HOW I

SYSTEMATIC
A SPEECH AND LANGUAGE THERAPISTS TOOL BOX SHOULD INCLUDE A VARIETY OF APPROACHES TO SUIT A CLIENTS CLINICAL NEED AND LEARNING STYLE.
OUR TWO CONTRIBUTIONS HERE FOCUS ON THERAPY PROGRAMMES THAT ARE SYSTEMATIC AND FINELY GRADED, ONE FOR PEOPLE WITH SEVERE APHASIA, THE OTHER FOR CHILDREN WITH DISORDERED PHONOLOGY. AS WELL AS EXPLAINING THEIR CHOICE OF A SYSTEMATIC APPROACH FOR PARTICULAR CLIENTS AND DISCUSSING THE RESULTS, THE AUTHORS HIGHLIGHT THE IMPORTANCE OF TIMING WHEN MAKING MANAGEMENT DECISIONS.

USED A

HOW I

THE RIGHT TIME TO ACT

READ THIS IF YOU WANT TO NEGOTIATE GOALS WITH CLIENTS AND FAMILIES LOOK FOR AND BUILD ON ABILITIES IMPROVE DISCHARGE PLANNING
CLIENT-CENTRED GOAL NEGOTIATION, OUTCOMES THAT REALLY MAKE A DIFFERENCE, EFFECTIVE USE OF LIMITED THERAPY TIME ALL OUR IDEALS CAN BE CHALLENGED WHEN WE ARE WORKING WITH CLIENTS WITH CHRONIC SEVERE APHASIA. FOR LINDA ARMSTRONG AND JACLYN DALLAS, THE TIME CAME TO ACT WITH ONE SUCH CLIENT WHEN HE INDICATED HE WANTED TO TRY SOMETHING DIFFERENT. HERE, THEY DISCUSS THE BENEFITS AND LIMITATIONS OF INTRODUCING MR MCDONALD TO BEESONS ANAGRAM AND COPY TREATMENT (ACT) AND COPY AND RECALL TREATMENT (CART) PROTOCOLS. The fact that the written word can be constructed one letter at a time, with ample time to examine, reject and revise, provides a flexibility that is unavailable for speech production. This difference may be a critical element in allowing individuals with multiple processing deficits to re-establish written communication, when spoken communication fails (Beeson, 1999)

HOW I (1): APHASIA

APPROACH

SYSTEMATIC APPROACHES (1) APHASIA THE RIGHT TIME TO ACT SYSTEMATIC APPROACHES (2) PHONOLOGY NEVER TOO SOON TO START

peech and language therapy intervention for the person with chronic severe aphasia is problematic for many reasons. With only limited spontaneous recovery and compensation the person will continue to have restricted means of expressing their thoughts, feelLinda Armstrong ings and needs and may have ongoing significant difficulty in understanding both what people say to them and the written word. While these problems clearly impact on everyday communication and social integration, they will also reduce therapeutic options, for example through difficulty in understanding task requirements. The person may already have had a significant amount of speech and language therapy input, with little or no perceived positive benefit in terms especially of spoken language expression (often the outcome measure for people Jaclyn Dallas with aphasia and their families). They may become dependent on the speech and language therapy service as one of the remaining health services provided on discharge from hospital and so resist discharge. Alternatively the person and their family may feel disappointed by the lack of progress. In our experience the speech and language therapist should be very clear about the aim and outcome of continued professional input so that there is evidence of met goals to support the ongoing efforts of the therapist, the client and the clients family. There may be rehabilitative as well as supportive episodes of care. A move towards discharge from speech and language therapy is sometimes accompanied by onward referral to a social group, such as those run by Chest, Heart and Stroke Scotland or the Volunteer Stroke Scheme. Discharge may be the eventual outcome of weaning the client from therapy by one or more of a range of means, including wait and see, negotiation, preparation, separation and replacement (Hersch, 2003).

