Treatment of Word retrieval impairments:
Do we know which tasks work
for whom and why?
Continued!
Associate Professor Lyndsey Nickels
National Health and Medical Research Council
Senior Research Fellow,
Macquarie Centre for Cognitive Science (MACCS),
Macquarie University, Sydney, Australia
How do we decide which treatment?
Each different level of breakdown in word production will
be best remediated by a different type of treatment
(e.g. Hillis & Caramazza, 1994; Nettleton & Lesser, 1991)
Remember….
• impaired word meaning
(semantics)
Therapy
word
→ treatment focusing
onfor
meaning
retrieval DOES NOT
• impaired retrieval of the phonological form from
semantics have to include word
retrieval
→ treatment focusing on providing/accessing the
phonological form
• impaired phoneme level/phonological encoding
→ treatment focusing on phonemes
How do we decide which treatment?
Each different level of breakdown in word production will
be best remediated by a different type of treatment
(e.g. Hillis & Caramazza, 1994; Nettleton & Lesser, 1991)
• impaired word meaning (semantics)
→ treatment focusing on meaning
• impaired retrieval of the phonological form from
semantics
→ treatment focusing on providing/accessing the
phonological form
• impaired phoneme level/phonological encoding
→ treatment focusing on phonemes
What treatment is appropriate?
Semantic impairments
The most successful therapy seems to
involve exploring the semantic attributes
of a stimulus.
e.g. Boyle & Coelho, 1995.
Coelho, McHugh & Boyle, 2000.
Hillis, 1991, 1998.
Nickels & Best, 1996.
Lexical
Semantics
Phonological
Output Lexicon
Phonological
Output Buffer
Speech
Therapy for semantic impairments
Exploring semantic attributes of a stimulus
e.g. Semantic feature analysis (SFA)
Can we be sure
this is effective?
(Boyle & Coelho, 1995; Coelho, McHugh & Boyle, 2000)
• name a picture
• generate features relating to …..
GROUP: is an ANIMAL
Not entirely … they use very
small numbers of items in the
USE: is used for protection
sets, and examine changes in
performance using visual
ACTION: does what? Barks
inspection with no statistics
LOCATION: is found at home
ASSOCIATION: reminds me of a kennel
Therapy for semantic impairments (cont)
e.g. Nickels & Best (1996)
AER
“Relatedness judgements” (with feedback)




Nickels & Best argue
that feedback is critical
to obtaining
generalisation to
untreated items


Statistically significantly improved naming of treated
and untreated stimuli
Therapy for semantic impairments (cont)
e.g. Hillis (1991, 1998)
HG.
Lemon
Red vs yellow
Round vs oval
Thin skin vs thick skin
Sweet vs sour
Therapy for semantic impairments (cont)
e.g. Hillis (1991, 1998)
HG.
• name a picture,
• if  and semantic error was produced,
• → drawing of error
• compare drawing to the target picture
• discuss semantic distinctions
• Significant improvement in written naming (treated)
• also in spoken naming and word comprehension
• Improvement of treated items and untreated items in the
same semantic category
(but this may just be that untreated items appeared in
therapy)
How does the
treatment for
semantic
impairment work?
Doesn’t it
improve the
semantic
impairment?
If so what
would the
effects be?
Print
Heard Speech
Idea, Picture,
or
seen object
Lexical
Lexical
Semantics
Semantics
Phonological
Output Lexicon
Phonological
Output Buffer
Speech
output
Writing
Print
Heard Speech
Idea, Picture,
or
seen object
Lexical
Lexical
Semantics
Semantics
Phonological
Output Lexicon
Phonological
Output Buffer
Speech
output
Writing
Print
Heard Speech
Idea, Picture,
or
seen object
Lexical
Lexical
Semantics
Semantics
Phonological
Output Lexicon
Phonological
Output Buffer
Speech
output
Writing
Print
Heard Speech
Idea, Picture,
or
seen object
But although this
was true for
Hillis’ study with
HG, it was not
for AER.
