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Self-Reported and Partner-Reported FunctionalCommunication and Their Relation to Languageand Non-Verbal Cognition in Mild to ModerateAphasiaPaula J. MessamerUniversity of Colorado at Boulder, [email protected]

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Recommended CitationMessamer, Paula J., "Self-Reported and Partner-Reported Functional Communication and Their Relation to Language and Non-VerbalCognition in Mild to Moderate Aphasia" (2016). Speech, Language, and Hearing Sciences Graduate Theses & Dissertations. 36.https://scholar.colorado.edu/slhs_gradetds/36

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SELF-REPORTEDANDPARTNER-REPORTEDFUNCTIONALCOMMUNICATIONAND

THEIRRELATIONTOLANGUAGEANDNON-VERBALCOGNITIONINMILDTOMODERATE

APHASIA

by

PAULAJ.MESSAMER

B.A.,UniversityofCalifornia,LosAngeles,1986

M.A.,UniversityofColorado,Boulder,1991

Athesissubmittedtothe

FacultyoftheGraduateSchoolofthe

UniversityofColoradoinpartialfulfillment

oftherequirementsforthedegreeof

DoctorofPhilosophy

DepartmentofSpeech,LanguageandHearingSciences

2016

Thisdissertationentitled:

SELF-REPORTEDANDPARTNER-REPORTEDFUNCTIONALCOMMUNICATIONANDTHEIRRELATIONTO

LANGUAGEANDNON-VERBALCOGNITIONINMILDTOMODERATEAPHASIA

writtenbyPaulaJ.Messamer

hasbeenapprovedforthe

DepartmentofSpeechLanguageandHearingsSciences

GailRamsberger,Sc.D.(chair)

PuiFongKan,Ph.D.

NeerajaSadagopan,Ph.D.

ClaytonLewis,Ph.D.

AnneWhitney,Ed.D.

February26,2016

Thefinalcopyofthisthesishasbeenexaminedbythesignatories,andwefindthatboththe

contentandtheformmeetacceptablepresentationstandardsofscholarlyworkinthe

above-mentioneddiscipline.

HRCprotocol#14-0353

ABSTRACT

PaulaJ.Messamer(Ph.D.Speech,LanguageandHearingSciences)

Self-andpartner-reportedfunctionalcommunicationandtheirrelationtolanguage

andnon-verbalcognitioninmildtomoderateaphasia

DirectedbyGailRamsberger,AssociateProfessorandChair,DepartmentofSpeech

LanguageandHearingSciences,UniversityofColoradoatBoulder

Purpose:Non-verbalcognitionandlanguagefunctionswereexaminedinadultstroke

survivorswithaphasia.Thespecificpurposeofthestudywastwofold:1)toexaminethe

relationshipbetweenself-reportedoutcomesfrompeoplewithaphasia(PwA),measuresof

non-verbalcognition(Delis-KaplanExecutiveFunctionSystemsTest(D-KEFS),Delis,

Kaplan,&Kramer,2001)andmeasuresoflanguage(WesternAphasiaBattery-Revised

(WAB-R),Kertesz,2007;BostonNamingTestSecondEdition(BNT-2),Kaplan,Goodglass,&

Weintraub,2001)and2)toexaminethesesamerelationshipsusingpartner-reported

outcomesforthatsamegroupofPwA.ThisstudyusedtheAphasiaCommunication

OutcomeMeasure(ACOM,Doyleetal.,2013)togatherbothself-reportedACOMdataand

partner-reportedACOMdata(ratingsofthepersonwithaphasia’scommunicationmadeby

aregularconversationpartner).

Method:Seventeenparticipantswithaphasiaunderwentexaminationwithanextensive

testbatteryincludingmeasuresoffunctionalcommunication,non-verbalcognition,and

languageimpairment.Inaddition,16oftheirregularcommunicationpartnersrated

functionalcommunicationperformance.

Results:Self-reportedfunctionalcommunicationisstronglyrelatedtothenumberof

errorscommittedontheD-KEFSdesignfluencytest(r=.81,p=.001).Furthermore,a

modifiedformoftheD-KEFSdesignfluencytest(inwhichtheexamineeisallowed

unlimitedtime)showsthattheproportionoferrorscontributessignificantlytoatwo-

predictorlinearregressionmodel.Thesetwopredictorsaccountfor66%ofthevariancein

self-reportedfunctionalcommunicationratings.Theseresultssuggestthatnon-verbal

cognitionforpeoplewithmildtomoderateaphasiamayserveanimportantrolein

functionalcommunication.Bycontrast,self-reportedfunctionalcommunicationwas

uncorrelatedwithaphasiaseverity(r=.04,p=.88),namingperformanceoneitherthe

WAB-R(r=.059,p=.823)ortheBNT-2(r=.097,p=.713),andcategoryfluency(r=.086,

p=.741).

Partner-reportedfunctionalcommunicationwashighlycorrelatedtothenaming

subtestonWesternAphasiaBattery-Revised(WAB-R)scores(r=.71,p=.02)andto

performanceontheBostonNamingTest(BNT-2;r=.56,p=.026).Partner-reported

functionalcommunicationwasalsostronglypredictedbasedonthenumberofanimals

namedduringthecategoryfluencytaskontheWAB-R(r=.782,p=.000).Alinear

regressionmodelincludingWAB-Rcategoryfluencyaccountedfor61.1%ofthevariancein

partner-reportedratings.Asecondlinearregressionaddingnamingasapredictorwasnot

significant(Fchange=2.18,p=.163).Bycontrast,noneofthenon-verbalcognitionmeasures

wereusefulpredictorsofpartner-reportedfunctionalcommunication.Theseresults

suggestthataphasiaseverityservesanimportantroleinpartnerratingsoffunctional

communicationwhereasnon-verbalcognitiondoesnot.

Takentogether,theseresultssuggestthatPwAandtheirpartnersrelyondifferent

aspectsofcommunicationwhenjudgingfunctionalcommunication.

Furtherworktoexploretheuseofpatient-reportedoutcome(PRO)measuresandto

identifyfactorsthatcontributetoself-reportedfunctionalcommunicationisneeded.The

discussionaddressestheappropriatenessofusingPROmeasuresinaphasiaandtheuseof

surrogatereports.

Keywords:Aphasia,patient-reportedoutcomes,partner-reportedoutcomes,

functionalcommunication,non-verbalcognition,languageimpairment

vi

DEDICATION

Thisdissertationisdedicatedtomyhusband,FrankEparvier.Yourunwavering

supportandencouragementhasmeantsomuchtome.Withoutit,Iwouldneverhave

succeededatthisendeavor.Let’sgohavesomefun.

vii

ACKNOWLEDGEMENTS

Thankyoutothemembersofmydoctoralcommittee,Drs.PuiFongKan,Clayton

Lewis,NeerajaSadagopan,andAnneWhitney,foryoursupportduringmydoctoral

program.Thankyoutothechairofmycommittee,Dr.GailRamsberger,forherguidancein

mentoringmethroughoutmydoctoralstudies.

ThankyoutotheSpeech,Language,HearingSciencesdepartmentandtotheDeanof

theGraduateSchoolforprovidingfinancialsupporttopaymyresearchparticipantsandto

covertravelexpensesduringmydatacollection.

Thankyoutothepeoplewithaphasiaandtheirpartnersforparticipatinginmy

study.IwouldnothavefoundeveryonewithoutthehelpofnumerousSLPsinDenver,CO,

Minneapolis,MN,andtheSnyderCenterforAphasiaLifeEnhancement(SCALE)in

Baltimore,MD.

Thankyoutomycrazygroupoffriends:“TheRanchers”whohaveprovidedsafe

havenfromalltheinsanitiesoflife.

Finally,thankyoutomysmoogie-boo.Youarethemostamazingpartnerandfriend.

IknowyoulookforwardtothisbeingoverjustasmuchasIdo.

viii

TABLEOFCONTENTS

CHAPTER1:INTRODUCTION.............................................................................................................1

CHAPTER2:BACKGROUNDANDSIGNIFICANCE.........................................................................5

LINGUISTICIMPAIRMENTSINAPHASIA................................................................................................................5

Measuringlinguisticimpairments................................................................................................................6

COGNITIVEIMPAIRMENTSINAPHASIA.................................................................................................................8

Measuringcognitionimpairmentsinaphasia.........................................................................................8

MEASURINGFUNCTIONALCOMMUNICATIONINAPHASIA.............................................................................10

PATIENTREPORTEDOUTCOMEMEASURES.......................................................................................................12

BarrierstotheuseofPROmeasuresinaphasia...................................................................................13

TypesofPROmeasuresinaphasia.............................................................................................................14

StrokespecificPROmeasures.......................................................................................................................15

AphasiaspecificPROmeasures....................................................................................................................16

FindingsfromstudiesusingPROmeasures............................................................................................16

WHYACOM?.........................................................................................................................................................16

Proxyreportasasubstituteforself-report............................................................................................18

ProxyReportasaComplementtoSelf-Report......................................................................................21

SUMMARYANDHYPOTHESES...............................................................................................................................22

CHAPTER3:METHODSANDPROCEDURE...................................................................................24

PARTICIPANTS........................................................................................................................................................24

DEMOGRAPHICS.....................................................................................................................................................26

ix

WesternAphasiaBattery-Revised...............................................................................................................26

ASSESSMENTS.........................................................................................................................................................30

AphasiaCommunicationOutcomeMeasure..........................................................................................30

BostonNamingTest(SecondEdition)......................................................................................................31

D-KEFSDesignFluencyTest..........................................................................................................................31

D-KEFSVerbalFluencyTest..........................................................................................................................33

D-KEFSTwentyQuestionsTest....................................................................................................................34

D-KEFSCardSortTest.....................................................................................................................................36

TorranceTestofCreativeThinking...........................................................................................................36

PROCEDURE............................................................................................................................................................37

AphasiaCommunicationOutcomeMeasure..........................................................................................38

BostonNamingTest(SecondEdition)......................................................................................................40

D-KEFSDesignFluencyTest..........................................................................................................................40

D-KEFSVerbalFluencyTest..........................................................................................................................42




CHAPTER4:RESULTS.........................................................................................................................46

DESCRIPTIVESTATISTICS.....................................................................................................................................46

Self-ratedandPartner-ratedAphasiaCommunicationOutcomeMeasure..............................46

BostonNamingTest..........................................................................................................................................47

D-KEFSDesignFluency-StandardAdministration.............................................................................48

D-KEFSDesignFluency-UntimedAdministration...............................................................................50

D-KEFSVerbalFluency....................................................................................................................................52


x



HYPOTHESESRELATEDTOSELF-REPORTEDFUNCTIONALCOMMUNICATION.........................................55

Hypothesis1a:Selfreportedfunctionalcommunicationwouldbecorrelatedwithaphasia

severity....................................................................................................................................................................................55

Hypothesis1B:Self-reportedfunctionalcommunicationwouldbecorrelatedwith

cognition.................................................................................................................................................................................56

Hypothesis1C:Alinearregressionmodelpredictingself-reportedfunctional

communicationusingbothaphasiaseverityandcognitionwouldaccountforsignificantlymore

variancethanamodelusingaphasiaseverityalone..........................................................................................58

HYPOTHESESRELATEDTOPARTNER-REPORTEDFUNCTIONALCOMMUNICATION................................60

Hypothesis2a:Partner-reportedfunctionalcommunicationwouldbecorrelatedwith

self-reportedfunctionalcommunication..................................................................................................................60

InterraterAgreement(kappa)betweenSelf-ratedandPartner-ratedACOMscores..........60

Hypothesis2B:Partner-reportedfunctionalcommunicationwouldbecorrelatedwith

aphasiaseverityandcognition.....................................................................................................................................62

Partner-ratedACOMscorecorrelationstolanguage.........................................................................62

Partner-ratedACOMscorecorrelationstocognition........................................................................63

Hypothesis2C:Alinearregressionmodelpredictingpartner-reportedfunctional



SUMMARYOFRESULTS.........................................................................................................................................66

CHAPTER5:DISCUSSION...................................................................................................................67

HYPOTHESESRELATEDTOSELF-REPORTEDFUNCTIONALCOMMUNICATION............................................67

xi

Hypothesis1a.Selfreportedfunctionalcommunicationwouldbecorrelatedwithaphasia

severity....................................................................................................................................................................................67

Hypothesis1B.Self-reportedfunctionalcommunicationwouldbecorrelatedwith

cognition.................................................................................................................................................................................69

DesignFluencyasaPredictor.......................................................................................................................69

TwentyQuestionsTestasaPredictor.......................................................................................................70

Hypothesis1C.Alinearregressionmodelpredictingself-reportedfunctional



HYPOTHESESRELATEDTOPARTNER-REPORTEDFUNCTIONALCOMMUNICATION...................................72

Hypothesis2a.Partner-reportedfunctionalcommunicationwouldbecorrelatedwith

self-reportedfunctionalcommunication..................................................................................................................72

Hypothesis2b.Partner-reportedfunctionalcommunicationwouldbecorrelatedwith

aphasiaseverityandnon-verbalcognition.............................................................................................................73

Hypothesis2c.Alinearregressionmodelpredictingpartner-reportedfunctional



IMPLICATIONS........................................................................................................................................................75

STUDYLIMITATIONS.............................................................................................................................................76

GENERALCONCLUSIONS.......................................................................................................................................77

REFERENCES..........................................................................................................................................80

FIGURES..................................................................................................................................................92

APPENDIXA:SAMPLEPROCEDURE...............................................................................................99

APPENDIXB:ACOMQUESTIONS..................................................................................................100

xii

APPENDIXC:D-KEFSTWENTYQUESTIONSITEMGROUPINGS.........................................103

APPENDIXD:MODIFIEDINSTRUCTIONS..................................................................................104

OVERVIEW.............................................................................................................................................................104

xiii

LISTOFTABLES

Table1.Participantcharacteristics...............................................................................................................28

Table2.WAB-AQandsubtestscores...............................................Error!Bookmarknotdefined.

Table3PwAandPartnerACOMscores.......................................................................................................47

Table4.PercentcorrectnamingonBostonNamingTest(BNT-2).................................................48

Table5.D-KEFSDesignFluencydataforStandardAdministration...............................................50

Table6.D-KEFSDesignFluencydataforUntimedAdministratio...................................................52

Table7.D-KEFSVerbalFluencydata............................................................................................................53

Table8.D-KEFSTwentyQuestionsdata.....................................................................................................54

Table9.PearsoncorrelationsforSelf-reportedACOMscoresandWAB-R(withsubtests)

andBNT-2measures..................................................................................................................................56

Table10.CorrelationmatrixforSelf-ratedACOMandcognitionscores......................................57

Table11.BreakdownofparticipantsaccordingtocognitionlevelandACOMscores............60

Table12.Cohen’skappascoresforeachPwA-Partnerpair...............................................................61

Table13.CorrelationmatrixforPartner-reportedACOMscoresandlanguagemeasures..63

Table14.CorrelationmatrixforPartner-reportedACOMscoresandcognitivemeasures..64

xiv

LISTOFFIGURES

Figure1.ExampleofD-KEFSDesignFluencytask.................................................................................92

Figure2.ScatterplotsofACOMself-ratings(left)andACOMpartner-ratings(right)asa

functionofWAB-Rcategoryfluencyscore..........................Error!Bookmarknotdefined.

Figure3.ScatterplotsofACOMself-ratings(left)andACOMpartner-ratings(right)asa

functionofWAB-Rnamingscore.............................................Error!Bookmarknotdefined.

Figure4.Scatterplotofself-reportedACOMratingsinrelationtothenumberoferrorson

theD-KEFSDesignFluencyTest..............................................Error!Bookmarknotdefined.

Figure5.Scatterplotofself-reportedACOMratingsinrelationtotheproportionoferrors

ontheuntimedadministrationoftheD-KEFSDesignFluencyTest....Error!Bookmark

notdefined.

Figure6.Scatterplotofself-reportedACOMversuspartner-reportedACOMscores.Error!

Bookmarknotdefined.

Figure7.ScatterplotofWAB-AQtoACOMT-Scores................Error!Bookmarknotdefined.

1

CHAPTER1:

INTRODUCTION

Aphasiaisanacquiredlanguagedisorderresultingfrombraindamage.Aphasiacan

occurfollowingstroke,braininjury,tumor,degenerativedisease,etc.Approximately

100,000newcasesofaphasiaoccurannuallyintheU.S.(NationalInstituteonDeafnessand

OtherCommunicationDisorders,2008)andmorethan1millionAmericansarelivingwith

aphasia(NationalAphasiaAssociation,2016).Thecommunicationdeficitsthatoccurfrom

aphasiaaffectspeaking,comprehension,reading,and/orwriting.

Inadditiontocompromisedlanguageabilities,peoplewithaphasia(PwA)

frequentlypresentwithcognitivedeficitsaffectingattention(Erickson,Goldinger,&

LaPointe,1996,Korda&Douglas,1997;LaPointe&Erickson,1991;Laures,Odell,&Coe,

2003;Murray,Holland,&Beeson,1998),workingmemory(Caspari,Parkinson,LaPointe,&

Katz,1998;Christensen&Wright,2010;Murray,2012;Wright,Downey,Gravier,Love,&

Shapiro,2007)andexecutivefunction(Fridriksson,Nettles,David,Morrow,&

Montgomery,2006),whichmayalsocontributetotheirproblemswithcommunication.

AlthoughPwAcanbeactive,productivemembersoftheirfamiliesandcommunities,

therearesignificantpersonalandsocietalcostsassociatedwithacquiredneurogenic

changesincommunication.Theseincludelossofproductivity(Ownsworth&Shum,2008),

reducedfunctionalindependence(Simmons-Mackie,Threats,&Kagan,2005)andchanges

inself-identity(Simmons-Mackie&Elman,2011).Mostpeoplewhoacquireaphasianever

2

returntowork(Morris,Franklin,&Menger,2011).Peoplewhowereoncevoracious

readersmaybeunabletoreadevensimpletexts.Peoplewhoenjoyedpublicspeakingor

activeconversationsmaybeunabletocontributetoconversations(atleastatthelevelof

interactiontheyonceenjoyed).

Giventhepersonalandsocietalimpactsofaphasia,greatemphasisisbeingplaced

onoutcomemeasuresthatreflectimprovementsineverydayfunctionandqualityoflife.

Accordingtothepatient-centeredcaremodel,patientsshouldplayanactiverolein

evaluatingthequalityandeffectivenessofthecaretheyreceiveandindecidinggoalsfor

treatment(Davis,Schoenbaum,&Audet,2005).Thatis,theindividualwithaphasiashould

beregardedastheultimatejudgeofhis/herownqualityoflifebecausepatientexperience

isconsideredamoresensitiveandspecificmeasureofimportanttherapeuticeffects,and

self-reportmayrevealdisabilityanddiseaserelatedlifelossesmuchmoreaccuratelythan

conventionalassessmentsofimpairment(e.g.abilitytowalk,performanceonlanguage

tests).

Itfollowsthatcollectingdataonthepatient'sviewsoftheirownoutcomesisan

increasinglyimportantpartofthehealthcaredeliveryprocess(AmericanSpeechHearing

Association,2013;Irwin,2012;Rao,2015;)andtheuseofpatient-reportedoutcome(PRO)

measuresiskeytounderstandingtheimpactofaphasiafromtheperspectiveoftheperson

withaphasia(Chue,Rose,&Swinburn,2010).Patient-reportedoutcomes(PROs)are

outcomesreporteddirectlybythepatientconcerningtheiroverallfunctioningandsenseof

wellbeing(Threats,2012;U.S.FoodandDrugAdministration,2016).

Priorresearchhasshownthatcommunicativefunctioningisonlypartiallyexplained

bytheleveloflanguageimpairment.Furthermore,evidencesuggeststhat,inadditionto

3

language,theremaybeexplanatoryvalueinalsousinglevelofcognitiveimpairmentasa

predictorofcommunicativefunction.Thisstudylooksatwhethermeasuresofcognition

canbeusedtopredictself-reportedfunctionalcommunication.

Inaddition,becausepost-strokedeficitsandaphasiamaypreventsomepeoplefrom

providingtheirownself-reports,itiscommontorelyonsurrogatereportsfromregular

communicationpartners(e.g.family,friends,andcaregivers).Thisstudy,therefore,looks

atwhetherpartner-reportedfunctionalcommunicationis1)correlatedwithself-reported

functionalcommunicationand2)whetherpartner-reportedfunctionalcommunicationis

associatedwiththesamelanguageandcognitionpredictorsasself-reportedfunctional

communication.

ChapterIIprovidesareviewoftheliterature.Theaimsoftheliteraturerevieware:

1) Toprovidebackgroundabouttherelationshipofimpairment-basedmeasuresof

aphasia,cognitionandfunctionalcommunicationmeasures.

2) TodescribetheuseandvalueofPROmeasuresingeneralandinthecontextof

strokeandaphasia.

3) ToaddressissuesspecifictotheuseofPROmeasuresinaphasia

4) ToaddressissuesspecifictotheuseofsurrogatePROmeasuresinaphasia

Theremainingchapterspresentaresearchstudy.Theaimsofthisresearchstudyare:

1) Toreplicatepreviousfindingsshowingthatself-reportedandpartner-reported

functionalcommunicationarestronglyrelated.

2) Toexploretherelationshipbetweenself-reportedfunctionalcommunicationand

4

measuresofcognition.

3) Toexploretherelationshipbetweenpartner-reportedfunctionalcommunication

andmeasuresoflanguageandcognition.

5

CHAPTER2:

BACKGROUNDANDSIGNIFICANCE

LINGUISTICIMPAIRMENTSINAPHASIA

Aphasiaisanacquiredneurogeniclanguagedisorderwhichresultsfrominjuryto

theareasofthebraininvolvedinlanguage.Aphasiaisnotasingledisorder,butinsteadisa

familyofdisordersthatinvolvevaryingdegreesofimpairmentacrosslanguagemodalities

(AmericanSpeech-Language-HearingAssociation,2016).

Thesignsandsymptomsofaphasiavarywidelyacrossindividualsdependingonthe

locationandextentoftheirbraindamage(Kagan,Black,Duchan,Simmons-Mackie,&

Square,2001).Languageimpairmentsincludedisturbancesofreceptiveandexpressive

abilitiesaffectingspokenlanguageoutput,spokenlanguagecomprehension,written

expressionandreadingcomprehension(ASHA,2016).

Impairmentsofverbalexpressionincludeanimpairedabilitytoexpressthoughts

usingasmooth,uninterruptedflowandrateofspeech;difficultyfindingwords,difficulty

namingobjects;speakinginsinglewords,speakinginshortfragmentedphrases,omitting

shortwordslike“the”,“of”,and“was”;aninabilitytorepeatwhatsomeoneelsehassaid;

substitutingsoundswithinwords;substitutingonewordforanother(e.g.“yes”for“no”);

makingupnewwords;stringingtogetherrealormade-upwordsintonon-informative

sentences.

6

Impairmentsofauditorycomprehensionincludedifficultyunderstandingspoken

utterances;providingunreliableanswerto"yes/no"questions;failingtounderstand

complexgrammar(e.g.,Thefarmerwaschasedbythecow.);requiringextratimeto

understandspokenmessagesandfindingitveryhardtofollowfastspeech(e.g.,radioor

televisionnews);misinterpretingsubtletiesoflanguage(e.g.,takestheliteralmeaningof

figurativespeechsuchas"It'srainingcatsanddogs.");andalackofawarenessoflanguage

deficits.

Impairmentsofwriting(agraphia)includedifficultywritingorcopyingletters,

words,andsentences;writingonlysinglewords;substitutingincorrectlettersorwords;

spellingorwritingnonsensesyllablesorwords;writingrun-onsentencesthatdon'tmake

sense;andwritingsentenceswithincorrectgrammar.

