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Reading recovery: a case study using a

multicomponent treatment for acquired alexia

Jessica Brown, Karen Hux & Stephanie Fairbanks

To cite this article: Jessica Brown, Karen Hux & Stephanie Fairbanks (2016) Reading recovery:
a case study using a multicomponent treatment for acquired alexia, Aphasiology, 30:1, 23-44,
DOI: 10.1080/02687038.2015.1052728

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Published online: 08 Jun 2015.

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Aphasiology, 2016
Vol. 30, No. 1, 23–44,

Reading recovery: a case study using a multicomponent treatment for

acquired alexia
Jessica Brown*, Karen Hux and Stephanie Fairbanks

Department of Special Education and Communication Disorders, University of Nebraska-Lincoln,

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Lincoln, NE, USA

(Received 17 December 2014; accepted 11 May 2015)

Background: Individuals with acquired alexia have reading deficits that typically
impede successful completion of daily activities, thus resulting in impaired functional
independence. Research-based treatment approaches for acquired alexia often address
single aspects underlying reading. To date, no research has explored the simultaneous
presentation of several treatments or treatment including functional daily reading
Aims: The purpose of this study was to determine the effectiveness of a multicompo-
nent reading intervention to increase letter recognition, grapheme-to-phoneme conver-
sion, and single-word decoding by an individual with acquired alexia.
Methods & Procedures: The study participant, JB, was an 86-year-old female 5 months
postonset of a left cerebrovascular accident. JB attended 40 1-hr treatment sessions
over a 5-month period. She completed five activities during each session: (a) decoding
consonant-vowel-consonant (CVC) words; (b) performing grapheme-to-phoneme
activities requiring letter recognition, naming, and associated phoneme production;
(c) engaging in repeated and choral reading tasks; (d) performing modified Anagram
and Copy Treatment and Copy and Recall tasks; and (e) engaging in reading of
functional materials.
Outcomes & Results: Intervention was effective in enhancing JB’s letter identification,
grapheme-to-phoneme conversion, and single-word decoding skills. Decoding of CVC
words, phonological awareness, and functional reading skills improved steadily over
the treatment period.
Conclusions: The participant progressed from meeting criteria for global alexia to
displaying behaviours more consistent with pure alexia. By the conclusion of treat-
ment, she accurately identified most graphemes and produced corresponding pho-
nemes for letter-by-letter and phonological single-word decoding; in the home
setting, she attempted to read and write independently, requested assistance with
reading when necessary, and independently attended to pictorial cues presented with
reading materials.
Keywords: acquired alexia; reading recovery; multicomponent intervention

Acquired alexia can greatly impair an individual’s successful daily task completion and
functional independence. Despite this, clinicians may postpone reading remediation dur-
ing acute treatment to focus instead on language comprehension and expression deficits
(McKelvey, Hux, Dietz, & Beukelman, 2010). Once initiated, alexia treatment often
focuses on a single skill or method for facilitating improved reading (Ablinger &
Domahs, 2009; Beeson, Rising, Kim, & Rapcsak, 2010; Lott, Carney, Glezer, &
Friedman, 2010). To date, no research has explored possible benefits associated with

*Corresponding author. Email:

© 2015 Taylor & Francis

24 J. Brown et al.

multicomponent interventions simultaneously incorporating several treatment approaches.

The purpose of this single subject research was to document the effects of such a
programme on a woman displaying acquired alexia.

Classifying acquired alexia

Classifying alexia is difficult because professionals from varying specialties use different
terms to describe similar disorders and individuals may not fit cleanly into a disorder
classification schema (Leff & Behrmann, 2008). Historically, acquired reading impair-
ments were described either as alexia with or without agraphia—that is, with or without
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the presence of associated hearing, speaking, or writing impairments (Cherney, 2004;

Dejerine, 1892; Leff & Behrmann, 2008). This initial classification schema evolved into
the terms more commonly used today—central and peripheral alexias. Peripheral (i.e.,
hemianopic, pure, global, neglect, and attentional) alexias involve isolated reading dis-
orders with relatively spared linguistic function, whereas central (i.e., surface, phonolo-
gical, or deep) alexias involve deficits both in language processing and in reading
(Cherney, 2004; Helm-Estabrooks & Albert, 2004; Klein & Mancinelli, 2010; Leff &
Behrmann, 2008; Leff & Schofield, 2010). Although symptoms and definitions of each
alexia type are relatively clear-cut, associated clinical findings vary considerably depend-
ing on the extent of lesions and involvement of other cerebral areas (Cherney, 2004). In
fact, the incidence of clear-cut cases is unknown but probably quite rare. Instead, most
people demonstrate behaviours associated with multiple forms of alexia (Helm-Estabrooks
& Albert, 2004).

Treating acquired alexia

Treating acquired alexia requires tailoring interventions in accordance with distinctive
strengths and weaknesses (Leff & Behrmann, 2008). In recent decades, increased focus on
acquired alexia has led to clinically relevant advances fostering systematic evaluation and
treatment using theory-based approaches. Specifically, several researchers have studied
the effectiveness of single-component treatment programmes on improving decoding by
individuals with alexia. These methods include ones targeting mastery of letter–sound
correspondences, application of tactile-kinesthetic principles, and whole-word reading
Phonological interventions focus on improving letter–sound (i.e., grapheme-to-
phoneme) correspondences. These approaches are common for instructing developing
readers and, thus, have intuitive appeal for serving as the basis of alexia rehabilitation
programmes. Researchers have hypothesised that strengthening phonological processing
and sublexical skills may improve word decoding (Harris, Olson, & Humphreys, 2013).
Treatment activities emphasise grapheme identification and naming along with corre-
sponding phoneme production. Such phonological programmes may promote gains in
phonological awareness and production abilities, although functional reading challenges
often persist (Beeson et al., 2010; Harris et al., 2013).
Tactile-kinesthetic treatments apply motor learning principles to reading development.
Research supports using sensorimotor association tasks to enhance phonological proces-
sing and reading accuracy (Alexander & Sligner-Constant, 2004). Regarding treatment for
people with acquired alexia, tactile-kinesthetic treatments focus on distinguishing letter
forms and improving letter naming through tracing, Anagram and Copy Treatment (ACT),
and single-word copy and recall tasks (CART) (Beeson, 1999; Kim, Rapcsak, Andersen,
Aphasiology 25

& Beeson, 2011; Lott et al., 2010). Researchers have noted improved letter identification
and decoding of trained words; however, minimal generalisation to novel word reading
has been reported (Lott et al., 2010).
Another acquired alexia intervention emphasises whole-word reading via implementa-
tion of multiple oral reading (MOR) procedures (Moyer, 1979). MOR entails repeated
practice decoding whole words appearing within passages rather than targeting letter
identification (Ablinger & Domahs, 2009; Beeson, Magloire, & Robey, 2005;
Woodhead et al., 2013). Increased decoding skills following MOR and whole-word
reading treatments are attributable to repeated exposure and practice of target words.
However, because of presentation of a relatively small number of reading passages,
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limited generalisation occurs to novel word stimuli (Harris et al., 2013).

