Supported Reading Comprehension for People with Aphasia: Visual and Linguistic Supports

Supported Reading Comprehension for People with Aphasia: Visual and Linguistic Supports Aimee Dietz, Ph.D. Department of Communication Sciences and Disorders University of Cincinnati, Cincinnati, OH Kelly Knollman-Porter, Ph.D. Department of Speech Pathology and Audiology Miami University, Oxford, OH Karen Hux, Ph.D. Department of Special Education and Communication Disorders University of Nebraska-Lincoln, Lincoln, NE Karyn Toth, M.A., CFY-SLP Department of Communication Sciences and Disorders University of Cincinnati, Cincinnati, OH Bridget Brown, B.S. Department of Speech and Hearing Science Ohio State University, Columbus, OH Researchers have documented that certain aphasia-friendly and pretask stimulation strategies facilitate the reading and/or auditory comprehension of people with aphasia. The purpose of this preliminary study was to document the effects of no supports, visual (i.e., photograph) supports, and linguistic (i.e., heading and key words) supports provided both as pretask and during-task stimulation on the comprehension of 17 adults with aphasia when they read narratives presented with unsimplified text. A repeated measure ANOVA revealed a significant difference across the four reading support conditions. The post hoc analyses revealed that, as a group, the participants performed significantly better with supports in the form of a high-context photograph than a bank of key words. The comparison between the photograph and no support conditions approached, but did not reach, significance. Individual differences among participants were evident and underscore the need to assess various types of reading supports on an individual basis when attempting to maximize reading comprehension for people with aphasia. Key Words: aphasia, supported reading, reading comprehension, aphasia-friendly, linguistic supports, photographic supports, visual supports Journal of Medical Speech-Language Pathology Volume 21, Number 4, pp. 319 331 Copyright 2014 by Plural Publishing, Inc.

320 JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY, VOL. 21, NO. 4 People with aphasia often experience residual reading comprehension deficits long into the chronic phase of recovery (Brennan, Worrall, & McKenna, 2005; Dietz, Ball, & Griffith, 2011; Parr, 1995, 2007; Rose, Worrall, Hickson, & Hoffman, 2011a, 2011b). In part, this may be because early rehabilitation efforts tend to focus on remediating verbal expression to address the immediate demands of everyday life rather than on bolstering reading skills (Conklyn, Novak, Boissy, Bethoux, & Chemali, 2012). Also, insurance companies often limit speech-language therapy visits to 20 per year (Cameron & Wright, 2009), thus leaving little or no time to address reading comprehension deficits. Consequently, the effect of reading comprehension challenges on a person s return to work and engagement in leisure activities may remain unexplored until after completion of formal speech and language intervention services. Developing and implementing strategies to support reading comprehension may help minimize the adverse effect of aphasia on activities of daily living (Parr, 2007; Worrall et al., 2011). Over the past decade, reports outlining methods of supporting the reading comprehension of people with aphasia have emerged in the literature (e.g., Brennan et al., 2005; Dietz, Hux, McKelvey, Beukelman, & Weissling, 2009; Egan, Worrall, & Oxenham, 2004; Rose, Worrall, Hickson, & Hoffman, 2011a, 2011b; Rose, Worrall, McKenna, 2003; Worrall, Rose, Howe, Brennan, Egan, & McKenna, 2005). One result of these efforts has been the suggestion to make reading materials aphasia-friendly (Pound, Parr, Lindsay, & Woolf, 2000; Rose et al., 2003; Rose et al., 2011b). Aphasia-friendly formatting refers to the application of specific formatting guidelines that differ from those typical of print materials produced for people without reading challenges. Specifically, aphasia-friendly materials differ from standard materials in that they include abundant white space, use large and standard fonts, avoid long sentences with complex syntax and vocabulary, and, when appropriate, incorporate relevant visual supports (Brennan et al., 2005; Worrall et al., 2005). Supporting Reading Comprehension Research groups have performed investigations substantiating the benefit of using aphasia-friendly materials with people who have reading challenges associated with aphasia. For example, Rose and colleagues (2003) compared the accuracy with which people with aphasia comprehended the content of printed education materials presented in standard versus aphasia-friendly formats. Results revealed that participants comprehended significantly more information when it appeared in the aphasia-friendly versus standard format. Subsequently, Brennan and colleagues (2005) explored the individual and joint contributions of aphasia-friendly principles on the comprehension of single written paragraphs by people with aphasia. Data analysis revealed that participants comprehended significantly more when using materials incorporating a combination of four aphasia-friendly principles (i.e., simple words and sentences, large print, substantial white space, and pictures) than when using materials with none of those features. The participants with aphasia also performed significantly better given materials that incorporated simple words and sentences, large print, and large amounts of white space