Tapping executive function capabilities of clients with aphasia –Robert C. Marshall,
11/21/10 American Speech‐Language –
Hearing Association Convention,
The Situation
“Tapping” Executive Function p
p
Capabilities of Clients with Aphasia
• 4 SLPs are driving to ASHA in a mid‐size car. Their luggage sits on the driveway to be packed into a trunk that seems too small. Robert C. Marshall, Ph.D., F‐ASHA
University of Kentucky
Lexington, KY, USA
Human Behavior
Involves complex, integrated interplay of 3 functional systems:
• Cognition – information handling
• Emotional –
i
l feelings and motivation
f li
d
i i
• Executive – how behavior is expressed
Another Definition
• “A collection of high‐level interconnected control processes that allow us to generate, choose, organize, and regulate our goal‐
directed adaptive and non‐automatic
directed, adaptive, and non
automatic behaviors” (Phillips, 1997)
Executive Functions
• “Capacities that enable a person to engage successfully in independent, purposive, self‐
serving behavior”(Lezak et al., 2004)
Another Definition
• “Integrative cognitive processes that determine goal‐directed and purposeful behavior and are superordinate in the orderly execution of daily life functions” (Cicerone, execution of daily life functions
(Cicerone
2000)
1
Tapping executive function capabilities of clients with aphasia –Robert C. Marshall,
EF and Aphasia – Who Cares?
• Some PWA can communicate with you in spite of severe language disablements; others, seemingly less disabled, cannot.
• Some research suggests that differences in EF Some research suggests that differences in EF
exist among PWA, and that these are related to site of lesion, and impact outcomes and ability to compensate for aphasic deficits.
11/21/10 American Speech‐Language –
Hearing Association Convention,
Glosser & Goodglass (1990)
• Found PWA and frontal lobe lesions more impaired on EF tasks than those with post‐
Rolandic lesions and that impairments in EF were independent of visual‐spatial
were independent of visual
spatial and and
language deficits. Beeson et al. (1993)
Van Mourik et al. (1991)
• Found PWA impaired relative to control subjects on tests of verbal memory and that limitations in LTM were associated with anterior lesions whereas limitations in
anterior lesions, whereas limitations in working memory were associated with posterior lesions; • Memory deficits were not strongly correlated with severity of aphasia
• Found that outcomes in Global aphasia were highly related to subjects’ performance on a neuropsychological test battery. • Group 1 –
Group 1 communicate with single words
communicate with single words
• Group 2 – communicate with pictographs
• Group 3 – limited communication; little communication drive Nicholas et al. (2005)
Purdy (1994)
• Found ability of PWA to use a computerized communication system related to performance on EF tests.
• Trained 15 PWA to communicate symbols verbally, by gesture, and with a communication book. • All clients were successful in the training All clients were successful in the training
situation, but many were unable to use the alternative modes of communication, gesture and the communication book, in a functional situation. 2
Tapping executive function capabilities of clients with aphasia –Robert C. Marshall,
Purdy & Koch (2006)
• Re‐examined the performance of the 15 subjects from Purdy (2004) on the CADL using a unique method for quantifying performance, a “cognitive
a cognitive flexibility
flexibility” score. They found a score They found a
high correlation between cognitive flexibility and subjects’ performance on the Wisconsin Card Sort, a well known test of EF. Formal EF Tests
• Developed by neuropsychologists
• Usually have normative data
• Often have cutoff Of
h
ff
scores and administration guidelines
• Often referred to as frontal lobe tests
• Present the examinee with a novel task to perform
• Examinee must perform task without direction
task without direction of examiner
• Assess overlapping functions of volition, planning, purposive action, and effective performance
Planning
• Ability to organize the steps needed to complete an action;
• Ability to prepare for setbacks or difficulties in carrying out a plan;
carrying out a plan;
• Ability to assemble the needed materials and skills needed to execute a plan
11/21/10 American Speech‐Language –
Hearing Association Convention,
Assessing EF of Persons with Aphasia
• Structured approach – Formal test
• Semi‐structured approach – EF task
• Non‐structured approach ‐ Observation
Volition
• The ability to conceptualize one’s goals and form a plan to reach them;
• Capacity for intentional, goal‐directed behavior
Purposive Action
• Ability to maintain, switch, and stop sequences of complex behavior in an orderly and integrated manner. 3
Tapping executive function capabilities of clients with aphasia –Robert C. Marshall,
11/21/10 American Speech‐Language –
Hearing Association Convention,
Effective Performance
• Relates to aspects of execution of one’s actions such as self‐correction, self‐
monitoring, and the quality of the mistakes a person makes
person makes
Verbal or Non‐Verbal EF Tests?
