Post-Conversation Feedback in Adults with Right-Hemisphere Brain Damage

1
Post-Conversation Feedback in Adults with
Right-Hemisphere Brain Damage

• Kelsey Meiring, M.A., CF-SLP
• Indiana University
• Speech and Hearing Sciences
• kmeiring_at_indiana.edu

2
Introduction

• Despite growing research focused on
  right-hemisphere brain damage (RHD), there is
  still a lack of research about this population,
  especially regarding treatment of
  cognitive-linguistic deficits (Blake, 2007)
• Although many SLPs do not evaluate or treat this
  population very often (Blake, 2006), only half of
  those with RHD cognitive-linguistic deficits are
  referred for S/L services (Blake, Duffy, Myers,
  Tompkins, 2002 )
• Since research is increasing awareness of RHD,
  more of these patients are likely to be referred
  for services, so SLPs need to be prepared to
  treat them

3
Etiology v. Deficits

• The study is a treatment study involving only
  right-hemisphere TBI addressing the symptoms of
  RHD
• According to Blake (2007), treating the deficits
  of RHD regardless of etiology is more
  appropriate therefore, it may also be applicable
  for right-hemisphere CVA

4
Purpose

• The purpose of this study is to investigate a
  possible treatment protocol to address discourse
  and pragmatic issues related to RHD.
• This treatment focuses on the use of feedback to
  increase awareness of deficits and to provide
  ways to improve discourse and pragmatic
  performance.

5
Normal Right Hemisphere Fx

• Production of automated speech and the
  comprehension and production of prosody,
  emotional speech, narrative discourse, and
  pragmatics (Lindell, 2006)
• Right-hemisphere is more involved in
  comprehension of language than production
  (Baynes, Tramo, Gazzaniga, 1992 Gazzaniga,
  LeDoux, Wilson, 1977 Zaidel, 1978)
• Primarily responsible for integrating and
  producing connections across sentences and within
  sentences in discourse to obtain or convey the
  main idea (Gernsbacher Kaschak, 2003)

6
Deficits Aprosodia

• Comprehension
• Inability to interpret prosody to deduce a
  meaning from discourse. Therefore, jokes,
  sarcasm, and emotionally ambiguous sentences are
  often difficult to understand for this population
  
• Production
• Inability to produce prosody to express the
  intended communicative intent. Therefore,
  expressing emotions and conveying the correct
  form of sentences (e.g., interrogative versus
  declarative sentence) are very difficult for this
  population
• Can have a combo of these (Lindell, 2006)

7
Deficits Discourse/Pragmatics

• Some variability in particular discourse and
  pragmatic deficits has been reported (Blake,
  2006 Myers, 2001)
• Common deficits
• Disinhibition
• Impulsivity
• Verbosity or paucity
• Unbalanced turn taking
• Difficulty generating inferences
• Lack of or inappropriate eye contact
• Topic digressions and tangentiality
• Inappropriate topic and/or word choice
• Difficulty comprehending discourse
• Egocentricity
• Disorganization and lack of cohesion
• Lack of initiation
• Ideational perseveration
• (Blake, 2006 Chantraine, Joanette, Ska, 1998
  Glosser, 1993).

8
Deficits Anosognosia

• Presence of anosognosia tends to lead to poorer
  outcomes in treatment (Hartman-Maeir, Soroker,
  Oman, Katz, 2003 Jehkonen et al., 2001 Noe et
  al., 2005)
• This issue is central to the premise of the
  study if one can become aware of his or her
  deficits, he or she may then begin the process to
  develop strategies to overcome these deficits.

9
Treatment Aprosodia

• Most treatments for aprosodia only focus on
  expressive deficits.
• The most common treatments for aprosodia
  following RHD involve
• Biofeedback (Stringer, 1996),
• Cognitive-linguistic treatment (Leon et al.,
  2005 Rosenbek et al., 2004 Stringer, 1996), and
  
• Imitative treatment with errorless learning
  cueing hierarchies (Leon et al., 2005 Rosenbek
  et al., 2004).

10
Treatment Discourse/Pragmatics

• Group treatment (Klonoff, Sheperd, OBrien,
  Chiapello, Hodak, 1990)
• 3 participants
• 5 hours of therapy, 5 days a week
• Treatment involved role-playing, self-monitoring,
  and behavioral reviews.
• Results were vague and did not formally assess
  pragmatics or discourse but rather gave
  subjective information regarding the progress in
  these areas.
• Self-monitoring continued to be an issue for most
  participants at the termination of the group
  treatment.
• Group treatment - Murray and Clark (2006)

11
Treatment Discourse/Pragmatics

• Most effective
• Role-playing
• Self-monitoring
• Behavior modification
• Feedback, usually via videotape review
• (Coelho, DeRuyter, Stein, 1996)

12
Treatment Anosognosia

• Usually involves the prediction of performance on
  certain tasks or the use of feedback, similar to
  the treatments described for discourse and
  pragmatics
• Youngjohn and Altman (1989)
• 36 brain-injured participants
• Predicted their performance on a free recall task
  and a written math task
• Predictions and actual performance were reviewed
  with the participants in a group setting
• More accurate self-predictions were reported by
  the end of the treatment.

