Guideline adherence in speech and language therapy in stroke aftercare. A health insurance claims data analysis.

BACKGROUND: Impairments to comprehension and production of speech (aphasia, dysarthria) and swallowing disorders (dysphagia) are common sequelae of stroke, reducing patients' quality of life and social participation. Treatment oriented on evidence-based guidelines seems likely to improve outcomes. Currently, little is known about guideline adherence in stroke aftercare for the above-mentioned sequelae. This study aims to analyse guideline adherence in the treatment of aphasia, dysarthria and dysphagia after stroke, based on suitable test parameters, and to determine factors that influence the implementation of recommended therapies. METHODS: Six test parameters were defined, based on systematic study of guidelines for the treatment of speech impairments and swallowing disorders (e.g. comprehensive diagnostics, early initiation and continuity). Guideline adherence in treatment was tested using claims data from four statutory health insurance companies. Multivariate logistic and linear regression analyses were performed in order to test the outcomes. RESULTS: 4,486 stroke patients who were diagnosed with specific disorders or received speech therapy were included in the study. The median age was 78 years; the proportion of women was 55.9%. Within the first year after the stroke, 90.3% of patients were diagnosed with speech impairments and swallowing disorders. Overall, 44.1% of patients received outpatient speech and language therapy aftercare. Women were less frequently diagnosed with specific disorders (OR 0.70 [95%CI:0.55/0.88], p = 0.003) and less frequently received longer therapy sessions (OR 0.64 [95%CI:0.43/0.94], p = 0.022). Older age and longer hospitalization duration increased the likelihood of guideline recommendations being implemented and of earlier initiation of stroke aftercare measures. CONCLUSIONS: Our observations indicate deficits in the implementation of guideline recommendations in stroke aftercare. At the same time, they underscore the need for regular monitoring of implementation measures in stroke aftercare to address group-based disparities in care.

Treatment Fidelity Procedures for an Aphasia Intervention Within a Randomized Controlled Trial: Design, Feasibility, and Results.

Purpose This study reports on the treatment fidelity procedures implemented during a 5-year randomized controlled trial comparing intensive and distributed comprehensive aphasia therapy. Specifically, the results of 1 treatment, verb network strengthening treatment (VNeST), are examined. Method Eight participants were recruited for each of 7 consecutive cohorts for a total of 56 participants. Participants completed 60 hr of aphasia therapy, including 15 hr of VNeST. Two experienced speech-language pathologists delivered the treatment. To promote treatment fidelity, the study team developed a detailed manual of procedures and fidelity checklists, completed role plays to standardize treatment administration, and video-recorded all treatment sessions for review. To assess protocol adherence during treatment delivery, trained research assistants not involved in the treatment reviewed video recordings of a subset of randomly selected VNeST treatment sessions and completed the fidelity checklists. This process was completed for 32 participants representing 2 early cohorts and 2 later cohorts, which allowed for measurement of protocol adherence over time. Percent accuracy of protocol adherence was calculated across clinicians, cohorts, and study condition (intensive vs. distributed therapy). Results The fidelity procedures were sufficient to promote and verify a high level of adherence to the treatment protocol across clinicians, cohorts, and study condition. Conclusion Treatment fidelity strategies and monitoring are feasible when incorporated into the study design. Treatment fidelity monitoring should be completed at regular intervals during the course of a study to ensure that high levels of protocol adherence are maintained over time and across conditions.

To See or Not to See: How Does Seeing Spellings Support Vocabulary Learning?

Purpose The aim of this study was to determine when, why, and how the presence of a word's written form during instruction aids vocabulary learning (a process known as orthographic facilitation). Method A systematic review of the research on orthographic facilitation was carried out. PsycInfo, Web of Science, ProQuest, and OpenGrey databases were searched. The search returned 3,529 results, and 23 of these met inclusion criteria. Studies were included in the review if they were written in English, published in a peer-reviewed journal, and compared vocabulary learning outcomes when words were taught with and without their written forms. Conclusions There is strong evidence that the presence of a word's written form leads to improved learning of its spelling and spoken form. There is also some evidence that it may lead to better learning of a word's meaning. A small number of studies have also shown that the presence of a word's written form benefits vocabulary learning in children with developmental language disorder, autism, Down syndrome, and reading difficulties. However, further research into the effects of orthographic facilitation in special populations is needed. In particular, ecologically valid experiments in clinical and educational settings are required in order to better understand how exposure to a word's written form can aid naturalistic vocabulary learning.

