Tried, tested and trusted Language assessment for rehabilitation'

1
Tried, tested and trusted? Language assessment
for rehabilitation.  

• Lyndsey Nickels
• Macquarie Centre for Cognitive Science (MACCS)
• Macquarie University, Sydney.
• Paper presented at International Conference on
  the Effectiveness of Rehabilitation for Cognitive
  Deficits, Cardiff, Wales, 17th 19th September,
  2002

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What is the purpose of assessment?

• A diagnostic tool
• Differential diagnosis
• from e.g. dysarthria, dyspraxia
• Aphasia subtype
• e.g. Wernickes vs Brocas vs Conduction aphasia
• Impact on communication
• Impact on quality of life
• The diversity of assessment for aphasia reflects
  the different perspectives regarding the aims of
  the diagnostic process.

3
What is the purpose of assessment?

• .to enable formulation of a hypothesis regarding
  the areas of strength and weakness in
  functioning, in order to set appropriate goals
  for therapy
• and
• .to evaluate the outcome of the therapy process

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The scope of the (aphasia) rehabilitation process.

• rehabilitation of aphasia is complex and
  wide-ranging
• Byng (1993)
• delineate the uses of language for the individual
• facilitate adjustment
• investigate the language deficit
• remediate the language deficit itself
• increase the use of other means of communication
• provide an opportunity to use newly acquired and
  emerging language skills
• attempt to change the communication skills of
  those around the person with aphasia  
• a duty to document the efficacy of
  rehabilitation

5
Evaluating the outcome of the (aphasia)
rehabilitation process.

• requires appropriate assessment before
  rehabilitation begins, during the rehabilitation
  process and after rehabilitation (by the
  therapist) has ended.
• Requires testing that is
• reliable enough to give consistent measures
• sensitive enough to measure the improvement that
  the particular therapy involved is intended to
  produce
• valid so that it measures changes that are of
  real consequence (Howard Hatfield, 1987,
  p113).

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Assesment of aphasia

• Assessment of
• language functions
• communication activities and participation
• quality of life/psychosocial issues.

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Language Functions Assessment of the language
impairment.

• Reception of language
• spoken language
• written language
• sign language
• Expression of language
• spoken language
• written language
• Sign language
• Integrative language functions
• Mental functions that organize semantic and
  symbolic meaning, grammatical structure and ideas
  for the production of messages in spoken, written
  or other forms of language.

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Approaches to the assessment of language function

• battery approach
• hypothesis testing approach.

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BATTERY approach to the assessment of language
function

• e.g. Boston Diagnostic Aphasia Examination
  (Goodglass Kaplan, 1983)
• Minnesota Test for Differential Diagnosis of
  Aphasia (Schuell, 1965),
• Porch Index of Communicative Ability (PICA
  Porch, 1967, 1981)
• Western Aphasia Battery (WAB, Kertesz, 1982),
• Screening assessments
• e.g. Aphasia Screening Test (Whurr, 1996)
• Frenchay Aphasia Screening Test (FAST Enderby et
  al., 1987 Enderby Crow, 1996).
• not designed primarily to elucidate the
  underlying nature of the language disorder
• interpretation is in terms of diagnosis of a
  syndrome on the basis of the surface symptoms of
  the language impairment

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HYPOTHESIS TESTING approach to the assessment
of language function

• uses observations to form a hypothesis regarding
  language processing
• hypothesis must be related to a particular theory
  of language processing
• and will comprise predictions regarding which
  language functions are intact and which are
  impaired
• on the basis of this hypothesis the clinician
  chooses the (formal/informal) assessment that
  they believe initially will be the most
  informative to support/refute the hypothesis
• the results of assessment revise the hypothesis
• cyclical testing will continue until a
  sufficiently clear picture is formed to provide a
  focus for therapy.

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HYPOTHESIS TESTING approach to the assessment
of language function (cont.)

