Kathryn L. Garrett, Ph.D., CCC-SLP Duquesne University, Pittsburgh, PA Kelly M. Sestric, MS, CFY

1. THE EFFECTS OF TOPICAL VOCA MESSAGES & INSTRUCTION ON THE CONVERSATIONAL INTERACTIONS OF SEVERELY APHASIC COMMUNICATORS Kathryn L. Garrett, Ph.D., CCC-SLP Duquesne University, Pittsburgh, PA Kelly M. Sestric, MS, CFY Mt. Lebanon School District, Pittsburgh, PA

2. Abstract • In this single subject experiment, 2 communicators with severe expressive aphasia conversed with a partner about a personal event and a news event in baseline, VOCA topical messages, and VOCA + instruction conditions. Dependent variables included: exchanges per topic, participant initiations, success-fulness, modality, and elapsed topic time. Qualitative ratings were also obtained. Results showed increases in the number of turns, length of time, successful-ness, and ability of the participant to initiate/add novel info in the VOCA conditions. Interaction effectswere noted for topic, condition, and participants.

3. Background/Review of the Lit • Garrett & Beukelman (1995) showed that communicators with severe aphasia can participate more fully in interactions using the Written Choice Conversational Strategy. However, this strategy does not allow nonspeaking communicators to introduce novel, semantically specific information to a conversational interaction • Garrett, Heldman, & Dunning (1994) described a case in which a gentleman with severe aphasia and AOS successfully learned to use a voice output communication aid (VOCA) to communicate consecutive messages in a conversation. • However, few controlled studies have investigated whether nonspeaking individuals with severe aphasia can systematically learn to reference externally stored conversational messages to participate more fully in conversational exchanges.

4. Purposes of this Study • To investigate how VOCA-based conversational message availability affects the ability of 2 individuals with severe expressive aphasia to initiate and participate in conversation in the following conditions: • 1) Baseline vs. VOCA vs. VOCA+Instruction • 3) Personal Event vs. Current Event

5. Age 52, married 4 years post L CVA WAB Aphasia Quotient = 13.9/100 Spont. Speech = 3/20 Comprehen.= 3.65/10 Repetition = .2/10 Naming = .1/10 Reading = 24/100 Age 73, married 3 years post L CVA WAB Aphasia Quotient = 13.3/100 Spont. Speech = 0/20 Comprehen.= 6.65/10 Repetition = 0/10 Naming = 0/10 Reading = 24/100 Participant Demographics T.K. A.A.

6. Methods • Design • Modified Single Subject (ABAC) Sequential Design • Participant 1: 3 Baseline sessions (A1) (T.K.) 4 Voca topical message sessions (B1) 2 Baseline sessions (A2) 2 Instruction + VOCA sessions (C1) 11 sessions total • Participant 2:: 2 Baseline sessions (A1’) (A.A.) 5 VOCA topical message sessions (B1’) 2 baseline sessions (A2’) 4 Instruction + VOCA sessions (C1’) 13 sessions total

7. Methods (cont.) • Data Collection Procedures • Topic Selection: Personal event topic obtained from interview with spouse prior to session; Current event from 1st or 2nd headliner story in primary newspaper sections. • Topic Representation: key word + optional symbol represented messages on device displays; VOCA messages then stored as follows: • T.K - Dynavox - 2-3 text-to-speech topical messages were programmed per selection area. E.g., Helicopter = Did you hear about the Army helicopter crash? It was terrible! • A.A. - Techspeak - 1 2.5 sec., digitized, male-voice message was recorded per selection area. E.g., Marcia= Marcia went on a trip today • Yes/no and Good/So-So/Bad message buttons were also represented on both systems

8. Methods (cont.) • Data Collection Procedures - continued • General Instructions: Talk for as long as you want about …. Or ….. (2-exchange breakdown = Topic Termination rule.) Topic presentation was randomly ordered. Each interaction was videofilmed. • Instruction Condition: “Rules” for conversation were introduced (see below); then participant rehearsed the conversation with the primary investigator prior to data collection. Feedback provided to communicator on: opportunities for initiation, adequacy of message, etc.