Semantic
therapy for
semantic
impairments
should improve
all modalities
Lexical
Improvement Lexical
in
all
Semantics
Semantics
modalities only
occurs if treatment
improves semantic
Phonological
processing
Output Lexicon
Phonological
Output Buffer
Speech
output
Writing
Consistent with
How did the authors think these
treatments for
improvement
semantic impairments were havingacross
their effects?
modalities
Hillis (1998)
“improvement at the semantic level itself – perhaps
through increased specificity of semantic representations
of trained items”
Coelho et al (2000) - a strategy for word retrieval
“by activating the semantic network surrounding the target
word, that word may be activated above its threshold,
Consistent with
thereby facilitating retrieval”
Nickels and Best (1996)
improvement
restricted to
speech production
“the use of a strategy (which may be unconscious) of
exploring the semantics of an item … which facilitates
retrieval of that item (perhaps by increasing the semantic
information addressing the output lexicon…)”
Semantic tasks and semantic impairments
Hold on! How can
therapy tasks
for semantic
• Semantic
improve
– impairments
Those tasks which
involve focusing on word meanings
word retrieval without
improving
semantics
• Semantic
tasks
may be used to treat semantic
impairments
– Those tasks which seem to most often improve semantic
impairments involve reflecting on semantic features
Didn’t we contrast
semantic impairments
Yes, but semantic
– However even then they may NOT improve semantics itself
and post-semantic
impairments
but may instead provide a strategy for improving
word
word retrieval
cause word
retrieval.
impairments?
retrieval
impairments …
Post semantic word
retrieval impairment
purrs
fur
Object, picture
or idea
barks
4-legs
pet
Semantics
scales
Phonological
Lexicon
robin
cat
k
d
dog
æ
rabbit
o
fish
g
house
t
Phonological
Buffer/
Phonemes
Semantic impairment
Semantic impairment
purrs
fur
Sem impairment
barks
4-legs
pet
Object, picture
or idea
Semantics
scales
Phonological
Lexicon
robin
cat
k
d
dog
æ
rabbit
o
fish
g
house
t
Phonological
Buffer/
Phonemes
Semantic impairment
Object, picture
So tasks can be
effective in
barks
purrs
fur word
improving
retrieval WITHOUT
improving the
semantic
impairment
robin
cat
k
d
dog
æ
4-legs
pet
Although, as we will
or idea
see, this is usually
only the case in
people with less
severe semantic
impairments. Semantics
scales
Phonological
Lexicon
rabbit
fish
house
Semantic impairment
also leads to a
Phonological
reduction in activation
Buffer/
o
t
at the word gform level
Phonemes
SUMMARY: What treatment is appropriate?
Semantic impairments
The most successful therapy seems to
involve exploring the semantic attributes
of a stimulus.
Any
questions?
e.g. Boyle & Coelho, 1995.
Coelho, McHugh & Boyle, 2000.
Hillis, 1991, 1998.
Nickels & Best, 1996.
Lexical
Semantics
Phonological
Output Lexicon
Phonological
Output Buffer
Speech
Therapy for semantic impairments or
semantic tasks as therapy?
• Virtually all tasks involve semantic processing
These
tasks
widelyprocessing
used in
• Some
focus
onare
semantic
to a greater extent
the remediation
of word(we tend
to refer to these
as semantic tasks)
retrieval impairments, however,
e.g. their use is not restricted to
odd one out
those individuals with semantic
impairments.
(spoken or written) word to picture matching
word-picture verification
Semantic tasks for improving word retrieval
The use of semantic tasks is not restricted to individuals
with semantic impairments…...
semantic tasks can improve word production even for
those individuals with good semantic processing and
even when the tasks are performed accurately
(e.g. Nickels & Best, 1996).
…. In fact they are probably more likely to improve word
production for those with relatively less semantic
impairment – those with ‘post-semantic lexical retrieval
impairments’.
What treatment is appropriate?
Word retrieval impairments
Tasks focusing on semantics and
phonology
- improve word retrieval
e.g. Howard et al 1985
Nickels & Best 1996
Lexical
Semantics
Phonological
Output Lexicon
Phonological
Output Buffer
Speech
What treatment is appropriate?
Word retrieval impairments
Tasks involve activation of both
semantics and phonology
But may focus more on semantics….
Lexical
Semantics
Phonological
Output Lexicon
Phonological
Output Buffer
Speech
What treatment is appropriate?
Word retrieval impairments
All the tasks involve activation of both
semantics and phonology
But may focus more on semantics
or phonology
Lexical
Semantics
Phonological
Output Lexicon
Phonological
Output Buffer
Speech
Repeat
“kangaroo”
It starts with /k/
What treatment is appropriate?
Word retrieval impairments
All the tasks involve activation of both
semantics and phonology
They produce long lasting, item specific
effects in the majority of individuals with
impaired activation of the correct target
in the phonological lexicon
Lexical
Semantics
Phonological
Output Lexicon
Phonological
Output Buffer
Speech
Improves likelihood of the target being
sufficiently activated to be retrieved
successfully.
