Intensive Auditory Comprehension Treatment for People with Severe Aphasia

Home , Spontaneous recovery

Intensive Auditory Comprehension Treatment for People with Severe Aphasia:

Outcomes and Use of Self-Directed Strategies

A dissertation proposal submitted to the

Division of Graduate Education and Research Of the University of Cincinnati

in partial fulfillment of the requirements of the degree of

DOCTOR OF PHILOSOPHY

In the Department of Communication Sciences and Disorders In the College of Allied Health Sciences

Dissertation Committee: Aimee Dietz, Ph D., chair Lisa Kelchner, Ph.D. Robin Thomas, Ph.D. Pete Scheifele, Ph.D

2012

Kelly Knollman-Porter

Intensive Auditory Comprehension Treatment

Abstract

The purpose of this study was to determine the efficacy of an intensive (2 hours/day, 5 days/week for 3 weeks) treatment protocol on individuals with severe, chronic speech perception or auditory comprehension deficits associated with aphasia. Two experiments were implemented to examine this purpose. Experiment I: Single Word Comprehension Approach (SWCA) established the effectiveness of an intensive treatment protocol on single word auditory comprehension (n = 6). Alternatively, Experiment II: Speech Perception Approach (SPA) examined the outcomes of an intensive treatment protocol on speech perception in individuals with profound global aphasia (n = 2). The researcher employed an ABA single subject design for both experiments, and examined the following variables: (1) changes in single word comprehension (SWCA) or speech perception (SPA); (2) the number of self-initiated requests for repetition and lip-reading cues; (3) the effectiveness of repetition and lip-reading cues; (4) the indirect effects of the protocols on verbal expression (SWCA – naming; SPA – repetition;

Both – narrative skills); (5) and generalization to functional communication environments.

Results revealed that all participants enrolled in the SWCA or SPA exhibited a lack of awareness regarding their comprehension impairment at the onset of treatment. Despite this reduced awareness, 7 of the 8 demonstrated a large effect on either single word comprehension or speech perception. A generalization effect to untrained stimuli was also exhibited by these participants.

The use of repetition successfully improved speech perception and single word comprehension in all participants; however lip-reading was beneficial in only 1 of the 8 participants. An indirect effect on verbal expression naming ability was demonstrated by 5 of the 6 SWCA participants; this effect was not observed in the SPA participants. Carryover of these skills to functional communication situations was reported by one of the eight caregivers. These finding suggest that

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individuals with severe to profound, deficits have the potential for continued improvements in speech perception or auditory comprehension, even in the chronic stages of recovery. However, caregiver involvement, use of personally relevant stimuli and rehabilitation protocols designed to increase self-awareness of speech perception and single word comprehension impairments may be a crucial link to generalization of communication gains to functional situations with this population.

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Acknowledgements

This work is dedicated to the men and women with aphasia who have willingly and openly allowed me to be a part of their lives. Without hesitation, they have been my true teachers. These individuals and their families have not only demonstrated to me the unique, complex world of aphasia, but more so, the true meaning of perseverance, dedication, and strength. They have and continue to inspire and challenge me as a clinician, researcher and as a human being.

I would also like to specifically thank my mentor, Dr. Lisa Kelchner, who has been and continues to be a role model for me in the field. Her passion and depth of knowledge are astounding. Even with these skills, she consistently displays humility and grace; never demeaning or critical. Words cannot thank her enough for the many years of training, advice, and guidance she has provided me over the past 15 years.

Three years ago, I had the pleasure of meeting Dr. Aimee Dietz. Little did I know at the time, she would play such a crucial role in the success of my program. Even through pregnancy and the birth of her beautiful son, she continued to challenge and encourage me to develop my skills as a clinical researcher. She supported me in my belief that clinical research, while time intensive, can make a difference in the lives of individuals with aphasia. My sincere thanks goes to her for the many hours of editing and guidance provided through this journey.

I will forever be indebted to my parents, Don and Doris Knollman. From a very young age, they instilled in me the importance of education, integrity, and hard work. During every stage in my life, they have been a constant source of assistance and encouragement. I thank them

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for standing in the gap while I chased yet another dream. I couldn’t ask for a better Mom and

Dad.

In addition, one of my greatest blessings are my children. Both Anna and Eric have been a constant support for me along this long journey. More than once, they used my own words against me when the more challenging phases of the Ph.D. program arose. It was a joy to watch them grow and mature through this process. It is my hope, that through my experiences they can realize that with persistence and dedication anything in life is possible.

Finally, over twenty years ago, God brought an amazing man into my life. Never have I known anyone as self-sacrificing and supportive as my husband, Randy Porter. He was my midnight tech support, statistics and excel tutor, my cheerleader and my counselor when the challenges of the program became overwhelming. Without hesitation, he is the best thing that ever happened to me. I love him very much and am forever grateful for his never ceasing, unconditional support.

This dissertation is truly not my own; and could not have been initiated or completed without the support of many other wonderful individuals. To the following I am also thankful:

Dr. Pete Scheifele, Dr. Robin Thomas, Miami University Aphasia Support Group members and their families, my wonderful colleagues at Miami University, my students, and my church family.

“We are like clay jars in which this treasure is stored. The real power comes from God and not from us.” 2 Corinthians 4:7

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Table of Contents

List of Tables xvii

List of Figures xx

Chapter 1

Introduction 1

Purpose of the Investigation 5

Chapter 2

Review of the Literature 7

Normal Comprehension: The Process 7 Acoustic phonetic analysis 8 Phonological processing 8 Lexical semantic system 9

Speech Perception/Auditory Comprehension Deficits Associated with Aphasia 10

The Influence of Short-Term Working Memory on Comprehension 11 Short-term working memory: Normal Comprehension 11 Short-term working memory: Comprehension in aphasia 12

Self-Awareness 13

Self-Awareness in Aphasia 14

Assessment of Comprehension Deficits in Aphasia 18 Assessment of short-term working memory and comprehension 19

Therapeutic Management of Comprehension Deficits in Aphasia 20 Intensity of treatment 22 Utilization of repetition cues 23 Utilization of lip-reading cues 24

Research Questions and Research Hypothesis: Experiment I - SWCA 25

Research Questions and Research Hypothesis: Experiment II – SPA 27

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Chapter 3

Methods 29 Participants 31

Setting 34

Design 34

Screening and Cognitive-Linguistic Assessment Materials 34

Equipment 34 Audio and video equipment 34 Audiometer 35

Screening 35 Social and medical history survey 35 Hearing screening 35 Visual acuity screening 35 Response screening 36 Comprehension severity screening 36

Cognitive-Linguistic Assessment 36 Phonological processing 36 Semantic processing 37 Working memory 37 Non-linguistic cognitive assessment tools 37

Screening and Cognitive-Linguistic Assessment Procedures 38

Video recording protocol 38

Screening 38 Medical and social history survey 38 Hearing screening 38 Visual acuity screening 39 Response screening 39 Comprehension severity screening 40 Neuroimaging 40

Cognitive-Linguistic Assessment 40 Measurement of phonological processing and working memory 41 Measurement of semantic comprehension and working memory 43 Non-linguistic cognitive assessment protocol 44

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Assessment of Experimental Complexity Stimuli Materials 44

Experiment I: SWCA assessment materials 44

Experiment II: SPA assessment materials 46

Assessment of Experimental Stimuli Complexity Procedures 46

Experiment I: SWCA assessment procedures 47

Experiment II: SPA assessment procedures 50

Experimental Materials 53

Experiment I: SWCA 53 Equipment 53 Single word comprehension stimuli 53 Verbal naming stimuli 54

Experiment II: SPA 54 Speech perception stimuli 54 Verbal repetition stimuli 55

Common experimental materials 55 Audio and video equipment 55 Picture description 55 Communication history survey 55 Frustration/fatigue monitoring 55

Experimental Procedures 55

Experiment I: SWCA 56 SWCA baseline phase 56 Single word comprehension 56 Verbal naming measures 56 SWCA treatment phase 56 SWCA probe data 59 SWCA maintenance phase 59

Experiment II: SPA 60 SPA baseline phase 60 Speech perception 60 Verbal repetition measures 60 SPA treatment phase 61 SPA probe data 62

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SPA maintenance phase 62

Common experimental procedures 62 Picture description 62 Communication history survey 63 Frustration/fatigue monitoring 63

Independent and Dependent Variables 63

Experiment I: SWCA independent and dependent variables 63

Experiment II: SPA independent and dependent variables 64

Research Fidelity 65

Analyses 66

Ethical Issues 66

Chapter 4

Results 68

Single Word Comprehension Study 68

Participant T.G. 68

Single word comprehension – Response to intervention 69 Trained stimuli 69 Untrained stimuli 70 Comprehension error patterns 71

Self-initiated requests for cues 72 Repetition 72 Lip-reading 73

Comprehension accuracy following cues 73 Repetition 73 Lip-reading 75

Verbal Expression – Indirect treatment effects 75 Naming of trained comprehension stimuli 75 Naming of untrained comprehension stimuli 76 Picture description 77

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Generalization to functional communication environments 78

Participant B.G. 81

Single word comprehension – Response to intervention 81 Trained stimuli 82 Untrained stimuli 82 Comprehension error patterns 83

Self-initiated requests for cues 84 Repetition 84 Lip-reading 85

Comprehension accuracy following cues 86 Repetition 86 Lip-reading 87

Verbal Expression – Indirect treatment effects 88 Naming of trained comprehension stimuli 88 Naming of untrained comprehension stimuli 89 Picture description 91

Generalization to functional communication environments 92

Participant T.O. 93

Single word comprehension – Response to intervention 93 Trained stimuli 94 Untrained stimuli 94 Comprehension error patterns 95

Self-initiated requests for cues 96 Repetition 96 Lip-reading 97

Comprehension accuracy following cues 98 Repetition 98 Lip-reading 99

Verbal Expression – Indirect treatment effects 99 Naming of trained comprehension stimuli 99 Naming of untrained comprehension stimuli 100 Picture description 102

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Generalization to functional communication environments 103

Participant B.D. 105

Single word comprehension – Response to intervention 105 Trained stimuli 105 Untrained stimuli 106 Comprehension error patterns 107

Self-initiated requests for cues 108 Repetition 108 Lip-reading 109

Comprehension accuracy following cues 110 Repetition 110 Lip-reading 111

Verbal Expression – Indirect treatment effects 112 Naming of trained comprehension stimuli 112 Naming of untrained comprehension stimuli 114 Picture description 115

Generalization to functional communication environments 116

Participant D.W. 119

Single word comprehension – Response to intervention 120 Trained stimuli 120 Untrained stimuli 120 Comprehension error patterns 121

Self-initiated requests for cues 122 Repetition 122 Lip-reading 123

Comprehension accuracy following cues 124 Repetition 124 Lip-reading 125

Verbal Expression – Indirect treatment effects 126 Naming of trained comprehension stimuli 126 Naming of untrained comprehension stimuli 128 Picture description 129 Generalization to functional communication environments 130

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Participant R.K. 133

Single word comprehension – Response to intervention 133 Trained stimuli 134 Untrained stimuli 134 Comprehension error patterns 135

Self-initiated requests for cues 136 Repetition 136 Lip-reading 137

Comprehension accuracy following cues 138 Repetition 138 Lip-reading 139

Verbal Expression – Indirect treatment effects 140 Naming of trained comprehension stimuli 140 Naming of untrained comprehension stimuli 141 Picture description 142

Generalization to functional communication environments 143

Experiment I: SWCA – Summary of results 146

Research Question 1 146 Research Question 2 147 Research Question 3 148 Research Question 4 148 Research Question 5 149 Research Question 6 150 Research Question 7 151 Research Question 8 151

Speech Perception Study 152

Participant T.L. 152

Speech perception – Response to intervention 153 Trained stimuli 153 Untrained stimuli 153 Speech perception error patterns 154

Self-initiated requests for cues 156 Repetition 156

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Lip-reading 156

Speech perception accuracy following cues 157 Repetition 157 Lip-reading 158

Verbal Expression – Indirect treatment effects 158 Repetition of trained speech perception stimuli 158 Repetition of untrained speech perception stimuli 159 Picture description 160

Generalization to functional communication environments 161

Participant E.R. 164

Speech perception – Response to intervention 165 Trained stimuli 165 Untrained stimuli 165 Speech perception error patterns 166

Self-initiated requests for cues 167 Repetition 167 Lip-reading 168

Speech perception accuracy following cues 169 Repetition 169 Lip-reading 170

Verbal Expression – Indirect treatment effects 171 Repetition of trained speech perception stimuli 171 Repetition of untrained speech perception stimuli 172 Picture description 173

Generalization to functional communication environments 174

Experiment I: SPA – Summary of results 177

Research Question 1 177 Research Question 2 178 Research Question 3 178 Research Question 4 178 Research Question 5 179 Research Question 6 179 Research Question 7 180 Research Question 8 180

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Chapter 5

Discussion 181

Experiment I: SWCA – Major Outcomes 181

Response to intervention 182 Effectiveness of self-initiated requests for cues 185 Repetition 185 Lip-reading 188 Verbal expression: Indirect treatment effects 191 Generalization to functional communication environments 192

Experiment II: SPA – Major Outcomes 195

Response to intervention 196 Effectiveness of self-initiated requests for cues 197 Verbal expression: Indirect treatment effects 200 Generalization to functional communication environments 201

Limitations and Direction for Future Research 202

Intensity of the treatment protocol 202 Neurologic correlates 203 Utilization of lip-reading cues 204 Indirect impact on verbal expression 205 Functional relevance of treatment stimuli 206 Functional communication 206 Were the outcomes worth the effort? 208

Conclusions 210

References 211

Appendix A. Inclusion/Exclusion Criteria 225

Appendix B. Hearing Screening 228

Appendix C. Visual Acuity Screening 229

Appendix D. Response Screening 230

Appendix E. Lexical Analysis SWCA 231

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Appendix F. Experimental Stimuli Complexity Assessment SWCA High Frequency 233

Appendix G. Experimental Stimuli Complexity Assessment SWCA Medium Frequency 235

Appendix H. Experimental Stimuli Complexity Assessment SWCA Low Frequency 237

Appendix I. Experimental Stimuli Complexity Assessment SPA CV 239

Appendix J. Experimental Stimuli Complexity Assessment SPA CVC 242

Appendix K. Experimental Stimuli Complexity Assessment SPA CCVC 244

Appendix L. Baseline and Probe SWCA High Frequency Version A 246

Appendix M. Baseline and Probe SWCA High Frequency Version B 248

Appendix N. Baseline and Probe SWCA Medium Frequency Version A 250

Appendix O. Baseline and Probe SWCA Medium Frequency Version B 252

Appendix P. Baseline and Probe SWCA Low Frequency Version A 254

Appendix Q. Baseline and Probe SWCA Low Frequency Version B 256

Appendix R. Treatment SWCA High Frequency 258

Appendix S. Treatment SWCA Medium Frequency 263

Appendix T. Treatment SWCA Low Frequency 267

Appendix U. Baseline and Probe SPA - CV Version A 271

Appendix V. Baseline and Probe SPA - CV Version B 273

Appendix W. Baseline and Probe SPA - CVC Version A 275

Appendix X. Baseline and Probe SPA - CVC Version B 277

Appendix Y. Treatment SPA – CV Stimuli 279

Appendix Z. Communication History Survey 283

Appendix AA. Fatigue/Frustration Scale 287

Appendix BB. Frustration Form 288

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List of Tables

Table 1. Participant Demographic Data 32

Table 2. Neuroimaging Results 33

Table 3. Measures of Phonological Processing and Working Memory 42

Table 4. Measures of Semantic Comprehension and Working Memory 43

Table 5. Measures of Non-Linguistic Cognitive Ability 44

Table 6. Results – Level of Experimental Stimuli Complexity SWCA 50

Table 7. Results – Level of Experimental Stimuli Complexity SPA 53

Table 8. Results of verbal naming of trained comprehension stimuli for 76 Participant T.G.

Table 9. Results of verbal naming of untrained comprehension stimuli for 77 Participant T.G.

Table 10. Narrative picture description analysis 78

Table 11. Pre- and Post-Intervention – Caregiver perceived functional communication 79 Performance.

Table 12. Results of verbal naming of trained comprehension stimuli for 89 Participant B.G.

Table 13. Results of verbal naming of untrained comprehension stimuli for 90 Participant B.G.

Table 14. Narrative picture description analysis 91

Table 15. Results of verbal naming of trained comprehension stimuli for 100 Participant T.O.

Table 16. Results of verbal naming of untrained comprehension stimuli for 101 Participant T.O.

Table 17. Narrative picture description analysis 102

Table 18. Pre- and Post-Intervention – Caregiver perceived functional communication 103 Performance.

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Table 19. Results of verbal naming of trained comprehension stimuli for 113 Participant B.D.

Table 20. Results of verbal naming of untrained comprehension stimuli for 115 Participant B.D.

Table 21. Narrative picture description analysis 116

Table 22. Pre- and Post-Intervention – Caregiver perceived functional communication 117 Performance.

Table 23. Results of verbal naming of trained comprehension stimuli for 127 Participant D.W.

Table 24. Results of verbal naming of untrained comprehension stimuli for 129 Participant D.W.

Table 25. Narrative picture description analysis 130

Table 26. Pre- and Post-Intervention – Caregiver perceived functional communication 131 Performance.

Table 27. Results of verbal naming of trained comprehension stimuli for 141 Participant R.K.

Table 28. Results of verbal naming of untrained comprehension stimuli for 142 Participant R.K.

Table 29. Narrative picture description analysis 143

Table 30. Pre- and Post-Intervention – Caregiver perceived functional communication 144 Performance.

Table 31. Results of verbal repetition of trained speech perception stimuli for 159 Participant T.L.

Table 32. Results of verbal repetition of untrained speech perception stimuli for 160 Participant T.L.

Table 33. Narrative picture description analysis 161

Table 34. Pre- and Post-Intervention – Caregiver perceived functional communication 162 Performance.

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Table 35. Results of verbal repetition of trained speech perception stimuli for 172 Participant E.R.

Table 36. Results of verbal repetition of untrained speech perception stimuli for 173 Participant E.R.

Table 37. Narrative picture description analysis 174

Table 38. Pre- and Post-Intervention – Caregiver perceived functional communication 175 Performance.

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List of Figures

Figure 1. Overview of the assessment and experimental procedures for each experiment 30

Figure 2. Sample Stimuli 45

Figure 3. Example of SWCA stimuli presentation 48

Figure 4. Protocol to determine experimental stimuli complexity – SWCA 49

Figure 5. Example of SPA stimuli presentation 51

Figure 6. Protocol to determine experimental stimuli complexity –SPA 52

Figure 7. SWCG treatment phase protocol 57

Figure 8. Protocol for stimuli presentation and repetition and lip-reading cues 59

Figure 9. SPA treatment phase protocol 61

Figure 10. Average percent of correct responses on medium frequency word 71 comprehension tasks by Participant T.G.

Figure 11. Average percentage of comprehension error types for Participant T.G. 72

Figure 12. Average number of requests for repetition and lip-reading cues by 73 Participant T.G.

Figure 13. Average number of correct/incorrect responses to repetition cues by 74 Participant T.G.

Figure 14. Average percent of correct responses on high frequency word 83 comprehension tasks by Participant B.G.

Figure 15. Average percentage of comprehension error types for Participant B.G. 84

Figure 16. Average number of requests for repetition and lip-reading cues by 86 Participant B.G.

Figure 17. Average number of correct/incorrect responses to repetition cues by 87 Participant B.G.

Figure 18. Average number of correct/incorrect responses to lip-reading cues by 88 Participant B.G.

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Figure 19. Average percent of correct responses on low frequency word 95 comprehension tasks by Participant T.O.

Figure 20. Average percentage of comprehension error types for Participant T.O. 96

Figure 21. Average number of requests for repetition and lip-reading cues by 97 Participant T.O.

Figure 22. Average number of correct/incorrect responses to repetition cues by 99 Participant T.O.

Figure 23. Average percent of correct responses on Medium frequency word 107 comprehension tasks by Participant B.D.

Figure 24. Average percentage of comprehension error types for Participant B.D. 108

Figure 25. Average number of requests for repetition and lip-reading cues by 110 Participant B.D.

Figure 26. Average number of correct/incorrect responses to repetition cues by 111 Participant B.D.

Figure 27. Average number of correct/incorrect responses to lip-reading cues by 112 Participant B.D.

Figure 28. Average percent of correct responses on High frequency word 121 comprehension tasks by Participant D.W.

Figure 29. Average percentage of comprehension error types for Participant D.W. 122

Figure 30. Average number of requests for repetition and lip-reading cues by 124 Participant D.W.

Figure 31. Average number of correct/incorrect responses to repetition cues by 125 Participant D.W.

Figure 32. Average number of correct/incorrect responses to lip-reading cues by 126 Participant D.W.

Figure 33. Average percent of correct responses on High frequency word 135 comprehension tasks by Participant R.K.

Figure 34. Average percentage of comprehension error types for Participant R.K. 136

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Figure 35. Average number of requests for repetition and lip-reading cues by 138 Participant R.K.

Figure 36. Average number of correct/incorrect responses to repetition cues by 139 Participant R.K.

Figure 37. Average number of correct/incorrect responses to lip-reading cues by 140 Participant R.K.

Figure 38. Average percent of correct responses on CV speech perception tasks by 154 Participant T.L.

Figure 39. Average percentage of speech perception error types for Participant T.L. 155

Figure 40. Average number of requests for repetition and lip-reading cues by 157 Participant T.L.

Figure 41. Average number of correct/incorrect responses to repetition cues by 158 Participant T.L.

Figure 42. Average percent of correct responses on CV speech perception tasks by 166 Participant E.R.

Figure 43. Average percentage of speech perception error types for Participant E.R. 167

Figure 44. Average number of requests for repetition and lip-reading cues by 169 Participant E.R.

Figure 45. Average number of correct/incorrect responses to repetition cues by 170 Participant E.R.

Figure 46. Average number of correct/incorrect responses to lip-reading cues by 171 Participant E.R.

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CHAPTER 1:

INTRODUCTION & MOTIVATION

Aphasia, a disability secondary to stroke, can adversely affect a person’s ability to perceive and comprehend even the most basic information (e.g., perception of speech sounds and comprehension of words) for months, years or a lifetime. Critical to the development and maintenance of social and vocational relationships is an individual’s ability to comprehend a spoken message. Effective and efficient speech perception and comprehension helps people fulfill basic needs such as understanding warnings of impending harm, or the comprehension of life-impacting information from a medical professional. But more importantly, successful comprehension of even the most basic spoken word can relay messages of support, encouragement, dedication and love. When the ability to recognize and process speech sounds and single words is compromised, comprehension of such crucial information is impacted and interactions become inefficient.

In the last 30 years, significant medical advances and use of neuroimaging techniques have contributed to increased detection of stroke, improved accuracy of stroke diagnosis, and decreased mortality rates (Lakshminarayan, Anderson, Jacobs, Barber, & Luepker, 2009). As such, stroke mortality has declined from 97.1 per 100,000 in 1979 to 43.6 per 100,000 in 2006

(United States Environmental Protection Agency [EPA], 2009). Hence, individuals with severe, diffuse, neurological damage secondary to stroke, are surviving for years with long term communication impairments, while in the past they did not. Approximately 1 million of these stroke survivors have a diagnosis of aphasia (NAA, 2010). The incidence and severity of auditory comprehension deficits resulting from aphasia is unknown; however as the number of people surviving stroke increases, it is logical to conclude that the number of people living with

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severe auditory comprehension deficits associated with aphasia is increasing. Thus the long-term functional and emotional success of an individual with severe, chronic comprehension deficits is dependent on many factors; one of which is the behavioral management of the comprehension impairment.

Greater long term functional disabilities in activities of daily living and mobility occur more often in people with severe comprehension deficits (Paolucci et al., 2005). In fact, the severity of the comprehension deficit directly correlates with a person’s rehabilitative outcomes.

That is, individuals with more severe comprehension deficits experience higher drop-out rates for physical, occupational and speech-language therapy when compared to people with milder comprehension deficits (Paolucci et al., 2005). In addition, comprehension impairments adversely impact the quantity and quality of social relationships and vocational opportunities, which causes social isolation and decreased quality of life (Davidson et al., 2008; Garcia,

Laroche, & Barrette, 2002; LaPoint, 1997). These factors lead to depression in roughly 33% of all stroke survivors. (Hackett, Yapa, Parag, & Anderson, 2005).

For decades, researchers and clinicians have developed interventions to offset the debilitating effects aphasia has on speaking ability (Schuell, Jenkins, & Landis, 1964, Robey,

1998, Mortley, Wade, & Enderby, 2004; Choe, Azuma, Mathy, Liss, & Edgar, 2007). However, treatment protocols that address the restorative management of severe comprehension deficits is limited (Helm-Estabrooks & Albert, 2004; Crerar, Ellis, & Dean, 1996; Morris, Franklin, Ellis,

Turner, & Bailey, 1996). To further complicate this limitation, individuals, who are classified with severe, chronic comprehension impairments vary significantly in the degree and extent of deficit secondary to the size and location of a neurologic injury associated with stroke (Dronkers,

Wilkins, Van Valin, Redfer, & Jaeger, 2004). Some individuals may have comprehension

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breakdown at the single word level, while others with more profound deficits may exhibit impairments at the speech perception level. As a result, treatment that is implemented without considering this variability, even within a similar severity level based on standardized diagnostic batteries, may be at risk for negative outcomes (Knollman-Porter, Dietz, Lundeen, 2012.

Even though research is limited addressing the therapeutic management of severe, chronic comprehension deficits in aphasia, information can be gleaned from studies of verbal expression. Evidence suggests that intensive treatment, which focuses on verbal expression tasks, can improve the speaking ability of people with chronic aphasia (Cherney, Patterson,

Raymer, Frymark, & Schooling, 2008; Kleim, & Jones, 2008). Specifically, a meta-analysis revealed that treatment sessions that last between 2-4 hours daily, facilitated improved communicative ability (Basso, 2005). Historically, intervention protocols for chronic comprehension deficits are administered across two, one-hour sessions each week (Crerar, Ellis,

& Dean, 1996; Morris, Franklin, Ellis, Turner, & Bailey, 1996). Further, traditional therapeutic management of aphasia typically involves a multi-modality approach that addresses verbal expression, auditory comprehension, reading comprehension and written expression in the same

1 hour treatment session. In essence, interventions that focus on comprehension tasks are not a frequently employed in aphasia rehabilitation.

Recently, a feasibility study revealed that an intensive comprehensive treatment protocol (i.e.,5 days per week, 2 hours per day, across 4 weeks) improved single word comprehension in two out of the three participants with severe, chronic auditory comprehension deficits (Knollman-Porter, Dietz, & Lundeen, 2012). Despite demographic similarities, these two participants displayed noticeably different patterns of improvement. A number of variables could have contributed to the gains demonstrated (i.e., intensity of treatment, cueing strategies utilized,

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self-awareness of deficits). Given the presence of these factors, it was difficult to determine which variable ultimately led to the greatest positive change in single word comprehension.

Another limitation of this study lies in the fact that data was not collected to determine whether participants achieved gains in functional communication tasks or whether the intervention had a secondary positive impact on other verbal expression skills.

Additionally, findings of Knollman-Porter and colleagues (2012) indicated that not all individuals formally diagnosed with severe auditory comprehension deficits based on standardized assessment protocols exhibited improvement in single-word auditory comprehension ability. The researchers offer two possible reasons for this discrepancy. One possible cause is that the treatment protocol (single word, high frequency level) was too complex for one participant .This suggests that the underlying impairment was at the level of speech perception (i.e., pre-comprehension). Another factor that may have impacted progress in the one participant exhibited reduced self-awareness regarding the occurrence of a breakdown.

In summary, the evidence based research supporting restorative interventions for individuals with severe, chronic comprehension deficits is lacking. The previously discussed feasibility study provided preliminary findings regarding the positive impact of an intensive comprehension treatment protocol for people with severe, chronic aphasia. Nonetheless, a number of factors may have contributed to comprehension gains and in one participant, lack of improvement. Therefore, additional research is necessary. Clinicians today must implement treatment protocols that not only result in positive gains in the clinical environment, but also generalize functional communication settings. These protocols must be unique to the individual needs of the client and achieve the greatest gains over the shortest period of time. For this reason, a more critical assessment of the impact of intensity of treatment, utilization of compensatory

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strategies, and self-awareness, on comprehension outcomes is warranted. Moreover, it is critical to determine the impact of such an intervention on a person’s functional comprehension skills and verbal expression abilities.

Purpose of the Investigation

Extant literature reinforces the use of a more intensive treatment protocol for people with severe, chronic expressive aphasia. The aforementioned pilot study revealed that people with severe, chronic comprehension deficits can also benefit from an intensive treatment protocol; however, additional research is needed to determine the specific variables (i.e., intensity of treatment, utilization of compensatory strategies, degree self-awareness) necessary to meet the treatment needs of a variety people with chronic, severe, speech perception and comprehension deficits in aphasia. Therefore, the goal of this dissertation project was to implement and examine two separate but similar experiments: Experiment I: Single Word Comprehension Approach

(SWCA) and Experiment II: Speech Perception Approach (SPA). The ultimate purpose of these experiments was to provide a foundation for restorative treatment methods for the management of this unique population.

The primary purpose of Experiment I: SWCA was to determine the effectiveness of an intensive treatment protocol on single word auditory comprehension in individuals with severe, chronic aphasia. Alternatively, the primary purpose of Experiment II: SPA was to examine the outcomes of an intensive treatment protocol on speech perception in individuals with profound global aphasia. For both experiments, the following variables were examined: (1) the clinical utility of auditory (i.e. repetition of stimuli) and visual supports (i.e., lip-reading cues) on outcomes and the ability to detect breakdowns and (2) the indirect effects of the experimental

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protocols on verbal expression (i.e., Experiment I = naming and Experiment II = repetition) and functional communication will be examined.

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CHAPTER 2

REVIEW OF THE LITERATURE

This chapter includes a review of the current research in the areas of normal and disordered speech perception and comprehension. Six sections have been included in this review. First, the author will discuss the normal comprehension process and the neurological correlates observed healthy adults. This is followed by an examination of speech perception and single word comprehension impairments following the diagnosis of stroke. Next, is a review of the role of short-term working memory in normal individuals, and its neurologic correlates.

Additionally, the short-term working memory deficits that often co-occur with aphasia following stroke will be reviewed. Following this, is a discussion of self-awareness, the neurological correlates, and its potential influence on individuals with neurologic damage secondary to stroke.

Then, the strengths and limitations of current diagnostic assessment batteries typically used to assess comprehension impairments will be discussed. Finally, this chapter concludes with an overview of the current methods of therapeutic management in the treatment of speech perception and comprehension deficits associated with aphasia.

Normal Comprehension: The Process

Everyday people are bombarded with auditory messages that are sent quickly with the intent of being comprehended and acted upon. This process is very fast and automatic in healthy individuals. However, before single word comprehension can occur, multiple cortical organizations within the brain work together in a multi-step process to analyze and organize speech sounds before they can be understood. The following sections provide an overview of this complex process.

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Acoustic phonetic analysis. Speech signals are the most complex sounds to analyze for comprehension (Scott, S. K. & Wise, R. J. S., 2004). Before single word comprehension can occur, the speech sounds must be detected by an individual. Once detected, the complex acoustic information of the speech signal is encoded and analyzed by the peripheral auditory system based on psychophysical properties (Pisoni & Luce, 1987; Klatt, 1982). The acoustic features of this coded speech signal are further analyzed in the central auditory system, where speech signal interpretations are formed (Stevens, 1980; Pisoni & Luce, 1987). These representations are then mapped based on their distinctive phonetic features (e.g. voicing, place of articulation, frequency) during the process called acoustic-phonetic analysis (Pisoni & Luce,

1987). Even though this is a multi-step process, an electrocortical mapping study suggest that the left middle-posterior portion of the superior temporal gyrus is focally responsible for acoustic phonetic analysis of speech sounds in healthy individuals. (Boatman, 2004).

Acoustic-phonetic analysis is one portion of the process that will lead to single word comprehension. Clinically, the acoustic-phonetic analysis abilities can be assessed using several functional measures. For example, auditory discrimination protocols can be used to successfully measure acoustic-phonetic analysis through a forced choice format (Morris, Franklin, Ellis,

Turner & Bailey, 1996). Specifically, minimal pairs are presented to listeners who are required to determine whether the syllables are the same or different (i.e., /de/ - /te/). Following this critical pre-comprehension process, the information analyzed during this phase will then be transferred on for further analysis in the phonological processing stage.

Phonological processing. The next obligatory phase completed prior to the comprehension of the spoken word is phonological processing. During this phase, the information processed during the acoustic-phonetic phase is decoded and mapped onto the

8 Intensive Auditory Comprehension Treatment

listener’s internal representations. Specifically, phonological processing is the ability to hear a word, break it down to distinct sounds, and then associate each sound with letters that make up the word. This information is then used to access semantic and lexical word information for comprehension (Martin, Schwartz, & Kohen, 2006). An electrocortical mapping study offer data to support the contribution of five different cortical regions to phonological processing. These include the posterior-middle superior temporal gyrus, the anterior middle superior temporal gyrus, ventral and dorsal portions of the posterior superior temporal gyrus, and the inferior frontal lobe (Boatman, 2004).

Even through phonologic processing can involve multiple but independent cortical regions, specific pre-comprehension clinical behaviors can be exhibited that are specific to this process. Common behavioral tasks that can be utilized to assess phonological processing include:

(1) determining if two words spoken rhyme (i.e., time – dime); (2) phoneme monitoring: determining if a specific sound occurs in a spoken stream of sounds; (3) phoneme identification: ability to detect and label speech sounds through repetition (Boatman, 2004). Following this process, speech sound information can be further analyzed in the lexical semantic system.

Lexical semantic system. Word information and meaning is obtained when speech perception information gained from acoustic-phonetic analysis and phonological processing interfaces with the lexical semantic system (Martin, Schwartz, & Kohen, 2006). Previously analyzed speech characteristics are paired with similar word representations stored in long-term memory. Lexical access occurs when word meanings are retrieved from the long-term semantic memory, which allows for single-word comprehension (Pisoni & Luce, 1987). Neurologic correlates for lexical-phonetic analysis are more diffuse than previous levels of speech perception and involves all of the cortical areas previously identified for acoustic-phonetic

9 Intensive Auditory Comprehension Treatment

analysis and phonological processing. Additional areas responsible for lexical semantic processing include multiple temporal, parietal, and frontal lobe sites (Boatman, 2004; Dronkers,

Wilkins, Van Valin, Redfern, & Jaeger, 2004).

At this stage, single word comprehension occurs. Clinically, lexical-semantic processing can initially be assessed by an individual’s ability to match a single spoken word with a pictured representation (Breese & Hillis, 2004). More complex lexical-semantic measures include phrase, or complex sentence level comprehension tasks (i.e., Revised Token Test) (McNeil & Prescott,

1987). This multifaceted process occurs quickly and efficiently for an individual to successfully comprehend spoken messages; however, neurologic damage to any part of this system (i.e., acoustic-phonetic, phonological processing) can result in speech perception and comprehension impairments.

Speech Perception and Auditory Comprehension Deficits Associated with Aphasia

Currently, 6 million people in the United States are stroke survivors, with approximately

795,000 additional strokes occurring annually (United States Department of Health and Human

Services [DHHS], 2010; Lloyd-Jones et al., 2010. Strokes or cerebrovascular Accidents (CVA) can significantly impact an individual’s ability to understand speech input at any level of the comprehension continuum previously discussed (Morris et al., 1996; Breese et al., 2003).

Deficits in speech perception are associated with impairments to cortical sites responsible for acoustic-phonetic and phonological processing (e.g., distinguishing between phonemes, rhyming, repetition). In addition, the cortical areas responsible for lexical-semantic processing can result in comprehension impairment at the single word level (Boatman, 2004; Dronkers, Wilkins, Van

Valin, Redfern, & Jaeger, 2004). Since the process of comprehension is hierarchically based, neurologic damage in the areas responsible for acoustic phonetic analysis can create subsequent

10 Intensive Auditory Comprehension Treatment

impairments in single word comprehension (Boatman, 2004). Hence, word comprehension deficits may occur in isolation, or in combination with phonological processing and/or acoustic- phonetic analysis deficits. In addition to the specific location of the cortical damage, the size and the extent of the lesion can also directly affect the severity of the resultant comprehension impairment (Dronkers, Wilkins, Van Valin, Redfern, & Jaeger, 2004). Because of this, all individuals who have comprehension deficits following stroke will not present in the same manner or severity level. Each will be unique in their strengths and limitations. Therefore, management of this debilitating disorder must be based on the specific comprehension impairments and needs of the individual.

The Influence of Short-Term Working Memory on Comprehension

Additional cognitive prerequisites are necessary for effective speech processing.

Previously, aphasia was primarily and often exclusively perceived as a linguistic impairment.

However, current research is providing foundational evidence that concomitant cognitive factors may influence language performance (Helms-Estabrooks, Connor, Albert, 2000; Martin, Kohen,

& Kalinyak-Fliszar, 2007; Nicholas, Sinotte, & Helm-Estabrooks, 2011). The following sections provide an overview of the role of short-term working memory in normal comprehension and in the individuals with severe speech perception or comprehension impairments.

