9/19/2014
Today’s Objectives
Maximizing Communication Effectiveness for Speakers with Dysarthria
Jane Mertz Garcia, PhD
Communication Sciences & Disorders
[email protected]
1. Describe benefits of supplementation strategies to communication as supported in the literature
2. Identify factors that impact clinical decision‐making about the use of speech supplementation strategies
3. Explain ways communication partners impact successful application of supplemental strategies School of Family Studies & Human Services
Overview of Presentation
• Basis of Supplementation Strategies • Topic, Alphabet, Gestural Supplementation
– Application or Purpose
– Research findings
– Clinical Implications (decisions about use)
• Factors that Impact Outcomes (speaker and listener considerations) • Discussion and Questions
The reality is…
• There are limitations to changes we can make to the speech signal for many speakers with dysarthria
• Other sources of signal‐independent information contribute to communication, such as speech supplemental strategies Traditional View of Intelligibility
• Deficit belongs to the speaker – Identify subsystem problems
– Provide intervention to remediate subsystem problems
• Less consideration of partner‐related variables and their contribution to speaker intelligibility
Speech Supplementation
• Speaker implemented strategies that augment or enhance natural speech
– Topic cues (providing context to message)
– Alphabet cues (pointing to the 1st letter of each word spoken)
– Hand gestures while speaking (providing nonverbal content during speech)
– Syntactic information (knowledge about word class)
(Hanson, Yorkston, & Beukelman, 2004)
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Simply stated…
Supplemental strategies provide “clues” and “extra” sources of information that help listeners understand less intelligible speech
Mutuality of Communication (Lindblom, 1980)
Rich Good Understanding (High Intelligibility) SIGNAL INFORMATION Poor Ideal Case Poor Understanding (Low Intelligibility) Poor Rich SIGNAL‐INDEPENDENT INFORMATION Supplemental strategies …
• Take advantage of the interactive and dynamic aspect of speaker‐listener interactions
• Recognize that listeners naturally apply multiple sources of “shared” information in a difficult listening situation • Provide listeners additional content information to help understand less intelligible speech
What do we know about possible contributions to communication?
Result…Speakers with dysarthria are more effective communicators as messages are understand with greater accuracy.
Topic Supplementation
• Semantic context cue
– “Primes” listening for related information
– Often studied by providing listener a category name, topic, or theme (e.g., “relates to politics” or situation such as “in the house”)
Summary of Findings
• Average gains in intelligibility
– Word – 28% – Sentence – 10%
(Hanson et al., 2004; Hanson et al., 2013)
• Magnitude of benefit may vary
– Age of listener (Jones, Azuma & Liss, 2004)
– Type of dysarthria (Utianski et al., 2011) • Successful outcomes in combination with other strategies (like alphabet supplementation)
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Clinical Implications
• Implementation (Aided or Unaided)
– Write down information (e.g., key word)
– Point to or indicate topic in some manner (e.g., selection from print options)
Implementation (cont.)
– Discourse organization (introduce the “key” or main point first)
I have a question about my diet.
• Why can’t I eat pancakes? I have a headache.
• Please get me a Tylenol.
Clinical Implications
• Integration of mobile technologies to support capture and image display (Beukelman et al., 2013)
Alphabet Supplementation
• “Aided” strategy—speaker points to the first letter of each word while speaking.
Provide “short cut” to topics
Application (Purpose)
• Improve speaker understanding by enhancing listeners’ linguistic knowledge
• Increase redundancy in signal
• Slow speaking rate
– Modify speakers’ production characteristics in helpful ways
– Help resolve communication breakdown due to word by word approach • Instruction in its use is relatively “easy”
Research findings reflect…
• Consistently positive benefits for most – Listeners only hear speakers – 10% to 25% increases in sentence scores (Crow & Enderby, 1989; Hustad & Garcia, 2005; Hustad & Lee, 2008)
– Listeners see and hear speakers – 25% to 40% increases in sentence scores (Hustad & Garcia, 2005; Hustad, Jones, & Dailey, 2003)
• Mean gains of 26% (greatest impact for more severe profiles) across studies (Hanson et al., 2004) 3
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Clinical Implications
• Speaker…
– Provides additional time to execute motor movements (improve articulation)
– Decreases habitual speaking rate by about 70%
• Listener…
– 1st Letter cue narrows range of word choices
– Increases processing time for listeners
– Creates clear word boundaries (instruct listeners to “shadow”)
Clinical Implications (cont.)