Let’s explore these
tasks that improve
word retrieval in
more detail
“Semantic” tasks as therapy
Word-picture matching
Word-picture verification
The tasks work best with
These tasks typically
people that can do them
Widely
effective (Howard et al, 1985; Marshall
et al, 1989)
don’t require
word
easily (people with less
production but improve
of a semantic problem)
Long lasting effects (Pring et al., 1990)naming at a later point
nevertheless
Generally, lasting effects are item specific
How important is the
emphasis on
semantic
processing?
Howard et al (2006)
Compared the efficacy of word-picture matching with
related and unrelated distractors
(related distractors = deeper processing = more effective?)
How important is the
emphasis on
semantic
processing?
Howard et al (2006)
Compared the efficacy of word-picture matching with
related and unrelated distractors
Alleven
incorrect
before word-picture matching
Not
for those
No evidence that deeper
with
more
severe
After word-picture matching
semantic processing improves
semantic
Related
distractors:
45%efficacy
correctof word-picture
impairments?
matching
Unrelated distractors: 50% correct
Controls:
30% correct
How important is the
emphasis on
semantic
processing?
Howard et al (2006)
Compared the efficacy of word-picture matching with
related and unrelated distractors
No evidence that deeper semantic
All incorrect before word-picture
matching
processing improves efficacy of
After word-picture matching
therapy:
not even More
for those
withimp.
more
Less sem imp.
sem
severe semantic impairments
Related distractors:
50%
40%
Unrelated distractors: 60%
40%
Controls:
40%
23%
How important is the
emphasis on
semantic
processing?
Martin, Laine et al (2000, 2003, 2004, 2005)
‘Contextual Priming’
Compared the efficacy of naming/repetition in the
context of semantically related distractors and
unrelated distractors.
How important is the
emphasis on
semantic
processing?
Martin, Laine et al (2000, 2003, 2004, 2005)
‘Contextual Priming’
How important is the
emphasis on
semantic
processing?
Martin, Laine et al (2000, 2003, 2004, 2005)
‘contextual priming’
Compared the efficacy of naming/repetition in the
context of semantically related distractors and
unrelated distractors. No evidence that a
semantic
context
- Naming is worse at the time
with semantically
improves efficacy of
related distractors.
therapy
- Naming is improved no more (at a later point) with
semantically related distractors.
How important is the
emphasis on
semantic
processing?
Not as important as
we thought!
• Tasks which have traditionally been labelled ‘semantic’, such
as word-picture matching are equally effective with unrelated
items.
• Adding a semantic context to a (naming/repetition) task does
not make it more effective.
How important is the
phonological form in
the semantic task?
Word form is usually provided.
Most probably
critical to its
effectiveness
e.g. Le Dorze et al (1994)
“Show me the octopus”

“Show me the mollusc with
long legs”

Nickels, McDonald, Makin, Moses & Taylor –
Facilitation Experiments
What is a
facilitation
experiment?
It looks at the effect of a
task performed ONCE on
another task at a later
point and contrasts with…
Therapy: The
application of a
technique several times,
over days, weeks or
months
Immediate Cueing
effects: The effect of a
technique at the time of
its application
Cueing, Facilitation, Therapy
“k”
kangaro
o
Cueing, Facilitation, Therapy
….later
“k”
kangaroo
Cueing, Facilitation, Therapy
kangaroo
“k”
“k”
“k”
“k”
“k”
“k”
“k”
“k”
“k”
Nickels, McDonald, Makin, Moses & Taylor –
Facilitation Experiments
Phonological
Repetition
“kangaroo”
Semantic without
the word form
Feature verification
Does it hop?