Short-Term working memory: Normal comprehension. One process critical to speech perception and comprehension is short-term working memory. Models of phonemic and semantic processing suggest that target representations of a sound or word must compete with similar non-target representations that are activated in the short-term working memory (Dell,

1986). These competing forms may be phonemically related (cat/hat) or semantically related

(couch/bed). If the phonemic or semantic representation cannot be maintained for sufficient

11 Intensive Auditory Comprehension Treatment

processing, a non-target may be selected, causing a breakdown in comprehension. In order for the target to successfully compete with neighboring words and concepts, the semantic and phonological representations must be maintained for an adequate amount of time in working memory (Martin, Schwartz, & Kohen, 2006). Even in healthy individuals, background noise, increased speed of stimulus presentation, complexity of information, or other factors have been shown to reduce the resources needed for comprehension (Caplan, Waters, DeDe, Michaud, &

Reddy, 2007). As healthy individuals age, the efficiency of memory skills are reduced (to various degrees) which can have an adverse impact the speed and efficiency of processing speech stimuli. While there are some consistent correlates associated with cognitive changes in normal aging, no two people respond to these changes in exactly the same way (Park & Reuter-

Lorenz, 2009). Functional neuroimaging techniques have been used to identify the neurologic correlates responsible for working memory (Carpenter, Just & Reichle, 2000; Jonides et al.,

1997). The frontal and parietal regions contribute specifically to verbal working memory; specifically, the posterior parietal cortex of the parietal lobe and the, dorsolateral prefrontal cortex and Broca’s area of the frontal cortex (Neuman, Just, & Carpenter, 2002).

Short-term working memory: Comprehension in Aphasia. Deficits in short-term memory can also affect speech perception and single word comprehension in individuals following neurologic damage. Traditional aphasia classification models suggest that individuals with Broca’s Aphasia have intact single word comprehension (Goodglass & Kaplan, 1983).

However, comprehension in Broca’s aphasia is highly dependent on general cognitive resources, such as working memory. A decline in processing capacity can adversely impact single word comprehension even in individuals without the diagnosis of comprehension impairment.

(Moineau, Dronkers, & Bates, 2005). Hence, the comprehension deficits associated with stroke

12 Intensive Auditory Comprehension Treatment

and subsequent aphasia may be due to localized damage to cortical areas responsible for linguistic function (acoustic-phonetic analysis) as well as a reduction in the resources available for processing capacity (Martin & Allen, 2008; Caplan, Waters, DeDe, Michaud, & Reddy,

2007). In summary, individuals diagnosed comprehension impairments may have faulty inhibition mechanisms, which negatively impact the evaluation of correct and incorrect representations held in working memory (Wiener et al., 2004).

Based on these findings, individuals with severe aphasia tend to have more extensive brain damage and are more likely to present with both linguistic and non-linguistic cognitive deficits (e.g., attention, working memory, inhibition) that may subsequently impede auditory comprehension (Nicholas et al., 2011). Therefore, individuals with severe speech perception or comprehension impairments are faced with the daily challenge of how to best manage this debilitating condition. To a large degree, awareness of the perception or comprehension deficit will dictate the success of any given intervention. The following section provides an overview of self-awareness and implications for treatment in individuals with severe, chronic perception and comprehension deficits.

Self-Awareness

Metacognition has been defined as thinking about thinking and includes self-awareness, self-monitoring, and self-control (Kennedy & Coelho, 2005). In particular, self-awareness, is the capacity to recognize and analyze behaviors and performance on tasks in relative objectivity, while still being receptive to personal subjective scrutiny (Prigatano & Schachter, 1991). Sense of self is an important aspect of self-awareness. Sense of self is the collection of self-reflecting judgments regarding a person’s abilities, traits, and attitudes, which guide their behaviors, choices, and interactions (Johnson et al., 2002). This judgment becomes especially important

13 Intensive Auditory Comprehension Treatment

during unfamiliar or difficult tasks because these undertakings require monitoring of progress and comparison of actual performance with the expected performance goal even in individuals without neurologic damage (Kennedy & Coelho, 2005). During these tasks, sense of self may be accurate, suggesting high-levels of self-awareness. In this case, if performance is judged to be deficient, behaviors would be modified to achieve the desired outcome. On the other hand, sense of self may be inaccurate, suggesting decreased levels of self-awareness. Consequently, behaviors would not be modified and the desired outcomes not achieved (e.g., erroneous comprehension of a message).

Self-awareness skills are necessary for all aspects of communication, including auditory comprehension. Functional imaging studies conducted on healthy adults suggest that self- awareness may be controlled by several cortical areas within the brain. Variable activation patterns in frontal lobe structures, specifically in the medial frontal lobe (Johnson et al., 2002;

Kelley et al., 2002) have been observed. Additionally, increased activation can be found in the posterior parietal lobe, temporal lobes, and the cingulated areas when individuals performed tasks that required self-reflection or self-monitoring (Kjaer, Nowak, & Lou, 2002). Some of these same cortical areas have also been associated with comprehension (Boatman, 2004).

Based on these findings, individuals with speech perception/comprehension deficits associated with severe aphasia may experience concurrent deficits in self-awareness.

Self-Awareness in Aphasia

The relationship between aphasia and self-awareness is not fully understood. More specifically, little is known about the relation of self-awareness (of comprehension deficits) and comprehension performance.

14 Intensive Auditory Comprehension Treatment

Impaired self-awareness, has been extensively studied in traumatic brain injury (TBI) and is described as having four distinct dimensions:

1) accurate acknowledgment of the presence of a problem or deficit,

2) demonstration of an appropriate emotional response toward the deficit,

3) comprehension of the implications the deficit has on daily life, and

4) taking the deficit into account in future actions/behaviors (Flashman, Amador, &

McAllister, 1998).

Impaired self-awareness can have the most significant impact on an individual’s potential for return to functional community and activities of daily living following TBI (Prigatano, 2005).

A review of research revealed that: (1) people with severe TBI can underestimate the degree and type of cognitive deficit several years after the incident, (2) impaired self-awareness can contribute to longer lengths of stay and poor therapeutic compliance, and (3) ratings of impaired self-awareness is a significant predictor of return to work status following treatment (Prigatano,

2005).

The Awareness Pyramid Model provides an additional framework for understanding impaired self-awareness. The following levels of awareness are hierarchically arranged within the Awareness Pyramid Model:

(1) intellectual awareness: individual demonstrates superficial knowledge that ability is

impaired on a task,

(2) emergent awareness: individual recognizes when a breakdown in task performance

has occurred, and

(3) anticipatory awareness: individual anticipates and predicts when breakdowns or

problems may occur (Crosson et al., 1989; Toglia & Kirk, 2000).

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Absent or poor awareness at any level within the Awareness Pyramid Model may interfere with successful performance in activities of daily living and in language treatment programs. It can be reasoned that individuals with impaired aphasia and subsequent self-awareness deficits are likely to implement fewer compensatory strategies and fail to consistently recognize or repair communication breakdowns (Cocchini et al., 2010). A variety of potential factors associated with impaired self-awareness (e.g., low motivation to participate in treatment, poor response to feedback, and overestimation of performance, etc.) may be responsible for limited language recovery (Toglia & Kirk, 2000).

Self-awareness impairments can be diagnosed when a discrepancy occurs between the perceived deficits and the actual deficits. Oftentimes, this is measured by comparing responses from a verbal questionnaire (perceived deficits) and an objective evaluation that documents performance during identified tasks (actual deficits) (Starkstein, Jorge, & Robinson, 2010).

Despite the extensive research on self-awareness in TBI, there is limited data on self-awareness deficits in individuals with left-hemispheric stroke and subsequent aphasia. In fact, most studies that address self-awareness after stroke include only patients with bilateral damage (60%) or right-hemisphere damage only (35%) (Orfei, Caltagirone, & Spalletta, 2009). At the time of this writing, no study has focused exclusively on left-hemisphere stroke (and aphasia).

Because individuals with aphasia present with interfering language barriers, reliable assessment methodology and prevalence data for self-awareness impairments has not been established for this population (Cocchini, Gregg, Beschin, Dean, & Sala, 2010; Starkstein et al.,

2010). In fact, aphasia is frequently cited as a confounding factor during the assessment of self- awareness; therefore researchers often include the diagnosis of aphasia as part of the exclusion criteria to participate in self-awareness studies. Furthermore, some investigators propose that it is

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not possible to assess self-awareness in people with global aphasia/severe comprehension deficits associated with aphasia (Orfei, Caltagirone, & Spalletta, 2009).

Individuals with aphasia may exhibit signs that their perceived degree and extent of comprehension impairment may not coincide with rehabilitation specialist’s or caregiver’s perception of the impairment (Kertesz, 2010). As a result, they may deny comprehension difficulties, fail to request clarification when a comprehension breakdown occurs, or under utilize compensatory strategies to aid in the understanding of messages. These factors may contribute to the negative long-term social, therapeutic, and vocational outcomes associated with individuals with severe, chronic comprehension deficits; results from a recent pilot study support this notion (Knollman-Porter, et al., 2012). Following an intensive treatment regime (2 hours per day, daily for 3 weeks), 2 out of 3 participants with severe comprehension deficits demonstrated an increase in requests for clarification (via verbal and gestural communication and/or facial expressions) when a breakdown in understanding occurred. The two participants who demonstrated the most significant gains also demonstrated an increase in requests for clarification as the intervention progressed. The one participant who made the least amount of progress did not request clarification and did not exhibit signs of misunderstanding. It is hypothesized that deficiencies in the participant’s perception of the degree of comprehension impairment may have contributed to the lack of utilization of compensatory strategies and resultant lack of comprehension gains.

In summary, the successful perception and comprehension of speech sounds and single words is a multi-step process that can be influenced by short-term working memory and self- awareness. For that reason, the assessment of individuals with comprehension impairments can be multifaceted and time intensive. A detailed diagnostic protocol can yield crucial information

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that may help determine why some individuals respond to treatment and why others do not. In addition, an assessment that provides information regarding both speech perception and single word comprehension performance can provide baseline data that will guide the development of treatment goals and the selection of appropriate management protocols. A less detailed comprehension assessment may result in the establishment of inappropriate goals (e.g., complexity level that is too difficult for the individual). In turn, this may result in increased frustration and confusion during the treatment session, decreased functional gains, and a greater risk of treatment drop-out. A review of the challenges associated with the assessment of severe comprehension disorders are discussed in the following section.

Assessment of Comprehension Deficits in Aphasia

Cerebrovascular accidents can impair the perception and processing of semantic and phonological aspects of a spoken word to varying degrees and at any stage along the comprehension continuum (e.g., acoustic-phonetic, etc.). As a result, a single phonological or semantic measure will not sufficiently discriminate the level of speech perception or comprehension impairment (Martin, Kohen, Kalinyak-Fliszar, 2010). Traditional diagnostic test batteries that measure auditory comprehension typically include subtests that assess simple to complex yes/no questions and/or the identification of a named picture or object from a group

(Dunn & Dunn, 2007; Goodglass, Kaplan, & Barresi, 2001; Kertesz, 2007). Due to the high probability of providing a correct response (50%), these tasks pose a strong risk of yielding false positive or false negative responses. Therefore, results from these tools do not provide clinicians with a reliable measure of comprehension ability. Furthermore, standardized assessment batteries do not provide a measurement of impairment at the level of speech perception (Dunn & Dunn,

2007; Goodglass, Kaplan, & Barresi, 2001; Kertesz, 2007).

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A less frequently employed task to measure comprehension is word/picture verification.

In the word/picture protocol, only one picture or object is presented at a time and individuals must decide if it matches the spoken name (Rapp & Caramazza, 2002). To decrease false positive/negative responses previously discussed, individuals are presented each picture, non- consecutively, three times in a series of varying pictures. Each picture is presented once, with a verbally spoken semantically related foil (calendar), a phonologically related foil (lime), and with the target word (time) (Hillis, Rapp, Romani, & Caramazza, 1990). Individuals must reject both foils and accept the target to be given full credit for a correct response. When compared to tasks used in standardized batteries, word/picture verification tasks are significantly more sensitive in indentifying deficits of single word comprehension (Breese & Hillis, 2004). At this time, commercially available standardized tools that employ this technique are not available (for single word comprehension or speech perception) and available batteries may not provide an accurate assessment of the unique strengths and limitations exhibited by an individual with severe, chronic comprehension deficits. As a result, erroneous assumption may be made that adversely influence the analysis of research findings or in the clinic, rehabilitative outcomes. For these reasons, continued development of appropriate assessments for individuals with more severe speech perception or comprehension deficits are warranted. By doing this a more detailed differential diagnosis can be obtained.

Assessment of short-term working memory and comprehension. Traditional standardized diagnostic language batteries do not assess the adverse impact of short-term working memory on comprehension skills. Recently, more reliable and valid methods of assessing the impact of verbal short-term memory (STM) on comprehension deficits in aphasia

(Martin, Kohen, & Kalinyak-Fliszar, 2010) have been developed. These tests are based on the

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notion that there are two types of processing deficits that can impact comprehension abilities.

The first is slowed activation. Slowed activation occurs when the listener requires more time to successfully process words. The second is too-fast decay. Too-fast decay occurs when a listener is unable to maintain activation of representations in the working memory long enough for processing (Martin, Kohen, & Kalinyak-Fliszar, 2010). The Temple Assessment of Language and

Short-Term Memory in Aphasia (TALSA) has been shown to be effective in identifying both linguistic and STM deficits in aphasia (Martin, Kohen, & Kalinyak-Fliszar, 2010).

Attempts have been made to further classify comprehension deficits based on more discrete diagnostic methods (Martin, Schwartz, & Kohen, 2006; Franklin, 1989). Specifically, the use of phoneme discrimination, lexical decision, synonym matching, and word and non-word repetition tests have been utilized to analyze single word comprehension performance in aphasia.

Results demonstrate that different types of comprehension impairment were observed and that the areas of deficit were extremely diverse across participants. These differences were so diverse, that no two participants demonstrated exactly the same pattern of impairment across all tests administered (Franklin, 1989). Together, these findings support the argument for implementing detailed diagnostic auditory comprehension protocols designed to differentially diagnose comprehension deficits in people with aphasia. This approach to assessment will facilitate the development of treatment protocols tailored to meet the individual needs of people with aphasia and subsequent comprehension deficits.

Therapeutic Management of Comprehension Deficits in Aphasia

Extant aphasia research has established that clinical and functional outcomes are positive when intervention protocols are implemented by a speech-language pathologist (Barthel,

Meinzer, Djundja, & Rockstroh, 2008; Meinzer, Streiftau, & Rockstroh, 2007; Mortley, Wade, &

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Enderby, 2004; Robey, 1998; Katz & Wertz, 1997). More specifically, early treatment may be maximally beneficial while treatment in the chronic stages of recovery can also positively impact language use (Kendal et al., 2006; Kleim et al, 2008; Raymer et al, 2008) In addition, intervention provided at an intensive level (i.e., 2-4 hours daily), over more treatment sessions, result in greater gains than those that are provided less than 2 hours per week (Basso, 2005). But of most importance, extant research has found that treatments based on research grounded principals, while still focusing on the unique needs and desires of the individual patients are most effective (Robey, 1998).

Multimodality stimulation approaches which incorporate intense, adequate, repetitive stimuli while eliciting a maximum number of responses have been found to be more effective than other approaches in the management of aphasia (Helm-Estabrooks, Fitzpatrick, & Barresi,

1982; Schuell, Jenkins, & Landis, 1964; Robey, 1998). The most established of these protocols is

Schuell’s Stimulation Approach. The foundation to this method is that intensive, controlled auditory stimulation is incorporated into all treatment sessions. However, there is limited evidence based research supporting the use of this protocol to remediate speech perception and single word comprehension individuals with chronic aphasia. Furthermore, it has been suggested that utilization of this approach would be contraindicated in individuals with severe or irreversible aphasia (Schuell et al., 1964). However, results from a feasibility study raise questions regarding the validity of previous recommendations regarding candidacy for a

Schuellian approach to aphasia therapy (Knollman-Porter, et al., 2012).

Treatment protocols that are designed to remediate severe, chronic speech perception or comprehension deficits in aphasia are sparse. A case study that described a single participant with severe aphasia exists (Morris, Franklin, Ellis, Turner, & Bailey, 1996). The treatment

21 Intensive Auditory Comprehension Treatment

protocol focused on auditory discrimination at the phonemic level and utilized lip-reading as a compensatory strategy. Positive outcomes included improvements in phonemic discrimination, along with generalization to other auditory tasks However, limitations inherent to the case study format limit the generalizability of the results. Furthermore, the participant was less than 1 year post-onset of stroke; thus, spontaneous recovery may have contributed to the positive outcomes.

Finally, it did not provide results regarding the utility of compensatory strategies, such requesting repetition of information, which might positively influence outcomes. Thus, further research is warranted to control for these factors and examine the effectiveness of an intense protocol, which incorporates compensatory strategies such as repetition and lip-reading.

Intensity of treatment. Before a review of the effects of an intensive treatment can be performed, further clarification is warranted to determine the different guidelines for the term intensity. Amount of treatment can be quantified within the following guidelines: (1) low intensity: when treatment does not exceed 1.5 hours per week; (2) moderate intensity: when it lasted 2-3 hours per week; (3) high intensity: when treatment lasted at least 5 hours per week

(Robey, 1998). Other factors, such as stage of recovery may also influence how individuals with aphasia respond to an intensive treatment. Frequently, stages of recovery are referenced in three phases: (1) acute, (2) post-acute, or (3) chronic. Based on research synthesis, no studies were available for review that included individuals with chronic aphasia receiving speech perception or comprehension treatment exclusively at a high intensity level (Robey, 1988). However, the effectiveness of treatment protocols that address other language domains, such as verbal expression, can provide information that may facilitate the development of intensive comprehension interventions. Participants who received treatment at a high intensity level made greater gains in expression than those that received treatments at a shorter duration (Robey,

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1998). For this reason, the minimum recommended intensity levels is 2 hours per week; if patients are able to withstand the intensity of the treatment protocol (Robey, 1998). Although improvements on structured language tasks were noted, the outcomes on functional communication tasks following intensive treatment are mixed (Cherney et al., 2008). As such, continued research is warranted to evaluate generalization of language skill to functional communication tasks outside the clinic. Further, the specific strategies (i.e., compensatory and restorative) utilized during treatment are as crucial to positive outcomes as the intensity of the intervention.

Utilization of repetition cues. In addition to treatment intensity, the effectiveness of compensatory strategies utilized by the person with comprehension deficits should also be examined. During normal communication exchanges, it is commonplace for a confused listener to ask for repetition during a communication breakdown (Wallace, Dietz, Hux, & Weissling,

2012). . Research regarding the impact of repetition on individuals learning English as a second language suggests that repetition promotes improved comprehension (Sakai, 2009). Although, clinicians commonly employ repetition to promote comprehension during for individuals with aphasia (Hedge, 2006); there is little evidence documenting the effectiveness of this technique in people with severe, chronic speech perception or comprehension deficits. In participants with mild-moderate auditory comprehension impairment, it was found that repetition of the stimulus following a mis-understanding led to improved comprehension performance. In addition, improvement was greatest on the first and second repetition but continued through five repetitions (LaPointe, Rothi, & Campanella, 1978). Based on these findings, it can be assumed that repetition of stimuli may positively influence comprehension in individuals with more severe speech perception or single word comprehension impairments. Moreover, comprehension

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of the speech signal is a multimodal process that includes auditory and visual components

(Hessler, Jonkers, & Bastiaanse, 2010; Stephens & Holt, 2010); thus it is logical that visual cues, such as lip-reading would facilitate improved speech perception or word comprehension.

Utilization of lip-reading cues. The integration of both auditory and visual information have been found to improve the ability to understand speech in noise and in non-compromised listening situations in healthy adults (Eramudugolla, Henderson, & Mattingley, 2011; Stephens

& Holt, 2010). The listener’s ability to see the speaker’s lips and face, in order to visualize their articulatory gestures provide the multisensory means to assist in the understanding of messages that are ambiguous or not perceived clearly. More specifically, in healthy adults, the listener’s threshold for detecting a speech signal in a noisy background is lowered if they are able to see the speakers articulatory movements. In the same respect, the detection threshold must be increased if the speech signal is paired with a visual image that does not correspond with the auditory information being presented (Grant & Seitz, 2000; Kim & Davis, 2004). While these findings support the use of the integration of both auditory and visual stimuli in healthy individuals, it does not provide evidence to support use of multisensory stimulation in those with speech perception or severe single word comprehension impairments. Further examination of the influence of lip-reading feedback is warranted to determine how it influences comprehension in those with semantic confusions following stroke.

Individuals with severe, chronic speech perception or single word comprehension impairments secondary to stroke daily must face the challenges of trying to perceive and understand the messages delivered to them by caregivers and society. Without the means to understand this critical information, these individuals can become isolated from the world around them. Crucial to their quality of life is the development of treatment protocols that can provide

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them with foundational strategies to assist in comprehension not just in the clinic, but in functional communication situations. A further understanding of the strategies (i.e., repetition or lip-reading) that may result in the greatest improvement is warranted. In addition, a critical review of the influence of intensity of treatment will provide foundational information regarding appropriate dosaging of treatment for this very unique population. In conclusion, for treatment protocols to be effective, it requires a team approach between the clinician and the patients. A further understanding of the role of self-awareness in individuals with severe aphasia is warranted to determine its potential influence on rehabilitative outcomes.

In light of this, the overarching purpose of this dissertation project was to determine the effectiveness of an intensive treatment protocol and the utility of repetition and lip-reading on single word comprehension (SWCA) or speech perception (SPA) on individuals with severe, chronic aphasia. The following section provides an overview of the research questions addressed in the two experiments.

Research Questions and Research Hypotheses: Experiment I – SWCA

Following an intensive (2 hours/day, 5 days/week for 3/weeks) single word comprehension intervention protocol:

Research question 1. Will the average percentage accuracy on single word

comprehension tasks improve?

Research hypothesis 1. The average percentage accuracy on single word

comprehension tasks will improve.

Research question 2. Will the average number of self-initiated requests for repetition

cues increase?

25 Intensive Auditory Comprehension Treatment

Research hypothesis 2. The average number of self-initiated requests for

repetition cues will increase.

Research question 3. Will the average number of self-initiated requests for lip-reading

cues increase?

Research hypothesis 3. The average number of self-initiated requests for lip-

reading cues will increase.

Research question 4. Will the average number of correct responses on single word

comprehension tasks increase following repetition cues?

Research hypothesis 4. The average number of correct responses on single word

comprehension tasks will increase following repetition cues.

Research question 5: Will the average number of correct responses on single word

comprehension tasks increase following lip-reading cues?

Research hypothesis 5: The average number of correct responses on single word

comprehension tasks will increase following lip-reading cues.

Research question 6. Will the average number of correct single word naming responses

increase?

Research hypothesis 6. The average number of correct single word naming

responses will increase.

Research question 7. Will the number of correct narrative utterances increase during

picture description tasks?

Research hypothesis 7. The number of correct narrative utterance will increase

during picture description tasks.

26 Intensive Auditory Comprehension Treatment

Research question 8. Will participants demonstrate generalization of comprehension

skills and/or independent use of compensatory strategies as documented via the

Communicative Effectiveness Index (Lomas et al., 1989)?

Research hypothesis 8. Participants will demonstrate generalization of

comprehension skills and/or independent use of strategies as documented via the

Communicative Effectiveness Index (Lomas et al., 1989)?

Research Questions and Research Hypotheses: Experiment II – SPA

Following an intensive (2 hours/day, 5 days/week for 3/weeks) single word comprehension intervention protocol:

Research question 1. Will the average percentage accuracy on speech perception tasks

improve?

Research hypothesis 1. The average percentage accuracy on speech perception

tasks will improve.

Research question 2. Will the average number of self-initiated request for repetition

cues increase?

Research hypothesis 2. The average number of self-initiated requests for

repetition cues will increase.

Research question 3. Will the average number of self-initiated request for lip-reading

cues increase?

Research hypothesis 3. The average number of self-initiated requests for

lip-reading cues will increase.

Research question 4. Will the average number of correct responses on speech

perception tasks increase following repetition cues?

27 Intensive Auditory Comprehension Treatment

Research hypothesis 4. The average number of correct responses on speech

perception tasks will increase following repetition cues.

Research question 5. Will the average number of correct responses on speech

perception tasks increase following lip-reading cues?

Research hypothesis 5. The average number of correct responses on speech

perception tasks will increase following lip-reading cues.

. Research question 6. Will the average number of correct verbal repetition responses

increase?

Research hypothesis 6. The average number of correct verbal repetition

responses will increase.

Research question 7. Will the number of correct narrative utterances increase during

picture description tasks?

Research hypothesis 7. The number of correct narrative utterance will increase

during picture description tasks.

Research question 8. Will participants demonstrate generalization of comprehension

skills and/or independent use of compensatory strategies as documented via the

Communicative Effectiveness Index (Lomas et al., 1989)?

Research hypothesis 8. Participants will demonstrate generalization of

comprehension skills and/or independent use of strategies as documented via the

Communicative Effectiveness Index (Lomas et al., 1989)?

28 Intensive Auditory Comprehension Treatment

Chapter 3

Methods

The purpose of this dissertation study was to execute and examine two separate, but similar Experiments. The Methods section is divided into segments that describe materials and procedures that (a) pertain to both experiments and (b) are unique to each experiment. First, the screening and comprehensive cognitive-linguistic assessment protocol used to determine inclusion into the dissertation study and the two experiments is described. Next, the assessment procedures to determine the complexity level of experimental stimuli are reviewed. Following this, the treatment procedures unique to each Experiment are outlined. Finally, this section concludes with a discussion regarding procedural consistencies relevant to the treatment phase of both Experiments (see Figure 1).

Due to the specific nature of the target population, all participants were provided detailed verbal, written, and/or gestural instructions prior to the start of each task. In addition, examples were provided, as needed, to aid with comprehension of specific instructions. Comprehension of the protocol throughout each phase of the study had to be demonstrated by the participant prior to the start of data collection.

29 Intensive Auditory Comprehension Treatment

Screening: To determine inclusion into the study

Cognitive Linguistic Assessment: To determine assignment to SWCA or SPA

Experiment I: SWCA Experiment II: SPA

Assessment to determine the complexity level of stimuli

SWCA Stimuli: high SPA Stimuli: CV, medium, or low CVC, or CCVC pairs frequency words

Experiment I: SWCA Experiment II: SPA

baseline, treatment and baseline, treatment and maintenance phases maintenance phases

SWCA & SPA Experimental Study:

Procedural Consistencies

Figure 1. Overview of the assessment and experimental procedures for each assessment.

30 Intensive Auditory Comprehension Treatment

Participants

Participants included eight adults ranging in age from 56-81 years, with aphasia and subsequent chronic, severe auditory comprehension deficits (see Table 1). All participants experienced a left hemisphere stroke, diagnosed via Computerized Tomography (CT) and/or

Magnetic Resonance Imaging (MRI) (see Table 2). Additionally all participants: (1) were at least 1 year post onset of stroke; (2) had at least a high school education; (3) were native speakers of American English; and (4) demonstrated hearing and vision adequate to perform the experimental tasks. Participants were excluded if they: (1) demonstrated pre-morbid dementia or other progressive neurologic disease affecting cognition; (2) demonstrated pre-morbid known hearing or vision loss that was uncorrected with appropriate aids; (3) demonstrated impaired level of consciousness or ongoing sedation; (4) had a history of major psychotic episodes or intractable substance abuse; or (5) was actively receiving speech-language therapy.

Participants were recruited from the Miami University Aphasia Support Group,

University of Cincinnati Communication Helps Achieve Together (CHAT) Group, Drake

Hospital Stroke Support Group, and by word-of mouth. Nine candidates were screened; eight were enrolled in the study. Informed consent to participate was obtained from each individual or their legal guardian prior to screening procedures. No monetary compensation was provided for participation in the study.

31 Intensive Auditory Comprehension Treatment

Table 1. Participant Demographic Data.

Speech Single Word Comprehension Approach Perception Approach

Variable T.G. B.G. T.O. B.D. D.W. R.K. T.L. E.R.

Months Post Onset 130 75 46 71 21 28 100 68

Age 65 74 56 65 76 78 81 73

Gender Male Female Male Female Male Male Male Female Handedness Right Right Right Left Right Right Right Right Years of 14 12 18 18 16 12 12 12 Educationa

Type of Aphasia Global WR TM Global Global Global Global Global

WAB-R Aphasia 24.8 48.8 60.9 20.9 43.1 9.5 12.5 4.6 Quotient WAB-R Comprehension 72 116 143 105 95 104 81 32 Subtest Scoreb

Note. aYears of Education: 12 = high school, 16 = bachelor’s, 18 = master’s; bWAB-R Comprehension Subtest Score (300 Possible). WAB-R = Western Aphasia Battery-Revised; WR = Wernicke’s Aphasia; TS = Transcortical Motor Aphasia;.

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Table 2. Neuroimaging Results

Neuroimaging Impacted Blood Distribution Supply

Single Word Comprehension Approach

T.G. CT Left MCA Mild loss of left gray/white matter differentiation in the frontal and temporal lobes. Non-hemorrhagic

B.G. CT Left MCA Left temporal parietal region infarction. Non- hemorrhagic

T.O. CT/MRI Left MCA Low attenuation area in the anterior paramedian left frontal lobe predominantly involving the left superior frontal gyrus. Small left parietal lobe white matter lesion. Non-hemorrhagic

B.D. Not available

D.W. CT/MRI Left/Right Findings exhibit restricted-diffusion both anteriorly and posteriorly – left frontal and MCA parietal lobe infarction. There is also restricted- diffusion near the convexity of the Rt hemisphere suggesting a stroke in his hemisphere as well. The findings are consistent with a Bilateral stroke. Non-hemorrhagic.

R.K. CT Left MCA Left frontal parietal infarction also involving the left lentiform nucleus. Non-hemorrhagic.

Speech Perception Approach

T.L. MRI Left MCA A diffuse increased signal is noted throughout the left MCA involving portions of the temporal, frontal, and parietal lobe regions.

E.R. CT /MRI Left MCA Large 7 cm non-hemorrhagic infarct involving the posterior insula and temporal lobe; measures

33 Intensive Auditory Comprehension Treatment

9 cm anterior to posterior and 4 cm right to left. Posterior aspect of the insular and the left temporal operculum extending back into the posterior left temporal region.

Note: CT = Computed Tomography; MRI = Magnetic Resonance Imaging; MCA = Middle Cerebral Artery

Setting

Assessment and treatment protocols were completed at the Drake Center and the Miami

University Speech and Hearing Clinic. These facilities provided quiet, individualized assessment and treatment rooms that were appropriate for working with adults with aphasia. The participants were seen on an individual basis to maintain confidentiality.

Design

An ABA single subject design was used to investigate the research questions by examining and comparing the effects of treatment between phases (e.g. baseline, experimental, and maintenance). This design began with observations of baseline performance with at least 3 data collection sessions completed to establish stability.

The following sections provide an overview of the materials and procedures used to screen and assess all participants. Materials and procedures that are unique to Experiment I

(SWCA) and Experiment II (SPA) will be discussed in the representative sections.

Screening and Cognitive- Linguistic Assessment Materials

Equipment. The following describes the equipment utilized during screening and the comprehensive cognitive linguistic assessment.

Audio and video equipment. The use of audio-visual recording has been used successfully as a method of data collection for years across many disciplines (Grimshaw, 1982;

34 Intensive Auditory Comprehension Treatment

Wade, Mortley & Enderby, 2003). One Cannon FS300 digital video cameras was used to record all screening and assessment sessions for transcription and analysis.

Audiometer. A Maico MA40 audiometer was used to screen hearing acuity. The device met the applicable specifications of ANSI S3.6-2004 (American National Standards Institute,

2004b).

Screening. The following describes the screening materials.

Social and medical history survey. The social and medical history survey consisted of yes/no, multiple choice, and short answer questions (see Appendix A). The survey results provided the investigator with specific information concerning the following: (1) date of onset of CVA; (2) history of speech-language therapy; (3) medication use and its impact on cognitive function and alertness; (4) functional hearing status; (5) functional vision status; (6) functional daily cognitive status; (7) level of education prior to CVA; and (8) occupational status prior to

CVA. The information obtained from the survey was used to determine inclusion into the study and to ascertain the best time for completion of diagnostic and experimental protocols.

Hearing screening. A hearing screening was performed. Adequate hearing was necessary in order for the candidates to detect spoken stimuli for the diagnostic and experimental protocol. See Appendix B for the hearing screening form.

Visual acuity screening. Vision suitable for the experimental tasks was verified through a visual screening protocol (see Appendix C). Ten colored pictures of equal size (4x6) of individual high frequency objects were utilized. Picture stimuli were selected based on Francis &

Kucera’s frequency analysis of English usage lexicon and grammar (1982).

35 Intensive Auditory Comprehension Treatment

Response screening. Ten high-frequency objects were used as a response screening to determine candidates’ ability to produce a yes and a no response. In addition, the screening served as a method to rule out perseveration of a ‘yes’ or ‘no’ response. The stimuli used were realistic, commonly used items selected from the Western Aphasia Battery Revised (WAB-R)

(Kertesz, 2007). The following objects were selected: cup, pencil, flower, ball, knife, toothbrush, key, watch, hammer, and spoon (see Appendix D).

Comprehension severity screening. Part 1 of the Western Aphasia Battery-Revised

(WAB-R), a standardized assessment designed to evaluate language function following CVA

(Kertesz, 2007), was used to determine aphasia type and severity of comprehension and verbal expression deficits.

Cognitive-Linguistic Assessment. This section describes the cognitive-linguistic assessment materials.

Phonological processing. The following assessments were used to assess phonological processing from the stage of sound discrimination to the mapping of phonemes onto lexical representations.

(1) Phoneme Discrimination – Word & Non-word Minimal Pairs Subtest of the Temple

University Assessment of Language and Verbal Short-term Memory in Aphasia (TALSA) (Martin,

Kohen, Klinyak-Fliszar, 2007). This subtest assesses the ability of participants to distinguish two words or two non-words (1-2 syllable) as the same or different.

(2) Rhyming Judgments – Word & Non-word Pairs Subtest of the TALSA (Martin,

Kohen, Linyak- Fliszar, 2007). This subtest assesses the ability of participants to determine whether pairs of words and non-word rhyme (10 rhyming and 10 non-rhyming).

36 Intensive Auditory Comprehension Treatment

Semantic processing. The following assessments were used to assess single word comprehension or non-verbal conceptual semantic processing.

(1) Peabody Picture Vocabulary Test, 4th Edition (PPVT-Form B) (Dunn & Dunn,

2007). This is a standardized measure of word comprehension and used a spoken word-to picture matching format.

(2) Lexical Comprehension Subtest of the TALSA (Martin, Kohen, Klinyak-Fliszar, 2007).

This assessment differs from the PPVT in that participant matched a spoken word to one of four pictures that were members of the same semantic category.

(3) Pyramids and Palm Trees Test – picture version (Howard & Patterson, 1992). This tool is a measure of non-verbal conceptual semantic processing.

Working memory. Data was collected to determine the impact of short- term working memory (e.g., weak activation or too rapid decay) on activated semantic and phonological representations during the following phonological and semantic processing tasks. During these assessments there were two memory conditions: 1 second unfilled interval and 5 second unfilled interval.

(1) Phoneme Discrimination – Word & Non-word Minimal Pairs Subtest of the TALSA

(Martin, Kohen, Klinyak-Fliszar, 2007). See description above.

(2) Lexical Comprehension Subtest of the TALSA (Martin, Kohen, Klinyak-Fliszar, 2007).

See description above.

Non-linguistic cognitive assessment tool. The following assessment was administered to assess participant’s non-linguistic cognitive skills.

37 Intensive Auditory Comprehension Treatment

(1) Symbol trails subtest of the Cognitive Linguistic Quick Test (CLQT) (Helm-

Estabrooks, 2001). This subtest measures attention, working memory, organization, and problem solving (Helm-Estabrooks, 2001).

Screening and Cognitive-Linguistic Assessment Procedures

This section will provide an overview of the procedure used during the screening and comprehensive cognitive linguistic assessment for all candidates and participants. Procedures that are specific to Experiment 1 and Experiment 2 will be discussed in their representative sections.

Video recording protocol. The video recording device was set up in the treatment room and turned on prior to the start of the session to avoid distraction.

Screening. All candidates completed the screening protocol in the order listed below during 1 session. Prior to start of testing, candidates and/or their legal guardians met one-on-one with the researcher and were informed of the purpose of the screening protocol. Gestural, written, and verbal instructions were provided to facilitate comprehension. The screening protocol did not start until the candidate relayed comfort and willingness to participate via verbal, gestural or written means.

Medical and social history survey. Candidates and/or their legal guardians completed a medical and social history survey (see Appendix A).

Hearing screening. The researcher screened candidates hearing acuity to ensure performance on the experimental tasks would not be negatively influenced by hearing loss. The process of familiarization was performed prior to the screening to confirm that the candidate understood and could perform the task (ASHA, 2005). Once a consistent response was noted, hearing was screened at 40 dB in the frequency region from 1000, 2000, and 4000 Hz (Martin et

38 Intensive Auditory Comprehension Treatment

al., 2009). For both the familiarization and screening tasks, the candidate was asked to respond with a gesture whenever they heard a tone. Consistent behaviors were accepted as a correct response (e.g. turning head toward the source of sound during the protocol). Candidates were required to respond at 40 dB on all frequencies screened, in at least one ear, to be included in the study (see Appendix B).

Visual acuity screening. Screening of candidates visual acuity was performed to ensure performance on the experimental tasks would not be negatively influenced by visual acuity deficits. In this protocol, the researcher placed 3 color pictures of equal size (4x6) of individual objects on the table in front the candidates. The researcher then gave candidates a picture that was identical to only 1 of the 3 pictures choices. The candidates were then asked to match the picture provided to 1 of the 3 picture choices on the table. Examples of the required task were provided by the examiner until the candidates demonstrated understanding or until it was determined that they could not complete the task. The candidates were required to match 9 out of

10 correctly to be considered for the study (see Appendix C).

