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Aphasiology
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Semantic feature analysis

as a treatment for aphasic
dysnomia: A replication
Carl A. Coelho , Regina E. McHugh & Mary
Boyle
Published online: 31 Aug 2010.

To cite this article: Carl A. Coelho , Regina E. McHugh & Mary Boyle (2000)
Semantic feature analysis as a treatment for aphasic dysnomia: A replication,
Aphasiology, 14:2, 133-142, DOI: 10.1080/026870300401513

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 aphasiology, 2000, vol. 14, no. 2, 133±142

Case Study
Semantic feature analysis as a treatment
for aphasic dysnomia: A replication

C AR L A. COE LHO" , R E GI NA E. McH UG H#

and MAR Y B OYL E$
" University of Connecticut, Communication Sciences Department, U-85,
850 Bolton Road, Storrs, Connecticut, 06269-1085, USA
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# Brooklyn Hospital, Brooklyn, New York, USA

$ The Burke Rehabilitation Center, White Plains, New York, USA

(Received 26 August 1998 ; accepted 4 March 1999)

Abstract
Semantic Feature Analysis (SFA) is a treatment technique designed to improve
lexical retrieval by increasing the level of activation within a semantic network.
The purpose of this study was to replicate the Boyle and Coelho (1995) study
in which SFA was applied with a mild non-¯uent aphasic individual resulting
in improved confrontation naming of trained and untrained items but no
generalization to connected speech. The present study investigated whether a
comparable treatment eåect could be demonstrated, and to what extent severity
and type aphasia might impact overall outcome. SFA was applied to an
individual with a moderate ¯uent aphasia secondary to a closed head injury.
Gains in confrontation naming of both trained and untrained stimulus pictures
were noted as well as measures of connected speech. Potential explanations for
these ®ndings are discussed.

Introduction
Dysnomia, a disturbance in word retrieval, is a common de®cit which all aphasic
patients demonstrate. Severity can range from a simple pause in the ¯ow of
conversation to groping for a word inde®nitely. Dysnomia is noted in patients with
cerebral damage to either hemisphere, regardless of etiology. Naming di¬culties
result from impairments at diåerent stages of the naming process : decoding,
storage, selection, retrieval or encoding (Benson and Ardilla 1996). Aphasic
naming errors can diåer and some diåerences may be related to the type of aphasia
an individual presents with. For example, naming may be hindered because of
impaired access to semantic networks as in Broca’s aphasia, or because of a
disruption in the semantic networks themselves as in Wernicke’s aphasia (Rosenbek

Please address correspondence to Carl Coelho, e-mail : coelho! uconnvm.uconn.edu

Aphasiology ISSN 0268±7038 print} ISSN 1464±5041 online ’ 2000 Psychology Press Ltd
http:} } www.psypress.co.uk
 134 Carl A. Coelho et al.

