The Use of Goal Attainment Scaling
for Setting, Monitoring, and Upgrading Language
Goals in the Treatment of Chronic Aphasia
Presented by
Wendy Duke
RSLP,
Registered Speech-Language Pathologist,
M.Sc., CCC(SLP)
Director, Columbia Speech and Language Services, Inc. (CSLSI) and
iTAWC ( a speciality clinic of CSLSI)
Assistant Clinical Instructor, and Sessional Instructor UBC School of
Audiology and Speech Sciences
Authored by Wendy Duke, Ramanjit Bains, Alisa Ferdinandi and
Lauren Tittley
wendy@columbiaspeech.com www.columbiaspeech.com
www.itawc.com
STATEMENT OF PROBLEM:
• Most aphasia assessment batteries focus on
categorizing aphasia type (e.g. BDAE-3 and
WAB-R), outlining functional difficulties (e.g.
CADL-2, ALFA), or identifying psycholinguistic
processes affected (e.g. PALPA).
• None of these, however, provide a framework
to help clinicians to set specific functional
goals.
• Nor do they help the clinician to easily
monitor incremental changes in these
functional goals
• Nor do they provide the clinician with a
framework to advance goals systematically.
• And, such tests may lack the sensitivity to
measure ongoing “subtle but important
changes” (Schlosser, 2004) in functional
communication that may occur months or
even years post-stroke.
What is the right measurement tool
for the job?
What are we measuring?
How should we measure it?
What tool should we use to measure it?
We believe that GAS is the right tool to
• Customize a functional speech or language
goal for an individual with chronic aphasia
• Measure progress toward the goal
systematically
• Adjust goals to increase or decrease challenge
as the treatment proceeds
• Communicate meaningful numeric data to
funding sources
So…..
• What is Goal Attainment Scaling?
• Originally developed as a clinical tool in
psychiatry, GAS is a numeric scale written
around a specific goal, in which the client’s
baseline and desired outcomes are defined,
and each are assigned a numeric or alphabetic
value along a scale
• But what does GAS look like?
Structure
• +2 highest outcome reasonably attainable for
client on a given goal
• + 1 outcome in which expectations are exceeded
by the client on a given goal
• 0 expected outcome for client on a given goal
• -1 client’s baseline performance on a given goal
• -2 decline in client’s performance from baseline
• Using a 5-point scale, G.A.S. allows the
clinician to set graduated, personalized target
outcomes predicated upon the client’s
observed baseline and desired outcome.
• It can be used for a wide variety of
behaviours.
My Teenage son’s laundry behaviour
• +2 – independently washes, dries and puts away own
laundry
• + 1 – washes, dries, puts away own laundry with reminder
from Mum
• 0 - dries, puts away own laundry with reminder from Mum
• -1 - only puts laundry in hamper when Mum threatens to
donate clothing left on various floors around house
• -2 – makes dramatic attempt to load clothing in machine
without emptying pockets, “accidentally” includes rocks,
gum and weight-lifting chalk, breaks machine in vain hope
that Mum will never mention laundry again.
• It has been adapted for use for various
communication disorders (Schlosser, 2004).
History of the use of GAS at our clinic
• At ASHA in 1990, I attended a talk on the use of
GAS for TBI ( author unknown)
• Throughout 1990s and beyond, we used this as a
tool for setting collaborative goals and measuring
communication behaviours (and as a teaching
tool) in a group therapy program for people with
TBI (more later if time and interest permits)
• In the 2000s, we started using GAS for our
chronic aphasia conversation group, and in 2011,
we started using it in our intensive program.
G.A.S. IN CHRONIC APHASIA
TREATMENT:
• We applied G.A.S. both within a conversationbased aphasia group and a recovery-focused
intensive aphasia treatment program (iTAWC* –
Intensive Treatment for Aphasia in Western
Canada). Goals were established taking into
account the desired outcome expressed by
clients, therapist observations, and the
expectations of therapists as to realistic,
achievable outcomes within a given timeframe.
Conversation group
• Goal area – Conversation participation,
specifically to increase participation of
individuals with various levels of aphasia in
Monday morning conversation group and
measure this.
• Funder ( government ) wanted numerical
outcome data.
• No available measures seemed sufficiently
sensitive
G.A.S
+2 – best expected outcome
Goal
The client asks the question “How was your
weekend?” independently.
+1 – more than expected
The client asks the question “How was your
weekend?” when cued to their turn in the
conversation.
0 – expected outcome
The client asks the question “How was your
weekend?” with the starter prompt “How was
your…”
-1 – baseline
The client repeats the question “How was
your weekend?” after clinician model.
-2 – regression
The client is unable to repeat the question
“How was your weekend?” even with
maximal cueing.
