1. Developing Intentional, Symbolic Communication in Global Aphasia: A Case Study Kathryn L. Garrett, Ph.D., CCC-SLP Laura A. Mancini, B.S. Amy E. Fuscaldo, B.S. * * * * * * * Duquesne University Pittsburgh, PA ASHA 2001/PSHA 2002

2. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 2 Abstract Abstract This case study describes how a variety of pre-linguistic teaching strategies assisted a client with global aphasia to intentionally: request items by pointing to pictorial symbols answer conversational questions by pointing to written word choices or signaling yes/no using head nods Develop joint attention and reference others during group interactions Preliminary outcomes are also reported

3. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 3 Background Background Many individuals with global aphasia have difficulty engaging in pre-linguistic communication behaviors that are necessary to establish reciprocal communication exchanges, such as joint attention, acknowledging, choosing, requesting, and commenting (Garrett and Beukelman, 1992; 1998; Warren & Yoder, 1998). In addition, many people with global have challenges using symbols (gestures, words, pictures) to request, comment, or convey information in a functional manner.

4. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 4 However, many current therapy approaches for people with global aphasia fail to address preliminary, prelinguistic communication skills prior to working on linguistic-level challenges In addition, only a few instructional interventions have successfully taught people with global aphasia to communicate symbolically in functional, socially interactive contexts (Bellaire, et al. 1991; Helm-Estabrooks & Albert, 1991; Johannsen-Horbach, et al. 1985; Weinrich et al. 1989)

5. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 5 Participant Demographics J.V. - Male, 59-year old ruptured cerebral aneurysm and possible episode of hypoxia in 1993. profound aphasia across all modalities, severe oral motor apraxia and apraxia of speech, limb apraxia, a severe right visual field cut, and severe cognitive deficits (poor attention, reduced short term memory, limited reasoning skills, poor self monitoring)

6. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 6 Demographics continued 7 years post onset, J.V. remained functionally non-speaking w/ poor comp. Test scores: –WAB quotient.6/100 –BASA 2nd %ile (global aphasia norms) Enrolled in individual and group therapy at the Duquesne University SLP clinic –June 2000 through November 2001 –Total treatment period - 13 months (vacation months excluded)

7. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 7 Means of communication at the start of therapy Means of communication at the start of therapy –Vocalizations and stereotypic utterances (“Wah, wah wah”; “Howahyu”) –Grabbing/reaching –Changes in intonation and facial expression –Familiar partner interpretation of these preintentional signals ----------------------------------------------------------- –Most successful when communicating simple needs to wife in familiar, routinized contexts

8. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 8 Needs assessment Needs assessment Family had difficulty understanding his requests for specific items. Limited ability to communicate specific comments or ideas in social interactions with family and people in community/dependent on wife to initiate and maintain interactions. Extreme difficulty comprehending others’ communication exchanges/semantically specific information. Inability to maintain attention and required frequent cues to refer to others or to focus on topical stimuli.

9. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 9 Intervention Objectives/Activities A.Basic Requesting Skills 1. Reference (point to) objects during joint attention activities1. Reference (point to) objects during joint attention activities »Use mand-model technique (Halle, 1982) to physically assist J.V. to point to referents during matching game, or to pictures/objects in group conversational activities in response to “What do you want?); fade mand across time 2. Match symbols to objects in contextual activities (e.g., breakfast, shopping):2. Match symbols to objects in contextual activities (e.g., breakfast, shopping): »Matching game: model/instruct J.V. to pick up or point to picture symbol (n=4-6) matching target object (after presentation of target object), then provide natural consequences for correct match (present object, talk about it, use it in a humorous manner)

10. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 10 3. Request objects by pointing to picture symbols in contextual activities:3. Request objects by pointing to picture symbols in contextual activities: »Mand-model technique, incidental teaching (Peck, 1985) during familiar contextual activity (e.g. grocery shopping) with natural consequences (providing selected item even if not desired) 4. Request objects via VOCA symbols in contextual activities:4. Request objects via VOCA symbols in contextual activities: »Same as 2 and 3 above, also provide voice output via VOCA; embed objects within sequential routine (e.g, "What do you need to make breakfast?") »Prelinguistic Milieu Teaching - incorporates simple techniques to teach requesting and commenting (providing time delays and expectant looks during routines in which an object is needed) (Warren and Yoder, 1998).

11. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 11 5. Request items using mini-board in home environment5. Request items using mini-board in home environment (Alwell et al. 1989): »Teach spouse (via role-plays) to provide opportunity for J.V. to access a 5x7 board with 6 color symbols to make choices at home (e.g., breakfast, activities); provide natural consequences

12. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 12 B. Conversational Skills 1. Increase comprehension of conversational info:1. Increase comprehension of conversational info: »Teach partners to use Augmented Input (written key words, partner's point to referent, partner's gestures) in all situations to supplement J.V.’s understanding of main ideas, others’ comments, potential choices, etc. (Garrett & Beukelman, 1992; Romski & Sevcik, 1996) 2. Increase clarity and consistency of J.V.'s gestural Yes/No Signal:2. Increase clarity and consistency of J.V.'s gestural Yes/No Signal: »Clinician asks 5-10 questions related to recent events or autobiographical information given tagged question form ("yes…or no?") and visual model (nodding Y/N) plus augmented input; natural consequences provided

13. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 13 3. Answer conversational questions by pointing to written choices:3. Answer conversational questions by pointing to written choices: »Ask conversational wh- questions (e.g., What kind of music do you like?) then generate 3-4 written key words in vertical alignment, read choices aloud, then ask J.V. to point to his answer; partner responds with sincerity to content of responses (Garrett & Beukelman, 1992; 1995). 4. Tell novel information via VOCA:4. Tell novel information via VOCA: »Implement natural communication opportunities, wh- question prompts, and expectant delays (Halle et al., 1981) to prompt J.V. to access VOCA "news" message in group conversational activities.

14. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 14 5. Ask 1 social automatic question ("What's new with you?") via generic VOCA message:5. Ask 1 social automatic question ("What's new with you?") via generic VOCA message: »Use mand-model technique to teach J.V. to access VOCA message (faded across time), natural opportunities to use message in group 6. Reference conversational partners and topics by pointing/shifting gaze:6. Reference conversational partners and topics by pointing/shifting gaze: »Natural communication opportunities, prompts, mand-model technique and fading during group therapy.

15. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 15 Clinical Outcomes Formal testing was not readministered -- changes were not measurable on standard tools (WAB, BASA) A jury of 3 familiar graduate clinicians and 1 experienced supervising clinician counted the number of preintentional, intentional, and intentional/symbolic communication behaviors prior to tx and post tx on 2 informal tools:

16. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 16 Communication Interview (modified from Schuler, Peck, Willard, & Theimer, 1989): Percentage of preintentional, intentional, and intentional/symbolic communication behaviors (total # behaviors rated = 14; total # of ratings = 159; 82% intrarater reliability)

17. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 17

18. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 18 Categorical Assessment Form for Communicators With Aphasia (Garrett & Beukelman, 1992)

19. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 19 Criterion-referenced measures from conversationally-based therapy activities:

20. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 20 Functional Outcomes J.V.’s wife reported the following functional changes at home: More alert and attentive Less perseverative, stereotypic echolalia (Wa/wa/wa) Began to take her to items or locations at home to show her what he wanted Occasionally used simple VOCA to get her attention/ request help Began answering yes/no questions pertaining to needs/preferences/events with a clear head shake When wife initiated, would choose picture symbol to indicate breakfast or activity preferences (located in communication notebook)

21. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 21 Summary and Conclusions Outcomes of this case study suggest that prelinguistic teaching paradigms may be beneficial in treating global aphasia. Additionally, some communicators may transition to intentional/symbolic communication in some contexts Partner-assisted strategies (making symbols available, augmented comprehension, naturalistic consequences) may also be of assistance

22. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 22 Future Directions Develop a formal tool to catalogue the preintentional, intentional, and intentional/ symbolic communication skills of people with profound aphasia during interactive communication activities. Formalize “clinical pathways” to teach attentional, referential, basic pragmatic, and emerging symbolic communication skills within interactive contexts Gather effectiveness data for add’l cases

23. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 23 Acknowledgments Thanks to J.V., his wife, and caregivers for all of their extra efforts to participate in clinical research Thanks to Sara Osier and Lisa Bosco, graduate SLP clinicians, for their assistance in compiling data Thanks to the Duquesne SLP Clinic for its support of clinical research

24. ASHA 2001/New OrleansGarrett, Mancini, Fuscaldo - Global Aphasia Case Intervention 24 FOR HANDOUTS….. Please write down your name and email address –Thanks for clear handwriting –Please make sure your address accepts attachments Or retrieve this presentation from the following website: http://aac.unl.edu –Thank you for your interest!!!