Nickels, McDonald, Makin, Moses & Taylor –
Facilitation Experiments
Name 300 pictures until 95 failed
(10 second limit)
Sort the failed items into 3 (frequency & length)
matched sets
Facilitation Task 1 Facilitation Task 2
1 week later
Facilitation
10 mins later
Name all 3 sets of pictures+
30 easy fillers
Control
Comparing repetition and a semantic task with no
word form
0.40
semantic
phonological
0.30
0.20
0.10
-0.20
participant
SMG
Group
JOW
MFT
FAB
MCB
WVK
JMM
DIP
JUE
SJS
DRS
-0.10
KCC
PSJ
0.00
FME
JNI
benefit compared to controls
0.50
Comparing repetition and a semantic task with no
word form
0.40
semantic
phonological
0.30
0.20
0.10
-0.20
participant
SMG
Group
JOW
MFT
FAB
MCB
WVK
JMM
DIP
JUE
SJS
DRS
-0.10
KCC
PSJ
0.00
FME
JNI
benefit compared to controls
0.50
semantic task without
the word form for most
individuals
0.50
0.40
semantic
phonological
0.30
0.20
-0.20
participant
Group
SMG
JOW
FAB
WVK
MCB
DIP
JMM
SJS
JUE
DRS
PSJ
KCC
-0.10
JNI
0.00
MFT
0.10
FME
benefit compared to control pictures
Comparing repetition and a semantic task with no
word form Very little benefit from a
Semantic tasks without the word form
We also looked at the same tasks used as therapy with
4 individuals with aphasia
… once again, semantic tasks without the word form
had little benefit
…. for example….
DRS
8 sessions of semantic therapy (feature verification)
over 2-3 weeks
Before each therapy session named all those items that
were to be treated, and a set of control pictures (50
items in each set).
DRS - Semantic Therapy
40
But the untreated items seem to
improve.....
Spontaneous recovery?
Generalisation?
Benefits from repeated naming
attempts?
35
number correct ( /50)
30
25
no. correct THERAPY
no. correct CONTROL
20
Linear no. correct THERAPY
Linear no. correct CONTROL
15
10
5
0
1
2
3
4
5
daily pretests
Sem Treat
McNemar Day 1 vs
Day 8
ns
Sem control
p= 0.0117
Sem treat vs
sem control
Wilcoxon 2 sample
6
No extra benefit
from the semantic
Wilcoxon 1
task
7
8
sample
0.028773653
0.04377147
NS
40
35
30
25
Treated (sem)
20
Naming control
Unseen
15
10
5
0
Pre-test 1
Pre-test 2 Post sem 1 Post sem 2
40
35
30
25
Treated (sem)
20
Naming control
Unseen
15
10
5
0
Pre-test 1
Treated items and
repeatedly named items
improve to the same
degree – so there is no
specific benefit from the
semantic task
Pre-test 2 Post sem 1 Post sem 2
The improvement from
naming controls isn’t
generalisation or
spontaneous recovery
(unseen controls don’t
improve) – but benefit from
repeated attempts at
naming
40
35
30
25
Treated (sem)
Naming control
20
Unseen
15
10
5
0
Pre-test 1
Pre-test 2
Treated items and
repeatedly named items
improve to the same
degree – so there is no
specific benefit from the
semantic task
Post sem 1 Post sem 2
Summary: semantic tasks in word retrieval
• Degree/depth of semantic processing appears not to
be critical (Howard et al)
• Presenting tasks in a semantic context can interfere
short-term and mostly has no long term advantage
Any contexts (Martin, Laine
over presentation in unrelated
et al)
questions?
• Presence of phonological form appears critical in
most cases (Le Dorze et al; Nickels et al: facilitation
studies, DRS therapy study)
…… and so to Phonological tasks
“Phonological” tasks
•
•
•
•
•
•
•
Repetition of target
Reading aloud
Phonological & orthographic cueing
Rhyme judgements
Syllable and phoneme counting
Phoneme segmentation
Anagrams
Again we need to remember the
distinction between the nature of
…….but nearly alwaysthe
in task
the and
presence
of of
thethepicture.
the nature
impairment…. Here we are talking
about phonological tasks but NOT
impairments to the phoneme level.
Phonological tasks and word retrieval
• Widely argued to be the most appropriate for
impairments in retrieval of (or damage to) the
phonological form from the phonological output
lexicon
(e.g. Hillis & Caramazza, 1994; Miceli,et al, 1996; Nettleton &
Lesser, 1991)
Miceli et al (1996): as these tasks focus at the level of
activation of individual entries in the phonological
output lexicon, their effects should be item specific
– a result of ‘priming’ retrieval of the phonological form.
For many years ‘semantic’
tasks were thought to be
more effective than
‘phonological’ tasks in
improving word retrieval
How true is this?
