Transcript Principals of Assessment and Intervention in Acquired Language

Principals of Assessment and
Intervention in Acquired
Language Disorders
Goals of Assessment
• To determine the presence of communication
impairment
– Severity and type of impairment
– Determine the individual’s strengths and weaknesses
• To identify exacerbating factors
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Vision and hearing
Agnosias (recognition deficits) in various modalities
Deficits in proprioception or praxis
Affective (mood) disorders
Effects of medications
• To identify intervention goals
Goals of Assessment
• To assess potential for future recovery
(prognosis)
• To monitor change – e.g. spontaneous recovery,
treatment efficacy
• To evaluate maintenance of treatment gains
• To define factors that facilitate comprehension,
production and use of language
• To establish a working relationship with client
and significant others
Goals of Assessment
• To determine the presence of aphasia, and
severity and type of aphasia, using the
_____________, and profile the client’s
strengths and weaknesses
NOT
• To administer the BDAE
Components of language function
Cognitive
Recognition,
understanding,
memory, attention,
reasoning ability
Linguistic
Auditory comprehension,
language production (form
and content)
Communicative/
Pragmatic
Turntaking, topic initiation
and maintenance, repairs,
speech acts produced,
nonverbal aspects
Assessment Defined
• Organised, goal directed evaluation of the
components of communication
• Evaluation of person’s QOL
• Evaluation of communicative interactions
within family/social unit
• Their role in larger unit of society
• Carried out to determine how strengths
fortified and weaknesses modified
Chapey 2008
Before you start
• Gain information and form initial
hypotheses from:
– Initial referral
– Verbal information from MDT members
– Medical notes
• Remember introductions and endings
– Why you are there, what you want to do, why
it was useful, what happens next
Informal Language Assessments
• What to assess:
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speech fluency
speech output
auditory comprehension
repetition
naming
written output
reading comprehension
drawing
gesture
facial expression
awareness of deficit
• NOT all at once! Be sensitive to client’s medical /
cognitive / emotional state
Informal Assessment
• For each aspect of communication:
– What the individual is able to do?
– Where does the task break down?
– language production: Single words  short phrases  sentence
 2-3 sentences  paragraph  monologue  conversation
– Auditory comprehension: Single words  yes/no questions 
sequential commands  non-sequential commands
• Have a hiearchy of tasks for each area to allow flexibility
• Try to start at the appropriate level for that client
Informal assessment
• Manipulate the structure you provide for the task
– Unstructured (no control or interference)
– Moderately structured (retell a story, describe a
picture or a sequence of activities)
– Highly structured (sentence completion, object
naming)
• Be systematic
– Check hearing and visual perception first
– Assess language comprehension before language
production
– Writing and calculation later
Informal assessment
Brookshire 2003
Informal assessment
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Auditory comprehension
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Speech
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Recitation
Object / picture naming
Phrase or sentence completion
Phrase / sentence repetition
Produce single sentences  longer utterances
Reading
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Answer closed  open questions
Point to objects / pictures named by the examiner
Follow spoken directions
Answer questions about spoken discourse
Match pictures, letters, geometric forms
Match printed words to pictures
Read aloud: numbers, letters, words, phrases
Answer written questions
Silent reading / comprehension – answer questions about a written test
Writing
– Copy letters, numbers, shapes, words
– Write to dictation – letters, numbers, words, sentences
– Write a paragraph / written narrative
Brookshire 2003
Formal Language Assessments
• Acute
– Boston Naming Test
– Bedside Evaluation Screening Test (BEST)
– Western Aphasia Battery
• Chronic
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BDAE (subtests)
PALPA
Pyramids and Palm Trees
Minnesota Test for Differential Diagnosis of Aphasia
Porch Index of Communicative Ability (PICA)
Comprehensive Aphasia Test (CAT)
– Appropriacy for Sri Lanka?
Assessment of communicative
functioning
• Not language per se – performance, pragmatics
• Communication skills in everyday life
• Example: CADL-2 (Communicative Activities in Daily
Living)
• Provides a snapshot of functional communication skills
using a variety of simulated communication activities
• Involves people reading timetables, menus; pretending
to go to doctor, shopping; making a phone call; writing a
shopping list
• For people with aphasia, HI, dementia, intellectual
impairment, hearing impairment
Aphasia Recovery
• Spontaneous recovery: decelerating curve
– Maximum recovery 1-3m
– Flattening out 6-7m
– Little/no spontaneous recovery after 1yr – plateau
Basso 1992 Benson and Ardila 1996 in Chapey 2008
• Prognosis: TBI better than stroke, haemorrhagic better
than infarction
Lesser and Milroy 1993
Neural Mechanisms for Recovery
• Reduction of cerebral oedema/improvement of
local circulation: Spontaneous recovery
• Brain plasticity: cortical reorganisation to engage
pre-existing but functionally depressed
pathways. Called upon when dominant system
fails
• Lesion size = negative influence on recovery
Aphasia Treatment
• Efficacy: does aphasia treatment result in a significant
improvement on one or more tests of language
functioning?
• Yes, provided that:
– Treatment is delivered by qualified professionals
– Global aphasics are excluded
– Content, intensity, duration and timing of treatment are
appropriate
– Sensitive and reliable measures are used to track changes
• Effectiveness: does aphasia treatment result in
meaningful improvements in communicative functioning
in daily life?
