Referential Skills and Expressive Communication in Severe Aphasia: Therapy Implications

1. Referential Skills and Expressive Communication in Severe Aphasia: Therapy Implications Kathryn L. Garrett, Ph.D. CCC-SLP Duquesne University Pittsburgh, PA garrettk@duq.edu PSHA 2002, Pittsburgh

2. Words of reassurance/disclaimer... • Aphasia • Severe Disability • Child Language Kathryn L. Garrett, Ph.D. CCC-SLP

3. Relevant information for aphasia... Kathryn L. Garrett, Ph.D. CCC-SLP

4. I. Introduction • Referential communication is a fundamental component of socio-communicative interactions • Referential communication skills emerge before the age of 1 year, and before the onset of verbal communication in young children Kathryn L. Garrett, Ph.D. CCC-SLP

5. What is referential communication? • Abbeduto, Short-Meyerson, Benson, Dolish, & Weissman (1998) described “physical referencing” as: • ...an understanding that an item that is present in an individual’s 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. Kathryn L. Garrett, Ph.D. CCC-SLP

6. Examples of Early Referential Skills • 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 another’s turn • Searching for items or symbols that represent answers to questions (“What do you want to play with?”) Kathryn L. Garrett, Ph.D. CCC-SLP

7. Deictic referencing “It happened right here in Pittsburgh!” [I want you to pick me up] Kathryn L. Garrett, Ph.D. CCC-SLP

8. Evolves to…... Object level deictic Temporally displaced referencing- present verbal referencing “Did you hear what happened to the gym floor at the dance last weekend?” “What’s dat?” Kathryn L. Garrett, Ph.D. CCC-SLP

9. To complex referential communication, in which multiple referents are displaced over time and space…. “First, I’d like you to recall our decision from a week ago…wewere discussing the land management plan for this wetlands area…you can see here how the data show a decrease in…. Kathryn L. Garrett, Ph.D. CCC-SLP

10. The relationship of referential skills to attention….. • Referential communication skills develop as a result of learning how to manage one’s own and direct others’ attention (from Bruner, 1983; p. 68). Kathryn L. Garrett, Ph.D. CCC-SLP

11. The evolution of coordinated joint attention in the young child occurs in 3 stages: (Wetherby et al., 1998): • Stage 1)Attention to social partners: • Intense, prolonged interest in caregivers • Quieting, shared gaze with/to others Kathryn L. Garrett, Ph.D. CCC-SLP

12. Adamson & Chance, 1998 • As infants near 1 year of age, they begin to communicate with their caregivers about objects and events in their immediate surroundings…they transition from reflexive to intentional communication. • Nonverbal grunts, cries, gestures, and movements shift to…. • Pointing, offering, reaching, requesting, indentifiable vocalizations Kathryn L. Garrett, Ph.D. CCC-SLP

13. This coincides with the emergence of…. • Stage 2) Joint Attention: • Fascination with others decreases • Attention shifts to external activities or objects • Partners can share in the object focus • Attention skillfully flows between objects and people by approximately 1 and 1/2 years of age Kathryn L. Garrett, Ph.D. CCC-SLP

14. Another major shift in the development of attention coincides with the emergence of symbolic language Kathryn L. Garrett, Ph.D. CCC-SLP

15. Stage 3) Coordinated Joint Engagement: • Social and object realms become entwined • Symbolic skills/language become part of attentional routines • Child and partner focus on events from the present as well as the past, or from imaginary thinking • Child acts in a manner that matches (or intentionally does not match) what the partner says, with or without looking at the partner • Symbolic code itself may become the focus of joint attention (e.g., naming games - “What’s dat?”) Kathryn L. Garrett, Ph.D. CCC-SLP

16. To reiterate…. • The expansion of referential skills and the development of coordinated joint attention co-occur with intentional-symbolic communication and early word and language learning in the young child Kathryn L. Garrett, Ph.D. CCC-SLP

17. So what does this have to do with severe aphasia?

18. II. Statement of the Problem • Some communicators with severe-to-profound aphasia appear to have an elemental challenge in referential as well as verbal/linguistic communication skills Kathryn L. Garrett, Ph.D. CCC-SLP

19. And... • Communicators with severe aphasia often need explicit instruction to engage in: • Activities involving coordinated joint attention - between communicator, social participants and physical referents • Basic deictic referencing to signal others to look, to take a turn, to refer to an item, to yield info e.g., “Show me where you went” Kathryn L. Garrett, Ph.D. CCC-SLP

20. However... • Many therapy approaches for communicators with severe aphasia (speech stimulation, MIT, linguistic process tx, AAC) assume a foundation of: • Joint attention skills • Referential communication skills • Intentional communication signals • Basic symbolic ability - understanding that external symbols represent meanings Kathryn L. Garrett, Ph.D. CCC-SLP

