Principals of Assessment and Intervention in Acquired Language Disorders

1. Principals of Assessment and Intervention in Acquired Language Disorders

2. Goals of Assessment To determine the presence of communication impairment Severity and type of impairment Determine the individual’s 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

3. 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

4. Goals of Assessment To determine the presence of aphasia, and severity and type of aphasia, using the _____________, and profile the client’s strengths and weaknesses NOT To administer the BDAE

5. 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

6. Assessment Defined • Organised, goal directed evaluation of the components of communication • Evaluation of person’s 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

7. 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

8. 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 client’s medical / cognitive / emotional state

9. 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

10. 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

11. Informal assessment Brookshire 2003

12. 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 Write to dictation – letters, numbers, words, sentences Write a paragraph / written narrative Brookshire 2003

13. 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?

14. 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

15. 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

16. 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

17. 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?

18. 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”

19. 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

20. 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

21. 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, can’t travel

22. 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)

23. Planning intervention What person can do cannot do does do What person needs to do wants to do closing the gap

24. Example – treatment planning MJ’s 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 MJ’s wish: to talk better with family and friends

25. Setting goals Overall goal: To maximise MJ’s 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 MJ’s 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 MJ’s goal

26. 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

27. Task hierarchies to draw single items communicatively to draw single events communicatively therapy tasks will involve encouraging Pt to be aware of the conversation partner’s needs, focusing on issues such as listening to the other person’s 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

28. 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).

29. 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

30. 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