Impairmentsofreading(alexia)includedifficultycomprehendingwrittenmaterial;

difficultyrecognizingwordsbysight;inabilitytosound-outwords;substitutingassociated

wordsforaword;difficultyreadingnon-contentwords(e.g.,functionwordssuchasto,

from,the).

Thesignsandsymptomsdisplayedbyagivenindividualvarybasedonsituation,

partner,andtopic.Forexample,agivenindividualseeminglymayhavenodifficultieswhen

chattingwithfamiliarpartnersbutshowsignificantslowingorwordfindingproblems

whenconversationtopicsaremorecomplexorunfamiliar.

MEASURINGLINGUISTICIMPAIRMENTS

Assessmentofaphasiaiscompletedinanumberofwaysandusingarangeof

assessmentmeasures.Insomecases,anentirestandardizedtestbatteryisadministered.In

othercases,aclinicianmaygiveselectedsubtestsfromstandardizedtestbatteriesinorder

7

toprovidesubjectivedescriptionsofaperson'sfunctioning.Inothercases,

nonstandardizedtoolsdevelopedbytheclinicianareusedtoprobeaspectsofspeech,

language,andcognition(ASHA,2016).

Thedecisiontousestandardizedornonstandardizedassessmentproceduresis

determinedbytheclinicianbaseduponavarietyoffactors,includingtheneedsofthe

personwithaphasia,thecomplexityofimpairment,payerrules,facilitypolicy,andother

considerations.Whentimeandbillingconstraintslimitthetimeallowedforassessment,

screeningtestssuchastheBedsideEvaluationScreeningTest(BEST-2;West,Sands,&

Ross-Swain1998)areoftenused.Screeningsservetoidentifypatientswhoshouldbefully

evaluatedtodetermineifthereisadisorderbutdonotprovidesufficientdatatofully

characterizeit.

Inresearch,aphasiaistypicallyassessedusingastandardizedtestbatteryshownto

havestrongpsychometricpropertiessuchashighinter-andintra-raterreliability.These

assessmentsdiagnoseandgraderelativestrengthsandweaknessesacrossthelanguage

andcognitiveareasaffectedbyaphasia.ExamplesofsuchassessmentaretheWestern

AphasiaBattery-Revised(WAB-R,Kertesz,2007),theBostonDiagnosticAphasia

Examination(BDAE;Kaplan,1983),andthePorchIndexofCommunicativeAbility(PICA;

Porch,1971).

TheWAB-Rwasselectedasthemeasureoflanguageforthisresearchstudybecause,in

additiontoestimatingoverallaphasiaseverity(WAB-AphasiaQuotientorAQ),italso

providesdifferentialdiagnosisofaphasiatypeandprovidesaprofileofgeneralstrengths

andweaknessesinasubsetofareasincludingfluency,auditorycomprehension,and

naming.Spontaneousspeechisassessedviaresponsestopersonalquestionsandthe

8

patient’sdescriptionofalinedrawing.Spontaneousspeechisratedontwo10-pointscales:

informationcontentandfluency,whichincludesgrammaticalcompetenceandpresenceof

paraphasias.Comprehensionisassessedbasedonresponsestoyes/noquestions(thatmay

beansweredineitherverbalornonverbalfashion),byphysicalresponsestospokenwords

(touchthepen);andbyphysicalresponsestosequentialcommands(e.g.pickupthepen

andthenturnoverthebook).Repetitionisassessedusing15progressivelylongeritems

thatarescoredascorrect,partiallycorrect(duetopresenceofphonemicerrors)oras

completeerrors.Thenamingscoreiscomprisedofobjectnaming(withoutcuingor,if

necessary,withtactileand/orphonemiccuing),categoryfluency(numberofanimals

namedin60seconds),sentencecompletion,andresponsivespeech.

COGNITIVEIMPAIRMENTSINAPHASIA

Separatefromlanguagedeficits,PwAalsoshowimpairmentsontestsofcognition

includingattention(Erickson,Goldinger,&LaPointe,1996;Korda&Douglas,1997;

LaPointe&Erickson,1991;Lauresetal.,2003;Murray,Holland,&Beeson,1998;Murray,

2012;Robin&Rizzo,1989),workingmemory(Caspari,Parkinson,LaPointe,&Katz,1998;

Christensen&Wright,2010;Wright,Downey,Gravier,Love,&Shapiro,2007),executive

function(Fridriksson,Nettles,Davis,Morrow,&Montgomery,2006)andprocessingspeed

(Gerritsen,Berg,Deelman,Visser-Keizer,&Jong,2003;Neto&Santos,2012).

MEASURINGCOGNITIONIMPAIRMENTSINAPHASIA

Becauseofthelanguagedeficits,assessmentmeasuresintendedfornon-aphasic

populationsmaybetoolinguisticallycomplexforPwA.Forthisreason,researchershave

employedtasksdesignedtoassesscognitionwhileminimizingorreducinglanguage

9

demands.ExamplesincludetheWisconsinCardSortingTest(Baldo,Dronkers,Wilkins,

Ludy,Raskin,&Kim,2005;Grant&Berg,1993;Fridrickssonetal.,2006;Hinckley&Carr,

2001;LambonRalph,Snell,Fillingham,Conroy,Sage,2010;Purdy,2002;),theTowerof

HanoiandTowerofLondontests(Purdy,2002),theRavensColoredProgressiveMatrices

(Hinckley&Carr,2001;Raven,1962),PyramidsandPalmTrees(LambonRalphetal.,

2010),theTestofEverydayAttention(Robertson,Ward,Ridgeway,&Nimmo-Smith,

1996),theRey-OsterreithComplexFigure(Keil&Kazniak,2002),andthePorteusMazes

(Murray,2012;Porteus,1959;Purdy,2002).

Evidencesuggeststhatcognitionandlanguageimpairmentsoperateindependently

ofoneanother(Helm-Estabrooks,2002;Hinckley&Nash,2007).Thatis,PwAsometimes

haveimpairmentsoncognitivetasksthatarenotconsistentlyrelatedtoaphasiaseverity.

Inaddition,thereisahighdegreeofvariabilityincognitiveperformanceacross

individuals(Hinckley&Nash,2007).Forexample,Murray(2012)foundthatasagroup

PwAperformedsignificantlyworsethananeurologicallyunimpairedcontrolgroupon

cognitivemeasuresbutthatwithinthegrouptherewaslargevariabilityinthepresence,

types,andseverityofindividual’sattentionandothercognitivedeficits.

Furthermore,evidencesuggeststhatthatpoorercognitivestatusleadstopoorer

treatmentoutcomes.LambonRalphetal.(2010)showedthathigherperformanceontests

oflanguageandcognitiveabilitybeforetreatmentwasassociatedwithlargergainsfrom

anomiatherapy.Fillingham,Sage,andLambonRalph(2005a,2005b;2006)showedthat

pre-treatmentmeasuresofexecutivefunction(WisconsinCardSortTask,WCST;Grant&

Berg,1993)andself-monitoringskillspredictedparticipants’responsetotreatment.

Similarly,Seniów,Litwin,&Leśniak(2009)showedthatvisuo-spatialworkingmemory

10

waspositivelyassociatedimprovementinnamingandcomprehension(althoughno

relationshipwasfoundbetweenlanguagetherapyoutcomeandabstractthinkingability).

TheDelis-KaplanExecutiveFunctionSystemstest(D-KEFS;Delis,Kaplan,&Kramer,

2001)isdesignedfortheassessmentofexecutivefunctions(Homack,Lee,&Riccio,2005).

Thesubtestsassessavarietyofareasincludingflexibilityofthinking,inhibition,problem

solving,planning,impulsecontrol,conceptformation,abstractthinking,andcreativity.The

D-KEFSwasselectedasthemeasuresofcognitionforthisstudybecauseitincludeda

numberoftasksthathadminimallanguagedemandsanditwasnormedonalarge

representativesampleofneurologicallyunimpairedpeople(ages8to89).Afterreviewing

the9subtestsinthefullD-KEFStestingbattery,4wereselectedforinclusioninthis

researchstudy:VerbalFluency,DesignFluency,CardSorting,andTwentyQuestions(TQT).

TheremainingsubtestswereomittedduetoevenhighlinguisticdemandsthanVerbal

FluencyandTQT(WordContext;Color-WordInterference,ProverbTest),physical

demands(TowerTest)ortimerestrictions(TrailMakingTest).

MEASURINGFUNCTIONALCOMMUNICATIONINAPHASIA

Impairmentmeasures(suchasthosedescribedinthepriortwosections)helpto

characterizedeficitsbutfunctionalcommunicationisonlypartiallydeterminedbythe

impairmentsofaphasia.Functionalcommunicationalsodependsuponfactorssuchas

communicationpartners,motorskills,communicationneedsandcontext.Thismeansthat

impairmentmeasuresalonemaynotprovidevalidinformationaboutanindividual’sday-

to-dayfunction.

11

Functionalcommunicationisdefinedasthe‘abilitytoreceiveortoconveya

message,regardlessofthemode,tocommunicateeffectivelyandindependentlyinagiven

[natural]environment’(Frattali,Thompson,Holland,Wohl,&Ferketic,1995,p.12).

Functionalcommunicationassessmentmethodshaveincludeddirectmeasurementof

communicationbehaviors,indirectreportsbytrainedanduntrainedobservers,and

reportsfromPwA(self-reports).Directmeasuresoffunctionalcommunicationthat

maintainanaturalenvironmentaredifficulttoachieve.Ramsberger(2005)reportedona

measureofconversationalsuccessinwhichshecodedhowmuchinformationapartner

wasabletogleanfromaconversationwiththePwAabouttheplotlinefromatelevision

show(“ILoveLucy”).Whilethisiscertainlyanexampleoffunctionalcommunication,it

doesnotcoverthebroadspectrumofbehaviorsthatconstitutefunctionalcommunication

initsentirety.Indirectmeasuresoffunctionalcommunicationaremorecommonand

includeestimatesoffunctionalcommunicationprovidedbytherapists,caregivers,and

familymembers.Thesemeasuresalsosometimesrelyonretrospectivereportsof

communicativebehaviors.

Clinician-providedestimatesoffunctionalcommunicationincludethe

CommunicativeActivitiesofDailyLiving-2(CADL-2)(Holland,Frattali,&Fromm,1998),

AmericanSpeechLanguageHearingAssociationAssessmentofFunctionalCommunication

SkillsforAdults(ASHA-FACS)(Frattali,Thompson,Holland,Wohl,&Ferketic,1995),and

theTherapyOutcomeMeasure(TOM)(John&Enderby,2000).Tocompletethe

CommunicationActivitiesofDailyLiving-2(CADL-2;Holland,Frattali,&Fromm,1998),an

observerassesssevencategoriesofverbalandnon-verbalcommunicationduringrole-play

offamiliarsituations(e.g.,shoppingormakingatelephonecall).Categoriesinclude:social

12

interaction,divergentcommunication,contextualcommunication;sequentialrelationships,

nonverbalcommunication,reading,writingandusingnumbers,and

humor/metaphor/absurdity.

TocompletetheFunctionalCommunicationProfile(FCP;Sarno,1969)theclinician

assessesfunctionalcapacitythroughobservationsofthepatient’sbehaviorwhile

interactingwiththeclinician.Communicationcategoriesincludemovement,speaking,

understanding,reading,andother(e.g.,writingandcalculations).

Studieshaveshownthatpoorerperformanceontestsoflanguagelevel(Holland,

1982;Irwin,Wertz&Avent,2002;Ross,1999)andcognition(Fridrikssonetal.,2006)are

correlatedwithpoorerfunctionalcommunicationwhenratedbytrained

observers/therapists.Fridrickssonandhiscolleagues(2006)showedthatmost

participantsperformedbelownormallimitsonnon-verbalexecutivefunctiontests(Color

TrailsTestandWCST)andtherewasasignificantrelationshipbetweencognitionand

functionalcommunication(measuredusingtheSLP-ratedASHA-FACS).Decreased

cognitiveabilitymightcoincidewithdecreasedfunctionalcommunicationabilityinPwA.

PATIENTREPORTEDOUTCOMEMEASURES

Asdiscussedintheintroduction,patientreportedoutcomes(PROs)arekeyto

understandingtheimpactofaphasiafromtheperspectiveofthepersonwithaphasia

becausetheygivePwAmorepowertoexpresshowaphasiaaffectsthem.PROmeasures

areespeciallyimportantiftheyproducedifferentinformationthanwouldevidentbasedon

eitherimpairmentbasedassessmentsorother-reported(partner-reported,care-giver

reported,ortherapist-reported)functionalcommunication.

13

Insuranceprovidersandgovernmentalagenciesarerequiringpatient-reported

outcome(PRO)measuresasevidenceoftreatmentbenefits(Barrett,2009;Irwin,2012,

Doyleetal.,2013).MedicareandotherinsuranceagenciesarecompellingtheuseofPRO

measurestocollectdataonpatientfunctionduringthecourseoftherapyservicesasa

meansofdocumentingchangeinpatientconditionandoutcomes(Irwin,2012;MCTRJCA,

2012;Pub.L.112-96;Snyder&Aaronson,2009)andtheDepartmentofHealthandHuman

Serviceshasprioritizedpatient-reportedoutcomesinresearchandclinicalcare(De

Riesthal&Ross,2015).PROmeasuresarenowbeingusedtojustifyreimbursementfor

therapyservices,demonstratetreatmenteffectiveness,justifythecontinuanceofservices,

providepatienteducation,andmakedecisionsregardinghowtobestallocateresources

(Threats,2012).

BARRIERSTOTHEUSEOFPROMEASURESINAPHASIA

Despitethepush,theintegrationofPROmeasuresintoresearchandclinicalpractice

facessignificantchallenges.ThereareconcernsaboutthewaythatPROmeasuresmay

impactservicedelivery(negativeimpactsonbillingandserviceprovision,challengingSLPs

todemonstratethevalueoftheirservices,timeandefforttocollectPROdatafurther

limitingtreatmenttime),andconcernsabouttheirusefulness(toobroadtocapturethe

typesofchangesseenovershortcoursesoftherapy,PROmeasuresdon’ttelltherapists

whattreatmentmethodstouse).Inthespecificcaseofaphasia,thereareongoingconcerns

abouttheirappropriateness(notclearthatpatientscanunderstandthetestorthatthey

cangivevalidandreliablefeedback)andtheircorrespondencewithimpairmentmeasures

thathavebeenusedasthe“goldstandard”inthefieldfordecades.

14

TYPESOFPROMEASURESINAPHASIA

TherearetwobroadtypesofPROmeasures:GenericandDiseasespecific(Cella,

Hahn.,Jensen,Butt,Nowinski,&Rothrock.2015;Patrick&Deyo,1989).GenericPRO

measuresareoftenusedwhenthegoalistolookatqualityoflifeorfunctionacrossawide

varietyofhealthissues.DiseasespecificPROmeasuresareusedwhenthereisaspecific

subsetofpatientswhoashareaparticulardiagnosisorarereceivingcommontreatment.

Thatis,diseasespecificmeasuresbetterenabledifferentiationofgroupsatthelevelof

specificsymptomsorpatientconcerns.Genericmeasuresoftencaptureadifferentcategory

ofoutcomesthancondition-specificPROmeasures.Forexample,aGenericmeasuremay

assessdomainsofgeneralfunction,wellbeing,orqualityoflife,whereasacondition-

specificPROmaymeasuresymptomsexpectedgivenaspecificdiagnosis(suchasstrokeor

aphasia).Inthecaseofstroke,diseasespecificPROshaveaddressedareassuchasmobility,

self-care,communication,cognition,andmood.Whenthefocusisonaspecificsymptomor

setofsymptomsthatareuniquetothecondition,condition-specificinstrumentare

preferred.

GenericPROmeasurescanbeappliedtoindividualswithoutspecifichealth

conditions,andtheycandifferentiategroupsonindicesofoverallhealthandwell-being.

GenericPROmeasureshavetheadvantageofallowingforcomparisonsacrosspatient

groupsandpopulationsbutarelikelytobelessresponsivethancondition-specific

measurestofocalchangesthatarerelatedtoaspecificconditionandmaybetargetedin

treatment(e.g.aphasia).Thatis,genericPROmeasuresmayfailtocaptureimportant

condition-specificconcerns.

15

Tobeclinicallyuseful,PROmeasuresmustbesensitivetochange.Sensitivityto

changeistheabilitytodetectasmall,butmeaningful,differencesandisnecessarywhen

monitoringpatientsandimplementingclinicalinterventions.Evidencesuggeststhat

condition-specificPROmeasurescanbemoresensitivetochangethangenericPRO

measures.GenericPROmeasuresmaybelesssensitivebecausetheycontainmulti-trait

scalesthatmaynotberelevanttothetargetpopulationbeingassessed.Certainly,

conditionspecificscalescanlacksensitivityiftheyassessabroadrangeoffactorswhen

onlyoneofthosefactorsisbeingtargetedintreatment.Forexample,itisproblematicto

assessgeneralchangeonastrokeimpactassessmentwhentreatmenthastargeteda

specificareasuchasmobilityorspeech.Toaddressthisconcern,itiscommontofocuson

aspecificsubtest.However,becausethereareoftensofewitemsinsubtests,thisagain

raisesconcernsaboutsensitivity.Forexample,measuresdevelopedtoemphasizespecific

contentareaswouldbeexpectedtoshowgreaterpost-treatmentchangeinthosecontent

areas.Inotherwords,thegreatersensitivitytochangeincondition-specificPROmeasures

maybeattributedtothestrongcontentvalidityinherentincondition-specificmeasures.

STROKESPECIFICPROMEASURES

Thereareanumberofassessmentsavailableforassessingtheeffectofstrokeon

qualityoflifeorparticipationinactivitiesofdailyliving.TheseincludetheStroke-Specific

QualityofLife(SS-QOL;Williams,Weinberger,Harris,Clark&Biller1999),theBurdenof

StrokeScale(BOSS,Doyleetal.,2004).Thesecontainverybriefsubsections(7to10items)

addressingverbalexpression,verbalcomprehension,readingandwriting.

16

APHASIASPECIFICPROMEASURES

There are also a number of aphasia specific PRO measures. These include the

Communicative Effectiveness Index (CETI; Lomas, Pickard, Bester, Elbard, Finlayson, &

Zoghaib, 1989), the Self-Reported Functional Communication: Communication Outcome

After Stroke (COAST; Long, Hesketh, & Bowen, 2009), Communication Disability Profile

(CDP; Swinburn & Byng, 2006; Chue, Rose, & Swinburn, 2010), the Stroke and Aphasia

Quality of Life Scale (SAQOL-39; Hilari, Byng, Lamping, & Smith, 2003) and the Aphasia

CommunicationOutcomeMeasure(ACOM;Hulaetal.,2015).

FINDINGSFROMSTUDIESUSINGPROMEASURES

Onlyafewstudieshavelookedattherelationshipofpatient-reportedfunctional

communicationandimpairment-levelperformance.Doyleandhiscolleaguesfounda

correlationof0.65(r2=.423,n=83)betweentheWesternAphasiaBatteryAphasiaQuotient

scoreandtheACOM(Hulaetal.,2015).Althoughsignificant,thismeansthatonly42%of

thevarianceinthePROmeasurewasexplainedusingaphasiaseverity.

Todate,nostudieshavecorrelatedpatient-reportedfunctionalcommunicationwith

cognitionmeasures.Therefore,thisstudyexamineswhetheradding-verbalcognition

measuresproducesamorepowerfulmodelthanwhenusingaphasiaseverityalone.Itis

alsopossiblethattheeffectsofcognitivedysfunctionondailyactivitiesmayinteractwith

oramplifylimitationsduetotheirlanguagedisorder(Keil&Kasniak,2002).

WHYACOM?

TheACOMwasselectedforanumberofreasons:1)itwasconditionspecificfor

aphasia2)ithadundergonesignificantverificationandvalidationusingItemResponse

17

Theory(IRT)methodsasdescribedbelow,3)itisspecificenoughthatitshouldbe

sensitivetocommunicationissuesthataretargetedintherapy,4)ithasstrongrelevance

(itasksaboutthingsthatareimportantandrelevanttoPwAandtheirpartners)and

changesontheACOMwouldreflectimprovementsineverydayfunctionandqualityoflife

and5)ithasstrongtest-retestreliability(.86;Hula,Kellough,&Doyle,2015)

TheACOMwasdevelopedacrosstimebasedonIRTprinciples(Doyle,McNeil,Le,

Hula,Ventura2008).First,aninitialsetof673itemswasgatheredfrom33existing

functionalcommunicationinstruments.Theseitemswerereviewedwithstrokesurvivors,

partners,andSLPstoexploretheircontentrelevanceandrepresentativeness.Multiple

studieshaveresultedina59itemversion(Doyle,Hula,Hula,Stone,Waumbaugh,Ross,&

Schumacher,2013;Hulaetal.,2015).Atthetimethatthedatainthisstudywerecollected,

thereductionto59itemswasnotyetcomplete.Thereforethisstudyusedacombinationof

the101itemsfromtheDoyleetal.(2012)surveyandthe59itemsfromtheDoyleetal.

(2014-pre-publicationversion).Allanalyses,however,arebasedonthedatafromthe59-

itemsinthemostrecentversionoftheACOM.

ThereasonsforchoosingtheACOMarewellsummarizedbyHulaetal.(2015):

“The ACOM represents an advance over previously available patient-reported

measures foraphasiabecause it isbasedonacoherentandempiricallysupported

measurement model, provides highly precise score estimates across all levels of

functioning,anditsdevelopmentandvalidationarebeingpursuedwithinamodern

psychometricframeworkthatwillofferusersahighdegreeofflexibilityinchoosing

betweentestburdenandmeasurementprecision”.(pg.917).

18

PROXYREPORTASASUBSTITUTEFORSELF-REPORT

Amajorconcernaboutusingpatient-reportedoutcomemeasuresiswhether,

becauseofcommonstroke-relatedneuropsychologicaldeficits,PwAcanprovidevalidself-

assessments.Barrett(2009)citesspecificdeficitssuchasfailuretoadjustfortheeffecton

self-reportofspatialneglect,deficitsofmagnitudeestimation,pathologicalterationofself-

awareness,andalterationindistributedcorticalsystemssupportingemotionalsemantics

andabstraction(pg.17).Beyondthese,othershavecitedconcernsaboutthePwA’sability

tounderstandthequestionsandvalidlyandreliablycommunicatetheirownperceptions

(Doyleetal.,2013)

ConcernslikethesehaveleadmanyPROstudiestoexcludepeoplePwAaltogether.

Unfortunately,thisapproachrepresentsalargedeviationfromthespiritofself-reported

PROmeasures.Cellaetal.(2012)states“Failingtoincludethesepopulationscanresultin

potentiallymisleadinginterpretationsofresults.Thus,attemptingtoincludetheminPRO

assessmenteffortsiscrucial;usingallpossiblemechanismsforobtainingself-reportsisa

highpriority,butaccomplishingthismaybeoutofthequestionforsomepopulations.”(pg.

18).TheexclusionofPwAalsoattenuatesgeneralizabilityofresearchresults(Pickardet

al,2004).

Onewaytoincludealargernumberofpatientsinresearchistouseproxy

respondentstoobtainPROinformationforpatientswhoareunabletorespond.Proxies

aretypicallysignificantothers(e.g.,parents,spousesorotherfamilymembers,close

friends)orformalcaregivers(physicians,nurses,aides,teachers).Usingproxiescan

provideanumberofpotentialbenefits.Theuseofproxiesnotonlyallowsinclusionofa

19

broaderandmorerepresentativerangeofpatientsintheentiremeasurementeffort,butit

canalsohelpminimizemissingdataandincreasethefeasibilityoflongitudinalassessment.

