TAILORING SUPPORTED CONVERSATION
A Thesis by
Maria Martinez
Bachelor of Arts, The University of Kansas, 2011
Submitted to the Department of Communication Sciences and Disorders
and the faculty of the Graduate School of
Wichita State University
in partial fulfillment of
the requirements for the degree of
Master of Arts
May 2014
© Copyright 2014 by Maria Martinez
All Rights Reserved
TAILORING SUPPORTED CONVERSATION
The following faculty members have examined the final copy of this thesis for form and content,
and recommend that it be accepted in partial fulfillment of the requirement for the degree of
Master of Arts, with a major in Communication Sciences and Disorders.
______________________________________
Julie Scherz, Committee Chair
______________________________________
Anthony DiLollo, Committee Member
______________________________________
Nicole Rogers, Committee Member
iii
DEDICATION
To my parents, Rodrigo Martinez and Lorena Basaure, who have modeled perseverance and
whose love and support, are constant. Also, to Daniel Klapper who has been my strength through
this journey
iv
ACKNOWLEDGEMENTS
I would like to thank my supervisor and committee chair, Dr. Julie Scherz, for her
support and guidance. Your expertise and understanding of AAC is inspiring. I would like to also
thank the aphasia group student clinicians without whom this study would not have been
possible. Thank you to all my participants whose stories and lives have enriched mine.
Quiero agradecer a mi familia: Mama, Papa, Alexa y Daniel. La ayuda y el apoyo de
ellos ha sido fundamental para mi desarrollo educacional.
v
ABSTRACT
The purpose of this study was to determine if tailoring communication notebooks and
methods of conversation to the individual needs of clients with aphasia would enhance their
quality of life.
Nine adults (4 females and 5 males) attending an aphasia group at a University-based
clinic participated in the study. The Multimodal Communication Screening Test for Persons
with Aphasia (MCST-A) was administered along with the AAC-Aphasia Categories of
Communicators Checklist to determine the conversation abilities and preferences of the
participants. These scores were compared to scores obtained on the Western Aphasia Battery
(WAB) to determine if severity of aphasia affected communicator preferences. Communication
notebooks were created using the MCST-A scores to customize the supports available for each
participant. These communication notebooks were used during the 90-minute aphasia group
sessions weekly for fifteen weeks.
A Quality of Communication Life Scale (ASHA QCL) was given to aphasia group
members before and after the use of individualized communication notebooks. Additionally to a
brief questionnaire was created and administered before and after the 15 weeks of treatment with
the communication notebooks.
Results indicated severity of aphasia determined by the WAB did not predict the
communicator preferences determined by the MCST-A assessment. This study showed that
certain areas of aphasia group participants’ quality of life, as measured by the Quality of
Communication Life Scale (ASHA QCL) improved after the introduction of communication
notebooks during aphasia group sessions. Student clinicians’ experience and confidence with
using supported conversation also increased after being introduced to supported conversation.
vi
TABLE OF CONTENTS
Page
Chapter
I. INTRODUCTION………………………………………………………………………..……..1
II. LITERATURE REVIEW……………………………………………………………………...3
Aphasia and Augmentative and Alternative Communication (AAC)…………………………….3
Providers…………………………………………………………………………………………..4
Supported Conversation………………………………………………………………….……….5
Supported Conversation Strategies………………………………………………………….….....6
MCST-A…………………………………………………………………………………………..7
Types of communicators…………………………………………………………….…...………..7
Partner Dependent Communicators…………………………………………………...………......7
Independent Communicators…….…………………………………………………….………….8
Quality of Life……………………………………………………………………………………10
Purpose of study………………………………………………………………………………….12
III. METHODOLOGY ………………………………………………………………………….13
Participants………………………………………………………………………………...…….13
Assessments………………………………………………………………………….…....……..13
WAB……………………………………………………………………………...…...…13
MCST-A………………………………………………………………………….….…..14
Scoring of MCST-A………………………………………………………………..……14
Quality of Communication Life Scale……………………………………………......….15
Aphasia Group Communication Notebooks………………………………………..……16
Aphasia Group Student Clinician In-service………………...…………………….…….16
Aphasia Clinician Questionnaire ………………………………………………......……17
Data Analysis…………………………………………………………………….………17
IV. RESULTS …………………………………………………………………………………..18
Patient Demographics………………………………………………………………………..…..18
Relationship: WAB scores to MCST-A Scores……………………………………………....….19
Quality of Life Scores……………………………………………………………………………19
Student Clinician Questionnaire…………………………………………………………………20
V. DISCUSSION ……………………………………………………………………….......…...22
vii
TABLE OF CONTENTS (continued)
Chapter
Page
Explanation of findings: WAB and MCST-A scores……………………………………………22
Explanation of findings: Participant quality of life………………………………………………23
Explanation of findings: Student clinician questionnaire …………………………………….…24
Clinical implications………………………………………………………………………….….25
Study Limitations………………………………………………………………………………...25
Future Research………………………………………………………………………………….25
REFERENCES ………………………………………………………………………………….27
APPENDIXES ………………………………………………………………………………..…31
A. MCST-A Scoring Sheet………………………………………………………………………32
B. AAC- Aphasia Categories of Communicators Checklist……………………………….…….33
C. Quality of Communication Life Scale (ASHA QCL)………………………………….……..35
D. Aphasia Group Clinician Handouts…………………………………………………………..56
E. Aphasia Group Student Clinician Questionnaire……………………………………………..59
viii
LIST OF TABLES
Page
Table
1
Data of Participants in Research Study…………………………….……………..…….18
2
Scores of Participants on the ASHA-QCL………………………………………..…….19
3
Scores of Student Clinicians on the Aphasia Group Clinician Questionnaire……..……21
ix
CHAPTER 1
Introduction
Research suggests that augmentative and alternative communication strategies (AAC)
helps bridge the communication gaps created by aphasia by increasing clients’ options for
communication (Garrett, Beukelman, & Low-Morrow, 1989; Fox & Fried-Oken, 1996). Aphasia
is a communication disorder typically resulting from a stroke or other neurological event. AAC
strategies and supports are a means by which people with aphasia can increase their daily
communication opportunities and therefore improve participation in activities of daily living.
