MGEA Measure of Cognitive- Linguistic Abilities Wendy J. Ellmo Jill M. Graser Elizabeth A. Krchnavek Deborah B. Calabrese Kimberly Hauck MANUAL The Speesh BimDedication To our families, who inspire us. To our clients, past, present, and future. ©1995 by The Speech Bin, Inc. All rights reserved. Permission is granted for the user to reproduce pages so indicated in limited form for instructional use only. No other parts of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying and recording, or by any information storage and retrieval system, without written permission from the publisher. The Speech Bin, Inc. 1965 Twenty-Fifth Avenue Vero Beach, Florida 32960 ISBN 0-937857-57-2 Catalog Number 1450 Printed in the United States of AmericaTable of Contents Introduction Rationale nee see sae ‘Theoretical Background and Test Design. . Administration and Scoring Procedures... . . Testing Environment, Scoring, and Behavior Communication Functioning Intake ‘Receptive Language Subtest Expressive Language Subtest. . Pragmatic Language... ... Reading. eee Written Language . . Oral Mechanism . . . Family Questionnaire Forms ........ Interpretation Case Illustrations Eileen Steven .. Allison . . Standardization and Norms References 2.0... eee eee ee Appendix Appendix A—Discourse Rating Scale: Definitions Appendix B—Pragmatic Rating Scale: Definitions Appendix C-Answer Key 2... eee eee eee aes <4 - 22 ..10 . 10 eee i .. it .19 19 20 21 23 ». 81 - 31 37 43 47Acknowledgements We are deeply indebted to two accomplished speech-languag: =—=r== Eileen Ryan and Allison Murray-Imbalzano, for their assistan=: pily proofed and reproofed many versions of the manus = forms, regardless of how full their own caseloads became many non-head injured people to gather the normative = = = tributed to the intertester reliability. Many of their suggestiax = porated in the manual, Fileen and Allison, we appreciate yor = == and cherish you as friends. We thank Kathleen Ryan and Gayle Butrico for their help in ci=—=—= mative data. They worked with us as student interns and now =: === ing clinicians in their own right. We appreciate Joe Giacino’s help in editing portions of the maxx—— his willingness to share ideas. Thank you to the many volunteers who agreed to be tested & = — have normative data for the MCLA. Many inconvenienced === order to participate. Your altruism sets a standard for us all. ‘Thanks to Ronald Pfeiffer and Glen A. Schofield for their illu And finally, thank you to the staff and administration at the 7 Rehabilitation Institute’s Center for Head Injuries, espo—- Cicerone, Clinical Director, and Carolyn Weil, Clinical C: supporting us in all that we do. We couldn’t ask for a better p= =Introduction The Measure of CognitiveLinguistic Abilities (MCLA) provides systematic evaluation of clients who have mild to moderate impairments caused by traumatically induced brain injuries (TBI). The MCLA has three major purposes: * Toassess linguistic abilities + To help identify cognitive deficits that have an impact on linguistic performance + To recognize the important interrelationship between cognition and language. Cognition and language are intimately related. One cannot assess linguistic deficits in TBI without acknowledging the impact of cognition on language (American Speech-Lan- guage-Hearing Association, 1988; Groher, 1990; Hagen, 1984; Holland, 1982; and Mc- Donald, 1992). Clinically, impaired cognition can affect the content, form, and use of language. Because the primary concern of speech-language pathologists is the assessment and treatment of all areas of linguistic functioning, they must be involved in the assess- ment and treatment of individuals with cognitive deficits Traumatically induced brain injury is a growing problem. In the United States two hundred people in every 100,000 sustain a brain injury in any given year. Approximately eighty percent of those injuries are mild, and another ten percent are moderate (Soren- son and Kraus, 1991). These statistics represent only those people admitted to a hospital. ‘They underestimate the total number of people who sustain brain injuries because many people with mild traumatic brain injury (MTBI) do not seek medical care, Rationale Thorough linguistic assessment of individuals with traumatic brain injury is essential. Three different studies (Sarno, 1980, 1984; Sarno, Buonaguro, and Levita, 1986) found all patients examined showed evidence of linguistic impairment after closed head injury. Unfortunately, linguistic functioning is often not evaluated after TBI. Groher (1990, page 148) recognized this tendency to overlook speech and language assessment: “Most of the literature has dealt with the medical management of the patient, treating communication and its role in total rehabilitation in an accessory manner. The importance of speech and language deficits after head trauma has been minimized, partly from failure to agree on an accepted terminology that accurately describes the deficits, partly from the lack of empirical data about the treatment of communication disorders and partly from the failure to believe that communication deficits secondary to head trauma deserve special attention because they represent a unique speech and language symptomatology.” MLE, Groher in Rehobiation of he Adult aid Child wth Troumatie Bran Injury. Roses, M. Griffith, ERs Bowl, MR, and Mien }D. (edn) FA: Das Company, Pagel, 1990, reprinted wth penmsson.In its position statement oni interdisciplinary approaches to brain damage (ASIIA, 1990), the American-SpeechLanguage-Hearing Association recognizes the broad base of neuro- psychology