Treatment of Word retrieval impairments: Do we know which tasks work for whom and why? Continued! Associate Professor Lyndsey Nickels National Health and Medical Research Council Senior Research Fellow, Macquarie Centre for Cognitive Science (MACCS), Macquarie University, Sydney, Australia

How do we decide which treatment? Remember…. Therapy for word retrieval DOES NOT have to include word retrieval Each different level of breakdown in word production will be best remediated by a different type of treatment (e.g. Hillis & Caramazza, 1994; Nettleton & Lesser, 1991) impaired word meaning (semantics) → treatment focusing on meaning impaired retrieval of the phonological form from semantics → treatment focusing on providing/accessing the phonological form impaired phoneme level/phonological encoding treatment focusing on phonemes

How do we decide which treatment? Each different level of breakdown in word production will be best remediated by a different type of treatment (e.g. Hillis & Caramazza, 1994; Nettleton & Lesser, 1991) impaired word meaning (semantics) → treatment focusing on meaning impaired retrieval of the phonological form from semantics → treatment focusing on providing/accessing the phonological form impaired phoneme level/phonological encoding treatment focusing on phonemes

What treatment is appropriate? Semantic impairments The most successful therapy seems to involve exploring the semantic attributes of a stimulus. e.g. Boyle & Coelho, 1995. Coelho, McHugh & Boyle, 2000. Hillis, 1991, 1998. Nickels & Best, 1996. Lexical Semantics Phonological Output Lexicon Phonological Output Buffer Speech

Therapy for semantic impairments Exploring semantic attributes of a stimulus e.g. Semantic feature analysis (SFA) (Boyle & Coelho, 1995; Coelho, McHugh & Boyle, 2000) name a picture generate features relating to ….. Can we be sure this is effective? Not entirely … they use very small numbers of items in the sets, and examine changes in performance using visual inspection with no statistics GROUP: is an ANIMAL USE: is used for protection ACTION: does what? Barks LOCATION: is found at home ASSOCIATION: reminds me of a kennel

Therapy for semantic impairments (cont) e.g. Nickels & Best (1996) AER “Relatedness judgements” (with feedback) Nickels & Best argue that feedback is critical to obtaining generalisation to untreated items       Statistically significantly improved naming of treated and untreated stimuli

Therapy for semantic impairments (cont) e.g. Hillis (1991, 1998) HG. Lemon Red vs yellow Round vs oval Thin skin vs thick skin Sweet vs sour

Therapy for semantic impairments (cont) e.g. Hillis (1991, 1998) HG. name a picture, if  and semantic error was produced, → drawing of error compare drawing to the target picture discuss semantic distinctions Significant improvement in written naming (treated) also in spoken naming and word comprehension Improvement of treated items and untreated items in the same semantic category (but this may just be that untreated items appeared in therapy) Hillis (1991, 1998) used a similar technique to remediate the semantic impairment and improve (written) naming for HG. HG was asked to attempt to name a picture, if this attempt failed and a semantic error was produced, a drawing of her error was made. This drawing was compared to the target picture and semantic distinctions between the two were discussed. Both treatments are argued to be successful. In the case of HG, there is a clear demonstration that there is improvement not only in written naming, which was treated, but also in spoken naming and word comprehension (as would be predicted for a treatment targeting semantic processing).

How does the treatment for semantic impairment work? If so what would the effects be? Doesn’t it improve the semantic impairment?

Heard Speech Phonological Output Lexicon Speech output Phonological Output Buffer Lexical Semantics Writing Heard Speech Print Idea, Picture, or seen object Lexical Semantics

Heard Speech Print Idea, Picture, or seen object Lexical Semantics Phonological Output Lexicon Phonological Output Buffer Speech output Writing

Heard Speech Print Idea, Picture, or seen object Lexical Semantics Phonological Output Lexicon Phonological Output Buffer Speech output Writing

Print Heard Speech Idea, Picture, or seen object But although this was true for Hillis’ study with HG, it was not for AER. Improvement in all modalities only occurs if treatment improves semantic processing Lexical Semantics Lexical Semantics Phonological Output Lexicon Semantic therapy for semantic impairments should improve all modalities Phonological Output Buffer Speech output Writing

