Week 12: SPH801B

Acquired Language Disorders I

Dr Scott Barnes
Unit Convenor

Overview of Week 12

Week 11 clean up
Assessment 2
Interaction and aphasia
Related assessment and intervention

Assessment 2

Source: http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf
4

Sources: http://www.aphasia.ca; Kagan (2011).

Consequences, cont...

Beyond impairment
Many different labels used for functional
approaches to aphasia
They address the consequences of aphasia
However, there are many ways categorising,
conceptualising, assessing, and treating these
consequences

Consequences of aphasia
...including:
o Discourse & pragmatics
o Functional communication
o Psychosocial
o Social participation
o Interactional

Philosophical frame
Byng & Duchan (2005); Elman (2011)

Social and Life Participation models offer a

framework for approaching intervention
NOT a distinct type of intervention
Often contrasted with a medical model for
service delivery

Philosophical frame
Byng & Duchan (2005); Elman (2011)

Re-orients the relationship between service

provider and service users
Views services users as partners, with their own
expertise to contribute
Encourages user participation in determining
the nature of services
In doing so, places the life of PWA at the centre
of service provision

Interaction and aphasia

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Why interaction?
...the organization of interaction needs to beand is
robust enough, flexible enough, and sufficiently selfmaintaining to sustain social order at family dinners and
in coal mining pits, around the surgical operating table
and on skid row, in New York City and Montenegro and
Rossel Island, and so forth, in every nook and cranny
where human life is to be found.
Schegloff (2006, p. 71)

Why interaction?
Wilkinson (1999); Simmons-Mackie (2008)
Most human activities are conducted with others
It is the medium through which we live our lives
Therefore, it is likely to reveal unique information about
impairments and consequences of aphasia

Why interaction?
Wilkinson (1999); Simmons-Mackie (2008)

Appealing for aphasiologists because:

o Focus is on authentic contexts
o Focus is on communicative activities
o Highlights the jointly-achieved nature of
communication
o Highlights the competencies of PWA, as well as
(sometimes, unexpected) deficits

Why interaction?
Simmons-Mackie et al. (2010); Beckley et al. (2013)

There are a variety of interaction-focused approaches:

o
o
o
o
o

Counselling-focused vs. strategy-focused

Generic vs. individualised
Partner-focused vs. PWA-focused
Authentic interactions vs. controlled interactions
Everyday communication partners vs. unfamiliars, clinicians

All agree on the importance of training CPs

Conversation partner training

Simmons-Mackie et al. (2010); Cherney et al. (2013)

Who is trained? And why? Principally:

o Family, friends
o Health professionals

However, if one is to make society more communicatively

accessible, training should be broadly conducted
Perhaps schools are an appropriate starting point?

Conversation partner training

Hopper et al. (2002)

Conversation coaching
PWA and familiar CP are encouraged to use facilitative
strategies in interactions guided by the clinician
Baseline and outcome measures involved PWA
independently watching a video, then re-telling to CP
Same during Rx sessions; clinician coached when
communication problems emerged
Dyads improved information transfer following treatment
o See also Boles (1997, 2010) for a related intervention

Source: Hopper et al. (2002)

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Conversation partner training

Lyon et al. (1997)

Communication Partners training program

Focused on authentic communication situations
Intervention involves PWA, their significant other,
and a community volunteer
PWA and CPs are trained to develop effective
communication strategies
Then, together, they participate in various activities
selected by the PWA
Demonstrated improvements in psychosocial
wellbeing

Conversation partner training

Kagan (1998); Kagan et al. (2001)

Supported Conversation for Adults with Aphasia (SCA)

Kagan began developing this program after noticing the
contrast between what PWA could accomplish with a good
conversation partner, vs. a poor one
Focus is on competence
That is, Kagan argues that aphasia obscures the inherent
competence of PWA
SCA fosters attitude, strategies to facilitate recognition of
that competence

SCA
Supported Conversation for Adults with Aphasia
Acknowledging Competence
Strategies to help people with aphasia feel as though
they are being treated respectfully
Revealing Competence
Strategies to get and to give accurate information
Aim is to make communication accessible

Acknowledging competence
Speak naturally (with normal loudness), using an adult
tone of voice
Acknowledge the frustrations of the person with aphasia
Explicitly attribute breakdowns to your own limitations
as a communicator (e.g. through humour)
Be open about whether you have understood. Dont
pretend to understand when you havent
Check that it is ok to seek information from others (e.g. a
spouse)