• most commonly associated with the cognitive
  neuropsychological approach
• e.g. PALPA (Psycholinguistic Assessments of
  Language Processing Ability in Aphasia Kay,
  Lesser and Coltheart, 1992)
• Pyramids and Palm Trees Test (Howard
  Patterson, 1992)
• Sentence Processing Resource Pack (Marshall et
  al., 1998).
• Majority of clinicians have advanced hypothesis
  formation skills
• Not restricted to assessment of impairments of
  language function.

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Are standardised aphasia batteries adequate for
rehabilitation-focused assessment of aphasia?

• Are syndrome classifications useful for planning
  therapy?
• widely acknowledged that individuals within these
  syndrome categories are not homogeneous
• hence the categories do not reveal the individual
  variations in the nature of the language
  impairment
• Kertesz (1988) - remain useful
• cf Byng et al (1990). little benefit for
  focusing treatment

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Are standardised aphasia batteries adequate for
rehabilitation-focused assessment of aphasia?
(cont).

• Goodglass (1990) - batteries also aim to provide
  the clinician with an overview of language skills
• Is the overview of processing skills across
  domains useful?
• Batteries do not provide a theoretical framework
  within which to interpret performance.
• surface symptoms are not reliable indicators of
  underlying language impairment
• e.g. impaired auditory comprehension on BDAE
• Impaired semantic processing?
• impaired processing of auditory input?
• impaired non-language skills (e.g.acoustic
  processing)?
• Does performing the battery provide sufficient
  additional information over and above informal
  observation and assessment to warrant the time
  taken?

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Are standardised aphasia batteries adequate for
rehabilitation-focused assessment of aphasia?
(cont).

• Are standardised aphasia batteries adequate for
  documenting change over time?
• lack of sensitivity to change
• improvement in a specific area will not be
  evident in the overall score
• problem of variability
• the smaller the numbers of items, the harder it
  is to distinguish real change from the noise
  caused by variability
• standardised tests that measure a non-specific
  overall level of deficit cannot be expected to
  measure specific improvement particularly when
  the unreliability of performance is taken into
  account
• (Howard Hatfield, 1987 p114).

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Summary Assessment of the impairment of language
functions.

• Hypothesis testing approach
• most efficient and clinically useful
• clear identification of retained and impaired
  language functions
• Limitations
• accuracy and degree of detail of theories of
  language processing
• skill of the clinician at relating observations
  to theory to form hypotheses.
• No assessment approach specifies what specific
  treatment, nor what treatment approach, is
  appropriate but.
• a clearer understanding of the underlying nature
  of the language disorder better enables the
  clinician to determine which kind of treatment
  might be appropriate

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ICF Communication activities

• Communicating - receiving  
• Spoken messages nonverbal messages written
  messages
• Communicating - producing 
• Speaking producing nonverbal messages writing
  messages
• Conversation and use of communication devices and
  techniques
• Conversation Starting, sustaining and ending an
  interchange of thoughts and ideas, carried out by
  means of spoken, written, sign or other forms of
  language, with one or more people one knows or
  who are strangers, in formal or casual settings.
• DiscussionStarting, sustaining and ending an
  examination of a matter, with arguments for or
  against, or debate carried out by means of
  spoken, written, sign or other forms of language,
  with one or more people one knows or who are
  strangers, in formal or casual settings.
• Using communication devices and techniques Using
  devices, techniques and other means for the
  purposes of communicating, such as calling a
  friend on the telephone.

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Communication activities and participation
Functional assessments of language use

• Here we will distinguish
• functional communication assessments developed as
  measures of limitations in communication
  activities and participation
• assessments from a more linguistic/pragmatic
  perspective which also examine in more detail how
  and why these limitations might be occurring.