Comparing repetition and a semantic task with no
word form
0.40
semantic
phonological
0.30
0.20
0.10
-0.20
participant
SMG
Group
JOW
MFT
FAB
MCB
WVK
JMM
DIP
JUE
SJS
DRS
-0.10
KCC
PSJ
0.00
FME
JNI
benefit compared to controls
0.50
semantic task without the
word form … repetition is
almost always more
beneficial
0.50
0.40
semantic
phonological
0.30
0.20
-0.20
participant
Group
SMG
JOW
FAB
WVK
MCB
DIP
JMM
SJS
JUE
DRS
PSJ
KCC
-0.10
JNI
0.00
MFT
0.10
FME
benefit compared to control pictures
Comparing repetition and a semantic task with no
word form Very little benefit from a
DRS - Phonological Therapy
50
45
40
number correct (/50)
35
No. correct
THERAPY
30
25
no. correct
CONTROL
20
Linear no.
correct
THERAPY
15
10
Linear no.
correct
CONTROL
5
0
1
2
3
4
5
6
7
8
daily pretests
Phon Treat
Phon control
McNemar
Day 1 vs Day 8
p= 0.0001
p= 0.0042
Wilcoxon 1
sample
Significant extra
benefit from the
< .0001
0.002304428 repetition task
Phon treat vs
phon control
Wilcoxon 2
sample
p(1 tail)
=.048
For many years ‘semantic’
tasks were thought to be
more effective than
‘phonological’ tasks in
improving word retrieval
This seems NOT to be true
in general, particularly if
the semantic task does not
include the word form
Semantic & phonological treatments: an
overstated distinction?
• BOTH have semantic and phonological components
– Semantic tasks without the phonological form are generally not
effective
• Howard (2000)
– tasks having the same effects in the same way
• Strengthening the connections between semantics and
phonological form when both are simultaneously active
• equivalent effects for semantic and phonological tasks
for most individuals
Object, picture
or idea
purrs
fur
barks
4-legs
pet
Semantics
scales
Phonological
Lexicon
robin
cat
k
d
dog
æ
rabbit
o
fish
g
house
t
Phonological
Buffer/
Phonemes
Object, picture
or idea
purrs
fur
barks
4-legs
pet
Semantics
scales
Phonological
Lexicon
robin
cat
k
d
dog
æ
rabbit
o
fish
g
house
t
Phonological
Buffer/
Phonemes
Object, picture
or idea
purrs
fur
barks
4-legs
pet
Semantics
scales
Phonological
Lexicon
robin
cat
k
d
dog
æ
rabbit
o
fish
g
house
t
Phonological
Buffer/
Phonemes
‘Semantic’ and ‘phonological’
tasks are working in similar
ways
By strengthening the
connections between
semantics and word form
by activating both
semantics and phonology
The role of effort and error
How does amount of
‘effort’ or accuracy in
a task affect the
benefit for naming?
• Effortful >benefit than automatic?
– Greater semantic processing
• Errorless >benefit than errorful?
Comparing Phonological Tasks
Repetition
Phonemic cueing
Effortless,
‘shallow’ processing,
error reducing
Effortful,
deeper processing,
errorful
“kangaroo”
“k”
Method
Name 300 pictures until 95 failed
(10 second limit)
Sort the failed items into 3 (frequency & length)
matched sets
1 week later
Facilitation Task 1 Facilitation Task 2
Facilitation
10 mins later
Name all 3 sets of pictures+
30 easy fillers
Control
Facilitation effect compared to control pictures:
Errorless/Automatic (Repetition) vs
Errorful /Effortful (Phonemic cues)
*
0.50
Phon Cues
Repetition
*
0.40
*
*
0.30
*
*
0.20
*
0.10
*
Mean
SMG
MFT
JOW
FAB
WVK
MCB
DIP
JMM
SJS
JUE
DRS
PSJ
KCC
JNI
-0.10
FME
0.00
Facilitation effect compared to control pictures:
Errorless/Automatic (Repetition) vs
Errorful /Effortful (Phonemic cues)
*
0.50
Phon Cues
Repetition
*
0.40
*
*
0.30
*
*
0.20
*
0.10
*
Mean
SMG
MFT
JOW
FAB
WVK
MCB
DIP
JMM
SJS
JUE
DRS
PSJ
KCC
JNI
-0.10
FME
0.00
Comparing Phonological Tasks
Repetition
>
benefit than
Effortless,
‘shallow’ processing,
error reducing
“kangaroo”
No need for it to be
effortful to be helpful
– FOR MOST PEOPLE
Phonemic
Well,
repetitioncueing
is better
and it does improve more
Effortful,
BUT the proper
deeper processing,
comparison
is within a
errorful
task ….
“k”
Is errorless (or error
reducing) better than
errorful?
