View
17
Download
0
Category
Preview:
Citation preview
University of Colorado, BoulderCU ScholarSpeech, Language, and Hearing Sciences GraduateTheses & Dissertations Speech, Language and Hearing Sciences
Spring 1-1-2016
Self-Reported and Partner-Reported FunctionalCommunication and Their Relation to Languageand Non-Verbal Cognition in Mild to ModerateAphasiaPaula J. MessamerUniversity of Colorado at Boulder, pmessamer@gmail.com
Follow this and additional works at: https://scholar.colorado.edu/slhs_gradetds
Part of the Communication Sciences and Disorders Commons
This Dissertation is brought to you for free and open access by Speech, Language and Hearing Sciences at CU Scholar. It has been accepted forinclusion in Speech, Language, and Hearing Sciences Graduate Theses & Dissertations by an authorized administrator of CU Scholar. For moreinformation, please contact cuscholaradmin@colorado.edu.
Recommended CitationMessamer, Paula J., "Self-Reported and Partner-Reported Functional Communication and Their Relation to Language and Non-VerbalCognition in Mild to Moderate Aphasia" (2016). Speech, Language, and Hearing Sciences Graduate Theses & Dissertations. 36.https://scholar.colorado.edu/slhs_gradetds/36
SELF-REPORTEDANDPARTNER-REPORTEDFUNCTIONALCOMMUNICATIONAND
THEIRRELATIONTOLANGUAGEANDNON-VERBALCOGNITIONINMILDTOMODERATE
APHASIA
by
PAULAJ.MESSAMER
B.A.,UniversityofCalifornia,LosAngeles,1986
M.A.,UniversityofColorado,Boulder,1991
Athesissubmittedtothe
FacultyoftheGraduateSchoolofthe
UniversityofColoradoinpartialfulfillment
oftherequirementsforthedegreeof
DoctorofPhilosophy
DepartmentofSpeech,LanguageandHearingSciences
2016
Thisdissertationentitled:
SELF-REPORTEDANDPARTNER-REPORTEDFUNCTIONALCOMMUNICATIONANDTHEIRRELATIONTO
LANGUAGEANDNON-VERBALCOGNITIONINMILDTOMODERATEAPHASIA
writtenbyPaulaJ.Messamer
hasbeenapprovedforthe
DepartmentofSpeechLanguageandHearingsSciences
GailRamsberger,Sc.D.(chair)
PuiFongKan,Ph.D.
NeerajaSadagopan,Ph.D.
ClaytonLewis,Ph.D.
AnneWhitney,Ed.D.
February26,2016
Thefinalcopyofthisthesishasbeenexaminedbythesignatories,andwefindthatboththe
contentandtheformmeetacceptablepresentationstandardsofscholarlyworkinthe
above-mentioneddiscipline.
HRCprotocol#14-0353
ABSTRACT
PaulaJ.Messamer(Ph.D.Speech,LanguageandHearingSciences)
Self-andpartner-reportedfunctionalcommunicationandtheirrelationtolanguage
andnon-verbalcognitioninmildtomoderateaphasia
DirectedbyGailRamsberger,AssociateProfessorandChair,DepartmentofSpeech
LanguageandHearingSciences,UniversityofColoradoatBoulder
Purpose:Non-verbalcognitionandlanguagefunctionswereexaminedinadultstroke
survivorswithaphasia.Thespecificpurposeofthestudywastwofold:1)toexaminethe
relationshipbetweenself-reportedoutcomesfrompeoplewithaphasia(PwA),measuresof
non-verbalcognition(Delis-KaplanExecutiveFunctionSystemsTest(D-KEFS),Delis,
Kaplan,&Kramer,2001)andmeasuresoflanguage(WesternAphasiaBattery-Revised
(WAB-R),Kertesz,2007;BostonNamingTestSecondEdition(BNT-2),Kaplan,Goodglass,&
Weintraub,2001)and2)toexaminethesesamerelationshipsusingpartner-reported
outcomesforthatsamegroupofPwA.ThisstudyusedtheAphasiaCommunication
OutcomeMeasure(ACOM,Doyleetal.,2013)togatherbothself-reportedACOMdataand
partner-reportedACOMdata(ratingsofthepersonwithaphasia’scommunicationmadeby
aregularconversationpartner).
Method:Seventeenparticipantswithaphasiaunderwentexaminationwithanextensive
testbatteryincludingmeasuresoffunctionalcommunication,non-verbalcognition,and
languageimpairment.Inaddition,16oftheirregularcommunicationpartnersrated
functionalcommunicationperformance.
Results:Self-reportedfunctionalcommunicationisstronglyrelatedtothenumberof
errorscommittedontheD-KEFSdesignfluencytest(r=.81,p=.001).Furthermore,a
modifiedformoftheD-KEFSdesignfluencytest(inwhichtheexamineeisallowed
unlimitedtime)showsthattheproportionoferrorscontributessignificantlytoatwo-
predictorlinearregressionmodel.Thesetwopredictorsaccountfor66%ofthevariancein
self-reportedfunctionalcommunicationratings.Theseresultssuggestthatnon-verbal
cognitionforpeoplewithmildtomoderateaphasiamayserveanimportantrolein
functionalcommunication.Bycontrast,self-reportedfunctionalcommunicationwas
uncorrelatedwithaphasiaseverity(r=.04,p=.88),namingperformanceoneitherthe
WAB-R(r=.059,p=.823)ortheBNT-2(r=.097,p=.713),andcategoryfluency(r=.086,
p=.741).
Partner-reportedfunctionalcommunicationwashighlycorrelatedtothenaming
subtestonWesternAphasiaBattery-Revised(WAB-R)scores(r=.71,p=.02)andto
performanceontheBostonNamingTest(BNT-2;r=.56,p=.026).Partner-reported
functionalcommunicationwasalsostronglypredictedbasedonthenumberofanimals
namedduringthecategoryfluencytaskontheWAB-R(r=.782,p=.000).Alinear
regressionmodelincludingWAB-Rcategoryfluencyaccountedfor61.1%ofthevariancein
partner-reportedratings.Asecondlinearregressionaddingnamingasapredictorwasnot
significant(Fchange=2.18,p=.163).Bycontrast,noneofthenon-verbalcognitionmeasures
wereusefulpredictorsofpartner-reportedfunctionalcommunication.Theseresults
suggestthataphasiaseverityservesanimportantroleinpartnerratingsoffunctional
communicationwhereasnon-verbalcognitiondoesnot.
Takentogether,theseresultssuggestthatPwAandtheirpartnersrelyondifferent
aspectsofcommunicationwhenjudgingfunctionalcommunication.
Furtherworktoexploretheuseofpatient-reportedoutcome(PRO)measuresandto
identifyfactorsthatcontributetoself-reportedfunctionalcommunicationisneeded.The
discussionaddressestheappropriatenessofusingPROmeasuresinaphasiaandtheuseof
surrogatereports.
Keywords:Aphasia,patient-reportedoutcomes,partner-reportedoutcomes,
functionalcommunication,non-verbalcognition,languageimpairment
vi
DEDICATION
Thisdissertationisdedicatedtomyhusband,FrankEparvier.Yourunwavering
supportandencouragementhasmeantsomuchtome.Withoutit,Iwouldneverhave
succeededatthisendeavor.Let’sgohavesomefun.
vii
ACKNOWLEDGEMENTS
Thankyoutothemembersofmydoctoralcommittee,Drs.PuiFongKan,Clayton
Lewis,NeerajaSadagopan,andAnneWhitney,foryoursupportduringmydoctoral
program.Thankyoutothechairofmycommittee,Dr.GailRamsberger,forherguidancein
mentoringmethroughoutmydoctoralstudies.
ThankyoutotheSpeech,Language,HearingSciencesdepartmentandtotheDeanof
theGraduateSchoolforprovidingfinancialsupporttopaymyresearchparticipantsandto
covertravelexpensesduringmydatacollection.
Thankyoutothepeoplewithaphasiaandtheirpartnersforparticipatinginmy
study.IwouldnothavefoundeveryonewithoutthehelpofnumerousSLPsinDenver,CO,
Minneapolis,MN,andtheSnyderCenterforAphasiaLifeEnhancement(SCALE)in
Baltimore,MD.
Thankyoutomycrazygroupoffriends:“TheRanchers”whohaveprovidedsafe
havenfromalltheinsanitiesoflife.
Finally,thankyoutomysmoogie-boo.Youarethemostamazingpartnerandfriend.
IknowyoulookforwardtothisbeingoverjustasmuchasIdo.
viii
TABLEOFCONTENTS
CHAPTER1:INTRODUCTION.............................................................................................................1
CHAPTER2:BACKGROUNDANDSIGNIFICANCE.........................................................................5
LINGUISTICIMPAIRMENTSINAPHASIA................................................................................................................5
Measuringlinguisticimpairments................................................................................................................6
COGNITIVEIMPAIRMENTSINAPHASIA.................................................................................................................8
Measuringcognitionimpairmentsinaphasia.........................................................................................8
MEASURINGFUNCTIONALCOMMUNICATIONINAPHASIA.............................................................................10
PATIENTREPORTEDOUTCOMEMEASURES.......................................................................................................12
BarrierstotheuseofPROmeasuresinaphasia...................................................................................13
TypesofPROmeasuresinaphasia.............................................................................................................14
StrokespecificPROmeasures.......................................................................................................................15
AphasiaspecificPROmeasures....................................................................................................................16
FindingsfromstudiesusingPROmeasures............................................................................................16
WHYACOM?.........................................................................................................................................................16
Proxyreportasasubstituteforself-report............................................................................................18
ProxyReportasaComplementtoSelf-Report......................................................................................21
SUMMARYANDHYPOTHESES...............................................................................................................................22
CHAPTER3:METHODSANDPROCEDURE...................................................................................24
PARTICIPANTS........................................................................................................................................................24
DEMOGRAPHICS.....................................................................................................................................................26
ix
WesternAphasiaBattery-Revised...............................................................................................................26
ASSESSMENTS.........................................................................................................................................................30
AphasiaCommunicationOutcomeMeasure..........................................................................................30
BostonNamingTest(SecondEdition)......................................................................................................31
D-KEFSDesignFluencyTest..........................................................................................................................31
D-KEFSVerbalFluencyTest..........................................................................................................................33
D-KEFSTwentyQuestionsTest....................................................................................................................34
D-KEFSCardSortTest.....................................................................................................................................36
TorranceTestofCreativeThinking...........................................................................................................36
PROCEDURE............................................................................................................................................................37
AphasiaCommunicationOutcomeMeasure..........................................................................................38
BostonNamingTest(SecondEdition)......................................................................................................40
D-KEFSDesignFluencyTest..........................................................................................................................40
D-KEFSVerbalFluencyTest..........................................................................................................................42
D-KEFSTwentyQuestionsTest....................................................................................................................43
D-KEFSCardSortTest.....................................................................................................................................44
TorranceTestofCreativeThinking...........................................................................................................44
CHAPTER4:RESULTS.........................................................................................................................46
DESCRIPTIVESTATISTICS.....................................................................................................................................46
Self-ratedandPartner-ratedAphasiaCommunicationOutcomeMeasure..............................46
BostonNamingTest..........................................................................................................................................47
D-KEFSDesignFluency-StandardAdministration.............................................................................48
D-KEFSDesignFluency-UntimedAdministration...............................................................................50
D-KEFSVerbalFluency....................................................................................................................................52
D-KEFSTwentyQuestionsTest....................................................................................................................53
x
D-KEFSCardSortTest.....................................................................................................................................55
TorranceTestofCreativeThinking...........................................................................................................55
HYPOTHESESRELATEDTOSELF-REPORTEDFUNCTIONALCOMMUNICATION.........................................55
Hypothesis1a:Selfreportedfunctionalcommunicationwouldbecorrelatedwithaphasia
severity....................................................................................................................................................................................55
Hypothesis1B:Self-reportedfunctionalcommunicationwouldbecorrelatedwith
cognition.................................................................................................................................................................................56
Hypothesis1C:Alinearregressionmodelpredictingself-reportedfunctional
communicationusingbothaphasiaseverityandcognitionwouldaccountforsignificantlymore
variancethanamodelusingaphasiaseverityalone..........................................................................................58
HYPOTHESESRELATEDTOPARTNER-REPORTEDFUNCTIONALCOMMUNICATION................................60
Hypothesis2a:Partner-reportedfunctionalcommunicationwouldbecorrelatedwith
self-reportedfunctionalcommunication..................................................................................................................60
InterraterAgreement(kappa)betweenSelf-ratedandPartner-ratedACOMscores..........60
Hypothesis2B:Partner-reportedfunctionalcommunicationwouldbecorrelatedwith
aphasiaseverityandcognition.....................................................................................................................................62
Partner-ratedACOMscorecorrelationstolanguage.........................................................................62
Partner-ratedACOMscorecorrelationstocognition........................................................................63
Hypothesis2C:Alinearregressionmodelpredictingpartner-reportedfunctional
communicationusingbothaphasiaseverityandcognitionwouldaccountforsignificantlymore
variancethanamodelusingaphasiaseverityalone..........................................................................................65
SUMMARYOFRESULTS.........................................................................................................................................66
CHAPTER5:DISCUSSION...................................................................................................................67
HYPOTHESESRELATEDTOSELF-REPORTEDFUNCTIONALCOMMUNICATION............................................67
xi
Hypothesis1a.Selfreportedfunctionalcommunicationwouldbecorrelatedwithaphasia
severity....................................................................................................................................................................................67
Hypothesis1B.Self-reportedfunctionalcommunicationwouldbecorrelatedwith
cognition.................................................................................................................................................................................69
DesignFluencyasaPredictor.......................................................................................................................69
TwentyQuestionsTestasaPredictor.......................................................................................................70
Hypothesis1C.Alinearregressionmodelpredictingself-reportedfunctional
communicationusingbothaphasiaseverityandcognitionwouldaccountforsignificantlymore
variancethanamodelusingaphasiaseverityalone..........................................................................................72
HYPOTHESESRELATEDTOPARTNER-REPORTEDFUNCTIONALCOMMUNICATION...................................72
Hypothesis2a.Partner-reportedfunctionalcommunicationwouldbecorrelatedwith
self-reportedfunctionalcommunication..................................................................................................................72
Hypothesis2b.Partner-reportedfunctionalcommunicationwouldbecorrelatedwith
aphasiaseverityandnon-verbalcognition.............................................................................................................73
Hypothesis2c.Alinearregressionmodelpredictingpartner-reportedfunctional
communicationusingbothaphasiaseverityandcognitionwouldaccountforsignificantlymore
variancethanamodelusingaphasiaseverityalone..........................................................................................74
IMPLICATIONS........................................................................................................................................................75
STUDYLIMITATIONS.............................................................................................................................................76
GENERALCONCLUSIONS.......................................................................................................................................77
REFERENCES..........................................................................................................................................80
FIGURES..................................................................................................................................................92
APPENDIXA:SAMPLEPROCEDURE...............................................................................................99
APPENDIXB:ACOMQUESTIONS..................................................................................................100
xii
APPENDIXC:D-KEFSTWENTYQUESTIONSITEMGROUPINGS.........................................103
APPENDIXD:MODIFIEDINSTRUCTIONS..................................................................................104
OVERVIEW.............................................................................................................................................................104
xiii
LISTOFTABLES
Table1.Participantcharacteristics...............................................................................................................28
Table2.WAB-AQandsubtestscores...............................................Error!Bookmarknotdefined.
Table3PwAandPartnerACOMscores.......................................................................................................47
Table4.PercentcorrectnamingonBostonNamingTest(BNT-2).................................................48
Table5.D-KEFSDesignFluencydataforStandardAdministration...............................................50
Table6.D-KEFSDesignFluencydataforUntimedAdministratio...................................................52
Table7.D-KEFSVerbalFluencydata............................................................................................................53
Table8.D-KEFSTwentyQuestionsdata.....................................................................................................54
Table9.PearsoncorrelationsforSelf-reportedACOMscoresandWAB-R(withsubtests)
andBNT-2measures..................................................................................................................................56
Table10.CorrelationmatrixforSelf-ratedACOMandcognitionscores......................................57
Table11.BreakdownofparticipantsaccordingtocognitionlevelandACOMscores............60
Table12.Cohen’skappascoresforeachPwA-Partnerpair...............................................................61
Table13.CorrelationmatrixforPartner-reportedACOMscoresandlanguagemeasures..63
Table14.CorrelationmatrixforPartner-reportedACOMscoresandcognitivemeasures..64
xiv
LISTOFFIGURES
Figure1.ExampleofD-KEFSDesignFluencytask.................................................................................92
Figure2.ScatterplotsofACOMself-ratings(left)andACOMpartner-ratings(right)asa
functionofWAB-Rcategoryfluencyscore..........................Error!Bookmarknotdefined.
Figure3.ScatterplotsofACOMself-ratings(left)andACOMpartner-ratings(right)asa
functionofWAB-Rnamingscore.............................................Error!Bookmarknotdefined.
Figure4.Scatterplotofself-reportedACOMratingsinrelationtothenumberoferrorson
theD-KEFSDesignFluencyTest..............................................Error!Bookmarknotdefined.
Figure5.Scatterplotofself-reportedACOMratingsinrelationtotheproportionoferrors
ontheuntimedadministrationoftheD-KEFSDesignFluencyTest....Error!Bookmark
notdefined.
Figure6.Scatterplotofself-reportedACOMversuspartner-reportedACOMscores.Error!
Bookmarknotdefined.
Figure7.ScatterplotofWAB-AQtoACOMT-Scores................Error!Bookmarknotdefined.
1
CHAPTER1:
INTRODUCTION
Aphasiaisanacquiredlanguagedisorderresultingfrombraindamage.Aphasiacan
occurfollowingstroke,braininjury,tumor,degenerativedisease,etc.Approximately
100,000newcasesofaphasiaoccurannuallyintheU.S.(NationalInstituteonDeafnessand
OtherCommunicationDisorders,2008)andmorethan1millionAmericansarelivingwith
aphasia(NationalAphasiaAssociation,2016).Thecommunicationdeficitsthatoccurfrom
aphasiaaffectspeaking,comprehension,reading,and/orwriting.
Inadditiontocompromisedlanguageabilities,peoplewithaphasia(PwA)
frequentlypresentwithcognitivedeficitsaffectingattention(Erickson,Goldinger,&
LaPointe,1996,Korda&Douglas,1997;LaPointe&Erickson,1991;Laures,Odell,&Coe,
2003;Murray,Holland,&Beeson,1998),workingmemory(Caspari,Parkinson,LaPointe,&
Katz,1998;Christensen&Wright,2010;Murray,2012;Wright,Downey,Gravier,Love,&
Shapiro,2007)andexecutivefunction(Fridriksson,Nettles,David,Morrow,&
Montgomery,2006),whichmayalsocontributetotheirproblemswithcommunication.
AlthoughPwAcanbeactive,productivemembersoftheirfamiliesandcommunities,
therearesignificantpersonalandsocietalcostsassociatedwithacquiredneurogenic
changesincommunication.Theseincludelossofproductivity(Ownsworth&Shum,2008),
reducedfunctionalindependence(Simmons-Mackie,Threats,&Kagan,2005)andchanges
inself-identity(Simmons-Mackie&Elman,2011).Mostpeoplewhoacquireaphasianever
2
returntowork(Morris,Franklin,&Menger,2011).Peoplewhowereoncevoracious
readersmaybeunabletoreadevensimpletexts.Peoplewhoenjoyedpublicspeakingor
activeconversationsmaybeunabletocontributetoconversations(atleastatthelevelof
interactiontheyonceenjoyed).
Giventhepersonalandsocietalimpactsofaphasia,greatemphasisisbeingplaced
onoutcomemeasuresthatreflectimprovementsineverydayfunctionandqualityoflife.
Accordingtothepatient-centeredcaremodel,patientsshouldplayanactiverolein
evaluatingthequalityandeffectivenessofthecaretheyreceiveandindecidinggoalsfor
treatment(Davis,Schoenbaum,&Audet,2005).Thatis,theindividualwithaphasiashould
beregardedastheultimatejudgeofhis/herownqualityoflifebecausepatientexperience
isconsideredamoresensitiveandspecificmeasureofimportanttherapeuticeffects,and
self-reportmayrevealdisabilityanddiseaserelatedlifelossesmuchmoreaccuratelythan
conventionalassessmentsofimpairment(e.g.abilitytowalk,performanceonlanguage
tests).
Itfollowsthatcollectingdataonthepatient'sviewsoftheirownoutcomesisan
increasinglyimportantpartofthehealthcaredeliveryprocess(AmericanSpeechHearing
Association,2013;Irwin,2012;Rao,2015;)andtheuseofpatient-reportedoutcome(PRO)
measuresiskeytounderstandingtheimpactofaphasiafromtheperspectiveoftheperson
withaphasia(Chue,Rose,&Swinburn,2010).Patient-reportedoutcomes(PROs)are
outcomesreporteddirectlybythepatientconcerningtheiroverallfunctioningandsenseof
wellbeing(Threats,2012;U.S.FoodandDrugAdministration,2016).
Priorresearchhasshownthatcommunicativefunctioningisonlypartiallyexplained
bytheleveloflanguageimpairment.Furthermore,evidencesuggeststhat,inadditionto
3
language,theremaybeexplanatoryvalueinalsousinglevelofcognitiveimpairmentasa
predictorofcommunicativefunction.Thisstudylooksatwhethermeasuresofcognition
canbeusedtopredictself-reportedfunctionalcommunication.
Inaddition,becausepost-strokedeficitsandaphasiamaypreventsomepeoplefrom
providingtheirownself-reports,itiscommontorelyonsurrogatereportsfromregular
communicationpartners(e.g.family,friends,andcaregivers).Thisstudy,therefore,looks
atwhetherpartner-reportedfunctionalcommunicationis1)correlatedwithself-reported
functionalcommunicationand2)whetherpartner-reportedfunctionalcommunicationis
associatedwiththesamelanguageandcognitionpredictorsasself-reportedfunctional
communication.
ChapterIIprovidesareviewoftheliterature.Theaimsoftheliteraturerevieware:
1) Toprovidebackgroundabouttherelationshipofimpairment-basedmeasuresof
aphasia,cognitionandfunctionalcommunicationmeasures.
2) TodescribetheuseandvalueofPROmeasuresingeneralandinthecontextof
strokeandaphasia.
3) ToaddressissuesspecifictotheuseofPROmeasuresinaphasia
4) ToaddressissuesspecifictotheuseofsurrogatePROmeasuresinaphasia
Theremainingchapterspresentaresearchstudy.Theaimsofthisresearchstudyare:
1) Toreplicatepreviousfindingsshowingthatself-reportedandpartner-reported
functionalcommunicationarestronglyrelated.
2) Toexploretherelationshipbetweenself-reportedfunctionalcommunicationand
4
measuresofcognition.
3) Toexploretherelationshipbetweenpartner-reportedfunctionalcommunication
andmeasuresoflanguageandcognition.
5
CHAPTER2:
BACKGROUNDANDSIGNIFICANCE
LINGUISTICIMPAIRMENTSINAPHASIA
Aphasiaisanacquiredneurogeniclanguagedisorderwhichresultsfrominjuryto
theareasofthebraininvolvedinlanguage.Aphasiaisnotasingledisorder,butinsteadisa
familyofdisordersthatinvolvevaryingdegreesofimpairmentacrosslanguagemodalities
(AmericanSpeech-Language-HearingAssociation,2016).
Thesignsandsymptomsofaphasiavarywidelyacrossindividualsdependingonthe
locationandextentoftheirbraindamage(Kagan,Black,Duchan,Simmons-Mackie,&
Square,2001).Languageimpairmentsincludedisturbancesofreceptiveandexpressive
abilitiesaffectingspokenlanguageoutput,spokenlanguagecomprehension,written
expressionandreadingcomprehension(ASHA,2016).
Impairmentsofverbalexpressionincludeanimpairedabilitytoexpressthoughts
usingasmooth,uninterruptedflowandrateofspeech;difficultyfindingwords,difficulty
namingobjects;speakinginsinglewords,speakinginshortfragmentedphrases,omitting
shortwordslike“the”,“of”,and“was”;aninabilitytorepeatwhatsomeoneelsehassaid;
substitutingsoundswithinwords;substitutingonewordforanother(e.g.“yes”for“no”);
makingupnewwords;stringingtogetherrealormade-upwordsintonon-informative
sentences.
6
Impairmentsofauditorycomprehensionincludedifficultyunderstandingspoken
utterances;providingunreliableanswerto"yes/no"questions;failingtounderstand
complexgrammar(e.g.,Thefarmerwaschasedbythecow.);requiringextratimeto
understandspokenmessagesandfindingitveryhardtofollowfastspeech(e.g.,radioor
televisionnews);misinterpretingsubtletiesoflanguage(e.g.,takestheliteralmeaningof
figurativespeechsuchas"It'srainingcatsanddogs.");andalackofawarenessoflanguage
deficits.
Impairmentsofwriting(agraphia)includedifficultywritingorcopyingletters,
words,andsentences;writingonlysinglewords;substitutingincorrectlettersorwords;
spellingorwritingnonsensesyllablesorwords;writingrun-onsentencesthatdon'tmake
sense;andwritingsentenceswithincorrectgrammar.
Impairmentsofreading(alexia)includedifficultycomprehendingwrittenmaterial;
difficultyrecognizingwordsbysight;inabilitytosound-outwords;substitutingassociated
wordsforaword;difficultyreadingnon-contentwords(e.g.,functionwordssuchasto,
from,the).
Thesignsandsymptomsdisplayedbyagivenindividualvarybasedonsituation,
partner,andtopic.Forexample,agivenindividualseeminglymayhavenodifficultieswhen
chattingwithfamiliarpartnersbutshowsignificantslowingorwordfindingproblems
whenconversationtopicsaremorecomplexorunfamiliar.
MEASURINGLINGUISTICIMPAIRMENTS
Assessmentofaphasiaiscompletedinanumberofwaysandusingarangeof
assessmentmeasures.Insomecases,anentirestandardizedtestbatteryisadministered.In
othercases,aclinicianmaygiveselectedsubtestsfromstandardizedtestbatteriesinorder
7
toprovidesubjectivedescriptionsofaperson'sfunctioning.Inothercases,
nonstandardizedtoolsdevelopedbytheclinicianareusedtoprobeaspectsofspeech,
language,andcognition(ASHA,2016).
Thedecisiontousestandardizedornonstandardizedassessmentproceduresis
determinedbytheclinicianbaseduponavarietyoffactors,includingtheneedsofthe
personwithaphasia,thecomplexityofimpairment,payerrules,facilitypolicy,andother
considerations.Whentimeandbillingconstraintslimitthetimeallowedforassessment,
screeningtestssuchastheBedsideEvaluationScreeningTest(BEST-2;West,Sands,&
Ross-Swain1998)areoftenused.Screeningsservetoidentifypatientswhoshouldbefully
evaluatedtodetermineifthereisadisorderbutdonotprovidesufficientdatatofully
characterizeit.
