Post-Conversation Feedback in Adults with Right-Hemisphere Brain Damage

1. Post-Conversation Feedback in Adults with Right-Hemisphere Brain Damage Kelsey Meiring, M.A., CF-SLP Indiana University Speech and Hearing Sciences kmeiring@indiana.edu

2. Introduction • Despite growing research focused on right-hemisphere brain damage (RHD), there is still a lack of research about this population, especially regarding treatment of cognitive-linguistic deficits (Blake, 2007) • Although many SLP’s do not evaluate or treat this population very often (Blake, 2006), only half of those with RHD cognitive-linguistic deficits are referred for S/L services (Blake, Duffy, Myers, Tompkins, 2002 ) • Since research is increasing awareness of RHD, more of these patients are likely to be referred for services, so SLP’s need to be prepared to treat them

3. Etiology v. Deficits • The study is a treatment study involving only right-hemisphere TBI addressing the symptoms of RHD • According to Blake (2007), treating the deficits of RHD regardless of etiology is more appropriate; therefore, it may also be applicable for right-hemisphere CVA

4. Purpose • The purpose of this study is to investigate a possible treatment protocol to address discourse and pragmatic issues related to RHD. • This treatment focuses on the use of feedback to increase awareness of deficits and to provide ways to improve discourse and pragmatic performance.

5. Normal Right Hemisphere Fx • Production of automated speech and the comprehension and production of prosody, emotional speech, narrative discourse, and pragmatics (Lindell, 2006) • Right-hemisphere is more involved in comprehension of language than production (Baynes, Tramo, & Gazzaniga, 1992; Gazzaniga, LeDoux, & Wilson, 1977; Zaidel, 1978) • Primarily responsible for integrating and producing connections across sentences and within sentences in discourse to obtain or convey the main idea (Gernsbacher & Kaschak, 2003)

6. Deficits – Aprosodia • Comprehension • Inability to interpret prosody to deduce a meaning from discourse. Therefore, jokes, sarcasm, and emotionally ambiguous sentences are often difficult to understand for this population • Production • Inability to produce prosody to express the intended communicative intent. Therefore, expressing emotions and conveying the correct form of sentences (e.g., interrogative versus declarative sentence) are very difficult for this population • Can have a combo of these (Lindell, 2006)

7. Deficits – Discourse/Pragmatics • Some variability in particular discourse and pragmatic deficits has been reported (Blake, 2006; Myers, 2001) • Common deficits: • Disinhibition • Impulsivity • Verbosity or paucity • Unbalanced turn taking • Difficulty generating inferences • Lack of or inappropriate eye contact • Topic digressions and tangentiality • Inappropriate topic and/or word choice • Difficulty comprehending discourse • Egocentricity • Disorganization and lack of cohesion • Lack of initiation • Ideational perseveration • (Blake, 2006; Chantraine, Joanette, & Ska, 1998; Glosser, 1993).

8. Deficits – Anosognosia • Presence of anosognosia tends to lead to poorer outcomes in treatment (Hartman-Maeir, Soroker, Oman, & Katz, 2003; Jehkonen et al., 2001; Noe et al., 2005) • This issue is central to the premise of the study; if one can become aware of his or her deficits, he or she may then begin the process to develop strategies to overcome these deficits.

9. Treatment – Aprosodia • Most treatments for aprosodia only focus on expressive deficits. • The most common treatments for aprosodia following RHD involve • Biofeedback (Stringer, 1996), • Cognitive-linguistic treatment (Leon et al., 2005; Rosenbek et al., 2004; Stringer, 1996), and • Imitative treatment with errorless learning cueing hierarchies (Leon et al., 2005; Rosenbek et al., 2004).