Revealing competence (IN)

Use short, simple sentences and a clear voice
Eliminate environmental distractions (e.g. noise, people,
material clutter)
Support speech with multiple other modalities (e.g.
gesture, writing, pictures)

Revealing competence (OUT)

Ask yes/no questions and make sure that the person
with aphasia has a way to respond
Ask one thing at a time, and give the person with aphasia
time to respond
Ask the person with aphasia to give clues by gesturing, or
pointing to objects, pictures, and written key words (e.g.
can you show me what youre talking about?)

Revealing competence (VERIFY)

Summarise slowly and clearly what you think the
person with aphasia is trying to say, (e.g., so let me
make sure I understand)
Reflecting

Repeating the message

Expanding Add to what you think the person with aphasia

may be trying to say
Combining Pulling things together at the end of a longer
discussion

Conversation partner training

Kagan (1998); Kagan et al. (2001)

Evidence for using SCA is sound

Conducted an RCT; found significant improvement in
information transfer and social affiliation for people who
had received training
However, these were volunteers; no published validations
of intervention and measures for family, friends
Modified versions have been used with health
professionals, with positive outcomes (e.g., Legg et al.,
2005)

Conversation partner training

Simmons-Mackie et al. (2007)

Training health professionals aims to make health system

more accessible
Rather than training individuals it may therefore be more
appropriate to focus on the systems they maintain
SCA was used to train acute, rehab, and long-term care
teams
Teams had communication accessibility solutions tailored
to their contexts; had a person in charge of coordinating

Conversation partner training

Simmons-Mackie et al. (2007)

Outcomes were assessed with interviews, focus groups

Rehab and long-term care teams adopted practices
well, maintained them at subsequent follow-up
Acute team had much more difficulty with change
practices
Perhaps due to inherent staffing and organisational
differences
Or, may be due to different cultures of care

Summary: SCA
Focused on recognising PWAs competence, and
related attitudes and strategies
Good evidence that it effective for volunteers,
some health professional groups
If the health system is to be made more
accessible, systemic solutions are likely required

Limitations of these CPT approaches

Based on intuitive characterisations of aphasia in
conversation, and conversation more generally
Up until the early 80s, there was little information on
how PWA communicate in daily life (cf. Holland, 1982)
As such, many approaches are not sufficiently grounded
in the actual organisation of interaction
This is causes problems for developing optimal
measures and interventions

Conversation analysis (CA)

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Analytic objectives of CA
Concerned with how people produce and
recognise social action in interaction
Aims to reveal the orderly, procedural basis of
interaction
Immense evidence that people interact
systematically
o Sorry Noam!, vis. competence vs. performance

CA and language
Language is viewed as resource for achieving
social action
CA views language as adapted to interaction
Language development and evolution are
mediated by interaction (see Schegloff, 1996)

Interactional structures; problems

Organisations of practice (Schegloff, 2006)
Turn-taking
o

managing participation

Sequence organisation
o

linking series of turns

Repair
o

solving problems with speaking, hearing, and understanding

Word selection
o

choosing between possible words

(More on this in 827 next semester! Joy!)

Aphasia and CA

35

Contribution to aphasiology

Better understanding of:

o
o
o
o

linguistic practices used by PWA

communicative demands of everyday life
aphasia as practical problem
intervention targets and measurement

Aphasia and turn construction

How PWA create turns from limited resources has
received some attention
Not the case that PWA randomly use these resources;
there is a methodic basis to how they speak
Linked linguistic practices directly to interactional
contingencies
o e.g., Wilkinson et al. (2003); Beeke et al. (2007)

Hence, how PWA use language reflects both impairment

and compensation

Aphasia and turn construction

Wilkinson et al. (2003, 2010); Beeke et al. (2007a)

The speed of conversation forces PWA to construct turns

promptly lest they lose their chance to speak
As such, PWA adopt grammatical & lexical practices that
are efficient (and effective as they can be)
Leads to use of semantically-weak lexical items (e.g.,
thing, stuff, man), mime and gesture in place of talk, and
particular grammatical structures for their turns

Aphasia and turn construction

Barnes (2013); see also Wilkinson (2009)