Coelho et al (2000) - a strategy for word retrieval Consistent with improvement across modalities How did the authors think these treatments for semantic impairments were having their effects? Hillis (1998) “improvement at the semantic level itself – perhaps through increased specificity of semantic representations of trained items” Coelho et al (2000) - a strategy for word retrieval “by activating the semantic network surrounding the target word, that word may be activated above its threshold, thereby facilitating retrieval” Consistent with improvement restricted to speech production How might these semantic treatments be having their effects? Hillis is explicit that HG’s improvement was “improvement at the semantic level itself – perhaps through increased specificity of semantic representations of trained items” (Hillis, 1998, p654). Coelho et al (2000) do not appear to advocate a relearning of semantic distinctions, but instead focus on the facilitative effects of SFA “by activating the semantic network surrounding the target word, that word may be activated above its threshold, thereby facilitating retrieval” (p135). Indeed they are explicit in suggesting that SFA is a strategy for word retrieval, noting that the aphasic individual treated by Boyle & Coelho (1995) was “less able to internalise the SFA strategy to facilitate word retrieval” (Coelho et al, 2000, p140). Nickels and Best (1996b) discuss a similar account for a man with a semantic impairment, AER, following ‘relatedness’ judgements (and following ‘function’ judgements). They suggest that naming improvement showed generalisation by “the use of a strategy (which may be unconscious) of exploring the semantics of an item (when naming fails) which facilitates retrieval of that item (perhaps by increasing the semantic information addressing the output lexicon to a ‘critical’ level where retrieval can occur)” (p119). Hence, techniques promoting reflection on semantic properties may be better viewed as teaching a strategy , albeit an unconscious strategy, rather than remediating semantic processing, at least for some of the individuals targeted. Nickels and Best (1996) “the use of a strategy (which may be unconscious) of exploring the semantics of an item … which facilitates retrieval of that item (perhaps by increasing the semantic information addressing the output lexicon…)”

Semantic tasks and semantic impairments Hold on! How can therapy for semantic impairments improve word retrieval without improving semantics Semantic tasks Those tasks which involve focusing on word meanings Semantic tasks may be used to treat semantic impairments Those tasks which seem to most often improve semantic impairments involve reflecting on semantic features However even then they may NOT improve semantics itself but may instead provide a strategy for improving word retrieval. Didn’t we contrast semantic impairments and post-semantic word retrieval impairments? Yes, but semantic impairments cause word retrieval impairments …

Post semantic word retrieval impairment Object, picture or idea Semantics purrs barks 4-legs fur pet scales Phonological Lexicon robin cat dog rabbit fish house PhonologicalBuffer/ Phonemes k d æ o g t

Semantic impairment

PhonologicalBuffer/ Phonemes Sem impairment Semantic impairment Object, picture or idea Semantics barks fur pet 4-legs scales purrs Phonological Lexicon robin cat dog rabbit fish house PhonologicalBuffer/ Phonemes k d æ o g t

PhonologicalBuffer/ Phonemes Semantic impairment Although, as we will see, this is usually only the case in people with less severe semantic impairments. Object, picture or idea So tasks can be effective in improving word retrieval WITHOUT improving the semantic impairment Semantics purrs 4-legs fur barks pet scales Phonological Lexicon robin cat dog rabbit fish house Semantic impairment also leads to a reduction in activation at the word form level PhonologicalBuffer/ Phonemes k d æ o g t

SUMMARY: What treatment is appropriate? Any questions? Semantic impairments The most successful therapy seems to involve exploring the semantic attributes of a stimulus. e.g. Boyle & Coelho, 1995. Coelho, McHugh & Boyle, 2000. Hillis, 1991, 1998. Nickels & Best, 1996. Lexical Semantics Phonological Output Lexicon Phonological Output Buffer Speech

Therapy for semantic impairments or semantic tasks as therapy? These tasks are widely used in the remediation of word-retrieval impairments, however, their use is not restricted to those individuals with semantic impairments. Virtually all tasks involve semantic processing Some focus on semantic processing to a greater extent (we tend to refer to these as semantic tasks) e.g. odd one out (spoken or written) word to picture matching word-picture verification

Semantic tasks for improving word retrieval The use of semantic tasks is not restricted to individuals with semantic impairments…... semantic tasks can improve word production even for those individuals with good semantic processing and even when the tasks are performed accurately (e.g. Nickels & Best, 1996). …. In fact they are probably more likely to improve word production for those with relatively less semantic impairment – those with ‘post-semantic lexical retrieval impairments’.

