Dr. John C. Rosenbek Professor & Chair, Department of Communicative Disorders

2. Dr. John C. RosenbekProfessor & Chair,Department of Communicative Disorders Harrison Jones, M.S. RSD/Doctoral Student Department of Communicative Disorders

3. APROSODIA Definition, Theory, Evaluation, Treatment

4. OR • It don’t mean a thing if it ain’t got that swing • Or worse in some ways it means the wrong thing

5. CHALLENGES • Realizing this outline is a difficult talk • Because prosody and its disorder-aprosodia-are difficult to define, describe, evaluate (reliably) and treat (effectively)

6. NONETHELESS • Certain general notions are robust enough for us to make a beginning • Common to think of linguistic prosody • And emotional prosody

7. BUT FIRST • what is prosody? • The suprasegmental features (segments are sounds) of speech conveyed perceptually by pitch stress and duration • And acoustically as changes in frequency, intensity and timing

8. VALUE OF ACOUSTIC • Aids in quantification of perceptual judgement • Especially critical in area such as aprosodia where diagnosis is so difficult

9. WAY TO THINK ABOUT DIFFICULTY • Segmentals are the prose • suprasegmentals are the poetry

10. CONSIDER • I took my shotgun from the corner and slipped out the door as fast as I could. When mama talked about praying fir me it was time to go. • This Rock by Robert Morgan

11. AND THIS • Behold the moralist hildago • Whose whore is morning star • Dressed in metal, silk and stone • Syringa, cicada, his flea • A Thought Revolved by Wallace Stevens

12. DIFFERENCES • Meaning is less transparent in one than the other • This captures the huge difficulty of assessing, diagnosing and treating aprosodia • But progress has been made • Agreed upon types

13. LINGUISTIC • Disambiguates words (black bird and blackbird) and • Sentences (He wrote poetry. He wrote poetry?) • Also called intrinsic prosody • Thought to be primarily the product of left hemisphere mechanisms

14. AFFECTIVE • Conveys a speaker’s emotions and attitudes • I missed spending time with my father in law uttered with joy or great sorrow • Sometimes called extrinsic prosody • Thought to be primarily the product of right hemisphere mechanisms • Depends heavily on changes in fundamental frequency

15. APROSODIA • Our emphasis • Ross in 1981 referred to deficits in expression and reception of affective or emotional prosody as the aprosodias • He said “their functional-anatomic organization in the right hemisphere (mirrors) that of propositional language in the left..) P. 561

16. THEREFORE • He identified a motor aprosodia in which reception of emotional prosody was intact • A receptive in which reception was inordinately impaired • And counter parts of global, transcortical motor, transcortical sensory and so on

17. VALIDITY • These are notions in search of data • Nonetheless clinicians know right hemisphere damage (especially) can effect the processing of emotional prosody • Ross describes divorce as a consequence of a patient’s not being able to express emotion • Clinicians have other similar tales

18. HOWEVER • Until our recent work no therapies • In general clinicians were likely to throw up their hands when confronted with the multiple problems of right hemisphere damage

19. THE PROBLEMS • Limited measurement tools or tests • Non-data based cutoffs of normal and abnormal for those that do exist • Variability in the emotional prosody of the population • The thorny problem of laboratory versus true emotional prosody

20. DESPITE ALL THIS • Theories have begun to emerge • Evaluation procedures likewise • Treatment techniques have begun to appear • With the deepest roots right here at the University of Florida • Nourished by our own Ken Heilman

21. THEORIES • Against the background that Myers (1999) establishes with her comment that “Mechanisms of RHD prosodic deficits are not presently understood” • Heilman and his colleagues have proposed some • One is a motor theory • In simplest form the notion is that (especially expressive aprosodia) results from a deficit of execution or of programming

22. `THE SECOND • Degredation of a modality specific affect lexicon • Clearly this is the right hemisphere equivalent of the verbal lexicon in the left hemisphere

23. NADEAU EXPANSION • The affective lexicon “may be instantiated in a pattern associator network linking predominately right hemisphere association cortices and limbic structures and limbic structures with right prefrontal and and premotor cortex”

24. EXCLUDED EXPLANATIONS • Depression • Agnosognosia • Neglect • Dysarthria

25. EVALUATION • Here is where challenge of poetry is most acute • Judgment of presence of both expressive and receptive aprosodia is subjective • Tools have been developed to standardize the stimuli • Response evaluation is still subjective

26. THE FAB • Bowers, Blonder, Heilman, 1998 • Assesses ability to identify spoken prosody • And facial expression • And interesting notion is the relationship of facial and spoken expression

27. THE FEEB • Not yet non-standardized • Assesses spontaneous and and imitative prosody, both affective and linguisitic • Evaluation is perceptual • Meaning judges say aprosodic or not.

28. COMING TOGETHER • The theories, primarily, generated two treatments • One called Imitative • The other called cognitive-linguistic • Both comprised six steps • Both are loosely based on notions of errorless learning • In that they go from maximum to minimum cueing • Both motivated by theories of pathophysiology

29. IMITATIVE TREATMENT • Step One: Cl models the requested emotional utterance and then cl and pt say together • Step Two: cl models and the pt produces after delay • finally, Produce the sentence in target tone of voice while imagining speaking to a family member

30. COGNITIVE-LINGUISTIC • Step One: Pt given a written description of characteristics of a given tone of voice • Step Two: Pt given cards listing names of emotions and asked to pick which emotion matches the tone of voice just described • Advances to Step six in which pt is asked to produce tone of voice based on all written cues previously provided

31. RESEARCH • Heilman and colleagues won a program project grant from NIH

32. THE DESIGN • Heilman and colleagues chose the replication of an ABAC design • A equals baseline • B equals one of the two treatments chosen randomly • The second A is baseline after one month “wash out” period • C is the second treatment

33. DETAILS • Stable baseline confirmed with C statistic • 20 sessions of the first treatment selected randomly • Post test • One month “washout” • Pretest • 20 sessions of treatment two • Post test immediately and at one and three months

34. DEPENDENT MEASURE • Participants were shown a card with a sentence and asked to utter the senteNce in a particular tone of voice • Adequacy of emotion judged by naïve person • Knew nothing of stage or treatment

35. EMOTIONS • Treated • Sad • Happy • Angry • Control • Fearful

36. PROGRESS TO DATE • 14 pts treated • The data are informative • Data are in the form of effect size and visual analysis • Consider the data

40. Statistical Analysis Visual Analysis

41. CONCLUSIONS • The treatments seem to have an effect • Analysis underway to determine if one more influential than the other • And to determine responders and non- responders • Submitted another grant and got butchered • So more work to do

42. BUT • Hope is the thing with feathers • That perches in the soul • And sings the tune without the words • And never stops at all