as isolated features than they did given standard materials; however, the inclusion of pictures as an isolated feature did not emerge as an independently-beneficial aspect of aphasia-friendly formatting. Visual Supports The lack of a significant benefit associated with pairing pictures with the reading materials used in Brennan and colleagues (2005) research is intriguing. Visual supports in the form of pictures are common in everyday reading materials such as Web pages and magazines. Intuitively, their presence seems likely to foster comprehension of related textual material. Indeed, when asked whether visual supports facilitated their reading comprehension, reading speed, and reading ease, a majority of people with aphasia responded positively (Dietz et al., 2009; Rose et al., 2011a, 2011b). One possible explanation for Brennan and colleagues finding of no significant benefit associated with pairing pictures with reading materials may relate to the type of pictures the researchers used in their experimental tasks. Specifically, the provision of line drawings rather than photographic images as visual supports may not have been optimal for the participants with aphasia. The notion that photographs are more transparent and more easily interpreted than line drawings has long-standing support (Beukelman & Mirenda, 2013). With specific regard to people with aphasia, McKelvey and her colleagues (McKelvey, Hux, Dietz, & Beukelman,

Supported Reading Comprehension for People with Aphasia 321 2010) established that high-context visual supports with realistic representations of people and events (i.e., photographs) provide greater support than line drawings during auditory comprehension tasks. During reading tasks, Dietz and her colleagues (2009) found that people with nonfluent aphasia achieved significantly higher reading comprehension scores given passages paired with photographs than passages paired with no visual supports. Rose and colleagues (2011a) further investigated this issue by comparing reading comprehension outcomes when they paired short passages with photographs, line drawings, or no visual supports. The findings contradicted those of Dietz and colleagues (2009) in that Rose s participants with aphasia performed comparably on reading comprehension accuracy across the three visual support conditions, whereas Dietz s participants performed significantly better given photographic supports than no supports. Several factors may have contributed to these discrepant findings. First, fundamental differences existed in the type of experimental reading task presented in these two studies. Dietz had participants read ten-sentence narrative passages that were second-grade-level, either with or without accompanying photographic supports. The researchers assessed comprehension by presenting cloze statements accompanied by four possible answer choices presented both in written and auditory form. In contrast, Rose had participants perform a cloze procedure to select a final word of two-sentence sixth-grade-level passages. The response options appeared as written words only, written words and line drawings, or written words and photographs. Second, differences existed in the types of participants included in the two research projects. Dietz and colleagues included only individuals with nonfluent aphasia, whereas participants in the Rose study included people both with fluent and nonfluent aphasia. In addition, Dietz s participants demonstrated relatively severe language and reading impairments based on standardized test scores, whereas Rose s participants, as a whole, achieved substantially higher scores on the same standardized measures. The conflicting findings from these two studies suggest that researchers need to investigate further the benefits of using visual supports to facilitate the reading comprehension of people with aphasia. Linguistic Supports Linguistically-based supports may also bolster the reading comprehension of people with aphasia. Rose and her colleagues (2011b) interviewed 40 people with aphasia to examine which characteristics of printed education materials and everyday reading materials they perceived as barriers versus facilitators to comprehension. Of the many important findings, participants believed linguistic supports would improve the information readability. In particular, they suggested that drawing attention to certain aspects of the material with headings or the highlighting of key elements would be beneficial. Although researchers have not extensively examined the effects of these types of linguistic supports on the reading comprehension of people with aphasia, the interview data collected by Rose and her colleagues and the findings reported in health education literature (Boyd, 1987; Davis, Fredrickson, Arnold, Murphy, Herbst, & Bocchini, 1998) suggest that such techniques have potential value. Hence, providing these types of supports to people with aphasia may facilitate their understanding of the overall gist of written passages as well as their comprehension of specific details. Pretask Stimulation Existing literature also supports the idea that providing people with aphasia with pretask stimulation facilitates their performance of linguistic tasks. More specifically, researchers have documented that hearing predictive sentences or viewing predictive drawings prior to hearing a passage improves auditory comprehension for at least some people with aphasia (Hough et al., 1989; Jones, Pierce, Mahoney, Smeach, 2007; Pierce, 1991; Pierce & Beekman, 1985; Wallace, Dietz, Hux, & Weissling, 2012; Waller & Darley, 1978). The proposed explanation for this benefit is that pretask stimulation helps contextualize information by activating prior knowledge, and, thus, people with aphasia allocate resources more efficiently to the subsequent linguistic information. Given this advantage when engaging in auditory comprehension tasks, a reasonable assumption is that pretask stimulation may also improve the reading comprehension of people with aphasia. Researchers have yet to explore this idea, however. Study Rationale and Purpose Researchers have documented that certain aphasia-friendly and prestimulation strategies facilitate the comprehension of people with aphasia.