Response screening. After candidates passed the visual acuity screening, they completed a “Response Screening” using 10 simple yes/no questions. The researcher showed candidates an object and then said, “Is this a ____?” with the object being named either correctly or incorrectly.

Candidates had to demonstrate the ability to signal a yes and no response via voice, gesture, or through a picture choice selection in response to the researcher’s request. The accuracy of candidates’ responses were not considered. The accepted criteria, was that candidates demonstrate the ability to respond on 9 out of 10 questions. At least 1 ‘yes’ and 1 ‘no’ response had to be provided (see Appendix D). Examples of the required task were provided by the

39 Intensive Auditory Comprehension Treatment

examiner until the candidates demonstrated understanding or until it was determined that they could not complete the task.

Comprehension severity screening. The final criterion of the screening protocol was to determine candidates’ aphasia type and severity rating. This was assessed by calculating the

Aphasia Quotient (AQ) using the Western Aphasia Battery-Revised (WAB-R, Kertesz, 2007).

Auditory comprehension severity ratings were determined using the Auditory Comprehension

Subtest of the WAB-R. An Auditory Comprehension Subtest score of 150 or less was the criterion used to confirm the diagnosis of severe auditory comprehension impairment for inclusion in the project.

Neuroimaging. Post screening, CT and/or MRI reports were obtained from the medical institution where the diagnosis of CVA was made. Attempts were made to procure neuroimaging films for further analysis of the specific location of neurologic damage. However, secondary to the length of time since the onset of CVA, the majority of images could not be obtained. Thus, the written radiology report from the original hospitalization was accepted as a means of confirming diagnosis of left CVA.

Eight of the 9 candidates met inclusion/exclusion criteria and successfully completed the screening protocol. These participants were enrolled in the study and proceeded to complete the assessment protocol.

Cognitive-Linguistic Assessment. Following successful completion of the screening protocol, further assessment was completed to differentially diagnose speech perception, auditory comprehension and non-linguistic cognitive skills. In addition, results obtained from specific measures of phonological processing were used to determine inclusion into: Experiment

I: Single Word Comprehension Approach (SWCA) or Experiment 2: Speech Perception

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Approach (SPA). Detailed instructions were provided for each assessment task which included verbal, gestural, and written support. Examples were provided prior to the start of formal testing to confirm participant understanding of protocol. Gestural, written, and/or verbal responses provided by the participants were accepted on all assessment tasks. All participants completed the assessment protocol in the order listed below, during 1 session that was scheduled within 1 week of the initial screening.

Measurement of phonological processing and working memory. Each of the following subtests was administered in the order listed below. If performance on the measures of phoneme discrimination were greater than by chance, participants were included in Experiment I: SWCA.

If participants’ performance on the measure of phoneme discrimination was less than chance

(50%), they were enrolled in Experiment II: SPA. The following assessments were administered:

(1) Phoneme Discrimination – Word & Non-word Minimal Pairs Subtest of the TALSA

(Martin, Kohen, Klinyak-Fliszar, 2007).

(2) Rhyming Judgments – Word & Non-word Pairs Subtests of the TALSA.

SPG. Six of the eight participants scored greater than 50% on the phoneme discrimination subtest and were enrolled in Experiment I: SWCA. Two of the eight participants scored less than 50% on the measure of phoneme discrimination and therefore were enrolled in

Experiment II: SPA (see Table 3 for results).

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Table 3. Measures of Phonological Processing and Working Memory

Phoneme Phoneme Rhyming Discriminationa Discrimination

With 5 Sec. Delay Single Word Comprehension Approach

T.G. 90% 90% 0%

B.G. 85% 85% 0%

T.O. 95% 100% 100%

B.D. 60% 55% 80%

D.W 95% 95% 85%

R.K. 95% 95% 0%

Speech Perception Approach

T.L. 0% 0% 0%

E.R. 50% 40% 0%

Note. aWhen participant accuracy dropped to 50% or less on Phoneme Discrimination task, the pre-experimental assessment was terminated and individuals were included in the speech perception protocol.

All participants completed the remaining assessments, in the order outlined below. The data obtained from these assessments were used to gain a deeper appreciation of the extent of each participant’s comprehension deficits and the potential impact of cognition/working memory on experimental performance.

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Measurement of semantic comprehension and working memory . The following assessments were administered: (1) Peabody Picture Vocabulary Test, 4th Edition (PPVT-Form

B) (Dunn & Dunn, 2007), (2) Lexical Comprehension Subtest of the TALSA (Martin, Kohen,

Klinyak-Fliszar, 2007), and (3) Pyramids and Palm Trees Test – picture version (Howard &

Patterson, 1992).

Variable results were obtained from the participants enrolled in each study. Some overlap of scores was noted between the SWCA and SPA participants: PPVT-4 and Lexical

Comprehension (TALSA) Results: Participants D.W., T.L., and E.R. Only one participant

(T.O.) scored within normal limits on the PPVT-4. See Table 4 for results.

Table 4.

Measures of Semantic Comprehension and Working Memory

Speech Single Word Comprehension Approach Perception Approach Measures of T.G. B.G. T.O. B.D. D.W. R.K. T.L. E.R. Semantic Comprehension PPVT – 4a 89 65 191 165 10 111 10 9

Lexical Comprehension 93% 88% 100% 93% 56% 88% 68% 13% (TALSA)

Lexical Comprehension 88% 63% 100% 88% 56% 93% 50% 0% (TALSA) with 5 sec. delay

Pyramids and Palm 31 46 47 44 34 36 19 35 Treesb Note. PPVT-4 = Peabody Picture Vocabulary Test 4th Edition a(228 Possible); bPyramids and Palm Trees (52 Possible). TALSA-Temple University Assessment of Language and Verbal Short-term Memory in Aphasia.

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Non-linguistic cognitive assessment protocol. One assessment was utilized to assess non-linguistic cognitive function: Symbols Trails subtest of the Cognitive Linguistic Quick Test

(CLQT) (Helm-Estabrooks, 2001). Only two of the participants scored within normal limits on the CLQT (T.O. and D.W.) (Helm-Estabrooks, 2001). See Table 5 for results.

Table 5.

Measure of Non-Linguistic Cognitive Ability.

Speech Single Word Comprehension Approach Perception Approach T.G. B.G. T.O. B.D. D.W. R.K. T.L. E.R.

CLQT 0% 0% 100% 55% 100% 27% 0% 0% Symbol Trails Subtest Note. CLQT = Cognitive Linguistic Quick Test

Assessment of Experimental Complexity Stimuli Materials

This section will provide an explanation of the materials used and how specific stimuli were developed for the experimental phases of Experiment I: SWCA and Experiment II: SPA.

Experiment I: SWCA assessment materials. The materials utilized included high-, medium-, and low-frequency target words that were originally selected based on Francis &

Kucera’s frequency analysis of English usage lexicon and grammar (1982). Further target word analysis was completed using the English Lexicon Database to analyze the following lexical characteristics: (1) frequency of usage, (2) number of phonologic neighbors (excluding homophones), and (3) number of syllables. Frequency counts from the Hyperspace Analogue of

Language (HAL) were used (Balota et al. 2007; Cognitive Psychology, Washington University,

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2009). Because standards defining frequency ranges have not been established, the following arbitrary ranges were used: (1) high frequency: greater than 25,000 appearances within the HAL electronic database; (2) medium frequency: 5,000-25,000 appearances; and (3) low frequency: less than 5,000 appearances. See Appendix E for average lexical characteristics.

In order to determine the specific complexity level of stimuli to be used by a participant in the SWCA, 3 different sets of target word stimuli were created (e.g. high, medium, and low frequency). Each set included a list of 15 target words and a corresponding semantic and phonemically related foil (e.g., target: clock, semantic foil: calendar, phonologic foil: block).

All target stimuli were content nouns. An entire list of the stimuli used to assess complexity can be found in appendices F, G, and H. A corresponding colored 10x7 computer generated image was created which represented the target word stimuli only. Three independent raters judged the images created to be accurate representations of the target words. The images were presented visually on a laptop computer (see Figure 2).

Figure 2. Sample stimuli. target: clock; semantic foil: calendar; phonemic foil: block

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Experiment II: SPA assessment materials. The following materials were used to determine the complexity level of stimuli that would be used by participants in the SPA. The materials included three sets of 15 CV, CVC and CCVC word and/or non-word pairs. The sets generated were phonetically balanced such that the phonemes in each set were evenly distributed in the syllable list.

(1) CV Stimuli: CV stimuli sets included the following: 15 initial consonants

/m,n,p,b,t,d,k,g,w,h,v,s,l,r,f,z/ and 9 vowels /i,I,e,Ԑ,ӕ,a,o,u,ai/. Each target stimuli was either paired with itself (e.g., bi/bi), a CV foil with similar placement (e.g., bi/pi) or a CV foil with different placement (e.g., bi/li) (see Appendix I).

(2) CVC Stimuli: CVC stimuli sets included the following: 15 initial consonants

/m,n,p,b,t,d,k,g,w,h,v,f,l,r,s,/, 9 vowels /i,I,e,Ԑ,ӕ,a,o,u,ai/ , and 13 final consonants

/m,n,p,b,t,d,k,g,v,f,l,r,z/. Each target stimuli was either paired with itself (e.g., moon/moon), a

CVC foil with a substituted initial consonant (e.g., moon/toon) and a CVC foil with substituted final consonant (e.g., moon/mood) (see Appendix J).

(3) CCVC Stimuli: Real word pairs were utilized in this set. All sets included blends ,

/br,cr,dr,fr,gr,pr,tr,bl,cl,fl,gl,pl,sl/. Each target stimuli was either paired with itself (e.g., glad/glad), a foil utilizing deletion (e.g., glad/lad), and a foil utilizing substitution (e.g., glad/plaid) (see Appendix K).

Assessment of Experimental Stimuli Complexity Procedures

The following protocols were used to determine the complexity level of stimuli used during either Experiment I: SWCA or Experiment II: SPA. After participants were provided with procedural instructions and demonstrated understanding of the protocol, the assessment was

46 Intensive Auditory Comprehension Treatment

initiated. No feedback was provided directly to the participant regarding the accuracy of their responses during this level of assessment.

Experiment I: SWCA assessment procedures. All participants were required to demonstrate understanding of the protocol before data collection could be initiated. Verbal, gestural and written instructions were provided utilizing unique non-experimental stimuli for training purposes. On average, less than 5 minutes of training was needed with participants.

SWCA participants were required to correctly determine if the single word, spoken by the researcher, matched the image of an object being shown. Participants were shown each image three times, on nonconsecutive occasions. The stimuli were presented once with a semantically related foil, once with a phonologically related foil, and once with the target word. Participants were required to identify the correct target and reject the semantic and phonemic foil in order to obtain full credit for a response. (Example: Target Word– Book, Semantic Foil – Magazine,

Phonemic Foil – Hook) (see Figure 3). Participants responded to stimuli with verbal, gestural, and/or a selected choice of visually displayed written choice of ‘yes’ or ‘no’. Responses were recorded and analyzed for accuracy.

47 Intensive Auditory Comprehension Treatment

“Book” (Target word spoken by examiner)

“Yes” (Verbal, gesture or written response by participant)

Picture stimuli observed by participant “Bus” (Semantic foil spoken by examiner)

“No” (Verbal, gesture or written response by participant)

Picture stimuli observed by participant

Figure 3. Examples of SWCA stimuli presentation

All SWCA participants were required to start the stimuli complexity assessment at the first level (high frequency words) and could only progress to the next level of the hierarchy

(moderate frequency words) if 90% accuracy was obtained. When participant accuracy dropped to 60-80% accuracy or lower the assessment phase ended. This determined the complexity level of stimuli used during the baseline and experimental phases of the protocol. Figure 4 provides an overview of this procedure.

48 Intensive Auditory Comprehension Treatment

Single Word Comprehension Approach Protocol

Assessment to Determine the Complexity Level of Experimental Stimuli

-All participants started at first level of stimuli (high frequency words)

-Stimuli: 15 10x7 color computer images representing the target word stimuli

- Participants were presented with each image 3 times on nonconsecutive occasions

-Participants were required to identify the correct spoken target and reject the semantic and phonemic foil to obtain full credit

Example: Target - car, semantic foil - bus, phonemic foil - tar

Participants could only progress to next level of stimuli (medium, high frequency) if 90% accuracy was obtained

When participant accuracy dropped to 60-80% or lower the assessment was terminated

Figure 4. Protocol to determine experimental stimuli complexity – SWCA

Based on the results from the stimuli complexity assessment, two SWCA participants

utilized high frequency words, three participants used medium frequency words, and one

participant used low frequency words during the experimental phase. See Table 6 for results

from the experimental stimuli complexity assessment.

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Table 6

Results – Level of Experimental Stimuli Complexity SWCA

Complexity Level of High Frequency Medium Frequency Low Frequency Stimuli Words Words Words T.G. 80% 50% NA

B.G. 50% NA NA

T.O 80% 80% 40%

B.D 86% 53% NA

D.W 25% NA NA

R.K. 25% NA NA

Note. NA = not assess secondary to performance on previous level being less than 80%.

Experiment II: SPA assessment procedures. Participants were required to correctly determine if CV pairs, spoken by the researcher, were the same or different. All participants completed pre-experimental training (approximately five minutes) on how to respond to the verbal stimuli presented by the researcher. Verbal, gestural, and written instructions were provided using unique non-experimental stimuli. Both participants demonstrated the ability to select a visual representation of ‘same’ or ‘different’ before the start of data collection (see

Figure 5). Following training, participants were presented each CV pair three times, on nonconsecutive occasions. Participants were required to identify the correct target (same) and reject foil (different) in order to obtain full credit for a response. (Example: Target- ba/ba,

Similar Placement Foil – ba/pa, Different Placement Foil – ba/ha) (see Figure 5). Responses were recorded and analyzed for accuracy.

50 Intensive Auditory Comprehension Treatment

“Ba, Ba” “Same” (Target CV pair spoken (Participant physically selects by examiner) visual picture response below)

Same

Different

Figure 5. Examples of SPA stimuli presentation

All SPA participants started the stimuli complexity assessment at the first level (CV pairs) and could only progress to the next level of the hierarchy (CVC pairs) if 90% accuracy was obtained. When accuracy dropped to 60-80% accuracy or lower, the assessment phase

51 Intensive Auditory Comprehension Treatment

ended. This determined the level where the baseline phase of the experimental protocol began and the complexity level of treatment stimuli to be used in the experimental study. Figure 6 provides an overview of this procedure.

Speech Perception Approach

Assessment to Determine the Complexity Level of Experimental Stimuli

-All participants started at first level of stimuli (CV pairs) -Stimuli: 3 set of 15 CV pairs

-Participants identified if the CV pair spoken by the investigator was the same of different

Example: Target: bi/bi, similar placement foil: bi/pi, different placement foil: bi/li

Participants could only progress to next level of stimuli (CVC,CCVC) if 90% accuracy was obtained

When participant accuracy dropped to 60-80% or lower the assessment was terminated

Figure 6. Protocol to determine experimental stimuli complexity - SPA

Based on the stimuli complexity assessment results, both participants performed at 40% or less on CV discrimination tasks (See Table 7). Therefore, both participants began Experiment

II using the CV pairs.

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Table 7.

Results – Level of Experimental Stimuli Complexity SPA

Pre-Experimental CV Requests for Lip Reading Utilized Stimuli Repetition T.L. 40% 0% 0%

E.R. 6.67% 0% 0%

Note. CV = Consonant Vowel

Following the stimuli complexity assessment, all participants began the experimental portion of the study.

Experimental Materials

Materials that were unique to the baseline, treatment, and maintenance phases of

Experiment I: SWCA and Experiment II: SPA are discussed separately in the first sections of this section. At the end of this section, there is a review of materials common to both experiments.

Experiment I: SWCG The materials unique to the SWCA are discussed in this section.

Equipment. Picture stimuli utilized during the SWCA protocol was presented on a Dell

Latitude E4300 laptop computer.

Single word comprehension stimuli. The same format that was previously discussed to develop the complexity assessment stimuli was also employed for the development of the experimental stimuli (see section: Experiment I: SWCA Assessment Materials, page 44, above).

Based on the results from the complexity assessment, three participants used high-frequency stimuli, two used medium frequency, and one used low frequency stimuli. All stimulus sets included target words with matched semantic and phonemic foils based on the appropriate

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complexity level. The stimuli were displayed on a laptop computer and included 10x7 colored images, which represented the target words. A unique set of stimuli materials were created for each phase in the SWCA study. Specifically, 15 target words and related semantic and phonemic foils were utilized during the baseline and maintenance phases, and for the probe measures; 30 target words were used during the treatment phase. In addition, two sets of baseline stimuli were created to reduce familiarization. See Appendices L through T for a complete list of all SWCG experimental stimuli.

Verbal naming stimuli. The same unique set of complexity specific visual stimuli used during experimental phase of Experiment I was employed to measure the participants’ naming ability.

Experiment II: SPA. Within this section, materials unique to the SPA are discussed.

Speech perception stimuli. The same format that was previously discussed to develop the complexity assessment stimuli was also employed for the development of stimuli in all phases of the SPA experimental study (see section: Experiment II: SPA Assessment Materials, page 46 above). Based on the results from the complexity assessment, all SPA participants utilized CV stimuli. All stimuli sets included phonetically balanced CV target stimuli that was either paired with itself (e.g., bi/bi), a CV foil with similar placement (e.g. bi/pi) or a CV foil with different placement (e.g. bi/li). A unique set of stimuli materials were created for each specific phase in the SPG study. Specifically, 15 target CV pairs and related foils were utilized during the baseline and maintenance phases, and for the probe measures; 30 targets used during the treatment phase. In addition, two sets of baseline stimuli were created to reduce familiarization. See Appendices U through Y for a complete list of all SPA experimental stimuli.

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Verbal repetition stimuli. The same distinctive set of stimuli used during the experimental phase of Experiment II was employed to measure the participants’ repetition ability.

Common experimental materials.

Materials were utilized by all participants in both experiments are discussed in this section.

Audio and video equipment. One Cannon FS300 digital video cameras was used to record all experimental sessions for transcription and analysis.

Picture description. 8x11 colored picture with multiple subjects and actions was utilized to assess connected speech.

Communication history survey. A survey was used to provide the researcher with the data on the participants speaking and comprehension ability in functional settings. It consisted of 27 questions that were adapted from the Communicative Effectiveness Index (Lomas et al.,

1989) (see Appendix Z).

Frustration/fatigue monitoring. A five-point Likert scale was used by participants to rate their perceived level of frustration and fatigue throughout the study (see Appendix AA). In addition, the examiner employed a monitoring sheet to provide a perceived rating of the participants’ level of frustration/fatigue during all phases of the experimental study (see

Appendix BB).

Experimental Procedures

All procedures that are unique to the baseline, treatment, and maintenance phases of the specific SWCA and SPA studies will be discussed. In addition, at the end of this section, procedures common to both Experiment I: SWCA and Experiment II: SPA are reviewed.

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Experiment I: SWCA. Prior to the start of each phase of the SWCA study, participants were provided detailed verbal and gestural instructions. Participants were required to demonstrate comprehension of the protocol prior to the start of data collection. This was demonstrated through their ability to prove a ‘yes’ or ‘no’ response to at least five trial stimuli in sequence. Participants could respond to stimuli with verbal, gestural, and /or selected choice of visually displayed written choice of ‘yes’ or ‘no’.

SWCA baseline phase. The procedure for single word comprehension and verbal naming measures are discussed in this section.

Single word comprehension. The baseline phase followed the same protocol described to determine the complexity level of experimental stimuli; however, individualized stimuli were presented (see Figure 3, page 48). Participants were required to determine if the word spoken by the examiner corresponded with the visual image of the object. Identification of the correct target and rejection of both foils were required in order to obtain full credit for a response. No feedback was provided to the participant regarding their accuracy of response. Performance accuracy was calculated following each baseline phase session. A stable baseline was established for each participant over the course of at least 3 sessions.

Verbal naming measures. Participants were asked to verbally name the target stimuli presented during the comprehension measure. Data was obtained to determine accuracy of naming ability and number of correct, incorrect/no response, related words, semantic and phonemic paraphasic errors. This data was collected one time during the baseline phase.

SWCA treatment phase. The treatment phase was comprised of a five day per week, three week intervention protocol, with each session lasting two hours. Participants completed single word comprehension activities, as discussed in the baseline phase, based on their

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previously-determined level of functioning. The treatment phase followed the same protocol as the baseline phase with the following exceptions: (1) 30 unique target stimuli were utilized, (2) corrective feedback was provided, and (3) participants were provided the option for repetition and visual cues (see Figure 7 for protocol).

Single Word Comprehension Approach Protocol

Treatment Phase

-Stimuli: 30 4x6 color images representing the target word complexity stimuli established during the stimuli complexity assessment (high, medium, or low frequency words)

-Participants were presented with each picture 3 times on nonconsecutive occasions

-Participants were required to identify the correct spoken target and reject the semantic and phonemic foil to obtain full credit

Example: Target - coat, semantic foil - boot, phonemic foil - boat

Figure 7. SWCA treatment phase protocol.

The first time any stimulus was presented, it was done without visual feedback (e.g., participants were unable to see the examiner’s face when the word is spoken). After the examiner verbally stated the stimuli, participants were given the opportunity to provide a response or request clarification. If repetition of stimuli was requested, the examiner did so without providing visual feedback. At that time, participants were again given the opportunity to respond or request clarification. If repetition was requested, they were then provided with a visual cue to

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look directly at the researcher’s mouth while the word stimuli were presented verbally (see

Figure 8).

Participants were given immediate feedback on the accuracy of their response whenever an answer was provided. If there was an error in participants’ response, the examiner provided both repetition and visual cues of the correct stimuli. Responses were recorded and analyzed for accuracy. Data was collected and analyzed in terms of the number of times participants requested repetition or clarification and response accuracy based on auditory and visual feedback provided by the examiner. If participants obtained 90% accuracy or greater over a period of 3 sessions the treatment protocol was terminated and they entered into the maintenance phase.

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Stimuli presented with no visual feedback

Opportunity to respond or request clarification

Participant requests clarification. Correct Response Incorrect Response Examiner repeats stimuli with no visual cues Correct answer is provided with visual and auditory

Opportunity to respond or feedback request clarification

Correct Response Incorrect Response

Participant requests clarification. Correct answer is provided Examiner repeats stimuli with with visual and auditory

visual cues feedback

Correct Response Incorrect Response

Figure 8. Protocol for stimuli presentation and repetition and lip-reading cues.

SWCA probe data. Probe data was collected utilizing the original baseline stimuli at the conclusion of each five day sequence. Following the completion of comprehension probe stimuli, participants also verbally named the stimuli presented during both the baseline and treatment phases. Data was obtained and analyzed as previously discussed in the baseline phase.

SWCA maintenance phase. One and three weeks post–treatment, probes were elicited.

The protocol for stimuli administration followed the procedures described for the treatment phase of the study, however, both probe and treatment stimuli were presented. Each set of

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stimuli was only presented one time to assess for maintenance. Participants were also asked to verbally name target stimuli presented during both the baseline and experimental phases.

Responses were videotaped and transcribed for accuracy and content.

Experiment II: SPA. Prior to the start of each phase of the experiment, participants were provided detailed verbal and gestural instructions. Participants were required to demonstrate comprehension of the protocol prior to the start of data collection. This was demonstrated through their ability to prove a ‘same’ or ‘different’ response to at least five trial stimuli in sequence. Participants could respond to stimuli with verbal, gestural, and /or selected choice of visually displayed written choice of ‘same’ or ‘different’.

SPA baseline phase. The procedure for speech perception and verbal repetition measures will be discussed in this section.

Speech perception. The baseline phase followed the same protocol as was described to determine the complexity level of experimental stimuli; however, unique stimuli were presented

(see Figure 5, page 51). Participants were required to determine if the CV pair spoken by the examiner, were the same or different. Identification of the correct target and rejection of both foils were required in order to obtain full credit for a response. No feedback was provided to the participant regarding their accuracy of response. Performance accuracy was calculated following each baseline phase session. A stable baseline was established for each participant over the course of at least 3 sessions.

Verbal repetition measures. Participants were asked to verbally repeat the target CV stimuli presented during the speech perception measure. Data was obtained to determine accuracy of repetition ability and number of correct, incorrect/no response, and phonemic substitution errors. This data was collected one time during the baseline phase.

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SPA treatment phase. The treatment phase was comprised of a five day per week, three week intervention protocol, with each session lasting two hours. Participants completed speech perception activities, as discussed in the baseline phase, based on their previously determined level of functioning. The treatment phase followed the same protocol as the baseline phase with the following exceptions: (1) 30 unique target stimuli were utilized, (2) corrective feedback was provided, and (3) participants were provided the option for repetition and visual cues (see Figure

9 for protocol).

Speech Perception Approach Protocol

Treatment Phase

-All participants started at first level of stimuli determined during the pre-assessment phase

-Stimuli: 30 CV pairs

-Participants identified if the target pair spoken by the investigator was the same of different

Example: Target: bi/bi, similar placement foil: bi/pi, different placement foil: bi/li

Figure 9. SPA treatment phase protocol.

The first time any stimulus was presented, a procedure was implemented to provide the participant feedback or cues. The same protocol that was utilized in the SWCA was used with the SPA (see Figure 8 for the protocol).

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SPA probe data. Probe data was collected utilizing the original baseline stimuli at the conclusion of each five day sequence. In addition, participants were asked to verbally repeat all stimuli presented during both the baseline and treatment phases. Data was obtained and analyzed as previously discussed in the baseline phase.

SPA maintenance phase. One and three weeks post-treatment, probes were elicited.

The protocol for stimuli administration was followed procedures described for the treatment phase of the study, however, both probe and treatment stimuli were presented. Each set of stimuli was only presented one time to assess for maintenance. Participants were also asked to verbally repeat target stimuli presented during both the baseline and experimental phases.

Responses were videotaped and transcribed for accuracy and content.

Common experimental procedures. The following procedures were used in both

Experiment I: SWCA and Experiment II: SPA.

Picture description. In order to assess connected speech output, SWCA and SPA participants verbally described, to the best of their abilities, a picture scene. Participants were given five minutes to describe the stimuli in as much detail as they could provide. Responses were videotaped and transcribed for accuracy, content and number of empty clauses (e.g. “I don’t know.”), subclausal utterances (e.g., single word of any part of speech), single clause utterance (e.g., contains a single verb, its subject, and its object), and multiclausal utterances

(e.g. contains one or more independent clauses and one or more dependent clauses each with its verb and required object) (Goodglass, Kaplan, & Barresi, 2001). Participants completed this task

5 times; one time during the baseline phase, at the end of each treatment phase week, and during the maintenance phase.

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Communication history survey. The investigator provided detailed instructions to the caregiver on how to complete the survey prior to initiation and remained available to provide further clarification as needed. Caregivers were asked to provide a perceived rating, on a 12-cm visual analogue scale of the participants’ functional communication skills. The survey was during baseline and at the end of the maintenance phase.

Frustration/fatigue monitoring. Prior to the start of the study, verbal and gestural instructions were provided to all participants regarding use of a frustration rating scale.

Participants were instructed to use the scale at their discretion if increased frustration occurred at any point during the study. If participants did not use the rating scale, a cue was given by the researcher to rate frustration upon completion of the experimental activity. Frustration levels were monitored throughout the experimental phase. In addition, a 5 minute break was provided to the participant every 30 minutes. Additional opportunities for a break were offered if requested by the participant or if deemed appropriate by the examiner. Data was collected based on level of frustration/fatigue throughout each session and if any additional breaks were required

(see Appendix AA & BB).

Independent and Dependent Variables

The independent and dependent variables for both Experiment I: SWCA and Experiment

II: SPA are discussed separately in the following sections.

Experiment I: SWCA independent and dependent variables.

Independent variables. An intensive single word comprehension treatment protocol, enhanced with auditory and visual supports.

Dependent variables. The researcher will measure the:

(1) number of correct yes/no responses to the target and semantic and phonemic foils.

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(2) number of participant directed requests for repetition cues when breakdown in auditory comprehension occurs.

(3) number of participant directed requests for lip-reading cues when breakdown in auditory comprehension occurs.

(4) number of correct responses to the target and semantic and phonemic foils following repetition cues.

(5) number of correct responses to the target and semantic and phonemic foils following lip- reading cues.

(6) number of correct verbal responses during confrontational naming of baseline and treatment stimuli versus the number of paraphasic errors or anomia.

(7) number of correct verbally expressed utterances during picture description task.

(8) percentage of changes in caregiver perceived rating of functional communication performance during a pre- and post-communication survey.

Experiment II: SPA independent and dependent variables.

Independent variables. An intensive speech perception treatment protocol, enhanced with auditory and visual supports.

Dependent variables. The researcher will measure the:

(1) number of correct same/different responses to the target and phonemic foils.

(2) number of participant directed requests for repetition cues when breakdown in speech perception occurs.

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(3) number of participant directed requests for lip-reading cues when breakdown in speech perception occurs.

(4) number of correct responses to the target and phonemic foils following repetition cues.

(5) number of correct responses to the target and phonemic foils following lip-reading cues.

(6) verbal repetition accuracy of C-V baseline and experimental stimuli.

(7) number of correct verbally expressed utterances during picture description task.

(8) percentage of changes in caregiver perceived rating of functional communication performance during a pre- and post-communication survey.

Research Fidelity. All screening and diagnostic procedures were completed by the primary investigator or a student investigatory under direct 100% supervision by the primary investigator. In addition, a monitoring sheet was kept in each participant confidential file. When a step was completed in the screening and assessment procedures it was marked and dated on the monitoring sheet.

Student investigators were utilized to assist with data collection and stimuli preparation.

Prior to the start of data collection, student investigators were required to complete orientation sessions to become familiar with the experimental procedures. This was accomplished through demonstration and mock experimental sessions. The primary investigator supervised these sessions and provided feedback regarding performance. The students were required to demonstrate mastery in the procedures set forth in the protocol before being permitted to collect experimental data. Twenty percent of the diagnostic and experimental sessions were observed randomly either directly or via taped video recording by the primary investigator to maintain research fidelity. Data collection sheets were kept by both the student investigator and the primary investigator during these reliability sessions. When this was accomplished, results were

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compared to determine reliability. The frequency ratio resulted in 100% agreement between observers; yielding a strong positive correlation using Pearson product-moment correlation (r =

+1.00).

Analyses. Data was examined by measuring effects of the intervention at different points in time. The experimental criterion was assessed by determining whether performance shifted at the point that the intervention was introduced. Pre-treatment and post-treatment levels of performance levels of performance were contrasted by determining Cohen’s d and effect size (Beeson & Robey, 2006). Small, medium, and large effect sizes are 0.2, 0.5, and 0.8 respectively (Cohen, 1988). In addition, a visual inspection of the data was performed. The following criteria were implemented to evaluate the data (Kazdin, 2011):

(1) changes in means across phases: a shift in the rate/accuracy of performance between

the baseline, treatment, and maintenance phases.

(2) changes in level across phases: a distinct variation in performance between phases

(3) changes in trend or slope: tendency of the data to demonstrate an increase or

decrease over time

(4) latency of the change: the amount of time between the onset of a variable and a

demonstrated variation in performance

(5) overlapping of data: the comparison of data points on the graph in one phase to

another (i.e., data points in the baseline phase do not overlap with the data points in the

treatment phase.)

Ethical Issues

The primary risk factor for the participants during the study was fatigue due to the length of the intervention sessions (2 hours). A second risk for the participants was frustration, due to

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difficulty as a result of stroke/aphasia. The level of risk associated with the intervention was minimal. It is important to note that typical multidisciplinary treatment programs require a patient to tolerate three hours of treatment per day. In addition, probe data completed prior to the initiation of this study revealed no inherent increases in fatigue or frustration during the protocol (Knollman-

Porter, Dietz, Lundeen, 2012). Potential risks are not regarded as out of the ordinary in comparison to stand aphasia rehabilitation programs. To avoid fatigue, the participants were provided a 5 minute rest break every 30 minutes or as needed. Excessive fatigue or frustration was not noted during this study.

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Chapter 4

Results

The data for the six participants who completed the Single Word Comprehension

Experiment and the two participants in the Speech Perception Experiment are presented individually in the subsequent sections. The following information will be presented on each participant: (1) narrative summary of pre-treatment social and communication skills and a overview of treatment protocol tolerance, (2) graphic and narrative representation of performance across baseline, treatment, and maintenance phases, and (3) effect sizes. A collective analysis of all Experiment I: SWCA participants and all Experiment II: SPA participants will be provided at the end of each respective section.

Single Word Comprehension Study

Participant T.G.. T.G. was a sixty five-year-old male who sustained a left middle cerebral artery (MCA) cerebrovascular accident (CVA), which involved the frontal and temporal lobes, 130 months prior to the experiment. The following history was provided by his spouse or gathered through observation during the assessment portion of the experiment. Prior to his CVA, he was employed as a project manager but was required to terminate employment secondary to severe communication deficits associated with the diagnosis of global aphasia and verbal apraxia. During the study, he lived at home with his wife, who was responsible for tasks that he previously performed independently (i.e. driving, cooking, finances). T.G. demonstrated significant difficulty expressing basic information through verbal channels. A DynaVox® high- technology AAC device had been purchased to augment communication; however, T.G. exhibited difficulty using it independently during functional communication tasks.

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Despite T.G.’s expressive challenges, his pragmatic skills were appropriate in both social and experimental contexts. T.G. demonstrated the ability to recognize when changes in routine occurred, with use of vocalization or gesture to indicate his concern. Comprehension breakdowns during basic conversation were common; however T.G. was not consistently aware of these challenges. In social situations, he made no attempt to request repetition or clarification to improve comprehension.

T.G. completed all experimental sessions. He actively participated, was highly motivated during each session, and did not demonstrate fatigue. While T.G. never conveyed frustration on the fatigue/frustration rating scale, intermittent outward signs of frustration were demonstrated when errors occurred during sessions, but these signs dissipated quickly. As the experiment progressed, T.G. was able to recognize and anticipate stimuli that were difficult to comprehend.

Single word comprehension – Response to intervention. This section provides an overview of T.G.’s comprehension of trained and untrained stimuli. A graphic representation of these results are presented in Figure 10.

Trained stimuli. T.G. exhibited a declining trend during the baseline phase. There was an immediate rapid response to intervention with a positive change in level between the baseline and treatment phases for the trained stimuli. A stable trend was noted during the first 2 weeks of intervention with a rapid increase in average comprehension percentage accuracy during the last

2 days of the treatment phase. This trend continued during the maintenance phase with no change in level between phases.

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An increase in the average percentage accuracy on single word comprehension tasks across phases was observed: baseline  = 52%, treatment  = 76%, maintenance = 87%. A large effect size was exhibited (Cohen’s d = 4.11) (Cohen, 1988).

Untrained stimuli. A positive change in level was observed between the baseline and treatment phases. Improved auditory comprehension was demonstrated compared to baseline; this stable trend continued throughout the intervention. In addition, an immediate rapid change in level was demonstrated during the maintenance phase with a decline in trend observed 1 month post intervention. A comparison of average percentage comprehension accuracy across phases revealed that generalization to untrained stimuli occurred and was maintained: baseline =

52%, treatment = 62%, maintenance = 73%. A large effect size was exhibited (Cohen' d =

2.05) (Cohen, 1988).

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Figure 10. Average percent of correct responses on medium frequency word comprehension tasks by Participant T.G.. Total possible data values: Probe – 15; Treatment – 30. Comprehension error patterns. Further analyses were completed to determine which stimuli (i.e., target word, semantic foil, phonemic foil) resulted in the greatest percentage of comprehension errors. The baseline phase revealed a higher rate of semantic foil errors (  =

35%) when compared to target word ( = 15%) and phonemic foil ( = 6.7%) errors.

As observed in Figure 11, there was a sharp decrease in the percentage of comprehension errors of semantic foils once intervention was initiated. A stable trend of comprehension errors was demonstrated throughout the intervention. Specifically, a higher percentage of errors on semantic foils ( = 13%) and target words ( = 13%) was observed when compared with phonemic foils ( = 4%). This trend continued in the maintenance phase: semantic foil errors

( = 8.3%); target word errors ( = 4.5%); phonemic foil errors ( = 1.7%).

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Figure 11. Average percentage of comprehension error types for Participant T.G..

Self-initiated requests for cues. The following section illustrates T.G.’s use of repetition and lip reading cues to assist with comprehension of single word stimuli. Graphic representation of the results can be found in Figure 12.

Repetition. T.G. demonstrated a stable baseline trend with no change in level between the baseline and treatment phases. Analysis of data revealed a rapid positive change in trend with an increased number of requests for repetition throughout the intervention. A change in level was exhibited between the intervention and maintenance phases with a swift decline in number of requests for repetition. However, self-initiated repetition requests did not drop as low as the baseline levels. An across phases analysis revealed an overall increase in self-initiated requests for repetition to aid in comprehension: baseline  = 7.5; treatment = 40; maintenance

=29. A large effect size was exhibited (Cohen’s d = 13.8) (Cohen, 1988).

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Lip-reading. T.G. did not utilize lip-reading cues during any phase of the study. Even when direct prompts were provided, T.G. opted to look away and not utilize the visual cue.

There was no overlap in data across phases in the number of requests for repetition and lip-reading cues. Repetition cues were self requested and utilized to a much greater degree: treatment repetition  = 39.8; treatment lip-reading = 0.

Figure 12. Average number of requests for repetition and lip reading cues by Participant T.G..

Comprehension accuracy following cues. Response accuracy following repetition and lip reading cues will be discussed in this section.

