developing intentional, symbolic communication in global aphasia: a case study kathryn l. garrett,...

Developing Intentional, Developing Intentional, Symbolic Communication in Symbolic Communication in

Global Aphasia: Global Aphasia: A Case StudyA Case Study

Kathryn L. Garrett, Ph.D., CCC-SLP

Laura A. Mancini, B.S.

Amy E. Fuscaldo, B.S.* * * * * * *

Duquesne UniversityPittsburgh, PA

ASHA 2001/PSHA 2002

ASHA 2001/New Orleans Garrett, Mancini, Fuscaldo - Global Aphasia Case Intervention

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AbstractAbstract

• This case study describes how a variety of pre-linguistic teaching strategies assisted a client with global aphasia to intentionally:

• request items by pointing to pictorial symbols• answer conversational questions by pointing to written

word choices or signaling yes/no using head nods• Develop joint attention and reference others during

group interactions

• Preliminary outcomes are also reported


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BackgroundBackground

• Many individuals with global aphasia have difficulty engaging in pre-linguistic communication behaviors that are necessary to establish reciprocal communication exchanges, such as joint attention, acknowledging, choosing, requesting, and commenting (Garrett and Beukelman, 1992; 1998; Warren & Yoder, 1998).

• In addition, many people with global have challenges using symbols (gestures, words, pictures) to request, comment, or convey information in a functional manner.


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• However, many current therapy approaches for people with global aphasia fail to address preliminary, prelinguistic communication skills prior to working on linguistic-level challenges

• In addition, only a few instructional interventions have successfully taught people with global aphasia to communicate symbolically in functional, socially interactive contexts (Bellaire, et al. 1991; Helm-Estabrooks & Albert, 1991; Johannsen-Horbach, et al. 1985; Weinrich et al. 1989)


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Participant DemographicsParticipant Demographics

• J.V. - Male, 59-year old • ruptured cerebral aneurysm and possible

episode of hypoxia in 1993.• profound aphasia across all modalities,

severe oral motor apraxia and apraxia of speech, limb apraxia, a severe right visual field cut, and severe cognitive deficits (poor attention, reduced short term memory, limited reasoning skills, poor self monitoring)


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Demographics continuedDemographics continued

• 7 years post onset, J.V. remained functionally non-speaking w/ poor comp.

• Test scores:– WAB quotient .6/100

– BASA 2nd %ile (global aphasia norms)

• Enrolled in individual and group therapy at the Duquesne University SLP clinic– June 2000 through November 2001– Total treatment period - 13 months (vacation

months excluded)


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Means of communication at the start of Means of communication at the start of therapytherapy

– Vocalizations and stereotypic utterances (“Wah, wah wah”; “Howahyu”)

– Grabbing/reaching– Changes in intonation and facial expression– Familiar partner interpretation of these

preintentional signals

• -----------------------------------------------------------– Most successful when communicating simple

needs to wife in familiar, routinized contexts


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Needs assessment Needs assessment

• Family had difficulty understanding his requests for specific items.

• Limited ability to communicate specific comments or ideas in social interactions with family and people in community/dependent on wife to initiate and maintain interactions.

• Extreme difficulty comprehending others’ communication exchanges/semantically specific information.

• Inability to maintain attention and required frequent cues to refer to others or to focus on topical stimuli.


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Intervention Objectives/ActivitiesIntervention Objectives/Activities

• A. Basic Requesting Skills• 1. 1. Reference (point to) objectsReference (point to) objects during during

joint attention activitiesjoint attention activities» Use mand-model technique (Halle, 1982) to physically assist J.V. to

point to referents during matching game, or to pictures/objects in group conversational activities in response to “What do you want?); fade mand across time

• 2. 2. Match symbols to objects in contextual Match symbols to objects in contextual activitiesactivities (e.g., breakfast, shopping): (e.g., breakfast, shopping):

» Matching game: model/instruct J.V. to pick up or point to picture symbol (n=4-6) matching target object (after presentation of target object), then provide natural consequences for correct match (present object, talk about it, use it in a humorous manner)


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• 3. 3. Request objects by pointing to Request objects by pointing to picture picture symbols in contextual activitiessymbols in contextual activities::

» Mand-model technique, incidental teaching (Peck, 1985) during familiar contextual activity (e.g. grocery shopping) with natural consequences (providing selected item even if not desired)

• 4. 4. Request objects via VOCA symbols Request objects via VOCA symbols in in contextual activitiescontextual activities::

» Same as 2 and 3 above, also provide voice output via VOCA; embed objects within sequential routine (e.g, "What do you need to make breakfast?")

» Prelinguistic Milieu Teaching - incorporates simple techniques to teach requesting and commenting (providing time delays and expectant looks during routines in which an object is needed) (Warren and Yoder, 1998).


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• 5. 5. Request items using mini-Request items using mini-board board in home environmentin home environment (Alwell et

al. 1989): » Teach spouse (via role-plays) to provide

opportunity for J.V. to access a 5x7 board with 6 color symbols to make choices at home (e.g., breakfast, activities); provide natural consequences


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• B. Conversational Skills

• 1. 1. Increase comprehension of Increase comprehension of conversational infoconversational info::

» Teach partners to use Augmented Input (written key words, partner's point to referent, partner's gestures) in all situations to supplement J.V.’s understanding of main ideas, others’ comments, potential choices, etc. (Garrett & Beukelman, 1992; Romski & Sevcik, 1996)

• 2. 2. Increase clarity and consistency Increase clarity and consistency of of J.V.'s gestural Yes/No Signal:J.V.'s gestural Yes/No Signal:

» Clinician asks 5-10 questions related to recent events or autobiographical information given tagged question form ("yes…or no?") and visual model (nodding Y/N) plus augmented input; natural consequences provided


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• 3. 3. Answer conversational questions Answer conversational questions by by pointing to written choices:pointing to written choices:

» Ask conversational wh- questions (e.g., What kind of music do you like?) then generate 3-4 written key words in vertical alignment, read choices aloud, then ask J.V. to point to his answer; partner responds with sincerity to content of responses (Garrett & Beukelman, 1992; 1995).

