Successful single-word writing treatment: Experimental analyses of four cases

Background: Individuals with severe aphasia may fail to regain spoken language, so that treatment should target other communication modalities such as writing. There is relatively limited documentation of successful writing treatment, particularly in individuals with severe aphasia. Aims: The present study was designed to examine treatment outcomes in response to two writing treatment protocols intended to rebuild single-word vocabulary for written communication. Methods & Procedures: Writing treatments were implemented with four individuals who had significant aphasia and severe agraphia. Two participants received Anagram and Copy Treatment (ACT) which involved arrangement of component letters and repeated copying of target words, along with a homework programme called Copy and Recall Treatment (CART) that included copying and recall of target words. The other two participants received the homework-based CART only. Single-subject multiple-baseline designs were used with sets of words sequentially targeted for treatment. Outcomes & Results: All four participants responded positively to treatment. Three of the participants had severely limited spoken language, so that mastery of written words provided a much-needed means of communication. The fourth participant, who had adequate spoken language for face-to-face conversation, employed his improved spelling for written messages such as e-mail. Conclusions: Single-word writing abilities may improve with treatment despite long times post onset and persistent impairments to spoken language.     

Discrepant oral and written spelling after left hemisphere tumour.

Repetition, reading, confrontation naming, and oral and written spelling were studied in a 57 year-old man with a left hemisphere tumour. These tasks were repeated over a period of two weeks when the patient was being treated for brain oedema prior and subsequent to neurosurgical intervention. In the context of intact repetition and good reading, the most striking finding was a significant qualitative and quantitative discrepancy between oral and written spelling, with the latter task more severely affected. The pattern on oral spelling was that of lexical (or surface) agraphia. On written output, however, orthographic errors predominated. The relatively greater impairment of written spelling was not secondary to a motoric or visuo-spatial deficit. The observed patterns are not easily accommodated by current models of writing.     

Conversational use of writing in severe aphasia: A group treatment approach

Background: Several studies have documented the ability of individuals with severe aphasia to relearn the spelling of target words so that written communication can augment limited spoken language abilities. To date, there has been little documentation of clinical methods to facilitate the conversational use of written communication in such individuals. Aims: The present study was designed to examine treatment outcomes in response to single-word writing treatment complemented by a group treatment approach to facilitate the use of writing for conversation. Methods & Procedures: Four individuals with chronic, severe aphasia and agraphia received copy and recall treatment (CART) that included repeated copying and recall trials for spelling target words, as well as small group writing treatment. Single-subject multiple baseline designs were implemented to document progress on sets of words sequentially targeted for treatment. Writing was probed in the context of individual treatment sessions, structured group conversation, and in conversation with an unfamiliar person. Outcomes & Results: All four participants responded positively to treatment by demonstrating improved spelling of target words in individual sessions, and use of single-word writing in structured group conversations. In addition, all subjects showed the ability to use telegraphic written communication with new people, albeit with fewer words written in the most naturalistic context. Conclusions: Single-word writing abilities may improve with treatment despite persistent impairments to spoken language and considerable passage of time since the onset of aphasia. Group treatment appears to be an appropriate context to facilitate conversational use of written communication in such individuals.     

Phonological dyslexia and dysgraphia: cognitive mechanisms and neural substrates

To examine the validity of different theoretical assumptions about the neuropsychological mechanisms and lesion correlates of phonological dyslexia and dysgraphia, we studied written and spoken language performance in a large cohort of patients with focal damage to perisylvian cortical regions implicated in phonological processing. Despite considerable variation in accuracy for both words and non-words, the majority of participants demonstrated the increased lexicality effects in reading and spelling that are considered the hallmark features of phonological dyslexia and dysgraphia. Increased lexicality effects were also documented in spoken language tasks such as oral repetition, and patients performed poorly on a battery of phonological tests that did not involve an orthographic component. Furthermore, a composite measure of general phonological ability was strongly predictive of both reading and spelling accuracy, and we obtained evidence that the continuum of severity that characterized the written language disorder of our patients was attributable to an underlying continuum of phonological impairment. Although patients demonstrated qualitatively similar deficits across measures of written and spoken language processing, there were quantitative differences in levels of performance reflecting task difficulty effects. Spelling was more severely affected than reading by the reduction in phonological capacity and this differential vulnerability accounted for occasional disparities between patterns of impairment on the two written language tasks. Our findings suggest that phonological dyslexia and dysgraphia in patients with perisylvian lesions are manifestations of a central or modality-independent phonological deficit rather than the result of damage to cognitive components dedicated to reading or spelling. Our results also provide empirical support for shared-components models of written language processing, according to which the same central cognitive systems support both reading and spelling. Lesion-deficit correlations indicated that phonological dyslexia and dysgraphia may be produced by damage to a variety of perisylvian cortical regions, consistent with distributed network models of phonological processing.     

