the new information is interleaved with rehearsal of the old most common and disabling aspects of aphasia. capacity on his or her own in the course of routine conversa- strated expectable severe deficits in episodic memory acquisi. suggested to the authors that two separate declara- features with knowledge represented in the cortex (they rep. catastrophic section. source of difficulty). degradation of the old information occurs (McClelland The importance of this issue for speech-language therapy et al. Direct information. then a network is capable of instanti. 1995. because in neural network simulations. the sus.. During subsequent gives the subject the tools to continue growth of language intensive neuropsychological testing. For example. All three. then it follows that memories that cannot be readily of this phenomenon in previous case studies. knowledge underlying translation teristic strengths and weaknesses relevant to their recruitment of phonemic articulatory representations into motor in therapy for aphasia. McCloskey & Cohen. The observations of thought that the hippocampal system provides the brain Vargha-Khadem and colleagues raise the possibility of a with a means to circumvent this impasse: It serves both as a completely different declarative memory–like brain mecha- repository of newly acquired declarative knowledge and as a nism underlying the acquisition of lexical-semantic knowl- teacher to the cortex that. and autobiographical memories ries. be able to substantially improve the efficiency of naming The new knowledge is added gradually to the old knowl. in the three subjects reported) that suffices for declarative pocampus and its associated structures. and of a critical sentations to phonemic sequences or to articulatory or mass of phonemic sequence knowledge will provide the proce- acoustic representations? This. Acquisition of certain skills in manipu- knowledge declarative or procedural? lating distributed concept representations should generalize to A famous paper by Vargha-Khadem and colleagues (1997) all distributed concept representations susceptible to those provides some hints. spans the declarative-procedural divide. tive memory acquisition systems exist: one resident in the hip- resent knowledge of particular places and times that are of pocampus that is essential to acquisition of episodic memo- only personal significance). semantic memory acquisition. however. sequences into phonemic acoustic representations (rarely a sciously accessible.qxd 01/21/08 03:02 PM Page 709 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 709 correct. in other words. 1989).g. and one in entorhinal/perirhinal cortex (relatively spared are highly susceptible to disruption by lesions of the hip. constitute varieties of procedural memory. in conjunction with the results of studies in nonhuman the case: Autobiographical memories generally share few primates. approaches to this problem—that is. Is this the native vocabulary. serves to interleave edge. Rolls & Treves. If only we better understood this principle. during sleep. weighs strongly against this interpretation. ful even in subjects with substantial hippocampal dysfunc- catastrophic degradation of old knowledge does not occur. the basis for lexical-semantic dural knowledge basis for decoding and producing all words in knowledge. and phonologic sequence knowledge all may knowledge underlying language is that it generalizes widely. There had been similar reports examples of such therapies later in this chapter. of skills in translating phonemic articula- What about knowledge linking distributed concept repre. They reported three subjects who. however. is prototypic declarative knowledge. we might the new knowledge with rehearsal of old. In contrast.GRBQ344-C26[689-734] . the acquisition of skills in decoding of sound knowledge of concepts. related knowledge. 1998). and because the changes in neural connections are leagues also suggest that naming therapies might be success- made incrementally and the new is interleaved with the old.. the evidence that the hippocampus required. because of traumatic brain injury). therapies. tion (e. as discussed in an earlier network by the new knowledge. Lexical-Semantic Memory Properties of Procedural and Declarative Memory Systems Relevant to Therapy for Aphasia In our discussion so far. early manipulations. had acquired language function that acquisition in early childhood. A second major advantage is that achieving an in life.. 1995. This hypothesis remains to be It currently is thought that the hippocampal system is fully tested. but none nearly incorporated into the cortex. had experienced severe bilateral damage to the hip. . adequate foundation of procedural language skills potentially pocampus as a result of anoxic insults. tory representations into motor programs. by virtue of being discrete and con. The nearly normal language function and the dependent on connections within the hippocampus and its remarkably good general knowledge acquisition of these sub- immediately adjacent neural structures. One major advantage of procedural sequences. we have suggested that knowledge underlying translation of sound sequences into phonemic Both procedural and declarative memory systems have charac- acoustic representations. It is tend to be extraordinarily inefficient. not a binary system (McClelland in replacement of old knowledge already represented in the et al. these subjects demon. “naming” therapies— ating both old and new knowledge simultaneously. and adjacent cortices are anatomically and functionally orga- tained presentation of new information to networks results nized as a cascade system. Cox. phonologic sequences.g. semantic therapy could benefit oral word produc- peutic strategy that depends on acquisition of lexical-seman. apy (e. On the mal subjects (else all attentive students would score 100% on other hand. tion. In this section. manipulation may require such extensive practice that only a 1997). motivation—and who are capable of engaging motiva- The potential for generalization of semantic knowledge may tion to employ the technique—can use during and out- be considerably greater. the ultimate devel. or syn- one concept may benefit the ability to generate a distributed tactic therapy). Second. Successful glimpses of generalization effects. to the extent that they share features. We have not remotely learned in therapy that is crucial to ongoing progress plumbed all the possibilities for engaging shared semantic outside of therapy (although a critical mass of substan- features to best advantage in therapy for aphasia. & Acquisition of grammatical skills in distributed concept Doyle. & McCall. but only in a very unusual individual (Basso. capacities involve pattern associator networks linked to ulary for the subject—something that. Wambaugh. This limitation is most serious for lexical-semantic gained in therapy. tures and. either through further therapy or by the 1.GRBQ344-C26[689-734] . generalization from semantic therapy will tests of knowledge). to situations that allow application of the acquired pist’s task is to develop these remnants until they reach the techniques (Kiran & Thompson. Generalization is sition is that it is incremental. These various types tive memories. Thompson critical mass needed for daily spoken communication. First. the learning process sion. and the mechanisms procedural linguistic memory acquisition in the domain of remain poorly understood. and written word comprehension. semantic features. In the preceding section on phonologic knowledge would only build the phonemic/ memory.) For . during speech-language therapy sessions. be applied regardless of the subject of com- major disadvantages also exist. Extrinsic Development during therapy of a knowledge that would be needed. 2003. 2003. The advantage of declarative knowledge underlying lan. and its efficiency drops substantially in be limited to concepts that share semantic features the face of extensive damage to cortices supporting declara. 1998. phonologic sequence therapy. impact on the daily communicative lives of subjects. West. 1996). written word production.g. can continue to apply in the months GENERALIZATION and years outside of therapy. Whelton. because all four must be extended to incorporate a full. tice. useful working vocab. Because knowledge gained about phonetics. training of semantic therapy. with the concepts actually trained. the integrity of the semantic field). and the thera. Here. have the potential for extensive generalization. knowledge that shares these features or sequences or nants of previous knowledge (Plaut. demographic and cultural modifications in this vocabulary 3. evidence from clinical trials has only provided language also pose their own particular problems. it is not the substantive material representation of another concept. therefore. Thus. Fortunately. we briefly consider the knowledge. therapies that develop this knowledge tive memory is considerably less than 100% efficient in nor. but two principle. in guage is that it can potentially be acquired all at once.. We touched on this principle in the section on very limited repertoire of such skills can be trained. the potential for generalization is of generalization stem directly from the knowledge limited.qxd 01/21/08 03:02 PM Page 710 Aptara(PPG Quark) 710 Section IV ■ Traditional Approaches to Language Intervention The major disadvantage of procedural knowledge acqui. tion.. side of therapy to rebuild language function (e. and the practical means for training acquisition/skill learning technique that subjects with subjects in this extended vocabulary are largely unknown. Weinrich. Kalinyak-Fliszar. because little relationship exists between the 2. for any thera. munication. remarkably. acquisition of declara. oral word comprehen- tic knowledge to achieve practical value. or syntactic techniques) to other brain likely is not a tabula rasa: There exist extensive rem. phonologic sequences. Seven (listed in Table 26–2) are posited: latory sequences that would enable naming would still have to be developed. The actual links between distributed concept full spectrum of mechanisms that might underlie generaliza- representations (semantic knowledge) and phonemic/articu. Specific domains of procedural memory underlying however. even in the context of extensive brain damage. Intrinsic Application of knowledge acquired in ther- subject in the course of daily use of language. the language phonetic sounds. because many concepts share fea. (in traditional terms. memory. ple. and syntactic techniques can. knowledge.. tive knowledge may be necessary)—it is the acquisition of a therapeutic technique that the subject. 2003). (This will be further eluci- Generalization is the process by which the effects of therapy dated in some of the specific examples that are discussed extend to material or circumstances not explicitly taught in the section on specific rehabilitative strategies. et al. Cross-function Development of knowledge during meaning of a word and its sound: When you have learned therapy that can be applied to multiple tasks. essential if speech-language therapy is to have an important opment of a useful level of skill will require extensive prac. all four capacities depend on the The number of words that would be necessary for this. For exam- one word. perhaps with help from family. To date. you have learned one word. has been association cortices supporting concept representations achieved. we introduced the concept of generalization in sev- articulatory foundation for acquisition of lexical-semantic eral specific contexts. working memory). subjects must be motivated to continue 1997). further the therapeutic process. with the adoption of a new/revised role that subsumes more expectation of speech. alization to occur. and they must have the brain generating the representations) and Broca’s aphasia mechanisms (which presumably depend. both those that can be named and multiple distributed concept representations need to those that cannot. or pronouns) require some tic therapy can make use of this generalization mecha. b.a. during speech-language therapy that aids in retrieval of knowledge outside of therapy by establishing additional commonality between the training situation and the retrieval situation.g.g. they may perform almost normally. or intentional bias to use language that is essential to language function. 2006).. as discussed.. comprehension and production) involving verbal and orthographic modalities. We have preliminary evidence from a study of semantic therapy that only subjects who demonstrate intact frontal function show widespread 10 Subjects with adynamic aphasia characteristically are extremely non- generalization that also impacts daily communicative fluent in internally generated language and. predominantly contextual. semantic) that can be applied to multiple functions (e. Socially mediated Change in the perception of the subject and his or her family regarding his or her role in the family unit. be maintained simultaneously for sufficient time for vation and the capacity for translating motivation into appropriate modifications to be made. which is needed to communicate in daily life. can use during and outside of therapy to rebuild language function. Substrate mediated Development of the critical mass of language skill needed to enable conversation at home and elsewhere and. in which attributes of concepts. semantics). Three representations are “planted” in their brain by showing them a picture. and greater language production. Mechanistic Development of a nonlinguistic brain resource (e. essential gests that when called on to generate their own distributed concept rep- to language processing but not fundamentally linguistic. is likely to be particularly therapy for systematically identifying the semantic important for normal grammatical function. long after the conclusion of therapy. on (in which there appears to be particular difficulty in frontal systems) to translate this motivation into effective post-therapeutic practice.GRBQ344-C26[689-734] . but when distributed concept that enables improvement in language function.g. Extrinsic Development during therapy of a knowledge acquisition/skill learning technique that subjects with motivation. as demonstrated by Basso (2003): Exceptionally which may be represented as working memory. and who are capable of engaging motivation to employ the technique. subtypes can be postulated: they are capable of substantially normal language production. because all these functions depend on the integrity of the core domain (in this case. some of nism. The differences to use therapeutic techniques learned during therapy between adynamic aphasia (in which there is difficulty after completion of therapy. example.qxd 01/21/08 03:02 PM Page 711 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 711 TABLE 26–2 Mechanisms of Generalization Mechanism Description Intrinsic Application of knowledge acquired in therapy (e. This sug- 4.g. incapable of more than occasional single-word production. Development of the ability to endogenously gener- niques to practice naming of the thousands of words ate distributed concept representations. Cross-function Development of knowledge during therapy (e. Even lexical-seman. ability to endogenously generate distributed concept representations. most impaired in adynamic aphasia10 (Gold et al. resentations... recollection of what has recently been said.. may be the same as 4. For extrinsic gener. and syntactic techniques) to other knowledge that shares these features or sequences or to situations that allow application of the acquired techniques. however. semantic features. in extreme cases. and some action. phonologic sequences. Contextual Acquisition of knowledge. Development of working memory capacity needed could continue to use the techniques acquired during for language. In picture description tasks. thereby. a subject who has received semantic therapy a. . provided that he or she has the moti.g. more pressure to speak. auxiliary verbs. they have great difficulty.. may be behavior (Nadeau & Kendall. thereby continuing to develop the semantic field grammatical functions dependent on reference (e. articles. phonetic sounds. Mechanistic Training of a key brain resource. capable subjects can be given the guidance and tech. in part. qxd 01/21/08 03:02 PM Page 712 Aptara(PPG Quark) 712 Section IV ■ Traditional Approaches to Language Intervention modifying and manipulating the representations). and (3) feedback during treatment. the alterations recovered language function. modification of inten. We will focus on three topics: (1) the distribution of strengthening connectivity between concept represen- aphasia treatment over time. Under these cir- the treatment of aphasia. however. developed constraint-induced movement therapy. Elbert. Socially mediated Change in the perception of the gesture. and performance at baseline. In essence. The greater induced language therapy (Maher et al. suggest an important difference. Because. and greater language production enable the subject to take full advantage of partially (Blonder. environment and context in the retrieval environment. leads to alternative communicative modes.. during speech-language therapy that aids retrieval of knowledge outside of therapy (detailed in Distribution of Aphasia Treatment over Time the next section). the educational psy- sequence knowledge that covers most words encoun- chology literature can provide evidence that may be useful in tered in their daily communication. As Blonder has shown. the principle is that when Condensed Versus Distributed Practice we learn. to varying degrees. that subsumes more expectation of speech. This intentional bias then persists despite subject and her or his family regarding his or her role in substantial improvement in capacity for language the family unit. The predominant focus in neurorehabilitation in general This knowledge may include attributes of other stimuli has been on knowledge or skill acquisition—in other words. The therapy might influence the acquisition of knowledge by the brain does not include training in the ability to link phonemic during therapy and the retention of that knowledge after the sequences to concepts—this must occur outside the conclusion of therapy. Training that alters the bias can sure to speak. will provide an opportunity for tion. Djundja. actually inhibits linguistic communica. Most. reduced. below we will discuss our experience in using The focus of clinical research on treatment of aphasia has training in phonemic awareness. Most of because of frustration with language impairment that us have encountered the negative effects of absence of is particularly severe in the months immediately fol. introduced during a treatment session. where the treatment was provided. the knowledge acquired includes not only the intended material but also knowledge about the context. Contextual Acquisition of knowledge.GRBQ344-C26[689-734] . c. thereby.e. STIMULUS PROPERTIES. would agree . the social context that will promote language use as an sible for the gains associated with the previously instrumental measure.. more pres- tion in the long run.g. straint-induced language therapy (e. patients develop an intentional habit name of a professional acquaintance during a chance of minimal effort to communicate or a habit that encounter outside our professional environment. in a cogent way. the production of most words. The idea here is that the higher the likelihood of success in retrieval. therapy for aphasia. 2000). the resemblance between context in the learning Meinzer. 2001). if patients with stroke do not become socially isolated. who else was present. Thus. communicative ability may require some restoration of ment of this therapy and appears to be most respon. 2005.. 2003. participant attitudes to language use over either non-use or gestural commu. characteristics of the however. predominantly contextual. Substrate mediated Development of the critical mass of language skill needed to enable conversation at home and elsewhere and. further the therapeutic TEMPORAL SPACING. and phonologic sequence knowledge to ameliorate and very little attention has been devoted to factors that impairment of lexical access in aphasia. therapy for aphasia is likely to produce its effects by subjects have acquired a repertoire of phoneme engaging normal learning mechanisms. with the adoption of a new/revised role and. (2) the structure and context of tations and corresponding phonemic sequences. Barthel. phoneme production. We presume that it can only occur if stroke. the stroke experience and associated disability. the value of language facility may be fundamentally but this particular one (i. in the subject with chronic treatment session. For FEEDBACK DURING THERAPY example.g. STRUCTURE. strategies the participant brings to therapy). thereby. to brain structure and func- without caregiver help. restoration of daily tional bias) is the one that has motivated the develop. contextual similarity when we try to remember the lowing stroke. AND process. Development of a new intentional bias that favors the mood of the participant. with or can be related. & Rockstroh. It probably is necessary to enable intrinsic and CONTEXT. It also may the difference between performance at the end of treatment include more general attributes of the situation (e. and the nication. 6. such as 7. the cardinal example being constraint. AND extrinsic generalization mechanisms to operate. Pulvermüller et al. overwhelmingly been on the substance of that treatment. 5. treatment room and the therapist. The discoveries in this research cumstances... There may be other in lives produced by aphasia may be profound. and even mechanisms at play in mediating the effects of con. see 7 below). “Distributed practice” Figure 26–7. very few studies have directly compared the treatment schedule density remains a matter of great scientific impact of different degrees of distribution of practice over and clinical interest in all fields of rehabilitation. Thus. Unfortunately. ically are separated by many intervening. a dramatic loss of constraint-induced move. that must be sustained over days.” Often. The more distributed drill was more effective. Donovan & Murphy (1916) found that training schoolgirls in a left- Radosevich. Pyle (1913) compared that we are aware of provides definitive answers. has largely been proven (Taub. each separated by an interlude of minutes. no study has been conducted regarding the relative do not provide data regarding training. Thus. the impact of an addition drill given to third-grade students Studies contrasting the relative impact of massed practice twice a day for 5 days with the same drill given once a day for and distributed practice on learning rate and knowledge 10 days. following treatment. & Pidikiti. no speech-language therapy conforms to traditional definitions of massed prac. with the net result that long-term retention typically In speech-language therapy. This superiority has come to be known as the “spacing notion that the case for large amounts of highly condensed effect. activity. tion task practice on retention of knowledge and skill. simple motor skills. rate of loss. and the development of strate- extremity paresis following stroke may have cultivated the gies. and quality of life. however. Studies have consistently demon. More distributed Less distributed rally condensed is very much germane to this issue. 1999. 1996. and no study these more extended periods of time. the difference between performance long after the conclusion of treatment and per- formance at baseline—rather than on acquisition. retention date back to 1885 (Dempster. learning regimens. and our major focus here will be on evidence bearing on training involves factual knowledge. participation. Black. phase of more condensed training than it is after more dis- sures. weeks. which are likely to be considerably less than those acquired by the end of treatment. More condensed (less distributed) regi- mens commonly achieve greater acquisition of knowledge and hours. recall is greater at the end of the acquisition practice. target stimulus repetitions typ. The degree to which practice is more or less tempo. a tributed practice has been found to be superior to massed dynamic balance task and a calibrated sequential key-press . dis. This superior acquisition efficacy is offset 1999. Relatively little attention has been Although these studies provide strong evidence for the devoted to treatments after constraint-induced movement superiority of modest temporal distribution of short-dura- therapy that might help to sustain gains. Lai. or the impact of more or less temporally distributed therapy. is greater with less condensed (more distributed) regimens. such that long- strated. however. With very few exceptions. Only changes retained by the brain over the long run can have a lasting impact on daily performance.. and the limits of human endurance dictate that sessions be conducted over multiple days.qxd 01/21/08 03:02 PM Page 713 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 713 that the real measure of treatment efficacy is the knowledge and skills acquired during treatment that the subject retains through the months and years after the conclusion of treat- ment. Taub et al. This Outcome suggests that our primary focus in treatment studies should be on long-term outcome—that is. It also poses the challenge of understanding the neural mechanisms underlying the relationship between retention and acquisi- tion. term retention usually ends up being greater with more dis- ment therapy–associated gains over the weeks and months tributed training (Fig. 26–7). tributed training. & Park (2000) studied training on two tasks. or days. and to our knowl. such as rehabilitation impact of more versus less distributed constraint-induced therapy. nontarget stimuli. Cartoon illustrating the trajectory of skill/knowl- traditionally is defined as practice that is broken up into two edge as a function of time with more and less condensed or more sessions. Shea. Uswatte. of knowledge and skill types. whether the tice. Literally hundreds of handed javelin throw produced a higher rate of learning if investigations have been conducted involving a wide range done one or three times weekly than if done daily. or months. they edge. movement therapy schedules on long-term retention. 1885). more complex tasks involving acquisition of factual knowl- Studies of constraint-induced movement therapy for upper edge. 2006). advanced motor skills. by relatively greater forgetting. or a single session in which repetitions of tar- skill by the end of training. by virtue of the dramatic impact on outcome mea. Ebbinghaus.GRBQ344-C26[689-734] . but this is then followed by a higher get stimuli are separated by one or more nontarget stimuli. “Massed practice” traditionally is defined as continuous practice conducted over a single day in which the stimuli or Time skills to be remembered are presented without any interven- ing irrelevant stimuli or activities. practice in its effects on knowledge retention. 1980) comes closest. 1955. and Day (1999) compared (Glenberg. General and structural context exert their impact by modifying sions. the component-levels theory of Glenberg Shebilske. which is directly analo. general context are nearly identical. three attrib- better when training was distributed over 4 days compared to utes of that item are encoded: (1) its semantic attributes. similar and because both are different from the general context tion of therapy within day are needed. the cognitive and affective state and degree was 15% among those trained with a 30-day intersession of fatigue of the subject. as in massed practice. 2. word lists and cued recall from word pair learning tasks.. very substantial degrees of tempo. spacing effects in the workers to type. In massed practice. pates current concepts of episodic memory. largely involving free recall of words from ing acquisition of factual knowledge. they are perceived and organized by the subject (structural con- Bahrick and Phelps (1987) found that among subjects trained text).e. his own and other’s. cumulative treat.GRBQ344-C26[689-734] .. (Craik & Lockhart. at the time of the first presentation of the item (thereby largely eliminating its contribution to recall). as of 5 or 10 days were associated with poorer performance. Third. Distributed presentations generally produce extended periods of time. Thus. 2003). Hintzman. but degree of distribution was con. Estes. rep- founded with dose (shorter studies typically involved more etition confers minimal advantage. related to spacing. performance is inversely declarative and procedural knowledge. the neighbor- not impair performance. Glenberg considered only declarative memory experiments. First. the inter-trial training schedule. and strat. the real- ral distribution of practice may yield superior long-term ization of the potential effect of repetition is controlled by the retention of knowledge and skill. Three principles are essen- (2002) trained 2-year-old children on novel nouns and verbs tial to his theory. Although no theory has been port a proportionality rule: When the retention interval is shown to account for all experimental results. They found that production performance was that when an item to be remembered is learned. If structural and probably was superior. for both tasks. 8% among those on a 1-day intersession reminiscence of salient stimuli and strategy formation). This egy.g. for retention a week later. If structural and general hours of therapy) (Bhogal. within which it is embedded. Subjects trained over 10 days performed better on both work finds it origins in encoding variability theory (Bower. differences in general and structural context.. in a conceptualization that fully antici- (i.e. and to fully accommo. but gaps between training sessions ing words in the word list). training over 2 or 3 days proved to date our current understanding of the neurobiologic bases be more efficacious than distributed training over 1 day. training distributed over 2 days with equal training distrib. Melton. motor skills. (2) 1. context differ but recall is requested shortly after the item is Thus. both because the general speech-language therapy over days as a function of domain context at the time of repetition and at the time of recall are of knowledge being trained as well as studies of the distribu. Two-day gaps between training sessions did attributes of the neighboring task stimuli (e. including both short relative to spacing intervals. Goettl. Repetition will contribute to language therapy that involve intensive. 1989. no spacing effect will occur.. 1979. 1972). Glenberg posited dural divide). 1999). acquisition and retention measures. & Speechley. the No studies provide definitive data regarding the impact retrieval environment (i. recall to the extent that structural and general context attrib- ment conducted up to hours at a time over many days. and in complex tasks. and 6% among those with no spacing between ses. recent review concluded that more concentrated therapy thereby increasing the probability of recall. Teasell. Second. and (3) the general context of the experiment (e. bered add together to increase the likelihood that some of fering degrees of distribution of speech-language therapy. Glenberg & Lehmann. are very nearly identical for every presentation of the item to ous studies suggest that when training must be sustained over be remembered. Shebilske et al. Childers and Tomasello 1972. perceptual) hour per day over 60 days than when given in two 2-hour ses. Baddeley and Longman (1978) trained British postal the semantic representation. a complex task involv. and when the retention interval is long .g. 1970). retrieval context interaction effect). general and structural context declarative knowledge to procedural knowledge. Glenberg and Lehmann (1980) have shown that these principles apply not just to learn- Potential Mechanisms Underling the Spacing Effect ing studies/retention probes that occur within a single day but Many theories have been offered to account for the relative also to learning epochs that take place a week apart with tests superiority of distributed practice (Greene. or 3 days. of memory. recall ing environment. a repetition is potentially sions per day over 15 days..qxd 01/21/08 03:02 PM Page 714 Aptara(PPG Quark) 714 Section IV ■ Traditional Approaches to Language Intervention timing task.g.. nor to utes associated with each presentation of the item to be remem- our knowledge have any studies examined the effect of dif. storage of information distinct from that stored at the first pre- gous to lexical-semantic knowledge in that it involves linking sentation. The task involves training of effective to the degree that the second presentation allows the typographical-semantic knowledge. conditions at the time of the memory test—that is. Corrington. the test- on 50 English-Spanish word pairs tested 8 years later. the spacing effect reflects a storage- of degree of distribution on training programs like speech. both studies of the impact of variable distribution of repeated. uted over 10 days on Space Fortress. Studies by Glenberg and others sup- 1974. These vari. lexical-semantic training bridging a declarative-proce. Learning was more effective (as defined by declarative domain are attenuated with stimuli being retention up to 9 months later) when training was given 1 processed only at more superficial levels (e. interval. A these same attributes will be present in the recall environment. contexts within a short period of time. there likely will be no benefit from the long ter recall of the new skill under a variety of situations that do spacing intervals that enhance the likelihood of change in not exactly match the training situation. the long-term retention. Squire & Zola-Morgan. connection strengths are altered in a relatively lim- engages normal learning mechanisms. whereas with massed practice. during which training spacing—hence the value of highly distributed training on in the new skill is interleaved with retraining of old skills. retrieval during retention testing: (1) It enhances the likeli- edge acquired through distributed practice (Sejinowski & hood that structural and general context conditions at the Rosenberg.qxd 01/21/08 03:02 PM Page 715 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 715 relative to spacing intervals. albeit with variable efficiency. The more attributes are unlikely to be encoded as part of the proce. 1995). distribution of procedural training connectivity and. both because pendent. becomes hippocampally inde- could provide a relative advantage in retention. Rolls & a variety of action contexts and because it allows more occa. through massed practice.e. new skill is retained. On the ory.. converting a novel less than 100% efficient. to the extent that this knowledge has features in com- ther consolidative and re-consolidative processes that take mon with knowledge already represented in the cerebral place during sleep (Stickgold & Walker. Thus. eventually. a process referred to as “memory consolidation” it provides a greater opportunity to train individual skills in (Alvarez & Squire. we can posit two mecha- in skill learning (Schmidt & Bjork. consolidation (i. In a sense. time of test will share attributes with conditions at the time ponent-levels theory of Glenberg. Thus. 1988). Thus. Declarative memory is acquired as involves a consolidation phase that takes place over several episodic memory all at once. connection strengths are altered throughout the net- types of therapy for various types of impairment remain work in a way that optimizes encoding of attributes that uncertain. more paired expo- When tested immediately after training. receives “refresher training” in its old knowledge repertoire. it attributes are important to the spacing effect on procedural learns the new skill by rote. A pattern associator net. the conversion of episodic memory into sive knowledge is already stored in its connections can semantic memory that is substantially independent of con- readily. nisms by which highly distributed training in declarative In the domain of procedural memory is an alternative. Because declarative memory acquisition is far formance on a particular new skill (e. it apparently is introduced gradually into cortical Stickgold. 1994. & Bizzi. 1998. both declarative and ited part of the network and in a way that supports the new procedural. current knowledge of the neurobiology of declarative (fact) Evidence suggests that procedural memory acquisition memory acquisition. particularly in face of damaged cor- acoustic sequence into a novel articulatory motor sequence). it is worth asking whether the princi. performance is directly related to other hand. 2005. Thus.GRBQ344-C26[689-734] . memory domains may enhance the likelihood of successful connectionist account for the superior retention of knowl. Shadmehr. learn to achieve high per. 1991). Treves. with dis- general context attributes. accumulating that the process of consolidation also occurs The advantage of distributed over massed practice also can substantially during sleep (Stickgold & Walker. 2004). This connectionist conceptualization salient difference between declarative and procedural mem. Very little data regarding this are available. reflected in the superiority of distrib- however. even as the relative contributions of each of skill at the expense of the old skills. 1996). 1992). Evidence is sions for sleep-associated consolidative processes to occur. Only structural context underlying the new skill. and (2) it increases the opportunity for memory work employing distributed representations in which exten. The explanation is this: With massed It seems likely that treatment of aphasia after stroke practice. this connectionist account memory retention. Thus. performance of the new skill will rapidly decline uted over fully massed practice in inducing long-term mem- (catastrophic degradation) (McClelland et al. Walker & cortex. also has been observed in a number of relatively primitive .g. with distributed practice. there should be no Glenberg’s theory also can be logically reconciled with advantage to distributing training over a longer period. of learning. a major contributor to spacing tributed practice. if a particular skill to be learned also suggests that some distribution of procedural training can be repeated within each one of a full spectrum of skill may be superior to massed practice as traditionally defined.. 1995. Therefore. This account is compatible with the com.. 2004). performance of the sure-consolidation events and more than one night of con- new skill will be excellent. widely disseminated instantiation of network knowledge of dural memory trace (because the hippocampus is not the new skill achieved with distributed practice enables bet- involved). has demonstrated a complex of fur. With distributed prac- these two learning mechanisms to training effects in various tice. be seen in the superiority of “random” over blocked practice Walker & Stickgold. however. Thus. can be viewed as the neural network embodiment of the ory that we need to contend with is that general context structural context knowledge discussed above. tical repositories for long-term memory. 2005. the network implicitly learns the rules effects on declarative memory recall. hours (Brashers-Krug. Over recent studies. When the network subsequently solidation per exposure may achieve superior efficacy. both new and old skills have in common. distributed ples proposed by Glenberg to account for the spacing effect practice optimizes compatibility between new and old by in declarative learning might apply to procedural learning as distributing connection strength changes more widely well. A flurry of through fast Hebbian learning in the hippocampus. McClelland et al.. The most through the network. time. The spacing effect. text effects). ing of structural and general context. Structure and Context of Aphasia Therapy crabs. the greater strongly supports the superiority of more over less distrib- the likelihood of similarities between the language environ- uted practice in promoting long-term retention. and whether we could achieve mechanisms provides the opportunity to benefit from varia- some benefits of the spacing effect by enhancing intra-ses- tion in general context attributes during the course of train- sion linguistic richness and variability without increasing the ing. with an attendant increase dural memory retention. It also is worth greater long-term attenuation of gain than expected with noting that every successful recall by the subject that is overtly less distributed practice. considered in this population as well. We have no good ideas MAP kinase. reduced practice between sessions. goldfish. tine speech-language therapy environment and the environ- Hochhalter. The Presently. the training thus may be too small to be of importance in the need to distribute therapy over time possibly will be reduced clinical population. a nudibranch. 2002). Distribution of train- the typical current speech-language therapy session is as rich ing that engages declarative (but not procedural) memory and varied as it could be. the greater the variety of contexts in which any robiology of learning. however. Drosophila. reduced concentration on therapy. The spacing effect literature suggests that memory consolidation. and subsequent RNA and protein synthesis. and (2) time for broaden- ing induction of cAMP-response element–binding protein. Subjects the people present. Ide. the greater will be the likelihood of similarities jects with brain damage. both declarative and pro- the more variability in the general conditions in which indi- cedural. The effect size of greater distribution of ditions during therapy and during recall can be achieved. but for somewhat different reasons in the probability of recall. and greater distribution may lead to at the same time that retention is enhanced.qxd 01/21/08 03:02 PM Page 716 Aptara(PPG Quark) 716 Section IV ■ Traditional Approaches to Language Intervention organisms. such as the sea snail Aplysia. and strategizing with brain injury typically have a heterogeneous mixes of by subject and caregivers between sessions all are factors to be deficits. We can (2003) found a significant spacing effect on a word therefore ask how much resemblance exists between the rou- list–learning task in subjects with traumatic brain injury. The physical environs. and it takes full advantage of hippocampal consolidation temporal distribution of therapy sessions. it seems unlikely that such mechanisms underlie broadening of structural and general context need not be left the differential effects of more versus less distributed training to time and accident. and honeybees (Sutton. and Holub (2005) ments in which the subject ultimately will be struggling day to found no such effect on either a pill name or a nonverbal day to use language to communicate. loss of continuity. however. the mood of the subject. and general context. Very few studies have examined the spacing effect in sub- therefore. one fact or skill will be acquired and. If greater similarity between general context con- support systems. The emerg- General context pertains to the conditions of individual ing importance of brain processes occurring during sleep for therapy sessions. Craik and long-term advantage of more distributed practice. but this possibility cannot be ruled out therapeutic programs in a way that will enhance structural entirely. variability in motivation and fatigability. and uneven considered. however. as well as connectionist work. includ- lution of neurobiologic processes. processes that are known to continue for years. A number of other factors need to be sessions and the general environment at the time of recall. of conditions in which any one fact or skill is acquired and. Overmier. the greater will be the variety to be just as important for procedural memory retention. Gasper. and their results have between the therapy environment in one or more training been inconclusive. could indicate that distribution effects will turn out vidual therapy sessions are held. for how to manipulate the neurobiologic processes. therefore. The spacing effect literature suggests that the richer and more variable the language contexts in a ther- A large body of evidence regarding the psychology and neu- apy session. Hillary and colleagues with an attendant increase in the probability of recall. in a landmark paper. that memory retention was strongly influenced by depth of . These factors may lead to a greater-than-expected disparity between outcomes at Stimulus Properties the end of the acquisition phase that mitigates the potential More than 30 years ago.GRBQ344-C26[689-734] . We can therefore ask whether and in incompletely understood ways. Bakke. Structural context pertains to the content of individual The Spacing Effect: Summary therapy sessions. The potential advantages of more recognized by the subject and caregivers constitutes a contin- distributed practice may be outweighed by the effects of uation of the training process outside of therapy. and reduced motivation. sequence–learning task in subjects with dementia. Only Lockhart (1972) argued from extensive experimental data empirical studies can address these questions. reduced involvement by caregivers. Masters. In many of these experimental models. we could deliberately alter over days in humans. the two major factors that might contribute to the relative spacing effect appears to reflect the differential impact of advantage of more distributed training: (1) time for the evo- spacing on molecular mechanisms of synaptic change. we noted Carew. & In our preceding discussion of the spacing effect. This spac- ment in one or more training sessions and the language ing effect appears to apply to both declarative and proce- environment at the time of recall. or intonation actually aid of counseling by the therapist (Proctor & Dutta. the subject understand what attributes of his or her response porting limbic and predicative representations. potential for retrieval at a later time. the therapist Counting vowels would require a distributed representation might respond to an error with observations such as “The of the orthographic form of the word in a relatively restricted word you produced isn’t exactly correct but it is related in part of visual association cortices. the therapist to the subject. Knowledge of performance can benefit retention via all Feedback can be divided into two categories: knowledge the mechanisms underlying the benefits of knowledge of of results. just as tests all the stimuli to which a subject is exposed during a thera. Feedback about performance “Your answer was correct” or “Your answer was incorrect.” In a phono- (Fig. using Visipitch [Kay Elemetrics. it can help to focus subjects on the par- results consists of information provided to subjects regard. for being remembered in some spacing effect). and detailed feedback about test performance can enhance peutic session have the potential for altering neural network retention of knowledge acquired in the classroom (via the connectivity and. might become a useful general substantive information regarding performance provided by context attribute that may carry over to recall situations. in a lexical- us to define depth of processing in neural network terms. mirrors. Feedback about results provided to subjects one or more times later in a therapy ses- sion. response (e. develop a strategy for improving performance. are particu. might theoretically benefit in nine subjects with aphasia. gies to systematically correct them. not just those involving a lim. We define “feedback” as mance and. different therapies have different larly important to long-term retention. if encouraged..GRBQ344-C26[689-734] . and knowledge of performance.g. however. Furthermore.]) to help ever. movement complex led to the error produced through the ited portion of visual association cortices. In a prosody treatment program. is to assure that the jects with graphic knowledge about the pattern of their stimuli targeted by the therapist are particularly well estab. such of this thesis in a study of noun and verb naming treatment as semantic or syntactic therapy.qxd 01/21/08 03:02 PM Page 717 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 717 processing of the material presented. Any therapy in which there might be Raymer and colleagues (2006) provided evidence in support useful information in pattern of performance. Feedback about results. 2004). responses over time. The therapeutic goal. the therapist might seek to help cortical–hippocampal–cortical loops involving association subjects understand what components of the pharyngeal cortices throughout the brain. that certain connections. then with certain therapies this might lished in neural connectivity in a way that will maximize the help subjects to see a pattern in their errors and. speech or aprosodia).. perhaps with the (e. of each word. can be complicated. the phoneme.g. however. sentence. therapies for apraxia of sented during language therapy may enhance retention. 26–3). and motor therapies most readily lend themselves multi-component distributed representations of stimuli pre. to feedback about performance (e.. 1995. The concepts elaborated in this chapter enable Schmidt & Wrisberg. It also is possible. the deep processing may provide the entire basis for the superior therapist might show subjects the acoustic profile of their retention of “deeply encoded” items. semantic or semantic treatment program. 2004).” Feedback about performance needed to define optimal programs for individual subjects. thereby. produced). In nearly all the subjects. Inc.g. how. learning was markedly enhanced when picture presentation Knowledge of results generally has little potential for pro- was accompanied by a pantomime of the use of the object or viding subjects with the insight regarding the causes of their the motion of the verb and the subject imitated the gesture errors that might engage them in the development of strate- as he or she repeated the name. ticular attributes of the performance that are contributing to ing the correctness of a response at the operational level error and to develop their own strategies. or at subsequent sessions can serve to vary the Feedback during Treatment structural and general context associated with that particular In the preceding sections. Making a judgment about meaning to (or it is in the same category as) the correct the meaning of a word is more likely to engage the full. such as those to cortices sup. In addition. This would set the stage for closure of long-loop logic treatment program. and considerable research will be here is the correct answer. however. if it is possible to provide sub- form. 1995. were incorrect. Clearly. Such feedback might consist of responses such as Schmidt & Wrisberg. potential for the provision of feedback about results and per- These observations suggest that measures taken to assure formance. For example. The much larger use of diagrams. a subject consists of information provided to subjects regarding who is asked to count vowels in each of a series of presented attributes of their response that might help them to under- words is likely to exhibit far poorer recall of these words than stand what was wrong with the response and what measures if he or she is asked to make a judgment about the meaning might be taken to improve it (Proctor & Dutta. word. from feedback about performance. word” or “I think you responded too quickly and ended up multi-component distributed representation of the word just repeating your answer to the last question. This strategy uli to which a subject is exposed during therapy are those will have the potential for directly enhancing future perfor- that we might classify as feedback. If . For example. Among the many stim. hence. contribute to retention. we have presented evidence that response and. thereby. and palpation by subjects of their number of connections that are susceptible to alteration with own lips and larynx. whether in internally gen- Nicholson. representations–articulatory motor representations pathway ments have been cogent. we will discuss some specific therapies for Lexical-semantic knowledge (Fig. erated language or in naming to confrontation. Winstein. resentations suggests two potential treatment strategies. “naming ther- will provide opportunities to introduce some new ideas apies” also typically involve a component of semantic or phonologic treat- about therapeutic approaches. Impairment of lexical access (manifested as tive (Knock.qxd 01/21/08 03:02 PM Page 718 Aptara(PPG Quark) 718 Section IV ■ Traditional Approaches to Language Intervention feedback is too complex or is presented inadequately. specifically encourage one to view naming impairments as stemming exclusively from deficits in semantics or deficits in phonologic standing by providing some concrete clinical examples. is by far the 1998. . Hodgson. and presenting pathway). therapy (re-teaching of the names of things). and no improvement in naming with phonemic cues). develop linking concept representations to the acoustic-articulatory strategies. which we view as a disor- inhibit the subject from developing an understanding of the der stemming from damage to neural networks lying pattern of response that is leading to error (Goodman & between articulatory motor representations (Fig. we have ing distributed concept representations with phonologic rep- introduced evidence that the temporal spacing of therapy. it may inhibit self-evaluation. stimulus proper. fronted the problem of anomia head-on.. 26–1) defines three domains of knowl- tion by the subject. 2000. suggests that two additional approaches nents of this model. it may example. within a target range may be more conducive to strategy for- mation and constructive responses (Schmidt & Wrisberg. (2) semantic (latent in concept representations). We hope that this discussion will help to consolidate that of Patterson and Shewell (1987. have already provided support for the In fact. then it might be improved by redeveloping the knowl- and the mechanisms that might mediate it. see Raymer and Gonzalez Rothi. because these have strong implications may be of value in selected subjects. some of the ideas we have already introduced and aid under. Patterson. Feedback that guides the subject to responses projection targets of motor cortex. reduced auditory verbal short-term memory. Winstein & most common and debilitating component of aphasia. through naming lexical-semantics. Robin. We have association cortices supporting distributed concept represen- drawn particular attention to the principle of generalization tations.11 Our core model ered the types of knowledge implicit in the various compo. (poor repetition. semantic ization will be absolutely essential if we are to succeed in the therapy. pathway 1-2). traditional naming therapy approach might logically be ties. which re-teaching the names of objects features prominently (see Fillingham. Thus. Fading the amount of feedback about edge: (1) sequence (latent in the acoustic-articulatory motor performance over time. As we will show below. ment studies will be major contributors to this testing. 26–1. it may to therapies within the scope of the model. the presence of two pathways link- the daily communicative lives of subjects. The structure and context of therapy sessions. however. Schmidt. 26–1. Swinnen. and patterns in attributes of performance may put needed pres. Orchard-Lisle. anomia and word finding difficulty). At this point.e. improving lexical-semantic function. Ranklin. Merians. We will not. 1990. Our core model (Fig. edge underlying these concept representations (i. pathways 1-2 and 4-3) has not aphasia that receive theoretic justification from the model heretofore been commonly recognized as a separate domain of knowledge. discuss apraxia of speech. motor pathway). tests of learning will 11 be important to testing the hypotheses implicit in the We use the term “naming therapy” to designate therapeutic approaches in model. Chapter 23). If feedback is too immediate or frequent. Phonologic and Lexical-Semantic Impairment 2004). In this section. 26–1). Weeks & Kordus. directed to subjects in whom the target is the direct concept term retention of therapeutic gain. Our discussion will be limited ment (Howard. It word form rather than the “arrow” that connects them. We have carefully consid. and. polymodal. Traditional approaches have con- of language processes that subsumes phonology. (Fig. This target would be most logical in is new theoretic territory and that vast work remains ahead subjects with essentially no evidence of phonologic function to test these theories. and strategy forma. for overwhelm the subject. & Morton. no phonemic paraphasias in spontaneous language or repeti- Learning processes are implicit in the model (a by-product tion. Treatment of impairment in lexical-semantic access must directly or indirectly retrain lexical-semantic knowledge—that is. cognitive neuropsychological models of language function. semantics. in some cases. but we concede that much of this (Fig. Sage. of the PDP principle that memory and processing involve the same neural network). for a relatively recent inventory). 2003. 26–1) and Wood. because general. Finally. delaying feedback. self-judgment. & Shapiro. If naming is failing for the types of therapy we might pursue in subjects with because of damage to unimodal. 1985). and supramodal aphasia and for the success we might expect. therefore. pathways 1-2 and 4-3). (3) lexical-semantic (latent in the pattern associator networks sure on the subject to make the necessary changes. the knowledge latent in the pathways between concept rep- SPECIFIC REHABILITATIVE STRATEGIES resentations and articulatory motor representations (Fig. and see whether those strategies have been effec. and type of feedback could profoundly influence long. 2004). and grammar. 1990). Ballard. & Sullivan. If feedback is too focused. we have developed a conceptual PDP model 26–1. see below). Schmidt. & Lambon Ralph. such as model. 1999. If naming is failing because of impaired ultimate goal of therapy for aphasia—namely. We hope that our argu. & Schmidt. aphasia treat.GRBQ344-C26[689-734] . Once a target frontation naming therapy with naming to definition ther- vocabulary starts to emerge. The use of phonologic sequence therapy in the treatment of access to articulatory motor representations during inter. it might depend. Typically. we see the ficient time to overcome the inefficiencies of naming thera. In fact. to train names in the context of sentences. then if you are later shown this phasias in naming or repetition (especially nonword repeti. the symbol is a framezoid. if you are told that might improve naming. thereby not require a therapist would then need to be developed. Severe damage to the direct route and partial damage to the indirect route presumably provide the basis for optic aphasia. The relative preservation of the direct route presumably pro- critical limitation is lack of potential for intrinsic generaliza. provide support for this two-pathway con- articulatory motor pathway. lexical-semantic deficits (specifically. which a subject must employ in vocabulary would need to be determined. indefinitely) to enable mainte- nance and expansion of the vocabulary over time. This is not necessar. 1993). in internally generated language) is predicated on the exis- tion have been treated as if they were supported by identi. This assumption provided the basis motor representations (Fig. on the individualized. Consequently. embedded in the acoustic-articulatory motor pattern associ- alize to internally generated language. They typically exhibit inexpensive techniques will have to be developed to extend impaired lexical access during internally generated lan- training to encompass useful working vocabularies and to guage. Just how many words comprise a useful working concept representations. symbol . tence of the indirect pathway from concepts to articulatory cal neural structures. presumably because of associated damage to the carry out that training with sufficient intensity and over suf. however. if subjects have some for directly associating an object representation in visual evidence of phonologic function. An might occur is unknown. reflecting a double sequence knowledge and partial integrity of the acoustic. perhaps. 1998). Thus. pathway 4-3). and then an articulatory motor representa. In the best known (the hemisphere)—that is. phonologic sequence knowledge and some connections tion is formed. In this discussion. association cortex with an articulatory motor representa- ence of an indirect concept representations–acoustic/articu. the object is seen. So long as some remnants of this pathway are left after ily so. The presence of phonemic para. the route invoking process. On the other hand. albeit impaired. and it might provide a useful comple. ator. tions and the acoustic-articulatory motor pattern associators . risk latent in naming therapy: It might train the direct route pies—in essence. For example. a training algorithm that does apy. building an extrinsic generalization without impacting the semantic route. ongoing dynamic vocabulary list develop. The report Phonologic Sequence Therapy of Basso (2003) is paradigmatic (but see also Hillis. impaired lexical access nally generated language and during naming to confronta. be engaged.GRBQ344-C26[689-734] . such as phonologic therapy (see below). practical and relatively name them with relative facility.qxd 01/21/08 03:02 PM Page 719 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 719 such as repetition conduction aphasia and some cases of The second pathway (the “direct route”) provides the basis deep dysphasia. frontation naming hypothesis. the pres. To the extent ment project involving both subject and caregivers may be the that it does occur. The extent to which this culture-specific vocabularies would need to be developed. and internally generated language. Two clinical syndromes. would be the only at but cannot name it. tion. tion—that is. Severe damage to the semantic route with impairment. it might be necessary to complement con- best way to define such personal vocabularies. 16–1. or to provide sufficient semantic therapy to puters. many months (and. a pathway for the implicit conclusion that if subjects are adequately that takes advantage of the phonologic sequence knowledge trained in naming to confrontation. increasing the probability that concept representations will almost certainly involving caregivers and possibly using com. the complete absence of any meaning beyond the visual ing would constitute evidence of some residual phonologic configuration. Age-. vides the basis for nonoptic aphasia (Shuren & Heilman. access during internally generated language (Bauer & ment to other techniques for treating lexical-semantic Demery. however. without recourse to an intervening concept or latory motor pathway suggests that phonologic therapy any associated meaning. degree of semantic impairment that is present. in our conceptualization. you will be able to provide the correct name despite tion) or evidence of improved naming with phonemic cue. because there is little resemblance between word mean. dissociation. subjects with this disor- Naming Therapy der exhibit some knowledge of the object they are looking Naming therapy. this capacity will gener. This algorithm would then need to be executed over assure that the subject adopts a semantic set (see below). neural basis for concept representations. so long as there remain some existing “semantic route”). gender-. a concept representa. A word of caution is in order. they can name the object lexical-semantic therapy available to us in subjects with no given a definition and have relatively preserved lexical phonologic function. between neural networks supporting concept representa- tion is elicited in one of the ways described in the foregoing. there appear to be two pathways by a stroke (either in the damaged hemisphere or in the normal which we name to confrontation. 2003). Subjects with this disorder may have difficulty ing and word sound (except for onomatopoeic words and describing attributes or functions of objects they see but can derivational forms). in part. to.g. articulatory. 1999). 60 months) with anomic aphasia (Kertesz. however. we would not be able to speak about them or time poststroke. If our knowledge of phonemes were confined to their acoustic and articu- Ten right-handed subjects (mean age. Our knowledge of this symbol will tation in pathway 7-3. If this principle of language development distributed representation of individual phonemes. insertion of the acoustic be possible to improve word retrieval by enhancing phono. the ability to engage phonologic sequence knowledge by tion impairments (Forde & Humphreys. when a subject hears a word. this simultaneously considerations support this broadening. but one cannot The ultimate goal of the treatment was to enable naming hope to develop knowledge of sequences without neural via the indirect concepts–articulatory pathway (Fig. and so on. representations were presumably generated in all domains ing treatment. form of /b/ into the acoustic domain (by saying /b/ to the logic sequence knowledge.. subject) would instantly lead to the generation of distrib- Support for this hypothesis comes from studies of uted representations of the articulatory form of /b/. 26–1 (not pathway 4). They first learn many cept of /b/. domain-specific distributed phoneme representations cepts (meaning). they learn to assemble these various sequences into contribute to the process). pathway 7-3). 26–8 illustrates a guage (Gathercole. pathway 4. 52 years. at the end of with aphasia with a repertoire of phonologic sequences that they can then learn.GRBQ344-C26[689-734] . just as appears to occur during normal language phoneme and can respond to queries about what letters it corresponds development in children. because it is the only that training some phonologic sequences will generalize to pattern associator in the phonologic network that is other phonologic sequences (e. is and the substrate for phonologic sequence knowledge and to uniquely equipped for accumulating knowledge of the reg- steadily rebuild their working vocabularies.. and (2) training of pathway 7-3 provides adults acoustic. Eventually.qxd 01/21/08 03:02 PM Page 720 Aptara(PPG Quark) 720 Section IV ■ Traditional Approaches to Language Intervention supporting phonologic sequence knowledge—then it may completely successful training. building up phonologic sequence knowledge in the logic sequence therapy for impaired lexical access (Kendall acoustic-articulatory pattern associator networks on the et al.12 For example. through shared distinctive exposed to sequential input paired with sequential output. input. If treatment We assume two mechanisms by which training of only were completely successful. insertion of any form of a pathway 7-3. feature and motor programming sequences). we will readily be able to meaning of the word and a phonologic sequence represen- name this symbol if we see it again. all the individual combinations and to associate these combinations with con. if told generates a concept representation corresponding to the that a novel abstract symbol  is a framezoid. and orthographic). The operational goal of the treatment was two sides of the brain. without explicit training of pathway 4. the acoustic-articulatory pattern asso- nections between the substrate for concept representations ciator network (Fig. outside of therapy. to combine and link to concept representations through further development of 12 The validity of this statement requires considerable broadening of the pathway 4. 26–1. This Hebbian type of abbreviated semantic representation could be viewed as an extreme manifestation of the heterogeneity of semantic knowledge dis- learning would provide the basis for continued growth in tribution that underlies the phenomenon of category-specific recogni. This ing the connections in pathway 4 to occur. instantiation of individual phonemes. Second. The first phase of pathway 4-3). it second phase of treatment consisted of training in the reg- suggests two possibilities: (1) that effective retraining in ularities of English phonologic sequences. subjects with aphasia should be able to con. It also is possible ularities of phonologic sequences. sponding to the letter “b” (Fig. enabling both word comprehension and would be linked through the network into a multi-domain word production. For example. is enhanced by therapy. Further development of pathway 4 can occur traditional notion of concept representations (semantic knowledge). and an orthographic representation corre- of the various phonologic sequence regularities of their lan. Gathercole & Martin. 1995. in press). The simultaneous engagement of consist entirely of the memory of the visual image of the symbol that is these two representations enables Hebbian learning involv- stored in hippocampal and visual association cortex connectivity. 1982) received a total of 96 hours of therapy (2 hours/day. Sub. mechanism by which orthographic representations might sequently. Only the knowledge in pathway 7-3 of Figure treatment therefore consisted of developing linked distrib. . mean latory representations. to develop phoneme sequence knowledge. Thus. First. One network. whether a heard sound corresponds to that phoneme. might phoneme into any given domain of the network would enhance naming by the indirect pathway: (1) Training of instantly generate distributed representations of all corre. if we have distributed concept representations to produce spoken phonological awareness. we clearly have knowledge of any given words. the second phase of treatment primarily involved We have recently completed a phase I study of phono. 26–1. make decisions involving them. Two because. a con- language acquisition in young children. uted representations of individual phonemes. and (2) that once given an or three-syllable nonwords into the network. The also applies to language redevelopment after brain injury. meaning can be instanti- ated by very abbreviated knowledge of an object. 1996). Distributed adequate repertoire of phonologic sequence knowledge dur. and pathways of the network by this phonologic sequence tinue after therapy to enhance existing but inadequate con. pathway 7-3 enables better use of residual knowledge in sponding forms in all domains (conceptual. first by inserting phonologic sequence knowledge may generalize to all words single syllables into the network and later by inserting two- containing the trained sequences. however. et al. 1998). and LAC). it must be refined and knowledge lost in the disconnection. The left hemisphere perisyl- Furthermore. Connectionist model of phonologic pro- cessing. for detection and quantitation of semantic impair- significant gains on the Boston Naming Test and the ment). To the extent that the made considerably more efficient. (From Kendall. Heilman. the increase in Boston Naming Test and vian lesions that commonly are responsible for aphasia and Controlled Oral Word Association Test scores between its associated anomia frequently do not involve much of the completion of therapy and 3 months later suggests that con. An elaboration of the model that Hidden units Hidden units includes networks supporting reading.. 1 week after completion of therapy and 2000. In a PDP conceptualization. Subjects also demonstrated sig. association cortices that provide the basis for semantic rep- tinued acquisition of lexical-semantic knowledge (Fig.. distinguish concepts from each other (see Raymer & Rothi. Action Naming Test. J. to the extent that it CTOPP-APA. L. Gonzalez Rothi. D. and better measures of daily communication Lindamood Phoneme Sequencing Program (Lindamood & need to be employed. (Fig. the Object. lexical-semantic therapy is the best strategy to retrain the tive. evi. Conway. items are relatively disengaged. anomia.GRBQ344-C26[689-734] . One week after completion of therapy. Phoneme-based rehabilitation of anomia in aphasia. (in press). If this therapy is to be viable. reflects insufficient significant 3 months later. depicted in gray.e. however. semantic therapy might aid anomia in all . predictors of response subject has the potential for engaging right hemisphere and predictors of extrinsic generalization need to be better mechanisms. The group results are summarized in Tables 26–3 and 26–4. engagement of representations of the critical features that nificant gains on the primary outcome measure... such that these distinguishing features are more reliably pletion of therapy. and vice versa. resentations. damage Brodmann’s area pathway 4-3) occurred after conclusion of therapy (i. Lindamood. The core model (from Figure 26–1) is depicted in black... K. Rosenbek. The results suggest cortices supporting semantic representations and the domi- that a phonologic sequence therapy can be used to treat nant perisylvian language cortex (producing anomia as a dis- lexical-semantic deficits and provide support for the model connection syndrome). but they are not remotely defini. One might naturally conclude that a that motivated the study. J. Klenberg. Semantic Impairment they demonstrated significant gains on the outcome mea- sures most directly related to the treatment (CTOPP-PA. Because the treatment involved no train. 37 and surrounding regions in the posterior temporal cortex dence of extrinsic generalization). L..) representations representations Orthographic representations 4 days/week. Articulatory Acoustic motor Brain and Language with permission. 26–1. these results suggest generalization. engaged at the same time that features shared with other ing of words. C. M. suggests a means by which letter and ortho- graphic sequence knowledge introduced during the Hidden units phonologic rehabilitation process might contribute to the development of phonologic awareness (conceptu- alization of discrete phonemes) and to phonologic sequence knowledge. K.qxd 01/21/08 03:02 PM Page 721 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 721 Concept Hidden units representation Figure 26–8. the gain on the LAC remained results from semantic impairment. T. They may. which appear to provide the interface between This was a phase I investigation. 26–5). The goal of therapy is to alter network connectivity Controlled Oral Word Association Test 3 months after com. W. for 12 weeks) using a modified version of the understood. 12 4.88 10/10 0.60 0. BNT  Boston Naming Test.. COWA  Controlled Word Association Test.6 7. W. L.38 7.70 8. C.50 8. et al. T. (in press).88 8.qxd 01/21/08 03:02 PM Page 722 Aptara(PPG Quark) 722 Section IV ■ Traditional Approaches to Language Intervention TABLE 26–3 Acquisition and Retention Data from Before and After Phonologic Sequence Therapy Immediately Post-Treatment Termination – Pre-Treatment (Acquisition) n Mean Difference SD p* WAB 10 5. SD  standard deviation. J. Conway.. J.633 BNT 8 9.85 0.95 5/6 After 3 months 1.73 5/8 1. Gonzalez Rothi.011 CTOPP-PA 7 5.006 O-ANT 7 5. K.008 LAC 10 16 18..35 0.71 7. D. APA  alternate phonologic awareness/nonwords. L. Rosenbek.) TABLE 26–4 Repeated Probe Results: Primary and Secondary Outcome Measures* Secondary Outcome: Secondary Discourse Primary Outcome: Production: Secondary Secondary Outcome: Discourse Content Outcome: Outcome: Confrontation Production: Information Phonologic Nonword Naming Word Count Units Production Repetition Effect Visual Effect Visual Effect Visual Effect Visual Effect Visual Size Inspection Size Inspection Size Inspection Size Inspection Size Inspection After 1 week 1. Phoneme-based rehabilitation of anomia in aphasia. K.039 CTOPP-APA 8 9.138 Mean Diff  mean difference..70 3.22 0.18 0. (From Kendall.. T..021 O-ANT 10 7..25 0.62 11.63 9/10 1..) . J. CTOPP  Comprehensive Test of Phonologic Processes. L. W. * Uncorrected for multiple comparisons.026 COWA 10 0. LAC  Lindamood Auditory Conceptualization. M. Conway. Brain and Language with permission. et al.41 4/6 5..27 0.017 Post 3-Months – Pre-Treatment (Retention) n Mean Diff SD p WAB 8 2.2 0. K. O-ANT  Object-Action Naming Test. C. Klenberg.8 0.233 CTOPP-APA 7 8. Gonzalez Rothi. Heilman.43 10. WAB  Western Aphasia Battery.53 7/8 1. Phoneme-based rehabilitation of anomia in aphasia. (From Kendall.. Rosenbek. Klenberg.017 COWA 8 5.83 0.80 0.49 5/8 1. Heilman.. L.12 5/6 * Average effect size and number of subjects with efficacy as judged by visual inspection of graphs.GRBQ344-C26[689-734] .60 4.001 BNT 10 3. M. D.71 4/8 6. K.90 3.40 1/6 1. Brain and Language with permission. (in press).26 LAC 8 10.74 0.394 CTOPP-PA 8 7. PA  phono- logic awareness/real words.. J.77 0.7 0.71 8. Systematic training in the semantic features of objects. and mother) or three patients for each verb (e. therapy directed to more purely semantic deficits might be Some details about the therapy will help to illustrate. Individualization of vocabulary develop.g. and three semantically cor- for the targeting of semantic therapy at particular represen. very broad range of possibilities for both agent and patient. three containing an inappropriate agent. The alization..g. training on a spectrum of unusual exemplars of a questions. Word-picture matching tasks using semantically related ration) have developed an innovative and fundamentally foils. may achieve impressive results. pairs (e. acceptable agents or patients for the verb being presented.g. Nadeau and Kiran (in prepa- 1. This is because cally cued through provision of appropriate targets mixed in unusual exemplars convey information about both the core with foils. The design of the therapy sug- because their principle aim is to enlarge knowledge of the gests that these results were achieved through intrinsic gener- semantic attributes of single items. author/story). They suggest that a thereby. They then had to create suitable agent/patient category can be more effective than training on typical exem. semantic therapy might have very broad applicability to Knowledge of particular semantic domains (e. 1996). rect but with agent and patient reversed). because In the first phase of therapy. why questions about particular agent/patient pairs (an gory exemplars from each other. 2003. 3. story. these results are very promising. training. Results of therapy on ment. Counter. 1996).GRBQ344-C26[689-734] . the therapy vastly expands the semantic information that distinguishes the erroneous spectrum of semantic features that are incorporated in the response from the correct response. articles. and tasked ties in the knowledge implicit in the network) will benefit with producing three agents for each verb (e. way. “write”).g. It takes advantage of the fact that many verbs admit a pictured objects. especially through A variety of approaches to semantic therapy have been presentation of atypical exemplars (see above) (Kiran & employed with some success (Raymer & Rothi. Variously cued matching of semantic associates as the cations of the distributed concept representations of agent number and relatedness of semantic foils is increased. In the third phase of treatment. and therapeutic techniques appears to be very modest unless the impact on measures of language function in daily life estab- scope of intrinsic generalization can be expanded (and. which help to distinguish it response (e. and that are crucial in distinguishing all the different within-cate. lished. Correction of naming errors by provision of additional agent and patient. Subjects also were asked to produce one personal regularities defining the category. one at a time. might usefully be fleshed out in this way. The therapy also provides subjects with the oppor- 6. A fourth phase tational domains (e. The correct. subjects were read information. broader approach.. representations with a substantial replicated phase 1 but without cueing.. so the task of therapy is to refine network 12 sentences containing the target verb (three semantically knowledge rather than to reestablish it (Plaut. 1996). author. Edmonds. jour- naming of untrained items to the extent that they share some nalist. and the greater range of regularities apy. expected to intrinsically generalize substantially. husband/songs). 1996). subjects were semanti- plars in inducing generalization (Plaut. but of course. subjects were presented with refining featural relationships of trained items (the regulari. and patient as well as engagement of atypical exemplars of 5. Thompson. In the second phase of ther- from other categories. three con- distributed nature of semantics may provide some rationale taining an inappropriate patient. the subject’s own life. of these featural relationships (Plaut. animals) the treatment of aphasia associated with significant anomia. In this way. subject. tunity to draw exemplars from daily life so long as they are Unlike naming therapy directed at lexical-semantic deficits. but semantic knowledge that These have included: spans the breadth of daily life is difficult to achieve with this approach.g. impact a significant portion of the semantic domain therapy engineered to develop semantic representations in a used in daily life) or mechanisms for promoting extrinsic particularly broad way. where. predictors of response identified. Plaut. Broad intrinsic generaliza.. Recently. in which therapy focuses on verb argu- 2.. Although clearly this therapy needs to be tested The potential for generalization using current semantic in larger populations. Recent clinical work has approach that might particularly invite responses related to confirmed this concept (Kiran & Thompson. 10 individual verbs (e. tion is difficult to achieve for most semantic therapies. also would be needed. and to-do list) while being cued with who or what intuitively. Table 26–5. thereby providing an opportunity for highly diverse modifi- 4.qxd 01/21/08 03:02 PM Page 723 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 723 affected subjects by training up inadequately trained right extent to which this leads to incorporation of semantic fea- brain cortices supporting semantic representations.g.g. thereby facilitating generalization to Even a damaged network still contains a great deal of daily life).. In this tures shared with other entities is largely a matter of chance. Semantic sorting of objects. Answering yes/no questions about semantic features of ments. If necessary. Four subjects received visual component in subjects with selective deficits in nam. 2003). 2000).. as in therapy for lexical-semantic impairment (see measures reflecting intrinsic generalization are presented in above). one cannot rule out contributions . explicitly connect the content of therapy to their daily lives. 2 hours of therapy per week for 4 to 6 weeks in a single- ing living things). one item at a time. subjects were tasked with answering when. and in a way that allows subjects to generalization can be developed. multiple-baseline design. Concept manipulation (modification of individual con- intrinsic generalization in the therapy we used. These multiple-noun concept representations. as reflected in the American meet the situation at hand).GRBQ344-C26[689-734] . Effect of verb network strengthening treatment (vnest) on sentence production in persons with aphasia.4 52. plans for action may be formulated deliberately as part of an . despite the relatively modest potential for 2.7 52.. rience with subjects with attention-deficit hyperactivity dis- • Capacity for simultaneous endogenous generation of order (ADHD) (Heilman.8 WAB = Western Aphasia Battery (Kertesz. how- semantic deficits. Connected speech from picture description test of the Western Aphasia Battery.1 2 TM 78. We ities underlying grammatical function that may be logical suggest two possible strategies. Assuming that therapy for grammatical ever. These essential neural processes are discussed in some haps be devoted to explicitly developing extrinsic general. detail in the following sections. It is possible that treatment of working modest handicap and. Quotient (Nadeau & Kendall.0 82. suggest that more attention should per. though very preliminary. cal morphology and phrase structure rules). S. 2000). Sequence knowledge. 1982). subjects appear to have a disorder involving the selection of • Capacity for maintenance of memory of the immediately plans for action. termed “reactive intention.7 81. (From Edmonds. and it likely is no accident that grammatical impair- For subjects who have good lexical-semantic function.” which is driven primarily by • Multi-word sequence knowledge (underlying grammati. provides relatively less memory impairment relevant to language will have to be motivation for language therapy compared with lexical- specific to particular language constructs. Nadeau. & Segal. with or without object. we have identified a number of facil- ity will enable improvement in grammatical function.. E.6 82. have not yet been well defined.7 58. the Boston Diagnostic Aphasia Examination (Goodglass & Kaplan.0 68.8 3 Conduction 73. on the basis of memory or reflex) in more or less automatic • Capacity for manipulation of multiple related. involving either • Capacity for arbitrary modification of single-noun con. TM = Transcortical motor. 2006). Working memory (engagement of one or more concept alluded to results of a trial of semantic therapy we performed representations and recall of immediately preceding lin- that suggested that subjects with evidence of intact frontal guistic history). and were relevant to the topic. and the Cinderella story. * Percentage of sentences that contained subject and verb.5 90. Alternatively.qxd 01/21/08 03:02 PM Page 724 Aptara(PPG Quark) 724 Section IV ■ Traditional Approaches to Language Intervention TABLE 26–5 Results of a Broad Semantic Therapy WAB BNT (%) Connected Speech* Aphasia Subject Type Pre-Treatment Post-Treatment Pre-Treatment Post-Treatment Pre-Treatment Post-Treatment 1 TM 76.0 50. ment is seen predominantly in subjects with major domi- impairment in grammatical function may represent only a nant frontal lesions. that generic improvement in working memory capac- impairment is desired. one pharmacologic and one targets of therapy: behavioral.7 91. These results. Weintraub. we 1.5 71.2 40. Plans for action may be formulated (often preceding discourse. a process that might be noun concept representations to fit the particular situation. therefore.4 86.8 81. with permission. The pharmacologic therapy. A. It may be. 1991). S.4 82. We suggest at least three: In our previous discussion of extrinsic generalization. Speech-Language-Hearing Association Functional Aphasia 3.) from extrinsic. BNT = Boston Naming Test (Kaplan. Goodglass.3 44. & Kiran. contextual. L.9 67.3 62.5 86. modified response to environmental stimuli. temporoparietal and brain-stem systems. Voeller.7 50. ization techniques on which subjects can be trained and monitored after completion of therapy. 1983). were the cepts and adaptation of temporal order and content only ones who exhibited extensive generalization as well as relationships of multiple concept representations to gain in daily communication. methylphenidate or D-amphetamine. (in preparation). & Nadeau. Working Memory Working memory is an intrinsic brain function that Grammatical Impairment appears to be particularly dependent on frontal lobe sys- tems. systems function. is motivated by expe- cept representations.8 4 Conduction 70. and mechanistic generalization The essential neural processes underlying these capacities mechanisms. lend themselves to adaptation production of what questions (both involve a verb that as training devices to enhance working memory capacity requires an agent and a theme) but not to production of (the main problem being to reduce task difficulty such that when or where questions (in which the verb does not take a subjects with aphasia can make some correct responses). What constitutes authors trained subjects with closed-head injury and subjects a useful repertoire of syntactic skills has not been defined.. Carlan. The effect on PASAT termed “intentional intention. theme but may take an adjunctive phrase. “He is sleep- Both tasks require the maintenance of two working memory ing in the bedroom” and “Where is he sleeping?”). to sustain the intentional intention that is necessary to memories akin to procedural memory) (see also Ullman. At first glance. one to support recall of a previous stimulus trained to produce when questions showed generalization to and one to support a computation (in direct analogy to the where questions. Subjects with syntactic impairment Peterson. and will require extensive practice. cleft object constructions) showed generalization The study of Stablum. tice may need to involve a variety of constructions. no less Our proposal for behavioral treatment of working mem- than phonologic therapy must involve a substantial portion ory deficits contributing to syntactic dysfunction also is of the repertoire of native phonemic sequences to be suc- predicated on the concept of something approaching a cessful. second.GRBQ344-C26[689-734] . which also involve verbs that take adjunc- working memory demands of language). whether the letters were the same or dif- ferent (verbal report). which was cussed above. Notably. We propose methylphenidate 2004). This working memory compartments can be trained but provides suggests that training on more complex variants may consti- no insight regarding how this might impact language. subjects with ADHD have a skill to other content domains. first. Treating these subjects with methylphenidate Concept manipulation may have declarative components appears to redress this imbalance. 2003). but not to who or what questions.e. relative imbalance between reactive and intentional plan formulation such that their behavior is dominated by reac. methylphenidate treatment one would expect much generalization from training on might have to be accompanied by behavioral treatment of serves in tennis to backhand skills. Thompson (2001) has shown explicitly that subjects generic working memory capacity for language and that can be trained on specific distributed concept manipulation training of this capacity in one domain will generalize to skills and show generalization to different applications of other domains. Mogentale... placed to the right or left significant difference. One articulating complex concepts that might be related in part would not necessarily expect generalization from one type of to working memory deficits. it may be necessary these subjects showed generalization to passive-voice sen- to couple working memory training with other behavioral tence production. of the center of a display screen. but we suspect that it pre- achieve more balanced plan formulation and. enabling these subjects to that render it domain specific. None of the testing of methylphenidate effects. the Brown-Peterson paradigm (Peterson & manipulation capacity. Thus. and to simpler variants of the same manipulation (e. tion (e. who have had anterior communicating artery aneurysm rup- much less the extended line of therapies that would be ture on a dual-task paradigm in which the stimuli consisted needed to train enough of these skills to make a clinically of two letters.g. the extensive prac- associated deficits (see below) to demonstrate efficacy. With the phonologic sequence knowledge. however. Subjects compartments. Umiltà. successfully complete tasks.” which is driven primarily by performance suggests generalization of the trained dual-task frontal systems. 1977).. The chief dependent measure was the To the extent that multi-word sequence knowledge is like reaction time cost of introducing the second task. this may not be so.g.g. subjects showed significant improve. the side of the stimulus (manual reaction time para- Word Sequence Knowledge digm) and. it is procedural in nature training on this task. In this view. sure to an almost infinite number of word sequences. As dis- parable improvement in PASAT performance. any more than have multi-component deficits. 1959) and the Paced Auditory Serial Addition Test trained to produce who questions showed generalization to (Gronwall.. however. most particu- dominantly represents a set of skills (i. Those tute a more efficient therapeutic approach. Two tests commonly used to probe working these skills but not a generic improvement in concept memory. Because these subjects likely concept manipulation to another. it might ment that was sustained over time (to the extent that they seem that this training process would require repeated expo- became indistinguishable from controls) together with com.qxd 01/21/08 03:02 PM Page 725 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 725 ongoing problem-solving strategy. subjects trained on more com- training in subjects who have syntactic dysfunction before plex variants of a particular distributed concept manipula- the benefit of working memory training becomes evident. As we cautioned in tive phrases. e. Concept Manipulation tive planning. nondeclarative larly. one above the other. a process that might be highly correlated with dual-task cost. most sive practice and that there should be good generalization of particularly those with simplification of syntax and difficulty skills across exemplars of particular manipulations. or PASAT. who Guerrini (2000) suggests that facility with operating two questions) but not vice versa (Thompson et al. This means that effective training will require exten- treatment of subjects with grammatical dysfunction. because the . Subjects had to indicate. Constraint-induced language therapy with the first letter of the names). for strategies that are precisely targeted at specific deficits. et al. 2004). 1992). Errorless tional bias in subjects with stroke to use the normal hand by learning techniques have since been tried in amnesic popu- engaging them in intensive functional task practice with the lations for a variety of tasks. Fink. typically while the normal hand is con. In the errorful condition. Up to rationale for treatments seeking errorless learning. including associating names impaired hand. Any of the therapies discussed also could learning disabilities provided some further support for the benefit from socially mediated generalization. thus placing considerable pressure on sub. means of engaging extrinsic generalization. subjects with severe anterograde amnesia). Their tion with others. hypothesis that these patients. Baddeley and Wilson interpreted this as supporting their guage (the constraint) and placing them in situations (e. which are relatively less sus. noun. & Howard. There is nothing about constraint-induced language therapy per se Constraint-Induced Language Therapy that precludes incorporation of a program that would Up to this point... concept (Jones & Eayrs. late them into approaches that substantially improve the com. a semantic therapy could be pursued in a con- are predicated on careful evaluation of the various compo. Squires. although the principles that motivate repetition priming municative lives of subjects. Its goal is nar.qxd 01/21/08 03:02 PM Page 726 Aptara(PPG Quark) 726 Section IV ■ Traditional Approaches to Language Intervention essential memories that are being acquired are between rowly construed as developing an intentional bias to use lan- word classes (e.g. explore their potential for elucidating the neural basis of lan. and adjective) rather than guage. Thompson. con- guage processes. Constraint-induced language therapy seeks to engage Subjects trained in the errorless condition showed better subjects in intensive language production by absolutely lim. see Fillingham et al.g. to one degree or another.. 1983. & Tidy. Raymer..g. Meinzer et al. we consider the neural mechanisms underlying generalization (Table 26–2). we have discussed language rehabilitation engage mechanisms of intrinsic generalization. later studies of human subjects with severe tion mechanisms. learning that might subserve intrinsic generalization. therapeutic sessions to maximize efficacy and efficiency. this point in our discussion of specific types of therapy. condition. textual repetition priming (Martin. The ceptible to the effects of discrete lesions. nents of the subject’s aphasia. learning routes around a does not seek to develop a corpus of language knowledge room defined in relationship to objects in the room. Herbert. Thus. applied it for the first time to subjects with acquired brain engage a particular type of mechanistic generalization— damage (i. results have since been replicated many times. 2003). In addition. Patterson. studies of pigeons. The achieve- ment of success with such therapies not only is clinically Therapy employing an errorless learning feature has important but also yields scientific information about the recently achieved some popularity as an approach to speech- neural basis of language processes (see. In the errorless is to develop intentional bias to use language. verb. and design of a specific treatment that Errorless Learning takes into account the underlying mechanisms. they had to make three guesses apy (Maher et al. Parkin. language therapy (for review. 1998). a route through an array of patterned stepping stones. identify predictors of response. Much further work also is in order to trans. Jacobs. Much work remains to refine these therapies. experimental paradigm was somewhat contrived: Subjects guage in lieu of other communicative techniques developed to were presented with the first two letters of a five-letter word. The efficacy reported in published trials has been between word exemplars. & Laine. and . & Morton. we The efficacy of errorless learning was first demonstrated in have focused primarily on intrinsic and extrinsic generaliza. in which the goal is to overcome inten. lenged (Hunkin. 1993) and its variant. Thompson. In 1994. ate challenge is how to design the process and content of tations and their modifications.. with their severe impairment partially scripted scenarios. compensate for aphasia. & Le Grand. Constraint-induced language ther. It is inspired by constraint-induced implicit memory hypothesis has been successfully chal- movement therapy. Osborne. Pulvermüller regarding the word before being told the correct answer. The namely.. and fully 2002. 2005.. This will require further study of treatment are quite different. iting their opportunities for communication to spoken lan. but the jects to speak at length.. applicable to different profiles of impairment. identification of the salient neural system deficits. To the extent that word class sufficient to encourage further research. with photos of unfamiliar people (with or without cueing strained in a mitt.e. Here. Hickin. develop variations tion priming (Best. and socially mediated generalization. improve Essentially the same therapy goes under the guise of repeti- efficacy. the size of the recruitment of caregivers into the process might provide a training task will be reduced. the development of an intentional bias to use lan. they were immediately told the correct answer. The most immedi- knowledge is incorporated in distributed concept represen. Boddey and Wilson any of the therapies discussed could. were relying substantially on tasks) that absolutely require verbally mediated collabora. 2001). They example. Purell. retention of word knowledge given the two-letter cues.GRBQ344-C26[689-734] . contextual gen- eralization. e. or problem-solving in explicit memory function. implicit memory function for performance of the task. 2003. straint-induced language therapy format. 2001) represents an approach in which the primary aim which they were instructed to write down. games. strain the domain of error. 1998). vanishing cues. as pus by the medial septal nuclei that signals the neurons in in patents with semantic impairment or apraxia of speech. Errorless learning might be beneficial in nam- quate basis for drawing conclusions about the mechanisms ing therapy (with the caveats noted in the foregoing) not so by which errorless learning might or might not provide ben. tions of the literature. These (yet unproven) hypotheses are simultaneous auditory presentation of the object name will broadly congruent with the conclusions drawn by Jones and not be of value. rather. an important distinction needs to be made. then simultaneous Errorless learning techniques facilitated cued learning of auditory presentation might actually be dysfunctional. Nevertheless. and no evident reason exists why permitting the patient the situation in patients with aphasia. Truly errorless learning is defined as learning in an environ- ment in which the goal is to completely prevent erroneous 13 The implicit memory hypothesis is important here. foxes. we can only offer some tentative The errorless learning literature does not provide an ade. For other therapies. This will occur responses with successive corrections by the therapist. it is posited that if subjects are reduced number of crude motor responses must be differen- asked to name an object and are left to their own devices and tiated into a larger number of more refined and specific arrive at the wrong answer. because auditory input will not elicit an Eayrs (1992) in their critique of errorless learning. too few studies have employed errorless techniques paradigm be beneficial or harmful? Because of the limita- to draw any conclusions (Fillingham et al. much because of its impact on Hebbian learning but.. tral tendency of those categories (e. in naming therapy. the evidence against the implicit memory hypothesis pletely unconstrained. If the subject has no phonologic when re-differentiation of procedural or semantic represen- function (e. as in treatment of lexical-semantic input delivered by the therapist elicits the correct articula. Thus. 2000). the various exemplars of strengthening of connections between that particular con. 2003). Hebbian learning dogs and particular individual dogs. nor about the deficit domains in which it might be effec. hyenas and dingoes).e. cues. as well as wolves. it does not provide information frustrating word searches and perseverative responses. only one answer is cor- knowledge to produce the correct response reliably). however. the therapeutic goal is extent two connected neurons are coactive. a example.GRBQ344-C26[689-734] . and reducing patient frustration. names of unfamiliar people. among other things. efit. tive. that to the speech apraxia and semantic deficits. then tations is needed. coy- (and the related synaptic process. Most important. which a wrong answer Feedback of some type is essential. improving subject focus in a way . because it might lead to production of incorrect patterns of cally important advantage or worse performance on these activity in the cortex supporting articulatory motor repre- other tasks. The same may be true for learning techniques have recently gained some popularity in phonologic therapy directed at disorders of phonemic treatment of aphasia. (multiple concept manipulations) to any particular commu- ered to the cortex by the nucleus basalis or to the hippocam. hypotheses.. deficits. but also that it may be less effective or deleterious tory motor representation. regarding the potential benefit of errorless learning for thereby vastly increasing the number of stimuli presented patients with intact memory function who already have par. long-term potentiation) is otes. For de-differentiated because of injury.. but it provided either no clini.13 Second. in naming therapy. a complex and incompletely understood process that there typically exist many different syntactic approaches requires. however. Guidelines. at least in part on the presumption that sequencing.g. In naming therapy tial knowledge of the correct answer (simply not enough directed at lexical-semantic deficits. from the general con- tion of that wrong answer. Thus.. and provided by Hunkin and colleagues (1998) is directly relevant to the key prompts (error reduction techniques) can be used to con- hypothesis that motivates errorless learning therapies. errorless to struggle might be beneficial. because it is possible responses. In patients with syntactic impairment. such as those for errorless learning obeys Hebbian principles (i. has repetition conduction aphasia).. question that the activity in which they are engaged is there may be value in allowing the patient to produce important (Kilgard & Merzenich. an opportunity exists for responses. production of phonemic paraphasias. Under what circumstances might an errorless learning niques. First. This is rect. because it can markedly speed therapy and cut through long. only if the behavior is rewarded. semantic categories must be re-differentiated from the cen- cept representation and the articulatory motor representa. A review of naming therapies for aphasia found sentations. nicative problem. the Hebbian posit that errorless learning may be of value when only one learning rationale will apply only to the extent that auditory response is correct. the strength of for the patient to re-differentiate functions that have become the synaptic connection between them will increase). a burst of acetylcholine deliv. With semantic deficits.qxd 01/21/08 03:02 PM Page 727 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 727 programming an electronic organizer (Evans et al. In the realm of syntax. we may tentatively would not be. no advantage for treatments employing error reduction tech. Errorful learning. need not be com- —even likely—that implicit memories can be established in the absence of reward. In apraxia of speech. Two immediate problems can be cept of “dogness” must be differentiated specific breeds of seen with this conceptualization.g. If repetition commonly is associated with approach to treatment of apraxia of speech or semantic or syntactic deficits. articulatory motor representation except via the concept In considering errorful learning techniques as an representation. g.. whole sentences are provided by the therapist in pursuit of semantic. Thompson. research. If potential for intrinsic generalization (e.. (long-term memory. both because of their intrinsic scientific interest and 4. those stimuli must be attended. and pro- cific predictions regarding approaches to be taken in lan- cessing (as transformation of input patterns into out- guage therapy. The success or failure of implementation of these therapeu- 3.GRBQ344-C26[689-734] .g. conceptualization of spoken language processes. Many of the ideas are new. attempting properties of stimuli. as we have discussed throughout this chapter. a profitable middle ground likely normal learning mechanisms and it behooves us to deter- exists between errorless learning and wild guessing. CONCLUSION • Further study of the impact of temporal distribution of In this review. all aspects of our model represent hypotheses only. A techniques. In short. • Further study of mechanisms of generalization per se. it is quite possible that the sub- • Further study of therapies predicated on mechanistic gen- ject will attend to the phonologic sequence (i. .. Finally. task paradigm that sustains subject interest. capacity and constraint-induced language therapy). put patterns).qxd 01/21/08 03:02 PM Page 728 Aptara(PPG Quark) 728 Section IV ■ Traditional Approaches to Language Intervention that will permit the subject to learn from the pattern of We also have devoted substantial space to the educational errors and prevent the subject from becoming overwhelmed psychology literature. Much of what we have discussed finds support in research sory stimuli. If this is true extending over decades (120 years in the case of the psychol- throughout the brain. organization of the brain. e. as connection strengths). because we have avidly sought to 2. redevelopment of working memory repetition) rather than to the syntactic structure. Nevertheless. alexia without agraphia because of of linguistic inquiry. mine ways of conducting language therapy that will maxi- Defining this middle ground and adapting it to individual mize retention of knowledge in forms that are most readily subjects may be a useful topic for speech-language therapy retrievable by subjects in daily life. and nature of feedback on long-term to be as specific as possible about the nature of the knowl. ogy of learning). PDP models are particularly appealing. work- As tentative as these hypotheses are.g. other aspects are somewhat more speculative (e. we have introduced a general neural network training... but it may be a problem at the sentence level. will require much study for validation. studies of neural network reorganization in the somatosensory cortex (Buonomano & Merzenich. They can apy is to impact the daily communicative lives of subjects. as opposed to strictly empir- syndromes. the target of the subject’s attention must be of research inquiry can be defined: adequately constrained. This should pose no major difficulty • Further study of neural network models of language func- at the single-word level (barring subject fatigue and given a tion. grammar). and syntactic). we have strived to show although disconnection from sources of knowledge how conceptualizing aphasic language and language therapy (loss of access) may play an important role in certain in relation to neural processes. errorless syntactic therapy. edge represented in the various domains and the neural • Further study of error reduction and errorless learning principles underlying modification of that knowledge. structure and context of treatment sessions. performing eralization (e. ization. Several specific paths ing paradigms. phonologic. because language therapy engages or frustrated. synapses (neural connections) that were destroyed. however. often referred to as “disconnection syn- ically defined processes.g.g. 1998) FUTURE TRENDS suggest that for change to occur in response to somatosen. Neural networks simultaneously support knowledge make these hypotheses neurally plausible (O’Reilly. contributes to the scientific richness dromes” (e. Deficits resulting from brain lesions stem predomi- tic strategies will serve to further test these underlying nantly from loss of knowledge represented in the hypotheses and will add specificity to their predictions (see. substantial body of evidence supports certain aspects of this conceptualization (particularly phonology). including the association cortices sup. 1998).e. The par- KEY POINTS ticular value of these hypotheses is that experiments testing them will challenge not just a conceptualization of language 1. retention. they make many spe- ing memory (as patterns of neural activity). In all of this. because because extensive generalization must occur if language ther- their structure emulates that of the brain. and • Further study of specific language therapies with high effort). 2001). lesions of the left occipital cortex and the splenium of We have given major emphasis to mechanisms of general- the corpus callosum). attention. and porting language function. Neural networks are the essential unit of brain func- function but also a conceptualization of the neural network tion.. it suggests that in errorless learn. phonologic sequence and (to a substantial extent) 16. Research on retraining of such grammatical capaci- word sequence knowledge. 7. be defined. function.e. Measures taken during therapy to achieve maximal 5. A number of generalization mechanisms can structure. 17. develop a natural intention to use language in the 9. are specific to type of sentence sions. alization. Training of working memory capacity per se might knowledge represent fact memories that depend on benefit a number of components of grammatical hippocampal function for their acquisition. specific but. possibly. adjectives. the “spacing effect”). mechanistic. impaired lexical access. and likely represent procedural knowledge acquired incre. cross-function. and socially mediated. rather. 1972). and grammatical skill ties as the ability to generate who. when. Generalization is the process by which the effects of set of skills in manipulating distributed concept rep- speech-language therapy extend to material or cir. indicate that a given amount of knowledge taught 18. for simultaneously supporting multiple distributed unlike “naming therapies. lexi. what. by engaging visual. Retention of knowledge acquired during speech-lan- to logically account for complex behavior in terms guage therapy can potentially be increased not only of brain microstructure. extent of representation of stimuli in cerebral cortical tic function can be defined in a PDP model support. therefore. lexical-semantic. be employed to induce subjects with aphasia to re- tual. Phonologic sequence therapy may provide a logical the brain that are modified in various ways. networks (e. resentations. support for the PDP conceptualization of syntax as a 8. . thereby maximizing the potential for gener- manipulating concept representations. and it has the potential Grammatical function is based on the brain capacity advantage of achieving effects that generalize widely. PDP models enable us 10. diverse modifications of distributed concept repre- tributed concept representations. the 14. Extensive studies conducted over the past 100 years various circumstances of daily life. often reci.g. Individual syntactic skills are not word cumstances not explicitly trained during therapy ses. ing phonologic sequence.” concept representations (as working memory). and the ditions at the time of acquisition and conditions at optimal degree of constraint likely will depend on the the time of retrieval or by the effects of sleep particular aphasic deficit being rehabilitated. Constraint-induced language therapy might usefully extrinsic. processes on the consolidation of declarative and and implicit rules emerge that represent regularities procedural memory. Processes underlying phonologic and lexical-seman. Although the idea that completely errorless learning over a greater period of time is more likely to be techniques are beneficial in aphasia therapy has neither retained (i. The manner and form in which feedback is provided 6. acquired knowledge sentations and highly atypical exemplars of agent and of word sequence regularities. lexical-semantic 15. Phonetics. have a natural ability to by greater spacing of sessions but also by increasing capture bottom-up/top-down processing effects. varying degrees of accounted for either by an interaction between con. brain damage. and predicative. Semantic knowledge and. constraint on allowable errors may be of value. and retention.qxd 01/21/08 03:02 PM Page 729 Aptara(PPG Quark) Chapter 26 ■ Language Rehabilitation from a Neural Perspective 729 learn naturally from experience. the tongue in normal subjects and phonologic. cept representations in association cortices throughout 13. The during therapy may have a major impact on learning picture that emerges is one of multiple distributed con.GRBQ344-C26[689-734] . including intrinsic. and acquired skill in patient. in the knowledge acquired. susceptible to modification (the depth of cal-semantic and semantic errors in subjects with processing effect of Craik and Lockhart. approach to many subjects with aphasia who have procally. tactile. where questions from declarative sentences provides mentally via hippocampally independent mechanisms. substrate mediated. auditory. 11. and gestural representations of the semantic knowledge in a way that accounts for nearly object) may benefit learning by maximizing the num- all the findings of psycholinguistic studies on slips of ber of neural connections that are engaged and. and prepositions.. Grammar can be conceptualized in PDP terms. contex. This effect can be a theoretic nor an empirical basis. Verbs might be usefully employed in semantic ther- ready capacity of PDP systems to accommodate an apy as an effective device to achieve maximally almost arbitrarily large number of modifications of dis. 12. as does the brain.. by verbs. aphasia. the commonalities between the conditions of therapy and have been remarkably successful at emulating and the normal living conditions of the subjects the behaviors of normal subjects and those with being treated. & Squire. neurally plausible account. By what mechanisms might phonemic paraphasic straint induced language therapy might be increased. mal constraint of error might be desirable in treatment guage production. naming therapy cannot? 8. The influence of of the PDP conceptualization introduced in this chap- length and frequency of training session on the rate of learning ter. Cortex. A. Aphasia and its therapy.. and consider how each accounts for of aphasia. Age and evolution of language area functions. A. aphasia reflects loss of access to knowledge rather than 16. 91. more versus less temporally distributed treatment of tial preservation of language knowledge after stroke aphasia. J. 22.. supporting distributed representations confer? What are Discuss the various reasons that training a subject to the implications of distributed semantic representations name objects may have little impact on that subject’s for the spectrum of category-specific naming errors? ability to name concepts (both those corresponding to 6. PNAS. What unique properties does a network capable of form is essential to effective verbal communication. A. Discuss the ways in which a representation can be distrib. M. Journal of Experimental Psychology: Learning. (1978). 475–483. Why is it likely that we use two pathways. M. Discuss potential advantages and disadvantages of provide an alternative account for the evidence of par. Capitani. Explain how a PDP model eliminates the need to posit condensed scheduling? the buffers and error correction devices frequently 18. Ergonomics. L. tions that occurs with stroke? How do PDP models 17.GRBQ344-C26[689-734] . and syntactic therapy generalize in ways that provide an alternate. 19. Are there alternate. How can this concept be procedural and declarative knowledge acquisition reconciled with the extensive loss of neural connec. medial temporal lobe: A simple network model. semantic not neurally plausible? Describe how PDP models can therapy. Why are phrase structure rules so infrequently violated lary over 8 years. neurally plausible accounts for to type. The ability to translate concepts into spoken word uted. E. & Longman. Why might phonological sequence therapy. 627–635. and Cognition. D. & Phelps. 7. Do language errors produced by subjects with aphasia aphasia therapy and their potential advantages and dis- support the concept of graceful degradation? advantages. Discuss the various mechanisms of generalization of efits of more temporally distributed treatment sessions treatment effects and what could be done to promote while retaining a relatively condensed schedule? What these mechanisms.. (1994). Discuss the potential roles of sequence knowledge in objects trained and those corresponding to objects that language function. . & Zanobio. 12. 7041–7045. R. D. Why is the traditional conceptualization of a lexicon 21. In what ways might improvement in working memory nantly whole-word pathway and a predominantly benefit grammatic function? phonologic pathway. Discuss the various factors that constrain article use in Basso. A study of adult stroke patients. M. Describe serial and parallel processing theories of lan. A. Discuss the relative advantages and disadvantages of loss of the knowledge itself. Laiacona. any of these features? Bahrick. Discuss ways in which feedback might be given during 4. Discuss the evidence for and against the concept that whose acquisition requires the hippocampus. (1987). have not been trained).qxd 01/21/08 03:02 PM Page 730 Aptara(PPG Quark) 730 Section IV ■ Traditional Approaches to Language Intervention ACTIVITIES FOR REFLECTION AND DISCUSSION 15. Discuss the problems with the theory that lexical semantic knowledge represents declarative knowledge 1. is likely to be an unavoidable consequence of more 3. Bracchi. 20. Memory consolidation and the uted concept representations. 11. Discuss the depth of learning concept of Craik and incorporated into information processing models of Lockart and how it might be relevant to aphasia therapy? language. a predomi. 23. E. Discuss the various features of Broca’s aphasia in terms Baddeley. Retention of Spanish vocabu- 13. H.. P. 344–349. 21. E. P. 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Philadelphia: Lippincott Williams and learning after unilateral brain damage.... 69. T. Relative frequency of Chatterjee. & Shapiro. S. W.. Agrammatic and non-brain damaged subjects’ verb and knowledge of results enhances motor skill learning. M. E. R.. An interactive activation model of lan. C. 224–230.. Interaction between amount and pattern of training in the Wambaugh. Wilkins. C. & Walker. 1045–1049. Neuropsychologia. Connelly. 58. Rehabilitation of executive deficits in closed head injury Vargha-Khadem. 40. L. Brain. J. Effects of treatment for sound errors in apraxia of speech tion in aplysia. Information feedback for skill acquisition— Warrington. M.qxd 01/21/08 03:02 PM Page 734 Aptara(PPG Quark) 734 Section IV ■ Traditional Approaches to Language Intervention Squire.. E. Thompson. The deficits in agrammatic aphasia: The complexity account of callosal syndromes. & Guerrini. D. Science. D. 46. 829–854. In A. C. 885–896. Kalinyak-Fliszar. Experimental Psychology Learning and Memory Cognition... Neuron... J.. (1914). 211–228. Crago. D. & Shallice. Lange. & Kordus. S. N. A. treatment efficacy (CATE). E. K. Ellis (Ed. Differential effects Psychological Research. T. Journal of Speech. & Doyle. 143–186). West. 37. E.. S. 231–270. D. induction of intermediate.. of early hippocampal pathology on episodic and semantic mem- Stemberger.. (2002). Shelton. of Rehabilitation Research and Development. agreement). verbs. 1995). Thompson et al. Lorch. Franklin.. individuals for improving grammatical morphology. sparing the entirety of the perisylvian lateral cortex. & Gallagher. structures.. Hanna. Berndt. Pearson. and in the latter.. Zingeser & Berndt. Christiansen. complementizers (if. Derived from with agrammatic aphasia have marked difficulty producing mutually supportive linguistic and language processing complex sentences in which noun phrases (NPs) have been theories. occupying lesions located in the frontal lobe or outside the frontal lobe. however. 1993. the site of lesion is scans from 20 cross-linguistic cases of agrammatism. WHAT IS AGRAMMATISM? 1 The lesion site associated with agrammatism can vary greatly. & Schwartz. ranging from small associated with the frontal opercular region. and efficacy data for two treatments for et al. the theme is designed for improving syntactic deficits and the other is missing from the object position. The generalization effects of these treatments Even when individuals with agrammatic aphasia produce to untrained structures and narrative discourse are empha. SVO in English).GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 735 Aptara(PPG Quark) Chapter 27 Treatment of Syntactic and Morphologic Deficits in Agrammatic Aphasia: Treatment of Underlying Forms Cynthia K. ning treatment with more complex rather than simple Christiansen. Goodglass. 1989. “metalinguistic” training procedure. 1998.. to middle-sized lesions affecting Brodmann’s areas 44 and 45 adjacent cortical and subcortical both cortical and subcortical structures to large lesions affecting the regions (Damasio. 2000. Individuals with agrammatism often use strings of OBJECTIVES (primarily) content words and have greater difficulty pro- ducing verbs as compared to nouns (Kohn. including finite cally related to those trained but not to linguistically unre- verb inflections (tense. both treatments promote generalization using a moved out of their canonical order (i. verb-object (e. agrammatism. 1991). Kim & Thompson. & Goodglass. Today. 1990). & Howard. Classically. it is well known entire perisylvian area and other structures in the distribution of the that agrammatic speech patterns can result from lesions middle cerebral artery. treatments for sentence production (and comprehension) Shoe uh fit) sequences are common. Saffran. and (2) generalization is enhanced by begin- whether.. Vanier Agrammatism is a symptom complex seen in the context of and Caplan (1990) reported lesions quantified by computed tomographic nonfluent (Broca’s) aphasia. 1989). One treatment is missing from subject position. 1989. subject-verb-object (SVO) constructions (Caplan & effects of treatment on brain activity. For This chapter discusses two recently developed and researched example. The arguments of the verb—that is. Cinderella where? should be guistic nature and complexity of structures trained based Where is Cinderella?) (Saffran et al.1 The disorder refers to a pattern of erroneous sentence produc- tion in which grammatical structure is diminished (or absent). Bird.g.g. controlling the lin- such as “wh-” questions (e. the structures in which they appear generally are sim- sized. on the underlying representation of target structures. 735 . Two principles of generalization underlie these treatments: Another key problem in agrammatism is production (1) generalization occurs to structures that are linguisti- of grammatical/functional morphology. fit her) and subject-verb (e. 1997. and other free-standing morphemes (Benedet. In the former.. 1998. 2004. the participant roles required by the verb— also may be missing or mis-ordered around the verb. Neuroimaging data also are presented that show the ple.g. the agent deficits in non-fluent. methods.. that). Notably. & The objectives of this chapter are to present the back.e. lated material. Thompson (both large and small) occupying these and other areas. agrammatic aphasia. Thompson ground. . . Marantz. however. He is telling the impairments are caused by faulty processing or access to rel- story of Cinderella: evant linguistic representations. . whether focused ments renders sentences ungrammatical (e. which effectively connects one part of the tree to another) and Several theories of agrammatism exist. scrubbing and uh . Caplan & Hildebrandt. Pullum. Tree structures are abstract Dress break . the Principles and Parameters (P & P) frameworks. for historical review. accommodates “wh-” words in sentences such as Who did Prince can’t uh uh stepmother fitting slipper? the hiker follow?. tense and agree- chased). pumpkin and uh . . CP). . CP.4 The sub- comprehending noncanonical sentences. Midnight uh clock uh Cinderella clock! ments project: the specifier position (Spec. see also de the INFL (the local head of IP). . . .e. No one theory. and argument structure are of the action). The morphology is projected from IP (Bobaljik & Thráinsson. comprehension. is comprised of two positions from which linguistic ele- Cinderella dance. beautiful and carriage where? ruption in agrammatism can be compared. functional control). . . Menn approaches described below are discussed. that. tational description of the syntactic tree. mother uh go . Grodzinsky. but no. both lexical and functional. .. but they provide a template for well-formed Mother Teresa . magic uh .. linguistic constructs phrase (Koopman & Sportiche. . 1992). CP is crucial for complex sentences And probably uh prince and Cinderella marrying and happy.e. 1989. 1991). subcategorization. Caramazza & Hillis. 1987). Some linguists suggest that all inflectional sentences or those with subject relative clauses (e. IP is the subject posi- Blesser. those in which two nouns are but they also have their counterparts in other linguistic theories. The artist was the lady at the party also occupies Spec. . These patients show particular difficulty tion as in The lady chased the bartender at the party.g. . but less difficulty is noted in comprehending active ment information. 2005. such as passive ject in passive sentences such as The bartender was chased by sentences and object relative clauses (e. in the English language. that often are impaired in agrammatism. This pattern of comprehension impairment is referred to as “asyntactic 2 comprehension.. although general descriptions of the dis. . and the head position (COMP). . X-bar theory. includes the complementizer phrase (CP). and whether in sentences Well locked. . Mitchum. . I can uh .3 Thus. The tree diagram shown in Figure 27–1. IP). 1976. uh uh magic godmother! sentences against which observed patterns of sentence dis- Dress . The INFL posi- chased by the thief or The man saw the artist who the thief tion contains finite verb inflections—that is. accommodates 3 COMP also is the landing site for auxiliary verb movement—for exam- deficits in both production and comprehension. the site for Cinderella where? complementizers such as if. not exactly . . . Spec.. . complement Agrammatic aphasia also is associated with deficits in clauses). Goodglass. In this section.. stepmother and now what dress? descriptions. Consider tional (linguistic) theory (within the framework of genera- the following selected utterances produced by a 41-year-old tive syntax. IP. and processing. tions and sentences with embeddings (e. part of Generalized Phrase Structure Grammar (GPSG) (Gazdar. & Sag. Scrubbing uh uh whatchacallit uh uh working. top-down. with embedded clauses such as I wonder whether the team will Sure enough fits because Cinderella uh . which pumpkin carriage gone. . 1995)..g. Noncontinuous dependencies of the sort that are targeted in syn- THEORETIC UNDERPINNINGS tactic treatment also are considered in GPSG (e. while others contend that IP is subdivided into pro- thief) (Berndt. Slipper fell on syntactic or morphologic deficits. 1986). 1995)2 and processing gentleman with nonfluent Broca’s aphasia illustrating many accounts of language. 2004. the subject is generated within the verb ing agrammatic speech. & Obler. and theories that are most relevant to the treatment Faroqi-Shah & Thompson.g. Treatment of underlying forms (TUF). . which also order suggest that comprehension remains relatively has two major branches: the SPEC position (Spec. hard worker. 1990). girl. better midnight . 1993. like “wh-” ques- That’s it. For equally probable candidates for the thematic role of agent example. hierarchy of nodes describing the relation among elements. . servants and horse and beau. and no one ple. Klein. We begin with a represen- Cinderella uh . . 1988. 1986. 1985) and Lexical Functional Grammar (LFG) (Bresnan. But. and patients often show particular difficulty with semantically the Minimalist Program (Chomsky. 1976. . 1996.GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 736 Aptara(PPG Quark) 736 Section IV ■ Traditional Approaches to Language Intervention 2002. play next week. that form clauses and sentences Stepmother really ugly. 4 According to current theory. both representational LFG (i. 1993. which provides a Step fa . 1995. reversible sentences (i. going from the tiful carriage and so magic.g. and moves to Spec. Either omission or substitution of these ele. which suggest that agrammatic of the characteristics of agrammatic speech.g. the category SLASH. The next level is the inflection phrase (IP). .. and spared (Goodglass.” It is important to note that agrammatic The theoretical constructs that we exploit are integral to Government- Binding Theory. see Chomsky 1986. which Slipper fall. & Haendiges. Druks & Carroll. thief chased the artist or The man saw the thief who chased the 1988). in yes/no questions such as Are you going to the opera tonight? theory completely accommodates all available data regard. is based on representa- should be The slipper is falling or The slipper fell ). For example *the fairy Godmother fixes. General linguistic tree structure. Consider the following sen- agrammatic speakers have selective deficits producing tences: verb inflections. and *The step. Jonkers & Bastiaanse. 2002. 2004. Everyday. arguments of the verb are not represented. or adverbs). Everyday. with the verb serving as the core of the sen.. see. This pattern has been tences. Kemmerer & Tranel. CP (C. 1998. the verb provides the type of arguments required by the verb influence produc- scaffolding of grammatical sentences. and VP (verb phrase).g.GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 737 Aptara(PPG Quark) Chapter 27 ■ Treatment of Syntactic and Morphologic Deficits in Agrammatic Aphasia 737 CP SPEC C’ Figure 27–1. VP ment) also takes this position. such as wonder.g.. jections for a tense phrase (TP). Thus. including argument structure and thematic roles. verbs. that. a tion. Going from the complementizers SPEC top down. The main verb projects from the head of VP. IP (inflection Position for phrase). Its specifier position (Spec. rendering their Research in agrammatism shows that the number and sentences ungrammatical. the editor AGENT wonders whether the writer tence. Italian. This means that only one participant role is NPs (theme arguments) or CPs (sentential complements). and features.. 1997). Agrammatic speakers have difficulty producing verbs finished the article SENTENTIAL COMPLEMENT/INTERROGATIVE as well as the arguments that go with them. 2000. Landing site for illustrating positions for various structures in the wh-words COMP English language. the VP accommodates sentence elements that are it assigns two thematic roles: agent and theme. without a verb. COMP) is the position for complementiz- INFL ers. verbs such as wonder are difficult for patients with Broca’s . 2000. Thompson et al. 2000. and sisters put Cinderella.. German. several types of verbs are defined by their agreement phrase (AgrP) (Pollock. 1989). assigns three-arguments (agent.e. the configuration of IP is relevant to 1. The verb put impaired in agrammatism as discussed below.or one-argument verbs. pro- word string does not qualify as a sentence. nouns. tory arguments often are omitted. obliga- These features also must be present in grammatical sen. movement from the VP). IP) is the NP-movement. 2. the dancer AGENT fixes her shoes THEME The next level in the tree is the verb phrase (VP). The next level Landing site for moved element in down is IP. Everyday. Other verbs. Everyday. CP) (e. Further. the specifier position of CP (Spec. complement 5 The status of IP (i. if whether). the parrot AGENT laughs treatment.e. In addition. are ungrammatical. The head of Auxiliary verbs t’ also occupy this site. NP/CP verb tense and agreement information. or believe. noted in English as well as in Dutch. and Importantly. IP by CP (complementizer phrase). whether. 4. The VP 3. The local head INFL contains verb inflection. care. Kiss 2000. negative phrase. Kim & Thompson. when these verbs are produced in sentence contexts. The auxiliary verb Position for the subject (after in subject-auxiliary inversion (i. the verb. and goal). split or unsplit) likely is language specific. Shown are local trees headed in Wh-movement. As argument structure becomes more complex. V Location of subject position. That is..5 Because many syntactic and semantic features. Finally. internal arguments of the verb—which can be either sitive) verb. is the landing site for “wh-” words. Fix is a two-argument verb as in sentence 2. theme. such as if. because all of the Hungarian agrammatic speakers (de Bleser & Kauschke. the artist AGENT puts fresh flowers THEME in is associated with basic lexical categories (e. the duction ability decreases: Three-argument verbs are more verb selects and assigns associated syntactic and semantic difficult to produce than two.. are complement Canonical Sentence Computation: The Role of the Verb verbs that assign sentential complements as in sentence 4 below: The canonical (usual) form of sentences in the English lan- guage is SVO. verb move. required: agent. verbs and other lexical material are generated Location of in VP. the studio GOAL adjectives. and in its sister position are verb complements— The verb laugh (sentence 1) is a one-argument (pure intran- that is. Luzzatti et al. the cat) to yield V’ and assigns the thematic role theme. movement are relevant to agrammatism: Wh-movement. Shapiro & Levine. 1993. and van Zonneveld (2005) found that speakers with Broca’s aphasic are better at producing unaccusative verbs like melt in transitive sentence frames (e. a lexical item (e. serves to amalgamate two cate. whereas resource-based accounts suggest a sentence. Of course. V  verb. 2004. (chase) (cat) Some theories of agrammatic production attribute sen. The sun melted the snow- man) than in intransitive frames (e. Thompson. the canonical form of sentences in the Theoretic accounts of phrase structure building suggest that English language is SVO.GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 738 Aptara(PPG Quark) 738 Section IV ■ Traditional Approaches to Language Intervention aphasia (Thompson et al. Merge. The fact that that agrammatism results from reduced short-term working individuals with Broca’s aphasia retain this ability after brain memory or limited processing capacity (Goodglass 1976.g. . Figure 27–2. The verb (chase) merges with a determiner phrase ing structure) (DP. 2004. are more difficult to produce than agentive V’ DP intransitive such as sleep and admire-type psychological (dog) verbs. 1991). because Using a cross-modal lexical decision task. (object cleft) is assigned to the direct object position.g. and despite appearing in different positions. Shapiro. Zack is 2003). Friedmann & when the verb is accessed during the temporal unfolding of Grodzinsky 1997).. Zurif. Katadin was climbed by Zack. e. 2003). The number of argu. and intransitive unac. 1995. Mt. see Lee & ment is involved in passives (sentence 7) and subject raising Thompson. Figure 27–2 demon- 7. 1993. so. & Killacky. and a series of Merge ever. What mountain did Zack climb? (object “wh-” question) theme). & Cermak. Wh-movement is involved in wh-ques- required to build phrase structural frames. a verb) is selected the agent (the person doing the climbing) and Mt Katadin from the lexicon and combines with other selected items to (or what) is the theme (the thing that was climbed) in all form a higher-order category. Simply put. than those with less complex argument structure. Two types of ments selected by the verb affects phrase structure opera. (passive) strates how this occurs in a sentence such as The dog chased 8. arguments in the lexical entry of the verb) are more difficult Shapiro. Lee & Thompson. Other theories point to representational those with more dense argument structure entries) are deficits. and theme 6. considering sentences: the two-argument verb chase and its thematic grid (agent. too. Bastiaanse verb phrase (VP). resentations when listening to sentences (see. 1995.. which do not (Bastiaanse & van Zonneveld. Hack. The snowman melted). a new surface form is derived. all sentences are derived from their underlying SVO operations builds the syntactic structure of sentences representation. ment structure (considering both the number and type of Gordon. such as Zack climbed Mt.. Zack seems to have climbed Mt. Both normal and agrammatic speakers sentence. Psycholinguistic and neurolinguistic research findings because the latter word order involves movement of the indicate that verb argument structure also influences sen- theme argument (snowman) to the subject position of the tence processing. 2005. DP  determiner phrase. So. the Argument Structure Complexity appear to access not only the verb but also its thematic rep- Hypothesis suggests that verbs with more complex argu. ple pattern (see sentences 5–8 below). Theoretically. Kolk & Heeschen. 2003). tions (sentence 5) and object clefts (sentence 6). Lanzoni. VP cusative verbs such as melt and amuse-type psychological DP V’ verbs. the more steps and NP-movement. see also Adger. tion. Marantz. how- gories to yield a higher-order category. (Thompson. (For further dis. assigning the By displacement—movement—of sentence constituents role of agent and forming a VP. In the Minimalist Program. tions: The greater the number of arguments. Katadin. It was Mt. 5. which involve complex syntactic and/or semantic computations. longer than for simple verbs. many sentences do not follow this sim- syntactic operation.) sentences (sentence 8). (subject rais- the cat. These findings suggest that cussed in detail below) (Friedmann 2002. dis. agent is assigned to the subject position.g. for example. a Katadin. damage is important in the treatment of agrammatism. the verb guides this process. Schematic representation of merge within the tence deficits to verbs and verb argument structure. 1990).g. Kolk 1987. Shapiro and col- the former entail greater phrase structure building demands leagues found that reaction times for complex verbs (i.e. are its thematic properties. such as the Tree Pruning Hypothesis (TPH.. Similarly. 1990. 1997). McNamara. The VP then merges with from their underlying position to a different location in the higher nodes in the syntactic tree. The V’ then merges with another DP (the dog). Katadin that Zack climbed... sentence. NP-move- cussion of phrase structure building operations. Noncanonical Sentence Computation Phrase Structure Building As noted above. a pure representation of lexical informa- (Chomsky. . corresponds to a locative adjunct prepositional 11a. as illustrated in sen. which involves movement from an argument (i. to be quite different. object clefts is that in the latter. Movement is from the direct object position to Spec. Indeed.. 9a.  was climbed Mt. underlying form of sentence 7 approximated in sentence 11a the direct object NP. in the garage. NP-movement involves displacement of an argument (i. as in Matt below: fixed the car [in the garage] -> Where did Matt fix the car? In this example. Katadini THEME was climbed [ti] by Zack AGENT . 11b. CP. Unlike Wh- face form (sentence 10b) of an object cleft construction: movement. Consider the underlying form (sentence 10a) and sur. as in sentences 7 and 8 above. NP-movement forms. in that both involve Wh-movement.GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 739 Aptara(PPG Quark) Chapter 27 ■ Treatment of Syntactic and Morphologic Deficits in Agrammatic Aphasia 739 CP TP DP C’ SPEC T’ (who) (it) C TP T VP (did) (was) DP T’ V’ (thief) T VP V DP Object cleft structure t DP V’ t (artist)( j) CP t V DP SPEC TP (who)(i)( j) (chase) t SPEC T’ (thief) (chased) VP Figure 27–3. theme) position to a non-argument position (Spec. on the face of it. as in ever. consider again the 7 The example above (sentence 9b) illustrates movement of an argument. object clefts renders them more complex than object “wh-” ture is called an object “wh-” question. theme) to another argument position (Spec. Katadin?). They are fundamentally similar. the derived struc. Tree diagram illustrating Wh-movement in “wh-” V’ questions. movement occurs in an embed- tences 9a and 9b below. leaving behind a copy or trace (t) in The crucial difference between object “wh-” questions and the direct object argument position. who) and the head noun of the main clause (the artist). Subject-auxiliary V DP verb inversion also is depicted. IP. “wh-” questions. Importantly. Mt. how. what is in the direct object position and is 10a.g. such as It was the artist who the thief chased.. Zack AGENT climbed Mt. CP. marked by subscripted j. Katadini THEME that Zack AGENT climbed [ti] derive the noncanonical surface form.7 Object cleft structures as in sentence 6 above also are NP-Movement formed by movement of the direct object (theme) to Spec. It was Mt. the 6 Subject “wh-” questions do not involve Wh-movement (e. questions. CP). The issue of structural complexity is addressed trates this movement from the direct object position to further below. To 10b. Katadin THEME assigned the thematic role of theme by the verb climb. where. Tree diagram illustrating Wh-movement in object above. sentence 9a is an approximation of ded clause. Consider sen. Who subject position of the sentence). movement occurs within an tence 9b. t t(i) Wh-Movement Consider the Wh-movement structures in sentences 5 and 6 Figure 27–4. such as Who did the thief chase? Movement is from t the direct object position to the Spec. This property of the object position to the subject position. CP. To illustrate the NP- climbed Mt. Because the object or theme argument moves from embedded clause. Spec. Zack AGENT climbed what THEME 9b.6 Figure 27–3 illus. Katadin THEME by the Zack AGENT phrase. quite different from Wh-movment forms. what is moved to the sentence initial position. these two sentences appear cleft structures.g. Whati THEME did Zack AGENT climb [ti] In sentence 9a.. Note that there is a co-referential relation between the underlying representation of sentence 9b: the moved element (e. a non-argument position. are CP.e.e. Wh-movement also can apply to adjuncts. the moved element. movement involved in passive sentences. as shown in Figure 27–4. theme. greater processing resources are DP T’ required as compared to when the ordering of constituents (the artist) T VP is canonical. (Friedmann & Grodzinsky. 1995. Some debate exists regarding whether agrammatic speakers retain the ability to do this.  seems Zack to have climbed Mt. 2000. Swinney. Note that the moved element lands in the subject posi. 1997. Hagiwara 1995). 1993). Prather. for example. Impairment may occur at any level of the tree. Others suggest that. Mt. movement is from the subject position of a sentential com. Some researchers have shown that they do not (Swinney & Zurif. 1995. 1993). Love. as in The artist was chased by the thief. suggests that the problem (the thief) lies in mapping semantic representations onto the syntax. On this account. T VP based on the observation that some agrammatic speakers V’ have little difficulty determining the grammaticality of sen- tences but still show comprehension problems (Linebarger. Fromkin. & Thompson. Katadin) in sentence 11a is moved. . & sentence production and comprehension. and their antecedents are “reactivated” at the trace site. it appears V’ that they “reaccess” the moved element in the vicinity of the trace—well after it has occurred in the sentence.GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 740 Aptara(PPG Quark) 740 Section IV ■ Traditional Approaches to Language Intervention TP or listening to sentences in which constituents are not in their canonical form. (i. the direct object NP. Prather. The linear order of constituents in a sentence affects both & Wong. Piñango. V’ PP (by the thief) they “hold on to” the moved constituent such that it can be V DP assigned its proper thematic role once the verb in the sen- (chased) tence is heard. the Trace Deletion Hypothesis and structions (see sentence 8 above). Katadin claims. Choy. Some theories of agrammatism suggest that the source of ment is left behind. Accordingly. When individuals without brain damage (was) process noncanonical sentences with movement. trace/copy—for example. as in sentences 12a and 12b (Fig. more at risk than those projecting from lower nodes tion (Spec. the matrix sentence. Prather. that comprehension of complex sen- 12b. Zurif. The Slow-Syntax Hypothesis 12a. 2007). traces (or copies) of movement and/or failure to establish co- This movement is illustrated in Figure 27–5. Dickey.. Note that the but others have found that these speakers show normal landing site for movement is the subject position. Zacki seems [ti] to have climbed Mt. online processing of complex. traces are present in the syntactic representation. its variants (e. & Love. the problem is related to processing deficiencies. When producing Brownell. as in The thief seems to have chased the artist.e. (Blumstein et al. 2003. TP)*. sives. & Cornell. That is. impairment would also impair CP structures. Tree diagram illustrating NP-movement in pas. 1998. as in sentence 11b.g. TP). an IP * IP is replaced by TP when the inflection phrase is split. Katadin tences results from delayed processing (Burkhardt. referential relations between moved constituents and the NP-movement also is involved in subject-raising con.. and a trace of this move. This latter theory is similar to (seems) the Argument Linking Hypothesis (Piñago. Piñango. 1986. Solomon. Another theory. In this type of sentence. suggests that functional cate- Figure 27–6. V TP Schwartz. DP T’ the Mapping Deficit Hypothesis. but it will nec- essarily result in deficits at all higher levels. 1997. Figure 27–5. as in passive constructions. The landing site of the moved NP is the asyntactic comprehension relates to an inability to form empty subject position (. Spec. 27–6): rather than a representational deficit. Tree diagram illustrating NP-movement in sub- gories projecting from higher nodes in the syntactic tree are ject raising structures. 1990) and the Double Dependency Hypothesis plement (subordinate clause) to the empty subject position of (Mauner. 2000). The TP problem is that this reactivation is delayed. The Tree Pruning Hypothesis (TPH). & Saffran. The Trace Based Account) (Grodzinsky. 2000). & Bushell.. Swinney. noncanonical sentences despite their inability to comprehend or produce them To derive the passive. 1983). Zurif. which t T’ suggests that the deficit relates to difficulty coordinating T VP semantic and syntactic linking. V’ Grammatical Morphology V DP (chase) (the artist) One representational theory of agrammatism. tences. subtest of the BDAE-3 (Goodglass et al. Friedmann & Grodzinsky (1997) describe a Hebrew patient with agrammatic aphasia who showed intact represen- Assessment of Agrammatic Deficits tation of lower nodes within IP (AgrP) but selective impair- ment in higher ones (TP). 2002). most are focused on improving syn- plementizers). 1988). 2002). Examination. Swobody-Moll. In this section. treatment may be deemed ineffective. 2002). which would be expected if a syntactic node or latter. In addition. and deficits in grammatical morphology. or Agr (agreement)—may be tactic deficits. 2006) or the Boston Diagnostic Aphasia by research showing patterns of impairment in agramma. Edwards. example. 2000). 3rd Edition (BDAE-3. training tense should improve agreement. Thus. however. 27–7). and English (Lee & Thompson. few published tests are available for detailing syn- should be more impaired than agreement. trolled for argument structure. & de Bleser. Illustration of ways that the syntactic tree can be Treating agrammatic aphasia is a challenge. without it. T and Agr hypotheses about generalization within and across func- Agr’ impaired tional category members. and of these. Few treatments “pruned” according to the Tree Pruning Hypothesis. see Arabatzi & Edwards. because the TP is tactic and morphological impairments seen in agramma- higher in the tree than the agreement phrase (AgrP). and within IP. & Rispens. which can be diagnosed by administration of a stan- impaired CP as well (Fig. these treatments improve language or result in generaliza- tion to untrained language structures and/or language use in untrained contexts is not always clear. The loss of ability. dardized aphasia test battery. Lee and sion and production of canonical and noncanonical sen- Thompson (2005). for example. developed for Dutch speakers and translated into nodes were simply absent of “pruned. indicat. consider the Agr0 VP processing mechanisms engaged in accessing and producing them. indicating aphasia. . a short overview of assessment tools is Supporting data have come from Hebrew and Palestinian presented. to (Lee 2003). German (Burchert. has been challenged Battery (Kertesz. One cessing or access to relevant representation (for a discussion drawback of these tests is that they are not completely con- of processing accounts. Naming Test (Druks & Masterson.. Finally. with fewer being concerned with improving impaired or underspecified. the Action pants showed variability in their production ability. tism. the partici. studied four English-speak. such as the Western Aphasia The validity of the THP. 1997) tactic and morphological impairments in agrammatism. we use the AgrP syntactic tree to select treatment targets and to generate C. Friedmann and Grodzinsky.GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 741 Aptara(PPG Quark) Chapter 27 ■ Treatment of Syntactic and Morphologic Deficits in Agrammatic Aphasia 741 CP Considering recovery of grammatical morphology. training CP struc- C TP tures should improve IP structures. however. the ment. all grammatical morphology. When a node is impaired. the Only C TPH suggests that training higher nodes will improve struc- C’ impaired tures projected from lower ones. and the Verbs and ing retention of partial knowledge rather than a complete Sentences Test (Bastiaanse. In our functional T0 category (grammatical morphology) treatment. We also. ing patients with agrammatism with spared CP but impaired In recent years. also evaluates comprehension and production of that the impairment is more likely the result of faulty pro. T (tense). sentence types that are compromised in agrammatism.” These data suggest English. Goodglass. which have been developed for improving grammatical deficits in assumes a “split-IP. general- As discussed previously. however. In addition. & tism that do not follow the proposed hierarchies in Korean Barresi. 2002. however. That is.. comprehen- 2005). followed by discussion of the treatment for syn- Arabic (Friedmann. In TPH also predicts that morphology associated with tense addition.” Functional category members—C (com. None of these patients showed more difficulty with tense testing verb comprehension and production. and train- NegP ing agreement should not influence tense. For respectively. Pollock (1989) suggested that IP is ization has become the gold standard for efficacious treat- “split” into separate tense and agreement nodes. 2005). Kaplan. detail verb and verb argument structure deficits. and Spanish agrammatic speakers (Benedet et al. including one as compared to agreement inflection. aphasia. several measures have been published for IP. Indeed. their subject showed Agrammatism exists within the context of nonfluent (Broca’s) difficulty with complementizers and embeddings. 2000). the extent to which nodes above the pruned one will be impaired as well. NP V’ V NP TREATMENT OF AGRAMMATISM Figure 27–7. Training IP structures C and T T’ impaired should have no effect on CP structures. Additional measures are required. and three-argument verbs (ditransitive both obligatory and optional)8 using action pictures (Table 27–1). Optional three-arguments Production Test for production of sentences with two-argument verbs allow omission of an argument. . To test comprehension.g.. they are asked to name the action depicted. lick a two.GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 742 Aptara(PPG Quark) 742 Section IV ■ Traditional Approaches to Language Intervention Give Bark Lick Figure 27–8. and subject relative constructions (see Table 27–2 for Pull 8 Obligatory three-argument verbs are those that require all arguments be Figure 27–9. Arrows refer to arguments of the verb. Bark is a one-argument verb. (2) the Test of Verb Production. yes/no questions. (two-argument) verbs are used. transi- tive).argument verb. send). Comprehension is tested sure consists of five tests: (1) the Test of Verb using a sentence-picture matching task: A picture pair is pre- Comprehension. object rela- tives. using one of the pictures in the pair and asking the patient to intransitive). even though it is part of the verb’s verbs on the Northwestern Assessment of Verbs and lexical entry (e. Stimulus used in the Argument Structure overtly represented in sentences (e.. The Northwestern Assessment of Verbs and Sentences sample sentences of each type). The mea. In both tests. and (5) the Sentence Production tences by the examiner modeling the target sentence type Priming Test. Sample picture stimuli for testing production of one-. subject “wh-” questions. subjects are asked to point to the verb named (out of four pictures). and the one corresponding to a spoken sentence is Verb Argument Structure Production Test. two-. put). Sample stimuli used to elicit production of verbs and verb arguments are shown in Figures 27–8 and 27–9.. and give a three-argument verb. and three-argu- ment verbs using the Northwestern Assessment of Verbs and Sentences (NAVS). action picture (Thompson).e. passives. The Sentence Comprehension and Sentence Production Priming Tests examine actives. object “wh-” questions.e. Verb argument struc- ture production is tested by adding arrows to denote objects or people in the picture that represent arguments of the verb. Sentences (NAVS). The verb tests examine one-argument (i. The Sentence Production Priming Test elicits sen- Comprehension Test. obligatory two-argument verbs (i.g.. and to assess verb naming. (3) the sented. in preparation is a battery of tests developed pairs depicting semantically reversible scenes with transitive particularly for evaluating agrammatic aphasia. (4) the Sentence selected. object segmented into utterances based on syntactic. The boy tickled the girl. although as noted 1. and from these sleep stir throw (Op) data. Saffran and col- bark cut build (Op) leagues (1989) recommend using a story-retelling task to col- crawl kiss deliver (Op) lect language sample. Sentence con- laugh pull read (Op) sit shove send (Op) stituents (e. some canonical forms also present difficulty for some non-sentence are entered (utterances without verbs are patients. and “wh-” questions. Subject relative I see the girl who tickled the boy. I see the boy who tickled the girl. both lexical and sentence structural analyses are under- swim tickle write (Op) taken to derive information such as noun-to-verb ratio.g. agrammatic speakers show relatively intact regardless of elicitation condition. 2. verb inflections. it is transcribed and hension of noncanonical sentences (i. open class–to–closed class ratio. are in type and as simple or complex. The samples are then coded for dive lick give (Ob) utterance type. Thompson and colleagues (1995) developed a similar method. Each utterance then is coded at five levels: often is seen in production. A similar pattern semantic criteria. Virtually no published tests are available for evaluating 2. subject matic aphasia show very similar patterns of language pro- “wh-” questions. passives. a sentence completion task and action pictures are Two-Argument Three-Argument used. Respectively. NPs or VPs) also are coded. The Sentences Level. TABLE 27–2 Sentences Tested for Comprehension (Test 4) and Production (Test 5) in the Northwestern Assessment of Verbs and Sentences Sentence Type Sample Stimulus Semantically Reversed Active The girl tickled the boy. actives. therefore. Obligatory Verbs. A sample picture pair and instructions used to test a silent Charlie Chaplin film and then tell about it and comprehension and production are shown in Figure 27–10. To elicit these forms. and 3. and object relatives). and ines production of finite (inflected) and nonfinite verb forms Argument Sructure Production (in Simple Sentences) (Table 27–3). and so on howl pinch put (Ob) (Rochon. where codes for a sentence or above. We also have asked individuals to watch picture. Berndt.GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 743 Aptara(PPG Quark) Chapter 27 ■ Treatment of Syntactic and Morphologic Deficits in Agrammatic Aphasia 743 TABLE 27–1 the processing of developing the Northwestern Assessment of Verb Inflection (Thompson. Object “wh-” question Who did the girl tickle? Who did the boy tickle? Subject “wh-” question Who tickled the boy? Who tickled the girl? Yes/no question Did the girl tickle the boy? Did the boy tickle the girl? Object relative I see the boy who the girl tickled. individuals with agram- comprehension of canonical sentences (i. number of words produced in sen- tences. and proportion of utterances with complete sentences. The Utterance Level.. which exam- Verbs Tested for Comprehension. . where sentences are coded by functional category deficits in aphasia. Verbs (Ob) (Ob) and Optional (Op) Analysis of spontaneous discourse also is crucial for uncov- ering grammatical deficits in agrammatism.e. & Schwartz. The task requires production of the missing verb with One-Argument Verbs. in which canonical forms are less impaired than noncanonical structures.e. I see the girl who the boy tickled. on the plural. Finite forms include present singular. The girl was tickled by the boy.. in preparation). Saffran. We. target Red Riding Hood. Once the sample is collected. describe pictures depicting a sequence of events. Obligatory the correct verb form. 2000). Production. and subject relatives) and poorer compre- duction. present in Tests 1. Nonfinite forms include: present pro- Northwestern Assessment of Verbs and Sentences gressive (aspectual ing) and the infinitive. Patients are asked to tell the story of Cinderella or produce a sentence of the same type with the other. Passive The boy was tickled by the girl.. not sentences). prosodic. and past tense. word class. Notably. On these tests. 0 Few treatments for improving sentence structural (syntactic) Present plural: The cats watch the dog. verbs produced with correct arguments. The Helm-Estabrooks Language Infinitive: The cat will watch the dog. closed class ratio. The Verb Level. 80 certain types of sentences. 0 on instruction and practice in producing the surface form of Present progressive: The cat is watching the dog. the examiner says. the proportion of tional morphemes are entered.” For production elicitation. 1981. which details verbs by type and argu.GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 744 Aptara(PPG Quark) 744 Section IV ■ Traditional Approaches to Language Intervention Figure 27–10. “For this picture [pointing to the picture on the left]. The Lexical Level. where all lexical items are coded by The analysis yields data such as mean length of utterance. the proportion of grammatical sentences. where codes for inflec. The cat was watched by the dog. . for this picture [pointing to the picture on the right]. you could say. it is worth- while for clinicians to become familiar with analyses of this TABLE 27–3 type not only to diagnose the patient but also because changes in these language variables often are seen with Northwestern Assessment of Verb Inflection treatment. several focus Regular past tense: The cat watched the dog. The Bound Morpheme Level. noun-to-verb ratio. Percent Verb Inflection Condition Correct Treatment of Syntactic Deficits Present singular: The cat watches the dog. For compre- hension.) 3. Table 27–4 presents a typical spontaneous lan- Sores for an Agrammatic Speaker guage profile for an agrammatic aphasic speaker (compared to unimpaired speakers). and the proportion 5. ment structure.” (Expected response: The dog was watched by the cat. Although this coding system is quite complex. “Point to. the examiner says. Picture pair used to test sentence comprehension and production on the Northwestern Assessment of Verbs and Sentences (NAVS). . the dog was watched by the cat. . and of those. you could say . open class–to– 4. word class. of verbs and nouns produced with correct inflection. 20 deficits in aphasia are available. 80 Program for Syntax Stimulation (Helm-Estabrooks. 95 Schwartz. Further. exploits the fact that individuals with agrammatic aphasia have normal access to verbs and thematic information. patients are asked to underline the agent and theme in response to questions concerning the logical subject and the logical object (e. are provided Declarative transitive He teaches school.g. we (Thompson. get verbs. (see Appendix 27-1 for detailed treatment protocols). they do not always assign thematic roles normally.73 0. showed generalization across sentences resulting from TUF Rather than focusing on the surface form of sentences.. based on the premises Sample Spontaneous Language Profile for an that. have shown improved comprehension of both canonical and viduals with agrammatic aphasia to produce (Table 27–5). One sentence type is trained at a time. *Values are for normal speakers and are presented as the mean (standard devia- tion). & Hyde (1972) to be difficult for indi. For example. tence types trained. active sentences. this approach is theoretically motivated. Saffran. Patients are trained to produce verbs together with AS Normal* specific sentence constituents (usually NPs) that are assigned various thematic roles by the verb (e.25) Another treatment designed to improve both compre- Proportion of grammatical 0.91 (0. tence NPs in both canonical and noncanonical structures.50 0. Thompson et al. But the generalization patterns differed eralization across sentence types (Doyle. Rochon. . as compared to MT. 1996. efficacy of this approach has indicated that patients improve Shapiro. Crucially. 2005. TUFSYNTAX uses the active form of target sen- tences as a starting point for treatment.08) hension and production of sentences is Mapping Therapy sentences (Byng.12 1.57 NA as Core training. she/he chasing?”).5 (2. instructions as to how various sentence Imperative transitive Drink your milk. Jacobs & Thompson.08) ing this approach is available. first. 1999. Embedded sentences She wanted him to be rich. Presented with sentences in written form. in preparation) found that both in their ability to produce trained sentences. 1995).g. In a recent study directly [e. other approaches exploit processes thought to be operating Treatment of Underlying Forms for Syntax (TUFSYNTAX) in normal sentence processing and production. Bernholtz.. Helm-Estabrooks & Ramsberger. Noun to verb ratio 2. Passive The car was towed.g. Helm-Elicited Language Program for Syntax these patients have difficulty comprehending sentences with Stimulation Sentence Types movement. Laird. access to verbs often is disrupted in agrammatic Agrammatic Speaker (AS) aphasia and. Fink et al. & Martin. & Mass. verbs are required for grammatical sen- tences. treatment results in successful generalization to structures Yes/no questions Did you watch the news? that are related linguistically to the structures trained. second. improves sentence production and comprehension. 1994). Little research examin- Open to closed class ratio 1. it has been shown that this approach Comparative He’s taller. nor TABLE 27–5 do they use them fully in sentence production. Results of research using this method Gleason. Treatment focuses on verbs and the thematic role of sen- Key: NA  data unavailable. & for the two treatments. & Selinger (1986) developed a method known as “Verb as Core” treatment. agent and Mean length of utterance 4. for example. In a series of studies. is “Which one is doing the chasing?” and “What/who is focused on training a set of sentences shown by Goodglass. Shapiro et al.19 0. Goldstein. Myers.GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 745 Aptara(PPG Quark) Chapter 27 ■ Treatment of Syntactic and Morphologic Deficits in Agrammatic Aphasia 745 TABLE 27–4 Loverso. Thompson.. Declarative intransitive He swims.g. Ballard & Thompson..89 (0. Like Verb arguments Proportion of correctly inflected 0. Proportion of verbs with correct 0. and tasks are Sentence Type Sample Sentence directed toward establishing and improving knowledge of and access to the thematic role information entailed in tar- Imperative intransitive Sit down.. less approaches improve comprehension and production of sen- impressive findings have been reported with regard to gen. Like Syntax Stimulation. verbs based on the Mapping Deficit Hypothesis discussed above. Data from Kim and Thompson (2000). Bose.21 (0. 2000. improvement is constrained largely to the types of considered to be the easiest (e. & Scofield. 1988. a greater number of participants Bourgeois. Prescott. 1986). while retaining their thematic roles. Future He will sleep. Direct and indirect object He brings his mother flowers. how- ever.2) theme) in simple. Research concerned with establishing the comparing Mapping Therapy to TUF. however. 1997. Then. Fink. 1993.75 14. imperative intransitives sentences entered into treatment. 1987. Sit down]). constituents move to derive the surface form of target sen- “Wh-” interrogative Where are my shoes? tences. beginning with that however. noncanonical sentence forms. Kiran.. generalization from object clefts to “wh-” (from simple to complex structures. trained both object clefts and passive sentences in four tence types. Tait. improved both trained and untrained Wh-movement struc. from passives to object clefts. The Wh-movement treatment. NP-movement Results of studies directly examining the effects of complex- structures were selected for treatment and generalization test. Ballard. Who did the waitress kiss? trained. however. Shapiro et al. where and when). object relative these sentence types at a time using active sentences. we ies (Thompson & Shapiro.. no “wh-” questions. (active) participants trained to produce and comprehend complex Results showed that training Wh-movement structures structures show generalization to simpler structures (86%). (subject Sobecks. gener- 9 alization is not seen from sentences relying on one type of Also see Thompson. Figure 27–11 illustrates the collective results of raising) training more than 30 subjects with agrammatic aphasia. Similarly. as in sentence 18 below. The teacher was pinched by the boy. but tic operations of Wh. respectively. object clefts are the most complex. (object cleft) not improve object clefts (sentence 19) or object relative clause 15. structures. seman- and NP-movement sentences. (passive) constructions (sentence 18) (Thompson. Jacobs and Thompson (2000) Work concerned with examining Wh. In consideration of the complexity of these raising structures improves not only untrained subject rais. It was the busboy who the waitress kissed. Object “wh-” none showed generalization from object clefts to passives or questions and object clefts are Wh-movement structures.or NP-movement. does 14. depending on whether they involve the syntac.. Thompson. Close examination of data reported in earlier stud- sia? In sentence production and comprehension work. 1994. whereas passive sentences and subject raising forms are NP. 1997).. who and what) however..GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 746 Aptara(PPG Quark) 746 Section IV ■ Traditional Approaches to Language Intervention As noted above. whereas fewer show generalization in the opposite direction tures—that is. In addition. What do these linguistic descriptions direction of treatment is from more complex to less complex have to do with treatment and recovery of language in apha. and object cleft sen. results in general- tence 17 below.. Who did the boy pinch? (object “wh-” question) pler “wh-” question structures (sentence 20). sentences that rely on the same type of movement and adjunct “wh-” questions (e. and “wh- ” questions. cussion of complexity in treatment of phonological. as in sentence 14 below. generalization occurred from subject raising Training complex structures before training simpler ones to passives). better generalization was noted from object clefts example.g. Again. below. structures. and Schneider (1996) for movement to sentences relying on the other. see Gierut (2007).. generalization occurred to other NP-movement structures (e. Generalization from sim- 13. the movement in Wh. Shapiro. Kiran (2007).g.and NP-movement shows that they are functionally independent. form a functional class. Shapiro et al. when NP-movement structures were 20. Importantly. generalization across from one form . all improved on the structures trained. Shapiro. training object cleft sentences improves both to object “wh-” questions than from object “wh-” questions object who and what questions. ever. as in sen. For training. The two ing structures but also passive sentences. training subject to object clefts. and syntactic deficits. & 16. as in sentence 19 below. All subjects improved in production of Wh-movement structures. Similarly. That is. Ballard and Thompson tic. generalization occurs more readily ing. however. & Shapiro. studies training object (argument) “wh-” questions (e. Another finding is that generalization is enhanced if the movement structures. These included passives and subject-raising sentences as from object clefts to “wh-” questions than vice versa in sentences 15 and 16. 17%): questions was found. Shapiro. had little influence on production of NP-movement 19. as in sentence 13 below. but no change in Summary of Syntax Training Effects passive forms was seen. tences. (1999) trained five patients to produce object clefts and/or and Thompson and Shapiro (2007). Most 17.and NP-movement (Thompson. ity showed that.g. as in sentence 20 below. It was the teacher who the boy pinched. 2003). The boy pinched the teacher. Individuals with (Thompson. but these studies. clause structures. and Thompson. Shapiro et al. The boy seems to have pinched the teacher. and TUFSYNTAX protocols: ization to both object clefts. embedding is required. patients. “wh-” questions and tested passives. as well as those object “wh-” questions was seen. Thompson & Shapiro (1994). indeed. Kiran. a distinction exists among certain sen. object clefts is within an embedded clause. have found that sentences that are linguistically related 1997) showed that for subjects who received Wh-movement recover together (see Thompson. 1998). Further. in a study examining the relation between ment. 1997). training even agrammatic Broca’s aphasia were trained to produce one of more complex sentences with Wh-movement. but no change in production of object clefts or may seem counterintuitive.9 structures are similar in that they both require Wh-move- For example. The chef saw the busboy who the waitress kissed. structures. indicate that optimal generaliza- Ballard and Thompson (1999) as well as Jacobs and tion results from this approach (Thompson 2007). and Roberts (1993). how- 18. in other language domains. respectively. Jacobs. The movement the Wh-movement structures selected for treatment included in object “wh-” questions occurs in the matrix clause. For dis- Thompson (2000) found a similar dissociation between Wh. as pointed out above. such as were not completely considered. tures. Tense is above agreement (Pollock. sentence 21 ing accounts suggest that complementizers are more diffi- is more difficult than either sentence 22 or sentence 23. again because tense is higher in the tree than ones. The people wonder if/whether the boy is ticking the girl.e. 1993). because cessing demands of the grammatical morphemes trained they are directly selected for by complement verbs.e. These data show that the linguistic underpinnings of agreement (Fig. both representation and process- From a linguistic representational point of view. 1998). agrammatism? Simply put. Both are subsumed under IP (Bobaljik & Thráinsson. Because the .. but it does not select the verb’s 23. respectively. Categories) 3. the TPH suggests this because complementizers tences are very different in their surface form. 27–11). They are strongly syntactically constrained. 1993). Treatment of Grammatical Morphology (Functional 2.g. Further. are bound grammatical morphemes that rely on processes phology or functional categories (TUFFUNCAT) considers such as grammatical encoding and well-formedness con- both functional category projections from the syntactic tree straints (Arabatzi & Edwards.GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 747 Aptara(PPG Quark) Chapter 27 ■ Treatment of Syntactic and Morphologic Deficits in Agrammatic Aphasia 747 100 90 80 Proportion of participants 70 60 Figure 27–11. Agreement is above tense (Chomsky. with tense or agreement (i. Conversely. 1. because the underlying representation and pro. The boy tickles the girl. Verb tense. strained by the adverb: The adverb introduces information 22. CP) in the syntactic tree compared alization is enhanced when complex. Past tense. Consider the follow. Proportion of participants showing successful generalization from less 50 complex to more complex structures. are functional category members. is only indirectly con- 21. 1984). however. the TPH holds structures are used as the starting point for treatment as long that tense (sentence 22) is more vulnerable than agreement as the simpler structures are related to the more complex (sentence 23). Halle & Marantz. Cannito & Vogel. rather than simple. occupy a higher node (i. about the temporal context. gener. 1989). Faroqi-Shah & as well as computational processes involved in producing Thompson. requires encoding a past-tense meaning (provided ing sentences: by the temporal adverb yesterday or by other contextual information). even when sen. 40 30 20 10 0 Simple to complex Complex to simple to others within the same movement class. Complementizers (whether. for grammatical morphemes in sentences. 1987.. tense in the same way that complement verbs select comple- The complementizer if/whether in sentence 21 as well as ment clauses. see. As cult (or complex) than tense or agreement. morphemes marking verb tense and agreement in sentences Why are these distinctions important for treatment of 22 and 23. IP). The boy tickled the girl. wonder. The position of tense and agreement sentences are important to consider in treatment of syntactic in the syntactic tree is debatable: Some suggest that: deficits in aphasia. noted above. 2007. tense and agreement Treatment of Underlying Forms for grammatical mor. 2002. if. e.. Kearns & Salmon. the computational routines and processing for improving access to grammatical morphemes—either demands required for sentences with complementizers dif- bound or free-standing—is limited to a handful of studies fer from those involved in marking tense/agreement fea- (see. that) are free-standing These treatments can be considered surface form morphemes that introduce a complement or subordinate approaches. Treatment research concerned with establishing methods In addition. clause. Further. know. and vice versa. example.. and care. however. participants received treatment focused on Wh-movement structures. but no specific prediction regarding the direction of necessarily more complex than the other. the lawyer tripped. improved production and comprehension of all forms. Thus.GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 748 Aptara(PPG Quark) 748 Section IV ■ Traditional Approaches to Language Intervention underlying representation as well as the processing routines ticipants trained on tense or agreement showed improve- involved in the two structures are different. generalization to tense or agreement. Thematic role training of constituents in the matrix including object–relative clause constructions. Given this. Participants read or repeated the target sentence at each step. In one study of TUFSYNTAX. We recently trained 12 participants to produce comple- mentizers. Ballard and Thompson (1999) found approximated in sentences 25 and 26. Nowadays [IP the bride [VP carry s [DP the groom]]] TAX and TUFFUNCAT affects the neural mechanisms of lan- Treatment involved the use of written-sentence constituent guage. TUFFUNCAT considers the underlying form of grammatical sentences produced. These findings suggest that the two inflected forms functional relationship between tense and agreement is pre. [IP the bride [VP is carrying [DP the groom]]]] The language improvement resulting from both TUFSYN- 26b. [ed]. This latter finding indi- 24b. with increases in mean length of utterance. and agreement and examined generalization Effects of Treatment on Discourse Patterns across structures (Thompson et al. They may or may them. or [s]. even though both are functional though complementizers and verb inflections are functional category members. which results from argument structure. Regardless of the amount of active tissue. movement studies. Yesterday [IP the bride [VP carry ed [DP the groom]]] Neural Mechanisms of Recovery 26a. tense. respectively: improvements in informativeness and efficiency of produc- 24a. they involve different types of move- forms involve attachment of inflections to base-form verbs. [that]. training one did not influence the other. generalization can clearly be made. Changes in discourse characteristics have resulted from both tures were trained. Syntactic treatment also mated in sentence 24a below. this is approxi. a pants. find two patterns of recovery: Some participants show get as well as cards for [if]. however. The three struc. agreement to tense was seen. one is not dicted. Both agrammatic aphasia. another. are functionally related to one another. Reassembly of scrambled written sentence constituent which object cleft sentences.. training complementizers category members. 2006). object clefts. Generalization from tense to agreement or from not occupy different nodes in the syntactic tree. whereas the third participant of four participants trained on complementizers showed no showed more widespread activation following treatment. however. however. For complementizers. [whether]. verbs (as compared to nouns). the proportion As in TUFSYNTAX. with all showing as well. the underlying and surface forms are verbs. however. such as “It was the judge who tripped the lawyer. Introduction of the grammatical morpheme. [IP the people [VP see [DP/CP something]]] [IP the bride tion following syntactic treatment using the analysis system [VP is carrying [DP the groom]]] of Nicholas and Brookhire (1993). cates that treatment focused on structural deficits impacts ing [DP the groom]]]]]] functional language use. and its placement in the sentence. while performing a sentence-picture matching task in 3. ment. [IP the bride [VP is carrying [DP the groom]]]] 25b. sen. increases in areas of the brain that are active during lan- depending on the grammatical morpheme in training. 2. clause and for complementizers in the embedded clause and object-extracted “wh-” questions. and the proportion of of target structures. [IP the people [VP see [CP that [IP the bride [VP is carry. for 7 of 11 partici- and one may occupy a higher node than the other.and NP- effect on complementizers. order of structure trained counterbalanced across participants. 25a. a functional relationship does not exist between which likely entail similar computations. Thus. with two separate clauses. improves the proportion of verbs produced with correct tence 24b below shows the surface from. using TUFFUNCAT.” and simpler subject cleft sentences. These data suggest that even are linguistically distinct. This ment. and training verb tense and agreement should have no finding is similar to that derived from our Wh. thus. morphology increases the proportion of correctly inflected For tense and agreement. Two (of three) participants showed decreased neural forms following low and stable baseline performance. Each guage processing. such as “It was the judge who cards. even though sentences with both types of Predicting generalization from tense to agreement or movement are noncanonical and difficult for patients with from agreement to tense is more difficult. Notably. and treatment focused on grammatical combining the two clauses with the complementizer  that. the patients were scanned tion. with the syntactic and morphologic treatment in many participants. the final . we cards corresponding with the active sentence(s) for each tar. and others show decreases following training trial consisted of: treatment. its func- Before and following treatment. however. Three activity following treatment. and zero of eight par.” were Results showed that all participants improved on trained tested. they ment on complementizers. 1. Using functional magnetic resonance imaging. they are not functionally related to one should have no effect on production of verb tense or agree. one at a time. which was not active during pre-scanning. the gentleman TUFFUNCAT. pri- marily right hemisphere activation was noted. Interestingly.and who did not improve with treatment showed an increase in before after Figure 27–13. activation was limited to small clusters of active tissue for tense (e. widespread. whereas one did not. This participant showed a decrease in activation following treatment. five underwent pre. The activation shown reflects the following contrast: production of ((tense  agreement)  bare stem). Before treatment. save) or inflected ment. The scan task involved which was not seen on his pre-treatment scan. decrease in activation following treatment.g.. Note that treatment resulted in increased activation in the left and right perisylvian regions. production of verbs in their base form (e. Results showed in the right superior parietal and the middle temporal gyri. whereas following treatment..GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 749 Aptara(PPG Quark) Chapter 27 ■ Treatment of Syntactic and Morphologic Deficits in Agrammatic Aphasia 749 Figure 27–12. Before treat. Figure 27–13 shows A similar pattern was found for participants receiving this pattern for one patient. saves).g. Four of these five participants tissue.g. that the four patients who improved with treatment showed a No activation was seen in the left hemisphere. Figure showed improved production of grammatical morphology 27–12 shows post-treatment activation for one participant with treatment. scans for all participants showed recruitment of perisylvian post-treatment scanning. . Of 12 patients studied. Note that this participant had a large left hemisphere lesion that encompassed the inferior frontal area and extended to superior and anterior temporal regions. Areas of significant activation found in post-treatment scans that were not active in pre-treatment scans. Areas of significant activation before (grey) and after (black) treatment of grammatical morphology for one agrammatic participant. saved) or agreement (e. a shift to more focal right perisylvian and left perilesional activation was found. Treatment improves the grammar. Do your results match extended to the aphasic participants and their family mem. Special thanks are ratio. Discuss how butions. 1. When sentences are not linguistically When lexical and syntactic properties of sentences are not related. considered. Indeed. develop a treatment plan for this client. the more we sion/production in aphasia. treatment of both syntactic and morpho. grammatical sentences. those of other students in the class? For advanced stu- bers. Calculate the fol- the National Institutes on Deafness and other lowing: mean length of utterance. little or no discernible complex structures first. and effi- The results of our work have important clinical implica. why generalization is important for successful treat- In conclusion. the sentences selected for treat. when sentences are linguistically related to one ment. try coding the Sentence Level. Consider one of your cur- learn about the linguistic and psycholinguistic underpin. and the treatment strategy used are considered. Consideration of the lexical and morphosyntactic effects of treatment for agrammatism indicate that treat. Beginning treatment with complex structures is coun- processing/production system has been affected with brain terintuitive. and create a treat- nings of sentence production and comprehension and in ment plan for this client using this concept. another. Generalization may be enhanced by training more ished—or even absent. While additional data are needed to further substantiate the latter. and generalization to untrained contexts (stimu- with aphasia who present with deficits like those seen in our lus generalization). rent or previous clients with aphasia. Morpheme Level. facilitating generalization. the proportion of Communication Disorders (NIDCD) grant RO1-DC01948. and Verb Levels. Michael 4. Use the methods described under Assessment of Agrammatic Deficits (see p. underpinnings of the language deficit exhibited by the 3. Steve Fix. . Generalization from more improvement in sentence production beyond construc. Bound Lisa Milman). with all KEY POINTS activity in the right hemisphere both before and following treatment. Generalization from one structure to another occurs individual with aphasia. Discuss subjects. changes can be mapped onto the brain. it is essential that clin. generalization is limited. Miseon Lee. and colleagues and collaborators. content. Based on the results of coding (in activity 3 above). Walsh-Dickey and Lew Shapiro. 4. We also find that the complexity of structures involve common linguistic representations structures trained is a factor that needs to be considered in and psycholinguistic processes. Two types of generalization occur: generalization to we conclude that linguistically based treatment can be used untrained language structures (response generaliza- successfully for training sentence production in individuals tion). you will evaluate the effects of treatment. properties of sentences selected for treatment and for ment for sentence production deficits in patients with generalization analysis is important for obtaining agrammatic aphasia is efficacious when the linguistic optimal generalization. complex to simple structures occurs when simple tions trained is found. for their invaluable contri. what ways these are disrupted in aphasia. generalization effects are considerably dimin. open class–to–closed class for which the author is very grateful. 5. chapter. Application of treatment explicitly designed to treatment of both naming and sentence comprehen- address these deficits is recommended. Provide examples of both. The literature indicates that individuals with agram- matic aphasia show particular deficit patterns that CONCLUSION must be carefully tested before application of treat- ment. Neural correlates of treatment-induced behavioral imposed for individuals with aphasia. Code the language sample presented in section 2 of this we can be about the design of treatment. ciency of spontaneous discourse. analysis of how and in what ways the sentence 2. Our data suggest that optimal generalization results from treatment when structures that are linguistically simi- lar are selected as treatment targets and when treatment is ACTIVITIES FOR DISCUSSION AND REFLECTION applied to the most complex of these structures first. 1.GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 750 Aptara(PPG Quark) 750 Section IV ■ Traditional Approaches to Language Intervention cortical tissue engaged while performing the task. tions. and noun-to-verb ratio. but it has been shown to be successful for damage. the more detailed 3. Findings from our work in developing and testing the 2. and research assistants involved in this work. Because of restrictions in health care presently 6. icians provide treatment that will result in optimal general- ization. 741) for coding the ▼ Acknowledgment—The work reported here was funded by Utterance Level and Lexical Level. and dents. ment and what can be done if generalization does not logical aspects of sentence production requires careful occur. That is. postdoctoral fellows (Drs. particularly Drs. De Bleser. Piñango. Semantic. 52.. 86. J. what treatments might have this patients in a constrained task. Real-time ization of complex sentence production in agrammatism. N. Brain and Language. & Grodzinsky.). P. (2003). for some clinicians because of limits in their knowledge Chomsky. Keyser (Eds.. (2007). Druks. & de Bleser. Bird. F. J. N. Discuss Cognitive neuropsychology. J. F. & Wong. Brain and Language. T. D. Dickey. American Journal Bobaljik. References Damasio. language are influenced by aphasia treatment. The role of the Press. J. (2002). A. Faroqi-Shah. 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[THE BOY] [IS] [KISSING] [THE GIRL] is placed below the together with [WHO] and [IT WAS] cards (as in Treatment Step boy-kissing-girl picture. the examiner explains. the examiner explains. it is the Post-Trial Probe Task action of the sentence”. . he is the person kissing”. and object “wh-” questions have been son being kissed. The verb and verb arguments (thematic roles) are identified by the examiner in the following manner: Pointing to the verb. go to http://cslr. edu/beginweb/sentactics/sentactics. object clefts.1 Treatment Protocols1 Protocol for Training Object Clefts woman kissed. sentence again. Additional cards for [WHO] and [IT WAS] are tence. it is the action of the sentence”. “To make the new sentence. such as. the new sentence as in the old one.” The client is then asked to point to and name the developed and are currently being studied. “Wh-” question The examiner first explains. [WHO] is added next to [THE GIRL]. the examiner explains. The client moves the cards to form the target object cleft sen- active sentence. “Let’s work on that sentence. semantically reversible picture pair is presented. TREATMENT STEP 3: THEMATIC ROLE TRAINING Object cleft production and comprehension are tested using sentence-picture matching and sentence production priming (see The examiner explains that the agent/action/theme are the same in Assessment of Agrammatic Deficits on p. semantically reversible picture pair is pre- sented. The clinician says. “This is the boy. For example. The client is asked to point to and name the Agent/Action/Theme. The examiner BOY] [IS] [KISSING] [THE GIRL] is placed under the boy-kissing- explains.html. the examiner explains. “Let’s work on that sentence. pointing to the Agent (subject NP). pointing to the Agent (subject NP). A randomly selected. “This is the girl. The client reads aloud or repeats the 1). examiner explains.” The [IT WAS] card is placed at the beginning of the sentence. The client reads aloud/repeats the target sentence: Pre-Trial Probe Task [IT WAS] [THE MAN] [WHO] [THE WOMAN] [KISSED].GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 754 Aptara(PPG Quark) 754 Section IV ■ Traditional Approaches to Language Intervention APPENDIX 27.” Sentence con- TREATMENT STEP 4: PRACTICE stituents comprising the active form of the target sentence are pre- sented on individual cards under the target picture. he is the person doing the kissing”. Assistance is provided as needed.” Sentence con- The Theme [THE GIRL] and the [WHO] cards are moved to stituents comprising the active training sentence are presented on the sentence initial position. because the girl is the person who is kissed.colorado. The client reads aloud or repeats the active sentence again.” The [WHO] card is matching and sentence production priming (see Assessment of placed next to the Theme card [THE GIRL]. [THE [THE GIRL] [WHO] [THE BOY] [KISSED]. 741). The client reads aloud or repeats the active sentence. these words are moved to the girl picture. The client reads aloud or repeats the active updates. creating the following word string: individual cards under the target picture. such as (a) girl kissing a boy and (b) boy kissing a girl. “We are going to make a new sentence production and comprehension are tested using sentence-picture to go with this picture using these cards. The clinician says. “This is kissing. For example. The clinician Agrammatiic Deficits on p. “This is the boy. “This is kissing.” The client is then asked to Object “Wh-” Questions point to and name the Agent/Action/Theme. explains that to make a new sentence. Pre-Trial Probe Task TREATMENT STEP 2: SENTENCE BUILDING A randomly selected. For description of the program and Agent/Action/Theme. pointing to the Theme 1 (object NP). “This is the girl. Sentence constituents are rearranged in active sentence form. object relative clause structures. the [IT examiner in the following manner: Pointing to the verb. she is the person being kissed. the The same procedures as in the Pre-Trial Probe Task are used. the exam- WAS] card needs to be added “because it was the man who the iner explains. They move together because the girl is Additional cards. The TREATMENT STEP 1: THEMATIC ROLE TRAINING client is instructed to read aloud/repeat the sentence in the order of the cards: [THE BOY] [KISSED] [THE GIRL] [WHO]. point- ing to the Theme (object NP).” verb and verb arguments (thematic roles) are identified by the The examiner explains that to make a correct sentence. The the person who is kissed. 741). placed next to the picture. (a) girl kissing a boy and (b) boy kissing a girl. [WHO] and [?]. The client reads aloud or TREATMENT STEP 1: THEMATIC ROLE TRAINING repeats the target sentence again. she is the per- Computerized protocols (Sentactic®) for training three Wh-movement sentences. are put next to the picture. beginning of the sentence. Theme [THE GIRL] card is replaced by [WHO]. The client moves the cards to form the target “wh-” question.” The reads/repeats the question. The client reads aloud or questions. We use who for simplification. repeats the target sentence again. TREATMENT STEP 4: PRACTICE The clinician says. The client tence. then reads or repeats it. resulting in the following string: [IS] [THE BOY] [KISSING] [WHO] [?]. The client reads aloud or repeats the echo to and name the Agent/Action/Theme. Assistance is provided as needed.” Sentence constituents are rearranged in active sentence form. The client is asked to point a question sentence.GRBQ344-3513G-C27[735-755]qxd 01/22/08 06:42 PM Page 755 Aptara(PPG Quark) Chapter 27 ■ Treatment of Syntactic and Morphologic Deficits in Agrammatic Aphasia 755 TREATMENT STEP 2: SENTENCE BUILDING Movement of [WHO] to the sentence initial position is demon- strated. The same procedures as in the Pre-Trial Probe Task are used. 2 We recognize that proper English requires whom rather than who in the object posi. Post-Trial Probe Task tion. Subject/auxiliary verb inversion is demonstrated. The clinician explains that the [?] card is needed to make in the new sentence as in the old one. we also note that who in the object position is now accepted. and the exam- iner explains that this is done because the girl is WHO is kissed. [WHO]: [WHO] [IS] [THE BOY] [KISSING] [?]. “To make the question sentence. together with the [WHO] and [?] cards (as in Treatment Step 1). a question. to go with this picture using these cards. “We are going to make a new sen. we need to switch [THE BOY] and [IS]. TREATMENT STEP 3: THEMATIC ROLE TRAINING The question mark card then is placed at the end of the card string. . forming an echo question: [THE BOY] [IS] [KISSING] [WHO]2 The examiner explains that the Agent/Action/Theme are the same [?]. as the examiner explains that the question starts with The examiner first explains. Reportedly. relative to the efficacy of treatment. Prins. both in this era and in the 1960s. • To outline the implementation of LOT 1950). 1979). After World War II. and ment. The ideal study.. had not been completed. The data published about guistic research evidence to treatment. In addition. Blackman & • To demonstrate the efficacy of LOT Tureen. neurolinguistic approach to treatment. 1973. 1978. it strives to In the 1950s. & Muraski. and whether aphasia treatment guage normally is processed and how it is altered in the was efficacious remained an issue. Frazier & (David. The focus of these rehabilitation efforts was on reeducation. these groups provided support and posi- • To describe the benefits of an LOT approach tively influenced both communication and personality • To highlight the functional aspects of LOT adjustment (Aronson. 1978. Weisenburg & McBride. & Jimenez-Pabon. 1984. Jenkins. To acquaint the Faglioni. that supported the efficacy of language treatment in patients tured methodology coupled with content based on research with aphasia (Basso. reflecting how lan. & Bainton. Because of the neurolinguistic under. & Cook. Despite some stud- century.GRBQ344-3513G-C28[756-799]. data were primarily anecdotal and not statistically supported. with the aim of creating an approach consisting of a struc. ented approach is based on the application of psycholin. Snow. data from normal and disordered language. over a 2-year period. 1956. reader with the climate in which LOT was conceived. Sefer. treatment were controversial. aphasia treatment shifted. London. Chapter 28 Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia Donna L. 1904. Helm-Estabrooks (1988) categorized LOT as a failed to show the positive effects of language treatment. interest regarding aphasia treatment surged because of the number of war veterans with aphasia OBJECTIVES as a result of trauma. 756 . Broida. On the one hand. the approach developed for treatment. Shewan & Kertesz. some with and some without control groups. Silverman.qxd 1/21/08 1:44 PM Page 756 Aptara Inc. Shewan (1977) The 1970s and early 1980s witnessed the publication of developed LOT during the 1970s. Because of the effects of trauma on the personal- The objectives of this chapter are: ity of these individuals. Dabul & Hanson. In the early 1900s. 1973. As such. application. Leri. Hagen. 1924. Smith. Enderby. and some Little in the way of what we now know as orthodox treat. & Vignolo. 1920. although Cynthia M. the data focused Language-Oriented Treatment (LOT) is a psycholinguistic on trauma rather than on stroke. a 1975. believed that only this study would put to rest their doubts ment for aphasia appeared before the beginning of the 20th about the efficacy of aphasia treatment. 1935). using a randomized no- HISTORY OF APHASIA TREATMENT treatment control group.. 1981). This language-ori. Vignolo’s presence of aphasia. Champoux. & Vignolo. Wegenaar. focusing on indi- enable a person with aphasia to use a language processing viduals who developed aphasia as a result of stroke. 1978. Wertz et al. questions were raised. 1975. Shewan not answered. & brief history of aphasia treatment will be reviewed. study (1964) reported the significantly positive effects of treat- pinnings of LOT with respect to theory. 1979. Schuell’s system at its maximum functional level. 1964). 1906. many psychotherapy groups became • To define Language-Oriented Treatment (LOT) a part of rehabilitation efforts (Backus. 1977. With the exceptions of Eisenson (1949) and Wepman (1951). Shatin. Capitani. Meikle et al. 1948). Blackman. but the study by Sarno. 1982. several studies. Bandur and Ingham. 1952. and even as far back as this. work. Deal & Deal. predominated (Schuell. and Sands (1970) evolution. Mills. 1972. Basso. approach to the treatment of aphasia. the literature reported a few ies that disputed the efficaciousness of language treatment studies describing treatment (Franz. however. book fully describing LOT. the brain’s plasticity and ability to adjust to injury have been emerging and lend further support for the importance of our language interventions (Belin et al.. treatment materials. it became imperative that theoret- nificant and positive effects of treatment (Brindley. 1996. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 757 enough evidence had been gathered by 1982 for Darley not bring about significant change. Martin. Huber.. which incorporated the accumulating research lectively provides a series of answers and together lays our data regarding how individuals with and without aphasia doubt about efficacy to rest” (p. one can see how both the Warburton. The authors scale clinical trial (described later in this chapter). outlining Springer. became apparent. or PICA. Because the tions. 2003). 1997. single-subject experimental studies and individ. particularly to the content of LOT. replication. individuals studied in these reports generally have been in The 21st century has witnessed a surge in the use of tech- the chronic stages of their recovery. 1986). Demain. De therapy based on psycholinguistic research data.GRBQ344-3513G-C28[756-799].. LOT was designed. & Welch. George. actually replicating that treatment. and Stein (1996) described them as demonstrating was pilot tested (Shewan. Ongoing research has necessitated modifica- when applied to particular language problems. Vikinstad. & Willmes. across patients. Calvert et al. As additional research find- and describe what processes we are addressing that result in ings emerge. complete with treatment guide- ual case studies. and efficacy data (Shewan & detailed descriptions about the efficacy of specific approaches Bandur. along with greater specification of language only in improved linguistic performance but also in mean. Our work would support the various areas of the human brain. These investigations have provided more lines. EVOLUTION OF LANGUAGE-ORIENTED 2000. As defined here. which in turn can positively impact nature and complexity of the behavioral symptoms will best our clinical efficiency and outcomes. accompanying rationales. emission tomography and functional magnetic resonance More recently. LOT Ruyter. A decade also highlighted the contributions made in recent years by passed from ideational conception to the publication of a small-group. 1989). Holland. the possible relationship between intensity of therapy and lan. particularly when therapy is patients. however. and Speechley (2003) imaging have enabled the growth in our understanding of reviewed the aphasia literature for language treatment studies how those with and without aphasia process and produce lan- reported from January 1975 through May 2002 to determine guage (Gernsbacher & Kaschak. LOT will continue to evolve. ical information be incorporated into designing therapy and Copeland. Cappa. Subsequently.qxd 1/21/08 1:44 PM Page 757 Aptara Inc. TREATMENT Altenmuller. 