Theusefulnessofproxyresponsesassubstitutesforpatientresponsesdependson

thevalidityandreliabilityofproxyresponsescomparedwiththoseattributesforpatient

responses.Agreementbetweentheproxyandpatientistypicallyassessedateitherthe

subscalelevel,usingintraclasscorrelationcoefficients(ICC),ortheitemlevel,usingthe

kappastatistic.Inaddition,groupcomparisonsareusedtodetectthesizeanddirectionof

systematicbias.

Somelargestudieshavefoundpositivecorrelationsbetweenself-reportedandproxy-

reportedmeasuresofoutcomes(e.g.health-relatedqualityoflife,functional

communication)inchronicdisease(Sneeuw,Sprangers,&Aaronson,2002)stroke(Duncan

etal.,2002)andaphasia(Williamsetal.,2006;Bakheit,Carrington,Griffiths&Searle,

2005).

Findingssuggestthatagreementishigherbetweenproxyandpatientratingswhen

ratingmoredirectlyobservabledomains(e.g.,physicalfunctionvs.energy)(Doyleetal.,

2013).Stroke-specificstudiesthathaveincludedparticipantswithaphasiahavereported

intraclasscorrelationcoefficientsrangingfrom0.50to0.70forlanguageand

communicationscales.

Oczkowski&O’Donnell(2010)completedasystematicreviewofresearchonthe

reliabilityofproxyrespondentsforpatientswithstrokecovering13studies(2618

participants).Theirreviewcomparedpatientandproxyreportedoutcomesforactivitiesof

dailyliving(ADL)and/orqualityoflife(QoL)andfoundthatinthechronicstage,patient

andproxyagreementwasstrongestwhenstrokewassevereandwhenthequestions

20

pertainedtoobservabledomains.Usingthethreecategoriesforinter-ratercorrelations

(ICCork-statistic)resultsofpoor(<=.40),moderate(.41-.60),substantial(.61-.80)or

excellent(>.80),theyconcludedthatreliabilitywassubstantialtoexcellentforADL

outcomemeasuresandmoderatetosubstantialforQoLoutcomemeasures.

Whilepatientandproxyratingarecorrelated,thereisevidenceofbiasinsurrogate

ratings.Frost,Reeve,Liepa,Stauffer,&Hays(2007)andIrwin,Wertz,&Avent(2002)

reportedthatproxiesconsistentlyratefunctionaloutcomesmorenegativelythanpatients.

Anexceptiontothisispainaboutwhichproxiestendtounder-report(Andresen,Vahle,

Lollar,2001)

Doyleetal.(2013)correlatedACOMscoresacrossalargesample(n=133)ofpeople

withseveretomildaphasia.Theyshowedamoderatecorrelationbetweenself-and

surrogate-reportsontheACOMwithanoverallcorrelationof.69(W.Hula,personal

communication;December4,2015).Althoughsignificant,itisinterestingthat52%ofthe

varianceintheself-reportedACOMisstillunaccountedforwhenpredictedusingthe

partner’sratingsandimpliesthattheremaybeotherrelevantfactorsdrivingACOMscores.

Basedonthedata,Doyleandhiscolleagues(2013)concluded“Correlationsbetweenself-

andsurrogatereportsweremoderate-to-strong,butthereweresignificantdisagreements

inasubstantialnumberofindividualcases.”(pg.957)and“Despiteminimalbiasand

relativelystrongassociation,surrogatereportsofcommunicativefunctioninginaphasia

arenotreliablesubstitutesforself-reportsbypersonswithaphasia”(pg.957).

Tosummarize,whileanumberofstudieshavefoundmoderatetostrongcorrelations

betweenpatientandproxyreportedoutcomes,thereareenoughinstancesinwhichthe

disagreementsarelargethatresearcherscannotrecommendusingsurrogateratingsin

21

placeofpatientratings.Frostetal.(2007)warned:

“Investigators need to be cautious in trying substitute proxy reports

for patient self-report data because of inherent differences between the

two typesof respondents.Themoreobservable the function, thegreater

theagreementbetweenaproxyandapatient’sreport;betterconcordance

betweenproxiesandpatientstendstooccurforthephysicaldomainsthan

for psychosocial domains. Proxies tend to report more disability and

depression about the patients than patients report about themselves. In

contrast,proxiestendtoattributehigher levelsofcognitiveabilitytothe

patients than do patients when rating their own cognitive ability.” (pg.

S100).

PROXYREPORTASACOMPLEMENTTOSELF-REPORT

Ratherthanviewingproxyassessmentsasreplacementsforself-reports,another

strategyistoviewthemasprovidingcomplementaryinformation.Thatis,proxyreports

constituteavalidperspectiveintheirownright,regardlessoftheircorrespondencewith

patients’ratings(Doyleetal.,2013)andinthesecases,patient-otheragreementmaynot

necessarilybedesirable.

If,forexample,thepatientfailstorecognizedeficitsandproblemsinfunctioning,

thenpatientandpartnerratingsshoulddeviate.Subtlerthougharethepotential

differencesbetweenthelivedexperienceofthepersonwithaphasiaandapartner.Even

withsignificantcorrelationsbetweenself-reportedandproxy-reportedoutcomemeasures,

thereisnoguaranteethattheunderlyingfactorsdeterminingtheratingsofpatientsand

partnersarethesame.Thatis,itispossiblethatthepersonwithaphasiaandthepartner

22

givethesameratingonaspecificfunctionalcommunicationitemsimilarly(e.g.asking

questionsoftheirdoctor)buttheyarejudgingtheperformancebasedondifferentcriteria.

SupportforthisideacomesfromFucetola&Connor(2015)whoshowedthat

family/partnersratetheeffectivenessofcommunicationprimarilybasedonexpressive

languagedespitethefactthatotheraspectsofaphasia(e.g.listeningcomprehension)areas

importantforeverydaycommunication.Ifsurrogateratersrelyondifferentinformationto

judgefunctionalcommunication,thenusingpartner-ratingswouldbeinappropriate.Based

ontheexistingevidence,partnerACOMscoresaremorelikelytocorrelatewithobservable

componentsoflanguage(suchasnamingandfluency)andlesslikelytocorrelatewithless-

observablecomponents(suchasauditorycomprehension).

SUMMARYANDHYPOTHESES

Insummary,theeffectsofaphasiahavebeenmeasuredinanumberofdifferent

ways.Impairmentmeasureshavetheadvantagethattheycharacterizespecificdeficitsbut

onlypartlycorrelatetofunctionalcommunication.Functionalcommunicationmeasures

havetheadvantageofassessingreal-worldperformancethatislikelytohaverelevanceto

thepatientandfamily.Functionalcommunicationhasoftenbeenmeasuredusingthe

opinionofothers,beittherapist,caregivers,orfamily.Withthepushtoincludethepatient

inassessingtheirownoutcomes,thereisaneedtounderstandhowpatient-reported

functionalcommunicationrelatestoimpairmentmeasuresandother-reportedmeasures.If

itcanbeshownthatself-reportedmeasuresarehighlyconsistentwith1)impairment

measuresand/or2)other-reportedmeasuresthenthesemeasurescanbetreatedas

equivalent.Iftheyarenotcorrelatedthenthisimpliesthatself-reportedmeasuresdo,in

23

fact,provideauniquelyvalidperspectiveabouttheimpactofaphasiaontheindividual.

Basedontheliteraturereview,wedevelopedthefollowinghypotheses:

1) RelatedtoSelf-ReportedFunctionalCommunication

a) Selfreportedfunctionalcommunicationwouldbecorrelatedwithaphasiaseverity.

b) Self-reportedfunctionalcommunicationwouldbecorrelatedwithcognition.

c) Alinearregressionmodelpredictingself-reportedfunctionalcommunicationusing

bothaphasiaseverityandcognitionwouldaccountforsignificantlymorevariance

thanamodelusingaphasiaseverityalone.

2) RelatedtoPartner-ReportedFunctionalCommunication

a) Partner-reportedfunctionalcommunicationwouldbecorrelatedwithself-reported

functionalcommunication.

b) Partner-reportedfunctionalcommunicationwouldbecorrelatedwithaphasia

severityandcognition.

c) Alinearregressionmodelpredictingpartner-reportedfunctionalcommunication

usingbothaphasiaseverityandcognitionwouldaccountforsignificantlymore

variancethanamodelusingaphasiaseverityalone.

24

CHAPTER3:

METHODSANDPROCEDURE

Thischapterdescribesthemethodsusedfordatacollectionandanalysesincludinga

discussionofthesubjects,assessmentmeasures,andexperimentalprocedures.

PARTICIPANTS

Seventeencommunity-dwellingadults(10males)withchronicaphasia(greaterthan6-

monthspost-onset)completedthestudy.Inaddition,16oftheirregularcommunication

partnersratedfunctionalcommunicationperformance.Participantswithaphasiawere

prescreened(in-personorbytelephone)formild-moderatenon-fluentaphasiaoranomic

aphasiawithrelativelystrongauditoryverbalcomprehensionandevidenceofword

findingdifficulty.Volunteerswithfluentaphasia,severeapraxiaofspeechandsevere

dysarthriawereexcluded.ParticipantswererequiredtobemonolingualEnglishspeakers.

Participantswererequiredtohavesufficientstaminatocomplete4hoursoftestingina

singleday.EachPwAwasrequiredtoidentifyanEnglish-speakingpartnerwithwhom

he/shehadfrequentcontactbothpriortoandafteraphasiaonsetandwhowaswillingto

participateinthestudy.

Participantswererecruitedthroughmultiplechannels.Somewererecruitedusing

flyerspostedattheUniversityofColorado,Speech,LanguageandHearingSciences

DepartmentClinicandotherswererecruitedthroughabulletinboardpostingtotheASHA

25

NeurophysiologyandNeurogenicSpeechandLanguageDisordersSpecialInterestGroup

(SIG2).SpeechLanguagePathologistswhoidentifiedpotentialparticipantsweresenta

copyoftheflyerandwereaskedtoprovideittopotentialparticipants.Thesepotential

participantswerethenrequiredtoinitiateanyfurthercontact.Inadditiontoparticipants

fromBoulder/Denver,participantswererecruitedinMinneapolis,MNandBaltimore,MD.

TheInstitutionalReviewBoardoftheUniversityofColoradoapprovedthestudy,and

signedinformedconsentwasobtainedfromeachparticipantafterpassingthepre-

screening.ConsentformsweremailedtothePwA’shomeaddresstoallowampletimefor

reviewpriortothefirstsession.Thosewithaphasiawereencouragedtohaveafamily

memberorfriendreviewtheformwiththem.Consentwasobtainedatthebeginningof

thefirstsessionandcriticalpointswerereviewedinpersonverballyandhighlightedonthe

form.Criticalpointsincludedthetotaltimecommitment,thetypesofactivitiestheywould

bedoing,theabilitytowithdrawatanytimeandforanyreason,thecompensationamount

andthepartialcompensationamountiftheyterminatedtheirparticipation.Whenthe

participantdidnotholdhis/herlegalpowerofattorney,boththeparticipantandthe

personwhoholdsthepowerofattorneysignedtheconsentform.Participantswithaphasia

werecompensated$200whilecommunicationpartnerswerecompensated$25.

Atotalof27peoplewereprescreenedandatotalof22peopleenteredintothestudy.

Fourofthefivenonentrantswerenotenrolledbecausetheyappearedtohavefluent

aphasiaornolongerhaveaphasia.Onewasclearedforparticipationbuthadotherhealth

issuesthatpreventedscheduling.Ofthe22peoplewhoenteredthestudy,5peoplefailed

tocompleteitafterbeingconsented.Participantsweredischargedforthefollowing

reasons:Participant5hadastrokebetweendays1and2oftesting;Participant10scored

26

26/100ontheWAB-AQ(cut-offwas50orhigher)andwasdismissedfromthestudy;

Participant18arrivedsickonday2andwasunabletocompletethestudy;Participant20

askedtobedismissedfromthestudyaftercompletingthefirsthalfoftheACOM,theWAB-

RandthetimedBNT-2.Participant21decidedshedidnotwanttoparticipateafter

completing1-houroftasks.Participantswhofailedtocompletethestudywerepaid$10

perhourforeachhourcompletedor$60whicheverwassmaller.Thislesseramountwas

intendedtoonlypartiallycompensatetheparticipantbecausetheirdata,sinceitwas

incomplete,couldnotbeused.

DEMOGRAPHICS

ThedemographicandclinicalcharacteristicsofthegrouparesummarizedinTable1.

TheseventeenPwAwhocompletedthestudyrangedinagefrom30to72(M=53.24,and

SD=11.27).Allcompletedhighschoolandmorethanhalfheld4-yearoradvanceddegrees.

WESTERNAPHASIABATTERY-REVISED.

Allparticipantswithaphasiaincludedinthefinaldatasetpresentedwithmild-to-

moderateaphasiaasmeasuredbytheWAB-AQ(range54.3-96.2;x=76.9,s.d.=10.70)and

relativelygoodauditorycomprehensionasindicatedbyWAB-Rauditorycomprehension

subtestscores(range7.2–10.00;x=8.61,s.d..91).SeeTable2forcompleteWAB-Rdata

summary.

Despitetheprescreening,twoparticipants(6and9)receivedsufficientlyhighWAB-

AQscorestobecategorizedasnon-aphasic(ascoreinexcessof93.7isconsidered

“normal”;Kertesz,1982).BecausetheirACOMself-reportsindicatedongoing

27

communicationchallenges(ACOMscores=191,176outof236respectively,wemodified

ouroriginalselectioncriteriaandretainedthese2participantsintheanalysis.Notethat

thisisconsistentwiththeinclusioncriteriausedbyDoyleandcolleagueswhohadaWAB-

AQrangemin-maxof10.2–100(Hula,personalcommunication,January27,2015).

Partner/familyratersconsistedofspousesorromanticpartners(44%),siblings(19%),

adultchildren(13%),orparents(25%).Participant3’spartnerhadpoorfamiliarity(she

workedatthefrontdeskofthelivingfacility),didnotknowtheparticipantpriortothe

onsetofaphasia,andneversawhimengageinactivitiesoutsidethelivingfacility.Because

ofthislackoffamiliarity,shewasunabletocommentonmanyoftheitemsontheACOM.

Forthesereasons,herdatawereexcludedfromthestudy.

Table1.

Participantcharacteristics:Mean,standarddeviation(s.d.),andrangefor17personswithaphasia(PwA)with

PartnerGenderandRelationshiptoPwA.(Note:“.”Indicatesmissingparticipantdata.Seetextforexplanation).

PwA PartnerParticipant Gender Age WAB-AQ Gender Reside

TogetherRelationship

1 F 66 74.7 F No Daughter2 M 53 81.0 F Yes Spouse3 M 55 69.3 . . .4 M 57 85.2 F Yes Spouse5 . . . . . .6 M 45 94.8 F No Mother7 F 55 76.7 F Yes Mother8 M 30 86.9 F No Mother9 F 58 96.2 F No Daughter10 . . . . . .11 F 30 76 M Yes Spouse12 M 42 79.2 F Yes Spouse13 F 52 79.5 M No Brother14 M 63 73.4 M No Brother15 F 54 72.8 F No Mother16 F 56 78.6 F No Sister17 M 72 54.3 F Yes Spouse18 . . . . . .19 M 54 60.4 F Yes Spouse20 . . . . . .21 . . . . . .22 M 63 68.9 F Yes SpouseMean M=59% 53.24 76.9 M=18% s.d. 11.27 10.7

Table2.

WAB-AQandsubtestscoresforeachparticipantwithaphasia.

Participant WAB-AQ Spont.Speech

Fluency AuditoryComp.

SequentialCommands

Repetition Naming AnimalFluency

1 74.7 11 6 9.3 71 9.8 6.8 52 81.0 14 6 8.8 62 8.7 9 133 69.3 13 6 7.65 42 5.8 8.2 114 85.2 15 6 9.6 75 8.8 9.2 126 94.8 19 9 9.9 89 9.2 9.3 137 76.7 17 8 8.25 50 5.7 7.4 208 86.9 18 9 8.45 67 8.0 9 139 96.2 19 9 10 80 9.5 9.6 1611 76.0 13 5 8.30 54 8.0 8.7 1012 79.2 14 6 8 40 8.2 9.4 1913 79.5 12 4 9.45 72 7.8 9.5 1514 73.4 12 4 9.20 64 7.8 7.7 415 72.8 13 5 7.45 50 7.8 8.1 816 78.6 14 5 7.80 40 6.4 8.1 917 54.3 9 4 7.65 42 6.9 3.6 119 60.4 11 4 7.20 28 4.6 7.4 722 68.9 8 4 9.45 78 5.0 8.0 7

Mean 76.9 13.65 5.88 8.61 59.06 7.53 8.18 10.76s.d. 10.7 3.20 1.83 .91 17.35 1.56 1.45 5.18

30

ASSESSMENTS

Aseriesoffunctionalcommunication,non-verbalcognition,andlanguageimpairment

testswereadministeredtoallparticipants(AppendixA).Thissectiondescribeseach

assessmentanditspurpose.Afullexplanationofmodifiedinstructionsisprovidedinthe

appendix(AppendixD).

APHASIACOMMUNICATIONOUTCOMEMEASURE

TheAphasiaCommunicationOutcomeMeasure(ACOM;Doyle,etal.,2013)wasusedto

assessself-reportedandpartner-reportedfunctionalcommunicationability.TheACOM

consistsof59-items(AppendixB).Thequestionnaireaskstherespondenttoratehow

effectivelythey(ortheirpartnerwithaphasia)engageincertaincommon,everyday

behaviors,tasks,activities,andlifesituationsthatinvolvedunderstandingandor

producingspoken,written,andornon-verbalmessages,signs,andsymbols(Doyle,McNeil,

Le,Hula,&Ventura,2008,p.720).Someexamplequestionsare“howeffectivelydoyou

startanewtopicinconversation?”;“howeffectivelydoyoumakeyourselfunderstood

whenspeakingwithfamilyandfriends?”and“howeffectivelydoyoucorrectmistakesyou

makewhenyoutalk?”.Effectivenessisdefinedas“accomplishingwhatyouwantto,

withouthelp,andwithoutittakingtoomuchtimeoreffort”(Hulaetal.,2015,p910).

ACOMitemsareratedona4-point(ordinal)scale.Therespondentmayalsoindicate

thattheydonotengageinaspecificbehavior(e.g.writingchecks)withafollow-up

questionaboutwhetherornotitisduetotheiraphasia.ResponseswereconvertedintoT-

ScorevaluesusingsoftwareprovidedbyHula(Hulaetal.,2015).T-Scorearenormalized

tohaveapopulationmeanof10andastandarddeviationof3.

31

BOSTONNAMINGTEST(SECONDEDITION)

TheBostonNamingTestsecondedition(BNT-2;Kaplan,Goodglass,&Weintraub,2001)

isavisualconfrontation-namingtestthatassessesnamingability.TheBNT-2wasselected

becauseitisamoreextensiveassessmentofwordfindingdifficultythanisprovidedbythe

WAB-R.TheBNT-2consistsof60blackandwhitelinedrawingsofobjects.Itemsonthe

BNT-2areorderedaccordingtodecreasingfrequencyandfamiliarity.(Brookshire&

Nicholas,1995).

ThisstudyusedamodifiedversionoftheBNT-2.Unlikethestandardadministration,no

cuingwasprovidedfollowingerrorsorsignificantresponsedelays(i.e.nosemanticor

phonemiccuingwasgiven).Inaddition,theBNT-2stimuliwerepresentedviacomputer

usingPowerPointtmsoftware.Thedrawingswereshownoneslideatatimeandthe

participantwasaskedtonameeachitem.Toachieveacorrectresponse,thecorrectanswer

musthavebeenthefirstword(s)spoken,withnophonemicparaphasicerrors(e.g.

“strethoscope”forstethoscopewouldbeincorrect).Thepercentcorrectscoreisthesumof

thecorrectresponsesdividedbythetotalnumberofitems(60).

D-KEFSDESIGNFLUENCYTEST

TheDKEFSdesignfluencytestassessesattention,processingspeed,workingmemory,

initiation,perseveration,cognitiveflexibility,andnonverbalabstraction(Zinn,Bosworth,

Hoenig,&Swartzwelder,2007).Participantsmustgeneratenewdesignswhileabidingby

therulesandavoidingimpulsiveorperseverativeresponses(Mikola,2010).

DesignfluencyisespeciallyusefulintheassessmentofPwAbecauselanguageisnot

requiredtoperformwellonthetest.Therefore,poorperformanceonDesignFluency

32

cannotbeexplainedbylanguage,memory,ormotordeficits(Ruff,Evans,&Marshall,

1986).Normativedataforthistestisavailableforagesfrom8to89.

TheDesignFluencytestiscomprisedofthreeconditions:basic,filter,andswitch

(Figure1).Thetaskistodrawasmanyuniquedesignsaspossiblein60-seconds.The

responsesheetisprintedwithanarrayof35squares.Insideeachsquareisadotpattern.

Thesamedotpatternappearsineachsquare.Inthebasiccondition(condition1),the

squaresontheresponsesheetcontainfivefilled(i.e.,black)dots.Theexamineeis

instructedtodrawuniquedesignsbyconnectingthedotswithfourstraightlines.Creditis

notgivenifadesignisrepeatedacrosssquares.Inthefiltercondition(condition2)each

squarecontainsfiveemptydotsandfivefilleddots.Theexamineeisinstructedtoconnect

onlytheemptydotsusingfourstraightlines(whileignoringthefilleddots).Creditisnot

givenifadesignisrepeatedorifadesignincludesafilleddot.Thisiscalledthefilter

conditionbecausethetaskrequirestheexamineeto“filter”out(inhibit)relevantresponses

fromcondition1.Intheswitchcondition(condition3)eachsquarecontainsfiveempty

dotsandfivefilleddots(arrangeddifferentlythaninthefiltercondition)andtheexaminee

isinstructedtoalternatebetweenconnectingemptydotsandfilleddots.Creditisnotgiven

ifadesignisrepeatedorifadesignfailstoincludefilledandemptydotsinanalternating

order.Thisiscalledtheswitchconditionbecausethetaskrequirestheexamineetoflexibly

switchbetweenthefilledandemptydots.Possibleerrorsincludeset-losserrors(the

designcontainsgreaterorfewerthanfourslinesordoesnotfollowtherulesforthat

condition)andrepetitionerrors.

AccordingtoDelis-Kaplan(Delis,Kaplan,&Kramer,2001b),condition1providesa

basictestofdesignfluency,condition2measuresbothdesignfluencyandresponse

33

inhibitionandcondition3measuresbothdesignfluencyandcognitiveflexibility.

Inadditiontocompletingthestandardversionofthedesignfluencytest,

participantscompletedanuntimedversioninwhichtheywereallowedtotakeasmuch

timeastheywantedtocompletethetaskandwereallowedtodecidewhentheywere

finished.Someparticipantsfilledall35squaresineachconditionwhileothersstoppedon

theirown.Becausethetaskwasthesameinthestandardanduntimedversionstheorder

wascounterbalancedacrosssubjects.Thetaskwascompletedasingledaywithtest

administrationsbeingatleasttwo-hoursapart.Theuntimedversionofthetestprovides

additionalinformationabouterrorsandinhibitionofimpulsiveorperseverativeresponses.