Inresearch,aphasiaistypicallyassessedusingastandardizedtestbatteryshownto
havestrongpsychometricpropertiessuchashighinter-andintra-raterreliability.These
assessmentsdiagnoseandgraderelativestrengthsandweaknessesacrossthelanguage
andcognitiveareasaffectedbyaphasia.ExamplesofsuchassessmentaretheWestern
AphasiaBattery-Revised(WAB-R,Kertesz,2007),theBostonDiagnosticAphasia
Examination(BDAE;Kaplan,1983),andthePorchIndexofCommunicativeAbility(PICA;
Porch,1971).
TheWAB-Rwasselectedasthemeasureoflanguageforthisresearchstudybecause,in
additiontoestimatingoverallaphasiaseverity(WAB-AphasiaQuotientorAQ),italso
providesdifferentialdiagnosisofaphasiatypeandprovidesaprofileofgeneralstrengths
andweaknessesinasubsetofareasincludingfluency,auditorycomprehension,and
naming.Spontaneousspeechisassessedviaresponsestopersonalquestionsandthe
8
patient’sdescriptionofalinedrawing.Spontaneousspeechisratedontwo10-pointscales:
informationcontentandfluency,whichincludesgrammaticalcompetenceandpresenceof
paraphasias.Comprehensionisassessedbasedonresponsestoyes/noquestions(thatmay
beansweredineitherverbalornonverbalfashion),byphysicalresponsestospokenwords
(touchthepen);andbyphysicalresponsestosequentialcommands(e.g.pickupthepen
andthenturnoverthebook).Repetitionisassessedusing15progressivelylongeritems
thatarescoredascorrect,partiallycorrect(duetopresenceofphonemicerrors)oras
completeerrors.Thenamingscoreiscomprisedofobjectnaming(withoutcuingor,if
necessary,withtactileand/orphonemiccuing),categoryfluency(numberofanimals
namedin60seconds),sentencecompletion,andresponsivespeech.
COGNITIVEIMPAIRMENTSINAPHASIA
Separatefromlanguagedeficits,PwAalsoshowimpairmentsontestsofcognition
includingattention(Erickson,Goldinger,&LaPointe,1996;Korda&Douglas,1997;
LaPointe&Erickson,1991;Lauresetal.,2003;Murray,Holland,&Beeson,1998;Murray,
2012;Robin&Rizzo,1989),workingmemory(Caspari,Parkinson,LaPointe,&Katz,1998;
Christensen&Wright,2010;Wright,Downey,Gravier,Love,&Shapiro,2007),executive
function(Fridriksson,Nettles,Davis,Morrow,&Montgomery,2006)andprocessingspeed
(Gerritsen,Berg,Deelman,Visser-Keizer,&Jong,2003;Neto&Santos,2012).
MEASURINGCOGNITIONIMPAIRMENTSINAPHASIA
Becauseofthelanguagedeficits,assessmentmeasuresintendedfornon-aphasic
populationsmaybetoolinguisticallycomplexforPwA.Forthisreason,researchershave
employedtasksdesignedtoassesscognitionwhileminimizingorreducinglanguage
9
demands.ExamplesincludetheWisconsinCardSortingTest(Baldo,Dronkers,Wilkins,
Ludy,Raskin,&Kim,2005;Grant&Berg,1993;Fridrickssonetal.,2006;Hinckley&Carr,
2001;LambonRalph,Snell,Fillingham,Conroy,Sage,2010;Purdy,2002;),theTowerof
HanoiandTowerofLondontests(Purdy,2002),theRavensColoredProgressiveMatrices
(Hinckley&Carr,2001;Raven,1962),PyramidsandPalmTrees(LambonRalphetal.,
2010),theTestofEverydayAttention(Robertson,Ward,Ridgeway,&Nimmo-Smith,
1996),theRey-OsterreithComplexFigure(Keil&Kazniak,2002),andthePorteusMazes
(Murray,2012;Porteus,1959;Purdy,2002).
Evidencesuggeststhatcognitionandlanguageimpairmentsoperateindependently
ofoneanother(Helm-Estabrooks,2002;Hinckley&Nash,2007).Thatis,PwAsometimes
haveimpairmentsoncognitivetasksthatarenotconsistentlyrelatedtoaphasiaseverity.
Inaddition,thereisahighdegreeofvariabilityincognitiveperformanceacross
individuals(Hinckley&Nash,2007).Forexample,Murray(2012)foundthatasagroup
PwAperformedsignificantlyworsethananeurologicallyunimpairedcontrolgroupon
cognitivemeasuresbutthatwithinthegrouptherewaslargevariabilityinthepresence,
types,andseverityofindividual’sattentionandothercognitivedeficits.
Furthermore,evidencesuggeststhatthatpoorercognitivestatusleadstopoorer
treatmentoutcomes.LambonRalphetal.(2010)showedthathigherperformanceontests
oflanguageandcognitiveabilitybeforetreatmentwasassociatedwithlargergainsfrom
anomiatherapy.Fillingham,Sage,andLambonRalph(2005a,2005b;2006)showedthat
pre-treatmentmeasuresofexecutivefunction(WisconsinCardSortTask,WCST;Grant&
Berg,1993)andself-monitoringskillspredictedparticipants’responsetotreatment.
Similarly,Seniów,Litwin,&Leśniak(2009)showedthatvisuo-spatialworkingmemory
10
waspositivelyassociatedimprovementinnamingandcomprehension(althoughno
relationshipwasfoundbetweenlanguagetherapyoutcomeandabstractthinkingability).
TheDelis-KaplanExecutiveFunctionSystemstest(D-KEFS;Delis,Kaplan,&Kramer,
2001)isdesignedfortheassessmentofexecutivefunctions(Homack,Lee,&Riccio,2005).
Thesubtestsassessavarietyofareasincludingflexibilityofthinking,inhibition,problem
solving,planning,impulsecontrol,conceptformation,abstractthinking,andcreativity.The
D-KEFSwasselectedasthemeasuresofcognitionforthisstudybecauseitincludeda
numberoftasksthathadminimallanguagedemandsanditwasnormedonalarge
representativesampleofneurologicallyunimpairedpeople(ages8to89).Afterreviewing
the9subtestsinthefullD-KEFStestingbattery,4wereselectedforinclusioninthis
researchstudy:VerbalFluency,DesignFluency,CardSorting,andTwentyQuestions(TQT).
TheremainingsubtestswereomittedduetoevenhighlinguisticdemandsthanVerbal
FluencyandTQT(WordContext;Color-WordInterference,ProverbTest),physical
demands(TowerTest)ortimerestrictions(TrailMakingTest).
MEASURINGFUNCTIONALCOMMUNICATIONINAPHASIA
Impairmentmeasures(suchasthosedescribedinthepriortwosections)helpto
characterizedeficitsbutfunctionalcommunicationisonlypartiallydeterminedbythe
impairmentsofaphasia.Functionalcommunicationalsodependsuponfactorssuchas
communicationpartners,motorskills,communicationneedsandcontext.Thismeansthat
impairmentmeasuresalonemaynotprovidevalidinformationaboutanindividual’sday-
to-dayfunction.
11
Functionalcommunicationisdefinedasthe‘abilitytoreceiveortoconveya
message,regardlessofthemode,tocommunicateeffectivelyandindependentlyinagiven
[natural]environment’(Frattali,Thompson,Holland,Wohl,&Ferketic,1995,p.12).
Functionalcommunicationassessmentmethodshaveincludeddirectmeasurementof
communicationbehaviors,indirectreportsbytrainedanduntrainedobservers,and
reportsfromPwA(self-reports).Directmeasuresoffunctionalcommunicationthat
maintainanaturalenvironmentaredifficulttoachieve.Ramsberger(2005)reportedona
measureofconversationalsuccessinwhichshecodedhowmuchinformationapartner
wasabletogleanfromaconversationwiththePwAabouttheplotlinefromatelevision
show(“ILoveLucy”).Whilethisiscertainlyanexampleoffunctionalcommunication,it
doesnotcoverthebroadspectrumofbehaviorsthatconstitutefunctionalcommunication
initsentirety.Indirectmeasuresoffunctionalcommunicationaremorecommonand
includeestimatesoffunctionalcommunicationprovidedbytherapists,caregivers,and
familymembers.Thesemeasuresalsosometimesrelyonretrospectivereportsof
communicativebehaviors.
Clinician-providedestimatesoffunctionalcommunicationincludethe
CommunicativeActivitiesofDailyLiving-2(CADL-2)(Holland,Frattali,&Fromm,1998),
AmericanSpeechLanguageHearingAssociationAssessmentofFunctionalCommunication
SkillsforAdults(ASHA-FACS)(Frattali,Thompson,Holland,Wohl,&Ferketic,1995),and
theTherapyOutcomeMeasure(TOM)(John&Enderby,2000).Tocompletethe
CommunicationActivitiesofDailyLiving-2(CADL-2;Holland,Frattali,&Fromm,1998),an
observerassesssevencategoriesofverbalandnon-verbalcommunicationduringrole-play
offamiliarsituations(e.g.,shoppingormakingatelephonecall).Categoriesinclude:social
12
interaction,divergentcommunication,contextualcommunication;sequentialrelationships,
nonverbalcommunication,reading,writingandusingnumbers,and
humor/metaphor/absurdity.
TocompletetheFunctionalCommunicationProfile(FCP;Sarno,1969)theclinician
assessesfunctionalcapacitythroughobservationsofthepatient’sbehaviorwhile
interactingwiththeclinician.Communicationcategoriesincludemovement,speaking,
understanding,reading,andother(e.g.,writingandcalculations).
Studieshaveshownthatpoorerperformanceontestsoflanguagelevel(Holland,
1982;Irwin,Wertz&Avent,2002;Ross,1999)andcognition(Fridrikssonetal.,2006)are
correlatedwithpoorerfunctionalcommunicationwhenratedbytrained
observers/therapists.Fridrickssonandhiscolleagues(2006)showedthatmost
participantsperformedbelownormallimitsonnon-verbalexecutivefunctiontests(Color
TrailsTestandWCST)andtherewasasignificantrelationshipbetweencognitionand
functionalcommunication(measuredusingtheSLP-ratedASHA-FACS).Decreased
cognitiveabilitymightcoincidewithdecreasedfunctionalcommunicationabilityinPwA.
PATIENTREPORTEDOUTCOMEMEASURES
Asdiscussedintheintroduction,patientreportedoutcomes(PROs)arekeyto
understandingtheimpactofaphasiafromtheperspectiveofthepersonwithaphasia
becausetheygivePwAmorepowertoexpresshowaphasiaaffectsthem.PROmeasures
areespeciallyimportantiftheyproducedifferentinformationthanwouldevidentbasedon
eitherimpairmentbasedassessmentsorother-reported(partner-reported,care-giver
reported,ortherapist-reported)functionalcommunication.
13
Insuranceprovidersandgovernmentalagenciesarerequiringpatient-reported
outcome(PRO)measuresasevidenceoftreatmentbenefits(Barrett,2009;Irwin,2012,
Doyleetal.,2013).MedicareandotherinsuranceagenciesarecompellingtheuseofPRO
measurestocollectdataonpatientfunctionduringthecourseoftherapyservicesasa
meansofdocumentingchangeinpatientconditionandoutcomes(Irwin,2012;MCTRJCA,
2012;Pub.L.112-96;Snyder&Aaronson,2009)andtheDepartmentofHealthandHuman
Serviceshasprioritizedpatient-reportedoutcomesinresearchandclinicalcare(De
Riesthal&Ross,2015).PROmeasuresarenowbeingusedtojustifyreimbursementfor
therapyservices,demonstratetreatmenteffectiveness,justifythecontinuanceofservices,
providepatienteducation,andmakedecisionsregardinghowtobestallocateresources
(Threats,2012).
BARRIERSTOTHEUSEOFPROMEASURESINAPHASIA
Despitethepush,theintegrationofPROmeasuresintoresearchandclinicalpractice
facessignificantchallenges.ThereareconcernsaboutthewaythatPROmeasuresmay
impactservicedelivery(negativeimpactsonbillingandserviceprovision,challengingSLPs
todemonstratethevalueoftheirservices,timeandefforttocollectPROdatafurther
limitingtreatmenttime),andconcernsabouttheirusefulness(toobroadtocapturethe
typesofchangesseenovershortcoursesoftherapy,PROmeasuresdon’ttelltherapists
whattreatmentmethodstouse).Inthespecificcaseofaphasia,thereareongoingconcerns
abouttheirappropriateness(notclearthatpatientscanunderstandthetestorthatthey
cangivevalidandreliablefeedback)andtheircorrespondencewithimpairmentmeasures
thathavebeenusedasthe“goldstandard”inthefieldfordecades.
14
TYPESOFPROMEASURESINAPHASIA
TherearetwobroadtypesofPROmeasures:GenericandDiseasespecific(Cella,
Hahn.,Jensen,Butt,Nowinski,&Rothrock.2015;Patrick&Deyo,1989).GenericPRO
measuresareoftenusedwhenthegoalistolookatqualityoflifeorfunctionacrossawide
varietyofhealthissues.DiseasespecificPROmeasuresareusedwhenthereisaspecific
subsetofpatientswhoashareaparticulardiagnosisorarereceivingcommontreatment.
Thatis,diseasespecificmeasuresbetterenabledifferentiationofgroupsatthelevelof
specificsymptomsorpatientconcerns.Genericmeasuresoftencaptureadifferentcategory
ofoutcomesthancondition-specificPROmeasures.Forexample,aGenericmeasuremay
assessdomainsofgeneralfunction,wellbeing,orqualityoflife,whereasacondition-
specificPROmaymeasuresymptomsexpectedgivenaspecificdiagnosis(suchasstrokeor
aphasia).Inthecaseofstroke,diseasespecificPROshaveaddressedareassuchasmobility,
self-care,communication,cognition,andmood.Whenthefocusisonaspecificsymptomor
setofsymptomsthatareuniquetothecondition,condition-specificinstrumentare
preferred.
GenericPROmeasurescanbeappliedtoindividualswithoutspecifichealth
conditions,andtheycandifferentiategroupsonindicesofoverallhealthandwell-being.
GenericPROmeasureshavetheadvantageofallowingforcomparisonsacrosspatient
groupsandpopulationsbutarelikelytobelessresponsivethancondition-specific
measurestofocalchangesthatarerelatedtoaspecificconditionandmaybetargetedin
treatment(e.g.aphasia).Thatis,genericPROmeasuresmayfailtocaptureimportant
condition-specificconcerns.
15
Tobeclinicallyuseful,PROmeasuresmustbesensitivetochange.Sensitivityto
changeistheabilitytodetectasmall,butmeaningful,differencesandisnecessarywhen
monitoringpatientsandimplementingclinicalinterventions.Evidencesuggeststhat
condition-specificPROmeasurescanbemoresensitivetochangethangenericPRO
measures.GenericPROmeasuresmaybelesssensitivebecausetheycontainmulti-trait
scalesthatmaynotberelevanttothetargetpopulationbeingassessed.Certainly,
conditionspecificscalescanlacksensitivityiftheyassessabroadrangeoffactorswhen
onlyoneofthosefactorsisbeingtargetedintreatment.Forexample,itisproblematicto
assessgeneralchangeonastrokeimpactassessmentwhentreatmenthastargeteda
specificareasuchasmobilityorspeech.Toaddressthisconcern,itiscommontofocuson
aspecificsubtest.However,becausethereareoftensofewitemsinsubtests,thisagain
raisesconcernsaboutsensitivity.Forexample,measuresdevelopedtoemphasizespecific
contentareaswouldbeexpectedtoshowgreaterpost-treatmentchangeinthosecontent
areas.Inotherwords,thegreatersensitivitytochangeincondition-specificPROmeasures
maybeattributedtothestrongcontentvalidityinherentincondition-specificmeasures.
STROKESPECIFICPROMEASURES
Thereareanumberofassessmentsavailableforassessingtheeffectofstrokeon
qualityoflifeorparticipationinactivitiesofdailyliving.TheseincludetheStroke-Specific
QualityofLife(SS-QOL;Williams,Weinberger,Harris,Clark&Biller1999),theBurdenof
StrokeScale(BOSS,Doyleetal.,2004).Thesecontainverybriefsubsections(7to10items)
addressingverbalexpression,verbalcomprehension,readingandwriting.
16
APHASIASPECIFICPROMEASURES
There are also a number of aphasia specific PRO measures. These include the
Communicative Effectiveness Index (CETI; Lomas, Pickard, Bester, Elbard, Finlayson, &
Zoghaib, 1989), the Self-Reported Functional Communication: Communication Outcome
After Stroke (COAST; Long, Hesketh, & Bowen, 2009), Communication Disability Profile
(CDP; Swinburn & Byng, 2006; Chue, Rose, & Swinburn, 2010), the Stroke and Aphasia
Quality of Life Scale (SAQOL-39; Hilari, Byng, Lamping, & Smith, 2003) and the Aphasia
CommunicationOutcomeMeasure(ACOM;Hulaetal.,2015).
FINDINGSFROMSTUDIESUSINGPROMEASURES
Onlyafewstudieshavelookedattherelationshipofpatient-reportedfunctional
communicationandimpairment-levelperformance.Doyleandhiscolleaguesfounda
correlationof0.65(r2=.423,n=83)betweentheWesternAphasiaBatteryAphasiaQuotient
scoreandtheACOM(Hulaetal.,2015).Althoughsignificant,thismeansthatonly42%of
thevarianceinthePROmeasurewasexplainedusingaphasiaseverity.
Todate,nostudieshavecorrelatedpatient-reportedfunctionalcommunicationwith
cognitionmeasures.Therefore,thisstudyexamineswhetheradding-verbalcognition
measuresproducesamorepowerfulmodelthanwhenusingaphasiaseverityalone.Itis
alsopossiblethattheeffectsofcognitivedysfunctionondailyactivitiesmayinteractwith
oramplifylimitationsduetotheirlanguagedisorder(Keil&Kasniak,2002).
WHYACOM?
TheACOMwasselectedforanumberofreasons:1)itwasconditionspecificfor
aphasia2)ithadundergonesignificantverificationandvalidationusingItemResponse
17
Theory(IRT)methodsasdescribedbelow,3)itisspecificenoughthatitshouldbe
sensitivetocommunicationissuesthataretargetedintherapy,4)ithasstrongrelevance
(itasksaboutthingsthatareimportantandrelevanttoPwAandtheirpartners)and
changesontheACOMwouldreflectimprovementsineverydayfunctionandqualityoflife
and5)ithasstrongtest-retestreliability(.86;Hula,Kellough,&Doyle,2015)
TheACOMwasdevelopedacrosstimebasedonIRTprinciples(Doyle,McNeil,Le,
Hula,Ventura2008).First,aninitialsetof673itemswasgatheredfrom33existing
functionalcommunicationinstruments.Theseitemswerereviewedwithstrokesurvivors,
partners,andSLPstoexploretheircontentrelevanceandrepresentativeness.Multiple
studieshaveresultedina59itemversion(Doyle,Hula,Hula,Stone,Waumbaugh,Ross,&
Schumacher,2013;Hulaetal.,2015).Atthetimethatthedatainthisstudywerecollected,
thereductionto59itemswasnotyetcomplete.Thereforethisstudyusedacombinationof
the101itemsfromtheDoyleetal.(2012)surveyandthe59itemsfromtheDoyleetal.
(2014-pre-publicationversion).Allanalyses,however,arebasedonthedatafromthe59-
itemsinthemostrecentversionoftheACOM.
ThereasonsforchoosingtheACOMarewellsummarizedbyHulaetal.(2015):
“The ACOM represents an advance over previously available patient-reported
measures foraphasiabecause it isbasedonacoherentandempiricallysupported
measurement model, provides highly precise score estimates across all levels of
functioning,anditsdevelopmentandvalidationarebeingpursuedwithinamodern
psychometricframeworkthatwillofferusersahighdegreeofflexibilityinchoosing
betweentestburdenandmeasurementprecision”.(pg.917).
18
PROXYREPORTASASUBSTITUTEFORSELF-REPORT
Amajorconcernaboutusingpatient-reportedoutcomemeasuresiswhether,
becauseofcommonstroke-relatedneuropsychologicaldeficits,PwAcanprovidevalidself-
assessments.Barrett(2009)citesspecificdeficitssuchasfailuretoadjustfortheeffecton
self-reportofspatialneglect,deficitsofmagnitudeestimation,pathologicalterationofself-
awareness,andalterationindistributedcorticalsystemssupportingemotionalsemantics
andabstraction(pg.17).Beyondthese,othershavecitedconcernsaboutthePwA’sability
tounderstandthequestionsandvalidlyandreliablycommunicatetheirownperceptions
(Doyleetal.,2013)
ConcernslikethesehaveleadmanyPROstudiestoexcludepeoplePwAaltogether.
Unfortunately,thisapproachrepresentsalargedeviationfromthespiritofself-reported
PROmeasures.Cellaetal.(2012)states“Failingtoincludethesepopulationscanresultin
potentiallymisleadinginterpretationsofresults.Thus,attemptingtoincludetheminPRO
assessmenteffortsiscrucial;usingallpossiblemechanismsforobtainingself-reportsisa
highpriority,butaccomplishingthismaybeoutofthequestionforsomepopulations.”(pg.
18).TheexclusionofPwAalsoattenuatesgeneralizabilityofresearchresults(Pickardet
al,2004).
Onewaytoincludealargernumberofpatientsinresearchistouseproxy
respondentstoobtainPROinformationforpatientswhoareunabletorespond.Proxies
aretypicallysignificantothers(e.g.,parents,spousesorotherfamilymembers,close
friends)orformalcaregivers(physicians,nurses,aides,teachers).Usingproxiescan
provideanumberofpotentialbenefits.Theuseofproxiesnotonlyallowsinclusionofa
19
broaderandmorerepresentativerangeofpatientsintheentiremeasurementeffort,butit
canalsohelpminimizemissingdataandincreasethefeasibilityoflongitudinalassessment.
Theusefulnessofproxyresponsesassubstitutesforpatientresponsesdependson
thevalidityandreliabilityofproxyresponsescomparedwiththoseattributesforpatient
responses.Agreementbetweentheproxyandpatientistypicallyassessedateitherthe
subscalelevel,usingintraclasscorrelationcoefficients(ICC),ortheitemlevel,usingthe
kappastatistic.Inaddition,groupcomparisonsareusedtodetectthesizeanddirectionof
systematicbias.
Somelargestudieshavefoundpositivecorrelationsbetweenself-reportedandproxy-
reportedmeasuresofoutcomes(e.g.health-relatedqualityoflife,functional
communication)inchronicdisease(Sneeuw,Sprangers,&Aaronson,2002)stroke(Duncan
etal.,2002)andaphasia(Williamsetal.,2006;Bakheit,Carrington,Griffiths&Searle,
2005).
Findingssuggestthatagreementishigherbetweenproxyandpatientratingswhen
ratingmoredirectlyobservabledomains(e.g.,physicalfunctionvs.energy)(Doyleetal.,
2013).Stroke-specificstudiesthathaveincludedparticipantswithaphasiahavereported
intraclasscorrelationcoefficientsrangingfrom0.50to0.70forlanguageand
communicationscales.
Oczkowski&O’Donnell(2010)completedasystematicreviewofresearchonthe
reliabilityofproxyrespondentsforpatientswithstrokecovering13studies(2618
participants).Theirreviewcomparedpatientandproxyreportedoutcomesforactivitiesof
dailyliving(ADL)and/orqualityoflife(QoL)andfoundthatinthechronicstage,patient
andproxyagreementwasstrongestwhenstrokewassevereandwhenthequestions
20
pertainedtoobservabledomains.Usingthethreecategoriesforinter-ratercorrelations
(ICCork-statistic)resultsofpoor(<=.40),moderate(.41-.60),substantial(.61-.80)or
excellent(>.80),theyconcludedthatreliabilitywassubstantialtoexcellentforADL
outcomemeasuresandmoderatetosubstantialforQoLoutcomemeasures.
Whilepatientandproxyratingarecorrelated,thereisevidenceofbiasinsurrogate
ratings.Frost,Reeve,Liepa,Stauffer,&Hays(2007)andIrwin,Wertz,&Avent(2002)
reportedthatproxiesconsistentlyratefunctionaloutcomesmorenegativelythanpatients.
Anexceptiontothisispainaboutwhichproxiestendtounder-report(Andresen,Vahle,
Lollar,2001)
Doyleetal.(2013)correlatedACOMscoresacrossalargesample(n=133)ofpeople
withseveretomildaphasia.Theyshowedamoderatecorrelationbetweenself-and
surrogate-reportsontheACOMwithanoverallcorrelationof.69(W.Hula,personal
communication;December4,2015).Althoughsignificant,itisinterestingthat52%ofthe
varianceintheself-reportedACOMisstillunaccountedforwhenpredictedusingthe
partner’sratingsandimpliesthattheremaybeotherrelevantfactorsdrivingACOMscores.
Basedonthedata,Doyleandhiscolleagues(2013)concluded“Correlationsbetweenself-
andsurrogatereportsweremoderate-to-strong,butthereweresignificantdisagreements
inasubstantialnumberofindividualcases.”(pg.957)and“Despiteminimalbiasand
relativelystrongassociation,surrogatereportsofcommunicativefunctioninginaphasia
arenotreliablesubstitutesforself-reportsbypersonswithaphasia”(pg.957).
Tosummarize,whileanumberofstudieshavefoundmoderatetostrongcorrelations
betweenpatientandproxyreportedoutcomes,thereareenoughinstancesinwhichthe
disagreementsarelargethatresearcherscannotrecommendusingsurrogateratingsin
21
placeofpatientratings.Frostetal.(2007)warned:
“Investigators need to be cautious in trying substitute proxy reports
for patient self-report data because of inherent differences between the
two typesof respondents.Themoreobservable the function, thegreater
theagreementbetweenaproxyandapatient’sreport;betterconcordance
betweenproxiesandpatientstendstooccurforthephysicaldomainsthan
for psychosocial domains. Proxies tend to report more disability and
depression about the patients than patients report about themselves. In
contrast,proxiestendtoattributehigher levelsofcognitiveabilitytothe
patients than do patients when rating their own cognitive ability.” (pg.
S100).
PROXYREPORTASACOMPLEMENTTOSELF-REPORT
Ratherthanviewingproxyassessmentsasreplacementsforself-reports,another
strategyistoviewthemasprovidingcomplementaryinformation.Thatis,proxyreports
constituteavalidperspectiveintheirownright,regardlessoftheircorrespondencewith
patients’ratings(Doyleetal.,2013)andinthesecases,patient-otheragreementmaynot
necessarilybedesirable.
If,forexample,thepatientfailstorecognizedeficitsandproblemsinfunctioning,
thenpatientandpartnerratingsshoulddeviate.Subtlerthougharethepotential
differencesbetweenthelivedexperienceofthepersonwithaphasiaandapartner.Even
withsignificantcorrelationsbetweenself-reportedandproxy-reportedoutcomemeasures,
thereisnoguaranteethattheunderlyingfactorsdeterminingtheratingsofpatientsand
partnersarethesame.Thatis,itispossiblethatthepersonwithaphasiaandthepartner
22
givethesameratingonaspecificfunctionalcommunicationitemsimilarly(e.g.asking
questionsoftheirdoctor)buttheyarejudgingtheperformancebasedondifferentcriteria.