What treatment is appropriate? Word retrieval impairments Tasks focusing on semantics and phonology - improve word retrieval e.g. Howard et al 1985 Nickels & Best 1996 Lexical Semantics Phonological Output Lexicon Phonological Output Buffer Speech

What treatment is appropriate? Word retrieval impairments Tasks involve activation of both semantics and phonology But may focus more on semantics…. Lexical Semantics Phonological Output Lexicon Phonological Output Buffer Speech

What treatment is appropriate? Word retrieval impairments All the tasks involve activation of both semantics and phonology But may focus more on semantics or phonology Lexical Semantics Phonological Output Lexicon Phonological Output Buffer Speech Repeat “kangaroo” It starts with /k/

What treatment is appropriate? Word retrieval impairments All the tasks involve activation of both semantics and phonology They produce long lasting, item specific effects in the majority of individuals with impaired activation of the correct target in the phonological lexicon Improves likelihood of the target being sufficiently activated to be retrieved successfully. Lexical Semantics Phonological Output Lexicon Phonological Output Buffer Speech

Let’s explore these tasks that improve word retrieval in more detail

“Semantic” tasks as therapy Word-picture matching Word-picture verification The tasks work best with people that can do them easily (people with less of a semantic problem) These tasks typically don’t require word production but improve naming at a later point nevertheless Widely effective (Howard et al, 1985; Marshall et al, 1989) Long lasting effects (Pring et al., 1990) Generally, lasting effects are item specific

How important is the emphasis on semantic processing? Howard et al (2006) Compared the efficacy of word-picture matching with related and unrelated distractors (related distractors = deeper processing = more effective?)

How important is the emphasis on semantic processing? Howard et al (2006) Compared the efficacy of word-picture matching with related and unrelated distractors All incorrect before word-picture matching After word-picture matching Related distractors: 45% correct Unrelated distractors: 50% correct Controls: 30% correct Not even for those with more severe semantic impairments? No evidence that deeper semantic processing improves efficacy of word-picture matching

How important is the emphasis on semantic processing? Howard et al (2006) Compared the efficacy of word-picture matching with related and unrelated distractors All incorrect before word-picture matching After word-picture matching Less sem imp. More sem imp. Related distractors: 50% 40% Unrelated distractors: 60% 40% Controls: 40% 23% No evidence that deeper semantic processing improves efficacy of therapy: not even for those with more severe semantic impairments

How important is the emphasis on semantic processing? Martin, Laine et al (2000, 2003, 2004, 2005) ‘Contextual Priming’ Compared the efficacy of naming/repetition in the context of semantically related distractors and unrelated distractors.

How important is the emphasis on semantic processing? Martin, Laine et al (2000, 2003, 2004, 2005) ‘Contextual Priming’

How important is the emphasis on semantic processing? Martin, Laine et al (2000, 2003, 2004, 2005) ‘contextual priming’ Compared the efficacy of naming/repetition in the context of semantically related distractors and unrelated distractors. - Naming is worse at the time with semantically related distractors. Naming is improved no more (at a later point) with semantically related distractors. No evidence that a semantic context improves efficacy of therapy

How important is the emphasis on semantic processing? Not as important as we thought! Tasks which have traditionally been labelled ‘semantic’, such as word-picture matching are equally effective with unrelated items. Adding a semantic context to a (naming/repetition) task does not make it more effective.

