Kelsey Meiring, M.A., CF-SLP Indiana University Speech and Hearing Sciences

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

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

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.

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)

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)

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).

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.

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).

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)

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

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.

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.

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)

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

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)

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

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

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: 1. Poor 2. Fair 3. Good 4. Better 5. 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.

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?”

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

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

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

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

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

Results – Formal Assessment

Results – Agreement in Ratings

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

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.”

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.”

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!”

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?”

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”

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”

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.”

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”

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”

Results – T-units

Results – Words

Results – Words per T-unit

Results – Specificity

Results – Nonspecific with referent

Cohesive Devices per T-unit

Ineffective Cohesive Devices

Types of Cohesive Devices Used

Text-level Analysis Results

Ideational Perseveration

Appropriate Questions Asked

Word Length of Questions

Spoken Discourse Analysis Data collected and resulting patterns observed in written discourse appears to reflect that in the spoken discourse probes The changes in spoken discourse were judged to be not quite as dramatic as those in written discourse Despite the assumed similarities, conclusions may not be drawn from this subjective account Notable difference in appropriateness of discourse – increased in written, but appeared to decrease in spoken Possibly due to increased comfort with investigator

Results Summary The most substantial improvements were made in improving the overall cohesion of her written discourse through the use of connecting her thoughts with cohesive devices (local coherence), increasing the effectiveness of the cohesive devices she used, and decreasing instances of ideational perseveration She also increased the specificity of her language, particularly with familiar conversation partners, and nonspecific language with clear referents with unfamiliar conversation partners

Results Summary (cont.) Her written discourse was also longer and more meaningful through the use of including stories and questions, which created more of a dialogue between her and her conversation partners Not only did she increase the number of cohesive devices she used during written discourse, but she also used them more effectively and used a wider variety of types of cohesive devices, making her written discourse richer with more fluidity The appropriateness of her written discourse improved

Results – Some discrepancies Although JB made improvements in the written procedural, story generation, and monologue discourse tasks, her greatest gains involved writing to actual people rather than writing non-motivating discourse to no one (actually performed worse in some areas on those tasks) Naturally, her written discourse had more meaningful content to those who were familiar to her; however, large gains were also seen in her written discourse with unfamiliar partners

Results - Maintenance Conversational Discourse length and complexity of written discourse, increased specificity, an increase in the number of cohesive devices used, wider variability of cohesive devices used, increased local coherence, increased appropriateness, and decreased ideational perseveration Procedural, Picture Description, Monologue length of complexity of written discourse, increased specificity, an increase in the number of cohesive devices used, increased effectiveness of cohesive devices used, wider variability of cohesive devices used, and increased local coherence

Discussion Variability in the written discourse results was noted, even within one task. Her performance may have been dependent on the discourse task, which is consistent with findings from Mentis and Prutting (1987) who found different cohesion patterns in each participant, depending on if the task was narrative or conversational in nature.

Discussion (cont.) JB’s difficulty with coherence may be explained by Kennedy (2000), who suggested that many seemingly-irrelevant comments during conversation from those with RHD may actually be secondary topic scenes that they are unable to inhibit or connect through the use of cohesive devices. JB would often have seemingly-extraneous comments that would actually be related to the previous topic; however, no connection was made between the two topics nor could she inhibit the secondary topics. As she became aware of this lack of cohesion through the treatment activities, she was better able to use cohesive devices effectively to reduce topic digressions and increase local coherence.

Discussion (cont.) The number and variety of cohesive devices JB used post- treatment resembled those of normal healthy adults, as reported by Mentis and Prutting (1987). Normal participants used cohesive ties approximately 60% of the time whereas those with TBI used ties only 30% of the time. JB’s local coherence of using ties 57.14% of the time when writing to unfamiliar conversation partners thus resembles data from normal healthy adults more so than those with TBI. Additionally, the wider variety of types of cohesive devices used by JB post-treatment also reflects patterns used by normal healthy adults, particularly with the increased use of lexical cohesion (Mentis & Prutting, 1987).

Discussion (cont.) Although JB made improvements in the written procedural, story generation, and monologue discourse tasks, her greatest gains involved writing to actual people (written conversation tasks) rather than writing non-motivating discourse to no certain person (i.e., performance of procedural, story generation, and monologue tasks).

Limitations Inter-rater agreement not adequate No multiple baseline data collected Number of participants Spoken data not analyzed Variability in the written discourse results was noted, even within one task

Clinical Implications Spoken conversation probes that were collected appear to reflect the results in written conversation probes Easy-to-use scale to promote self-feedback and awareness of conversation skills Can individualize targets to reflect patients’ deficits Can individualize scale for different cognitive levels Inexpensive No harm Can use for different modalities (writing, speaking, etc.) Can use in a variety of settings (SNF, outpatient rehab, inpatient rehab, group treatment, etc.)

Considerations Must be able to take detailed notes during conversation about discourse targets to support rating you assign while still participating in conversation Must be able to be honest with patient – try to write down your rating before you hear theirs Must pick up on instances of “dishonesty” of ratings from patient

More Considerations Beware of extremely “off” ratings from patient – they may not be able to accurately self-evaluate at first, but if this still persists into treatment, may not be effective for that individual Beware of no change in targets, even if ratings are accurate – they may be able to self-evaulate, but may have difficulty modifying their behavior to achieve higher ratings Always encourage them to strive for the highest rating! With increased awareness, some patients will become confused, depressed, angry, resistant, etc. – PROCEED WITH CAUTION!

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