10. Treatment – Discourse/Pragmatics • Group treatment (Klonoff, Sheperd, O’Brien, Chiapello, & Hodak, 1990) • 3 participants • 5 hours of therapy, 5 days a week • Treatment involved role-playing, self-monitoring, and behavioral reviews. • Results were vague and did not formally assess pragmatics or discourse but rather gave subjective information regarding the progress in these areas. • Self-monitoring continued to be an issue for most participants at the termination of the group treatment. • Group treatment - Murray and Clark (2006)

11. Treatment – Discourse/Pragmatics • Most effective: • Role-playing • Self-monitoring • Behavior modification • Feedback, usually via videotape review • (Coelho, DeRuyter, & Stein, 1996)

12. Treatment – Anosognosia • Usually involves the prediction of performance on certain tasks or the use of feedback, similar to the treatments described for discourse and pragmatics • Youngjohn and Altman (1989) • 36 brain-injured participants • Predicted their performance on a free recall task and a written math task • Predictions and actual performance were reviewed with the participants in a group setting • More accurate self-predictions were reported by the end of the treatment.

13. Ethical Issues – Anosognosia tx • Cherney, 2006 • If the client does not see a need for treatment and refuses to attend, therapy may ethically not be pursued. • Even if the participant agrees to come to therapy, the lack of awareness of deficits will result in little motivation to participate and respond to treatment, which is essential to successful treatment. • Since unaware of the deficits, the participant cannot participate in the development of treatment goals or express his or her preferences for the direction of treatment. • If anosognosia persists, treatment to address safety issues still needs to be pursued at the discretion of the clinician.

14. Discourse Analysis • There are many ways to analyze discourse, making cross-study comparisons difficult (Togher, 2001) • Lê, Mozeiko, and Coelho (2011) developed four main areas of anaylsis of discourse: • Within-sentence • Across-sentence • Text-level • Story grammar analyses (Not used in this study)

15. Rationale of Study • Many patients with RHD have anosognosia, or a lack of awareness of deficits (Blake, 2006) • Patients are unable to modify behavior if they are unaware of the undesirable behavior • Therefore, increase awareness, increase ability to modify behavior • How do we increase awareness? • FEEDBACK

16. Methods • Single-subject design • Subject: • 62 year old female (“JB” to protect identity) • Right TBI sustained after being hit by a car while on bicycle in 1987 (22 years post-onset) • Presenting symptoms: • Subject’s symptoms consist with findings of Blake (2006), although RHD deficits may vary widely among individuals – reinforces idea to TREAT SYMPTOMS, not etiology • Disinhibition • Anosognosia • Verbosity • Lack of specificity • Ideational perseveration • Lack of transitions • Frequent topic digressions • Pragmatics (frequently inappropriate)

17. Methods (cont.) • 20 treatment visits • 2x/week, 60-minute session & 90-minute session • Pre- and post- treatment testing • 4-6 week post-treatment testing

18. Methods (cont.) • Discourse elicitation tasks: • Story retell • Spoken Conversation • Written Conversation • Only written conversation was analyzed • 5 probes in each task area were collected throughout the study for a total of 15 probes in addition to pre- and post- treatment probes

19. Methods (cont.) • After each communication event, the subject was asked how she believed she performed during the conversation, story retell, etc. on several discourse measures using the following scale: • Poor • Fair • Good • Better • Best • Then, investigator would provide a rating and give specific examples supporting the rating. • Also, teaching the participant on how to improve her ratings was also targeted through discussion, examples, etc.

20. Example Prompts • “On this scale, how well do you think you used specific names of people, places, or things? How well do you think you provided a reference for me to know what you’re talking about?” • “On this scale, how well do you think you used transition words or phrases going from one topic of the conversation to the next?” • “On this scale, how well do you think you did on talking for an equal amount of time as me during the conversation?”

21. Within-sentence Analysis • T-units • Words • Words per T-unit • Subordinate clauses per T-unit • Written output errors • Nonspecific instances per T-unit • Specific instances per T-unit • Nonspecific instances with a clear referent per T-unit

22. Across-sentence Analysis • Cohesive devices used per T-unit • Effectiveness of cohesive devices used • Types of cohesive devices used: • Reference • Ellipsis • Substitution • Conjunction • Lexical Cohesion

23. Text-level Analysis • Global Coherence • Local Coherence • Appropriateness • Ideational Perseveration • Questions (monologue v. dialogue)

24. Agreement • Intra-rater: 90.7% • Inter-rater: 55.5% with T-units • Inter-rater: 77.2% without T-units • Interpret results with caution • Since much of JB’s written discourse was incomplete sentences missing main components of a T-unit, such as subjects, verbs, and objects, clear boundaries still could not be established