  How important is the phonological form in the semantic task? Most probably critical to its effectiveness Word form is usually provided. e.g. Le Dorze et al (1994) “Show me the octopus”  “Show me the mollusc with long legs” 

Nickels, McDonald, Makin, Moses & Taylor –Facilitation Experiments It looks at the effect of a task performed ONCE on another task at a later point and contrasts with… What is a facilitation experiment? Immediate Cueing effects: The effect of a technique at the time of its application As I said earlier, we used two tasks which had been used in the earlier phase of the study - that is, (click) repetition with the picture present, in the phonological treatment component. In the semantic treatment component the person was asked a yes/no question about a feature of the picture. The picture was in front of them but the question didn’t include the target word (we’ll touch on why this was important in the discussion a bit later on). Therapy: The application of a technique several times, over days, weeks or months

Cueing, Facilitation, Therapy “k” kangaroo

Cueing, Facilitation, Therapy ….later “k” kangaroo

Cueing, Facilitation, Therapy “k” “k” “k” “k” “k” kangaroo “k” “k” “k” “k”

Nickels, McDonald, Makin, Moses & Taylor –Facilitation Experiments Semantic without the word form Feature verification Does it hop? Phonological Repetition “kangaroo”

Nickels, McDonald, Makin, Moses & Taylor –Facilitation Experiments Name 300 pictures until 95 failed (10 second limit) Sort the failed items into 3 (frequency & length) matched sets Facilitation Task 1 Facilitation Task 2 Control 1 week later Facilitation 10 mins later Name all 3 sets of pictures+ 30 easy fillers

Comparing repetition and a semantic task with no word form

Comparing repetition and a semantic task with no word form

Comparing repetition and a semantic task with no word form Very little benefit from a semantic task without the word form for most individuals

Semantic tasks without the word form We also looked at the same tasks used as therapy with 4 individuals with aphasia … once again, semantic tasks without the word form had little benefit …. for example…. DRS 8 sessions of semantic therapy (feature verification) over 2-3 weeks Before each therapy session named all those items that were to be treated, and a set of control pictures (50 items in each set).

DRS - Semantic Therapy No extra benefit from the semantic task But the untreated items seem to improve..... Spontaneous recovery? Generalisation? Benefits from repeated naming attempts? No extra benefit from the semantic task

Treated items and repeatedly named items improve to the same degree – so there is no specific benefit from the semantic task

The improvement from naming controls isn’t generalisation or spontaneous recovery (unseen controls don’t improve) – but benefit from repeated attempts at naming Treated items and repeatedly named items improve to the same degree – so there is no specific benefit from the semantic task

Summary: semantic tasks in word retrieval Any questions? Degree/depth of semantic processing appears not to be critical (Howard et al) Presenting tasks in a semantic context can interfere short-term and mostly has no long term advantage over presentation in unrelated contexts (Martin, Laine et al) Presence of phonological form appears critical in most cases (Le Dorze et al; Nickels et al: facilitation studies, DRS therapy study) …… and so to Phonological tasks

“Phonological” tasks Repetition of target Reading aloud Phonological & orthographic cueing Rhyme judgements Syllable and phoneme counting Phoneme segmentation Anagrams …….but nearly always in the presence of the picture. Again we need to remember the distinction between the nature of the task and the nature of the impairment…. Here we are talking about phonological tasks but NOT impairments to the phoneme level. They range from repetition of the target, phonological (and orthographic) cueing of picture naming, tasks involving phonological judgements such as rhyme judgements, syllable and phoneme counting, and phoneme segmentation to tasks combining orthography and phonology using reading, anagrams and scrabble tiles. In much the same way as with semantic tasks, many of these have been used to facilitate word retrieval and not exclusively in individuals with phonological impairments.

Phonological tasks and word retrieval Widely argued to be the most appropriate for impairments in retrieval of (or damage to) the phonological form from the phonological output lexicon (e.g. Hillis & Caramazza, 1994; Miceli,et al, 1996; Nettleton & Lesser, 1991) Miceli et al (1996): as these tasks focus at the level of activation of individual entries in the phonological output lexicon, their effects should be item specific – a result of ‘priming’ retrieval of the phonological form. Phonological tasks have been widely argued to be the most appropriate for impairments in retrieval of (or damage to) the phonological form from the phonological output lexicon (e.g. Miceli, Amitrano, Capasso & Caramazza, 1996; Nettleton & Lesser, 1991). Miceli et al (1996) argue that as these tasks focus at the level of activation of individual entries in the phonological output lexicon, their effects should be item specific – a result of ‘priming’ retrieval of the phonological form. Indeed that is what has been found in several studies (e.g. Miceli et al., 1996; Hillis & Caramazza, 1994, HW; Nettleton & Lesser, 1991, DF). But as already mentioned – item specific effects are also what has been the most common outcome for so called semantic tasks when used to remediate word retrieval impairments.