These supports may be improved by customizing them to the individual user’s needs.
In order to help clinicians identify specific types of communicators with aphasia, Garrett
and Lasker (2005) created a screening tool, the Multimodal Communication Screening for
People with Aphasia (MCST-A), to accompany their AAC- Aphasia Categories of
Communicators Checklist (2005). This screening tool and checklist were used to help identify
persons with aphasia as “partner dependent” or “independent” communicators. These two
categories are further divided into three subcategories depending on communication skills. The
three subcategories for the partner dependent profile are: “emerging communicator”, “contextual
choice communicator” and “transitional communicator”. The independent sub-categories are
“stored message communicator”, “generative communicator” and “specific needs
communicator”.
These tools have been widely disseminated in the literature, but little research has been
done to document their efficacy or ability to predict the communicator styles of persons with
aphasia. No specific criteria are available for the related aspects of scoring the MCST-A and
then determining a communicator category.
1
The current study had three objectives, all relating to the conversation abilities of
persons with aphasia. The first was to analyze the correspondence between MCST-A test scores,
and severity of aphasia as measured by the Western Aphasia Battery (WAB). The next objective
was to determine if creating communicator specific communication notebooks to support the
needs of aphasia clients, based on the AAC – Aphasia Categories of Communication Checklist,
would help improve quality of life measures for the persons with aphasia. The third objective
examined the experiences of student clinicians serving as conversation partners for the persons
with aphasia in an aphasia group setting regarding the efficacy of supported conversation with
the tailored communication notebooks.
2
CHAPTER 2
Review of the Literature
Aphasia and Augmentative and Alternative (AAC)
Aphasia impairs a person’s ability to communicate functionally, despite having intact
intelligence. Approximately 1 out of 250 older adults in the United States has aphasia. (National
Stroke Association, 2008). Aphasia is an acquired language impairment that usually occurs after
a stroke. Although a percentage of people with sudden-onset aphasia are able to recover or
preserve natural speech, a large number of people with aphasia are faced with long-term complex
communication needs.
Individuals living with communication disorders have long been treated by speech
pathologists attempting to restore their previous communication abilities. Augmentative and
alternative communication (AAC) strategies offer a different, but certainly not an exclusive
approach. These strategies work to support and facilitate overall communication effectiveness
and well-being, without the specific focus of restoring the person with aphasia to their previous
level of communication skills (Fried-Oken, Beukelman & Hux 2011).
Types of individuals who can benefit from AAC strategies
There are many types of individuals who will benefit from AAC–focused therapy. The
existing strategies range from low-tech graphic supports to state of the art computer-based
adaptive displays, and the rapidly developing technology environment is providing more
opportunities for innovative devices to serve individuals’ needs better than ever before. For
example, Johnson, Hough, King, Vos & Jeffs, (2008) examined the abilities of three individuals
with chronic non-fluent aphasia while using a dynamic display AAC device to enhance
3
communication. The results showed that there was improvement in the quality and
communication output for all of three participants while using the AAC device.
Individuals with chronic aphasia are often not introduced to AAC devices until long after
their condition has been diagnosed. Traditional therapy, focusing on restoring previous levels of
communication skills, is often the initial focus of care providers. If the aphasia seems to be
causing severe, long-term communication disorders, AAC strategies begin to enter the
therapeutic picture. This is more likely after the condition has existed for over a year, when
traditional techniques are shown to plateau in their effectiveness (Hough & Johnson 2009)
Two factors seem to specifically increase the efficacy of these AAC strategies. When
both the person with aphasia and their communication partner were able to use the AAC devices,
the perceived benefit was the highest and information was transferred most effectively (FriedOken, et al. 2012). Secondly, when photographs were part of the AAC system, those that were
contextually relevant and meaningful to the user were clearly superior in therapeutic effect.
(Beukelman, n.d.)
