2008 Extravaganza ADULT LANGUAGE EVIDENCE BASED PRACTICE GROUP Anika Roseby and Kate Schuj Group Co- Leaders with Lyndsey Nickels Academic Member

Clinical Question Last year the Group completed a CAT on repetition as a treatment for word retrieval problems in aphasia. This lead to a new question…

Question “How and in what circumstances does orthographic cueing as therapy improve later spoken word retrieval in aphasia?” Or letter cueing

CAPping the Articles 16 possible articles were found Only 5 actually answered our clinical question and were included in our CAT Some articles were not included because we couldn’t be sure that orthographic cueing alone assisted verbal naming (combination of cueing types used e.g. semantic or repetition).

Exploring the Question.. How does Orthographic Cueing work? Why does it work? Who does it work for? Are the effects lasting? Is there more than one way that orthographic cueing works? Our aim in using orthographic cueing as therapy is try to retrieve the phonological form i.e. spoken word. We were keen to find out how letters help you speak. And as such we had to have a good understanding of the cognitive processes involved in the comprehension and production of single words. It’s not within the scope of this talk to go into the cognitive processing model in detail but hopefully it is somewhat familiar to you all. Roughly there are 2 ways of getting language/ info in (i.e. seeing or hearing) and 2 ways of expressing language (i.e. writing or talking).

Approaches to rehabilitation: Restoration vs. compensation Improving the functioning of defective processes Re-teaching of missing information, rules or procedures (or regaining retrieval of that information) Just a quick note on approaches to rehabilitation: Restoration is trying to fix what’s not there…re-teaching of missing information e.g. practicing/ relearning letter-sound rules rather than finding another way. This involves lots of repetition to learn, e.g. P= /p/ over and over.

Approaches to rehabilitation: Restoration vs. compensation Teaching a different way to perform the same function – using intact skills within the same cognitive domain Teaching a way to compensate for the lost function using different skills. Compensation is finding another way around the part of the system that no longer works, e.g. using a different route through intact parts of the language processing system. E.g. using a direct orthographic route instead of a phonemic route.

Cueing, Facilitation, Therapy K Cueing, facilitation and therapy are all ways that we can help people to speak. We will be referencing these methods throughout the talk so here is just a quick run-down on what we see the differences between them to be. In these examples we use orthographic cues, but also phonemic cues as they are closely related when attempting to verbally name. Here is what orthographic (or letter) cueing is: - Orthographic cues work just like phonemic cues – some people can name pictures better at the time with the cue there than without the cue .. And then go on to say that the same is true of later naming in facilitation and therapy? kangaroo

Cueing, Facilitation, Therapy ….later “k” (spoken by SP) In facilitation you need to provide the help for the person to be able to say the word. As clinicians we were very interested in finding out what types of therapy generalise and we will talk more about this later. kangaroo

Cueing, Facilitation, Therapy “k” “k” In therapy the SP is priming the retrieval of Kangaroo by repeating ‘k’ “k” “k” kangaroo “k” “k” “k” “k” “k”

Use of orthography to facilitate retrieval of phonological form most beneficial when written naming is less impaired than spoken naming: Someone else cueing – priming for that item only Self-cueing – generalises and compensatory Using orthography to facilitate retrieval of spoken words works in this way: Whereas if someone else gives a cue, the only lasting benefit is priming of that item (that has happened by that item (lexical entry) being activated when you were given the cue in therapy). For YOU to generate your own cue you need to have better written than spoken naming, then you can generate the cues every time and they will work by the same mechanisms every time. If you are generating your own cues, this is considered compensatory. What we found was that if attempting to ‘compensate’ for spoken naming impairment (i.e. using an alternative route through the system), using orthographic cues was most beneficial when written naming was less impaired than spoken naming. For people who are equally impaired in both modalities (i.e. spoken and written naming) this method is unlikely to be as helpful. You prob have this fine – but I just want to confirm that this is under the ‘compensation’ umbrella - the cueing of naming when someone else gives the cue doesn’t rely on this – However, there are still the two ways that the cue works (via lexicon and sublexically) whether someone else gives it OR you provide it…. The difference is that if someone else gives it, the only lasting benefit is priming of the lexical entry (that has happened by the lexical entry being activated when you were given the cue in therapy by one of those two mechanisms). When YOU generate your own cue you need to have better written than spoken, then you can generate the cues every time and they will work by these mechanisms every time.