SupportforthisideacomesfromFucetola&Connor(2015)whoshowedthat
family/partnersratetheeffectivenessofcommunicationprimarilybasedonexpressive
languagedespitethefactthatotheraspectsofaphasia(e.g.listeningcomprehension)areas
importantforeverydaycommunication.Ifsurrogateratersrelyondifferentinformationto
judgefunctionalcommunication,thenusingpartner-ratingswouldbeinappropriate.Based
ontheexistingevidence,partnerACOMscoresaremorelikelytocorrelatewithobservable
componentsoflanguage(suchasnamingandfluency)andlesslikelytocorrelatewithless-
observablecomponents(suchasauditorycomprehension).
SUMMARYANDHYPOTHESES
Insummary,theeffectsofaphasiahavebeenmeasuredinanumberofdifferent
ways.Impairmentmeasureshavetheadvantagethattheycharacterizespecificdeficitsbut
onlypartlycorrelatetofunctionalcommunication.Functionalcommunicationmeasures
havetheadvantageofassessingreal-worldperformancethatislikelytohaverelevanceto
thepatientandfamily.Functionalcommunicationhasoftenbeenmeasuredusingthe
opinionofothers,beittherapist,caregivers,orfamily.Withthepushtoincludethepatient
inassessingtheirownoutcomes,thereisaneedtounderstandhowpatient-reported
functionalcommunicationrelatestoimpairmentmeasuresandother-reportedmeasures.If
itcanbeshownthatself-reportedmeasuresarehighlyconsistentwith1)impairment
measuresand/or2)other-reportedmeasuresthenthesemeasurescanbetreatedas
equivalent.Iftheyarenotcorrelatedthenthisimpliesthatself-reportedmeasuresdo,in
23
fact,provideauniquelyvalidperspectiveabouttheimpactofaphasiaontheindividual.
Basedontheliteraturereview,wedevelopedthefollowinghypotheses:
1) RelatedtoSelf-ReportedFunctionalCommunication
a) Selfreportedfunctionalcommunicationwouldbecorrelatedwithaphasiaseverity.
b) Self-reportedfunctionalcommunicationwouldbecorrelatedwithcognition.
c) Alinearregressionmodelpredictingself-reportedfunctionalcommunicationusing
bothaphasiaseverityandcognitionwouldaccountforsignificantlymorevariance
thanamodelusingaphasiaseverityalone.
2) RelatedtoPartner-ReportedFunctionalCommunication
a) Partner-reportedfunctionalcommunicationwouldbecorrelatedwithself-reported
functionalcommunication.
b) Partner-reportedfunctionalcommunicationwouldbecorrelatedwithaphasia
severityandcognition.
c) Alinearregressionmodelpredictingpartner-reportedfunctionalcommunication
usingbothaphasiaseverityandcognitionwouldaccountforsignificantlymore
variancethanamodelusingaphasiaseverityalone.
24
CHAPTER3:
METHODSANDPROCEDURE
Thischapterdescribesthemethodsusedfordatacollectionandanalysesincludinga
discussionofthesubjects,assessmentmeasures,andexperimentalprocedures.
PARTICIPANTS
Seventeencommunity-dwellingadults(10males)withchronicaphasia(greaterthan6-
monthspost-onset)completedthestudy.Inaddition,16oftheirregularcommunication
partnersratedfunctionalcommunicationperformance.Participantswithaphasiawere
prescreened(in-personorbytelephone)formild-moderatenon-fluentaphasiaoranomic
aphasiawithrelativelystrongauditoryverbalcomprehensionandevidenceofword
findingdifficulty.Volunteerswithfluentaphasia,severeapraxiaofspeechandsevere
dysarthriawereexcluded.ParticipantswererequiredtobemonolingualEnglishspeakers.
Participantswererequiredtohavesufficientstaminatocomplete4hoursoftestingina
singleday.EachPwAwasrequiredtoidentifyanEnglish-speakingpartnerwithwhom
he/shehadfrequentcontactbothpriortoandafteraphasiaonsetandwhowaswillingto
participateinthestudy.
Participantswererecruitedthroughmultiplechannels.Somewererecruitedusing
flyerspostedattheUniversityofColorado,Speech,LanguageandHearingSciences
DepartmentClinicandotherswererecruitedthroughabulletinboardpostingtotheASHA
25
NeurophysiologyandNeurogenicSpeechandLanguageDisordersSpecialInterestGroup
(SIG2).SpeechLanguagePathologistswhoidentifiedpotentialparticipantsweresenta
copyoftheflyerandwereaskedtoprovideittopotentialparticipants.Thesepotential
participantswerethenrequiredtoinitiateanyfurthercontact.Inadditiontoparticipants
fromBoulder/Denver,participantswererecruitedinMinneapolis,MNandBaltimore,MD.
TheInstitutionalReviewBoardoftheUniversityofColoradoapprovedthestudy,and
signedinformedconsentwasobtainedfromeachparticipantafterpassingthepre-
screening.ConsentformsweremailedtothePwA’shomeaddresstoallowampletimefor
reviewpriortothefirstsession.Thosewithaphasiawereencouragedtohaveafamily
memberorfriendreviewtheformwiththem.Consentwasobtainedatthebeginningof
thefirstsessionandcriticalpointswerereviewedinpersonverballyandhighlightedonthe
form.Criticalpointsincludedthetotaltimecommitment,thetypesofactivitiestheywould
bedoing,theabilitytowithdrawatanytimeandforanyreason,thecompensationamount
andthepartialcompensationamountiftheyterminatedtheirparticipation.Whenthe
participantdidnotholdhis/herlegalpowerofattorney,boththeparticipantandthe
personwhoholdsthepowerofattorneysignedtheconsentform.Participantswithaphasia
werecompensated$200whilecommunicationpartnerswerecompensated$25.
Atotalof27peoplewereprescreenedandatotalof22peopleenteredintothestudy.
Fourofthefivenonentrantswerenotenrolledbecausetheyappearedtohavefluent
aphasiaornolongerhaveaphasia.Onewasclearedforparticipationbuthadotherhealth
issuesthatpreventedscheduling.Ofthe22peoplewhoenteredthestudy,5peoplefailed
tocompleteitafterbeingconsented.Participantsweredischargedforthefollowing
reasons:Participant5hadastrokebetweendays1and2oftesting;Participant10scored
26
26/100ontheWAB-AQ(cut-offwas50orhigher)andwasdismissedfromthestudy;
Participant18arrivedsickonday2andwasunabletocompletethestudy;Participant20
askedtobedismissedfromthestudyaftercompletingthefirsthalfoftheACOM,theWAB-
RandthetimedBNT-2.Participant21decidedshedidnotwanttoparticipateafter
completing1-houroftasks.Participantswhofailedtocompletethestudywerepaid$10
perhourforeachhourcompletedor$60whicheverwassmaller.Thislesseramountwas
intendedtoonlypartiallycompensatetheparticipantbecausetheirdata,sinceitwas
incomplete,couldnotbeused.
DEMOGRAPHICS
ThedemographicandclinicalcharacteristicsofthegrouparesummarizedinTable1.
TheseventeenPwAwhocompletedthestudyrangedinagefrom30to72(M=53.24,and
SD=11.27).Allcompletedhighschoolandmorethanhalfheld4-yearoradvanceddegrees.
WESTERNAPHASIABATTERY-REVISED.
Allparticipantswithaphasiaincludedinthefinaldatasetpresentedwithmild-to-
moderateaphasiaasmeasuredbytheWAB-AQ(range54.3-96.2;x=76.9,s.d.=10.70)and
relativelygoodauditorycomprehensionasindicatedbyWAB-Rauditorycomprehension
subtestscores(range7.2–10.00;x=8.61,s.d..91).SeeTable2forcompleteWAB-Rdata
summary.
Despitetheprescreening,twoparticipants(6and9)receivedsufficientlyhighWAB-
AQscorestobecategorizedasnon-aphasic(ascoreinexcessof93.7isconsidered
“normal”;Kertesz,1982).BecausetheirACOMself-reportsindicatedongoing
27
communicationchallenges(ACOMscores=191,176outof236respectively,wemodified
ouroriginalselectioncriteriaandretainedthese2participantsintheanalysis.Notethat
thisisconsistentwiththeinclusioncriteriausedbyDoyleandcolleagueswhohadaWAB-
AQrangemin-maxof10.2–100(Hula,personalcommunication,January27,2015).
Partner/familyratersconsistedofspousesorromanticpartners(44%),siblings(19%),
adultchildren(13%),orparents(25%).Participant3’spartnerhadpoorfamiliarity(she
workedatthefrontdeskofthelivingfacility),didnotknowtheparticipantpriortothe
onsetofaphasia,andneversawhimengageinactivitiesoutsidethelivingfacility.Because
ofthislackoffamiliarity,shewasunabletocommentonmanyoftheitemsontheACOM.
Forthesereasons,herdatawereexcludedfromthestudy.
Table1.
Participantcharacteristics:Mean,standarddeviation(s.d.),andrangefor17personswithaphasia(PwA)with
PartnerGenderandRelationshiptoPwA.(Note:“.”Indicatesmissingparticipantdata.Seetextforexplanation).
PwA PartnerParticipant Gender Age WAB-AQ Gender Reside
TogetherRelationship
1 F 66 74.7 F No Daughter2 M 53 81.0 F Yes Spouse3 M 55 69.3 . . .4 M 57 85.2 F Yes Spouse5 . . . . . .6 M 45 94.8 F No Mother7 F 55 76.7 F Yes Mother8 M 30 86.9 F No Mother9 F 58 96.2 F No Daughter10 . . . . . .11 F 30 76 M Yes Spouse12 M 42 79.2 F Yes Spouse13 F 52 79.5 M No Brother14 M 63 73.4 M No Brother15 F 54 72.8 F No Mother16 F 56 78.6 F No Sister17 M 72 54.3 F Yes Spouse18 . . . . . .19 M 54 60.4 F Yes Spouse20 . . . . . .21 . . . . . .22 M 63 68.9 F Yes SpouseMean M=59% 53.24 76.9 M=18% s.d. 11.27 10.7
Table2.
WAB-AQandsubtestscoresforeachparticipantwithaphasia.
Participant WAB-AQ Spont.Speech
Fluency AuditoryComp.
SequentialCommands
Repetition Naming AnimalFluency
1 74.7 11 6 9.3 71 9.8 6.8 52 81.0 14 6 8.8 62 8.7 9 133 69.3 13 6 7.65 42 5.8 8.2 114 85.2 15 6 9.6 75 8.8 9.2 126 94.8 19 9 9.9 89 9.2 9.3 137 76.7 17 8 8.25 50 5.7 7.4 208 86.9 18 9 8.45 67 8.0 9 139 96.2 19 9 10 80 9.5 9.6 1611 76.0 13 5 8.30 54 8.0 8.7 1012 79.2 14 6 8 40 8.2 9.4 1913 79.5 12 4 9.45 72 7.8 9.5 1514 73.4 12 4 9.20 64 7.8 7.7 415 72.8 13 5 7.45 50 7.8 8.1 816 78.6 14 5 7.80 40 6.4 8.1 917 54.3 9 4 7.65 42 6.9 3.6 119 60.4 11 4 7.20 28 4.6 7.4 722 68.9 8 4 9.45 78 5.0 8.0 7
Mean 76.9 13.65 5.88 8.61 59.06 7.53 8.18 10.76s.d. 10.7 3.20 1.83 .91 17.35 1.56 1.45 5.18
30
ASSESSMENTS
Aseriesoffunctionalcommunication,non-verbalcognition,andlanguageimpairment
testswereadministeredtoallparticipants(AppendixA).Thissectiondescribeseach
assessmentanditspurpose.Afullexplanationofmodifiedinstructionsisprovidedinthe
appendix(AppendixD).
APHASIACOMMUNICATIONOUTCOMEMEASURE
TheAphasiaCommunicationOutcomeMeasure(ACOM;Doyle,etal.,2013)wasusedto
assessself-reportedandpartner-reportedfunctionalcommunicationability.TheACOM
consistsof59-items(AppendixB).Thequestionnaireaskstherespondenttoratehow
effectivelythey(ortheirpartnerwithaphasia)engageincertaincommon,everyday
behaviors,tasks,activities,andlifesituationsthatinvolvedunderstandingandor
producingspoken,written,andornon-verbalmessages,signs,andsymbols(Doyle,McNeil,
Le,Hula,&Ventura,2008,p.720).Someexamplequestionsare“howeffectivelydoyou
startanewtopicinconversation?”;“howeffectivelydoyoumakeyourselfunderstood
whenspeakingwithfamilyandfriends?”and“howeffectivelydoyoucorrectmistakesyou
makewhenyoutalk?”.Effectivenessisdefinedas“accomplishingwhatyouwantto,
withouthelp,andwithoutittakingtoomuchtimeoreffort”(Hulaetal.,2015,p910).
ACOMitemsareratedona4-point(ordinal)scale.Therespondentmayalsoindicate
thattheydonotengageinaspecificbehavior(e.g.writingchecks)withafollow-up
questionaboutwhetherornotitisduetotheiraphasia.ResponseswereconvertedintoT-
ScorevaluesusingsoftwareprovidedbyHula(Hulaetal.,2015).T-Scorearenormalized
tohaveapopulationmeanof10andastandarddeviationof3.
31
BOSTONNAMINGTEST(SECONDEDITION)
TheBostonNamingTestsecondedition(BNT-2;Kaplan,Goodglass,&Weintraub,2001)
isavisualconfrontation-namingtestthatassessesnamingability.TheBNT-2wasselected
becauseitisamoreextensiveassessmentofwordfindingdifficultythanisprovidedbythe
WAB-R.TheBNT-2consistsof60blackandwhitelinedrawingsofobjects.Itemsonthe
BNT-2areorderedaccordingtodecreasingfrequencyandfamiliarity.(Brookshire&
Nicholas,1995).
ThisstudyusedamodifiedversionoftheBNT-2.Unlikethestandardadministration,no
cuingwasprovidedfollowingerrorsorsignificantresponsedelays(i.e.nosemanticor
phonemiccuingwasgiven).Inaddition,theBNT-2stimuliwerepresentedviacomputer
usingPowerPointtmsoftware.Thedrawingswereshownoneslideatatimeandthe
participantwasaskedtonameeachitem.Toachieveacorrectresponse,thecorrectanswer
musthavebeenthefirstword(s)spoken,withnophonemicparaphasicerrors(e.g.
“strethoscope”forstethoscopewouldbeincorrect).Thepercentcorrectscoreisthesumof
thecorrectresponsesdividedbythetotalnumberofitems(60).
D-KEFSDESIGNFLUENCYTEST
TheDKEFSdesignfluencytestassessesattention,processingspeed,workingmemory,
initiation,perseveration,cognitiveflexibility,andnonverbalabstraction(Zinn,Bosworth,
Hoenig,&Swartzwelder,2007).Participantsmustgeneratenewdesignswhileabidingby
therulesandavoidingimpulsiveorperseverativeresponses(Mikola,2010).
DesignfluencyisespeciallyusefulintheassessmentofPwAbecauselanguageisnot
requiredtoperformwellonthetest.Therefore,poorperformanceonDesignFluency
32
cannotbeexplainedbylanguage,memory,ormotordeficits(Ruff,Evans,&Marshall,
1986).Normativedataforthistestisavailableforagesfrom8to89.
TheDesignFluencytestiscomprisedofthreeconditions:basic,filter,andswitch
(Figure1).Thetaskistodrawasmanyuniquedesignsaspossiblein60-seconds.The
responsesheetisprintedwithanarrayof35squares.Insideeachsquareisadotpattern.
Thesamedotpatternappearsineachsquare.Inthebasiccondition(condition1),the
squaresontheresponsesheetcontainfivefilled(i.e.,black)dots.Theexamineeis
instructedtodrawuniquedesignsbyconnectingthedotswithfourstraightlines.Creditis
notgivenifadesignisrepeatedacrosssquares.Inthefiltercondition(condition2)each
squarecontainsfiveemptydotsandfivefilleddots.Theexamineeisinstructedtoconnect
onlytheemptydotsusingfourstraightlines(whileignoringthefilleddots).Creditisnot
givenifadesignisrepeatedorifadesignincludesafilleddot.Thisiscalledthefilter
conditionbecausethetaskrequirestheexamineeto“filter”out(inhibit)relevantresponses
fromcondition1.Intheswitchcondition(condition3)eachsquarecontainsfiveempty
dotsandfivefilleddots(arrangeddifferentlythaninthefiltercondition)andtheexaminee
isinstructedtoalternatebetweenconnectingemptydotsandfilleddots.Creditisnotgiven
ifadesignisrepeatedorifadesignfailstoincludefilledandemptydotsinanalternating
order.Thisiscalledtheswitchconditionbecausethetaskrequirestheexamineetoflexibly
switchbetweenthefilledandemptydots.Possibleerrorsincludeset-losserrors(the
designcontainsgreaterorfewerthanfourslinesordoesnotfollowtherulesforthat
condition)andrepetitionerrors.
AccordingtoDelis-Kaplan(Delis,Kaplan,&Kramer,2001b),condition1providesa
basictestofdesignfluency,condition2measuresbothdesignfluencyandresponse
33
inhibitionandcondition3measuresbothdesignfluencyandcognitiveflexibility.
Inadditiontocompletingthestandardversionofthedesignfluencytest,
participantscompletedanuntimedversioninwhichtheywereallowedtotakeasmuch
timeastheywantedtocompletethetaskandwereallowedtodecidewhentheywere
finished.Someparticipantsfilledall35squaresineachconditionwhileothersstoppedon
theirown.Becausethetaskwasthesameinthestandardanduntimedversionstheorder
wascounterbalancedacrosssubjects.Thetaskwascompletedasingledaywithtest
administrationsbeingatleasttwo-hoursapart.Theuntimedversionofthetestprovides
additionalinformationabouterrorsandinhibitionofimpulsiveorperseverativeresponses.
Therearetwobasicerrorsthatcanbecommittedduringthedesignfluencytest:set
lossdesignsandrepeateddesigns.Setlossdesignsareerrorsinwhichthedesignhastoo
manyortoofewlines.Incondition1,asetlossdesignhasmoreorlessthan4lines
connectingthedots.Incondition2,asetlossdesignhasmoreorlessthan4lines
connectingthedotsoritcanincludeasoliddot.Incondition3,asetlossdesignhasmore
orlessthan4linesoritfailstoswitchbetweensolidandopendots.Repeateddesignsare
errorsinwhichthesamedesignwasalreadyproducedonthecurrentresponsepage.Note
thatmanyrepeateddesignsoccurbecause,althoughtheexamineeusesadifferentstroke
sequence,thesamedesignisultimatelyproduced.Thisoftenoccurswhencloseddesigns
(formingasquareorrectangle)arebegunarestartedatdifferentinitialdots.
D-KEFSVERBALFLUENCYTEST.
Verbalfluencyreferstoaperson’sabilitytogenerateitemsfromagivencue(Baldo
etal.,2001).Categoryfluencyisitemgenerationbasedonsemanticcues(e.g.animals,
34
musicalinstruments).Letterfluencyisitemgenerationbasedonphonemiccues(e.g.
wordsbeginningwiththeletterForH).
WhilesimilartothecategoryfluencytaskintheWAB-R,theD-KEFSverbalfluency
testismorecomplete.Therewerethreeconditionsintheverbalfluencytask:letterfluency
(F,A,Sinset1;B,H,Rinset2),categoryfluency(animal’sandboysnameinset1;itemsof
clothingandgirlsnamesinset2)andcategoryswitchfluency(alternatingbetweenfruits
andfurnitureinset1andvegetablesandmusicalinstrumentsinset2).Theorderofthese
conditionswasfixedaswastheorderofthesets(thatis,F,A,Swasalwaysdonefirst).The
timedversusuntimedconditionswerecounterbalancedacrossparticipants.
Verbalfluencyrateswerebasedonthenumberofcorrectitemsproducedinone
minute.Itemswerecountedascorrectiftheymettheconstraintsoftheconditionandwere
notrepetitions.Letterfluencyscoreswerebasedontheaveragenumberofitems
generatedacrossthethreeletterconditions.Categoryscoresweretheaveragenumberof
itemsgeneratedinthetwocategories.Switchscoresarecalculatedintwoways:Switch
Fluencyisthetotalnumberofitemsnamedfromeithercategory(irrespectiveofwhether
adjacentitemsarefromalternatecategories)andSwitchTotalsisthenumberoftimesthe
participantswitchesbetweencategoriesasitemsarenamed.
D-KEFSTWENTYQUESTIONSTEST
TheD-KEFSTwentyQuestionTask(TQT)isaproblem-solvingtaskthatassessesboth
languageandcognition.Problemsolvingrequiresconceptualizing,planning,executionand
modifyingstrategiesbasedonfeedback(Marshall,Harvey,Freed,&Phillips,1996).The
TQTtaxesabstractreasoningability,abilitytoshiftcognitiveset,andworkingmemory
35
(Delisetal.,2001).
Forthistest,theparticipantispresentedwithastimuluspagedepictingcommon
objectsin8-columnby5-rowarray.The30commonobjectsbelongtovariouscategories
andsubcategoriesdifferingintermsofthenumberofobjectsineach.Forexample,the
stimuluspicturesinclude15non-livingthings,8thingsfoundinakitchen,and2appliances
(AppendixC).
Theparticipantisinstructedtoaskthefewestnumberofyes/noquestionsinorderto
identifyanunknowntargetobjectdepictedonthestimuluspage.Themosteffective
problem-solvingstrategyonthistaskistheparticipant’saskingyes/noquestionsthat
eliminatethemaximumnumberofobjectsregardlessofwhethertheexaminer’sansweris
yesorno.Forexample,theinitialquestion“Isitalivingthing?”eliminateshalfofthe
objects(15outof30)regardlessofwhethertheexamineranswersyesorno;thus,this
questionreflectsahighlevelofabstractthinking.Incontrast,ifanparticipantasksahighly
concreteinitialquestion(e.g.“Isitanstove?”or“Isitanappliance?”)onlyafewobjects
wouldbeeliminatedbytheexaminer’sanswer.
ToefficientlysolvetheTQT,theexamineemust(a)perceivethevariouscategoriesand
subcategoriesrepresentedbythe30objects,(b)formulateabstract,yes/noquestionsthat
eliminatethemaximumnumberofobjectsregardlessoftheexaminer’sanswer(c)
effectivelyusefeedbackwhenformulatingquestions(c)incorporatetheexaminer’s
feedbackinordertoformulatemoreefficientyes/noquestions(d)useworkingmemoryto
trackinformationthathasalreadybeendiscovered(inordertoavoidaskingquestionsthat
donoteliminatenewobjects),and(e)switchfromaconceptualtoaspecific-naming
strategywhenauniquecategoryisidentified.
36
D-KEFSCARDSORTTEST
TheD-KEFSCardSortTask(CST;Delisetal.,2001)assessesconceptgeneration,
conceptidentification,andconceptexecutionaswellperseveration(Beatty&Monson,
1990).
TheD-KEFSCardSortingtaskconsistsof16differentsortingconceptsacrosstwo
conditions:FreeSortandSortRecognition.Infreesortingexamineeisrequiredtosortsix
cardsintotwogroups,threecardspergroup,accordingtoeightpossiblesortingrules
(threeverbalandfivenonverbal),andtodescribethesortingruleaftereachsortmade.In
recognitionsortingtheexaminersortsthecardsintotwogroupsandthenasksthe
examineetoidentifythesortingruleorconceptthatwasusedtosortthecards(Shunk,
Davis,andDean,2006).
ToperformwellontheCST,theexamineemust(a)perceivethevariouscard-set
groupings(b)formulatedescriptionofthegroupings(e.g.theseareallfoundintheairand
theseareallfoundontheground)(c)effectivelyshiftthinkingtoidentifynewgroupings
andd)avoidrepetitionsofgroupings.
TORRANCETESTOFCREATIVETHINKING
TTCTisawell-knownandwidelyusedtestofcreativity(Torrance,1968).It
assessesfourprincipalcognitiveprocessesofcreativity:(a)fluencyornumberofrelevant
responses;(b)flexibilityasreferredtoavarietyofcategoriesorshiftsinresponses;(c)
originality(consideringnoveltyresponses,notfamiliarandunusual,butrelevant)and(d)
elaboration(thenumberofdetailsusedtoextendaresponse)(Almeida,Prieto,Ferrando,
Oliveira,&Ferrandiz,2008).
37
Forthisstudyweusedtwosubtests:ProductImprovementandUnusualUses.For
ProductImprovements,theexamineelistwaystochangeastuffedanimaltoysothata
childwouldhavemorefunplayingwithit.ForUnusualUses,theexamineelistinteresting
andunusualusesofacommonobject.Thescoringforeachtaskisbasedonproprietary
scoringmethods.Nocreditisgivenforrepeatedsolutions/ideas.Forexample,creditis
givenoncefortheideatoclothethetoybutnotforlistingindividualclothingitems.
ToperformwellontheTTCT,theexamineemust(a)generateunique,creative
suggestions(b)effectivelyshiftthinkingtogeneratenewideas(c)articulateorusegesture
toconveytheideatotheexaminer.
PROCEDURE
Testingwasdoneacross2dayswith4hoursofevaluationandtestingeachday
(maximumof8hourstotaltestingtime).Nomorethan1weeklapsedbetweenthefirst
andsecondtestday.Testingwasconductedinaquietroomwithonlytheexaminerand
participantpresent.Allofthesessionswerevideorecorded.
Eachtestingday,consistedofa2-hourtestingsessioninthemorning,a1.5-2hour
break,followedbya2-hourtestingsessionintheafternoon.Thetotaltimecommitment
was8hoursbutmanycompleteditinfewerhours.Testingwasconductedinaquietroom
withonlytheexaminerandparticipantpresent.Allofthesessionswerevideorecorded.
Thefirst2-hourperiodusedeithertimedoruntimedcondition(counterbalanced)and
thesecond2-hourperiodwillusetheoppositecondition.Thisapproachwaschosen
becauserepeatedtestswithinashortperiodoftimemayresultincriticismsthat
38
performancedifferencesareduetolearning/familiaritybut,sincethereislargevariability
inperformanceacrossdays,itensuresthattimedanduntimedtestsversionsare
completedwithinasingleday.
Testswereadministeredinblocks.Testingorderoftheblockswascounterbalanced
usingaLatinSquareDesignwithreplacementforlostparticipants.BlocksAandBwere
completedononedayandBlocksCandDwerecompletedonanotherday.BlockA
consistedoftheuntimedversionsoftheBostonNamingTest,theD-KEFSVerbalFluency
test,theD-KEFSDesignFluencytest,theAlphabetFluencyTest.BlockBconsistedofthe
timedversionsofthesetests.BlockCconsistedoftheuntimedversionsoftheD-KEFS
Sortingtest,theD-KEFSTwentyQuestionstest,and4testsfromtheTorranceTestof
CreativeThinking(AppendixF).