Researchers have noted conservative gains in decoding targeted letters and words
and minimal generalisation to novel word reading when people with acquired alexia
participate in single-modality reading interventions. Given this, no existing treatment
approach in isolation has proven sufficient for remediating acquired reading deficits.
Additionally, despite recent initiatives to incorporate functional activities into aphasia
interventions, research about reading treatments that include functional, personalised
tasks as a major component is lacking (Lynch, Damico, Damico, Tetnowski, &
Tetnowski, 2009).

Multimodal treatment approaches for individuals with aphasia

Further research is warranted regarding the effectiveness of treatment methodologies for
people with acquired alexia. Professionals endorse different treatment approaches for
various types of alexia. However, when a client does not fit cleanly into one alexia
category, clinicians may struggle to select the best treatment. Combining approaches
may be a viable option in these circumstances. Examining multicomponent interventions
for people with acquired alexia seems reasonable given the limited success of single-
modality treatments and the reported benefits of multicomponent regimens for aspects of
cognitive, linguistic, and motor rehabilitation following neurological injury (Pulvermüller
& Berthier, 2008; Purdy & Van Dyke, 2011; Rose, 2013).
Another rationale for multicomponent treatment is that theoretical reading models
support the notion that decoding and comprehension involve multiple systems and routes.
As an example, Nadeau’s (2001) parallel distributed processing model of phonology
suggests that phonological representations exist as connected patterns between auditory,
motor, orthographic, and conceptual domains. Regarding people with alexia, Rapcsak,
Henry, Teague, Carnahan, and Beeson (2007) proposed incorporating dual-route models
including both lexical (i.e., whole-word reading) and nonlexical (i.e., sound–letter corre-
spondences) components to take advantage of two interactive forms of written language
processing. Conceptualisations such as these support coordination of multiple treatment
targets into a single therapeutic method.

Research questions
The purpose of this study was to determine the extent to which a multicomponent reading
intervention including phonological, whole-word, kinesthetic, and functional activities
would increase letter recognition and single-word decoding accuracy by an individual
with acquired alexia. Additionally, we investigated treatment generalisation to functional,
independent reading activities. Specific research questions included the following:
26 J. Brown et al.

(1) How does programme engagement affect performance on standardised and infor-
mal phonological and single-word decoding tests?
(2) How does programme engagement generalise to reading untrained CVC words
and functional materials?
(3) How do grapheme-to-phoneme conversion accuracy, paragraph-level reading
fluency, high-frequency word recognition, and independent decoding of readily
available contextualised reading materials change across the course of programme
(4) What does the participant report about the treatment programme’s social validity?
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The study participant, JB, was an 86-year-old right-handed female 5 months postonset of
a left temporoparietal haemorrhagic cerebrovascular accident (CVA). She had sustained a
traumatic brain injury (TBI) 6 years prior to her CVA. JB completed a master’s level
education and, prior to her CVA, worked as an author and journalist, thus confirming high
premorbid literacy skills.
JB sustained her TBI from a fall. CT scans revealed a left temporal subarachnoid
haemorrhage resulting in acute care hospitalisation for 5 days. She then received daily
inpatient physical, occupational, and speech therapy services for approximately 1 month.
JB transitioned to outpatient rehabilitation for 6 months during which she continued
receiving therapy services. During this time, JB exhibited aphasia characterised by
expressive language deficits but no comprehension problems. Specifically, she produced
primarily simple sentence structures, experienced word-finding difficulties, and demon-
strated frequent word substitutions. Additionally, JB demonstrated reading and writing
limitations. She retained motor skills for independent writing and typing. When writing,
she demonstrated deficits similar to her verbal expression limitations (i.e., word finding
errors and lexical substitutions); however, JB could write stories and read her own work.
With regard to reading, JB did not show evidence of comprehension deficits but demon-
strated difficulty decoding multisyllabic words. She also had substantial visual acuity and
perception deficits including diplopia, split field vision, visual midline shift, and a right
upper quadrantanopia. She used prism glasses to correct these vision deficits.
JB lived independently following outpatient therapy; however, she could not resume
independent work as a journalist. She returned to work 1 month following her TBI, even
though her language challenges limited her ability to write professionally or give oral
presentations without assistance. To remediate these difficulties, JB had an editor review
her written work, and she performed repeated rehearsals before making oral presentations.
JB was admitted to an acute care hospital for 4 days when she sustained her CVA
5 months prior to initiation of this study. Brain imaging scans showed a dominant
haemorrhagic infarct within the left temporal lobe, posterior left parietal lobe, and exten-
sion into the occipital lobe. After acute care, JB transitioned to inpatient rehabilitation,
receiving speech-language, occupational, and physical therapies. The primary treatment
focus was improved basic cognitive skills, independent completion of daily living activ-
ities, and increased physical strength. At the family’s request, expressive language goals
were added to the treatment regimen. After 3 weeks, JB was discharged to outpatient
therapy. She persisted in exhibiting severe expressive and receptive language and cogni-
tive deficits. She displayed fluent but empty speech characterised by word retrieval
Aphasiology 27

deficits. JB could not recognise single letters or decode words; however, she retained
some ability to write—that is, she successfully wrote single words and short phrases
spontaneously but could not edit or read what she had written. She could copy single
words and phrases accurately. Her family reported a loss of interest in printed materials,
with little initiation or attempt to read independently. JB’s visual deficits returned and
included visual-spatial deficits, diplopia, and right neglect. She once again utilised prism
glasses to remediate these impairments. With the glasses, she reported no double vision
nor displayed obvious right neglect of environmental stimuli. Additionally, her family
reported personality changes, increased impulsivity, decreased self-awareness, and theory
of mind deficits. JB was discharged from outpatient therapy 3 months prior to initiating
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study participation and did not receive rehabilitative services during the interim. JB’s
reading, writing, and expressive language deficits prevented her return to work.