Repetition. Baseline performance revealed a relatively stable baseline trend with no change in level between the baseline and treatment phases (see Figure 13). When the treatment phase was introduced an accelerated trend was evident with a clear intervention effect from one

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session to the next. Hence, with the onset of intervention, there was a greater number of correct versus incorrect responses following repetition cues. The maintenance phase revealed a relatively stable trend with maintenance of comprehension accuracy following repetition cues.

Comparison of accuracy, following repetition cues, across phases further supports that with the use of these cues, T.G. demonstrated a greater number of correct/incorrect responses: baseline  = 4/3.5; treatment = 37/4.5; maintenance = 53/3.5. There was an overlap in correct/incorrect response following cues in the baseline phase. This indicates that repetition cues alone, prior to the initiation of the intensive treatment were not successful in increasing comprehension accuracy. However, this effect was not observed after intervention was initiated.

A large effect size was exhibited (Cohen’s d = 39) (Cohen, 1988).

Figure 13. Average number of correct/incorrect responses to repetition cues by Participant T.G..

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Lip-reading. Lip reading cues were not utilized by the participant.

Verbal expression – Indirect treatment effects. Indirect effects on verbal naming of trained and untrained comprehension stimuli and on picture description task will be discussed in this section.

Naming of trained comprehension stimuli. As seen in Table 8, an immediate response to indirect intervention was noted with increased correct naming of comprehension stimuli: baseline correct = 0%; treatment correct  = 11%; maintenance correct = 6%. In addition, an increase in the percentage of words that were related to the target words was also demonstrated: baseline related words = 3%; treatment related words = 9%; maintenance related words =

6.5%. Lastly, more verbal attempts in the form of semantic paraphasias were made when compared to baseline levels of performance: baseline semantic paraphasia = 0%; treatment semantic paraphasia = 10%; maintenance semantic paraphasias =6.5%. Similarly, more verbal attempts, in the form of phonemic paraphasias were observed: baseline phonemic paraphasias = 0%; treatment phonemic paraphasias; = 7%; maintenance phonemic paraphasias

= 5%.

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Table 8.

Results of verbal naming of trained comprehension stimuli for Participant T.G.

Trained Semantic Phonemic a Correct Related Word Incorrect or Stimuli Paraphasia Paraphasia No Response Baselineb 0% 0% 0% 3% 97%

1 Week Probe 3% 7% 10% 10% 70%

2 Week Probe 13% 17% 7% 10% 53%

3 Week Probe 17% 7% 3% 7% 67%

1 Week 10% 10% 7% 3% 70% Maintenance

1 Month 3% 3% 3% 10% 80% Maintenance

Note: a Total Possible – 30; bOne naming baseline measure was taken.

Naming of untrained comprehension stimuli. As seen in Table 9, a stable naming trend was exhibited throughout all phases of the study with no significant change in number of correct naming responses: baseline correct = 13%; treatment correct  = 15%; maintenance correct

= 10%. A slight increase in naming attempts was demonstrated with more related words, and semantic paraphasias produced when compared across phases: baseline semantic paraphasias =

0%; treatment semantic paraphasias =16%; maintenance semantic paraphasias = 7%. A similar pattern was observed on baseline related words = 0%; treatment related words = 18%; maintenance related words = 17%.

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Table 9.

Results of verbal confrontational naming of untrained comprehension stimuli for Participant

T.G.

Untrained Semantic Phonemic Incorrect or a Correct Related Word Stimuli Paraphasia Paraphasia No Response Baselineb 13% 0% 0% 0% 87%

1 Week Probe 20% 20% 0% 7% 53%

2 Week Probe 13% 7% 0% 20% 60%

3 Week Probe 13% 20% 0% 27% 40%

1 Week 7% 7% 7% 7% 73% Maintenance

1 Month 13% 7% 0% 27% 53% Maintenance

Note: aTotal Possible – 15; bOne naming baseline measure was taken.

Picture description. Discourse analysis revealed an increase in number of empty phrases across phases (e.g. “Uh…you know.”): baseline empty phrases = 7; treatment empty phrases 

= 19; maintenance empty phrases = 10. Only a slight gain in subclausal utterance (e.g. “bike”) was demonstrated during the treatment phase: baseline subclausal utterances = 1; treatment subclausal utterances = 3; maintenance subclausal utterance = 0. As presented in Table 10, single clause and multiclausal utterances were not produced across phases.

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Table 10

Narrative picture description analysis

Type and Number of Empty Subclausal Single Clause Multiclausal Utterance Utterance Utterance

Baselinea 7 1 0 0

1 Week Probe 21 4 0 0

2 Week Probe 22 1 0 0

3 Week Probe 15 3 0 0

5 0 0 0 1 Week Maintenance

15 0 0 0 1 Month Maintenance

Note: aOne narrative baseline measure was taken.

Generalization to functional communication environments. The caregiver who completed these surveys was not present during any assessment or treatment session. Review of pre- and post-treatment caregiver surveys revealed an overall decline in perceived communication performance on 15 out of the 25 questions (see Table 11). An increase in functioning was reported on 7 questions with 6 out of the 7 being verbal expression measures.

Performance on 3 questions remained stable.

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Table 11 Pre- and Post-Intervention – Caregiver Perceived Functional Communication Performance

Pre- Post- Functional Communication Survey Questions: Intervention Intervention

Getting somebody’s attention. 100% 75%a

Getting involved in group conversations that are about him/her. 100% 36% Giving yes/no answers appropriately. 68% 36%

Communicating his/her emotions. 60% 75%b

Comprehending simple yes/no questions. 70% 40%

Comprehending conversations about a familiar topic. 75% 40%

Comprehending conversations about new, unfamiliar topics. 45% 20%

Indicating to you that he/she does not understand what is being said to 80% 70% him/her.

Indicating to friends that he/she does not understand what is being said to 30% 70% him/her.

Indicating to strangers that he/she does not understand what is being said 30% 25% to him/her.

Requesting repetition of information when a breakdown in 85% 70% comprehension occurs with you.

Requesting repetition of information when a breakdown in 85% 70% comprehension occurs with family

Requesting repetition of information when a breakdown in 35% 35% comprehension occurs with strangers.

Recognizes when a change in the topic of conversation occurs. 75% 65%

Demonstrates of awareness of his/her comprehension difficulty. 75% 70%

Having visits and conversation with friends and neighbors. 75% 75%

Having a one-to-one conversation with you. 55% 73%

Communicating physical problems such as aches and pains. 85% 85%

Having a spontaneous conversation (i.e., starting the conversation or 55% 75% changing a subject).

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Starting a conversation with people who are not close family. 65% 55%

Responding to or communicating anything without words. 70% 75%

Being a part of a conversation when it is fast and a number of people are 10% 30% involved.

Describing or discussing something in depth. 10% 30%

How often do you use preventive measures to increase comprehension 80% 75% with him/her?

How often does he/she use preventive measures to increase 78% 70% comprehension with you?

Note. aBolded numbers indicate a decrease in function. b Number in italics indicate an increase in function.

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Participant B.G.. B.G. was a 74-year-old female who sustained a left MCA CVA 75 months prior to the research study. She lived at home alone, but required assistance from family and friends for specific tasks that she performed independently prior to the CVA (e.g., finances, driving, grocery shopping). B.G. presented with fluent aphasia, with an average mean length of utterance of greater than 10 words with semantic, phonemic and neologistic paraphasic errors which were not consistently self-recognized or self-corrected in conversation. Circumlocution and press of speech was displayed frequently with an inability to consistently utilize appropriate turn taking skills. In addition, recurrent comprehension impairments were demonstrated in conversation. B.G. inconsistently recognized when breakdowns occurred and did not independently utilize compensatory strategies to request clarification to improve comprehension.

She would erratically exhibit outward signs of frustration but would then proceed with the conversation. B.G. demonstrated the ability to recognize changes in routines and verbally relayed concerns when this occurred.

B.G. attended all assessment and experimental sessions. Lethargy was inconsistently noted during the 2 hour experimental sessions with peak episodes of increased performance.

Neither time of day, nor use of periodic breaks, influenced the variability of her alertness. In addition, B.G. did not appear to be aware that lethargy impacted performance. Hence, variable outcomes were exhibited within and between experimental sessions.

Single word comprehension – Response to intervention. Within this section, B.G.’s comprehension performance on trained and untrained stimuli will be discussed. A graphic representation of these results can be found in Figure 14.

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Trained stimuli. B.G. displayed a stable baseline trend over 3 sessions. No initial variation in percentage accuracy on comprehension tasks was demonstrated between the baseline and treatment phases. A gradual positive change was observed over the course of the treatment, with a trend toward improved single word comprehension. Once treatment was terminated, no change in level was noted between the treatment and maintenance phases. Comprehension performance was stable during the maintenance phase. Overall, an increased average percentage accuracy on single word comprehension tasks was observed across phases with a maintenance effect: baseline  = 53%, treatment = 66%, maintenance = 72%. A large effect size was exhibited (Cohen’s d = 2.79) (Cohen, 1988).

Untrained stimuli. A steep positive change in level can be observed between the baseline and treatment phases with an accelerated declining trend in percentage accuracy over the course of treatment. Significant fatigue was demonstrated during data collection for the third probe within the treatment phase which may have contributed to this trend. Upon termination of treatment, a positive change in level between phases was observed with a trend of increased comprehension percentage accuracy at 1 month post-intervention. A comparison of comprehension accuracy across phases revealed that generalization to untrained stimuli occurred and was maintained post treatment: baseline = 53%, treatment = 60%, maintenance =

70%. This was further demonstrated by an overlap of data across phases. A large effect size was exhibited (Cohen’s d = 1.57) (Cohen, 1988).

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Figure 14. Average percent of correct responses on high frequency word comprehension tasks by Participant B.G.. Total possible data values: Probe – 15; Treatment – 30. Arrow indicates session during which B.G. exhibited signs of fatigue. Comprehension error patterns. Further analyses were completed to determine which stimuli (i.e., target word, semantic foil, phonemic foil) resulted in the greatest percentage of comprehension errors. The baseline phase revealed an equivalent percentage of target word (  =

50%), semantic foil ( = 54%), and phonemic foil ( = 52%) error types with some overlap of data points noted.

As observed in Figure 15, there was a sharp decline in the percentage of semantic and phonemic foil errors once the intervention was initiated. A more specific analysis of target word errors revealed a steep initial declining change in level between phases with an gradual decrease of these errors over the course of intervention. However, a greater percentage of errors on target words ( = 31%) was observed when compared to semantic foil ( = 13%) and phonemic foil

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(  = 6.7%) errors during the course of treatment. During the maintenance phase, semantic foil errors ( = 17%) became more prominent with a decline in the percentage of target word errors

( = 10%) compared to phonemic foil errors ( = 6.7%).

Figure 15. Average comprehension error types for Participant B.G..

Self-initiated requests for cues. The following outlines B.G’s use of repetition and lip reading cues to assist with comprehension of single word stimuli. Figure 16 provides a graphic representation of these results.

Repetition. B.G. demonstrated a stable baseline trend in self-initiated requests for repetition. A large positive change in level between the baseline and treatment phases was demonstrated with a rapid increase in requests for repetition once intervention was initiated.

Analysis of performance revealed a gradual decline in the average number of requests for

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repetition as treatment progressed; but did not return to previous baseline levels. No change in level or trend was noted in the maintenance phase. An across phases analysis revealed an increase in the average number of self-initiated requests for repetition: baseline  = 23; treatment = 42; maintenance = 36. A large effect size was exhibited (Cohen’s d = 7.5)

(Cohen, 1988).

Lip-reading. B.G. did not attend to or request lip reading cues during the baseline phase.

A mild change in level was demonstrated with a small increase in use once intervention was initiated. This stable trend was exhibited during the treatment and maintenance phases. An analysis of the average number of requests for lip-reading cues between phases suggests use of this cue was limited: baseline = 0; treatment = 5.8; maintenance = 5. A large effect size was demonstrated (Cohen’s d = 1.6) (Cohen, 1988). There was no overlap between repetition and lip-reading data across phases. Repetition cues were self-requested and utilized to the greatest degree: treatment repetition = 42; treatment lip-reading = 5.8.

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Figure 16. Average number of requests for repetition and lip reading cues by Participant B.G..

Comprehension accuracy following cues. Response accuracy following repetition and lip reading cues will be discussed in this section.

Repetition. Baseline performance revealed a stable trend in comprehension accuracy following repetition cues with a greater average number of correct/incorrect responses. A positive change in level between the baseline and treatment phases was observed with a larger increase in accuracy of responses. Throughout the intervention, increased accuracy was demonstrated with a greater number of correct/incorrect responses following repetition cues. The maintenance phase revealed a relatively stable trend with comprehension accuracy maintained.

Comparison of response accuracy following repetition cues across phases further supports that with the use of these cues, B.G. demonstrated a greater number of correct/incorrect responses: baseline  = 18.3/4.7; treatment = 32/9.8; maintenance = 30/6. As exhibited in Figure 17,

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there was no overlap of correct and incorrect responses across phases suggesting that comprehension accuracy increased with the use of repetition cues. A large effect size was exhibited (Cohen’s d = 4.85) (Cohen, 1988).

Figure 17. Average number of correct/incorrect responses to repetition cues by Participant B.G.

Lip-reading. A stable baseline was exhibited with no utilization of lip-reading cues by

B.G.. Upon initiation of the treatment phase, an increase in requests for these cues was demonstrated. Throughout intervention and maintenance, an inconsistent trend was observed with B.G. exhibiting a variable response to lip reading cues with some overlap correct/incorrect data points (see Figure 18). A comparison of response accuracy across phases suggests that with use of lip-reading cues, B.G. demonstrated a greater number of correct/incorrect responses: baseline  = 0/0; treatment = 3.7/2.1; maintenace = 2/3. A large effect size was exhibited

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(Cohen’s d = 2) (Cohen, 1988). However, secondary to lack of utilization of these cues, results should be interpreted with caution.

Figure 18. Average number of correct/incorrect responses to lip-reading cues by Participant B.G.

Verbal expression – Indirect treatment effects. Indirect effects on verbal naming of trained and untrained comprehension stimuli and on picture description task will be discussed.

Naming of trained comprehension stimuli. A comparison of percentage accuracy across phases revealed that there was no indirect change in the correct naming of comprehension stimuli: baseline correct = 43%; treatment correct  = 45%; maintenance correct = 45%. In addition, B.G.’s percentage of naming attempts did not increase across phases: baseline related words = 27%; treatment related words = 25%; maintenance related words = 22%.

Similarly, there was not an increase in the production of semantic paraphasias across phases:

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baseline semantic paraphasias = 3%; treatment semantic paraphasias  = 5%; maintenance semantic paraphasias = 3%. Lastly, no phonemic paraphasias were produced across phases: baseline phonemic paraphasias = 0%; treatment phonemic paraphasias = 0%; maintenance phonemic paraphasias = 0%. See Table 12 for a full representation of these results.

Table 12.

Results of verbal naming of trained comprehension stimuli for Participant B.G.

Trained Semantic Phonemic a Correct Related Word Incorrect or Stimuli Paraphasia Paraphasia No Response Baselineb 43% 3% 0% 27% 27%

1 Week Probe 40% 3% 0% 27% 30%

2 Week Probe 43% 3% 0% 30% 23%

3 Week Probe 53% 10% 0% 17% 20%

1 Week 43% 0% 0% 30% 27% Maintenance

1 Month 47% 7% 0% 13% 33% Maintenance

Note: a Total Possible – 30; b One naming baseline measure was taken.

Naming of untrained comprehension stimuli. As seen in Table 13, a immediate positive response to indirect intervention can be noted with an overall increase in naming accuracy during comprehension intervention. This trend continued during the intervention phase with peak performance demonstrated during the maintenance phase: baseline correct = 40%; treatment correct = 47%; maintenance correct = 70%. A decrease in the percentage of produced

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related words was exhibited during the treatment phase but increased during the maintenance phase: baseline related words =20%; treatment related words  = 15%; maintenance related words = 24%. In addition, a small increase in the percentage of phonemic paraphasias was exhibited during the treatment phase only: baseline phonemic paraphasias = 0%; treatment phonemic paraphasias = 4%; maintenance phonemic paraphasias = 0%. Lastly, a comparison across phases reveals a decline in the percentage of semantic paraphasic errors: baseline semantic paraphasias = 13%; treatment semantic paraphasias = 16%; maintenance semantic paraphasias = 0%.

Table 13.

Results of verbal naming of untrained comprehension stimuli for Participant B.G.

Untrained Semantic Phonemic Incorrect or a Correct Related Word Stimuli Paraphasia Paraphasia No Response Baselineb 40% 13% 0% 20% 27%

1 Week Probe 47% 13% 0% 20% 20%

2 Week Probe 40% 27% 0% 13% 20%

3 Week Probe 53% 7% 7% 13% 20%

1 Week 67% 0% 7% 20% 7% Maintenance

1 Month 73% 0% 0% 27% 0% Maintenance

Note: a Total Possible – 15; b One naming baseline measure was taken.

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Picture description. Discourse analysis revealed an increase in the number of empty utterances produced during treatment, with return to previous baseline levels during the maintenance phase: baseline empty utterances = 6; treatment empty utterances  = 13; maintenance empty utterances = 6. Further analysis showed no change in the number of produced subclausal utterances: baseline subclausal utterances = 2; treatment subclausal utterances = 1; maintenance subclausal utterances = 3. In addition, there was no change in the number of single clause utterances: baseline single clause = 4; treatment single clause =

3; maintenance single clause = 3. See Table 14 for a full representation of these results.

Table 14.

Narrative picture description analysis

Type and Number of Empty Subclausal Single Clause Multiclausal Utterance Utterance Utterance Utterance

Baselinea 6 2 4 0

1 Week Probe 10 1 4 0

2 Week Probe 16 0 5 0

3 Week Probe 13 2 1 1

1 5 2 0 1 Week Maintenance

12 0 3 1 1 Month Maintenance

Note: aOne narrative baseline measure was taken.

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Generalization to functional communication environments. Results could not be analyzed secondary to caregiver not competing survey even thought repeated requests were made by the examiner.

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Participant T.O.. T.O. was a 56 year old male who led an active independent life as a corporate chief financial officer, prior to sustaining a left MCA CVA, which involved the frontal and parietal lobe, 46 months prior to participation in this study. Following the CVA, he was required to terminate employment and move into an assisted living facility. He continued to demonstrate the ability to perform basic financial tasks (e.g., making change when purchasing small items) but was unable to independently manage personal finances (e.g. paying personal bills). During assessment, he presented with severe non-fluent mixed aphasia. He engaged in conversation with frequent moments of anomia. When this occurred, he independently attempted to spell the word on the table with his finger in an attempt to relay his message to the listener.

Repetition ability was accurate up to 7 word sentence. In conversation, moments of comprehension breakdown would occur but was not consistently recognized by T.O.. No independent attempts were made to improve comprehension limitations.

T.O. actively participated, and was highly motivated, during each session and did not demonstrate fatigue. When reinforcement was not provided by the examiner, T.O. was unable to independently recognize errors. However, once feedback was provided, he was able to identify and anticipate specific targets that were previously difficult and would independently make attempts to self correct in future trials. T.O. demonstrated excellent recall from session to session which resulted in him reaching greater than 90% accuracy for 3 consecutive days. Per established guidelines, the treatment phase was terminated after 5 days.

Single word comprehension – Response to intervention. This section provides a synopsis of T.O.’s performance on trained and untrained comprehension stimuli tasks. Results are graphically represented in Figure 19.

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Trained stimuli. A declining baseline trend was exhibited with an immediate positive change in level demonstrated upon initiation of the intervention. A short latency from the change in condition (treatment) to the change in performance suggests that the intervention was responsible for improved percentage accuracy in single word comprehension. This improvement was sustained throughout the treatment phase and at 1 week and 1 month post termination of the intervention. An increase in the percentage accuracy on single word comprehension tasks across phases was demonstrated: baseline  = 39%; treatment = 89%; maintenance = 90%. A large effect size was exhibited (Cohen’s d = 4.97) (Cohen, 1988).

Untrained stimuli. A positive change in level was observed between the baseline and treatment phases. Due to early termination of treatment (described above), only one treatment probe was obtained, so latency and trend could not be determined during the treatment phase.

However, comparison of percentage accuracy on comprehension tasks across phases suggests that treatment did indirectly improve comprehension of untrained stimuli: baseline = 39%; treatment = 60%; maintenance = 43%. A small effect size was exhibited (Cohen’s d =

.390) (Cohen, 1988).

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Figure 19. Average percent of correct responses on low frequency word comprehension tasks by Participant T.O.. Total possible data values: Probe – 15; Treatment – 30.

Comprehension error pattern. Further analyses were completed to determine which stimuli (i.e., target word, semantic foil, phonemic foil) resulted in the greatest percentage of comprehension errors. The baseline phase revealed a higher percentage rate of semantic foil errors (  = 79%) when compared to target word ( = 52%) and phonemic foil ( = 54%) error types.

As observed in Figure 20, there was a sharp change in level between baseline and treatment phases with a sudden decrease in the percentage of all error types once intervention was initiated. A stable trend of comprehension errors was demonstrated throughout the intervention with an overlap of all error types with semantic foil errors slightly higher.

Specifically, a higher percentage of semantic foil errors ( = 7%) was observed when compared

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to target word (  = 2.8%) and phonemic foil ( = 2.1%) error types. This trend continued during the maintenance phase: semantic foil errors ( = 8.3%); target word errors ( = 1.7%); phonemic foil errors ( = 1.6%).

Figure 20. Average percentage of comprehension error types for Participant T.O.

Self-initiated requests for cues. The following section illustrates T.O’s use of repetition and lip reading cues to assist with comprehension of single word stimuli. Graphic representation of the results can be found in Figure 21.

Repetition. T.O. exhibited a stable baseline trend with a positive change in level once the treatment phase was initiated. An increase in number of requests for repetition was noted with a rapid positive change in trend. However, as the intervention continued a slight decrease in trend was noted as T.O. became more aware of error patterns. T.O. only requested repetition on words

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that on previous attempts were corrected by the examiner. A positive change in level was observed between the treatment and maintenance phases. Requests for repetition increased during the maintenance phase. An across phase analysis reveals an overall increase in self- initiated requests for repetition to aid in comprehension: baseline  =.33; treatment = 3.2; maintenance = 4.5. A large effect size was exhibited (Cohen’s d = 6.7) (Cohen, 1988).

Lip-reading. T.O. did not utilize lip-reading cues during any phase of the study. Even when direct prompts were provided, T.O. opted to look away and not utilize the visual cue.

Figure 21. Average number of requests for repetition and lip reading cues by Participant T.O.. Note: Smaller scale size.

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Comprehension accuracy following cues. Response accuracy following repetition and lip-reading cues will be discussed in this section.

Repetition. A stable baseline trend was demonstrated with an equivalent number of correct and incorrect values noted. An immediate response to intervention was observed with a positive change in level between baseline and treatment phases with a short latency of effect exhibited (see Figure 22). Thus, with the onset of intervention, an increased accuracy of response was demonstrated following repetition cues. The maintenance phase revealed a stable trend with comprehension accuracy maintained following repetition cues.

Comparison of accuracy, following repetition cues, across phases further supports that with the use of these cues, T.O. demonstrated a greater number of correct/incorrect responses: baseline  =.17/.17; treatment = 3.1/.11; maintenance = 4/.5. While there was an overlap in correct versus incorrect response following cues in the baseline phase, this was not noted once intervention was initiated. This indicates that repetition cues alone, prior to the initiation of the intensive treatment were not successful in increasing comprehension accuracy. A large effect size was exhibited (Cohen’s d = 3.69) (Cohen, 1988).

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Figure 22. Average number of correct/incorrect responses to repetition cues by Participant T.O.. Note: Smaller scale size

Lip-reading. Lip reading cues were not utilized by T.O. and hence resulted in no change in mean, level, trend, or latency.

Verbal expression – Indirect treatment effects. Indirect effects on verbal naming of trained and untrained comprehension stimuli and on picture description task will be discussed.

Naming of trained comprehension stimuli. As seen in Table 15, an immediate response to indirect intervention was noted with an increase in percentage accuracy across phases on naming tasks involving trained comprehension stimuli: baseline correct = 20%; treatment correct = 60%; maintenance correct  = 60%. A comparison of the percentage of phonemic paraphasic productions across phases reveals an increase during the treatment phase with a decrease in level during the maintenance phase: baseline phonemic paraphasias = 0%; treatment

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phonemic paraphasias = 10%; maintenance phonemic paraphasias  = 1.5%. In addition, a decrease in the percentage of semantic paraphasias was exhibited across phases: baseline semantic paraphasias = 10%; treatment semantic paraphasias = 7%; maintenance phonemic paraphasias = 3.5%. Similarly, a decrease in the percentage of related words was also exhibited: baseline related words = 13%; treatment related words = 0%; maintenance related words = 0%. An overall decrease in incorrect or no response productions were noted across phases which suggests that auditory comprehension tasks had an indirect effect on naming ability for T.O.: baseline = 57%; treatment = 23%; maintenance = 35%.

Table 15.

Results of verbal naming of trained comprehension stimuli for Participant T.O.

Trained Semantic Phonemic a Correct Related Word Incorrect or Stimuli Paraphasia Paraphasia No Response Baselineb 20% 10% 0% 13% 57%

1 Week Probe 60% 7% 10% 0% 23%

2 Week n/a n/a n/a n/a n/a Probec

3 Week Probe n/a n/a n/a n/a n/a

1 Week 63% 0% 3% 0% 33% Maintenance

1 Month 57% 7% 0% 0% 37% Maintenance

Note: a Total Possible – 30; b One naming baseline measure was taken; c 2 and 3 week probes were not completed secondary to T.O. meeting protocol criteria for termination of treatment.

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Naming of untrained comprehension stimuli. As reported in Table 16, a comparison of correct naming ability across phases revealed an inconsistent pattern of accuracy: baseline correct = 60%; treatment correct =53%; maintenance correct  = 67%. However, an increase in the percentage of semantic paraphasias across phases was noted suggesting an increase in naming attempts: baseline semantic paraphasias = 13%; treatment semantic paraphasias = 20%; maintenance = 24%. Lastly, a decrease in the percentages of related words across phases was exhibited: baseline related words = 13%; treatment related words = 7%; maintenance related words = 0%.

Table 16.

Results of verbal naming of untrained comprehension stimuli for Participant T.O.

Untrained Semantic Phonemic Incorrect or a Correct Related Word Stimuli Paraphasia Paraphasia No Response Baselineb 60% 13% 0% 13% 13%

1 Week Probe 53% 20% 0% 7% 20%

2 Week n/a n/a n/a n/a n/a Probec

3 Week Probe n/a n/a n/a n/a n/a

1 Week 67% 20% 0% 0% 13% Maintenance

1 Month 67% 27% 7% 0% 0% Maintenance

Note: a Total Possible – 15; b One naming baseline measure was taken; c2 and 3 week probes were not completed secondary to T.O. meeting protocol criteria for termination of treatment.

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Picture description. As seen in Table 17, an initial decrease in number of empty utterances was demonstrated during the treatment phase; however, this trend reversed during the maintenance phase with an increase in empty phrases produced: baseline empty phrases = 12; treatment empty phrases = 10; maintenance empty phrases  = 20. In addition, an increase subclausal phrase production was exhibited across phases: baseline subclausal phrases = 2; treatment subclausal phrases = 4; maintenance subclausal phrases = 7. No change in single or multiclausal utterances was observed.

Table 17

Narrative picture description analysis.

Type and Number of Empty Subclausal Single Clause Multiclausal Utterance Utterance Utterance Utterance

Baselinea 12 2 0 0

1 Week Probe 10 4 0 0

2 Week Probeb n/a n/a n/a n/a

3 Week Probe n/a n/a n/a n/a

22 11 0 0 1 Week Maintenance

18 3 0 0 1 Month Maintenance

Note: a One narrative baseline measure was taken; b2 and 3 week probes were not completed secondary to T.O. meeting protocol criteria for termination of treatment.

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Generalization to functional communication environments. The caregiver who completed these surveys was present only during the initial diagnostic session. A review of pre- and post-treatment caregiver surveys revealed an overall decline in perceived communication performance on 16 out of the 25 questions (see Table 18). An increase in functioning was reported on 6 questions with 5 out of the 6 relating to an increase awareness of comprehension limitations and use of compensatory strategies. The response on 3 questions remained stable.

Table 18 Pre- and Post-Intervention – Caregiver Perceived Functional Communication Performance

Pre- Post- Functional Communication Survey Questions: Intervention Intervention

Getting somebody’s attention. 85% 80%a

Getting involved in group conversations that are about him/her. 65% 55%

Giving yes/no answers appropriately. 70% 70%

Communicating his/her emotions. 70% 70%

Comprehending simple yes/no questions. 80% 70% Comprehending conversations about a familiar topic. 80% 60%

Comprehending conversations about new, unfamiliar topics. 65% 55%

Indicating to you that he/she does not understand what is being said to 70% 70% him/her.

Indicating to friends that he/she does not understand what is being said to 70% 65% him/her.

Indicating to strangers that he/she does not understand what is being said 30% 60%b to him/her.

Requesting repetition of information when a breakdown in 65% 60% comprehension occurs with you.

Requesting repetition of information when a breakdown in 70% 55% comprehension occurs with family

Requesting repetition of information when a breakdown in 70% 50%

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comprehension occurs with strangers.

Recognizes when a change in the topic of conversation occurs. 65% 80%

Demonstrates of awareness of his/her comprehension difficulty. 70% 75%

Having visits and conversation with friends and neighbors. 50% 30%

Having a one-to-one conversation with you. 60% 30% Communicating physical problems such as aches and pains. 70% 55%

Having a spontaneous conversation (i.e., starting the conversation or 65% 45% changing a subject).

Starting a conversation with people who are not close family. 50% 45%

Responding to or communicating anything without words. 75% 90%

Being a part of a conversation when it is fast and a number of people are 45% 15% involved.

Describing or discussing something in depth. 30% 5%

How often do you use preventive measures to increase comprehension 45% 70% with him/her?

How often does he/she use preventive measures to increase 50% 65% comprehension with you?

Note. aBolded numbers indicate a decrease in function. bNumbers in italics indicate an increase in function.

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Participant B.D.. B.D. was a 65 year-old female who sustained a left CVA 71 months prior to the onset of the study. Preceding her stroke, she earned a masters degree and was actively employed as a social worker. During the assessment, she presented with severe non- fluent expressive aphasia primarily characterized by unintelligible distorted utterances with occasional use of intelligible perseverative phrases (e.g., “Up up and away.”). B.D. actively attempted to verbalize and would independently use gestures to facilitate communication but was unable to consistently recognize when a listener was unable to understand her relayed verbal message. Comprehension of conversation was also impaired with decreased self-awareness of when this occurred. No attempts were made to utilize strategies to compensate for these breakdowns in communication. During the study, if corrective feedback was given, B.D. would often use gestures and facial expressions to question the examiners reliability. Denial of the extent of her deficits was evident and influenced her willingness to consistently provide full effort during the intervention. B.D.’s spouses supported these findings, and relayed that she would often get angry and blame him when a miscommunication occurred at home.

B.D. completed all experimental sessions as intended based on established criteria. No fatigue was demonstrated.

Single word comprehension – Response to intervention. Within this section, a review of B.D’s comprehension performance on trained and untrained stimuli is discussed. Figure 23 provides a graphic representation of results.

Trained stimuli. B.D. exhibited a stable baseline trend over 3 sessions. No initial variation in percentage level of performance was demonstrated between the baseline and treatment phases. After the onset of intervention, this stable trend continued throughout both the

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treatment and maintenance phases with no gains in comprehension percentage accuracy on trained stimuli exhibited. Analysis of average percentage accuracy on single word comprehension task across phases further represents this lack of change: baseline  = 57%, treatment = 60%, maintenance = 56%. A positive effect on single word comprehension was not exhibited: (Cohen’s d = .181) (Cohen, 1988).

Untrained stimuli. A positive change in level was exhibited between baseline and treatment phases. A stable trend was demonstrated during intervention with peak percentage comprehension accuracy noted on the last day of treatment, suggesting a slow latency effect.

Following termination of treatment, a decline in level was demonstrated in the maintenance phase. Maintenance performance did not return to previous baseline levels. An increase in the average percentage accuracy on single word comprehension tasks across phases could be observed suggesting a generalization effect: baseline = 57%; treatment = 75%; maintenance

= 70%. A large effect size was exhibited: (Cohen’s d = 2.04) (Cohen, 1988).

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Figure 23. Average percent of correct responses on medium frequency word comprehension tasks by Participant B.D.. Total possible data values: Probe – 15; Treatment – 30.

Comprehension error patterns. Further analyses were completed to determine which stimuli (target word, semantic foil, phonemic foil) resulted in the greatest percentage of comprehension errors. The baseline phase revealed a higher rate of semantic foil errors (  =

24% ) when compared to target word ( = 6.7%) and phonemic foil ( = 2.2%) error types. A positive change in level was noted at the onset of intervention as demonstrated by an increase in percentage of target errors. Throughout the treatment phase, data represented a stable trend with semantic foil and target word errors being dominant but irregular in occurrence (see Figure 24).

The rate of phonemic foil errors represented a stable trend, always occurring less often then target and semantic foil error types: target errors ( = 21.7%); semantic foil errors ( = 21.1%); phonemic foil errors ( = 2.3%). A change in level between the treatment and maintenance

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phases was again exhibited with an increase in percentage of target word errors demonstrated. A comparison of error types revealed that target word errors (  = 30%) occurred at greater percentage than semantic foil ( = 25%) and phonemic foil ( = 1.7%) error types during the maintenance phase.

Figure 24. Average percentage of comprehension error types for Participant B.D.

Self-initiated requests for cues. The following section illustrates B.D.’s use of repetition and lip reading cues to assist with comprehension of single word stimuli. Graphic representation of the results can be found in Figure 25.

Repetition. B.D. demonstrated a stable baseline over 3 sessions. A positive jump in level was demonstrated between the baseline and treatment phases suggesting an immediate response to intervention. As intervention progressed, a declining trend in number of requests for repetition

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was demonstrated with rate moving toward previous baseline levels. A positive change in level was then demonstrated between the treatment and maintenance phases with an increase in requests for repetition noted 1 week post termination of treatment. A declining trend was then demonstrated as 1 month data suggested a return to baseline levels. An across phases analysis revealed an immediate increase in requests for repetition; but comparison does not fully represent the downward trend at 1 month post treatment: baseline  = 11.3; treatment = 41; maintenance = 40. A large effect size was exhibited: (Cohen’s d = 1.97) (Cohen, 1988).

Lip-reading. B.D. did not utilize lip-reading cues during the baseline or initial treatment sessions. As intervention progressed, a gradual change in trend was demonstrated with an increased number of requests for lip reading cues. This level was not sustained during the maintenance phase with a sharp decline in trend demonstrated at 1 week post and then a sharp increase again at 1 month post treatment. An analysis of the number of requests across phases, revealed an increase in the utilization of lip reading cues: baseline = 0; treatment = 10.5; maintenance = 13. A large effect size was exhibited (Cohen’s d = 1.18) (Cohen, 1988).

Overlap of repetition and lip-reading data did not occur until the last 2 treatment sessions. At that time, use of lip reading cues exceeded use of repetition cues. This suggests that as the treatment session progressed, B.D. realized that lip reading cues may benefit comprehension more than repetition cues. Hence, more requests were made for lip-reading cues.

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Figure 25. Average number of requests for repetition and lip reading cues by Participant B.D..

Comprehension accuracy following cues. Response accuracy following repetition and lip-reading cues will be discussed in this section.

Repetition. As observed in Figure 26, accuracy following repetition cues during the baseline phase was stable with slightly more correct versus incorrect responses made. An immediate positive change in level was demonstrated upon implementation of the treatment phase with a greater number of correct than incorrect responses made following cues. After this increase, a declining trend was demonstrated with the distance between correct and incorrect response data points becoming narrower: A sharp increase in correct response was again demonstrated 1 week post termination of intervention. But, a trend to return to baseline level was demonstrated at 1 month. A comparison of comprehension response accuracy, following repetition cues across phases further supports that with the use of these cues, B.D. demonstrated

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a greater number of correct/incorrect responses: baseline  = 10/1; treatment = 34/6.7; maintenance = 30/10. A large effect size was exhibited (Cohen’s d = 1.8; r = .669) (Cohen,

1988).

Figure 26. Average number of correct/incorrect responses to repetition cues by Participant B.D..

Lip-reading. A stable baseline was demonstrated with B.D. not requesting or utilizing lip-reading cues. Upon initiation of the intervention phase, with increased use of lip reading cues, initial overlap of data points suggested that cues did not improve comprehension accuracy.

However, as intervention continued B.D. exhibited a slow latency effect with a greater gap between correct and incorrect responses. However, a sharp declining change in level was demonstrated between the treatment and maintenace phase with the number of correct versus incorrect responses returning to baseline levels signifying a lack of maintenance (see Figure 27).

However, at 1 month post treatment, accuracy following lip-reading cues returned to peak

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treatment levels. A comparsion of comprehension accuracy, following lip-reading cues, across phases further supports that with the use of these cues, B.D. demonstrated a greater number of correct/incorrect responses: baseline  = 0/0; treatment = 6/3.2; maintenance = 9.5/3.5. A large effect size was exhibited: (Cohen’s d = 1.1) (Cohen, 1988)

Figure 27. Average number of correct/incorrect responses to lip-reading cues by Participant

B.D..

Verbal expression – Indirect treatment effects. Indirect effects on verbal naming of trained and untrained comprehension stimuli and on picture description task will be discussed.