Alongbreak(1.5-2hours)wasgivenbetweenblockstoallowtimefortheimpactof
timepressuretoabatebetweenblocks.Forexample,ifthetimedanduntimedtaskswere
interleaved,thentheimpactofpressureislikelytobleedoverontoconditionsthatdonot
requiretimedperformance.Whenthetimedconditionfollowsanuntimedcondition,an
equivalentlengthbreakisprovidedforrestandservesasageneralcontrolfortotaltesting
time.
APHASIACOMMUNICATIONOUTCOMEMEASURE.
Forparticipantwithaphasia,ACOMdatawascollectedusinganinterviewer-
assistedadministrationformatasdescribedinDoyleetal.(2013).Itemsweredisplayedon
acomputerscreeninlargefontalongwiththestem‘‘Howeffectivelydoyou…’’The
examinerreadeachitemaloudandalsopermittedtherespondenttoreadit.Responses
wereprovidedorallyorbypointingtotheirchoiceonavisualscale.Thecomputerscreen
39
alsodisplayedaverticalbarrepresentingtheresponsecategorieswithtextlabels.Incases
wheretherewasanyuncertaintyaboutthevalidityoftheresponse,theexaminerverbally
repeatedtheitemandtheresponsebacktotheparticipantandalsopointedtothechosen
responseonthescreen.Forpartnerquestionnaires,theitemstemsweremodifiedto“How
effectivelydoesyourpartner…”.Partnertestingwasunsupervisedandemployedanonline
surveyformorapaperversionperthepreferenceoftherespondent.
TocollecttheACOMdata,theexaminersatalongsidetheclientandreadeach
questionaloud.Theclientcouldprovidetheirresponseorallyorbypointingtotheir
choiceonavisualscale.
Forpartners,ACOMdatawascollectedusingacomputerbasedquestionnaireor,for
oneparticipant,aprintedversionofthesurvey.
40
BOSTONNAMINGTEST(SECONDEDITION)
TheBNT-2wasadministeredtwiceundertimedanduntimedconditions.Inthetimed
condition,eachstimuluswaspresentedfor3secondsthenthesoftwareautomatically
progressedtothenextimage.Intheuntimedcondition,eachstimuluswaspresenteduntil
theparticipantprovidedanameorindicatedthattheydidnotknowthename.Because
participantsoftenrespondusingrisingintonation(e.g.Flower?),weretoldthatthey
neededtobeclearthattheyweredoneortheywouldbeasked“Isthatyourfinalanswer?”.
Itemswerescoredascorrecteveniftheywerenamedafter3-secondpresentationtime.
D-KEFSDESIGNFLUENCYTEST
Thedesignfluencytestconsistsofthreeconditions:basic,filter,andswitch(described
intheAssessmentsectionabove).Thethreeconditionswereadministeredinthisfixed
order.Participantsusedtheir“postmorbid”handtodraw.
Foreachofthethreeconditions,participantswerefirstshownapracticepageswith3
squares,eachofwhichcontainedanarrayofdotsidenticaltothearrayonthetestpage.
Theinstructionsforeachconditionweregivenorally.Participantswereinstructedtomake
adifferentdesignineachsquarebyconnectingthedotswithstraightlines.Theyweretold
touseonly4straightlines.Participantswereallowedtoliftthepenfromthepage.
Participantswereencouragedtopracticebeforeeachconditionandweregivenfeedback
abouttheirpracticedesigns.Incaseswherethedesignwasincorrect,theexaminer
explainedbythedesignwasincorrectandrecommendedanotherpracticeattempt.All
participantsproducedatleastonecorrectdesignduringpractice.
Eachparticipantcompletedthedesignfluencytasktwice:timed(standard
administration:60seconds)anduntimed(unlimitedtime).Theorderwascounterbalanced
41
acrossparticipantsandtestadministrationswereatleasttwo-hoursapartonthesameday.
Inthetimedcondition,whentimeexpired,theparticipantwasNOTallowedtofinisha
designinprogress(loudringingnoiseinterruptedtask).Intheuntimedcondition,
participantsself-terminatedorstoppedonceall35ofthearraysontheresponsepagehad
beencompleted.
DuringthetimedconditionaniPaddisplayingacountdowntimerwitharedclockface
withasweepinghandwasplacedinaprominentpositioninfrontoftheparticipant.When
the1-minutetimeended,aringingsoundplayedandtheexaminerstoppedtheparticipant
immediately.Duringtheuntimedcondition,aniPaddisplayingananalogclockwasplaced
inthesamepositioninfrontoftheparticipantbutnoreferencewasmadetotime.The
examinerstartedthetaskandthenspentthedurationofthetasklookingatpaperworkor
othermaterialsuntiltheparticipantindicatedtheyweredoneorcompletedall35squares.
Ifaparticipantaskedforclarificationduringthetimedcondition,theexaminersuspended
thetimeruntilthequestionwasanswered.Themostcommonquestionswereaboutwhat
todowhentheexamineerealizedthathe/shehascommittedanerror.Participantswere
toldtocrossoutanyerrorsandcontinuewiththetask.
Designswerecodedascorrectiftheyused4straightlines,wereunique(this
includeddesignsinwhichonelinesdidnottouchanotheratanendpoint.)andmetother
constraintsbasedoncondition(explainedbelow).Inthetimedcondition,theparticipant
wasNOTallowedtofinishanydeigninprogresswhenthetimeexpired(loudringingnoise
interruptedtask).Intheuntimedcondition,participantsselfterminatedorstoppedonce
all35ofthearraysontheresponsepagehadbeencompleted.
42
D-KEFSVERBALFLUENCYTEST.
Therewerethreeconditionsintheverbalfluencytask:letterfluency(F,A,Sinset1;
BHRinset2),categoryfluency(animal’sandboysnameinset1;itemsofclothingand
girlsnamesinset2)andcategoryswitchfluency(alternatingbetweenfruitsandfurniture
inset1andvegetablesandmusicalinstrumentsinset2).Theorderoftheseconditionswas
fixedasweretheorderofthesets(thatis,F-A-Swasalwaysdonefirst).Thetimedversus
untimedconditionswerecounterbalancedacrossparticipants.
Inordertoavoidincreasingthecomplexityoftheinstructionsandincreasing
working-memoryload,participantswereallowedtousenamesofpeople,placesand
numbersduringtheletterfluencytask(theseconstraintsareusedinstandard
administrationsofthistask).Despitethisdifference,veryfewparticipantsviolatedthe
ruleand,whentheydid,theygeneratedpeople’snames.
Instructionsweregivenorally.Justbeforestarting,thetargetletterwaswritten
downandshowntotheparticipantthenremovedfromviewwhenthetaskbegan.Inthe
timedcondition,participantsweregiven60secondstogenerateitems.AniPadshowinga
clockwitharedsweepingcount-downindicatorwasplaceddirectlyinfrontofthe
participantandtheexaminerbeganthetaskwitha“Ready,Set,Go!”whilestartingthe
timer.IntheuntimedconditionaniPadwithaclockwasplacedinthesamepositionbut
participantsweretoldtoworkathis/herownpace.Theexaminerlistenedandwrotedown
eachitemgeneratedandencouragedtheparticipanttocontinueworkingaslongass/he
wanted.
Toavoidcomplexityandworking-memoryload,participantswereallowedtouse
namesofpeople,placesandnumbersduringtheletterfluencytask(theseconstraintsare
43
usedinstandardadministrationsofthistask).Despitethisdifference,veryfew
participantsviolatedtheruleand,whentheydid,theygeneratedpeople’snames.
ScoringwascompletedfollowingthescoringmethodologydescribedintheD-KEFS
ExaminersManual(Delis,Kaplan,&Kramer,2001c).Verbalfluencyrateswerebasedon
thenumberofcorrectitemsproducedinoneminute.Itemswerecountedascorrectifthey
mettheconstraintsoftheconditionandwerenotrepetitions.Letterfluencyscoreswere
basedontheaveragenumberofitemsgeneratedacrossthethreeletterconditions.
Categoryscoresweretheaveragenumberofitemsgeneratedinthetwocategories.Switch
scoresarebasedonthenumberofcorrectitemsgeneratedintheconditionregardlessof
whetherornottheparticipantaccuratelyfollowedtheswitchingrule.
D-KEFSTWENTYQUESTIONSTEST.
TheD-KEFSTwentyQuestionstestwasadministeredtwice,oncewithnotimelimits
andoncewithtimepressure.Inthetimepressuredconditionacount-uptimerwasplaced
infrontoftheparticipantandhe/shewasinstructedtoaskquestionsasquicklyas
possible.Theclockwasstartedandthetimerstartedastheexaminersaid“Ready,Set,
Go!”.Thepresentationorderforthetwoversionswascounterbalancedacrossparticipants.
Eachadministrationconsistsof4trials.Thefirsttestadministrationwasalways
completedwiththeitems“banana”,“spoon”,“owl”and“helicopter”.Thesecondtestused
theitems“airplane”,“rose”,“stove”and“corn”.Acrossallfourtrials,thereistheneedto
avoidinterferencefromprioritems.
Forthepurposeofthisstudy,threescoresfromtheTQTwerederivedfromthedata:1)
thetotalnumberofquestionsrequiredtoidentifythetargetitem,2)theabstractionofthe
44
firstquestionineachtrial(abstractionreferstothenumberofitemseliminatedbya
questionregardlessofwhethertheresponseisyesorno),and3)thetotalweighted
achievement(thisscoringcorrectsforfortuitousguessing).
D-KEFSCARDSORTTEST
TheD-KEFSCardSorttestwasadministeredtwice,oncewithnotimelimitsandonce
withtimelimits(4minutespercardset-uptoeightsortsperset).Inthetimelimited
conditionacount-downtimerwasplacedinfrontoftheparticipantandhe/shewas
instructedtoaskquestionsasquicklyaspossible.Theclockwasstartedandthetimer
startedastheexaminersaid“Ready,Set,Go!”.Thepresentationorderforthetwoversions
wascounterbalancedacrossparticipants.
Participantsareshownhowtosortthecardsusingasamplecardset.Thesamplesorts
includeonebasedonperceptualfeatures(cardsgroupedbycolor:yellowandblue)and
onebasedonthewordsappearingonthecards(BoyversusGirlsnames).Toconfirmthat
theywereabletoreadthewordsonthecards,participantswereaskedtoreadthewords
onthecardsaloudbeforethesortingtaskbegan.
Forthesortrecognitiontask,theparticipantwastoldtolookawayasthecards
wereplacedintotwogroups.Theywereaskedtodescribehowthecardswerethesamein
eachgroup.Inthetimedcondition,viewingtimewaslimitedto30seconds.
Explanation/descriptiontimewasallowedtocontinuepastthe30secondstimelimit.
TORRANCETESTOFCREATIVETHINKING
TheTTCThastwoparallelforms(AandB).Thepresentationorderforthetwoversions
wascounterbalancedacrossparticipants.Eachsubtest(ProductImprovementandUnusual
45
Uses)wasadministeredtwice,oncewithnotimelimitsandoncewithtimelimits(4
minutespercardset-uptoeightsortsperset).
FortheProductImprovementtask,theparticipantwasallowedtohold,manipulate,
andgesturewiththestuffedtoy.Whengesturewasused,theexaminerworkedwiththe
participanttoagreeonthemeaning.Forexample,iftheparticipantmovedtheanimal
acrossthetable,thentheexaminermightask“Makeitwalk”?andwaitfortheparticipant
toconfirmorredirect.
FortheUnusualUsestask,theexamineracknowledgedideasandaskedquestionsto
clarifyuses.Forexample,iftheparticipantsaid“painting”,theexaminermightask“You
wouldpaintit?”andwaitfortheparticipanttoclarify.
46
CHAPTER4:
RESULTS
DESCRIPTIVESTATISTICS
SELF-RATEDANDPARTNER-RATEDAPHASIACOMMUNICATIONOUTCOMEMEASURE
AsTable3shows,themeanACOMT-ScoreforthePwAgroupwas53.18andthe
standarddeviationwas7.3.Participant2’sACOMratingscorewasanoutlier(score=
36.30)howeveranalysesofthedatawithouthisscoredidnotchangethepatternofresults.
ThemeanACOMT-ScoreforthePartnersgroupwas49.44andthestandarddeviationwas
9.53.TherewerenooutliersinthepartnerACOMscores.
Partner-reportedscoreswereonaveragemorepositivethanPwA-reportedscores.The
averagedifferencebetweenPwAandPartnerscoreswas3.24(s.d.=10.60).However,38%
ofthePwA(6/16)ratedthemselveshigherthandidtheirpartnerontheACOM.
47
Table3.
PwAandPartnerACOMscoreswithgroupmeansandstandarddeviations.
Participant WAB-AQ PwAACOM
PartnerACOM
Diff(Partner–PwA)
1 74.8 54.29 34.75 19.542 81.0 36.30 45.62 -9.323 69.3 61.37 . 4 85.2 49.04 62.43 -13.396 94.8 56.35 50.23 6.127 76.7 48.31 56.98 -8.678 86.9 57.34 48.64 8.79 96.2 62.58 53.42 9.1611 76.0 54.03 50.24 3.7912 79.2 51.67 60.69 -9.0213 79.5 60.74 67.20 -6.4614 73.4 39.76 43.60 -3.8415 72.8 47.06 41.36 5.716 78.6 55.63 47.93 7.717 54.3 54.05 31.70 22.3519 60.4 60.58 51.73 8.8522 68.9 55.03 44.46 10.57mean 76.94 53.18 49.43 3.24s.d. 10.70 7.30 9.53 10.60
Note:Missingratings(“doesnotapply”or“Idon’tknow”)wereomittedfromthecalculation.
BOSTONNAMINGTEST
ThepercentcorrectforthetwoconditionsisshowninTable4.Timed
responses(Mean=.56,s.d.=.22)weresignificantlylessaccuratethanuntimed
responses(Mean=.46,s.d.=.22);Pairedt-test(16)=5.44,p=.000.
48
Table4.
PercentcorrectnamingonBostonNamingTest(BNT-2)forUntimedandTimed
Conditions.
Participant WAB-AQ BNT-2
TimedBNT-2
1 74.8 .58 .302 81.0 .47 .403 69.3 .48 .424 85.2 .73 .576 94.8 .83 .787 76.7 .53 .328 86.9 .72 .539 96.2 .92 .9211 76.0 .63 .4212 79.2 .82 .7213 79.5 .62 .5514 73.4 .57 .5015 72.8 .52 .4216 78.6 .52 .3517 54.3 .05 .0219 60.4 .30 .2722 68.9 .27 .25Mean 76.94 .56 .45s.d. 10.70 .22 .22
D-KEFSDESIGNFLUENCY-STANDARDADMINISTRATION
Table5showsthatthenumberofcorrectdesignsproducedbyoursample
summedacrossthe3conditionsrangedfrom8to29(mean=17.82ands.d.=
6.00).Thenumberofattempteddesignsrangedfrom11to44(mean=24.59,s.d.
=7.77).
49
Thenumberofrepeateddesignsproducedbyoursamplesummedacross
the3conditionsrangedfrom0to13(mean=3.06ands.d.=3.79)andsetloss
designrangedfrom0to11(mean=3.82ands.d.=3.05).Addingtheerrors
together,thisresultedinproportionoferrorsrangingfrom.08to.55(mean=27
ands.d.=.15).
50
Table5.
D-KEFSDesignFluencydataforStandardAdministration.Scoresaresummed
acrossthe3conditions.
D-KEFSDesignFluency(StandardAdmin)Participant WAB-
AQAttemptedDesigns
CorrectDesigns
RepeatedDesigns
SetLossDesigns
ProportionofErrors
1 74.7 27 22 2 4 .222 81.0 44 23 13 8 .483 69.3 18 16 0 2 .114 85.2 20 14 5 1 .306 94.8 19 16 0 3 .167 76.7 34 18 5 11 .478 86.9 32 29 3 0 .099 96.2 16 11 1 4 .3111 76.0 30 27 0 3 .1012 79.2 23 17 0 6 .2613 79.5 27 23 2 2 .1514 73.4 25 19 3 3 .2415 72.8 20 10 2 9 .5516 78.6 25 23 1 1 .0817 54.3 20 12 4 4 .4019 60.4 11 8 0 3 .2722 68.9 27 15 11 1 .44Mean 76.9 24.59 17.82 3.06 3.82 0.27s.d. 10.7 7.77 6.00 3.78 3.05 0.15Note:BecauseasingledesigncanbebothaSetLossDesignandaRepeatedDesign,thesumofCorrect+Repeated+SetLossmaybelargerthanAttempted.
D-KEFSDESIGNFLUENCY-UNTIMEDADMINISTRATION
Whengivenunlimitedtime,ourparticipantsproducedanaverageof45.1
correctdesignsacrossthethreeconditions(s.d.=17.6)(Table6).Thenumberof
attempteddesignsrangedfrom18to103(mean=61.7,s.d.=25.6).
Thenumberofrepeateddesignsproducedbyoursamplesummedacross
the3conditionsrangedfrom0to34(mean=7.9ands.d.=11.5)andsetloss
designrangedfrom0to52(mean=8.1ands.d.=12.25).Addingtheerrors
51
together,thisresultedinproportionoferrorsrangingfrom.02to.67(mean=.22
ands.d.=.196).
Participants15,and22hadmarkedlyhighernumberofrepetitionerrors
whileParticipant7hadmanymoresetlosserrorsthantheotherparticipants.
Participant2producedlargenumbersofrepetitionandsetlosserrors.Generally,
participantswhoproducedfewerdesignswerealsomoreaccurate.
52
Table6.
D-KEFSDesignFluencydataforUntimedAdministration.Scoresaresummedacross
the3conditions.
D-KEFSDesignFluency(StandardAdmin)Participant WAB-
AQAttemptedDesigns
CorrectDesigns
RepeatedDesigns
SetLossDesigns
ProportionofErrors
1 74.7 36 32 0 4 .112 81.0 98 52 34 12 .473 69.3 18 16 0 2 .114 85.2 73 58 6 9 .216 94.8 45 45 0 0 .007 76.7 81 27 2 52 .678 86.9 80 69 8 3 .149 96.2 55 50 3 2 .0911 76.0 54 53 0 1 .0212 79.2 94 83 7 4 .1213 79.5 70 60 5 5 .1414 73.4 45 43 2 0 .0415 72.8 103 56 32 5 .3616 78.6 29 27 1 1 .0717 54.3 40 24 4 12 .4019 60.4 45 32 2 11 .2922 68.9 83 40 28 15 .52Mean 76.9 61.7 45.1 7.9 8.1 .22s.d. 10.7 25.6 17.6 11.5 12.25 .196Note:BecauseasingledesigncanbebothaSetLossDesignandaRepeatedDesign,thesumofCorrect+Repeated+SetLossmaybelargerthanAttempted.Themaximumnumberofattempteddesignswaslimitedto105(35designsperresponsesheet).
D-KEFSVERBALFLUENCY
Table7showsthedatafortheD-KEFSVerbalFluencytask.Averaged
acrossparticipantstheLetterFluency(thenumberofwordsbeginningwitha
specificletter)across3trialsrangedfrom1to43(mean=14.00s.d.=9.35).
CategoryFluency(thenumberofwordsfromaspecificcategory)across3trials
rangedfrom4to36(mean=17.35s.d.=9.68).Intheswitchingcondition,the
53
totalnumberofitemsnamed(singletrial)rangedfrom1to12(mean=6.18and
s.d.=2.98)andthetotalnumberofswitchesrangedfrom0to12(mean=4.7and
s.d.=3.48).
Table7.
D-KEFSVerbalFluencydata
D-KEFSVerbalFluencyParticipant WAB-AQ Word
FluencyRatio
LetterFluencyTotal
CategoryFluencyTotal
SwitchFluencyTotal
SwitchesTotal
1 74.7 .26 7.00 13.00 5.00 1.002 81.0 .34 17.00 22.00 7.00 6.003 69.3 .55 9.00 5.00 3.00 1.004 85.2 .34 13.00 17.00 8.00 7.006 94.8 .28 14.00 24.00 8.00 7.007 76.7 .27 17.00 31.00 6.00 4.008 86.9 .39 18.00 19.00 9.00 8.009 96.2 .44 43.00 36.00 7.00 6.0011 76.0 .31 16.00 24.00 7.00 6.0012 79.2 .34 20.00 26.00 11.00 10.0013 79.5 .36 19.00 23.00 12.00 12.0014 73.4 .40 7.00 7.00 5.00 4.0015 72.8 .25 8.00 16.00 2.00 .0016 78.6 .39 16.00 17.00 6.00 3.0017 54.3 .14 1.00 4.00 3.00 2.0019 60.4 .60 9.00 4.00 5.00 3.0022 68.9 .28 4.00 7.00 1.00 .00Mean 76.9 .35 14.00 17.35 6.18 4.7s.d. 10.7 .11 9.35 9.68 2.98 3.48
D-KEFSTWENTYQUESTIONSTEST.
DatafortheD-KEFSTwentyQuestionsTestarepresentedinTable8.All
datarepresentthetotalacross4trials.Participant14wasunabletoachievetasks
set.Thetotalnumberofquestionsaveraged33.38questions(s.d.=19.84)witha
54
rangeof16to80(themaximum).Theweightedabstractionsscoresforthefirst
questionaveraged21.63(s.d.=14.47)witharangeof0to53.Totaledacross4
trials,weightedachievementscoresaveraged13.69(s.d.=5.87)witharangeof0
to20.
Table8.
D-KEFSTwentyQuestionsTestdataforStandardAdministration.
TwentyQuestionsTestParticipant WAB-AQ TotalQuestions Weighted
AbstractionWeighted
Achievement1 74.7 35 11 142 81.0 49 14 93 69.3 30 4 154 85.2 18 32 206 94.8 21 25 187 76.7 19 36 158 86.9 25 32 169 96.2 25 53 1811 76.0 16 32 1712 79.2 25 32 1613 79.5 34 14 1314 73.4 . . .15 72.8 80 0 016 78.6 28 22 1517 54.3 26 16 1619 60.4 80 0 022 68.9 23 23 17Mean 76.9 33.38 21.63 13.69s.d. 10.7 19.84 14.47 5.87Note:Participant14wasunabletocompleteanytrialsoftheTQT
55
D-KEFSCARDSORTTEST
TheD-KEFSCardSortdatawasnotanalyzedbecausemanyparticipantsrequiredalot
ofassistancetoachievetasksetand/ortoaccuratelyexplainthecardgroupingsandthe
interventionbytheexaminerhadanundueinfluenceontheresults.
TORRANCETESTOFCREATIVETHINKING
TheTorranceTestofCreativeThinkingwasalsonotanalyzedbecauseparticipantshad
difficultiesachievingandmaintainingtaskset.Forexample,participant2beganthe
ProductImprovementtaskbut,withtime,morphedthetaskintoastory-tellaboutthe
stuffedtoy.Formanyparticipantsthetaskmorphedintoalistingtaskinwhichthey
itemizedspecificexamplesofanidea(e.g.“youcouldgiveitahat,gloves,atie,pants...”).
HYPOTHESESRELATEDTOSELF-REPORTEDFUNCTIONALCOMMUNICATION
HYPOTHESIS1A:SELFREPORTEDFUNCTIONALCOMMUNICATIONWOULDBECORRELATEDWITH
APHASIASEVERITY.
TherelationshipbetweenWAB-AQscoresandpatient-reportedfunctional
communicationwasnotsignificant(F(1,15)=.022;p=.884).Inaddition,therewereno
significantrelationshipsbetweenself-reportedACOMscoresandanyWAB-Rsubtest
measuresortheBNT-2(Table9).
56
Table9.
PearsoncorrelationsforSelf-reportedACOMscoresandWAB-R(withsubtests)andBNT-2
measures(n=17).
Self-reportedACOM
Pvalues
WesternAphasiaBattery(WAB-AQ) r=.038 p=.884SpontaneousSpeech r=.076 p=.770Fluency r=.162 p=.534AuditoryComprehension r=-.016 p=.952SequentialCommands r=-.009 p=.973Repetition r=-.195 p=.453Naming r=.059 p=.823CategoryFluency r=.086 p=.741
BostonNamingTest(BNT-2) r=.097 p=.713
Figure2 (leftpanel) showsascatterplotof self-reportedACOMratings in relation to
categoryfluencyscores.CategoryfluencyisasubtestoftheWAB-Randrepresentsthetotal
numberanimalsnamedin60seconds(excludingrepetitions).
Figure3 (leftpanel) showsascatterplotof self-reportedACOMratings in relation to
namingscores.NamingisasubtestoftheWAB-R.NotethatwhileParticipant17’sNaming
subtestwasanoutlier(score=3.6),ananalysisofthedatawithouthisscoredidnotchange
thepatternofresults.(ThespecificscatterplotsshowninFigures2and3chosenbecause
theyarerelevantforcomparisontoresultspresentedbelow).
HYPOTHESIS1B:SELF-REPORTEDFUNCTIONALCOMMUNICATIONWOULDBECORRELATEDWITH
COGNITION
APearsoncorrelationcoefficientmatrixwasgeneratedtoinquireabouttheassociation
betweenself-ratedfunctionalcommunicationandimpairment-basedmeasuresofnon-
57
verbalcognition.Self-reportedfunctionalcommunication(ACOMT-scores)was
significantlycorrelatedwithdesignfluencyerrors(timed)(Table10).
Table10.
CorrelationmatrixforSelf-ratedACOMandcognitionscores.
1. 2. 3. 4. 5. 6.
1.Self-RatedACOMTSCORE
Pearson’sr 1 Sig.(2-tailed)
2.DesignFluencyErrors-Timed
Pearson’sr -.700** 1 Sig.(2-tailed) .002
3.DesignFluencyProp.Errors-Untimed
Pearson’sr -.343 .823** 1 Sig.(2-tailed) .178 0
4.TQTTotalAbstraction
Pearson’sr .080 -.031 -.139 1 Sig.(2-tailed) .769 .910 .608
5.TQTTotalQuestions
Pearson’sr -.144 .162 .218 -.719** 1 Sig.(2-tailed) .594 .550 .416 2
6.TQTWeightedAchievement
Pearson’sr .187 -.214 -.291 .718 -.981 1Sig.(2-tailed) .488 .425 .274 2 0
**.Correlationissignificantatthe0.01level(2-tailed).*.Correlationissignificantatthe0.05level(2-tailed).
Self-ratedfunctionalcommunicationwaspredictedbasedonerrorscommittedonthe
designfluencytest(r=.71,p=.002)butnotbasedonanyoftheTQTmeasures(Table10).
Figure4(leftpanel)showsascatterplotofself-reportedACOMratingsinrelationto
designfluencyerrors.DesignFluencyErrorsisthetotalnumberofsetlossandrepetition
errorsinthetimedcondition(60seconds).
Figure5showsascatterplotofself-reportedACOMratingsinrelationtotheproportion
oferrorsontheuntimedversionofthedesignfluencytask.Proportionoferrorsisthe
58
ratiooftotalerrors(setlossandrepetition)dividedbythetotalnumberofdesignsinthe
untimedcondition.Thereisalsoanegativerelationshipbetweentheproportionoferrors
committedontheuntimedversionofthedesignfluencytestandACOMself-ratings.