Therapy Approaches
• Approaches that assume the brain can
relearn what has been lost/skills can be reaccessed
• Approaches that assume lost language
functions not recoverable. Therapy aimed
at “getting around the problem”
Models of Therapy
• WHO International classification of
Functioning, Disability and Health (2002)
– Body functions and structures i.e.
impairments of brain
– Activity i.e. ability to make a phone call, read a
menu
– Participation i.e. pursuit and enjoyment of real
life goals e.g. volunteering/getting a job
Treatment Considerations
• Timing:
– During spontaneous recovery period or wait?
– Vignolo (1964): treatment is only really effective if it
begins when physiologic recovery is most rapid
– Poeck et al (1989): time post-onset does not affect
recovery of language, but it does affect response to
treatment
– Generally, delaying treatment has not been
conclusively demonstrated to have any effects on
eventual outcome; but it likely does have effects on
the patient and their family
Treatment Considerations
• Candidacy:
– Some patients have very mild impairments
and recover spontaneously
– Some are so severely impaired that they
cannot benefit
– Some refuse, lack motivation, can’t travel
Treatment planning
• Use assessment results
• Use discussion with client (where
possible) and family
• Set long and short term goals
• Consider design of task, the
psycholinguistic nature of stimuli selected,
modality of material, type of facilitation
given, duration and intensity of therapy
(Byng and Black 1995)
Planning intervention
What person
can do
cannot do
does do
closing the gap
What person
needs to do
wants to do
Example – treatment planning
• MJ’s assessments show:
– Strengths:
• Good lexical comprehension
• Good sentence comprehension using non reversible active,
passive & comparative verbs
• Can draw and gesture to convey some aspects of meaning
• Semantic cueing facilitates naming
• Written support facilitates comprehension
– Weaknesses:
• Poor complex auditory sentence comprehension
• Spoken confrontation naming difficulties
• Difficulties in written confrontation naming when word frequency
decreases
• Drawings and gestures may not be recognisable outside context as
tend not to be well defined
• MJ’s wish: to talk better with family and friends
Setting goals
• Overall goal: To maximise MJ’s current communication abilities
• This will involve use of his existing strengths to compensate for his
weaknesses (use drawing, gesture, writing of words etc - total
communication)
• Relate this to MJ’s goal, when setting goals for therapy, using phrases like
“in order to”
This is the overall goal
For MJ to improve his communication skills (esp. drawing, gesture, & keyword
writing) in order for him to be able to engage in conversations with his family.
This includes the following:
• to draw communicatively to convey meaning in conversation with his wife
• To gesture… to write… etc
This is MJ’s goal
• Then take one long term goal at a time, and break it down – that is, what
steps would be involved in getting the client from where he is now:
His drawings are sometimes useful but are not well-defined
To the long term goal:
Drawing communicatively in conversation with his wife
Task hierarchies
• Arrange the steps in order of difficulty:
• To draw well defined single items
– to command (draw an apple)
• therapy tasks include drawing basic shape, then differentiating items
from one another on visual features (e.g.. apple vs. orange)
– based on function (draw something you wear) – extending
from objects to actions
– based on gesture (may or may not incorporate the verb
function from above) (e.g. gesture a banana; gesture a
shovel)
– in whole and parts (involves semantic breakdown)
– within a category/ generative drawing
– from memory
• To draw well defined single events
– from stimulus pictures
– from part of stimulus
– from memory
Task hierarchies
• to draw single items communicatively
• to draw single events communicatively
– therapy tasks will involve encouraging Pt to be aware of the
conversation partner’s needs, focusing on issues such as
listening to the other person’s guesses, conveying one piece of
information at a time
• to draw communicatively in conversation with SLT
– therapy tasks will include drawing ‘answers’ to questions – e.g.
what did you do on the weekend?
• to draw communicatively in conversation with wife
– therapy tasks will include working with wife to assist her to
develop interpretation strategies, such as ‘homing-in’ questions;
asking for details; adding to the drawings; writing key words to
check; recapping what she knows about the drawing every few
minutes
Drawing and total communication
• Beeson & Ramage, (2000). Drawing from experience:
The development of alternative communication
strategies. Topics in Stroke Rehabilitation, 7(2), 10-20.
• Lawson & Fawcus (1999). Increasing effective
communication using a total communication approach. In
Byng, S. & Swinburn, K. (Eds): The aphasia therapy file.
Pp 61-71. Hove, England: Psychology Press.
• Sacchett et al (1999). Drawing together: evaluation of a
therapy programme for severe aphasia. International
Journal of Language & Communication disorders, 34(3),
265-289).
Task Hierarchies
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Simple  more complex
Less demanding  more demanding
More support  less support
E.g. cuing hierarchy for anomia:
Brookshire
2003 p 313
Imitation
First sound / syllable
Sentence completion
Word spelled aloud
Rhyme
Synonym / antonym
Function / location
Superordinate
• Make hierarchies personal
Goals for treatment
• “The primary objective in treatment of aphasia is to
increase communication. What the aphasic patient wants
is to recover enough language to get on with his life.”
(Schuell et al 1964, 333.)
• Usually will not be complete recovery of language and
communicative function
• Treatment may enhance recovery, but recovery will stop
• Identify strengths and weaknesses; use the strengths to
compensate for the weaknesses; help the aphasic
person to be an effective communicator in spite of their
language deficits
• Generalization – recovery must not be limited to the
treatment room
• Generalization does not just happen – it must be
planned for, worked towards, tested for