322 JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY, VOL. 21, NO. 4 Everyday reading materials available to the lay public routinely incorporate or can easily integrate, given small modifications, some of these strategies. For example, adding pictures, enlarging font, or including headings is easy to accomplish with existing materials. Other supports, however, require specialized materials and/or timely preparation. For example, altering materials to have simplified vocabulary and sentence structures requires someone to rewrite entire documents. The availability of such materials is limited, thus restricting the practicality of implementation by practitioners and family members. Given this scenario, investigations incorporating the types of supports that are easy to append to or modify within existing materials are particularly important. The intent of the research presented herein was to investigate the effects of three commonly implemented supports, that is, providing photographs, key words, or headings. To maximize the likelihood of being beneficial, the researchers provided the supports both before and during the actual reading activities. Therefore, as a part of a larger investigation, the purpose of this preliminary study was to document the effects of linguistic and visual supports, provided both as pretask and during-task stimulation, on the comprehension of people with aphasia when they read narratives presented with unsimplified text. More specifically, the researchers compared reading comprehension accuracy scores achieved when participants read narratives with no support, linguistic support, or visual support. Linguistic support included provision of either a heading or a list of key words; photographic support involved provision of a high-context photograph depicting relevant environmental and relational information. Participants Methods Participants included 17 right-hand dominant adults who had aphasia secondary to left hemisphere cerebrovascular accidents. All participants had negative histories of major psychotic episodes or intractable substance abuse, had at least high school educations, and were native speakers of American English. Performance of screening tests confirmed visual and hearing acuity adequate for performance of the experimental tasks. The participants with aphasia were at least 12 months poststroke (M = 87.71, SD = 78.55) at the time of study completion. Twelve displayed nonfluent aphasia (i.e., nine with Broca s aphasia and three with global aphasia), and the remaining five displayed fluent aphasia (i.e., one with Wernicke s aphasia, one with conduction aphasia, one with transcortical sensory aphasia, and two with anomic aphasia) as determined through their performance on the Aphasia Quotient portion of the Western Aphasia Battery-Revised (WAB-R) (Kertesz, 2007). The eight men and nine women ranged in age from 42 to 85 years (M = 64.00, SD = 11.7). All were Caucasian and had completed between 12 and 18 years of education (M = 14.76, SD = 2.49). Table 1 provides a summary of the participants demographic data. All participants with aphasia demonstrated mild or moderate acquired reading comprehension deficits. The researchers determined reading comprehension severity through administration and scoring of the Reading Comprehension Battery for Aphasia-2 (RCBA-2) (LaPointe & Horner, 1998). Participants obtained scores between 43 and 92 (M = 72.90, SD = 17.40). Despite their reading comprehension challenges, all participants performed with 100% accuracy on a screening task using the Written Choice Communication strategy (Garrett & Beukelman, 1995) to verify they could comprehend and indicate through pointing their desired answers to contextually relevant cloze statements presented simultaneously in verbal and written modalities. Language and reading performance data for individual participants with aphasia also appear in Table 1. Materials Written Stories The researchers developed six stories about fictitious events happening to specified characters as part of a larger project. All written stories described the scenario for a problem, a conflict or dilemma faced by one or more characters, and a problem resolution. Each included 10 sentences, contained between 124 and 136 words (M = 129.33, SD = 4.62), corresponded with a Flesch-Kincaid grade level between 5.80 and 6.00 (M = 5.93, SD = 0.06), and a Flesch-Kincaid reading ease between 73.60 and 76.00 (M = 75.33, SD = 0.29) (Flesch, 1948). Sentences within the stories had a mean length of 12.93 words (SD = 0.46) and used only active voice sentence structures. For this study, the researchers used these stories across four reading conditions: no support, heading, key words, and photograph. An example story appears in Appendix A.