HYPOTHESIS1C:ALINEARREGRESSIONMODELPREDICTINGSELF-REPORTEDFUNCTIONAL
COMMUNICATIONUSINGBOTHAPHASIASEVERITYANDCOGNITIONWOULDACCOUNTFORSIGNIFICANTLY
MOREVARIANCETHANAMODELUSINGAPHASIASEVERITYALONE.
AmultiplelinearregressionwascalculatedtopredictACOMself-ratingsbasedonTotal
ErrorsandProportionofErrorsfromtheDesignFluencytask.Althoughthecorrelationof
self-reportedfunctionalcommunicationandproportionoferrorscommittedonthedesign
fluencytestwasnotsignificant(r=.343,p=.178),proportionoferrorswasauseful
predictorwhenaddedtoalinearregressionthatalsoincludeddesignfluencyerrors.A
significantlinearregressionequationwasfoundF(2,15)=13.53,p=1withanr2of.66
(adjustedr2=.61).Thatis,morethan60%ofthevarianceinACOMscorescouldbe
accountedforwithinformationaboutthenumberandproportionofdesignfluencyerrors.
Tobettervisualizetherelationshipbetweentheleveloffunctionalcommunicationand
non-verbalcognitionwegroupedparticipantsintocategoriesbasedonACOMRatingsand
CognitionScores(Table11).Toaccomplishthis,atotalscoreontheACOMwasusedasa
groupingfactorwhereparticipantswhoreceivedbelowaverageT-scorescompriseda
moreseveregroup(n=5),participantswhoreceivedaveragescores(ACOMT-Scoreratings
50-60)comprisedanaveragegroup(n=5)andthosewhowereratedhigher(ACOMT-
Scoreratings>60)madeupthelessseveregroup(n=4).TocreategroupsbasedonHigh,
Normal,andLowcognitiveperformance,eachparticipant’sscaledscoresforthedesign
59
fluencytestwerereviewed.Ifoneormoreofthescaledscoreswas1standarddeviation
higherthanthenormativesample(13orhigher)thenthatparticipantswasgroupedinto
theHiCoggroup.Ifnoneofthescaledscoreswas1standarddeviationhigherorlower
thanthenormativesamplethenthatparticipantswasgroupedintotheNormalCoggroup.
Finally,ifanyofthescaledscores1ormorestandarddeviationlower(scores7orlower)
thanthenormativesamplethenthatparticipantwasgroupedintotheLowCoggroup.
Table11showsthatof8ofthe9participantswithHighCognitionalsohadhigherthan
averageACOMscores(89%)while3ofthe5participantswithLowCognitionalsohad
lowerthanaverageACOMscores(60%).
60
Table11.
BreakdownofparticipantsaccordingtocognitionlevelandACOMscores(cellsindicatethe
numberofparticipantsineachgroup).
HiACOM(>60)
AverageACOM(50-60)
LowACOM(<50)
HiCog(Atleastonescaledscores>1s.d.
abovenorm)
3 5 1
NormCog(Allscaledscoresbetween+/-1s.d.)
1 1 1
LowCog(Atleastonescaledscore1s.d.below
norm)
0 2 3
HYPOTHESESRELATEDTOPARTNER-REPORTEDFUNCTIONALCOMMUNICATION
HYPOTHESIS2A:PARTNER-REPORTEDFUNCTIONALCOMMUNICATIONWOULDBECORRELATED
WITHSELF-REPORTEDFUNCTIONALCOMMUNICATION.
TherewasnocorrelationbetweenPwA-reportedandPartner-reportedACOMscores(F
(1,15)=.723,p=.41,r=.222,r2=.049(adjustedr2=-.019).).Figure6showsthatthe
correlationmaybestrongerwhenACOMscoresarelowerbecausethereislarger
variabilityastheACOMscoresrise.
INTERRATERAGREEMENT(KAPPA)BETWEENSELF-RATEDANDPARTNER-RATEDACOMSCORES.
Tofurthercharacterizetheinter-rateragreementbetweenPwA-PartnerpairsaCohen’s
kappaanalysiswascomputedforeachpair(Fleiss&Cohen,1973).Cohen’skappaisthe
61
proportionofagreementcorrectedforchanceagreementbetweentworaters.Kappa
scoresrangefrom-1to+1withnegativevaluesindicatingapoorerthanchanceagreement,
zerovaluesindicatingchangeagreement,andpositivevaluesindicatingbetterthanchance
agreement(Viera&Garrett,2005).Table12showsthatthekappascoresinoursample
rangedfrom.013(slightagreement)to.391(fairagreement).Onaverage,agreementwas
lowwithameanof.141ands.d.of.135.P-values<.05wereobtainedinsevenoutof
sixteenpairs;thisindicatesthattheagreementinitem-levelACOMratingswassignificantly
betterthanwouldbeexpectedbychance.
Table12.
Cohen’skappascoresforeachPwA-Partnerpair.
Participant WAB-AQ Kappa p
1 74.7 0.032 0.5872 81.0 0.203 .00074 85.2 0.076 0.2076 94.8 0.295 .00007 76.7 0.050 0.5418 86.9 0.165 0.0409 96.2 0.081 0.03411 76.0 0.391 .000012 79.2 0.265 .000113 79.5 0.181 0.04014 73.4 -0.147 0.07415 72.8 0.16 0.02416 78.6 0.316 .000017 54.3 0.095 0.11619 60.4 0.013 0.86022 68.9 0.077 0.264
62
HYPOTHESIS2B:PARTNER-REPORTEDFUNCTIONALCOMMUNICATIONWOULDBECORRELATED
WITHAPHASIASEVERITYANDCOGNITION.
PARTNER-RATEDACOMSCORECORRELATIONSTOLANGUAGE.
Therewasanear-significantrelationshipbetweenWAB-AQscoresandpartner-
reportedfunctionalcommunication(F(1,14)=3.97;p=.07).Furtheranalysisrevealed
partner-reportedfunctionalcommunicationwashighlyrelatedto2subtestsoftheWAB-R
andtotheBostonNamingTest(Table13).Notethattherearehighcorrelationsamong
subtestmeasuresandtheBNT-2.
Alone,WAB-Rcategoryfluencyaccountedfor61.1percentofthevariance(adjustedr2
=.584);F(1,14)=22.033,p=0.(Figure2,right)
AlthoughNamingwasalsohighlycorrelatedwithpartnerACOMscores,addingitasa
secondpredictortothemodeldidnotproduceasignificantlylargechangeinexplained
variancetoadoptthe2-predictormodel(Fchange=2.18,p=.163)(Figure3,right).This
maybeduetotheintercorrelationbetweenNamingandWAB-Rcategoryfluency(r=.69,
p=2)(Figure3,right).
63
Table13.
CorrelationmatrixforPartner-reportedACOMscoresandlanguagemeasures.
1. 2. 3. 4. 5.1.PartnerACOM Pearson’sr 1 .
Sig.(2-tailed) N 16
2.WAB-AQ Pearson’sr .470 1 Sig.(2-tailed) .066 N 16 17
3.Naming(WAB-RSubtest)
Pearson’sr .711** .790** 1 Sig.(2-tailed) .002 .000 N 16 17 17
4.BNT-2 Pearson’sr .555* .906** .803** 1 Sig.(2-tailed) .026 .000 .000 N 16 17 17 17
5.CategoryFluency(WAB-R)
Pearson’sr .782** .639** .690** .660** 1Sig.(2-tailed) .000 .006 .002 .004 N 16 17 17 17 17
**.Correlationissignificantatthe0.01level(2-tailed).*.Correlationissignificantatthe0.05level(2-tailed).
PARTNER-RATEDACOMSCORECORRELATIONSTOCOGNITION.
APearsonCorrelationCoefficientmatrixwasgeneratedtoinquireaboutthe
associationbetweenpartner-ratedfunctionalcommunicationandimpairment-based
measuresnon-verbalcognition.Partner-reportedcommunicativeeffectiveness(ACOMT-
scores)wasnotcorrelatedwithnon-verbalcognition(Table14).Thesamplesizeforeach
correlationanalysiswas17exceptforthosethatincludedtheD-KEFSTwentyQuestions
Test,whichwas16,becausethevideodatawaslost.
64
Table14.
CorrelationmatrixforPartner-reportedACOMscoresandcognitivemeasures.
1. 2. 3. 4. 5. 6.1.PartnerACOM Pearson’sr 1 .
Sig. N 16
2.DesignFluencyErrors(Timed)
Pearson’sr -.171 1 Sig. .526 N 16 17
3.DesignFluencyProportionofErrors(Untimed)
Pearson’sr -.135 .823** 1 Sig. .617 .000 N 16 17 17
4.TQTTotalAbstraction
Pearson’sr .388 -.031 -.139 1 Sig. .154 .910 .608 N 15 16 16 16
5.TQTTotalQuestions
Pearson’sr -.217 .162 .218 -.719 1 Sig. .438 .550 .416 .002 N 15 16 16 16 16
6.TQTTotalWeightedAchievement
Pearson’sr .194 -.214 -.291 -.718 -.981 1Sig. .488 .425 .274 .002 .000 N 15 16 16 16 .16 16
**.Correlationissignificantatthe0.01level(2-tailed).*.Correlationissignificantatthe0.05level(2-tailed).
Incontrasttotheself-ratings,scatterplotsofthepartnerACOMratingsshowthat
partnerACOMscorescouldnotbepredictedbasedonthenumber(Figure4,right)or
proportionoferrors(Figure5,right)onthedesignfluencytest.
Unlikeself-reportedfunctionalcommunication,ACOMpartner-ratingscouldnotbe
predictedbasedontheDesignFluencytask:asimplelinearregressionwascalculatedto
predictACOMself-ratingsbasedonTotalErrorsandProportionofErrorsonthedesign
fluencytask.Anon-significantregressionequationwasfound(F(2,13)=.197,p=.823),with
anr2of.029.
65
HYPOTHESIS2C:ALINEARREGRESSIONMODELPREDICTINGPARTNER-REPORTEDFUNCTIONAL
COMMUNICATIONUSINGBOTHAPHASIASEVERITYANDCOGNITIONWOULDACCOUNTFORSIGNIFICANTLY
MOREVARIANCETHANAMODELUSINGAPHASIASEVERITYALONE.
AstepwiselinearregressionwascalculatedtopredictACOMpartner-ratingsusingallof
theWAB-RsubtestsandtheBNT-2.Fromthis,atwo-factormodelincludingWAB-R
CategoryFluencyandWAB-RFluencyaccountedfor74.7percentofthevariance(adjusted
r2=.697);F(2,13)=18.235,p=.000.TheremainderoftheWAB-Rsubtestswereexcluded
fromthemodel:WAB-AQ,SpontaneousSpeech,AuditoryComprehension,Sequential
Commands,Repetition,andBNT-2.TherewasnocorrelationbetweenpartnerACOM
scoresandFluencyhoweverFluencybecomesareliablepredictoroncetheerror
associatedwithCategoryFluency/Namingisremoved.
TheverbalfluencytestontheD-KEFSissimilartotheWAB-Rcategoryfluencysubtest
andexplainsthesamevariance.However,condition3oftheD-KEFSVerbalFluencytest
assessesanadditionalfactor:categoryswitching.Categoryswitchingreferstothenumber
oftimestheparticipantcanmovebackandforthbetweentwocategories(e.g.vegetables
anditemsofclothing).AlinearregressionaddingSwitching(thenumberofcategory
switchesperformedin60seconds)asathirdpredictorresultedinasignificantmodel:
F(3,12)=17.581,p=.000.TheadditionofSwitchingasapredictorincreasedtheexplained
varianceto.815(adjustedr2=.768).Note:alinearregressionreplacingWAB-Rcategory
fluencywithDKEFSCategoryFluencywasalsosignificant:F(3,12)=7.782,p=.004.The
explainedvariancewas.595(adjustedr2=.566).
66
SUMMARYOFRESULTS
SelfandPartner-reportedACOMscoreswerenotcorrelated.Self-reportedfunctional
communicationwasunrelatedtomeasuresoflanguageimpairmentbutwasstrongly
relatedtoseveralmeasuresofnon-verbalcognition.Incontrast,partner-reported
functionalcommunicationwasunrelatedtomeasuresofnon-verbalcognitionbutwas
stronglyrelatedtoseveralmeasuresoflanguageimpairment.
67
CHAPTER5:
DISCUSSION
HYPOTHESESRELATEDTOSELF-REPORTEDFUNCTIONALCOMMUNICATION
HYPOTHESIS1A.SELFREPORTEDFUNCTIONALCOMMUNICATIONWOULDBECORRELATEDWITH
APHASIASEVERITY.
Onaverage,ourparticipantshadhigherthanaverageWAB-AQscoresbuttheACOM
scoresofthePwAandpartnerswerenotsignificantlydifferentfromthereferenceT-Score
meanof10(Hulaetal.,2015).Thisindicatesthatwhileourparticipantshadhigherthan
averageWAB-Rscores(Mean=76.94),theACOMscoresclusteraroundtheACOM
populationmean.Similarly,resultsfromtheBNT-2showedthatparticipants,asagroup,
demonstratedimpairedperformancerelativetoage-matchedneurologicallyintactnormals
(Tombaughetal.,1997;GoodglassandKaplan,1980).
Wefoundnocorrelationbetweenaphasiaseverityandself-ratedACOMscores.Inlight
ofpriorresearchshowingacorrelationbetweenself-reportedmeasuresandaphasia
severity,ourlackofcorrelationissurprising.
Thereareseveralpossibleexplanationsoftheseresults.First,itispossiblethatwedid
notshowacorrelationbetweenWAB-RscoresandACOMscoresbecause,byselecting
participantswhohadloweraphasiaseveritiesandhigherauditorycomprehension,we
limitedthevariabilityintheWAB-Rscores.Perhaps,giventhisrestrictedrange,the
68
predictivepowerofthelanguagemeasuressimplycouldnotbedetected.
Second,itispossiblethattherelationshipbetweenACOMandWAB-Risdifferentwhen
aphasiaislesssevere.OurstudyincludedpeoplewithWAB-AQscoresgreaterthan50
whileDoyleetal.’sstudyincludedWAB-AQsrangingfrom10to100(Figure7).Figure7
showsmorevariabilityforWAB-AQscoresgreaterthan50andraisesthequestionof
whethertherelationshipofWAB-AQtoACOMdifferswhenaphasiaislesssevere.Asimilar
patternofdataisreportedinLaska,Bartfai,Hellblom,Murray,&Kahan(2007).The
scatterplotofthedatashowsthatthedataisbestfitbyacurveratherthanalinebutco-
authorWillHulaattributesthechangeinslopetoaceilingeffectontheWAB-R.Thatis,
whenaphasiaismild,WAB-Rscorestop-outtherebycreatingpoorerfit.
Tofurtherpursuethehypothesisthattherelationshipbetweenaphasiaseverityand
ACOMscoresisdifferentwhenaphasiaislesssevere,werequestedafollow-upanalysisof
thisdatatoincludeonlythosepeoplewithWAB-AQscoresbetween55and100.This
resultedinasampleof71withamean=83.3ands.d.of13.1(W.Hula,personal
communication;January27,2015).Thecorrelationwas.67(r2=.449).Inotherwords,
thesedatashowthat45%ofthevarianceintheACOMcanbepredictedusingWAB-AQ;
leaving55%ofthevarianceunexplained.Hulaetal.(2015)acknowledgesthatthe
explanatoryvalueofaphasiaseverityislimited:“giventhataphasiaseverityaccountedfor
onlyapproximatelyhalfofthevarianceinACOMscores,itwillbenecessarytoinvestigate
otherpotentialdeterminantsofself-reportedcommunicativefunctioninginaphasia.”(pg.
917).
69
HYPOTHESIS1B.SELF-REPORTEDFUNCTIONALCOMMUNICATIONWOULDBECORRELATEDWITH
COGNITION.
Basedonpriorevidencethatfunctionalcommunicationisnotsolelydrivenbyaphasia
severity,wetestedthehypothesisthatvarianceinACOMscorescouldbepredictedbased
onnon-verbalcognition.Ourdatashowthatself-ratedfunctionalcommunicationishighly
relatedtoperformanceontheDesignFluencytest.Becausewesampledpeoplewithless
severeaphasia,weareunabletotellwhethercognitionisausefulpredictorovertheentire
rangeofaphasiaseveritiesorcognitionisusefulonlywhenlanguagedeficitsareless
severe.Itispossiblethatwhenaphasiaseverityisgreaterithasaproportionallylarger
effectonfunctionalcommunication.
DESIGNFLUENCYASAPREDICTOR
TheD-KEFSoffersnormsforindividualsfromages8to89usingascaledmeanof10
andstandarddeviationof3.Onthestandardadministration,ourparticipantsproduced
significantlyfewercorrectdesignsthanthenormativesamplewithage-scaledscoresfor
thenumberofcorrectdesignsrangingfrom3to10(mean=7.35ands.d.=2.12,t(16)=-
5.149,p=.000).Althoughnotsignificant,theage-scaledscoresforthenumberofattempted
designswerealsolower(Range3-16;mean=8.53,s.d.=2.94,t(16)=-2.063,p=.056).Thus,
althoughoursampleattemptedfewerdesigns,itdidnotsignificantlydifferfromthe
normativesample.Itispossiblethatthetendencytoproducefewerdesignsreflects
diminishedprocessingspeedormotor-speeddeficitsduetousinganon-preferredhand
whendrawingthedesigns.
70
OurfindingthatPwAwhocommitmoredesignfluencyerrorsreportthattheir
functionalcommunicationispoorerthanthosewhodonotcommitsucherrorsisnew.No
priorstudiesusingtheACOMhaveexaminednon-verbalcognitionasapredictor.
Todowellonthestandard(timed)versionoftheDesignFluencytaskonemust
workquicklywhilemaintainingtasksetandavoidingrepetitions.Interestingly,category
fluency(asubtestoftheWAB-R)didnotcorrelatewithACOMscoresdespiteclaimsthat
categoryfluencyalsorequiresspeed,self-monitoring,andtask-setmaintenance.The
designfluencytaskdiffersfromcategoryfluencyintermsofthelanguageload,the
persistenceoftheevokingstimulus(dotsonthepage),andmemoryload(designscanbe
reviewed).Thesedifferencesshouldbeexploredfurther.
Thisstudyalsoemployedanewversionofthedesignfluencytestthatallowed
unlimitedtimetoproducedesigns.Theuntimedversioncapturedmoreinformationabout
repetitionsandset-losserrors.KeilandKazniak(2002)havesuggestedthatdesignfluency
errorsreflectpoorerself-monitoringskillsandaninabilitytotrackandcomplywith
environmentalconstraints.Thefactthatthepeoplewhocommitmoreerrorsonthe
DesignFluencytaskarealsoreportingpoorerfunctionalcommunicationimpliesthatthey
areawareoftheirdeficitsbutunabletoavoidtheirerrors.Thisimpliesadistinction
betweenself-awarenessandself-controlsuchthatoutparticipantsrealizethattheymake
mistakesbutcannotpreventthem.
TWENTYQUESTIONSTESTASAPREDICTOR
Asagroup,participantsperformednormallyonthetwentyquestionstestwhen
comparedtoage-matchednorms.Onaverage,ourparticipantsaskedaboutthesame
numberofquestionsacrossthefourtrialsasthenormativesamplebutwithalarger
71
variability(t(15)=.109,p=.91.).Scaled-scoresfortotalnumberofquestionshadamean=
8.69ands.d.=3.32.
Relatedtotheabstractnessofthefirstquestions,ourparticipantseliminated
slightlyfewerobjectswiththeirfirstquestionthanthenormativesample.Age-scaled
abstractionscoresrangingfrom4to16butthedifferencewasnotstatisticallydifferent
fromthescaledmeanof10(mean=8.69,s.d.=3.32,t(15)=-1.581,p=.135.).
Similarly,totalweightedachievementscoreswerenotsignificantlydifferentfrom
thenormativesample.Scaled-scoresforweightedachievement(untimedmean=10.50,s.d.
=4.46,t(15)=.449,p=.66.)wereveryclosetothescaledmeanof10.
Interestingly,unlikeanotherstudyinvolvingpeoplewithtraumaticbraininjury
(Marshall,Karow,Morelli,Iden,&Dixon,2003),ourparticipantsdidnotimproveinthe
TQTacrosstrials.Fewpeopleswitchedquestionstrategiesacrossthetrialsinorderto
improveefficiency(e.g.iftheyusedacolorstrategytheyrarelyswitchedtoanother
strategyonlatertrialsevenifadifferentstrategywasmoreefficient).
TQTwasnotusefulasapredictorofself-reportedfunctionalcommunicationas
noneoftheTQTmeasuresloadedinthelinearregression.TheTQTtestmaynothavebeen
usefulforanumberofreasons.First,thetaskisafamiliarchildhoodgameandperhapsour
participantsreliedonpriorexperiencewhendoingthetask.Thiswouldmeanthatthetest
ismoreanassessmentofmemorythannovelproblemsolvingandwouldexplainage-
normalperformance.Second,itispossiblethattheTQTsimplydoesnotassesstheaspects
ofcognitionthataremostaffectedinthispopulation.
72
HYPOTHESIS1C.ALINEARREGRESSIONMODELPREDICTINGSELF-REPORTEDFUNCTIONAL
COMMUNICATIONUSINGBOTHAPHASIASEVERITYANDCOGNITIONWOULDACCOUNTFORSIGNIFICANTLY
MOREVARIANCETHANAMODELUSINGAPHASIASEVERITYALONE.
Ouroriginalexpectationwasthatalinearregressiontopredictpartner-reported
ACOMscoreswouldfindpredictivevalueinbothaphasiaseverityandcognitionmeasures.
However,noneofthelanguagemeasureswerereliablepredictorsofself-reportedACOM
scores.
Weidentifiedatwofactorlinearregressionmodelthataccountedfor66%ofthe
varianceinself-reportedACOMscores.Thepredictivevaluesoftwocognitionsubtests,
TotalErrorsandProportionofErrorsfromtheDesignFluencytasksupportstheclaimthat
functionalcommunicationisdriven,atleastinpart,bycognitivestatus.
HYPOTHESESRELATEDTOPARTNER-REPORTEDFUNCTIONALCOMMUNICATION
HYPOTHESIS2A.PARTNER-REPORTEDFUNCTIONALCOMMUNICATIONWOULDBECORRELATED
WITHSELF-REPORTEDFUNCTIONALCOMMUNICATION.
Wefoundnocorrelationbetweenself-andpartner-reportedACOMscores.Thiswas
unexpectedgivenpriorresearchshowingagreementbetweenpatientandproxyreported
outcomes.Ourselectionofparticipantswithrelativelylesssevereaphasiasmaybe
impactingthecorrelation.ThisissupportedbySegal&Schall(1994)whofoundthat
correlationofscoreswassubstantiallyweakerwhenagroupoflessseverelyimpaired
survivorswasconsideredseparately.
Ourfindingssuggestthatthepatient’sexperienceofaphasiamaybedifferentthan
whatcanbesurmisedbyacommunicationpartner.Thatis,partnersmaybeinterpreting
73
theACOMitemsdifferentlyorbasingtheirjudgmentsondifferentaspectsofbehavior.This
raisessomesignificantquestionsabouttheusefulnessofPROmeasureswhentheycannot
beobtaineddirectlyfromthePwA.Forexample,apartnermaynotappreciatethe
differencesbetweenwhatthepersonwithaphasiawants/intendstocommunicateand
whathe/sheactuallyconveys.Thesefindingsimplythatusingproxy-reportedratingsasa
replacementforpatientratingsattheleveloftheindividualpatientmaybeproblematic.
However,itmaystillbeusefultousebothpatientandpartnerratingsoffunctional
communicationtoformamorecompleteimpressionoftheoverallrecoveryenvironment
(Hesketh,Long,&Bowen,2011).
HYPOTHESIS2B.PARTNER-REPORTEDFUNCTIONALCOMMUNICATIONWOULDBECORRELATED
WITHAPHASIASEVERITYANDNON-VERBALCOGNITION.
Thisstudyfoundasignificantcorrelationbetweenpartner-reportedfunctional
communicationandaphasiaseveritybutnotwithnon-verbalcognition.Partnersappearto
bejudgingfunctionalcommunication,atleastinpart,basedonhowreadilytheirpartner
canfindthewordshe/sheneeds.ThissuggeststhatthepartnersofPwAmaybeunaware
ofreceptivelanguageproblemsandcognitionissuesthattheirpartnersexperiencein
everydayactivities.Thefindingthatobservablelanguageperformance(especiallycategory
fluencyandnaming)ishighlypredictiveofpartnerratingsisconsistentwithfindingsfrom
otherstudiesthathighlyobservablebehaviorstendtodrivepartnerratings(Visser-Keizer,
Jong,Deelman,Berg,&Gerritsen,2002).
TheperspectiveofthePwAincludesinternalinformationaboutintention,
motivation,andself-awareness.Anoutsider’sinformationisbasedoninteractionswith
thePwAandobservationsoftheirbehavior.Anoutsidersperspectivewillbedetermined
74
bytheirownworldviewandunderstandingofaphasia.Cliniciansaretrainedtoevaluate
behaviorintermsoflanguageandcognition.So,anSLPismorelikelytospotissuesrelated
toinattention,short-termmemorydeficits,executivefunctiondeficits,etc.Incontrast,
manypartnersandcaregiversofPwAreceivelittleornoinformationabouttheimpactsof
strokeand/oraphasiabeyondbriefdefinitions.Itfollowsthatapartnermightattribute
behaviorstolanguagedeficitsthat,infact,arebetterexplainedintermsofcognition
deficits.Thisisnottosaythatallpartnerslackanunderstanding.However,theinterplay
betweencognitionandlanguageisnoteasilyseparableand,giventhelackofeducationand
trainingrequiredtoisolatethem,itiseasytounderstandwhypartnersmightnotidentify
cognitionissuesinthePwA.
HYPOTHESIS2C.ALINEARREGRESSIONMODELPREDICTINGPARTNER-REPORTEDFUNCTIONAL
COMMUNICATIONUSINGBOTHAPHASIASEVERITYANDCOGNITIONWOULDACCOUNTFORSIGNIFICANTLY
MOREVARIANCETHANAMODELUSINGAPHASIASEVERITYALONE.
Aswithself-reportedACOMscores,ouroriginalexpectationwasthatpartner-
reportedACOMscoreswouldbepredictedbasedonbothaphasiaseverityandcognition.
However,noneofthecognitionmeasureswerereliablepredictorsofpartner-reported
ACOMscores.
Weidentifiedathreefactorlinearregressionmodelthataccountedfor82%ofthe
varianceinpartner-reportedACOMscores.Thepredictivevaluesofthreelanguage
subtests,WAB-RCategoryFluency,WAB-RFluency,aD-KEFSSwitchinglendssupportto
theclaimsthatpartnersrelymoreheavilyonobservablefeaturesofspeechandlanguage
whenassessingfunctionalcommunication.
