Alexia: Theoretical Perspectives, Diagnosis, and Treatment

Home , Agraphia, Aphasia, Aphasiology, Deep dyslexia, Pure alexia, Surface dyslexia

BRETT MCCARDEL, MS, CCC-SLP ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC

Disclosure: Brett McCardel is the owner and founder of Archways-Aphasia Rehabilitation Services PLLC, a private practice that specializes in providing speech and language services to people with aphasia.

Mr. McCardel has no other relevant financial or nonfinancial relationships to disclose.

• Undergrad: University of Georgia • Graduate School: Boston University • Clinical Fellowship: VA Puget Sound • Professional Memberships: Aphasia Access, Academy of Neurological Communication Disorders

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Overview • Classification (Syndrome and Psycholinguistic Approaches) • Psycholinguistic Models for Alexia • Diagnosing with a Psycholinguistic Approach • Treating with a Psycholinguistic Approach • Single Word-Level • Sentence-Level • Paragraph-Level • Life Participation Approach to Aphasia

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC What is Alexia? • Alexia is an acquired impairment of reading • Different from dyslexia (developmental reading disorder) • There can be different alexia profiles in individuals with brain damage • Understanding the nature of the reading impairment informs our treatment • Distinct cognitive components of reading  development of psycholinguistic models

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Syndrome Classifications •Alexia with Agraphia • Left angular gyrus lesions • Difficulties in reading and writing • Alexia without Agraphia (Pure Alexia) • https://www.youtube.com/watch?v=KERQv9FIxkw • Left occipital damage • Typically preserved writing abilities • Reading is characterized by “letter-by-letter” approach • Often accompanied by right homonymous hemianopia • Third Alexia (also known as Frontal/Anterior Alexia) • Pros: Efficient, easy to communicate between providers • Cons: Lesion sites can vary, patients within categories drastically different

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Psycholinguistic Approach • Language is made of various processing components • Flow of information between components • Attempt to describe normal language processing • Classify patient by damage to these components • Can have more than one impairment •Understand underlying impairment • Guide appropriate treatment approaches

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Language Processing model for single words, based on Patterson and Shewell’s (1987) logogen model (image taken from Whitworth, Webster, and Howard, 2013)

• Each component of the model is responsible for a separate function in the reading process • Accounts for reading both real words and nonwords

• Lexical Reading Route • Lexical Nonsemantic Reading Route • Nonlexical Reading Route

• Analyze the individual visual parts of each letter • “P”: single vertical line attached to a curved line

• Identify the letter • Its position to other letters in word • Identify graphemes in a word • Bush: 4 letters, but 3 graphemes (b-u-sh) • Identifies letters simultaneously and in parallel

• Is this word familiar to me or not? • Does NOT allow the reader to pronounce or derive meaning • Multiple words compete for activation

• Associate visual form of word to its meaning • Cat: small, 4 legs, furry, whiskers

• Store of the phonological form of familiar words • Do I know what it should sound like in my head before I say it? • The “blueprint” for the word’s sounds

• Break down word into its individual sounds • The “assembly line”

• Process of the following steps: • Visual Feature Analysis • Orthographic Input Lexicon • Semantic System • Phonological Output Lexicon • Phonological Assembly • Reading for meaning

• Process of the following steps: • Visual Feature Analysis • Orthographic Input Lexicon • Semantic System • Phonological Output Lexicon • Phonological Assembly • Read a word correctly, but no idea behind meaning • “Hyena….what is that?”

• Reading by using Grapheme-Phoneme Conversion skills (Letter-Sound Correspondence) • Not reading for meaning; can correctly read word, but unknow

• Lexical Reading Route • Lexical Nonsemantic Reading Route • Nonlexical Reading Route

Lexical Processing: • Orthographic Input Lexicon • Semantic System Central • Phonological Output Lexicon Sublexical Processing: • Grapheme-Phoneme Conversion

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Peripheral • Neglect Alexia and Hemianopic Alexia • Attentional Alexia • Visual Alexia Psycholinguistic • Letter-by-Letter Alexia Classifications Central • Surface Alexia • Deep Alexia • Phonological Alexia

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Diagnosing an Alexia Need to consider linguistic variables • Real words vs Non-words • Regular vs Irregular • Regular: cat, drink • Irregular: yacht, psychic • Imageability • High-imageability: jury • Low-Imageability: justice