2000. 1989. the language gains real. we are compelled to examine aphasia. 2002. treatment approaches directed at addressing the underlying and strategies is possible. 2001. the aphasia literature contained few descriptions of treat- Philosophy and Rationale ment that were sufficiently detailed to assure clinicians they were. there remained many patients for whom this approach did aphasia represents impairment in the language system and in . these positive changes. LOT has been refined. Price. Marckmann. and LOT is no exception. Wertz et a structured methodology in which an individual progressed al. methods. 2003. standing the neural basis of language and cognition and how ies with positive treatment results were associated with greater those functions may be altered in the presence of lesions in than 2 hours of therapy per week. indeed. The resulting data were promising and led to a full- frequent and conducted over a lengthy interval. The need for alternative (1982) to conclude that the foregoing collage of studies “col. 1977) with a small group of the value of aphasia treatment. Aphasia treatments typically are based on a theoretic con- dominant type of treatment was stimulation therapy. Positron- ized are not likely to be attributed to spontaneous recovery. Fromm. idea that further studies employing carefully tailored. convince every. & Dichgans. 1991. Studies demonstrating delineate what specific approaches work best for whom. Next. intensive greater customization of assessment tools. Whitney & Goldstein. With As our understanding of normal language processing has pressures not only to demonstrate that therapy results not advanced. but struct of aphasia. nology. Schonle. Teasell. Huber. and the Functional measures of language to assist clinicians in better under- Communication Profile. Poeck. 1986. impairments and their functional impact on those with ingful functional outcomes. Thiel et al. Because clinicians were being one. 1989. study and our understanding of aphasia have evolved. be described in such a way as to be systemically applied 1988. When LOT was first conceptualized. and efficacy studies continued throughout the 1980s pressured to reexamine their treatment approaches and and into the next decade. 1999). In summarizing the through steps of increasing difficulty. Glindemann. The pre. Holland & Wertz. 1999. The authors found that stud. with the majority favoring the sig. Swinburn.. 1988. with advances in neuroimaging techniques. Kahrs. & Wise. or FCP. treatment goals. & Martyn. Information derived from these avenues of research can guage outcomes as assessed using the Porch Index of complement the work of those addressing psycholinguistic Communicative Abilities. From the foregoing summary. Bhogal. 175). Thomas. With this understanding. & Willmes. with the content of results of most large group studies.. Leger et al. Cao. process language and which could be clearly defined for Darley’s proclamation did not. Johnson. ticular individual. the content of language treatment is understanding of the pattern of deficits presented by a par- extremely important. Green. A hypothesis regarding the underlying vide the patient with a language-processing system that nature of the problems is based on available information operates at its maximum functional level by applying neu. and implementing therapy but are not intended to be pre- leagues (Zurif and Caramazza. For example. Caramazza. with the ultimate goal being to pro. with expectations that exposure to a variety symptoms is guided by theoretic hypotheses rather than of tasks will facilitate change in performance. no longer can be accessed automatically. high degree of flexibility with the approach while providing 1976). & scriptive in nature. Processes for understanding based on the language profile. which are Language-Oriented Treatment is designed to provide a non-overlapping and mutually exclusive (Fig. tem whereby the content of language can be described com- and when changes in communicative performance ulti. & Goodenough. Byng. Caramazza. and the goals of and producing language thereby are affected. This theoretic the patient. edge base is not lost in aphasia but. Language. Zurif. A psycholinguistic approach emphasizes the trast to that of providing indiscriminant stimulation of the need for clinicians to ensure that their interpretation of language system. LOT divides mately are not realized. the communication system into five modalities. must be mediated by more conscious and explicit mechanisms (Byng & Black. prehensively and to facilitate data collection. Schematic model of the language modalities and areas within these modal- ities that make up the communication system. from normal language processing and that found in those rolinguistic findings to treatment. (2) visual processing. with aphasia. Guidelines are detailed to assist with organizing view of aphasia is derived from the work of Zurif and his col. or Content at least certain aspects of language. rather. 1998. 1995). the interests. 28–1). This approach is in con. enough structure to allow effective replication. Figure 28–1. 1976. 1992).qxd 1/21/08 1:44 PM Page 758 Aptara Inc. The five highly individualized and tailored approach to treatment modalities are (1) auditory processing.GRBQ344-3513G-C28[756-799]. It is proposed that the linguistic or conceptual knowl. 758 Section IV ■ Traditional Approaches to Language Intervention access to the language system. at an unconscious level. 1972. An effort has been made to maintain a Myerson. . when difficulty levels may be inappropriate. Implementation of LOT requires careful analysis and In the LOT method. To provide a sys- be inconsistent. relying on intuition and that treatment is individualized with workbook activities selected to match symptoms can lead to respect to the symptoms displayed by the specific person frustration and discouragement when responding appears to being treated (Albert. Zurif. within the same activity. The Approaching treatment from a stimulus–response– goal of language treatment is to improve a patient’s language reinforcement construct enables the clinician to collect data deficits by presenting material that increases in difficulty about performance and provides objective feedback to both level at a pace that the individual can accommodate. the division is intended to facil. ing. such as certain words in a word retrieval task or spe. the block of 10 stimulus items Methodology is repeated. mode of presentation. this method provides monitoring. As our understanding of feelings of frustration and failure on the part of the patient. the clinician and the patient about progress over time on Although the modalities have been delineated to assist in particular tasks and/or areas. response to the patient at a given point in time has been pro- ment materials are organized according to the level of diffi. A criterion of 70% the goal is not to learn specific stimulus–response connec. treatment may not be immediately reflected in changes on treatment within one modality or area may be targeted to standardized test measures. the difficulty of the task is increased to the next level in the hierarchy. Several variables can affect the difficulty level of a task. posed to be one of the critical elements of therapy. For example. objective information. oral reading rarely would be cho. Rather than advocating a particular breakdown of Facilitated Problem Solving has been used to describe treat- the communication system. Because improvements in outlining LOT content and areas for potential treatment. demonstration of steady gains facilitate performance in another. continuation of the task should the alteration in task diffi- forcement. the delaying progress in treatment. The difficulty level of the task is decreased if the The methodology of LOT has adopted a paradigm in which patient is unable to meet the 70% criterion. aphasia evolves. modifications may be made to the stimuli or clinician can clearly specify the content of treatment being task requirements because difficulties are encountered.g. given their current capabilities. In contrast to operant conditioning. reinforcement for the patient. a responding. Alternatively. To enhance correct With each modality segmented into component parts. activities are presented in order of increasing diffi- they are not necessarily arranged in a hierarchical order or culty to optimize opportunities for success and minimize intended for use with every patient.GRBQ344-3513G-C28[756-799]. Difficulty levels may be based on an analy- the use of procedures that facilitate optimal responding by sis of results from standardized testing and systematic prob- the patient. even essential that it correspond to the established goal. and organize task. on two consecutive blocks of items at the same level of diffi- mented. 1995). mance and to accommodate some error without unduly cific sentences in a sentence formulation task. and the interaction with the clinician (Byng Within each area of a modality (e. correct was chosen to allow flexibility in response perfor- tions. perhaps. responses within an activity. culty not produce the desired outcome. yet challeng- sive areas that. Instead. comprehension of & Black. within the across a hierarchy of activities can be an invaluable source of Oral Expression modality. along with our knowledge about the effec. such as self. such tiveness of specific treatment techniques. This process of adjusting the task in sentences within the Auditory Processing modality) treat. an oral reading task may who may be challenging the value of financial support for be selected to achieve a variety of objectives. process or use language at levels appropriate. To advance the level of a design tasks that can meet the goals selected. collectively. When selecting an activity within an area. response. what the patient is required its replication. and (5) graphic expression. and those sen as a goal in and of itself. When this criterion is met. significant others. reading comprehension. Rather. auditory processing. as type of materials incorporated. more than one modality typically are treated ing in concert with information from research literature simultaneously. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 759 (3) gestural and combined gestural-verbal communication.qxd 1/21/08 1:44 PM Page 759 Aptara Inc. it is task or procedure should be modified or. followed by dis- the major components are stimulus. in a timely manner. regarding when a and so forth. a patient must achieve 70% or more correct responses them in ways that allow changes to be measured and docu. ongoing treatment. however. these advance. the clinician must be The stimuli and their responses in treatment are pre- cognizant of the many variables that impact performance. ments can be incorporated into the content of LOT. or modality might reflect or challenge other language processes must be considered. accompanying descriptive feedback enables patients to Each modality is further subdivided into mutually exclu. ment that is characterized by the relationship between a nar- itate specification of the content of treatment and to permit row focus in the materials used. and amount of clinician Because LOT was designed to be flexible and promote support provided. and how abandoned. provided. area. To this end. culty based on available data from research literature. but In LOT. to do with them.. and rein. paradigm of presenting stimuli followed by responses with (4) oral expression. Difficulty Levels The content areas within each modality are considered to be the base in treatment or guidelines for consideration. If a particular patient . culty. sented in blocks of 10 items each. either within the same session or even regarding normal and/or disordered language functioning. complexity of response required. If the 70% cor- rect criterion is not achieved. encompass the entire modality. to transfer the responsibility task. Le Dorze and Brassard (1995) have correct response may be required to score it as meeting reported on the impact of aphasia on both patients and their criterion. impact on interpersonal relationships. and to increase the production of independent record. include increased effort. group rather than omitting some of the material. a who have suffered strokes can contribute to their functional clinician may decide that. The patient can serve as an invaluable creates the foundation for working through the many chal- source of information and insight for the clinician. should be increased or decreased in difficulty. Helping patients engaging in mutual problem-solving exchanges and encour. 1998). with language disabilities having a marked ician can create levels of intermediate difficulty (branching). and psychosocial mines that dividing a large group of equally difficult mater. many different levels of response are possible. communication uation requiring branching may arise when a clinician deter. issues for the first year positively impacts the quality of life ial into two subgroups might be advantageous in providing of persons with aphasia. the importance of additional language processing opportunities with each sub. through indi. As described earlier. rehabilitation that addresses language. sometimes. Criterion Response and Branching Defining the elements of a correct response is required to Patient–Clinician Relationship advance the level of difficulty. a recognizable abilities. communication. The difficulty level. with based on the amount of support provided by the clinician. Because Although LOT is structured in content and methodology. By relationship is to the treatment of aphasia. A LOT Data Record The goal in implementing a cueing system is to determine Form (Appendix 28-2) specifies the amount of time spent in which cues are facilitative. Albert (1998) describes the loss of ability to com- tasks. with a hierarchy of difficulty levels established. in concert . Another sit. aphasia is a necessary component of treatment. the defin. with a lenges and. this ticipant in treatment. tered throughout the rehabilitation process. cating or describing how a particular response has occurred Language-Oriented Treatment employs a structured and/or was facilitated. to develop the individual’s aware. Two forms can be help- Cueing ful in this respect. the patient becomes a more active par. correct response. Understanding and respecting premorbid personality and lifestyle characteristics of patients are the first steps in devel- oping collaborative. Branching constructs a link between the initial task and Sarno (1997) has described how intensive. criterion for a activity. In this context. although the efficacy data reported later in this Because the patient’s performance dictates when tasks chapter reflects the use of the 70% criterion. long term assists the patient in advancing to the next level. early during treatment. disappointments that are encoun- personal and. however. each session for each area and modality. and fatigue in culty proves to be too great for a patient to master. response promotes a better understanding of the language Skilful clinicians are mindful of how central the therapeutic impairment and the factors influencing performance. and response method are recorded. In most ronment. the clin. irritation. Later. the be used for each area in each modality. open and honest exchange of ideas and feelings is needed to Information regarding the correctness and quality of a facilitate mutual goal setting and a sense of partnership. recording data is an important component in LOT. 760 Section IV ■ Traditional Approaches to Language Intervention demonstrates the need for a higher criterion. In turn. and their support systems understand the loss accompanying aging self-evaluation. richer perspective. presentation method. the clini- cian decides what constitutes a correct response. Negative communication consequences When the difference between two adjacent levels of diffi. a phonetically & MacKenzie. functional communication. and any for initiating and providing cues from the clinician to the other pertinent observations that a clinician may wish to patient. many times. strategies. type of cueing. A LOT Goals Form (Appendix 28-1) may If a patient cannot generate an independent response. and municate as being tantamount to the loss of personhood. difficulty level of the ness of those that are effective. it flexibility in establishing this decision is available. significant others. For example. with self-cueing as needed. space for additional observations. the patient–clinician relationship cannot be overstated. methodology of stimulus–response–reinforcement. Creating a climate for an Feedback is a key aspect to the implementation of LOT.qxd 1/21/08 1:44 PM Page 760 Aptara Inc. data collected. supportive relationships both with them Feedback and with their significant others. clinician may incorporate the presentation of cues within an stimuli. in a naming task. Both forms are useful in charting the course of treat- responses. number of items presented. is carried out within a caring and positive interpersonal envi- ition of a correct response may differ for each task. what is accepted as correct may change with time and as and evidence suggests that the self-esteem of individuals improvement occurs. it can be Recording Data altered.GRBQ344-3513G-C28[756-799]. at least during the early phases of recovery (Chang production meets criterion. ment and highlighting for the clinician when difficulty levels or tasks might be altered. frustration. Guiding Principles Weinrich. but The Role of Computers this approach does not preclude the establishment of a patient-centered milieu in treatment. puter in delivering therapeutic tasks and in serving both as tion approach to aphasia. 2.and low- regarding which modalities and areas to introduce initially frequency pictured words were provided. home.qxd 1/21/08 1:44 PM Page 761 Aptara Inc. It is worth noting that this chart cognitive load required in the former task. therapy for aphasia takes place in a face-to-face nificant others play integral roles in determining goals and setting between the clinician and the patient. Generally. Those authors sug. Wade. Positive gains in naming skills in a integration of knowledge about neural substrates and psy. Boser. When evaluating the results of an unsuper- enable participation in his or her environment as a compe. and these new or expanded treatment leagues (2004) described positive changes in naming perfor- applications will be discussed in the descriptions of the mance by a group of patients with chronic aphasia. The amount illustrations will be provided to demonstrate the practical of daily home practice (mean. Approach (Shewan & Bandur. Petheram (1996) failed tent individual. Icons associ- tions. The patient and sig. These descriptions provide evidence that Mortley. 1989). again. the clinician must develop an understand. Kleczewsda. were manipulated in a range of activities. opportunities for the user to independently determine in guiding a comprehensive assessment. Only with of a 2-month period. approaches to treatment have been reported in the realm of word retrieval. the tool for work and recreational activities has been examined. Advances in computer technology and its increased ing about the impact of aphasia on the whole person and accessibility have lead investigators to explore computer the world in which he or she participates. implementation of a computer-based treatment program. Wertz. & Carlson. Consideration of lesion site and an understanding of that With Multicue (Van Mourik & Van de Sandt-Koenderman. McCall. clinician needs to understand and address the impact of The literature reflects varying degrees of improvement in aphasia on the attainment of the patient’s personal goals language functioning related to implementation of computer- and direct treatment to identify the supports needed to ized programs. some case gories. at every step of the rehabilitation process. patient. Improvements in during treatment can be made once a hypothesis as to the word retrieval were found on standardized testing at the end nature of the underlying deficits is established. with chronic aphasia. representing various cate- At the conclusion of the treatment section. following modalities that follow. To cian presenting activities and related feedback while modify- facilitate the transfer of skills to more functional aspects of ing tasks according to the response characteristics of the the patient’s life. and Wertz (1997) through coupling sions and educate our patients regarding prognostic implica. Doesborgh and col- refined in some areas. Aftonomos. which the investigators attributed to the increased found in Figure 28–1. A complete listing of Spoken was described as less accurate than C-VIC produc- the areas incorporated in each of the modalities also is tions. 1986). The decision and select cues to facilitate naming of both high. and abilities. for untrained vocabulary. Amount of time spent on the computer varied widely and appeared to be associated with less frequent opportunities IMPLEMENTATION OF LANGUAGE-ORIENTED for hobbies or other forms of social interaction. group of patients with chronic aphasia also were reported by cholinguistic principles can we inform our treatment deci. and Virata (2002) examined the impact of Computerized Visual Communication (Steele. Since then. interests. aphasic deficits. ated with natural lexical items. reflects the content of LOT at the time of its original devel. . It is not possible to address all the areas patients with nonfluent aphasia. so only some of them ment in sentence formulation skills on a picture description will be highlighted. task both in oral and C-VIC formulation for trained items tice or changes since the inception of LOT. Greater success with computerized treatment has been opment. vised home-based computer program. particularly as they reflect current prac. TREATMENT Weinrich. In the following sections. The role of the com- leagues (2000) described the importance of a life participa. with the clini- activities based on their needs. area’s role in cognitive and linguistic processes are essential 1992). and Enderby (2004) used their com- systematically addressing the underlying problems results in puter-based treatment program to target word retrieval functional improvements.and clinic-based computer instruction. skills in a group of patients. or LPAA. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 761 with clearly defined hierarchies and scoring systems. Chapey and col.GRBQ344-3513G-C28[756-799]. They found an improve- within the confines of this chapter. to find a relationship between progression through a hierar- chy of tasks and improvements on formalized language mea- sures. applications in aphasia management. to a lesser extent. Steele. The reader is and. or C-VIC.04 hours) was judged to be a applications of LOT with patients exhibiting a range of significant contributor to the treatment outcome. a description of each modality training on sentence production and discourse in five will be provided. Procedural referred to Treatment of Aphasia: A Language-Oriented and narrative discourse performance proved to be similar. an alternative-augmentative communication system and as a gested that. 3 months to 13 years. photographs. and pic- demonstrated significantly more improved scores on overall tograms. efficacy. Fink. communication exchanges or transfer of skills outside the able improvement in auditory processing. drawings.. has become available. and Cain (2001) considered whether With many individuals now having computers in their voice recognition software could be a tool to assist those homes. a Personal Communication Assistant for Dysphasic also were reported by Katz and Wertz (1997). with minimal clinician method of communication for those with agrammatism. in addition to the issues of auditory presentation. Saffran. Active. passive. input. Following therapy. employing a People. field of AAC to be attributed to the few published case Others have studied the treatment of syntactic compre. along with a voice output option. defin. ronmental controls and. Other stated benefits communication in those with aphasia was reviewed by Van were family and patient reports of the improved confidence de Sandt-Koendermann (2004). with the subjects required to arrange acceptance by the user and/or communication partner. with time post-onset ranging from computer stimulation tasks. randomized. which then hension deficits through application of computerized tasks. More Positive treatment outcomes in reading comprehension recently. Petheram. In use of computers. Phase 1 and 2 investigations).qxd 1/21/08 1:44 PM Page 762 Aptara Inc. as an input modality for porated into the LOT approach. clinical environment has not been demonstrated. perhaps. success in establishing online comprehension for trained sentence forms. potentially. with limited resources for a heterogeneous Multimedia Microworld. be appropriate for the user. Challenges with implementation of low-tech therapy protocol (Schwartz. portable device that is tence comprehension tasks. including words. They studied six individuals with a range in avenues for practice. effectiveness. The American sessions. At the conclusion of therapy. on average. Wiegers. Construction and processing of electronic mail A great amount of variability was found in both groups . impairment and poor auditory comprehension. and efficiency. disorder and. expert opinion. Studies were evaluated with respect to the their investigation. lation. consisting of individually configured according to the modules that might 3 hours of practice per week over the course of 26 weeks. with aphasia in functions such as dictation and use of envi- ities using a hierarchy of difficulty levels may well be incor. Myers. hierarchy and bridge the gap between structured therapeu- Significant improvements in naming scores were found after tic tasks to those of a more functional nature. with the participants The use of both low and high-tech Alternative and spending. & Martin. and object cleft sentences were pro. nonrandomized his.GRBQ344-3513G-C28[756-799]. or PCAD. Eight 1-hour The C-VIC was designed both for treatment and as a treatment sessions were provided. devices include factors such as the severity of the language 1994). & Sinner (1998).e. Overall. (e-mail) could be effectively incorporated into a treatment tored through the Internet and telephone interviews. Wertz and Katz (2004) reviewed the literature for reports and Philippa (2005) determined that PCAD could be used as on treatment outcomes in patients with aphasia through the a functional communication system in the environment.e.. over a period of five sessions. 762 Section IV ■ Traditional Approaches to Language Intervention implementing a home-practice paradigm that was moni. Those who were most successful were older. Schultz. reports with respect to design and efficacy. this option may hold further promise for at least torical controls. cognitive impairments faced by the duced by the computer in written form. or one or more case reports obtained in some individuals with aphasia. Crawford. The previous studies suggest that read. Wade. along participants reported use of the device outside of the therapy with a five-phase outcome research model. accompanied by individuals most in need of them. Van de Sandt-Koendermann. Van de Sandt- hierarchy of activities from simple letter matching to sen. Only the Katz device might occur only when patients are in the more and Wertz (1997) study met the criterion of Class 1 evidence chronic phase of their disability and have accepted their lim- (i. pictorial elements to represent the sentences. Van de Sandt- and independence in everyday communication exchanges Koendermann suggested the lack of advancement within the exhibited by the patients. a program based on a mapping population. assignments. severity of aphasic deficits along with a control group and ing comprehension and naming activities might well be examined their success. with the remainder providing ity and familiarity of handheld devices in the general popu- Class 3 evidence (i. evidence from one or more well-designed. a 27-week period of home practice. A hierarchy of options is avail- those who had received reading comprehension training able. along with vari. all three patients Although it has proven to be effective in improving oral demonstrated significant improvement in written sentence sentence formulation skills. Because of the increasing popular- controlled clinical trials). Koendermann described it as a small. itations with oral speech. 2 hours and 45 minutes per week Augmentative Communication (AAC) strategies to support engaged in the computer activities. places the burden on clinicians to establish time-consuming Beveridge and Crerar (2002) reported on the use of alternatives. The Academy of Neurology’s 1994 level of evidence scale also authors suggested that acceptance of a communication was incorporated into evaluating the findings. 77% of the ing outcome. development of carefully structured treatment activ. in areas of consideration for supplementation with computer training the software to recognize 50 words and 24 phrases. providing additional treatment. In a later study of language measures than those who were provided with only 28 patients with aphasia. which excluded those with cognitive model of Robey. and trail making. included. and so on. execu- of independence with computer tasks. writ- Cognition and Language ten spelling was significantly impacted. the lowest accuracy levels were associ. making it challenging to separate vidual’s ability to manage the large number of errors during their potential effects.org as being the one containing the high- demonstrating even greater variation in the group with apha. and www. Successful remediation approaches have . The investiga. with the differing processes are at work. and lists. these difficulties may occur with both visual and auditory including right and left hemisphere strokes. searching Advancing her claims that aphasia therapy outcomes are the World Wide Web.. written The relationship between cognition and language has been skills had improved. 2003). that as the technology undergoes further refinement. est quality of information and accessibility.qxd 1/21/08 1:44 PM Page 763 Aptara Inc. Murray (2004) posited that. The roles tem for constructing e-mail.aphasiahope. A range of tasks was comprehension. and Sutcliffe (2003) experience problems even with tasks that involve orienting. From these studies. specified tasks. on verbal memory may not all be equal and may reflect that sia has been placed on facilitating Internet access. aphasia Web sites have more recently tions were the cognitive skills most often associated with drawn attention. Helm-Estabrooks (2002) Before training. Not unexpectedly. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 763 during single-word training. ing graphomotor patterns. attention and working memory may be disturbed in by samples of patients with aphasia and speech-language those with aphasia and may. and/or visual input. because of common lesion Smart. Burgio and Basso (1997) have the recognition training of the system. org. one might conclude were found across all of their subjects in the acute phase. Edmundson. a some individuals showed improved performance over time future role exists for voice recognition software in assisting with story retelling as compared to word list (paired associ- those with milder forms of aphasia. CQLT. memory. Those with sia. Problems with generating ideas for message construc. explored for a patient with problems involving word finding aphasiocenter. of attention and memory in aphasia are intertwined with the tors postulated that the system’s success depends on an indi.org. with 8 of 20 patients tive functions. accessible site. At the conclusion of 8 months of training and practice with the system. however. conducted a study to examine e-mail training with a small sustaining. Fickas.GRBQ344-3513G-C28[756-799]. The accessibility and quality of Web sites aphasia. etal stroke (Bruce.org. www.org also proved to The introduction of voice recognition software also was be highly rated. and semantic knowledge. (1998) to meet with success.org. aphasia ranked www. 1999). These findings indicate that tasks dependent A more recent focus in computer use by those with apha. 2001). Other aphasia Web sites included www. Sohleberg. language.speakability. the partici. and expression of complex information following a left pari. and subsequent limitations in approach to treatment was reported by Helm-Estabrooks editing also were apparent. Murray. described long-term problems with verbal memory associ- served spelling skills also were judged to be important in ated with even mild aphasia. McKenna. and the patient reported using the sys. with the phrase training www. lack of error detection. constructing e-mail. and Worrall (2005) through ratings given sites. Other cognitive Egan. Overall.aphasiahelp. and visuospatial skills—as impor- ultimately achieving a high level of independence on the tant areas to consider in developing therapeutic approaches. intensify the actual pathologists. Especially with patients who have that the major barriers were lack of computer familiarity and more severe impairments and are unresponsive to auditory difficulty with learning to operate the mouse/cursor func. letters.uk as being the most ated with greater levels of severity in speech production. E-mail use proved to be the most popular She designed the Cognitive Linguistic Quick Test. Post- development of a written guide and a series of six training treatment testing revealed significant gains with auditory sessions provided by a volunteer. A specific cognitive tion. for those with aphasia were examined by Ghidella. patients could be taught to access the Internet through visuoperception. directly addressing attentional skills may tions. or function for all subjects. and Oxenham (2004) examined whether tasks were incorporated that addressed visual memory. Attention and concentration pants proved to be highly enthusiastic and motivated to activities included cancellation tasks. Some partially pre.aphasiahelp. Although reading skills were relatively well preserved. be the first avenue of treatment. focusing. in fact. of long-standing debate in the aphasia literature. the subjects were found to have a low level cited five domains of cognition—attention. to screen for problems in cognition that potentially Given that many people with aphasia are able to access— impact linguistic performance (Helm-Estabrooks. judgment. repeating and alternat- develop their abilities to formulate and send e-mails. or dividing their attention and that group of subjects having varying neurologic etiologies. Although memory problems error correction. ate) learning. They concluded input (Murray. such as turning on and off the computer. Ehlhardt. although www. impaired language system. goal of broadening opportunities for communication Evidence suggests that some individuals with aphasia may exchanges. dependent on cognitive processes. The speech-language pathologists judged language symptoms. Worrall.aphasia. & Coleman. or have the potential for learning to access—information with findings indicating that impairments of executive func- from the Internet. By developing auditory percep. The investigators further sug- improve semantic associations between written words and gested that verbal working memory is a “specialized form of related pictures. existence of a general working memory or attentional allo- cation system that underlies both language and problem Auditory Comprehension solving. The authors hypothe- patients (Marshall. at least.qxd 1/21/08 1:44 PM Page 764 Aptara Inc. Treatment for auditory comprehension has been divided into five areas: Auditory Processing 1. activities are incor- Kay. the patient must attach meaning to the stimuli pre- between language and problem solving in those with normal sented. It has been proposed that auditory com- activities. Another possible explanation may be the off-line but who persist with erroneous online judgments. ability to detect neologisms was purported to be on covert vocalization to aid performance. and semantic category. Carey. how- Baldo and colleagues (2005) explored the relationship ever.GRBQ344-3513G-C28[756-799]. whether these naming scores in the patients with aphasia. familiar and unfamiliar graphs. Depending on the type of aphasia. Comprehension of Single Units involves stimuli at the sion and. with no changes in auditory compre- not necessarily to demonstrate recognition of the stimuli. A hierarchy for semantic word cate- tory comprehension tasks. In designing activities. After 50 hours of In establishing awareness of nonspeech and speech stim- treatment. Robson. such as matching a telephone ring to its correspond- language skills and in those with aphasia. significantly improved judgments regarding covert verbalization that allows one to rehearse/maintain the accuracy of verbal responses were noted. Awareness of Nonspeech and Speech Stimuli Karcher (2006) with a patient demonstrating long-standing 2. consequently. 248). Klein. Comprehension of Paragraphs aphasia. some important designing treatment strategies. Although developed Auditory Perception for the population with acquired brain injury. Recognition of Nonspeech and Speech Stimuli. however. In LOT. Chelune. area. 1998). was used by Murray. or APT. pure-word deaf- 5. Monitoring Speech to the patient’s hierarchy of task difficulty. 1966. In the second changes from a functional perspective. or WCST. various hierarchies may hension Deficits. and foreign languages may be used. Goodglass & modality and prepare this mechanism for comprehension Wingfield. Comprehension of Short Meaningful Linguistic Units Various types of auditory processing problems occur in 4. Using the ing referent. Comprehension of Single Units General Considerations 2. but scores were reported. Talley. modest improvements in attention and memory uli. 2001). may not totally vocalize during administration of the WCST. they found a consistent porated to develop the patient’s ability to monitor the accu- correlation between this measure and comprehension and racy and/or meaningfulness of speech stimuli. auditory processing factors related to vocabulary selection are frequency of has been divided into two major categories: Auditory occurrence. Wisconsin Card Sorting Test (Heaton. gories for three types of aphasia is illustrated in Figure 28–2 tual skills. Pring. and response variables. & Chiat. Comprehension of Short Series 3. whereas covert verbalization is a more might be used with those patients who are able to identify general capacity for subvocalizing ongoing thought clinician errors as well as errors in their own productions processes” (p. In this sized that as tasks become particularly complex. Attention Auditory perceptual deficits are addressed in three areas: Processing Training-11 (Sohlberg. prehension of visually presented stimuli may be negatively . including auditory imperception. In the final area. These findings stimuli are his or her own productions or those of others. & Curtis. Following a course of treatment designed to capacity may therefore occur. Generally. Raskin. hension other than improved latencies in listening to para- Environmental sounds. and auditory agnosia. their perfor- account for the monitoring problems encountered by mance became significantly impaired. Monitoring Speech. Keeton. the patient is required only to respond differentially. and 1. and Auditory Compre. a reduced working memory from semantics. 1993). When has been suggested that auditory comprehension may not be the subjects with normal language skills were required to tied directly to monitoring skills or. & Mateer. Perceptual Processing Deficits. Paule. & Jones. one relies account. 1993). generally are associated with auditory comprehen. It were most evident in those with Wernicke’s aphasia. Recognition of Nonspeech and Speech Stimuli conduction aphasia. The patient and caregiver reported no positive speakers. grammatical class. Johnson. auditory perceptual activities be established through systematic alteration of both stimuli are introduced only if success cannot be attained with audi. The most prominent difficulties. 764 Section IV ■ Traditional Approaches to Language Intervention heretofore not been well documented. the patient may learn to tune into the auditory (Goodglass. This approach information online. When access to affected by impaired access to the phonologic output lexicon “inner” speech is disrupted. music. Comprehension of Narratives and Discourse ness. have received the most attention in single-word level. The APT hierarchy did not correspond 3. comprehension has example.. stress as a suprasegmental formed is influenced by situational variables (e. 1990).e. details.GRBQ344-3513G-C28[756-799]. . man-made objects (e. Kellar. emotional content. they identify the microstructure (words and their formance on language tasks. and previous experience to the inter- include situational context. 1997). which assists with among questions. from both predictive and non-predictive paragraphs preced- ing sentence presentation. Other issues to be considered goals. In aphasia. 1976. 1974). including comprehension of relationship to the text) and macrostructure (gist) as the two yes/no questions (Wallace & Canter. Moss.g. evidence from lex. a weak link between comprehension of when memory variables need to be stressed. Altering the using narratives with several topic changes can facilitate canonicity of thematic roles (i. Individuals with aphasia have demonstrated superior per. Repetition of key lexical items in the paragraph was believed to reduce the semantic process- impacted if the items depicted represent functionally con. speech rate. associated with those who were able to make the best use of ical decision tasks indicates that both normal controls and context. subjects and those with aphasia. the patient been shown to be superior for main ideas as compared to must attend to each item in order to identify the series cor. Less cohesive narratives may be Sentences that are longer and reflect more complex syn. tax tend to be more difficult (Shewan. theme. & salient or redundant cues in the narratives and then use them Jennings.g. Syntactic units are incorporated in the area of greater accuracy than implied information. Green & Boller. Finally. Schemas will and topic familiarity. coherence. ing stimuli. Cannito. Pashek & Brookshire. statements. sion activities might incorporate a hierarchy of sentence crete versus abstract word pairs. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 765 incorporating a second verb or proposition in a sentence has been shown to negatively impact comprehension in aphasia (Caplan. it is suggested that with greater Green. animals) (Goodglass. Hierarchies in difficulty levels. Comprehension of Short Series might be introduced 1995b). Decreased verbal memory span also was (e. 1972. and commands (Boller & inferencing.. Patients in the Figure 28–2. Word frequency has coherence or a strong relationship between propositions. been shown to affect comprehension in sentences. Alternatively. the 1975. when presenting a group of numbers. comprehension. to a news broadcast versus a classroom lecture). Finally. pretation of the narrative forms a schema. Briefly. vary among individuals. Knowledge common. thereby predictive paragraphs.. with comprehension and retention are facilitated. impact on discourse processing (Nicholas & Brookshire. & Cannito. by both normal Comprehension of Short Meaningful Linguistic Units. manipulating response variables such as picture Although sentence comprehension is influenced by word relatedness and number of response choices can increase frequency and syntactic complexity. suggesting that abstract types in concert with a presentation of predictive and non- words may be less rich in semantic representations. & Hildebrandt. 1985) when personally major text components.. chronic stages of recovery (6 months) benefited equally ences according to semantic categories. and ulti- processing. furniture) rather than those could be assigned to understanding the relationships that are visually conceived or based on physical properties between the nouns. In analyzing discourse. showing differ. For been offered. 1995). listening cue has been found to influence performance (Goodglass. Vogel. Bringing one’s own formulation of relevant material is used. and Pierce (1996) found that patients in the post-acute phase (5 weeks to 6 months) of their recovery experienced a facilitative effect in processing reversible passive sentences when they followed a paragraph of a predictive nature. Patients also may benefit from the use of context in sentence comprehension activities (Pierce. sentence comprehen- subjects with aphasia experience greater priming for con. With these findings in mind. better understood by providing a topic theme. frequently occurring vocabulary items facilitating about the topic increases inferencing. Jarecki. and goal) or recall of details. agent. because the individual sentences and comprehension of discourse has word series themselves do not form a syntactic unit. In addition. to assist with sentence processing. where variables such as word frequency and topic familiarity Pierce and Grogan (1992) describe a number of factors are important to consider.qxd 1/21/08 1:44 PM Page 765 Aptara Inc. Hough. and the macrostructure that is Particularly with sentences. these variables have less task difficulty (Pierce. the listener brings his or her own information from intonational contour to differentiate knowledge and opinions to the topic. teaching the patient to recognize making them more difficult to access (Tyler. mately. ing load for the target sentences so that more resources ceived.g. Waters. expectations. 1979). authors point out that while a text base (meaning of the nar- Patients with severe comprehension problems may obtain rative) is being developed. that normally are involved in narrative comprehension. and directly stated information is recalled with rectly. 1993). 1988). In addition to carefully selecting and order. 1978. 1980). When addressing Comprehension of Paragraphs and Comprehension of Narratives and Discourse. with the auditory modality. this term is used only when particular patterns . many of the Sample Activities above variables can be manipulated to form individualized Level 1 hierarchies depending on the nature and degree of the Stimuli: Paragraphs 60 to 80 syllables in length. mode of presentation goals and hierarchies. Altering the amount of cohesion and/or redundancy within narratives Level 2 and discourse could be additional factors to control while Stimuli: Paragraphs 60 to 80 syllables in length. resulting in problems with so that. Finally. and regarding the variables that he found affected his perfor- live presentations can have varying impacts.. Inability to comprehend written material because of Further information was then extracted through use of brain damage is referred to as alexia. letters. the Auditory familiarity. speaking between the participants is significantly dispropor. Identification of the gist. 1989) and may benefit from specific instruction by videotaped news segments and lengthier documentaries. and tracking. low varying the response requirements. visual perception and reading comprehension. Procedure: The paragraph is read aloud by the clinician. with aphasia. Further probing revealed that SK experi- General Considerations enced increased difficulty when required to make inferences and when the number of facts included within a paragraph Visual processing refers to the processing of information was substantially increased. with SK required to answer inferential questions. aphasia demonstrate reading impairments of varying When a 70% success rate was achieved at this level. for processing them. and mild Stimuli: Paragraphs 60 to 80 syllables in length. versity to complete his Master’s degree. he demonstrated fluent aphasia characterized by moderate Level 3 anomia. and high degree of topic familiarity. As For the first level of difficulty. scanning. more degrees. include those directed at improving inferencing skills by followed by inferential questions requiring a capitalizing on the patient’s knowledge of scripts and devel- yes/no response. Other tasks might Procedure: The paragraph is read aloud by the clinician. and adjusted by altering topic familiarity. auditory and visual processing problems. male university student. Patients with dancy. gestural. can experience limitations with visual recognition such that As treatment progressed.e. and high degree of topic details in narratives of increasing length and decreasing per- familiarity. before questioning by the clinician. Following exci- yes/no response. lengthy instruc- tions. sion of a left temporo-occipital arteriovenous malformation. forms. When applied to those either factual or inferential questions. high impairment. followed by inferential questions requiring a Auditory comprehension problems were initially found in yes/no response. this area can be subdivided into vided short paragraphs consisting of a high degree of redun. drawings.qxd 1/21/08 1:44 PM Page 766 Aptara Inc. the Revised Token Test. degree of redundancy. Case Example Procedure: The paragraph is read aloud by the clinician. SK was an active participant in developing treatment tionate) also have been noted. Comprehension Test for Sentences. and the Boston Naming Test. He provided detailed feedback may affect performance such that audiotape. followed Ulatowska. presented in pictorial. oping awareness and use of contextual cues. SK’s comprehension of material at the paragraph level and in his processing of linguistically complex. sonal relevance could be considered. and degree of redundancy. Visual acuity and field deficits responses on the part of the patient were gradually required also can affect performance. low agraphia. Short radio broadcasts were presented. ones in which the amount of of the response and varying the degree of topic familiarity. followed by inferential questions requiring a SK is a 24-year-old. Comprehension of Narratives and Discourse was next ing referents from contextual information (Chapman & developed. the clinician aurally pro. difficulty levels were further even matching objects. depending on mance and reported on written spelling. More complex words may be compromised.GRBQ344-3513G-C28[756-799]. More errors in recalling details of Task difficulty was again altered by increasing the complexity high-ratio dialogues (i. and/or written forms. Those with the most severe language impairments facts were included in the paragraphs to increase difficulty. main ideas. Formalized testing included administration of the degree of redundancy. 766 Section IV ■ Traditional Approaches to Language Intervention Some patients may experience difficulty in comprehend. The first treatment area selected was comprehension Visual Processing of paragraphs. and low degree of topic Boston Diagnostic Aphasia Evaluation. videotape. SK was asked to visual attention. colors. SK returned to uni- the individual. recall as many details as possible from the paragraph. it will be addressed temporal gyrus. which in turn impacts formulation of the abstract for reading that details the effects of breakdowns at the var.. involves Although no accompanying agraphia is present. reducing sublexical ments in aphasia tend to focus on construction of a model activation.GRBQ344-3513G-C28[756-799]. Some consider deep whereas difficulty with word comprehension was related to dyslexia to be a variant of phonologic alexia (Friedman. rate of presentation. and Mitchum (2005) summarized the (e. Eisenson. the orthographic input lexicon (OIL) is accessed their targets. 1984). of the visual word form area. These investigators found that more than Beauchamp. called the “graphemic Various patterns of symptoms have been associated with description” (p.g. Hypoperfusion of BA 37 was asso- to read are nouns. tion of a sequence of graphemes. Webb & Love. Once the lexical-semantic may have difficulty recognizing words. touch and hearing) can meet with success. is unable to read his or her own writing. in the prelexical activity of forming a representa- words may be encountered. and Wityk (2001) identified the processes that half of the errors in oral reading consisted of word substitu- most researchers agree are involved in reading. The most salient feature of deep dyslexia is substitution of Hillis and colleagues (2005) later studied the contribution semantically related words bearing no structural or phono. Barker. als to be caused by impairment of a possible lack of availabil- More current approaches in studying reading impair. The left angular gyrus relies on stored surface dyslexia. The investigators hypothesized that both the grapheme-to-phoneme correspondence rules to enable the right and left midfusiform gyri play roles. Tracing or palpating letters is not facilitative more than one cortical area. Breakdown reading impairments of left dominant hemisphere individu- occurs for both verbal and nonverbal material. was considered to be essential for var- Another reported syndrome. to reading because of its known consistent activa- being substituted or omitted. grapheme conversion rules. Errors involving visually similar is essential. Marked writing problems usually are found mechanisms were associated with hypoperfusion of the in conjunction with a right homonymous hemianopsia. Hillis. presented visually (Benson & Geschwind. but presentation of stimuli through another modality Berndt. They determined that some regions were responsi- notes and numbers. and 1995). From easiest to most difficult tion during reading tasks. sequential code for graphemes required for accessing the ious levels or stages of processing. parietal. Lexical-semantic impairments were noted here for ease of description and application. when irregularly spelled vocabulary is introduced. Those affected ble for more than one component of the reading system. involving frontal. depending on factors such as agnosia. Disruption of OPC and OIL (Lecours. Orthography-to-phonology approach. final stage. with the most important role being pattern of errors (Goodglass. pseudo-words also is encountered.qxd 1/21/08 1:44 PM Page 767 Aptara Inc. Comprehension aloud pseudo-words or regularly spelled vocabulary. Three disorders in four areas: the left angular and supramarginal gyri and of oral reading have been described because of their unique middle temporal gyrus. graphemic lexicon. the patient motor planning and articulation. with functor words typically (BA 37). although identifica. con. meaning of a word is derived from the lexical-semantic level. temporal. which of oral spelling typically is intact. Both color naming In attempting to determine the neural correlates of read- and color name recognition can be impaired. phonological output lexicon if reading aloud of irregularly rior. and adjectives. is visual ious aspects of reading. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 767 are observed. often along with problems in reading musical stroke. and the majority of these items were visually similar to marized. Haendiges. although rare. Although some individual variation was noted. Kane. level is sufficiently activated. which is activated for all spoken tasks. hypoperfusion in the left posterior. angular gyrus. and level of an individual’s reading skills. are unable to recognize orally spelled words and to spell whereas some individual components were associated with words aloud. The letter errors increased from the beginnings to the ends of . 37. Hillis and colleagues (2001) assessed hypoperfusion of Alexia with agraphia is characterized by a severe reading cortical areas in patients during the hyperacute stages of impairment. A cortical network. ity of grapheme-to-sound conversion. with the modality-independent lexical effectively accessing semantics and whole-word phonology representations required for output being subsumed by BA along with an overuse and faulty application of phoneme-to. Patients experience difficulty recognizing material spelling regularity. which is characterized by disruption in applying angular gyri. 1994). played by Wernicke’s area. 554). or pure alexia. and words traced in the do not need to rely on meaning or activation of OIL. and a calculation deficit. and occipital cortices. Patients which is activated by the OIL. tions. Commonalities reflect impairments in knowledge for OPC. Reading usually is accomplished using a letter-by-letter spelled vocabulary is required. Failure to read ciated with impairments in oral and written naming. Alexia without agraphia. although access to the OIL also was nega- Although the area of Oral Reading was initially included tively impacted by hypoperfusion of the posterior middle under the Oral Expression modality. 1993. sists of reading problems with preserved writing. making longer words more difficult to decode conversion (OPC) is responsible for one’s ability to read because of memory load (Goodglass. Briefly sum. although only one reading of pseudo-words. 1993). verbs. ing. 1999). 1969. The palm of the hand or palpated often can be recognized. superotemporal. word familiarity. or the left midfusiform gyrus logic similarity to the targets. it in turn provides input to the tion of high-frequency vocabulary and letters may be supe. pictures. In Reading Comprehension developing a hierarchy of difficulty. We took our/hour car) (Scott & Byng.g. relationships. Additional detail better preserved than others (Helm & Barresi. 1986). 1982. or Area 6. 1983) and can serve as an appropriate entry Gestural-Verbal Communication modality. letters. tion may be a less impaired modality (Porch.GRBQ344-3513G-C28[756-799]. characters. Noll. sentences. visual similarity. the stimulus category). Two areas for treatment of visual processing fall under the and time. the task may require matching a at the beginning of a word. Typically. Helm- will therefore follow in discussion of the Gestural and Estabrooks.” or the ability to with aphasia. This hypothesis Area 3. Fristoe. such as the individual’s educational level. that a tendency exists for those with left hemisphere dys. The theory of mind tasks. and line occupation. in reading. the patient make decisions about subordinate–superordinate Under normal conditions. 1989). with involvement of the temporal. are considered in drawing to corresponding gestures (Daniloff. in the left superior temporal gyrus and the with aphasia to imitate non-meaningful movements (Wang posterior cingulate cortex. Netsu & Marguardt. In addition. tend to perform more poorly in understand the behavior of others based on interpretation interpreting pantomimes than do those with normal lan- of. parietal. The right hemisphere activations are height- category of visual comprehension. is associating object. individuals with surface dyslexia may benefit from sen- tion. or matching trade- because of the activation of subsequent letters and then an marks to referents. Activation has been found bilaterally in the between gesture recognition and the ability of the person temporal poles. For example. To tax attention and memory. with patients area would be developed in the context of preparing a demonstrating severe impairments. 1967). This activity might be considered a form of moni- Treatment of visual processing is divided into six areas. 2005). 1995).. The task may then be made more Reading Comprehension activities are initiated in which difficult by requiring category recognition. 1980. 1999) that the patient recognize different visual forms of the same demonstrating that. 1984). as a group. intent. Matching Nonverbal Material. such as demonstrate faster reaction times in naming words that numbers. phrases. Because subjects without neurologic impairment Area 2 incorporates Matching of Verbal Material. Recognition of Spelling is addressed in Area 5. (e. ter overlap in the early part of the word. toring for those who rely heavily on written communication. Area 4 focuses on ened toward the ends of the narratives. in increasing order of difficulty. Other activities in this area might increase at the final letter position because no additional attempt to strengthen semantic activation through having letters follow. however. and words. and geometric forms. and avocational interests. or . that more complex social interactions were found in those One hierarchy that has been suggested for developing stories. Visual Correspondence/Recognition. Fratali. 1992). patients Others have examined “theory of mind. this addressed during treatment. of these items may be introduced. Although gesture recogni- is being synthesized and conclusions are being drawn. Kemeny. a series function to substitute their targets with words that have let. 768 Section IV ■ Traditional Approaches to Language Intervention words. processing of single words. point in treatment. A strong relationship has been found et al.g. In narrative involve functional relationships (e. Tasks may involve proofreading activities that include presentation of Visual Perception the patient’s written production or those of others for cor- rection. Area 1. when information Reception of Gestured Messages. Park. Three of these areas fall under the category of visual percep- Also.. & Braun. These regions are deemed to be implicated in the processing of Visual Comprehension the factual aspects of a narrative. and size of the stimuli. determining the extent to which the visual modality is & Lloyd. things that write) as processing. with the first specifically addressing visual perceptual tence judgment tasks requiring homophone recognition deficits. during narrative processing & Goodglass. activation levels are highest stimulus. Individuals with aphasia may experience even sentences. picture complexity and degree of stylization can be adjusted (in addition to altering In the final area for treatment of visual processing. comprehension of gestures. object picture. followed by a gradual decline printed word to a corresponding object.qxd 1/21/08 1:44 PM Page 768 Aptara Inc. requires the patient to match objects. and opercular areas at the beginning of a story. Many factors. feelings. demands was supported by earlier work (Whitney & Berndt. Individual hierarchies are have several orthographic neighbors. (McCleary & Hirst. but not with a global measure of aphasia. this modality may be patient for a gestural production system. the left hemisphere activations have been found opposed to those consisting of superordinate relations to be stronger. action picture. the authors contend established considering variables of length. implicated the tion are correlated with each other and with auditory com- left medial frontal gyrus. and narratives reflects changes in neural circuitry more difficulty in performing categorization tasks that (Xu. with further analysis revealing prehension. Pantomime recognition and produc- tasks. such as setting. stimuli may consist of single words.. for example. and motivation (Fletcher guage abilities. improvements in both the trained and 1994) addressed what those authors posited as being the untrained word sets were realized. Greenbaum. intact lexical-ortho. & Schwartz. Improvements were particularly evident production. with generalization to treatment hierarchy was established. that were untreated. 1998). & Garrett. with no generalization unable to encode individual letters and has limited ability to to the control items. although performance was monitored before this read more poorly than open class words. establish the route from the visual input lexicon to the sentation of cards with printed words for copying and oral semantic system. Greater reading accuracy did occur. more difficulty ing them in the subject’s hand. with an increase in semantic and visual errors. Tactile Coslett. Treatment of single-word reading deficits has Errors in reading words of increased length and reduced received the most attention in the literature and will be familiarity were described in a patient with some preserved addressed in greater detail. in which the impairment is believed to Another method in treating pure alexia has been to capi. morphemes. 1996). 1979) to improve the reading rate phonologic output lexicons) and must access the semantic of text. ing in context might be more advantageous than single- Although reading rate continued to be slow. Reading of both trained and untrained word with treated homophones and. with independent oral reading then being required. At the end of 7 weeks. pairing words with mnemonic aids talize on the tactile-kinesthetic feedback that the patient such as pictures improved oral reading of irregularly spelled may be able to use (Lott. in some patients with deep dyslexia. Hesketh. At the end of 7 weeks. This. Gradually. typically. Repetition of the word was then required until graphic and phonologic knowledge (Arguin & Bub. 1994). Patients were taught to . especially in the list format. Bound class morphemes were read more accurately the gains made during the period (1–3 months) associated than free class morphemes. route for reading. the failure of the patient decrease occurred in the number of errors after the imple- to encode abstract letter types. & Ralph. It has and visual cues were introduced later to assist in meeting the been hypothesized that the encoding of printed words is criterion. does not appear to be the sole contributing factor Spontaneous recovery of letter naming and single-word (Siverberg. followed by naming of the target and then pre.qxd 1/21/08 1:44 PM Page 769 Aptara Inc. with those lists improved with this therapy. correspondence rules. first. 1993). 1998). occur at the lexical level. 1995). and functors implemented in an attempt to improve the accuracy and (Burbaum & Coslett. to a lesser extent. Uppercase and lowercase let. In to increased speed and accuracy of reading letter strings. Vigliocco. spontaneous recovery (Robey et al.GRBQ344-3513G-C28[756-799]. Many treatment methods have ability to make semantic judgments of concrete words. Insaluco. the patient word reading or the training of phoneme-to-grapheme reported being able to once again read for pleasure. support was with- in reading lowercase as compared to uppercase letters may drawn. correspondence rules. be encountered. 1994.. but semantic value time to assess changes as a result of spontaneous recovery. Teaching grapheme-to-phoneme An errorless learning approach has been applied to treat. in turn. Treatment was not initiated until 22 weeks post. particularly for closed class in reading rate after treatment was threefold greater than words. which is reading of the trained set occurred. Although an overall underlying problem of pure alexia. forces the patient speed of the patient’s letter-by-letter reading. The instructor to analyze individual letters rather than using a more holis. with the most significant improvements resulting from although again. the investigators noted that the ters of varying fonts were used in matching tasks. One therapeutic approach (Arguin & Bub. however. with a slow reading rate of text accuracy in oral reading was found when comparing list to persisting until the initiation of therapy. The second treatment method was process low-imageability words. using a whole-word approach. The improvement text forms of presentation. Another patient was provided with sen- sets of individual letters in a uniform way. 2005). the Those authors suggested that treatment emphasizing read- length effect in reading single words was no longer present. consisting of uppercase letters and a font resembling script. A words. By week 54. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 769 paragraphs. Investigators tend to agree word reading by having the patient listen to production of a that the deficits found in pure alexia are associated with word along with simultaneous visual presentation of its prelexical problems and. Specific treatment techniques also have been applied to the Improvements were reported for matching tasks. identified the individual letters of printed words while trac- tic approach in reading words. & Linebaugh. printed form. Closed class words and pseudo-words are stroke. the word was read spontaneously with 80% accuracy. Saffran. starting with copying untrained items. in addition problems associated with surface dyslexia (Nickels. in the palm tence completion tasks involving homophone selection to of the hand. Additionally. significant improvement in forced to be accomplished by the right hemisphere. Friedman. has been used successfully ing letter-by-letter reading (Sage. both benefited from text presentation. surface dyslexia. mentation of both methods. followed patient’s reading pattern evolved to resemble that of deep by speeded reading of pronounceable four-letter strings dyslexia. The been designed for those who demonstrate features of pure first treatment method was designed to facilitate whole- alexia or letter-by-letter reading. Beeson and colleagues (2003) examined the natural Individuals with deep dyslexia are impaired in using recovery and treatment response of a letter-by-letter reader grapheme-to-phoneme correspondence rules and in using through implementation of a program involving multiple the whole-word reading route (orthographic input to oral reading trails (Moyer. redundancy. other factors such as syntax and number of con- late them orally using printed who. many of the factors outlined in auditory compre- gets. The second phase of treatment was non-lexical. hension of narratives and discourse could be applied to and After 10 sessions. what. overall length can be systemati- ing romance novels for enjoyment. were presented on a computer screen. abstract- tence forms (Germani & Pierce. when. the tion of predictive and non-predictive preceding paragraphs same length of paragraph was used. and why/how prompts. one strives for high passage dependency. use of anaphoric reference. activities from other modalities. Over time. where. Because the patient reported being an avid processes overlapped in time course. efforts have been made to associate the symptomatol- Additional probing demonstrated reading comprehension to ogy with a breakdown in one or more aspects of a model for be compromised above a Grade 3 readability level. with presentation of semanti. visual that a combined lexical and non-lexical approach might processing activities were introduced simultaneously with prove to be the most beneficial. where.GRBQ344-3513G-C28[756-799]. simple paragraphs. 1997). Similar to why/how prompts. As empirical data are limited. Material. Altering the degree ness. the authors speculated reader up until the time of her most recent stroke. reading significantly improved from for Sentences and the Boston Naming Test revealed a mild pre-treatment measures for both trained and untrained auditory processing problem. paragraph. Degree processing written words. incorporated in this section. grammatical complexity. duced. although generalization to untrained vocabulary did not occur. of redundancy and amount of context can be used in devel- Newspaper articles and short stories were gradually intro- oping a hierarchy for treating various sentence types. what. alexia. when. and famil- cally and/or phonologically related words. Once NH was successful in recounting performance in listening. com- plexity. what. Area 7 completes this modality with Reading Textual ment for deep dyslexia in a single case study. other and the plausibility of the answers given a multiple. higher passage dependency is indicated. The first treat. Battery. individual hierar- ment applied was lexically based. vocabulary difficulty. Administration of the Western Aphasia pairing graphemes with specific words selected by the patient. Stadie and Rilling (2006) compared two forms of treat. vocabulary. patients benefit from the presenta- the significant points from the paragraphs at this level. paragraph length. when. with the patient eventually reporting success in read- At the paragraph level. nificantly improved. Treatment hierarchies can then be of abstractness also significantly affected performance. teach- ple strokes resulting in left frontal and right parietal occipi- ing grapheme-phoneme correspondence rules by initially tal lobe infarcts. and moderate visual processing and graphic expres- content words.qxd 1/21/08 1:44 PM Page 770 Aptara Inc. 1986). a mild verbal dyspraxia. It is suggested that if the patient is able nonwords using these established associations (Nickels. Prime words iarity (Shewan & Bandur. 770 Section IV ■ Traditional Approaches to Language Intervention link letters of the alphabet with specific words that they had harder to answer without having read the paragraph on selected and then to sound out letters of simple words and which they are based. In devel- Sample Activities oping or selecting paragraphs. and of the Auditory Comprehension Test Following 19 sessions. and dependency are the relatedness of the test questions to each why/how cards. but the grade level was to facilitate comprehension of at least certain complex sen- increased to Grade 5. 1992). Feedback and additional cues were provided as needed. could be achieved by priming. followed by their tar. Procedure: The patient reads the paragraph and choice sentence format. with the underlying chies must be developed considering variables such as over- premise being that greater activation of the target word all length. As well. Questions involving little known orally responds to who. or WAB. vocabulary. and (Thomas & Jackson. reading accuracy for trained items had sig. . amount of cohesion. and grade level were systematically increased. having read the paragraph and not on previous knowledge Grade 3 to Grade 4 readability. The ders based on site of lesion. Other issues affecting passage printed who. to answer less than half the questions without having read the 1995). From the foregoing descriptions of treatment approaches Language testing suggested good single-word reading for some of the more clearly defined and studied forms of comprehension and ability to read short. and thematic content. The investigators did note that a Case Example part of speech effect no longer was apparent following ther- NH is a 69-year-old homemaker who suffered from multi- apy. Particular gains were found in the reading of anomia. cally adjusted while varying individual sentence length. facts and those requiring more detailed answers would be where. Because lexical and sublexical reading sion difficulties. which reflects the degree to which accurate Level 1 responses to questions about the paragraph are dependent on Stimuli: Paragraphs 75 to 100 syllables in length. When phrases and sentences are patient was required to read the paragraphs and to reformu- introduced. The established by altering vocabulary and contextual variables first difficulty level involved presentation of short para- that are known to play specific roles in each of these disor- graphs with a readability level of Grade 3 to Grade 4. and tent words relevant to length may be considered. & Johannsen- The patient learns to obtain the attention of a communica- Horbach. been described (Schlanger & Freemann. patients with severe aphasia com. 1986). Social Signals municate more often and for longer periods of time through Area 1 of gestural and gestural-verbal communication. or VAT. rmann. and that limb apraxia is not severe and predominantly ideo- motor rather than ideational in nature. a greater use of ture. with gradual transition to oral expression reinforcement. capitalizing on opportunities to provide point in treatment. cific instruction and coaching may be required for it to be taneously in their communication attempts. Fitzpatrick. with gestures successfully incorporated into communication exchanges. . Aphasia severity may. General Considerations requiring abstract thought. be the tural communication abilities (Helm-Estabrooks. with Amer-Ind code include good pantomime recognition where. visual/gestural program. and no printed cues. although not nec- tory comprehension skills and measures of pantomime essarily understood. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 771 Level 2 & Duffy. whom had demonstrated a limb apraxia on formalized test- Procedure: The patient reads the paragraph and ing. so spe- have been shown to use fewer complex gestural forms spon. although individuals with more severe impairments Individuals may not automatically use this strategy. and why/how prompts. recognition and expression. such as a head nod. 1987). is an elementary step in gestural communication. A possi- able to acquire some single signs. but at least in untrained users. or a combination of these. Gestural Communication. perhaps. the gestural modality tion for some patients by serving as a cue for word retrieval tends to be less affected than others in aphasia (Porch. gestural use in seven patients with nonfluent aphasia. activities. They suggested that gestural impairments or may be used to augment verbal expression training and/or enhancement might best be targeted in nat- attempts. 1982). when. Acknowledgment of the Message Received. the patients demon- strated several instances of gestural use to supplement or Gestural and Gestural-Verbal Communication replace their oral speech attempts. when. been used with varying reports of success. Finally. 1979). what. & Kaplan. ges- quent. this modality may serve as a starting uralistic settings. most significant determinant of successful sign use (Coelho & Barresi. production of gestures through pantomime training have Grade 5 readability. that they require less creativity and praxis skills. Wang and some form of gesture. 1990). in improving both apraxia and ges- (Coelho & Duffy. and printed who. conventional gestures. Watt. Successful outcomes have been described with Visual alize signs has been inversely related to severity of aphasia Action Therapy. These investigators con- cluded that the highly conscious nature of the testing. and propositional gestures. all of Grade 5 readability. Duffy. 1967). is developed to Goodglass (1992) found a strong correlation between audi- indicate that a message has been received. modeling. The what. perhaps. and shaping of behaviors. With Area 2. Pantomime performance also was strongly linked to the ability to produce meaningless Gestures gestures on imitation.GRBQ344-3513G-C28[756-799]. in fact. As a group. and why/how American-Indian (Amer-Ind) Sign System (Skelly. Rao (1994) has Procedure: The patient reads the paragraph and suggested that possible prognostic indicators for success orally responds to who. Some positive effects on the reception and Stimuli: Paragraphs 75 to 100 syllables in length. and Duffy (1994) have proposed that both language and neurophysiologic motor Single gestures and combinations of gestures are used in and visual processing disorders are tied to pantomime Area 3. Wiener. 1988). becoming nonspecific and unclear (Glosser. the presence of gestures.qxd 1/21/08 1:44 PM Page 771 Aptara Inc. eralizing simple grammars (Coelho. codified gestures has been observed. Rose and Douglas Level 3 (2003) studied the relationship between limb apraxia and Stimuli: Paragraphs 75 to 100 syllables in length. Pantomime production is reportedly infre- tion partner through eye contact. Reichle. Lucius-Hoene. use of gestures can facilitate oral speech produc- As noted in the previous section. involvement may. 1986). be capable of acquiring and gen. Conversational samples were elicited and analyzed for orally provides the relevant information. Some investigators have deficits. where. or by adding greater descriptive value to verbal output. 1980). and patients with less ble hierarchy might consist of appropriate facial expressions. Ability to gener. vocalization. nonverbal means than their communication partners (Her- Attention. touch. For others. 1979) has prompts. Despite the presence of an identi- fied limb apraxia on test measures. Wallesch. found propositional gestures to be more difficult to acquire Individuals with significant language limitations may be than nonpropositional ones (Buck & Duffy. In this nonvocal. suggesting. in addition to the removal of Gestural production may prove to be an alternative mode of meaningful context negatively impacted the patients’ per- communication for some patients with severe aphasic formance on those measures. In the next phase of treatment. however. Relative strengths were found in the areas of oral-gestural Oral expression problems vary with respect to both nature expression. along with 20 foils. movements compared with those involving distal move. agent. ranging from tasks such as requiring The Amer-Ind Sign System (Skelly. recognition. AG was required to produce the gesture in response advancing to implementation of Amer-Ind code training. and discourse planning/production. Additional strategies to ensure generalization to the patient and produces a gesture corre- include involving significant others in the program and sponding to one of the actions depicted. a strict LOT paradigm could not apply. replication. Simple Speech Acts. Elocutionary force is communicated with gestures Procedure: The pictures are presented one at a time. Ten com- culty using gestures representing objects involving proximal mon agents and actions were chosen for training. and severity in aphasia. to an action picture. 1986). ated gesture. is used. Procedure: The clinician presents an array of four pictures and initiation. Area 5. Although oral expression patterns Various treatment strategies were used to develop oral differ among types of aphasia.g. Other important variables to con. When Case Example you are hungry.qxd 1/21/08 1:44 PM Page 772 Aptara Inc. (Coelho & Duffy. poststroke. Modifications to VAT learning as opposed to stimulation of previously learned were based on the finding that patients experience less diffi. Functional oral communication skills.. Stimuli: Ten pictured actions. AG is a 62-year-old. gesture recognition. includes a combination of ver. 772 Section IV ■ Traditional Approaches to Language Intervention a hierarchy of activities. tion. The encouraging some risk taking on the part of the patient. statement. Problems may be encountered with highly Therapy as well as LOT naming and sentence formulation overlearned or automatic speech. suc- based on their physical or structural characteristics cessfully producing gestures that had not even been trained. & Albert. retired political consultant who suf- fered a stroke. lished. the clinician provided a gesture along with an array of four ments (Helm-Estabrooks. action pictures from which the patient was to select the one 1989). Oral Expression resulting in global aphasia and a right hemiplegia. General Considerations the Boston Assessment of Severe Aphasia was administered. skills. 1986). nicate content. and and/or vocalization to signal a command. those for which the meaning is evident sistently progressed through his treatment program. 1984). Continuous encouragement and counseling were needed. Patients also have a tendency to experience The subsequent difficulty level involved encouraging the less difficulty in learning signs that have a high degree of use of trained gestures in conversational attempts. although some Procedure: A sentence or brief story is aurally presented. Simple pointing gestures may be used to commu. including VAT and Melodic Intonation impairments. incorporates both message con. you). retrieval. associated with the gesture. imitation. verbalization may be produced. Ramsberger. or the patient is required to produce the associ- question. material. & Duffy. Objects however. Once recognition was estab- lems. VAT may serve as the initial phase in treatment. and visuospatial tasks. such as indicating the action. or object. to carry the burden of communication. A treatment hierarchy has been described by Rao (1994) Sample Activities for training patients with aphasia in the use of Amer-Ind Level 1 code. Because these . ever. how. consolidation. repetition. phonologic articulatory activities. Gestures continue. sider are the stimuli selected to teach the gestures. 1979) was next intro- the patient to match objects and pictures to gesturing the duced. even several months tural performance to line drawings (Netsu & Marguardt. and the patient is required to complete the sen- tence with the appropriate gesture (e. nication as a substitute for oral speech. Stimuli: The 10 action pictures used in Level 1 for iden- tent (proposition) and intent of the speaker (elocutionary tification. because AG was reluctant to use gestural commu- and action pictures have been found to evoke superior ges. With patients demonstrating severe language prob. Level 3 bal and nonverbal communication. AG con- iconicity—that is. It consists of a continuum of tasks: demonstration. with a large left middle cerebral artery infarct. Speech Acts Level 2 Area 4. patient points to the appropriate picture. naming. Initially. Speech Acts. Because this treatment approach focuses on new use of items hidden from view. Brownell. many patients share common expression skills. Initially. force). oral reading. Stimuli: The 10 action pictures used in Levels 1 and 2.GRBQ344-3513G-C28[756-799]. situa- Communicative importance or personal relevance is one tions were simulated in which AG provided the gesture in factor that may affect the ease of sign acquisition (Coelho the absence of the action picture. sentence formula- remained severely limited. Support provided by Repetition the clinician is gradually reduced to ensure that the patient develops more independence in oral speech. When introducing single words. vowels are easier to produce mance of other related speech-language behaviors. or a combina. production of the stereotypic words and phrases. Inserting a schwa (/ /) between consonants in a cluster may e phasias. In both picture naming and Speech Series. factors can influence performance. are carefully examined. Treatment therefore may group of 12 individuals with aphasia who demonstrated simultaneously incorporate two or more areas. impaired in both repetition and naming tasks. Phonologic-articulatory impairment resulting production requiring a number of consecutive responses. stress pat- a step to develop meaningful propositional speech (Helm & tern. such as production following a model. and conversation involving sentation methods also can be incorporated into a hierarchy. At the phoneme level. high-proba- place. lems with phonologic assembly when stress does not auto- is a treatment approach designed for patients with nonfluent matically occur on the first syllable. Separate hierarchies for presentation method. days of authors found that weak-stress and weak-strong-weak pat- the week. praxia and play an important component of Melodic teristics also play a role in ease of production. phonological problems. temporarily by some and be required as long-term strategies Phonologic-Articulatory Production. As the patient advances within the treatment hierarchy. months of the year. type of response. which consists of a hierarchy of three and voicing features being less problematic than manner and levels in which multisyllabic words and short. In conclusion. In repetition. such as finger tapping.qxd 1/21/08 1:44 PM Page 773 Aptara Inc. associated move- left hemisphere lesions also may result in sound production ments. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 773 areas are not mutually exclusive. additional response complexity can be required while main- acteristics. three-syllable words with primary stress on the speech in those patients with very limited verbal output. cited in Helm-Estabrooks & Albert. Single-word repetition is . Differing pre- reading. More spontaneous productions These hierarchies are based on data provided by a variety of are incorporated. stimulus char. 1991). 1980). Helm. They found that two-sylla- ing a therapeutic plan. phonologic errors in repetition. establish a hierarchy incorporating all of these parameters. or VCIU. and letters of the alphabet may terns were less likely to be produced correctly. example. as the patient can accommodate. with nasality Intonation Therapy. and facilitation of response vari. the majority of errors of stress assignment were produced on words with Area 1 of Oral Expression addresses development of Automatic weak-strong stress patterns. repetition tasks may be used in treating verbal dys- ficult than those of low frequency. or tion of both. those Stimuli such as greetings. For example. phonologically complex sentences (Sparks. phrase/sentence length. In develop. the areas of deficit. response variables constant. articulatory problems. In phoneme selection.GRBQ344-3513G-C28[756-799]. Distinctive feature charac. and highly frequent consonants are less dif. & Albert. poems. Facilitating responses may be used Language-Oriented Treatment activities in Area 2. may accompany speech. achieving spontaneous production of propositional speech is used. Howard and Smith (2002) examined a area may directly affect another. They be incorporated. errors. Combined auditory-visual presentation may facilitate cor- rect speech production more easily than either auditory or Phonological-Articulatory Production visual presentation in isolation. most often is termed verbal dyspraxia. from an anterior left hemisphere lesion. several variables may be ment. are based on Shewan’s by others. and facilitating ables have been constructed according to difficulty levels. limitations involving one quency and length. Although the ability to repeat is not an end goal in treat- In selecting treatment stimuli. taining the presentation method. to facilitate perfor- critical. generally in the form of literal or phonemic para. with the clinician gradually withdrawing researchers. Additional When preparing stimuli for repetition activities. the clinician therefore can bility phrases are musically intoned. enced positively by concrete. confrontation naming. It incorporates a progression through oral to increase the difficulty levels in treatment. in and surrounding Facilitating response variables can be manipulated to elicit Broca’s area. followed by longer. and linguistic complexity may be systematically varied Barresi. Activities are designed to facilitate oral repetition. errors were significantly more frequent on pro- Automatic Speech duction of the second syllable. unison production. functional words. second syllable were the most affected. performance is influ. For than consonants. stimuli. Misarticulations that occur with aphasia may be the result of The clinician may alter the type of response required. A step-by-step progression toward the goal of assistance. enhance performance. number sequences. When they did occur. (1980) Content Network for treating verbal dyspraxia. Posterior more accurate productions. hypothesized that stress-related errors are related to prob- Voluntary Control of Involuntary Utterances. along with their ble words with word final stress were most likely to be nature and severity. many variables that may be important to control are word fre. aphasia that attempts to use their stereotypic expressions as Beyond single words. this skill is described in Area 3. Tuomainen & Laine. 1972. site exists for words but. Martin. triggering and conducting the process demonstrate repetition difficulty with increasing syntactic of reconstruction. sentation of word forms. Anomic aphasia has been associated with lesions out. within a large network. 1991). 1996). enabling the patient to develop a greater understanding of Area 4. Merbitz. logic. the phoneme level provides feed- detail in the discussion of the Visual Processing modality. Responses can be analyzed more effectively. Activation also spreads to the Some forms of dyslexia have been characterized by differ- phoneme level. and if the stimulus is a foreign or pseudo. Martin and Saffran (2002) examined the outcomes of orders. which would preferentially assist in duction. Roelofs. 1997. such as reading single-word production are semantic or meaning-based. When sentence. For some individuals. 1976) can be used. On measures of Adolphs.GRBQ344-3513G-C28[756-799]. at the L-Level is chosen and spelling skills and be practiced as a strategy for word feeds information down to the phoneme level. Continued feedback from the phoneme level to the L-Level eventually results in Word Retrieval the most appropriate word being selected from those with Word-finding problems are associated with all types of competing semantic and syntactic information. which is used to access phonemes (Goldrick & Rapp. anterior insula. Researchers disagree concerning the degree to which reading of sentences and paragraphs. It therefore is important for the clinician to and formulating hypotheses regarding the cause of word determine the direction of this effect before its implementa. & Gagnon. Area 5. phoneme discrimination and on rhyming judgment tasks. These were described in related neighbors. The model of Goldrick and Rapp (2002) is termed a Presentation of scrambled written sentences for oral reading restricted interaction account of spoken word production. aphasia and also may occur in patients with non-aphasic dis. as are in the transient reconstruction and explicit phonemic repre- shorter items (Gardner & Winner. auditory comprehension. retrieval symptoms in a given patient can lead to the design tion in treatment. errors semantic class. that separable regions exist Response variables can affect accuracy and/or ease of pro. as Area 3 is. this strategy may have a negative impact (Gardner & Having an appreciation for a model of lexical processing Winner. Damasio. The most active unit. 1978). with sentences being systematically adjusted for and its neighbors that share semantic and/or syntactic infor- length and syntactic complexity.. whether in unison and these two processes interact (Dell. not only enabling the clinician to Oral Reading and Spelling successively respond online but also. In can be used with patients who may demonstrate impulsive the first stage. mation being activated. 774 Section IV ■ Traditional Approaches to Language Intervention affected by phonologic complexity. and dorsal temporo-occipital are controlled. Oral that are phonologically similar. Levelt. In turn. frequency of occurrence. Oral 2002). & Grip. cific categories in individuals with brain damage. Schwartz. those with fluent and those with nonfluent aphasia. During . and errors in naming of tools in the posterolateral that of nonemotional vocabulary.g. because patients perisylvian structures. High probability temporo-occipito-parietal junction. a hierarchy that varies sentence between those that support conceptual knowledge and the forms (Goodglass 1968. esis that such a relationship exists. with explanation.qxd 1/21/08 1:44 PM Page 774 Aptara Inc. unique persons). a concept activates numerous semantic fea- responding and poor self-monitoring skills. & Myers. comprehension. errors in naming unique persons were associ. The generally agreed-on cognitive processes involved in Improvements in language functioning. 1986. oral expression. and Damasio (2004) examined the naming of spe. repetition of emotional words is superior to junction. with the target word aloud. These investigators (Goodglass & Kaplan. of individualized treatment procedures. and output phonologic processing and tested their hypoth- ral regions. others. Tranel. 1983) and personally relevant proposed that although the perisylvian structures are involved material (Wallace & Canter. 1978). may be used as an activity to enhance written compared to its neighbors. and phono- and written expression. back to the L-Level. phonologically related errors on picture naming. ated with lesions primarily in the left temporal pole. have been described (Cherney. In their those with poor performance also made more nonword but investigations. use of a delay before initia. in naming of animals with lesions in the left anteroinferior word (Ramsberger. When abstractness and frequency temporal lobe. 1985) are easier to repeat. They can be tures. the processing of words denoting varied kinds of entities tion of a response can facilitate performance. along with retrieval with some patients. activating the target and competitors within the area of Reading Comprehension. has resulted in improved language skills in Saffran. involving word selection to convey a concept. as Spelling. rather. weaker activation of its competitors. For example. treating other aspects of speech-language skills. Oral Reading. although for (e. investigations concerning the relationship between input side the perisylvian region in the anterior or inferior tempo. most often is used as a vehicle for how and when errors may be generated. Grabowski. with the activation spreading to the next level required to point to each word in the sentence while reading (L-Level or lexical representations). 1999). independently. again activating the target word and its ences in oral reading performance. additional neural sites mediate level material is introduced. They claimed that no single mediational complexity. 1997). various errors can occur because gyri. Many patients also demonstrate greater duction. If vation noted in the posterior middle and inferior temporal noise affects the L-Level. Reporting on the fre- word retrieval problem of the individual patient. that members of living categories are discriminated among Berndt. be better named. Bruce. animals. process the breakdown appears to occur. founding effects are controlled. Burton.GRBQ344-3513G-C28[756-799]. actual word retrieval process rather than to teach specific The influence of grammatical class on naming has been vocabulary items. Differences in the frontal operculum and the left inferior temporal area. Parrent. with impairment at the phoneme level caus. ani- Damage to the semantic or L-Levels results in production of mals. representations. 1995).qxd 1/21/08 1:44 PM Page 775 Aptara Inc. Haendiges. including word characteristics. or body the non-homonymous nouns only produced activation in parts) as opposed to non-living object labels have been the left inferior temporal lobe. Best. Holland. Grabowski. animals and tools activated the ing multiple error types. Bandur. In other activation studies involving normal subjects. acoustic information is mapped to phono. followed by semantic and then not play significant roles in word retrieval (Howard. 2002). & Murray. The naming of homonymous verbs (e.. It might be argued that greater specificity regarding some indication of word form has been established or. which is consistent with results from lesion studies and acti- case studies.g. Methods of quently observed tip-of-the-tongue phenomenon. tion in the temporal lobe for naming unique persons. Martin. confrontation naming. and determines whether patterns of performance posterior middle temporal region. Of those sites. because the benefit from lexical. The authors proposed that. some instances. Others argue that when con. word retrieval treatment methods described through single. the Nickels (2002) reviewed the aphasia literature addressing majority included naming errors involving unique persons. . the strengthening activation patterns at the levels of disruption authors found that these two groups were more successful during the naming process need to be explored so that the than chance in identifying the initial letters of target words underlying nature of the deficit can be treated with greater (names of famous faces). with tool naming acti- parable to introducing noise into the processing system. When matched for frequency. flowers. The effect is postulated to be com. in selection and control of vocabulary as well as cueing strate. comb) Selecting vocabulary and developing a hierarchy includes resulted in less activation of the frontal operculum and mid- consideration of the lesion site and its known impact on dle temporal area. in pro. the goal is to facilitate the for patients with Wernicke’s and anomic aphasia. animacy and operativity do logic and then to lexical. tools.. input process. may reflect unsuccessful lemma retrieval gies might be better delineated according to the specific (Beeson. Damasio. ical context (e. establishes the and Hichwa (2005) reported that areas associated with vocabulary level and type with which the patient experiences action naming were the left frontal operculum and the left errors. Findings indicated the positive effects of treat. more limited evi- precision. The clinician first attempts to determine examined in neurologically intact subjects using positron- the nature of the word retrieval problem or where in the emission tomography. vation findings in normal subjects. It has been purported that word retrieval of common ment might work best for a given individual and how these nouns in conduction and Broca’s aphasia can occur late in improvements can be generalized to functional language lexical retrieval once semantic activation has occurred and use. however. and tools. Tranel. traditional language mapping tasks. tive naming errors in patients undergoing dominant ante- nity for increased activation of semantically related and rior temporal lobectomies for epilepsy. 1994). Disrupted feedback to the phoneme stimulation.g. A trend does. left posteroinferior temporal region. and area was more activated in naming actions than in naming conversational activities. During electrical unrelated neighbors. impairment of a single phonologic network would success in naming objects that are not embedded in a phys- create a greater challenge. but ability to recall living (e. appear tic processing could help to compensate for an impaired to exist for objects experienced through multiple senses to phonologic network. Increases also were found in rCBF in the left semantic errors.g. Alternatively. of various elicitation contexts. and Steven (2006) studied intraopera- of decreased activation of the target. One explanation is grammatical class does play a role in word retrieval. dence exists to suggest that word form knowledge is intact In creating activities in Area 6. The top-down lexical-seman. The authors concluded that described (De Renzi & Lucchelli. ment but left unanswered specifically what form of treat. & Gatehouse. allowing an opportu. temporal pole for persons.. naming errors were incurred at sites located level can result in nonword errors being produced from the more anterior to those identified during implementation of lack of signal strength of the appropriate phonemes. doorknob) or are separate from their semantic feedback is less than that provided during the environment. The homonymous nouns activated the naming. and Mitchum (2002) studied each other based on visual features. food. conceptual. These models can be used to account for the various Damasio and colleagues (2004) found a small area of activa- error types found in aphasia (Goldrick & Rapp. rendering them more the effect of word class on word retrieval of nouns and verbs difficult to name. whereas identification of tools is based on in aphasia and a matched normal control group through use functional characteristics. The middle temporal vary across picture description. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 775 comprehension. Best. and Patterson information. Pindzola. rhyme. some additional stimulus variables to consider are naming task at the end of 8 weeks of treatment conducted word length. ities and contexts may be employed to assist the patient in graphic cues. however. graphic cueing in facilitating word retrieval with 8 patients sistent problem in producing regular past tense verbs were who demonstrated difficulty mapping semantics to phonol- those who were most impacted by phonologic complexity ogy. Best. and would potentially aid recall. Training sessions occurred come). Saffron. and phonemic and ortho. have been specifically associated with severe anomia. Herbert. Herber. For the group meanings when activated. Some individuals may be sensitive to prototyp. the controversy regarding whether category-specific nam. Some findings (Stimley & Noll. demonstrated a significant improvement on a 200-word Finally. This group Patients with anomia also seem to demonstrate a prefer- also tended to substitute nouns for verbs across all the tasks ence for semantic cues (Li & Williams. with a decrease in unrelated word errors. patients were given the choice of cues that (consonant clusters) and atypicality (syllabic stress falling on they wished to be presented. The largest cue effects difficulty in naming pictured actions using latency measures. presented. frequency. demonstrated a verbs (e. although frequently used.g. no effect for cue type on learning was difficult to retrieve compared with heavy or more complex found. Lambon-Ralph. The three individuals who benefited most from Once stimuli have been selected. and stop) (Breedin. & beneficial. easier to name if its label is of low uncertainty. Seven of the eight patients the second syllable).. logic and semantic cues in the treatment of one patient with matical categories may be differentially affected depending chronic anomia. human action. within the same sessions. Goodglass et al. The authors suggested that the ticular name. Wambaugh (2003) compared the use of phono- Some investigators have reported that semantic and gram. McClelland. 1986). The authors did not cues. Although both types of cues proved to be on the type of aphasia (Berndt. Uncertainty which could reflect the fact that both cues were trained indicates the consistency with which an item is called a par. positive effect for semantic as compared to only phonologic 1998). success of their study might be related to the patients choos- icality. Freed. run. Particularly with those who demonstrate more lobectomies and that both groups were less successful at severe impairments.qxd 1/21/08 1:44 PM Page 776 Aptara Inc. initial syllable combined with sentence completion more poorly than those who had undergone right temporal format). Another factor to gory specifications. (2005) studied a group of patients with nonfluent aphasia to Hickin. in turn. combined presentation may be most naming actions than at naming objects. No one cue was found to be more effective. and Osborne (2002) stud- compare production of regular and irregular verb forms. Osborne. and Babcock (2002) examined the facilitation demonstrated better naming of objects defined by visual effects of personalized cues on naming in a group of unim- attributes compared with those associated more with paired speakers and in a group with patients with aphasia.. & Schwartz. An item may be once weekly. & Werdner. render them more without brain damage. ied the long-term effectiveness of phonologic and ortho- They found that those patients demonstrating the most con. The group with aphasia. that patients in the left anterior temporal lobectomy group Karow. Phonemic cue presentation.. Less difficulty may be encountered in naming pictured find a relationship between degree of impairment and the stimuli than in providing responses to definition or sentence . may generate a number of three times per week over a 4-week period.g. A number of activ- including repetition. They found that patients who had consider in cue presentation is the use of simultaneous cues undergone left anterior temporal lobectomies performed (e. All cue conditions were effective. Noun impairments found with the lists trained using semantic cues. 776 Section IV ■ Traditional Approaches to Language Intervention both patients with aphasia and controls demonstrated more ultimate size of the facilitation effect. In this study. the number of phonemic paraphasias. It also was noted effective (Huntley. Howard. 1997. Hickin.g. correlated with poor sentence production skills. Braber. and they developing an understanding of the effectiveness and use of remained so for a period of 10 minutes. therapy were those with good repetition and oral reading gies are determined for each patient. and concreteness. were found in those whose impairments did not lay at either The authors judged that imageability was not a contributing the semantic or phonologic levels but appeared to be associ- factor. Light verbs (e.. Mitchum. 1990) when verbs are as compared to those with anomia. may increase ing deficits are attributed to grammatical or semantic cate. do. other factors ordinate category (dogs) by developing their own cues that also may affect performance. 1991) indicate that pre- although verb retrieval deficits can occur with both Broca’s sentation of semantic cues increases the number of semantic and Wernicke’s aphasia. skills. effective cueing strate. have. The poorer naming performance of verbs by patients ated with mapping between the two levels. Marshall. which. and Howard (2002) studied a group of 11 individ. Each group was required to learn a list of names from a sub- Within the grammatical category of verbs. Haendiges. hit. a greater and sustained effect after 6 weeks was Sandson.GRBQ344-3513G-C28[756-799]. the tasks. The hierarchy shown in Figure 28–3 is an attempt to inte- uals with aphasia to examine the effects of training with cues grate the findings of various researchers. 1966). or the degree to which an item is characteristic of its ing the cues. on the other hand. perhaps signaling more active reflection during class. Lu and colleagues (2002) studied paraphasias. Bisiach.. 1997). Use of stress in these cases would be an tion. for example. or line drawings have been cited. or HELPSS. No one particular ing strategies (Li. esis suggests that some patients are unable to relate sentence ingly difficult levels of vocabulary and cue presentation— form to meaning (Marshall. with prompts from the clinician to enable the A hierarchy of sentence types for training also might be development and use of self-monitoring and problem-solving created based on order of reappearance in language samples skills. Shelton. phrase/sentence length. application of mapping therapy has proven to result in qual- itatively or quantitatively similar outcomes for all patients. Both the syntactic context and/or syntactic with Broca’s aphasia. structures in canonical (e.GRBQ344-3513G-C28[756-799]. has met with some success in developing effective cue. and ician may need to alter this presentation variable on an indi. Sentence Formulation treatment involves both comprehension and production Area 7. 1994). Ultimately. using increas. Hierarchy of cues according to effectiveness level. subject-verb-object) and non- chy of sentence types may be established.qxd 1/21/08 1:44 PM Page 777 Aptara Inc. 1981). Difficulty presence of auditory comprehension problems. application of Promoting Aphasics’ Communicative moved argument structures are lost. cal markers (Goodglass & Berko. Another highly researched approach in treating agram- colored photos. Schwartz et al. important variable to include in the treatment hierarchy. tasks should be implemented that allow mation about its thematic structure (goal or agent) or a pro- practice to occur in meaningful.. This (noun phrase and verb). although patients encourages patients to use multiple channels to communi. Kitselman. the patient is required to produce the imperative intransitive to use of the future verb tense. 1994. 1995). 1994.. Sentence types range from et al. 1972. 1966). naturalistic situations.. so the clin. Colored in the Helm Elicited Language Program for Syntax lines may be drawn on cards to represent syntactic class Stimulation (Helm-Estabrooks. requiring highly individualized implementation. Patients Weinrich. Eventually. & Spinelli. Sentence Formulation. which in both comprehension and production. supplemented by semantic informa. cate. The stress pattern of a sentence cally related to the target (McCall. Nickels. Typically. The mapping deficit hypoth- As patients advance along a hierarchy—that is. matism has been mapping therapy (Byng. Thompson & Shapiro. & Lang. with the patient required to select approach was developed for patients with nonfluent aphasia the appropriate color-coded written phrases to match the to improve their use of syntax by training 11 sentence types cards and corresponding pictured representation (Byng with a story completion format. Patients levels can be developed by varying the uses of morphologi- with anomia. Smith. perhaps related to residual syntactic skills.g. The problem can arise responsibility for cueing is shifted from the clinician to the from a lexical deficit in which the verb fails to provide infor- patient. 1960) and by varying sentation of a sentence frame containing a word semanti. Black.. generally are able to carry out grammaticality judgments. A hierar. vidual basis (Benton. 1973) elicited from those with aphasia. Differing findings regarding the use of real objects. Cox. 1988). 1997). Dusatko. tend to initiate utterances constraints imposed. may benefit from the pre. 1981). or PACE. & may influence performance of some individuals. particularly in the (Ludlow. 1994). focuses on the generation of tasks to encourage explicit analysis of verb-noun relational meaningful units at the phrase and sentence levels. appear to be facilitative. 1995. Byng and colleagues (1994) described increased verb . Marshall. such as that found canonical sentence types (Schwartz et al. on the other hand. completion tasks (Berndt et al. For cedural deficit in which the rules assigning thematic roles to example. the sentence. 1995). These limitations occur Effectiveness (Davis & Wilcox. with stressed words. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 777 Figure 28–3. such as use of pictured stim- of five patients with Broca’s aphasia. The authors claimed that improvement on untrained tion have not been reported (Weinrich. and modifiers. 1997). For some with severe aphasic limita- ings from complex to less complex structures (Thompson. Flowers are plants). 2003). ent aphasia. Significant improvements in grammar were chronic. generalization to untrained items verb-object constructions improved both when using C- could be enabled. Some patients produce a . At the Estabrooks. The LST was applied to training of sen. To the less complex sentences of the same type and. Some patients have demonstrated a positive ment with more complex forms: NP-Verb-NP-PP (e. VIC. anterior systems involved in language recovery. tions. they found that more complex were good indicators of response to C-VIC when consid- sentences in discourse were evident. Bose. and it leads us to reexamine Improvements on all trained sentence structures were found the complexity factor within that context. patients were introduced to treatment. even before the beginning of Thomas. opment of sentence hierarchies. Cox. 1989b) also completion of treatment. In a study conducted to validate the generalization find. treatment approaches for sentence formulation were target. & Nicholas. Morgan. tion (Weinrich. Schwartz and colleagues (1994) not shown. Overall test Generalization of LST treatment gains to discourse was scores on the Boston Assessment of Severe Aphasia (Helm- further studied by Thompson and Shapiro (1995). They might play a role in determining successful candidacy for C- also found an improvement in comprehension skills. Individual differences were noted The C-VIC training might be employed as a branch step across patients. They proposed that by constructions. successful attempts to facilitate the generalization of the eight patients. & Sobecks. group of patients with severe aphasia to isolate factors that tion occurring when simpler forms were trained first. Improvements also were tences in which noun phrases (NPs) had been moved out of noted in the use of locative prepositional phrases (e. those with the least uli or conversation. to address therapy. the underlying nature of agrammatism has shown promising Mapping therapy for sentence production has been inves. & Thornburg. and Scofield (2005). In summary. in the number of verbs produced.. & McCall.GRBQ344-3513G-C28[756-799]. such as LST. McCall. such as lesion site and/or psychological fac. Kiran. Thompson and Shapiro (1994) concerned that a lexicon consisting of animate nouns. Employing comprehension and formulation addressing the underlying representations and processes of tasks. needs to be considered in terms of how severe impairments benefited most. These authors concluded that the best outcome (abil- although a similar generalization pattern was not apparent. Jacobs improvements were noted but varied with individuals. the (1999) determined this approach to be successful in a group impact of contextual variables. The investigators initiated treat. Shelton. McCall. In this system (Weinrich.g. & sentence types resulted because they involved similar under. Inability to umented in narrative analysis. strated by the participants. prepositions. They found generalization to retrieving verbs also were a by-product of this approach. with varied degrees of generalization. with for more customized approaches. unable to make gains in these abilities using the methods tors. (2001) further detailed discourse changes following LST haps reflecting differing patterns of deficits and/or a need and found that communicative efficiency improved. ity to initiate communication with C-VIC) was associated Other noteworthy findings were an increase in utterance with a lesion sparing large portions of either the posterior or length and in the proportion of grammatical sentences doc. were available to be inserted into slots provided for the guistic and psycholinguistic underpinnings developed a patient and clinician/interactant to form simple syntactic Linguistic-Specific Approach (LST). 778 Section IV ■ Traditional Approaches to Language Intervention retrieval with their patients using this method. Ballard and Thompson Finally. 1997). 1995). per. with narrative produc. Weber. the application of a sys- of their production measures following a course of mapping tematic psycholinguistic approach. in selecting treatment tasks and or materials. subject- sentence formulation. Shelton. nonfluent aphasia. in three of date. Naeser and colleagues (1998) studied a revealed this phenomenon with significantly less generaliza.g. on. Ramsberger. their canonical positions.. Although no specific only a positive trend in informativeness for four of the five training in production was provided to their group with patients studied. This approach challenges our thinking in the devel- tigated by Rochon. use C-VIC was associated with bilateral lesions.. The response through C-VIC training that targets tense inflec- mother is taking flowers from her son) vs. along with an increase ered along with lesion data. Other tions becoming more informative and efficient. Cox. common nouns.qxd 1/21/08 1:44 PM Page 778 Aptara Inc. verbs. while encouraging subsequent verbalization. Icons with printed words ing only the surface forms of sentences and not their lin. Gains in NP (e. The authors com. The use of C-VIC has been widely investigated. NP-Verb (copula). the authors again communication. particu- mented that performance might have been reflective of the larly with respect to its use with patients exhibiting nonflu- heterogeneous skills with thematic role mapping demon. described previously. and by). they may be impact responses. Laird. indicating that other variables may need to in LOT to facilitate oral sentence forms with those who are be considered. results. C-VIC might serve as a more permanent avenue of Shapiro. although listener comfort was rated as being found that the majority of patients improved on one or more higher post-treatment. VIC and in spontaneous speech. lying forms and processes.g. generalization to untrained sentence single sentence production in C-VIC to narrative produc- types. in. The authors maintained that. which can impact turn 2003). has been examined in the context of aphasia (Hengst. posture. requiring the patient. Simmons-Mackie. Unique to conversation. & Nicholas. 1998). Frame. and topic shifts. and introduction of individual discourse styles. nication partner in identifying opportunities for and practic. expository. ing implementation of effective strategies to facilitate the These patients were in the chronic stage of aphasia. of the trials. than in working to modify them through collaborative Another form of communication. patterns of seven individuals with aphasia who had either . the presence of contextual referents to enable the person to successfully significant difficulties in oral expression in the context of convey his or her message. 1991) uses prepared scripts.GRBQ344-3513G-C28[756-799]. so it was exchange. Aphasia. and/or restating may consist of the production of one’s own Kagan. The investigators suggested that address in establishing more functional communication developing an understanding of the couples’ communication exchanges and/or in attempting to generalize targeted areas patterns and styles before treatment were important factors in treatment. others benefit from more direct training. perspectives. communication became less effortful and overt. The study does. their ture (Correia. Turn taking was teers and the effectiveness of conversations in those with found to be unimpaired in a sample of speakers with fluent aphasia. Reported speech is a common form of conversation and Using a modified approach in a case report. strategies were described. others may pro. The couples treating conversation has been reported by authors incorpo. Hengst. Variability of tolerance for pauses also can be found ing. are the roles proven to be effective in improving the skills of the volun- of turn taking and repair (Ferguson. Brookshire. in facilitating conversational success. Ten played in enabling them to use various strategies with their treatment sessions were provided in which communication routine communication partners. For example. This process was examined in a group of patients with taking and repair. verbally and/or nonverbally. to communicate the histories to frame their communication. with aphasia to express. The program was designed to assist those duce more words. matched control group. a pattern similar to that found in those without aphasia. be an act of discourse for quoting or paraphrasing an indi- ticipated more effectively and to a greater extent in conver. degree of linguistic impairment. Hopper. and Square words or of someone else’s. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 779 greater number of major utterances (subject-predicate) in tional strategies to communication partners of those with response to pictures compared with the number in conversa. In examining the conversational (2001) reported on the effectiveness of teaching conversa. The rephrasing sation.qxd 1/21/08 1:44 PM Page 779 Aptara Inc. Neuman- intervention. Conversational coaching means to communicate information. shared knowledge regarding a particular topic may result in although some individuals might intuitively adopt these glossing over of problematic aspects in conversation rather behaviors. This approach was that section. demonstrated a number of different verbal and nonverbal rating different approaches. depending on the gender bias of the pic. collaborative referenc- repair. and goals. vidual’s words from another point in time. the patients demonstrated sia can learn and modify behavior through collaborative ref- an increase in the number of main ideas conveyed in telling erencing tasks. and then practiced by demonstrate that even those with moderate to severe apha- the pairs. and Schultz (2004) studied communication partners. Strizel. aphasia and familiar communication partners when they Successful use of the involvement of significant others in were jointly performing a complex task. (Holland. It was observed that the pairs relied on their shared personal with initial support from the clinician. aphasia. and behaviors. and feelings by directly training oth- ers to enhance communication opportunities. thoughts. followed by conversational opportunities. Holland. Boles (1998) one that may be enhanced in those with aphasia to promote selected three aspects of a spouse’s conversational style for more functional communication. knowledge. and this area may be an important one to stories to their partners. & Perera. aphasia called Supported Conversation for Adults with tion (Easterbrook. 1990). the patient par. The clinician assists the commu. With the spouse reducing her rate of speech. 1982). however. both as a lis- tener and as an enabler for more successful communication Conversation and Discourse attempts. Kingston. and over the course story to a significant other. Duchan. and Rewega (2002) studied the difficult to determine the role that treatment may have efficacy of conversational couching with two couples. Black. aphasia when conversing with both familiar and unfamiliar Simmons-Mackie. Brown. and Gannaway (2005) described reported speech to percentage of talking turns. Perkins (1995) suggested that the conversational interactions of a patient when the com- conversational partners respond based on the amount of munication partner was successful in using a variety of shared knowledge. in which many of the parameters affecting performance also apply to the volunteers’ skills were rated and compared to those of an other forms of discourse (Area 9) and will be outlined in untrained. Following treatment. acknowledging and revealing the competence of those with Although conversation is formally addressed in Area 8. or SCA. however. such as eye gaze. The volunteer training program consisted of a Current practice delineates four categories of discourse: 1-day workshop focusing on behaviors that assist in both conversational. modeled. among communication partners. procedural and narrative. characters. indirect (paraphrased).g. tion units. should have said or to speak for animals/objects). Expository discourse (related to a components of discourse production.. effec. seeking clarification.GRBQ344-3513G-C28[756-799]. One might initiate treatment with what I heard). tasks to improve grammatical form or word retrieval skills in A model for evaluating discourse can be useful for both discourse.qxd 1/21/08 1:44 PM Page 780 Aptara Inc. authors. and condition. Superstructure refers to particular topic. about an event. such instruction in the use of pronouns and other devices for as word retrieval.” e. one might develop a hierarchy of activities in Patients with less severe aphasia generally were found to enhancing conversational exchanges between patients and have fewer absent main concepts and more accurate/com- significant others. Pierce. identifying the main hero. either conceptually or chrono- complicating action (sequence of events). completeness. and narrative discourse (information global meaning or semantic content is termed macrostruc. topic maintenance. and resolution. In some instances. ence. is important to elicit samples from different forms of dis- tion is controlled. and place). aphasia. through lexical rather than grammatical avenues. In contrast. and ellipsis (the sentence con- syntactic and linguistic errors. articles.g. the sequencing of information and the establishment of ing repairs. Appropriate use of pronouns (with corre- their partner for them to successfully communicate despite sponding referents). minute and percentage of words that are correct informa- ing. 780 Section IV ■ Traditional Approaches to Language Intervention completed or were in the course of the therapy. and initiat. indexed many variables can be altered. maintaining cohesion may be needed. gestural production. Patients may demonstrate vary- and Ulatowska (1992) described discourse as involving an ing degrees of grammatical complexity in relation to the interaction between cognition and language and detailed the type of discourse involved. The first tasks that require identification of the components of the two forms of reported speech are the ones used most often superstructure in relation to a particular topic. Chapman opportunities for practice. and undecided (unable to categorize). Treatment in the area of conversation also may coherence at the macro. Practice in and may be appropriate tasks for treatment. ture. grammatical complexity . grammar was elicited through picture description. procedural dis- elements such as setting (e.. The logically associated). which is closely tied to cognition and. course (consisting of steps. projected (suggesting what someone When developing a hierarchy for discourse production. selecting the main by the procedural discourse task and then the story retelling idea/gist. Brookshire and Nicholas (1994) concluded that it in which the amount of shared knowledge or new informa. the investi. course and that a total sample of 300 to 400 words leads to tion have been documented less frequently in those with more reliable interpretation. in some way. The most complex linguistic performance. When constructing day communication situations. ment of accuracy and completeness of information. so involving significant others in this aspect of treatment Nicholas and Brookshire (1995a) determined that the pres- would be especially important. and accuracy of main concepts in con- Drawing on the work of the previously mentioned nected speech were related to the severity of aphasia. time. some may require instruction and practice in turn The difficulty level can further be increased by requiring taking. or writing. Five forms of reported Coherence also is aided by inclusion of cohesive ties speech were described and coded: direct (direct quotation). 1994). to a lesser degree.and microstructure levels. but the intent is understood) signal measures of reported speech could be used for documenting that the speaker is aware of when information is novel or functional changes in communication over time and could has. The value of a identifying the main concepts can be followed by develop- shared history was an important factor in reported speech. or story retelling) have been compared (Li. altering their rate of speech. Microstructure coherence deals with the con- gators found that reported speech was used by those with ceptual links that are established between sentences or aphasia and actually provided contextual information to propositions. As the complexity and degree of centage of content words was found with story retelling as abstraction are increased with these activities. be included as a goal in therapy. Although pragmatic deficits in conversa. topic familiarity may play a role with fied theme depends not only on the macrostructure but also grammatical complexity in discourse production. Specific focus on the generalization of specific linguistic skills. The authors suggested that struction is incomplete. opportunities compared to expository and procedural discourse. between sentences such as coreference and anaphora. Ritterman. the context might be altered to promote greater assessment and planning intervention in Area 9. Tasks that address this aspect of dis. 1996). to every. and modifying their turn tak. suggest- for incorporating more linguistically complex sentence forms ing that the patients were conveying the informational load become available. Various forms of conversation also could be introduced. Communication partners might benefit plete main concepts than those with more severe aphasia from specific instruction in dealing appropriately with when a variety of speech samples were studied. That’s profile of the patient. lyzing speech samples for number of words spoken per tively introducing new topics. formulating a title. When ana- pauses in conversation. Volpe. The ability of the speaker to maintain coherence or a uni. already been communicated to the listener. & Williams. a significantly higher per- deriving a lesson/moral. When on the microstructure components of discourse (Hough & provided with less familiar topics. as in picture description). however. depending on the particular (not stated directly or indirectly but “pointed to. followed course may include summarizing the story. For higher verbal ability demonstrate less of a decline with age example. or proverb. Performance has been shown to peek at 20 years and Written prompts were used on individual cards to remind the declines significantly after 70 years of age. 1992). Because the clinician ability to provide correct idiom interpretation has been cor. ments and frequent word retrieval problems. The WAB. In selecting stimuli. Polysyllabic nouns were named spontaneously. Subsequent testing determined that the most effective cation partners. What size?. idiom.. sion skills. The processing and production of figurative language are description of physical and/or functional properties. Picture description and procedural discourse tasks involv. 1997). strategies may be introduced to facilitate self- Alternatively. however. presenting a variety of ideas. Divergent think. information of a more abstract nature. however. specific train- educational level and age (Nippold. Written the direction of one’s responses. and on another. the ing demands the production of alternatives from given Auditory Comprehension Test for Sentences. cues for LP were presentation of the initial phoneme. ing in the area of providing physical and functional descrip- 1997). dancy and tangential or off-topic remarks. the situation in nication. use of descrip- hension skills (Tompkins. and compared to those with lower verbal ability. with oral speech limited to sentence frag- ducing alternate perspectives. either by having the patient write his or her narrative when tions (Chapey. Finally. Those with patient of the various physical and functional attributes. and judging what can and were elicited when pictured actions were presented. In addressing these aspects of commu. making inferences. with highly educated subjects without brain damage tions and identifying situational contexts for pictured polysyl- performing better than their peers in all age groups. in addition Along with activities targeting other areas. In examining What material? were printed on one card. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 781 can increase for procedural discourse but appears to have no contrast to the significantly impaired performance of sub- similar effect for story retelling (Williams. cannot be said in various contexts with different communi. describing procedures. 50% accuracy at these grade levels. tion and situational contexts was emphasized. and ing less familiar topics might be chosen when the emphasis familiarity with the stimuli must be considered. and the information. thinking or the development of logical conclusions based on information provided is involved in tasks such as explaining Case Example similarities and differences between concepts. A hierarchy of tasks could output paralleled spoken speech. Auditory and predicting different outcomes or solutions. & jects in providing explanations for both familiar and unfa- Ritterman. several factors must be considered. retelling sto- ries. Boada. with an emphasis on quantity.. story retelling and procedural discourse tasks evaluation. Li. this skill might be reflected by pro. In this activity. with resection of a left frontal glioma. successful in naming pictured objects characterized by mono- Chapey also highlighted the role of evaluative thinking or syllabic word forms using Grade 1 and Grade 2 vocabulary judgment. Some aspects included in discourse are selecting levels. provision of the situational context (i. cognitive-linguis- retelling conditions involving familiar topics. 70% success rate in providing the required information. A nonfluent apha- originality. Convergent and editing. be constructed addressing all these parameters. labic objects at a Grade 1 to a Grade 3 level was provided. In that study. Once LP achieved a with fluent aphasia and relatively high auditory comprehen. elaboration. and Boston Naming Test were administered. to transfer from the clinician to the patient.GRBQ344-3513G-C28[756-799]. the patient’s age. Interpretation and explanation of idioms words increased with both procedural discourse and story and proverbs can be used as higher-level. the number of content miliar proverbs. and organiz. the proverb interpretation and explanation abilities in patients question What is it used for? was printed. word retrieval to varying the degree of abstractness and the familiarity of was chosen for treatment. LP is a 44-year-old engineer who underwent a craniotomy ing ideas in a logical order for expression. the patient. particularly evident in discourse. What shape?. & Schwarz. such as monitoring for inclusion of and appro- incorporating familiar topics could be presented when one is priate sequencing of relevant details and checking for redun- attempting to elicit a greater number of content words. Probing revealed that LP was 80% the stimuli. and changing reading comprehension were both mildly impaired. another series of stimuli at the same level of difficulty was pre- tively intact (Chapman et al. Accurate explanation of proverbs also tends to be related to In the first stage of the treatment hierarchy. some of the mental opera. the phrases What color?.e. sia was exhibited. No successful responses ate metaphor. & McGarry. In discourse. The use of Because the interplay between cognition and language is written stimuli can be particularly beneficial in this area. by providing descriptions . Volpe. Uhden.qxd 1/21/08 1:44 PM Page 781 Aptara Inc. and integral to discourse. The which the item may be found). with the best word to fit the situation. educational background. believed that phonemic cueing would be a difficult process related with years of formal education and auditory compre. 1994). Listener tic tasks with patients experiencing problems in conveying familiarity evidenced no impact on discourse production. on discourse production is to improve grammatical form. 2001) associated with language processing possible or by having the clinician transcribe it for review and production are considered in this section. comprehension of proverbs proved to be rela. determining an appropri. This performance is in sented. agraphia. and spelling has been termed lexical or surface dysgraphia What is it used for?). Differing (e. computational models to describe the various processes ful in assisting him to retrieve the intended word. Margolin. was required to help the clinician Writing frequently is the most severely affected modality in identify pictured objects hidden from her view. 1993. he or she strate a word frequency effect. and then its spelling. Signs may include the inability to write words.. What shape?. Ellis. posterior middle and inferior cian to guess the identity of the pictures. 1984). provided needed cues only when naming was not sponta. icon (OOL). Hillis et al. a relationship was identified between Graphic Expression hypoperfusion/infarcts in BA 44. encountering word. (Beeson et al. supramar- ginal gyrus (BA 40). as versational activities. symptoms and localization have been noted in pure menting self-cueing strategies was provided in various con. the agraphia. . and ciate patterns of written performance with areas of cortical What is it used for?). along with for LP. 782 Section IV ■ Traditional Approaches to Language Intervention and situational contexts. verbs and adjectives). The patient first attempts to name the rules. They include pure neous. although accurate spelling of pseudo-words was possi- ble. their strokes. Level 3 Patients experiencing difficulty accessing their semantic Stimuli: Grade 1 to Grade 3 polysyllabic pictured systems demonstrate imageability effects (Schmalzl & objects and printed cue cards (What color?. 1979. Maintenance and sequencing of these What size?. To limit the patient’s reliance on the clinician.g. What shape?. intact. with involvement of Broca’s area (BA 44 and by the clinician. 2006). in which writing defects occur in relative isolation pictured items were again seen only by LP. conversion of graphemes to letters during writing. 45.GRBQ344-3513G-C28[756-799]. sometimes. Specific damage to the lexical route of What size?. resulting from hypoperfusion/infarct in the following prompted by the cue cards to enable the clini- areas: Wernicke’s (BA 22). aphasia. More recently.. practice with imple. What material?. In addition. involved in writing. His self-cueing strategies usually proved to be success. It generally is agreed that the writing of a familiar word first involves activation of the semantic system or the Level 1 word meaning. angular gyrus (BA 39). 2003. even individual letters. Hillis and colleagues (2002) provides the information prompted by the cue noted regularization errors and/or omissions in spelling cards to facilitate self-retrieval or identification familiar words. Level 2 Change. although oral spelling is was a highly functional communicator. What material?. When treatment was discontinued. 2006). In the writing of less to information requested on the cue cards. Nickels. until written production is completed through allographic Procedure: The patient is required to provide oral responses conversion and a motor response. Schmalzl & Nickels. Difficulty levels of other language impairments. 45). confrontation naming tasks were used.. finding problems primarily beyond a Grade 6 vocabulary More recent research trends have focused on developing level. Weekes. and graphemes are the responsibility of the graphemic buffer What is it used for?). What shape?. phonology-to- orthography conversion rules are implicated (Hillis. Breese. Procedure: The pictures are hidden from the clinician’s although sparing phoneme-to-grapheme conversion (PGC) view. with attempts being made to relate dis- ruption at or between given levels to specific cortical Sample Activities regions. Impairments with semantic-lexical processes Procedure: The pictures are hidden from the clinician’s were reflected in the production of semantic errors in writ- view. dysfunction. 2004. as were the skills required for nication through the use of graphemes (letters) or drawing. and agraphia with alexia. Hillis and colleagues (2002) were able to asso- What size?. LP compared to individual letters. varying patterns of writing problems When the provision of the cues became more automatic or agraphia have been described in the literature. and 6 and three cases of pure agraphia. & Heider. Historically. 2004).. familiar vocabulary and pseudo-words. Goodglass.qxd 1/21/08 1:44 PM Page 782 Aptara Inc. through access of its Stimuli: Grade 1 to Grade 3 polysyllabic pictured orthographic representation in the orthographic output lex- objects and printed cue cards (What color?. with disrupted access to lexical ortho- General Considerations graphic representations (Hillis et al. in also were systematically increased by introducing advanced which patients are unable to retrieve the graphic form of let- vocabulary grade levels and other grammatical form classes ter strings and. What material?. involve irregularly spelled vocabulary and demon- object spontaneously. The patient provides information ing. If unsuccessful. be particularly error-prone. 2002). Stimuli: Grade 1 to Grade 3 polysyllabic pictured In studying patients during the hyperacute phases of objects and printed cue cards (What color?. and visual association cortex (BA 19). Errors. temporal gyrus (BA 37). Verbs proved to Graphic Expression refers to the written output of commu. 1982. in which he a number of classification systems (Benson. spelling of nouns is more readily available than neighbors with similar strokes also occurs so that disruption verbs. therapy was designed to teach semantic implementation. stimuli. perhaps. even be the sole focus Words containing suffixes may prove to be more difficult for of treatment. rotation of gyrus. inappropriate spatial positioning. also might be included in designing tasks or considering with production of semantic substitutions. Generalization of improved written naming to . and orthographic information. Partial activation of observed. has been termed response variables. address. activities such as writing to dictation. 1983). is characterized by disrupted phoneme-to grapheme letters/elements. so this variable both the OOL and to the phonology-orthography levels. naming problems. For example. double The premorbid skills and interests of the patient will dic. Co-occurring impairments consisted of alexia and dimensional representations of nonverbal material are used. A hierarchy can be established by selec- preserved spelling of lowercase versus uppercase letters and tion of vocabulary across several dimensions.g. dependent on the use of dence rules are easier than those in which letter combina- skilled hand movements. followed by adjectives and grammatical functors at this level can result in substitution of visually similar let. Del Grosso Destreri and colleagues (2000) Areas 4 and 5.. This channel for expression of the orthographic output model have been detailed (Hillis. letter stroke patient’s performance. will be incorporated into or. impacting multiple Tracing and/or Copying Verbal Material. omissions. and repetition of elements/letters. and of their targets were noted. and yet accurate copying. Hanley & Peters. because shorter claimed to be related to impairment of additional compo. are incorporated. with Area 3 stressing the recall of highly an association between lexical agraphia and damage to the overlearned grapheme motor patterns. with damage to the angular ments. 2004). grammatical class may influence the accuracy of the With activation of graphomotor patterns. (1988) detailed a number of stages that intervene between selection of graphemes and handwriting. words that were learned earlier in life Areas 1 and 2 focus on establishing graphic and graphemic were better spared. Tracing left fusiform gyrus and inferior temporal gyrus (BA 37 and and/or Copying Nonverbal Material. and order of strokes and has been termed apractic regular expression of phoneme-to-grapheme correspon- agraphia. treatment approaches The final portion of this section will briefly address the directed at addressing breakdowns within the various levels use of drawing in aphasia. 1993). culty varies among patients and types of aphasia. and words are introduced in Area 2. 1993. & Goodglass.g.and three- 20). letter substitutions. In some instances. 1992). Word fre- impaired letter substitutions resembling the physical forms quency. 1981). With a patient demonstrating deficits within the cation. leading the investigators to conclude Task difficulty may be increased by altering the complexity that BA 37 and 20 may be involved in a variety of language of the designs in producing geometric forms and objects. Although order of diffi- area (Exner’s area. Written Spelling and Naming. 1981). highly overlearned include word length effects. Stimuli containing the most tion. tasks that require integration of semantic. tence or discourse formulation skills are being developed. vowels. Rapcsak and Beeson (2004) discovered motor patterns.GRBQ344-3513G-C28[756-799]. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 783 Davies. Better written naming. emotionality. as may production of for oral naming or can be targeted simultaneously when sen. spelling of pseudo-words and uppercase letters than to write in cursive script unfamiliar words is negatively impacted.qxd 1/21/08 1:44 PM Page 783 Aptara Inc.. Production of poorly formed or illegible letters are Length is an important variable to alter. homonyms and homophones. In the last number of years.. such as the patient’s name. ters. Writing Familiar Material. tions are a less frequent realization of sounds (e. double consonants. words occasion fewer errors than longer ones do (Friederici. 1996). fol- deep agraphia. designed to address such problems as incorrect letter ele- Phonologic dysgraphia. and telephone and sequencing errors. and Parris (2003) found that in their subjects with Graphomotor Access surface agraphia. may include described a patient with severe alexia and agraphia subse. phonologic-lexi- Letters. Although real words may be accessed through patients have demonstrated better ability to print in the lexical output system. might be considered as a compensatory form of communi. BA 6) (Hillis et al. and regular versus irregular tate the degree to which the Graphic Expression modality spelling may be incorporated into a treatment hierarchy. In Graphemic buffer deficits as a result of injury to BA 39 Area 3. writing can be facilitative patients (Langmore & Canter. Ellis number. oral spelling. orienta. Allographic conversion. distinctions. numbers. two.. In Area 1. concreteness. Impairments to (Goodglass. lowed by those in a series (e. imageability. and quent to a left temporoparieto-occipital hemorrhage. (Goodglass. Activities are modalities. has been associated with hypoper. nents of the graphomotor pattern that affect size. letters and numbers). Some conversion. with varying degrees of success being reported in its semantic system. When a part-of-speech effect is sequences can be specified in detail. /f/ in fusion/infarct in the area anterior and posterior to Broca’s telephone) (Friederici et al. Schonle. The allographic Word Orthography system is responsible for selecting letter case and style. Single items may be practiced. cal. exhibited an agraphia impacting the OOL. 1992). improvement on treated items at the conclusion of therapy. improvements. Follow up assessment of conversa- plemented by home practice. ing written communication in a group of patients with jar- Raymer. and written naming. with regular and irreg. and insertions. with the clinician then covering was not found. such as omission of letters in the latter halves of words. the OOL deficits. The first phase of the the same approach to better understand the underlying cog- treatment program consisted of the patient studying a word nitive deficits and how they respond to treatment. self-cueing with no signs of generalization. whose lesion involved the left anterior words trained with mnemonics improved. The clinician continued to conceal sions of “message therapy” incorporating treated vocabu- additional letters until the entire word was hidden and lary. which had been sup. although all patients demonstrated some ular words being error-prone. and Pring (2001) examined the potential for develop- changes in other areas. If disruption the word. demonstrated impairments in the grapheme buffer charac. with a different patient. experienced a consequent graphemic buffer of generalization to untreated items found. Three sets of words were developed that errors at the conclusion of treatment. tated. Each received six 45-minute ses- reproduce the letters. may result in errors that are phonologically the clinician provided the written word. The overall severity of the agraphia was similar worthy finding was the reduction of phonologically related in both patients. In one example. Generalization to untreated was established for a patient with verbal apraxia. The patient with OOL deficits demonstrated a significant ful outcomes with tasks designed to develop the PGC sys. Initially. similar spellings indicated improvements in the OOL. along with word-picture matching. Therapy concluded when the subjects had to the PGC mechanism is invoked with an intact OOL. If unsuccessful. PGC skills. phase incorporated the use of mnemonics. The therapy paradigm consisted of auditory spelling. achieved a 95% success rate in writing the treated words. In this instance. the patient was required to copy Generalization to the control sets or to use in conversation a presented written word. and conducted that incorporated a number of tasks. The investigators cited evidence that involved implementation of a cueing hierarchy for written the treatment had impacted both the graphemic buffer and naming incorporating anagrams and initial letter cues. copying it. with attempts made to strengthen or improve access to selective deficits in the OOL and the graphemic buffer using their orthographic representations. with more The treatment method consisted of copying and recall of correct responses and closer approximations to the targets. with impaired access to graphemic buffer. completion of anagrams. transpositions. spelling to dictation was found. however. Persisting errors were matched according to frequency and length. tem using cueing hierarchies.to 60-minute treatment sessions were terized by spelling errors. in writing narratives. written monitoring of semantic errors was facili. was noted in the patient with the graphemic another. items were nouns. with the remainder consisting of verbs suggesting increased attempts to access the lexical route of and adjectives. Initially. spelling of nonwords is problematic.GRBQ344-3513G-C28[756-799]. followed by repetition and Problems arising from the OOL. At the conclusion of treatment. identified each of plausible (Hillis. hundred irregularly spelled words were chosen for remedia. and Haley (2003) examined the gon aphasia. Cudworth. The patients and their partners were instructed on the reproduction required. Another note. removed the card. The second temporal areas. delayed letter substitutions. Although the goals of addressing the impaired PGC Treatment of writing also has been investigated to pro- system were different in these patients. 784 Section IV ■ Traditional Approaches to Language Intervention untrained items was found within the same semantic cate. printed word lists. Only the set of The second patient. to treating the disorder produced positive functional Chiat. A personalized vocabulary consisting of 20 effectiveness of a treatment program for a patient who common and 20 proper nouns was used as stimuli. with no evidence parietal region. buffer deficit. impairment. and asked the patient to write production of homophones could be beneficial. along with greater accuracy gory. a significant improvement in tions and partner interviews revealed that patients were . 45. along with a frequency effect. presentation of the stimulus. Marshall. The copying. and in items. and then rewriting it once patient. with lesions involving the left posterior parietal and the card was removed after a 5-second delay. A second stage of therapy was introduced to the first two letters and requiring the patient to recall and three of the participants. Generalization to at least some sets of Schmalzl and Nickels (2006) applied two types of therapy to untreated words suggested increased capacity of the address a semantic spelling deficit. Robson. Most resembled the orthographic representations of their targets. meaningful exchanges. whereas transfer of spelling knowledge output orthography and suspected degradation within the from the trained words to at least some untrained items with OOL in a patient with a left temporal lobe infarction. treatment targeting the letters. Four patients made significant OOL also demonstrated disruption. The word sets crossed a number of utility of writing words to convey information in conversa- grammatical classes and were controlled for frequency and tion and were provided with strategies to facilitate more length. twice-weekly. The first presented on a card. increasing with word length. in the context of intact attempted written spelling by the patient.qxd 1/21/08 1:44 PM Page 784 Aptara Inc. Hillis reported success. Two. Another successful approach. treatment gains after approximately 12 sessions. Rapp and Kane (2002) treated two patients who had tion. systematic approaches mote more functional communication. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 785 using writing in these contexts. skills. cited in oped. Copy and may serve in a patient’s day-to-day activities. personal history. His daily work activities relied heavily on written Many of the same variables found to influence oral expres. Once BC was able to write stimuli at the Grade 7 and Freedman-Stern. and agraphia were revealed. and expository (Freedman-Stern et al. with extension into the white matter in the left to provide a natural communication setting for the subjects corona radiata. success required before proceeding to training of the next At the time of initial testing.qxd 1/21/08 1:44 PM Page 785 Aptara Inc. Once the patient is successful in including these oblig. impaired auditory comprehension. participants. and the difficulty level was increased by using place. lier trained words being better maintained than those more Spelling errors were found mainly at the ends of words. followed by oral spelling. and result/resolu. Once criterion was reached in the group set. irregularly spelled words. conversational exchanges in a small group of subjects with Writing Complex Material. a conversational interaction was arranged with a novel numbers to 20 were correctly written. Only a portion of the alphabet and ting. Instruction in the use of cohesive word length. In their study. . interests. and narrative. BC identified graphic expression as an important focus in ity and length may be altered. spontaneous improvement was noted such that short in that more routinized context. Written Naming. with the goal of establishing conversation in a 1984). Clausen and Beeson (2003) targeted writing to develop In addition to the variables stated above.. can be systematically approached. recall training was provided. and paragraph levels may be used. for the most part. tutions and additions made words. A facilitator attempted angular gyrus. per. spelled nouns. Ulatowska. complicating action. name but not his address. the Auditory Comprehension Test to practice their trained vocabulary in the absence of any for Sentences. with untreated words being ing comprehension activities and then by their incorpora- incorporated in this functional activity. anomia. lems identical to those in oral speech. Eventually. recently targeted. where letter substitutions were noted. tence. and activities were later incorporated into Area 7. ing. work.GRBQ344-3513G-C28[756-799]. was simultaneously devel- lished focusing on the structure of the text (Labov. A possible progression from easy to difficult is words pertaining to family. Complex Material. in which material at the phrase. particularly related to correspondence. or spelling regularity. mildly impaired reading comprehen- set by an individual in the group session was the measure of sion. return to work. with the subjects required to write a word in response to a picture representation accom- Case Example panied by auditory presentation. with word-finding prob- miliar communication partner was more limited. may be required. The vocabulary was not controlled for fre. along with topic familiarity. including polysyllabic. Writing single words communication partner. the vocabu- atory elements. tion in written output. A neously in response to the picture stimulus. along with grammatical form class. letter. followed by weekly white matter in the region of the superior temporal lobe and group sessions with the four patients. BC is a 64-year-old. ten words in the group setting and demonstrated support for unidentifiable. with ear. A fluent aphasia. Area 5. The writing of four out of five words in a production. Irregularly spelled words occasioned the most errors. The WAB. such as adjectives and verbs. BC to write the word correctly. Baker. in preparation for the patient’s eventual haps initially through identifying their application in read. followed by other word tion. Oral nam- Grammatical structures are first introduced in Area 6. relative clauses. proved to be effective cues for Written Formulation. grammatical class. with paraphasic speech bers of the group. 1984) Grade 8 levels successfully. Written naming devices. Each of the participants was encouraged to tered. Sentence complex. such as anaphoric reference. and degree of imageability. a hierarchy can be estab. ment. a response hierarchy that chronic aphasia. istic application given the diversity of functions that writing quency. Because oral naming activities were being used in treat- taneously. classes. sion can be incorporated into this area and developed simul. in Area 7. characterized by moderately provide written responses or questions to the other mem. a model was provided for copying until success was achieved sponta. Further probing revealed that written naming was 50% successful using Grade 7 and Text Grade 8 polysyllabic. production with an unfa. BC successfully wrote his set of words. Thirteen weeks left hemisphere stroke resulted in an infarct involving the of individual treatment were provided. optional ones. sen. treatment. story. such as coda/moral of the lary level was altered. nouns with irregular spelling. sentence formulation was possible. & Delacoste. Writing temporal ordering. Over the course of the next 2 weeks. regularly such that task requirements might include mention of time. The authors reported that the to dictation resulted in no correct responses. how- one another. and the Boston Naming Test were adminis- pictured stimuli. Although written words were used frequently ever. self-employed business consultant. If unsuccessful. This aspect of treatment requires a highly individual- group setting. At the paragraph level. they trained four patients addresses the purpose and complexity of the text can be with global aphasia to write a list of personally relevant established. Letter substi- patients demonstrated improved pragmatic use of the writ. with a mean age of 62. could be advantageous. cited in Helm-Estabrooks & Albert. 1995). Involving of 9. 1976). Subjects who achieved an initial WAB Aphasia Quotient Uncaptioned cartoons are presented for copying from mem. and finally writes it. 9 years represents completion of significant others in communication exchanges through the first year of high school. As skills years.3 years (Table 28–2). regularly of both the drawings and their communicative intents spelled nouns. with a mean with strategies to reflect different time periods. and finally writes it. not as a replacement for language.8. those who have retained inner thought. The patient orally provides symptoms had lasted for at least 5 days were included in the the word. with the patient encouraged to respond Demographic Data of LOT Subjects through drawing. appeared to behave differently from those with ischemic Lyon (1995) considered drawing as an augmentative form stroke. practice in conveying information to significant oth.92 was similar to the mean for a The development of drawing in LOT may provide an group of 60 older. The clinician aids in correcting or expanding portions that may be unidentifiable through Ages of the subjects with aphasia ranged from 28 to 82 questions and/or adding features to the drawings. The mean rating of 38. Procedure: A written sentence is presented with the stimu. The upper cutoff of 85 years was used to eliminate Stimuli: Grade 7 and Grade 8 polysyllabic. 786 Section IV ■ Traditional Approaches to Language Intervention Sample Activities aphasia initially may be simplistic (Lyon. This suggested that the access communication through more conventional means. of severity or type of aphasia. the cutoff score defining normal per- ory until the patient is able to produce triple-panel formance. The clinician provides coaching to elicit draw. Because patients with hemorrhagic strokes ers is incorporated. along ranged from 4 to 21 years of formal education.e. score of less than 93. information are viewed as a key components in this treat.85 years. Because the drawings of patients with of 1. and the surrounding southwestern Ontario lus word omitted. spells it aloud. spells it aloud.) Socioeconomic status was mea- drawing and teaching them to interpret and probe for more sured using the Blishen Scale (Blishen & McRoberts.7:1. unilateral stroke and whose lus word omitted.qxd 1/21/08 1:44 PM Page 786 Aptara Inc. and finally writes it. Native speakers of English and competent bilinguals for tions in their oral expression abilities (Morgan & Helm. treatment duration provided in the study. which rates 500 occupations based on income and educa- ment approach. To avoid an imbalance in terms ideas and essential details. for from data analysis.0 was similar to ratios in other literature reports .. with productions including main jects being assigned to LOT. spells it aloud. Estabrooks. This ratio ful oral output. During the later phase of treat. of the general older population. as a tool for communication by patients with severe limita. (In Ontario. The spelled nouns. The patient orally provides EFFICACY STUDY the word. implemen- Level 1 tation of a treatment hierarchy to improve the complexity Stimuli: Grade 7 and Grade 8 polysyllabic. tion. The patient orally provides region in Canada. were included in the study. these variables. sample. Education are developed. 1991). The LOT subjects for whom the efficacy data are reported Level 2 here were part of a larger project designed to study the Stimuli: Grade 7 and Grade 8 polysyllabic. individuals between the ages of 18 and 85 Level 3 years). sequences. irregularly efficacy of three different types of aphasia treatment. Only adult subjects were included (i. The LOT group was com- ing with their limited written output to facilitate meaning. as were subjects with a Compensatory Communication hearing impairment or blindness. socioeconomic status of the LOT group was similar to that Some patients may encounter success in combining draw. Ontario. Only literate sub- Procedure: A written sentence is presented with the stimu. more complex topics are introduced. assignment was stratified for ment. normal subjects gathered in the area avenue of communication for those who are unable to (Shewan & Henderson. Table 28–1 shows the entry criteria that the word.GRBQ344-3513G-C28[756-799]. were met by all subjects. Procedure: A written sentence is presented with the stimu- lus word omitted. LOT subjects were drawn from a population in London. posed of 17 male subjects and 10 female subjects. the subject with a hemorrhagic stroke was excluded of communication. jects and those with a single. Subjects were included if Back to the Drawing Board is an approach that was designed they were referred and tested within 2 to 4 weeks poststroke. Hypothetical situa- tions are posed. Subjects who had a medical condition that interfered with testing or survival were eliminated. regularly subjects at high risk of not being available for the 1-year spelled verbs. whom treatment in English was appropriate were included. 1988). Random assignment to treatment type resulted in 28 sub- ings that are recognizable. or ACTS. Voluntary withdrawal Subject did not wish further 1974). five subjects spoke two or more languages. puted tomography or isotope brain scan. or RCPM. All subjects received 7 weeks postonset of aphasia. and always within ambidextrous person in the group. the Auditory Comprehension Test for Sentences treatment and/or tests Termination of project Data collection terminated at end (Shewan. and one had a right-sided lesion. 6. & Nelson.33 Etiology Infarcts Median 63. 246). Raven’s Colored Progressive of funding period Matrices (Raven. with the site and side of lesion confirmed by com- Treatment of aphasia. reliable test administra- Death Subject died tors who were independent of the clinicians providing treat- Second stroke Neurologic deficit persisting ment in the study. Treatment was controlled for treatment in English. A language-oriented approach (p. and 11 demonstrated some hemisensory loss. and 12 months after the first test. Choi. TX: Pro-Ed. Seventeen subjects showed some hemiplegia. A Prolonged illness Absence or illness longer than follow-up test at 6 months after termination of treatment also 3 weeks duration was completed for as many subjects as possible. Austin. 1975.qxd 1/21/08 1:44 PM Page 787 Aptara Inc.92 excluded Sex Medical status Excluded unstable medical illnesses Male 17 interfering with testing or survival Female 10 Sensory status Passed hearing screening for age Handedness appropriateness Right 25 Blind patients (defined clinically) Left 1 excluded Ambidextrous 1 Tactile dysfunction not excluded Language Time post-onset 2–4 weeks poststroke English 22 Language severity Native speakers of English or Polyglot 5 competent bilinguals for whom Etiology treatment in English was Infarction 27 appropriate Severe language barrier or Treatment of aphasia.0 Stable intracerebral hemorrhages Range 28–82 Excluded hemorrhages because of: Education (years) Arteriovenous malformation Mean 9. Most Speech and language treatment was initiated as soon after subjects were right-handed. 1979). Twenty-six sub- jects had left-sided lesions. A language-oriented approach (p. Austin. Geographic relocation Subject moved The test battery included the WAB (Kertesz & Poole. see Table 28–1). Kurtzke. criteria. accent excluded Criterion Variable Exit Criteria Methods and Procedures Language recovery Western Aphasia Battery Language Quotient of 94. Subjects received treatment for 1 language. with one left-handed and one administration of the Entry Test as possible. 1976). and a neurologic exami- nation. 1956). Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 787 TABLE 28–1 TABLE 28–2 Entry and Exit Criteria for Aphasic Subjects Demographic Data for 27 LOT Subjectsa Criterion Variable Entry Criteria Variable Value Age 18–85 years Age (years) Education Literacy by history Mean 62. English was their only both duration and intensity. one of year unless they exited from the study before that time (for exit which was English. For 22 subjects. (Abu-Zeid.0 All LOT subjects met the entry criteria (Table 28–1) and were or above tested at periodic intervals by trained. Tests occurred 2 to 4 weeks poststroke longer than 5 days (Entry Test) and at 3.85 Subarachnoid hemorrhage Median 9. eight were hemianoptic. TX: Pro-Ed. Intensity of treatment was controlled .0 Aneurysm Range 4–21 Single unilateral strokes Socioeconomic status Transient ischemic attacks (5 days) Mean 38.GRBQ344-3513G-C28[756-799]. 249). As with other groups. Six subjects Quotient (LQ) Outcome Measure for Language- were lost to follow-up: One died. however.50. Only subjects who received at least 3 months of treat. ery curves. (NTC) Groupsa Treatment was provided by trained speech-language pathologists. because Type of Aphasia the LQ score was designed to be a measure of severity of language impairment. Summary of Analyses of Covariance for Language ment were included in the efficacy evaluation.19 treatment type being provided. Competence was assessed by having each clinician design a Entry—Last Test 1-month LOT patient treatment plan. results remained essentially the same. language.93 4. Before providing LOT in the study. gains in the streams analysis of covariance. small to permit statistical comparisons among groups. in turn. At follow-up. The dependent variable in the com- Substantial gains were noted at each test thereafter. to the mean LQ score at each test could be different as a Unlike the LOT group. these subjects both started and ended with lower LQ that could possibly influence outcome results) were added as scores compared with those of subjects who had the other concomitant variables in the analysis of covariance. although those with global aphasia did make notable with a standard error of 4.3 sessions. As seen in Figure adjusting for entry score and educational level. grouped according to the number of tests that they received Whether LOT resulted in significantly greater language and were followed accordingly in streams (Fig. TX: Pro-Ed. After this time. The subjects with Broca’s aphasia made gains throughout To control for the effects of spontaneous recovery. was 11. and three withdrew voluntarily. 254). Treatment of aphasia. language impairment.  Mean Difference Standard Error each clinician demonstrated the competence to plan LOT. controlling for initial severity. Again. external evaluator. Initial severity was controlled through covarying for initial WAB LQ score (LQENTRY). with a range of 1 to 118 ses- sions. handedness. showed some interesting recov- was comparable with the LOT group for age. The NTC group through follow-up. Entry—Test 2 0. however. (Shewan. external evaluator to ensure that LOT was the 0. Estimate of Adjusted the developer of LOT.4 points lower than that at Test 4 (treatment termination).qxd 1/21/08 1:44 PM Page 788 Aptara Inc. no generalizations can be . The group of subjects with Wernicke’s aphasia contained sis of covariance indicated the gains for the LOT group only four subjects. who made substantial gains in the first 3 were significantly greater than those for the NTC group months of treatment.43 3. When age and sex (variables gains.02 5. the NTC group contained result of subjects exiting from the group. two relocated geographi. the analy. each clinician was evaluated by a second Test 2—Last Test independent. 28–4). the largest gains tional analyses of covariance were performed comparing were during the first 3 months. 0.71. which passed evalua. the treatment period.86 2. LQ scores Test and the Last Test were compared. LQLAST. addi. 1986). Because the number of subjects who contributed socioeconomic status. The LQ mean at Test 5 (follow-up) was only composite of the WAB oral and written language tests 1. the subjects were an equal number of men (n  11) and women (n  11). 28–4. controlling for the initial severity of were greatest within the first 3 months of treatment. Efficacy Data The efficacy of LOT was demonstrated by comparing the The number of subjects within each aphasia type was too LOT subjects with a no-treatment control (NTC) group. For the three subjects with follow-up tests. after gains from treatment were maintained. the types of aphasia. Oriented Therapy (LOT) and No-Treatment Control cally. gains were greatest during guage outcome.GRBQ344-3513G-C28[756-799]. A language-oriented approach (p. is known to affect lan. At 6.50 4. When gains compared with no treatment was examined using the entire LOT group was considered. scores were LQTEST 2 (3 months after the Entry Test) with slightly lower than those at the end of treatment (2. although gains were substantial during compared with no treatment (Table 28–3) when the Entry the second 3 months as well. 788 Section IV ■ Traditional Approaches to Language Intervention by providing three 1-hour sessions weekly. The LQ score is a ing treatment. Because scores for only one subject (Table 28–3).4 points). education. Shewan.02 11. and the parison was the final test Language Quotient (LQ) score gains were maintained for the most part for 6 months follow- (LQLAST) on the WAB for each subject. M.90 month intervals. The LOT had significant positive effects the first 3 months. The estimate of the plateaued. The NTC group contained 22 subjects with aphasia who did Tracking the LQ scores over the course of treatment and not wish to or could not attend treatment. Each clinician was trained by C. were available beyond that point. The LOT subjects TABLE 28–3 received a mean of 55. Austin. For subjects with global aphasia.75 tion by CMS and an independent. and etiology. which. the difference between LOT and NTC group means. The numbers in parentheses refer to the number of patients included at each test. (LQ  94). Severity of Aphasia although no scores at follow-up were available. these subjects were less severely impaired than erate. In concert period. 3. Termination of treat- ment (Rx termination) is represented with a dashed line. The single subject remaining beyond that time made additional gains during the 6. mod- in general. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 789 Figure 28–4. and severe groups on the basis of the initial test bat- the subjects with Broca’s. and subjects in these groups were followed in streams. as with the other groups. 2. tery. Test 5 is a follow-up test conducted 6 months after the termination of treatment. made. The subjects with aphasia were separated into mild. . No scores were available beyond this point. 4. Broca’s. and conduction.to 12-month period. Overall. with other groups. and 5 for the total Language- Oriented Treatment (LOT) group and the five types of aphasia: global. as might be expected. ment period. although Test 3 (6-month test) were approaching complete recovery gains also were substantial during the next 3-month treat.qxd 1/21/08 1:44 PM Page 789 Aptara Inc.GRBQ344-3513G-C28[756-799]. Wernicke’s or global aphasia. Wernicke’s. Patients have been grouped into streams according to the number of tests received. anomic. Mean Language Quotient (LQ) scores at Tests 1. first 3 months of treatment. they made the greatest gains during the Subjects with anomic aphasia. gains for the subjects with anomia were nearly 20 LQ points. This subject did make gains in all treatment periods Individuals with conduction aphasia were among the less and showed a slight decline during the 6-month follow-up severely impaired subjects. The two subjects remaining at made their greatest gains during the first 3 months. qxd 1/21/08 1:44 PM Page 790 Aptara Inc. communication is a highly dynamic and inti- when detailed descriptions of language therapy and its mate reflection of our personhood. on the LQ. 28–5). Patients have been grouped into streams according to the number of tests received. mine how cortical and subcortical areas contribute to lan- Subjects with moderate aphasia showed the greatest LQ guage. and severe groups. in fact. It evolved primarily out of a need to remain at the forefront of our efforts. 3. Bridging the gap between therapeutic tasks and support to those suffering from aphasia and that our treat. As we implement various treatment methods with decline in the LQ score from the termination of treatment. we have come to observe more directly their The group with severe aphasia. and 5 for the mild. patients. numerous advances have been made in our patients and their significant others in achieving mutually understanding of the complexities of the language system. which can and does efficacy were sparse. functional communication can be accomplished through ment was. relates to neuroimaging. Over the last flexibility. over time. gains The fundamental principles of LOT have not changed also were seen during the second 3-month treatment period. These gains were maintained proliferation of studies examining language in highly speci- at the follow-up test. Termination of treatment (Rx termination) is represented with a dashed line.8 LQ points. fied ways. although the content has become enriched by the after which scores leveled off. averaging 24. based on scientific principles. Although greatest in the first 3 months. and successful engagement of our two decades. Most Language Oriented Treatment was conceived at a time importantly.8 points of our therapy. determined and achievable goals. both in those with intact communication The mean overall gain for the group was 33. did improve an average of 24.8 LQ points.GRBQ344-3513G-C28[756-799]. Test 5 is a follow-up test conducted 6 months after the termination of treatment. even within the con- demonstrate that speech-language interventions served as text of this highly structured and systematic approach to more than just a vehicle for providing emotional and social treatment. despite obtaining the impact on the brain’s plasticity and the positive outcomes lowest scores overall. functioning and in those who have been affected by apha- The one subject available at follow-up showed a moderate sia. 790 Section IV ■ Traditional Approaches to Language Intervention Figure 28–5. moderate. guage processes. The numbers in parentheses refer to the number of patients included at each test. Mean Language Quotient (LQ) scores at Tests 1. treatment period. ingenuity. We are now provided with rich up test showed only a slight decline from the termination opportunities to better visualize brain lesions and deter- of treatment. The its interplay with cognition. An analytical framework continues to be impera- tive in breaking down the components that underlie the behavioral symptoms of aphasia so that we provide treat- FUTURE TRENDS ment that is customized to the needs of our patients. occurred through the development of technology as it The single subject with aphasia remaining for the follow. 4. 2. It remains critical that speech-language patholo- gains during the first 3-month period (at least 20 LQ points gists demonstrate a comprehensive understanding of the on average). . and how it becomes altered in group with mild aphasia made visible gains throughout the the face of neurologic insult. similar to the analysis for type of aphasia (Fig. Scores stabilized for the next 3 months and neural substrates and their relationship to speech and lan- increased again for the 6-to 12-month treatment period. The greatest Some of the most exciting discoveries in our field have gains occurred during the first 3 months of treatment. Orthographic effects in the word substitutions of aphasic patients: An epidemic of right neglect dyslexia? Brain and Language... D.. S. (1994).. L. P. C. Parrent. cacious in a full-scale clinical trial incorporating a Benson. M. within five language modalities. Identification and understanding of the substrates study. C. 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Veterans Administration Narr Verlag. Widening the horizons? Aphasiology. The role of syntactic complexity in treatment of sentence Narrative and procedural discourse production by severly apha- deficits in agrammatic aphasia: The complexity account of sic patients. 102. 50. C. 18(3). K.. group treatment. 24. Abstract word Weisenburg. pp.. DC.GRBQ344-3513G-C28[756-799]. & D. Plasticity of language networks in 385–390. T. adult aphasia (pp. M. J. 347–351). Marckmann. & Thornburg.. 66.. C. (2004). (1994). Journal of Speech and Hearing Disorders. 653–658. Journal of Speech.. Tranel. Baltimore. (1997). Neurorehabilitation and Neural Repair 16(3).. and aphasia. J. Swinburn. P. (1999). W. 201–224.. encoding: Simulating right neglect dyslexia. T. J. H. A. 5(4–5). approach to treatment of sentence production deficits in apha.. & Virata. R. K.. brain-damaged patients (pp. (2003). L. C. Habedank. Cox. 17(5).qxd 1/21/08 1:44 PM Page 797 Aptara Inc. 179–183. 6. (1981). Kurtzke..W. R. Price. aphasia: Can computers understand aphasic speech? Disability Whitney. 42. Age of acquisition Thompson. 121. (Eds. 244. 307–323.. 58.. Damasio. 402–418. Archives of Wade. 367... Aphasia. Training on an iconic communication system for severe processing of familiar idioms by brain-damaged and normally aphasia can improve natural language production. Clinical Aphasiology. (1964). aging adults. 591–607. (1997).. Holland. phonologic and semantic cueing treatments.. C. 229– Multicue. (1986). aphasia. 529–533. R. J. H. & McGarry. Kremin.. & 433–444. New York: Ronald Van de Sandt-Koenderman... M. R. 18(3). McCall. Collins. sic individuals. F. R. Voice recognition and Neurology. R... and deferred language treatment for aphasia. L. J. (2005). M. J. Language. Collins. & Pierce. L. 263. T. Experiences with multi-cue. 9. In F. The access and (1995). Ruppin. A. Warburton. & Canter.). orders. (2001). Aphasiology.). 354–363. Altenmuller.. Chapey (Ed. (1997). J. D. K. et al. Boada. Koyuncu. In R. K.. Aphasiology. & Wise. D. 327–352. Wepman. Hearing Research. tech AAC Press. & Hichwa.. Weinrich. (1995). L. M. H. Petheram. A. 231–243. Weinrich. K. & Laine.. Journal of Speech and Hearing Research. lates of naming concrete entities and actions.. 17(6/7).. and apha- in lateralization patterns during recovery reflect cerebral plas... & Cox. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 797 Thiel. & Katz. 245– Wertz. G. McCall. Boser. Weiss. Disorders. M.. R. treatment efficacy (CATE). T.. Weiss. W. & Goodglass.. Progress in brain research (Vol. K. Tyler. Martin. A. (1991). Xu. 25. Li.. Neurolinguistics (Vol. A.. L. G. (2005). R. E.. Whitaker (Eds. C. Whitaker & H.. A. J. Zurif. A. B. Park. & Caramazza. (1976). Psycholinguistic structures in reduce disfluencies in speakers with mild aphasia. C.qxd 1/21/08 1:44 PM Page 798 Aptara Inc. Journal of Communication Disorders. Green. Fratali.. 576–586. 1002–1015. & Goodenough. APPENDIX 28. 54.. & Goldstein. S. E. 798 Section IV ■ Traditional Approaches to Language Intervention Whitney. sentence. 182–186. (1989). & Braun. H. S.1 Language-Oriented Treatment Goals Form MODALITY: _________________ CLIENT: ___________________ AREA: _______________________ CLINICIAN: ________________ GOAL: _______________________ LOT GOALS Presentation Cuing Criterion Response Additional Level Stimulus Method Provided Correct Response Method Responses . Journal of aphasia. and Grammatical intuitions of aphasic patients: Sensitivity to func- narrative comprehension.. 12. A. (1994). 207–222. E. (1976).. E. In H..GRBQ344-3513G-C28[756-799].. (1972). Volpe. 1). Williams. 10. Caramazza. Language in context: Emergent features of word. Using self-monitoring to Zurif. A. Caramazza. Kemeny. B. J... B. E. Zurif. D.). & Ritterman. 27. Cortex.. course. NeuroImage. Grammatical The influence of topic and listener familiarity on aphasic dis. Neuropsychologia.. & Myerson. A. Studies in Speech and Hearing Disorders. 405–417. tors. judgments of agrammatic aphasics. E. New York: Academic Press. S. C. 2 Language-Oriented Treatment Data Record Form MODALITY: _________________ CLIENT: ___________________ AREA: _______________________ LOT DATA RECORD CLINICIAN: ________________ ______________________________________________________________________________________________________________________ Time Difficulty No. Date (minutes) Level items Data and Comments .qxd 1/21/08 1:44 PM Page 799 Aptara Inc. Chapter 28 ■ Language-Oriented Treatment: A Psycholinguistic Approach to Aphasia 799 APPENDIX 28. of Session No.GRBQ344-3513G-C28[756-799]. The discussion that follows will consider some of these treatment issues and will illustrate how PICA test results and 1.GRBQ344-3513G-C29[800-813]. the and information is treated as tentative and not stored. to rely on the test results to of this concept to the understanding of brain function and to help with the therapeutic decision making has been growing. self-cor- rections. Decisions about the patient’s potential for change as a principle pervades every aspect of treatment and must be result of treatment should be made on the basis of a psy- used by the clinician to anticipate what must be done. or PICA. answers to these problems are evolved empiri- cally during treatment through trial-and-error methods or The major objective of this chapter is to demonstrate that the are arbitrarily determined because of the clinician’s bias for nature of response behavior is indicative of the status of the certain techniques and methods. OBJECTIVES Traditionally. The 3. the brain and their components are intimately interrelated ing the therapeutic process. The negatively without affecting all systems. This 4. The following main arguments among clinicians who use the Porch Index of Communicative are presented to help the clinician appreciate the importance Ability (Porch. and responds to damage are all biased by the ulti- diate responses on progressively more difficult tasks. Because accuracy in the use of this multidimensional scoring system. Chapter 29 Treatment of Aphasia Subsequent to the Porch Index of Communicative Ability (PICA) Bruce E. Treatment planning based on this model therefore is ways in which the brain processes information. more circuits are required to do simpler tasks. Therefore. Much of this material is drawn from basic and advanced tion that is accurate. and stimuli should be used in treatment. the development of viable plans for treatment of aphasia. tasks. the use A SYSTEMS ANALYSIS APPROACH TO of plus-minus scoring in testing or treatment is not APHASIA TREATMENT appropriate. and when should treatment be terminated. while treating the patient. what modalities.qxd 1/21/08 1:45 PM Page 800 Aptara Inc. reacts to directed at assisting the patient in achieving easy. and chometric sampling of the patient processing. concepts presented here are useful to a general audience. function quickly and easily and when it stores informa. response changes. whether those deficits are treatable. in both normal and damaged states. sig- nal significant changes within the brain systems. imme- stimuli. A brief look at a issues of major concern are how the brain lesion has affected hypothetical brain circuit might illustrate the practical 800 . what must be avoided. the tendency brain’s circuits and systems. why it does what it does necessary clinically. and at various critical points dur. what behavior should be rein- forced. and multidimensional scoring or some The principle of the brain as survival mechanism is funda- other method of observing small behavioral changes is mental to understanding the brain. A second principle essential to the development of an appropriate sequence of treatment is that all the systems of Before initiating treatment. information is processed more slowly and inef. although it is hoped that the ficiently. The brain survives best when its circuits and systems PICA theory can assist the clinician in planning therapy. In recent years. the clinician must answer a series and that no part of a system can be affected positively or of critical questions about the conduct of that treatment. Porch the communicative ability of the patient. 2001). and requests for repetition of the stimulus. such as delayed responses. full application of some of these methods will necessarily be 2. for use of the test. The patient’s response behavior reflects these changes limited to PICA-trained clinicians who have demonstrated in the brain circuitry’s reduced efficiency. and how to treat it. mate effect of that moment on its capacity to survive. When these circuits and systems are training courses that are designed to prepare the clinician damaged. in age. or from other circuits to the can inform the previous modules that the information being feature detection modules. and is chal- tures module in its processing storage. and succeeding circuits are cuit will maintain data temporarily. must once again “pattern recognition. The goal of treatment is to scans its operational storage to see if the features coming in restore circuitry efficiency. unique. such as the ears. If. Each mod. therefore. It then compares the retrieved information from its connectedness of the brain’s circuits and systems and why storage.qxd 1/21/08 1:45 PM Page 801 Aptara Inc. especially to survival. long-term storage. for example. cessing of a data bit sent to it and. Chapter 29 ■ Treatment of Aphasia Subsequent to the Porch Index of Communicative Ability (PICA) 801 implications of these two principles and serve as an intro. The more important that infor. remember that path and those bushes after one exposure ule has the capacity to enhance the information. Another interesting characteristic of these storage ing for the patterns module to send it some data. scanning in memory occurs. The comparator must The storage units in this model are conceived of as an then request that the input data be sent again from the pre- access core that defines the nature of the information stored vious module. Furthermore. The entire units (operational and permanent cores and surrounds) is circuit is locked up. If a At the simplest level. and the comparator patterns is established. Survival is facilitated by . so no processing storage. and the signal processing module is wait- reach it. how- information from multiple circuits. this next module lenged by previously easy tasks. and subsurrounds. or it must rescan memory in an attempt to around it. interrelated modules and when the data bit has high impact. This information is moved to the efficient. compares it with the input data in processing stor. be appropriate for operational. because one small part of one module is that they tend not to store tentative or nonverified informa. to simply stop functioning or to assume that the retrieved tionship to the access core. The immature brain uses many circuits to finds a good match between the input data and the retrieved carry out relatively simple tasks. it would be important to information on to the next module in the circuit. ever. The entire system is is processed immediately and accurately is it considered to affected. reject it as rather than repeating the walk and watching friends disap- inaccurate. use its circuits to cope with less complex tasks. circuit to accept information. the the features recognition module is waiting to send the next more retrievable it is. each of which processes bushes and a saber-toothed tiger jumped out and devoured data from the previous module and then sends the processed one of the group. and this system is interlocked with all other systems. that it must be remembered after one exposure to it and duction to PICA theory as applied to treatment. in terms of survival. the pear over the next few days! auditory processing circuit shows three levels of modules Feedback loops may be used when a module finds that it between the input of each bit of raw data to the circuit and does not have sufficient information to complete the pro- the output of the circuit to other circuits or integrators. or mark it as a survival message. circuitry reduction results in more its significance to survival. These feedback loops also transducers. and the more frequently that it is used. and each core has a “surround” made of data. Thus. Nothing is stored in processing storage. it allows the combined product to be sent on to the the number of circuits necessary to carry out a task to a min- next module in the circuit. This frees the operational storage. faster processing of familiar data and allows the cir- comparator to verify that the retrieved data explain or define cuit to use its energy on more complex. or to integrators that combine nal input data. and if it matches. Usually. the processed information may now attempts to match the retrieved information with the origi- be sent on to other circuits. sends it to the signal processing mod. Only when a bit of data waiting for the output of this circuit. because it requires less switching to bit of data forward. or need exists to process the rest of the series. have a pattern that was processed previously as valid infor. The module then scans its data banks. The damaged brain is less efficient. therefore. mation is to survival. a brain circuit may be viewed as caveman with friends was walking down a path lined with being made of a series of modules. A final important observation has to do with the inter- mation.” After storing the output of the fea. to determine if the raw data have been previous modules for processing new and less familiar data processed before and if some information exists about the and reduces the circuitry necessary to process familiar data data that can further define that data. In summary. this systems analysis model that we will be operational storage is achieved through processing a data bit applying to treatment of aphasia suggests that the brain is enough times to verify it is both accurate and useable or made of complex. the processing storage in the pattern ule to determine if the recognized patterns have a specific recognition module fails to function. all of which share a common rela. the raw data enter the significance. damage has such widespread implications in the brain. If the comparator kinds of data. the closer it is to the core or subcore and. While all this is going on in the pattern recognition module. broken. trial-and-error learning is not conducive to survival. If the significance of the module. our theoretic circuit. or “danger” the raw data stored in processing storage. needs the pre- When the input pathway sends basic data from the input vious module to send more data. which in this simple circuit is imum. previous circuits are waiting for this tion. sub. so circuits that are survival biased. The comparator’s other options are cores. interlocked. information is accurate and send it on to the next module. and comparison is impossible. The mature brain reduces data. the data are stored temporarily in processed is the first in a series that is well known.GRBQ344-3513G-C29[800-813]. Processing storage and a general persistence in the cir. For example. especially in terms of to a minimum. verify the information. a damaged comparator might accept incorrect tem by carefully observing the patient’s response behavior information from storage and send it on to the next module. When the retrieved information is sent to the final benefit of multidimensional scoring is that it forces . types of behavior that could have resulted. when feed back to earlier modules or to sensory transducers a data move through each of the modules of a circuit both eas. Several curate. prompt. is not patients’ response behavior and why the use of plus-minus stored in operational storage (Aaronson.qxd 1/21/08 1:45 PM Page 802 Aptara Inc. behaviorally. the clinician must infer what is going on in a sys. the discrepancy between this retrieved informa- storing only verified information that is not tentative. 802 Section IV ■ Traditional Approaches to Language Intervention Figure 29–1. it sends it on to the next module for the system. as a storage and circuitry reduction do not occur if any aspect of brief hesitancy or processing delay (score of 13) but is signif- processing is not easy and immediate. during a treatment task. After double therefore. stored information in that module was inadequate. A wide range of behavior is possible If this incorrect information produces an error response but in a response to a given stimulus and task. not reduced. circuitry for its processing. A tional storage. is why any response other than an easy. with the patient rejecting the item efficient (score of 15). the clinician examples of response behavior to follow will illustrate this observes this use of an external comparator as a self-correc- and will show how PICA multidimensional scoring is used tion (score of 10). it has proven to be equally vital in docu- inaccurate or incomplete information when scanning opera. menting the response characteristics during treatment. because that bit of information is still con- “easy and immediate” brings us to a consideration of the sidered to be tentative by the circuit and. “I don’t know” (score of 5). Multidimensional binary-choice scoring system. If such information is not available earlier in the circuit. accurate. This unproductive. is recognized as being inac- the involved circuits are able to process the data. complete. and not produce a response. looping. The clinical caution here is that both operational processing. During treatment. Such double looping appears. a patient might retrieve test behavior. and circuitry reduction may occur for the comparator might just send on the erroneous informa- those data. it is these 15-type by saying. responses that are the target behavior the clinician strives for Although this scoring system was developed for sensi- on every response. or the PICA scoring system shown in Figure 29–1 would score such comparator might stop all processing and accept that it can- responses as accurate. depending on how the response reenters the circuit.GRBQ344-3513G-C29[800-813]. Multidimensional Scoring Let us examine this double-looping example for other The circuitry within the brain defies direct observation. tively and reliably quantifying subtle changes in a patient’s In contrast to an “easy” response. responsive. What constitutes icant clinically. 1974). binary-choice tion to produce an incorrect response (score of 6). those data are permanently stored in 9). and is then changed to be accurate. better match. necessitates looping back to operational storage to retrieve a tion that allows fewer modules or fewer circuits to be neces. This efficiency of a circuit is further increased by circuitry reduc. Use of the multidimensional. The tion and what is stored in processing storage is noted. maximizing the efficiency of these circuits by permanently comparator. immediate response (score of 15) means further treatment is necessary on that item. If the comparator recognized that the to quantify behavior. therefore. it might Returning to the theoretic circuit described earlier. request for additional information about the data bit (score ily and immediately and produce an accurate. well-produced of 8) or for the same data to be sent through again (score of output from the circuit. When the comparator finds that the second sary to quickly process accurate and familiar data entering information is accurate. operational storage. It still scoring during treatment of aphasia is both impractical and requires total. arising in recent years as treatment has become more expensive and available funding for treatment Examples of Patterns of Response scarce.qxd 1/21/08 1:45 PM Page 803 Aptara Inc. and finally. Patient A rejects the first item but is able to respond to the next few DESIGNING A PLAN OF TREATMENT items after the stimulus is repeated or cued or after a signif. Patient C has a performance that is very homogeneous and shows no variation from item to item. Wertz. in an effort to develop earlier predictions.0 decades. indicating that they were all functioning at about the same communicative level on this task. but eventually. Although making it possible to compare the patient’s skill across Patient C got all 10 items correct on a plus-minus basis. In this method. and Jiminez- Pabon (1964) did some work on prognosis that assigned Patient postrecovery. stabilized patients to one of five major or two Stimulus A B C minor prognostic groups. Keith. task. it is possible to detect patterns of response Because the PICA has high internal consistency. 1983). In this simple exam. & Darley. Table 29–1 shows how having stimuli that are relatively These same principles can be employed in treatment if the equal in difficulty will reveal various types of processing clinician will take the time to ensure that the stimulus items problems during testing or treatment. Wertz. 1970) Soup 15 9 11 that was developed during the late 1960s as an interim Ball 15 8 11 approach to prediction but proved to be reasonably accurate Pie 15 5 11 and simple to use and. Schuell. tions at this point is to determine if the patient is a suitable Patient B starts out with no difficulty but gradually has candidate for treatment. he modalities and tasks. During the 1960s. it is able that normally are obscured by conventional aphasia tests to give some indication about these types of processing prob- beginning with easy items and getting progressively more lems. Eventually. changes We see in the bottom row of Table 29–1 that all three in behavior. these conditions. however. Porch. Clearly. In addition. Chapter 29 ■ Treatment of Aphasia Subsequent to the Porch Index of Communicative Ability (PICA) 803 the clinician to be sensitive to small. Once the clinician has gained a thorough familiarity with icant delay. Selecting Patients for Treatment Determining whether a patient is treatable is a relatively TABLE 29–1 new concern. sug- 10 common objects. he reached fully operational levels. these studies employing multiple discriminate Cup 13 15 11 analysis have not yet been validated for clinical use. Shoe 15 13 11 Perhaps the most widely used clinical method currently is Car 15 10 11 the high-overall-prediction (HOAP) method (Porch. His high internal consistency. has completed compre- els and receives scores of 15. it was theorized that the capacity of .0. the patient and his or her history. it is being relatively equal in difficulty for the patient. to decide on which types of he lacks the ability to keep his system locked into the task or behavior will be reinforced on each task. but important. and Friden (1980) Dog 8 15 11 have described other prognostic studies that attempted to Boy 9 15 11 develop more accurate predictions of eventual recovery lev- Apple 10 15 11 els.0 11. task once the processing problems are resolved. he begins to respond at normal lev. may have on a given task (Disimoni. With Patient A. and has found that the patient’s condition is that he had trouble tuning into the task and adjusting his no longer changing dramatically from day to day. Jenkins. This has the psychometric advantage of gesting that their circuits have the capacity to carry out the holding content constant across subtests and. used on the task are relatively equal in difficulty. we see the scores for three different patients on a task involving 10 items of relatively equal difficulty. therefore. patients got a mean score of 11. and Collins Cat 5 15 11 (1974) as well as Porch. it is apparent hensive testing. with all the items on a subtest system is indicating that. to to handle cumulative noise that might build up during the determine when treatment should be terminated. to choose the tasks and stimuli to decreasing scores and tunes out on the task. and it indicates potential levels of ability that a patient difficult. patients A The PICA is designed so that all the subtests revolve around and B demonstrate several fully operational responses. The usual sequence of considera- task. the type of processing difficulties Internal Consistency of Tasks that each manifests is quite different. however. treatment system to perform adequately during the first part of the planning can be initiated. Collins.GRBQ344-3513G-C29[800-813]. Under performing the task as well as it can. at least at this point in time. has persisted for three Mean score 11. therefore. ple. It also produces subtests that have very showed no ability to do the task at operational levels. suggesting that be used during treatment. More recently.0 11. it is not unusual for a patient to right to left on the task continuum and. PICA scores are helpful in of the task continuum. at least at that point in time. dif. age level.qxd 1/21/08 1:45 PM Page 804 Aptara Inc. Before the discussion on treatment can continue. to modify the score. is functioning at near. ranging at the top from the most com- Estimating treatment potential is equally important later plex levels of responses to the bottom of the continuum. whichever was the greatest. cessing abilities on a series of tasks that are ranked according . storage. who has a pre- consideration the normal recovery stages. this sigmoidal function curve would move from given response. predicts how far positively that curve can low responses that might be brought up to the patient’s aver. therefore. it is neces- tracting the 1-month post-onset PICA Overall percentile sary to introduce some concepts and terminology related to from the 2-month post-onset PICA Overall percentile. which even mild patients demonstrate some processing Second.GRBQ344-3513G-C29[800-813]. The subject longitudinally from infancy to adult levels of com- PICA scoring system provides 16 possible scores for any munication. seems to stabilize. it must gradually reduces until all the item scores within the subtests use more circuits to carry out simpler tasks (the reverse of are quite homogeneous. does not store it easily in operational patient. Eventually. 