75
IMPLICATIONS
TheACOMprovedtobeavaluabletooltoobtainvalidandefficientinformationabout
functionalcommunicationdirectlyfromthepersonwithaphasia.Thepresentstudy
suggeststhatfunctionalcommunicationratingsbypatientsandpartnersarebasedon
differentunderlyingvariables.Inoursampleofpeoplewithlesssevereaphasia,PwA
appeartobesensitivetodeficitsrelatedtonon-verbalperformancesuchasattention,self-
monitoring,task-setmaintenance,andspeed.Incontrast,partnersappeartobesensitiveto
observabledeficitsoflanguagesuchasnamingandfluency.
Ourfindingsraisesomeinterestingquestionsaboutthevalueofpartnerratingswhen
assessingfunctionalcommunicationinaphasia.Functionalcommunicationisaboutthe
interactionbetweenthePwAandothers.Thatis,thereisalwaysatleastoneotherperson
involved.TheACOMasksthepartnertoprovidetheirownopinionofthe“effectiveness”of
interactions(thattheyparticipateinorobserve)ratherthanactasasurrogateinwhich
theyguesshowthePwAwouldratehim/herself.Ourfindingthatpartner-ratingsdonot
correlatewithself-ratingsaffirmsthestancethatpartnerreportsconstituteavalid
perspectiveintheirownright,regardlessoftheircorrespondencewithpatients’ratings.
Furthermore,ourresultsprovidesomeinsightsintothefactorsthatcontributetothe
differingperspectives.
Extendedtoclinicalcontexts,theseresultssuggestthatcognitionisanimportantfactor
determininghowPwAperceivetheeffectivenessoftheirowneverydayinteractionsand
furtherstressestheimportanceofaddressingcognitionintheevaluationandmanagement
ofpersonswithaphasia.Clinically,thesefindingsimplythatPwAandpartnersmayjudge
treatmentqualitydifferentlybasedonwhichbehaviorsarechangedbytreatment.
76
Partnersmayratefunctionalcommunicationhigheriftreatmentimprovesobservable
languagebehaviors(e.gwordfindingerrorsanddelays)whileaPwAmayratefunctional
communicationhigheriftheabilitytoself-monitor,inhibiterrors,andcognitiveflexibly
improved.Furthermore,thesedataimplythattreatmenttoimprovestandardizedlinguistic
testingscores(suchastheWAB-R)mightnotresultinchangesthatclient’sregardas
functionallyrelevant.
Expandingfromtheseresults,ourdatasuggestthat,forpeoplewithmildtomoderate
aphasia,successfultreatmentofcognitivedeficitsmightproducelargergainsinself-
reportedfunctionalcommunicationthantreatmentsthattargetlanguageimpairments
alone.Perhapsthereisaleveloflanguagethat,onceachieved,issufficienttosupport
functionalcommunicationandthefocusoftreatmentshouldshifttofactorsimpacting
cognition.WemusthoweveracknowledgethatwhileACOMself-ratingsarecorrelatedwith
cognition,acausalrelationshipcannotbeinferredfromthepresentdata.
STUDYLIMITATIONS
Theresultsofthisinvestigationmustbeconsideredwithinthecontextofthefollowing
limitations.First,thestudysamplesizeissmall.Itwouldbeveryinformativetofurther
analyzewhethercertainfunctionalcommunicationtasksaremorerelatedtocognitionbut,
giventhesamplesize,thisanalysiscouldnotbecompleted.Secondareconcernsaboutthe
recruitingpool.OurparticipantswererecruitedusingcontactswithSLPproviders.This
meansthattheparticipantswereeitherreceivingongoingrehabilitationservicesorhad
receivedservices.Thefactthatparticipantswerereceivingservicesimpliesthattheywere
abletodrive,navigatepublictransportationservices,orhadapartner/caregiverwho
77
assistedthem.Inaddition,thesepeoplewereeitherabletofundongoingtreatmentorhad
accesstofreeaphasiaresourcesintheircommunities.Thesepeoplearepotentially
differentfromindividualswithaphasiawhohavenotreceivedextensivetherapyservices
andthereforeourresultsmaynotbegeneralizabletoindividualswhoselanguageand
physicalstatus,financial,orsocialsupportsprecludetheirparticipationincommunity
activities.Finally,byspecificallyrecruitingpeoplewithlesssevereaphasiaincluding
relativelyintactauditorycomprehension,thesedatamightnotapplytoothers.
GENERALCONCLUSIONS
PROmeasuresgivethepatientadirectvoicetosayhowtheyareaffectedbyaphasia.
Thisstudycorrelatedimpairment-basedmeasuresoflanguageandcognitionwithselfand
partner-reportedfunctionalcommunication.
Ourgeneralfindingswere:
• Whenpeoplewithmildtomoderateaphasiaratedtheirownfunctional
communication,theseratingscorrelatedwithnon-verbalcognitionandnotwith
aphasiaseverity.
• Theratingsoffamilymembersorcaregiversdidnotalignwithpatientratings.
• Partner-ratingsdidnotcorrelatewiththesameimpairmentmeasuresasthe
patient-reportedoutcomes.Instead,aphasiaseveritywashighlypredictivewhile
non-verbalcognitionwasnot.
Ourfindingssuggestoneoftwothings:1)thatself-reportedfunctional
communicationismorecloselyrelatedtonon-verbalcognitionthanitistolanguagelevel
or2)thatbyrestrictingtherangeofWAB-Rscoreswe,ineffect,controlledfortheeffectof
78
languagethatwouldbeotherwisepresentandbothaphasiaseverityandcognitionare
factorsinACOMselfratings.MoredatawithalargerrangeofWAB-AQscoreswould
differentiatebetweenthesetwoexplanations.
Thisstudysuggeststhatself-reportedmeasuresandpartner-reportedmeasuresarenot
interchangeablebuteachprovidesauniquelyvalidperspectiveabouttheimpactofaphasia
ontheindividual.
Bycorrelatingimpairment-basedmeasuresoflanguageandcognitionwithselfand
partner-reportedfunctionalcommunication,weshowedthatpartnersappeartojudge
functionalcommunication,atleastinpart,basedonhowreadilythePwAcanfindthe
wordshe/sheneeds.Thisfindingisnot,inandofitself,surprising.Whatissurprisingis
thatPwAdonotappeartobeusingword-findingdifficultyandverbalfluencywhenjudging
theirowncommunicativeeffectiveness.Thisstudyalsofoundthatwhileself-reported
communicativeeffectivenesscouldbepredictedbasedonnon-verbalcognition,partner-
reportedcommunicativeeffectivenesscouldnot.Itappearsthatindividualswithaphasia
assesstheirowncommunicativeeffectivenessintermsoflessobservablebehaviorsthat
aremorerelatedtocognitivefunctionthanaphasiaseverity.Theimplicationisthatthetwo
groupsmaybeusingverydifferentcriteriatojudgecommunicativeeffectiveness.Thefact
thatpatient-reportscorrelatetocognitiondeficitsthatpartnersfailtorecognizeisa
significantfindingandraisesseriousquestionsabouttheuseofsurrogateraterswhen
collectingPROdata.
Furtherresearchiswarrantedtoexploretherelationshipoffunctionalcommunication
withlanguageandcognition.Thedifferencesinexplanatorypowerbetweencategory
fluencyanddesignfluencyacrossthetwosubjectgroupsareespeciallyinteresting.Given
79
thatcategoryfluencyhasbeenusedasbothatestofaphasiaandasatestofexecutive
functionbutitfailedtocaptureanyvarianceinself-reportedfunctionalcommunication
demandsfurtherinvestigation.
Futurestudiesshouldalsoexaminetheinterplayoflanguageandcognitionon
treatmenteffectsandhowtheygeneralizetochangesinfunctionalcommunication.
80
REFERENCES
Almeida,L.S.,Prieto,L.P.,Ferrando,M.,Oliveira,E.,&Ferrándiz,C.(2008).TorranceTest
ofCreativeThinking:Thequestionofitsconstructvalidity.ThinkingSkillsand
Creativity,3(1),53-58.
AmericanSpeech-Language-HearingAssociation.(2013).ASHASLPHealthCareSurvey
2013:OutcomeMeasures.Availablefromwww.asha.org.
AmericanSpeech-Language-HearingAssociation.(2016).Aphasia:Overview.Retrieved
fromhttp://www.asha.org/Practice-Portal/Clinical-Topics/aphasia/
Andresen,E.M.,Vahle,V.J.,&Lollar,D.(2001).Proxyreliability:health-relatedqualityof
life(HRQoL)measuresforpeoplewithdisability.QualityofLifeResearch,10(7),
609-619.
Bakheit,A.M.O.,Carrington,S.,Griffiths,S.,&Searle,K.(2005).HighscoresontheWestern
AphasiaBatterycorrelatewithgoodfunctionalcommunicationskills(asmeasured
withtheCommunicativeEffectivenessIndex)inaphasicstrokepatients.Disability
andRehabilitation,27(6),287-291.
Baldo,J.V.,Dronkers,N.F.,Wilkins,D.,Ludy,C.,Raskin,P.,&Kim,J.(2005).Isproblem
solvingdependentonlanguage?.Brainandlanguage,92(3),240-250.
Baldo,J.V.,Shimamura,A.P.,Delis,D.C.,Kramer,J.,&Kaplan,E.(2001).Verbalanddesign
fluencyinpatientswithfrontallobelesions.JournaloftheInternational
NeuropsychologicalSociety,7(05),586-596.
81
Barrett(2009)Rose-coloredanswers:Neuropsychologicaldeficitsandpatient-reported
outcomesafterstroke.BehaviouralNeurology22(2009/2010)17–2317.DOI
10.3233/BEN-2009-0250.
Brookshire,R.H.,&Nicholas,L.E.(1995).Relationshipofwordfrequencyinprinted
materialsandjudgmentsofwordfrequencyindailylifetoBostonNamingTest
performanceofaphasicadults.ClinicalAphasiology,107-119.
Caspari,I.,Parkinson,S.R.,LaPointe,L.L.,&Katz,R.C.(1998).Workingmemoryand
aphasia.Brainandcognition,37(2),205-223.
Cella,D.,Hahn,E.A.,Jensen,S.E.,Butt,Z.,Nowinski,J.,&Rothrock,N.(2012).
MethodologicalIssuesintheSelection,AdministrationandUseofPatient-Reported
OutcomesinPerformanceMeasurementinHealthCareSettings.Washington,DC:
NationalQualityForum(NQF).
Christensen,S.C.,&Wright,H.H.(2010).Verbalandnon-verbalworkingmemoryin
aphasia:Whatthreen-backtasksreveal.Aphasiology,24(6-8),752-762.
Chue,W.L.,Rose,M.L.,&Swinburn,K.(2010).ThereliabilityoftheCommunication
DisabilityProfile:Apatient-reportedoutcomemeasureforaphasia.Aphasiology,
24(6-8),940-956.
Davis,K.,Schoenbaum,S.C.,&Audet,A.M.(2005).A2020visionofpatient-centered
primarycare.Journalofgeneralinternalmedicine,20(10),953-957.
Delis,D.C.,Kaplan,E.,&Kramer,J.H.(2001).Delis-Kaplanexecutivefunctionsystem(D-
KEFS).ExaminersManual.PsychologicalCorporation.
Delis,D.C.,Kaplan,E.,&Kramer,J.H.(2001b).Delis-Kaplanexecutivefunctionsystem:
Technicalmanual.PsychologicalCorporation.
82
deRiesthal,M.,&Ross,K.B.(2015).Patientreportedoutcomemeasuresinneurologic
communicationdisorders:Anupdate.SIG2PerspectivesonNeurophysiologyand
NeurogenicSpeechandLanguageDisorders,25(3),114-120.
Doyle,P.J.,Hula,W.D.,Hula,S.N.A.,Stone,C.A.,Wambaugh,J.L.,Ross,K.B.,&Schumacher,
J.G.(2013).Self-andsurrogate-reportedcommunicationfunctioninginaphasia.
QualityofLifeResearch,22(5),957-967.
Doyle,P.J.,Hula,W.D.,McNeil,M.R.,Mikolic,J.M.,&Matthews,C.(2005).Anapplicationof
Raschanalysistothemeasurementofcommunicativefunctioning.JournalofSpeech,
Language,andHearingResearch,48(6),1412-1428.
Doyle,P.J.,McNeil,M.R.,Bost,J.E.,Ross,K.B.,Wambaugh,J.L.,Hula,W.D.,&Mikolic,J.M.
(2007).TheBurdenofStrokeScale(BOSS)providedvalid,reliable,andresponsive
scoreestimatesoffunctioningandwell-beingduringthefirstyearofrecoveryfrom
stroke.QualityofLifeResearch,16(8),1389-1398.
Doyle,P.J.,McNeil,M.R.,Le,K.,Hula,W.D.,&Ventura,M.B.(2008).Measuring
communicativefunctioningincommunity-dwellingstrokesurvivors:Conceptual
foundationanditemdevelopment.Aphasiology,22(7-8),718-728.
Duncan,P.W.,Horner,R.D.,Reker,D.M.,Samsa,G.P.,Hoenig,H.,Hamilton,B.,...&Dudley,
T.K.(2002).Adherencetopostacuterehabilitationguidelinesisassociatedwith
functionalrecoveryinstroke.Stroke,33(1),167-178.
Erickson,R.J.,Goldinger,S.D.,&LaPointe,L.L.(1996).Auditoryvigilanceinaphasic
individuals:Detectingnonlinguisticstimuliwithfullordividedattention.Brainand
Cognition,30(2),244-253.
83
Fleiss,J.L.,&Cohen,J.(1973).Theequivalenceofweightedkappaandtheintraclass
correlationcoefficientasmeasuresofreliability.Educationalandpsychological
measurement.
Fillingham,J.K.,Sage,K.,&LambonRalph,M.A.(2005a).Furtherexplorationsandan
overviewoferrorlessanderrorfultherapyforaphasicword-findingdifficulties:The
numberofnamingattemptsduringtherapyaffectsoutcome.Aphasiology,19,597–
614.
Fillingham,J.K.,Sage,K.,&LambonRalph,M.A.(2005b).Treatmentofanomiausing
errorlessversuserrorfullearning:Arefrontalexecutiveskillsandfeedback
important?InternationalJournalofLanguage&CommunicationDisorders,40,505–
523.
Fillingham,J.K.,Sage,K.,&LambonRalph,M.A.(2006).Thetreatmentofanomiausing
errorlesslearning.NeuropsychologicalRehabilitation,16,129–154.
Frattali,C.M.,Thompson,C.M.,Holland,A.L.,Wohl,C.B.,&Ferketic,M.M.(1995).The
FACSoflifeASHAfacs--afunctionaloutcomemeasureforadults.Asha,37(4),40-46.
Fridriksson,J.,Nettles,C.,Davis,M.,Morrow,L.,&Montgomery,A.(2006).Functional
communicationandexecutivefunctioninaphasia.Clinicallinguistics&phonetics,
20(6),401-410.
Frost,M.H.,Reeve,B.B.,Liepa,A.M.,Stauffer,J.W.,&Hays,R.D.(2007).WhatIsSufficient
EvidencefortheReliabilityandValidityofPatient-ReportedOutcomeMeasures?.
ValueinHealth,10(s2),S94-S105.
84
Fucetola,R.,&Connor,L.T.(2014).Familyratingsofcommunicationlargelyreflect
expressivelanguageandconversation-levelabilityinpeoplewithaphasia.American
JournalofSpeech-LanguagePathology,1-8.
Gerritsen,M.J.,Berg,I.J.,Deelman,B.G.,Visser-Keizer,A.C.,&Jong,B.M.D.(2003).Speed
ofinformationprocessingafterunilateralstroke.Journalofclinicalandexperimental
neuropsychology,25(1),1-13.
Grant,D.A.,&Berg,E.A.(1993).WisconsinCardSortingTest(WCST).PAR.Chicago.
Helm-Estabrooks,N.(2002).Cognitionandaphasia:Adiscussionandastudy.Journalof
CommunicationDisorders,35,171–186.
Hesketh,A.,Long,A.,Bowen,A.,&onbehalfoftheACTNoWResearchStudy.(2011).
Agreementonoutcome:Speaker,carer,andtherapistperspectivesonfunctional
communicationafterstroke.Aphasiology,25(3),291-308.
Hilari,K.,Byng,S.,Lamping,D.L.,&Smith,S.C.(2003).Strokeandaphasiaqualityoflife
scale-39(SAQOL-39)evaluationofacceptability,reliability,andvalidity.Stroke,
34(8),1944-1950.
Hinckley,J.,&Carr,T.(2005).Comparingtheoutcomesofintensiveandnon-intensive
context-basedaphasiatreatment.Aphasiology,19(10-11),965-974.
Hinckley,J.,&Nash,C.(2007).Cognitiveassessmentandaphasiaseverity.Brainand
Language,103(1),195-196.
Holland,A.(1982).Observingfunctionalcommunicationofaphasicadults.Journalof
SpeechandHearingDisorders,47,50–56.
Holland,A.,Frattali,C.,&Fromm,D.(1998).Communicativeactivitiesofdailyliving—
Secondedition(CADL-2).
85
Homack,S.,Lee,D.,&Riccio,C.A.(2005).Testreview:Delis-Kaplanexecutivefunction
system.JournalofClinicalandExperimentalNeuropsychology,27(5),599-609.
Hula,W.D.,Doyle,P.J.,Stone,C.A.,Hula,S.N.A.,Kellough,S.,Wambaugh,J.L.,...&Jacque,
A.S.(2015).Theaphasiacommunicationoutcomemeasure(ACOM):
Dimensionality,itembankcalibration,andinitialvalidation.JournalofSpeech,
Language,andHearingResearch,58(3),906-919.
Hula,W.D.,KelloughS.,&Doyle,P.J.(May2015).ReliabilityandValidityofAdaptiveand
StaticShortFormsoftheAphasiaCommunicationOutcomeMeasure.Acceptedfor
presentationtotheClinicalAphasiologyConference.Monterey,CA
Irwin,B.(2012).Patient-ReportedOutcomeMeasuresinAphasia.SIG2Perspectiveson
NeurophysiologyandNeurogenicSpeechandLanguageDisorders,22(4),160-166.
Irwin,W.H.,Wertz,R.T.,&Avent,J.R.(2002).Relationshipsamonglanguageimpairment,
functionalcommunication,andpragmaticalperformanceinaphasia.Aphasiology,
16,823–835.
John,A.,&Enderby,P.(2000).Reliabilityofspeechandlanguagetherapistsusingtherapy
outcomemeasures.InternationalJournalofCommunicationDisorders,35(2),287–
302.
Kagan,A.,Black,S.E.,Duchan,J.F.,Simmons-Mackie,N.,&Square,P.(2001).Training
volunteersasconversationpartnersusingsupportedconversationforadultswith
aphasia(SCA)acontrolledtrial.JournalofSpeech,Language,andHearingResearch,
44(3),624-638.
Kaplan,E.(1983).Bostondiagnosticaphasiaexaminationbooklet.Lea&Febiger.
Kaplan,E.,Goodglass,H.,&Weintraub,S.(2001).Bostonnamingtest.Pro-ed.
86
Keil,K.,&Kaszniak,A.W.(2002).Examiningexecutivefunctioninindividualswithbrain
injury:Areview.Aphasiology,16,305–335.
Kertesz,A.(2007).WesternAphasiaBattery-Revised.SanAntonio,Tex:Harcourt
Assessment,Inc.
Korda,R.J.,&Douglas,J.M.(1997).Attentiondeficitsinstrokepatientswithaphasia.
JournalofClinicalandExperimentalNeuropsychology,19(4),525-542.
LambonRalph,M.A.,Snell,C.,Fillingham,J.K.,Conroy,P.,&Sage,K.(2010).Predictingthe
outcomeofanomiatherapyforpeoplewithaphasiapostCVA:Bothlanguageand
cognitivestatusarekeypredictors.NeuropsychologicalRehabilitation,20(2),289-
305.
LaPointe,L.L.,&Erickson,R.J.(1991).Auditoryvigilanceduringdividedtaskattentionin
aphasicindividuals.Aphasiology,5(6),511-520.
Laska,A.C.,Bartfai,A.,Hellblom,A.,Murray,V.,&Kahan,T.(2007).Clinicalandprognostic
propertiesofstandardizedandfunctionalaphasiaassessments.Journalof
rehabilitationmedicine,39(5),387-392.
Laures,J.,Odell,K.,&Coe,C.(2003).Arousalandauditoryvigilanceinindividualswith
aphasiaduringalinguisticandnonlinguistictask.Aphasiology,17(12),1133-1152.
Lomas,J.,Pickard,L.,Bester,S.,Elbard,H.,Finlayson,A.,&Zoghaib,C.(1989).The
CommunicativeEffectivenessIndexDevelopmentandPsychometricEvaluationofa
FunctionalCommunicationMeasureforAdultAphasia.Journalofspeechandhearing
disorders,54(1),113-124.
Long,A.,Hesketh,A.,&Bowen,A.(2009).Communicationoutcomeafterstroke:anew
measureofthecarer’sperspective.ClinicalRehabilitation.
87
Marshall,R.C.,Harvey,S.R.,Freed,D.B.,&Phillips,D.S.(1996).Questionaskingstrategies
ofaphasicandnon-brain-damagedsubjects.ClinicalAphasiology,24,181-192.
Marshall,R.C.,Karow,C.M.,Morelli,C.A.,Iden,K.K.,&Dixon,J.(2003).Aclinicalmeasure
fortheassessmentofproblemsolvinginbrain-injuredadults.AmericanJournalof
Speech-LanguagePathology,12(3),333-348.
MCTRJCA.(2012).TheMiddleClassTaxReliefandJobCreationAct(MCTRJCA),(Pub.L.
112–96).
Mikola,J.M.(2010).Communicativecompetenceinpersonswithaphasia:Theimpactof
executivefunction(Doctoraldissertation,WayneStateUniversity).
Morris,J.,Franklin,S.,&Menger,F.(2011).Returningtoworkwithaphasia:Acasestudy.
Aphasiology,25(8),890-907.
Murray,L.L.(2012).Attentionandothercognitivedeficitsinaphasia:Presenceand
relationtolanguageandcommunicationmeasures.AmericanJournalofSpeech-
LanguagePathology,21(2),S51-S64.
Murray,L.L.,Holland,A.L.,&Beeson,P.M.(1998).Spokenlanguageofindividualswith
mildfluentaphasiaunderfocusedanddivided-attentionconditions.Journalof
Speech,Language,andHearingResearch,41(1),213-227.
NationalAphasiaAssociation(2016).Retrievedfromhttp://www.aphasia.org
NationalInstituteonDeafnessandOtherCommunicationDisorders(2008).NIDCDfact
sheet:Aphasia.PublicationNo.08-4232.Retrievedfrom
http://www.nidcd.nih.gov/staticresources/health/voice/FactSheetAphasia.pdf.
Neto,B.,&Santos,E.M.(2012).Languageafteraphasia:Onlyamatterofspeedprocessing?.
Aphasiology,26(11),1352-1361.
88
OczkowskiC,O'DonnellM.ReliabilityofProxyRespondentsforPatientsWithStroke:A
SystematicReview.J.StrokeCerebrovasc.Dis.2010;19(5):410-416.
Ownsworth,T.,&Shum,D.(2008).Relationshipbetweenexecutivefunctionsand
productivityoutcomesfollowingstroke.DisabilityandRehabilitation,30(7),531-
540.
Patrick,D.L.,&Deyo,R.A.(1989).Genericanddisease-specificmeasuresinassessing
healthstatusandqualityoflife.Medicalcare,S217-S232.
Pickard,A.S.,Johnson,J.A.,Feeny,D.H.,Shuaib,A.,Carriere,K.C.,&Nasser,A.M.(2004).
Agreementbetweenpatientandproxyassessmentsofhealth-relatedqualityoflife
afterstrokeusingtheEQ-5DandHealthUtilitiesIndex.Stroke,35(2),607-612.
Neuropsychologicalrehabilitation,21(3),322-366.
Porch,B.E.(1971).Porchindexofcommunicativeability:Theoryanddevelopment(Vol.
1).ConsultingPsychologistsPress.
Porteus,S.D.(1959).TheMazeTestandclinicalpsychology.
Purdy,M.(2002).Executivefunctionabilityinpersonswithaphasia.Aphasiology,16,549–
557.
Ramsberger,G.(2005).Achievingconversationalsuccessinaphasiabyfocusingonnon-
linguisticcognitiveskills:Apotentiallypromisingnewapproach.Aphasiology,
19(10-11),1066-1073.
Rao,P.R.(2015).Outcomesandquality:KeycharacteristicsofasuccessfulSLPvalue
journey.SIG2PerspectivesonNeurophysiologyandNeurogenicSpeechandLanguage
Disorders,25(3),94-106.
Raven,J.C.(1962).ColouredProgressiveMatrices.London:H.K.Lewis.
89
Robertson,I.H.,Ward,T.,Ridgeway,V.,&Nimmo-Smith,I.(1996).Thestructureofnormal
humanattention:TheTestofEverydayAttention.JournaloftheInternational
NeuropsychologicalSociety,2(06),525-534.
Robin,D.A.,&Rizzo,M.(1989).Theeffectoffocalcerebrallesionsonintramodaland
cross-modalorientingofattention.Clinicalaphasiology,18(1),61-74.
Ross,K.B.(1999).Comparisonofimpairmentanddisabilitymeasuresforassessing
severityof,andimprovementin,aphasia.Aphasiology,13(2),113-124.
Ruff,R.M.,Evans,R.,&Marshall,L.F.(1986).Impairedverbalandfiguralfluencyafterhead
injury.ArchivesofClinicalNeuropsychology,1(2),87-101.
Sarno,M.T.(1969).Thefunctionalcommunicationprofile:Manualofdirections.Instituteof
RehabilitationMedicine,NewYorkUniv.Medical Center.
Segal,M.E.,&Schall,R.R.(1994).Determiningfunctional/healthstatusanditsrelationto
disabilityinstrokesurvivors.Stroke,25(12),2391-2397.
Seniów,J.,Litwin,M.,&Leśniak,M.(2009).Therelationshipbetweennon-linguistic
cognitivedeficitsandlanguagerecoveryinpatientswithaphasia.Journalofthe
NeurologicalSciences,283(1),91-94.
Shallice,T.(1982).Specificimpairmentsofplanning.PhilosophicalTransactionsoftheRoyal
SocietyofLondonB:BiologicalSciences,298(1089),199-209.
Simmons-Mackie,N.,&Elman,R.J.(2015).Negotiationofidentityingrouptherapyfor
aphasia:theAphasiaCafé.InternationalJournalofLanguage&Communication
Disorders,1-12.
Simmons-Mackie,N.,Threats,T.T.,&Kagan,A.(2005).Outcomeassessmentinaphasia:A
survey.JournalofCommunicationDisorders,38(1),1-27.
90
Sneeuw,K.C.,Sprangers,M.A.,&Aaronson,N.K.(2002).Theroleofhealthcareproviders
andsignificantothersinevaluatingthequalityoflifeofpatientswithchronic
disease.Journalofclinicalepidemiology,55(11),1130-1143.