Pretreatment assessment
We administered reading and language assessments across three pretreatment sessions.
Standardised assessments included the Western Aphasia Battery—Revised (Kertesz,
2006), the Comprehensive Test of Phonological Processing (CTOPP; Wagner, Torgesen,
& Rashotte, 1999), the Reading Comprehension Battery for Aphasia—2 (RCBA-2;
LaPointe & Horner, 1998), and the Boston Naming Test (BNT; Kaplan, Goodglass, &
Weintraub, 2001). JB’s performance on each measure is given in Table 1.
JB also performed nonstandardised reading assessments to quantify her pretreatment
knowledge of letter names and sounds and her single-word decoding abilities. First, across
three testing sessions, we presented JB with randomised sets of capital letters to assess
grapheme-to-phoneme conversion accuracy and consistency. When viewing letter sets, JB
(a) receptively identified named letters, (b) stated letter names, and (c) produced pho-
nemes corresponding with each letter presented in a randomised order. If JB provided an
incorrect response for a given letter, we removed that letter from presentation in any
subsequent testing session to minimise her frustration. This resulted in JB performing the
assessment task with 26 alphabet letters in the first session, 9 letters in the second session,
and 7 letters in the third session. Across the testing sessions, JB consistently and
accurately identified, named, and produced the correct phoneme of only two letters (i.e.,
B and D). Due to her poor performance with uppercase letters, clinical observation

Table 1. Pretreatment performance on standardised measures of language and reading.

Assessment measure Subtest or composite Score Interpretation

Western Aphasia Battery—Revised Aphasia quotient 61.3 Anomic aphasia

Spontaneous speech 13/20
Auditory verbal comp. 7.85/10
Repetition 7.8/10
Naming & word finding 2/10
Comprehensive Test of Phonological Phonological awareness 61 Percentile rank: <1%
Processing Composite score
Reading Comprehension Battery for Word—visual subtest 4/10
Aphasia—2 Word—auditory subtest 7/10
Functional reading subtest 0/10
Boston Naming Test 4/60 *Percentile rank: <1%
Note: *Data interpretation based on finding from Ivnik, Malec, Smith, Tangalos, and Petersen (1996).
28 J. Brown et al.

suggesting comparable difficulty with lowercase letters, and our desire to minimise
frustration, we did not test JB’s grapheme-to-phoneme conversion with lowercase letters.
Second, to assess single-word decoding, we administered a subset of the list of
increasingly-difficult regular, irregular, and nonwords developed by Beeson et al.
(2010). JB accurately decoded 4 of 10 regular words, 1 of 5 irregular words, and 0 of 5
nonwords. She exhibited oral letter-reading strategies to facilitate word decoding, but
these were largely unsuccessful. Because of her poor performance with the initial 20
words, we did not administer the more challenging word list stimuli.
JB’s symptoms and pretreatment assessment data suggested reading deficits most
closely aligned with global alexia despite her concomitant presentation of expressive
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aphasia. Global alexia is the most severe form of acquired alexia according to Leff and
Schofield (2010). In its pure form, global alexia appears as a reading impairment in the
absence of other language deficits. JB, however, displayed global alexia along with
anomic aphasia. Her reading challenges were consistent with global alexia, because she
could not recognise or name individual letters consistently (Leff & Schofield, 2010).
Consequently, she struggled to decode both phonemically regular and irregular words, as
is typical of people with global alexia (Beeson et al., 2005; Leff et al., 2001). Also
consistent with global alexia, JB retained substantial ability to write words, phrases, and
even some sentences—a phenomenon referred to as alexia without agraphia (Ablinger &
Domahs, 2009; Leff & Schofield, 2010).

Decoding probes
We generated a list of 180 consonant-vowel-consonant (CVC) words from which to select
probe activity stimuli. We first randomly selected without replacement words from the list
to create 18 unique 10-item probes. After using all 180 words across the multiple probe
lists, we repeated this randomisation procedure to generate additional unique probe lists
until we had a total of 40. Each probe list appeared on a sheet of white paper with the
words printed one per line in 28-point font. We used one probe list at the start of each
treatment session to measure improvement in single-word decoding over time. No probe
words appeared as targeted stimuli within the grapheme-to-phoneme conversion, repeated
and choral reading, or modified ACT/CART intervention activities.
We analysed probe list stimuli across three separate lexical factors—that is, word
frequency, word length, and orthographic consistency. We used the SUBTLEX-US Zipf
word-frequency scale (Brysbaert & New, 2009; Van Heuven, Mandera, Keuleers, &
Brysbaert, 2014) to determine word frequency. This scale determines a word’s frequency
per billion words and logarithmically scales this number to create a Zipf score ranging
from 1 to 7. Zipf scores of 1 correspond to very low-frequency words, whereas Zipf
scores of 7 correspond to very high-frequency words. Average Zipf scores for the 40
decoding stimuli lists ranged from 3.71 to 4.96 with an average Zipf score of 4.42 across
probe lists (SD = 0.31). Additionally, we calculated the average number of letters within
each word and determined an average word length of 3.14 letters across the 40 decoding
probe stimulus sets (range: 3.00–3.14, SD = 0.11). As a final step, we evaluated probe
stimulus words for orthographic consistency. Orthographically consistent words repre-
sented those whose phonological rhymes could be spelled only one way (e.g., duck vs.
stuck), whereas orthographically inconsistent words represented those whose phonologi-
cal rhymes could be spelled in multiple ways (e.g., sun vs. done vs. won; Ziegler, Ferrand,
Aphasiology 29

& Montant, 2004). The percent of orthographically consistent words on decoding probe
lists ranged from 50.00% to 100.00% (M = 77.75%, SD = 12.09).

