Referential Skills of Adults with Aphasia vs. Peers in a Photo-Reminiscing Task

1. Kathryn Garrett: DON”T PRINT SLIDE #1 - TITLE -- HAVE SEPARATE BANNER Referential Skills of Adults with Aphasia vs. Peers in a Photo-Reminiscing Task Kathryn L. Garrett, Ph.D. CCC-SLP Alison L. Wilber, MS, SLP Marissa J. Krisak, MS, SLP Duquesne University Pittsburgh, PA ASHA 2003, Chicago

2. I. Introduction • Referential communication is a fundamental component of socio-communicative interactions for both children and adults. • Referential communication skills emerge before the age of 1 year, and before the onset of verbal communication in young children

3. What is referential communication? • Abbeduto, Short-Meyerson, Benson, Dolish, & Weissman (1998) described “physical referencing” as: • “...an understanding that an item that is present in an individual’s proximal life space may be the topic of conversation or concept under discussion.” • Their research indicated that referential skills (particularly physical referencing) are present in young children as well as older children with developmental language delays.

4. Examples of Early Referential Skills • Visually attending to others (especially speakers) • Pointing deictically/gesturing to request • Pointing deictically to an object, picture or written word to clarify the referent when answering/commenting • Pointing deictically to request info or indicate another’s turn • Searching for items or symbols that represent answers to questions (“What do you want to play with?”) [I want you to pick me up] “What’s dat?”

5. “Did you hear what happened to the mascot at the game last weekend?” The relationship of referential skills to attention….. • Bruner (1983) stated that verbal referential communication skills develop as a result of learning how to manage one’s own and direct others’ attention • Early, object-level, deictic referencing that occurs in conjunction with joint attention... • …to referential communication that is complex, intentional, verbal-symbolic, and displaced over time and space……………. EVOLVES

6. So what does this have to do with severe aphasia? Do people with severe aphasia engage in joint attention and referential communication at the same level as peers with no aphasia? Is referential communication a prerequisite for intentional linguistic communication in aphasia?

7. II. Statement of the Problem • Some communicators with severe-to-profound aphasia appear to have an elemental challenge in referential as well as verbal/linguistic communication skills • In group therapy, communicators with severe aphasia often need explicit instruction to: • establish coordinated joint attention between the communicator, partners, and physical referents (“Show that to Liz -- she wants to know too”) • signal others to look, take a turn, refer to an item, or share info (“Show me where you went”; “Point to John - ask him!”)

8. So...according to child language learning principles… • Is it appropriate to begin working on speech, symbolic gestures, or symbolic AAC strategies before communicators demonstrate some evidence of ATTENTION and REFERENTIAL skills?

9. III. Hypotheses KG CC Limb • A) Individuals with moderate, severe, or profound aphasia may not engage in referential communication as much as speaking peers • B) Individuals with severe aphasia may not be able to produce propositional, verbal-symbolic communication (speech or nonspeech modalities) until basic referential skills emerge (either naturally or with facilitation) • pointing to others • shifting gaze to a speaker • physically manipulating externally-stored symbols (pictures, words, etc.) to answer a question.

10. C) Perceptions of communication competence in communicators with severe aphasia may correlate with referential ability as well as linguistic ability • D) Perhaps explicitly teaching communicators with severe aphasia to engage in referential communication can improve their overall communication and/or linguistic skills • “Who did you come with? Show me!” • “Ask Robert - where did you go for Thanksgiving [point]?”

11. IV. Research Study -- Phase 1 • Research Question for Hypothesis #1: Is there a difference between the referential communication skills of adults with acquired aphasia and those of adult peers? • Participants: • 2 adults with chronic aphasia (1 mild-mod, 1 severe) with minimal experience in referential communication training during interactive communication therapy • PWA #1: age 61, WAB AQ = 9.2 • PWA #2: age 74, WAB AQ = 76.4 • 2 adult peers with no brain injury • Peer #1: age 54 • Peer #2: age 55

12. Procedures • Participants constructed a different personalized photo album for each (n=4) data collection session • 1 photo per page, 11 photos per album • 2 albums of recent events, 2 of past events • Instructions: “Talk about your pictures as much as you want…” • Partner was instructed to refrain from asking more than 5 yes/no questions • First 2 minutes of each videotaped interaction was extracted for analysis and coding • 2 sessions X 2 topics = 4 sessions per 4 participants (16 sessions total)

13. Dependent Variables • Verbal and nonverbal referential behaviors were coded for the communicators with aphasia and peers, including:(adapted from Mundy, Hogan, & Doehring, 1996) • Role of Referential Communicator (Initiate vs. Respond) • Number of Referential Communication Acts and Subacts • Function of Referential Communication Act • Establishing Joint Attention • Providing Specific Semantic Information • Commenting/Confirming • Level of Intentionality of Referential Communication Act • Eye gaze (Preintentional) ex. look at partner • Deictic-referential (Intentional/nonsymbolic) ex. point to self • Locutionary (Intentional, verbal-symbolic referential communication) Ex. “Twenty years ago we went to...”