The design of AAC strategies for people with aphasia is a determining factor in their
efficacy. It is critical that the strategies strike a balance between sophistication, sufficient to
allow in-depth communication, while maintaining user-friendliness. Even the best supports are
useless if they are too unwieldy and end up discouraging the user.
Providers
In order for AAC strategies to be successful for a person with aphasia, a speech-language
pathologist may need to assume many responsibilities (Beukelman, Ball & Fager 2008). Speechlanguage pathologists must keep current with strategies that are known to help aid individuals
4
with aphasia. Most importantly they need to be focused on how various strategies are designed to
meet different communication needs.
The SLP must also serve as a facilitator to help instruct new communication partners and
caregivers. As a facilitator, the SLP would help collect content for AAC strategies (e.g.
communication notebooks) and support the client through instruction and practice.
Supported Conversation
Since communication is a two way street, the person with aphasia should not be left
without any resources to interact in a conversation. Supported Conversation (Kagan, 1998) was a
strategy designed to help alleviate/ share the conversational load. In order for a person with
aphasia to feel as though their message is getting through, the conversational partner should
actively participate. What sets Supported Conversation apart from other techniques is that
natural-sounding conversation is emphasized. (Kagan, 1998)
Several factors were taken into consideration when developing supported conversation
(Kagan, 1998). The first was that aphasia has the ability to mask competence that is normally
revealed in conversation. Because people with aphasia have difficulty expressing themselves
during conversations, they are sometimes treated as being socially incompetent. The second
factor was that there may be an interactive relationship between perceived competence and
opportunity for conversation. The result of being considered socially incompetent is that it leads
to a reduction of confidence in social interaction and the opportunities to interact socially. The
last factor involved the communication partners and their responsibilities to provide support.
They can increase social interactions by being trained to highlight the competence of the person
with aphasia.
5
There are several methods for training conversation partners. Technical modules can be
provided to communication partners. These include specific ways to interact with a person with
aphasia most effectively. The most important points in Kagan’s (1998) approach were to
acknowledge and reveal the competence of the partner with aphasia. To do this, the topic needs
to be clearly conveyed by using gestures, written key words, drawings, etc. Using yes/no or
fixed-choice questions and allowing the person with aphasia ample time to respond can also help
promote the conversational competency of the person with aphasia. Verifying responses is
another technique that should be used where the communication partner confirms their
understanding of the person with aphasia.
Supported Conversation Strategies
The goal of supported conversation is to teach the individual with aphasia and their
communication partners how to use multiple modalities of communication. The hope is that
supported conversation will promote opportunities for social interaction.
There are specific strategies that will help to avoid communication breakdowns. One of
these is the Augmented Input strategy where the conversation partner provides written key
words, gestures, drawings or diagrams. These supports are provided in “real time”, pairing visual
and auditory stimulation to help the person with aphasia to respond. (Ball & Lasker, 2013)
Another type of communication strategy is Written Choice Conversational Strategy. With
this technique the partner may scaffold the conversation by generating written key word response
options for the communicator. A scale can be used to help facilitate conversation when using this
technique. When communicating with a person with severe aphasia, questions are sometimes
difficult to answer. Therefore, it is beneficial to tag questions with either a “yes” or “no” in order
6
to help give the communicator an indication of how to respond as well as how to understand the
context of the conversation (Ball& Lasker, 2013).
Multimodal Communication Screening Task for Persons with Aphasia (MCST-A)
The MCST-A was developed to measure skills required to use AAC systems and
strategies. The authors created a two-tier classification system to describe interactive
communication ability and patterns of AAC strategy use in individuals with severe aphasia
(Garrett & Lasker, 2005). This screening is beneficial for clinicians because the results can help
classify different types of communicators. Identification of the appropriate mode of
communication is critical in tailoring interventions for maximum effectiveness.
Types of communicators
The MCST-A helps identify the following types of communicators: partner-dependent,
independent and nonusers. Each of communicator types will benefit more from certain
approaches than others.
Partner Dependent Communicators
Aphasia leaves most individuals with the inability to meet their daily communication
needs and rely on conversational partners to help manage communicational demands. Individuals
with aphasia who have severe linguistic or motor speech impairments that obstruct the use of
independent communication are categorized as “partner-dependent communicators”.
Characteristics of this type include difficulty with initiating communication, signaling partners,
and actively participating in activities. To help support conversation, the conversation partner
must be able to regulate the amount of information provided as well as providing appropriate
choices that are personally relevant. According to Lasker, Garrett and Fox (2007), there are three
7
types of partner dependent communicator types: emerging communicator, contextual choice
communicator and transitional communicator.
An “emerging communicator” is unable to understand messages unless they are placed in
personal context. Abilities seen in an emerging communicator are giving attention when greeted,
and starting to show an inclination towards preferred items. Both expressive and receptive
language has been severely affected in these individuals and therefore treatment focuses on
teaching conversation skills such as choice making, turn taking and confirmation/rejection.
(Garrett & Lasker, 2005)
The goals for a “contextual choice communicator” are to improve their gesture and
speech intelligibility through supported conversation such as written or picture response choices.