Non‐verbal
Verbal
• Stick Design (Baiyewu et al. 2005) – examinee duplicates designs with 4 matches
t h
• Tinker Toy Test (Lezak et al., 2004) – examinee is given 50 TT pieces and told to make whatever you want.
• Homophone Meaning Generation Test (HMGT), (Crawford et al. 2002) –
examinee is given 8 i
i i
8
homophones, tick, tip, slip, form, plain, right, bored and sent. He’s asked to come up with as many meanings of the words as possible
Modifying Tests for HTT Clients
• Remove time constraints
• Simplify instructions
• Supplement verbal instructions with written i
instructions
i
• Establish method of communication that allows patient to give reliable response
• Break test into parts; give rest breaks
Information on EF Testing
•
Murray L & Rammage A (2000). Assessing the executive function abilities of adults with neurogenic communication disorders. Seminars in Speech and Language, 21, 153‐167.
•
Kiel K, & Kaszniak A (2002). Examining executive function in individuals with brain injury. Aphasiology, 16, 305‐336.
PWA are ‘Hard to Test’
• Unable to use dominant hand to draw, write, or manipulate objects
• Unable to communicate verbally
• Have difficulty understanding spoken language
diffi l
d
di
k l
• WE deficits compromise understanding/remembering of instructions
• Perceptual difficulties limit performance
Costs of Modifying Standard Procedures
• May not be able to compare patient’s performance with normal sample
• May affect patient’s performance by giving insight into the test
insight into the test
• May reduce novelty of EF task through practice effects
4
Tapping executive function capabilities of clients with aphasia –Robert C. Marshall,
Acceptable Modifications
• Select tests that limit the need to produce speech
• Use communication aids when giving instructions
• Point to test items or examples when explaining them
• Role play taking the test with another clinician
11/21/10 American Speech‐Language –
Hearing Association Convention,
Semi‐Structured Approach
Low ‐ verbal
Verbal
• Naturalistic Action Test (Schwartz et al., 2002).
• Client is given materials to perform 3 tasks, making toast with PB&J, wrapping a gift, and packing a child’s lunchbox
• Response are scored for steps accomplished and errors committed.
• Test for Functional Executive Abilities (TOFEA), (Bamdad et al. 2003). Client must call hotel, find its t ll h t l fi d it
address, phone number, hours of operation of its restaurant, and directions.
Semi‐Structured Approach
SLP uses a common task requiring EF
SLP creates her own task
• Following a recipe
• Identify normal group
• Organizing a weeks worth of • Have normal group perform pills in a ill organizer
task
• Finding your way to a certain location in the medical center
In general the SLP wants to know
• What the PWA does to spark an interaction or start a conversation?
• What the PWA does speed up information exchange?
• How the PWA clarifies misunderstandings? • If the PWA can correct inaccuracies to fulfill the primary functions of communication, requesting, rejecting, and commenting?
Non‐Structured
Observation
In a foreign country
• How does the PWA use of his/her EF capabilities solve this problem?
• Transmission of thoughts and feelings from his mind to the mind of a listener when language is impaired
• This problem is a lot like being in a foreign country where you don’t speak the l
language and cannot d
t
understand much of what you hear
Specifically, the SLP wants to know
• The kinds of words the PWA uses to start a conversation
Ron (AQ=33): “Biking”
( Q 33) “ iki ”
Clinician: “You have been riding a bike?”
Ron: “No (writes Vikings, Randy Moss, WR)”
5
Tapping executive function capabilities of clients with aphasia –Robert C. Marshall,
The Earwig Story
• If the PWA can come up with a novel strategy to convey a complex thought
Clinician: “How’s it going?”