• Use of high‐tech system (SGD) for alphabet supplementation, if possible – SGD keyboard for providing alphabet cues (ideally with partner‐facing displays)
– Customizing AAC system to include alphabet board as page content
• Alphabet supplemented speech recognition systems (predicts word based on combination of first letter and speaker’s production) Clinical Implications (cont.)
• Explore alternative options for direct selection (to maximize first letter pointing)
• Adapt for use with mobile technologies
Prestored “Control Phrases” voiced with SGD
“Symbol” or Static image of board for Alphabet Supplementation
Hand Gestures (Gesticulations)
As a Supplementation Strategy…
• Natural hand movements people use while speaking
• By definition…they occur during speech and are idiosyncratic in nature
• Various forms of gesticulations that differ in information content and function – Iconic gestures—illustrate some aspect of the spoken message (concrete representation of action, event, or object)
– Beat gestures—add emphasis and accentuate parts of speech (no information content)
• “Unaided” technique (nothing external to the body)
• Maximizes a natural aspect of communication (hand gestures naturally occur while speaking)
• Iconic hand gestures—illustrate aspects of message (e.g., corresponding gestures about an action, event, or object)
– Adds information content about spoken message – Provides listener 2 signals (nonverbal +spoken) about the same underlying message
(particularly iconic hand gestures)
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Intelligibility Scores While Gesturing Audio + Visual Listening Condition
(Garcia & Cannito, 1996)
(Garcia & Dagenais, 1998)
Benefit of 2 signals:
26.5% Visual 80
70
60
(nonverbal alone)
50
60%
30
(spoken alone)
20
61.4% Audio + Visual
10
Audio
With Gesture
30%
20%
10%
Speaker Speaker Speaker Speaker
1*
2
3
4*
0
Visual
No Gesture
50%
40%
+ 36.3% Audio 40
100%
90%
80%
70%
A+V
*Sentence intelligibility scores increased by 20% and 35% with the addition of hand gestures while talking Changes to Habitual Pattern of Speaking (PALS)
Shut
the
door
Shut the door and lock it.
(Garcia & Cobb, 2000)
and
lock
Impact of Hand Gestures
(Garcia, Crowe, Redler & Hustad, 2004)
it.
No Gesture (habitual)
• Word‐by‐word approach (42 wpm)
With Gestures
• Naturally “chunked” verbal to correspond to gesture (68 wpm)
Monologues reflected…
• Similarity in length, speaking rate, and amount of iconic gesturing
• Sample ‐ How to Make Chocolate Milk
“To make chocolate milk you need a glass and milk. And you pour the milk into the glass. And then you add some chocolate mix into, into the milk. And you have to stir it up real well until there is no powder on the bottom of the glass.”
• Examined spontaneous gestures used by 12 year‐
old‐male with severe flaccid dysarthria (SIT = 27%) • Intervention program included increasing use of iconic hand gestures while speaking
– Initial focus on adding content gestures to illustrate actions/descriptions within sentences
– Progressed to procedural and description discourse activities (reflected his self‐generated language and gestural content)
Methods
• Cue Conditions
– Full view (all visual cues ‐ included gesticulations)
– Face cues (only showed his face while speaking)
– Audio‐only (eliminated the video signal)
• 36 everyday listeners heard a different monologue in each condition
– Percent Intelligibility – Message Comprehension • Counterbalanced monologues for order of cue condition and assessment format
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Percent Intelligibility
Message Comprehension
Intelligibility (Words Correct) of Monologues
What phrase or sentence could you write to describe the main theme of this speaker’s story?
If you were having a conversation with this speaker and he told you this story, what question or comment would you use to add to the conversation?
100
90
P ercent Understanding
80
70
60
69.2
57.6
50
40
30
20
19.5
10
0
Full View (including
gesticulations)
Face Cues only
What people and/or objects were mentioned by the speaker in his story?
What actions were mentioned by the speaker in his story?
