(c) University of Sydney, Prof.

Leanne
Togher

Communication treatment approaches

for people with ABI

Welcome!

Leanne Togher Ph.D.

The University of Sydney
Australia

(c) University of Sydney, Prof. Leanne

Togher

Today

Background to TBI Express

Background to TBI Express development

Sociolinguistics
Systemic Functional Grammar (Halliday 2001)
Observation of interactions of people with TBI
Dr Mark Ylvisaker Joint construction of narratives

Evidence based assessment measures of

discourse including conversation

- Collaboration and elaboration

Findings of the TBI Express clinical trial

Overview of the TBI Express training

(c) University of Sydney, Prof. Leanne

Togher

PRAGMATIC
ELEMENTS

SENSORY AND
COGNITIVE
PREREQUISITES

PERCEPTION

METAPRAGMATIC
SKILLS

Sensation and
Perception
Situation
Selective and
Focused Attention

Listener
Self

Self-awareness of
strengths and limitations

Social Cognition
Awareness that there are
behaviour options

Language
Working Memory

GENERATING BEHAVIOUR
OPTIONS
Awareness that there are
consequences of
behaviour

Executive Functions
Explicit Long-term
Memory
Implicit Long-term
Memory
Motor Skills

DECISION-MAKING
Behaviour Evaluation
Behaviour Selection

Knowledge of personal
adaptive strategies

EXECUTION

Strategy Use

McDonald, S., Turkstra, L. & Togher, L. (2012). Pragmatic language impairment after brain injury:
social implications and treatment models. In: Developmental Social Neuroscience: Contributions to
Childhood Brain Disorders, Anderson, V. & Beauchamp, M. (Eds.) pp 325-349, Guildford
Publications.

Systemic functional linguistics

Context of situation

(Halliday, 1994, Halliday & Matthiesen, 2004)

Sociolinguistic theory

FIELD: What is happening

TENOR: Who is involved

MODE: Spoken vs. written

Describes discourse in social terms

Provides a way of examining the co-construction
of discourse between conversational partners

(c) University of Sydney, Prof. Leanne

Togher

TENOR

Meeting a new friend at the pub

FIELD: casual conversation

TENOR: equal participants, unfamiliar

MODE: spoken

STATUS: relative position of the interlocutors in

a cultures social hierarchy

CONTACT: degree of institutional involvement

with each other

AFFECT: degree of emotional charge in

the relationship between participants (Halliday, 1978)

STATUS

Context of culture

Reciprocity of choice

Global context

Equal status = similar kinds of choices whereas

unequal status means that they take up different
choices

Cultural rules

Choices are predetermined and reflected

directly in the language that is produced

Choices are usually made unconsciously and

therefore it is context and to a certain extent,
society, which makes these choices available
(Poynton, 1985)

(c) University of Sydney, Prof. Leanne

Togher

Exchange structure analysis

Language and its environment (Martin, 1992)

ideology
ideology

SYNOPTIC MOVES

genre
genre

semantics
semantics

Ask for or provide information or action

Necessary for the interaction to be
completed

wording
wording

Exchange structure analysis

DYNAMIC MOVES

Embedded in an exchange to negotiate meanings

Keep the interaction going during
communication breakdown or to facilitate
completion

Exchange structure example

K2
rprq
rrprq
K1

Have you been to the shops?

Pardon?
The shops
Yes I got the groceries this
morning

(c) University of Sydney, Prof. Leanne

Togher

The teaching exchange

Exchange structure analysis example

K1

Shane:

K2
Jane:
cfrq Shane:
rcfrq Jane:
K1
Shane:
K2
K1

Asking for information that you already have

I think Ill head off for a swim later

dK1 Therapist: What did we do yesterday?

K2 Patient: We worked on staying on topic
K1 Therapist: Thats right

Are you going to Bondi beach?

Where?
Bondi
Either there or over to Manly

Shane: Would you like to come with me?

