Conversational Script Training for Aphasia: Case Studies

American Speech-Language Hearing Association, Boston, MA (November, 27) Conversational Script Training for Aphasia: Case Studies Leora R. Cherney Audrey L. Holland Edie Babbitt Anita S. Halper Jaime B. Lee Ronald Cole Research Team Rehabilitation Institute of Chicago Leora R. Cherney, PhD, CCC-SLP, BC-NCD Anita S. Halper, MA, CCC-SLP, BC-NCD Edie Babbitt, MEd, CCC-SLP Rosalind Hurwitz, MA, CCC-SLP Jaime Lee, MA, CCC-SLP Center for Spoken Language Research Ron Cole, PhD Sarel Van Vuuren, PhD Nattawut Ngampatipatpong, MS Consultant Audrey L. Holland, PhD. CCC-SLP, BC-NCD Supported by Grant H133B31127 from the National Institute on Disability and Rehabilitation Research, Department of Education Conversational Script Training Background Functional approach to aphasia therapy State-of-the-art computer treatment software with animated agent that simulates the therapist Presenting results from five participants with chronic aphasia Scripts guide and facilitate identification of participants and actions involved in social situations Script knowledge includes understanding, remembering and recalling the temporal organization of events in routine activities Research indicates that script knowledge is not seriously compromised by aphasia, at least when the language deficit is mild to moderate thus making aphasic individuals candidates for script training (Armus et al, 1989; Lojeck-Osiejuk, 1996). Script Training Rationale Instance Theory of Automatization Automatic processing is fast, effortless, autonomous, stereotypic and unavailable to conscious awareness Automaticity of skills achieved by retrieving memories of complete, context-bound, skilled performance These memories are formed with repeated exposures to a consistent task (practice) (Logan, 1988) Instance Theory of Automatization Each instance of exposure contributes to the acquisition of a domain specific knowledge base when stimuli are mapped consistently on to the same responses Retrieval occurs automatically when the same stimuli from the practice environment are present Practice increases amount and speed of retrieval (Logan, 1988) 1

American Speech-Language Hearing Association, Boston, MA (November, 27) Implications for Script Training Focus on complete meaningful segments rather than single words Use discourse relevant to daily life Practice with a communication partner Practice consistently Practice intensively Cued Massed Practice Provides maximum support to facilitate accurate production; support is gradually decreased Intensive repetitive practice accomplishes automatization of script production Whole task, massed practice and drill can be accomplished by using repeated oral reading Cost effectiveness can be achieved with use of computers AphasiaScripts Computer program providing practice in conversational script training Uses an animated agent with visible speech Allows repeated and consistent practice of an individualized conversational script Training Sequence Listening/reading whole conversation Single sentence practice Self-monitoring Individual word practice Conversation practice Removing cues (face, voice, written words) AphasiaScripts Sentence and conversation practice involves reading the script aloud with the following cues: Visual verbal - words are highlighted on the screen Visual motor correct articulatory movements are seen on an animated agent Auditory - words are heard Conversation practice - cues are removed in a step-by-step process in a fixed order 2

3 American Speech-Language Hearing Association, Boston, MA (November, 27)

12 1 8 6 4 2 p American Speech-Language Hearing Association, Boston, MA (November, 27) Research Protocol Three personalized scripts are developed for each subject Each script is practiced for three weeks Scripts are practiced daily at home for at least 3-minutes on a loaned laptop Once-weekly sessions with SLP to check status and ensure compliance Home Computer Practice Compliance Log-on and log-off times stamped on computer Practiced stimuli are stored Practice logs completed by subject and reviewed at weekly visit Subject Inclusion Criteria Moderate or mild aphasia after left-hemisphere stroke Type and severity of aphasia determined by performance on the Western Aphasia Battery At least six months post stroke. Right hand-dominant, with no history of other premorbid neurological or psychiatric disorders. At least eighth grade and literate in English prior to stroke Case Study: Subject 1() 68 year old male 8 years post-stroke Moderate Broca s aphasia WAB AQ 8.3 Scripts Introduction to the Midwest Aphasia Conference Dialogue about family and interests Dialogue about a Mediterranean cruise Introduction at Aphasia Conference Welcome lords, ladies, gentlemen, and honored guests. My name is Jim R I had a stroke eight years ago. And like many of you, I have aphasia. Living with aphasia can be a challenge. But stop, look around, we are in this together. I may have trouble finding the words I want to say. But I still have my sense of humor. That reminds me of a joke. Before you criticize someone, walk a mile in their shoes. That way, when you criticize them, You re a mile away and you have their shoes! Thank you and enjoy the wonderful day ahead. # SCRIPT RELATED WORDS Script Related Words - % SCRIPT RELATED WORDS 12 1 8 6 4 2 P 4