Maximising recovery from aphasia with central and peripheral agraphia: The benefit of sequential treatments

ABSTRACT

Maximal recovery from acquired language impairment may require progression from one behavioural treatment protocol to the next in order to build upon residual and relearned cognitive-linguistic and sensory-motor processes. We present a five-stage treatment sequence that was initiated at one year post stroke in a woman with acquired impairments of spoken and written language. As is typical of individuals with left perisylvian damage, she demonstrated marked impairment of phonological retrieval and sublexical phonology, but she also faced additional challenges due to impaired letter shape knowledge and visual attention. The treatment sequence included (1) written spelling of targeted words, (2) retraining sublexical sound-to-letter correspondences and phonological manipulation skills, (3) training strategic approaches to maximise interactive use of lexical, phonological, and orthographic knowledge, (4) lexical retrieval of spoken words, and finally (5) sentence-level stimulation to improve grammatical form of written narratives. This Phase II clinical study documented positive direct treatment outcomes along with evidence of a significant reduction in the underlying deficits and generalisation to untrained items and language tasks. Improvements on a comprehensive assessment battery were realised as functional gains in everyday written and spoken communication, including improved lexical retrieval and grammatical complexity of written narratives. This case provides a valuable example of the cumulative therapeutic benefit of sequential application of theoretically motivated treatment protocols.     

Case Study Impairment to phonological processes in a Cantonese‐speaking brain‐damaged patient

Background: Previous studies have shown that brain‐damaged patients with selective deficits to phonological processes produced frequent phonological errors and similar error patterns in all spoken tasks, exhibited the effects of word frequency, grammatical class, and imageability, and were unable to make rhyming judgements, due to impaired lexical retrieval and/or phonological representations. Aims: This paper describes a Cantonese‐speaking brain‐damaged patient, LKK, whose performance patterns in spoken tasks indicate impairment to both the lexically mediated non‐semantic and semantic pathways of oral production, as well as the phonological output buffer. Methods & Procedures: A range of tasks was conducted including repetition, reading aloud, oral naming, written/spoken word–picture matching, non‐verbal semantic tests, written lexical decision, and homophone judgements. Outcomes & Results: LKK performed normally on written lexical decision, word–picture matching, and non‐verbal semantic tests, but he was unable to make homophone judgements and showed impaired production in all oral tasks. He was better able to read aloud names of objects than to name them. He also made more semantic errors in naming than reading. His accuracy in reading single words was affected by word frequency and form class. Further observations of his oral production included better (but nevertheless impaired) performance on repetition than reading and naming, a consistent effect of word length across tasks, and a tendency for phonological errors to occur on the coda compared with the onset. Conclusions: There was sufficient evidence for deficits of the phonological lexicon and/or the access to it along the non‐semantic route and the semantic pathway at the post‐semantic level in LKK. The effect of word length and comparable patterns of error distribution across spoken tasks suggested additional impairment to the phonological output buffer. The different levels of accuracy in repetition, reading, and naming, as well as the differential rates of semantic errors in these tasks were consistent with predictions of the summation hypothesis.     

The nature and treatment of phonological text agraphia

Phonological alexia and agraphia are written language disorders characterised by disproportionate difficulty reading and spelling nonwords in comparison to real words. In phonological alexia, it has been shown that, despite relatively accurate reading of words in isolation, text-level reading deficits are often marked and persistent. Specifically, some individuals demonstrate difficulty reading functors and affixes in sentences, a profile referred to as phonological text alexia. In this paper, we demonstrate an analogous manifestation of the phonological impairment on text-level writing and suggest the term “phonological text agraphia”. We examined four individuals with phonological alexia/agraphia who also showed disproportionate difficulty writing well-formed sentences in comparison to their grammatical competence in spoken utterances. Implementation of a phonological treatment protocol resulted in significantly improved sublexical phonology skills as well as improvements in grammatical accuracy of written narratives. These findings support the notion of a common phonological impairment underlying nonword reading/spelling deficits and sentence-level difficulties.     

Lexical access via letter naming in a profoundly alexic and anomic patient: a treatment study.