et al. 1989). It is important to identify the level at which the naming process breaks
down in order to implement eåective treatment.
There are several treatment approaches which have been employed to aid aphasic
individuals in word retrieval. Rosenbek et al. (1989) have noted that these
approaches exist along a treatment continuum ranging, at the extremes, from
facilitation to didacticism. In facilitation, clinicians select the stimuli, usually on the
basis of frequency of occurrence and manipulate the timing, order, form (i.e.
objects, pictures, words) and presentation mode (i.e. auditory, visual, auditory and
visual). The classic example of this treatment would be Schuell’s stimulation
approach (see Duåy (1994) for a review). At the other end of the continuum are the
didactic approaches. In these approaches to therapy clinicians also select treatment
stimuli and manipulate timing, order, form and presentation mode. However, the
emphasis is less on the number of correct responses as teaching the patient self-
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cueing strategies and how to deal with their errors. Cueing hierarchies to improve
naming (e.g. see Linebaugh and Lehner 1977, Pease and Goodglass 1978,
Thompson and Kearns 1981) have been adopted by both treatment `camps ’
because the systematic presentation of carefully selected cues is fundamental in
aphasia treatment (Rosenbek et al. 1989).
Of the many treatment approaches employed to facilitate naming, none have
been shown to be `most ’ eåective. Research regarding the e¬cacy of speci®c
treatment approaches is currently being conducted. For example, Freed et al. (1995)
have compared personalized cueing and generic cueing for improving verbal
labelling in aphasic subjects. The authors hypothesized that personalized cues
enhanced recall of word-symbol pairs because they included information that was
personally relevant to the subjects. Results, however, indicated that there was no
diåerence between the two types of cueing up to thirty days after training.
Labelling accuracy increased equally for both types of cues as training progressed.
Along similar lines, Lowell et al. (1995) studied the eåects of self-selected semantic
cues on naming performance in three individuals with aphasia. These cues were
derived from a semantic feature analysis diagram comparable to that used in the
present study. Two subjects showed improved naming performance on trained
items, with generalization to untrained items and maintenance over a one week
period. Performance was monitored on a control measure of productive
morphology which indicated that improved naming performance was not due to
generalized language improvement. The third subject did not show substantial
improvement.
A study conducted by Li and Canter (1987) investigated the use of prompting in
the treatment of aphasic naming disturbances. The study was based on Luria’s
hypothesis that the ability of aphasic individuals to utilize cues consisting of initial
sounds of the target word may be an important means for identifying the nature of
naming breakdown. The authors speculated that an aphasic patient’s ability to
eåectively employ phonemic prompts indicated that the breakdown did not
involve distortion of the phonemic structure of a word. Conversely, an inability to
pro®t from cueing would suggest a disruption in the sound structure. Their
purpose was to determine whether Luria’s hypothesis on cueing would hold when
the severity of naming impairment was controlled. Li and Canter hypothesized that
individuals with Wernicke’s aphasia would not be responsive to phonemic cueing
while those with Broca’s aphasia would. Results indicated that subjects with
diåerent types of aphasia responded diåerentially to the cueing, supporting Luria’s
 Semantic feature analysis 135

hypothesis. Individuals with Broca’s aphasia were able to employ phonemic cueing
while those with Wernicke’s aphasia were not. This suggested a disruption of the
underlying phonological structure of the word for the Wernicke’s group.
Semantic feature analysis (SFA) is a treatment approach which is thought to
improve the retrieval of conceptual information by accessing semantic networks
(Boyle and Coelho 1995). In this technique the patient is encouraged to produce
words semantically related to the target word (e.g. listing its : group, use, action,
properties, location and association). By activating the semantic network
surrounding the target word, that word may be activated above its threshold
thereby facilitating retrieval. SFA has been utilized in the treatment of traumatically
brain injured (TBI) patients (Massaro and Tompkins 1992, Ylvisaker and Szekeres
1985). According to the spreading activation theory of semantic processing
(Collins and Loftus 1975), by activating the semantic network surroundin g the
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target, the target itself may be activated above its `threshold’ level, increasing the
probability that its name can be retrieved.
Massaro and Tompkins set out to develop a systematic protocol for feature
analysis training and to determine it e¬cacy. Results indicated clear treatment
eåects, maintenance and response generalization for two TBI subjects. The authors
concluded that SFA was useful for accessing existing semantic networks in such
subjects. Boyle and Coelho (1995) investigated whether SFA would be successful
for individuals with word retrieval de®cits secondary to aphasia. A mildly aphasic
individual was studied. Results indicated that SFA was associated with improved
confrontation naming on trained and untrained stimulus items, but not with
measures of connected speech.
An issue related to the treatment of dysnomia involves the number of stimuli
which should be presented during a treatment session. Several authors concerned
with generalization of treatment to untreated items have discussed the importance
of training su¬cient exemplars as a strategy to enhance generalization (Rosenbek
et al. 1989, Stokes and Baer 1977, Thompson 1989). Thompson noted that this issue
has not been speci®cally addressed in studies of aphasia.
The purpose of this investigation was to replicate the Boyle and Coelho (1995)
study. The rationale for this replication was that although numerous studies have
been conducted related to the treatment of dysnomia, it is still unclear as to which
aphasic individuals bene®t from which types of treatment. Further, while the
strength of single-subject designs is that they allow us to examine treatment eåects
in detail, we cannot assume generalization to other kinds of aphasic individuals. In
the Boyle and Coelho investigation, application of SFA with a mild, non¯uent
aphasic individual resulted in improved confrontation naming of trained and
untrained stimulus items. The present study applied SFA treatment to an individual
with a moderate ¯uent aphasia secondary to a closed head injury. Thus this study
investigated whether a comparable treatment eåect could be demonstrated and to
what extent severity and type of aphasia would impact the overall outcome. In
addition, we were interested in determining whether using a large number of
stimuli during treatment (i.e. using many diåerent stimulus items so that the same
items were not being used repetitively in each session) would promote general-
ization more e¬ciently than using the same small number of stimulus items in
each session.
 136 Carl A. Coelho et al.