Grapheme-to-phoneme conversion stimuli

Grapheme-to-phoneme conversion stimuli consisted of 26 capital letters presented on
3 × 3-inch wooden squares. We randomly assigned each letter to one of five stimulus
subsets containing either five or six letters.
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Repeated and choral reading stimuli

We selected four preprimer and one primer level Qualitative Reading Inventory-4 (QRI-4;
Leslie & Caldwell, 2006) passages for repeated and choral reading task stimuli. Preprimer
passages contained 35–49 total words (M = 41.50, SD = 6.61) in 5–12 sentences (M = 9.75,
SD = 3.30); reading ease as determined by Flesch–Kincaid Readability formulas (Flesch,
1948) was 100.0% with reading grade levels ranging from 0.0 to 0.6 (M = 0.15, SD = 0.3).
The primer level reading passage contained 119 words and 19 sentences; it had a reading
ease of 86.5% and a grade level of 2.4. We presented reading passages in black 36-point font
on white paper, with each sentence appearing on a separate line.

Modified ACT and CART stimuli

We created four 10-word lists from Fry High-Frequency Word Lists (1980) for modified
ACT and CART (Beeson, 1999) activities. The first stimulus set included Fry’s first 10
listed words, and we continued generating subsequent lists using words in sequential
order. Each set appeared in black 28-point font on white paper, with each word appearing
on a separate line.

Functional reading materials

We provided JB with a selection of commonly found reading materials during the last
portion of therapy sessions. Items included materials such as grocery advertisements,
magazines, newspapers, and children’s books. The text was of various sizes, styles, and
amounts. We presented two children’s books over the final 23 sessions. The first book’s
Flesch–Kincaid grade level (Flesch, 1948) was 3.7; however, frequent repetition of the
main character’s three-syllable name artificially inflated this grade level. Replacing the
name with a one-syllable substitute reduced the grade level to 2.8 and yielded text
statistics of 4.1 characters per word, 1.2 syllables per word, and 10.3 words per sentence.
The second book’s grade level was 2.6, with 4.0 characters per word, 1.2 syllables per
word, and 9.1 words per sentence.

JB participated in three pretreatment assessment sessions, 40 treatment sessions, and
three posttreatment assessment sessions over 5 months. Sessions occurred one to three
times per week, each lasting approximately 1 hr and including five components: (a)
decoding probe list words, (b) practising grapheme-to-phoneme conversions, (c) per-
forming repeated and choral reading tasks, (d) performing modified ACT and CART
30 J. Brown et al.

activities, and (e) engaging in functional reading tasks. Treatment components lasted
5–20 min per session.
We took field notes during experimental sessions to capture unsolicited comments
from JB and her family members. These notes provided information about the inter-
vention’s social validity. Measures of social validity function to ensure interventions
account for the concerns of society and consumers (Schwartz & Baer, 1991) and
encompass three questions: (a) Are targeted goals relevant to everyday life? (b) Are
intervention procedures acceptable to consumers? and (c) Do treatment outcomes make
a difference in daily activities? (Kazdin, 2011). Social validation of the intervention
discussed herein involved subjective evaluation—that is, the client’s self-reflections
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and evaluation of her behaviour by people who had regular contact with her (Kazdin,
Simultaneous with the reading intervention programme, JB participated in separate
treatment for expressive language deficits. Coordination with the clinician providing
expressive language treatment ensured no reading activities occurred during language
sessions. Instead, the focus was strictly on facilitating JB’s recall and production of
selected nouns and family member names during confrontation naming and conversa-
tional speech.

Probe task
JB read aloud a 10-item probe list at the start of each session. We recorded JB’s single-
word decoding accuracy and reviewed each incorrect response following completion of
the entire list. We administered probe lists in their order of creation such that all words
appeared once before appearing again in a subsequent list.

Grapheme-to-phoneme conversion tasks

Grapheme-to-phoneme conversion tasks required JB to identify, name, and produce
corresponding phonemes for each presented letter. We then implemented drill and practice
treatment for incorrect responses. The criterion for adding each additional letter subset
was 100% accuracy on the current subset for two consecutive sessions. If JB did not reach
criterion within 12 consecutive sessions, we nevertheless added another letter subset to the
task. We continued to present mastered subsets in addition to the most recently added
subset regardless of performance accuracy. Thus, in initial treatment sessions, JB worked
with only the first stimulus subset but, in later sessions, completed grapheme-to-phoneme
conversion tasks for all five subsets.

Repeated and choral reading tasks

During repeated and choral reading tasks, JB read aloud a QRI-4 passage independently,
followed by repeated or choral passage reading with the examiner approximately five
times per session. Progression criteria required independent decoding of greater than 90%
of words for two consecutive sessions and a reading rate of greater than 10 words per
minute. If JB did not meet criteria within 12 consecutive sessions, we introduced the next
passage regardless of decoding accuracy or reading rate.
Aphasiology 31

Modified ACT and CART

Modified ACT and CART procedures differed from traditional approaches in several
ways. First, JB read aloud the 10 words in a given stimulus set. Although not a
component of ACT or CART treatments, we used oral reading as an additional method
of enhancing connections between JB’s preserved written copying skill and her reading
deficits. The progression criterion required correct independent decoding of each
stimulus word within approximately 3 s (i.e., indicative of sight-word reading) for
two consecutive sessions. If JB did not reach criterion in a session, we proceeded with
ACT and CART activities for that word list. This required JB to arrange letters—
including both those included and not included in a target word—in the correct order.
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A second difference from traditional ACT and CART approaches related to writing
requirements. Specifically, JB copied each stimulus word 10 times while simulta-
neously saying it aloud. We again chose this procedure to enhance the connection
between reading and writing. JB received feedback on each written word and did not
write words from memory as is traditional for ACT and CART treatments. Finally, she
did not complete homework to practice target words independently because of concerns
about potential incorrect practice. Once JB met the criterion for a stimulus set, we
implemented these same procedures for the next set. Past target items were not
reviewed after implementing a new set.

Functional reading tasks

Initial functional reading activities included letter identification, number identification,
and word matching using reading materials such as newspapers and magazines. As JB’s
single-word decoding improved, we adapted functional tasks to include reading of
motivating informational pamphlets and children’s books.