For many years ‘semantic’ tasks were thought to be more effective than ‘phonological’ tasks in improving word retrieval How true is this?

Comparing repetition and a semantic task with no word form

Comparing repetition and a semantic task with no word form Very little benefit from a semantic task without the word form … repetition is almost always more beneficial

DRS - Phonological Therapy Significant extra benefit from the repetition task

For many years ‘semantic’ tasks were thought to be more effective than ‘phonological’ tasks in improving word retrieval This seems NOT to be true in general, particularly if the semantic task does not include the word form

Semantic & phonological treatments: an overstated distinction? BOTH have semantic and phonological components Semantic tasks without the phonological form are generally not effective Howard (2000) – tasks having the same effects in the same way Strengthening the connections between semantics and phonological form when both are simultaneously active equivalent effects for semantic and phonological tasks for most individuals Howard (2000) suggests that the difference between semantic and phonological tasks may well be overstated. In the majority of the studies with semantic treatments, the form of the word is provided (as a spoken or written word), and as we have already noted, in ‘phonological’ tasks, the picture is usually present (evoking semantic processing) and/or a word provided for repetition, which will also access word meaning. Hence in both tasks there is semantic and phonological information available. Howard (2000) argues that the difference between these tasks is indeed more apparent than real and that both tasks are indeed having their effects in exactly the same way – by strengthening mappings between semantics and phonological form when both are simultaneously active. This predicts equivalent effects for semantic and phonological tasks for most individuals. Unfortunately, there are few studies which examine this issue. Howard (2000), in a reanalysis of Howard et al. (1985b), found a very high correlation between the rate of improvement during the two types of therapy, and naming accuracy on items treated by the two methods. Moreover, a homogeneity test on the difference between the effects of the two treatments confirmed that there was no evidence that any patient benefited more from one treatment than the other. Nevertheless, one of the cases studied by Nickels & Best (1996b), PA, does seem to counter Howard’s prediction – she benefited from tasks providing the word form (in her case the written word) but failed to benefit from semantic tasks (including the word form). Clearly, once again, further investigation is warranted[ii]. [ii] It is also probable that the choice of stimuli has an influence on the success of treatment. Martin, Laine & colleagues (Laine & Martin, 1996; Martin & Laine, 1997, 2000; Martin, Fink, Laine & Ayala, 2001) have recently observed that some individuals benefit from facilitation using sets of either phonologically or semantically related items, whereas others are impaired by these contexts.

PhonologicalBuffer/ Phonemes Object, picture or idea Semantics purrs barks 4-legs fur pet scales Phonological Lexicon robin cat dog rabbit fish house PhonologicalBuffer/ Phonemes k d æ o g t

PhonologicalBuffer/ Phonemes Object, picture or idea Semantics purrs barks 4-legs fur pet scales Phonological Lexicon robin cat dog rabbit fish house PhonologicalBuffer/ Phonemes k d æ o g t

PhonologicalBuffer/ Phonemes Object, picture or idea Semantics purrs barks 4-legs fur pet scales Phonological Lexicon robin cat dog rabbit fish house PhonologicalBuffer/ Phonemes k d æ o g t

‘Semantic’ and ‘phonological’ tasks are working in similar ways By strengthening the connections between semantics and word form by activating both semantics and phonology

The role of effort and error How does amount of ‘effort’ or accuracy in a task affect the benefit for naming? Effortful >benefit than automatic? Greater semantic processing Errorless >benefit than errorful?

