The Situation Tapping Executive Function Capabilities of Clients with Aphasia 4 SLPs are driving to ASHA in a mid size car. Their luggage sits on the driveway to be packed into a trunk that seems too small. Robert C. Marshall, Ph.D., F ASHA University of Kentucky Lexington, KY, USA Human Behavior Involves complex, integrated interplay of 3 functional systems: Cognition information handling Emotional feelings and motivation i Executive how behavior is expressed Executive Functions Capacities that enable a person to engage successfully in independent, purposive, selfserving behavior (Lezak et al., 2004) Another Definition A collection of high level interconnected control processes that allow us to generate, choose, organize, and regulate our goal directed, adaptive, and non automatic behaviors (Phillips, 1997) Another Definition Integrative cognitive processes that determine goal directed and purposeful behavior and are superordinate in the orderly execution of dailylifefunctions life functions (Cicerone, 2000) 1
EF and Aphasia Who Cares? Some PWA can communicate with you in spite of severe language disablements; others, seemingly less disabled, cannot. Some research suggests that differencesin in EF exist among PWA, and that these are related to site of lesion, and impact outcomes and ability to compensate for aphasic deficits. Glosser & Goodglass (1990) Found PWA and frontal lobe lesions more impaired on EF tasks than those with post Rolandic lesions and that impairments in EF were independent of visual spatial spatial and language deficits. Beeson et al. (1993) Found PWA impaired relative to control subjects on tests of verbal memory and that limitations in LTM were associated with anterior lesions, whereas limitations in working memory were associated with posterior lesions; Memory deficits were not strongly correlated with severity of aphasia Van Mourik et al. (1991) Found that outcomes in Global aphasia were highly related to subjects performance on a neuropsychological test battery. Group 1 communicate with single words Group 2 communicate with pictographs Group 3 limited communication; little communication drive Nicholas et al. (2005) Found ability of PWA to use a computerized communication system related to performance on EF tests. Purdy (1994) Trained 15 PWA to communicate symbols verbally, by gesture, and with a communication book. All clients were successful in the training situation, but many were unable to use the alternative modes of communication, gesture and the communication book, in a functional situation. 2
Purdy & Koch (2006) Re examined the performance of the 15 subjects from Purdy (2004) on the CADL using a unique method for quantifying performance, a cognitive flexibility score. They found a high correlation between cognitive flexibility and subjects performance on the Wisconsin Card Sort, a well known test of EF. Assessing EF of Persons with Aphasia Structured approach Formal test Semi structured approach EF task Non structured approach Observation Formal EF Tests Volition Developed by neuropsychologists Usually have normative data Often have cutoff scores and administration guidelines Often referred to as frontal lobe tests Present the examinee with a novel task to perform Examinee must perform task without direction of examiner Assess overlapping functions of volition, planning, purposive action, and effective performance The ability to conceptualize one s goals and form a plan to reach them; Capacity for intentional, goal directed behavior Planning Ability to organize the steps needed to complete an action; Ability to prepare for setbacks or difficulties in carrying out a plan; Ability to assemble the needed materials and skills needed to execute a plan Purposive Action Ability to maintain, switch, and stop sequences of complex behavior in an orderly and integrated manner. 3
Effective Performance Relates to aspects of execution of one s actions such as self correction, selfmonitoring, and the quality of the mistakes a person makes Information on EF Testing Murray L & Rammage A (2000). Assessing the executive function abilities of adults with neurogenic communication disorders. Seminars in Speech and Language, 21, 153 167. Kiel K, & Kaszniak A (2002). Examining executive function in individuals with brain injury. Aphasiology, 16, 305 336. Verbal or Non Verbal EF Tests? PWA are Hard to Test Non verbal Stick Design (Baiyewu et al. 2005) examinee duplicates designs with 4 matches th Tinker Toy Test (Lezak et al., 2004) examinee is given 50 TT pieces and told to make whatever you want. Verbal Homophone Meaning Generation Test (HMGT), (Crawford et al. 2002) examinee is given 8 homophones, tick, tip, slip, form, plain, right, bored and sent. He s asked to come up with as many meanings of the words as possible Unable to use dominant hand to draw, write, or manipulate objects Unable to communicate verbally Have difficulty understanding di spoken language WE deficits compromise understanding/remembering of instructions Perceptual difficulties limit performance Modifying Tests for HTT Clients Remove time constraints Simplify instructions Supplement verbal instructions with written instructionsi Establish method of communication that allows patient to give reliable response Break test into parts; give rest breaks Costs of Modifying Standard Procedures May not be able to compare patient s performance with normal sample May affect patient s performance by giving insight into the test May reduce novelty of EF task through practice effects 4