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Assessments for Alexia (Single Word) • Arizona Battery for Reading and Spelling (http://aphasia.arizona.edu/A phasia_Research_Project/Ass essment_Materials.html) • 80 words (40 regularly spelled, 40 irregularly spelled, 20 nonwords) • All real words controlled for frequency and # of letters

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Assessments for Alexia (Single Word) • Psycholinguistic Assessment of Language Processing in Aphasia (PALPA) • Comprehensive Aphasia Test (CAT) • Johns Hopkins University Dyslexia and Dysgraphia Batteries • Reading Comprehension Battery for Aphasia-2nd edition (RCBA-2)

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Neglect/Hemianopic Alexia • Incorrectly identifying initial or final letters in a word •Result of impaired letter analysis • Neglect alexia IS NOT necessarily a consequence of a general visual neglect • Hemianopic alexia IS a consequence of general visual neglect •Neglect alexia: • Consistent spatially determined errors • Can typically find a “neglect point” across words • Errors typically similar in length to stimulus word

Left Neglect Alexia Right Neglect Alexia LOG’dog’ LOG’lot’ RIVER’liver’ BOOK’boot’ YELLOW’pillow’ BUCKET’buckle’

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Attentional Alexia • Interference/migration of letters from other words • Result of impaired letter analysis • Difficulty identifying spatial relationship between letter • Examples: • RIVERBANK’biverbank’ • HOT MEAL’hot heal’ • BUTTERFLY’flutterfly’ • BARE’rare’

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Visual Alexia • Misidentifying one word for a visually similar one • No detectable pattern for where errors occur • Errors are almost always real-word substitutions • Result of impaired letter analysis OR orthographic input lexicon • Examples: • LEND’land’ • EASEL’aerial’ • CALM’claim’

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Letter-by-Letter Alexia • Letters unable to be identified simultaneously and/or in parallel • Incredibly slow reading • 50% of patients reported to have accompanying surface alexia • Result of impaired access to letter analysis OR access to OIL • Lack of cognitive resources to transition to different systems • Examples: • CHAIR’c-h-a-i-r…chair’ • TABLE’t-a-b…table’ • LAMP’l-a-n-p…no….l-a-m…lamp’ • TOOL’f-o-o-l…fool’

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Additional Standardized and Unstandardized Assessment for Peripheral Alexias •Standardized Assessment: • PALPA 18: Mirror Reversal • PALPA 19: Upper-case/lower-case matching • PALPA 20: Lower-case/upper-case matching • PALPA 21: Letter Discrimination • PALPA 22: Letter Naming/Sounding • PALPA 23: Spoken Letter/Written Letter Matching • PALPA 29: Letter Length Reading •May also consider general visual screening: • Go see optician for eye exam • Ensure glasses are worn if needed • Check influence of print size • Line bisection/letter cancellation/star cancellation

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Surface Alexia • Impairment in lexically-mediated reading route • Grapheme-phoneme conversion is relatively preserved • Lexical route could be impacted at any/multiple points • OIL, SS, POL • Characteristic Features: • Regular words read better than irregular words • Relatively preserved nonword reading

• Examples: • Phonologically plausible errors: YACHT’/jaet∫t/’ • Regularization errors: PINT’/pInt/’ • Visual errors: BLANK’bank’ • Both visual and semantic errors: CAR’cab’

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Deep Alexia • Impairment in lexically-mediated reading route AND G-P Conversion • G-P Conversion and at least one lexical component impaired • Characteristic Features: • Semantic errors • Unable to read nonwords • High-imageability read better than low-imageability • Content words read better than functor words

• Examples: • Semantic errors: MONKEY’ape’ • Morphological errors: LOVING’lovely’ • Visual errors: DOOR’doom’ • Function word substitutions: HIM’was’

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Phonological Alexia • Impairment in G-P Conversion • Relatively preserved lexical components • Characteristic Features: • Poor/non-existent nonword reading • Often lexicalized (e.g., SOOF’soot’) • Difficulties with segmenting, blending • Preserved/relatively good real word reading • Problems with function words and bound morphemes • High-imageability better than low-imageability words • Content words better than function words • Morphologically simple better than morphologically complex words

• Examples if real word reading is impaired: • Semantic errors: MONKEY’ape’ • Morphological errors: LOVING’lovely’ • Visual errors: DOOR’doom’