In comparison to the emerging communicator, the contextual choice communicator is able to
clearly indicate their preferred choices and can sustain multiple-turn conversations with the help
of a conversation partner. The conversation partner’s role is crucial to help the contextual choice
communicator express his or her intentions. It is important for them to provide the communicator
with supports (written or picture response choices) to help increase comprehension during
interactions. (Garrett & Lasker, 2005)
A “transitional communicator” has many strengths, such as shifting modalities with cues,
and starting the initial steps to convey their intended message. The challenges lie in cueing the
communicator to access stored messages. Therapy should focus on practicing initiating a
conversation as well as responding with available modalities. (Garrett, 2005)
Independent Communicators
Another category of communicator is the “independent communicator”. What separates
these from partner-dependent communicators is their ability to locate, select and convey
8
messages through spelling, writing, drawing, and/or gesturing. Because of their abilities in
retrieving and encoding messages independently, treatment can focus on teaching them to
systematically select a modality to match a specific situation. At the same time they can be
gathering the most relevant and powerful vocabulary storage in an aided AAC system. More
advanced independent communicators might be able to use more advanced strategies such as
word prediction. (Lasker, Garrett & Fox, 2007).
There are three types of independent communicators: stored message communicators,
generative message communicator and specific need communicator. Each type of communicator
has a set of abilities that specifically help support their communicative needs.
“Stored message communicators” have the ability to use AAC without support during
well-known situations. They also are able to use different types of modalities such as writing or
gesturing for some words in their vocabulary. Their deficits lie in clarifying or elaborating
messages during conversation, therefore treatment strategies include repeated trials and
practicing scripts to help them learn how and when to use their AAC. It is important to model
and practice navigating through their communication book so they become familiar and
comfortable finding their targeted response. (Beukelman & Mirenda, 2005)
“Generative message communicators” are able to access different modalities in different
environments. Although they are equipped with a variety of conversation techniques they lack
the ability to choose the most effective modality. Another skill of a generative message
communicator is that they are able to independently search through several location of a
communication system to communicate their response. It is important to give the communicator
ample time to compose their message because of their ability to access different modalities.
(Beukelman & Mirenda, 2005)
9
The most proficient independent communicator is the “specific need communicator”.
They do not require AAC as their main support for communication, but may require help when
confronted with unfamiliar situations where a specific response is required. One example is
communicating an emergency. The specific need communicator may need assistance in
practicing how to respond to life situations such as these where a very specific and timely
response is required. (Beukelman & Mirenda, 2005)
The third category, non-users, includes individuals who rely on unaided conversation
strategies such as speech and gesturing even though these approaches may not be adequate.
Typically these types of communicators have either not been exposed to AAC strategies and the
opportunities that brings or have made a conscious decision that AAC strategies were not an
effective tool. (Lasker, Garrett & Fox, 2007). It is important to explain to clients, especially to
those beginning to experiment with AAC, that AAC is a “comprehensive collection of
communication strategies that provide external support for people who cannot understand or
generate messages on their own.” (Lasker & Garrett, 2008, pg. 1)
Quality of Life
Quality of life (QOL) is defined as individuals’ “perceptions of their position in life in the
context of the culture and value systems where they live and in relation to their goals,
expectations, standards and concerns” (The WHQOL Group, 1996, p.5). For most people, the
ability to communicate is a major factor in their quality of life. After stroke, an individual is
faced with many obstacles that are created from their communication deficit that may then affect
their quality of life.
There are many areas that can be assessed for quality of life such as physical health,
mental health, emotional health, psychological health, and social support. There are few studies
10
concentrating on quality of life specifically for communication. Two studies have investigated
the consequence of aphasia on people’s lives (Le Dorze & Brassard, 1995; Zemva, 1999). After
interviewing people with aphasia and their significant others, both studies showed the impact of
aphasia, which included changes in communication situations and interpersonal relationships,
fewer social contacts and changed social life, loss of autonomy, restricted activities, difficulty
controlling emotions, and physical dependency as well as negative feelings such as anxiety,
loneliness, frustration, stress, and annoyance.
The aim in creating supports to lessen the burden of communication is to improve quality
of life (QOL). There are several studies that show social participation is an important component
to maintaining a high QOL (Hilari, Byng, Lamping & Smith, 2003; Cruice, Worrall, Hickerson,
Murison, 2003; Ross and Wertz 2003). Training and supplying communicators with functional
skills, as well as promoting supported conversation with conversational partners, enhances
communicative ability (Cruice et al. 2003; Pound, Parr, Lindsay, Woolf, 2000).
The Quality of Communication Life Scale (ASHA QCL) (Paul, Frattali, Holland,
Thompson, Caperton, Slater, 2004) concentrates on the person with aphasia and their views on
their communication abilities. There are many advantages to the AHSA QCL, including the
available 10 point scale that helps the person with aphasia express their point of view. Each
question includes picture symbols (stick figures and smiley faces) to help the person with aphasia
understand the two extremes of the question. For example, for the question “It’s easy for me to
communicate”, there is a picture of a smiley face with a full dialog box to indicate the ease of
talking. On the bottom of the scale there is a face with an empty dialog, signifying difficulty
communicating.
