Communication partner training facilitates
everyday outcomes for people with acquired
communication
disability
Leanne Togher1, Skye Mcdonald2, Robyn Tate3,4,
Emma Power1 & Rachel Rietdijk1,5
1 Speech Pathology, Faculty of Health Sciences, the University of Sydney, Sydney
2 School of Psychology, the University of New South Wales, Sydney
3 Rehabilitation Studies unit, Northern Clinical School, Faculty of Medicine, University of Sydney
4 Royal Rehabilitation Centre, Sydney
5 Brain Injury Rehabilitation Unit, Liverpool Health Service, Sydney
Acknowledgements
› NH&MRC project Grant 402687
› We are grateful to study
participants as well as staff from:
› Liverpool Brain Injury Unit, including Dr
Grahame Simpson, Dr Adeline
Hodgkinson, Manal Nasreddine, Kasey
Metcalf
Westmead Brain
Injury Unit
› Westmead Brain Injury Unit and speech
pathology department, including Dr Kathy
McCarthy, Anna Jones, Dr Alex Walker, Dr
Ian Baguley, Dr Joe Gurka, Rod Gilroy
› Royal Rehab Centre Sydney Brain
Injury Unit, including Audrey McCarry,
Vanessa Aird, Alanna Huck and Dr
Clayton King
› Gaye Murrills, private speech pathologist
Approaches to improve communication in TBI
Train the person with TBI
(Flanagan, McDonald & Togher, 1995, Medd & Tate, 2000, Tate, 1987,
Cannizzaro & Coelho, 2002; Cramon et al, 1992, Helffenstein & Wechsier,
1982 ; Dahlberg et al., 2007)
Train communication partners
(Togher, McDonald, Code & Grant, 2004)
Train both
NH&MRC Clinical trial
(Togher, McDonald & Tate, 2007-2009)
3 arm trial which compares:
1. Treating communication deficits of person with TBI directly
(TBI SOLO)
2. Training everyday communication partners (ECP) along
with the person with TBI (TBI JOINT)
3. A delayed treatment control group (CTRL)
TBI Participants
 44 participants with TBI
 recruited from Liverpool, Royal Ryde and Westmead Brain Injury Units,
Sydney Australia
 Mean age = 36 years (SD=14, range=18-68)
 Mean education = 12 years (SD=3, range=7-20 )
 Mean time post injury = 8 years (SD=7.2, range=1-25)
 Mean PTA = 83.15 days (SD=61, range=6-182)
 38 males: 6 females
Everyday communication partner (ECP)
participants
44 communication partners of person with TBI
 Mean age = 50 years (SD = 15.5, range = 17-79)
 Mean education = 13 years (SD = 2.7, 9-19)
 80% were female
 80% knew the person before the TBI
 The majority were partners or parents, however siblings and friends also
participated in the study
Study Participants
Allocated to
 TBI JOINT - Communication partner treatment
 n=14 ( 1 dropout = 13)
 TBI SOLO - Person with TBI alone treatment
 n=15 ( 1 dropout = 14)
 CTRL - Delayed treatment control
 n=15 ( 1 dropout = 14)
 93 % retention rate at post assessment and 87.5% retention at 6 mo f/up
ANOVA comparison across groups ‘ns’ for:
 Age, education
 Time post onset, PTA
 Cognitive-linguistic impairment (SCATBI)
 ECP age
 ECP education
Treatment – Communication Partner training
Group and individual training for TBI JOINT group
 Group of 4-5 people with TBI & their communication partners
 2.5 hr weekly group sessions (+ morning tea/social break)
 1 hour weekly individual sessions for each pair
 10 week program
 Manualised approach
• Interpersonal communication skills
• Collaborative and elaborative conversational strategies (Ylvisaker et al
1998)
• Enhancing / supporting communication of person with TBI/ question
asking
Treatment – TBI only training
Group and individual training TBI SOLO group
 Group of 4-5 people with TBI
 No communication partners
 2 therapists
 2.5 hr weekly group sessions (with morning tea/social break)
 1 hour weekly individual sessions
 10 week program
 Manualised approach – parallels JOINT contents
Control condition
Waitlist group
 deferred treatment
Conversation assessment
Outcome measures were collected at:
 Initial assessment,
 1-3 weeks after group intervention and
 6 months after assessment
2 discourse samples were collected:
 Casual conversation
 Purposeful conversation
Primary outcome measures
Adapted Kagan scale