Data analysis
Dependent variables included accuracy scores on probes and objectively measured tasks
corresponding with each intervention component.
The dependent variable for the probe task was the percent of accurately decoded
words per stimulus list. We scored accurate responses based on JB’s initial decoding
attempt; hence, self-corrected responses were scored as inaccurate. Additionally, we
performed Pearson’s correlation computations to determine the presence of significant
linear relations between JB’s probe decoding accuracy and probe list lexical factors (i.e.,
word frequency, word length, and orthographic consistency).
Grapheme-to-phoneme conversion data consisted of JB’s combined accuracy percen-
tage scores achieved on individual letter recognition, naming, and phoneme production
tasks for all stimulus letters presented in a given session. JB received one point for each
accurate response. We scored initial incorrect responses immediately revised without
delay or prompt as accurate. Production either of short or long vowel sounds associated
with a vowel grapheme was accepted as correct. As previously described, subsequent
letter subsets were added once JB met criterion. Because this led to inclusion of different
numbers of stimuli across sessions, we calculated accuracy as a percentage score for each
Dependent variables for repeated and choral reading tasks included the percent of
accurately decoded words and reading fluency calculated in correct words per minute
32 J. Brown et al.

(CWPM). Accuracy data reflected JB’s initial word-decoding attempts; self-corrections

did not receive credit.
Modified ACT and CART data reflected the number of accurately decoded words at
the start of the activity. We did not score self-corrected responses as accurate and did not
analyse anagram accuracy data.
Functional reading activities began with letter, word, and number identification tasks.
Because of the severity of JB’s reading deficits, she initially could not locate or decode
any targets. We did not collect quantitative data during initial treatment sessions, because
targets varied across sessions. However, as JB progressed, we introduced children’s books
and collected data reflecting the percentage of independently decoded words (i.e., via
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whole-word recognition or letter-by-letter reading).

We calculated trend lines associated with dependent variable progressions over time
when applicable and used trend lines to facilitate visual interpretation of graphed data
and determination of performance improvement and variability. Additionally, computa-
tion of simple nonoverlap Tau-U statistics allowed determination of whether the
average proportion of data points increasing across treatment sessions was significant
for an intervention component (Parker, Vannest, Davis, & Sauber, 2011). This proce-
dure also provided a means of interpreting separately the treatment effect size of each
intervention component.
Finally, field notes collected during treatment sessions served as a means of analysing
unsolicited participant and caregiver comments regarding the treatment effectiveness and
acceptability. We evaluated this information to determine the intervention’s social validity.
Specifically, we analysed JB’s self-evaluative reports, participant and caregiver comments
relating to social impact, and the intervention’s clinical significance. Subjective self-
evaluation consisted of impressions expressed by JB or her family about perceptible
changes in daily functioning. Social impact evaluation relied on documenting changes
considered critically important to personal and social consequences. Clinical significance
was defined as a departure from dysfunctional behaviour or change in diagnostic level
(Jacobson & Revenstorf, 1998; Kazdin, 2011).

Inter-rater reliability
A trained research assistant performed online data collection during 29 of the 40 treatment
sessions (i.e., 72.5%) to allow for calculation of inter-rater reliability with the researcher
conducting the session. Inter-rater reliability computation involved determining the per-
centage of agreed upon correct responses. The computed average inter-rater reliability was

Overall, JB progressed from displaying global alexia at treatment initiation to displaying
behaviours most consistent with pure alexia at treatment conclusion. JB’s improved
accuracy (i.e., from 2 to 17 letters) in stating letter names, producing phonemes associated
with graphemes, and identifying letters was fundamental to her changed diagnosis.
Further evidence of JB’s progression from global to pure alexia came from her general-
isation of improved letter recognition, naming, and grapheme-to-phoneme conversion
from uppercase letter stimuli used during treatment sessions to lowercase letters presented
during posttreatment assessment. Data for each intervention treatment component con-
tributing to JB’s diagnostic change appear in the following sections.
Aphasiology 33

Probe measurement
Probe list decoding accuracy varied from 0% to 100% across sessions (M = 49.5%,
SD = 25.72%). JB exhibited increasing reliance on letter-by-letter reading strategies for
probe decoding over the course of treatment as demonstrated by her naming of each letter
before attempting to read a word as a unit. As visible from the trend line displayed in
Figure 1, JB exhibited a gradually increasing positive trend with high performance
variability across sessions. Tau-U computation revealed a significant increase in decoding
accuracy performance and a moderate-to-large treatment effect, U = 0.5756, p = 0.000,
90% CI [0.395, 0.757]. Computation of Pearson’s correlations revealed no significant
linear relations between JB’s probe decoding accuracy performance and probe list word
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frequency, r = 0.209, p = 0.196, word length, r =−0.309, p = 0.053, or orthographic

consistency, r =−0.061, p = 0.706.

Grapheme-to-phoneme correspondence tasks

Visual display of JB’s performance scores on all five alphabet stimulus subsets appear in
Figure 2. Subset 1 performance across all 40 sessions ranged from 73.33% to 100.00%
and yielded the highest average accuracy score across subsets (M = 94.33%, SD = 7.33%);
however, JB demonstrated particular difficulty with the letter “U” in subset 1. Subset 2
performance also ranged from 73.33% to 100.00% (M = 91.58%, SD = 7.85%). Inclusion
of the letter “J” limited JB’s performance accuracy for subset 2. JB’s subset 3 accuracy
ranged from 66.67% to 100.00% and yielded the lowest mean accuracy score and highest
variability across subsets (M = 87.08%, SD = 11.71%). JB displayed particular difficulty
with the letter “Y” in subset 3. JB’s subset 4 performance ranged from 66.67% to
100.00% (M = 94.00%, SD = 9.65%). The researchers presented subset 5 in the final
17 sessions. JB did not reach performance criterion for subset 5; however, given that it

Figure 1. Probe list decoding accuracy.

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Figure 2.
J. Brown et al.

Grapheme-to-phoneme conversion task accuracy.