We report the results of a letter naming treatment designed to facilitate letter-by-letter reading in an aphasic patient with no reading ability. Patient M.R.'s anomia for written letters reflected two loci of impairment within visual naming: impaired letter activation from print (a deficit commonly seen in pure alexic patients who read letter by letter) and impaired access to phonology via semantics (documented in a severe multimodality anomia). Remarkably, M.R. retained an excellent ability to pronounce orally spelled words, demonstrating that abstract letter identities could be activated normally via spoken letter names, and also that lexical phonological representations were intact when accessed via spoken letter names. M.R.'s training in oral naming of written letters resulted in significant improvement in her oral naming of trained letters. Importantly, as M.R.'s letter naming improved, she became able to employ letter-by-letter reading as a compensatory strategy for oral word reading. M.R.'s success in letter naming and letter-by-letter reading suggests that other patients with a similar pattern of spared and impaired cognitive abilities may benefit from a similar treatment. Moreover, this study highlights the value of testing the pronunciation of orally spelled words in localizing the source of prelexical reading impairment and in predicting the functional outcome of treatment for impaired letter activation in reading.     

Facilitating and disrupting speech perception in word deafness

Background: Word deafness is a rare condition where pathologically degraded speech perception results in impaired repetition and comprehension but otherwise intact linguistic skills. Although impaired linguistic systems in aphasia resulting from damage to the neural language system (here termed central impairments) have consistently been shown to be amenable to external influences such as linguistic or contextual information (e.g., cueing effects in naming), it is not known whether similar influences can be shown for aphasia arising from damage to a perceptual system (here termed peripheral impairments).

Aims: This study aimed to investigate the extent to which pathologically degraded speech perception could be facilitated or disrupted by providing visual as well as auditory information.

Methods & Procedures: In three word repetition tasks, the participant with word deafness (AB) repeated words under different conditions: words were repeated in the context of a pictorial or written target, a distractor (semantic, unrelated, rhyme, or phonological neighbour) or a blank page (nothing). Accuracy and error types were analysed.

Outcomes & Results: AB was impaired at repetition in the blank condition, confirming her degraded speech perception. Repetition was significantly facilitated when accompanied by a picture or written example of the word and significantly impaired by the presence of a written rhyme. Errors in the blank condition were primarily formal, whereas errors in the rhyme condition were primarily miscues (saying the distractor word rather than the target).

Conclusions: Cross-modal input can both facilitate and further disrupt repetition in word deafness. The cognitive mechanisms behind these findings are discussed. Both top-down influence from the lexical layer on perceptual processes and intra-lexical competition within the lexical layer may play a role.     

Dysgraphia in primary progressive aphasia: Characterisation of impairments and therapy options

Background: Spelling impairment is common in primary progressive aphasia (PPA). Although behavioural interventions tend to focus on spoken language, remediation of written language may be desirable, either because an individual’s regular use of writing makes it a priority or because writing is needed for communication in cases where it is better preserved than spoken language.

Aims: This paper has three aims: (1) to provide an up-to-date survey of spelling and handwriting impairments in each variant of PPA, (2) to provide guidance on characterisation of dysgraphia and identification of loci of impairment, and (3) to outline possible interventions. Because the number of studies which have specifically evaluated therapy for dysgraphia in PPA is small, this paper also reviews relevant studies of therapy in non-progressive dysgraphia.

Main Contribution: Review of the literature indicated that the most common pattern of spelling impairment in the semantic variant of PPA is surface dysgraphia (impairment in lexical spelling). The profile is more variable in the non-fluent and logopenic variants of PPA, but most commonly there is impairment in lexical spelling and in phoneme-to-grapheme conversion. Review of the literature on therapy for dysgraphia indicated that four main types of therapy have been evaluated and shown to improve spelling performance: (1) training of spelling of specific target words (used to ameliorate lexical and graphemic buffer impairments), (2) training of sound-to-spelling correspondence rules (used to treat impairment in assembled spelling), (3) training in segmentation of stimulus words into smaller chunks (to make them manageable for a damaged graphemic buffer, or as a first stage in applying sound-to-spelling correspondence rules), and (4) learning to identify and self-correct errors (used in treatment of graphemic buffer disorder).

Conclusions: It is likely that spelling impairment in PPA would be responsive to treatment, although this has only been demonstrated in the logopenic variant. Reported improvements following therapy for anomia demonstrate that relearning is possible in PPA, despite the progressive nature of the condition. This gives reason for optimism regarding a positive response to therapy for dysgraphia in all variants of PPA.     