• 4. 4. Tell novel information via VOCATell novel information via VOCA::

» Implement natural communication opportunities, wh-question prompts, and expectant delays (Halle et al., 1981) to prompt J.V. to access VOCA "news" message in group conversational activities.


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• 5. 5. Ask 1 social automatic question Ask 1 social automatic question ("What's new with you?") via ("What's new with you?") via

generic generic VOCA messageVOCA message:: » Use mand-model technique to teach J.V. to access VOCA

message (faded across time), natural opportunities to use message in group

• 6. 6. Reference conversational partners Reference conversational partners and topics by pointing/shifting gazeand topics by pointing/shifting gaze::

» Natural communication opportunities, prompts, mand-model technique and fading during group therapy.


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Clinical OutcomesClinical Outcomes

• Formal testing was not readministered -- changes were not measurable on standard tools (WAB, BASA)

• A jury of 3 familiar graduate clinicians and 1 experienced supervising clinician counted the number of preintentional, intentional, and intentional/symbolic communication behaviors prior to tx and post tx on 2 informal tools:


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Communication InterviewCommunication Interview (modified from (modified from Schuler, Peck, Willard, & Theimer, 1989):Schuler, Peck, Willard, & Theimer, 1989):

54%58%

18%26%

0%11%

0%10%20%30%40%50%60%70%80%90%

100%

Preintentional Intentional Intentionaland Symbolic

PreTxPostTx

Percentage of preintentional, intentional, and intentional/symbolic communication behaviors (total # behaviors rated = 14; total # of ratings = 159; 82% intrarater reliability)


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(Modified from the Communication Interview by Schuler, A.L., Peck, C.A., Willard, C., & Theimer, K., 1989, Assessment of communicative means and functions through interview: Assessing the communicative capabilities of individuals with limited language.

PreTx n = 159

Post Tx n =159

Pre Tx n = 159

Post Tx n = 159

Pre Tx n = 159

Post Tx n = 159

54% 58% 18% 26% 0% 11%

RESULTS OF JURY COUNTS/COMPUTATIONS OF % PREINTENTIONAL, INTENTIONAL, AND INTENTIONAL/SYMBOLIC SIGNALS PER BEHAVIOR FOR J.V.: PRE- AND POST TX.

Preintentional Communication Signals : withdrawal, passive gaze, proximity, pulling other's hands, grabbing/reaching, facial expression, intonation, inappropriate echolalia

Intentional Communication Signals : enactment, remove self/walk away, vocalize, active gaze, gives object/pushes away, gestures/pointing, appropriate echolalia

Intentional/Symbolic Communication Signals : Shakes head "no"/"yes", anwers questions by pointing to written choices, points to pictorial symbols

42 0 1814 BEHAVIORS RATED: 1) request for adult to sit near, 2) request for adult to look at him, 3) request for assistance with daily living activities, 4) request to go outside/to store, 5) request for an object out of reach, 6) request for a door/ containe

86 92 29.5


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Categorical Assessment Form for Categorical Assessment Form for Communicators With AphasiaCommunicators With Aphasia (Garrett & (Garrett &

Beukelman, 1992)Beukelman, 1992)

62%

87.50%

40%

90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

# Behaviors/Basic ChoiceCommunicator

# Behaviors/ControlledSituation Communicator

Communicator Type

PrePost


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Criterion-referenced measuresCriterion-referenced measures from from conversationally-based therapy activities:conversationally-based therapy activities:

Pre-Treatment

Post-Treatment

Answers Tagged Y/NQuestions 10% 70%-100%

Answers WrittenChoice Questions 0% 85%

Requests ContextualObjects (from routine)By pointing topictures or Dynavoxsymbols

0% 83%

References othersprior tocommunicating

Max cues 75% min.cues


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Functional OutcomesFunctional Outcomes

• J.V.’s wife reported the following functional changes at home:

• More alert and attentive• Less perseverative, stereotypic echolalia (Wa/wa/wa)• Began to take her to items or locations at home to show her

what he wanted• Occasionally used simple VOCA to get her attention/

request help• Began answering yes/no questions pertaining to

needs/preferences/events with a clear head shake• When wife initiated, would choose picture symbol to

indicate breakfast or activity preferences (located in communication notebook)


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Summary and ConclusionsSummary and Conclusions

• Outcomes of this case study suggest that prelinguistic teaching paradigms may be beneficial in treating global aphasia.

• Additionally, some communicators may transition to intentional/symbolic communication in some contexts

• Partner-assisted strategies (making symbols available, augmented comprehension, naturalistic consequences) may also be of assistance


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Future DirectionsFuture Directions

• Develop a formal tool to catalogue the preintentional, intentional, and intentional/ symbolic communication skills of people with profound aphasia during interactive communication activities.

• Formalize “clinical pathways” to teach attentional, referential, basic pragmatic, and emerging symbolic communication skills within interactive contexts

• Gather effectiveness data for add’l cases


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AcknowledgmentsAcknowledgments

• Thanks to J.V., his wife, and caregivers for all of their extra efforts to participate in clinical research

• Thanks to Sara Osier and Lisa Bosco, graduate SLP clinicians, for their assistance in compiling data

• Thanks to the Duquesne SLP Clinic for its support of clinical research


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FOR HANDOUTS…..FOR HANDOUTS…..

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– Thank you for your interest!!!

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