Aphasiology 35

was the final letter set, the researchers continued drill and practice therapy with all letters
throughout the remainder of treatment. Subset 5 performance varied from 72.22% to
100.00% and yielded the second lowest average score and least variability across stimulus
subsets (M = 89.21%, SD = 6.94%). JB demonstrated particular difficulty with phoneme
production of the letter “X” in subset 5. Tau-U computation combining performance on all
five letter subsets revealed a significant, yet small, treatment effect for grapheme-to-
phoneme correspondence across the 40 treatment sessions, U = 0.1516, p = 0.0092,
90% CI [0.056, 0.247].
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Repeated and choral reading tasks

We presented JB with five reading passages during repeated and choral tasks across
treatment sessions. Figure 3 provides a graphic representation of her decoding accuracy
percentage scores. Overall, JB demonstrated variable performance, with decoding accu-
racy ranging from 70% to 95% across all five passages. Tau-U computation revealed that
the average proportion of data points increasing across the first four reading passages was
not significant, indicating little-to-no treatment effect for repeated and choral reading
relating to word decoding accuracy, U = 0.1881, p = 0.1350, 90% CI [−0.019, 0.395].
This analysis excluded the final reading passage, because we only presented it to JB three
Figure 4 illustrates JB’s correctly read words per minute for each passage.
Examination of CWPM revealed that JB tended to achieve initial scores between three
and eight words per minute, followed by a gradual increase in reading fluency. Visual data
inspection revealed two exceptions to this pattern. Specifically, for passages one and three
—those in which the criterion was met—JB demonstrated sharp increases in reading
fluency during the eighth and fifth exposures, respectively, indicating periods of substan-
tial improvement. Tau-U computation revealed a significant increase and moderate-to-
large treatment effect for repeated and choral reading relating to an increase in CWPM,
U = 0.58220, p = 0.0000, 90% CI [0.375, 0.789]. Again, this analysis included only the
first four reading passages.

Figure 3. Repeated and choral reading passages decoding accuracy percentage.

36 J. Brown et al.
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Figure 4. Repeated and choral reading passages correctly read words per minute.

Modified ACT and CART

We presented JB with four sets of high-frequency words across the 40 treatment sessions.
Figure 5 displays JB’s decoding accuracy scores for all stimulus sets. JB’s set 1 decoding
accuracy ranged from five to nine words correct (M = 7.42, SD = 1.24) across 12 sessions.
Her decoding accuracy for set 2 words ranged from 5 and 10 words correct (M = 8.38,
SD = 1.77). JB demonstrated the least variability in decoding accuracy for set 3 words,
with scores ranging from seven to nine correct (M = 8.50, SD = 0.67) across 12
experimental sessions. JB achieved the highest average decoding accuracy scores on set
4 words, with accuracy ranging from 7 to 10 correct (M = 8.57, SD = 1.13). We presented
JB with set 4 words for the seven final treatment sessions. Despite inaccuracies in initial
word decoding, JB demonstrated 100% accuracy during repeated copying of target words.
Tau-U computation combining performances on all four high-frequency word sets
revealed a significant, small-to-moderate treatment effect for single-word decoding accu-
racy following implementation of modified ACT and CART procedures, U = 0.38110,
p = 0.0025, 90% CI [0.174, 0.588].

Functional reading tasks

We collected functional reading task data when children’s books were introduced into the
stimulus corpus (i.e., the final 23 sessions). Decoding accuracy varied from 54.39% to
88.89% across sessions (M = 75.90%, SD = 10.48). As visible from the trend line
displayed in Figure 6, JB exhibited a gradually increasing positive trend with relatively

Figure 5. High-frequency word decoding accuracy.

Aphasiology 37
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Figure 6. Percent of correctly decoded words read independently during functional reading.

high performance variability. Tau-U computation revealed a significant increase in inde-

pendent decoding accuracy with a moderate treatment effect given functional reading
materials, U = 0.4269, p = 0.0043, 90% CI [0.181, 0.673].
Inspection of field notes collected during functional reading tasks indicated several
performance trends. First, JB successfully recognised words repeated within passages as
demonstrated by statements such as “There’s my word again”; however, she could not
always recall the word’s phonological representation. Second, JB often perseverated on
letters or words within a given session. Third, JB accurately decoded single words using
both whole-word recognition and letter-by-letter strategies. She most often recognised
previously practiced high-frequency words appearing in functional contexts using a
whole-word reading approach but demonstrated oral letter-by-letter reading strategies to
decode less familiar and lengthy words. Fourth, we often prompted JB to use pictures
included in functional reading materials to aid decoding accuracy and comprehension.
Despite substantial time spent viewing pictures, JB was unsuccessful in using them to aid
her reading during treatment. This lack of success appeared to relate to word retrieval

Posttreatment assessment
JB’s performance scores for standardised and non-standardised reading, language, and
phonological awareness assessments following treatment completion appear in Table 2.
JB performed nonstandardised reading assessment measures to quantify her letter name,
sound knowledge, and single-word decoding abilities. We presented JB with randomised
capital alphabet letters across three consecutive sessions. Once JB provided an incorrect task
response for a given letter, we removed that letter from any subsequent testing.
Consequently, JB performed the assessment task using all 26 alphabet letters in the first
session, 22 letters in the second session, and 20 letters in the final session. Across sessions,
JB consistently and accurately identified, named, and produced the corresponding phoneme
of 17 letters. To assess single-word decoding, we gave JB the entire written list (i.e., 80
words) of increasingly difficult regular, irregular, and nonwords developed by Beeson and
colleagues (2010). JB attempted to read all words on the list and successfully decoded 16 of
30 regular words, 6 of 30 irregular words, and 7 of 20 non-words. Additionally, we presented
JB with a randomised set of 26 lowercase letters during one posttreatment session to assess
38 J. Brown et al.

Table 2. Posttreatment performance on standardised measures of language and reading.

Assessment measure Subtest or composite Score Interpretation

Comprehensive Test of Phonological Phonological awareness 45 Percentile rank: <1%

Processing composite score
Reading Comprehension Battery for Word—visual subtest 6/10
Word—auditory subtest 10/10
Functional reading subtest 6/10
Boston Naming Test 5/60 *Percentile rank: <1%
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Note: *Data interpretation based on finding from Ivnik et al. (1996).

generalisation of grapheme-to-phoneme conversion knowledge to untrained, lowercase

stimuli. JB accurately identified, named, and produced the corresponding phoneme of 22
lowercase letters. Specifically, JB correctly identified 26 letters, correctly named 23 letters,
and produced the correct corresponding phoneme for 24 letters.