Snyder,C.F.,&Aaronson,N.K.(2009).Useofpatient-reportedoutcomesinclinicalpractice.
TheLancet,374(9687),369-370.
Threats,T.T.(2012).UseoftheICFforguidingpatient-reportedoutcomemeasures.SIG2
PerspectivesonNeurophysiologyandNeurogenicSpeechandLanguageDisorders,
22(4),128-135.
Torrance,E.P.(1968).Torrancetestsofcreativethinking.PersonnelPress,Incorporated.
U.S.FoodandDrugAdministration(2016).GuidanceforIndustryPatient-Reported
OutcomeMeasures:UseinMedicalProductDevelopmenttoSupportLabeling
Claims.http://www.fda.gov/downloads/Drugs/.../Guidances/UCM193282.pdf
Viera,A.J.,&Garrett,J.M.(2005).Understandinginterobserveragreement:thekappa
statistic.FamMed,37(5),360-363.
Visser-Keizer,A.C.,Jong,B.,Deelman,B.G.,Berg,I.J.,&Gerritsen,M.J.(2002).Subjective
changeinemotive,cognitionandbehaviourafterstroke:factorsaffectingthe
perceptionofpatientsandpartners.Journalofclinicalandexperimental
neuropsychology,24(8),1032-1045.
Williams,L.S.,Bakas,T.,Brizendine,E.,Plue,L.,Tu,W.,Hendrie,H.,&Kroenke,K.(2006).
Howvalidarefamilyproxyassessmentsofstrokepatients’health-relatedqualityof
life?.Stroke,37(8),2081-2085.
Williams,L.S.,Weinberger,M.,Harris,L.E.,Clark,D.O.,&Biller,J.(1999).Developmentofa
stroke-specificqualityoflifescale.Stroke,30(7),1362-1369.
91
Wright,H.H.,Downey,R.A.,Gravier,M.,Love,T.,&Shapiro,L.P.(2007).Processingdistinct
linguisticinformationtypesinworkingmemoryinaphasia.Aphasiology,21(6-8),
802-813.
Zinn,S.,Bosworth,H.B.,Hoenig,H.M.,&Swartzwelder,H.S.(2007).Executivefunction
deficitsinacutestroke.Archivesofphysicalmedicineandrehabilitation,88(2),173-
180.
92
FIGURES
Figure1.ExampleofD-KEFSDesignFluencytask(fromBaldo,Shimamura,Delis,Kramer,&Kaplan,2001.
Figure2.ScatterplotsofACOMself-ratings(left)andACOMpartner-ratings(right)asafunctionofWAB-Rcategoryfluencyscore.Self-reportedfunctionalcommunicationwasNOTpredictedbasedonWAB-Rcategory
fluencyscores(r=.086,p=.741)whilepartner-reportedfunctionalcommunicationwaspredictedbasedonWAB-Rcategoryfluencyscores(r=.782,p=.000)
Figure3.ScatterplotsofACOMself-ratings(left)andACOMpartner-ratings(right)asafunctionofWAB-Rnamingscore.Self-reportedfunctionalcommunicationwasNOTpredictedbasedonWAB-Rnamingscores(r=.059,p=.823)whilepartner-reportedfunctionalcommunicationwaspredictedbasedonWAB-Rnaming
scores(r=.711,p=.002)
Figure4.Scatterplotofself-reportedACOMratingsinrelationtothenumberoferrorsontheD-KEFSDesignFluencyTest.Self-reportedfunctionalcommunicationwaspredictedbasedondesignfluencyerrors(r=-
.700p=.002)whilepartner-reportedfunctionalcommunicationwasNOTpredictedbasedondesignfluencyerrors(r=.-.171,p=.526).
Figure5.Scatterplotofself-reportedACOMratingsinrelationtotheproportionoferrorsontheuntimedadministrationoftheD-KEFSDesignFluencyTest.Self-reportedfunctionalcommunicationwasNOT
predictedbasedonproportionoferrorsonthedesignfluencytask(r=-.343p=.178)butproportionoferrorswasusefulinthetwofactorlinearregression.Partner-reportedfunctionalcommunicationwasNOT
predictedbasedonproportionoferrorsonthedesignfluencytask(r=.-.135,p=.617).
Figure6.Scatterplotofself-reportedACOMversuspartner-reportedACOMscores(r=.222,p=.41).
Figure7.ScatterplotofWAB-AQtoACOMT-Scores.FigureprovidedbyWillHula(personalcommunication,January17,2015).
99
APPENDIXA:
SAMPLEPROCEDURE
Day1Activity/Test
1. Reviewandcompleteconsentformprocedures 2. DemographicsQuestionnaire 3. Visionscreening 4. ApraxiaBatteryforAdults 5. 144itemACOMfirst-half
AssessmentBlockA
1. BostonNamingTest(Untimed) 2. Delis-KaplanVerbalFluency(Untimed)3. Delis-KaplanDesignFluency(Untimed)
AssessmentBlockB
1. BostonNamingTest(Timed) 2. Delis-KaplanVerbalFluency(Timed)3. Delis-KaplanDesignFluency(Timed)
Day2Activity/Test
1. 144itemACOMsecond-half 2. WesternAphasiaBattery-Revised
AssessmentBlockC
1. Delis-KaplanSortingTest(Timed)2. Delis-KaplanTwentyQuestions(Timed)3. TorranceTestofCreativeThinking-ProductImprovement(Timed)4. TorranceTestofCreativeThinking-UnusualUses(Timed)
AssessmentBlockD
1. Delis-KaplanSortingTest(Untimed)2. Delis-KaplanTwentyQuestions(Untimed)3. TorranceTestofCreativeThinking-ProductImprovement(Untimed)4. TorranceTestofCreativeThinking-UnusualUses(Untimed)
100
APPENDIXB:
ACOMQUESTIONS
Howeffectivelydoyou…. Howeffectivelydoesyourpartner….
1. talktoyourclosestfamilymemberorfriend
1. talktohis/herclosestfamilymemberorfriend
2. saythenamesoffooditems 2. saythenamesoffooditems3. saythenamesofbodyparts 3. saythenamesofbodyparts4. talkaboutcurrent/previouswork 4. talkaboutcurrent/previouswork5. askforinformationfromstoreemployees
5. askforinformationfromstoreemployees
6. discussfamilymatterswithyourspouseandchildren
6. discussfamilymatterswithhis/herspouseandchildren
7. sayyouraddress 7. sayhis/heraddress8. leaveamessageonanansweringmachine
8. leaveamessageonanansweringmachine
9. saythenamesofclothingitems 9. saythenamesofclothingitems10. talkaboutyourfutureplanswithfamilyorfriends
10. talkabouthis/herfutureplanswithfamilyorfriends
11. tellastory 11. tellastory12. introduceyourself 12. introducehimself/herself13. haveaconversationwithstrangers 13. haveaconversationwithstrangers14. sayyourname 14. sayhis/hername15. talkaboutyourdaywithfamilyorfriends
15. talkabouthis/herdaywithfamilyorfriends
16. saythenamesofcommonobjects(e.g.,bed,lamp,pencil)
16. saythenamesofcommonobjects(e.g.,bed,lamp,pencil)
17. explainyourhealthconcernstoyourdoctor
17. explainhis/herhealthconcernstohis/herdoctor
18. talkaboutyourhealthconcernswithfamilymembers
18. talkabouthis/herhealthconcernswithfamilymembers
19. callfamilymembersbyname 19. callfamilymembersbyname20. findthewordsyouwanttosayduringconversation
20. findthewordshe/shewantstosayduringconversation
101
21. explainhowtogetsomewhere 21. explainhowtogetsomewhere22. tellajoke 22. tellajoke23. makeyourselfunderstoodwhenyouspeakwithstrangers
23. makehimself/herselfunderstoodwhenhe/shespeakwithstrangers
24. filloutsimpleforms 24. filloutsimpleforms25. keepaconversationgoing 25. keepaconversationgoing26. tellpeopleaboutyourself 26. tellpeopleabouthimself/herself27. explainhowtodosomething 27. explainhowtodosomething28. correctyourselfwhenpeopledonotunderstandyou
28. correcthimself/herselfwhenpeopledonotunderstandhim/her
29. makeyourselfunderstoodwhenyouspeakwithfamilyorfriends
29. makehimself/herselfunderstoodwhenhe/shespeakswithfamilyorfriends
30. followconversationaboutfamiliartopics
30. followconversationaboutfamiliartopics
31. startaconversationwithotherpeople
31. startaconversationwithotherpeople
32. talkaboutmoviesthatyouhaveseen 32. talkaboutmoviesthathe/shehasseen
33. understandyourclosestfamilymemberorfriendwhentheytalktoyou
33. understandhis/herclosestfamilymemberorfriendwhentheytalktohim/her
34. followsimplespokenrequests(e.g.,passthesalt)
34. followsimplespokenrequests(e.g.,passthesalt)
35. startanewtopicinconversation 35. startanewtopicinconversation36. shareopinions 36. shareopinions37. makeyourwantsandneedsknown 37. makehis/herwantsandneeds
known38. talkwithagroupofpeople 38. talkwithagroupofpeople39. writeyourphonenumber 39. writehis/herphonenumber40. filloutcomplexforms 40. filloutcomplexforms41. correctmistakesyoumakewhenyoutalk
41. correctmistakeshe/shemakeswhenhe/shetalks
42. writeasimple"todo"list 42. writeasimple"todo"list43. understandyourbank/creditcardstatements
43. understandhis/herbank/creditcardstatements
44. tellpeoplewhyyoucan'ttalkverywell
44. tellpeoplewhyhe/shecan'ttalkverywell
45. readsignsinastoretofindwhatyouneed
45. readsignsinastoretofindwhathe/sheneeds
46. writeyouraddress 46. writehis/heraddress47. understandmagazine/newspaperarticles
47. understandmagazine/newspaperarticles
48. understandnewspaperheadlines 48. understandnewspaperheadlines49. readstreetnamesigns 49. readstreetnamesigns
102
50. answeryes/noquestions 50. answeryes/noquestions51. readproductlabels 51. readproductlabels52. followtherapyinstructions 52. followtherapyinstructions53. understandmedicinelabels 53. understandmedicinelabels54. writemessagesingreetingcards 54. writemessagesingreetingcards55. followastorysomeonetells 55. followastorysomeonetells56. readtrafficsigns 56. readtrafficsigns57. readfoodlabels 57. readfoodlabels58. understandhumorinpictures(e.g.,comics,photographs)
58. understandhumorinpictures(e.g.,comics,photographs)
59. writeapersonalletter 59. writeapersonalletter
103
APPENDIXC:
D-KEFSTWENTYQUESTIONSITEMGROUPINGS
D-KEFSCategoricalHierarchyCategory Sub-category Sub-category ObjectLivingThings Plants Fruits Apple Banana Oranges Vegetables Carrot Corn Common Tree Rose Animals Mammals Dog Cow Elephant Birds Ducks Eagle Owl Fish Goldfish SharkNon-LivingThings KitchenItems Silverware Knife Fork Spoon Dishes Bowl Cup Plate Appliances Refrigerator Stove Transportation Ground Cars Bus Train Air Airplane Helicopter Water Boat Submarine
104
APPENDIXD:
MODIFIEDINSTRUCTIONS
OVERVIEW
ModifiedinstructionswerecreatedfortheBostonNamingTest,theDelis-KaplanExecutive
FunctionsSystemsTest(D-KEFS;Delis,Kaplan,&Kramer,2001),andtheTorranceTestof
CreativeThinking(TTCT).Thesemodifiedinstructionsareintendedtoincreaseor
decreasetheemphasisonspeedofresponse.
Forallspeededtasks,acomputershowingastopwatchandtheremainingtimewere
prominentlydisplayed.Seehttp://www.online-stopwatch.com/countdown-clock/full-
screen/.
105
Toavoidtopotentialcriticismthatthetimeriscreatingvisualdistractionratherthantime
pressure,aclockwiththetimewasdisplayedwhennon-timedtasksarebeingcompleted.
http://www.online-stopwatch.com/large-online-clock/
106
BostonNamingTest(BNT-2)ModifiedInstructions
ð Inordertocontrolpresentationspeed,theBNTitemsarebeingshownonacomputerscreenusingaPowerPointpresentation.
ð Unspeededð BlockA/C:I’mgoingtoshowyouaseriesofpicturesonthiscomputer.Yourtaskistotellmethenameforeachpicture.Takeasmuchtimeasyouneedtoanswer.
ð BlockB/D:NowI’mgoingtoshowyouthesamepicturesagain.Thistime,youcantakeallthetimeyouneedtoanswer.
ð TimePressureConditionð BlockA/C:I’mgoingtoshowyouaseriesofpicturesusingthiscomputer.Thecomputerwillshoweachpictureforexactly3secondsandthenitwillmoveonautomatically.Yourtaskistonameeachitemasquicklyasyoucan.Oncethepicturechanges,youshouldmoveontothenextpictureevenifyouhaven’tnamedthepreviouspicture.ð BlockB/D:NowIamgoingtoshowyouthesamepicturesagain.Thistime,thecomputerwillshoweachpictureforexactly3secondsandthenitwillmoveonautomatically.Yourtaskistonameeachitemasquicklyasyoucan.Oncethepicture
107
changes,youshouldmoveontothenextpictureevenifyouhaven’tnamedthepreviouspicture.
WesternAphasiaBattery-Revised(WAB-R)ModifiedInstructions
TheWesternAphasiaBatterywasgivenusingthestandardizedprocedureonly;no
speededpresentationmethodwasbeused.
D-KEFSAlternateInstructions
VerbalFluency
ð Condition1:LetterFluency-UnpressuredInstructions:ð BlockA/C:I’mgoingtosayaletterofthealphabet.WhenIbegin,Iwantyoutotellmeasmanywordsasyoucanthatbeginwiththatletter.Noneofthewordscanbenamesofpeople,orplaces,ornumbers.Forexample,IfIgaveyoutheletterT,youcouldsaytoy,tooth,andsoforthbutyoushouldnotsayTombecausethatisaperson’sname,youshouldnotsayTexasbecausethatisthenameofaplace,andyoushouldnotsaytwelvebecausethatisanumber.Also,donotgivemethesamewordwithdifferentendings.Forexample,ifyousaytake,youshouldnotalsosaytakesortaking.Doyouhaveanyquestions?Takeasmuchtimeasyouneed.Thefirstletteris__________<Allowatleast60secondsorlongerifparticipantisstillgeneratingitems-scoreonlythosefromfirst60seconds>
ð BlockB/D:Wearegoingtodothistaskagainusingsomenewletters.Asbefore,I’mgoingtosayaletterofthealphabet.Forexample,ifyousaytake,youshouldnotalsosaytakesortaking.Doyouhaveanyquestions?Takeasmuchtimeasyouneed.Thefirstletteris__________<Allowatleast60secondsorlongerifparticipantisstillgeneratingitems-scoreonlythosefromfirst60seconds>
ð Condition1:LetterFluency-TimePressuredInstructions:ð BlockA/C:I’mgoingtosayaletterofthealphabet.WhenIbegin,Iwantyoutotellmeasmanywordsasyoucanthatbeginwiththatletter.Noneofthewordscanbenamesofpeople,orplaces,ornumbers.Forexample,IfIgaveyoutheletterT,youcouldsaytoy,tooth,andsoforthbutyoushouldnotsayTombecausethatisaperson’sname,youshouldnotsayTexasbecausethatisthenameofaplace,andyoushouldnotsaytwelvebecausethatisanumber.Also,donotgivemethesamewordwithdifferentendings.Forexample,ifyousaytake,youshouldnotalsosaytakesortaking.Doyouhaveanyquestions?Iammeasuringthenumberofwordsyoucangeneratein60secondssoitisimportantthatyouworkveryfast.Doyouhaveanyquestions?Thefirstletteris__________<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds>
108
ð BlockB/D:Wearegoingtodothistaskagainusingsomenewletters.Asbefore,I’mgoingtosayaletterofthealphabet.Forexample,ifyousaytake,youshouldnotalsosaytakesortaking.Doyouhaveanyquestions?Iammeasuringthenumberofwordsyoucangeneratein60secondssoitisimportantthatyouworkveryfast.Doyouhaveanyquestions?Thefirstletteris__________<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds>
ð Condition2:CategoryFluency-OriginalInstructions:ð BlockA/C:Nowwearegoingtodosomethingalittledifferent.Thistime,Iwantyoutotellmeasmanyanimals/itemsofclothingasyoucan.Itdoesn’tmatterwhatlettertheystartwith.Doyouhaveanyquestions?Beginwhenyouareready<Allowatleast60secondsorlongerifparticipantisstillgeneratingitems-scoreonlythosefromfirst60seconds>
ð 2ndTask:Nowtellmeasmanyboys/girlsnamesasyoucan.Ready?Beginwhenyouareready<Allowatleast60secondsorlongerifparticipantisstillgeneratingitems-scoreonlythosefromfirst60seconds>
ð BlockB/D:Thistimewearegoingtodothisagainwithanewcategory.Thistime,Iwantyoutotellmeasmanyanimals/itemsofclothingasyoucan.Doyouhaveanyquestions?Ready?Beginwhenyouareready<Allowatleast60secondsorlongerifparticipantisstillgeneratingitems-scoreonlythosefromfirst60seconds>
ð 2ndTask:Nowtellmeasmanyboys/girlsnamesasyoucan.Ready?Beginwhenyouareready<Allowatleast60secondsorlongerifparticipantisstillgeneratingitems-scoreonlythosefromfirst60seconds>
ð Condition2:CategoryFluency-TimePressuredInstructions:ð BlockA/C:Nowwearegoingtodosomethingalittledifferent.Thistime,Iwantyoutotellmeasmanyanimals/itemsofclothingasyoucan.Itdoesn’tmatterwhatlettertheystartwith.Iammeasuringthenumberofwordsyoucangeneratein60secondssoitisimportantthatyouworkveryfast.Doyouhaveanyquestions?WhenIsayGo,tellmeasmanyanimals/itemsofclothingasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds>
ð 2ndTask:Nowtellmeasmanyboys/girlsnamesasyoucan.Iamstillmeasuringthenumberofwordsyoucangeneratein60secondssoworkveryfast.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds.>
ð BlockB/D:Thistimewearegoingtodothisagainwithanewcategory.Thistime,Iwantyoutotellmeasmanyanimals/itemsofclothingasyoucan..Iammeasuringthenumberofwordsyoucangeneratein60secondssoitisimportantthatyouworkveryfast.Doyouhaveanyquestions?WhenIsayGo,tellmeasmanyanimals/itemsofclothingasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds>
109
ð 2ndTask:Nowtellmeasmanyboys/girlsnamesasyoucan.Iamstillmeasuringthenumberofwordsyoucangeneratein60secondssoworkveryfast.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds>
ð Condition3:CategorySwitching-UnpressuredInstructions:ð BlockA/C:Nowwearegoingtodosomethingalittledifferent.Iwantyoutoswitchbackandforthbetweensayingasmanyfruits/vegetablesandasmanypiecesoffurniture/musicalinstrumentsasyoucan.Itdoesn’tmatterwhatlettertheystartwith.So,youwouldsayafruit/vegetable,thenapieceoffurniture/musicalinstrumentandsoon.Youcanstartwitheitherafruit/vegetableorapieceoffurniture/musicalinstrument.Doyouhaveanyquestions?Beginwhenyouareready<Allowatleast60secondsorlongerifparticipantisstillgeneratingitems-scoreonlythosefromfirst60seconds>
ð BlockB/D:Thistimewearegoingtodothisagainwithtwonewcategories.Iwantyoutoswitchbackandforthbetweensayingasmanyfruits/vegetablesandasmanypiecesoffurniture/musicalinstrumentsasyoucan.Itdoesn’tmatterwhatlettertheystartwith.Youwillhave60secondsbeforeItellyoutostop.Doyouhaveanyquestions?Beginwhenyouareready<Allowatleast60secondsorlongerifparticipantisstillgeneratingitems-scoreonlythosefromfirst60seconds>
ð Condition3:CategorySwitching-TimePressuredInstructions:ð BlockA/C:Nowwearegoingtodosomethingalittledifferent.Iwantyoutoswitchbackandforthbetweensayingasmanyfruitsandasmanypiecesoffurniture/musicalinstrumentsasyoucan.Itdoesn’tmatterwhatlettertheystartwith.Youwillhave60secondsbeforeItellyoutostop.So,youwouldsayafruit/vegetable,thenapieceoffurniture/musicalinstrumentandsoon.Youcanstartwitheitherafruit/vegetableorapieceoffurniture/musicalinstrument.Iamstillmeasuringthenumberofwordsyoucangeneratein60secondssoworkveryfast.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds.>
ð BlockB/D:Thistimewearegoingtodothisagainwithtwonewcategories.Iwantyoutoswitchbackandforthbetweensayingasmanyfruits/vegetablesandasmanypiecesoffurniture/musicalinstrumentsasyoucan.Itdoesn’tmatterwhatlettertheystartwith.Youwillhave60secondsbeforeItellyoutostop.Iamstillmeasuringthenumberofwordsyoucangeneratein60secondssoworkveryfast.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds.>
DesignFluency
ð TheDesignFluencyTestmeasuresone’sinitiationofproblem-solvingbehavior,fluencyingeneratingvisualpatterns,creativityindrawingnewdesigns,simultaneousprocessingindrawingthedesignswhileobservingtherulesandrestrictionsofthe
110
task,andinhibitingpreviouslydrawnresponses.
ð Condition1:FilledDots-UntimedInstructions:ð BlockA/C:Herearethreesquares,eachwithdotsinside.Iwantyoutomakeadifferentdesignineachsquarebyconnectingdotsandalwaysusingstraightlines.I’dlikeyoutomakethedesignsusingonlyfourstraightlinestoconnectthedots.Makesureeachlineyoudrawstartswithadotandendswithadot.Also,makeeachlinetouchatleastoneotherlineatadot,likethis.[DRAWEXAMPLE]Seehowthesetwolinestouchatthisdot?It’sOKifyourlinescrosseachother,anditdoesn’tmatterwhetherornotyourdesignscanbenamed.Doyouhaveanyquestions?
[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]Whenyouarereadytobegin,drawasmanydifferentdesignsasyoucan.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?Beginwhenyouareready.
ð BlockB/D:Herearethreesquares,eachwithdotsinside.Iwantyoutomakeadifferentdesignineachsquarebyconnectingdotsandalwaysusingstraightlines.I’dlikeyoutomakethedesignsusingonlyfourstraightlinestoconnectthedots.Makesureeachlineyoudrawstartswithadotandendswithadot.Also,makeeachlinetouchatleastoneotherlineatadot,likethis.[DRAWEXAMPLE]Seehowthesetwolinestouchatthisdot?It’sOKifyourlinescrosseachother,anditdoesn’tmatterwhetherornotyourdesignscanbenamed.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]
Whenyouarereadytobegin,drawasmanydifferentdesignsasyoucan.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?Beginwhenyouareready.
ð Condition1:FilledDots-Time-PressuredInstructions:ð BlockA/C:Herearethreesquares,eachwithdotsinside.Iwantyoutomakeadifferentdesignineachsquarebyconnectingdotsandalwaysusingstraightlines.I’dlikeyoutomakethedesignsusingonlyfourstraightlinestoconnectthedots.Makesureeachlineyoudrawstartswithadotandendswithadot.Also,makeeachlinetouchatleastoneotherlineatadot,likethis.[DRAWEXAMPLE]Seehowthesetwolinestouchatthisdot?It’sOKifyourlinescrosseachother,anditdoesn’tmatterwhetherornotyourdesignscanbenamed.Doyouhaveanyquestions?
111
[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]
ð WhenIsaybegin,drawasmanydifferentdesignsasyoucanin60seconds.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?.Remember,Iammeasuringthenumberofdifferentdesignsyoucancreatein60seconds.Soworkasfastasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds.>
ð BlockB/D:Herearethreesquares,eachwithdotsinside.Iwantyoutomakeadifferentdesignineachsquarebyconnectingdotsandalwaysusingstraightlines.I’dlikeyoutomakethedesignsusingonlyfourstraightlinestoconnectthedots.Makesureeachlineyoudrawstartswithadotandendswithadot.Also,makeeachlinetouchatleastoneotherlineatadot,likethis.[DRAWEXAMPLE]Seehowthesetwolinestouchatthisdot?It’sOKifyourlinescrosseachother,anditdoesn’tmatterwhetherornotyourdesignscanbenamed.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]
ð WhenIsaybegin,drawasmanydifferentdesignsasyoucanin60seconds.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?.Remember,Iammeasuringthenumberofdifferentdesignsyoucancreatein60seconds.Soworkasfastasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds.>
ð Condition2:EmptyDotsOnly-UntimedInstructions:ð BlockA/C:Herearethreesquares,eachwithtendots.Fiveofthedotsarefilledandfiveofthemempty(pointtoanexampleofeach).Iwantyoutomakeadifferencedesignineachsquarebyconnectingonlyemptydots.Thatis,don’ttouchthefilleddots;justconnecttheemptydots.Likebefore,useonlystraightlinesandmakeeachlinetouchatleastoneotherlineatthedot.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]
Whenyouarereadytobegin,drawasmanydifferentdesignsasyoucan.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?Beginwhenyouareready.
112
ð BlockB/D:Herearethreesquares,eachwithtendots.Fiveofthedotsarefilledandfiveofthemempty(pointtoanexampleofeach).Iwantyoutomakeadifferencedesignineachsquarebyconnectingonlyemptydots.Thatis,don’ttouchthefilleddots;justconnecttheemptydots.Likebefore,useonlystraightlinesandmakeeachlinetouchatleastoneotherlineatthedot.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]
Whenyouarereadytobegin,drawasmanydifferentdesignsasyoucan.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?Beginwhenyouareready.
ð Condition2:EmptyDotsOnly-Time-PressuredInstructions:ð BlockA/C:Herearethreesquares,eachwithtendots.Fiveofthedotsarefilledandfiveofthemempty(pointtoanexampleofeach).Iwantyoutomakeadifferencedesignineachsquarebyconnectingonlyemptydots.Thatis,don’ttouchthefilleddots;justconnecttheemptydots.Likebefore,useonlystraightlinesandmakeeachlinetouchatleastoneotherlineatthedot.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]
ð WhenIsaybegin,drawasmanydifferentdesignsasyoucanin60seconds.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?.Remember,Iammeasuringthenumberofdifferentdesignsyoucancreatein60seconds.Soworkasfastasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds.>
ð BlockB/D:Herearethreesquares,eachwithtendots.Fiveofthedotsarefilledandfiveofthemempty(pointtoanexampleofeach).Iwantyoutomakeadifferencedesignineachsquarebyconnectingonlyemptydots.Thatis,don’ttouchthefilleddots;justconnecttheemptydots.Likebefore,useonlystraightlinesandmakeeachlinetouchatleastoneotherlineatthedot.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]
ð WhenIsaybegin,drawasmanydifferentdesignsasyoucanin60seconds.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?.Remember,Iammeasuringthenumberofdifferentdesignsyoucancreatein60seconds.Soworkasfastasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds.>
113
ð Condition3:Switching-UntimedInstructions:ð BlockA/C:Herearethreesquares,eachwithtendots.Fiveofthedotsarefilledandfiveofthemempty(pointtoanexampleofeach).Iwantyoutomakeadifferencedesignineachsquarebyconnectingonlyemptydots.Thatis,don’ttouchthefilleddots;justconnecttheemptydots.Likebefore,useonlystraightlinesandmakeeachlinetouchatleastoneotherlineatthedot.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]
Whenyouarereadytobegin,drawasmanydifferentdesignsasyoucan.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?Beginwhenyouareready.