1981). stabilize at obtain a wide range of item scores. after the patient is past the acute stage. the intrasubtest variability of scores mal brain is damaged. Those with slower complex learned processes. ranging from the most this period tend to exceed the HOAP target percentile by simple vegetative communicative processes to the most the time they reach 6 months post-onset. the clinician is in dicted overall percentile significantly above his or her pre- a better position to select the patients who are most treatable sent overall score. This is determined by sub. PICA theory. For clinicians who use the PICA to test their patients Selecting Treatment Tasks early in the recovery process. and who exhibits variation on item scores and to counsel families and physicians regarding the even. by a sigmoidal function curve. Appropriate tables or patient’s environment to facilitate his or her communica- graphs enable the clinician to convert these scores into an tion. within subtests in some modalities. it is expected problems. The tasks that were sampled range several ways for making this decision. and the clinician must decide whether to The PICA samples a test field somewhere in the middle continue treatment. make about the status of the patient’s abilities and deficits and how appropriate plans regarding treatment of the patient. therefore. in the course of recovery. The standard PICA test battery samples 18 points that when he or she is at maximum recovery. If one were to test a normal These same principles hold true within subtests. its circuits are less efficient. to assist that patient. the patient’s condition where the patient fails to attend or give any type of response. and there are no higher scores that might serve as Returning to our premise that aphasia represents a reduc- a target level toward which to strive. ferences between the nine highest subtest percentiles and The PICA tests have demonstrated that the interaction the nine lowest subtest percentiles also will suggest a range between the task and the response continua is best depicted of possible change or the lack of it. Therefore. As we see in Figure 29–2. his or her sub. First. and it treats more entering data as ten- of ability on the task. This homogeneity suggests that the tative and. highest current potential levels of efficiency: There are no as indicated above. As a patient undergoes some fairly high level of communicative ability. Because of these changes. out tasks of varying difficulty. tual recovery levels (Porch & Callaghan. When a nor- treatment for aphasia. Once again. curve shifts negatively to the right. finally. At that point. an ideal treatment candidate is a cooperative month post-onset in most cases. The circuits neces. the clinician level of functioning and that further treatment of the pro- could estimate the maximum potential for communication cessing problems may not be fruitful. the sigmoidal function maximum ability on that particular task. therefore. Because this HOAP method may be applied as early as 1 In summary. and to educate the people in his or her environment estimate of the eventual outcome level and. in the test field and establishes the subject’s capacity to carry test percentiles will be approximately equal. the clin- by using the average of the nine highest subtest scores ician may evolve new treatment goals to maximize the achieved on the PICA or by using the highest modality patient’s use of his or her functional systems. and because it takes into patient whose medical condition is stable. indicating no peaks or depressions circuitry reduction). The ordinate represents the early recovery tend to not reach the early PICA predictions. another prognostic indicator is the acceleration rate of recovery. the sigmoidal function curve depicts the individual’s pro- his or her brain is indicating that it is performing commu. The PICA locates the sary to carry that task are consistently performing at their position of that response curve on the task continuum and. be shifted with treatment. thereby. we may visualize a Patients who improve more than 12 percentile points during continuum of communicative tasks. response continuum. 804 Section IV ■ Traditional Approaches to Language Intervention the patient’s total communicative system was indicated by nicatively and cybernetically near its maximum potential the highest scores or peak abilities. discrepancies from relatively simple tasks in which only the most involved between the patient’s overall score and the high modality patients have difficulty to moderately challenging tasks in score indicate the amount of potential change that remains. we can see that demonstrates homogeneity in all modalities on the PICA. When the patient tion in the processing efficiency of the brain. Although it is and do not require treatment. such as those that are active at curve). Chapter 29 ■ Treatment of Aphasia Subsequent to the Porch Index of Communicative Ability (PICA) 805 Figure 29–2. and cannot participate in more complex time or that the stimuli have been poorly chosen. person at that time.qxd 1/21/08 1:45 PM Page 805 Aptara Inc. Finally. As The reader should not confuse the concept of the ful- the tasks become a little more complex and require more crum of the curve with the earlier suggestion that tasks on communicative ability. the problem of task and modality Selecting Treatment Stimuli selection is greatly simplified for the clinician. but such tasks are too far become increasingly complex.e. self-corrections. Using this schema. however. therefore. assume that these tions. it is necessary to select appropriate and the results plotted to indicate the patient’s response treatment stimuli to serve as vehicles for resolving the curve. scores and low scores that may be improved. patient does not have enough information to monitor the the sigmoidal curve bottoms out at the lower end of the developing processing before responding by using internal response continuum. and efficiently. and which are beyond the are all within the capacity of the individual’s circuits and are capacity of the patient’s system at this time and should be carried out accurately. note that as the tasks potential for eventual change. this area is referred to as the fulcrum of the curve. excluded from the treatment format. errors during treatment usually suggest the fulcrum of the curve. therefore. to their level of difficulty. These circuits are not yet opera. Attempts at treatment produce some errors. Tasks on which the see. promptly. most potential for change and. responsively. the test responses are performed which the patient has the greatest item variability have the accurately but with some delays. they do not require treatment. or distor. The tasks to the right of the curve the curve and should be treated. the curve begins to drop down the curve. which are on the fulcrum of common practice for clinicians to select stimuli on some a . and it patient has a large variety of scores. it is quite apparent which tasks are already operational patient’s processing problems on those tasks. As we will tasks should be chosen for treatment.. more within the capacity of the circuits (i. more precipitously as the person being tested begins to suggesting either that the circuits involved are getting insuf- make errors and requires more information or more assis. completely. farther up the tion of more basic circuitry. either that the task selected is too difficult at this point in tional. indicating that all tasks on the task comparators or to evaluate the output after responding continuum beyond this point are beyond the capacity of that using external comparators. so the response curve begins to descend. In general. ciency in the circuit needs to be developed by using tasks cuits necessary for doing these tasks require the participa. To put it in terms of circuit theory. ficient information to perform the task or that more effi- tance to respond. as the tasks become even more complex. because the patient’s system indicates precisely those tasks that need After the tasks in various modalities have been selected from immediate attention. have good Referring again to Figure 29–2. Task and response continua. The processing.GRBQ344-3513G-C29[800-813]. including high target is the primary focus of treatment. Once the PICA has been administered the fulcrum of the curve. the cir. In the insensitive to processing disorders. these types of trends are not seen. Hat 9 9 uli. or Trial those that are too “noisy” and interfere with processing. Shoe 10 13 ated by testing their appropriateness on selected tasks. expected to do. In addition. Having selected 20 or 30 example in Table 29–2. because the classic plus-minus scoring is relatively and they gradually tune out on the succeeding stimuli. ably elicit 15-level responses Such an analysis will give the suddenly. lus can be considered as sacred.qxd 1/21/08 1:45 PM Page 806 Aptara Inc. words makes it easier to process them. expecting the TABLE 29–2 patient to do as well with whatever stimuli are selected is dangerous. have decreasing scores as the trial proceeds. Finally. either too noisy or too difficult to be used in treatment and sent them again after a brief rest period to see how consis. the patient tends creates a spread of poor processing to other stimuli in the to improve slightly on the second trial. and whenever one presents labic words. it usually is informative to pre.e.GRBQ344-3513G-C29[800-813]. Each stimulus. the inexperienced clinician will attempt to “teach” these Table 29–2 shows how a few stimuli might be scored dur. The fact that the patient got error scores responses are scored for later analysis. no given stimu- appears that the patient does somewhat better on polysyl. which has been listed on a treat. it does not because items that are too difficult may have an interaction appear that. words to the patient but. words with consonant Bicycle 15 15 blends. The Cup 6 6 PICA score sheet may have already indicated to the clinician Baseball 15 15 that the patient has more difficulty on certain types of stim. It generally is a good policy when run- trials. tent the patient’s processing is on each stimulus. scoring. clinician important information about what variables affect . stimuli that seem to be appropriate for the task. A second some common nouns for treatment stimuli and has pre. It also is useful to explain to the patient that Having made these general observations. Hammer 13 15 The danger of using inappropriate stimuli can be obvi. ends up putting more noise ing a stimulus verification session. instead. not Stimulus First Second only may reduce the amount of positive results from treat- ment but actually may produce problems rather than resolve Apple 8 9 them. or words that are too short to provide adequate clues Car 7 10 for decoding. consequence of using error-type responses is that not only sented the list twice. Stimulus verification is done through the use of PICA cating that they are unable to lock their system into the task. After all the stimuli on one of the trials on those stimuli indicates that they are have been presented once. any stimuli on which the patient received errors (i. the variation in scores probably is attributable to explains to the patient what the task is and what he or she is the stimuli themselves. the clinician is the clinician will be scoring the responses so as to determine now ready to decide on which stimuli he or she will use in which stimuli will be the best to use in subsequent treatment subsequent treatment sessions. thus suggesting that the auditory system may a problem. In addition to the specific item scores do you prohibit the facilitation of good switching on these the patient received. such as polysyllabic words. the clinician therefore. The first rule here is to drop sessions. Too often. and it may be made about these two trials. Second. First. it should be dropped out of the program. can only interfere with processing and progress. more general observations stimuli. the effect spreads to other stimuli on the list. and the patient’s of seven or below). as one scans down the column of scores for both effect on other items. Stimuli that are too difficult and overdrive the patient’s system. not be able to decode short stimuli rapidly enough and that This concept of dropping error items or stimuli also the longer duration and increased information in longer should be incorporated into the stimulus verification process. This type of information might be used in Window 13 13 assisting in the selection of the repertoire of stimuli that the Bus 9 10 clinician plans to use for the treatment tasks. that any orderly changes occurred. demonstrating a treatment trial (Brookshire. to verify the selected stimuli under the actual treatment conditions. It is not unusual to ning such trials to eliminate any error items from second find some patients whose scores gradually increase during a and third trials to rule out possible interactions. it ing the processing problems of the patient. scores ment score sheet. some other. 1976). however. because it does not take into consideration the Verification of Treatment Stimuli specific type of processing problem the patient has. When a clinician is treat- good potential for improving after repeated trials. indi. 806 Section IV ■ Traditional Approaches to Language Intervention priori basis and then proceed with treatment. The clinician has selected into his or her system along with practicing errors. It remains important. Other for characteristics that are in contrast with items that invari- patients may start out a given trial with high scores and then. suggesting that it takes several items for them to make the items that produce errors should be analyzed carefully the necessary adjustments to carry out the task. trial. is presented in order.. because we are expecting the patient to carry out complex “Point to the . which the patient demonstrates delays and self-corrections A simple auditory task might illustrate how one carries are tentative processes that break down when used in more out this probe technique. treatment format that is designed to present a consistent instead of simply presenting the task multiple times to even. ment. Clinicians for subsequent treatment have been documented. and be sorted into three separate piles if card-type stimuli are the entire response curve moves toward the more complex used. reaches the all-15 level in carrying out the processes. M. end of the task continuum. 2. in eventually respond to every stimulus on the task without fact. a self-correction (score of 10). Having Once the tasks and the stimuli have been selected for treat- selected a treatment task on which the patient gets 9. by working in reverse order down the repeats of the stimuli or after cues or additional information curve.g.g. we should note how differ- or attention problems. In addition. but one more preliminary step is quite informative.”) to negate rise-time problems. this and future therapeutic tasks. and “hard”—items that yield error responses. then The clinician on the initial presentation obtained three easy these become available farther down the curve. Chapter 29 ■ Treatment of Aphasia Subsequent to the Porch Index of Communicative Ability (PICA) 807 the circuits involved and what type of stimuli should be she finally achieves all scores of 15. move from one task to the next in that sequence doc- are given. or the clinician may. as various modifications of the task succeed. “Ready? . “medium”—items that are responded to accu. use a carrier phrase before the noun (e. If a particular manipulation does. the clinician without effort or delay and in a manner that might be referred documented the location of the various modifications of the to as “normal”.to 15. This phenomenon may explain. task on the curve during this upward movement.” Processes in the task.qxd 1/21/08 1:45 PM Page 807 Aptara Inc. repeats. the clinician is now ready to organize them into a type scores (easy and medium responses). rately. simpler processes. give an Finally. it gradually moved up the curve until it “easy”—items that the patient has responded to accurately. During the process. a correct response after a repeat of more complex processes can take advantage of the now nor- the stimulus (score of 9). ent the fulcrum of the multidimensional curve is from the Gradually. it tries to facilitate the tion produces lower scores.. after all the sorting and analyzing of stimuli is complete. Car”) for system activation overdriving the patient’s systems. the clinician. All these principles discussed thus far are roughly what is able is not a relevant factor in the patient’s performance of meant by “treating on the fulcrum of the curve. The question now is how part. the avoided in treatment. As each task is raised to the all- When using this system. If you refer again to Figure 29–2. presentation of tasks that will facilitate the patient respond- tually achieve all “easy” responses. “car”) to the picture to add available to him or her. No change in out any processing difficulty. however. in a delayed response (score of 13). may achieve original probe task that started out down the curve was similar results by sorting stimuli into three categories: manipulated. it is customary to designate the type easy level. As the who are not trained in PICA methods. . . but only after processing delays. umented during the probe.. it would seem that the selection of tasks and Treatment Format stimuli is complete and the actual treatment might begin. If these that involves placing six pictures of common things in front minor processing problems are cleared up and the patient of the patient and having him point to the one that is named. Not only is this type of treatment designed to be to function successfully. plus-minus curve. or the stimuli may assisting the processing of other tasks down the curve. and 1). Therefore. . in connection with this issue of the dangers of arousal signal (e. self-corrections. visual information to assist the auditory system. possible tasks and that PICA scoring should be used if possible. At this point. . the clinician has discovered an requiring cues. reached the all-15 level. In other words. working as a team. or significant important factor about the patient’s system and what helps it delays. and mal. why so many times we see tasks improving in the clinic may the task be modified to produce all easy-type responses that have not been treated directly during the therapeutic immediately? Several possibilities exist—reduce the number process. improve responses. error free. which is information that will assist in to yield meaningful information about the patient’s system. By the same token. clinician learns what factors make the patient’s processing It should be apparent that plus-minus scoring is too gross more or less efficient.. evidence is obtained as to what patient’s responses so that they are produced easily and with- variables have negative effects on the system. and so on.g. you will the patient is able to come to all easy responses until he or note that the response curve for the average patient with . The clinician has selected a task complex tasks employed farther down the curve. is to have the patient produce higher scores. and all the responses (scores of 15). if the manipula. responses as a result of the manipulation signifies that vari. the goal of the clini- single variable of the task in a way that will immediately cian and the patient. but as much as possible. should manipulate some ing at the all-15 level. add the processes that require other basic processes that are not yet printed word for the noun (e. This schema also makes clear why it is so inappro- of items from six to four to simplify the task and reduce priate to treat tasks too far down the response curve— visual loading.GRBQ344-3513G-C29[800-813]. With each change. self-corrections. or H (or as 3. the circuits under treatment become available for of response as E. they will Once it is certain that the patient is functioning adequately maintain a more efficient. the clinician announces to of functioning. is a multidimensional response curvethat drops off ily to see if there has been an exacerbation of the patient’s on the tasks on which the patient first begins to have some medical problem. After the patient enters the tasks that. The clinician should explain what the task will be and . were on the fulcrum of the curve but room and sits down at the treatment table. Consolidation (old stuff) level of functioning on that day. it may be necessary to redesign the treatment ses. at one time. Finally. the cial occurrences. quieter system. seems to be responding easily to simpler processing tasks. some of sition in between tasks is important. informa- tion about what might be suitable warm-up tasks might be Adjustment Period: Checking and obtained from the PICA score sheet if one looks at the all-15 Clearing Out Circuits items on the easiest subtests. First. Conclusion (winder upper) When initiating treatment with a new patient. This fairly easy. the patient has less serious delays. inadequate circuits and are being attacked during treatment to a spontaneous speech switching. the clinician that. or methods of reinforcement invariably produce distraction and noise in the patient’s communicative system. on the other hand. For this purpose. problems. is trying to observe several patient so that he or she can clear out his or her system and things about the patient. the clinician is carefully not- When setting up the sequence of presentation for treat. while the clinician makes notes about what has occurred in sion or to retest the patient to determine his or her new level the session until that point. General activation (warmer upper) up and for furnishing the patient with a gradual transition into 3. become fully operational. ing the quality of the patient’s communication and observing ment activities. or consolidated. situation. In the case of a patient who has The adjustment period that initiates the treatment session is been treated for a period of time. or questions that may have clinician is ready to move on to the next step in treatment. arisen since the last session.GRBQ344-3513G-C29[800-813]. all-15-type task is for activat- 1. the plus-minus logical or social issue that produces a depression in his or her response curve would not begin to drop until the patient ability and may make it necessary to be somewhat less gets some responses wrong. in a free-speech situation. target behavior. Adjustment period (clearing out) ing the patient’s communicative systems and warming them 2. part of the patient’s response curve. but important. and has cleared his or her storage systems in preparation for A useful format for ensuring adequate stimulation of the treatment. a point at which tasks tend to be beyond the room and to the clinician and is getting prepared for the capacity of the patient’s circuits. Selecting these greets him or her and simply asks a broad. where making a definite and clear tran- opportunity to try out. The plus-minus fulcrum of the adventurous in the treatment session on that day. Modification (new stuff) vide the clinician with a second check on the patient’s general 5. any significant difference between how the patient This is done by giving the patient a general positive rein- currently appears compared with how he or she appeared in forcement for his or her efforts on the previous task and previous sessions should be noted. it is advis- General Activation: Turning On and able to establish an orderly and fairly fixed treatment format. self-corrections. If the patient is functioning poorly compared the patient that they are going to be doing something differ- with previous sessions. This response curve. the clinician may elect a brief. such as “How’s everything?” or “What’s new?” that were worked on formerly. Because sudden changes in tasks. or repeats. cause of the problem or to discuss the matter with the fam- however. the patient out his or her system and to tell the clinician about any spe. 7. If he or she is markedly then suggesting that the patient just relax for a moment improved. Warming Up Systems If patients can anticipate the treatment events and have time to make leisurely transitions from task to task. realize that the goal of treatment is to assist how much carryover has occurred from those processes that the patient in mastering noisy. This is designed to give the patient the opportunity to clear If. It also gives the patient an Just as in testing. curve would be equivalent to a point far down the multidi. therefore. eventually. Modification (new stuff) successful start in the treatment session. the change between one the processes that he or she has been working on previously. problems. Consolidation (old stuff) the more difficult tasks. make the necessary switching adjustments for the new task.qxd 1/21/08 1:45 PM Page 808 Aptara Inc. 808 Section IV ■ Traditional Approaches to Language Intervention aphasia is in the middle of the test field. such as headache. In plus-minus scoring. This activation period also will pro- 4. time. a task is be summarized as follows: selected from the highest. it may be necessary to probe into the ent. Then. the clinician can begin to focus the patient’s atten- patient’s system without producing noise or overload might tion on treatment-type tasks. shoulder pain. or some psycho- these behaviors are ignored. and it gets the patient off to a 6. while the patient is gradually adjusting his or her system to mensional curve. more difficult treatment tasks. step in treatment to the next should be made obvious to the The clinician. Sometimes. nondirective old tasks serves to verify that the patient is maintaining skills question. after a short period of general activation. an auditory task that requires the patient to point to one of these newly consolidated processes are available for use on four pictures after the clinician says the noun. there may be two or three modules in a Conclusion: A Positive Wind Up 1-hour treatment session. the modification is larger than should then be started with the demonstration item so that expected. to two pictures instead of one. A treatment module is a series of priate. In addition. The the first presentation. and the task should move more in the direction of the patient’s system is gently eased into the task. if appro- several treatment modules. dure is then followed. When it is errors or requires multiple repeats and cues before he or she apparent that the patient understands the task. For instance. moving on to some new modifications of the task to tasks directed at a given modality or process. the in the module. it is found that this task is done at the all-15 level on will assure winding up the session on a successful note. on the other hand. If. the clinician might consider using that clinician also may use this final step as a verification that the task as a warm-up in the future. This helps the patient to get back to ule. For instance. consolidated part of the curve. turn to work on reading or writing as a third have moved through a variety of fairly arduous tasks during module.qxd 1/21/08 1:45 PM Page 809 Aptara Inc. If. he or she should anxiety and fatigue. that task gets a correct response. the task might other tasks. This same general proce- Having moved through the adjustment and activation steps. modification task that has been somewhat difficult. and then the first item of small modification in the task and the patient begins to make that task should be demonstrated for the patient. if. At that point. The goal then would be to increase the patient’s performance until he or she achieves all 15s on the Implicit in the treatment method being described here is the new task. The final step in the treatment format should involve a fairly ond module for consolidating and modifying verbal process. and the clinician may then move on to the sec. and these are worked on until some new aspect of switching or storage. the next day’s session. which on cluding the treatment session on that note would be psycho- the first presentation has occasional delays in it but by the logically undesirable. Chapter 29 ■ Treatment of Aphasia Subsequent to the Porch Index of Communicative Ability (PICA) 809 what the patient is expected to do. the patient is maintaining his or her skills on one of the earlier patient has continuing difficulty and cannot get to the all-15 treated processes. session. Generally. beginning with old material in the the patient and clinician now are ready to begin the first of modality that needs to be consolidated and then. As the patient approaches the point at which he or she is all-15 part of the curve to prepare those circuits for the more fully operational on a given task. Usually. it generally means that wind-up tasks from one day’s session for a warm-up task on he or she is not ready to proceed to new tasks in that mod. idate those 15s and then prepare to move on to the next step To summarize this section on the treatment format. it becomes appropriate to difficult tasks. therefore. finally. and it reduces intersession regression. Next. on the patient eventually reaches the all-15 level. shifting to a new modality means shifting to Consolidation: Pushing for All “Easy” Responses new stimuli and treatment materials.GRBQ344-3513G-C29[800-813]. following this type of transition will minimize the amount of If the patient does fairly well with the new material and noise in the patient’s system and greatly reduce his or her seems to understand it after several trials. the previous hour and have just completed a relatively new ician is trying to consolidate and make fully operational. If. and con- This task is quite high on the fulcrum of the curve. slightly more difficult tasks are selected think about modifying that task slightly so that it involves from the fulcrum of the curve. Depending on increase the patient’s processing capabilities. or by not allowing the patient to see the pictures while the clinician is saying the noun. A module usually is begun with a task that the clin. easy task at the all-15 level. be given a brief rest period in preparation for the next mod- ule. but once again. which session. after a few presentations. the first module to the Treatment Session might be devoted to consolidating and modifying auditory processing. Therefore. the patient’s response curve moves be modified by using six pictures. the clinician should select second or third presentation is all scores of 15. Any of these changes probably would produce an increase in the TREATMENT PRINCIPLES number of delays or self-corrections that the patient might Patient–Clinician Team have on the task. the on Old Stuff transition should be verbalized to help the patient readjust his or her system for the new task. The patient and the clinician ing and. in a given a task from the easy. the consolidation task. If the clinician makes what is considered to be a involvement of the patient in the conduct of the treatment . how many steps are in each module and how much time the total program takes. tasks are selected and sequenced in such a way as to maxi- mize the efficiency of the patient’s communicative systems Modification: Moving Down the Curve to New Tasks and to minimize noise. Treatment of a given process or modality is begun with tasks selected from the consolidated. it is a nice technique to use level even after several presentations. the patient is able to get all the same point at which he or she was at during the previous 15s. the clinician should do the task several times to consol. by having the patient point positively toward the predicted target level. . This is essentially testing rather than treating. of self-corrections. For instance. In turn.to 15-level tasks should be treated. this means that the repeated some more so that the circuit can sense what 15. and they can document PICA score sheet. This is If the patient has problems that are more random or are undoubtedly too low. because this would allow the patient to stimulus related. prefer tasks. the two people become a team in which the plus-minus scoring is completely inadequate for carrying patient relies on the clinician to assist with selecting the out this type of treatment and that a more detailed type of tasks and stimuli and in which the patient keeps the clini. and then rescore to measure change. By this point in the discussion. is attempt. those problems are overcome by getting have repeats. self-corrections. every task to decide whether he or she should repeat the item or move on to the next one. he or she also Criteria for Shifting Tasks must be taught to advise the clinician when a response is tentative or slightly off-target so that it can be consolidated. regardless of the their discussion on response-contingent. It probably is more beneficial to move lower scores the task using all “medium” items first and then to repeat to 15 and then practice the 15s if stable improvement is the task with all “easy” items so that the patient can get the desired. available for use on tasks farther down the curve. and tuning out. by LaPointe (1974). is should be repeated until a score of 15 is achieved and then not stored for long-term use. then to work on the task for appropriate as modification tasks in the format. In that way. self-corrections. The number for selecting tasks and stimuli and the criteria for shifting to then is gradually increased until the patient can keep his or new tasks or terminating tasks. and by them. The patient should understand that the clinician is Very often. the clinician must mentally score every response of system. a specific program may be designed to overcome scoring as used in Base 10 Program Stimulation. These to score the responses at the beginning of the treatment problems are diagnosed when a series of homogeneous week and then rescore them at the end of the week to see items are presented on a task and the patient always has what changes have taken place. therefore. when slightly simplified. must be used. cessing occurs. 810 Section IV ■ Traditional Approaches to Language Intervention process. who plan their treatment for a longer are not stimulus related. and these are grams and the PICA program described here are the criteria worked on until the patient achieves all 15s. or delays on every item and the circuits necessary for the task to the 15 level and then still meet the criterion. only a few stimuli are used.. Many programs suggest a cri- her system locked in to the task for a full complement of terion of 80% or 90% correct as an indication that the stimuli.GRBQ344-3513G-C29[800-813]. Still In general. Some clinicians like to write down every score for every response during the session Setting Treatment Priorities so that they have a running account of exactly what hap- The establishment of the specific modalities and processes pened in the patient’s system. This includes difficulty in shifting period of time and change the format less frequently. ment. the information being processed probably is ceeds. clinicians move through a series of stimuli and not trying to teach the patient words but. such as a PICA scoring system. It sometimes is helpful experience the target behavior and achieve fully operational in teaching what is meant by “easy” processing to present circuits. tuning in. Specific application of PICA trouble (e. Once this distinction is clear to the patient. feel of the contrast between the two levels of performance. patient is ready to proceed to more difficult tasks.g. cumulative noise. and 9. scoring. small-step treat- order of stimulus presentation. rather. score responses without repeating items enough for success ing to return him or her to “easy” processing—that is. repeats. repeats. cian informed as to the impact of those items on his or her Second. When this amount of interference in pro- once the 15 level is achieved. then presenting stimuli that generally elicit 15-type Some of the major differences between these types of pro- responses. a period of time. Therefore. 13. they can make the to be treated is facilitated by careful examination of the correct adjustments in the program. All-15 tasks are selected for warm-up and the patient’s change very precisely over time. and delays. as treatment pro. The circuits for the or better allows the patient to have significant problems with task are facilitated and will store processing information 5% of the items. it should be apparent that In this sense.qxd 1/21/08 1:45 PM Page 810 Aptara Inc. The patient must be because the patient’s circuits never have the opportunity to taught what this behavior feels like. At first. Even a standard of 95% 13s (delays) processing multiple times at that level. those items on which the patient scored below 15 considered by the system as being tentative and. free to occur. it is best to first treat processing problems that other clinicians. who gives examples of PICA lems occur. Another wind-up tasks. approach is to record the scores on the first presentation of to 13-level tasks. or delays) with the scoring has been described by Bollinger and Stout (1974) in first few items or tunes out the last few. When these temporal prob. may soon be the task to establish a baseline. process being treated is not fully consolidated and is not level processing entails and can store that information. the goal of eliminating tuning out might Brookshire (1973) in his general consideration regarding be achieved by discussing the problem with the patient and treatment of aphasia. it recently was corrections. and so on. multidimensional scoring systems the clinician will find in focuses on modalities and processes that the patient’s own the clinical armamentarium. Finally. time-consuming. it as an error.” It may be that Schuell and colleagues stimulus. Those authors recom- response is easy. such rewards are not required. of the tasks. and the exact difficulty levels seem to be overly idealistic but. if the patient develops response behavior in detail and to convert the behavior into a good awareness of what “easy” responses are and achieves scores: It requires careful preparation and planning based on them on all the items on the task. All this evolves naturally out of a treat- patient’s system. transfer can be maximized the patient’s responses at every stage of treatment. this indicates to the patient that the last response (1964) erred when they considered the necessity to have a appeared to be easy. multidimensional methods is cumbersome. This may modify at that point in time. Unless a and the measures of intrasubtest variability indicate when task is fully consolidated. The treatment. in fact. self- both demanding and complicated. the stimuli. because they tend to interrupt processing and to dis- many pluses and minuses. and this can be computed quite early during the PICA scoring system probably will be just one of many the course of recovery. all suggested by Odekar and Hallowell (2005) that using such responses are correct but may or may not be easy. “If the results are viewed as so able. the clinician and the patient are offered a or category scoring methods are replacing simpler scoring specific target level of overall communicative ability to systems that have been found to be imprecise. someday. delayed responses (13) shift to lower. and made. requires that the clinician REINFORCEMENT OF RESPONSES always be sensitive to the many variables that affect the patient’s processing. and because of the emphasis on systems analysis rather that on language per se. Perhaps. it will tend to deteriorate in a nor. is realistic and essential. because the tasks and the stimuli scribed and verified by the level of multidimensional scores used have been carefully chosen and verified through the the patient achieves. more tentative scores. an increasing number of multidimensional scoring systems ing treatment. and so on are necessary the types of behavior that the patient with aphasia can because the stimuli are too complex for the patient to eval- show during a treatment task. in which the use of tangible it is not clinically important to recognize and quantify all reinforcements. however. because treatment has disadvantages. In fact. these approaches to treatment of aphasia can seem ing an “easy” 15-type response as opposed to delays. . It appears. no real tract the patient. ciency yet minimizes the possibility that the clinician is ate treatment goal is that this type of processing seems to misdesigning the treatment. suggests that the target for communicative systems have indicated are appropriate to changing or terminating tasks is all-15 responses. someone will demonstrate that doing plus-minus treatment. and it should be reintroduced into that mend plus-minus scoring as a faster. useful. less expensive module later to verify that the response is still easy. one will discover that several advantages over less structured approaches.qxd 1/21/08 1:45 PM Page 811 Aptara Inc. ment format that maximizes the patient’s processing effi- The second reason that all-15 responses are an appropri. In start.GRBQ344-3513G-C29[800-813]. once initiated. Unlike method. Whenever either the patient or the clinician feels that the and may not be efficient and cost-effective within many response was not easy. As the clinician presents stimuli. Goldstein (1945) may have uate. In the future. tates accurately recording and analyzing of the response scores. necessi- and regression prevented. In contrast to these advantages. therefore. that the current trend is not toward The treatment methods based on PICA test results and simplified scoring. transfer of these skills rarely occurs. the patient is at last functioning at his or her highest possi- mal life situation or in a more difficult treatment task. If one peruses the literature. or even desir- been wrong when he said. It could be that the treatment using multidi- mensional scoring described in this chapter will be superceded by other methods that use less complicated scor- FUTURE TRENDS ing. It requires training to see the they are not operational. who must concentrate on improving insight is gained as to what the patient can still do and what processing. Conversely. not only in multidimensional scoring described in this chapter offer aphasiology but in many other fields. as being so significant that they scored effective processing. When the clinician simply presents the next he can no longer do. the PICA approach to For this reason. verbal praise. and the target behavior are pre- Such a goal is attainable. the patient stimulus repeated. One of the advantages in using an error-free program is To clinicians who have not been trained in using the that the focus of the patient and the clinician is on achiev- PICA. work toward. the predictive formulas transfer better and is more resistant to regression. as often is the case. Chapter 29 ■ Treatment of Aphasia Subsequent to the Porch Index of Communicative Ability (PICA) 811 The PICA theory. Cued ble levels so that plans for terminating treatment may be (8) to self-corrected (10) responses often become errors. a response behavior that generally was knows that the response was not easy and needs more ignored at the time. If the stimulus is repeated. it should be repeated until the current service-delivery contexts. qxd 1/21/08 1:45 PM Page 812 Aptara Inc. and it does the tasks less quickly and efficiently. L. L. H. which is the goal of treatment.. ACTIVITIES FOR REFLECTION AND DISCUSSION Brookshire. self-corrections. scoring. Treatment should focus on those tasks and stimuli on multidimensional scoring system shown in Figure 29–2 which the patient produces accurate but not easy to score each response. Error responses suggest that that item.” efficient responses. immediate I use poker chips as reinforcement so he knows if he’s response. Saying the scores out loud as responses. 2. . scoring. Aaronson. 108–132. K. Journal of Communication Disorders.). Porch (Ed. Why would it be impossible for a clinician to do the Disimoni. is necessary in treatment of aphasia. Response contingent small step treatment. F.). In B. 812 Section IV ■ Traditional Approaches to Language Intervention KEY POINTS 5.” 2. and plotting performance in aphasia ther- having high internal consistency. ing new activities to surprise my patients. Bollinger. In B. Considering this discussion on PICA treatment. R. related errors. 6. The clinician must be able to discern and document • “When he has to point to one of six pictures I name. from less right or wrong. Goldstein. What is the danger in having a clinician select tasks and 31–40. them all right. NM: VA Hospital. I can find out 5. and so on. because and/or clinicians watch a videotape of a patient with both the patient and the clinician must make these aphasia doing some test or treatment tasks. R. (1974). 8. ate for the patient? LaPointe. distorted patient’s circuits and systems have been selected. or some other method that how the patient is doing while I’m doing treatment. how should you react to these clinicians’ statements: 1. testing or treatment might be preferable to using items McNeil. Minneapolis. 3. For a short distinctions.GRBQ344-3513G-C29[800-813]. Darley (Ed. MN: BRK. Base 10 “programmed-stimulation”: Task 4. (1948). G. Keith. Cognitive Psychology. L. New York: Grune and Stratton. systems analysis view of apha.” 4. This reduced processing efficiency is evident in the • “He’s doing pretty well on that task. but use the 6. a responses. (1976). Plus-minus scoring fails to make these period of time. (1974). they occur will give everyone some immediate feedback task. “Tuning in” kind of treatment described in this chapter using plus. F. R. In of undetermined difficult or items going from easy to F. R. all the behaviors that distinguish an easy. I think I’ll go on response behavior of the individual.). and “tuning out”: Performance of aphasic patients on order- minus scoring? ing PICA subtests.” 3. D. MA: Addison-Wesley. Can you describe apy.. The inefficient brain must use its circuits for simpler • “I don’t go on to a new task in treatment until he gets tasks. An efficient brain processes information both quickly • “I like to make my therapy sessions interesting by and accurately and only stores information that it can doing a variety of different things and by always try- trust for survival. Clinical aphasiology: Conference proceedings. Decisions about the reasonableness of treating or References continuing to treat a patient should be made on a psychometric basis. & Stout. Once tasks and stimuli that are appropriate for the breaking. (1974). Next. NM: VA Hospital. The Porch index of communicative ability. score each response using plus-minus distinctions and is not useful in treatment. & Darley. each person is seeing delays. Multidimensional scoring. C. Communication Disorders. Several psychometric reasons exist for an aphasia test specification. 9. An introduction to aphasia. Discuss how a cybernetic. Journal of aphasia (e. Language and language disturbances. R. Porch (Ed. E. treatment format should be organized to maximize the probability that the patient will achieve easy responses on items that previously were tentative. Albuquerque.. E. E. repeated stimuli. H. to something else. • “I don’t have time to test my patients. stimuli a priori without verifying that they are appropri.” distinguishes easy responses from less efficient 6. Brookshire. Clinical aphasiology: Conference proceed- some clinical reasons why using homogeneous items in ings. or stimulus is beyond the capacity of the patient’s as to what response behavior is occurring and how well circuits at that time and is not appropriate now. Effects of task difficulty on sentence sia contrasts with the one using the classic subtypes of comprehension performance of aphasic subjects. (1979). 16. L. Cambridge. Stimulus factors and listening strategies in auditory memory: A theoretical analysis. rule 7. Albuquerque. replay the same responses. Evaluation of appraisal techniques in speech and difficult? language pathology. Improving your clinical skills: Have a group of students responses. 167–173. L. (1973). which samples the patient’s pro- cessing potential. (1983).g. Wernicke’s or Broca’s). 1. M. . B. & Jiminez-Pabon. 337–345. clinical procedures for predicting recovery from aphasia. T. Schuell. Brookshire (Ed. 14. Porch. Alto. (2005) Comparison of alternatives to Porch. E. Harper & Row. 23. Jenkins. & Callaghan. NM: VA Hospital. Minneapolis. Clinical aphasiology: Conference proceedings. B. (1970). H. 777–792. CA: Consulting Psychologists Press.. Wertz. B. . R. E. (1981). E. PICA interpretation: Recovery and treatment Statistical prediction of change in aphasia. Albuquerque. 312–321. Journal of Speech and (video training tape).. (1974). Chapter 29 ■ Treatment of Aphasia Subsequent to the Porch Index of Communicative Ability (PICA) 813 Odekar.. Porch. Wertz. Porch (Ed. Statistical and Journal of Speech and Hearing Research. Porch. & Friden.. & Hallowell.. B. J. American Journal of Speech-Language aphasiology: Conference proceedings. Porch. (1981). R. P.GRBQ344-3513G-C29[800-813]. The Porch index of communicative ability. Collins. Aphasia in Albuquerque: Pica Programs. H.. (1971). B. (1964). Albuquerque.. E. Porch. Pathology. E. M. MN: BRK. (1980). (2001). Clinical prehension in aphasia. S. NM: VA Hospital. T. Hearing Research. M. Making predictions about multidimensional scoring in the assessment of language com. B.).). E. recovery: Is there HOAP? In R. B. New York. A. & Collins. T. E. The Porch index of communicative ability. E. B. In B. Palo E. 14. Multidimensional scoring in aphasia testing. adults. Porch.qxd 1/21/08 1:45 PM Page 813 Aptara Inc.. to support the communicative interactions of people with The Holland and Beeson (1993) statement also reinforces aphasia. Specialized Interventions for Patients with Aphasia Chapter 30 Communication-Based Interventions: Augmentative and Alternative Communication for People with Aphasia Karen Hux. however. a strong inclination to restore “In all but the most transient of aphasia. stimulation to people with aphasia. at its core. Despite these phenomena. sia. face demand a flexible clinical approach that takes into account the complexities of augmenting impaired symbolic processing systems. This statement highlights a major problem with notion that providing systematic and extensive language which aphasiologists have long struggled: Existing interven. will help to re-establish language sia to their premorbid levels and. and partner-independent communicators nication skills compared to people with severe aphasia. Kristy Weissling.GRBQ344-3513G-C30[814-836]. and relationships that tive and alternative communication (AAC) options available they enjoyed previously. brain regions or through recruitment of alternate brain 814 . either through recovery of language-specific with unmet communication and social needs (LaPointe. Traditional therapy for aphasia has. Months or even years of speech and lan- guage intervention services. within the population of adults with aphasia. D. 1998). 2005). especially during the tions do not always restore the abilities of people with apha. 1993. leave some people processing. partner-dependent. Robey. activities. the p. & Stein. The persistent struggles these people with people with aphasia.qxd 06/02/2008 15:23 Page 814 Aptara Inc. and various AAC techniques and strategies for use of chronic aphasia. various types Those with initial aphasia severity levels that are moderate of assessment procedures that allow practitioners to match or worse may make gains in recovering some aspects of lan- cognitive and linguistic strengths and challenges with AAC guage functioning. pation in the social roles. Readers will learn about barriers and assets regard. 1996. but they frequently experience a degree methods. This does not mean that therapy for aphasia is inef- and Sarah Wallace fective in facilitating linguistic improvements in many peo- ple with aphasia (Holland. hence. 582). another well-known phenomenon concerning aphasia ing the incorporation of AAC into communication-based recovery: People with mild aphasia typically have better interventions for people with aphasia. outcomes and are more likely to regain functional commu- transitional. and perhaps its impaired language underlies the efforts of many speech- mildest forms. acute stage of recovery. do not spare some OBJECTIVES people with aphasia from facing futures in which communi- cation challenges repeatedly prevent or impede full partici- This chapter introduces readers to the variety of augmenta. there is little reason to believe that aphasia language pathologists working with people who have apha- therapy ‘removes’ the aphasia” (Holland & Beeson. Fromm. DeRuyter. The alternative strategy—namely. we address future trends concerning the ated with augmentative and alternative communication integration of AAC interventions into standard clinical prac- (AAC) devices. transitional. A consistent tions is important to allow adequate time for people with theme across these discussions is that AAC holds consider- aphasia to adjust to. refine. the rapid tion procedures associated with communication-based AAC changes observed in many people during the first several strategies and techniques that support the residual speech weeks or months following the onset of aphasia support the and language capabilities of people with aphasia. we notion that language restoration is a viable goal. master. Information in this chapter is organized into five sections. aspects of AAC systems to people with varying types and mentation of restorative intervention approaches with ones severities of aphasia. This includes distinguish. 1985. Chapter 30 ■ Communication-Based Interventions 815 regions to assume language functions. Indeed. aphasia are likely as speech-language pathologists increas- To compensate for the persistent communication chal. providing only Rehabilitation professionals have long recognized the restorative intervention initially and. 4). facilitating ongoing partner support of communicative . and partner-indepen. the early introduction of AAC interven. Third. Kraat. Ogletree. Speech-language pathologists have the challenging job of The successful development and implementation of AAC designing and implementing intervention programs to assist interventions for people with aphasia requires that speech- people with aphasia in mastering these compensatory behav. sections. Second. tance by other practitioners both within and outside the actions across diverse settings and with multiple partners. as opposed to a single entity” (2004. 2004. the lay public. and the symbolic strategies. or even dismissing Drew. are needed. The purpose of this chapter is to provide speech. generalize compensatory strategies to a variety of communi. Finally. need frequent dent communicators and aligning them with traditional updating to meet changing needs. ple with aphasia almost invariably require multi-modal ing partner-dependent. The devel- clinical profiles of people with aphasia regarding their com. and applications most likely to bene. appeared periodically in professional journals. aphasia (Beukelman. that are compensatory in nature.qxd 06/02/2008 15:23 Page 815 Aptara Inc. restoration may not be realized. and provide a means of types of aphasia classification. we We believe that practitioners can improve the long-term provide case examples to illustrate the application of specific outcomes of people with aphasia by providing early supple. and strategies to the variety of communication faced with moderate or severe aphasia. Discussion about adapting existing tional communication. highlighting the complexity of implementing AAC interventions with individuals who have weakened As stated in the American Speech-Language-Hearing symbol processing abilities. Jacobs. and (c) promote greater AAC accep- strategies and techniques that support communicative inter. such as those associ. Given the limited reimbursement AAC interventions or creating new strategies and tech- that insurance companies currently provide for speech and niques to meet the needs of people with aphasia has language services. strategies. we present interven. profession. Fourth. functional and effective communication. & Pierce. For them. when insufficient gains potential for exploring AAC interventions for people with signal that natural speech will not reach functional levels. language pathologists have accurate information regarding iors. two issues: the nature of AAC interventions for people with language pathologists with the information they need to aphasia as multifaceted systems geared toward maximizing make informed decisions about the types of AAC devices. Association Technical Report. we address AAC assess. and people with aphasia. “AAC is best thought of as a ment issues by providing guidelines for determining the system. practice. additional situations and interactions encountered by people with compensation-oriented interventions. approaches that combine several strategies. tice for people with aphasia. Total discuss the generalization and application of AAC systems. belatedly introducing AAC interventions. First. Early introduction of com- pensatory AAC strategies and techniques supports the resid- ual verbal comprehension and expression of people with RELATION BETWEEN AAC AND APHASIA aphasia. & Dowden. (b) develop and refine AAC multi-modal communication strategies that include the use interventions to address the specific needs and capabilities of of residual speech and language as well as compensatory people with aphasia. Throughout this chapter. we provide an overview of the relation between AAC Multifaceted AAC Interventions and aphasia. Koenderman. 1990. especially by those who are techniques.GRBQ344-3513G-C30[814-836]. van de Sandt- clients from therapy altogether—is unlikely to support func. and techniques. and begin to able promise for supporting individuals with aphasia. and needs associated with differing types and severities of These issues are discussed separately in the following aphasia. Yorkston. 2004). p. Improved communication outcomes for people with chronic cation situations. techniques. opment and maintenance of successful AAC systems for peo- municative capabilities and needs. people with aphasia need instruction about ments to restorative approaches. processing weaknesses that underlie aphasia and that influ- fit people who display various communicative capabilities ence the design and application of AAC interventions. aphasia. ingly (a) introduce compensatory techniques as early supple- lenges they face. 1997). transmitting specific information from accessing and using symbolic elements. the systems have iso- tions. to communicate during a social types of symbols (McNeil & Pratt. Hence. multiple modalities. speech-language pathologists concerns the notion that people with aphasia have informa- can create systems that address the multiple challenges faced tion processing challenges that not only include language by people with aphasia when they attempt to participate in but also extend beyond language to the processing of all activities. when design- strategy or device is unlikely to foster sufficient success for a ing a system. reliance on only one compartments of a grid for use to construct linguistic struc- communication modality or a single type of compensatory tures (Light et al. and structure that extend beyond the mere substitution of one symbol system for another and that do not use normal language processing as the underlying Viewing Aphasia as a Symbolic Processing Weakness framework. This approach will be discussed in the . It is affected by and affects other phys. 739). written language. Second. through the use of multiple modalities and iological information processing and cognitive processes to contextual supports. chronic aphasia ple with aphasia have difficulty processing all symbol types may need compensatory strategies to assist with understand.. low-tech communication books. . drink) using a combination of spoken and written language. association. auditory comprehension limita. 2004). First. compensatory strategies. or high- that people with aphasia are inefficient. design. it is a behind the development of AAC strategies for individuals problem that limits an individual’s ability to process all types with aphasia.e. dynamic. capabilities of people with aphasia. or reference to tance regarding AAC applications. professionals can lation are not totally devoid of this ability. . in manipulating verbal symbols (McNeil & Pratt. implementation).. and agrammatism) could potentially con. ges. tech communication devices. retrieval. well as transactional functions—has been a driving force Aphasia is not simply a language disorder. Within the realm of designing and teaching of symbolic information.qxd 06/02/2008 15:23 Page 816 Aptara Inc. individual verbal symbols) arranged in separate tribute to communication breakdowns. developing and extend across all symbol systems. niques geared toward minimizing barriers to successful A second important feature of McNeil’s (1988) definition communicative interactions. use language. storage. interact with.g. resemble “language in a box”—that is.e. organization. 816 Section IV ■ Traditional Approaches to Language Intervention interactions. The tures.GRBQ344-3513G-C30[814-836]. drawing. oped. The devices. gestures. rather. and references to pre-stored problem stems from the fact that many existing AAC sys- information or remnants.. professionals can modality physiological inefficiency with verbal symbolic design systems that supplement a person’s inefficient lan- manipulations (e. two types of approaches exist for tion of aphasia highlighting the symbolic nature of the using AAC to support the residual speech and language underlying deficit that is experienced: “Aphasia is a multi. and techniques By viewing AAC as a combination of strategies and tech. First is the stipulation environmental cues.g. One of the biggest challenges to designing and implement. many current AAC tech- people with aphasia and their communication partners mul. they are design systems that minimize reliance on linguistic or sym- likely to benefit from compensatory strategies that provide bolic processing. it is crucial that speech-language pathologists teach organization and structure. and adaptable. For AAC to benefit people maintaining interpersonal relationships) communication with aphasia. The fact that peo- gathering of friends. For people with aphasia. increases the likelihood of accurate comprehension and 2001). This strategy does not work well for most peo- mize communication breakdowns interfering with either ple with aphasia precisely because they are inefficient in transactional (i. AAC is most effective redundancy through the presentation of information in when it is multifaceted. ing verbal statements made by others as well as with relating substituting the written word drink or a line drawing of a details about recent personal experiences. expression of intended meanings. strategies. the need for improved outcomes in overall ing AAC interventions for people with aphasia relates to the communication—including goals relating to interactional as nature of aphasia as a symbolic processing weakness. For example. unimpaired language systems as the basis for Hence. verbal lated and decontextualized representations of language con- perseveration.. means that simply substituting one symbol for another (e. will not provide sufficient support or compensation. production of jargon.. This occurs because. Such informational redundancy cient.. cepts (i. tems designed for people with disabilities other than aphasia ciated with aphasia (e. McNeil (1988) provided a defini. and their challenges one person to another) or interactional (i. professionals need novel approaches to system goals (Simmons-Mackie & Damico. Because multiple challenges asso. self-generated drawings..e. Hence. This may mean person lifting a cup to his mouth for the spoken word. 2001). nologies reflect how people without language impairments tiple strategies that they can employ systematically to mini. a person with severe. and rule guage processing by providing informational redundancy. In summary. word retrieval problems. gle message through simultaneous or sequential use of Certain features of this definition have particular impor. rather than defi. People who are inefficient in verbal symbol manipu. . AAC specialists rely on their own fully devel- person with aphasia to engage in this type of social event. speech. people with aphasia and their commu- the degree that they support. or are supported nication partners promote redundancy by presenting a sin- by the symbolic deficits” (p.g. This means that. of AAC can provide this type of informational redundancy. Lasker. ever. this appeal is because this provides a aphasia is a complex undertaking. & Morgan. 2004) suggested an alternate an AAC treatment plan. writing. relatively preserved cognitive PICA. how- nication contexts. Clinicians may find the BASA particularly useful for processes. see also Garrett & Lasker. such as visual perception. assessing both linguistic and paralinguis- aphasia specialists have an array of communication-based tic skills. Porch Index of Communicative Ability (Porch. AAC and spoken responses. Boston Assessment of Severe Aphasia (Helm-Estabrooks. tic and symbolic processing abilities of a person with apha- ceeded primarily in developing treatment approaches corre. 1989). 2004). the clinical applicability of the Boston Classification Attempting to determine which of the many possible AAC System has made it popular among clinicians (Kertesz & intervention techniques will help a particular person with Poole. For AAC purposes. & Barresi. can be matched against clinical trials with about the status of a person’s retrieval of words. and Fox (2007. 1967). ering innovative ways of supporting the weakened language Ramsberger. may provide little practical information to guide prac- titioners in selecting and applying appropriate AAC interventions. and Speech-language pathologists can choose from several stan- holistic processing of contextual information.qxd 06/02/2008 15:23 Page 817 Aptara Inc. For people with aphasia. however. Terms such as Broca’s aphasia. 2001). with communication needs is a starting point for developing 2005a. sia. dardized assessment tools to help determine current linguis- To date. Boston Diagnostic Aphasia Examination–3rd Edition mational redundancy. Ward-Lonergan. The remainder of this chapter provides individuals who retain greater linguistic processing abili- information to assist speech-language pathologists in decid. By combining existing knowledge about systems people displaying very limited communication behaviors. This profile. 1993). more recently. 1982). if not. Capability Profile Beukelman and Garrett (1998) and. and repeti- hold the most promise for generalization into real commu- tion of utterances produced by others. also have (Goodglass. or WAB. Morgan. comprehension of auditory messages. or BDAE-3. Some of the more commonly used options include the sponding with the first of these strategies—that is. & Nicholas. Most teristics and severities as well as information about how to standardized aphasia batteries allow clinicians to identify design and implement a variety of communication-based areas of preserved strength relative to overall linguistic AAC intervention strategies. and observing and identifying some AAC strategies treatments from which to choose when supplementing the spontaneously used by the person with aphasia (Nicholas. instead. Lasker & Garrett. Recent advances. reading. Often. The primary goal during consistent vocabulary for discussing the clinical features of AAC assessment for people with aphasia is the development subgroups of people. systems. Classification of aphasia types has a long ASSESSING PEOPLE WITH APHASIA FOR history and broad appeal among speech-language patholo- SELECTION OF AAC INTERVENTIONS gists and other rehabilitation medicine professionals. the revealed new possibilities for bypassing sole dependence on Western Aphasia Battery (Kertesz. fluency in various AAC strategies and devices to determine those that speaking. AAC professionals and aphasiologists have suc. In addition. Kaplan. Many comprehensive aphasia tests allow the classification of aphasia by type. clinicians who has aphasia communicates and less emphasis on the may wish to administer such a battery. and the linguistic elements and symbolic processing by. constructing a capability profile of a person Garrett. and gesturing. and anomic aphasia convey information once developed. speaking. supporting language processing with development of sys. of a clinical profile of capabilities and needs. if desired. These labels. In part. The basic premise with this approach is that people with aphasia communicate most effectively when relying on Aphasia Batteries cognitive processes that are non-symbolic in nature. functioning. because this tool provides a means of acknowledging non- tems minimizing reliance on symbolic processing. tening. Chapter 30 ■ Communication-Based Interventions 817 portion of this chapter that explains the incorporation of and/or specific AAC assessment measures to provide a more visual scenes into low-tech and high-tech communication complete profile of a client’s capabilities. clinicians may prefer assessment measures that provide ing which AAC techniques and strategies are most likely to a means of observing behaviors across the modalities of lis- be effective with people displaying different aphasia charac. this type of classification system of additional measures looking at specific cognitive functions can be a beneficial supplement to help speech-language . memory for important life events. scores reflecting previous classification system placing greater emphasis on the administration of a standard aphasia battery are available to partner-independent/dependent status with which a person begin formulation of the capability profile. In par- ticular. ties. by uncov. restorative intervention approaches commonly used to assist Helm-Estabrooks. or BASA. modality-specific language characteristics that he or she dis- clinicians can supplement these scores with administration plays. Historically. the systems of people with aphasia through provision of infor. Wernicke’s aphasia. or increasing reliance on other.GRBQ344-3513G-C30[814-836]. many partner-dependent communicators evolve dent communicators. uum.qxd 06/02/2008 15:23 Page 818 Aptara Inc. In addition to determining aphasia characteristics. may rely heavily on characteristics distinguishing partner-independent and partner. 1982). to communicate. Other fac. also contribute to determination of a 2001). municative competence displayed by these individuals. aphasia types that correspond to severe comprehension Helm-Estabrooks (2002) attempted to determine the problems and limited awareness of production errors (e. Supplemental Cognitive Assessments Similarly. The Clinicians familiar with the Boston Classification System label transitional communicator serves to describe the com- may find it helpful to consider how the corresponding apha. 1998). transcortical sensory. Some partner-independent communicators use or anomic aphasia. people Court.g. many aphasiologists into transitional communicators as they gain skill and confi- have come to view the Boston Classification System as a dence applying AAC strategies and techniques to a variety of severity continuum (Kertesz & Poole. the middle of the partner-independent/dependent contin- hend messages and to reveal their communicative compe. and Wisconsin Card Sorting Test (Heaton. partner-dependent communica. many individuals with aphasia fall somewhere in tors require assistance from others to convey and compre. tend to be partner-independent commu- pre-stored messages. These individuals may be independent communicators tence. Indeed. 2004). sia types relate to partner-independent and partner-depen. severity by itself is an may wish to assess cognitive skills if they feel this informa- insufficient indicator (Garrett & Lasker. speaking and gesturing) • Does not use AAC strategies without support and may not and AAC strategies to communicate search. pictures. Specifically.g. Tools such as tors. and dependent communicators (Garrett & Lasker. Of note. partner support to convey intents.. aphasia severity has a large impact on a person’s classification as a partner-independent versus a partner. Raven. tion will add meaningfully to a client’s profile. correspondence between aphasia battery scores and scores . These mea- Boston Classification System as being severe (e. engage in meaningful communicative interactions. partner-inde. People with less severe types of aphasia and good awareness pendently in many situations. clinicians dependent communicator.. or searches ineffectively. 2005a). comprehend others.g. intents to to inconsistent success communicating messages others • Recognizes when communication breakdowns occur • Does not consistently recognize errors in communication • Combines some symbols (e. however. such as awareness of production errors and motivation the Cognitive Linguistic Quick Test (Helm-Estabrooks. is situations and with multiple communication partners. from others. 818 Section IV ■ Traditional Approaches to Language Intervention TABLE 30–1 Characteristics of Partner-Independent and Partner-Dependent Communicators Partner-Independent Communicator Partner-Dependent Communicator • Initiates communicative interactions with others frequently • Needs assistance from a partner to initiate and maintain and independently communicative interactions • Uses both natural modalities (e.g.. • May have difficulty using symbols of any kind written words) to create simple and some complex messages • Displays relatively good pragmatic behaviors during • May not engage in appropriate turn-taking during conversational interactions conversation • Has relatively good comprehension skills • May require support for comprehension and/or expression of messages Key: AAC  augmentative and alternative communication. at other times. Table 30–1 summarizes some of the common in some instances but. for ways to communicate • Experiences frequent communication breakdowns leading • Relies on a partner to interpret most. Raven’s Progressive Matrices (Raven. This. without the need for assistance of their challenges. in fact. if not all. aphasia) tend to be partner-dependent communicators. or subcortical sensory treatment approaches. & person’s partner-dependency status. pathologists make decisions about communication-based Wernicke’s.. the underlying premise of the Aphasia Quotient score derived from administration of the WAB (Kertesz. such as sures give clinicians information about nonverbal processing global or mixed transcortical aphasia) or people having those and executive functions. In contrast. novel messages. conduction. whereas others generate their own nicators. pendent communicators are ones who communicate inde. 2005a). exhibiting those types of aphasia identified through the 1981) may be useful for assessing such skills. such as those with Broca’s. As implied by the label.GRBQ344-3513G-C30[814-836]. Over the years. spoken words. Spelling to supplement communication attempts. A typical utterance follows. him at the 25th percentile. Using symbols to complete a transaction and to con- ments. Selecting a symbol to request a basic need or provide a municative interactions.e. and his performance on the Test 2005b. and so on that he stores in a verse with another person. These include (a) two low-tech response to a biographical question.4. Raven. communication books differing in size and complexity. Using a map to provide information about places. (b) 2. sage. yielding an Aphasia external system. illustrating the nature of Tom’s stereotypies and word The specific assessment of the AAC strategy as used by peo- retrieval challenges: “Well / let’s see / I see a / I see a / ple with aphasia is a relatively new undertaking. at the age of 52 years. Choosing symbols that are exemplars of a given cate- tions with professionals. Tom is a tion systems with specific individuals who have aphasia. Fluency  4. Therefore. use of AAC by people with aphasia. 4. really bad / I see a / no that’s not it / well it floats / and For example. Instead. Comprehension  7.9. This assessment.edu/screen/screen. tool includes eight activities: Tom uses multiple AAC materials to support his com. 6. Tom’s performance on Raven’s Colored bols. Chapter 30 ■ Communication-Based Interventions 819 on assessments of non-linguistic functions. advertise. search pictures. (c) expansion of his use of writing. individ- Case Study 1 uals with aphasia appear to have unique profiles of cognitive strengths and weaknesses that are not predictable based on Tom sustained a left hemisphere cerebrovascular accident language test results. & Johnsen. financial concerns. & Court. generative communicator. through administration of this tool assists clinicians in mak- 1997) placed him in the 39th percentile. Tom’s auditory comprehension skills surpassed his Aphasia-Based AAC Assessments verbal expression abilities. Sherbenou. In recent you know I have a problem / I really do / I am bad / it’s years. events/activities in the form of news articles. Information gathered of Nonverbal Intelligence (Brown. and other matters involving interac. 1982) (i. (c) remnants about current gory. . html) assesses a person’s ability to communicate with an Repetition  0. tive functions that allow flexibility and performance of goal- Following his stroke. a clinician marks the type and ing production of more content words. 3. tion was nonfluent in nature. Listening to a clinician tell a story. used several stereotypic phrases repeatedly ments to measure the status of these functions may provide during conversational interactions. letters or partial words and for drawing simple pictures. restaurant napkins. some tools for examining these skills have emerged. including introduction of a spelling board for cue..qxd 06/02/2008 15:23 Page 819 Aptara Inc. combine communication modalities. and (d) paper and pencil for writing first 5. the erate to severe Broca’s aphasia. His language produc. As an ilar aphasia severities may stem from discrepancies in their adult.GRBQ344-3513G-C30[814-836]. with poor verbal repetition skills. Before his stroke. (Kertesz. 2004). A summary score sheet allows clinicians to interpret ings by communication partners. and (d) mastery of frequency of cueing that a person needs to perform specific conversational repair strategies related to misunderstand. shoulder pouch. ferences in the long-term outcomes of individuals with sim- he lived by himself and worked as a photographer. developing a profile of a person with aphasia. Selecting two or more symbols to convey a specific mes- a business card organizer for discussion of health care. and use symbols Progressive Matrices (Raven. Tom had frequent word finding directed behaviors. administration of assess- difficulties. When administering the tool. Lasker & Garrett. tasks. test results with regard to an individual’s communication partner-dependency. business cards and remnants.unl. a diagnosis confirmed by his Multi-Modal Communication Screening Task for Persons achieved scores on subtests of the Western Aphasia Battery with Aphasia (available at http://aac. Naming  2.” a communication assessment measure relating specifically to Tom’s language characteristics are consistent with mod. categorize. (b) refinement of an organizational strategy for 8. According to ing decisions about the viability of using aided communica- Garrett and Lasker’s (2005a) classification system. Helm-Estabrooks postulated that dif- (CVA) 9 years ago. within the realm of execu- for his own enjoyment and as part of his vocation.3). Pointing to sequential pictures to tell a story. combine sym- Quotient of 38. both cognitive abilities—specifically. using pictures or other available materials. 1998) placed for story telling or to convey a message (Garrett & Lasker. Garrett and Beukelman (1998) originally kids and things / you know I really have a problem / developed—and Garrett and Lasker (2005b) later updated— I really do. She found no Box 30–1 consistent pattern of performance regarding the relation between linguistic and non-linguistic skills. 1. The partner-independent. and then retelling it His ongoing intervention goals include (a) further devel. and perseverated on additional important information for consideration when certain ideas and verbal responses. opment and expansion of use of low-tech communication 7. he had traveled throughout much of the world. books. For example. checklists stages of the disease process. people communicate for a variety of purposes. has a progressive form Checklists completed by caregivers provide a means of of aphasia—primary progressive aphasia (PPA)—associated obtaining information about the needs and abilities of peo. Alarcon.. which are viable during communication attempts. the imentation and implementation over multiple sessions is term should not be limited to requests for objects or actions. including sharing Additional Considerations information. willingness. Beyond meeting basic needs.. or dependent-com- available. and spelling as well as to the per- People with Aphasia. to maintain maximum com- topics. a clin- describing contextually rich pictures. Communication checklists Most people with aphasia have sustained strokes or and informal interviews are common ways of obtaining this acquired brain damage from other types of acute incidents. the strategies should be explored. While eliciting such a ician first must identify a cluster of potentially useful strate- sample. A subgroup of individuals. by watching and listening as the person municator status.GRBQ344-3513G-C30[814-836]. such as pencil and paper and a spelling board. 820 Section IV ■ Traditional Approaches to Language Intervention Another way of collecting this partner-dependency infor. exper- interactions in which a person desires to communicate. functions.e. however. options for further training. People with aphasia and Needs Profile the professionals working with them sometimes require only a single session to decide whether a particular strategy or A needs profile involves identifying all the contexts and device has potential value. summarized in Communication-Based Interventions for gestures. An Form and Partner Attitudinal Survey (Garrett & Beukelman. engagement.) son’s overall comprehension level. overriding strategy regarding people with PPA is to provide 1992) to family or caregivers may assist in delineating instruction early during the disease process. and maintaining social etiquette (Light. during early and routine behaviors and needs. they will show the opposite shift regard- through informal interviews. Administering the Partner Skill Screening vant to people with aphasia resulting from acute events. may gies. alternate with aphasia engages in the communication process. eventually. com- Once a clinician has generated a list of potential strate- bined with results from other assessment procedures. actional (i. he or she introduces them to a person with aphasia to provide a sufficient basis for determining partner-dependency determine which are used with ease. transmitting lar strategies based on the person’s responsiveness in terms specific information from one person to another) and inter- of ability. necessary. having a family member com. Additionally. (Approaches that are appro- clinician can make a judgment about partner-dependency. priate for independent and dependent communicators are paying particularly attention to spontaneous uses of speech. Strategy and Device Trials mation is to engage the person with aphasia in spontaneous The final aspect of assessing people with aphasia for AAC communication using activities such as responding to open- interventions involves the implementation of communica- ended questions (e. however. practitioners . municative performance for as long as possible. the Aphasia Needs Assessment tors and then. establishing social closeness. techniques. This information. This can be guided by identification of tools. people with PPA function as provide clinicians with a means for amassing information independent communicators. The same with aphasia. 1992) gies.qxd 06/02/2008 15:23 Page 820 Aptara Inc. Then. in press). about the communication roles. and modes rou. Specifically. 1997) (available at http://aac. As the disease progresses. readily the person’s independent-. What is your typical day like?) or tion strategy and device trials. 1988).g. with a decline in communicative function over time. when the indi- strengths of the communication partners regarding the vidual still has adequate language and cognitive skills to facilitation of comprehension and expression by people understand and master compensatory strategies. people have unique needs regarding AAC assessment. checklists provide a systematic ing their partner-dependency status compared to people way of collecting information about a person’s functional with acutely acquired aphasia. This deterioration in communication independence edu/screen/screen. more frequently. To perform such trials. In particular. tors.html) includes items relating to a variety has implications regarding the introduction and application of communication needs that an individual with aphasia of AAC strategies and devices that differ from those rele- may experience. people with PPA become transitional communica- tinely used. however.. Although experi. writing. If initial trials are unsuccessful. enced clinicians may prefer to gather such information because over time. drawing. and which the person with aphasia is not yet ready to attempt. the clinician provides alternative means with which gies for exploration by matching a person’s clinical profile to the person who has aphasia can communicate by making available strategies. Specifically. developing and maintaining interpersonal rela- tionships) activities. & may assist clinicians in identifying potential communication Rogers.e. These ple with aphasia regarding use of AAC. transitional-. type of information.unl. and comfort. Clinicians should judge the usefulness of particu- A needs profile include both transactional (i. philosophy extends to instruction regarding AAC strate- plete the Inventory of Topics (Garrett & Beukelman. and device usage (King. partner-dependent communica- (Garrett & Beukelman. and caretak. and business cards). thus eliminating the need question in its entirety but only augments key elements: to communicate with another person about these activities. Note that the communication part. Augmented input. a communication book may include content specifically tar- Communication Books geting communication with grandchildren while babysitting. 1992). contextually organized pages providing information about ventions designed to promote successful interactions among frequently discussed topics as well as topics of high interest. and providing prosodic needs. to your sister’s [points to word. Independent communicators benefit from access to multiple types of conversational supports. not all people with aphasia use communica- [writes. individual with PPA is still functioning as an independent although the type. or family accuracy with which a person who has aphasia understands member anticipates will be frequent or desirable topics. the communication partner verbalizes the dressing. although it is easily paired individuals experience when using them varies widely. needs. strategy to express basic needs. or grooming. yes [nods head]. Communication books are used with many populations of requesting directions to sale items in a store when shopping. depending on the content. These multiple-input modalities typically occur often anticipate these needs. Communication partner Did you go to your sister’s Because of this. with a method of requesting attention to basic wants and tual information in the environment. they are ways of providing tools for generative communica- Garrett & Beukelman. than the expression of basic wants and needs and.GRBQ344-3513G-C30[814-836]. They are among the most commonly used of all AAC input is on improving receptive. and pages for drawing or refers to a set of compensatory strategies that speech-lan. Augmented input is appropriate for use with any individual who has reduced auditory-verbal comprehension. 1998. a person living at home may not need assistance mented input. and partner-dependency status. sister] on Sunday [points Communication books have many potential uses other to Sunday on calendar]. delivered at routine times and water available at all times on ner uses augmented input to verify the person’s response as a bedside table. a per- The following example shows augmented input in an son residing in a long-term care facility may have meals interactional exchange. people who have communication disorders. thus eliminating the necessity in combination with spoken messages. organization. for communicating directly about them. Dependent com- COMMUNICATION-BASED INTERVENTIONS municators are most likely to benefit from communication books that include instructions to others about ways to fos- FOR PEOPLE WITH APHASIA ter communicative interactions along with relatively simple. referencing readily available contex. For example. with other AAC techniques. such as maps of buildings Augmented Input/Augmented Comprehension or local areas. such as the written choice com. can be used to assist with communicative interactions in a wide variety of contexts. nicative intents. Inexperienced clinicians may believe that the intent of com- munication partners of people with aphasia use drawing. Although some people with aphasia require an AAC emphasis to supplement spoken words as a means of com. Regarding people or relaying personal information about an individual. staff and family members municating. For example. This section presents information about multiple AAC inter. gesturing.. aphasia severity. will vary substantially based on capabilities. you did go generally are unsatisfactory. thus eliminating the need to request food or well as to convey the initial question. with aphasia. As is typical of aug. Thus. also called augmented comprehension. pensive ways of allowing people with aphasia to communi- The purpose of augmented input is to increase the ease and cate about subjects that a clinician. Com. targeting the expression of commu. his or .qxd 06/02/2008 15:23 Page 821 Aptara Inc. liquids. toileting. and instruction munication strategy. strategies for people with aphasia. or organization. newspaper clippings. Communication Book Content Augmented input is multi-modal by nature. people with aphasia and their communication partners. writ. places for collecting and storing important remnants from recent events (e. Chapter 30 ■ Communication-Based Interventions 821 should teach AAC strategies that are appropriate for transi. Regardless of content guage pathologists can teach to family. depending Person with aphasia [nods head vigorously] on their content. although the success that aspects of language processing. munication books is to provide people who have aphasia ing key words. ticket stubs. complexity of information.g. the focus of augmented tion. provided. sister?] on Sunday [points to Sunday on calendar]? tion books to express basic needs. communication books are relatively inex- ers of partner-dependent and transitional communicators. and format communicator. and communication books Person with aphasia [nods head] that solely provide a means of expressing such information Communication partner So. communication books can be helpful to tional and partner-dependent communicators while the individuals across the spectrum of partner-dependency. writing to supplement verbalizations. friends. caretaker. and the verbalizations of others (Beukelman & Garrett. rather than expressive. I can understand what you say if you speak slowly.GRBQ344-3513G-C30[814-836]. communication books in which family member. the opportu. context for a communication exchange. he knew most of the people who Communication is about forming social relationships with passed by. this dilemma. playing. eating.. communicative interactions. riences and opinions. and communication books need to allow their families or projects at work. The failure of clini. impaired following strokes to the language-dominant hemi- Once use of a communication book has been established. He could say only a few words. John used these cians to include ways of engaging in communication acts trips as an opportunity to catch up with friends and beyond requesting assistance to provide for basic wants acquaintances by sitting in the car while his wife shopped. to ensure that they are logical to the person with aphasia and do not require symbolic or linguis. a sphere. After talking with someone. tion by category requires symbolic abilities that often are ity to meet the changing needs of a person with aphasia. He used a communication book through small talk and storytelling. the exchange of information.g. assume responsibility for updating the book as needed after or getting ready for work) or location (e. Interviewing Case Study 2 key people and reviewing information in the case history are good ways to make initial decisions about content and John had severe Broca’s aphasia resulting from a stroke. context. Determination of content and the context for use of com. Lasker. people with aphasia to do that through the development of Unfortunately. and needs is one of the prime reasons that people with Because John had spent most of his adult life living and aphasia sometimes reject their communication books. Com- Organization. Categorical organization. John’s chats with friends frequently conversations. cation repairs. 2000). ters to indicate different social relationships with others One of his favorite activities was accompanying his wife to (Stuart. a speech-language pathologist As more pages and additional types of information are must teach the designated individual how to make such added to a communication book. although he often under- Among the major goals of communication books are stood comments made by others when the topics were the provision of means to establish social closeness familiar and predictable. he struggled to tell his wife with whom he had with aphasia. Please be patient. they should change in content and complex. John was eager to share the latest news with his wife. and interests when meeting new acquaintances.. 822 Section IV ■ Traditional Approaches to Language Intervention her family.) prehension of traditional categorical organization may be Finally. Box 30–2 munication books stems from careful consideration of an individual’s needs and communication desires. & Beukelman. however. Inclusion of simple messages explaining why talked—a problem exacerbated by the fact that John knew an individual struggles with speaking or ways of helping to many people who his wife knew by name only. To solve determine communicative intents can minimize the embar. Another important aspect of communication book con. communicate. working in the town. or other person should pages are organized according to topic (e.qxd 06/02/2008 15:23 Page 822 Aptara Inc. office at work or . staff member. Organizational strategies need careful consideration and Communication Book Organization adjustment. were followed by difficult conversations with his wife. and the chance to relate personal expe. Having visited with several friends and acquaintances. John’s clinician added a sign-in sheet and rassment that people with aphasia may experience when written instructions to the front of John’s communication their communication attempts are less than perfect or the book. A sample message the person could write his or her name and the topic might be “I have aphasia. and I use this book to help me discussed. For this reason. because organiza- nature—that is. (Ideas about tactic features. For this to be successful. divide it into sections to foster easy location of material. share information along with a collection of remnants to support many of his through generation of unique messages. based on either semantic or syn- tic processing beyond the person’s capabilities. John lived with his wife in a small. Although he could often use his communication book and tent is to provide instructions about methods of facilitating remnant collection to indicate the topics of his conversa- communicative interactions to people who are not familiar tions. and he enjoyed hearing the latest news about other people.” Specific directions to write down words or repeat utterances also may be helpful in setting the the termination of formal speech and language intervention. make communi. town to purchase groceries or run errands.g. and use a variety of communication regis. rural community. communication books need to be dynamic in difficult for people with aphasia. is common in AAC devices for people with how to organize books are provided in Communication Book communication disorders other than aphasia. John simply presented discomfort that others may feel when they do not know any his communication partner with the sign-in sheet so that strategies for facilitating communication. nity to tell stories. the clinician may need to additions and changes to the existing book. however. g. (McKelvey. played in Figure 30–1. contextualized photograph shown in Figure 30–1c. and the activity in which they are ally relevant people. people with aphasia. These pictures contrast with the other AAC devices for people with aphasia. an alternate organiza. animals. or adjectives)—as may be appropriate for liter.qxd 06/02/2008 15:23 Page 823 Aptara Inc. consider the photographs dis- ations are difficult for people with symbolic deficits. a textualized photographs and visual scene displays are ways of considerable amount of informational content is available accomplishing this. regardless of the pictorial or lexical nature a neutral background. Although the image is clear and the of individual items. Hux.. and objects appear in a setting engaged. Examples of non-contextual Non-contextualized family portrait and contextual photographs. A contextualized photograph shows an to foster communication about the depicted individuals. Dietz. in which a person not engaged in an activity appears against cal organization. the photograph is of little munication books using other organizational schemes to use communicatively other than to identify the individual. Similarly. nouns. the activity or experienced event in which familiar and person. suggest the type or nature of relationships among people. isolated pictures of objects in that they include contextual or These strategies require rather complex linguistic processes environmental content. Chapter 30 ■ Communication-Based Interventions 823 bedroom at home)—as is common for some children needing that is congruent with the depicted activity or event AAC materials—or according to syntactic categories (e. Here. gories. Figure 30–1b shows a family picture with little Because of the nature of aphasia. Contextualized photographs contrast with portraits or ate adults—are not beneficial to some people with aphasia. Figure 30–1a shows a typical portrait communication books using semantic or syntactic categori. 2007). may not provide as much benefit as com. implied story. tant life experience that is conducive to relating a story. B Figure 30–1. pose is typical of static portraits. & Beukelmen. A Non-contextualized individual portrait C Contextualized photograph . For comparison purposes. show an ongoing activity or impor- involving the recall of specific lexical items and the associa. the communicative potential relating ing may help when structuring communication books and to the image is limited. meaningful contextual information and no action or tional strategy not reliant on symbolic or linguistic process. and tion of those items with either semantic or syntactic cate. relationship among them. Weissling. The use of con.GRBQ344-3513G-C30[814-836]. Because these types of semantic and syntactic associ. verbs. Again. both because the person with aphasia has not had when determining what type of AAC layout will best support sufficient time to master use of the book and because the clinician has not had sufficient time to make the necessary adjustments to maximize communication. The goal of using high-tech AAC to support sponta- • My daughter-in-law neous generative communication remains elusive to most people with aphasia. 1996). tional grid layouts common to many AAC systems. A few anecdotal Becky’s decoration of the reports and case studies exist suggesting that some individuals— table is a tradition. A potential advan- cation books can be an effective strategy for people with tage exists in using visual scene displays. 2005a.edu. 2004). Delays in implement- et al. This allows the clinician to gauge an individ- ual’s feelings about using the communication book as well as to monitor his or her success.g. often those with motor speech challenges masking relatively intact residual language abilities—are successful in using high-tech devices to support communication attempts in The family really looks forward to seeing what she does with real-life situations extending beyond the therapeutic envi- the table each year. 2003. The most common scenario.GRBQ344-3513G-C30[814-836]. Lasker & Garrett. hence. vidually and equally. with those that use traditional grid formats. ask me about: texts (e. As noted by Wilkinson and Jagaroo (2004). Using highly contextualized pho. The problem that people with aphasia Figure 30–2. holistic. rather than the tradi- aphasia. In the past. Recognizing pictures of familiar people and events is a rel. It allows the person with apha- sia to practice using the book in a supportive setting and to participate in decision making about changes or additions to its structure and content. ronment (Garrett & Lasker. can result in highly personalized support objects displayed in a cohesive. scene display allows recognition of natural relations among ing or highlighting. when tographs into the display of a visual scene that incorporates dealing with people with aphasia.qxd 06/02/2008 15:23 Page 824 Aptara Inc. Templates providing potential layouts from AAC systems that use visual scene displays compared for making visual scene displays to include in low-tech com. processing information contained in a visual as supplemental organizational strategies such as color cod. People process visual scenes in a “gist” format that does not An example of a visual scene display for incorporation into a require full comprehension of all depicted elements to inter- low-tech communication book of a person with aphasia pret meaning. devices is circumventing their symbolic processing challenges. or sentences relating to the content depicted. people with aphasia may benefit more appears in Figure 30–2. to the conversational interactions of a person with aphasia. Introducing the concept of using a communication book tographs in visual scene displays capitalizes on the intact visual early in the treatment process may improve overall commu- processing and memory skills of people with aphasia as well as nication as well as allow a person with aphasia and his or her on the holistic nature of contextually rich pictures to organize family to become accustomed to the idea of using AAC content information and support conversation (McKelvey strategies to support natural speech. ordering at a restaurant or getting tickets at a box • What I did for Thanksgiving or office). Sample visual scene display from a low-tech face when attempting to use high-tech communication device. and familiar context. ing communication books may contribute to their eventual consideration of visual processing abilities is important rejection. Instruction in Using Communication Books atively preserved cognitive skill for most people with aphasia (Fox & Fried-Oken. because grid processing digital reproductions of personally relevant photographs requires individuals to evaluate all items in a grid both indi- from an individual’s private collection. Incorporating one or more contextualized pho. an individual’s attempts at communication. munication books are available at http://aac. 2007). as well port. In contrast. . is that such a device is used only for a limited number of situational con- To get started. written words. the use of high-tech AAC devices by people with aphasia has met with only limited success. We went to my son Jack and High-Tech Devices daughter-in-law Becky’s home for Thanksgiving.. 824 Section IV ■ Traditional Approaches to Language Intervention Using contextualized photographs to organize communi.unl. without the benefit of contextual sup- phrases. however. Success most often occurs when practitioners introduce and teach the use of communication books in therapeutic activities that mirror real contexts.. Use of letters. Hence. Weissling. and device. This is the giant aquarium. simplify organization. highly contextualized photographs along with related & Hux. Researchers working on the development and imple- people with aphasia to select low-tech options providing mentation of high-tech AAC devices using visual scene dis- comparable features. using such symbols to construct linguistically based miniaturized pictures (i. Dietz. high-tech devices displaying personally rele. Copyright Beukelman. As with low-tech communi. vant. Luke was fascinated by all the fish.. and improving able promise for facilitating the use of high-tech AAC the overall quality of their communicative interactions as devices by people with aphasia. and access within the tech devices persuades most clinicians. An example of a screen from a navigation emphasize reliance on the intact visual process. using them to communicate sto- advances incorporating visual scene displays hold consider.qxd 06/02/2008 15:23 Page 825 Aptara Inc. ries to unfamiliar communication partners. McKelvey. signature pictures) revealing the generative messages remains difficult. McKelvey. S Printed with permission. 2005. Here my wife is teaching Luke about penguin habitat. Sample visual scene display from a high-tech device. In language does not change the underlying symbolic process. reported by family members (Dietz. new in navigating their systems. Furthermore.GRBQ344-3513G-C30[814-836]. 2007). McKelvey. The large pictures in the center region of the Each summer. although people with aphasia may advantages over their low-tech counterparts in that they benefit from the multiple modalities that are presented on allow digitized or synthetic speech output and increased displays with written words. the content/topics of hidden levels and touch-screen technology expense associated with purchasing and maintaining high.e. high-tech applications of visual scene display offer ing problems. 2006. Figure 30–3. family members. 2007. navigation. Beukelman. S What does your family like to do together? ? 1 2 3 4 5 6 7 8 9 10 + . pictures of items. Weissling. Dietz. Hux. What does your family like to do together? ? Figure 30–3. & cation books. or alphabet amounts and complexity of included information. & words or phrases and color-coding to assist recognition and Beukelman. addition. 2005. we take our S grandson Luke to the zoo. plays have reported success by people with chronic aphasia Despite the challenges experienced in the past. high-tech device showing a visual scene display appears in ing and memory skills of people with aphasia while simulta. S Luke thought all of the different colored jellyfish were ‘cool’. Chapter 30 ■ Communication-Based Interventions 825 Simply substituting an alternate symbol system for spoken neously minimizing the need for symbolic processing. Beukelman. intervention programs for people with aphasia are not expected to increase artistic talent. aug. Frick. For example. many people with aphasia do not practitioner needs to explore the impact of using devices spontaneously use drawing to convey ideas (Lyon. or clarify an intended meaning (Boling. Instead. because most people without should develop a scenario to assess the person’s use of the communication challenges do not routinely incorporate device to relate stories and communicate novel messages. ory. the prime objec- tives of drawing programs are. are symbolic in nature. 826 Section IV ■ Traditional Approaches to Language Intervention screen correspond with the selected topic.Helm-Estabrooks & Albert. they may have dif. 2005a. relatively intact visual mem- to people with aphasia are available (Garrett & Lasker. Smith. When assessing tion partners relating to limited artistic ability or coordina- the usefulness of a high-tech AAC device. Although drawings conversational topics or other supplements to convey com.qxd 06/02/2008 15:23 Page 826 Aptara Inc. neither concern should limit (a) uses the device successfully to communicate part or all of exploration of the potential benefits of using drawing to a message.g. These include both sponta. Lasker & Garrett. clinicians need to allay the symbols to encode and represent content. such as enlargement of main ideas and cial when used by communication partners as a type of inclusion of graphic elements. . grates aided and unaided communication strategies. 2004. concerns of both people with aphasia and their communica- ficulty with complex encoding strategies. 1995b). low-tech communication books. First. as well as other exam- neous.g. 1995b). people with aphasia may interpret the municative intents or resolve communication breakdowns non-linguistic symbols used in drawings more easily than the (e. aphasia. gesturing ples of graphic elements that people with aphasia and their and using facial expressions) as well as more formal. tion challenges resulting from use of the nondominant gested (Garrett & Lasker. calendars. The icons. with synthetic versus digitized speech.. when added to illustrations. cally uses simple line drawings and stick figures. and aphasia to co-construct messages or revise communication the signature pictures around the perimeter of the screen. (d) nav. The value of communicative drawing stems available digitized speech. adjusting the volume. & tures for turning the device on and off. and augmented input. a stopped car or one that is moving at either a fast or a slow Virtually all people with aphasia who use high-tech AAC rate of speed. linguistic symbols used in spoken and written messages. Clinicians also need to observe in isolation but that. supplement other modes of communication. Movement lines. and lists). to augment unrecognizable portions of drawings to use drawings to express simple thoughts and ideas. drawing tive recognition and problem-solving skills. communication partners can use to supplement drawings. This is not surprising. written text. the multi-modal nature of these strate. and direct instruction often is necessary to a store. Because communicative drawing typi- modality does not maximize a person’s use of residual cogni.e. program specifically geared toward improving communica- gies is paramount in making them beneficial to people with tive drawing (see. people such as placing a phone call to order clothing from a mail. the optimal size and Estabrooks & Alberts. drawing in their communication attempts. 2004). to correct or expand Drawing drawings so they better convey their intended meaning and. is moving quickly. The addition of three lines (i. it has been sug. (b) initiates communicative interactions. 1995a. 1995a. and (f) resolves elements are non-text symbols that do not convey meaning communication breakdowns. Because people with aphasia have difficulty using encourage its use. a drawing of a car might connote and troubleshooting unanticipated problems. drawings also are benefi. people with aphasia can learn second. Despite frequent preservation number of symbols per page needs specification. allow from two features: first. make through clinician feedback and implementation of additional requests. (e. providing additional time for people with as well as triggering production of digitized messages. nants. (e) uses municative drawing can include graphic elements. maps. Lasker & Garrett. Third. can extend the competence with which the person handles control fea. and gain social closeness. (e. natural communication strategies. When People with aphasia may initially benefit from a drawing used in combination. Because of the simplistic nature of drawings required record information about the number of times that a person for communicative purposes. drawing strategies. do not automatically recognize the potential for commu- order catalogue or asking a stranger for directions to locate nicative drawing. 2004). when touched. and second.. attempts. Given appropriate instruction. 2004) to hand. Hence. a of these skills. its provision of a permanent or semi- navigation to higher or lower levels within the selected topic permanent record. Limiting AAC strategies to a single device or Lyon. mentative communication strategies.. however. its lack of reliance on the processing of when touched provide access to screens relating to other linguistic symbols (Lyon.. 2004). Graphic organizational strategies to search for items. first. Second. or instructions to com. Effective communicative drawing by people with aphasia Basic guidelines for introducing high-tech AAC devices requires good visual attention. munication partners). referring to rem. 1995. In particular. In addition to the creation of simple illustrations. movement devices also employ multiple other strategies to support lines) behind the vehicle provides the impression that the car their communication attempts. are presented in Figure 30–4. rating scales. Eccarius. com- igates from one section or level of the device to another. e.g.GRBQ344-3513G-C30[814-836].. (c) inte. the clinician 1995b).g. and the ability to copy one-dimensional shapes (Helm- 2005a. Following following a recent church service. of communication. Only when others are simple yes/no questions to confirm the drawing’s accuracy supportive of the inclusion of drawing in communication or appropriateness concerning the intended message. use of communicative drawing provision of information in multiple modalities. First. tiate communication of an intended message. the during therapeutic contexts does not guarantee its use dur. she copied shapes of increasing complexity. communication preferences. interpret. Eventually. such as intended message. correct. not replace it. the copied shapes became sufficiently complex so that they resemble objects. speaking. and writing. Mary practiced identifying key shapes (e.. Eventually. Mary’s verbalizations were limited primarily to automatic speech and stereotypic and perseverative responses. The strategy capitalizes on the partners draw. tion is presented through multiple modalities rather than a . she traced these shapes. Mary and her speech-language pathologist devoted a portion of their individual therapy time to improving Mary’s generation of drawings as a means of supplementing her limited verbal and written output. the stroke. tive drawing is highly dependent on the ability of a commu- nication partner to interpret a drawing.qxd 06/02/2008 15:23 Page 827 Aptara Inc. tion with not being included in a women’s discussion group brovascular accident when she was 58 years old. This means that each person intermittently communication strategy as a means for partner-dependent contributes features or details to a shared drawing during individuals with severe aphasia to express personal ideas. gesturing. Then. Because of the severity of her expressive language chal- lenges. the course of an interaction. circle. tional redundancy and comprehend better when informa- Especially when a person with aphasia does not draw to ini. The next treatment step involved Mary’s completion of drawings made by her clin- ician but lacking key elements. communica. By describing details while they draw. People with aphasia may shift between may need to start the process by making a guess about an drawing and using other forms of communication. or triangle) in simple line drawings. In this manner. She generated the drawing shown below to express her frustra- Communicative drawing serves to augment communica. Mary independently initiated drawing as a supplement to verbalizations and/or written words or parts of words to convey communicative intents to others. person with aphasia may add to a partial drawing or answer ing natural communication settings. and probe while jointly observation that people with aphasia benefit from informa- creating an image along with a person who has aphasia. This attempts and encourage and embrace its use are people with approach also provides a way for the communication partner aphasia likely to generalize it to natural settings. Only after repeated success with this activity did Mary’s clinician engage her in com- munication-based tasks during which Mary had to use drawing to convey information displayed on cards visible to her but not to her communication partner. square.g. Some communica- Written Choice Communication tion partners and people with aphasia find that using a drawing as a basis for a dynamic communicative interaction Garrett and Beukelman (1992) developed the written choice is beneficial. and after demonstrating adequate tracing skills.GRBQ344-3513G-C30[814-836]. the partner tion. she sometimes was successful in writing simple words or the first few letters of the words she wished to say. to model the use of drawing as a supplement to other modes Particularly for dependent communicators. and opinions. Chapter 30 ■ Communication-Based Interventions 827 Box 30–3 Case Study 3 Mary acquired severe Broca’s aphasia as a result of a cere. As with many aphasia communication partners foster comprehension through treatments and supports. Then. Speech-language with aphasia determine a topic of mutual interest. that it allows a person with severe aphasia to express per- cation partners present spoken questions simultaneously sonal desires and opinions—a communication skill that with written key words and followed by possible responses. & Eischeid.qxd 06/02/2008 15:23 Page 828 Aptara Inc. The communica- tion partner presents subsequent questions and potential answers relating to the selected topic in the same manner. often eludes such patients. Speech balloon 1995). The communication partner then confirms the selection by cir- cling it on the piece of paper and verbalizing it (e. Movement lines with the interaction continuing until the topic is exhausted. Also. This is pathologists must ensure that family members. munication strategy. largely is dependent on initiate an interaction. a key single modality. however. For example. printing and structured practice using the technique. a communication partner or cartoon sequences to improve written narratives of hard of person with aphasia can supplement the written choice com- hearing students. with 1 corresponding to a very negative response and 5 cor- responding to a very positive response). Unpublished doctoral dissertation. and suggesting several possi- Gestures ble topics. comparable to family visit. advantage of the written choice communication strategy is dependent communicators become evident when communi. Residual skills and competencies of partner. Many variations in applying the written choice communi- cation strategy make it adaptable to the needs of a particular Thought bubble person with aphasia. Using graphic elements in tions or response choices. For example. Garrett & Beukelman. with Path line his or her fingers. To the written choice strategy.GRBQ344-3513G-C30[814-836]. Usually. underlining the word Topic at the top of a piece of paper vis- ible to the person with aphasia. 1997). as speech production. Eccarius. with drawings or gestures serving as forms of augmented input or alternative forms of expression. in case the person with aphasia has a topic in mind other than those ini- Impact star tially suggested. Examples of graphic elements. Other variations involve altering the pace of an interaction through inclusion of Figure 30–4. some people with aphasia do not need the support of written key words and can use the strategy by having the communication partner simply write numbers or signal. The quality of interactions using again presented both in spoken and written modalities. Moncrief. or plans the individual has for returning home after completing his or her stay at a rehabilitation Facial expression hospital. a communication partner and person the skill of the communication partner. Hux. Finally. Gestures are a standard supplement to most people’s natural ceded by a bullet on the piece of paper. and achieved by the communication partner asking a question caretakers of a person with aphasia receive instruction and such as What topic would you like to talk about?. a communication partner presents three to five options from which the person with aphasia can choose. the partner might suggest talking retain some spontaneous use of gestures as supplements to about events that occurred the previous weekend during a speaking. University of Nebraska-Lincoln. a scale ranging from 1 to Simultaneous time marker 5. the strategy works well to elicit opinions or Directional arrow ratings corresponding to a continuum of responses presented on Likert-type response scales (e. Although some people with aphasia shown in Figure 30–5. a number to correspond with each verbal- ized option (Lasker.. The person with aphasia responds to the question by pointing to one of the printed options. 828 Section IV ■ Traditional Approaches to Language Intervention sporting event. In addition. he or she prints a key word or phrase relating to that topic and pre.g. with one option being Something else or Other. As shown in the example illustrated in Figure 30–5. M (2004). the number of possible responses that a communication partner proposes for ques- tions can vary according to a person’s ability to manage multi- ple potential answers (Garrett. 1993. Printed with additional repetitions by a communication partner of ques- permission. friends. the performance of a favorite team in a recent their challenges with other forms of linguistic and symbolic . You want Sound waves to talk about your family’s visit last weekend)..g. Garrett. As the partner suggests each topic. most struggle with using gestures. Waving a hand. mouth in imitation of holding a glass and drinking from Gestures can serve many purposes during interactions. Have you had their soup before? partner: Person with (nods) aphasia: Communication Is the soup good? partner: 1 2 3 4 5 bad okay great Person with (points to 2) aphasia: Communication Well. respectively).. Sample interaction using the written choice communication strategy.g. Pointing to a desired object to replace a verbal request indicate indecision or doubt. soup. down to indicate approval or disapproval. partner: Person with (nods) aphasia: Communication What are you going to eat? Do you want to get pasta.g.GRBQ344-3513G-C30[814-836]. I was going to get the soup (points to soup). pasta (points to pasta). or somewhere else? Restaurants Old India Italian Kitchen Rudy’s Steak House Somewhere else Person with (points to Italian Kitchen) aphasia: Communication You want to go to Italian Kitchen? (points to Italian Kitchen). systems. eyebrows to indicate surprise. Common examples include: 4. Affirming or refuting statements made by others through head nods and shakes. In general. Using iconic or charade-like movements to express instruction to encourage use of gestures as an AAC strategy needs or transfer information (e..qxd 06/02/2008 15:23 Page 829 Aptara Inc. That sounds good to me. or something else? partner: Eat Pasta Soup Salad Something else Person with (points to pasta) aphasia: Communication Oh. Indicating feelings. 1. touching another person’s arm. it). Rudy’s Steak House. practitioners need to provide direct 3. raising the tion. or 5. or pointing the thumb up or for the item. shrugging the shoulders to 2. or reactions through facial establishing joint eye contact to gain a person’s atten. Chapter 30 ■ Communication-Based Interventions 829 Communication What restaurant do you want to go to? partner: Do you want to go to Old India. opinions. Italian Kitchen. raising a hand to the for people with aphasia (Collins. salad. expressions and standardized gestures (e. . maybe I will get the pasta too! partner: Figure 30–5. 1986). the person with aphasia practices making gestures typically are easier for people with aphasia to mas- appropriate signs or gestures when presented with a pictures ter as compared to those with low iconicity (Coelho & of referents. Duffy. spa- following a hierarchy that begins with matching objects to tial orientation. Finally. clinicians should consider loca- line drawings. or partner-independent communicators. appropriate gestures. In addition.. Independent prompt the person with aphasia to provide increasingly spe. Wiener. ognizable gestures. hand shape. given a bal output also may have a limited repertoire of inter- picture of an object or action. interpret gestures. facial apraxia. real objects. Various stimuli (e. socially or culturally rec- recognition level. and improve the use of gestures for communica. 1986). During the portrayals of an intended message. Again. such as waving or saluting. procedures in which. 1986). Highly iconic level of training. Fitzpatrick. Although the various gesture training programs differ In addition to the specific AAC strategies and techniques somewhat in their instructional methods. important factor for consideration when selecting gestures Coelho and Duffy (1986) developed another gesture to include in an intervention program. focusing on development of proximal limb.g. For example. To address aphasia. motor impairments may Concerns exist about the generalization of gesture use to impede acquisition and use of even highly iconic gestures. 830 Section IV ■ Traditional Approaches to Language Intervention Clinician. a review of distinctive features. depending on the context. For most individuals with program (Coelho. Promoting Aphasic’s Communicative Effectiveness (Davis hence.GRBQ344-3513G-C30[814-836]. 2004). however. For example. and Montagna (1991) used residual verbal output (Glosser. provides a platform for refinement and practice generating idiosyncratic gestures. the presence of limb governing the incorporation of AAC strategies. Iconicity refers to training program that included levels of imitation. friendly environments refer to settings that are conducive to Gestures used without a pre-established topic may be maximizing the effectiveness of people with aphasia by . improve verbal DeCoste. Also. The intent of Visual Action Therapy is to gestural communication about current events (Glennen & decrease the effects of apraxia of speech. techniques. The development use by people with aphasia depends on factors such as the of aphasia-friendly environments is an overarching principle amount of contextual support available. iconicity is an represent objects unknown to a communication partner. function. apraxia. blance to a physical entity. 1986). also have a son with aphasia matches the gesture to the appropriate pic. and oral gestures. The success of gesture friendly environments warrants attention. recogni. direct tomimes an intended message to his or her communication instruction in use of gestures is particularly important for partner or clinician. the notion of aphasia- challenges regarding effectiveness. and the and devices into communication-based interactions involv- iconicity of selected gestures. After successful conveyance of the intended nication supplement may find it helpful to carry a dictionary meaning. and the per. Coelho & Duffy. distal are the easiest for people with aphasia to master (Coelho & limb. 1990.and researcher-developed treatment programs ambiguous to communication partners because of multiple exist that specifically target the use of gestures by people possible interpretations. they face similar described in the previous sections. pretable gestural communication. or other motor impairments. high degree of iconicity for members within a society or ture given a group of four choices. and production. In addition. communicators who routinely rely on gestures as a commu- cific gestures. motor impairments in the expression. and handedness of the person with aphasia pictures and concludes with independent use of gestures to when selecting gestures for training. dependent and transitional communicators use sessions both for Visual Action Therapy (Helm-Estrabrooks gestures less frequently and less effectively compared with et al. 1987). & Kaplan. Because of this. and pictures) are presented to elicit responses tion. communicative interactions outside of structured treatment As a rule. of gestures for communicative purposes. Clinicians typically Estabrooks & Albert. Aphasia- shape can mean peace or two. form of paresis or apraxia complicate the acquisition and use tive purposes by people with severe aphasia (Helm. During the imitation level. or PACE.. The program includes three find that gestures requiring only simple motor movements phases. During the production social group (Glennen & DeCoste. pantomimes are tioner shows a person with aphasia a picture and a corre. and not physically present are considerably more difficult than Barresi (1982). Questions and cues from the listener dependent and transitional communicators. concrete sponding gesture or sign for imitation. a practi. two fingers held in a “V” transitional. 1985). 1997). although the emphasis remains on message communication rather than on perfection in per- Aphasia-Friendly Environments formance of gestures. how apparent the meaning of a gesture is based on its resem- tion. 1997). One such training program is Visual Action nication relating to previous or future activities or objects Therapy developed by Helm-Estabrooks. Duffy. a person with aphasia pan. or form of gestures with them to help partners interpret specific. 1982) and Coelho and Duffy’s (1986) gesture-training independent communicators. the clinician signs a referent. spontaneous gesture use is roughly comparable to this concern.qxd 06/02/2008 15:23 Page 830 Aptara Inc. movements associated with the sign. Cubelli. Trentini. dependent communicators with limited effective ver- & Wilcox. highly iconic movements designed to be direct. Context affects how people ing people with aphasia who function as partner-dependent. attempts at gestural commu- with aphasia. Members of society demonstrate accepting environmental supports. a professional strives to . more support groups and services in the Regarding the first two domains. Compensatory. tant ways. This includes a wide rating visual scenes. and ing low-tech and high-tech communication books incorpo- serve to educate others about aphasia. The final domain—services. 2004). These domains are especially important because ification to meet individual needs. Given proper support. they benefit from attention to 1. with or supplements traditional aphasia intervention ser- portation services. products and technology. Natural environments and human-made changes to the than individual people. and policies—is evident in aphasia-friendly envi. systems. & Hickson. Chapter 30 ■ Communication-Based Interventions 831 increasing situational supports and decreasing barriers inter. or device usage. real-time task mod- ment. and ser- 2. aphasia-friendly ment and use of computer-based treatment approaches. Regarding the domain of the natural environment and A final issue warranting attention concerns the develop- human-made changes to the environment. The third domain—products Other AAC strategies that are particularly helpful for inde- and technology—affects the establishment of aphasia. tions) focus on the incorporation of multiple communication grams and products that are easily accessed by people with modalities through drawing. and access- aphasia. technologic advances may provide the basis for and formulation.e. based treatment approach is to facilitate language restora- For dependent communicators. ranging from specially adapted computer applications to public-information materials describing the Computer-Based Treatment Approaches strengths and challenges experienced by people with apha- sia. hence. 2004). Howe and colleagues (2004) tures to present information through multiple modalities relate the components of aphasia-friendly environments to and to enhance comprehension and expression. a pro- and friends to modify various aspects of the environment for fessional’s goal when applying AAC interventions is to teach facilitation of effective communication. and reduced time pressure dependent communicators rely heavily on family members (Wallesch & Johannsen-Horbach. strategies. Support and relationships the domains of attitudes. more widely ronments are ones in which partners acknowledge the com. with extended processing time for language comprehension In addition. settings are conducive to optimizing communicative interac. profession. and responding to written correspondence. minimize challenges associated with aphasia. and communication services to aid peo. well as unfamiliar partners. adult language port groups or rallying for services not otherwise provided. two domains are of par. gesturing. A professional’s goal when applying a computer- telephone calls. provision of intervention services in a manner that contrasts ronments through the availability of support groups. vices in which a professional interacts during individualized ple with aphasia as they participate in daily activities.GRBQ344-3513G-C30[814-836]. provid- fering with the success of communication attempts (Howe. aphasia-friendly envi. systems. Disability. pendent communicators (and reviewed in the following sec- friendly environments through the development of pro. placing aphasia. providing augmented input). judgmental feedback.. ing written choices. tion by providing opportunities for massed practice. independent communicators petence of people with aphasia by including them in deci. and the nat. however. writing key words (i. may even be the individuals responsible for organizing sup- sion-making activities and by using simple. For example. Computer-based treatment approaches allow the systems. the possibility of practicing outside ural environment and human-made changes to the environ. people with aphasia and their communication partners the als must ensure that communication partners of people with strategies that will support communication in diverse settings aphasia are adept in supporting conversation.qxd 06/02/2008 15:23 Page 831 Aptara Inc. such as or group therapy sessions with one or more people who have running errands. Elaboration the five domains identified in the International about implementing each of these strategies is provided in Classification of Functioning. Products and technology reflect modifications affecting the whole of society rather 4. non- ticular importance: support and relationships. Hence. and polices nication challenges. Changes in these domains 3. Independent communicators may rely on some of the 2001): same types of supports that are used by dependent commu- nicators. in addition. A skilled com. differ from computer-based treatment approaches in impor- ground noises and distractions. trans. communication-based. diversity of items. attending meetings/appointments. By teaching AAC tech- munication partner must know how to use strategies such as niques. formal speech-language therapy sessions. and policies. community will become accessible and. Independent communi- aphasia in novel as well as established activities and by cators are the subset of people with aphasia most likely to encouraging people with aphasia to interact with familiar as benefit from traditional high-tech communication systems. Environmental Factors Model (World Health Organization. and Health the following sections. allowing independent communica- attitudes by facilitating the participation of people with tors to maintain their independence. writing. and referencing contextually rich pic- Worrall. Attitudes vices. AAC interventions tions through strategies such as eliminating competing back. used. as society becomes environment more accepting of and educated about people with commu- 5. In contrast. and with a wide variety of people. Services. Computer-based interven. 1996). Wade. AAC interventions aim to support a the AAC strategy to attempt more substantive interactions. The clinician’s plan for long-term generalization of the tings and with multiple partners. recognition of the differences between the ing generalization to real-life conversational interactions. The generalization of AAC systems into everyday. in the extent to which sia and those who interact with them are likely to benefit they are client. if any. ment. ate. people with apha- parts of comprehensive programs. & techniques and strategies. is true of AAC inter. 2003. multiple settings to enhance an individual’s formation and puter-based approaches that emphasize massed practice may maintenance of relationships with others. (3) designing a home program. although people with aphasia often do not have suffi- AND TECHNIQUES cient linguistic competence to use such systems in multidi. the clinician might teach take the form of higher scores on formal aphasia assessments family members to use written choice as a communication (Aftonomos et al. ful communication activities is the desired outcome of such Other computer-based treatments support only one aspect intervention. & Dean. Given the large in the field of aphasiology and warrant the attention of investment in time and/or money needed to pursue com- speech-language pathologists and other rehabilitation spe. 1997). com. clinicians construct ideas about generalization at A major concern expressed by some aphasia specialists is the outset of treatment. & Weinrich. 2004.. By engaging in a planning Wertz. 1996). such as word retrieval (Adrian. engage in independent practice using specific linguistic Generalization planning involves identifying immedi- structures (Mortley. Mortley. (2) providing intervention services to Ellis. The key to the have the unintended negative effect of increasing isolation planning stage is that the clinician considers generalization . some programs are designed to function as replacements for GENERALIZATION OF AAC STRATEGIES spoken language (Steele. 1992). a for generalizing learned skills to communicative interactions clinician first might plan activities that require a small and limited. approaches and AAC have important contributions to make Wallash & Johannsen-Horbach. The long- only occurring after many hours of work with a speech-lan. number of exchanges and for which family members may tion. & Enderby. person’s real-life communicative interactions in diverse set. two approaches is important. using it for more generalized and conversational purposes. to experience success. and long-term goals that a person with 1996) to programs requiring professional input to guide aphasia can achieve through application of specific AAC intervention and monitor progress (Aftonomos. strategy when providing choices to a person with aphasia cate overall improvement in language processing. generalization is a four-step process 2005) or sentence-level auditory comprehension (Crerar. For example. improvement in functional communica. Although such a change may indi. have limitations as well as advantages. Steele. Sobel. & Buiza. meaning- mensional ways that extend beyond treatment settings. & Schwartz. with mastery recital or discussing events of the past week. Carlson.or therapist-directed. Generalization is unlikely. 2004). such as talking about an upcoming grandchild’s dance tems can be expensive and time-consuming. As long as profes- designed several types of technology-based programs to sionals recognize that computer-based treatment approaches support treatment of aphasia.qxd 06/02/2008 15:23 Page 832 Aptara Inc. Petheram.. and (4) perform- range from programs allowing people with aphasia to ing monitoring activities to make adjustments as appropriate. For example. and reducing time spent engaging in other activities or munication challenges. Instead. 2003. Fink. & Enderby. and that tions vary in their status as sole methods of treatment or as they are distinct from AAC interventions. regarding instruction that computer-based treatments provide little opportunity about using written choice as a communication strategy. Initial activities such as this are ones ensure generalization to conversational interactions with in which people with aphasia and their caretakers are likely other people. Both computer-based treatment interacting with others (Wade. puter-based treatments is important. 832 Section IV ■ Traditional Approaches to Language Intervention help a person with aphasia compensate for persistent com. 1997. therapist strategically plans for it from the inception of treat- Gonzalez. observed improvements following application have preexisting knowledge about probable preferences. Conceptually. of computer-based treatment approaches almost invariably To achieve this short-term goal. Brecher. Crerar et al. puter-based approaches and the lack of evidence document- cialists. unless a of language performance. term goal is to facilitate expression of intents to a variety of guage pathologist over a period of weeks or even months familiar and unfamiliar communication partners across (Wallesch & Johnnsen-Horbach. however. professionals have computers solely for treatment purposes. number of treatment goals that are targeted. process. Kleczewska. however.GRBQ344-3513G-C30[814-836]. however. Computer-based sys. Differences regarding client/ a person with aphasia and instruction to family members or therapist direction and support during practice sessions caretakers. short-term. The opposite. and in the type and from advances regarding both types of treatment. it does not about the day’s meals. however. written choice strategy might involve progress toward Recognizing potential limitations associated with com. careful and individualized weighing of the risk–benefit ratio As covered more extensively in this book’s chapter about is necessary before embarking on extensive programs using computer-based treatment approaches. involving (1) planning. thus encouraging continued use of ventions: By definition. 2004). In additional. and with new AAC applications as they become dent success. few empirical research arti- Although such dual instruction is well-established when cles appearing in aphasia journals have addressed the appli- treatment involves children with AAC needs (Bruno & cation of AAC interventions. Few AAC specialists consider ment goals. intervention targets both family Advances in AAC and in aphasiology largely have occurred and client development of the skills needed to meet treat. In particular. specific instructions about goal of all aphasia-based interventions—whether they when and where to implement certain techniques is initially involve AAC strategies. their family members. practitioners need to maintain their focus on designing view the techniques as only applying to therapy and may not and implementing strategies and techniques that apply to attempt their use in real-world situations. home assignments encourage generalization of the opment of innovative and effective communication-based learned skills. such as Arranging outings and accompanying people to specific memory and visual perception. Again. they often think of additional aphasia. while minimizing reliance on locations are other ways of providing highly structured linguistic and symbolic processing. available. using an AAC through multiple modalities to maximize the likelihood of device to place a phone call. With this knowledge. In addition. people may ever. and after transactional needs of adults with aphasia. therapists need to model AAC sions and that address the day-to-day interactional and strategy use whenever possible before. The combination of skilled intervention for a themselves to be experts in aphasia. other rehabilitation experiences multiple communication breakdowns or professionals. a clinician might instruct a person other language restoration strategies—must be greater with aphasia to use drawing to facilitate his or her commu.qxd 06/02/2008 15:23 Page 833 Aptara Inc. coupled with increased attention regarding the clinicians must keep in mind the goal of providing ways for training of communication partners for people with aphasia people with aphasia to convey communicative intents. These applica- the next week. the clinician can provide more generalized new AAC devices and strategies specifically taking into con- instructions. sia intervention. Adjustments to the home program tion and acceptance of compensatory strategy use by people and overall plan may be necessary if a person with aphasia with aphasia. evening or when having coffee with a neighbor the next New interventions are likely to include the development of morning. and techniques or rely on beneficial. Chapter 30 ■ Communication-Based Interventions 833 issues at the start of strategy instruction rather than wait. A Regarding home assignments. After the planning stage. in turn promoting greater skill acquisi- AAC skills as needed. independently from each other. advance. during. challenges holds considerable promise regarding the devel- tings. these applica- homework tasks. allowing the formation and maintenance of relationships could substantially impact the overall effectiveness of apha- with others. This type of treatment encounters resistance from others in certain settings. and the establishment of aphasia-friendly environments. and equally few articles Dribbon. FUTURE TRENDS ing for mastery first. tions will exploit relatively preserved cognitive skills. tionist or other employee of a health care facility with Clinical professionals have a responsibility to be familiar which the person with aphasia is familiar. approaches for people with aphasia. to interactions extending beyond the confines of treatment ses- facilitate generalization. The melding of assessment and intervention strategies that Once both family members and a person with aphasia can support both restoring speech and language functions to the successfully implement AAC strategies and techniques to greatest extent possible and compensating for persistent perform tasks presented within structured therapeutic set. As people with and comfortable with the notion of AAC for people with aphasia experience success. For example. comprehension and expression by people with aphasia. and society in general. For this to occur. Examples include planning a trip to a tions will foster the provision of communicative information local store to allow interaction with a clerk. 1998). Later. Likewise. with existing communication-based AAC strategies ideas on their own and report back about their indepen. how- tings outside of therapy is important. or interacting with a recep. isolation that people with aphasia commonly experience. treatment sessions and not restrict it to treatment time interventions must be directed toward decreasing the social devoted specifically to practicing AAC techniques.GRBQ344-3513G-C30[814-836]. the concept of providing instruction to fam. and few aphasiologists person with aphasia and instruction to family members about feel comfortable implementing a wide variety of AAC strate- AAC strategies is important for successful generalization. gies and techniques. appearing in AAC journals have reported the effectiveness of ily members often is overlooked when dealing with adults implementing such interventions for people with aphasia. In addition. devices. early introduction of com- The last step in establishing a generalization program is pensatory and communication-based AAC interventions to arrange a method for monitoring progress and refining will be more likely. with aphasia. social reintegration of people with aphasia through increased nication during dinner with a granddaughter the following opportunities and participation in social activities. Otherwise. . such as telling the person with aphasia to find sideration the preserved and impaired aspects of cognitive two people with which to use the drawing strategy within functioning displayed by people with aphasia. Not waiting too long to transfer skills to set. and devices. M. environment? 5. The use of com- of individuals with aphasia. and aphasia-based AAC assessments and by implementing strategy and device trials. L. What distinguishes a portrait from a contextual scene? language comprehension and production by pro. may not necessarily generalize to communication Beukelman.. 981–1002. Many people with aphasia—particularly those with and devices into communication-based treatments more severe forms of the disorder—experience chronic for people with aphasia.. 7. and gestures. 4. porting individuals with aphasia. & Buiza. 6. Mirenda (Eds. D. contextually rich photographs or visual scene displays? mental cognitive assessments. Steele. How does partner-dependency status impact a practi- 4. puter-assisted therapy in anomia rehabilitation: A single-case report. R. AAC systems can minimize reliance on linguistic who might benefit from written choice communication? or symbolic processing by incorporating contex. practitioners need to consider the partner-dependent. Adults with severe used for interactive purposes. 78. requires innovative and non-symbolic approaches try with a person who has aphasia? to the design. aphasia. Gonzalez. 8. Specific AAC strategies and techniques for people Aftonomos. and untimed practice.. but professionals 2. 841–846. American Speech-Language-Hearing Association [ASHA] (2004). Archives of Physical Medicine and Rehabilitation. Computer-based treatment approaches differ from Roles and responsibilities of speech-language pathologists with AAC interventions. In addition to restorative treatment approaches. J. ACTIVITIES FOR REFLECTION AND DISCUSSION 3. peo- need to continue working on generalizing use of ple with aphasia can benefit from exposure to AAC AAC to natural contexts and everyday settings. 2. Promoting with aphasia include the use of augmented input. A. R. as tioner’s selection of AAC strategies and techniques to such. communication challenges that negatively impact their 11. 9. T. References 7. expressive communication attempts of people with 6. transitional. and geared toward minimizing communi. & Garrett. For AAC purposes. & Wertz. techniques. beneficial to people with aphasia? cation breakdowns. supple. For people with aphasia. 17. K. drawing. or partner- independent status of the communication attempts Adrian. and application of AAC 3. AAC systems can supplement a person’s inefficient 5. Augmentative and alternative communication management of severe communication . (2003). Aphasiology. they Technical report. communication checklists. non-judgmental. L. D. written choice communication. and relationships. recovery in chronic aphasia with an interactive technology.and low-tech communication books and devices. ASHA Supplement. AAC is most effective when it is conceptualized as a combination of procedures 1. high. Aphasia-friendly environments are crucial to the suc- cessful incorporation of AAC strategies. interventions during all stages of recovery—includ- ing the acute stages—to ensure sufficient time and opportunity to practice and refine strategies that will help them to compensate for persistent communica- tion challenges. What are the relatively intact cognitive processes retained well as their potential to use various AAC strategies by many people with aphasia that allow them to benefit and techniques effectively by administering and from communication book or device organization using interpreting results from aphasia batteries.GRBQ344-3513G-C30[814-836]. What are the key characteristics of an aphasia-friendly interventions. AAC approaches hold considerable promise for sup- participation in social roles. J. R. In D.. R. Aphasia is a weakness of symbolic processing and.qxd 06/02/2008 15:23 Page 834 Aptara Inc. compensatory. (1998). form) as substitutions for spoken words only partially adaptable. What are the characteristics of a person with aphasia b. Practitioners can obtain important information about aphasia? a person’s communicative capabilities and needs as 9. J. Beukelman & P. B. 24. 834 Section IV ■ Traditional Approaches to Language Intervention KEY POINTS 10. (1997). What AAC strategies and techniques provide informa- tual scenes or visual scene displays into low-tech tional redundancy to support either the receptive or or high-tech devices. Two types of approaches exist for using AAC to sup. Why should family members and caretakers of people viding informational redundancy through the use with aphasia learn AAC strategies and techniques? of multiple modalities and contextual supports. 8. activities. Why are AAC systems that provide symbols (in any and processes that are multi-modal.. organization. 1–17. 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McKelvey. Steele. R. & and aphasia: Widening horizons? Aphasiology. R. Wilkinson. K.. D. San 223–228. Mortley. & Beukelman. Lasker. Aphasiology. R. D. J. 20. (2004).. J. 245–263. (2005). (1988).. 193–211. CA: Consulting Psychologists. van de Sandt-Koenderman. In N... W. Carlson. M. & Johannsen-Horbach. Garrett.. The probability that this is increased melodic intonation therapy (MIT). the orities of therapeutic purpose for such patients would rele- right hemisphere functions in a tandem relationship with gate the quality of articulation and syntax to secondary con- the left hemisphere both for encoding and for emission of sideration. discuss the administra. takes place in the temporal lobe of the left hemisphere. and Albert (1974) reviewed some of the lit. Their accurate emission of the distinct from other forms of singing in that each intoned words of the song is of greater interest. Martin and Rigrodsky (1979). we can produce no better word to describe such lan. verbal utterances for these persons with aphasia is the pri- ever. and premorbid use of trous results. and its contrast with their inability to communicate the most the points of stress in the spoken model. and Whitaker (1970). describe the verbal Code’s discussion of the role of the right hemisphere in the behavior of both good candidates and poor candidates for treatment of aphasia. because of utterance is based on the melody pattern. therapeutically speaking. This type of singing is an ancient persons. how. Indeed. recovery of the ability to use some language accurately. Jackson (1931) classified such utterances as non. Their analysis suggests that. Good candidates demonstrate extreme paucity of speech ments of speech. because they do not involve encod. AFFECTING MIT guage. and the spe- Numerous studies have indicated that an unimpaired right cific techniques that we call intonation are described in some cerebral hemisphere is dominant for music in right-handed detail later in the chapter. Studies of adult aphasia that have described language sure to this language intervention strategy. research indicates that the right hemisphere is involved in processing the prosody The original intention for developing MIT for those with of propositional language. Reasonable pri- right-handed persons and many left-handed persons. mary goal of MIT. are using the 837 . offer suggestions for involving when we consider the right hemisphere’s dominance for the families of those with aphasia who are selected for expo. Some clinicians. however. however. Helm. Gordon (1972) states that a long period may be involved in increasing the The objectives of this chapter are to instruct the clinician in function of the right hemisphere. The reader is referred to the technique of melodic intonation.GRBQ344-3513G-C31[837-851]qxd 1/21/08 1:53 PM Page 837 Aptara Inc. Of equal importance in this reorganization are preserved interhemi- OBJECTIVES spheral pathways for language. dating back at least to the Judeo-Christian period. some social gesture phrases. severe nonfluent aphasia was to achieve at least a basic Sparks. song. although we no longer label the right hemisphere as Objectives of MIT being a nondominant one. Indeed. so-called nondominant hemisphere of a person with aphasia. He the- orized that such utterances are processed in an undamaged. Melodic intonation therapy involves singing. the rhythm. ing of a message that contains specific information. erature on right hemisphere processing of the prosodic ele. It is melody of a familiar song. Blumstein (1973). Emphasis on the linguistic or semantic aspects of propositional language. Use of an intoned basic needs. The familiar melody profanity. PRINCIPLES OF LANGUAGE THERAPY Today. music. by melodic intonation therapy (MIT) is even more likely tion of the MIT hierarchy. Sparks Reorganization of this interhemispheric process with increased participation of the right hemisphere probably occurs only when recovery is slow and incomplete. The final integrative process. Chapter 31 Melodic Intonation Therapy Robert W. This explains why persons with aphasia can sing the form. This preserved skill also includes recitation of utterance that resembles a familiar song may produce disas- prayers. will stimulate recall of the nonpropositional words of that propositional language. and suggest performance from a phonologic model have included future trends in further development of MIT. in normal and show concern about such an incapacity. apraxia. a gradual withdrawal of partici. process. The eighth principle pertains to the frequency of ther- or simple sentences more efficiently than they can more apy sessions. In any event. & Jimenez-Pabon (1964)—maintains that direct attempts 6. often than every ninth or tenth session of therapy. aphasia and severe auditory deficits may respond better 3. the examination that the aphasic candidate has a distinct Another use of latency is between the completion of one potential for some recovery of language. The second principle—one endorsed by Schuell. holistic approach to therapeutic intervention in seldom can effectively correct his or her verbal errors by general. A review of our physiological model implies that the Accurate repetition deteriorates in longer units. Eight Principles of Language Therapy 5. Attempts to correct errors accomplish little. enough variety of meaningful material is level of the MIT hierarchy. The person severely handi. A sion of the length and difficulty of the tasks in the ther. and ple. however. This. The fourth principle is concerned with latencies of tary para-standardized examination of persons with aphasia response. 7. The person with aphasia may or may not good candidates for MIT who have auditory compre- be aware of the purpose of this procedure. repetition involves a rather complex MIT. however. but some word substitutions have been used for the restatement. but it is not hension that permits them to understand and retain drawn to his or her attention. The fact that normal persons can repeat familiar 8. For exam- errors. The fifth principle is avoidance of practice effect by Involved in MIT using the same material or carrier phrases repeatedly. the use of repetition in MIT gradually decreases as are used to evaluate a potential candidate for MIT is not an the level of difficulty of tasks increases. which thus reinforces it. One such control is use of latency between that make it possible to investigate more specific language completion of stimulus presentation by the clinician and skills in addition to those sampled by standardized examina- permission for response by the person with aphasia so tion batteries. 1. In this task. Language that is pation by the clinician in that are purely repetition. Twice-daily treatment sessions are essen- difficult sentences suggests that a process of decoding the tial for the person with aphasia and severe impairment . The third principle maintains that repetition is a highly to auditory stimuli when they are accompanied by pic- effective therapeutic device. The seventh principle maintains that written or pictor- attempts are made to achieve correct responses by means ial materials should not be used as added stimuli. This is particularly true of he or she failed. Our premise is or she is immediately guided through a repetition of the that these materials actually distract rather than support previous step and then a second attempt of the step that the MIT therapeutic process. MIT depends on evidence from that the complete stimulus is received and decoded. Persons with never attempted if failure occurs again. tion of the error. when the person with aphasia fails a step. The first principle is concerned with gradual progres. Jenkins. encouraged for MIT so that no utterance is used more 2. sentence-item progression in the hierarchy and the beginning of the next. recall of premorbid language skills. A second backup retrial is spoken stimuli in a variety of contexts. issue. Perhaps the most dif- Speech Pathology Principles Applied to MIT ficult repetition task involves unknown words of another The Examination language or nonsense syllables. Sparks (1978) has presented guidelines for supplemen- 4. serve just as well or better. then. and alien to the person with aphasia should not be used. This is not an indictment of capped by aphasia who is considered to be a candidate a warm. reduction of reliance on melodic intonation in the last Therefore. Repetition serves as the core tures. 838 Section IV ■ Traditional Approaches to Language Intervention technique as a more phonologic intervention for verbal stimulus and then re-encoding it for emission is involved. exuberant reinforcements within a sequence of even may do some harm. The sixth principle maintains that the clinician should to correct the verbal errors of the person with aphasia fail pay scrupulous attention to the purpose and semantic because he or she cannot recall the specific nature of his value of each of his or her verbal utterances. Such retrials often result in a perseverated repeti. The right hemisphere controls prosody. The stimulus has been accu- rately received and decoded. however. As stated previ- A preference as to standardized aphasia examinations that ously. during MIT. use of MIT for the phonologic defects of such patients. well-constructed program of intervention will include apeutic hierarchy. Such progression involves the type of many useful high-probability utterances that trigger linguistic material used. justifies the paraphrased repetition of the longer sentence. if they detract from the smooth steps are disruptive. A smile of encouragement will progression of the hierarchy. clinicians should practice restraint retrial. This often is tedious and not therapeutically effective. During MIT. does not alter the meaning. Actually. the usual decode–encode process is less efficient.” believe the presumption that such material is supportive Specifically. he to the auditory stimulus is very suspect. We of a second trial that involves the technique of “backup. such patients are not candidates for of MIT.GRBQ344-3513G-C31[837-851]qxd 1/21/08 1:53 PM Page 838 Aptara Inc. Chapter 31 ■ Melodic Intonation Therapy 839 of language. . lesions as predictions of candidacy for MIT. population. or forceful imperative The question as to whether achieved language improvement statement. Hospital— ance has been observed in some persons with aphasia who you. A agrammatical but telegraphically appropriate.GRBQ344-3513G-C31[837-851]qxd 1/21/08 1:53 PM Page 839 Aptara Inc. evidence of pre. Unfortunately. they also always an appropriate communication. some patients with global aphasia. several the product usually is not improved by this effort. this telegram is because it is similar to the stereotypical jargon utterances of a triumph. they  will be annoyed by the meaning. “Home—weekend—Saturday and Sunday. guage are essentially normal in a variety of contexts. or Phonologic performance by the good candidate who has transportation are involved.—Monday. aspects of verbal expression. continue to improve in their own home environment. and nonlanguage behavior. but it is tempting to describe the verbal output of person with aphasia and a marked paucity of any kind of ver. Language Profile after MIT Verbal Language A diagnosis of “classical” this or “classical” that usually is The clinical impression of the good candidate is that of a careless. Language profiles of both good and poor expected in persons with aphasia who are acutely aware candidates are presented here as guides for selection. he or she is a nonfluent aphasic. This is to be contribute much. It is and they accept MIT. CANDIDACY FOR MIT A summary of the results from examination of verbal Assessment regarding the efficacy of MIT has proved that no expression produces a profile of the good candidate as single language intervention strategy for aphasia is a panacea. This. When the articulation is analyzed. MIT is effective for only a portion of the aphasic 1.” Considering the graduate’s almost total have subsequently responded well to MIT. resources. served self-criticism in the good candidate is important. or sen- of each person with aphasia who is being considered for tence completion. They manifest a strong desire good candidate’s understanding and retention of spoken lan. the training of family mem. single substantive word that is not only do they maintain their new competency. a system- atic reorganization of sound patterns may seem to occur. no language impairment other than speech production bers to function as assistants in the MIT program may includes effortful but indistinct speech that is interrupted by be very effective. In any event. In other words. First. word and phrase repetition. Almost no responses occur in confrontation naming. such stereotyped jargon utterances. Concurrent Abnormalities Actually. but they Auditory Comprehension almost always are emotionally stable. little speech is initiated follow-up examinations of MIT graduates have shown that except for an occasional. Fortunately. Nonverbal Behavior The Good Candidate Good candidates often are reasonably depressed. pauses for attempted initiation of each utterance and attempts to correct himself or herself. Emphasis is placed on auditory comprehension. It is enigmatic inability to communicate before the therapy. Some of the This is accompanied by demonstration of frustration and person’s utterances continue to be poorly articulated and despondency concerning his or her language impairment. Second. simplistic to presume that the process of monitoring one’s own verbal utterances is solely through auditory feedback. then. that of a person with classical Broca’s aphasia. With the exception of ful MIT produces some concern for clinicians. An example is curious and enigmatic perseveration of a neologistic utter. good candidates will modify the Further Improvement after MIT prosody of the utterance so that it reflects their intention to make a declarative. kinesthetic feedback probably alerts us to phono. will be retained by the person with aphasia following success- less morphology of the utterance. The good candidate usually demonstrates a significant buc- logic or semantic errors immediately before the auditory cofacial apraxia and has a hemiplegia that is more severe in feedback has commenced. to enter into intensive efforts to rehabilitate their speech. but two points of differ- ence are notable. An occasional response. will exposure to this method. the arm than in the leg. follows: Indeed. with a mature response Examination of auditory comprehension indicates that the to counseling by the clinician. of making errors in their verbal output. Effort at self-correction often is vigorous. Chapter 3 of this text described be poorly articulated but accurate enough to indicate computed tomographic findings of cortical and subcortical correct encoding of the target word. however. Speech is phonologi- cally distorted. implies a need for careful evaluation responsive naming. interrogative. When restrictions of time. the person with aphasia after MIT as having evolved into bal output. Such studies 2. GRBQ344-3513G-C31[837-851]qxd 1/21/08 1:53 PM Page 840 Aptara Inc. based solely on the spoken prosody of verbal utterances. this is all that is necessary to achieve an ade- Wernicke’s aphasia are in marked contrast to those of the quate variety of melodic patterns. the verbal behavior involved in each of the three types. Certainty regarding the appropriateness of the intonation including the melody. dial. These patients accurately duplicate intonation patterns. The need for this appropriate- is in contrast to their replacement of the words in the ness becomes essential in the final level of the hierarchy. First. transcortical. Second. . Specifically. The important the varying pitch of speech is reduced and stylized into a feature of this form of aphasia is an isolated skill at accu. a review of the final steps of the hierarchy will be beneficial in the continuing improvement. Concerted have distinct melodies. when intoned utterances gradually are transposed back to spoken prosody. they usu. and by Schuell and col- Three aphasic syndromes are not responsive to the present leagues (1964). Transcortical Aphasia Some exaggeration of the three elements of a spoken The person with aphasia demonstrating this profile may be prosody model occurs when that utterance is intoned. 2. often hostile. with Wernicke’s aphasia has produced poor results. MIT is no more effective than other form of MIT—namely. The range is about the good candidate: same as that of the melodic line of speech. phrase or sentence. The Form of Melodic Intonation mal. but sometimes extremely cor. Those untrained voice of adults. notes. The melodic line or variation of pitch in the spoken unstable. melodic pattern involving the constant pitch of intoned rately repeating long phrases and sentences. This limited range of sung notes is comfortable for the 1. by Sarno. These three modifications of spoken carryover to improved functional language occurs. They include abundant Melodic intonation is based on three elements of spoken paraphasic errors for the substantive words. MELODIC INTONATION Wernicke’s Aphasia Sparks and Holland (1976) briefly describe the difference Achieving therapeutic success in those with Wernicke’s between songs and melodic intonation. 3. this usually involves increased loudness and eleva- person with aphasia performs perfectly in MIT. Those with Wernicke’s aphasia are often emotionally 1. however. The tempo and rhythm of the utterance. suggest that the ability to repeat even single words may be a Graduates of MIT and their families should be advised that negative prognostic factor for MIT candidacy. In contrast. Auditory comprehension is poor and variable. The labels are not as important as brief reviews of munication. syntactically nor. 840 Section IV ■ Traditional Approaches to Language Intervention Syntactic substance begins to appear in their verbal output. the rhythm and stress are exaggerated for out the normal decoding process mentioned earlier. This was The Poor Candidate pointed out by Albert and Helm-Estabrook (1988). but no tion of intoned notes. 3. This pattern is essential in MIT. and global language therapy in reestablishing any useful verbal com- aphasia. melodic intonation is effort by some speech pathologists to produce more effec. similar in some ways to the good candidate and in other the tempo is lengthened to a more lyrical utterance. The application of MIT techniques to patients 2. and points of stress. It is important to point out the with Wernicke’s aphasia show no evidence of being necessity of avoiding melodic intonation patterns that are aware that they fail to be understood. prosody: and the end result is bizarre and meaningless. The points of stress for emphasis. ally reject language therapy. and clearly articulated. ways to the person with Wernicke’s aphasia. and Sands (1970). Third. Wernicke’s. tive language therapy for persons with this type of aphasia is The latter uses a vocal range that is limited to three or four essential. songs aphasia is a very difficult and challenging task. prosody serve as a means for emphasizing the prosodic Investigation of repetition skill as a candidacy factor would structure of the utterance. Global Aphasia cuss the extent of the family’s participation and be available as a continuing consultant. and their reaction to MIT is either explosive or one of amused condescension. seemingly with. In fact. similar to those of long-lasting popular songs. stimulus model with their own paraphasic jargon. The emphasis. In fact. rhythm. The history of language therapy for persons with global aphasia indicates that such therapy has been unsuccessful in improving their functional verbal language. The following characteristics of those with whole notes. Verbal utterances are overly fluent. Silverman. The clinician should dis. All are clearly distinct from the profile of the good candidate that has been presented. This is fol- lowed by the cluster of words. The clinician must exercise his or her judgment functor words in the cluster.GRBQ344-3513G-C31[837-851]qxd 1/21/08 1:53 PM Page 841 Aptara Inc.” Emphasis stress is on the first syllable of “coffee. A single-syllable word is indicated by a single vertical bar.” along with the higher pitch Acceptable Variety of Melodic Patterns that such stress produces. Two such variations are illustrated in 31–1. The last syllable of this declarative and Regional Differences phrase has the customary drop in pitch. the of functor or relational words in the patient’s speech. pattern of the northeastern parts of the United States and a Samples of regional differences are presented in Figure 31–2. Regional differences in patterns of spoken pitch. L indicates lower pitch. Key of C in treble cleff is used for illustra- cates stress on that word or syllable. Prosodic patterns of speech. This may Regional differences of speech prosody sometimes are be desirable as the person with aphasia improves and the clin- quite pronounced. same region.” the stress is on “go. gradually rising inflectional pattern of at least some parts of the South. and are in. Vertical bars that are connected represent multi-syllabic words or clusters of words. An arrow preceding a vertical bar indi. No attempt is made to present accurate musical tempo. prosody for one sentence. stantive importance of the word places it alone. is detached from the rest of the cluster that follows. then a return to the higher as to which one will be used for a phrase or sentence in any pitch along with stress for the substantive word. Chapter 31 ■ Melodic Intonation Therapy 841 Figure 31–1.” one session of language therapy. The second illustrates a model in which the word “for” Figure 31–1.” preceding a vertical bar indicates stress on that word or the utterance starts on a lower pitch for “cup. An arrow In the first phrase shown in Figure 31–1. This is not a matter of concern if the clin- ician thinks that therapy should begin to attack the absence ician and the person with aphasia come from. Plotting Spoken Prosody Patterns Two illustrations of the method of graphically plotting ver. Using a different intona- Figure 31–2 plots the difference of two variations for the tion pattern in a subsequent session is a means for achieving phrase “Go for a walk. however. tion. The emigration of a clinician from one prosod- In Figure 31–3. a comparison of prosody for the social ically distinct area to another. Transposing Speech to Intonation bal utterances along with an explanation of the plotting Illustrations of the transposition of plotted speech prosody technique are presented in Figure 31–1. In the second illus- tration. A single-syllable word is indi. will be used in all subsequent illustrations. Vertical bars that are connected represent multi-syllabic words Figure 31–4. “of coffee. cated by a single vertical bar. then a drop in pitch for the two utterance. H indicates higher Figure 31–3. H indicates higher pitch. Transposition of spoken prosody models to or clusters of words. This method.” but the sub- syllable. implies that he or gesture utterance “good morning” shows a rise–fall melody she must make an adjustment when MIT is involved. Two equally acceptable spoken prosody pat- terns. “Go for a walk.” The first is as illustrated in Figure variety of stimulation. an models into melodic intonation are presented in Figure 31–4 adaptation of the one developed at the Kodaly Musical Training Institute and presented by Knighton (1973). “cup of coffee. . “walk.” with an Several alternative prosody patterns exist for any verbal accompanying higher pitch. melodic intonation. Figure 31–2. L indicates lower pitch. rhythm. Read the newspaper. Considerable musical license has been taken—and musicians are requested not to take issue. The selection of phrases and 3. but addition to being meaningful for the individual patient. 5. in which the technique is so atypical of normal verbal clinician will meet with the candidate and family and explain behavior. in in all therapy for the traumatized person with aphasia. He will furnish a cassette sam- 3. 842 Section IV ■ Traditional Approaches to Language Intervention using the phrases illustrated in Figure 31–1. Go for a walk. however. It is ten o’clock. son with aphasia’s inability to communicate and the useful. or “spoken song. all material should be egocentric for Meaningful stimulus items for the aphemic candidate who the individual person with aphasia. Table 31–1 illustrates the use of phonologic pat- greater significance. which terns in selecting stimulus materials. personal needs. It is Figure 31–5. For those who are interested. bowl of soup 8. I am sleepy LINGUISTIC CONTENT 4. Information about such things as basic family the importance of gaining information about specific lin- routines. family relationships and customs. Sample Material for Level II 1. Look at the sports page. Sit down in a chair. time for lunch 7. the key of C is used in the illustrations so that variations of sung note combinations may be demonstrated. glass of milk 3. 2. I am very tired. . 7. Additional constant pitch of intoned notes. Four thematic. 9. sented by Sparks and Holland (1976) is included here with The senior author lays claim to the use of this art form as the permission of the senior author of that article: a bridging technique in the MIT hierarchy after having heard a performance of Ode to Napoleon by the Boston Symphony Orchestra in 1973. 6. Clusters logic errors makes it more difficult to select meaningful of sentences that have a spherical relationship add an even material. 8. Schoenberg defined the technique as sprechgesang. Time to Go to Bed ple of sprechgesang on request. however. This is illustrated in Figure 31–5. short sentences should be high-priority communication. take a nap 5. Turn on the TV. replaces the more ther illustration of melodic intonation plotting. The matic relationship of therapeutic material along with fur- more variable pitch of speech. It Figure 31–1. The pri- mary purpose here is to duplicate graphically the pattern of spoken prosody that has served as the model. Therapeutic concern for consistent phono- material with both universal and individual appeal. ham sandwich The importance of a linguistically sophisticated control of the grammatical structure of phrases and sentences used in Sample Material for Levels III and IV MIT depends largely on the severity of the individual per. apple pie 2. it is particularly important as a counterbalance during focus on facilitating more intelligible speech. The creative MIT. twelve o’clock 6. three-item illustrations of melodic intonation material using the same figure legend presented in a technique that lies halfway between speech and singing. although such skill is an advantage. salt and pepper 9. In other words. The placing of the notes on a musical staff in these illustrations does not imply that ability to read music is a prerequisite to adminis- tering MIT. is used in choral reading but more lyrically by Schoenberg in his Ode to Napoleon and Pierrot Luraire. Sprechgesang The fading of melodic intonation and a return to spoken prosody occurs in the fourth level of the MIT hierarchy. Look at the Sports Page 6. provided that the request is accompanied by phrases to be illustrated and a cassette. The utterance is lyrical but illustration of the thematic arrangement of material pre- spoken rather than sung.” The exaggerated tempo. ness of the verbal material. Time to go to bed. It is getting late. guistic preferences that the patient used in his or her pre- and personal likes and dislikes will suggest an abundance of morbid speech.GRBQ344-3513G-C31[837-851]qxd 1/21/08 1:53 PM Page 842 Aptara Inc. and points of stress in presents four three-item themes as an illustration of the- sprechgesang are the same as in the intoned model. 4. This involves investigation of basic aspects of the patient’s premorbid milieu that may be used and then some creativ- ity on the part of the clinician to produce stimulating mate- rial. This should be the case has no impairment other than phonologic errors should. 1. it is presented in explicit grasps the patient’s left hand so that he or she can engage it detail. called Sample Phonologic Patterns for Melodic Intonation “backups. a detailed and illustrated discussion of the four lev. The clinician’s par- using hierarchies is understood. Sparks and Holland (1976) ticipation may then be faded to that of monitoring accuracy referred to the dilemma of presenting a hierarchy in a way while continuing to hold the patient’s hand. Dropped with a finger pointed at the Specific Aspects of the Technique patient. perhaps.GRBQ344-3513G-C31[837-851]qxd 1/21/08 1:53 PM Page 843 Aptara Inc. This method is use- Discussion of the hierarchy will be made more explicit by ful in enforcing latency if it is used consistently. This should be strategies. box Hand Tapping and Control by Hand Signals It is recommended that the clinician seat himself or herself across the table from the patient with aphasia so that his or MELODIC INTONATION HIERARCHY her participation is visible to the patient and the patient’s The hierarchy of MIT is highly structured for gradual pro. The clinician’s use of his or her left hand as a means of els of the hierarchy. has proved to be an important and effective supportive stim- cians and. first the audible and then the visible component. and so forth. The clinician gression of difficulty. The clini- first describing the several techniques that are involved. Many subjects begin cians who prefer less structured language intervention to exercise some control of the hand tapping. Hand tapping that is too detailed and seemingly dogmatic for some clini. the left hand advises the patient to remain silent and listen. the third is stamp please go back home last street repeated as a backup. The pre. It has a cueing value that often seems to be as effective sentation here will include a description of the technique of as the verbal component it accompanies. along with their important visual compo- by the Clinician nents. Held up. cian has just presented. This is consistent with the concept trees that overt attempts to correct errors are not useful with the it’s a democracy open the refrigerator fix the machine read it in the paper time for breakfast play the music type of aphasia that indicates a patient is a candidate for MIT. The use of such cues An early step in all levels of the hierarchy involves clini- is limited to assisting those with aphasia in the initiation of cian—patient unison repetition of the stimulus that the clini- their responses when it is apparent that they are having dif. in the subsequent levels. As illustrated. as a nonverbal and nondistracting means of exercising such control. to a lesser extent. necessary for the clinician to rejoin the patient when it is . and then the rhythm of the responses. the clinician terminates any further effort Facilitation of Syllable Sequencing with that sentence-item and proceeds to the first step of the build a snowman light the Christmas more ice cubes level with a new sentence. in tapping out the rhythm of the stimulus as it is presented tributed to its success. because attention to every specification has con.” It often is with aphasia. and we assure them that their reservations about encouraged provided that it is accurate. We are sympathetic with those clini. ulus. so purposes of correcting errors in the responses of the person that the patient is repeating the sentence “solo. Use of Verbal Cueing Unison Repetition and Fading Participation Phonemic cues. This second trial often is effective in producing the cor- make music big lake can of coke rect response without distracting the patient or making him or her directly aware of the error. are used in the second level of the program and. If the response of the person with aphasia in any step is not considered to be adequate. and a suggested method of scoring each controlling onset of the patient’s responses is recommended MIT session. not explicit enough for others. the clinician has the person Facilitation of Velar Production repeat the preceding step and then attempt the failed step cup of coffee corn on the cob piece of cake calico cat good cookie call a cab again. performance is clearly visible to him or her. The clinician fades his or her partici- ficulty. It is never used as a means of repeating the task for pation. the second is repeated and the third is then ask the man pass the salt small price attempted again. it signals him or her to respond. if the third step Facilitation of Cluster Production of a level is failed.” is used in the third and fourth levels of the pro- Therapy Stimuli gram. Therefore. cian may feel like a traffic officer and may wish that he or she could develop a means of also using his or her feet. If the person with aphasia deep snow fall spare room sports coat again repeats the error or produces a different one after a backup sequence. If the fourth step is failed. Chapter 31 ■ Melodic Intonation Therapy 843 TABLE 31–1 Backups and Patient’s Failures A means of attempting indirect correction of errors. intoning. the clinician and the patient begin a uni- technique. however. accurate repetition of the verbal minutes for some patients to two full therapy sessions for material is the primary goal. Rather. the clini. The clinician then fades his or her verbal participation in the pose. If the patient’s performance is acceptable. cannot be permitted soon as the patient is comfortable in the set of intoning. the clinician pauses cian signals the patient to join him or her in unison humming for several seconds and then proceeds to the next sentence to of the melody along with the hand tapping. In any event. Modification of the rhythm or others. An acceptable per- is suggested rather than a vowel of “la-la” because of its less formance implies progression to the third step. and the max- distinct phonemic quality.GRBQ344-3513G-C31[837-851]qxd 1/21/08 1:53 PM Page 844 Aptara Inc. The clinician hums the melody-tempo-stress intonation pat- chy will include a fully detailed description. Attempts to correct such modifications is an unnec. then repeats it with the sentence added. The maximum score for ing a set for holding hands and. mance terminates further progression. The patient may be attempted. preliminary means of establish- then proceeds to the next sentence. This is acceptable in this first nonverbal level. Hand tapping by the clinician and the patient occurs in all stimuli and responses. If the patient’s Level I performance is not acceptable. Each of the four suring the efficiency of the method for producing steady steps in the level is presented in detail below. When the clinician thinks the patient is ready for a solo Adapting to the Patient’s Modification effort. The Hierarchy of MIT Step 1 The discussion of each of the four levels of the MIT hierar. the idea by a simple description of the process and its pur. singing odd little nothings. in with the clinician. An unacceptable perfor- illustrated in Figure 31–5 should be used. A second table for each level with the patient. The clinician hums a melody twice while hand tapping manner described earlier but continues to hand tap the the rhythm-tempo-stress pattern with the patient. The melodies are those that are used for intoning phrases and sentences. The model improvement by any one patient. tition of the intoned sentence. Scoring involves two points for a response from with cueing or after a backup. the clinician pauses for several seconds to produce decay of the strength of the stimulus and The first level is a one-step. . The time required to complete this first level varies from 15 essary distraction. tapping. a one-point score for an accurate response achieved applicable. The use of phonemic cueing is indicated when backup. as far as the person with an acceptable performance by the patient is one point. Second. hand because of their effect on the substance of the sentence. Level II tured form of language therapy for aphasia is to use or develop an objective system of scoring each therapy session. MIT Session Scoring The best way to judge the effectiveness of any highly struc. from the clinician. and a reduction of the maxi. and Table 31–5 tern that is to be used with the sentence while hand tapping it will provide a quick reference. the clinician proceeds to Step 2. to the next melody pattern. and complying with the hand-signal controls of the clinician. Step 2 They should increase in length and complexity of melody and stress points as the person with aphasia adapts to the After a brief pause. The method suggested presented by Sparks and Holland (1976) had five steps. 844 Section IV ■ Traditional Approaches to Language Intervention evident that the patient is not quite ready to proceed in the use a more phonemic verbal utterance when he or she joins repetition on his or her own. A good candidate usually can be introduced to son intoning of the same sentence along with hand tapping. the patient that does not require a cue to initiate it and one mum possible score for any sentence-item if steps have not point if the response is acceptable when initiated by a cue been completed. In Level II. and a review of the types of errors clinician signals the patient to join him or her in unison repe- most frequently encountered. linguistic material is added to the type of into- This principle is recommended for MIT as a means of mea. The presents a sample therapy session that includes management clinician pauses briefly and then repeats it again. the of errors and scoring. The here involves a two-point score for an accurate response that present model has combined the first two steps of that has not required a phonemic cue to initiate a response or a model. the clinical fades his or her vocal participation but of Melody Patterns continues hand tapping with the patient. Melody patterns similar to those imum score is again one point. No scoring takes place in Level I. aphasia may see it. moving to the second level occurs as number of intoned syllables. nation patterns introduced in the first level. the clinician The clinician should be prepared to change the key of the reinforces the performance by saying “good” and proceeding melody to that of the person with aphasia’s inadvertent mod. Humming rhythm stress pattern with the patient. When the patient has completed his unaccompanied repetition. ification. Next. This may be acceptable to the clinician. mitted responses and less specific questions in the last step TABLE 31–2 Sample Melodic Intonation Therapy Level II Session With Step and Summation Scores Scores Patient Performance Step 1 Step 2 Step 3 Step 4 First sentence: Patient succeeds in all steps. this is accompanied by the becomes progressively more active in the subsequent levels. and 1 0 — — no scores are given for Steps 3 and 4. the patient is signaled to repeat it. Second. and hopefully. five-item therapy session and its scoring is presented tion. without patient. The clinician should be generous in enough to be acceptable terminates progression to the reentering the unison repetition as much as he or she con- fourth step. The Most Common Errors Occurring in Level II the score is two points. the clinician presents The patient who succeeds in Level II has acquired the skill the same intoned sentence. Chapter 31 ■ Melodic Intonation Therapy 845 Step 3 Level II Accomplishment The patient is signaled to listen. After a suitable pause. of the sentence. Scores 5/5 4/5 5/8 4/6 Total 18/24 (75%) . hand tapping. Third sentence: Patient succeeds in Steps 1 and 2. A brief.GRBQ344-3513G-C31[837-851]qxd 1/21/08 1:53 PM Page 845 Aptara Inc. and this will continue throughout the MIT program for that In the final step of the second level. If this third step is completed without cueing. intones the question “What did you say?” increasing linguistic skill. only one point is given when a cue was necessary participation in Level II and the return to speech prosody for initiation. Then. Again. the clinician. unaccom. Scoring is the same as that of the third The third level actually is a liaison between the recovery by step. and fails Step 4 because of an unacceptable response after backup. the patient may modify the sentence in Table 31–2 to illustrate management of errors in the slightly by omitting a functor word or by a slight paraphrase patient’s performance. Occasionally. patient’s performance. the clinician gives a phonemic cue for the first coding the stimulus for responsive speech. The patient is reinforced if he or she success. As stated previously. and requires a backup to initiate Step 4. Next. Two points are given for an acceptable uncued the patient with aphasia of his or her ability to repeat during response. Progression is stopped. The clinician then signals the patient to repeat the intoned Sample MIT Session and Scoring for Level II sentence. the patient will respond to the cue accurately. increasing repetition skill Step 4 may disclose significant evidence of poor articulation. Failure to initiate the etition when the clinician fades his or her participation that utterance after one cueing effort or to produce it accurately the patient will falter. the patient may be so surprised by his or her solo rep- for initiation. because the question not only acts in the hand tapping. This is accompanied by the hand of repeating intoned sentences immediately after hearing tapping. and responsive speech in the fourth level. If the patient has difficulty initiating the as a masking intrusion but also initiates the process of reen- repetition. the score is one point. if it is unacceptable only after cueing First. the model and then in response to a question. The latter is panied by the clinician except for the clinician’s participation more difficult. the clinician proceeds to siders it to be useful in producing improvement of the the next sentence. Cueing along with the hand tapping is offered once if the patient is having difficulty initiating the repeti. We Level III maintain that any appropriate near-target response is evi- dence of progress. requires a cue to initiate response in 1 1 1 1 Step 3. 1 1 2 2 Second sentence: Patient succeeds in all steps but requires a cue to initiate response in 1 1 1 1 Steps 3 and 4. Attention to this phoneme of the sentence. however. we give greater priority to hand tapping. Fifth sentence: Patient succeeds in Step 1 but fails in Step 2. Maximum scores attained. requires a cue to initiate response in 1 1 1 0 Step 3. Fourth sentence: Patient succeeds in Steps 1 and 2. Latency of per- fully completes the four steps for the sentence. immediately after successful completion of the third step. Such ping with the patient. As the patient him/her to do so. but we believe that any improvement should unusual for the patient to fail this step. The detailed description of this third level follows. The clinician cian before he or she permits the person with aphasia to intones a question asking for a substantive response concern. The patient alone. and the clinician proceeds to Step 2. Scores are the same as for Step 2: two replaced by the backup system already discussed. Again. a verbal error. join him or her in unison sprechgesang repetition of the sen- ician. but fades his or her verbal participation. The clinician should not solicit some response of his speech. One point is given for an adequate response following a backup if it is necessary. points.. Finally. particularly if the questions are open-ended enough to intoned repetition. Then. attention to syntax at this point in the progression of the hier- archy. This is not. the score is two errors. They are not patient–clinician hand tapping. then a sec- backup to Step 2 (i. returning briefly if nec- because of the increasing difficulty of the tasks. seconds is imposed by a hand signal from the clinician.GRBQ344-3513G-C31[837-851]qxd 1/21/08 1:53 PM Page 846 Aptara Inc. responses to the ques. A second failure terminates . He or she then invites the patient to responses please and surprise the patient and reward the clin. be free of criticism and should not be inhibited by too much the progression for that sentence is discontinued. the clinician essary and then fading again until the patient can continue must insist on compliance with his or her controls. the clinician required. Step 1 The Most Common “Errors” Occurring in Level III The clinician presents the intoned sentence with the usual The patient’s burgeoning confidence and enthusiasm may hand tapping once. a brief. The patient’s response will be errors. 846 Section IV ■ Traditional Approaches to Language Intervention begin to put more stress on the encoding of responsive Step 3. but if he or she does. Failure of the patient to prosody. backups also are used as an indirect means of correcting an error in a Level III Accomplishment response. particularly when delayed response is shows evidence that he or she can continue. longer delays are imposed by the clini- No hand tapping is performed in this step. In addition points without a backup. Sample MIT Session and Scoring of Level III Failure involves an immediate backup to Step 1 (i. Perhaps this is an formance. strictly speaking. In this last level. Such responses seem to be ahead of any other evidence sentence twice in sprechgesang accompanied by hand tap- of recovery in the patient’s functional language. These responses usually are uttered in normal speech tence with continued hand tapping. ning of attempts at encoded responses to specific questions. if the sentence used in the pre- ceding steps was “I want some pie. the clinician signals the patient to repeat the intoned sentence. If the step is completed without a backup. unison As in Level II. The clinician then pauses briefly and presents the tion. The clinician signals the patient to listen.. the Sparks and Holland (1976) hierarchy has tition that is well supported by the clinician’s participation to been modified by combining their first and second steps into more difficult responses involving some retrieval and a begin- one. Failure to respond appropriately calls for a backup to the clinician’s respond appropriately to the question implies an immediate solo presentation accompanied by hand tapping. been presented. then signals the patient to join in unison prompt him/her to respond before the clinician has signaled intoning and hand tapping the sentence. but nondirected. sentence. the variety of appropriate but unanticipated Step 2 responses to the question in Step 3 should be praised even The clinician intones the same sentence once with the usual though they may not be what was expected. delayed repetition) and then a retrial of ond trial of the unison repetition. and more spontaneous and appropriate verbal ing some element of information in the sentence that has intrusions by the person with aphasia may be expected. five-item therapy session and its scor- intoning with clinician fading) and then retrial of the second ing are presented in Table 31–3 to illustrate management of step. phonemic cueing by the clinician is or her own choosing. The maximum score is one point for acceptable per- also may omit an occasional functor word. In this level. As in cueing. then intones the sional appropriate.e. to their use as an aid for initiation of responses. Failure after one retrial terminates Level IV progression to the third step for that sentence.” the question for Step 3 Step 1 could be “What kind of pie?” Perhaps the encouraging early indications of language recovery during MIT are the occa.e. and they certainly should be accepted. respond. It would be error of omission. For instance. only one backup and retrial of a failed Satisfactory completion of this third level of MIT has begun step is permitted if the hierarchy is followed without modifi- the modification of the patient’s responses from simpler repe- cation. and one point after a backup. the return to normal speech prosody by way Step 3 of the sprechgesang technique described earlier occurs for each sentence used. but delay in his or her response of 1 or 2 make it possible for a variety of responses to occur. be used are less specific as this last step in the hierarchy minates progression to the third step for that sentence. delays permission for the patient to respond Sentence for 2 or 3 seconds.e. fails to repeat accurately in Step 2. 1 2 2 Second sentence: Patient succeeds in all steps but requires backups for Steps 2 and 3. the clinician signals the patient to repeat the the above guidelines for acceptability of responses. and then signals the patient to repeat it in I want to watch TV. if a backup was necessary. requires a backup for Step 2 because of inaccurate 1 1 0 response. becomes less rigidly structured. the clinician asks ques- point if a backup is necessary. Backups should be used only for failures to IV for each sentence. and one point after a backup that produces an questions yields two points for each one. Response to one or more of the gression to the fourth step for that sentence. requires a backup to initiate Step 2. it will be Step 3 (i. If the step is completed Step 4 without a backup. Fifth sentence: Patient succeeds in Step 1. the score is two points. speech prosody. the clinician asks questions that are more associative clinician presents the same sentence in sprechgesang with in nature. The clinician again signals the patient to listen. initiate responses to the specific questions or when such ten. Failure to respond appropriately after one backup ter. (a) What do you want to watch? (b) Who wants to? (c) diate backup to the first step (i. but only one point acceptable response. After delaying permission to respond for 1 Principles of suggested scoring are modified to conform to or 2 seconds. Scoring is the same: Two points with. One suggested solution is to demand accurate responses to the specific questions based on material in the sentence and reward the patient Step 3 with extra credit for appropriate responses to the less spe- Hand tapping is now discontinued for the remainder of Level cific questions. Failure involves a backup to the second step (i.e.. Failure involves an imme. and fails after a 1 0 — backup. then presents the same sentence twice but now in normal responses are inferior to the patient’s current ability. Progression is stopped. and succeeds 1 1 2 in Step 3.GRBQ344-3513G-C31[837-851]qxd 1/21/08 1:53 PM Page 847 Aptara Inc.. the score is one As in the last step of the third level.e. because responses to the less then a retrial of Step 3. Chapter 31 ■ Melodic Intonation Therapy 847 TABLE 31–3 Sample Melodic Intonation Therapy Level III Session with Step and Summation Scores Scores Patient Performance Step 1 Step 2 Step 3 First sentence: Patient succeeds in all steps. but the number of such questions may be increased. Response to the specific out a backup. less specific questions would yield a single score of three . the score is two points. If the step is com- pleted without a backup. If a sentence as presented in normal speech prosody. As illustration. specific questions are bonus items. and fails to initiate response in Step 3 after a backup. Scores 5/5 5/10 5/8 Total 15/23 (65%) further effort with that sentence. Fourth sentence: Patient succeeds in Step 1. sprechgesang with hand tapping. Failure after a backup terminates pro. Maximum scores attained. The clinician signals the patient to lis. this fourth step. the following example is given: hand tapping. and no score may be given for Step 3. tions concerning substantive information contained in the same sentence immediately after successful completion of Step 2 Step 3. unison repetition in When do you like to do that? (d) What programs do you sprechgesang with hand tapping and fading participation by enjoy most? the clinician) and then a retrial of Step 2. 