Transcript Developing Intentional, Symbolic Communication in Global

Developing Intentional,
Symbolic Communication in
Global Aphasia:
A Case Study
Kathryn L. Garrett, Ph.D., CCC-SLP
Laura A. Mancini, B.S.
Amy E. Fuscaldo, B.S.
*******
Duquesne University
Pittsburgh, PA
ASHA 2001/PSHA 2002
Abstract
• 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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Background
• 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 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 continued
• 7 years post onset, J.V. remained
functionally non-speaking w/ poor comp.
• Test scores:
– WAB quotient
– BASA
.6/100
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
therapy
– 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
• 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/Activities
•
A.
• 1.
Basic Requesting Skills
Reference (point to) objects during
joint 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.
Match symbols to objects in contextual
activities (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.
Request objects by pointing to picture
symbols 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.
Request objects via VOCA symbols in
contextual 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). Garrett, Mancini, Fuscaldo - Global Aphasia
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• 5.
Request items using mini-board
in 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.
Increase comprehension of
conversational 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.
Increase clarity and consistency of
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.
Answer conversational questions by
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.
Tell novel information via VOCA:
» Implement natural communication opportunities, whquestion 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.
Ask 1 social automatic question
("What's new with you?") via generic
VOCA message:
» Use mand-model technique to teach J.V. to access
VOCA message (faded across time), natural
opportunities to use message in group
• 6.
Reference conversational partners
and topics by pointing/shifting gaze:
» Natural communication opportunities, prompts,
mand-model technique and fading during group
therapy.
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Clinical 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 Interview (modified from
Schuler, Peck, Willard, & Theimer, 1989):
Percentage of preintentional, intentional, and
intentional/symbolic communication behaviors (total #
behaviors rated = 14; total # of ratings = 159; 82% intrarater reliability)
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RESULTS OF JURY COUNTS/COMPUTATIONS OF % PREINTENTIONAL, INTENTIONAL, AND
INTENTIONAL/SYMBOLIC SIGNALS PER BEHAVIOR FOR J.V.: PRE- AND POST TX.
(Modi fied from the
Communication
Intervi ew by Schuler ,
A.L., Peck, C.A.,
Will ar d, C., & Theimer,
K., 1989, Assessment
of communicati ve means
and functions throug h
intervi ew: Assessing
the communi cative
capabilities of
indi viduals with li mi ted
lang uag e.
Prein ten tio n al
C o mmu n icatio n
Sig n al s : withdrawal ,
pas s iv e gaze, prox im it y ,
pul ling other's hands,
grabbing/reac hing, f ac ial
expres si on, intonat ion,
inappropriate ec holali a
In ten ti o n al
C o mmu n icatio n
Sig n al s : enac tm ent,
rem ov e self /walk away ,
v oc alize, ac tiv e gaze,
giv es object /pushes
away , ges tures /poi nt ing,
appropriat e ec hol ali a
In ten ti o n al /Sym bo l ic
C o mmu n icatio n
Sig n al s : Shak es head
"no"/ "y es ", anwers
ques tions by pointi ng t o
writ ten c hoic es, poi nt s to
pic torial sy m bols
PreTx
n = 159
Pre Tx
n = 159
Pre Tx
n = 159
Post Tx
n =159
Post Tx
n = 159
Post Tx
n = 159
86
92
29.5
42
0
18
54%
58%
18%
26%
0%
11%
14 B EH AVIOR S
R ATED :
1) req uest
for adult to sit near, 2)
req uest for adult to look
at him, 3) r eq uest for
assistance with dail y
li ving activiti es, 4)
req uest to g o outside/to
stor e, 5) req uest for an
object out of reach, 6)
req uest for a door/
contai ne
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Categorical Assessment Form for
Communicators With Aphasia (Garrett &
Beukelman, 1992)
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Criterion-referenced measures from
conversationally-based therapy activities:
PreTreatment
PostTreatment
10%
70%-100%
Answers Written
Choice Q uestions
0%
85%
Requests Contextual
Objects (from routine)
By pointing to
pictures or Dynavox
symbols
0%
83%
Max cues
75% min.
cues
Answers Tagged Y/N
Questions
References others
prior to
communicating
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Functional 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 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 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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Acknowledgments
• 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…..
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• Or retrieve this presentation from the
following website: http://aac.unl.edu
– Thank you for your interest!!!
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