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Treatment at the Single-Word Level • Treatment will be grouped by alexia subtype • Not everyone will fit into these, though • Many individual case studies that address a single language processing component • Class 3 quality (weakest evidence) • Worthwhile to incorporate principles from these studies if needed • Refer to end of powerpoint for textbooks and online web resources that go into further detail for all these studies and treatment approaches

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Treatment for Neglect/Hemianopic Alexia •Hemianopic (potentially Neglect as well): Moving Text/Read Right Software (Kerkhoff et al., 1992; Spitzyna et al., 2007; Ong et al., 2012; Woodhead, et al. 2015) • http://www.readright.ucl.ac.uk/index.php • https://www.youtube.com/watch?v=Ec5sRGNPKIM • Words are read aloud as they move across a screen from left to right • Training of eye movements to assist in reading • Hemianopic + Neglect: Oculomotor Training (Schuett et al., 2008) • Word appears on screenpatient instructed to intentionally shift gaze to beginning/end of word • Gradually decrease stimulus presentation time • Neglect: Prism adaptation (Redding, 2006)

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Treatment for Visual, Attentional, and Letter-by-Letter Alexia • Letter ID training (Ablinger & Domahs, 2009; Lott et al. 2010; Sage et al., 2005) • Consider both upper and lower case • Consider training digraphs as well (https://www.math.cornell.edu/~mec/2003- 2004/cryptography/subs/digraphs.html) • Consider training grapheme-phoneme correspondence at same time • Some people advocate teaching letter-by-letter as compensatory strategy (tactile-kinesthetic cueing) • Multi-component Reading Intervention (Brown et al., 2016) • (a) decoding consonant-vowel-consonant (CVC) words • (b) performing grapheme-to-phoneme activities requiring letter recognition, naming, and associated phoneme production • (c) engaging in repeated and choral reading tasks • (d) performing modified Anagram and Copy Treatment and Copy and Recall tasks • (e) engaging in reading of functional materials.

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Treatment for Visual, Attentional, and Letter-by-Letter Alexia • Whole Word Reading • Brief Exposure Training (Ablinger and Domahs, 2009) • Show word for a limited amount of time in order to prevent letter-by-letter reading • Force direct access/fast mapping • Consider training the most common words in English and personally-relevant words • Example of a corpus: Dolch Words (https://en.wikipedia.org/wiki/Dolch_word_list) • Semantic Approach (Viswanathan and Kiran, 2005) • Sublexical Conversion and Semantic Feature Analysis—protocol is as follows: • 1. Oral Reading of Target Word • 2. Written Spelling • 3. ID of Letters from the Word from Phonological and Orthographic Distractors • 4. ID of Randomly Selected Letters of Target Word • 5. Oral Reading of Letter Names of Target Word • 6. SFA of Target Word • 7. Oral Reading of Target Word

• Sentence/Passage Level: Multiple Oral Reading (Kim and Russo, 2010; Lacey et al., 2010) •To be explained further in Sentence-Level Treatment Slides

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Treatment for Surface Alexia • Lexical/whole word reading treatment (Coltheart & Byng, 1989; Scott and Byng, 1989) • Train irregular patterns in English (e..g, “-ough”) • Create cards with written word and picture, and have patient read aloud each word • Speeded Presentation (Moss et al., 1991): 3 Tasks • Task 1: Forced semantic analysis (pt saw word for 1 second and asked to name category) • Task 2: Rapid reading aloud of irregular words • Task 3: Homophone selection (pt read paragraph silently and selected appropriate homophone based on context e.g., flour/flower) • Building Sight Vocabulary (Weekes and Coltheart, 1996) • Target word presented on card with corresponding picture and phonetic spelling also written (e.g., Litre=“leeter” •Simultaneous Spelling (Francis et al., 2001) • Simultaneous oral spelling of irregular words

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Treatment for Phonological/Deep Alexia • Beeson’s Phonological Treatment (2010) https://aphasia.sites.arizona.edu/content/10 •Cueing hierarchy used to train phoneme-grapheme/G-P correspondence • Teach “key words” for each sound • Step 1: Write letter that goes with target phoneme • Step 2: Think of “key word” paired with phoneme and try to write or say it • Step 3: Show picture of key word, write the word, and underline target phoneme • Step 4: Copy key word • Also consider adding segmentation and blending tasks using words and non-words