11
Two studies have reported the use of the ASHA QCL (2004) with persons with aphasia.
Hough (2010) showed that using melodic intonation therapy increased the score on the ASHA
QCL for one patient by 25 points, indicating that this individual felt an increase in
communicative effectiveness and independence following the use of a specific therapeutic
intervention. Hough and Johnson (2009) sought to determine the effect of AAC devices on
quality of life and used the ASHA-QCL as the assessment measure. They found that the
participant showed an increase on the assessment. The treatment for a person with severe,
chronic non-fluent aphasia used hierarchical strategies to facilitate communication.
Purpose of the Study
This study was designed to answer the following questions:

Does tailoring supports to meet the needs of persons with aphasia increase their
perceptions of their quality of life?

Do MCST-A descriptions of communication types correlate with severity of
aphasia as determined by WAB scores?

Do student clinician’s perceptions about the impact of using supported
converstaion strategies change over time?
12
CHAPTER 3
Methodology
Participants
The participants in this study were participants in an aphasia group program provided at
Wichita State University’s Evelyn Hendren Cassat Speech-Language-Hearing Clinic. This group
met once a week for 90 minutes. The group consisted of 4 females and 5 males. Participants
were between 36 and 73 years of age. Of the 9 participants, 7 were also attending individual
speech therapy during the duration of the study.
Each participant was administered three assessments: two (WAB and MCST-A) only at
the beginning of the study; one (ASHA QCL) both as a pre-test and post-test measure. The
Western Aphasia Battery (WAB) is a test that assesses spontaneous speech, auditory verbal
comprehension, repetition, naming, reading, writing, apraxia, constructional, visuospatial and
calculation tasks. The length of the test varied between 60-90 minutes. These subtests are scored
on a numerical scale which is then used to create an overall score, the Aphasia Quotient.
Scoring of WAB
The raw scores for spontaneous speech, comprehension, repetition, naming, reading and
writing, praxis, and construction were added and multiplied by two to obtain the Aphasia
Quotient. An Aphasia Quotient (AQ) of 100 was considered normal. Since the AQ measures the
severity of the language deficit, these scores were used to see if there were any correlations
between the severity of aphasia and the MCST-A (e.g. higher WAB scores may correspond to
lower cueing scores on the MCST-A).
13
Multimodal Communication Screening Test for Persons with Aphasia (MCST-A)
The test is administered by presenting a question or scenario and allowing the person
with aphasia to turn to the appropriate page in a notebook to select pictorial symbols to answer
the question or relay a specific message. There are three opportunities for the communicator to
answer appropriately. In the first trial the person with aphasia is required to answer
independently. The consecutive two trials are supported by the clinician who provides cues
needed to elicit the appropriate message. There are several tasks included in the MCST-A:
request basic needs, complete a category, retell a story, complete a transaction in a drug store,
identify locations on a map, etc.
Scoring of MCST-A
The communicator’s responses are scored in terms of the accuracy of messages/ symbols
selected, the number of cues provided, the number of attempts and the evaluator’s rating of
adequacy. The participant’s response was judged with the number 1, 0.5 or 0 points depending
on their adequacy. The skills targeted in the MCST-A are the following: 1-symbol message to
request basic needs or respond to biographical questions, combining 2-3 symbols, categorizing,
using environmentally-stored phrases in specific context, storytelling using a descriptive scene
sequence, story retelling using a descriptive scene sequence, telling about locations from a map
and spelling.
Cues available during the MCST-A are the following: repetitions, expansion, feedback,
opening the book, turning to the correct page, narrowing options by pointing to a restricted area
of a page, directing clients visual attention to a general area on the page, confirming that the
participant is in the right track, and modeling to show how to relay the intended message. Cueing
data can help to determine whether the communicator falls into the category of partner-
14
dependent or independent. The number of times these cues were used in the screening were
added to a summary sheet. (See Appendix A)
Based on MCST-A scores, participants were identified as specific communicator types
(See Appendix B). This assignment to specific communicator type was highly subjective as no
specific instructions or scoring rubric is provided to guide those decisions.
Quality of Communication Life Scale (ASHA QCL)
The Quality of Communication Life Scale (ASHA QCL) (Paul, et al., 2004) (See
Appendix C) was given to each member of the aphasia group at the beginning of the semester
and at the completion of the 15 week semester. This inventory consisted of 18 questions that
describe specific areas of functioning that were impacted after suffering a stroke and that
affected communication. Questions addressing social participation, confidence in speaking and
daily living communication participation were answered. Participants were allowed to take as
long as they required to consider and select their answer. The participant was given the option of
having the questions read aloud, or reading the scale independently.
For each question, a scale from marked from one to 10 was provided. A mark toward the
top of the scale (10) represented that the item described the participant well, while a mark toward
the bottom of the scale (1) represented that the item did not describe the individual. The ASHA
QCL was scored by noting the number on the scale designated by the participant for each
question. These scores were collected before and after the communication notebooks were used
and were analyzed to determine if quality of life measures changed, after communication
notebooks were tailored to specific communication needs.
