Principals of Assessment and Intervention in Acquired Language Disorders

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Principals of Assessment and Intervention in
Acquired Language Disorders
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Goals of Assessment

• To determine the presence of communication
  impairment
• Severity and type of impairment
• Determine the individuals strengths and
  weaknesses
• To identify exacerbating factors
• Vision and hearing
• Agnosias (recognition deficits) in various
  modalities
• Deficits in proprioception or praxis
• Affective (mood) disorders
• Effects of medications
• To identify intervention goals

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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

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Goals of Assessment

• To determine the presence of aphasia, and
  severity and type of aphasia, using the
  _____________, and profile the clients strengths
  and weaknesses
• NOT
• To administer the BDAE

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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
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Assessment Defined

• Organised, goal directed evaluation of the
  components of communication
• Evaluation of persons 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

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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

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Informal Language Assessments

• What to assess
• 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 clients medical
  / cognitive / emotional state

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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

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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

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Informal assessment
Brookshire 2003
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Informal assessment

• Auditory comprehension
• Answer closed ? open questions
• Point to objects / pictures named by the examiner
• Follow spoken directions
• Answer questions about spoken discourse
• Speech
• Recitation
• Object / picture naming
• Phrase or sentence completion
• Phrase / sentence repetition
• Produce single sentences ? longer utterances
• Reading
• 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

Brookshire 2003
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Formal Language Assessments

• Acute
• Boston Naming Test
• Bedside Evaluation Screening Test (BEST)
• Western Aphasia Battery
• Chronic
• 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?

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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

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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

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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

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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?

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Therapy Approaches

• Approaches that assume the brain can relearn what
  has been lost/skills can be re-accessed
• Approaches that assume lost language functions
  not recoverable. Therapy aimed at getting
  around the problem

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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

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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

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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, cant travel

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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)

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Planning intervention
What person can do cannot do does do
What person needs to do wants to do
closing the gap
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Example treatment planning

• MJs 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
• MJs wish to talk better with family and friends

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Setting goals

• Overall goal To maximise MJs 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 MJs goal, when setting goals for
  therapy, using phrases like in order to
• 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
• 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

This is the overall goal
This is MJs goal
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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

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Task hierarchies

• to draw single items communicatively
• to draw single events communicatively
• therapy tasks will involve encouraging Pt to be
  aware of the conversation partners needs,
  focusing on issues such as listening to the other
  persons 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

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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).

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Task Hierarchies

• Simple ? more complex
• Less demanding ? more demanding
• More support ? less support
• E.g. cuing hierarchy for anomia
• Imitation
• First sound / syllable
• Sentence completion
• Word spelled aloud
• Rhyme
• Synonym / antonym
• Function / location
• Superordinate
• Make hierarchies personal

Brookshire 2003 p 313
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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