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Treatment for Phonological/Deep Alexia • Bigraph segment blending (Bowes and Martin, 2007; Friedman and Lott, 2002; Kim and Beaudoin- Parsons, 2007)) • 1-syllable reading: read bigraphs and then blend together into whole word • 2-syllable reading: progress from reading bigraphs to syllables to whole words (e.g., CA-ME-ELCA- MELCAMEL) • Reading phrases: Nouns and verbs read syllable by syllable and then as a phrase • Phonomotor Treatment (Brookshire et al., 2014) • https://canvas.uw.edu/courses/1166215 • https://www.youtube.com/watch?v=Vq1zIUiACOk • Phonological Complexity Training (Riley and Thompson, 2015) • Pick training of initial consonant clusters with large/complex (pl) and small/simple (gl) sonority differences • Have patient read target word and then complete 3 phonological tasks: • 1. Phoneme segmentation • 2. Grapheme-Phoneme Matching • 3. Phoneme Blending •Semantic Association (Ska et al., 2003) • Form mental associations between a picture and a written word

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC 1. Lexical Decision 2. Oral Reading 3. Repetition Combined 4. Word-Picture Matching Lexical and 5. Semantic Feature Analysis/Generation Sublexical 6. Grapheme to Phoneme Conversion 7. Anagram Spelling Approach 8. Grapheme to Phoneme Conversion (Johnson et al., 9. Phoneme to Grapheme Conversion 2017) 10. Oral Reading

11. Repetition Steps 2, 6-10, and 12 12. Delayed Reading considered by researchers to be the most impactful 13. Repetition

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Combined Lexical and Sublexical Approach (Johnson et al., 2017) 1. Lexical Decision: The clinician presented the written target word and a non-word foil and asked the patient to identify the target. If correct, they proceeded to Step 2. If incorrect, the clinician corrected the patient before proceeding (targets the OIL) 2. Oral Reading: The clinician prompted the patient to read the target word aloud. Accuracy feedback was provided and treatment proceeded to Step 3 (targets the OIL and POL) 3. Repetition: With the target still visible, the clinician verbally stated the target and asked the patient to repeat it. If incorrect, the clinician provided cues (e.g., visual articulatory placement cues or segmenting the target into smaller chunks) and the task was attempted again (targets the OIL, PIL, POL) 4. Word-Picture Matching: The clinician presented the written target and three pictures (the target plus two other items from the trained set) and asked the patient to identify the picture corresponding to the target. If incorrect, the clinician removed the incorrectly identified picture and the task was repeated with a field of two. If still incorrect, the clinician corrected the patient before proceeding to Step 5 (targets OIL, SS)

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Combined Lexical and Sublexical Approach (Johnson et al., 2017) 5. Semantic Feature Analysis/Generation: Presented with the picture of the target, the patient was prompted to generate features and/or verify the accuracy of features as presented by the clinician. Feedback was provided regarding the accuracy of patient responses (targets the SS) 6. Grapheme-Phoneme Conversion: Individual letters comprising the target word plus a number of extra letters were presented to the patient in random order. The patient produced the phoneme associated with each letter. If the patient produced the incorrect phoneme, s/he was instructed to repeat it after the clinician produced it (targets the GPC) 7. Anagram Spelling: Using the tiles presented in Step 6, the patient spelled the target word. As needed, the clinician provided the phonemes as cues to help the patient with letter selection (e.g., “find the letter that makes the sound /b/”). If the patient selected the wrong letter, the clinician identified it and provided the phoneme so that the patient could repeat it (targets the OOL and PGC)

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Combined Lexical and Sublexical Approach (Johnson et al., 2017) 8. Grapheme-Phoneme Conversion: The clinician pointed out the individual graphemes moving from left to right across the target word and the patient produced the corresponding phonemes. For this step, the patient was prompted to produce the phoneme associated with the grapheme in the specific context of the target word. Incorrect productions were corrected by the clinician and the patient was instructed to repeat the clinician’s production (targets the GPC) 9. Phoneme-Grapheme Conversion: The clinician randomly produced a phoneme and the patient identified the corresponding grapheme in the target word. If the patient selected the incorrect grapheme, the correct grapheme was identified and the patient was instructed to study it while repeating the phoneme (targets the PGC) 10. Oral Reading: The clinician prompted the patient to read the target word aloud. Accuracy feedback was provided and treatment continued with Step 11 (targets the OIL and POL).