Positive experience
This single case study demonstrates that at 2 years and 5 months post-onset, a simple therapy paradigm effected significant improvement in the written language ability of a person with chronic severe aphasia. Through sharing it, we hope to show how this made the move towards discharge a more positive experience for the client, his family and the therapist, provided a therapy paradigm that could easily be continued and developed by the client and his family, and demonstrated an ability which has the potential to improve his functional communication ability. Mr McDonald is a previously literate right-handed gentleman in his early 70s, who in 2002 suffered an extensive left middle cerebral artery territory infarct, with resultant right

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hemiplegia, dysphagia, severe aphasia and later seizures. He also has other medical conditions that affect his general health. Speech and language therapy input began immediately post stroke, while he was an in-patient, and continued after this on a domiciliary basis, initially twice a week and latterly once a week. Re-administrations of the Aphasia Screening Test (Whurr, 1996) at intervals (table 1) showed improvements in auditory comprehension, reading comprehension, spoken language expression and written language expression but functionally, in 2005, he continued to exhibit severe expressive and receptive aphasia, exacerbated by articulatory dyspraxia. On the three-picture version of Pyramids and Palm Trees, he scored 42/52 in August 2003 and again in July 2004.
Table 1 Aphasia Screening Test results Date Comprehension (possible maximum 100) November 2002 44 January 2003 70 July 2003 76 July 2004 76 Expression (possible maximum 150) 0 15 27 35

At the beginning of 2005 Mr McDonalds speech output consisted of a few intelligible words and a recurrent unintelligible utterance, very occasional spontaneous use of appropriate single words as well as intelligible use of a four letter swear word. Speech attempts were increasingly accompanied by meaningful gesture and intonational variety. Auditory comprehension and reading comprehension were adequate for his everyday needs. He had a very socially and emotionally supportive family network and he and his wife were highly motivated to carry out therapy tasks. He was most able to get his message across in conversation with his wife and his daughter but found it very difficult to express his ideas to others and tended to sit quietly in company. There were still many occasions when the family gave up and tried again later. Mr McDonald was referred to the Volunteer Stroke Scheme in 2003 in retrospect too early and attended once. He declined to try again. Formal review sessions at regular but infrequent intervals throughout his domiciliary therapy provided opportunities for reflection on the past block of therapy and progress made, and for discussion about the next block. These reviews took place in April 2003, July 2003, December 2003, June 2004 and December 2004. They consisted of planned meetings including the client, his wife and daughter and the speech and language therapist. The speech and language therapist explained a simple written report and left a copy with Mr McDonald. This report included progress towards goals, assessment results and observations of any qualitative improvements in tasks or functional communication. Time was spent in evaluating the effectiveness of the past block of therapy, deciding whether speech and language therapy input should continue and what aspect of communication would be the forthcoming focus in therapy. Mr McDonalds wife had increasingly taken over the tasks and activities initiated by the speech and language therapist, thus ensuring regular practice. Mr McDonald had never wished to support his speech attempts through a low-tech communication aid based on words and pictures, despite several speech and language therapist attempts to demonstrate the usefulness of such an aid (for example a family tree, gardening words). Written expression received attention in therapy from time to time but again was not his chosen focus. By January 2005 he could consistently write basic biographical information. Previous therapy had, according to his wishes, focused mainly on speech production, using cueing methods such as articulograms for single sound and word production drills. Metrical therapy focused at word-level rhythm to try to reduce the use of his recurrent utterance.