Supported Reading Comprehension for People with Aphasia 323 Table 1. Participant Demographic and Assessment Data Age (years) Gender Time Poststroke (months) Education (years) WAB-R Aphasia Type WAB-R Aphasia Quotient 1 a F 35 13 Broca s 72.0 86 Participant Number RCBA-2 Total Score 2 73 F 268 12 Broca s 61.1 84 3 42 F 47 16 Broca s 63.3 84 4 66 F 156 18 Broca s 52.1 88 5 70 F 73 18 Global 20.9 43 6 64 M 264 12 Broca s 59.4 58 7 54 F 58 14 Global 34.4 49 8 64 M 27 16 Broca s 33.4 55 9 59 M 71 16 Transcortical motor 72.4 92 10 59 M 66 16 Broca s 61.8 68 11 64 M 15 16 Global 25.1 64 12 50 M 14 12 Broca s 16.6 66 13 57 F 156 12 Conduction 78.1 91 14 82 F 29 12 Anomic 88.7 86 15 85 M 78 18 Transcortical sensory 62.7 45 16 56 F 48 18 Anomic 60.9 51 17 79 M 86 12 Wernicke s 73.6 90 a Participant refused to provide age. Headings The researchers developed a heading for each story. Headings were in the form of story titles and provided information about the primary setting or situation of a story (Garrett & Huth, 2002). Each heading was a phrase including either two or three words. The headings were designed to include information while not revealing the solution to the central problem presented in the narrative. Key Words The researchers identified keywords within each story. They defined keywords as nouns or verbs conveying critical content regarding major events described in the stories. To identify key words, each of three research team members independently reviewed each story and selected the 15 words she considered most salient. Then, the researchers compared their word lists to identify those selected in common by at least two of the three reviewers. They then used consensus to identify additional key words to those selected in common to generate a list of 15 per story. Photographs The photographic supports captured the meaning conveyed at the beginning of each story. For example, for the Home Break-In story, the photograph depicted a woman surprised to find a stranger sleeping on her living room couch (see Appendix A). Stimulus Material Formatting Each story appeared as a single, double-spaced paragraph printed in black ink and 18-point Arial font on an 8.5 x 11-inch sheet of white paper. The paper for each story was taped to the inside, right-

324 JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY, VOL. 21, NO. 4 hand portion of a manila file folder. The linguistic supports (i.e., heading or key words) appeared in the same color, font, and size as the story text on separate sheets of 8.5 x 5.5-inch white paper, copies of which were taped both to the outside cover and the inside left-hand portion of the appropriate manila file folders. Similarly, the researchers sized the photographic supports to 5 x 7-inches and placed them on the outside cover and inside, lefthand portions of the appropriate stimulus folders. Comprehension Assessments A set of 15 cloze statements, each with four possible answer choices, corresponded with each story and provided the researchers with a means of assessing reading comprehension. Each question was in the format of a sentence stem with omission of the final word or phrase. One correct response and three foils accompanied each sentence stem. To establish the passage dependency index (PDI) (Tuinman, 1974) of the question sets, five adults without communication impairments responded to the questions without having read the corresponding passage and then again after having read the passage. The researchers calculated the PDI by subtracting from 1 the number of correct responses each reader made before reading the passage, divided by the number of correct responses made after reading the passage; this value was then averaged over the five readers to determine a PDI for each passage and over all passages to determine the overall PDI. PDIs obtained for each of the six passages ranged from 0.87 to 0.97, and the overall PDI was.93 (SD = 0.03), thus confirming that adults without communication impairments could not respond accurately to the majority of questions without first reading the passages. The researchers printed a hard copy of each question set using black ink and 18-point Arial font on pieces of 8.5 x 11-inch paper. One question and the associated response options appeared per page. Each response option was preceded by a letter (i.e., a, b, c, or d) to aid in response identification and confirmation. Procedures Each participant with aphasia attended two sessions on separate days within a one-week period. During the first session, the participant performed the screening and assessment battery activities; during the second session, he/she performed the experimental tasks. The experimental tasks included reading the stimulus story, with or without reading supports, and completing the associated comprehension assessment for each of the four experimental conditions. To minimize order effects or unidentified differences in story complexity from influencing the