Comparing Phonological Tasks Repetition Effortless, ‘shallow’ processing, error reducing Phonemic cueing Effortful, deeper processing, errorful “kangaroo” “k”

Method Name 300 pictures until 95 failed (10 second limit) Sort the failed items into 3 (frequency & length) matched sets 1 week later Facilitation Task 1 Facilitation Task 2 Control Facilitation 10 mins later Name all 3 sets of pictures+ 30 easy fillers

Facilitation effect compared to control pictures: Errorless/Automatic (Repetition) vs Errorful /Effortful (Phonemic cues) * * * * * * * *

Facilitation effect compared to control pictures: Errorless/Automatic (Repetition) vs Errorful /Effortful (Phonemic cues) * * * * * * * *

Comparing Phonological Tasks > benefit than Repetition Effortless, ‘shallow’ processing, error reducing Well, repetition is better and it does improve more BUT the proper comparison is within a task …. Phonemic cueing Effortful, deeper processing, errorful “kangaroo” “k” Is errorless (or error reducing) better than errorful? No need for it to be effortful to be helpful – FOR MOST PEOPLE

Fewer errors means greater benefit? Repetition is more error-free than cueing… but the proper comparison is within a task Cueing Do the people who are more accurate with cueing (at the time) have more benefit for naming (later)?

Errorless items benefit more? Repetition is more error-free than cueing… but the proper comparison is within a task Cueing no significant correlation between success of the cue during facilitation and benefit of cueing for subsequent naming. i.e. errorless is not better than errorful for cueing. Why did we think errorless might be better in the first place?

Errorless learning Hypothesis Remediation is more effective if errors are prevented - the act of producing an error may strengthen the incorrect association, and make the correct response less likely to occur. History Animal learning (Terrace, 1963) Children with developmental learning difficulties (e.g. Sidman & Stoddard, 1967). Acquired memory impairments (amnesia) (e.g. Baddeley & Wilson, 1994)

Errorless learning and anomia treatment Fillingham et al (2003) “error reducing techniques do have positive effects for patients with word finding difficulties. As yet there is limited information on which to judge whether this technique is significantly advantageous over errorful approaches” (p358). Fillingham et al (2005, 2006) No significant difference between errorless (repetition) and errorful (cueing) tasks. Abel et al (2005) No significant difference between increasing and vanishing cues methods (errorful vs error reducing). BUT nonetheless repetition may be more beneficial than phonemic cueing for many people Remember that this will all depend on the processing strengths and weaknesses of the aphasic individual There appears to be no difference between errorful and errorless techniques in aphasia

How semantic & phonological tasks work Any questions? How semantic & phonological tasks work Error & Effort

Generalisation in the treatment of word retrieval. the most successful treatment is one which effects improvement not only for the items used in therapy but also for any other item, in any other context. many treatments produce clear long lasting effects on the treated items, generalisation to untreated items is less common, and when obtained, often less robust (e.g. Nickels and Best, 1996b)

When perceived generalisation is actually an effect of (assessment during) treatment! DRS

When perceived generalisation is actually an effect of (assessment during) treatment! DRS

When perceived generalisation is actually an effect of (assessment during) treatment! Howard et al (1985) “Naming controls” naming daily but NOT treated Improved significantly Widely interpreted as generalisation of treatment effects – more probably the result of repeated attempts at naming (Howard, 2000) Nickels (2002) JAW Repeatedly attempted to name a set of pictures (daily for a week) Significantly improved naming

Practice makes (closer to) perfect: trying to name helps naming! But it could have important implications Use it or lose it (Attempts at) conversation might improve word retrieval - (Trying to) talk about the same topics may be better HOW? some names will be successfully retrieved on one occasion but not on another. When, by chance, an individual produces a picture name successfully, both the semantic representation and the phonological representation for that item are simultaneously active. This will then strengthen the mapping for that item, making it more likely that the word will be produced correctly on a subsequent occasion (which will again strengthen the mapping). Over time, more items will have strong enough mappings to be produced accurately on every occasion Or perhaps just partially activating the phonological representation when trying to name is enough to strengthen the mappings More work needs to be done to determine who this works for, how close together naming attempts have to be etc etc