25. Results – Formal Assessment • Improvements in: • visual scanning, visuoverbal processing, higher-level language skills, and right-left differentiation • auditory working memory, visual focused attention, and visual-spatial working memory • sustained auditory attention, divided attention, selective attention, attention switching • deductive reasoning skills, information integration, hypothesis testing, flexibility of thinking, descriptive narrative, and verbal abstraction skills

28. Results – Formal Assessment

29. Results – Formal Assessment

30. Results – Formal Assessment

31. Results – Formal Assessment

32. Results – Agreement in Ratings

33. Results – Written Conversation • Improvements in all areas, particularly: • Length of emails • Appropriateness of emails • Questions asked in emails • “Flow” of emails – less topic digressions and more transitions used • Specificity of language in emails – explained names, acronyms, places, etc. • Typing accuracy continued to be a struggle, but was not a focus of the treatment study

34. Pre-treatment • Familiar partner • “Bcum was great I,ve always been a teacher.I,ve read Doris kearns Goodwin.i miss you” • Unfamiliar partner • “happy Valinetine,s Day.speech and hearing used to be the University gym.”

35. Week 3 • Familiar partner • “Peters was fine and something happened there.I read Goldilocks and the three bears.After that,theKindertend class was talking about people with disabilities and they talked about me.The teacher had .them write with their weak hand,and it was hard..She said"dowe laugh at people who have disabilities? they said noI It was good.As Misty said I have things that go beyond my disabilities..Thanks to Speech and Hearing.Bcum was good as always.”

36. Week 3 • Unfamiliar partner • “Bayside county united Ministries ,where I read to the children, was good as always.Amutual admiration society just like you people here at Speech and Hearing.How are you and who are you?I,d like to meet you sometime!”

37. Week 7 • Familiar partner • “I havin,t talked to you for a long time. How,s everything? I,m reading the Health care Bill with Kelsey. What do you think of it? Too many specifics. As George Will says "We have to wai.t and se how it plays out.“ How,s your husband? Remember Misty,the good ole Alpha Chi? She didn't have time for the computer,her daughter,Melissa did. I got a computer Facebook letter from her Good old computer! I miss you how,s Spring break and how,s school?”

38. Week 9 • Unfamiliar partner • “Now that I,ve got to know you on the computer.Today was my birthday. Kelsey and Rebecca sent me a card. Ive had a pretty good life . Do you like this weather? I hope to meet you sometime in PERSON. Over and out”

39. Final Week • Familiar partner • “I haven,t talked to you in a long time. How is Nick and Tutu and you? Are you ready for summer? Ididn,t go to BCUM (Bayside CountyUnited Ministries) Thursday. Iwalked with the walker last week . My knees are getting better after the knee muscle tear Ihad the last week. Just old age,I think. Are you ready for school? I miss you and I love you”

40. Final Week • Unfamiliar partner • “Ive heard a lot about you. Are youa figment of Kelsey,s imagination/? How is school? Did you go to commencement? .I heard Quincy Jones and Dave Baker from our Music-jazz school spoke. Are you ready for summer?No classes going on. I love you.”

41. 4-6 Weeks Post • Familiar partner • “How are you? Iknow your hubby and Tutu ,but who is that new person you mentioned inthe bunch?I can't remember. One bad thing happened tome this summer. My apartment door was unlocked with no one in it and my fanny pack was stolen, nomoneyinit. Just a hassle (Kelsey taught me how to spell it) That's O.K. At least my kitty Sofie wasn't stolen. Someone from Bayside House took it. No big deal except my private space was invaded. Howis the summer for you and Nick and Tutu? Imiss seeing you here. I love you”

42. 4-6 Weeks Post • Unfamiliar partner • “How are you? Quite a summer ,isn't it?I have no plans 'except school starting' reading to the kids at Peters,at Bayside County United Ministries, and at my church and here at Speech and Hearing and I'm fine . I. U. is quite a place to be.isn't it? Over and out”

43. Results – T-units

44. Results – Words

45. Results – Words per T-unit

46. Results – Specificity

47. Results – Nonspecific with referent

48. Cohesive Devices per T-unit

49. Ineffective Cohesive Devices

50. Types of Cohesive Devices Used