Acceptable Modifications Semi Structured Approach Select tests that limit the need to produce speech Use communication aids when giving instructions Point to test items or examples when explaining them Role play taking the test with another clinician Low verbal Naturalistic Action Test (Schwartz et al., 2002). Client is given materials to perform 3 tasks, making toast with PB&J, wrapping a gift, and packing a child s lunchbox Response are scored for steps accomplished and errors committed. Verbal Test for Functional Executive Abilities (TOFEA), (Bamdad et al. 2003). Client must call hotel, find its address, phone number, hours of operation of its restaurant, and directions. Semi Structured Approach Non Structured SLP uses a common task requiring EF Following a recipe Organizing a weeks worth of pills in a ill organizer SLP creates her own task Identify normal group Have normal group perform task Finding your way to a certain location in the medical center Observation How does the PWA use of his/her EF capabilities solve this problem? Transmission of thoughts and feelings from his mind to the mind of a listener when language is impaired In a foreign country This problem is a lot like being in a foreign country where you don t speak the language and cannot understand much of what you hear In general the SLP wants to know What the PWA does to spark an interaction or start a conversation? What the PWA does speed up information exchange? How the PWA clarifies misunderstandings? If the PWA can correct inaccuracies to fulfill the primary functions of communication, requesting, rejecting, and commenting? Specifically, the SLP wants to know The kinds of words the PWA uses to start a conversation ( Q 33) iki Ron (AQ=33): Biking Clinician: You have been riding a bike? Ron: No (writes Vikings, Randy Moss, WR) 5
The Earwig Story If the PWA can come up with a novel strategy to convey a complex thought Clinician: How s it going? Vern (AQ = 48): Not good, I ve got, I can t tell you, but I can show you. It s this. Points to his ear. And it s this (Points to his bald head), I haven t got any, but I could get some. Of course it wouldn t look very good. He s in the doghouse Use the few words they have to express different meanings. Clinician: i i How are you today? Barb (AQ = 51): Brian (uttered in a tone of anger with an appropriate facial expression) The car is ready to be picked up Select and produce an utterance that will motivate action on the part of another. Ron (AQ=31) hears a voice mail that states his father s car is ready to be picked up. He opens the back door and yells to his father who is working in the back yard car, car, car. I went to the game Saturday Can the PWA put things in a temporal context? Clinician: What s exciting in your life? Mary (AQ = 39): Football (points to last Saturday on the calendar) What s Dad Doing? Can the PWA use writing/drawing to quickly convey a complex idea? Mother: What s your dad been doing? Ron: Writes Ph.D Ph.D. candidate Karate Chop Does the PWA take the quickest route to communicating the information? Clinician: What did you do this weekend? Marilyn (AQ = 29) points to Cincinnati i i on the map and makes a karate chop with her hand. 6
Social Appropriateness Does the PWA use gesture, speech, drawing, and writing appropriate to the social situation? Communication with clinician pull out all the stops Out to lunch in a restaurant pad and paper Holliday party Social greetings and gesture Cognitive flexibility PWA that is often severe are able to do productive things to aid communication that override their scores on aphasia tests. They demonstrate cognitive flexibility. Cognitive flexibility is the ability to shift cognitive set, thought or attention to perceive, process, or respond to situations in different ways. (Rende, 2000) Categories of Cognitive Flexibility Can EF Be Treated? Reactive Allows person to shift or change their behavior in response to a situation. Spontaneous Allows the person to consider alternatives, formulate ideas on his own, and adapt ttheir plan to the situation at hand Executive functions can be tapped but not treated. This distinction is not trivial as suggested by the title of the seminar. Things to Ponder Tapping EF Have you noticed how some PWA reflect their executive capabilities immediately? Who has gone to the bedside of a patient shortly after a stroke and had the patient immediately and effectively engage you even though he cannot speak? Possible we curtail use of executive capabilities by forcing verbal responses? Could emphasis on speech rather than communication be harmful? We have not been successful in teaching compensations that can be used in context. How do we improve, refine, and expand on what the patient does naturally to transfer thoughts and feelings from his mind to the mind of a listener? Tend the garden 7