3 2 2 1 1 pe 3 2 2 1 1 American Speech-Language Hearing Association, Boston, MA (November, 27) Grammatical Complexity & Rate- # VERBS # SCRIPT RELATED MORPHEMES 14 12 1 8 6 4 2 SCRIPT RELATED WORDS PER MINUTE 9 8 7 6 4 3 2 1 P # NOUNS # MODIFIERS 16 14 12 1 8 6 4 2 Exit Interview W: I would say there was a major change. SLP: Do you have a few examples? W: Well, just sort of the feeling, we go to the exercise club every morning, and Jim has always enjoyed the group of guys who are there. But now it s Jimmy this and Jimmy that and hi Jimmy and here, you know he really is part of the group SLP: Do you think that s happened because you were able to initiate with them a question about asking them, so that they have been talking more to you just because you ve been able to initiate the question? R: Yes yes yeah yeah Exit Interview W: Just socially, it seems like there was a big jump. From being there and listening, but not really participating, to participating. Even there was a party in the condo with other neighbors, and you were, I don t even know what was going on there, but you were in the midst of a very noisy group. R: yeah /yeah/ sometimes I uh / uh uh uh c- um/ noisy/ and sometimes I hes-hesitated-ed/ with a noisy group W: yeah you might not have talked as much, but you were part of the group R: yeah W: in a different way than you had been in the past R: yeah Case Study: Subject 2 () 42 year old female 19 months post-stroke Moderate Broca s aphasia WAB AQ 77. Scripts Phone conversation with prospective client Dialogue while showing a house Dialogue at house closing Script 2 Pam: Hi I m Pam C. Nice to meet you. Pat: I m Pat and this is my husband Jerry. Pam: Did you have any trouble finding the place? Pat: Oh no. The directions were easy. Pam: I love this house. It was just painted and they put in new carpet. Pat: Sounds great. Pam: Let s start in the kitchen. There s a deck out to the landscaped backyard. Pat: It s beautiful. Pam: This bathroom was just remodeled Pat: Oh I love it.

16 14 12 1 8 6 4 2 14 12 1 3 2 2 1 1 8 6 4 2 12 1 8 6 4 2 3 3 2 2 1 1 American Speech-Language Hearing Association, Boston, MA (November, 27) Pam: Let s go see the upstairs. There s a whirlpool tub in the master bath. Pat: Very nice. Pam: Here s the extra bedroom. It could be an office or playroom. Pat: Perfect. Pam: Let s go down to the basement now. You ll love it. Pat: Great. Pam: The finished basement has a fireplace and bathroom. The washer and dryer stay. Pat: We love the house. We want it. Pam: I will call your mortgage lender so we can get the ball rolling. Pat: Great. # SCRIPT RELATED WORDS Script Related Words- % SCRIPT RELATED WORDS 12 1 8 6 4 2 Grammatical Complexity & Rate- # VERBS # SCRIPT RELATED MORPHEMES SCRIPT RELATED WORDS PER MINUTE 2 18 16 14 12 1 8 6 4 2 # NOUNS # MODIFIERS : Exit Interview SLP: Can you tell me since you started the project did you notice any changes in your speech? C: Oh, yes a lot. SLP: Ok, can you give me um an example, anything? C: Well, well, um, everybody seems they can notice to, um. : Exit Interview SLP: Ok um, did you notice any other changes in yourself after doing the program? C: Yes I did. SLP: Yeah, like- C: I m not, I m not uh upset as much you know. SLP: Oh ok. So you don t get upset as much as you used to? C: Right. 6