Method
Subject
The subject treated in this study was T H, a 52 year old right-handed male, He was
a high school graduate and was employed as a sheet metal worker. At the time of
the study he was approximately 17 months post onset of a closed head injury,
suåered when he was struck by a batted ball while pitching in a softball game.
Findings of a CT scan revealed a left temporal fracture and lateral temporal lobe
contusion. He initially presented with a moderate to severe ¯uent aphasia with
minimal cognitive de®cits and a mild right hemiparesis. Prior to this study T H had
undergone periods of intensive inpatient and outpatient multidisciplinary therapy.
Language testing conducted prior to the initiation of SFA treatment revealed an
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Aphasia Quotient of 56.6 on the Western Aphasia Battery (WAB) (Kertesz 1982).
Dysnomia was the primary feature of T H’s spontaneous speech. Dysnomia was
also evident in formal test scores : 11} 60 on the Boston Naming Test (BNT)
(Kaplan et al. 1983), 22} 107 on the Test of Adolescent and Adult Word Finding
(German 1990). T H’s oral-verbal expression was characterized by a moderate
number of paraphasic errors, both semantic (e.g. `spoon’ for knife) and literal
(e.g. `crush ’ for crutch). Errors were well articulated with a fair to good ability to
self-correct.

Stimuli selection procedure

Black and white line drawings standardized by Snodgrass and Vanderwart
(1980) were utilized as stimuli. Drawings were standardized by name agreement,
image agreement, familiarity and visual complexity. The subject was presented
with these pictures for naming across three trials without cueing or feedback.
Results of these probe measures were charted to determine levels of di¬culty for
the subject. Levels of di¬culty consisted of: control pictures (correct in 0 out of 3
trials), treatment pictures (correct in 1 out of 3 trials) and easy pictures (correct in
3 out of 3 trials). Ten randomly chosen control pictures were presented every three
sessions in order to chart progress over time. Forty treatment pictures were
randomly chosen and divided as follows : 10 to be employed in the `few exemplars ’
condition and 30 in the `many exemplars ’ condition. These treatment conditions
are described below. Five easy pictures were randomly chosen and served to ensure
intermittent success during treatment sessions. Data from easy pictures were not
entered into analysis.

Treatment procedure
An A-B single subject design was used. Three 60 minute treatment sessions were
conducted each week. After the baseline phase, two treatment conditions were
introduced : `few exemplars ’ and `many exemplars ’. In the `few exemplars ’
condition, T H was presented with 10 randomly selected treatment pictures along
with 5 easy pictures during each session. In the `many exemplars ’ condition, T H
was presented with 30 treatment pictures which were randomized into 3 sets of 10.
These sets were presented in successive treatment sessions along with 5 easy
pictures. T H continued the `few exemplars ’ condition until 80% naming accuracy
 Semantic feature analysis 137
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Figure 1. Feature analysis chart used during treatment sessions.

was achieved across three consecutive sessions (this occurred after 12 sessions).
Following a one week break, T H was then switched to the `many exemplars ’
condition until 80% naming accuracy was achieved across three consecutive
sessions (this occurred after 8 sessions).
Semantic feature analysis was used in both treatment conditions. A picture was
placed in the centre of the feature analysis chart (see ®gure 1) and T H was asked
to name the picture. Next, regardless of his ability to name the picture, T H was
guided in verbalizing the semantic features of each target with the aid of the chart
and cues from the clinician. The clinician wrote the semantic features in the
appropriate locations on the chart after T H said them. If T H couldn’t provide a
feature, the clinician provided it orally and in writing. Sometimes he was able to
name the target after one or more of the features were listed. In order to establish
and encourage use of the technique, all features were produced for all pictures, even
those that T H had named on initial confrontation or those that he named during
semantic feature production. If T H was still unable to name the picture after all
features were written on the chart, the clinician said the name aloud and required
T H to repeat it and to review all its features.