results, the researchers systematically alternated the pairing of stories across the various conditions. Video and audio recording of all experimental sessions allowed for later review and analysis. Performance of the experimental tasks began with the researcher presenting a participant with a stimulus folder for the first condition. The researcher advised participants ahead of time that they would read four passages, one with no reading support and the other three with a heading, key words, or a photograph as a reading support. For the no support condition, the researcher instructed the participant to read the passage carefully, taking as long as he or she wished. For the three reading support conditions, the researcher placed the unopened stimulus folder in front of the participant, pointed to the heading, key words, or photograph and explained that the support provided information about a story topic and content. To allow participants time to review the reading support as pretask stimulation, the researcher feigned business preparing for the experimental task for the next 30 seconds. Then, she opened the folder displaying the support on the left and the narrative on the right and instructed the participant to read the passage carefully and review the reading support for as long as desired. When a participant indicated he/she was done, the researcher placed the first cloze statement next to the reading materials, which remained available for review during the comprehension assessment, and read the statement and all response options aloud. Repetition of a cloze statement and response options was provided as requested. The participant indicated his or her response selection through a pointing and/ or verbal response, and the researcher circled the indicated choice to confirm response selection. This procedure continued for all subsequent cloze statements associated with that stimulus story. The researcher then proceeded through the remaining conditions using the same procedures and allowing participants to take breaks between conditions as desired. Table 2 provides an overview of the materials participants viewed during each of the four experimental conditions. At the end of the session, the investigators asked participants a forced choice question to ascertain which reading support they preferred, including the no support option.

Supported Reading Comprehension for People with Aphasia 325 Table 2. Overview of Materials Viewed in Each Experimental Condition Condition 30-Second Pretask Stimulation Reading Task & Comprehension Assessment No Support None Narrative Heading Heading Heading and narrative Key words Key words Key words and narrative Photograph Photograph Photograph and narrative Procedural Integrity A trained research assistant viewed the experimental sessions of 4 of the 17 participants to provide a means of evaluating the procedural integrity of the examiner s presentation of the experimental tasks. The research assistant tracked 11 prespecified researcher behaviors and used the following formula to compute procedural integrity: [ Number of times researcher performed each task Total number of opportunties to perform each task 100 The procedural integrity analysis yielded a 100% compliance rate for each of the 11 researcher behaviors. Research Design and Data Analysis The researchers employed a repeated measures ANOVA (p.05) to determine whether a significant difference occurred across the four support conditions. Computation of Fisher s Protected LSD procedure (Rosner, 2005) (p.05) provided a means of further evaluating differences among the support conditions. Results Individual participants earned comprehension accuracy scores ranging from 6.25% to 100% across the four reading support conditions (see Table 3). The magnitude of difference among comprehension accuracy scores across conditions for individual participants ranged from 11.25 to 33.75 percentage points (M = 18.46; SD = 8.14). A closer look at the data revealed that six participants (i.e., 9, 10, 11, 13, 16, and 17) demonstrated their highest response accuracy scores in the photograph support condition. One person (i.e., 5) performed best in the no support condition and two people each performed best in the key words (i.e., 1 and 15) and the heading conditions (i.e., 2 and 12). The remaining six ] participants (i.e., 3, 4, 6, 7, 8, and 14) demonstrated equivalent high scores in at least two conditions. Mean accuracy scores across the group ranged from a low of 60.74% (SD = 24.87) in the key words condition to a high of 68.75% (SD = 24.61) in the photograph condition; mean scores for the heading and no support conditions were 62.13% (SD = 24.45) and 63.24% (SD = 21.86), respectively. Computation of a repeated measures ANOVA revealed a significant difference across the four reading support conditions (F (3, 16) = 2.78, p =.05, MSE = 75.124). To determine the source of significance, the researchers examined simple effects using