12 1 8 6 4 2 American Speech-Language Hearing Association, Boston, MA (November, 27) : Exit Interview SLP: Ok, um what did you think about the program itself like Ms. Pat, what did you think about Ms. Pat? C: Well um, um me and Pat we have to argue but it helps. (laughs) SLP: Ok, did you did you like working with her as opposed-? C: Oh yes I, oh yeah, yeah. : Exit Interview with Significant Other D: Her family says that they can understand her better now. SLP: Oh they do too. Oh good. Ok D: I noticed it quite a bit SLP: Ok, um and did you notice anything any other changes with her.. D: Her mannerisms, have gotten once again I don t know how to describe it but her mannerisms are she s getting some of those facial expressions back like she used to have little quirky things people have it just um you can just tell it is kind of the old Pam so to speak. Case Study: Subject 3 () 36 year old male 3 years post-stroke Moderate Broca s aphasia WAB AQ 77 Scripts Dialogue about family plans for summer including seeing movie X-Men 3 with 4-year old son Monologue about his stroke Dialogue with friends about fantasy football Fantasy Football Script DICK: What have you been up to? SHAWN: Just getting ready for this year s draft. DICK: Yeah. SHAWN: I really love Fantasy Football! My favorite time of year. DICK: I know. SHAWN: I m researching my draft picks. DICK: And? SHAWN: I want a good quarterback with high ratings. DICK: I think it s Vicks year. SHAWN: You know how much I think Michael Vicks stinks. DICK: Come on. SHAWN: Drew Breese should put up some good numbers this year. DICK: I don t think so. SHAWN: I bet his rushing yards will be high, but probably not his passing yards. DICK: Maybe. SHAWN: Who do you think you ll take, Dick? DICK: Maybe Brett Favre. SHAWN: But who will you pick if Favre retires soon? DICK: I don t know. SHAWN: I should call Green in Boston for his draft picks and also Willie and Junior. Script Related Words- Grammatical Complexity & Rate- # SCRIPT RELATED WORDS % SCRIPT RELATED WORDS 12 1 8 6 4 2 # SCRIPT RELATED MORPHEMES 14 12 1 8 6 4 2 SCRIPT RELATED WORDS PER MINUTE 14 12 1 8 6 4 2 7

12 1 8 6 4 2 2 18 16 14 12 1 8 6 4 2 12 1 8 6 4 2 14 12 1 8 6 4 2 9 8 7 6 4 3 2 1 American Speech-Language Hearing Association, Boston, MA (November, 27) # NOUNS 3 2 2 1 1 # VERBS 3 2 2 1 1 # MODIFIERS : Exit Interview SLP: How satisfied were you with the whole program in general? L: I liked uh/ program /and especially with/computer/ and/ / it s / a /new /task/ on the computer SLP: What did you think of the actual computer program itself? L: Very good. It helped me to/ sit down/ and / write it / sit down/ to/ understand / and computer/ and / me / and / computer / one on one / See it / my name is (1st name) / speak it/ my name is (1st name) : Exit Interview Case Study: Subject 4 () SLP: With this research program with the computer, have you noticed any changes? L: Improvement? Um/ sort of. / Um / For example / seems/ talking in general/ it s /ss it s / a little bit easy / um / writing / the words / um / on the computer / it s // it s the same / it s the same L: Um // Uh man / let me see / talking / in / general /in the publics / area I m / talking / with the people/ by now /details / in them / very um /very um / good practice 6 year old female 18 months post-stroke Moderate anomic aphasia WAB AQ 9.2 Scripts Graduation toast to her son Dialogue about her art class Dialogue about her Florida vacation Script Related Words- Grammatical Complexity & Rate- # SCRIPT RELATED WORDS % SCRIPT RELATED WORDS # SCRIPT RELATED MORPHEMES SCRIPT RELATED WORDS PER MINUTE 8