expression of biographical information had improved in a previous block through copy and practice, we agreed that his written language expression would be the focus of the next block of therapy. An informal baseline assessment of his writing skills was carried out in early February 2005 to determine current strengths and weaknesses. This assessment consisted of basic shape copying, letter copying and word copying, then delayed copying of five words which were not to be targeted in therapy (and five which were), writing familiar words to dictation, written picture naming and written picture description. He scored 0 on all subtests of the assessment, except the copying and delayed copying subtests. This suggested that copying and delayed copying skills were relatively intact and therefore we decided that these abilities would be targeted in therapy as a means of making writing ability more functional and as a possible means of communicative support. The intervention used with Mr McDonald was based on Beesons (1999) Anagram and Copy Treatment (ACT) protocol and Copy and Recall Treatment (CART) protocol. These protocols were carried out once weekly over the course of Jaclyns final clinical placement. They are based on repeated exposure and practice of target words. The rationale is that particular orthographic representations will thus be relearned and strengthened. Mrs McDonald and one of their daughters produced a list of 23 target words (see figure 1), which were divided into four sets, with most of the verbs in the final set. These consisted of common nouns, verbs and adjectives of varying length and included yes and no. Each of the four word sets was targeted for one therapy session only and was revisited briefly during the following session.

Formal review sessions provided opportunities for reflection on the past block of therapy and progress made, and for discussion about the next block.
Figure 1 Target word lists

Ownership
The block of therapy to be described here derived from the review at the end of 2004. At that time the speech and language therapy view was that regular therapy input was beginning to be less integral to Mr McDonalds ongoing slow communication recovery as he and his wife had taken ownership of his speech practice, were observed to be adjusting to his aphasic status and the goals of the previous block of therapy had been met (in relation to word meaning and use of money). After reflecting on the review, Mr McDonald expressed through his wife that he now wished to explore new possible communicative means as an alternative to his impaired speech production. As written

We used the ACT protocol (see figure 2) during the 10 sessions (two of these were for assessment and some lists took two sessions to cover). It is a cueing hierarchy used to elicit the correct spellings of specific target words. We presented a Boardmaker symbol (or picture) of the target to the client along with related semantic information (for example, MONEY. You buy things with money in a shop). This optimises the likelihood that the graphemic representation is linked to the appropriate semantic information. In Mr McDonalds case, we only provided gestural semantic information (gesturing what is done with an object) as too much verbal information proved confusing. Initially, the client is asked to spell the word without any cues. If this is successful, the next item is targeted. If not, the letters of the target are presented randomly as an anagram to arrange. Following successful arrangement of the letters, the target is copied three times. The component letters are presented again, with the addition of two foil letters. After these have been arranged and discarded respectively, the word is again copied three times. The final step in the protocol is for the word to be written three times with all previous instances covered up. Throughout the protocol there is repeated copying of the target word to strengthen the Figure 2 ACT protocol words internal rep(Beeson et al., 2002) resentation.
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HOW I

The ACT protocol was complemented by the use of the CART protocol (see figure 3), which was used between therapy sessions on a daily basis by Mr and Mrs McDonald to direct writing practice. Again, the client was presented with a Boardmaker symbol and a written model for each target word. He was then asked to copy each word 15-20 times daily. This copying task was followed by a self-test recall task for practice with no reference to a written model. We reviewed these tasks at the beginning of the following session to ensure completion and, although it was impossible to ascertain whether the self-test recall was completed without reference to a written model, the sheets left provided proof of the repeated copying of the target words.

Multiple repetitions...would not be suitable for clients who require variety in task and stimulus to maintain their interest.
Figure 3 CART protocol (Beeson et al., 2003)
Typically sessions began with asking Mr McDonald to write the target words for the session given only the word and a semantic cue (for example, cupyou drink from a cup). He was unable to write any of the 23 target words given only these and required the extra semantic (gestural cue) and visual information (written word to copy) to attempt the task. However, each time we re-visited the previous sessions targets at the outset of the following session, having implemented the ACT and the home based CART protocols, he was able to write on average 60-70 per cent of the words given the verbal and symbolic cues.

