Exploring Animal-Assisted Therapy for Creating Rich Communicative Environments and Targeting Communication Goals in Subacute Rehabilitation.

PURPOSE: This study continues our research examining the use of animal-assisted therapy (AAT) for patients with acquired neurogenic communication disorders. AAT pairs an animal/handler team with a licensed therapist during sessions to target discipline-specific goals. Our original study focused on dog/handler teams paired with occupational and physical therapists during inpatient rehabilitation sessions. We documented multiple ways that AAT enriched the communicative environment, increasing the amount, complexity, and voluntariness of patient participation. This study focuses on speech-language pathology sessions, comparing communicative environments during AAT and traditional sessions. We also examined the speech-language pathologists' (SLPs') experiences in learning to plan for and target communication goals for patients during AAT sessions. METHOD: This interpretive design combines ethnographic methods with participatory action research. We recruited 10 patients from an inpatient rehabilitation unit and two SLPs. We video-recorded 20 speech-language pathology sessions (one AAT and one traditional for each patient) and conducted 26 interviews. We consulted with SLPs on how to incorporate AAT into their treatment during their preparation time and used self-report measures to track changes in their planning time and confidence across the 6-week study. FINDINGS: Across participants, AAT sessions provided richer communicative environments than traditional speech-language pathology sessions as measured by participant talk time, mean length of turns, and use of interactional discourse resources such as narrative use and playful language. The SLPs were rapidly able to adapt their clinical practice to incorporate AAT and displayed rapid and marked decreases in their initial planning time and increases in confidence. CONCLUSION: AAT sessions created meaningful, rich, and complex communicative environments in a clinical space for participants to align with others around a shared interest.

The Efficacy of Collaborative Referencing Intervention in Chronic Aphasia: A Mixed-Methods Study.

Purpose The feasibility of a collaborative referencing intervention (CRI) for adults with chronic aphasia has been documented in two descriptive case studies (Devanga, 2014; Hengst et al., 2010, 2008). The current Phase II mixed-methods treatment study replicates the CRI with four additional participants (using interpretive research) and investigates how it impacts a traditional measure, participants' confrontational naming abilities, outside of game play (using multiple-probe single-case experimental design). Method Four adults with chronic aphasia participated in the study composed of (a) three preparatory sessions, (b) five baseline sessions, (c) 15 CRI sessions with five treatment probes, and (d) six maintenance sessions. A collaborative confrontation naming (CCN) probe (i.e., dependent variable) was administered in each baseline, treatment probe, and maintenance session. Each CRI session (i.e., independent variable) consisted of a photo-matching game with participant and clinician partner taking alternative turns identifying and matching personally relevant treatment cards. CCN probes were scored using a multidimensional rating scale. Fidelity and social validity were also assessed. Results Replication of the CRI showed successful and consistent referential learning in all four participant pairs. The multiple-probe analysis of CCN revealed a positive treatment effect on naming in three participants indicating that the CRI was efficacious. High fidelity was maintained throughout the study. Social validity interviews revealed positive outcomes and significant impacts of treatment on the participants' lives. Conclusion The CRI demonstrates strong clinical implications for adults with chronic aphasia. Future research exploring the treatment effectiveness and the implementation to a variety of clinical settings is warranted.

Enriching Communicative Environments: Leveraging Advances in Neuroplasticity for Improving Outcomes in Neurogenic Communication Disorders.

Purpose Research manipulating the complexity of housing environments for healthy and brain-damaged animals has offered strong, well-replicated evidence for the positive impacts in animal models of enriched environments on neuroplasticity and behavioral outcomes across the lifespan. This article reviews foundational work on environmental enrichment from the animal literature and considers how it relates to a line of research examining rich communicative environments among adults with aphasia, amnesia, and related cognitive-communication disorders. Method Drawing on the authors' own research and the broader literature, this article first presents a critical review of environmental complexity from the animal literature. Building on that animal research, the second section begins by defining rich communicative environments for humans (highlighting the combined effects of complexity, voluntariness, and experiential quality). It then introduces key frameworks for analyzing and designing rich communicative environments: distributed communication and functional systems along with sociocultural theories of learning and development in humans that support them. The final section provides an overview of Hengst's and Duff's basic and translational research, which has been designed to exploit the insights of sociocultural theories and research on environmental complexity. In particular, this research has aimed to enrich communicative interactions in clinical settings, to trace specific communicative resources that characterize such interactions, and to marshal rich communicative environments for therapeutic goals for individuals with aphasia and amnesia. Conclusions This article concludes by arguing that enriching and optimizing environments and experiences offers a very promising approach to rehabilitation efforts designed to enhance the reorganization of cognitive-communicative abilities after brain injury. Such interventions would require clinicians to use the principles outlined here to enrich communicative environments and to target distributed communication in functional systems (not the isolated language of individuals).