How does orthographic cueing work? Two methods we discuss: Generating phonemic cues from the initial letter Using direct orthographic route

Method 1: Generating phonemic cues from the initial letter Nickels (1992) TC 1. Spoken naming  2. Written naming  3. Convert letters to sounds  dog

Generating phonemic cues from the initial letter Nickels (1992) retaught letter-sound correspondences 1. Spoken naming  2. Visualise written word  3. Sound out initial letter & cue word production  dog d dog

This means…. This improved TC’s spoken naming to almost the same level as his written naming. He used this spontaneously in conversation. Could be used for any word he was trying to retrieve (and was) (only fails for words with irregular initial letters e.g. onion, Cinderella)

Can use a computer cueing aid to do the conversion Who will this work with? Phonologically-mediated self-cueing (e.g.; Nickels, 1992) Requires access to the written form when the spoken form is unavailable Requires phonological cueability Requires an ability to convert letters into sounds Can use a computer cueing aid to do the conversion Can be retaught

Using a computer to generate phonemic cues from the initial letter Best et al. (1997) 1. Spoken naming  d   2. Visualise first letter  3. Press letter  /d/  4. Computer produces phoneme  dog 5. Cue word production 

Generating phonemic cues from the initial letter – who? If they are phonemically cueable  They may be able to use a computer to generate the cues If they can (or be taught to) convert letters to sounds  They may be able to generate their own phonological cues In summary:

Method 2: Self-generated orthographic cues When spoken naming  IF individuals can identify initial letter  They may be able to use direct orthographic cueing (without needing to convert letters into phonemes) The next way that orthographic cues can be used is via a direct orthographic cueing route. In this instance, if a person has impaired spoken naming, but can identify the initial letter of the word they may be able to use this route. This means that there is no need to convert letters into phonemes.

How does direct orthographic cueing work? Print Orthographic Input Lexicon knife kick king etc Lexical Semantics Changed the title here Phonological Output Lexicon Orthographic Output Lexicon Knife kick king etc Knife knife Visualise K Point to “K” Writing “knife” Speech

Cueing aid reorganising the naming system: JOW Best et al, 1997 A direct orthographic cueing mechanism Substantial and long-lasting effects of treatment Improvement in treated and untreated items Treatment drew attention to the relationship between orthography and phonology

Treatment tasks can work in different ways for different people CAT Clinical bottom line: The use of orthography to facilitate retrieval of phonological form is most beneficial when written naming is less impaired than spoken naming. Using orthographic cues in therapy can lead to lasting improvements in naming treated items (just like repetition in our last CAT). Generalisation generally seem to happen when people didn’t need external cueing (i.e. they could cue themselves). Remember …. Treatment tasks can work in different ways for different people

Acknowledgements All the Adult Language EBP group members for all their hard work, dedication and contributions Lyndsey Nickels, our academic link; whose expertise has been invaluable!

References Basso A, Marangolo P, Piras F, Galuzzi C (2001) Acquisition of new "words" in normal subjects: A suggestion for the treatment of anomia. Brain and Language. Vol. 77(1), 45-59. Best W, Herbert R, Hickin J, Osborne F, Howard D.(2002) Phonological and orthographic facilitation of word-retrieval in aphasia: Immediate and delayed effects. Aphasiology, Volume 16 Issue 1 & 2 January, pages 151-168 Best W, Howard D, Bruce C, Gatehouse C. (1997) Cueing the Words: A Single Case Study of Treatments for Anomia. Neuropsychological Rehabilitation 7 (2) 105-141 Nickels, Lyndsey, (1992), The Autocue? Self-generated Phonemic Cues in the Treatment of a Disorder of Reading and Naming. Cognitive Neuropsychology, 9 (2) 155-182 Lorenz, A, Nickels, L .( 2007), Orthographic cueing in anomic aphasia: How does it work? Aphasiology. Vol 21(6-8) Aug, 670-686.