Naming of trained comprehension stimuli. An increase in the percentage of correct naming responses was demonstrated in the treatment phase when compared to the baseline level of performance. Upon termination of treatment, a decline in level of naming accuracy was exhibited but did not return to baseline levels: baseline correct = 3%; treatment correct = 11%;

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maintenance correct  = 7%. An analysis of semantic paraphasic productions suggested no percentage change was exhibited across phases: baseline semantic paraphasias = 3%; treatment semantic paraphasias = 3%; maintenance semantic paraphasias =0%. In addition, there was no percentage change in phonemic paraphasic productions across phases: baseline phonemic paraphasias = 0%; treatment phonemic paraphasias = 1%; maintenance phonemic paraphasias

=0%. Lastly, a slight increase in the percentage of related word production was noted across phases: baseline related words = 0%; treatment related words = 1%; maintenance related words = 3%.

Table 19.

Results of verbal naming of trained comprehension stimuli for Participant B.D.

Trained Semantic Phonemic a Correct Related Word Incorrect or Stimuli Paraphasia Paraphasia No Response Baselineb 3% 3% 0% 0% 94%

1 Week Probe 13% 3% 0% 0% 84%

2 Week Probe 7% 0% 3% 3% 87%

3 Week Probe 13% 7% 0% 0% 80%

1 Week 7% 0% 0% 3% 90% Maintenance

1 Month 7% 0% 0% 3% 90% Maintenance

Note: a Total Possible – 30; b One naming baseline measure was taken.

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Naming of untrained comprehension stimuli. As seen on Table 20, the percentage of correct naming productions of untrained stimuli did not indirectly improve across phases following comprehension intervention. A decrease in percentage accuracy was noted across phases: baseline correct = 7%; treatment correct  = 2%; maintenance correct = 0%. In addition, a slight percentage change increase in semantic paraphasic productions were noted across phases: baseline semantic paraphasias = 0%; treatment semantic paraphasias = 4%; maintenance semantic paraphasias =3.5. Similarly, a slight percentage increase in phonemic paraphasic productions was also exhibited: baseline phonemic paraphasias = 0%; treatment phonemic paraphasias = 4%; maintenance phonemic paraphasias =3.5. Production of related words also increased, but only during the maintenance phase: baseline related words =

0%; treatment related words = 0%; maintenance related words = 3.5%.

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Table 20.

Results of verbal naming of untrained comprehension stimuli for Participant B.D.

Trained Semantic Phonemic a Correct Related Word Incorrect or Stimuli Paraphasia Paraphasia No Response Baselineb 7% 0% 0% 0% 93%

1 Week Probe 0% 0% 13% 0% 87%

2 Week Probe 0% 13% 0% 0% 87%

3 Week Probe 7% 0% 0% 0% 93%

1 Week 0% 7% 0% 7% 86% Maintenance

1 Month 0% 0% 7% 0% 93% Maintenance

Note: a Total Possible – 15; b One naming baseline measure was taken.

Picture description. Discourse analysis revealed a variable number of empty utterances produced across phases which suggests no indirect treatment effect on narrative production skills: baseline empty phrases = 13; treatment  = 12; maintenance = 8. No increase in subclausal, single clause of multiclausal utterances was demonstrated (see Table 21).

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Table 21.

Narrative picture description analysis

Type and Number of Empty Subclausal Single Clause Multiclausal Utterance

Baselinea 13 0 0 0

1 Week Probe 9 0 0 0

2 Week Probe 13 0 0 0

3 Week Probe 15 0 0 0

7 0 0 0 1 Week Maintenance

9 0 0 0 1 Month Maintenance

Note: a One narrative baseline measure was taken.

Generalization to functional communication environments. The caregiver who completed these surveys was present during all diagnostic and treatment sessions. A review of pre- and post-treatment caregiver surveys revealed an overall decline in perceived communication performance on 12 out of the 25 questions (see Table 22). An increase in functioning was reported on 3 questions with 2 out of the 3 relating to an increased use of compensatory strategies to aid with comprehension.

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Table 22.

Pre- and Post-Intervention – Caregiver Perceived Functional Communication Performance

Pre- Post- Functional Communication Survey Questions: Intervention Intervention

Getting somebody’s attention. 90% 90%

Getting involved in group conversations that are about him/her. 70% 50%a Giving yes/no answers appropriately. 30% 20%

Communicating his/her emotions. 50% 50%

Comprehending simple yes/no questions. 30% 20%

Comprehending conversations about a familiar topic. 80% 50%

Comprehending conversations about new, unfamiliar topics. 70% 40%

Indicating to you that he/she does not understand what is being said to 95% 60% him/her.

Indicating to friends that he/she does not understand what is being said to 80% 60% him/her.

Indicating to strangers that he/she does not understand what is being said 60% 60% to him/her.

Requesting repetition of information when a breakdown in 55% 40% comprehension occurs with you.

Requesting repetition of information when a breakdown in 60% 30% comprehension occurs with family

Requesting repetition of information when a breakdown in 35% 20% comprehension occurs with strangers.

Recognizes when a change in the topic of conversation occurs. 45% 45%

Demonstrates of awareness of his/her comprehension difficulty. 65% 40%

Having visits and conversation with friends and neighbors. 75% 75%

Having a one-to-one conversation with you. 75% 75%

Communicating physical problems such as aches and pains. 75% 75%

Having a spontaneous conversation (i.e., starting the conversation or 45% 45% changing a subject).

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Starting a conversation with people who are not close family. 20% 20%

Responding to or communicating anything without words. 60% 70%b

Being a part of a conversation when it is fast and a number of people are 20% 20% involved.

Describing or discussing something in depth. 35% 20%

How often do you use preventive measures to increase comprehension 20% 40% with him/her?

How often does he/she use preventive measures to increase 20% 30% comprehension with you?

Note. aBolded numbers indicate a decrease in function. bNumber in italics indicate an increase in function.

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Participant D.W.. D.W., was a 76 year-old male with global aphasia from a bilateral

CVA involving the left frontal and parietal lobes, sustained 21 months prior to the study. Details regarding the extent of right hemisphere involvement were not provided on the MRI. The following information was obtained through spousal reports or observation. D.W. resided at home with his wife who assisted him with all activities of daily living. D.W. was a retired mechanical engineer who had an active social life prior to the CVA. Extensive testing revealed severe non-fluent expressive aphasia characterized by a mean length of utterance of 2 words with anomia and intermittent phonemic and semantic paraphasias. In addition, he presented with mild dysarthria characterized by decreased intensity and pitch variability. D.W. used suitable greetings and was appropriate pragmatically, but passively participated in conversation and would frequently turn to his wife to answer questions that were asked of him. Behaviors demonstrated suggested a superficial awareness of his expressive deficits. D.W. presented with severe auditory comprehension deficits at the single word level. When he was given corrective feedback he often appeared surprised by his error. D.W. did not independently request clarification to improve comprehension prior to the start of the study.

D.W. completed all experimental sessions. He was consistently cooperative and demonstrated a general desire to improve. However, during treatment sessions, he often experienced intermittent moments of lethargy which at times, negatively impacted performance.

To remediate this, increased breaks were provided. His best level of performance was in the first and last 45 minutes of the 2 hour session. As the study progressed, D.W. was able to recognize and anticipate stimuli that were consistently difficult for him to comprehend; however, he was unable to recognize when lethargy was impacting comprehension performance.

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Single word comprehension – Response to intervention. Within this section, D.W.’s comprehension performance on trained and untrained stimuli are discussed. A graphic representation of these results are displayed in Figure 28.

Trained stimuli. A declining baseline trend was observed with no change in level between the baseline and treatment phases. Over time, a gradual increase in percentage accuracy on single word comprehension tasks occurred within the first week of treatment suggesting a direct intervention effect. A stable pattern was then exhibited until the end of the treatment phase when an additional percentage increase in comprehension was noted. Upon termination of treatment, comprehension performance accuracy declined but did not return to previous baseline levels. A comparison of percentage accuracy on single word comprehension tasks across phases suggests that intervention did result in improved comprehension which was maintained: baseline

 = 20%; treatment = 56.1%; maintenance = 53.3%. A large effect size was exhibited

(Cohen’s d = 3.72) (Cohen, 1988).

Untrained stimuli. D.W. exhibited an initial positive change in level between the baseline and treatment phases. A declining trend in percentage accuracy was demonstrated during the treatment and maintenance phases on untrained comprehension stimuli. A comparison of percentage accuracy across phases on untrained comprehension stimuli suggests that only a small degree of improvement was demonstrated during the treatment phase: baseline

= 20%; treatment = 31.1%; maintenance = 20%. Effect size analysis reveals no change in effect with intervention: (Cohen’s d = 0) (Cohen, 1988). No overlap of data points was observed between trained and untrained stimuli suggesting generalization to untrained stimuli did not occur.

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Figure 28. Average percent of correct responses on high frequency word comprehension tasks by Participant D.W.. Total possible data values: Probe – 15; Treatment – 30.

Comprehension error patterns. Further analyses were completed to determine which stimuli (i.e., target word, semantic foil, phonemic foil) resulted in the greatest percentage of comprehension errors. The baseline phase revealed a greater percentage of semantic foil (  =

47%) and phonemic foil errors ( = 31.1%) when compared to target word errors ( = 8.9%). A declining percentage of semantic foil errors was demonstrated between the baseline and treatment phases. A short latency of effect was noted post onset of intervention with an decline in semantic foil and phonemic foil error types (see Figure 29). After this initial decline, a stable pattern was demonstrated with an overlap of all error type data points. An analysis of error types throughout the treatment phase revealed a higher percentage of semantic foil errors ( = 25%) compared to target word ( = 15.6%) and phonemic foil ( = 17%) error types.

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Upon termination of intervention, target word (  = 16.7%) and phonemic foil ( = 15%) error types maintained a stable pattern while semantic foil errors ( = 30%) increased in occurrence.

Figure 29. Average percentage of comprehension error types for Participant D.W..

Self-initiated requests for cues. The following section illustrates D.W.’s use of repetition and lip reading cues to assist with comprehension of single words. Figure 30 provides a graphic representation of the results.

Repetition. D.W. exhibited a stable trend with no requests for repetition made during the baseline phase. A abrupt increase in the number of requests for repetition was exhibited with the start of treatment suggesting an intervention effect. This trend continued throughout week 2 of treatment with a decline in trend demonstrated during the last week of intervention. This decline in number of requests for repetition continued during the maintenance phase with a trend

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to return to previous baseline levels. An across phases analysis revealed an overall increase in self-initiated requests for repetition to aid in comprehension: baseline  = 0; treatment = 12.7; maintenance mean = 8. A large effect size was exhibited: (Cohen’s d= 2.66) (Cohen, 1988).

Lip-reading. The number of lip reading cues requested by D.W. was limited throughout all phases of the study. A comparison of the average number of requests across phases further demonstrates this stable pattern: baseline = 0; treatment = 1.1; maintenance = .5. A large effect size was noted (Cohen’s d= 1). However, this data should be interpreted with caution secondary to the small number of requests for this cueing method. Once intervention was initiated there was no overlap in repetition and lip-reading data points suggesting that repetition was requested more than lip-reading cues: repetition treatment = 12.7; lip-reading treatment

= 1.1.

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Figure 30. Average number of requests for repetition and lip reading cues by Participant D.W..

Comprehension accuracy following cues. Response accuracy following repetition and lip reading cues will be discussed in this section.

Repetition. An immediate response to intervention was demonstrated with a greater number of correct/ incorrect responses following repetition cues suggesting improved comprehension accuracy. This trend continued throughout the first 2 weeks of the treatment phase. During the final week of treatment a decline in accuracy was noted with less distance between correct and incorrect data points. This inconsistency in accuracy continued during the maintenance phase (see Figure 31). A comparison of response accuracy, following repetition cues across phases supports that with the use of these cues, D.W. demonstrated a greater number of correct/incorrect responses. However, upon termination of treatment, a decline in accuracy

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was noted: baseline  = 0/0; treatment = 8/4.4; maintenance = 4.5/3.5. A large effect size was exhibited (Cohen’s d = 1.5) (Cohen, 1988).

Figure 31. Average number of correct/incorrect responses to repetition cues by Participant D.W.. Lip-reading. A gradual response to intervention was demonstrated with a greater number of correct versus incorrect responses to lip-reading cues observed during the second week of treatment. A change in trend was exhibited during the third week of intervention with a greater degree of overlap between data points (see Figure 32). An analysis of correct/incorrect responses revealed that lip reading cues during the treatment and maintenance phases did not significantly improve single word comprehension accuracy: baseline = 0/0; treatment = 1/0; maintenance = 0/1. A large effect size was exhibited (Cohen’s d = 1; r = .447) (Cohen, 1988) but should be interpreted with caution secondary to D.W. limited use of this cueing method.

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Figure 32. Average number of correct versus incorrect responses to lip-reading cues by

Participant D.W..

Verbal expression – Indirect treatment effects. Indirect effects on verbal naming of trained and untrained comprehension stimuli and on picture description task will be discussed.

Naming of trained comprehension stimuli. A comparison between baseline and treatment phases revealed an immediate response to indirect intervention with an increase in the percentage of correct naming responses. Following this immediate gain, a declining trend occurred with a decrease in naming skills noted. Fatigue was demonstrated during these sessions which may have impacted performance levels. A gradual increase in performance returned following the termination of treatment and continued throughout the maintenance phase (see Table 23). A comparison of percentage naming accuracy across phases suggests that the comprehension

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treatment had an indirect effect on naming skills: baseline correct = 23%; treatment correct  =

24%; maintenance correct: = 39%.

An analysis of related word productions suggested a limited positive percentage change was exhibited across phase: baseline related words = 0%; treatment related words = 2%; maintenance related words = 3.5%. Similarly, more verbal attempts, in the form of phonemic paraphasias were observed: baseline phonemic paraphasias = 0%; treatment phonemic paraphasias = 2%; maintenance phonemic paraphasias = 0%. Lastly, across phases, there was a decrease in semantic paraphasic productions: baseline semantic paraphasias = 3%; treatment semantic paraphasias = 2%; maintenance semantic paraphasias = 0%.

Table 23.

Results of verbal naming of trained comprehension stimuli for Participant D.W.

Trained Semantic Phonemic Incorrect or a Correct Related Word Stimuli Paraphasia Paraphasia No Response Baselineb 23% 3% 0% 0% 74%

1 Week Probe 50% 0% 0% 0% 50%

2 Week Probe 13% 3% 3% 3% 78%

3 Week Probe 10% 3% 3% 3% 81%

1 Week 27% 0% 0% 0% 73% Maintenance

1 Month 50% 7% 0% 0% 43% Maintenance

Note: a Total Possible – 30; b One naming baseline measure was taken.

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Naming of untrained comprehension stimuli. As seen in Table 24, a positive initial change in percentage accuracy on naming tasks was demonstrated with the onset of intervention.

This was followed by a decline in naming ability during week 2 and 3 of the treatment phase and continued at 1 week post treatment. At 1 month post treatment, a peak in naming performance was observed. Again, fatigue may have contributed to this inconsistent performance. A comparison of percentage naming accuracy across phases suggests that the comprehension treatment had a negative effect on the naming of untrained stimuli: baseline correct = 33%; treatment correct  = 25%; maintenance correct = 27%.

In addition, a decline in the percentage of phonemic paraphasias was also exhibited: baseline phonemic paraphasias = 13%; treatment phonemic paraphasias = 2%; maintenance phonemic paraphasias = 0%. This pattern was also exhibited in related word production with a decline in productions noted during treatment: baseline related words = 3.5%; treatment related words = 2%; maintenance related words = 3.5%. Lastly, more verbal attempts in the form of semantic paraphasias were made when compared to baseline levels of performance: baseline semantic paraphasias = 0%; treatment semantic paraphasias = 2%; maintenance semantic paraphasias = 3.5%.

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Table 24.

Results of verbal naming of untrained comprehension stimuli for Participant D.W.

Untrained Semantic Phonemic Incorrect or a Correct Related Word Stimuli Paraphasia Paraphasia No Response Baselineb 33% 0% 13% 0% 54%

1 Week Probe 40% 0% 7% 7% 46%

2 Week Probe 7% 0% 0% 0% 93%

3 Week Probe 27% 7% 0% 0% 66%

1 Week 7% 0% 0% 7% 86% Maintenance

1 Month 47% 7% 0% 0% 46% Maintenance

Note: aTotal Possible – 15; b One naming baseline measure was taken.

Picture description. No change in the verbal production of subclausal, single clause, or multiclausal utterances was demonstrated across phases of the study (see Table 25). A comparison of the number empty utterances produced during picture description tasks suggested a decline in number across phases: baseline empty utterances = 3; treatment empty utterances

 = 2; maintenance empty utterances = 0. Comprehension treatment did not have an indirect impact on verbal narrative productions.

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Table 25.

Narrative picture description analysis

Type and Number of Empty Subclausal Single Clause Multiclausal Utterance

Baselinea 3 0 0 0

1 Week Probe 0 0 0 0

2 Week Probe 4 0 1 0

3 Week Probe 2 0 0 0

0 0 0 0 1 Week Maintenance

0 1 0 0 1 Month Maintenance

Note: aOne narrative baseline measure was taken.

Generalization to functional communication environments. The caregiver who completed the surveys was present during all assessment sessions and was able to indirectly view all treatment sessions. A review of pre- and post-treatment caregiver surveys revealed an overall increase in perceived communication performance on 22 out of the 25 questions (see Table 26).

A stable rating was given on 3 questions. Two of these questions involved use of compensatory strategies to aid in comprehension. No decline in function was reported.

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Table 26.

Pre- and Post-Intervention – Caregiver Perceived Functional Communication Performance

Pre- Post- Functional Communication Survey Questions: Intervention Intervention

Getting somebody’s attention. 65% 75%a

Getting involved in group conversations that are about him/her. 15% 60%

Giving yes/no answers appropriately. 35% 75%

Communicating his/her emotions. 40% 75%

Comprehending simple yes/no questions. 25% 85%

Comprehending conversations about a familiar topic. 75% 80%

Comprehending conversations about new, unfamiliar topics. 45% 65%

Indicating to you that he/she does not understand what is being said to 45% 50% him/her.

Indicating to friends that he/she does not understand what is being said to 30% 50% him/her.

Indicating to strangers that he/she does not understand what is being said 25% 45% to him/her.

Requesting repetition of information when a breakdown in 50% 75% comprehension occurs with you.

Requesting repetition of information when a breakdown in 25% 75% comprehension occurs with family

Requesting repetition of information when a breakdown in 15% 40% comprehension occurs with strangers.

Recognizes when a change in the topic of conversation occurs. 75% 75%

Demonstrates of awareness of his/her comprehension difficulty. 65% 85%

Having visits and conversation with friends and neighbors. 40% 65%

Having a one-to-one conversation with you. 55% 65%

Communicating physical problems such as aches and pains. 40% 75%

Having a spontaneous conversation (i.e., starting the conversation or 20% 40% changing a subject).

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Starting a conversation with people who are not close family. 5% 25%

Responding to or communicating anything without words. 20% 60%

Being a part of a conversation when it is fast and a number of people are 5% 25% involved.

Describing or discussing something in depth. 5% 25%

How often do you use preventive measures to increase comprehension 30% 30% with him/her?

How often does he/she use preventive measures to increase 5% 5% comprehension with you?

Note. aItalicized numbers indicate an increase in function.

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Participant R.K.. R.K. was a 79 year-old gentleman who lived at home with his wife and caregiver who assisted him with all activities of daily living. He had sustained a left CVA involving the frontal and parietal lobes, 28 months prior to the study. Preceding the CVA, he was a retired foreman. Although he had participated in an extensive period of rehabilitation, he continued to present with dense right hemiparesis, was wheelchair dependent, and had not regained the ability to communicate content information verbally secondary to severe verbal apraxia. His speech was non-fluent and he frequently responded “yes” and “no” when asked questions of emotional significance, but the accuracy of his responses was inconsistent. He owned a Lingraphica® high-tech augmentative communication device that was specifically programmed for his unique needs, but he refused to utilize it at home or in social situations. He would often gesture to relay information regarding basic needs and would get frustrated if the listener did not immediately understand his intentions.

R.K. was cooperative, motivated and actively participated during all experimental sessions with no evidence of fatigue demonstrated. At the onset of the intervention, R.K. frequently exhibited impulsivity of response. However, with minimal corrective feedback he spontaneously corrected this behavior and independently applied the strategy to future sessions..

R.K. would demonstrate moment of frustration, but would dissipated quickly and did not interfere with future tasks. As treatment progressed, he was able to recognize and anticipate stimuli that were consistently difficult to comprehend.

Single word comprehension- Response to intervention. This section provides an overview of R.K.’s performance on trained and untrained stimuli communication tasks. Results are displayed in Figure 33.

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Trained stimuli. R.K. demonstrated a declining baseline trend. A positive change in level was exhibited between the baseline and treatment phases. Over the course of treatment, a gradual increase in the average percentage of correct responses to comprehension stimuli was demonstrated. This positive trend was maintained throughout the maintenance phase. An increase in the average percentage accuracy across phases suggests that treatment resulted in greater single word comprehension on trained stimuli tasks: baseline  = 40%; treatment =

58%; maintenance = 67%. A large effect size was exhibited (Cohen’s d = 1.66) (Cohen, 1988).

Untrained stimuli. No change in level was demonstrated between the baseline and treatment phases. However, a significant increase in percentage accuracy on untrained stimuli single word comprehension tasks was exhibited at the two week probe. This trend was maintained throughout the remainder of the treatment phase with an overlap of treated and untreated data points demonstrated. A positive change in level was demonstrated between the treatment and maintenance phases with peak comprehension performance exhibited 1 week post termination of treatment. A decline in trend was noted at the 1 month probe suggesting limited maintenance. A comparison of comprehension percentage accuracy across phases suggests that generalization to untrained stimuli did occur: baseline = 40%; treatment = 53%; maintenance = 70%. A large effect size was exhibited (Cohen’s d = 1.054) (Cohen, 1988).

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Figure 33. Average percent of correct responses on high frequency word comprehension tasks by Participant R.K.. Total possible data values: Probe – 15; Treatment – 30.

Comprehension error patterns. Further analyses were completed to determine which stimuli (i.e., target word, semantic foil, phonemic foil) resulted in the greatest comprehension errors. Graphic representation of comprehension errors types are displayed in Figure 34. During the baseline phase, R.K. demonstrated a greater percentage semantic foil errors (  = 49%) when compared to target word ( = 11%) and phonemic foil ( = 27%) error types. However, a decline in the average percentage of semantic foil ( = 17%) and phonemic foil ( = 18%) errors and an increase in target word ( = 20%) error types were exhibited during the treatment phase. This trend was maintained during the maintenance phase with a greater percentage of target error types: target word errors ( = 25%); semantic foil errors ( = 7%); phonemic foil errors ( = 13%).

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Figure 34. Average percentage of comprehension error types for Participant R.K..

Self-initiated requests for cues. The following outlines the use of repetition and lip reading cues utilized by R.K. to assist with comprehension of single word stimuli. Graphic representation of the results can be found in Figure 35.

Repetition: R.K. requested repetition cues during the baseline phase by looking directly at the examiner and then looking back at the visual stimuli. There was no change in level between the baseline and treatment phases. A gradual increase in the average number of participant directed requests for repetition cues was observed during the treatment phase with a peak number of requests made during the last 2 sessions. A declining change in level was demonstrated between the treatment and maintenance phases. An across phases analysis revealed an overall increase in the number of self-initiated requests for repetition to aid in

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comprehension: baseline  = 13; treatment = 40; maintenance = 44. A large effect size was exhibited: (Cohen’s d = 5.57) (Cohen, 1988).

Lip-reading: R.K. intermittently utilized lip reading cues during the baseline phase. No change in level was demonstrated between the baseline and treatment phases with only a slight gradual increase in average number of requests for lip-reading cues over the course of treatment.

A declining change in level was demonstrated between the treatment and maintenance phase.

An across phases analysis revealed an increase in the number of requests for lip-reading cues across phases: baseline =.33; treatment = 2; maintenance = 3. A large effect size was exhibited: (Cohen’s d = 6.54) (Cohen, 1988). There was no overlap in repetition and lip reading data points once the treatment phase was initiated suggesting that repetition cues were utilized more often than lip-reading cues: treatment repetition cues = 40; treatment lip-reading cues

= 2.

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Figure 35. Average number of requests for repetition and lip reading cues by Participant R.K..

Comprehension accuracy following cues. Response accuracy following repetition and lip reading cues will be discussed in this section.

Repetition. Baseline performance revealed a stable trend in accuracy following repetition cues with a greater occurrence of correct/ incorrect responses. This trend continued throughout the treatment phase with a widening gap between correct and incorrect responses following cues

(see Figure 36). A comparsion of accuracy during the treatment phase exhibites a greater average number of correct responses following repetition cues. This positive trend was maintained during the maintenance phase. A comparison of accuracy, following repetition cues, across phases further supports that with the use of these cues, R.K. demonstrated a greater number of correct/ incorrect responses: baseline  = 9/3; treatment = 31/9; maintenance =

33/12. A large effect size was exhibited (Cohen’s d = 5.87) (Cohen, 1988).

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Figure 36. Average number of correct/ incorrect responses to repetition cues by Participant R.K.. Lip-reading. A stable baseline was exhibited with a similar number of correct and incorrect responses following lip-reading cues. A gradual increase in correct/ incorrect responses was demonstrated during the last 2 sessions of the treatment phase (see Figure 37).

However, a comparsion of accuracy across the treatment phase did not exhibit this trend. A decline in level between the treatment and maintenance phase suggests a declining maintenance effect once treatment was terminated. A comparison of accuracy, following repetition cues, across phases further supports that with the use of these cues, R.K. demonstrated a greater number of correct/incorrect responses: baseline  = .5/0; treatment = 1/1; maintenance =

3/1. A large effect size was exhibited: (Cohen’s d = 3.87) (Cohen, 1988).

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Figure 37. Average number of correct/incorrect responses to lip-reading cues by Participant R.K..

Verbal expression – Indirect treatment effects. Indirect effects on verbal naming of trained and untrained comprehension stimuli and on picture description task will be discussed.

Naming of trained comprehension stimuli. R.K. demonstrated significant struggle behavior on all naming tasks. A stable trend was demonstrated during the baseline and treatment phases with limited change in naming percentage accuracy of trained comprehension stimuli. A peak in naming performance was exhibited at 1 week post termination of treatment (see Table

27) but this was not maintained at 1 month post treatment. A comparison of percentage accuracy across phases suggests that the comprehension treatment had only a minimal effect on correct naming ability with R.K.: baseline = 0%; treatment  = 3%; maintenance mean = 9%. No

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change in the production of related words and semantic and phonemic paraphasias was demonstrated across phases.

Table 27.

Results of verbal naming of trained comprehension stimuli for Participant R.K..

Trained Semantic Phonemic Incorrect or a Correct Related Word Stimuli Paraphasia Paraphasia No Response Baselineb 0% 0% 0% 0% 100%

1 Week Probe 0% 0% 0% 0% 100%

2 Week Probe 10% 0% 0% 0% 90%

3 Week Probe 0% 0% 0% 0% 100%

1 Week 17% 0% 3% 3% 77% Maintenance

1 Month 0% 0% 0% 0% 100% Maintenance

Note: a Total Possible – 30; b One naming baseline measure was taken.

Naming of untrained comprehension stimuli. As seen in Table 28, a comparison of percentage accuracy across phases suggests that the comprehension treatment had no effect on correct naming ability with R.K. While a peak in naming performance was noted during probe

3, this level was not maintained post termination of treatment: baseline correct = 7%; treatment correct  = 7%; maintenance correct = 0%. No change in the average percent of semantic and phonemic paraphasias was demonstrated across phases. Only minimal increases in related word productions were exhibited during the treatment phase: baseline related words = 0%; treatment related words = 2.3%; maintenance related words = 0%.

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Table 28.

Results of verbal naming of untrained comprehension stimuli for Participant R.K..

Trained Semantic Phonemic Incorrect or a Correct Related Word Stimuli Paraphasia Paraphasia No Response Baselineb 7% 0% 0% 0% 0%

1 Week Probe 0% 0% 0% 7% 93%

2 Week Probe 0% 0% 0% 0% 100%

3 Week Probe 20% 0% 0% 7% 73%

1 Week 0% 0% 0% 0% 100% Maintenance

1 Month 0% 0% 0% 0% 100% Maintenance

Note: a Total Possible – 15; b One naming baseline measure was taken.

Picture description. A comparsion of clause production across phases reveals a minimal increase in number empty utterances produced: baseline empty utterances (  = 0); treatment empty utterances ( = 2); maintenance empty utterances ( = 1). This data suggests that the comprehension treatment did not indirectly effect functional narrative communication (see Table

29).

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Table 29.

Narrative picture description analysis

Type and Number of Empty Subclausal Single Clause Multiclausal Utterance

Baselinea 0 0 0 0

1 Week Probe 1 0 0 0

2 Week Probe 0 0 0 0

3 Week Probe 4 1 0 0

3 0 0 0 1 Week Maintenance

0 0 0 0 1 Month Maintenance

Note: aOne narrative baseline measure was taken.

Generalization to functional communication environments. A review of pre- and post- treatment caregiver surveys revealed a stable level of perceived communication performance on

13 out of the 25 questions (see Table 30). A decreased rating was given on 10 questions. Four of these questions pertained to verbal expression and 6 were related to auditory comprehension and self awareness. An increase in perceived performance occurred on 2 questions; one in regards to increased Participant use of strategies to aid with comprehension. In should be noted that the caregiver was never present during experimental sessions and often relayed to the examiner that the Participant had “no difficulty understanding”.

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Table 30.

Pre-and Post-Intervention – Caregiver Perceived Functional Communication Performance

Pre- Post- Functional Communication Survey Questions: Intervention Intervention

Getting somebody’s attention. 80% 45%a

Getting involved in group conversations that are about him/her. 20% 15%

Giving yes/no answers appropriately. 75% 75%

Communicating his/her emotions. 70% 50%

Comprehending simple yes/no questions. 85% 85%

Comprehending conversations about a familiar topic. 85% 85%

Comprehending conversations about new, unfamiliar topics. 70% 70%

Indicating to you that he/she does not understand what is being said to 75% 75% him/her.

Indicating to friends that he/she does not understand what is being said to 50% 45% him/her.

Indicating to strangers that he/she does not understand what is being said 50% 45% to him/her.

Requesting repetition of information when a breakdown in 75% 75% comprehension occurs with you.

Requesting repetition of information when a breakdown in 75% 75% comprehension occurs with family

Requesting repetition of information when a breakdown in 50% 45% comprehension occurs with strangers.

Recognizes when a change in the topic of conversation occurs. 90% 80%

Demonstrates of awareness of his/her comprehension difficulty. 60% 45%

Having visits and conversation with friends and neighbors. 5% 5%

Having a one-to-one conversation with you. 80% 85%b

Communicating physical problems such as aches and pains. 55% 55%

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Having a spontaneous conversation (i.e., starting the conversation or 5% 5% changing a subject).

Starting a conversation with people who are not close family. 5% 5%

Responding to or communicating anything without words. 70% 65%

Being a part of a conversation when it is fast and a number of people are 5% 5% involved.

Describing or discussing something in depth. 5% 5%

How often do you use preventive measures to increase comprehension 60% 45% with him/her?

How often does he/she use preventive measures to increase 20% 25% comprehension with you? Note: aBolded numbers indicate a decrease in function. bNumbers in italics indicate an increase in function.

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Experiment I: SWCA – Summary of results. A brief summary of the results from

Experiment I: SWCA will be reviewed. This will be an integration of the findings from all six

SWCA participants. The research questions specific to each section will be addressed.

Single word comprehension – Response to intervention. This section will summarize the SWCA performance on trained and untrained single word comprehension tasks.

Research Question 1. Will the average percentage accuracy on single word comprehension tasks improve? Consistent with the research hypothesis, five out of the six participants demonstrated a positive response to the intensive treatment and improved performance on single word comprehension tasks. A further review of these findings will be summarized in the following sections.

Trained stimuli. For five of the six participants, trained single word comprehension percentage accuracy directly increased with the onset of intervention with a large effect size exhibited (Cohen’s d range: 1.66 to 4.11). In addition, comprehension accuracy was maintained

1 month post termination of the treatment protocol suggesting a maintenance effect. Two of these participants demonstrated intermittent fatigue during the two hour treatment sessions.

Hence, comprehension accuracy could have been even greater if fatigue had not occur.

One participant (B.D.) did not demonstrate comprehension gains and relayed feeling overwhelmed by treatment stimuli. While no fatigue was demonstrated, this participant became frustrated early in the intervention protocol and questioned the accuracy of the examiners feedback.

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When comprehension errors did occur during the experiment, the following patterns were exhibited. Semantic foil errors occurred at a greater rate than target word and phonemic foil error types across all six participants during the baseline phase. With the onset of intervention, all SWCA participants demonstrated a decrease in phonemic foil errors and five of the six participants exhibited a decrease in semantic foil errors when compared to baseline levels. A decline in target word errors was also noted with three of these participants across phases. An increase in target word errors was exhibited by three participants with the onset of intervention when compared to baseline percentage of occurrence. One participant (BD) demonstrated no change in the number of semantic foil errors.

Untrained stimuli. Five of the six participants exhibited a generalization effect, with improved comprehension percentage accuracy on untrained stimuli. Of these participants, four exhibited a large effect size and one a small effect size (Cohen’s d range: .390 to 2.05). One participant did not demonstrate generalization to untrained stimuli.

The one participant (B.D.), who did not show comprehension gains with trained stimuli, demonstrated gains on the untrained stimuli (Cohen’s d = 2.04). It should be noted, that increased relaxation and decreased frustration was exhibited when untrained stimuli was presented to this participant (as compared to when trained stimuli were presented).

Self-initiated requests for cues. The following results summarize the average number of requests of repetition and lip reading cues utilized by the SWCA.

Research Question 2. Will the average number of self-initiated requests for repetition cues increase? Consistent with the hypothesis, all participants exhibited an increase in requests

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for repetition cues. A further review of these findings will be summarized in the following section.

Repetition. All SWCA participants demonstrated an increased number of requests for repetition cues with a large effect size (Cohen’s d range: 1.97 to 13.8). This positive change was exhibited when compared to baseline levels across all phases and continued throughout the maintenance phase.

Research Question 3. Will the average number of self-initiated requests for lip-reading cues increase? Consistent with the hypothesis, four out of the six participants exhibited an increased in the average number of self-initiated requests for lip reading cues. However, overall, the use of this cue was underutilized when compared to repetition cues. A further review of these findings will be summarized in the following section.

Lip-reading. Lip-reading cues were requested to a lesser degree by all participants when compared to repetition levels with two of the six participants not using the cues even when offered. However, an increase in the number of lip-reading requests and a large effect size was demonstrated across phases for all four participants that utilized this cueing method (Cohen’s d range: 1 to 6.54). Even with this positive finding, the average number of lip-reading requests per session was less then 5.

Single word comprehension accuracy following cues. SWCA Response accuracy following repetition and lip reading cues will be discussed in this section.

Research Question 4. Will the average number of correct responses on single word comprehension tasks increase following repetition cues? Consistent with the hypothesis, all

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participants demonstrated an increase in single word comprehension accuracy following the use of repetition cues. A further review of these findings will be summarized in the following section.

Repetition. All SWCA participants demonstrated an increase in single word comprehension accuracy following repetition cues with a large treatment effect (Cohen’s d range: 39 to 1.5). For five out of the six participants, no overlap in correct/ incorrect data points was observed. This lack of overlap suggests that with the use of repetition cues, there is greater single word comprehension accuracy. In one participant (DW), intermittent overlapping of correct and incorrect data points was exhibited. This indicates that use of repetition cues did not consistently result in improved comprehension; however, it should be noted, fatigue may have contributed to this inconsistency.

Research Question 5. Will the average number of correct responses on single word comprehension tasks increase following lip-reading cues? Consistent with the research hypothesis, comprehension accuracy improved following use of the lip-reading cue in four participants. A further review of these findings can be found in the following section.

Lip-reading. In the same respect, for the four participants that utilized lip-reading cues, all demonstrated increased comprehension accuracy with a large treatment effect (Cohen’s d range: 1 to 3.8).

Verbal expression - Indirect treatment effects. A summary of SWCA naming performance of trained and untrained comprehension stimuli, and picture description tasks will be discussed.

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Research Question 6. Will the average number of correct single word naming responses

increase? Consistent with the research hypothesis, five out of the six participants demonstrated improved single word naming of treated comprehension stimuli suggesting an indirect treatment effect. A summary of these findings can be found in the following section.

Naming of trained comprehension stimuli. For five of the six SWCA participants, an average percentage accuracy increase was exhibited during trained stimuli naming tasks. This suggests an indirect treatment effect. Naming accuracy for one participant remained stable. In addition, increased naming attempts were demonstrated through a greater percentage increase in the production of related words when compared to baseline levels for three of the six participants. Related word production decreased for two participants and remained stable for one. The production of phonemic paraphasias increased for two participants and remained stable for four participants. The average percentage of semantic paraphasias decreased in three of six participants, increased in one, and remained stable in two participants.

Naming of untrained comprehension stimuli. For two of the six SWCA participants, an average percentage accuracy increase was exhibited during untrained stimuli naming tasks, suggesting a generalization effect. However, four participants demonstrated an average percentage decline on these tasks, suggesting a negative indirect treatment effect. An increase in the percentage of naming attempts was also exhibited by three of the six participants through the production of more related words. Production of related words remained stable for two participants and declined in one participant. For four of the six participants, an increase in semantic paraphasias was demonstrated. Production of semantic paraphasias remained stable for one participant and declined in one participant.