Person with proper noun production deficit

Examined how references to entities nameable with
proper nouns was managed in conversation
Observed two key features:
1. Delaying of reference forms
2. Use of common noun phrase references

Delayed reference forms

Used grammatical structures that pushed reference
forms to the end of turns
Used practices that extended the duration of turns
Provided extra time to access the desired proper noun
However, also made problems visible

Person reference
Principle: Recipient design
Factors relevant for reference selection:
o
o

Whether the recipient knows the referent

Whether it is the first time the referent is being
mentioned

Person reference
Maxim: When mentioning for the first time a unique
entity known by your conversation partner, use
the most specific reference form possible
o Initial recognitional reference
o Proper nouns are uniquely suited to this task
o Departures from proper nouns are noticeable

Common noun phrase references

Easier to access than proper nouns
However, they are sub-optimal
Effectively, solicits proper nouns from
conversation partners
Implicates them in production and responsibility
for absence

Barnes (2013)
Summary

Delaying provided extra time for retrieval;

signalled problematicity
Common noun phrase references distributed
burden of proper noun production
Referencing practices represent more than
underlying impairment
Can we use these practices in therapy?
o Target linguistic forms
o Increase partner awareness, collaboration

Aphasia and self-repair

Laakso (1997, 2003); Wilkinson et al. (2007)

Aphasia diminishes ability to self-repair, but

increases the likelihood that it is necessary
However, even people with severe fluent aphasia
still detect errors and initiate repair even if they
have difficulty completing it
May be more likely to initiate repair on semantic
paraphasias as they are not clearly erroneous
See Laakso (1997, 2003)

Aphasia and self-repair

Laakso (1997, 2003); Wilkinson et al. (2007)

Self-repair practices may change over the course

of recovery
Wilkinson et al. (2007) suggest that repair
becomes more covert
Instead of producing erroneous forms, people
with anomic aphasia stop before then, and insert
other forms

Source: Wilkinson et al. (2007)

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Source: Wilkinson et al. (2007)

48

Aphasia and other-initiated repair

Laakso & Klippi (1999); Oelschlaeger & Damico (2000)

Conversation partners are key for resolving

problems PWA encounter
Often takes the form of hint and guess
sequences
Conduct of PWA and guesses of CP steadily
narrow possible targets until trouble is
sufficiently resolved

Choosing not to repair

Barnes & Ferguson (2014)

Repair is optional; conversation partners may

choose to start, assist with, or pursue it; or not
What do they do instead?
o Minimal responses
o Accounts
o Jokes

And how do they move on?

o Keep going regardless
o Start something new
o Propose abandoning talk

Choosing not to repair

Summary

Can lead to PWA becoming marginalised in the

interaction
May contribute to social withdrawal
However, sometimes problems can be difficult to
resolve; may need to abandon the problematic talk

Aphasia and correction

Beeke et al. (2007b); Lock et al. (2001); Aaltonen & Laakso (2010)

Familiar CPs may correct PWA despite adequate

mutual understanding
May take the form of known-answer questions
o (e.g., whats your sons name?)

Can also take the form of correct production

sequences, which focus on cosmetic aspects of talk
Both have potential to make aphasia the primary
focus of talk, rather than other activities

Topic initiation
Barnes et al. (2013); Wilkinson et al. (2011)

Often difficult for PWA

Important for contributing to the direction of a
conversation, social participation
Requires both referential and sequential disjunction
from prior talk
PWA needs to make clear that they are doing
something new, but may not have the resources to do
it via new, semantically-rich lexical items

Topic initiation
Barnes et al. (2013); Wilkinson et al. (2011)

One solution is turn prefacing

Involves position a discourse-marking object at turn
beginning (e.g. oh, and, so, by the way)
Distances turn from immediately prior talk, but links it to
other structures/resources available to recipient
Can help contextualise problematic items in the turn

Summary: Aphasia and CA

Armstrong & Ferguson (2010); Barnes & Ferguson (2013)

Explication of exactly how PWA use language; contributes

to understanding of linguistic deficits
Explication of functional communication
Highlights novel linguistic forms and behaviours for
assessment and intervention
Insight into aphasia as a lived problem; both practically
and socially

Assessment

56

Types of measures
Direct vs. impressionistic
Linguistic vs. interactional
Partner vs. PWA

Kagan rating scales

Kagan et al. (2004)