This single case study provides some evidence for an effective speech and language therapy intervention for a person with chronic severe aphasia through a relatively simple therapeutic paradigm. Delayed copying provides a therapeutic approach for people whose degree of spelling deficit is so severe that a cognitive neuropsychological approach to assessment and therapy has little to offer. As Mr McDonald was unable to write any words spontaneously before the delayed copy therapy was tried, we were not able to assess with any degree of certainty the source of his problem with writing words or whether any characteristics of the words themselves were significant (including length, grammaticality, frequency, regularity). The combination of ACT and CART worked for Mr McDonald. However, the nature of the protocols is multiple repetitions (parallel to the articulatory drilling used to try to improve speech production). This suited this client well but would not be suitable for clients who require variety in task and stimulus to maintain their interest. While there was significant improvement noted in this clients ability to spell the target words, there can be no automatic claim made that the therapy will generalise to other words. Rapp and Kane (2002) provide some evidence from two case studies that there can be benefits of this therapy for the spelling of trained words that are long-lasting. Both of their participants had less severe language deficit than the person reported here. Their participant with graphemic buffer problems was able to generalise to untrained words but the other, with orthographic output lexicon problems, was not. Therefore, increasing the number of words that can be correctly spelled may require the protocol to be repeated for each word, depending on the nature of the clients spelling deficits. This implicates a very high degree of motivation on the part of the client, therapist and / or significant others, over a lengthy period of time. Delayed copy therapy was successful towards the end of a very long episode of care for this client, at least partly because of a change in interest and motivation by him and his wife in exploring the potential of improving his writing ability. It could of course be employed with other clients much earlier in the therapy process. Linda Armstrong is based at the speech and language therapy department in Perth Royal Infirmary and Jaclyn Dallas is now working in the speech and language therapy department, Centre for Child Health, Dundee. This single case study was carried out during Jaclyns final student clinical placement.

References
Beeson, P.M. (1999) Treating acquired writing impairment: Strengthening graphemic representations, Aphasiology 13, pp. 367-386. Beeson, P.M., Hirsch, F.M. & Rewega, M.A. (2002) Successful single-word writing treatment: experimental analyses of four cases, Aphasiology 16, pp. 473-491. Beeson, P.M., Rising, K. & Volk, K. (2003) Writing treatment for severe aphasia Who Benefits? Journal of Speech, Language and Hearing Research 46, pp. 1038-1060. Hersch, D. (2003) Weaning clients from aphasia therapy: speech pathologists strategies for discharge, Aphasiology 17, pp. 1007-1029. Rapp, B. & Kane, A. (2002) Remediation of deficits affecting different components of the spelling process, Aphasiology 16, pp. 439-454. Whurr, R. (1996) Aphasia Screening Test. London: Whurr.

Figure 4 Summary of client response during final session

Considerable improvement
At the end of the block of therapy described here, Mr McDonald was able to spell correctly 14 of the 23 target words given only the symbolic cue (figure 4). The results show considerable improvement for Mr McDonald in his ability to write the target words, with little direct therapeutic time. After the end of the block, Mr McDonald received no regular therapy for six weeks but we provided him and his wife with materials and instructions for continuing with the delayed copy therapy. At the six-week review it was clear that, without the motivation of regular therapist visits, less practice was being undertaken, but improvement though slower was still ongoing. There was some positive anecdotal evidence though from his wife that during a conversation Mr McDonald had written the word football (one of the trained words) appropriately and in context. The McDonalds plan to build up gradually and over a lengthy period of time the number of words targeted using delayed copying. Training in their functional use will include practice of direct questioning to elicit the targets already practised, overt training during role-played conversation then opportunistic encouragement during conversations by his wife to use practised words functionally.

REFLECTIONS
DO I AVOID REINVENTING THE WHEEL BY CHECKING FOR TRIED AND TESTED TECHNIQUES TO SUIT A PARTICULAR SITUATION? DO I FIND A WAY TO RESPECT A CLIENTS WISHES AND RESPOND TO HOW THESE MAY CHANGE OVER TIME, EVEN IF I THINK I KNOW BETTER? DO I REGULARLY PLAN TIME WITH CLIENTS AND FAMILIES TO REFLECT ON THE THERAPY PROCESS AND AGREE THE NEXT STEPS?

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