Audio-only
Natural hand gestures while speaking enhanced intelligibility (compared to face & audio only) (p < .05) In what location would this speaker’s story take place? Message Comprehension
Specific Questions
Comprehension of Monologues
100
90
90
80
70
Percent of Com prehension
Percent Understanding
80
75.3
60
50
52.5
40
30
20
20.8
10
70
60
Audio-only
50
Face Cues only
40
Full View (with
ges ticulations )
30
20
10
0
0
Full View (including
gesticula tions)
Face Cue s only
Audio-only
Natural hand gestures while speaking enhanced message comprehension (p < .05) Clinical Implications
• Hand gestures while speaking…
– may be of most benefit to the “gestalt” (understanding of message themes & ideas) – emphasize a natural aspect of communication (“Take what you do naturally, but do it more often”)
• Consider pre‐injury & current gestural tendencies
• Addition of hand gestures may cause speaker to modify aspects of speech in positive or negative ways that impact intelligibility – consider habitual pattern of speech
Main
Them e
Add
Com ment
Actions
Objects
Location
Accuracy in indicating Main Theme, being able to Add to Conversation, and recognize Actions mentioned were superior in Full view vs. Face cues condition Integrating Supplementation Strategies
• Most individuals with dysarthria can benefit from having multiple communication options
• Hand gestures and alphabet supplementation are not mutually exclusive strategies
• In fact, some individuals benefit similarly from both strategies 6
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Hand Gestures Vs. Alphabet Cues
Hand Gestures Vs. Alphabet Cues
(Hustad & Garcia, 2005)
(Hustad & Garcia, 2005)
100
Audio-only
A-V
70
70
40
30
Speaker A
Speaker C
Speaker A
Cue Condition by Speaker
Strategies impacted speaking rate differently...
Words Per M inute
Speaking Rate
180
160
140
120
100
80
60
40
20
0
Habitual
Gestures
AC
Speaker B
Speaker C
Cue Condition by Speaker
See & Hear Speaker (A‐V): • Similar changes to sentence intelligibility for Speakers A & C
• Both strategies benefited Speaker B (AC even more so)
Speaker A
Speaker B
No Cues
No Cues
Alphabet
Cues
No Cues
Speaker B
Gestures
Alphabet
Cues
No Cues
Gestures
Alphabet
Cues
0
No Cues
10
0
Gestures
20
10
Alphabet
Cues
20
50
No Cues
30
60
Gestures
40
Alphabet
Cues
50
Gestures
Mean Intelligibility Score
80
60
Audio-only
A-V
90
80
Gestures
Mean Intelligibility Score
90
Alphabet
Cues
100
Speaker C
Hear Speaker (Audio‐only): Intelligibility scores for alphabet cues and hand gestures did not differ from one another; benefit ranged from 8‐18% across speakers in comparison to “No Cues” condition.
Clinical Decision‐Making
Alphabet Supplementation
Hand Gestures • “Aided” strategy (you need an alphabet board)
• Requires functional literacy skills (1st letter pointing)
• Some means to indicate letter
• Rate reduction often benefits production (with trade‐off to naturalness)
• Some cognitive demands (relatively easy to learn)
• Promotes partner dependence
• “Unaided” strategy (nothing extrinsic to body)
• Must have adequate motor skills (clarity of UE gestures)
• May help maintain or contribute to naturalness–
given adequate respiratory support for speech
• Strong metacognitive skills
• Promotes partner independence
Speakers with Dysarthria
Additional Considerations or Complicating Factors in the Effective Use of Supplementation Strategies
• Attitudes and motivation to use strategies are important to outcomes
• Influencing factors
– Cognitive demands of strategy
– Perceived as less natural interaction
• Prefer to constantly repeat vs. speak slowly
• Requires board (alphabet supplementation)
– Dependency on communication partner
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Lack of Communicative Empathy?
• Mutuality of communication also involves “taking the role of the person you are communicating with”
• Communication breakdowns may reflect “failure to correctly predict the receiver’s viewpoint and to adapt to it”
(Lindblom, 1990)
Levels of Awareness
Premises:
Anticipatory
Emergent
• Intellectual awareness
provides important
foundation
• Level of awareness
impacts ability to
adapt (use strategy)
(Crosson et al., 1989)
Awareness Disorder
• May contribute to client’s inability to “carryover” strategy
• Patient may not or has limited …
– Understanding of communication breakdown
– Impact of breakdown to everyday living
– May subsequently resist use of supplementation strategy in natural settings
– Not understand strategy and/or know how or when to apply it Enhancing Awareness
• Educate/inform—make sure patient has a clear “concept or label”
• Use consistent terminology
• Provide multiple forms of feedback(e.g., audio or video, rating scales, chart, graphing of progress, and clarity with on‐line tracking/feedback) Intellectual
Importance of Listener Questions of Interest (Communication Partner)
Shares responsibility for the effectiveness of a communication interaction
“The communication partner must not only receive and interpret the acoustic signal, but also provide feedback and respond to the message.” • Do communication partners find it difficult (effortful) to listen to dysarthric speech?