ð BlockB/D:Herearethreesquares,eachwithtendots.Fiveofthedotsarefilledandfiveofthemempty(pointtoanexampleofeach).Iwantyoutomakeadifferencedesignineachsquarebyconnectingonlyemptydots.Thatis,don’ttouchthefilleddots;justconnecttheemptydots.Likebefore,useonlystraightlinesandmakeeachlinetouchatleastoneotherlineatthedot.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]Whenyouarereadytobegin,drawasmanydifferentdesignsasyoucan.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?Beginwhenyouareready.
ð Condition3:Switching-Time-PressuredInstructions:ð BlockA/C:Herearethreesquares,eachwithtendots.Fiveofthedotsarefilledandfiveofthemempty(pointtoanexampleofeach).Iwantyoutomakeadifferencedesignineachsquarebyconnectingonlyemptydots.Thatis,don’ttouchthefilleddots;justconnecttheemptydots.Likebefore,useonlystraightlinesandmakeeachlinetouchatleastoneotherlineatthedot.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]
ð WhenIsaybegin,drawasmanydifferentdesignsasyoucanin60seconds.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?Remember,Iammeasuringthenumberofdifferentdesignsyoucancreatein60seconds.Workasfastasyoucan.Go!
114
<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds.>
ð BlockB/D:Herearethreesquares,eachwithtendots.Fiveofthedotsarefilledandfiveofthemempty(pointtoanexampleofeach).Iwantyoutomakeadifferencedesignineachsquarebyconnectingonlyemptydots.Thatis,don’ttouchthefilleddots;justconnecttheemptydots.Likebefore,useonlystraightlinesandmakeeachlinetouchatleastoneotherlineatthedot.Doyouhaveanyquestions?[INTRUCTIONSGOTHROUGHSEVERALEXAMPLES]
ð WhenIsaybegin,drawasmanydifferentdesignsasyoucanin60seconds.Remember,useonlyfourstraightlinestoconnectthedotsandmakeeachlinetouchatleastoneotherlineatadot.Starthere(pointtothesquareattheexaminee’supperleft)andgothisway(gesturefromtheexaminee’slefttoright).Whenyoufinishthisline,gotothenext(gesturetothenextlowerline).Anyquestions?Remember,Iammeasuringthenumberofdifferentdesignsyoucancreatein60seconds.Workasfastasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=60seconds.>
CardSorting
ð TheSortingTestmeasuresconcept-formationskills,modality-specificproblem-solvingskills(verbal/nonverbal),andtheabilitytoexplainsortingconceptsabstractly
ð FreeSorting-Pre-Instructions:I’mgoingtoshowyousixcardsthatcanbesortedindifferentways.Iwantyoutoseehowmanydifferentwaysyoucansortthecards.LetmeshowyouwhatImeanwiththesecards>.Lookatthesecards.WatchhowIsortthemintotwogroupswiththreecardsineachgroup.<point>Next,I’llexplainhowIsortedthembysaying,thisgrouphascircles,andthisgrouphassquares.NoticehowIexplainedbothgroupsnotjustoneofthem.NowwatchwhileIsortthemanotherway,againwithtwogroupsonthreecardsineachgroup.IwillexplainhowIsortedthembysaying,thisgrouphasboys’namesandthisgrouphasgirls’names.DoyouhaveanyquestionsabouthowIdidthis?
ð Condition1:FreeSorting-UnpressuredInstructions:ð BlockA/C:ð CardSet1/3:I’mgoingtoshowyousixnewcardsthatcanbesortedinmanydifferentways.I’dliketoseehowmanydifferentwaysyoucansortthecards.Eachtime,makeonlytwogroupswiththreecardsineachgroup.Thethreecardsineachgroupshouldbesimilarinsomeway.Afteryousorttwocardsintotwogroups,tellmehowyoudidit.Besuretotellmehowyousortedbothgroups,notjustoneofthem.Onceyousortthecardsoneway,donotsortthemthatwayagain.Takeasmuchtimeasyouneed.Hereisapagethatwillhelpyouremembertheserules.<flipcard>Now,trysortingthesecardsinasmanydifferentwaysasyoucan.Ready?Begin.<UseCardSet1/3>Stoptimewhen
115
examineecompleteshisorhersortandbeginstodescribethesortingstrategy>Nowtrytosorttheminadifferentway<restarttimerduringsort>
ð CardSet2/4:I’mgoingtoshowyousixnewcardsthatcanbesortedinmanydifferentways.Likebefore,I’dliketoseehowmanydifferentwaysyoucansortthesecards.Eachtime,makeonlytwogroupswiththreecardsineachgroup.Thethreecardsineachgroupshouldbesimilarinsomeway.Afteryousorttwocardsintotwogroups,tellmehowyoudidit.Besuretotellmehowyousortedbothgroups,notjustoneofthem.Onceyousortthecardsoneway,donotsortthemthatwayagain.Takeasmuchtimeasyouneed.Againhereisapagethatwillhelpyouremembertheserules.<flipcard>Now,trysortingthesecardsinasmanydifferentwaysasyoucan.Ready?Begin.<UseCardSet1/3>Stoptimewhenexamineecompleteshisorhersortandbeginstodescribethesortingstrategy>Nowtrytosorttheminadifferentway.<restarttimerduringsort>
ð <Discontinueafter4minutessorttime(doesn’tincludedescriptiontime)orwhenparticipantindicatesthattheycannotthinkofanotherway>
ð BlockB/D:ð CardSet1/3:I’mgoingtoshowyousixnewcardsthatcanbesortedinmanydifferentways.I’dliketoseehowmanydifferentwaysyoucansortthecards.Eachtime,makeonlytwogroupswiththreecardsineachgroup.Thethreecardsineachgroupshouldbesimilarinsomeway.Afteryousorttwocardsintotwogroups,tellmehowyoudidit.Besuretotellmehowyousortedbothgroups,notjustoneofthem.Onceyousortthecardsoneway,donotsortthemthatwayagain.Takeasmuchtimeasyouneed.Hereisapagethatwillhelpyouremembertheserules.<flipcard>Now,trysortingthesecardsinasmanydifferentwaysasyoucan.Ready?Begin.<UseCardSet1/3;Stoptimewhenexamineecompleteshisorhersortandbeginstodescribethesortingstrategy>Nowtrytosorttheminadifferentway<restarttimerduringsort>
ð CardSet2/4:I’mgoingtoshowyousixnewcardsthatcanbesortedinmanydifferentways.Likebefore,I’dliketoseehowmanydifferentwaysyoucansortthesecards.Eachtime,makeonlytwogroupswiththreecardsineachgroup.Thethreecardsineachgroupshouldbesimilarinsomeway.Afteryousorttwocardsintotwogroups,tellmehowyoudidit.Besuretotellmehowyousortedbothgroups,notjustoneofthem.Onceyousortthecardsoneway,donotsortthemthatwayagain.Takeasmuchtimeasyouneed.Againhereisapagethatwillhelpyouremembertheserules.<flipcard>Now,trysortingthesecardsinasmanydifferentwaysasyoucan.Ready?Begin.<UseCardSet1/3;Stoptimewhenexamineecompleteshisorhersortandbeginstodescribethesortingstrategy>Nowtrytosorttheminadifferentway.<restarttimerduringsort>
ð <Discontinueafter4minutessorttime(doesn’tincludedescriptiontime)orwhenparticipantindicatesthattheycannotthinkofanotherway>
ð Condition1:FreeSorting–Time-PressuredInstructions:ð BlockA/C:ð CardSet1/3:I’mgoingtoshowyousixnewcardsthatcanbesortedinmanydifferentways.I’dliketoseehowmanydifferentwaysyoucansortthecards.Eachtime,makeonlytwogroupswiththreecardsineachgroup.Thethreecardsineachgroupshouldbe
116
similarinsomeway.Afteryousorttwocardsintotwogroups,tellmehowyoudidit.Besuretotellmehowyousortedbothgroups,notjustoneofthem.Onceyousortthecardsoneway,donotsortthemthatwayagain.Remember,Iammeasuringthenumberofdifferentsortyoucancompletein4minutes.Workasfastasyoucan.Hereisapagethatwillhelpyouremembertheserules.<flipcard>Now,trysortingthesecardsinasmanydifferentwaysasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=240seconds.><UseCardSet1/3;Stoptimewhenexamineecompleteshisorhersortandbeginstodescribethesortingstrategy>Nowtrytosorttheminadifferentway<restarttimerduringsort>
ð CardSet2/4:I’mgoingtoshowyousixnewcardsthatcanbesortedinmanydifferentways.Likebefore,I’dliketoseehowmanydifferentwaysyoucansortthesecards.Eachtime,makeonlytwogroupswiththreecardsineachgroup.Thethreecardsineachgroupshouldbesimilarinsomeway.Afteryousorttwocardsintotwogroups,tellmehowyoudidit.Besuretotellmehowyousortedbothgroups,notjustoneofthem.Onceyousortthecardsoneway,donotsortthemthatwayagain.Remember,Iammeasuringthenumberofdifferentsortsyoucancompletein4minutes.Workasfastasyoucan.Hereisapagethatwillhelpyouremembertheserules.<flipcard>Now,trysortingthesecardsinasmanydifferentwaysasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=240seconds.><UseCardSet1/3>Stoptimewhenexamineecompleteshisorhersortandbeginstodescribethesortingstrategy>Nowtrytosorttheminadifferentway.<restarttimerduringsort>
ð <Discontinueafter4minutessorttime(doesn’tincludedescriptiontime)orwhenparticipantindicatesthattheycannotthinkofanotherway>
ð BlockB/D:ð CardSet1/3:I’mgoingtoshowyousixnewcardsthatcanbesortedinmanydifferentways.I’dliketoseehowmanydifferentwaysyoucansortthecards.Eachtime,makeonlytwogroupswiththreecardsineachgroup.Thethreecardsineachgroupshouldbesimilarinsomeway.Afteryousorttwocardsintotwogroups,tellmehowyoudidit.Besuretotellmehowyousortedbothgroups,notjustoneofthem.Onceyousortthecardsoneway,donotsortthemthatwayagain.Remember,Iammeasuringthenumberofdifferentsortsyoucancompletein4minutes.Workasfastasyoucan.Hereisapagethatwillhelpyouremembertheserules.<flipcard>Now,trysortingthesecardsinasmanydifferentwaysasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=240seconds.><UseCardSet1/3>Stoptimewhenexamineecompleteshisorhersortandbeginstodescribethesortingstrategy>Nowtrytosorttheminadifferentway<restarttimerduringsort>
ð CardSet2/4:I’mgoingtoshowyousixnewcardsthatcanbesortedinmanydifferentways.Likebefore,I’dliketoseehowmanydifferentwaysyoucansortthesecards.Eachtime,makeonlytwogroupswiththreecardsineachgroup.Thethreecardsineachgroupshouldbesimilarinsomeway.Afteryousorttwocardsintotwogroups,tellmehowyoudidit.Besuretotellmehowyousortedbothgroups,notjustoneofthem.Onceyousortthecardsoneway,donotsortthemthatwayagain.Remember,Iammeasuringthenumberofdifferentsortsyoucancompletein4minutes.Workasfastasyoucan.
117
Hereisapagethatwillhelpyouremembertheserules.<flipcard>Now,trysortingthesecardsinasmanydifferentwaysasyoucan.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=240seconds.><UseCardSet1/3>Stoptimewhenexamineecompleteshisorhersortandbeginstodescribethesortingstrategy>Nowtrytosorttheminadifferentway.<restarttimerduringsort>
ð <Discontinueafter4minutessorttime(doesn’tincludedescriptiontime)orwhenparticipantindicatesthattheycannotthinkofanotherway>
ð Condition2:SortRecognition-UnpressuredInstructions:ð BlockA/C:ð CardSet1/3:NowI’mgoingtoputthesecardsintotwogroupsofthreecardseach.Thethreecardsineachgroupwillbethesameinsomeway.Iwantyoutotellmehowthecardsarethesameineachgroup.BesuretotellmehowIsortedbothgroups,notjustoneofthem.IwillusedifferentwayofsortingthecardseachtimeIputthemintogroups.Takeasmuchtimeasyouneed.<placecardsintosetaccordingtorulesintestmanual;waitforparticipanttoexplainsort.>Good,nowI’mgoingtosortthecardsinadifferentway.AgainIwantyoutotellmehowIsortedthetwogroups.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=240seconds.><Repeatthrough8sorts>.
ð CardSet2/4:Likebefore,I’mgoingtoputthesecardsintotwogroupsofthreecardseach.Thethreecardsineachgroupwillbethesameinsomeway.Iwantyoutotellmehowthecardsarethesameineachgroup.BesuretotellmehowIsortedbothgroups,notjustoneofthem.IwillusedifferentwayofsortingthecardseachtimeIputthemintogroups.Takeasmuchtimeasyouneed.<placecardsintosetaccordingtorulesintestmanual;waitforparticipanttoexplainsort.>Good,nowI’mgoingtosortthecardsinadifferentway.AgainIwantyoutotellmehowIsortedthetwogroups.Takeasmuchtimeasyouneed.<Repeatthrough8sorts>.
ð BlockB/D:ð CardSet1/3:NowI’mgoingtoputthesecardsintotwogroupsofthreecardseach.Thethreecardsineachgroupwillbethesameinsomeway.Iwantyoutotellmehowthecardsarethesameineachgroup.BesuretotellmehowIsortedbothgroups,notjustoneofthem.IwillusedifferentwayofsortingthecardseachtimeIputthemintogroups.Takeasmuchtimeasyouneed.<placecardsintosetaccordingtorulesintestmanual;waitforparticipanttoexplainsort.>Good,nowI’mgoingtosortthecardsinadifferentway.AgainIwantyoutotellmehowIsortedthetwogroups.Takeasmuchtimeasyouneed.<Repeatthrough8sorts>.
ð CardSet2/4:Likebefore,I’mgoingtoputthesecardsintotwogroupsofthreecardseach.Thethreecardsineachgroupwillbethesameinsomeway.Iwantyoutotellmehowthecardsarethesameineachgroup.BesuretotellmehowIsortedbothgroups,notjustoneofthem.IwillusedifferentwayofsortingthecardseachtimeIputthemintogroups.Takeasmuchtimeasyouneed.<placecardsintosetaccordingtorulesintestmanual;waitforparticipanttoexplainsort.>Good,nowI’mgoingtosortthecards
118
inadifferentway.AgainIwantyoutotellmehowIsortedthetwogroups.Takeasmuchtimeasyouneed.<Repeatthrough8sorts>.
ð Condition2:SortRecognition–Time-PressuredInstructions:ð BlockA/C:ð CardSet1/3:NowI’mgoingtoputthesecardsintotwogroupsofthreecardseach.Thethreecardsineachgroupwillbethesameinsomeway.Iwantyoutotellmehowthecardsarethesameineachgroup.BesuretotellmehowIsortedbothgroups,notjustoneofthem.IwillusedifferentwayofsortingthecardseachtimeIputthemintogroups.Iammeasuringhowfastyoucanidentifythesortingrules.Workasfastasyoucan.<placecardsintosetaccordingtorulesintestmanual;waitforparticipanttoexplainsort.>Good,nowI’mgoingtosortthecardsinadifferentway.AgainIwantyoutotellmehowIsortedthetwogroups.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Assoonasoneisidentified,sortnewsetandsayGo!<Repeatthrough8sorts>.
ð CardSet2/4:Likebefore,I’mgoingtoputthesecardsintotwogroupsofthreecardseach.Thethreecardsineachgroupwillbethesameinsomeway.Iwantyoutotellmehowthecardsarethesameineachgroup.BesuretotellmehowIsortedbothgroups,notjustoneofthem.IwillusedifferentwayofsortingthecardseachtimeIputthemintogroups.Iammeasuringhowfastyoucanidentifythesortingrules.Workasfastasyoucan.<placecardsintosetaccordingtorulesintestmanual;waitforparticipanttoexplainsort.>Good,nowI’mgoingtosortthecardsinadifferentway.AgainIwantyoutotellmehowIsortedthetwogroups.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Assoonasoneisidentified,sortnewsetandsayGo!.<Repeatthrough8sorts>.
ð BlockB/D:ð CardSet1/3:NowI’mgoingtoputthesecardsintotwogroupsofthreecardseach.Thethreecardsineachgroupwillbethesameinsomeway.Iwantyoutotellmehowthecardsarethesameineachgroup.BesuretotellmehowIsortedbothgroups,notjustoneofthem.IwillusedifferentwayofsortingthecardseachtimeIputthemintogroups.Iammeasuringhowfastyoucanidentifythesortingrules.Workasfastasyoucan.<placecardsintosetaccordingtorulesintestmanual;waitforparticipanttoexplainsort.>Good,nowI’mgoingtosortthecardsinadifferentway.AgainIwantyoutotellmehowIsortedthetwogroups.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Assoonasoneisidentified,sortnewsetandsayGo!<Repeatthrough8sorts>.
ð CardSet2/4:Likebefore,I’mgoingtoputthesecardsintotwogroupsofthreecardseach.Thethreecardsineachgroupwillbethesameinsomeway.Iwantyoutotellmehowthecardsarethesameineachgroup.BesuretotellmehowIsortedbothgroups,notjustoneofthem.IwillusedifferentwayofsortingthecardseachtimeIputthemintogroups.Iammeasuringhowfastyoucanidentifythesortingrules.Workasfastasyoucan.<placecardsintosetaccordingtorulesintestmanual;waitforparticipanttoexplainsort.>Good,nowI’mgoingtosortthecardsinadifferentway.AgainIwantyou
119
totellmehowIsortedthetwogroups.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Assoonasoneisidentified,sortnewsetandsayGo!<Repeatthrough8sorts>.
TwentyQuestions
ð TheTwentyQuestionsTestmeasurestheabilitytocategorize,formulateabstract,yes/noquestions,andincorporatetheexaminer’sfeedbacktoformulatemoreefficientyes/noquestions
ð OriginalInstructions:ð BlockA/C:Nowwearegoingtodosomethingwhereyouaskmequestions.IhavepickedoneofthesepicturesandIwantyoutofigureoutwhichonebyaskingmequestions.YoucanonlyaskquestionsthatIcanansweryesorno.Youcanaskanyquestionatall,aslongasIcanansweryesorno.TrytoguessthepicturethatIhavepickedwiththefewestnumberofquestionsyoucan.IamgoingtowritedownyourquestionssoIcanrememberthem.Youcantakeasmuchtimeasyouneedtothinkofthequestions.Butyouarelimitedtoatotalof20questionstofigureoutwhichpictureIhaveselected.2ndTask:Good,Let’strythenextone.I’vepickedanewpicture,andIwantyoutoaskmethefewestnumberofyes/noquestionsyoucantofigureoutwhichoneitis.Takeasmuchtimeasyouneed.Beginwhenyouareready.(FormA/Citems:banana,spoon,owl,helicopter)
ð BlockB/D:BlockA/C:Nowwearegoingtodosomethingwhereyouaskmequestions.IhavepickedoneofthesepicturesandIwantyoutofigureoutwhichonebyaskingmequestions.YoucanonlyaskquestionsthatIcanansweryesorno.Youcanaskanyquestionatall,aslongasIcanansweryesorno.TrytoguessthepicturethatIhavepickedwiththefewestnumberofquestionsyoucan.IamgoingtowritedownyourquestionssoIcanrememberthem.Youcantakeasmuchtimeasyouneedtothinkofthequestions.Butyouarelimitedtoatotalof20questionstofigureoutwhichpictureIhaveselected.2ndTask:Good,Let’strythenextone.I’vepickedanewpicture,andIwantyoutoaskmethefewestnumberofyes/noquestionsyoucantofigureoutwhichoneitis.Takeasmuchtimeasyouneed.Beginwhenyouareready.(FormA/Citems:airplane,rose,stove,corn)
ð Time-PressuredInstructions:ð BlockA/C:Nowwearegoingtodosomethingwhereyouaskmequestions.IhavepickedoneofthesepicturesandIwantyoutofigureoutwhichonebyaskingmequestions.YoucanonlyaskquestionsthatIcanansweryesorno.Youcanaskanyquestionatall,aslongasIcanansweryesorno.TrytoguessthepicturethatIhavepickedwiththefewestnumberofquestionsyoucan.IamgoingtowritedownyourquestionssoIcanrememberthem.Iammeasuringhowfastyoucanaskmethequestionsandyouarelimitedtoatotalof20questionstofigureoutwhichpictureIhaveselected.2ndTask:Good,Let’strythenextone.I’vepickedanewpicture,andIwantyoutoaskmethe
120
fewestnumberofyes/noquestionsyoucantofigureoutwhichoneitis.Iammeasuringhowfastyouare.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.>(FormA/Citems:banana,spoon,owl,helicopter)
ð BlockB/D:BlockA/C:Nowwearegoingtodosomethingwhereyouaskmequestions.IhavepickedoneofthesepicturesandIwantyoutofigureoutwhichonebyaskingmequestions.YoucanonlyaskquestionsthatIcanansweryesorno.Youcanaskanyquestionatall,aslongasIcanansweryesorno.TrytoguessthepicturethatIhavepickedwiththefewestnumberofquestionsyoucan.IamgoingtowritedownyourquestionssoIcanrememberthem.Iammeasuringhowfastyoucanaskmethequestionsandyouarelimitedtoatotalof20questionstofigureoutwhichpictureIhaveselected.2ndTask:Good,Let’strythenextone.I’vepickedanewpicture,andIwantyoutoaskmethefewestnumberofyes/noquestionsyoucantofigureoutwhichoneitis.Iammeasuringhowfastyouare.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.>(FormA/Citems:airplane,rose,stove,corn)
TorranceTestofCreativeThinkingAlternateInstructions
ð ProductImprovementð OriginalInstructionsforWrittenResponse(Forreferenceonly-notused)ð Hereisastuffedtoymonkey/elephantofthekindyoucanbuyinmostnoveltystoresforaboutfivetosixdollars.Itisaboutsixinchestallandweighsaboutsixounces/halfapound.Inthespacesonthispageandthenextone,Iwantyoutogivemealistofthecleverest,mostinterestingandunusualwaysyoucanthinkofforchangingthistoymonkey/elephantsothatchildrenwouldhavemorefunplayingwithit.Don’tworryabouthowmuchthechangewouldcost.Thinkonlyaboutwhatwouldmakeitmorefuntoplaywithasatoy.
ð AphasiaFriendlyInstructions,Verbalresponse,andPhysicalobjectð Thisisatoymonkey/elephant(handtotheparticipant).Youmightbuyitforaboutfivetosixdollars.Asyoucansee,itisaboutsixinchestallandweighsaboutsixounces.Forthistask,Iwantyoutogivemealistofthecleverest,mostinterestingandunusualwaysyoucanthinkofforchangingthistoymonkey/elephantsothatchildrenwouldhavemorefunplayingwithit.Don’tworryabouthowmuchthechangewouldcost.Thinkonlyaboutwhatwouldmakeitmorefuntoplaywithasatoy.
ð Participantisallowed(althoughnottold)topickupandmanipulateobjectbutwillonlybegivencreditforverbalresponses.
121
ð TimePressureCondition-AphasiaFriendlyInstructions,Verbalresponse,andPhysicalobject
ð Thisisatoymonkey/elephant(handtotheparticipant).Youmightbuyitforaboutfivetosixdollars.Asyoucansee,itisaboutsixinchestallandweighsaboutsixounces.Forthistask,Iwantyoutogivemealistofthecleverest,mostinterestingandunusualwaysyoucanthinkofforchangingthistoymonkey/elephantsothatchildrenwouldhavemorefunplayingwithit.Don’tworryabouthowmuchthechangewouldcost.Thinkonlyaboutwhatwouldmakeitmorefuntoplaywithasatoy.Youonlyhave3minutes.Soworkquicklyanduseyourtimewisely.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=3minutes.>
ð Participantisallowed(althoughnottold)topickupandmanipulateobjectbutwillonlybegivencreditforverbalresponses.
UnusualUses
ð OriginalInstructionsforWrittenResponse(Forreferenceonly-notused)ð Mostpeoplethrowtheiremptycardboardboxesaway,buttheyhavethousandsofinterestingandunusualuses.Inthespacesbelowandonthenextpage,listasmanyoftheseinterestingandunusualusesasyoucanthinkof.Donotlimityourselftoanyonesizeofbox.Youmayuseasmanyboxesasyoulike.Donotlimityourselftotheusesyouhaveseenorheardabout;thinkaboutasmanypossibleusesasyoucan.
ð AphasiaFriendlyInstructionsandVerbalresponseð Mostpeoplethrowtheiremptycardboardboxesaway,buttheyhavethousandsofinterestingandunusualuses.Forthistask,Iwantyoutolistasmanyoftheseinterestingandunusualusesasyoucanthinkofforacardboardbox.Donotlimityourselftoanyonesizeofbox.Youmayuseasmanyboxesasyoulike.Donotlimityourselftotheusesyouhaveseenorheardabout;thinkaboutasmanypossibleusesasyoucan.
ð TimePressureCondition-AphasiaFriendlyInstructionsandVerbalresponseð Mostpeoplethrowtheiremptycardboardboxesaway,buttheyhavethousandsofinterestingandunusualuses.Forthistask,Iwantyoutolistasmanyoftheseinterestingandunusualusesasyoucanthinkofforacardboardbox.Donotlimityourselftoanyonesizeofbox.Youmayuseasmanyboxesasyoulike.Donotlimityourselftotheusesyouhaveseenorheardabout;thinkaboutasmanypossibleusesasyoucan.Youonlyhave3minutes.Soworkquicklyanduseyourtimewisely.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=3minutes.>
122
CommonUses
ð Verbalresponseð Weuseducttape/stringforanendlessvarietyofthings.Forthistask,Iwantyoutolistasmanyofthecommonwaysweuseducttape.Thinkaboutwaysthatyouhaveseenducttapeused.Youhaveallthetimeyouwant.
ð TimePressureCondition-Verbalresponseð Weuseducttape/stringforanendlessvarietyofthings.Forthistask,Iwantyoutolistasmanyofthecommonwaysweuseducttape.Thinkaboutwaysthatyouhaveseenducttapeused..Youonlyhave3minutes.Soworkquicklyanduseyourtimewisely.Go!<Prominentlydisplaystopwatchandshowthatyouhavepressedthestartbuttontobegintiming.Timeallowed=3minutes.>
Recommended