1 1 1 Third sentence: Patient succeeds in Step 1. the Then. the score is one ered to be acceptable responses and when a backup should point. delayed repetition of of the delay may be lengthened as the patient develops profi. if a backup The guidelines for decisions regarding what may be consid- is necessary to get an acceptable response. with hand tapping) and the first specific questions. Backups should be restricted to use with delayed repetition in sprechgesang. the sentence in normal speech prosody) and then a retrial of ciency. Then. The length backup is used.. MIT to therapy that involves normal prosody makes it TABLE 31–4 Sample Melodic Intonation Therapy Level IV Session with Step and Summation Scores Scores Patient Performance Step 1 Step 2 Step 3 Step 4 First sentence: Patient succeeds in Steps 1 and 2 requires a backup to initiate normal 2 2 1 2 prosody in Step 3. and efficiency of retrieval. Fourth sentence: Patient succeeds in Steps 1. This would place the method alongside other techniques that are concerned with improv- Concurrent Language Therapies ing syntax. It is useful to encourage the reach it. Scores 9/10 9/10 8/10 11/15 Total 37/45 (82%) . 2. Its design includes only sprechge- This last level of the MIT hierarchy is more permissive sang and normal speech prosody repetition. Some clini- cians may think that the goals should be expanded to help The four levels of the MIT hierarchy are presented in Table the patient with aphasia and less severe impairment. 2 1 1 3 Patient succeeds with bonus in Step 4. but no bonus because of failure on last associative question. how. an added bonus that is a nice reinforcement the A fifth. retire melodic intonation. That discussion. 848 Section IV ■ Traditional Approaches to Language Intervention points. Many of us have modified the speech.GRBQ344-3513G-C31[837-851]qxd 1/21/08 1:53 PM Page 848 Aptara Inc. encode and emit at least basic verbal communication. Third sentence: Patient requires a backup to succeed in Step 1 and then succeeds in 1 2 2 3 subsequent steps. Perhaps this recovery now exceeds. whose 31–5 for the convenience of the clinician during administra- language profile is essentially that of the good candidate but tion of the therapy. we recommend that no other therapy that is directed The issue could be raised as to how long language therapy specifically to improved verbal output be used concurrently. involving normal speech prosody. 2. and because of its carefully planned program of pro- hierarchy for limited use after completion of the four levels. and another uses a procedure recovery in his or her own milieu. The MIT might be used concurrently with these techniques in Because MIT involves a marked departure from normal post-MIT language therapy. along with an than the first three and demands significantly more from the increased emphasis on answering questions. along with an ongoing recovery of ability to is presented in Table 31–4. The patient who has completed the MIT program has Sample MIT Session and Scoring for Level IV maintained the skills that he or she acquired earlier in the program and has carried them over to normal speech A five-item therapy session with scoring for the fourth level prosody. should continue when the improving patient reaches a The patient may easily be confused if one form demands point at which he or she can experience some continuing intoning all verbal output. with less acute impairment. and 3 and requires a backup for one 2 2 2 2 specific question in Step 4 but answers all associative questions. The gradual transition in ever. Most MIT graduates find it difficult to use the technique unless some prompting takes Level IV Accomplishments and Post-MIT Therapy place before final discharge from the realm of MIT. Patient succeeds in Step 4. Second sentence: Patient succeeds in Step 1 but requires backups for Steps 2 and 3. less structured postgraduate step has been used to patient will enjoy. does not belong here. or will exceed. such as those patient because he or she has recovered enough speech to used in Step 4 of the last level. phonemic structure of words. and 3 but requires a backup for 2 2 2 1 Step 4 and fails to answer any associative question. gression. Fifth sentence: Patient succeeds in Steps 1. the lim- Quick Reference Guide for the Hierarchy its of what MIT currently is designed to offer. articulation. The somewhat less stringent form lends itself to patient to use sprechgesang as an auto-therapy when he or transition to any other language therapies that the clinician she is experiencing difficulty with word finding and the may want to employ after completion of MIT. same sentence. C signals A after 1 or 2 seconds. C signals A. Proceed to Step 3. Score and progression: Acceptable without (B)—2 points. Score and progression: Acceptable without cue—2 points. Unacceptable—Discontinue progression for sentence. Proceed to Step 2. Chapter 31 ■ Melodic Intonation Therapy 849 TABLE 31–5 Quick Reference Hierarchy Guide Melodic Intonation Therapy Levels I to IV LEVEL I Single Step C (HT) hums melody twice. Unacceptable—Discontinue progression for sentence. LEVEL II Step 1 C (HT) hums melody → intones sentence. C fades. (B) to Step 1 if A fails → retrial of Step 2. C and A (HT) (U) intone sentence. Proceed to Step 1 for next sentence. C fades. Proceed to Step 3. same sentence. Step 2 C intones same sentence → C signals A to wait. Unacceptable after (B)—Discontinue progression for sentence. same sentence. C intones cue if necessary. Proceed to Step 4. Acceptable with cue—1 point. Step 3 C (HT) intones same sentence → C signals A. C and A as A intones sentence. Unacceptable—Discontinue progress for sentence. C intones sentence.GRBQ344-3513G-C31[837-851]qxd 1/21/08 1:53 PM Page 849 Aptara Inc. Step 4 C intones “What did you say?” → C signals A. LEVEL III Step 1 C (HT) intones sentence → C signals A. Score and progression: Acceptable—1 point. Proceed to next melody. Proceed to Step 2. C intones cue if necessary. Score and progression: Acceptable—1 point. . Proceed to Step 4. same sentence. Acceptable after (B)—1 point. same sentence. Proceed to Step 3. Score and progression: No score. Score and progression: Acceptable—1 point. Score and progression: Acceptable without cue—2 points. A repeats intoned sentence. C and A (HT) (U) intone sentence. C and A (U) hum melody twice. Acceptable with cue—1 point. Step 2 C (HT) hums melody → intones same sentence. C signals A. C and A (HT) (U) intone sentence. same sentence. C fades. Unacceptable—Discontinue progression for sentence. same sentence. A (HT) repeats intoned sentence. A gives an appropriate answer. LEVEL IV Step 1 C (HT) intones sentence → C signals A to wait. (B) to Step 2 if A fails → retrial of Step 3. (B) to C presentation in normal speech prosody if A fails. A Any appropriate response. intoned or spoken. (B) = backup. A repeats sentence in normal speech prosody. C Questions about associative information. Unacceptable—Discontinue progression for sentence. C and A (HT) (U) sprechgesang of sentence. C signals A. Acceptable after (B)—1 point. Score and progression: Acceptable without (B)—2 points. Proceed to next sentence. Proceed to Step 1 for next sentence. Score and progression: 2 points without (B). same sentence. A Any appropriate responses. same sentence. one or more responses to associative questions. Unacceptable—Discontinue progression for sentence. Proceed to Step 2. same sentence. Key: A = patient with aphasia. Score and progression: Acceptable sprechgesang—2 points. same sentence. same sentence. Unacceptable—Discontinue progression for sentence. . Step 3 No hand tapping. Acceptable after (B)—1 point. same sentence. substantive content. Proceed to Step 3. Proceed to Step 4.GRBQ344-3513G-C31[837-851]qxd 1/21/08 1:53 PM Page 850 Aptara Inc. Score and progression: Acceptable after (B)—2 points. Step 2 C (HT) presents same sentence in sprechgesang → C signals A to wait. Retrial of A repetition. C = clinician. Step 4 C Question about substantive content. 3 bonus points. 1 point after (B). Score and progression: Acceptable without (B)—2 points. (B) to Step 1 if A fails → retrial of Step 2. Acceptable after (B)—1 point. Proceed to Step 2. C signals A to wait 2 or 3 seconds → then signals to repeat. C signals A after 2 or 3 seconds. Retrial of C and A (HT) (U) sprechgesang. Proceed to Step 4. A (HT) repeats sentence in sprechgesang. C (HT) presents sentence twice in sprechgesang. (B) to Step 3 if response is unacceptable → retrial of Step 4. (HT) = hand tapping by clinician with patient. 850 Section IV ■ Traditional Approaches to Language Intervention TABLE 31–5 Quick Reference Hierarchy Guide Melodic Intonation Therapy Levels I to IV (continued) Step 3 C intones a question → C signals A. (U) = unison. C presents same sentence twice in normal speech prosody. (B) to C (HT) presentation in sprechgesang if aphasic fails. 10. H. six major elements of MIT are covered in this resulting from melodic intonation therapy. The family of the person with aphasia who is receiving. & Jimenez-Pabon. Selected writings of John Hughlings Jackson. It is important that these lists be London: Hodder & Stoughton. and his or her family to offer information and vocabulary Martin. R. is The Hague: Mouton. H. occur after sufficient evidence shows that the patient has 5. E. A discussion of participation by family members during participation of the right hemisphere occurs in MIT implies clinical intervention and after its completion. H. Actually. MA: Kodaly Musical Training Institute. 287–297. Our hypothesis that increased 6. the household. M. W. has received. extensive to provide great variety of word orders. Speech therapy and The role of the family to encourage sprechgesang as a language recovery in severe aphasia. A discussion of the candidacy that contrasts the lan- easily after completion of the hierarchy. (1970). or from Level IV to post-MIT therapy should hierarchy. A description of the technique of intoning and plotting Progression from One Level to the Next One intonation patterns. Silverman. A. S. (1979).GRBQ344-3513G-C31[837-851]qxd 1/21/08 1:53 PM Page 851 Aptara Inc. Cortex. R. (1970). (1974). 13. N. selection of useful phrases used frequently by themselves and Jackson. 1208–1209. 318–328. Method: Melodic intonation 1. A. viewed with reservations unless supervision is provided by Gordon. 10. however... clinician. K. MIT should be systematically involved as a support team. An investigation of phono- based on observations and experience in their daily activities. E. E. & Sands. The family should be encouraged to assist in for audition.. family during the early period. as discussed earlier. Doctoral thesis. Papers. British Journal of Disorders of Communication. Progression from Level II to Level III. 607–623. developed a stable proficiency. 259. D. New York: Harper & Row.. A. (1931). guage profiles of good and poor candidates for this type of language intervention. Journal of Speech and Hearing Disorders. Sparks. M. that a somewhat prolonged process is involved. The contributions of careful language examination and scientific studies are of equal importance. MIT. (1988). H. L. entirely on intonation and accuracy of intonation patterns. . Verbal and non-verbal cerebral processing in man the clinician.. Their support is particularly essential when the patient higher one should occur only after a mean score of 90% or is receiving less than one therapy session each day with the better for 10 consecutive therapy sessions has been achieved. Cortex. (1973). A model for neurolinguistics. 3. N. Experience Knighton. Journal of Speech and means of word-retrieval efficiency for the patient in the Hearing Research. from Level III to 4. Wellesley. (1972). M. Occasional have influenced the design of the MIT strategy. A phonological investigation of aphasic speech. Sarno. A detailed instruction of administration of the MIT Level IV. & Rigrodsky. R. for aphasia and associated phonologic disorders that Whitaker. When we consider the usual fluctuation of performance in Further collection of data regarding candidacy is essential those with aphasia from day to day. Participation of the Family During and After Clinical MIT References Much emphasis is placed on members of the person with aphasia’s family participating in the process of attempted Albert. Aphasia in for words and phrases that have a high frequency of use in adults. Jenkins. (1973). Sparks. Parastandardized examination guidelines for adult aphasia.. Part II. Participation of the Association. Journal of the American Medical rehabilitation of his or her language. chapter: 303–316. M. H. Part I. & Holland. California Institute of Technology. Aphasia rehabilitation In summary. Helm. this often may involve as a means of providing further evidence of the efficacy of some approach-retreat before the 90% mean is achieved. logical impairment in aphasia. Diagnosis and treat- ment of aphasia.. Future development of MIT should include Suggested Means of Controlling Rate of Progression the development of published guidelines that the family may We recommend that moving from one level to the next use. SUMMARY Sparks. 41. (1964). A discussion of certain principles of language therapy therapy. Whether the clinician who uses MIT agrees with our hypothesis is less essential than whether he or she progresses slowly. Beginning teaching techniques: Teaching music at with this selective process makes it possible for the patient beginning levels. the patient premorbidly. (1976). S. (1978). to ensure FUTURE TRENDS that improvement from this method is maintained. 41. A discussion of post-MIT strategies. 135–146. Chapter 31 ■ Melodic Intonation Therapy 851 possible to transfer to other language intervention strategies 2. & Albert. home and among selected friends is strongly recommended Schuell. when the focus is Blumstein. or the rate of progress made by the good candidate will be slow.. & Helm-Estabrook. is presented on a computer by a clinician working at of adults with aphasia. The third. (AAC).. Brecher. refers to small comput- tance of the clinician or others (e. to CAT).GRBQ344-3513G-C32[852-876]. The role of 2. Katz particularly those who cannot read extensive instructions or other text. The clinician later reviews patient boards. such as COT. computer-assisted treatment (CAT) soft- computers and related technology in the rehabilitation ware. as part of a clinician-provided conditions. and summa- 3.” Unlike the devices used by patients with severe performance (“off-line”) by examining task performance dysarthria or other speech problems. To familiarize reader with the various applications of The second. spouse or speech. and Robey (2002) com- use of computers and software to improve communication pared the benefits of the same computerized treatment for skills in people with aphasia. and other treatment. other software. In addition. In addition to treatment programs written specifically for use with clinicians. by cannot simply type the words they want to say. with.g. 852 . usually. to practice alone at the computer. approach. non-computer activities or tests. drills) and supplementary tasks designed to reinforce or help generalize recently learned skills. pictures. the computer is limited to elements of basic task structure. such as presenting stimuli. word processing. To describe classic and recent research literature rizing performance. Operation both communication partners to use the device to exchange of the program should be familiar and intuitive for patients. text. Fink. Consequentally. the same time (“side-by-side”) with the patient.qxd 1/21/08 1:55 PM Page 852 Aptara Inc. partial indepen- in aphasia treatment can be described as three discontinuous dence (similar to COT) and full clinician guidance (similar categories. digitized speech. is adults with chronic aphasia was demonstrated under both designed to allow a patient. ers functioning as sophisticated “electronic pointing pathology assistant). appropriate into the diagnostic and treatment process thus compensating for the limitations inherent in the COT for people with aphasia. COT software usu- ally consists of convergent tasks with simple. can be used in this manner as long as the clinician provides the DEFINITIONS patient with the additional information needed to perform “Computerized aphasia treatment” refers to the systematic the task. information to modify the activity to accommodate the 4. and animation. patients with aphasia scores saved on disk by the program for later review. Some allow tion to related. clinicians and programmers cannot anticipate every possible cue or strategy that may be helpful to every patient. To evaluate the effectiveness and appropriateness of patient’s needs in the same way as during tradition. additional cueing. Schwartz. Chapter 32 Computer Applications in Aphasia Treatment Richard C. in aphasia treatment. This symbiotic relation between 5. whereas the clinician provides special demonstrating the efficacy of computerized aphasia instruction. 1.g. or by measuring generaliza. treatment program. The AAC directly observing performance using the software during a devices designed for speakers with aphasia may incorporate subsequent treatment session. messages during conversations. clini- treatment software for patients with aphasia. and found that training-specific learning for The first. obvious goals The objects of this chapter are: (e. To discuss the strengths and limitations of computer. To incorporate computers and related technology when clinician and computer permits considerable flexibility. alternative and augmentative communication out the simultaneous (“online”) supervision or direct assis. ized aphasia treatment. cian-provided treatment. or video game programs. resulting in simplistic or nonexistent inter- OBJECTIVES vention components. intervention. computer-only treatment (COT) software.. storing responses. The roles that computers play naming disorders under two conditions. digital) units. ing face-to-face communication. theory and sufficiently experienced in both the clinic and ural language” (e. Mehrabian (1968) will writing.g. sage’s affect (i. and less expensive. Only banks.e. communications (modem). such as controlling all the lights in ogy” (Rheingold. Although individual language tasks can be pro- stage in this evolution. “Microcomputers” were first tinct. computers cannot under- technology for building electronic devices recognizable to stand speech or writing very well) ensure that computerized us as computers did not exist until the 20th century. 38% vocally. qualitative description and decisions are Over the years. In the 1950s. kinesics and proxemics) a promise that the computer industry’s sales force has channels of communication (Egolf & Chester. 1822). The concept of a machine computer programming that can be used to illustrate the capable of complex decision making without human inter. language) and nonverbal (e. via facial cues. Alan Turing (1936). treatment will be a subset of clinician-provided treatment Another English mathematician. computer-provided treatment is based on a finite set of rules A BRIEF HISTORY OF COMPUTERS that are stated explicitly to specify actions likely to occur A mechanical computer was first built by an English math. large corpora- tions. p. and so on. (2) conventional. software developers saw a market universally recognized. and mechanical relays and that read rolls of punch tape and. data base. 216). educated in communication improved performance on standardized tests and in “nat.. the emotional content) for listeners dur- graphics. Markel. LaPointe.GRBQ344-3513G-C32[852-876]. Chapter 32 ■ Computer Applications in Aphasia Treatment 853 The organization and semantic content of the AAC LIMITATIONS OF COMPUTERIZED devices frequently can be modified for each patient’s particu- lar needs and abilities. however. the rules never . a computer. Events must first be separated into dis- reliable. In contrast. and (4) computers were large.. but the Limitations in modalities (e. vacuum tubes. estimated that 55% of a message’s affect is communicated top. some researchers attribute A speech-language pathologist. it aphasia rehabilitation requires an appreciation of the intri- is understandable why many expect an imminent break. and modify 1997). treatment activities in response to previously unacknowl- edged associations and unanticipated responses. that filled rooms with switches. word processing.. Regardless of the value of the sym- patient with aphasia. As computers began to show guage and communication are not well deliniated or even up in offices and homes. financial planning.. more difficult to make. Looking back on the recent rapid grammed. ematician almost 200 years ago (Babbage. evaluate. limitations inherent in the application of computers to apha- vention was revolutionary (Turing.. made since the mid-1950s. spreadsheet..e. sia treatment: (1) discrete. through that will abruptly change our lives for the better. speaking and listeing) to treatment real-life. computers grew smaller. unconnected elements before they can be acted on by sold in the mid to late 1970s to hobbyists and other tech. ated promises made by an avid computer industry intent on increasing sales. (3) finite. 1978. clinicians. 2005. cacies and interdependence of elements within verbal (i. Bolter plex calculations that.e. Discrete later. While the world rushes forward to Conventional embrace technology. and palm-size personal computers that access infor. lap. 1991. & Silkes. 2005). electronic calculating machines isolated. Computers cannot be all things to everyone. at particular points during a future treatment session. bols or the outcome of the program. Katz. Steele. those of us engaged in rehabilitation should step cautiously and apply accepted standards to Computers apply predetermined rules to symbols that have determine the value of computer applications for each no effect on the rules. and civilian and military governmental agencies Because computers acknowledge and manipulate discrete could afford to purchase and operate these machines. described as our “oldest and highest bandwidth technol- form specialized tasks. People with aphasia and their LaPointe & Markel. Katz. can generate an infinite number of novel and rele- involving AAC devices (Aftonomos. & Wertz.g. applying computer technology appropriately to growth—or. until then. but only 7% by the actual mation from the World Wide Web are only the latest words. Today’s multimedia desktop. In summarizing research concern- for functional and entertaining programs for the general ing perception of the meaning of words versus the mes- public: games. some might say. and supplemental to treatment provided by properly trained described a device similar to a typewriter that used a “con. Face-to-face communication is a complex act nology enthusiasts who programmed the machines to per. 1973. families may be particularly vulnerable to the unsubstanti. had been completed only (1984) described four general properties of computers and by specially trained personnel. tingency table” (criteria and algorithms) to perform com. (i. In addition to providing an alterna- TREATMENT SOFTWARE tive mode of communication. vant treatment stimuli and recognize. reels of electronic tape.qxd 1/21/08 1:55 PM Page 853 Aptara Inc.g. intrusion—of technology. 1950). Many elements of lan- a house or measuring rainfall. Guyard et al. Not all therapeutically relevant If a program were written that could completely repre- behaviors are identified.. chaining. “artificial (e. Guyard.g. for whom such treatment appears promis- Treatment is recognized as a multi-level. and enjoyment). No single Quiniou. such iors have been identified.f.qxd 1/21/08 1:55 PM Page 854 Aptara Inc. treatment software is becoming commercially available. including cognition (e. Odor Isolated (1988) referred to this problem when he wrote that com- Problems and their solutions presented by computers exist puter intervention defers decisions to programmers who within the computer’s own parameters.. and those that have often vary in sent clinician-provided treatment.. environmental) factors and cannot be controlled effec. Dean (1987) stated that the with a finite number of steps. chronic aphasia.g. Kotten. & Morrison. improving communication is quite another matter. because computer programs are not powerful enough knowledge” is. plan in advance how to handle the learning inter- rithm—that is. relevance. Odor. Divergent behavioral exchange.. use of linguistic models to right under all conditions (Rosenbek.. ment continues to remain a challenge for contemporary soft- meters of therapy and fundamental skills of clinicians have ware developers.. and those that are accepted may not be (Rosenbek. functionality) as Language Activities of Daily Living (Learning Systems). 1979). Not all therapeutically relevant behav. much like a game of chess. the resultant computerized activity highlights the technical limitations of the computer medium. particularly drills. a finite series of steps described with ade. novelty.g. construct software to diagnose and treat aphasia is appealing only treatment does not follow the clinical cycle of (a) (see. however. 1990. 1989). idiopathic) and external but as of this writing.g. e. presents the opposite case. and predominantly symbolic puter program (c. Some researchers (see.. noise buildup. the most significant impedance to to represent every potentially relevant nuance of interac- comprehensive computer-provided treatment. adaptation of divergent therapy to computer-provided treat- tively by a computer. and The rules and symbols that control computer-provided intermittent imperception).g. trivial. pragmatics program. e. all the rules are not guidelines of aphasia treatment. Odor concluded that computer- tasks as presented by computers essentially differ from the assisted instruction often is based on convergent rather meaningful.. and then encode these steps into a computer pro- quate detail to guide the program to respond to input. memory.. and emotion (e. only consider ment studies reported in the aphasia research literature problems in which all the variables and rules are known describe convergent activities. all the rules are not known.g. many that have (e. perhaps. Rigrodsky. Although a consensus exists for some fundamental been identified (Goldberg.g. Most computer treat- occurs among people. cybernetics (e. the scope of treatment software is lim- answer questions..g.g. the software would be importance between patients and situations. e. unforeseen problems and associations do therapeutic approach currently encompasses all known not result in the creation of new rules and symbols. pragmatic setting in which communication than divergent theories of learning.g. (b) measure performance. inability to incorporate divergent strategies in computer Learning to solve linguistic riddles on a computer program programs severely limits their value and application to may lead to better scores on conventional aphasia tests. behavioral factors (e. interactive ing (Chapey. By reducing the scope of the problem to a size that designers and programmers who are not physically present is manageable for the computer. apart from the real are not physically present during the session. 1990) and. and (d) re-administer treatment and.g. gram. dis- treatment are limited to those that are defined within the criminatory stimuli. Computer-pro. This lack of “world ited. whereas many basic para.e.g. Consequently. 1988) and aphasia treatment. vigilance. Problems are stated in a way such that symbols can be gather and send information only through the computer manipulated to solve the problem by following an algo. guage therapy in small. Katz. Except for the most sophisticated (i. treatment software has during the session but who must plan in advance how to been squeezed and shaped to imitate cognitive and lan- handle the intervention and code these steps into a com.. (c) modify much about language (see.. is not adequately responsive to the dynamics of patient 1986. 1976). ultimately. logic language behavior of people with aphasia also is influ- enced by a variety of other factors.g. intelligence”) programs (see. 854 Section IV ■ Traditional Approaches to Language Intervention change. therefore.. treatment of patients with aphasia. Computer. 1997). are influenced by internal (e. e. e.. (see. no data exist to support efficacy. functionality and social status). . therefore. and resource alloca- Finite tion). Therapy intervening variables. The (e. or solve problems. attention. 1979). particularly those with however.GRBQ344-3513G-C32[852-876].. Computers. slow rise time. 1990). For example. however. & interest. In addition. Wallich. in which ahead of time and can be solved in a step-by-step procedure specific responses are learned. 1991). medium. but must world. Language tion during therapy. action. activities. Fenstad. massive and exceed the capacity of modern personal com- vided learning commonly defers decisions to software puters. and those on which we agree may not be correct known. can teach us administer treatment. believe that the patho- performance. Masson. and extinction).. Rather than emphasize state-of-the-art aphasia treatment. 1988). Some of these devices were pro. which can administer some aspects of review. especially as Supplementary Treatment it relates to the construct of quality of life. e.qxd 1/21/08 1:55 PM Page 855 Aptara Inc. In many Translations of the SF-36 are being tested in more than 40 areas. researcher to develop treatment protocols for specific The widely used health care assessment tool. Chapter 32 ■ Computer Applications in Aphasia Treatment 855 TREATMENT Treatment Efficacy and Prognosis The earliest applications of computers to aphasia rehabilita.. It treatment session if they are presented in a structured setting is imperative that the clinician actively train generalization. such as the Language Master (Keenan. accuracy. Generalization can be requirements and recording of session performance for later aided by the computer. and writing between 125 and 150 trials to learn to write or print 10 func- devices and minicomputers (e. The face validity of this tool is impres- sive for clinicians and researchers interested in investigating quality of health care across health disciplines. and physical variables on communication and task perfor- totypes and experimental (see. 1977). 1974). 1958). but the SF-36. microprocessor-driven auditory. Speech-language patholo- ment of instrumental learning devices or “teaching gists assess the influences of various linguistic. maintain. general principles of aphasia treatment should be used throughout health. 1989. Computer-provided treatment is an environment very differ- tors. acquired skills. The SF-36 soft- ware that provides administration.g. 1973). e. the SF-36 patients and types of problems (see.g. Keith & Darley. emotional role function- our increasing repertoire of clinical techniques. this version can be used for assessing effects from the power of computers in rehabilitation is not simply the clinical trials. a similar task should be pre- responses but also measure overall performance and adjust sented without the computer—for example. Contemporary commercial treatment and LaPointe & Wertz. Matthews & LaPointe. Generalization Patients can work longer and more often on a variety of activities designed to stabilize. vitality. computers will evolve as the technology improves. the PDP-11) to provide tionally relevant words at the third-grade level (LaPointe. 1967) and the ties in a standard manner and routinely store performance Programmed Assistance to Learning filmstrip projector data for later descriptive and statistical analysis.. 1981). Programs can vary along a continuum according to treatment without the familiar presence and constant con- structure and content. than a computer simulation. or generalize newly “Prepare for rather than pray for generalization” (Rosenbek. It pro- Schuell. Rosenbek and colleagues (1989) . ranging from simple. Jenkins.GRBQ344-3513G-C32[852-876]. treatment-related aphasia treatment is measured by the degree to which skills language and cognitive activities beyond the confines of the acquired in treatment are observed in real-life situations.. such as control of stimulus characteristics and response ent from real-life communication. is available for downloading from the Speed. e. bodily pain. that incorporates important therapeutic principles and fac. Computers present treatment activi- used. repetitive drills scious (and unconscious) control of the clinician. will require small. 1984). and reported health transition. psychological. and data export Supplementary treatment in the form of workbooks and for research support is available for Windows. For example.sf-36. Additionally. 1997). reliability. Assessment Project. By the time that personal computers (then called as an invaluable clinical yardstick against which the success of “microcomputers”) were introduced in the mid to late treatment could be measured (see. and ease of use are valued Internet (http://www. other structured activities has always been a useful option for clinicians (Brubaker.com). This benchmark of prognostic resolution would serve cology).g.g. visual. a 55-year-old adult with Broca’s aphasia who 1-year clinicians to use computers to meet the needs of patients post-onset is at the 50th percentile on the Porch Index of with aphasia. 1996. On fulfill- to interactive tasks that not only evaluate individual ing criteria for a computer task. Ultimately. p. machines” (Skinner. or PICA. 1972).. mance to evaluate the effectiveness of a treatment approach or whereas others were commercially available and widely activity (Darley. reports began to appear in prognostic data bases to predict with confidence that. Katz of typing. Measuring the effects of intervention on aphasia is an essen- tion owe much to behavior modification and the develop. Health Survey. 138). mental health. Schwartz. treatment to outpatients over the telephone (telecommuni. screening medical patients for mental health referral. 1970s. The role of ing. social functioning. Eisenson. computers have the potential to become significant countries as part of the International Quality of Life tools for treating aphasia. sufficient interest had grown among clinicians and 1981. Vaughn (1980) incorporated Communicative Ability (Porch. the value of educational software extend controlled. (Pfau. 1991. for professional journals describing attempts by researchers and example. Following the introduction of small mainframe computers can help clinicians to develop local and national computers (“minicomputers”). Dressler. 1967). and result of faster microprocessors or larger storage devices. tial part of any treatment regimen. or performing the actual functional activity rather & Wertz.. Like the print version of characteristics wherever personal computers are used. writing instead the type and degree of intervention provided (see. e. monitoring outcomes in clinical practice. and Jiménez-Pabón (1964) stated that vides measures of physical functioning. 1983).g. scoring. Schulz (1976). 1999). Administrative Functions Programs like MultiCue (Van de Sandt-Koenderman.GRBQ344-3513G-C32[852-876]. history information (Silverman. This long-term goal of aphasia treatment is to have patients ability saves time and greatly simplifies the process of retriev- become their own best therapists. the low-cost foundation of a nationwide electronic health Factors such as motivation. One of the most comprehensive systems is Computerized selves can then determine when and how often they partici. and multiple-choice list containing the word). Morrison (1998a) describes an active role for com- MultiCue offers several different strategies simultaneously.g. and help patients to develop insight regarding their (database programs). Innovations include treatment software with minimal assistance from others. Chart Links is based on Lotus Notes. Hamburg & Adams. are concerns that may become increasingly important to Commercially available software provide another path to people with aphasia and their families as recovery slows and incorporating technology into administrative activities. patients should be able to use jecting values (spreadsheet programs). This is consistent icians using PCs in every medical center in the Department of with Wertz’s (1981) statement that we should allow patients Veterans Affairs (the “VA”) to access patient records not only to maintain as much independence as possible and that a within their own medical centers but also from others. which enables clin- pate in supplementary language activities. 1998b). so description. Expose each patient to numerous repetitions. they will soon to do even more (Hallowell & Katz. calculating. minimize dependency and depres. Extend treatment outside of the clinic. patient encounter. The VA used instead of ignored. the degree of disability and its subsequent effect on life Chart Links (Chart Links) is a commercially available sys- become more apparent. treatment by providing patients with aphasia a degree of con- 3. and recalling information sion. 4. many cueing strategies that have been shown to be effective in clinicians use computers to gather. Patient Records System (Kolodner. and treatment schedule. and in this way. positive effect on their satisfaction and physical tions appear well suited for the computer: well-being. It lessness and hopelessness. hard drive. and report case treatment. the use of voice recognition in report writing to increase The required computer skills include turning on the com. recording. 1994) Currently. Under conditions of perceived help. Train a large number of items in a given category. report and letter writing (word processing pro- To foster independence. general purpose programs have useful applications for clinicians working with patients—for Independence and Emotional Factors example. and others have shown that giv. Bengston (1973). Large-scale systems are expensive to set up and maintain. first letter. puter system. the institutionalized elderly) can likelihood of generalization. the speed of generating reports (Tonkovich. and automated review of patient infor- ing some options and responsibilities to persons in otherwise mation. & Kronick. program. Patients them. and following authoring systems to customize data base entry and retrieval. sorting. recommended treatment. Decision making and expression of personal pref- erences by each patient should be a basic part of any treatment 1. and organizing.. before attempting to integrate technology and clinical and Ideally. 1997). have a strong. Several of the recommenda. Langer and Workflow applications allow charting. especially for patients who have regarding their problems and their strengths can be are treated at different facilities across the country.g. grams). trol over the content and frequency of treatment. or the Internet. patients can take a officials have developed a system that many believe could be more active role in their recovery. tem that is based on electronic patient medical records. The insight that patients ing and updating patient records.. dependency. lab report. and pro- communication problems. selecting the treatment program from a Kawahigashi. patients should develop and practice their own self. filing. first sound) and visual (e. 1997). support staff (Morrison. Horowitz. 1975) and have greater difficulty cop. As is the case for many other professions. sis. which allows . Krainen. team report. organizing. On a smaller scale. and quality of life record system. 1974). Rodin (1976).e.qxd 1/21/08 1:55 PM Page 856 Aptara Inc. report writing.. are audible (i. puters and related technology in the evaluation of many fac- whereas Visual Confrontation Naming provides cues that tors essential to the delivery of services and quality of care. 856 Section IV ■ Traditional Approaches to Language Intervention recommended a series of clinical activities to increase the dependent situations (e. Computerized activities can address this aspect of 2. word-finding problems by selecting among possible cues. medical diagno- ing with and adapting to changes and problems (Coelho. Organize treatment to maximize independence so that patients learn to use treated responses when they want to rather than when told to by the clinician. and in all likeli- teach the patient a strategy to stimulate or compensate for hood. the protocol for each particular program. organizing. computers are assisting clinicians in the perfor- and Visual Confrontation Naming (Parrot Software) help to mance of administrative and clinical duties. 1991) and the use of removable disk. it is essential to plan carefully and consult with information The CD-ROM version has more than 500 target words with technology specialists who are experienced in health care pictures that aid in generalization of self-cueing strategies. people frequently become creates a record for each patient and tracks reports of each depressed (Seligman. organize. but clinicians nicative behaviors used to classify most types of aphasia also should provide additional non-computerized reading (Goodglass & Kaplan. To understand duce variable errors. tening. & Katz.g. For most patients. through typing. patient’s particular need beyond the capacity of computer more than other language modalities. whether face-to. 1987). and evaluating treatment activities aphasia. many ways less direct and responsive than speaking and lis- taining manner for patients with aphasia.e. treatment time so that face-to-face.qxd 1/21/08 1:55 PM Page 857 Aptara Inc. 1982) and are the and writing treatment that is individualized to each focus of most therapy for aphasia. Management of auditory and verbal skills therefore is and verbal output skills that computers do not address.. Listening and talking are the commu. multiple speakers (as would be the situation found in the All tasks have a goal.. such as apraxia of speech and phone.. and STRUCTURE OF TREATMENT ACTIVITIES physicians. An tance to clinicians treating the speaking and listening understanding of these task components is useful for problems that occur during conversation for patients with describing. 1983). the output of the computer is dis- played on the monitor screen and read by the user. emphasize complex elements of auditory comprehension tion. incorporate computer game activities. Typing enjoyment (e.g. developing. Laureate Learning Systems). merely repeat object names or offer nonlinguistic visual Equally important. In many .GRBQ344-3513G-C32[852-876].g. Computerized MODALITY CONSIDERATIONS reading and writing treatment tasks can free up valuable Conversation (i. with the our scope of practice. individual therapy can face or via cell phones. The major contribution of computers to aphasia treat- apist Helper (Therapist Helper) is another clinical practice ment currently appears to be in the areas of reading and writ- management software developed to facilitate patient and ing. The clinician should provide the patient with potential to developing automated. and even the Internet to help promote intellec. typing on a keyboard. skills appear to be an appropriate focus of computerized ture games) have long found a limited but useful role in aphasia treatment for several reasons. Kertesz. but programs that lying purpose of the task (why the task is being required). Listening and talking. a person with aphasia’s successful reintegration into the community—the final demonstration of the success of ther- apy. Ther. the patient should be aware from the cues are of limited value to patients with auditory compre. Enderby (1987) discussed the pos.. Prescott.. graphic-oriented insurance billing transactions and accounting as well as report machines. the perception of recovery and treatment success Many elements are common to the structure of all treatment is driven by improvement in listening and talking. they are in tual stimulation and social interaction in a novel and enter. and although some are obvious. having greater interpersonal distance.. Speech recognition is limited and unreliable for for the computer. talking and listening). a valuable service for many patients. alone. the patient should recognize both the mic paraphasia. Scott and Byng. 1989). is outside of tral to writing (Selinger. 1983. Listening drills are promising. arcade and adven. central to the concept of aphasia rehabilitation (see. reading and writing are appropriate com- munication (as opposed to therapeutic) activities for people with aphasia to practice on computers. apashia have problems reading (Rosenbek et al. The computer can provide valuable reading and writing Schuell et al. delivery. writing tasks. activities regardless of the underlying principles or mode of Contemporary treatment software offers little assis. the goal of the task. 1964). This makes the computer well suited for presenting reading tasks Recreational Activities and. Most patients with treatment (Lynch. response from the patient. e. educational software reading and writing as communicative acts usually are done programs. but the the goal. The stimuli used and the desired responses yet been realized. which usually is an intermediate step treatment rooms of any clinic) and for speakers who pro. As such. friends. affect the likelihood of software. and for their families. none are trivial.g. but speech-language clinicians can obvious exception of the mechanics of handwriting. toward a major or long-term treatment goal. Also. e. Recreation on the keyboard can be used to address many aspects cen- therapy. Reading and writing Commercial recreational programs (e. Reading requires minimal social and intellectual stimulation for patients with aphasia. beginning of the steps within the task that advance toward hension deficits. 1989) and sibility of computers in this role providing a path toward writing (Geschwind. Programs for treating reading Many educational and treatment programs use familiar can run on standard personal computers. is our primary mode of communica. without expen- game formats to minimize learning time and heighten sive modification or specialized peripheral devices. High-quality digital speech is common on objective of the task (what is being required) and the under- today’s multimedia computer systems. 1973).. Computers are basically visuomotor. should be consistent with the purpose of the task. complex listening task instructions so that the patient knows from the beginning that address specific patterns of auditory problems has not what is expected. activities (see. Information from the user normally is entered by writing. Chapter 32 ■ Computer Applications in Aphasia Treatment 857 advantageous communication and security features. and loudness) of elements cen- McReynolds & Kearns. Many computer programs control some aspect of stimulus characteristics and provide rein- forcement to patients in the form of corrective and general MODELS FOR COMPUTER REHABILITATION feedback. exposure time). Teaching specific responses may be the goal of some tasks (e. such as requiring a typing response of brain functions so that new methods existed of perform- (i. iors that result in punishment (Skinner.. software developers rarely pro- Educational Models vide thorough descriptions of the treatment models influ- encing software evolution. e.. 1989). 1981.g. word retrieval. Mills. stimulus characteristics Finally. learning general skills compared with direct.. sustained attention. unnecessary response requirements that could 1973) believed the return of skills involved a reorganization confound performance. tral to behavior modification (e. 1985. actual. associate printed names of family members Behavior modification (operant conditioning and instru- to their pictures). 1980) in the development of rehabilitation soft. The patient’s performance and the which we communicate and use language. Scott & Byng.. up the Language Activities of Daily Living (Laureate . 1982. the intervention may be modified or the activity dis. 1948). and motor skills) ing behaviors previously executed through the damaged instead of a simple two key (yes/no) response on a compre- structures (“intersystemic reorganization”). Selinger.e. Although they are not mutu. The three programs that make examined. additional. didactic ally exclusive. Lepper (1985) contrasted three approaches to learning with early reports of computerized aphasia treatment (see. new behavior or eliminating an established one through the cue or compensatory) to improve communication during systematic application of consequences (Goldberg. but the theory that function salient behaviors within the task (accuracy being only one). and highly individualized instruction. e. 1984. 1981) to identify and measure the occurrence of recovery of cognitive functions. 1983.. 858 Section IV ■ Traditional Approaches to Language Intervention instances. the models offer a basis from which the role of approaches. size. color.g. In contrast to the considerable attention afforded the arrival of new treatment programs. 1985. Recent studies have reversed the trend providing immediate feedback. 1983. Criteria for woven into the fabric of human behavior—simply put. inductive. Matthews & LaPointe. Bracy (1986) described four theories accounting for the Porch. direct application to treatment software: (1) individualized Katz & Nagy. and (3) simulations. [According Responses and performance scores should be stored for to Skinner (1957). Having an explicit model facilitates the systematic ment. “discovery-based” learning is better for develop and evaluate software. a more valuable goal commonly is to mental learning) describes the process of either teaching a develop a task to help the patient learn a strategy (i. also called microworlds.g. The clinician should provide an intervention (strategy or cue) to improve performance as Behavior Modification needed. The contingencies between actions and outcome development of software and provides a basis for clinicians should lead the patient to an understanding of basic principles selecting software for their patients.. Responses should be as simple as possible to computerized treatment therefore is to provide the patient reflect accurately the performance of the target behavior.] The frequency intervention can be evaluated using various techniques of occurrence. point to name on card The principles of behavior modification are thoroughly when referring to particular family member). 1973). and specific feedback to describe the most recent response should be readily provided.g. These programs assume of rehabilitation provide clinicians with the structure to that active. peo- termination of the task should be specified to provide a tar. Katz & Wertz. these principles even guide the way in later review and analysis. involve Luria (1973. 1983. duration (e. Loverso.e. which seem to be more effective when learning computers in aphasia rehabilitation can be directed and highly specified information.g. Bracy (1986) games stimulate a person’s interest through game-like activi- was among the first to explicitly incorporate the work of ties. Educational Wheeler.qxd 1/21/08 1:55 PM Page 858 Aptara Inc. analysis. as indicated. functional situations (e. trolled with a computer. Prescott. 1960) to encourage the patient the reorganization. 1982) provided drill and practice. (2) educational games. no explicit models of rehabilitation from which the software Drill and practice capitalize on the computer’s advantages in could be evaluated. data (see. 1977. Luria (1963. As described by Wolfe (1987).. Educational simulations.g. 1997. 1997).. the patient in a series of problems in an imaginary environ- ware. and other (LaPointe. responses should be described and quantified Brain-Behavior Relationships using a multi-dimensional scoring system (LaPointe. parameters (e. One function of hension task. ple tend to do things that result in rewards and avoid behav- get against which the patient can measure progress. 1977.g. and reinforcement schedules) can be monitored and con- continued. self. Prescott & McNeil. & Smith. with the direction and opportunity to retrain skills through General feedback (Stoicheff.. Three general models relevant to real-world environments. recovers through the retraining process is the most closely Care should be taken that the patient is not burdened with allied to the modern concept of rehabilitation.GRBQ344-3513G-C32[852-876]. spelling ability. qxd 1/21/08 1:55 PM Page 859 Aptara Inc. because the accurate response must match the tar. Results are displayed or stored on disk patient/family profile. Seron. Complex programs more closely sim- ment activity may have several purposes and demonstrate ulate a real-life situation by using pictures and sound. At the most fundamental level. The characteristics of more than one type—for example.. Examples of tion for family members in the future when new problems drill and practice programs are described by Katz and Nagy and questions arise.g. Stimuli are not selected primarily for informa. Schubitowski. tions to a problem. Overall accuracy and other salient response characteristics (e. latency) usually are dis- played at the end of the task.. appropriately realized in a hypertext format.. informational program can be number of stimuli are presented and are replaced when cri. cific stimuli.g. stimulation situations that otherwise would be too dangerous to experi- activities offer the patient numerous opportunities to ence firsthand.g. such as found terion is reached. the program should present an intervention or cues gate through text. Simulations TYPES OF COMPUTERIZED Simulations (i.g. with particular patient and goal. meteorology. (2) drill and offered. Katz and Wertz (1997). and Devitt represent microworlds in which the patient is free to explore (1989). therapy (Davis & salient stimulus characteristics (e. Simulations provide the opportunity to respond quickly and. the patient’s response accuracy. Davidoff.g. Moulard. An early example of a computer Tutorials stimulation task is the auditory comprehension task Some authors (see. 1991) describes a totally tion and drill and practice (see. and astrophysics to test condi- Stimulation tions that are impossible to experience or to train people in As described by Schuell and colleagues (1964).. in gent tasks. such as during Promoting Aphasics tional content (e. length. Because response accuracy is the focus of on the World Wide Web. by more traditional.. 1985). Simulations have been used in fields such as chem- istry. The tutorial response. Katz. which detailed information is provided in response to a get response exactly. (3) simulations. ing possible solutions. simulated environment created through the interaction of a & Rouselle. term “virtual reality” (Rheingold. Chapter 32 ■ Computer Applications in Aphasia Treatment 859 Learning Systems) are examples of computer software that (1984). computer and a human along both verbal and nonverbal channels. animation.. e. e. . 1973) have suggested that described by Mills (1982). and (4) tutorials. and Seron and colleagues the total simulated environment rather than respond to spe.GRBQ344-3513G-C32[852-876]. complexity. rather. Computer tions can improve generalization of newly acquired behavior programs can easily be designed that contain a large data. patients with aphasia are best served by modification of their communication environment. program could incorporate features of an expert system. to real-life settings as well as or better than traditional meth- base of stimuli and control these variables as a function of ods remains to be tested. so an authoring or editing mode additional modules provided when needed or requested. tutorials offer valuable information regarding communication and quality Drill and Practice of life to the family. and types are not mutually exclusive. Drill and practice exercises therefore are conver. usually. Eisenson. convergent computer tasks—for exam- ing a new set of responses. The question of whether computer simula- ical elements. and sound describing to help shape the patient’s response toward the target relevant aspects of aphasia and communication. stimula. by including several alternative but equally correct solu- of the task. interest and relevance) but. microworlds) are programs that present TREATMENT TASKS the patient with a structured environment in which a prob- Four major types of treatment activities are appropriate for lem or problems are presented and possible solutions are presentation on the computer: (1) stimulation. the computer information so that the patient is able to—or appears able tutorial could present information commonly found in to—function more independently. and function as a source of informa- and show the effectiveness of the intervention. or PACE. where a family member can navi- the task. Wertz. (1980). friends. and others who influence the The goal of drill and practice exercises is to teach specific patient’s world. In that respect. such as presenting a practice. This list is not series of paragraphs describing stages of a problem and list- exhaustive. number of crit. pictures. A limited This type of self-paced. and presentation rate). One treat.e. Deloche. correctly over a relatively long design divergent treatment tasks that could address real-life period of time for the purpose of maintaining and stabilizing problem-solving strategies more fully than those addressed the underlying processes or skills rather than simply learn. Wilcox. is needed to modify stimuli and target responses. Simulations may be simple. Stimuli are selected for a patient information pamphlets in an interactive format. 1980). geology. for Communicative Effectiveness. The process therefore is the focus ple. typing tend to produce programs with only limited therapeutic on the keyboard. 267). and other deficiencies. Robinson. Others ers exists in aphasiology. visual neglect. According to Rosenbek (1995). e. Selinger. In other words. problem-oriented same scientific scrutiny and systematic modification as all software. Crerar. Wolfe (1987) found that early reports of com.GRBQ344-3513G-C32[852-876]. autonomous computerized aphasia improved as a result of a specific intervention (McGlynn. Prognostic indicators common to patients Dean. Ineffective treatment pro- Severely impaired patients may be limited to simple treat. treatment software is not to be limited in its effectiveness. clin. Rushakoff. provided to patients with aphasia. efficacy is improve. treatment programs. Robinson claimed that many of rehabilitation from which the software could be evalu.g. Robinson (1990). and to some extent. and self-monitoring. Bracy. time post-onset. 1942. In an extensive review of the literature.qxd 1/21/08 1:55 PM Page 860 Aptara Inc. stated intervention goals. 1973). like those described for Wertz & Katz. Robinson ized treatment is effective by asking what works with whom (1990) reported that the efficacy of computerized treatment under what conditions. 1984) described the development of Treatment efficacy considers whether outcomes are clinician-independent. cannot reproduce every process. whereas others have surveyed trends lesion. detect errors Prescott. listening can practice able. and so on reported in the research literature (Cicerone et al. e. whereas right hemiparesis can pre. patients who are their potential. Katz. lar computerized interventions (see. e. treatment activities must be effec- ical impairments. not available to support the use of computers for most lan- puterized aphasia treatment did not provide explicit models guage and cognitive problems.. Other authors (see. or even sitting comfortably in front of a value. thus limiting the clinician. 1997. writing. who they see as supportive and sympathetic—feelings that A range of support for the clinical application of comput- patients do not get from working with a computer. & plementary role. 1983.. 1948). modality.. sensory and phys. 860 Section IV ■ Traditional Approaches to Language Intervention CANDIDACY FOR THERAPY inappropriate experimental designs. He con- for aphasia as well as other cognitive disorders had not been cluded that computers are prematurely promoted in clinical demonstrated. EFFICACY OF APHASIA TREATMENT 1977. vari- reading. It is equally important that programmers have more computer for an extended period of time (Petheram. Prescott. ment resulting from treatment applied in a rigidly con. tiveness. a Most patients with aphasia can benefit from the thoughtful number of publications have described the effect of particu- application of appropriate treatment software used in a sup. with aphasia in general will apply. patients suffering right hemisphere damage (Myers. Perhaps most critically. also focus on “appealing” features of computers. their use should be conservative and practical. 1987. grams would be damaging to the overall quality of treatment ment drills. conflicting opinions of the efficacy of computers (see. providing little real value or generalization.g. Cognitive factors. however. ician-provided treatment. Mills (1988) accurately sug- on the computer display. Katz & Wertz. and a few SOFTWARE (see. If computerized treatment whereas the meta-communication needs of mildly impaired is to continue to develop and improve. arguing that research evidence was simply are compared. Ellis. Loverso. (Eisenson. 1988).g. Dean (1987) wrote that existing may not have sufficient initiative or discipline to maintain a computer treatment programs “are not firmly grounded in a treatment program without the continual watchful eye of theoretical rationale for remediation” (p. as Darley (1972) suggested. issued a trolled design when treatment and no-treatment conditions strong statement. most computer advocates or bilateral brain damage (Goldstein. e. other aspects of treatment do. educational level.. These patients may benefit from more direct. 1999) According to Loverso (1987). but the real issue benefit most from computerized aphasia treatment. or simply changes in visual likelihood that software is efficacious is to develop and test acuity can interfere with the patient’s ability to view material their own treatment programs..g. 1992. 1986) as well as Loverso. age. and Riley (1988). and nuance that occur during treatment. 2000. treatment software consisted of drills with no explicitly tle or no value from working independently on a computer. The research studies reviewed suffered from work and that their routine clinical use may be causing . such as cost- should be considered. gested that clinicians with only limited programming skills vent a patient from easily using the computer mouse. unable to monitor their own performance (e. tive before they can be efficient. 1992). One way clinicians can increase the Hemianopsia. insufficient statistical analyses. To Katz (1984. Patients with problems involving Software. 1984) advocated the computer rather than the clinician as the primary treatment medium. ician-provided treatment. than a superficial understanding of treatment principles if Many patients look forward to working with their clinicians.g. Since Robinson’s critique. Early literature reviews resulted in 1996). 2004).. Many factors influence which patients effectiveness and operational efficiency. so computer- and maintain skills and compensatory strategies learned ized treatment in this sense will never be as efficacious as clin- from the clinician by using various computer programs. 1990). 1996. such as etiology and site of & Selinger. independence. it should undergo the patients may not be served by complex. Skilbeck. most contemporary after feedback or modify subsequent responses) will gain lit. Lucas. but the that demands attention from clinicians is treatment effec- most critical factors are severity. researchers obscured the basic issue of whether computer- ated. word form. Robey & Shultz. When the patient recognized the ranging from simple Phase I and II studies. 1982) to large. The goal of the program is to allow the patient to evaluate Colby and colleagues made extensive use of computers and and practice several word-finding strategies. [Most patients with dysnomia Nagy. and the word was pro- and comparisons of pre.and post-treatment testing (Katz & duced via synthesized speech. 1998. and “. Therapeutics and Technology Assessment Subcommittee. and speculating where we are and where we may need puter printed a series of questions designed to help the indi- to go to demonstrate the influence of computer-provided vidual with dysnomia identify the forgotten word—for treatment on improvement in aphasia. communication in autistic and other “non-speaking” chil- Wertz and Katz (2004) evaluate examples of reports con.. 1983. When the subject expe- ing a level-of-evidence scale to rate the evidence provided by rienced word-finding problems (Brown & Cullinan.any other studies. 1962) scores. single-subject research dysnomia identify and select self-cueing and compensatory strategies were used. usually can recognize the correct word and say it after a domly assigned single-subject studies (Loverso et al. 2004). Colby & Smith. 1998). As more powerful portable computers are used tory “pointing” commands in a simple drill to a patient with as compensatory devices.. A decade and half later. Later. computer carried by a subject with dysnomia on a sling and ples within the context of the five-phase treatment outcomes shoulder-strap combination.and post. Chapter 32 ■ Computer Applications in Aphasia Treatment 861 patients more harm than good. 1985. Even so. 1981) and Token Test during actual communicative situations..g. forgotten word. cerning the computerized treatment for aphasia outcomes in 1973). Christinaz. and the computer.. ultimately speech synthesizers in attempts to increase verbalization and changing the process of word-finding for the patient.g.. Graham. e. words that go with the forgotten word?” The subject’s tific foundation of aphasiology. Improvement was noted on pre. The frequency and success of this varied. 1984. puter may be viewed as strictly an AAC device. she pressed a button. Benson. Christinaz (personal communication) reported that the cueing algo- rithm subsequently generalized to non-computer settings. Efficacy of computerized aphasia treatment is being tional and communicatively stressful. 1975)..g. Until the same series of questions previously displayed by the recently. Although their com- addressed one study at a time. 1982. On a small liquid crystal display (LCD) screen. If the patient does not know the name (or cannot type it). word meaning. in actual communicative situations. A picture is presented toward adapting auditory comprehension activities to the in the left upper quarter of the computer screen. Researchers apply technology to dysnomia in different ways. the com- 1994). Colby & Kraemer. and the research literature by applying precise definitions of the Karpf (1981) built and programmed a small. Colby. various cues can be selected (e. No substitute exists for carefully controlled. Intervention was limited to repetitions of the functional communication behaviors may occur if these or auditory stimulus. but the implication of sion problems. example. Multicue. Parkison..] The and Phase III clinical trials incorporating randomly assigned authors reported that the subject was cued successfully by treatment and no-treatment groups (Katz & Wertz. 1975. dren (see. randomized “. The .. apply. and three-part audi.. the portable computer in real-life situations that were func- 1997).g. significant.any other letters?”. beginning with the of computerized aphasia treatment (Wertz & Katz. ran. observation was not reported.. 1981).. that is designed to help patients with no withdrawal or multiple-baseline.qxd 1/21/08 1:55 PM Page 861 Aptara Inc.GRBQ344-3513G-C32[852-876]. 1992. Auditory Comprehension Patients reported after several weeks of using the computer Few studies have investigated the effects of computerized that they no longer required it. portable micro- treatment outcome research terminology. The influence of other Van de Sandt-Koenderman (1994) described a computer factors (e. (De Renzi & Vignolo. 1992) visual or auditory model (see.the last letter?”. “. and transient nature of auditory comprehen. the selected examples (American Academy of Neurology she pushed keys in response to prompts from the computer. Mills. and sen- Verbal Output tence completion) to help the patient retrieve the word. complex. instead asking themselves treatment drills on auditory comprehension problems. because program. the documentation of which has become the scien. e. similar devices modeled self-cueing strategies for patients treatment testing and on PICA (Porch. “Do you remember the first letter of the word?”. the study is a good first step strategies for word-finding problems. most “probable” words. Mills (1982) first used computer-controlled Christinaz’s statement is certainly relevant and potentially digitized speech to provide one-. thus allowing use of the device research model (Robey. placing the exam. agreement on treatment approaches was limited by the need of external prompts. patient’s goal is to type the appropriate name. and a list of possible words was produced and designs and greater numbers of subjects to assess the efficacy displayed across the computer screen. acquisition and generalization of chronic aphasia. high-quality digitized speech was costly and difficult computer. Research reported over the answers were applied according to an algorithm outlined in last 15 years has incorporated increasingly sophisticated the program. Christinaz reasoned that the subjects had “inter- to include in the computer systems found in most clinics. two-. A-B-A designs. placebo effect) should not be discounted. nalized the algorithm” and now cued themselves without the Also. which was run 29 times over a 10-week researchers recognize the necessity of further testing their period. Adrian. 1985) lated untreated homophones and spelling of irregular words demonstrated various functions that computers could pro.GRBQ344-3513G-C32[852-876]. following year. The reported. treatment changes on the treatment items that ranged from ance” (similar to CAT).001) and untreated ( p  0. Katz and Nagy (1985) described bilitation software and computer games that used movement. arranged tasks and measurement of performance on baseline The goal of the program was to help increase and stabilize and generalization stimulus sets. totaling 232 different tasks. Katz and Wertz (1997) conducted a longitudinal group sia. The computer program. a self-modifying drill and practice computerized reading shape.02). and/or color to focus on reaction time. 1984. and the performance of untrained words doubled this particular aspect of the subject’s reading problem. semantic/phonologic cueing to facilitate naming in a Reading was slow and labored. cueing”) for naming disorders under two conditions.8%). based mance of the practiced words improved 17% (from 53% to on an information processing model. Improvement also was demon- strated on recognition of isolated homophones that were treated ( p  0. attention span. activities and computer stimulation on language test scores Katz and Nagy (1982) described a program designed to test for adults with chronic aphasia.5% to 65. Treatment software automatically adjusted task cian and used the advantages of a computer. conditions: (a) 78 hours of Computer Reading Treatment. vide when treating reading problems in patients with apha. ple choices. & Schnider (2003) reported that “computerized puter program designed to improve comprehension of treatment of anomia” resulted in item-specific improvement homophones (similar-sounding words) for a 24-year-old for four subjects with chronic aphasia but only three of seven subject who suffered traumatic head injury and underwent subjects with acute aphasia. Fink and colleagues (2002) compared outcomes of gram also generated. The Computer Reading attempted items on some computer tasks.to post- independence” (similar to COT) and “full clinician guid. Gonzalez. presenting particular administration of the 12-day treatment program. Fifty-five subjects with reading and provide reading stimulation for patients with chronic aphasia who were no longer receiving speech- aphasia.03) Reading Comprehension and untreated homophones ( p  0. The ing eight levels of difficulty. Eight months after described the Computer-Assisted Anomia Rehabilitation the accident. and found that training-specific 16% to 54%. changes in pre. Software used in the Computer on pre. or (c) No Treatment. Although several subjects demonstrated improved accuracy. each contain- and post-treatment test performance were minimal. she was able to understand speaker with aphasia. match-to-sample format with two to five multi- to accomplish a task that is difficult to undertake for a clini. (b) 78 hours of Computer Stimulation (“non-language” decreased response latency. The (from 32. The program difficulty in response to subject performance by incorporat- presented 65 words that occur frequently in text and varied ing traditional treatment procedures. . through a printer. The program was designed a standard.qxd 1/21/08 1:55 PM Page 862 Aptara Inc. They reported that 30 days after printed words by sounding them out. Five subjects with aphasia ran the computer pro. but no changes were observed plex branching algorithms.05) and on defining isolated treated ( p  0. All treatment program. 1983. in conjunction with com- the subject’s sight vocabulary. phonologic. Laganaro. Katz and Nagy (1983) reported a drill and Treatment tasks required visual-matching and reading com- practice computer program for improving word recognition prehension skills. objective of the study was to improve functional reading. and increased number of activities). and used in patients with chronic aphasia. displayed only text (no pictures). subject demonstrated steady improvement on the 136-item tion of the strategies provided during treatment.002) homo- experimental designs. Naming continues to be the most frequent aspect of verbal and a program was developed to teach subjects to read single output studied by researchers developing aphasia treatment words without intensive clinician involvement. although interpretation of the results must be tempered study to investigate the effects of computerized language because of small sample sizes and limited research designs. was designed to focus on 70%). Later. The subject improved in recognition and comprehen- software using additional subjects and more sophisticated sion of treated ( p  0. showed no improvement. Treatment software consisted of 29 activities. and symptoms as well as surface dyslexia and surface dysgraphia. Scott and Byng (1989) tested the effectiveness of a com- Di Pietro. problems with homophones. language therapy were randomly assigned to one of three grams two to four times per week for 8 to 12 weeks. homework (writing the same computerized treatment (“hierarchical phonologic activities) that corresponded to the subject’s performance. learning was demonstrated under both conditions. The pro- software. the subject continued to demonstrate aphasic Program that used semantic. & Buiza (2003) subsequent left temporal lobe surgery. Recognition of iso- Early work by Katz and Nagy (1982. perfor. 862 Section IV ■ Traditional Approaches to Language Intervention effectiveness of Multicue in a controlled study has not been program for severely impaired adults with aphasia.and post-treatment measures for the five subjects Stimulation condition was a combination of cognitive reha- with chronic aphasia. suggesting the patient’s internaliza. such as hierarchically the rate of exposure as a function of accuracy of response. “partial Four of the five subjects demonstrated pre. written. phones used in sentences. uli. from a clinician. and another picture was dis- target word and the subject typed a response on the computer played. Chapter 32 ■ Computer Applications in Aphasia Treatment 863 memory. Subjects in the two less of whether that letter was in the correct position. for the No Treatment group. The treatment program required subjects tilevel intervention. Subjects from all three generalization set of single words to dictation. or WAB. and (3) when the correct letter was typed.GRBQ344-3513G-C32[852-876]. Patients main- were found between scores on the PICA subtests as gener. At the end of the computer session. In a comparison of writing and typing abilities of screen. If the name was typed cor- aphasia learn to type words to dictation. A decrease ( p conditions were tested using the PICA and Western Aphasia  0.05) in the number of misspelled words and in the total Battery. common computer to evaluate handwriting and printing. 3 months. Cues continued until assess differences between PICA graphic scores on subtests either the patient typed the word correctly or the program A through E using standardized PICA graphics responses displayed the entire word. No differences ity to type the target words without cues. These results suggest that the graphic language generalization to writing was not measured. of the stimuli programmed in the computer. within six treatment sessions. The results suggest that (1) gram. The computer reading treat. feedback was provided. Writing activities. Four of the five subjects maintained group. The clinician said the rectly. although computer. and a drawing representing the stimulus was displayed computerized reading treatment can be administered with on the computer screen. and (4) the computerized read. Cues included displaying the number of letters in the subjects with aphasia. If an error was made. Katz and Nagy (1984) used complex branching steps to ment group displayed significantly more improvement on evaluate responses and provide patients with specific feed- the PICA Overall and Verbal modality percentiles and on back in a computerized typing/handwriting confrontation/ the WAB Aphasia Quotient and Repetition subtest com. regard- guage or other communication abilities. Pre- per week for 26 weeks. & Katz (1987) word and displaying the first and subsequent letters in the examined seven subjects with left hemisphere damage to word. at baseline.) Intervention Five of the nine subjects achieved criterion for success consisted of three levels of feedback: (1) the number of let. text printed on the screen. (2) whether the letter typed was in nine subjects improved an average of 40% on the computer . one or all at a time. response to the number of errors made for each of 10 stim- tion provided by a computer. (2) improvement on the on the keyboard. and other skills that did not overtly require lan. Clinician interaction during the two and post-treatment tests required the subjects to write a computer conditions was minimal.and post-writing tests revealed to the computer. (3) improvement resulted hierarchy of six cues were selected by the program in from the language content of the software and not stimula. Feedback consisted of auditory sounds and computerized reading treatment tasks generalized to non. and Tuving (1986) reported the ability The computerized writing treatment programs described in of four memory-impaired subjects without aphasia to type the literature substitute typing for writing during the inter. A seven-point multi-dimensional scoring system was ing treatment we provided to patients with chronic aphasia used to describe performance and track the effectiveness of was efficacious. hierarchically arranged cues keyboard. Selinger. The computer conditions worked on the computer for 3 hours five subjects completed the program in 7 to 30 sessions. All patients improved in the abil- and PICA responses typed on a computer. the word. abilities of brain-damaged adults are equally represented by Katz and colleagues (1989) developed and tested a com- the two output systems. tained their gains after a 6-week period of no treatment and ated with a pencil and paper and PICA responses typed on a demonstrated generalization to another typing task. are less easily improved spelling of the target words for seven of the eight adapted. Glisky. A stimulus was randomly selected by the pro- pared with the other two groups. Additional feedback included repetition of the successful and most recently failed cues. and the performance of all ters in the target word. pencil and paper copying assignments Writing: Typing and Spelling Words automatically generated via the computer printer were com- Many reading comprehension activities are easily transferred pleted by the subject. (The clinician had to know in advance the order were presented. Single and multiple cues from a computer language performance. the various cues. Seron and colleagues (1980) described a to type the names of 10 animals in response to pictures dis- minicomputer/clinician combination that helped patients with played on the computer monitor.qxd 1/21/08 1:55 PM Page 863 Aptara Inc. number of errors made on the post-treatment test suggested Significant improvement over the 26 weeks occurred on five that the computer program had improved spelling of words language measures for the Computer Reading Treatment written by hand. Pre. Prescott. and on none of the language measures administered 6 weeks later. puter program designed to improve written confrontation Several investigators have incorporated complex branching naming of animals for nine subjects with minimal assistance algorithms in computerized writing programs to provide mul. however. Schlacter. The most obvious problem is the inability of the subjects with aphasia ( p  0. spelling task. and response requirements were modified. and 6 months. as needed.01). The subject responded by typing minimal assistance from a clinician. words in response to definitions displayed on the computer vention. on one language measure for the Computer improved performance on a second post-treatment test Stimulation group. & Cox. The message can be read via the on non-computerized written naming tasks.. Shelton. technology adapted to the communicative needs of patients Weinrich.05). insufficient training.. Weinrich.001). e.g. 1976).g. The lack of change in these latter lan. computer-based Aftonomos and colleagues (1997) formed the basis of multi- alternate communication system called the Computer. These reports stimulated Aftonomos and colleagues (1997) used Lingraphica with 20 efforts to teach visually based. result of the treatment. 2000). called icons. Powerbook computer. each of which represents a general category. Weinrich and colleagues Writing modality score improved by 4. Weinrich and colleagues contin- to faciliate repetitive practice” and to “encourage the inde. including a specially designed word processing pro. improvement did not—and was to support the efficacy of C-VIC was collected in a series of not expected to—generalize to written word fluency for an single-case studies (Steele et al. Weinrich. 1993). a surface Broca’s aphasia in the production of locative prepositional dysgraphic and a conduction aphasic. Thornburg (1995). including verbal. pictures (icons).GRBQ344-3513G-C32[852-876]. subject and group research using standardized measure- ther. “string” of pictures represents the message. heard through digitized speech. or metaphor. and Carlson ments is needed to test the effectiveness of new computer (1987).1 percentile points (1989) reported that concrete icons were learned and gener- ( p  0. erably. Wertz. orally. and Steele. After selecting the desired item. Subjects use the mouse the application of AAC to aphasia. read via the sequence of icons and words printed below the chimps and apes) the use of nonverbal. Weber. but that neither type of icon and Reading scores. In subsequent reports (see. The intervention phrases and Subject-Verb-Object (S-V-O) sentences on C- focused on written naming from the keyboard. McCall. unchanged. Wertz. Weinrich et al. each of which Koenderman (2004) reviewed the state of the art in AAC represents a general category. Enderby. modal treatment for aphasia administered by speech- Aided Visual Communication. Berry. pointing board that runs on a Macintosh computer and uses Other researchers have taken different approaches to a picture-card design. and Kremin (1993) developed soft.. which can be tion described success teaching non-human primates (e. and Petheram (2001) used the computer as “a tool Weinrich. improvement was measured represents the message. approach to improve the communication and natural lan- despite his chronic dysgraphia. was able to spell target words guage of adults with aphasia. e.0001). inadequate vocabulary. called Lingraphica. Steele and colleagues (1987) noted that. The patient was able to move puterized communication system that combines spoken from non-functional tasks to more functional activities as a words. system for adults language pathologists using Lingraphica at Lingraphi Care with chronic global aphasia.g. regime. bolic communication systems. Improvement did not extend to PICA Overall alized faster than abstract icons. further single- Zurif. McCall. Developing the concept fur. After selecting the desired item. tion. The PICA is given to the selection of icons. language-like sym. incorporates animation and digitized speech on a Macintosh gram to help with carryover and use of a dictionary to sup. Much attention word fluency for animal names ( p  0. this Premack (1970). Steele. The empirical evidence teach subjects the 10 names. Computer practice was part of a more comprehensive A commercial version of C-VIC. ued to develop and test C-VIC as a potential therapeutic pendent use” of the treatment strategy for an adult who. and Carlson (1989) devel. or C-VIC. and text processing. communication words. sequence or can be heard through digitized speech. systems to people with severe aphasia (see. Weinrich and colleagues (1989). such as written sequence of icons. Gardner. Patients use a mouse device to select one of several icons. Lingraphica is an integrated. 1989. Thomas. com- port the spelling strategy. printed words.. 1987. however.qxd 1/21/08 1:55 PM Page 864 Aptara Inc. The C-VIC is an interactive clinics. with aphasia. 864 Section IV ■ Traditional Approaches to Language Intervention task ( p  0.. Both subjects VIC and reported that their verbal ability improved consid- maintained improvements 1 year following therapy. Clearly. & Baker. and lim- gory. The selected icon then “opens up” to reveal pictures of the items within Augmentative Communication Device the selected category. Kleczewska. or in confrontation naming of the treatment stimuli and written some cases. The selected icon then “opens applications for aphasia and suggested that lack of motiva- up” to reveal pictures of the items within the selected cate. Mortley. picture is added to a sequence of other selected pictures. Van de Sandt- to select one of several pictures. although guage activities for these 10 subjects with chronic aphasia globally impaired subjects with aphasia using C-VIC contrasts with their improved performance on treated improve on expressive and receptive tasks. and others involved in animal communica. Because the goal of the program was to generalized well to new situations. through more traditional modes of communication remains Deloche. this “string” of pictures cles to the functional use of assistive technology in the . alternative communication subjects and reported improvement in multiple modalities. unrelated category. for most subjects. In addition. words printed below the sequence. the picture is added to itations in cognition and language abilities are major obsta- a sequence of other selected pictures. Dordain. and ware to treat oral and written modality differences in con. trained two subjects with frontation naming for two subjects with aphasia. Kleczewska. The treatment approach refered to in oped and tested a graphically oriented. the Published reports from Gardner and Gardner (1969). multi- function to patients (e. visual. Topics of tasks are familiar and ders in patients of a small. series of experiments (Crerar & Ellis. She points to the relatively frequent Telemedicine appearance of small. and traditional face-to- for aphasia therapy so that a computer program would face interaction for providing appraisal and treatment of determine the type. Subjects in all based on evaluation of the patient’s responses. responsiveness.GRBQ344-3513G-C32[852-876]. no explicit provision with chronic aphasia after a relatively short duration of involves coverage for speech-language pathology services treatment. and spatial relations lines exist for the use of telecommunications to deliver were manipulated to improve sentence comprehension. respectively) in which patients. Barr & Geigenbaum. Goldberg. software by integrating artificial intelligence (AI) program. 1996) demonstrated improvement in subjects health services (c. (Porch.” a computer system based on and language disorders. showed gains in language after vide clinical services has numerous potential advantages. provide assessment and treatment over the telephone. Brodin and Simulations Magnusson (1994) reported numerous studies conducted Roth (1992) as well as Gadler and Zechner (1992) have in Sweden demonstrating the feasibility of treatment described computer-simulated worlds (NeueWEGE and provided over telephone lines for patients with aphasia in AUSWEGE. Duffy... Technology has been used in the past to provide assess- Artificial Intelligence ment and treatment for patients with communication impair- Reports by Guyard and colleagues (1990) represent the ments who live in remote locations. at this time. Researchers (see. They services. Disorders are good signs that telecommunications tech- puterized intervention that incorporated speech recogni. independent home use of the software. A services in the field of speech-language pathology. Although Medicare does provide coverage for some tele- & Dean. 1987) incorporated small. Crerar and Ellis (1995) described acceptable to patients with a variety of acquired speech the “Microworld Project. however. This technology permits improved access to health struct spoken sentences “piecemeal” for later use.g. Werven. 1995. their clinicians. The use of telecommunications technology to pro- using one or both programs. and cacy has been reported. tion software with software that allowed patients to con. Crerar. Dronkers. Tele-Communicology beginnings of new stage in the development of treatment (Vaughn. ICAI has met with limited success in aphasia nificant improvement as indexed by scores on the PICA rehabilitation. microprocessor-driven auditory. quality. To date. beneficial. appropriateness of the fields of view. no controlled study measuring effi. sponsored by the National Center for Communication Linebarger. 1980. portable devices with ready-made messages tailored to specific communicative situations and American Speech-Language-Hearing Association telesem- calls for more research to refine these devices and improve inars and videoconferences as well as the Telerounds series their adaptability to the needs of individual patients. making decisions. validity of the diagnostic findings using such technology (Peters & Peters. and Deal (1987) com- and CAI as “Intelligent CAI” (ICAI). sequence. To my disciplinary medical practices. telemedicine evaluations can be reliable. such as image that this improvement may have resulted from training dur. cost. 1998). Ellis. In their view. tions. The results suggest that aphasia therapy (Katz. both in rural settings and within sound neuropsychological and psycholinguistic theory and large. Knight..” and taking chances without any real physical of telemedicine evaluations of speech and language disor- or interpersonal risks.. and Aronson (1997) summarized results “traveling. 1990). ICAI can pared the effectiveness of closed-circuit television. e.qxd 1/21/08 1:55 PM Page 865 Aptara Inc. primarily because of two factors: the hetero. While valued three treatment conditions demonstrated clinically sig- in education. 1981). No significant differences among the geneity of the aphasic population. Vaughn et al. explore a microworld. object. and reliability and cation settings. . and Kohn (2001) described a com. com- expand the scope. and rate of stimuli presented patients with aphasia in remote settings. television and video laserdisc transmitted over telephone lines could be employed to provide services for patients who live where services do not exist. planning a vacation). guided by rural settings. Chapter 32 ■ Computer Applications in Aphasia Treatment 865 aphasic population. They concluded that knowledge. and the complexity of three conditions were observed. and writing devices ming and computer-assisted instruction (CAI) for the reha. nology is coming of age in our own discipline (Duffy. 1982) described this union between AI Wertz. training ing therapy followed by practice under “normal” communi. placed in the homes of patients and remote computers to bilitation of patients with aphasia. and flexibility of software puter-controlled video laserdisc. action. especially for remote and underserved popula- reported that their five patients with agrammatism patients. multi-disciplinary medical settings.f. user preferences. Schwartz. and they concluded but many factors must be carefully evaluated.g. requirements. 1997). 1998). no designed to treat impairments in sentence processing. Shenaut. rural hospital and large. explicit technical or clinical national standards or guide- Concepts such as agent. 1979. & Prescott. who ally suited to administer tests to patients with aphasia. provided treatment approach—the “verb as core”—from its Dirkx.5 months of treatment for each of the two subjects with lar performance on the task under both conditions.05) was demonstrated on the PICA following colleagues (1985).” and “why” for the object. with different “wh-” question words to provide cues to tially equivalent under all three conditions. Based on the diagnoses assigned to subjects. and Fuller (1987) initially developed ized versions of the Raven matrices with a traditional. Subjects responded verbally and graphically and were sentation: two-dimensional color computer simulation of scheduled for treatment three to five times per week.. Some researchers think that. Level II elicited actor-action-object puzzle. 30 stimulus verbs were presented for model. Davidoff. the puzzle versus the manipulation of the actual wooden During each session. and tested a treatment protocol for patients with aphasia in cian-controlled. who have documented a series of data-based reports describing can then work at their own pace and without embarrassment the development and testing of a model-driven. and feedback in the clinician–computer condition normally controlled video laserdisc. sions of the Raven Colored Progressive Matrices (Raven. Prescott. task comple. The of performance for the subjects with aphasia.. paper booklet administration of the test. Results suggested no the task under both conditions but took longer to reach cri- significant differences among the three conditions in the teria under the computer–clinician condition. The program used high-resolution graphics and a its encoding and refinement as a computer/clinician-assisted touch screen input device to administer and analyze test per. from a clinician. which verbs were presented as starting points and paired The performances of 16 subjects with aphasia were essen. subjects with aphasia demonstrated simi. and relative autonomy. 1992). indicating that about the influence of the medium and the relative effective. program (Loverso et al. patients with aphasia could benefit from treatment provided ness of the treatment. the spoken response was in error. Level I presented stimulus without brain damage and adults with aphasia on another verbs and the question words “who” or “what” to elicit an nonverbal problem-solving task. reliability. The hierar- did not present greater visual or cognitive demands on the chy was divided into two major levels. simulate accepted testing and treatment protocols on the An excellent example of the process of demonstrating computer. Loverso and colleagues (1985) compared the the puzzle in the computer condition than when manipulat. “The Towers of Hanoi” actor-action sentence. The authors compared the two computer. Collins. however. The subject improved on leagues (1987) was described earlier. provided by a clinician versus when it was provided by a although the computer medium did not affect the accuracy computer and speech synthesizer assisted by a clinician. The results suggest that. As in the study by Odell and ment ( p  0. subject with aphasia responded in the clinician-only condi- tion took longer and was less efficient under the computer tion by speaking and writing and in the clinician–computer condition. computer. condition by speaking and typing.g. each consisting of an subjects. No significant differences in improvement among by two different mediums should improve understanding the three treatment groups were observed. years of published research by Loverso and colleagues. initial module and two submodules that provided addi- Wolfe. clini. leading the elicit sentences in an actor-action-object framework. additionally. Enderby. 1987). 1985. Many researchers are attempting to in any of the three conditions. 1988. because of their efficacy in a computerized treatment program involves 14 speed.” “where. Loverso. and traditional face-to-face inter. formance quickly and accurately. origins as a “clinician-delivered therapy” (Loverso. 1988) to 1975). & Selinger. The clinician inter- action for providing appraisal and treatment to patients with vened only if the patient’s typed response was correct but aphasia in remote settings as measured by Wertz and col. effects of the same treatment approach when treatment was ing the actual wooden model. tional cueing for subjects unable to achieve 60% or better object and computer simulation performances of adults accuracy on the initial module. and Kelso (1985) developed two computerized ver. with minimal supervision Loverso and colleagues (1979. required more time to complete Later. and Selinger (1984). Subjects without brain damage performed equally generation of sentences. Selinger. These aphasia.. subjects in all subject’s improvement. Odell. The performances words “who” or “what” for the actor and the question of 19 subjects with aphasia and 19 subjects without brain words “how. 1988) and Selinger. Prescott. 866 Section IV ■ Traditional Approaches to Language Intervention Comparison of Traditional and Computer Mediums three treatment conditions demonstrated clinically signifi- cant change (between 12 and 17 percentile points on the Comparing the effect of similar treatment activities provided PICA). and Katz (1987) compared the real. damage were compared using two different methods of pre.GRBQ344-3513G-C32[852-876]. Statistically significant improve- well under both conditions. Loverso. 3. computers are ide. both on the treatment task and on .” “when. was provided only by the computer. clinician- or fear of humiliation (e.qxd 1/21/08 1:55 PM Page 866 Aptara Inc. authors to conclude that the computer testing conditions Thirty verbs were used at each of six modules. same subjects. Loverso. Stimulus presentation The effectiveness of closed-circuit television. originally administered to subjects with aphasia by sentences by presenting stimulus verbs and the question Prescott. Text (name or function) also can be displayed. whether the voice recognition software is sufficiently accu- eight showed significant improvement ( p  0.qxd 1/21/08 1:55 PM Page 867 Aptara Inc. but clinicians may wish to determine for themselves than under the clinician-only condition. The CD-ROM version has more than 500 target was as effective as a clinician alone when treating various words with pictures. if that response is incorrect. Also. A natural. Loverso and colleagues (1988) lems by selecting among possible cues. It also includes a module allowing “practical drawn with color and charm.g. month post-treatment or longer. Ideally. Items are paragraphs.. thus simplifying software development. rooms within a ple with aphasia—even mild. My Town. or function (pre-elected by the clinician). reading. They suggested that. and . and both the computer model and the patient’s EXAMPLES OF COMMERCIALLY response are played back for comparison.g. The task requirements for patients are not more sessions. in My House. lamp. For example. and nonlinguistic (visual) cues following incorrect responses allowing progression from letters to words to sentences to to help the patient complete the item successfully. however. the program indicates accuracy visually and/or audi.. residual aphasia—report prob- house can be viewed. All sub- (e.. The patient is prompted to name a sessions ( p  0. if available) to designate an expensive systems. less uses the mouse (or touch screen. three pro- Reading Comprehension grams under the title Language Activities of Daily Living (Laureate Learning Systems)—My House. on the Verbal modality recognition software designed for some versions of Windows measure. activities. item. Reading requires minimal responses sounding. as gle-page short stories written to be of interest to adults. and subjects with nonfluent aphasia required 33% presented. and clinicians can add their own AVAILABLE SOFTWARE words (in the “Professional version”). Subjects with fluent aphasia required 24% more ses- prompts the patient to repeat the word after it is verbally sions. Verbal Output trations of the PICA ( p  0. or five subjects having fluent and five subjects having conflu- multiple-choice list containing the word). some recent programs show promise. Windows 95/98) may not work for others (e. first sound) or visual (e. first letter. the bedroom contains a bed. clothes. aphasia Confrontation Naming (Parrot) helps to teach the patient a treatment administered by computers is practical and has strategy to stimulate or compensate for word-finding prob- the capacity for success.05) on the rate for the needs of each patient.01).e. tion. and so on. The software pro- vides more than 400 words. such as newspapers. ing the word using digitized speech. 1992). bureau. Of the 10 subjects. jects maintained gains after a maintenance phase of 1 Windows NT. My School—are good examples of software be particularly appropriate when considering the nature of that can be used to provide stimulation treatment for adults patients.. patients ent aphasia for the purpose of examining whether treat- should develop self-cueing strategies using the most success- ment provided under the computer–clinician condition ful cue. be aware that speech PICA Overall percentile measure.g.. Auditory Comprehension Although developed for primarily for children. and typing activities under the clin- problems than to the complex and less completely under- ician–computer condition had a positive influence on the stood language formulation problems of adults with aphasia. product labels. patient’s language performance. priate to practice alone. For example. description. The 10 subjects required 28% more recognition technology. Visual although still in the early stages of development. Similar results were Aphasia Tutor 0: Sights ‘n Sounds (Bungalow) is a word reported following a replication of the study using 20 sub- repetition task that displays a word or picture while present- jects (Loverso et al. digitized voice identifies the target item by name by the patient. selected by the clinician. interventions.05) to reach criteria under the computer– picture displayed by the computer. Most peo- with aphasia. along with many items typically found lems understanding long or complex text. reading” of items. Verbal Picture Naming Plus (Parrot) types and severities of aphasia using their cueing-verb- recognizes spoken words by using sophisticated speech treatment technique.GRBQ344-3513G-C32[852-876]. Cues may be audible replicated the study by Loverso and colleagues (1985) with (i. and on the Graphic modality measure. the authors concluded that Technology has been more readily adapted to motor speech their listening. Window Vista). Chapter 32 ■ Computer Applications in Aphasia Treatment 867 “clinically meaningful” changes during successive adminis. The computer then eval- clinician condition than under the clinician-only condi- uates the verbal response and. it is socially appro- table. and computers. After the patient These programs can run on minimally configured. The patient’s repetition is recorded. and to Treatment of reading problems using computers appears to a lesser extent. under the computer–clinician conditions unusual. The program provides repetitions AphasiaTutor (Bungalow) is a series of programs that pro- when requested by the patient and options for repetitions vide reading exercises to improve reading comprehension. end a task that we typically engage in alone. Because reading is in the rooms. Reading Comprehension Adults (Parrot) presents sin- torally. closet. print size. The computer can become a very powerful clinical tool by visuospatial and memory skills. thus providing more independence for the user. the clin- such as Word (Microsoft). Another example of an AAC device is the DynaVox 2c.. 1990). offers many features that could ician records a series of instructions or steps into the device. a treatment gram allows interactive practice with traffic sign recogni. writing tasks usually are Raybeck. such as memory or visual spatial skills. exercises that can be arranged and printed to create person. but they can provide tasks that are (Ablelink Technologies) is a portable voice recorder designed to improve other components of written language.500 Lingraphica as a compensatory device was described earlier. The clinician then reviews on screen demographics and outcome measures. Electronic scheduling and reminding devices as well as writing disorders. This pro. ments. It allows tracking of perfor.5-inch disk that contains Soft Tools. Clinicians also may build puter industry. ment of adults with aphasia by combining the use of tive tasks.” which task is completed. providing For example. and Lingraphica technology with standardized clinical treat- type face. VCRs. 1996) are increasingly affordable for integration done alone.. better platforms for treatment software focusing on prob- either visually or auditorally. program (frequently. a goal for the entire com- icons on-screen with the mouse. Alternative and Augmentative Communication Devices Brubaker on Disk: Database of Customized Language and Cognitive Exercises (Parrot) contains more than 1. technology. Infrared capability tive treatment programs that are shared among profes. treatment. and problem solving. many devices are designed to help patients Writing: Typing and Spelling with cognitive impairments cope with complex daily activi- Computers also are an appropriate medium for treating ties. It has built-in infrared environment treatment (Robinson. complex. alized activities or workbooks for patients to complete either as LingraphiCARE America. assist mildly impaired patients. executive skills. response types. Multimedia PCs are now common. can result in an entirely new generation of . but researchers are striving to control capabilities that permit the user to easily transmit files better assess efficacy. 868 Section IV ■ Traditional Approaches to Language Intervention bills. enabling programs that focus on visuomotor. on a different cognitive problem. Traffic their software libraries by subscribing to the Journal of Sign Tutor (Bungalow) may complement functional Cognitive Rehabilitation (Psychological). Captain’s Log includes 33 separate computer and a searchable “concept tagged” vocabulary list. The device uses a color display and text- less clearly documented than that for speech and language to-speech conversion. until the mar check. Conditional Statements (Parrot) presents. designed to help patients with cognitive problems complete such as spelling and grammar.GRBQ344-3513G-C32[852-876]. also permits control of televisions. Like reading. Steele and colleagues recently have redirected their efforts. Using his or her own voice. a hierarchy of conditional state. The patient then plays back the steps. Word processing software. further single-subject and group research using standardized measurements is needed. automatically provides guidance when writing letters or per- forming other common functions. and numeric faster programming and automatically generated “pages” or skills as well as on attention. include in a personalized workbook. Although preliminary the selected exercises and prints what he or she wants to outcome data have been reported (Aftonomos et al. thesauraus. It is unexpected for computers to improve the into cognitive rehabilitation programs. Herrmann. For patients who drive or hope to drive again. The program uses these choices to select exercises ment strategies and a growing patient data base containing from a large data base. includes a 3. mance across several sessions and includes reaction time mea- sures and analyses of error responses. and the “Assistant. Yoder. ances. Wells. a Cognitive Problems lightweight (approximately 6 pounds) system designed for Treatment efficacy for computerized cognitive retraining is children and adults. Additionally. between the DynaVox and a desktop PC. one at a time. difficulty levels. lems of auditory comprehension and verbal output. conceptual. Responses are indicated by pointing and dragging Improved speech recognition. templates. they have begun to establish a during treatment sessions or as homework.qxd 1/21/08 1:55 PM Page 868 Aptara Inc. Many incorporating what we know about aphasia. gram. screens of associated pictures and words. ogy are Captain’s Log (BrainTrain) and PSSCogReHab DynaVox software uses symbol and word prediction capability (Psychological). The clinician network of specialized “Language Care Centers” for treat- uses a mouse to select among different language and cogni. Each monthly issue reading as well as symbolic comprehension goals. 1997). PSSCogReHab (Psychological) includes a set of eight software packages with FUTURE TRENDS treatment activities focused on attention. such as spelling check. and other appli- sionals in neuropsychology and speech-language pathol. Two multi-level computerized cogni. & patients with aphasia. a common and persistent problem in computerized calendars (c. real-life tasks. a “game”) designed for the PC to focus tion and response to written hypothetical driving scenarios. and other programs are designed to help treat specific problems.f. PocketCoach mechanics of writing. Treatment software.GRBQ344-3513G-C32[852-876]. simulation. than real world). tested the patients. become significant tools for treating patients with ment studies cited in this chapter. a machine can behavior modification. In the best tradition of scientific and observed in real-life situations. Three basic models are brain–behavior relationships. represent. KEY POINTS tional. apy for aphasia to assume that. and flexibility are required. it is unreasonable.qxd 1/21/08 1:55 PM Page 869 Aptara Inc. but by improving the software. Fitz-Gibbon. Palm-size PCs will 2. and tutorial. and to a lesser extend. programmers. The real danger any treatment software considered for use by patients comes from a failure to appreciate the scope and depth of with aphasia: goal. fostering independence and a more active the computers. static. Speech recognition software has improved in recent treatment software. An autonomous. 1986. and measured treatment efficacy. clinician-provided therapy. helping gen- and modified the treatment tasks. Treatment efficacy refers to whether outcomes are question of efficacy itself in aphasia rehabilitation (Darley. experience. 1972. type and clinician. reading treatment. and much on the costs of care and not enough on the efficacy of scores stored for later analysis. of labor between computers and clinicians—a combination 6. 11. stimulus characteris- clinical work. which can administer some shape this tool of technology for the development of their aspects of treatment without the familiar presence professions and the benefit of all patients. at this time. for treatment effectiveness. and a misrepresentation of the complexity of ther. A large body of research published in peer-reviewed of computer use in aphasia treatment cannot be answered journals demonstrates the effectiveness of aphasia with a simple “yes” or “no.” More work is needed. and isolated (artificial rather Technology is helping us do that. instructions. trained the patients to use eralization. different speakers as well as speakers with than emphasize what computers can or cannot do better variable phonologic errors (as in aphasic paraphasias than clinicians. clinicians selected and aphasia include providing supplemental treatment. with the clin. mance and other considerations. conventional cians consider changes the environment of patients with (pre-applied. Clinicians should assess the following components of that can do more than either one alone. drill and practice. instead. The role of computers and 5. response requirements. patients with aphasia continues to be studied. still images with dynamic digital video seg- ments in treatment software increases interest and relevance 1. clinical. unchanging rules). is a fantasy dreamed up by people who focus too degree of intervention. Chapter 32 ■ Computer Applications in Aphasia Treatment 869 treatment programs and AAC devices. The most influential element. writing treatment (through ician providing critical intervention as indicated by perfor. 8. What is believed about aphasia and treatment should for many patients. Replacing tradi. designed the treatment plans. Computers. specific problems in individual patients. typing). allowing clinicians to intervene tions in aphasia because of poor ability to understand when skills. 3. should be viewed as supplementary treatment. designed measuring efficacy. role in treatment. tics. Affordable digital still and video cameras be reflected in treatment software and not dimin- increase the ease with which software can be individualized ished by the limitations of computers. Major areas in which computers have the potential to ical but. Contemporary multi-media computers are ideal for cannot be effectively “prescribed” like medicine. 1986) the effectiveness 10. scoring system. is not technolog. Howard. The value of aphasia treatment is measured by the clinicians and programmers will learn more about how and degree to which skills acquired during treatment are why treatment works. like that of all tools. unethical. finite (cannot antic- aphasia to maximize their communicative potential. publishers. our focus should be on an intelligent division and apraxia of speech). however. care. In all computerized aphasia treat. Because treatment 4. treatment—and of computerized aphasia treatment— Treatment software may always be an imperfect reflection of for various populations of people with aphasia. Four basic types of treatment software are stimula- The true value of computers in the rehabilitation of tion. . for each patient’s needs and interests. Rather multiple. Just like the 9. general ing the knowledge and experience of a competent aphasia feedback. Four properties of computers and computer pro- influence the development of AAC devices and computers in gramming that illustrate the limitations inherent in rehabilitation in the same manner that laptop computers did the application of computers to aphasia treatment are just a few years ago. should be based on a treatment model or models. clinicians are. Generalization can be rehabilitative efforts. specific (“corrective”) feedback. providing recreational activities. and educational models perform the functions of a clinician. criteria for termination. discrete (quantity rather than quality). Until we can describe to others precisely how to treat 7. should extend the years but is still inadequate for most clinical applica- abilities of the clinician. robotic therapist. Eisenson (1973) suggested that clini. aphasiologists can work together to aided by the computer. software providing auditory stimulation. like all treatment activities. ipate every possibility). making prognoses. improved as a result of a specific intervention. or researchers are not responsible and performing administrative functions. Journal of Speech and Hearing be worthwhile as treatment activities or supplementary Research. and/or writing by nitive rehabilitation: Recommendations for clinical practice. Basic level workbook for aphasia. (1981). 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GRBQ344-3513G-C32[852-876].qxd 1/21/08 1:55 PM Page 874 Aptara Inc. 874 Section IV ■ Traditional Approaches to Language Intervention APPENDIX 32.1 Clinical Examples Example 1: Auditory Comprehension MODALITY: Listening DESIGN: Stimulation GOALS: To maintain accuracy, self-monitoring, and attention as response time decreases TASK: Using digitized speech, the computer states the name (or function) of an item in a complex scene containing several functionally related items displayed on the monitor. The patient selects the correct item with the mouse. SOFTWARE: Language Activities of Daily Living: My House (Laureate Learning Systems) PROCEDURE: The clinician selects a response time (e.g., 10 seconds) that permits the patient to respond to all items with 100% accuracy. Response time is reduced for subsequent trials until the patient begins to make errors. INTERVENTION: Keep response time at the level when errors first occurred. Reduce the number of items to two, and identify those two items for the patient before beginning (e.g., “The computer is going to ask you to point to only this one or that one.”). When 100% accurate for three consecutive trials, increase number of items to three, four, and so on until all items are presented. SCORING: 1 point per correctly selected item Example 2: Writing/Printing Personal ID Information MODALITY: Writing (typing) DESIGN: Drill and practice GOAL: To improve the ability to write or print personal information for a chronic, severely impaired, predominantly nonverbal patient with aphasia using a typing drill TASK: Type name, address, and telephone number in response to a diminishing set of cues SOFTWARE: Word processor PROCEDURE: The clinician creates a series of word processing documents with diminishing cues (e.g., Document 1 has the intact model for simple copying, Document 2 has every third letter or number missing, Document 3 has every other word missing, and so on.) The diminishing cues can take any form thought useful by the clinician. From either the word processing program or from within a Windows (or Macintosh) folder, the patient selects the document containing the level of cueing needed to successfully type the personal information. The patient can save the file, or the “autosave” option can be invoked, for later review of performance by the clinician. To aid in generalization, the documents are printed, and the patient practices writing (printing) at home directly on the same pages. INTERVENTION: The clinician dictates error items to the patient. If errors persist, the clinician provides models or other cues as needed. SCORING: Number of correctly spelled words, legible words, etc. GRBQ344-3513G-C32[852-876].qxd 1/21/08 1:55 PM Page 875 Aptara Inc. Chapter 32 ■ Computer Applications in Aphasia Treatment 875 APPENDIX 32.2 Sources for Software and Other Relevant Technology AbleLink Technologies Armonk, NY 10504 528 North Tejon Street, Suite 100 800-426-4968 Colorado Springs, CO 80903 www.ibm.com (719) 592-0347 www.ablelinktech.com Interactive Learning Materials 150 Croton Lake Road Avaaz Innovations P.O. Box S 258 Beckley Lane Katonah, NY 10536 P.O. Box 1055 (914) 232-4682 Dublin, OH 43017-6055 614-932-0757 Laureate Learning Systems, Inc. www.avaaz.com 110 East Spring Street Winooski, VT 05404-1898 BrainTrain 800-562-6801 727 Twin Ridge Lane www.llsys.com Richmond, VA 23235 800-822-0538 The Learning Company www.braintrain.com One Athenaeum Street Cambridge, MA 02142 Bungalow Software 617-494-5700 5390 NE Stanchion Court www.learningco.com Hillsboro, OR 97124 800-891-9937 LingraphiCARE www.BungalowSoftware.com 20 Nassau Street, Suite 235 Princeton, NJ 08542 Chart Links 888-274-2742 74 Forbes Avenue www.aphasia.com New Haven, CT 06512 203-469-0707 Madentec Limited www.chartlinks.com 4664 99th Street Edmonton, Alberta Communication Skill Builders/ T6E 5H5, Canada The Psychological Corporation 877-623-3682 555 Academic Court www.madentec.com San Antonio, TX 78204-2498 800-211-8378 Mayer-Johnson Co. 800-232-1223 P.O. Box 1579 Solana Beach, CA 92075-1579 Don Johnston 800-588-4548 1000 North Rand Road, Bldg. 115 www.mayer-johnson.com P.O. Box 639 Wauconda, IL 60084-0639 800-999-4660 Medical Software Products www.donjohnston.com 6415 Oak Hill Drive Granite Bay, CA 95746-8909 Gus Communications 916-797-2363 1006 Lonetree Court www.medsoftware.com Bellingham, WA 98226 360-715-8580 Microsoft www.gusinc.com One Microsoft Way Redmond, WA 98052-6399 IBM 425-882-8080 New Orchard Road www.microsoft.com/ms.htm GRBQ344-3513G-C32[852-876].qxd 1/21/08 1:55 PM Page 876 Aptara Inc. 876 Section IV ■ Traditional Approaches to Language Intervention Parrot Software 317-257-9672 P.O. Box 250755 www.neuroscience.cnter.com West Bloomfield, MI 48325 800-PARROT-1 Sunburst Communications www.parrotsoftware.com/index.html 1550 Executive Drive Elgin, IL 60123-9979 Prentke Romich Company 800-321-7511 1022 Heyl Road www.store.sunburst.com Wooster, OH 44691 800-262-1984 SPSS www.prentrom.com 233 South Wacker Drive Chicago, IL 60606 Pro-Ed 312-651-3000 8700 Shoal Creek www.spss.com Austin, TX 78758-6897 800-897-3202 Therapist Helper Brand Software www.proedinc.com 600 West Cummings Park Suite 3450 Psychological Software Services Woburn, MA 01801 6555 Carrollton Avenue 800-343-5737 Indianapolis, IN 46220 www.helper.com APPENDIX 32.3 Web Sites of Interest Academy of Aphasia http://www.academyofaphasia.org Clinical Aphasiology Conference www.clinicalaphasiology.org Academy of Neurologic Communication Disorders and Sciences (ANCDS) Mayo Clinic: Cardiology and Vascular Medicine www.ancds.org http://www.mayoclinic.org/cardiovascular-rst American Stroke Association (American Heart Association) Mayo Clinic: Rehabilitation After Stroke http://www.strokeassociation.org http://www.mayoclinic.org/stroke/rehabilitation.html American Medical Association (AMA) Insight: Atlas of the National Aphasia Association (NAA) Human Body www.aphasia.org http://www.ama-assn.org/insight/gen_hlth/atlas/atlas.htm National Institutes of Health (NIH) American Speech-Language-Hearing Association (ASHA) www.nih.gov www.asha.org National Institute of Neurologic Diseases and Stroke (NINDS) Brain Injury Associations, Inc. http://www.ninds.nih.gov www.biausa.org National Resource Center for Traumatic Brain Injury CenterNet Homepage (National Center for Neurogenic www.neuro.pmr.vcu.edu Communication Disorders at the University of Arizona) http://cnet.shs.arizona.edu/cnet National Stroke Association www.stroke.org Communication Disorders and Sciences Home Page (resource center by Judith Kuster) Neurology Web Forums at Massachusetts General Hospital http://www.mnsu.edu/comdis/kuster2/welcome.html http://neuro-www.mgh.harvard.edu/forum/ GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 877 Aptara Inc. Section V Therapy for Associated Neuropathologies of Speech- and Language- Related Functions GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 878 Aptara Inc. GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 879 Aptara Inc. Chapter 33 Communication Disorders Associated with Traumatic Brain Injury Mark Ylvisaker, Shirley F. Szekeres, and 11. Create functional cognitive rehabilitation and support plans. Timothy Feeney 12. Implement self-coaching procedures for individuals with social communication problems. 13. Distinguish between antecedent-focused and conse- OBJECTIVES quence-focused behavior management, and offer a rationale for antecedent-focused approaches for indi- viduals with TBI. The reader will be able to: 14. Create functional intervention plans designed to teach positive communication alternatives to negative behavior. 1. Describe epidemiologic trends related to traumatic 15. Offer several rationales for collaborating with everyday brain injury (TBI). people, and describe effective ways to create such col- 2. Describe central themes in the pathophysiology of TBI, laborative relationships. including both primary injuries (e.g., diffuse axonal injury and focal damage related to irregular surfaces on the floor of the skull) and secondary injuries (e.g., asso- ciated with elevated pressure, swelling, bleeding, neuro- In this chapter, we offer a functional and highly context- transmitter surges, and others). sensitive perspective on assessment and intervention for 3. Describe risk factors for TBI and the relation between individuals with chronic cognitive and behavioral impair- preinjury factors and long-term outcome. ments, which underlie the most common and most debili- 4. Describe central tendencies in long-term outcome from tating communication-related disabilities after traumatic the perspectives of communication, cognition, executive brain injury (TBI; i.e., damage to the brain caused by exter- functions, and behavior. nal forces acting on the skull). The perspective is based on 5. Describe central themes in rehabilitation and ongoing (1) our combined 85 years of clinical experience in the field, support for individuals with chronic cognitive, commu- (2) current theory and research in cognitive neuroscience, nication, and behavioral impairment after TBI. (3) a considerable body of efficacy research in related dis- 6. Offer several rationales for a context-sensitive, every- ability fields, and (4) a growing body of efficacy literature in day, routine-based approach to intervention. TBI rehabilitation. The importance of the approach to cog- 7. Describe procedures associated with ongoing, context- nitive rehabilitation described in this chapter is under- sensitive, collaborative hypothesis testing assessment, scored by pessimistic reviews concerning the effectiveness and give a rationale for this approach to assessment for of restorative, decontextualized cognitive and executive planning intervention. function exercises, possibly combined with neuropharma- 8. Create functional, individualized rehabilitation plans in cologic management. the domains of executive functions/self-regulation, cog- The length of this chapter is dictated by our attempt to nition, social communication, and behavior. address many critical themes associated with an increasingly 9. Describe executive function routines, and give illustra- important disability group for specialists in cognitive, tions for individuals at varied stages of recovery. behavioral, and communication disorders. Because readers 10. Give reasons for avoiding process-specific cognitive tend to use this textbook as an ongoing resource, we have exercises. included a large number of tables, figures, and appendices 879 GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 880 Aptara Inc. 880 Section V ■ Therapy for Associated Neuropathologies of Speech- and Language-Related Functions designed to organize and summarize large quantities of most, but not all, cases (80%–90% excellent recovery) (Kraus information for easy access. The chapter is divided into & Nourjah, 1988; Ruff, 2005). Many more cases of mild eight sections: injury are uncounted, either because those affected do not seek medical attention or because the brain injury is masked 1. Epidemiology by more pressing medical concerns (e.g., high spinal cord 2. Pathophysiology injury). Direct medical costs (acute hospitalization and reha- 3. Disability associated with TBI, including frequently bilitation) have been estimated at $48.3 billion per year, not used measures of disability, considerations associated including the enormous financial and psychological costs with prediction of outcome, stages of improvement, and associated with ongoing support and reduced employability commonly occurring communication consequences of (AHCPR, 1999). TBI 4. Framework for everyday, routine-based intervention, including theoretical, neuropsychological, and economic Risk Factors rationales The incidence of TBI is highest among young people, with 5. Functional assessment for planning intervention 15- to 24-year-old males being most vulnerable. Secondary 6. Intervention for self-regulatory impairments: cognitive peaks have been identified in people older than 65 years and and executive function disorders associated with TBI in children 5 years or younger (CDC, 1997; Kraus, Rock, & 7. Intervention for self-regulatory impairments: social- Hemyari, 1990). With the introduction of TBI as an educa- communication and behavioral disorders associated tional disability category in the revised Individuals with with TBI Disability Education Act (IDEA: Federal Register, 1991), 8. Collaboration among professional clinicians, the person children have received increasing attention in the clinical with disability, and the everyday people in that person’s and education literatures. In contrast, elderly individuals, life. who also are at risk both for TBI and for relatively severe Throughout the chapter, we highlight the role of the self- consequences of the injury, continue to be under-repre- regulatory/executive system because of its vulnerability after sented in the literature (Goldstein & Levin, 1995; Payne, frontal lobe injury and its significance in relation to successful 1999). outcome in the domains of rehabilitation discussed in this Several risk factors in addition to age have been identi- chapter. In other publications, we have developed these fied. Historically, males have been said to have twice the rate themes in greater detail than is possible here (see, e.g., Feeney of TBI as females, with this ratio being even higher (3:1 or & Ylvisaker, 1995, 1997; Szekeres, Ylvisaker, & Cohen, 1987; 4:1) for the highest risk group of older adolescents and Ylvisaker, 2003, 2006; Ylvisaker & Feeney, 1996, 1998a, 1998b, young adults (Kraus, 1993). More recent CDC estimates 2000a, 2000b; Ylvisaker, Feeney, & Feeney, 1999; Ylvisaker, place the male-to-female ratio at closer to 1.5:1. Clinicians Feeney, & Szekeres, 1998; Ylvisaker, Szekeres, & Feeney, often characterize the highest risk group as including ado- 1998; Ylvisaker, Szekeres, & Haarbauer-Krupa, 1998). lescent and young adult males from lower socioeconomic groups, whose preinjury lives may have been characterized by some degree of risk-taking behavior, poor academic and EPIDEMIOLOGY OF TBI vocational achievement, and greater-than-average use of alcohol and recreational drugs. Supporting this stereotype, Incidence and Prevalence incidence studies have suggested that TBI appears to be According to the Centers for Disease Control and especially common in lower socioeconomic groups, among Prevention (CDC; 2001), at least 1.5 million TBIs occur in people with less than a high school education, and among the United States annually, resulting in approximately 50,000 those with a history of poor academic performance (Fife, deaths and 235,000 hospitalizations. Of the 1.5 million Faich, Hollinshead, & Boynton, 1986: Haas, Cope, & Hall, injured people, 80,000 are expected to experience persist- 1987; Sosin, Sniezek, & Thurman, 1996). Alcohol often is a ing disability, yielding a prevalence estimate of 5.3 million contributing factor in the occurrence of TBI, strongly asso- Americans living with TBI-related disability. These esti- ciated with both motor vehicle–related injuries and with falls mates are lower than previously reported (Kraus, 1993), in both young adults and the elderly (Hartshorne, Harruff, possibly representing a positive trend in highway safety & Alvord, 1997; Kraus, 1993; Santora, Schinco, & Trooskin, and increasingly restrictive criteria for hospital admission. 1994; U.S. Department of Transportation, 1995). Previous Because of the relative youth of most individuals with TBI increases the risk of subsequent TBI by threefold TBI, prevalence-to-incidence ratios are much higher than (Annegers, Grabow, Kurland, & Laws, 1980; Gerberich, those for neurogenic disorders associated with aging. Priest, Boen, Staub, & Maxwell, 1983). Previous TBI also Approximately 80% of those hospitalized with TBI have may increase the negative consequences of subsequent TBI mild injuries, with an expectation of excellent recovery in (Collins et al., 1999; Gronwall & Wrightson, 1975). GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 881 Aptara Inc. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 881 Not all epidemiologic reports, however, are consistent a stationary surface may cause skull distortion and fracture with the stereotype. For example, in two Australian studies, and, traditionally, is thought to be responsible for coup Tate (1998) failed to find a high rate of pretrauma social mal- (site of contact) and contrecoup (opposite side) brain contu- adjustment in her cohort and, more surprisingly, did find sion and cavitation injury (Fig. 33–3). Neurobehavioral that such maladjustment, when present, appeared not to deficits associated with lesions that vary with the site of have a pronounced effect on outcome. In contrast to Tate, impact cannot explain central tendencies within the popula- our experience with several hundred young adults referred tion as a whole. Rather, damage associated with differential for neurobehavioral support as a result of behavior-related tissue movements within the skull, both brain—skull and community reintegration problems suggests that preinjury brain—brain movements created by inertial forces (especially factors play a significant role in outcome, with preinjury rotational inertia), often plays the greatest role in determin- developmental and adjustment problems often exacerbated ing outcome and best explains population commonalities. by the injury (Ylvisaker & Feeney, 2000a). This type of injury is possible even in the absence of a blow With respect to the cause of injury, transportation- to the head if the skull is accelerated and/or decelerated related events account for approximately 50% of TBI cases rapidly (e.g., shaken baby syndrome) (Gennarelli et al., (CDC, 1997), followed by falls (slightly more than 20% of 1982). the total, but much higher in young children and the In severe CHI, brain–skull differential movement in the elderly), assaults (approximately 20%), and finally, sports- area of bony prominences within the skull can cause surface related injuries and other causes. Tragically, abuse is a major contusion and laceration as well as deeper shearing of axons factor in infants and the elderly. Consideration of the causes (diffuse axonal injury) and blood vessels (subdural and of TBI reveals that this is a largely preventable epidemic. intracerebral hematoma) (Povlishock & Katz, 2005). With concerted efforts to improve automobile safety, reduce Regardless of site of impact in high-speed CHI, focal contu- alcohol-impaired driving, enhance safety measures in sports, sion as well as axon shearing often are concentrated within and eliminate child and elder abuse, the epidemiology of anterior and inferior frontal and temporal lobe structures TBI could be dramatically changed. bilaterally because of their adjacency to sharp, irregular sur- faces inside the skull (Alexander, 1987; Courville, 1937; Katz, 1992) (Figs. 33–4 and 33–5). Damage to these areas PATHOPHYSIOLOGY OF TBI explains many of the commonly observed behavioral symp- The term “traumatic brain injury” refers to damage to the toms that negatively affect communication after CHI, brain caused by external forces. Traumatic brain injuries can including (a) depressed executive control over cognitive and be open, involving penetration of the dural covering of the communicative functions (prefrontal damage), (b) impaired brain, or closed. Penetrating missile injuries, in which focal social perception and social reactivity (prefrontal and fron- damage is related to the site of penetration and trajectory of tolimbic damage, particularly right hemisphere), and (c) the missile, are more strongly associated with aphasia than is generally reduced behavioral self-regulation (prefrontal, closed head injury (CHI) (Newcomb, 1969). Generally, CHI frontolimbic, and anterior temporal lobe damage). Diffuse refers to brain injuries in which the primary mechanism of neuronal shearing also often is concentrated in subcortical damage is a blunt blow to the head or rapid changes of skull white matter, brain stem, and corpus callosum, contributing motion, both of which are associated with acceleration/decel- to initial coma and subsequent arousal/attentional deficits as eration forces acting on the brain (Levin, Benton, & well as slowed mental processing (Adams, Graham, Murray, Grossman, 1982). In special education discussions of students & Scott, 1982). Over the weeks and months after severe with brain injury, acquired brain injury often is used to iden- TBI, diffuse axonal injury can continue to contribute to tify an even broader pathophysiologic category, including degeneration at nerve terminals. Characteristic stages of stroke, tumor, anoxia, toxic encephalopathy, meningitis, recovery are related to diffuse rather than focal injuries encephalitis, and other causes of noncongenital brain impair- (Povlishock & Katz, 2005). The relative infrequency of spe- ment. Federal education law, PL 101-476 (Individuals with cific aphasic syndromes in CHI is, in part, a consequence of Disabilities Education Act, 1990; amended 1997), defined the smooth interior surface of the skull adjacent to the tradi- TBI in relation to external causes, but some state departments tional perisylvian language centers in the brain. of education use TBI as a synonym for acquired brain injury. Secondary Damage Primary Impact Damage Secondary damage in TBI is associated with slowly develop- Primary and secondary injuries associated with TBI are ing hemorrhages and localized or widespread swelling and summarized in Figures 33–1 and 33–2 (information taken edema, both of which contribute to increased intracranial from Alexander, 1987; Katz, 1992; Pang, 1985; Povlishock pressure, which can be acutely life-threatening and con- & Katz., 2005; Young, 1999). Contact of a moving skull with tribute to morbidity in those who survive. In addition, 882 GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 882 Aptara Inc. Figure 33–1. Mechanisms of immediate injury in closed and open traumatic brain injuries. GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 883 Aptara Inc. Figure 33–2. Pathologic events that often follow severe traumatic brain injury and contribute to impairment. 883 GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 884 Aptara Inc. 884 Section V ■ Therapy for Associated Neuropathologies of Speech- and Language-Related Functions Figure 33–3. Representation of coup injury (i.e., contusion and cavitation at the site of impact) and contrecoup injury (i.e., contusion and cavitation at the opposite side of the brain). (Adapted with permission from Walker & the North Carolina State Board of Education, 1997; with permission.) hypoxic-ischemic injury and pathologic neurotransmitter ominous consequence for young people who face substantial surges (specifically glutamate), both of which are common new learning challenges in school and on the job. Tragically, secondary consequences of severe TBI, often pick out spe- the vast majority of individuals with TBI are children, ado- cific vulnerable structures, notably the hippocampus bilater- lescents, and young adults. Post-traumatic seizures, includ- ally, thereby contributing to memory and new learning ing both early onset (within the first week) and late onset problems after the injury (Katz, 1992). This is an especially (appearing after the first week), also can complicate recovery and become a major concern if epilepsy persists. DISABILITY FOLLOWING TBI Predictable inconsistencies are found in the published descriptions of disability following TBI. Because of the extended period of neurologic improvement, the time post- injury at which consequences of the injury are assessed influ- ences the description of central tendencies in the population. Figure 33–5. Contusions after traumatic brain injury, based on Figure 33–4. Diffuse axonal injury: twisting, tearing, and 40 consecutive cases, clearly depict the tendency for maxi- breaking of axons associated with primary impact damage in mum pathology in the orbitofrontal and temporal regions. traumatic brain injury. (Reprinted from Courville, 1937; with permission.) GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 885 Aptara Inc. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 885 Variation in the severity mix from study to study also adds to the same underlying impairment can result in dramatically variation in this outcome picture. Furthermore, as increas- different types and degrees of activity and participation lim- ingly valid language and cognitive assessments have become itations in different individuals with varying activity and available (e.g., sensitive analysis of extended discourse versus environmental demands, compensatory strategies, emo- aphasia batteries developed for a different clinical popula- tional adjustment, and social/educational/vocational sup- tion) (Coehlo, Ylvisaker, & Turkstra, 2005), increasing num- ports. Furthermore, as we argue later in this chapter, inter- bers of individuals with TBI have been shown to have vention that begins with a focus on context supports, and language and more general cognitive processing and self- then emerging into an activity/participation-oriented focus regulatory difficulties. Finally, because of the variable associ- on compensatory strategies, can ultimately result in reduced ations among impairment, activity/participation, and con- impairment as the individual practices supported compen- text, different outcome profiles inevitably emerge depending satory procedures until they become habitual and automatic on which domain is assessed. aspects of information processing. The World Health Organization International Measures of Injury and Disability Severity Classification of Functioning Several rating scales have enjoyed increasing popularity as Throughout the chapter, we use the World Health measures of initial severity of injury, ongoing improvement, Organization (WHO) framework of body structure and and chronic disability. These scales are not intended for use function (previously impairment), activity/participation in planning interventions with specific individuals; sensitive, (previously disability and handicap), and environmental individualized assessments are needed for that purpose. context (WHO, 2001). Disorders of body structure and Furthermore, rating scales rarely are sufficient to measure function include the underlying physiological or psycholog- the effectiveness of intervention in individual cases. For that ical (“in the head”) impairments traditionally measured by purpose, no substitute exists for objective documentation of office-bound test batteries (e.g., slowed processing, memory progress toward or achievement of individualized functional impairment, loss of organizing schemata, disruption of objectives directly related to important personal life goals. phonologic or grammatical systems, and hemiplegia). General rating scales, however, have become part of the Disorders at the level of activity and participation, which lingua franca of medical rehabilitation, are useful in captur- may or may not be directly associated with the underlying ing severity of injury and disability in general terms, and impairment, refer to reduced ability to successfully perform often are used in epidemiologic and program evaluation activities that are important in the individual’s life (e.g., dif- studies. Table 33–1 includes descriptions of commonly used ficulty maintaining a conversation, problems comprehend- scales. Many other functional scales have been developed, ing school textbooks, difficulty remaining focused and orga- attesting to the shortcomings of impairment-oriented tests nized at work, and impulsive or aggressive interaction under for measuring functional disability after TBI. These include stress). This level also includes the individual’s potential the Patient Competency Rating Scale (Prigatano & Altman, educational, vocational, and social losses as a result of the 1990), Mayo-Portland Adaptability Inventory (Malec & disability, including loss of work, educational opportunity, Thompson, 1994), Neurobehavioral Functioning Inventory friends, living situation, avocational pursuits, social status, (Kreutzer, Marwitz, Seel, & Serio, 1996), Supervision community mobility, and the like. Context or environmen- Rating Scale (Boake, 1996), and BIRCO-39 Scales (Powell, tal factors include potential barriers or facilitators in the Beckers, & Greenwood, 1998). physical and social environments. For example, ramps are a positive environmental factor for people with physical dis- Prediction of Outcome ability. Well-oriented and trained communication partners, on-the-job supports, and understanding work supervisors Many studies suggest a general “dose–response” relation are examples of positive context factors for individuals with between injury severity and long-term outcome (Katz & cognitive and communication disability. Alexander, 1994). Most studies correlating injury severity Many of the changes in rehabilitation over the past two and outcome after TBI, however, use broad severity cate- decades have been associated with an increasing emphasis on gories (e.g., four or five grades of severity, based on Glasgow functional activities and participation (Level 2 of the WHO Coma Scale score, duration of coma, or duration of post- classification system) and context/environmental supports traumatic amnesia, possibly combined with focal neurologic for social, educational, vocational, and avocational participa- signs) and broad outcome categories (e.g., the five grades of tion (Level 3), in contrast to the primary focus on the under- outcome defined by the Glasgow Outcome Scale). Although lying impairment, as with traditional rehabilitation. Clearly, useful for epidemiologic purposes, these studies must be the relationships among the three levels are complex and interpreted cautiously by rehabilitation clinicians. First, cor- relative to individuals and their contexts in life. For example, relation studies will always contain individuals who deviate GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 886 Aptara Inc. 886 Section V ■ Therapy for Associated Neuropathologies of Speech- and Language-Related Functions TABLE 33–1 Assessments Commonly Used to Measure Injury Severity and Associated Disability Assessment Procedure Description Glasgow Coma Scale (GCS) A three-category (eye opening, motor response, and verbal response), 15-point scale (Teasdale & Jennett, 1974) commonly used to measure the initial severity of TBI. Scores of 8 or lower within the first several hours after injury typically are classified as severe injuries, scores of 11 or 12 as moderate, and scores of 13–15 as mild. Duration of Coma Generally based on time from injury to eye opening and resumption of normal sleep–wake cycles. Measured in minutes or hours for mild to moderate injuries and in days, weeks, or months for severe injuries. Sometimes used more informally to refer to the period of significantly altered consciousness. Duration of Post-Traumatic Amnesia Based on time from injury to resumption of orientation and integration of day-to-day memories. Very hard to establish with precision in severe cases. Galveston Orientation and Amnesia Test A 10-question test of orientation to person, place, and time and of memory for (GOAT) (Levin, O’Donnell, & recent, postinjury events as well as for most recent preinjury events. Grossman, 1979) Glasgow Outcome Scale (Jennett & A five-category global outcome scale: death, persistent vegetative state, severe Bond, 1975) disability (conscious but disabled and dependent), moderate disability (disabled but independent), and good recovery (relatively normal life but possibly with ongoing minor impairment). Rancho Los Amigos Levels of Cognitive An eight-level scale of cognitive recovery based on observation of responsiveness, Functioning (Hagen, 1981) purposeful activity, orientation, memory, self-regulation, spontaneity, and independence. Levels: no response, generalized response, localized response, confused-agitated, confused-nonagitated, confused-appropriate, automatic- appropriate, and purposeful-appropriate. Disability Rating Scale (Rappaport, Hall, A rating scale developed to track improvement of people with TBI from coma Hopkins, Belleza, & Cope, 1982) to community. Includes subscales for impairment (similar to GCS), disability (cognitive ability for feeding, toileting, and grooming), and handicap (level of community functioning, and employability). Functional Assessment Measure (FIMFAM) A rating scale that adds 12 domains for disability rating to the 12 domains of the (Hall, 1992) older Functional Independence Measure (FIM). The additional items, added specifically for individuals with brain injury, include swallowing, reading, writing, orientation, attention, safety judgment, emotional status, and adjustment to limitations. Community Integration Questionnaire A 15-item questionnaire designed to assess home and social integration and (Willer, Ottenbacher, & Coad, 1994) productivity in the following domains: household activities, shopping, errands, and leisure activities. American Speech-Language-Hearing A rating scale designed to assess functional communication with greater precision Association FACS than is possible with most general disability rating tools. Communication Effectiveness Survey A survey designed to assess functional communication in natural contexts. (Beukelman, 1998) LaTrobe Communication Questionnaire A 30-item questionnaire divided into six communication domains: conversational (Douglas, O’Flaherty, & Snow, 2000) tone, effectiveness, flow, engagement, partner sensitivity, and attention/focus. Self and “close other” forms are available. Key: TBI  traumatic brain injury. GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 887 Aptara Inc. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 887 sharply from the general population relationships (Ponsford, terms of the amount and types of support needed by the indi- Olver, Current, & Ng, 1995), and these exceptional individ- vidual to function. Any discussion of stages, however, must uals and their families often are those with whom clinicians be sensitive to the varied patterns and rates of improvement interact in their everyday clinical practice. Second, within experienced by specific individuals and to the many small broad severity of injury and outcome categories is substantial changes in functioning, required supports, and appropriate individual variation, rendering specific predictions hazardous expectations that are more properly represented as a contin- and leaving room for optimism regarding the potential effec- uum rather than a series of qualitatively different stages. tiveness of intervention efforts. For example, two individuals in the good outcome category can be extremely different Early Stage: Intensive Cognitive Supports with respect to (a) their level of success measured in relation to preinjury success, (b) the effort required to maintain that This stage begins with the first generalized responses to level of functioning, (c) the level of supports they require and environmental stimuli and ends with stimulus-specific the associated caregiver burden, and (d) their subjective level responses (e.g., visual tracking or localizing to sound), of satisfaction and adjustment to life after the injury. Because recognition of some common objects through appropriate of these sources of variability, intervention that fails to use of the object (if motorically capable), and comprehen- change a person’s outcome category may, nevertheless, be sion of some simple commands in context. From a cognitive very effective for the individual and caregivers alike. perspective, this stage often is called the sensory or coma stimulation stage of rehabilitation, a controversial and hotly debated field of intervention. Zasler, Kreutzer, and Taylor Patterns and Stages of “Recovery” (1991) presented a useful review of these themes and a con- In the heading, the word recovery is in quotation marks servative approach to coma management. From the perspec- because it is a frequent source of miscommunication. In tive of performance of everyday activities (e.g., self-care), ordinary language, “to recover” is to return to normal. In individuals at this stage require intensive levels of support. contrast, rehabilitation professionals typically use the word to refer to gradual improvement, without intending to sug- Middle Stage: Moderate Cognitive Supports gest that improvement will continue until a full recovery is This stage begins with heightened alertness and increased achieved. Indeed, full recovery is rare following TBI with activity combined with some degree of confusion and disori- coma of a few days or more. Therefore, improvement may be entation, which may include agitated behavior unrelated to a better choice of words to communicate what professionals environmental provocation. This stage ends with a reduc- often intend with recovery (Kay & Lezak, 1990). tion in confusion, which is manifested by adequate orienta- Most individuals with severe TBI experience a large tion and behavior that generally is goal directed in a familiar number of distinct stages or levels of cognitive and self-reg- environment. Most individuals experience gradual improve- ulatory functioning over the course of their spontaneous ment in focused attention and episodic (autobiographical) neurologic improvement and rehabilitation. In many cases, memory, but memory impairment may remain a residual improvement is characterized by a stairstep pattern rather deficit. Behavior, including social communication, may con- than a smooth recovery curve, as commonly is observed fol- tinue to be impulsive; lack of initiation is an alternative pos- lowing ischemic stroke (Brookshire, 1997). Furthermore, sibility. Most individuals have difficulty with organizing spontaneous neurologic improvement may continue for complex tasks, including discourse tasks, and with planning many months and, in some cases, even years (at decreasing how to achieve their goals. rates of improvement) after severe TBI. During this stage, individuals require moderate, but sys- The popular Rancho Los Amigos Hospital Levels of tematically decreasing, levels of support to succeed at every- Cognitive Functioning (see Table 33–1) organizes cognitive day tasks. The rehabilitation (or home) environment as well and behavioral recovery into eight relatively distinct levels. as group and individual therapy sessions are simplified, struc- An understanding of typical levels of improvement helps tured, focused, and rich in external compensatory supports so treatment staff, family members, and individuals with TBI to as to reduce confusion, facilitate improved and increasingly place in perspective behaviors that would otherwise be dis- independent performance of functional activities (including tressing (e.g., agitation associated with Level IV) and to orga- relevant social, educational, and vocational activities), and nize their rehabilitative efforts effectively. For purposes of promote adaptive behavior and a progressively increasing discussing broadly different focuses of assessment and inter- ability to process information and communicate effectively. vention—and, importantly, different levels and types of sup- port provided to the patient by rehabilitation staff and fami- Late Stage: Minimal and Variable Cognitive Supports lies—we have collapsed the eight Rancho Los Amigos levels into three broadly distinct stages of recovery (Szekeres, This stage begins with an adequate, though perhaps superfi- Ylvisaker, & Holland, 1985) that also can be understood in cial and fragile, orientation to important aspects of life, and GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 888 Aptara Inc. 888 Section V ■ Therapy for Associated Neuropathologies of Speech- and Language-Related Functions it ends with the individual’s ultimate level of neurologic 80%–90%), mild TBI is associated with excellent recovery improvement, which may or may not include cognitive and within a few days to a few weeks (Ruff, 2005). Persistent, communicative impairments that are functionally disabling. serious disability is possible, however, requiring professional Environmental supports are gradually withdrawn to help support and possible work or school accommodations. individuals become maximally independent and learn how Individuals with a history of previous concussion or other to compensate for and adjust to their residual deficits. This neurologic vulnerability (e.g., learning disabilities or neuro- stage also is the stage of refinement of skills, with a focus on logic impairment associated with aging) are at increased risk effective information processing and social communication for persistent symptoms (Collins et al., 1999; Gronwall & in real-world settings and with real-life demands (e.g., Wrightson, 1975; Rimel, Giordani, Barth, Boll, & Jane, school, work, and social life). No specific upper limit exists 1981). to learning, compensation, and adjustment that can be facil- itated by creative clinicians and, thereby, substantially Long-Term Communication-Related Outcome improve real-world success. Earlier, we stated that the relation between injury severity and outcome is, at best, very general. Many factors interact Sequence of Service Settings to determine a person’s ultimate level of impairment; ability Severe TBI typically is associated with many service settings to perform activities of daily living; ability to maintain and sets of service providers. Emergency medical services desired levels of participation in social, educational, voca- routinely are administered at the site of the injury and dur- tional, and avocational pursuits; level of personal satisfaction ing transport to a trauma center. Emergency room care with life after the injury; and level of support required from largely is devoted to managing life-threatening increases in everyday people in the environment. In addition to the intracranial pressure as well as treating other injuries (e.g., injury itself, these factors include preinjury and postinjury orthopaedic injuries and internal organ injuries) that fre- variables summarized in Figures 33–6 and 33–7. quently accompany TBI. Following initial stabilization, Given preinjury variability (Fig. 33–6) and the variety of patients are transferred to the intensive care unit for ongo- pathophysiologic mechanisms in TBI (Figs. 33–1 and ing management of critical intracranial dynamics. Stabi- 33–2), some of which are related to site of impact, it is lization of intracranial pressure often is followed by transfer understandable that no consistent outcome profiles exist to the hospital’s neurologic care floor and the beginning of with respect to communication. Constellations of commu- early rehabilitation. Speech-language pathologists may be nication-related strengths and weaknesses potentially asso- members of the early rehabilitation team, often focusing ciated with TBI are extremely varied, depending on the their efforts on resumption of oral feeding, development of nature, location, and severity of the injury as well as on the simple communication systems, and family education and characteristics of the individual who is injured and post- support. trauma supports. Indeed, many professionals consider TBI In the event of slow recovery, patients may be transferred to be, at best, misleading as a disability category, because it to a rehabilitation unit or free-standing rehabilitation hospi- actually is an etiologic category, identifying a potential tal for intensive acute rehabilitation. When cognitive, cause of varied disabilities and not the disability itself. In behavioral, physical, and general medical needs reach a level this respect, TBI is comparable to stroke or perinatal at which the person can be cared for in a less restrictive set- asphyxia, neurologic events that may or may not produce ting, the individual is discharged to home—and, often, varied disabilities. Therefore, clinicians should expect not ongoing outpatient or community support services—or to a only great diversity within this group but also possible over- community reintegration post-acute rehabilitation facility. lap between TBI and other categories of adult neurogenic Individuals with ongoing intense medical needs (e.g., communication disorder, such as aphasia, dementia, and the respirator-dependent patients) or severe and unchanging so-called right hemisphere syndrome. cognitive impairment (e.g., persistent unresponsiveness) As indicated in Figures 33–6 and 33–7, heterogeneity may be discharged to a long-term care nursing facility, with within the population is increased by diversity in pre- the possibility of resuming aggressive rehabilitation if signs traumatic intelligence, educational and vocational levels, of neurologic improvement are noted. age, personality, and coping styles as well as by variation in Individuals with concussion (i.e., traumatically induced post-traumatic environments, support systems, and emo- alteration in mental status not necessarily resulting in loss of tional and behavioral reactions of the individual. Despite consciousness) or mild TBI (i.e., brief loss of consciousness many commonalities among survivors of severe TBI or initial Glasgow Coma Scale score of 13–15) may be exam- (described below), these considerations underscore the ined in a physician’s office, observed in a hospital emergency importance of customizing assessment procedures as well room, admitted briefly, or not come to the attention of as intervention goals and methods for this diverse clinical medical professionals at all. In most cases (approximately population. GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 889 Aptara Inc. Figure 33–6. Factors that often are present before traumatic brain injury and that may contribute to outcome. 889 890 GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 890 Aptara Inc. Figure 33–7. Factors that occur after traumatic brain injury and that contribute to outcome. GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 891 Aptara Inc. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 891 Infrequency of Aphasia tem, cognitive, and psychosocial/behavioral impairments. In important respects, these four lists are descriptions of the Although symptoms of aphasia often are present early in consequences of the same underlying impairments, using recovery and, in some cases, specific language impairment four distinct professional frameworks. The extent of overlap does persist, aphasia, as defined in terms of the classical syn- in deficit domains underscores the importance of profes- dromes, is relatively uncommon after TBI in adults sionals from different clinical fields collaborating in their (Heilman, Safran, & Geschwind, 1971; Sarno, 1980, 1984; approach to assessment and intervention. Sarno, Buonaguro, & Levita, 1986) and children (Chapman, 1997; Ylvisaker, 1993). Anomia, which can be associated with a wide variety of brain lesions, often is reported to be Communication Disorders Associated with Executive the primary residual aphasic symptom in the absence of gen- Function/Self-Regulatory Impairment eral cognitive disruption (Heilman et al., 1971; Levin, The same executive function/self-regulatory (EF/SR) skills Grossman, Sarwar, & Meyers, 1981; Sarno, 1980, 1984; underlie emotional/social/behavioral self-regulation (e.g., Thomsen, 1975). Generalized and persistent expressive and controlling affective states, inhibiting impulses, deferring grat- receptive language impairment usually is associated with ification, communicating respectfully, and benefitting from widespread diffuse injury that also produces global cognitive feedback) (Vohs & Ciarocco, 2004) and cognitive-vocational- deficits (Levin et al., 1981). If aphasia is present, clinicians academic self-regulation (e.g., planning a work task, reading should apply the assessment and intervention frameworks strategically, studying efficiently, and taking responsibility for presented elsewhere in this text. vocational and academic success) (Meichenbaum & Biemiller, 1998) and, thus, should be viewed within one consistent inter- Non-Aphasic Communication Disorders: Executive vention framework (Ylvisaker, Jacobs, & Feeney, 2003). Functions, Cognition, Behavior, and Communication Consistent with our previous work on the subject, we have Communication challenges following TBI most often are chosen a functional definition of the construct, based on an “non-aphasic” in nature; that is, they co-exist with intelligible analysis of prerequisites for successful performance of any dif- speech, reasonably fluent and grammatical expressive lan- ficult task (Ylvisaker & Feeney, 1998a; Ylvisaker, Szekeres, & guage, and comprehension adequate to support everyday Haarbauer-Krupa, 1998). These include: (1) some degree of interaction. Depending on the severity of injury, stage of awareness of ones strengths and weaknesses (thereby enabling recovery, and particular focus of research, the characteristic a judgment of task difficulty) and (2) an ability to set reasonable communication profiles following TBI have been variously goals, (3) organize plans to achieve the goals, (3) initiate goal- referred to as “the language of confusion” (early in recovery) directed behavior, (4) inhibit impulses that interfere with goal (Halpern, Darley, & Brown, 1973), “non-aphasic language achievement, (5) monitor behavior and (6) evaluate it in rela- disturbances” (Prigatano, 1986; Prigatano, Roueche, & tion to the goals, (7) benefit from feedback, (8) flexibly select Fordyce, 1985), “cognitive-language disturbances” (Hagen, and modify strategies in response to performance feedback, 1981), and “subclinical aphasia” (Sarno, 1980, 1984). Sarno and (9) flexibly perceive situations from a variety of possible (1984) found that, although a distinct minority of a consecu- perspectives. Each of these components falls on a continuum tive series of 69 severely injured individuals admitted to an of performance and develops gradually during childhood, in inpatient rehabilitation facility could be diagnosed with apha- dynamic interaction both with each other and with related sia, all of the patients were found to have some combination domains of cognitive and social development (Flavell, Miller, of language deficits that were not apparent in everyday inter- & Miller, 2002). Because the term “self-regulation” is better action. These included impaired confrontation naming, word understood by those who are unfamiliar with neuropsycholog- fluency, and comprehension of complex oral commands. ical discussions of the topic, and because that term brings to Sarno did not evaluate their interactive competence with the table a large literature in related fields of psychology, we increasing cognitive and social demands, social competence, have chosen to combine the terms to form the general con- or behavioral self-regulation—factors that clinicians, teach- struct, EF/SR. ers, family members, and recent investigators often identify as The growing literature on self-regulation has close theo- major contributors to communication breakdowns after TBI. retic ties with psychological theory construction regarding The overlapping collections of communication deficits the self and clinical ties with fields such as substance abuse, highlighted by these investigators have been grouped by the eating disorders, health problems, crime, motivation, pro- American Speech-Language-Hearing Association (ASHA) crastination, and the like (Baumeister & Vohs, 2004). Self- under the heading “cognitive-communication impairment” regulation and self-determination also have come to be used (ASHA, 1988) and are all associated with frontolimbic dam- as the central terms within theory construction and research age, the most common damage in CHI. These impairments related to intrinsic motivation (Ryan & Deci, 2002). The lit- are included in Table 33–2, which also includes lists of erature on executive functions has close theoretic ties with impairments under three additional headings: executive sys- neuropsychological investigations and clinical ties with GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 892 Aptara Inc. 892 Section V ■ Therapy for Associated Neuropathologies of Speech- and Language-Related Functions TABLE 33–2 Vulnerable Frontolimbic Structures and Frequently Associated Impairments Frontolimbic Injury and Executive System Impairment • Reduced awareness of personal strengths and weaknesses • Difficulty setting realistic goals • Difficulty planning and organizing behavior to achieve the goals • Impaired ability to initiate action needed to achieve the goals • Difficulty inhibiting behavior incompatible with achieving the goals • Difficulty self-monitoring and self-evaluating • Difficulty thinking and acting strategically and solving real-world problems in a flexible and efficient manner • General inflexibility and concreteness in thinking, talking, and acting Frontolimbic Injury and Cognitive-Communication Impairment • Disorganized, poorly controlled discourse or paucity of discourse (spoken and written) • Inefficient comprehension of language related to increasing amounts of information to be processed (spoken or written) and to rate of speech imprecise language and word retrieval problems • Difficulty understanding and expressing abstract and indirect language • Difficulty reading social cues, interpreting speaker intent, and flexibly adjusting interactive styles to meet situational demands in varied social contexts • Awkward or inappropriate communication in stressful social contexts • Impaired verbal learning Frontolimbic Injury and Cognitive Impairment • Reduced internal control over all cognitive functions (e.g., attentional, perceptual, memory, organizational, and reasoning processes) • Impaired working memory • Impaired declarative and explicit memory (encoding and retrieval) • Disorganized behavior related to impaired organizing schemes (managerial knowledge frames, such as scripts, themes, schemas, and mental models) • Impaired reasoning • Concrete thinking • Difficulty generalizing Frontolimbic Injury and Psychosocial/Behavioral Impairment • Disinhibited, socially inappropriate, and possibly aggressive behavior • Impaired initiation or paucity of behavior • Inefficient learning from consequences • Perseverative behavior • Impaired social perception and interpretation Adapted from Ylvisaker, Feeney, & Feeney, 1999; with permission. rehabilitation for individuals who have frank neurologic cover much the same ground in discussions of developmental impairment (Burgess & Robertson, 2002; Cicerone, 2005; disabilities (Wehmeyer, Agran, & Hughes, 1998). We have Shallice & Burgess, 1991; Ylvisaker, Szekeres, & Feeney, attempted to mine all these fields in formulating a theoreti- 1998). In educational psychology and special education, the cally informed but practice-based approach to serving chil- term “meta-cognition” has, historically, been used to refer to dren and adolescents with EF/SR impairment. “executive self-regulatory” control over cognitive processes in the context of learning and academic performance (Flavell, Pathophysiological Bases: Frontolimbic Injury Miller, & Miller, 2002); today, however, “self-determined learning” is increasingly used to describe these approaches It has long been known that prefrontal or frontolimbic struc- (Martin et al., 2003; Meichenbaum & Beimiller, 1998). tures are most vulnerable in CHI (Adams, Graham, Scott, Finally, the term “self-determination” commonly is used to Parker, & Doyle, 1980; Levin, Goldstein, Williams, & GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 893 Aptara Inc. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 893 Eisenberg, 1991; Mendelsohn et al., 1992; Mesulam, 2002; sion) probably has received more attention than other com- Povlishock & Katz, 2005; Varney & Menefee, 1993). munication-related deficits in the recent TBI research liter- Although it certainly is possible to escape frontolimbic injury ature (Coehlo et al., 2005). Both adults and children with in TBI, its frequency and profound impact on communica- TBI have been found to be impaired relative to controls on tive effectiveness combine to give it—and its general neu- many measures of interactive (conversational) and noninter- robehavioral correlate, EF/SR dysfunction—an important active (monologic) discourse (Biddle, McCabe, & Bliss, heuristic role in organizing intervention planning (Ylvisaker, 1996; Chapman, 1997; Chapman, Levin, Matejka, Harward, 1992). In recent years, investigators have increasingly differ- & Kufera, 1995; Chapmen et al., 1992, 1997; Coelho, Liles, entiated varied frontal and limbic functions and have loos- & Duffy, 1991; Dennis, 1991, 1992; Dennis & Barnes, 1990; ened, to some degree, the connection between frontal lobe Dennis, Barnes, Donnelly, Wilkinson, & Humphreys, 1996; functions and executive functions (Stuss, 1999a, 1999b). The Dennis & Lovett, 1990; Ehrlich, 1988; Groher, 1990; most common communication-related themes after TBI, Hagen, 1981; Hartley, 1995; Hartley & Jenson, 1991; Liles, however, continue to be associated with frontolimbic injury. Coelho, Duffy, & Zalagens, 1989; McDonald, 1992a, 1992b; Indeed, all the symptoms listed in Table 33–2 are associated 1993; McDonald & Pearce, 1998; Mentis & Prutting, 1991; with damage to the frontal lobes, limbic structures, and/or the Pearce, McDonald, & Coltheart, 1998; Sarno et al., 1986; critical axonal connections between prefrontal and limbic Togher, Hand, & Code, 1997; Turkstra & Holland, 1998; structures (Alexander, Benson, & Stuss, 1989; Povlishock & Ylvisaker, 1992, 1993). Katz, 2005; Stuss & Benson, 1986). For example, both right Discourse impairment in the presence of adequate vocab- and left hemisphere prefrontal structures are associated with ulary, grammar, and motor speech ability often can be self-regulation (e.g., initiation, inhibition, and direction) of understood as a language consequence of more general cog- behavior, including communication behavior; with organiza- nitive disruption—that is, the loss or inaccessibility of the tion of language into coherent discourse; and with control knowledge structures needed to organize thought units over attentional and memory processes to make them useful in across multiple utterances (sometimes referred to as ideational daily life. Both left and right hemisphere orbital frontal dam- apraxia). Alternatively, discourse impairment may be a con- age have been associated with personality changes, including sequence of failure to select and implement the appropriate disinhibition, volatility, and verbal “dysdecorum” (Alexander organizing schemas when they are needed (sometimes et al., 1989). Right frontal lobe damage has been associated referred to as frontal apraxia), or to maintain directed atten- with more specific pragmatic deficits, such as (1) decreased tion to the organizing scheme in a conversation or monolog, ability to produce appropriate para-linguistic accompaniments and monitor success of the communication. The latter phe- to speech, including gesture and facial expression as well as nomenon sometimes is referred to as impairment of the prosody in speech; (2) decreased ability to comprehend supervisory attentional system, which is the component of prosodic features in the speech of others and to interpret indi- the executive system responsible for controlling behavior- rect pragmatic intents, including humor, sarcasm, metaphor, regulating schemas in nonroutine contexts (Shallice, 1982). and other indirect meanings (McDonald, 2005); and (3) inat- In most cases, discourse impairment after TBI represents a tention to context, including social context, resulting in failure of executive control over cognitive and linguistic socially inappropriate behavior (Alexander et al., 1989; organizing processes rather than a linguistic impairment per Shammi & Stuss, 1999; Stuss & Alexander, 1999). se (Schwartz, 1995; Schwartz, Mayer, FitzpatrickDeSalme, Damage to the hippocampus and surrounding limbic tissue & Montgomery, 1993). Alexander (2002) refers to the disor- is associated with impaired declarative and explicit memory— der as impaired action planning in the verbal domain. roughly, memory for facts rather than procedures, combined In the intervention section of this chapter, we focus on with a subjective sense that one possesses the memory organizational functioning in part because of its important (Schacter, 1996; Squire, 1992). Because of the extreme vulner- relation to these common discourse impairments. According ability of the hippocampus to postinjury anoxia, new learning to many cognitive theories, the same cognitive macrostruc- problems are very common after TBI, despite potentially good tures or managerial knowledge units (e.g., scripts, themes, recovery of pretraumatically acquired and effectively stored schemas, plans, and mental models) that guide organized knowledge and skills. Damage to other limbic structures and thinking, remembering, reasoning, and acting also guide frontolimbic connections contribute to the transient or persis- organized talking, writing, and comprehension of lengthy tent difficulty with emotional and behavioral self-regulation discourse. According to one leading neuropsychological the- commonly seen after TBI (Izard, 1992; Ledoux, 1991, 1996). ory, such managerial knowledge units are stored in prefrontal parts of the cortex, explaining the frequency of organiza- tional impairment in TBI (Grafman, 1995; Grafman, Sirigu, Discourse Impairment Sepctor, & Hendler, 1993), particularly with left hemisphere Discourse impairment (i.e., difficulty organizing language dorsolateral prefrontal involvement. Thus, discourse is one over more than one utterance for production or comprehen- of the critical points of intersection between language and GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 894 Aptara Inc. 894 Section V ■ Therapy for Associated Neuropathologies of Speech- and Language-Related Functions cognition, mandating an informed cognitive focus during Kapur, Craik, Moscovitch, & Houle, 1994). Meta-cognitive intervention and collaboration among professionals who skills, particularly the ability to monitor memory searches, address the cognitive dimensions of behavior. are required for effective retrieval and are an aspect of exec- utive functioning that often is impaired in TBI (Hanton, Bartha, & Levin, 2000; Kennedy & Yorkston, 2000). Communication Disability Related These memory problems affect communication in a vari- to Memory/Retrieval Impairment ety of ways. Inefficient information and word retrieval slows Memory deficits are among the most commonly reported interaction and can be socially distracting. Failure to recall problems after TBI. Encoding of new information into information can result in tedious repetition during conver- memory often is impaired, either as a result of damage to the sation and embarrassing social breakdowns. Impaired verbal vulnerable hippocampal system responsible for consolidat- learning has an obvious negative impact on return to school ing new declarative memories (Giap, Jong, Ricker, Cullen, or to a job that requires new learning, possibly resulting in & Zafonte, 2000) or of damage to the frontal lobes (espe- failure that may lead to social withdrawal. Impaired prospec- cially left hemisphere), resulting in poorly focused attention tive memory without effective compensation creates sub- and/or shallow, nonstrategic organization and elaboration of stantial everyday difficulties as the individual misses information during its initial processing (Anderson, appointments or other scheduled activities, forgets medica- Damasio, Tranel, & Damasio, 1988; Brazzeli, Colombo, tion, and the like. DellaSala, & Spinnler, 1994; Cabeza & Nyberg, 1997; Gluck & Myers, 1995; Schacter, 1996; Squire, Knowlton, & Communication Disability Associated with Musen, 1993). Encoding new memories for facts and events Psychosocial and Behavioral Impairment (declarative memory) often is more severely impaired than encoding for procedures (procedural memory); similarly, Any combination of the deficits listed in Table 33–2 can sub- memories stored with some awareness of the memory stantially affect life after TBI. Often, however, it is the (explicit memory) often are more vulnerable than those communication-related personality and psychosocial stored without such awareness (implicit memory) (Ewert, changes that most profoundly influence the individual’s Levin, Watson, & Kalisky, 1989; Schacter, 1996). Procedural social, vocational, familial, and academic reintegration. For and implicit memory often are run together in the TBI lit- example, families routinely report that it is easier to adjust to erature but, in fact, are neuropsychologically distinct physical disability in a loved one than to personality changes (Salmon & Butters, 1995). Storage over time is less com- manifested in stressful and unsatisfying communication; monly impaired in TBI; once information is adequately employers often highlight communication-related obstacles processed and encoded, it is unlikely to decay rapidly, as is to maintenance of employment; and teachers frequently the case in degenerative diseases, such as Alzheimer’s. identify social and behavioral changes as most problematic Retrieval may be impaired in TBI as a result of posterior in school reentry (Bond, 1990; Brooks, Campsie, damage that reduces the number of retrieval routes in the Symington, Beattie, Bryden, & McKinley, 1987; Brooks & networks of neural connections that compose the storage McKinlay, 1983; Brooks, McKinlay, Symington, Beattie, & system (Buschke & Fuld, 1974). More commonly, however, Campsie, 1987; Brown, Chadwick, Shaffer, Rutter, & Traub, word and information retrieval is impaired as a result of 1981; Filley, Cranberg, Alexander, & Hart, 1987; Fletcher, frontal lobe injury, which can result in nonstrategic searches Levin, & Butler, 1995; Hall et al., 1994; Jacobs, 1993; of memory (Petrides, 1995; Schacter, 1996; Shimamura, Klonoff, Costa, & Snow, 1986; Lezak, 1986; 1987; 2002) and degraded managerial knowledge units being used Livingston & Brooks, 1988; McKinlay, Brooks, Bond, to direct those searches (Grafman, 1995, 2002). For exam- Martinage, & Marshall, 1981; Morton & Wehman, 1995; ple, when looking for car keys, people characteristically Perlesz, Kinsella, & Crowe, 2000; Prigatano, 1986; Taylor focus their search around organized routines of everyday et al., 2002; Thomsen, 1974, 1984, 1987; Weddell, Oddy, life. Similar organizational schemas are used to guide inter- & Jenkins, 1980; Ylvisaker et al., 2001). Social communica- nal searches of memory, which therefore are rendered inef- tion and general psychosocial problems were found to be fective in the presence of degraded schemas. Recent critical predictors of vocational failure and poor quality of positron-emission tomographic investigations of explicit adult life in two groups of young adults who were injured retrieval of information have isolated important contribu- as children and followed into adulthood (Cattelani, tions of left lateral prefrontal cortex, right anterior fron- Lombardi, Brianti, & Mazzuchi, 1998; Nybo & topolar cortex, and anterior cingulate gyrus (Buckner et al., Koskiniemi, 1999). 1995; Shimamura, 2002). Retrieval of episodic memories is These social communication problems are common in differentially impaired by right frontal lobe damage, even if both children and adults with TBI, and they often are associ- encoding of that same information may have made greater ated with personality changes, including increases in negative use of left frontal lobe systems (Schacter, 1996; Tulving, behavior and awkward or impulsive social communication GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 895 Aptara Inc. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 895 (see the review by Ylvisaker, Jacobs, & Feeney, 2003). Among flexible problem solving, self-awareness, and the like) can children and adolescents with severe TBI, estimates of new further reduce social effectiveness directly and also indi- persisting behavior and psychosocial problems (i.e., those not rectly by contributing to failure and frustration. predating the injury) range from approximately 35% (Max et al., 1997) to a high of 70% (Costeff, Grosswasser, Variability in Performance Landmen, & Brenner, 1985). Behavior and social-communi- Teachers, family members, work supervisors, and others often cation problems also are common among adults with TBI emphasize a frustrating inconsistency in performance when and remain at high levels at long-term follow-up (Baguley, describing people with TBI. An uncharitable but common Cooper, & Felmingham, 2006). Preexisting behavior and interpretation of this variability is that the person is unmoti- social interaction problems, which are common among both vated (i.e., lazy) or excessively moody, perhaps even depressed. children (Cattelani et al., 1998) and adults (MacMillan, Hart, Although these characteristics may be present, neuropsycho- Martelli, & Zasler, 2002), add to this already alarming total. logical investigations have found relatively extreme variability The intensity of behavior and psychosocial disorders has in performance to be associated with frontal lobe injury, par- been associated in some studies with the severity of injury ticularly injury to the right frontal lobes (Stuss, 1999b; Stuss, (Schwartz et al., 2003) and with preinjury problems Pogue, Buckle, & Bondar, 1994). Variability is increased with (MacMillan et al., 2002). increasing task demands and with aging. This inconsistency in Personality changes frequently highlighted in the TBI performance is one of several reasons for caution when inter- literature include irritability, impatience, frequent loss of preting the results of standardized tests with this population temper, emotional volatility, egocentrism, impulsiveness, (see below). anxiety, depression, loss of social contact, lack of interests, and reduced initiation. Blumer and Benson (1975) summa- rized the inhibition-related and initiation-related personal- FRAMEWORK FOR COGNITIVE AND ity changes associated with frontal lobe injury with the labels pseudo-psychopathic and pseudo-depressed personalities, PSYCHOSOCIAL REHABILITATION respectively. Mesalum (2002) used the terms “frontal disin- Our goal in this section is to explain and offer a rationale for hibition syndrome” and “frontal abulic syndrome” to cover an approach to intervention that deviates in important ways much the same territory. For communication specialists, from traditional approaches to medical rehabilitation for these psychosocial and behavioral themes typically are individuals with severe TBI. In addition, we offer opera- grouped under the heading “pragmatics of language.” tional definitions of cognition and executive functions, two Aggressive, poorly controlled, or otherwise awkward of the primary targets of intervention for individuals with social behavior has been linked to disruption in a variety of TBI. Later in this chapter, we offer procedural detail in four frontal lobe or frontolimbic circuits, which often are injured overlapping domains: (1) executive functions/self-regula- in TBI (Scheibel & Levin, 1997), but most often to tion, (2) specific aspects of cognition, (3) social communica- orbitofrontal damage and/or connections between these tion, and (4) behavioral self-regulation. areas and limbic structures (e.g., the amygdala). Further- Appendix 33-2 contrasts central tendencies in two gener- more, damage to prefrontal areas, in association with the ally different approaches to communication, behavioral, and amygdala, insula, anterior cingulate gyrus, and basal ganglia cognitive rehabilitation for people with TBI. We have (right hemisphere more than left), results in difficulty inter- labeled these approaches conventional and functional, with preting the emotional states of others and in “reading” the the caveat that any approach to rehabilitation that is success- non-literal aspects of their communication (McDonald, ful as measured by real-world indices is functional. 2005). Difficulty with interpreting sarcasm (and, possibly, Therefore, the appropriateness of these labels depends, in other non-literal meanings) and with recognizing vocal part, on relatively disappointing results of TBI efficacy expressions of emotions is common in TBI and has a nega- research conducted within the traditional or conventional tive impact on social communication (Channon, Pellijeff, & paradigm (Carney et al., 1999; Cicerone et al., 2005; Park & Rule, 2005; Milders, Fuchs, & Crawford, 2003). Brothers Ingles, 2001; Ylvisaker, 2003) and on the accumulation of (1997) used the term “damaged social editor” to characterize supporting research conducted within the functional para- the functional consequences of damage to a circuit that digm (Feeney et al., 2001; Park & Ingles, 2001). What we includes the orbitofrontal cortex, amygdala, anterior cingu- refer to as the conventional approach has a long history in late gyrus, and temporal poles; the individual has difficulty medical speech-language pathology (and other fields), fea- “editing” social behavior because of impairment in the abil- turing restorative services offered in clinical settings and ity to read social situations and interpret the emotional dominated by massed practice of hierarchically organized, states of others (i.e., impaired “theory of mind”). Commonly decontextualized training exercises. In this section, we occurring cognitive and executive function impairments (in explain the general approach referred to as “functional” in the domains of attention, memory, organization, planning, Appendix 33-2. the same group of collaborators identifies what 1986). and educational erwise difficult work tasks because they have the help of a life and involve everyday communication partners (ECPs). 2003). 1996. changes in everyday routines (including context supports) tions themselves. is to help people acquire flexible and situa- and behavioral intervention (discussed later).. a primary goal Sherron. general script.. Cook. which is an organized Feeney. successful routines of everyday life. Everyday routines using the more familiar model of supported employment. Second. therefore.GRBQ344-3513G-C33[877-962]. use customized equipment and including family members. Later in this chapter. and acting in Progression of Intervention social context. Jacobs & that includes the people. recreational. 1999). friends. associated objects. 1996) and with behaviorally stressful tasks (“sup- internal (mental) representation of a type of event complex ported behavioral self-regulation”) (Ylvisaker. Stuss & Benson. decision making. from McDonald’s to fine restaurants. First.. Supported employment has oriented and behave successfully in a variety of restaurants. from cept.qxd 1/21/08 1:57 PM Page 896 Aptara Inc. places. vocational. Countless Third. We highlight the word “routine” for several reasons. remembering. and strategies to compensate for their disability. 2002. The goal of intervention. the same stakeholders collaborate to identify the studies of generalization and maintenance of learned behav. motivating clinicians to move beyond commercial Systematic hypothesis testing (described in the next section) therapeutic materials. we suggest that executive func. routine-based approach to interven- next link and a conditioned reinforcer for the previous link tion. is an example of a fairly Fraser. in reduction of disabil- practice of executive function routines within everyday ity (i. a routine is a concrete ports commonly used to facilitate success with cognitively structured event complex (Grafman et al. and communication injury and associated executive function impairment. & Kreutzer. in the longer run. can become routine with extensive coached participation and. everyday routines Sternberg. and prob. behavior that does not sistent with a context-sensitive. problem solving. job coach or designated peer. staff and everyday people (ideally ual behavior often is relatively unaffected. 1993) and is one of rehabilitation is to help people with TBI acquire and of the few areas of TBI rehabilitation found by a govern- apply appropriate scripts and other general knowledge ment-sponsored. To say that tionally successful behavior chains (defined by stimulus and routines of action or interaction are positive and supported response classes) that include observable as well as internal is to say that people with disability are provided with the (cognitive and emotional) behaviors as links in the chains— supports or “scaffolding” (Wood. becomes a script. 1993). et al. 1993). The organized knowledge that enables one to be other environmental supports. routine-based require effortful deliberation or planning. supported. Bruner. whereas behavior including the person with disability) collaborate to identify that requires a novel plan for unfamiliar circumstances may what is and is not working in the everyday routines of life. action contexts. which. could quickly produce increases in domains of activity and lem solving.and Language-Related Functions Positive. including planning. and scripts are those that occur during the course of every- wherein workers with disability are enabled to perform oth- day social. In both cases. a “routine” is a behavior chain in which each link—that is. connected with a Vygotskyan approach to cognitive this perspective. routine suggests habit—that is. habit. Second. 1995. at a demanding tasks (“supported cognition”) (Ylvisaker & more general level. they need to be successful. systematic evidence review to have a solid structures (or Managerial Knowledge Units) (Grafman research base (National Institutes of Health. and/or rely on teachers. psychosocial. rehabilitation. From a cognitive perspective. this stage .e. enjoyed considerable success among adults with TBI (Curl. Table 33–4 outlines a progression of intervention that is con- First. 1976) that that is. Everyday Routine-Based Intervention setting—even after mastery of the skill using personally meaningful activities—is no guarantee for ongoing use of Central to the functional approach outlined in Appendix the skill in the routines of everyday life (Detterman & 33–2 is the concept of positive. 1993). and often is required to identify the source of the manifest prob- exclusively clinical intervention settings and. work supervisors. West. From a behavioral perspective.. in reduction of the underlying impairment. Wehmen et al. supports needed for positive changes in everyday routines iors with many disability groups support the conclusion that and ways to motivate these changes for the person with dis- adequate performance of targeted skills in a treatment ability and for others in the environment. capi. & Ross. & Clemmens. of action and interaction. be severely impaired (Mesulam. the technical term “support” designates a pivotal con- (Halle & Spradlin. With frontal lobe approach to cognitive. everyday. and their organization. Table 33–3 lists examples of sup- From a cognitive perspective. and using ECPs as collaborators in intervention. 896 Section V ■ Therapy for Associated Neuropathologies of Speech. routine suggests normal activities ultimately. organizing. talking. familial. improved performance of functional activities) and. Supports (Scaffolding) each discrete behavior—is a discriminative stimulus for the Within an everyday. Often. supports can be understood ated language. 1993) to guide successful thinking. of life. instead. generic therapeutic activities. associ- Feeney. lem and. Kregel. Wehman. to identify the most useful and positive talizing on the activities that are routine for the individual changes in everyday routines. . relaxation. relaxation. 5. 1998a. Establish well-rehearsed routines and scripts. 3. • Rest. Ensure orientation to setting and task. 12. facilitative instructions. Ensure that communication partners use supportive cognitive scripts (see later in this chapter).GRBQ344-3513G-C33[877-962]. meaningful roles to play and goals to achieve. Induce positive internal setting events (see section on behavioral intervention) before cognitively demanding tasks: • Positive behavioral momentum (see section on behavioral intervention). levels of support are systematically reduced as the 33–5 outlines this reversal. absence of pain. Adapted from Ylvisaker and Feeney. Table Finally. memory aids. and attention aids). organizationally clear graphic organizers) for complex tasks. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 897 TABLE 33–3 Antecedent Procedures for Supporting Individuals with Cognitive and Behavioral Impairment Supported Cognition 1. Ensure do-ability of tasks. Help the individual to manage behavioral antecedents (e. Establish alternative scripts to negative behavior (e. individual becomes more successful at everyday tasks and/or the initial goal generally has been to eliminate or reduce the . with permission. give the individual a positive role that requires responsible behavior). 9. 8. 8. at the same tation textbook can prescribe the unique combinations of time. habituates the use of compensatory procedures.g. Use collaboration to complete difficult tasks (e. systems of support are implemented so that This context-sensitive. pation). organization aids. Ensure that communication partners use elaborative and collaborative conversational competencies (see later in this chapter). Teach positive communication alternatives to negative behavior. cooperative work/learning groups. • Rest. • Choice and control. Within traditional rehabilitation. buddy system). finally context” hierarchy in rehabilitation. Ensure do-ability of tasks. Ensure that the individual has positive. 10. possibly including compensatory then disability (functional activities). can be practiced extensively in real-world contexts. including unreasonable demands. • Choice and control. 4. requires considerable creativity and flexibility. avoid overly stressful tasks. Supported Behavioral Self-Regulation 1. 9. 7. everyday.qxd 1/21/08 1:57 PM Page 897 Aptara Inc.g. 6.. No rehabili. Use appropriate cognitive prosthetics as needed (e. create scripts for potentially negative interactions. 5. 4. 2. Fourth.g. routine-based approach everyday routines of action and interaction are successful to rehabilitation reverses the traditional “first impairment. applies across the continuum of recovery after severe TBI. tematically increased.. and that important skills. contexts of successful action and interaction are sys- supports that often are needed in people’s real-world con. Use advance organizers (e. Desensitize the individual to events and tasks that cause anxiety. and alert friends and supervisors to how they might help during a stressful experience). Eliminate unreasonable provocation. Induce positive internal setting events before stressful tasks: • Positive behavioral momentum. electronic pager/reminder systems. 6. Help the individual to manage cognitive antecedents.. 3. Later in this section. then handicap (partici- skills.. 2. Ensure orientation to setting and tasks. 7. Create facilitative work/study environment. Desensitize the individual to events that cause anxiety. eliminate unreasonable demands. use clear.g.g. we illustrate how texts or can show how these changes in everyday routine can the process of modification and reduction of supports be motivating for everyone involved. absence of pain. 11. and Behavioral everyday life: What is working. modifying the environment. in the behavior of others. 898 Section V ■ Therapy for Associated Neuropathologies of Speech. and behav- reduction was a long-term outcome of intervention that ioral intervention for children and adults with TBI has been . educational contexts if impairment. port behaviors of others in the environment. with permission. Rather. • Modification of the support behaviors of other people in the environment underlying impairment with decontextualized exercises or • Modification of the attitudes of important people in the medical interventions. Finally. nizer to succeed in complex vocational planning tasks or dis. in the individual’s everyday routines and ensuring intensive ties by focusing on the environmental context: simplifying context-sensitive practice in the use of those compensatory tasks. neuropharmacology. impairment. unsuccessful routines into • Medical treatments (e. thereby Cognitive Psychology reducing the original underlying impairment. For example. the case of individuals with significant chronic cognitive and psychosocial impairment after TBI. give little reason for such optimism in From Ylvisaker and colleagues (1999). began with participation-oriented and context supports for Reversing the traditional hierarchy does not imply aban- successful performance of everyday activities (Ylvisaker & doning the goal of reducing the individual’s underlying Feeney. • Practice with compensatory procedures Step 4 Implement whatever supports are necessary for • Extensive practice of specific functional activities intensive practice of positive routines in real. Cognitive. Second: Attempt to improve performance of daily Step 3 Identify how those changes in everyday routines activities and increase participation if impairment-oriented can be become motivating for the individual and treatment is insufficiently successful. and Behavioral Rehabilitation course tasks may internalize the organizer so that it becomes Theoretical Support: Developmental an automatically applied knowledge structure. for critical everyday people in that environment. with permission. to transform negative. Based Approach to Executive System. Communication. 1999). however. vocational. First: Increase participation by modifying everyday form functional activities and overcome the ongoing disabil.. Second: Potentially.qxd 1/21/08 1:57 PM Page 898 Aptara Inc. people in the environment. social. Research and clinical or her automatic cognitive or self-regulatory mechanism. which they are internalized and become components of his oriented interventions are effective. Disability-Oriented. and increasing the sup.and disability-oriented Step 5 Systematically withdraw supports and expand interventions are insufficiently successful. 2000a. in the event of insufficiently successful disability. and Handicap- Oriented Interventions for People with Chronic Step 1 Identify successful and unsuccessful routines of Cognitive.g. Social. contexts as it becomes possible to do so. Everyday. impairment is potentially reduced as a result of internalizing habits of action and interaction that may have originated as deliberate compensations for chronic Rationale for a Context-Sensitive. impairment.GRBQ344-3513G-C33[877-962]. Several case illustrations have been presented in which impairment For many years. and in First: Attempt to eliminate the individual’s underlying the individual’s own behavior) hold the potential impairment with impairment-oriented treatments. • Modification of tasks. surgery) positive. and the environments in which they take place From Ylvisaker and colleagues (1999). restorative. Third: Attempt to modify the social. successful routines and to build • Impairment-oriented exercises repertoires of positive behavior. THE TRADITION IN REHABILITATION environment. Third: Potentially reduce the underlying impairment by tional approach often is most efficient in the case of physical ensuring that the individual practices compensatory proce- restoration—and in other domains as well. if reason exists to dures—in increasingly varied contexts—to the point at believe that decontextualized. This tradi. improve performance of daily oriented interventions. the intervention has tended to shift to attempts to II. routines. experience. If these efforts are insufficiently suc. this time to activities by including functional compensatory procedures attempts to increase the individual’s participation possibili. 