(Kagan et al., 2001,2004; Togher et al, in press)
 Measure of Participation in Conversation (MPC)(TBI)
 La Trobe Communication Questionnaire (LCQ)
(Douglas, O’Flaherty & Snow, 2000)
 Self report
 Other report
Primary outcome measure
 Adapted Kagan scale (Kagan et al., 2001,2004; Togher et al, in press)
 Measure of Participation in Conversation (TBI)
 level and quality of conversational participation
 Ability to interact and socially connect (Interaction
scale)
 Ability to respond to and/or initiate content
(Transaction scale)
 videotaped interactions rated by 2 blind assessors
 9-point Likert scales, presented as a range of 0 to 4 with 0.5 levels
for ease of scoring
The Adapted Kagan scales for TBI Interactions
 Scales ranged from 0 (no participation) through 2
(some) participation to 4 (full participation) in
conversation
 Inter-rater reliability scores for both the Adapted MPC
scales were excellent
(MPC: ICC = 0.84-0.89). Over 90% of ratings scored within 0.5
on a 9 point scale
 Intra-rater agreement was also strong
(MPC: ICC = 0.81-0.92). Over 90% of ratings scored within 0.5
on a 9 point scale
(Togher et al., 2010, Aphasiology)
Secondary measures
 Adapted Measure of Support in Conversation (MSC)(Kagan et al.,
2001,2004; Togher et al, in press)
 Global ratings of communication (Bond & Godfrey, 1997)
 Appropriate
 Effortful
 Interesting/engaging
 Rewarding
 on a 9 point scale, 0-4
 Social perception ability: The Awareness of Social Inference Test
(McDonald, Flanagan & Rollins, 2002)
 Social participation: Sydney Psychosocial Reintegration Scale (Tate et al.,
1999)
 Confidence and self esteem: Rosenberg Self Esteem Scale (Rosenberg,
1965)
 Caregiver satisfaction: Modified Care Burden Scale (Machamer et al., 2002)
 Discourse analysis measures
Analysis
 Initial analysis compared amount of change across the
3 groups with repeated measures ANOVA pre and post
treatment in purposeful and casual conversation
conditions
 Intention to treat analysis used
RESULTS
No statistically significant differences between the three
groups at baseline on MPC ratings
Significant treatment effect measured on the MPC
Interaction scale in both casual conversation and
purposeful conversation conditions
 i.e., the JOINT group improved relative to the other two
19
Casual conversation: Interaction scale
CC = Casual
conversation
20
Purposeful conversation: Interaction scale
PC = Purposeful
conversation
21
Results
Significant treatment effect was also found on the MPC
Transaction Scale in both casual conversation and
purposeful conversation conditions
Casual conversation: Transaction scale
CC = Casual
conversation
23
Purposeful interaction: Transaction scale
PC = Purposeful
conversation
24
Discussion
Training communication partners was more efficacious than
training the person with TBI alone
Success was due to key training principles including:
 Communication being a collaborative and elaborative process (Ylvisaker
et al., 1998)
 Training the ECP to reveal the competence of the disabled speaker
(Kagan et al., 2004)
 Sensitively targeting behaviours of the ECP (eg test questions, speaking
for the person with TBI) led to a significant change in everyday
interactions
Discussion
Communication partners were challenged to change
THEIR OWN communication behaviours
 Eliminating “testing” questions to which they already knew
the answer
 Reducing questions which checked the accuracy of the
person with TBI’s contribution
 Speaking to the person with TBI as an adult and not a child
Conclusions in the context of the World
Disability Report
A person’s communication environment will significantly
impact on their ability to engage in daily living activities
Building capacity within the family unit will promote good
psychosocial outcomes for both the person with brain injury
and their family members
Training everyday communication partners is an
important complementary treatment for people with TBI
and their families to facilitate and promote improved
communication outcomes