Concurrent Validity of the Fluharty Preschool Speech and Language Screening Test-Second Edition at Age 3: Comparison With Four Diagnostic Measures.

Purpose The aim of this study was to examine the concurrent validity of the Fluharty Preschool Speech and Language Screening Test-Second Edition (Fluharty-2; Fluharty, 2001) for mass screenings of language at age 3 years. Method Participants were sixty-two 3-year-old children, 31 who had failed and 31 who had passed the Fluharty-2. Performance on the screening was compared to 4 diagnostic measures: Structured Photographic Expressive Language Test-Preschool, Second Edition; mean length of utterance in morphemes (MLUm), finite verb morphology composite, and Index of Productive Syntax (IPSyn). Results Children who failed the Fluharty-2 scored significantly lower on each of the diagnostic measures than children who passed the Fluharty-2, but the effect size for MLUm was small. Scores on the Fluharty-2 were significantly correlated with scores on the diagnostic measures. There was significant agreement for pass/fail decisions between the Fluharty-2 and diagnostic measures only for IPSyn. However, even for the IPSyn, the agreement rate for passing was only moderate (80%) and the agreement rate for failing was only fair (68%). Conclusion The Fluharty-2 showed limited agreement for pass/fail decisions with all 4 of the diagnostic measures. There was reason to question the validity of 2 of the diagnostic measures-Structured Photographic Expressive Language Test-Preschool, Second Edition and MLUm-for diagnosing language impairment in 3-year-old children. However, there were no such concerns about finite verb morphology composite or IPSyn to account for the limited agreement. Thus, it seems reasonable to conclude that the Fluharty-2 would refer both too few at-risk children and too many nonrisk children for a follow-up assessment, making it an inefficient tool for mass screenings of language.

Speech and language therapy best practice for patients in prolonged disorders of consciousness: a modified Delphi study.

BACKGROUND: Research regarding speech and language therapy (SLT) for patients in prolonged disorders of consciousness (PDOC) is very limited. The Royal College of Physicians' (RCP) PDOC guideline provides recommendations regarding best practice, but does not give detail about many aspects of assessment and management. As a result, SLTs have little information regarding best practice for this complex patient group. AIMS: To ascertain the degree of consensus amongst expert SLTs regarding SLT best practice for patients in PDOC in order to inform the future development of SLT guidelines. METHODS & PROCEDURES: A two-round modified Delphi technique was used. Participants were recruited from major trauma centres and neurorehabilitation units in England and national SLT clinical excellence networks. To participate, SLTs had to be working on neurosciences, neurosurgery or neurorehabilitation wards that treat adult PDOC patients, or have ≥ 3 years' experience of working with PDOC. The Round 1 questionnaire was developed from the RCP's PDOC guideline and from existing research literature. It included ratings of statements regarding SLT best practice using Likert or temporal scales, with optional written justifications/comments and opportunities for participants to suggest additional statements. The percentage agreement amongst participants was calculated for each Round 1 statement. Written justifications for views were analysed using content analysis. The Round 2 questionnaire contained both quantitative and qualitative feedback from Round 1, allowing participants to reappraise their views. The final degree of consensus was then calculated after completion of both rounds. OUTCOMES & RESULTS: A total of 40 SLTs completed Round 1, with 36 completing Round 2 (90% response rate). Consensus was achieved for 87% (67/77) of statements regarding best practice on a variety of topics including communication, tracheostomy, dysphagia and oral hypersensitivity. The statements represented assessment, management and service delivery components of SLT practice. CONCLUSIONS & IMPLICATIONS: A total of 67 best practice statements were created. The statements provide a useful starting point for the creation of SLT guidelines to support best practice, and also have the potential to be used to advocate for the provision of SLT services for patients in PDOC. Future studies should focus on whether the expert opinion generated here can be borne out in experimental research.

The Methodological Quality of Short-Term/Working Memory Treatments in Poststroke Aphasia: A Systematic Review.