When generalisation is a reflection of (strategic When generalisation is a reflection of (strategic?) changes in processing Semantic tasks (with semantic disorders) Techniques promoting reflection on semantic properties may be better viewed as teaching a strategy, albeit an unconscious strategy. Phonological tasks Best (2006) examined who showed generalisation using a cueing treatment – it was those individuals with relatively more of a phonological impairment (and less semantic impairment) Self-cueing E.g. phonologically mediated orthographic cueing

Mostly generalisation is limited… Therefore the emphasis is on the clinician to ensure that all items used in therapy are functionally relevant and chosen in collaboration with the person with aphasia. Nickels et al – in progress ‘Home Programme’ Using the most successful task (repetition) 60-100 items chosen by the person with aphasia as being words they wanted to be able to say. Therapy presented by computer in powerpoint ‘Structured’ conversation used to evaluate carry-over from naming to conversation

Treatments aimed at remediating word production impairments Tasks can be effective (e.g. Hillis & Caramazza, 1994; Howard et al, 1985b), produce durable effects (e.g. Pring et al, 1990), be administered by clinician &/or computer (e.g. Fink et al, 2002) be obtained on verbs & nouns (e.g. Murray & Karcher, 2000; Raymer and Ellsworth, 2002). carry-over into connected speech & conversation (e.g. Hickin et al, 2002), BUT treatment tasks are not invariably effective

Do impairment-based treatments impact on functional skills and increase activity & participation? word retrieval/production underlies every attempt at verbal communication hence improving word retrieval impairments is of course functionally relevant Simplistic and/or fundamentally misguided BUT the importance of an increased ability to name treated items following therapy should not be underestimated Hillis (1998) HG - small change in impairment – significant gains in activity & participation with the use of functionally relevant personal items (Bacardi & Coke!)

Do impairment-based treatments impact on functional skills and increase activity & participation? Yes …. (functional gains can be achieved) but…. (they are by no means guaranteed) few studies that have formally evaluated the effects on disability of impairment-based remediation. It seems particularly important given the prevalence of item specific effects that remediation should include personally relevant stimuli.

Any questions? Generalisation Effects of repeated naming Functional relevance

Lets take another look at cueing So far we’ve talked about tasks that aim to improve the underlying word retrieval impairment – some tasks may work in other ways too Lets take another look at cueing

?

? /t/

tomato /t/

? T

tomato T Letter cueing has been found to have the same effects as phonemic cues – both immediate and longer term benefits for naming for some individuals (Best et al. 2002)

Some individuals can generate their own orthographic cues ?

TOMATO ?

TOMATO tomato How does this work?

? How does this work? Phonologically-mediated self-cueing T -> /t/ ? How does this work? Phonologically-mediated self-cueing (e.g. Bachy-Langedock & DePartz, 1986; Nickels, 1992)

Phonologically-mediated self-cueing T -> /t/ Requires access to the written form when the spoken form is unavailable tomato Requires an ability to convert letters into sounds Requires phonological cueability Phonologically-mediated self-cueing (e.g. Bachy-Langedock & DePartz, 1986; Nickels, 1992)

Phonologically-mediated self-cueing Can be retaught Can use a computer cueing aid to do the conversion Requires access to the written form when the spoken form is unavailable Requires an ability to convert letters into sounds Requires phonological cueability Phonologically-mediated self-cueing (e.g. Bachy-Langedock & DePartz, 1986; Nickels, 1992)

Generating phonemic cues from the initial letter Nickels (1992) TC 1. Spoken naming  2. Written naming  3. Convert letters to sounds  dog

Generating phonemic cues from the initial letter Nickels (1992) retaught letter-sound correspondences This improved TCs spoken naming to almost the same level as his written naming. He used this spontaneously in conversation. Could be (and was) used for any word he was trying to retrieve (only fails for words with irregular initial letters e.g. onion, Cinderella) 1. Spoken naming  2. Visualise written word  3. Sound out initial letter & cue word production  dog d dog

Using a computer to generate phonemic cues from the initial letter e.g. Bruce & Howard (1987); Best et al. (1997) 1. Spoken naming  d   2. Visualise first letter  3. Press letter  /d/  4. Computer produces phoneme  dog 5. Cue word production 

Generating phonemic cues When spoken naming  IF individuals can identify initial letter  convert letters to sounds  and are phonemically cueable  Then they can generate their own cues. If unable to convert letters to sounds Can be retaught Can use computer generated cues - may be able to use the letters without converting to sounds – Direct orthographic cueing.