and the contributions made by many other disciplines. The statement also as- is inappropriate that the knowledge base of neuropsychology be regarded as proprietary by any given discipline or profession” (page 3). ASHA recognizes the need for adequate training by saying, “It is assumed that such practice will include techniques and procedures included in discipline-specific training and exclude those for which com- petence had not been established through such training criteria” (page 3). Brain injury rehabilitation needs a comprehensive, practical test instrument to assess cognitivelinguistic abilities. In a survey of 104 randomly selected colleagues, speechlan- guage pathologists reported their low level of satisfaction with traditional aphasia test in- struments for evaluating persons with mild traumatically induced brain injury because these tests are not sensitive enough to detect the subtle impairments seen (Ellmo, Graser, and Calabrese, 1994). The speech-language pathologists surveyed, who work with persons who have moderate, mild, and minor levels of impairment, appear to spend a substantial amount of their assessment time testing in areas outside speech and lan- guage, primarily in cognition, with language assessment often superseded by cognitive assessment. A further finding revealed that traditional aphasia tests are used to measure the traumatically induced language deficits that Halpern, Darley, and Brown (1973) called confused language. A critical problem in the field of speech-language pathology, one with far-reaching im- plications for high-level clients, is the lack of tests sensitive enough to detect the subtle, yet functionally significant, linguistic deficits of these individuals. Frequently these per- sons are evaluated by using traditional aphasia tests, yet Wertz (1978) found that tests of aphasia do not detect the linguistic disturbances present after TBI. The reason for this is clear: language disturbance after TBI is not aphasia (Adamovich, 1992; Baxter, Cohen, and Yivisaker, 1985; Hagen, 1981, 1984; Halpern, Darley, and Brown, 1973; Holland, 1982; Mentis and Prutting, 1987; Milton, 1988; Rand, Trudeau, and Nelson, 1990; Rosenbek, LaPointe, and Wertz, 1989; Sarno, 1980, 1984; Wyckoff, 1984; and Yivisaker and Szekeres, 1986). Important differences exist between language deficits caused by ‘TBI and those associated with aphasia following cerebral vascular accidents (Adamovich, 1992; Baxter, Cohen, and Yivisaker, 1985; Hagen, 1981, 1984; Halpern, Darley, and Brown, 1978; Holland, 1982; Mentis and Prutting, 1987; Milton, 1988; Rand, Trudeau, and Nelson, 1990; Rosenbek, LaPointe, and Wertz, 1989; Sarno, 1980, 1984; Wyckoff, 1984; and Yivisaker and Szekeres, 1986). Researchers (Arseni, Constantinovici, Iliescu, Dobrota, and Gagea, 1970) have found that aphasic syndromes rarely occur after TBI. ‘The use of aphasia batteries in the assessment of traumatically induced linguistic deficits has been questioned (Mentis and Prutting, 1987; Milton, Prutting, and Binder, 1984; and Yivisaker, 1988). Subtle deficits are often not detected by traditional neuropsychological tests (Leininger and Kreutzer, 1992) or aphasia tests (Wertz, 1978). Researchers (Mentisand Prutting, 1987; Milton, Prutting, and Binder, 1984; and Yivisaker, 1988) who have at- tempted to detect traumatically induced linguistic deficits using tests designed to measure aphasic disturbances found these aphasia tests inadequate for this purpose. Cognitivelinguistic deficits after TBI are frequently high-level and subtle. Using either cognitively or linguistically-based tests designed for clients with severe impairments presents a real possibility of failing to diagnose clients who have subtle, yet functionally significant, deficits (Adamovich, 1992; Alves, Colohan, O'Leary, Rimel, and Jane, 1986; Leininger and Kreutzer, 1992; Sarno, 1980; Yivisaker, 1988; and Ylvisaker and Szekeres, 1986). Yivisaker and Szekeres wrote, “There currently exists no collection or battery of tests that have been validated on a population of head-injured patients and that specifi- cally address the complex of cognitive and communicative deficits associated with closed head injury” (1986, page 478). The cognitive-linguistic skills of these higher-level clients must be accurately assessed to ensure that appropriate remediation and compensation occur. The MCLA was developed to meet this longstanding need for a comprehensive, standardized assess- ment tool to measure the cognitivelinguistic abilities of individuals who have ex- perienced traumatic brain injuries. It determines clients’ high-level cognitivelinguistic deficits in order to reveal their strengths, to assist in treatment planning, and to provide a basis for client and family education. Often the goal of programs treating these clients is to assist clients in returning to high-functioning positions at work, school, and/or home where the presence of these mild deficits may have a tremendous deleterious im- pact on their lives. ‘The MCLA was developed at the JFK Johnson Rehabilitation Institute, Center for Head Injuries, Cognitive Rehabilitation Department in Edison, New Jersey. The Cognitive Rehabilitation Department is the final step in a continuum of brain injury care. Treat- ment there focuses on returning clients with brain injuries to the highest level of inde- pendent functioning possible. For people with mild impairments, this may include preparing them to return to work or school. The JFK Johnson Rehabilitation Institute seeks to support research with this group of clients to help define this group more precisely, facilitate