Jane: Thatd be great

Five interactions

TBI Subject S1

32 years
Severe TBI 4 years post-injury
PTA = 6 months LOC = 8 weeks
CT scan: frontal haemorrhages/contusions
Cognitive-communication disorder: poor topic
management, impaired social judgment,
overfamiliarity & poor self monitoring

INFORMATION REQUESTING

Mother
Therapist
Bus timetable service
Police

INFORMATION GIVING

Community education re driver safety to school students

(c) University of Sydney, Prof. Leanne

Togher

Exchange structure data - S1

Mother condition - TBI subject S1

10
rchall S: If you could just tell me a few things I did
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dK1 M: You tell me a few things you did
12
dK1 M: What days did you go?
13
K2 S: Monday, Wednesday
14
K1 M: Yes
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dK1 M: And what did you do on Mondays?
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K2 S: Wasnt that the day, that afternoon we went to the
swimming pool?
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K1
M: Yesthats right
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K2 S: And there was speech group in the morning
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K1-Fg M: Yes and they did
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dK1 M: what else did they do?
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K2 S: I cant recall
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chall M: Of course you can
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chall M: Think of some of the things you did there
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K2 S: Aerobics class
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K1 M: Thats right

Mother condition - Control subject C1

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5
6
7
8
9
10
11
12
13
14
15
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K2

C: Yeah can you tell me what sort of things

R. was doing at the ADP?
K1-Fg M: Well
clrq
C: Is that right?
clrq
C: Adult Development Program?
rclrq M: What at Headway?
rclrq C: Ah
rclrq M: Yeah thatd be it
cf
C: [Yeah thatd be it
K1
M: Oh he used to go a couple of days a week
K1
M: Um they did exercises and
clrq
C: Physical?
rclrq M: Yeah some physical and mental things
K1
M: and played games

Results

People with TBI were given less information when

compared with the brothers

People with TBI asked more questions, but were still

given less information

People with TBI had fewer opportunities to give

information than their brothers, particularly with
therapists and their mothers
(Togher, Hand & Code, 1996, 1997a, 1997b, Togher & Hand, 1998)

(c) University of Sydney, Prof. Leanne

Togher

Some implications
People with TBI have a problem developing and sustaining
social relationships maybe some of the problem is how
partners are interacting with them

Joint construction of narratives

Jorgensen, M. & Togher, L. (2009). Narrative after traumatic brain injury: a
comparison of monologic and jointly-produced discourse, Brain Injury, 23 (9), 727740.

Suggestion that we can teach communication partners the

structure of a range of interactions and with this awareness
they can use conversational strategies to foster appropriate
interaction

Narrative

Why assess jointly-produced narrative?

Narrative

Abstract
Orientation
Complication

does not typically exist as a monologue in

everyday interactions

Advances

in measurement tools (Coelho, 2007;

Togher et al., 2006; Turkstra, Brehm & Montgomery, 2006)

Evaluation
Resolution

Varied communication partners:

researcher/ therapist vs.

everyday communication partners

Coda
People with

TBI differed in language use across

communication partners (Togher, Hand & Code, 1997, Guo &
Togher, 2007)

(c) University of Sydney, Prof. Leanne

Togher

Aim

Questions

To study the effects of a familiar

partner on the production of
narrative after TBI

1.

Are participants with TBI as able to jointlyproduce a narrative as control participants?

2.

Does a familiar partner facilitate the production

of narrative in those with TBI?

Participants

Participants (n=20)
TBI PARTICIPANTS

10 participants with severe TBI with a friend

Inclusion criteria for TBI participants:

Age: Mean= 39.4 years (27 67)

Length of PTA: Mean = 17.8

weeks, (range = 1.5 days to 40
weeks)

Time since injury: Mean = 13.05

years (range = 4 - 28)

SCATBI severity scores: Mean=

10.1 1.60 (range = 8-12)

Length of friendships: Mean =

14.1 14.2 years

Severe TBI according to PTA

Cognitive communication disorder on the Scales of Cognitive

Ability following TBI (SCATBI)(Adamovich & Henderson, 1992)
Social communication disorder on the Pragmatic Protocol
(Prutting & Kirchner, 1987)