Purpose The aims of this systematic review are to provide a critical overview of short-term memory (STM) and working memory (WM) treatments in stroke aphasia and to systematically evaluate the internal and external validity of STM/WM treatments. Method A systematic search was conducted in February 2014 and then updated in December 2016 using 13 electronic databases. We provided descriptive characteristics of the included studies and assessed their methodological quality using the Risk of Bias in N-of-1 Trials quantitative scale ( Tate et al., 2015 ), which was completed by 2 independent raters. Results The systematic search and inclusion/exclusion procedure yielded 17 single-case or case-series studies with 37 participants for inclusion. Nine studies targeted auditory STM consisting of repetition and/or recognition tasks, whereas 8 targeted attention and WM, such as attention process training including n-back tasks with shapes and clock faces as well as mental math tasks. In terms of their methodological quality, quality scores on the Risk of Bias in N-of-1 Trials scale ranged from 4 to 17 ( M = 9.5) on a 0-30 scale, indicating a high risk of bias in the reviewed studies. Effects of treatment were most frequently assessed on STM, WM, and spoken language comprehension. Transfer effects on communication and memory in activities of daily living were tested in only 5 studies. Conclusions Methodological limitations of the reviewed studies make it difficult, at present, to draw firm conclusions about the effects of STM/WM treatments in poststroke aphasia. Further studies with more rigorous methodology and stronger experimental control are needed to determine the beneficial effects of this type of intervention. To understand the underlying mechanisms of STM/WM treatment effects and how they relate to language functioning, a careful choice of outcome measures and specific hypotheses about potential improvements on these measures are required. Future studies need to include outcome measures of memory functioning in everyday life and psychosocial functioning more generally to demonstrate the ecological validity of STM and WM treatments.

Speech-Language Clinicians Working with Deaf Children: A Qualitative Study in Context.

Students who are deaf or hard of hearing (DHH) increasingly attend local public schools, in which speech and language clinicians (SLCs) may lack experience with the individualized needs of a heterogeneous student population. This study explored the experiences of SLCs with students who are DHH in three different types of educational settings. Fourteen SLCs were interviewed and discussed a case study. Responses were transcribed, data coded, and emergent themes identified. Analysis was verified through triangulation of data and trustworthiness strategies. Results indicated that the skill sets of SLCs working with children who were DHH were dependent on contextual factors, such as educational placement and communication mode used, and that development of these skills requires direct experience, collaboration, and structural supports. Institutions across the deaf education spectrum should consider forming alliances to improve information-sharing and collaborative learning in order to improve service delivery in all settings.

Engaging multiple stakeholders to improve speech and language therapy services in schools: an appreciative inquiry-based study.

BACKGROUND: Effective collaboration between speech and language therapists (SLTs) and teachers is essential in meeting the needs of children with developmental language disorders in school, but it is difficult to achieve. Currently, many children receive inadequate speech and language therapy services and/or support in school. The aim of this study was to engage key stakeholders (SLTs, teachers, parents and children with DLD) in the co-design of their ideal speech and language therapy service and support in school. The study was undertaken in order to inform the development of a conceptual model to guide collaborative practice when working with this population. METHODS: A qualitative study involving a diverse range of key stakeholders and using appreciative inquiry. This is a method which enables those involved to construct their 'ideal' about a topic of interest. Recruitment was carried out using purposive sampling. We conducted focus groups with practitioners (SLTs and teachers) and parents as well as semi-structured interviews with children who have DLD using 'draw and tell' techniques. A total of five focus groups and nine interviews were conducted with participants (n = 27). RESULTS: The children described their ideal supports as those which enabled them to connect, contribute and achieve. They describe ways in which environmental barriers in school needed to be addressed to allow them to do so. The professionals primarily described ways in which the language skills of the child could be improved. Both parents and practitioner groups described the importance of strengthening networks between service providers and service users. They also highlighted the need to promote a collaborative culture if stakeholders are to work effectively together across sectors. CONCLUSIONS: There were differences in perspectives about the ways in which speech and language therapy services and supports could be improved, demonstrating the importance of engaging a diverse group of stakeholders. Of note were the unique insights the children brought about the barriers they faced as a result of their difficulties. Based on our findings we propose that children should be given influence in decisions about the supports that they receive in school. Implications for policy, research and practice are discussed.

Effect Size Benchmarks for Response Elaboration Training: A Meta-Analysis.