effective treatment, and produce the highest possible outcomes. Theoretical Background and Test Design The Measure of Cognitive-Linguistic Abilities (MCLA) is based on five premises: * Language and cognition are interrelated. * Language disturbance after traumatically induced brain injury is not aphasia. * Highevel and subtle deficits often exist following traumatically induced brain injury. + Language must be assessed and treated after traumatically induced brain injury. * Information processing is a hallmark deficit of mild waumatically induced brain{ | | jury (MTBI) and a significant deficit in all levels of brain injuries. Each premise is incorporated into the test design. The belief that assessing linguistic per- formance is essential in adults with traumatic brain injuries is incorporated by examining five major linguistic areas: Receptive language Expressive language Reading Writing Pragmatics ‘The battery also includes a supplemental Oral Motor Screening instrument. ‘The intricate relationship between cognition and language is implicit in all MCLA rating scales which contain cognitive as well as linguistic elements. Examiners are encouraged to note any cognitive deficits affecting clients’ performance in the “Comments” sections whenever appropriate. Doing so supports the second premise, that linguistic disturbance after TBI is not aphasia. The impact of cognitive disturbance on linguistic performance is given substantial consideration throughout the test battery. ‘The MCLA also takes into account the third premise, that highevel and subtle deficits often exist following TBI. This test assesses receptive language beginning at the para graph level instead of single word level; continuing with recall and ending with verbal abstract reasoning. Expressive language is examined in two ways. Discourse skills are evaluated in varying degrees of structure and complexity, from picture description to self generated narrative. Verbal fluency skills are assessed through several different tasks, also varying in degree of structure. Evaluation of reading skills begins with functional material and progresses to lengthy, integrated passages. Writing is examined at para- graph level, as opposed to letters and single words. Information processing, a core deficit in mild and moderate brain injury, is also a central focus of this test. The Information Processing Checklist provides clinicians with a struc- tured way of looking for deficits in information processing throughout the testing situa- tion. Elements of information processing also are incorporated into the Narrative, Discourse, Pragmatic, and Written Narrative Rating Scales. Using these tools, examiners can then easily integrate information processing findings into written evaluations. Decreased information processing is a hallmark deficit in MTBI and is a frequent finding with all levels of severity of brain injury. Results of several studies using neuro- psychological measures and/or reaction time tests showed decreased information processing with MTBI (Gronwall, 1977; Gronwall and Wrightson, 1974; Hugenholwz, Stuss, Stethem, and Richard, 1988; Leininger, Gramling, Farrell, Kreutzer, and Peck,1990; MacFlynn, Montgomery, Fenton, and Rutherford, 1984; and Stuss, Stethem, Hugenholtz, Picton, Pivic, and Richard, 1989). In their review of the post-concussive syndrome literature, Szymanski and Linn note, “Ihe most commonly found neuro- psychological deficit is in information processing” (1992, page 370). In addition to the MTBI studies above, other authors (Gronwall and Wrightson, 1981; and Stuss, Ely, Hugenholtz, Richard, LaRochelle, Poirier, and Bell, 1985) have found information processing problems with all levels of brain injury severity. Stuss, et al. wrote, “We postulate that the basic disorder of acceleration-deceleration CHI (upon which other disorders may be superimposed) is a divided attention deficit, a limitation of the damaged brain in information processing capacity, either in terms of speed 6f processing or in terms of the amount of information that can be handled simul- taneously” (1985, page 44). In his-article on neuropsychological diagnosis, Kay (1992) noted that, because of the influence of information processing deficits, one must look at how the client takes the test—their process—not simply at their test scores. Because of the close relationship between cognition and language, the speech-language pathologist's as- sessment of language in TBI also must look at the impact of information processing deficits on linguistic abilities. In summary, the Measure of Cognitive Linguistic Abilities is a comprehensive battery for the assessment of traumaticallyinduced cognitivelinguistic deficits. Through the informa- tion it yields, examiners can develop appropriate intervention programs to treat the lin- guistic deficits following mild and moderate TBI.Administration and Scoring Procedures Testing Environment The testing environment should be quiet and welllighted. The subtests may be ad- ministered in any order. More than one assessment session may be needed. Assessment typically takes from one and one-half to four hours depending on the client’s abilities. Scoring The MCLA uses the following scoring system of 0, 1, or 2 points. Op On components of some subtests (Paragraph Comprehension, for example), only 0 or 2 points may be credited because answers to these items cannot be partially correct; they are either right or wrong. Answers are provided in the Appendix. Test Behavior The examiner should make written notes about the client's testing behavior during the assessment. These