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Research Question 7. Will the number of correct narrative utterances increase during picture description tasks? Contrary to the hypothesis, the number of correct narrative utterances did not increase following the comprehension protocol. A summary of these results can be found in the following section.

Picture description. An increase in the number of empty utterances was demonstrated for four of the six participants with a decline noted in two participants. Production of subclausal utterances increased in two participants with a stable pattern demonstrated in four participants.

No change in the number of single clause or multiclause utterances was demonstrated across all participants.

Generalization to functional communication environments.

Research Question 8. Will participants demonstrate generalization of comprehension skills and/or independent use of compensatory strategies as documented via the Communicative

Effectiveness Index (Lomas et al., 1989)? Contrary to the research hypothesis, four of the five surveys completed reported a perceived decline in functional communication task performance.

A summary of the results can be found in the following section.

Pre- and post functional communication surveys were completed by five out of the six participant caregivers. For four of the five caregivers, the perceived level of the participants’ performance on verbal expression and auditory comprehension tasks decreased on 40% or more of the questions. One caregiver, reported an increase in performance on 22 of the 25 questions.

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Speech Perception Study

Participant T.L.. T.L. was a 81 year old male who sustained a left MCA CVA involving the frontal, temporal and parietal lobes, 100 months prior to the experiment. He lived at home with his wife, who assisted with most activities of daily living (e.g. dressing, bathing, cooking, finances). A wheelchair was utilized for mobility secondary to right hemiparesis. T.L. presented with severe expressive aphasia and verbal apraxia characterized by anomia, perseverative paraphasic errors, and phrases (e.g. “Goin on there...been there.”). He was unable to express basic wants and needs verbally.. Even with this limitation, he actively participated in conversations and did not appear to recognize that his aphasia impacted his ability to relay meaningful information to the listener. A heightened awareness of his expressive limitations could be seen only when T.L. was asked a direct question. When this occurred, significant hesitation and struggle behavior was observed with no spontaneous use of compensatory strategies utilized to relay intended meaning. In addition, severe auditory comprehension deficits were also present. His spouse relayed that even more than speaking, she wished he could answer simple yes/no questions with accuracy. In conversation, when comprehension breakdowns occurred, T.L. did not request clarification.

T.L. completed all experimental sessions. At the onset of the study, T.L. did not appear to actively engage in the protocol. He seemed to randomly select answers. Over the course of the treatment phase, increased active participation was observed with slower, and less random, response times. At the start of the third week of treatment, T.L. was required to have a medical procedure, so the experiment was put on hold for 2 days. After resuming, increased fatigue was demonstrated. Prior level of alertness did not resume until the last day of the treatment phase.

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Speech perception – Response to intervention. This section provides an overview of

T.L.’s performance on speech perception tasks utilizing trained and untrained stimuli. Results are displayed in Figure 38.

Trained stimuli. T.L. demonstrated a declining baseline trend over 5 sessions. An immediate positive change of level was exhibited between the baseline and treatment phases. A stable percentage accuracy trend was demonstrated during the first two weeks of intervention with an increase in speech perception during the 10th and 11th treatment sessions. After this peak in performance, treatment sessions were put on hold for 2 days while the Participant received unanticipated medical intervention. When sessions were resumed, increased fatigue was demonstrated (compared with previous performance), with a decline in percentage accuracy on speech perception tasks exhibited. During the last treatment session, T.L. demonstrated a positive gain in perception. Decreased fatigue was noted compared to the previous three sessions. No change in level was demonstrated between the treatment and maintenance phases.

However, a decline in percentage accuracy was exhibited at 1 month post treatment suggesting a decrease in ability to maintain performance over time. An increase in the average percentage accuracy on CV speech perception tasks suggests a positive response to intervention: baseline

 = 18%; treatment = 22%; maintenance = 33%. A large effect size was exhibited:

(Cohen’s d = 1.11) (Cohen, 1988).

Untrained stimuli. A positive change in level between the baseline and treatment phases was demonstrated with a gradual increase in percentage accuracy on speech perception tasks exhibited during intervention. Accuracy of performance was maintained during the first week of the maintenance phase but a declining trend was observed at 1 month post intervention. A

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comparison of the percentage accuracy across phases on speech perception tasks utilizing untrained stimuli revealed that minimal generalization did occur: baseline  = 18%; treatment

= 24%; maintenance = 23%. A small effect size was exhibited: (Cohen’s d = .367) (Cohen,

1988).

Figure 38. Average percent of correct responses on CV speech perception tasks by Participant T.L.. Total possible data values: Probe – 15; Treatment – 30. Note: Arrow denotes when treatment was resumed following a 2 day break for medical intervention.

Speech perception error patterns. Further analyses were completed to determine which stimuli (target CV, similar phonemic placement foil, different phonemic placement foil) resulted in the greatest percentage of speech perception errors (see Figure 39). The baseline phase revealed a higher percentage of target CV errors ( = 67%) when compared to similar placement

( = 36%) and different placement ( = 37%) foil errors. This trend continued during the

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treatment phase with a greater percentage of target CV errors (  = 64%) than similar placement

( = 19%) and different placement ( = 17%) foil errors. A drop in percentage of target errors was observed between the treatment and maintenance phases. However, the occurrence of target

CV errors increased at 1 month post treatment and returned to previous error rates. A comparison of the percentages of error types during the maintenance phase revealed that target

CV errors remained most common: target CV errors ( = 38%); similar placement foil errors

( = 25%); different placement foil errors ( = 25%).

Figure 39. Average percentage of speech perception error types for Participant T.L.

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Self-initiated requests for cues. The following results illustrate the average number of requests of repetition and lip reading cues utilized by T.L.. Figure 40 provides a graphic representation of the results.

Repetition. Upon initiation of the treatment phase, an increase in the number of requests for repetition cues was exhibited. An unstable trend in the average number of requests was demonstrated during intervention. A change in level was noted between the treatment and maintenance phases with the highest number of requests for repetition noted at 1 week post treatment. However, at 1 month post treatment, the number of requests declined closer to previous baseline levels. An across phases analysis revealed an increase in the number of self- initiated requests for repetition to aid in speech perception: baseline  = 1.4; treatment = 16; maintenance = 19. A large effect size was exhibited: (Cohen’s d = 1.46) (Cohen, 1988)

Lip-reading. T.L. did not request or utilize lip-reading cues during any phase of the study, even when direct prompts were provided. There was no overlap between repetition and lip-reading data across phases. Repetition cues were self-requested and utilized to the greatest degree: treatment repetition = 16; treatment lip-reading = 0.

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Figure 40. Average number of requests for repetition and lip reading cues by Participant T.L..

Speech perception accuracy following cues. Response accuracy following repetition and lip reading cues will be discussed in this section.

Repetition. A stable baseline trend was observed with minimal difference between average number of correct and incorrect responses following repetition cues. Inconsistent accuracy following repetition cues was noted throughout the treatment phase with some overlapping of correct and incorrect data points (see Figure 41). However, a comparison of average response accuracy across the treatment phase revealed a greater number of correct/ incorrect responses. This trend continued during the maintenance phase. A comparison of accuracy, following repetition cues, across phases further supports that with the use of these cues, T.L. demonstrated a greater number of correct/incorrect responses: baseline  = 1/0;

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treatment  = 11/6; maintenance: = 9/3. A large effect size was exhibited: (Cohen’s d = 1.05)

(Cohen, 1988)

Figure 41. Average number of correct/incorrect responses to repetition cues by Participant T.L..

Lip-reading. Lip reading cues were not utilized by T.L. and hence resulted in no change in mean, level, trend, or latency.

Verbal expression – Indirect treatment effects. Indirect effects on repetition of trained and untrained speech perception stimuli and on picture description task will be discussed.

Repetition of trained speech perception stimuli. An indirect effect on verbal repetition ability was not demonstrated. A change in the average percentage of correct, phonemic

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paraphasia, or incorrect/no response productions was not exhibited across phases (see Table 31).

All verbal productions were effortful perseverative, non-related errors.

Table 31.

Results of verbal repetition of trained CV stimuli for Participant T.L.

Trained Stimulia Correct Phonemic Paraphasia Incorrect/No Response

Baselineb 0% 0% 100%

1 Week Probe 0% 0% 100%

2 Week Probe 0% 0% 100%

3 Week Probe 0% 0% 100%

1 Week Maintenance 0% 0% 100%

1 Month Maintenance 0% 0% 100%

Note: a Total Possible – 30; b One repetition baseline measure was taken.

Repetition of untrained speech perception stimuli. An indirect effect on verbal repetition ability of untrained was not demonstrated. A change in the average percentage of correct, phonemic paraphasia, or incorrect/no response productions was not exhibited across phases. All verbal productions were effortful perseverative, non-related errors (see Table 32).

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Table 32.

Results of verbal repetition of untrained CV stimuli for Participant T.L.

Untrained Stimulia Correct Phonemic Paraphasia Incorrect/No Response

Baselineb 0% 0% 100%

1 Week Probe 0% 0% 100%

2 Week Probe 0% 0% 100%

3 Week Probe 0% 0% 100%

1 Week Maintenance 0% 0% 100%

1 Month Maintenance 0% 0% 100%

Note: a Total Possible – 15; b One repetition baseline measure was taken.

Picture description. No increase in the number of subclausal, single clause, or multiclausal utterances was demonstrated across phases of the study (see Table 33). A comparison of number of empty phrases utilized across phases during a picture description task suggested a decline in number: baseline = 8; treatment  = 8; mean maintenance = 5.5.

Based on these findings, speech perception treatment did not have an indirect impact on verbal narrative productions.

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Table 33.

Narrative picture description analysis

Type and Number of Empty Subclausal Single Clause Multiclausal Utterance

Baselinea 8 0 0 0

1 Week Probe 13 0 0 0

2 Week Probe 7 0 0 0

3 Week Probe 5 0 0 0

6 0 0 0 1 Week Maintenance

5 0 0 0 1 Month Maintenance

Note: a One narrative baseline measure was taken.

Generalization to functional communication environments. A review of pre- and post- treatment caregiver surveys revealed an overall increase in perceived communication performance on 17 out of the 25 questions (see Table 34). A decline of function was noted on 7 questions. Six of these questions pertained to the Participant’s self-awareness of comprehension limitations, comprehension abilities, or use of compensatory strategies. A stable rating was given on 1 question. It should be noted that the caregiver was present throughout all diagnostic sessions and intermittently during treatment sessions.

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Table 34.

Pre- and Post-Intervention – Caregiver Perceived Functional Communication Performance

Pre- Post- Functional Communication Survey Questions: Intervention Intervention

Getting somebody’s attention. 65% 70%

Getting involved in group conversations that are about him/her. 2% 20%

Giving yes/no answers appropriately. 20% 2%

Communicating his/her emotions. 50% 60%

Comprehending simple yes/no questions. 15% 20%

Comprehending conversations about a familiar topic. 15% 2%

Comprehending conversations about new, unfamiliar topics. 2% 2%

Indicating to you that he/she does not understand what is being said to 30% 70% him/her.

Indicating to friends that he/she does not understand what is being said to 2% 15% him/her.

Indicating to strangers that he/she does not understand what is being said 2% 10% to him/her.

Requesting repetition of information when a breakdown in 2% 60% comprehension occurs with you.

Requesting repetition of information when a breakdown in 2% 20% comprehension occurs with family

Requesting repetition of information when a breakdown in 2% 30% comprehension occurs with strangers.

Recognizes when a change in the topic of conversation occurs. 35% 5%

Demonstrates of awareness of his/her comprehension difficulty. 50% 15%

Having visits and conversation with friends and neighbors. 2% 10%

Having a one-to-one conversation with you. 2% 10%

Communicating physical problems such as aches and pains. 25% 65%

Having a spontaneous conversation (i.e., starting the conversation or 5% 65% changing a subject).

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Starting a conversation with people who are not close family. 5% 25%

Responding to or communicating anything without words. 5% 20%

Being a part of a conversation when it is fast and a number of people are 5% 2% involved.

Describing or discussing something in depth. 5% 2%

How often do you use preventive measures to increase comprehension 30% 28% with him/her?

How often does he/she use preventive measures to increase 5% 20% comprehension with you?

Note. Italicized numbers indicate an increase in function. Bolded numbers denote a decline in function.

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Participant: E.R. E.R. is a 73-year-old female with global aphasia from a large left

MCA CVA involving the insula and temporal lobes, sustained 68 months prior to the study. She resided at home, with her spouse who assisted her with all activities of daily living. E.R. presented with severe expressive aphasia characterized by perseverative fluent neologistic errors and phrases (e.g. “Iogrowthemaro, thank you grandpa.” ). These perseverative phrases were used in all communication contexts. However, E.R. used varied inflection when saying these phrases to relay emotions. Rising inflection was noted when she had a question and a softer, declining inflection was utilized when she voiced concern. No appropriate content words were utilized in conversation. E.R. did not appear to realize that verbalizations did not relay meaning and never showed frustration or anger. Her spouse relayed that since her stroke, he never saw her upset or angry even though she had severe communication limitations. Auditory comprehension skills were also severely impaired. E.R. was unable to comprehend simple, personally relevant questions with no attempts made to request clarification when breakdowns occurred. At times,

E.R. demonstrated inappropriate pragmatic behaviors (e.g. greeting strangers like friends; yelling for joy loudly in public).

E.R. completed all treatment sessions with no fatigue demonstrated. To relay requests for repetition, she was instructed to tap on the table with her fingers. She was able to carryover use of this cue with minimal reminders at the start of each session. Brief moments of frustration were noted when she was told a response was in error. However, this frustration did not carryover to other trials.

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Speech perception – Response to intervention. This section provides an overview of

E.R.’s performance on trained and untrained speech perception tasks. Results are displayed in

Figure 42.

Trained stimuli. An unstable baseline trend was demonstrated with no change in average percentage accuracy between the baseline and treatment phases. A stable pattern of response was exhibited throughout the treatment phase. A positive change in level was observed between the treatment and maintenance phases with a peak average percentage of speech perception accuracy noted at 1 month post treatment. A comparison of percentage accuracy across phases suggests that a positive change in speech perception task accuracy was only noted during the maintenance phase: baseline  = 15%; treatment = 16%; maintenance = 30%. A large effect size was exhibited (Cohen’s d = 1.08) (Cohen, 1988).

Untrained stimuli. There was no change in level demonstrated between the baseline and treatment phases. An unstable pattern of percentage accuracy on speech perception tasks was exhibited during the treatment phase. Following termination of treatment, a gradual increase in average percentage accuracy was noted with peak performance exhibited at the 1 month maintenance measure suggesting a generalization effect: baseline = 15%; treatment = 15%; maintenance = 33%. A large effect size was exhibited: (Cohen’s d = 1.77) (Cohen, 1988).

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Figure 42. Average percent of correct responses on CV speech perception tasks by Participant E.R.. Total possible data values: Probe – 15; Treatment – 30.

Speech perception error patterns. Further analyses were completed to determine which stimuli (i.e., target CV, similar phonemic placement foil, different phonemic placement foil) resulted in the greatest percentage of speech perception errors (see Figure 43). The average percentage of error types during the baseline phase was evenly distributed between target CV

(  = 76%), similar placement ( = 73%) and different placement ( = 72%) foil errors. A declining trend was demonstrated between the baseline and treatment phases with a decrease in all error types. An overlap in data points was observed during the treatment phase; however a comparison percent accuracy revealed a greater number of similar placement ( = 48%) and different placement ( = 49%) foil errors compared with target CV errors( = 38%). A continued decline in the average percentage of error types was demonstrated during the

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maintenance phase with different placement foil errors occurring at a greater rate: target CV errors (  = 23%); similar placement foil errors ( = 23%); different placement foil errors ( =

38%).

Figure 43. Average percentage of speech perception error types for Participant E.R.

Self-initiated requests for cues. The following section illustrated E.R.’s use of repetition and lip-reading cues to assist with speech perception of single word stimuli. Figure 44 provides a graphic representation of the results.

Repetition. A stable baseline was demonstrated with no requests made for repetition cues. A positive increase in level was demonstrated between the baseline and treatment phases with a greater number of repetition cues requested as treatment was initiated. A variable pattern of requests was exhibited throughout the treatment phase with a peak number of requests during the last two treatment sessions. A drop in level was noted between the treatment and

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maintenance phases. An analysis of performance across phases revealed an increase in self- initiated requests for repetition to aid in speech perception during the treatment phase. This suggests that intervention resulted in a direct effect on repetition requests; but this level was not consistently maintained when intervention was terminated: baseline  = 0; treatment = 13; maintenance = 4. A large effect size was exhibited (Cohen’s d = 1) (Cohen, 1988).

Lip-reading. A stable baseline was observed with E.R. making no requests for lip reading cues. No change in level was demonstrated between any of the phases. A stable pattern was demonstrated throughout the treatment phase with a minimal number of requests for lip- reading cues made by E.R.. A comparison of means across phases suggests that lip-reading cues were not consistently requested by E.R.: baseline = 0; treatment = 1; maintenance = 0.

No treatment effect was exhibited (Cohen’s d = 0) (Cohen, 1988). A comparison of means supports that E.R. utilized repetition cues to a greater extent than lip-reading cues: treatment repetition = 13; treatment lip-reading = 1.

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Figure 44. Average number of requests for repetition and lip reading cues by Participant E.R..

Speech perception accuracy following cues. Response accuracy following repetition and lip reading cues will be discussed in this section.

Repetition. Throughout all phases of the experimental study, an overlap of correct/ incorrect data points was observed. A comparison of average number of correct/incorrect responses across phases suggests that use of repetition cues did improve speech perception accuracy: baseline  = 0/0; treatment = 7/6; maintenance = 3/2 (see Figure 45). A large effect size was exhibited (Cohen’s d = 1.0) (Cohen, 1988).

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Figure 45. Average number of correct/ incorrect responses to repetition cues by Participant E.R..

Lip-reading. Lip reading cues were not consistently utilized by E.R. and hence resulted in no change in mean, level, trend, or latency. A comparison of accuracy, following repetition cues, across phases further supports that with the use of these cues, E.R. demonstrated no difference in correct/incorrect responses: baseline  = 0/0; treatment = .3/.5; maintenance

= 0/0 (see Figure 46). No treatment effect was exhibited (Cohen’s d = 0) (Cohen, 1988).

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Figure 46. Average number of correct/incorrect responses to lip-reading cues by Participant E.R.. Verbal expression – Indirect treatment effects. Indirect effects on repetition of trained and untrained speech perception stimuli and on picture description task will be discussed.

Repetition of trained speech perception stimuli. An indirect effect on verbal repetition ability was not demonstrated. A change in the average percentage of correct, phonemic paraphasia, or incorrect/no response productions was not exhibited across phases (see Table 35).

All verbal productions consisted of perseverative neologistic paraphasic errors with no content.

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Table 35.

Results of verbal repetition of trained CV stimuli for Participant E.R..

Trained Stimulia Correct Phonemic Paraphasia Incorrect/No Response

Baselineb 0% 0% 100%

1 Week Probe 0% 0% 100%

2 Week Probe 0% 0% 100%

3 Week Probe 0% 0% 100%

1 Week Maintenance 0% 0% 100%

1 Month Maintenance 0% 0% 100%

Note: a Total Possible – 30; b One repetition baseline measure was taken.

Table 36). All verbal productions were perseverative neologistic paraphasic errors.

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Table 36.

Results of verbal repetition of untrained CV stimuli for Participant E.R..

Untrained Stimulia Correct Phonemic Paraphasia Incorrect/No Response

Baselineb 0% 0% 100%

1 Week Probe 0% 0% 100%

2 Week Probe 0% 0% 100%

3 Week Probe 0% 0% 100%

1 Week Maintenance 0% 0% 100%

1 Month Maintenance 0% 0% 100%

Note: a Total Possible – 15; b One repetition baseline measure was taken.

Picture description. No increase in the number of subclausal, single clause, or multiclausal utterances was demonstrated across phases of the study (see Table 37). A comparison across phases suggested a stable trend in the number of empty phrases was utilized: baseline empty phrases = 7; treatment empty phrases  = 9; maintenance empty phrases = 7.

Empty phrases lacked content and consisted of perseverative neologistic errors (e.g.

“Iohgrowthemmarrow”). Comprehension treatment did not have an indirect impact on verbal narrative productions.

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Table 37.

Narrative picture description analysis

Type and Number of Empty Subclausal Single Clause Multiclausal Utterance

Baselinea 7 0 0 0

1 Week Probe 5 0 0 0

2 Week Probe 7 0 0 0

3 Week Probe 15 0 0 0

8 0 0 0 1 Week Maintenance

5 0 0 0 1 Month Maintenance

Note: aOne narrative baseline measure was taken.

Generalization to functional communication environments. A review of pre- and post- treatment caregiver surveys revealed that the perceived communication performance of E.R. remained stable on 17 out of the 25 questions (see Table 38). A decline of function was noted on

8 questions. Six of these questions pertained to the Participant’s self-awareness of comprehension limitations, comprehension abilities, or use of compensatory strategies. The caregiver who completed the surveys was not present during any assessment or treatment session.

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Table 38.

Pre- and Post-Intervention – Caregiver Perceived Functional Communication Performance

Pre- Post- Functional Communication Survey Questions: Intervention Intervention

Getting somebody’s attention. 75% 75%

Getting involved in group conversations that are about him/her. 0% 0%

Giving yes/no answers appropriately. 50% 25%a

Communicating his/her emotions. 25% 25%

Comprehending simple yes/no questions. 50% 25%

Comprehending conversations about a familiar topic. 75% 50%

Comprehending conversations about new, unfamiliar topics. 15% 10%

Indicating to you that he/she does not understand what is being said to 75% 40% him/her.

Indicating to friends that he/she does not understand what is being said to 75% 40% him/her.

Indicating to strangers that he/she does not understand what is being said 0% 0% to him/her.

Requesting repetition of information when a breakdown in 15% 15% comprehension occurs with you.

Requesting repetition of information when a breakdown in 15% 15% comprehension occurs with family

Requesting repetition of information when a breakdown in 15% 0% comprehension occurs with strangers.

Recognizes when a change in the topic of conversation occurs. 10% 10%

Demonstrates of awareness of his/her comprehension difficulty. 10% `10%

Having visits and conversation with friends and neighbors. 10% 5%

Having a one-to-one conversation with you. 10% 10%

Communicating physical problems such as aches and pains. 10% 10%

Having a spontaneous conversation (i.e., starting the conversation or 10% 10% changing a subject).

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Starting a conversation with people who are not close family. 10% 10%

Responding to or communicating anything without words. 10% 10%

Being a part of a conversation when it is fast and a number of people are 10% 10% involved.

Describing or discussing something in depth. 10% 0%

How often do you use preventive measures to increase comprehension 5% 5% with him/her?

How often does he/she use preventive measures to increase 10% 10% comprehension with you?

Note. aBolded numbers denote a decline in function.

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Experiment II: SPA – Summary of results. A brief summary of the results from

Experiment II: SPA will be reviewed. This will be an integration of the findings from all SPA participants. The research questions specific to each section will be reviewed.

Speech perception – Response to intervention. This section will summarize the SPA performance on trained and untrained single word comprehension tasks.

Research Question 1. Will the average percentage accuracy on speech perception tasks improve? Consistent with the research hypothesis, both participants exhibited increased speech perception of CV stimuli. A summary of the findings with be further reviewed in the following sections.

Trained stimuli. Both participants in the SPA group demonstrated an increase in percentage accuracy on speech perceptions tasks utilizing trained stimuli. A large treatment effect was exhibited for both participants (Cohen’s d range: 1.08 to 1.11). A maintenance effect was demonstrated with one participant and a declining maintenance trend was demonstrated by the other.

Untrained stimuli. Both participants in the SPA group demonstrated an increase in percentage accuracy on speech perception tasks utilizing untrained stimuli. One participant demonstrated a large treatment effect and one exhibited a small treatment effect.

Error patterns. Target CV errors occurred more often than similar and different placement error types in both SPA participants. Upon the onset of intervention, both participants demonstrated a decline in the percentage of all error types across phases.

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Self-initiated requests for cues. The following results summarize the average number of requests of repetition and lip reading cues utilized by the SPA.

Research Question 2. Will the average number of self-initiated request for repetition cues increase? Consistent with the research hypothesis, both participants exhibited an increase in self- initiated requests for repetition. A summary of these findings will be reviewed in the following section.

Repetition. Both participants in the SPa exhibited an increase in the number of self- initiated requests for repetition when compared to baseline. A large treatment effect was exhibited by both participants.

Research Question 3. Will the average number of self-initiated request for lip-reading cues increase? Contrary to the hypothesis, the average number of self-initiated requests for lip reading cues did not increase with this intervention protocol. A summary of these findings will be reviewed in the following section.

Lip-reading. Requests for lip reading cues were only made by one of the two SPA participants. However, the average number of requests made by this participant was limited with no treatment effect demonstrated.

Speech perception accuracy following cues. SPA response accuracy following repetition and lip reading cues will be discussed in this section.

Research Question 4. Will the average number of correct responses on speech perception tasks increase following repetition cues? Consistent with the research hypothesis,

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both participants exhibited an increase in speech perception accuracy following repetition cues.

A summary of the results will be provided in the following section.

Repetition. Both SPA participants demonstrated a greater number of correct versus incorrect responses following repetition cues. A large effect size was exhibited by both participants. However, an overlap of correct and incorrect data points was noted for the other participant, suggesting that repetition cues did not improve speech perception accuracy.

Research Question 5. Will the average number of correct responses on speech perception tasks increase following lip-reading cues? Contrary to the research hypothesis, speech perception accuracy did not improve following use of lip-reading cues. A summary of the results will be provided in the following section.

Lip-reading. Requests for lip-reading cues were made only by one of the two SPA participants. Utilization of these cues did not impact speech perception accuracy. No treatment effect was exhibited.

Verbal expression - Indirect treatment effects. No change was exhibited on verbal expression tasks when compared to baseline levels of function (i.e., repetition of trained and untrained speech perception stimuli, and picture description) for either SPA participant.

Research Question 6. Will the average number of correct verbal repetition responses increase? Contrary to the research hypothesis, both participants did not exhibit an increase in verbal repetition accuracy following the intensive comprehension protocol.

Research Question 7. Will the number of correct narrative utterances increase during picture description tasks? Contrary to the research hypothesis, both participants did not exhibit

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an increase in the production of narrative utterances following the intensive comprehension protocol.

Generalization to functional communication environments.

Research Question 8. Will participants demonstrate generalization of comprehension skills and/or independent use of compensatory strategies as documented via the Communicative

Effectiveness Index (Lomas et al., 1989)? Contrary to the research hypothesis, inconsistent results could be found. A summary of the results can be found in the following section.

Pre- and post functional communication surveys were completed by the participants’ caregivers. Mixed results were noted. One caregiver reported an increase in auditory comprehension function or use of compensatory strategies on 17 of the 25 questions and a decline in 7 questions. The other caregiver reported no change on 17 of the 25 questions and a decline on 8 questions.

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Discussion

Due to advances in medical care, individuals who experience neurologic damage secondary to stroke have the potential to live with chronic, severe comprehension deficits associated with aphasia longer than ever before (United States Environmental Protection Agency

[EPA], 2009). Despite this, evidence supporting successful treatment programs for the remediation of severe, chronic comprehension deficits are limited (Knollman-Porter, et al., 2011;

Morris et al., 1996; Franklin, 1986). These factors, combined with the long standing adverse implications on rehabilitative outcomes and social relationships for this population, create a grim prognosis for recovery (Paolucci, 2005). For these reasons, this dissertation project included two separate but similar experiments that examined an intensive treatment, enhanced by visual and auditory feedback, for individuals with severe, chronic aphasia.

For the purposes of this discussion, the two experiments are discussed separately. First, a summary of the major outcomes and clinical implications of each experiment are reviewed.

Next, the limitations of the experiments and suggestions for future research are summarized.

This chapter will conclude with the author’s conclusions.

Experiment I: SWCA – Major Outcomes

This section will include a discussion of the major outcomes of Experiment I.

Specifically, it will review participants: (1) response to the intensive single word comprehension intervention; (2) utilization and effectiveness of repetition and lip-reading strategies; (3) indirect responses to the speech perception treatment on verbal expression skills; and (4) generalization to functional communication environments

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Response to intervention. Results from the current investigation indicate that individuals with severe chronic aphasia can improve single word comprehension abilities following an intensive treatment protocol. Five of the six participants demonstrated improved comprehension of trained single word stimuli, while the remaining participant displayed increased comprehension of novel, untrained stimuli. A maintenance effect was also exhibited, with comprehension accuracy maintained 1 month post-treatment. Furthermore, four of the five participants who increased comprehension accuracy of trained items demonstrated generalization to untrained single word stimuli. These findings substantiate our previous pilot research supporting the efficacy of intensive auditory comprehension treatment for individuals with severe chronic deficits (Knollman-Porter et al., 2012). The present investigation also supports existing research indicating that individuals with chronic aphasia can demonstrate improvement of language functions following intensive treatment (Basso & Macis, 2011; Code, Torney,

Gildea-Howardine, Willmes, 2010; Wendt et al., 2008).

In order to further explain and explore the trends of single word comprehension performance during this experiment, the patterns of comprehension errors were examined. In all participants, semantic foil errors occurred at a greater rate than target word and phonemic foil error types during the baseline phase. These baseline error patterns are in line with previous research, which suggests that individuals with acute aphasia tend to exhibit more semantic than phonemic related errors when performing word-to-picture verification tasks (Baker et al., 1980;

Breese & Hillis, 2004; Miceli et al., 1980; Rogalsky et al., 2008).

Following the onset of intervention, an overall decline in comprehension errors occurred in all but one of the participants. In addition, five of the six participants demonstrated a decline in the average percentage of semantic errors when compared to baseline measures. This decrease

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in error type continued throughout the maintenance phase. However, even with this decline, two of the six participants continued to exhibit a greater percentage of semantic foil errors when compared to other error types. A higher percentage of target word errors were noted in two participants and two additional participants presented with an equal percentage of both target and semantic errors. All participants demonstrated a large decline in phonemic foil errors with this error occurring less than any other error type across participants.

Comprehension error patterns from Experiment I support a distributed model of semantic processing. The distributed model of semantic processing purports that the semantic features of a distinct item are scattered across various nodes. That is, each characteristic of an item is represented separately so that every object activates a different pattern of features. These patterns of features can overlap from item to item, but are never identical. That is, words are only accessed when the correct semantic features nodes are highlighted and closely associated foils are suppressed (Masson, 1995). Operating under this framework, proponents of this theory suggest that semantic foils are correctly accepted as target words because the organized network has been degraded following cortical damage from stroke (Balota & Coane, 2008; Breese &

Hillis, 2004). In Experiment I, all participants displayed or approximated this pattern, by exhibiting an equal or greater number of semantic and target errors. No participant demonstrated the greatest difficulty rejecting phonemic foils at any point during the experiment, thus, providing indirect support for the distributed model of semantic processing.

The majority of participants (five out of six) exhibited a decline in semantic foil errors during treatment, suggesting that an intensive treatment can help decrease the high rate of semantic foil comprehension errors in individuals with severe, chronic aphasia. In contrast the one participant (B.D.) who did not demonstrate comprehension gains relayed feeling

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overwhelmed by treatment stimuli. While no fatigue was exhibited, this participant became frustrated early in the intervention protocol and questioned the accuracy of the examiners feedback. One possible reason for this frustration is that the protocol utilized repeated auditory bombardment of target word stimuli and semantic foils which could have lead to heightened semantic foil/target confusions. If individuals can not consistently apply corrective feedback and decipher between the target and the foil increased comprehension errors could occur using this approach. In contrast, this same participant did exhibit comprehension gains with untrained stimuli (Cohen’s d = 2.04). This suggests that B.D. may have indirectly benefited from the treatment by applying skills gained to untrained stimuli. The untrained stimuli were presented only once weekly which may have decreased the risk of semantic foil/target confusions.

This experiment demonstrated that an intensive repetitive treatment can improve single word comprehension in some individuals with severe, chronic aphasia. However, it is hypothesized that the intensive repetitive nature of this approach may also negatively impact comprehension performance in some individuals that are unable to distinguish the difference between target and semantic foils. For this reason, further research is warranted to determine the specific characteristics that make some individuals benefit from this approach and why others do not.

Overall, the results from this Experiment contradict theories derived from foundational schools of thought, which suggest that individuals with severe aphasia cannot benefit from repeated auditory stimulation (Schuell, 1964). The Schuell’s Stimulation Approach is a treatment protocol that has been successfully utilized by clinicians for decades (Robey, 1998).

The basic philosophy of this rehabilitative approach is that treatment should employ strong,

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controlled, and intensive auditory stimulation to maximize the individual’s ability reorganize and regain language function (Schuell, 1964). In contrast to the traditional Schuellian theory, the findings from Experiment I: SWCA suggest that at least some individuals with severe deficits benefit from intense repeated auditory stimulation to improve comprehension

Effectiveness of self-initiated requests for cues. In the subsequent sections, the use and relative benefit of repetition and lip-reading cues on single word comprehension is discussed.

Further, the role of self-awareness of comprehension errors is examined.

Repetition. All participants demonstrated an increase in the number of requests for repetition cues; this effect was maintained post termination of treatment. In addition, all participants exhibited a greater occurrence of correct/incorrect responses on single word comprehension tasks following repetition cues. For five out of the six participants, no overlap in correct/incorrect data points was observed suggesting that with the use of repetition cues, comprehension accuracy improved. These findings further support the long-held Schuellian theory, that repetition cues are beneficial in the management of aphasia (Schuell, 1964).

However, the current experiment extends this theory to include individuals with severe, chronic comprehension deficits associated with aphasia. Although the analyses revealed a general trend for increased self-initiated requests for repetition, individualized trends were also identified.

It should be noted that the greatest increase in self-initiated requests for repetition did not occur until the onset of treatment, when participants were first given feedback from the investigator regarding the accuracy of their comprehension responses. Following this corrective feedback, all participants indicated that they were surprised, suggesting a lack of emergent awareness regarding comprehension errors. As treatment progressed, three of the six participants

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consistently accepted the investigator’s feedback as being accurate once provided. These three participants also demonstrated the largest gains in single word comprehension (Cohen’s d range:

3.72 to 4.11), as compared to the remaining participants. Two participants intermittently questioned the corrective feedback, but would accept the feedback once clarification was provided by the investigator. These participants did demonstrate improved comprehension but to a lesser degree than the previously discussed participants (Cohen’s d range: 1.66 to 2.79). The remaining participant repeatedly questioned the corrective feedback and looked to her caregiver for verification. This behavior was exhibited by this participant during every session throughout the treatment phase. It should also be noted that this participant was the only individual who did not demonstrate gains in single word comprehension accuracy (Cohen’s d = .181).

Over the course of treatment, all participants demonstrated heightened anticipatory awareness, to varying degrees, by exhibiting cognizance of repeatedly missed stimuli items through nonverbal language (e.g., sighing, shaking one’s head, etc.). Four of the six participants, demonstrated the ability to recognize stimuli previously comprehended in error. When this occurred, participants requested that the investigator repeat the stimuli multiple times before providing a response. In addition, these same participants also demonstrated increased focus/concentration when the investigator presented the stimuli verbally (e.g., closed eyes, looked away from the examiner’s face). These behaviors were not observed on stimuli that were consistently comprehended with accuracy. In many cases, successful use of these strategies improved comprehension of stimuli. However, even when all of these strategies were successfully employed by the participants, comprehension errors still occurred on specific stimuli. It should be noted that these comprehension errors were not random across the set of treatment stimuli. Each participant displayed a unique pattern of difficulty with specific stimuli

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during the treatment phase. These four participants consistently recognized these “trouble words” but could not consistently distinguish the target word from the semantic foil error, even with the use of repetition.

Of these four participants, T.O. demonstrated the strongest ability to employ repetition cues and apply the clinician’s feedback in the shortest amount of time (i.e., 5 days), subsequently achieving the greatest single word comprehension performance accuracy. In addition, this level of accuracy was maintained one month post-treatment. It should also be noted, that this T.O. scored the highest on all assessment tasks.

Although the majority of participants learned to recognize and anticipate difficult items as treatment progressed, two participants did not consistently alter their comprehension strategy.

These two participants did not readily recognize their comprehension errors, suggesting decreased emergent awareness (i.e., the ability to recognize a breakdown in performance when it occurs), even when provided feedback; it was as if they were unable to effectively compare their perception of what was heard to the correct target. In addition, both participants appeared to take a more passive role during the intervention. That is, they demonstrated less effort (e.g., responded quickly) and relied on the investigator to guide them through the process.

Self-awareness can significantly impact rehabilitative performance, as well as the individual’s potential to return to functional activities for individuals following traumatic brain injury (Prigatano et. al., 1991; Prigatano, 2005). Along these lines, individuals with severe comprehension deficits associated with aphasia, may also exhibit impaired self-awareness. This impairment impedes their ability to independently recognize errors; and subsequently their ability to utilize strategies to compensate for this limitation. As previously stated, the four

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participants who exhibited the greatest gains in improved comprehension also exhibited the greatest degree of anticipatory awareness (i.e., ability to recognize and anticipate when breakdowns and problems are likely to occur) once corrective feedback was provided. However, none of these participants realized the extent of their comprehension deficits until corrective feedback was provided. This indicates that all participants exhibited deficits in emergent awareness. Hence, the corrective feedback that was provided by the examiner was foundational to participants’ use of compensatory strategies. Further research is warranted to determine the rate and type of corrective feedback provided to individuals with comprehension impairments by rehabilitation specialists and caregivers. The trends identified in Experiment I could lead to a greater understanding of how to determine the most effective, and efficient, feedback techniques for individuals with severe, comprehension impairments.