13
Ethical Issues Anosognosia tx

• Cherney, 2006
• If the client does not see a need for treatment
  and refuses to attend, therapy may ethically not
  be pursued.
• Even if the participant agrees to come to
  therapy, the lack of awareness of deficits will
  result in little motivation to participate and
  respond to treatment, which is essential to
  successful treatment.
• Since unaware of the deficits, the participant
  cannot participate in the development of
  treatment goals or express his or her preferences
  for the direction of treatment.
• If anosognosia persists, treatment to address
  safety issues still needs to be pursued at the
  discretion of the clinician.

14
Discourse Analysis

• There are many ways to analyze discourse, making
  cross-study comparisons difficult (Togher, 2001)
• Lê, Mozeiko, and Coelho (2011) developed four
  main areas of anaylsis of discourse
• Within-sentence
• Across-sentence
• Text-level
• Story grammar analyses (Not used in this study)

15
Rationale of Study

• Many patients with RHD have anosognosia, or a
  lack of awareness of deficits (Blake, 2006)
• Patients are unable to modify behavior if they
  are unaware of the undesirable behavior
• Therefore, increase awareness, increase ability
  to modify behavior
• How do we increase awareness?
• FEEDBACK

16
Methods

• Single-subject design
• Subject
• 62 year old female (JB to protect identity)
• Right TBI sustained after being hit by a car
  while on bicycle in 1987 (22 years post-onset)
• Presenting symptoms
• Subjects symptoms consist with findings of
  Blake (2006), although RHD deficits may vary
  widely among individuals reinforces idea to
  TREAT SYMPTOMS, not etiology

• Disinhibition
• Anosognosia
• Verbosity
• Lack of specificity
• Ideational perseveration
• Lack of transitions
• Frequent topic digressions
• Pragmatics (frequently inappropriate)

17
Methods (cont.)

• 20 treatment visits
• 2x/week, 60-minute session 90-minute session
• Pre- and post- treatment testing
• 4-6 week post-treatment testing

18
Methods (cont.)

• Discourse elicitation tasks
• Story retell
• Spoken Conversation
• Written Conversation
• Only written conversation was analyzed
• 5 probes in each task area were collected
  throughout the study for a total of 15 probes in
  addition to pre- and post- treatment probes

19
Methods (cont.)

• After each communication event, the subject was
  asked how she believed she performed during the
  conversation, story retell, etc. on several
  discourse measures using the following scale
• Poor
• Fair
• Good
• Better
• Best
• Then, investigator would provide a rating and
  give specific examples supporting the rating.
• Also, teaching the participant on how to improve
  her ratings was also targeted through discussion,
  examples, etc.

20
Example Prompts

• On this scale, how well do you think you used
  specific names of people, places, or things? How
  well do you think you provided a reference for me
  to know what youre talking about?
• On this scale, how well do you think you used
  transition words or phrases going from one topic
  of the conversation to the next?
• On this scale, how well do you think you did on
  talking for an equal amount of time as me during
  the conversation?

21
Within-sentence Analysis

• T-units
• Words
• Words per T-unit
• Subordinate clauses per T-unit
• Written output errors
• Nonspecific instances per T-unit
• Specific instances per T-unit
• Nonspecific instances with a clear referent per
  T-unit

22
Across-sentence Analysis

• Cohesive devices used per T-unit
• Effectiveness of cohesive devices used
• Types of cohesive devices used
• Reference
• Ellipsis
• Substitution
• Conjunction
• Lexical Cohesion

23
Text-level Analysis

• Global Coherence
• Local Coherence
• Appropriateness
• Ideational Perseveration
• Questions (monologue v. dialogue)

24
Agreement

• Intra-rater 90.7
• Inter-rater 55.5 with T-units
• Inter-rater 77.2 without T-units
• Interpret results with caution
• Since much of JBs written discourse was
  incomplete sentences missing main components of a
  T-unit, such as subjects, verbs, and objects,
  clear boundaries still could not be established

25
Results Formal Assessment

• Improvements in
• visual scanning, visuoverbal processing,
  higher-level language skills, and right-left
  differentiation
• auditory working memory, visual focused
  attention, and visual-spatial working memory
• sustained auditory attention, divided attention,
  selective attention, attention switching
• deductive reasoning skills, information
  integration, hypothesis testing, flexibility of
  thinking, descriptive narrative, and verbal
  abstraction skills

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28
Results Formal Assessment
29
Results Formal Assessment
30
Results Formal Assessment
31
Results Formal Assessment
32
Results Agreement in Ratings
33
Results Written Conversation

• Improvements in all areas, particularly
• Length of emails
• Appropriateness of emails
• Questions asked in emails
• Flow of emails less topic digressions and
  more transitions used
• Specificity of language in emails explained
  names, acronyms, places, etc.
• Typing accuracy continued to be a struggle, but
  was not a focus of the treatment study

34
Pre-treatment

• Familiar partner
• Bcum was great I,ve always been a teacher.I,ve
  read Doris kearns Goodwin.i miss you
• Unfamiliar partner
• happy Valinetine,s Day.speech and hearing used
  to be the University gym.