Therearetwobasicerrorsthatcanbecommittedduringthedesignfluencytest:set

lossdesignsandrepeateddesigns.Setlossdesignsareerrorsinwhichthedesignhastoo

manyortoofewlines.Incondition1,asetlossdesignhasmoreorlessthan4lines

connectingthedots.Incondition2,asetlossdesignhasmoreorlessthan4lines

connectingthedotsoritcanincludeasoliddot.Incondition3,asetlossdesignhasmore

orlessthan4linesoritfailstoswitchbetweensolidandopendots.Repeateddesignsare

errorsinwhichthesamedesignwasalreadyproducedonthecurrentresponsepage.Note

thatmanyrepeateddesignsoccurbecause,althoughtheexamineeusesadifferentstroke

sequence,thesamedesignisultimatelyproduced.Thisoftenoccurswhencloseddesigns

(formingasquareorrectangle)arebegunarestartedatdifferentinitialdots.

D-KEFSVERBALFLUENCYTEST.

Verbalfluencyreferstoaperson’sabilitytogenerateitemsfromagivencue(Baldo

etal.,2001).Categoryfluencyisitemgenerationbasedonsemanticcues(e.g.animals,

34

musicalinstruments).Letterfluencyisitemgenerationbasedonphonemiccues(e.g.

wordsbeginningwiththeletterForH).

WhilesimilartothecategoryfluencytaskintheWAB-R,theD-KEFSverbalfluency

testismorecomplete.Therewerethreeconditionsintheverbalfluencytask:letterfluency

(F,A,Sinset1;B,H,Rinset2),categoryfluency(animal’sandboysnameinset1;itemsof

clothingandgirlsnamesinset2)andcategoryswitchfluency(alternatingbetweenfruits

andfurnitureinset1andvegetablesandmusicalinstrumentsinset2).Theorderofthese

conditionswasfixedaswastheorderofthesets(thatis,F,A,Swasalwaysdonefirst).The

timedversusuntimedconditionswerecounterbalancedacrossparticipants.

Verbalfluencyrateswerebasedonthenumberofcorrectitemsproducedinone

minute.Itemswerecountedascorrectiftheymettheconstraintsoftheconditionandwere

notrepetitions.Letterfluencyscoreswerebasedontheaveragenumberofitems

generatedacrossthethreeletterconditions.Categoryscoresweretheaveragenumberof

itemsgeneratedinthetwocategories.Switchscoresarecalculatedintwoways:Switch

Fluencyisthetotalnumberofitemsnamedfromeithercategory(irrespectiveofwhether

adjacentitemsarefromalternatecategories)andSwitchTotalsisthenumberoftimesthe

participantswitchesbetweencategoriesasitemsarenamed.

D-KEFSTWENTYQUESTIONSTEST

TheD-KEFSTwentyQuestionTask(TQT)isaproblem-solvingtaskthatassessesboth

languageandcognition.Problemsolvingrequiresconceptualizing,planning,executionand

modifyingstrategiesbasedonfeedback(Marshall,Harvey,Freed,&Phillips,1996).The

TQTtaxesabstractreasoningability,abilitytoshiftcognitiveset,andworkingmemory

35

(Delisetal.,2001).

Forthistest,theparticipantispresentedwithastimuluspagedepictingcommon

objectsin8-columnby5-rowarray.The30commonobjectsbelongtovariouscategories

andsubcategoriesdifferingintermsofthenumberofobjectsineach.Forexample,the

stimuluspicturesinclude15non-livingthings,8thingsfoundinakitchen,and2appliances

(AppendixC).

Theparticipantisinstructedtoaskthefewestnumberofyes/noquestionsinorderto

identifyanunknowntargetobjectdepictedonthestimuluspage.Themosteffective

problem-solvingstrategyonthistaskistheparticipant’saskingyes/noquestionsthat

eliminatethemaximumnumberofobjectsregardlessofwhethertheexaminer’sansweris

yesorno.Forexample,theinitialquestion“Isitalivingthing?”eliminateshalfofthe

objects(15outof30)regardlessofwhethertheexamineranswersyesorno;thus,this

questionreflectsahighlevelofabstractthinking.Incontrast,ifanparticipantasksahighly

concreteinitialquestion(e.g.“Isitanstove?”or“Isitanappliance?”)onlyafewobjects

wouldbeeliminatedbytheexaminer’sanswer.

ToefficientlysolvetheTQT,theexamineemust(a)perceivethevariouscategoriesand

subcategoriesrepresentedbythe30objects,(b)formulateabstract,yes/noquestionsthat

eliminatethemaximumnumberofobjectsregardlessoftheexaminer’sanswer(c)

effectivelyusefeedbackwhenformulatingquestions(c)incorporatetheexaminer’s

feedbackinordertoformulatemoreefficientyes/noquestions(d)useworkingmemoryto

trackinformationthathasalreadybeendiscovered(inordertoavoidaskingquestionsthat

donoteliminatenewobjects),and(e)switchfromaconceptualtoaspecific-naming

strategywhenauniquecategoryisidentified.

36

D-KEFSCARDSORTTEST

TheD-KEFSCardSortTask(CST;Delisetal.,2001)assessesconceptgeneration,

conceptidentification,andconceptexecutionaswellperseveration(Beatty&Monson,

1990).

TheD-KEFSCardSortingtaskconsistsof16differentsortingconceptsacrosstwo

conditions:FreeSortandSortRecognition.Infreesortingexamineeisrequiredtosortsix

cardsintotwogroups,threecardspergroup,accordingtoeightpossiblesortingrules

(threeverbalandfivenonverbal),andtodescribethesortingruleaftereachsortmade.In

recognitionsortingtheexaminersortsthecardsintotwogroupsandthenasksthe

examineetoidentifythesortingruleorconceptthatwasusedtosortthecards(Shunk,

Davis,andDean,2006).

ToperformwellontheCST,theexamineemust(a)perceivethevariouscard-set

groupings(b)formulatedescriptionofthegroupings(e.g.theseareallfoundintheairand

theseareallfoundontheground)(c)effectivelyshiftthinkingtoidentifynewgroupings

andd)avoidrepetitionsofgroupings.

TORRANCETESTOFCREATIVETHINKING

TTCTisawell-knownandwidelyusedtestofcreativity(Torrance,1968).It

assessesfourprincipalcognitiveprocessesofcreativity:(a)fluencyornumberofrelevant

responses;(b)flexibilityasreferredtoavarietyofcategoriesorshiftsinresponses;(c)

originality(consideringnoveltyresponses,notfamiliarandunusual,butrelevant)and(d)

elaboration(thenumberofdetailsusedtoextendaresponse)(Almeida,Prieto,Ferrando,

Oliveira,&Ferrandiz,2008).

37

Forthisstudyweusedtwosubtests:ProductImprovementandUnusualUses.For

ProductImprovements,theexamineelistwaystochangeastuffedanimaltoysothata

childwouldhavemorefunplayingwithit.ForUnusualUses,theexamineelistinteresting

andunusualusesofacommonobject.Thescoringforeachtaskisbasedonproprietary

scoringmethods.Nocreditisgivenforrepeatedsolutions/ideas.Forexample,creditis

givenoncefortheideatoclothethetoybutnotforlistingindividualclothingitems.

ToperformwellontheTTCT,theexamineemust(a)generateunique,creative

suggestions(b)effectivelyshiftthinkingtogeneratenewideas(c)articulateorusegesture

toconveytheideatotheexaminer.

PROCEDURE

Testingwasdoneacross2dayswith4hoursofevaluationandtestingeachday

(maximumof8hourstotaltestingtime).Nomorethan1weeklapsedbetweenthefirst

andsecondtestday.Testingwasconductedinaquietroomwithonlytheexaminerand

participantpresent.Allofthesessionswerevideorecorded.

Eachtestingday,consistedofa2-hourtestingsessioninthemorning,a1.5-2hour

break,followedbya2-hourtestingsessionintheafternoon.Thetotaltimecommitment

was8hoursbutmanycompleteditinfewerhours.Testingwasconductedinaquietroom

withonlytheexaminerandparticipantpresent.Allofthesessionswerevideorecorded.

Thefirst2-hourperiodusedeithertimedoruntimedcondition(counterbalanced)and

thesecond2-hourperiodwillusetheoppositecondition.Thisapproachwaschosen

becauserepeatedtestswithinashortperiodoftimemayresultincriticismsthat

38

performancedifferencesareduetolearning/familiaritybut,sincethereislargevariability

inperformanceacrossdays,itensuresthattimedanduntimedtestsversionsare

completedwithinasingleday.

Testswereadministeredinblocks.Testingorderoftheblockswascounterbalanced

usingaLatinSquareDesignwithreplacementforlostparticipants.BlocksAandBwere

completedononedayandBlocksCandDwerecompletedonanotherday.BlockA

consistedoftheuntimedversionsoftheBostonNamingTest,theD-KEFSVerbalFluency

test,theD-KEFSDesignFluencytest,theAlphabetFluencyTest.BlockBconsistedofthe

timedversionsofthesetests.BlockCconsistedoftheuntimedversionsoftheD-KEFS

Sortingtest,theD-KEFSTwentyQuestionstest,and4testsfromtheTorranceTestof

CreativeThinking(AppendixF).

Alongbreak(1.5-2hours)wasgivenbetweenblockstoallowtimefortheimpactof

timepressuretoabatebetweenblocks.Forexample,ifthetimedanduntimedtaskswere

interleaved,thentheimpactofpressureislikelytobleedoverontoconditionsthatdonot

requiretimedperformance.Whenthetimedconditionfollowsanuntimedcondition,an

equivalentlengthbreakisprovidedforrestandservesasageneralcontrolfortotaltesting

time.

APHASIACOMMUNICATIONOUTCOMEMEASURE.

Forparticipantwithaphasia,ACOMdatawascollectedusinganinterviewer-

assistedadministrationformatasdescribedinDoyleetal.(2013).Itemsweredisplayedon

acomputerscreeninlargefontalongwiththestem‘‘Howeffectivelydoyou…’’The

examinerreadeachitemaloudandalsopermittedtherespondenttoreadit.Responses

wereprovidedorallyorbypointingtotheirchoiceonavisualscale.Thecomputerscreen

39

alsodisplayedaverticalbarrepresentingtheresponsecategorieswithtextlabels.Incases

wheretherewasanyuncertaintyaboutthevalidityoftheresponse,theexaminerverbally

repeatedtheitemandtheresponsebacktotheparticipantandalsopointedtothechosen

responseonthescreen.Forpartnerquestionnaires,theitemstemsweremodifiedto“How

effectivelydoesyourpartner…”.Partnertestingwasunsupervisedandemployedanonline

surveyformorapaperversionperthepreferenceoftherespondent.

TocollecttheACOMdata,theexaminersatalongsidetheclientandreadeach

questionaloud.Theclientcouldprovidetheirresponseorallyorbypointingtotheir

choiceonavisualscale.

Forpartners,ACOMdatawascollectedusingacomputerbasedquestionnaireor,for

oneparticipant,aprintedversionofthesurvey.

40

BOSTONNAMINGTEST(SECONDEDITION)

TheBNT-2wasadministeredtwiceundertimedanduntimedconditions.Inthetimed

condition,eachstimuluswaspresentedfor3secondsthenthesoftwareautomatically

progressedtothenextimage.Intheuntimedcondition,eachstimuluswaspresenteduntil

theparticipantprovidedanameorindicatedthattheydidnotknowthename.Because

participantsoftenrespondusingrisingintonation(e.g.Flower?),weretoldthatthey

neededtobeclearthattheyweredoneortheywouldbeasked“Isthatyourfinalanswer?”.

Itemswerescoredascorrecteveniftheywerenamedafter3-secondpresentationtime.

D-KEFSDESIGNFLUENCYTEST

Thedesignfluencytestconsistsofthreeconditions:basic,filter,andswitch(described

intheAssessmentsectionabove).Thethreeconditionswereadministeredinthisfixed

order.Participantsusedtheir“postmorbid”handtodraw.

Foreachofthethreeconditions,participantswerefirstshownapracticepageswith3

squares,eachofwhichcontainedanarrayofdotsidenticaltothearrayonthetestpage.

Theinstructionsforeachconditionweregivenorally.Participantswereinstructedtomake

adifferentdesignineachsquarebyconnectingthedotswithstraightlines.Theyweretold

touseonly4straightlines.Participantswereallowedtoliftthepenfromthepage.

Participantswereencouragedtopracticebeforeeachconditionandweregivenfeedback

abouttheirpracticedesigns.Incaseswherethedesignwasincorrect,theexaminer

explainedbythedesignwasincorrectandrecommendedanotherpracticeattempt.All

participantsproducedatleastonecorrectdesignduringpractice.

Eachparticipantcompletedthedesignfluencytasktwice:timed(standard

administration:60seconds)anduntimed(unlimitedtime).Theorderwascounterbalanced

41

acrossparticipantsandtestadministrationswereatleasttwo-hoursapartonthesameday.

Inthetimedcondition,whentimeexpired,theparticipantwasNOTallowedtofinisha

designinprogress(loudringingnoiseinterruptedtask).Intheuntimedcondition,

participantsself-terminatedorstoppedonceall35ofthearraysontheresponsepagehad

beencompleted.

DuringthetimedconditionaniPaddisplayingacountdowntimerwitharedclockface

withasweepinghandwasplacedinaprominentpositioninfrontoftheparticipant.When

the1-minutetimeended,aringingsoundplayedandtheexaminerstoppedtheparticipant

immediately.Duringtheuntimedcondition,aniPaddisplayingananalogclockwasplaced

inthesamepositioninfrontoftheparticipantbutnoreferencewasmadetotime.The

examinerstartedthetaskandthenspentthedurationofthetasklookingatpaperworkor

othermaterialsuntiltheparticipantindicatedtheyweredoneorcompletedall35squares.

Ifaparticipantaskedforclarificationduringthetimedcondition,theexaminersuspended

thetimeruntilthequestionwasanswered.Themostcommonquestionswereaboutwhat

todowhentheexamineerealizedthathe/shehascommittedanerror.Participantswere

toldtocrossoutanyerrorsandcontinuewiththetask.

Designswerecodedascorrectiftheyused4straightlines,wereunique(this

includeddesignsinwhichonelinesdidnottouchanotheratanendpoint.)andmetother

constraintsbasedoncondition(explainedbelow).Inthetimedcondition,theparticipant

wasNOTallowedtofinishanydeigninprogresswhenthetimeexpired(loudringingnoise

interruptedtask).Intheuntimedcondition,participantsselfterminatedorstoppedonce

all35ofthearraysontheresponsepagehadbeencompleted.

42

D-KEFSVERBALFLUENCYTEST.

Therewerethreeconditionsintheverbalfluencytask:letterfluency(F,A,Sinset1;

BHRinset2),categoryfluency(animal’sandboysnameinset1;itemsofclothingand

girlsnamesinset2)andcategoryswitchfluency(alternatingbetweenfruitsandfurniture

inset1andvegetablesandmusicalinstrumentsinset2).Theorderoftheseconditionswas

fixedasweretheorderofthesets(thatis,F-A-Swasalwaysdonefirst).Thetimedversus

untimedconditionswerecounterbalancedacrossparticipants.

Inordertoavoidincreasingthecomplexityoftheinstructionsandincreasing

working-memoryload,participantswereallowedtousenamesofpeople,placesand

numbersduringtheletterfluencytask(theseconstraintsareusedinstandard

administrationsofthistask).Despitethisdifference,veryfewparticipantsviolatedthe

ruleand,whentheydid,theygeneratedpeople’snames.

Instructionsweregivenorally.Justbeforestarting,thetargetletterwaswritten

downandshowntotheparticipantthenremovedfromviewwhenthetaskbegan.Inthe

timedcondition,participantsweregiven60secondstogenerateitems.AniPadshowinga

clockwitharedsweepingcount-downindicatorwasplaceddirectlyinfrontofthe

participantandtheexaminerbeganthetaskwitha“Ready,Set,Go!”whilestartingthe

timer.IntheuntimedconditionaniPadwithaclockwasplacedinthesamepositionbut

participantsweretoldtoworkathis/herownpace.Theexaminerlistenedandwrotedown

eachitemgeneratedandencouragedtheparticipanttocontinueworkingaslongass/he

wanted.

Toavoidcomplexityandworking-memoryload,participantswereallowedtouse

namesofpeople,placesandnumbersduringtheletterfluencytask(theseconstraintsare

43

usedinstandardadministrationsofthistask).Despitethisdifference,veryfew

participantsviolatedtheruleand,whentheydid,theygeneratedpeople’snames.

ScoringwascompletedfollowingthescoringmethodologydescribedintheD-KEFS

ExaminersManual(Delis,Kaplan,&Kramer,2001c).Verbalfluencyrateswerebasedon

thenumberofcorrectitemsproducedinoneminute.Itemswerecountedascorrectifthey

mettheconstraintsoftheconditionandwerenotrepetitions.Letterfluencyscoreswere

basedontheaveragenumberofitemsgeneratedacrossthethreeletterconditions.

Categoryscoresweretheaveragenumberofitemsgeneratedinthetwocategories.Switch

scoresarebasedonthenumberofcorrectitemsgeneratedintheconditionregardlessof

whetherornottheparticipantaccuratelyfollowedtheswitchingrule.

D-KEFSTWENTYQUESTIONSTEST.

TheD-KEFSTwentyQuestionstestwasadministeredtwice,oncewithnotimelimits

andoncewithtimepressure.Inthetimepressuredconditionacount-uptimerwasplaced

infrontoftheparticipantandhe/shewasinstructedtoaskquestionsasquicklyas

possible.Theclockwasstartedandthetimerstartedastheexaminersaid“Ready,Set,

Go!”.Thepresentationorderforthetwoversionswascounterbalancedacrossparticipants.

Eachadministrationconsistsof4trials.Thefirsttestadministrationwasalways

completedwiththeitems“banana”,“spoon”,“owl”and“helicopter”.Thesecondtestused

theitems“airplane”,“rose”,“stove”and“corn”.Acrossallfourtrials,thereistheneedto

avoidinterferencefromprioritems.

Forthepurposeofthisstudy,threescoresfromtheTQTwerederivedfromthedata:1)

thetotalnumberofquestionsrequiredtoidentifythetargetitem,2)theabstractionofthe

44

firstquestionineachtrial(abstractionreferstothenumberofitemseliminatedbya

questionregardlessofwhethertheresponseisyesorno),and3)thetotalweighted

achievement(thisscoringcorrectsforfortuitousguessing).

D-KEFSCARDSORTTEST

TheD-KEFSCardSorttestwasadministeredtwice,oncewithnotimelimitsandonce

withtimelimits(4minutespercardset-uptoeightsortsperset).Inthetimelimited

conditionacount-downtimerwasplacedinfrontoftheparticipantandhe/shewas

instructedtoaskquestionsasquicklyaspossible.Theclockwasstartedandthetimer

startedastheexaminersaid“Ready,Set,Go!”.Thepresentationorderforthetwoversions

wascounterbalancedacrossparticipants.

Participantsareshownhowtosortthecardsusingasamplecardset.Thesamplesorts

includeonebasedonperceptualfeatures(cardsgroupedbycolor:yellowandblue)and

onebasedonthewordsappearingonthecards(BoyversusGirlsnames).Toconfirmthat

theywereabletoreadthewordsonthecards,participantswereaskedtoreadthewords

onthecardsaloudbeforethesortingtaskbegan.

Forthesortrecognitiontask,theparticipantwastoldtolookawayasthecards

wereplacedintotwogroups.Theywereaskedtodescribehowthecardswerethesamein

eachgroup.Inthetimedcondition,viewingtimewaslimitedto30seconds.

Explanation/descriptiontimewasallowedtocontinuepastthe30secondstimelimit.


TheTTCThastwoparallelforms(AandB).Thepresentationorderforthetwoversions

wascounterbalancedacrossparticipants.Eachsubtest(ProductImprovementandUnusual

45

Uses)wasadministeredtwice,oncewithnotimelimitsandoncewithtimelimits(4

minutespercardset-uptoeightsortsperset).

FortheProductImprovementtask,theparticipantwasallowedtohold,manipulate,

andgesturewiththestuffedtoy.Whengesturewasused,theexaminerworkedwiththe

participanttoagreeonthemeaning.Forexample,iftheparticipantmovedtheanimal

acrossthetable,thentheexaminermightask“Makeitwalk”?andwaitfortheparticipant

toconfirmorredirect.

FortheUnusualUsestask,theexamineracknowledgedideasandaskedquestionsto

clarifyuses.Forexample,iftheparticipantsaid“painting”,theexaminermightask“You

wouldpaintit?”andwaitfortheparticipanttoclarify.

46

CHAPTER4:

RESULTS

DESCRIPTIVESTATISTICS

SELF-RATEDANDPARTNER-RATEDAPHASIACOMMUNICATIONOUTCOMEMEASURE

AsTable3shows,themeanACOMT-ScoreforthePwAgroupwas53.18andthe

standarddeviationwas7.3.Participant2’sACOMratingscorewasanoutlier(score=

36.30)howeveranalysesofthedatawithouthisscoredidnotchangethepatternofresults.

ThemeanACOMT-ScoreforthePartnersgroupwas49.44andthestandarddeviationwas

9.53.TherewerenooutliersinthepartnerACOMscores.

Partner-reportedscoreswereonaveragemorepositivethanPwA-reportedscores.The

averagedifferencebetweenPwAandPartnerscoreswas3.24(s.d.=10.60).However,38%

ofthePwA(6/16)ratedthemselveshigherthandidtheirpartnerontheACOM.

47

Table3.

PwAandPartnerACOMscoreswithgroupmeansandstandarddeviations.

Participant WAB-AQ PwAACOM

PartnerACOM

Diff(Partner–PwA)

1 74.8 54.29 34.75 19.542 81.0 36.30 45.62 -9.323 69.3 61.37 . 4 85.2 49.04 62.43 -13.396 94.8 56.35 50.23 6.127 76.7 48.31 56.98 -8.678 86.9 57.34 48.64 8.79 96.2 62.58 53.42 9.1611 76.0 54.03 50.24 3.7912 79.2 51.67 60.69 -9.0213 79.5 60.74 67.20 -6.4614 73.4 39.76 43.60 -3.8415 72.8 47.06 41.36 5.716 78.6 55.63 47.93 7.717 54.3 54.05 31.70 22.3519 60.4 60.58 51.73 8.8522 68.9 55.03 44.46 10.57mean 76.94 53.18 49.43 3.24s.d. 10.70 7.30 9.53 10.60

Note:Missingratings(“doesnotapply”or“Idon’tknow”)wereomittedfromthecalculation.

BOSTONNAMINGTEST

ThepercentcorrectforthetwoconditionsisshowninTable4.Timed

responses(Mean=.56,s.d.=.22)weresignificantlylessaccuratethanuntimed

responses(Mean=.46,s.d.=.22);Pairedt-test(16)=5.44,p=.000.

48

Table4.

PercentcorrectnamingonBostonNamingTest(BNT-2)forUntimedandTimed

Conditions.

Participant WAB-AQ BNT-2

TimedBNT-2

1 74.8 .58 .302 81.0 .47 .403 69.3 .48 .424 85.2 .73 .576 94.8 .83 .787 76.7 .53 .328 86.9 .72 .539 96.2 .92 .9211 76.0 .63 .4212 79.2 .82 .7213 79.5 .62 .5514 73.4 .57 .5015 72.8 .52 .4216 78.6 .52 .3517 54.3 .05 .0219 60.4 .30 .2722 68.9 .27 .25Mean 76.94 .56 .45s.d. 10.70 .22 .22

D-KEFSDESIGNFLUENCY-STANDARDADMINISTRATION

Table5showsthatthenumberofcorrectdesignsproducedbyoursample

summedacrossthe3conditionsrangedfrom8to29(mean=17.82ands.d.=

6.00).Thenumberofattempteddesignsrangedfrom11to44(mean=24.59,s.d.

=7.77).