21. So…. • Is it appropriate to begin working on speech, symbolic gestures, or symbolic AAC strategies before communicators demonstrate some evidence of these skills? • Or without simultaneously working on attentional and referential skills? Kathryn L. Garrett, Ph.D. CCC-SLP

22. Video Interlude... Watch for instances of communicators with severe aphasia requiring assistance to attend to a shared activity/referent, to establish reference, or to intentionally signal each other while conversing

23. Who’s who in aphasia group…. Ray Steve Clinician John Charley Kathryn L. Garrett, Ph.D. CCC-SLP

24. III. Hypotheses KG limb Kathryn L. Garrett, Ph.D. CCC-SLP

25. Hypotheses cont. • A) Individuals with severe aphasia may not be able to produce propositional, verbal-symbolic communication (speech or nonspeech modalities) until basic referential skills emerge (either naturally or with facilitation) Kathryn L. Garrett, Ph.D. CCC-SLP

26. Hypotheses continued • B) the emergence of meaningful spoken or alternative communication may coincide with/parallel the reacquisition of basic referential skills in severe aphasia • pointing to others • shifting gaze to a speaker • physically manipulating externally-stored symbols (pictures, words, etc.) to answer a question. Kathryn L. Garrett, Ph.D. CCC-SLP

27. C) Perceptions of communication competence in communicators with severe aphasia may be more correlated with referential ability than with linguistic performance on standardized aphasia tests Kathryn L. Garrett, Ph.D. CCC-SLP

28. Hypotheses continued • D) perhaps explicitly teaching communicators with severe aphasia to engage in referential communication can improve their overall communication and/or linguistic skills • “Who did you come with -- show me?” • “Ask Robert - where did you go for Thanksgiving [point]?” Kathryn L. Garrett, Ph.D. CCC-SLP

29. IV. Preliminary Data Kathryn L. Garrett, Ph.D. CCC-SLP

30. Preliminary Data were derived from…. • Perceptual rankings and ratings of overall communication competence were derived after jury members (4 student clinicians, 1 supervisor) interacted with participants in aphasia group therapy for an entire semester. • Quantitative data on frequency of referential acts was derived from one randomly selected aphasia group therapy session that was judged to be representative of typical skills Kathryn L. Garrett, Ph.D. CCC-SLP

31. Participant Demographics • Ray - age 69 • 2 years post left CVA (subcortical, plus multiple small infarcts); 1+ years of group tx • Mixed output - some utterances were complete, propositional sentences, but often perseverated or did not attempt to communication • WAB Aphasia Quotient of 69/100 • Limited initiations or efforts to communicate symbolically, but good participation when instructed or in structured language tasks. Limited deixis. • Steve – age 72 • 2 years post left CVA (thrombotic); 2 years tx in group • nonfluent, agrammatic; moderate-to-severe aphasia • WAB Aphasia Quotient of 35/100 • Intentional, frequent initiations; some gestures , writing and speech; frequent deictic communication Kathryn L. Garrett, Ph.D. CCC-SLP

32. Demographics cont. • John – age 59 • 7 years post left CVA (hemorrhagic) and hypoxic episode; 1+ year tx in group • Most nearly fit category of global aphasia • WAB Aphasia Quotient of .6/100; BASA 2nd %ile (global norms) • Most communication acts were presymbolic and preintentional prior to beginning group therapy - became intentional but with limited referential ability Kathryn L. Garrett, Ph.D. CCC-SLP

33. Charley - age 68 • 1 year post left CVA; 3 prior mild CVAs plus 2 MCI’s; 4 months tx in group • Former athlete, good comprehension, spoke grammatical sentences with significant anomia and apraxia of speech (thus frequent communication breakdowns) • WAB Aphasia Quotient of 70/100 • Discourse level communication, but frequently did not clarify referents when partners signaled they did not understand. Spelled at times; otherwise, did not compensate with alternate symbolic modality Kathryn L. Garrett, Ph.D. CCC-SLP

34. Who’s who in aphasia group…. Ray Steve Clinician John Charley Kathryn L. Garrett, Ph.D. CCC-SLP

35. Clinician Juried Rankings/Ratings of Overall Communication Competence - Unstructured and Assisted Conversation • RankingSuccess in (1 = best, 4 = worst) Message Participation Transmission • #1) Steve………………1.5……………….. 3.5 • #2) Charlie……………. 2.5……………….. 3.0 • #3) Ray…………………6.0……………….. 5.0 • #4) John………………..3.5……………….. 6.0 Ratings on 7-pt. Conversational Competence Scale (1 = best, 7 = worst) Kathryn L. Garrett, Ph.D. CCC-SLP

