Transcript EVENT NAME!!! - Robert's Web Resources

Kathryn
Garrett:
Referential Skills of Adults
with Aphasia vs. Peers in a
Photo-Reminiscing Task
DON”T PRINT
SLIDE #1 TITLE -- HAVE
SEPARATE
BANNER
Kathryn L. Garrett, Ph.D. CCC-SLP
Alison L. Wilber, MS, SLP
Marissa J. Krisak, MS, SLP
Duquesne University
Pittsburgh, PA
ASHA 2003, Chicago
I.
Introduction
 Referential communication is a fundamental
component of socio-communicative interactions for
both children and adults.
 Referential communication skills emerge before the
age of 1 year, and before the onset of verbal
communication in young children
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What is referential
communication?
 Abbeduto, Short-Meyerson, Benson, Dolish, &
Weissman (1998) described “physical
referencing” as:
– “...an understanding that an item that is present
in an individual’s proximal life space may be the
topic of conversation or concept under
discussion.”
 Their research indicated that referential skills
(particularly physical referencing) are present
in young children as well as older children
with developmental language delays.
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Examples of Early Referential
Skills
 Visually attending to others (especially speakers)
 Pointing deictically/gesturing to request
 Pointing deictically to an object,
[I want you to pick me up]
picture or written word to clarify the
referent when answering/commenting
 Pointing deictically to request info
or indicate another’s turn
What’s dat?”
 Searching for items or symbols that represent
answers to questions (“What do you want to play
with?”)
“
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The relationship of referential
skills to attention…..
 Bruner (1983) stated that verbal referential
communication skills develop as a result of learning
how to manage one’s own and direct others’
attention
 Early, object-level, deictic referencing that “Did you hear what
happened to the mascot at
occurs in conjunction with joint attention...
the game last weekend?”
EVOLVES
 …to referential communication that is
complex, intentional, verbal-symbolic,
and displaced over time and
space…………….
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So what does this have to do
with severe aphasia?
Do people with severe aphasia
engage in joint attention and
referential communication at the
same level as peers with no
aphasia? Is referential
communication a prerequisite
for intentional linguistic
communication in aphasia?
II. Statement of the Problem
 Some communicators with severe-to-profound
aphasia appear to have an elemental challenge in
referential as well as verbal/linguistic
communication skills
 In group therapy, communicators with severe
aphasia often need explicit instruction to:
• establish coordinated joint attention between the
communicator, partners, and physical referents
(“Show that to Liz -- she wants to know too”)
• signal others to look, take a turn, refer to an item, or
share info (“Show me where you went”;
“Point to John - ask him!”)
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So...according to child language
learning principles…
Is it appropriate to begin
working on speech, symbolic
gestures, or symbolic AAC
strategies before
communicators demonstrate
some evidence of ATTENTION
and REFERENTIAL skills?
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III. Hypotheses
KG
CC
Limb
 A) Individuals with moderate, severe, or profound
aphasia may not engage in referential
communication as much as speaking peers
 B) Individuals with severe aphasia may not be able
to produce propositional, verbal-symbolic
communication (speech or nonspeech
modalities) until basic referential skills emerge
(either naturally or with facilitation)
• pointing to others
• shifting gaze to a speaker
• physically manipulating externally-stored symbols
(pictures, words, etc.) to answer a question.
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 C) Perceptions of communication competence in
communicators with severe aphasia may
correlate with referential ability as well as
linguistic ability
 D) Perhaps explicitly teaching communicators with
severe aphasia to engage in referential
communication can improve their overall
communication and/or linguistic skills
• “Who did you come with? Show me!”
• “Ask Robert - where did you go for Thanksgiving
[point]?”
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IV. Research Study -- Phase 1
 Research Question for Hypothesis #1:
Is there a difference between the referential
communication skills of adults with acquired
aphasia and those of adult peers?
• Participants:
– 2 adults with chronic aphasia (1 mild-mod, 1 severe) with minimal
experience in referential communication training during interactive
communication therapy
• PWA #1: age 61, WAB AQ = 9.2
• PWA #2: age 74, WAB AQ = 76.4
– 2 adult peers with no brain injury
• Peer #1: age 54
• Peer #2: age 55
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Procedures
 Participants constructed a different personalized
photo album for each (n=4) data collection session
• 1 photo per page, 11 photos per album
• 2 albums of recent events, 2 of past events
 Instructions: “Talk about your pictures as much as
you want…”
• Partner was instructed to refrain from asking more than 5
yes/no questions
 First 2 minutes of each videotaped interaction was
extracted for analysis and coding
 2 sessions X 2 topics = 4 sessions per 4
participants (16 sessions total)
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Dependent Variables
 Verbal and nonverbal referential behaviors were
coded for the communicators with aphasia and
peers, including:(adapted from Mundy, Hogan, & Doehring, 1996)
• Role of Referential Communicator (Initiate vs. Respond)
• Number of Referential Communication Acts and Subacts
• Function of Referential Communication Act
– Establishing Joint Attention
– Providing Specific Semantic Information
– Commenting/Confirming
• Level of Intentionality of Referential Communication Act
– Eye gaze (Preintentional) ex. look at partner
– Deictic-referential (Intentional/nonsymbolic) ex. point to self
– Locutionary (Intentional, verbal-symbolic referential
communication) Ex. “Twenty years ago we went to...”