35
Week 3

• Familiar partner
• Peters was fine and something happened there.I
  read Goldilocks and the three bears.After
  that,theKindertend class was talking about people
  with disabilities and they talked about me.The
  teacher had .them write with their weak hand,and
  it was hard..She said"dowe laugh at people who
  have disabilities? they said noI It was good.As
  Misty said I have things that go beyond my
  disabilities..Thanks to Speech and Hearing.Bcum
  was good as always.

36
Week 3

• Unfamiliar partner
• Bayside county united Ministries ,where I read
  to the children, was good as always.Amutual
  admiration society just like you people here at
  Speech and Hearing.How are you and who are
  you?I,d like to meet you sometime!

37
Week 7

• Familiar partner
• I havin,t talked to you for a long time. How,s
  everything? I,m reading the Health care Bill
  with Kelsey. What do you think of it? Too many
  specifics. As George Will says "We have to wai.t
  and se how it plays out. How,s your husband?
  Remember Misty,the good ole Alpha Chi? She didn't
  have time for the computer,her daughter,Melissa
  did. I got a computer Facebook letter from her
  Good old computer! I miss you how,s Spring
  break and how,s school?

38
Week 9

• Unfamiliar partner
• Now that I,ve got to know you on the
  computer.Today was my birthday. Kelsey and
  Rebecca sent me a card. Ive had a pretty good
  life . Do you like this weather? I hope to meet
  you sometime in PERSON. Over and out

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Final Week

• Familiar partner
• I haven,t talked to you in a long time. How is
  Nick and Tutu and you? Are you ready for summer?
  Ididn,t go to BCUM (Bayside CountyUnited
  Ministries) Thursday. Iwalked with the walker
  last week . My knees are getting better after
  the knee muscle tear Ihad the last week. Just
  old age,I think. Are you ready for school? I
  miss you and I love you

40
Final Week

• Unfamiliar partner
• Ive heard a lot about you. Are youa figment of
  Kelsey,s imagination/? How is school? Did you go
  to commencement? .I heard Quincy Jones and Dave
  Baker from our Music-jazz school spoke. Are you
  ready for summer?No classes going on. I love you.

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4-6 Weeks Post

• Familiar partner
• How are you? Iknow your hubby and Tutu ,but who
  is that new person you mentioned inthe bunch?I
  can't remember. One bad thing happened tome this
  summer. My apartment door was unlocked with no
  one in it and my fanny pack was stolen,
  nomoneyinit. Just a hassle (Kelsey taught me how
  to spell it) That's O.K. At least my kitty Sofie
  wasn't stolen. Someone from Bayside House took
  it. No big deal except my private space was
  invaded. Howis the summer for you and Nick and
  Tutu? Imiss seeing you here. I love you

42
4-6 Weeks Post

• Unfamiliar partner
• How are you? Quite a summer ,isn't it?I have no
  plans 'except school starting' reading to the
  kids at Peters,at Bayside County United
  Ministries, and at my church and here at
  Speech and Hearing and I'm fine . I. U. is quite
  a place to be.isn't it? Over and out

43
Results T-units
44
Results Words
45
Results Words per T-unit
46
Results Specificity
47
Results Nonspecific with referent
48
Cohesive Devices per T-unit
49
Ineffective Cohesive Devices
50
Types of Cohesive Devices Used
51
Text-level Analysis Results
52
Ideational Perseveration
53
Appropriate Questions Asked
54
Word Length of Questions
55
Spoken Discourse Analysis

• Data collected and resulting patterns observed in
  written discourse appears to reflect that in the
  spoken discourse probes
• The changes in spoken discourse were judged to be
  not quite as dramatic as those in written
  discourse
• Despite the assumed similarities, conclusions may
  not be drawn from this subjective account
• Notable difference in appropriateness of
  discourse increased in written, but appeared to
  decrease in spoken
• Possibly due to increased comfort with
  investigator

56
Results Summary

• The most substantial improvements were made in
  improving the overall cohesion of her written
  discourse through the use of connecting her
  thoughts with cohesive devices (local coherence),
  increasing the effectiveness of the cohesive
  devices she used, and decreasing instances of
  ideational perseveration
• She also increased the specificity of her
  language, particularly with familiar conversation
  partners, and nonspecific language with clear
  referents with unfamiliar conversation partners