Pragmatic communication abilities in children and adults: implications for rehabilitation professionals.

PURPOSE: The purpose of this study is to provide a review of pragmatic communication ability and its disorders, as a resource for rehabilitation team members. This review is a product of the Joint Committee on Interprofessional Relations Between the American Speech-Language-Hearing Association and Division 40: Society for Clinical Neuropsychology of the American Psychological Association. METHOD: Review of the literature and expert opinion. RESULTS: We summarize key theoretical frameworks that guide assessment of pragmatic communication ability, describe the developmental progression of pragmatic skills and expectations for children and adults, provide an overview of pragmatic communication disorders, and discuss current assessment approaches. CONCLUSIONS: An understanding of pragmatic communication disorders may assist all rehabilitation team members, as impairments in this domain may have significant effects on rehabilitation progress and outcomes. Implications for Rehabilitation Pragmatic communication ability is the ability to use language in context, beyond understanding and expressing basic word meanings (semantics) in the correct grammatical forms (syntax). Pragmatic communication deficits have been documented in many of the populations frequently referred for rehabilitation, and can affect both progress during rehabilitation and outcomes from treatment. A broader understanding of pragmatic communication functions can help team members identify a patient's strengths and limitations, inform treatment planning, and improve communication among healthcare professionals, thereby contributing to improved outcomes for patients and their families.

Distributed communication: Implications of cultural-historical activity theory (CHAT) for communication disorders.

UNLABELLED: This article proposes distributed communication as a promising theoretical framework for building supportive environments for child language development. Distributed communication is grounded in an emerging intersection of cultural-historical activity theory (CHAT) and theories of communicative practices that argue for integrating accounts of language, cognition and culture. The article first defines and illustrates through selected research articles, three key principles of distributed communication: (a) language and all communicative resources are inextricably embedded in activity; (b) successful communication depends on common ground built up through short- and long-term histories of participation in activities; and (c) language cannot act alone, but is always orchestrated with other communicative resources. It then illustrates how these principles are fully integrated in everyday interactions by drawing from my research on Cindy Magic, a verbal make-believe game played by a father and his two daughters. Overall, the research presented here points to the remarkably complex communicative environments and sophisticated forms of distributed communication children routinely engage in as they interact with peer and adult communication partners in everyday settings. The article concludes by considering implications of these theories for, and examples of, distributed communication relevant to clinical intervention. LEARNING OUTCOMES: Readers will learn about (1) distributed communication as a conceptual tool grounded in an emerging intersection of cultural-historical activity theory and theories of communicative practices and (2) how to apply distributed communication to the study of child language development and to interventions for children with communication disorders.

Thin Versus Thick Description: Analyzing Representations of People and Their Life Worlds in the Literature of Communication Sciences and Disorders.

PURPOSE: Evidence-based practice relies on clinicians to translate research evidence for individual clients. This study, the initial phase of a broader research project, examines the textual resources of such translations by analyzing how people with acquired cognitive-communication disorders (ACCD) and their life worlds have been represented in Communication Sciences and Disorders (CSD) research articles. METHOD: Using textual analysis, we completed a categorical analysis of 6,059 articles published between 1936 and 2012, coding for genre, population, and any evidence of thick representations of people and their life worlds, and a discourse analysis of representations used in 56 ACCD research articles, identifying thin and thick representations in 4 domains (derived from the International Classification of Functioning, Disability, and Health) and across article sections. RESULTS: The categorical analysis identified a higher percentage of ACCD articles with some evidence of thick representation (30%) compared with all CSD articles (12%) sampled. However, discourse analysis of ACCD research articles found that thick representations were quite limited; 34/56 articles had thin representational profiles, 19/56 had mixed profiles, and 3/56 had thick profiles. CONCLUSIONS: These findings document the dominance of thin representations in the CSD literature, which we suggest makes translational work more difficult. How clinicians translate such evidence will be addressed in the next research phase, an interview study of speech-language pathologists.

Severe speech sound disorders: an integrated multimodal intervention.