• In the context of the conversation group, all
participants shared the same general goal area,
but had different baseline and target points on
the scale based on individual abilities and needs.
The preceding shows results for one client who
achieved his expected outcome during one round
of treatment and then achieved the next level up
in the following round of treatment. Although
time consuming to set goals initially, G.A.S. allows
for easy adjustment of targeted goals as clients
improve.
iTAWC
• Intensive Treatment for Aphasia in Western
Canada
• Developed three GAS goals for each client
• First example ( of three) is for a man with
fluent aphasia, for whom the following GAS is
in the goal area of Communication Efficiency
G.A.S.
Goal
+2 – best expected outcome
In conversation, client conveys more than 6
distinct and relevant content units per
minute.
+1 – more than expected
In conversation, client conveys 6 distinct and
relevant content units per minute.
0 – expected outcome
In conversation, client conveys 5 distinct and
relevant content units per minute.
-1 – baseline
In conversation, client conveys 3 distinct and
relevant content units per minute.
-2 – regression
In conversation, client conveys less than 3
distinct and relevant content units per
minute.
•
•
•
This client surpassed his best expected outcome.
For this gentleman with fluent aphasia, the goal of
communication efficiency was strongly identified by
his family as an important goal. Relevant content
words were counted as an indicator of efficiency.
This improvement in communication efficiency was
not reflected in changes on sections of the WAB-R
that measured narrative production, indicating that
G.A.S. is a more sensitive marker of functional
change in conversation ability.
G.A.S.
Goal
+2 – best expected outcome
Client independently reads and comprehends
an article of her choice.
+1 – more than expected
Client independently reads and comprehends
a 2 to 3 paragraph passage from an article of
her choice.
0 – expected outcome
With support (decoding difficult words), client
reads and comprehends a 2 to 3 paragraph
passage from an article of her choice, e.g.
Savage Love.
-1 – baseline
The client requires support to read and
comprehend a single paragraph.
-2 – regression
The client cannot read and comprehend a
single paragraph even with support.
• This client achieved her expected outcome
in reading for pleasure.
• This goal was identified as important by
the client who had previously been an avid
reader prior to her stroke.
Goal area – email composition
• Email correspondence was of particular
importance to this next woman, who wanted
to keep in touch with her husband and young
children throughout her month long stay at
iTAWC and with extended family when she
returned home.
G.A.S.
Goal
+2 – best expected outcome
Composed
directly on computer,
independently, with “email helper” list
+1 – more than expected
Composed directly on computer, with
minimal assistance and with “email helper”
list
Composed directly on computer, with
maximal assistance and with “email helper”
list
Wrote thoughts on paper first, then typed
on computer. 45-60 minutes to compose
short email with maximal assistance
Wrote thoughts on paper first, then typed
on computer. 61+ minutes to compose short
email with maximal assistance
0 – expected outcome
-1 – baseline
-2 – regression
• Her “email helper list” consisted of a bank of
common phrases and names.
• Specific suggestions for how to help her move
toward independence with this goal were
shared in the exit meeting and in her final
report.
BENEFITS of G.A.S.
•
•
•
•
Easily allowed clinicians to determine the next
steps in treatment once an expected outcome
had been achieved.
Facilitates communication with families
regarding goals.
Facilitates discussion with funding agencies
regarding functional progress.
Is a sensitive indicator of functional
improvement.
CHALLENGES of G.A.S.
•
•
Goal-setting is very time consuming.
Setting of the expected outcome is best
when delayed until a few sessions into
treatment, as it is difficult to determine a
realistic outcome for a client without first
observing their response to therapy.
CHALLENGES of G.A.S. cont’d
•
•
Many of our clients surpassed the expected
outcome, which is meant to be the most
probable and realistic expectation for
achievement of a goal, thus indicating that
better goal setting is necessary.
Schlosser (2004) suggested having an
independent rater to determine if a goal is
achieved. Due to time, budgetary and other
constraints, this was not achievable in our
settings.
CONCLUSION:
• For people with chronic aphasia, Goal
Attainment Scaling is a useful clinical tool to
allow measurement of functional changes, to
monitor progress, and to systematically
adjust goals upward as clients progress.
• Goal Attainment Scaling measured some
functional changes in communication that
standardized testing did not capture.
REFERENCE
Schlosser, R.W. (2004). Goal attainment scaling
as a clinical measurement technique in
communication disorders: A clinical review.
Journal of Communication Disorders, 37, 217239.
Disclosure: The author receives financial compensation from
Columbia Speech and Language Services, Inc., the clinic in which
the programs described are provided
Questions?
Wendy Duke 604-875-9100
wendyduke@shaw.ca