57
Results Summary (cont.)

• Her written discourse was also longer and more
  meaningful through the use of including stories
  and questions, which created more of a dialogue
  between her and her conversation partners
• Not only did she increase the number of cohesive
  devices she used during written discourse, but
  she also used them more effectively and used a
  wider variety of types of cohesive devices,
  making her written discourse richer with more
  fluidity
• The appropriateness of her written discourse
  improved

58
Results Some discrepancies

• Although JB made improvements in the written
  procedural, story generation, and monologue
  discourse tasks, her greatest gains involved
  writing to actual people rather than writing
  non-motivating discourse to no one (actually
  performed worse in some areas on those tasks)
• Naturally, her written discourse had more
  meaningful content to those who were familiar to
  her however, large gains were also seen in her
  written discourse with unfamiliar partners

59
Results - Maintenance

• Conversational Discourse
• length and complexity of written discourse,
  increased specificity, an increase in the number
  of cohesive devices used, wider variability of
  cohesive devices used, increased local coherence,
  increased appropriateness, and decreased
  ideational perseveration
• Procedural, Picture Description, Monologue
• length of complexity of written discourse,
  increased specificity, an increase in the number
  of cohesive devices used, increased effectiveness
  of cohesive devices used, wider variability of
  cohesive devices used, and increased local
  coherence

60
Discussion

• Variability in the written discourse results was
  noted, even within one task.
• Her performance may have been dependent on the
  discourse task, which is consistent with findings
  from Mentis and Prutting (1987) who found
  different cohesion patterns in each participant,
  depending on if the task was narrative or
  conversational in nature.

61
Discussion (cont.)

• JBs difficulty with coherence may be explained
  by Kennedy (2000), who suggested that many
  seemingly-irrelevant comments during conversation
  from those with RHD may actually be secondary
  topic scenes that they are unable to inhibit or
  connect through the use of cohesive devices.
• JB would often have seemingly-extraneous comments
  that would actually be related to the previous
  topic however, no connection was made between
  the two topics nor could she inhibit the
  secondary topics.
• As she became aware of this lack of cohesion
  through the treatment activities, she was better
  able to use cohesive devices effectively to
  reduce topic digressions and increase local
  coherence.

62
Discussion (cont.)

• The number and variety of cohesive devices JB
  used post-treatment resembled those of normal
  healthy adults, as reported by Mentis and
  Prutting (1987).
• Normal participants used cohesive ties
  approximately 60 of the time whereas those with
  TBI used ties only 30 of the time. JBs local
  coherence of using ties 57.14 of the time when
  writing to unfamiliar conversation partners thus
  resembles data from normal healthy adults more so
  than those with TBI.
• Additionally, the wider variety of types of
  cohesive devices used by JB post-treatment also
  reflects patterns used by normal healthy adults,
  particularly with the increased use of lexical
  cohesion (Mentis Prutting, 1987).

63
Discussion (cont.)

• Although JB made improvements in the written
  procedural, story generation, and monologue
  discourse tasks, her greatest gains involved
  writing to actual people (written conversation
  tasks) rather than writing non-motivating
  discourse to no certain person (i.e., performance
  of procedural, story generation, and monologue
  tasks).

64
Limitations

• Inter-rater agreement not adequate
• No multiple baseline data collected
• Number of participants
• Spoken data not analyzed
• Variability in the written discourse results was
  noted, even within one task

65
Clinical Implications

• Spoken conversation probes that were collected
  appear to reflect the results in written
  conversation probes
• Easy-to-use scale to promote self-feedback and
  awareness of conversation skills
• Can individualize targets to reflect patients
  deficits
• Can individualize scale for different cognitive
  levels
• Inexpensive
• No harm
• Can use for different modalities (writing,
  speaking, etc.)
• Can use in a variety of settings (SNF, outpatient
  rehab, inpatient rehab, group treatment, etc.)

66
Considerations

• Must be able to take detailed notes during
  conversation about discourse targets to support
  rating you assign while still participating in
  conversation
• Must be able to be honest with patient try to
  write down your rating before you hear theirs
• Must pick up on instances of dishonesty of
  ratings from patient

67
More Considerations

• Beware of extremely off ratings from patient
  they may not be able to accurately self-evaluate
  at first, but if this still persists into
  treatment, may not be effective for that
  individual
• Beware of no change in targets, even if ratings
  are accurate they may be able to self-evaulate,
  but may have difficulty modifying their behavior
  to achieve higher ratings
• Always encourage them to strive for the highest
  rating!
• With increased awareness, some patients will
  become confused, depressed, angry, resistant,
  etc. PROCEED WITH CAUTION!

68
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