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Combined Lexical and Sublexical Approach (Johnson et al., 2017) 11. Repetition: With the target visible, the clinician verbally produced the target and the patient repeated it. Cueing was provided as needed (as in Step 3; targets the OIL, PIL, and POL) 12. Delayed Reading: The patient counted to 10 and then read the word aloud. Accuracy feedback was provided and treatment continued with Step 13 (targets the PB and POL) 13. Repetition: The clinician produced the target word and the patient repeated it. Cueing was provided as in Steps 3 and 11.

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Assessment at the Sentence- Level • CAT: Written Sentence Comprehension • Kempler Sentence Comprehension Test (http://word.emerson.edu/daniel_kempler /kempler-sentence-comprehension-testt/) • PAL 27: Written Sentence Comprehension • Psycholinguistic Assessment of Language (Caplan, unpublished; contact Dr. David Caplan at [email protected])

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Assessment at the Sentence-Level Difficulties may be due to a variety of reasons: • Syntax difficulties • Kempler Sentence Comprehension Test • Northwestern Assessment of Verbs and Sentences (NAVS): Sentence Comprehension Test

• Attention and Working Memory • N-Back (Wright et al., 2007)

• Morphology (especially tense) • Northwestern Assessment of Verb Inflection

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Treatment at the Sentence-Level Multiple Oral Rereading—MOR (Kim and Russo, 2010; Lacey et al., 2010) http://tactustherapy.com/mor-multiple-oral-rereading-how-to/

• Goal: Increase reading rate and accuracy for novel text • Rationale: Semantic and syntactic context of text provides top-down facilitation of whole-word recognition • Steps: • 1. Choose a reading passage • 2. Collect reading rate and accuracy baseline • 3. Repeated oral reading of text • Clinician points out errors and provides assistance • 4. Daily Homework: 3-5 times/day

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Treatment at the Sentence-Level Oral Reading for Language in Aphasia—ORLA (Cherney, 2005) • Repetitive multimodal stimulation is presented to elicit response • Steps: • 1. Clinician reads aloud to patient, pointing to each word as they go • 2. Same as step 1, except patient also points along • 3. Same as Step 2, but patient reads aloud with clinician • 4. For each line or sentence, clinician states a word and patient must find it • 5. For each line or sentence, clinician points to a word and patient must read it • 6. Clinician and patient read aloud passage together again • https://www.youtube.com/watch?v=IO-uQ0N9bL0 (1:06)

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Treatments for Sentence Level • Syntax • Mapping Therapy (Scwartz, 1994), Object Manipulation Therapy (Kiran, 2012), Treatment of Underlying Forms (Thompson, 2005) • Working Memory • N-Back Task (Cicerone, 2002) • Kalinyak-Fliszar, M., Martin, N., & Kohen, F. (2012) • Grammar • Morphosemantic Treatment (Faroqi-Shah, 2008)

https://www.youtube.com/watch?v=CKeCDv3qqMs

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Object Manipulation Therapy Protocol (Kiran, 2012) 1. Upon hearing the sentence read aloud by the clinician (e.g., the aunt was kissed by the man), the patient enacted the target sentence using dolls (aunt, man) and feedback regarding accuracy was provided; 2. The clinician enacted the sentence using the dolls, placed a strip of paper with the target sentence printed on it beneath the target picture and further explained the roles of the agent and theme (e.g., “In this sentence, the aunt was kissed by the man, the man is kissing the aunt.”); 3. The clinician emphasized the agent of the action as well as a sentence strip in which the agent was bolded/emphasized and the theme was un- bolded/de-emphasized, on the table and saying, “In this part of the sentence, the aunt was kissed by the man, the man is doing the action. Ok, now you show me who is doing the action”. Feedback regarding accuracy was again provided;

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Object Manipulation Therapy Protocol (Kiran, 2012) 4. The clinician emphasized the theme of the action in a similar manner (e.g., “In this part of the sentence, the aunt was kissed by the man, the woman is being kissed. Ok, now you show me who is receiving the action”) and then the theme of the action was emphasized in a similar manner 5. The clinician put the original target picture and target sentence strip back on the table and once again read the full sentence and explained the roles of the agent and theme; 6. The patient enacted the sentence with feedback from the clinician.