Lip-reading. The trends observed for the provision of lip-reading cues were markedly different than the patterns observed for repetition requests. Lip-reading cues were requested to a lesser degree by all participants when compared to repetition cues. Two of the six participants did not use the lip-reading cues, even when offered by the investigator. For three of the four participants who did use these cues, the average number of requests during a two hour session was three. The analysis of this trend, revealed a large effect size for both the average number of requests and improved comprehension accuracy. However, these positive results should be interpreted with caution secondary to small degree in which lip-reading cues were utilized.

One hypothesis for the under utilization of this strategy was that all of the participants exhibited greater semantic foil confusions than phonemic foil errors. Even if participants were able to see the mouth of the examiner, the visual information obtained would not provide the

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supplemental sensory feedback needed to decipher between the target and the semantic foil. The added visual information may contribute to greater confusion in individuals with severe comprehension impairments. Participant T.G. would intentionally look away from the examiner when visual feedback was provided to not be distracted by the lip-reading cues. This implied that the lip-reading cues did more to hinder than aid in comprehension with this individual. While multisensory integration of auditory and visual can supplement comprehension in a noisy environment in healthy individuals, it could potentially hinder comprehension in individuals with frequent semantic confusions. For example, multisensory stimulation can impede comprehension when the auditory and visual information are out of phase (Grant & Seitz, 2000;

Kim & Davis, 2004).

Only one participant (B.D.), gradually increased the frequency in which lip-reading cues were requested over the course of treatment. In fact, he/she preferred the lip-reading cues over repetition cues. In addition, a heightened number of correct versus incorrect responses were demonstrated, indicating that this participant benefitted from this cue during treatment. This was not consistently exhibited during the maintenance phase suggesting a lack of carryover. Further examination of this trend will be discussed.

Previous research has primarily investigated the use and benefit of lip-reading cues for neurologically normal listeners in noise-comprised environments (Eramudugolla et al., 2011;

Ross, Saint-Amour, Leavitt, Javitt, & Foxe, 2007; Sumby & Pollack, 1954). A small subset of research promotes the use of visual support for individuals with word-sound deafness and speech perception deficits. Aphasiologists have speculated that lip-reading cues may be particularly beneficial for individuals with impaired acoustic-phonetic processing (Morris, Franklin, Ellis,

Turner, & Bailey, 1996). It should be noted that five of the six participants enrolled in

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Experiment I performed at greater than 85% accuracy on phonemic discrimination assessment task completed prior to the start of the experiment. This suggests relatively intact acoustic- phonetic processing, which may explain why the individuals in this group, overall, did not directly benefit from lip-reading cues. However, the one participant (B.D.) that exhibited no improvements in comprehension accuracy, scored at 60% accuracy on the phoneme discrimination assessment. B.D. also utilized lip-reading cues to the greatest degree at the end of the treatment protocol. This suggests a degree of impairment in the acoustic-phonetic processing of auditory information and that lip-reading cues, may be beneficial if utilized to a greater degree. However, further assessment of this theory is warranted due to the small sample obtained.

These findings support that there is a high degree of variability in comprehension performance and use of strategies even in individuals diagnosed with severe comprehension deficits based on standardized assessment batteries. Findings from the present investigation have several theoretical implications. Breese and Hillis (2004) determined that the more commonly used multiple choice methods were not as sensitive in measuring single word comprehension when compared to word-to-picture verification tasks (Dunn & Dunn, 2007; Kertesz, 2007), supporting a distributed model of processing. Because target words and semantic foils are often both accepted as correct in concordance with the distributed model of processing, individuals are likely to select the target word or the semantic foils when a field is presented. When a field of four choices is presented consisting of one correct target and one semantic foil, the probability of selecting a correct response is 50%. In contrast, during a word-to-picture verification task a plethora of foils must be ruled out to select the correct target. Three participants enrolled in

Experiment I demonstrated analogous patterns, displaying a high discrepancy between

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performance on the PPVT (a multiple-choice receptive vocabulary assessment) and accuracy of single word comprehension on presented word/picture verification tasks (Dunn & Dunn, 2007).

Therefore, word-to-picture verification tasks should be employed to assess single word comprehension ability. If abilities are inflated (e.g., exhibited comprehension impairment at the single word level when true level of breakdown is at the speech perception level) treatment may target goals that vastly exceed participant ability levels. Consequently, frustration and subsequent treatment drop-out rates could increase.

Verbal expression: Indirect treatment effects. Experiment I also examined whether an intensive comprehension treatment protocol would indirectly influence the participants’ verbal naming and discourse abilities.

Results from Experiment I revealed that five of the six participants, exhibited an increase in the verbal naming of trained stimuli during the maintenance phase, when compared to baseline measures. However, naming accuracy for one participant remained stable. In addition, the participants demonstrated increased naming attempts through a increased production of related words when compared to baseline levels for three of the six participants. The same degree of improvement was not exhibited on untrained comprehension stimuli. For two of the six participants, exhibited an accuracy increase on untrained stimuli naming tasks, suggesting a generalization effect. However, four participants demonstrated a decline on these tasks, suggesting a negative indirect treatment effect. One potential reason for this decline in performance was that verbal naming of untrained stimuli was always the last probe data collected. Because of this, less effort could have been exhibited by participants.

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Four of the six participants, also demonstrated an increase in empty utterances during picture description tasks suggesting more verbal attempts were made as treatment progressed.

However, the intensive comprehension treatment did not improve content word production in narrative tasks, suggesting a lack of generalization to functional verbal expression discourse tasks. Improvements in comprehension have been demonstrated in individuals following an intensive treatment to improve verbal naming (Pulvermueller, et al., 2001). Also, severe auditory comprehension deficits have improved following treatment for alexia (Barber, B. & Mayer, J.,

2012). In addition, this preliminary research suggests that indirect improvements to verbal naming can be made.

Generalization to functional communication environments. Functional communication surveys were completed by five out of the six participant caregivers (pre- and post-treatment). Of these caregivers, four reported that the participants’ performance on verbal expression and auditory comprehension tasks decreased on nearly half of the questions (i.e.,

40%). This data suggests that the intervention protocol had a negative effect on the majority of participants. Only one caregiver reported an increase in performance on 88% questions.

Discussion regarding this seeming decline in communication functioning is warranted.

Over the course of the study, four of six (66%) participants were never observed by their caregivers/family members during the assessment or treatment sessions. The investigator observed that family members, as well as the participants themselves, demonstrated an inaccurate perception of their loved one’s auditory comprehension impairments. In fact, at the time of recruitment for the study, five of the six caregivers reported to the investigator that participants had difficulty only with expression and not comprehension. Some family members

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displayed superficial awareness of comprehension deficits, but few understood the magnitude and severity of their spouse’s or parent’s comprehension impairment.

In order to understand the ‘story’ behind these results, a more detailed review of the perceptions of three caregivers (i.e., D.W., B.D., & R.K.) will be discussed. These three caregivers were selected because, initially, they expressed that the loved ones’ comprehension was not impaired.

One spouse had a history of being very active in the daily care and rehabilitative management of participant (D.W.). At the time of the initial meeting, she eagerly relayed her perceptions of the participant’s strengths and weaknesses. She frequently spoke for the participant when questions were directed to him. Prior to the start of the assessment, she relayed to the investigator that she wanted to observe but needed to sit where the participant could not see her. When asked why, she relayed that if she sat where she could see D.W., she would try to help him by providing the answers. During the assessment, she closely observed her spouse and showed signs of heightened emotion when comprehension was being assessed. Following the completion of the assessment she commented, “I didn’t realize he had that much trouble.” This spouse, was the one caregiver that completed the survey after observing the assessment. In addition, this was the one caregiver that reported an increase in functional communication on 22 of the 25 questions. Throughout the experiment, she sat outside the treatment room so that she could listen to the session but not actively participate.

A separate caregiver requested to be present during all assessment and experimental sessions. In advance, he agreed to not engage with the participant (B.D.) during treatments or carryover activities at home. He completed the functional communication survey within the first five minutes of the evaluation. At the conclusion of the testing protocol, the caregiver

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questioned the validity of the assessments and appeared to deny the extent of B.D.’s comprehension impairment (i.e., “She went too fast.”; “We were just on an airplane. I think it messed up her hearing.”). As the treatment protocol continued, the caregiver displayed heightened awareness of the extent of the participant’s comprehension deficits. At the conclusion of the experiment, he reported a decline in communication performance on 12 of the

25 questions suggesting a heightened awareness of the participant’s comprehension skills. At the end of the experiment, he requested feedback on how to better manage the participant’s comprehension deficits.

The final caregiver discussed here was not present during any of the assessment or experimental sessions. At the onset, he relayed to the investigator that he was more concerned about the participant’s expression than comprehension and would frequently take the lead on conversations or speak for the participant (R.K.). Ratings of functional communication did decline post measure, but did not consistently reflect finding from standardized assessment. It appeared that the caregivers who did not directly observe the assessment or treatment exhibited a decreased awareness of the extent of the loved ones’ deficits. The implications of these findings will be reviewed below.

Even though caregivers interact with their loved one on a daily basis, these findings suggest that caregivers may not be fully aware of the extent of their comprehension impairment.

As such, they may inadvertently rate functional communication performance higher than demonstrated on standard assessment batteries.. There are many potential reasons for this discrepancy between caregiver ratings and standardized scores. One explanation may be due to the nature of caregiver interactions with individuals who have severe comprehension deficits.

These interactions can be challenging for the individual with comprehension impairments. After

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repeated failed attempts at comprehending the meaning of spoken messages, individuals with aphasia can intentionally become passive listeners. This can be demonstrated in many ways: (1) lack of self-initiated requests for clarification when information is unclear; (2) the intentional transmission of false understanding to hide their comprehension impairment; (3) lack of eye contact to avoid further interactions; or (4) passively allowing caregivers to take the lead in interactions. These behaviors may lead, caregivers to assume that their loved one comprehends the intended information, even though they do not. This decreased caregiver awareness may, in turn, facilitate the continued use of these passive behaviors by individuals with chronic comprehension deficits for years following the stroke.

Aphasia is a family concern and requires family involvement (Worrall et al., 2010;

Marshall, 2002). In addition, when caregivers are actively involved in treatment, rehabilitative outcomes are better (Visser-Meily et al., 2006). Effective management of comprehension deficits cannot be fully achieved unless caregivers are aware of the extent of impairment.

Without this knowledge, use of compensatory strategies may not be used effectively with individuals with comprehension impairment, which may result in ineffective communication interactions.

Experiment II: SPA - Major Outcomes

This section will include a discussion of the major outcomes of Experiment II.

Specifically, it will review participants: (1) response to the intensive speech perception intervention; (2) utilization and effectiveness of repetition and lip-reading strategies; (3) indirect responses to the speech perception treatment on verbal expression skills; and (4) generalization to functional communication environments

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Response to intervention. The two participants in the SPA had not received speech- language intervention for over five years and exhibited global aphasia.. These participants were dependent on their caregivers for most activities of daily living and could not express basic wants and needs verbally. The analysis revealed that both participants demonstrated an increase in percentage accuracy on speech perception tasks utilizing trained stimuli and generalization to untrained stimuli. For both participants, a slow treatment effect was noted with the greatest gains noted either during the final week of treatment (T.L.) or in the maintenance phase (E.R.); suggesting that this population may require more time in treatment before linguistic gains are demonstrated. A mixed maintenance effect was also observed for these two participants, with one exhibiting a positive trend and the other exhibiting a declining trend over time.

In order to determine performance trends during this experiment, the patterns of perception errors were examined. Both participants exhibited a greater percentage of target CV errors (ta/ta) when compared to similar (ta/da) and different (ta/la) placement error types. After the onset of intervention, both participants demonstrated an overall decline in the percentage of all error types. One participant maintained a greater percentage of target errors while the other exhibited an equal distribution of error types. Based on these findings, intervention, did result in improved speech perception for both participants. However, error patterns were variable.

Treatment protocols for the management of speech perception deficits are limited. One case study did result in positive outcomes for an individual with speech perception deficits when lip-reading cues were utilized (Morris, et al., 1996). However, this individual was in the acute stages of recovery. So questions can be raised regarding how the impact of spontaneous recovery influenced these results. In addition, my preliminary research found that an individual with

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profound, chronic global aphasia did not demonstrate gains following an intensive treatment approach, which focused on the comprehension of high frequency single words (Knollman-

Porter, et al., 2012). However, rather than the inability of an individual with profound, global aphasia to respond to treatment, the lack of progress may have been due to the use of stimuli that were too complex. That is, the level of breakdown was at the pre-comprehension, speech perception level. The responses on comprehension tasks were consistently random with no change in progress throughout all phases of the experiment. At the current time, there is support that treatment materials should be at a challenging complexity level (Thompson & Shapiro,

2007). That is, by using more complex materials, there is a greater chance of language improvement and generalization to more simple language structures. The results of the current study, along with those from a pilot study (Knollman-Porter et al., 2012) contradict this recommendation. Specifically these more recent findings suggest that, when the complexity level of the treatment stimuli are provided at an appropriate level, there is a greater chance that improvement can be made, even in individuals with profound, chronic, global aphasia.

Effectiveness of self-initiated requests for cues. In subsequent sections, the use and relative benefit of repetition and lip-reading cues on perception are discussed. Further examinations of the role of self-awareness of comprehension errors are also examined.

At the onset of baseline testing, both participants required instruction on how to request repetition and lip reading cues when needed. Both participants were unable to consistently make these requests verbally or via written or picture choice. It was determined, after repeated trials that the best method for requesting repetition and lip-reading cues was through tapping on the table. Both individuals required verbal cues at the start of each treatment session to utilize this

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method as needed. If these cues were not provided, the participant would not request repetition independently throughout treatment.

An increase in the number of self-initiated requests for repetition cues was demonstrated by both participants. This positive change was exhibited during the treatment phase when compared to baseline level. However, even with this increase, the average number of requests made during the treatment sessions were still minimal for T.L. and E.R. Interestingly, there was a declining trend in the average number of requests post - treatment for each participant; which is indicative of poor maintenance of this skill. But more importantly, analysis of the accuracy of response following repetition cues revealed that only one of the two participants (T.L.) benefited from these cues. The other participant (E.R.), did not demonstrate improved speech perception accuracy following the repetition cues. Therefore, use of repetition cues resulted in mixed accuracy results.

The utilization of lip-reading cues was also examined. At the start of every session, the investigator encouraged the participants to request lip-reading cues to aid in perception.

However, only one of the two participants utilized this cue and it was done so on a limited basis with less than five requests made per session. When this strategy was utilized by this participant

(E.R.) it did not improve speech perception accuracy. This contradicts past findings that individuals with speech perception deficits, can benefit from lip-reading cues (Morris et al.,

1996).

These findings suggest that repetition and lip-reading cues may not benefit all individuals with speech perception deficits. However, these results should be interpreted with caution for many reasons. First, the effectiveness of repetition and lip-reading cues could not be fully

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examined based on the established experimental protocol. Participants were not provided repetition or lip-reading cues unless requested. This method was utilized to determine, if with the corrective feedback provided by the investigator, the participant would exhibit greater emergent awareness of their speech perception deficits and in turn, make more requests for assistance. These two participants did not consistently recognize their perception errors, even when provided feedback. This indicates that they had difficulty comparing their perception of what was heard against the correct target. Anticipatory awareness (i.e., the ability to recognize and anticipate when breakdowns or problems are likely to occur) was not exhibited on stimuli that were consistently perceived in error and the number of self-initiated requests for cues increased from baseline but was limited. As well, both appeared to take a more passive role in treatment with less effort demonstrated. Taken together, it is logical to question the participants’ extent of self-awareness of their communication limitations and their desire to use strategies to improve. Both spoke to the examiner using severe jargon-like aphasia and could not recognize, even with strong verbal and non-verbal cues that their intended message was not being relayed.

While the participants may possess a superficial knowledge that their speech perception ability is impaired, neither were able to consistently recognize a breakdown when it occurred.

Self-reflection is crucial to the rehabilitation process, especially when unfamiliar or complex cognitive or physical task are performed. These tasks require an individual to self- monitor their performance while comparing their actual with the expected performance goals

(Kennedy & Coelho, 2005). If an individual’s performance is lacking, a person with functional self- monitoring skills will make adaptations in their behaviors in order to achieve a more positive outcome. If this awareness is impaired secondary to neurologic damage, rehabilitation outcomes can be negatively impacted (Lam, McMahon, Priddy, & Gehred-Schultz, 1988; Sherer

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et al., 1998; Sherer et al., 2003). Per the caregiver reports, these participants did not make significant gains in rehabilitation treatments immediately post stroke. Unfortunately, a standardized method to measure the influence of comprehension versus self-awareness on rehabilitative has not been established for individuals with aphasia. Therefore, clinicians may be required to use their best clinical judgment regarding the influence of awareness on treatment performance and outcomes. Until more standardized measures of self-awareness can be established, close monitoring of individuals responses to linguistic and non-linguistic tasks by multiple rehabilitation professionals in many environments may be warranted. This would allow the professional and caregiver to informally assess patterns of self-monitoring behavior exhibited. A team approach to the management of deficits in self-awareness may lead to better management and better rehabilitative outcomes in individuals with severe speech perception deficits.

Verbal expression - Indirect treatment effects. No change was exhibited on verbal expression tasks when compared to baseline levels of function (i.e. repetition of trained and untrained speech perception stimuli, picture description) for both participants. Cues were provided to both participants to look at the examiners mouth when the CV combinations were spoken. Both complied with this request, but even with increased effort demonstrated, the participants could not replicate any portion of the CV pattern expressed. Responses on these tasks consisted of perseverative semantic or neologistic error patterns. One possible cause for this pattern is secondary to the nature of the speech perception processing deficits they exhibit.

If participants are unable to perceive the differences between CV combinations, it can be assumed that it would be difficult to verbally produce the sounds that they cannot distinguish.

Further research is warranted to further examine this hypothesis.

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Generalization to functional communication environments. Functional communication surveys were completed by both participant caregivers (pre- and post-treatment), which yielded mixed results. One caregiver reported an increase in communication function on

17 of the 25 questions, a decline in 7 questions and remained stable on 1 question. In contrast, the other caregiver reported no change on 17 of the 25 questions and a decline on 8 questions. It should be noted that neither caregiver attended the assessment or treatment sessions; however, their perceived assessment of participants’ comprehension ability was relatively accurate. SPA participants comprehension deficits were more obvious mainly because these individuals made no attempt to hide their limitations. Both were very vocal even though interactions contained no content.

One factor that may have impacted generalization of strategy use to functional communication environments was that both participants exhibited decreased self-awareness of deficits and did not fully recognize when a misunderstanding had occurred. This failure to realize these breakdowns could be further facilitated if no corrective feedback was provided by the speaker relaying the message. Individual with global aphasia may have a false sense of understanding information relayed in conversation if they are unaware of the miscommunication. In addition, if corrective feedback is not provided consistently by the speaker, the person with severe aphasia may question the validity of feedback provided by some individuals and not others. For the purposes of this study, caregivers were not educated on use of strategies, nor were they encouraged to utilize these strategies at home. Therefore, without the guidance of the caregiver, the chances of the participants realizing when breakdown occurred would be limited. People are living with aphasia longer than ever before, as a result, these behaviors may be facilitated over time. At the current time, there is no standardized method to

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assess which of these behaviors are being utilized by the individual with severe comprehension deficits. Secondary to the high co-occurring rate of severe expressive deficits, the person with aphasia may not be able to verbally relay what they are feeling.

Limitations and Direction for Future Research

Experiment I: SWCA and Experiment II: SPA provided a foundation for the rehabilitative management of single word comprehension and speech perception deficits in individuals with severe, chronic aphasia. The following section highlights seven limitations and considerations for future research in this area.

Intensity of the treatment protocol. The majority of participants from both experiments were able to tolerate the intensity of the intervention without exhibiting fatigue. Still, two individuals demonstrated intermittent fatigue during the 2 hour sessions. In an attempt to remediate this confound, extra breaks were incorporated within the session. However, even with this added accommodation, continued intermittent fatigue was observed. It should be noted, that even when fatigued, both of these participants expressed the desire to continue with the intervention protocol. Even though these participants continued to be motivated to continue, the reliability of performance was variable, with peak high and low levels of comprehension accuracy. These peaks were directly correlated with degree of fatigue as noted on the frustration and fatigue monitor form utilized during all experimental sessions (see Appendix BB). These findings conflicts with previous preliminary data (Knollman-Porter, 2012); however it should be expected that all individuals will not tolerate the same intensity of treatment due to age, medical conditions, or personal preference. Even though this intensive protocol resulted in positive gains for 7/8 individuals in both experiments, variability should be anticipated. Therefore, treatment

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intensity should be based on clinical judgment and the client’s specific needs. This may be challenging in the current health care environment where 3rd party payers may dictate the intensity of treatment for continued reimbursement of services. For that reason, continued research is warranted in the area of patient specific dosage requirements that will lead to the greatest rehabilitative gains. A one size fits all approach may not be appropriate in the rehabilitation for severe, chronic aphasia.

The intensity of the treatment protocol also limited the utilization of the originally intended research design. During the original development of this experiment, it was proposed that a multiple-baseline across participants design be implemented to analyze performance across phases and participants. This design would have allowed the investigator to gather baseline data on two participants at the same time and then analyze participant performance as the treatment condition was implemented. Additionally, this is considered a stronger single subject design than the standard ABA design (Kazdin, 2011). Implementation of a multiple baseline design was not possible due to scheduling challenges (i.e., scheduling two participants, concurrently for 10 hours/week).

Neurologic correlates. Successful speech perception and auditory comprehension require the integration of numerous brain locations and interconnections (Boatman, 2004). The original intent at the onset of this dissertation project was to obtain MRI/CT scan films from all participants to specifically define the lesion size and location. The images obtained would have supplemented information obtained during the experiment to determine specific patterns of behavior (i.e., speech perception, comprehension, self-awareness) that may have contributed to reported outcomes. Unfortunately, MRI/CT films are often destroyed after five years; therefore

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radiology reports were obtained. The information in these reports was often general and did not provide specific detail regarding lesion location or size. Advances in neuroimaging research can contribute to the knowledge base from both a scientific and clinical perspective (Kleim & Jones,

2008). This information, combined with clinical findings can be utilized to determine how specific treatment protocols may be utilized most effectively and most efficiently for individuals with highly variable speech perception and single word comprehension impairments.

Utilization of lip-reading cues. Visual support (i.e.,lip-reading cues) was provided upon the third request for repetition in both experiments. Since repetition cues were offered first, there was a greater chance that participants would utilize these cues at a greater rate than lip-reading cues. It is reasonable to consider then, that the curing procedure adversely impacted utilization outcomes. Between the two experiments, only one participant (B.D.) recognized the cueing pattern and specifically requested (via nonverbal gestures) that the investigator employ lip- reading cues only. However, in order to remain in accordance to the established protocol, the investigator withheld visual support until three repetitions were provided. Repeated use of an ineffective, non-personalized cueing method during treatment could have lead to increased frustration and impulsive responses for this individual.. For this reason, cue type and administration procedure should be more closely evaluated to avoid negative responses to intervention.

Moreover, the SPA participants may have benefitted more from lip-reading cues (Morris et al., 1996), but were unable to comprehend the established pattern of cue delivery. In turn, they were unable to consistently request the lip-reading cues. One participant in the SWCA was able to recognize the pattern for cue delivery; however individuals with more pronounced speech

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perception deficits may not be able to perceive and carryover this protocol. Therefore, because the protocol dictated that participants make three requests for repetition before lip-reading cues could be provided, fewer requests for lip-reading cues were made, even though this type of cue may have improved speech perception/comprehension to a greater degree. Future iterations of these protocols should examine whether participants with severe speech perception or single word comprehension deficits are able to identify the most beneficial compensatory strategy.

Along these lines, continued examination of the impact of lip-reading strategies with these populations is warranted secondary to limited utilization in these experiments.

Indirect impact on verbal expression. Results from Experiment I revealed that five of the six participants, exhibited an increased average percentage naming accuracy on trained

(auditory comprehension) stimuli. However, no change in repetition or verbal narrative abilities was observed in Experiment II. A weakness to both Experiment I: SWCA and Experiment II

SPA is that only one baseline measure of verbal expression and narrative skills were obtained prior to the start of intervention. To properly assess the impact of an intervention protocol, it is essential to establish a stable baseline over at least three sessions prior to the initiation of treatment (Kazdin, 2011; Beeson & Robey, 2006). These baseline measures describe the participants current level of performance and is used as a method of prediction. Therefore, only a stable baseline is necessary in order for the researcher to conclude that change is related to treatment (Kazdin, 2011). These preliminary findings on the indirect effects of an intense comprehension intervention on the naming and narrative skills following are exciting because it supports that an intensive comprehension treatment may improve verbal expression abilities.

But continued examination is warranted to determine if the effect was truly secondary to the intervention and not due to increased comfort with the examiner.

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Functional relevance of treatment stimuli. For the purpose of this dissertation project, all stimuli were selected by the examiner in order to be consistent and decrease variability. This is a methodological strength; however it also may have limited generalization of treatment to functional activities. Use of personally relevant stimuli in treatment can lead to greater outcomes in word retrieval issues associated with chronic aphasia (Mason et al., 2011; McKelvey, Hux,

Dietz, & Beukelman, 2010). The use of personally relevant treatment stimuli within the single word protocol may influence auditory comprehension outcomes to a greater degree than what was expressed in this work. The ultimate goal of any language treatment for aphasia is to increase functional communication in the day-to-day environment. Future iterations of this project should include personally relevant stimuli. Incorporation of personally relevant stimuli may allow speech-language pathologists to promote effective and more efficient functional communication for individuals with severe, chronic comprehension impairments. Additionally, the use of meaningful stimuli may increase motivation for participants enrolled in the interventions that are repetitive by nature.

Functional communication. An additional limitation to the present investigation was limited participation of caregivers within the experimental treatment protocol. The majority of caregivers perceived functional communication performance to either decline or remained stable following intervention.

Caregiver involvement (or lack thereof) has been known to influence treatment outcomes in the management of aphasia (Tsouna-Hadjis, Vemmos, Zakopoulou, & Stamatelopoulous,

2000; Wahrborg & Borenstein, 1990; Kagan, 1998). In this dissertation project, the caregivers were not involved in the intervention, nor were they encouraged to utilize the compensatory strategies at home. During the course of both experiments, the investigator noted that all eight

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participants exhibited reduced awareness regarding their comprehension or speech perception deficits. As a result, most participants did not request cues to help facilitate comprehension until after the investigator provided corrective feedback. If the reduced awareness observed in this project is commonplace amongst individuals with severe comprehension deficits, this population may be dependent on caregivers to successfully employ these strategies during functional communication interactions. The lack of caregiver involvement in this project may have been one factor that contributed to the lack of gains observed on the functional communication survey.

Speech-language pathologists believe that caregiver’s knowledge of the impairment and participation in treatment, is critical to the effective training and utilization of communication strategies in individuals with aphasia. However, caregiver involvement in the management of aphasia is often limited due to time restraints or perceived limited skill and knowledge regarding the individual’s communication limitations by the caregiver (Johansson, Carlsson, & Sonnander,

2011). In the current project, the majority of the caregivers did not observe the experimental sessions secondary to work or social demands. Since many of the participants were dependent on their caregivers for support in all activities of daily living, the time restraints on the caregivers were demanding. Laypersons can be trained to effectively administer intensive, standardized language treatment to individuals with chronic aphasia (Meinzer, Streiftau, Rockstroh, 2007); however they may not have the time or resources available to successfully implement the strategies necessary for successful carryover. For example, one of the SPA caregivers reported that the participant’s limited comprehension ability made caring for him more challenging. She also reported repeatedly attempting to use strategies to increase his understanding but over time, he became resistive to their use. Hence, it became easier for her to compensate for his limitations than push him to utilize a strategy against his will. Perhaps if caregivers do have the time and

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the resources to be actively involved in the protocol, there would be a greater chance of carryover to functional environments.

The current experiments revealed that that the majority of caregivers did not fully perceive, prior to the onset of intervention, the full extent of participants comprehension impairments. This lack of awareness may further confound functional communication gains. The misperception of comprehension impairments by the caregiver may lead to lack of corrective feedback and as a result, an underutilization of strategies for successful understanding. The caregivers in these experiments, were not provided with assessment findings unless they specifically requested the information from the investigator. Only two caregivers observed the assessment process. It should be noted that these caregivers also exhibited the greatest increase in awareness of the participant’s comprehension skills. Treatment protocols involving caregivers to a greater extent in the assessment and treatment progress should be examined to determine their influence on generalization of strategies to functional communication environments.

Consideration of caregiver time restraints and expectations should also be included within this protocol for greater long-term success.

Were the outcomes worth the effort? Critical in the evaluation of a treatment protocol is to consider if the benefits exceeded the sacrifices required of the intervention (i.e., time, effort).

This assessment should incorporate the opinions of participants, caregivers, and investigators equally. These treatments were both time and labor intensive with significant time sacrifices made by all that were involved in the experiments. The caregivers were able to provide a perspective on functional communication outcomes via the Communicative Effectiveness Index

(Lomas et al., 1989); however, they were not directly asked if the cost (i.e., time etc.) was worth

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the benefit of participating in the study. Additionally, participants were not given the opportunity to provide their perceived benefit/lack of benefit from the experiment. Even though seven participants in these experiments exhibited large effect sizes, suggesting large gains in single word comprehension or speech perception abilities, limited improvements in functional communication were documented. The foundation of evidence based practice involves the integration of (1) best available external evidence from research; (2) best available evidence from clinical practice; and (3) best available evidence concerning the preferences of a fully informed client (Dollaghan, 2007). These experiments did provide external evidence regarding the efficacy of an intensive speech perception /comprehension with the realities of clinical practice considered. Conversely, the participants’ perceptions were not measured. Continued analysis of patient/caregiver perception of outcomes is warranted both in research and in the clinic. This information may challenge rehabilitation professionals to develop treatment protocol that not only result in positive clinical outcomes but also functional communication outcomes.

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Conclusions

Individuals with severe, chronic comprehension impairments desire to interact with people in an efficient and effective manner. The challenges they face to accomplish this goal are extensive and require collaboration among rehabilitation professional and caregivers. This dissertation project demonstrated that improvements in speech perception or single word comprehension can occur in individuals with severe, chronic, deficits associated with aphasia.

Additionally, corrective feedback and compensatory strategies such as repetition and lip-reading cues can also be utilized in this population with success to further support comprehension gains.

Moreover, these findings suggest that individuals with severe, chronic comprehension deficits may also exhibit impaired self-awareness. Caregiver involvement and rehabilitation protocols focusing on heightening patient’s awareness of comprehension limitations may be a crucial link to rehabilitation success. Although the obstacles faced by this unique and challenging population are significant; this project provided positive evidence that improvements in speech perception and comprehension can still occur, years after stroke.

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Appendix A: Inclusion/Exclusion Criteria

History

Participant ID: ______Date: ______Investigator: ______

Please complete the following:

1. Are you between 18-90 years of age? Yes No

2. Have you been diagnosed with a LEFT cerebrovascular accident (CVA)? Yes No -Was there co-occurring damage in the right hemisphere? Yes No

3. Was the onset of the CVA over 1 year ago? Yes No -Date of CVA (month/year):______-Hospital: ______

4. Have you been diagnosed with any other CVA or TIA? Yes No -If so, please list approximate date(s): ______

5. Are you currently receiving Speech-Language Pathology Services? Yes No -History of Speech-Language Therapy: -Location: ______-Therapist: ______-Duration:______

5. Were you right handed before your stroke? Yes No

6. Do you have at least an 8th grade education? Yes No +Level of Education: ___Some high school ___Completed high school

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___1 year of college ___2 years of college (or A.A./A.S.) ___3 years of college ___4 years of college (B.S./B.A.) ___Master’s Degree ___MD or PhD

7. Please describe your previous (or currently held) occupation: Job Title: ______Brief Description of Work Responsibilities: ______

8. Are you a native speaker of American English? Yes No

9. Do you have a negative history of major psychotic episodes and/or intractable substance abuse? Yes No

10. Have you been diagnosed with depression? Yes No -Do you believe you have depression that has not been formally diagnosed or identified? Yes No

11. Do you currently take any medications? Yes No -If so, please list below: ______

12. Do you feel as if any of the medications affect cognitive functioning or alertness (e.g., do medications make it hard for you to focus or induce drowsiness?) Yes No

13. What time of day do you feel you function best?

Morning Afternoon Evening

14. Hearing loss Yes No -Diagnosed Yes No

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-Severity: ______-Bilateral -Unilateral -Hearing Aids Yes No -Undiagnosed hearing impairment Yes No -To what degree? ( Mild / Moderate / Severe ) -Contexts the impairment is most significant (please describe): ______

15. Vision Loss: -Diagnosed Yes No -Near Sighted -Far Sighted -Glasses Yes No -Other visual deficits Yes No -Hemianopsia -Field cuts (please specify): ______-Undiagnosed vision impairment Yes No -To what degree? ( Mild / Moderate / Severe ) -Near Sighted -Far sighted

16. Diagnosis of Cognitive Impairment: Yes No -Dementia Yes No -Head Injury Yes No -Right CVA Yes No -Other (e.g., Parkinson’s Disease, etc.) Yes No -Presence of undiagnosed cognitive impairment Yes No -If yes, please describe: ______

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Appendix B: Hearing Screening

Hearing Screening Form

Participant Name: ______Participant ID: ______

Date: ______Examiner: ______

Test all frequencies at 40dB:

Right Ear Left Ear

1000 Hz ______1000 Hz ______

2000 Hz ______2000 Hz ______

4000 Hz ______4000 Hz ______

P = Pass F = Fail

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Appendix C: Visual Acuity Screening

Visual Acuity Screening Form

Participant Name: ______Participant ID: ______

Date: ______Examiner: ______

Stimulus Correct Incorrect

Dog

Apple

Fork

Banana

Hammer

Bicycle

Chair

Cat

Comb

Shirt

Method of response used by participant (circle all that apply):

verbal gestural written choice other:

Total Correct: ____/10

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Appendix D: Response Screening

Response Screening Form

Participant Name: ______Participant ID: ______

Date: ______Examiner: ______

Question Response

1. Is this a cup

2. Is this a pencil

3. Is this a flower

4. Is this a ball

5. Is this a knife

6. Is this a toothbrush

7. Is this a key

8. Is this a watch

9. Is this a hammer

10. Is this a spoon

Method of response used by participant (circle all that apply):

verbal gestural written choice other:

Total “yes” responses: ____/10 Total “no” responses: _____/10

Total Responses: ____/10

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Appendix E: Lexical Analysis SWCG

Lexical Characteristics

High Frequency Stimuli

Mean Mean Mean Mean Phonological Phase of Study Frequency of Number of Length Neighborhood Usage Density Syllables

Pre-Experimental

Probe A 4.27 70,915.33 22.33 1.2

Probe B 4.27 70,451.2 17.93 1.27

Experimental 4.97 74,029.8 16.57 1.6

Total Average

Across Phases

Medium Frequency Stimuli

Mean Mean Mean Mean Phonological Phase of Study Frequency of Number of Length Neighborhood Usage Density Syllables

Pre-Experimental 4.2 12,350.93 18.27 1.13

Probe A 4.67 11,976.6 15.6 1.2

Probe B 4.53 11,914.67 15.67 1.2

Experimental 5 11,577.27 16.57 1.3

Total Average 11,954.87 16.53 1.21 Across Phases 4.6

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Low Frequency Stimuli

Mean Mean Mean Mean Phonological Phase of Study Frequency of Number of Length Neighborhood Usage Density Syllables

Pre-Experimental 5.13 1,791.4 15.8 1.47

Probe A 5.07 1,618.8 16.8 1.47

Probe B 4.93 1,632.8 13.87 1.4

Experimental 4.83 1,651.4 15.53 1.4

Total Average 4.99 1,673.6 15.5 1.44 Across Phases

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Appendix F: Experimental Stimuli Complexity Assessment - Single Word Comprehension High Frequency Stimuli

Single Word Comp Date: Participant ID: Pre-Experimental Assessment Data Collection form: High Frequency repetition Correct=+ incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target foil foil Score baby bottle maybe 1 + - 0 F + - 0 F + - 0 F baby R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- fly bird crya 2 + - 0 F + - 0 F + - 0 F fly R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- town country brown 3 + - 0 F + - 0 F + - 0 F town R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- doctor nurse proctor 4 + - 0 F + - 0 F + - 0 F doctor R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- church school perch 5 + - 0 F + - 0 F + - 0 F church R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Floor ceiling door 6 + - 0 F + - 0 F + - 0 F floor R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- money wallet honey 7 + - 0 F + - 0 F + - 0 F money R+ R- D R+ R- D R+ R- D

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R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

phone radio load 8 + - 0 F + - 0 F + - 0 F phone R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- battery power flattery 9 + - 0 F + - 0 F + - 0 F battery R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- apple pear maple 10 + - 0 F + - 0 F + - 0 F apple R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- watch calendar walk 11 + - 0 F + - 0 F + - 0 F watch R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- river lake liver 12 + - 0 F + - 0 F + - 0 F river R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- game work name 13 + - 0 F + - 0 F + - 0 F game R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- boy girl toy 14 + - 0 F + - 0 F + - 0 F boy R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- door window pour 15 + - 0 F + - 0 F + - 0 F door R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

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Appendix G: Experimental Stimuli Complexity Assessment - Single Word Comprehension Medium Frequency Stimuli