1998a. a person who uses a graphic orga. our work in cognitive. including the support provided by everyday ity. AN ALTERNATIVE PERSPECTIVE equip the individual with compensatory behaviors to per. environment cessful. Routine- impairment. procedures. Ylvisaker et al. the focus again shifts.and Language-Related Functions TABLE 33–4 TABLE 33–5 Progression of Intervention Within a Functional Two Perspectives on Relations Between Impairment- Everyday Approach to Rehabilitation Oriented. and what is not Impairment after Brain Injury working? Step 2 Identify what changes (including changes in the I. routines.. or world contexts. . impulsive action.. Context dependence. Campione & Brown. 1996). child language disorders (see. p. 1990). Schneider & routine-based approach to rehabilitation. based on careful consideration of the information ized and become internal. Weber. frontolimbic injury jeopardizes both routes to suc- latory skills needed for success in his or her chosen contexts cessful action. Unfort- the client with the cognitive. Thus. e. or (2) act on the basis of learned and other ECPs play a role comparable to expert-parents in behaviors derived from one’s personal history of reinforce- relation to apprentice-children.. Gradually. injury as well as with frontal lobe injury can similarly be league. routine orienta- Palinscar & Brown. are more competent within the context of social-communi- cation routines. Table 33–6 contrasts two differ. can be resolved with supported everyday routines of action his work has enjoyed a striking renaissance in many applied and interaction as the basis for learning and successful fields. damage to the hippocampus. it is rather surprising addressed with automatized routines of action and interac- that relatively little attention has been paid to Vygotsky’s tion in everyday contexts. Real-world apprenticeship latory functions. helps in of many relevant factors.g. (however unconscious they may be). Damasio’s frontal lobe injury dilemma Russian psychologist Lev Vygotsky. are derived in childhood (and later) from that are. past rewards and . and an ability to flexibly transfer learning ent approaches to teaching: the traditional behavioral train.g. Grafman’s theory of executive e.GRBQ344-3513G-C33[877-962]. e. tolimbic injury tend to be impaired in all of these cognitive ter underpins interventions described later in this chapter. processes. For example. Over the past 30 years. everyday. processes as complex representations stored in the pre- cial education (see. People with significant fron- ing model. cognitive processes like for an everyday. clinicians “high reason” approach). or intrapsychological. The lat. 1996. tion to rehabilitation. available and memory for past successes and failures (the Within cognitive and psychosocial rehabilitation. with the goal of equipping ment (the operant or “somatic marker” approach).. functions. as interac. e. & McGilly. including educational psychology (see. The limitations of Watkins. as well as after TBI. Finally. in part. of life. 2002). ated with frontolimbic injury.. severe memory impairments associated with TBI-related According to Vygotsky. they are gradually internal- ized as the child becomes more and more proficient and Ylvisaker and Feeney (1998a) borrowed from the work of needs less and less cueing and other support from the adult” Antonio Damasio in building neuropsychological support (Vygotsky. communication.qxd 1/21/08 1:57 PM Page 899 Aptara Inc.g. first exist as (1994) sketched an apparently destructive dilemma associ- supported interpsychological processes—that is. yields an alternative neuropsychological 2001. internal cognitive and self-regu. Bodrova & Leong. Ashman & Conway. Evans. organizing. 1981. e. In his classic book Descartes Error. it appears that one must either (1) make good more mature thinker. and other professions. developmental cognitive psychology (see.g. Success via high reason presupposes reasonable planning The apprenticeship metaphor. beyond those that are instinctive or purely teaching offers the possibility of rehabilitation interventions sensorimotor. routine-based approach to rehabilita. frontal cortex lends further support for a systematic. behavior.. Alexander Luria (Luria. 1979). 261). of those behaviors. Brown. ports errorless learning practices with individuals who have 1998a). “Higher mental functions evolve through A Rehabilitation Dilemma and Its Resolution social interactions with adults. Damasio self-regulatory processes like self-instructing. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 899 guided.g. and problem solving. Westby. In information processing capacity associated with diffuse light of Vygotsky’s lifelong influence on the work of his col. frontal lobe injury. ecologically valid as well as internalization/appropriation of interaction with others who designed to minimize errors. Berk & Winsler. from one context to another. Without such connections in memory port to an everyday. others as being central to the diverse manifestations of 1990). 1989. Berk. highlighted by Mesulam and Campione. at the same time. decisions. and self-regu. 1994). spe. Flavell et al. e. adequate space in working memory for consideration ture the spirit of Vygotsky’s theories (Rogoff. jeopardizing the high reason approach to success- ful decision making and action. early childhood education (see. reasonable ability to inhibit during adult rehabilitation. 1989). and a Vygotskyan apprenticeship model. rationale for a context-sensitive.. 1992. by the theoretic formulations of the great tion. routine-based approach to rehabilitation remembering. and memory for the “somatic TBI—and most leading neuroscience theories designed to markers” or feeling states associated with the consequences explained these profiles—can be understood as lending sup. 1993). skill. increasing evidence sup- work in adult neurologic rehabilitation (Ylvisaker & Feeney. which often is used to cap. 1995.g. reading instruction (see. unately. To be successful in everyday tion between a child or other “apprentice-in-thinking” and a activities. adequate explicit memory for past translating a developmental theory into operational terms actions and their consequences. Success via learning from consequences presupposes rea- Theoretical Support: Cognitive Neuroscience sonable intactness of the neural circuits that are responsible and Neuropsychology for connecting two types of memory: memory for the fac- Commonly observed neuropsychological profiles following tual aspects of past behavior. the processes are internal. • The teacher coaches (including suggestions. • The learner contributes what he or she can contribute. • The learner performs. the collaborator is available to contribute whatever the learner cannot contribute to successful completion of the task. • The trainer may model performance. repeated practice is required to habituate the learned behavior. modeling. with permission. and encouragement) and continues to collaborate as the learner accomplishes more components of the task. • When performance is adequate. • Performance is solo. • Transfer is guaranteed because it is part of the context-sensitive teaching process from the outset of the teaching process. • Performance of the learner is demanded by the trainer. or both. • Systematic transfer procedures are then applied. From Ylvisaker and Feeney (1998a). • The teacher engages the learner in collaborative. feedback. • Reduces the difficulty of the task. the learner is reinforced. • Tasks and components of tasks are hierarchically organized. prompts. Task structure • The teacher (facilitator. shaping procedures. • Learning takes place within the context of projects designed to achieve a meaningful goal. • The teacher continues to provide ongoing incidental coaching. the trainer either: • Requests a hierarchically easier task. goal-oriented. not social. functional. not solo.and Language-Related Functions TABLE 33–6 Features of Teaching Tasks: Traditional Training Model Versus Vygotskyan Apprenticeship Model Traditional Training Model Context • Training takes place outside of a natural setting. • Provides needed cues. • As the learner improves. brainstorming. the task is completed collaboratively. • If the performance is inadequate. • If the performance is adequate. Task structure • The trainer requests performance of a specific task. • The learner is not expected to fail. rather. • Tasks are not necessarily organized hierarchically. 900 Section V ■ Therapy for Associated Neuropathologies of Speech. project- oriented work. the learner can learn aspects of difficult tasks by participating with a collaborator. cues.GRBQ344-3513G-C33[877-962]. . • Performance is not demanded from the learner. collaborator) introduces a task and engages the learner in guided observation (not necessarily task specific).qxd 1/21/08 1:57 PM Page 900 Aptara Inc. Vygotskyan Apprenticeship Model Context • Learning (ideally) takes place in a natural setting for the behavior or skill that is to be learned. the task is made more difficult. • Completion of the task is social. supports are systematically withdrawn. which are very common in sciousness beyond the here and now) CHI. Individuals with frontal lobe or diffuse neuronal pathology. This explains the observed phe. to appreciate ambiguity. “executive direction” of orbitofrontal cortex. In our view. The theory of Rolls. These representations or knowledge structures are nomenon of individuals with frontal lobe injury failing to strengthened by multiple experiences with activities in the learn from the consequences of their behavior. difficulty expanding con- ventromedial prefrontal lesions. Distractibility. Rolls also world.. and changing direction. Difficulty with decision making in novel situations who respond immediately to rewards and punishments but 4. shifting. activity failures and contextually inappropriate behaviors are Context Dependence and Frontal Lobe Injury likely to occur. 2002). return to this theme in the section on assessment. escaping through the horns perspective that is context sensitive and attempts to build of this dilemma requires the development of contextually repertoires of successful behavior.GRBQ344-3513G-C33[877-962]. Grafman’s theory of prefrontal function proposes that exec- Related to the somatic marker theory is Roll’s view. Damasio. is activation quences and to modify behavior in relation to changing con. lack of con. action and interaction triggered by contextually appropriate ing. socially inappropriate and disinhibited behavior. insensitivity to contextual subtleties. ecological invalidity of office-bound assessments.) ditional behavior management. as well as scripts of self-regulation should be practiced to function highlights. experience. and self- relevant cognitive. is to distinguish rewarding conse. In the section on behavioral and psychosocial rehabilitation (below). and whose behavior in the long run is inefficiently shaped by the emotion organized arrangement of such consequences (Damasio. both of which are common in TBI. thinking Some clinicians respond to this dilemma by suggesting (a) 6. From this central theme evolve the everyday life. 1990. When additional demands are placed on those resources. we return to this Executive Dysfunction as Impairment theme of relative inefficiency in learning from of Structured Event Complexes consequences. perseveration.e. Mesulam also uses procedures (see Tables 33–3 and 33–6 for operational defin. 2002). 5. Cognitive egocentrism or difficulty switching perspec- that consequences must be much more extreme than is com- tives (otherwise known as impaired “theory of mind”) monly necessary or (b) that individuals with significant fron- tolimbic injury may require a substantial degree of external Each of these themes is addressed within an intervention control indefinitely. regulation triggered by environmental stimuli specifically acquired with the help of antecedent-focused apprenticeship relevant to the individual being served. and impaired perception/identification of facial Limited Processing Capacity and voice emotion—with associated alteration of emotional processing and increased disinhibition and behavioral prob. like that of Damasio and col. lack of affect. Thus.qxd 1/21/08 1:57 PM Page 901 Aptara Inc. often have limited pro- leagues. The clinical need to automatize self-regulation . resulting in the common clinical profile of people 3. Extensive investigations of adults with frontal injury: lobe injury have convinced Damasio and colleagues that 1. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 901 punishments lack the power to drive future decision making commonly observed deficits associated with frontal lobe and behavior. provides a comfortable theoretical home for cessing resources (Schmitter-Edgecombe. These lim- intervention based on the creation of positive. Thus. or inadequately rehearsed activities. Inflexibility. (We will ior. everyday. of novel. based utive processes really are complex mental representations on extensive research with primates and humans. as its central theme. cern/egocentrism. including diffi. complex activities. particularly in the context context-sensitive routines of action and interaction. lems. weaken the ability to connect these two types of 2. Tranel & Damasio. Impaired integration of reason. that the (“structured event complexes”) at greater or lesser levels of key function of ventral prefrontal cortex. Furthermore. understood neurologically. euphoria. Grafman’s view supports attempts to bring more general frontal lobe phenomena an approach to rehabilitation that attempts to strengthen under this reinforcement-learning umbrella. complex. Poor working memory (i. Tranel. environmental stimuli. 1996). and difficulty with abstract 2002). that the frontal habituation. we argue later that everyday activities Mesulam’s (2002) review of frontal lobe function and dys. as in traditional training models of intervention and tra. communication. 1991. perseverat. ity. irresponsibility. and disinhibition memory. in particular the generality (Grafman. thinking. Like the previous theories. this practice should take place lobes enable humans to transcend “the default mode” of within the context of everyday activities so that the environ- inflexible stimulus–response linkages tied to the immediate mental triggers are those that the individual will encounter in stimulus environment. these complex knowledge structures by creating routines of culty sorting. failure 1998. and behavioral habits. his default mode theory to explain the well-documented itions) rather than relying on consequences to shape behav. ited resources are easily exhausted. of a complex knowledge structure that represents that activ- tingencies (Rolls. the teach- ory training: “the retention of particular things” but not ing/learning process can be conducted either in a trial- “general physiological retentiveness. 1989). strategy intervention for stu. 2001. at the time of injury. Baker. 1983). Isolating components of people (e. Pressley. 1994. Dunlap. Thus.. For example. who have a history of TBI and ongoing difficulty with com- dents with and without specific disability (see. 2002. routine-based & Anderson. 2005. Economic Support: Managed Care and the Demand for Efficient Rehabilitation Empirical Support: Transfer (Generalization) A fourth category of support for an everyday. Reichle & Wacker. Morris.. working memory. Giangreco. everyday. 1999).. State Department of Health. Reeve. Singley & Hallowell. 1989. yielding substantial savings for the New York 1995. and deductive rea. Nippold. learning disabilities (Kavale & Mattson.g. & Dunlap. retraining exercises (popular during the 1980s for TBI reha. designed specifically for individuals with serious. Wiener & Harris. e. Park & explicit memory and learning in many individuals with TBI Ingles. selective attention. e. 1989). 1890. 2003). Gersten. Ylvisaker et al. Sweet & Snow. over the past 10 years. specialists to intensify their collaboration with everyday sitive to this important principle. 2004) showing that self-regulatory resources are tasks largely unrelated to functional application tasks falls depleted with effortful self-regulation. assuming that the teaching was adequately sensitive to context. & Iverson.g. positive outcomes for the participants but also proved to be 1986. Resource Project has served more than 1. cognitive. such as cognitive rehabilitation. 1993). e. 1994. colleagues (2001) found that the program not only yielded and language and social skills intervention (see. Implicit Memory. yields the following heuristic principle: Behaviors or skills Some funders routinely deny reimbursement for interven- acquired in a laboratory or training context are unlikely to trans. routine-based approach to intervention. 1999. rehabilitation planning. 2003. tions. 1998). the use of decontextualized cognitive ists to creatively design ways to accomplish more with less. chronic Carr. Sugai. squarely in the tradition of decontextualized cognitive train- ing that has been found to be relatively ineffective with Procedural Memory. cost-effective. routine-based and Maintenance approach to rehabilitation is provided by the fierce eco- Decades of experimental studies of generalization and main. 902 Section V ■ Therapy for Associated Neuropathologies of Speech. job coaches. special education (see.g. and educational the lengths of inpatient rehabilitation stay and reduced psychology have amassed large quantities of evidence that access to outpatient services (AHCPR. eral supports for rehabilitation have dramatically shortened Many investigators in behavioral. behavioral intervention (see. 665).. At the same time.g.. & Horner. Carr et al. cognition (e. 1979). 2001). Anderson. Koegel & Koegel. Individuals practice (James. Feeney and Koegel. 1997. Fey. in large part in the context of the everyday routines of life . Under these stressful eco- & Noell. direct care staff. 1993)... More than 100 years ago. Walker. 1999. 1997.” can be improved with and-error manner or in an errorless manner. 1999. Johnson. Kennedy. to achieve positive outcomes with fewer resources.and Language-Related Functions scripts is based on studies (see review by Schmeichel & soning) and engaging people in massed learning trials with Baumeister. Schmidt. Cicerone et al.. family members.000 young adults Cloninger. e. New York State Department of Health Neurobehavioral 1993. 1994. the prevalence of TBI-related disability con- has led to the development and validation of increasingly tinues to increase because of the population’s relative youth context-sensitive interventions in many clinical fields. dures of action and interaction can be learned without error and triggered by environmental stimuli. This Medicaid waiver community support program was 2002). it is critical for rehabilitation special- In our judgment. The systematically increasing with significant memory disorders associated with damage use of everyday contexts for cognitive and behavioral inter- to the hippocampus benefit from errorless teaching proce- ventions bears testimony to these concerns about transfer dures (described below). munity reintegration. and others) so that long-term rehabilitation can be provided sequential or categorical organization. & Koegel. return for their limited support of rehabilitation (Henri & 1988. 1997). Irvin. As we describe apprenticeship teaching. MacDonald. Martin & Pear. nomic circumstances. Inviting bilitation and still used today by some practitioners) is insen.. Recognition of the impact of this principle Meanwhile. Wehman et al. 1995. that are said to have fer to functional application contexts and be maintained over time an inadequate research base.qxd 1/21/08 1:57 PM Page 902 Aptara Inc. & Scanlon. and Errorless Learning many disability groups. William approach to rehabilitation and errorless teaching proce- James made the same observation in connection with mem- dures. Gresham. cognitive and behavioral impairment after TBI. Schwarz. funders without heroic efforts to facilitate that transfer and maintenance increasingly demand improved functional outcomes in (Detterman & Sternberg. 1996. e. p. the including vocational rehabilitation (see.g.GRBQ344-3513G-C33[877-962]. often many years after their injury.. 1995). Horner.. & Magito-McLaughlin.g.g. nomic realities that have come to play a prominent role in tenance offer yet another support for a richly context-sensi. Koegel. and The superiority of implicit memory and learning over TBI (Carney et al. 1993. 1992. as well as in people without disability (Singley provides additional support for an everyday. everyday habits and proce- (Ylvisaker. Managed care and cutbacks in fed- tive.. including mental retardation (Mann. GRBQ344-3513G-C33[877-962]. C. (2) tie interventions to positive personal metaphors or life narratives. (d) preparing for legal testimony. (2) help the individual self-manage antecedents. difficulty remembering past successes and failures. the tests may offer little guidance in creating the most fruitful approach to ASSESSMENT FOR PLANNING FUNCTIONAL. alarm watch).qxd 1/21/08 1:57 PM Page 903 Aptara Inc. Possible Solution: Proceduralize positive context-sensitive routines using implicit versus explicit memory processes. Possible Solution: Facilitate acquisition of social competencies in the context of everyday social interaction. several standardized tests have Cognitive and communication assessments may be con. Threat to Social Success: Reduced initiation. (3) Create positive metaphors that package several pieces of information into one thought unit.g. represents a positive response to the crisis of funding for a disorder. such as positive setting events and avoidance of identified triggers. (e) acquiring services or funding. Threat to Social Success: Inefficiency in learning from consequences. For example. Threat to Social Success: Reduced inhibition. work within the individual’s world of meaning and personal goals. Threat to Social Success: Reduced organizational skills. Possible Solution: Provide needed supports in everyday routines. obviating the need for complex thought processes. participation limitations. with permission. Threat to Social Success: Difficulty transferring newly acquired skills from training to application contexts. routine. From Ylvisaker and Feeney (2000a).. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 903 TABLE 33–7 Rationale for an Everyday. (2) create prosthetic reminder systems (e. (b) formulating a prognosis. procedural versus declarative memory systems. lowing directions at work). Threat to Social Success: Difficulty making good decisions based on thoughtful consideration of consequences and other relevant factors. Furthermore. a standardized based approach to rehabilitation addresses chronic obstacles aphasia battery may be useful in diagnosing a specific lan- to social success after TBI. purposes of assessment. Threat to Social Success: Impaired working memory. CONTEXT-SENSITIVE INTERVENTION Over the past 15 years. and behavior. Possible Solutions: (1) Practice positive everyday routines so that they come to be elicited by everyday environmental cues. reducing the individual’s impairment and increasing activity and participation domains.e. been developed for use with adults who have TBI. From the Perspective of Behavior Management A. possibly including graphic advance organizers. and (g) monitoring the results of intervention. Possible Solutions: (1) As much as possible. Routine-Based Approach to Intervention for Individuals with TBI From the Perspective of Executive Functions A. associated activity reductions (i. cognition. D. and context facilitators and barriers. everyday routines that include external organizers. Possible Solution: Build repertoires of positive behaviors using antecedent supports versus relying on consequences to shape positive behaviors. such as initiation scripts. degree of difficulty fol- Some of the solutions are elaborated later in this chapter. Summary Specific assessment procedures may be valid for some. (f ) developing an interven- tion plan. Possible Solutions: (1) Create everyday routines that include ample antecedent supports. (c) generating epi- rehabilitation. From the Perspective of Cognition A. Possible Solution: Create everyday routines that include initiation supports.g.. Obstacles are grouped under the guage impairment but offers little help in identifying the headings of executive functions. not all. and peer support for initiation. including (a) diagnosing the Scales of Cognitive Ability for Traumatic Brain Injury .. stopping short of a degree of support that creates learned helplessness or oppositional behavior. but Table 33–7 summarizes ways in which an everyday. including ducted for several distinct purposes. Threat to Social Success: Impaired explicit and strategic memory. and involuntary versus strategic or effortful learning tasks. demiologic information. Threat to Social Success: Oppositional behavior. initiation cues (e. B. B. Possible Solution: Create positive. B. C. pager systems). friends. functional tasks of everyday life ing a type of assessment designed for other purposes. and to identify tional. Turkstra. or RIPA-2. everyday approach to intervention described in this changes in the behavior of communication chapter (Ylvisaker & Feeney. job supervisors. Functional interven. Standardized aphasia tests and test batteries and Ylvisaker (2005) discussed the strengths and limitations Standardized motor speech tests of standardized testing for individuals with TBI. Baddeley. 1998a. Ylvisaker & Gioia. mental modification strategies that may enhance Hypothesis-Testing Assessment for Planning participation. academic. Context-Oriented Assessment Purposes: For treatment planning: to identify facilitators and barriers in the environment. Rivermead Behavioral Memory Test (Wilson. to identify environ- Functional. Coehlo. Brown. Approaches to Communication Assessment for or BTHI. collaborative. others (OCCHTA) & Campione. using to assessment for purposes of planning. special education. individual with ongoing disability. FIM.qxd 1/21/08 1:57 PM Page 904 Aptara Inc. static versus dynamic assessments are con. and context. & Calabrese. 1996). Dynamic: Context-sensitive experimentation with environmental supports and with potentially rated by Feuerstein (1979) and. Standardized: Functional scales (e. activity/partici. assess. we restrict our discussion explain unsuccessful performance. Static: Standardized neuropsychological tests and test 2005). office-bound assess- associated limitations of social. Graser. family members. This approach to assessment has its historical roots vocational pursuits and roles in Vygotsky’s dynamic assessment (Vygotsky. 1988) tion often is directed at reducing disability by improving compensatory behavior in specific functional contexts of Activity/Particiaption-Oriented Assessment activity or at increasing participation either by modifying Purposes: For diagnosis: to identify possible effects of the environment or by improving the support behaviors of neuropsychological impairments on real-world performance of functional activities and others. and others.and Language-Related Functions (Adamovich & Henderson. e. 1978). This scheme for classifying assessment identify strategies that may improve performance procedures may help clinicians to avoid the common pitfall Static: Customized: Observation of performance of of attempting to achieve an assessment goal by administer. Dynamic: Experimentation with strategies and supports that hold the potential to improve performance of sis-testing assessment is designed to identify the interven- daily activities (OCCHTA) tion and support procedures that hold the greatest promise for rehabilitation of the individual. con. Burgess. Speech-Language-Hearing Association FACS. Measure of Purpose: For diagnosis: to identify underlying Cognitive-Linguistic Abilities (Ellmo. 1991). Collaborative. and DRS) classification. monitoring. as elabo. Dynamic: Process assessment: to identify what intact neuropsychological process explains successful Standardized assessments can serve a variety of useful performance and what affected processes purposes. standardized. For treatment planning: to identify everyday grouped under the headings of impairment. Ross Information TABLE 33–8 Processing Assessment (Ross-Swain. In the case of individuals with complex impairment Static: Standardized: Quality-of-life inventories and disability in the domains addressed in this chapter. Whereas static assessment often is used for diagnosis. we present categories of assessments. Context-Sensitive. 1994). 1995). dynamic hypothe. test items (Kaplan. and teachers) Elsewhere. Behavior Rating Inventory of Executive Function People with Traumatic Brain Injury –Adult Version (Roth. 2005). by many practi- helpful changes in the support behaviors of tioners in educational psychology (see. more recently. trasted. Impairment-Oriented Assessment Alderman. batteries Cockburn. In these cases. and hypotheses. Customized: Observation of and interviews ment for purposes of planning intervention is ongoing. Isquith. however. speech-language . Elmslie. 1985).. regarding level of participation and level of text-sensitive. 1992). Functional Assessment of motor. Behavioral Assessment of the Dysexecutive Syndrome (Wilson.g.. vocational. Palinscar. to identify strengths and needs of Intervention everyday communication partners (e. 1996).GRBQ344-3513G-C33[877-962]. and ments are not particularly helpful.g. and based on careful tests of success in social.g. American Furthermore. & Evans. & Gioia. familial. we have described and illustrated an experimen- relative to their ability to serve as supports for the tal approach to assessment that is consistent with the func. activities that require intervention and to pation. In this chapter. Krchnavek. strengths and weaknesses Verbal Reasoning and Executive Strategies (MacDonald. partners that may enhance successful participation 1998). including linguistic and Hauck. Brief Test of Head Injury (Helm-Estabrooks & Hotz. 904 Section V ■ Therapy for Associated Neuropathologies of Speech. neuropsychological. and outcome monitoring. educational participation In Table 33–8.. and systematic hypothesis-testing modification of modifying individualized intervention. therefore. specialists in rehabilitation do not know why people succeed changes in environmental and task demands. 1990. In addition. learn about the realities associated with the disability. & Desmarais. 1985. collaborative formulation. 1996. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 905 pathology. the process included collaborative with TBI (or. 1994). because the tasks are novel and the familiar stim- mation. Crépeau. contributes to line of the steps of functional. self-monitoring. 2005. & Finally. or real-world strategic Collaboratively Formulate Hypotheses thinking. Participation in collabora- long history of assessment by means of experimental analy. 1999). if a person has trouble with a task. Alderman. In these cases. & Damasio. tional problem that calls for intervention. issue may be identified by one person as defiance. and skills are involved in most Why Ongoing? human behavior. & Diller. oped. & Paulman. the same behavioral Varney & Menefee. 1988).. Burgess. ness. Collaboratively Identify the Problem 1991. Assessment Process Why Context Sensitive? Ylvisaker and Feeney (1998a) illustrated the processes of The ecological validity of office-bound. plans and to identify interventions that have a demonstra- laborate in implementing the intervention plan resulting ble effect. challenged by the results of many neuropsychological stud. Hayden. Our goal in this section is restricted to present. Stuss & Buckle. Rath. Kern. that suc- neurologic recovery for months and. Simon. profound statement of respect and. aides. Scherzer. bers. Others perform surprisingly poorly on standard- Hypotheses may be derived from neurodiagnostic infor- ized tests. that be performed. program. frontal lobe injury) has been identification of the problem. these specialists are not in a position skill levels of everyday people in the environment all con- to create a meaningful. task identi- fication. cess may be a product of varied strategies (Kaplan. in the individ- when they succeed or what underlying impairment explains ual’s ability levels and psychoreactive responses. more specifically. If This by itself mandates ongoing assessment. it is critical to agree to a neutral descrip- mance. processes. appropriately targeted intervention tribute to ongoing unpredictability in evolving outcome. and collaborative inter- ies (Anderson. 1991. it is not so easy. 1986. Sherr.GRBQ344-3513G-C33[877-962]. & Wilson. family mem- Falk. individuals can continue spontaneous that difficulty. standardized tests of collaborative. 1993). little difficulty exists in identifying the func- Langenbahn. Turkstra et al. Why Tests of Hypotheses? Rationale Many capacities. Emslie. Tranel. impose few demands in the areas of goal setting. selection and testing of hypotheses. and in the failure when they fail. 2000. however. clinical expe- ulus cues of everyday life are not present to support perfor- rience with similar individuals. inviting ongoing assessment to ensure that services and sup- ports are maximally effective. 2000. Typically. tive assessment also is an ideal way for everyday people to sis of variables that potentially influence behavior (Iwata. Stuss & Benson. and the number of functional experiments that can hypotheses.qxd 1/21/08 1:57 PM Page 905 Aptara Inc. because the tests are externally structured and tion of the problem behavior before proceeding. Dennis. when a person succeeds. 1992. Therefore. For example. the number of real-world contexts that can be hypothesis and then subject it to testing along with other explored. Behavioral psychologists have a from the assessment is increased. initiation. Eslinger & Damasio. however. hypothesis-testing assessment team building. in some cases. Vollmer. Dunlap. or real-world interaction mance. years. Clarke. In some cases. . by another ment of executive function perform better on standardized as withdrawal. and others to become collaborators in assessment is a ing a brief rationale for this type of assessment and an out. In either case. Benton. In each case.. tests must be supplemented by with the person whose intervention plan is being devel- effective use of real-world contexts in functional assessment. context-sensitive hypothesis-testing assess- cognitive and communication functioning for individuals ment. Childs. It may Collaboration increases the number of observations that can not be as easy to label one’s favored explanation as a be made. teams of professionals and others have lit- tle difficulty in generating possible explanations for the Why Collaborative? person’s behavior or proposing intervention plans. the likelihood that these same people will col. and other fields. Similarly. when many people collaborate in enables teams to move beyond conflict over treatment assessment. This is precisely the process. Therefore. pretation of the findings in relation to planning interven- tions and supports. & Zarcone. there typically are scores of potential explanations for Following severe TBI. Belleville. alternative hypotheses must be tested. 1998. In addition. Some individuals with impair. Tranel. 2002. LeBlanc. 1997. Evans. (Ylvisaker et al. 2000. neuropsychological or other testing. Dywan & Segalowitz. asking professional colleagues. Damasio. In other cases. and by still others as lack of initiation or lazi- tests than one would expect based on real-world perfor. g. it is stimulation associated with pathologic responses or with- important to start with hypotheses that are readily testable.. more interesting medication. vocational. Before her injury. trial intervention works well. In other cases. then the treatment plan may In addition to diffuse injury. auditory stimuli. 1998a). context-sensitive impact of hypothesized variables one at a time. neglect and suspected abuse. if the intervention is successful). context-sensitive experimental available community support funding through a Medicaid assessment from the perspective of cognition.g.g. a trial intervention. Variables that need to be explored include time of day. and given a job in a developmental disabilities sheltered tions under which the individual is maximally alert. communication. within a controlled assess.g. and wandering. In the social environment of that work setting. In the individual appears to give little response at the time. Context-Sensitive. and physically aggressive behavior. circumlocution. movement Some hypotheses may be easier to test than others. and to encourage basic levels of communication with results that will be recognized and accepted by all (e. Feeney and Ylvisaker (1995) presented of the disability and the supports that are useful in increas- three single-subject experimental designs that fit this ing participation and improving everyday functional activi- description. it may not be recreational. At the time of our involvement. waiver program. If the complex hypothesis is con. and nursing staff are encouraged to engage the individual ment setting. cognitive. some cases.. and behavioral domains. ties (Table 33–9)..GRBQ344-3513G-C33[877-962]. When people have chronic disability in the executive factory.. aggressive communication. nally focused. She had Feeney.. Selecting ration is to maximize the amount of time the individual hypotheses to test—and the order in which to test them— spends at the highest levels of responsiveness. highlighted later in this chapter (Table 33–9) often are the firmed and in what combination.qxd 1/21/08 1:57 PM Page 906 Aptara Inc. in effect. neurodiagnostic imaging follow in a relatively automatic manner. in which the issue to be explored is serious (e. and behavior is designed. Sue was employed as a laborer in a large ments. She had a history of marital conflict. If the Sue incurred severe TBI at age 35 in a motor-vehicle crash. and home until she demonstrated the communication and anger . self-care.. and Collaboratively Test Hypotheses controlling sources of stimulation like tape-recorded music). Sue was 47 years old and fied as positive by means of hypothesis testing (Ylvisaker & had been a resident of a nursing home for 12 years. several hypotheses can be tested within a Once appropriate supports are identified. the revealed significant left hemisphere frontotemporal damage. to identify the condi. to minimize requires balancing these considerations. warm bath). exter. and responsive to environmental stimuli. lighting. the process extends for weeks frequently in meaningful activities of everyday life. Formulate an Intervention Plan Collaborative Hypothesis Testing In many cases. staff explore ways in which the individual can be supported in participating in activities of everyday life (e. firmed (i. but at least the clinical variables manipulated experimentally to identify the nature problem is solved. to experiment with a form adaptively on activities of daily living as well as on per- multifaceted intervention. disorganized behavior in all domains of life. drawal. possibly. In some cases. been diagnosed with serious cognitive-language impairment (including anomia. the test is. reduced anger Early and Middle Stages of Recovery control. and behavior largely is designed to identify behavior) and requires immediate attention. 906 Section V ■ Therapy for Associated Neuropathologies of Speech. she was placed in a supported apartment tion. Sue’s aggression escalated. and some (e. levels of may have greater face validity than others.g. In addition. and differential responses to people and their implications for intervention than others. in part. it may be desir. in other cases. the environmental and task supports that are needed to per- able to combine hypotheses—that is. Collaboratively Interpret the Results and Illustration of Context-Sensitive. With newly Early in neurologic recovery. In general. children had been removed from her home as a result of intervention often takes the form of supportive modifica. educational. reaching for desired objects or pushing undesired members of the team. the Local staff proposed that she be returned to the nursing sensory environment (e. in other cases experimental assessment from the perspective of cognition.and Language-Related Functions Collaboratively Select Hypotheses to Test tactile responsiveness). and social tasks.. and be embraced communication styles. even if and mandates exploration in several real-world settings. The goal of this systematic explo- by more members of the team than others. hypothesis testing is designed to explore the During the middle stage of recovery. responses to positioning.g. objects away). Experimental Assessment in the episodic and semantic memory impairment. tions of everyday routines—modifications that were identi. communica. turning on and off lights.e. sonally meaningful communication. workshop. family members short period of time and. rocking) and temperature (e. treatment plan may be an elaboration of the initial experi. and her two system. tangen- tial discourse). The supports and scaffolding possible to know which individual hypotheses were con. in group therapy). • Develop strategies and organizers for devices (e. self-awareness. and • Improve organization of spoken and written and extended texts related to reactions. manager. and self- • Increase recognition of objects activity. • Improve external focus. banking or shopping). deficits. visitors to see. • On request. Memory. memory. planning. • Determine value of cards and list prices. expression management. organizers.. • Write names of players on each team.. decreasing use of external organizers. determine shows. on the nursing unit.qxd 1/21/08 1:57 PM Page 907 Aptara Inc. direct care staff. including • Purchase and organize new cards in the album sleeves. with external supports. review. (Maximal Support) (Moderate Support) Support as Needed) EF-Cognitive-Language Goals: EF-Cognitive-Language Goals: EF-Cognitive-Language Goals: • Increase alertness and arousal. • Increase independent creation.g. friends. (continued) 907 . determine availability and cost of cards. married father of two with a pretrauma avocational and vocational interest in baseball cards. and self. switches to control electronic • Plan menus. Late Stages Early Stages Middle Stages (Relative Independence. orientation. Facilitators: Therapists. recorder). • Improve basic communication: • Use a prosthetic log/memory system to aid • Improve organization of discourse with comprehension of simple. prepare script in advance with collections. the help of a graphic organizer. activate members). family members. • Move cards in and out of • Show and describe cards to others. • Interact with visitors at a card show. card collecting..g. • Create organized displays for card • Help find all the cards from a • Role play selling cards at a show. everyday language. • Improve comprehension of vocabulary of basic wants. and people.g.. Language. • Explain features of card trading to peers in • Help his children with their • Place cards into rows for group therapy. and Executive Functions Client: Tom is a 30-year-old. vocational and avocational interests. prepare own lunch. • Increase independent use of strategies • Increase engagement in • Use organizing schemes. activities of daily living recovery or with greater disability. and self-monitoring). writing letters to family • Work with his children in the use of • With prompts. Meaningful Activities/ Meaningful Activities/Everyday Everyday Routines: Meaningful Activities/Everyday Routines: Routines: • Turn pages of a baseball card • Organize cards by team or value. • Stack cards as others look at • Read/write short narratives or biographical • Keep financial records. page. children. experiences to offer visitors. collection. Residual impairment in the areas of executive functions (e. discourse. memory. TABLE 33–9 Illustration of Functional. and organization of language were associated with frontolimbic injury. He collected cards and traded them at shows and on the Internet. organization. Transfer Activities: Transfer Activities: Transfer Activities: • Assist other individuals with traumatic • With support. team. needs. ability to shift • Improve awareness of self as a thinker. planning. participate in • Use graphic organizers and written reminders brain injury at an earlier stage of self-care activities and other for other tasks (e. costs for purchase of various combinations of • Set up a display at a card show. including external to compensate for ongoing cognitive overlearned activities. and revision of compensatory strategies. ability filter out distractions. organizing systems for their homework. TV or tape • Organize narratives and descriptions of other demanding activities (e.g. and self-evaluating. communicator. describe players to • Read and write articles about baseball • Find particular cards on the others (e. • Increase duration of attention. attention from object to object and activity to learner. initiating. organizing. • Improve perceptual scanning abilities. Content. sketches about players. activities of daily living.and Context-Sensitive Executive Function/Cognitive Rehabilitation Through the Continuum of Recovery: Organization.GRBQ344-3513G-C33[877-962]. them. to complete functional tasks. viewing. compensate for deficits. hand the cards to cards.g.. implementation. • Use sales books and the Internet to album or collector book. Long-Term Goal: The client will regulate his behavior adequately to manage his baseball card collection and resume trading with minimal assistance. • Improve awareness of needs and strategies to • Improve independent goal setting. • Use goal-plan-do-review format in all therapies. in system. facilitator encourages future reference. the task. Content.. feature analysis guide brainstorming if systems fail. the facilitator helps Tom the important aspects of each component of identify barriers to success (e. be included. and inattention to scheduled responsibilities. makes reading comprehension problems. ultimate goal of improving recall included in the book. initiates work. Facilitators Photographs of staff. and Executive Functions (continued) • Review family picture albums..g..g.”). An outline of cognitive and adaptive plan activities. • Continue to use goal-plan-do-review • Look at greeting cards. “Did makes plans. components of tasks to Tom. • Facilitator may be required to progress (“Let’s make sure we’re getting the facilitator provides feedback. He begins to write his own entries. system and/or computer memory review the log with Tom with the and graphic organizers for important tasks are system may be used. inventory independent use of memory aids. no. progress. monitors write) in an organized manner. and helps Tom record self and products. The system is used.g.g.qxd 1/21/08 1:57 PM Page 908 Aptara Inc.g. Memory. independent use of organizing systems “Let’s see if we can find a • Facilitator begins all activities with (e. prepared Yankee. thank you cards. Tom gain greater insight into his strengths Scaffolding: and needs. which progress. graphic organizers. well-organized schedules. biographical sketches. format for major life activities. gaps in his knowledge base) and develop customized strategies to overcome them. as (e. identification of the goal and formulation of a scripts) to communicate (speak and Scaffolding: plan (e. touching a card sheets... Facilitator Expectations and Facilitator Expectations and Mediation: Facilitator Expectations and Mediation: • Facilitator ensures that the environment is Mediation: • Facilitator is responsible for appropriate for efficient information • Tom increasingly assumes modifying the environment processing. models organized thinking. that’s a Dodger. hand-over-hand) to verbal (simple role. facilitator (e. TABLE 33–9 Illustration of Functional. Tom’s • Facilitator treats Tom’s actions.. and facilitate memory. know his schedule. graphic • Tom assumes responsibility for seem appropriate to the organizers such as price sheets. engaging Tom in any way do?”) and usefulness of supports (e. • Play simple card games with children. • Facilitator plays an ongoing role as Scaffolding: coach (if necessary).and Context-Sensitive Executive Function/Cognitive Rehabilitation Through the Continuum of Recovery: Organization. • Facilitator changes prompts from physical wife) may simply play a monitoring even if accidental. evaluates possible (e. 908 . consultant. An electronic pager with one another. Log/Journal/Memory Book: Log/Journal/Memory Book: Log/Journal/Memory Book: Facilitators keep a log of Tom’s Tom gradually assumes greater responsibility Tom has primary responsibility for significant experiences and for management of the log/memory book upkeep and use of the book.g. remember important events. • Facilitator associated simple for organizing full descriptions and practicing • Tom assumes responsibility for language with actions (e. with may become more like a traditional part. meaningful and makes them instructions) to graphic (e. discourse guides for narrative and facilitator engages Tom in is interpreted as a request). ends all sessions with review • Tom assumes primary responsibility task. and • In addition to cues and organizers. Language. disorganized record keeping. responsibility for creating organizing and stimulus presentation to fit • Facilitator gradually turns over more systems to accomplish home and work Tom’s response potential. daily use of executive function routines • Facilitator highlights improvements and the and brainstorms with Tom about value of the supports that are used. connections to related activities. organized word retrieval). and needs and strategies may continue to functioning and to communicate keep track of goals and assignments.. the source of emotional support.”). and chooses strategic joint performance of the task)... As a facilitator uses verbal mediation to highlight consultant.g.g. of daily events and establishing a routine of review.g. but collaboratively of achievement (“Did you finish? How’d you for self-management (e. helping strategies. hand-over-hand this organizer help?”). tasks.g..GRBQ344-3513G-C33[877-962]. use of an organizer).. important information in a memory book for compensations). sets goals. including physical therapies. routinely reviews the goal. therapist. The book plays a meaningful role in day planner to organize daily events factors that promote improved helping Tom stay oriented. to help facilitators identify guidance. plan. • Write letters.g. situation (e. perform all components of the job done right. With 4. Sue continues to be successful in her nonsupported job and community In Appendix 33. Social communication intervention. communication. poorly controlled atten- ing those plans in response to feedback (Lezak.g. people with frontal lobe real-world routines as the context for those tests. The staff insisted that she must first virtual reality (VR) in rehabilitation.g. we do address mem- work to complete a large number of assigned tasks). learn. execu- four main sections: tive functions often are characterized as being high on a hier- 1. the EF/SR lectual. because of executive system impairment. 1982. a discussion of positive job with detailed. demonstrate work and interpersonal skills in a sheltered set. paying attention in the presence of distractions). Yet even in these cases. inhibiting aggressive behavior when nition.g. and in our discussion below. Most cognitive ning how to achieve them.qxd 1/21/08 1:57 PM Page 909 Aptara Inc. of traditional social skills and pragmatics training. fail to FUNCTIONS/SELF-REGULATION AS THE use their cognitive processes effectively under real-world UNIFYING THEME conditions. Behavioral intervention. including work in uals with severe memory impairment.g. an inappropriate tating compensatory strategies in general and discourse target for intervention until late in recovery after most strategies specifically.. the executive self-regulatory system includes stated that we would organize the intervention sections of those mental functions involved in formulating goals.g. could be seen as independent of the important literatures in related fields. not just cognitive processes.. and generally.g. initiator. we explicitly tied our discussion of EF/SR to injury and. aspects of cognition have undergone substantial recovery. people to be successful—that is. and a special focus on teaching posi- needed and for anticipating and dealing with frustration. including a critique of tradi- the approval of her preinjury boss. Four years later. 1996).. In this limited and “cold” sense of the alternative recommendations (those of the staff versus that term (Denckla. weak encoding and retrieval of new information. Relevant employees in the factory were oriented to Sue’s cognitive and communication deficits and given scripts to Executive Functions/Self-Regulation: An Intervention- negotiate routine.. In discussions of TBI and frontal lobe injury. therefore. .. the same set of control functions impaired planning and organizing). work-related interaction. Understood most term “executive functions/self-regulation” [EF/SR]). carrying out the plans. in part.1. Therefore. planning a day at however.GRBQ344-3513G-C33[877-962]. wise unsuccessful social communication). to make efficient real-world Following general comments about executive functions/ use the abilities and knowledge that they possess. and regulator of all aspects of more general concept of self-regulation (using the hybrid behavior. including cogni- lems (e. the executive system is included as a com- living—an achievement made possible. With considerable encouragement. organize. Sue’s opposing view. and behavior as opposed to prob- provoked). was that she cussions of memory aids..g. controlling anger). and 1966). and behavioral emotional (e. This is not universally true. therefore. Sue was placed in her old tional contingency management. tive communication alternatives to negative behavior. using effective reading and lems specific to the domain. the most common functional operational definition of the executive system. injury may perform well on tests of intelligence and may appear to attend. executive In our discussion of disability associated with TBI. nonroutine behavior. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 909 management skills as well as the positive attitude needed to 2. aggression and sexually inappropriate behav- planning an effective way to express a complex or sensitive ior) can be traced to weak executive control over their cog- thought). Cognitive rehabilitation.. and the use of a “real” work setting. including a critique ting. we functions often are highlighted for separate consideration in offered a definition of executive functions. A job coach was Relevant Operational Definition used for less than a month. approach to intervention is compensation for the problem as based in part on analysis of the characteristics (beyond intel- opposed to restoration of function. linguistic. negotiated plans for asking for help when behavior supports. archy of cognitive functions and. which tional processes-specific cognitive retraining and dis- she offered in emotionally strong language. 3. by framing ponent of cognition. perceive. including the processes of facili. vinced to treat Sue’s proposal as a testable hypothesis. tion. problems (e. communication (e. executive functions direct and regu- of Sue) as hypotheses to be tested collaboratively and using late cognitive processes. social (e. tied it to the their role as planner.. including a critique of tradi- live and work in the community. and motor skills) that enable successful system again becomes the key to successful rehabilitation. Luria.. and vocational (e. and reason ade- quately under highly structured and externally directed con- TBI REHABILITATION: EXECUTIVE ditions but. plan- the chapter around this unifying concept. our discussion of intervention is divided into In discussions of neuropsychological rehabilitation. EF/SR interventions. self-regulation. In this broad sense. Table 33–10 offers a EF/SR system. writing strategies). Earlier ory problems that are not a consequence of frontal lobe in this chapter. and revis- problems of people with TBI (e.g. Thus. errorless learning for individ- would do fine if she had a meaningful life. communication prob- directs all deliberate. educational (e. staff were con. disorganized discourse and impulsive or other- tive (e.g. 1993). along with all other aspects of cognition (see activity) have been shown to facilitate self-determined learners Table. • Set reasonable goals. 2002. Bronson. self-regulatory A Functional Operational Definition of the Executive self-talk (Ylvisaker & Feeney. Landry and colleagues recently docu- bility of development with experience and training (Bjorklund. Fitzsimons and • Flexibly revise plans and strategically solve problems in the Bargh (2004) disputed this dichotomy by summarizing evi- event of difficulty or failure. Ability to think abstractly and transfer skills from training states” (p. Thus. style and growth in the preschool child’s executive self- Welsh & Pennington. 1995. “the capacity of others’ mental states. and classical developmental cognitive psychology (see. the theme is facilitation of automatic self- regulation or EF/SR habits via internalized. Recent work in developmental cognitive often have limited processing resources even without placing psychology strongly suggests a developmental course for exec- additional demands on those resources with deliberate self- utive functions characterized by early onset of development (in regulation (Schmitter-Edgecombe. Ability to assume a non-egocentric perspective and “read” dence showing that self regulation—that is. Smith. .qxd 1/21/08 1:57 PM Page 910 Aptara Inc. 3. In educational psychol- with these developmental themes as background. 151)—can be active. the operation of these self-regu- • Initiate behavior toward achieving goals. 2002. 2000. The section ends System with a discussion of empirical evidence. deliberate. and auto- to application contexts. 2004) showing that self-regulatory mental studies of both immature primates (Goldman. this hierarchical view is insensitive to develop- Schmeichel & Baumeister. Larsen and Prizmic (2004) reviewed the available interventions that address specific components of executive developmental evidence regarding affect-regulation strategies. matic or habitual behavior on the other. we introduce ogy. (Reeve. between self-regulated behavior on the one hand and auto- • Benefit from feedback. linguistic. that might be encouraged within of EF/SR intervention by describing routines or scripts of these everyday routines of interaction. toward important goal 4. hints that executive functions as a rehabilitation target relatively early facilitate success without taking over the problem-solving in recovery. Because many pro- fessionals take over the executive. 1999). Assel. individuals to guide themselves . Based on this awareness. Smith. including self-regula- 1.and Language-Related Functions TABLE 33–10 self-talk. & Vellet. and Feeney (1998) described a variety of helplessness. e. infancy). and humans (Bjorklund. Plato in the 2. and social development. & Cai. Miller-Loncar. 2001. dynamic interaction with other aspects talk internalized from interaction with more competent mem- of cognitive. executive function. many theorists draw a sharp contrast • Monitor and evaluate performance in relation to the goals. Bronson. 1988).. Tranel. organizes preschool activ- Smith. they should be alerted to the importance of engaging their clients in scripted Executive Function/Self-Regulatory Scripts and EF/SR routines. The clinical need to automatize EF/SR scripts is based on studies (for review.g. an ability to: Phaedrus). 33–9 and 33–11). and associated tory self-talk. 910 Section V ■ Therapy for Associated Neuropathologies of Speech. specifically problem-solving skills and successful curricula for preschoolers with and without dis- (Landry. Our goal in this section is to highlight the core including self-talk strategies. is internalized speech has a varied and venerable understanding of the difficulty level of tasks. mented a significant association between parents’ interactive 1990. Table 33–11 includes examples of specific EF/SR scripts ually internalizes the script as automatic. e. goal-plan-do-review 2003). slow maturation of functions (continuing through Consistent with the Vygotskyan theme of thinking as self- the adolescent years).g. matic. the High Scope Curriculum. & Benton. 1988).. 1971) resources are depleted with effortful self-regulation. Indeed. 1934). dynamic. Skinner. Vygotsky.e. Automatic EF/SR behavior in adults is illustrated by the habit or automatically triggered routine of fastening the seat belt when entering an automobile. • Plan and organize behavior designed to achieve the goals. 1953). self-regulatory as well as the most general goal-obstacle-plan-do-review . ities around a simple. classical behavioral psychology (see. and modifia- bers of the culture. Landry. Landry. Effective parental scaffolding (including hints. Awareness of strengths and limitations. lineage.. in press). . Szekeres. functioning. Swank. & Swank. Recognizing the pro- and other verbal supports) at age 3 predicted high scores on found importance of executive functions for success in life and executive function measures at age 6. Reeve. routine (Schweinhart & Weikart. & Swank. e. including classical philosophy (see. Welsh & Individuals with frontal lobe or diffuse neuronal pathology Pennington. ability. Indeed. Often. 1990.g. Anderson. prompts. latory executive functions is assumed to be conscious and • Inhibit behavior incompatible with achieving those goals. self-regulatory aspects of Executive Function Intervention Themes functioning for individuals with disability.. The general notion that thinking. 1996). 2000. complex. one of the most popular regulatory functions. see Unfortunately.GRBQ344-3513G-C33[877-962]. Bolt. interaction organized in such a way that the individual grad. providing whatever support may be necessary Development of Autonomy but stopping short of threatening the development of learned Ylvisaker. teacher “scaffolding” for problem solving (i. 3. (or Why is this a problem?). Big Deal/Little Deal Script 1. . 2.? 3. It’s a big (or little) deal because . Scary/Not Scary (Dangerous/Not Dangerous) Script 1. There’s always something that works. 2. Because it’s hard. . I think it’s hard (easy) because . 4. (or Why is it a big deal?). 3. I think you are ready now (or You ready?). There’s always something that works. . (or Why do you suppose we disagree?). Because it’s dangerous. . . . Because it’s a big (little) deal. 4. Questions can be used rather than statements if you are confident that the individual can answer the question. We disagree because . What About You Script 1. It’s important to know what John thinks/John feels (or What’s John’s perspective?).qxd 1/21/08 1:57 PM Page 911 Aptara Inc. . There’s always something that works. 4. (or Why dangerous?). you should probably . . Review it: How did it work out? What worked for you? What didn’t work? What adjustments need to be made? Hard/Easy Script 1. There’s always something that works. Let’s see if this works . (or What do you want to try to solve the problem?). . Here’s a way to find out (or How can you find out what John’s perspective is?). Let’s try it both ways and see what works best. . you . There’s always something that works. . . . (or What do you think you should do?). (or What makes you think you’re ready?). 4. So you need a plan. non-punitive. 2. . There’s always something that works. Because you’re ready. 4. 4. 2. 4. . 2. General EF/SR Script: Goal-Obstacle-Plan-Do-Review 1. 2. 3. This seems to be kind of hard (or easy) for you (or Hard or easy for you?). . make happen. (or What do you think you can do?). . You and I have different ideas about how to get this done. . 2. It’s dangerous (or not) because . It’s important because . It’s a problem because . you . This is the goal (what do you want to accomplish. . . 4. There’s always something that works. I think this is a big deal (or not a big deal) (or Is this a big deal?). . (or What do you think you should do?). 3. You look ready because . what will it look like when you’re done?). . This might be hard because . (or Why should you try to get into John’s head?). This seems to be a problem. Ready/Not Ready Script 1. 2. Experimental Script 1. Problem-Solving Script 1. . . 3. and delivery should be conversational. . . 3. . . 3. Do it.GRBQ344-3513G-C33[877-962]. you can . how about . This is kind of dangerous (or not dangerous) (or Do you think this might be dangerous?). and motivating. (or What do you think you should do?). . (or Why do you think it’s hard/easy?). Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 911 TABLE 33–11 Examples of Executive Function/Self-Regulation (EF/SR) Scripts of Interaction Designed to be Used at Appropriate Times in Real-World Contexts with the Goal of Having the Individual Internalize EF/SR Self-Talk The words can be customized for specific individuals. (Sports: big deal or a little deal?”). but maybe I’d better get the facts. 1999). “Is this a ing him. and (f) review their performance. or should he change the play at the line of ment). To Evidence for Self-Regulatory/Self-Talk Interventions avoid negative associations with the scripts. it is important for metaphors should be used liberally to create positive associ- clinicians to formulate the script for the individual carefully. I feel overwhelmed. because I didn’t study enough? What will I do the next and the like. social self-control. “self-guid- understands and reacts to positively. and the person with TBI to become comfort- For example. ultimately.. In some cases. and not scary) Self-talk interventions have been studied with a variety of should predominate early in the facilitation process. the facilitation process from preschool through adulthood. did I interpret his behavior correctly? (Sports: components of any task. we have framed this self-regulatory self-talk as self-coaching As a rule. (d) create intelligent plans for achiev. “Let’s think about that. erable support from others to engage in these intellectual Commonly used adolescent and young adult “self- processes and. to significant impairment of executive function require consid. The video can then be ity. “What exactly am I trying to accomplish?” For example. did I get a low grade devised for strategy exploration routines. questions should be Should the coach throw the replay flag or not?) avoided. are the goal of executive function Table 33–11. such as “self-direction” (drama. To remind indi- 2. (Sports: as relatively automatic. Precisely coaching plays. 1998). (c) identify obstacles “self-coach” are used by the client. particularly those of executive self-regulatory functioning that should pervade with experience in sports (strongly valued in many cultures). the positive ver- sions (e.g. sports minded.qxd 1/21/08 1:57 PM Page 912 Aptara Inc. this general schema can be used to incrementally scrimmage?) improve everyday routines of self-regulation. 2006). self-regulatory thought processes Call time out. film). the scripts can be framed as questions (e. These same self-regulatory processes and social worlds—all within the compelling context of per- can—and should—become routine for people with disabil. for others.GRBQ344-3513G-C33[877-962]. In other words. With relevant modifications (e. The video ing the goals (possibly predicting their level of success).g. negotiated to achieving the goals. mainly children and adolescents. successful people facing important decisions (a) (Ylvisaker.” pos- act on the plans. 912 Section V ■ Therapy for Associated Neuropathologies of Speech. Often. not a problem. taped during role-playing activities in which the words of the ing of their strengths and limitations). include the following: intervention. make them habitual. but maybe if I just stop reduction of supports. these scripts are ing” (hiking). from preschoolers through adults. (b) set ing) “plays” can be negotiated with the person and then video- reasonable goals for themselves (based on their understand. within everyday action contexts when the person ideally should have use of the script as self-regulatory self-talk. I’ll get back on track. “self-supervis- used frequently (while avoiding boredom and nagging) and ing” (business). “self-choreographing” (dance). what do I need to do to prepare for this able with simple. staff. am I sure that John is angry Figure 33–8 presents a guide for addressing the executive at me. particularly for those individuals whose anxiety is aroused by questions or who would have difficulty answer. the scripts should be delivered in a supportive. and perhaps. With repetition and gradual example. little deal.” in addition to those core plays listed in such habits. Clearly. much as an athlete views game films. For sports-minded adolescents and young adults. conversational use of the routine.g. viduals with disability and their caregivers to use the routine. listed first because it is a simple operational definition For many adolescents and young adults. “Call time out! Spike the ball! Get organized!” For process would be helpful. Has the quarterback called the right play for this simplifying the routine for people with substantial impair- defense. profiting sibly including relevant information about brains as well as from the feedback they receive (what worked and what did about situations in which the play is important. however. 1. cueing words can be used by staff or other ECPs. For those who are not In each case. For some indi- 6.) everyday occurrences for which that self-regulatory thought 5. easy. Ideally. sports ing the question accurately. The goal is to associate the scripts with the time? (Sports: Review the game films. (e) also should include a meaningful rationale for the “play.” For example. sonally meaningful sports metaphors. “Am I sure?” For example. improve performance by internalizing the self-coaching script. ations with effortful self-regulation. “What’s the game plan? What do I need to do to win?” members.. people with repeatedly viewed. I feel like smack- viduals. not work) (Meichenbaum & Biemiller. a variety of other positive metaphors are conversational manner using language that the person available. do I have a major test to study for or an important pro- we frequently post brightly colored reminders with the words ject at work? (Sports: Who’s the opponent this week?) GOAL-OBSTACLE-PLAN-DO-REVIEW and help family 3. these scripts can then be internalized and organize my tasks.and Language-Related Functions script. . “How’d I do?” For example. Individualized self-regulatory (self-coach- make choices about what they wish to accomplish. test? (Sports: What’s the game plan?) Scripts similar to those listed in Table 33–11 can be 4. disability populations. and “self-conducting” (music). these the goal is not only to improve self-regulation of behavior and processes operate in a relatively automatic manner (Bargh & emotions but also to increase understanding of the personal Chartrand..) triggered by relevant environmental events. 1. 2. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 913 Goal What do I want to accomplish? Obstacle What might stand in the way of achieving my goal? Plan How am I going to accomplish my goal? Materials/equipment Steps/assignments 1. (Reproduced from Ylvisaker. therapist. 2.GRBQ344-3513G-C33[877-962]. 3. 4. 3. 2. and Feeney.) . with permission. 3. 1. Predict How well will I do? How much will I get done? Choose Do Problems arise? Formulate solutions! 1. 2. 1998. 3. 4. 3. A guide for explicitly teaching or highlighting the executive components of any task. Review How did I do? Self rating: 1 2 3 4 5 6 7 8 9 10 Other rating (teacher. family member) 1 2 3 4 5 6 7 8 9 10 What worked? What didn’t work? 1. 2. peer. 3. What will I try differently next time? Figure 33–8. Szekeres. 2.qxd 1/21/08 1:57 PM Page 913 Aptara Inc. 1. This form can be simplified to goal-obstacle-plan-do-review for ease of remember- ing. & Martin (2000) of peer-reviewed studies that examined the effectiveness of evaluated the effectiveness of the Self-Determined Learning more specific self-regulation interventions for children with Model as applied to 40 adolescents with mild mental retarda- ADHD. self-regulated It is reasonable to interpret this positive meta-analysis— strategy development. At least two underscoring the importance of a culture in which the inter. socially appropriate behavior. tion. learning disabilities. to use something like the goal-obstacle-plan-do-review ment. their executive function academic curriculum. the Teacher facilitation of these self-talk questions resulted in self-regulation interventions showed a strong additive effect goal attainment beyond teacher expectations and improve- in those cases in which the children were simultaneously ments on standardized measures of self-determination. 914 Section V ■ Therapy for Associated Neuropathologies of Speech. evi. and to terminate the study in implemented in everyday school settings for adolescent the event of likely failure of the intervention. learning routines in which the adolescent student is trained especially for children and adolescents with EF/SR impair. Each of these ior. despite documentation of statistically significant were decontextualized and. tional and behavioral problems. or emotional/behavioral distur- toring training. understood as an EF disorder) and con. students with aggressive behavior associated with ADHD. Trout. and self-evaluating). The meta-analysis of Reid and colleagues (2005) regard. relation to what is known about the underlying impairment. poorly conceived in improvements. 2004). and academic accuracy and productivity. Averaging across all interventions significant differences were found among the three disability and outcomes. additional studies have evaluated the effectiveness of teaching- ventions are embedded within the routines of everyday life. Berk (2001) pointed EF/SR routine described in Table 33–11. Furthermore.. ulatory self-talk should be provided within the individual’s improved the self-regulated learning of intellectually normal authentic tasks and settings. and (2) the positive meta-analysis of Reid and colleagues however. the effect sizes were greater than 1. & Schartz (2005) completed a meta-analysis Wehmeyer. Smith. Hechtman et al.GRBQ344-3513G-C33[877-962].. Martin and col- out that clinic-based CBM is not consistent with its purported leagues (2003) found that a plan-work-evaluate-adjust rou- Vygotskyan roots. Teaching-learning routines included 12 self-addressed reinforcement. to select subjects likely wisely restricted the scope of their meta-analysis to studies to benefit from the intervention. 2004. tine. The most thoroughly These investigators found that none of the behavioral or studied self-talk/self-regulation intervention is cognitive psychosocial interventions for students with ADHD added behavior modification (CBM) (Meichenbaum. the literature has failed to demonstrate clini. questions that the students used to guide their learning behav- toring. was a meta-analysis in which the investigators mainly considered single-subject experiments. Graham and Harris (2003) presented results of meta- Twelve studies (with 36 effect size measures) yielded a large analysis of 18 experimental studies that yielded large to very mean effect size of 0. grams are adolescents or young adults. Missing from Barkley’s review. and colleagues (Abikoff et al.qxd 1/21/08 1:57 PM Page 914 Aptara Inc. study). modeling and coaching for self-reg. which included 51 par- • Goal “What do I want to learn?” ticipants. dence from the adolescent literature is relevant in this chapter. delivered in the context of everyday academic lessons. Mithaug. self-rating. The 16 studies. The approach described in this students in a residential school for students with severe emo- chapter is fully consistent with Berk’s authoritative advice. groups. No treated pharmacologically. and self-management (combining self-moni. suggesting equal effectiveness across disabilities. 1977).0.8) were found for • Do “When will I take action?” most of the interventions in relation to most of the outcome • Review “Do I now know what I want to know?” variables: on-task behavior. Robinson. or a 24-percentile rank increase for large effect sizes across a variety of outcome measures using the CBM subjects compared to controls. implemented in their educational • Plan “What can I do to make this happen?” setting. the goal-obstacle-plan-do-review EF/SR routine interventions can be readily incorporated within the scripts described in Figure 33–8 was represented in these questions: listed in Table 33–11. Miller. controlled clinical trial reported a year earlier by Abikoff because many of the patients and clients in adult TBI pro. self-monitoring plus reinforcement.64. Again. This program embeds several self- particularly in contrast to earlier pessimistic reviews—as regulation scripts within its teaching routines. Reid. and social interventions in the study by Abikoff and colleagues cluded that. self. The four interventions examined were self-moni. perhaps. therefore. The lesson to be derived for clinicians from the variety of ing executive function interventions for children with overlapping studies is that an underlying intervention theme . be explained by some com- applied to adolescents with attention-deficit/hyperactivity bination of the following two differences: (1) The behavioral disorder (ADHD. Single-subject restricted their review to studies in which the intervention studies tend to use highly individualized and context-sensitive was delivered in the setting in which the problems were interventions (in contrast to group intervention protocols like occurring. Barkley to the effect size produced by medication alone. Agran. Palmer. were mainly single-subject experiments with ele- • Obstacle “What could keep me from taking action?” mentary school students. cally meaningful outcomes. These con- (2004) reviewed the reviews and meta-analyses of CBM tradictory findings can. and Brownell (1999) those used in the Abikoff et al. ADHD contrasts sharply with the results of a randomized. Rather. Consistent with this interpretation. Large effect sizes (greater than 0. bance.and Language-Related Functions Although this book is devoted to interventions for adults. task guide. it also has been found to intervention (Table 33–9). support sys. rigid adher. Unfortunately. the clinician book system over the continuum of recovery. or structured after TBI and retained residual cognitive impairment. all the truly strategic. therapists. settings with a variety of individuals.. has clinical wis- resources. routines of life to facilitate improved cognitive functioning. If strategies are what strate- clinicians to similarly apply. Therefore. alarm watch. memory book. routine-based intervention (Table 33–4) and also in the Furthermore. activities. vention around a model of a good strategy user (Pressley. in an individualized manner. request- In Table 33–9. 1990). routine-based framework. It is tempting to conceive of strategy intervention as Table 33–9 also suggests evolving uses for a log or memory being no different from other teaching—that is. therefore. as discussed in earlier sections. selects an appropriate strategy. Feeney. the acute rehabilitation. friends. and routines of life. even if not but also helps to separate reasonable from risky candidates . 1995.e. Our goal in offering client’s role is. which are procedures used by therapists and teachers. Clearly. mental rehearsal or elaboration. and others) and als with strategic procedures for overcoming obstacles is. in TBI. they may be tion plan was implemented (including transfer activities) as used indefinitely to reduce the functional disability of people well as a description of the types of mediation and support with chronic impairment. we present a plan for improving cognitive ing clarification or repetition) or covert behavior (e. Pressley. problem-solving behavior is assumed tems. problems posed by cognitive and communicative weakness. which often is referred to as a strategy. & Schneider. passive reliance on others to solve critical In the general five-step template for functional. identifies the client’s needs. Compensatory strategies are applied to a variety of populations of impaired learners procedures—sometimes unconventional—that an individ. co-workers. we highlighted the use of fail the litmus tests of generalization and maintenance when compensatory procedures. 1989).g. everyday. (by no means exhaustive) of strategic procedures that appro- ory. then this model of teaching must be intervention framework described earlier to specific individ. the clinician might inadvertently contribute to the client’s learned help- Compensatory Strategies and Strategic Behavior lessness—that is. by the clinician. 2002. with sufficient practice. Alternatively. thought of as antistrategic strategy intervention. & Miller. not only does this model of teaching fail to description of Tom’s cognitive and executive function promote truly strategic behavior. ual deliberately uses to achieve goals that cannot be achieved 1998. ment. The tion vary from individual to individual. although any priately selected individuals can use to compensate for selected aspect of cognition could be targeted within this everyday. egy.. ence to a specific model is clinically dangerous. however. behavior (i. cognitive and communicative deficits. (Flavell.g. printed reminders. mem. Continuum of Recovery a person might compensate using overt behavior (e. Such a model serves not only to identify a variety of this sense of “strategy” from the general notion of organized diverse goals that may be components of this intervention behavior. without such special effort. family members.qxd 1/21/08 1:57 PM Page 915 Aptara Inc. External memory aids are dis- Cognitive Processes and Systems through the cussed in the section on cognitive rehabilitation. Project-oriented rehabilitation was used require effort initially but. Alternatively. We use the term “facilitator” to refer to parts of the brain associated with strategic thinking and people who have regular interaction with the person with dis. Appendix 33–3 includes a large number focus of intervention in this case included organization.. extremely important and extremely tricky. and then monitors and evaluates the outcome. Strategies designed to compensate for cognitive deficits may involve the use of external aids (e. Compensatory procedures may used at each phase. needs. In denying the client the right to participate in the strategic aspects of strategy learning. thereby possibly reducing the underlying impair- explore project-oriented interventions and supports in post. to follow the clinician’s lead and the detailed intervention plan in Table 33–9 is to encourage acquire the strategic procedure. and Capo (2007) system. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 915 can be operationalized in a variety of ways in a variety of deliberate. Meichenbaum & Beimuller. The table includes appropriate Compensatory strategies may be used temporarily in the goals. Although the ultimate goal of Following Pressley’s advice to structure strategy inter- intervention is habituation (“routinization”) of the proce.g. and from instructional or treatment strategies... the gic people do. The thinking procedures). job coaches. Ylvisaker. electronic Functional Approaches to Executive Function and organizer. direct care staff.GRBQ344-3513G-C33[877-962]. intervention designed to equip individu- teachers. specific activities and routines as well as specific selects appropriate teaching procedures. at who therefore are in a position to use everyday activities and the same time. and general executive functions. Pressley & Associates. and daily routines within which the interven. Therefore. interests. therefore. Miller. teaches the strat- intervention emphases within the broad domain of cogni. we emphasize the word “deliberate” to distinguish dom. dures so that their use need not consume limited attentional Borkowski. case of transient impairment. or pager system). language. self- functioning for a specific individual who improved slowly reminders. the frontal lobes) are particularly vulnerable ability (e. because uals.g. integrating their goals. become a with Tom (Table 33-9) during both the middle and late stages routine component of the individual’s automatic processing of his cognitive recovery. maps. work on generalization (Component members to use strategies. For most people with TBI. IV) should begin early. attempts to promote improved • They are not so anxious that they neglect strategic behav- awareness of strengths and weaknesses (part of Component ior because of their focus on fear of failure. For example. can select • Whether its degree of complexity and abstractness fits the the procedure most relevant to a particular challenge. are motivated. In addition. meaning- strategic behavior (e. the most simple external aid strategies (e.and Language-Related Functions for strategy intervention. & Brentnall. have suffi. • How difficult the procedure is to use relative to its payoff • They use strategic procedures frequently so that they • Whether it fits the client’s profile of neuropsychological become relatively automatic and require little effort or strengths planning. For example. Intervention should be embedded in natural. importance of the following principles of strategy inter- cient meta-cognitive maturity to think about thinking. like to play games of strategy). and other cognitive issues. are aware of their needs. are disposed to 1.qxd 1/21/08 1:57 PM Page 916 Aptara Inc. cle-plan-do-review format. Other things being equal. we have found to be useful in working with individuals who • They are not so impulsive that they habitually act before have TBI. plex tasks or memory books) often are preferable to Selection of the areas for compensation and of specific internal elaboration and organization strategies (Evans. expect shy and generally noninteractive individuals to that strategies enhance performance. and client’s cognitive level can flexibly modify it as needed or create new procedures. client. • Whether it fits the client’s personality • They have adequate “space” in working memory so that • Whether it specifically addresses obstacles to the individ- they can think about the task at hand and the strategic ual’s concrete goals procedures at the same time (assuming that the strategies In Table 33–12. strategic procedures must involve active engagement of the Needham.) hierarchical. high-tech options. it is quixotic at best to • They know that their performance needs to be enhanced. 2 The individual should be maximally engaged in experi- College students returning to school after a mild to moder- menting with strategies. Wilson. • They have goals to which strategies are relevant. The environment as a whole should be supportive of her natural strategic inclinations and the judgment of the and promote strategic thinking and strategic behavior. automatic use and improved performance in natural unlikely to be maintained over time (Wilson & Watson. • Whether the procedure is used spontaneously • They know a number of strategic procedures.g. which frequently includes a tension between his or 6. using the general goal-obsta- ate injury often fall into this category.g. and that they are enthusiastically adopt an input control strategy that requires capable of using strategies.g. simple. clinician. strategy interven- 5. and coping. At the other extreme. selecting the strategies to individuals who are extremely weak in many of these use. The In the absence of sensitivity to these principles. Truly strategic people have the settings. we outline intervention procedures that have not become automatic). I) often continue throughout a client’s entire rehabilitation • They have the support of teachers. strategic ultimate test of the appropriateness of the strategy is sponta. our experience in helping individuals with Ideal candidates for strategy intervention are individuals TBI to become increasingly strategic underscores the who have specific goals. and family program.GRBQ344-3513G-C33[877-962]. and why to use specific strategic plify their language. and monitoring their effectiveness. Goals should be modest. 2003). the selection of strategies include: • They monitor and evaluate the effectiveness of their per- formance so that being strategic is its own reward.. dimensions may require considerable support to use all but 3. vention: communicating. In summary. . The three components are very roughly sequen- considering a strategic maneuver. (Context-sensitive auto- tial but should not be considered as mutually exclusive or matization may overcome this obstacle. low-tech options tion includes attempts to improve functioning in a variety often are preferable to complicated. with strategic procedures adequate attentional resources. compensations for cognitive or others impairments are neous. can meaningfully use strategies to learn more. graphic organizers for com- behavior. before a procedure is habituated in a • They know enough about the subject at hand that they clinical setting. interacting. employers. able self-control. Brainstorming and experimentation with alterna- tive strategies (Table 33–12) help to resolve this tension.. them to request that speakers slow down or clarify and sim- • They know when. Variables to be reviewed in negotiating procedures.. ules or maps). and live in supportive environments. 916 Section V ■ Therapy for Associated Neuropathologies of Speech. printed sched- 4. have reason- specifically related to the client’s goals. have ful activities and settings. Intervention should be intensive and long term. where. of domains (outlined above) that are related to strategic and external supports (e. Intervention will inevitably fail if clients do not see following characteristics: the usefulness of the strategy relative to their goals or if the strategy does not fit the individual’s overall style of learning. self-awareness is frequently compromised. or other relevant model. analyze the performances in sufficient detail that the client can identify the features that account for successful versus unsuccessful performance. Include high level of motivation and initiative. become increasingly aware of their strengths and needs. sports heroes or military heroes). ability to monitor and evaluate performance. first without commentary. Clinicians also should clearly model their own strategic behavior and discuss the value of their own strategies. Objective: Improve the client’s awareness of his or her own strengths and weaknesses. Objective: Heighten the client’s appreciation of strategic behavior.g. Objective: Improve the client’s understanding of the behaviors that are part of being strategic. sports. Note: These meta-cognitive discoveries are facilitated if the activities are personally meaningful and intimately connected to the client’s goals.) Review the tapes (beginning with strong performance). read and discuss literature on the effects of TBI. Procedures: Videotape the client in activities designed to reveal strong and weak areas of functioning. ability to identify and clarify obstacles to goals. Component I: General Strategic thinking A. willingness to engage in ongoing problem solving. Meta-cognitive Awareness Goals: Clients will discriminate effective from ineffective performance. Jointly create a list of specific skills and resources needed to achieve these goals. Objective: Improve the client’s ability to perceive functional impairments. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 917 TABLE 33–12 Teaching Compensatory Strategies Note: These components of intervention are not necessarily hierarchical or mutually exclusive. Value of Being Strategic Goal: Clients will recognize the importance of being strategic and will identify the characteristics of strategic people. Individuals are unlikely to acquire and use procedures designed to compensate for problems that they do not recognize as problems.g. Rationale: Since the ultimate goal of this intervention is to promote strategic thinking and strategic behavior in general—not simply to teach specific strategic behaviors as routines—it is important that the client understand what it is to be strategic and that these are valuable attributes.qxd 1/21/08 1:57 PM Page 917 Aptara Inc. Procedures: 1. request that the client make note of specific deficits of other clients in the program or of individuals observed on tape. (Alternatively. Procedures: Using games. (continued) . ability to plan procedures to overcome obstacles.. Note: Considerable desensitizing may be needed before video self-viewing is possible. Rationale: Given the frequency of frontolimbic and right hemisphere damage in TBI. Procedures: Illustrate successful and unsuccessful performance of a functional task through role play or on videotape. Procedures: 1. Discuss the effects of TBI on cognitive and social functioning. recognize implications of their deficits. Component II: Selecting Specific Strategic Procedures Goal: Clients will identify specific procedures useful in overcoming important personal obstacles.GRBQ344-3513G-C33[877-962]. Jointly identify the skills that are present and those that are weak relative to this goal. 2. Discuss these observations. or business analogies). With the client. 4. Procedures: Individually. use role play. Discuss why they are considered to be heroic. Gradually turn over to the client the responsibility for stopping the tape when problems are noted. 3. subsequently inviting comments about what was done well and what needs improvement. military. Objective: Improve the client’s understanding of strategy. B. If appropriate. sports. Procedures: Together with the client. Procedures: Discuss in concrete detail the individual’s long-term goals and expectations. 2. 3. Planned peer teaching is useful. Procedures: Using models relevant to the client (e. brainstorm about the characteris- tics of people who are known to be very strategic. Objective: Improve the client’s understanding of the relation between deficits and long-term goals. identify several individuals who are known to be very strategic (e.. Rationale: It is important that clients participate in the selection of strategic procedures that they will use and that the procedures be truly useful in achieving their goals. clarify the concept of strategy as something that one does to achieve goals when there are obstacles. Objective: Improve the client’s perception of successful versus unsuccessful task performance. Procedures: A. 1987.. 3. C.g. Note 1: Generalization includes generalized use of specific strategies as well as strategic behavior in general. Martin of reports regarding the effectiveness of compensatory et al. Objective: Increase the client’s acceptance of strategic behavior. and Ylvisaker (1985). but a much larger attempted to apply to the field of cognitive intervention evidence base exists in educational psychology (Baker et al.. 2. 2003. Modeling is initially accompanied by overt verbalization of the strategy by the model. Williams. 4.. and teachers in strategy intervention to (1) provide varied opportu- nities for the use of specific strategies and of strategic behavior in general. Key: TBI  traumatic brain injury. Cicerone et al. Meichenbaum (1993) discussed the application . Functional Practice: However the strategy is acquired. 1. B.. 918 Section V ■ Therapy for Associated Neuropathologies of Speech. Modified from Haarbauer-Krupa. brainstorming and product monitoring) are effective. & Baker.) 3. Pressley & Associates. Promote emotional acceptance of strategic behavior by using whatever motivating procedures work (e. the best result likely will be the acquisition of a learned sequence of behaviors (which may be a desirable outcome) without positive movement in the direction of becoming a strategic person.g. testimonials. Use short videotaped scenes to train the client in efficient and accurate judgments as to whether a strategy is appro- priate in a context. inappropriate use of the strategy. If this is the only approach used.qxd 1/21/08 1:57 PM Page 918 Aptara Inc. personal images or metaphors. 1990.g. Use group brainstorming procedures to identify possible strategies. Note 2: Generalization may not be a separate phase if the acquisition stage takes place in the context of functional activities and natural settings. Discuss the conditions that require the strategy. Resnick. This is particularly important for very concrete people.. Gersten. and so forth) by people who do not have brain injury. Henry. and specific teaching procedures designed to enhance generalization. lists. and the like). Have advanced clients demonstrate the value of certain procedures or offer testimonials. Objective: Increase the client’s spontaneous use of strategies in varied situations.GRBQ344-3513G-C33[877-962].. it must be frequently rehearsed in natural settings using functional activities. Use “product monitoring” tasks to test the value of strategies: Have the client perform a task with and without the strategy or with a variety of different strategies. Component IV: Generalization and Maintenance Generalization of strategic behavior beyond the context of training is a combined consequence of the perceived utility of the strategy for the individual. Procedures: Include family members. Procedures: Ensure that the client is successful using strategies. however. work supervisors. The client then rehearses the strategy with gradually decreasing cues and self-talk. after TBI. 2001. the inherent generalizability and utility of the strategy. Procedures: Use videotaped scenes or role playing to illustrate the correct use of a strategy in an appropriate situation. tape recorders. and (3) model strategic behavior themselves. Modeling: The steps in the strategy can be modeled by the therapist. memos. 1996). Objectively compare the results. Szekeres. Sweet & Snow. Component III: Teaching Specific Strategies Note: If the discovery procedures in Component II (e. Kennedy et al. which Pressley (1993) has 2005. The TBI literature contains an increasing number 2002. with permission. Direct Instruction: The carefully programmed behavioral teaching procedures of direct instruction can be used to teach strate- gies.. intensive practice in a variety of real-world contexts. there may be little need for specific teaching procedures. (Video analysis may be useful here. accepted).and Language-Related Functions TABLE 33–12 Teaching Compensatory Strategies (continued) Procedures: 1. 2. Note 4: Some individuals may need environmental reminders indefinitely to use their strategic procedures. by a peer. Fuchs. or by means of videotape or other media. Discuss the widespread use of compensatory procedures (e. strategy intervention (Carney et al. Objective: Improve the client’s discrimination of situations that require or do not require a given strategy. Ask clients to keep a log in which they record their successes and failures in strategy use.. and failure to use the strategy when appropriate. 2007. Make generalization an explicit goal. Note 3: Generalization may be a relatively unimportant phase of intervention if the individual has acquired a strategic attitude and actively seeks occasions for transfer. widespread environmental support for strategic behavior and thinking. 2002). 1999. (2) reinforce the client’s use of strategies. all with adolescent participants with or Strategies and Discourse Impairment without disability. tangential. discourse requires action planning in the verbal domain Elementary students benefit from a clear flow diagram that (Alexander. and sequences of pictures to guide individuals through the facility with perspective taking (to be sensitive to the needs assembly of products that are sold unassembled. the diagram remembering. For Some discourse schemas or managerial knowledge units purposes of exposition in this chapter. Advance organizational supports for 1980. Dodd & White.GRBQ344-3513G-C33[877-962]. including graphic organizers of a variety of 2004). Because this also is the complexes and managerial knowledge units (Grafman. the Grafman’s neuropsychological theory of specific event ensuing action. this organizer is particularly important. organization of the mental representation of everyday events 1995. Krupa (1998) presented a variety of graphic advance organiz- nized knowledge structures (schemas) of greater or lesser ers and procedures for their implementation. complex tasks. CBM. and the use of virtual reality in rehabilitation. in a meaningful and broad sense of individuals with impairment of executive function associated the term. the construction of a coherent and manageable . process- friend to give up smoking. We then discuss frontal damage tends to result in discourse that is impover. supports for nondisabled adults. 2002). vious sections under the heading of executive functions. explaining much of the disorganized discourse of Cognitive rehabilitation. Discourse. of that which is to be organized. we present a critique of traditional. cessful communication of complex ideas. progress downward in a linear manner and include the initi- and other complex social. We have culty organizing thoughts and behavior for effective learn. effective planning. basic narratives. support approaches. and menus. to TBI types. Perhaps the most studied discourse structure in both chil- nizing schemas to specific contexts and material.g. memory aids. complex eracy group. Effective dren and adults is narrative structure or story grammar. and socially ing. Barsalou. comprehend and produce stories more effectively. ters’ reactions to that event. includes all the interventions described in the pre- with prefrontal brain pathology. and Haarbauer- nizationally demanding task lies in the effective use of orga. understood as the organization of lan. narrative as circular rather than linear). as well as the variety of theoretical cussed organizational impairment within a neuropsycholog. specific cognitive retraining exercises. we have separated out are tightly structured. as a compo. requires management for suc. blueprints. Szekeres. & Miller. Effective applica- tion of these knowledge schemas relies on the development Specific Cognitive Interventions of domain-specific knowledge and intactness of frontal lobe structures. 2002). and strategic direction of orga. errorless learn- hemisphere damage may be verbose. themes in cognitive rehabilitation that have received special ished in both words and themes. Left hemisphere dorsolateral pre. Graphic organizers also are commonplace For language specialists. such as the organizational structure of specific cognitive themes for discussion in the current sec- scientific reports. the main charac- that require organization.. Flavell.g. but fail to meet this obvious standard (e. 2002. 1992. Grafman et al. Miller. After offering a functional operational definition of less structured. socially ineffective discourse (Alexander. Many graphic organizers tification of the need for neurologic management of complex available in special education materials are visually attractive behavior. the plan that is developed. including maps. Bulgren and Schumaker (2006) reviewed 19 successful studies of advance organizers. organized thinking and talking. Impaired theory of mind. tion of language skill. have become an evidence-based standard of practice in rehabilitation. representing a guage over many sentences. 2002. The remaining boxes tasks (speaking and writing).. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 919 of a related set of intervention procedures. causes Operational Definition inattention to the needs and tolerance of listeners and. cognitive/organizational schemas. such as describing a vacation or persuading a cognition. and the resolution. of communication partners). often result in diffi. e. extended text comprehension. many settings in which disorganized individuals are supported. Szekeres. Because of the complexity of cognition and the relationships Ylvisaker. includes the components of a narrative as they attempt to nent of executive function impairment. and Haarbauer-Krupa (1998) dis.qxd 1/21/08 1:57 PM Page 919 Aptara Inc. among its components. “Managerial of organizers is that they accurately capture the organization knowledge unit” is a particularly felicitous phrase in its iden. and success with any orga. educational. expressive discourse the top for characters. Organizational difficulties. The organizer has three side-by-side boxes at work activities. therefore. efficient ponents of narrative structure are internalized. As the com- focused attention. Siegler & Alibali. efficient word retrieval. A critical feature generality with respect to domains of content. Individuals with right attention over the past decade. asso- Cognition: An Intervention-Relevant ciated with prefrontal damage (more right than left). can be gradually faded. discourse represents the intersec.. Ashcraft. place. 1993) maintains that the foundation for in life. Others are tion. 1994. descriptions of cognition and its development in childhood ical framework and presented a variety of intervention and (see. or vocational tasks ating event (that starts the narrative action). used a similar graphic organizer for adults with TBI in a lit- ing and performance of activities of daily living. and time. awkward in their discourse. Ylvisaker. & Miller. has given way to a focus on attention within the context of tive rehabilitation for adults. 1983. 1960s. effect size. In the 1970s. organization and memory. requiring thorough exploration with formal largely unsuccessful efforts in the 1950s. The scheme cific aspects of cognition in a hierarchical manner. software. Ben- cific mental structures and environmental constraints and Yishay.. For This sea change in cognitive rehabilitation has been example. in part. decontextualized cognitive mation slowly.. These may be separate vocational. umenting the failure of transfer from improvements on Alternatively. show training tasks have largely given way to context-sensitive evidence of disorganized thinking and behavior. 2002.g. directed by the executive control system (Dodd & White. Sohlberg & Mateer. 1987). and other daily activities. This decontextualized memory exercises have been found to be model is inconsistent with the essential interrelations among ineffective at any stage of recovery after TBI (Baddeley. For example. social. 1996. cognitive rehabilitation was understood by communication among professionals and between clinicians many practitioners as being an enterprise that involved and clients. strengthened with exercises). 1979). difficulty attending and slowed processing may decontexualized training tasks to everyday performance in be caused.qxd 1/21/08 1:57 PM Page 920 Aptara Inc. we have found it productive to designed for the delivery of cognitive exercises. at least some are related. 1983. forget easily. perhaps. memory rehabilitation approach to intervention. 920 Section V ■ Therapy for Associated Neuropathologies of Speech. 1999. everyday settings. therefore has focused on the use of external memory aids. however.1 presents a scheme for organizing descrip. by a growing experimental literature doc- perception all may be secondary to attentional impairment. such as driving cognitive processes are serially ordered in development are (Park & Ingles. describe cognitive functioning and recovery in terms of these devices largely were replaced by cognitive retraining three general aspects of cognition: (1) processes. Park and Ingles (2001) subjected studies jury knowledge. 1996. impairments. (b) creation of cognitive exercises that targeted spe- tions of behavior from a cognitive perspective. Siegler & stantial effect size. Treatment decisions are further driven by these older fields of intervention (based on the 19th-century decisions about relationships among cognitive processes and concept of separate “faculties of the mind” that can be systems. 2004) is useful in avoiding common pitfalls in cogni. a person with TBI may process infor. organization. 2001). 1987. which also may reduce memory efficiency. Mann. rehabilitation. Just such a framework is critical. and (3) functional-integrative performance. Piasetsky. . 2002. Thus. facilitates severe TBI. perception. in part. 1995). social and vocational knowledge. customized retraining devices were 1980). to lan. general attention process training Alibali. Schacter. wherein cognition is viewed broadly as the pro. and serves as a source of intervention principles processes (e. as exercises (Kavale & Mattson. respond impulsively. remarkably similar in theory and practice to unsuccessful guage and communication.GRBQ344-3513G-C33[877-962]. but more likely. in identifiable ways. then. (2) systems. In recent years. components of cognition that dominate cognitive develop. 2005. and social motivated. more importantly for cure learning disabilities with decontextualized cognitive treatment purposes. first addressing components of attention and Cicerone et al. context-sensitive hypothesis-testing. or attention training with a meta- naturally inclined to embrace a hierarchical progression in cognitive or compensatory strategy focus (Cicerone. which often are left unanswered concluded that well-controlled studies showed a minimal by comprehensive neuropsychological assessment.and Language-Related Functions framework for cognitive-communication intervention Decontextualized Cognitive Retraining becomes a major challenge. Each of the These early developments in TBI rehabilitation were processes and systems relates. tion). Cicerone et al. efforts to improve memory functioning with finally. misperceive efforts to improve cognitive processing and self-regulated social cues. whereas efforts to improve attention within the An understanding of cognition from a developmental context of specific everyday activities demonstrated a sub- perspective (Flavell. and is based generally on information processing theories of (c) efficient delivery of exercises using massed learning trials cognition. and Similarly. Miller. by loss of organizing schemes and prein. In both of described earlier. and procedures. and maintaining attention is more basic than shifting atten- Appendix 33. In the 1980s. attention is more basic than organization. and 1970s to neuropsychological assessments and. outside the context of functional application of the cognitive cessing of information for particular purposes within spe. In our clinical work. 2005).. attempts in the early 20th century to cure mental retardation Profiles of cognitive impairment after TBI can be varied with hierarchically organized cognitive exercises and to and complex. processes being trained (Ben-Yishay & Diller. problems with memory. Thoene. concerning the effectiveness of decontextualized attention Hypothesis testing with alternative support strategies helps process training in TBI rehabilitation to a meta-analysis and to answer these questions. because it helps clinicians to avoid a haphazard and In the early period of program development for survivors of inefficient “workbook” approach to treatment. ment in children and yields an inefficient and misguided Wilson. promotes systematic observation and program (a) hierarchical organization of cognitive processes and sub- evaluation. executive control over cognitive processes. & Rattok. and appear to have lost learning within the context of meaningful academic. Clinicians who believe that specific tasks that require attentional skill. appear to be inattentive. used) and superficial internal mnemonics (rarely used). and more aware of and commonly used—and the most effective—intervention for distressed about their memory impairment. Sony IC Recorder. enables people with memory. reminder systems have been developed that do ics actively used by the individual (e. integration of computer and paging technologies that ticipants. Ylvisaker. son (e. such as air bags. Dayus. & Evans. and electronic memory aids). because rehabilitation professionals ment.. positioning Many people with memory impairment predictably for- to-be-remembered items. memory notebook (60/94). cognitive retraining computer programs role in running a household and caring for children. Training methods often were unspecified. sufficient evidence was found for the authors to at specified times through an alphanumeric pager (Hersh & conclude that provision of memory aids to individuals with Treadgold. 2003. patients with prospective memory impairment. Van den Evans and colleagues (2003) studied the use of memory Broek. mainly that the Voice Organizer. screen. Quirk. 1995). memory impairment (discussed below). For example. creating a dramatic improvement in their everyday often are drawn to sophisticated electronic devices (rarely lives. a hand-held.. in facilitating retrieval. however. that (unlike seat belts) do not rely on the individual to do Sohlberg and colleagues (2007) reviewed 19 studies con. The most commonly used was the memory sufficiently effective that it is covered by the British health notebook. and the like. up with research. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 921 internal memory strategies. 1992). The most commonly used aids were a voice output reminder device. and Hilton (2000) found aids in 94 individuals with memory impairment. Emslie. etc. atten- Although most of the studies were single-subject designs or tion. served as a successful prompt rhymes (2/94). tape recorder producing approximately 300 spoken messages (48 min- (2/94). ety of memory aids or strategies to be used for specific mate- rial or on specific occasions. As often is the case. benefitted five of five calendar or wall chart (68/94). Uncommonly used aids or proce. Thus. .. tem by the individual or a caregiver. higher in intel- External memory aids are widely considered to be the most lectual ability. not rely on the individual’s initiation or ability to remember appointment books/calendars. get to use their memory prostheses (Kapur. it may be that clinicians need to improvements with these exercises to transfer to everyday equip individuals who have memory impairment with a vari- tasks (Carney et al. which also was the most commonly studied (nine system (Wilson. pager systems). lived alone. Johnson. rable to passive restraints in automobiles..g. 2003). memory prosthet. and “chunking” (1/94). and asking others and colleagues (2002) found that the recently developed for reminders (46/94). Yasuda lists (59/94). thereby. all with significant memory impairments. Downes. better at attending. For people who cannot read effectively or who have siderable variation existed among those studies that did other impairments that interfere with attending to a pager describe the training. first-letter mnemonics (5/94). many practitioners continue to use were full-time students. 1999. visual imagery (9/94).g. These numbers are for five of eight patients with prospective memory impair- worth attending to. categorizing. organization. by eating and taking prescribed medications at appropriate Studies in educational psychology indicate that elaborative times and improving quality of life by reducing painful encoding strategies that go beyond superficial rhyming and reliance on others. sus simply more use). increasing the likeli- artifact of the participants (e. or initiation problems to receive pre-dictated reminders case studies. Evans as well as workbooks with page after page of exercises in and colleagues (2003) identified a statistically significant cognitive skills. color coding. may be an capable of reducing caregiver burden. association between independence and regular use of three ing.GRBQ344-3513G-C33[877-962].g. Higher execu- chronic memory impairments (Evans. a minimal level of initiation. NeuroPage is an cerning the effectiveness of memory aids involving 267 par. Those participants who main- tained regular use of six or more types of memory aids Memory Aids tended to be younger. more recently injured. Thus. and training communication part. dictaphone-type associated with TBI. “Passive” systems of this sort are compa- and memory prosthetics requiring no activation by the per.. relatively few students who hood that people with memory impairment will stay healthy need to study for exams) and of the mnemonics sampled. ners to be effective memory prosthetics). studies).. associat. This system has been tice guideline. planning. Forty-seven percent of the 94 participants were consid- practice in the field of cognitive rehabilitation has not kept ered to be independent in the sense that they worked for pay. memory books. appointment diary (41/94).qxd 1/21/08 1:57 PM Page 921 Aptara Inc. The reminders can be typed into the sys- memory impairment after TBI should be considered a prac. cupboards. and/or played a major exercise-oriented. tive function scores predicted more effective use of aids (ver- External aids include environmental modifications (e. Therefore. 2001). anything to be protected. utes) at programmed times. voice reminder systems are available. a voice output memory aid capable of dures included electronic organizer (7/94). despite the well-documented failure of or more memory aids. The Intelligently prescribed passive reminder systems are infrequent use of internal mnemonics. However. Wilson. and errorless teaching/learning first-letter mnemonics are useful in deepening comprehen- procedures specifically designed for individuals with severe sion and. to use the system. labeling rooms. and con. 1994). such as sequencing.g. e. & Hallett. increasingly complex circumstances (e. Baddeley. including motor iors being rehearsed are the correct information and the sequences. Wilson & Evans. In the case of less severe memory impair. or other habits) and implicit desired behaviors. clinicians must possesses the memory) but may leave procedural memory ensure that the information being processed and the behav- (i. 1997). 2002). withdrawn (Brooks et al..e. homes. The practice of teaching habits (routines) of thought.g. approach to rehabilitation for people with significant cogni- In their now-classic studies. trial-and-error learning may be preferable to error. 2004).. Sweeper. Precise presentation and control of dynamic multi-sen- significant memory problems should be organized in such a sory. Therapy tasks for individuals with 1.. Advanced methods for recording behavioral responses can be given before a response and then systematically and delivering immediate performance feedback. remembering that such and such is the case) tional reactions—and errors often elicit strong emotional and explicit memory (i. 2005. driving. insidious manner. 1996. Tranel and Damasio (1993) found that individ- ing tasks and task environments. three-dimensional stimulus environments. people who seem to have severe Significant damage to the hippocampus and para-hippocam. In their “good guy/bad guy” tion is ecological validity and context-sensitivity of the train- experiments. Wilson. learning procedures to be a critical component of rehabili- Compared with both traditional artificial tasks and real- tation (Evans et al. particularly when associated with strong emo- memory (i. Provision of pre-planned systematic cueing to support Mateer. Tailby & following (as summarized by Rizzo et al. Riley & Heaton. Hunkin.. and they serve as an Pascual-Leone. 1989) have found that people with apparently dense amnesia after brain injury are still capable of implicit memory and Virtual Reality and Cognitive Rehabilitation procedural learning. . When people with severe explicit and declarative mem- ory impairment make errors and experience a rush of Implicit Memory and Errorless Learning embarrassment or anger when those errors are corrected. poorly on explicit memory tasks but comparable to controls The central theme of VR as applied to cognitive rehabilita- on implicit memory tasks. Kerns. 4. and others have found errorless ment and training tasks can be constructed. possessing a memory trace that influences have revived a decades-old tradition of errorless learning in future behavior but lacking a subjective sense that one animal training (Terrace. supermarkets. 1963) and in developmental dis- remembers) relatively intact (Bachman.and Language-Related Functions motivation. Schulteis. everyday. and more. ment. & Shiel. 2000. Izard.. Potential for “after-action reviews” from a variety of vir- less learning. Within these which are common in varying degrees after TBI. having a subjective sense that one reactions. 1999. Under these circumstances. thereby addressing the fail- uals with severe amnesia associated with damage to para- ure of much traditional rehabilitation at the level of transfer hippocampal structures nevertheless create implicitly stored of treatment gains to real-world settings and activities. 1996. additionally bolstered by recent findings in the areas of the erroneous memory influences future behavior in an implicit and procedural memory and errorless learning. the need for error-free learning is one preparation).e. These neuropsychological considerations memory (i.qxd 1/21/08 1:57 PM Page 922 Aptara Inc. Barbara realistic environments. remembering how to do something.e. 1992). In the presence of such neuropsychological profiles. and social conduct using antecedent supports is ciated with an awareness of the response as an error. Shum. Evans. because it encourages deeper processing and tual perspectives. ries for those people. 1992. kitchens. 1967).GRBQ344-3513G-C33[877-962]. skilled operations. Similarly. Schacter. error-free learning. 2004): Haslam. of tasks within a realistic VR environment for develop- cedures can achieve this goal as the teacher/collaborator ment of compensatory strategies or just practice under ensures successful and error-free performance during learn. 2005. Apprenticeship (“scaffolded”) teaching pro. 922 Section V ■ Therapy for Associated Neuropathologies of Speech. For way that potential errors are anticipated and prevented with example. it is possible to gradually build up complexity advance cues.. school environments. 1994). memory impairment may encode and store some memories pal structures (common in TBI) typically impairs declarative effectively. 1995. com.. of the supports for VR technology in rehabilitation. Kessels & De Haan. tive impairment after TBI. workspaces. Similarly.. systems to succeed (Yasuda et al. 2003. abilities (Sidman & Stoddard. meal ing tasks. and Murray Rizzo and colleagues (2004) summarized the potential ben- (1996) found that subjects with TBI performed relatively efits of VR technology in neuropsychological rehabilitation. Cues 2. affective memories about people with whom they have had Current applications of VR technology (in research centers) positive or negative experiences despite no explicit memo- enable the creation of real-world virtual environments. 1992. Jonathan Evans. routine-based Squire. Grafman. & 3. That is. but not asso- munication.. Glisky and Schacter (1988. additional buttress for a supported. Thus. they are likely to store the erroneous response. Rizzo.. and self-awareness likely is necessary for such improved explicit memory (Squires. world tasks. a variety of ecologically valid assess- Wilson. & Parkin. 2000. advantages of VR intervention include the Kessels et al. including virtual cities. Goldstein. we have served more than 1. self-coaching approach Evaluation of the effectiveness of VR interventions is in to social skills weakness. Safe testing and training environments. a positive. 1999). Improved access to assessment and training for persons tives to challenging behavior. e.. 1988). a component of which problems. both declarative interaction exist between cognitive and behavioral conse. with approach to challenging behavior. 1989.000 young adults social skills or pragmatics groups—outside of the context of through a New York State community support project for real social interaction—guided by a curriculum that specifies individuals with TBI.000. contexts) and procedural (knowing how to perform the Furthermore. preliminary studies are promising. finding (Brooks et al. nity support program. we outline and offer a rationale for a context-sensitive. the programs are organized around training (Feeney et al. and awareness of social cues. complex patterns of the service is to impart social knowledge. and ationally relative social behaviors (e. trol). or psychiatric projected enormous lifetime costs for this population disorders. Reichle & Johnston.g. Gershaw. annually.. Todis. Sheinker & Sheinker. This technologic development may create the troversial but is included in the ASHA’s scope of practice and possibility of VR training in social interaction. antecedent-focused its infancy. costs associated with failure of rehabilita.g. adoles- were more than 5 years postinjury at the time of referral and cents. and general community reintegration difficulty suggests that routines along with the communication competencies that behavioral and psychosocial themes often are at the core of are components of those routines. their introduction to the program. bar room conversations. Walker. Many structured SST programs have Conservative Department of Health estimates regarding the been developed for individuals representing varied popula- cost of serving these individuals without a targeted commu.g. 1994). or adults from culturally diverse backgrounds or with had failed in previous rehabilitation attempts. academic. 1994. Reichle & Wacker. 1993. label of social skills. Until such procedures are well validated and the technology reasonably priced.. of language and teaching positive communication alterna- 6. natural. tion and community support efforts are staggering. con- documented success. enable a person to be socially successful in selected settings. tions (see. 2001). and a collaborative. groups within which the participants practice social behav- Speech-language pathologists have a natural role in this iors considered to be relevant to their social success. & Horton. In this section. route alternatives to negative behavior. Thus. Difficulties scripts appropriate for the workplace. roles. Building Repertoires of Positive Social Communication Routines Behavioral and Psychosocial Rehabilitation Traditional Social Skills (and Pragmatics) Training Importance of Behavioral and Psychosocial Issues Social skills include general competencies (e. 2006). Walker et al. and demonstrated lack of success in community the types of modeling and role playing that are used to teach reintegration using standard services and supports. In Traditional social skills training (SST) often takes place in recent years.GRBQ344-3513G-C33[877-962]. self-con- In the earlier section on outcome. the state had developmental disabilities. some degree of chronic behavioral the social competencies needed by the group members and impairment. and rehearse the skills. Messmer.. including transfer of training. has been understood as an effort to young adults with chronic school and work problems and equip individuals with knowledge of social rules.. Such domain of service delivery under the headings of pragmatics training programs differ with respect to the degree to which . VR may remain only a promise in TBI rehabilitation. learning problems.qxd 1/21/08 1:57 PM Page 923 Aptara Inc. we highlighted the fre. & Klein. although in most cases.. orders and public speaking phobias. Pragmatics has a long history with sensorimotor impairments via adapted interface within the profession—and in other professions—under the devices and tailored sensory modality presentations. 1988. however. the primary goal of these problems. on tasks text-sensitive approach to teaching positive communication such as meal preparation (Fidopiastis et al.. in this domain may be a result of the injury but often are church groups. based on expenses for the year before 1980. 1993. and others) that complicated by preinjury challenges and postinjury social. Ylvisaker & Feeney. and vocational failure and consequent adjustment Historically.000 & Waksman. The role of speech-language patholo- 7. Designed for children. behaviors). 1988. social skills intervention. Our work with several hundred adolescents and is pragmatics training. 2001). Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 923 5. Because most of the people served by the program Holmes. exceed $40. (knowing that certain behaviors are desirable in specific quences of the injury. classroom interaction. personal attributes (e. concern for others). Increasingly realistic virtual human representations gists in behavior management may be somewhat more con- (avatars). Related procedures are now used in treating anxiety dis. als with developmental disabilities are served (Carr et al. has become commonplace in many settings where individu- istic communication. Waksman.. communication associated social interactive weakness after TBI. and situ- quency of personality changes.g. Sprafkin. and driving (Schulteis & Mou- rant. behavioral problems.. the profile of many individuals with TBI is According to Berk (2001). (3) possess the capacity to transfer cognitive-behavior modification (Meichenbaum. Thomas. or script. Thompson. of their interactive social competence and the effects of their ing. however. Ylvisaker and colleagues have used support in the many experimental studies of its use with a self-coaching as a metaphor and set of procedures in TBI variety of clinical populations.and Language-Related Functions they emphasize discrete trial training or social problem solv. self-coaching most closely social rules. assumes that the participants (1) lack knowledge of relevant As a psychological therapy. no reason exists to believe that socially decontextualized training setting. Unfortunately. traditional SST (or pragmatics training) holds promise for In part because of the logistical ease with which such those individuals with TBI with the most common neu- group SST can be implemented in rehabilitation hospitals ropsychological profiles. plan. planning. the social contexts in which the skills in question are needed. The term “play” refers to an orga- of 0. ultimately. however. a clear enable a person to successfully negotiate personally relevant disconnect exists between traditional SST and the types of social environments. First. and vocational lives disturbance. individuals with a common became clinical interventions delivered in a manner insensi- profile after TBI typically possess relevant declarative social tive to everyday contextual realities. initiation. this “everyday routine” approach the opposite of that suggested by these assumptions. their social behavior. Rather. they system concerns and potential social strategies. tion. Applied to social tion alone (Abikoff et al. Johnson & Newton. Likewise. 924 Section V ■ Therapy for Associated Neuropathologies of Speech. (2) are motivated to change resembles cognitive-behavior therapy and.g. alized selection of teaching targets and extensive coached Wisotzek. and routines. even if that self-talk is automatic and minimally groups typically led by speech-language pathologists) conscious. Gajar. Hechtman et al. 1986. an application settings. difficulty interpreting . such as that performed during by Abikoff and colleagues of interventions for students with a football game or other athletic contest. the randomized. tion.GRBQ344-3513G-C33[877-962]. 1977). context-sensitive (versus clinic-bound) interven- planned contingencies. decreasing impulsive and reactive behavior. self-regulatory success of traditional SST groups (including pragmatics self-talk. and (5) are reasonably self-regulated. educational. 1984. working memory. particularly if the injury has reduced their awareness otherwise ineffective social interaction. The the view that self-regulation is.21. Creation of positive habits of interaction requires individu- McMorrow. SST or pragmatics groups enjoy con. particu.20. Lloyd. often agree to organize themselves around self-coaching ond included 53 studies of SST applied to students with procedures (“plays”) despite possible opposition to other learning disabilities. respond inefficiently to scripts) can be designed to address a variety of obstacles behavioral contingencies. Limited evidence allocation impairments common in TBI lends itself to inter- suggests that SST of this sort can be somewhat effective vention designed to create positive habits of interaction in with some adolescents and young adults with TBI. 1985). ADHD (a population similar in pathophysiology and symp. Thus. Schloss. arise at several levels. & practice in context. Individuals described two meta-analyses. knowledge but are poorly regulated. With to self-regulatory self-talk is consistent with the views of relatively damaged anterior brain structures and relatively Vygotsky. Concerns about the usefulness of decontextualized role play–based Self-Coaching and Scripts of Social Interaction SST. Schloss. Ylvisaker & Holland. even at the level of theoretical rationale. controlled clinical trial nized strategy. 2004. socially important. impulsive or change. The general goal of self-coaching is to improve planful tomatology to those with TBI) found that decontextualized goal-oriented and. with a similarly small mean effect size intervention approaches. traditional SST (defined above) has received little Since the early 1980s. The common thread.. with a small mean effect size of 0. but skills acquired in a training setting to varied real-world with the important caveat that self-coaching is. The sec. or with sports as participants or fans. Self-coaching has its historical roots in social interaction problems that are common after TBI. 1988. ideally. self-coaching plays include specific scripts that Second. more specifically. and may lack the motivation to common after TBI: poorly controlled emotions. Specifically. is repeated practice in a behavior on others. larly with an emphasis on self-monitoring (Braunling. Self-coaching plays (including self-regulatory self-talk ring social knowledge to daily living.. Gresham and colleagues rehabilitation (see. have difficulty transfer. and resource siderable popularity in TBI rehabilitation. e. 331). the self-coaching generalized changes in the social competence of students metaphor yields insight regarding self-regulatory/executive with high-incidence disabilities” (p. & Fralish..qxd 1/21/08 1:57 PM Page 924 Aptara Inc. & Milan. which were distorted when self-talk therapies preserved posterior structures. 2004). Because (2001) reviewed several narrative reviews and meta-analyses TBI disproportionately affects active young people who typ- of this extensive research literature and concluded that “SST ically have personal experiences and positive associations has not produced large. roles. 1987). successful behavior while SST added nothing to the effect size produced by medica. long-term. Brotherton. (4) modify their behavior in response to everyday. the combination of inhibi- and outpatient clinics. at its core. The first included 99 studies who have self-regulatory impairment but desire higher lev- of SST applied to students with emotional and behavioral els of success in their social. with “plays” that also specify roles for ECPs. interaction. ness of self-coaching plays must be carefully monitored. self-observation. script). know and are com. sobriety. “coaching” scripts are negotiated Table 33–13 lists the principles underlying this self-coaching and developed for the individual (self-coaching scripts) and approach. and personally appealing. and evaluate their effectiveness and comfort level. or self-destructive behavior.. When we create . or discomfort. or other symbols of strength and success. frustration. (2) identify what is blocking successful achievement reasons for video self-modeling is that many of these of that goal (obstacle). following about the person’s injury and its effects. specific issues that have a direct and measurable effect on • Try the plays in real “games” (i. authorization for self- with brain injury. with permission. Practice: Automaticity of self-coaching “plays” cannot be describe what they want to accomplish or get better at achieved without a great deal of practice. Monitoring. and the like to make their meaning clear unsuccessful. stimuli. Revisions. participants are encouraged to (1) 7. they allow the understand the plays and their rationale. (do). That is.. and weight loss). This short circuits later objections can be customized to meet individual needs. The need for automatization also is one of observation should be granted by a relevant clinician (e.g. automatizing the self-coaching plays and scripts is critical. elicitation of the self-coaching play by natural everyday personally meaningful goals. participants to observe themselves being unsuccessful with- fortable with their roles (e. numbers of learning trials for habituation. prompting the play). environmental cues automatically trigger effective self- regulatory/self-coaching thoughts and behaviors rather than • Associate those plays/scripts with compelling images. many people have relatively weak self-monitoring and the intervention must take into account the routines of self-awareness. personal goals (e. the self-coaching videos serve three Third. 5. Self-Coaching Plays/Scripts and Communication Partner Scripts: Ideally. If well constructed. possibly using video and respectful collaboration with the participants in learning trials (“game films”). discussed earlier. (4) try learning trials can be logged as the individual watches the it under highly supported and then real-world conditions video (“the game film”). successfully. and (5) review what is working and what is not work. money management. impulsive. These self-coaching videos allow the par- coaching scripts within those routines. Particularly for individuals with limited space in working with revisions as necessary and ample celebration of success. 6. • Negotiate acceptable reminder plays or partner scripts 3.g. negative. (3) create a play (plan. In some cases. both of which might be improved with video everyday life and ensure considerable practice with the self. using the self-regulatory self-coaching plays/scripts people. Thus. how to cue within the general goal-obstacle-plan-do-review framework self-coaching without eliciting oppositional responses). TBI.GRBQ344-3513G-C33[877-962]. real-world interaction). the plays need to be automatized within the settings and routines in which the difficulties arise. Automatic Self-Regulation: The ultimate goal of self- of self-regulation or interaction designed to solve specific coaching is to create situations in which relevant problems or overcome specific obstacles. heroes. and acceptable supports from others. with the goal of automatic identifying difficult situations and negative behaviors. Participant Involvement: Self-coaching requires creative • Rehearse the plays/scripts repeatedly. Principles of Self Coaching as a Social Competence hygiene. goals. Furthermore.. Negotiation of Scripts and Metaphors: Plays/scripts and metaphors are individually negotiated to be as personally • Modify the plays.qxd 1/21/08 1:57 PM Page 925 Aptara Inc. the videos can contain simple educational content purposes beyond habituation of the plays. the reasons for using self-coaching videos to ensure large clinical psychologist. or social worker). and others. These short Second. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 925 others’ social behavior and reading others’ emotional states. Motivating Associations: The self-regulatory plays/scripts • Ensure celebration of everyday successes that result from should be creatively associated with motivating images. triggering poorly controlled. in the event of fail- meaningful as possible. Because self-observation execute their roles without irritating or boring the person can be emotionally challenging. based on faulty recollection of the rationale for the play. TABLE 33–13 difficulty managing everyday routines. Ideally. The key procedural Intervention concepts are: • Negotiate personally appealing and effective plays/scripts 1. Specificity of Real-World Needs: Self-coaching targets that can be used by ECPs. 8. habituating or From Ylvisaker (2006). ure. useful self-talk plays/scripts. All self-coaching interventions are organized also for everyday communication partners (e. the video can include the negotiation and agree- videos typically include content outlined in Table 33–14 but ments that led to the play.e. or design new plays. problems at work or school.g. 4..g. psychiatrist. and Celebration: The effective- ing. and can out the self-coaching play/script. 2. This is one of the ticipants to observe themselves being successful using the reasons for the involvement of ECPs. First. relevant ECPs self-coaching plays and scripts. One of the (goal).. memory and weak online decision making. making modifications as needed (review). the quality of the individual’s life. and Language-Related Functions TABLE 33–14 self-coaching videos. successful negotiation of the difficult situation. From Ylvisaker (2006). Hallowell & an acceptable cue for the participant to use self-coaching Ratey. et al.. 1991. You have a hard time stopping yourself tradition. Within this an impulsive guy.g. Introduction to the concept and importance of self. ative or no consequences for undesirable behavior. TBI). whether congenital segment could include an admired peer using the self. while hold- 1. An enormous literature and impres- working out these special plays. ADHD) or acquired (e. that’s why you’re behaviors or modifying undesirable behavior. Damasio. this statement is made Concerns About Traditional Consequence-Based collaboratively by the person and the therapist. 33–15. 1995. frontal lobe research literature.g. at best. we routinely begin with a few minutes of educational content about brain injury and the individ- Possible Content for Self-Coaching Videos ual’s specific injury. Possibly a description of what changes in behavior will potential explanations. 1996. (e. dating back to Skinner’s early work (Skinner.. Damasio. For some individuals. This who have frontal lobe impairment.. 4.. But he had to wear special equipment.qxd 1/21/08 1:57 PM Page 926 Aptara Inc. and and observable antecedents (e.. information may be included in this segment. 1994. that’s why we’re time of the behavior). point out relevant areas and their coaching. are associated with the stored representation of the original behavior. Damasio. Bechera. 1987. 1938). Your brain is injured here. right? But that doesn’t mean you can’t be successful. quarterback of the more. This inefficiency has been documented in the script. Possibly an everyday communication partner demonstrating ior modification programs (Barkley.. Slifer. ideally using a model of the brain to make the information as concrete as possible. established in the group. but he still played and played very well. implementation of primarily consequence-oriented behav- 5. with permission. reports have documented some automatic!” success with traditional consequence management applied 3. It’s not cues. ing a model of a brain. Possibly some “cheerleading” from group members for Damasio. Participants who are many years post-injury the group and then used as the introduction to many or all often report that this information is new and important for of the individual self-coaching videos. accept special help—and it wasn’t easy.g. 1991. and prompts as well as environmental stressors at the easy for you to control your impulses.g. 1994. Alderman & situation looks like without self-coaching (e.GRBQ344-3513G-C33[877-962]. intervention strategies largely are reactive.. & motivational purposes. Behavior Management and Communication 2. This may be particularly valuable for those with sig. & Anderson. But he did it. Often. Damasio and colleagues (Bechera. consequences of behavior can influence future behavior nificant memory impairment. only if somatic markers.. 8. 1996) with TBI. Last week he had a banged up knee and behavior management. Brief vignette demonstrating what the difficult social to both adults (see. and that’s why you’re going sive technology of behavioral change have evolved within to get the video and watch it many times to make the plays this tradition. clinicians who work with individuals situation looks like with the self-coaching script—that is. 7. This may be a videotaped live discussion within importance. Furthermore. Damasio et al. we typically sit next to the participant and. Damasio. then statements about the person’s have explained behavior as a consequence of both ante- difficulty can and should be clear and direct—for example. Brain injury–related them and their ECPs. & Kurtz. or feeling states. it may be desirable to include in the video the entire discussion and negotiation that leads to the Tranel. Explanation of the individual’s specific difficulty that requires self-coaching. Brief vignette demonstrating what the difficult social Unfortunately. Cataldo. Slifer person’s behavior). cedents and consequences but have placed the major bur- “Bob. the trainer’s commands. 2003. 2002) have suggested that favorable or unfavorable scripts. speci- from doing or saying the first thing that pops into your fying positive consequences for desirable behavior and neg- head. Behavior Management specific brain injury information may be included in this segment—again using a model of the brain.g. to the extent that antecedents are targeted in Pittsburgh Steelers. Pace & Ivancic. Alderman. often report a frus- coaching script so that it has positive associations as it is trating lack of success or. 1990) and loses his temper. Wood. 1987. 1994). e. 1994. or the participant misinterprets another children (see. use special strategies. Person. If an Traditional operant applications of applied behavior analy- appropriate level of comfort and mutual respect has been sis. participant Ward. Tranel. 926 Section V ■ Therapy for Associated Neuropathologies of Speech. e.g. Further- Think about Ben Rothlisburger. you see this part of the brain? It helps us to control den on manipulation of consequences in teaching new our impulses. it largely has been the immediate broken thumb. During these few minutes of presenta- tion. which are summarized in Table demonstrate success of the self-coaching script. inefficiency in their viewed on the video. which offers at least four 6. Their neuropsychological investigations indicate that ven- tromedial prefrontal cortex is critical to laying down somatic markers and connecting them to memories of past . a satisfactory explana- contingencies and impulsiveness. Alderman found a correlation between impaired working memory and difficulty learning from consequences. Wade. Working Memory Because of the relative frequency of dorsolateral prefrontal Hypothesis (Alderman. 1998a) behavior management systems may be counterproductive. attachment of somatic markers (feeling 1994) states associated with rewards and punishments) to stored representations of past experiences is inefficient. some individuals lack organically based initiation/activation capacity to act in situa- tions in which they have learned the correct behavior and are adequately motivated to act. as a hypothesis capable of explaining the ment may include a combination of these four phenomena. 2000a). behavior. traditional & Feeney. 1986) dorsomesial) prefrontal injury in TBI. given its high frequency of ventral prefrontal tion/activation. 1986). In some cases. & McGrath session of the appropriate learned response (Stuss & (1994) highlighted inflexibility in response to changing Benson. reduced working memory is a common 1996) impairment. . but immediate impulses easily overwhelm learned behaviors on the occasion of action. including reinforcement. especially adolescents Oppositionality and young adults. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 927 TABLE 33–15 Possible Explanations for Inefficiency of Consequence-Oriented Behavior Management in Rehabilitation of Traumatic Brain Injury Hypothesis Discussion Disinhibition Hypothesis Because of the high frequency of orbitofrontal injury in (Rolls et al. Key: TBI  traumatic brain injury. the research working memory may explain the failure of many individu.qxd 1/21/08 1:57 PM Page 927 Aptara Inc. like young children. Initiation Hypothesis Because of the relative frequency of dorsal (especially (Stuss & Benson. People who are impulsive. For our purposes. injury in TBI. may explain failure to act despite pos- Rolls (2002) as well as Rolls. training techniques. literature at least directs clinicians to focus their attention als with frontal lobe injury to respond to traditional operant on both immediate and remote antecedents of behavior. react negatively to attempts by others Hypothesis (Ylvisaker to manage their behavior with consequences. associated with orbito. Hornak. Somatic Marker Because of the high frequency of ventromedial prefrontal Hypothesis (Damasio. maintenance of behaviors that have resulted in a history of possibly exacerbated by oppositionality. thereby explaining the inefficiency of conse. extinction. reduced initia- with CHI. somatic marker storage is critical to learning from consequences and is weak in individuals with ventrome- dial prefrontal damage. tion for the inefficiency of traditional behavior manage- frontal lesions.GRBQ344-3513G-C33[877-962]. perhaps suggesting that reasonably adequate working mem- ory is needed for correct selection of learned responses. According to this theory. 1994) TBI. quence-oriented behavior management in many people and time-out interventions. The common complaint is that reward and punishment sys- tems are child-like or that external manipulation beyond their control and approval is in general offensive to them. Alderman (1996) con. impulsiveness is a common impairment. which may grow in seriously punishing consequences. In individual cases. are capable of learning from consequences. response to ineffective consequence-oriented management cluded that weakness in the central executive component of (Ylvisaker & Feeney.. injury in TBI. Infantilization and Because many people with TBI. sial) prefrontal injury. associated with dorsal (especially dorsome- damage. competencies.g. behav. 1989). work. Ylvisaker et al. Carlson. Assessment: • To identify the background antecedents or non-immediate “setting events” that may be related to positive or negative Building Positive. & McQuade. and building repertoires • May be most efficiently met by educating and training of positive behaviors. From Ylvisaker & Feeney (2000a). is completely consistent with the theoretical and procedural • Self-perception. Ylvisaker. the behavior (e.and Language-Related Functions Positive.qxd 1/21/08 1:57 PM Page 928 Aptara Inc. • Living arrangements. • Leisure (frequency and quality of enjoyable activities). Critical to antecedent management is the concept of “setting events” (Michael.e. Magito-McLaughlin. which are potentially remote occurrences or conditions that increase or decrease the likelihood of a behavior and deter- . Langdon. an unpleasant interaction earlier in the behavior and increase or decrease its likelihood of occurrence day) or internal states of the individual (e. 2003. everyday communication partners and. the • The relation between the person’s needs. everyday. often in controlled settings (i. modify antecedents.. social. (Carr. demands. generally in natural settings. relatively little attention has been paid to Antecedents: Discrete measurable stimuli that precede a remote events (e. perceived meaningfulness). level of success.. Ylvisaker & Feeney. Zencius.g. et al. and vocational Earlier. Antecedent-Focused Behavior Management TABLE 33–16 In Table 33–16. cue. Turkstra et al. and/or educational environments and Preventing Negative Behavior with Antecedent Manipulations activities.. illness). Wesolowski. we outline alternative approaches to the Behavior Management Via Control of Antecedents: role of antecedent manipulation in behavior management Alternative Approaches (based on Carr. • Work (e. Historically.g. 1993). to avoid negative behavioral Based on Carr and colleagues (1998). anxiety over lost skills. a specific instruction. including communication routines.. 1999). potentially continuous. Communication Routines • To assess the “goodness of fit” between the person’s needs. Furthermore. demands. procedures designed.g. analog decrease the likelihood of certain behaviors. Everyday Behavioral and behaviors. often hard to approach in Table 33–16). and social. and level of success). application of antecedent technologies • Social relationships. eliminate triggers. in other ways. Part 2 of Table 33–3 in Framework for Cognitive and Secondary Purpose: To indirectly increase desirable and Psychosocial Rehabilitation lists several categories of antecedent decrease undesirable behaviors. and communication impairment.. 1996. 1995. with per- routines and increase the likelihood that positive behaviors mission. competencies. including active experimentation with life) as potentially modifiable antecedents that increase or antecedents).. will become habitual.. presented earlier.g. and 1993. Although most of the research measure variables that may increase or decrease the likelihood and clinical discussions within this new tradition address of occurrence of positive or negative behavior: behavioral issues associated with developmental disabilities • Internal states (e..GRBQ344-3513G-C33[877-962].g. 2000a. 928 Section V ■ Therapy for Associated Neuropathologies of Speech. momentum has grown within the Intervention: To increase or decrease specific behaviors by field of applied behavior analysis favoring an approach to manipulating the specific immediate antecedents related to teaching and supporting individuals with challenging behav.g. in part. including immediate and remote as well as Molar Approach To Antecedent Control observable and unobservable antecedents (the “molar” Antecedents: Broad. 1982. routine-based approach to rehabilitation equally applicable Intervention: to intervention for individuals with chronic cognitive. has entered the experimental and clinical literatures in TBI • Education (e. 1998). routine-based intervention thinking and behavior. including implicit metaphors that guide discussion of positive. or promise). rehabilitation (Feeney & Ylvisaker. the narrow “molecular” Molecular Approach to Antecedent Control: The Tradition in approach co-existed with a primary focus on consequences. assessment). and fade antecedents in or out). demands.. we offered a rationale for a positive. everyday.. Applied Behavior Analysis Until recently. anger resulting (e. placement. ior that places greatest emphasis on the manipulation of antecedents. educational. from loss of friends. 1998a. Over the past 20 years. (2007). or frustration Assessment: To identify these antecedents for purposes of associated with an unsatisfying job or no meaningful role in control (a-b-c analysis. 1997. and molar approach to antecedent-focused behavior management environmental demands. creating a “best fit” between the individual and his or her living. Jacobs. Behavior management events and conditions with the goal of helping the individual to within this approach can be divided into two overlapping create a satisfying lifestyle: efforts: preventing negative behaviors. placement. Primary Purpose: To influence major background setting ioral. & Yarbrough. Burke. warning. Negative setting events: pain. over medication. achievement. success. with permission. acceptance by others. • Perception of Task Meaningfulness and Difficulty Positive setting events: belief that assigned tasks are meaningful and can be accomplished. satiation. frequent changes in living situation and . and adequate recognition of things and people. anger. Wolf. and feeling in control. relaxation. limited control over include in Table 33–17 a list of positive and negative setting major life events. and sensory deficits. 1987). disorientation. seizures. neurotransmitter disruption. • Presence or Absence of Specific People Positive setting events: presence of preferred people and reciprocal friendships. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 929 TABLE 33–17 Categories and Examples of Setting Events that Potentially Influence Behavior Internal States of the Individual • Neurologic States Positive setting events: normal neurology. “event” ing with people who have acquired brain injury because of the is not restricted to temporally discrete occurrences but. and appropriate levels of medication. hunger. and presence of nonpreferred people. ambient noise. External Events and Conditions • Living Arrangement Positive setting events: living in a self-selected environment without excessive restrictions. Negative setting events: irritating environmental stimulation (e. respect from others. adequate recall of relevant events. mine whether a specific behavioral intervention will be events that can be used as a checklist in working with indi- effective (Baer. motor deficits. depression. frustration. • Time of Day Positive setting events: alertness. can include internal states and conditions).qxd 1/21/08 1:57 PM Page 929 Aptara Inc.g. Negative setting events: living in an excessively restrictive setting. Negative setting events: belief that assigned tasks are meaningless. decreased cerebral blood flow. & Risley.GRBQ344-3513G-C33[877-962]. • Other Physiologic States Positive setting events: rest. and inadequate recall and recognition. under medication.. of setting events is unfamiliar to some rehabilitation special. infantilizing. or impossible. Negative setting events: confusion. meaningful role. Negative setting events: anxiety. Negative setting events: bad time of day relative to the individual’s natural cycles. loss of friends. • Other Environmental Stressors Positive setting events: appropriate and desirable environmental stimulation.g. • Cognitive States Positive setting events: orientation to task. Negative setting events: overactivity of the limbic regions.. sense of self consistent with life circumstances. living at home with parents after having lived independently. Because the concept viduals with difficult behavior after TBI. and other distractors). and sense of loss and failure. Negative setting events: absence of preferred people. From Ylvisaker and Feeney (1998a). illness. we restrictions on activities and choices. Attention to setting events is particularly critical in work- ists and bears meaning that is not transparent (e. best time of day relative to the individual’s natural cycles. improper lighting. familiarity with routine. • Emotional States Positive setting events: sense of accomplishment. cumulative negative effect on behavior of chronic discomfort. Negative setting events: recent conflict or disrespectful interaction. rather. • Recent History of Interaction Positive setting events: recent positive and pleasurable interactions. 1997. Dunlap Figure 33–10. Mace et al. with permission. Conversely. Boyajian. & Lindquist. including creating positive behavioral momentum before olds that. Sherman. Belz. vates those thresholds and increases the likelihood that the 1990.) routines. Corsi. (Modified from Feeney & Ylvisaker. (Modified from Feeney & Ylvisaker. tive effects on behavior of inducing positive setting events. a background of positive setting events ele. 1993. Fowler. ground of negative setting events lowers behavioral thresh.. as a result of the injury. with permission.and Language-Related Functions Figure 33–9. Mauro. Relationship between negative set- ting events and challenging behavior. 1995. Harchik. 930 Section V ■ Therapy for Associated Neuropathologies of Speech. Kennedy. The developmental disabilities behavioral litera.qxd 1/21/08 1:57 PM Page 930 Aptara Inc. Itkonen.) . A back. Brown. introducing difficult tasks (Carr et al. 33–10). 1997.GRBQ344-3513G-C33[877-962]. & (Fig.. Sheldon. 1997. & Eckert. 1988. failure to achieve goals ture is rich in reports of experiments demonstrating the posi- consistent with preinjury expectations and aspirations. already may be low (Fig. 1997) and offering individual will become productively engaged in difficult tasks choice and control (Bannerman. Mace. 1990. 33–9). 1996. & Wenig. and perhaps most critically. Relationship between positive setting events and positive behavior. the natural connection between appropriate conver- The Role of Consequences sational openers and subsequent satisfying conversations is In emphasizing antecedents in behavior management for violated. in individual cases. 1984. 2002). which are popular components of ture and concluded that increasing an individual’s opportuni- consequence-oriented behavioral programs. Mirenda. some basic rules apply. with the goal of helping people to succeed in the groups typically indicates that the behavior serves a commu- real world. we present a summary of the communica- tantrum. and increases subjective reports of sat- in the real world. & Robinson. 1993). jail) may serve as Teaching Positive Communication Alternatives motivation for participation in the development of to Challenging Behavior antecedent-supported routines. tional bid from a person known for acting out sexually is rewarded with a token that can be exchanged later for a cig- arette. can be expected to be many times in many contexts over the past 30 years (Deci. if an appropriate conversa- isfaction derived from that participation. autism. or place. because they result meaningful. Moniz. positive communication training has that may breed anger and additional failure. 1985. Reichle & Wacker. Mesaros. person. Organized pro- quence of effective preparation for a test. • “That’s not an appropriate way to request cigarettes. need consequences that are immediate (versus delayed) and Carr et al. in part. In premises underlying the approach. often expressing an intention to gain and logically related to the individual’s behavior as possible.. the following contingent responses are not related ment. liberal use of extrinsic rewards can people with TBI. I’ll give you a approach to behavior management for individuals with TBI point for that. Doss & Reichle.GRBQ344-3513G-C33[877-962]. dure. obstacles to success.. and finally. and an enjoyable social interaction is a natural and teaching positive alternatives are available in the develop- logical consequence of socially appropriate initiation. viduals who are impulsive and concrete in their thinking Dores. considerations in assess- contrast. even those who are Behavior management and SST come together in the inefficient at learning from consequences benefit from a process of helping people with challenging behavior to sub- positive culture in which there is ample noncontingent rein- stitute a socially acceptable mode of communication for forcement. often fail to ties for choice and control decreases challenging behavior. many people with TBI escape fron.” experimental reports in the developmental disabilities litera- Token economies. thing. & salient. Functional analysis of problem behavior in those Second. and failure and negative behavior elicit ate in their social contexts. its roots in work with individuals who have mental retarda- In using consequences. in extrinsic or intrinsic rewards for the person. positive behaviors: for overcoming the obstacles. Sherman. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 931 et al. Fourth. successful performance is greeted with encour- behavior that is unsuccessful or considered to be inappropri- agement and praise. we do not wish to recommend inattention create dependence on such rewards and interfere with inter- to consequences. 1995. nally driven motivation. and demonstrated the effectiveness of this • “I liked the way you responded to Jeremy. Harchik. 1993). as efficient as their uninjured peers at learning from conse. As cognition improves. Deci & Ryan. we have discussed.” illustrated. along with suggestions are not likely to help shape enduring. Durand & Crimmins.” in greater detail (Feeney & Ylvisaker. access to a desired activity. Furthermore. 2003. Third. 1992) and for the job. a good grade is a natural and logical conse- escape an activity. As an organized approach to efforts to help the person succeed rather than punishment behavior management. may not be serious. logical consequence of “trashing” the room during a In Table 33–18. progressively more delayed and less salient.. and receiving a poor grade is a natural and logical tion approach to behavior management. or place or to For example. First. Carr & Durand. the possibility of serious punishment (e. e. promote understanding of natural and logical relationships increases participation. including the consequence of failing to prepare for an examination. On mental disabilities literature. or other developmental disabilities (Bird. preteaching activities. cleaning one’s room is a natural and effectiveness of these efforts. the frontolimbic threats to efficiency that many oppositional young people become increasingly of consequence-oriented behavior management come in oppositional in an environment that they perceive as being degrees and. a finding that has been replicated tolimbic injury entirely and. a raise or promo- cedures for assessing the communication value of challeng- tion is a natural and logical consequence of hard work on ing behavior (see. Donnellan. John. person. everyday routines that antecedent supports are pense rewards and punishments that are not personally designed to facilitate are positive. Finally. 1994. 1995. you Harchik and colleagues (1993) reviewed more than 100 will not be allowed to go on the outing tonight. therefore. • “Nice talking. demand. 1989. indi- tion. rewards and punishments should be as natural nication function. categories of teaching proce- in a natural and logical way to the behavior and. Elsewhere.g. Finally. consequences can become Fassbender. dominated by arbitrary authority figures who arbitrarily dis- the positive. along with evidence of the the punishment side. therefore. 1997. 1994. 1989. First. .g.qxd 1/21/08 1:57 PM Page 931 Aptara Inc. & Bannerman.. For example. our experience suggests quences. Furthermore. gain access to desirable tasks. person. context-sensitive. it is unlikely to be adopted.g. 3. Collaboratively identify and describe the unacceptable behavior and the contexts in which it occurs.e. (See also Durand & Crimmins.. Contrived opportunities. to access/acquire (e.. This may require considerable focus on antecedent supports (e. • Satisfying: The positive communication alternative should fit the person’s personality and communication milieu. active experimentation with hypotheses regarding the meaning/purpose of the challenging behavior (e. and the discussion of collaborative. 5. Gradually reduce prompts and other supports. people. One cannot not communicate. Collaboratively explore potential positive alternatives to the challenging behavior. 3. access a task. b. • Interpretable: The communication must be interpretable by all relevant communication partners. Few behaviors are truly maladaptive..GRBQ344-3513G-C33[877-962].. Collaboratively interpret the meaning of the challenging behavior: a. Assessment 1. protest restrictions on behavior or disrespectful interaction).. 6. 2. place. Preteaching 1.g. b. positive behavioral momentum or other positive setting events) to ensure that the individual does not revert to challenging behavior during stressful tasks. or to protest (e. place. or activity). 5.. people. gesturing. Ideally. settings). hypothesis-testing assessment earlier in this chapter.) 3. 4. Clearly defined communication routines of everyday life. thing. Gradually re-introduce normal demands: a. 932 Section V ■ Therapy for Associated Neuropathologies of Speech. • Effective: The alternative must be at least as effective for the individual as the negative behavior it is replacing.g.g.g. communication goal. if communication partners routinely reward verbal requests for a desirable activity. talking) during the initial stages of teaching. successful. Systematic. Initially attempt to achieve a high ratio of positive communication alternatives to challenging behavior (e.. All behaviors (potentially) communicate something to someone. rewarded use of the positive communication alternative) throughout the day and in a variety of contexts: a..g.. 1992.qxd 1/21/08 1:57 PM Page 932 Aptara Inc. does the challenging behavior disappear? If so. Collaboratively ensure many successful positive communication routines daily (i.g. (continued) ...g.and Language-Related Functions TABLE 33–18 Behavior as Communication: Teaching Positive Communication Alternatives to Challenging Behavior Premises 1. The messages communicated with challenging behavior often can be understood as communicating the individual’s need to escape (e. although not all communication is intentional. • Promptable: There is an advantage to physically promptable communication alternatives (e. activity. are the ideal context within which communication and behavior goals are optimally achieved. Monitor and modify as necessary. Systematic. escape undesirable tasks. and withdrawal) achieve a social. 4. person. passive observation: What are the stimuli and responses that trigger and maintain the undesirable behavior in varied everyday contexts? b.g. settings. The behavior of communication partners is a critical part of the context of behavior (antecedent conditions and consequences that potentially elicit and maintain types of behavior) and must figure prominently in intervention efforts. Communication specialists and behavior specialists play essentially the same role in helping individuals with communication- related behavioral problems. 2. supported by well-trained everyday communication partners. Naturally occurring opportunities. Collaboratively select a positive communication alternative to the negative behavior. or pointing to a picture on a board) versus those that are not promptable (e.g. self-injury. aggression. the meaning/purpose of the challenging probably was “I want that activity!”). form of stimulation. 10:1). Teaching the Positive Communication Alternative 1. signing. 2. escape a task. the communication alternative should have the following characteristics: • Easy to produce: If the alternative is harder for the individual to produce than the behavior it is intended to replace. 2. or attention from others). most apparently maladaptive behaviors (e. Collaboratively decide under what circumstances the individual will be allowed to control tasks and settings with positive communication (e. This may require explicit teaching of the difference between choice and no-choice situations. but this often is not possible. with prompts and other supports as necessary. 1998a. 7. 2. therefore. Possible Solutions: a. taking medication) and those that are forbidden and. Possible Solutions: a.. therefore. & Szekeres. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 933 TABLE 33–18 Behavior as Communication: Teaching Positive Communication Alternatives to Challenging Behavior (continued) Obstacles to Teaching Communication Alternatives 1. Possible Solutions: a.g. interacting with dangerous materials. particularly people with relatively good behavior after TBI. Try to help all everyday communication partners agree that improving behavior and communication is a high priority at this time. No Choice Times Heavily Outweigh Choice Times: It is unlikely that the individual will change old communication habits in the absence of a large number of meaningful. Possible Solutions: a. Others Forbidden. 5. Concern that Some Activities Are Mandatory. 3. Help everybody to understand the importance of substituting positive for negative communication and that this may require giving the individual a sense of power with positive communication. resist creating the impression that a client or student or employee is in a position of power or authority over them. particularly people with cognitive and motor recovery but complex behavioral and significant cognitive. Possible Solutions: a. Create—artificially if necessary—a large number of choice occasions so that the individual has many opportunities to practice and be rewarded for the positive communication alternative. 1998). b. Concern about Contributing to the Behavior Problem: Many staff and family members are concerned that rewarding positive escape or access-motivated behavior will give the individual too much control. escape demands). Feeney. Difficulty with Timing.. and in modifying everyday routines of communication so that the individual has many opportunities to practice positive communication alternatives. Ylvisaker & Feeney. successful. harming others. Concern about Power/Authority Roles: Some adults.g. necessitating considerable control by the individual using positive communication alternatives. Possible Solutions: 1. behavioral. ways were relatively simple to decipher (e. 2.. 2006.. Help everybody to understand that normal expectations will be re-instituted once the challenging behavior is under adequate control. the impairment.GRBQ344-3513G-C33[877-962]. Ylvisaker. In some cases. authority. b. Try to achieve agreement about those activities that are mandatory and. cannot be escaped (e. the individual is likely to revert to the challenging behavior—and will likely be unintentionally rewarded for the challenging behavior. Staff Insularity: The success of this teaching depends on all or most everyday communication partners being generally consistent in their communication with the person with challenging behavior. particularly those who are personally insecure. Possible Solutions: a.qxd 1/21/08 1:57 PM Page 933 Aptara Inc. and placing oneself at risk). Behavior Management Is Somebody Else’s Job: Some people believe that behavioral problems should be dealt with by behavior specialists and not by others. the messages communicated in problematic messages delivered in challenging ways were more complex. not less. In other cases. Point out research and experience that shows that this natural fear is unfounded if the teaching is implemented correctly. 3. b. Ensure that all relevant communication partners are involved in identifying the need for behavioral change. 6. rewarded learning trials with the positive alternative. Work with resistive staff to help them understand that this teaching strategy ultimately gives them more. . and the intervention process was not We have used the approach outlined in Table 33–18 with unlike that described in the developmental disabilities liter- a large number of children and adults who show challenging ature. Emphasize that normal demands will be reintroduced once the challenging behavior is substantially eliminated. cannot be chosen (e. and possibly also motor emotional profiles both before and after their injuries.g. a desire to 1999. Ensure that communication partners know that they must respond to the positive communication alternative promptly— knowing that if they wait. 1994. Negotiate the behavior plan so that all relevant people agree that the plan is reasonable and do-able. in implementing the functional analysis of behavior. Ylvisaker et al. Try to include everybody in the initial functional assessment of behavior. 4. viduals who struggle to maintain the level of effort needed to single-subject experiments (Class III). not a specific intervention protocol) for behavioral prob. academic texts would like to get to know you better. psychosocial.” and tasks for a college student) and also people (e. of recovery. we do not wish to suggest that such as the following: both individual and group therapy have no role. too hard to ask for help!” tocols cannot be supported by the available evidence. • “I know I can’t do this and it’s driving me crazy. and 25 were case studies be successful after their injury (Step 3 of everyday interven- or poorly designed. with the Person with Disability tent with the available evidence and based on individualized functional behavior assessments. controlled trials (Class I). • “You just treated me disrespectfully and I won’t take it!” stronger recommendations (i. and colleagues (2007 located 65 stud. reimbursed therapy into several hours of well-conceived rehabilita- lems after TBI in both children and adults should be consid. cents and young adults.. 2 were group studies the motivational and supportive interaction needed by indi- with inadequate controls (Class II). Clinicians can contextualize therapy sessions with per- • “Is there any chance we could spend some time talking? I sonally meaningful activities and materials (e. increasingly stressful family interaction may be the result of negative communication behavior. Furthermore. intervention designed to The Role of Individual and Group Therapy within substitute positive alternatives can be critical to social. Turkstra.g. Because most of the evidence is Class III or Class IV. the studies showed positive effects of the intervention. motivation everyday intervention in Table 33–4). single-subject experiments (Class IV).. cate messages like the following: and because intervention protocols vary from study to study. but I think we need to spend some quality the traditional roles played by speech-language pathologists in time working on our relationship because I find your atti- relation to swallowing. particularly those from ported routines of everyday life as the core of rehabilitation for cultural backgrounds in which communication often is individuals with chronic cognitive.GRBQ344-3513G-C33[877-962]. Please help me. and others often communi- options. In our experience. but it’s just vention guidelines) for specific behavioral intervention pro. Ylvisaker. ies with a total of 172 participants). In these cases. Proud and oppositional adoles- In highlighting the importance of context and the role of sup. 934 Section V ■ Therapy for Associated Neuropathologies of Speech. the most critical component of inter- Third. and Collaboration ically organized behavioral interventions and supports consis. In the case of adolescents and young adults who are strug- ioral interventions grouped under the headings of traditional gling unsuccessfully to reestablish preinjury activities and contingency management and positive behavior interventions levels of success. ongoing impairment. somewhat unrefined. we wish to stress the goal of transforming every hour of (i. and supports can be considered as evidence-based treatment withdrawal. Having highlighted the potential value of therapy sessions. individual and group therapy sessions can be used vention is the negotiation that leads to communication to brainstorm about and explore the usefulness of alternative scripts or a general communication style enabling the . sexual acting out. and commu. individual or group sessions are a useful venue for randomized. plans can be implemented for context-sensitive practice in the routines of everyday life.qxd 1/21/08 1:57 PM Page 934 Aptara Inc. difficulty maintaining work. porting the conclusion that behavioral intervention in general however.and Language-Related Functions and the process of intervention involved a higher level of strategies. supports. and I would like to spend time Interestingly. the intimacy of individual therapy sessions often interventions for individuals with behavioral problems after is necessary to address the sensitive issue of self-awareness of TBI. specific behav. tion by virtue of effective alliances with everyday people and cre- ered as a practice guideline at both acute and post-acute stages ative use of the routines of everyday life. and aphasic deficits are tude unacceptable. and familial success. voca- an Everyday Rehabilitation Framework tional.g. motor speech. and over the past 30 years. Motivation.” the direction of positive behavior interventions and supports Because loss of friends. however.” ting. I need a lot of help.. Metaphor. possibly supported Behavioral Interventions: Evidence by everyday people and even self-managed. First. or self-coaching “plays” (Step 2 of collaboration with the individual. 36 were well-controlled.e. the review documented a sharp movement in with you. conditions. including family members in communication therapy sessions). sup. practice standards or inter. Two of the studies were Finally..” appropriate and necessary for some individuals with TBI. All tion in Table 33–4). challenging behaviors such as aggression. many of • “Excuse me. • “I find you very attractive.e. In a systematic review of the evidence regarding behavioral Fourth. The authors concluded that individuals with chal- lenging behavior after TBI should be provided with systemat. • “Since my accident I have a hard time doing even simple Second. are most unlikely to accept alternatives nication impairment after TBI. Having identified and negotiation (discussed in the next section) are central to what works—and what does not work—under controlled the intervention. the meaning of “context” is not restricted to set- things. book. They illustrated this role by describing their inter. Requests for clarification as journalistic behavior. effective player whose impulsiveness had led to substance abuse metaphors are components of the “implicational code” or and serious trouble with the authorities came to agree organized set of “emotional beliefs. self- regulated behavior and compensated for reduced space in 1. Cognitive prostheses as common workplace prac- ful people who are not suck ups but. which he played message (and increasing social withdrawal) once she effectively—and which routinely got him into serious trou. 1997). when he connected these strategies with the and (3) as a winner. His initial resis. A former basketball working memory. Risk-taking behavior as red-card violations in soc- During his context-sensitive practice. and he reviewed trucks and drivers available for emergency purposes if the tapes as part of his responsibilities as a consultant to the the others broke down.” Social skills training then became a process Ylvisaker and Feeney (2000a) explored the facilitating of defining successful plays. Often. A riding goal in interacting with authority figures and many well-educated young woman with a commitment to peers was to avoid being a “suck up” (his term). (2) as his traditional defiant self. consistent never comfortable) and which were successful (the defiant with his or her sense of self (Step 3 of the intervention style was never successful). stressed yielded a compelling image of self-control as well as Other metaphors described by Ylvisaker and Feeney a script that included a few words designed to extricate him. A young man who before his injury had been a needs to be done to achieve their goals. began to work with discussion of which of these three interactive styles hard on his recovery after formulating the following . a good job. opposed to the cues (i. At the same time. include: the Clint Eastwood metaphor motivated positive. the well-known femi- (to cast it in a negative light) and worked with the clinicians nist and journalist Gloria Steinem. who had been arrested (speech-language pathology intern) mediated his experience twice on drug charges after his injury. other personally significant goals. such as a small memory three ways: (1) as a suck up. notebook. tinely interpreted as nagging and to which he had routinely Compelling metaphors have the added advantage that reacted with oppositional behavior. The only feminism before her injury overcame her reluctance to “non-suck-up” role with which he was familiar was that of a asking communication partners for clarification of their fiercely oppositional and defiant bulldog. He agreed to refer to this role with a vulgar metaphor nalistic practices of her heroine.. tinizing the plays. which he continued to practice cerations.e. crazy kid. use set plays rather than running around the court like a chotherapy (Teasdale. cessful social interaction. rather. at the same time. Perhaps more impor- they combine into one thought unit a set of social behaviors tant. calling up the image of Clint Eastwood when with considerable success. nagging) that staff had previ- tance to any intervention was overcome by hiring him as a ously used and that had routinely elicited oppositional consultant to develop a training video about oppositionality. In his capacity as a paid consultant. behavior.GRBQ344-3513G-C33[877-962]. 3. Thus.qxd 1/21/08 1:57 PM Page 935 Aptara Inc. were comfortable for him (predictably. and when considered separately. He then agreed to truck driver at a gravel pit overcame his resistance to practice negotiating many everyday social interactions in compensatory procedures. that of “winners”—success. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 935 person to be successful in chosen educational. particularly under stress. he revealed that his over. (2000a) and used successfully in TBI rehabilitation self from potentially volatile situations. Social cues for this extremely disin- vention for a fiercely oppositional adolescent who had hibited person were then reduced to the nonthreatening been in serious trouble with the law and threatened several “What’s the play?” and “Is this play in the play book?” as staff members in his residential program. 4. associated these requests for clarification with the jour- ble. These interactions were videotaped (as common practice at his former job site of having unused part of developing the training program). to identify a third way of acting. Social skills as basketball plays. 2. putting them in his play role played by positive metaphors for individuals with cog. project and as part of his communication therapy. Functioning in this manner. who do what tices. a social skills coach cer. Social cues could then be model or metaphor that can help the individual to overcome reduced to one positive reminder—“You can be a winner”— emotional barriers to positive communication alternatives to as opposed to the top-down admonitions that he had rou- negative behavior. the suck-up style was and social contexts and that is. and videotaping him while engaged in these plays nitive impairment and oppositional behavior following so that he could review the game films as part of rou- TBI.” as those concepts have that he needed “to be like Mike [Michael Jordan] and recently emerged in new interpretations of cognitive psy. This metaphorical trans- for one young adult with a post-injury history of aggressive formation at least brought him onto the playing field of suc- behavior and multiple psychiatric hospitalizations and incar. this negotiation is came to be associated with a wide range of positive (“win- facilitated by collaborative identification of a positive role ner”) interactive behaviors. success came to be associated with a conviction that or scripts that otherwise could be difficult to remember “winner behavior” was his route to freedom. Success and adequate comfort sequence outlined in Table 33–4). vocational. A former soccer player. many obstacles to the creation of such collaborative alliances exist. but I’ve got to pay attention to the staff. John routinely reacted with physical and verbal principles of sound.. Strong their collaboration with other rehabilitation professionals.4. the rap musician LL Cool J. Ignoring provocation at work came to everyday coaches/facilitators.. in part. This emphasis is motivated. work supervisors. I can play and enjoy played by everyday people (e. and I’m off the field.” others) in the long-term rehabilitation of individuals with 5. family members. strength of LL Cool J. along with who not only delivers fiery lyrics in his performances obstacles to establishing collaborative alliances. With this in mind. lives. and rules. In our experience. strategies but also is a successful and self-controlled businessman for overcoming the obstacles. are but. Because of their expertise in communication. therapists. rather. A young adult chronic cognitive. we list reasons for such alliances. consistent with the needs of others. and every. economic realities governing neurologic rehabilitation at ties workshop as part of his community reintegration the turn of the century but also. it’s a red card. direct care playing and win. he explained that it was difficult to tion facilities play a critical role in supporting a culture of overcome instincts and communication styles fashioned rehabilitation that values alliances with everyday people. to help them communicate in ways that Appendix 33. Specific scripts may be tion with colleagues. But my teammates will still be THROUGHOUT RECOVERY playing—and playing at a disadvantage because I got In this chapter. resulting staff who did not learn collaborative principles and proce- in his successful effort to regain control because of its asso. everyday routines of flexibility and effective problem solv- tive alliances among all relevant stakeholders. followed by turning away). speech- vention themes are further elaborated by Ylvisaker and language pathologists often play a central role in developing Feeney (2000b). ing. In after discussion of his hero. as an aspect of the options. by the New York City was placed in a developmental disabili. These inter. by nature. That this aspect Traditional training procedures (e. work supervi- munication specialists to force individuals to communicate sors. family members.GRBQ344-3513G-C33[877-962].4 lists In a self-advocacy videotape that we helped John (see some of these obstacles and offers a menu of strategies to illustration 5 above) produce and that he asked his work overcome them. but I COLLABORATION WITH EVERYDAY PEOPLE have two yellow cards. The next time. Ignoring provocation as cool behavior. assistant-level staff. we have placed major emphasis on the role myself thrown out of the game. rather. It is not the job of com. therapists’ schedules are creatively designed resist impulsive aggressive responses and to use the behavior so that they have natural opportunities to interact collabora- that he had chosen as a substitute (a somewhat sarcastic. Appendix 33. Situational coaching and support typically are frighten away communication specialists inadequately necessary to change behavior (just as clinical practicum trained as counselors but. who need to create allowed to take root in the real world. communication. by the enduring plan.. Appendix 33. In during his years on the streets.g. 936 Section V ■ Therapy for Associated Neuropathologies of Speech.4 includes a list of characteristics of people People will be who they are. in part.and Language-Related Functions metaphorical insight: “I want to play the game. rather.” training opportunities and materials (e. peer coaching and Subsequently. and training and support be seen not as weakness but. Some people in becoming who they are. rather. the person with disability. characteristics of effective and family man.g. teachers. . ciation with his positive self-metaphor. interaction scripts and in general staff and family training. flexible or day people in the environment. needed by those people who are not. this supervisor used a subtle written cue customized training videos) are available for orientation of (“Cool J”) at the first sign of John’s loss of control. and family members. and behavioral impair- who before his injury was a drug user and drug dealer in ment after TBI. He described his efforts to such facilities. Appendix 33. one who are effective in their role as everyday coach and facilita- responsibility of rehabilitation professionals is to assist tor for people with chronic impairment after TBI. including collabora. video with a plea to the supervisor. “Please.4 concludes with a list of procedures that can contribute to the achievement of meaningful goals in their be used to put everyday people in a position to play this role. let me be me. optimism become severely strained. in ways that are foreign to their understanding of who they Others need considerable help to play their role effectively. cause them to redouble experiences are critical for clinicians in training). tively with one another. In medical rehabilitation. dis. Rehabilitation within this framework mandates resistance to ignoring these provocations was overcome effective collaborative alliances with everyday people. His vention. support systems are critical for people whose resilience and Through such collaborative efforts. friends. direct care staff and family conferences) are notoriously discovery and self-acceptance counseling should not insufficient. managers in rehabilita- supervisor to watch. facilitated by posi. nursing staff (in an inpatient facil- missive comment.qxd 1/21/08 1:57 PM Page 936 Aptara Inc. brief in-services for of communication intervention enters the domain of self.g. and others have these characteristics in abundance. In addition. direct care staff. dures in their professional training programs. He ended his ity). functional intervention is enthusiastic problem solvers but. coworkers. appropriately context-sensitive inter- aggression when co-workers irritated him at work. . importantly. A general protocol general headings: collaboration and elaboration. In addition. enjoying related fields of intervention. In INCOMPLETE EVIDENCE effect. protocols are in place that enable all par- rather than demand performance from them. have cognitive impairment in an inquisitorial and nonelabo- rative manner.qxd 1/21/08 1:57 PM Page 937 Aptara Inc. including variety of topics. Fivush & Reese. how to teach. training vehicle may be useful. serious considera- pleasant conversations about topics of mutual interest. facilitative conver. a style of interaction that tends to elicit neg- ative behavioral responses and that is the opposite of facili- Communication Partner Conversational tative from a cognitive perspective. Furthermore. The person with disability is and socially enjoyable way have children who develop inter. This can be a project for the last 2 or 3 weeks of the The evolving view is that parents who interact frequently inpatient rehabilitation program or at any time when such a with their preschool children in a collaborative. 1997. 1998b) explored these themes ence. therapists. elaborative. in individuals who otherwise are rigid and disorganized in logic rehabilitation settings (Ylvisaker. these competencies often have the effect of reducing tension Therefore. ticipants to create and use self-advocacy videotapes. 1992. family members. aides. functions in rehabilitation. Hudson. In our view. 1993).GRBQ344-3513G-C33[877-962]. At this time. their approach to everyday problems. Appendix 33. many well-meaning people interact with adults who in greater detail. conversation partners who are effective in facilitating individuals and situations) and its rationale are presented in cognitive growth in children or people with cognitive Table 33–19. however. developmental investigations in this area consolidation of collaborative alliances through product-ori- largely have targeted parent–child interaction while jointly ented efforts.5 in in many practice settings. to the teaching or support procedures that are most helpful. clinicians must make responsible clinical judg- between people with TBI and staff members. often is enhanced when important information and proce- cies associated with a cognitively facilitative style under two dures are processed to teach someone else. socially co-constructed narratives about the past. In other (that can and should be modified to meet the needs of specific words. Haden. Reese. son. mary purpose to orient and train future (or current) staff in Fivush. ilarly supportive. An additional component Support Competencies of staff communication training. routine-based approach to intervention. this process helps the person with talking about events that they have experienced together— disability. 1990. ple to gain insight regarding postinjury issues. and events CLINICAL DECISION MAKING IN THE FACE OF in the world are organized—that is. it is useful to engage individuals graphical memory (Fivush. teachers. Recent research in developmental Self-Advocacy Videotapes cognitive psychology has emphasized the role of parent–child conversations about the past in facilitating chil. is the develop- direct care staff and others in the interactive competencies ment of scripts that promote problem solving and flexibility needed to communicate effectively with patients in neuro. Although these interactions can focus on a This project also has several secondary purposes. in closely to organize their thoughts while. 1988. tion of these literatures. & Urbanczyk. with TBI. bers of subjects is insufficient to draw strong conclusions. Nelson. coach. In addition evidence from well-designed clinical trials with large num- to enhancing the cognitive value of everyday interaction. 1993. in the production of a videotape that has as its pri- Haine.5 con- 1993a). Hudson. As part of a general focus on collaboration and executive dren’s development of thought organization and autobio. ments in the absence of accepted standards of practice. are able to teach their partner how to think and how ture in TBI rehabilitation and. whether parents. help. 2003. they gradually clarify the many ways in which things in the world go together. working collaboratively with staff and family Fivush & Haden. supports the general approach to the training of family members and staff serving children intervention described in this chapter. Haden & Fivush. people. 1991. members. Throughout this chapter. within this Vygotskyan framework. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 937 Ylvisaker and Feeney (1998a. In our experi. Fivush & Fromhoff. & Bauer. and other relevant everyday peo- that is. at the same time. however. It is less common. & Fivush. 2004. In at least two New York State TBI community impairment tend to participate with them in conversation support programs. partner training to be considered as a critical component of cognitive rehabilitation. Reese & Fivush.5. to help others more effectively than comparable children whose parents understand their strengths and needs and become oriented interact with them less frequently or in a way that is not sim. Their learning In Appendix 33. for communication cludes with examples of such scripts. engaged in a meaningful and important project that has a nal cognitive organization and autobiographical memory concrete and very legitimate goal—namely. or imental literature and general reviews of the efficacy litera- others. facilitators use conversational procedures to help their con- versation partner understand how things. combined with clinical experience We have used the competencies listed in Appendix 33. we attempt to capture the competen. associated with an every- Speech-language pathologists often are called on to train day. and adults with cognitive impairment after TBI. and otherwise work with the per- 1992. we have cited key pieces of exper- sationalists. Lucariello. McCabe & Peterson. 1991. Feeney. This could include: • Physical strengths.g. • Cognitive strengths. procedures for preventing behavioral problems. employers.. It is critical that both strengths and the goals of the individual with disability and family members be highlighted. depending on many factors. and eating). This videoing can be made after the person has watched the other segments..qxd 1/21/08 1:57 PM Page 938 Aptara Inc.. • Gain greater appreciation for the perspective of students and parents. return to work or school) staff. • Progressively become more strategic in their thinking about themselves and their rehabilitation and school careers. positioning. • Behavioral/social strengths. Staff will: • Strengthen their collaborative relationships with other team members (including parents) as they work together to produce the video. 2. OT. or other processing problems. (2) failing at an important but difficult task when appropriate procedures.” 3.g. If other individuals are present. The purposes of this meeting are: a. and others) who may need to be trained in how to teach.g. If possible. It is ideal to videotape the individual’s own orientation to and commentary about the video segments and then edit these into the tape as orientation for the viewer.. the person with disability should play a leading role (possibly with considerable support). as opposed to simply videoing a “talking head. To decide who should play what role in the video.g. seating. To work out logistics of videoing and editing. mobility. If the person is extremely impaired. weaknesses and intervention/support issues (e. and family members hold a planning meeting. home health aides.. To decide what format and scripts would be most effective in demonstrating critical points: 1. and other therapies. To decide what content would be most important to demonstrate on video. Several weeks before a substantial transition (e. 938 Section V ■ Therapy for Associated Neuropathologies of Speech. The individual and family members may be more or less involved in this planning. c.g. use of an augmentative communication system. For example. ST. discharge from inpatient rehabilitation. It often is effective to show the individual (1) succeeding at a task that he or she is good at. • Gain progressively more insight regarding the child’s strengths and needs and share their insights with staff. and then (3) succeeding when they are in place. demonstration of partner communication styles that facilitate comprehension). and intervention/support issues (e. and ways to facilitate peer interaction). It often is effective to communicate content by means of a conversation between individual with disability and staff or between staff and family members. development of scripts can be part of speech-language therapy sessions. Procedures (Subject to Considerable Variation in Individual Cases) 1. Important Associated Goals: The individual with disability will: • Gain a sense of empowerment. the planning of video demonstrations can be included in therapy sessions. 2. family members can play a leading role. d. • Gain progressively more insight regarding their strengths and needs. school staff. • Communication strengths. • Gain an appreciation of the importance of executive functions and the student’s participation in goal setting. interact with. weaknesses. and strategic thinking. Family members will: • Gain a sense of empowerment. they must have signed releases. modifications. The actual videotaping may be no more than a camera in a therapy session capturing an important demonstration. or equipment are not in place. types of advance organizers needed.. 3. types of cues and prompts needed). (continued) . individual with disability. family members. and intervention/support issues (e. and intervention/support issues (e. and development of physical demonstrations can be part of PT. weaknesses. or otherwise support the person with disability. b. During the following weeks. planning. development of presentation of strengths and needs can be part of counseling sessions.GRBQ344-3513G-C33[877-962]. The videotape may or may not be edited. ways to diffuse behavioral outbursts. depending on the skills of staff and time available. weaknesses.g. perceptual.and Language-Related Functions TABLE 33–19 Transitional/Self-Advocacy Video: Rationale and Procedures Goals Primary Goal: To produce a videotape that can be used to orient and train people (e. types of environmental or materials modifications needed because of attentional. dressing. . Costumer Satisfaction: In general. but can be effective and func- • Is the proposed intervention supported by intervention tional. data outcome studies with related populations (e. managed care and asso- ing neuropsychological. product-oriented activity. Furthermore. people with disability and family members are pleased when staff accord them the respect that is implicit in this activity. The staggering cost of cata- ity of support personnel. executive functions. pedagogi. and adequate resources? 1993 to be approximately $4 billion a year. morally justifiable. 4. self-advocacy videos serve a number of purposes: 1.g. including expertise of service providers. services is undeniable but published experimental guidance and consistent with the scope of practice and relevant is. has motivated known alternatives—in relation to predicted functional out. cognitive. 2002): disability in the territory in which communication. • Is the proposed intervention supported by trial interven- tion with the client? • Is the proposed intervention supported by extensive clini- cal experience with clients who have TBI? FUTURE TRENDS • Is the proposed intervention supported by theory.. the transitional. 6. cogni- • Is the proposed intervention supported by any interven. funders of services increasingly demand meaningful . 