36. Then we looked at the frequency of each participant’s referential communication acts in a 12-minute structured interaction (aphasia group therapy - context building about going to the bar) • A clinician-led session was selected because more communication acts were elicited across participants; this aided in the development of pilot protocols for observing target referential behaviors Kathryn L. Garrett, Ph.D. CCC-SLP

37. Definitions of Coded Referential Skills • A. Social/Pragmatic Referential Skills • Deictic expressions for the purposes of initiating interaction or turn-taking • Simple social gestures (Hi!, “Why”) • B. Semantic/Symbolic Referential Skills • Deictic expressions that included some fixed semantic content or symbolic meaning • E.g., symbolic gestures, 1-2 word responses • C. Discourse Level Referential Skills • Sentence length utterances that specified relationships between actors, objects and events across time and space Kathryn L. Garrett, Ph.D. CCC-SLP

38. Frequency of Referential Communication Acts - 12 min group interaction 0 Kathryn L. Garrett, Ph.D. CCC-SLP

39. V. Target Referential Skills for Communicators with Severe-to-Profound Aphasia – A Proposed Tx ‘Hierarchy’ A. Social/Pragmatic Referential Skills B. Semantic/Symbolic Referential Skills C. Discourse Level Referential Skills

40. A. Social-Pragmatic Referential Skills • 1. Basic Deixis (nonsymbolic gestures that establish reference) • For turn-taking • For requesting items or additional information • To indicate a referent of shared interest “Dean - ask Jerry what he thought of the election...[hand-over-hand assist to point to Jerry to request info]” Kathryn L. Garrett, Ph.D. CCC-SLP

41. A. Social-Pragmatic Referential Skills cont. • 2. Tangible Referent Identification • immediate environment Example: “Show us what you bought this weekend” [visual prompt to encourage Jane to point to her own new sweater] Kathryn L. Garrett, Ph.D. CCC-SLP

42. The transition to symbolic-level referential communication... • Symbolic communication signals (gestures, pointing to symbols, spoken words) establish reference, but also convey some fixed semantic content (Hunt-Berg, 2001) Kathryn L. Garrett, Ph.D. CCC-SLP

43. B. Semantic/Symbolic Referential Skills - cont. • 1. Reference visual symbols to answer conversational questions Example: Photo Album Conversations - point to pictures to answer auto-biographical questions such as… “Where was your favorite vacation?” Kathryn L. Garrett, Ph.D. CCC-SLP

44. B. Semantic/Symbolic Referential Skills - cont. • 2. Point to/present a tangible topic setterto initiate a conversational topic (Garrett, 2001; Weiss & Ho, 1997) Example: Teach family members to place remnant of an outing or activity in view or in communicator’s pocket. Use verbal or physical cues to trigger presentation of remnant in response to peer question “What’s new?” Fade cues as appropriate Kathryn L. Garrett, Ph.D. CCC-SLP

45. Ex. of Tangible Topic Setter - Cruise Brochure Kathryn L. Garrett, Ph.D. CCC-SLP

46. B. Semantic/Symbolic Referential Skills cont. • 3. Access 1 or more prestored messages to convey “NEWS” on a Voice Output Communication Aid (VOCA) in response to conversational question “What’s new?” • Every activation yields a meaningful, semantically specific response that is always “accurate” • The communicator is not required to cognitively discriminate and choose the correct message. Also, there are minimal to no sequencing demands. Kathryn L. Garrett, Ph.D. CCC-SLP

47. I spent it all already - a necklace for my wife, and a lobster dinner. Whoo Hoo!!!! Guess what! We went gambling and I won $500!!! Example: SIMPLE VOCA DISPLAY Kathryn L. Garrett, Ph.D. CCC-SLP

48. B. Semantic/Symbolic Referential Skills cont. • 4. Access semantically specific messages to request or answer specific questions on VOCA or low tech communication display • More complex than accessing an “always accurate” news or autobiographical message • Communicator must listen to content of question, then select from an array of message representations Kathryn L. Garrett, Ph.D. CCC-SLP

49. J.V. telling Sara he wants to watch a movie by pointing to a photo choice after she asked “Well, what do you feel like doing right now?” Kathryn L. Garrett, Ph.D. CCC-SLP

50. B. Semantic/Symbolic Referential Skills cont. • 5. Point to semantically specific written word choices to answer conversational questions (Written Choice Conversation Strategy -- Garrett & Beukelman, 1992; 1995 * * * * * * * * * * * * * Example: “Which part of the turkey will you eat for dinner on Thanksgiving…? • white meat • drumstick • the giblets • None - I’m a vegetarian! Kathryn L. Garrett, Ph.D. CCC-SLP