Impairment in non‐word repetition: a marker for language impairment or reading impairment?

Aim A deficit in non‐word repetition (NWR), a measure of short‐term phonological memory proposed as a marker for language impairment, is found not only in language impairment but also in reading impairment. We evaluated the strength of association between language impairment and reading impairment in children with current, past, and no language impairment and assessed any differential impairment of NWR, compared with two other tests of verbal memory in children with language impairment with and without reading impairment. Method Our sample comprised children aged 6–16y 11mo participating in a study of the genetics of language impairment: 78 children from 68 families (53 males, 25 females) with current language impairment (C‐LI), compared with their 74 siblings: 25 children (18 males, seven females) with a past history of language impairment and 49 children (27 males, 22 females) who had never had a language impairment. The tests used were the Clinical Evaluation of Language Fundamentals (CELF III), the Children’s Test of Non‐word Repetition (CN‐Rep), the Wide Range Assessment of Memory and Learning (WRAML) verbal memory index, the Wechsler Intelligence Scale for Children‐III (WISC‐III) digit span, and the Wechsler Objective Reading Dimensions (WORD^UK). Results Reading impairment was present in two‐thirds of the children with current language impairment. NWR deficits were significantly worse in children with language impairment who had reading impairment in reading decoding (p=0.007 and 0.004 – average group compared with borderline and definitely impaired groups respectively) or spelling (p=0.002 and 0.005 – average group compared with borderline and severely impaired groups respectively) (not correlated with severity of language impairment) but not comprehension impairment. In contrast, WISC digit span and WRAML verbal memory were impaired in all children with language impairment and did not differentiate those who also had reading impairment. Interpretation We suggest that current NWR ability may be a marker of a process specifically underlying language impairment, co‐occurring with reading impairment involving reading decoding and spelling, rather than a generic correlate of language impairment. Other verbal memory deficits appear to be pervasive in children with language impairment.     

Age of acquisition effects on spelling in surface dysgraphia

Background: It is not known whether the age of acquisition (AoA) of a word has any significant effect on the spelling performance of normal or impaired speakers. One way to explore this question is to examine the effects of AoA on surface dysgraphia. Aims: We report MK, a patient who suffered herpes simplex viral encephalitis (HSVE) resulting in semantic anomia and surface dysgraphia that we characterise as a tendency to produce a legitimate alternative spelling of a component defined as a LASC error. Methods & Procedures: We describe MK's neuropsychological profile, giving details of impaired naming, spoken and written word comprehension, written picture naming, oral reading, and spelling to dictation, but preserved repetition of whole words. We report experiments designed (1) to test the effect of AoA on spelling by controlling for word frequency as well as other correlated variables using logistic regression and ANOVA, and (2) to test the effects of AoA and sound to spelling predictability on MK's spelling. Outcomes and Results: The results show an effect of AoA but no independent effect of frequency on spelling and an interaction between AoA and predictability, i.e., an effect of AoA on unpredictable word spelling but no effect of AoA on predictable word spelling. Conclusions: We discuss these data with reference to accounts of AoA that locate the effect at the level of mappings between input (phonological) and output (orthographic) representations. We argue that the effect of AoA on spelling is not the result of lexeme activation per se but instead reflects the largely unpredictable mappings between sound and spelling that characterise the majority of English word spellings.     

Remediation of language processing in aphasia: Improving activation and maintenance of linguistic representations in (verbal) short-term memory