Fisher s Protected LSD procedure (Rosner, 2005) (critical LSD value = 6.008). The post hoc analyses revealed that, as a group, the participants performed significantly better with photograph than key word supports (mean difference = 8.015). The comparison between the photograph and no support conditions approached, but did not reach, significance (mean difference = 5.515). The forced choice probe revealed that15 of the 17 participants preferred the photograph support option to the keywords, heading, or no support conditions. In comparison, only one person (i.e., 15) preferred to read without support, and another (i.e., 2) indicated that he preferred to use only key words (see Table 3). Discussion The purpose of this study was to examine the effects of linguistic and visual supports, provided both as pretask and during-task stimulation, on the comprehension of people with aphasia when they read unsimplified narratives. The analyses revealed three major findings warranting further discussion. First, as a group, the participants with aphasia achieved significantly higher comprehension scores given photographs as a form of visual support than they did given the other reading support conditions. Second, neither a heading nor a list

326 JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY, VOL. 21, NO. 4 Table 3. Participants Percent Correct Scores and Preferred Reading Conditions Reading support condition Participants No Support Heading Key Words Photograph Nonfluent aphasia 1 75.00 68.75 80.00 75.00 * 2 87.50 100.00 75.00 * 75.00 3 93.75 87.50 93.75 87.50 * 4 81.25 75.00 93.75 93.75 * 5 50.00 43.75 25.00 43.75 * 6 37.50 37.50 31.25 37.50 * 7 56.25 68.75 43.75 68.75 * 8 43.75 37.50 25.00 43.75 * 9 68.75 68.75 75.00 100.00 * 10 37.50 37.50 31.25 43.75 * 11 50.00 56.25 56.25 62.50 * 12 37.50 50.00 43.705 37.50 * Fluent aphasia 13 93.75 87.50 81.25 100.00 * 14 87.50 93.75 81.25 93.75 * 15 31.25 * 6.25 40.00 31.25 16 62.50 68.75 68.75 81.25 * 17 81.25 68.75 87.50 93.75 * Note: *preferred condition. Shaded cells indicate each participant s highest performance condition(s). of key words provided as isolated linguistic support fostered improved comprehension. Third, individual variability across participants was evident. The clinical implications of these findings and future directions appear in the following sections. Using Relevant and High-Context Photographs to Facilitate Reading Comprehension Previous researchers have reported inconsistent findings regarding the helpfulness of visual supports to promote the reading comprehension accuracy of people with aphasia (Brennan et al., 2005; Dietz et al., 2009; Rose et al., 2011a). As hypothesized earlier, differences in the types of pictures employed as visual supports may explain at least some of these inconsistencies. In particular, people with aphasia may benefit more from high-context photographic supports than from other types of visual images. The current study findings confirm the notion that supplementing written materials with relevant and high-context photographs is beneficial to people with aphasia. A possible explanation for why people with aphasia find the provision of relevant and high-context photographs helpful when reading narratives is that this type of visual support reduces resource allocation and working memory demands when processing linguistic material. Previous researchers have documented that people with aphasia have difficulty with the efficient allocation of cognitive resources when performing tasks involving symbolic processing (McNeil, 1983; McNeil, Odell, & Tseng, 1991; Mayer & Murray, 2002; Murray, 1999). As such, viewing a high-context photograph prior to or while reading an associated passage may promote gist comprehension and provide

Supported Reading Comprehension for People with Aphasia 327 clues about the written content, that is, details such as who the characters are, where the events take place, and, perhaps, what type of events occur. The fact that these clues are embedded within the context of a scene and appear in a nonlinguistic form is probably of particular benefit, because people with aphasia can process visual spatial and nonsymbolic information better than they can symbolic (e.g., linguistic) information (Blake, 2005; Brookshire, 2003; McNeil, 1983; Murray, 1999). Thus, the presence of high-context photographs may lessen the resource allocation demands placed on people with aphasia during reading tasks and may reduce strain on working memory, because some of the content information presented in the written passage appears in a nonlinguistic form as well. As such, the person with aphasia can refer back to the photograph to facilitate understanding, validate assumptions, and recall key points about characters, settings, and events. Specific features of the photographs provided as visual supports may be important when developing intervention materials. For the present study, the researchers used high-context