Vern (AQ = 48): “Not good, I’ve got, I can’t tell ( Q 8) “
d ’
’ ll
you, but I can show you. It’s this.” Points to his ear. “And it’s this” (Points to his bald head), “I haven’t got any, but I could get some. Of course it wouldn’t look very good.” The car is ready to be picked up
• Select and produce an utterance that will motivate action on the part of another.
Ron (AQ=31) hears a voice mail that states his father’ss car is ready to be picked up. He opens father
car is ready to be picked up He opens
the back door and yells to his father who is working in the back yard “car, car, car.”
What’s Dad Doing?
• Can the PWA use writing/drawing to quickly convey a complex idea?
Mother: “What’s your dad been doing?”
Ron: Writes ‐
i
Ph.D h
Ph.D.
h
11/21/10 American Speech‐Language –
Hearing Association Convention,
He’s in the doghouse • Use the few words they have to express different meanings.
Clinician: “How are you today?”
li i i
“
d ?”
Barb (AQ = 51): “Brian” (uttered in a tone of anger with an appropriate facial expression)
I went to the game Saturday
• Can the PWA put things in a temporal context?
Clinician: “What’s exciting in your life?”
Mary (AQ = 39): “Football”(points to last ( Q 39) “
b ll”( i
l
Saturday on the calendar)
Karate Chop
• Does the PWA take the quickest route to communicating the information?
Clinician: “What did you do this weekend?”
Marilyn (AQ = 29) –
il ( Q 29) points to Cincinnati on the i
i i
i
h
map and makes a karate chop with her hand.
“candidate”
6
Tapping executive function capabilities of clients with aphasia –Robert C. Marshall,
Social Appropriateness
• Does the PWA use gesture, speech, drawing, and writing appropriate to the social situation?
Communication with clinician pull out all the Communication with clinician –
pull out all the
stops
Out to lunch in a restaurant ‐ pad and paper
Holliday party – Social greetings and gesture
Categories of Cognitive Flexibility
Reactive
Spontaneous
• Allows person to shift or change their behavior in response to a situation.
• Allows the person to consider alternatives, formulate ideas on his own, and adapt their plan to the d d t th i l t th
situation at hand
Things to Ponder
• Have you noticed how some PWA reflect their executive capabilities immediately?
g
• Who has gone to the bedside of a patient shortly after a stroke and had the patient immediately and effectively engage you even though he cannot speak?
• Possible we curtail use of executive capabilities by forcing verbal responses? • Could emphasis on speech rather than p
communication be harmful?
• We have not been successful in teaching compensations that can be used in context.
11/21/10 American Speech‐Language –
Hearing Association Convention,
Cognitive flexibility
• PWA that is often severe are able to do productive things to aid communication that override their scores on aphasia tests. They demonstrate cognitive flexibility
demonstrate cognitive flexibility.
• Cognitive flexibility is the ability to shift cognitive set, thought or attention to perceive, process, or respond to situations in different ways.” (Rende, 2000)
Can EF Be Treated?
• Executive functions can be “tapped” but not treated. This distinction is not trivial as suggested by the title of the seminar.
“Tapping EF”
• How do we improve, refine, and expand on what the patient does naturally to transfer thoughts and feelings from his mind to the mind of a listener? Tend the garden
7
Tapping executive function capabilities of clients with aphasia –Robert C. Marshall,
Four Important Considerations
•
•
•
•
Willingness
Automaticity
Selectivity
Appropriateness
Automaticity
• We want the patient to use his EF capabilities to facilitate communication automatically, not as a last resort. • This means the patient will draw, write, or p
,
,
gesture first.
• He will consider his listener’s needs and weigh the necessity of going through a long series of verbal struggles and self‐repairs requiring a lot of guessing in inference by the listener.
11/21/10 American Speech‐Language –
Hearing Association Convention,
Willingness
• We want the patient to be willing to communicate in a different way;
• To acknowledge and understand it may be more productive and beneficial to gesture
more productive and beneficial to gesture, point, write, draw than to speak
• The patient will be willing if there is a pay off.