comments should be made on the individual score forms or the ‘MCLA Evaluation Summary Form. The examiner should note such behaviors as: Speed of response Self-corrections Selfreported guessing Requests for repetition or clarification Highlighting Underlining Outlining After each subtest component, clients should be asked to report any differences from their premorbid performance that they can identify. The reason for this request is that, especially in mild brain injury, clients may score within the normal range, yet the process they go through to perform the task may be different. For these clients, the time re- quired is likely longer than it was premorbidly. Subtests ‘The MCLA is comprised of an intake interview procedure; subtests measuring receptive Tt0-language, expressive language, fluency, pragmatics, reading, writing, and oral motor functioning; and a family questionnaire. Results should be recorded on the MCLA Evaluation Summary Form. Communication Functioning Intake The Communication Functioning Intake guides examiners through the initial interview with clients. The intake procedure elicits background information, information regard- ing speech and language changes, preinjury work or school status, previous speech and language treatment, strategy usage, and hearing evaluation. All responses to questions and information about deficits observed should be written in the appropriate spaces. Presentation of Subtest Components In addition to the directions presented below for each component, directions for recep- tive and expressive language subtests are provided on the scoring forms. The directions below are more detailed regarding cuing. The examiner should not rely solely on the ab- breviated instructions found on the scoring forms. Receptive Language Subtest Information Processing Checklist: This checklist consolidates information about the client's information processing skills. These skills are listed in the lefhand column. If difficulty in an area is observed during the evaluation, the examiner checks the box cor- responding to the situation in which the difficulty was observed (either listening, read- ing, or both). Space for additional comments is provided at the bottom of the form. Paragraph Comprehension: This component has three short stories with five yes/no questions each. The examiner says: then ask some r “no”, Ready?” Neither paragraphs nor questions may be repeated; any request for repetition should be noted. If the client asks for clarification about a paragraph, the examiner should indicate no information may be repeated, encouraging the client to guess when unsure of an answer. When guessing is reported, this should be noted, but points are not deducted if the answer is correct. If the client does not answer “yes” or “no”, the examiner should cue the client to do so. Two points are awarded for a correct answer; no points are awarded for an incorrect answer. No partial credit is given. The maximum score is thirty points, ten points per paragraph. Answers are provided on the administration form. Story Recall: The Story Recall component has two stories. The first is told in the format of vita story, as if one person was casually relating an event to someone else. The second story contains a short list. The examiner says: EH Begin reading. Maintain a slow pace. Once the client has finished recalling the story, ask, “Anything else?” Introduce the second story by saying, “Here is another story. Ready?” The examiner may ask questions for cued recall, but additional information elicited should not count toward the client's score. The stories may not be repeated. If the client did not appear to be paying attention, the examiner should encourage the client to recall anything about the story, even if the response is fragmented. On the scoring form, several Hines have a slash mark (/) dividing the line in half. To score two points for that line, the client must provide content from both halves. If only onechalf is given, one point is scored. No points are scored when the content from a line is omitted. Points are awarded if the client provides the main idea; exact words need not be used. For example, in the first story, the following are acceptable: Line2: Carrying a book Line 4: You knocked into a man Line 7: He wanted to know where the train station was Line 10: You were excited/when you looked at it Line 11: Because you realized it must have been the author Clients (and persons who are not head.injured) commonly change the “I” to “you” or “he” to “she”; such a change is acceptable. For Story 2, the following answers are acceptable: Line 1: Fred and his wife = No points for that half. Both names must be given to score one point for that half of the line. Line 5: Dr. West gave Jake a good examination, or ‘The doctor gave him a thorough checkup (Award two points for the line if Dr. West's name was mentioned elsewhere.) Line 7: His teeth look good, healthy, or okay Line He gave him Line 10: A dog bone Line 11: Because he was good If the story is significantly changed or confabulated, full credit is given for each main idea included, even if it is given in the wrong context. However, the examiner should 12note the changes and the accuracy of the client’s recall in the written evaluation, Note the scoring of the following response to Story 1: 2points Reading a book Qpoints —_ I was late for my agent points _Tasked someone for directions to the train 1 point I was walking down the street The third and fourth lines of the response are awarded two points each, even though it was not the “I” who was late and needed to get to the