photographs showing interactions among depicted people, objects, and/or the environment. The benefit people with aphasia derive from high-context photographs may be dependent on specific characteristics of, or content displayed in images. For example, high-context photographs can differ from one another in: (a) the inclusion/exclusion of nonsalient people or objects in the background; (b) the extent of activity engagement displayed by key individuals, and (c) the number of activities depicted within one scene. In addition, the potential benefit of high-context photographs may vary based on the presentation format of the image. For example, presenting one photograph as a visual support may be more or less effective than presenting multiple photographs. Similarly, having access to one or more relevant photographs only before attempting to process written material may be more or less effective than having access during or after exposure to the associated passage. Researchers have not yet examined the effects of these variables on the reading comprehension of people with aphasia. Using Linguistic Supports to Facilitate Reading Comprehension The researchers found no significant reading comprehension effects when they provided study participants with passages paired with headings or key words versus no supports. This is surprising, particularly with regard to the incorporation of headings, because of the frequency with which these appear in everyday reading materials such as websites, magazines, and newspapers. Additionally, Rose and colleagues (2011b) reported that, in general, people with aphasia believe headings are helpful when reading and that the use of bold text and color might increase this usefulness. Indeed, some individuals with aphasia have reported that headings are the only things they attempt to read when reviewing written information (Rose et al., 2011b). Perhaps headings would have been more helpful in the current study if they had included information about the narrative resolution rather than simply providing clues about the setting or situation. Additionally, although short headings promote syntactic and semantic simplicity, including somewhat longer headings to highlight multiple narrative elements may be more effective for people with aphasia. The use of key words may provide more reading comprehension support to people with aphasia if utilized in a different manner than occurred in the current study. Specifically, work by Rose and colleagues (2011b) suggests that people with aphasia like having key words within a text highlighted using bold font; for example, one person with aphasia commented about highlighted words,...beautifully done... bold bold yeah I like... those words (Rose et al., 2011b, p. 341). In the current study, the key words appeared in a separate word bank rather than as embedded words with boldface type. By presenting key words in this manner, the researchers may have inadvertently violated a principle of cognitive load theory in that the separate word bank did not physically integrate the added source of information (Kalyuga, Chandler, & Sweller, 1999; Sweller, 1999). Thus, inclusion of the key words may have taxed working memory and reduced the efficiency with which the participants processed the information rather than facilitating their comprehension. Individual Differences Fifteen of the 17 study participants indicated a preference for having a high-context photograph serve as a reading support rather than having no support, headings, or key words. Despite this strong endorsement and the finding of significantly better group performance given the photograph condition, viewing the individual data revealed that only about one-third of the participants (n = 6) achieved their highest accuracy score in the

328 JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY, VOL. 21, NO. 4 photograph condition. Another six participants performed equally well in at least one other condition, and the remaining five participants scored highest given headings, key words, or no support. Thus, individual differences occurred across participants, and some did not benefit most from having high-context photographs available as a form of visual support. This variable performance across participants is a well-known phenomenon among aphasiologists and highlights the importance of determining supports on an individual basis. The individual differences observed in this study might be attributable to one or more of several characteristics of the participant group. First, the participants included people with various subtypes of fluent and nonfluent aphasia as well as wide range of overall aphasia and reading comprehension severity. Restricting the inclusion criteria in future studies to include a more homogeneous group, or subgroups of aphasia types and severity, may yield greater consistency regarding the benefits derived from various reading supports. Second, the participants