Fewer errors means greater benefit?
Repetition is more error-free than cueing… but the
proper comparison is within a task
Phon Cue - Facilitation
0.9 Cueing
accuracy
Phon Cuewith
naming
benefit (at
0.8 Do the people who are more accurate
cueing
0.7
the time) have more benefit for naming (later)?
0.6
0.5
0.4
0.3
0.2
0.1
PS
J
JU
E
W
VK
SM
G
JO
W
JN
I
JM
M
M
C
B
-0.2
D
IP
M
FT
D
R
S
FA
B
FM
E
KC
C
-0.1
SJ
S
0
Errorless items benefit more?
Repetition is more error-free than cueing… but the
proper comparison is within a task
Cueing
•
no significant correlation between success of the
cue during facilitation and benefit of cueing for
subsequent naming.
• i.e. errorless is not better than errorful for cueing.
Why did we think
errorless might be
better in the first
place?
Errorless learning
Hypothesis
• Remediation is more effective if errors are prevented
- the act of producing an error may strengthen the
incorrect association, and make the correct response
less likely to occur.
History
• Animal learning (Terrace, 1963)
• Children with developmental learning difficulties
(e.g. Sidman & Stoddard, 1967).
• Acquired memory impairments (amnesia)
(e.g. Baddeley & Wilson, 1994)
Errorless learning and anomia treatment
• Fillingham et al (2003)
“error reducing techniques do have positive effects for patients
BUT nonetheless
with word
finding difficulties. As yet there is limited
repetition may be more
information
on which to judge whether this technique is
beneficial than
significantly
advantageous
phonemic
cueing for over errorful approaches” (p358).
many people
• Fillingham et al (2005, 2006)
There appears to be no
– No
significant
difference
between
errorless
(repetition) and
Remember
that
this
difference
between
errorful
(cueing)
will all depend
on tasks.
the
errorful and errorless
•
processing strengths
and weaknesses of
Abeltheetaphasic
al (2005)
individual
techniques in aphasia
– No significant difference between increasing and vanishing
cues methods (errorful vs error reducing).
Any questions?
•How semantic &
phonological tasks work
•Error & Effort
Generalisation
in the treatment of word retrieval.
• the most successful treatment is one which effects
improvement not only for the items used in therapy
but also for any other item, in any other context.
• many treatments produce clear long lasting effects on
the treated items, generalisation to untreated items is
less common, and when obtained, often less robust
(e.g. Nickels and Best, 1996b)
When perceived generalisation is actually an
effect of (assessment during) treatment!
DRS
40
35
30
25
Treated (sem)
20
Naming control
15
10
5
0
Pre-test 1
Pre-test 2
Post sem 1 Post sem 2
When perceived generalisation is actually an
effect of (assessment during) treatment!
DRS
40
35
30
25
Treated (sem)
Naming control
20
Unseen
15
10
5
0
Pre-test 1
Pre-test 2
Post sem 1 Post sem 2
When perceived generalisation is actually an
effect of (assessment during) treatment!
Howard et al (1985) “Naming controls”
• naming daily but NOT treated
• Improved significantly
• Widely interpreted as generalisation of treatment effects
– more probably the result of repeated attempts at naming
(Howard, 2000)
Nickels (2002)
JAW
- Repeatedly attempted to name a set of pictures (daily
for a week)
- Significantly improved naming
Practice makes (closer to) perfect:
trying to name helps naming!
HOW?
Or perhaps
just partially
- some names will be successfully retrieved
on one occasion
but not on
activating the phonological
another.
But it could representation
have
when trying to
important implications
name is enough to strengthen
- When, by chance, an individual
produces
name successfully,
-Use it or
lose it a picture
the mappings
both the semantic
representation
the phonological representation
- (Attempts
at) and
conversation
for that item are might
simultaneously
improve active.
word retrieval
- (Trying to) talk about the
same topics
may beforbetter
- This will then strengthen
the mapping
that item, making it more
More work needs to be done
likely that the word will be produced correctly on a subsequent
to determine who this works
occasion (which will again strengthen the mapping).
for, how close together
naming attempts have to be
- Over time, more
items will have strong enough mappings to be
etc etc
produced accurately on every occasion
When generalisation is a reflection of
(strategic?) changes in processing
• Semantic tasks (with semantic disorders)
Techniques promoting reflection on semantic properties may be better
viewed as teaching a strategy, albeit an unconscious strategy.