15
Aphasia Group Communication Notebooks
Participants in the Aphasia Group had been introduced to the AAC strategy of a
communication notebook in prior semesters. During those semesters, however, one or two books
were available for the entire group and no specific training had been provided to the students
who served as conversation partners as to how to use these notebooks with their clients.
For the duration of this study (one 15-week semester), a communication notebook was
made for each participant in the group that was designed to have supports available for them that
would be most useful based on the type of communicator they had been identified to be.
Weekly material and activities used by the aphasia group were inserted in the first sections of the
communication notebook. At the end of each communication notebook, tailored supported
conversation pages (e.g. scales, images, alphabet, and maps) were inserted for aphasia group
members to access during conversation. Categories included in communication notebooks
included the following: rating scales, calendars, state and country maps, alphabet board, health
care communication board, months of the year, days of the week and social connections. Paper
and pencils were available for each aphasia client for the entire group session.
Aphasia Group Student Clinician In-service
A one-hour in-service was conducted to teach aphasia group student clinicians some
information about supported conversation as well as the different communicator types the
aphasia group consisted of. Handouts were given to the student clinicians that included
communicator strategies, partner strategies, a description of the skills and challenges each type
of communicator might experience (See Appendix D). Aphasia group student clinicians were
instructed to use strategies that corresponded to each communicator type (e.g. tagged yes/no
16
questions for contextual choice communicators) and to use the supports that were available in
each participant’s tailored communication notebook.
Aphasia Clinician Questionnaire
Four aphasia group student clinicians were asked to answer six questions regarding their
past and present experiences with supported conversation (See Appendix E). The questionnaire
requested information of the student clinician’s opinion on the effectiveness of the
communication notebooks as well as their familiarity with using supported conversation. Each
question included a scale from 0-10 and was given to the clinicians before and after the use of
communication notebooks during aphasia group. The responses to the questionnaire were
analyzed to judge the clinicians perception of using supported conversation and AAC
strategies/supports over time.
Data Analysis
Research question 1: Does tailoring supports to meet the needs of persons with aphasia
increase their perceptions of their quality of life? The pre- and post-treatment scores on the
ASHA QCL were compared using a paired sample T-test.
Research question 2: Do MCST-A descriptions of communication types correlate with
severity of aphasia as determined by WAB scores? The WAB scores will be compared with the
MCST-A scores in terms of aphasia quotient severity ratings. It would be speculated that the
more severe the aphasia, the more partner-dependent the communicator type might be.
Research questions 3: Do student clinician’s perceptions about the impact of using
supported conversation strategies change over time? Pre- and post-test scores on the student
clinician questionnaire were compared using a paired-sample T-test.
17
CHAPTER 4
Results
Participant demographics
Nine persons with aphasia completed this study (pre- and post-testing and 15 weeks of
participation in the Aphasia Group sessions). Demographic information for all participants is
summarized in Table 1.
Table 1
Data of Participants in Research Study
Participant
MCST-A
WAB Age
Number Communicator AQ
Type
Score
Gender
1
Transitional
89.6
55
M
Previous
Semesters
in
Aphasia
Group
3
2
80.35
58
M
3
yes
100%
3
Stored
Message
Transitional
64.4
48
F
4
yes
100%
4
Transitional
60.75
55
M
5
yes
100%
5
Contextual
41.95
67
M
2
yes
71%
6
Contextual
54.05
36
F
15
yes
100%
7
Transitional
88.03
73
F
4
no
93%
8
Stored
Message
96.2
48
M
3
yes
100%
9
Generative
Message
83.25
61
F
3
no
93%
18
Simultaneous
Individual
Therapy
Aphasia
Group
Attendance
yes
100%
Relationship of WAB scores to the MCST-A scores: There appeared to be no
significant relationship between the WAB and MCST-A scores. Clients who had higher MCSTA scores did not also score higher on the WAB. The scores did not seem to follow any pattern. It
should be noted, however, that the clients who scored lowest on the WAB were considered
“contextual communicators”, which is the group that requires the most supports. “Stored
message communicators” and “generative communicators” had the higher WAB scores on
average, but the severity of the WAB scores did not appear to predict communicator types.
Quality of Life Scores
All aphasia group members were administered the quality of life assessment. Table 2
indicates the scores for each participant.