Four Important Considerations Willingness Automaticity Selectivity Appropriateness Willingness We want the patient to be willing to communicate in a different way; To acknowledge and understand it may be more productive and beneficialto gesture, point, write, draw than to speak The patient will be willing if there is a pay off. Automaticity We want the patient to use his EF capabilities to facilitate communication automatically, not as a last resort. This means the patient will draw, write, or gesture first. He will consider his listener s needs and weigh the necessity of going through a long series of verbal struggles and self repairs requiring a lot of guessing in inference by the listener. Selectivity When speaking or writing, we want the patient to select a word or phrase to convey his thoughts and feelings that will put the listener on track rather than leadthe conversation astray. Appropriateness Vehicles for Tapping EF We want the patient to make appropriate decisions about when he/she uses gesture, writing, drawing, speaking, and pointing to communicate. What he does should fit the communication context and his/personal feelings about how much to reveal. Restorative treatment and drill do not seem opportune for tapping the patient s EF capabilities. Conversation and group treatment seem better suited for this To tend the garden the clinician needs to have opportunities to reinforce (fertilize) behaviors that facilitate and mildly reprimand (kill weeds) those that are ineffective and wast time. 8
Clients that Surprise Questions Some clients surprise us with how well they do in spite of severe speech and language disablements. Think about what it was that separated these clients from the pack. Lezak suggests that when EF remain intact, a person can sustain considerable cognitive and physical disability yet still remain independent, constructively selfserving, and productive. References Babbage, DR, & Leathem, JM (2001). Neuropsychological assessment difficulties associated with hard to test individuals: a retrospective review. Brain Injury, 673 682. Baiyewu, O. et al. (2005). The stick design test. Journal of the International Neuropsychological Association, 11, 598 605. Bamdad, JM, Ryan, LM,& Warden, DL (2003). Functional assessment of executive abilities following traumatic brain injury. Brain Injury, 17, 1 11. Beeson, P., Bayles, K., Rubens, A., Kaszniak, A. (1993). Memory impairment and executive control in individuals with stroke induced aphasia. Brain and Language, 45, 253 275. References Cicerone, KD, Dahlberg, C, Kalmar K et al. (2000). Evidence based cognitive Rehabilitation: recommendations for clinical practice. Archives of Physical Medicine and Rehabilitation, 81, 1596 1615. Glosser, G., Goodglass, H. (1990). Disorders of executive control functions among aphasic and other brain damaged patients. Journal of Clinical and Experimental Psychology, 12, 485 501. Keil, K., Kaszniak, A. (2002). Examining executive function in individuals with brain injury. Aphasiology, 16, 305 336. Lezak, M., Howieson, D., Loring, J. (2004). Neuropsychological assessment. (4 th Ed.). New York: Oxford. Murray, L., Ramage, A. (2000). Assessing the executive function abilities of adults with neurogenic communication disorders. Seminars in Speech and Language 21, 153 168. References Nicholas, M., Sinotte, M., Helm Estabrooks, N. (2005). Using a computer to communicate: Effect of executive function impairments in people with severe aphasia. Aphasiology, 19, 1052 1065. Phillips, L. H. (1997). Do frontal tests measure executive function? Issues of assessment and evidence from fluency tests. In P. Rabbit (Ed.) Methodology of frontal and executive function (pp. 191 213). Hove, UK: Psychology Press. Purdy, M. (2002). Executive function ability in aphasia. Aphasiology, 16, 549 557. Purdy, M., Koch, A. (2006). Prediction of strategy use by adults with aphasia. Aphasiology, 20, 337 348. References Rende, B. (2000). Cognitive flexibility: Theory, assessment, and treatment. Seminars in Speech and Language, 21, 121 122. Schwartz, MF, et al. (2002). The naturalistic action test: a standardized di dassessment for everyday action impairment. i Neuropsychological rehabilitation, 12, 311 339. Van Mourik, C., et al. (1991). Cognitive in global aphasia: indicators for therapy. Aphasiology, 6, 491 500. 9