• Phonological tasks
– Best (2006) examined who showed generalisation using a
cueing treatment – it was those individuals with relatively more
of a phonological impairment (and less semantic impairment)
•
Self-cueing
– E.g. phonologically mediated orthographic cueing
Mostly generalisation is limited…
Therefore the emphasis is on the clinician to ensure that
all items used in therapy are functionally relevant and
chosen in collaboration with the person with aphasia.
Nickels et al – in progress
‘Home Programme’
• Using the most successful task (repetition)
• 60-100 items chosen by the person with aphasia as
being words they wanted to be able to say.
• Therapy presented by computer in powerpoint
• ‘Structured’ conversation used to evaluate carry-over
from naming to conversation
Treatments aimed at remediating word
production impairments
Tasks can be
• effective (e.g. Hillis & Caramazza, 1994; Howard et al, 1985b),
• produce durable effects (e.g. Pring et al, 1990),
• be administered by clinician &/or computer (e.g. Fink et al, 2002)
• be obtained on verbs & nouns (e.g. Murray & Karcher, 2000; Raymer
and Ellsworth, 2002).
• carry-over into connected speech & conversation (e.g. Hickin
et al, 2002),
BUT
treatment tasks are not invariably effective
Do impairment-based treatments impact on
functional skills and increase activity &
participation?
• word retrieval/production underlies every attempt at verbal
communication hence improving word retrieval impairments
is of course functionally relevant
Simplistic and/or fundamentally misguided
BUT
the importance of an increased ability to name treated items
following therapy should not be underestimated
Hillis (1998) HG
- small change in impairment – significant gains in activity &
participation with the use of functionally relevant
personal items (Bacardi & Coke!)
Do impairment-based treatments impact on
functional skills and increase activity &
participation?
• Yes …. (functional gains can be achieved)
• but…. (they are by no means guaranteed)
• few studies that have formally evaluated the effects on
disability of impairment-based remediation.
• It seems particularly important given the prevalence of item
specific effects that remediation should include personally
relevant stimuli.
Any questions?
•Generalisation
•Effects of repeated naming
•Functional relevance
So far we’ve talked about
tasks that aim to improve
the underlying word
retrieval impairment –
some tasks may work in
other ways too
Lets take
another look
at cueing
?
?
/t/
tomato
/t/
?
T
tomato
T
Letter cueing has been found to have the same
effects as phonemic cues
– both immediate and longer term benefits for
naming for some individuals
(Best et al. 2002)
Some individuals
can generate their
own orthographic
cues
?
TOMATO
?
TOMATO
tomato
How does this
work?
T ->
/t/
?
How does this
work?
Phonologically-mediated self-cueing
(e.g. Bachy-Langedock & DePartz, 1986;
Nickels, 1992)
T ->
/t/
Requires access
to the written
form when the
spoken form is
unavailable
Requires
phonological
cueability
tomato
Requires an
ability to convert
letters into
sounds
Phonologically-mediated self-cueing
(e.g. Bachy-Langedock & DePartz, 1986;
Nickels, 1992)
Can be retaught
Requires access
to the written
form when the
spoken form is
unavailable
Requires
phonological
cueability
Can use a
computer
cueing aid to do
the conversion
Requires an
ability to convert
letters into
sounds
Phonologically-mediated self-cueing
(e.g. Bachy-Langedock & DePartz, 1986;
Nickels, 1992)
Generating phonemic cues from the initial
letter
Nickels (1992)
TC
1. Spoken naming 
2. Written naming 
3. Convert letters to sounds 
dog
Generating phonemic cues from the initial letter
Nickels (1992)• This improved TCs spoken naming to almost the
same level
as his written naming.
retaught letter-sound
correspondences
• He used this spontaneously in conversation.
• Could be (and was) used for any word he was trying
1. Spoken naming

to retrieve
(only fails for words with irregular initial letters e.g.do
g
onion, Cinderella)
2. Visualise written word 
d
3. Sound out initial letter
&
cue word production 
dog
Using a computer to generate phonemic
cues from the initial letter
e.g. Bruce & Howard (1987);
Best et al. (1997)
1. Spoken naming 
d
3. Press letter 
2. Visualise first letter 
4. Computer produces phoneme 

/d/
dog
5. Cue word production 


Generating phonemic cues
When spoken naming 
IF individuals can
identify initial letter 
convert letters to sounds 
and are
phonemically cueable 
Then they can generate their own cues.