agent. In this response the main ideas of lateness, getting to an agent, and asking for directions to the train were preserved. Comment should be made, however, about such changes during recall. Note the scoring of the confabulatory response to Story 1 below: points They were reading a book Lpoint Someone was walking down the street Lpoint They were going to take the train, but they were late O points That was going to be published Points were awarded for the italicized portions even though the context in which these details were reported was confabulated, In confabulatory responses, the total point score should be interpreted with caution. Until the examiner has had some experience with this subtest, audiotaping the client’s responses so they can be scored after the testing session is recommended. Additional scoring examples are given in the scoring booklet. ‘The maximum score for Story Recall is forty-four points, twenty-two points per story. Verbal Abstract Reasoning This subtest contains five quotations the client must interpret. The examiner says: “Now Iam going to read a few quotations to you. I would like you to tell me what they mean.” After each quotation ask, “What do you think he (she) meant?” The quotations may be repeated. Make note of the repetition but do not adjust the scor- ing. If the client gives a partially correct answer, the examiner may cue for more infor- mation by saying, “What do you mean?” or “Tell me more.” Responses to these general cues may be scored, However, if more specific cues are given, the information should not contribute to the client's score but should be used for the examiner's reference. ~13-Verbal Abstract Reasoning is probably the most difficult component to score because of the considerable variety of possible answers. Yet, by becoming familiar with what con. stitutes correct answers, scoring becomes simpler. The examiner may want to audiotape and/or transcribe the client's answers and score them following the testing session. Consult the answers in the scoring booklet frequently when scoring for sample zero, one, and two-point answers. Note that correct interpretation of two separate elements for cach quotation is needed to score two points. Clients may include an element in their explanation but use it in the wrong context; such answers receive no points. For ex. ample, in response to the quotation, “Success is the best revenge,” the answer, “As long as you are successful, you can get back whatever you do,” includes the idea of success, but it is not within the right context. This answer contrasts with one such as, “If you suc. ceed when people have told you that you will fail, you have proven them wrong.” This latter response is on the right track but is not fully complete because it omits the idea of revenge. Such an answer would be awarded one point for accurately maintaining the idea of success. Examiners are encouraged to consult the sample two-point answers provided in the scor- ing booklet for an understanding of the meaning of the quotation. They should score this section carefully and compare clients’ answers with the ones provided. A maximum of ten points can be awarded. 1fclients have expressive difficulties that limit their ability to respond verbally, the multi- Plechoice version of Verbal Abstract Reasoning may be administered instead. (Note: This is. simpler task; norms do not apply.) The examiner gives the client the form and says: “I would like you to read each quotation and éircle the answer that best explains what it means.” Tithe client also has visual difficulties, multiple choice items may be administered orally. A maximum of ten points can be earned. Expressive Language Subtest Discourse Measures: The examiner may transcribe and/or audiotape narratives in order to score them after the testing session. No time limits are imposed. The examiner may, however, request that the client stop speaking after five minutes. Discourse Rating Scale: The Discourse Rating Scale (DRS) is a nine-item, five-point scale used to record the percentage of time the client adequately or appropriately performs each discourse skill. Three supplemental measures are included. These supplemental measures are rated as either Remarkable or Unremarkable. The examiner scores the DRS based on the client's overall performance during all testing sessions. Judgments should a14-be made regarding performance on the three narratives below, the intake —zerview, and conversations with the examiner. Although the DRS has been designed for use within testing sessions, in a aware of significant fatigue after performing any type of cognitively based task. He noted that his friends had noticed many of these changes in him as well. He was aware of few strategies that he was using to improve his performance. Step 2: Analysis of Individual Components of Subtests RECEPTIVE LANGUAGE Paragraph Comprehension: Steven achieved a low score on Paragraph Comprehension and appeared unsure of many of his answers. He reported having difficulty staying focused. ‘Story Recall: Performance was mildly reduced. He was mildly disorganized in his recall of the story elements. He reported being distracted by the air conditioner and asked to turn it off after the first story. For the second story, he rested his head in his hands and looked down at the table. Verbal Abstract Reasoning: Steven's score on the Verbal Abstract Reasoning component reflected good abstract reasoning skills; however, he requested that two of the quota- tions be repeated as he had “not gotten it” the first time. On three of the items he fre- quently revised his