Title: Grand Rounds on Aphasia Group Treatment ASHA 2000 Washington, D.C.
1SEVERE APHASIA GROUP TEACHING REFERENTIAL
SKILLS TO ENHANCE BASIC INTERACTIONAL
COMMUNICATIONKathryn L. Garrett, Ph.D., CCC-SLP
Duquesne University, Pittsburgh, PA
- Grand Rounds on Aphasia Group TreatmentASHA
2000Washington, D.C.
2I. Overview of Duquesne University /Nebraska
Aphasia Group Model
3A. History
- University of Nebraska-Lincoln - 1993-1997
Garrett Ellis - Student training programs
- Adults with a wide variety of aphasia types,
ages, backgrounds - Duquesne University (Pittsburgh) - 1998-present
Garrett Staltari - Ever-increasing demand for services at the
post-acute rehabilitation phase
4- B. Types of Groups (2)
- Mild-Moderate Aphasia Group
- Difficulties with fluency, semantic flexibility
and specificity, organization of discourse,
timing, and integration of language with high
level social-pragmatic skills - Participants tend to have generally good auditory
comprehension primarily communicate by speaking
(although enhancement through other modalities is
often a goal)
5- Severe Aphasia Group
- Participants have limited to no verbal
communication. Typically have some degree of
auditory comprehension breakdown as well -- from
mild to severe. - Have difficulties initiating communication acts
conveying novel,semantically specific
information referencing what theyre talking
about attending to relevant info/conversational
partners engaging in reciprocal exchanges
6C. Purposes (4) of Therapy Groups
- To improve linguistic skills
- Semantic
- Discourse
- To improve interactional skills in
- Conversational Contexts
- Transactional Contexts
7C. Purposes (4) of Therapy Groups (cont.)
- To increase communicators use of compensatory
strategies when appropriate - To assist clients and significant others to learn
to live with aphasia (after Lyon, 1996)
8D. 3 Basic Principles Communication in
Meaningful Contexts
- (1) USE language vs. practice
- Embed language targets in a connected sequence of
communication acts that have a purpose - EX Asking your wife out on a date vs.
practicing her name and I love you in an
isolated context
9- Prepare for challenges to resource allocation
practice compensating for situational demands in
tx - EX Practice standing up, walking to movie
counter, asking for a ticket, being bumped,
getting back on track and requesting a
ticket
10- (2) Communicate at the level of discourse
- Have a GOAL (conduct a transaction, to tell a
story, to explain how to do something) - ORGANIZE the communication acts you need to
achieve this goal - Ex. Hi honey - come here gesture. Date?
11- Add enough REFERENTIAL/ SEMANTIC SPECIFICTY and
COHESION to convey ideas - Ex. Movies - you? or show newspaper
- Consolidate multiple communication modalities
into one communication act - EX Hand her flowers and say I love you
vs. practicing speech and gestures separately
12- (3) utilize thematic, situational activities
in tx - Examples
- Planning a party for group member
- Going to the bank
- Greeting trick-or-treater
- May facilitate retrieval of language associated
with episodic memory - Preliminary observations increased complexity
and automaticity of expressive communication
13E. Structure of the Model- In Brief
- Conversation
- Context-Building
- Language Mediation
- Discourse
14Reference
- Garrett, K., Ellis, G. (1999) Group
communication therapy for people with long-term
aphasia Scaffolded thematic discourse
activities. In R. J. Elman (Ed.), Group
Treatment of Neurogenic Communication Disorders
The Expert Clinician's Approach. Boston
Butterworth-Heinemann. Pp. 85-96.
15II. SEVERE APHASIA AND REFERENTIAL COMMUNICATION
16A. Preliminary observations
- Some communicators with severe aphasia (across
modalities) appear to have an elemental challenge
in referencing ability - Need explicit instruction to engage in basic
referential skills..
17- Attending to others (especially speakers)
- Pointing to request
- Pointing (indexing) an object, picture or written
word to clarify the referent when
answering/commenting - Gesturing deictically to request info or indicate
anothers turn - Searching for tangible information when answering
questions (e.g., in communication notebooks,
etc.)