Speech Perception/Single Word Comp Date: Participant ID: Pre-Experimental Assessment/Baseline Data Collection form: Medium repetition Correct=+ incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target foil foil Score butter jelly brother 1 + - 0 F + - 0 F + - 0 F butter R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- arm leg alarm 2 + - 0 F + - 0 F + - 0 F arm R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- pipe cigar wipe 3 + - 0 F + - 0 F + - 0 F pipe R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- egg chicken peg 4 + - 0 F + - 0 F + - 0 F egg R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- lung brain rung 5 + - 0 F + - 0 F + - 0 F lung R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- farm town alarm 6 + - 0 F + - 0 F + - 0 F farm R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- grass weeds glass 7 + - 0 F + - 0 F + - 0 F grass R+ R- D R+ R- D R+ R- D

235 Intensive Auditory Comprehension Treatment

R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

lamp fire tramp 8 + - 0 F + - 0 F + - 0 F lamp R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- ear nose beer 9 + - 0 F + - 0 F + - 0 F ear R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- bag purse tag 10 + - 0 F + - 0 F + - 0 F bag R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- pin threat pit 11 + - 0 F + - 0 F + - 0 F pin R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- flood earthquake mud 12 + - 0 F + - 0 F + - 0 F flood R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- glasses binoculars masses 13 + - 0 F + - 0 F + - 0 F glasses R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- thumb pinky plum 14 + - 0 F + - 0 F + - 0 F thumb R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- wing bird king 15 + - 0 F + - 0 F + - 0 F wing R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

236 Intensive Auditory Comprehension Treatment

Appendix H: Experimental Stimuli Complexity Assessment - Single Word Comprehension Low Frequency Stimuli

Single Word Pre-Experimental Assessment – Date: Participant ID: Low Frequency correct repetition = + incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target semantic phonemic Score cuff collar cup 1 + - 0 F + - 0 F + - 0 F cuff R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- hinge door fringe 2 + - 0 F + - 0 F + - 0 F hinge R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- slug worm mug 3 + - 0 F + - 0 F + - 0 F slug R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- mango pear tango 4 + - 0 F + - 0 F + - 0 F mango R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- kettle tea metal 5 + - 0 F + - 0 F + - 0 F kettle R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- locket necklace rocket 6 + - 0 F + - 0 F + - 0 F locket R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- owl Blue jay towel 7 + - 0 F + - 0 F + - 0 F owl R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2

237 Intensive Auditory Comprehension Treatment

V+ V- V+ V- V+ V-

bride groom slide 8 + - 0 F + - 0 F + - 0 F bride R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- coaster glass toaster 9 + - 0 F + - 0 F + - 0 F coaster R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- knot bow pot 10 + - 0 F + - 0 F + - 0 F knot R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- daisy rose gravy 11 + - 0 F + - 0 F + - 0 F daisy R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- trellis deck crevice 12 + - 0 F + - 0 F + - 0 F trellis R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- pier boat tear 13 + - 0 F + - 0 F + - 0 F pier R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- candle fireplace handle 14 + - 0 F + - 0 F + - 0 F candle R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- wrench screwdriver bench 15 + - 0 F + - 0 F + - 0 F wrench R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

238 Intensive Auditory Comprehension Treatment

Appendix I: Experimental Stimuli Complexity Assessment. CV Stimuli

Speech Perception Date: Participant ID: Pre-Experimental Assessment Data Collection form: CV repetition Correct=+ incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target foil foil Score ma/ma ma/ba ma/ta

1 + - 0 F + - 0 F + - 0 F ma/ma R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- ne/ne ne/ge Ne/pe

2 + - 0 F + - 0 F + - 0 F ne/ne R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- ho/ho Ho/do Ho/mo

3 + - 0 F + - 0 F + - 0 F ho/ho R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Wi/wi Wi/bi Wi/si 4 + - 0 F + - 0 F + - 0 F Wi/wi R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Pae/pae Pae/bae Pae/gae 5 + - 0 F + - 0 F + - 0 F Pae/pae R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Li/Li Li/ti Li/ri 6 + - 0 F + - 0 F + - 0 F Li/Li R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

239 Intensive Auditory Comprehension Treatment

bE/bE bE/pE bE/vE

7 + - 0 F + - 0 F + - 0 F bE/bE R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Tu/tu Tu/du Tu/lu 8 + - 0 F + - 0 F + - 0 F Tu/tu R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Ko/ko Ko/go Ko/wo 9 + - 0 F + - 0 F + - 0 F Ko/ko R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Ve/ve Ve/fe Ve/he 10 + - 0 F + - 0 F + - 0 F Ve/ve R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Do/do Do/to Do/no 11 + - 0 F + - 0 F + - 0 F Do/do R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Gai/gai Gai/kai Gai/lai 12 + - 0 F + - 0 F + - 0 F Gai/gai R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- sE/sE sE/zE sE/mE 13 + - 0 F + - 0 F + - 0 F sE/sE R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Rae/rae Rae/nae Rae/kae 14 + - 0 F + - 0 F + - 0 F Rae/rae R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

240 Intensive Auditory Comprehension Treatment

Fi/fi Fi/vi Fi/wi 15 + - 0 F + - 0 F + - 0 F Fi/fi R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

241 Intensive Auditory Comprehension Treatment

Appendix J: : Experimental Stimuli Complexity Assessment CVC stimuli

Speech Perception Date: Participant ID: Pre-Experimental Assessment Data Collection form: CVC repetition Correct=+ incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target foil foil Score Mit/mit Mit/bit Mit/mik 1 + - 0 F + - 0 F + - 0 F Mit/mit R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Nat/nat Nat/kat Nat/nab 2 + - 0 F + - 0 F + - 0 F Nat/nat R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- pIk/pIk pIk/lIk pIk/pIn 3 + - 0 F + - 0 F + - 0 F pIk/pIk R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Bed/bed Bed/ped Bed/ber 4 + - 0 F + - 0 F + - 0 F Bed/bed R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Daef/daef Daef/laef Daef/daep 5 + - 0 F + - 0 F + - 0 F daef/daef R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- tEl/tEl tEl/wEl tEl/tEn 6 + - 0 F + - 0 F + - 0 F tEI/tEl R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Kon/kon Kon/mon Kon/kod 7 + - 0 F + - 0 F + - 0 F Kon/kon R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2

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V+ V- V+ V- V+ V-

Gus/.gus Gus/mus Gus/mus 8 + - 0 F + - 0 F + - 0 F Gus/gus R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Wait/wait Wait/hait Wait/waik 9 + - 0 F + - 0 F + - 0 F Wait/wait R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Hir/hir Hir/gir Hir/hit 10 + - 0 F + - 0 F + - 0 F Hir/hir R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Vls/vls Vls/nis Vls/vlb 11 + - 0 F + - 0 F + - 0 F Vls/vls R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Fed/fed Fed/ped Fed/fez 12 + - 0 F + - 0 F + - 0 F Fed/fed R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- lEs/lEs lEs/gEs lEs/lEg 13 + - 0 F + - 0 F + - 0 F lEs/lEs R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Raet/raet Raet/vaet Raet/raem 14 + - 0 F + - 0 F + - 0 F Raet/raet R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Sad/sad Sad/rad Sad/sat 15 + - 0 F + - 0 F + - 0 F Sad/sad R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

243 Intensive Auditory Comprehension Treatment

Appendix K: Experimental Stimuli Complexity Assessment – CCVC Stimuli

Speech Perception/Single Word Comp Date: Participant ID: Pre-Experimental Assessment/Baseline Data Collection form: CCVC repetition Correct=+ incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli Target foil foil Score Brace/brace Brace/race Brace/grace 1 + - 0 F + - 0 F + - 0 F Brace/brade R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Crab/crab Crab/cab Crab/drab 2 + - 0 F + - 0 F + - 0 F Crab/crab R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Frail/frail Frail/rail Frail/brail 3 + - 0 F + - 0 F + - 0 F Frail/frail R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Grave/grave Grave/rave Grave/brave 4 + - 0 F + - 0 F + - 0 F Grave/grave R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Trim/trim Trim/rim Trim/brim 5 + - 0 F + - 0 F + - 0 F Trim/trim R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Prize/prize Prize/rise Prize/fries 6 + - 0 F + - 0 F + - 0 F Prize/prize R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Creek/creek Creek/reek Creek/freek 7 + - 0 F + - 0 F + - 0 F Creek/creek R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2

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V+ V- V+ V- V+ V-

Drum/drum Drum/drum Drum/drum 8 + - 0 F + - 0 F + - 0 F Drum/drum R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Grace/grace Grace/race Grace/brace 9 + - 0 F + - 0 F + - 0 F Grace/grace R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Prod/prod Prod/rod Prod/brod 10 + - 0 F + - 0 F + - 0 F Prod/prod R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Grow/grow Grow/row Grow/crow 11 + - 0 F + - 0 F + - 0 F Grow/grow R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Claim/claim Claim/laim Claim/blame 12 + - 0 F + - 0 F + - 0 F Claim/claim R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Clap/clap Clap/cap Clap/flap 13 + - 0 F + - 0 F + - 0 F Clap/clap R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Blow/blow Blow/low Blow/flow 14 + - 0 F + - 0 F + - 0 F Blow/blow R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Flick/flick Flick/lick Flick/click 15 + - 0 F + - 0 F + - 0 F Flick/flick R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

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Appendix L: Baseline and Probe Single Word Comprehension High Frequency Stimuli Version A

Single Word Comp Date: Participant ID: Baseline Probe A Data Collection form: High Frequency repetition Correct=+ incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target semantic phonemic Score city country kitty 1 + - 0 F + - 0 F + - 0 F City R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- box present fox 2 + - 0 F + - 0 F + - 0 F box R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- cat mouse mat 3 + - 0 F + - 0 F + - 0 F cat R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- face back base 4 + - 0 F + - 0 F + - 0 F face R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- mint gum lint 5 + - 0 F + - 0 F + - 0 F mint R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- keys lock knees 6 + - 0 F + - 0 F + - 0 F keys R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- house store mouse 7 + - 0 F + - 0 F + - 0 F house R+ R- D R+ R- D R+ R- D

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R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

blood water mud 8 + - 0 F + - 0 F + - 0 F blood R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- eyes ears prize 9 + - 0 F + - 0 F + - 0 F eyes R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- brain lung plane 10 + - 0 F + - 0 F + - 0 F brain R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- earth sun surf 11 + - 0 F + - 0 F + - 0 F earth R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- car Truck bar 12 + - 0 F + - 0 F + - 0 F car R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- remote television boat 13 + - 0 F + - 0 F + - 0 F remote R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- dog cat log 14 + - 0 F + - 0 F + - 0 F dog R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- window door meadow 15 + - 0 F + - 0 F + - 0 F window R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

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Appendix M: Baseline and Probe Single Word Comprehension High Frequency Stimuli Version B

Single Word Comp Date: Participant ID: Baseline Probe B Data Collection form: High Frequency repetition Correct=+ incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target semantic phonemic Score book magazine hook 1 + - 0 F + - 0 F + - 0 F book R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- hand foot band 2 + - 0 F + - 0 F + - 0 F hand R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- family grandparents phantom 3 + - 0 F + - 0 F + - 0 F family R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- gas car bass 4 + - 0 F + - 0 F + - 0 F gas R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- child adults tiled 5 + - 0 F + - 0 F + - 0 F child R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- king queen wing 6 + - 0 F + - 0 F + - 0 F king R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- map book mat 7 + - 0 F + - 0 F + - 0 F map R+ R- D R+ R- D R+ R- D

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R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

police fireman geese 8 + - 0 F + - 0 F + - 0 F police R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- table chair cable 9 + - 0 F + - 0 F + - 0 F table R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- star moon car 10 + - 0 F + - 0 F + - 0 F star R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- oil water soil 11 + - 0 F + - 0 F + - 0 F oil R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- fish Snake dish 12 + - 0 F + - 0 F + - 0 F fish R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- road stream rope 13 + - 0 F + - 0 F + - 0 F road R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- school home tool 14 + - 0 F + - 0 F + - 0 F school R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- van truck fan 15 + - 0 F + - 0 F + - 0 F van R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

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Appendix N: Baseline and Probe Single Word Comprehension Medium Frequency Stimuli Version A

Speech Perception/Single Word Comp Date: Participant ID: Pre-Experimental Assessment/Baseline Data Collection form – medium A repetition Correct=+ incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target foil foil Score bottle pacifier throttle 1 + - 0 F + - 0 F + - 0 F bottle R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- lock key block 2 + - 0 F + - 0 F + - 0 F lock R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- cloud sun round 3 + - 0 F + - 0 F + - 0 F cloud R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- fork spoon pork 4 + - 0 F + - 0 F + - 0 F fork R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- bath towel math 5 + - 0 F + - 0 F + - 0 F bath R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- meat fruit feet 6 + - 0 F + - 0 F + - 0 F meat R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- soup cereal loop 7 + - 0 F + - 0 F + - 0 F

250 Intensive Auditory Comprehension Treatment

soup R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

priest church yeast 8 + - 0 F + - 0 F + - 0 F priest R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- arrow triangle pharaoh 9 + - 0 F + - 0 F + - 0 F arrow R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- leg arm keg 10 + - 0 F + - 0 F + - 0 F leg R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- desk shelf pesk 11 + - 0 F + - 0 F + - 0 F desk R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- pants skirt plants 12 + - 0 F + - 0 F + - 0 F pants R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- spider fly glider 13 + - 0 F + - 0 F + - 0 F spider R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- bread muffin lead 14 + - 0 F + - 0 F + - 0 F bread R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- wheel bumper seal 15 + - 0 F + - 0 F + - 0 F wheel R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

251 Intensive Auditory Comprehension Treatment

Appendix O: Baseline and Probe Single Word Comprehension Medium Frequency Stimuli Version B

Speech Perception/Single Word Comp Date: Participant ID: Baseline Data Collection form – medium B repetition Correct=+ incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target foil foil Score tissue bandana issue 1 + - 0 F + - 0 F + - 0 F tissue R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- bench couch wrench 2 + - 0 F + - 0 F + - 0 F bench R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- hat scarf ham 3 + - 0 F + - 0 F + - 0 F hat R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- stamp envelope stand 4 + - 0 F + - 0 F + - 0 F stamp R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- dress coat press 5 + - 0 F + - 0 F + - 0 F dress R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- clock calendar rock 6 + - 0 F + - 0 F + - 0 F clock R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- foot hand crook 7 + - 0 F + - 0 F + - 0 F foot R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2

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V+ V- V+ V- V+ V-

snow rain bow 8 + - 0 F + - 0 F + - 0 F snow R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- nurse doctor purse 9 + - 0 F + - 0 F + - 0 F nurse R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- pan stove man 10 + - 0 F + - 0 F + - 0 F pan R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- shirt pants skirt 11 + - 0 F + - 0 F + - 0 F shirt R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- piano organ piece 12 + - 0 F + - 0 F + - 0 F piano R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- teeth braces team 13 + - 0 F + - 0 F + - 0 F teeth R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- pig goat pill 14 + - 0 F + - 0 F + - 0 F pig R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- swing slide ring 15 + - 0 F + - 0 F + - 0 F swing R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

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Appendix P: Baseline and Probe Single Word Comprehension Low Frequency Stimuli Version A Single Word Comprehension Date: Participant ID: Baseline and Probe – Low Version A correct repetition = + incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target semantic phonemic Score binder notebook grinder 1 + - 0 F + - 0 F + - 0 F binder R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- rattle Baby cattle 2 + - 0 F + - 0 F + - 0 F rattle R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- flute trumpet suit 3 + - 0 F + - 0 F + - 0 F flute R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- joker queen smoker 4 + - 0 F + - 0 F + - 0 F joker R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- tuba clarinet cuba 5 + - 0 F + - 0 F + - 0 F tuba R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- cork wine fork 6 + - 0 F + - 0 F + - 0 F cork R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- funnel collander tunnel 7 + - 0 F + - 0 F + - 0 F funnel R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

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sock shoe lock 8 + - 0 F + - 0 F + - 0 F sock R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- kite plane light 9 + - 0 F + - 0 F + - 0 F kite R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- cab van tab 10 + - 0 F + - 0 F + - 0 F cab R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- scone bagel loan 11 + - 0 F + - 0 F + - 0 F scone R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- goose swan moose 12 + - 0 F + - 0 F + - 0 F goose R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- thimble needle cymbal 13 + - 0 F + - 0 F + - 0 F thimble R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- collar cuff dollar 14 + - 0 F + - 0 F + - 0 F collar R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- wreath tree teeth 15 + - 0 F + - 0 F + - 0 F wreath R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

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Appendix Q: Baseline and Probe Single Word Comprehension Low Frequency Stimuli Version B

Single Words Date: Participant ID: Baseline and Probe Low Version B correct repetition = + incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target semantic phonemic Score crib High chair bib 1 + - 0 F + - 0 F + - 0 F crib R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- jelly butter belly 2 + - 0 F + - 0 F + - 0 F jelly R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- blimp plane shrimp 3 + - 0 F + - 0 F + - 0 F blimp R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- knuckle elbow buckle 4 + - 0 F + - 0 F + - 0 F knuckle R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- ladle spatula cradle 5 + - 0 F + - 0 F + - 0 F ladle R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- yarn knit barn 6 + - 0 F + - 0 F + - 0 F yarn R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- cactus leaf mattress 7 + - 0 F + - 0 F + - 0 F cactus R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2

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V+ V- V+ V- V+ V-

robe coat globe 8 + - 0 F + - 0 F + - 0 F robe R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- feather bird leather 9 + - 0 F + - 0 F + - 0 F feather R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- jug milk drub 10 + - 0 F + - 0 F + - 0 F jug R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- rind crust mind 11 + - 0 F + - 0 F + - 0 F rind R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- nail hammer pail 12 + - 0 F + - 0 F + - 0 F nail R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- whisk fork whip 13 + - 0 F + - 0 F + - 0 F whisk R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- violet daisy pilot 14 + - 0 F + - 0 F + - 0 F violet R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- shack mansion rack 15 + - 0 F + - 0 F + - 0 F shack R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

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Appendix R: Treatment Phase Single Word Comprehension High Frequency Stimuli

Single Word Experimental Date: Participant ID: High Frequency correct repetition = + incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target Semantic Phonemic Score radio record video 1 + - 0 F + - 0 F + - 0 F radio R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- hair face fair 2 + - 0 F + - 0 F + - 0 F hair R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- girl boy pearl 3 + - 0 F + - 0 F + - 0 F girl R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- cup plate pup 4 + - 0 F + - 0 F + - 0 F cup R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- button zipper mutton 5 + - 0 F + - 0 F + - 0 F button R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- president police resident 6 + - 0 F + - 0 F + - 0 F president R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- bus car dust

258 Intensive Auditory Comprehension Treatment

7 + - 0 F + - 0 F + - 0 F bus R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

heart circle dart 8 + - 0 F + - 0 F + - 0 F heart R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- printer computer winter 9 + - 0 F + - 0 F + - 0 F printer R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- tree bush flea 10 + - 0 F + - 0 F + - 0 F tree R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- neck chin check 11 + - 0 F + - 0 F + - 0 F neck R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- ice snow dice 12 + - 0 F + - 0 F + - 0 F ice R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- money credit honey 13 + - 0 F + - 0 F + - 0 F money R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- frame photo freight 14 + - 0 F + - 0 F + - 0 F frame R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- movie television bouy

259 Intensive Auditory Comprehension Treatment

15 + - 0 F + - 0 F + - 0 F movie R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

card present lard 16 + - 0 F + - 0 F + - 0 F card R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

bed sofa bread 17 + - 0 F + - 0 F + - 0 F bed R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- library court canary 18 + - 0 F + - 0 F + - 0 F library R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- fire ice wire 19 + - 0 F + - 0 F + - 0 F fire R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- tape stapler nape 20 + - 0 F + - 0 F + - 0 F tape R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- finger toe stinger 21 + - 0 F + - 0 F + - 0 F finger R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- computer phone shooter

260 Intensive Auditory Comprehension Treatment

22 + - 0 F + - 0 F + - 0 F computer R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- water coffee daughter 23 + - 0 F + - 0 F + - 0 F water R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

mouth ear south 24 + - 0 F + - 0 F + - 0 F mouth R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- paper pen scraper 25 + - 0 F + - 0 F + - 0 F paper R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

ball hoop mall 26 + - 0 F + - 0 F + - 0 F ball R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- woman man airman 27 + - 0 F + - 0 F + - 0 F woman R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- shell ocean shelter 28 + - 0 F + - 0 F + - 0 F shell R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- magazine record limosine 29 + - 0 F + - 0 F + - 0 F magazine R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- line circle pine

261 Intensive Auditory Comprehension Treatment

30 + - 0 F + - 0 F + - 0 F line R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

262 Intensive Auditory Comprehension Treatment

Appendix S: Treatment Phase Single Word Comprehension Medium Frequency Stimuli

Single Word Experimental Date: Participant ID: Medium Frequency correct repetition = + incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target Semantic Phonemic Score bomb gun mom 1 + - 0 F + - 0 F + - 0 F bomb R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- nose mouth note 2 + - 0 F + - 0 F + - 0 F nose R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- sand shell band 3 + - 0 F + - 0 F + - 0 F sand R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- chair couch hair 4 + - 0 F + - 0 F + - 0 F chair R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- shoe foot two 5 + - 0 F + - 0 F + - 0 F shoe R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- milk juice silk 6 + - 0 F + - 0 F + - 0 F milk R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- drain faucet train

263 Intensive Auditory Comprehension Treatment

7 + - 0 F + - 0 F + - 0 F drain R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

knife fork wife 8 + - 0 F + - 0 F + - 0 F knife R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- turkey chicken jerky 9 + - 0 F + - 0 F + - 0 F turkey R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- glass straw grass 10 + - 0 F + - 0 F + - 0 F glass R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- horse llama source 11 + - 0 F + - 0 F + - 0 F horse R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- pepper salt leper 12 + - 0 F + - 0 F + - 0 F pepper R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- mailbox letter mailman 13 + - 0 F + - 0 F + - 0 F mailbox R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- ladder stairs bladder 14 + - 0 F + - 0 F + - 0 F ladder R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- toilet sink toil

264 Intensive Auditory Comprehension Treatment

15 + - 0 F + - 0 F + - 0 F toilet R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

mask cape mast 16 + - 0 F + - 0 F + - 0 F mask R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

pool lake tool 17 + - 0 F + - 0 F + - 0 F pool R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- chess checkers dress 18 + - 0 F + - 0 F + - 0 F chess R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- bicycle skateboard tricycle 19 + - 0 F + - 0 F + - 0 F bicycle R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- coat hat comb 20 + - 0 F + - 0 F + - 0 F coat R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- slide swing slime 21 + - 0 F + - 0 F + - 0 F slide R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- truck car duck 22 + - 0 F + - 0 F + - 0 F truck R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- drum piano drug

265 Intensive Auditory Comprehension Treatment

23 + - 0 F + - 0 F + - 0 F drum R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

carpet tile carpenter 24 + - 0 F + - 0 F + - 0 F carpet R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- flower tree tower 25 + - 0 F + - 0 F + - 0 F flower R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

plane train brain 26 + - 0 F + - 0 F + - 0 F plane R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- castle king cast 27 + - 0 F + - 0 F + - 0 F castle R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- train bus crane 28 + - 0 F + - 0 F + - 0 F train R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- cow horse brow 29 + - 0 F + - 0 F + - 0 F cow R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- brush comb blush 30 + - 0 F + - 0 F + - 0 F brush R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

266 Intensive Auditory Comprehension Treatment

Appendix T: Treatment Phase Single Word Comprehension Low Frequency Stimuli

Single Word Experimental Date: Participant ID: Low Frequency correct repetition = + incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target Semantic Phonemic Score hoop basketball stoop 1 + - 0 F + - 0 F + - 0 F hoop R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- baboon chimpanzee raccoon 2 + - 0 F + - 0 F + - 0 F baboon R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- fountain water mountain 3 + - 0 F + - 0 F + - 0 F fountain R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- pear pineapple fair 4 + - 0 F + - 0 F + - 0 F pear R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- axe saw jacks 5 + - 0 F + - 0 F + - 0 F axe R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- syrup waffle Europe 6 + - 0 F + - 0 F + - 0 F syrup R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2

267 Intensive Auditory Comprehension Treatment

V+ V- V+ V- V+ V- booth chair boot 7 + - 0 F + - 0 F + - 0 F booth R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

calf colt cat 8 + - 0 F + - 0 F + - 0 F calf R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- yam onion lamb 9 + - 0 F + - 0 F + - 0 F yam R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- eyebrow nose sow 10 + - 0 F + - 0 F + - 0 F eyebrow R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- bee fly flea 11 + - 0 F + - 0 F + - 0 F bee R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- frown smile crown 12 + - 0 F + - 0 F + - 0 F frown R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- clam snail jam 13 + - 0 F + - 0 F + - 0 F clam R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- lipstick mascara dipstick 14 + - 0 F + - 0 F + - 0 F lipstick R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- tusk elephant musk

268 Intensive Auditory Comprehension Treatment

15 + - 0 F + - 0 F + - 0 F tuck R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

racket Tennis ball jacket 16 + - 0 F + - 0 F + - 0 F racket R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

mop broom pop 17 + - 0 F + - 0 F + - 0 F mop R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- zipper button clipper 18 + - 0 F + - 0 F + - 0 F zipper R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- mat rug map 19 + - 0 F + - 0 F + - 0 F mat R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- rust dirt crust 20 + - 0 F + - 0 F + - 0 F rust R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- perfume deodorant legume 21 + - 0 F + - 0 F + - 0 F perfume R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- tassel pillow castle 22 + - 0 F + - 0 F + - 0 F tassel R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- ant fly plant

269 Intensive Auditory Comprehension Treatment

23 + - 0 F + - 0 F + - 0 F ant R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- gavel judge gravel 24 + - 0 F + - 0 F + - 0 F gavel R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- cone Ice cream coat 25 + - 0 F + - 0 F + - 0 F cone R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

braces dentist faces 26 + - 0 F + - 0 F + - 0 F braces R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- vase bucket base 27 + - 0 F + - 0 F + - 0 F vase R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- shrub vine tub 28 + - 0 F + - 0 F + - 0 F shrub R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- curtain window person 29 + - 0 F + - 0 F + - 0 F curtain R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Gum mint bum 30 + - 0 F + - 0 F + - 0 F gum R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

270 Intensive Auditory Comprehension Treatment

Appendix U: Baseline and Probe CV Stimuli Version A

Speech Perception Date: Participant ID: Baseline Data Collection form – CV A repetition Correct=+ incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target foil foil Score Zu/zu Zu/su Zu/hu 1 + - 0 F + - 0 F + - 0 F Zu/zu R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Mi/mi Mi/pi Mi/ri 2 + - 0 F + - 0 F + - 0 F Mi/mi R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Na/na Na/ka Na/za 3 + - 0 F + - 0 F + - 0 F Na/na R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Pl/pl Pl/bl Pl/fl 4 + - 0 F + - 0 F + - 0 F Pl/pl R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Bai/bai Bai/pai Bai/rai 5 + - 0 F + - 0 F + - 0 F Bai/bai R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Ti/ti Ti/di Ti/si 6 + - 0 F + - 0 F + - 0 F Ti/ti R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Dae/dae Dae/tae Dae/lae 7 + - 0 F + - 0 F + - 0 F Dae/dae R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

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Kl/kl Kl/gl Kl/vl 8 + - 0 F + - 0 F + - 0 F Kl/kl R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Ge/ge Ge/ke Ge/ze 9 + - 0 F + - 0 F + - 0 F Ge/ge R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- wE/wE wE/rE wE/zE 10 + - 0 F + - 0 F + - 0 F wE/wE R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Hae/hae Hae/dae Hae/wae 11 + - 0 F + - 0 F + - 0 F Hae/hae R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Va/va Va/fa Va/na 12 + - 0 F + - 0 F + - 0 F Va/va R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- wE/wE wE/rE wE/zE 13 + - 0 F + - 0 F + - 0 F wE/wE R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Li/li Li/di li/ki 14 + - 0 F + - 0 F + - 0 F Li/li R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Rl/rl Rl/hl Rl/wl 15 + - 0 F + - 0 F + - 0 F Rl/rl R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

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Appendix V: Baseline and Probe CV Stimuli Version B

Speech Perception Date: Participant ID: Baseline Data Collection form – CV B repetition Correct=+ incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target foil foil Score Fo/fo Fo/vo Fo/lo 1 + - 0 F + - 0 F + - 0 F Fo/fo R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- zE/zE zE/sE zE/mE 2 + - 0 F + - 0 F + - 0 F zE/zE R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Mae/mae Mae/pae Mae/hae 3 + - 0 F + - 0 F + - 0 F Mae/mae R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- No/no No/go No/ho 4 + - 0 F + - 0 F + - 0 F No/no R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Pa/pa Pa/ba Pa/fa 5 + - 0 F + - 0 F + - 0 F Pa/pa R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Bu/bu Bu/mu b/nu 6 + - 0 F + - 0 F + - 0 F Bu/bu R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Tai/tai Tai/rai Tai/fai 7 + - 0 F + - 0 F + - 0 F Tai/tai R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

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Dl/dl Dl/tl Dl/zl 8 + - 0 F + - 0 F + - 0 F Dl/dl R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Ki/ki Ki/gi Ki/ni 9 + - 0 F + - 0 F + - 0 F Ki/ki R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- gE/gE gE/kE gE/lE 10 + - 0 F + - 0 F + - 0 F gE/gE R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- We/we We/pe We/se 11 + - 0 F + - 0 F + - 0 F We/we R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Ha/ha Ha/sa Ha/va 12 + - 0 F + - 0 F + - 0 F Ha/ha R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- gE/gE gE/kE gE/lE 13 + - 0 F + - 0 F + - 0 F gE/gE R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Sai/sai Sai/zai Sai/mai 14 + - 0 F + - 0 F + - 0 F Sai/sai R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Lo/lo Lo/ro Lo/vo 15 + - 0 F + - 0 F + - 0 F Lo/lo R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

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Appendix W: Baseline and Probe CVC Stimuli Version A

Speech Perception Date: Participant ID: Baseline Data Collection form – CV C A repetition Correct=+ incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target foil foil Score Got/got Got/vot Got/gol 1 + - 0 F + - 0 F + - 0 F Got/got R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Mun/mun Mun/tun Mun.muv 2 + - 0 F + - 0 F + - 0 F Mun/mun R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Nait/nait Nait/sait Nait/naif 3 + - 0 F + - 0 F + - 0 F Nait/nait R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Pik/pik Pik/wik Pik/piz 4 + - 0 F + - 0 F + - 0 F Pik/pik R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Bld/bld Bld/rld Bld/bll 5 + - 0 F + - 0 F + - 0 F Bld/bld R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Tek/tek Tek/fek Tek/tem 6 + - 0 F + - 0 F + - 0 F Tek/tek R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- dEn/dEn dEn/tEn dEn/dEf 7 + - 0 F + - 0 F + - 0 F dEn/dEn R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

275 Intensive Auditory Comprehension Treatment

Kaet/kaet Kaet/vaet Kaet/kaep 8 + - 0 F + - 0 F + - 0 F Kaet/kaet R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Gat/gat Gat/dat Gat/gal 9 + - 0 F + - 0 F + - 0 F Gat/gat R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Wov/wov Wov/dov Wov/wok 10 + - 0 F + - 0 F + - 0 F Wov/wov R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Hut/hut Hut/but Hut/hum 11 + - 0 F + - 0 F + - 0 F Hut/hut R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Vain/vain Vain/sain Vain/vail 12 + - 0 F + - 0 F + - 0 F Vain/vain R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Fit/fit Fit/hit Fit/fir 13 + - 0 F + - 0 F + - 0 F Fit/fit R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- lIk/lIk lIk/nIk lIk/lId 14 + - 0 F + - 0 F + - 0 F lIk/lIk R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Red/red Red/ped Red/rev 15 + - 0 F + - 0 F + - 0 F Red/red R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

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Appendix X: Baseline and Probe CVC Stimuli Version B

Speech Perception Date: Participant ID: Baseline Data Collection form – CV C B repetition Correct=+ incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

Stimuli target foil foil Score Sell/sell Sell/well Sell/set 1 + - 0 F + - 0 F + - 0 F sell R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Map/map Map/cap Map/man 2 + - 0 F + - 0 F + - 0 F map R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- nake Nake/make Nake/nabe 3 + - 0 F + - 0 F + - 0 F nake R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Poke/poke Poke/soak Poke/pose 4 + - 0 F + - 0 F + - 0 F poke R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Bum./bum Bum/rum Bum/buz 5 + - 0 F + - 0 F + - 0 F bum R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Tade/tade Tade/laid Taid/tape 6 + - 0 F + - 0 F + - 0 F tade R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Dine/dine Dine/bine Dine/dire 7 + - 0 F + - 0 F + - 0 F dine R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

277 Intensive Auditory Comprehension Treatment

Kit/kit Kit/pit Kit/kid 8 + - 0 F + - 0 F + - 0 F kit R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Game/game Game/dame Game/gave 9 + - 0 F + - 0 F + - 0 F game R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Well/well Well/fell Well/web 10 + - 0 F + - 0 F + - 0 F well R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Half/half Half/laugh Half/ham 11 + - 0 F + - 0 F + - 0 F half R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Vote/vote Vote/goat Vote/vole 12 + - 0 F + - 0 F + - 0 F vote R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Fate/fate Fate/hate Fate/fame 13 + - 0 F + - 0 F + - 0 F fate R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Loop/loop Loop/soup Loop/lure 14 + - 0 F + - 0 F + - 0 F loop R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Raid/raid Raid/fade Raid/rain 15 + - 0 F + - 0 F + - 0 F raid R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

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Appendix Y: Treatment Phase CV Stimuli

Speech Perception Experimental - CV Date: Participant ID: correct repetition = + incorrect = - repetition correct = R+ incorrect = R - no response = 0 fatigue = F repetition correct 2 = R+2 repetition incorrect = R - 2 distracted = D visual cue correct = V+ visual cue incorrect = V -

CV Stimuli target foil foil Score Ru/ru Ru/hu Ru/fu 1 + - 0 F + - 0 F + - 0 F Ru/ru R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- fI/fI fI/vI fI/zI 2 + - 0 F + - 0 F + - 0 F fI/fI R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Za/za Za/sa Za/ra 3 + - 0 F + - 0 F + - 0 F Za/za R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Me/me Me/be Me/we 4 + - 0 F + - 0 F + - 0 F Me/me R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Ni/ni Ni/ti Ni/hi 5 + - 0 F + - 0 F + - 0 F Ni/ni R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Pi/pi Pi/bi Pi/di 6 + - 0 F + - 0 F + - 0 F Pi/pi R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Be/be Be/pe Be/le 7 + - 0 F + - 0 F + - 0 F Be/be R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

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Ta/ta Ta/da Ta/ga 8 + - 0 F + - 0 F + - 0 F Ta/ta R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- De/de De/te De/ke 9 + - 0 F + - 0 F + - 0 F De/de R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Ku/ku Ku/gu Ku/zu 10 + - 0 F + - 0 F + - 0 F Ku/ku R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Ga/ga Ga/ka Ga/ra 11 + - 0 F + - 0 F + - 0 F Ga/ga R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Wu/wu Wu/pu Wu/fu 12 + - 0 F + - 0 F + - 0 F Wu/wu R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Hai/hai Hai/nai Nai/wai 13 + - 0 F + - 0 F + - 0 F Hai/hai R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- vE/vE vE/fE vE/lE 14 + - 0 F + - 0 F + - 0 F vE/vE R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Si/si Si/zi Si/mi 15 + - 0 F + - 0 F + - 0 F Si/si R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Lai/lai Lai/nai Lai/hai

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16 + - 0 F + - 0 F + - 0 F Lai/lai R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

Ri/ri Ri/ti Ri/vi 17 + - 0 F + - 0 F + - 0 F Ri/ri R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Fu/fu Fu/vu Fu/tu 18 + - 0 F + - 0 F + - 0 F Fu/fu R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- zI/zI zI/sI zI/wI 19 + - 0 F + - 0 F + - 0 F zI/zI R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Mu/mu Mu/pu Mu/gu 20 + - 0 F + - 0 F + - 0 F Mu/mu R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- nE/nE nE/hE nE/mE 21 + - 0 F + - 0 F + - 0 F nE/nE R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Po/po Po/bo Po/wo 22 + - 0 F + - 0 F + - 0 F Po/po R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- lE/rE lE/rE lE/fE 23 + - 0 F + - 0 F + - 0 F lE/lE R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- tE/tE tE/dE tE/nE 24 + - 0 F + - 0 F + - 0 F tE/tE R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2

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V+ V- V+ V- V+ V- Ro/ro Ro/do Ro/ko 25 + - 0 F + - 0 F + - 0 F Ro/ro R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

Kae/kae Kae/gae Kae/mae 26 + - 0 F + - 0 F + - 0 F Kae/kae R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Wai/wai Wai/bai Wai/lai 27 + - 0 F + - 0 F + - 0 F Wai/wai R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Wo/wo Wo/bo Wo/so 28 + - 0 F + - 0 F + - 0 F Wo/wo R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Hu/hu Hu/ru Hu/ku 29 + - 0 F + - 0 F + - 0 F Hu/hu R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V- Vai/vai Vai/fai Vai/zai 30 + - 0 F + - 0 F + - 0 F Vai/vai R+ R- D R+ R- D R+ R- D R+2 R-2 R+2 R-2 R+2 R-2 V+ V- V+ V- V+ V-

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Appendix Z: Communication History Survey

Communication History Survey Date: Participant ID:

Individual Completing the Survey:

Please mark on the line how well you think he/she performs on each task.

1. Getting somebody’s attention.

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