answers, stating, “I know what it means; I just don’t know how to say it” Some mild word finding difficulty was noted. EXPRESSIVE LANGUAGE Picture Description Narrati: His narrative was complete and organized. Procedural Narrative: Complete and sequentially organized, it contained circumlocutions. SelfGenerated Narrative: Mild disorganization was observed. Steven forgot his point once but spontaneously stopped to think, remembered his point, and continued. Even though the door was closed, Steven turned his head toward it any time footsteps could be heard in the hallway. Mild word finding problems were evident. Steven attempted to circum- locute; these circumlocutions tended to be descriptive in nature. In other instances, Steven paused to think, and then generated the target word. When asked later what he was doing when he paused, he said that sometimes he could “see” the object and other times he was able to read the name of it in his head. He was surprised to learn that he was actually doing something to help generate the word. Visual Confrontational Naming: Steven exhibited good concentration with no hesitations. FLUENCY FAS, Countries, Things That Can Be Closed: Steven's performance on the fluency tasks wasgood. His use of phonemic strategies appeared effective in facilitating generation of words beginning with the letters F~A—S. He named the countries geographically. Only concrete objects were listed for things that can be closed. PRAGMATIC FUNCTIONING Pragmatic Rating Scale: Overall, pragmatic performance was within normal limits. Eye contact and quality of listening decreased when he was distracted. Steven was not always aware that he had missed information; therefore, he did not always seck clarification, Other pragmatic skills were good. READING Functional Reading: Accuracy and speed were good. Factual Reading: Accuracy and speed were good. High and Low Inferential Reading: Performance was slowed. Steven reported needing to reread sentences and paragraphs because “I know I read the words, but they didn’t mean anything.” When reading, Steven often whispered the word to himself and put his pencil on each word as he read it. Some difficulty was seen with inferencing and written expression, His answers, at times, reflected that he knew the information but had dif- ficulty organizing it into an integrated whole. WRITTEN LANGUAGE Written Self Generated Narrative/Written Narrative Rating Scale: Steven's written narrative skills were good. He demonstrated good punctuation, capitalization, grammar, com- plexity, organization, and integration. He did not appear distracted while writing about the familiar topic, Afterwards, he stated that he has more difficulty maintaining his con- centration when writing about the technical subjects he must write about at work. ORAL MOTOR FUNCTIONING Oral Motor Screening: Structure and function were judged to be within normal limits. Step 3: Analysis of Subtests Receptive Language: Steven demonstrated difficulty maintaining attention and processing information with all auditory-based tasks. He demonstrated use of strategies to compen- sate for difficulties in attention (for example, turning off air conditioning and putting head in hands). Verbal abstract reasoning skills were within normal limits although processing at this complex level was more difficult. Expressive difficulties were seen onthe Verbal Abstract Reasoning component. Expressive Language: Performance was better with higher levels of structure (Picture Description and Procedural Narrative). Mild word finding problems were seen when a visual stimulus was not available. Circumlocution and visualization of both the word and the object appeared to be effective strategies for him, although he had limited awareness that he was using compensatory strategies. Visual stimuli (Visual Confrontational Naming) appeared to increase attention and facilitate word retrieval. Steven had a plan or end point in mind when speaking; however, he sometimes forgot his plan and/or be- came disorganized on Self-Generated Narrative and in conversation. He always ultimate- ly made his point. Other fluency measures were satisfactory; strategy usage was evident. Pragmatic Functioning, Writing, and Oral Motor Functioning: See Step 2. Because Prag- matic Functioning, Oral Motor Functioning, and Writing are assessed by only one meas- urement tool, integration of these subtests takes place at Step 2. Reading: Basic functional reading skills were intact. Performance slowed significantly as complexity increased; in addition, decreased attention and reduced ability to derive meaning were noted, Steven demonstrated use of strategies to increase depth of process- ing. Difficulty with organization of written expression increased as the thought com- plexity increased. Step 4: Analysis of the Battery as a Whole Steven demonstrated use of compensatory strategies on several different subtests of the battery. He was largely unaware that he was using strategies or that he could do anything that would improve his performance. He should be made more conscious of the useful: ness of these strategies, and treatment should build on them. Steven did demonstrate good awareness of the changes in his functioning. Processing abilities (attention, ability to derive meaning, memory, and speed) were decreased in several linguistic areas (receptive, expressive, reading, and writing), espe- cially as complexity increased. Difficulty with recall and mental manipulation of information led to occasional verbal disorganization. Disorganization in writing increased as complexity of thought increased. Word retrieval