2. Indeed.qxd 1/21/08 1:57 PM Page 939 Aptara Inc. Feeney (1998). Even as they cut funding. Incidental Learning: Staff—Staff members acquire important information about the person with disability. 2001). come for the client—based on the previous considerations? however. behavioral. at best.. the person with disability and family will have an invaluable permanent record of the recovery process. time to complete the interven. increasing at a • Can the proposed intervention be judged as preferable to rate of 15% a year (Cope & O’Lear. responsible clinicians make decisions licensing laws governing the provider of services? about intervention for specific individuals with disability In our experience with several hundred children. tional outpatient therapies also has been substantially straints. this can be a vehicle for overcoming an adversarial relationship if that exists. and adults who have chronic disability after TBI— (Ylvisaker et al. and their own program by being engaged in a fun. Modified from Ylvisaker. product-oriented activity. developmental disabilities. Health TBI Medicaid Waiver Program demonstrates the or behavioral disorders)? cost effectiveness of this approach (Feeney et al. Inpatient lengths of stay have decreased with the client and relevant stakeholders in the client’s life? dramatically over the past 20 years. which was estimated in tion. ciated reductions in funding for rehabilitation have become cal. with permission. Incidental Learning: Individual with Disability—People acquire important information about themselves and about their rehabilitation program by being engaged in a fun. product-oriented activity. ADHD. Development of a Shared Conceptual Framework: The intervention team refines its own shared conceptual framework by being engaged in a fun. tion. based on all these considerations. strophic neurologic rehabilitation. the family. and behavior overlap and tion outcome studies with subjects who have TBI and who interact—the approach outlined and illustrated in this chap- possess the same impairments and needs as the client? ter requires creative effort. 1999). 7. 8. adoles- based on informed consideration of the following factors cents. those with from our work with the New York State Department of learning disabilities. draconian cost-cutting measures. reduced (AHCPR. availabil. At the beginning of the 21st century. includ. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 939 TABLE 33–19 Transitional/Self-Advocacy Video: Rationale and Procedures (continued) Advantages of this Transitional/Self-Advocacy Routine Beyond the obvious goal of orienting future staff and caregivers. product-oriented activity.GRBQ344-3513G-C33[877-962]. and other theories? thoroughly established as dominant themes in adult neuro- • Is the proposed intervention supported by negotiation genic rehabilitation. 5. In domains of impairment in which the need for clinical • Is the proposed intervention humane. Efficient Cross-Training: Staff currently working with the person may learn important things from other staff or from family members without the stigma associated with being singled out for remedial instruction. Fun: Producing this video can be fun. Szekeres. 1993). Permanent Record: If this practice becomes routine. Incidental Learning: Family Members—Family members acquire important information about the individual and the intervention program by being engaged in a fun. incomplete. and funding for tradi- • Is the proposed intervention consistent with known con. 3. behavioral. and communication interven. The participants endorsed the ioral impairment may offer wisdom regarding the process of benefits of e-mailing and reported feeling more connected contextualizing and “de-medicalizing” long-term services with family and friends. and others. KEY POINTS ticularly if the person with TBI has experienced consider- able failure in attempting community reintegration and. such as the workplace. mail at a 9-month follow-up. als with chronic impairment will be derived from a combina- based cognitive. fam. the ongoing impairments affect demonstrated benefit in promoting cognitive and motor social life. We with ongoing impairment. In our experience. recreational possibilities. Community-based models of service Sohlberg. In particular. vices and supports.. 3. in many (e. limbic structures. the greatest effects for individu- these domains. Therefore. humanistic. and neural con- Potentially lifelong supports through community support nections among these regions. behavioral. the prevalence of TBI is expect that more states will recognize the combined rehabil. and the costs to society are extraordinary. The investigators found that all four participants More generally. opened to individuals with varying cognitive disabilities. Reason exists to believe that these with disability. we described the promise and supports. Furthermore. communication. family life. and communication however. trends will continue. Fickas. indirectly. must be muted by the realistic expectation that. community-based ser. had preinjury predisposing factors. Ehlhardt. Hopefulness. & Capo. with damage to the vulnera- et al. to escape the pain of ongoing failure. we believe that p. 2007). 269). psychiatric hospitalization or jail). itative. live for several decades alcohol and drugs. agencies. and physician with expertise in TBI pharmacology.and Language-Related Functions evidence of improved functional outcomes. tion of behavioral interventions and environmental supports. that VR technology holds in potentially providing ecologi- Although driven by economic forces. TBI does not randomly select its victims. Feeney. Although virtually any combination of preserved and community support services. including appropriate supported housing impaired individuals receive needed evaluations from a and work. Ylvisaker. Despite the tions generally leave survivors with some degree of impair. like those provided through the impaired functions is technically possible after TBI. mental health. ble frontal lobes. opments in this field and to ensure that significantly vices and supports. volunteers. communication. behavioral services. Developing technologies continue to hold promise for We urge professionals in brain injury rehabilitation to individuals with disability. cialists in rehabilitation will increasingly deliver their services apy using adequately trained support staff. professionals serving other populations of became independent users of the system and continued to e- people with chronic cognitive. Clinicians are well advised to remain alert to devel- demands will continue to increase for community-based ser.. “there are currently no drugs available that are of people are relatively young. and other community settings. family supports. and community living in recovery from TBI” (National Institutes of Health.GRBQ344-3513G-C33[877-962]. par. spe- the form of increased use of group therapy and indirect ther. Communication cases. 940 Section V ■ Therapy for Associated Neuropathologies of Speech. Because a majority of these ever. 1. including specialists will need to be comfortable delivering services . tise in cognition. directions in service delivery may simply be good practice Reports from animal laboratories regarding the potential finally come of age. and Todis (2005) evaluated the delivery have a longer (although not uniformly successful) effectiveness of adapted e-mail access for four adults with history in developmental disabilities. and behav. how- ment and associated disability. and behavior. 1999. 2001. the world of elec- increasingly look to other disability groups for insights tronic communication and access to the Internet have been regarding the provision of effective. high.qxd 1/21/08 1:57 PM Page 940 Aptara Inc. specialists trained in community. therefore. Therefore. within teams that necessarily include the person with disabil- attempting to meet the challenge of having a greater effect ity and in nonstandard venues. in large part. Because most individuals with severe TBI are rela- possibly. Cognitive. there are central tendencies within the population. have attempted to create efficiencies in residences. such as abuse of tively young and. New York State TBI Medicaid Waiver Program. Following severe TBI. individuals with TBI continue to be promising. even the best usefulness of neuropharmacologic agents in the treatment of combination of medical and other clinically based interven. tion likely will be in increasing demand. private with fewer resources.g. including the services of professionals with exper. delivery of services and supports becomes increasingly challenging years after the injury. dynamic and evolving ways. for individ. through everyday people in the life of the person ily members. Clinicians. work. Ylvisaker. will be Disproportionately large numbers of people with found cheaper and more effective than periodic crisis services TBI are adolescents or young adults and. uals with TBI who are particularly difficult to serve (Feeney associated. isolation. trumpeting of this promise for at least two decades. and budgetary advantages of long-term 2. has made unfortunate choices. some of the new cally valid training within a clinical setting. competence plays a critical role in real-world success in into the foreseeable future. and severe cognitive impairments after TBI and associated social spinal cord injury compared with brain injury rehabilitation. Earlier. 1999. List and explain several possible hypotheses that could tion hypotheses. in recent developments in 4. Historically. antecedents in TBI behavior management? 10. 5. reviewing the usefulness of the plans. 3. List and explain common communication-related tion has its rationale in the special needs of people impairments associated with frontal lobe injury. What are the most important reasons for focusing on functioning. long-term rehabilitation. L. Hechtman. routine-based interven. Abikoff. in large part. improve neurologi- 4. and is supported. the dominant intervention approach in practice requires that specialists collaborate with medical rehabilitation has been characterized by a everyday people who become the primary facilitators focus on reducing the underlying impairment with of improved performance. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 941 weak academic and vocational histories. behavior. Describe differences in executive function routines for centered around goals and activities that are impor. Why are the frontal lobes especially vulnerable in TBI? 6. (2004). sive amounts of supported practice in the routines of communication. 2. Klien. concept of an executive function routine. J. and social behavior generally. decontextualized exercises administered by special- ists in specialized treatment settings. explain why a specific individual with TBI speaks very tion is associated with an approach to assessment that little and only when spoken to.” and why is it disabilities targeted within the context of these activ. improve perfor.. Etcovitch. and would you test the hypotheses? reflecting on what does and does not work for that 8. Among the common consequences of TBI is weak cally mediated processing) frequently requires mas- executive control over behavior.GRBQ344-3513G-C33[877-962]. K. individualized rehabilitation plans are 9. by everyday people. R. Describe strategies for maximizing the effects that can understanding antecedents broadly to include both be obtained from shrinking resources available for immediate and remote setting events. List and explain several possible hypotheses that could 7. 13. reduce their impairments (i. with varied impairments and 10. ADHD treated with long-term methylphenidate and multimodal . substance abuse. Helping individuals with TBI to increase their par. Explain why TBI is associated with extraordinary soci- text-sensitive practice of successful everyday routines etal costs. ing assessment for individuals with TBI? rologic rehabilitation. Context-sensitive.. Communication/behavior plans for individuals with TBI often focus on teaching positive communication alternatives to negative behavior. creating plans for achieving the way that is disorganized. Explain the difference between incidence and prevalence. 11. For reasons that are in part neuropsychological and 12. What are the most important reasons for contextualiz- person in attempting to achieve his or her goals. Context-sensitive. tant to the individual.. and context—often starting with context modi. and in the economic realities of neu. What are the most important reasons for contextualiz- learning theory. Functional. Why is it important for speech-language pathologists in part psychological. List and explain several possible hypotheses that could sible to identifying goals and potential obstacles to explain why a specific individual with TBI speaks in a achieving the goals.. everyday.. important? ities in an attempt to routinize improved cognitive 11. including cognition. and ultimately. An alternative approach that has gained increasing acceptance ACTIVITIES FOR REFLECTION AND DISCUSSION focuses flexibly on impairment. Gallagher. people in the middle and late stages of recovery from TBI. risk-taking mance of activities of everyday life. 1. everyday. the hypotheses? laborative and that involves the testing of interven. 12. routine-based interven. ensuring adequate amounts of 5. 7.qxd 1/21/08 1:57 PM Page 941 Aptara Inc. tangential. ing intervention for individuals with TBI? 9.. explain why a young adult with TBI becomes verbally 8. activity/participa- tion. At the center of executive system intervention is the aggressive when reminded to perform a routine task. everyday life. behavior plans for individuals to be included on behavior management teams? with TBI should be largely antecedent-focused. 6. sensitive to real-world contexts.. H. Positive communi- cation scripts must be integrated into the individual’s References sense of personal identity that may have to be revised after the injury. wherein the How would you test the hypotheses? individual with disability contributes as much as pos. G. 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Wesolowski. depen- • Dividing/sharing attention dent/independent. active/passive processing LEVEL: Developmental. linguistic. .GRBQ344-3513G-C33[877-962]. • Declarative (remembering that . • Sensory modality–specific (e. main ideas. and retrieval (retrieving items from memory) . . and rience. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 955 APPENDIX 33.. • Organization by categories mation. word meanings.qxd 1/21/08 1:57 PM Page 955 Aptara Inc.g. themes. associated • Deductive (formal inference) versus inductive (inference from with retrograde amnesia) versus recent memory (memory for experience) reasoning postinjury events. ) versus procedural and scripts (remembering how to . associated with anterograde amnesia) • Analogical reasoning (drawing indirect inferences from expe- EXECUTIVE SYSTEM (system for initiating. and other holding spaces versus ORGANIZATION supervisory control system • Feature identification KNOWLEDGE BASE (system for long-term storage of infor. • Convergent (identifying main ideas and themes) versus diver- including speech. auditory versus verbal) memory ing) • Phonologic. • Verbal versus nonverbal memory tional capacity (information organized for efficient process. . and other modalities) gent (exploring possibilities) thinking COMPONENT PROCESSES FUNCTIONAL INTEGRATIVE PERFORMANCE ATTENTION EFFICIENCY of information processing • Arousal and alertness • Preparing attention • Rate of performance • Maintaining/sustaining attention • Amount accomplished • Selecting a focus of attention (concentrating attention) SCOPE of processing. including settings and knowledge • Suppressing/filtering distractions domains in which processing is efficient • Shifting/switching attention MANNER of processing. academic. visuospatial. ) memory • Explicit (including awareness of the memory) versus implicit (no awareness) memory REASONING • Remote memory (memory for preinjury events. storage (holding memo- ries over time). rules. or vocational PERCEPTION level at which information can be processed MEMORY AND LEARNING • Encoding (placing items in memory). writing. including impulsive/reflective.1 Aspects of Cognition COMPONENT SYSTEMS • Involuntary (memory as a by-product of functional activity) versus deliberate (effortful or strategic) memory WORKING MEMORY (system for holding and acting on • Retrospective (memory for the past) versus prospective (mem- information in consciousness) ory for appointments and other future events) memory • Structural capacity (7  2 units of information) versus func. and other memories) • Organization by temporal sequences • Organization by analysis into parts • Episodic (autobiographical) versus semantic memory • Organization by integration into wholes. . schemas. directing. perceiving relationships) regulating all cognitive processes) • Evaluative reasoning (value judgments) RESPONSE SYSTEM (system for expressing knowledge. rigid/flexible. Cognitive Rehabilitation.. Success is a goal throughout intervention. are never simply extinguished with- assessment and intervention by separate professionals working out an attempt to substitute a positive alternative that achieves in relative isolation. developed in an integrated manner. Cognition. Functional Approach: Strength Orientation 2. The speech-language pathologist uses repetitive drill and prac- cialists (including special educators). 956 Section V ■ Therapy for Associated Neuropathologies of Speech. 3. cognitive rehabilitation spe- 1. and plans for intervention are communication activities. cognitive deficits and restore specific preexisting cognitive 3. weaknesses.. Service Delivery: Settings and Activities Functional Approach Conventional Approach 1. syntax. Evaluation reports. The behavioral psychologist attempts to eliminate undesirable behaviors (e. 2. Functional Approach 3. texts. Speech-Language Pathology. applied behavior analysis in psychol- ogy.g. The focus is on speech and Orientation of Intervention: Deficits and Strengths specific aspects of linguistic competence (semantics. Activities the important overlap in their services is explicitly acknowledged. in therapeutic settings are not necessarily related to real-world 2. using whatever Integration of Intervention: Collaboration antecedent supports may be necessary to succeed at functional Conventional Approach tasks at the individual’s current level of ability. individual’s current level of capacity. c. Individuals with disability and significant everyday people in their lives are included as contributing members of the collab- Conventional Approach orative assessment and intervention teams. Conventional Approach: Deficit Orientation 2.qxd 1/21/08 1:57 PM Page 956 Aptara Inc.g. reports are written 2. and behavior are targeted for communicative behaviors. The speech-language pathologist attempts to remediate com- rate components of cognition. participation and brain injury achieve their real-world goals in real-world con. Each professional begins with existing strengths and builds on cognitive intervention in cognitive rehabilitation are essen.. necessitating close collaboration among a. The cognitive rehabilitation specialist attempts to remediate cific problem behaviors in a narrow sense. and speech-language pathol- tice in isolated settings that bear little resemblance to real- ogists are recognized as possessing special and unique expertise. and 4. Ideally.g.GRBQ344-3513G-C33[877-962]. Correctly understood.g. cross-disciplinary documents. Activities in therapeutic settings . Each profession recognizes the overarching importance of b. including academic. pull-out therapy using workbook or computer exercises that are insensitive to context and to *Modified from Ylvisaker and Feeney (1998a). noncompliance. Behavior. personally meaningful content). 3. Undesirable and challenging behaviors.. “socially appropriate” behaviors). The cognitive rehabilitation specialist uses repetitive drill and as integrated. Assessments are conducted. Compensatory strategies. pull-out therapy). The focus is on neuropsychologi- skills in areas of impairment. 1. practice in isolated settings that bear little resemblance to real- world settings (e. and social success. The focus of each profession is on helping individuals with and increase specific desirable behaviors (e. Although behavioral psychologists. Attempts to ensure success in functional activities at the service providers. three professionals.and Language-Related Functions APPENDIX 33. morphology). language skills in areas of impairment. including explicitly 1. vocational.2 Conventional Versus Functional Approaches to Intervention after Brain Injury: Communication. are produced separately by a background goal for all professionals. executive or self-control functions for academic. cal assessment and intervention that sequentially targets sepa- 2. using strengths to compensate for and social success. pragmatics in speech-language pathology. The focus is on management of spe- 1. communication. and combativeness) 1. 2. 1. objectives. vocational. agitation. Apprenticeship procedures (including chaining and shaping). world communication settings (e. the same goal. with permission. arranged in a hierarchy for munication deficits and restore specific preexisting speech and treatment purposes. including proposed goals. them with: tially the same service. and Cognition* Scope of Intervention 3. and social. Preservation and enhancement of the individual’s self-esteem is plans to achieve the objectives. Behavioral Psychology. Source of Control a. but he or she turns over responsibility to over the course of intervention.g. As much as possible. a cost of some kind. Modification of behavior (including cognitive and social behav- the individual. removal from the situation. and when Little emphasis is placed on helping the individual to set goals people use strategies. goals. Therefore. everyday communication part. assume responsibility for most executive dimensions of behavior. and by natural communication partners (e. Prescriptive behavioral objectives specify isolated targets. Initially. when people initiate social interac- 1.. A primary role of rehabilitation specialists is to train and provide ing scripts for negotiating difficult social situations. Modification of behavior largely is a result of manipulating the 3. behavior) focuses on positive consequences for desirable behavior tive and therapeutically efficient rehabilitation environment. and cognitive skills in real-world contexts. or some other neutral or Providers of Service: Involvement of Everyday undesirable consequence. The individual with disability is not included as a member of apprenticeship relationship. social. creating opportunities for choice and control. As much as possible. Conventional Approach 2. manipulation of consequences of nized as being particularly critical to the development of a posi. correct per- behavioral goals largely is in the context of everyday routines.. Each profession focuses primarily on remediation of deficits in 2. 2. and example. The goal is an acceptable range of behaviors (versus a specific 1. Pursuit of cognitive. Professionals are considered to be the primary agents of behavior) that may vary in their effectiveness in achieving the change in the individual with disability. Each profession focuses on improvement of function within environmental supports. b. Within training tasks. feedback (positive or negative) is given monitor and evaluate behavior in relation to those goals. communication. paraprofessional aides.qxd 1/21/08 1:57 PM Page 957 Aptara Inc. monitor and evaluate perfor. facilitate transfer of training to real-world settings and tasks. coworkers. 2. in settings that 1. routines. family members. that is. in the context of meaningful activities. when people request something appropriately..g. peers or family make strategic decisions in the face of failure. formance of the target behavior is consequated with presum- involving modification of those routines with supports that ably desirable objects or events.e. Professionals members). plan intervention. everyday routines. 4. providing advance organizers for difficult tasks. Specific aspects of the individual’s environments and demands Intervention Procedures in those environments are considered in choosing objectives. strategic thinking. specific language behaviors are selected for training. 2. There is near total reliance on external control of behavior. The individual with disability is included as a member of the Functional Approach team of people who perform assessments. communicative objective. select goals and objectives. self-regulation of behavior. The ultimate goal is to ensure that the individual controls his vices on a behavior unit. The behavioral psychologist delivers targeted behavioral ser. establishing famil- teachers. 1. 3. monitor and evaluate perfor- 1. . goals in real-world contexts and practice of functional commu- nication. the learner/apprentice as soon as possible. positive routines and effective procedures for deviating from bilitation services and supports. avoiding triggers for negative behavior. for resemble settings in which the skills will need to be used. As much as possible. in a neurobehavioral rehabilitation or her behavior as much as possible by means of effective deci- facility. ior is followed by a withholding of rewards. Each profession focuses on real-world needs in real-world con- mance. The teacher and the learner are the team of people who perform assessments. select goals and jointly engaged in projects designed to achieve meaningful objectives.. 3. This focus includes supports for achieving real-world over the course of intervention. evening and weekend staff are recog. iar. supervisors. Antecedent-control procedures include creating 1. and self-regulated control over environmental contingencies. ners (e. they succeed in their endeavors). teach- 2. with little opportunity to sion making. and ensuring ongoing supports for everyday communication partners. Communication Partners Functional Approach Conventional Approach 1.GRBQ344-3513G-C33[877-962]. As much as possible. and friends) are critical deliverers of reha. failure to use the target behav- gradually are withdrawn as the individual’s skills improve. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 957 are not necessarily related to real-world activities that require Functional Approach the targeted cognitive skill. plan how to achieve selected goals. plan intervention.g. and make good choices. or in a behavior classroom. executive function. inducing positive setting events. the teacher assumes much of the responsibility mance. they get it. the intervention is impairment oriented. they are rewarded with a pleasant interaction. a rehabilitation facility. teaching and learning take place within an 2. Within that the individual has maximal self-management skills. generating positive momentum. Contingency management (i. tion. ior) is considered to be a result of manipulating the conse- Functional Approach quences as well as antecedents of the behavior. and create strategic solutions to problems as they arise texts. and create strategic solutions to problems as they arise for achieving the goal. and consequences of behavior. communication and behavioral services are delivered in meaningful social groups. rewards are internally related to the Conventional Approach action performed (e. (versus punishing consequences and “time out” for negative behavior) and on natural contingencies (versus artificial rewards). but the focus is on antecedents. label places or routes.: Use a log book. *Please see text for suggestions and cautions about the teaching and facilitating process. SQ3R: survey.qxd 1/21/08 1:57 PM Page 958 Aptara Inc. and then attempt to reconstruct previous or subsequent points in time • Retrospective memory.. • Use symbols to mark right and left margins of written Internal Procedures material. with speaker or source. read. question? How is this meaningful to me? How does this fit with • Schedule. • Place a symbol or picture card in an obvious place in the work • Create charts or graphs to assist in comprehending complex area as a reminder to maintain attention. in log • Attempt to summarize and explain information to oneself.GRBQ344-3513G-C33[877-962]. or handheld personal information storage system. including work time. permission. “Slow down. that down for me”). • Event. and reinforcement. Use photos of persons not readily identified (e. speed up.g.. visual distractions. Person. Sullivan. What should I be doing now?”). • Set increasingly demanding goals for self. 958 Section V ■ Therapy for Associated Neuropathologies of Speech. journal. and the like as self-reminders. check book). • Impose organization using diagrams or other advance organizers nificant information and events of the day. telememo watch. Use a log book or journal or tape recorder to record sig. (see below). E-mail self reminders. and organization Modified from Ylvisaker. Use a daytimer or other user-friendly schedule what I know?”). • Place. Use a watch that included day and date. graphic time lines. • Request longer viewing time or repeated readings. cant information and events of the day. Orientation (To Time. Written cue cards may be • Place items to be viewed in the best visual field and eliminate needed. • Prospective memory. and building frames of relevant background information. “Could you write that • Use a written or graphic task planner. . Use memos.g. Use pager system.3 Examples of Compensatory Strategies for Individuals with Cognitive Impairments* Attention and Concentration Input Control/Comprehension External Aids External Procedures • Use a timer or alarm watch to focus attention for a specified • Give feedback to speakers (e.g.g. and other information from others. material. • Person. Memory Internal Procedures External Procedures • Select anchor points or events during the week. keys). See attention. move a marker along to show progress. and Events) Internal Procedures External Procedures • Use self-questioning (e. Henry.. and Wheeler (1987). date. • Keep items in a designated place (e. • Encoding. • Organize the work environment to reduce distractions.g. “My birthday was yesterday—Wednesday—so today must or computerized information storage system to record signifi- be Thursday and I have to go to work. Label the places.. • Turn head to compensate for visual field cut. • Use a study guide for complex material (e. Electronic. comprehension. • Use a finger or index card to assist in scanning and reading. post-it notes.g. Szekeres. pictures. question..g. “Am I wandering? What am I supposed to do? weak. with built-in rest periods down please?”). calendars.. beeping watch. • Use large-print books. and review). “Do I understand? Do I need to ask a • Time.g. Nonelectronic. use an alarm watch or pager system to stay oriented to • Prepare self for new information by presetting with questions schedule.and Language-Related Functions APPENDIX 33.. (e. Place.. • Request time. • Alternate low-interest tasks with high-interest tasks. with strategies. • Use books on tape. Refer to customized maps or diagrams for spatial orienta. recite. • Request repetition in another form (e. tape recorder.”). request a verbal description if reading is • Self-instruct (e. tion. form. • Scan environment for landmarks. break period. content. “I eat with a .. appropriate for the task or content. . main character’s response. listen to self. meaningful/novel imagery. Word Retrieval • Note topics in conversation. assign space as task demands. • Create an image of the item in a scene. • Scan environment for cues to appropriateness of action. the scene.. verbalize visuospatial information. action. “What kind of thing is it? What does it do? What is it used for? What are its parts? What are its attributes? Where is it found? Reasoning. • Task organizer. • Prepare work space. event scripts like going out to eat. • Rehearse important comments. sequence of steps. having an image in mind. am I doing?” and Organized Expression • Place monitoring reminder cards in books. • Use self-questioning for alternative courses of action or conse- gory. People.g. timeline. time.g. comprehension. Problem Solving. and organization strategies.g. places. of encoding. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 959 Internal Procedures • Narrative discourse organizer. . quences.g. • Attempt to retrieve the overlearned opposite..g. and Judgment What do I associated with it?”). • Start a sentence with a carrier phrase (e. plan. visiting a doctor scripts). and resolu- • See attention. tion. • Use others for reality checks. and wherever needed (e.g. • Attempt to write the word.”). and evaluation of results. • Post important social rules to follow Internal Procedures Internal Procedures • Search lexical memory using an organized feature analysis sys- tem (e. • Instruct self about when and why the information will be • Alert others before shifting topic in conversation. proceeding through the each? Which is best? [Following action] How’d I do”). and appropriate only for items in a limited cate. tion. method of loci. self-question about the main point. alphabet (slow. people and their responsibilities. “Am I being • Relate information to personal life experiences and current clear?” knowledge.”). reconstruct the environment at the time • Use knowledge scripts (e. materials needed. needed.. Goal. • Use a mental representation of a graphic organizer or flow chart • Visualize verbal information. • Use outlining software • Use knowledge of common scripts to reconstruct to-be-remem- bered events. pan. ask.. • Engage in free association. tomime). • Post reminder: goal-plan-do-review. • Construct a timeline to maintain appropriate sequence of events. applying for a job. such as proper names). Task Organization. are some possible solutions? What are the pro’s and con’s of • Attempt to cue self with phoneme cues. • Rehearse to-be-remembered information (covert or overt. “What kind of thing is it? What does it do? What is it • Use an organized problem-solving guide (e. initiat- ing event. • Post reminders or use alarms that mean “Pause and review: How Thought Organization. • Watch others for feedback in conversation. • At the time of retrieval. • Ask others for advice or problem-solving guidance. then attempt to describe • Examine possible courses of action from at least two perspectives. External Procedures • Set limits of time or allowable sentences in any turn of conversa- • Circumlocute. discourse scripts like narrative form.GRBQ344-3513G-C33[877-962]. “How am I doing?” or “Summarize what External Procedures you have read or done. External Procedures • Use gestures of signs.g.. and rhymes). • Set aside a review time at the end of the day or at the end of the • Use a graphic organizer or flow chart appropriate for the task or workday. Internal Procedures • Use mnemonics (e.qxd 1/21/08 1:57 PM Page 959 Aptara Inc. describing the items in an organized way (e. “What exactly is used for? What are its parts? What are its attributes? Where is it the problem? What do I need to know in order to solve it? What found? What do I associated with it?”). at work station. Self-Monitoring and Self-Evaluating • Associate person’s names with physical characteristics or a known person of the same name.. . they do not collab- orate with everyday people. Empathy based on rich experience with the realities of the • Failure to respect the other’s perspective. Language barriers: vocabulary. To enhance generalization and maintenance of treatment 4. Optimism 5. individual’s life 2. . Competency-based training sessions • Time. Apprenticeship teaching 5. 960 Section V ■ Therapy for Associated Neuropathologies of Speech. Competence in facilitation procedures intervention decisions are made. and duration of services • Identify effective communicator. • Collaboratively produced transitional/self-advocacy videos • Seek capacity.GRBQ344-3513G-C33[877-962]. Creation of support networks • Family: severely competing priorities: exhaustion and stress. as unpredictable problems are encountered (often associated • Generic videos. nondefensiveness 1. 5. • Acknowledge mistakes. 1. Sense of humor • Judgmental attitudes (staff or everyday people). Flexibility Obstacles to Collaborative Alliances with Family Members 6. and Support Options vices are provided entirely outside of natural contexts. common sense. 5. 6. Listen actively and nonjudgmentally. To enhance community inclusion by creating networks of • Collaboratively produced transitional/self-advocacy videos. • Ensure that everyday people are supported. ment). adversarial relationships based on: 9. To integrate useful insights and skills of everyday people. Problem-solving ability and enthusiasm 8. To infuse reality. Potential barriers to learning: 1. Use in vivo coaching—demonstrate competence in context. To increase the amount of available data on the basis of which 3. Clarify roles and expectations.” • Customized videos • Respect diversity. cross-cultural barriers. possibly because ser. 2. flexibility. To increase the intensity.) 8. Maturity. Distrust. 4. • Generic videos 3. Conflict of priorities between rehabilitation professionals and • Teaching in vivo everyday people. Training videos 2. with major life transitions).qxd 1/21/08 1:57 PM Page 960 Aptara Inc. 2. by ensuring concordance among all relevant people. 3. including problem- solving. and optimism scripts • Community meetings Strategies to Overcome Obstacles to Alliances • Peer teaching and support with Everyday People • Staff and family training chains 1. and functional goals into pro. Be respectful: “I am a guest in your home. gains.and Language-Related Functions APPENDIX 33. • Customized videos. • Collaborative formulation of scripts. 7. 6. consistency. 10. 4. To stretch limited professional resources in an era of managed 1. 6. To communicate respect. 4. 2. • Understand grieving. Creativity and Other Everyday People 7. 4. Professional self-perception that as experts. community support. • Respect expertise. Provide training videos. fessional practice. 3. Informational in-services • Quantity and complexity of information and skills. Collaborating with Everyday People: Training 3. Interactive competence 9. • Self-observation on video 6. Knowledge care. Insufficient access to everyday people.4 Rationale for Collaborative Relationships with Everyday People Purposes Served by Collaboration with Everyday People • Be sensitive to differences in behavior in different circum- stances. Be available to interact with everyday people in contexts that • Child peers facilitate collaborative activity. To ensure appropriate services and supports over the long term 7. (Individuals rely more on community supports than on rehabilitation professionals over the long Characteristics of Effective Everyday Coach/Facilitator term. Collaborate in assessment (see section on collaborative assess- 5. Family conferences • Family: accepting need to learn is a threat to hope. .5 Communication-Partner Competencies for Supporting and Improving Cognition in Individuals with Cognitive Impairment* These conversational support procedures are designed to ensure participation (overcome handicap) and. “Let’s think about this. with repetition.g. such as “How are you going to get that done?”) Collaborative Turn Taking Noncollaborative Turn Taking • Takes appropriate conversational turns • Interrupts in a way that disrupts partner’s thought process and • Helps partner express thoughts when struggle occurs (e. cal.. Illustrations of associated interactive scripts also are provided.GRBQ344-3513G-C33[877-962].qxd 1/21/08 1:57 PM Page 961 Aptara Inc. such as “Do you need a wake-up call in the • Questions in a nonsupportive manner (e. “It’s hard to • Fails to acknowledge difficulty of the task put all these things in order.g.”) • Talks as teacher or trainer • Communicates understanding of partner’s contribution • Fails to communicate understanding of partner’s contribution • Invites partner to evaluate own contribution • Fails to invite partner to evaluate own contribution • Confirms partner’s contributions • Fails to confirm partner’s contribution • Shows enthusiasm for partner’s contributions • Expresses lack of enthusiasm • Makes effort to establish equal leadership roles • Takes leadership role. photos.. Chapter 33 ■ Communication Disorders Associated with Traumatic Brain Injury 961 APPENDIX 33. perspectives. despite other’s attempt to contribute Cognitive Support Lack of Cognitive Support • Gives information when needed (within statements or questions) • Does not give information when needed.g.e. • Fails to use cognitive supports at appropriate times endar. memory book. isn’t it?”) Questions: Positive Style Questions: Negative Style • Questions in a nondemanding manner • Questions in a demanding manner (i. statements word finding difficulties) • Fails to help partner when struggle occurs .g. Testing) Intent • Shares information • Demands information • Uses collaborative talk (e. abilities and abilities • Explicitly acknowledges difficulty of the task (e. Teaching..g. and • Fails to communicate respect for other’s concerns. nonpunitive manner Emotional Support Lack of Emotional Support • Communicates respects for other’s concerns. questions lack morning?”) needed cues. improve cognitive function (reduce impairment). Collaboration Procedures Implicit message: “We are doing this together as a cooperative project” Supportive Collaborative Style Noncollaborative Style Collaborative Intent Noncollaborative (e.. continues to quiz • Makes available memory and organization supports (e.g. perspectives. performance-oriented • Questions in a supportive manner (e.. gestures) • Fails to give necessary cues • Gives cues in a conversational manner • Corrects errors in a punishing manner • Responds to errors by giving correct information in a non- threatening. questions include quizzing) needed cues.g. Sellars.g. . fails • Invites explanations for events to invite partner to address problems and solutions • Invites discussion of problems and solutions (e. . “Maybe you’re avoiding it themes. (OR Let’s think there’s gotta be something that can be done about this. “I wonder • Fails to reflect on or invite the other to reflect on other’s whether we can think of a better way to handle this if it comes physical or psychological status up again. “The radio’s not working because it • Fails to make connections explicit when topics change got wet. 962 Section V ■ Therapy for Associated Neuropathologies of Speech. Let’s try your idea. because .”) • Does little problem solving or all of the problem solving.GRBQ344-3513G-C33[877-962]. . .”) • Reviews organization of information • Makes connections when topics change • Makes connections among day to day conversational themes Elaborative Explanation Nonelaborative Explanation • Conversationally adds explanation for events (e. . .g..g.”) • Fails to make connections among day to day conversational • Psychological causality (e.g.. Staff “Alright. “Maybe the • Offers few explanations fact that you were drunk at the time had something to do with • Fails to invite explanations it. and Edelman (1998).. ) What are we trying to make happen here? You’re Person with TBI Expresses frustration. . You have another thought? chooses one to try. .. “That reminds me of . reflection about what *Modified from Ylvisaker. (OR Here’s another way (or thought) .”) • Fails to review organization of information • Physical causality (e. .qxd 1/21/08 1:57 PM Page 962 Aptara Inc. . Alternatively. .”).. . There’s got Staff Invites reflection about what might work (e.. then we . ? Am I right?” Staff Outlines a few possible solutions.and another. .. “You must have felt miserable about that.g. about it . “Let’s see. and invites other to reflect on his or her physical and psychological states Problem-Solving Conversation Script Flexibility Conversation Script Problem arises: Person with TBI resists an activity: Staff or Person with TBI Identifies the problematic issue.g.g.”). “Yes. they’re similar because . meaning is vague because you’re scared.. .”) • Analogy and association (e. trying to be successful at . “I wonder what happened . “First we .)” Staff Facilitates an experimental attitude. invites partner to address problems and solutions • Reflects on other’s physical and psychological status (e. to be another way to do this. .and Language-Related Functions Elaboration Procedures Implicit message: “I am going to help you organize and extend your thinking” Positive Elaborative Style Nonelaborative Style Elaboration of Topics Nonelaboration of Topics • Introduces/initiates topics of interest with potential for • Introduces topics of marginal interest.g.. .g. .”) • Similarity and difference (e.”).”) • Fails to invite other to add information Elaborative Organization Nonelaborative Organization • Conversationally organizes information as clearly as possible: • Fails to organize information • Sequential order of events (e. person with TBI perseverates on an action or thought: Person with TBI Rejects one or more. with permission.. .g. with little potential for elaboration elaboration • Maintains topic for many turns • Changes topic frequently • Contributes many pieces of information to topic • Fails to add adequate information to topic • Invites elaboration (e. .. Staff Continues review of possibilities until person with TBI Staff: “This isn’t working real well. does and does not work. maybe my idea wasn’t such a good one. (7) distinguish process. Their digress furthers the impression that he is either confused or command over basic linguistic structures is usually adequate. Questions about the weather. Although quick to provide a response. Mr. He may and their impact on communication. fail to Patients with damage confined to the right hemisphere assess. (3) explain the potential impact of neglect on dis. or back suggestions and scoring systems to their clinical work with to his room. and may speak in a monotone. yet be unable to transfer himself from bed to that knowledge to management of RHD deficits. and to the emotional tone of verbal and nonverbal messages. he may demonstrate dif- generate appropriate stimuli. An initial and fairly casual encounter with Mr. ances about resuming all aspects of his former life. visual perception. Once in his wheelchair. Not all patients with right-hemisphere tendency to personalize abstract topics. He may interrupt. He prosodic production and comprehension can be impaired may be unable to groom himself properly or to figure out independently of one another. Mr. but appropriate as well. He may not respect conversational rules. and selective atten. general effects of his recent trauma. His communication. his seeming difficulty damage (RHD) have communication impairments. but these that knowledge to clinical work. it might be useful to draw a very general portrait of a typical patient with RHD. and apply various treatment ficulty finding his way to the nearby nurses station. but it is in grasping the point of a conversation. the very factors that (4) describe the extralinguistic deficits associated with RHD led to a firm belief in his full recovery seem suspect. His assessment of his capabil- deficits in specific prosodic parameters and recognize that ities may be at odds with his progress in simple self-care. how to put on his shirt. Their communication problems typically become may trivialize topics and focus on tangential and unneces- apparent in more complex communicative events in which sary detail. He (RH) may have a variety of processing deficits. Before discussing these Margaret Lehman Blake problems in detail. and his tendency to generally accepted that those who do are not aphasic. adults with RHD. course as well as on reading and writing in adults with RHD. including may not maintain eye contact. Smith. His jocularity will now strike a discordant note. vigilance. (2) recognize the impact of characteristics might easily be attributed to fatigue and to the deficits in arousal. Smith may have trouble recognizing friends and may deny that they have visited him before. he may 963 . the quality of the Upon completion of this chapter.GRBQ344-3513G-C34[963-987]. He may talk about returning to work oriented from task-oriented treatment strategies and apply next week. treatment by the hospital staff. deny a need for rehabilitative services. however. orienting. readers will be able to food. and (8) wheelchair. and they may do well in superficial or straightforward con. (6) describe physical limitations seriously. and he versation. and he may seem unresponsive impairments in attention. The visitor may even be tion on the communicative performance of adults with cheered by Mr. Smith’s occasional jocularity and blithe assur- RHD. Chapter 34 Communication Disorders Associated with Right-Hemisphere Damage Penelope S. cognition.qxd 1/21/08 2:00 PM Page 963 Aptara Inc. refusing to take his tive from true affective deficits caused by RHD. He may seem a with acquired right-hemisphere damage (RHD) and apply bit less responsive. and appear not to care about his listener’s reaction. In extended conver- sation he may seem excessively bound up in himself. During subsequent visits. (5) distinguish cogni. that he operates in isolation during conversation. and so on will elicit responses that seem not only lin- (1) describe the major communication deficits associated guistically accurate. Smith may OBJECTIVES leave the visitor with an overly optimistic picture of his cog- nitive and communicative capacity. Myers and verbal and nonverbal contextual cues must be used to assess and convey communicative intent. temporal. 2004). Audet. 1993. but it other deficits is characteristic of patients with neglect. This phenomenon can occur in the auditory as well as 1987. sided neglect. or olfactory senses. Humphreys.. to input from contralesional space. Neglect can differentially affect body space 1984). & Chui. 1987. & Watson. Wong. Heidler. 1986) and the basal ganglia (Buxbaum the visual modality (Farah. 1990.” refrain of friends and families associated with communica. on the left). 1978. related to the phenomenon of “extinction. Monheit. zational base. & Seiger. They may which patients fail to report. Walker. their left (and thus may look to the right when a phone rings Schwartz. alleviate left-sided neglect. Friedrich. Nydevik. Buxbaum. & Heilman.and Language-Related Functions take an excessive amount of time to actually answer substan. & Watson. & Heilman. They may not include left-sided detail in their draw- Unilateral or hemispatial neglect is a complex disorder in ings (sometimes called “constructional apraxia”). patients with neglect may fail to perform tasks that require visual exploration or movements on both sides of the Neglect body. 1995. but can occur as well with subcortical lesions. when it is captured by right-sided stimuli (Posner. nor localize sounds to (1) arousal (Coslett. Neglect most often occurs with Posner. Mesulam. 2005. 2004. According to Mesulam (1981). 1999). The near-universal part of a more generalized disorder called “anosognosia. or far space responses. attentional deficits. thus Perani. Duncan tory. pro. Chokron. progressed through the task (Mark. 1984). including people on the left side of their beds. Rafal & Posner. exploring and manipulating stimuli in contralesional space. Monteleone. 1999. audi. making it difficult to disengage attention viduals with RHD lesions (Bowen. His ready answers may seem impulsive. Gainotti. Neglect can have a motor as well as a sensory component. severity of neglect (DiPellegrino & DeRenzi. 1988). 1986).. 1989). Vallar & task when asked to erase (rather than cancel) the lines. McKenna. Newhart. Bundesen. Damasio. The imaginary line dividing their world the patient. 2004. removing the attention-attracting right-sided stimuli as they specifically in the thalamus (Hillis. 1985). Valenstein. 1981. whether these deficits affect communication directly or indi. Chabada. isn’t the same. For example.. and more common in indi. Barker. His peri-personal space (within arms’ reach). They Most theories of neglect hold that it is a deficit in atten- may not eat food on the left side of their trays. Heilman. bodies.”). or in combinations thereof. 1980). It can be worse in the lower quadrants of NONLINGISTIC DEFICITS space than in the upper quadrants. Although it may Reduced attention to the left may be combined with a occur with left-hemisphere damage (LHD). D’Erme. Clinicians should take the level of right-sided most commonly observed in the visual modality. but it is et al. a difficulty that can extend to the have communication impairments. individuals with RHD not only the left of their midline. Thus. rectly. they fail to reach over to the contralesional side of their despite the motor and sensory capacity to do so (Heilman. Throwalls. & Raphal. nor notice tion. 2004.g. & Degaonkar. 1986). Nonlinguistic deficits associated with RHD include left. & Tallis. Heilman. “magnetic attraction” to stimuli on the right (Bartolomeo & ally longer-lasting.” in which the tical lesions may be related to decreased perfusion to distant presence of bilateral competing stimuli can increase the cortical areas. & Lecours. co-occur with somatoparaphrenia. Valenstein. and many types of attention are implicated. Damasio. This type of delusion can be in communicative events as they once did. 1983).. Vallar & Perani. “He (she) can talk. recognize paralyzed or weakened limbs as one’s own (“I’d be many patients with RHD neither respond to nor participate all right if I had my own arm. lack of grooming or dressing the left side of the body). (e. & Shibuya. 1999). Neglect and attention can affect communication and motor sequences (including eye movements) necessary for are discussed below. Regardless of environment (Duncan.GRBQ344-3513G-C34[963-987]. despite an apparently adequate linguistic system. respond. Watson. & Damasio. into neglected and non-neglected space can also shift based on how many things are in the environment and on instruc- tions or cues given. the clinician must recognize their potential impact on & Silveri. et al.qxd 1/21/08 2:00 PM Page 964 Aptara Inc. that is. regardless of where it appears in the a variety of other cognitive impairments. sided input. Herskovits. (2) sustained attention (Bub. and visuoperceptual prob. Karlsson. lesions of the frontal. 964 Section V ■ Therapy for Associated Neuropathologies of Speech. neglect may disrupt the lems. Vallar. Denial of neglect and tively impaired adults with RHD is. but may also suffer from left side of any item. stimulation into account in tasks designed to measure or Patients with RHD with neglect fail to attend to left. may seem inefficient and lacking an organi. Neglect may occur in the visual. Bowers. which is the failure to In short. more severe. . or parietal cortex (Buxbaum subjects with RHD canceled more lines in a cancellation et al. or orient to stimuli on not be able to dress or groom themselves properly because the side opposite their brain lesion (the contralesional side). Hillis and 1989. which is a lack of awareness of illness. 1985. He may seem verbose and disorganized.” Patients with neglect have difficulty processing stimuli to As this portrait suggests. Robin & Rizzo. Mesulam. tive questions. & Morrow. (Appelros. tactile. neglect is usu. Kooistra. then. 1980. 1999. More severe manifestations of neglect may duced without internal reflection. Magnetic attraction may be colleagues (2005) have suggested that neglect due to subcor. Olson. Marshall. 1989). directed attention (Bartolomeo. and words trailing down the right regardless of their spatial location. 1989. iterations and/or omis- attention can be measured by the total number missed. Several researchers (Beis et al. Fleet.g. for a scoring method foils (e...g. Duncan how far to the right of center the patient’s vertical line is et al. The patient is of left-sided details to those included on the right in the asked to cancel instances of a particular target in a field of patient’s rendition (see Myers. “able” for “table”) or neglect can be established by published tests or by the infor. Tompkins. Chase. patients may be asked to draw from memory or task is considered simple. 1999. (“cancel”) all occurrences of the stimuli. (3) the capacity to disengage attention (versus rows). A particularly sensitive mal tasks described below. inaccuracies (e.g. Whelan. Because the target stim. & Marshall.. scanning. & shorter the line. 1996. occupational therapists. 2001. & Dawson. Generalized contain excessive left-sided margins. 2001. Levander. The metric form. The presence of the form of left-sided omissions (e. may miss targets on the right and may miss more targets on but also disorganized and disconnected. 1985. margin is randomly indented from 2 to 25 spaces (Caplan. Halligan & operations involved in communication (Myers & Brookshire. Several studies have found that there is wide vari- 1999a). The include physicians. more than one feature. 1994). 2004. Sieroff. Horner. Verfaellie. Neglect is mea. Cancellation 1987).g. Task difficulty can be increased by increasing the another at detecting neglect. & Baumgaertner. Coslett.g. ded in a row of foils (e. more gen. the more likely neglect will surface in gists. and drawing tasks. Evaluation of Neglect Patients can also be asked to read compound words. It may also interfere in some of the cognitive center (Halligan. Mesulam. Tegner. Massey. Typically. Ogden. longer the material. 1996. the more accurate people are in judging its Flynn. letters. but Those from patients with RHD may not only be primitive. combinations of tasks should field density. numbers. individ. 1984). Mesulam. line bisection. Patients may omit the left half of sentences and words (e. 2003..qxd 1/21/08 2:00 PM Page 965 Aptara Inc. or paragraphs presented at their visual midline. Bowers. 1980). Rapcsak. and/or by having targets and foils differ in from ipsilesional space (Heilman. require patients to scan an array of letters. size. numbers. 1999). The unpredictability of the left margin makes this tasks require patients to look at an array of stimuli (e. 1990). finding all the instances of the let- ter “A” in a line of letters). 1981. Rivers & Love. or shapes) that are distributed in of the number of words read aloud by the patient. or shapes in which instances of a target stimulus are embed- Bloise. ings from patients with LHD are somewhat primitive.. line bisection helps determine the degree to which the Neglect may be one manifestation of a larger. Husain & Rorden. Chokron. or color. Jehkonen et al. Attention has an obvious impact on cognition. Marshall & Halligan. but see Odell. By using both simple and complex cancellation tasks. & Watson. tion. by placing targets and foils in random arrays be administered. 1989. sen- Professionals participating in the evaluation of neglect tences. Drawings can also be inspected for over- and squares). Performance on Heilman. 1985. draw- neglect in complex visual search and cancellation tasks. 1973). uals initially diagnosed with neglect often demonstrate Scanning tasks.. The patient is asked to make a mark through patients to write or copy sentences or a short paragraph. Neglect is measured by comparing the number stimuli may differ in shape. & Line bisection requires patients to bisect a horizontal line by Decaix. Thus. Chapter 34 ■ Communication Disorders Associated with Right-Hemisphere Damage 965 Duncan et al. & Caneman. Manning. 1999a. Wollack. & making a vertical mark through its center. such as shape and color (Myers.. a patient may not only omit left-sided stimuli. equal numbers on the left and right across a sheet of paper The effect of neglect on writing can be assessed by asking (Albert. 2005).. test requires the patient to read a paragraph in which the left Typical paper-and-pencil tests of neglect include cancella. and speech-language pathologists. side of the page. a man. 2002. Posner et al. or a geo- Complex cancellation tasks involve selective attention. copy symmetrical objects such as a flower. neuropsycholo. the left in a complex compared to a simple cancellation task.. Myers placed. this type of cancellation Finally. Selective attention deficits may exacerbate all structure and integration of object parts. Some ability in the normal population in accuracy of line bisection studies have reported that neglect has significant negative and that deviations of approximately 1/4 inch on a 10. Timko.. and even if recovered. 1990.. In general. sions of letters and words. “tree” for “three”). sured by comparing the number of left-sided to the number “house” for “greenhouse”). and their writing samples may of right-sided stimuli missed by the patient. the al..5-inch ramifications for the recovery of independence (Buxbaum et line can be considered within normal limits. 1985) have can assess the influence of selective attention on a patient’s reported that because no one task is substantially better than neglect. and (4) selective and 1999a). used to assess the influence of neglect on greater cognitive-communicative deficits than those who reading.g. one Woodruff. uli do not differ from each other. Severity can be estimated by combining . never had neglect (Myers & Brookshire. red triangles in an array of red and blue triangles for scene-copying). patient’s sense of space is skewed to the right by measuring eralized attentional impairment (Cherney. The score consists lines. test well-suited to detecting mild neglect. 1988. Neglect is measured by the num- ber of target stimuli missed to the left of the midline. 2004.GRBQ344-3513G-C34[963-987]. For should be included in understanding neglect as an attention example. Mackisack (1990). and autonomic evi- voluntary attention without external cuing. Because the number of targets is low. 1995). and eventually they may improve performance in therapy. & Shulman. Lo. Finally. colored cubes) within specified borders. 1998). Attention Deficits tinue the search voluntarily until the total number is found. vigilance. if one accepts that various types of attention are a Management of neglect revolves around the issue of significant factor in neglect and in RHD deficits in general. Manly. one can present a very simple leftward search task disorder and its effects on communication. scious perception.g. stimuli that are contigu- ous. patients typically con. that enables patients to overcome possible denial. This cue is then shared with the patient (he or increase visual scanning are rarely effective because while she says “attend” when the clinician knocks). anatomical. described in detail by Myers (1999a) and Myers and 1987. in which patients are required to find only one or two target objects (e. Families ception (see Myers. neurochemical..qxd 1/21/08 2:00 PM Page 966 Aptara Inc. (1999a) and Brooks. which demon- and sustain effortful. However. Patients with RHD with and without demonstrable neglect Cubes can be placed on a flat board that has been divided may have attention deficits. and people in the drawing. but their efficacy has yet to be evaluated. Manly. the most common of which is letter sub- neglect may signal a decrease in the patient’s general level of stitution (versus omission) in single-word reading (e. 1999a and 1999b for specific tasks). such as a person on the right side of a page holding hands with someone on the left side. 1992).g. 2004. Each type of RHD attention into quadrants. & Martin. and selec- that are meant to encourage leftward scanning. demonstrate the problems in a way tasks and (b) tasks designed to stimulate unconscious per. This type of task has been they are generally less attentive and less alert (Coslett et al. with as few as two cubes of a single color.and Language-Related Functions scores across tasks. Nimmo-Smith. highlighting strated generalization requires the clinician to knock loudly stimuli on the left (e. 2002. they rarely trans. Other tasks of this type are described by Myers (Calvanio. including communica- self-cuing include (a) internally motivated leftward search tion. It helps establish the patient’s capacity attention without external monitoring. Symptomatic treat. 1999a. it makes sense to work on attention directly in tasks ment attempts to compensate for neglect by external aids designed to increase the level of arousal. The literature con- to attend to stimuli in other diagnostic and therapeutic tains numerous examples of the phenomenon of uncon- material. role in arousal and in orienting to the external environment tage. noted clinically. 2002). is that it appears to increase patients’ (Corbetta. 2000. & Vohn. One may begin such a search-and-find task disorder is discussed briefly in the sections that follow. The underlying theory is that by enlisting Behavioral. 1993. 1998.” increasing the number of cubes.. One such treatment with demon- verbally cuing the patient to look to the left.. and if necessary.g. 1993. such as reading and writing does not always occur.. 2002. Halper & Cherney.. can encourage move- Treatment of Neglect ment of attention leftward such that the patient reports two There have been many studies of treatment for neglect. treating the symptoms versus the cause. & tasks (Calvanio et al. directed attention during complex strates that patients have processed left letters at some early communicative events. general level of attention and thus may be a good start-up Weiss. although generalization of gains to functional tasks motivated. then in the lower-left quadrant as well as the upper-left quadrant). Herzog. by Individuals with RHD are sometimes called “hypoaroused. unconsciously perceiving them as a several reviews of the efficacy of treatment of neglect single object. Unlike the left hemisphere (LH). Tham. For example. A second advan. Tegner. Cicerone et al. level of processing. Clinicians should counsel patients about their neglect and Examples of tasks that are thought to encourage internal its effects on activities of daily living. drawing a red line down the left on the table and say “ATTEND!” at random times during a margin of a printed page). internalized by the patient (he or she subvocally says late into internal self-cues or generalize to more functional “attend” during tasks) (Robertson. as a reflection of a general attention deficit. Scanning treatments generally are search and unconscious processing tasks are theoretically effective. Finally. Levine. task for cognitive and communication therapy. for a review). Fedio.. Leftward 2005. and by having target cubes and studies comparing them to those with LHD suggest differ in color from foils. Establishing the presence of neglect Tapping into unconscious perception of left-sided details helps clarify whether or not reading and writing deficits are is another potential way to stimulate leftward movement of linguistically based. Longoni. arousal and his or her readiness to respond and to produce reading “table” and not “able” for “sable”). Sturm. tive attention capacity. Specht. Davidson. the . Tompkins & Lehman. & Robertson (2005). Smith.. Kincade. Aureille. and other external reminders to scanning task. Task difficulty can be increased by changing cube placement (e.GRBQ344-3513G-C34[963-987]. 966 Section V ■ Therapy for Associated Neuropathologies of Speech. the potential for dence suggests that the right hemisphere (RH) plays a special generalization of leftward search increases. Wong.g. placing Arousal and Orienting cubes to the left as well as the right of midline. & Petrone. also see Myers. neglect may inhibit the scanning neces. attention deficits may sustained attention (Arruda. Wiese.. Physiologic correlates remaining vigilant. Tucker & Williamson. 1991). & Nordahl. rial than those with LHD or those without brain damage (Davidson et al. & Evaluation and Treatment Eisenberg. carry important pragmatic information. Caplan. Finally. Medford. They may not be as attuned to the environment.qxd 1/21/08 2:00 PM Page 967 Aptara Inc. Posner & Petersen. Koski & Petrides. 2000. A narrowed accurately than those with lesions in other cortical areas focus of attention and poor orienting. patients with RHD may need more and in the right as opposed to the left frontal cortex of intense stimulation or more time to get ready to attend than non–brain-damaged (NBD) participants (Deutsch et al. Meadows. 1987). 1987. Their level of attention during any demanding com- response. Frith. Selective Attention & Tranel. For example. during conversations. Verfaillie. Evidence suggests that neurotransmitter LH areas only with increased task difficulty (Nebel. 1999). Walker. Rapcsak et al. Alexander. Studies suggest that the RH is attention. patients with RHD have difficulty sustaining attention and 1985. Toth. 1991.. Finally. Holcomb. Jennings. Deutsch. 1988. Reaction-time tasks have been conceptualized as measures of general attention and/or of vigilance. Yokoyama. These findings support the Vigilance is a state of alertness in anticipation of an event. 1993. Attention deficits may impair the appreciation of the tion over long periods of time. indicate that subjects with RHD have significantly municative situation can fluctuate such that they may not lower physiologic responses to pain and to emotional mate. Semple. These results support the clinical impression that some Lewis. Robinson. Farrow. pathways supporting arousal are to some extent lateralized Stude. Janer. Coull. notion that neglect is a symptom of a larger attentional deficit. Fox. Chapter 34 ■ Communication Disorders Associated with Right-Hemisphere Damage 967 RH appears to be able to orient attention to both right and first in focused attention tasks. 1991). & Raichle. Patients may be less able to shift of individuals with LHD (Sturm & Willmes. 1996. characteristic of (Ruff. with recruitment of specific left hemispace. Pardo. Deiner. process crucial information even when prepared to do so. actively or covertly. stimuli and to recognize stimulus significance. Zahn. Gross. to the right (Oke. 1989. & Herbert. suggesting a reduction in arousal or general enting. 1992. 1987). 1990. Collard. & Keidel. Ackles. & Raichle. 2005). Individuals with RHD also have slower reac- tion times in response to simple visual and auditory stimuli. These effects will be addressed more thoroughly in the section and increased metabolic activity in the RH during vigilance on extralinguistic disorders. Tipper. tasks (Cohen. & Adams. Selective attention enables one to screen out distracting such as a point of light or a simple tone (Ladavas. Del Pesce. To measure attention adequately. for resources are strained and patients become overwhelmed. not be able to attend selectively to important information Studies of healthy adults indicate a RH dominance for during communicative events. Grafman. They deteriorates over time (Bub et al. & de Witt. In reaction-time tasks calling for selective attention lesions.. 1990).. may affect all levels of experience. nor patients with right frontal lesions performed slower and less able to expand attention beyond a narrow focus. & Wylie. Heilman et al. other populations of brain-damaged patients with focal 1987). neglect increases as the selective attention demands of tasks increase (Kaplan. It can be & Provinciali. 1999).GRBQ344-3513G-C34[963-987]. Bourbon. 1990. 1999). (Bench et al. Results from a recent study using functional magnetic resonance imaging It should be emphasized that most individuals with RHD (fMRI) suggest that RH attentional networks are activated will have some type of impaired attention. may be less able to sustain attention to stimuli anywhere in 2001) and with longer interstimulus intervals (Wilkins. & Valentino. Vigilance and Sustained Attention Riddoch & Humphreys. but see interactions become more complex and demanding. conflicting results) and vigilance (Cherry & Hellige. 1978. ori- Boller. Peasin. & McCarthy. 1987). Thus. reaction. & automatic or voluntary. Pardo. Stuss. & Adams. Mercier. Papanicolaou. Allen. 1978. tion. deGreiff. factors that may affect their progress in of arousal. Dowling. the environment and to filter out distracters. In functional terms. Pardo. they may Shallice. neglect. 1980. 1989. & Grasby. particularly important for selective attention. 1984). Keller. and is dependent on the arousal. Studies have found that the verbal and visual cues that specify the context within which performance of participants with RHD is poorer than that communication takes place. and vigilance systems.. Hood. sary to generate the broad-based view that is fundamental to positron emission tomography (PET) studies have found environmental scanning and for which the arousal and ori. Weiler. In addition. can reduce sensitivity to environmental cues that Franchi. & Craik. and attention. Frackowiak. Participants must Effect of Attention Deficits on Communication be ready to respond to stimuli that occur at unpredictable or Attentional impairments have cognitive consequences that random intervals. including communica- time tasks elicit many responses that require sustained atten.. Oke. cognitive Audet. Nieman. regardless of the . Rochette. prominent activation of the right anterior cingulate gyrus enting systems are critical. such as electrodermal activity or galvanic skin therapy. 1992. place demands on patients’ internal resources such that as 1999. . In conversation they may not under- tences and paragraphs according to the rules of their lan. all patients with RHD should be level of communication. Stemmer. These same cues Kitselman. 1968. naming rather than scene description). designed to test language in constructions that literature on cognitive rehabilitation (e. The extralinguistic and pragmatic aspects of com- tion of attention treatments specifically for adults with munication specify the context within which communica- RHD. They do not have particular problems in retrieving main points a speaker is making because they focus on unim- words. as discussed in the section on extralin- tested for attentional deficits. they may miss the theme or (Adamovich & Brooks. comprehension (e. Rossi. included in family counseling and taken into account in evaluating and treating RHD communication impairments.and Language-Related Functions presence of neglect. & Dwyer. 1999a). a patient colleagues (Sturm. It is true that some individuals such as gesture. and rarely affect communication versation (e. or in addition to. one is being funny or sarcastic or serious. Tasks that problem rather than.. ing of words themselves. Thus. among characters. portant details and have difficulty integrating information their control over linguistic structure may belie a more gen. emotional tone. Longoni. Direct attention training is effective. Extralinguistic deficits represent the heart of RHD commu- sequent to brain injury can be found in commercial materi. the roles played by participants in a con- characteristic of aphasia. Although individuals with RHD typically do not have apha- cellation tasks designed for evaluating neglect (Myers. point of a story. 1969). and whether some- significantly (Archibald & Wepman. and with RHD may make errors on straightforward expressive prosodic contour. object the literature on traumatic brain injury (Cappa. 1979. following verbal commands rather Evidence of treatment efficacy is available primarily in than interpreting paragraphs) and expression (e. although If the clinician feels certain that the patient has a language generalization to more functional tasks is limited. 2004) reported with RHD could have aphasia. their emotional state. 1981. facial expression..GRBQ344-3513G-C34[963-987]. Fimm et al. They may not attend to a speaker’s eral problem with language use at the narrative and discourse facial expression. 2003).qxd 1/21/08 2:00 PM Page 968 Aptara Inc.g. In addition. 1962). They may miss the guage. 1968. 968 Section V ■ Therapy for Associated Neuropathologies of Speech. interpret intended meaning (what is meant from what is bal fluency. many of them do have communication disorders. Thus. the available said) and to understand the relative formality and emotional data suggest that the problems are relatively mild. 2005. ver. and implied meaning. Deal. body language. treat- require attention over time to the occurrence of simple but ment should follow the traditional approaches used in the unpredictable stimuli may increase the capacity for vigilance management of aphasia.. and reading and writing. & van Heugten. and the results should be guistic deficits. stand humor or the subtleties of irony. They may not recognize relationships Swisher & Sarno. in nature. Sturm and left-handed people. help us express our own intended meanings.g. are essentially context-free... However. visuospatial deficits. Benke. These aspects of communication extend communicated meaning LINGUISTIC DEFICITS beyond the literal or surface structure of words and sen- Pure linguistic deficits are not considered a source of RHD tences. It is important to remember that (e. Extralinguistic cues allow us to ination. However. Deal. Eisenson. word definitions. are useful in assessing linguistic 2005).. although extremely rare. Research is needed on the efficacy and generaliza. Additional tasks for treating attentional deficits sub. tion takes place and allow one to understand and convey intentions.g. The term “extralinguistic” refers to fac- als. as observed on PET and fMRI scans. peer versus subordinate). neglect. sia. Selective EXTRALINGUISTIC DEFICITS attention may be addressed by modifying the complex can. behind their actions. as well as in published materials If a true linguistic problem is suspected. Errors should be Clarke. patients with RHD are able to structure sen. Thus. Context is conveyed through an array of sensory cues communication impairments. improvements in internal alertness in a computerized task with concomitant changes in the function of RH attentional networks. Sohlberg examined in light of visuoperceptual and attentional deficits. and they rarely make paraphasic errors. Wertz. as well as through the choice and group- and receptive language tasks such as naming. particularly in a computer screen for the appearance of a target). subtests from apha- designed for patients with traumatic brain injury and in the sia batteries. including computer software designed for attention tors that affect communication but are not strictly linguistic training. Evaluation and Treatment Tests of attention and treatment techniques can be found in some of the RHD batteries. word discrim. Turkstra et al. the prosodic cues that convey emotion and .g. signs of RHD. nication problems. and/or the motives In general. following simple commands. listening for a target word in a word list or monitoring language is not always lateralized to the LH. et al. into an overall theme. and attentional impairments Some patients with RHD appear to have difficulty using have been cited as possible contaminating factors in some these cues to understand the implied meaning of complex studies investigating linguistic disorders in adults with RHD discourse and narratives.g.. Archibald & Wepman. are not tone of discourse. but must be sorted for relevance. it has only been in the past inference. for further discussion of this topic). Joanette. That is. studies have now begun to waves into phonemes. Hypotheses about several possible interpretations when more than one infer- underlying mechanisms will move management toward ence is generated (Blake & Lesniewicz. 1986. 1997a. adults with RHD do not have difficulty with simple or auto- Brownell. form. inferences. or sidered relevant must be combined or integrated to create a main point of narratives. In the the RHD communicative impairments. Gardner. In general. there may be specific semantic deficits that have an impact on and (4) association of cues with prior experience. recognizing the intended meaning of concepts.GRBQ344-3513G-C34[963-987]. These operations are complex communication. verbal communication requires that one go beyond the mary statement for story contents. They may have hypotheses about sensations. and lack specificity. Ska. Kaplan.” which expand or embellish information and Rehak. 1987. the color of the man’s hair would be consid- ered an irrelevant cue. Wapner. data such that input is not only sensed. & Gardner. they can be generated by .qxd 1/21/08 2:00 PM Page 969 Aptara Inc. matic inferences (Brownell. impairments experienced by adults with RHD suggests that Early studies focused on describing the deficits and the con. Chapter 34 ■ Communication Disorders Associated with Right-Hemisphere Damage 969 emphasis. These Discourse Deficits combined cues create the context from which the inference of royalty is made. & Michelow. above example. and shadow. wearing cues that convey emotion and intention through gesture and a crown. The inference may have to be maintained in the extralinguistic deficits associated with RHD (see Myers. inference breaks down at a later stage of processing. Moya. They may miss the point of con. and perhaps the color purple. & Nespoulous. Inferences about individual features must be integrated Patients with RHD may also have difficulty expressing within the entire context to produce the overall theme we their own intended meaning. light. or referential meaning of individual extracting story morals and themes in linguistic and pictured words to their implied or inferred meaning. Later-stage inferences are problems getting to the point they are trying to make. Individuals with RHD may have difficulty generat. (3) integration of relevant cues with one another. pictured scenes. Myers. and determining that the image is that of a man is 25 years that the notion of communication disorders associ. Weylman. & Finklestein. a viewer Finally. communication disorders” to describe these symptoms. hypotheses based on those initial beliefs. Lojek-Osiejuk. treating the cause. and have difficulty superficial. 1986). but interpreted” (p. Goulet. 1992. rather ditions under which deficits may be observed. 2005). rather than the symptoms. Generation of inferences depends on at least four opera- impaired attentional mechanisms contribute to all levels of tions: (1) attention to individual cues. have problems giving titles to or choosing a sum. Hough. 1989). Waters. that he is a king is a hypothesis about the intended meaning It is of note that we still use the term “right-hemisphere of the visual image. However. we may eventually The process of inferencing does not end once an inference is arrive at a more appropriate term to capture the nature of generated. nition of color. gist of their own messages. Myers & Brookshire. The conclusion prosody. the elements must not only be Macrostructure Deficits recognized. They may have more difficulty with “elaborative Levine. Potter. “an inference is a hypothesis about sensory can be cognitively demanding. 1986. 9). (2) selection of rele- cognitive processing. than at the level of translating light rays into shapes or sound tions more firmly established. they may have difficulty using the extralinguistic might interpret a picture of a man in a purple robe. and the scepter. or dis. Certainly. & Gardner. & Levine. & Brownell. 1983. In addition. In the above example. label that refers to a location in the brain rather than the organizing the visual image into the form of a human is an nature of the problem. Lehman & Tompkins. the type of communication ated with “minor” hemisphere damage gained credence. working memory until required for selection from one of 2001. not necessarily ordered sequentially. They may produce fewer core In similar fashion. Despite the fact that these inferences Myers (1992). 1986. another inference. 1996. Bihrle. Benowitz. According to elaborative inferences. 2000. 1997b). 1996. and those con- A macrostructure is the overall theme. & Caplan. The cues also must ing macrostructures in comprehension and expression of be associated with prior experience. Hamby. Initial inferences are beliefs or cient and uninformative. McDonald & Wales. 1990. literal. Thus. Their speech may be ineffi. With descrip. or to the physical setting in which the commu. vant cues. 1981). Wapner. central message. Relevant cues include the crown. the mechanisms of the impairments. By addressing antecedents (Leonard. place demands on processing resources (McKoon & Ratcliff. call a macrostructure. Mackisack. & Duffy. a There are many levels of inference. 1990. Moya. and holding a scepter as a king. or even linking pronouns to their address underlying cause in a systematic way. the robe. In general. nicative act takes place. Making predictions and determining the emotions or Generating a macrostructure depends on the capacity to motives of story characters or conversational partners are draw inferences or interpret information. context or pattern or meaning beyond the superficial recog- course. including communication. but more likely occur versation and be unable to stick to the point or convey the in parallel. Kelly. stories (Benowitz. situations. 2001) . irrelevant details such as the garden outside the window or the tences and the integration of their meaning into the context cups on the counter. Determining that the children are not just reaching for cookies. requires the extraction and inte. 1990. 2005.e.qxd 1/21/08 2:00 PM Page 970 Aptara Inc. 2001). “shhh.. then. For example. Kaplan. woman a mother (versus a woman) is an inference based on lems tend to arise when correct interpretations rely on recognizing and integrating the appliances that suggest a integrating multiple cues or selecting one of several possible kitchen. Joanette et al. but stealing them. 1988. documented in a study using Norman Rockwell illustrations Impaired ability to extract and integrate selected bits of in which subjects with RHD labeled more than twice as many information can be demonstrated by patient descriptions of items as did NBD controls (Mackisack et al. understanding the theme or overall gist of narratives often begin their descriptions of this picture by discussing involves the extraction of meaning from individual sen. describing the “cookie theft” picture compared to NBD con- gration of individual units of meaning (explicit and implicit) trols. semantic links between sentences because not all the links and Myers and Linebaugh (1980) found that subjects with are explicitly stated (Brownell. the jar. Hough (1990) asked sub- Kaplan. Lehman.” et al. 2001). This problem in selecting relevant infor- supplied by the other sentences. an observation also objects and their integration with one another. & Barresi... inferencing prob.GRBQ344-3513G-C34[963-987]. As explained by Hough (1990) and Brownell Clinical experience suggests that individuals with RHD (1988). Cookie Theft Picture from the Boston Diagnostic Aphasia Examination (Goodglass. Myers (1979. and the girl has her finger to her mouth without grating contextual information (Hough. More likely. Similarly..” Adults with RHD may say the boy has his hand in ture for narrative discourse may be related to deficits in inte. Adequate interpretation of the jects to interpret the theme of short narratives and found scene (i. 1986). & Barresi. in verbal-comprehension studies. her apron. the overall implication of disaster) requires that those with RHD tended to list information and selecting and integrating relevant cues to build elaborative “retained isolated pieces of paragraph data rather than Figure 34–1. One must often infer the mation alters the overall interpretation.and Language-Related Functions adults with RHD when they are strongly suggested or sup. 2005). and noted that they tended to list items without explic- into a larger whole. 1981). 1987). requires the integration of the action of the boy reaching in the cookie jar with the action Selection and Integration Deficits of the girl who has her finger to her mouth in the gesture of Problems generating an organizing principle or macrostruc. These deficits are discussed below. the familiar “cookie theft” picture (Fig. calling the Blake & Tompkins. interpreting pictured scenes itly connecting them to each other or to the central action. and the children behind her. inferences about individual elements upon which the overall ported by a context (Blake & Lesniewicz. Wapner combining the two actions into the inference of “stealing. or real situations involves the extraction of key individual Much of what they did list was irrelevant. theme or macrostructure rests. 34–1) from the Selection and integration deficits have also been reported Boston Diagnostic Aphasia Examination (Goodglass. interpretations. 970 Section V ■ Therapy for Associated Neuropathologies of Speech. RHD produced significantly fewer inferential concepts in Narrative discourse. Trupe & Hillis. Duffy. Brownell. giving the most immediate response without reflection narratives” (p. (Blake & Lesniewicz. that of Failing to infer the examiner’s intended meaning when asked others as truncated and abrupt (Myers. Brownell & put (verbosity) is characterized as digressive and tangential. For example. about or interest in its accuracy or adequacy. co-worker). . Gardner (1992) found that individuals with RHD were ing internal information in such a way as to generate efficient impaired in judging the effects of tangentiality on conversa- narrative expression. 1990. 2002). the fall. Their lack of sensitivity to the interference of other people’s tangential remarks seems to mirror insen- sitivity to their own tendencies in this direction. asked what had happened to her and why she 1990. Tangential comments may not be off the topic altogether. but also in filtering. Rehak. but as I get there my mind. Obler. “I know the are asked to organize printed sentences into paragraphs point I want to reach. the cause of her hospitalization was a (1990) found a relationship between difficulty organizing stroke. Kaplan. 1996. Verfaellie. Producing Informative Content Occasionally. & Moses. enemies). Sherratt & tents. because the carpet softened spatial relations and problems integrating verbal informa.GRBQ344-3513G-C34[963-987]. Macrostructure deficits can be influenced by other prob. Jacobs. and under... 2005. 1986. Blum. 1987. less relevant concepts. nize important contextual cues. They are tan- patient grasps the components. employer vs. They also may not use contextual cues 1992. & Basili. “My husband saw I wasn’t in bed. 1995). Happe. intact (Lojek-Osiejuk. As a result.” That is. integration deficits everything.” extending straight out from the side of a house or the petals of a flower trailing away from the stem. Selective attention deficits may her listener was burdened with having to fill in the missing inhibit the ability to filter irrelevant information and recog. Rehak. individuals with RHD unelaborated output (paucity of speech) often seem perfunc. . tain fewer concepts. more than two inches down tional apraxia. not the blow to her head. Diggs effectively to constrain the generation of elaborative infer.. reflecting “repetitiveness. Wapner. integrating. For example. but cannot put them gential. 1991. has been described as hyperfluent and digressive. what they call a also occur at the perceptual level. without ever describing the action (Blake. & Liles.” and “irrelevant comments” Integration deficits also surface when adults with RHD (p. 1983) and to name uum cleaner. Piecemeal processing in sculptured pattern with swirls and all that. Brownell. information. and he found me in the clothes that I came to the hospital in. 1997. Simpson. ences. 1999a. Stringfellow. Potter. script knowledge) is but their presence signals difficulty in getting to the point. Excessive out- Pincus.. mand over basic narrative structure (i. individuals with Digressive and inefficient output may be related to RHD may have difficulty not only comprehending external impaired appreciation of listener needs. It goes down to the the visuospatial realm is thought to be a factor in “construc. Blum. Roman. & Tompkins. & Gardner. 1987. one patient with RHD discussed the size and weight Penn. but related—related to the fact that although she together into a coherent structure. Cimino. same robe and gown and lems associated with RHD. its plastic coating. And we have a very thick rug. 1992). & Gerstman. For example. Borod. confabulate when faced with uncertainty or nonsensical . like a vac- (Delis.g. & Winner. For example. and thus tion in subjects with RHD. base—fiber base. tional partners. Individuals with RHD may produce as many or more 1990. 1985). Duffy. Myers & Brookshire. RHD can was in the hospital. 1999. suggesting that the Her comments about the carpet continued. Kaplan. they have been found to generate multi. Studies investigating informative content have such as familiarity between characters. Seibold. She was unable to make her point explicitly. Kaplan. Bowers. Chapter 34 ■ Communication Disorders Associated with Right-Hemisphere Damage 971 integrating this information to deduce the meaning of the tory. relationships (friends found that subjects with RHD produce narratives that con- vs. and the type of ink used to of output occur with approximately the same frequency create the drawing. Urayse. to describe a pictured scene. Deficits in all spews it out. Joanette et al. Rehak. tangential or irrelevant output appears to The conversational expression of some patients with RHD reflect uncertainty about the intended meaning of events. sucks up every thought along the way and object categories (Myers & Brookshire. Tompkins ple possible predictions about a story’s outcome regardless of and Flowers (1985) noted that low concept scores were how specific the context is about the most plausible outcome overwhelmingly associated with excessive verbal output. appropriate responses. & Weylman et al. Ostrove. These opposing patterns of the paper. and less specific standing of another’s knowledge (sometimes referred to as information than those of NBD participants (Bartels-Tobin “theory of mind”) to determine speakers’ intents and generate & Hinckley. status (e. about two. or perhaps confused by its con- Brownell. and organiz. Patients with depicted in the picture. Gardner.e. 1996. Brownell and colleagues (Brownell. & Heilman. 271). 1998) have words than NBD adults. 1991). but what they say may convey less demonstrated that adults with RHD have difficulty using cues information. one patient responded: interfere in integrating isolated pieces of information. Winner. Bloom. a patient may draw a chimney deep . Benowitz and colleagues had fallen on the floor. Sometimes. & Gardner. & Gardner.qxd 1/21/08 2:00 PM Page 971 Aptara Inc. Myers. 2005). 529). & Pincus.” of these tasks support the notion that although the com. As one of the first author’s patients said. and information. Gardner. depending on the context. Potter. eral studies of scene description have demonstrated that these impairments “may not be restricted to metaphor. patients confabulate reasons for ings for sentences and phrases (Brownell et al. Connotative We are continually confronted with new information that meanings refer to alternative. rather than writing one. Kaplan and colleagues (1990) found subjects with RHD impaired in interpreting whether or not conversational Generating Alternative Meanings remarks between two speakers were to be taken literally. 1988). if we walk in on a conversation as 2000. For exam- beyond visual material. & Gardner.” overtax resources. we would have to revise our ond sentence. If we lis- interpreting the meaning of sentence pairs when misleading ten further and find it is a discussion about the Wright information was presented in the first as opposed to the sec- brothers and their first aircraft. 1984. as in the example.” Its conno- son with RHD such seemingly automatic revisions may tative meanings may include “regal. As Brownell and colleagues (1990) suggest.. embedded in context (Brownell. or alternative meanings during discourse. Understanding the iar. Roman. However. Either meaning Explanatory Theories: Activation and Suppression Deficit may be called upon. RHD subjects had more difficulty than the NBD group in revising their Connotative and Metaphoric Meanings original interpretations to accommodate the information contained in the second sentence.” we might assume that Fassbinder. idiomatic phrases have two meanings—the literal face value of the words. For example. & prise or nonsensical endings.qxd 1/21/08 2:00 PM Page 972 Aptara Inc. tion that alters our original interpretation. Myers impaired performance. required to interpret a scene significantly affected perfor- mance. Gardner & Denes. Tompkins. 1977) and indirect requests (Foldi. 1990. for example. Lehman-Blake. the first sentence implies that RHD have been found to have difficulty producing alternate Barbara is reading a book. 1991. less familiar. 1989). tain less informative content because adults with RHD have LeDoux.. individuals with RHD do not have problems recognizing rather they may be but one reflection of a more pervasive objects and people in scenes as visually complex as Norman impairment affecting appreciation of different types of alter- Rockwell illustrations and that the level of inference native meanings” (p.. for example. 1984. Tompkins. when re-telling stories with sur. Thus. Sometimes intended meaning of these nonliteral remarks required rein- this occurs because we need to accommodate new informa- terpreting them in light of previous information. less famil- fun. Nonliteral remarks occurred when one speaker was making It often happens that we must generate different. 376).and Language-Related Functions information. where further interpretation is not called for.” Taken in isolation. or interpretive alters our original interpretations as we negotiate the twists meanings. suggesting that problems with content extend problems with following everyday conversation. Brownell and Tompkins and their colleagues need to call on a less familiar meaning for a word or set of (Brownell et al. Gardner. Van Lancker & Kempler. She had already spent five years person really was flying—in an airplane. 1996). Myers & Brookshire. the denotative meaning of the and turns in everyday events and conversations. & details to make the events more plausible (Wapner et al. 1986. “He was really flying. or telling a white lie. 1987. 1973). For the per- word “lion” is “large animal that lives in Africa.” “king of the jungle. This same tendency can be seen in everyday situa. misleading information was presented first. Reduced informa- Sometimes. Potter.. subjects with RHD made up Gardner. 2001) found subjects with RHD impaired in he was talking about someone going at great speed. sented narrative passages (Cimino et al.” Figurative language and inadequately and entire meanings are missed. Michelow. It has been postulated that the intact RH is more adept at ating connotative meanings for single words that are not processing multiple. one must change one’s original interpretation of tive content has also been found in response to verbally pre- sentences or events to accommodate new information. Studies have demonstrated RHD impairments in gener. Brownell. more loosely . & Linebaugh. and in appreciat- 1981). Hirst. “Barbara became too bored initial assumption and reinterpret the phrase to mean the to finish the history book. Brownell. Sometimes we Similarly.. Impairments in revision Individual words may evoke a denotative or connotative have even been found in a lexical task that required revising meaning. Wapner Impaired ability to revise expectations may be a factor in et al. Denotative meanings are like dictionary defini- the lexical function of a single word (Schneiderman & tions and are appropriate for words taken out of context Saddy. sev. Simpson. ing both metaphoric and nonmetaphoric alternative mean- tions when. while levels of visual complexity did not (Mackisack Revising Initial Interpretations et al. 1981). For example. 1981. When meanings under effortful processing conditions. Individuals with writing it. and the metaphoric meaning.. Winner It is possible that narratives based on visual stimuli con. Baumgaertner. so that new information is processed “ferocious. & someone says. & problems perceiving what is in the pictures. alternate. 1987.GRBQ344-3513G-C34[963-987]. & Stein. Baumgaertner. 1990. being sarcastic. & Lehman. 1987. 972 Section V ■ Therapy for Associated Neuropathologies of Speech. Weylman. nonliteral.” or even “MGM. words. Bihrle. ple. The second goal of the interview is to obtain a sample of Joanette & Goulet. which (Tompkins et al. can be assessed for content and structure. Two oppos. are able to activate multiple meanings. it appears that RHD can interfere wonder why they are seeing a speech-language clinician in the semantic processing of alternate meanings. integrating verbal information into following television shows and complex conversations. and uninformative. reviewed for structure and content. and revising original interpretations as new infor- admit to these problems in the face of family relief that they mation unfolds. 1984.or videotape that can be is establishing the presence or absence of deficits. Finally. nonspecific. make Evaluation of Discourse Deficits problems seem more manageable. meaning(s) can contribute to impaired discourse processing Another reason patients may be resistant is that they are in adults with RHD. 1990. Most. Continued activation of meanings that are not appropriate to the context interferes in the selection of the The purpose of the interview is to establish rapport and to particular alternate meaning that is most appropriate obtain a sample of the patients’ conversational speech. to agree with patients that they may Problems in generating elaborative inferences. or subordinate be a result of brain damage. integrating. they may not appreciate figurative and other nonlit- are having difficulty that have nothing to do with their men- eral forms of language. They may be afraid to mation. and to explain that communication information. by explaining that help is available. 2002. to measure mild deficits associated with RHD.. but have difficulty suppressing (versus activating) the less likely meanings for a Patient Interview concept. They lems”). They may have problems inferring the aware of some of their deficits (perhaps they have trouble links among sentences. their assessment of their prob- tion with the informal approaches described below. There is a wide interpretations (see Myers.GRBQ344-3513G-C34[963-987]. Richards. inter. and that the LH is more not all. Chiarello. families may not be immediately aware of them. 1999a. or several meanings that are tightly overlapped (Beeman. many published tests are not sensitive enough 1993. Their fears can be allayed by clinician information and be digressive and verbose. while fering with efficient and accurate processing. ments (estimates range from 50% to 90%. For now.qxd 1/21/08 2:00 PM Page 973 Aptara Inc. address patients’ orientation. The activation theory holds that brain damage impairs the and it is essential to determine which aspects are idiosyn- normal RH functions noted above. For example. One way of addressing denial is to explain in Summary the initial interview that all stroke patients are tested for communication deficits. 1994). It is important to obtain information from the ability to manage alternative meanings and to revise initial patient’s family as part of this assessment. may not recognize or may deny their problems. integrating not have any problems. patients with RHD best explains the problems adults with RHD have with alter. for a review). families problem can disrupt the ability to manage complex dis. As a result they may fixate on irrelevant can talk (and hence. ambiguous. cooperation. distant. Discourse and pragmatics are often assessed using infor- ing theories have been proposed to accommodate impaired mal tasks. so the primary goal in evaluation conversational speech on audio. 2001). Brownell et al. often support the patient’s denial unwittingly by exhibiting course that contains ambiguities and/or requires revising their relief that the patient “can talk. and generating or selecting the most plausible consists of more than speech and language. range of “normal” conversational and pragmatic behavior. meanings (Beeman. Goldsmith. and Beatty (1999) reported that speech-language patholo- mal to generate alternate meanings during discourse.. Explaining and demon- strating problems to the patient can decrease fear. filtering unnecessary infor- have noticed problems in reading). Chapter 34 ■ Communication Disorders Associated with Right-Hemisphere Damage 973 connected meanings than the LH. Burgess & Simpson.. The clinician can help patients overcome denial accommodating new. Questions should mercially available assessment tools can be used in conjunc. Blake et al. This when their speech sounds fine to them. Burgess. and organizing erally confused. Baron. They may nate meanings. their daily activities. they may have difficulty tal stability. 2000. and increase insight and Not every person with RHD has communication impair.” If patients have com- initial impressions. 1990). 1988. In some circum- assurances that there may be very specific reasons why they stances. and so must be carefully evaluated and selected. munication problems. of these tools have weaknesses in reliability or valid- adept at automatic processing of dominant single meanings ity. Additionally. 1993). or seemingly conflicting by demonstrating some specific problems they may have and information. if lems. something about their work . First. Com. or an overall structure and theme. It may take more effort than nor. Establishing rap- More studies are needed to sort out which hypothesis port is crucial for several reasons. & Pollock. gists often rated pragmatic behaviors as inappropriate. “do not have communication prob- details and be vague. They may fear they are mentally unbalanced or gen- may have problems selecting. such that patients have cratic to a patient’s pre-stroke personality and which ones may difficulty in activating multiple. family members reported that these same behaviors were The suppression theory holds that individuals with RHD typical of the patient prior to the stroke. Second. in the of these two methods for deficits associated with RHD).. main theme of the stimulus item. turn-taking. For that reason they may have greater from there arrive at an integrated concept of the picture’s potential for generalization across tasks. 1999b). it does not involve memory. and (4) explain the relationships among items or some variant thereof. etc. the insignificance of the bushes Task-oriented treatments typically attempt to retrain perfor. and their plans for the future. macrostructure and integration deficits. 1999a). such as the (1998). the extralinguistic deficits associated with RHD is to work listener burden. in a scene. 1999a. and other pragmatic deficits. The problems relies on clinical experience and our current interview thus addresses memory. stories. 1993. and Nicholas & Brookshire.GRBQ344-3513G-C34[963-987]. The next sections pro- description task enables the clinician to quickly assess the vide some general directions for designing therapy tech- patient’s abilities to attend to and interpret contextual or niques for RHD discourse deficits. “What are the most important items in the deficits. increasing informative content. (3) point to items that are related. The less developed (Myers. and on generating or selecting alternate mean- Picture Description ings and inference revisions. and efficient. to understand the significant items. 974 Section V ■ Therapy for Associated Neuropathologies of Speech. chies and to probe patient progress. one must Treatment of Extralinguistic Deficits have a sense of the overall theme in a “chicken-egg” conun- Management of extralinguistic deficits usually consists of a drum. However. 2001) can be used. on generating elaborative inferences. A picture. No studies have meaning. also see Myers. Urayse et al. on the other hand. items in a scene. the more difficult the infer- fit and used during treatment as a probe task to measure ence. 1993. scenes or stories for which the patient was not able to arrive 1995. Patients can be asked to (1) label shared knowledge. picture?” Typically. 1999a and 1999b. (2) specify the relevant or significant items tact. for reviews come closer to the overall theme. One should also work on informative. and Tompkins and Baumgaertner able pictures that require elaborative inferences. or conversational The patient’s response can be scored in several ways. headlines for news stories.). It can be adapted as clinicians see explicit or concrete the theme. Obviously. extralinguistic information. overall themes of pictured scenes. “cookie theft” picture.. patients will point to the mother and address underlying processes and attempt to stimulate children and to the water overflowing from the sink and recovery of function. The advantages over asking patients to retell stories are that it elicits a more spontaneous production. Inference and Macrostructure Generation curate concepts can be pointed out by directing the patient’s Macrostructure tasks include asking patients to report the attention to the visually present contextual cues. turn-taking. Responses can be assessed for the degree to which they One way of stimulating recovery of function for many of observe pragmatic rules of conversation (e. and the degree to which content is directly on attention and neglect. the number of inferential concepts generated can titles for pictures. beyond the window and the dishes on the counter to which mance on a specific task—usually through compensation— patients with RHD are often so attracted becomes clear and address symptoms. Pragmatic rat. or to state the be compared to the number of noninferential concepts. often the process of asking the patient to combination of functional or task-oriented and process.and Language-Related Functions history or personal lives. 1990. It is assumed that clinicians will use the techniques “cookie theft” picture from the Boston Diagnostic Aphasia mentioned elsewhere in this book to establish cuing hierar- Examination (Goodglass et al. eye con. and insight. organized. therapy for these printed sentences into a story or pictures into a logical . accurate. Treatment tasks that be used to elicit narrative discourse for the evaluation of are grounded in theory can be found in Myers (1999a. This can be done by asking them to produce example. orientation. the clinician attempts to and disadvantages of these scoring systems). Process-oriented treatments.. Commercially avail. Task difficulty depends on Such a scoring system for the “cookie theft” picture has been the complexity of the inference to be generated. 1991) or other types of concept analysis (see One can also guide inference generation by working on Cherney & Canter. for a review of the advantages at an inference. overtly specify significant items usually helps him or her oriented methods (see Myers.qxd 1/21/08 2:00 PM Page 974 Aptara Inc. Clinicians must be creative in designing tasks and evalu- A pictured scene that tells a story or depicts a situation can ating their impact on communication. For interactions. been conducted on treatment outcomes for extralinguistic Integration tasks include asking patients to organize deficits associated with RHD. understanding of the deficits and their underlying cause. By manipulating the level of inferential complexity.g. Tompkins (1995). progress in therapy. facilitate the patient’s conscious control over what was once ing scales can assess problems in recognizing the limits of a more automatic task. In this process. and missed or inac. As a result. one can stimulate the process of inference generation Transcribed picture descriptions can also be evaluated by through repeated trials at a level at which the patient reaches techniques of discourse analysis (see Sherratt & Penn. rather than the underlying cause of when one asks. a pre-set accuracy criterion. topic maintenance. For example. reduced concentra- 106) (see Bloise & Tompkins. If one subscribes to the activation is inconclusive (Folstein. Audio or video Several investigators have suggested that the RH plays a recording of conversational interactions is a useful way to special role in processing emotional content (Bear. Ng. integration can be addressed in Individuals with RHD may have difficulty interpreting and tasks that require patients to arrange puzzle pieces or iden. loss of energy. expressing emotional content.g. 1998. dough) or to group sets of words according to their denota. DiPiero. 1986). 1978).g. Chapter 34 ■ Communication Disorders Associated with Right-Hemisphere Damage 975 sequence. deficits may also interfere in emotional processing. transcribed. 1997. followed by a discussion of why the including the cues that signal emotions. and flattened prosodic production also can be second sentence. This can be seen in use and tify fragmented objects from their individual parts. 1981). & Marshall. one can simply photocopy large line draw. Although it may seem logical minute answers can be tape recorded. 1992. & Price. Brownell & explicit or implicit the content is. disas- ters. familiarity between speakers. tion. although a recent study suggests that emotional deficits If one subscribes to the suppression deficit theory. these individuals may patient identify contextual cues that lead to the most appro. tive or connotative meanings. Jacques. For ters and conversational partners. the clinician can then help the arousal (Heilman et al. reduced levels of arousal. 1990]). cut them into several pieces. Goldenberg. turn-taking). 1999). 1993. reduced affective response was diagnosed in rearrange and re-photocopy them. Maiberger. & Lauritzen. Kubos.g. sleep disturbance. 1990. priate interpretation. That is. prehension of emotion requires generation of elaborative sions may include presenting patients with two-sentence inferences using contextual and other extralinguistic cues stories. Patients can be asked to group pictured objects. what is known as “indifference” sentence into context. Starr.. & McHugh. and Kaplan et al. she pulled out her key and signs of depression. Evidence of an association between altered Improving the ability to manage alternative meanings can be internal emotional states and site of lesion following stroke addressed in several ways. & Coopersmith. the sentence.. Sinyor. Com- Tasks designed to improve the ability to formulate revi. Stories can be followed by inferential to recognize commonalities may also improve integration questions that probe patients’ abilities to revise their initial skills.. celebrations. choke. Prior to sorting. Depression occurs in 30% to for other examples).” reduced the gate” might lead one to picture an airport scene until the responsivity. In adults with RHD. tional processes. sion of alternate meanings by putting an ambiguous word or 2001). or printed words into categories. and cortical structures (Karow. and char- range from concrete (e. The different meanings of the ambi. population (Blake et al. and recent study. 1994. cognitive interference.. foods. Lipsey.. 1984.g. Kalpoupek. vehicles) to more acter attitudes or emotions [Kaplan et al. and In addition. suspicion). Chan. & . One. the first of which leads one to a faulty conclusion that enable us to recognize emotional states of story charac- unless it is reevaluated in light of the second sentence. Starr.qxd 1/21/08 2:00 PM Page 975 Aptara Inc. 1977. and (3) emotionally laden words.. Rao. Blake and colleagues found that they did and coherent the answer is. To make comprehension of (1) facial expression. ings of hopelessness. meanings for homographs (e.. relevant. and “flattened affect” may be associated with reduced guity can be discussed. and Tompkins & Baumgaertner. Tasks that require patients Stringfellow. complete. Another type of stimulus is a brief story 60% of stroke survivors in the acute phase (Andersen. 1984. Padovani.. psychomotor slowing or agitation. Becker. 1999a. Brownell et al. that ends in a statement by the main character. statement may be either congruent or incongruent with the Iacoboni. Cummings. and their ability to use cues scenes. Other signs of depression include feel- unlocked it” leads to a different conclusion (Myers. In a ings of common objects. At the perceptual level.GRBQ344-3513G-C34[963-987]. Silberman & Weingartner. Marquardt. bat. The final Vestergaard. one can ask the patient to provide two Robinson. topic maintenance. 1986. 2002). Categories can within the text (e. Impairments in each of these not frequently co-occur. 1986. 1995. significant changes in weight. areas can then be worked on separately. the clinician can identify Processing Emotional Content the categories. bank. or some combina- Managing Alternative Meanings tion thereof. Riis.g. one can most commonly occur when lesions affect both basal ganglia help the patient enlist conscious control over the suppres.. Cognitive-processing original interpretation was no longer accurate. (2) emotional such materials. patients can be asked to provide an opinion aprosodia specifically was diagnosed in 20% of the same for open-ended questions on current topics of interest. 30% of patients with RHD on a rehabilitation unit. abstract themes for pictured scenes (e. efficient. & Lenzi. 1983. Borod. deficit hypothesis. be less aware of and less responsive to external stimuli. “Ella grabbed her bag and rushed to It is important to remember that “flat affect. example. tools. Stimuli can vary in number of details and in how preceding information (Brownell et al. It is not clear whether these impairments are the result of an altered internal experience of emotion.. or require the patient to generate them. “Once there. review various pragmatic deficits (e. prosody (aprosodia). 1994. & Price.. Rao. Robinson. and rated that the two deficits might have similar underlying emo- according to how integrated. knot. impressions of story content. p. Tucker. . clear that they have an affective disorder per se. & Heilman. Damasio. 1991. NBD group. difficulty interpreting facial expressions depicting emotions Determining the emotional valance of situations. & Nicholas. Obler. 2002). sions. Koff. 1988) and sub. & Valenstein. 1991. Weylman et al. 1980. individual features tral cues for both groups. “He went into the house” is inferen- Heilman.qxd 1/21/08 2:00 PM Page 976 Aptara Inc. Blonder. so it is difficult to know (Blonder et al. in the latter study subjects with LHD were responsiveness to the external environment. Bowers. 1999. expres- (Adolfs. a referral patients to identify emotions depicted in pictures or for psychiatric evaluation should be made. and so on. Emotional “indifference” may be a tion. 2001). described in sentences or stories. Cicone et al.. & Sperry. Cicero et al. duced conflicting results. Karow et al. 2002. 1986. Benowitz. Cicero et al. Studies of spontaneous facial expression have Summary found that subjects with RHD had reduced facial expression in response to slides depicting emotional situations in com. Most studies of the verbal expression of emotional content level perception to cognitive selection and interpretation involve a comprehension task. Studies Blonder and colleagues (2005) also reported reduced facial investigating emotional status following stroke have pro- expression in subjects with RHD during casual conversa. Coslett. or when responses require to the nonverbal cues that signify emotional expression. While the earlier studies did not control for the effects component of a more general attention deficit that reduces of facial paresis. and narratives requires generation of elaborative in- Mesulam. 1992. Not surprisingly. Bear. conscious thought. feature integration may also play a role. 976 Section V ■ Therapy for Associated Neuropathologies of Speech. Comprehension of Verbal Emotional Content if other signs of depression are present or if depression is Comprehension of emotion has been assessed by asking suspected in addition to the clinical signs of RHD. Wapner. 1980. Bowers. 1985. the degree to which the tral. and RH neocortex and somatosensory-related emotional content independent of inferential complexity. failure to express emotions. 1994). ing and in expressing emotional content. 1987. and Koff (1990) and Borod. Some studies expression present faces in isolation without other contex. Koff.and Language-Related Functions Straughan. Subjects with RHD are impaired relative to Comprehension of Facial Expression NBD controls primarily when tasks are more complex Decreased arousal and attention may affect patients’ responses (Borod. Cicone.. Borod. deficits.. 1990. the responses from the RHD must be combined with one another to arrive at an accurate group were significantly less emotional than those of the judgment.. For example. or to match emotional words (Blonder et al. such as answering questions or making Numerous studies have reported that adults with RHD have explicit judgments (Rehak. it is not jects with LHD (Borod et al. Bloom. and Nicholas (1985) found Production of Facial Expression that adults with RHD used fewer and less intense emotional words when they described pictures. 2001). it is difficult to know whether the findings relate to basal ganglia. subjects’ capacity to infer nonemotional or neutral content. without a comprehension component still reported deficits tual cues to specify the emotion. or both. 1980). (1991) asked subjects to recall episodes from their own lives acteristics of facial features such as how close the eyebrows in response to a cue word that was either emotional or neu- are. DeKosky. & ferences. 2001). Furthermore. However.. 1986. Reduced responsivity may impair the appreciation . 1992. Borod. how wide open the eyes are. Facial Expression Deficits Cancelliere & Kertesz. & Gardner. Lorch. Thus.” Most Bowers. Zaidel. Ramasubbu & Kennedy. 1991. 1990. Lorch. and some researchers speculate that emotional processing relies on a hierarchy ranging from low. stimuli have not included comparable tasks designed to test Heilman. The basal ganglia appears to play an important role in interpretation of emotional material Verbal Expression of Emotional Content (Karow et al. whether impairments are based on failure to comprehend Most studies investigating the interpretation of facial emotions. Borod. Cimino and colleagues be determined by inspection and analysis of the spatial char. Rosenthal.. or it may be more likely to have facial paresis but also to produce more related to a patient’s denial or lack of awareness of his or her facial expression. orbitofrontal regions. 1999). tially less complex than “He stole into the house. Thus. Karow et al. Bauer.. Although the emotional judgments that may be in the province of the intact RH cue words produced higher emotionality ratings than neu- (Kosslyn. 1983. Individuals with RHD may have problems both in interpret- parison to NBD subjects (Mammucari et al. 1995.. Obviously. 1992. 1988). Even in patients without “flat affect. & Tranel.. This type of were rated as less specific than those from the NBD group perceptual-feature analysis depends on spatial or “metric” regardless of the type of cue word. areas (Adolphs et al. the responses of subjects with RHD corners of the mouth are upturned. Similarly.GRBQ344-3513G-C34[963-987]. Buck & Duffy. Kaplan.” facial expressivity may be reduced. Areas of the brain thought to be important in recognizing Studies that have done so have produced mixed results. 1981). For example.. 1992).. Bloom et al.. The expression must thus in adults with RHD. facial expression include the amygdala. Cancelliere & studies documenting problems in inferring emotions from Kertesz. sound duration. Robin et al. 1985). Tompkins & Flowers. generally test a group of individuals with damage to the RH. OBject versus obJECT).GRBQ344-3513G-C34[963-987].. The pound nouns (e.g. Ziegler. 1987. sad versus happy). 1981). a minority of whom may actually have aproso. RHD. emotional valance of situations and narratives. Recent studies 1977). Adults with RHD may be impaired in their appreciation Sidtis & van Lancker-Sidtis. Weintraub.. while emotional prosody is processed primarily by the RH. “green house” from “greenhouse”) and RH is thought to be more adept at processing nontemporal interrogative from declarative sentences. hearing “I lost my purse” spo- 1981). Alterations in pitch. In many studies participants prosodic deficits. 1999.” versus “Joe structure. The redundancy emotion (e. & Kramer. Caldognetto. Tompkins. emotional facial expression. prosodic comprehension deficit when prosody is in conflict Daigle. Bowers et al.. 2002. Another processing component that may affect task per- regardless of whether or not they have been screened for formance is sustained attention. 2003). & Coslett. The group results may not be reflective of must listen to sentences but dissociate meaning from tone. The cause of impaired prosodic comprehension is uncer- tain. 1980). Tucker. that the LH is dominant for processing prosody at the word itation of many studies designed to describe or explain the level. aid in Another aspect of processing complexity involves deter- syntactic parsing (“listen to the choir. and NBD participants in judging accurate in making same/different judgments. 1984. and intervals tional states. suggest that adults with RHD are able to use prosody to Schlanger. Adults with RHD demonstrate a greater ments (Heilman. In addition. & Watson. been found to be selectively impaired subsequent to RHD der termed “aprosodia” (Ross. Bowers..qxd 1/21/08 2:00 PM Page 977 Aptara Inc. 1990. volume. 2003. Heilman. distinguishing noun phrases from com. Chapter 34 ■ Communication Disorders Associated with Right-Hemisphere Damage 977 of the extralinguistic cues from which one can infer the remained while words did not (Denes. linguistic content. Behrens. Some studies that have evaluated neglect report that subjects with RHD and neglect have difficulty Prosodic Comprehension with prosodic tasks (Heilman. Scholes. Emotional prosody captures not only emo. such as nature of prosodic deficits associated with RHD is that they phrases and sentences (Baum & Pell. either The prosodic features of speech convey both emotional and tonal/rhythmic or fast/spectral. & Heilman. 1985) and in identifying emo- integration may contribute to impaired ability to identify tional prosody in nonsense sentences (Pell. 2006). 1976). be it explicit intonational patterns that add extralinguistic information to (and effortful). Tompkins & Flowers. 1988). and in detecting or rating also improved the RHD groups’ prosodic judgments of neu- the amount of emotion conveyed prosodically. whereas the LH is specialized for processing tem- loves Ella. or implicit. Semenza. processing mode. of both linguistic and emotional prosody. & Buzzard. have been found to have impairments in discriminating The last component. ceptual deficit in detecting changes in tonal patterns. it is surprising to note that neglect is not often prosodic impairments in those who have them. Other evidence comes from Tompkins Adults with RHD generally demonstrate more difficulty (1991b). identifying the mood conveyed in a short paragraph. A variety of tasks have been used to examine comprehension Tompkins & Flowers. and requires off-line. These will be discussed in turn. 1990. while the RH is involved with larger regions. Another hypothesis suggests or by bilateral frontal regions (Van Lancker. 1991a. Mesulam. Walker. Compared to the form of a word suggesting a given emotion improved both healthy adults and individuals with LHD. Pitch perception has and expression of these prosodic features of speech. Watson. & Damasio. but intents such as sarcasm and irony.”). 1975. and harmonic ing through the use of stress (“Joe loves Ella. boy” versus “listen to mining communicative intent when the prosodic and linguis- the choirboy”). but not necessarily about the characteristics of deficits. they are less accuracy of LHD. that linguistic prosody is processed primarily by the LH. & Zettin. and clarifies mean. refers to whether emotions when speech was filtered so that prosodic features the task is explicit. One theory suggests (Chobor & Brown. (2) the processing compo- linguistic information. The results provide general information about inci. between sound (Chobor & Brown. sequence. Robin. Considering that neglect is associated with attention dence.. poral order. including linguistic and cog- duration of utterances and pause time between words create nitive demands. forcing them to divide their attention in a rather unnatural dia.g.g. tested or reported in studies of prosody (even those that use picture stimuli). and Geigenberger (2003) suggest three components influence interpretation of prosody: Prosodic Processing (1) input—the type of perceptual processing required.g.. Sidtis & Van Lancker-Sidtis. ken in a happy voice). One lim. They also tral sentences that followed the paragraphs. & Gerstman. while those without neglect may not (Schlanger. Tranel. who found that increased semantic redundancy in with emotional than with linguistic prosody. Speedie. metalinguistic . and the nents or complexity of the task. Vagges. individuals. properties of spectral information. Linguistic prosody disambiguates word Prosodic-comprehension deficits may be related to a per- and sentence types. task. and (3) the processing mode. with linguistic meaning (e. 1984. perceptual impairments in spatial judgment and feature 1984. 1987. 1985. tic meanings differ. a disor. Wunderlich. and to differentiate questions from state. identify word meaning (e. pitch. veyed in prerecorded sentences with neutral content (e. Acoustic examinations of speech waves suggest that individ. The extent to which patients suffer from difficulty in Van Lancker & Sidtis.” These findings. Adults with RHD Prosodic-production impairments may also exist in some who have prosodic production deficits (aprosodia) tend to individuals with RHD. to signal syntactic bound. & emotion). reduced volume and pitch range and that their voices some- viduals with RHD may not be able to mount the resources times felt “hoarse” and “strangled.. In more severe cases. A patient seen by the first author stated Thus. Wunderlich and colleagues (2003) suggest prosody (Shah et al. and to ignore one thing while attending to another.g. pitch variation is one formance on a variety of other tasks (e. Prosodic production can be difficult to assess. & Dwivedi. ing patients to identify the emotion (happy. com- to attend to these important extralinguistic cues. 1982). reduced acoustic con. It is likely that some indi. 1985. Patients tend to be volume to signal emotions. sad.. Ross. Clinical impressions of impaired rely less on pitch variation and more on shifts in intensity or prosody have been difficult to quantify. Joanette.g. “The boy came home”).g. amplitude. In general.. 2004). Pelletier. 1986). However. 1987). emotional tone in NBD speakers (Shapiro & Danly. fundamental frequency. imitate the prosodic pro- tional deficits in response to tasks designed to isolate prosodic duction of a speaker. given that such demands influence per. It is possible tion and pause time.. Other studies report no significant dif. Prosodic productions have been analyzed perceptu- comprehension deficits found in the laboratory translate into ally and acoustically. using acoustic analysis. 2006. & Reif. 1992). automatic terms of duration. it is uncertain whether or not prosodic impairments that she tried to get more inflection into her speech. attenuated pitch varia- prosodic comprehension in everyday conversation is not tion has the potential to have a negative impact on the pro- clear. particularly in studies similar deficits in natural conversation is not clear. Thus.e. and that bined with problems in voluntary control over prosody. 1998). Summary Prosodic Production Prosodic comprehension and production deficits may occur subsequent to RHD. or whether it measures more on-line. Most studies have reduced use of pitch variation and increased use of intensity used explicit tasks (e.. mechanical and stilted. a form of of contextual information specifying the speaker’s intended dysarthria).. have been mixed. meaning.and Language-Related Functions responses. 2006. Ryalls.GRBQ344-3513G-C34[963-987]. be asked to match a spoken word to one of a set of two that trast. The findings. Homan. For linguistic prosody. they may sound has not been formally addressed. although this possibility sound fatigued. Patients ferences between individuals with and without RHD in can be asked to produce or imitate prosodic contour that . it appears that damage to the RH can result in prosodic (linguistic and cognitive) factors. Of note. and responses from which comprehension of prosodic meaning pause duration on tasks requiring manipulation of linguistic can be inferred. to control the variables that operate in natural conversation. “hot dog” versus “hotdog”). & Rosenbek. & demands. but that in the laboratory reflect true deficits in processing prosodic it required “a lot of concentration” and was often ineffective. Walker. that dysarthria plays a role in prosodic-production impair- Patients with mild prosodic production impairments may ments in some adults with RHD. Cooper. Comprehension impairments may Emotional and linguistic prosodic production has been include both emotional and linguistic prosodic deficits. Seibert.g. The gest that impaired prosodic production subsequent to RHD severity of the deficit may vary with the level of redundancy may be in part a motor execution disorder (i. but unable to correct. 1979. these deficits. Patients with RHD with prosodic-production impair- Subjects with RHD are impaired in tasks that force them to ments may complain of difficulty getting emotional tone select and detect relevant features. aspects of conversations in which multiple cues signal Patients in the Ryalls (1987) study reported a sense of meaning and emotional content. & Feldman. and tested by asking subjects to repeat or read neutral sentences may be related to impaired pitch perception and/or to atten- with a specified emotional tone. that the task demands may increase the influence of the non. Ryalls. 978 Section V ■ Therapy for Associated Neuropathologies of Speech. sug- they may have specific problems with pitch perception. they likely play a role in prosody too. or to differentiate statements from questions (Shah. Laboratory investigations of prosodic deficits attempt duction of emotional prosody. giving a robotic quality to their speech. 1988. Whether or not prosodic- stress. to attend to two things at into their speech (Ross & Mesulam. once. point to the picture that matches the to convey emphatic emotional stress (Colsher. Walker et al. and reduced energy in frequencies above 500 Hz (Kent vary in stress placement (e. so it is difficult to determine the effect of task Graff-Radford. Individuals with RHD generally do not have problems Evaluation producing linguistic prosodic contours to distinguish noun phrases from compound nouns. Edmondson.qxd 1/21/08 2:00 PM Page 978 Aptara Inc. Emotional prosodic comprehension can be assessed by ask- aries.. 2004). and tend to use consistent dura- aware of. patients can uals with RHD may have a fast rate. Tompkins & of the most critical prosodic features used to distinguish Baumgaertner. angry) con- Baum. and/or spontaneously produce emphatic from linguistic information. 1987. When using a motoric approach.g. Chapter 34 ■ Communication Disorders Associated with Right-Hemisphere Damage 979 distinguishes words or phrases from one another either in (2) potential connections between nonlinguistic and mood or in emphatic stress.. Stringer. 2005. 2004. agreed-upon al. for patients with few other RHD problems.. findings. (1) mechanisms that underlie identified communication In the past. neurologists. clinicians should remem. which may be different from the (6) treatment efficacy.. such training may be worth the attempt.qxd 1/21/08 2:00 PM Page 979 Aptara Inc.” on the other hand.. an apparently motoric treatment involves imitation of productions of dif. Rosenbek et location in the brain. and it may interfere example). but as often as it may occur with LHD. some predictable consequences and defined subtypes. (4) incidence and prevalence of identified deficits. Both terms avoid “RHD” in the label in recognition ments are effective in increasing expressive prosody. It is a condition that ies of treatment for aprosodia have been developed to treat includes some features and excludes others—a disorder with the disorder as if it were a cognitive deficit (Leon et al. The “pragmatics” relates to communicative intent.” Myers (2001) argued against the term the prosodic characteristics used to convey specific emo. Productions should be tape extralinguistic deficits. tary control over their production or the ability to improve. that not all those with RHD have communication disorders. 2004) or a purely motoric disorder communication impairment. To understand how essential Treatment for prosodic deficits may not be a priority in this is. Rosenbek et al. recorded and played for judges (e.” because tions. one need only imagine the term “LHD communication patient management if the patient has other extralinguistic impairment” to describe aphasia. to families and patients. This method can be cumbersome. other speech-language pathologists. spontaneous expression of emotion through prosody. Recent stud. “aphasia” and suggested instead “apragmatism. There are many things that deficits. Research and practice would both benefit from consensus about the core deficits that define communication disorders Treatment associated with RHD and an operational definition and label that adequately captures them. Joanette and Ansaldo (1999) suggested the term emotional words and prosody. It makes it difficult to explain the deficits everyday conversations. and there is uncertainty about whether acoustic mea- sures translate into clinical relevance.GRBQ344-3513G-C34[963-987].. prosodic impairment can occur in aphasia is and many that it is not (a motor speech disorder. Perhaps a term such as “cognitive-communication disorder of ber that such training is not like accent reduction therapy. identify the emotion the patient was attempting to express. and the patient can be trained to state cult to raise public awareness and to gain recognition from more explicitly the emotion they are trying to convey in third-party payors. and it is research continued research aimed at: that will lead us toward that list. If the patient is free of communicate about the disorders with colleagues. other staff) who try to (3) prognosis and recovery patterns subsequent to RHD. who often equate the ability to speak with adequate communication. identifies a (e. subjects were often selected only on the basis and cognitive deficits. In clinical work. lack of an adequate label that reflects an particularly if the effort required diverts resources from other agreed-upon set of defining features makes it difficult to types of extralinguistic processing. rehabilitation profes- In addition. While appropriate for . but may not be available to clin- Defining Core Deficits icians. does not rest on lesion localization. the RHD type” better captures the broad range of communi- Although aware of their deficit. similar to a dysarthria) (Leon et al. and it provides information (5) theory-driven assessment tools based on new research only about how well a person can volitionally control and pro. FUTURE DIRECTIONS Research Needs We hope that the description of deficits and the framework Arriving at the core deficits that define a label is the more in which they have been laid out in this chapter will help difficult and vexing problem—one which requires continued clinicians recognize and understand RHD communication research. researchers would disorders and design innovative therapy techniques for benefit from having a list of operationally defined core them. patients and family members should be counseled sionals. Preliminary data suggest that both treat. central feature of the extralinguistic deficits associated with ferent emotions. its diagnosis in the resumption of their daily lives and work. Improved treatment rests on clinical insights and on deficits for purposes of subject selection.. RHD. In a chicken-egg conundrum. It makes it diffi- about the problem. The cognitive treatment is based understanding of the behavioral deficits it includes and on the theory that aprosodia is caused by reduced access to excludes. 1996). Patients are asked to explain “pragmatic aphasia. and to match prosody to facial expressions. and other physicians. but there is no common.g. and duce emotional prosody. of a lesion site confined to the RH. However. patients may not have volun. including other impairments. cation deficits that may be present with RHD. “RHD 2005. Acoustic measures are more objective. role in communication and that damage to it can affect com. As an attentional inferences. subsequent to RHD. Assessment for extralinguistic deficits should consist of an initial screening that includes an interview. 4.e. 9. It is important to remember 11. only as a control group when the research goal is to further 7..and Language-Related Functions studies of incidence or prevalence. this once “silent” hemisphere.GRBQ344-3513G-C34[963-987]. 980 Section V ■ Therapy for Associated Neuropathologies of Speech.. expression. RHD may include pragmatic deficits in recognizing disorders. KEY POINTS 10. . regardless of whether they had tive processes that contribute to the pragmatic and anomia or even aphasia. tests 1. extralinguistic aspects of communication. it is reasonable to ask if we now know enough about the disorders to move beyond deficit. We look to a future in which continued nonemotional prosodic comprehension and expres- clinical insight and informed research bring us to a compre. Attentional deficits associated with RHD include tance of subject selection for studies of this type. better understanding guistic and extralinguistic deficits described in this of their natural history and cause. only consider how potentially misleading a study on the maintenance. 8. sion. chapter. Prosodic impairments may include emotional and municative function. This chapter is focused on the nature and character. individuals with RHD who are free of any vations of others. plays a spoken discourse. as well as ment” has yet to be determined. neglect may affect cognitive processing. RHD may affect the capacity to process alternative our understanding of RHD communication disorders. and. How can we best achieve subject selection without reli. study. meanings in discourse. macrostructure. To understand the impor. disam- and/or attention that have good psychometric properties biguating information. in ipsilesional as ability to process alternate meanings and generate well as in contralesional space. of neglect. a capacity for which the intact RH is thought to be dominant. 3. most importantly. neglect. However. to reduce neglect and attentional deficits. These deficits may presence or absence or severity of the specific deficit under result in reduced levels of informative content in dis- study or related deficits either á priori or during the study. course production and reduced sensitivity to shades Including subjects who do and do not have the deficits under of meaning in discourse comprehension. tasks to stimulate integration abilities. and following conversational con- signs of communication impairment should be included ventions. Patient management should include task-oriented that not every person with RHD has communication (i. They should be managed according to improved patient care. Treatment for discourse deficits should include tasks deficits that define “RHD communication impair. and selective attention. and a discourse sample. and written and nizing that the RH. functional) and process-oriented treatment impairment and that while we have come a long way approaches as well as patient and family counseling. and lesion lateralization for subject selection when the research hence communicative ability as well as recovery of goal is to delineate the nature of a single disorder or group independence. of RHD communication deficits. and drawing complex infer- can also be used. word retrieval. Neglect can occur across modalities. Subjects can be grouped according to the ences based on contextual cues. body language. one need hypoarousal and deficits in orienting. Basic linguistic performance (e.qxd 1/21/08 2:00 PM Page 980 Aptara Inc. Tests of cognitive function. increase the 2. vigilance. allows for examination of relationships among speaker intentions. These deficits nature of anomia would be if subjects were selected on the may have a significant negative impact on the cogni- basis of unilateral LHD. patient need relative to other potentially more press- ing communicative impairments and the patient’s ability to exert volitional cognitive or motor control over prosodic features. but do have some related cognitive or communicative 6. and improve the use of contextual cues. understanding the internal moti- deficits. tasks from the literature that have demonstrated sensitivity 5. gesture. able and valid measures of RHD communication disorders sentence structure) is rarely affected by unilateral or an agreed-upon definition of them? We can start by using RHD. RHD may reduce sensitivity to emotional content Summary and can affect the ability to express emotion in facial We have made great strides over the past 30 years in recog.g. They may occur independently of the nonlin- hensive definition of the core deficits. a core set of 12. in our understanding of these disorders. followed by fur- istics of communication impairments that can occur ther testing using informal and/or formal measures. RHD discourse impairments tend to be cognitively to RHD communication deficits and/or to the specific based and include deficits in generating a deficit under study. integrating information. H. (1991). L. 114. 18. Bear. L. E. Appelros. M. P. S. discuss ways to evaluate Chokron. O. Blake. K.). 28. (1993). 21. K. P. I. Archives of Neurology. conduct treatment to address deficits in each area of Bear. 1115–1127... Baum. Neuropsychologia. & Lesniewicz. Compare and contrast the communication deficits asso. & Levine.. 907–922. J. J. (1983). 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Implicit guistic prosodic structures in subjects with right hemisphere processing of prosodic information in patients with left and brain damage. Hood. International Journal of Human Communication. 32. 1227–1241. Blum. Weintraub. & Kempler.. Brownell. 85–106. Zahn. & Boller. A. Roman. Comprehension of conventionality of wording. & Gardner.but not by right hemisphere damaged 580–591. (1981)... & Tranel. M. R. D.. D. R. and their neuroanatomy. of dementia. systems. The cognitive-communication difficulties experienced by indi- viduals with dementia. apraxia. Explain the effects of memory impairment on cognitive. not occur exclusively with delirium. and represent a sig- ment of the world’s population. Chapter 35 Management of Neurogenic Communication Disorders Associated with Dementia Tammy Hopper and Kathryn A. Specifically. short and long-term memory impairment. mon causes of dementia. for a diagnosis of dementia. a direct result of deterioration in higher cognitive processes. speech-language pathologists primarily deal with dementia. discuss the effects of dementia on 1999. an estimated 4 million people in the U. 1997). Define the dementia syndrome and commonly associ. 2005a. patients who have irreversible dementia caused by degener- were living with Alzheimer’s disease (AD). understanding memory Understanding the pathogenesis of AD and other dis. and although many cases of dementia are to an increased incidence and prevalence of individuals with reversible. tremendous growth in the number of older adults translates trauma. Diagnostic and Statistical Manual of Mental Disorders (4th ed. and retrieval through chapter is to define the dementia syndrome. The chapter will con- clude with examples of evidence-based treatment programs that promote clinically significant changes in individuals OBJECTIVES with dementia. the reader will be able to: THE DEMENTIA SYNDROME 1. In 2000.S. agnosia. The impaired memory functions in dementia. increasing most rapidly (Kinsella & Velkoff. b). with the oldest old (85) nificant decline from premorbid levels of functioning. Bennett. infections. Discuss assessment of individuals with dementia. Scherr. Describe memory and the pattern of spared and severe enough to interfere with daily life activities. Memory is not a unitary 988 . Bayles & Tomoeda. and toxins. Design treatment programs based on principles of multiple cognitive deficits that include both (1) evidence of dementia management. is necessary to under- eases that cause dementia. are national research priorities. The purpose of this processes of encoding. These deficits must result in significant problems with employment and social function- Older adults (65 years) comprise the fastest growing seg. or impaired executive functioning. the leading cause ative neurologic disease. Text Revision) (DSM-IV-TR. & Evans. and this number is predicted to increase to 13.2 The cognitive-communication problems of dementia are million by 2050 (Hebert. American Psychiatric communication abilities of individuals with dementia. 2001). and developing pharmacologic standing why and how communicative functioning is and behavioral strategies for improving quality of life for affected in individuals with dementing diseases. necessitate speech-language Memory can be defined as stored representations and the pathology services (ASHA. Dementia is a clinical syndrome defined by deterioration of ated diseases.. After reading this chapter. affected individuals. 2003) unless a cure or effective prevention is found. 3.GRBQ344-3513G-C35[988-1008]. which knowledge is acquired and manipulated (Baddeley. a patient must have 5. This Dementia is associated with many diseases. Association. most notably memory.qxd 1/21/08 2:05 PM Page 988 Aptara Inc. and (2) at least one of the following conditions: aphasia. explain com. ing. Bienias. consolidation. and the contribution of these deficits MEMORY to diminished quality of life. Bayles communication. and outline principles for cognitive-com- munication assessment and treatment. 2000) specifies certain criteria that must be met 4. memory and at least one other cognitive function that is 2. Therefore. patients with neu. 2003.GRBQ344-3513G-C35[988-1008]. The phonologic loop and the visu. 2002) as well as areas of prefrontal diagnosis are specified in the DSM-IV-TR (APA. 1994). Chapter 35 ■ Management of Neurogenic Communication Disorders Associated with Dementia 989 phenomenon. 2000). 1990. is referred to as positive Braak. neither do they result from a psychiatric disorder such Implicit memory is the “unintentional or nonconscious as schizophrenia or depression. 35–1). Working memory not only integrates ory systems varies by disease. Tulving (1983) defines episodic memory as an individual’s autobiographical memory. Semantic mem. inferior and lateral temporal lobes. Rombouts. Heindel. The memory and language declarative or nondeclarative (Squire. lection (Squire. The vunerability of declarative and nondeclarative mem- mation. edge for motor procedures. Tulving. Diagnosis of facts (Schacter & Tulving. Declarative memory is AD can only be made upon postmortem examination of the dependent upon the hippocampus and adjacent structures brain. procedural memory subsystems. prefrontal cortex. and other neuro- the central executive system functions to integrate sensory motor regions and connections (Daselaar. 1994). Schacter & The idea of memory systems is not without controversy. Patients with damage to these neu. systemic conditions. cerebellum. priming in individuals with deficits in explicit memory sug- rologic disease or injury that affects specific brain regions gests that priming depends on different neuroanatomic and may demonstrate relative preservation of one type of mem. Raaijmakers. probable AD can be made by exclusion. Rather. reflexes. and habit memory Short-term. The anatomic systems underlying procedural mem- scratchpad (Baddeley & Hitch. However. spreading in stages practiced word may come to mind. 1997) and occipital (Tomlinson. Declarative profiles of four common diseases associated with progressive memory is memory for factual information. and Veltman. Changes are less apparent in primary sensorimotor (Braak & ing exposure to a related stimulus. Working memory is described as compris. etal and frontal regions) (Braak & Braak. & Salmon. and comprises dementia will be presented in the following section (Table semantic. but also is affect cortical structures are more likely to produce declara- involved in processing of information retrieved from long. patients with dementia in the development of AD (Fig. the nal cortex (adjacent to the hippocampus). Neuropathologic may be unable to recall consciously a previous learning changes are characterized by neurofibrillary tangles and episode in which several words were practiced. ospatial scratchpad are buffers for acoustic and visual infor. such as the basal ganglia. encoded in a temporal/spatial context. implicit memory expression may be preserved. follow. declara- ory whereas another memory system is severely impaired. 1994. Diseases that primarily affect subcorti- term memory. however. Importantly. Although the systems are interrelated. 1982) areas. 12). and is thought to be subserved by the dorsolateral require conscious recollection of previous study episodes. holding infor. ologies. functional systems than those that support explicit. coordinate and allocate processing resources. plan and control actions. This exemplifies how to the hippocampus.and long-term Nondeclarative memory consists of verbal and motor memory systems is generally accepted. input. 1991. produce nondeclar- Long-term memory can be conceptualized as being ative memory impairments. ory refers to general conceptual knowledge. buffer systems: the phonologic loop and the visuospatial 1994). This facilitated performance. 1996). tive memory (Butters. 35–1). 2002). while an individual is alive. some and/or increased response accuracy. or working. Zola. learning of procedures may not 1986). ing snow. and two “slave” or by behavioral change rather than explicit recall (Squire. lexical. such as playing tennis or shovel- mation in consciousness. 2000) and cortex that are active during encoding and retrieval include gradual onset of cognitive deficits that progressively (Schacter. The occurrence of degree of modularity exists. worsen and are not due to other central nervous system eti- roanatomic areas have difficulty with explicit memory.qxd 1/21/08 2:05 PM Page 989 Aptara Inc. the diagnosis of and connections of the medial temporal lobe (Broadbent. motor learning can be implicit. memory is the system responsi. & Squire. use of previously acquired information” (Schacter & Neuropathologic and neurochemical changes play a role Tulving. respectively. cal structures. Procedural motor memory refers to knowl- ble for activating and retrieving information. . 1994). Those diseases that primarily sensory information from the environment. whereas lexical memory comprises knowledge for words. (Squire. the distinction between short. Doyon & Ungerleider. 1994). “priming” and is inferred from decreased response time tiple systems. tive memory deficits. & Jonker. and focusing attention (Baddeley. however. 1994). p. and knowledge gained in the training sessions is expressed eventually other neocortical association areas (temporopari- through improved performance rather than conscious recol. Declarative ALZHEIMER’S DISEASE memory is assessed routinely using explicit memory tasks The most common cause of irreversible dementia is that require recall or recognition of past episodes or specific Alzheimer’s disease (Katzman & Bick. tions. For example. 1974). and is demonstrated ing a central executive control system. The criteria for Clark. For example. 1997). and episodic subsystems. ory include the basal ganglia. or substance-induced condi- However. In Baddeley’s model. but is better characterized as comprising mul. if neuritic plaques that are distributed initially in the entorhi- given the first few letters or stem of the practiced word. visuospatial deficits. these neuropathologic changes interfere with axonal trans- tein tau in an abnormally phosphorylated state (Goedert. it may be an inert by. network that transmits nerve impulses through acetyl- Neuronal degeneration in AD is marked by a loss of choline. and is seen in areas that have sion at the cellular level. 1991. Taken together.qxd 1/21/08 2:05 PM Page 990 Aptara Inc. that these paired helical filaments are composed of the pro. Neuropathological changes associated with • Declarative memory deficits Alzheimer’s disease.and Language-Related Functions TABLE 35–1 Common Etiologies of Irreversible Dementia and Associated Cognitive Profiles Alzheimer’s disease • Early stage: deficits in episodic and working memory • Later stage: impairments in semantic memory • Relatively spared procedural memory in early to middle stages of disease Cerebrovascular disease • Cognitive signs and symptoms are heterogeneous depending on lesion distribution • Cortical lesions are associated with amnesia. 2002).) Neurofibrillary tangles are intracellular deposits that occur when fibers within the neuron become twisted in a helical fashion. NIH Publication #96-3782. 1999). It is not clear how to warrant a definite neuropathologic diagnosis of AD in amyloid deposition is related to AD. Neurochemical deficiencies. specifically in the cholinergic General overall neuronal atrophy also is present in the system. Neuritic plaques are extracellular deposits best that researchers have discovered the presence of neurofibril- described as aggregations of neurons with an amyloid core lary tangles and neuritic plaques in sufficient numbers surrounded by a ring of granular material. Wekstein & degeneration (Goldman & Côté. Nerve cells (neurons) in several regions when cortical lesions exist of the brain are affected. attention. and acetylcholinesterase . 1991).GRBQ344-3513G-C35[988-1008]. 1991). Scientists have provided evidence to suggest and hippocampus (Goldman & Côté. and motor function Lewy body disease • Fluctuating presentation of cognitive symptoms • Procedural memory and learning deficits may occur with subcortical pathology • Declarative memory systems may be impaired with cortical pathology Parkinson’s disease • Procedural memory impairment Figure 35–1. The cholinergic system is a neuronal plaque and tangle pathology (Goldman & Côté. Brabander. also contribute to the disruption of nerve transmis- brains of individuals with AD. port and cause synaptic dysfunction. National Institutes of Health. choline acetyltransferase. It is important to note 1993). executive functions. 990 Section V ■ Therapy for Associated Neuropathologies of Speech. Uylings & de Markesbery. Enzymes necessary for the manufacture of acetyl- synapses and “presynaptic marker proteins” in the neocortex choline. Illustration by Lydia Kibiuk. and aphasia • Subcortical lesions (common in the periventricular white matter and basal ganglia) are associated with impairments of memory. Schmitt. individuals who did not meet the criteria for a diagnosis of product of neuronal death. or a causative agent in neuronal probable AD while alive (Davis. 1995. (Reprinted with permission from Alzheimer’s disease: Unraveling the mystery. and verbal fluency (Bayles & Kaszniak. 1983. These types of are useful for early differential diagnosis. Besides age. Other evidence tion between lack of cortical cholinergic input and the for relative preservation of semantic memory comes from development of neuritic plaques and neurofibrillary tangles. occurs when a response is facilitated by previous exposure to tion that drugs that interfere with acetylcholine can pro. 1995). . 1996. Bayles. Shults. Apolipoprotein E culty on tasks that require the use of conceptual informa- (ApoE). Logie. 1975). 1984).g. Della Sala. 1988). Individuals having one or two alle. tests of episodic memory. Beth. Smith. & Trosset.qxd 1/21/08 2:05 PM Page 991 Aptara Inc. or Individuals with early AD consistently perform poorly on demonstrate the ability to acquire and retain a skill (Dick. 2004. 1997). late-onset AD is not char. cerebellum. such as naming.” but risk factor of ApoE-4 presence. Buckner. with of cholinergic neurons has occurred within the nucleus some participants even demonstrating intact abilities as basalis. Other types of memory that may be spared in AD Memory Deficits of Individuals with AD include nondeclarative types of memory such as motor pro- The neuropathology of AD begins and is distributed most cedural memory. 1983). & Brady. The gene for ApoE is knowledge. Of executive function (e. & Holland.GRBQ344-3513G-C35[988-1008]. such as “orange” for “lemon. same category. the literature on priming. certain risk factors have been identified ory at least in the early stages of AD. Evidence from than those who do not have the e4 allele (Honig. the exact nature of the breakdown in semantic allelic forms in humans: ApoE-2. & and serotonin. ory is affected. 1994. 1996).” The argu- matched controls (National Institute on Aging/Alzheimer’s ment is that individuals with AD lose knowledge of the Association Working Group. 1983). Shimamura. showing that individuals with AD are as 2005). likely to give attributes as category information when asked to define words. a protein involved in cholesterol transport. Chapter 35 ■ Management of Neurogenic Communication Disorders Associated with Dementia 991 have been found to be reduced by 80% in individuals with demonstrated diminished performance on tasks of central AD (Bowen. 1974. rons. category knowledge. as dementia severity increases semantic mem- important risk factor. Davies. Salmon. the most commonly reported have been shown to improve task performance over time initial symptom is difficulty remembering recent events. & changes and subcortical nuclei containing cholinergic neu. On implicit memory tasks of motor learn- densely in areas of the brain important to episodic memory. Nebes. attribute ciated with an increased risk of AD. (Heindel. therefore. & Cotman. individuals with AD in the mild to moderate stages Not surprisingly. is not always Price. Butters. 1989). retain the categorical knowledge that they are “fruit. 1988). Nebes autosomal dominant inheritance (van der Flier & Scheltens. 1991). Some researchers have found that indi- duce memory impairment and confusion in normal individ. As mentioned earlier. 1997). Bressi. which is the most Of course. Hodges and Patterson (1995) nent of the substantia innominata located beneath the reported that individuals with early-stage AD exhibited vari- globus pallidus. the presence of positive priming Although specific causative factors of AD have not been supports the notion of gross preservation of semantic mem- determined. Nebes.” with knowledge of attributes Working Group. Della Sala. Nevertheless. among them dopamine report negative effects (Salmon. Several investigators have challenged the “bottom-up” tion of AD cases (approximately 5%) are transmitted by deterioration theory (Cox. 1981. 1991). viduals with AD demonstrate intact priming (Lustig & uals (Drachman & Leavitt. 1987). a related stimulus. & DeLong. found on chromosome 19 and exists in three common However.” acterized as an “inherited” disorder. tion. of objects being lost before generic categorical knowledge les for the e4 form are at a greater risk for developing AD (Martin & Fedio. and other neuromo- span tasks have been reported (Spinnler. Davison. Semantic memory. & Horn. & Butters. 1996). & Sims. Individuals with AD have particular diffi- ment of late-onset AD is now recognized. a genetic contribution to the develop. Deficits in verbal and visuospatial because the basal ganglia. 1988). & Baddeley. reductions are 1986. a finding that has led researchers to theorize a rela. Despite the genetic attributes that distinguish “orange” from “lemon. Working memory memory are preserved relative to declarative memory also is impaired in AD. ApoE-3. Shankle.. tor areas are relatively spared throughout much of the Bandera. ing. and this hypothesis comes from the misnamings of individuals the e4 form has been found to exist about three times with AD who often give the name of another item in the more frequently in individuals with AD than among age. Martin. which Nielson. dual task performance) compared to interest to scientists is the connection between cortical control subjects (Baddeley. Warrington. Only a small propor. particularly the nucleus basalis of Meynert (Coyle. and ApoE-4 memory is debatable. (Salmon & Bondi. Boller. and individuals with AD have course of the disease. This nucleus is a major compo. such as verbal recall tasks. Walicke. extensive reduction ability in their performance on semantic memory tasks. Spinnler. impaired in early AD. Some researchers have argued that it (National Institute on Aging/Alzheimer’s Association occurs from the “bottom up. In individuals with AD. In addition to the loss of acetylcholine. priming Consistent with the cholinergic hypothesis is the observa. on the other hand. is asso. Nebes. although others apparent in other neurochemicals. compared to healthy control participants. Goldman & Côté. that patients with cardinal feature of VaD (Jefferson. logic distribution of Lewy bodies can be classified as brain- VaD can be caused by ischemia (and less frequently by stem predominant. Dementia with Lewy bodies (DLB) rivals VaD as the second ria for dementia. 2006). neuroimaging report that it is neuropathologically distinct from AD (Cercy results of multiple infarctions involving cortex and underly. patients often have thrombosis or tures. 1998. the diagnosis of VaD remains The neuropathology of DLB is marked by protein controversial owing to its various causes and differing clini.. the presence of cerebrovascular movement. Other features (classified Cognitive signs and symptoms associated with VaD are as core. prominent or (Román. periventricular sion. Although DLB commonly diagnosis of VaD be based upon presence of the following: co-occurs with AD. Galasko. The basal gan- VaD is the recognition that VaD may actually moderate the glia are important in the control of movement. abilities that are not typically present in individuals with bles AD in that it is chronic and progressive. penetrating 1996. 2001. however. Berrios. suggestive. and neocortical (McKeith et al. 1997) and can occur in isolation (“pure” DLB).. recurrent visual hallucinations that deficits in attention. Core fea- lesions involved. Salmon et al. These include presence of dementia with a progres- infarct in cortical areas important for cognition and lan. Tiraboschi. In these cases. However. As a result of decreased levels of dopamine. 1975). lesions may actually promote clinical expression of AD patients with PD have difficulty initiating movement and . 1999). ble (in the case of two or more) or possible (if one feature is The prominence of dysexecutive syndrome in individuals present) DLB. 1997). others extremity). Aloia. Cerebrovascular disease (CVD) is increasingly common and may be the second most common cause of dementia (Dubois & Hébért. Salmon. Weiner. Specifically. 2005). Thal. Dening. Riley. Hodges. dete. penetrating persistent memory impairment that may not necessarily arteries or arterioles are most affected. Bloom. & tuations in cognitive and functional abilities (Hachinski Thal. with subcortical VaD (Kramer. causing infarcts in occur in the early stages but is usually evident with progres- subcortical structures and pathways (e. limbic.g. In small-vessel disease. with marked fluc. deposits (Lewy bodies) in neuronal-cell bodies. Brickman. Erzinclioglu. ing white matter).. Román. as in large-ves. are typically well-formed and detailed. Small-vessel disease is considered the most tures of fluctuating cognition with pronounced variations in common cause of VaD and is marked by multiple cognitive attention and alertness. resting tremor. & Paul. McKeith & O’Brien. memory. hemorrhage) in large arteries and in smaller.. & Corey- Individuals who suffer from acute strokes. or laboratory evidence (i. 2005 for a review. 1996. despite Idiopathic Parkinson’s disease (PD) accounts for most cases the demonstration of other cognitive deficits and evidence of parkinsonism. & Continued research with larger samples is needed to fur- Chui. function. certain features. Researchers have noted. Hofstetter. 992 Section V ■ Therapy for Associated Neuropathologies of Speech.qxd 1/21/08 2:05 PM Page 992 Aptara Inc. the DSM-IV-TR (2000) specifies that a most common type of dementia. Connor. of cerebrovascular disease. Sandy. and visuospatial ability. called “central fea- large-vessel disease. and expression of AD when the diseases co-occur (“mixed dopamine is a neurotransmitter involved in the initiation of dementia”). executive functions.g. Mungas. Hansen. sel disease. Grenier. weakness of an occur most often as a variant of AD (LBV of AD). executive white matter. & Bylsma. patients may not PARKINSON’S DISEASE meet the DSM-IV-TR (2000) criteria for dementia. & rioration can occur in a stepwise fashion. deep. Aloia. Reed. In addition to the basic crite. et al. and is considered by some researchers to focal neurologic signs and symptoms (e. Mortimer. 2003.e. McKeith & O’Brien. early AD (Calderon. recurrent infarcts in these same areas with normal social or occupational function. sive cognitive decline of sufficient magnitude to interfere guage or multiple. 1997). Perry. 1997. and motor skills (see Jefferson. The patho- cal manifestations. Hansen. and bradykinesia are consequent with deterioration of One of the most important developments in research on dopaminergic neurons in the basal ganglia. The classic signs of rigidity. 2001). McPherson & Cummings. In the case of and colleagues (2005). basal ganglia) (Mungas. 1999. and prominent deficits on tests of attention. Brickman. Salmon. 2005). According to McKeith arteries (McPherson & Cummings. 2005). The clinical course of subcortical VaD also resem. & tures of parkinsonism are considered sufficient for a proba- Paul. 2002) has prompted researchers to call for revised ther elucidate the cognitive and linguistic characteristics of diagnostic criteria that include dysexecutive syndrome as a DLB.. and spontaneous fea- guage. When CVD causes dementia. 2005). DLB have marked deficits in visuospatial and construction 2005)..and Language-Related Functions CEREBROVASCULAR DISEASE symptomatology (Snowdon. & Markesbery. and supportive) can help contribute to heterogeneous and depend on the distribution and type of the certainty of a possible or probable diagnosis.GRBQ344-3513G-C35[988-1008].” are essential for a diagnosis of possible or probable embolism in cerebral arteries that causes a single “strategic” DLB. it is referred LEWY BODY DISEASE to as vascular dementia (VaD). lan. however. may not always present with prominent memory problems and may have a stable or improving progression of symptoms (Román. not looking at the reading. Marder. & Stern. 2003). mask-like face. Most of the research on communica. 1993). Jacobs. great. These similarities E: Okay. and perseverations (Hier. E: What’s happening in this picture? guage also is impaired because memory for what was S: Well. Andersen. how- PD who develop dementia over the course of the disease ever. The prevalence of dementia among individuals with PD has been reported to range from 10% to 20% (Tison. 2003. (Bayles & Kaszniak. Taylor. somebody that really tangentiality (Obler. so more diffuse (Emre. E: Yes. Don’t you think? of individuals with PDD. The neuropsychological profiles of individuals for all that. As a result of memory and other cognitive impair. in particular the substantia E: Describe what’s happening there. thank you. SantaCruz et al. thanks. in PD without he’s he’s talking to these beautiful ladies here. then.. titious and forget what they have heard or read. 2003). Hagenlocker. So every- researchers have also found AD-type pathology in the brains thing is all right with him. 2004). Letenneur. What can you tell me about that terized by a lack of coherence (Ripich & Terrill. Manly. & Alperovitch. process. His responses to the same stimulus picture reveal the disease Increasingly. S: There’s a man that thinks maybe something else might be.. S: Well.qxd 1/21/08 2:05 PM Page 993 Aptara Inc. culty communicating. they do. with and without dementia) and are a prerequisite for post. but he’s left everything alone except his newspaper. one at a time as they march past him going to their own reading or whatever else they do. I don’t think anything needs to be seen on it. However. good. between PDD and DLB have led some researchers to con. clude that PDD is a subtype of DLB (Press. sometimes clinically indistinguishable. Mmhm. But um they have their their special aqualelge over. 1987). Sample 2—Year 2 E: Describe what’s going on in this picture. 1999). Lewy bodies are present in all patients with PD (both Describe what’s happening in the picture. Lolk. Chapter 35 ■ Management of Neurogenic Communication Disorders Associated with Dementia 993 commonly exhibit a slow. the term “Parkinson’s disease with demen. 2004) and are S: No. whereas in PDD the distribution of Lewy bodies is S: Well the father’s gotten a little tired of reading all this. but he’s mortem diagnosis of PD (Braak. actable that it makes you want to run away for some reason ments. or other. (laughs) E: All right. Kragh-Sorensen. here’s a man reading something. individuals with dementia have considerable diffi. & newspaper. do you want to say anything else about that? (Noe. Auriacombe. E: Tell me about this picture. S: He’s he’s keeping some of the papers with his teeth. 1988). Examiner (E): Now I’d like you to look at that picture there. Nonetheless. AD cannot be ruled out as E: Yeah. It’s happening. effects on linguistic communication. 1995) up to 70% (Aarsland. stages of the disease. & Subject (S): Too many children. And then he has a few down here like this. The ability to formulate E: What’s happening in this picture? ideas and express them orally and in writing diminishes S: No. Unsurprisingly. the relative preservation of grammar. And here’s his little boy. 2003). Sample 1—Year 1 Dartigues. 1988). Rüb. Early in the disease. and also reading dementia the distribution of the Lewy bodies tends to be his own paper beside. The following discourse samples are . see. Isn’t he cute? confined to subcortical areas. great great big procedural memory and learning (Saint-Cyr. Larsen. Auditory comprehension of lan. See he’s looking someplace else. the discourse of individuals with AD becomes impoverished Sample 3—Year 3 and fragmented (Tomoeda & Bayles. ah.GRBQ344-3513G-C35[988-1008]. great. they look like the pictures that uh don’t want to be COMMUNICATION ABILITY OF INDIVIDUALS pick-picketed or or made made up into an odd creature in in WITH ALZHEIMER-TYPE DEMENTIA the meantime. de Vos. thus. However. and from a patient with AD who was followed for several years. both he’s just getting rid of that. And he has his own great big. shuffling gait. there’s that’s something that we’d be supplied with it. and is charac. individuals with AD become repe. Boller. an inexpressive. Two feet Lang. & Braak. The way people take uh take uh an (actoba) that they don’t tion in dementia has been conducted with individuals with even know anything about. The devastation of tia” (PDD) is being used to describe those individuals with semantic content and verbal output is apparent. and say what you would like to about that. I’d like you to tell me everything you can about that. 1985). & Shindler. flexed posture. the cause of dementia among patients with PD (Braak et al. It must be a ah. They they they they they actually look so abilities. (laugh) groups of individuals with PD demonstrate difficulties with That’s real good. nigra. EFFECTS OF MEMORY DEFICITS ON S: Well. with these other people who have their. but usually goes away with a ogy and syntax are relatively preserved into the advanced E: Okay. That’s a cute thing right there. E: Okay. Del Tredici. E: Is there anything else that you want to say about that? Intact cognition is necessary for normal communication S: Yes. Note. Bell. phonol. 1983). Over time. and Jansen Steur. But they just don’t try to bother AD. (laughing) with PDD greatly resemble those of individuals with DLB E: Okay. picture? S: Yes. thought themselves really gone and close way. recently seen or heard fades rapidly. hearing and Communication Disorders of Dementia (ABCD.. or generative.. The subtest Another condition that can cause the performance of takes about 5 minutes to administer. hearing it and again after an imposed delay. 1960). For example. nonautomatic. but who was a Phi Beta Kappa in college.e. AD and VaD commonly co. 1991). Screening Miller & Seligman. Chastain. Caregivers commonly reported memory linguistic function that can be used to screen for dementia. Bayles & visual problems may exist and can confound the dementia Tomoeda. Steinmetz. such are not demented as being nondemented) (Bayles & as the Hamilton Rating Scale (Hamilton. caregiver. However.and Language-Related Functions ASSESSMENT Neuropsychological Tests Sensitive to Dementia Clinicians need to evaluate for the presence of dementia and The neuropsychological test most sensitive to early demen- its effect on communication skills. is advantageous. The Hamilton Rating Scale is an interview-based rating scale composed of a 17-item inventory of symptoms. & Brown. such as in retelling a story or generating names using demographic information (Barona. and comprehensively evaluate trouble writing letters as antedating the medical diagnosis of the communicative abilities of individuals with dementia the disease. making it important to Tomoeda. The scores of individuals with mild and Beck Depression Inventory (Beck. 1973). and the Tomoeda.e. Arizona Battery for As mentioned previously. Interviewing the primary ropsychologists typically evaluate attention. Wilson.. Polypharmacy also can confound the diagnosis subjects are asked to tell a short story immediately after because many drugs affect mental status. correctly classifies adults who have dementia as having referred to as pseudodementia.. Story Retelling Subtest. Identifying the presence of dementia demands considera- tion of whether current behavior is congruent with the indi. Premorbid intelligence can be estimated creative way. Global Deterioration Scale (Reisberg et al. deficits. 1994) risk for VaD. and has been used extensively in Summary of Assessment Measures research and screening applications with elderly adults (Gallagher. As part of a reasoning. that are rated for severity by one or two clinicians. Ward. usually the spouse.. 1984. It is beyond the scope of this chapter to review all of mary caregivers of 99 individuals with AD were interviewed the neuropsychological tests used with individuals with about early linguistic and nonlinguistic symptomatology dementia. 1993). an indi- Tasks most sensitive to the dementia syndrome are those vidual whose clinical performance on intellectual tasks was that are active. Instead. because dementia clinician will benefit from case history information about is by definition the loss of multiple cognitive abilities. The Hachinski Ischemic Staging Severity Scale (Hachinski et al. correctly classifies adults who depression using one of the many depression scales. 1993) consider the possibility of cerebrovascular disease in patients FAS Verbal Fluency Test (Borkowski et al. Functioning sion. Active nonautomatic tasks suspect.. often (i. focal neurologic signs. such as history of hyperten. the pri. In this test. Screening Tests vidual’s premorbid intellectual ability. Mini-Mental State Examination (Folstein et al. and abrupt onset. the tia is the episodic memory test. Rosenbaum. 1983. and stage dementia severity. Communication Disorders of Dementia (Bayles & occur in individuals with dementia. Breckenridge. The TABLE 35–2 Beck Depression Inventory is a self-report instrument comprising 21 items. both physical and psychological. problem-solving.GRBQ344-3513G-C35[988-1008]. The Functional Linguistic Communication Inventory Individuals who have seven or more points are considered at (Bayles & Tomoeda. memory. To detect dementia. 1975) viduals with symptoms typically associated with vascular dis. moderate AD and the scores of individuals with PD (with Mock. and other intellectual functions in addition to longitudinal study of the effects of AD on language. and ones that average. the focus will be on measures of cognitive- (Bayles. 1961). Such an individual would be expected to perform require the patient’s mental and linguistic involvement in a above average. would be depend on logical reasoning. & of items in a category. 1967) suspected of having dementia. 1982) ease and stroke. The scale comprises 13 features associated Comprehensive Assessment of Cognitive-Communicative with vascular disease and stroke. & Thompson. . (Table 35–2). 1979). & Erbaugh. Consider screening for dementia) and specificity (i. 1993) is evaluated and points are accumulated for those present. 994 Section V ■ Therapy for Associated Neuropathologies of Speech. Each feature The Arizona Battery for Communication Disorders of Dementia (Bayles & Tomoeda. 1993) is an effective screening tool. neu- any neuropsychological changes. Mendelson. diagnosis. 1975) is widely used to identify indi. and has high sensitivity the individual to mimic dementia is depression.qxd 1/21/08 2:05 PM Page 994 Aptara Inc. Reynolds. difficulty with finances. The Story Retelling subtest of the Arizona Battery for Because individuals with dementia are older. word-finding problems. Note that assessing mental status have been reported to be high individuals with moderate AD remember nothing about the (Farber. in which an individ- ual must think of as many words as possible beginning with Although individual tests are appropriate for domain- the letters F.0) 13. Delis. The rules of phonol- Folstein.g.. and age- story in the delayed condition.0) 12. & Folstein. and education-adjusted norms have been reported (Crum.1 (6. and takes 5 to 10 minutes to test battery for patients with dementia. and the Arizona Battery for Communication Franssen.4 (4. Because verbal-fluency performance involves recruitment of Pragmatic and semantic skills are more vulnerable to multiple cognitive systems. reliability and validity of the measure for clinical settings to assess the cognitive and language abilities .0 (2. tery of tests. calculation. 1967).GRBQ344-3513G-C35[988-1008].1) 2. attention. Improving function in dementia and other cognitive-linguistic disorders. Immediate 14.0 (2. composed of seven stages that include detailed descriptions Semantic verbal fluency requires that individuals produce of functional deficits typical of individuals at each stage of words in a specific category.9) 4. 1990. and S in 1 minute. & Crook. a One of the most commonly used scales to stage dementia series of related ideas of examples of objects in a category. particularly memory Bayles. involve the production of words that begin with a target let- ter. deLeon. dressing. Reisberg. Dronkers. such as animals. 1993) both con- functional abilities (e. are performing a generative task. scious thought. of language and the purpose for which it is used require con- The Mini-Mental State Examination (MMSE. the effects of cognitive deterioration. was developed to better characterize the Disorders of Dementia (Bayles & Tomoeda. & Tomoeda. 1982). Individuals with AD have specific assessment. A battery for testing the communicative func- Patients with PD and those with DLB also are reported to tions of individuals with dementia must contain measures of be deficient on generative naming tasks (Salmon et al. C.3 (4. it is an extremely sensitive indi. Although education may influence examinee A relatively short test that is being increasingly used in performance.6) 0.. An extension of the GDS. The Boston disease severity.3) *NPD  nondemented Parkinson’s disease. Mild and Moderate Alzheimer’s Disease (AD) Patients. An observation scale.6 (3. DPD  demented Parkinson’s disease (Reprinted with permission from Bayles. Schmitt. & McHugh. Trosset. An example of a letter task is the FAS Verbal Fluency Comprehensive Evaluation of Cognitive- Test or the Controlled Oral Word Association Test Communicative Functioning (Borkowski. K.qxd 1/21/08 2:05 PM Page 995 Aptara Inc. & Friedland. 1987). Austin.8 (2. The two most common Ferris. either in writing or orally.9 (3. they severity is the Global Deterioration Scale (GDS. administer. and semantic and pragmatic reasoning should be included in a visuospatial construction. & Logue. Folstein. Koss. TX: Pro-Ed. Tomoeda. & 1983). Benton.5) 1. A. the Functional Diagnostic Aphasia Examination (Goodglass & Kaplan. Ober. and without dementia) are shown in Table 35–3. require conscious attention. and typically do not instrument. 1993). communication) of indi- tain semantic verbal fluency tests. & Spreen. Assessment Staging Scale (FAST. deficits.5) 7. 1996. 1997).3 (4. This is understandable because the content dementia (Azuma & Bayles. For this reason. 1985). 1986). memory. and Parkinson’s Disease Patients with and without Dementia on Story Retelling in the Immediate and Delayed Conditions Old NC Mild AD Mod AD NPD* DPD* Story Retelling. K. to the presence of dementia (Chertkow & Bub. language. Bassett. (1997). Delayed 12. Reisberg. 1993). likely because of frontal-lobe damage. A. & Wilson. on communication. The MMSE comprises 11 items related to ori. Letter-fluency tasks viduals in the more severe stages of cognitive decline. a comprehensive evaluation of language been reported to be deficient in performing both types of and communication abilities is best accomplished with a bat- verbal fluency tests. memory. measures of entation. it is types of fluency tasks are semantic and letter tests. Montgomery. deficits in higher cognitive functions than phonologic and cator of the cognitive impairments of individuals with syntactic skills. 1988.3) 7. 1975) is a widely used screening ogy and syntax are finite. and planning. Ferris. Foreman. Chapter 35 ■ Management of Neurogenic Communication Disorders Associated with Dementia 995 TABLE 35–3 Mean Scores and Standard Deviations of Normal Elders (NC). When individuals Staging Severity have to conceive of and produce.1) Story Retelling. predictable.0 (0.. Generative naming or verbal fluency tests also are sensitive Anthony. Douglas. and reducing demands on episodic and working memory. comprehending to the stimulus question and retention of information over signs. & Stampp. Spaced-retrieval training (SRT) is a technique used to teach For the patient with more severe dementia. and qual. The functional deficits that individuals with dementia expe. Raw scores are obtained from individual subtests sory cues that will evoke positive fact memory. increasingly longer periods of time. and very severe dementia (Bayles & Tomoeda. ory systems. improving function in individuals with AD. Summary scores can be converted to con. activities of daily living. mental status. Panaccio. Therefore. reasoning. Rosen. & Tomoeda. As mentioned previously. and 1985). the Functional Linguistic Com. require little cognitive effort (Schacter. Also of interest to these investigators was whether the effects rience in communication. the pattern of mately 30 minutes and continued for 10 weeks. The battery contains should first reduce demands on episodic and working mem- 14 subtests that yield information about five cognitive con. and fourth. 1984). Great Britain (Armstrong. patterns recall of the training situation. Recognition of residual capacities in Although not considered a comprehensive evaluation mea. Third. involves strengthening of associations. a second new and forgotten information and behaviors to patients test battery was developed. Camp and col- leagues (1996) assessed the effectiveness of SRT to teach cal- INDIVIDUALS WITH AD endar use for improving prospective memory performance. provide activities that strengthen bal episodic memory. increase reliance on nondeclarative structs: linguistic expression. ver. certain aspects of cognitive processing attention. Also. Clinicians ated with mild to moderate dementia. In AD. The validity and relia. 1994). addition to diminished abilities will provide the basis for sure. praxis. Bayles. of the calendar intervention would be maintained at least ity of life result directly from the cognitive impairments that 6 months after training. and healthy or related dementias.and Language-Related Functions of individuals with AD is the Cognitive Subscale of the these impairments depends upon the distribution of the Alzheimer’s Disease Assessment Scale (ADAS-Cog. 1997). Spaced-Retrieval Training 1996) and Australia (Moorhouse. memory systems. tion and then is asked to recall that information repeatedly The FLCI has 10 components that allow quantification of and systematically over time. Stevens. SRT ing care plans. administration of the ADAS-Cog may yield informa. other cognitive areas. Principles for Successful Intervention Bayles and Tomoeda (1993) designed the Arizona Battery of Communication Disorders of Dementia (ABCD) for the Bayles and Tomoeda (1997) propose several principles for purpose of quantifying the communication disorders associ. as well as for designing individualized stimu. and and are converted to summary scores to allow comparisons emotion. Subtests include tasks such as facilitate production of a high number of correct responses greeting and naming. a patient is told a piece of informa- munication Inventory (FLCI. Additionally. Borthwick. 1990) and develop. lexical and conceptual associations. & Steel. and comprehension (following commands). and construct improve or maintain cognitive-linguistic abilities of individ- scores can be summed to obtain a total score for the com. Bayles and Tomoeda. linguistic comprehension. Application of these principles to treatment can help to struct scores. and visuospatial con. 1997). successful interventions for individuals with dementia. memory. despite severe impairments in (naming). This test includes items related to dementia. because strength of of responses to test questions can be profiled to determine association between concepts in semantic memory depends intra-individual communication strengths and weaknesses. PD. Treatment sessions lasted approxi- define dementia. and can occur without the patient having explicit has established reliability and validity. action. In SRT. O’Hanlon. Rich. provide sen- struction. tion on cognition and language useful in structuring further in-depth assessment. 996 Section V ■ Therapy for Associated Neuropathologies of Speech. on how often they are activated. young and elderly control subjects in the United States. 1996). SRT is considered to ences in patients with moderate. uals with AD. increasing reliance lation and activity programs for individuals with moderate on implicit memory expression (Camp. Morris et al. Clinicians may use SRT to teach individuals with demen- BEHAVIORAL TREATMENT FOR tia new information and helpful behaviors. reminiscing. and the test has been been utilized to improve functioning of individuals with AD standardized on individuals with AD. language production remain relatively preserved. Each session . moderately severe. between subtests. & and severe dementia. In the following section. accessibility (Bayles & Tomoeda. neuropathology associated with different diseases that cause Mohs. are reviewed in which one or more of these principles has bility have been reported to be high. Second.. Intervals are manipulated to linguistic communication. 1999). severe. with dementia. repeatedly bringing into These profiles are extremely useful for completing the consciousness these associations will result in their increased Minimum Data Set (MDS. for interconstruct comparisons. The test battery is sensitive to differ. Foss. several recent studies plete test (Bayles & Tomoeda. writing. 1994). & Davis.qxd 1/21/08 2:05 PM Page 996 Aptara Inc. and gesturing.GRBQ344-3513G-C35[988-1008]. (1998) conducted a study with nine participants: seven with Once calendar training was successful. Vanhalle. In conclusion. and moderately severe dementia were able to recall the number). To demon- ticipant could recall the strategy after a 1-week interval. If a response was incorrect on any trial. 1999) for SRT with people who have examiner. teaching the patient to recall new names..g. Camp. mance of activities of daily living (ADLs) of individuals with Other functional information also has been taught to mild to moderate AD. the participant was given a dollar. on the SRT task and that more severe memory dysfunction Magni. using SRT to teach coupon to the experimenter at the start of the following compensatory strategies that enhance communication is a week’s session. The three pieces of up visits showed that calendar use continued well after com. such as . information were taught sequentially. they may show an increase in the number of cor- The results again showed that individuals with AD could rect responses produced and exhibit a change in the trained learn to perform a task following intensive training. Five of the participants with dementia completed the McKitrick. Although patients may not remember the specific episodes sively. All learned the three pieces of information but had study in which prospective memory was targeted. therapy. coupon for money. a delay was followed by another recall trial. varying levels of recall of the information at 4 weeks post- viduals with mild to moderate dementia participated. Although participants did not consistently perform tasks on Successful recall of the information at the beginning of two each day. and a compensatory technique that was being calendar strategy over a 1-week period.. and Black (1992) also conducted a study. and involved teaching cessfully completed the study and demonstrated consistent subjects verbal and motor responses necessary to redeem a recall of the information at the 4-week follow-up probe. (i. If the response found that the patient was affected by proactive interference was correct. SRT within the speech-language therapy session. ness in aiding performance of prospective memory tasks in Three pieces of information were taught to each partici- daily life (e. Chapter 35 ■ Management of Neurogenic Communication Disorders Associated with Dementia 997 started with the prompt question “How are you going to Linden. pletion of the study. strate the utility of SRT in this context. and Gilbert (1998) used SRT to teach remember what to do each day?” The participant had to face–name associations to a dementia patient. learning of previous items interfered with the learning Intervals were increased if the participant continued with of subsequent items). This finding suggests that level of cogni.. Ten individuals with AD were trained individuals with dementia using SRT.g. cally procedural memory skills. actually performed better on the task than the two Treatment approaches that draw on spared abilities. Zanetti. Two of Capitalizing on Spared-Memory Processes the participants. In this way. Four indi. Different colored coupons were trained to criterion succes. promising technique for speech-language pathologists. Belleville. Van der to perform different basic and instrumental ADLs. moder. practiced in speech-language therapy sessions (e. SRT for each piece of information. using a pants used the calendar to remember to perform daily tasks. The researchers reviewed 15 studies [pink] coupon”). Bianchetti. Binetti. the SRT technique was successful in correct responses. ered important to the person (e.e. To be successful. who had the lowest cognitive functioning scores. walk the dog. the participant had to hand the AD or a related dementia.qxd 1/21/08 2:05 PM Page 997 Aptara Inc. The goal was teach each patient to complete two tasks on each page of the to assess the effect of SRT with memory disordered patients daily calendar. Rozzini.. of learning. and two patients additional therapy. describing an item when unable to name it). and some partici. have been shown to be effec- tive function may not be the only predictor of performance tive when used with individuals with AD. The motor response consisted of having that were judged to provide Class II and III research evi- the subject select the correct coupon and hand it to the dence (Miller et al. of the participants required only one session of therapy. Brush and Camp SRT was terminated. the experimenter provided the correct answer and then SRT can be implemented in the context of other activi- immediately repeated the prompt question.GRBQ344-3513G-C35[988-1008].g. the investigators were able to of different etiologies. room ate. ties. write a letter). whereas one subject required five training sessions. pant: the therapist’s name. Three behavior. The two patients who had suffered strokes also suc- Sessions were conducted once weekly. a personal fact that was consid- Results indicated that the individuals with mild.. they showed improvement in using the calendar to consecutive sessions was criterion for completion of the carry out the majority of the noted tasks. Although they answer “Look at my calendar” to be correct. wife’s birthday. and to examine the application of teach the implementation of the skill and evaluate its useful. and Trabucchi (1997) assessed does not prevent the learning of some types of factual and the effects of procedural-memory stimulation on perfor- procedural information. such as speech-language therapy sessions. In return. was provided to with memory disorders resulting from stroke. louder voice. specifi- with higher scores. Six-month follow. one session per week. When the par. up to 5 weeks of memory deficits resulting from dementia. SRT was used to first teach participants The aforementioned studies were included in a system- a verbal response to the prompt question “What are you atic review of the literature on SRT conducted by Hopper going to do when I come back next week?” (“Give you the and colleagues (2005). consist- systems and that may be beneficial for promoting new learn. although practice rials in the form of wallets with photographs. including tests of skill-learning. Wilson (1994) suggest that individuals with episodic mem. demonstrated some generalization from the weeks. rather than AD and their caregivers were trained to use the memory learning from the errors and making corrections. Next. and data were col- are allowed to occur during learning trials. These manipulation of stimulus characteristics and response con- measures were given at the beginning and end of the treat. Wilson. No significant differences evant information. and to investigate ing learning trials because they cannot explicitly recall the whether training the use of the wallets was necessary for learning experience. strain errors through practice of correct responding over After 3 weeks of training. Therefore. Hodges. 1994). pants generated more novel. Also. individuals with dementia by capitalizing on spared recogni- dural aspects of tasks may be an effective technique for tion memory and decreasing demands on impaired episodic improving performance of individuals with AD. For example. information. Gosses. these preliminary results provide evidence Bourgeois (1990. The and working memory systems. with patients making more novel. although a statis- Reducing Demands on Episodic and Working Memory tical trend for improvement by patients on the lexical prim- Systems: Using Recognition Memory ing tests was reported. ropsychological batteries. Bourgeois (1992) sought to replicate ory impairment have difficulty eliminating errors made dur. these individuals continue patients to use them effectively. Clare. The experimenter served as the communication Hodges (1999) used errorless learning principles. subjects made significantly error” techniques to promote learning. 2000. memory books for individuals with tasks in significantly less time than they did at baseline test. Positive treatment effects were The errorless learning technique has been used success. Baddeley and more statements of fact and fewer ambiguous utterances. errorless rather than episodic memory processes (Zanetti et al. and retained the ties. The term “errorless learning” does not connote a stan- word-stem completion (a measure of lexical priming). dementia contain printed and pictorial materials to reduce ing. Wilson. The time taken for patients in both groups to positive results of errorless learning paradigms reported by perform the trained and untrained activities was recorded. the authors (Clare. learning principles were the core component of the instruc- Specifically. Evans.qxd 1/21/08 2:05 PM Page 998 Aptara Inc. Training sessions were structured such that makes it difficult to attribute the improved performance performance would be more dependent on procedural solely to reduced errors during learning trials. on-topic utterances when the old man with early AD to learn the names and faces of mem. 1999). wallets were used in conversation. spaced-retrieval training may con- ment program. In 1990. ing of pictures of events and persons the patient could not ing by individuals with AD is errorless learning. This approach lected on communicative behaviors that occurred when the differs from usual protocols for rehabilitation of memory wallets were used in conversation. Carter. Baddeley. When caregivers used the and language deficits in that it does not involve “trial and memory wallets in conversation. Over 3 associations. tingencies. and the other five patients were trained on activities in information for 9 months. Two of the partici- junction with several other techniques. Although limited by the absence of a control group. to teach a 72-year. Three subjects effects may have contributed to improved performance. pictures to real faces in the environment. Although the design of the study the second set. 1994. although the third .. five patients were trained on the first set of 10 activi. obtained. Subsequent studies have been conducted and form any task. Initially.GRBQ344-3513G-C35[988-1008]. An individualized Another technique that capitalizes on spared memory memory wallet was assembled for each AD subject. Breen. she studied the improvement on the untrained tasks may have resulted from effect on conversational ability of providing stimulus mate- generalization from trained activities. Breen. Caregivers were trained to use the memory wal- learning involves minimization of the number of errors that lets in conversation with the subjects. Errorless remember. Winter & Hunkin. in con. 1997). verbal cues and prompts were provided during tion and clearly contributed to learning and retention of new tasks. 998 Section V ■ Therapy for Associated Neuropathologies of Speech. six patients with to make the same errors on subsequent trials. and patients were not asked to remember how to per. three additional participants technique has been applied to memory rehabilitation with with AD were given memory wallets without any specific individuals who have AD. ments and fewer ambiguous statements when wallets were Wilson. and recently the used in conversation.and Language-Related Functions washing the face and using the telephone. the treatment effects of the first study. 1992) has improved the functioning of that ADL training that is focused on the motor or proce. patients performed the trained several trials. Twenty activities bers of his social club. wallets in conversation. and dardized treatment program but a practice achieved through paired-associate learning (a test of episodic memory). The subject learned the name–face were chosen for treatment and divided into two sets. on-topic state- fully with amnesic patients (Baddeley & Wilson. & Other outcome measures included performance on neu. & Shiel. They also showed a significant improvement in the time effort and errors associated with free recall of personally rel- taken to perform untrained tasks. between scores on neuropsychological tests administered before and after treatment were obtained. partner during this phase of the study. In a second study. and training. and their spouses participated in the study. versational group therapy. Five studies met criteria for inclusion in the to questions. Cleary. and reduces demands on episodic and working lets improved communication even when participants were memory by using structured tasks and repetition. Action. Camp and colleagues (1997) describe intergenerational Positive results have been reported in subsequent studies Montessori programming between individuals with demen- by Bourgeois and other researchers (Hoerster. reading aloud). action. Bayles. five vention developed and described by Camp and colleagues days per week for 12 weeks. stimulation of positive emotions. spared reading ability and may promote positive reminis. Four groups of five mid-stage ence of individuals with AD is the Montessori-based inter. & tia and children. for the use of Montessori programming for individuals with The results lend support to the use of tangible stimuli. Results showed that individuals when four patients with AD were given dolls and stuffed ani- participating in the Montessori group activities were more mals. the photographs stimulated activities (e. primary measure of interest was “disengagement. 