BACKGROUND: Verbal short-term memory (STM) impairments are invariably present in aphasia. Word processing involves a minimal form of verbal STM, i.e., the time course over which semantic and phonological representations are activated and maintained until they are comprehended, produced, or repeated. Thus it is reasonable that impairments of word processing and verbal STM may co-occur. The co-occurrence of language and STM impairments in aphasia has motivated an active area of research that has revealed much about the relationship of these two systems and the effect of their impairment on language function and verbal learning (Freedman & Martin, 2001; Martin & Saffran, 1999; Trojano & Grossi, 1995). In keeping with this view a number of researchers have developed treatment protocols to improve verbal STM in order to improve language function (e.g., Koenig-Bruhin & Studer-Eichenberger, 2007). This account of aphasia predicts that treatment of a fundamental ability, such as STM, which supports language function, should lead to improvements that generalise to content and tasks beyond those implemented in treatment. AIMS: We investigated the efficacy of a treatment for language impairment that targets two language support processes: verbal short-term memory (STM) and executive processing, in the context of a language task (repetition). We hypothesised that treatment of these abilities would improve repetition abilities and performance on other language tasks that require STM. METHOD: A single-participant, multiple-baseline, multiple-probe design across behaviours was used with a participant with conduction aphasia. The treatment involved repetition of words and nonwords under three "interval" conditions, which varied the time between hearing and repeating the stimulus. Measures of treatment effects included acquisition, maintenance, and follow-up data, effect sizes, and pre- and post-treatment performance on a test battery that varies the STM and executive function demands of language tasks. OUTCOMES #ENTITYSTARTX00026; RESULTS: Improvement of repetition was mostly specific to treated stimuli. Post-treatment measures of language ability indicated improvements in single and multiple word processing tasks, verbal working memory tasks, and verbal span. CONCLUSIONS: Treatment of STM and executive processes in the context of a word repetition task resulted in improvements in other non-treated language tasks. The approach used in this study can be incorporated into other language-processing tasks typically used in treatment of language disorders (e.g., sentence processing).     

Teaching self-cues: A treatment approach for verbal naming

Background: Very few treatment studies have examined the effects of training individuals with anomia to self-generate phonological cues. There is evidence that treatments using written language can improve phonological access for some patients. Such approaches are most effective when the patients are taught strategies to facilitate oral reading of targets. Aim: The goal of the present study was to evaluate the effects of a naming treatment designed to teach a chronic nonfluent aphasic to generate self-cues based on partial access to the written form of words and tactile (placement) cues. Methods: Therapy focused on naming items using a modified cueing hierarchy that incorporated written naming and tactile cues. An AB design was used to examine treatment effects in an individual with aphasia and apraxia of speech. Outcomes and Results: Verbal naming improved in target compared to control items. Generalisation was observed to verbal and written naming on standardised measures but not to novel stimuli with initial target and control phonemes. Testing 6 weeks post-treatment revealed limited loss of treatment gains. Conclusions: The results provide qualified support for the treatment programme.     

Improved verbal learning in the semantic variant of primary progressive aphasia when using semantic cues

The semantic variant of primary progressive aphasia (PPA-S) is characterized by impairments in confrontation naming and single word comprehension. Although episodic memory may be relatively spared, there can be impairment in verbal learning tasks. We report a patient with PPA-S and impaired verbal learning who was tested to learn if when provided with semantic categories, her learning would improve. A 70-year-old right-handed woman with a 2-year history of progressive difficulties with word finding, naming, and memory was tested for language and memory deficits using the Hopkins Verbal Learning Test-Revised (HVLT-R). She was then retested with the HVLT-R after being provided with the three semantic categories to which these words belonged. Confrontation naming was impaired on the Boston Naming Test. Sentence repetition was normal. Comprehension testing with word picture matching and sentence comprehension was normal. On a test of semantic associations, Pyramids and Palm Trees, she was impaired. She was also impaired on tests of verbal learning (HVLT-R) (total: 13) but not recall. When a different version of the HVLT-R was given with the semantic categories of the words given beforehand, her scores improved (total: 26). This patient with PPA-S had an impairment of verbal learning, but not delayed recall. When given a semantic category cue beforehand, her verbal learning performance improved. This observation suggests that this patient did not spontaneously use semantic encoding. Using a semantic cueing strategy may help other patients with PPA-S improve their capacity for verbal learning.     

Semantic-phonologic treatment for noun and verb retrieval impairments in aphasia

Nouns and verbs differ in their neural and psycholinguistic attributes. It is not known whether these differences lead to distinct patterns of response to treatment for individuals with word retrieval impairments associated with aphasia. Eight participants with naming disorders induced by left hemisphere strokes were treated with a semantic-phonologic treatment protocol for nouns and verbs using a single participant multiple baseline design. We measured treatment gains in a picture naming measure and other secondary language and communication measures. Treatment led to improved picture naming for trained nouns and verbs in five of eight patients, with no difference evident between nouns and verbs. Improvements for untrained words were minimal. Improvement in verb retrieval was associated with increases on a functional measure of communicative effectiveness. Improvement for nouns and verbs was associated with severity of word retrieval impairment at onset. Although distinct in neural and psycholinguistic attributes, nouns and verbs were affected by treatment in a similar pattern in this group of individuals. Training-specific effects suggest the need for careful selection of training words to have potential for functional benefit in daily communication.