had varying levels of reading interest both prior to and following their acquisition of aphasia. Certainly, reading practices among neurologically intact adults are quite variable (Parr, 1992), and the acquisition of aphasia can substantially change reading practices based on the extent of the associated language impairment (Parr, 1995). However, because the researchers did not question participants about their current or former reading interests and habits, the amount that these factors affected comprehension performance is unknown. Further complicating interpretation of the group data is the lack of personal relevance in the narrative passages used in the current study. Previous research findings have established that people with aphasia perform auditory comprehension tasks better when the materials are personally relevant (McKelvey et al., 2010; Schuell, 1953; Wallace & Canter, 1985). The same pattern appears true for reading comprehension tasks (Jones, Pierce, Mahoney, & Smeach, 2007). Hence, taking into consideration the personal relevance of reading materials, including any reading supports provided to facilitate comprehension, may be an important variable regarding individual differences in performance. Clinical Implications and Future Directions Numerous questions persist regarding the usefulness of visual and linguistic supports to facilitate the reading comprehension of people with aphasia. In addition to the questions posed earlier about the optimal formatting and presentation of photographs as visual supports and heading and keywords as linguistic supports, researchers need to investigate further the relative benefits of presenting isolated versus multiple supports. People with aphasia may find that a combination of visual and linguistic supports is more conducive to facilitating comprehension than such supports presented in isolation. Conversely, the inclusion of multiple supports might prove to be cognitively challenging for people with aphasia, thus, adversely affect reading comprehension. Additional research about this is warranted, as well as further exploration of whether people with aphasia are comparable to neurotypical adults regarding their interpretation and integration of main messages, details, and inferential information conveyed via visual and linguistic supports. As we continue into the 21st century and technological advances make communication through the written modality increasingly common, people with aphasia will encounter a great deal of unsimplified reading materials (Dietz, Ball, & Griffith, 2011; Elman, Parr, & Moss, 2003). Consequently, determining the best ways to support people with aphasia in their understanding of everyday reading materials is critical. Acknowledgments. The authors thank Devan Macke for her help with assembling the tables and Jessica Brown for her assistance with the statistical analyses. The authors also thank the participants who so graciously helped us learn about ways to support the reading comprehension of people with aphasia. Portions of this paper were presented at the 2013 Clinical Aphasiology Conference, Tucson, Arizona. Address correspondence to Aimee Dietz, University of Cincinnati, Department of Communication Sciences & Disorders, 3202 Eden Avenue, PO Box 670379, Cincinnati, OH 45267-0379. email: aimee.dietz@uc.edu; Tel: (513) 558 8551. References Beukelman, D. R., & Mirenda, P. (2013). Augmentative and alternative communication: Supporting children and adults with complex communication needs. Baltimore, MD: Brookes Publishing. Blake, M. L. (2005). Right hemisphere syndrome. In L. LaPointe (Ed.), Aphasia and related neurogenic language disorders (pp. 213 224). New York, NY: Thieme Medical.

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Supported Reading Comprehension for People with Aphasia 331 Appendix A Example Narrative, Heading, Key Words, and Photographic Supports Narrative Betty walked to the kitchen early one morning to make her first cup of coffee. Heading to the living room, she noticed a young man sprawled on the couch. Disoriented, the man stood, took a few shaky steps, and then fell back onto the couch. Betty debated whether she should confront the man or telephone the police. She decided to call for assistance. An officer arrived and approached the stranger. The man said he was visiting a friend nearby and had attended a party the previous night. Leaving at 3:00 am, he lost his way and thought Betty s house was his friend s. In an attempt to not wake anyone, he climbed in an open window and curled up on the couch to sleep. The officer escorted him out to the police car and charged him with trespassing. Home Break-In Heading Key words Betty Morning Coffee Living room Man Couch Police Call Officer Party 3:00 am Lost Window Charged Trespassing Photograph (Figure 1) Figure 1. Photographic support depicting the beginning of the home break-in story. Note: Materials were formatted as described in the manuscript.