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Principals of Assessment and

Intervention in Acquired
Language Disorders
Goals of Assessment
To determine the presence of communication
impairment
Severity and type of impairment
Determine the individuals strengths and weaknesses
To identify exacerbating factors
Vision and hearing
Agnosias (recognition deficits) in various modalities
Deficits in proprioception or praxis
Affective (mood) disorders
Effects of medications
To identify intervention goals
Goals of Assessment
To assess potential for future recovery
(prognosis)
To monitor change e.g. spontaneous recovery,
treatment efficacy
To evaluate maintenance of treatment gains
To define factors that facilitate comprehension,
production and use of language
To establish a working relationship with client
and significant others
Goals of Assessment

To determine the presence of aphasia,


and severity and type of aphasia, using
the _____________, and profile the
clients strengths and weaknesses

NOT

To administer the BDAE


Components of language function
Cognitive
Recognition,
understanding,
memory, attention,
reasoning ability

Linguistic Communicative/
Pragmatic
Auditory comprehension,
Turntaking, topic initiation
language production (form
and maintenance, repairs,
and content)
speech acts produced,
nonverbal aspects
Assessment Defined
Organised, goal directed evaluation of the
components of communication
Evaluation of persons QOL
Evaluation of communicative interactions
within family/social unit
Their role in larger unit of society
Carried out to determine how strengths
fortified and weaknesses modified

Chapey 2008
Before you start
Gain information and form initial
hypotheses from:
Initial referral
Verbal information from MDT members
Medical notes

Remember introductions and endings


Why you are there, what you want to do, why
it was useful, what happens next
Informal Language Assessments
What to assess:
speech fluency
speech output
auditory comprehension
repetition
naming
written output
reading comprehension
drawing
gesture
facial expression
awareness of deficit
NOT all at once! Be sensitive to clients medical /
cognitive / emotional state
Informal Assessment
For each aspect of communication:
What the individual is able to do?
Where does the task break down?

language production: Single words short phrases sentence


2-3 sentences paragraph monologue conversation
Auditory comprehension: Single words yes/no questions
sequential commands non-sequential commands

Have a hiearchy of tasks for each area to allow flexibility


Try to start at the appropriate level for that client
Informal assessment
Manipulate the structure you provide for the task
Unstructured (no control or interference)
Moderately structured (retell a story, describe a
picture or a sequence of activities)
Highly structured (sentence completion, object
naming)
Be systematic
Check hearing and visual perception first
Assess language comprehension before language
production
Writing and calculation later
Informal assessment

Brookshire 2003
Informal assessment
Auditory comprehension
Answer closed open questions
Point to objects / pictures named by the examiner
Follow spoken directions
Answer questions about spoken discourse
Speech
Recitation
Object / picture naming
Phrase or sentence completion
Phrase / sentence repetition
Produce single sentences longer utterances
Reading
Match pictures, letters, geometric forms
Match printed words to pictures
Read aloud: numbers, letters, words, phrases
Answer written questions
Silent reading / comprehension answer questions about a written test
Writing
Copy letters, numbers, shapes, words
Write to dictation letters, numbers, words, sentences
Write a paragraph / written narrative
Brookshire 2003
Formal Language Assessments
Acute
Boston Naming Test
Bedside Evaluation Screening Test (BEST)
Western Aphasia Battery
Chronic
BDAE (subtests)
PALPA
Pyramids and Palm Trees
Minnesota Test for Differential Diagnosis of Aphasia
Porch Index of Communicative Ability (PICA)
Comprehensive Aphasia Test (CAT)

Appropriacy for Sri Lanka?


Assessment of communicative
functioning
Not language per se performance, pragmatics
Communication skills in everyday life
Example: CADL-2 (Communicative Activities in Daily
Living)
Provides a snapshot of functional communication skills
using a variety of simulated communication activities
Involves people reading timetables, menus; pretending
to go to doctor, shopping; making a phone call; writing a
shopping list
For people with aphasia, HI, dementia, intellectual
impairment, hearing impairment
Aphasia Recovery
Spontaneous recovery: decelerating curve
Maximum recovery 1-3m
Flattening out 6-7m
Little/no spontaneous recovery after 1yr plateau

Basso 1992 Benson and Ardila 1996 in Chapey 2008

Prognosis: TBI better than stroke, haemorrhagic better


than infarction
Lesser and Milroy 1993
Neural Mechanisms for Recovery
Reduction of cerebral oedema/improvement of
local circulation: Spontaneous recovery

Brain plasticity: cortical reorganisation to engage


pre-existing but functionally depressed
pathways. Called upon when dominant system
fails

Lesion size = negative influence on recovery


Aphasia Treatment
Efficacy: does aphasia treatment result in a significant
improvement on one or more tests of language
functioning?
Yes, provided that:
Treatment is delivered by qualified professionals
Global aphasics are excluded
Content, intensity, duration and timing of treatment are
appropriate
Sensitive and reliable measures are used to track changes
Effectiveness: does aphasia treatment result in
meaningful improvements in communicative functioning
in daily life?
Therapy Approaches
Approaches that assume the brain can
relearn what has been lost/skills can be re-
accessed