• Are some listening strategies reported to be more helpful than others?
• Are communication partners supportive of a speaker’s use of supplemental strategies?
(Yorkston, Beukelman, Strand, & Hakel, 2010, p. 328)
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Listening Effort
• Intelligibility reflects percent of words correctly identified • Intelligibility does not measure the perceptual load (effort) expended in that process
Beukelman et al. (2011)
• Participants (Young Adult Listeners)
– Orthographically transcribed sentences of SIT (32 speakers with ALS)
– Rated self‐perception of attention allocation (7‐point Likert scale) for each sentence
“1” – Listening to a professional announcer over the radio
“2” – Listening to a very important message under extremely difficult listening conditions
Key Finding
• Self‐perceptions of attention allocation – Increased rapidly as speaker intelligibility decreased from 100 to 75%
– Self‐perceptions of attention allocation peaked at 75% ‐ 80% (expended the highest level of effort)
Perceived Attention Allocation (Measure of Perceptual Load)
Beukelman, D. R., Childes, J., Carrell, T., Funk, T., Ball, L. J., & Pattee, G. L. (2011). Perceived attention allocation of listeners who transcribe the speech of speakers with amyotrophic lateral sclerosis. Speech Communication, 53, 801–806. …Beukelman et al. (2011)
• Results
– Sentence intelligibility scores of speakers ranged from 3.6% to 100% – Mean ratings of attention allocation ranged from 1.7 (less attention) to 6.7 (extreme attention) Findings Highlight…
• Small changes in speaker intelligibility have important implications to communication • Clinical Interpretations
– “Half‐empty” ‐ may help explain disengagement or reluctance of some partners to interact – “Half‐full” – reinforces the importance of supplemental strategies (to minimize effort and help promote continued engagement)
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Types of Listening Strategies
Methods
Hustad, K. C., Dardis, C. M, & Dramper, A. J. (2011). Use of listening strategies for the speech of individuals with dysarthria and cerebral palsy. Augmentative & Alternative Communication, 27, 5‐15.
• 8 speakers with mild‐moderate dysarthria (75‐95% intelligibility)
• Young adults listened to audio recordings
Hustad et al. (2011) identified:
Findings highlight…
• 5 Core Listening Strategies – I tried to understand the unclear words from the context (linguistic)
– I had to concentrate on understanding the sentence (cognitive)
– I listened the first time and filled in the blanks the second time I listened (linguistic)
– I used the context to help me understand the whole sentence (linguistic)
– I used repetition of the sentence to help me remember the whole sentence (cognitive)
What are listeners’ perceptions about supplemental strategies?
• Positive attitude ratings toward alphabet cues, topic cues, and their combined use (Hustad & Gearhart, 2004)
• Positive attitude ratings for alphabet cues for person with mild dysarthria (Hustad, 2005)
• Supplementation was perceived most acceptable for more severely involved (Hanson et al., 2004)
• Higher “helpfulness” ratings when speakers used alphabet cues and also when they viewed hand gestures with speech (Hustad & Garcia, 2005)
– 10 listeners orthographically transcribed SIT sentences for one speaker
– Provided endorsement ratings for 24‐listening strategies for the same speaker afterwards (1 = strongly disagree to 4 = strongly agree) • Prominence of cognitive and linguistic strategies to listening • Listeners’ ability to recognize their use of strategies
• Results further support
– Value of context (communicating in complete thoughts/sentences vs. words)
– Importance of speaker strategies that provide additional sources of information during communication interactions
Clinical Implications
• More targeted instruction for communication partners (listening strategies)
• Reinforces the importance of talking in sentences for many speakers (use of context)
• Introducing supplementation strategies for less severely involved, especially techniques that preserve speech naturalness (promote partner‐
independence)
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…Clinical Implications
• Combining supplementation strategies may help lessen the listening burden for more severely involved speech • Help speakers with dysarthria understand the perspective of partner (listening burden) and its importance to outcomes
• Listeners adapt – use various sources of information to help understand distorted speech
Questions & Discussion
[email protected]
…References
References
Beukelman, D. R., Childes, J., Carrell, T., Funk, T., Ball, L. J., & Pattee, G. L. (2011). Perceived attention allocation of listeners who transcribe the speech of speakers with amyotrophic lateral sclerosis. Speech Communication, 53, 801–806. Beukelman, D., Taylor, S., & Ullman, C. (2013). Digital image capture and management. In N. Simons‐Mackie, J. King, & D. Beukelman (Eds). Communication support for people with aphasia. (pp. 326‐336). Baltimore, MD: Paul H. Brookes. Crosson, B., Barco, P. P., Velozo, C. A., Bolesta, M, Cooper, P. V., Wetz, D., & Brobeck, T. C. (1989). Awareness and compensation in postacute head injury rehabilitation. Journal of Head Trauma Rehabilitation, 4, 46‐54.