PURPOSE: This study introduces an integrated multimodal intervention (IMI) and examines its effectiveness for the treatment of persistent and severe speech sound disorders (SSD) in young children. The IMI is an activity-based intervention that focuses simultaneously on increasing the quantity of a child's meaningful productions of target words and providing supports to shape the quality of natural speech productions of target sounds by systematically incorporating the full range of each child's communicative repertoire, including augmentative and alternative communication (AAC) systems and natural speech and language. METHOD: A multiple-probe single-subject research design was used to assess the effectiveness of the IMI for 3 boys (ages 4 to 8) with moderate to severe SSD, all of whom used speech-generating AAC. RESULTS: All 3 participants demonstrated an increase in the amount of speech they produced (i.e., quantity) and an increase in the production accuracy of their target speech sounds (i.e., quality). CONCLUSION: This study demonstrated that simultaneously targeting natural speech and AAC speech using an integrated multimodal approach was effective in producing positive changes in both communication and speech production goals. These findings strongly suggest that integrating multimodal speech-generating AAC with traditional speech intervention was effective at supporting natural speech production for these children.

Distributed impact of cognitive-communication impairment: Disruptions in the use of definite references when speaking to individuals with amnesia.

BACKGROUND: Definite references signal a speaker's belief that a listener can uniquely identify the referent (e.g., the dog, as the only dog among a group of animals). Clark's (1992) collaborative referencing model provides a way to examine the speaker's display of confidence that his/her reference will be understood by the listener without further clarification. We previously found that amnesia participants, as directors in a barrier task with a familiar partner, used referencing forms that displayed less confidence than forms used by comparison participants. If this is an interactional consequence of managing the memory impairment (as opposed to a language deficit), we should also expect a decrease in definite referencing by their partners. AIMS: To examine the use of definite references by healthy non-brain-damaged participants when speaking to their memory-impaired partner during repeated trials of a barrier task. METHODS #ENTITYSTARTX00026; PROCEDURES: We replicated our previous work with 11 of the same participant pairs-6 individuals with hippocampal amnesia and 5 comparison participants-each of whom was paired with a familiar partner of their choosing. Focusing on the productions of the partners (i.e., partners became directors) we (1) coded referential expressions as definite or indefinite; (2) tracked changes in the use of indefinite and definite references across trials; and (3) compared data to previous analyses (when amnesia participants were directors). OUTCOMES #ENTITYSTARTX00026; RESULTS: The productions of comparison pairs were overwhelming definite (95%, 1359). In sharp contrast, partners of the amnesia participants used a definite initiating reference less than half the time (48%, 825), when speaking to their memory-impaired partner and used definite references that signalled a lack of confidence more often and across more trials. CONCLUSIONS: These findings support the assumption that disruptions in language-and-memory-in-use are not limited to the productions of the individuals with amnesia, but rather extend to the discourse of their communication partners. Observing disruptions in the use of definite references of individuals with intact language and declarative memory, when communicating with their partner with amnesia, points to the complex interaction of memory and language. Even when attention is paid to grammatical forms, the decisions are never linguistic alone.

The use of definite references signals declarative memory: evidence from patients with hippocampal amnesia.

Language function in patients with impaired declarative memory presents a compelling opportunity to investigate the inter-dependence of memory and language in referential communication. We examined amnesic patients' use of definite references during a referential communication task. Discursively, definite references can be used to mark a referent as situationally unique (e.g., "the game," as in the case of a recently publicized game) or as shared information (e.g., "the game," as in one discussed previously). We found that despite showing normal collaborative learning after repeated referring-as indexed by consistent and increasingly efficient descriptive labels for previously unfamiliar tangram figures-amnesic patients did not consistently use definite references in referring to those figures. The use of definite references seems to be critically dependent on declarative memory, and the engagement of such memory is signaled by language.

Hippocampal amnesia disrupts verbal play and the creative use of language in social interaction.

BACKGROUND: While the neural substrates and cognitive components of creativity have received considerable attention in cognitive neuroscience, the creative use of language in social interaction has been less well studied. As part of a broader program of research on language-and-memory-in-use in individuals with hippocampal amnesia, we analyzed verbal play, a creative use of language that is pervasive in everyday communicative interaction. AIMS: To identify instances of creative uses of language in the protocols of social and collaborative interactions, to characterize the qualitative nature, and to determine the frequency of these interactions initiated by participants with hippocampal amnesia vs. comparison participants in order to ascertain whether amnesia impairs this aspect of social communication. METHODS AND PROCEDURES: This study uses quantitative group comparisons and detailed discourse analysis to analyze verbal play in the interactional discourse sessions of 4 participants with hippocampal amnesia and 4 healthy (demographically matched) comparison participants, each interacting with a familiar partner while completing a collaborative referencing task and with a researcher between task trials. RESULTS: All participants used verbal play. However, significantly fewer episodes were initiated in sessions with amnesia participants (312) and by participants with amnesia themselves (187) than in sessions with comparison participants (572) and by comparison participants (395). No significant group differences were observed for interactional forms, resources, or functions. Qualitative differences were also observed in amnesia sessions (e.g., more rotely produced episodes, lack of thematically linked episodes). CONCLUSIONS: These findings suggest that hippocampal amnesia disrupts the creative use of language in social interaction and accord with our previous work pointing to impairments in language-and-memory-in-use more broadly. These findings highlight the interdependence of language and memory especially in the interactional aspects of communication.