Purpose With a number of single-case experimental design studies reporting the effects of treatment for response (and modified response) elaboration training (RET/M-RET), it is important to consolidate data over multiple participants to allow comparison within/between individuals and across similar treatments. The purpose of this study was to conduct a meta-analysis of single-case experimental design studies of RET/M-RET and to determine effect size (ES) benchmarks to allow comparison to "group" data. Method Database and bibliographical searches identified 20 investigations of RET/M-RET. Nine studies had sufficient experimental quality, compliance with the essential components of the RET protocol, and consistency in the dependent variable (i.e., accurate content production in response to picture stimuli) to be retained for the meta-analysis. Probe data for a total of 26 persons with aphasia (PWA) were extracted from published graphs (if raw data were not available) to calculate weighted ESs at the end of treatment and at follow-up for both treated and untreated stimuli. The first, second, and third quartiles of the distributions were used to serve at benchmarks for small, medium, and large effects. Results Nearly all participants demonstrated positive effects as a result of RET/M-RET, indicating an association with positive changes in content production for PWA. Small, medium, and large benchmarks are reported for treated items after treatment and at follow-up, as well as for untreated items after treatment and at follow-up. Conclusions With a larger sample of 26 participants, this analysis indicates that RET/M-RET are associated with positive changes in content production for PWA. ES benchmarks allow clinicians/researchers to compare an individual's performance across multiple applications of treatment to performance of other PWA and to other treatments with similar outcomes.

Treatment integrity of elaborated semantic feature analysis aphasia therapy delivered in individual and group settings.

BACKGROUND & AIMS: This study ran within the framework of the Thales Aphasia Project that investigated the efficacy of elaborated semantic feature analysis (ESFA). We evaluated the treatment integrity (TI) of ESFA, i.e., the degree to which therapists implemented treatment as intended by the treatment protocol, in two different formats: individual and group therapy. METHODS & PROCEDURES: Based on the ESFA manual, observation of therapy videos and TI literature, we developed two ESFA integrity checklists, for individual and group therapy, and used them to rate 15 videos of therapy sessions, delivered by three speech-language therapists (SLTs). Thirteen people with aphasia (PwA) were involved in this study. Reliability of the checklists was checked using Kappa statistics. Each session's TI was calculated. Differences in TI scores between the two therapy approaches were calculated using independent sample t-tests. Treating SLTs' views on what facilitates TI were also explored through a survey. OUTCOMES & RESULTS: Inter- and intra-rater reliability were excellent (.75 ≤ κ ≤ 1.00) for all but one video (κ = .63). Overall, a high TI level (91.4%) was achieved. Although both approaches' TI was high, TI for individual therapy sessions was significantly higher than for group sessions (94.6% and 86.7% respectively), t(13) = 2.68, p = .019. SLTs found training, use of the treatment manual, supervision and peer support useful in implementing ESFA therapy accurately. CONCLUSIONS & IMPLICATIONS: ESFA therapy as delivered in Thales is well described and therapists can implement it as intended. The high TI scores found enhance the internal validity of the main research project and facilitate its replication. The need for more emphasis on the methodological quality of TI studies is discussed.

Information behaviour of French-speaking speech-language therapists in Belgium: results of a questionnaire survey.

BACKGROUND: Speech-language therapists (SLTs) are encouraged to implement evidence-based practice (EBP). Nevertheless, EBP use by practitioners can be questioned. OBJECTIVES: The objective of this study was to explore Belgian French-speaking SLTs' information behaviour and their awareness of EBP. The collected data allow one to determine how far they have embraced this approach. METHODS: The two Belgian French-speaking SLT professional associations promoted an online questionnaire survey by email. Additionally, clinical supervisors of students were asked to participate. In March 2012, 2068 emails were sent. RESULTS: The participation rate was at least 20% (n = 415). The reported information needs mainly concerned treatment or diagnosis. Most of the time, to attempt to fulfil their information needs, SLTs relied on their own resources (personal experience and libraries) and on colleagues in the workplace. When they searched on the Internet, they preferred to use a general search engine rather than a specialised bibliographic database. Barriers to obtaining scientific information are highlighted. Only 12% of the respondents had already heard about EBP. CONCLUSION: This study provides the first overview of the information behaviour of SLTs working in the French community of Belgium. Several recommendations are suggested for SLTs and librarians.

Integrating external evidence of intervention effectiveness with both practice and the parent perspective: development of 'What Works' for speech, language, and communication needs.