Table 2
Scores of Participants on the ASHA QCL
Participant
P1
Before/After
10/10
P2
P3
P4
P5
P6
P7
P8
P9
10/10
8/8
2/7
10/10
5/10
5/7
2/10
10/10
Q1
10/7
10/10
8/5
2/6
10/10
7/10
6/7
1/8
10/10
Q2
7/5
7/6
2/4
2/6
4/0
4/10
6/5
0/6
4/5
Q3
10/10
1/5
9/10
2/8
8/10
10/10
5/6
6/10
8/8
Q4
10/10
10/10
7/6
1/5
10/10
10/10
10/6
6/8
10/10
Q5
10/10
3/6
3/3
3/7
5/10
8/10
5/8
5/8
5/10
Q6
8/7
3/6
9/7
1/5
9/10
9/10
6/7
7/10
9/8
Q7
9/6
4/5
7/7
3/7
7/0
6/10
4/7
3/7
7/8
Q8
10/10
7/7
10/9
8/9
10/7
10/10
7/8
10/10
10/10
Q9
6/5
5/8
2/4
0/1
3/0
2/6
6/8
1/2
3/3
Practice
19
Table 2 (continued)
Q10
10/10
7/8
7/8
4/4
10/0
10/10
7/8
5/8
10/10
Q11
5/6
3/7
4/5
4/5
6/0
3/10
5/7
6/6
6/5
Q12
9/10
5/6
8/7
2/5
10/0
10/10
6/7
9/9
10/9
Q13
10/10
6/7
5/5
7/9
8/10
5/10
7/9
10/8
8/8
Q14
10/8
6/7
6/4
5/6
5/0
5/10
7/7
4/5
5/6
Q15
8/10
6/7
7/8
4/6
10/10
10/10
7/6
8/10
10/10
Q16
10/10
5/10
4/7
2/2
10/10
3/10
5/7
7/9
10/10
Q17
8/7
7/7
7/8
5/8
10/0
1/10
7/9
8/8
10/10
Q18
10/10
7/7
7/7
3/5
7/0
10/10
10/10
6/9
7/10
A paired sample T-test was administered to assess significant differences between preintervention and post-intervention scores. The results show that there was a significant difference
for the questions Q#3 “My role in the family is the same” (p = 0.03), and Q#5 “I meet the
communication needs at home” (p = 0.001) after using the specifically tailored conversation
supports. The scores for the other questions did not show a significant difference, although Q# 6
“I stay in touch with family and friends” (p = 0.07), and Q#16 “I have household
responsibilities” (p = 0.07) showed a possible trend toward significance.
Student Clinician Questionnaire
All aphasia group student clinicians completed a questionnaire before and after the
semester of aphasia group. Table 3 shows the results from the four student clinicians who served
as conversation partners for the participants with aphasia during the Aphasia Group sessions.
20
Table 3
Scores of student clinicians (SC) on the Aphasia Group Clinician Questionnaire
Participant
SC2
SC3
SC4
Q1
SC1
Before/After
10/10
9/10
8/10
10/10
Q2
3/6
10/10
7/10
1/8
Q3
10/9
8/10
6/8
9/10
Q4
3/5
7/10
4/7
5/10
Q5
3/7
6/9
8/9
5/7
Q6
4/5
10/10
6/9
7/8
A paired sample T-test was administered to assess significant differences between the
clinicians’ scores. The results showed that there was a significant difference for question #2
“How familiar are you with supported communication” (p=0.01) after a semester of using the
communication books and supported conversation with clients with aphasia. The scores for the
other questions did not show a significant difference, although Q #4 “How comfortable do you
feel drawing when communicating with an aphasia group client” (p=0.07) and #5 “How
comfortable do you feel gesturing when communicating with an aphasia group client” (p=0.09)
showed a possible trend towards significance.
21
CHAPTER V
Discussion
This study sought to answer three questions regarding supported conversation and AAC.
First we determined if creating individualized communication notebooks and supplying
supported conversation to client with aphasia would lead to improvements ratings of quality of
life. Next, results of the MCT-A and the WAB were analyzed for any relationships. Finally the
perceptions of student clinicians providing therapy during aphasia group about the impact of
using supported conversation strategies were compared over the course of the semester.
Explanation of findings: WAB and MCST-A scores
A prior study by Lasker and Garrett (2006) showed a correlation between severity of
impairment seen in the WAB and MCST-A scores. Their study showed that if an individual’s
MCST-A had higher cueing scores, their WAB score would indicate a higher level of aphasia
severity. The results of the current study showed that the participants’ WAB results were not
necessarily correlated with the specific types of communicator as identified by the MCST-A. It
is possible that the scores were not related because their study included four participants while
this study included nine participants. This sample sizes in both studies may be insufficient to
reliably predict the relationship.
Most of the individuals in this study had participated in group therapy for several
semesters and may have acquired the ability to use some supported conversation strategies prior
to this study. This may have reflected in their higher scores on the MCST-A. This could result in
a more severe WAB score, but a higher MCST-A because of the participant’s ability to
compensate for their difficulty communicating with supported conversation, such as gesturing or
22
pointing. Also, some of the individuals in this study possessed communication notebooks of their
own, allowing them to navigate through the pages of the screening tool more efficiently (more
experience), and in consequence, scoring higher on the MCST-A.
It should be noted that when scoring the MCSTA there is not a set number system that
correlates to the type of communicator. The investigators used their best judgment as to the
ability of the aphasia participants, and categorized them as a specific type of communicator. This
section of the study was subjective and could vary from clinician to clinician.
