3 The Case for Cognitive Neuropsychological Remediation Marlene Behrmann, MA (Speech Path.) (Witwatersrand) Sharon Herdan, BA (Sp. and H. Therapy) (Witwatersrand) Department of Speech Pathology and Audiology, University of the Witwatersrand, Johannesburg ABSTRACT Developments in the field of cognitive neuropsychology have recently begun to have an impact on therapeutic approaches to aphasia. Increasingly, clinicians have started adopting theoretical models of normal cognitive processing for the assessment and rehabilitation of individuals with acquired language deficits. This study describes and evaluates a single case, tested and treated within this framework. The subject, a surface dysgraphic, was assessed in detail pre-therapy and a deficit in lexical processing was diagnosed. Treatment desi- gned to stimulate the lexical route of writing was undertaken and post-therapy evaluation was conducted. The results revealed a signifi- cant improvement in the writing of both regular and irregular treated words with generalisation to certain untreated words. Such impro- vement was shown to be a direct consequence of the intervention procedure. Therapeutic findings strengthen the basis of cognitive pro- cessing models which, in turn, provide a streamlined clinical framework for the practitioner. OPSOMMING Resente ontwikkeling in die vakgebied van kognitiewe neuropsigologie begin om 'n invloed uit te oefen op terapeutiese benaderings tot afhsie. Terapeute begin toenemend om teoretiese modelle van normale kognitiewe prosessering aan te wend vir die evaluering en rehabi- litering van individue met verworwe taalafwykings. Hierdie studie beskryfen evalueer 'n enkele geval wat binne hierdie raamwerk gee- valueer en behandel is. Voor die aanvang van die behandeling is 'n diepte-evaluasie op 'n pasient met oppervlakdisgrafie uitgevoer en 'n ) 2 afwyking in leksikale prosessering is gediagnoseer. Behandeling gerig op die stimulering van die leksikale roete van skryfvermoens is uit- 1 0 gevoer en die pasient is na afloop van die behandeling geherevalueer. Resultate dui op 'n beduidende verbetering in die skryfvan beide 2 reelmatige en onreelmatige behandelde woorde met veralgemening na sekere onbehandelde woorde. Hierdie verbetering is bewys om 'n d e t direkte gevolg van die intervensieprosedure te wees. Terapeutiese bevindinge verstrek die basis van kognitiewe prosesseringsmodelle wat a op hulle beurt 'n gerasionaliseerde kliniese raamwerk aan die klinikus verskaf. d ( r e h The'last decade has witnessed the rapid expansion of a disci- in the literature (Behrmann 1987; Byng and Coltheart 1986 s i l pline which has come to be called cognitive neuropsycho- and de Partz 1986). The cognitive neuropsychological ap- b u logy. This discipline postulates that an information-proces- proach has facilitated the locating of a specific acquired P sing system, consisting of a number of modular subcompo- deficit in precise terms and has then provided guidelines for e h nents, underlies the normal execution of any cognitive acti- formulating an individually tailored treatment program. Ac- t y vity (Coltheart 1983, 1985).!These modular, domain-specific cording to Hatfield (1983), this new orientation has made it b subcomponents function independently and are intercon- possible to develop new methods which depend on a well- d e nected by a network of pathways. Whereas all the subsys- thought out theory of normal cognitive processing. t n tems function adequately in normals, they are susceptible to a A basic concern of the above cited remediation studies is r discrete disruption following brain damage. Brain damage, g thus, leads to observable dissociations between functions. methodological integrity. Treatment studies have always e c Such dissociations have been studied in detail and have been subject to methodological inadequacies and as such, n e evolved into a detailed description of the various patterns of results have been ambiguous and undefined. In many in- c i l stances, it has been impossible to determine whether the acquired cognitive deficits (see Coltheart 1980). r positive findings were attributable to the treatment itself or e d to other co-occurring but non-specific causes such as sponta- n The study of brain damaged patients within the cognitive u neous recovery or increased motivation (Byng and Coltheart y neuropsychological paradigm has been informative on a 1986). The cognitive neuropsychological remediation stu- a number of levels. It has confirmed the existence of theoreti- w dies, on the other hand, have been designed in such a way e cally postulated dissociations and has lent credibility to the t that the outcome of therapy may be unequivocally inter- a existing theoretical models, especially in the field of ac- preted