Treatment acceptance and social validity

Both JB and her primary caregiver reported high treatment acceptance and impact on functional
reading skills. Several examples validate the treatment’s social acceptance. First, JB made
unsolicited self-evaluative reports during and following treatment sessions, stating she was
“thrilled” with the treatment goals and methods and she was “doing better” with reading
subskills. These comments were in direct contrast to JB’s frequent negative statements about
persisting communicative and reading challenges. Given the frequency with which JB reported
negative thoughts, she did not appear biased to make positive comments regarding the
treatment regimen. Second, both JB and her family reported on the intervention’s social impact.
For example, prior to treatment initiation, both parties reported JB’s reluctance to attempt
functional reading at home (e.g., reading newspapers, magazines, or books); however, they
reported a substantial increase in reading attempts following therapy completion. Additionally,
JB’s primary caregiver reported substantial increases in JB’s written expression, independent
reading accuracy, willingness to request assistance when necessary, and unprompted attempts
to use pictures to aid reading comprehension. Given that JB evolved from displaying global to
pure alexia, validation of the intervention’s clinical significance occurred.

The purpose of this study was to examine the effects of multicomponent reading
intervention on letter recognition, grapheme-to-phoneme conversion, and single-word
decoding by an individual with symptoms of acquired global alexia. Additionally, we
sought to determine the intervention’s generalisability to functional reading of
untrained stimuli.

Demonstrated changes in reading ability

JB’s performance following intervention indicated a shift from abilities most closely
associated with global alexia to those most closely associated with pure alexia. Global
alexia differs from pure alexia in that the former involves impaired letter recognition and
Aphasiology 39

naming in addition to poor single-word and nonword reading, and the latter is charac-
terised by intact letter recognition and naming, difficulty with efficient single-word and
nonword reading, and evidence of letter-by-letter reading strategies (Beeson et al., 2010;
Fung, Halpern, & Sivjee, 2011). Evidence of JB’s progression towards pure alexia came
from her increased grapheme and phoneme knowledge—as demonstrated by pretreatment
to posttreatment improvements in alphabet letter knowledge—and single-word decoding
—as evidenced by probe data and Beeson word list decoding; she also increased her
reliance on letter-by-letter reading for single-word decoding.
Standardised test results revealed improved reading skills as demonstrated by JB’s
RCBA-2 performance; however, she received a lower score on the posttreatment CTOPP
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testing than she did pretreatment. This apparent decrease in phonological skills may be
reflective of JB’s variable performance throughout treatment or may reflect the nature of
CTOPP items. Despite professionals’ reliance on standardised tests to ensure objectivity
(Eslinger, Zappala, Chakara, & Barrett, 2011), the ecological validity of such tools for
individuals with acquired brain injury has repeatedly come under question (Ponsford,
Sloan, & Snow, 2013). Measuring gains in functional reading skills using informal probes
may provide ecologically valid information that is more meaningful than that provided via
standardised assessments. This appears to be the case for JB. Hence, despite apparent
phonological awareness improvements as demonstrated through her performance on
treatment activities, JB did not have sufficient skills to respond accurately to CTOPP
Although we can determine treatment effect sizes for each intervention component
separately, ascertaining the relative contribution of various components to probe perfor-
mance is difficult, if not impossible. However, an additional aspect of change associated
with JB’s reading intervention was generalisation to stimuli not directly targeted during
treatment. Inspection of probe data revealed generalisation through a significant increase
in single CVC-word decoding accuracy over the course of treatment. This finding differs
from those of other researchers who have documented limited generalisation to untrained
stimuli following alexia treatment (Beeson et al., 2010; Harris et al., 2013; Lott et al.,
2010). Several explanations for JB’s improved probe performance may exist. First,
inclusion of and exposure to functional reading materials may have contributed substan-
tially to the noted improvement. The extent of improvement JB demonstrated during
engagement with readily available reading materials versus that observed in some other
aspects of her treatment lends support to this idea. Second, similar results may have
occurred had JB engaged in only one of the treatment components in isolation (i.e.,
grapheme-to-phoneme conversion, repeated and choral passage reading, and modified
ACT and CART). Of the traditional approaches, JB demonstrated the greatest improve-
ment in grapheme-to-phoneme associations. Perhaps her observed improvement in decod-
ing words and performing contextually based reading resulted primarily from inclusion of
this treatment component. A third possibility is that the combination of treatment
approaches facilitated JB’s improved decoding. Future research may help determine
which treatment components contribute most to increasing a person’s decoding accuracy
when they exhibit global alexia.
Additionally, as demonstrated by pretreatment/posttreatment comparison of oral read-
ing accuracy of Beeson’s word lists (Beeson et al., 2010), JB decoded regular, irregular,
and nonwords better following treatment than she did prior. JB’s improvement reflected
increased sight-word recognition of high-frequency words and increased reliance on a
letter-by-letter reading strategy—as is typical of individuals with pure alexia—on non-
words (Beeson, 1998; Beeson et al., 2005). Although letter-by-letter word decoding
40 J. Brown et al.

results in a pronounced word length effect in reading (Geschwind, 1965; Price &
Humphreys, 1992) and is inefficient for fluent reading (Beeson, 1998; Beeson et al.,
2005; Harris et al., 2013; Lott et al., 2010), it represents a substantial improvement from
JB’s initial status of being largely unable to decode any words.