Generalization to connected speech

Samples of connected speech were collected during each baseline session, as well as
following each generalization probe. Five diåerent conditions were utilized to
sample connected speech : request for procedural information (tell me how you
would go about writing and sending a letter), request for personal information (tell
me what you usually do on Sundays), picture sequence (the sequence contained six
pictures that related a story), and two picture descriptions (the `cookie theft ’ from
the Boston Diagnostic Aphasia exam and the `birthday cake ’ see Nicholas and
Brookshire 1993). This procedure was diåerent than that employed by Boyle and
Coelho (1995) who utilized ten diåerent elicitation conditions. The baseline
samples, two samples from each of the `few exemplars ’ and `many exemplars ’ and
samples from the one and two month follow-up sessions were recorded, transcribed
 138 Carl A. Coelho et al.

verbatim and analyzed in order to assess generalization to connected speech.

Nicholas and Brookshire’s (1993) procedures for calculating words per minute and
correct information units (CIUs) were followed in this process.

Reliability and data analysis

Transcription and scoring were done by the second author. To assess reliability,
the ®rst author independently scored 20% of the speech samples collected during
baseline and probe sessions. The second author rescored 10% of the samples one
month after they had been initially scored. Point-to-point inter and intrarater
agreement exceeded 96% for accuracy of transcription and exceeded 94 % for all
dependent measures. Discussion resolved transcription and scoring discrepancies.
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Data was evaluated by means of visual inspection to reveal the eåects of

experimental manipulation and to identify any treatment eåects and generalization
to untreated items. Analysis of generalization to connected speech was conducted
via Nicholas and Brookshire’s rules for scoring and counting words and CIUs.
Total words, total CIUs, total time, words per minute and CIUs per minute were
all calculated and charted for visual inspection of results.

Results
Eåectiveness of treatment
During baseline sessions, T H was able to name fewer than 50 % of the treatment
pictures accurately (see ®gure 2). Visual inspection of results indicated that
performance increased during the `few exemplars ’ condition, until criterion (80 %
accuracy over three consecutive sessions) was attained after 12 sessions. It should
be noted that criterion was actually attained in this condition after the sixth session.
During the third session, T H had achieved 90 % accuracy and criterion was
temporarily elevated to 90 %, however, after additional sessions it became apparent
that T H was going to have di¬culty attaining the 90 % criterion and therefore
the 80 % criterion was restored. After a one week break the `many exemplars ’
condition was initiated. Naming accuracy dropped initially, but gradually increased
and criterion was attained after the eighth session. Follow-up sessions indicated the
eåects of treatment were maintained at the 80% accuracy level at one month post-
treatment and dropped to 70 % accuracy at two months post treatment. Number
and type of paraphasic errors did not show any signi®cant change from pre to post-
treatment.

Generalization of confrontation naming to untreated pictures

Accuracy of control pictures gradually improved to 50 % during the `few
exemplars ’ condition (see ®gure 2). During the `many exemplars ’ condition
accuracy gradually decreased to the baseline level of 10 %. At the time criterion for
the treatment pictures in the `many exemplars ’ condition was attained, naming
accuracy for the control pictures had improved to 30%. Naming accuracy for the
control pictures at the one and two month post treatment follow-up sessions had
returned to the 50% accuracy level noted during the `few exemplars ’ condition.
 Semantic feature analysis 139
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Figure 2. Percent treatment and control pictures named accurately.

Figure 3. Mean words and correct information units per minute produced by TH.

Generalization to connected speech

Figure 3 illustrates that T H demonstrated modest increases over the baseline levels
for both CIUs per minute and words per minute over the course of the two
treatment conditions which were noted to be maintained during the follow-up
sessions. An analysis of overall percent of CIUs in response to the connected speech
stimuli presented during baseline probe and follow-up sessions indicated that T H
was providing more information pertinent to the presented stimuli (see ®gure 4).
 140 Carl A. Coelho et al.
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Figure 4. Percentage of all words that were correct information units produced by TH.