If unable to convert letters to sounds
- Can be retaught
- Can use computer generated cues
- may be able to use the letters without converting to
sounds – Direct orthographic cueing.
Direct Orthographic Cueing
SD: Howard & Harding (1998)
• impaired access to the phonological output lexicon
(good semantics)
• Unable to form letters
• Given an alphabet board
– naming improved dramatically
• Was not using phonological mediation
• unable to convert letters to sounds
• unaffected by initial letter regularity (e.g. onion;
eye)
Self-generated orthographic cues
When spoken naming 
IF individuals can
identify initial letter 
They may be able to use directAny
orthographic cueing
questions?
• If they are phonemically cueable 
They may be able to use•Self-generated
a computer to cues
generate the cues
• If they can (or be taught to) convert letters to sounds 
They may be able to generate their own phonological cues.
When things don’t
go the way you
planned!
Using a cueing aid as therapy – who
benefits?
Best, Howard, Bruce & Gatehouse (1997)
• 13 individuals treated with the cueing aid
• predicted benefit only for those who
when spoken naming 
can
identify initial letter 
& are phonemically cueable 
•They should be better at naming with the aid than without it (this is
providing the cues).
• Only two individuals had both skills
After treatment:
Only 1 individual had better naming with the aid than without.
BUT 12 showed significant improvement in naming.
WHY???
Why does treatment with a cueing aid help
individuals who are not predicted to benefit?
Treatment tasks can work in different ways for different
individuals
Multicomponent treatment
• orthography
• phonology
• semantics (presentation of the picture and
attempted naming).
Only one individual was
helped by the aid providing
the cue - for many others
this was a standard word
retrieval therapy
Phonemic cueing
Repetition in the
presence of the
picture
Cueing aid reorganising the naming system:
JOW (Best et al, 1997)
• Substantial and long-lasting effects of treatment
• Improvement in treated and untreated items
• treatment drew attention to the relationship between
orthography and phonology
• altered automatic (not strategic) processes in his
word retrieval
• A direct orthographic cueing mechanism
Why does treatment with a cueing aid help
individuals who are not predicted to benefit?
Treatment tasks can work in different ways for different
individuals
How
tasks
…. especially when
they
are multicomponent
actually work
may not be
how you
planned them
And sometimes
to!
they don’t work
even though you
would predict
they should!
RECAP
BEFORE THE BREAK
• Assessment of level of breakdown in word production
• Methodological issues in evaluating treatment
RECAP (continued)
AFTER THE BREAK
• Improving naming when there are semantic
impairments
– Exploring semantic features
– It may work by providing a strategy to improve naming rather
than improving semantics itself.
• Word retrieval impairments
– Semantic vs phonological tasks
– Semantic tasks require the word form, depth of semantic
processing is not important
– Phonological tasks are also effective
– Tasks are working in the same way
• Effort & error
– Tasks do not need to be effortful
– There is no additional benefit from errorless performance
RECAP (continued)
• Generalisation
– Treatment for Word retrieval impairments usually result in item
specific improvements
– but may generalise to conversation, and can produce effects on
participation/quality of life
– Use of functionally relevant items is a priority
– Repeated attempts at naming may improve word retrieval for some
individuals
– Generalisation can result from strategic/compensatory approaches
• Self-generated Cues
– Phonologically mediated/computer generated/direct orthographic
• Tasks may not always work the way you expect
• ALL OF THE ABOVE ARE GENERALISATIONS
– every person with aphasia is different and could be the
exception to these general principles
Relationship between task, impairment and
efficacy
Therapist’s dream = Prescription guide
“to unambiguously pair a particular functional impairment with a
treatment task that has guaranteed success for that impairment”
Clinicians need to know what to do NOW!!!
• choose a therapy that has the best chance of
succeeding
• Choose a task that has successfully improved
naming for a wide variety of people with spoken word
retrieval impairments
- multicomponent approaches (e.g. cueing
hierarchies or multimodality/multi-task therapies –
see e.g. Best et al, 1997; Hickin et al, 2002)
• Use pilot studies using different tasks for short
periods (e.g. 1 week) to establish which tasks seem
effective and which do not prior to continuing with the
most effective therapies over longer period.
Prove that it works!
• ensure that it is possible to establish whether or not a
particular therapy is effective by using a sound
methodology.
We have a duty to be able to demonstrate that a
therapy is effective to the individuals with
aphasia, their families/friends/carers, those
funding the treatment and not least to ourselves.
Thank you!
Any questions
or comments?