Crow, E., & Enderby, P. (1989). The effects of an alphabet chart on the speaking rate and intelligibility of speakers with dysarthria. In K. M. Yorkston & D. R. Beukelamn (Eds.), Recent advances in clinical dysarthria (pp. 99‐108). Boston: College Hill Press.
Garcia, J. M., & Cannito, M. P. (1996). Influence of verbal and nonverbal contexts on the sentence intelligibility of a dysarthric speaker. Journal of Speech and Hearing Research, 39,
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Garcia, J. M., & Cobb, D. S. (2000). The effects of gesturing on speech intelligibility and rate in ALS dysarthria: A case study. Journal of Medical Speech‐Language Pathology, 8, 353‐357.
Garcia, J. M., Crowe, L. K., Redler, D., & Hustad, K. (2004). Effects of spontaneous gestures on comprehension & intelligibility of dysarthric speech: A case report. Journal of Medical Speech‐Language Pathology, 12, 145‐148.
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Garcia, J. M., & Dagenais, P. A. (1998). Dysarthric sentence intelligibility: Contribution of iconic gestures & message predictiveness. Journal of Speech, Language, & Hearing Research, 41, 1282‐1293.
Hanson, E. K., Yorkston, K. M., & Beukelman, D. R., & (2004). Speech supplementation techniques for dysarthria: A systematic review. Journal of Medical Speech‐Language Pathology, 12, ix‐xxix. Hanson, E. K., Beukelman, D. R., & Yorkston, K. M. (2013). Communication support through multimodal supplementation: A scoping review. Augmentative & Alternative Communication, 29 (4), 310‐31. doi: 10.3109/07434618.2013.848934
Hanson, E. K., Beukelman, D. R., Fager, S., & Ullman, C. (2004). Listener attitudes toward speech supplementation strategies used by speakers with dysarthria. Journal of Medical Speech‐Language Pathology, 12, 161‐166.
Hustad, K. C. (2005). Effects of speech supplementation strategies on intelligibility and listener attitudes for a speaker with mild dysarthria. Augmentative & Alternative Communication, 21, 256‐263.
Hustad, K. C., Dardis, C. M, & Dramper, A. J. (2011). Use of listening strategies for the speech of individuals with dysarthria and cerebral palsy. Augmentative & Alternative Communication, 27, 5‐15.
Hustad, K. C., & Garcia, J. M. (2005). Aided and unaided speech supplementation strategies: Effect of alphabet cues and iconic hand gestures on dysarthric speech. Journal of Speech, Language, and Hearing Research, 48, 996‐1012.
…References
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Hustad, K. C., Gearhart, K. J. (2004). Listener attitudes toward individuals with cerebral palsy who use speech supplementation strategies. American Journal of Speech‐Language Pathology, 13, 168‐181.
Hustad, K. C., Jones, T., & Dailey, S. (2003). Implementing speech supplementation strategies: Effects on intelligbility and speech rate of individuals with chronic severe dysarthria. Journal of Speech, Language, and Hearing Research, 46, 462‐474.
Jones, W., Mathy, P., Azuma, T., & Liss, J. (2004). The effect of aging and synthetic topic cues on the intelligibility of dysarthric speech. Augmentative and Alternative Communication, 20, 22‐29.
Lindblom, B. (1990). On the communication process: Speaker‐listener interaction and the development of speech. Augmentative and Alternative Communication, 5, 137‐144.
Sohlberg, M. M., & Mateer, C. A. (2001). Cognitive rehabilitaion: An integrative neuropsychological approach. New York: Guilford Press.
Utianski, R. L., Lansford, K. L., Liss, J. M., & Azuma, T. (2011). The effects of topic knowledge on intelligibility and lexical segmentation in hypokinetic and ataxic dysarthria. Journal of Medical Speech‐Language Pathology, 19, 25‐36. Yorkston, K. M., Beukelman, D. R., Strand, E. A., & Hakel M. (2010). Management of motor speech disorders in children and adults (3rd ed). Austin, TX: Pro‐Ed.
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