Discussion
Previous investigations have demonstrated the eåectiveness of Semantic Feature
Analysis (SFA) as an intervention for dysnomia in TBI and mildly aphasic
individuals. The present study investigated the application of SFA for dysnomia in
a moderately aphasic individual. Results indicated that SFA resulted in improved
confrontation naming on trained and untrained items and was associated with
modest improvements in measures of connected speech. Generalization to
untreated items was noted to be more substantial when only a small number of
exemplars were trained. The treatment and generalization eåects were maintained
for two months after treatment was discontinued.
These ®ndings are both similar and diåerent from those of Boyle and Coelho
(1995). The diåerences between the two studies will be discussed ®rst. Results of
the Boyle and Coelho investigation indicated a more substantial treatment eåect
with their mildly aphasic individual, however no generalization to connected
speech was noted. These discrepancies may be attributed to a variety of factors
including severity of aphasia and etiology. With regard to the issue of severity of
aphasia the subject studied by Boyle and Coelho was mildly aphasic ((WAB)
Aphasia Quotient (AQ) 5 82) whereas the individual from the present investi-
gation, T H, was moderately aphasic (WAB AQ 5 57). It might have been
predicted that because T H began treatment at a lower level of language functioning
(i.e. T H’s aphasia was more severe) than the subject from the Boyle and Coelho
study, he would have been less able to internalize the SFA strategy to facilitate
word retrieval. However, in reality it appeared that just the opposite occurred.
T H’s confrontational naming improved on trained and untrained items and
generalization to connected speech was noted. Therefore, this diåerence in ®ndings
of the two studies appeared not to be simply the result of aphasia severity.
An alternative explanation may involve diåerences in type of aphasia. The
subject studied in Boyle and Coelho’s investigation was described as having
 Semantic feature analysis 141

Broca’s aphasia. That subject presented with less connected speech pre-treatment
as well as post-treatment (approximately 23 words per minute and 10 CIUs per
minute) than T H. T H demonstrated a ¯uent aphasia and was noted to produce
more than twice the amount of connected speech per minute (approximately 56
words and 23 CIUs per minute) than Boyle and Coelho’s subject. It may be that,
based upon type of aphasia, T H had more potential for improvement. As can be
seen in ®gure 3, T H demonstrated a steady increase from baseline in words per
minute and CIUs per minute. The percentage of all words that were correct CIUs
also increased slightly (see ®gure 4). Thus, T H was not simply talking more, but
also providing a greater proportion of meaningful content. All of these gains were
noted to be maintained in the follow-up probes. Boyle and Coelho’s investigation
suggested that possibly direct treatment of word retrieval in connected speech
might be necessary in order to achieve improvement at the discourse level. This did
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not seem to be the case with T H. He appeared to experience more di¬culty with
confrontation naming than with discourse, which is consistent with ¯uent aphasia.
Although it is not possible to come to any de®nitive conclusions regarding e¬cacy
of SFA for aphasia on the basis of two subjects, it is not unreasonable to suggest
that the eåectiveness of SFA may be in¯uenced by not only severity but also type
of aphasia. Further, to eåect an increase in the connected discourse of non-¯uent
aphasic individuals, intervention may need to be focused on more than just generic
word retrieval, but rather on more speci®c aspects of word retrieval such as
verbs (e.g. see Schneider and Thompson 1997). Alternatively, with ¯uent aphasic
individuals, SFA may provide an organizational structure to existing language that
the individual already has access to. The eåect of SFA intervention is therefore
re¯ected in an increase in communicative e¬ciency (i.e. an increase in the
proportion of CIUs to total words produced).
In the interpretation of these ®ndings, it is important not to neglect the potential
in¯uence of etiology. The subject from the Boyle and Coelho study demonstrated
a diåerent type of aphasia that was also less severe than T H. In addition, the
subject’s aphasia was secondary to a CVA, whereas T H’s aphasia was the result of
a closed head injury. The observation that SFA appeared to improve T H’s
organization of his connected speech may in reality have simply improved his
organization in general, a common problem following closed head injury, as
opposed to eåecting speci®c linguistic processes. It appears that diåerent types of
aphasia may respond diåerentially to SFA. Additional aphasic subjects need to be
studied to delineate the consistency of the eåects on speci®c types and levels of
aphasia severity.
Finally, the Boyle and Coelho study noted generalization of improved
confrontation naming to untreated pictures when as few as seven exemplars were
treated. A similar ®nding was noted in the present study in which improvements
in confrontation naming generalized to untreated pictures when only 10 exemplars
were treated. However, when training was shifted to the `many exemplars ’
condition generalization to untreated pictures dropped temporarily, but eventually
increased only to the level attained in the `few exemplars ’ condition. A similar
pattern was also noted to occur in the Boyle and Coelho study. These ®ndings
provide additional support to the contention that training a relatively small number
of exemplars may be su¬cient to achieve generalization to untrained stimuli.
 142 Carl A. Coelho et al.

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