49

Thenumberofrepeateddesignsproducedbyoursamplesummedacross

the3conditionsrangedfrom0to13(mean=3.06ands.d.=3.79)andsetloss

designrangedfrom0to11(mean=3.82ands.d.=3.05).Addingtheerrors

together,thisresultedinproportionoferrorsrangingfrom.08to.55(mean=27

ands.d.=.15).

50

Table5.

D-KEFSDesignFluencydataforStandardAdministration.Scoresaresummed

acrossthe3conditions.

D-KEFSDesignFluency(StandardAdmin)Participant WAB-

AQAttemptedDesigns

CorrectDesigns

RepeatedDesigns

SetLossDesigns

ProportionofErrors

1 74.7 27 22 2 4 .222 81.0 44 23 13 8 .483 69.3 18 16 0 2 .114 85.2 20 14 5 1 .306 94.8 19 16 0 3 .167 76.7 34 18 5 11 .478 86.9 32 29 3 0 .099 96.2 16 11 1 4 .3111 76.0 30 27 0 3 .1012 79.2 23 17 0 6 .2613 79.5 27 23 2 2 .1514 73.4 25 19 3 3 .2415 72.8 20 10 2 9 .5516 78.6 25 23 1 1 .0817 54.3 20 12 4 4 .4019 60.4 11 8 0 3 .2722 68.9 27 15 11 1 .44Mean 76.9 24.59 17.82 3.06 3.82 0.27s.d. 10.7 7.77 6.00 3.78 3.05 0.15Note:BecauseasingledesigncanbebothaSetLossDesignandaRepeatedDesign,thesumofCorrect+Repeated+SetLossmaybelargerthanAttempted.

D-KEFSDESIGNFLUENCY-UNTIMEDADMINISTRATION

Whengivenunlimitedtime,ourparticipantsproducedanaverageof45.1

correctdesignsacrossthethreeconditions(s.d.=17.6)(Table6).Thenumberof

attempteddesignsrangedfrom18to103(mean=61.7,s.d.=25.6).

Thenumberofrepeateddesignsproducedbyoursamplesummedacross

the3conditionsrangedfrom0to34(mean=7.9ands.d.=11.5)andsetloss

designrangedfrom0to52(mean=8.1ands.d.=12.25).Addingtheerrors

51

together,thisresultedinproportionoferrorsrangingfrom.02to.67(mean=.22

ands.d.=.196).

Participants15,and22hadmarkedlyhighernumberofrepetitionerrors

whileParticipant7hadmanymoresetlosserrorsthantheotherparticipants.

Participant2producedlargenumbersofrepetitionandsetlosserrors.Generally,

participantswhoproducedfewerdesignswerealsomoreaccurate.

52

Table6.

D-KEFSDesignFluencydataforUntimedAdministration.Scoresaresummedacross

the3conditions.

D-KEFSDesignFluency(StandardAdmin)Participant WAB-

AQAttemptedDesigns

CorrectDesigns

RepeatedDesigns

SetLossDesigns

ProportionofErrors

1 74.7 36 32 0 4 .112 81.0 98 52 34 12 .473 69.3 18 16 0 2 .114 85.2 73 58 6 9 .216 94.8 45 45 0 0 .007 76.7 81 27 2 52 .678 86.9 80 69 8 3 .149 96.2 55 50 3 2 .0911 76.0 54 53 0 1 .0212 79.2 94 83 7 4 .1213 79.5 70 60 5 5 .1414 73.4 45 43 2 0 .0415 72.8 103 56 32 5 .3616 78.6 29 27 1 1 .0717 54.3 40 24 4 12 .4019 60.4 45 32 2 11 .2922 68.9 83 40 28 15 .52Mean 76.9 61.7 45.1 7.9 8.1 .22s.d. 10.7 25.6 17.6 11.5 12.25 .196Note:BecauseasingledesigncanbebothaSetLossDesignandaRepeatedDesign,thesumofCorrect+Repeated+SetLossmaybelargerthanAttempted.Themaximumnumberofattempteddesignswaslimitedto105(35designsperresponsesheet).

D-KEFSVERBALFLUENCY

Table7showsthedatafortheD-KEFSVerbalFluencytask.Averaged

acrossparticipantstheLetterFluency(thenumberofwordsbeginningwitha

specificletter)across3trialsrangedfrom1to43(mean=14.00s.d.=9.35).

CategoryFluency(thenumberofwordsfromaspecificcategory)across3trials

rangedfrom4to36(mean=17.35s.d.=9.68).Intheswitchingcondition,the

53

totalnumberofitemsnamed(singletrial)rangedfrom1to12(mean=6.18and

s.d.=2.98)andthetotalnumberofswitchesrangedfrom0to12(mean=4.7and

s.d.=3.48).

Table7.

D-KEFSVerbalFluencydata

D-KEFSVerbalFluencyParticipant WAB-AQ Word

FluencyRatio

LetterFluencyTotal

CategoryFluencyTotal

SwitchFluencyTotal

SwitchesTotal

1 74.7 .26 7.00 13.00 5.00 1.002 81.0 .34 17.00 22.00 7.00 6.003 69.3 .55 9.00 5.00 3.00 1.004 85.2 .34 13.00 17.00 8.00 7.006 94.8 .28 14.00 24.00 8.00 7.007 76.7 .27 17.00 31.00 6.00 4.008 86.9 .39 18.00 19.00 9.00 8.009 96.2 .44 43.00 36.00 7.00 6.0011 76.0 .31 16.00 24.00 7.00 6.0012 79.2 .34 20.00 26.00 11.00 10.0013 79.5 .36 19.00 23.00 12.00 12.0014 73.4 .40 7.00 7.00 5.00 4.0015 72.8 .25 8.00 16.00 2.00 .0016 78.6 .39 16.00 17.00 6.00 3.0017 54.3 .14 1.00 4.00 3.00 2.0019 60.4 .60 9.00 4.00 5.00 3.0022 68.9 .28 4.00 7.00 1.00 .00Mean 76.9 .35 14.00 17.35 6.18 4.7s.d. 10.7 .11 9.35 9.68 2.98 3.48

D-KEFSTWENTYQUESTIONSTEST.

DatafortheD-KEFSTwentyQuestionsTestarepresentedinTable8.All

datarepresentthetotalacross4trials.Participant14wasunabletoachievetasks

set.Thetotalnumberofquestionsaveraged33.38questions(s.d.=19.84)witha

54

rangeof16to80(themaximum).Theweightedabstractionsscoresforthefirst

questionaveraged21.63(s.d.=14.47)witharangeof0to53.Totaledacross4

trials,weightedachievementscoresaveraged13.69(s.d.=5.87)witharangeof0

to20.

Table8.

D-KEFSTwentyQuestionsTestdataforStandardAdministration.

TwentyQuestionsTestParticipant WAB-AQ TotalQuestions Weighted

AbstractionWeighted

Achievement1 74.7 35 11 142 81.0 49 14 93 69.3 30 4 154 85.2 18 32 206 94.8 21 25 187 76.7 19 36 158 86.9 25 32 169 96.2 25 53 1811 76.0 16 32 1712 79.2 25 32 1613 79.5 34 14 1314 73.4 . . .15 72.8 80 0 016 78.6 28 22 1517 54.3 26 16 1619 60.4 80 0 022 68.9 23 23 17Mean 76.9 33.38 21.63 13.69s.d. 10.7 19.84 14.47 5.87Note:Participant14wasunabletocompleteanytrialsoftheTQT

55

D-KEFSCARDSORTTEST

TheD-KEFSCardSortdatawasnotanalyzedbecausemanyparticipantsrequiredalot

ofassistancetoachievetasksetand/ortoaccuratelyexplainthecardgroupingsandthe

interventionbytheexaminerhadanundueinfluenceontheresults.


TheTorranceTestofCreativeThinkingwasalsonotanalyzedbecauseparticipantshad

difficultiesachievingandmaintainingtaskset.Forexample,participant2beganthe

ProductImprovementtaskbut,withtime,morphedthetaskintoastory-tellaboutthe

stuffedtoy.Formanyparticipantsthetaskmorphedintoalistingtaskinwhichthey

itemizedspecificexamplesofanidea(e.g.“youcouldgiveitahat,gloves,atie,pants...”).

HYPOTHESESRELATEDTOSELF-REPORTEDFUNCTIONALCOMMUNICATION

HYPOTHESIS1A:SELFREPORTEDFUNCTIONALCOMMUNICATIONWOULDBECORRELATEDWITH

APHASIASEVERITY.

TherelationshipbetweenWAB-AQscoresandpatient-reportedfunctional

communicationwasnotsignificant(F(1,15)=.022;p=.884).Inaddition,therewereno

significantrelationshipsbetweenself-reportedACOMscoresandanyWAB-Rsubtest

measuresortheBNT-2(Table9).

56

Table9.

PearsoncorrelationsforSelf-reportedACOMscoresandWAB-R(withsubtests)andBNT-2

measures(n=17).

Self-reportedACOM

Pvalues

WesternAphasiaBattery(WAB-AQ) r=.038 p=.884SpontaneousSpeech r=.076 p=.770Fluency r=.162 p=.534AuditoryComprehension r=-.016 p=.952SequentialCommands r=-.009 p=.973Repetition r=-.195 p=.453Naming r=.059 p=.823CategoryFluency r=.086 p=.741

BostonNamingTest(BNT-2) r=.097 p=.713

Figure2 (leftpanel) showsascatterplotof self-reportedACOMratings in relation to

categoryfluencyscores.CategoryfluencyisasubtestoftheWAB-Randrepresentsthetotal

numberanimalsnamedin60seconds(excludingrepetitions).

Figure3 (leftpanel) showsascatterplotof self-reportedACOMratings in relation to

namingscores.NamingisasubtestoftheWAB-R.NotethatwhileParticipant17’sNaming

subtestwasanoutlier(score=3.6),ananalysisofthedatawithouthisscoredidnotchange

thepatternofresults.(ThespecificscatterplotsshowninFigures2and3chosenbecause

theyarerelevantforcomparisontoresultspresentedbelow).

HYPOTHESIS1B:SELF-REPORTEDFUNCTIONALCOMMUNICATIONWOULDBECORRELATEDWITH

COGNITION

APearsoncorrelationcoefficientmatrixwasgeneratedtoinquireabouttheassociation

betweenself-ratedfunctionalcommunicationandimpairment-basedmeasuresofnon-

57

verbalcognition.Self-reportedfunctionalcommunication(ACOMT-scores)was

significantlycorrelatedwithdesignfluencyerrors(timed)(Table10).

Table10.

CorrelationmatrixforSelf-ratedACOMandcognitionscores.

1. 2. 3. 4. 5. 6.

1.Self-RatedACOMTSCORE

Pearson’sr 1 Sig.(2-tailed)

2.DesignFluencyErrors-Timed

Pearson’sr -.700** 1 Sig.(2-tailed) .002

3.DesignFluencyProp.Errors-Untimed

Pearson’sr -.343 .823** 1 Sig.(2-tailed) .178 0

4.TQTTotalAbstraction

Pearson’sr .080 -.031 -.139 1 Sig.(2-tailed) .769 .910 .608

5.TQTTotalQuestions

Pearson’sr -.144 .162 .218 -.719** 1 Sig.(2-tailed) .594 .550 .416 2

6.TQTWeightedAchievement

Pearson’sr .187 -.214 -.291 .718 -.981 1Sig.(2-tailed) .488 .425 .274 2 0

**.Correlationissignificantatthe0.01level(2-tailed).*.Correlationissignificantatthe0.05level(2-tailed).

Self-ratedfunctionalcommunicationwaspredictedbasedonerrorscommittedonthe

designfluencytest(r=.71,p=.002)butnotbasedonanyoftheTQTmeasures(Table10).

Figure4(leftpanel)showsascatterplotofself-reportedACOMratingsinrelationto

designfluencyerrors.DesignFluencyErrorsisthetotalnumberofsetlossandrepetition

errorsinthetimedcondition(60seconds).

Figure5showsascatterplotofself-reportedACOMratingsinrelationtotheproportion

oferrorsontheuntimedversionofthedesignfluencytask.Proportionoferrorsisthe

58

ratiooftotalerrors(setlossandrepetition)dividedbythetotalnumberofdesignsinthe

untimedcondition.Thereisalsoanegativerelationshipbetweentheproportionoferrors

committedontheuntimedversionofthedesignfluencytestandACOMself-ratings.

HYPOTHESIS1C:ALINEARREGRESSIONMODELPREDICTINGSELF-REPORTEDFUNCTIONAL

COMMUNICATIONUSINGBOTHAPHASIASEVERITYANDCOGNITIONWOULDACCOUNTFORSIGNIFICANTLY

MOREVARIANCETHANAMODELUSINGAPHASIASEVERITYALONE.

AmultiplelinearregressionwascalculatedtopredictACOMself-ratingsbasedonTotal

ErrorsandProportionofErrorsfromtheDesignFluencytask.Althoughthecorrelationof

self-reportedfunctionalcommunicationandproportionoferrorscommittedonthedesign

fluencytestwasnotsignificant(r=.343,p=.178),proportionoferrorswasauseful

predictorwhenaddedtoalinearregressionthatalsoincludeddesignfluencyerrors.A

significantlinearregressionequationwasfoundF(2,15)=13.53,p=1withanr2of.66

(adjustedr2=.61).Thatis,morethan60%ofthevarianceinACOMscorescouldbe

accountedforwithinformationaboutthenumberandproportionofdesignfluencyerrors.

Tobettervisualizetherelationshipbetweentheleveloffunctionalcommunicationand

non-verbalcognitionwegroupedparticipantsintocategoriesbasedonACOMRatingsand

CognitionScores(Table11).Toaccomplishthis,atotalscoreontheACOMwasusedasa

groupingfactorwhereparticipantswhoreceivedbelowaverageT-scorescompriseda

moreseveregroup(n=5),participantswhoreceivedaveragescores(ACOMT-Scoreratings

50-60)comprisedanaveragegroup(n=5)andthosewhowereratedhigher(ACOMT-

Scoreratings>60)madeupthelessseveregroup(n=4).TocreategroupsbasedonHigh,

Normal,andLowcognitiveperformance,eachparticipant’sscaledscoresforthedesign

59

fluencytestwerereviewed.Ifoneormoreofthescaledscoreswas1standarddeviation

higherthanthenormativesample(13orhigher)thenthatparticipantswasgroupedinto

theHiCoggroup.Ifnoneofthescaledscoreswas1standarddeviationhigherorlower

thanthenormativesamplethenthatparticipantswasgroupedintotheNormalCoggroup.

Finally,ifanyofthescaledscores1ormorestandarddeviationlower(scores7orlower)

thanthenormativesamplethenthatparticipantwasgroupedintotheLowCoggroup.

Table11showsthatof8ofthe9participantswithHighCognitionalsohadhigherthan

averageACOMscores(89%)while3ofthe5participantswithLowCognitionalsohad

lowerthanaverageACOMscores(60%).

60

Table11.

BreakdownofparticipantsaccordingtocognitionlevelandACOMscores(cellsindicatethe

numberofparticipantsineachgroup).

HiACOM(>60)

AverageACOM(50-60)

LowACOM(<50)

HiCog(Atleastonescaledscores>1s.d.

abovenorm)

3 5 1

NormCog(Allscaledscoresbetween+/-1s.d.)

1 1 1

LowCog(Atleastonescaledscore1s.d.below

norm)

0 2 3

HYPOTHESESRELATEDTOPARTNER-REPORTEDFUNCTIONALCOMMUNICATION

HYPOTHESIS2A:PARTNER-REPORTEDFUNCTIONALCOMMUNICATIONWOULDBECORRELATED

WITHSELF-REPORTEDFUNCTIONALCOMMUNICATION.

TherewasnocorrelationbetweenPwA-reportedandPartner-reportedACOMscores(F

(1,15)=.723,p=.41,r=.222,r2=.049(adjustedr2=-.019).).Figure6showsthatthe

correlationmaybestrongerwhenACOMscoresarelowerbecausethereislarger

variabilityastheACOMscoresrise.

INTERRATERAGREEMENT(KAPPA)BETWEENSELF-RATEDANDPARTNER-RATEDACOMSCORES.

Tofurthercharacterizetheinter-rateragreementbetweenPwA-PartnerpairsaCohen’s

kappaanalysiswascomputedforeachpair(Fleiss&Cohen,1973).Cohen’skappaisthe

61

proportionofagreementcorrectedforchanceagreementbetweentworaters.Kappa

scoresrangefrom-1to+1withnegativevaluesindicatingapoorerthanchanceagreement,

zerovaluesindicatingchangeagreement,andpositivevaluesindicatingbetterthanchance

agreement(Viera&Garrett,2005).Table12showsthatthekappascoresinoursample

rangedfrom.013(slightagreement)to.391(fairagreement).Onaverage,agreementwas

lowwithameanof.141ands.d.of.135.P-values<.05wereobtainedinsevenoutof

sixteenpairs;thisindicatesthattheagreementinitem-levelACOMratingswassignificantly

betterthanwouldbeexpectedbychance.

Table12.

Cohen’skappascoresforeachPwA-Partnerpair.

Participant WAB-AQ Kappa p

1 74.7 0.032 0.5872 81.0 0.203 .00074 85.2 0.076 0.2076 94.8 0.295 .00007 76.7 0.050 0.5418 86.9 0.165 0.0409 96.2 0.081 0.03411 76.0 0.391 .000012 79.2 0.265 .000113 79.5 0.181 0.04014 73.4 -0.147 0.07415 72.8 0.16 0.02416 78.6 0.316 .000017 54.3 0.095 0.11619 60.4 0.013 0.86022 68.9 0.077 0.264

62

HYPOTHESIS2B:PARTNER-REPORTEDFUNCTIONALCOMMUNICATIONWOULDBECORRELATED

WITHAPHASIASEVERITYANDCOGNITION.

PARTNER-RATEDACOMSCORECORRELATIONSTOLANGUAGE.

Therewasanear-significantrelationshipbetweenWAB-AQscoresandpartner-

reportedfunctionalcommunication(F(1,14)=3.97;p=.07).Furtheranalysisrevealed

partner-reportedfunctionalcommunicationwashighlyrelatedto2subtestsoftheWAB-R

andtotheBostonNamingTest(Table13).Notethattherearehighcorrelationsamong

subtestmeasuresandtheBNT-2.

Alone,WAB-Rcategoryfluencyaccountedfor61.1percentofthevariance(adjustedr2

=.584);F(1,14)=22.033,p=0.(Figure2,right)

AlthoughNamingwasalsohighlycorrelatedwithpartnerACOMscores,addingitasa

secondpredictortothemodeldidnotproduceasignificantlylargechangeinexplained

variancetoadoptthe2-predictormodel(Fchange=2.18,p=.163)(Figure3,right).This

maybeduetotheintercorrelationbetweenNamingandWAB-Rcategoryfluency(r=.69,

p=2)(Figure3,right).

63

Table13.

CorrelationmatrixforPartner-reportedACOMscoresandlanguagemeasures.

1. 2. 3. 4. 5.1.PartnerACOM Pearson’sr 1 .

Sig.(2-tailed) N 16

2.WAB-AQ Pearson’sr .470 1 Sig.(2-tailed) .066 N 16 17

3.Naming(WAB-RSubtest)

Pearson’sr .711** .790** 1 Sig.(2-tailed) .002 .000 N 16 17 17

4.BNT-2 Pearson’sr .555* .906** .803** 1 Sig.(2-tailed) .026 .000 .000 N 16 17 17 17

5.CategoryFluency(WAB-R)

Pearson’sr .782** .639** .690** .660** 1Sig.(2-tailed) .000 .006 .002 .004 N 16 17 17 17 17


PARTNER-RATEDACOMSCORECORRELATIONSTOCOGNITION.

APearsonCorrelationCoefficientmatrixwasgeneratedtoinquireaboutthe

associationbetweenpartner-ratedfunctionalcommunicationandimpairment-based

measuresnon-verbalcognition.Partner-reportedcommunicativeeffectiveness(ACOMT-

scores)wasnotcorrelatedwithnon-verbalcognition(Table14).Thesamplesizeforeach

correlationanalysiswas17exceptforthosethatincludedtheD-KEFSTwentyQuestions

Test,whichwas16,becausethevideodatawaslost.

64

Table14.

CorrelationmatrixforPartner-reportedACOMscoresandcognitivemeasures.

1. 2. 3. 4. 5. 6.1.PartnerACOM Pearson’sr 1 .

Sig. N 16

2.DesignFluencyErrors(Timed)

Pearson’sr -.171 1 Sig. .526 N 16 17

3.DesignFluencyProportionofErrors(Untimed)

Pearson’sr -.135 .823** 1 Sig. .617 .000 N 16 17 17

4.TQTTotalAbstraction

Pearson’sr .388 -.031 -.139 1 Sig. .154 .910 .608 N 15 16 16 16

5.TQTTotalQuestions

Pearson’sr -.217 .162 .218 -.719 1 Sig. .438 .550 .416 .002 N 15 16 16 16 16

6.TQTTotalWeightedAchievement

Pearson’sr .194 -.214 -.291 -.718 -.981 1Sig. .488 .425 .274 .002 .000 N 15 16 16 16 .16 16


Incontrasttotheself-ratings,scatterplotsofthepartnerACOMratingsshowthat

partnerACOMscorescouldnotbepredictedbasedonthenumber(Figure4,right)or

proportionoferrors(Figure5,right)onthedesignfluencytest.

Unlikeself-reportedfunctionalcommunication,ACOMpartner-ratingscouldnotbe

predictedbasedontheDesignFluencytask:asimplelinearregressionwascalculatedto

predictACOMself-ratingsbasedonTotalErrorsandProportionofErrorsonthedesign

fluencytask.Anon-significantregressionequationwasfound(F(2,13)=.197,p=.823),with

anr2of.029.

65

HYPOTHESIS2C:ALINEARREGRESSIONMODELPREDICTINGPARTNER-REPORTEDFUNCTIONAL



AstepwiselinearregressionwascalculatedtopredictACOMpartner-ratingsusingallof

theWAB-RsubtestsandtheBNT-2.Fromthis,atwo-factormodelincludingWAB-R

CategoryFluencyandWAB-RFluencyaccountedfor74.7percentofthevariance(adjusted

r2=.697);F(2,13)=18.235,p=.000.TheremainderoftheWAB-Rsubtestswereexcluded

fromthemodel:WAB-AQ,SpontaneousSpeech,AuditoryComprehension,Sequential

Commands,Repetition,andBNT-2.TherewasnocorrelationbetweenpartnerACOM

scoresandFluencyhoweverFluencybecomesareliablepredictoroncetheerror

associatedwithCategoryFluency/Namingisremoved.

TheverbalfluencytestontheD-KEFSissimilartotheWAB-Rcategoryfluencysubtest

andexplainsthesamevariance.However,condition3oftheD-KEFSVerbalFluencytest

assessesanadditionalfactor:categoryswitching.Categoryswitchingreferstothenumber

oftimestheparticipantcanmovebackandforthbetweentwocategories(e.g.vegetables

anditemsofclothing).AlinearregressionaddingSwitching(thenumberofcategory

switchesperformedin60seconds)asathirdpredictorresultedinasignificantmodel:

F(3,12)=17.581,p=.000.TheadditionofSwitchingasapredictorincreasedtheexplained

varianceto.815(adjustedr2=.768).Note:alinearregressionreplacingWAB-Rcategory

fluencywithDKEFSCategoryFluencywasalsosignificant:F(3,12)=7.782,p=.004.The

explainedvariancewas.595(adjustedr2=.566).

66

SUMMARYOFRESULTS

SelfandPartner-reportedACOMscoreswerenotcorrelated.Self-reportedfunctional

communicationwasunrelatedtomeasuresoflanguageimpairmentbutwasstrongly

relatedtoseveralmeasuresofnon-verbalcognition.Incontrast,partner-reported

functionalcommunicationwasunrelatedtomeasuresofnon-verbalcognitionbutwas

stronglyrelatedtoseveralmeasuresoflanguageimpairment.