difficulties were more pronounced in non-visual tasks; for example, per- formance was better on Visual Confrontational Naming than on the SelfGenerated Nar- rative and on the writing subtest versus the expressive language subtest. This finding suggests visualization may be an effective word retrieval strategy for Steven to learn. Ad- ditionally, his attention was better on tasks which gave Steven something to look at. He needs to work on strategies to improve attention in auditory-based tasks. ~atCASE ILLUSTRATION #3 DEMOGRAPHICS Name: Allison Age: 48 Education: PhD in English Occupation: Professor of English Injury: Allison was hit by a car as a pedestrian. She was thrown into the air and landed on her buttocks. Loss of consciousness was not re- ported; however, she experienced lapses in memory around the time of the accident. She fractured her right arm and sustained lum- bar and cervical injuries. The current evaluation was performed ap- proximately two years after the accident. NEUROLOGIC FINDINGS MRI and EEG one year later revealed no abnormalities. These tests were not performed at the time of the injury. INTERPRETATION ‘Comparison with Norms Paragraph Comprehension: Good performance Story Recall: Good performance Verbal Abstract Reasoning: Good performance Discourse Rating Scale: Mild difficulty Visual Confrontational Naming: Good performance Fluency PA-S: Good performance Countries: Good performance Closed: Good performance Pragmatic Rating Scale: Good performance Reading Functional Reading: Good performance; Time: Good Factual Reading: Good performance; Time: Slowed Low Inferential Reading: Good performance; Time: Slowed High Inferential Rating Scale: Good performance; Time: Slowed Written Narrative Rating Scale: Good performance; Time: Good Analysis of Test Taking Behaviors ‘Step 1: Analysis of Communication Functioning Intake. Allison was very aware of changes ~a2-MCLA Evaluation Summary Name Ct bez nt txaminer C7 Date '/7 | ‘COMMUNICATION FUNCTIONING INTAKE — RECEPTIVE LANGUAGE Paragraph Comprehension So/ao Story Recall Bole Verbal Abstract Reasoning 4O[L0 | Other | EXPRESSIVE LANGUAGE Discourse Measures Picture Description = | Procedural Narrative - a i Self-Generated Narrative = Discourse Rating Scale Leas Fluency Measures | Word Fluency: FAS: o2/ , /B , /9 58 ‘Controlled Fluency: Countries BL | Divergent Naming: Closed lo Visual Confrontational Naming PETA Other PRAGMATIC FUNCTIONING / Pragmatic Functioning Scale Gs/los~ Other READING Functional Functional Reading Time: bamies. Higher Level Factual Comprehension Time: Bares, ; Low Level Inferenti High Level Inferen Other ‘Time: . | Time: LGinin. WRITING Self-Generated Narrative Time: Sinem Written Narrative Rating Scale Other ORAL MOTOR FUNCTIONING Oral Mechanism Screening Other h LES TRH COMMENTS ~43-in her functioning since her accident. She described herself premorbidly as very articu- late, an excellent writer, and someone who “loved words and devoured books.” Since the accident, she reported she rambles trying to get her message across, makes errors on simple tasks, has difficulty identifying simple spelling mistakes, has problems finding the right words in speaking and writing, and experiences difficulty understanding others in one-on-one and group situations. She also finds herself very distractible, especially when reading and writing. She frequently needs to reread what she has just read, has difficulty organizing her thoughts on paper, and finds reading and writing cognitively fatiguing. Allison has withdrawn from many social situations because she is afraid she will “ramble on” or “appear stupid.” She was aware of using several compensations, learned over the two years since her injury, which improve her cognitive linguistic performance. Step 2: Analysis of Individual Components of Subtests RECEPTIVE LANGUAGE Paragraph Comprehension: Comprehension was excellent; no response delays were seen. Story Recall: Allison demonstrated excellent recall with good organization and accuracy. Verbal Abstract Reasoning: Allison showed excellent verbal abstract reasoning skills. Her responses revealed slight difficulty with word finding; however, she compensated for this difficulty well. Her answers were immediate and well-organized. EXPRESSIVE LANGUAGE Picture Description Narrative: Excellent narrative, complete and organized. Procedural Narrative: Mild word finding difficulties were noted; however, the narrative was organized and sequential overall. Her gestures helped facilitate word finding. SelfGenerated Narrative: Mild word finding problems were observed; at times Allison cir- cumlocuted to make her point. The narrative was well-organized; the vocabulary was ap- propriate based on her educational level. Visual Confrontational Naming: No errors or hesitations in responses noted. FLUENCY FA‘S, Countries, Things That Can Be Closed: Performance was within normal limits. Allison demonstrated good fluency skills. She used categorization and phonemic strategies to facilitate generation. TasPRAGMATIC FUNCTIONING Pragmatic Rating Scale: Allison demonstrated appropriate nonverbal communication, conversational skills, and use of linguistic context. READING Functional Reading: No difficulties noted; good speed. Factual Reading: No errors made. Completion took longer that anticipated, given premorbid level of ability. High and Low Inferential Reading: Allison demonstrated good inferential skills. Mild word selection problems were noted in written answers to questions. Completion took longer than expected. WRITTEN LANGUAGE Written SelfGenerated Narrative/Written Narrative Rating Scale: The