Betsy Cutler Schreiber, MMS CCC
A cognitively based approach to language rehabilitation has been shown to improve communicative outcomes for those who have been impacted due to accident or disease, by developing communication strategies to facilitate functional communication. (Cognitive/Linguistic Strategies Across Aphasia Types, Sonal Chitlis IFNR 2015,MET Mumbai India) These might include writing/drawing, gesturing, using an AAC, or a combination of these items. Keeping in mind that the ultimate goal of therapy is to improve functionality of the client as much as possible, there are several parts to an effective therapy plan:
1. Fostering conversation using what ever means necessary, (writing, gesture, pictures)
2. Stimulating language via all modalities (visual/writing,drawing auditory/ phonemic/intonation; tactile/prompting/gesturing, cognitive memory/attention/experiential)
3. Improving oral motor range of motion, increase tactile feed back for phonemic placement, eating/swallowing while normalizing muscle tone and teaching relaxation techniques, (ba,be,bi,bo,bu or bat, bet, beet, boat, boot, I like to use real cv words with my aphasics to help them link the sounds to something cognitive..sometimes they are daunted by the cv’s alone)
4. Developing pragmatic skills to improve communication independently, practicing functional activities such as using a phone, ordering, making appointments, greetings, reading the newspaper, writing on a calendar, signing or filling out forms, using a cd player or any device they might use for music or books on tape.
Along with the goals we establish for our clients, we must always be evaluating their behavior and trying new materials and varied activities to facilitate language. Each client is unique, so we learn to be good observers of behavior and good listeners of the sounds our clients are making as approximations to their communication. During diagnostic therapy, which is often a part of the therapy plan, I look for the modality that can serve the client best. For clients with progressive disorders particularly, regular assessment of function is critical. Again, a good clinician is a good observer of both the client and the clinician’s behaviors. At no time do I continue to frustrate them, stress reduces the chances that they will succeed. We reinforce communication approximations by affirming their productions and confirming their utterances. Even if you have been in practice for many years, it is good to reorient ourselves to these objectives.
The concept of establishing a Cueing Hierarchy: In order to organize the therapy objectives and cuing types for gradual independence, I developed a chart for as a “Cueing Hierarchy” with stimuli and behaviors as if placed on an imaginary linear continuum, from easy to hard and from simple to complex. The simplistic table below lists target response category and the type of cue to elicit the responses.
As we converse with others, we derive cues from the environment and from the people we are speaking with. (That is part of the reason why conversation amongst the adult neurologically language impaired looks better than when we test them by looking for specific words and longer utterances.) Our goal with establishing a starting point on a Cueing Hierarchy is to outline the steps we may use to develop SELF-cues and elicit more independently generated functional language.
When the client leaves the therapy room, we want him/her to be able to use their own skills as much as possible, rather than rely on others. Since they may not be able to develop their own means of self-cueing, we include self-cue skill development as part of the therapy plan. The client may or may not have the ability to provide his or her own cues, yet. But throughout the therapy we work with the clients abilities toward each clients’ unique the ways of use self-cuing strategies, such as writing, gesturing, drawing pictures, pointing to pictures on an AAC and talking about the item or activity with words that are available.
During our diagnostic phase, the clinician first guides the client to use the above means of self-cuing. If the client can write or figure out the word with categorization the clinician will cue the strategies the client could use: think about what you use it for (categorization) Show me how you use it (gesture,) What letter does it start with or can you write the word?(writing). Most of the time, these “strategies” need to be taught and practiced with the client. They do not realize they’re are things they can do already. That becomes one of our therapy objectives depending on the client’s basic language and cognitive abilities. Once the client is familiar with these strategies, they will begin to use them if practiced when they are unable to find a word or say it. This behavior begins to form new neural links even if the link and resulting response is slow at first, it is a link that the client is developing himself. This is “Neuroplasticity” at work. (“Harnassing Neuroplacticity for Clinical Applications”, DOI: http://dx.doi.org/10.1093/brain/awr039 1591-1609 First published online: 11 April 2011)
Clinician or Listener assisted cues look like this: Therapeutic Objective: The client will name objects in a category with moderate phonemic and semantic clinician cues with 80% accuracy. The hierarchy of cues are part of the branches you will list on the therapy log:
Procedures: The client will name objects to pack in a suitcase for a trip to the Bahamas.
I have established a cognitive umbrella (categorization) (the trip to the Bahamas)
Using visual supports ( a small suitcase with pictures or different objects and/or
a picture of a suitcase )
The clients task is to choose and name the items he/she will pack. If the client is unable to do what you are asking him to do, see what you can elicit using the various cues such as gesturing the use of the item, providing an open ended phrase, or the first sound of the word. Get a baseline of where on the continuum they fall. You will begin to get a picture of how close they are to developing self cueing skills they and what skills you need to develop.
Based on your previous observations and diagnostic information, start with the highest level strategy you think the client can achieve, then branch down to imitation and repetition if necessary. Always try to give the client a chance to give a correct response. Setting up a cognitive umbrella makes the activity more functional, with pictures or objects. This aids in facilitating more interaction via verbal expression, writing, drawing, use of the AAC and gestures. Why does the cognitive link help with word finding? Think about your experiences you have had with a plastic razor. There are a lot of memories/experiences i.e. neural links associated with the object and the word. The more links / memories there are for any word, the more likely the client will be able to get to them because if the direct route isn’t working, they can learn to look for the other still intact “visceral” links. Relinking these words with experiences can cooperate with Repetition for the word “razor”. Two Graphs can be found below which might help you visualize a fluid Cueing Hierarchy for Adult. If you place them next to each other, you can see how they might form a continuum. However, people have unique language abilities after CVA,TBI, PPA and abilities may be scattered. The goal is to find the key to unlocking and maximizing their functional language abilities.
Client generated cues are those that the client uses to get to the word that he/she wants to say. This is the type of skill we want to encourage and practice. It is more difficult, but it breaks down and individualizes the process which will help the client reconnect to that word. We call it self cueing. Hopefully, the client will be able to self cue with out writing the first letter or gesturing, they may retrieve the word by revisualizing or getting into the correct category through circumlocution, which is normal!