Email me at [email protected] for step-by- step instructions and pdf materials—too involved to put on a powerpoint slide!

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Morphosemantic Treatment (Faroqi- Shah, 2008) 1. Confrontation Naming for each treatment verb 2. Anomaly Judgement: Patients presented spoken sentences and asked to judge whether the tense matches adverb (e.g., Yesterday the boy will wash his hands) 3. Auditory Comprehension: Matching an auditorily presented picture with the correct sentence from a group of 3 (3 different pictures for past, present, future) 4. Sentence Completion: Using the correct verb form for a sentence that corresponds to a picture (e.g., The boy ______his hands) 5. Sentence Construction: Selecting and arranging word cards to form a sentence that corresponds to a given picture.

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Treatment at Paragraph-Level • Strategy-Based Interventions • Griffiths, Sohlberg, Kirk et al., 2015: • Preview Headings • Identify 3 key points per paragraph • Summarize • PQRST—Preview, Question, Read, State, Test (Ciaramelli et al., 2015) • SQ3R—Survey, Question, Read, Recite, Review (Gunning, 2002)

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC © 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Treatment at Paragraph-Level •Attentive Reading and Constrained Summarization (Rogalski and Edmonds, 2008; Webster et al., 2013) • 1. Patient reads passage aloud • 2. Patient reads passage again silently in 2- or 3- sentence chunks • 3. Patient provides short oral summary

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC © 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Treatment at Paragraph-Level •Proposition Identification and Constrained Summarization (Webster et al., 2013) • 1. Patient reads passage as many times as necessary • 2. Patient identifies “key messages” • 3. Patient writes down key words • 4. Patient provides oral summary

•Supported Reading Comprehension (Dietz, Knollman-Porter, Hux, Toth, & Brown, 2014; Knollman-Porter, Brown, Hux, Wallace, & Uchtman, 2016; Rose et al. 2003, 2011) • Focus on improving reading comprehension by incorporating aphasia-friendly text supports: • Drawings, Personally relevant photographs, Reader-friendly format • Linguistic Supports • Headings, Bolded texts

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Resources for Paragraph-Level Treatment • https://newsela.com/ • FREE site that uploads news articles daily that are written at levels from Kindergarten-College, with already assembled reading comp multiple choice questions and answers • https://www.readworks.org/ • Similar to Newsela, but more academic-based texts

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Quality of Life Assessment • Quality of Life Measure (Alexia Specific) • Comprehensive Aphasia Test: Disability Questionnaire (Reading Specific questions)

•Quality of Life Measure (General) • Assessment for Living with Aphasia (ALA) • ASHA Functional Assessment of Communication Skills for Adults (ASHA FACS)

Patient Example: • Participation in Life: Reading a story-book to grandchild • Severity of aphasia: Reading is relatively intact at single-word level (phonological alexia), but breaks down at sentence level • Personal identity: Unsure of himself to complete task, distressed at always needing to rely on wife to read any material • Environment: Grandchild lives in a home with 2 other siblings and 2 pets (busy and noisy)

Treatment • Severity of aphasia: Using EBP treatments (MOR, Phonological Treatment) and Assistive Technology (C-Pen Reader) as tools to help return to participation in life activity • Personal identity: Counseling patient regarding his feelings, engaging patient and wife in communication partner training • Environment: Brainstorming environmental modifications (e.g., picking one book to focus on, reading to grandkid in a quiet room)

• Text-to-speech software • Natural Reader (https://www.naturalreaders.com/index.html) for online reading • Read Aloud: A Text to Speech Voice Reader (Google Chrome Extension)

•iPhone Accessibility • Speak Screen (https://support.apple.com/guide/iphone/spoken-content- iph96b214f0/ios)

• Tactus Therapy—Reading Therapy and Advanced Reading Therapy (http://tactustherapy.com/apps/)

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Group Treatment Integrated Group Approaches to Improve Reading for People with Aphasia by Alison Lemke, MA, MPA, CCC-SLP, CBIS ◦ https://www.speechpathology.com/slp-ceus/

Aphasia Access—Resource Exchange ◦ https://aphasiaacc.memberclicks.net/resource-exchange