Approaches that assume lost language


functions not recoverable. Therapy aimed
at getting around the problem
Models of Therapy
WHO International classification of
Functioning, Disability and Health (2002)
Body functions and structures i.e.
impairments of brain
Activity i.e. ability to make a phone call, read a
menu
Participation i.e. pursuit and enjoyment of real
life goals e.g. volunteering/getting a job
Treatment Considerations
Timing:
During spontaneous recovery period or wait?
Vignolo (1964): treatment is only really effective if it
begins when physiologic recovery is most rapid
Poeck et al (1989): time post-onset does not affect
recovery of language, but it does affect response to
treatment
Generally, delaying treatment has not been
conclusively demonstrated to have any effects on
eventual outcome; but it likely does have effects on
the patient and their family
Treatment Considerations
Candidacy:
Some patients have very mild impairments
and recover spontaneously
Some are so severely impaired that they
cannot benefit
Some refuse, lack motivation, cant travel
Treatment planning
Use assessment results
Use discussion with client (where
possible) and family
Set long and short term goals
Consider design of task, the
psycholinguistic nature of stimuli selected,
modality of material, type of facilitation
given, duration and intensity of therapy
(Byng and Black 1995)
Planning intervention

What person can do What person needs to do


closing the gap
cannot do wants to do
does do
Example treatment planning
MJs assessments show:
Strengths:
Good lexical comprehension
Good sentence comprehension using non reversible active,
passive & comparative verbs
Can draw and gesture to convey some aspects of meaning
Semantic cueing facilitates naming
Written support facilitates comprehension
Weaknesses:
Poor complex auditory sentence comprehension
Spoken confrontation naming difficulties
Difficulties in written confrontation naming when word frequency
decreases
Drawings and gestures may not be recognisable outside context as
tend not to be well defined
MJs wish: to talk better with family and friends
Setting goals
Overall goal: To maximise MJs current communication abilities
This will involve use of his existing strengths to compensate for his
weaknesses (use drawing, gesture, writing of words etc - total
communication)
Relate this to MJs goal, when setting goals for therapy, using phrases like
in order to This is the overall goal

For MJ to improve his communication skills (esp. drawing, gesture, & keyword
writing) in order for him to be able to engage in conversations with his family.
This includes the following:
to draw communicatively to convey meaning in conversation with his wife
To gesture to write etc This is MJs goal

Then take one long term goal at a time, and break it down that is, what
steps would be involved in getting the client from where he is now:
His drawings are sometimes useful but are not well-defined

To the long term goal:

Drawing communicatively in conversation with his wife


Task hierarchies
Arrange the steps in order of difficulty:
To draw well defined single items
to command (draw an apple)
therapy tasks include drawing basic shape, then differentiating items
from one another on visual features (e.g.. apple vs. orange)
based on function (draw something you wear) extending
from objects to actions
based on gesture (may or may not incorporate the verb
function from above) (e.g. gesture a banana; gesture a
shovel)
in whole and parts (involves semantic breakdown)
within a category/ generative drawing
from memory
To draw well defined single events
from stimulus pictures
from part of stimulus
from memory
Task hierarchies
to draw single items communicatively
to draw single events communicatively
therapy tasks will involve encouraging Pt to be aware of the
conversation partners needs, focusing on issues such as
listening to the other persons guesses, conveying one piece of
information at a time
to draw communicatively in conversation with SLT
therapy tasks will include drawing answers to questions e.g.
what did you do on the weekend?
to draw communicatively in conversation with wife
therapy tasks will include working with wife to assist her to
develop interpretation strategies, such as homing-in questions;
asking for details; adding to the drawings; writing key words to
check; recapping what she knows about the drawing every few
minutes
Drawing and total communication
Beeson & Ramage, (2000). Drawing from experience:
The development of alternative communication
strategies. Topics in Stroke Rehabilitation, 7(2), 10-20.
Lawson & Fawcus (1999). Increasing effective
communication using a total communication approach. In
Byng, S. & Swinburn, K. (Eds): The aphasia therapy file.
Pp 61-71. Hove, England: Psychology Press.
Sacchett et al (1999). Drawing together: evaluation of a
therapy programme for severe aphasia. International
Journal of Language & Communication disorders, 34(3),
265-289).
Task Hierarchies
Simple more complex
Less demanding more demanding
More support less support
E.g. cuing hierarchy for anomia:
Imitation
First sound / syllable
Sentence completion
Brookshire Word spelled aloud
2003 p 313 Rhyme
Synonym / antonym
Function / location
Superordinate
Make hierarchies personal
Goals for treatment
The primary objective in treatment of aphasia is to
increase communication. What the aphasic patient wants
is to recover enough language to get on with his life.
(Schuell et al 1964, 333.)
Usually will not be complete recovery of language and
communicative function
Treatment may enhance recovery, but recovery will stop
Identify strengths and weaknesses; use the strengths to
compensate for the weaknesses; help the aphasic
person to be an effective communicator in spite of their
language deficits
Generalization recovery must not be limited to the
treatment room
Generalization does not just happen it must be
planned for, worked towards, tested for