10 matched control participants (age, sex and education)

with a friend
Recruited through brain injury rehabilitation units in
Sydney, Australia

CONTROL
PARTICIPANTS
Age: Mean= 39.50
11.57 years (29 to 67
years)

Length of friendships:
Mean= 16.45 12.84
years

(c) University of Sydney, Prof. Leanne

Togher

Procedure
Monologic narrative

Control and TBI participants on their own

Story generation picture sequence

The Flowerpot Incident

Analysis

Procedure
Jointly-produced narrative
Participants

Story

and friends together

retell task

Holidays/home

Productivity total C-units, words/C-unit

Cohesion % cohesive ties
Content story grammar, essential units
Exchange structure analysis % K1 moves

improvement video

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(c) University of Sydney, Prof. Leanne

Togher

TBI vs. control in monologic narrative

Statistical differences in all measures

TBI vs. control in jointly-produced narrative

No significant difference between groups

across all measures

More C-units but fewer words per C-unit

Less cohesive
Fewer story grammar elements
Less essential content
Consistent with Hartley & Jensen 1992,
Coelho et al. 1991, Biddle et al. 1996, Snow et
al., 1999

Empowered to participate and produce narrative

Implications

Consistent with equal participation in problemsolving task with friends (Kilov, Togher & Grant, 2009,
Aphasiology)

Discourse assessment

Friends can fill supportive and therapeutic

roles in treatment

La Trobe Communication Questionnaire

Talkbank TBI Bank
Adapted Kagan rating scales

Use of everyday partners in therapy

Training parents of children with TBI

(Ylvisaker et al. 2003)

Supporting Partners of People with Aphasia in

Relationships and conversation (SPPARC) (Lock et al.
2001)

Police officer training for people with TBI

(Togher, McDonald,

Code & Grant, 2004)

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(c) University of Sydney, Prof. Leanne

Togher

La Trobe Communication Questionnaire (LCQ)

Self report
Other

scale for TBI

report scale for communication partner

30

items, 22 based on Grices maxims and 8 on

typical communication problems following TBI
30 = No/ rare perceived communication
difficulty
120 =

Always / greater perceived

communication difficulty

(Douglas, OFlaherty & Snow, 2000)

www.talkbank.org

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TBI Bank

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(c) University of Sydney, Prof. Leanne

Togher

Aphasia Bank

Talk Bank
Operated from Carnegie Mellon University, Pittsburgh
Brian MacWhinney
Web accessible multimedia databases for human
communication
Powerful analytic tools
Community for collaborative commentary (cross
disciplinary)
Displays transcript and video simultaneously
CHILDES, PhonBANK, Aphasia BANK and now TBI
Bank
Can be used for teaching purposes

A. BRAIN INJURY STORY and COPING

TBI Bank Protocol

1. Im going to be asking you to do some talking. How do you think your

speech is these days?

Monologic Discourse Tasks

I. Free Speech Samples (Brain Injury Story & Important
Event)

If no response in approximately 10 seconds, prompt:

II. Picture Descriptions (Broken Window; Refused Umbrella &

Listen, encourage full response. If no response, use Troubleshooting questions.

How's your talking?

Cat Rescue)

2. Tell me what you remember about when you had your head injury.

III. Story Narrative (Cinderella)

If no response in approximately 10 seconds, prompt:

IV. Procedural Discourse (Peanut Butter & Jelly Sandwich or

similar)

What other things have people told you about when you had your head
injury?
Listen, encourage full response.
At a natural juncture add:

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(c) University of Sydney, Prof. Leanne

Togher

Brain injury story and coping contd

Example: Picture descriptions

3. "Tell me about your recovery. What kinds of things have you done
to try to get better since your head injury?
If no response in approximately 10 seconds, prompt:
Tell me about any changes youve needed to make in your daily life.