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC Alexia Resources for Clinicians • Alexia—Diagnosis, Treatment, and Management by Alexander Leff • https://www.springer.com/us/book/9781447155287 • The Handbook of Adult Language Disorders—Second Edition // Edited by Argye Hillis • https://www.bookdepository.com/Handbook-Adult-Language-Disorders-Argye-E-Hillis/9781848726864 • A Cognitive Neuropsychological Approach to Assessment and Intervention in Aphasia-2nd Edition by Anne Whitworth, Janet Webster, and David Howard • https://www.amazon.com/Cognitive-Neuropsychological-Approach-Assessment-Intervention/dp/1848720971 • Aphasia and Related Neurogenic Communication Disorders—2nd Edition • https://digitalbookstream.com/product/aphasia-and-related-neurogenic-communication-disorders-ebook/ • University of Arizona Aphasia Lab (Beeson) • http://www.aphasia.arizona.edu/Aphasia_Research_Project/For_Professionals.html • Academy of Neurologic Communication Disorders and Sciences—Aphasia Treatment Evidence Tables • http://aphasiatx.arizona.edu/

© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC My Personal Go-To’s Assessment Treatment • • Single-Word Single Word •Beeson’s Phonological Treatment • Arizona Battery for Reading and •Johnson and Kiran’s Combined Lexical and Sublexical Spelling Approach • Sentence •Kendall’s Phonomotor Treatment • Comprehensive Aphasia Test (Written Sentences), Kempler Sentences •Sentence: • Paragraph •Multiple Oral Rereading • Discourse Comprehension Test, •Oral Reading Language in Aphasia GORT-5 •Treatment of Underlying Forms • Quality of Life Measure •Paragraph: • CAT: Disability Questionnaire •Attentive Reading and Constrained Summarization • Supported Reading Comprehension

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© 2019 ARCHWAYS-APHASIA REHABILITATION SERVICES PLLC References •Jeffrey P. Johnson, Katrina Ross & Swathi Kiran (2017) Multi-step treatment for acquired alexia and agraphia (Part I): efficacy, generalisation, and identification of beneficial treatment steps, Neuropsychological Rehabilitation, DOI: 10.1080/09602011.2017.1311271 • Kerkhoff, G., MunBinger, U., Eberle-strauss, G., & Stogerer, E. (1992). Rehabilitation of hemianopic alexia in patients with postgeniculate visual field disorders. Neuropsychological Rehabilitation, 2(1), 21-42. •Kim, M. & Beaudoin-Parsons, D. (2007). Training phonological reading in deep dyslexia: Does it improve reading words with low-imageability? Clinical Linguistics and Phonetics, 21(5), 321-351. • Lott, S., Carney, A., Glezer, L., & Friedman, R. (2010). Overt use of a tactile/kinesthetic strategy shifts to covert processing in rehabilitation of letter-by-letter reading. Aphasilogy, 24(11), 1424-1442. •Moss, S.E., Gonzalez Rothi, L. J., & Fennell, E. B. (1991). Treating a case of surface dyslexia after closed head injury. Archives of Clinical Neuropsychology, 6, 35-47. • Ong, YH., Brown, M.M., Robinson, P. et al. J Neurol (2012) 259: 2611. https://doi.org/10.1007/s00415-012-6549-8. •Redding GM, Wallace B. Prism adaptation and unilateral neglect: review and analysis. Neuropsychologia 2006; 44:1–20. •Riley, E. A. & Thompson, C. K. (2015). Training psuedoword reading in acquired dyslexia: A phonological complexity approach. Aphasiology, 29(2), 129-150.

• Sage, K., Hesketh, A., & Lambon Ralph, M. (2005). Using error-less learning to treat letter-by-letter reading: Contrastig word versus letter-based therapy. Neuropsychological Rehabilitation, 15, 619-642.

• Scott, C. & Byng, S. (1989). Computer assisted remediation of a homophone comprehension disorder in surface dyslexia. Aphasiology, 3, 301-320.

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• Ska, B., Garneau-Beaumont, D., Chesneau, S., & Damien, B. (2003). Diagnosis and rehabilitation attempt of a patient with acquired deep dyslexia. Brain and Cognition, 53(2), 359-363.

• Spitzyna, G., Wise, R., McDonald, S., Plant, G., Kidd, D., Crewes, H., & Leff, A. (2007). Optokinetic therapy improves text reading in patients with hemianopic alexia. Neurology, 68(22),1922-1930.

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