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Referential Skills and Expressive Communication in Severe Aphasia: Therapy Implications. Kathryn L. Garrett, Ph.D. CCC-SLP Duquesne University Pittsburgh, PA garrettk@duq.edu PSHA 2002, Pittsburgh. Words of reassurance/disclaimer. Aphasia Severe Disability Child Language.

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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-SLP

Duquesne University

Pittsburgh, PA

garrettk@duq.edu

PSHA 2002, Pittsburgh

words of reassurance disclaimer
Words of reassurance/disclaimer...
  • Aphasia
  • Severe Disability
  • Child Language

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

relevant information for aphasia
Relevant information for aphasia...

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

i introduction
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

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

what is referential communication
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.

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

examples of early referential skills
Examples of Early 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 items or symbols that represent answers to questions (“What do you want to play with?”)

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

deictic referencing
Deictic referencing

“It happened right here in Pittsburgh!”

[I want you to pick me up]

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

object level deictic temporally displaced referencing present verbal referencing

Evolves to…...

Object level deictic Temporally displaced referencing- present verbal referencing

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

“What’s dat?”

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

to complex referential communication in which multiple referents are displaced over time and space
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…wewere discussing the land management plan for this wetlands area…you can see here how the data show a decrease in….

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

the relationship of referential skills to attention
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).

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

slide11
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

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

adamson chance 1998
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

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

this coincides with the emergence of
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

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

slide14
Another major shift in the development of attention coincides with the emergence of symbolic language

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

stage 3 coordinated joint engagement
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?”)

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

to reiterate
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

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

ii statement of the problem
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

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

slide19
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”

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

however
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

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

slide21
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?

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

video interlude

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

who s who in aphasia group
Who’s who in aphasia group….

Ray

Steve

Clinician

John

Charley

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

iii hypotheses
III. Hypotheses

KG

limb

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

hypotheses cont
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)

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

hypotheses continued
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.

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

slide27
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

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

hypotheses continued1
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]?”

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

iv preliminary data
IV. Preliminary Data

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

preliminary data were derived from
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

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

participant demographics
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

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

demographics cont
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

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

slide33
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

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

who s who in aphasia group1
Who’s who in aphasia group….

Ray

Steve

Clinician

John

Charley

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

slide35
Clinician Juried Rankings/Ratings of Overall Communication Competence - Unstructured and Assisted Conversation
  • RankingSuccess 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)

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

slide36
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

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

definitions of coded referential skills
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

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

frequency of referential communication acts 12 min group interaction
Frequency of Referential Communication Acts - 12 min group interaction

0

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

slide39

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

a social pragmatic referential skills
A. Social-Pragmatic Referential Skills
  • 1. Basic Deixis (nonsymbolic gestures that establish reference)
      • For turn-taking
      • For requesting items or additional information
      • To indicate a referent of shared interest

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

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

a social pragmatic referential skills cont
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]

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

the transition to symbolic level referential communication
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)

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

b semantic symbolic referential skills cont
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?”

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

b semantic symbolic referential skills cont1
B. Semantic/Symbolic Referential Skills - cont.
  • 2. Point to/present a tangible topic setterto 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

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

ex of tangible topic setter cruise brochure
Ex. of Tangible Topic Setter - Cruise Brochure

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

b semantic symbolic referential skills cont2
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.

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

example

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

Whoo Hoo!!!!

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

Example:

SIMPLE VOCA DISPLAY

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

b semantic symbolic referential skills cont3
B. Semantic/Symbolic Referential Skills cont.
  • 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

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

slide49
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?”

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

b semantic symbolic referential skills cont4
B. Semantic/Symbolic Referential Skills cont.
  • 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!

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

c discourse level referential skills not a focus today
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…”)

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

in these higher level communicators
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

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

video interlude1
Video interlude…
  • How can referential communication opportunities be embedded in group therapy activities for people with severe aphasia?

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

cautions
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

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

directions for future research
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

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

clinical implications
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

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

conclusions
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

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

for handouts
For handouts…..
  • Email me at garrettk@duq.edu -- 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!!

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

selected references
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.

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

slide60
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.

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