67

CHAPTER5:

DISCUSSION

HYPOTHESESRELATEDTOSELF-REPORTEDFUNCTIONALCOMMUNICATION

HYPOTHESIS1A.SELFREPORTEDFUNCTIONALCOMMUNICATIONWOULDBECORRELATEDWITH

APHASIASEVERITY.

Onaverage,ourparticipantshadhigherthanaverageWAB-AQscoresbuttheACOM

scoresofthePwAandpartnerswerenotsignificantlydifferentfromthereferenceT-Score

meanof10(Hulaetal.,2015).Thisindicatesthatwhileourparticipantshadhigherthan

averageWAB-Rscores(Mean=76.94),theACOMscoresclusteraroundtheACOM

populationmean.Similarly,resultsfromtheBNT-2showedthatparticipants,asagroup,

demonstratedimpairedperformancerelativetoage-matchedneurologicallyintactnormals

(Tombaughetal.,1997;GoodglassandKaplan,1980).

Wefoundnocorrelationbetweenaphasiaseverityandself-ratedACOMscores.Inlight

ofpriorresearchshowingacorrelationbetweenself-reportedmeasuresandaphasia

severity,ourlackofcorrelationissurprising.

Thereareseveralpossibleexplanationsoftheseresults.First,itispossiblethatwedid

notshowacorrelationbetweenWAB-RscoresandACOMscoresbecause,byselecting

participantswhohadloweraphasiaseveritiesandhigherauditorycomprehension,we

limitedthevariabilityintheWAB-Rscores.Perhaps,giventhisrestrictedrange,the

68

predictivepowerofthelanguagemeasuressimplycouldnotbedetected.

Second,itispossiblethattherelationshipbetweenACOMandWAB-Risdifferentwhen

aphasiaislesssevere.OurstudyincludedpeoplewithWAB-AQscoresgreaterthan50

whileDoyleetal.’sstudyincludedWAB-AQsrangingfrom10to100(Figure7).Figure7

showsmorevariabilityforWAB-AQscoresgreaterthan50andraisesthequestionof

whethertherelationshipofWAB-AQtoACOMdifferswhenaphasiaislesssevere.Asimilar

patternofdataisreportedinLaska,Bartfai,Hellblom,Murray,&Kahan(2007).The

scatterplotofthedatashowsthatthedataisbestfitbyacurveratherthanalinebutco-

authorWillHulaattributesthechangeinslopetoaceilingeffectontheWAB-R.Thatis,

whenaphasiaismild,WAB-Rscorestop-outtherebycreatingpoorerfit.

Tofurtherpursuethehypothesisthattherelationshipbetweenaphasiaseverityand

ACOMscoresisdifferentwhenaphasiaislesssevere,werequestedafollow-upanalysisof

thisdatatoincludeonlythosepeoplewithWAB-AQscoresbetween55and100.This

resultedinasampleof71withamean=83.3ands.d.of13.1(W.Hula,personal

communication;January27,2015).Thecorrelationwas.67(r2=.449).Inotherwords,

thesedatashowthat45%ofthevarianceintheACOMcanbepredictedusingWAB-AQ;

leaving55%ofthevarianceunexplained.Hulaetal.(2015)acknowledgesthatthe

explanatoryvalueofaphasiaseverityislimited:“giventhataphasiaseverityaccountedfor

onlyapproximatelyhalfofthevarianceinACOMscores,itwillbenecessarytoinvestigate

otherpotentialdeterminantsofself-reportedcommunicativefunctioninginaphasia.”(pg.

917).

69

HYPOTHESIS1B.SELF-REPORTEDFUNCTIONALCOMMUNICATIONWOULDBECORRELATEDWITH

COGNITION.

Basedonpriorevidencethatfunctionalcommunicationisnotsolelydrivenbyaphasia

severity,wetestedthehypothesisthatvarianceinACOMscorescouldbepredictedbased

onnon-verbalcognition.Ourdatashowthatself-ratedfunctionalcommunicationishighly

relatedtoperformanceontheDesignFluencytest.Becausewesampledpeoplewithless

severeaphasia,weareunabletotellwhethercognitionisausefulpredictorovertheentire

rangeofaphasiaseveritiesorcognitionisusefulonlywhenlanguagedeficitsareless

severe.Itispossiblethatwhenaphasiaseverityisgreaterithasaproportionallylarger

effectonfunctionalcommunication.

DESIGNFLUENCYASAPREDICTOR

TheD-KEFSoffersnormsforindividualsfromages8to89usingascaledmeanof10

andstandarddeviationof3.Onthestandardadministration,ourparticipantsproduced

significantlyfewercorrectdesignsthanthenormativesamplewithage-scaledscoresfor

thenumberofcorrectdesignsrangingfrom3to10(mean=7.35ands.d.=2.12,t(16)=-

5.149,p=.000).Althoughnotsignificant,theage-scaledscoresforthenumberofattempted

designswerealsolower(Range3-16;mean=8.53,s.d.=2.94,t(16)=-2.063,p=.056).Thus,

althoughoursampleattemptedfewerdesigns,itdidnotsignificantlydifferfromthe

normativesample.Itispossiblethatthetendencytoproducefewerdesignsreflects

diminishedprocessingspeedormotor-speeddeficitsduetousinganon-preferredhand

whendrawingthedesigns.

70

OurfindingthatPwAwhocommitmoredesignfluencyerrorsreportthattheir

functionalcommunicationispoorerthanthosewhodonotcommitsucherrorsisnew.No

priorstudiesusingtheACOMhaveexaminednon-verbalcognitionasapredictor.

Todowellonthestandard(timed)versionoftheDesignFluencytaskonemust

workquicklywhilemaintainingtasksetandavoidingrepetitions.Interestingly,category

fluency(asubtestoftheWAB-R)didnotcorrelatewithACOMscoresdespiteclaimsthat

categoryfluencyalsorequiresspeed,self-monitoring,andtask-setmaintenance.The

designfluencytaskdiffersfromcategoryfluencyintermsofthelanguageload,the

persistenceoftheevokingstimulus(dotsonthepage),andmemoryload(designscanbe

reviewed).Thesedifferencesshouldbeexploredfurther.

Thisstudyalsoemployedanewversionofthedesignfluencytestthatallowed

unlimitedtimetoproducedesigns.Theuntimedversioncapturedmoreinformationabout

repetitionsandset-losserrors.KeilandKazniak(2002)havesuggestedthatdesignfluency

errorsreflectpoorerself-monitoringskillsandaninabilitytotrackandcomplywith

environmentalconstraints.Thefactthatthepeoplewhocommitmoreerrorsonthe

DesignFluencytaskarealsoreportingpoorerfunctionalcommunicationimpliesthatthey

areawareoftheirdeficitsbutunabletoavoidtheirerrors.Thisimpliesadistinction

betweenself-awarenessandself-controlsuchthatoutparticipantsrealizethattheymake

mistakesbutcannotpreventthem.

TWENTYQUESTIONSTESTASAPREDICTOR

Asagroup,participantsperformednormallyonthetwentyquestionstestwhen

comparedtoage-matchednorms.Onaverage,ourparticipantsaskedaboutthesame

numberofquestionsacrossthefourtrialsasthenormativesamplebutwithalarger

71

variability(t(15)=.109,p=.91.).Scaled-scoresfortotalnumberofquestionshadamean=

8.69ands.d.=3.32.

Relatedtotheabstractnessofthefirstquestions,ourparticipantseliminated

slightlyfewerobjectswiththeirfirstquestionthanthenormativesample.Age-scaled

abstractionscoresrangingfrom4to16butthedifferencewasnotstatisticallydifferent

fromthescaledmeanof10(mean=8.69,s.d.=3.32,t(15)=-1.581,p=.135.).

Similarly,totalweightedachievementscoreswerenotsignificantlydifferentfrom

thenormativesample.Scaled-scoresforweightedachievement(untimedmean=10.50,s.d.

=4.46,t(15)=.449,p=.66.)wereveryclosetothescaledmeanof10.

Interestingly,unlikeanotherstudyinvolvingpeoplewithtraumaticbraininjury

(Marshall,Karow,Morelli,Iden,&Dixon,2003),ourparticipantsdidnotimproveinthe

TQTacrosstrials.Fewpeopleswitchedquestionstrategiesacrossthetrialsinorderto

improveefficiency(e.g.iftheyusedacolorstrategytheyrarelyswitchedtoanother

strategyonlatertrialsevenifadifferentstrategywasmoreefficient).

TQTwasnotusefulasapredictorofself-reportedfunctionalcommunicationas

noneoftheTQTmeasuresloadedinthelinearregression.TheTQTtestmaynothavebeen

usefulforanumberofreasons.First,thetaskisafamiliarchildhoodgameandperhapsour

participantsreliedonpriorexperiencewhendoingthetask.Thiswouldmeanthatthetest

ismoreanassessmentofmemorythannovelproblemsolvingandwouldexplainage-

normalperformance.Second,itispossiblethattheTQTsimplydoesnotassesstheaspects

ofcognitionthataremostaffectedinthispopulation.

72

HYPOTHESIS1C.ALINEARREGRESSIONMODELPREDICTINGSELF-REPORTEDFUNCTIONAL



Ouroriginalexpectationwasthatalinearregressiontopredictpartner-reported

ACOMscoreswouldfindpredictivevalueinbothaphasiaseverityandcognitionmeasures.

However,noneofthelanguagemeasureswerereliablepredictorsofself-reportedACOM

scores.

Weidentifiedatwofactorlinearregressionmodelthataccountedfor66%ofthe

varianceinself-reportedACOMscores.Thepredictivevaluesoftwocognitionsubtests,

TotalErrorsandProportionofErrorsfromtheDesignFluencytasksupportstheclaimthat

functionalcommunicationisdriven,atleastinpart,bycognitivestatus.

HYPOTHESESRELATEDTOPARTNER-REPORTEDFUNCTIONALCOMMUNICATION

HYPOTHESIS2A.PARTNER-REPORTEDFUNCTIONALCOMMUNICATIONWOULDBECORRELATED

WITHSELF-REPORTEDFUNCTIONALCOMMUNICATION.

Wefoundnocorrelationbetweenself-andpartner-reportedACOMscores.Thiswas

unexpectedgivenpriorresearchshowingagreementbetweenpatientandproxyreported

outcomes.Ourselectionofparticipantswithrelativelylesssevereaphasiasmaybe

impactingthecorrelation.ThisissupportedbySegal&Schall(1994)whofoundthat

correlationofscoreswassubstantiallyweakerwhenagroupoflessseverelyimpaired

survivorswasconsideredseparately.

Ourfindingssuggestthatthepatient’sexperienceofaphasiamaybedifferentthan

whatcanbesurmisedbyacommunicationpartner.Thatis,partnersmaybeinterpreting

73

theACOMitemsdifferentlyorbasingtheirjudgmentsondifferentaspectsofbehavior.This

raisessomesignificantquestionsabouttheusefulnessofPROmeasureswhentheycannot

beobtaineddirectlyfromthePwA.Forexample,apartnermaynotappreciatethe

differencesbetweenwhatthepersonwithaphasiawants/intendstocommunicateand

whathe/sheactuallyconveys.Thesefindingsimplythatusingproxy-reportedratingsasa

replacementforpatientratingsattheleveloftheindividualpatientmaybeproblematic.

However,itmaystillbeusefultousebothpatientandpartnerratingsoffunctional

communicationtoformamorecompleteimpressionoftheoverallrecoveryenvironment

(Hesketh,Long,&Bowen,2011).

HYPOTHESIS2B.PARTNER-REPORTEDFUNCTIONALCOMMUNICATIONWOULDBECORRELATED

WITHAPHASIASEVERITYANDNON-VERBALCOGNITION.

Thisstudyfoundasignificantcorrelationbetweenpartner-reportedfunctional

communicationandaphasiaseveritybutnotwithnon-verbalcognition.Partnersappearto

bejudgingfunctionalcommunication,atleastinpart,basedonhowreadilytheirpartner

canfindthewordshe/sheneeds.ThissuggeststhatthepartnersofPwAmaybeunaware

ofreceptivelanguageproblemsandcognitionissuesthattheirpartnersexperiencein

everydayactivities.Thefindingthatobservablelanguageperformance(especiallycategory

fluencyandnaming)ishighlypredictiveofpartnerratingsisconsistentwithfindingsfrom

otherstudiesthathighlyobservablebehaviorstendtodrivepartnerratings(Visser-Keizer,

Jong,Deelman,Berg,&Gerritsen,2002).

TheperspectiveofthePwAincludesinternalinformationaboutintention,

motivation,andself-awareness.Anoutsider’sinformationisbasedoninteractionswith

thePwAandobservationsoftheirbehavior.Anoutsidersperspectivewillbedetermined

74

bytheirownworldviewandunderstandingofaphasia.Cliniciansaretrainedtoevaluate

behaviorintermsoflanguageandcognition.So,anSLPismorelikelytospotissuesrelated

toinattention,short-termmemorydeficits,executivefunctiondeficits,etc.Incontrast,

manypartnersandcaregiversofPwAreceivelittleornoinformationabouttheimpactsof

strokeand/oraphasiabeyondbriefdefinitions.Itfollowsthatapartnermightattribute

behaviorstolanguagedeficitsthat,infact,arebetterexplainedintermsofcognition

deficits.Thisisnottosaythatallpartnerslackanunderstanding.However,theinterplay

betweencognitionandlanguageisnoteasilyseparableand,giventhelackofeducationand

trainingrequiredtoisolatethem,itiseasytounderstandwhypartnersmightnotidentify

cognitionissuesinthePwA.

HYPOTHESIS2C.ALINEARREGRESSIONMODELPREDICTINGPARTNER-REPORTEDFUNCTIONAL



Aswithself-reportedACOMscores,ouroriginalexpectationwasthatpartner-

reportedACOMscoreswouldbepredictedbasedonbothaphasiaseverityandcognition.

However,noneofthecognitionmeasureswerereliablepredictorsofpartner-reported

ACOMscores.

Weidentifiedathreefactorlinearregressionmodelthataccountedfor82%ofthe

varianceinpartner-reportedACOMscores.Thepredictivevaluesofthreelanguage

subtests,WAB-RCategoryFluency,WAB-RFluency,aD-KEFSSwitchinglendssupportto

theclaimsthatpartnersrelymoreheavilyonobservablefeaturesofspeechandlanguage

whenassessingfunctionalcommunication.

75

IMPLICATIONS

TheACOMprovedtobeavaluabletooltoobtainvalidandefficientinformationabout

functionalcommunicationdirectlyfromthepersonwithaphasia.Thepresentstudy

suggeststhatfunctionalcommunicationratingsbypatientsandpartnersarebasedon

differentunderlyingvariables.Inoursampleofpeoplewithlesssevereaphasia,PwA

appeartobesensitivetodeficitsrelatedtonon-verbalperformancesuchasattention,self-

monitoring,task-setmaintenance,andspeed.Incontrast,partnersappeartobesensitiveto

observabledeficitsoflanguagesuchasnamingandfluency.

Ourfindingsraisesomeinterestingquestionsaboutthevalueofpartnerratingswhen

assessingfunctionalcommunicationinaphasia.Functionalcommunicationisaboutthe

interactionbetweenthePwAandothers.Thatis,thereisalwaysatleastoneotherperson

involved.TheACOMasksthepartnertoprovidetheirownopinionofthe“effectiveness”of

interactions(thattheyparticipateinorobserve)ratherthanactasasurrogateinwhich

theyguesshowthePwAwouldratehim/herself.Ourfindingthatpartner-ratingsdonot

correlatewithself-ratingsaffirmsthestancethatpartnerreportsconstituteavalid

perspectiveintheirownright,regardlessoftheircorrespondencewithpatients’ratings.

Furthermore,ourresultsprovidesomeinsightsintothefactorsthatcontributetothe

differingperspectives.

Extendedtoclinicalcontexts,theseresultssuggestthatcognitionisanimportantfactor

determininghowPwAperceivetheeffectivenessoftheirowneverydayinteractionsand

furtherstressestheimportanceofaddressingcognitionintheevaluationandmanagement

ofpersonswithaphasia.Clinically,thesefindingsimplythatPwAandpartnersmayjudge

treatmentqualitydifferentlybasedonwhichbehaviorsarechangedbytreatment.

76

Partnersmayratefunctionalcommunicationhigheriftreatmentimprovesobservable

languagebehaviors(e.gwordfindingerrorsanddelays)whileaPwAmayratefunctional

communicationhigheriftheabilitytoself-monitor,inhibiterrors,andcognitiveflexibly

improved.Furthermore,thesedataimplythattreatmenttoimprovestandardizedlinguistic

testingscores(suchastheWAB-R)mightnotresultinchangesthatclient’sregardas

functionallyrelevant.

Expandingfromtheseresults,ourdatasuggestthat,forpeoplewithmildtomoderate

aphasia,successfultreatmentofcognitivedeficitsmightproducelargergainsinself-

reportedfunctionalcommunicationthantreatmentsthattargetlanguageimpairments

alone.Perhapsthereisaleveloflanguagethat,onceachieved,issufficienttosupport

functionalcommunicationandthefocusoftreatmentshouldshifttofactorsimpacting

cognition.WemusthoweveracknowledgethatwhileACOMself-ratingsarecorrelatedwith

cognition,acausalrelationshipcannotbeinferredfromthepresentdata.

STUDYLIMITATIONS

Theresultsofthisinvestigationmustbeconsideredwithinthecontextofthefollowing

limitations.First,thestudysamplesizeissmall.Itwouldbeveryinformativetofurther

analyzewhethercertainfunctionalcommunicationtasksaremorerelatedtocognitionbut,

giventhesamplesize,thisanalysiscouldnotbecompleted.Secondareconcernsaboutthe

recruitingpool.OurparticipantswererecruitedusingcontactswithSLPproviders.This

meansthattheparticipantswereeitherreceivingongoingrehabilitationservicesorhad

receivedservices.Thefactthatparticipantswerereceivingservicesimpliesthattheywere

abletodrive,navigatepublictransportationservices,orhadapartner/caregiverwho

77

assistedthem.Inaddition,thesepeoplewereeitherabletofundongoingtreatmentorhad

accesstofreeaphasiaresourcesintheircommunities.Thesepeoplearepotentially

differentfromindividualswithaphasiawhohavenotreceivedextensivetherapyservices

andthereforeourresultsmaynotbegeneralizabletoindividualswhoselanguageand

physicalstatus,financial,orsocialsupportsprecludetheirparticipationincommunity

activities.Finally,byspecificallyrecruitingpeoplewithlesssevereaphasiaincluding

relativelyintactauditorycomprehension,thesedatamightnotapplytoothers.

GENERALCONCLUSIONS

PROmeasuresgivethepatientadirectvoicetosayhowtheyareaffectedbyaphasia.

Thisstudycorrelatedimpairment-basedmeasuresoflanguageandcognitionwithselfand

partner-reportedfunctionalcommunication.

Ourgeneralfindingswere:

• Whenpeoplewithmildtomoderateaphasiaratedtheirownfunctional

communication,theseratingscorrelatedwithnon-verbalcognitionandnotwith

aphasiaseverity.

• Theratingsoffamilymembersorcaregiversdidnotalignwithpatientratings.

• Partner-ratingsdidnotcorrelatewiththesameimpairmentmeasuresasthe

patient-reportedoutcomes.Instead,aphasiaseveritywashighlypredictivewhile

non-verbalcognitionwasnot.

Ourfindingssuggestoneoftwothings:1)thatself-reportedfunctional

communicationismorecloselyrelatedtonon-verbalcognitionthanitistolanguagelevel

or2)thatbyrestrictingtherangeofWAB-Rscoreswe,ineffect,controlledfortheeffectof

78

languagethatwouldbeotherwisepresentandbothaphasiaseverityandcognitionare

factorsinACOMselfratings.MoredatawithalargerrangeofWAB-AQscoreswould

differentiatebetweenthesetwoexplanations.

Thisstudysuggeststhatself-reportedmeasuresandpartner-reportedmeasuresarenot

interchangeablebuteachprovidesauniquelyvalidperspectiveabouttheimpactofaphasia

ontheindividual.

Bycorrelatingimpairment-basedmeasuresoflanguageandcognitionwithselfand

partner-reportedfunctionalcommunication,weshowedthatpartnersappeartojudge

functionalcommunication,atleastinpart,basedonhowreadilythePwAcanfindthe

wordshe/sheneeds.Thisfindingisnot,inandofitself,surprising.Whatissurprisingis

thatPwAdonotappeartobeusingword-findingdifficultyandverbalfluencywhenjudging

theirowncommunicativeeffectiveness.Thisstudyalsofoundthatwhileself-reported

communicativeeffectivenesscouldbepredictedbasedonnon-verbalcognition,partner-

reportedcommunicativeeffectivenesscouldnot.Itappearsthatindividualswithaphasia

assesstheirowncommunicativeeffectivenessintermsoflessobservablebehaviorsthat

aremorerelatedtocognitivefunctionthanaphasiaseverity.Theimplicationisthatthetwo

groupsmaybeusingverydifferentcriteriatojudgecommunicativeeffectiveness.Thefact

thatpatient-reportscorrelatetocognitiondeficitsthatpartnersfailtorecognizeisa

significantfindingandraisesseriousquestionsabouttheuseofsurrogateraterswhen

collectingPROdata.

Furtherresearchiswarrantedtoexploretherelationshipoffunctionalcommunication

withlanguageandcognition.Thedifferencesinexplanatorypowerbetweencategory

fluencyanddesignfluencyacrossthetwosubjectgroupsareespeciallyinteresting.Given

79

thatcategoryfluencyhasbeenusedasbothatestofaphasiaandasatestofexecutive

functionbutitfailedtocaptureanyvarianceinself-reportedfunctionalcommunication

demandsfurtherinvestigation.

Futurestudiesshouldalsoexaminetheinterplayoflanguageandcognitionon

treatmenteffectsandhowtheygeneralizetochangesinfunctionalcommunication.

80

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FIGURES

Figure1.ExampleofD-KEFSDesignFluencytask(fromBaldo,Shimamura,Delis,Kramer,&Kaplan,2001.

Figure2.ScatterplotsofACOMself-ratings(left)andACOMpartner-ratings(right)asafunctionofWAB-Rcategoryfluencyscore.Self-reportedfunctionalcommunicationwasNOTpredictedbasedonWAB-Rcategory

fluencyscores(r=.086,p=.741)whilepartner-reportedfunctionalcommunicationwaspredictedbasedonWAB-Rcategoryfluencyscores(r=.782,p=.000)

Figure3.ScatterplotsofACOMself-ratings(left)andACOMpartner-ratings(right)asafunctionofWAB-Rnamingscore.Self-reportedfunctionalcommunicationwasNOTpredictedbasedonWAB-Rnamingscores(r=.059,p=.823)whilepartner-reportedfunctionalcommunicationwaspredictedbasedonWAB-Rnaming

scores(r=.711,p=.002)

Figure4.Scatterplotofself-reportedACOMratingsinrelationtothenumberoferrorsontheD-KEFSDesignFluencyTest.Self-reportedfunctionalcommunicationwaspredictedbasedondesignfluencyerrors(r=-

.700p=.002)whilepartner-reportedfunctionalcommunicationwasNOTpredictedbasedondesignfluencyerrors(r=.-.171,p=.526).

Figure5.Scatterplotofself-reportedACOMratingsinrelationtotheproportionoferrorsontheuntimedadministrationoftheD-KEFSDesignFluencyTest.Self-reportedfunctionalcommunicationwasNOT

predictedbasedonproportionoferrorsonthedesignfluencytask(r=-.343p=.178)butproportionoferrorswasusefulinthetwofactorlinearregression.Partner-reportedfunctionalcommunicationwasNOT

predictedbasedonproportionoferrorsonthedesignfluencytask(r=.-.135,p=.617).