narrative was or- ganized and legible; the topic was maintained; syntax, grammar, vocabulary, and word selection were good. The topic was very familiar to Allison. ORAL MOTOR FUNCTIONING Oral Motor Screening: Structure and function were judged to be within normal limits. Step 3: Analysis of Subtests Receptive Language: Excellent receptive skills were noted within the controlled testing en- vironment. Good recognition, recall, and abstract reasoning skills were demonstrated. Mild word finding problems were observed. Expressive Language: Mild word finding difficulties were noted on the narratives and in conversation. Allison may be using visualization as a strategy to facilitate word retrieval as her performance on Visual Confrontational Naming was 100%. Use of other strategies was evident as well, including gesture, categorization, phonemic cuing, and circumlocu- tion. Organization, planning, fluency, and vocabulary were good. The topic was main- tained. No verbosity was noted. Pragmatic Functioning, Writing, and Oral Motor Functioning: See Step 2. Because Pragmatic Functioning, Oral Motor Functioning, and Writing are assessed by only one measure- ment tool, integration of these subtests takes place at Step 2.Reading: Allison demonstrated good understanding, integration, inferencing, and wy tion to detail at all complexity levels. Mild word selection problems were seen in wr, expression when the ideas became more complex. Processing was slowed as ser, slowed reading times. Step 4: Analysis of the Battery as a Whole Mild word finding difficulties were observed on several subtests. Allison demons, use of a variety of good compensatory skills for these difficulties, however. Slowed /., mation processing was seen in reading only. Other areas of cognitivelinguistic furs. ing appeared intact within the structured, quiet testing environment. FOLLOW-UP : Allison’s performance on the MCLA was not consistent with her self-reported difficure Therefore, Allison was informally assessed within a more distracting environment.» more similar to her work and social environments. Significant deficits were rey under these conditions. Allison’s attention deteriorated markedly with increased visual and auditory distrac:,, This decrease in attention had a significant impact on her linguistic abilities. Alle, verbal expression became disorganized and verbose; word finding difficulty incrre... Reading took significantly longer, and accuracy decreased. She required frequent :«,- tions in conversation, Written organization decreased, and errors in writing increase. addition, Allison demonstrated increased cognitive fatigue, often needing a break « . thirty minutes. Both formal MCLA testing and informal assessment sessions in a more distractir; vironment were essential. Formal testing established Allison's cognitive-linguistic 2, in a quiet controlled environment; informal sessions in a more natural environmerr -._ firmed her self-reported difficulties. Had formal testing not been done, Allison’s de, would have appeared more pervasive and extreme than they were. For example, £ testing revealed the skills of spelling, grammar, and organization were intact, ye: - broke down when she was in a distracting environment. Had the informal session. been conducted, she would have appeared to function more competently than stv tually does in her natural environment. These informal testing sessions revealed tha Primary deficits were in attention and information processing After the assessment, intervention focused on developing and implementing strate. help lessen the impact of these deficits on her cognitivelinguistic performance distracting settings and with high-level tasks. 746- ok aaa.Standardization The Measure of Cognitive Linguistic Abilities was administered by licensed speechJanguage pathologists and graduate students in spcechlanguage pathology. All protocols were scored by speech-language pathologists. In total, 204 people, ranging in age from 16 to ‘75 years, participated in the testing. All subjects spoke English as their primary language and lacked previous head injury or neurologic involvement. Reading subtests and writing subtests were not completed by all subjects due to time constraints. ‘The tables that follow provide the average score and the standard deviation for each por- tion, as well as the average time in minutes to complete the reading and writing portions. ‘The tables are divided by age and education (in years). Reliability Intertester reliability was the primary type of reliability investigated. This measure of reliability examines whether two different scorers can reliably score the test with similar results. The Story Recall, Verbal Abstract Reasoning, Discourse Rating Scale, Pragmatic Rating Scale, Functional Reading, Factual Comprehension Reading, Low Level Inferen- tial Reading, High Level Inferential Reading, and Written Narrative Rating Scale subtests were scored by two different scorers for a subset of the normative population. These cor- relation analyses were performed using the Pearson Product Moment Correlational Statistic. Scoring for all subtests demonstrated a significant degree of reliability; all were reliable at the .05 level of significance. The values are presented in the table below. SUBTEST VALUE N Story Recall 0.97515 a Verbal Abstract Reasoning 0.94889 70 Discourse Rating Scale 0.90048 5 Pragmatic Rating Scale 1.00000 10 Functional Reading (Total) 0.99557 76 Factual Comprehension Reading 0.97010 76 Low Level Inferential Reading 0.93688 75 High Level Inferential Reading 0.97385 70 Reading Total 0.98605 70 WNRS 0.94597 69 ~47~