AIM: The aim of the study was to develop an ecologically valid synthesis of the evidence underpinning interventions for children with speech, language, and communication needs (SLCN), integrating a range of different data sources. METHOD: Three sources of information were integrated: the Cochrane Review of interventions for children with primary speech and language delays/disorder; current practice from an online survey of 534 speech and language therapists and other professionals working with children with SLCN; and parent reports of preferred outcomes. Evidence was ranked as strong, moderate, or indicative. RESULTS: Of the 58 interventions identified, three (5%) were found to have a strong level of evidence, 32 (56%) had moderate evidence, and 23 (39%) had indicative evidence. Five were universal interventions, the remainder targeted and universal. The integrated findings were then turned into an online interactive database, which is moderated and updated at regular intervals. INTERPRETATION: There are a number of interventions that have a moderate or strong level of evidence underpinning them but they tend not to be those used by practitioners who often favour well-established familiar programmes even if they have only indicative evidence. There is a degree of complementarity between professional and parent views about outcomes, albeit with different emphases.

Prologue: improving clinical practice from the inside out.

PURPOSE: This prologue introduces a clinical forum entitled "Reflections on Improving Clinical Practice" and orients the reader to the scope of articles included within it. METHOD: The purpose of the clinical forum is described, its lead article is introduced, and brief summaries of the 7 response articles are provided. CONCLUSIONS: The commentaries in this clinical forum draw on scientific evidence and assert that current intervention services for children and adolescents who have language and learning disorders could be improved. Authors describe rationales for doing so and provide practical suggestions that could promote better intervention outcomes.

Improving clinical practices for children with language and learning disorders.

PURPOSE: This lead article of the Clinical Forum addresses some of the gaps that exist between clinical practice and current knowledge about instructional factors that influence learning and language development. METHOD: Topics reviewed and discussed include principles of learning, generalization, treatment intensity, processing interventions, components of language therapy, grammar goals, and goal prioritization for students with language and learning difficulties. CONCLUSION: The gaps that exist between current knowledge about learning, language development, and clinical practice often do not receive as much attention as the gaps in the evidence base that addresses the efficacy and effectiveness of language intervention practices and service delivery models. Fortunately, clinicians do not have to wait for future intervention studies to apply their knowledge of learning and language development to clinical practices.

Improving clinical practice: a school-age and school-based perspective.

PURPOSE: In this article, the author presents a conceptual framework for intervention at school-age levels reflecting upon a number of aspects raised by Kamhi (2014) in the lead article of this forum. The focus is on the persistence of traditional practices, components of language intervention, and prioritizing goals for students with language learning difficulties. Weaving together learning and generalization challenges, the author considers advanced levels of language that move beyond preschool and early elementary grade goals and objectives with a focus on comprehension and meta-abilities. METHOD: Using a 3-tiered macrostructure, the author demonstrates how integrating students' background knowledge into intervention, helping them develop an awareness of structure and content interactions, and addressing the increasing demands of the curriculum provide a roadmap for improving clinical practices at school-age levels. CONCLUSION: Reiterating some of Kamhi's notions, the author addresses gaps that exist between available and, often, exciting research in language, literacy, and current practices in schools. Professionals are challenged by the persistence of approaches and techniques that defy what they know about children and adolescents with language learning disabilities. Nonetheless, there are reasons to remain optimistic about the future.

Improving clinical services: be aware of fuzzy connections between principles and strategies.

PURPOSE: This article is a response to Alan Kamhi's treatise on improving clinical practices for children with language and learning disorders by focusing on what is known about learning (see Kamhi, 2014, article in this issue). METHOD: Descriptive methods are used to discuss general learning principles and the fact that they do not always translate readily into effective language intervention practices. The authors give examples of 2 instances in which popular intervention strategies should have worked but did not. The authors also summarize what they learned about their own approach to contextualized language intervention for teaching priority goals related to narration and the Common Core State Standards (CCSS; National Governors Association Center for Best Practices, & Council of Chief State School Officers, 2010). CONCLUSION: Even theoretically sound, well-intentioned, and carefully implemented interventions can result in equivocal outcomes. When they do, careful attention to the evidence and willingness to rethink strategy often serves to right the course.

One size does not fit all: improving clinical practice in older children and adolescents with language and learning disorders.

