Referential Skills and Expressive Communication in Severe Aphasia: Therapy Implications

Referential Skills and Expressive Communication in Severe Aphasia: Therapy

Implications

Kathryn L. Garrett, Ph.D. CCC-SLPDuquesne University

Pittsburgh, PA

[email protected]

PSHA 2002, Pittsburgh

ASHA 2001/New Orleans

Kathryn L. Garrett, Ph.D. CCC-SLP

Referential Comm/Severe

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Words of reassurance/disclaimer...

AphasiaSevere DisabilityChild Language




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Relevant information for aphasia...




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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




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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.




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Examples of Early Referential Skills

Attending to others (especially speakers)Pointing to requestPointing (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?”)




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Deictic referencing

“It happened right here in Pittsburgh!”

[I want you to pick me up]




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Object level deictic Temporally displaced referencing- present verbal referencing

“What’s dat?”

“Did you hear what happened to the gym floor at the dance last weekend?”

Evolves to…...




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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…we were discussing the land management plan for this wetlands area…you can see here how the data show a decrease in….




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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).




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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




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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




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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




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Another major shift in the development of attention coincides with the emergence of symbolic language




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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?”)




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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

So what does this have to do with severe aphasia?




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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




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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”




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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




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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?

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




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Steve

Ray

Charley

Clinician

Who’s who in aphasia group….

John




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III. Hypotheses

limb

KG




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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)




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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.




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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




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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]?”




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IV. Preliminary Data




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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




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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




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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




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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




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Steve

Ray

Charley

Clinician

Who’s who in aphasia group….

John




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Clinician Juried Rankings/Ratings of Overall Communication Competence - Unstructured and

Assisted Conversation

Ranking Success 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)




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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




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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




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Frequency of Referential Communication Acts - 12 min group interaction

8

1

2

9

15

6

5

5

1

18

2

0

Steve

Charlie

Ray

JohnDiscourse Level

Semantic/Symbolic

Social/Pragmatic

0

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




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1. Basic Deixis (nonsymbolic gestures that establish reference)

• For turn-taking• For requesting items or additional information• To indicate a referent of shared interest

A. Social-Pragmatic Referential Skills

“Dean - ask Jerry what he thought of the election...[hand-over-hand assist to point to Jerry to request info]”




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1. 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]




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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)




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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?”




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B. Semantic/Symbolic Referential Skills - cont.

2. Point to/present a tangible topic setter to 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




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Ex. of Tangible Topic Setter - Cruise Brochure




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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.




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Example:

Guess what! We went gambling and I won $500!!!

I spent it all already - a necklace for my wife, and a lobster dinner.

Whoo Hoo!!!!

SIMPLE VOCA DISPLAY




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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




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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?”




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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!




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C. Discourse Level Referential Skills (not a focus today)

For advanced communicators with mild-moderate aphasia:

• 1. Answering questions with semantically specific referents (“I bought a snow

shovel...yesterday”)

• 2. Commenting (“That’s a bad thing…”)• 3. Asking questions (“You…are you from

Dormont?”)

• 4. Using time markers (“and..then we left.”)

• 5. Using continuers (“and…”, “but…”)




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In these “higher level” communicators….

Explicit, referential communication often occurs in one or more modalities

• Gestural - Vocal - AAC/external• Verbal - Writing symbols

Self-initiated communication acts appear to increase

Symbolic, propositional communication (speech, symbolic gestures, writing) increases

Turn-taking and other pragmatic aspects of interactional communication occur without cues




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Video interlude…

How can referential communication opportunities be embedded in group therapy activities for people with severe aphasia?




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Cautions

May need to use a great deal of caution when applying developmental concepts to an adult population

Further observational analysis of communicators with severe aphasia is warranted




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Directions for Future Research

Develop a formal tool to catalogue the referential, intentional, symbolic, pragmatic, and linguistic communication skills of people with severe aphasia during interactive communication activities

Compare data to determine if referential ability correlates with other communication skills; also measure whether perceptions of referential ability correlate with perceptions of communication competence

Formalize “Clinical Pathways’ to teach attentional, referential, pragmatic, and symbolic communication skills within interactive contexts - gather outcomes and effectiveness data




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Clinical Implications

Clinicians may want to begin…• Observing the referential skills of their

communicators with severe aphasia

• Explicitly instructing individuals to reference external representations of meanings AND other conversational participants -- perhaps before or while working on verbal-symbolic communication




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Conclusions

Perhaps some of the information on referential communication, intentionality, and symbolic communication from the child language and severe disability literature can contribute to our therapy approaches for people with severe aphasia

Further investigation is warranted




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For handouts…..

Email me at [email protected] -- I will send you this Powerpoint presentation as an attachment

Visit the University of Nebraska-Lincoln AAC website: http://aac.unl.edu

• But give me and the folks at UN-L a few days to post this.

• Thanks for your interest!!




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Selected References

• 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.

• Adamson, L, & Ellis Chance, S. (1998) Coordinating attention to people, objects, and language. In A. Wetherby, S. Warren, & J. Reichle. (Eds.) Transitions in Prelinguistic Communication. Baltimore: Brookes Publishing Co.

• Bruner, J. (1983) Child’s talk: Learning to use language. New York: Norton.

• Hunt-Berg, M. (2001) Gestures in development: Implications for early intervention in AAC. In R. Sevcik (Ed.), Augmentative and Alternative Communication Special Interest Division 12 Newletter, 10, 4-10.




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• 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: Butterworth-Heinemann, 137-160.

• Wetherby, A., Reichle, J., & Pierce, P. (1998) The transition to symbolic communication. In A. Wetherby, S. Warren, & J. Reichle. (Eds.) Transitions in Prelinguistic Communication. Baltimore: Brookes Publishing Co.

• 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.

Documents

Referential Skills and Expressive Communication in Severe Aphasia: Therapy Implications