1985). participation. and decreased agitation adult day-care activities. Hopper. The recognition of episodes and people in the patients’ lives. and . Disengagement was defined as time spent staring into space ing conversations about remote and recent events (episodic for at least 10 seconds or sleeping (Camp & Brush.” reducing the reliance on free recall that usually occurs dur. adults and children were matched according to by individuals with AD and communication partners acted cognitive level. Activities in the Breakfast Club were based on facilitation motes learning through procedural memory processes. The memory wallets used In the study. and Mahendra. Santo Pietro and Boczko (1998) compared the effectiveness of different group therapies for individuals with AD. and Emotion Camp and Brush (1998) also reported on the use of Montessori-type tasks in group activities for individuals with Providing sensory stimulation to evoke positive-fact mem- dementia in skilled-nursing facilities. and four matched control (1997). with the adult being more advanced cogni- as tangible stimuli that remained visible in a conversation. the time spent actively and passively engaged during regular increased smiling and nodding. Montessori activities were originally developed for groups participated in conversation groups at the same fre- children and include materials and tasks that require active quency and duration. of procedural memory. indi- AD or a related dementia.GRBQ344-3513G-C35[988-1008]. Results showed that when the adults were working with the cence and emotion. Bourgeois. The use of pictures and sentences about familiar Five-minute observation intervals were used to record data people and places in patients’ lives capitalizes on often on the amount of time individuals with AD were disengaged. suggesting that the use of memory wal. Judge. programming. Generally. 1986. In a single-subject experiment. Hopper. Chapter 35 ■ Management of Neurogenic Communication Disorders Associated with Dementia 999 participant’s behavior was more variable. and emotion is an important principle in the ties. and Kim Tomoeda (1998) showed that using toy stimuli improved the (2006) conducted a systematic review of Montessori tech- amount and quality of language produced by four females niques conducted individually and in groups for individuals with moderate to moderately severe dementia. vidualized according to patient preferences. and ing Montessori activities. Investigators col- ple with AD in the more moderate to advanced stages are lected data on the amount of time individuals spent in active given stuffed animals as companions or decorations in their engagement (defined as verbal or motor activity focused on rooms. Multicomponent Treatment Programs Outcomes of a group communication therapy called the A program that is based on several of the aforementioned “Breakfast Club” were compared to those of “standard” con- treatment principles and that capitalizes on the life experi. sorting. individuals with AD participated in the Breakfast Club. memory). In these group activi- ory. 2001. Holmes. In response with dementia. Azuma. the utilizes concrete everyday stimuli to facilitate action and results were positive. Gilbert. children. Memory.. and the positive results from a pilot study. peo- (see Orsulic-Jeras. Bayles. Hickey. matching.g. tively than the child. Bailey. memory. Other researchers have noted similar outcomes actively engaged than those who participated in the regular (Francis & Baly. no instances of disengagement were observed. Results of several case studies and anecdotal reports the environment) and passive engagement (defined as pas- support the use of such stimuli to improve communicative sively observing what is going on in the environment) dur- function of individuals with AD. when attempt- In another type of multicomponent treatment program. The use of Montessori programming pro. 2000). Additionally. 1998). This pairing allowed the adult to act as alleviating the demands that conversation typically places on a mentor and teacher to the child during the Montessori working memory. the subjects produced more information units review and were judged to provide Class II and III evidence when toy stimuli were present than when they were absent. not trained in their use. Frequently. engagement was a primary treatment outcome measure management of individuals with dementia.qxd 1/21/08 2:05 PM Page 999 Aptara Inc. & Camp. Milton & MacPhail. in contrast to the times when adults were not working with the Using Sensory Stimulation to Evoke Positive-Fact children and episodes of disengagement were common. and compared those instances to Herweyer (1992) observed improved levels of alertness. 2000). ing to improve conversation and social interaction. the patients in the treatment group had signifi- Quayhagen. although their performance returned to improvements for Breakfast Club participants were noted. paired choices. verbal fluency. based intervention program of active cognitive stimulation col to facilitate communication. and control groups. weeks of treatment. and Interestingly.qxd 1/21/08 2:05 PM Page 1000 Aptara Inc. some recent activities. including cog- programs. Memory Individuals in the control conversation group sat at a techniques were characterized by the recall and recognition table with a clinician who facilitated conversation by intro. Patients in all three groups were tested at to cognition. Results showed that individuals control group declined on all measures. physical. instead of playing the game “Hangman” in the experimental treatment scores on the Arizona Battery for Communication group. Fruhwald.and post. Pairs of individuals with AD were introduced and the group members engaged in the and their primary caregivers were assigned to experimental. and clean-up. problem-solving. manual/creative impaired in dementing diseases. Topics related to breakfast provided by family caregivers. and Rodgers (1995) cantly better scores than the people in the functional group produced preliminary evidence that intensive cognitive on measures of cognition. and the for therapy sessions after the study was completed. eating. Multiple Communication Outcomes of Communicative and behavioral and cognitive measures were used to assess inter- Functional Independence Scale (COMFI. 1993). rehabilitation. and measures of depression. communication and three points in time: on entrance into the study. and self-management tasks.GRBQ344-3513G-C35[988-1008]. Santo Pietro & vention effects on memory. including increased interest and involvement in meal-time Bach. and 6 months after completion ber of incidents of “cross-conversation” between members (Quayhagen et al. 1000 Section V ■ Therapy for Associated Neuropathologies of Speech. familiar task of choosing and preparing a breakfast. and included a 10-step proto. and key-word visual to match experimental interventions. decline associated with dementia. The placebo group ducing a topic for discussion. measures of psychosocial function. ties in which the patient had to participate actively. Corbeil. within a group was compared. Several other within-group function on others. Language was elicited using engaged in more “passive” interventions that were designed open-ended questions. Most investigators have favored procedures and programs and speech therapists. The results showed that both groups had sig- nificantly higher levels of cognitive performance and a Strengthening Associations through decrease in depressive symptoms after 24 weeks of treatment. group. language skills. The control-group families were placed on a wait list Disorders of Dementia (Bayles & Tomoeda. and meal-time independence. the num. 1995). after 12 conversation. nitive tests. and yet not require prompts. have beneficial effects for individuals with AD has led .. a caregiver rating scale with 20 items related and attention. Cross-conversation was The individuals with AD who received the active cogni- defined as any utterance between one group member and tive stimulation showed no decline from pre to post-testing another. and was used as a measure of social awareness on the measures of global cognitive functioning. The subjects group activities and the Breakfast Club were effective in were randomly assigned to a control group or a treatment promoting meaningful change in the cognitive and commu. Also. in addition to twice-weekly small-group attempted to directly stimulate the cognitive processes treatment consisting of memory training. Bach. including tasks from occupational. The control group received 24 weeks of “functional” nicative abilities of individuals with mild to moderate AD. semantic associ.. and maintained their pre-treatment level of cognitive improvement on any measure. Boczko. active participation by the subject. 1995). The placebo group in the Breakfast Club exhibited significantly improved declined on some measures and remained stable on others. problem-solving. Roth. placebo. language was elicited by the clinician who group were trained to provide 60 minutes of “active” cogni- “facilitated” conversation using visual cues. Social conversation was encouraged during greet. The treatment group received the same that focus on relatively preserved skills and have not functional treatment. For example. and depression (Bach et al. and Grilc (1995) also activities. whereas the and communicative ability. However. baseline levels at the 9-month probe. Quayhagen. measures throughout treatment and for a period after treat- bers in the standard conversation groups who showed no ment. Several measures were research provides encouragement for cognitive-stimulation used to assess change as a result of treatment. compared the effects of two treatments on the function of 44 The multifaceted approaches underlying the Montessori individuals with mild to moderate dementia. and paired-choice questions during meal prepara. of verbal and visual information. sisted of memory. psychosocial behavior. These researchers sought The recognition that cognitive-stimulation programs to determine the impact on individuals with AD of a home. Cognitive Stimulation However. and conversation activi- tion. tive stimulation. patients ing and leave-taking. might watch “Wheel of Fortune” in the placebo group Group differences were compared using pre. subjec- therapy may slow the general cognitive and behavioral tive well-being. 1997). Families in the experimental Throughout. Bohmer.and Language-Related Functions strengthening of associations. improved functional independence. the experimental group improved on some increased use of cross-conversation as compared to mem. The cognitive-stimulation program con- ations. psychosocial functioning. Promoting Generalization Choosing treatment behaviors that are functional and impor- A primary goal of any cognitive-communication interven. an semantic information regarding any word they wished to acetylcholinesterase inhibitor prescribed for people with AD. showing transfer of the trained response munication disorders and strategies for improving commu- to an untrained context. monly used. sometimes more than 10 years. retrieve” (p. individuals with dementia. Introducing natural maintaining contingencies involves teaching the patient behaviors that will be reinforced in the natural environment. Results Response generalization is the occurrence of untrained revealed that role-playing was more effective than lecture responses or behaviors as a result of training other. The ated with dementia may prevent robust response generaliza- tasks included discussions about current events. yet frequently ineffective. thus demonstrating response generaliza- The participants were randomly assigned to a control group tion. The Program A was traditional in-service training (i. and therefore is worth inves- tigating. playing (i. Little situation (Bourgeois. it is highly desir- of dementia leads clinicians to think that generalization over able to include caregivers in the treatment program. tating generalization. Nash. although . and their problem-solving skills. responses or behaviors (Thompson. n  28) and a treatment group (donepezil Stimulus generalization may be the more appropriate plus stimulation group. To assess generalization and maintenance of treat. is a com- after the end of the 2-month stimulation program). measure for documenting the effects of treatment of individ- tion stimulation program consisted of activities implemented uals with dementia. that can be used in different stimulus situations. hobbies or work). Stokes and Baer (1977) recommend strated a slower rate of decline than did participants in the several techniques for facilitating generalization. with the clinician. and overall functioning. Rackley.. members. Further.GRBQ344-3513G-C35[988-1008]. common stimuli during treatment. The cognitive-communica. communication.e. and quality of life at baseline. Similarly. and aphasia to use a semantic-features diagram to aid in self-cue- Zientz (2004) recruited 54 patients with mild to moderate ing and naming. related for promoting a change in employee behavior. They time is unrealistic. who later asks for help outside of the Outcome scores on a test of knowledge of geriatric com- treatment session. these behaviors will be maintained outside of the treatment tinuance after the intervention is discontinued. in which clinicians symptoms. Chapman. generalizes to dif. emotional and hope” (Stokes & Baer. n  26). One group of nursing assis- taught a strategy for requesting help in a treatment session tants received no training.e. lecture format) and Program B involved in-service role- ferent stimulus conditions. 1-hour training with the focus on enacting sit- ization is exhibited by the patient with dementia who is uations and problem solving). 110). stimulus general. Lowell. (donepezil only.. such as names of family tures). be focused on trained responses. grams in conjunction with commonly prescribed medica. Weiner. as the multiple cognitive deficits associ- in a group format for 12 hours over a 2-month period. and Lubinski (1991) have evaluated different ment effects. Thompson. sessions (Olswang & Bain. personal narratives with pic. Treatment and measurement of generalization should related to AD. Koury. A treatment that improves function for several months can improve quality of life and Caregiver Training Programs reduce demands on caregivers. cognitive status occurs gradually. among control group on caregiver interview and standardized mea. situations. and change in with opportunities to strengthen their communication skills. life stories (i. them the introduction of natural contingencies and the use of sures of discourse abilities. the use of common research has been conducted to determine the factors that stimuli increases the probability that the individual with promote generalization and maintenance of behaviors in dementia will exhibit trained behaviors in other contexts. or materials than those used in treatment communication disorders. the progressive nature Given the importance of generalization. The “train measured aspects of cognition. 1989). The investigators followed the participants for 1 year and Clinicians need to program for generalization. nication were compared before and after treatment.. Beeson. ADLs.e. 8 months. the duration of dementia can can learn to promote generalization and provide patients be quite long.g. information tion. 4 months (1 month conduct treatment and hope for functional effects. 1994. However. Participants in the treatment group demon. 1977) method.qxd 1/21/08 2:05 PM Page 1001 Aptara Inc. 1-hour trained response. Hynan. Chapter 35 ■ Management of Neurogenic Communication Disorders Associated with Dementia 1001 researchers to investigate the combined effects of these pro.. and Holland (1995) taught patients with tions to treat AD. Two of the three subjects used the schema AD to participate in a study to assess the effects of combining to improve naming of trained items as well as to “generate cognitive-communication stimulation with donepezil. or treatment behavior. These researchers investi- Stimulus generalization is the occurrence of trained gated the effect of two training programs on nursing assis- behaviors in nontraining conditions that include different tants’ interactions with patients. For example. methods of training nursing staff to communicate effectively ulus generalization rather than response generalization. their knowledge of geriatric people. with individuals with dementia. For example. procedure for facili- and 12 months. 1991). and life-interest topics (e. tant to patients and caregivers increases the likelihood that tion is the generalization of treatment effects and their con. 1989). consider evaluating behaviors that reflect stim. 1002 Section V ■ Therapy for Associated Neuropathologies of Speech. Doing volunteer work in partnership with uni- individual (BW) with moderately severe dementia (Mini. FMT typically consists of an other residents in nursing homes. Gillespie. and reading short passages of scribed by clinicians. givers. vide memory and language stimulation.qxd 1/21/08 2:05 PM Page 1002 Aptara Inc. Hopper. This case illustrates the benefit of collaborating with viduals with AD (Ripich. Individuals with mild to mod- pathologists who work with individuals with dementia in erate dementia are paired with university students who assist skilled-nursing facilities under Medicare reimbursement them in performing weekly volunteer services and who pro- policies is through functional maintenance therapy (FMT). and Tomoeda (1998). and three of four patients. at day-care centers. Memory and language evaluation by the rehabilitation professional. how to solve real-life problems. The patient tences. which was used consistently during training. Knowledge of communication strategies pockets” or “put them on my lap.and Language-Related Functions nursing assistants in the lecture group also showed improved 1975) was reported by Bayles. (U) unstick to teach him transfer strategies. sions. up. Volunteer activities Glickstein and Neustadt (1995) define FMT as a program are tailored to each patient’s preferences. from treatment. Eight behaviors to the natural environment. their implementation. BW was living at home with tance of staff training in creating a supportive communica. You go to sit down. from his chair to the bed. would make it impossible for them topic. the word FOCUSED refers to a strategy for improving com. BW was admitted to the hospital tionalized individuals with dementia. simple sen. substantially increased their recall of biographical facts An example of a functional maintenance program for an (Arkin. and (D) direct. using the spaced-retrieval training (SRT) encourage interaction. technique. (E) exchange conversation and ily caregivers. The speech-language any communication blocks. Audio-taped quiz tasks (Arkin. Cleary. 24-hour care. and then discharged to a skilled-nursing facility Ripich (1994) developed a functional communication pro. Arkin (1995) pro- Functional Maintenance Therapy vided a model for the use of volunteers with her Volunteers The primary avenue of service delivery for speech-language in Partnership (VIP) program. Such an approach is patients produced more information units during picture preferable to one in which the planning takes place only description. a pilot study was conducted. was prompted with the stimulus question. see Zientz and colleagues (2006). for short-term rehabilitation. who used memory when the patient is discharged from therapy. The ogist evaluated BW and spoke with caregivers about tech- seven-step program is called “FOCUSED. and include helping for individuals with chronic conditions who need interven. after only eight was measured before and after completion of the training. seven of eleven patients produced other short-term treatment programs necessitate early plan. Further positive treatment caregivers to promote improved functioning after discharge effects associated with FOCUSED were noted by Ripich. it provides respite for family caregivers. In a pilot program. (C) continuity of topic and concrete topics. Collaborations with activities personnel and recruitment of volunteers are two other ways to extend services to individu- als with AD following skilled treatment. The FOCUSED training program is divided into six. more on-topic utterances in response to questions about spe- ning and inclusion of caregivers for carry-over of treatment cific topics. (O) orient to a moderate hearing loss. to teach a “safe transfer” maneuver. followed by tasks are designed by the clinician and students are trained in the development. until he fractured his hip while transferring tion environment and improved quality of care for institu. “You are standing 2-hour modules designed for family and “formal” caregivers. What do you do with your hands?” To test its effectiveness. are used to teach factual information.. 1992) tation of a treatment program. sessions of SRT. solicitation by the student of opinions or advice about role. Initially. 1995). versity students not only stimulates individuals with demen- Mental State Examination score of 9/30) (Folstein et al. for 3 days. and assisting tion by skilled professionals.” Each letter in niques to improve communication during transfers. The speech-language pathol- gram for training caregivers of individuals with AD. and anecdotally ized this strategy to everyday situations when cued by care- reported increased satisfaction during interactions with indi. For a review of caregiver education and training programs and the Use of Volunteers in Treatment with Dementia evidence for their use with caregivers of individuals with AD and related dementias. and language is stimu- gists and other rehabilitation professionals increasingly pro. Wykle. short. (S) structure with yes/no and pathologist worked with the physical therapist and the fam- multiple-choice questions. lated through activities such as association. Mahendra. caregivers must be trained to carry out treatment pre.GRBQ344-3513G-C35[988-1008]. test performance.” However. working at animal shelters. the Seventeen nursing assistants completed the FOCUSED patient responded with statements such as “put them in my training program. and short-term implemen. picture descrip- vide services to individuals with dementia in a consultant tion. Functional maintenance therapy and text. . Caregivers were concerned that his dementia. tia. tapes. As speech-language patholo. such as President Kennedy’s assassination. coupled with munication: (F) functional and face-to-face. he learned to reach back with his hands and general- municative strategies following training. and correct responding in the therapy ses- The participants demonstrated increased knowledge of com. 1994). These findings underscore the impor. establishment. and Niles (1995) and Ripich and Ziol (1999). 2005). such as degree of memory impair- With knowledge of preserved abilities and effective inter- ment. Dementia is a syndrome associated with several dif- quate with patients whose impairments are progressive. measures of quality of life. particularly improvement on specific treatment tasks. Knowledge of these patterns is necessary to provide cation problems of individuals with dementia has increased appropriate assessment and treatment services. However. however. this population. despite exhibiting frequency. 3.and post-standardized tests of memory and lan- individuals with dementia can be minimized. Specifically. Individuals with dementia develop multiple cognitive deficits and therefore problems in communicating. degree of caregiver support. Future research should examine treat. making it difficult dementia is especially challenging because intellectual dete- to extend results from working with individuals who reside rioration is progressive. (b) tells when and where he . ACTIVITIES FOR REFLECTION AND DISCUSSION Data are needed from large numbers of individuals with dementia to support treatment for individuals at different 1. most of the treatment studies are other diseases that cause dementia? reported in this chapter involved participants with mild to 2. Since and impaired cognitive abilities. of activities and participation levels of functioning (World Speech-language pathologists can make important con- Health Organization. treatment sessions. Assessment of cational background and expertise of the person providing change as a result of treatment should include consideration the therapy still require systematic investigation.. and skills or behaviors taught in therapeutic interventions. b) regarding must evaluate patient function in personal activities the roles of SLPs working with individuals who have and participation in daily life. the most common of which is Inclusion of multiple measures allows the clinician to deter. assessing change with vention principles. Positive out- guage will not capture the improvement that individuals comes of behavioral treatment are promising and provide with dementia may exhibit in conversational ability. Bourgeois reviewed the meager literature on dementing diseases explains the patterns of spared behavioral treatments for individuals with dementia. and type of therapy. The distribution of neuropathology of the various In 1991. What stages of decline. Alzheimer’s disease.GRBQ344-3513G-C35[988-1008]. Future researchers should continue to focus on factors that influence patient performance in behavioral therapy. 5. Bayles et al. type of dementing illness. 2005 a. will be insufficient. Individuals with dementia can learn new information development of practice guidelines for speech-language and behaviors with appropriate therapeutic tech- pathologists working with individuals with dementia (see niques. intensity. enough literature exists to support the 7. 2001). treatment. Focusing KEY POINTS solely on improvement in the amount or degree of deficit as a means of demonstrating improvement in therapy is inade. including stage of cognitive decline. as Camp and colleagues at home to patients living in long-term-care centers. The functioning of individuals with dementia can be with dementia can improve function and maintain abilities improved by capitalizing on spared memory systems longer when they participate in cognitive-communication and reducing demands on impaired memory systems. In fact. Generally. dimension of function. Chapter 35 ■ Management of Neurogenic Communication Disorders Associated with Dementia 1003 Measurement Issues ment of individuals with moderate and moderately severe dementia. ferent causes. However. Explain the difference between dementia and AD. as well as the edu- an overall decline in cognitive function. To measure change as a result of therapy. rather than focusing dementia and the theory and evidence for clinical work with solely on level of cognitive impairment. quality and quantity of communicative interactions. Evaluating change in one tributions to the well-being of individuals with dementia. FUTURE TRENDS IN TREATMENT RESEARCH 4. the steps in changing a tire. Individuals with dementia are the profession’s fastest behavioral change. level of engagement and activity participation. Also. 1. and change in behav- ior may reveal the positive impact of treatment. mine treatment effects by providing converging evidence of 2. What kind of memory is used when a person (a) explains moderate dementia. profile of cognitive deficits. differences exist between institutionalized Measuring the effects of treatment for individuals with and non-institutionalized individuals. clinicians statement and technical report (ASHA. growing clinical population. the cognitive-communication deficits of only pre. affect the foundation for continued investigation of effective and level of engagement. and results of studies to date suggest that many older adults 6.qxd 1/21/08 2:05 PM Page 1003 Aptara Inc. individuals with AD can demonstrate Characteristics of the learning environment. and ASHA has published a position 8. and type of living situation. 1991. 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(1979)... L. (2006). (1998). J. M. & Bayles. (1994). 1. changes in normal human aging and Alzheimer’s disease. population based study in ambulatory and institutionalized Winter.. B. Procedural memory stimulation in University Press. & Corey-Bloom. G. J. 15(1). Psychiatry. Acta Uylings. Neuronal Neurologica Scandinavica. & de Brabander. Alzheimer’s disease: Impact of a training program. Generalization 8(4).C. 729–735. 1008 Section V ■ Therapy for Associated Neuropathologies of Speech. Geneva. Letenneur. Psychological Medicine. Brain. A. (1999). 45. (M1) cortex. To provide suggestions for assessment of apraxia of Lemieux. have revealed a Damage to the language-dominant hemisphere may result speech production network that includes the primary motor not only in aphasia but also in neuromotor speech disorders. Jones. 2. 2001). programs and measuring treatment effects. as well as scores of earlier lesion. functional magnetic resonance brain networks play in speech production. To provide evidence from the literature that argues for tigate the structural and functional neuroanatomy underlying the hypothesis that motor speech deficits resulting from speech and language. erful tools for studying speech behavior in humans in vivo. and magnetoencephalogra- 5. 2001). and post-mortem studies on humans. and this chapter will serve to 1. ani- mal. based upon functional neuroanatomy. 2005). the cerebellum. rologic bases of motor-speech production. These new studies. keeping with previous editions of this text. Each of available for AOS along with a description of the ratio. specifically speech movement. speech and language is rapidly expanding and changing. imaging (fMRI.. Schulz. Square. e. Bohland & Guenther. Hoshiyama. the left cerebral cortex in the control of movement. the left posterior inferior frontal gyrus.. & Bose. most probably because of the overlap of AND FUNCTIONAL NEUROANATOMY several of the neural substrates mediating linguistic and In the past few years. this chapter will motor speech disorders that co-occur with aphasia and to provide the reader with current information concerning make appropriate management decisions based upon the developments in our understanding of the underlying neu- current available evidence. Whereas it is well accepted that the dominant hemi- sphere is crucial for both language and motor-speech func- OBJECTIVES tioning (Square et al.g. medial premotor areas. 2006. using a variety of (mainly noninvasive) technologies to inves- 3. heterogeneous because of the varied roles that different Ludlow. early reports of neuromotor speech disorders associated the left parietal cortex. our knowledge concerning the structural and functional neuroanatomy associated with The primary objective of this chapter is to provide the clin. To demonstrate. the left superior temporal gyrus with dominant-hemisphere damage (Square & Martin. the basal ganglia. these technologies has its drawbacks. & Kakigi. and the thalamus. lateral Previous editions of this text have provided summaries of premotor areas (PM). e. Catani. MOTOR-SPEECH DISORDERS that neuromotor speech impairments are probable in many patients with acquired brain damage that pro- ACCOMPANYING APHASIA: STRUCTURAL duces aphasia.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1009 APTARA(GRG QUARK) Chapter 36 The Nature and Management of Neuromotor Speech Disorders Accompanying Aphasia Julie Wambaugh and Linda Shuster 1994. however. To provide a summary of the techniques and treatments phy (MEG. Varga. & ffytche. & Braun. In ician with the information needed to understand the neuro. they are pow- nale underlying those treatments. Shuster & 4. there has been an explosion of studies motor behaviors. 2004). 2001). 2005).. Jeffires. To achieve this overarching goal. the left insula. 2005). and the reader is referred to those sources for historical accounts of these dis- orders. Martin. To provide readers with an understanding of the role of inform the reader about treatment advances. speech (AOS) for the purposes of developing treatment Watkins & Paus. 1009 . Progress has also the following objectives were specified: been made relative to the management of neuromotor speech disoders in aphasia. diffusion tensor imaging (DTI. transcranial magnetic stimulation (TMS. Gunji. (STG).g. These technologies include positron damage to the dominant hemisphere are likely to be emission tomography (PET. & Fitzpatrick. The pyramidal cells (also called Betz cells) Figure 36–1. We describe the corti. that there is a tight coupling between the 2000. it networks involved in speech perception and speech produc. corticospinal tract. While there is still much to be dorsal and ventral premotor areas on the lateral surface of the learned. Area 44  Broca’s area. In a recent study using cortical stimulation in patients with epilepsy who were undergoing surgery. evidence continues to accumulate in support of including Brodmann’s area (BA) 1. Brodmann’s areas of the human cerebral cortex. also receives direct inputs from four premotor regions: the tion (Watkins & Paus. 2. M1 provides direct outputs to of the precentral sulcus in area 4 of Brodmann’s cytoarchitec. M1 receives direct tract and to spinal motor neurons in the spinal cord via the inputs from somatosensory regions in the parietal lobe. Cortical motor fields are also indicated. as well as the view. Lateral view. (Adapted from Brodmann 1909. A. 2001). as well as how lesions to on the medial surface of the hemisphere. inputs from the basal ganglia and cerebellum via the ventro- cal areas of the network and their functions below. B. 2006. 2004). Augustine. cranial-nerve nuclei in the brain stem via the corticobulbar tonic map of the human cortex (Fig. and 3b. Medial view. MI  primary motor cortex.) . In primates. SMA  supplementary motor area. Mattingly (1985). Greenlee and colleagues (2004) provided evidence of a con- Primary Motor Area (M1) nection between the orofacial region of M1 and the inferior The primary motor area (M1) is located in the anterior bank frontal gyrus (Broca’s area). lateral thalamus. we do have some idea of the role that each of these hemisphere and the supplementary and cingulate motor areas areas plays in speech production.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1010 APTARA(GRG QUARK) 1010 Section V ■ Therapy for Associated Neuropathologies of Speech. with permission. M1 receives indirect these areas affect speech production. 36–1).and Language-Related Functions Moreover. 3a. PM  premotor cortex. proposed by investigators such as Liberman and from BA 5 in the posterior parietal lobe (Ghez & Krakauer. Purves. leg. & Brown. such as (Schubotz & von Cramon. the pre-SMA. by synaptic changes in the horizontal connections within M1 sion in recent years. & King. Importantly. arm. this is because animals can be studied more easily direction from the original movement that was elicited. Hallett. cortical neurons act on eral lesion to the face region demonstrate an inability to move multiple muscles that behave together in a synergistic way to their lower faces voluntarily or in response to command. Huang.. elicit thumb movements that were consistently in a particular 1998). Allen. spasticity. 2004). 2002). & Porter. 1995. 1989. & Cohen. Liepert. tinuing to evolve. M1 demonstrates plasticity. In the Mayo nomenclature of perform the opposite movements. The lateral areas in humans . which are tuned to particular visuospatial ori. Amirikian. Sanes & Donoghue. suggest that medial surface of the hemispheres (Asanuma & Rosen. and Iacoboni (2004) found that listening to these divisions (Barinaga. and the final position of the mouth at the end of the movement was Premotor Areas the same for a given site. To a large TMS evoked the same thumb movement. but in the opposite extent. 2001). In human beings. humans adjust their speech move. leg. However. and to inhibit muscles that tions such as laughing or crying. 2000). and this is thought to be driven ates voluntary movements has undergone considerable revi. The medial areas include the supplemen- ing (Warren. in a study using MEG. Thus.. Our conceptualization of M1 as an area that simply initi. while allow the performance of complex movements (Cheney & maintaining the ability to move involuntarily. the limb) movement (Sanes & Donoghue. Watkins and Paus Penfield & Roberts.g. Much of our knowledge regarding the functional orga. Taylor. tions of patients during seizures in the late 19th century. For in primates appear to be universal across body divisions (arm. After the practice.). 1995). there is considerable evi. etc. Sirisko. and Salmelin (2006) found that face motor cortex We have known.. Aronson. 1972. They then asked subjects to practice movements in nization of M1 comes from studies of limb (particularly upper the opposite direction for 30 minutes. speech activated motor areas. Merchant. 2001). of M1 in monkeys evoked complex mouth movements. lesions to speech areas of M1 produce spastic (2002) found that electrical microstimulation to the face area dysarthria (Darley. face. since John Hughlings Jackson’s observa. 1991). & Donoghue. That is. 1985. Finally. 1931). and our knowledge is con- having a bite block clenched between their teeth while speak. & Georgopoulos. Graziano et al.e. 2000). 1984). & Moore. and target position (Paninski et al. and that it can undergo rapid plastic changes. such as single-unit recording. Saarinen. Wilson. regardless of the starting position of the mouth. tary motor area (SMA. Graziano and colleagues dysarthria. Lesions to M1 result in a variety of symptoms. that learning to make a particular movement in response to a M1 is organized somatotopically (Jackson. hyporeflexia. also have extensive horizontal connections within M1 (Ghosh 2006). including Sanes. 1959). parceled speech production and speech perception into two resented more laterally and the feet being represented on the separate processes. there are different. Recent studies. Thangaraj. the dorsal cingulate visual neurons. Parviainen. 1975. direction. Evidence suggests that it participates in (Sanes & Donoghue. M1 However. This plasticity is believed to con- motor-learning and cognitive behaviors (Sanes & Donoghue. 2004). 2000). Edelman. Rather. and the loss of the ability to produce M1 is not organized as a one-to-one mapping of cortical neu. distance (Paninski. 1996. (2004) found that listening to but not watching speech dence to show that. and the ventral cingulate motor area entations. Sereno. may underlie both motor learning and recovery of function For example.. participates in processes such as visuomotor mapping (e. Individuals with a unilat- rons to individual muscles. motor area (CMAd). although there are separable motor resulted in larger motor evoked potentials recorded from regions in M1 for the major body divisions (i. similar to in the cingulate sulcus (the cingulate motor area [CMA]): the auditory neurons. such as referred to as upper motor neurons. under condi- Fetz. the orbicularis oris muscle. Huntley & Jones.. Fellows. and rostral cingulate motor area (CMAr). Classen and colleagues (1991) used TMS to after a lesion (Classen. BA 6).. Murray. and three areas Another aspect of the organization of M1 is that. illus- using invasive techniques.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1011 APTARA(GRG QUARK) Chapter 36 ■ The Nature and Management of Neuromotor Speech Disorders Accompanying Aphasia 1011 in cortical layer V of M1 that give rise to these tracts are tuned to particular higher level movement parameters. we have ety of different ways. so far. example. these processes are not so easily separable. fine movements (Purves et al. however. & Warach. the general principles underlying movement is thought to be involved in higher cognitive functions. these cells direction (Naselaris. keys (Picard & Strick. 2001). there is considerable overlap in the representation within Saygin. 1988. These data show that M1 is organized to allow us There are six premotor areas on the lateral and medial sur- to achieve particular movement goals and that the nature of faces of the hemispheres that have been well defined in mon- this organization permits us to achieve the same goal in a vari. Duffy. Wise. Donoghue. motor neurons that are involved in reaching are (CMAv) (Picard & Strick. Graziano. 2002. Hatsopoulos. separable regions of M1 that represent the At least since the time of Broca and Wernicke. Laaksonen. with the head being rep. 2005). 2003). etc. 1988. and the plastic changes can occur quite rapidly. which a brain lesion. Hiraba. learned about these areas mainly through imaging studies ments remarkably well in response to perturbations. trating the rapid use–dependent plasticity of M1. & Sessle. In an fMRI study. including M1. which are tuned to specific frequencies. tribute to both motor learning and recovery of function after 2000). we have body’s musculature from head to feet. visual symbol) and movement sequencing. and hindlimbs in somatopic order (Picard & this area. The basis for this recovery seems between rostral and caudal PMd are similar to those that . the precise locations and boundaries of human syndrome” (Krainik et al. 1996. also based on anatomical and functional dif- nearly complete recovery occurs within a few weeks or months ferences. and colleagues (2001) found that the pattern of brain activa- The role of the pre-SMA was originally thought to be in tion (which was analyzed individually for each subject) was learning sequential movements. Chainay. (Picard & Strick. while the RCZa terior portion of the putamen. Lesions to either the left or right SMA from sur. and Kahane and Cohen (2006) suggested. appears to be involved in motor execution. refer to these as the rostral cingulate zone (RCZ). In a recent study using right asymmetries. Like M1. and the caudal cingulate zone (CCZ). Kremer. 2004). which they suggested revealed “a marker of the post-selection encoding processes that pre. the PCS to be present in the left hemisphere than in the right matter pathways). the precentral gyrus. 2001. is intercon. and response selection. 1998) based on functional ther subdivided into anterior (RCZa) and posterior (RCZp) and anatomical differences. that the pre-SMA could be subdivided. 135). The patient was able to describe SMA revealed an interaction between factors of word famil. see Vorobiev. 1996. Schubotz & von Cramon.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1012 APTARA(GRG QUARK) 1012 Section V ■ Therapy for Associated Neuropathologies of Speech. In the majority of subjects who had a PCS. With regard to function. CS that was divided into two or three segments. SMA is organized and the RCZp appear to be involved in conflict monitoring somatotopically.. both her urge to grasp and her inability to resist the urge. based on an fMRI study of (2001) used electrical stimulation to stimulate the ventral bank speech production. (PCS). Three cingulate motor areas within the cingulate sulcus have been identified in primates: the rostral cingulate motor area (CMAr). majority of subjects they studied. Lehéricy. 2001. which lie immediately anterior to the precentral gyrus hemisphere (Krainik et al. in subjects who did functionally considered to be a part of the prefrontal cortex. Moreover. was activation in the PCS during the word-generation task ings. 1996). based on both anatomical and functional articulation. 2003). The resulting speech PMd and PMv are not certain (Picard & Strick. Paus and colleagues also found left- nected with the prefrontal cortex. there ing attention and working memory. however. However. Picard and Strick The supplementary motor area (SMA) has been subdivided (2001) proposed that humans have corresponding areas and into two areas (possibly three. found that the SMA was active during word tor areas are divided. in the fMRI study the section on the inferior frontal cortex. 2004). the activation did extend into the rather than being a motor area. complete or ther subdivided. there is the pre-SMA (Picard & Strick. Benabid. there is little interconnection between the In an fMRI study of word generation by category. which was rare. The pre-SMA projects to the middle portion imaging studies of the CS. Govoni. CS. 2004). of the CS in a patient undergoing surgery for epilepsy. a “significant number” had a rior-posterior commissure line (Picard & Strick. Picard and Strick (2001) suggested that it might be that did not extend into the CS. & Luppino. Hoffman.. while the SMA (and M1) project to the pos. 2003. 1996). Matelli. Chassagnon. which is an imaginary vertical line passing that. and the intra-lim- Conversely. However. respectively. into a rostral and a caudal division. which was present in most subjects. However. The lateral premo- described above. the paracingulate sulcus M1 and to the spinal cord. we will discuss BA 44 along with BA 45 in Strick. into dorsal (PMd) and ventral (PMv) regions.. impairments range in severity from complete mutism to Schubotz & Yves von Cramon. there was no object present). BA 44 is sometimes included as part of forelimbs. The PMd can be fur- reduced spontaneous speech output. however. Lehéricy and colleagues (2004) found that hemisphere. while the pre-SMA is not (Picard & Strick. bic sulcus. Intracortical The lateral premotor area (BA 6) lies immediately anterior to stimulation to the SMA produces movements of the head. and Medial Premotor Areas the dorsal cingulate motor area (CMAd). the CCZ of the putamen. Alario and colleagues (2006). differences. The SMA projects directly to they observed two secondary sulci. it has been shown dependent on whether a subject did or did not have a promi- that it is active during cognitive tasks. such as those involv. the ventral cingulate motor area (CMAv). not have a prominent PCS. The boundary considerable variability in the configuration of the human cin- between the SMA and the pre-SMA is the verticofrontal gulate sulcus (Paus et al.and Language-Related Functions include dorsal (PMd) and ventral (PMv) premotor areas (also to be in the recruitment of the SMA in the contralesional BA 6). The CS was more likely to be divided and DTI in humans (which permits visualization of the white. but not the SMA. The They found that the anterior pre-SMA was active during stimulation produced an urge to grasp an object (although effortful word selection. 2001). Talairach & Tournoux. although the cingulate sulcus (CS) was continuous in the through the anterior commissure. iarity and word length. The differences (Krainik et al. while the pre-SMA does not. which is fur- Rizzolatti. Paus and colleagues found (VCA) line. the pre-SMA. These anatomical variations suggest that we need the SMA and the pre-SMA also project to different areas of to be cautious in interpreting group data from functional the striatum. 2003). 2001). Alario. gical resection lead to a cluster of deficits called the “SMA However. The role of the SMA is related to movement. Finally. 2003. Lateral Premotor Areas cede articulatory execution” (p. perpendicular to the ante. In light of these find. 1988). Crosson pre-SMA and the SMA.. Activation in the posterior pre. nent PCS. 2001. They are the SMA proper and zones. and BA 45. 2002). & Amunts. while dorsomedial and external (Schluter. von Cramon. Augustine. while BA 45 occupies pars tri. Uylings. The number was greater in the left execution. a human equivalent of F4.. number of subjects. 2001. They found that the volume in left BA cortex. asymmetry reached statistical significance only in the females. that is. They found evidence for three separate anatomical In monkeys. generally occupies the pars opercularis. tecture continues to change throughout life. Schleicher. 1999. 2001). 2006). capsule connections were more dominant in BA 45. 2004). and Petrides (2006) found considerable variability are using neuroimaging to study speech may want to analyze in the morphology of human PMd. This region is also known as Imaging studies have shown that IFG is active during a Broca’s area. Friederici. rostral PMd has connections with the prefrontal ume of BA 44 and 45. phono- Amunts. on pars triangularis. one from the intention to move to the execution of than in the right in female subjects. Purves. respectively. 2001).GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1013 APTARA(GRG QUARK) Chapter 36 ■ The Nature and Management of Neuromotor Speech Disorders Accompanying Aphasia 1013 underlie the pre-SMA/SMA distinction (Picard & Strick. this region demonstrates plasticity. Studies have shown that the borders of tasks. represented a man-made object (Devlin et al. and one from early to late sensorimotor learning reach statistical significance. that corre- two fields. 2003). 2002). & Mills. Giacomo Rizzolatti and colleagues (de Pellegrino. In five of the six subjects. in addition fMRI. and these differ. all five females and one male showed greater volume of & von Cramon. It has been proposed that BA 44 The deep frontal operculum projected through the anterior (often considered to be part of Broca’s area) is the equivalent subinsular white matter and the external capsule to the tempo- of monkey F5 (Rizzolatti & Arbib. Matthews. although this their summary of functional imaging studies of the PM. into further detail below. 2004. opercularis and triangularis are BA 44 and syntactically complex sentences (Friederici. There are Fadiga. & Burton. temporary lesion effect) of the PMd in human subjects dis. Although the study had a limited stages... Rushworth. In 1992. Passingham. In addi- than motor functions (Picard & Strick. such as asking subjects to determine whether a word human BA 44 and 45 vary greatly (Amunts et al. to select frontal operculum did. & Rushworth. & Forssberg. This is discussed in ral isthmus and continued to the anterior temporal lobe. 1996. Like the leagues (2006) measured the number of neurons and the vol- pre-SMA. Kostopoulos. Schubotz tion. 1992) reported that asymmetries in the size of right and left IFG. Amiez. it may encroach on pars opercularis. depending on Knösche (2006) used DTI to study connectivity in Broca’s what color they saw on the computer screen. neurons in F5 in the premotor cortex of monkeys fired both ences are obvious in children as young as 1 year of age when the monkey performed an action and when the monkey (Amunts et al. The PMv appears to be particularly the inferior occipitofrontal fascicle and the inferior longitudi- involved during manipulation of objects by the hands. but it may encroach 2004). while rostral PMd does not. suggesting that it may be involved in cognitive rather 44 was greater than that of right BA 44 in all 10 cases. It is currently not clear whether there is sponded to the deep frontal operculum. including syn- was the seat of “articulate language” (Broca. Friederici. & Fitzpatrick. In the same study. Anwander and colleagues also found that the arcuate fasciculus rupted movement selection at an early stage of performance was more dominant in BA 44. such as asking subjects to segment words into al. since Broca originally proposed that this region variety of different speech and language tasks. the deep frontal opercu- example. 1861). 1998). the asymmetry in cytoarchi. Both BA 44 and 45 displayed the same Lesions to the PMd in monkeys and man affect the ability connections through the inferior external capsule as the deep to perform conditional motor learning tasks.g. these data suggest that investigators who Champod. Jacobsen. four subjects and to the dorsomedial prefrontal cortex and the Transcranial magnetic stimulation (TMS. cularis and the pars triangularis. 1999. 1990. In tactic tasks such as asking subjects to compare more or less Brodmann’s map. in BA 45 in the left hemisphere than in the right. but the difference did not movement. using the data of male and female subjects individually. BA 44. Krebs-Noble. Fogassi. The posterior inferior frontal gyrus consists of the pars oper. and to push a particular computer mouse button. Schubotz and von Cramon (2003). described three functional trends related to the rostral-caudal The total number of neurons was significantly greater in left anatomical gradient in the PMd: one from complex to simple than in right male BA 44. which produces a ventral portion of the precentral gyrus in all six subjects. Gullapalli. Ditterich. semantic 45. they projected to the pari- a movement based on a (typically visual) cue (Halsband & etal lobe and the perisylvian region via the arcuate fasciculus in Freund. & Rizzolatti. and speech articulation (Binkofski & Buccino. based on white-matter connections. they found activation in the PMd when subjects per.. 2003). 2003). Gallese. the ventral premotor area (PMv) consists of regions. They sug- gested that their structural data support the conclusions of functional-imaging investigations that have proposed that Left Posterior Inferior Frontal Gyrus (IFG) Broca’s area can be parceled into functional subdivisions (e. Moreover. it is active when subjects alter the force of their grip lum was also connected to the anterior temporal lobe via the on an object (Ehrsson. area. formed a conditional motor-response task in which they had Anwander. Zilles. 2003. observed a similar action performed by the experimenter. Similarly. Tomaiuolo et logic tasks. & Zilles. 1998). uncinate fasciculus. BA 44 phonemes (LoCasto. 2003. caudal PMd projects directly to study of 10 brains (five male and five female). F4 and F5. suggesting that They called these neurons “mirror” neurons and proposed . Uylings and col- M1 and the spinal cord.. angularis. to analyzing the data from the whole group. 2001). Moreover. In a recent study using MRI. Like the SMA. Devlin. For nal fascicle. Tittgemeyer. In a recent postmortem 1996. Fagergren. the superior-posterior ceptive stimulation (Purves et al. 1998). in turn. or what more primitive gestural communication system mediated by he calls the “mental syllabary” (Levelt. while BA 3a and 3b lie in the fundus actions” (p. Small.. 1995). It projects to more posterior areas superior-anterior and inferior BA 44 are involved in mem. Levelt has Moreover. & this claim is human beings’ ubiquitous use of gestures while Tourville. consonant (CVC) word stimulus. and BA 2 responds to both tactile and proprio- hension. In the model’s most recent incarnation. some investigators have argued that sound map cells because of the cells’ functional correspon- Broca’s area is not crucial for imitation (Makuuchi. particular subdivisions of the IFG. neuron mechanism is its implication that humans (and other Lesions to the IFG can produce apraxia of speech (Duffy. there production. in its speech sound map is hypothesized to correspond to tem that are designed to explore the role in human behavior. Fadiga. and the rostral bank.and Language-Related Functions that these neurons “represent” the observed action. while BA 45/47 and BA 44/45 and Jürgens (2005) found that all four subdivisions of S1 .. it has been suggested that the IFG human S1 have shown that. In some studies. they suggested that (2000) observed activation in the left IFG when subjects had observation of a movement elicits automatic preparation to to separate an initial consonant from a consonant-vowel- perform the same movement. & Zilles. 2001). 3a. According to the model. rather than being specific to speech and language functions. Guenther. Naeser. there is inter- tion. it gested that this is not the case. stimulation. they concluded that humans also possessed a mirror studies of speech and language. localize the activation to a specific region with the IFG. involve a large region of the IFG and often encompass the guage discounts the fact that much of speech articulation is underlying white matter. while BA 3a neurons respond to proprioceptive areas of the IFG play particular roles in auditory compre. The subdivisions of S1 generally respond to dif- IFG. Hillis. hidden in the mouth and invisible to the listener. & The IFG has also been shown to play a role in speech Fogassi. In a recent study in monkeys. they suggested that the mirror neuron system pro. 2000). primates) represent their own actions in the same way that 2005. insula. The anterior parietal lobe contains the primary somatosen- face integrating sensory stimuli and cognitive tasks with the sory cortex. Binkofski & Buccino. 2006) proposed the DIVA (Directions Into speaking (Rizzolatti & Arbib. vail on possible competitors (Rizzolatti. They can also produce aphasia. while in others. Moreover. 1978). Based on a subsequent study of humans using articulation. which they argued is the equivalent argued that the posterior IFG is involved in syllabification. PMv was chosen for the location of the speech mechanism supporters. they did not key to become faster at executing the movement and to pre. neurons in the left PMv and/or posterior Broca’s area particularly speech and language (e. 2006. Naeser & Hayward. & Rizzolatti. and Haggard leagues have proposed that the speech sound map cells form (2006) noted that an important aspect of the putative mirror the mental syllabary of Levelt. Guenther and col- Moreover. ing the location of these areas across brains. viduals who are congenitally blind acquire speech and lan- guage with little difficulty. 1996). Mancini.. (Guenther et al. their study sug. In particular. BA 1 and 3b neurons respond to cutaneous tive model of auditory sentence processing in which specific stimulation. Barker. something that will be discussed below. 2004. However. 1978). & Zilles. & Maurer. Velocities of Articulators) model of speech acquisition and Since the initial work by Rizzolatti and colleagues. 2005). or of monkey F5 (Fadiga. however. 2. and basal ganglia (Alexander. Aglioti. 2001). For example. in the parietal lobe. Breese. Fogassi. the suggestion that the is the case that lesions that produce persistent aphasia usually mirror neuron system is important for human speech and lan. 366). mirror neuron system. it is more likely to be an auditory bank of the postcentral gyrus (Geyer. semantics. also suggested that this area houses a repository of the motor vides evidence that modern language abilities arose from a patterns for all of the syllables that a speaker knows. 1999). & Palumbo. ferent stimuli.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1014 APTARA(GRG QUARK) 1014 Section V ■ Therapy for Associated Neuropathologies of Speech. The cells in the speech map repre- 2004. allows the mon. Binkofsky and Buccino (2004) sug- Parietal Lobe gested that.g. for a sent different speech sounds. while there is similarity regard- plays a role in syntax. dence with mirror neurons. Schürmann. Based on a meta-analysis of functional imaging TMS. Mohr et al.and face-related of the central sulcus. Schütz-Bosbach. or S1. Like M1. S1 is organized soma- gators have reported activation simply in Broca’s area of the totopically. Burton. 1990. and articula. the process of clustering segments into syllables. and the input from the thalamus. which. Finally. & Hari. Rizzolatti work to assign thematic structure based on semantic and and colleagues argued that the function of mirror neurons is morphosyntactic features. BA 1 lies in the crown related motor representation of hand. BA 2 lies in the caudal ical for speech and language. and 3b. phonology. Mohlberg. Jacobs. Guenther and F5 in primates. Schormann. posterior BA 44 is “a high level sensorimotor inter. According to Guenther and review). and Blumstein in movement preparation. Gallese. Pavesi. each cell have been numerous imaging studies of the mirror neuron sys.. However. investi. If there is a mirror neuron system that is crit. Schleicher. 2006). Friederici (2002) proposed a neurocogni. contrary to the claims of mirror neuron colleagues. Indefrey and Levelt (2004) neuron system in BA 44. BA 1. and that indi. 2005. Studies that have investigated the cytoarchitecture of As mentioned above. Work. Simonyan ory of syntactic structure. S1 receives direct region of BA 44 is involved in phonologic memory. they represent the actions of others. however. Ghosh. One piece of evidence that is often offered for colleagues (Bohland & Guenther. these functions have been localized to subject variability in their extent (Geyer. Amunts. respectively. see Nishitani. 1993).” In another 1997. In a study of bilingual indi- ways have been identified for processing visual objects. so that the plans can. and Since the seminal work of Liepmann (1913). The cytoarchitectonic regions are plans (Assmus. Longer words and more com- study the white-matter connections of perisylvian language plex syllable sequences would require more sequencing. & Fink. 2006. Amunts. and sulcus.. 2003. Eickhoff. 1891). In an fMRI study of the overt IPL is involved not only in the computation and storage of and covert (silent) repetition of mono. It is involved in processing spatial aspects of move. 2003). & Zilles. 2004). & proposed that space–time plans underlie the performance of Baulac. 2004. p.g. In this study. while the IPL is involved in processing temporal glia. The insula The right parietal cortex also appears to play a role in these projects to the cerebral cortex (including the SMA. pre- plans. of the model. such as rhythm (Assmus et al. 1993). Like limb apraxias. Schubotz & von from a variety of areas. so areas. 1996). Ritzl. Shuster and Lemieux (2005) found that there was ments. publication of a study by Dronkers in 1996. Göbel. Zilles. Hasboun. AOS (Dronkers. Jones. Although lesions to the left insula were thought to produce Poeppel & Hickok. Liepmann (Augustine. words. cortex is involved in selecting movements for movement The area of the parietal lobe posterior to the postcentral sequences. and limbic areas (Augustine. S2 is also somatotopically organized (Eickhoff. Functional imaging studies redirection. multiple. greater activation in the left insula during overt production In the literature on vision. The role of this component is to compare speech-motor 40. Develin (2003) suggested that the role of the IPL is in motor The insula has been implicated in language function for attention. but also in processing aspects of move. & Martin. There was an anterior segment that attributed to parietal-lobe lesions (Buckingham. the basal ganglia.. and visceral sensation. as (Nolte. temporal. 15). connected IPL to “Broca’s territory” and a posterior segment 2005. 1993). 2006) a component There is a secondary somatosensory area (S2) in the pari. limb apraxias parietal opercula. Roy. the somatosensory error map. These viduals. This pathway contralateral side. Square-Storer & Apeldoorn. and the anterior cingulate gyrus). The boundary between subjects produced longer words (something individuals with these areas is the intraparietal sulcus (IPS). that connected IPL to “Wernicke’s territory. the superior temporal Cramon. The IPL is further AOS putatively have more difficulty with). Duffy. Johansen-Berg. Rushworth. and ffytche (2006) used DTI to opposed to simpler sequences. Freud. somatosensory.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1015 APTARA(GRG QUARK) Chapter 36 ■ The Nature and Management of Neuromotor Speech Disorders Accompanying Aphasia 1015 projected to the larynx representation in M1. Neuroimaging studies in humans have supported this notion. & Shapiro. be modified. 2003). and Johansen- Berg (2006) found that BA 40 and the IPS were connected to Insula the PMv via the arcuate fasciculus. In Brodmanns’ map. Amunts. Chee. Scott & Wise. 2004. Rushworth. speech apraxias have been to the arcuate fasciculus. if necessary. Noth. Square. it is areas 13 to 16 have been attributed to lesions of the left IPL. Soon. including BA 43 and a small portion of BA IPL. gustatory. auditory. 1989. Redfern. Behrens. rather than the kinds of feeling natural would be particularly important for behaviors such as imita- stimuli produce (Nolte. she . Shuster and Lemieux gyrus is divided into two regions: the superior parietal lobule (2005) found greater activation in the left parietal cortex when and the inferior parietal lobule (IPL). including S1. These investi.and multisyllabic space–time plans. 1991). In the DIVA model (Guenther et al. 1979. The role of this pathway (which projects to frontal-lobe stimulation to S1 in humans usually produces a tingling or regions) is to map “speech sounds on to motor representations numbness sensation in the representative body part on the of articulation” (Scott & Wise. Lee. which they describe as movement preparation or many years (e. than during covert production. and visual functions. 2004. Dupont. recent study using DTI. and Pallier (2004) found that the include a “what” pathway (for identifying an object) and a left insula appeared to be involved in phonologic working “where” pathway (for identifying the location of an object in memory. It receives inputs aspects. parallel neural path. 2006. Electrical tion. Catani. lies within the etal operculum. They discovered a previously undescribed indirect the data from these studies are compatible with Kimura and pathway passing through the inferior parietal cortex parallel Watson’s view. Schleicher. In monkeys. Hickok & Poeppel. Semah. In a recent study using fMRI. 2003). and the thalamus. 2006). Assmus and colleagues (2003) proposed that the of speech have confirmed this. in particular the temporoparietal junc. the basal gan- ment. language (Guenther et al. S2. the insula is divided into three skilled movement and that apraxias are a disruption of these cytoarchitectonic areas. Kimura & Watson. Marshall. Zilles. SMA. including olfactory. related to different functions. Similar pathways have been proposed for speech and related with better second-language development. This region has been shown to be responsive Kimura and Watson (1989) suggested that the left parietal to light touch. 1996. and that better phonologic working memory cor- space).. & learning and feedback-based motor control. The insula lies hidden beneath the frontal. These areas are connected with the (2006) found activation in posterior parietal regions when pulvinar and the lateral posterior nuclei of the thalamus subjects produced more complex syllable sequences. and somatosensory information for the purposes of speech Mohlberg.. while posterior BA 39 was connected with the parahippocampal gyrus. Bohland and Guenther angular gyrus (BA 39). Bouilleret. the insula gators have suggested that there is an auditory “how” pathway received considerably more attention in this regard after the that involves the IPL. as compared to subdivided into the supramarginal gyrus (BA 40) and the when they produced shorter words. pain perception. tion. and Language-Related Functions found that 25 patients who had been diagnosed with AOS all demonstrate a pure AOS. 2003). rather lar deficit. or a disruption of This is not because the RH does not make an important phonologic processes. 1480). A lesion that encompasses tive and expressive speech and language behaviors. Blank. and also because some inves.” or an inability to detect subphonemic features speech perception. since they require more motor plan- probably why it has been so difficult to find individuals who ning/programming and sequencing. They found that the posterior left it is possible that all patients with apraxia of speech have superior temporal sulcus was active when subjects listened to insular damage. Moreover. fMRI and TMS). something that is occurring more and the posterior left STG). . evidence a significant influence on many investigators’ views of AOS suggests that the processes of speech production and speech and of normal speech production. reveal brain areas that are necessary for the these anatomical differences require further exploration. uncinate. not AOS. they do not tell us which areas are crit- Superior Temporal Gyrus ical for the normal performance of that behavior. our views of the role of different brain regions in could be perceived as substitution errors at times. involved in speech and language are multifunctional. view that the STG is only involved in speech reception As Hillis and colleagues (2004) noted. as well as Wernicke’s area (in (e. than speech perception. or to an Summary and Implications for a Model of Motor-Speech inability to determine how well the somatosensory feedback Disorders Accompanying Aphasia matches the intended movement. for example. these studies typically (Wise. and the problems. .. Studies are finding that there is dissociation that she observed.. as some have argued. attempt to develop such a model. As mentioned above. 2006). but that few patients with insular damage the speech of others and during recall of lists of words dur. The consequence of this is. have apraxia of speech” (p. that “. both because of the double perception are tightly coupled. rather than the areas that Developing a model of motor-speech disorders presents are involved in the performance of a behavior but might not some difficulties. a great deal of intersubject variability in the size and location of tigators believe that lesion studies. rather than assessing how many previous PET studies. These data suggest that left STG. . Murphy. Pell. which has long been associated with more frequently. The STG is connected to the frontal lobe terns found with technologies such as fMRI. and Wernicke’s area is not limited to evaluation. They found that the most posterior patients with a lesion to that area demonstrate that particu- part of the STG was active during speech production. ing verbal fluency tasks. tion of syllables from the mental syllabary. A lesion to this region might also result contribution to normal communicative function (Hickok & in difficulties with producing longer words. Scott. nearly every one of the brain (see Shuster & Wambaugh. A lesion encompassing the left IPL may result in distortion errors.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1016 APTARA(GRG QUARK) 1016 Section V ■ Therapy for Associated Neuropathologies of Speech. 2000 for a further discussion of regions that we reviewed has been shown to be involved in this issue). 2004. 2004. the parietal lobe via the arcuate fasciculus. from functional neuroimaging studies can be used to develop such a model. and cognitive-linguistic functions. unlike neuroimaging different brain regions. are new data-analysis methods. been universal agreement on the characteristics and labels for while 19 patients who had been diagnosed with aphasia. did not have left insula lesions. This could also result in greater difficulties in pro- speech. We have not explicitly described the role of the right These could result from problems such as the incorrect selec- cerebral hemisphere (RH) in speech and language behavior. which provide information 1885). & Warburton. Mummery. which would Poeppel. but the speech disorders that accompany aphasia. 1993). Wise and colleagues performed a re-analysis of four has a lesion in a certain area. 1874. that area (Nolte. normal performance of a behavior.g. Broca’s area is not limited to Buckingham and Yule (1987) have called “phonemic false speech production. is involved in a variety of different recep. In Brodmann’s map. but while these data tell us which areas are involved in a behavior. Hillis et al. language. Moreover. This is ducing longer words. and inferior occipitofrontal fasci. A lesion that encompasses face beyond the scope of this chapter. assess the probability that a patient with a particular deficit 2001). Such a discussion is simply require greater syllabification. due to what speech production is changing. Despite the difficulties described above. the IFG may result in speech sound-substitution errors. A1 is BA 41 and Wernicke’s area regarding the temporal characteristics of the activation pat- is posterior BA 22. It also may be why there has not had lesions encompassing the left anterior insular cortex. via the arcuate. areas of M1 may result in speech that has a paretic quality. This paper has had rather than a strict separation. Functional imaging data are changing our must be responsible for that function—may be erroneous. due to an impairment of motor sequencing. These distortion errors In summary. Data Marshall & Fink. An exciting development that will also help the comprehension of spoken language (Wernicke. we can make an like the left IFG. and the functional consequences of investigations. One way to The superior temporal gyrus (STG) is the location of the overcome this problem is to combine imaging technologies primary auditory cortex (A1). The assumption underlying lesion studies—that occipital lobe via the inferior occipitofrontal fasciculus if a lesion to a particular area disrupts a function. The use of lesion studies to develop a model also poses culi. the brain regions be critical for that behavior (although cf. speech disorders. sound errors that are relatively UUMN dysarthria are not currently available. the most frequently occurring ulation. published investigations of treatment for torted sound substitutions. UUMN dysarthria ered synthesis of classic and current perceptual. awareness of errors. made for several reasons.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1017 APTARA(GRG QUARK) Chapter 36 ■ The Nature and Management of Neuromotor Speech Disorders Accompanying Aphasia 1017 DISORDERS OF MOTOR-SPEECH consistent in type and location on repeated productions. Whereas some authors consider phonetic-level disrup- reported in approximately one-third of Duffy and Folger’s tions to be symptoms of aphasia (Blumstein. the symptoms that define the disorder. Duffy.. apraxia of speech. . are most likely the result of neuromotor 14% of cases. respectively (Duffy. Symptoms that are consistent with a PRODUCTION ACCOMPANYING APHASIA: diagnosis of AOS. 2001. Kurowski. AOS and UUMN The speech behaviors considered to define AOS have under. 2003). 2005). Descriptions of the defining characteris- tics and symptoms of AOS and UUMN dysarthria are pro- vided in the following sections. Although other dysarthrias may co- description of the disorder (Darley et al. 268). we will focus on the nostic criteria advanced by McNeil. AOS and UUMN dysarthria to be nonaphasic in nature. Duffy. A focal lesion in the language-dominant hemisphere that speech-initiation problems. with slow rate reported sion of the nosology of speech errors associated with apha- most often (note: imprecise and irregular AMRs were each sia. reflects findings from Duffy and Folger’s (1996) retrospective persons with “anterior” aphasia tend to evidence phonetic- study supplemented by additional confirmatory reports. segments and intersegment durations). As described by McNeil and colleagues “when UUMN dysarthria is the primary communication (1997). 2001. (AMRs) were the second most commonly occurring speech It is not the purpose of this chapter to engage in a discus- disorder seen in UUMN dysarthria. McNeil. cal presentation (Duffy. we believe phonetic-level errors such as sound tively high percentage of cases. primarily in the form of imprecise con- intact. Our decision (1997) and elaborated by Wambaugh. and increasing errors with increasing length or com- disorder (or disorders). These criteria reflect a carefully consid. in most cases additional neurologic con- Croot (2002) that our current understanding of AOS is a ditions beyond that which resulted in aphasia would proba- “work in progress” (p. Robin. perseverations. but do not allow a differential diagnosis in DEFINING FEATURES and of themselves include articulatory groping. and prosodic abnormalities. and Schmidt treatment of AOS rather than the dysarthrias. Behaviors that are more likely attribut- most likely to be associated with such a lesion are apraxia of able to a language disruption than to AOS would include speech (AOS) and unilateral upper motor neuron dysarthria transposition and anticipatory errors. and nonaphasic commu- for a diagnosis of AOS include slow speech rate (lengthened nication deficits are frequently not present” (p. Disorders of phonation were also reported in a rela- et al. 1975). Although sound errors in “posterior” aphasia are gen- speech deficit observed in UUMN dysarthria has been a dis- erally considered to be phonologic in nature and phonetically ruption of articulation. 2005). We ascribe to the diag. First of all. 2001. We agree with exist with aphasia. Furthermore. with harshness being the most distortions and slow rate of production are necessarily frequently reported symptom. aphasia. to limit discussion of the management of the dysarthrias was and Rogers (2006a). errors in aphasia are motoric (phonetic) or linguistic (phono- The reader is referred to Duffy (2005) for a concise summary logic) in nature. In the remainder of this chapter. 260). Hazen. acoustic. As summarized by Square and others of the speech characteristics observed in UUMN which (Blumstein. repeated results in aphasia may also result in a neuromotor speech attempts. Behaviors such as nor- (UUMN dysarthria. dysarthria are the neuromotor speech disorders most likely gone considerable revision since Darley and colleagues’ early to accompany aphasia.. mal prosody or consistently normal or fast rate of speech pro- We consider the speech production errors observed in duction would contraindicate a diagnosis of AOS. Square and colleagues (2001) provided a discussion of “speech UUMN Dysarthria errors in aphasia” and noted that a significant amount of Our understanding of the clinical characteristics and patho- research has been dedicated to determining whether speech physiology of UUMN dysarthria is also a work in progress. Kurowksi cases).. which includes our knowledge of bly be present. MANAGEMENT OF NEUROMOTOR SPEECH DISORDERS ACCOMPANYING APHASIA Apraxia of Speech As discussed in the previous section. The neuromotor speech disorders plexity of utterances. Mildly slowed rate and mild motoric disturbances and. even when observed in persons hypernasality and/or nasal emission were noted in 18% and with aphasia. & Blumstein. for a review). Duffy notes that viduals with AOS. Robin. dis. Disturbances in speech alternate-motion rates reported (see Square et al. In addition. and may often be mild and relatively transient in terms of clini- physiologic evidence concerning behaviors observed in indi. some subtle temporal speech differences have been sonants. As level disruptions realized as errors in various aspects of artic- reported by Duffy (2005). 2005). the speech characteristics considered to be necessary deficit. sound distortions. 2003). .. objective evidence. Since that time. knowledge gained through clinical expe- rience. logic event that caused the aphasia. Treatment for the Despite advances in understanding the effects of various dysarthrias is a complex subject. They task continuum. 2003). Robin. & effects. the Duffy. ing appropriate treatments and documenting treatment 2003. . 2004. Hakel. TABLE 36–1 Traditional Approaches for Patients with Apraxia of Speech of Different Degrees of Severity with Speculated Level of Intervention Severity Level Recommended Approaches Level of Intervention Severe Segmental/syllabic level Postural shaping (spatial imitation with targeting) and/or production • Imitation of functional units of speech • Phonetic placement (coordinative structures) • Phonetic derivation • Derivation plus placement • Key-word technique Rate and melodic flow Imitation of contrasts Contrastive stress drills Moderate Intersystemic facilitators Rate and melodic flow • Tapping foot • Tapping leg • Finger counting • Finger tapping Intrasystemic faclitators Pacing board Mild Expanded contrastive stress drills Rate and melodic flow (From Square.. Lemme. P. Specifically. particularly with respect to functional out- note of the treatment guidelines provided by the Academy comes. Yorkston et al. Square et al. other types of dysarthria may be present duction as a result of treatment. considerable progress has questioned the appropriateness of such an approach and been made and a substantial body of literature now exists instead. We will provide a summary of the available AOS of Neurologic Communication Disorders and Sciences treatment approaches along with considerations for select- (ANCDS. Considerations in the Treatment of AOS In the previous edition of this text. topic would be of little use to the reader. a technology of AOS treatment.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1018 APTARA(GRG QUARK) 1018 Section V ■ Therapy for Associated Neuropathologies of Speech.ancds. Beukelman.org) (Duffy. various treatment techniques were considered to operate. www. Spencer. Duffy & Yorkston. Yorkston. & Rogers. and a thorough does not exist. theoretical rationale. cian in the selection of a specific treatment for a specific ter. lxiii). 2001. Harris. of Neurologic Communication Disorders and Sciences Square and colleagues suggested that three types of deficits (ANCDS) Writing Committee of Treatment Guidelines for related directly to three types of interventions: (1) postural AOS recently reviewed and evaluated the existing evidence shaping. testing.and Language-Related Functions To reiterate. Square and colleagues The development. 2006. 2005. (2) production of functional units (coordinative base for AOS treatments and concluded that “taken as a whole. As noted by Wambaugh and colleagues (2006b). Duffy. & Fager. proposed that the presumed underlying pathophys- documenting the benefits of AOS treatments. p. a superficial review of the AOS treatments.. they specified levels of intervention at which AOS may be expected to make improvements in speech pro. 2003. Accordingly. even when AOS is chronic” with aphasia. 2001). interventions for AOS had historically been based upon and Wertz’s influential report of the effects of their eight-step AOS severity (see Table 36–1. Ahern. and consideration of patient requirements and wishes. Limited data are available to guide the clini- consideration of the topic is beyond the scope of this chap. as seen the AOS treatment literature indicates that individuals with in Table 36-1. Outcome prediction is extremely limited for most the management of dysarthria and is encouraged to take AOS approaches.) . treatment of individuals with AOS requires integration of Yorkston et al. The reader is directed to recent publications concerning patient. per se. 2006b. (Wambaugh. and reporting of treatments for noted that recommendations for selection of treatment AOS began in 1973 with Rosenbek. The Academy iologies should guide treatment selection. and (3) rhythm and pacing. but rarely will be the result of the same neuro. Hanson & Yorkston. Yorkston. structures). McNeil. A. Productions may be elicited through various modes. It is not unlikely that artic. that are highly constrained and have maximal clinician leagues (2001). syllable structure. outcome measures. the clinician illustrate the point that at present. of the guidelines. (Wambaugh & Martinez. Randomized presentations. Consequently.and bi-syllabic technique and presumed pathophysiology for the less severe words. treatment should be tailored to the individual. For may also be of interest in assessing and selecting sounds for example. Until treatment outcomes are demonstrated Mauszycki. well different elicitation modes approximate spontaneous fication of appropriate treatment targets. Therefore.. an individ- ual with AOS may present with difficulties in transitioning Assessment for Treatment Planning between sounds/syllables only in the context of multisyllabic words containing consonant clusters. This suggestion was made to opportunities for success as well as for challenges. treatment.or patient in the preceding paragraph. confrontation naming. rate control) was suggested for syllabic words. 2004). For example. Although both individuals demonstrate (Wambaugh et al. That is. the level of dis. productions in AOS. physiology and the level of severity. and that reflect a range of phoneme fre- reader should recognize that presently it is not possible to quency. should have data available for production contexts that are easy ments for AOS on the underlying speech disruption is not for the patient as well as for those that are difficult. 2000). The selection of a treatment should entail more than a elicitation modes may be constrained by language factors determination of severity and probable pathophysiology. and discourse. A disruption of coordinated production at the the patient. the clinician should have difficulties in coordination of movements. may not be the most . but produce increasing numbers of errors with three. A disruption of coordinated pro. but should also lead to the identi. van Heyst. Another individual Errors in sound production are a defining feature of AOS and may evidence difficulty in transitioning between sounds in articulatory precision is often the focus of AOS treatments monosyllabic words. Unfortunately. word type. The level at which sound production becomes multisyllabic level may require minimal clinician instruction problematic for the individual should be apparent from initial and may benefit from reducing the rate of production. delayed repetition.e.e. spatial target. Croot. some patients may pro- The reader may have noted a “mismatch” in suggested duce few sound errors with individual mono. 2006a). Guidelines Technical Report: Evidence Table (ANCDS. The AOS Treatment exemplars of a sound are presented in order.. and the reader is referred to Mines. For example. establish empirically a clear correspondence between patho.e. nales for the AOS treatments included in the development sentence completion.1. the impact of most treat. cases of severe AOS or extremely mild AOS are all sounds pro- duction at the syllabic level would likely require significant duced with equal difficulty or ease. assessment and should take into consideration both the theorized patho. Therefore. Hanson. As such. only rarely in the treatment approach. thorough knowledge of the patient’s strengths and weaknesses ruption in terms of severity obviously differs and so should in terms of sound production. stress patterns. Deacon. The way in which items are presented to elicit produc- physiology and purported level of intervention for a given tions can affect performance (Wambaugh. As noted by Square and col. A such as limited reading ability and significant word-retrieval thorough assessment should not only assist in making the deficits. Because most individuals with AOS will also have aphasia..and bi- melodic flow technique (i. and word frequency is the ulation-oriented treatments will eventually be shown to MRC Psycholinguistic Database (2006). consideration should be given across a range of behaviors for a specific AOS treatment. A useful Internet resource for selecting words ing and/or production of functional units of speech) on the basis of factors such as phonemes. are likely to and determine whether those mechanisms are compatible be more challenging than blocked presentations. An example of multisyllabic words that were kinematic treatment was associated with a reduction in selected to be balanced in terms of syllable shape and phoneme multiple attempts in a speaker with AOS. Phoneme frequency have a positive influence on rate and melodic flow.2). Bennett. contacts and assessments. such 2006) is a comprehensive resource for reviewing the ratio. treatment rationale) of target sounds are not presented sequentially. there are no data indicating how preceding determinations. To be able to structure therapy to include a problem of coordination. the type and position.. Appendix 36. Intuitively. and Law (2006) pro. a rate and four-syllable words or with phrases containing mono. neuromotor speech disorders associated with input.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1019 APTARA(GRG QUARK) Chapter 36 ■ The Nature and Management of Neuromotor Speech Disorders Accompanying Aphasia 1019 We would argue that the choice of a treatment approach aphasia are not homogeneous. such as repetition and modeling. modeling. Nessler. the to the structuring of the stimuli used in elicitation of sound clinician should understand the theoretical mechanisms by productions. and vided preliminary findings suggesting that an articulatory. and practice with integral exemplars of all sounds elicited at levels that are appropriate for stimulation. is provided by Mauszycki (2006) (Appendix 36. AOS treatment. length. It is strongly suggested that direction from the clinician and necessitate techniques such an inventory of sound production be conducted. In our experience. wherein exemplars which a treatment operates (i. as immediate repetition. with multiple as phonetic placement. An example well understood. Shoup (1978). oral reading. in which all with the patient’s pathophysiology. Rate and melodic flow treatments (to be of items used to elicit production of most consonants in the ini- termed “rate/rhythm treatments” in subsequent discussions) tial and final syllables of monosyllabic words is shown in have been shown to improve articulation (i. it would seem that modes and viable treatment techniques. ” would necessitate repeated measurement of the outcomes of interest prior to the initiation of treatment. 1989) and the Assessment of Intelligibility of to the VET. by pro. Clinician: “I’m going to say a sentence and I’d like you to Measures of intelligibility and comprehensibility should focus on the word at the end of the sentence. “the current unavailability of such measures should not prohibit . Multi-Speech™. treatment. . Whole-word durations as well as relative durations of sylla- tences are constructed for maximal cueing (i. Sentence-completion elicitation does not et al. and the After obtaining adequate samples of sound production at patient’s language disturbances may necessitate constrained appropriate levels of complexity. it may be difficult measuring the effects of rate/rhythm control treatments. it is more likely that the factors of low frequency of serve as treatment targets and/or outcomes. error analysis tions of significant sounds have not yet been developed. rate of speech in syllables per second may be of interest. so I’m going to take him to the priate for assessing intelligibility in AOS. performance should be elicitation conditions. Variability in speech production across different sampling occasions may or may not affect assessment for treatment Example 2 planning. Now you finish the sentence for me. To get the news.. 2006a). 2006.” such as those described by Duffy (2005) are also appropriate. ity level. pp. ____________. Qualitative ratings. Furthermore. completion in a delayed-repetition format may allow the clin. Now you finish the sentence that I’m would be well advised to establish a baseline of performance going to start. . . This per or a __________________. this notion may not be correct. should be individualized. interword intervals may reveal information pertinent to geting sound production at a multisyllabic level of produc. which may serve to make durations that may be germane to treatment. and patterns of errors. Although analysis of sound production summarized by sound. with speech production may affect an individual’s willing- duction of the desired word. I like to read a newspa.3.and Language-Related Functions desirable.” such as the Word Intelligibility Test (Kent. consequently.” measures of sound production. Tests designed to assess intelligibility in dysarthria. 2006]). Reliable measurement contexts and proce- tence for the patient to complete. 320–321). I would ment. the clinician MAGAZINE. Any error patterns are likely reliable methods for eliciting adequate numbers of produc. Kent. complex- in discourse may have appeal in terms of ecologic validity. I’m going always be considered for inclusion in pretreatment assess- to repeat the sentence leaving off the last word. AOS. to construct sentences that are appropriate for less frequently Durational measures of individual sound segments and occurring words. word position. upon selection of Clinician: “To get the news. To use this elicitation mode. assessment. The preceding types of measures are easily con- tion. & Clinician: “My dog is very sick. from attempting to estimate the effects of treatment at such levels. word-retrieval problems may be severe ducted using relatively inexpensive speech-analysis software enough to prohibit sentence completion. The clinician may wish to measure various entail provision of a clinician model. and such words may be necessary when tar. Model 3700 [Kayelemetrics. AOS treatments may also tar- words containing specific sounds of interest are provided in get and/or impact durational aspects of speech (Wambaugh Appendix 36. caveats regarding reli- Example 1 ability should be provided when interpreting findings” (Wambaugh. Difficulties in word retrieval may be minimized if sen.. AOS. associated with AOS. . the clinician may wish to conduct repeated know what to say when it’s your turn. . then models initiations may also be considered for inclusion during the desired response. as are ratings of comprehensibility (Duffy.g. it a more valid indicator of the patient’s true production abili. the ness to initiate speech. like you to finish the sentence for me. But first. silent or audible groping. Several practice trials may dures have not been developed for the preceding behaviors be necessary to establish the correct pattern of responding. that can be used to estimate the effects of treatment.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1020 APTARA(GRG QUARK) 1020 Section V ■ Therapy for Associated Neuropathologies of Speech. My Dysarthric Speech (Yorkston & Beukelman. Weismer. starters. to be unique to the individual. as noted by Wambaugh. I like to read a newspaper or a treatment targets and outcome measures. However. Other behaviors that are frequently observed with ician to work around the preceding problems. ties. Difficulty occurrence and word-retrieval deficits will not prohibit pro. quantification of speech clinician first provides an explanation of the task. and motor perseverations may request. however. However. Utilizing sentence (e. sound class. For example. (one) . if sentences bles within words may be useful measures for planning and are heavily semantically loaded). 2005). such as false starts. That is. To ensure that appropriate treatment goals and stim- ish it for me. However.e. and finally provides the incomplete sen. 1989) are appro- dog is very sick. filled viding the desired response prior to the sentence-completion or silent pauses. The extent to which productions vary from day to day is likely to be a factor that differs for each individual with Clinician: “I’m going to say a sentence and ask you to fin. Examples of sentence-completion items used to elicit Beyond sound production. As such.. so I’m going to take him Rosenbek. I’ll say the whole sentence so you uli are selected. Of course. using that word. the strength of the recommendation serves as improved spatial or temporal aspects of speech production. most of the articulatory-kinematic treatment siders the evidence to be less strong. Furthermore. motoric practice of rant a strong recommendation. AOS rate/rhythm control approaches. recommendations. The presumed mechanisms for treatment minations for each of the preceding treatment categories on effects will be discussed for each general approach so that the the basis of the quality of the evidence available through reader may relate the information to presumed pathophysiol- December. xix). traindications for a particular patient. That is.. The AOS committee concluded that ogy. Recommendations are assigned when the committee con. and AAC approaches were designated ments generally fell into one of the following categories of as treatment options in the AOS guidelines report... 1939)... originally described by sider patient preferences and be alert to new evidence con.. Clinicians The extant AOS treatment literature provides examples of should be watchful for new evidence relevant to the treat- many different treatment techniques. 2006b. but still substantial.. lxii). Wertz et Options are used as the designation for treatments when al. articulatory- of the recommendation. 864). like other authors (Square et al. None of the AOS An underlying theme crossing virtually all articulatory- treatment approaches had enough empirical support to war. speech targets is a necessary component of treatment. another.. general approaches: (1) articulatory-kinematic treatments.. Rosenbek. Treatment targets and candidacy issues will also be dis- “articulatory kinematic approaches were determined to be cussed so that the issue of severity may be taken into account. systemic treatments. kinematic treatments “were those in which the therapy tech- cide with recommendation strength in that the extent and niques were used to facilitate improved movement and/or quality of the evidence supporting treatment approaches positioning of the articulators in an attempt to promote bet- serves as the basis for the designation of both. ter speech production” (Wambaugh et al. is were recommended for use “with individuals with moderate integral stimulation. Articulatory-kinematic approaches has been incorporated into several treatment hierarchies. 1984) advocate a period of trial therapy to assist in select. A strong recommendation reflects extensively written about in the speech literature since the the guidelines committee’s belief that the evidence support. 2006a). there are virtually no data to guide due to disturbances in the spatial and temporal aspects of the clinician in the selection of one treatment approach over speech production” (Wambaugh et al. a guide for the clinician in terms of importance of adherence Many of the articulatory-kinematic techniques have been to the recommendation. but clinician judgment and patient preference should Theraputic Approaches for the Treatment of AOS play important roles in selecting treatment. Lemme.. 2006a). Ahern. and no was “enhancing postural shaping and re-establishing func- recommendation. We. The lines report were characterized as articulatory-kinematic in strength of the recommendation is an important component nature (Wambaugh et al. which cerning the approach. 2006b. the evidence base is relatively weak or when benefits do not ing a treatment approach. 2004). and approaches included in the AOS guidelines utilized model- benefits clearly exceed risks (Marcuse et al. (2) The following sections describe treatment techniques for rate/rhythm control treatments. 2006a). and (4) alternative augmentative treatment approaches identified in the AOS treatment guide- communication (AAC) approaches (Wambaugh et al. and Wertz (1973). p. Strong recom. options. The general reorganization treatments. rate/rhythm control approaches and intersystemic approaches were considered to be ‘possibly Articulatory-Kinematic Approaches effective’. in which the patient is instructed to . but should con. and AAC approaches could not be rated in terms of likelihood of benefit” (Wambaugh et al. clearly outweigh risks (Marcuse et al. A potentially pow- should typically follow recommendations. Clinicians ing/repetition to elicit desired productions. Numerous techniques have been used to promote 2004). Clinicians should be aware of such treatments as having potential util- ity. Approximately half of the treatment investigations that were The report also provided recommendations concerning the included as the evidence base for the AOS treatment guide- clinical utilization of the different AOS approaches. et al. 1930s (Van Riper. 2004). ‘probably effective’. inter- Guidelines Committee reported that existing AOS treat. by Wertz and colleagues (1984) and Square-Storer (1989). lxii). 2004) with potential recommendations types of techniques in terms of presumed pathophysiology being strong recommendations. lines will be used as the organizing framework (Wambaugh The AOS guidelines report provided effectiveness deter. The AOS guidelines report used the recommendation The terminology utilized in Square and colleagues’ (2001) scheme employed by the American Academy of Pediatrics previous version of this chapter to describe the foci of these (Marcuse et al. 2006a). (3) intersystemic facilitation/ AOS that have been reported in the literature. 2006a.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1021 APTARA(GRG QUARK) Chapter 36 ■ The Nature and Management of Neuromotor Speech Disorders Accompanying Aphasia 1021 As noted in the AOS treatment guidelines report to severe AOS who demonstrate disrupted communication (Wambaugh et al.. erful variant of modeling/repetition. Explanations of these facilitative ing a treatment approach is of high quality. That is.. Harris. 2003. intended as translational aids for clinicians (Marcuse et al. p. Effectiveness determinations coin. Recommendation-strength designations are tional units of speech” (p. 2001.. The AOS Treatment ment option. p. kinematic approaches is that repeated. techniques used with AOS and aphasia are presented in detail mendations should be followed unless there are strong con. tracked through the use of magnetic fields and receiver coils Or. Results revealed that all treat- (PROMPT. embedded with electrodes that detect contact of the tongue.. p. 1999. extent of mandibular opening. the nature of the information visual. & Doyle. receives visual feedback concerning the accuracy of his or her 1998b. PROMPT utilizes combinations of auditory. they suggest that for this speaker. and kinesthetic cues that are “dynamic in nature provided in treatment was more important than the modality and are designed to provide sensory input regarding the place of delivery. Florance & Deal. are designed to provide additional stimu- is described more thoroughly in Square et al. duction. /1/ may be derived from /s/ by having the patient slowly Carstens (1999) demonstrated the utility of EMA in im- draw his or her tongue posteriorly along the palate. Haley. Kalinyak-Fliszar. voice) sounds depicting tongue-to-palate contacts.. PROMPT repeated practice. vide visual and acoustic models for the patient. drawings (Raymer. Wambaugh. additional research is required to document ably and that contains the target sound being worked upon is the benefits of EMA for the treatment of AOS. p. ‘Sam. 2001. use.. Bharadwaj. 2002). “gestural” treatment employing gesturally cued articula- visual stimulation” (Square et al. of tongue-to-palate contacts are treatment techniques made 1973. Unfortunately. 1984.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1022 APTARA(GRG QUARK) 1022 Section V ■ Therapy for Associated Neuropathologies of Speech. and “combined” treatment involving all techniques used for Restructuring Oral and Muscular Phonetic Targets in the other two treatments. with the exception of Square. & Schmidt. the Wambaugh. lead to additional information concerning the potential bene- ing how to modify existing productions to obtain different or fits of EPG for AOS. 1998b. this action may serve as the basis for movement may be provided. Although the findings of this investigation require replication. with “verbal” treatment utilizing verbal and graphic informa- ing of dynamic tactile-kinesthetic input with auditory and tion. and/or manipulation of the to support the use of EPG in the treatment of AOS. and the patient can produce her husband’s name. Ballard. 1986). 1998a. proving /1/ . McNeil. As with EPG. Rosenbek et al. For instance. 769). Schlosser. 2005) will repertoire. The treatments differed Another method of improving speech production in AOS in terms of how the articulatory information was delivered. if the patient can produce is another method by which visual biofeedback of tongue nonspeech lip popping. a word that the patient can produce accept. visual display is provided in real time. tactile. with descriptions provided as verbal explanations. 1998a. a computerized.. All of the preceding techniques. Little research exists videotaped models (Aten. 1999). upon an articulatory or orofacial skill already in the patient’s EPG3 – Articulate Instruments. Phonetic-placement techniques involve the use of Thus. Integral stimula. Square et al. Katz. Prompts tion. Chumpelik. for articulatory movements and speech production in the treat.. With EPG. listen to me. LogoMetrix. patient (and usually the clinician as well) wears a pseudopalate West. & Doyle. LaPointe. (2001) and is lation in various forms to the speaker to facilitate accuracy of discussed further in the subsequent section “Formalized articulation.. and Varley (1995) reported improvements in articulation in a Phonetic derivation and shaping techniques (Wertz et al. descriptions of where (place) and how (manner. if the goal is volitional control over the production speaker with chronic. available through electropalatography (EPG). ment of AOS. Wambaugh. 2001). moderate AOS and aphasia. a patient may be able to produce /s/ but not that are attached to the articulators. and say it with me” (Deal & Florance. presence ative investigations of treatment techniques. 866). A tion attempts to bring to a conscious level of awareness the pseudopalate is custom-made from an impression of the indi- “look” and “sound” of the movement pattern. This is consistent with the concept of AOS Treatment Programs with Supporting Evidence. 2001. is to provide “enhanced sensory feedback through the pair. 1977. case study with an individual with AOS. who then with or without visual modeling (Wambaugh et al. The three of /s/.g. using speech. Enhanced feedback and cueing in the form of visual displays 1978. The key-word technique is related to phonetic derivation. Wertz et al. & Rogers. 2007./t1/ contrasts in an individual with AOS. and manner of articulation. produced by the patient while the clinician calls to his or her In a recent investigation. Articulator movements are providing both place and manner of production for /p/ and /b/. 1984.. tongue placement in target productions. Electrodes embedded in the plastic pseudopalate feed postures and movements are phonetic placement and phonetic information about tongue contact to computer-based software. The clinician may pro- are made. ments resulted in significant improvements in production. West. & Kendall. 1984.. It is expected that the Knock. vidual’s hard palate (typically obtained through a dental ser- ing this awareness with simultaneous practice. Howard orofacial musculature by the clinician (Square et al. while combin. EMA is prohibitively costly for most clinical In this approach. providing information about manner and place of pro- movement can be produced volitionally in other words. Rose (2006) compared three attention the feel (tactile and kinesthetic) of the sound. This study highlights the critical need for compar- of articulatory contact. That is. & van Lieshout. For methods of providing information concerning articulation in a instance. instructions or models are provided regard.’ treatments all involved contrasting target and error produc- the name would be used to enhance the feel of /s/ so that this tions. Hayden. vice) and bears similarities to the palatal portion of a dental Other techniques used to stimulate awareness of articulatory retainer. Martinez. 1984). Robin.” reflecting a disruption in the process of translation of cor- .1999. derivation. and /1/. Electromagnetic articulography (EMA) improved productions. imitation. 2000) are those that build decreasing costs and increasing availability of EPG (e. 2001) is a highly developed system for providing instruction with no difference in performance noted between treatments. and/or coarticulation” (Bose.and Language-Related Functions “watch me. and reinforcement. but random practice results in better retention phrases. difficulty of the contrasts by utilizing sounds that are more such as selection of stimuli. and utiliza- similar to the target (e. indi. Whether the lack of information stems 2000 for discussions and reviews). random practice resulted in superior retention. behaviors. 1995). xlvii). /r/-/k/-/r/-/r/-/k/-/r/-/k/-/k/- et al. practice of the remaining sound (e.. 1999). if two sounds have been targeted incorrect. blocked practice would require that one meta-speech in that they require conscious processing of sound be practiced first for X number of trials.. Thus. monosyllabic /r/). According to Schmidt and Lee. outcome measures. 2001). Stannard. /shu/ . /fi/). The reader is strongly encouraged to consult such practice in the form of minimal pair words. It may be the case that coping with novel situations. and EPG provide relatively direct have intuitive appeal for application to motor-speech treat- information about production of specific speech targets. blocked practice promotes more rapid acquisition of motor Wambaugh & Nessler. the practice is termed movement information that is presumed to be lacking or “random.g. In comparison to the total motor specifications related to the contrasting productions. tion of feedback. phonetic such as variable practice and blocked versus random practice derivation.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1023 APTARA(GRG QUARK) Chapter 36 ■ The Nature and Management of Neuromotor Speech Disorders Accompanying Aphasia 1023 rectly selected sounds to previously learned articulatory.. including individual move. PROMPT. 2002. 1998b). the participants in the articulatory-kinematic investi- learning concepts of variable practice and the scheduling of gations were more frequently rated as severe and none variable practice (e. have been discussed elsewhere (Odell. for a review). 2001.. Wambaugh and Additionally. How the variable practice is scheduled has been shown to be tion concerning either the general or specific aspects of sen. Knock and colleagues (2000) examined the effects of form of imitation of contrasts (Wertz. ment.. they recommended practice in contrasting behaviors during treatment.. Raymer et al. only limited data exist concerning their utility with rect information concerning production is provided in the AOS. Following mastery at this literature on limb motor learning in terms of acquisition of elementary level. of the information is debatable. 1999 and Knock et al.. it appears tice) (Schmidt & Lee. speech movements. ficult production environment for the target sound (e. that increased severity is associated with the selection of an important aspect of learning a task is being capable of articulatory-kinematic approaches. 1985). Random practice would involve various levels of production. Square items being randomized (e. /se/-/si/-/su/). followed by various cues associated with speech production. & LaPointe.. Wambaugh and colleagues have also used contrastive here. 1999. and 2% a mild-moderate rating. with the target resources and to take into consideration these issues when sound paired with the patient’s typically replacing sound planning therapy... there is sound is consistent with the principle of variable practice. 2006b) and will not be reiterated . 9% a moderate rating.g. 1997). random practice versus blocked prac. ticipant.g. Wertz and colleagues’ tion occur more frequently in cases of severe AOS or are . The literature on limb motor learning indicates that words (Kahn. blocked and random practice on production of stops and frica- 1984). & Skinner.. Rosenbek.g. Their results were not consistent with the different vowels (e.” For instance. Of course.g. group of 146 AOS participants studied across all investiga- The use of contrastive practice relates to the motor.. an assumption that speakers with AOS are lacking informa. allow the speaker to experience the difference in the sensori. /se/ ..e. 5% a moderate-severe rating. 2004).. and multisyllabic words. 1998a. Square and colleagues (1986. 1999. fol- The techniques described thus far have been applied at lowed by 100 trials of /k/)./chu/) or utilizing a more dif. Minimal pair words As noted previously. 100 trials of /r/. notion of varying the phonetic environment of a target kinematic parameters (McNeil et al. The treatments may be considered a form of for treatment. syllables (Knock et al. Regardless. the majority of the evidence sup- have also been used with electropalatographic feedback to porting treatment for AOS has taken the form of investiga- practice contrasting tongue contacts (Howard & Varley.. 1977.g. these types of the practice is termed “blocked. tions. 1998. /si/ . and transfer (see Schmidt & Lee. That is. When all practice trials from difficulty in accessing such information or from a loss with one target behavior occur together (i. Although the application of principles of motor learning Whereas techniques such as phonetic placement. with the order of the ments and sounds (Holtzapple & Marshall.. (Wambaugh et al.g. tions of articulatory-kinematic treatments./pe/. Wambaugh et al. practice of both sounds concurrently. but did suggest that for one par- the target sound with dissimilar sounds (e. “tight 2002. “84% were provided a severe movements (Square et al.. 2004). 2000). Wertz and colleagues suggested further increasing the Other issues related to articulatory-kinematic treatments.. 1989) employed colleagues (2006b) reported that of the 87 AOS participants minimal pairs during PROMPT treatment and have reported studied in articulatory-kinematic investigations for whom that PROMPT should be utilized to contrast articulatory severity ratings were available. every new speech disruptions in spatial and temporal aspects of sound produc- event is presumably a novel situation. important for limb learning in terms of retention and trans- sorimotor specifications necessary for carrying out intended fer of behaviors (see Schmidt & Lee. and sentences (Bose et al. Wambaugh et al. Contrastive practice may rating. received a mild severity rating” (p.” When trials of all targeted articulatory-kinematic treatment techniques seek to provide behaviors are randomly interspersed. Wertz and colleagues (1984) suggested beginning with tives in syllables and monosyllabic words with two participants imitation of syllables in which the target sound is paired with with severe AOS. sequentially).tyke”). Rate control Southwood (1987) Prolonged speech produced in oral reading at reduced rates with rate controlled by video display. 2006).g. and rhythmic manipu- likely to result in stable baselines) and. firmed or disproved. ments. there currently are no agreed. suggested that the entrainment provided by rhythmic sources (e. Rate Another general approach to AOS treatment identified in the and rhythm controls may also provide a mediating function AOS treatment guidelines was rate and rhythm control. In only one report were negative treat. Tasks progressed from imitation of functional phrases and multisyllabic words to structured responses/conversation to unstructured conversation. but faded.. AMRs. DAdada) and multisyllabic words with modeling. vowel sequences. Regardless of the cause for the preponderance of severe trol approaches is that AOS reflects an underlying disruption cases in the articulatory-kinematic literature. metronome or hand-tapping) may serve to facilitate or restore internal oscillatory mechanisms that may be involved Rate.g. rhythmic signals Stress patterning Tjaden (2000) Practice of reiterant speech (e. Dworkin and col- . lation through computerized control and feedback. Key: AMRs  “alternating motion rates (e. and Deger (2000) Production of target utterances in time with computerized. As seen in Table 36–2.g. Use of rhythmic treatments with AOS ment findings reported (Aten. feedback of relative syllable durations. erature may reflect conscious or unconscious experimenter A basic assumption associated with rate. pataka) (e. It has also been speech production in speakers with moderate and mild AOS. with respect to attention.. accompanied by hand tapping Rhythmic control Brendel. none of which have been con- cant sound errors. although other investi. More data are required to docu. and utilization of a pacing board. sentence repetition.g. even in speakers who already exhibit reduced rate. Or. it is clear that in the timing of speech production.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1024 APTARA(GRG QUARK) 1024 Section V ■ Therapy for Associated Neuropathologies of Speech. Unfortunately.and Language-Related Functions TABLE 36–2 Rate. There are many theorized these treatments may be expected to result in improved mechanisms by which rate. hand-tapping. Rate.. 2002. perhaps more tion. Slowing of speech produc- resistant than others for some speakers (Raymer et al.. Metronomic pacing Mauszycki (2006) Repeated practice of multisyllabic words at increased rates of plus hand tapping production in time with metronome./h/ sequences with metronome at slowed rate with gradual increasing of rate Metronomic pacing Wambaugh and Martinez (2000) Repeated production of multisyllabic words with metronome plus hand tapping and hand tapping. it may be the case that general approach include rate control through metronomic behaviors in severe AOS (versus moderate or mild AOS) are pacing. thought to allow additional time for motor planning and/or ment the effects of articulatory-kinematic treatments on programming and processing of feedback. thus.. and vowel . 1986). Clinician cueing used initially. is Wambaugh et al. clinician instruc- more amenable to experimental control (e. then faded. 1996). Ziegler. only upon.and rhythm-control treatments accuracy of speech production for individuals with signifi. Abkarian. To date. multisyllabic words.. the techniques included in this iology to perceived severity. Pacing board added. Feedback about rate provided. For example. tion. and finger tapping Rate control McHenry and Wilson (1994) Rate reduction with syllable-by-syllable production. data-based methods for documenting AOS severity a few investigations have reported the effects of such treat- and determining the contribution of underlying pathophys.and Rhythm-Control Approaches for the Treatment of AOS Treatment Type Reference Brief Treatment Description Metronomic pacing Dworkin.and rhythm-con- bias. puh puh puh puh) perceived as being more disruptive of communication in and rhythm-control approaches involve manipulations of rate severe AOS. Clinician modeling and unison production used initially. with both often being impacted. and Johns (1988) Following tasks practiced with a metronome at slowed rates of production: nonspeech tasks with bite-block. prolonged speaking. are thought to impact AOS.and Rhythm-Control Approaches in speech production (Dworkin & Abkarian.. rates were gradually increased Metronomic pacing Dworkin and Abkarian (1996) Practice of vowels. waveform and auditory feedback. Rate increased and syncopation added. have typically involved rate reduction (although see gators have reported that some sounds seem to be more Mauszycki & Wambaugh. and/or rhythm.g. 1998a). the existing lit. effects to untrained behaviors (e. Tjaden.” which were controlled for rate ual vowels. tice with the metronome set at extremely slow rates (e.. Dworkin et al. they provided descriptions of a task being gradually withdrawn. the hand-tapping was that the tapping (1) could serve as a Investigations focused on the rate and rhythmic facilitative self-initiated mediating device that could be used when the effects of surface prompts have not yet been reported. the beat of the metronome has been set at a rate that accuracy. ridge with a bite block in place) as well as speech activities (e.. Southwood (1987) encouraged use of a prolonged syncopated rhythm at the participant’s request.g. and vowel . 12. secutive section on the board for each unit of speech. Specifically. With metronomic pacing. it appeared that little clinical instruction was involved. Wambaugh and Martinez selected a rate controlled/trained through visual displays and/or feedback. although improvements were slightly less than Mauszycki & Wambaugh. which is a board divided horizontally into sections In the investigations by Dworkin and colleagues (1988. Tjaden reported negative results for a Martinez (2000) trained multisyllabic word productions that generalization measure of stress patterning. They provided clinician cueing. Dworkin et al./h/ alternations. with the metronomic pacing. Wambaugh and positive outcomes. board. play to have speakers match their productions to computer- tion. 1996) initiated prac. 2000. 2000. Wambaugh & Martinez. tip raising did not result in improved performance with Of the relatively few investigations designed to examine AMRs). Whereas Southwood and Brendel and colleagues reported SMRs and multisyllabic word productions). Wambaugh and Martinez (2000) and 1984). half have reported by Wambaugh and Martinez (2000) in that been focused on metronomic pacing (Dworkin & Abkarian.. Mauszycki and McHenry and Wilson (1994) used a combination of Wambaugh (2006) utilized multisyllabic words and phrases in techniques to reduce rate. Dworkin and Abkarian (1996) utilized stimuli minute). Tjaden (2000) used a wave- Dworkin. accuracy. 1988. generated “rhythmic cues. They also gradually increased rate and added a tion). manner of speaking and used a video display to present The behaviors that have been practiced with pacing words for oral reading at specified rates (30-130 words per have varied. were grouped according to stress pattern. Surface performing the speech tasks. those observed with trained words. In contrast. & Deger (2000) suggested a different attentional complex behaviors. and a numerical indicator activity (raising and lowering the tongue tip to the alveolar of relative syllable durations to treat stress patterning.. metronomic pacing and hand-tapping. vowel sequences. they proposed that their rhythmic-control treat. Patients are trained to touch each con- 1996). Such That is. that reflected a 50% reduction in the participant’s typical In a facilitation study (i.. Dworkin and colleagues (1988. Specifically. devices have been recommended for use (Wertz et al. The rationale for inclusion of prompts are those that highlight tempo and stress patterns.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1025 APTARA(GRG QUARK) Chapter 36 ■ The Nature and Management of Neuromotor Speech Disorders Accompanying Aphasia 1025 leagues (1998) hypothesized that use of a metronome may of apraxia (Dworkin & Abkarian.. treatment of tongue- trolling stimulus and away from speech movements. by raised dividers.g.e. 2000) have been rates to 120 bpm. along with use of a pacing with a speaker with mild AOS. Brendel and colleagues (2000) also used a video dis- designed to promote increased volitional control over phona.g. practice was largely independent and patient con. Mauszycki and Wambaugh (2006) also noted is considerably slower than the habitual rate used by the increased articulatory accuracy following practice with speaker. that Wambaugh and Martinez provided no training for artic- usually at a rate of one syllable or movement per beat. (1988) reported a lack of generalization of treatment ment may have drawn attention toward the externally con. Surface metronome was not present and (2) provided additional prompts are discussed further in “Formalized Treatment rhythmic stimulation. which involved increasing rates of production which was gradually faded. Most ulation and provided no feedback relative to articulatory often. have helped to focus the patient’s attention on the need 1996). the patient practiced production of individ. Dworkin and colleagues (1988) reported that training for increased precision during speech production. the patients were Another technique that may act at the level of rate/rhythm required to tap along with the beat of the metronome while modification is the application of surface prompts. their practice. The treatment protocol used continuum progressing from imitation of functional by Wambaugh and Martinez is shown in Appendix 36. It is important to note speech productions are produced to the beat of a metronome.. and metrical form. McHenry and Wilson’s rate-control treatment was eling in early treatment phases. 2006). In contrast. Generalization to untrained behaviors was also the effects of rate. trolled. effects at beginning levels of practice generalized to more Ziegler. Dworkin and Abkarian mechanism. 1987) and rhythm of 15.. with clinician involvement described only briefly. phrases and multisyllabic words to structured responses in Furthermore. Although Mauszycki and Wambaugh (in press) utilized clinician mod. Abkarian.and rhythm-control treatments. both investigations combined hand-tapping conversation to unstructured conversation. audiotory feedback. not a true treatment investiga- speaking rate. but little data exist concerning their utility. 1988.” Dworkin and colleagues reported positive changes for all Another technique that may function at the level of trained behaviors in terms of reduced presence of symptoms rate/rhythm that has not received direct investigation is . Rate of production (Southwood. Brendel. and Johns (1988) employed a non–speech form display. or 30 beats per minute [bpm]) and gradually increased production (Brendel et al. Additionally.4. Programs with Supporting Evidence. untrained words improved with respect to articulatory 1996. 1980). & imitation-only treatment. Intersystemic reorganization entails the utilization of a rela- tively intact system/modality to promote functioning of an Alternative/Augmentative Communication Approaches impaired system/modality (Rosenbek et al. and training in use of Blissymbols (Bailey. ily of cases in which AOS was accompanied by significant Improvements were noted in terms of improved articulation aphasia. 1982). 1978) treatment. 1982) and singing (Keith & Aronson. Florance. lvi). facilitation of speech rather than necessarily reorganization of “the common motivation for the eight treatment investiga- communication. Skelly. 1979) and Samples. The literature concerning AAC and AOS consists primar- tigations in which gestures were paired with verbalizations.. 1974. cation system (Yorkston & Waugh. The rationales for the treatments described tions involving alternative/augmentative approaches was the in this section carried no assumptions about presumed patho. 1981). They described a case production of targets such as words or sentences (Code in which an individual with chronic aphasia and AOS demon- & Gaunt. An and use emphatic stress to facilitate speech production. 2006b.e. 1978) ges. To work through this Marshall.. perceived need to improve communication through the use physiology associated with AOS. However. strated unwillingness to use an AAC device beyond the con- 1978.and Language-Related Functions contrastive stress drills... (1984) or Square Martin colleagues applied a vibratory source to a participant’s fin- & Bose (2001) and their colleagues for further discussion. Lane & Both iconic (e. Such drills have been advocated for being paired with verbalization (Dowden et al. Rubow and colleagues theorized sia have included development of a comprehensive communi- that gestural reorganization techniques may provide an orga. Rubow and The reader is directed to Wertz. Rubow et al. As noted in the AOS guidelines. finger-counting. the potential cussed in the next section. methods for either circumventing or supplementing Rubow and colleagues (1982) suggested that additional affer. & McCauslin. 1991.. PICA verbal scores)... Words begin- Additional techniques that may be considered rate and ning with fricatives received vibrotactile plus imitation rhythm techniques include finger counting (Simmons.. 1984) as well as increases in test scores (Simmons. Improvements were reported for all of the inves. 1989). the language disturbance may be the . Rosenbek. in terms of selecting the specific AAC approach and Skelly et al. although quan- Intersystemic Facilitation/Reorganization Approaches titative data were not provided. not be adopted by potential users or may be used ineffectively zation. while words beginning with plosives received and vibrotactile stimulation (Rubow.. fines of the speech-and-language clinic. because their developers consid. Additionally. When gestures were trained without designing treatment.. require stress to be placed on a particular word in the response. apy which involved choral singing of a familiar song and production of object names and functional phrases in song.g. temic facilitation/reorganization (Wambaugh et al. 2006a). answer dialogues that consist of short phrases centered on one Other techniques included in this general approach are or two target words are used. 1983. production. Facilitative effects of singing were reported. The AOS Treatment Guidelines Committee added the term “facilita. 1975).. al... Dowden. quently. That is. Lasker and Bedrosian (2001) noted that AAC options may tures have been studied. tion was judged to be less than optimally effective and conse- systemic facilitators/reorganizors effect changes in speech. 1978. Simmons. these approaches will be dis. Simmons. 1982. Although a superior treatment Longstreth. Amer-Ind gestural code.. Collins. ger during production of polysyllabic words. inequality in difficulty of the word lists served as a con- ered their therapeutic effects to derive from intersystemic found. effect was found for the vibrotactile treatment. 1986.. With gestural facilitation/reorgani. 1981) no ver- treatment of AOS (e. et al. p. Utilizing gestures to enhance speech production has been instruction in use of voice-output communication aids (Lasker the technique most often studied in terms of AOS intersys. 2006b).GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1026 APTARA(GRG QUARK) 1026 Section V ■ Therapy for Associated Neuropathologies of Speech. 1983. & Thompson. 1974). 1976). Few theories have been of modalities other than speech. total communication approach (Fawcus & Fawcus. Raymer varied stress provide a form of variable practice. Wertz et al. 1984). The remaining general approach to the treatment of AOS tion” to the description of these approaches because the identified in the AOS guidelines report was AAC intent as well as the outcome of the treatments appeared to be (Wambaugh et al. Wertz et al. and Tompkins (1981) trained only gestural pro. However. nonmeaningful (e. & Bedrosian. An added benefit of gestural plus verbal training may be improve- additional potential benefit is that repeated productions with ments in gestural productions (Code & Gaunt. ence provided through the engagement of additional systems Reports of AAC training with persons with AOS and apha- may play a role.. 1991. 2001.g. Rabidoux. 1991). speech were devised” (Wambaugh et al. It is impossible to determine the contribution of the (Raymer & Thomspon. problem. development of a nizational framework for speech production. Question-and. 1986.. Skelly et al. gestural production is typically paired with verbal because of problems with acceptance. verbal communica- advanced regarding the possible mechanisms by which inter. Wertz et co-occurring disorders to the need for AAC in these cases. 1990). Keith & Aronson reported a case of singing as ther- reorganization. Rosenbek. Questions are manipulated to the provision of vibrotactile stimulation (Rubow et al. they implemented a community-based treatment duction but measured the effects of treatment on verbal program utilizing role play and outings. 1984) bal changes were reported (i. Raymer & Thompson.g. Deal and Florance (1978) reported successful application of a modified version of the continuum As described in the previous sections. Formalized Treatment Programs with positive results were reported for the three participants. collaborative efforts of Square.. to treatment (e. 1984). These are treat- study the effects of a modified version of the continuum with ments that are relatively more developed than others available an individual with moderate AOS and aphasia. especially in terms of generalization research to address remaining questions regarding treatment to untrained items and to different stimulus conditions. ances. who had been blind from birth.5 shows the treatment protocol described by PROMPT was developed by Chumpelik (Hayden) (1984) as Rosenbek and colleagues (1973). rather. leagues (Square. Lustig and Tompkins applied treatment faded as the steps progress and ultimately. In addition. longer than 1 year post.”. the target utterances that required the participant to use a written response upon are elicited in simulated. and col- Rosenbek and colleagues chose five. PROMPT “home”. outcomes and optimal conditions of application.. some single words Tompkins (2002) for a complete explanation of treatment may not be appropriate for Steps 7 and 8) and rapid response and description of comprehensive outcome measures. transitioning. In this case. 2006b). However. “My name is ________.e. That is.”). functional target utter.g. Chumpelik. Chumpelik (Hayden). individualized for each client (e. Criterion for moving to the next step is 80% correct in 20 Two reports of AAC approaches that were designed consecutive treatment trials. many techniques are with four participants with severe AOS. data from seven cases and one experimental study indi- replications have not been attempted for the majority of AOS cate that individuals with AOS and aphasia may benefit from treatment reports. The reader is referred to Lustig and different types of treatment stimuli (e. chronic (i. & Adams. Of importance is the fact that their effects have been pant. In sum- been reported in subsequent investigations. repeated application of the eight-step continuum in terms of acquisition study of the treatments has provided a more substantial evi- of limited sets of functional words/phrases/sentences. naturalistic communication situa- the occurrence of spoken production that occurred with tions. 2002. Clinician cues are communication. in this text for information concerning AAC and aphasia. was trained on produc- replicated in two or more investigations. and amount and type of contraction) to children with severely viduals with severe. place of articulation. A weakness of the tion of 10 sentences under two training conditions: one with- existing AOS treatment literature is a lack of replications of out Braille and one with Braille... In the following sections. The partici- for AOS. Rosenbek and colleagues (1973) noted that various leagues reported on a case in which apraxia was considered response facilitators were necessary and were individualized to have selectively affected motor programming of the lar.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1027 APTARA(GRG QUARK) Chapter 36 ■ The Nature and Management of Neuromotor Speech Disorders Accompanying Aphasia 1027 primary consideration.e. & Windsor. Presentation facilitators such as slowed presen- and Tompkins (2002) designed a treatment for an individual tation. it is that mary. when the participant had difficulty in verbal expression. the continuum. and exaggerated articulation were with AOS and aphasia who had developed an unproductive reported. More dence base than exists for most AOS treatments. The participant improved positive treatment findings (Wambaugh. 2002. Morningstar.. The reader is directed to Chapter 30 into the continuum one at a time. the patient was provided with an electro. timing. additional therapeutic techniques were larynx to compensate for the deficits in phonation. production facilitators such as utiliza- communicative pattern of persistent verbal struggle. In a Supporting Evidence follow-up investigation. Steps of the continuum may be skipped to accommodate struggle behavior. Application of PROMPT to adult speakers onset) AOS and moderate aphasia. Marshall and col. increased stress. Simmons (1980) used a withdrawal design to three treatment programs are described. The treatment was originally described along articulation (i. impaired speech. Gandour. Since its initial description (Chumpelik. correctness. Eight-Step Continuum PROMPT Appendix 36. 1986). with communicative adequacy being stressed.g. tion of a mirror and phonetic placement cueing were used. 1985. with a report of three cases in which it was applied with indi. experimental investigations of this treatment are required to even the following treatments require substantial additional further specify its effects. called the eight-step task a dynamic method for delivering tactile cues concerning continuum. In the Rosenbek report. Lustig employed. & Adams. in addition to the steps of ynx. generalization may permit skipping steps). beginning at Step 1. Square.g. she The continuum begins with steps at which the clinician produced excessive verbal reattempts that were disruptive of exerts a relatively high degree of control. varying in length from one to seven words. The treatment entails with AOS and aphasia began during the 1980’s through selecting a limited set of target utterances for the client. clinician specifically to circumvent problems resulting specifically judgment apparently served as the primary determinant of from AOS are available (Lustig & Tompkins. For the treatments that follow. which were Chumpelik. three of whom had available for the treatment of AOS. Wambaugh under both conditions. chronic AOS. but demonstrated superior perfor- et al. 1988). Marshall. It is not the case that negative findings have mance when Braille was utilized in the continuum. That is. “It’s time to go. Target productions are entered has been developed into a comprehensive approach to the . In the original report concerning the eight-step continuum.. according to client needs. similar to those reported by Square and colleagues in response generalization to untrained exemplars of the tar- that the participant successfully learned the trained get sound may be expected to occur at levels of accuracy items. time of segments. predictions can- itive results for imperatives and active declaratives. tions. Freed and colleagues (1997) trained an reversed upon a correct response. 5). The original SPT hierarchy is shown in Appendix leagues (2001). description of its techniques is meant to provide the reader with the basic concepts associated with PROMPT. 36. leagues represent supporting data from independent Because of the complexity of PROMPT. mini- complex prompts.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1028 APTARA(GRG QUARK) 1028 Section V ■ Therapy for Associated Neuropathologies of Speech. extent of mandibular opening. and PROMPT can be applied consistent basis at some level of production. designed to facilitate improved production of specific ing. muscle tension. Specifically they measured the precision of has been observed for sounds that demonstrate similar production of short sentences grouped by imperatives. The level of at various levels of production ranging from movement production at which sound-production difficulty may be parameters such as jaw opening to sentence productions. SPT combines modeling. SPT was presence and extent of labial rounding and retraction. the minimal-contrast item is introduced cation of PROMPT with speakers with AOS suggested only upon incorrect production of the target item. from the extant literature concerning PROMPT applied to It is of importance to note that the positive results AOS that selected techniques rather than the entire treat. 2004. manner of production with similar types of errors active declaratives. .. extensively than other treatments for AOS.com). integral stimulation. in order to maximize repeated practice. repetition. No generalization to untrained Hayden. sounds targeted for treatment. Therefore. articulatory place- description of the different types of prompts as well as the ment cueing. The most recent & Frazier. upon the level of support required: parameter prompts. Findings indicated pos.and Language-Related Functions management of speech-production disorders in children (see not for interrogatives. Bose and colleagues (2001) examined the lated (i. trained productions in novel situations was reported 1999). the steps of the hierarchy are not treatment setting. It appears for gains made with imperatives and active declaratives. minimally contrastive word pairs. research groups. that are “designed to heighten sensory input regarding the Wambaugh & Nessler. and feedback in a response-contingent hier- contextual application of PROMPT see Square and col.. but generalization was not evident to untrained that approximate trained items (Wambaugh. 1997. 1989). archy. 2001. and interrogatives in an individual (Wambaugh & Cort. Partial generalization of PROMPT. 1998). which is an important component in the ing is recommended for its correct administration (www. but not be made concerning these effects with SPT. 1986. items. demonstration of treatment efficacy (Chambless & promptinstitute. 1998).. Square et al.7. Sounds selected for treat- tion. 1985. consequently. the following brief Hollon. In addition. Wambaugh et al. the SPT hierarchy (both versions) is untrained items was not evident. the silent-juncture step was eliminated. PROMPT uses a com- bination of proprioceptive. 2004. As seen in & Hayden. For a detailed mal-pair contrast. Steps of the hierarchy are used only indicated generalized use of trained phrases beyond the as needed.. that application of PROMPT resulted in positive Additional repetitions are elicited upon a correct response changes in production of trained individual sounds. Appendix 36. Initial research concerning the appli. However.. 2004. 2004) has been evaluated more place of articulatory contact. In addition. and/or coarticulation” (Bose & Square. 1986. pressure. monosyllabic words. Stimulus generalization in the form of use of Wambaugh & Nessler. and a reduced- gle words. 2004. and description of PROMPT). 2001. concep.6. phrases. not to Sound-Production Treatment provide instruction in its application. individual with severe AOS and aphasia in the produc. Wambaugh. and sentences. incorporate principles of motor learning.7. ment are those that are produced in error on a relatively Treatment is individualized. 1998. Research with SPT has shown that when eight to 10 tion of 30 functional words and phrases. Modifications to the original hierarchy have been The use of PROMPT is supported by the findings of made based upon research findings and the desire to several investigations (Bose et al. and phrases feedback schedule is used with those additional repeti- with speakers with AOS (Square et al. sin. for a thorough review of the history. Square-Storer version of SPT is shown in Appendix 36. Marshall. reported by Freed and colleagues and Square and col- ment approach have been utilized. 1985. Freed. Generalization to As noted previously. voic. Square-Storer & Hayden. are not cognates or closely related in manner of impact of the type of sentence construction on the effects production) is likely to be minimal. but anecdotal reports response contingent. Generalization to untrained sounds that are unre- anecdotally. clinician train. and kinesthetic cues Sound-Production Treatment (SPT. Stimulus generalization has not with moderate AOS and aphasia. Results were exemplars of the target sound are trained to criterion. been evaluated extensively. items was observed. evidenced and at which treatment is directed includes syl- Different types of prompts are available for use depending lables. and surface prompts. p.e. maintenance effects were positive tual framework. manner of articula. multisyllabic words. 1989). Wambaugh and Martinez guage-dominant hemisphere. length of stim. Wambaugh and Martinez same neurologic event that caused the aphasia. 2004. The presentation of such Wambaugh et al. mainly noninvasive. 2006a). language deficits frequently co-occur after damage to tion of aphasia has most often been reflected in the selection the left hemisphere. 2006a. speech-production accuracy have not been examined. Treatment Summary plex production conditions has been observed for some Persons with aphasia may also have neuromotor speech dis- speakers (Wambaugh. incorporated treatment techniques considered to facilitate 5. Treatment for AOS and Aphasia technologies. 2004. This may explain why speech and cial attention to the accompanying aphasia. That is. not simply in the execu- verbal expression have usually not been provided in sufficient tion of movement. have comes. but rarely will they be the result of the to patient-initiated verbalizations. aphasia (Wambaugh et al. Kearns. what we know about their function. 1998b). Clinicians should base treatment decisions on bal- AOS will necessitate significant amounts of repeated prac. guage deficits simultaneously in the future. 4. the appear to play a role in higher level cognitive func- descriptions of the accompanying aphasia and its impact on tions relating to movement.. which impact language pro.. Thanks to the advent of new. 1998b). modifications to existing aphasia treatments. Apraxia of speech (AOS) and unilateral upper motor speech production in AOS is Response Elaboration Training neuron dysarthria may occur with aphasia and may (RET. 2. For example. believed to be separate processes. anced consideration of the best available evidence. have provided relatively superfi. based on der in order to focus on the motor-speech deficit. Clinicians must understand the impact of both the integral stimulation. disorders associated with brain damage to the lan- sons with significant AOS. aphasia and AOS/dysarthria. the following factors. 1985). Other forms of dysarthria may be present through the use of modeling and forward-chaining applied with aphasia. 2004). why damage to the left IFG or the left IPL could result ified to accommodate the presence of AOS and that has in problems in producing longer words. may allow clinicians to target both speech and lan. KEY POINTS 1. Areas ment literature presented with some type and degree of such as M1. The considera. reported positive changes in production of verbal content 7. and patient RET. which were thought to be purely motor. such as the left IFG. particularly in terms of verbal increased production of content and length of utterances expression. much remains to be clarified about the outcomes associated with SPT. Clinicians should be aware of the treatment recom- upon application of modified RET in three speakers with mendations and options described in the AOS chronic AOS and aphasia. and patient preference. disorders will be unique for each individual.. needs and preferences. once treatment. it can be expected that SPT will result in improved production of targeted sounds for speakers with AOS. functionality. 6. brain regions that subserve speech production. orders such as AOS and dysarthria.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1029 APTARA(GRG QUARK) Chapter 36 ■ The Nature and Management of Neuromotor Speech Disorders Accompanying Aphasia 1029 positive stimulus generalization to longer and more com. we can understand One treatment for aphasia that has been specifically mod. Unfortunately. Speech production and speech perception. Several cortical regions. Although it is likely that changes in speech production in 8. The effects of modified RET on Treatment Guidelines (Wambaugh et al. In light of what we have learned about the role that dif- uli. we have learned a great deal about the Virtually all of the participants described in the AOS treat. and repeated practice of utterances to language and motor aspects of verbal-production make the treatment more amenable for application with per. and words elicited through sen- orders can benefit from treatment directed toward their tence completion (Wambaugh & Nessler. appear to be tightly duction as well as speech production.. (2000) modified RET by incorporating additional modeling. taken into account: frequency of occurrence. tice. 2004). Most treatments for AOS. Significant evidence exists indi- sentences containing numerous target words/sounds cating that persons with aphasia and neuromotor speech dis- (Wambaugh et al. . It is our impression ferent brain regions play in speech production. Although speech disruption. 2006b). of treatment stimuli. as will the com- SPT has been modified with successful results for applica- munication disruption resulting from the combination of tion to multiple sound targets (Wambaugh & Nessler. with a few exceptions (such been shown to play a role in both language and as those focused on AAC). could produce similar deficits. detail to allow inferences about its effect on treatment out. theoretical rationale. such as clinical experience. speech behaviors. we can that treatments for AOS have generally been designed to understand how damage to different brain regions work around the constraints of the patient’s language disor. Wambaugh & Nessler. have sometimes been linked in the brain. RET was developed to promote exacerbate its effects. in the selection of items for 3. K. Brodmann’s localisation in the cerebral cor- Alario. J.. 41. Circuitry and functional aspects of the insular lobe in primates including humans. The role of Amunts. Bohland. C. apraxia of speech. W. 11(4).. Zilles. Jones. S. Code & D. changes. J.. (Original work role of the Supplementary Motor Area (SMA) in word produc. M. & Yule. 241–327.. S. & Blumstein. In location of the lesion that produces apraxia of speech. speech perception and speech production has changed. Austin. suivies d’une observation d’aphémie. 66. P... F. Bulletin de la Academy of Neurologic Communication Disorders and Sciences Société Anatomique. (2003). 8–16. F. 353–362. (2004). Broca’s region revisited: cytoarchitec.and Language-Related Functions ACTIVITIES FOR REFLECTION AND DISCUSSION area. R.. Augustine.. a diagnosis of AOS. J.. J. R.L. (1995).. D.B. Comparable patterns of muscle Anwander. verbal fluency in cytoarchitectonically defined sterotaxic space— Proceedings of the National Academy of Sciences. Brain and Language. (1972). H. descriptors have changed. K.).. M. Describe how our view of the relationship between during collision judgments.... & Zilles. A.. J. 14. A. & facilitation evoked by individual corticomotoneuronal (CM) cells Knösche.. Ditterich.. Journal of Consulting and Clinical Psychology. (1990). 6..g. C. 22. In R. Develop at least two explanations for why. Discuss the possible advantages and dis. 1975) and discuss how the diagnostic region. K. Annals of Neurology. New York: Springer. Koastopoulos. 42–56. 15(8). 4. Journal of 1. Aten. Perisylvian lan- Neurophysiology. H. 319–341. Broca’s quences for the concept of apraxia of speech. G. 13. The tex (L. H. J. H. & Petrides.W. of study. Friederici. J. G. A. (2006). (2006). Review the characteristics that are considered necessary London: Edward Arnold. (1986). P. (2006). H. Left inferior parietal cortex integrates time and space 2. Soon.. A. K. A. Neuroscience. 243–256. M.GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1030 APTARA(GRG QUARK) 1030 Section V ■ Therapy for Associated Neuropathologies of Speech. Bose. H. E. (1999). The Journal of Comparative Neurology. Chambless. 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NeuroImage. H. 57. Lehéricy.com Asanuma. K. P. X. (1979). A. It appears that Broca’s area plays a role in multiple cortical efferent zones projecting to distal forelimb muscles in aspects of speech and language behavior. S.. Aphasiology. J. The roles of Brodmann areas 44 and 45. & Pallier. Darley et al.. et al. A. Eickhoff. person with aphasia. L. 2nd ed. H. Remapping the motor cortex. Case studies in apha- would change your approach to evaluation and/or treat. (1985). P. Ritzl.articulateinstruments. Muller (Eds. sia rehabilitation (pp. Left Gurd. Revisit the early descriptions of AOS Binkofski.. Journal of Cognitive Neuroscience. (2000). M. S82–S88. (2003). T. & Deger.. (ANCDS)(2007). Journal of Neurolinguistics. & van Lieshout. Chee. Aphasia Therapy (pp. 1696–1698. (2006). Tittgemeyer. (1998). ASHA Division 2 Newsletter. W. after decades 229–244. Square. & Rosen. & Cohen.. Local morphology predicts functional organization of Theoretical and clinical aspects.. there is still no universal agreement on the Bailey. M.. (2000). Mohlber.. C. P. (2005). K. Amunts. Marshall (Ed. G... 89. Blumstein. Articulate Instruments (2006). 767–785. Naeser. ture and intersubject variability. 119–132). Schleicher. & ffytche. L. Uylings. P..). Bose. D. 362–369. 3. for a diagnosis of AOS and those that are consistent with Barinaga. Noth. Describe the speech characteristics of a patient with AOS perception in aphasia.. guage networks of the human brain. P. functions and yet still be efficient. Topographical organization of 1. ment of motor-speech disorders. K. The synchronization paradigm in the treatment of apraxia of speech. Phonemic false evaluation: (2006).). & Zilles. A. (2001). Champod. Remarques sur le siége de la faculté du langage articulé.). A. PROMPT treatment method and 6. (1983). Language. C. 129–143.. the dorsal premotor region in the human brain. A.. 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Journal of Medical Speech Language Pathology, 14(2), ment of neuromotor speech disorders in aphasia. In R. H. xxxv–ixvii. Chapey (Ed.), Language intervention strategies in adult aphasia Wambaugh, J. L., Kalinyak-Fliszar, M. M., West, J. E., & Doyle, P. (4th ed., pp. 847–884). J. (1998a). Effects of treatment for sound errors in apraxia of Square-Storer, P. A. & Apeldoorn, S. (1991). An acoustic study of speech and aphasia. Journal of Speech, Language, Hearing apraxia of speech in patients with different lesion loci. In C.A. Research, 41, 725–743. Moore, K. M. Yorkston and D. R. Beukelman (Eds), Dysarthria Wambaugh, J. L., Martinez, A. L., McNeil, M. R., & Rogers, M. A. and apraxia of speech: Perspectives on management (pp. (1999). Sound production treatment for apraxia of speech: 217–286). Baltimore: Paul H. Brookes Publishing. Overgeneralization and maintenance effects. Aphasiology, Square-Storer, P. A., & Hayden, D. C. (1989). PROMPT treat- 13(9–11), 821–837. ment. In P. Square-Storer (Ed.), Acquired apraxia of speech in Wambaugh, J. L., & Martinez, A. L. (2000). Effects of modified aphasic adults (pp. 190–219). Hove and London: Lawrence response elaboration training with apraxic and aphasic speakers. Erlbaum. Aphasiology, 5/6, 603–617. Talairach, J., & Tournoux, P. (1988). Co-planar stereotaxic atlas of the Wambaugh, J. L., & Nessler, C. (2004). Modification of Sound human brain. New York: Thieme Medical. Production Treatment for aphasia: Generalization effects. Tjaden, K. (2000). Exploration of a treatment technique for Aphasiology, 18(5/6/7), 407–427. prosodic disturbance following stroke. Clinical Linguistics and Wambaugh, J., Nessler, C., Bennett, J., & Mauszycki, S. C. Phonetics, 14(8), 619–641. (2004). Variability in apraxia of speech: A perceptual and Tomaiuolo, F., MacDonald, J. D., Caramanos, Z., Posner, G., VOT analysis. Journal of Medical Speech Language Pathology, Chiavaras, M., Evans, A. C., et al. (1999). Morphology, mor- 12(4), 221–227. GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1035 APTARA(GRG QUARK) Chapter 36 ■ The Nature and Management of Neuromotor Speech Disorders Accompanying Aphasia 1035 Wambaugh, J. L., West, J. E., & Doyle, P. J. (1998b). Treatment Wise, R. J. S., Scott, S. K., Blank, S. C., Mummery, C. J., Murphy, for apraxia of speech: Effects of targeting sound groups. K., & Warburton, E. A. (2001). Separate neural subsystems Aphasiology, 12, 731–743. within “Wernicke’s area.” Brain, 124, 83–95. Warren, D. W., Allen, G., & King, H. A. (1984). Physiologic and Yorkston, K. M., & Beukelman, D. R. (1981). Assessment of intelligi- perceptual effects of induced anterior open bite. Folia bility of dysarthric speech. Austin, TX: Pro-ed. Phoniatrica, 36, 164–173. Yorkston, K. M., & Waugh, P .F. (1989). Use of augmentative com- Watkins, K., & Paus, T. (2004). Modulation of motor excitability munication devices with apractic individuals. In P. Square- during speech perception: The role of Broca’s area. Journal of Storer (Ed.), Acquired apraxia of speech in aphasic adults (pp. Cognitive Neuroscience, 16, 978–987. 267–283). Hove and London: Lawrence Erlbaum. Wernicke, C. (1874). Der aphasische symptomenkomplex. Breslau, Yorkston, K. M., Spencer, K., Duffy, J., Beukelman, D., Gopher, Germany: Cohn & Weigert. L. A., et al. (2001). Evidence-based practice guidelines for Wernicke, C. (1885). Die neueren arbeiten uber aphasie. dysarthria: Management of velopharyngeal function. Journal Forschritte der Medizin, 3, 824–830. of Medical Speech-Language Pathology, 9(4), 257–273. Wertz, R. T., LaPointe, L. L., & Rosenbek, J. C. (1984). Apraxia of Yorkston, K. M., Spencer, K., Duffy J. R. (2003). Behavioral man- speech in adults: The disorder and its management. Orlando, FL: agement of respiratory/phonatory dysfunction from dysarthria: Grune & Stratton. A systematic review of the evidence. Journal of Medical Speech- Wertz, R. T., LaPointe, L. L., & Rosenbek, J. C. (1984). Apraxia of Language Pathology, 11(2), xiii–xxxviii. speech in adults: The disorder and its management. Orlando, FL: Yorkston, K. M., Hakel, M., Beukelman, D. R., & Fager, S. Grune & Stratton. Square-Storer, P.A. (1989). Acquired apraxia (2006). Evidence for effectiveness of treatment of loudness, of speech in aphasic adults. London: Taylor & Francis. rate or prosody in dysarthria: A systematic review. Journal of Wilson, S. M., Saygin, A. P., Sereno, M. I., & Iacoboni, M. (2004). Medical Speech-Language Pathology. Manuscript submitted for Listening to speech activates motor areas involved in speech publication. production. Nature Neuroscience, 7, 701–702. APPENDIX 36.1 Consonant-Production Probe Syllable Initial Stops d t b p g k deer tear beer peer gore core dip tip bop pop gap cap die tie buy pie gay Kay dot tot bit pit got cot dame tame ban pan game came Syllable Final Stops d t b p g k pad pat pub pup pug puck god got gab gap gag gawk sad sat sob sap sag sack tad tat tab tap tag tack ride right rib rip rig Rick Syllable Initial Fricatives s z f v sh th sin zen fin vine shine thin same zoom fame voom shame thumb sore czar fear veer shore Thor sit zit fit vet sheet thought sauce Zeus face vase shoes thaws GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1036 APTARA(GRG QUARK) 1036 Section V ■ Therapy for Associated Neuropathologies of Speech- and Language-Related Functions Syllable Final Fricatives s z f v sh th bus buzz buff pave bush bath sauce saws safe save sash Seth face faze fife five fish faith race raise roof rave rash wrath kiss keys cuff cove cash Keith Syllable Initial Affricate/Nasals/Glides/Liquids ch j m n r w l choke joke mine nine wren win line chain Jane met net right wit light chill Jill mail nail rail wail liar choice juice mice nice rash wish lash cheat jet mock knock rack wick lack Syllable Final Affricates/Nasal/Liquids ch j m n r l fetch judge fame fan fire file batch budge bum bun bear bale latch ledge lime line wire while witch wedge some sun sore soil notch nudge numb nun near kneel Blends s-blends l-blends r-blends ski clown crown star black break sled flag freeze swing sled trip small glass grass (From Wambaugh, et al., 1998a) APPENDIX 36.2 Example of Lists of Balanced Multisyllabic Words Bi-Syllabic Words by Initial Phoneme h f m s d r n hazel focus minus sausage decal raisin notice hyphen faucet mason siphon diesel rebate nylon humus famous mobile siren demon rotate nation haven feline motive sinus donut regal native GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1037 APTARA(GRG QUARK) Chapter 36 ■ The Nature and Management of Neuromotor Speech Disorders Accompanying Aphasia 1037 Tri-Syllabic Words by Initial Phoneme h f m s d r n hesitate feminine magazine sanitize dedicate radical nominate habitat physical marathon sedative deficit relative navigate homicide fabulous monotone silicone dominate renovate negative halogen pheromone medicate salivate decorate ridicule nicotine Bi-Syllabic Words by Final Phoneme z d m s l k p rabies nomad forum bogus vocal basic tulip topaz Cupid Salem recess rival lilac julep series lucid totem Venus legal cubic gallop pisces moped serum cautious naval Kodak bebop Tri-Syllabic Words by Final Phoneme z d m s l k p memorize latitude catacomb nemesis chemical bailiwick teletype paralyze renegade maximum paradise topical tomahawk leadership televise marinade synonym Genesis parallel Similac lollipop maximize solitude minimum populous monorail Tillamook handicap (From Mauszycki, S. C. (2006). Variability of sound production in apraxia of speech and aphasia: Perceptual analyses. Unpublished doctoral dissertation.) APPENDIX 36.3 Examples of Sentence-Completion Items /s/ 4. (pat) Every time I get home, my dog wants me to play with him and give him a friendly _________________. 1. (see) Before I can read the newspaper, I need to put on my 5. (pier) I tied my boat up at the dock or the _____________. glasses because I can’t ________________. 2. (set) A track-and-field runner always gets ready when he or she hears the phrase: “On your marks, get _____________.” /v/ 3. (seal) In order for a passport to be legal, the immigration 1. (vee) The little boy learned today to write words such as violin, department has to stamp a ____________. van, and vase, which are words that begin with the letter 4. (Sue) My best friend’s name is Susan but I call her by the nick- ____________. names of Susie or ___________. 2. (veil) A bride bought her wedding gown, shoes, and accessories. 5. (sigh) Everybody knows when my father is extremely tired and But later she realized that she did not buy a _______________. ready to go to sleep because he tends to yawn and ___________. 3. (view) If you live on the mountain and look over the city, you have a beautiful ____________. /p/ 4. (vet) My dog has been very sick for the past two days. I need to take her to the ___________. 1. (pie) Julie usually makes desserts when she has company. Last 5. (veal) Instead of making my beef stew with beef, I prefer to use Saturday, her parents came and she baked a delicious apple the meat of a calf, which is better known as ___________. ________________. 2. (pail) The little boy wanted to build a sandcastle, so his mom bought him a shovel and a _____________. /k/ 3. (pet) We have a goldfish, a hamster, and a dog in my house. I’m 1. (key) I was frustrated because I locked myself out. Fortunately, I responsible for the hamster because she is my _____________. remembered that I was carrying an extra _____________. GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1038 APTARA(GRG QUARK) 1038 Section V ■ Therapy for Associated Neuropathologies of Speech- and Language-Related Functions 2. (cut) My hair is too long. I need to go to my hairdresser and get 2. (late) Tim is never on time. He usually gets to school ten to fif- a new hair __________. teen minutes _______________. 3. (cot) Grandpa came to visit. Mom said to my brother: 3. (lit) Julie doesn’t like to live in a dark house. When she was “Grandpa can sleep in your bed and you can unfold the looking for a home, she made sure that it was well- _________________.” ________________. 4. (coo) When I went to New York, I visited Central Park. I loved 4. (low) Ted wants to apply for medical school but he needs to to feed the pigeons and hear their ________________. retake the test because he scored too _______________. 5. (car) I’ve been riding the bus for many years. I finally saved (lie) I tried to believe what they said but it was very hard for me enough money to buy a good ___________. because they always __________________. /1/ /m/ 1. (shoe) The little boy is almost ready to go outside and play. He’ll 1. (mitt) Tim was ready to play baseball. He brought a ball and a be ready once he ties his left ______________. bat, but then he realized that he forgot to bring his baseball 2. (shot) The flu can be deadly in older people. That’s why older __________________. people have been encouraged to have a flu _____________. 2. (me) Julie’s mom told her to call home as soon as possible. So 3. (shut) The little boy was so tired that when his mom finished when Julie was leaving, mom said: “Don’t forget to call reading the story, his eyes were already _________. ____________________.” 4. (share) At the beginning of the school semester, the teacher did 3. (mate) Ted is always dating but never seems to find the right not have enough books for all the children so she said: “We’ll person. He’s still searching for the perfect _________________. have to _________.” 4. (mow) The big kids share the yard work with their dad. 5. (she) We saw a beautiful dog at the pet shop. We wanted to get The grass is tall and dad asked: “Who is going to a “he” so we asked: “Is it a he or a ________?” _______________?” 5. (moo) I would like to live on a farm. I love to hear the horses /d^/ neigh, the ducks quack, the pigs oink, and the cows ____________________. 1. (jail) A man committed a crime and was caught. He was sen- tenced to 15 years in ________________. /n/ 2. (Jew) My friend believes in Judaism, so everyone considers him a ________________. 1. (knit) I know how to cross-stitch, sew, and crochet, but I don’t 3. (jaw) The boxer threw a punch near his opponent’s mouth and know how to _______________. broke his ____________. 2. (know) The teacher asked a question about what the children 4. (jar) The little boy was so hungry that he couldn’t wait for his were studying in class. A kid raised his hand and said “I lunch and grabbed some cookies from the cookie ___________. _______________.” 5. (gee) The little girl learned in class today that the words girl, 3. (night) The mom put her son in his bed, covered him with a game, goat, and guitar begin with the letter ___________. blanket, gave him a kiss, and said: “Good ______________!” 4. (need) The Boy Scouts were knocking on every door, asking for /l/ donations for families in _______________. 5. (knee) The boy was running and tripped over a rock. He was 1. (light) I was reading a book and all of the sudden the crying because he scraped his left ____________. room became dark. I told my husband to turn on the (From Wambaugh, J. L., & Nessler, C. 2004) ___________________. GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1039 APTARA(GRG QUARK) Chapter 36 ■ The Nature and Management of Neuromotor Speech Disorders Accompanying Aphasia 1039 APPENDIX 36.4 Metronome and Hand-tapping Treatment Level One:- Clinician Model, Unison Production, Beginning 2. PPT - 3 productions Patient Production a) If any errors in tapping to the beat or in producing correct number of syllables: CM (1 production) plus PPT (3 pro- A. S/Ta ductions); if errors remain: CM (1 production) plus UPT (3 B. Metronome setting: 93 bpm productions); if errors remain: clinician presents next target C. Treatment steps: word 1. CMb - 1 production b) If correct, clinician begins treatment steps with next word 2. Patient taps along (no verbal production), while clinician D. Target item presentation: same as Level 1 produces word - 5 productions E. Feedback: same as Level 1 3. UPTc- 3 productions F. Scoring: “” or “” for first production of PPT step 4. PPTd - 1 production D. Target-item presentation: Clinician presents experimental Criterion: 95% accuracy for entire treatment session in two consec- words (treatment items only) in random order. Clinician pre- utive sessions sents as many items per session as possible. E. Feedback: Clinician provides positive or negative feedback Level Four:- Increased Rate of Production about tapping, production of correct number of syllables, A. Metronome setting: 100 to 110 bpm and/or production of syllables on beat, but not about sound accu- B. Treatment steps: same as Level 3 racy C. Target item presentation: same as Level 1 F. Scoring: “” or “” for PPT step ( “”  correct use of tap- D. Feedback: same as Level 1 ping with production of correct number of syllables on the E. Scoring: “” or “” for first production of PPT step beat) Criterion: 95% accuracy for entire treatment session in two consec- Criterion: 95% accuracy for entire treatment session in two consec- utive sessions and no decrease in accuracy of trained items on utive sessions probes Level Two:- Faded Clinician Model, Repeated Patient Level Five:- Syncopated Production Production A. Clinician explains concept of syncopation: The target word will A. S/T be produced in two beats, with the first syllable on downbeat of B. Metronome setting: 93 bpm hand tap, the second syllable on the upbeat, and the third sylla- C. Treatment steps: ble on the downbeat of second hand tap. 1. CM - 1 production B. S/T 2. PPT - 3 productions C. Metronome setting: 100 bpm a) If any errors in tapping to the beat or in producing the correct D. Treatment steps: apply syncopation sequentially at each of pre- number of syllables: CM (1 production) plus UPT (3 produc- ceding levels, beginning with Level 1 tions); if errors remain: clinician presents next target word b) If correct, clinician begins treatment steps with next word D. Target item presentation: same as Level 1 Abbreviations E. Feedback: same as Level 1 a Schematic/tapping review (S/T): Clinician explains/reviews F. Scoring: “” or “” for first production of PPT step schematic of stress pattern for words under treatment; clinician Criterion: 95% accuracy for entire treatment session in two consec- and patient practice tapping with the schematic ( __ __ T ). utive sessions b Clinician model (CM): Clinician produces word with metronome (one syllable per beat), while tapping c Level Three:- No Clinician Model, Repeated Patient Production Unison production and tapping (UPT): Clinician and patient simultaneously produce target word, while tapping A. S/T d Patient production and tapping (PPT): Patient produces target B. Metronome setting: 93 bpm word, while tapping; clinician provides no model or assistance C. Treatment steps: (From Wambaugh, J. L., & Martinez, A. L. (2000). 1. Clinician says word with normal rate and prosody (no metronome or tapping) GRBQ344-3513G-C36[1009-1042]qxd 02-13-2008 05:28 AM Page 1040 APTARA(GRG QUARK) 1040 Section V ■ Therapy for Associated Neuropathologies of Speech- and Language-Related Functions APPENDIX 36.5 Eight-Step Continuum Step 1. Integral Stimulation. The target utterance is produced Step 5. Written Stimuli and Simultaneous Production. The client simultaneously by the client and clinician simultaneously with reads the target utterance aloud with written stimulus present. auditory and visual stimulation. “Watch me, listen to me” plus Step 6. Written Stimuli and Delayed Production. The clinician simultaneous production. provides the written utterance, then the client is asked to produce Step 2. Integral Stimulation and Delayed Production. The clini- the utterance after the written stimulus is removed. cian provides a model of the utterance, then asks the client to pro- Step 7. Appropriate Utterance Elicited by Question. The clini- duce the utterance while the clinician produces the utterance cian asks a question that is appropriate for eliciting the target without sound. That is, the auditory model is eliminated during utterance. simultaneous production. Step 8. Appropriate Response in Role-Playing Situation. The Step 3. Integral Stimulation and Delayed Production with No clinician and others assume roles to elicit the target utterance in a Visual Cue. The clinician provides a model while instructing the contextually appropriate situation. client to watch and listen. The client is asked to repeat the utter- ance. “I’ll say it first, then you say it after me.” Rosenbek, J. C., Lemme, M. L., Ahern, M. B., et al. (1973). A treatment for apraxia of speech in adults. J Speech Hear Disord, 38, Step 4. Integral Stimulation and Successive Productions. The 462–472. clinician provides a verbal model and the client is asked to pro- duce the target several times without any cues. APPENDIX 36.6 Original Sound-Production Treatment Hierarchy Step 1—Modeling/Imitation: The therapist produces the mini- Step 3—Integral Stimulation: If only the target sound or both mal contrast pair* and instructs the speaker to repeat the pair (e.g., sounds are incorrect in Step 2, then the target sound only is focused “say pie ... buy”). If the speaker cannot repeat the paired words upon at this step. If only the contrasting sound is incorrect, then together, each member of the pair is presented separately. If the that sound is focused upon. Using the single item (i.e., nonpaired target sound and contrasting sound are correct, feedback about item), the therapist instructs the speaker to “watch me, listen to me, accuracy is provided, another production of the target word is and say it with me”. If correct, then feedback is provided, another elicited, and the next pair is presented. If either sound is incorrect, production is elicited, and the next pair is presented. If the con- feedback about accuracy is provided and this step is reattempted. If trasting sound is incorrect, feedback is provided and the next pair is either sound is incorrect upon second attempt, feedback is pro- presented. If the target sound is incorrect, the therapist provides vided and Step 2 is attempted. feedback and moves to Step 4. Step 2—Modeling plus Written Letter Cue/Imitation: The Step 4—Modeling with Silent Juncture/Imitation: The clini- therapist points to printed letters representing the target sound and cian models the target word using a silent juncture, separating the contrasting sound while modeling production of the minimal-pair sound from the rest of the word (e.g., “Say the word like this, items. The speaker is asked to repeat each item. If both sounds are p . . . ie). The speaker is instructed to repeat the word. If correct, correct, feedback is provided and the next pair is presented. If feedback is provided and the next pair is presented. If incorrect, either sound is incorrect, feedback is provided and Step 3 is feedback is provided and the clinician moves to Step 5. attempted. GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1041 APTARA(GRG QUARK) Chapter 36 ■ The Nature and Management of Neuromotor Speech Disorders Accompanying Aphasia 1041 Step 5—Articulatory Placement and Modeling: The therapist C. 0% to 49% correct production at Step 1 in a single trial, use two provides verbal articulatory placement instructions specific to the single-item trials alternately with one minimal-pair trial. speaker’s perceived error, models the sound in isolation, and asks Notes: the speaker to repeat the sound. If correct or incorrect, feedback is provided and the clinician moves to the next pair of contrasts at • 10 exemplars of the target sound presented in random order Step 1. constitute one trial * • As many productions as possible should be attempted per ses- Modifications to the Minimal-Pair Presentation: sion (attempt to complete a minimum of seven 10-item trials) A. 80% to 100% correct production at Step 1 in a single trial • Continue treatment until at least 80% of trained items are pro- (10 items), use hierarchy exactly as above. duced correctly in PROBES (not during application of treat- B. 50% to 79% correct production at Step 1 in a single trial, use sin- ment) in two of three consecutive sessions gle items in alternate trials instead of contrast pairs at every trial (From Wambaugh et al., 1998a) (i.e., use only the target item without the minimal-contrast item). APPENDIX 36.7 Modified Sound-Production Treatment 1) Clinician produces the target item and requests a repetition 3) The clinician requests production of the target item using inte- a) if correct, the clinician provides positive feedback concern- gral stimulation: “watch me, listen to me, and say it with me,” ing accuracy, requests five additional repetitions,* and moves for a maximum of three trials to the next target item a) if correct, the clinician provides feedback, requests five addi- b) if incorrect, the clinician gives feedback and says: “Now, let’s tional repetitions,* and moves to the next item try a different word” and models the minimal contrast word b) if incorrect, the clinician moves to Step 4 • if correct, the clinician says: “Now, let’s go back to the 4) The clinician provides articulatory placement cues appropriate other word” & goes to Step 2 with the target word to the participant’s error and requests production of the target • if incorrect, the clinician gives feedback, and attempts item using integral stimulation; if correct, request additional production of the contrast word with integral stimulation repetitions (five times*) for a maximum of 3 trials; the clinician then moves to Step a) if correct, the clinician provides feedback, requests five addi- 2 with the target word tional repetitions,* and moves to the next item 2) The clinician shows the letter representing the target sound, b) if incorrect, the clinician provides feedback and moves to the models the target item, and requests a repetition next item a) if correct, the clinician provides feedback, requests five addi- *Feedback is provided on approximately 60% of attempts. tional repetitions,* and moves to the next item (From Wambaugh, J. L., & Nessler, C. (2004). Modification of Sound Production b) if incorrect, the clinician goes to Step 3 Treatment for aphasia: Generalization effects. Aphasiology, 18(5/6/7), 407–427.) GRBQ344-3513G-C36[1009-1042]qxd 02-12-2008 10:01 PM Page 1042 APTARA(GRG QUARK) 1042 Section V ■ Therapy for Associated Neuropathologies of Speech- and Language-Related Functions APPENDIX 36.8 Modified Response Elaboration Training Treatment Steps the noun or verb production. If the response is correct, the clinician moves to Step 4. In the event of an incorrect or no Step 1. The clinician presents a picture and elicits a response (e.g., response, the next item is presented. “Tell me about this picture.”, What does this remind you of?”, “Tell me what’s happening.”) Step 4. The clinician reinforces the production from Step 3 and A. If the response is correct,* the clinician moves to Step 2. models a phrase/sentence that combines the participant’s produc- B. If there is no or an incorrect response, the clinician models tions from Steps 1 and 3 (e.g., “Right, tie. Tie shoe.”) two response options (e.g., “You could say something Step 5. The clinician models the combined production again and like . . . noun phrase [NP] or verb phrase [VP].”) If the requests a repetition. response is correct, the clinician moves to Step 2. A. If the response is correct, the clinician requests three more C. If there is no or an incorrect response, the clinician models a productions, using integral stimulation as needed. The clin- one-word response and requests a repetition (e.g., “Say ician moves to Step 6. noun.” or “Say verb.”) If the response is correct, the clinician B. If there is an incorrect or no response, the clinician attempts moves to Step 2. to elicit four productions of the target, using integral stimu- D. If there is no or an incorrect response, the clinician uses inte- lation. The clinician moves to Step 6. gral stimulation, with a maximum of four attempts, to elicit the noun or verb production. If the response is correct, the Step 6. The clinician removes the picture, waits for at least 5 sec- clinician moves to Step 2. In the event of an incorrect or no onds, returns the picture, and requests that the participant again response, the next item is presented. describe the picture. A. If the entire† elaborated response is produced, the clinician Step 2. The clinician models and reinforces the participant’s pro- reinforces the production and moves to the next item. duction from Step 1 (e.g., “Shoe. Great. That’s a shoe.”) B. If a partial elaborated response is produced, the clinician Step 3. The clinician requests an elaboration of the response from reinforces the production, models the entire elaboration, and Step 1 (e.g., “What’s happening with the shoe?”) requests a production with integral stimulation. The clini- A. If the response is correct, the clinician moves to Step 4. cian then moves to the next item. B. If there is no or an incorrect response, the clinician models C. If no response, the clinician reinforces the production, mod- two response options (e.g., “You could say something els the entire elaboration, and requests a production with like . . . noun phrase [NP] or verb phrase [VP].”) and integral stimulation. The clinician then moves to the next requests a response. If the response is correct, the clinician item. moves to Step 4. D. If an alternate correct response is produced, the clinician C. If there is no or an incorrect response, the clinician models a reinforces the production and moves to the next item. one-word response and requests a repetition (e.g., “Say *Any appropriate, intelligible noun, pronoun, verb, adjective, adverb, or preposi- noun.” or “Say verb.”) If the response is correct, the clinician tion; not perseverative, stereotypic, or reiterative. † moves to Step 4. Omission of functors is not considered incorrect. D. If there is no or an incorrect response, the clinician uses inte- (From Wambaugh, J. L., & Martinez, A. L. (2000).) gral stimulation, with a maximum of four attempts, to elicit GRBQ344-ind[1043-1072].qxd 04/02/2008 08:19 Page 1043 Aptara Inc. Author Index Aaronson, D., 802 Alazraki, N. P., 50 American Speech-Language-Hearing AARP Public Policy Institute, 206 Albers, G. W., 45 Association (ASHA), 15, 166, 176, Aarsland, D., 993 Albert, M., 253, 259, 297, 437, 438, 177, 178, 212, 219, 220, 222, 246, Abe, K., 50, 551 758, 760, 772, 773, 786, 826, 830, 306, 319, 321, 350, 356, 386, 457, 815, 891, Abernathy, C. D., 22 837, 840, 965 988, 1003 Abidi, R., 259 Albert, M. A., 507, 518 American Stroke Association, 382 Abikof, H., 914, 924 Albert, M. L., 56, 75, 92, 96, 102, 108, 191, American Telemedicine Association, 180 Abkarian, G. G., 1024, 1025 192, 195, 197, 198, 415, 416, 451, 515, 575, Americans with Disabilities Act (ADA), 306 Abo, M., 191 582, 583, 585 Amiez, C., 1013 Abrams, W., 13 Albert, N., 384 Amirikian, B., 1011 Abramson, R. K., 256 Alderman, N., 904, 905, 926, 927 Amitrano, A., 619 Abrous, D. N., 13 Alexander, D., 583 Ammons, J., 50 Absher, J. R., 535 Alexander, M. P., 21, 27, 32, 33, 35, 49, Amunts, K., 1013, 1014, 1015 Abutalebi, J., 250, 251 96, 108, 552, 566, 567, 569, 583, 611, 667, Anastasi, A., 77 Abu-Zeid, H. A. H., 787 881, 885, 893, 894, 919, 967, 1014 ANCDS. See Academy of Neurologic Academy of Neurologic Communication Alibali, M. W., 919, 920 Communication Disorders and Sciences Disorders and Sciences (ANCDS), 14, 177, Ali-Cherif, A., 11, 566 Andersen, G., 975 437, 438, 1018, 1019 Aliminosa, D., 600 Andersen, K., 993 Ackles, P., 967 Al-Khawaja, I., 70 Anderson, J. R., 902 ADA. See Americans with Disabilities Act Allamano, N., 257 Anderson, K., 52 Adamovich, B. L. B., 88, 904, 968 Allan, E., 326 Anderson, N., 207 Adams, H. P., 30, 34, 572 Allan, K., 365 Anderson, N. B., 217 Adams, J. E., 856 Allchin, J., 106 Anderson, P. E., 207 Adams, J. H., 881, 892 Allen, C. C., 967 Anderson, S. W., 20, 894, 905, 910, 926 Adams, M. R., 428 Allen, G., 1011 Andersson, S., 307, 308 Adams, R., 967 Allen, K. E., 229, 230, 233 Andrews, M., 206 Adams, S., 1027 Allen, M., 102 Andrews, R. J., 188 Adger, D., 738 Allport, A., 585 Andriaanse, H. P., 238 Adolfsson, R., 193 Allport, D. A., 95, 610 Angelini, F. J., 233 Adolphs, R., 37, 774, 976 Aloia, M., 992 Annegers, J. F., 880 Adrian, J. A., 413, 832, 862 Alperovitch, A., 993 Ansaldo, A., 114, 979 Afford, R. J., 566 Alpress, F., 229 Ansell, B. J., 423, 424 Aftonomos, L. B., 586, 587, 761, 832, 853, Altarriba, J., 252, 265 Anthony, J. C., 995 864, 868 Altenmuller, E., 757 Antiplatelet Trialists Collaboration, 46 Agan, J., 329 Altieri, M., 48 Antonello, R. M., 251 Agency for Health Care Research and Quality, Altman, I. M., 885 Antonucci, S. M., 612 254 Alvarez, P., 708, 715 Anwander, A., 1013 Ager, C., 52 Alves, W. M., 192 Apeldoorn, S., 1015 Aging Eye, 334 Alvord, E. C., 880 Aphasia Hope Foundaion, 382 Aglioti, S., 251, 259, 1014 Alzheimer’s Association, 349, 991 Appelros, P., 964 Agran, M., 892, 914 Alzheimer’s Disease and Related Disorders Appicciafuoco, A., 411 Agranowitz, A., 376, 383 Association, 176 Applebaum, J. S., 587 Agrell, B., 94 American Academy of Audiology, 335 Arabatzi, M., 741, 747 Aguado, G., 109 American Academy of Family Physicians, Aram, D. M., 165 AHCPR, 880, 902 336 Aran, D. M., 34 Ahern, M. B., 1018, 1021 American Academy of Neurology, 861 Arbib, M. A., 621, 1013, 1014 Ahlsen, E., 519, 520 American Association of University Women, Archer, C. R., 35 Ahlskog, J. E., 551 176, 177 Archibald, T. M., 968 Aichert, I., 113 American Heart Association, 10, 52 Ardila, A., 171, 186, 192, 246, 255, 256, Alajouanine, M. S., 568 American Medical Association, 210 257 Alarcon, N., 89, 295, 524, 545, 546, 550, American Medical Association (AMA), 213 Arguin, M., 769 557, 820 American Psychiatric Association, 988, Arima, K., 552 Alario, F. X., 1012 992 Arkin, S. M., 1002 1043 GRBQ344-ind[1043-1072].qxd 04/02/2008 08:19 Page 1044 Aptara Inc. 1044 Author Index Armstrong, E., 70, 80, 101, 106, 107, 109, 110, Bahrami, A., 56 Basford, J. R., 52 115, 116, 118, 119, 120, 295, 301, 302, 307, Bahrick, H. P., 249, 714 Basili, A., 484, 502, 611, 696, 971 309, 342, 524 Bahrick, L. E., 249 Basilico, D., 648 Armstrong, J., 342 Bailey, J., 617, 999 Bassett, S. S., 995 Armstrong, L., 256, 996 Bailey, K. G. D., 648 Basso, A., 81, 96, 123, 124, 125, 186, 188, 189, Armus, S. R., 426 Bailey, P., 413, 610, 617 192, 193, 198, 437, 565, 566, 567, 568, 572, Arne, L., 34 Bailey, S., 71, 124, 1026 575, 705, 710, 711, 719, 756, 763 Aronson, A. E., 65, 90, 205, 865, 1011, 1026 Bain, B., 1001 Bastiaanse, R., 103, 113, 174, 620, 737, 738, 741 Aronson, M., 376, 377, 379, 756 Bain, H., 49 Bates, B., 52 Arrigoni, G., 568 Baines, K. A., 80, 119, 579 Bates, D. G., 78 Arruda, J. E., 967 Bainton, D., 756 Bates, E., 64, 74, 79, 113, 114, 249, 253, 257, Arseni, C., 35 Bak, T., 575 265, 705 Asante, M. K., 246 Bakas, T., 364 Battle, D. E., 246, 248 Asanuma, H., 1011 Baker, E., 102, 105, 418, 586, 864 Bauer, P. J., 937 Ash, S., 89, 548, 549, 554 Baker, M., 550 Bauer, R. M., 65, 91, 719, 976 ASHA. See American Speech-Language- Baker, R., 78, 249, 253, 256 Baulac, M., 1015 Hearing Association Baker, S., 902, 918 Baum, C., 299 Ashayery, H., 259 Baker, T., 785 Baum, S. R., 86, 418, 424, 427, 977, 978 Ashbaugh, J., 215, 217 Bakke, B. L., 716 Baumeister, R. F., 891, 902, 910 Ashcraft, M., 919 Baldo, J., 764 Baumgaertner, A., 965, 972, 973, 974, 975, Ashman, A. F., 899 Ball, M., 119 978 Ashtry, F., 56, 57 Ballard, K. J., 92, 173, 425, 597, 601, 643, 718, Bautz-Holter, E., 291, 360 Asking, M., 378 745, 746, 748, 778, 1022 Bava, A., 251 Asplund, K., 11, 193 Baly, A., 999 Bawden, K., 295, 338 Assel, M. A., 910 Bambauer, D. E., 51 Bayard, K., 220 Asslid, R., 47 Bambauer, K. Z., 51 Bayles, K. A., 87, 88, 256, 437, 988, 991, 993, Assmus, A., 1015 Bandera, R., 991 994, 995, 996, 997, 999, 1000, 1002, 1003 Astrom, M., 193 Bandur, D. L., 756, 757, 761, 770, 775 Baylis, G. C., 524 Aten, J. L., 110, 377, 382, 386, 387, 389, 391, Bandura, A., 488 Baynes, K., 519 392, 1022, 1024 Bang, O. Y., 569, 573 Bays, C., 337, 360 Atkins-Mair, D. L., 53 Banja, S., 328 Beach, T. G., 551 Audet, T., 964, 967 Banker, B. Q., 544 Beach, W. A., 554 Auerbach, S., 508 Bannerman, D. J., 930, 931 Bear, D., 415, 975, 976 Augustine, G., 1010, 1013 Barat, M., 34 Beard, L. C., 174 Augustine, J., 1015 Barbarotto, R., 616 Beattie, A., 894 Augustine, L., 432 Baressi, B., 7, 71 Beatty, P. W., 973 Aureille, E., 966 Bargh, J. A., 910, 912 Beauchamp, B. G., 767 Aurelia, J., 492 Barinaga, M., 1011 Beaulieu, M-D., 229 Auriacombe, S., 993 Barker, L. M., 180 Bechera, A., 926 Ausman, J. I., 259 Barker, P. B., 767, 964, 1014 Beck, A. T., 994 Austermann, S., 361, 588 Barker-Collo, S. L., 78 Becker, R., 975 Austin, J., 115 Barkley, R. A., 914, 926 Beckers, K., 885 Australian Association of Speech and Hearing, Barnes, M., 893 Bedenbaugh, P. H., 692 246 Barnes, R., 565 Bedrosian, J. L., 1026 Ausubel, D., 477 Barnes, S., 336 Beecham, R., 260, 262 Auther, L. L., 117 Barnett, H. J., 46 Beeke, S., 118, 299 Avent, J., 83, 90, 117, 120, 126, 180, 302, 338, Baron, C. R., 180, 973 Beekman, L., 426, 509 339, 361, 376, 377, 382, 386, 391, 588 Baron, J. C., 50, 188, 406 Beeman, M., 973 Avery, J., 14 Barona, A., 124, 994 Beeson, P., 64, 82, 96, 102, 196, 197, 381, 382, Avrutin, S., 424 Barr, A., 865 389, 390, 419, 597, 598, 599, 602, 612, 619, Ayala, J., 414 Barresi, B., 108, 174, 196, 255, 256, 578, 581, 654, 657, 658, 659, 663, 665, 666, 667, 668, Azouvi, P., 547 582, 607, 657, 741, 768, 771, 773, 817, 830, 669, 670, 671, 673, 674, 769, 775, 782, 783, Azuma, T., 995, 999 970, 974 785, 814, 1001 Barrett, A. M., 659 Begley, C. E., 217 Babbage, C., 853 Barrett, H. M., 256 Behrens, S. J., 977 Babcock, P., 418, 776 Barrette, J., 305, 363 Behrens, T. E., 1015 Bach, D., 1000 Barry, C., 673 Behrmann, M., 599, 617, 622, 671 Bach, M., 1000 Barry, P., 297 Beis, J. M., 965 Bachman, D. L., 56, 80, 94, 507, 922 Barsalou, L. W., 919 Béland, R., 260 Bach-Y-Rita, P., 188 Bartels-Tobin, L. R., 85, 971 Belanger, L., 337 Backus, O., 377, 379, 756 Barth, J. T., 888 Belanger, S. A., 92 Baddeley, A. D., 95, 97, 601, 714, 726, 904, Bartha, M., 894 Belin, P., 190, 191, 264, 757 920, 922, 988, 989, 991, 998 Barthel, G., 712 Bell, A., 293, 301 Badecker, W., 102, 103, 611 Bartlett, C. L., 81, 123, 572 Bell, B. D., 102, 613 Baer, D. M., 392, 393, 394, 520, 929, 1001 Bartolomeo, P., 964, 965 Bell, K. L., 993 Baguley, I. J., 895 Barton, M., 413, 417 Bell, S., 212 GRBQ344-ind[1043-1072].qxd 04/02/2008 08:19 Page 1045 Aptara Inc. Author Index 1045 Bellaire, K. J., 584 Bianchetti, A., 997 Bogen, J., 697 Belleville, S., 905, 997 Biber, C., 423 Bogousslavsky, J., 50, 572 Belleza, T., 886 Bick, K., 989 Bohland, J. W., 1009, 1014, 1015 Bellugi, V., 20 Biddle, K. R., 893 Bohmer, F., 1000 Belz, P., 930 Biedermann, B., 565, 582 Bois, M., 253 Benabid, A. L., 1012 Biemiller, A., 891, 912 Boiten, J., 190 Benaim, C., 94 Bienias, J. L., 988 Bolduc, M., 337 Bench, C. J., 967 Biggers, A., 12 Boles, L., 69, 89, 108, 118, 295, 303, 304, 306, Bender, D. B., 535 Bigler, E., 327 308, 452, 779 Benedet, M. J., 735, 741 Bihrle, A. M., 969, 972 Boling, E., 826 Bengston, V. L., 856 Biller, J., 30, 319, 357, 572 Boll, T. J., 888 Benke, T., 968 Billups, J. J., 229 Boller, F., 102, 411, 413, 424, 431, 514, 515, Bennett, D. A., 988 Binetti, G., 997 765, 967, 991, 993 Bennett, J., 1019 Binkofski, F., 1013, 1014 Bollinger, R. L., 180, 386, 432, 433, 810 Benoit, N., 554 Bioulac, B., 34 Bolt, E., 910 Benowitz, L. I., 971, 976 Birch, H. G., 409 Bolter, J. D., 853 Benson, A. L., 410 Bird, F., 931 Bolwinick, J., 485 Benson, D. F., 28, 186, 192, 327, 437, 507, 609, Bird, H., 110, 111, 190, 735 Bombard, T., 69, 108, 118 767, 782, 861, 893, 896, 905, 927 Bishop, D. S., 94 Bonaffini, N., 48 Benson, F., 105, 895 Bishop, D. V. M., 75 Bond, M., 886, 894 Benton, A. I., 910 Bishop, R., 319 Bondar, J., 895 Benton, A. L., 21, 73, 74, 75, 76, 106, 110, 123, Bisiach, E., 410, 777 Bondi, M., 991 255, 410, 571, 578, 777, 881, 905, 995 Bissett, J., 340 Bonita, R., 42 Ben-Yishay, Y., 920 Bizzi, E., 715 Bookheimer, S., 251 Beretta, A., 104 Bjork, R. A., 715 Boone, D., 376, 411, 431 Berg, E. A., 97, 98 Bjorklund, D. F., 910 Boone, J. R., 611 Berg, M., 68, 69, 119, 120, 126 Black, C., 713 Boone, R. R., 14 Bergeman, C. S., 206 Black, F. W., 997 Booth, S., 118, 294, 295 Berger, S. A., 249 Black, M., 126, 174, 638, 758, 759, 777 Borenstein, P., 376, 378, 379, 382, 384 Bergeron, H., 352 Black, S. E., 179, 236, 290, 363, 517, 547, Borgwaldt, S., 252 Bergner, M., 81 565, 779 Borkowski, J. G., 96, 915, 994, 995 Bergstralh, E. J., 43 Blackman, N., 377, 379, 750, 756 Borod, J. C., 193, 971, 975, 976 Berk, L. E., 899, 914, 924 Blackstone, S., 68, 69, 119, 120, 126 Borthwick, S. E., 256, 996 Berko, J., 111, 424, 777 Blackwell, B., 56 Bos, M., 252 Berko, R., 13 Blair, J. R., 75 Bosch, L., 250 Berman, M., 205, 492 Blair, M., 548 Boschen, K., 364 Berndt, R. S., 37, 102, 103, 104, 109, 110, 188, Blake, M. L., 85, 86, 969, 970, 971, 973, Bose, A., 425, 647, 745, 778, 1022, 1023, 410, 413, 422, 425, 571, 572, 597, 600, 601, 975 1028 602, 610, 611, 612, 613, 614, 619, 632, 634, Blanc, M., 250, 253 Boser, K. I., 645 639, 640, 641, 643, 644, 645, 646, 647, 648, Blank, K., 437 Boser, K. K., 761 655, 664, 696, 704, 735, 736, 743, 767, 768, Blank, S. C., 190, 1016 Bosje, M., 174, 620 775, 776, 777 Blanken, G., 109, 568 Boston, B. O., 219 Bernholtz, N. D., 745 Blishen, B. R., 786 Bottenberg, D., 109, 174, 427 Bernstein-Ellis, E., 114, 118, 169, 180, 290, Bliss, L. S., 893 Bouchard, R., 28 295, 302, 304, 376, 377, 380, 381, 382, 390, Bloise, C. G. R., 174, 965, 975 Bouchard-Lamothe, D., 292, 366 391, 392, 394 Blomert, L., 80, 119, 297, 513 Boucher, V., 427 Berrios, G. E., 544, 992 Blonder, L. X., 86, 712, 976 Bouilleret, V., 1015 Berry, T., 586, 864 Bloom, D., 380 Boulay, N., 419, 618 Bertelson, P., 536 Bloom, L., 9, 382, 383, 478, 479, 480 Bourbon, T., 967 Berthier, M., 123 Bloom, P., 106 Bourgeois, M. S., 87, 168, 171, 179, 295, 302, Best, W., 110, 197, 580, 618, 620, 624, 726, Bloom, R. L., 109, 971, 976 361, 745, 998, 999, 1001, 1003 775, 776 Blum, A., 971 Bourhis, R., 293 Bester, S., 68 Blumer, D., 895 Bouvier, G., 26 Beth, R. E., 991 Blumstein, S. E., 102, 113, 415, 418, 423, 740, Bowden, J., 999 Bettinardi, V., 37 837, 1014, 1017 Bowen, A., 964 Bettoni, C., 249 Boada, R., 781 Bowen, D., 991 Beukelman, D., 93, 107, 295, 297, 306, 454, Boake, C., 885 Bowen, S. E., 233 457, 458, 492, 601, 815, 817, 819, 820, 821, Boatman, D., 507, 508, 514, 609 Bower, G. H., 714 822, 825, 827, 828, 886, 1018, 1020 Bobaljik, D. B., 736, 747 Bowers, D., 964, 971, 976, 977 Beveridge, M. A., 762 Bock, J., 641, 642 Bowers, L., 75, 100 Bevington, L. J., 381 Bock, R. D., 404 Boyajian, A. E., 930 Bezdudnaya, T., 533 Boczko, F., 999, 1000 Boyeson, M. G., 56 Bharadwaj, S. V., 1022 Boden, M., 477 Boyle, M., 69, 337, 419, 426, 450, 499, 500, Bhat, S., 259 Bodrova, E., 899 519, 520, 619, 622 Bhatnagar, S. C., 566 Boen, J. R., 880 Boynton, W., 880 Bhogal, S. K., 714, 757 Boeve, B. F., 547, 548, 551, 554 Braak, E., 989, 993 GRBQ344-ind[1043-1072].qxd 04/02/2008 08:19 Page 1046 Aptara Inc. 1046 Author Index Braak, H., 989, 993 Broussolle, E., 554, 555 Burgio, F., 96, 179, 763 Braber, N., 103, 776 Brown, A. L., 899, 904 Burk, F., 252, 265 Bracchi, M., 705 Brown, B. B., 779 Burke, J. E., 96 Bracy, O. L., 858, 860 Brown, C. M., 103 Burke, W. H., 928 Bradburn, N., 297 Brown, C. S., 861 Burkhardt, P., 740 Bradley, W. G., 48 Brown, F., 930 Burns, M., 91, 98 Brady, C. B., 991 Brown, G., 894, 994 Burns, R. B., 246 Bragoni, M., 56, 57 Brown, J. A., 53 Burr, J. A., 247 Brammer, M. J., 757 Brown, J. E., 230, 232 Burris, G. A., 376, 377, 379 Brandt, J. P., 21 Brown, J. R., 65, 891, 1011 Burton, M. W., 639, 775, 1013, 1014 Branker, B., 544 Brown, J. W., 7, 110, 430, 573, 705, 977 Buschke, H., 894 Brashers-Krug, T., 715 Brown, K., 177 Bushell, C., 740 Brassard, C., 70, 290, 294, 323, 337, 351, 419, Brown, L., 98, 100, 819 Bushnell, D. L., 50 618, 760 Brown, N. A., 205, 221 Busk, P. L., 196 Brassell, E. G., 70, 71, 124, 125, 192, 578 Brown, R. D., 43 Butfield, E., 492 Braswell, D., 100 Brown, R. S., 217 Butler, I., 206, 894 Braun, A., 768, 1009 Brown, V. J., 534 Butt, P., 98 Braunling-McMorrow, D., 924 Brown, V. L., 75 Butters, N., 258, 894, 989, 991 Braverman, K. M., 484, 502 Brownell, H. H., 86, 101, 410, 583, 740, 772, Butterworth, B., 536, 632 Brawley, E., 322, 334, 335 969, 970, 971, 972, 973, 975 Button, J., 293 Brazzeli, M., 894 Brownell, J., 221 Buxant, P., 361 Brecher, A., 109, 180, 420, 597, 612, 832, 852 Brownell, M. T., 914 Buxbaum, L. J., 964, 965 Breedin, S., 776 Brubaker, S. H., 855 Buzolich, M., 67 Breen, K., 106, 418, 998 Bruce, C., 178, 306, 620, 763, 775 Buzzard, M., 977 Breese, E. L., 412, 614, 616, 782, 1014 Brumfitt, S. M., 80, 94, 292, 293, 307, 308, Bylsma, F. W., 992 Breier, J. I., 190 319, 362 Byng, S., 10, 66, 77, 81, 82, 115, 126, 127, 174, Brendel, B., 1024, 1025 Bruner, J., 476, 477, 896 192, 259, 290, 292, 294, 301, 305, 307, 308, Brennan, A., 363 Brunet, P., 554 309, 310, 328, 349, 350, 355, 356, 357, 360, Brennan, D. M., 180 Brunner, R. J., 34, 49 379, 453, 484, 509, 598, 600, 618, 638, 647, Brenneise-Sarshad, R., 174, 427 Bruno, J., 833 648, 745, 758, 759, 768, 777, 857, 858, 862 Brenner, T., 895 Brush, J. A., 997, 999 Byrne, M. E., 171 Brentnall, S., 916 Brust, J. C., 30, 566, 572 Bresnan, J., 639, 736 Bruun, B., 566 Cabeza, R., 894 Bressi, S., 37, 991 Bryan, K. L., 85, 178, 638 Cai, Y., 910 Brianti, R., 894 Bryant, B. R., 75, 578, 657 Cain, R., 762 Brickencamp, R., 98 Bryden, J., 894 Cairns, A. Y., 361 Bricker, A. L., 420 Bryer, A., 517 Cairns, D., 638, 642 Brickman, A. M., 992 Brysbaert, M., 249 Calabrese, D. B., 904 Briggs, P., 231 Bub, D., 89, 103, 109, 111, 112, 545, 546, 549, Calautti, C., 406 Brigstocke, G., 319 550, 551, 552, 610, 611, 668, 698, 769, 964, Calderon, J., 992 Brindely, P., 376, 377 967, 995 Caldognetto, E. M., 977 Brindley, P., 757 Buccino, G., 1013, 1014 Caligiuri, M. P., 377 Brislin, R. W., 246 Buchel, C., 37 Calkins, M., 334 Broadbent, N. J., 989 Buchman, A. S., 609 Callaghan, S., 804 Broca, P., 20, 21, 26, 1011, 1013 Buchtel, H. A., 609 Caltagirone, C., 11, 568 Broderick, J., 42, 43 Buck, R., 771, 976 Calvanio, R., 966 Brodie, J., 361 Buckingham, H. W., 1015, 1016 Calvert, G. A., 757 Brodin, J., 865 Buckle, L., 895, 905 Calvin, J., 421 Brodmann, K., 1010 Buckner, R. L., 190, 894, 991 Camp, C., 333, 996, 997, 999, 1003 Broida, H., 756 Bucks, R., 98 Campanella, D. J., 414 Bronson, M. B., 910 Budka, H., 552 Campbell, C. R., 102, 108 Brooks, B. M., 922, 923 Buiza, J. J., 413, 832, 862 Campbell, D. T., 164, 169, 172, 194 Brooks, D. N., 894 Bulgren, J. A., 919 Campbell, T. F., 76, 178, 516 Brooks, J. L., 966 Bunch, W. H., 80 Campione, J. C., 899, 904 Brooks, R. L., 968 Bundesen, C., 964 Campsie, L., 894 Brookshire, R. H., 3, 4, 5, 56, 67, 70, 71, 75, 85, Bunn, E. M., 37 Canadian Cooperative Study Group, 46 87, 88, 101, 102, 107, 108, 109, 110, 120, Buonaguro, A., 123, 193, 891 Canadian Institutes of Health Research, 176 124, 127, 165, 167, 169, 171, 174, 258, 297, Buonomano, D. V., 689, 701, 728 Cancelliere, A. E. B., 976 377, 380, 384, 386, 387, 406, 408, 413, 415, Burani, C., 613 Caneman, G., 965 416, 421, 424, 425, 426, 427, 428, 429, 430, Burbaum, L. J., 769 Cannito, M. D., 425, 426 431, 432, 433, 436, 457, 508, 514, 515, 516, Burchardt, T., 328 Cannito, M. P., 102, 426, 509, 747, 765 669, 765, 779, 780, 806, 810, 887, 965, 969, Burchert, F., 741 Canter, G., 102, 416, 419, 420, 421, 422, 423, 971, 972, 974 Burger, L. K., 598 424, 426, 451, 509, 567, 578, 582, 765, 774, Brothers, L., 895 Burgess, C., 973 783, 974 Brotherton, F. A., 924 Burgess, P., 892, 904, 905 Cantor, N., 80 GRBQ344-ind[1043-1072].qxd 04/02/2008 08:19 Page 1047 Aptara Inc. Author Index 1047 Cao, Y., 191, 757 Cazden, C. B., 486 Chiat, S., 422, 620, 638, 641, 642, 643, 668, Capasso, R., 103, 619 Cazzato, G., 251 764, 784 Caperton, C. J., 319 Ceccaldi, M., 9, 555 Chiavari, L., 610 Capitani, E., 188, 192, 568, 610, 613, 616, Cegla, B., 584 CHIEF. See Craig Hospital Inventory of 705, 756 Celery, K., 519 Environmental Factors Caplan, B., 965 Cenkovich, F., 52 Chieffi, S., 411 Caplan, D., 9, 81, 82, 103, 104, 108, 109, 111, Cenoz, J., 250 Childers, J. B., 714 112, 423, 425, 609, 623, 648, 735, 736, Centers for Disease Control and Prevention, Childs, K. E., 905 765, 969 10, 11, 12, 15, 880, 881 Chiou, H. H., 73, 78 Caplan, L. R., 967 Central Brain Tumor Registry of the United Chissom, B. S., 658 Capo, M., 915, 940 States, 12 Chitiri, H.- F., 249 Capon, A., 189 Cercy, S. P., 992 Chitsaz, A., 56 Cappa, S. F., 35, 37, 50, 111, 124, 250, 251, Cermak, L., 516, 738 Chobor, K. L., 977 427, 566, 610, 612, 757, 968 Cesaro, P., 50 Choi, D., 10 Cappelletti, J. Y., 610 Chadwick, O., 894 Choi, H., 206 Caramazza, A., 37, 75, 89, 102, 103, 109, 252, Chainay, H., 1012 Choi, N. W., 787 410, 413, 421, 423, 597, 598, 599, 600, 601, Chambers, N., 304 Chokron, S., 964, 965 607, 609, 610, 611, 612, 614, 615, 617, 619, Chambless, D. L., 1028 Cholewa, J., 611 633, 634, 636, 640, 641, 646, 656, 657, 665, Champod, A.-S., 1013 Chomsky, N., 14, 479, 485, 706, 736, 738, 747 666, 668, 671, 672, 696, 736, 758 Champoux, R., 756 Choy, J., 740 Carbone, G., 610 Chan, K. L., 975 Christensen, A. L., 74 Cardebat, D., 50, 190 Chan, S. W.-C., 251, 257 Christensen, B., 256 Cardell, E. A., 668 Chang, A., 760 Christiansen, J. A., 111, 112, 424, 735 Cardol, M., 291, 294, 296, 300, 304, 305 Chang, E. C., 73 Christinaz, D., 861 Carew, T. J., 716 Chang, F., 637 Christman, M. A., 432 Carey, P., 423, 764 Chang, S., 782, 783 Chrotowski, J., 56 CARF. See Commission on Accreditation of Channon, S., 895 Chubon, R. A., 298 Rehabilitation Facilities Chapey, R., 3, 64, 65, 66, 67, 69, 70, 74, 77, Chui, D., 51 Carino, B. V., 246 79, 80, 81, 82, 84, 85, 95, 96, 97, 105, Chui, H. C., 964, 992 Carlan, M., 725 114, 125, 126, 127, 128, 129, 159, 160, Chujo, T., 173 Carlomagno, S., 264, 361, 411, 520, 600 203, 279, 452, 469, 470, 472, 473, 475, Chuma, T., 54 Carlson, G. S., 583, 586, 761, 832, 864 478, 484, 485, 487, 502, 523, 761, Chumpelik, D., 174, 1022, 1027 Carlson, J. I., 928 781, 854 Chung, A., 782 Carlsson, M., 357 Chapman, S., 118, 554, 555, 766, 780, 781, 891, Churchill, C., 239 Carmines, E. G., 76 893, 1001, 1003 Chytas, P., 205 Carney, N., 895, 902, 918, 921 Charbel, F., 259 Ciarocco, N. J., 891 Caroselli, J., 319 Chargualaf, J., 782 Cicciarelli, A. W., 188 Carpenter, E., 206 Chartrand, T. L., 912 Cicero, B. A., 976 Carpenter, P. A., 190 Charuvastra, A., 550 Cicerone, K., 860, 892, 895, 902, 918, 920, 966 Carpenter, S., 552 Chary, P., 260 Cicone, M., 976 Carper, J. M., 193 Chase, K. N., 965 Cifu, D., 290 Carr, E. G., 902, 923, 928, 930, 931 Chassagnon, S., 1012 Cifu, D. X., 229, 230, 239, 242 Carr, T., 302, 414, 509, 600 Chastain, R., 124, 994 Cimino, C. R., 971, 972, 976 Carroll, E., 644, 736 Chatterjee, A., 103, 111, 648 Cimino-Knight, A. M., 691, 697 Carroll, V., 406, 407, 408, 411, 416, 421, Chaudhary, P., 569, 611 Cioe, J., 689 430, 433 Chavada, S., 965 Cipolotti, L., 568, 609 Carstens, B., 1022 Chee, M. W. L., 251, 1015 Clare, L., 998 Carter, G., 998 Cheek, W. R., 35 Clarfield, A. M., 87 Carter, J., 124 Chelune, G. J., 764 Clark, A. E., 417 Carter, P., 124 Chen, H. C., 252 Clark, D. G., 89, 95, 550, 551, 554 Casadio, P., 361, 520 Chen, S., 257 Clark, D. O., 357 Caselli, R. J., 547, 551 Chenery, H. J., 418, 668 Clark, E., 71, 124 Casey, P. F., 508 Cheney, P. D., 1011 Clark, H., 66, 69, 82, 88, 97, 109, 124, 126, Casper, M. L., 11 Cheng, L. L., 253, 254 217, 293, 481 Castelein, P., 360, 361, 366, 367 Chengappa, S., 259 Clark, M. S., 52 Castellani, R. J., 550 Chenven, H., 376, 382, 391 Clark, N., 519 Castro-Caldas, A., 33 Cherney, L. R., 70, 86, 107, 186, 190, 191, 192, Clark, R. E., 989 Cataldo, M. D., 926 197, 665, 774, 965, 966, 974 Clarkberg, M., 206 Catani, J., 1009, 1015 Cherrie, C., 246 Clarke, S., 905, 968 Catani, M., 697 Cherry, B. J., 967 Classen, J., 1011 Catsman-Berrevoets, C. E., 56 Chertkow, H., 9, 610, 698, 995 Clausen, N. S., 668, 669, 670, 785 Cattani, B., 257 Chester, S. L., 114, 853 Clayton, M. C., 659 Cattelani, R., 894, 895 Cheung, S. W., 692 Clearman, R., 304 Cavanaugh, J., 533 Chial, M. R., 164 Cleary, S., 997, 1002 Cavus, I., 54 Chialant, D., 607, 610, 611 Clemens, C., 205 GRBQ344-ind[1043-1072].qxd 04/02/2008 08:19 Page 1048 Aptara Inc. 1048 Author Index Clemmons, D., 896 Conway, T. W., 721, 722 Crerar, M. A., 197, 762, 832, 860, 865 Cline, H., 13 Cook, D. A., 240 Crimmins, D. B., 931, 932 Clinical Aphasiology Conference, 177 Cook, J. C., 376, 756 Crinion, J., 50, 51, 251 Cloninger, C. J., 902 Cook, R. G., 896 Crisostomo, E. A., 56 Cloutier, R., 352 Cook, T. D., 194 Crisp, J., 119, 178, 295 Coad, M. L., 886 Cooper, J., 895 Crittsinger, B. A., 376 Coates, R., 27, 49, 186 Cooper, L., 488 Crockford, C., 120 Cochran, R. M., 582 Cooper, W. E., 978 Croft, S., 257 Cochrane, R., 391, 392, 497 Coopersmith, H., 975 Cronbach, L. J., 77 Cockburn, J., 92, 97, 904 Cope, D. N., 237, 238, 880, 886, 939 Croot, K., 1017, 1019 Code, C., 94, 101, 102, 115, 121, 124, 192, 193, Copeland, M., 376, 757 Cropley, A., 96, 472 203, 264, 292, 297, 309, 323, 337, 342, 362, Copper, B., 206, 207 Crosky, C. S., 428 513, 524, 893, 1026 Corbeil, R. R., 1000 Crosson, B., 108, 123, 530, 531, 533, 535, 536, Coelho, C., 14, 69, 70, 88, 89, 92, 109, 110, Corbetta, M., 190, 437, 966 537, 538, 539, 611, 615, 674, 704, 1012 127, 403, 419, 450, 452, 470, 499, 500, 519, Corbin, J., 178, 390 Croteau, C., 14, 70, 323 520, 583, 619, 622, 771, 772, 830, 856, 893 Corbin, M. A., 376 Crow, E., 70, 71 Cohan, M., 87 Corbin, M. L., 383 Crowe, S., 894 Cohen, E., 245 Corder, L. S., 13 Cruice, M., 121, 122, 179, 291, 295, 296, 308, Cohen, G., 701 Cordes, A. K., 76, 77 351, 355, 356, 362 Cohen, J. A., 35, 171 Corey-Bloom, J., 992 Cruickshank, M., 206, 207 Cohen, L., 54, 554, 555, 1011, 1012 Corlew, M. M., 410 Crum, R. M., 995 Cohen, M. P., 56 Cormier, L. S., 220, 221 Cubelli, R., 7, 830 Cohen, N. J., 96 Cormier, W. H., 220, 221 Cudworth, C., 672, 784 Cohen, R. M., 967 Cornelissen, K., 191, 414 Cuerva, A. G., 56 Cohen, S. B., 174, 880 Cornelius, B., 56 Cuetos, F., 109, 613 Cohen-Schneider, R., 306, 381 Cornell, S., 30, 572 Culbertson, W., 71 Cohn, R., 212 Cornell, T., 740 Culham, J., 609 Coker, S. B., 56 Cornman, C. B., 229 Culioli, A., 260 Colby, K. M., 861 Correia, L., 421, 427, 779 Cullen, N. K., 894 Cole, L., 246 Corrigan, J., 297 Cullinan, W. L., 861 Cole, M., 544 Corrington, K., 714 Cullum, C. M., 327 Coleman, M., 306, 763 Corsi, L., 930 Cummings, J. L., 86, 91, 94, 975, 992 Coles, R., 308, 388 Cort, R. C., 1028 Cunningham, R., 74, 110, 308, 361, 363, Cole-Virtue, J., 102 Corwin, M., 565 578, 580 Colheart, M., 657, 660 Coslett, H. B., 97, 105, 108, 539, 609, 656, 659, Curl, R. M., 896 Collard, M., 49 769, 964, 965, 966, 976, 977 Curtis, C., 319 Collard, S., 967 Costa, A., 250, 252, 607 Curtis, G., 764 Collin, C. F., 70 Costa, L. D., 894 Curtis, S., 56, 382 Collins, D., 229 Costeff, D. N., 895 Curtiss, S., 112, 416, 423 Collins, M., 566, 567, 568, 569, 574, 575, 577, Côté, J., 352 Cushner, K., 246 578, 580, 581, 582, 584, 803, 829, 866, 880, Côté, L., 990, 991 Cutler, A., 249, 427, 515 888, 1026 Cotman, C. W., 991 Czvik, P., 517 Colombo, A., 566, 574, 600 Cotton, J., 488 Colombo, L., 613 Coull, J. T., 967 Dabul, B., 92, 93, 380, 756 Colombo, N., 894 Court, J. H., 818, 819 Dagenbach, D., 535 Colombo, P., 11 Courville, J., 881, 884 D’Agostino, R. B., 256 Colonna, A., 568 Cox, C. L., 533 Daigle, T., 977 Colosimo, C., 35 Cox, D., 361, 418, 565, 645, 710, 777, 778, Dalen, J. E., 46 Colsher, P. L., 978 864, 991 D’Alessandro, P., 547 Coltheart, M., 77, 78, 82, 83, 259, 578, 597, Coyle, J. T., 991 Damasio, A., 7, 8, 9, 21, 28, 29, 34, 35, 37, 566, 598, 600, 607, 612, 613, 656, 660, 663, 893 Crabtree, J. W., 533 567, 611, 612, 774, 775, 894, 899, 901, 905, Comfort, A., 206 Craenhals, A., 552 922, 926, 927, 964 Commission on Accreditation of Rehabilitation Crago, M. B., 246 Damasio, D., 37 Facilities (CARF), 240, 242 Craig, A. H., 94 Damasio, H., 9, 20, 21, 22, 23, 24, 26, 27, 28, Conforta, A. B., 54 Craig, H., 64, 480 29, 30, 32, 34, 35, 37, 38, 572, 611, 735, Confraria, A., 33 Craig Hospital Research Department, 364 774, 775, 894, 901, 905, 926, 964, 976, 977 Conley, A., 419, 619 Craik, F., 714, 716, 894, 967 Damico, H., 300 Conlon, C. P., 108, 174, 520, 583 Cramazza, A., 75 Damico, J. S., 74, 119, 120, 121, 128, 129, 178, Connell, P. J., 172, 393 Cramer, S. C., 53 293, 294, 295, 296, 297, 298, 299, 300, 301, Connis, D., 319 Cranberg, M. D., 894 302, 307, 360, 361, 394, 523, 816 Connor, D. J., 992 Crandell, C., 335 D’Amour, D., 229, 240 Connor, L. T., 507 Crary, M. A., 71, 81, 259 Danault, S., 260 Connors, C. K., 98 Crawford, A. B., 195, 437, 524, 762 Daniele, A., 35 Consolini, T., 7 Crawford, J. R., 895 Daniels, S., 196, 611 Conway, R. N. F., 899 Crépeau, F., 905 Daniloff, J. K., 101, 102, 108, 427, 768 GRBQ344-ind[1043-1072].qxd 04/02/2008 08:19 Page 1049 Aptara Inc. Author Index 1049 Daniloff, R., 101, 427 Deal, J. L., 81, 168, 259, 756, 865, 968, Dettinger, E., 206 Danly, M., 978 1022, 1027 Deutsch, G., 967 Danys, I., 43 Deal, L. A., 756, 968 Devault, S. M., 376 Dapretto, M., 251 Dean, E. C., 197, 832, 854, 860, 865 Devitt, E. W., 859 Darley, F. L., 3, 65, 71, 90, 92, 93, 123, 124, Dean, M. P., 638 Devlieger, P. J., 248 125, 166, 167, 174, 207, 208, 377, 403, Deaudon, C., 698 Devlin, J., 1013 409, 410, 411, 418, 421, 425, 426, 429, Decaix, C., 965 Dewaele, J. M., 245 433, 437, 457, 509, 524, 544, 549, 757, Deci, E. L., 891, 931 Di Piero, V., 48, 50 803, 855, 860, 869, 891, 1011, 1017, Deco, G., 691, 701 Di Pietro, M., 180, 620, 862 1030 DeCoste, D., 830 Diamond, P. T., 192 Darley, R., 390 DeDe, G., 418, 620 Dichgans, J., 757 Dartigues, J. F., 993 Defer, G., 50 Dick, F., 103 Daselaar, S. M., 989 Defoor-Hill, L., 394 Dick, J. P., 547 David, R. M., 77, 78, 125, 750, 756 Degaonkar, M., 964 Dick, M. B., 991 Davidoff, M., 859, 866 Deger, K., 1024, 1025 Dick, W., 229 Davidson, B., 69, 298, 350, 351, 382 DeGiovani, R., 292 Dickey, M. W., 740 Davidson, R. A., 966, 967 deGreiff, A., 967 Dickson, D. W., 550 Davidson, W., 548, 549, 611 Dehaene, S., 251 Didic, M., 555 Davies, C., 580 Dehlin, O., 94 Diener, E., 12, 304 Davies, K. G., 613 Deiner, H.