2 2 1 1 2 2 1 1 2 2 1 1 American Speech-Language Hearing Association, Boston, MA (November, 27) # NOUNS # VERBS # MODIFIERS MCM Exit Interview SLP: Can you give us maybe some examples of some times when, since you started working on the program, your speaking has gotten better? H: She can now name our children, which she couldn t do before without being prompted MCM Exit Interview H: But one of the biggest things that I ve noticed about M, since she started this program is that, her ability to be able to read a little more than what she could before. She now picks up signs, words. She could always read to a degree, a very small degree, the menu in a restaurant, where today i think she pretty well can read the menu as a whole and understand pretty much what s there H: She s more eager now. She looks at her mail by herself. Magazines, literature when it comes, advertisements. MCM Exit Interview H: Since she started the program. And she s much better now, talking with her friends sometimes. As an example, Monday night, her girlfriends invited her to go play golf so she went and played golf. And at first they didn t talk to her. But after a while they started to talk to her and she opened up and she just... M: Talk talk talk talk talk (laughs) H: Talking quite a bit. So she s not afraid to talk now about some things. MCM Graduation Toast Case Study: Subject () Hello everyone. We re so glad you could join us today. I d like to say a few words about my son Joe. Today we celebrate yet another one of Joe s accomplishments. His MBA from Notre Dame. Joe is an amazing man, a wonderful son. He has a great sense of humor and just loves to laugh. He s a great husband, father, and friend. To say the least, he is intelligent and driven. That s obvious today, isn t it? A mother deserves to brag once in a while! Your father and I are so proud of you. Here s to Joe! 26 year old female 2. years post-stroke Mild-to-moderate anomic aphasia WAB AQ 78.7 Scripts Monologue about her aphasia Dialogue about animals Dialogue with a store clerk at Best Buy 9

11 1 1 3 2 2 1 1 9 9 8 8 18 16 14 12 1 8 6 4 2 12 1 98 96 94 92 9 88 86 3 2 2 1 1 13 12 12 11 11 1 1 16 14 12 1 8 6 4 2 American Speech-Language Hearing Association, Boston, MA (November, 27) Script Related Words- Grammatical Complexity & Rate- # SCRIPT RELATED WORDS % SCRIPT RELATED WORDS # SCRIPT RELATED MORPHEMES SCRIPT RELATED WORDS PER MINUTE # NOUNS # MODIFIERS # VERBS Amount of Practice Practice Time in Hours 7 6 4 3 2 1 1 2 3 Script Amount of Practice Summary practice time (hours) 2. 2. 1. 1... AphasiaScripts Practice Time by Week 1 2 3 4 6 7 8 9 Improvements on all measures on each script for the subjects Subjects 1(), 3 () & () Already producing script related words at more than 8% Notable increases on rate of production Subject 2 () Also producing script related words at a high percent - (6% to 88%) Remarkable increase on rate of production (17-2 words per minute to 168-184 words per minute) week 1

American Speech-Language Hearing Association, Boston, MA (November, 27) Summary Subject 4 () Script related words increased from less than 3% to more than 7-9% of the target scripts Accompanying improvements in grammatical productivity as measured by number of morphemes and improved production of nouns, verbs and modifiers Rate of production more than tripled Accompanying changes evident on WAB AQ (9.2 to 71.3) Summary : Exit Interview Themes Increased verbal communication Generalization to other modalities and situations Improvements noticed by others Increased confidence Satisfaction with program Conclusions Conversational script training resulted in improved production of the practiced scripts Reports from patients and family indicated improved communication skills in other situations Computer script training using virtual therapist software may be cost-effective means of delivering therapy Analysis of data from a larger sample of participants is underway 11