and as such, satisfy rigorous methodological criteria. G quired dyslexia. A further benefit of such an approach has t e been in the clinical sphere. Sophisticated diagnostic The purpose of this paper is to describe a remediation study n i methods have evolved in order to assess the independent b based on the cognitive neuropsychological theory of a functioning of the modular subcomponents. Additionally, writing. In recent years, models of the normal writing pro- S and more recently, remediation programs designed to y cess have become increasingly well developed and detailed b restore the malfunctioning subsystem, have been described investigations of the acquired dysgraphias have been under- d e c u Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 34, 1987 © SASHA 1987 d o r p e R 4 Marlene Behrmann and Sharon Herdan taken (Margolin 1984; Patterson and Shewell 1987). Despite spelling of words directly from the lexicon and are thus the fact that such theoretical development has much poten- forced to rely on the phonological route whereby phonologi- tial for therapeutic application, there are remarkably few cal segments are translated into orthographic representa- treatment studies in this area. The present study was design- tions (Ellis 1984; Hatfield and Patterson 1983). The outcome ed to apply a model of normal writing to the remediation of of this is that irregular and homophonic spelling is adversely an acquired agraphia. affected and since phoneme-grapheme conversion is used, resulting spelling errors are phonologically plausible for ex- As in most current models of the normal writing process, ample, 'yacht' may be written 'yot'. the writing model adopted for this study includes two major routes (see Figure 1). The phonological route involves the segmental translation from phonology to orthography Previous studies (Beauvois and Derouesne 1981; Hatfield AUDITORY ANALYSIS w W Phonological non-lexical Lexical route route r Phonological representation: word recognition 1Γ ι ) 2 1 0 2 d e t a d ( r e h Figure 1: Simplified information processing model of two major routes for single word writing to dictation (after s i l Ellis 1984: Patterson 1980.) b u through the application of rules of phoneme-to-grapheme- and Patterson 1983) have focussed on the assessment and P classification of acquired surface dysgraphia. Beauvois and e conversion. This route may only be utilised to write regular h t words whose spelling conforms to the spelling conventions Derouesne (1981), for example, reported that their subject; y of the language. In addition, one may use this route for R.G. wrote almost all non-words correctly but that his real b assembling the spelling of unfamiliar words or non-words word spelling depended on the degree of orthographic ambi-, d e which do not have prior entries in the lexicon. The second guity between sound and print. As words became less t n major route, the lexical route, involves an association bet- regular in their spelling pattern, so his performance dete-j a r ween word spelling and its meaning. Thus, the writer must riorated. Hatfield and Patterson's (1983) subject, T.P. alsoj g e recognise the phonological input of the dictated word and spelled via the non-lexical routine. He too showed superior/ c n must access its semantic representation and orthographic performance on regular compared with irregular words and e c form. This may only be achieved with words which have many of his errors were phonologically plausible (e.g., laugh i l prior entries in the lexicon, i.e., are real words which have — laf). Treatment of this disorder was undertaken by Hat- r e been encountered previously. The use of the lexical pro- field (1983) who described a positive therapy outcome for d n cedure is critical for spelling irregular words (which cannot her surface dysgraphic subject. Another study of surface u be assembled through phoneme-grapheme conversion) and dysgraphia treatment, undertaken by Behrmann (1987), was y a homophonic words (which are phonologically identical but devoted to the retraining of the subject's lexical route w differ in orthographic representation and semantics) (Hat- through the use of homophonic rather than irregular words. e t field and Patterson 1983; Margolin 1984). The subject benefitted from this intervention, showing a G marked improvement on treated homophones (from 49% to t e Surface dysgraphia is one of the patterns of deficit identified 67%). In addition, the subject improved on writing un- n i on the basis of models such as the one above. This problem, treated irregular words (32% to 67% across two lists), imply- b ing that a broad, rather than a specific, change within lexical a alternatively termed lexical or orthographic dysgraphia, ari- S ses from the defective