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Communication activities and participation
Functional assessments of language use

• Rating scales and observational inventories
• Including..
• Functional Communication Profile (FCP, Sarno,
  1969)
• American Speech Hearing Association Functional
  Assessment of Communication Skills (ASHA FACS,
  Frattali et al., 1995)
• Communicative Effectiveness Index (CETI Lomas et
  al., 1989)
• La Trobe Communication Questionnaire (LCQ
  Douglas et al., 2000)
• e.g. ASHA-FACS 4 domains.
• social communication (e.g. exchanges information
  on the telephone)
• communication of basic needs (e.g. responds in
  an emergency)
• reading, writing and number concepts (e.g.
  understands simple signs)
• daily planning (e.g. follows a map)

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Communication activities and participation
Functional assessments of language use

• Assessments where performance on test items is
  evaluated
• Including.
• Communicative Activities of Daily Living (CADL,
  Holland, 1980 CADL-2, Holland et al., 1998)
• Amsterdam-Nijmegen Everyday Language Test (ANELT,
  Blomert et al, 1994).
• e.g. ANELT, Scale A 10 scenarios of daily life,
• verbal response rated on a 5-point scale,
• representing the content of the message,
• independent of the linguistic form of the
  utterances.
• e.g. You have just moved in next door to me.
  You would like to meet me. You ring my doorbell
  and say . . ..

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Adequacy of Functional approaches to
rehabilitation-focused assessment

• Murray and Chapey (2001)
• further research is urgently required to
  determine whether they have sensitivity to change
  over time (as well as general sensitivity,
  reliability and validity).
• e.g. Lomas et al (1989)
• 2 groups - recovering (6-10 weeks post-onset)
  stable (gt65 weeks post onset)
• CETI ratings of communicative ability x 2 - 7
  weeks apart.
• 36 of the stable group show variability of as
  great (or greater) magnitude than 54 of the
  recovering group.

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Adequacy of Functional approaches to
rehabilitation-focused assessment (cont)

• Worrall (1992, 2000, Worrall et al., 2002)
• a single assessment is unlikely to be appropriate
  to assess all individuals with aphasia all
  cultures, all impairments, and all settings.
• clinicians should not rely on a single assessment
  of functional communication.
• Sacchett Marshall (1992)
• an assessment that attempts to capture the whole
  of an individuals functional communication
  ability will inevitably be inadequate

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Recommendation Functional approaches to
rehabilitation-focused assessment

• assessment that focuses on specific areas
  motivated by prioritisation
• Aim to..
• identify the reason for failure,
• the aspects successfully achieved,
• be detailed enough and sensitive enough to enable
  observation of change as a result of
  rehabilitation.

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Pragmatic approaches to assessing language use

• conversational analysis
• (e.g. Whitworth, Perkins Lesser, 1997 for
  discussion see Perkins, Crisp Walshaw, 1999)
• discourse analysis
• (for discussion see Armstrong, 2000 Togher,
  2001).
• a sample of communicative behaviour
• analysed with respect to any one of a number of
  aspects of communicative behaviour
• (e.g. turn taking behaviour, conversational
  repair, discourse cohesion, content and
  efficiency of language).
• the focus of the analysis can be highly specific
  according to the hypothesis to be tested.

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Adequacy of pragmatic approaches to assessing
language use (cont)

• methodological problems
• Variability across and within individuals and
  contexts
• Quantitative qualitative
• predominantly the more general measures that show
  stability across samples
• more subtle pragmatic aspects of communication
  (e.g. clause complexity analysis cohesion,
  conversational repair) appear less easy to
  quantify reliably

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Summary Assessment of communication activities
and participation

• Further research needed to determine if and how
  assessments of language use can possess.
• sensitivity to change over time
• reliability within and across raters, and over
  time
• sufficient range of performance measured to
  prevent threshold effects
• usefulness across different methods of
  administration
• usefulness during different phases of
  rehabilitation
• relevance to function outside the clinical
  setting
• Frattali (1992, p79)

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Assessment of Quality of life/psychosocial
issues.

• Simmons-Mackie (2001)
• disrupted communication entails social meanings
  and consequences.
• when social systems do not support communicative
  access for the individual with aphasia,
  psychosocial well-being and quality of life are
  reduced
• these psycho-social dimensions are seen as an
  integral part of aphasia and aphasia
  rehabilitation
• assessment is designed to provide insight into
  well-being, personal consequences and life-style
  effects of aphasia

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Assessment of Quality of Life/ Psychosocial
issues.