9. Sample VOCA Topical Message Displays • T.K. - Dynavox • A.A. - Techspeak 6X32

10. Sample Instructional Chart

11. Current Events Fighting in Kosovo Pirates Opener Murder Suspect Caught JFK Jr’s plane crash Drought Restrictions Charles Schultz’ Death Gas Prices Elian Gonzalez Personal Events Kids home from college Visit to Friend Chores Friend’s Birthday Going gambling Air Conditioner Broke Movie and Dinner Family visit from St. Louis Sample Topics (across Participants)

12. Methods Continued: • Data Analysis Procedures/Dependent Vars. • Tapes were transcribed and coded for: • Turns • Exchanges (clusters of turns related to a single idea) • Initiations (who initiated - partner or participant?) • Successfulness (was idea conveyed - fully or partially?) • Modality (including referential gestures to topic setter) • Elapsed time per topic • Perceptual Datawere also collected on Ss and Partner’s • Own Competence • Partner’s Competence • Comfort with Communication Technique • Enjoyment of Communication Technique.

13. Data Summarization • Data were initially plotted by individual sessions in accordance with single subject analysis techniques • However, inherent variability (perhaps because of the uniqueness of each topic) caused any potential effect to be obscured • To compensate for variability, quantitative data on turns, exchanges, initiations, etc. were then averaged by condition/topic and graphed (see display) • Descriptive statistics were calculated (see handout) • Inferential (nonparametric analysis) will follow, although independence of data is an issue

14. Results (Overview) • Condition Effects: • Average Elapsed Time of the topic increased for Participant 1 only • Total Turns increased from baseline to VOCA & Instructional conditions for both Participants for the Personal Event topic. Exchanges increased for both topics across both Participants. • The turns/exchange ratio decreased between baseline and VOCA conditions - perhaps because fewer turns were spent on resolving commu-nication breakdowns to understand the core idea.

15. Results (Overview) • Condition Effects: • % Initiations increased for both topics from baseline to VOCA conditions across both participants. • T.K demonstrated incremental increases in successfulness of exchanges when VOCA messages were available during interactions. However, increases were very slight for participant #2. • TK’s perceptual ratings showed no difference across conditions. However, AA’s ratingsincreased substantially in the VOCA condition, then remained high.

16. Results (Overview cont.) • Participant Effects • Experimental observations that Participant 1 was a more tenacious, resourceful communicator were supported empirically -- there was more of a tx effect with regard to # of exchanges, initiations, and % successfulness with Participant 1 (T.K.) than Participant 2, particularly for the personal event topic.

17. Results (Overview cont.) • Topic Effects • Length of interaction, as measured in seconds and/or number of turns, was typically greater for the personal event across both participants.. • However, when VOCA topical messages were available, there was a more pronounced increase in initiations for the current event for Participant 2 (A.A.) • Successfulness of exchanges increased relatively more for the current event than for the personal event for both participants.

18. Summary and Conclusions • Both participants quickly learned to utilize VOCA messages to initiate or add information to a topical conversation. • This access to semantically specific information generally extended topical interactions as measured by increases in turns and time. • The nature of the interactions changed - from clinician-dominated to shared roles as initiator. • Interaction effects were observed between partners, topics, and condition. • Further quantitative analysis is warranted to determine the significance of the effects and whether meaningful interactions exist among the variables (e.g., between referential acts, successfulness, contingent partner responses)

19. Clinical Application/Future Directions • The presence of external topical messages appears to immediately change the nature of interactions between people with severe expressive aphasia and their commu-nication partners. • Interactions are characterized by increased communicator initiations and overall successfulness of the exchanges. • Instruction in how to reference the topical messages in a timely and appropriate manner during a conversational exchange may benefit some communicators. • Teaching communicators to access renewable topical messages on a VOCA could be an easily implemented clinical intervention strategy -- a preliminary referential skill that nonetheless has significant communication power.

20. Acknowledgements • This investigation was supported, in part, by an Duquesne University 1998 Faculty Development Award. • The authors would also like to acknowledge the efforts of the following individuals: the participants (T.K. & A.A.) and their spouses; graduate students Katrina Dunnewold and Amy Morgan (experimental partners),and Jen Martonik (graduate research assistant/graph-maker extraordinaire)