14. Results #1

15. Summary of Results #1 • Participants with aphasia and peer controls had no difference in proportion of eye gaze acts (.08 and .09) • Participants with aphasia actually used proportionately more intentional deictic pointing than peers • * The person with the most severe aphasia (AQ = 10) used as many deictic points (n=29) in 2 minutes as a speaking peer • Descriptive results contradicted the experimental hypothesis

16. Results #2

17. Summary of Results #2 • Participants with aphasia utilized pointing and eye gaze to establish joint attention during this task more than peer controls • Participants with Aphasia: .52 • Peer Controls: .40 • Conversely, peers conveyed more specific semantic info than participants with aphasia • Participants with Aphasia: .31 • Peer Controls: .58 • Thus, an inverse relationship existed between joint attention and semantic-level communication.

18. Other Results • Both PWAs and Peers used an equal proportion of eye gaze to establish joint attention • Participants with Aphasia: .08 • Peer Controls: .09 • Both PWAs and Peers showed an equal ratio of communication subacts to acts; this meant that both groups contributed a similar amount of gestures, pointing, and verbal messages to convey one idea • Participants with Aphasia: 2.26 subacts per act • Peer Controls: 1.95 subacts per act • Successfulness • Participants with Aphasia: 41% of acts -- completely succ. • Peer Controls: 100% of acts -- completely succ.

19. Consistency of Results • All participants demonstrated good within-subject consistency across sessions • However, between-subject differences were observed within participant categories • In fact, PWA #1 and Peer #1 were more similar to one another than to the other member of their participant category in: • Proportion of joint attention subacts • Proportion of intentional deictic pointing • Proportion of unintentional eye gaze • Due to this variability, groups did not demonstrate a statistically significant difference in deictic communication when randomization tests were conducted

20. V. Interpretation of Results • In this photo-album reminiscing task, people with aphasia appeared to demonstrate the elemental cognitive ability to establish joint attention • Despite limitations in verbal output, the participants with aphasia made frequent attempts to establish joint attention and communicate specific referential information. • One of the subjects with aphasia (PWA #1) demonstrated an equal or greater amount of deictic pointing than adult peers, perhaps to compensate for an inability to verbally establish reference.

21. The reduced number of specific semantic acts and decreased proportion of message successfulness experienced by PWAs may have triggered their increased use of deictic referential gestures • In contrast, the linguistically competent peers could use language alone to establish reference.

22. Limitations of the Study • However, anecdotal observations indicate that people with aphasia may not always think to establish joint attention when communicating • Example 1: Both PWAs needed repetition of instructions to open the book and point to pictures at the beginning of data collection. PWA #1 also required an initial model. • Example 2: Both PWAs have enrolled in interactive group communication therapy since data collection was completed. In this context, they have required moderate-to-maximal cueing to point or reference for their partners in contextual conversations. • The photo album reminiscing task may have compelled communicators to use deictic pointing; therefore a true picture of referential ability in interactive conversation may not have been obtained.

23. Therefore, we may need to investigate referential skills in a more demanding communication situation • Topical materials should be available, but placed at a distance from the communicators with aphasia • Situations that involve a communication predicament could be constructed (e.g., Partner says something incorrect) • Finally, inter-subject variability was present for the most important dependent variables (function and type of referential act); therefore, a larger pool of participants may yield different results.

24. Directions for Future Research • Compare referential behavior with same-age peers (particularly elder peers) to people with aphasia in a larger group study. • Increase complexity of referential task • Determine if referential ability correlates with other communication skills (e.g., language ability; amount of expressive output, cognition) • Correlate quantitative measures of referential ability with perceptions of communication competence in communicators with aphasia

25. Clinical Implications • Clinicians may want consider… • Observing the referential skills of clients with moderate-to-severe/profound aphasia • Explicitly instructing individuals to reference external representations of meanings (e.g., objects, symbols, written words, people) AND establish joint attention with other conversational participants • perhaps before or while working on verbal-symbolic communication • teaching attentional, referential, pragmatic, and symbolic communication skills within interactive contexts

26. J.V. telling Sara he wants to watch a movie by pointing to a photo choice after she asked “Well, what do you feel like doing right now? Show me….”

27. Final Thoughts • Perhaps some of the information on referential communication, intentionality, and symbolic communication from the child language and severe disability literature can contribute to our therapy approaches for people with severe aphasia • Further investigation is warranted

28. For handouts…..choose an option! • Access the MS Word handout on the ASHA conference website (wait 1 week) • Email kg at garrettk@duq.edu -- she will send you this Powerpoint presentation as an attachment • Visit the University of Nebraska-Lincoln AAC website for the Powerpoint presentation: http://aac.unl.edu • But give me and the folks at UN-L a week or 2 to post this. Thanks for your interest!!

29. Acknowledgements • Thanks to graduate students Abby James and Kelly Hanna for their assistance in compiling data for this project. • Thanks to the clients with aphasia and the peers for their participation. • Partial funding for this project was obtained from a Duquesne University Faculty Development Award (2002).