Multiple voices in clinical discourse and as clinical intervention.

BACKGROUND: Grounded in sociocultural theories of language development and use, this paper explores the concept of dialogic voice. Building on the term 'dialogue', dialogic voice points to the fundamentally social nature of language-in-use. From this perspective, language emerges from specific histories and thus carries the multiple voices of previous speakers. People draw on these voices to think about and represent the world, communicate with others, construct their own identities, and engage in play. Prior (2001) identified three key dimensions of dialogic voicing: typified social voices, re-envoicing others' words and acts, and personalized voice. AIMS: To present a theoretical framing for dialogic voice; to detail the dimensions of dialogic voice; and to offer a preliminary analysis of dialogic voicing in clinical discourse. METHODS & PROCEDURES: Data consisted of ten treatment sessions for a 67-year-old man with amnesia and aphasia, using a collaborative barrier task protocol. Discourse analysis and selective coding were used to identify the three dimensions of dialogic voice in both clinician and client utterances. OUTCOMES & RESULTS: During this collaborative task, the client and clinician produced an array of voices, including: (1) typified social voices to display professional expertise, family identities, and shared interests; (2) re-envoicing others' words and acts in both task and non-task interactions; and (3) personalized voicing, displayed mostly in the client's discourse. CONCLUSIONS: Attention to dialogic voicing offers a way to see and reflect on the heterogeneity of discourse and the multiple identities that clinicians and clients alike can, and do, display in clinical settings. Tracing the complex interplay of multiple voices provides us with insights into rich communicative environments that, from a sociocultural perspective, provide opportunities for initiating change in the communicative practices of clients, their communicative partners, and ultimately clinical practice itself.

Hippocampal amnesia disrupts the flexible use of procedural discourse in social interaction.

BACKGROUND: We have worked to develop rich communicative environments as a way to study the real-world demands that communication places on language-and-memory-in-use by focusing on the impact of declarative memory impairments on social interaction. Here, we analyse procedural discourse-the practice of telling another person how to do something (e.g., giving directions). AIMS: To facilitate comparison to previous research on procedural discourse, this study includes an analysis of the procedural steps produced by target participants. This study also offers a novel approach by focusing on the collaborative and interactional nature of how procedural discourse is produced to meet the demands of real-world communication. METHODS AND PROCEDURES: Procedural discourse samples were obtained on nine individuals with hippocampal amnesia and nine comparison participants each interacting with a clinician. Using traditional procedural and linguistic-based measures and interactional discourse measures, we analysed target participants' individual contribution to procedural descriptions and contributions of both the clinician and participant across the samples. OUTCOMES #ENTITYSTARTX00026; RESULTS: No significant group differences were observed for procedural and linguistic-based measures. Rather, participants with amnesia were more reliably distinguished on interactional discourse measures (e.g., lack of engagement and support for clinician, less detail and personalisation of procedural steps, difficulty in shifting social stance). CONCLUSIONS: These findings accord with our previous research suggesting that hippocampal amnesia disrupts the flexible deployment of declarative knowledge and the ability to shift social stances/perspectives to meet the demands of social interaction. These findings contribute to the evolving portrait of language-and-memory-in-use and further support the value of examining interactional aspects of communication in the empirical study of brain-behaviour relationships.

Collaborative discourse facilitates efficient communication and new learning in amnesia.

In previous work we reported robust collaborative learning for referential labels in patients with hippocampal amnesia, resulting in increasingly rapid and economical communication or "common ground" with their partners [Duff, M. C., Hengst, J., Tranel, D., & Cohen, N. J. (2006). Development of shared information in communication despite hippocampal amnesia. Nature Neuroscience, 9(1), 140-146]. The current paper reports the results of discourse analysis, describing the communicative resources and practices used in extended, repeated collaborative interactions, as partners successfully referenced the target cards, managed the task itself, and engaged in non-task talk. Although amnesic pairs showed a normal rate of reduction across trials in the number of words and time-to-completion, their communicative effort was higher overall, particularly the discourse associated with task management, they exhibited a general lack of flexibility in their referential expressions, and they showed a number of striking differences in use of personal and communal knowledge and of multiple perspectives. The interactive sessions provided a potent learning environment, but also a very challenging task in the face of memory impairment. The results give insight into the acquisition of common ground and the manner in which amnesic patients accommodate their memory deficits during real-world interactions, and they have significant implications for memory intervention.