PWA: Measure of Participation in Conversation (MPC)

o Focuses on information transfer, social affiliation
CP: Measure of Support in Conversation (MSC)
o Focuses on use of strategies to AC, RC
Standardised with volunteers
9 point scale with range a 1-4 with 0.5 increments
Change of 1 point is clinically significant
See also Armstrong et al. (2010) on some issues on
sampling for rating

Transaction
Ramsberger & Rende (2002)

Some measures applied to monologue (e.g., CIUs) may

not be valid for interaction
Following Doyle, McNeil, developed conversation task
involving re-telling activities in an episode of I Love
Lucy to a nave listener
Outcomes were measured in number of main ideas
conveyed in listeners retelling to experimenter
Moderately strong relationship with CADL-2; weak
relationship with picture description

POWERS
Herbert et al. (2013)

Profile of Word Retrieval Errors in Speech

Measure aimed at quantifying anomia on conversation
Focuses on overall speech units, turn taking, word
retrieval, and repair
Different profiles for nouns, content words, turn types,
error types, repair
Some preliminary evidence that impairment-based
anomia Rx leads to improvements in conversation

CAPPA
Whitworth et al. (1997)

Conversation Analysis Profile for People with Aphasia

Structured interview with CP
Analysis of dyads spontaneous talk using CA
Findings of each are then compared, discussed with a
view to intervention
See Perkins (1995), Perkins & Booth (1999) for some
related quantitative measures

Interaction-focused intervention

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Nature of intervention
Rather than starting with language impairment, or
improving contrived activities, the focus is on
interactional problems
Its targets are inherently:
o

contextualised and shared

Interaction-focused
intervention

Mostly individualised
Focused on identifying patterns in dyads
Patterns are then collaboratively targeted
Beginning to target PWA and partner

SPPARC (Lock et al., 2001)

Supporting Partners of People with Aphasia in Relationships and Conversation

Individualised training program

Focused on repair, turns and sequences, and
topic and overall conversation
Begins with recordings of routine
conversations, and identification of patterns

SPPARC
Raising awareness

Clinician facilitates improved awareness of conversation;

both generally, and in dyad
Raising awareness accomplished through video
observation, provision of information, role plays, and
written exercises

Source: Lock et al. (2001)

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Source: Lock et al. (2001)

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SPPARC
Developing strategies

Strategies to improve interactions are then

selected and implemented
Can be selected by clinician, clients, or those
identified by SPPARC
Strategies are then practised in structured
activities, role plays, and in routine interaction

Source: Lock et al. (2001)

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Source: Beckley et al. (2013)

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Interaction-focused intervention
Wilkinson et al. (2011)

Case study involving woman with non-fluent aphasia, and

her husband
In pre-intervention interactions, PWA had difficulty
initiating topics, often due to husband not supporting them
PWA encouraged to use turn prefacing; husband
encouraged to use more minimal turns (e.g., mm), and
given PWA further time
Qualitative improvements in conversation; also improved
on disability questionnaire of CAT

Interaction-focused intervention
Beeke et al. (2011); Beeke et al. (2015)

Reports on case series

Following Beeke et al. (2007) on optimal turn
construction used by people with agrammatism
Targeted PWA and CP behaviours to ensure that PWA
is creating efficient and effective turns, even if they are
not grammatically complete
Clear qualitative and quantitative evidence of change
for CPs and PWA
o But some PWA not responsive!
o And it seems easier to eliminate negative behaviours
than implement new, positive behaviours

Source: Beeke et al. (2011)

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Intervention outcomes
Wielaert & Wilkinson (2012)

Positive behavioural changes detected using both

qualitative and quantitative measures
Some evidence of improved quality of life
Still in early stages; mostly single case experiments

Barriers to success
Reliant on complex learning process
Executive functioning of both PWA and conversation
partner implicated in intervention success (Beckley et
al., 2013; Saldert et al., 2012)
Willingness of CPs to be involved may also be an
issue; perhaps more easily addressed

Going forward...
Optimising efficacy/effectiveness
Best ways to quantify change
Relationship of interaction-focused intervention to
other kinds
Relationship between improvements in interaction
and impairment, QOL

Further intervention studies

Fox et al. (2009); Wilkinson et al. (2010); Beeke et al.
(2007b); Armstrong et al. (2013); Beckley et al. (2013)

Next week...
Cases
(...with a view to Assessment 2!)