PURPOSE: In the lead article for this clinical forum, Kamhi (2014) suggests ways that current knowledge on instructional practices in learning and language can be applied to clinical practice in language disorders. I propose that Kamhi's suggestions are in need of fine-tuning for older children and adolescents with language disorders. A one-size-fits-all approach to language intervention across a broad age range is untenable due to unique needs and capabilities of this older population. METHOD: Three intervention goal priorities for older students are presented with supporting research: complex (multiclausal) sentences, verb structure, and expository text. Methodologies for teaching complex sentences are discussed next, including topics of content/form balance and treatment intensity. These goals and methods are designed to assist students with language disorders in the comprehension and production of complex language they encounter in school. CONCLUSION: Guidance for high-priority language intervention goals with older students comes from a consideration of language needs in academic settings and language weaknesses that persist in this population. Although current research offers support for these goals, less is known about methodological variables such as treatment intensity.

Effects of intensive phonomotor treatment on reading in eight individuals with aphasia and phonological alexia.

PURPOSE: The aim of this study was to investigate effects of a multimodal treatment of phonology, phonomotor treatment, on the reading abilities of persons with aphasia (PWA) with phonological alexia. METHOD: In a retrospective, single-group design, this study presents pre-, post-, and 3-months posttreatment data for 8 PWA with phonological alexia. Participants completed 60 hr of phonomotor treatment over 6 weeks. Wilcoxon signed-ranks tests and group effect sizes comparing pre-, immediately post-, and 3-months posttreatment performance on tests of phonological processing and reading were performed. RESULTS: Group data showed phonological processing and oral reading of real words and nonwords improved significantly posttreatment; these gains were maintained 3 months later. No group improvement was found for reading comprehension; however, one individual did show improvement immediately post- and 3-months posttreatment. CONCLUSIONS: This study provides support that phonomotor treatment is a viable approach to improve phonological processing and oral reading for PWA with phonological alexia. The lack of improvement with comprehension is inconsistent with prior work using similar treatments (Conway et al., 1998; Kendall et al., 2003). However, this difference can, in part, be accounted for by differences in variables, such as treatment intensity and frequency, outcome measures, and alexia severity.

Dosing of a cued picture-naming treatment for anomia.

PURPOSE: Recent investigations into effects of intensity or distribution of aphasia therapy have provided moderate evidence supporting intensive therapy schedules on aphasia treatment response. The purpose of the present study was to investigate the feasibility of creating an intensive therapy session without extending the amount of daily time a person spends in treatment. METHOD: Individuals who presented with chronic anomia poststroke (N = 8) participated in 2 weeks of a computerized, therapist-delivered, cued, picture-naming treatment. Dosing parameters for each session were 8 presentations of 50 pictures, totaling 400 teaching episodes per session. RESULTS: Of the 8 participants, 6 achieved significant increases from baseline on trained items after 400 teaching episodes (i.e., 1 treatment hr), and the remaining 2 participants achieved significant increases from baseline after 1200 teaching episodes (i.e., 3 treatment hr). Maintenance data from 7 of the participants indicated that 6 participants maintained significant improvement from baseline on trained items. CONCLUSIONS: Given an intensive and saturated context, anomic individuals were surprisingly quick at relearning to produce problematic words successfully. Most participants demonstrated retention of the gains 2 months after treatment ended. The high density of teaching episodes within the treatment session (i.e., the intensive treatment schedule) may have contributed to the behavioral gains.

Acquisition and maintenance of scripts in aphasia: a comparison of two cuing conditions.

PURPOSE: This study was designed to compare acquisition and maintenance of scripts under two conditions: high cue, which provided numerous multimodality cues designed to minimize errors, and low cue, which provided minimal cues. METHOD: In a randomized controlled crossover study, eight individuals with chronic aphasia received intensive computer-based script training under two cuing conditions. Each condition lasted 3 weeks, with a 3-week washout period. Trained and untrained scripts were probed for accuracy and rate at baseline, during treatment, immediately posttreatment, and at 3 and 6 weeks posttreatment. Significance testing was conducted on gain scores, and effect sizes were calculated. RESULTS: Training resulted in significant gains in script acquisition with maintenance of skills at 3 and 6 weeks posttreatment. Differences between cuing conditions were not significant. When severity of aphasia was considered, there also were no significant differences between conditions, although magnitude of change was greater in the high-cue condition versus the low-cue condition for those with more severe aphasia. CONCLUSIONS: Both cuing conditions were effective in acquisition and maintenance of scripts. The high-cue condition may be advantageous for those with more severe aphasia. Findings support the clinical use of script training and the importance of considering aphasia severity.