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Results #1
PROPORTION OF DEICTIC REFERENTIAL AND
LINGUISTIC REFERENTIAL COMMUNICATION ACTS BY
PARTICIPANTS WITH APHASIA AND PEER PARTICIPANTS
1.00
PROPORTION OF COMMUNICATION
ACTS
0.90
0.80
0.70
0.58
0.60
0.42
0.51
0.50
0.40
0.30
0.32
0.20
0.10
0.00
S IA
HA
P
A
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LING
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S
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S
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Summary of Results #1
 Participants with aphasia and peer controls had no
difference in proportion of eye gaze acts (.08 and .09)
 Participants with aphasia actually used
proportionately more intentional deictic pointing than
peers
PWA
#1
PWA
#2
Peer
#1
Peer
#2
# of Deictic Points
29*
18
14
29*
% of Deictic Points/
Total Subacts
.50
.52
.28
.37
• * The person with the most severe aphasia (AQ = 10) used as many
deictic points (n=29) in 2 minutes as a speaking peer
 Descriptive results contradicted the experimental
hypothesis
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Results #2
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Summary of Results #2
 Participants with aphasia utilized pointing and eye
gaze to establish joint attention during this task
more than peer controls
• Participants with Aphasia:
• Peer Controls:
.52
.40
 Conversely, peers conveyed more specific semantic
info than participants with aphasia
• Participants with Aphasia:
• Peer Controls:
.31
.58
 Thus, an inverse relationship existed between joint
attention and semantic-level communication.
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Other Results
 Both PWAs and Peers used an equal proportion of eye
gaze to establish joint attention
• Participants with Aphasia:
• Peer Controls:
.08
.09
 Both PWAs and Peers showed an equal ratio of
communication subacts to acts; this meant that both
groups contributed a similar amount of gestures,
pointing, and verbal messages to convey one idea
• Participants with Aphasia:
• Peer Controls:
2.26 subacts per act
1.95 subacts per act
 Successfulness
• Participants with Aphasia:
• Peer Controls:
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41% of acts -- completely succ.
100% of acts -- completely succ.
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Consistency of Results
 All participants demonstrated good within-
subject consistency across sessions
 However, between-subject differences were
observed within participant categories
• In fact, PWA #1 and Peer #1 were more similar to one
another than to the other member of their participant
category in:
– Proportion of joint attention subacts
– Proportion of intentional deictic pointing
– Proportion of unintentional eye gaze
• Due to this variability, groups did not demonstrate a
statistically significant difference in deictic communication
when randomization tests were conducted
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V. Interpretation of Results
 In this photo-album reminiscing task, people with
aphasia appeared to demonstrate the elemental
cognitive ability to establish joint attention
 Despite limitations in verbal output, the participants
with aphasia made frequent attempts to establish
joint attention and communicate specific referential
information.
 One of the subjects with aphasia (PWA #1)
demonstrated an equal or greater amount of deictic
pointing than adult peers, perhaps to compensate
for an inability to verbally establish reference.
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 The reduced number of specific semantic acts
and decreased proportion of message
successfulness experienced by PWAs may
have triggered their increased use of deictic
referential gestures
 In contrast, the linguistically competent peers
could use language alone to establish
reference.
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Limitations of the Study
 However, anecdotal observations indicate that people
with aphasia may not always think to establish joint
attention when communicating
• Example 1: Both PWAs needed repetition of instructions to
open the book and point to pictures at the beginning of data
collection. PWA #1 also required an initial model.
• Example 2: Both PWAs have enrolled in interactive group
communication therapy since data collection was completed.
In this context, they have required moderate-to-maximal cueing
to point or reference for their partners in contextual
conversations.
 The photo album reminiscing task may have
compelled communicators to use deictic pointing;
therefore a true picture of referential ability in
interactive conversation may not have been obtained.
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 Therefore, we may need to investigate
referential skills in a more demanding
communication situation
• Topical materials should be available, but placed at a
distance from the communicators with aphasia
• Situations that involve a communication predicament
could be constructed (e.g., Partner says something
incorrect)
 Finally, inter-subject variability was present for
the most important dependent variables
(function and type of referential act); therefore, a
larger pool of participants may yield different
results.
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Directions for Future Research
 Compare referential behavior with same-age
peers (particularly elder peers) to people with
aphasia in a larger group study.
 Increase complexity of referential task
 Determine if referential ability correlates with
other communication skills (e.g., language
ability; amount of expressive output, cognition)
 Correlate quantitative measures of referential
ability with perceptions of communication
competence in communicators with aphasia
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Clinical Implications
 Clinicians may want consider…
• Observing the referential skills of clients with
moderate-to-severe/profound aphasia
• Explicitly instructing individuals to reference
external representations of meanings (e.g., objects,
symbols, written words, people) AND establish joint
attention with other conversational participants
– perhaps before or while working on verbal-symbolic
communication
• teaching attentional, referential, pragmatic, and
symbolic communication skills within interactive
contexts
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J.V. telling Sara he wants to watch a movie by pointing
to a photo choice after she asked “Well, what do you
feel like doing right now? Show me….”
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Final Thoughts
 Perhaps some of the information on referential
communication, intentionality, and symbolic
communication from the child language and
severe disability literature can contribute to
our therapy approaches for people with severe
aphasia
 Further investigation is warranted
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For handouts…..choose an
option!
 Access the MS Word handout on the ASHA
conference website (wait 1 week)
 Email kg at [email protected] -- she will send
you this Powerpoint presentation as an
attachment
 Visit the University of Nebraska-Lincoln AAC
website for the Powerpoint presentation:
http://aac.unl.edu
• But give me and the folks at UN-L a week or 2 to post this.
Thanks for your interest!!
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Acknowledgements
Thanks to graduate students Abby
James and Kelly Hanna for their
assistance in compiling data for this
project.
Thanks to the clients with aphasia and
the peers for their participation.
Partial funding for this project was
obtained from a Duquesne University
Faculty Development Award (2002).
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