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Example: Picture descriptions

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Example: Picture descriptions

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(c) University of Sydney, Prof. Leanne

Togher

Example: Picture descriptions

Cultural differences an Aussie adaptation

Cheese and vegemite
sandwich

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Supplementary Tests
Aphasia Bank Repetition Test (2007)
Verb Naming Test (from the Northwestern Assessment of
Verbs and Sentences-Revised, Field Test Version)
Boston Naming Test, Second Edition, Short Form (2001)
Western Aphasia Battery-Revised (2007) -- AQ only

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Longitudinal communication recovery following severe TBI

(Togher, McDonald, Tate, Turkstra, Holland & MacWhinney)

Background and progress

Major aims of this project are to identify predictive factors of
communication outcomes at 2 years and to identify optimal time frames
for recovery
5 year NHMRC Project Grant
N=58 participants
Data collected at 3, 6, 9, 12 and 24 months post injury

Optional - Verbal Fluency (F, A, S).

Data collection will be completed by March 2015 (i.e. 2 year data)

Repeatable Battery for the Assessment of Neuropsychological

Status (1998)

Protocol includes:
- Standardised communication assessments including aphasia, dysarthria,
cognitive communication
- TBI Bank Protocol range of standardised tests and discourse tasks including
picture description, procedural description, illness narrative, conversation with
significant other
- Neuropsychological screening battery
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(c) University of Sydney, Prof. Leanne

Togher

Feasibility of conducting TBI Bank protocol

Compliance with protocol completion

Question: Is it feasible to conduct the TBI Bank

protocol with TBI participants during the sub acute
phases of recovery (i.e. at 3 months and 6 months
post injury)?

At 3 months

Participants:

At 6 months

N=48 participants with severe TBI were assessed

using the TBI Bank protocol at 3 months

2/53 partially completed the protocol

45/48 completed the full protocol

3/48 partially completed the protocol

51/53 participants completed the full protocol

N=53 participants were assessed at 6 months

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Conclusions

Subtest completion
Participants were less likely to complete:

TBI Bank

 The Aphasia Bank Repetition Test

Diagnostic tool

 Describing an important event

Feasible for use with participants in the subacute stages of

recovery

All participants completed:

Objective discourse measures from computerised analysis

Cinderella Story

Aims to reduce participant burden in long term

Recovery narrative

Shared international database to foster collaborative

research activity

Procedural discourse task (making a Cheese and Vegemite

sandwich)

Interested parties can contribute discourse to the repository

Tool for students and researchers to study spoken discourse

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(c) University of Sydney, Prof. Leanne

Togher

Rating conversation
The modified Kagan scales

Method for adaptation

The original MPC and MSC scales are 9 point Likert scales with:
Range: Presented as a range of 0 to 4 with 0.5 levels

Leanne Togher, Emma Power, Robyn Tate, Skye

McDonald & Rachel Rietdijk (2009). Measuring the social
interactions of people with traumatic brain injury and their
communication partners: the adapted Kagan scales,
Aphasiology, 23 (5), 584-605.

Values: 0 (no participation / support), to 2 (adequate participation /

support) and 4 (full participation / support in conversation)
Measure of Participation in Conversation (MPC): 2 subscales Interaction and Transaction skills of person with TBI
Measure of support in communication (MSC): 2 subscales ECP
skill in Acknowledging Competence and Revealing Competence.
Revealing Competence includes 3 subscales; (a) Ensuring the adult
understands, (b) Ensuring the adult has a means of responding and
(c) Verification). These are scored separately and averaged.

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(c) University of Sydney, Prof. Leanne

Togher

Results
Inter-rater reliability scores for both the Adapted MPC and
the MSC scales were excellent
(MPC: ICC = 0.84-0.89; MSC: ICC = 0.85-0.97). Over 90% of
ratings scored within 0.5 on a 9 point scale
Intra-rater agreement was also strong
(MPC: ICC = 0.81-0.92; MSC: ICC = 0.80-0.90)
Over 90% of ratings scored within 0.5 on a 9 point scale

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