Performance variability within and across treatment components

A salient feature of JB’s performance within and across the various treatment components
was her session-to-session variability. Several possible external and internal factors may
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have contributed to her variability, and identification of a single precipitating factor is not
possible at this time. For example, factors that may have negatively affected JB’s
performance during sessions include fatigue, medication reactions, or changes in physical
or emotional status. In particular, JB’s perception of her deficits as reflected through self-
initiated comments about persistent challenges may have negatively affected her mood
and motivation during treatment.
With regard to grapheme-to-phoneme correspondence, JB demonstrated an overall
pattern of improvement, although persistent inconsistencies with certain letters may have
unnecessarily slowed her progress. Specifically, naming, identifying, and producing the
phonemes associated with the letters “U,” “J,” and “X” were particularly difficult.
Struggles with these letters forced us to devote multiple sessions to subsets including
these stimuli. Simply reorganising the letters or allowing for progression through letter
subsets despite inconsistencies on particular items may have increased treatment effi-
ciency. Additionally, difficulty with particular phonemes may have negatively affected her
decoding of some probe words. Still, JB’s grapheme-to-phoneme conversion improve-
ment was substantial and facilitated her eventual adoption of a letter-by-letter reading
strategy that, in turn, contributed to improved single-word decoding.
Another treatment component on which JB was highly variable was her decoding
accuracy and reading fluency during repeated and choral reading tasks. Two factors may
have contributed to JB’s inconsistency. First, we observed working and long-term memory
deficits that probably limited JB’s mastery of and progression through passages. Because
of memory challenges, JB did not recall passages from one treatment session to the next.
Second, to increase control and ensure JB did not practise incorrectly, we chose not to
include homework activities traditionally a part of whole-word reading treatments. An
alternative to eliminating homework activities would have been to establish a programme
in which JB engaged in errorless practice of passages by reading them simultaneously
with recordings, as suggested in Oral Reading for Language procedures (Cherney,
Merbitz, & Grip, 1986). The additional exposure thus provided may have benefitted JB
and reduced her performance variability.
JB’s performance on modified ACT and CART tasks was also highly variable and
reflected the least overall improvement of any intervention component. Treatment
included modified ACT and CART tasks to enhance connections between JB’s relatively
preserved writing skills and her impaired reading skills. JB accurately spelled and read
words aloud during practice; however, carryover to accurate initial decoding did not
occur. Decoding high-frequency words immediately—that is, as sight words—is an
important component to reading ease and fluency. These high-frequency words are
appropriate stimuli for treatment; however, traditional drill and practice techniques may
have benefitted JB’s sight-word learning and retention more than the modified ACT and
CART procedures did (Daniel, Bolter, & Long, 1992; Ardoin, McCall, & Klubnik, 2007).
Aphasiology 41

Extant research does not report the effects of functional reading activities on acquired
alexia; instead, previous intervention research has focused solely on the performance of
decontextualised reading activities. The current study findings suggest functional reading
is an important component for inclusion and may be highly motivating for clients.
Overall, JB’s most substantial improvement of the four intervention tasks occurred with
the functional, contextualised reading component. Furthermore, our subjective treatment
notes indicated that JB recognised words, named letters, produced corresponding gra-
phemes, and decoded high-frequency sight words more accurately during functional,
contextual reading tasks than during decontextualised treatment components. JB reported
functional reading activities as her favourite treatment component.
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Generalisability and future directions

Several factors limit generalisation of the findings presented herein. First, even though the
study participant demonstrated significant improvement on most of the included treatment
components (i.e., grapheme-phoneme conversion tasks, high-frequency word reading
accuracy, and independent functional reading), this was not the case for repeated and
choral passage reading. Separate analysis of intervention components provides a means of
speculating about which tasks may have positively contributed to JB’s generalised
improvement on the probe task; however, we cannot determine with certainty the relative
contributions of various intervention activities. We know only that at least one—but
perhaps more than one—component was responsible for JB’s functional gains.
Furthermore, comparison of effect sizes for individual treatment components with those
available in extant literature has little clinical relevance given the multicomponent nature
of the administered intervention. Given that other researchers who have implemented
single-treatment protocols have reported little or no generalisation, the inclusion of multi-
ple treatment foci appears as a likely contributor to JB’s observed functional gains. Future
research documenting the effects on generalisation measures of sequentially applying
treatment components may yield insight about the relative contribution of individual
components. Caution is warranted, however, because people with acquired alexia may
find such approaches less motivating and—at least at times—more frustrating than ones
targeting multiple aspects simultaneously.
Second, JB’s comorbid expressive deficits may have negatively influenced her reading
decoding performance and further contributed to performance variability. We collected
data solely regarding oral reading accuracy rather than word recognition or identification;
therefore, data were likely negatively skewed, because JB frequently displayed difficulty
saying words aloud that she appeared to comprehend. Given that most reading occurs
silently, written word recognition or identification measures would have provided further
elucidation of JB’s reading profile.
Finally, over the course of treatment, JB demonstrated significantly improved decod-
ing accuracy during functional reading tasks; however, as decoding performance
improved, reading comprehension problems became apparent. These challenges may
have reflected JB’s impaired linguistic processing. Alternately, they may have stemmed
from inefficient or limited resource allocation such that the mental effort JB expended to
decode words depleted her cognitive reserves to the extent that she had inadequate
resources left to comprehend written messages (Sohlberg, Griffiths, & Fickas, 2014;
Verhoeven & Perfetti, 2008). These comprehension difficulties were apparent despite
inclusion of pictures in functional reading materials. JB was unsuccessful in using pictures
to aid decoding and comprehension during therapeutic tasks. This is further supported by
42 J. Brown et al.

results on both pretreatment and posttreatment performance of the BNT (Kaplan et al.,
2001) which revealed severe word finding and confrontation naming deficits. However,
despite the unsuccessful use of pictures during treatment activities, JB’s family reported
increased attention to picture cues to aid reading comprehension at home. Cues to attend
to pictorial stimuli may have prompted a shift in JB’s behaviour and contributed to an
emerging reading comprehension strategy in naturalistic settings. Regardless, we did not
formally assess JB’s reading comprehension abilities. Because the presenting treatment
concern was word decoding and her initial decoding abilities were severely impaired,
assessing reading comprehension deficits would not have been possible; therefore, the
extent of her impaired comprehension was not formally documented and remains
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Overall, JB successfully progressed from displaying global alexia to displaying beha-
viours more consistent with pure alexia and demonstrated significant decoding improve-
ment given untrained stimuli. The multicomponent intervention, or at least some aspects
of it, appeared effective in enhancing letter identification, grapheme-to-phoneme conver-
sion, and single-word decoding accuracy given that JB’s skills in these areas improved
across time. Additionally, as evidenced by her performance on probes and functional
reading tasks, the administered intervention likely contributed to improved reading of
untrained materials. Administration of the treatment programme to one individual limits
the generalisability of the results; however, the findings suggest that a multicomponent
treatment programme and/or the inclusion of functional reading activities in therapy may
be beneficial for at least some individuals with acquired alexia. Inclusion of a variety of
stimuli and tasks may have also contributed positively to JB’s motivation and observed
performance gains. Future research is necessary to determine the intervention’s effects on
individuals with various forms of acquired alexia and to identify specific treatment
components most important to fostering improved word decoding.

Disclosure statement
No potential conflict of interest was reported by the authors.

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