• Scales for rating quality of life and
  psychological well-being are not designed
  specifically for aphasia
• e.g. Short-form-36 Health Survey SF-36 (Ware
  Sherbourne, 1992)
• Ryff Psychological Well-being Scale (Ryff,
  1989).
• often broad-ranging
• e.g. the Dartmouth COOP charts (Nelson, Wasson,
  Kirk et al., 1987)
• Some attempts to make scales more aphasia
  friendly (e.g. Hilari, Byng Pring, 2001)
• communication and social relationships are
  generally underrepresented in such assessments

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Assessments of Quality of Life/ Psychosocial
issues.

• Poor sensitivity
• Measurement over time
• quality of life is dynamic and changing dependent
  on mutiple factors in the social/psychological/phy
  sical environment
• harder to attribute these changes specifically to
  therapy and exclude the effects of other life
  influences
• more likely to be overcome if a treatment is
  aimed at specific aspects of psychosocial
  functioning, and uses a detailed and sensitive
  assessment that discriminates between these
  different aspects, which can show changes in some
  areas but not others

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Relationships between impairments of language
function limitations in communication
activities participation

• Is there any consistent relationship between the
  degree (and/or type) of impairment of language
  function and the limitations in language
  activities, restriction in participation and
  reduction in quality of life?
• Can we expect change at the level of language
  function to be reflected by change in activities,
  participation and quality of life?

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Relationships between impairments of language
function limitations in communication
activities participation

• a significant correlation between language
  impairment
• (e.g. WAB aphasia quotient Boston Naming Test)
• measures of communication activities and
  participation (e.g. CETI CADL)
• e.g. Aftonomos, Steele, Appelbaum Harris, 2001
  Cruice et al, in press Irwin, Wertz Avent,
  2002 Ross Wertz, 1999 but see Ulatowska,
  Olness, Wertz et al. 2001.
• less consistency in studies examining
  relationships between language impairment and
  quality of life
• (cf, for example, Cruice et al, in press, and
  Ross Wertz, 2002).

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Does language impairment correlate with
communication activities and participation?

• A simplistic ( misguided) question
• Instead.
• Which particular aspect of language impairment
  relates to which aspect of activity limitation/
  participation restriction?.
• e.g. Doesborgh et al (2002) Does lexical-semantic
  or phonological impairment have the greatest
  impact on verbal communication?
• multiple factors (over and above communicative
  competence) which affect activity and
  participation for an individual

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Summary

• inappropriate to use a general, broad ranging
  assessment
• assessment should be hypothesis driven
• Applicable to every aspect of an individual and
  their social context that is, or might be,
  impacted by the aphasia

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Summary (cont.)

• For documenting change over time
• assessments need to be reliable (show consistent
  test-retest) and sensitive
• relatively large samples of behaviour
• relationship between impairment of language
  function and restrictions in language activities,
  participation and quality of life is not
  straightforward.
• attempts to correlate change at one level with
  change at the other are fundamentally flawed
• activity, participation and quality of life are
  impacted by many factors over and above the
  language impairment

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Conclusions

• In order to effectively assess the individual
  with aphasia and use those assessments to track
  change over time, we must be acutely aware of the
  strengths and limitations of our assessment
  tools.
• We have a duty to all those involved in the
  rehabilitation process to strive to overcome
  these limitations and critically evaluate the
  efficacy of our interventions as part of routine
  clinical practice.

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failure to apply scientific thinking and
measurement during the clinical process is surely
as misguided as leaving our empathy, clinical
intuition, and caring attitudes behind as we
enter the clinical arena (Kearns, 1993
p71.)
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Full Reference.

• A paper based on this presentation will appear in
  
• P.A. Halligan D.T. Wade (Eds.) (2003). The
  effectiveness of rehabilitation for Cognitive
  Deficits. Oxford Oxford University Press.
• A preprint will be available from November 2002
  at
• http//www.maccs.mq.edu.au/lyndsey