Talking across time: Using reported speech as a communicative resource in amnesia.

BACKGROUND: Patients with amnesia may have more than pure memory deficits, as evidenced by reports of subtle linguistic impairments on formal laboratory tasks in the amnesic patient HM. However, little attention has been given to the impact of memory impairments on language use in regular, colloquial interactions. We analysed reported speech use by individuals with amnesia. Reported speech (RS), in which speakers represent thoughts/words from another time and/or place, requires management of two temporal frames, making it an interesting discourse practice in which to explore the impact of memory deficits on interactional aspects of communication. AIMS: This study: (1) documents frequency, type, and temporal contexts of reported speech used in discourse samples; (2) compares reported speech use by amnesic and comparison participants; (3) examines the interactional character of reported speech use in these discourse samples. METHODS AND PROCEDURES: Derived from a broader study of the discourse practices of individuals with amnesia, this study uses quantitative group comparisons and close discourse analysis to analyse reported speech episodes (RSEs) in interactional discourse samples between a clinician and each of 18 participants, 9 individuals with amnesia and 9 comparison participants (NC). OUTCOMES AND RESULTS: Reported speech was used by all participants. However, significantly fewer RSEs were produced in amnesia sessions (273) than in NC sessions (554). No significant group differences were observed for type or temporal domain. In addition, for the participants with amnesia, post-amnesia past RSEs differed qualitatively from the other RSEs in the data. CONCLUSIONS: These findings have important implications for understanding the interdependent relationship of memory and language, point to the value of examining interactional aspects of communication in the empirical study of brain-behaviour relationships, and reconceptualise interaction as a target in the remediation of functional communication following brain injury.

Using others' words: conversational use of reported speech by individuals with aphasia and their communication partners.

Reported speech, wherein one quotes or paraphrases the speech of another, has been studied extensively as a set of linguistic and discourse practices. Researchers agree that reported speech is pervasive, found across languages, and used in diverse contexts. However, to date, there have been no studies of the use of reported speech among individuals with aphasia. Grounded in an interactional sociolinguistic perspective, the study presented here documents and analyzes the use of reported speech by 7 adults with mild to moderately severe aphasia and their routine communication partners. Each of the 7 pairs was videotaped in 4 everyday activities at home or around the community, yielding over 27 hr of conversational interaction for analysis. A coding scheme was developed that identified 5 types of explicitly marked reported speech: direct, indirect, projected, indexed, and undecided. Analysis of the data documented reported speech as a common discourse practice used successfully by the individuals with aphasia and their communication partners. All participants produced reported speech at least once, and across all observations the target pairs produced 400 reported speech episodes (RSEs), 149 by individuals with aphasia and 251 by their communication partners. For all participants, direct and indirect forms were the most prevalent (70% of RSEs). Situated discourse analysis of specific episodes of reported speech used by 3 of the pairs provides detailed portraits of the diverse interactional, referential, social, and discourse functions of reported speech and explores ways that the pairs used reported speech to successfully frame talk despite their ongoing management of aphasia.

Collaborative referencing between individuals with aphasia and routine communication partners.

H. H. Clark (1992) argues that successful referencing depends on speakers and listeners working together to establish shared perspectives on target objects. In his collaborative referencing model, he identifies 3 phases in the referencing process: initiation, refashioning, and acceptance. For referencing tasks, successful collaboration can be seen in the streamlining of referencing expressions and in the decrease of overt collaborative effort across trials. Although previous studies have shown that speakers with aphasia can be successful on referencing tasks, they have not examined how that success is achieved through the collaborative work of the partners. Using a referencing task adapted from H. H. Clark and D. Wilkes-Gibbs (1986), this study examined how 4 adults with moderate-to-severe aphasia collaborated with routine communication partners (spouses or children). Overall, these pairs completed the referencing task trials with 96% accuracy and displayed referencing processes that generally conformed to Clark's collaborative referencing model. Close analysis of the discourse of these interactions revealed patterns of collaboration that went beyond Clark's model-the pairs used diverse verbal and nonverbal resources, actively negotiated the task across trials, and layered their own personal goals and perspectives onto these interactions. This study highlights the plasticity of functional communication (the diversity of ways the pairs worked together to complete the same task) and points to the importance of understanding processes of tacit learning that take place in social interactions.