Figure6.Scatterplotofself-reportedACOMversuspartner-reportedACOMscores(r=.222,p=.41).

Figure7.ScatterplotofWAB-AQtoACOMT-Scores.FigureprovidedbyWillHula(personalcommunication,January17,2015).

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APPENDIXA:

SAMPLEPROCEDURE

Day1Activity/Test

1. Reviewandcompleteconsentformprocedures 2. DemographicsQuestionnaire 3. Visionscreening 4. ApraxiaBatteryforAdults 5. 144itemACOMfirst-half

AssessmentBlockA

1. BostonNamingTest(Untimed) 2. Delis-KaplanVerbalFluency(Untimed)3. Delis-KaplanDesignFluency(Untimed)

AssessmentBlockB

1. BostonNamingTest(Timed) 2. Delis-KaplanVerbalFluency(Timed)3. Delis-KaplanDesignFluency(Timed)

Day2Activity/Test

1. 144itemACOMsecond-half 2. WesternAphasiaBattery-Revised

AssessmentBlockC

1. Delis-KaplanSortingTest(Timed)2. Delis-KaplanTwentyQuestions(Timed)3. TorranceTestofCreativeThinking-ProductImprovement(Timed)4. TorranceTestofCreativeThinking-UnusualUses(Timed)

AssessmentBlockD

1. Delis-KaplanSortingTest(Untimed)2. Delis-KaplanTwentyQuestions(Untimed)3. TorranceTestofCreativeThinking-ProductImprovement(Untimed)4. TorranceTestofCreativeThinking-UnusualUses(Untimed)

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APPENDIXB:

ACOMQUESTIONS

Howeffectivelydoyou…. Howeffectivelydoesyourpartner….

1. talktoyourclosestfamilymemberorfriend

1. talktohis/herclosestfamilymemberorfriend

2. saythenamesoffooditems 2. saythenamesoffooditems3. saythenamesofbodyparts 3. saythenamesofbodyparts4. talkaboutcurrent/previouswork 4. talkaboutcurrent/previouswork5. askforinformationfromstoreemployees

5. askforinformationfromstoreemployees

6. discussfamilymatterswithyourspouseandchildren

6. discussfamilymatterswithhis/herspouseandchildren

7. sayyouraddress 7. sayhis/heraddress8. leaveamessageonanansweringmachine

8. leaveamessageonanansweringmachine

9. saythenamesofclothingitems 9. saythenamesofclothingitems10. talkaboutyourfutureplanswithfamilyorfriends

10. talkabouthis/herfutureplanswithfamilyorfriends

11. tellastory 11. tellastory12. introduceyourself 12. introducehimself/herself13. haveaconversationwithstrangers 13. haveaconversationwithstrangers14. sayyourname 14. sayhis/hername15. talkaboutyourdaywithfamilyorfriends

15. talkabouthis/herdaywithfamilyorfriends

16. saythenamesofcommonobjects(e.g.,bed,lamp,pencil)

16. saythenamesofcommonobjects(e.g.,bed,lamp,pencil)

17. explainyourhealthconcernstoyourdoctor

17. explainhis/herhealthconcernstohis/herdoctor

18. talkaboutyourhealthconcernswithfamilymembers

18. talkabouthis/herhealthconcernswithfamilymembers

19. callfamilymembersbyname 19. callfamilymembersbyname20. findthewordsyouwanttosayduringconversation

20. findthewordshe/shewantstosayduringconversation

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21. explainhowtogetsomewhere 21. explainhowtogetsomewhere22. tellajoke 22. tellajoke23. makeyourselfunderstoodwhenyouspeakwithstrangers

23. makehimself/herselfunderstoodwhenhe/shespeakwithstrangers

24. filloutsimpleforms 24. filloutsimpleforms25. keepaconversationgoing 25. keepaconversationgoing26. tellpeopleaboutyourself 26. tellpeopleabouthimself/herself27. explainhowtodosomething 27. explainhowtodosomething28. correctyourselfwhenpeopledonotunderstandyou

28. correcthimself/herselfwhenpeopledonotunderstandhim/her

29. makeyourselfunderstoodwhenyouspeakwithfamilyorfriends

29. makehimself/herselfunderstoodwhenhe/shespeakswithfamilyorfriends

30. followconversationaboutfamiliartopics

30. followconversationaboutfamiliartopics

31. startaconversationwithotherpeople

31. startaconversationwithotherpeople

32. talkaboutmoviesthatyouhaveseen 32. talkaboutmoviesthathe/shehasseen

33. understandyourclosestfamilymemberorfriendwhentheytalktoyou

33. understandhis/herclosestfamilymemberorfriendwhentheytalktohim/her

34. followsimplespokenrequests(e.g.,passthesalt)

34. followsimplespokenrequests(e.g.,passthesalt)

35. startanewtopicinconversation 35. startanewtopicinconversation36. shareopinions 36. shareopinions37. makeyourwantsandneedsknown 37. makehis/herwantsandneeds

known38. talkwithagroupofpeople 38. talkwithagroupofpeople39. writeyourphonenumber 39. writehis/herphonenumber40. filloutcomplexforms 40. filloutcomplexforms41. correctmistakesyoumakewhenyoutalk

41. correctmistakeshe/shemakeswhenhe/shetalks

42. writeasimple"todo"list 42. writeasimple"todo"list43. understandyourbank/creditcardstatements

43. understandhis/herbank/creditcardstatements

44. tellpeoplewhyyoucan'ttalkverywell

44. tellpeoplewhyhe/shecan'ttalkverywell

45. readsignsinastoretofindwhatyouneed

45. readsignsinastoretofindwhathe/sheneeds

46. writeyouraddress 46. writehis/heraddress47. understandmagazine/newspaperarticles

47. understandmagazine/newspaperarticles

48. understandnewspaperheadlines 48. understandnewspaperheadlines49. readstreetnamesigns 49. readstreetnamesigns

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50. answeryes/noquestions 50. answeryes/noquestions51. readproductlabels 51. readproductlabels52. followtherapyinstructions 52. followtherapyinstructions53. understandmedicinelabels 53. understandmedicinelabels54. writemessagesingreetingcards 54. writemessagesingreetingcards55. followastorysomeonetells 55. followastorysomeonetells56. readtrafficsigns 56. readtrafficsigns57. readfoodlabels 57. readfoodlabels58. understandhumorinpictures(e.g.,comics,photographs)

58. understandhumorinpictures(e.g.,comics,photographs)

59. writeapersonalletter 59. writeapersonalletter

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APPENDIXC:

D-KEFSTWENTYQUESTIONSITEMGROUPINGS

D-KEFSCategoricalHierarchyCategory Sub-category Sub-category ObjectLivingThings Plants Fruits Apple Banana Oranges Vegetables Carrot Corn Common Tree Rose Animals Mammals Dog Cow Elephant Birds Ducks Eagle Owl Fish Goldfish SharkNon-LivingThings KitchenItems Silverware Knife Fork Spoon Dishes Bowl Cup Plate Appliances Refrigerator Stove Transportation Ground Cars Bus Train Air Airplane Helicopter Water Boat Submarine

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APPENDIXD:

MODIFIEDINSTRUCTIONS

OVERVIEW

ModifiedinstructionswerecreatedfortheBostonNamingTest,theDelis-KaplanExecutive

FunctionsSystemsTest(D-KEFS;Delis,Kaplan,&Kramer,2001),andtheTorranceTestof

CreativeThinking(TTCT).Thesemodifiedinstructionsareintendedtoincreaseor

decreasetheemphasisonspeedofresponse.

Forallspeededtasks,acomputershowingastopwatchandtheremainingtimewere

prominentlydisplayed.Seehttp://www.online-stopwatch.com/countdown-clock/full-

screen/.

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Toavoidtopotentialcriticismthatthetimeriscreatingvisualdistractionratherthantime

pressure,aclockwiththetimewasdisplayedwhennon-timedtasksarebeingcompleted.

http://www.online-stopwatch.com/large-online-clock/

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BostonNamingTest(BNT-2)ModifiedInstructions

ð Inordertocontrolpresentationspeed,theBNTitemsarebeingshownonacomputerscreenusingaPowerPointpresentation.

ð Unspeededð BlockA/C:I’mgoingtoshowyouaseriesofpicturesonthiscomputer.Yourtaskistotellmethenameforeachpicture.Takeasmuchtimeasyouneedtoanswer.

ð BlockB/D:NowI’mgoingtoshowyouthesamepicturesagain.Thistime,youcantakeallthetimeyouneedtoanswer.

ð TimePressureConditionð BlockA/C:I’mgoingtoshowyouaseriesofpicturesusingthiscomputer.Thecomputerwillshoweachpictureforexactly3secondsandthenitwillmoveonautomatically.Yourtaskistonameeachitemasquicklyasyoucan.Oncethepicturechanges,youshouldmoveontothenextpictureevenifyouhaven’tnamedthepreviouspicture.ð BlockB/D:NowIamgoingtoshowyouthesamepicturesagain.Thistime,thecomputerwillshoweachpictureforexactly3secondsandthenitwillmoveonautomatically.Yourtaskistonameeachitemasquicklyasyoucan.Oncethepicture

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changes,youshouldmoveontothenextpictureevenifyouhaven’tnamedthepreviouspicture.

WesternAphasiaBattery-Revised(WAB-R)ModifiedInstructions

TheWesternAphasiaBatterywasgivenusingthestandardizedprocedureonly;no

speededpresentationmethodwasbeused.

D-KEFSAlternateInstructions

VerbalFluency

ð Condition1:LetterFluency-UnpressuredInstructions:ð BlockA/C:I’mgoingtosayaletterofthealphabet.WhenIbegin,Iwantyoutotellmeasmanywordsasyoucanthatbeginwiththatletter.Noneofthewordscanbenamesofpeople,orplaces,ornumbers.Forexample,IfIgaveyoutheletterT,youcouldsaytoy,tooth,andsoforthbutyoushouldnotsayTombecausethatisaperson’sname,youshouldnotsayTexasbecausethatisthenameofaplace,andyoushouldnotsaytwelvebecausethatisanumber.Also,donotgivemethesamewordwithdifferentendings.Forexample,ifyousaytake,youshouldnotalsosaytakesortaking.Doyouhaveanyquestions?Takeasmuchtimeasyouneed.Thefirstletteris__________<Allowatleast60secondsorlongerifparticipantisstillgeneratingitems-scoreonlythosefromfirst60seconds>

ð BlockB/D:Wearegoingtodothistaskagainusingsomenewletters.Asbefore,I’mgoingtosayaletterofthealphabet.Forexample,ifyousaytake,youshouldnotalsosaytakesortaking.Doyouhaveanyquestions?Takeasmuchtimeasyouneed.Thefirstletteris__________<Allowatleast60secondsorlongerifparticipantisstillgeneratingitems-scoreonlythosefromfirst60seconds>

ð Condition1:LetterFluency-TimePressuredInstructions:ð BlockA/C:I’mgoingtosayaletterofthealphabet.WhenIbegin,Iwantyoutotellmeasmanywordsasyoucanthatbeginwiththatletter.Noneofthewordscanbenamesofpeople,orplaces,ornumbers.Forexample,IfIgaveyoutheletterT,youcouldsaytoy,tooth,andsoforthbutyoushouldnotsayTombecausethatisaperson’sname,youshouldnotsayTexasbecausethatisthenameofaplace,andyoushouldnotsaytwelvebecausethatisanumber.Also,donotgivemethesamewordwithdifferentendings.Forexample,ifyousaytake,youshouldnotalsosaytakesortaking.Doyouhaveanyquestions?Iammeasuringthenumberofwordsyoucangeneratein60secondssoitisimportantthatyouworkveryfast.Doyouhaveanyquestions?Thefirstletteris__________<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds>

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ð BlockB/D:Wearegoingtodothistaskagainusingsomenewletters.Asbefore,I’mgoingtosayaletterofthealphabet.Forexample,ifyousaytake,youshouldnotalsosaytakesortaking.Doyouhaveanyquestions?Iammeasuringthenumberofwordsyoucangeneratein60secondssoitisimportantthatyouworkveryfast.Doyouhaveanyquestions?Thefirstletteris__________<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds>

ð Condition2:CategoryFluency-OriginalInstructions:ð BlockA/C:Nowwearegoingtodosomethingalittledifferent.Thistime,Iwantyoutotellmeasmanyanimals/itemsofclothingasyoucan.Itdoesn’tmatterwhatlettertheystartwith.Doyouhaveanyquestions?Beginwhenyouareready<Allowatleast60secondsorlongerifparticipantisstillgeneratingitems-scoreonlythosefromfirst60seconds>

ð 2ndTask:Nowtellmeasmanyboys/girlsnamesasyoucan.Ready?Beginwhenyouareready<Allowatleast60secondsorlongerifparticipantisstillgeneratingitems-scoreonlythosefromfirst60seconds>

ð BlockB/D:Thistimewearegoingtodothisagainwithanewcategory.Thistime,Iwantyoutotellmeasmanyanimals/itemsofclothingasyoucan.Doyouhaveanyquestions?Ready?Beginwhenyouareready<Allowatleast60secondsorlongerifparticipantisstillgeneratingitems-scoreonlythosefromfirst60seconds>

ð 2ndTask:Nowtellmeasmanyboys/girlsnamesasyoucan.Ready?Beginwhenyouareready<Allowatleast60secondsorlongerifparticipantisstillgeneratingitems-scoreonlythosefromfirst60seconds>

ð Condition2:CategoryFluency-TimePressuredInstructions:ð BlockA/C:Nowwearegoingtodosomethingalittledifferent.Thistime,Iwantyoutotellmeasmanyanimals/itemsofclothingasyoucan.Itdoesn’tmatterwhatlettertheystartwith.Iammeasuringthenumberofwordsyoucangeneratein60secondssoitisimportantthatyouworkveryfast.Doyouhaveanyquestions?WhenIsayGo,tellmeasmanyanimals/itemsofclothingasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds>

ð 2ndTask:Nowtellmeasmanyboys/girlsnamesasyoucan.Iamstillmeasuringthenumberofwordsyoucangeneratein60secondssoworkveryfast.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds.>

ð BlockB/D:Thistimewearegoingtodothisagainwithanewcategory.Thistime,Iwantyoutotellmeasmanyanimals/itemsofclothingasyoucan..Iammeasuringthenumberofwordsyoucangeneratein60secondssoitisimportantthatyouworkveryfast.Doyouhaveanyquestions?WhenIsayGo,tellmeasmanyanimals/itemsofclothingasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds>

109

ð 2ndTask:Nowtellmeasmanyboys/girlsnamesasyoucan.Iamstillmeasuringthenumberofwordsyoucangeneratein60secondssoworkveryfast.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds>

ð Condition3:CategorySwitching-UnpressuredInstructions:ð BlockA/C:Nowwearegoingtodosomethingalittledifferent.Iwantyoutoswitchbackandforthbetweensayingasmanyfruits/vegetablesandasmanypiecesoffurniture/musicalinstrumentsasyoucan.Itdoesn’tmatterwhatlettertheystartwith.So,youwouldsayafruit/vegetable,thenapieceoffurniture/musicalinstrumentandsoon.Youcanstartwitheitherafruit/vegetableorapieceoffurniture/musicalinstrument.Doyouhaveanyquestions?Beginwhenyouareready<Allowatleast60secondsorlongerifparticipantisstillgeneratingitems-scoreonlythosefromfirst60seconds>

ð BlockB/D:Thistimewearegoingtodothisagainwithtwonewcategories.Iwantyoutoswitchbackandforthbetweensayingasmanyfruits/vegetablesandasmanypiecesoffurniture/musicalinstrumentsasyoucan.Itdoesn’tmatterwhatlettertheystartwith.Youwillhave60secondsbeforeItellyoutostop.Doyouhaveanyquestions?Beginwhenyouareready<Allowatleast60secondsorlongerifparticipantisstillgeneratingitems-scoreonlythosefromfirst60seconds>

ð Condition3:CategorySwitching-TimePressuredInstructions:ð BlockA/C:Nowwearegoingtodosomethingalittledifferent.Iwantyoutoswitchbackandforthbetweensayingasmanyfruitsandasmanypiecesoffurniture/musicalinstrumentsasyoucan.Itdoesn’tmatterwhatlettertheystartwith.Youwillhave60secondsbeforeItellyoutostop.So,youwouldsayafruit/vegetable,thenapieceoffurniture/musicalinstrumentandsoon.Youcanstartwitheitherafruit/vegetableorapieceoffurniture/musicalinstrument.Iamstillmeasuringthenumberofwordsyoucangeneratein60secondssoworkveryfast.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds.>

ð BlockB/D:Thistimewearegoingtodothisagainwithtwonewcategories.Iwantyoutoswitchbackandforthbetweensayingasmanyfruits/vegetablesandasmanypiecesoffurniture/musicalinstrumentsasyoucan.Itdoesn’tmatterwhatlettertheystartwith.Youwillhave60secondsbeforeItellyoutostop.Iamstillmeasuringthenumberofwordsyoucangeneratein60secondssoworkveryfast.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds.>

DesignFluency

ð TheDesignFluencyTestmeasuresone’sinitiationofproblem-solvingbehavior,fluencyingeneratingvisualpatterns,creativityindrawingnewdesigns,simultaneousprocessingindrawingthedesignswhileobservingtherulesandrestrictionsofthe

110

task,andinhibitingpreviouslydrawnresponses.

ð Condition1:FilledDots-UntimedInstructions:ð BlockA/C:Herearethreesquares,eachwithdotsinside.Iwantyoutomakeadifferentdesignineachsquarebyconnectingdotsandalwaysusingstraightlines.I’dlikeyoutomakethedesignsusingonlyfourstraightlinestoconnectthedots.Makesureeachlineyoudrawstartswithadotandendswithadot.Also,makeeachlinetouchatleastoneotherlineatadot,likethis.[DRAWEXAMPLE]Seehowthesetwolinestouchatthisdot?It’sOKifyourlinescrosseachother,anditdoesn’tmatterwhetherornotyourdesignscanbenamed.Doyouhaveanyquestions?

[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]Whenyouarereadytobegin,drawasmanydifferentdesignsasyoucan.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?Beginwhenyouareready.

ð BlockB/D:Herearethreesquares,eachwithdotsinside.Iwantyoutomakeadifferentdesignineachsquarebyconnectingdotsandalwaysusingstraightlines.I’dlikeyoutomakethedesignsusingonlyfourstraightlinestoconnectthedots.Makesureeachlineyoudrawstartswithadotandendswithadot.Also,makeeachlinetouchatleastoneotherlineatadot,likethis.[DRAWEXAMPLE]Seehowthesetwolinestouchatthisdot?It’sOKifyourlinescrosseachother,anditdoesn’tmatterwhetherornotyourdesignscanbenamed.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]

Whenyouarereadytobegin,drawasmanydifferentdesignsasyoucan.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?Beginwhenyouareready.

ð Condition1:FilledDots-Time-PressuredInstructions:ð BlockA/C:Herearethreesquares,eachwithdotsinside.Iwantyoutomakeadifferentdesignineachsquarebyconnectingdotsandalwaysusingstraightlines.I’dlikeyoutomakethedesignsusingonlyfourstraightlinestoconnectthedots.Makesureeachlineyoudrawstartswithadotandendswithadot.Also,makeeachlinetouchatleastoneotherlineatadot,likethis.[DRAWEXAMPLE]Seehowthesetwolinestouchatthisdot?It’sOKifyourlinescrosseachother,anditdoesn’tmatterwhetherornotyourdesignscanbenamed.Doyouhaveanyquestions?

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[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]

ð WhenIsaybegin,drawasmanydifferentdesignsasyoucanin60seconds.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?.Remember,Iammeasuringthenumberofdifferentdesignsyoucancreatein60seconds.Soworkasfastasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds.>

ð BlockB/D:Herearethreesquares,eachwithdotsinside.Iwantyoutomakeadifferentdesignineachsquarebyconnectingdotsandalwaysusingstraightlines.I’dlikeyoutomakethedesignsusingonlyfourstraightlinestoconnectthedots.Makesureeachlineyoudrawstartswithadotandendswithadot.Also,makeeachlinetouchatleastoneotherlineatadot,likethis.[DRAWEXAMPLE]Seehowthesetwolinestouchatthisdot?It’sOKifyourlinescrosseachother,anditdoesn’tmatterwhetherornotyourdesignscanbenamed.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]


ð Condition2:EmptyDotsOnly-UntimedInstructions:ð BlockA/C:Herearethreesquares,eachwithtendots.Fiveofthedotsarefilledandfiveofthemempty(pointtoanexampleofeach).Iwantyoutomakeadifferencedesignineachsquarebyconnectingonlyemptydots.Thatis,don’ttouchthefilleddots;justconnecttheemptydots.Likebefore,useonlystraightlinesandmakeeachlinetouchatleastoneotherlineatthedot.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]


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ð BlockB/D:Herearethreesquares,eachwithtendots.Fiveofthedotsarefilledandfiveofthemempty(pointtoanexampleofeach).Iwantyoutomakeadifferencedesignineachsquarebyconnectingonlyemptydots.Thatis,don’ttouchthefilleddots;justconnecttheemptydots.Likebefore,useonlystraightlinesandmakeeachlinetouchatleastoneotherlineatthedot.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]


ð Condition2:EmptyDotsOnly-Time-PressuredInstructions:ð BlockA/C:Herearethreesquares,eachwithtendots.Fiveofthedotsarefilledandfiveofthemempty(pointtoanexampleofeach).Iwantyoutomakeadifferencedesignineachsquarebyconnectingonlyemptydots.Thatis,don’ttouchthefilleddots;justconnecttheemptydots.Likebefore,useonlystraightlinesandmakeeachlinetouchatleastoneotherlineatthedot.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]




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ð Condition3:Switching-UntimedInstructions:ð BlockA/C:Herearethreesquares,eachwithtendots.Fiveofthedotsarefilledandfiveofthemempty(pointtoanexampleofeach).Iwantyoutomakeadifferencedesignineachsquarebyconnectingonlyemptydots.Thatis,don’ttouchthefilleddots;justconnecttheemptydots.Likebefore,useonlystraightlinesandmakeeachlinetouchatleastoneotherlineatthedot.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]


ð BlockB/D:Herearethreesquares,eachwithtendots.Fiveofthedotsarefilledandfiveofthemempty(pointtoanexampleofeach).Iwantyoutomakeadifferencedesignineachsquarebyconnectingonlyemptydots.Thatis,don’ttouchthefilleddots;justconnecttheemptydots.Likebefore,useonlystraightlinesandmakeeachlinetouchatleastoneotherlineatthedot.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]Whenyouarereadytobegin,drawasmanydifferentdesignsasyoucan.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?Beginwhenyouareready.

ð Condition3:Switching-Time-PressuredInstructions:ð BlockA/C:Herearethreesquares,eachwithtendots.Fiveofthedotsarefilledandfiveofthemempty(pointtoanexampleofeach).Iwantyoutomakeadifferencedesignineachsquarebyconnectingonlyemptydots.Thatis,don’ttouchthefilleddots;justconnecttheemptydots.Likebefore,useonlystraightlinesandmakeeachlinetouchatleastoneotherlineatthedot.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]

ð WhenIsaybegin,drawasmanydifferentdesignsasyoucanin60seconds.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?Remember,Iammeasuringthenumberofdifferentdesignsyoucancreatein60seconds.Workasfastasyoucan.Go!

