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

1
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

2
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

3
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.

4

• 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)

5
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)

6
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)

7
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

8
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.

9
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)

10

• 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).

11

• 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

12

• 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 ("yesor no?") and visual
  model (nodding Y/N) plus augmented input natural
  consequences provided

13

• 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,
  wh-question prompts, and expectant delays (Halle
  et al., 1981) to prompt J.V. to access VOCA
  "news" message in group conversational
  activities.

14

• 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.

15
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

16
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)
17
(No Transcript)
18
Categorical Assessment Form for Communicators
With Aphasia (Garrett Beukelman, 1992)
19
Criterion-referenced measures from
conversationally-based therapy activities
20
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)

21
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

22
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 addl cases

23
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

24
FOR HANDOUTS..

• Please write down your name and email address
• Thanks for clear handwriting
• Please make sure your address accepts attachments
• Or retrieve this presentation from the following
  website http//aac.unl.edu
• Thank you for your interest!!!