Direct Orthographic Cueing SD: Howard & Harding (1998) impaired access to the phonological output lexicon (good semantics) Unable to form letters Given an alphabet board – naming improved dramatically Was not using phonological mediation unable to convert letters to sounds unaffected by initial letter regularity (e.g. onion; eye)

Self-generated orthographic cues Any questions? Self-generated cues When spoken naming  IF individuals can identify initial letter  They may be able to use direct orthographic cueing If they are phonemically cueable  They may be able to use a computer to generate the cues If they can (or be taught to) convert letters to sounds  They may be able to generate their own phonological cues.

When things don’t go the way you planned!

Using a cueing aid as therapy – who benefits? Best, Howard, Bruce & Gatehouse (1997) 13 individuals treated with the cueing aid predicted benefit only for those who when spoken naming  can identify initial letter  & are phonemically cueable  They should be better at naming with the aid than without it (this is providing the cues). Only two individuals had both skills After treatment: Only 1 individual had better naming with the aid than without. BUT 12 showed significant improvement in naming. WHY???

Repetition in the presence of the picture Why does treatment with a cueing aid help individuals who are not predicted to benefit? Treatment tasks can work in different ways for different individuals Multicomponent treatment orthography phonology semantics (presentation of the picture and attempted naming). Only one individual was helped by the aid providing the cue - for many others this was a standard word retrieval therapy Phonemic cueing Repetition in the presence of the picture

Cueing aid reorganising the naming system: JOW (Best et al, 1997) Substantial and long-lasting effects of treatment Improvement in treated and untreated items treatment drew attention to the relationship between orthography and phonology altered automatic (not strategic) processes in his word retrieval A direct orthographic cueing mechanism

How tasks actually work may not be how you planned them to! Why does treatment with a cueing aid help individuals who are not predicted to benefit? Treatment tasks can work in different ways for different individuals …. especially when they are multicomponent How tasks actually work may not be how you planned them to! And sometimes they don’t work even though you would predict they should!

RECAP BEFORE THE BREAK Assessment of level of breakdown in word production Methodological issues in evaluating treatment

RECAP (continued) AFTER THE BREAK Improving naming when there are semantic impairments Exploring semantic features It may work by providing a strategy to improve naming rather than improving semantics itself. Word retrieval impairments Semantic vs phonological tasks Semantic tasks require the word form, depth of semantic processing is not important Phonological tasks are also effective Tasks are working in the same way Effort & error Tasks do not need to be effortful There is no additional benefit from errorless performance

RECAP (continued) Generalisation Self-generated Cues Treatment for Word retrieval impairments usually result in item specific improvements but may generalise to conversation, and can produce effects on participation/quality of life Use of functionally relevant items is a priority Repeated attempts at naming may improve word retrieval for some individuals Generalisation can result from strategic/compensatory approaches Self-generated Cues Phonologically mediated/computer generated/direct orthographic Tasks may not always work the way you expect ALL OF THE ABOVE ARE GENERALISATIONS – every person with aphasia is different and could be the exception to these general principles

Relationship between task, impairment and efficacy Therapist’s dream = Prescription guide “to unambiguously pair a particular functional impairment with a treatment task that has guaranteed success for that impairment”

Clinicians need to know what to do NOW!!! choose a therapy that has the best chance of succeeding Choose a task that has successfully improved naming for a wide variety of people with spoken word retrieval impairments - multicomponent approaches (e.g. cueing hierarchies or multimodality/multi-task therapies – see e.g. Best et al, 1997; Hickin et al, 2002) Use pilot studies using different tasks for short periods (e.g. 1 week) to establish which tasks seem effective and which do not prior to continuing with the most effective therapies over longer period.

Prove that it works! ensure that it is possible to establish whether or not a particular therapy is effective by using a sound methodology. We have a duty to be able to demonstrate that a therapy is effective to the individuals with aphasia, their families/friends/carers, those funding the treatment and not least to ourselves.

Thank you! Any questions or comments?