18- Abbeduto, Short-Meyerson, Benson, Dolish,
Weissman (1998) described physical referencing
as - ...an understanding that an item that is present
in an individuals proximal life space may be the
topic of conversation or concept under
discussion. - Their research indicated that referential skills
(particularly physical referencing) are present
in young children as well as older children with
developmental language delays.
19B. Hypotheses
- That individuals with severe aphasia may not be
able to produce propositional, verbal (speech or
nonspeech modalities) communication until basic
referential skills emerge (either naturally or
with facilitation) - That the emergence of meaningful spoken or
alternative communication coincides/ parallels
the reacquisition of basic referential skills
such as pointing to others, shifting gaze to a
speaker, physically manipulating
externally-stored info (pictures, words, etc.) to
answer a question.
20C. Target Referential Skills - A Proposed
Hierarchy
- 1. Social-Pragmatic Referential Skills
- 2. Semantic/Symbolic Referential Skills
- 3. Discourse Level Referential Skills
21- 1. Social-Pragmatic Referential Skills
- Basic Deixis
- For turn-taking
- For requesting additional information
- Dean - ask Jerry what he thought of the
election...hand-over-hand assist to point to
Jerry to request info
22- 1. Social-Pragmatic Referential Skills (cont).
- Tangible Referent Identification- immediate
envirionment - Example Show us what you bought this weekend
visual prompt to encourage Jane to point to her
own new sweater
23- 2. Semantic/Symbolic Referential Skills
- Visual symbol referencing
- Example Photo Album Conversations - point to
pictures to answer autobiographical questions
Where was your favorite vacation?
24- 2. Semantic/Symbolic Referential Skills continued
- Point to tangible topics setters to initiate a
conversational topic (Weiss Ho, 1997) - Example Teach family members to place remnant
of an outing or activity in view or in
communicators pocket. Use verbal or physical
cues to trigger presentation of remnant in
response to peer question Whats new?. Fade
cues as appropriate
25- 2. Semantic/Symbolic Referential Skills continued
- Access sequence of messages to convey NEWS on a
Voice Output Communication Aid (VOCA) - no
selection/minimal sequencing demands
We went gambling
26- 2. Semantic/Symbolic Referential Skills continued
- Access semantically specific messages to answer
specific questions -- on VOCA
STEAK
Id like to order.
rare
LOBSTER
Well-done
27- Point to semantically specific written word
choices to answer conversational questions
(Written Choice Conversation Strategy -- Garrett
Beukelman, 1995) - Example Who do you want to win the election
Gore Bush You dont CARE
anymore!
28- 3. Discourse Level Referential Skills (advanced
communicators - move to mild-moderate aphasia
group) - Answering questions with semantically specific
referents - Commenting
- Asking questions
- Time markers and (then)
- Continuers and, but
29- Explicit, referential communication occurs in one
or more modalities - Gestural - Vocal
- Verbal - Writing
- AAC or other external symbols
- Self-initiated communication acts increase
- Turn-taking and other pragmatic aspects of
interactional communication kick in
30D. How are referential communication
opportunities embedded in group activities for
people with severe aphasia?
VIDEO ILLUSTRATION
31Additional References
- Lyon, J. (1996) Optimizing communication and
participation in life settings for aphasic adults
and their primary caregivers in natural settings
A use model for treatment. In GL Wallace (Ed),
Adult Aphasia Rehabilitation. Boston
Butterwowrth-Heinemann, 1996 137-160.
32- Abbeduto, L., Short-Meyerson, K., Benson, G.,
Dolish, J., Weissman, M. (1998) Understanding
referential expressions in context Use of
common ground by children and adolescents with
mental retardation. JSHR, 41, 1348-1362.
33- Weiss, S., Ho, K. (1997, November) Remnant
books in aphasia AAC strategies for patients in
the acute rehabilitation setting. Poster session
presented at the annual meeting of the American
Speech-Language, and Hearing Association, Boston,
MA.