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Developing Intentional, Symbolic Communication in Global Aphasia: A Case Study


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. – PowerPoint PPT presentation

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Title: Developing Intentional, Symbolic Communication in Global Aphasia: A Case Study

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

  • 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

  • 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.

  • 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)

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)

Demographics continued
  • 7 years post onset, J.V. remained functionally
    non-speaking w/ poor comp.
  • Test scores
  • WAB quotient .6/100
  • BASA 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)

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

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
  • Inability to maintain attention and required
    frequent cues to refer to others or to focus on
    topical stimuli.

Intervention Objectives/Activities
  • A. Basic Requesting Skills
  • 1. 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 (n4-6) 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)

  • 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).

  • 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

  • B. Conversational Skills
  • 1. Increase comprehension of conversational
  • 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 ("yesor no?") and visual
    model (nodding Y/N) plus augmented input natural
    consequences provided

  • 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
  • 4. Tell novel information via VOCA
  • Implement natural communication opportunities,
    wh-question prompts, and expectant delays (Halle
    et al., 1981) to prompt J.V. to access VOCA
    "news" message in group conversational

  • 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

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

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)
(No Transcript)
Categorical Assessment Form for Communicators
With Aphasia (Garrett Beukelman, 1992)
Criterion-referenced measures from
conversationally-based therapy activities
Functional Outcomes
  • J.V.s wife reported the following functional
    changes at home
  • More alert and attentive
  • Less perseverative, stereotypic echolalia
  • 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)

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
  • Partner-assisted strategies (making symbols
    available, augmented comprehension, naturalistic
    consequences) may also be of assistance

Future Directions
  • Develop a formal tool to catalogue the
    preintentional, intentional, and intentional/
    symbolic communication skills of people with
    profound aphasia during interactive communication
  • Formalize clinical pathways to teach
    attentional, referential, basic pragmatic, and
    emerging symbolic communication skills within
    interactive contexts
  • Gather effectiveness data for addl cases

  • Thanks to J.V., his wife, and caregivers for all
    of their extra efforts to participate in clinical
  • Thanks to Sara Osier and Lisa Bosco, graduate SLP
    clinicians, for their assistance in compiling
  • Thanks to the Duquesne SLP Clinic for its support
    of clinical research

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