-C., 967 Diener, H., 46 Davies, P., 991 Dejerine, J., 29 Diener, R., 298 Davies, R., 551, 552, 783 DeKosky, S. T., 976 Dietz, A., 823, 825 Davis, A., 293, 301, 509, 520, 618 Del Grosso Destreri, N., 783 Diggs, C., 484, 502, 971 Davis, C., 109, 229, 242, 519, 611 Del Pesce, M., 967 Dijkstra, T., 245, 249, 250, 252 Davis, D. G., 990 Del Pozo, F., 205 Diller, L., 180, 905, 920 Davis, G., 385 Del Tredici, K., 993 Diner, E., 66 Davis, G. A., 70, 82, 85, 88, 107, 114, 116, 117, Delacoste, C., 785 DiPellegrino, G., 964 124, 125, 174, 196, 377, 378, 380, 381, 384, Delcey, M., 80 Dippel, D. W. J., 71, 420 385, 386, 391, 403, 426, 482, 497, 566, 567, DeLeon, J., 597, 995 Dipper, L. T., 638 586, 587, 777, 830, 859 Deleval, J., 572 Dirkx, T., 866 Davis, J. N., 55, 56 D’Elia, L. F., 98 DiSimoni, F., 71, 90, 92, 174, 429, 803 Davis, K. L., 996 Delis, D. C., 98, 971, 995 Disimoni, R., 390 Davis, K. R., 26, 1014 Dell, G. S., 598, 603, 636, 637, 641, 699, Ditterich, A., 1013 Davis, P. N., 246 700, 774 Djundja, D., 712 Davison, A. N., 991 Della Sala, S., 566, 991 Dodd, D., 919, 920 Davolt, S., 211 Deloche, G., 105, 110, 264, 421, 617, 859, Dodd, M. L., 53 Daw, J., 217 864 Doesborgh, S. J. C., 71, 420, 761 Dawson, D. V., 56, 965 DeLong, E. R., 187, 571, 572 Dogil, G., 113 Day, A. L., 26 DeLong, M. R., 991 Dollaghan, C. A., 76, 129, 178, 194 Day, E. A., 714 Demain, C., 376, 757 Dolphin, M. K., 377 Dayus, B., 921 Dember, W., 477 Donabedian, A., 164 De Bastiani, P., 673 Demery, J. A., 91, 719 Donaldson, N., 319 de Bleser, R., 73, 109, 252, 256, 567, 568, 611, Demeurisse, G., 189 Donaldson, R., 583 737, 741 Demonet, J. F., 757 Donati, F., 558 de Bot, K., 248, 250 Demos, G., 90, 471 Donnellan, A. M., 931 de Brabander, J. M., 990 Dempster, F. N., 713 Donnelly, R. E., 893 De Deyn, P. P., 256, 536 den Ouden, D. B., 113 Donoghue, J. P., 1011 De Gelder, B., 536 Denburg, N. L., 71 Donovan, J. J., 713 de Groot, A. M. B., 250, 252, 253 Denckla, M. B., 96, 909 Donovan, N. J., 178 de Groot, I., 296 Denes, G., 609, 972, 977 Doolittle, G. C., 205 de Haan, R., 296, 323, 922 Dening, T. R., 992 Dordain, M., 864 De Jong, B., 291 Denman, A., 115 Dore, J., 115, 480, 481 de Luca, G., 260, 264 Dennis, F., 361 Dores, P. A., 931 de Partz, M. P., 600, 664 Dennis, M., 893, 905 Dorland’s Illustrated Medical Dictionary, 42 de Pellegrino G., 1013 Denzin, N. K., 178 Doss, S., 931 De Renzi, E., 192, 566, 568, 574, 575, DeRenzi, E., 11, 75, 91, 411, 547, 861, 964 Doucet, N., 256 578, 775, 861 Derman, S., 380 Douglas, J. M., 92, 102, 110, 119, 122, 413, de Riesthal, M., 123, 125, 192 D’Erme, P., 568, 964 621, 771, 886, 996 De Ruyter, F., 757 DeRosa, E. A., 52 Douglass, E., 377, 379 de Ruyter, F., 437, 524, 814 Deser, T., 109, 110 Dowden, P., 815, 1026 De Tanti, A., 257 Desimone, R., 534, 535 Dowling, S. M., 967 de Vos, R. A. I., 993 Deslauriers, L., 252, 264, 265 Downes, J., 921 de Witt, D., 967 Desmarais, G., 905 Dowswell, G., 327 De Witte, L., 536, 537 Desrochers, A., 79, 85, 256 Doyel, A. W., 107, 118 Deacon, B., 1019 Detterman, D. K., 896, 902 Doyle, D., 892 GRBQ344-ind[1043-1072].qxd 04/02/2008 08:19 Page 1050 Aptara Inc. 1050 Author Index Doyle, P. J., 81, 92, 103, 108, 116, 122, 128, Eccarius, M., 826, 828 Eriksson, P. S., 13 171, 173, 178, 197, 291, 294, 295, 296, 298, Eccles, J. C., 406 Erlich, J., 297 357, 508, 553, 710, 745, 1022, 1023 Eccles, M., 14 Ernest-Baron, C., 102, 427 Doyon, J., 989 Echiverri, H. C., 56 Eslinger, P., 21, 34, 566, 905 Drachman, D. A., 991 Eckert, T. L., 930 Estes, W. K., 714 Dressler, R. A., 855 ECSTC, 51 Estrada, P., 257 Drew, R., 450, 519, 618, 620, 815 Edelman, G. M., 578, 580 European Carotid Trialists’ Collaborative Dribbon, M., 833 Edelman, R. R., 1011 Group, 46 Dromerick, A. W., 569 Edmonds, L., 173, 179, 260, 263, 265, 723, 724 Evans, A. C., 251 Dronkers, N. F., 92, 168, 192, 259, 260, 549, Edmundson, A., 178, 306, 453, 484, 618, 763 Evans, D. A., 988 550, 551, 554, 556, 574, 865, 995, 1015 Edwards, D., 299 Evans, D. H., 47 Druback, D. A., 53 Edwards, J., 248 Evans, J. J., 727, 904, 905, 916, 921, 922, 998 Druks, J., 75, 578, 621, 644, 736, 741 Edwards, S., 111, 112, 113, 741, 747 Evans, K. L., 423 Drummond, S., 93 Edwards-Schaefer, P., 343 Evans, P., 899 Dubois, J., 260 Egan, J., 307, 391, 763 Evans, R., 126, 319, 338, 339, 488 Dubois, M. F., 992 Egelko, S., 327 Ewart, C., 211 duBoulay, G. H. D., 994 Egnor, H., 670 Ewert, J., 894 Ducanis, A. J., 232, 233 Egolf, D. B., 114, 853 Ewing, S., 377, 379, 382, 391, 394 Ducarne, B., 554 Ehlhardt, L., 763, 940 Ezekowitz, M. D., 51 Duchan, J., 66, 126, 179, 236, 279, 290, 292, Ehrlich, J. S., 893 293, 303, 307, 309, 328, 349, 350, 355, 360, Ehrsson, H., 1013 Fabbro, F., 251, 259, 260 362, 363, 496, 497, 509, 517, 565, 588, 779 Eickhoff, S., 1015 Faber, M., 110 Duffy, F. D., 379, 411 Eischeid, T., 828 Fadiga, L., 1013, 1014 Duffy, J. R., 65, 89, 92, 93, 102, 127, 196, 205, Eisenberg, A., 249 Fagan, S. C., 124 403, 406, 411, 452, 470, 543, 544, 545, 547, Eisenberg, H. M., 893, 967 Fager, S., 1018 549, 550, 551, 554, 555, 556, 771, 865, 969, Eisenson, J., 73, 376, 377, 379, 382, 394, 409, Fagergren, A., 1013 971, 1011, 1014, 1015, 1017, 1018, 1020, 521, 578, 756, 767, 855, 859, 860, 869, 968 Faglioni, P., 192, 566, 568, 756 1026, 1029 Elbard, H., 68 Fahey, K. B., 117 Duffy, R. J., 92, 118, 325, 771, 772, 830, 893, Elbert, T., 712 Faich, G., 880 971, 976 Elias, M. F., 256 Fair, J., 173 Dugbartey, A. T., 96 Elias, P. K., 256 Falanga, A., 609 Dumond, D. L., 428 Elias, S., 13 Falconer, J. A., 233 Duncan, D. M., 249 Elliott, R., 90 Falk, G. D., 905 Duncan, G. W., 26, 35 Ellis, A., 77, 102, 110, 197, 413, 597, 609, 610, Family Caregiver Alliance, 206 Duncan, J., 964, 965 611, 613, 617, 618, 657, 666, 695, 782, 783, Family Caregivers Online, 336 Duncan, P., 319 832, 860, 865 Farabola, M., 193, 565, 566, 567, 572, 575 Duncan, P. W., 52, 56 Ellis, G., 382, 387 Farah, M. J., 91, 609, 610, 693, 964 Dunkle, R. E., 95 Ellis, N., 246 Farber, J. F., 995 Dunlap, G., 902, 905, 930 Ellis-Hill, C., 337 Farina, E., 610 Dunn, E. S., 75 Ellmo, W. J., 904 Faroqi-Shah, Y., 736, 746 Dunn, H., 377, 379 Ellsworth, T. A., 619, 620, 642, 643, 644 Farrier, L., 170 Dunn, L. M., 75 Elman, R., 66, 84, 114, 115, 118, 129, 169, 174, Farrow, C. E., 967 Dupont, S., 1015 175, 180, 279, 290, 295, 302, 304, 307, 308, Farrow, V., 580 Durand, V. M., 931, 932 309, 310, 362, 376, 377, 379, 381, 382, 389, Fassbender, L. L., 931 Durgunoglu, A. Y., 250 390, 391, 392, 394, 524 Fassbinder, W., 972 Dusatko, D., 520, 777 Elman, S., 309, 524 Fastenau, P. S., 71 Dutta, A., 717 Elmslie, H., 904 Faust, M., 102 Duvernoy, H., 22 Emanuelli, S., 361, 520 Fawcett, J. T., 246 Dvonch, V. M., 80 Emery, P., 518 Fawcus, M., 376, 377, 382, 389, 391, 522, 1026 Dwivedi, V. D., 978 Emmons, R., 298 Fawcus, R., 522, 1026 Dworetsky, B., 415 Emre, M., 993 Faxio, F., 610 Dworkin, J. P., 1024, 1025 Emslie, H., 905, 921 Fazio, F., 37 Dwyer, C., 968 Enderby, P., 70, 71, 93, 195, 198, 451, 756, 761, FDA. See Food and Drug Administration Dyer, W. M., 205 832, 857, 864, 866 Fedio, P., 966, 991 Dywan, J., 905 Engel, P. A., 552 Feeney, D., 56, 188, 880 Engelborghs, S., 536 Feeney, J., 880, 892 Eales, C., 308, 388 Engell, B., 122, 300, 355 Feeney, T. J., 96, 173, 879, 880, 891, 892, 895, Earp, J., 323 Englert, C. S., 499 896, 897, 898, 899, 900, 902, 903, 904, 905, Easterbrook, A., 779 English, A. C., 95, 470 906, 910, 912, 913, 915, 923, 927, 928, 929, Easton, J. D., 51 English, H. B., 95, 470 930, 931, 933, 935, 936, 937, 939, 940 Eastwood, C., 935 English, L., 517 Feher, E., 416 Eastwood, M. R., 52 Engvik, H., 571, 572 Fehst, C. A., 516 Eayrs, C. B., 726, 727 Erbaugh, J., 994 Feigin, V. L., 11 Ebbinghaus, H., 713 Erickson, J. G., 248 Feinstein, A., 88 Ebert, A. D., 536 Erickson, R. J., 507 Feldman, E., 255 GRBQ344-ind[1043-1072].qxd 04/02/2008 08:19 Page 1051 Aptara Inc. Author Index 1051 Feldman, L., 978 Florance, C., 115, 116, 1022, 1026, 1027 Frazier, K. E., 171, 1028 Fellows, M. R., 1011 Flores, D. K., 191 Fredman, M., 260, 264 Felmingham, K., 895 Flower, W., 15, 222 Freed, D. B., 93, 110, 125, 171, 173, 174, 179, Fenaughty, A., 205 Flowers, C. R., 179, 417, 423, 424, 971, 977 417, 418, 519, 776, 1028 Fenstad, J. E., 854 Flynn, C. D., 53 Freedman, M., 32 Fergus, S. L., 360 Flynn, M., 965 Freedman-Stern, R. F., 107, 785 Ferguson, A., 117, 178, 301, 307, 779 Fodor, I. G., 427 Freeman, S., 221 Ferketic, M., 80, 123, 178, 255, 298, 319, 356 Fogassi, G., 1014 Freemann, R., 771 Fernandez, B., 190 Fogassi, L., 1013, 1014 Freese, P., 300 Ferrada-Videla, M., 229 Foldi, N. S., 116, 426, 972 French, S., 305 Ferrand, L., 252, 264 Folstein, M. F., 98, 994, 995, 1002 Frenck-Mestre, C., 249 Ferrari, C., 75 Folstein, M. R., 975 Freud, S., 1015 Ferrari, P., 192, 566 Folstein, S. E., 995, 1002 Frick, T., 826 Ferraro, K., 343 Food and Drug Administration (FDA), 49, 51 Friden, T. P., 756, 803 Ferraro, V., 648 Forbes, M., 125, 264, 570, 572 Fridlund, B., 307, 308 Ferreira, C. T., 610 Ford, A. B., 43 Fridman, E. A., 54 Ferreira, F., 648 Ford, J., 382 Fridriksson, J., 110, 511 Ferreres, A. R., 257 Forde, E., 567, 693, 720 Friederici, A., 416, 423, 424, 509, 689, 706, Ferreri, T., 536 Fordyce, D. J., 891 783, 1013, 1014 Ferris, S. H., 995 Foreman, M. D., 995 Friedland, J., 379, 380, 381, 382, 384 Ferro, J. M., 187, 189, 192, 567, 572, 575 Foresti, A., 7 Friedland, R. P., 995 Ferroni, A., 547 Forssberg, H., 1013 Friedman, H. M., 411 Fetz, E. E., 1011 Forster, S., 377 Friedman, M. H., 379 Feuerstein, R., 904 Fortier-Blanc, J., 205 Friedman, O., 101 Fey, M., 117, 482, 902 Foss, J. W., 996 Friedman, R. B., 413, 597, 609, 663, 667, ffytche, D. H., 1009, 1015 Fossett, T. R. D., 549 767, 769 Fickas, S., 763, 940 Fougeyrollas, P., 66, 281, 351, 352, 353, 354, Friedmann, N., 103, 738, 740, 741 Fidopiastis, C. M., 923 357, 359, 364, 365 Fried-Oken, M., 824 Field, M. J., 205 Foundas, A. L., 611, 612, 613, 616 Friedrich, F. A., 534 Fields, W. S., 46 Fowler, C. G., 91 Friedrich, F. J., 696, 964 Fife, D., 880 Fowler, R., 930 Fristoe, M., 768 Filley, C. M., 894 Fox, H. B., 217 Friston, K., 37 Fillingham, J. K., 432, 718, 726, 727 Fox, L., 295, 304, 338, 817, 824 Frith, C. D., 37, 967 The FIM System, 80 Fox, P. T., 967 Fromhoff, F. A., 937 Findley, L. J., 554 Fraansen, M., 620 Fromkin, V., 740 Fink, G. R., 190, 565, 1015, 1016 Frackowiak, R. S., 37, 50, 547, 554, 967 Fromm, D., 34, 80, 178, 192, 297, 437, 524, Fink, R. B., 103, 180, 414, 420, 597, 619, 640, Frady, M., 13 572, 579, 757, 814 643, 647, 648, 726, 745, 762, 832, 852, 862 Fragassi, N. A., 609 Fruhwald, T., 1000 Finkelstein, S., 26, 969 Fralish, K., 924 Fucetola, R., 193, 437 Finlayson, A., 68 Frame, S., 293, 779 Fuchs, L. S., 918 Fischer, R. S., 32, 33, 667 Franchi, D., 967 Fuchs, S., 895 Fischette, M. R., 33 Francis, D., 519, 609, 618 Fuh, J. L., 550 Fischler, I., 106 Francis, G., 999 Fuhrer, M., 304 Fishbourne, R. P., 658 Francis, W. N., 613 Fukui, T., 552, 554, 555 Fisher, M., 48 Francois, L. K., 195 Fuld, P. A., 894 Fisher, R. S., 217 Frank, A., 297 Fuller, K., 866 Fishman, J. A., 249 Frank, C., 89, 94 Functional Communication Measure, 80 Fitch-West, J., 71 Frank, E. M., 256, 524 Funfgeld, M., 378 Fitz-Gibbon, C. T., 869 Frank, R., 22, 30, 37 Funkenstein, H. H., 26 Fitzpatrick, D., 1010, 1013 Franklin, L. R., 781 Funnell, E., 585, 610, 611, 674 Fitzpatrick, P. M., 108, 174, 581, 771, 830 Franklin, S., 110, 111, 173, 413, 599, 609, 610, Fust, R. S., 384 FitzpatrickDeSalme, E. J., 893 611, 617, 619, 620, 643, 718, 735 Fuster, J. M., 534 Fitzsimons, G. M., 910 Franklin, T. C., 74, 76 Fytche, D. H., 697 Fivush, R., 937 Frankoski, R. F., 46 Flack, J. M., 11, 12 Franssen, E., 995 Gabriel, C., 172 Flaherty, D., 76 Franssen, M., 174 Gabrieli, J. D., 96 Flavell, J., 891, 892, 899, 915, 919, 920 Franz, S. I., 756 Gaddie, A., 172, 496, 520, 573 Fleet, W. S., 965 Fraser, C., 54 Gaddie-Cariola, A., 394 Flege, J. E., 249 Fraser, R. T., 896 Gadler, H. P., 865 Fleiss, J. L., 168 Frattali, C. M., 14, 79, 80, 119, 120, 121, 128, Gage, F. H., 13 Fleming, P. D., 552 129, 130, 164, 178, 255, 290, 291, 295, 297, Gagnon, D. A., 699, 774 Fletcher, J. M., 894 298, 319, 356, 376, 377, 437, 487, 550, 551, Gailey, G., 291, 306, 497 Fletcher, R., 323, 768 555, 579, 768 Gaines, K., 11 Flexer, C., 335 Frayne, S. M., 246 Gainotti, G., 11, 35, 37, 411, 568, 610, 964 Flick, C. L., 239 Frazier, C. H., 756 Gajar, A., 924 GRBQ344-ind[1043-1072].qxd 04/02/2008 08:19 Page 1052 Aptara Inc. 1052 Author Index Galaburda, A. M., 27, 30 Gerstman, L. J., 110, 430, 573, 971, 977 Goldberg, D., 214 Galasko, D., 992 Geschwind, N., 9, 21, 28, 29, 33, 507, 690, 767, Goldberg, E., 98 Galens, J., 246 857, 891 Goldberg, G., 52, 539 Gallagher, A. J., 423 Geyer, S., 1014 Goldberg, M. S., 43 Gallagher, D., 994 Ghaemi, M., 50, 190 Goldberg, S. A., 854, 858, 865 Gallagher, R., 111, 112, 424, 735 Ghez, C., 1010 Goldblum, M. C., 259 Gallagher, T., 80, 114, 213, 481 Ghidella, C., 305, 307, 763 Goldenberg, G., 124, 189, 190, 508, 537 Gallese, V., 1013, 1014 Ghosh, S., 1011, 1014, 1015 Goldenberg, M., 975 Galt, J. R., 50 Giangreco, M. F., 902 Goldfader, P. R., 35 Galynker, I., 52 Giap, B. T., 894 Goldman, J., 990, 991 Gandek, B., 357 Gibbon, B., 229, 240, 242 Goldman, P. S., 910 Gandour, J., 251, 1027 Gibbs, L., 81 Goldman-Rakic, P. S., 534, 700 Ganguley, B., 566 Gierut, J., 746 Goldrick, M., 598, 607, 611, 774, 775 Gannaway, R., 293, 779 Gilbert, B., 997 Goldsmith, T., 973 Garcia, L., 79, 85, 256, 279, 305, 349, 351, Gilbert, E., 999 Goldstein, A. P., 923 360, 363, 427 Gilbert, T. P., 384 Goldstein, B., 246 García-Albea, J. E., 252 Giles, H., 207, 293, 301 Goldstein, F. C., 880, 892 Gardner, B., 413, 428, 864 Gilhooly, K. J., 613 Goldstein, H., 171, 173, 178, 431, 745, 757 Gardner, H., 102, 410, 415, 416, 417, 420, Gill, H. S., 204 Goldstein, J., 409 515, 567, 570, 576, 586, 774, 864, 969, Gillilan, L. A., 44 Goldstein, K., 6, 94, 105, 421, 492, 811, 860 971, 972, 976 Gillispie, M., 1002 Goldstein, L. B., 55 Gardner, R., 864 Gillum, R. F., 11 Goleman, D., 229, 232 Garrett, K., 67, 71, 173, 295, 297, 306, 377, Gilpin, S., 10, 115, 290, 328, 355 Golin, A. K., 232, 233 382, 387, 392, 393, 522, 584, 817, 818, 819, Ginsberg, G. M., 90 Gollnick, D., 246 820, 821, 824, 826, 827, 828 Gioia, G., 98, 904 Golper, L. A., 229, 232 Garrett, M. F., 597, 634, 635, 636, 637, 641, Giordani, B., 888 Golper, L. C., 80, 84, 363, 366, 417, 518 646, 769 Girling, D. M., 544 Gomez-Tortosa, E., 259 Garron, D. C., 609 Giroire, J. M., 34 Gomis, M., 11 Gasper, S. M., 716 Giusiano, B., 610 Gonatas, N., 549 Gass, S. M., 250 Giustolisi, L., 35, 611 Gontkovsky, S., 319 Gatehouse, C., 775 Gjengedal, E., 334 Gonzales, J., 56 Gates, G. A., 91 Glasberg, J. J., 52 Gonzalez, M., 413, 832, 862 Gathercole, S., 720 Glaser, R., 409, 411 Gonzalez-Rothi, L. J., 450, 530, 535, 536, 597, Gaudreau, J., 419, 618 Glass, T., 319 599, 600, 602, 607, 648, 674, 689, 704, 718, Gaunt, C., 1026 Gleason, J. B., 416, 745 721, 722, 776 Gaviria, M., 259 Gleick, J., 701 Goodale, M. A., 609 Gazdar, G., 736 Glenberg, A. M., 714 Goodenough, C., 758 Geffner, D., 213 Glenn, C. G., 696 Goodglass, H., 3, 4, 7, 8, 9, 21, 27, 35, 71, 72, Gehlbach, S. H., 81 Glennen, S., 830 74, 75, 79, 96, 102, 105, 109, 110, 111, 112, Geigenbaum, E. A., 865 Glickstein, J. K., 1002 113, 125, 192, 196, 255, 256, 389, 411, 413, Geigenberger, A., 977 Glindemann, R., 520, 757 415, 416, 418, 423, 424, 427, 457, 492, 507, Gelfer, C. E., 35 Glisky, E. L., 863, 922 508, 566, 567, 574, 578, 601, 607, 632, 644, Genereux, S., 306 Glomset, J. A., 44 657, 666, 698, 724, 735, 736, 738, 741, 745, Genesee, F., 260 Gloning, K., 192, 193 764, 765, 767, 768, 771, 774, 776, 777, 782, Gennarelli, T. A., 881 Glosser, G., 96, 109, 110, 114, 427, 663, 783, 817, 857, 970, 974, 995 Gentile, A., 253 771, 830 Goodman, J. S., 718 Gentry, B., 246 Gluck, M. A., 894 Goodman, P., 14, 77, 480 George, K. P., 123, 191 Glucroft, B., 557 Goodman, R. A., 75, 597, 656, 666 George, P., 757 Glueckauf, R., 119, 122 Goodman-Schulman, R., 600, 657 Georgeadis, A. C., 180 Glykas, M., 205 Goodwin, C., 101, 178, 291, 293, 294, 301 Georges, J. B., 584 Göbel, S., 1015 Goplerud, E., 212 Georgopoulos, A. P., 91, 1011 Gobin, P., 570 Goral, M., 245, 249, 252 Gerard, R., 219 Goda, A. J., 108, 128, 508 Gordon, B., 547, 609, 610, 611, 698, 738 Gerber, S., 118, 119 Godduhn, J., 377 Gordon, E., 376, 380 Gerberich, S. G., 880 Godfrey, C. M., 377, 379 Gordon, H., 259, 837 Gerdau, R., 13 Goedert, M., 990 Gordon, J. K., 81 German, D. J., 75, 105, 578 Goertzen, C. D., 53 Goren, A. R., 90 Germani, M. J., 770 Goettl, B. P., 714 Gorno-Tempini, M., 37, 549, 550, 551, 554, Gernsbacher, M. A., 757 Goff, D. C., 12 555, 556 Gerratt, B. R., 102, 420 Goffin, J., 50 Görtler, M., 536 Gersh, F., 21 Goffman, E., 327 Gottlieb, S. H., 11, 12 Gershaw, N. J., 923 Goffman, I., 291, 307, 308 Gouaze, A., 26 Gersten, J. W., 52 Goggin, J. P., 249, 257 Goulding, P. J., 547 Gersten, R., 902, 918 Gold, B. T., 574 Goulet, P., 612, 969, 973 Gerstenberger, D., 94, 333 Gold, M., 56, 537, 540, 711 Govoni, P., 1012 611. 747 Hart. M. 14 811. M. Author Index 1053 Gowan. D. P. 118. J. J. A. 992. J... H.. M. 5. 611 Guerrini. 937 Hardy.. M. A.. 965 Hartley. E. F. S.. Hagenlocker. 22. 880. W. A. 966 Harvey. A. 208 Groher... 97. 519 Greenwood.. S.... B. 610. K.. 477 Greenwood.. 902 Grice. M. 756. 539 Hanson. R. P. R... M. F. 415. 891 Grabow. J. 64.. A. 665. 297 Haendiges. 1011 Haas. 919 Hanson. W. M. 255 Graham. 880 Gronwall. P... 85. 248. 424. 891. 886. 1018 Harris. B. M. 428 Greener. 894. W.. K.. C. 98. M. 246. 891. C. D.. E. 92 Gurd.. M. P. 478. J. 880 Grilc. J.. 205. 1000 Hall. 52 . 211. 994 Grafman. 52. K. 643. 430 Harley. R. 502 Hamilton. D. 636. 246 Graziano. 215.. 89 Granger. J. J... S. 103. 619... 195.. 110. 557. R. 94 Hanks. 220. L. P. 894 Harskamp. 416.. E. E. J.. J. 484. A.. 51 Gupta. J. J.. J. 548. H. D. H. E. 893 Grogan. 639. 416.. 101 Grant.. 569. 49. E. 382. 634. 256. R. J. A.. K. Z.. M. 566 Happe. 297. W. P. E.. 56 Grosswasser.. R. H. 56 Hanley. 549. 895 Grober.. J. E. D.. C.. 76 Hansen.qxd 04/02/2008 08:19 Page 1053 Aptara Inc. K. M.. K. L. 110. 611. 572 648. 214... 1014. 880 Grossman. A. J. 3.. 195.. 758. 424. 80. L. M. 578 Guilford. M. J. 705 Halliday. P. 253 Graff-Radford.. 931 Greenbaum.. 896 Hart. 323 Graham. 193 Haaland.. G. K. 112 Hanson. 672. 230 Grand. S. C.. R. 893 Graham. 698 Grinspin. 46 Greenhalgh. 421... H. 861. A. 904 Hanratty. 888 Hallowell.. 550. 992 Gray. Green. M. 50. 299 Harris. 595. R. 102. M. 587 Griffin. I. 411. 892 Guenther.. H. 188. A.. E. 219. J. 775.. 886. 249. 924 Hake. S. J. L. 769 Hack. 736. 109. 124 Haley. A. 894 Grimshaw. 425. 248 Griffin. 103 Harris. 741 Halligan. 120. Han. 659 Haggard. 641. F. K. V. 765 Haberman. 471 Grossi.. 357 Graham. 937 Harris.. T.. B. 472. R. 50 Harruff... 537 Hardy. 698 Grassi. 740 Harrington. 881. R. 544 Hanna. 451 Haden. F. H. 1011 Hart.. 111. 902... 217. M. I.. G. J. 222 Hansen. B.. 620. 1022 Harris. 27. M. L. M. 37. B.. 740.. D. 208.. 774 Hallett. R.. D. E... R. 1014 Harlow. L. B. 75.. 50 Hanna.. 555... 413. 249 Haine. 471. R.. 238 Halle. 1018 Grayson. J. R. 89.. A. J. 856 Grade. D. L. 89 Gross. 422. 893 Harley. E. 250. 899.. 424 Grubeck-Loebenstein. P. 94 Graham. 617 Haas... P. J.. C. M.. 550. K. 88. S... 21. 98 922. J. 483. 901. 511 Habib.. 992 Haire. 252 Gunji... 885 Hagoort. 896. J. S.. 673. Hartman. 37. 485. 475. 487.. 767. G. 926 Hartsuiker... 218. 476. D. 380. 304 Grip. K. M. D. 429.. F.... 213. L. 14 Haarbauer-Krupa. J. 615. 930. C. 296. 969 Graetz. 246 Greene. K. 738 Hardt. 1009 Handlesman. J.. P.. 21. V.. 319. 1009. J. J. J. 35. H.. 552 Hammill. S. G. Harford... 250. 207. 554. 119 Hanna. 895 Hamby. 1019 Gray.. S... 48 Grainger.. 340 Harvey. G. C. 87 Grodzinsky. 488 Grey. Y. L.. 609 Halpern. 919. H.. P.. 96. 784. 609. 386. 583 Grant. 664 Grasby. 484.. 880. 650 Grosjean... P. 699 Greenwald. 52 Hakel. U... 641.. C. S. C.. A. 641. 95. 80. 248.. A. R. M. 56 Grill... H. E. 967 Halper. W.. 488 Gurland.. D... M. M. R. 425.. D. E. A. J. 978 Gruen. A. 893 212. 174 Grassly.. 612. 250 Haas. 323 Harrison.. 302. 431. B. P.. 554 Halsband. 886. 117 Haley.. 552 Hachinski.. 92.. 922. 735 Grantham. Z. 1014 Greenlee... 515 Hart. G. 881. G. 776 Hari. N. C.. J. M.. 509 Haarmann. 641. J.. N. 622... 249 Harris. M... L. 1013 Hand.. B.... 620 Hagiwara. 598 474. 192. 1018.. F. 248 Gybels. A. J. S. 967 Gudykunst. 473.. W.. 856. 774. J... 620 Haan.. S. K. W. 573. T. 96. 98.. 725 Hamsher. 104 Greenhouse. 210. R. M. J.. J... 492 Hand. 521 Grenier... 252. 424 Hanton. 914 Gresham. 75. A. 854.. 97. 608. 186 614. 357 Gresham. Z. 482 Griffin. C. 971 Green. 1013 Grabowski.. 251. 76 Hall. 891. J. 9. B.. 96. 413. N. 893. Hartman. 265 Halm. 572 Grol. 197. 203. P. 637. G. 1021 Grendel. 714 Hada. 914 Gullapalli. 765 Hallowell. M. 756 Green. 49. 641 Halkar.. L... R. 607. 217 Hakuta. N. J. 340 Harris. 387.. 187. F.. R.. 583 Haley. 1015 Hamrin. J. E. J. 993 Harlock. 250 Greenlee.. 637.. W. 918. 249 Hart. 216. 11. 198. E.. L. 634. 994 Harchik. 50. 1013 Hanlon.. 13 Hamers. 783 Granier. V. R. V. B. M. R. 967 Gyoubu. 14 Halle. 74 Guyard. 421. A. P.. T.. R. 297 Gupta. A. P.. J. D. 488 Harris... J.. J.GRBQ344-ind[1043-1072].. Grujic. 1010 Hageman. Y.. R. 609. 880. R. N. 56 Hagen. 550. J.. 246 Hammons. 655. 865 Hanna. T. 664 Graser.. 894 Green.. 880 508.. P.. 893 Hamburg. 775 Grossman. 738. 508 Hanson. 902 Hartshorne. 430. 736. D.. 4... M.. L. 725. J. 552. C. 88. 485. 406. J. 94. Hollon. 191 Hodges. 97. J. 77. A. 616. 641. 205. L. 904 216. 229 Hirsch. 50 Homan. 190. 697 Heiss.. 302. 568. 580.. J.. 578. K. 991 Hildebrandt. J. B. 292. 265. 508. P... 179. 539. 319 Healton. R. R. L.. 579 Hickman. 319 Hendricks. 581. J. 211. 765 Holley. 671. A. 967. E. 30. 612. 69. H. 295.. P. 323. 69. Heidler-Gary. A... 356. 166 Hermann. 197. 419. Hijdra. 999 Head.. 381. 777. K. 122. 776 Holland.. 517. 205 114. 420 Henry. 319 Hiraba. 599. 381. 736. 50 572. A. Holt. 356. 54 Heaton. 992.. Holm. H. 664 Hayes. W. 508 Ho. 668. 298 Henry. 71. G. 106 Hasan. 256. E. 570. E.. 600. B. 73.. N. L.. B. 826. 621. L. 607. 586. 427 Hickin. 197. 27.. H. 674.. 229 Hier. 499. 429 Helm-Estabrooks. M.. R.. 421. 384. 391 Hofstede... 575.. 192.. 89. 1022. T.. 69 Heron. 390.. 738 Hickok. S. N. 701 Herskovits. 249 Hécaen. H. 74. E. 891. 1017 Hernandez. 599. 918 Hirst. 109. 991. 597. 114 Heaton. 904 304. 1016 Holub. 511. 91. 178. 416. 779 Hird. A. 28. 187. 121. 661.GRBQ344-ind[1043-1072]. 409. 546. 999 Hogh. 300. 611.. L. 303.. E. 189. 784. E. 991. 82. 999 Helm. 768. 716 297. C. 577. 351. J. B. D. 588. 179. F.. C. Heeschen. 192.. 831 301. 295. 260. 476. K.. K. R. M. 260 Hesketh. 306 Hayward. 472. 379 Hazen. 93. 549 778.. A. 116. 298. 552. 558.. 614. D. J... 12 Heron. B. 106. 85. L. 229 Hebert. R.. 598. S. J. 432. J. P. H.. Holmes. E. 572 189. J. 118. 597... 102.. 337 Hinckley. 726. B. 610. 517 Hopkins. N. N. 518. D. 452. 668 Hatsopoulos. 991 Helmick. 1014. 233 Hoffman.. 567. L. 672. 192. 603. 384. 124. 768.. 1014 Hermann. 775 Holbrook. 71. 253. 102.. 214... 510. 999 Holcomb. 975. 80. 880 179. 719. 921 Hofstetter. 350. L. 51. 783. 94. 291. K. 103. 92. 724.. 610. L. E. 767. 615.. 191. O. 295. Hoodin. W. 361. 578. 967 Hodges. 294. D.. 904 Hilton. 967. 308. 298. 722. V. 613 Hauk. 94. M.. 893. M. 524. 35... 302. 128. F. 771. 786.. 358 893.. 1054 Author Index Harward. 515 Hendler.. 180. 69. 109. 492 He. G... 520. R. 362 Hebert.. K. N. 964 296. 634. 517. 180.. 902 Hirsch. 486. 536. 295. 291. B. G. 887.. 102. 293... 11. A. 256 Hindenlang.. P. A. 437. 1028 Hellblom. 569... B. 654. 557. B. Highley. 265 611. 382. B. J. R. 817. G. 220 Heinrich. 424. 473. 660... K. 178 Hoerster. 378. 294. 964 Hogan.. 719. 736.. V. J. 620. 115. M. A.. R. 113. 64. N. 14. 623. 585. S.. 290. D. 773. S. D. 219 572. 565 Hiller... J. 300. 691.. 669. 108.. 4. R. 597.. 110... 1016 127. 992 Herzog. 617. W... N. K.. 786 Hinnach... 610. 1027. 80. 229 Hellerstein. P. 221 Hatfield. D. D... 524. H. S. Hillman. 768... 654. 897 Henderson. R. 667 Hitch. T. 500 Heath. J. 212. 544 Herrmann. 783. 693 Hasboun. 597. D. 580. Hiltbronner. 584 Hawes. Hayden. 411. 118. 818. 989 Haviland. 756. 844. 197. P. R. 210. 391. 640. 337. 992 Hebb.. 308.. 386... J.. J. 114.. 548. 972 Havighurst. M... C. 665. 300.. W. W. 89. 474. 508.. 471.. E. 533. R. 964. 126. 82. 50 Hellige. Heeringa. 837 657. 96. 260. W. K. 110. 775.. 298. O. 178 Hodgson. 193... 967 Hemsley. 558 Hechtman.. M. 37. 192 Hirsch. 776. Hazenberg. B. 263... 218.. 576. 251. 976. 1015 Hendrick. 338. 624. 513 382. 570.. 414 Hilton. 886 . E. P.. 578.. 218 Herrin.. 264. 779. R. B. 319. 89. D. 220 595. R. Hickson. 304. 718 Haynes. B. 508.. S. 1015. 356. M. 406.. 21... 978 659. 355. M. 250 Haslam. 108. 247. 1001 Heindel. 767. A.. 814. 763. 34. L. C.. 921 Honig. 79. 716 Hayden.. 819. 297. 636. 221. 830. H. 548. 1011 Henri.. 213. 611 Hickson. P. 1012 Health Advocate. P.. Heikkila.. H. 219. 692. 771 Hoffman. 1011 Hashimoto. A.. 764. 362.. 394. J. 412. 620. G. 914. 613 Hoen. 43 Hillis. D. 50. 571. 323 Hedber-Borenstein. B. S. R. R. M. D.. L. 965. 432. J.. N. 611. 988 Herweyer. 118 497. 70 620. Heidler.. 621 Hengst. 583. J. 696. 484. 600. S. 565. 583 Hemyari. 118. 389. 508.. P. 508 Hillary. J. 49. 843. 72. 565 Heritage..qxd 04/02/2008 08:19 Page 1054 Aptara Inc. L. 14 Herholz. 840. 697. 92. D. 174.. 656. 80. 544 Hernandez. 840. C. 868 Hoffman. 123. 294. N. 362. C. 187. 378 Hoen. B.. A. J.. 37. A. Hilari. 924. 893 Hinton. D. 602. R. 745. 191. 1023 88. 721. A. 971. 601. 967 609. 123. 818 Hersh. 205. W. 125. 571.. 967 Hedberg. R. Holtzapple. E. 842. 392. 534. 104. 125. 598. G. 971. 621. Hillis Trupe. 1028 Herbert. 597.. E. 290... B. 32 Homma. R. W. H. 617 Hood.. 966. 294. 776.. 93. 580. 668. 377. 117. 124. 220. E. 669 Holzemer.. 70. M.. 619. 56.... 457.. 66. 253 Hoepfner. R. 329.. D. 782. V. R. J. 622.. 451. 251 Hauck. T.. A. 599 Hennes.. E. E.. 769 Hohl. 437. F. 357. 256 483.. K. W. J. 66. 659. 538. H. 609. M. 600.. A. 257. B. 552. S. A. G. 217. 579. 11 Hoffman. 977 356.. J. 295. Heilman. 455. 922 Henley.. 414. 572 Henson. 74. 301. M.. 98. 524. 124. 432 Hintzman.. 714 Haselkorn. 993 409. 608. J. Hirsch. 121. 846. L. 726. 744. 433.. 431. 773. 119. 76. 297. C.. 409. 363. S. C. 611. 423 Henderson. M. 989. 905 Heredia. 217 Hollinshead. 966 Hohenstein. 197. 300 Henderson. 582. L. J. 362.. 89. 691. 193. 924 Hichwa. S. 716 Hollingsworth. 648. D. 126... S. Holmes. H. 70. 782. Hoops. 998 Hayes. 295. 971 Hopcutt. R. 74.. 262. J. 481 Henson. R. 572 Herrmann. 616. 376. 923 Hellings. D. 544 Hochhalter. 255.. 964. 509. 111.. 600. Holman. 619. 598... 215. W. 922 Hersh. 351. 880 Held. 582. 378 Hickey.. Y. T. 419 Hubbard-Wiley.. 67... T. R.. T. 4.. 64. 588. 412. 819 Hudson. 524 Johns... G. K. 425. 290 Johannsen-Horbach. 120.. S. 615... U. C.. L. Jezewski.. J. A. 394 Iverson... 902 578.... 119 Ignativicius. M. 306. 965 Jacobs. 81. 415.. D. 597. R. 993 Joint Committee for Stroke Facilities. K. H. 477.. 902 568.. 323 Johnson... 993 Horton... 975. I. S. E. 624. P. 620.. Hyde. M. J. 895. 205 Hotz. K.. D. 999. 306.. K. 420. 21. 437. 920 Jennings. 300 Jacobson.. T. 508 Johnston. 95. 305.. D. 904 Ide. P.. 102. 969.. 391.. C.. L. 756.. 429.. 390 Irvine. 928 Jokel. 771.. Huth. 240. 73. D. 123.. 102. 965 Houghton. A. 825.. 10. 922 Johnson.. 75.. 856 Iacoboni. 923 Iavarone. S. 425. A. 970 Idrissi... 927 Hyde. L. 1009.. 921 Hunkin. D. 614... 697. W. K. B. Huber. 426. 242 Hurwitz. 765. 256. S.. G. 610 411. 295.. 1014 Jones... 965 Hyltenstam. 404. 108. 363. C. 540. D. C. 535 Ittelson. 416.. 256 Johnson. 1025 Huck. W.. 735. 290. 420. 424 Jackson. 173.. M. 727. D. Hovda. 609 Joanette. 85. J.. 426... 256 Imao. 1002 Hutter. 355.. 11 Disability and Health (ICF). R. 100. 869 Ingles.. J. 701 Hunter. R.. 382. R. 1015 Hubley. 978.. 51 Humphrey. 114. J. 49 Jagaroo. 88. 187... 888 Horner. H... 377. 411. 250 Itkonen. 300. A. 886 613. 779. J. 6. A. J.. H. 196. 418 Jennings. 765 Horton. R. 377. G. 217 Jennings. 423. 1022... 881 Jefferson. C. 973.. 894 Ikoma. B. 333 971. 14 Jacobs. W. G. W. K. 416. 81. 520. 250 Howland.. F. F. 363. 380. A. 306. 100 Humphreys. 74. 102. B. 457. 828 Jake. 583. W. J. B. 394. 665 Jessell. J. M. S. M. 12. 988. J. 895.. 240 Jenike. A.. M. 327 Houle. 114. C. 598. F. 775.qxd 04/02/2008 08:19 Page 1055 Aptara Inc. M.. 326 Jensen. N. 166.. M. G.. 926 Johnson. J. K. 6. Indefrey. 571. 392... 295. 967 Jack. 91.. H. K. J.. G. S. IDEA: Federal Register.. Z. 764 Hughy. D. 164. 405. 250 Jane. 488 831 Insalaco.. 891. M. 599. 726. 220 Johnson. 264.. 45. C.. 557 Hutchinson. 969.. 302. 56 Horowitz.. Inglehart. 393. 110. 657.. W. 126.. 612.. 484. K. 433 Inzaghi. 382. K. 78 Jackson.. 643.. 337 Hux. 350.. J. 823. Disability and Health Jarvis-Selinger.. 303. 610.. 838 Houston. J. 636. S.. 1023 Ingram. 549 Johnson. A.. 21. M. D. 924 Hughes. 971 Jones. 379 Jessner. 485 Ivnik. D. M. 851 Johnston. 726. 902 Hudson. M. 922. E. See International Classification of Jarvis. 123. 343.. 74 Irwin. K. W. A. 904 Johnson.. S. P. 991 Huvelle. W. 855 Huang. 756. 905 Johnson. 427 Jehkonen.. 814. A.. R. S. 257 Jinks. K. L. T. 746. T. 180. 970. M.. G. 26 Hütter. S. 102. 923 Huntley. 78. 169 Isaac.. 361. 967 Hornseth... R. 485. 425.. 191 Hufeisen. 410. 13 Hubbard. D. 382. 880. Hurford. 964. I. N. 470 773. 178. R. 757 Irvin. 355 Jacques.. M. 393. 720. 167. G. J. M. B. 599. 967 Howe. 79. 600 Jarecki. W. 82. 992 Hough. 837... L. 420. 930 Johnson... 128. L. 376. 778. E. 211 Hugdahl. 620. 427. K. 617. 516 Hughes. M. D. 71 Inskip. 252. 745 James. H. 776 Jacobs. R.. 1009 Functioning. 803. 119. D. 450. 855 Howard. 127.. 567. 328. S. H. 1009 Houghton. 902 Hynan. Johnson.. 831. 78. D. 166 609.... 102. 975 Horn. S. G. S.. 379.. 893. 756 Jennett. A.GRBQ344-ind[1043-1072]. 580. H.. 246 Iorio. 1011 Jansen Steur. 893. 648... M. H. L. 376. H.. 249. 632. 726. Jr.. M. 609 Horner. 351. A.. 1011 Johnston. M. 884. W. A. 392. Ireland. 433. 544 Jenkins. 997. V. W. J... D. M. 326 Hoyert. 716 Jefferson. 611. Healthcare Organizations (JCAHO).. 172 Hunt. 565. A. 73. 292.. N. 46 Husain. C..... T. 1011 210. A... 105. B. M. 102 International Classification of Functioning... 297 Jacobs. M. 411. R. 102.. 388 Jackson. Author Index 1055 Hopper.. 1013 517. 831 Jin.. G. 250 646. 56. 547 Johnston. 1014 Jenkins. J. 86.. Ingham... J. C. 902.. 603 197.. 102.. M. 250. L. S. E.. 902 Johnson. 54 Jenkins.. 718. 632 Hori. M.. S. 382 Hunt. 519. 552 Hula.. 35 Jenkins. 66. 815 212.. F. P. 894. S.. A. R... S. 603 Howieson. 306 Jacobsen. 75. A. 295. 824 Horn.. D. A.. G. L. 697. 382. W. 120. A. 509 80. B. 65. 552 Isquith. 299 ICF.. 383 Ireland. 609 Izard. J. 892 Ivancic... D. 838. 240 Ilinsky. 404.-O. T.. 770 Joint Commission on Accreditation of Huntley. J.. 357 Iwata. P. 745 James.. E. 350.. K. J. 1011 Jackson.. 776. J. 937 Isaacs. 56 Imbornone. R.. 757. A. J. R. W. 488 Janghorbani. D. J. 294. M.. C. 50. 509.. 249 Hoshiyama.. 1011 . 250 Hornak.. Ingstad. 648. 76 Jacobs. 416. B. 437. 535 Johansen-Berg. 572. 533 Johnsen. 745. 377. 117 780. L. S.. Hoyt. 378. W. J. 979 Huber. Jimenez-Pabon. 379. 765 Howard. 832 Huberman.. E. M. 674 Ielasi. 693. L. 1001 Janer. M. A. 295. A. 584.. G. B. J. 894 Housman.. E. P. 260 Jeffires. 998 Jack. C. C. V. P. 1024. 896. T. E. 1015 Hutchinson. 764. 404. 296. 87.. 111. 179. N. Z. 293. 125. Kim. 1022 Keenan. P. K. D. Kaplan. 768 621... 91 Kiosseoglu. 727 Kahan. 507. 172.. 578. F.. D. 741.. M. 902. H. T. K.. 765 King. 12 292. A. L. 710. 854. 109. 757 Kennedy. G. 28. 553. 777. 256 Kahana.. 125. 127. 549. 757 585. 976 Kenin. 114. M. 507. 295. 570 Kent. 70. 726. 573 Kagan. 574. Kim. K. J. R.. 534 Kandel. 115. 902.. 50. 249 588. 976 Kelly. M. N.. 764 Kincade. H. 580. 116.. 433. C. 390 King. 196. R. 327 Kayser. 611. M.. 187. 70.. 720. 905 Jones. 858. 90 Kennedy.. M. 356. 393. C.... L. S. S. 671 Kerr. 575. Keith. E. Kimbarow.. R. 616.. 297.... 863.. 450.. 866 88. 11. 708. 71.. S.GRBQ344-ind[1043-1072]. 203. A. 380 Kartsounis. G. 32. 364. Jonkers. E. 517. 508.. 21. M. 333 Kingston.. 578. 258.. H. S. D. C. 724. H. 855. 920 Ketonen.... 168. F. 342. 565. 452. J. J. 457. U. 595. J. J. 705. M. 425 Jonker. 376. 97. 214... 572 Kelly-Hayes. 599. 657.. 108. 377. P. 567. A. 129. 94.. 554. 297. 741. 857. 213. 565 Ketterson. 991. L... 437. 554. 556 Katzman. 618. 881. 764 Kahane.. R.. 89 Kirkevold.. 414. 193. 586.. A. 968 Kashima. J. 1026 King. B. G. 549. 11. 885. 904. 110. 601. E. 254. 964 Kendall. B.. Z. L.. 774. 79. M. R. 206. 853.. 382.. 853 Kenyon. 87. 180. 517. 918 Kiss. 124. 819. 857. 81. D. E. 290. 115. 658 Kang. 124.. 164 Kirsner.. 745.. 607.. T.. 423. P. 858.. 894 Katz. 98 King. 206 Khazei. Y.. M. R. H. G. A. 484.. 43 192. 989 572. 299. 643. 1024. 779 995 Keller. 325. 779 453. 974. 855. 82. 170. 852.. P. 894 Kempler. 205 Jong. M. 75. 207. 50 Katz. 79.. 8. 737. Kay. S. 665.. 832. 52 436.. 179. 425. A. P. Kertesz.. 102. A. D. 971. Kerschensteiner. Judge. 497. 720. M. 548. 197.. 555. M. 166. 79. 173. 69 Kahrs. 967 Kincaid. D. 480 Karcher. 188. Karbe. 737 746. 997 Kahana. 265. 86 666. J. J. 310.. 427. 576. S. 549 Jones. 103. 214.. 1011 Kaori.. 216 Kerns. M. 388. 250 Karow. L.. B. 803.. F. 549. 256. L. W. R. 75 818. 969. 88. J. 570.. 1009 Keefe... R. 999 Kaufer. W.. I. 178 Kaga. 893 Kerlinger. 724. J.. C. 988 Kaplan. Josephs. 550. 967 Kinsella. 381... 972 120.. 30.. 257. M.. A. 565. J.. 291. R. M.. 507. 817. 260. W. 71.. H... S. 205 305. B. 724.. 784 Keidel. 429 566.. 513. I. 966 Kane. 343. N. 418. 78. 251 Kahn. L. 328. 552 Khaw. 576 Kirwin. 327 Kazis. 264 Kaufman. A. Keller.. B.. R... 388. 776 Katz. R. 304. 303. R. 578. 764 Kiernan.. Jorgensen. 861 Kennedy. 325 Kiran.. 190. 857.. 972. 222 Kelly.. 1022 551. 300.. 727 Katz. 568.. 1056 Author Index Jones.. 95 Kaszniak. 975. 724. Junqué. 820 Kaplan. 197.. M. K. 657. E. 451. Katz.. F. J. 905. 81. 578. 352. 711. 745 Kahn. J. C. N. R. 976 Klatzky. 197. K. 260. 256 Kim.. Kim.. 976 Juola. 334 Karlsson.. J. 236. C. 856 Keyserlingk. K. 7.... D. 978. Kilborn. V. 48 Kadon.. 639. 189. 894. L.. 1015 Kalra.. Kellar. G. 552. 266. K. 544. K. A. 767. 737 Kessler. M. 425. 583. 723. R. 1020 Jones. 721. 764 Ken. 350. 385. Kalinyak-Fliszar. 515 Kent. 618. R. 710. 196. 1012 Kearns. D. 411. 92 Kendall. A. M. Kay. 646 Kim.. 191. 95 771. 657. 173 Keith. 975. C... 118. 73. 565 544. H. 508 Karnath. M. A. E. F. K. 327 Kean. K. 174. 186. M... A. P. 208. S. D. 247 Keil. M. M. 673 Kennedy.. 523. J. 508. 855 Kimura. 514 Kahneman. 72. 75 Kessels. 1023 174. 306. L.. P. 553. N. 566....qxd 04/02/2008 08:19 Page 1056 Aptara Inc. 27.. S. 50. 552. 578 Katz. D. 192. 970. R. 554. 603 Keeton. 492 Kimura. 612.. H. J. 175. C. S. K. 415.. 173. K. 188. 76 Karpf. 922 Jones. 859.. 416. A.. 413. 99. 572 Kay. R. 566. 66 394. A. 117. U. 656... J. 420.. M. 639 Katsumata. L. C.. 757 389. 102. 256 Kaplan.. C. 256 Kim. O.. 54 Kawabata. 523 King.. L. 89. 600. M. 469.. R. 756. 319 .. S. 787. K. 738 Kahana. 255. P... N. J. A. C. 191. 557. 967 Kelso. 666 Kilgard. 1020 Klees. 163 Jones. R. S. 426... 50. 7. 423. 735. 165.. 866 263. 639 Kemeny. 43. 496. 279. 737 Kaschak. 190. 123.. 11.. 337 363.. Kay. 190 Kauschke... 556. 618 Kawahigashi. 856. H. 567.. 14. 171. 93 Kleczewska. 264. B. 422. T. M. 163. 295.. 89 Kimelman. 515 Kalisky. 392. 570 Kern.. N. 412 Kaufman. L... 622. 864 Katsuki-Nakamura. 49. D. 256. 776. 611. 210.. 417. 861. 109.. 865. M.. F. 416.. 894 Keenan. 672. 884.. P. 103.. J. 574. 737 860.. 862. 565 Kavale. K. 7. 71. 830.. B. 50. 989 762. 180. Kaplan. 668. S. R. 74. Kawamura. 623. R. J. 544 Kitselman.. 362. 196. D.. M. S. 492. 179. 508. L. 550. L. 817. 325.. 419. 173. 567... 391. 109. H... J. M. 930 Kisley. H. 310 Kakigi. 894 Kaplan. R. 565. 1014 Kaufman. 520. 362. 720. C. 520. 722. J. H. 319 Keenan. 93. A. P. 515 Kessels. L. Kapur. 427. 124. 12. M. 71.. A.. 571. C.. 1029 Kimelman. 969 Kinsella. 921 Kemmerer. 379.. G. 78.. 294. R. 552. D. Kirchner. 77. K. 887 Killackey. 993 Kent. 190 Jürgens. 256. 366. 174. 747. C. 497. K. T. 778 Kapur. K. 922 Just.. Keith.. 610.-M. 1022 Kirshner. 551.. J. 186 Katz. 98 363. 119. 53 Katz. K. R. M.. 189 Koetsier.. 718. 567 Lecours. A.. B. 704 Knibb. 736 Labov. 418. M. 567 Larsen.. 295. 49. 476. 502 641. T. 101. L. 250 LaPointe.. 739. 1013 Kronick. 27. 544 Lasky. H. D. 550.. 257. 861 Lallanranta. P. 1012 Lambon Ralph. 421. J.. J. 294. P. 85 Kretschmann. M.. K. S. T. 599 Kosinski.. 926 Lasker. 738... 610 Kokmen. L. L. 352. 251 Kraus.. S.. M.... 295 Kufera.... 617. J. 363. H. 337. 887. 257. 259. 620. G. 893. D. 112. 49 Ladavas.. 425. 582 Krause. 118. R. P.. J. 738 Laaksonen. E. L. 726 Korpelainen. H. A. C. 124.. E.. A. 414 Law.. M. 509.. 206 Lee. 516 Kohnert. 82. L.. 964 Labarthe. 50 Kramer.. 544 Kubos.. G. 478. T. T. L. A. 896 Langdon. 301. 363 Koster. L.. J.. 73 Laterre. 229 Lafaury. A. 553. 708. 409. S. C.. J... 718. 290.. 880 Landrum. 894 Kremer. J. J. 253 le Grand. 556 Kremin. C. D. 611. 817. 856 292. E. 578.. 705 306... Knox.. 689 Lauritzen. 764 Kramer. 240 Klein. 992 Lamping. W. 432. K. 826. S. 98 Koehl.. Z. K. 778 Lee. 552 Langdon. R. 905 Kosslyn.. L. 52 Knock. A. 360 Law.. 229. B. 34. M. A. 1022. 415. 513 Lai. 70. 189. 14. R. J. 357 Lee. 822. 993 Kleinman. S.. 993 Lalor. K.. 995 Lahey. M. 261 Leander. P. 220 Laihinen. 976 114. 880 Kooistra... 258. 21 Kolb.GRBQ344-ind[1043-1072]. 976 Kurowski. 15.. 166. T. 49. 1022. R. J. 858. 306. 595 Klein. 429. Y. 292. 12 Lawton. 192... 420 Klein.... 477 Kordus. 610. 1010 Lambrecht. R. 416. W. F. E. A... 294.. G... C. 1023 . 193. C. 893 Larkins. M. 523 Kucera. 552.. H.. 568 Kudo. 293 Kregel. K.. K. B. 419. 783 Knighton. G. 102 Lane. 535 433. M.... 818. J. M. 65. 27. B. F... 75 Koff. 410.. 904 Lang. 323 Lane. J. 334 Lau. A.. L. D. 305. L.. 853. 119 Kravetz. A. F... J. A. 237. W. M.. A. 251.. 610... 69. 297. 713 Leblanc. 774 Lee.. A. 620. 411. 480 LeBlanc. 75.. B.-M. 102. S. 79. 73. H. 975 LaPointe. D. 760 Kovach. S. E.. 865 Kushner. K. 13 Koski. E. 613 Larfeuil.. 776 Lee.. 1011 Law. A.... S. 50 Laroche. N. R.. 544 Larson.. 508 Kroll. 94 Kung. H. 1015 Kraemer. 89. 28 Laine. 855. 13 Kuller. B. M.. P. 342 Lankhorse. 231 Koskiniemi.. 546. 43 Langer.. LeBlanc. 975 Kolk. F.. A. D. 9. U. T. Knösche. 515. 741 Krakauer. 896 Langmore. S. M.. 351 Kodras. S. E. P. 67. 508. E. K. 905 Knight. M... J... 558 Kurachi. L. 364 Koopman.. 573. 109 Larrabee. S.. 894 Kubat-Silman. 620. H. 1019 Koller. 636 Koch. R. J.. J.. 650. M. 902 Kuhl. L. 616. D... 856 Lambert.. 613. 180. K. 52 Laughlin. 421 Larkins. M.. T. K.. 609. H. 745.qxd 04/02/2008 08:19 Page 1057 Aptara Inc. M.. 738 Knopman. J. LeDorze. 118. F... M. 1023 Kroenke. 991 Koss. G.. 111. 706. 726. R. 308. H... 11 Larsen... 787 824... 647. W. K. 977 Landis. H. D. A. 785 Lazerson. 1013 Lang.. 125. L. 619 Kurtz. 1023 Kobayashi. J. 552 260. 121.. J. 113. K. Knowlton.. 864 Langenbahn.. M. 101 Koch. 71. 414.. Koul. V. 828. 254 Klippi.. 569 Laws. 260. H. 298. H. K. 205 Kotten. 125. 102. 567. 565. A. 422. 379 Le Moal.. H... R. 189. S. L. K. E.. 862 Leavitt. 180. 928 Klonoff. J. L.. 22 814. 423. 222 Koelman. 854 Lai. J. S. 657. 967 le Grand. 124. S.. 11 Larsen. S... A. 894 Laganaro.. S.. B.. H. 251 Krainen. D. 696 Laasko.. 50. 212 Lazorthes. J. A. 250 Lee.. 419.. 657. 484.. E. 251 LeDoux. H. 637. J.. 967 Laganaro. 567. 718 Labovitz. Q.. Kusunoki. 507.... A. 70. D.. 648. W. R.. 26 Kornhuber. 910 Klein. 360. K. 253.. J.. 52 Kurland. N.. 363 Koegel. 923 Krchnavek. 993 Koenig. 479. J. 74. 252. 251 Landry. 256. C... 114. C. L.. 253. 422. 1026 735... M. 357 Lafond. T... K. E. J. 56 Konorski. D.. Author Index 1057 Klein. 123. 264 Kvigne. P.. 335. G. 323. 295. 841 Kricos. 815 Laird... T. H. 53 Krause.. 229 Lee.. 611. 412 Kubik. 81. J. Kurtzke. W.. 123. C... 49.. 414. 1012 Lange. G. 618. 89 Koegel. 9. Laake.. 587 616. 810. R. 364 Lanzoni. Kohn. 66. 571. D. 293. 613. F. 291... 180.. S. J.. J. H. W.. E.. 85. 611 Krebs-Noble. 110. 68. 607. 125. A. 819. 767. M. 327. 111.. G. 205 Kraat. 550. 257. K. 972 Kozniewska. P. 377.. 856 Knight.. L. 1017 Laska. 247. 660. H. 423.. E. 74. 777 Klima. J. R. R.. G. C. C. J. 619. W. M. 880 Larson. J. E. J. 75 Krainik.. 52 Kumar... 964 Koudstaal.. H.. 566. 549 Kwakkel.. R.. 1026 Klein. P.. 910 Koenig-Bruhin.. 114. P. 902 Kulke. 102.. 865 Kreutzer. 100. 741 Kragh-Sorensen. 305.. D. 253. 20 Krefft. 885. 46 Laiacona.. E. N. 413 Lee. T. 28 Labar. 572 Kohen. 351. S.. T.. 565. 35. P. W.. Y. 858 599. F. 257. 82. A. Longstreth. F. 102.. 993 Maas. 344.. A. 206 Lockhart. 769 Lehoux.. L. 891. E. 28. 777. 361. S.. 582. 260 Leicester. 382 Levelt. 304. 418 Liddle. M. C.. L. E. 14.... 380. 418. T. 86. 415. L.. Levine.. 376. J. 714. 737 Levin. 46 Liles. M. 485.. C. 781 Loomis. J... Lekka. 970. 411. 585. 618 Lucchelli. 972. M. 613. 1012 Lesser. 100. R. 123. R.. 580 MacDonald. 306. 178 Lu. 122. E. 666 Litvan. 599. S. 551. 168. 904 Lewis. 37 Lyon.. 1009. E. C. J. S. 1058 Author Index Leek. 1009 LeRhun.GRBQ344-ind[1043-1072]. J. P. 392. 258 Loring. 245 356... 119. 887. 576 Lieberthal. 714 Mackay. I. 188.. B. S. 617. 429 Lott. 327 Leith. 622 Love... 255 LoCasto. P.. E. 50. 1014 Lloyd. 205 MacKay. 290. 860 Leonard. 632. 991 Levander. 256.. 969.. 308. 79 Lenzi. P. 569 Levin. 297. R. R... J.... B.. R. N. 966. 118. 123. 995 517.. E.... 255.. 376. D.. 119. 111. 486. Lüders. J. 894. D. P. A. H. W. 572 Li... 565. N. L... 94. A.. 114. 304. 965 Leigh. 290. E. P. 190 Lynch. 175. 75.. 343 Lesniewicz.. 786. J. 92 Ling. 116. 1001 Lemieux. 893 Lemhöfer. D. 361. 256 Lott. 257. Lincoln. 362. 427. 391. S. J. E. 413. 192.. M.. 213.. 967 Long. 249 Lhermitte. W... N. 858. 969. D. 87.. 1026 Lefkowitz. T. 745 Levkoff.. 392. E. 231 Lefrancois. 229 Lehmann. 423.. L... 319 Lucariello. 73. 937 Leonard. 279. 777. A. 369. M. D. Lissauer.. 423. 924 379. 826. A. Levin. 520 Lehman-Blake.. C. 256 Liles. Leon.. 820 Loverme.. M. 971 Lipsey. 893. A.. 570. A.. D.. 292.. R. 217 Liepert. E. 930 Lucas.. 108. 520. 415 Lombardi. E. S. 769... E. 413 Ludy. C. 636. L. 580 310. J. P. 657. R. 969 Lindfors. 555. 550 LPAA Project Group. C. 376. 429. C. P. R.. 566 Lum. 576. A. J. G. 68.. 619. 421 Legg. 120.. Leve. 297. H. 716 Lynch. 418. M. 14 Light. 470.. 246 Levin. 860. 1011 Love. 80. G.. G. Z. H.. 115. F. 323 Lowell. 976 Legatt. 861.. 308 London. 577. 257 Lieberman. 557 Letenneur.. Levine. 422. 378 Luecke. 507. 646. 1015 Lovegreen. 188. 389. E. 516.. 893 745. J.. 260.. M. 118... 667. F. 472. 425 Lorch. S. 714 Lichtheim. 970. A. R. 575. E. 362 . 388. N. J. L... W. 191. 612. H. J.. 894 Lustig.. H.. 205 Leslie. G. 909 578. 899. 89 Linebaugh.. 866. R. 56 Liepmann. A.. 92. 902 Lewis. M.. W. 325.. 975 Lindamood.. 572 Lindeman. A. 588 1021 Lincoln. 970. 557. 480 Leonard. J.. B. 428 Mace. P. 118.. 566 Lepper.. S. 379. 178. 775 Leonardi-Bee.. 343. 691. 115. 71 Lehman. 30. G. C. 98. M. 108 Lehner. 899 Linebaugh. 377. 886... 205 Li.. 973 Liberman. 1015 Lin. A. 300. 419. 738 Logan. 597 Lehtonen. L. 637. T.. 550 Lorimer. 427 Lommel. K.. S.. S.. K. B. 360. 477 Li. K. 308.. 622. J. 488. 231 Lehéricy.. Jr. 880... 971 Lovett. B. M. 52 Leger. S.. K. 349. T. B... P.. 328. N.. R. 509 780. 343 Loverso. 774.. 411 Lovati. 993 Liu. 580. 484. 424.. 107... W. K. 53 Levey.. K... 867 Lemak.. 95. 303 568. J. D.. 757 Li. C. Y. Levine. 295... R. 115. G.. 972 Ludlow. 971 572. J. 610 Lhermitte. 966 Lux.. W. 343 Lorge. B. T. 1027 Leung. P. 252. 544 363. 71. 70. T. T.. 122. 389.. 972. W. 767. 279. 966... 768 Lutsep. A. J. A.. C. N.. 550 Luring. S. 302 Lightfoot. 124. 299. H. 252 Limburg. 721 Lubinski. 108. 291. 43 Lloyd. 303... J... 217. 257 Livingston. M. 377. 1010 Losanno. 110. 894 MacDonald. 1012 Libben.. 83. M... 573 LogoMetrix. 858. 249 Lo. 544. G. 114. I. 632 Longoni. 360. R. 865 Lucius-Hoene. 891 Lolk. 1001 Leonard.. W. 205 Lieberman. 740.. 419. 291. 310 Mack. C. 13 Lindamood. L. A. I.. M. 10... 213. 109. 894. 319. 97.. 206 Lodder. 966.. 975 Luppino. N. 51 Logue. G. 909 Longan. 422. J.. R. D.qxd 04/02/2008 08:19 Page 1058 Aptara Inc. 245... 944 Levita. W. S. 75 Lewis.... 78. 648... S. 656. W. S. J. 583. 189... 299. 892. 499. 111. M. 290. 482 Lindquist. 299. 120.. 426. 457. 547. 578.. 46 Linebarger. 50. 969. 193.. 109. W. 206 Lomas. B. C. 881. R. A. L. 1018. E. 80. J. J. 704. 756 Linell. L. K. 174. L. 979 Lindeboom. F.. 735. 973 Lichtenberg. S. 337. 776 Lennon. J.. 46.. K. L. 117 Lindsay. 517 Liao. 969 Logie... 642. H. F.. D. 1022 328... 647. L.. 740 Leiguarda. H. J. J. S. Lemme. H. 82. 195... 49 Luterman.. 299. I. R. 991 294. W. R. D. N. 21. Macciocchi. 377. 584. 571. 487 Lucas. 968 Leff. 110. 109.. 486.. 193. 306. 965 Lloyd.. 721 Lu. 700 Lott. M. 117. L. E. 1013 Luzzatti. 422. 192 Levy. S.. R. 514 Lezak. M. 37 Lott. C. 412. 816... R. M. F. 764 Leri. 361. 609 Luria. 192. 334. M. M. 570. 265 Lorenze. 756 MacGinitie. 193. C. L.. 776.. 930 Lewis. C. Lojek-Osiejuk. 416... 83. 49 Leiwo. 857 Levine. L. A. 502.. D. J. 310. J.. 265 Lustig.. 537 Longman. 895 Lock. T. S. 771 Leong. G.. B. P. A. T. 1024. Maxim. 920 Masayk. 382. 77. 937 Makris. 620. P. 477 McCooey. 597. 660. 647. 552 Markwardt. 536 Matelli. 335 Mashima. 648.. B.. 419. 621 MacKenzie. 174. 892. 299 Madureira. 78. 655. 484. 377.. 197. W. Mazaux. B. V.. 186. R.. M. 34. K. 580.. S. 991 McAllister. 569 McCormick. 991 McCabe.. 609 Mauszycki... 975. 429. 380 Martinage. 115. 196. S.. A.. B. M. D.. 524.. C. 572 Manton. 419 McDermott. 245 Marquardsen. J. 552 Masand.. 572. A. 379. 634. 552 Makoni.. J. H.. 616. 389. 73 Mahendra. 205.. 757 McCarthy.. S. G. 657 Marshall. 865 413. 77. 51 Magito-McLaughlin... A. S.. P.. 232.. 192 965. E... 965 McDicken. J...... 762. 976. 565 McCullagh. 893. M.. G. 774. 738. 895 Mazzocchi. J. G. 893 Magni. 569. 254. 777. 693. L. A. 595.. 994. 118. 53 Martin. W. M. F. 111. H. 520. 515.. D.. I.. 92. 776 Manion. E. 255. 999. 710. 75 Mauer. 768. P. 617... 893. 414. N. D. M. 858 McHugh. 902. B. J. 1009. 79. S.. A.qxd 04/02/2008 08:19 Page 1059 Aptara Inc. 704 Matthews.. P. 1002 516. 1026. A. C. 965 Masih. 381. R. 319 Manning. 611 Malec.. 966 Marx. 488 Manly. 259 565. D. 28. 571. E. 519. 969. 192 Margolin. F.. 641. Maurer. 1012 McHugh.. 570. 248.. 121 643. 379 699. Malone. 895 Marsh. 193. Author Index 1059 MacKenzie. D. M. F... B. K. F. B..GRBQ344-ind[1043-1072]. 517. P. K. 712. D. 56 Martin. D. 854 McDonald. S. A. A. 995 Marin. M. 696. 920. 546.. 519 Marini. G. J.. 250. 259. J.. 255 Masson. F. 695. 101. 895 Madden. 83. 251. 384 Manly. 192. McAlonan. 764. T. 521... M. L. W. M. P. M. 50 McCauley. 423. 618 Marty. J. J.. A. 192. 994 Makely.. T. J. A. 437. B. A. 173. 668. Mayer.. 720. 1027. 756 Makhlouf. V. J. J. K. 1013 McKelvey. 775 McCabe.. N. K. 207 Matyas. E. 499 Matejka. M. M. 618.. R. F. J. 351 Mann... 895 Martin. S.. 521. W. 993 Matarrese. N. 361. C. 75.. 11. W. 639. 1028 Mazziotta. J. S... 1010 McKenna. 902. 899 Marder. D... 757 Masterson... 113 Magloire. 922 McGrath.. M. Mayo. 764.. U. 659. 46.. S. 522. 450.. D.. J... 705. 302. P. 49. 517. 76. 550 Mark. L... Makuuchi. J. E. K. 175. M. 106. Y. 855. Max. V. 247 Matsuo. 600. McCleary. 414. 660. J. 548... 429 McKeith. 251. 777. B. 417.. J... B. 622. 976 Martin. 610. 125. 382. R. 736. D. 1016 Maxwell. J. 106. C. 1002 Marin. J.. R. 918 McCall. P. 255 Massaro. K. 88 Manochiopinig. 257. N. 992 Mattingly. 47 Manuel-Dupont. Mazoyer. 579 McBurney. 696.. F. N... 726. A. H. 118. 195 Maly. 673. 251 611. 47 McCormick. 533 Makenzie. N. N.. J. A. G.. 781 Marcuse. 37.. C. 914. 747 Masterson. 1015. 233 McAfee. 179. 657. 763. 575... T. 205 McCullagh. 930 MacMillan. L. 88.. 757 McCloskey.. P. 417 McColl. D. M.. P. M. M. 551 Masters.. T. 964 Marks. 993 Marwitz. 35 Marckmann. 98. 550 Martin.. 966. A. 997 180. R. 578. 74 McKeel. 572. E. N. M. L. 37 McGlone.. 663. 885 McConnell. 565. 761. M. 43 Mauner. C. L. A. 37 Mammucari. 1025 MacPhail. J. G. N. 80. 740 Mackisack. 694. M. 384.. 853 Matthews.. P. P. 825 Markesbery. 360 Marantz.. 992.. E. 96.. 966. Mavroudakis. 479 Mann. 417 Mansur. 102. 1023 Mayer.... 11 McGilly.. K. G. 124.. 86 Matthews. 192.. 174 391. 572 MacWhinney.. 407.. 89. J. 100 Manaster. 972 Marquardt. 778.. 920 McKenna. D. M... 1029 McClelland. 242 Martin.. Maneta. 537 Martin.. 410 Maruszewski.. 902.. T. J.. 1024. 975 Mauro.. 1025 Mariën. 895.. 357. 1014 Martin. A. 864 Malone. 1024. 1014 Martinez. R. 376. 897 McHenry. 572. 574. 231 Martyn. 265 701.. K. G. J. 549. 778 McCallum. 171.. C... 708.. 206 Mattson. E. 568. 647. M... W. 56. 129 Majesky. 73.. 171. 187. 567 . C. C. 416. 236. N. 430. B. 772 Mateer. P. 125. 305. C. 642. L. C. 782 Matchar.. M.. 54 McHugh. 633. 641.. E. 418. 824. 88.. 376.. 413.. L. A. 975. 745.. 1026 Mancini. 71 Mackey. 43 Magnusson. 608. 1026 McCarthy. 11. W. D. L. 715. R. 823. 507.. I. 295... W. 598. 13 Massey. L.. M. 90. 119. 246 Malin.. M. 709. R. E.. 894 McCauslin. 581.. F. 760 Markson. 257 301. R.. 566 Maiberger.. 645.. 520. A. 86. 902 McCaffrey.. 1014 MacLennan. D. R. W. 975 Marthas. 586. C. 422.. 992 Markel. O. L. 380.. 638... J. 692. A. 377. 382.. R. 648. S. 295. 584 Marshall.. 188. 999 Marshall. 382. M. 967 Mampaey. 700. 726 Martelli. 110. 109 Martin. 620. 250 Martin. J. P. 860 Marguardt. 1015. M. E.. 55 McGlynn. 549 McGarry.. 418.. 376. 990. E. 103. R. R. 339 Mann.. G.. E. J.. M. E. 741 McFarling. 37 Maher. G. 619. 178. J. 1022. 964 Matthews. A. R. 619.. A. 995.. 768 Mandell. 784. Z.... I. 576. 411. 709 Manjaly.. 519. I. 124.. 168.. A.. 969 Maraganore.. 451. 894 Mayberg. 552 1025. E. E.. 342 McDearmon.. N. 101. 716 McDowell. L. 776... 123. 103. 379. T. S.. R. 571. 256 Martin... 1019.. 1019. 256. K. 249. 970. M. 103. 928 Marshall.. E. R. E. 391 837 McBride. R. W. 927 Mariage. S.. 119 Maslow.. S. 246.. H. I. M. 188. 697 Martin.. 575. 1021 Masullo.. 187. 880 Mager. 37. M. 1027 Mendez.. M... 56 Mendelson.. 257. J. 765 Metz. 894 Messmer.. T. 390 Moore. 307. S. 53 McNamara. T.. L. 220 Meador. T. 619. C.. Miceli. D.. 108. 173 Metoki. C. 967 Miozzo. L. 901. A.. 705 Monsalve. 816. 585. L.. 409.. 832. D.. B. 994 Milroy. E. 391. 665. 714 Mills. 488 Melvold.... E. I. 817 Mellancamp. 648.GRBQ344-ind[1043-1072]. M. G... G.. D.... 515... 613 429. 231 Monfils. 249 Miller. 599. M. 89 Morgan. A. 756 Miller-Loncar. L.. H. 995 McPherson. D. 293 Morningstar. 264. 928 Monsch.. 967 Miller. E. 858. V. L. 357 Montrul. R. 756 578. 610. 251.. J. 192. A. 928 Mikolic. B. N. P. 258 553. 98 Moncrief. D. 902 Menn. 251 Mohs... 550. H. D. P. 859... 95 Moore. 124. 636 Mohr. R. 864 Messick. 192 Mitchell. W.. I.-C. 830 1017. M. 554. M.. 643 Mentis. 1011 Meadows. 523. 174. M. G... 775. 212 Meyers. 552 Mehler. E. 914. J. 56 Miravalles. 544. Meline. 736. 102. 607 Deficit Milner... 251 Moritz.. 26. 892.. 392. J. 37. 111 Menefee.. 931 McNeil. Mortensen. 110. R. W.. 229 McWreath.. 853 Miller. 77 Mills. M. 550.. 427. 893. K. F. R. J. D. B. L. 50 Meikle. 893 McQuade.. 931 Morrison.. 583.. 972 Montgomery. L. C. 664. 178.. C. 81. 1014.. 891.. 92.. 915. M. G. L. 50 Montgomery. K. W. C. 218 McRoberts. M. 251 Miller. Jr. 566 Meichenbaum. M. 992 Miklossy. 1014 Moulard. 728 Mitchum. 13.. E. 704.... 237 Meyers-Briggs. 42. 380. 249 McReynolds. J. 924 Miller. Monroe. 412. D. R. 736 Minamimoto. J..qxd 04/02/2008 08:19 Page 1060 Aptara Inc. 609 Moore.. 544 Miller. F.. J. S. J. 971 548. R. J. S. 920 Moreines. 600. 554.. 893 Milo. 411. C. 257 Morrison.. 1015 Moss. 996 Mercier.. 413. B. 718 Mirenda.. 252. 708 (MEND). C. 641. L. 187. W. 659 Meyer.. 218 Mehler. 508. 259 Meinzer. M.. L. Milan. 786... 56. 509 Moss. 597. A. M.. G.. 726 Messick.. R. A.. 553. 550 Merbitz. 551. 964 McPherson.. Michael.. 413. 617. 965. E. 701. Mlcoch. J... A. 557. J. H. 640. 103 Moos. 550 Moorhouse. See Miami Emergency Neurologic Milner.. 632.. A. 969 Meyers. 49. 265 The Moran Company... A. 166. H.. 895. 696. 245 Monteleone.. K. M. G.. 338... 828 McLaurin. 586. 425.. A. E. A. L. E. 1019 Morris.. 893. 111 Milman. M. 996 Medford. 450. D. 565... 895 Moore. 86 McLean. Mortimer. G. R. L.... 242 Michelow.. 1060 Author Index McKinlay. 172. 129 Miura. 323 Megens. 1011 Minifie.. C. 550 Moore.. E. S. 997 Moraschini.. A. 534 Mehrabian.. 892. P. 109. 905 Milton. M. 13 Miozzo. L.. S... 544 Morris. K.. 767.. 599.. J. 323.. T. A. 601. J.. J. 1013 Morgan. 547. C.. 618. 920 Moran... 856 Mertz. 999 Moro. 436. 229 Morrow. 42. 76.. 891. 992 Messerli.... 336 Melton.. W. 387 McKitrick. L.. 516 918. 103. 73. S. 964 Merzenich. 187. 858. 924 Moonis. 712. 246 899. 35. S.. 644. 726 Millis.. M.. 915. 470. 761. 178. 892. 256. J. 50.... S. T. 50 Morley. 308 Metter. S. J. C. J. P. 51 Mechelli. S. 582 Morris. 558.. 430.. E. 214. 891 Molrine. 251. 619. 357. G. 549. P. L. V. 977. 854 Merians. E. B. B. 534 Morris. W. D. 923 Mizuno. 967 Miller. G. 543. H... 919. 207 Mills.. H. D. A. 603. 168. 170. 11. 173. 71 Moniz. 611. 56 Mendelsohn.. 413 Mechanic.. 611 Moskowitz. 572. 600... 50 Miller. A. 516. M. 552. 188. Moberg. J. 171. M. D. F.. 544. 738 Miami Emergency Neurologic Deficit Monheit. 608 Merck Institute of Aging and Health.. 12 Mogentale. G.. C. C. 609 Moriarty. 969. 550 Milton. 56 Moses. G. J. N. 497. D.. J. M. 597. A. 111. 620. M.. 570... J. 535. 222 Miller. 249 Miller. J.. 671. 113. 192 645. 416.. T... 727. 546. M. 221 Morris. 111. 919.. 392. M. 339 Montagna.. 50 Moir. 610. 915.. M.. 996 Mounin. 90 Moscovitch... 912. D. 117.. 978 Mock. J. G. 891. T. 639. K. S.... D. H. J. 545. L.. C. 55 MEND. B. 169 Mohlberg.. 634.. 776 Mortley. 190 Morton. 860. M. 611 Morris. 778.. H. 576. J... S. 549. 73. 89.. 92. 643.. C. M. P. 994 Moretti. P. B. 964. 612 Morris. M. 110. S. 48 393. 964 McNaughton. 251 Morganlander. M. 774 Mingazzini. 50. 98 Monetta. 213. J. 535 Merchant. 894 Meyer.. 994 Moss. T.. 757 Merens. 647.. 1018. W.. 725 Moss. 79.. 422.. Miller... 619. 597. D. 508 Mogil... 75. D. R.. 602. 418 Moore. 632 . W. Michallet.. 544.. 249. 718.. 356 Miles. 893 Mines. M. F. 910 Moretti. 319. 256 McKoon. J. 997 Meyers. A. 178.. 914 Morton. A.. 859 Meyer. 914 Moossy. A. 49 173. 614.. L. A. 229 Mesaros. A. 861 Morgan... M. I. 578. P. M. 894 Mesulam. M. S. 858 Milberg. K.. W. 976. A. H... 931 613. A.. 214 Mithaug. 52. J. M. R. 103. A. 689. 1022. 1023 Michel. R. P. R. D. 786 Milders.. 197. R. G.. 231. 386 Neary. 484. 106. 966 Musen.. J. 531. M. 700. 475. 416.. 963. 307 Nussbaum. 538. 482. 745. 611. 643. K. 858. 361. L. 253 82. L. 74 Noel. 15 110. C. J. 191 and systematic reviews. 704. 425. 232 Nahemow. 553.. K. 49 573. R. L. L.. 970. 295 Nagaratnam. 470 Noll.. 774 Nebel.. 582. 967 Murray. 85. K.... 706. 530. 116. L. 480.. 217 Nourjah. 357. 551. 357. J. 88. H. I. 90 Norris. 552 National Committee on Quality Assurance Nicholas... 166 343. 1016 National Institute of Neurological Disorders Nicklay. 51 NIDCD. 297. D. 296. C. 1002 Northouse.. 417. 427. H. 174. R. L. 88. 169. 211. 189. 11 and Stroke Study Group. 1011 National Institute on Aging. 410. 232 Nagy.. 554. N.qxd 04/02/2008 08:19 Page 1061 Aptara Inc. 657. 95. J... 110. 768.. 302. 125. 110. 102... 109. P. 107. 611. 940 Nieman. Ng. 485 National Center for Health Statistics. 566 National Head Injury Foundation.. C. 859. D. 772 Northcutt. 968.. 259. 971. 74. 49 Myers. 574. 937 Nolte. 544 Newacheck. T.. 337 Myers. 572. 519. 427 North American Symptomatic Carotid 189. 413 Naesser. 991 and Other Communication Disorders Murray. 664. 362... N.. S. 190.. 70. 28. 975. 974 Mungas. 1002 Murray. 1019 National Aphasia Association.. 293. 426 Nye.. 894 Nebes. Munoz. 770. R. Rehabilitation Research. D.. 69. M. A. C.. 111 Noreau. 723. 586. 380. 65. 577. 565. 431.. 778. P.. 575. J. 763. 508 Müller. 863 Neustadt. 257.. 64. 364 New Jersey Speech and Hearing Association.. R. E. 124. 66.. Nelson. 476. 1014 Musson.. 54. 975 Muir Gray. 108. 432 Munoz.. N. D. S. 363.. 85 Noel. 515. 71 Murray. S. Mummery. Nelson. J. 976 Muraski. G.. 922 Communicative Needs of Persons with NIH. 366 Nadeau.. 775 896. 532. 548... 718 Murdoch. 102.. 50 Communication Disorders. 1011 Newhoff. U. 584 Norris. 90. 572 National Stroke Foundation. 410 Newton. J. 110.. 172. 126... 586.. 75. L. 290. R. 75 Noll. 27.. 966. B. J. J. 887. 251. 360 Nobbs.. 360 Nybo. 247 Neault. 164 Naigles. 297. 566.. 292. 11. 13 Newton. D. J. P. 551.. S. 546.. 205 Neils-Strunjas.. 290 Nelson.. 379 National Center for Evidence-Based Practice in Nicholas. T... 241. K.. 571.-L.. 782. 965.. National Institute on Disability and Nielsen. 382 Niles. L. E. 1015.. 991 128. 964 Nydevik.. 1019. 698 Naujokat. 779 Northouse. 860. E. S. 116. 585. 108. D.. 171. J.. 894 Nakles. 536. 552. 246 647. 249 711. R.. 64. 537. A.. 1001 Newmark. 1015 Nakamura. 127. 174. 88. E.. L. 340 Nickel. 775. R. T. 784 Murphy. 880 Nakano. 756 National Faculty Center. M. 361 (NCQA).. 613. 1028. 694. 557 Nkase-Thompson. 49. D. 570. 552 Newbery.. M. 81. M. 416. 1014 Nessler. L. 187. 557. 643. Neiman. 648. Nespoulous. 969 Nation. 127. 972. 902 969. G. 565. 762 Needham.. V.. 565 Neuman-Stritzel. 86. 37 Myers. 607. 96. P. 779. K. K. F. 555. J. 620. C. C. H. 260 Murtha. A. 326 Nielson. 758 Nelson. 173. M. 582 Murphy. 565.. G. 241. 95.. R. M. 707. 249 369 Noth.. E. 967 Nobre. D. 21. J. 85. C. M. 508. 118. 765. 534. Muma. 180. 406.. 1016 Na. Author Index 1061 Mourant. 748. 186 Newcombe.. 9. 193. T. 129 Nishitani. 34.. M. 195 . 578. 724 Nemoto... 556 North Carolina State Board of Education. 364 674.. L.. 376. 411 Murison. 777. 539. 32. J. 923 Nash Koury. S. D. 246.. 573 Neugarten. 349 Nicholas. 509. S. H. S. 861.. S. B. 419.. S. 424. J. H. 92 Noell. 14. 1029 North. 256 Nelson. 618. 502 MRC Psycholinguistic Database. M.. 967 533.. J. 310. 713 Communication Disorders (NIDCD). 499.. National Institutes of Health (NIH). 11. S. 884 Nagarajan. 547. W.. 1016 National Center for Injury Prevention and 457. J. J. 67. 924 Moyer.. 781. 780.. 9. 763 National Stroke Association. 297. 973. E. P. 255. L.. 500 Naeser.. 424. 101.. 86. 415. 173. 248 Noll. K. M. P... 305 Severe Disabilities. S.. 550. B.. E. T. M. See National Institute for Deafness Murray. T. 308. A. 65. 535. 124. E. 102. G. 979 Neisser. S. 964 Naselaris. 862. 638. 212... 126. 77. 691.. 697. 565 Nimmo-Smith. 607. 193 Nestor. L.. 52 Myers. M... 423. 764... 769. A. 28. 102. 817. P. 70 Mutchler.. 567. 881 National Joint Committee for the Niemann. 250 Nelson. N. 611. K. G. K. A.. I. Nelson. 778. M. 547 Nagaratnam. 663.. 114. 768. 165. 380 Neils.. P. 231. 191 Myerson.. N. 105. Nespor. M... S. 108. 105. S. 902 Musso. 97. W. 381.. 548. L.. 246. L. 11. 576. I. 75. N.. 355 National Institute for Deafness and Other Nickels.. 425. 340 Noots-Villers. B. 258. 281 NIH Stroke Scale. 49. W. H. 595. J.. C. 360. 420. 257. A. 78 Nicholson. 611.. 480 Newhart. D. 776 Myers-Scotton. K. 1023. R.. D. K. L. 220 Moya. S. J.. 974. 423.. See National Institutes of Health Murray.. 56.. S. 426.. R. 993 Myers. V.. J.. M. R.. 298 Northen.. 210 386. A... 383 109. 916 Noe. 336. 218 571. R. Murphy. 769 National Academy on an Aging Society. 381 Niccum.. 991 Nocentini. 349.. 74. 508. 328 Nakayama.. 422 Myers. 340 Nilipour. 177. 81.. S. S.GRBQ344-ind[1043-1072]. U. 49. 291. 565 Murray. 894 Naremore. J. 992 Control. Muller. 207 176. 969 Endarterectomy Trial Collaborators. Murphy. M. 787 Nordahl. D. Norton-Ford. 565. 894 N-CEP registry of clinical practice guidelines Nippold.. 421. Nielson.. M.. 421.. J. A.. 80. D. N. B. C. 881 Nyberg. M. 171 Newell. 588.. C. 120. L. 689. 692 Netsu. 620. 249. 427. 728 Parkerson.qxd 04/02/2008 08:19 Page 1062 Aptara Inc. P. 37 Paninski. 379 Oesch-Serra. 260. L... A. 382. J. 125 Park.. 477 Parris.. 910 Oomen. 993 Owens. 115. R. T. 659 Oxenham. 259. G. R. 257 Park. 205 Pasquier.. Orjada.. J. M.. 589. 364 Orr. B. P. 1013 Obler.. 75 Parviainen. J.. 610. 114. 23 Peizer.. 379 Parker. 904 Paule. 382 Opie. S. J. D.. C. C. 920 Perani. T. 996 Pandya. 106. 52. 566. 120. 122.. 736. 614.. H. 964 255.. 1011. 726. 328. 295. 418. 557. 620 Pessin.. 54.. R.. 881 Peach. K. 811 Pachalska. A.. L. 253. R. 292. 600 Ochs.. 624. S. H. 89 O’Boyle. 124 Pashek... 978 Olson. 411 Paradis.. J. K. J. 338 Patterson. G. 290. 251 Patterson. 197. 597.. R.. S. R.. 964 Oradei. 212 . 708. 257 Patterson. 866... 411 O’Donnell. 391 Parris. 568 Peasin. J. 94. 229 Oelschlaeger. 610. G.. 895. 779 Orchard-Lisle. 26 Osnes. S. 205 Park. 250. M. J.. 188. 294. 355. 75. V. E. 665 Parkison... M. 125 Paltan-Ortiz. Ono.. 922 Perkins. 546.GRBQ344-ind[1043-1072].. C. A.. 565. B. M. Overton Venet. 615. M. 537 Penn.. 104. 294. 422. 423. 124. 319.. 126.. D. 37. 192. J. P. 362. M.. 261 Pate. 899. A. F. 620.. 965 Palmer. 967 Penman. B. 367. 415. 120 Panaccio.. 704 260. 308 Osiejek. C. 382 O’Sullivan. 309 Palinscar. 247. R. Y. S. 293. 895 Olson.. S.. 80. V. G. 291.. 382. 258.. M.. 217. 323 Pardo. 264 Pennington.. 776 Parrent. S.. V. 79 O’Hanlon. 995 Otto. 902 Oke. A. T.. 991 Odell. 427 Pell. N. 308. 190 Paniagua. 524 Pappenheim. S. A... 43 Paul-Brown. D. G. 580.. C.. 726... F. 251. B. 999 379. J.. S. 254... 80. J. 716 Passingham.... 299 Orpwood. 701. 552 Pavlenko.. 974 Onslow. M. C.. 118. 600. 257.. 304. 119. 718 Parker. S. 262. A.. 779 Orgogozo. R. 611. 360. M.. C. 663. 619... 297. 382. 27. 188 Pease. N. 735 Oldendorf.. 73.. 436. 173 Papanicolaou. 536 Pearson... M. Peters. 865 Ostrove. 783 Pertheram. 517. 1014 Pawlik. 92.. 509 Pellijeff. 576.. 967 Pedersen. 102. J. 180.. 480 Ozolins.. 926 598... A. P. 394 Parrish. N. 599. Odekar... D. 123. 549 511.. 122. 551 Pet. M.-H.. A. S. 77. M. 694. J. 174.. 573. 776. H.. 236. 567 Panzeri. L. S. P.. 64.. E. V. 328 Patton. F. 307. O. P. 241. 524. 259. J. 726. 389 692. 119.. 89 Palumbo. M. D. 126. Pelletier. 992 O’Flaherty. 260. L. 94 Pearce. 423. 376. A. K. 106 O’Connor. M. L.. 424 253.. R. Perlesz. 126. 1062 Author Index Ober. G. 306.. 118. 391 Olver.. 295 Padakannaya. 565. 660.. J. M. C.. 43. 81.. J. V.. G. 117. 783 Ottenbacher. W.. 673. 187.. W. 245. 383. 125. 260. 492 Olsen. J... 245.... J. S. F. 340 Peters. 249 Oh. 363. C. D. D. 622. 965. M. 575. D. R. 293. 884 Pace. M.. 967 Oleyar. 391. S. 550 Ochipa. 10. A. 265. D. 570 Park. 572. 566. H. R. 1015 Paulman. M. 611. P. 886 Pasquarello. 1016 Olsen.. 1011 Pear. M... S. F. U... 992 Osgood. 515. A.. 977. 94 Oster.. T. 588 Perry.. R. 11.. E. 409. 610. K. J. T. 250. A. R.. 613 O’Reilly. R.. R. 310. 259 Paul.. 1011 Olswang.. 967 Pansari. 298. H. R... 70. H.. C. 521.. 610. 192.. 250. 642. 260. 939 Papagno. 516. 124. R. C. F. A. 298. A... 570. D. A. J.. 976. 360. 92. 295. A. 865 Otsuki. 413 Olgar.. 886 Pajak. 565 Penfield.. 117.. 73 Parkin.. 580. 125. P.. 621. 121. L.. 700 Ohmoto..... J. 914 Paus. F. 100. 894 Orsulic-Jeras. 575. 854 Packard. 92. 893 Okuda.. D. 254 Patterson. 996 Payne-Johnson. E. 337 Oxbury. A. 391. 922 Peters. T. 552... 513 Pan.. 567 Payne. 640. K.. M. 570 Pang. 294. M. 22 Parisi.. P. M... W. 206 Osborne. J.. 179. 297.. 361.. 113. 119. 111. Ohyama. 387. 249 Padovani. T. L. B. 775 Perry. H.. 300 O’Fallon. 125. D. M. 378. G. S.. 251. S. 186. 599.. 296. D.. 217 Overmier. 319 Ogar. Perkins. B. 880 O’Halloran.. 971 Pascual-Leone. D. 1012 Ogletree. 1010. 975 Paul.. 28 Pederson... 567. E.. 610 Paul. 92. M. 507. J. 186 Paradis. 190. 297 Odor.. A. S. 1011 Peters.. 413 Paradign Health Corporation Publications. J... C. 1009. 768 971. 107 Paquier... J. T.. 119. S. A. W.. M. H. 30 PDP Research Group. Ono. B. M. S. 1001 Pardo. 193 Olness. M. K. 381. D... 75. 1023 Packard. K.. 508. 718. D. K. 611 Patronas. 205 Pallier.. 861 295.. 363. 1014 Ogrezeanu. 887 Parent. 96 Peelle. 620. A... M. 334 307. E. J. A. 566.. 190... 50. 815 Palmore. 391. C. 425. 971. 646. 658 Perera. 207 Pavesi. 110 O’Lear. 78. 377. 11. 103. R. 565 O’Halloran.. 119. L. T. G. 257. B. M..... G. M. 43 Paivio. 248 581. 886 Packard. 892 Perez. A. 81 Perkins. W. Oddy. W. 422 Parr. 765 Peters. 905 Ogden. 178. 295. 539. K. E. 713 Pennypacker. 179 Olsen. J. S. 570. M... 764 Ogasawara. L. M. M. C. 113 Paterson... J. H. B. 120. 646 Ojemann.. 902. B. 571. 297. 89 Oberlander. 48 Paolucci. 763 Patterson. . Propst. 610. 75. L.. 429. K. 190. T. M.. 73.. E. 383.. 96.. 259 Ratcliff. D. L. 383. 544 Poizner. E. H. 623. L. 295. 253 Puts-Zwartes. 102 Ralph. 28. 666.. P.. A. 418 Proctor. Price.. 598.. 423. 290. S. 310. 815 Poulsen.. 663 Pullum. 803. 765. 1026 Pieniadz. 858. I. 714 771. 674.. 409. 114. R.. D. 971. 98. P. M. T. 885 Rajan. 295 Radanovic. C. A. 674. 1013 Ponzio. 119. C. 382. C. R.GRBQ344-ind[1043-1072].. A. J. 382. Plaut. 304... K. E. 723 Priest. 761. 654. P. 415 Powell. J. 600.. P. B. M. R. 545. L. L.. T. 787. 381. J. 27. 496.. 116. 695. 762.. 597.. M. 300. 535. 964 Quayhagen. J. 186 Pickersgill. 672. 578.. 125 Quirk. 618.. 692. H.. D. 610 Puente.. 422. 430. -Y. 601. 705. 89. 783. 894. 13 Porter. 965 Plautz. 726 Peterson. 80 Pogue. G. 424. J. Z. L.qxd 04/02/2008 08:19 Page 1063 Aptara Inc. 566. 549 Porter. 1011. P.. L. 895 Prutting. 519. 764 Plunkett.. 98 Quadfaset. 328. R. 780 309. T.. D.. 1011 Quadfasel. L. F.. 971 Premack.. 576... M. 674. 967. H. 666.. 609. 1011. J. 555. 20 409. 774.. 964 Pieres.. C. 50. 9.. 583 Plante. F. 764 Plum. 35 Pressley. 926 Podraza. 522. 854 Picard.. 902. D. R.. 969 Podolsky.. J. 918 Rao... M. I. 597. J.. 638. 44. 95.. 991 Rapcsak. M. 1001 Pierce. F. 72. 598. 189. 417 Rabidoux. 657. Z. 745. S. 37. R. 256. 292.. 775. B. 64... J.. 774. 517 Pick. H. 190. 568. Radonjic. 920 567. D. W. 598 Piccirilli. 757 Rao. J. J. 747 Purdy. 517.. 246 Purves. 379. 392... 668. 188. D. 174 Raaijmakers. 863. 79. R.. M. 192. Peterson. 380 Quadagno... R. P... 49. 976 Pinault. 420. 378. Rand Corporation. E. 623.. 741. K.... G. B.. M. M. 547 Postma. 192 Phillips. 1013. 1012. 818.. 756 Raskin. 1016 Provinciali.. 818 Putnam.. H.. D. P. 376. 37.. S. 907. M... 552 Pigatt. A. A... 965. 246. 583. 891. 308. J. A.. I. 126. 921 Pichora-Fuller. 763. 860. 713 Pettit. J. 33 Pyle. 570.. 784 Plog. 618. 425. D.. S. 639 Press. G. 103. E. A.... 123. 73. 546.. 568. F. W. 264 Power. 858. 125. V. H. 425. 117. 1014 Petrides. J. 68 Potter. 102 Petrone. G. J. Pyypponen. E. 620. 124. E. 712. 321 Pineda. A. S.. 217 Pinker.. O. 78 642. 377.. 778. M. 725 Poncet. 175. 414. 388. 7. 79. H. 429. R. 51. 257. 557. 966 Poole.. 894 Rapp. D.. 610 308. 190. 969. 989 Pickard. 762 Porteus. 26 Poppe. A. 817. 674 Rafal. D. 671. 120. 85 Prather. E. 393 Power.. 784 Rappaport. 193 Potter. 417. H. 610. N. 388. 379 Puskaric. M. 73 Qu. 534... 967 Pietron. 868 . M. 663.. 1000 Phillips.. 488 Povlishock. 737. J. 905. K. 657 Pulvermüller... 180.. 866 Randall.. 547. M. J. 363. 197. 116 Raskins. M. E. 534.. 91 Piasetsky. 73. M. M. 102.. D. 776 Prescott. R. 694.. 967 698.. M. E. 769 Pimentel. E.. Radosevich. 713 Piercy. 558. 299. S. 704. K. 578. J. 893 Raven.. 295. P.. 865 Phelps. Pynte. B.. 44 Quatember.. 745.. 557. 382.. 548. A. 409. 937 Pollock. 14 Quiniou. T. 362. A... R. S.. S. S. 255 Raybeck. 206 Philbrick. 708 Rakuscek. K. E.. L. R. L.. 717 Rath.. I.... 391 Pimentel.. O. 508. M. 1013 Post. M. G... 772 Pizzamiglio. R. A. 819. R. 43 Posner.. 71. A. 427. 292. 251.. 771.. 673. 319 Quinlan. 437. V.. 179. J. 533 Pratt. 768. S. 50 Porter. P. 1015.. M. R. 993 Rao. 291. 307.. 291 Phelps.. D. R. 770. E.. J. 881. 817. A. 123. D. D. 866 Polk. R. 206 Philip.. 886 Plue. B. 668. M. B. 256... D.. S. 832 Pontón. 967 Ravaud. 772. 910 Ratey. 56 Rattok. 804. L. 471. 124 Raison-Van Ruymbeke. B. 549. 13 Pillon. 174. 302. 764. 725 Polster. 101. 213 Poot. M. D. 350. 323 Rau.. L.. E. J. T. 386. E. 632 Potechin Scher... 800. 338 Rackley. R... 572 Posner. F. T... 424 Price. 33 Phillips. 410. 964.. J. 975 667. 407. 740 Pratt. 887 Purtillo. 382 385. 179. 335 Potechin. 391 509. 380 Petrov. 450. 885. 111. 736 550. 192. B.. 518 Poeppel. 920 Post. 96... 643. P. 50. 297.. 115. 547.. 557 Ramasubbu. 361. R.. A. J. E. 480. 787. J. 905 Poeck. 415.. L.. K. H. 588. K. 975 Pitres. 544. 364 Prins. 125. 255 Pierce. 607.. 377. Pound. 79 516. 301. 8 Philippa.. 972 Raaschou. 757 Proshansky. Pincus. C.. N. Author Index 1063 Petersen. 551 Pollatsek. 701 Prior. 44 Prinz... 377. 568 391. F. 118. Z. 174.. C. 610 Purell. P.. 855. D. 179. 915. 376. 611. Ravel. 249 Pfalzgraf. 544.. 654.. 56 Pring.. V... Polkey.. K. 603. 102. 360. 710.. J. 120. H. 726 Petheram. G.. 893 Raichle. 97. P. 11. R.... 860 Ponsford. 816 Ramsberger. Petersen.. R. Pleger. M. H. 861. 477. 573 Poulsen.. M.. 817 Pindzola. 701. 673 Pinango. D.. 196.. 426. 411. 857. 523 Peterson... 964 Quillen. J... 173. E. 973 520.. 574. B. 864 570. J.. B. 192 Porch. 586.. V. 53 Prigatano.. M. 381 Prizmic. 782 Price. J. 256 Powell. F. 323 Petrosino. M.. 71. C. 740 Ramage. 578. 641. 880 Raphal. 188. 769. 11. 769. A. 481. 534 Posner. M. 384. 125. N. R. 384. G.. 411. 967 Pollock. 217 Petheram. 1010. 700. 174. R. H. 295.. 745. 968 Rheingold. 992 Rolls. M.. 857. 922 Rolland. 1000 Rosser.. 56 1018.. D. 249 Rodgers. 1013. 721.. 361.. 535.. 975 Rosenthal. G. 657 Rising.. S. R. 21.. 648. A. 597. 98. 965 Rose. 522.. K. 547. 620.. 523 Robinson. P. 73. 899 Roy... T. 888 Román. 722. 192 Ross-Swain.. S. E.. 599. 257. L. 901. D. 648 Robertson. 11 Records... N.. 717. 437.. 524. 180. H. 323 Rogoff. 967 Ross. 931 Roberts. 197. S.. 608. J. M. 558.. 614. D. 668. C. 256. B. C.. 81. S. 383. M. 79. 1002 Rombouts. 260. E.. A. 672. 619. L.. 192. 89. 1022 Rosenberg. 411 Redinger. R. 79. 979. 691. L.. 764. 165. J. 853. D. 265. 535 Rosenfeld. Riddoch. 108... 129. L. 607.. 414. 923.. 14. 350 Rivlin.. 108. 416 615. 82. 859 Rodriguez. 619. 726.. 623. 212 Richard. 967. L. 770 Rolnick. 95.. 715 Reisberg. 524. A. A. 614. 929 Rondeau. 894 Roelofs.. 1027 Reinvang. 1015 Riley. 413... 554 Reynolds. S. 78.. J. 379. T. E. 781 Rosazza. 14. A. 992 643. B.. 124. B... A. 978 Resnick. 778 319.. 545. 126. E. 381. J. R. 708. 242 Repo. N. 617. 264... 668. 264 Robinson. 34 Reed. S. A. 87... C.GRBQ344-ind[1043-1072]. 647. 197. 307. 110. M.qxd 04/02/2008 08:19 Page 1064 Aptara Inc. 1018. 616. 250 Rothi. 127. 1014 Roselli. 117. 610 Reese. 180.. M. G. 48 Ross. 297. 784 Ross. 168. 704 Reichle. A.. 77. R.. 880 Ross.. 701. 79 Razzano. 891 Rifat. 723. 865 Richter. 896 Retchin. R. 994 Rodin. J.. 1021. A. 621. 1022 Reed... 976 Rende. 125.. 689. 252. C. 922 Rose.. N. J. S. T. A. 221 611. 411. D. 965 Rectem. 118 Rizzo. J. 918 Rocca. B. 674. M.. 47 Reuterskiöld. 323 771. P. 382 Reeve. J. 1064 Author Index Raymer.. J. 721. 414. C. 576. 557. 295. 975 Rogers-Warren.. S. 192 Rijnders. C. 431.. 254. N. 902. A. 101. 295 Ripich... 377. C. M. 636. 622. 609. S. 582. 904 Richardson. 598. W. 304 Romani. L. 306. 325 Roy. 102. 166 Rodriquez. R. A. 611. A.. T. 856 Rossi. 623. E. 1026.. G. 723 Riege. 327. B. 613.. 192 Risley. L. 221 Roman. 709.. 205 743. 820. W.. 914 Robertson. 125. R.. 614 Rosamond.. J. R.. Revell. R. 35. 931 Rosenthal. R. 75. 413 Risser. 256. F. T. A. F. G... 536. 978 Robey.. M. 578 Rodesch. 121.. 646. B. 384 Rodriguez.. 612. 664 Roach. G. 81 Rosenberger. 978. M. 92. 995 Robin. E. 572 769. 392. B... 993. K. 689. 1023. 619 Robinson.. 1015 Ritterman. 102. D. 610. 612 Rosen. P... 89. Ringel.. 380 Rivas-Vasquez. R. 337 Riis. 860 927 602. A.. 433. 612. I. 419. J. 56. I. 552 Ritgert. 779 Rockstroh.. 110 Recanzone. V. D. J. R... A. Reed. J. H. 360.. 691. 1000 Richardson. 603 Rispens. C. 44. C. 214. 253. 409.. J. R. W. 1017. Rimel. 696. A. 583. W.. 308 671. 508. 255. H. 608.. 393.. 1022. Rosenberg. D. 300. 523.. 186. 420. Roueche. 112. W. N. 609. 610. R.. 1011 Rosen. 967 Rogers. 969. 259 Rogers. 621. 196. 996 Rodriguez.. 52. M. J. 303.. 470. B. 14. 52 1022 Rouselle. 77. 487 Rowley. 123. R. 300. 583... B. 92. G.. 166 Rekate. 966 Rosenbek... M. C. 255 Reyes. M.. 294 . 902. S.. A.. M. 698 Richardson. 127. 964 Rose. 89 Rodríguez-Campello. 76. 546. 861 Rosenberg. 295. 77.. M.. 741 Roquer. L. 43 Redfern. L. 98. 121.. A.. 166. 50. Reif. T. 470. B. 718.. 607. J. 298. 520. 1026 Rintala. L. 76.. 762. D. M. 50 Roberts. M.. K. 971. 623 Rossor. 379. F. M.... D... 566 Roediger. 976 Roberts. 669 Romero.. L. A... 771 258. 553.. 122. J. 659.. 554 Reisi. 994 Reichman.. D. 191 Rehak.... G. 246 Regli. 645. R.. 92.. 71... 619. 621. Rosen. T. J. 217 Rochette. 1024... 361. 971. 612 Rodriguez-Forwells. A. 697. R.. 362 Rewega.. 97. 698.. 814. M. 616. 617. B. 307. R. 540. 251 Robinson. R.. 1020. D. 166 Rodwin. 350. 1011 Reich. A. C. P. 1022. 657. 1018. H... 252 Roth. 868. I. N. K.. 571. 992 Rivers. 964. 597. 621. 966 178.. 645. 261. 85 Rorden. 559.. H. O. 299. E. A. 488. J. 420 Rosen... A. K. B. 91. G. P.. Rock. 1012. 102. 229 Roth. 989 Rayner. 972 784.. 220. 421 Rochon. 699 Roberts... M. W. 996 Reichle. 477 Renvall. 266 Rosenbaum. 855. 780.. B.. 656. 576 Relkin. 721. 34 Robinson. 164. 994. 389 Robson.. 100. J. Riley. M.. O. 79.. W.. H.. 892. R. 1023. 854 Rogers. 860. 256 Rey. 230. A. A.. J. 610 Redford. G. 572 Rosselli.. K. G. 718.. 100. 425. T. K. 609. G. Reinmuth. 636.. M. 361. 108. 644. 1015 Rose. A. 259. 613.. S. G. 837. 860.. 620. 255 Rose. V.. 609. A. 76... H. A. 70. 321. 56 Ritzl. W. 610. 552 195. 217 Roth. 859 Rigrodsky. 609. 852. 92. Riley. C. E.. J.. 977. 180. 914 Rosin.. 537. Ross. 109. J. 124 Roth. M... L.. 193. E. L. L. L. 977. L. 568 Rice. 904 Rich. 229. 715. A.. R. 11 Roth. M. 658 Rowe.. 567. Rilling. 1019. P. 1017. P. 409. 193. H.. 34. 190. 937 Rizzo. 187 550. 746 Rosen. 171 Reggia. P. 93. M. 854. Riddoch. 308. 482 Remy. 642... 774 109. 617.. L. A. N. 167. 108... B. Ricker. 712 Ross. 557.. J. A. P. 910 Rizzolatti. 674. 245. T. A. 671 Rayner. A. Reid.. M. M. R.. 433. N.. 120. 891 Scheltens. 437. 70 Schlanger. 575 704 Ruff. 180. D.. M. P. 655. 778. E. 996 382. P. A. S. 164. P. 580. M. 246 Scherr. 192. R.. 633. 746 Ruggieri. 452.. 756. 609. 52 Santo Pietro. 865. 291. 619 Scheerer. A. 582. 432. C. 75. V. 405. 458.. R.. 646. 193.. 376. 376 Sarno. J. 740. H. W.. 50 Scherzer. 894 Sato. R. 459. A. M. 549.. 470. 1013. A. 700. 89. 919 Sakurai. 430. 290.. D. 310. S.. 692 Saygin. N. 30 Sandson. Schegloff.. N. F. J. 901.. R.. L. P. 574 Schuell. A. 1009 Sahs.. 174 Sakai. 855 Salmelin. Schnider. 579. 893 Salverezza.. 931 Saurwein-Teissl. Schoenle. R.. 1022.. 582. J. 163.. 856 Saint-Cyr.. 37 Schwartz. 360. 774. 597 Schlenk. 379. 492. 607. E. 250 Sabe. 416. D. 106 Saletta. Sandok. P. B.. 1015 Sarwar.. 578. 79. R. 637. R. 597.. 188. 992. 891.. 991. 119. Scheibel. 910 Ruderman. 189. 774 Schell.. 72. 664 Santora. 1017.. K. 412 Schlanger.. 96.. 52 508. J. C. R. 701 292. 632. M. M.. 718. L. E. R. 255 Schreuder. 1014 Salamon. Schneiderman. 718... 995 Rubow. 421. C. J.. P. 363 Schulte. E. 101 Schultz.. 123.. L.. 535.. 431. 924 Schwarz. F. 910 Rubens. 219. 180. M. 572.. 406. S. L. L. D. 852. 21. 600. 66. R.. T. C. 264. 636. 319... B. 895 Salmon. 206... 408. 240. 777. 47 Sarno. 109. L. 118.. 743. 648 Schwartz. 376.. 715.. D. 811. 1011. 699. 297. m. M. 192. B. 1014 Ryff. 516. 101. M. R. W... L. 169. 576. 492. 103. 570. L. 977 422. 659.. E. 513 Rushworth.. 255. 102. D. 781. 319 Schulz. A. M. B. 1023 Royen. 620. V... N.. 117. 893. L. 894. K. 756.. H. T. 993 Sandler. 393. 612. 111. 108 Scannell. 404.. 166. H.. M. 206 Sasanuma. 502 Sampson. 575. 838. B. 81. 298. 993 Scher.... 643. 66 Sample. 123. Y. 550. 575... A. D. 632.. 117 Scharre. 579. 378. I. 366. 307. 180. 891 Scholes. 26. 50 Sanderson. 191 Schonle. 164. 76. 880 Schwartz. 166 Scharp... 549 Schonitzer. S. J. D. 173. M. K. 857. 103. L. R. D.. 639. 990. 256 Schatz. 557. 382. C. 29.. P.. E. 112. G. 167. 172 Schürmann. 756.. 760... Scheifelbusch. 1013.. 229 Schulte-Monting. L.. E. 35 Schultz. 378. R. Saltz. 1011 Schinco.. 988 Schumacher. D. 520 Schum. 326 Schelper. D. 762. Y. 880. U. J. 311. J. 56 Schlenk. R. K. 860 577. J. 609 450. 80 Schluter. 704.. 377... E. 52 Schmel’kov. 747 Schlaghecken. 349 Schreiner... 989. 642. 290 Schmalzl. 420.. 476 Schlaug. 992 Schinsky. A. 300. M. 640. 414. 658 Schubotz. G. 415. 524 Sage. 915 Rule. 539 Samples. 422. 129 Sanchez-Casas.. 127. 583 Schwartz. 840 Schneider. G.. S. P.qxd 04/02/2008 08:19 Page 1065 Aptara Inc. K... 192. B. 544. 647. 905 Schumaker. 992 1022.. 967 Sarno. 762. 993 Schmitter-Edgecombe.. R.. 172. 968 Schokker.. G. 233 Schloss.. A.. M. 862 Rummans. S. C. A.. 300 Saxe.. J. H.. 28. 195.. 232. 46 Scarpa. 584 Schultz.. 6. T. M. A. 256. 376 Safilios-Rothchild. J.. 433. 609.. A. M. 27 Schwartz. S. 193. 487... 169 Schmeichel. 432.. 384.... 252 Schlosser. 101 Saarinen.. 762. 71. Rubin. I. 13 Schormann. 597. 644. 407. 1015 Sacco. Sacks. N. I. C. A. L. H. 920. 647. B. S. 743. Salmon.. 1011 Schreiner. 241. 899 Rudorf. A. 771.. 902. 893.. 1014 Salamoura. 81. Saerens. 297.. 6 Schuloff. A.. M. J. R. G. J. 451. 863 Schwartz. R. A. 427 Saffran. 515. 71. G. 991 Schultz. 655. 50. P. 578. F. 13 Ryalls. 902 Schubitowski. 1026 Schlesinger. H.. 50.. B.. C.-J. 377.. 394.. D. 11. 639. 999. E. 51. 304. N. E. 641. 411. 102. 14. T. 735. V. M. C.. 102. 964 Salmon. 44. 888. 519 412. H. E. 648. J. M. Author Index 1065 Royal College of Speech and Language Sampson. R. J. 636. 641. W. P. 614. 430.. 989. 643. J. M. 409. C. 803. A. 617. 571. F. 902 Rubin. 241. B. 570. M. 997 Sandin.. 633. 11.. S. 208 Schepers. 1013 Rozzini. 257 Schiff. I. P. 859 Sacchett... 572.. 1026 SantaCruz. E.. 923 646. 699. 301 Schacter. 978 Saur. A. 779 Safran.. S. 1014. M.. 220. 769. 112.. 125. 190 859 Saffell. 260. 46. 576 Schneider. 480 Schütz-Bosbach. 117 Schwanenflugel.. T. 1012. 249 Schienberg.... A. Salvatore. 379.. 571... 438. E. 572 Sandy. 552. 416 Rushakoff. 323 Rutter. A. J. 924 Therapists: Clinical Guidelines. 995 Schlacter. 553. 403. L.. D. 566. J.. 125. 123. 565.. 1023 Rubin.... 648 Schwartz. 98 Schloss. R. P. 584 Schleicher. D.... R.GRBQ344-ind[1043-1072]. 566 Schieffelin. 1011 Scaff. L. M.. M. 895 Schulteis. 431 610. T. 11. 549 403. 769. A. 914 508.. P. 420. 840... 977 636. 1011 Schmitt. 257. 422 Schulz... 769 Sag. B. T. 123. 484.. D. 422. 492. 840 Schmidt. D. 894. 855.. L. Sachett. 377. L.. P. 736 Schempp. 668 Sands. 972 Rumelhart. 1013. 575 740. 783 Ryan. 56 Scanlon. 297. 539. J.. 972 Schartz. 293. 1000 Schneider. A. R. 977 Russo.. G... F. 485. 555 Schiavetti. 207 Schwartz-Crowley.. 717. 129. L. 124. M.. 704. 745. M. 862. 880 Schneider... 603 Salmon. 237. Ruff. J. 757.. Sackett. E. 49 735. 784 Rüb. L. 891. G.. 261. 922. 7. 782. 769 Schendel. J. R. N. D. M. 922. 745.. 94.. J. 776 Schmidt.... H. 546 Sanes. 14. W... H. N. H... 256 Saito. 1015 832. Saddy.. 895 Sarno. J... W. 379. M. 609. M. 696. M. 640. 692. M. 394. Salter. 415.. 776. A. 49. 693.. P. 572 Scholte op Reimer.. K. 902 . . 719 Scott.. J. D. J. 853 Seemiuller. C. C. 738. 705 671. W. N.. 816 Selinker. 13 Sen. 56 Shapira. 392. 421. 1011 Shipley. 757. A... E. X. 859. 376. 290. 177 Screen. R.. 363. 998 Sims. 718 Simpson. 74. 565. 28 856 Seibert.. A. M. 294. J. 173. 973 547. 611. 178. 377 Sieroff. 94. O. 101 Shiel. S. 477 708. Seligman. 967 Shimamura. D. 259 Segal.. 993 Singh.. C. 301. 179. J. 52. 279.. Shaw. D. 860. M. 205 Scott. F. P. 756 Shelton. W. 179. A. D.. 108. S. K. A. Seidenberg. 49.. 610. S. 106 Sivan. 383 Siirtola. 905 Sheppard.. 290. Z. E. 98.. 411.. 307 Seoane. 745. 102. 304. 118 Signer. 303. 189. 293. 480. 905 293. 120. Simonyan. 166. J.... G. P. 567 Shewell. 376 Shebilske. 576 Seddoh. 1016 Scott. H.. 597. 328 Shindler. 264.. 568 Shatin. 246 Silberman. J.. 384.. 578 Shaffer. E. Y. H. 1015 Sicotte.. 598. 91 Shulz. Shisler. 554 Sittner. 977. 1015 Shibuya.. 12 Sinyor. Shrout. A. K. 251 Sherman. 422... B. 536. 90. 583.. E. 787. J. 863 Shiota. -L. 129 Sirigu.. M. H.. M. 195. 303.. 575.. 76 .... 617. Seki. S. 457 Scott-Findlay. A. 128. 437. 1011 365.. 361.. G. 177.. 421 Simmons. A.. W.. M. R.. C. 972 Semah. 778 Shankwilder. 404. B.. 975 Seron.. L.. 310. G. 856. 264 Searle.. M.. 519. 566. 28. J. 250 Sherratt. C. K. 1014 Selnes. 307. 692. M.. 77 382..... 206 Seitz.. J. C. 583. 570.. 103. 361. 362 Siirtola.. 576 Sebastián-Galles.. 881.. 930. B. G... 977 Shiffrin.. 578.. W. 492. S. 863. M. 994 Sherron...qxd 04/02/2008 08:19 Page 1066 Aptara Inc. A. 103. E. D. K. J. 360. 967 Shubert. 609. 96. 893 Shubitowski. 87 Shill. M. D. 922 Scott. 125. 885 Shinton. R. J. T. 431.. 343 420... R. 392. 786. 437. H. 905 Sellers. 180. 428. L. M. 253 Shah. 598.. N. 11. 165.. G.. 857. E. 991 Semenza.. R. Sejinowski. 126 Scottish Intercollegiate Guideline Network. 250 Sheeran. 499. 1016 Shapiro... 819 Silverman. 420.. 415. J.. 858. 862 Shapiro. 293 Sin. 583. 756 Siegert. J. T... 107. 611. 991 Shulman. 381 Silverman. 292. B. 971. 362. M. 89 Sharwood Smith. E. 255.. 299. S. 100. 125. B... E. 762 Serio. G.. 111. 75. 746. T. B. 37. C. M. 123 Schwenkries. M.. 667.. 123 Shumway. J.. 765. 964 Segarra. P.. 70. 866 Shetty. 965 Scovel. C. Sidtis. W. A. 522 Shafer.. 250 Shea. D. G. 106. 715 Sherman. 524.. 81 Sisterhen.. 701.. 864 Silverberg. S.. J. 163.. 718 Sicks. 1027 Seiger. 588. 115. B. 167. 971 Sherman. 115. 508. A.. M. C. 1011 Shinn. 453.. 761.... 974 302. 11. J. 168 Skelly. 379 Shlonsky. 37. 249. R... 745. 768. 290. 922. 533 Simmons-Mackie. 969 Shallice. 550 Shuren.. G. 572. 377. J. V. 309. C. 80. 565. P. 43 Scott. M. 693. 566 Shoben. 964 Sims. 735. R. M. 300. R... 119.GRBQ344-ind[1043-1072]. 713 Sigma Xi Research Society. 205 Shapiro. A. M. R. 28.. B. L. 481 Sheehan. M. C. 72. R. 902 Sereno.. H. 618 Singley. M. 840 Seibold. 66 Semple. 13 127. 220 Seacat. R. 724 SHEP Cooperative Research Group. 610. R.. 612 Sidman.. 13 772.. 113 Sheets. 611. 696. N. C. 552. 424. 102. 645. 894 Shoup.. 778. 892 Shapiro. Simon. 256 Seeman. A. 1066 Author Index Schwarz. F. 360. 163 Shapiro. P. 249 Sheremata.. 771. 296. 108. Segui. K. 418. T.. 168. K.. 249 Siegenthaler. 910 Shanks.. 647. K. 453. Sherman.... 570. 192 Shum. 323 Sefer. M. L. 756. 991 Singer. W. E. J.. D. 168. 497. R. J. 12 Shankle. C. 896 350. 422. 585 Semel.. 570 777. S.. 610. 756. 859 Skenes.. 885 Sheinker... 56 Shankweiler.. B. 367.. A. S. 609 Semple. 425. C.. 978 Sherman.. 704.. 660 Sherr. H. 777. N.. 971... L. Selinger. 168.. 978 Scott. N.. 305. J. S.. 366. 597. 251 Sessle. 610.. 94. 770. 715 Shobe. 919. 484.. 409. 409 Scotti. 920 319 Shaw. E. 37. 618..... P.. J. 404 Siegler. 923 Silbershatz. W.. 301.... 930 Silliman. 975 Seel. E. P.. 894.. H. 249. 250 Shewan. 1015. 423 Simmons. 337 Sheinker. 425.. 978 Shrier. 43 Silveri. G. 125 Singer. R. T. A. 922 Scofield. M. 524 Sirisko. M. 168... Segalowitz.. 295.. 857. 893. 306. 256. 214 Sinner. M. 297. A. 33 Sherbenou. S. D. 356. Silvast. 694. D. J. 778 Siegel. 35. A. 710.. J. 79. 1015. 236. 570 517. J. 197. 129. 1026 Shammi. 1019 Sjardin. 35. 892. 217 Sheard.. 301 Segal. J. L. 583 Shadmehr. 394. 931 1026. T. 29. 306 Scolaro. P. A.. 423. M. H. S. 385. 418 Ska. 298. 27. 964 Sherman. J. 705 Sherman. 205 Shindo. 34 Sheldon.. W. 695.. B. Seliger.. 180.. G. I. 178. E. R. 178. J. 923 Silkes. A. O. J. M. 388.. N. 416. A. 342. G. R. 779. 576. M.. 552 Sipilae.. 329. E.. A.. 572. 788 Simpson... 50. C. 319.... S... R. A.. 371. 523.. J.... J. L. 858.. L. 978 Shuster. 714 Signoret. 51. 1009. 83. T. M. R. R. 50.. R. 893 Shadden.. M. 966 Schweinhart. 394. Q. 745. 757 Sternberg. 179. 994 Skinner.. 613 Srinivasan. 382. 746. 326 Stemmer. E. 192. C. 996 Smith.. 555 Stegall. 437.. 1014 Specht. 756 Slobin... 918 St. J. 390 Smith-Knapp. 567. 361 Stewart. L. 229 Soma. 861 Spencer. 1023 Sugishita.. 975 Sullivan. 28 Slama.. 1001 Smith. 92 Southwood.. 88 Smith. 87. 237. 298 Spreen. 600 Starkstein. R. C. 217 Skoloda. 95... R. 256 Spinelli. L. M. 335 Spatt. J. 75. 832. 855... 552. M.. J. 513. 910. 895. 972 Sveen.. D.. 125. M. 1015 Stein. J. C. 47 Sorgato. H. 236. E. 967 Snowdon. 309. 391. 11 Sutton.. G.. 511. K. 524 Smith. J. 894.. 926 Sparks. S. 575 Smith. 966 Stern. H. 976 Stewart. 56. 80. L.. 319 Snow.. W. 1018... A. 336 Smith. M.. 387 Stuss. 583. D. J. 696... M. 910 Spradley. 551 Stegmayr. 190.. J. L. J. J. F. 896. 249. 715 Smith. S. P. 886 Stadie. 282. V. 191. 967. 75 837... 166 Stout. 1018 Stewart.. 977 Steven. 570 Sokol. 249.. 893. 858 Spriestersbach. 996 Subirana. J.. J. R. 164. 94. L. 583 578. 571. 858. 558 Snow. 547. L. 305. M. 387. 968 Snowden.. E... 508.. 423 Summala. R. 822 Snow. 979 Snodgrass. 238 Sommers.. Straughan. L.. 569 Starr. 726. 406. 77.. 382 95. 775 Smith. H. 520.. H. S. 49.. 239.. 708.. W....... A. 97 Stiassny-Eder. J. D. M.. 364 Stroke Scales. 49 Stannard.. 95. A. A. 188. 770 Sturm. B.. 425. 252. 838. 193 Snyder. 357 Square. 290. 419. S... 49 Sobel. R. G. 880 Sundance. 570. S.. 1011. P. R. P.. K. 1022.. A. 77. U. P. 252... 536. 251 Skilbeck. T. 124.. 552 Sohlberg. B. 557 Staltari. 611 Spradlin. 50. 15. V. 248 Sonderman.. 549 Staub. E. 1028 Strauss... P. 902. 308.. J. 1026. 217 Sutcliffe. 477.. 566. 708. M. 73.. I... 843. 905. 586. A.. 89. 73. 295. W. 598 Sooy. 97. S. 880 Squires. 520. 384 Springer. C. F. 718 Solomon. T. 551 Soardi.. M. S.. 35 Sprafkin. G. 126 Stanczak. 432 864.. C.. 756 Staats. S. 178. 757 Strasser.. 80. P. C.. 642 Sparks. K. 619 Spikman. 180. 922 Smith. E... K. Stokes. Smithpeter. M. K. 478. 360 . 623 Sue.... J. 410. 391. 1023 Sotnick. 832 Stapleton.. H.. C. 546... 297 Square-Storer. K. 294. 296.. 123. 1015. J. R. 106. 392. 488. 242 Smith. W. 233 Suger.. L. 846 Stern. H. A. M. 487 Spicher. 777 Sportiche.. A. L.. 578 Soubrouillard. F. 1015.. 609 Smith. 716 Soon. D... R. J.. M. A. 180.. 576 Stablum. Sung. 573. Strait. 515 Smith.. 85. R. E.. J. 80. 233 Southwood. 840. G. J. F... 337 Small. 78. 411.. 46 Sommers. D. 612 Stanley. 229.qxd 04/02/2008 08:19 Page 1067 Aptara Inc. 764. 206 Steel. 308. M. T. E. 70. 779. 73. G. 415. T.. 13 Sturm. R.. F.. 56. D. 191. 508 Stern. 756 Speedie. P... 777 Stickgold. L. 252.. Y.. 860 Sorin-Peters.. 692. O. B.... 914 1009.. H. C.. G. S. 699 Skinner. 37. 11. E. 568. 71. 853. 524. D.. C. Y. 1013 Sniezek. 568 1023.. 394. 392. Y. 108. 773. 896 Stoddard. 826 Spinnler... P. 704 Sliwinski. Straus. D. A. 740 Statlender. B. 77. 880 Stemberger. 233. 432. 761. 52 Sperry. T. 968 Sklar.. K. D.. 868 Sutcliffe. 842.. 88... 193 Sullivan. B. 242 Smith. E. 197. 844. 648 Steriade. W. S.. 476. B. Stoioff. 94. M. 517. 763 Sonies. 565. 537 Slifer. 714.. 995 Stone. 763 Speechley. 1019.. S. G. J. B. 428. Stark. 96 Smith.... 110. 616. 1024. J. J.. L. D.. 97.. 989 Strick. C. 78. 992 Stampp. 896. G.. Stern. 95. M.. 991 Stiegler. 189. R. P. C.. 1012.. 814 Svec.. A. T. 15. S. 993 Smart. 548. 940. Author Index 1067 Skidmore. 123. 421. 190. 479. M. 976 Smith. 256. P. S.. 413 Squire... 1027.. 264.. P.. M.. J. D. 565 920... D. K. 172 Sugai.. A. 619 Solomon. 508 Stringfellow.. L.. S. C. 291. 763. J... 79. P. 1021. 100. 363. S.. K. 365 Steinmetz. 520. D. 9 Stenger. 236 Stern. 923 Stoicheff. G.. 297 Stimley. 103. 432.. 725 Stude.GRBQ344-ind[1043-1072].. M. 966 Spellacy. 1023. 124. M.. 926 Sosin. 1028 Strauss. C. E. L. R. 616. P. A. P. 567 Sugita. A. 660 Sobel.. 810 Smith. G. 966. 967 Snow. M.. 757. 902 Smith. 91. 215. L. 110. O. C. D... 124. B. K. 921. 297 Smaldino. 971. 457. 488 Stuart. D. 128. 71 Stevens.. A. 34. 14. 893. M.. 715. 1025 Stepien. N. P. N.. 256 Smolensky. 196 Studer-Eichenberger. S. 327 Sugiu. S. J.. K. S. R. 996 Sundt. 14. 894. 927. P. S. 222 Stein.. 192.. 406. L. S. M.. M. 776 Smith. 968 Starkstein. 991 648.. M. 514. 217.. 1017. T.. 95. D. P. 902 Sobecks. 352.. 122 Stach. 975 Snow. 169. 667 Sugita. L. H.. C. A. 94 Sonty. 409 Smith. J. W.. 693 922.... 389. 566 Steinmetz.. 894 Stallard. A. 265. 736 Stierwalt. 166 Smith. C. 230. S. C. 477.. 420.. R. 587.. 114. 411 Steele. M.. C.. R.. E. J. 922 Stringer. M.. R. G. 778 Stanley. J. 576. G. E. 549. 105. 304. Michel. A. 71. 858 Smith. 251.. 384.. C. 597. C. E. 71 Snow. P. 76. K. D.. C. 106. J.. Tourville. 1025 Tuffiash. S... V. 1012 392. 565 Thompson. 974. K. T. S. R. 102. 723. 511. S. Traub. R. 894 Tan. 112... P. Trabucchi. 435.. 79 Thorndike. L. D. 636. T. T.. 197. 419. 30. R. 977. 94.. G. 427.. 880 Trout. J. 429. P. 746... 735. 360 Tournoux. 965. C. 260 Thomas. 106 Tanaka.. M. 1000. Y. 207. K. 977 Tallis. 554 Tidy.. -J. 257. 294. 922 Toffolo. 992 Tuchman. 535 Torrence. K. 76. L.. 886 Tiraboschi. L. 96. 73. 853 Teskey. Swindell... J. 901. 968 Thal. J.. D. 964 725.. 1026. L. W.. 612. R.. C. 657. 293 Thomsen.. A. Tranel. L. R. W. 519. R.. R. 701. L.. 632 Tucker. 570. 171. V.. 173.. N.. 967. M. 124. 894 Thomas. S. A. 714. G. 736.. 999. 378 Tompkins. M. E.. L. 178. 885. I. 256.. 666 Thompson. H. D. 893 Turkheimer.. Swinnen. 939 Thomas. M. 50. J.. C. 885. A. M. 425. E. 300 Turnblom. 975.. M... C. M. 609. 1014 Ta’ir. 96. 570 742. 356. 993 Tucker. 621.. 251 Taylor.. A. 168. 34. M. A.. L. 994. L. W. K. 196 Thompson. L... 293. 910. 864 Torre. C. Talley. C. 174. 35 Thelander. J. J. R. F. W.. S. 599. 539 Threats. A. 756 Terrell. 1011 996. G. N. 549 Tate. 71. C. S. 119. K.. A. 196. M. 167. 426. 298 Tulving. 745. J. K.. D. M. 86. 79 Takeuchi.. 582. 191. 891. 770 Torrance. M. 74. 830 Tannen.. J. 419. 619. 170. 298.. 407 Timberlake. 891. 516 Tonkonogy. 1002 Sweet. 90 Tegner.. 696 301. 20. J. D. 192 Tuomainen. 103 Tobin. 774 Terr. 583.. B. 71 Thom.. 417. 126 Timko. 1013 Turkka. E. 993. 994 Trentini. 93 Tan. 484. G. 924 Toshiko.. J. 422. 12 Toth. D.. 1068 Author Index Swank. 95. R.. 123.. 737. A. 910 Thal. 103. T. 102 Szekeres. P.. L. 89. A. P. 894.. J. 992 Tomblin.. 757 Toraldo. A. 747 Trooskin. 781 Treadgold. S.. L. M. 966 Tittgemeyer.. F. 550. 437 Tegenthoff.. 319 Toussaint.. 922 Thommessen. 333 Thornburg. L. 708. 421 Trojanowski. 879.. 175. J.. 738. 256 Taylor. 366 Troske. D. Tetreault. Thomas. 292.. 740 Thistlethwaite. 989 Teraes. G. 572 Thiel.. 654 Tempo. D. C. 584. F.. 967 Tsvetkova.. G.. 971.. 291.. L.. 37.. 864 Trimble. H. 578. A. C. 905. 611. 53 Togher.... Tallberg. 856 Syder. 549. H. A. 997 Talairach.. 78.. 902.. A. 880 Tatemichi. I. 714 Turkstra. P.. A. H. 737.. 612 ter Keurs. M. B. 88 125. 190. E. 641.GRBQ344-ind[1043-1072].. 392. 597. 1013 Tuffash. J. 192 Tamiya. 166. 618 Thompson... 190. 778. A. 260 Tipper. C. 736. 910. 436 Taylor. 715 Tanner. 993 Thulborn. 978.. 880. 50. 905.. 1027 Swinney. 922 Tham. 488 Szilda. 56 Tait.. A.. Theurkauf. J. 965. G. R. T. 966. J. T. 42. 975. 75 Trupe. 520. 79. E. 565 Trosset. S. 457 Tikofsky. 118. 928.. 609 Taylor. 91 Taquemori. T. 190 Trouard. L. 709. 708. 935 Tison. 70. 98 Talbot. L. N. M. J. F. 601... E. 1026 Traynor. 356... 124. 595..... 743.. 192 Terrace. M.. 377... 192. 76 Tomasello. D. P. 740. Trappl. R. 912. Trahan.... F. 747. 21 173...qxd 04/02/2008 08:19 Page 1068 Aptara Inc. J. I. 646. J. 774. 380 .... G. A. 43 Taylor. S. N. 513 Turing. 111. Q. 8 Tsolaki. 919. E. 920 Tonkovich. 969. W. L... 188.. 966 Tomoeda. 115 Tureen. J. T. 620. P. M. 50. 31. H. 988. D. C. 778... 923... 691. P. 992 Tomlinson..... L.. 1012 Tainturier. 515. 887. 894 Thurstone. Swinburn. 971 Taylor. 251 1001. E. H. 764 642. K. 220 Tatum. E. S. 163. Tower. 622.. 893.. L... 39. 654. R. L. 174. 50. 178. S. 49 Tomaiuolo. 995 Taveras. B. E. L. E. T. Sweet. 255. 214. 728. 188.. 450. J. 49 559... E. S. 56 Tissot. P. 576. 94. 256 600. 251 972. 88. 74. 165. J..... Z. 26 Thomas. 967. 96 Tabouret-Kelly. 409 Tseng. M. C. 351. 1024... A. 27 Swisher. 171.. 566.. 921 Tanaka. 940 Tupper. S. L. 246 Tjaden. 56 Thron. 81. B. 648. 43 Toole. 904... 454.. 229 Tetnowski. D. 565 Thomas. 571 Toppin. 777. 710... 94. M. 644.. 256 Taylor.. 251 Todd-Pokropek. R.. 976. C. 579. K. D. 726 Tsantali. 757 Tissot. L. 748.. M.. D. 14. 970. 376 Teasdale. 922... 726. M. J. E.. 88. 173 Tachibana. 926. 597... 741. 549 Taylor-Sarno. 376. F.. R. 128. 379. 35 Throwalls.. 1011 Thurman. E. 623. 472. 933. 618. 323 Tombaugh. 778.. D. J. 125. 350. 775. M. 376 Todis. 924.. 190 Testa.. 918 Thangaraj. P... 973. 188. D.. 757 Theodoros.. W.. H. 43 Symington. 519. 74.. L. 109. L. 121.. K. C.. 781. 127. 965 Tsuji.. 967 Tailby. A. 704. 114. 746 Thompson. 21. C. L. 718 Thiel. 572.. J. 230 Teasdale. L. 894 Treves. 557.. J. 991. 191. M. L. 295. S. 881 Thráinsson. 757 507. 74 934. 126.. T... 964 Trost-Cardmone. 192 Tucker. H. R.. F.. 643. 913. 248 Toffolo. J. 257 892. O. 968 Thoene. 887 Thurstone. P. 995. 51... 377.. 894. B. 75 Truscott. 54 172. 914 Taylor. 895 Treisman.... A. L.. 251 Thomas. A. 989 Sweeper. 977 Teasell. 918. 100. 583. M. E. N.. 567. 663. R. C.. 1012 Ukita. 254 Wales... M. S.. 110. M. 291. A. 91. 910 Walker.S. 97. 856. 1022. 978 233. 617 Van Lancker-Sidtis.. D. 252 Vital. 50 Van Zagten. 101. 1023. L. 988 Walker. 361 Vail.. 11. 323 Van Lancker... 902.. 669 Turner. 221... R. 931 Ulrich. A.. 715 U.. K.. 421. 757 Visch-Brink.. 257. M. Vohn.... B.. R. 319 Ward. D.. 77 Vargha-Khadem... 761. 570. C. 97 781. 575. D. 176. M. 536 Warach. J.. E. 308. 553. D. 118 Varney. 411 Ukita. C. S. J.. 81. 964 Veteran’s Administration Cooperative Study Walters.. M. 735 Wagner. L. 774 Vagges. 865 Walker. Vendrell. 1015 Tzeng. 977.. 343 Wacker. C. C. 710. 965. A. D. J. 340 Villarroel. M. 552 Walker. 1011. 861. P.. 105. 250 Van der Flier. A. 451... Valentino. 180. 379 Urrutia.. 923 U. C. M. C. I. 520. 1021. L. 252 Villarreal. D. 323 Urbanczyk. R. D. Vigliocco. 377 Ward. F. G. 116. S.. 989 Vanderwoort. G. 725 Vandenberghe. J. 566. V... A. 597. 831.. 264.. P. J. A. R. 102.. 391. 89 Wade. 585.. B. 377 Visser-Meily. 92. 905 Turner. 179 van Loon.. M.. 567. 419. T.... 1016 Van Eekhout.. 426. J. H.. E.. 290.. General Acccounting Office.. F. V. 377.. 613 Valle. 166. Vaughn. C.. 976 Van der Linden. 905 Waksman. 127. 252 Voeller. 264 Vickery. V. 257 van Praag. D. R. 977 Volk.. I. 893. 509 Valenstein. 610. 978 Vohs. S.S. D.. G. H. 169.. P. A. R. 126. 187.. 567. R. D. W. H.. G. 249. 924 Ulatowska. 257 Wang. D. 817 .. J. 382. 256 536. 125. 389. J. 190 Vygotsky. A. 571. 192. T. 34 Ward. 997 Vinz.. G. 864 Vignolo.. 508. 411. T. 884 218. 205 Wang. 966 Turnbull. 997 Wagenaar. 357 Wapner.. 1016. 832 Valk. 761.. 220 Veltman.. E. K. 557 Varley. 319 Waltz. S.... R. 926 van Harskamp. 323 977. 49. Author Index 1069 Turnbull. J. 991 Vincent. 781 van Vendendaal. W. 186. W. G... 937 Varga.. 967. J. P. 35 Unwin. 769 Wambaugh. F.. N. H. 34. H.. R. J... M. 902. S. 815. R. A.GRBQ344-ind[1043-1072]. 426. 246. S. 565. B. 608 Van Mourik. D. 761 Warburton.. 967 U. 976 Verfaellie. N. J. 1024. P.. 1021 Vorano. 420. 747 Ward-Lonergan. 584. 582.. 891 Turner. M. 776... H. 761 Von Arbin.. 768. S. van den Bos. 1022 Vollmer. A. 264. 1026. 570. M. 990. 206 Ullman. 249 Ventry. 260 Wallace. 260 Verbeeten. E. M. 785 van Zonneveld..... A. D. 49. O. 253.. 119. P. 568.. 376. 547 Urbani. F... 1013.. C. A. 382. 572 Tyrrell. 126. 326.. R. M. 611. 780. 766.. W. 509.. 698 Van Riper. 971.. 551 Van Wijnendaele. 295 Vallar. S. 238 Vorobiev. Y. 709 Wahrborg. R. J. C. S. 671. 927 Underhill. van der Gaag.. Department of Health and Human Vasilakakos. 56 VanGrunsven. 118. 56 van de Sandt-Koenderman. 1023 Waksman. S. 193. 1028.. 609. 420.. 124.. R. 52 Urayse. 549 van Lieshout. R. 425. G. M. G. M.. Van Horn. 13 von Monakow.. 488 Van Amerongen. R.. 547... 35. W. 212 Waite.. 250. van Zomeren. 855. 70. J. S... M. 50 Volpe. 50. 974 Vanier... 1029 Van den Broek. 582. 406 VanDam. 178. 554. Y. 534. 671 Verderber. D.. 170 Vanhalle. 762. 188. Van Demark. 191 1027. 94. 105 Wafters. C. 21. W. 780.. 880 Vasterling. 832 Ungerleider. 923 Uryase. 910. 899.... 249 Vrtunski. 94. 180.. K..... 1009. M. M. G.. 383. Department of Transportation. M.. 605. 76 van Heyst. 1009 Wahner.. 725 VanBiervliet. T.. A. 696 Wang. B. 566. Velozo. 724 Warden. 378. 1019.. E. 572 Vogel. 814 Vaid.. K.. 127. R.. 252. 404 von Cramon. W. K. L.. M. 568. 544 Vestergaard. 972.. 361. 125. 247 Group on Antihypertensive Agents. J. 52 Vass... 26 Umiltà. P. W. 969.S. 390. M. 1013 Vendrell. R. L. 264. 550 Van den Heuvel.. 102. 610. 771 Van den Eijnden. H. S. M. J. A.. D.. R.. 964. D. 765. G. 619. 361 van Heutgen. 636. 107. J. 96... 738 Wachterman. 76 Vitevitch. 554 Van Pelt. J. 994 Van Heuven. E.. 1019 Vogel. 391. 13 Vellet... L.qxd 04/02/2008 08:19 Page 1069 Aptara Inc. 378 Urrea. C.. 989 Walker-Batson. M. M.. 215.. 43 Walters. H.. P. 56 Waddington. E. 92. 967 Vervaet. 964. 108. M. K. 28. A. 781 Tyler. 413 972. A. D..... 361 Waller. 969 Services. H. 1022. D. G. 904. J... 190. 260 509.. M. L. 260 Wallace. 856 Velkoff. 164... 765 572..S. C.. 977 Vendrell-Brucet. 1018.... 757.. 417 Varian. Department of Veteran’s Affairs. 967 U. 323 Vikingstad.. E. 260 Uhden. 611 Walker. C. K. B. H. 613 Wade. 75. P. 1025. 576 Uomoto. 50 Waller. 971. M. 178 Walker. K. 756. 923. 524 Uylings. 975 Walshaw.. 222 Vago. 327. 567. 395 Vinter.. 428 492. 81.. 206. 970. 648 Wagenaar. 762. 1017. J.. D. B. 576. D. F... 921 Villa.. M. 197. A. 1012. M. 56... S. M. K. A.. L.. T.S. 212 Vanderwart.. 695 Ward. D. G. Government Accountability Office. H. J. B. 125. 923 U. C. 771.. 79. 578. 971 Wallesch. 296. 861 1020. 172 Wallace.... 1011 Van der Werf. 534 Virata. 363 Van Hell. D. J. M. 122 Winner. H. W. 967 Weikart. 116. 535 Williams. 109. D.. 515 Williams. 421. 297. 53 Whelton. 972.. 319 Wegner... 992 White. E... 257 Wessinger.. 173. 1022. 765. F. 756 297. M. A. D.. 20. 361. 698 Wilson. 27.. L. F. 260. R. J. 967 Weinberger. D. 351.. 584 WHO. M. 165. A. 98. 803.. R.. A. 899 Werhahn. 856.. E. 192 Watkins. 485. J.. 771. 757 Winckel. 357.. M. 899 832. T. 718 West. M. A.. 383. D.. 904. 967 Weber.. L.. A.. 764 Weiss. 377. Wiener. G. J. C. 92. F. M. 43.. Wearing. 67. 499.. K. L. 360. 600. R. 212 404. L. 173. 781 419. 82.. 7. 191. 256 Wiegers. 246 Williamson. 253 Watson. 89. S. 174. J. L.. Wilkins. 928 Williams. 403..qxd 04/02/2008 08:19 Page 1070 Aptara Inc. Wester... N. 516 Westernoff. J. 509. 102. E. 930 Wiederholt. 54 Wepman. 618 Wilssens. 1010. 256. 259 1025.... 865. 899 Williams. 407... 964. M.. 578. 497. 300 Wilkinson. P. 427. H. 896 Williams. K. 990 WHOQOL: Measuring quality of life. 357 Wilson. 100.. H. 860.. 756. G. 823. M.. 340 Weeks. 910 Wichter. P. D.. I. D. 118. C. E. 299 Weddell.. M. D.. C. 825 WHOQOL Group. 1011 520. S. S. 893 Wechsler. 610 Wheeler. Wender. 855... 103. L. B. 437. 43 567.. H. J. 762 Watamori. Wineburgh.. 123.GRBQ344-ind[1043-1072]. 264 Wiebers. R. 1015 Wersinger.. 429. Wilkins. G. 169. 391.. 385. 756. A. D.. 253. 451.. 853.. 724. G.. 919. W. 89.. 391. 1027 Weismer. 991 Wenig. D.. S. K. 534 West. 696. 417.... 1011 Weintraub. 49 Weniger. 780. L. 67. 125. 551. 916. 419. 586. 578. W. Whitehead. P. J. 910 Weylman. M. 969. 121. C. 109 Weiner. 97. 1001 White. 976 Willich. 323 Wekstein. 382. 418. 54 Weissling.. 536 548.. M. P. K. 377 Wilcox.. 643 864. Wilkinson. 260 Watanabe. J. J.. 433. 610... B. 121. 94 Warren. 894 Werven.. 259 Wilson. 578. 620.. 1011 Wells. D.. 776 Wiggins.. G. J. C. E.. 422. B. B. 920. C. 611. 410 Wilson. 409. 892. 43 Weidner. M.. 546. B. 487. 79. 205 710. 767 395.. 77. 817 Welch.. 34 Wilson. K.. M. 178. 361. J. D. 297 Whurr. 568. 319.. P. J... P. 393 Weltens. 97.. M. 967 Watkins... 260. 100. T. F. 994. 339 Wei. P. 623. 37. 586. R. 296. 91.. 168.. J. R. 207 Weekes.. 415. 11 Williams. 520. 969 452. 101 Watson. D. 777. 552 Williams. M. R. 261. 1025 Weinstein. J. D... 496... 535 Williams.. J. 710. P.. 378. 205 Windsor. M... S. Wilkes-Gibbs. M. 693. G.. 409.. N. 206 Williamson. G. 492. 92. 293. 174.. 88. 411. 299 Wingfield. 1016 Wiig. 552. 196. 73. 411 Werdner. 968 Wilkinson. 549. J. 180. J. 902 Waterman. 98. 902 551. P.. 565... 861. 830 Watt. M. 117. Wiese... 198.. S. Wilcox. 920 905.. 437. 515. 96 West. 858. L. M. R. 294 Watkins. 204. 108. 914 Westby. F.. 1022 Williams. 172. 609 Warren. 645. 98 Wertz. W. 12 757. R. 967 Whatmough. 968 Wiggins. 431. 408. 249 Wicks. E. 356.. 569 Whyte... 422... 1021. R.. S. 921. 482. 264 Wenz. J. F. 623. 698 Willison. Weiner. 549. B. K. 357 Winkel. 523. 761. P. 392. 864 Whitehouse. 771 122. O. 864 567. Wilcox. C. 170. 75.. 121. 195. G. K. 54 Wiig. 8. 4.. A.. 35. 519. 778. 696 586. 411. 75 Webster Ross.. 832.. 192. 866. O. J. 418. L. 301. 15. T. E. 167. 756 Whitney. 965. J. 431... W. 385 Waugh. 217 Warrington. 125. 862.. I. 971. 190.. 782 Wesolowski. D.. 437. R. E. 998 Weingartner. 206 Wester. 896. 918 Weese. 757. 85. D.. 378 Wiener. 619... 1009... 11 Weiler. D. 416... 515 Westbury. 574. 554. T. 105.. V. 524. L. A. 892 Weigl. 977 Whitney. 362. D. 545. P. L. 518. 868 Whyte. J.. 106. 71. M. 124.. 894.. 426.. 75. 8. W. 495. 249 Weiner. 96 350. 75. R. L. 96. 102. 175. 418 Weston. M. D. 546. 451 Warren. 179. See World Health Ware. C. J. S. 757 WHOQOL-BREF. 93 Whitworth. 995 Weinrich. 487 Welsh... 249 Ween. 1026 Wilkinson. 609.. A. 1018. 128 Wells. 420. R. Williams. G. R. 972 . G. 89 Warren. B. 6. 814. R... M. 259. 587.. M. W. M. 538. H. 300. L. S... T. W.. J.. White-Thompson. R. 293 Weber. See World Health Organization Winhuisen. M.. 385.. 395 Wells. R. 859. 364 Wehman. 1024. N.. D. D. M. 392. 355. 761. M. 886 Weekes. 21. 120. J. S. T. K. 319. 916 Wertman. 1070 Author Index Ward-Longergan. J. S.. 102. C. M. 977 Wertz. 74 Organization Quality of LIfe Warren.. 306 Weismer. 1026 171. 922.. L. 587 Watson. 376. K.. 256. 46 Willows. 82. 764 Webster. 1023. 768 Wimmer. 75 Weiller. Y. 830 Waters.. 537 Weisenburg. 166.. 975 Whiteaker. 971.. 865 Willer.. 100 Wehmeyer. 859 Webb. Wilcox. 409 Whiteneck.. E. E.. 824 Webster’s New Collegiate Dictionary. 81. M. 126. E. 776.. A. 68. J. 205. W.. C. 416. J.. S. E. 416. 171. 419.. 415. 108. D. 508. L. 15 Weiss.. 406. 507 Whitaker. S..... 430. 545. 762. C. 858 Willmes.. 665. Watson. 236. G. 357 Whisnant.. K. 547. 377. 774. Wiener. 21. D. A. J. B. 483 Wertz.. 520. P. 583. L... 778. Weinand. 128. 657 Wasterlain. E... M... 177. 894 Wernicke.. C.. 837 Wilshire. 357 Welch. J. 777. 1020 Whitten. G. 550. P. 891. N. 256. 477 (WHOQOL-BREF). E. A... 377 Zalagens.. M. N. 904. I. 291. D. 76 Wood. J.... 12 Wipplinger. A. 937. R. E. 174. 1002 Work. Y. 660 Zaidel. 53 Zurif... 246. J. 552 Zencius.. A. A.. B. T.. 496. 865 Wood. M. P. J. 298. 1002 123. 860... 50 Zangwill. M. 928. 109. 902. 343. 757. 128. K. 13 Wrisberg. C. P... 14 Wu. R. 921. 967 Ziolko. H. 517 Zou.. 900. 14. D. 120. C... 704.. 965 Yedor. 613.. 259 Zarcone.. 305... 885. S. 933. 894. 49 Zeller.. 695 Zorzi... 190. 9–10. 717.. 897... 47 Yates. 1015. 257 Wright. 37. R. 114. Yong. 885. T. 894 Wise. M. A.. F. 173.. J...GRBQ344-ind[1043-1072]. 906. 360 Young. T. 122 935. 998 Wyller. 926. 11. 546. 893 Wolf.. M. 170 Wood. 718 Yarnell. 715 Wright. 351.. 306. A. 544 Yanagihara... A. 1016 Winter. K... 641 Youakim. J. 492. H. E.. 305. 362. J. V. 295. T.. J. 601. 740 Yang.. 964 Yang. 558 . 394.... 1014. E. 931. 926 Yardley. C. 302. M.. 642. J.. 195. 50. 119... A. S. 697 Wityk. J. 544 Youmans. 922 Zemva.. H. E.. A.. 304 Zraik. A.. M. 338 295. 1014.. 333 Yoshihata. 319. M. 535 Zola-Morgan. P. 939. 391 Yelnik. T.. 75 Yiu. 519 Wright. 80 Zhao. C.. 307.. 513. Y. 290. 611. W. 552 Zahn. A. R. 1001. 708. 767 Yajima. 718 Young. 422. O. 515.. A. 978. 994 42. P. S. B. 291. 294. 256. 966 Yarbrough. G. 251 Wong. M. 10. 13 Young.. C. 1018. S. W. 1025 Woolfolk. H. G. 297. J. 328. K.. A. M. X. R. 705 Wollack. 119 Xu. R. 391. M. 977. 257. 866 Yamamoto. J.. 1013. R. B. 1016 Ylvisaker.. 1003 910. 193 Wolfeck. L... 552 Zanobio. 89 Winstein.. 477 Zechner.. R. Zilbovicius. 14. 905... 470. 256 Yamaguchi. R. E. J.. 356 Yalom. 93. 912. 128. 323 Woodcock. 14 Yesavage. 4.. B. 998 Wolf. 565.. E... C. A.. 977 Woolf.. C. 50. F.. G. A.. 674 Wright.. 881. 1020. K. 567 Zatorre.. T. Zimmerman. 190.. 179. O. 864 Wulfeck. I.. 1002 Youse. 360. 69. 509 Wurtz... 705 Young. 363 Zientz. M. 533 Young-Charles. H. C.. 21 Zanetti. 13 Woolf. 1024. 919. 94 Ziegler. H. 879.. 738.. 77 Zorthian. 421. 363. 255. B. 1015 350. 567. 586. W. 967 Yule. 612. 290. 881 Zurif. 895.. M. 423 Yamanouchi. 924. M. 815. D. Y.. H. K. M. 291. 927. 758 Wunderlich. 294. Zilhka. K.. C. G.. E.. W.. 936.. 978 Young.. Zillmer. 79.qxd 04/02/2008 08:19 Page 1071 Aptara Inc.. 930.. 934. 454. 575 Wise. 929 Yamada. K.. A. L.. 551 Zasler. P.. 96. A. D. H.. 735 Worrall. 427.. 118. R.... 567 Zatz. 351. E. 896. M. M. 905 Wolters. 718 Wylie. 221. J. 492 Wolfe. 989 Wozniak. L. C... 858. 295. 899 Wykle. 89. 393. 174. D. 11.. H.. 296. T... E. D. 976 Wohl. E... 300. 164. D. 928 Zeches. 633. 173 Zola. J. M. 1011 Xuereb.. J. 121.. 887. 323 Zwahlen. G... 49 Wong. E. 763. R. 129 355.. P. 360 Yunis. Zivin. J. K. 940 Zingeser. 880. 113. R. 903. T. 88. 868 Ziol. 392 Winsler. J.. 977. 51 Worsley. 50 Zanobia. 898. B.. 292.. 585 Zettin. J. 831. 457. 385. 178. 170. 264 World Health Organization (WHO).. 918. 887. 98 World Health Organization Quality of Life 925. 91 Wong. 350. S. 997. 520. 921. 896. B. Y. 967 Wisotzek. 768 Zafonte. J.. 281. 646 Yang. 70 Yasuda. R.. E. N. 893. 915. 298. 1016 Xu. 356.. 426 Young. 831 Yorkston. 610.. 567 Zawacki. 96. 437.. Yokoyama. M. P. 965 Yamasaki.. W. 80 Young. 892. 923. Zilles. Author Index 1071 Winograd. 697. 378 458. E. 246 Zipoli. 895 Wong. 1026 Zoghaib. 924 Zaidel. 414 Wirz. C. 928 Woodruff. 740. R.. L. S. 191 Zahn. 423. M.. 296.. 574. G. M.. 68 Wotton.. Yoder. 361 Zonca. M. 80. J. 899. I. C. 913. 382. 343. 894.. 547. 929. qxd 04/02/2008 08:19 Page 1072 Aptara Inc.GRBQ344-ind[1043-1072]. . 215. 26 primary progressive aphasia and. 673–674 indirect approaches to. 972–973. 665–666 Angiography. 55. 997 720–721. 306 ACT. 207 multicomponent treatment programs for. 667–671 Americans with Disabilities Act (ADA). 741–744 spaced-retrieval training for. 206 deep. 975 verb. 309–310 Alzheimer’s disease (AD). 73. 363–364. 206 999–1000 bilingual. 670–671 280–281. See Amyotrophic lateral sclerosis traumatic brain injury and. 1002 Abstraction. 656t Amyotrophic lateral sclerosis (ALS). 335 Acoustic treatment. 518–519 ADL. 735–736 verbal fluency and. 256. AAC. 51. 745t 996 Acetylcholine. 550 communication and. See Anomic aphasia Activation theory. 663f American-Indian Code. 990–991 theoretic underpinnings of. See Attention deficit hyperactivity impairment of. See Activity Card Sort surface. 543. page numbers followed by the letter “f ” designate figures. See Assessment of Communication morphologic. treatments based on. 192 generalization and. 990 treatment of. 545. 9. 660–661. 633–634 sensory stimulation and. 206. 762 spared-memory processes and. 922 Action Naming Test. 47 Adaptation. 8. 37. See Anagram and Copy Treatment treatment for. 997 phonologic. See Aphasia Diagnostic Profiles Alternative meanings. 38f. 88 Acetylcholinesterase. 261t–263t. 570. 1001 acquiring. 335 Agraphia. 197. 518–520 context-based treatment and. 38f. 990f age and. 663f Test. 999 817 financial aspects of. 65 neurochemical deficiencies in. 552. 891 ADP.qxd 2/8/08 7:27AM Page 1073 Aptara Inc. 989–990. 47 ADA. 996–997. 3–4 Ageism. 661–663.GRBQ344-sub[1073-1092]. 991 anomic. 192. 214. 662f Amygdala. 518–520 Scale Allographics conversion process. See Augmentative or Alternative Agnosia. 656–657 Amsterdam-Nijmegan Everyday Language Activities of daily living (ADL). 661f 668–670. 997–998 Abstractness. 46. 558 Agrammatism. 667t American Sign Language (ASL). 10 assessment of. 1001–1002 Antiplatelet agents. 519–520 disorder treatment of. page numbers followed by the letter “t” designate tables. 657–661. 736–741 Alzheimer’s Quick Test. 666 noun. 667. 39f. 52. 524 894. 382–384 activities of daily living and. 993 AOS. 56 Activities and participation. Subject Index In this index. Activity limitations. See Assessment of Language-Related Anomia. ecological model of. 663–666 Amitriptyline (Elavil). 206. 388 AI. 10 surface. 862 ADHD. 382–384 behavioral treatment for. 6 assessment of. 670f AD. 37. 741 Akinetic mutism. 662f. See Alzheimer’s disease treatment for. 555 Activity Card Sort (ACS). 252–260. 741–750 Ambient noise. See Alzheimer’s Disease Assessment Functional Activities compensations and. ACS. 192. 37–38. 572 development of. 550 functional maintenance therapy and. 704 Alzheimer’s Disease Assessment Scale (ADAS). 55t. 56 Amnesic aphasia. 663–666 Aneurysm. 8. 46 Adynamic aphasia. 307. 708 Advocacy. 299 pure. 36f. 711 Aging hippocampus and. atypical. 609 recognition memory and. 20. 250 conceptual information and. 694–695 phonologic. 55 aphasia and. 776 ADAS. 20 Acoustic-articulatory motor pattern associator deep. 994 Anomic aphasia. 661f. See Americans with Disabilities Act unspecified. 571 Alzheimer’s disease and. 263–267 successful. 991 Apathy syndrome. 973. 294 ALFA. 522. 206–207 group therapy for. 990–991 Communication Systems visual. 711 caregiver training and. 817 Advocacy reports. 673f direct approaches for. 35. 546 profiles of. 245 1073 . 35. 783 computer-assisted therapy for. 989–991. 990f Aphasia primary progressive aphasia and. 209–212 ALS. 52 global aphasia and. 991 ACESA. 661–666. (see also) cross-references designate related topics or more detailed subtopic breakdowns. See also Aspirin Age cognitive stimulation and. 708 Administrative tasks. 570. 476–477 computer-aided communication and. 550 communication ability and. 55t Action for Dysphasic Adults. 991 bilingual/multilingual. 364f Montessori activities and. 87. See Apraxia of speech bilingualism and. 421 defining. 1000–1001 Anxiolytics. 998–999 Aachen Aphasia Test. See Artificial intelligence Amnesia. 9 Amphetamine. 988. 999–1000 adynamic. 207 naming and. 661–671. 772 network. See Activities of daily living Allographs. 37f language intervention and. 672–674. Wernicke’s aphasia and. 552. 999 Abstract attitude. 1002 AAC relation with. 656–660 Anagram and Copy Treatment (ACT). Effectiveness in Severe Aphasia spontaneous language profile for. 583. 720–721. 13 memory and. 975 Alexia. 666. 178–179. 307. 80. 78. 996–1003 Anticoagulation. 815–817 prognosis formulation and. 566 Scheull’s model of. 389 environment and. 343. 33. 404–405 705–706. 547t. 818 gesture and. 206–207 historical perspective of. 209 incidence of. 35f prevention of. 29f.qxd 2/8/08 7:27AM Page 1074 Aptara Inc. 71. 8. 632–634 fundraising and. 546–547 The Aphasia Handbook (Sarno & Peters). 94 affect and. 405 education and. 28f 697–698. multidimensional. 570–571. 419. 570. 696–698 verbal retention span and. thalamic. 569. 403–404 age and. 187 concrete-abstract. 15 epidemiology of. 578 etiologies of. 71–74 704–706. 817 interpersonal relationships and. 840 conduction. 4. 27f. 569 PPAOS and. 6 PDP model and. 209–211 assessment and. 568 resource allocation models and. rationale for. incidence of. 578 gender and. 326–327 primary progressive. 690–691. 9 optic. 565. 8–9. 7–8. 891 and participation. 573. 991 language and. 764. 696–698 characteristics of. 9. 259. 648 840 body structure and function. perspective of subject in. 65. 187–188 diagnostic criteria for. 33f. 8–9. 611. 551–553 Aphasia Needs Assessment. 74. 556–559 Aphasia Tutor. 209 comprehension and. 405 patient communication with. 632–634 interdisciplinary approaches to. 548. 349–350 classification of. 567–568 296. 572–576 systems analysis approach to. 9 nature of. irreversible. 537–540. 5t client selection for. 213–214 informal tests and. 9–10 language intervention in. 27–28. 404–405 ethical decision-making and. 57. speech patterns in. 405 microgenetic view of. 407. 550 Aphasia family groups. 545t. 570–572. 567 with scattered findings. 6 lexical-semantic impairment in. 7–8. 92 . 188. 709–710 543–544. 572–573 societal awareness of. 324t–325t roles of. 9 life areas framework of. treatment of. 12 sentence deficits and. 4. 206 histologic pathology of. 572t severity classification of. 84–90 character of. 566 sources of symptoms in. 81–82. 545t Aphasia Language Performance Scales. 31f. 26–27. 817. 32. 259. 696–698. 578t. 13–14 Wernicke’s. 89. 576. 71t neuroanatomy of. 587. 26 prognosis for. 207–214 intervention and. 576–577 social model of. 9. 295–296. 21–24. 125 with intermittent auditory imperception. 530. 382 future trends in. 556 assessment by. 581t comprehensive. 37. 7 life changes from. recovery from. 213 evolution of. 6 nonfluent. 550 treatment of. 3–4 406 transcortical motor. 716 Apomorphine. 208 577–578 referring to people with. 85. 342–343 referral from. 406 traumatic brain injury and. 37 advocacy by. 13 75t–76t characteristics of. 550–551 Aphasia centers. 817. 403–404 brain anatomy and. 840 as symbolic processing weakness. 800–803 Broca’s. 28–30. 537. 292 quality assurance and. 32f. 547–548. 840 classification of. 508 context and therapy for. 20–21. 31–32. 15 type evolution of. 544–546 Aphasia quotient (AQ). 416 information processing. 34f. 756–757 observational. 509 defining. conceptual frameworks for interpreting strategies and. 577 progressive. 405–406 excellence in. 55t lesion site and. 578–579. 10–11 psychometric considerations for. 552. 514–521 determining presence of. 7–9 life consequences of. 70. intervention by. 214 behavioral treatment targets and. 307–308 goal revisions and. 820–821 therapeutic window for. 25f. 81. 735 assessment of. 381 transcortical sensory. 774–777 disability and. 820 gerontology and. 27f infrequency of. 212 hemiplegia and. 900t. activity. 575–578 stroke and. 211 demographics of. 507–508. 568–569 risk factors for. 578t simple. 191. 572 procedural memory and. 509 crossed. 510–511. 891 specific language functions and. 566–567. 637–641 research by. 816–817 Apraxia Battery for Adults. 507 thought process. 30–31. 567–568 structure and therapy for. 68–70. 569. 8. 579–580 stages of. 213 depression and. 296 neuroanatomy of. 816 screening. 1074 Subject Index Aphasia (continued ) neuroimaging of. 405 Melodic Intonation Therapy and. 3–4. 697–698.GRBQ344-sub[1073-1092]. 6–7 with persisting dysfluency. prognosis and. 21. 309–310. 365 567. 818 marketing and. 436–437 consultation by. 208 expression and. sentence deficits and. 8. 609 causes of. 549–550 word retrieval and. 709–710 administrative tasks of. 11 counseling by. 538f Apprenticeship learning model. 187–188. 632 culture and. 517 declarative memory and. 74. 580–588. 8. 220–221 etiology of. 211–212 formal tests and. 513 psycholinguistic. 530–537 childhood. 570–571. 543–544 Aphasia Diagnostic Profiles (ADP). 575 subcortical. 899. 508t unidimensional. problem solving. 20–21. 296f with visual involvement. 405–406. 840 neuroimaging of. 27–28. 716 718–721 rapid discharge and. 735. 187. 76 canonical sentence computation and. 706 phonologic impairment in. 101–102 management of. 208 communication and. 547–548 Aphasia Bill of Rights. 855 historical overview of. 10–13 defining. 867 global. 72. 570–575 tests for 410. 554–555 Aphasiologist(s) age and. 573–574 symptoms of. 565. 567. 108 clinical presentation of. 28f. 569–570 demographics of. 8. 339–340 fluent. 207–208 cognition and. 551 Aphasic Depression Rating Scale. 830–831 deficits accompanying. 187. 241 drawing and. 259. 548–549 Aphasia Center Lifelink. 10–12 Apolipoprotein E. 76–77 738 information processing and. 840 propositional language. 569 with sensorimotor involvement. 30f. 389 epidemiology of. progressive nonfluent. 8. 70–71. 922 Melodic Intonation Therapy and. 512t–513t. 827. 10–13. 20. 569–570 sentence-level deficits in. 118–119. 97 Auto-associator network. 108–109 impairment of. 256. 430 AQ. 356. 828f of clinical performance on tasks. 725. 406 Arteriovenous malformation (AVM). ASL. 429 738 therapy prognosis determination. 975 pragmatics. 764–766 right hemisphere damage and. 510–511. error patterns and. 1022 aphasia presence and. 821–824 386. 299–300 Augmentative communication devices. 174 future trends in. 1015–1016 complicating conditions and. 821–832 apraxia of speech and. 924 1021–1024 executive functions and. language. 821 818–819 Attention. quality of life. 510–511. 101–102 Attentional networks. 297t–298t assessment for. 906 apraxia of speech and. 104t Auditory cortex. 994–996. 828f Assessment. 1018–1019. 581–582. sustained. 558. 513 gesture and. generalization of. 44 Augmented comprehension. 691 insula and. 51 traumatic brain injury and. 295–300. 93. 100 Auditory association cortex. See Primary auditory cortex Aprosodia. 84–90 Atypical aphasia. 903–906. 46 Augmented input. 577 Attentional systems. 966 memory and. 74. 1026 language content comprehension. 80. ASHA FACS. 254–255 Assessment of Language-Related Functional written choice communication and. 965 Apraxia. 763–764 AUSWEGE. 411 Arteriogram. 967–968 defining. 832–833 alexia and. 119–121. constructional. 119t 864–865. 967 AAC and. 868 Aspirin. 865 of pragmatics. 46 512t–513t Auditory system. 966–968 assessment of. 1026 language form comprehension and. 967–968 1018t further development in. 975–976. 579 827–828. 178 augmented input/comprehension and. 1019–1021 of functional communication. 614. Thematic Language Stimulation and. 1019–1021 Severe Aphasia (ACESA). 966–968 552. 113–121 Auditory deficit APT. 967–968 Speech. 965 Apraxia of speech (AOS). 88. 309–310. 741–744 Wernicke’s aphasia and. communication books and. ideomotor. 764 hyper. 511. 865 comprehension and. 249 feedback and. 886t 453–456 computer-based treatment and. 71. Subject Index 1075 Apraxia. 868. 36f. 90–95 Auditory comprehension. 44. 613t. 861. See American Sign Language thinking and. 825f bilingualism/multilingualism and. 406. 100 Attention deficits. 569. 429 Argument Structure Complexity Hypothesis. 65. 821 cognition and. See ASHA Functional quality of life and. 543. drawing in. 430 Arousal lexical model and. 67–74. 1022 gesture and. 66–67 right hemisphere damage and. 119t treatment of. 511 Activities (ALFA). 579. 97–98. 120. 28. 406. 867 approaches to. 1018. 76–84 Augmentative or Alternative Communication Life Scale psychosocial adjustment and. 300 864–865. 80. 1014 cognitive ability analysis and. 1017 global aphasia and. 869 Assessment of Communications real-life behavior. 539. 830–831 AAC and. 781 therapy approaches for. 1021. 476 Apraxia of limbs. information processing and. 121–123 noise buildup. 994–996. 967 considerations in treatment of. 406. 904t. 97 Assessment of Intelligibility of Dysarthric overview of. 1020 technology and. 995t. 454 Atherosclerosis. 98. 1021. 178. 100–102 speech rate and. 539 observation and. 29f. 869 ASHA CQL. 828–830 aphasiologists and. defining. 430. 257–258 slow rise time. 817–821 Communications Skills for Adults social-validity. 67t Attrition. 126–128 computerized treatment and. 208 Assessment of Communication Effectiveness in interventions in. 839 rate/rhythm control approach to. 429–430 Arizona Battery for Communication Disorders 123–126 retention deficit in. 92–93. 964. 814–815 attention deficits and. 511. 614t Auditory perception. communication and. See Attention Processing Training production of language form and. 534 eight-step task continuum for. Artificial intelligence (AI). 128–129 Attention Processing Training (APT). 967 apraxia of speech depression and. 46. 513 Auditory imperception. pattern of. 762.GRBQ344-sub[1073-1092]. 550 context-based treatment and. 92. treatment based on. 1021–1029 102–105. 826–827. 914. 764 cueing for. 95–98. 994t selective. 581t severity of. 513 neglect and. 510–511 Auditory processing. 429 in Dementia. Melodic Intonation Therapy and. See Aphasia quotient 111–113 information capacity deficit and. 1027 goals of. 612–614. 831–832. 1026–1027 ASHA Functional Assessment of social model and. 966–967 para-standardized testing for. 703 . 67. 692–693. 550 512t–513t. singing and. 483–484. 429 1000 interview for. See also specific measures 909 environment and. 100. 824–826. 94. 656–657 512t–513t. in-house translation for. 833 of agrammatism. Atrial fibrillation. biographical information and. 1026–1027 994 Attention deficit hyperactivity disorder articulatory-kinematic approaches to. 815–817 Skills for Adults of recovery. imperception and.qxd 2/8/08 7:27AM Page 1075 Aptara Inc. 409 impairment in. 861. 613–614 assessing. 764–766 intersystemic facilitation/reorganization intervention goals. 580 multifaceted interventions with. 614t (ADHD). 37f inferior frontal gyrus and. See Communication Quality of process of. 123. 95. 97–98 Auditory perceptual clarity. 415 1024–1026 language content production and. 98t. See also Primary progressive dementia and. 817–821 of treatments. 47 participation measures for. 700. 100 852–853. 178 aphasia relation with. 1018t 105–111 Auditory Comprehension Test for Sentences. 971 of content production. 821 (ASHA FACS). 815–816 attention and. Auditory stimulation. 362 Systems (AAC). 107. 910. 256. 530. 547–548 age and. 705. 991 consequence-based. 7. 255 Living of dementia. 190. CBD. See Arteriovenous malformation Blocked practice. 735. neglect and. 690 attention. Brain-behavior relationships. See Communication Effectiveness Index importance of. 82. 264–265 Broca’s area. 26. 21. 260. 26–27. 215 insula and. 700 352. 85. 992 CEA. See Calcarine fissure rehabilitation for. 188. 22 Reporting Technique Behavioral tests. 25f. 9 Behavioral disorders recurrent connections in. 26 impairment types in. 539–540 two-way connections in. 567. 992 Behavioral impairment. 42. 178 Classification of Impairments. 55t AVM. 701 Behavioral rehabilitation. See Corticobasal degeneration BDB. See Communication Activities of of primary progressive aphasia. International recovery and. developing. defining. 51 BASA. 76. 3 CETI. 88–89 Cerebral cortex. 577–578 Brain damage dementia and. 1010f Syndrome. 991. 530 Function. 8. 47. See Cerebral blood flow Beck Depression Inventory. 539 systems analysis model of. 484 Brief orthographic exposure. 1076 Subject Index Automatic language. See Communicative Activities of Daily Boston System for. frontal systems dysfunction. 34. 817–818 Case-managers. 1015 Behavioral Assessment of the Dysexecutive motor-speech disorders and. See Copy and Recall Treatment Basal ganglia. 73. 926–927. 856 Bias. 741. 25f. 569 Behavior modification. 817. CART. See Burden of Stroke Scale Carotid artery. 46 Cerebrovascular accident (CVA). Cholesterol. 700. See also Stroke nonlinguistic. 898t. degenerative communication alternatives and. 10 Model BOSS. 20. 46 global aphasia and. 407. 995 Bilingualism CADL-2. 569. 994 Boston Naming Test. 44 interpreters and. 933–934 bilingualism and. 1010. 817 Case rate arrangements. 990t treatment and. 279. 539–540 vascular supply of. 897t. 72. 52. 964 (BDAE). 79. 904 knowledge storage and. 250–252 Canonical sentence computation. 27f Circle of Willis. 195 Broca’s aphasia. 781 CC. 689–691 insula and. 252–253 704. 187. 49. 689–690 Cerebral infarcts. 912. 1016 Civil rights. 1009 positive. 817. 265–266 canonical sentence computation and. 691. See Computer-assisted instruction 554–555 level of. See Boston Assessment of Severe Aphasia 73–74. 256–257. 569. 21. 666. 188. 927t. 737–738 Automatic serial naming. 540 tumors in. See also International multi-language testing and. 105 Examination 578. 43–44 motor-speech disorders and. 1011 Chaotic order. 868 Disability and Health. 419. 657. 106 types of. 802f Cerebral tumors. 923–926 Brain plasticity. 883f arousal. Category naming. 260. 775 Behavior Rating Inventory of Executive injury to. 989. 405–406. See Complex Aphasia Rehabilitation Axonal injury. 258–260 Burden of Stroke Scale (BOSS). 632–634 CIT. 868 Autonomy. 71. 255. See Constraint Induced Therapy intervention issues for. 296. 929t Brain. 26. 582. See Boston Diagnostic Aphasia 196. patterns in. 46. 26 social skills training and.GRBQ344-sub[1073-1092]. See Craig Hospital Assessment and 923–926 Brainvox. Choline acetyltransferase. See Cognitive behavior modification Bedside tests. 858 information in. 26. 539 structure of. 47. 195 Classification. 885 Captain’s Log. 817–820 Automatic speech. 188. test-retest reliability and. 234 motor-speech disorders and. 585–586 Boston Assessment of Severe Aphasia (BASA). 253–254 Calcarine fissure (CF). 79. 700 Cerebral edema. 25f. 537. 989. See Carotid endarterectomy antecedent-focused. 1009 Boston Diagnostic Aphasia Examination CAT. 206–207 language choice and treatment of. Computer-aided therapy BDAE. 570–571. 738 Choroidal artery. 884f Body structure and function. 3–4 Bifemelane. 543 932t–933t. See Creutzfeldt-Jakob disease level of bilingualism and. 1009–1016 motor-speech disorders and. 264–265 CADL. 11 Bilingual aphasia 410. 855 Cholinergic system. 689. 258–259 neuroanatomy of. 584–585 Carbamazepine (Tegretol). 914–915 Blissymbols. 990–991 future trends for. 106 BIRCO-39 Scales. auto-associator networks in. 773 Biographical information. 71. 254–255 Brown-Peterson paradigm. 690–691 CF. 931 blood supply to. 26 Cerebrovascular disease. 23 CJD. 265 Brodmann’s regions. 261t–263t. 570–571. 253–254 Bromocriptine. 894–895 aphasia and. 55t. 22f. 250 Capability profile. 216 Automatic-closure naming. 20 concept formation. 904 Childhood aphasia. 818 . 20–21. 547–548. 24 of severity. 567. 1010. 659–660 Chart Links. 582. 1023 CARM.qxd 2/8/08 7:27AM Page 1076 Aptara Inc. 254 sentence deficits and. 1014 586. See Comprehensive Aphasia Test. 250–252 Cerebellum. 51 Back to the Drawing Board (BDB). 817–818 Bilingual Aphasia Test (BAT). 169 Brief Test of Head Injury. 817 treatment and. 700–701 Cerebral dominance. 894–903. See also Traumatic brain injury Central nervous system (CNS). 71t 721. 248–250 CAI. 309–310. 81. 706. 931 infection in. 800–803. 511 Capitation. 578. 47–51 Cerebral artery. 250 Daily Living-2 of primary progressive apraxia of speech. 258 Brubaker on Disk. 690 Cerebral blood flow (CBF). 10. 928t. 990 culture and. 454 localization and. 703 disease of. Carotid endarterectomy (CEA). See Conversation Analysis of aphasia. 389. 187. 995 CBF. 46. 970. 928–931. 566. 70. 931. See Back to the Drawing Board 971f. 933–934 imaging of. 858 CHART. 258 Disabilities and Handicaps tests for. See Corpus callosum Behavior management Bradykinesia. 994t. CBM. 255–257 CA. 259. 259. 56–57. 24. 81–82. 697f. 1015 Boston Classification System. 578–579. 904 PDP model emulating. 928–931. 827. 923 knowledge and. 88. 772. 566–567. 55. assessment and. 725 Classification of Functioning. 264. 74. 85. 919–920 drawing for. incomplete evidence Cognitive semantic therapy. 580 296 models of. 786 332 communication and. 120. 392 Cohesion analysis. 598–600 Communication Activities of Daily Living-2 lexical model and. 301–302 Cognitive approach global aphasia and. 293 Communication-impaired environment. 587 CNS. 91 tasks for. 293. 607–612 892t impairments of. 818. 453–454 Communicative Profiling System (CPS). 457 functional rehabilitation approaches to. 307–309 language and. 92–93 Wepman thought process therapy and. 81–82. 350. 894–903. 892t apraxia. 896. 919–923 patient-therapist. 91 response elaboration training and. 329. 568 334–336 counseling for. 550 Thematic Language Stimulation and. 597–598 social approach view of. 457. 786 rehabilitation for. 95–96 global aphasia and. 100. 329. 179 auditory and visual sensitivity. 891–895. 55t Combined cues. 828f Communicative Activities of Daily Living developmental. 102–103 goal of. 164–165. 483–484. 955 behavioral impairment and. 568–569 Complementarity principle. psychosocial impairment and. 891–895. 881. 13 Communication Environment Inventory. 818. Code switching. 119t. 332. 621–623 team processes and. natural interaction in. 993 culture and. 386. 119–121. 771–772 918–919 structure of intellect model and. 478. 822 Clinical meaningfulness. Compensatory communication.qxd 2/8/08 7:27AM Page 1077 Aptara Inc. 482 Alzheimer-type dementia and. 613–614 treatment methods and. 596 traumatic brain injury and. 580. 93–94 495–496 as problem solving/decision making task. right hemisphere function. 119–121. 230–231 Complementizer phrase (CP). 85–86. 350. 763–764. 818t case history and. 291–292 Cognition. 264 963–964 Comprehension basic assumptions of. 826–827. 188 organization of. 522–524 assessment of. 514–517 generalization and. 361 Complex Aphasia Rehabilitation Model intervention and. 920–921 gestural. 595–596 system of. 497t. 247t Communication-related quality of life computerized treatment and. 113–121 medical conditions. 293–294 Complicating conditions 496–497. 493t–495t partners for. 100 933–934 Communication Profile. 781 baseline. 98t. 502–503 Communication books. 96–97. 907t–908t 452–454 Compensatory strategies. 1000–1001 content of. 93 therapy principles of. 94–95 818 right hemisphere damage and. 308–309 increasing flexibility of. 419 Communication Effectiveness Index (CETI). 939 Cognitive stimulation. 967 Communication intervention Code-switching. 121 defining. 579. 543. 102 treatment focusing with. 233 limb apraxia. 119–121. 736–737. 230–231 context-based treatment of. 491–492 levels of. 246–248. 779 instruction in using. 583–587 auditory and visual agnosia. 993 CQL). 471 gestural-verbal. 114. 233 form words and. 488 937 identification of. 177 Collaborative referencing. 499–502 non-aphasic deficits in. future trends in. 920 functional. 356. 90–95 traumatic brain injury and. mental operations and. 337–341. 330t–332t. 498t. 122 818–819 as collaboration. 329. 502–503 intent in. 97–98.GRBQ344-sub[1073-1092]. motoric impairments. 300–302 assessing. 829f influential variables in. 649 team interventions and. 119t empowerment and. 93 therapy plan for. 894–895 Communication Quality of Life Scale (ASHA assessment of. 598 quality of life and. 824 Clinical significance. See Central nervous system Alternative Communication Systems Communication Effectiveness Survey. 993 (CRQOL). 868 dementia and. cognition and. 886t Cochrane systematic review. 177–178 Collateral sprouting. 250 barriers to. 914 469 post-stroke psychobehavioral disorders. 101 future trends in. 882f Communication. 737f. retraining. 617–621 (CADL-2). 114–115. 109–110 goals of. 90 therapy objectives of. 115–117 741. 488–490 compensatory. 390. 496–497 partner behaviors and. 886t primary progressive aphasia and. 9. 617–618 limitations of. 818t dysarthria. Subject Index 1077 Clinical accountability. 888. 993 330t–332t Code-Müller Protocols. self-actualization skills and. 579 morphology and. 249 accountability and. 917t–918t. 487–492 partner-independent. Closed head injury (CHI). 307–308 interviews for. 932t–933t. 91–92 Cognitive neuropsychological approaches. 758f connected language and. 600–602. 821–824 and. 108. 822–824 Clonidine. 492 partner-dependent. 922–923 patterns of. 747 integration in. 80. 92 Cognitive behavior modification (CBM). hemiparesis. 821–822 Clinical investigation. 623 written choice. 363. 101–102 lexical processing model in. 764–766 definitions for. See also Augmentative or 68t. 55. 937. 102–103 . 485–487 group. 342 analysis of. 92 rationale for. 569 auditory. 501 behavior management and. 484–487 memory impairment and. pragmatics and. 915 environment and. 120 aspects of. 484–485 non-speech aids for. 612–616 strategies for. 894 (CARM). 827–828. 585–586. 90 virtual reality and. 407. 771–772 Compensatory-strategy training. 232–233 psychosocial intervention and. 100–102 clinical applications and. 120. 584 Clinical decision making. 470–471. 898–899 dyadic nature of. 119t increasing. 391–392 Cognitive neuropsychology. Communicative confidence global aphasia and. 860. 321 (CADL). 178. 172–173. 915–916. 389 Life Participation Approach to Aphasia and. 362 attention deficits and. 80. 763. 129–130 Community Integration Questionnaire. 894–895 rating scales for. 308 impairment of. 95–98. 94 Cognitive Linguistic Quick Test (CQLT). cognitive therapy and. 931. 195 aging and. 485. 607 Communication boards. gesture and. 455. Confidence interval. 586. 435 limitations of. 716 CQLT. 565. 522 functional. 302–303 Computer Based Microword protocol. 230 models for. 672 Computer-assisted instruction (CAI). 419 stimulation and. 861. 76 CP. 499 writing and. 522–524 CT. 859 naturalistic quality of. 860–867 aphasia therapy and. Coumadin. 865 outcomes and. 692–693. 582 generalization and. 8. See also Warfarin cognitive problems and. 264 867–868 confidence development in. auditory comprehension and. 864 Connected utterances. See Computer-only treatment brain-behavior relationships and. 575 Confrontation naming. 515–516 POSSE strategy for. 111–112. 858–859 Context CQI. 706 intervention and. 638 Computer-Assisted Anomia Rehabilitation. 48. 111 Cortical reorganization. 519 . 778. 867 neuropsychological assessment of. Connected language. 868 treatment phase of. 573–574. 859 Content-oriented activities. 713f cognitive therapy and. 509 hierarchy for. 189 administrative functions and. 716 Cross-modality cueing. 555 behavioral modification and.GRBQ344-sub[1073-1092]. 832 Constructional apraxia. 703 Contusion. 669t. 901 Creutzfeldt-Jakob disease (CJD). Conversation Comprehensive Apraxia Test. See Continuous quality improvement efficacy of. 109 Corpus callosum (CC). 197 Connectionist models. 823–824. 704 Controlled Oral Word Association Test. 111 Cortical rim. 552 generalization and. 96. 49. 691–692. syntactic constructions and. 51. 555. 721f Conversation Analysis (CA). 517 of life prognosis and. 660 structure of. 540 Contrast medium. 868 112t Counseling. 995 taking responsibility for. 776–777. 862 cohesion analysis of. 100–102 impairment of. 712. 617–618 sentence production and. 515–517 cross-modality. 472 Comprehensive aphasia tests. 726 Conversational partners. 302–303 ViC). 512t–513t. 768–770. 112–113 Copy and Recall Treatment (CART). 483 visual. 583. 25f artificial intelligence applications in. 777f telemedicine and. 28–30. 113 COT. 760 traditional treatments compared with. 868 in structure of intellect model. 514. 862 Contextual priming. 865 neurolinguistic assessment of. 779 862 713. 414. 725 Contrecoup injury. 108–109 Corticobasal degeneration (CBD). 964. 867 temporal variables in. 862–863. 712–714. 619 867–868 Concept formation. 106 779–781 Computer aided visual communication (C. 524 perceptual. 231 CPS. 24. 857–858 measurement in. 690 Computerized aphasia treatment form words and. 410 tasks in. 111t. 47 restitutive treatments for. 110–111 Coup injury. 510 Language-Oriented Treatment and. 858 phonology and. 838f reading. 488–491 Comprehensive Aphasia Test (CAT). 501–502 word. 196 Consequential bias. 858–859 assessment for. 861 recreational programs and. 92 690–691. 861–862. 410 tutorials in. 363 AAC and. 308 commercial products for. 189–190. 977–978 Computerized Patient Records System. 517–520 combined. 71–74 Conduction aphasia. comprehension and. 76 Conversational prompting. 636–637. 1078 Subject Index Comprehension (continued ) verbal output and. 857 Context-based treatment Cross-training. 971 Conversational verbal tasks. 862–863.qxd 2/8/08 7:27AM Page 1078 Aptara Inc. 860 cognitive flexibility and. 33. 637f rehabilitation for. 859 linguistic variables in. 618 PDP model and. See Computed tomography reading comprehension and. 109–110 669–670. 831–832 Construct validity. 104t Concept representation 721. 513 CRQOL. 364 future trends in. 855–856 skill. 46. 197. 703 Contrastive stress drills. 518–520 Melodic Intonation Therapy and. 514–521 prosodic. 537 Convergent thinking. 435 supported. 1026 sentence. See Cognitive Linguistic Quick Test emotional factors in. 858 establishing. See Communication-related quality patient candidacy for. 859. 76 Conversation therapy. 898–899. 761–762. See Communicative Profiling System educational models and. 884f treatments for. 1022 simulations in. 884f definitions for. 103–105. 476 Continuous quality improvement (CQI). 856 dependence on. 654–656. 856 stimulation approach and. 863–864. 299 Computer Reading Treatment. 832 Content production. 76 independence and. See Complementizer phrase drill and practice in. 74. Constraint Induced Therapy (CIT). 858 syntactic constructions and. 508–510 neglect and. 901 Craig Hospital Assessment and Reporting feedback and. 300–301 Computed tomography (CT). 566. 607 Condensed practice. 197. 884f substitutive treatments for. 33. 843 866–867 rationale for. 171 Language-Oriented Treatment and. 545. 301 Computer-aided therapy (CAT). 180. Conversational coaching. 510–511. 865 error analysis of. 233 receptive vocabulary and. 23. 715. 852–853 Content validity. 856–857 morphology and. 856 Contextual photographs. 413. perseveration and. 859 self-correction and. 860 caregiver training and. 361. 855. 425–427 Crossed aphasia. 520 personalized. 521–524 algorithms for. 548. 692–693. 768 thalamic aphasia and. 617 Concept manipulation. 570. 29f. 868–869 rehabilitation sensitive to. 517 distributed. analysis of. 105–111 Copular constructions. 693f. 865 information exchange and. 697f Convergent semantic tests. 73 Conditional Statements. 515t Technique (CHART). 853–854 structural. 855 research and. 660 modality considerations in. 552. 588. 966 treatment supplementing. 852. 697–698. 101. 517 Cueing. 35f limitations of. 857 future trends in. 108–109 550–551. 715 Criterion-related validity. 633–634. 302. 110t scaffolded. 357–358. 867–868 variables influencing. 855. 524 apraxia of speech therapy with. Computer-only treatment (COT). 384–385 Dysgraphia 543 Direction following. 78 post-stroke. 353 rhythmic. 886t sentence production and. 556 Discourse impairment. 585–586. 10 deep. 474 Diagnostic and Statistical Manual of Mental Drawing. 117–118 Depression. 248 site of lesion in. 360–362 semantic. See also Disability Creation EBP. 350–354 self. computerized treatment measurement issues in. 1017 Defective utterances. 334–335 pseudo. 94 Divergent semantic tests. 418 Diagnosis-related group system (DRG). 355–358. 253–254. 970 Cultural milieu. 919 bilingual aphasia and. 975 Culture semantic skills and. 47 etiologies of. 96 reliability in. 868 treatment of. 417–420 pragmatics and. 974–975 communication vascular. 428 Dysarthria. 94. 1015 predictive considerations in. 353–354 course of. 4th Edition treating. 780 DynaVox. 988 treatment of. See Evidence-based practice depression and. See Computer aided visual syndrome of. 995 compensation strategies and. 995 informative content production and. 55t. 552. 862 Dementia. 999 evaluation of. 33 functional maintenance therapy for. 663f. 419. 22f. 249–250 Drill and practice. 893–894 245–248. 713f direct observations for. 708–710. 703 ethnocultural considerations in. 420 Parkinson’s disease and. communication with. 95. 858–859 . 1001–1002 aphasia and. 690–691 stimulation approach and. semantic. 80. 843 progressive. 56. 988. 1002 Health. 992 Disability Creation Process (DCP). 994t Discourse Comprehension Test. 490–491 reported observations for. See also Phenytoin Dysarthria Examination Battery. 20 Diabetes. 995 Discounted fee-for-service arrangements. 95 DIVA model. 215 Dopamine (DA). 994–995. 920–921 Diaschisis. 349–350 Dyslexia. Discriminability. 570 volunteers in treatment for. data collection and. 353–354. 919 Cytoarchitectonic fields. 55t Mental Disorders. 246–248. 975–976 Divergent thinking. 826–827. 779–781 visual. 994 Distributed practice. See Diagnosis-related group system aphasia and. 692–693. 1003 applying. 661–663. 294 surface. 86–87 Disability models. 715. 247t severity scales for. 992 Discourse patterns. 547. 67–74. 57 Decision making. 188 DSM-IV. 472 screening tests for. 108. 994–996. 4th Edition (DSM-IV). 326–327 screening tests for. 434 computer-based treatment and. 862 cerebrovascular disease and. 55t DLB. 411–412 Dartmouth COOP Charts. 548. 101 Culturally and linguistically diverse (CLD). 620. 87–88 selection/integration deficits. 712–714. 994t. 46 Do-not-resuscitate orders (DNR). 663–666 Difficulty Duke-UNC Health Profile. 360–366 Educational models. 663f level of. 360 Dysphagia. 990t of Functioning. 77 right hemisphere damage and. See Diagnostic and Statistical Manual of Deep agraphia. 663–666 order of. 363–364. 195 DNR. Declarative memory. 668 assessment of. 970–971 C-ViC. 988–989. 71t Desipramine. 776 994–996. 1000–1001 352f. 973–974 communication and. 975–976 cognitive therapy and. 885. 85. 20. 966 neuropsychological tests sensitive to. See Dementia with Lewy bodies standardization and. 93 Degenerative central nervous system disease. 1002 macrostructure deficits. 975–976. 611 alternative meanings and. 992 aphasia and. 364f future trends in. 245–248 spaced-retrieval training for. 993 operational definitions of. 861. Direct language treatment groups. 335 Discourse structures.qxd 2/8/08 7:27AM Page 1079 Aptara Inc. 77–78 Dextran. 668 Diffusion tensor imaging (DTI). 333. 696 memory and. 26 Dementia with Lewy bodies (DLB). 215 verbal. 354 phonologic hierarchy for. 545 Disability. 569. Disability and Echolalia. 418. 569 Distributed representation. 969–970 CVA. life activities/roles in. 213 Deblocking function. surface. 769–770 causes of. 992–993 Disconnection syndromes. 65. 52. Subject Index 1079 phonemic. 418. 535–536. 266 semantic dysfunction and. 972–973. 70–71. 49 Discourse. Disorders. 93. 483 psychometrics and. 11. 481–483 DA. 554 Deep dysgraphia. 52. 862 cognitive stimulation and. 994t adaptation v. 661–663. 81 Deep alexia. International Classification Ecological model of aging. 992 Discourse skills. 327. 55. 355 994 Disinhibition hypothesis. 767. See Dopamine assessment and. 992 DRG. See Electrical cortical stimulation Lewy body disease and. 354–355 and. 1009 unilateral upper motor neuron. 36f. Disabilities and ECP. 994 Process. 85. 989. 21–24. 1003 of Impairments. 1001 Handicaps ECS. 667–668 Diazepam. 78–79 identifying symptoms of. 252–253 sensory stimulation and. 709–710 Dialects. 517 Dilantin.GRBQ344-sub[1073-1092]. See Diffusion tensor imaging treatment of. 693f. International Classification Echocardiography. treatment on. 76–81 dementia and. 1025 999–1000 overview of. 480t. 994 narrative. 87t measures of severity of. 550 communication ability and. See Cerebrovascular accident stages of. 994t Disability Rating Scale. 975–976 in structure of intellect model. 68–69 stroke recovery and. 1002–1003 Discourse schemas. personal factors in. 352–353. 828f 989 989. 927t Data collection. 748 Cyclophosphamide. 993 environmental factors in. 235 DTI. 668–671 Dietitians. 69–70 global aphasia and. 78. 355. 76–77 recovery and. See Do-not-resuscitate orders Deafness. 87 971–972 diversity of. 886t computer-based treatment and. 618–620 multicomponent treatment programs for. 862 caregiver training and.. 550. See Everyday communication partner generalization and. 859 Decontextualized cognitive retraining. 93 Endarterectomy. Frontal systems. 322f. 334–335 integration and. 55. assessment and. 975 Functional cues. 977–979 1009. 129. 717–718 Deterioration Scale . 335–336 971–972 Functional magnetic resonance imaging lighting and. 975–976 Electrolarynx. 379–382 Functional-to-positional level. 54. 119–121. 868 (ESOPE). 921 Functional Communication Measure. 886t Environmental partner. 322 External validity. 894–903. 532. 336 apraxia of speech therapy with. 328–329 macrostructure. 781 FMT. 907t–908t assessment of. 913f quality of life and. AAC and. 1012. 115. participation measures and. 991 in-treatment. 636. 998 Feedback loops. 339–340 Family. 335–336 stimulation and. 50 Electronic scheduling devices. 119t improvement of. context and. 321–322 assessing. 830–831 166. 969–975 Functional Drawing Training. 513 Frontotemporal lobar degeneration (FTLD). 431–432 Efficacy research. 833 643–646 staff inservice and. 332 Evolution. 327–328 structured event complexes and. 757 Environmental intervention. 342–343 generalization and. societal awareness and. 47 Ethnographic interviews. 538. 340 Functional-level impairments. 339–340 emotional content and. 578 Skills for Adults. 354 defining. See Electropalatography computerized treatment and. 577. 325–326 Extralinguistic deficits 123. 912. 572t Functional Assessment of Communicative communication-promoting. 974–975 Functional outcome. 926 Frenchay Dysarthria Assessment. 55t. Global Episodic memory. See Functional Communication Profile (GOAT). 80. 911t. 1013. 521t Environmental press. See Functional Assessment Staging Scale Galveston Orientation and Amnesia Test wellness programs and. 586 aphasia family groups and. 972–973. 1022 535 EPG. 976 Functional Linguistic Communication environmental factors and. 555 Evaluation systémique des objectifs prioritaires Flat affect. 614. 892–893. 335 discourse and. 129–130 281 Explicit memory. 338 912. 164 Errorless learning. 80 cultural. 996 furniture arrangement and. teaching and. 639–640 self-help groups and. 300 Extension studies. 1002 safety issues and. 175. 340 selection and. 326–327 Executive-function abilities. 330t–332t Evidential bias. 915 Functional Auditory Comprehension Task. 364. 81. 321. Environmental props. 114. See Serotonin Electroencephalography (EEG). 472 production of. 80 physical. 579. 570–572. 891–892 Functional communication importance of. treatment of. See also Amitriptyline Ethics. 367f Fluoxitine. 55t Electropalatography (EPG). 172. Inventory. 968. 120. 975–977 Functional Independence Measure (FIM). 575. 490–491 Form words. 187–188 Electromagnetic articulography (EMA). global aphasia and. 50–51. 891. 109 Language-Oriented Treatment and. See Functional maintenance therapy EMA. 726 Thematic Language Stimulation and. 171 Error patterns. 639–640 skills improvement in. 333–334 counseling and support groups for. 1027 en réadaptation (Systemic Evaluation Fluent aphasias. 322–323. 831 impairment of. 1022 of Priority Goals in Rehabilitation) Fluorodeoxyglucose (FDG). 1016 respite and. 970–971 Functional maintenance therapy (FMT). props in. 967. See Electroencephalography Error analysis. 164 Functional Communication Profile (FCP). 909–910. 88. social. 116t stroke education and. 973–974 Functional Life Scale. 976 Functional representation. 14–15. 80 Emotional support. 340 FCP. 551. 319 self-efficacy skills and. 178 self-actualization skills and. 341–342 Facial expression deficits. 556 aphasia-friendly. 781 Electrical cortical stimulation (ECS). See Fluorodeoxyglucose Games. 989 120. See Geriatric Depression Scale. 552. 364–366 External memory aids. 296 5-HT. 1015. 100 Functional Assessment Staging Scale (FAST). 329 alternative meanings and. 194. 340–341 Melodic Intonation Therapy and. 121t Frontolimbic damage. 995 GABA. 46 Everyday communication partner (ECP). 910. 337–338 Family Interaction Analysis. 892t. 232–233 FIM. 830–831 Evidence-based practice (EBP). 53–54 Ethnocentrism. 341–342 Functional rehabilitation. handicap and. 539–540 Entorhinal cortex. Frenchay Activities Index. 76 Functional Assessment Measure. 338–339 FAS Verbal Fluency Test. 364f Feedback Gamma-aminobutyric-acid (GABA). 46. 902. 80 applications of. 614t stimulation approach and. 96. philosophy of. 111 transient ischemic attacks and. See Frontotemporal lobar degeneration communication. 886t communication-impaired. 51 Everyday Communicative Needs Assessment. 329. 901 global aphasia and. 550 Functional Assessment of Verbal Reasoning and defining. 548. 899 Environment. 521. 44. 801 Elavil. 7–8. 910t 995 ICF and. 362–364 informative content production and. 123 concerns in. 336 prosodic processing and. 96. 896. 1022–1023 Evaluative thinking. 970–971 (fMRI). 904 external. 992 in structure of intellect model. 366 rehabilitation of. 912. See Functional Independence Measure Electrocardiogram. 319 FTLD. 757. 851 Furniture arrangement. 368t–369t. 410 acoustic treatment in. 760 Effect size. 580 Life Participation Approach to Aphasia and. 323. 914–915 baseline. dysfunction of. 296 Everyday Language Test. 571. 362–364 scripts for. 10 functional rehabilitation approaches to. 858 GDS. See Gamma-aminobutyric-acid visual cues in.GRBQ344-sub[1073-1092]. 969–970 573–574. 922. 339. 362–363 ADHD and. 251. 221 Figurative language. 366. 102–103 Embolism. 369 evaluation of. 726–728. 914 Executive Strategies. 1080 Subject Index EEG. 47. 334–335 FAST. 258. 334–336 Examining for Aphasia–Third Edition. 213. 579. 578 IFC and.qxd 2/8/08 7:27AM Page 1080 Aptara Inc. 453–454 internal. 336 treatment of. 333t facial expression deficits and. 174 452–454 partners in. 21. See Electromagnetic articulography cognitive therapy and. 364–366 FDG. 603. 190–192. 379–382 Home health settings. 216 gesture and. Goal Attainment Scaling. 366 Health Environmental Factors Model.GRBQ344-sub[1073-1092]. 708. 782–786 HMPAO. See Individuals with Disabilities informal tests and. 353–354 Generality. 572–573 Impairments. 769 (HMPAO). 775 Heart disease. See High-overall-prediction method training for. 507–508 Stimulation (HELPSS). Traumatic comprehension and. 828–830 Graphemic lexicon. 394–395 Hospitals age and. 575–576 personal factors in. 576. 302 Holistic treatment approach. 581–588 family support groups and. 572–573 traumatic brain injury and. 706–707 Hemiplegia. 724–725 777–779 neglect and. 206 Melodic Intonation Therapy and. 830 naming and. 51 untrained stimuli and. 648 Global Deterioration Scale (GDS). 783 HIPAA. 783 amine oxide 621 Gray Oral Reading Tests. 203–204 assessment and. 579–580 Halperidol (Haldol). 573 across tasks. See also Halperidol IDEA. 575 Handicap. 1009 Functioning. 280–281 communication and. 11 intervention promoting. 622 auxiliary verbs in. 179–180. 566 Haldol. 748 PDP model and. 578–579. 565. 966 demographics of. 471 cognition and. 771–772 Graphemic input lexicon. 666 damage to. 567–568 left posterior inferior frontal. family counseling and. Subject Index 1081 Gender lesion site and. 886t clinical accountability and. 885. 832–833 749f Hematoma. 576–577 superior temporal. 966 Grammatical expression. 101–102. 581–583. 11. 581t. 568–569 psychosocial groups for. 94 Grapheme-to-phoneme conversion. 49 Gerontology. 80. mechanisms of. 566–567. 724–726 Hebbian learning. Disabilities and Handicaps incidence of. 393–394 Graphemes. 66 Generalization. 30f. 376–377 How the Mind Works (Pinker).qxd 2/8/08 7:27AM Page 1081 Aptara Inc. 707 Heparin. 52. 55t. 565 tense-agreement forms and. 666 803–804 Gestural programs. 567–568. 575–578 Hamilton Rating Scale. 747–748 Heschl’s gyrus. 994 Idebenone. 709. See Helm Elicited Language PDP model and. 572t Gyri. 740–741. 706–707 Hemiparesis. 1026 Graphic expression. 8. 833 class of. 767 Alzheimer’s disease and. 655. 354 primary progressive aphasia and. 259. language intervention in. 578. 578t motor-speech disorders and. 569 future trends in. 26. 171. 727 lack of. 379–382 205 affect and. 166 Alzheimer’s disease and. 588 Penetrating head injury. 300 Health Insurance Portability and constraint induced therapy and. 377–379 Huntington’s disease. 215 family and. 566 934 Hypertension. 206–207 Grapheme-to-sound conversion. aphasia and. 479 Accountability Act (HIPAA). 392–394 rehabilitation. 56. 46 semantic therapy and. 231 Hypothesis formation. 622–623 treatment of. 163. 847. 565. 573–574 life activities and roles and. 702. 657 HOAP. 353 salary/status and. 671–672. 423–425 Helm Elicited Language Program for Syntax lexical impairment and. 831 855–856. 672f. 844. 26 expression and. 52. 218 behavioral treatment targets and. complexity and. 701. 567 traumatic brain injury rehabilitation and. Gestural communication. 583–588 Set (OASIS). 654 Hippocampus. 723 articles in. 550 . 46 depression and. 220 prognosis for. 861 Goal-attainment scales. 583–584 impairment of. 664t 99mTc Hexamethylpropylene amine oxide Geriatric Depression Scale (GDS). 572 generalization planning and. 577–578 history of. 580 HCFA Outcomes and Assessment Information AAC and. 32f. 1016 ICIDH. 666 HMO. 744–745. 621–623 Wernicke’s aphasia and. 389. 476–477 treatment of. See Closed head injury. 990f content production with. 989 AAC and. 711t working memory and. 55t Education Act intervention and. 775 Health-maintenance organization (HMO). See also Glasgow Coma Scale (GCS). 550 neuroimaging of. 393–394 language intervention in. 82–84 evolution of. 569–570 Gus Multimedia Speech System. 707 HELPSS. 1024t Ideomotor apraxia. See 99mTc hexamethylpropylene substitutive word-retrieval treatment and. 81–82 etiology of. 710–712 Grammatical morphology. 578t. 93. 832–833 functional approaches to. Disability and Health goal revisions and. 833 rehabilitation strategies for. 570–572. See International Classification of hemiplegia and. 391–392 Model Global aphasia. 888 Alzheimer’s disease and. 995 brain injury computer-based treatment and. 840 environmental factors in. 21–24. 178 recovery from. 581t. 530 Generalization planning. 902 prepositions in. 710–712. 577 guiding principles of. 829–830 Group therapy. 726 Grammar. 989–990. Hyperarousal. 899. 999–1000 Complex Aphasia Rehabilitation Glasgow Outcome Scale. 587 Hypothesis testing. 706–707 global aphasia and. 746 social approaches to. 574–575 Hand tapping. 87 comprehension and. 187. 67–68. 569 Group treatment approaches. 24f. Program for Syntax Stimulation planning for. 10 language intervention and. 1024. 886t. See Health Insurance Portability and Gestural-verbal communication. 832. 647–648 pronouns in. 1013–1014 ICF. 31f. 568 multipurpose. 570–575 Handicap Creation Process. 45 of treatment effects. 771–772 treatment for. See Health-maintenance organization speech production enhancement with. 108 Graphemic output buffer. 67–68. 767 High-overall-prediction method (HOAP). 771–772 Graphemic buffer. 388–391 Human rights issues. 30–31. 707 Hemorrhagic stroke. 581t Head injury. 830 Graphemic output lexicon. 893. 644 stimulation approach and. 922 generalization of. See International Classification of formal tests and. Graphomotor access. 195 language and. 1001 impairment-based. 671–672 Accountability Act Gesture. 578t. 175 components of. 320f. 249 future trends for. 217–220 Imitation of contrasts. 783–785 societal participation and. 476 ICF framework and. 92 Intervention outcomes. 478. 771–772 Insula. 1023 Irreversible aphasia syndrome. 855 Immediate social milieu. 472. 252 patient-clinician relationship in. 404–405 Learning. 164. See also Treatment future trends is. 322–323. 9. 789f. 725–726 difficulty levels and. 100–105. 764–766 traumatic brain injury and. 772 295. 902 auditory perception and. 250 form of. 476–478 International Quality fo Life Assessment structure-of-intellect model and. 170 learning. 105–111. 757–761 memory and. 771–772 Institutional Review Board. 858. 758 Structure-of-Intellect Model and. 642 IP. 77. 10. 206 scaffolding and. 384–385 Dysgraphia Battery. 867 motor. 164. 104t. 120. 84. 900t. defining. 350–352. 477–478 Intersystemic reorganization/facilitation. 126. 760 Information exchange nondeclarative. 394–395 Interview Intonation. 215–220 Left posterior inferior frontal gyrus. 692 demographics of. Key-word technique. 786–790. 221–222 IFCI. 360–362 economics of. 230. 922 1026 constraint-induced. psycholinguistic approaches to. 831 nonpropositional. 781. 80–81 processing of. 578 IMP. 690 data recording and. 204 bilingual aphasia and. 102–105. 902 personal factors and. 104t. 163 functional links between. 6 Lateral premotor areas. 759–760 Interaction competence scale. 215. 523t defining. 265 gestural/gestural-verbal communication (IFCI). 350–352. 475–476 language feedback and. 781 oral reading and. 351f. 258–259 subcortical aphasia and. 790 Inpatient Functional Communication Interview choice of. 779–781 Inferotemporal cortex. 786 Infantilization and Oppositionality hypothesis. 880. 766–771 intervention and. 757–758 International Classification of Functioning. 726–728. 787t improving. 406 Language Master. 727 Interpreting strategies. 773 Individuals with Disabilities Education Act Judgement. 712 self-determined. 803 human experience and. propositional aspects of. 774–777 International Classification of Impairments. 886t 9–10. 1013–1014 . 14 philosophy of. 203–206 traumatic brain injury and. 781 and. 65f gestures and. 768 environment and. 855 use of. 774 Interlanguage. 513. 6 graphomotor access. See N-isopropyl-p-iodoamphetamine Ischemic strokes. 1082 Subject Index Ideomotor praxis. 82 word retrieval and. 479–480 oral spelling and. 48 language intervention in. 881 compensatory communication and. 79–80 neurophysiology of. 726–727. 363. 771 65–66. 927t attrition of. 230. Information processing. 480–483 errorless. 102 phonologic-articulatory production and. 105–106 visual comprehension. 885 naming and. 1015–1016 comprehension of. 196 Impairment dementia and. 102–103 speech acts and. 404 visual perception. 517–520 word sequence. Parallel 790f aphasia and. 376. 522. 922 Project. 787t.. 902.qxd 2/8/08 7:27AM Page 1082 Aptara Inc. 701. 120. 9 LaTrobe Communication Questionnaire. 113. 294 imaging of. 760 Initiation hypothesis. adaptation v. 865 content of. 763–764. 110t guiding principles of. 7–8 word orthography and. 656. 351f paraphrasic. 892 Intervention content of. 538 Language-Oriented Treatment (LOT). 998 Interpreters. 816 distributed processing model of evolution of. 414. See Inpatient Functional Communication outcomes generalization planning and. 351. Speech and Hearing centers. 327–328 influential variables in. 64–65. mechanism of. 530. 101. 7. 360. 522 cognition and. See also Evaluative thinking branching and. 764–766 Indirect language treatment groups. 760 Inflection phrase (IP). 100–102. 772–782 Interdisciplinary teams. 992 Language. 678–686 automatic speech and. 759–760. Melodic Intonation Therapy and. 899. 765f Information load. 478–483 oral expression and. 254 verbal. 774 Internal consistency. 969. 736 managerial units of. 758–759 Inference. 773 Internal validity. 760 brain and. aging and. 970–971 concrete. 51 Language Modalities Test for Aphasia. 756 Implicit memory. 692 rationale for. 761–763 927t Knowledge content and. 689–691 criterion response and. 760–761 task. 534 brain structures and. 837 visual processing and. 44–45. 77 Language intervention problem solving and. 768 activity and. 782–786 Integration deficits.GRBQ344-sub[1073-1092]. 760 (IDEA). 32–33 auditory comprehension and. 1022 computers in. 351f delivery contexts for. 837 legislative issues affecting. 1012–1013 Disabilities and Handicaps (ICIDH). 773–774 Disability and Health (ICF). 788t. 416 efficacy study of. 197 graphic expression and. 690–691 conversation/discourse and. 66f. 839 Hebbian. 970 brain damage and. 764 Implied meaning. 426 Johns Hopkins University Dyslexia and auditory processing and. 648 verbal fluency and. 715 Interprofessional Perception Scale. 106–108. 1023 Interrater reliability. 839 social signals and. morphology of. 231 figurative. 352 Scheull’s model of. 214–215 Imagery and gesture therapy. See also Bilingualism. 761 Intelligent CAI (ICAI). 478–479 methodology of. 105–106 mechanisms of. 404–405 repetition and. 471 connected. 887 Language performance. 114. studies of. 233 Language Activities of Daily Living. 478f apprenticeship model of. 708. See Inflection phrase managed care and. 4. 922. 690 PDP model and. 474–476 Language. 783 Intelligence. 919 cueing and. 757–758 Internal environment. 989 Isolated speech areas. 325–326 Ischemic penumbra. 922. 786–787. 843 1002 origins of. 843–848. 299t Medical chart. 111 . 531f cognitive intervention and. 1009 procedural. 618–621 resonance imaging PDP model and. 856 cognitive therapy and. 691–692 Massed practice. See Magnetoencephalography Midbrain. 522. 280t cueing in. 709 model of. 1012 and. 218 Life Satisfaction Questionnaire. 638–639. 55. 95–96. See Language-Oriented Treatment assessing. 709 Measure of Cognitive-Linguistic Abilities. 204 Alzheimer’s disease and. 607–612. 851 Minnesota Test for Differential Diagnosis of Life-H scale. 569. 357 family and. 922. 596–597. 578 Limbic system. 991 treatment and. 377 MEG. 539 498t. 847t. 716 MEND. 638–639 Lexical-semantic impairment. 376. 617–621 consequences of. 279 candidacy for. thalamic aphasia and. 550 Diagnosis-related group system. 851 production of. 609–610 Maintenance groups. 902. treatment of. focus of. 536 MAST. 844. 660–661 Mapping Therapy. 218 Methylphenidate (Ritalin). 998–999 recovery and. 921 comprehension impairments and. 843–844 Morphology. 9. 196 Memory. 365f Metaphor. 902 phonologic recognition and. 46. 614t 34. 55t. 969–970 impairment of. 234 Meyers-Briggs Inventory. 991. See also impaired. 71–72. 663–665. 851 grammatical. See Melodic Intonation Therapy insula and. 894 stage-specific analysis and. 191. 713 Message exchange task. 611–612 Lotus Notes. 231 PPAOS and. 708–710 orthographics mechanisms and. 857 Knowledge strengthening. 206 Medical social workers. 989 naming impairments and. 214. 709–710 Lexical agraphia. 893. 614t explicit. 902. 641–642 strategies for. 614. 661–663. 865. 848. 663–666 Managerial knowledge units. 614–616 accreditation of. 499–502 Melodic Intonation Therapy (MIT). See also Frontolimbic objectives of. Prehospital Checklist (MEND). 840–842. See Managed-care organizations Message representation. rehabilitation MDS. 919 working. 531f. 894. traumatic brain injury rehabilitation disrupted. 79. See Surface agraphia LOT. 359f. 865 (LPAA). 608f imaging. 453 disability models and. 496–497. 724–725. 611–612 Magnetoencephalography (MEG). Lexical-semantic memory. 389 linguistic content and. See also Diffusion tensor lexical-semantic. 848t. 424 Linguistic visuoperceptual clarity. 1015 principles of. 664t Long-term care centers. 763–764. 545. 646––647 Mental deficits. 894. 22. 989 Lexical phonologic recognition. 33. 497t. 357–358. 536 Lexical stimuli. 708–710.GRBQ344-sub[1073-1092]. 4 PDP model and. Subject Index 1083 Letter-to-sound conversion. 993 Loose training approaches. 778 therapies concurrent with. 838–839 MMSE. 522t thalamic aphasia and. 989 error patterns and. 661f Listening drills. 557 MCO. See Linguistic-Specific Approach episodic. 219–220 in structure of intellect model. 762. 360 Medial premotor areas. 551.qxd 2/8/08 7:27AM Page 1083 Aptara Inc. 416–417 Treatment (L-SAIT). 612–614. See Mini-Mental State Examination Lindamood Phoneme Sequencing Program. 842 256–257. 1024t Life expectancy. 991 pure alexia and. Lifelink. 427. 535–536. 596f LST. 657–660 MAP kinase. 264. 991 assessment and. 216–220 retrieval of. information processing and. 988–989 Lexical processing. 838. See Life Participation Approach to declarative. 555 Medicare. 84. 997–998 visual recognition and. 353 (MQE). 214–215. 613t. 420–421 Message-to-functional level. 990t. 997–999 Parkinson’s disease and. 499 phonologic output and. 745. 355–358. repetition and. 1024–1025. 995. 843 MOR. 488–491 tasks involving. 715. See also Miami Emergency Neurologic Deficit primary progressive aphasia and. 530. 904 642–643 Life activities Measure of the Quality of the Environment Metalinguistic dialogue. 214–215. 71 Life Participation Approach to Aphasia Prospective-payment system Microworld Project. 842f arousal impairment and. 102–103 LingraphiCARE America. 837–838 Mississippi Aphasia Screening Test (MAST). core values of. 885 Message redundancy. 621 1013. See Minimum Data Set Message-level impairment. 394–395 aphasia and. 921–922 Lewy bodies. 615 Aphasia dementia and. 655 Managed-care organizations (MCO). 508t. language intervention aids for. 843t MIT. 616–617 Managed care. 411 845t. 555. 364. 280–281 examination for. 500–501. 510 Metronomic pacing. 353 Medicaid. See Multiple oral reading 721 session scoring for. 636. 603 POSSE strategy for. 747–748. Functional magnetic nondeclarative. 704 Lingraphica. 726 clinical applications of. 777–778 Deficit Prehospital Checklist Lexical-semantic access Mapping-deficit hypothesis. 360 hand tapping and. 217–219 spared. 471–472 Lexical semantic route. 281–282 384. 536. 847 Aphasia (MTDDA). See Mississippi Aphasia Screening Test Message length. 655 Linguistic-specific treatment. 615–616 LPAA. 569 inventory of. Midbrain reticular formation (MRF). 586–587 techniques in. 749f Linguistic-Specific Approach (LST). 612–616 Macrostructure deficits. 70 damage phonologic patterns for. implicit. 844 Morphologic agrammatism. 708–710. 718–721 Meaningfulness. 87. Melodic intonation. 934–936 handicap and. 212. 849t–850t. 992 in. 715. 218 semantic. 475–476 gesture and. 838 Minimum Data Set (MDS). 97–98 Lexical phonologic output. 369. 838. 387 recognition. 921 Lexical treatment. 839–840 Mini-Mental State Examination (MMSE). 740–741. 608–609 positive impacts of. comprehension and. 47–49. 617–618 Magnetic resonance imaging (MRI). 232. 483. 620–621 Magnetic resonance perfusion. 726–727. 21. 218. 868 therapeutic hierarchy of. See Miami Emergency Neurologic surface alexia and. 10. 989. 391. 566. 416–417 Lexical-Semantic Activation Inhibition Mayo-Portland Adaptability Inventory. 612–613 216–219 traumatic brain injury and. 772 532–533 defining. 659t. 746 aphasia and. 69–70 1013–1014 NeueWEGE. 665. 1024–1025 repetition. 820 Nouns. 965 Nucleus basalis of Meynert. 190–191 Multiple oral reading. 802–803 Neurologic diseases. 778 acoustic-articulatory motor pathway in. 106 Normal comparison data. 691–692 attention and. 71 post-rehabilitation. See National Outcomes Measurement Orthography-to-phonology conversion (OPC). 700–701 . pathways for. 773–774 Multilingual Aphasia Examination. 700. 46 571. traumatic brain injury basal ganglia and. See Orthographic output lexicon MS. 234 rehabilitation and. 83f Noncanonical sentence computation. 388–391 N-isopropyl-p-iodoamphetamine (IMP). 230 Noise Orthographic output lexicon (OOL). 964–965 Object and Action Naming Battery. 543 773 Multidisciplinary teams. 744t Language Processing in Aphasia National Outcomes Measurement System Northwestern Assessment of Verbs and Pamelor. 74. System 767 Naming. 643–644. 665. 240 Alzheimer’s disease and. See Promoting Aphasic grammatical class and. 774 Multimedia Microworld. 991 brain emulation by. 964 OASIS. 609 MTDDA. PALPA. 197. Communicative Effectiveness impairments of. 727 743. 1023 self-cueing and. Mutism. 174–175 Pacing board. 728 OIL. 510–511 left posterior inferior frontal gyrus and. 990 direct. 767 Multi-skilling. 990f OOL. 409–411 Outcomes research. 583–587 PACE therapy. 70 parietal lobe and. 422 Non-speech communication aids. See Noun phrases articulatory domain in. 819 Neuroplasticity. 705 Occupational therapy (OT). 429 Orthographic word-retrieval treatments. 321 Sentences. 618–621 evaluating. 774–777 255–256. 578 Aphasia Multipurpose therapy groups. 106 Northwestern Assessment of Verb Inflection. 307 NP-movement. 690 Outcomes and Assessment Information Set. See also Nortriptyline (NOMS). 991 Nondeclarative knowledge. 76 management of. 837 deficits of. 187–188. 1009–1016 attractors in. 700 Occipital lobe. 966 Information Set Motor neuron disease. 838f Outcome-oriented rehabilitation. 774 665 Examination for Aphasia. 1016 thalamus and. 772–782 Diagnosis of Aphasia Neurogenesis. Neurologic incidents. See Occupational therapy accuracy in. 1020 ambient. 989 HCFA Outcomes and Assessment automatic-closure. 13. 56 control of. 743t. Multidimensional scoring. See Minnesota Test for Differential Neurofibrillary tangles. 735 Information Set category. 964 Object-Action Naming Test. 885 Optic aphasia. 762 Neurology. 191–192 Oral reading treatments. 241 Nortriptyline (Pamelor). 56 725 recognition. 696–698 Negative symptom complex. See Psycholinguistic Assessments of therapies for. 52–57 Oral Reading for Language in Aphasia Multimodal Communication Screening Task Neurophysiological studies (ORLA). 782. 165t repetition and. 964–966 NR. 55t language (PDP model). Neurosensory Center Comprehensive Oral spelling. See Reticular nucleus auditory domain in. assigning. 692 Neglect. 173. 990. 230 Neurologic impairment. 721 defining features of. 696–698 Norephinephrine (NE). See HCFA Outcomes and Assessment Motor learning. 52 NPs. See Magnetic resonance imaging Neuritic plaques. 990.qxd 2/8/08 7:27AM Page 1084 Aptara Inc. 39f. 689 automatic speech and. 235–236 MRF. 740f. See Primary motor cortex generalization and. 965–966 Nursing facilities. language intervention in. 701 structured. 1014–1015 auto-associator networks in. 856. 106 Nondeclarative memory. See Midbrain reticular formation reorganization of. 106 Nonpropositional language. 861 Neurogenic disorders. See automatic serial. 744f Parallel distributed processing model of National support groups. 742f. Multi-Speech. See Multiple sclerosis Neurobehavioral Functioning Inventory. 335 784 Muscimol. 578 Motor-speech disorders. 1017–1029 Neural networks. 665 for Persons with Aphasia. 578. 85 Oral reading. 735. 49 Orthographic input lexicon (OIL). 775 Nontraditional treatment approaches. 8. Needs profile. 1012–1013 703 Occipital cortex. 535 buildup of. 68–69 neuroanatomy of. 32 superior temporal gyrus and. 3–4 word retrieval and. 69–70 premotor areas and. 689–691 reported. 738–740 OT. 1017 treatment of. 719. 335 620–621 Myocardial infarction. 966 Motor impairment. akinetic. ORLA. 742. 1010–1011 emergent behavior of. 55. 106 Nonfluent aphasias.GRBQ344-sub[1073-1092]. 552 symptoms of. See also Aphasia phonologic-articulatory production and. Neocortex. 640 694–695 Negative rhetoric. 966 Observation insula and. 654. 101 assessment and. 659t. 105 Nonlinguistic visuoperceptual clarity. 657–659. 739–740. 690 primary motor cortex and. 773 MultiCue. 55t. 536. 578 Neurological deficit. 73. 1016 pattern associator. 37–38. See also Brain plasticity for Language in Aphasia Multiple oral reading (MOR). 823. 52. 865 nonstandard. 52. 1015–1016 Nelson Reading Skills Test. restorative. 179–180 Paced Auditory Serial Addition Test (PASAT). 44 NOMS. See Norephinephrine Noun phrases (NPs). Oral Reading for Persons with Aphasia. 964 Nurses. 204 Motor cortex. 990f Oral expression. unstructured. 934–936 evaluation of. 691f NE. 1084 Subject Index Motivation. See also Multi-Modal Communication Screening Task recovery-phase. 164 confrontation. 419 Non-contextual photographs. See Orthographic input lexicon MRI. 123. 197. 4 lesion sites in. See Oral Reading for Language in Multiple sclerosis (MS). 692–693. 197. 73. 657–659. 666. 57. stimulation approach and. 699t Phonetic derivation. 805f concepts representations in. 1022. 696–698. 654 Premotor areas. 251. 115 reading model of. 550 Pattern associator networks. 885 Point-to tasks. 115–117 sentence organization and. 476 task shifting and. 804–805. 87. 550–551 PDP model.qxd 2/8/08 7:27AM Page 1085 Aptara Inc. 85. 654 Preferred provider organization (PPO). 52. 519 757. clinical presentation of. 665 Predicate-argument structures (PAS). 810 concept manipulation and. 303–304. 55. 550 Penetrating head injury. 583–584 goal-attainment scales for. 697f Phonologic output Prazosin. 691–692 Prefrontal cortex. 299–300 Phonological reading route. 618–620 dementia and. 522. 456. 544–546 information processing and. 410 treatment plan design and. heuristic value of. 433–434 age and. 80–81 619–620 417–420 increasing. 719–721. 300 Phonologic treatment. 72–73. 410. 80–81 Phrase structure building. See Phoneme-to-grapheme conversion POSSE strategy. 694f Phonologic agraphia. 518 treatment task selection and. 55. 721f medial. 782. 708–710 Phenobarbitol. 692 Phonologic buffer. Prestimulation. 551–553 auditory. 698–701 Phonetic placement. 512t–513t Phonologic loop. 811 histologic pathology of. 666. 304–305 Phonological buffer. 697. 113–121 rehabilitation strategies and. 865. 187. 234–235 Post-stroke depression (PSD). 415. classification of. 298–299 Phonologic recognition. See Prospective-payment system phrase structure rules and. 499 lexicons and. 298 Phonologic processing. 637 generalization and. 783 discourse skills. 655 communicative intent. See Personal Communication Assistant Porch Index of Communicative Ability (PICA). 655 Presynaptic marker proteins. 697f Personal Communication Assistant for Positional level. 216 dementia and. 219 social intervention and. 696 lateral. 811 demographics of. 667–668 Pragmatics. production of. 235–236 Primary motor cortex. 695–696 Pharmacists. 820–821 (Ewing & Pfalzgraf). 702–704 Phonologic cueing hierarchy. 993 Phonologic paraphasic errors. 718–721 speech acts. 7–8 Phonologic input lexicon. 692–693. 810–811 management of. 456. 784 PPO. 549–550 PCAD. 705 Pons. See Predicate-argument structures Ability plasticity of. 691. 1010f 779–780 PICA. 738 Primary auditory cortex. 21. 768 treatment format and. 618t. 365 Positron emission tomography (PET). 655 Preventive care. 546 Patient Competency Rating Scale. 1016 Partner training. 551 Perceptual cues. Phoneme occurrences. 55t Parietal lobe. 1009 knowledge in. 585. 37. 990t lexicon of. 640–641 grammar and. 81. 881. 10. 1011–1013 environment and. 1022. 722t Preparatory training. 55 character of. 118–119. 724t Phonologic alexia. 1012–1013 Participation. 803–809 PPAOS and. 803–804 diagnostic criteria for. 691–692 cueing hierarchy for. 546–547 Per diem arrangements. 123. 556–559 visual. 721. 552. 87. 548. 867 defining. See Parkinson’s disease 386. 662f communication and. 611–612. 1023 Pragmatic Protocol. 428. 164 properties of. 56. 603. 805–807. 993 Phonologic output lexicon. 215 patient-clinician team and. 764 stimulus selection and. 861. 545t Perception response reinforcement and. 989 Lewy bodies and. 723–724. See Porch Index of Communicative neuroanatomy of. 601. 695 structure-of-intellect model and. 687 PPAOS. 385. 73t. 1009–1011 PAS. See Primary progressive apraxia of 722t Phoneme-to-grapheme conversion (PGC). 555 Primary physicians. 800. 306. 23. 992–993 PDP model and. 565. 609–610 neuroanatomy of. Pathways: Moving Beyond Stroke and Aphasia Piracetam. 990 measures of. 115–117 Paraphrasias. ICF and. 838 rationale for. 661–663. 107t Primary progressive aphasia (PPA). 615–616 Predictability. 989 training for. 1023 Practice effect. 55t 975–976 naming therapy and. 554–555 . 195 societal. 190. 550 PDD. 669t PPS. 692 PGC. 968. 37. 882f patient selection and. See Paced Auditory Serial Addition Pick’s disease. 545t. 113–121 semantic/conceptual domain in. 817. 543–544 model of language future trends of. 426 Parkinson’s disease (PD).GRBQ344-sub[1073-1092]. 702. See Progressive nonfluent aphasia activities of daily living and. 480–481 Para-standardized testing. 668–671 assessment of. 71. 1014–1015 lexical. 20. 923–924 Parietal cortex. 762 impairment of. 636. 719 Phenytoin (Dilantin). 694–695. 995 syntax and. 696 Practical significance. 809–810 epidemiology of. 705–706 Phonemic cues. 691–692. 123 49–50. 48. See Primary progressive aphasia phonologic sequence therapy and. 106–107. 724–725 Phonologic impairment. 806t historical perspective of. 1011 PASAT. 701 Perisylvanian region. 508t. Physical therapy (PT). 702–706 Phonologic dysgraphia. 863. 548–549 PD. grammatical morphology and. 662f. 702–708 Personal identity. 300 Phonologic sequence therapy. 710–712 Dysphasic People (PCAD). 719–721. 113 Pribedil. 54. 706–707 Personal Wellness Inventory. 8–9. 718–728 treating. 55t PPA. 430. 511. 1010 impairment of. 620. 775. 1012 activities and. See Parkinson’s disease with dementia 574. Subject Index 1085 chaotic order and. 195 89. 298–300 Phonology. 545. 382 PNFA. deficits accompanying. 1009 Parkinson’s disease with dementia (PDD). 565. See Preferred provider organization cessing and. 725 Perseveration. cognition and. 551. 701 Personalized cueing. 643 motor-speech disorders and. speech phonologic/semantic/lexical-semantic pro. 703–704. 802. 117–118 working memory and. 119t semantic therapy and. 697f treatment priorities and. 406. 94. 578. 429. 547–548 for Dysphasic People 56. See Parallel distributed processing 855. 807–809 neuroimaging of. 757. 233–234 Test Picture description tasks. memory and. 588. 702. 887–888. (PPAOS). 565. 306 semantic system and. 124 functional communication and. 52–57. 414. 867 neuroimaging of. 231 Psychosocial rehabilitation. 49 Random practice. 554–555 evaluation of. assessing. stroke and. 556 PSD. 570. 694 diagnostic criteria for. 291–292. 902 importance of. 748–750. 358f. 539–540 Promoting Aphasic Communicative Rating Scale of Attentional Behavior. Psycholinguistic approaches to language. 659t. bilingual aphasia and. 694–695. 189–190 biographical variables for. 240–241 PROMPT. 474 83f. 100 749f assessment goals and. 192 global aphasia and. 648 Progressive dementia. 572–575 Quality of life (QOL). 215. 616–617 age and. 903t Prompts for Restructuring Oral and Muscular compensation in. 655f. 975–976 personality/social variables for. 188–189. 37 Rancho Los Amigos Levels of Cognitive Recurrent connections. 9 578 554–555 Psycholinguistic Assessments of Language Real-life behavior assessment. 567 neural mechanisms of. 978–979 dyslexia and. 619 Processing in Aphasia (PALPA). 192–193 global aphasia and. 9. 619 historical perspective on. 1025 Reading. 578. 359f. 125–126 855 time course of. 189–190 Prognosis formulation Putamen. 901 Prompts rCBF. 296 phonologic routes and. 545 Rate control. 188 Progressive nonfluent aphasia (PNFA). 556–559 PSSCogReHab. stimulation approach and. 556 194 Rehabilitation Progressive supranuclear palsy. 554 Prosthetic communities. 121–123. 698 handedness and. 186–187 psychosocial factors in. 377–379 Recognition/understanding. 587–588. 553 Prosody patterns. 898–899. Receptive vocabulary. 555–556 Psychiatric disorders. 923–926 assessment of. 608–610 spelling as. 1086 Subject Index Primary progressive apraxia of speech Prosodic processing deficits. 923–926 collaboration in. 319 Propositional language. 531f lexical processing and. 1023 Regenerative sprouting. 923 aphasia severity and. 95 aphasia and. 846 PDP model and. 818 context-sensitive. 915 1022–1023. 862–863. 218 personal factors in. 356–358. 377–379. 103. 855 Radiopharmaceuticals. 237–239. 897t. 570–575 the Adult Aphasic. 860 Qualitative research approach. 555 production and. Randomized controlled clinical trial (RCT). 122 settings of. See also Computed 936–937. 237t limitations to. 192–193 Quality assurance. 907t–908t. 300 priorities in. 689 898–899 surface. 906 Process-oriented activities. 193 assessment and. 49 552. 841f. 654–656. 1024–1026. 100–101 Problem solving. 455. 768–770. 543 comprehension and. 907t–908t. 866 of concept manipulation. 121–123. 94–95 cognitive neuroscience and. 724–726 . contextual. 78. 169 rehabilitation for. 896–903. See Prompts for Restructuring Oral 568. 218 representations and. 1027–1028 654–656 functional. 977–979 computer-based treatment and. 936–937 Professional integrity. 455. 89–90 Reading Comprehension Battery for Aphasia. 125 Pyramids and Palm Trees test. See Randomized controlled clinical trial developmental cognitive psychology and. 548. 232–233 894–903. 520. 977–978 867–868 classification of. 998–999 Problem-focused treatment. 530.GRBQ344-sub[1073-1092]. 178 Priming. stimulability and. 708–710. 34. 915 Effectiveness (PACE). 978 impairments of. 588 learning and. 308. 385–386. 582 RCT. Rating scales. See Regional cerebral blood flow culture and. 115 Pure alexia. 665. 508 tomography Recovery-compensation continuum. 37 Functioning. 99f cognition and. 193 traumatic brain injury and. 121. 715 Psychosocial group therapy. 898t. 190–191 computerized treatment and. 48. 666 Reciprocal scaffolding. 886t. 129–130 spontaneous. 658f histologic pathology of. 235 Progressive aphasia. 979 oral. 326–327 conversational. goals on. 187. 700–701 Progressive degenerative diseases. 187–188 gender and. 656–660 lesion site/size and. 258–260 Professional ethnocentrism. 49 Recreation therapy. 436. 477–478 Psychologists. 656–657. 894–903. 212. 188 Procedural reliability. 76–77 Recognition memory. 555 treatment for. 975–976 Profile of the Communication Environment of PT. community and. 87. 389 Programmed Assistance to Learning. 417–420 Reactive plasticity. 52. 197. 55t 867–868 grammar and. 190. Regional cerebral blood flow (rCBF). 658f executive-function abilities. 575–576 family-reported. See also Alexia everyday routine-based. See Physical therapy global aphasia and.qxd 2/8/08 7:27AM Page 1086 Aptara Inc. 186. 122. See Post-stroke depression tasks for. 656–657 deficits accompanying. 769 neuropsychological variables for. comprehension mechanism for. 236–237. Phonetic Targets (PROMPT). 163. 555 Prospective-payment system (PPS). 774 defining. 8–9. 894–903. 868 Reading Comprehension Adults. 377 depression and. aphasia characteristics and. 235 Recognition level. 855. 830 Raven’s Colored Progressive Matrices (RCPM). 898t. 521 Psychosocial adjustment. 671 Psychometrics. mechanisms of. 901–902 391. 862–863. 237 Propranolol. 769–770 clinical presentation of. 219 Psychosocial support. 840–841. 125 Radiography. 894–903. 725 and Muscular Phonetic Targets Raven’s Progressive Matrices. 887 Reduced Syntax Therapy (REST). 994 treatment of. 362 Recognition naming. 938t–939t Wernicke’s aphasia and. 578. 769 management of. 264. See Quality of life neurophysiologic studies of. 899. 238t medical variables for. 123–126 neuroanatomical factors in. 694f demographics of. 709–710 Psychosocial impairment Recovery traumatic brain injury and. 553–554 Pseudodementia. 1024t behavioral disorders and. 178 pattern of. 124–125 measures of. 106 Procedural memory. 123–124 QOL. 657–659. primary progressive aphasia and. 837 comprehension of. 52–57 Screening instruments. 914 clinical processes and. See Revised Interprofessional Attitude outcome-oriented. See Resource-utilization group traumatic brain injury and. 703 Rey Complex Figure Test. normal comparison data and. 233 Selective attention. 168 switching. 195 Ritalin. 900t. 430 Science Reminiscence therapy. 458f 934–936 treatment assessment. 521 Response Elaboration Training (RET). 970–971 Replication studies. 704. 843 Restorative neurology. 427–428 attention/perception disorders and. 924–926. 434 stimulation (SWDM). 636. 71t naming. 106 RET. 86 Self-help groups. 176–177 future directions in. 692–693. See Request-Response-Evaluation training model for. 966–967 Self-efficacy. 610 attention deficits and. 912. 422 . 176–177 prosodic processing and. 692–693. 721. 85–86. 193–195. 900t systematic reviews of. 240 RIPS. 703–704 depression and. 966–968 Self-esteem. 904 scaffolding and. 638–639 Rhythm control. 894–903. 899. 196 Role release. 339–340 translating between. 537 cognitive deficit and. 173. 434 Revised Interprofessional Attitude Scale Selection deficits. 196t 97. See Response Elaboration Training SCT. 693f. 241 extending. See Stroke Aphasia Depression Vygotskyan apprenticeship model for. 639–640 RHD. 164 neglect and. Self-initiated verbal tasks. 524 linguistic defects in. See Right hemisphere damage Self-coaching. 901–903. 163. 911t. 366–367 evaluating. 430 Scales of Cognitive Ability for Traumatic Brain defining. 174 SADQ. 173. 1029 clinicians’ use of. 163 patterns of. 341–342 distributed. 341–342 semantic. 925t. 167t 773–774 REST. 218 with Aphasia Reimbursement schemes. 258 Language-Oriented Treatment and. 165–166 Repetition. 362 stress. 966 positional level. 803t Injury. 197. 637–641 Rheumatic heart disease. 897t. 532–533 Segmental phonology. treatment evaluation. 436–437 SCA. See also Methylphenidate psychosocial/behavioral. 901–902 interdisciplinary collaboration and. Questionnaire 900t. 164 criterion. 896 data collection and. 218 efficacy. 195 RUG. 20 procedural. 578 Selective engagement. 431 learning and. 637 communication disorders and. 340 Scaffolded conversations. 899. 968 inpatient. 178 Ross Information Processing Assessment. 689 meta-analyses of. 697f Rhythmic cues. 174 964–968 neurophysiologic studies following. See Semantic cueing treatment oral expression and. 923–926 outcomes. 52 replicating. 636. 230 of semantic impairment. 723–724. cognitive intervention and. Subject Index 1087 group therapy and. 174 (RIPS). 215 Research and Human Rights Committee. 496–497 diagnostic process and. 637. 640–641 Right hemisphere damage (RHD). 614–615 963–964 Self-regulation word. 88. 903t. national support groups and. 922 196t SAQOL. 165–166 facial expression deficits and. 977–979 191–192 initiating. 196 test-retest. 979–980 Semantic complexity. 697f. 414–415 Reticular nucleus (NR). 967 Representations Revised Token Test. 418. 692–693. See Stroke and Aphasia Quality of Rehabilitation Act. 912. 98 Self-actualization. 46 Self-correction. 164–165. 668 message. 113 tasks. 899. 215–216 Respite programs. 838. 240 managed care and.qxd 2/8/08 7:27AM Page 1087 Aptara Inc. 86 environmental intervention and. 258 temporal relationship in. 904 stroke and. 165t Melodic Intonation Therapy and. 896 primary studies. 482–483 settings of. 694 arousal and. 693f. 169 stimulation approach and. 204 Resource-utilization group (RUG). 861 PDP model and. Thematic Language Stimulation. 773–774 Retelling. language intervention Resource allocation models. 164. 967–968 Self-advocacy. 968–979 Self-talk. 898t. 174 RRE. 976 Semantic awareness tests. 938t–939t functional. 811 Schizophrenia. 910. 588 bilingualism and. 55t. 707 concept. 219–220 Scale processes enabling. 308 thalamic aphasia and. 964–966 interprofessional strategies for. 895–899. See Reduced Syntax Therapy principles of. 175 Life Scale Rehabilitation centers. 1024–1026 Self-cueing. 922 Reliability. See Semantic dementia stimulus. 166 Language-Oriented Treatment and. 923–926. 195. 103. 291–292. 934 context-based treatment and. 1025 neglect and. 77 mode of. 302–303. 174–175 Rivermead Behavioral Memory Test (RBMT). 537. Ryff Psychological Well-Being scale. 175–176 sustained attention and. 85–86. 588 Life Participation Approach to Aphasia and. 760 reciprocal. See also Support systems 281 characteristics of. 803. 77 reinforcement of. 300 discourse deficits in. 891–892 Research emotional content and. 430–431 Schuell-Wepman-Darley Multimodal- research evaluation and. 926t impairments involving. 85t Self-determined learning. funding. 897t. 308–309. 457–459. 903 interrater. 355 898t. 914–915 aphasiologists and. 520–521. 909–910 Request-Response-Evaluation (RRE). 520. 937. 703 RH attentional networks. 975–976 defining. 377–379.GRBQ344-sub[1073-1092]. 636. 163–164 Role/code switching. 975–977 scripts for. Response(s) Scaffolding. 239–240 qualitative. See Supported Conversation for Adults in. 892 reading and. 70–71. 419. 166–172. 213–214 extralinguistic deficits in. 435 visual object tasks for. 760 rehabilitation and. 164. 967 neuropsychology and. 77. 193–195. 454 393–394. 435 SD. clinical decision making and. 724t process of. 483 consultation assistance for. 194 nonlinguistic deficits associated with. 969–975 impairment of. 411 Serotonin (5-HT). 724t medical approach v. 610 rationale for. 406. 197 physical factors and. 429–430 Sentence construction. 32–33. 842. 847 723–725. See Social skills training Semantically reversible sentences. 454 Social-validity assessments. 964 combined sensory modalities in. 436 Single photon emission computed tomography advocacy reports and. 635f. 704 Sound-to-letter conversion cues and. 411–412 Sentence Production Priming Test. 530. See Speech-language pathology sociolinguistic. 380–381 impairment of. 999 Social networks. 298–299 mechanisms of. 818 Speech acts. 417–420 Shortened PICA (SPICA). 385–387 sequence of. 899. 292 Standard error. 666–668 Semantic cues. 742 Social skills training (SST). 68. 742 strengthening. 578 overview of. 416–417 Sequencing deficits. 548. 421–423 Social model SST. 721. 610–611. 437 Sentence recognition. 300–310 Standardization. 411 Sentence formulation. 435 Conversation length/redundancy and. 470 interpreting strategies and. 80–81 Speech-language pathology (SLP). 120. 636–637 Somatosensory error map. 636–637. 236. 691–692 participation measurement in. 309 problem-solving approach to. 417–420 cueing and. See Supplementary motor area transition. 290 Analysis tasks involving. 668. 1026 Speech-language treatment groups reading/writing tasks in. 295 Spouse intervention groups. 186. 567–568 Sentence comprehension. 655f. 728 compatibility of. 777 Somatic marker theory. 670–671 discriminability in. 859 Sentence Processing Resource Pack. 769 dementia and. 642. 1088 Subject Index Semantic comprehension training. 636 1028–1029 context and. 414–415 (SPECT). 428 SF-36 Health Survey. 618–619. 648 overreliance on. 291–292 Sprechgesang. 428–429 Simulations. 425–427 concept modification and. 556 activities/participation and.. consequences/feedback and. Social Services Subsidy. 774 Semantic feature analysis (SFA). 634.GRBQ344-sub[1073-1092]. See Spaced-retrieval training reading and. integrating. 658f principles of. 333. 380 rate/pause and. 433–434 Sentence computation. 668 efficacy of. 44. 115–117. 56 phases of. 424. 565 lexical treatments for. 387 starting. 390 Speech rate. 919 linguistic visuoperceptual clarity in. 923–924. 1002 frequency and. 668–670 Semantic dementia (SD). 406. 241. 309. 632–634 with Aphasia in Relationships and grammar and. 430–431 Skill contexts. 387–388 response mode and. 187. 1026 prestimulation and. 927t client selection for. non-canonical. 74 gestures enhancing. 384–385 auditory perceptual clarity in. 382–384 repetition in. 409 Sentence hierarchy. 55 SPECT. 667–668 defining. 551. 419. parts of speech in. 407–408 Shewan Spontaneous Language Analysis Speech production. 433 normal. 647f Spacing effect. 566. 292–295 SSLA. 382 semantic word category and. 295 SPICA. 416 Spaced-retrieval training (SRT). See Semantic feature analysis Wernicke’s area philosophical underpinnings of. 24. See Shortened PICA Alzheimer’s disease and. 300–302 Splenium. 297t–298t oral. 859. 931 auditory ability tasks in. 369. 310 Spontaneous recovery. 432–433 SMA. 48. 930t tomography nonlinguistic visuoperceptual clarity in. 619 Social action. See Supporting Partners of People general principles of. 421 Sentence Comprehension Test. 431–432 Sentence production. 901. 771 abstractness and. See Single photon emission computed meaningfulness and. 924–926 SS-QOL. 634. 406 Singing. 654–656. See Shewan Spontaneous Language representations and. See also Broca’s area. 995 goals of. 483 assessment and. 483 enhancing communication in. 393 rationale of. 555 direct. 412–414 aphasic. 291 Spiroperidol. 55t tests of. 215 Stimulation approach. computerized. 188. 385 response considerations in. 618t. 665. 638 Somatosensory cortex. 547. 171 Semantic-feature matrix training. 846. 81–82. 407 Sentence processing Somatoparaphrenia. 420 impaired. 619 intervention within. 68. 715 maintenance. 103 Sound-Production Treatment (SPT). auditory comprehension and. 291 SPT. 246–248. 865 254. 69f Stereotypes. 666 Semantic evaluation tests. psychological factors and. 1015 computerized treatment and. 190. 991 elements of. Spectroscopy. 929t. 615 Social interaction scripts. 415 prompts and. 772 order of difficulty and. 419. 296. 335 Scale Semantic word category. 178 auditory delivery and. 309–310 impairments of. 928–930. 714–716 future trends in. 421–423 SFA. 430 Sklar Aphasia Scale. 423–425 Sentence/phrase completion. 776 Social approach to intervention. 432–433 . 420–421 Sentence structure. 415–416 Sinemet. 603 409–411 407. 295–300. 420–421 Setting events. 421–423 SLP. 4 Social network theory. 47 Sensory stimulation. 737–740 Socialization.qxd 2/8/08 7:27AM Page 1088 Aptara Inc. 552. 49–50. 996–997. 190. 428–429 (SSLA). 410 637f Social signals. 668 Social isolation. 633–634. 84f Spelling Semantic cueing treatment (SCT). 408 Sentence-level deficits. 671 Semantic memory effectiveness of. 172–173 indirect. 418. See Sound-Production Treatment PDP model and. 319. 416 Specific event complexes. See Stroke-Specific Quality of Life treatment of. Severity classification. 777–779 Sociolinguistic treatment groups. 519–520 caveats of. 83–84. 618–619 SOAP note. 337 auditory deficit and. 404. 430–431 Single-subject experimental designs. 77–78 Sensory deficits. 299–300 SRT. apraxia of speech and. 298f Stenosis. 855 Speech areas. 634 defining. 690 Semantic system future of. 384–385 response characteristics and. 417–420 Sickness Impact Profile. 434 SPARCC. 437–439 Sentence verification. 645–646. 455–456 (SS-QOL). 537 depression and. 865 Strategy and device trials. 509 . 530. 532–533 etiology of. 426 goal definition in. 358f Syntactic deficits. 885 Telehealth. 670–671 Thalamus. 230–231 verbal and auditory tasks in. 456 composite abilities in. 702. 744–747 formal testing and. See also Thalamic aphasia models of. 1024t Support systems Temporal lobe. 647 convergent thinking in. 472 Programmin Capacity. 20 896–897. 452–454 (SADQ). 12t. 233–236 Story Retelling test. 46 PDP model and. 552 structure of stimulation in. 258 chronic therapy for. 450 pragmatics and. 457 Stroke education. 325. 366–367 success criteria in. See Schuell-Wepman-Darley assessment for. 240 Communication Disorders in 735. 803 treatment delivery in. 820 Supervision Rating Scale. 473 leadership for. language intervention in. 94 Syntax future trends in. 1011–1012 Telemedicine. 862 neglect and. 45 Surface agraphia. 901 thalamic aphasia and. 52 SVO. 232 Stimulus properties. 975–976 Supported Conversation for Adults with lexical-semantic access and. 975–976 Sustained attention. 454 transient ischemic attacks and. 52–57. 48. 453 Stroke-like syndromes. 484 aphasia and. 973. 472 Task orientation. 451 (SAQOL). 660–661. 478f Team interventions. 427–428 information processing and. Subject Index 1089 stress and. 531f pharmaceuticals and recovery form. 121. 539–540 neurologic findings in. 569 Suprasegmental phonology. 471–472 group barriers in. 459 Stroke clubs.GRBQ344-sub[1073-1092]. 470f Systems analysis approach. 379–382 Test of Problem Solving. 918–919 intraparietal. 55. 196 functional communication and. 51–52 Syntactic constructions. 43–44 Suppression theory. 423–425 results of. 862 motor-speech disorders and. 35 recovery from. 475f Tauopathy. 779 memory and. 478. 232–233 Thematic Language Stimulation and. 338–339 Supporting Partners of People with Aphasia in Thalamic gating mechanism. 338–339 Multimodal-stimulation behavioral considerations in. 457–458. 534–535 global aphasia and. 704–705 metalinguistic dialogue and. 702–706 Organization and delivery for. 450 Structure-of-Intellect Model. 43. 457–459. 738 weak links in. 21. 233 Dementia Sulci.qxd 2/8/08 7:27AM Page 1089 Aptara Inc. 302–303 syntax and. 1025 tumors of. 671 behavioral disorders related to. 51–52 prosthetic communities for. 11 (SPPARC). 454–455 Stroke Aphasia Depression Questionnaire Syntactic stimulation. See also Carbamazepine Strategic behavior. 434–435 products of. 458f Structural context. 112t definition of. 45t Surface alexia. 409–421 language model in. 11 providing. 455–456 treatment of. 231–232 Stimulus-recognition processes. 306–307 concept representation and. 357 sentence organization and. 363. 10. 323. 306 Test-retest reliability. 608 nonthalamic. 23. 9. 539–540 team development for. 450–451 Stroke and Aphasia Quality of Life Scale 111–112. 96–97. 433 learning in. 55t. 52. 240 syntax and. 11. 427–428 cognitive/behavioral impairment and. 43 Surface dyslexia. 453–456 stages of. 306 Test-retest stability. 1010 ischemic. 42–43 Relationships and Conversation disorders of. 451–452 cognition in. 533–534 Sylvian fissure (SF). 11 Surface prompts. 21–24. 661f functioning of. 964 racial factors in. 531f epidemiology of. 992 treatment of. 471–472 evaluations and. 716–717 Subcortical aphasia. 538. 451–452 Stroke-Specific Quality of Life Scale phrase structure rules and. 975 purpose of. 647 divergent thinking in. treatment of. 456 therapies for. 43t SWDM. 1015 Tele-Communicology. 42 resources for. 967 Thematic content. 414–415 behavioral disorders related to. 10–12 partner training for. 44t. 54–56 Surface dysgraphia. 538f team members for. 802–803 visual perception and. 103–105. 22f. 514 evaluative thinking in. 533–534 hemorrhagic. 46–47 Aphasia (SCA). 457f Structured event complexes. 44–45. 324t–325t. 338–339 disorders of. 121. 536–537 environmental intervention and. 96–97. 471 internal consistency of tasks and. 430–431 mental operations in. 451–452 rehabilitation after. 530. 485 multidimensional scoring and. 305–307 Thalamic aphasia. See Subject-verb-object constructions Thematic Language Stimulation (TLS) risk factors for. 569 clinical performance on tasks and. 705–706 patient involvement in. 205–206 Stress. 94. 887. 800–802 thematic content in. 456 cognitive considerations in. 92 Therapeutic window. 530. 803–809 Thematic mapping content in. 179. 530–537 definition of. 45–46 Symptom awareness. 97. 77 cultural factors in. 178 operation of. 716 stimulation approach and. 1009 prevention of. 64. 535–537 ethnic factors in. 474–476. 456–457 cognitive stimulation approach and. 230 Stimulus repetition. 476 documentation and. 455–456 thalamic gating function and. 196–197 stimulation delivery in. 472 Tasks for Assessing Motor Speech Planning or Therapeutic set. 536 diagnosis of. 80. 536 diagnostic studies for. 897t 105 acute therapy for. 12. 661f. 423–425 memory in. 47–51 Supported conversations. 24f. 104t. 229. 51 family. 865 Stress patterning. 480–481 group communication for. Stroke. 23 Stress representation. concept of. 702–704 research with. 240 temporal relationship and. treatment and. 26 Tegretol. 113 Supplementary motor area (SMA). 915–916. 452 469. See Arizona Battery for Subject-verb-object constructions (SVO). 113 stroke and. 537–539. 588. 536–537 stimulation approach and. 530. 473–474 treatment plan design and. Test of Adolescent and Adult Word Finding. 387 complexity of. treatments and. 472–473 impairment of. (UUMN dysarthria). 490–491 memory aids for. 903t. 163–164 Transfer. Treatment methods. 994 behavioral impairment from. 737. 721. 884–885. 718–728 Variable practice. 894–895 functional categories TLS. 164. 46 884f TUF. 888. VAT. 164 861–862. 904t. 49 outcome prediction and. 868 bilingualism and.qxd 2/8/08 7:27AM Page 1090 Aptara Inc. 881. 233 self-advocacy and recovery from. 992. computerized treatment and. 756–757 treatment interactions and. 74 primary impact damage in. 197 Thrombolytic therapy. 888 204–205 TQI. 748 Verbal cueing. 103. 741f Thrombosis. 902–903 (TUFFUNCAT). 880–881 Treatment of underlying forms for Syntax Verbal association. 931 900t. 888. 96. 915–916. 264–265 Transactional success. 723–724. 472. 170 anomia and. 894. 968 phonologic impairment and. 717–718 research evaluation and. computerized. 646–649 VADS. 100 long-term communication-related outcome primary studies on. 647–648 VaD. 482–483 Token economies. 583–588 social. 892t word retrieval and. 712–716 Third-party payers. 885. 71. 571. 909 PDP model and. 883f. 840 Treatment interactions. interpreting. 934 overall language performance and. 55t UUMN dysarthria. 781 memory impairment from. 803–811 VASES. 170 Transition groups. 196 assessing. 748–749 Verb production. 1023 attention deficits and. 96 934–936 time distribution and. 164 traumatic brain injury and. 883f. 867 . 195 types of. 178 Traumatic brain injury (TBI). 902 (TUFSyntax). 196 convergent. 484 secondary damage in. 992 pathophysiology of. See Total quality management Treatment effectiveness. See Transcortical sensory aphasia transient ischemic attacks and. 895–899. 897t. 581t VAMS. See also 934–936 Revised Token Test risk factors for. 857 generalization and. See Thematic Language Stimulation recovery from. 490–491. 34f. 886t. 197 creative. See Transient ischemic attacks processing capacity and. 172–173 (VADS) Transcortical sensory aphasia (TSA). Turn-taking rules. 882f. 581–583. See Visual Analogue Mood Scale aphasia and. 741 917t–918t. 936–937. 170 Transient ischemic attacks (TIA). 891 impairment-based. 51. 1013. 260. future trends for. 582–583 factors in. 387 functional approaches to. 96. 195 Thinking group therapy and. 902 syntax and. 581–582. 810 (VASES) 923–926 semantic impairment and. 578. 901–902 for grammatical morphology or Tissue plasminogen activator (t-PA). 939–940 measurement of. 644–645. 581t. 54. systematic reviews of. 588 VCIU. 164 31–32. 174 defining. 892t language comprehension and. 581t. Treatment format. 105–106. 76 Transcranial magnetic stimulation (TMS). 902 meta-analyses of. See also Specific content. 168–169. 196t divergent. TUFSyntax. 1017 Total quality management (TQM). 1009. 1090 Subject Index Therapist Helper. 582. 888. 881. 991. 891 lexical-semantic impairment and. 98. See Voxel-based morphometry collaboration in recovery from. 898t. 261t–263t. See Treatment of underlying forms Thurstone Word Fluency Test. verbal expression and. See Visual Analogue Dysphoric Scale 840 investigating. 995 frontolimbic. 320f Thought process therapy. 712–716 Utterances compensatory strategies and. 885. 472. 488–491. 887–888. 538. See Visual Action Therapy cognitive interventions for. 76 190. 918–919 Treatment of underlying forms (TUF). 164. 44. 891–895 reading/writing and. 264 internal. See Transcortical motor aphasia 938t–939t for Syntax TMS. 889f context-based treatment and. 747–748. 740–741. 892t morphology or functional categories Verb phrase (VP). 921 speech production/fluency and. Verb difficulty. 884f TUFFUNCAT. 901–903. 501–502 and. 96. 891–895. TSA. 320–321. 47. 704 disability following. 581t external. 45–46 feedback and. 197 evaluative. 886t research on. 880–881 Ultrasound. 476–477. 892t time distribution in. 8. See Vascular dementia Transcortical motor aphasia (TMA). 843 executive dysfunction and. 8. 884 Unilateral upper motor neuron dysarthria Total quality improvement (TQI). 901 Treatment outcomes Verbal expression.GRBQ344-sub[1073-1092]. See Treatment of underlying forms TIA. 737f economic support and. 884. See also Echocardiography Torrance Test of Creative Thinking. types of. 641–646 epidemiology of. 718–721 Vascular dementia (VaD). 581t. 887 Tree Pruning Hypothesis. Treatment of underlying forms for grammatical Verb morphology. 484 measures of. See Transcranial magnetic stimulation rehabilitation from. See Treatment of underlying forms TMA. 170 construct. t-PA. 472. 33f. 430. 902 bilingual aphasia and. 164 neuron dysarthria Traffic Sign Tutor. 57 psychosocial impairment from. 565. 891–895. 903–906. 923–926. 861. 582–583 Verb and Sentence Test. 645t 887–888. 230 assessing. 639 context dependence and. 745. 193–195. See Visual Analogue Self-Esteem Scale behavioral/psychosocial rehabilitation for. 881. 611. priorities in. 173. 894–895 PICA and. 736. 892–893. 415. 435 errorless learning and. 472 motivation and rehabilitation from. 510 Verbal fluency. 936–937 social approaches to. 738. 1016 approaches criterion-related. 522 generalization of. 196–197 structure of intellect model and. language intervention in. See Unilateral upper motor TQM. 919–923 724t VBM. 9. 886t. 901 745 Verb generation. 495–496 891–895. See Tissue plasminogen activator service settings and. See Voluntary Control of Involuntary communication and. 215 non-aphasic communication disorders with. 718–721 (VAMS) assessment of. 807–809 Validity. 76 Transdisciplinary teams. 937. See also Generalization auditory comprehension and. See Total quality improvement Trazodone. 882f. Tutorials. 197 Verbal output. 212 938t–939t University clinics. 32. 891. 859 Token Test. 88–89 history of. 867 Melodic Intonation Therapy and. 512t–513t. 927t Visual perception. 508 Word-exchange errors. 638 Voluntary Control of Involuntary Utterances 501 Verb-retrieval therapy. 666 therapeutic window for. Vocabulary 81. 725–726 Visual cues. 80. 703–704 Visual Analogue Mood Scale (VAMS). 582 Wh-movement. 817–818. 830 Wernicke-Lichtheim information processing Word level. 416 Voice recognition software. computer-based treatment and. 507–508. 97 Word frequency. 207. 197. 508t 618t Visual Confrontation Naming. 922–923 Wellness. 691–692 Word orthography. 609 model. 94–95. 575. 259. 24. 509 Working Memory Hypothesis. See Verb phrase 356–357 verb morphology and. 1020 771–772. 654 781. 1012 Visual Action Therapy (VAT). 93t Visual object recognition. 587. Written choice communication. 697f. 187. 97. 80. 868 94 569. Word representations. 724–725. 570–571. 609 Visual object representation tasks. 645–646. 390 Word comprehension. 863–864. 334–335 prognosis and. Voxel-based morphometry (VBM). 818 word form and. 420–421 Virtual reality (VR). 215 WAB Aphasia Quotient. 703–704 Veterans Health Administration. 1026 Warfarin. 967 Wechsler Memory Scale. Subject Index 1091 Verbal Picture Naming Plus. 507 restitutive treatments for. 573. 817 Word retrieval. 72. 517 Working memory. 697–698. 768 treatment of. 94 764. 783–785 Visual Analogue Dysphoric Scale (VADS). 386. 827–828. 643–644 Vigilance. 856. 614–615 speech patterns in. Visual Retrieval Language System. 607 Vibrotactile stimulation. 79. assessment of. 642 (VCIU). 825f Western Aphasia Battery (WAB). 215. Visual comprehension. 863 Yes/no questions. 510–511. 100–101 570–571. 583. 766–771 Wernicke’s area. 455 Visual processing. 28f Word sequence knowledge. 509 Word-intelligibility test. 513 impairment of. 644–645 VR. 636 Visual input lexicon. 643–644 Women. 191. Word processing software. 233. 763 What Is Aphasia? (Ewing & Pfalzgraf). 71. 739.qxd 2/8/08 7:27AM Page 1091 Aptara Inc. 499. See Western Aphasia Battery Word availability. 530 neuroanatomy of. 768 characteristics of. 551 WHOQOL Instrument. 390. 435 Verbal retention span. 856 WAB. Wepman thought process therapy. 7. 189–190. 514–521 Writing tasks. 647f VP. 829f receptive. 436. 256.GRBQ344-sub[1073-1092]. 427–428 “Wh-” questions. 618–620. See Virtual reality Wisconsin Card Sorting Test. 416 Visual agnosia. Verb-retrieval impairment. 340 Word generation. 867 Vocal stress. 654 rapid discharge and. 495–496 Word Intelligibility Test. impairment of. 382. 389 573. 774–777 Visual Analogue Self-Esteem Scale (VASES). 741. 581. 666. 1016 868 Visual scene display. 122. 746 non-canonical sentence structures and. 123. 259. 9. 566. 7–8. written. Wernicke’s aphasia. 991 Visual output lexicon. 362 causes of. 739f. 632 Word-meaning deafness. 657. 207 Veterans Affairs Department. 27–28. 93. 456. 507–508. ageism and. 51 Word form. 840 substitutive treatments for. 421. 567. 21. 434 . 21. 608–609 sentence deficits and. 764. 824. 85. 989. 824f. 705–706. 620–621 Visual cortex. 607 80. ~StormRG~ .qxd 2/8/08 7:27AM Page 1092 Aptara Inc.GRBQ344-sub[1073-1092].