SEVERE APHASIA GROUP: TEACHING REFERENTIAL SKILLS TO ENHANCE BASIC INTERACTIONAL COMMUNICATION
Kathryn L. Garrett, Ph.D., CCC-SLP Duquesne University, Pittsburgh, PA

Grand Rounds on Aphasia Group Treatment
ASHA 2000 Washington, D.C.

I. OVERVIEW OF DUQUESNE UNIVERSITY /UNIV. of NEBRASKA APHASIA GROUP MODEL

A. History

• University of Nebraska-Lincoln - 1993-1997: Garrett & Ellis

– Student training programs -

– Adults with a wide variety of aphasia types, ages, backgrounds

• Duquesne University (Pittsburgh) - 1998-present: Garrett & Staltari

– Ever-increasing demand for services at the post-acute rehabilitation phase

B. Types of Groups (2)

– Mild-Moderate Aphasia Group

• Difficulties with fluency, semantic flexibility and specificity, organization of discourse, timing, and integration of language with high level social-pragmatic skills

• Participants tend to have generally good auditory comprehension; primarily communicate by speaking (although enhancement through other modalities is often a goal)

– ***Severe Aphasia Group

• Participants have limited to no verbal communication. Typically have some degree of auditory comprehension breakdown as well -- from mild to severe.

• Have difficulties initiating communication acts; conveying novel,semantically specific information; referencing what they’re talking about; attending to relevant info/conversational partners; engaging in reciprocal exchanges

C. Purposes (4) of Therapy Groups

• To improve linguistic skills

– Semantic

– Discourse

• To improve interactional skills in

– Conversational Contexts

– Transactional Contexts

• To increase communicators’ use of compensatory strategies when appropriate

• To assist clients and significant others to learn to live with aphasia (after Lyon, 1996)

D. 3 Basic Principles: Communication in Meaningful Contexts

(1) USE language vs. practice

• Embed language targets in a connected sequence of communication acts that have a purpose
EX: Asking your wife out on a date vs. practicing her name and “I love you” in an isolated context

• Prepare for challenges to resource allocation: practice compensating for situational demands in tx

EX: Practice standing up, walking to movie counter, asking for a ticket, being bumped, getting back on track and requesting a ticket

(2) Communicate at the level of discourse

• Have a GOAL (conduct a transaction, to tell a story, to explain how to do something)

• ORGANIZE the communication acts you need to achieve this goal

Ex. Hi honey - come here [gesture]. Date?

• Add enough REFERENTIAL/ SEMANTIC SPECIFICTY and COHESION to convey ideas

– Ex. “Movies - you?” [or show newspaper]

• Consolidate multiple communication modalities into one communication act

– EX: Hand her flowers and say “I love you” vs. practicing ,speech and gestures separately

(3) utilize thematic, situational activities in tx

• Examples: Planning a party for group member, Going to the bank, Greeting trick-or-treater

• May facilitate retrieval of language associated with episodic memory

• Preliminary observations: increased complexity and automaticity of expressive communication

E. Structure of the Model- In Brief

• Conversation

• Context-Building

• Language Mediation

• Discourse

II. SEVERE APHASIA AND REFERENTIAL COMMUNICATION

A. Preliminary observations

• Some communicators with severe aphasia (across modalities) appear to have an elemental challenge in referencing ability

• Need explicit instruction to engage in basic referential skills…..

– Attending to others (especially speakers)

– Pointing to request

– Pointing (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 tangible information when answering questions (e.g., in communication notebooks, etc.)

• 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.

B. Hypotheses

• That individuals with severe aphasia may not be able to produce propositional, verbal (speech or nonspeech modalities) communication until basic referential skills emerge (either naturally or with facilitation)

• That the emergence of meaningful spoken or alternative communication coincides/ parallels the reacquisition of basic referential skills such as: pointing to others, shifting gaze to a speaker, physically manipulating externally-stored info (pictures, words, etc.) to answer a question.

C. Target Referential Skills - A Proposed Hierarchy

1. Social-Pragmatic Referential Skills

• Basic Deixis

– For turn-taking

– For requesting additional information

– “Dean - ask Jerry what he thought of the election...[hand-over-hand assist to point to Jerry

• Tangible Referent Identification- immediate environment

• Example: “Show us what you bought this weekend” [gest. prompt to Jane to point to own new sweater]

2. Semantic/Symbolic Referential Skills

• Visual symbol referencing

Example: Photo Album Conversations - point to pictures to answer autobiographical questions “Where was your favorite vacation?”

• Point to tangible topics setters to initiate a conversational topic (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

• Access sequence of messages to convey “NEWS” on a Voice Output Communication Aid (VOCA) - no selection/minimal sequencing demands

• Access semantically specific messages to answer specific questions -- on VOCA

• Point to semantically specific written word choices to answer conversational questions (Written Choice Conversation Strategy -- Garrett & Beukelman, 1995)

Example: “Who do you want to win the election…” • Gore • Bush • You don’t CARE anymore!

3. Discourse Level Referential Skills (advanced communicators - move to mild-moderate aphasia group)

• Answering questions with semantically specific referents

• Commenting

• Asking questions

• Time markers “and (then)

• Continuers “and…”, “but…”

• Explicit, referential communication occurs in one or more modalities

– Gestural - Vocal

– Verbal - Writing

– AAC or other external symbols

• Self-initiated communication acts increase

• Turn-taking and other pragmatic aspects of interactional communication kick in

D. How are referential communication opportunities embedded in group activities for people with severe aphasia? (Video)

Additional 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.

Garrett, K., & Ellis, G. (1999) Group communication therapy for people with long-term aphasia: Scaffolded thematic discourse activities. In R. J. Elman (Ed.), Group Treatment of Neurogenic Communication Disorders: The Expert Clinician's Approach. Boston: Butterworth-Heinemann. Pp. 85-96.

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: Butterwowrth-Heinemann, 1996; 137-160.

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.