Selectivity
• When speaking or writing, we want the patient to select a word or phrase to convey his thoughts and feelings that will put the listener “on
listener on track
track” rather than lead the rather than lead the
conversation astray.
Appropriateness
Vehicles for “Tapping” EF
• We want the patient to make appropriate decisions about when he/she uses gesture, writing, drawing, speaking, and pointing to communicate. communicate
• What he does should “fit” the communication context and his/personal feelings about how much to reveal.
• To “tend the garden” • Restorative treatment the clinician needs to and drill do not seem have opportunities to opportune for tapping reinforce (fertilize) the patient’s EF behaviors that facilitate capabilities.
and mildly reprimand • Conversation and group (kill weeds) those that treatment seem better are ineffective and wast
suited for this
time. 8
Tapping executive function capabilities of clients with aphasia –Robert C. Marshall,
11/21/10 American Speech‐Language –
Hearing Association Convention,
Clients that “Surprise”
Questions
• Some clients surprise us • Lezak suggests that when EF remain intact, with how well they do a person can sustain in spite of severe considerable cognitive speech and language and physical disability disablements. yet still remain • Think about what it was independent, that separated these constructively self‐
clients from the pack. serving, and productive.
• References
•
• Babbage, DR, & Leathem, JM (2001). Neuropsychological assessment difficulties associated with ‘hard to test’ individuals: a retrospective review. Brain Injury, 673‐682.
•
• Baiyewu, O. et al. (2005). The stick design test. Journal of the International Baiyewu O et al (2005) The stick design test Journal of the International
Neuropsychological Association, 11, 598‐605.
•
• Bamdad, JM, Ryan, LM,& Warden, DL (2003). Functional assessment of executive abilities following traumatic brain injury. Brain Injury, 17, 1‐11.
•
• Beeson, P., Bayles, K., Rubens, A., Kaszniak, A. (1993). Memory impairment and executive control in individuals with stroke‐induced aphasia. Brain and Language, 45, 253‐275.
References Cicerone, KD, Dahlberg, C, Kalmar K et al. (2000). Evidence‐based cognitive Rehabilitation: recommendations for clinical practice. Archives of Physical Medicine and Rehabilitation, 81, 1596‐1615.
Glosser, G., Goodglass, H. (1990). Disorders of executive control functions among aphasic and other brain‐damaged patients. Journal of Clinical and Experimental Psychology, 12, 485‐501.
Keil, K., Kaszniak, A. (2002). Examining executive function in individuals with brain injury. Aphasiology, 16, 305‐336.
Lezak, M., Howieson, D., Loring, J. (2004). Neuropsychological assessment. (4th Ed.). New York: Oxford.
Murray, L., Ramage, A. (2000). Assessing the executive function abilities of adults with neurogenic communication disorders. Seminars in Speech and Language 21, 153‐168.
References
Nicholas, M., Sinotte, M., Helm‐Estabrooks, N. (2005). Using a computer to communicate: Effect of executive function impairments in people with severe aphasia. Aphasiology, 19, 1052‐
1065.
Phillips, L. H. (1997). Do “frontal tests” measure executive function? I
Issues of assessment and evidence from fluency tests. In P. Rabbit f
d id
f
fl
I P R bbi
(Ed.) Methodology of frontal and executive function (pp. 191‐213). Hove, UK: Psychology Press.
Purdy, M. (2002). Executive function ability in aphasia. Aphasiology, 16, 549 ‐557.
Purdy, M., Koch, A. (2006). Prediction of strategy use by adults with aphasia. Aphasiology, 20, 337‐348.
References
Rende, B. (2000). Cognitive flexibility: Theory, assessment, and treatment. Seminars in Speech and Language, 21, 121‐122.
Schwartz, MF, et al. (2002). The naturalistic action test: a standardized assessment for everyday action impairment. d di d
f
d
i i
i
Neuropsychological rehabilitation, 12, 311‐339.
Van Mourik, C., et al. (1991). Cognitive in global aphasia: indicators for therapy. Aphasiology, 6, 491‐500.
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