Prognostic indicators Age of patient Premorbid language skills and literacy Education and occupation Extent and location of lesion(s) Presence of past neurological disorders Presence of past medical or behavioral disorders Current medical, neurological, behavioral disorders Current hearing ability Current visual status Current motor performance Current language performance Severity of aphasia

Prognostic indicators, continued Time of treatment initiation Treatment technique Accuracy of treatment application Length of treatment Intensity of treatment Family involvement Improvement/deterioration in general health during course of treatment Improvement/deterioration in language performance during course of treatment or trial period; Spontaneous recovery; Patient motivation, enthusiasm, attitude toward learning.

Limitations of research data Lack of control of variables that affect treatment outcomes Questionable internal validity Poor description of patients Poor description of treatment procedures and protocols

Negative indicators (Brookshire, 1992) Patients who have neurologically recovered but still exhibit the following characteristics may not benefit from treatment: Severe auditory comprehension problems coupled with verbal stereotypes; Failure to match identical stimuli; Indiscriminate “Yes-No” responses; Jargon and empty speech without self- correction.

General principles of treatment Select client-specific target behaviors that provide the greatest improvement in functional communication; Start treatment at a simpler level and move to progressively more complex tasks; Target behaviors that signal the system is just beginning to breakdown; Provide maximum amount of stimulus control in the beginning, including modeling, pictures, objects and events that help establish the behaviors; Reduce the clinically manipulated stimulus control in gradual steps so that the target behaviors are produced in response to more natural stimulus events;

General principles (continued) Provide immediate, response-contingent feedback to increase desirable behaviors and decrease undesirable behaviors (therefore you must keep score!!); Train self-monitoring skills Train significant others to evoke, prompt, support, reinforce and maintain appropriate communicative behaviors in the client; Elicit a large number of responses per session; Begin sessions with familiar items/tasks; Introduce new materials and procedures as extensions of familiar materials and procedures.

General principles, continued Work in a quiet environment; Use multi-modality stimulation, but do not overload the system; Give the patient plenty of time; Avoid precipitous repetitions; Use extralinguistic cues; Work in realistic contexts; Use alerting stimuli; Be positive, encouraging, success-oriented;

Philosophical statements: “Most clinicians and investigators agree that aphasia is not a loss of vocabulary or linguistic rules – instead it is the result of impairments in processes necessary for comprehending, formulating and producing spoken and written language.” “Clinicians who believe that aphasia represents a reduction in the speed and efficacy of processes underlying language, rather than loss of language, focus treatment on reactivating or restimulating language processes, rather than on teaching specific responses.” “…there is no strong empirical evidence that functional approaches to treatment are more successful than traditional approaches in improving daily life communication…the skills (or processes) targeted for treatment (must be) relevant to daily life communication.”

Cognitive stimulation (Martin, 1979) Aphasia is a “reduction of the efficiency of action and interaction of the cognitive processes which support language behavior…(Therapy is) the attempt to manipulate and to excite the action and interaction of the cognitive processes which support language behavior within and by the organism so as to maximize their effective usage…therapy is directed toward the subsystems which process language (e.g., cognition, memory, convergent thinking, divergent thinking and evaluation).”

Cognitive stimulation: general therapy objectives To stimulate ability to recognize and comprehend language; To stimulate ability to fix new information in memory in order to improve communication; To stimulation ability to generate logical information or conclusions during communication; To stimulate ability to generate logical alternatives to given information, to produce a quantity and variety of responses during communication, and to be able to elaborate on ideas and plans during communication;

Cognitive stimulation: general objectives (continued) To stimulate ability to make judgments or appraisals or to formulate evaluations in terms of criteria such as correctness, completeness, identity, relevance, adequacy, utility, safety, consistency, feasibility, social custom, and so forth in order to communicate more effectively and efficiently; To stimulate the integration of all cognitive operations through the use of problem-solving, decision-making, and planning tasks and through conversational discourse in order to communicate more effectively and efficiently.

Cognitive stimulation: treatment principles: Begin with………and move toward………: Tangible ………representational Concrete……… abstract Simple………complex Real………complex Actions………verbalizations Simple classifications……….multiple classifications Exaggerated sensory stimulation………decreased exaggeration Short stimuli/responses………longer stimuli/responses Continuous reinforcement………intermittent reinforcement Clinician reinforcement………self-reinforcement.

Treatment variables… …that may affect single word comprehension: Frequency of occurrence; Semantic or acoustic similarity between target words and foils; Part of speech; Referent ambiguity Fidelity …that may affect sentence comprehension: Length and syntactic complexity; Reversibility and plausibility; Predictability Personal reference; Semantic similarity; Reasoning and inferences; Rate; Redundancy; Number, similarity and nature of response choices.

Treatment variables… … that may affect compre- hension of spoken discourse: Same as above + world knowledge; Salience; Directness; Redundancy; Cohesion and coherence; Speech rate and emphatic stress. … that may affect naming accuracy: Frequency of occurrence; Length; Abstractness; Phonological complexity; Semantic category; Form of visual stimuli; Context.

Visual stimuli variables Real objects or 3-dimensional drawings; Color; Redundancy; Operativity and imageability; Physical properties; Lack of ambiguity in perceptual characteristics and context (e.g., flower in vase versus flower in computer).