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<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds.>


ð WhenIsaybegin,drawasmanydifferentdesignsasyoucanin60seconds.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?Remember,Iammeasuringthenumberofdifferentdesignsyoucancreatein60seconds.Workasfastasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds.>

CardSorting

ð TheSortingTestmeasuresconcept-formationskills,modality-specificproblem-solvingskills(verbal/nonverbal),andtheabilitytoexplainsortingconceptsabstractly

ð FreeSorting-Pre-Instructions:I’mgoingtoshowyousixcardsthatcanbesortedindifferentways.Iwantyoutoseehowmanydifferentwaysyoucansortthecards.LetmeshowyouwhatImeanwiththesecards>.Lookatthesecards.WatchhowIsortthemintotwogroupswiththreecardsineachgroup.<point>Next,I’llexplainhowIsortedthembysaying,thisgrouphascircles,andthisgrouphassquares.NoticehowIexplainedbothgroupsnotjustoneofthem.NowwatchwhileIsortthemanotherway,againwithtwogroupsonthreecardsineachgroup.IwillexplainhowIsortedthembysaying,thisgrouphasboys’namesandthisgrouphasgirls’names.DoyouhaveanyquestionsabouthowIdidthis?

ð Condition1:FreeSorting-UnpressuredInstructions:ð BlockA/C:ð CardSet1/3:I’mgoingtoshowyousixnewcardsthatcanbesortedinmanydifferentways.I’dliketoseehowmanydifferentwaysyoucansortthecards.Eachtime,makeonlytwogroupswiththreecardsineachgroup.Thethreecardsineachgroupshouldbesimilarinsomeway.Afteryousorttwocardsintotwogroups,tellmehowyoudidit.Besuretotellmehowyousortedbothgroups,notjustoneofthem.Onceyousortthecardsoneway,donotsortthemthatwayagain.Takeasmuchtimeasyouneed.Hereisapagethatwillhelpyouremembertheserules.<flipcard>Now,trysortingthesecardsinasmanydifferentwaysasyoucan.Ready?Begin.<UseCardSet1/3>Stoptimewhen

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examineecompleteshisorhersortandbeginstodescribethesortingstrategy>Nowtrytosorttheminadifferentway<restarttimerduringsort>

ð CardSet2/4:I’mgoingtoshowyousixnewcardsthatcanbesortedinmanydifferentways.Likebefore,I’dliketoseehowmanydifferentwaysyoucansortthesecards.Eachtime,makeonlytwogroupswiththreecardsineachgroup.Thethreecardsineachgroupshouldbesimilarinsomeway.Afteryousorttwocardsintotwogroups,tellmehowyoudidit.Besuretotellmehowyousortedbothgroups,notjustoneofthem.Onceyousortthecardsoneway,donotsortthemthatwayagain.Takeasmuchtimeasyouneed.Againhereisapagethatwillhelpyouremembertheserules.<flipcard>Now,trysortingthesecardsinasmanydifferentwaysasyoucan.Ready?Begin.<UseCardSet1/3>Stoptimewhenexamineecompleteshisorhersortandbeginstodescribethesortingstrategy>Nowtrytosorttheminadifferentway.<restarttimerduringsort>

ð <Discontinueafter4minutessorttime(doesn’tincludedescriptiontime)orwhenparticipantindicatesthattheycannotthinkofanotherway>

ð BlockB/D:ð CardSet1/3:I’mgoingtoshowyousixnewcardsthatcanbesortedinmanydifferentways.I’dliketoseehowmanydifferentwaysyoucansortthecards.Eachtime,makeonlytwogroupswiththreecardsineachgroup.Thethreecardsineachgroupshouldbesimilarinsomeway.Afteryousorttwocardsintotwogroups,tellmehowyoudidit.Besuretotellmehowyousortedbothgroups,notjustoneofthem.Onceyousortthecardsoneway,donotsortthemthatwayagain.Takeasmuchtimeasyouneed.Hereisapagethatwillhelpyouremembertheserules.<flipcard>Now,trysortingthesecardsinasmanydifferentwaysasyoucan.Ready?Begin.<UseCardSet1/3;Stoptimewhenexamineecompleteshisorhersortandbeginstodescribethesortingstrategy>Nowtrytosorttheminadifferentway<restarttimerduringsort>

ð CardSet2/4:I’mgoingtoshowyousixnewcardsthatcanbesortedinmanydifferentways.Likebefore,I’dliketoseehowmanydifferentwaysyoucansortthesecards.Eachtime,makeonlytwogroupswiththreecardsineachgroup.Thethreecardsineachgroupshouldbesimilarinsomeway.Afteryousorttwocardsintotwogroups,tellmehowyoudidit.Besuretotellmehowyousortedbothgroups,notjustoneofthem.Onceyousortthecardsoneway,donotsortthemthatwayagain.Takeasmuchtimeasyouneed.Againhereisapagethatwillhelpyouremembertheserules.<flipcard>Now,trysortingthesecardsinasmanydifferentwaysasyoucan.Ready?Begin.<UseCardSet1/3;Stoptimewhenexamineecompleteshisorhersortandbeginstodescribethesortingstrategy>Nowtrytosorttheminadifferentway.<restarttimerduringsort>


ð Condition1:FreeSorting–Time-PressuredInstructions:ð BlockA/C:ð CardSet1/3:I’mgoingtoshowyousixnewcardsthatcanbesortedinmanydifferentways.I’dliketoseehowmanydifferentwaysyoucansortthecards.Eachtime,makeonlytwogroupswiththreecardsineachgroup.Thethreecardsineachgroupshouldbe

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similarinsomeway.Afteryousorttwocardsintotwogroups,tellmehowyoudidit.Besuretotellmehowyousortedbothgroups,notjustoneofthem.Onceyousortthecardsoneway,donotsortthemthatwayagain.Remember,Iammeasuringthenumberofdifferentsortyoucancompletein4minutes.Workasfastasyoucan.Hereisapagethatwillhelpyouremembertheserules.<flipcard>Now,trysortingthesecardsinasmanydifferentwaysasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=240seconds.><UseCardSet1/3;Stoptimewhenexamineecompleteshisorhersortandbeginstodescribethesortingstrategy>Nowtrytosorttheminadifferentway<restarttimerduringsort>

ð CardSet2/4:I’mgoingtoshowyousixnewcardsthatcanbesortedinmanydifferentways.Likebefore,I’dliketoseehowmanydifferentwaysyoucansortthesecards.Eachtime,makeonlytwogroupswiththreecardsineachgroup.Thethreecardsineachgroupshouldbesimilarinsomeway.Afteryousorttwocardsintotwogroups,tellmehowyoudidit.Besuretotellmehowyousortedbothgroups,notjustoneofthem.Onceyousortthecardsoneway,donotsortthemthatwayagain.Remember,Iammeasuringthenumberofdifferentsortsyoucancompletein4minutes.Workasfastasyoucan.Hereisapagethatwillhelpyouremembertheserules.<flipcard>Now,trysortingthesecardsinasmanydifferentwaysasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=240seconds.><UseCardSet1/3>Stoptimewhenexamineecompleteshisorhersortandbeginstodescribethesortingstrategy>Nowtrytosorttheminadifferentway.<restarttimerduringsort>


ð BlockB/D:ð CardSet1/3:I’mgoingtoshowyousixnewcardsthatcanbesortedinmanydifferentways.I’dliketoseehowmanydifferentwaysyoucansortthecards.Eachtime,makeonlytwogroupswiththreecardsineachgroup.Thethreecardsineachgroupshouldbesimilarinsomeway.Afteryousorttwocardsintotwogroups,tellmehowyoudidit.Besuretotellmehowyousortedbothgroups,notjustoneofthem.Onceyousortthecardsoneway,donotsortthemthatwayagain.Remember,Iammeasuringthenumberofdifferentsortsyoucancompletein4minutes.Workasfastasyoucan.Hereisapagethatwillhelpyouremembertheserules.<flipcard>Now,trysortingthesecardsinasmanydifferentwaysasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=240seconds.><UseCardSet1/3>Stoptimewhenexamineecompleteshisorhersortandbeginstodescribethesortingstrategy>Nowtrytosorttheminadifferentway<restarttimerduringsort>

ð CardSet2/4:I’mgoingtoshowyousixnewcardsthatcanbesortedinmanydifferentways.Likebefore,I’dliketoseehowmanydifferentwaysyoucansortthesecards.Eachtime,makeonlytwogroupswiththreecardsineachgroup.Thethreecardsineachgroupshouldbesimilarinsomeway.Afteryousorttwocardsintotwogroups,tellmehowyoudidit.Besuretotellmehowyousortedbothgroups,notjustoneofthem.Onceyousortthecardsoneway,donotsortthemthatwayagain.Remember,Iammeasuringthenumberofdifferentsortsyoucancompletein4minutes.Workasfastasyoucan.

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Hereisapagethatwillhelpyouremembertheserules.<flipcard>Now,trysortingthesecardsinasmanydifferentwaysasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=240seconds.><UseCardSet1/3>Stoptimewhenexamineecompleteshisorhersortandbeginstodescribethesortingstrategy>Nowtrytosorttheminadifferentway.<restarttimerduringsort>


ð Condition2:SortRecognition-UnpressuredInstructions:ð BlockA/C:ð CardSet1/3:NowI’mgoingtoputthesecardsintotwogroupsofthreecardseach.Thethreecardsineachgroupwillbethesameinsomeway.Iwantyoutotellmehowthecardsarethesameineachgroup.BesuretotellmehowIsortedbothgroups,notjustoneofthem.IwillusedifferentwayofsortingthecardseachtimeIputthemintogroups.Takeasmuchtimeasyouneed.<placecardsintosetaccordingtorulesintestmanual;waitforparticipanttoexplainsort.>Good,nowI’mgoingtosortthecardsinadifferentway.AgainIwantyoutotellmehowIsortedthetwogroups.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=240seconds.><Repeatthrough8sorts>.

ð CardSet2/4:Likebefore,I’mgoingtoputthesecardsintotwogroupsofthreecardseach.Thethreecardsineachgroupwillbethesameinsomeway.Iwantyoutotellmehowthecardsarethesameineachgroup.BesuretotellmehowIsortedbothgroups,notjustoneofthem.IwillusedifferentwayofsortingthecardseachtimeIputthemintogroups.Takeasmuchtimeasyouneed.<placecardsintosetaccordingtorulesintestmanual;waitforparticipanttoexplainsort.>Good,nowI’mgoingtosortthecardsinadifferentway.AgainIwantyoutotellmehowIsortedthetwogroups.Takeasmuchtimeasyouneed.<Repeatthrough8sorts>.

ð BlockB/D:ð CardSet1/3:NowI’mgoingtoputthesecardsintotwogroupsofthreecardseach.Thethreecardsineachgroupwillbethesameinsomeway.Iwantyoutotellmehowthecardsarethesameineachgroup.BesuretotellmehowIsortedbothgroups,notjustoneofthem.IwillusedifferentwayofsortingthecardseachtimeIputthemintogroups.Takeasmuchtimeasyouneed.<placecardsintosetaccordingtorulesintestmanual;waitforparticipanttoexplainsort.>Good,nowI’mgoingtosortthecardsinadifferentway.AgainIwantyoutotellmehowIsortedthetwogroups.Takeasmuchtimeasyouneed.<Repeatthrough8sorts>.

ð CardSet2/4:Likebefore,I’mgoingtoputthesecardsintotwogroupsofthreecardseach.Thethreecardsineachgroupwillbethesameinsomeway.Iwantyoutotellmehowthecardsarethesameineachgroup.BesuretotellmehowIsortedbothgroups,notjustoneofthem.IwillusedifferentwayofsortingthecardseachtimeIputthemintogroups.Takeasmuchtimeasyouneed.<placecardsintosetaccordingtorulesintestmanual;waitforparticipanttoexplainsort.>Good,nowI’mgoingtosortthecards

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inadifferentway.AgainIwantyoutotellmehowIsortedthetwogroups.Takeasmuchtimeasyouneed.<Repeatthrough8sorts>.

ð Condition2:SortRecognition–Time-PressuredInstructions:ð BlockA/C:ð CardSet1/3:NowI’mgoingtoputthesecardsintotwogroupsofthreecardseach.Thethreecardsineachgroupwillbethesameinsomeway.Iwantyoutotellmehowthecardsarethesameineachgroup.BesuretotellmehowIsortedbothgroups,notjustoneofthem.IwillusedifferentwayofsortingthecardseachtimeIputthemintogroups.Iammeasuringhowfastyoucanidentifythesortingrules.Workasfastasyoucan.<placecardsintosetaccordingtorulesintestmanual;waitforparticipanttoexplainsort.>Good,nowI’mgoingtosortthecardsinadifferentway.AgainIwantyoutotellmehowIsortedthetwogroups.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Assoonasoneisidentified,sortnewsetandsayGo!<Repeatthrough8sorts>.

ð CardSet2/4:Likebefore,I’mgoingtoputthesecardsintotwogroupsofthreecardseach.Thethreecardsineachgroupwillbethesameinsomeway.Iwantyoutotellmehowthecardsarethesameineachgroup.BesuretotellmehowIsortedbothgroups,notjustoneofthem.IwillusedifferentwayofsortingthecardseachtimeIputthemintogroups.Iammeasuringhowfastyoucanidentifythesortingrules.Workasfastasyoucan.<placecardsintosetaccordingtorulesintestmanual;waitforparticipanttoexplainsort.>Good,nowI’mgoingtosortthecardsinadifferentway.AgainIwantyoutotellmehowIsortedthetwogroups.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Assoonasoneisidentified,sortnewsetandsayGo!.<Repeatthrough8sorts>.

ð BlockB/D:ð CardSet1/3:NowI’mgoingtoputthesecardsintotwogroupsofthreecardseach.Thethreecardsineachgroupwillbethesameinsomeway.Iwantyoutotellmehowthecardsarethesameineachgroup.BesuretotellmehowIsortedbothgroups,notjustoneofthem.IwillusedifferentwayofsortingthecardseachtimeIputthemintogroups.Iammeasuringhowfastyoucanidentifythesortingrules.Workasfastasyoucan.<placecardsintosetaccordingtorulesintestmanual;waitforparticipanttoexplainsort.>Good,nowI’mgoingtosortthecardsinadifferentway.AgainIwantyoutotellmehowIsortedthetwogroups.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Assoonasoneisidentified,sortnewsetandsayGo!<Repeatthrough8sorts>.

ð CardSet2/4:Likebefore,I’mgoingtoputthesecardsintotwogroupsofthreecardseach.Thethreecardsineachgroupwillbethesameinsomeway.Iwantyoutotellmehowthecardsarethesameineachgroup.BesuretotellmehowIsortedbothgroups,notjustoneofthem.IwillusedifferentwayofsortingthecardseachtimeIputthemintogroups.Iammeasuringhowfastyoucanidentifythesortingrules.Workasfastasyoucan.<placecardsintosetaccordingtorulesintestmanual;waitforparticipanttoexplainsort.>Good,nowI’mgoingtosortthecardsinadifferentway.AgainIwantyou

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totellmehowIsortedthetwogroups.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Assoonasoneisidentified,sortnewsetandsayGo!<Repeatthrough8sorts>.

TwentyQuestions

ð TheTwentyQuestionsTestmeasurestheabilitytocategorize,formulateabstract,yes/noquestions,andincorporatetheexaminer’sfeedbacktoformulatemoreefficientyes/noquestions

ð OriginalInstructions:ð BlockA/C:Nowwearegoingtodosomethingwhereyouaskmequestions.IhavepickedoneofthesepicturesandIwantyoutofigureoutwhichonebyaskingmequestions.YoucanonlyaskquestionsthatIcanansweryesorno.Youcanaskanyquestionatall,aslongasIcanansweryesorno.TrytoguessthepicturethatIhavepickedwiththefewestnumberofquestionsyoucan.IamgoingtowritedownyourquestionssoIcanrememberthem.Youcantakeasmuchtimeasyouneedtothinkofthequestions.Butyouarelimitedtoatotalof20questionstofigureoutwhichpictureIhaveselected.2ndTask:Good,Let’strythenextone.I’vepickedanewpicture,andIwantyoutoaskmethefewestnumberofyes/noquestionsyoucantofigureoutwhichoneitis.Takeasmuchtimeasyouneed.Beginwhenyouareready.(FormA/Citems:banana,spoon,owl,helicopter)

ð BlockB/D:BlockA/C:Nowwearegoingtodosomethingwhereyouaskmequestions.IhavepickedoneofthesepicturesandIwantyoutofigureoutwhichonebyaskingmequestions.YoucanonlyaskquestionsthatIcanansweryesorno.Youcanaskanyquestionatall,aslongasIcanansweryesorno.TrytoguessthepicturethatIhavepickedwiththefewestnumberofquestionsyoucan.IamgoingtowritedownyourquestionssoIcanrememberthem.Youcantakeasmuchtimeasyouneedtothinkofthequestions.Butyouarelimitedtoatotalof20questionstofigureoutwhichpictureIhaveselected.2ndTask:Good,Let’strythenextone.I’vepickedanewpicture,andIwantyoutoaskmethefewestnumberofyes/noquestionsyoucantofigureoutwhichoneitis.Takeasmuchtimeasyouneed.Beginwhenyouareready.(FormA/Citems:airplane,rose,stove,corn)

ð Time-PressuredInstructions:ð BlockA/C:Nowwearegoingtodosomethingwhereyouaskmequestions.IhavepickedoneofthesepicturesandIwantyoutofigureoutwhichonebyaskingmequestions.YoucanonlyaskquestionsthatIcanansweryesorno.Youcanaskanyquestionatall,aslongasIcanansweryesorno.TrytoguessthepicturethatIhavepickedwiththefewestnumberofquestionsyoucan.IamgoingtowritedownyourquestionssoIcanrememberthem.Iammeasuringhowfastyoucanaskmethequestionsandyouarelimitedtoatotalof20questionstofigureoutwhichpictureIhaveselected.2ndTask:Good,Let’strythenextone.I’vepickedanewpicture,andIwantyoutoaskmethe

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fewestnumberofyes/noquestionsyoucantofigureoutwhichoneitis.Iammeasuringhowfastyouare.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.>(FormA/Citems:banana,spoon,owl,helicopter)

ð BlockB/D:BlockA/C:Nowwearegoingtodosomethingwhereyouaskmequestions.IhavepickedoneofthesepicturesandIwantyoutofigureoutwhichonebyaskingmequestions.YoucanonlyaskquestionsthatIcanansweryesorno.Youcanaskanyquestionatall,aslongasIcanansweryesorno.TrytoguessthepicturethatIhavepickedwiththefewestnumberofquestionsyoucan.IamgoingtowritedownyourquestionssoIcanrememberthem.Iammeasuringhowfastyoucanaskmethequestionsandyouarelimitedtoatotalof20questionstofigureoutwhichpictureIhaveselected.2ndTask:Good,Let’strythenextone.I’vepickedanewpicture,andIwantyoutoaskmethefewestnumberofyes/noquestionsyoucantofigureoutwhichoneitis.Iammeasuringhowfastyouare.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.>(FormA/Citems:airplane,rose,stove,corn)

TorranceTestofCreativeThinkingAlternateInstructions

ð ProductImprovementð OriginalInstructionsforWrittenResponse(Forreferenceonly-notused)ð Hereisastuffedtoymonkey/elephantofthekindyoucanbuyinmostnoveltystoresforaboutfivetosixdollars.Itisaboutsixinchestallandweighsaboutsixounces/halfapound.Inthespacesonthispageandthenextone,Iwantyoutogivemealistofthecleverest,mostinterestingandunusualwaysyoucanthinkofforchangingthistoymonkey/elephantsothatchildrenwouldhavemorefunplayingwithit.Don’tworryabouthowmuchthechangewouldcost.Thinkonlyaboutwhatwouldmakeitmorefuntoplaywithasatoy.

ð AphasiaFriendlyInstructions,Verbalresponse,andPhysicalobjectð Thisisatoymonkey/elephant(handtotheparticipant).Youmightbuyitforaboutfivetosixdollars.Asyoucansee,itisaboutsixinchestallandweighsaboutsixounces.Forthistask,Iwantyoutogivemealistofthecleverest,mostinterestingandunusualwaysyoucanthinkofforchangingthistoymonkey/elephantsothatchildrenwouldhavemorefunplayingwithit.Don’tworryabouthowmuchthechangewouldcost.Thinkonlyaboutwhatwouldmakeitmorefuntoplaywithasatoy.

ð Participantisallowed(althoughnottold)topickupandmanipulateobjectbutwillonlybegivencreditforverbalresponses.

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ð TimePressureCondition-AphasiaFriendlyInstructions,Verbalresponse,andPhysicalobject

ð Thisisatoymonkey/elephant(handtotheparticipant).Youmightbuyitforaboutfivetosixdollars.Asyoucansee,itisaboutsixinchestallandweighsaboutsixounces.Forthistask,Iwantyoutogivemealistofthecleverest,mostinterestingandunusualwaysyoucanthinkofforchangingthistoymonkey/elephantsothatchildrenwouldhavemorefunplayingwithit.Don’tworryabouthowmuchthechangewouldcost.Thinkonlyaboutwhatwouldmakeitmorefuntoplaywithasatoy.Youonlyhave3minutes.Soworkquicklyanduseyourtimewisely.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=3minutes.>

ð Participantisallowed(althoughnottold)topickupandmanipulateobjectbutwillonlybegivencreditforverbalresponses.

UnusualUses

ð OriginalInstructionsforWrittenResponse(Forreferenceonly-notused)ð Mostpeoplethrowtheiremptycardboardboxesaway,buttheyhavethousandsofinterestingandunusualuses.Inthespacesbelowandonthenextpage,listasmanyoftheseinterestingandunusualusesasyoucanthinkof.Donotlimityourselftoanyonesizeofbox.Youmayuseasmanyboxesasyoulike.Donotlimityourselftotheusesyouhaveseenorheardabout;thinkaboutasmanypossibleusesasyoucan.

ð AphasiaFriendlyInstructionsandVerbalresponseð Mostpeoplethrowtheiremptycardboardboxesaway,buttheyhavethousandsofinterestingandunusualuses.Forthistask,Iwantyoutolistasmanyoftheseinterestingandunusualusesasyoucanthinkofforacardboardbox.Donotlimityourselftoanyonesizeofbox.Youmayuseasmanyboxesasyoulike.Donotlimityourselftotheusesyouhaveseenorheardabout;thinkaboutasmanypossibleusesasyoucan.

ð TimePressureCondition-AphasiaFriendlyInstructionsandVerbalresponseð Mostpeoplethrowtheiremptycardboardboxesaway,buttheyhavethousandsofinterestingandunusualuses.Forthistask,Iwantyoutolistasmanyoftheseinterestingandunusualusesasyoucanthinkofforacardboardbox.Donotlimityourselftoanyonesizeofbox.Youmayuseasmanyboxesasyoulike.Donotlimityourselftotheusesyouhaveseenorheardabout;thinkaboutasmanypossibleusesasyoucan.Youonlyhave3minutes.Soworkquicklyanduseyourtimewisely.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=3minutes.>

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CommonUses

ð Verbalresponseð Weuseducttape/stringforanendlessvarietyofthings.Forthistask,Iwantyoutolistasmanyofthecommonwaysweuseducttape.Thinkaboutwaysthatyouhaveseenducttapeused.Youhaveallthetimeyouwant.

ð TimePressureCondition-Verbalresponseð Weuseducttape/stringforanendlessvarietyofthings.Forthistask,Iwantyoutolistasmanyofthecommonwaysweuseducttape.Thinkaboutwaysthatyouhaveseenducttapeused..Youonlyhave3minutes.Soworkquicklyanduseyourtimewisely.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=3minutes.>

self-reported and partner-reported functional communication …€¦ · speech, language, and...

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