Explanation of findings: Participant quality of life
Only two areas of the participants’ ASHA QCL improved significantly. The participants
felt that their roles in the families were similar to their roles before their stroke and that they
were meeting the communication needs at home. Other areas of some increase were staying in
touch with family and friends and having household responsibilities. It is believed that these
areas may have seen an improvement for these individuals because they were able to use
supported conversation at homes (e.g. gesturing, writing) which in turn is helped them
communicate more efficiently.
By tailoring the communication notebook to each individual, their preference of
communication was used more often, which resulted in more successful interactions for family
and friends. At the beginning of each aphasia group meeting, aphasia group members were
allowed to share information about themselves to others. The communication notebooks allowed
the participants to show some personal information to others more successfully and accurately.
By using the books weekly, the participants were able to become well acquainted where certain
materials were found. Their familiarity with the location of items such calendars and scales
23
enabled the them to spend less time searching for the correct support, and more time sharing with
others.
The other areas measured by the ASHA QLS did not show significant change. This could
be due to the already high scores reported by the participants at the beginning of the semester.
Since their quality of life in some of these areas were already fairly high, there was not much
room for improvement.
Although the ASHA QCL was validated to specifically measure quality of life regarding
communication with persons with aphasia, it may not be the best instrument to demonstrate
change when looking at communication satisfaction when using communication notebooks or
AAC strategies. The ASHA QCL had many questions regarding relationships and daily
communication but did not specifically focus on the satisfaction of using supported conversation
or tailored communication notebooks. Another quality of life scale that could be more focused
on AAC strategies and supports might have shown greater improvement.
Explanation of findings: Student clinician questionnaire
The communication notebooks created offered the clinicians new ways to use partnersupported strategies. Each student clinician attended an in-service about the ways to use
supported conversation and was provided with information sheets to help remind them of ways
to communicate with clients in aphasia group. These reminders were needed with less frequency
toward the end of the semester. The in-service and weekly practice with supported conversation
helped the student clinicians increase their familiarity and have in turn helped them become more
confident and comfortable with using drawing and gesturing as supports during conversations
with aphasia group members.
24
Again, other areas of the questionnaire did not show a significant increase because the
scores placed by the clinicians were fairly high before the study. A majority of the clinicians
were familiar with the benefits of supported conversation as well as communication notebooks.
Clinical Implications
The findings from this study show that using communication notebooks that are
specifically created for a specific type of communicator, increases certain areas of quality of life.
Areas such as their roles and communication at home have shown an increase of quality due to
the communication notebooks. Communication notebooks and the use of supported conversation
have the ability to empower clients with aphasia to communicate more easily, become included
in conversations with others and motivate them to try different modalities shown to them by the
student clinician (e.g. written choice, gestures).
Student clinicians also showed an increase of understanding the use of supported
conversation through communication notebooks. It would be beneficial for clinicians who are
working with clients with aphasia, to become acquainted with supported conversation and to
focus on tailoring the communication book to the type of communicator.
Study Limitations
Limitations of the present study include the relatively small sample size. Although the
study was sensitive to differences between the aphasia group members, due to the small sample
size, it had limited power to predict individual preferences.
Future Research
Future research improvements could include aphasia client’s caregivers, family and/or
friends in using the communication notebooks. A questionnaire could be completed for the
client’s family members to compare the benefits they experience with AAC strategies. This
25
would allow the analysis of the efficacy of the notebooks from a different perspective. This
would be especially useful if the individual interviewed is the primary caregiver and
conversation partner to the client with aphasia. Additionally, an in-service could include family
members to inform them of ways to using the communication notebooks and supported
conversation.
In this study, aphasia participants used the communication notebooks solely during the
aphasia group period. It would be beneficial to widen the locations for the use of communication
notebooks; bringing them home or using them during individual treatment. In future research a
new questionnaire could be specifically created to determine the different types of
communication methods and their rate of proficiency.
26
REFERENCES
27
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30
APPENDIXES
31
APPENDIX A
MCST-A Scoring Sheet
32
APPENDIX B
AAC- Aphasia Categories of Communicators Checklist
33
APPENDIX B (continued)
34
APPENDIX C
Quality of Communication Life Scale (ASHA QCL)
35
APPENDIX C (continued)
36
APPENDIX C (continued)
37
APPENDIX C (continued)
38
APPENDIX C (continued)
39
APPENDIX C (continued)
40
APPENDIX C (continued)
41
APPENDIX C (continued)
42
APPENDIX C (continued)
43
APPENDIX C (continued)
44
APPENDIX C (continued)
45
APPENDIX C (continued)
46
APPENDIX C (continued)
47
APPENDIX C (continued)
48
APPENDIX C (continued)
49
APPENDIX C (continued)
50
APPENDIX C (continued)
51
APPENDIX C (continued)
52
APPENDIX C (continued)
53
APPENDIX C (continued)
54
APPENDIX C (continued)
55
APPENDIX D
Aphasia Group Clinician Handouts
56
APPENDIX D (continued)
57
APPENDIX D (continued)
58
APPENDIX E
Aphasia Group Student Clinician Questionnaire
59
APPENDIX E (continued)
60