Management of Acquired Language Disorders

Associated With Attentional Impairment

Richard K. Peach, Ph.D., CCC-SLP, BC-ANCDS
Departments of Communication Disorders & Sciences,
Neurological Sciences, and Otolaryngology
Rush University
Chicago, Illinois
richard_k_peach@rush.edu
Learning Objectives

• Identify attention deficits in patients with acquired

language disorders
• Provide a rationale for using a linguistic context to
treat language disorders due to attentional
impairments
• Describe the ways that language operates as an
attention director
• Describe the differences between direct process and
language-specific approaches to attentional
treatments for acquired language disorders
Attentional Impairments and Aphasia

• Less accurate and significantly longer response times

than non-brain-damaged controls on tasks of
semantic judgment and lexical decision under
focused and divided attention conditions; greater
interference when competing tasks are verbal
• Rapid decay for digit and word spans
• Reduced confrontation naming, oral word reading,
and auditory word recognition when tasks presented
to contralesional hemispace in patients with parietal
lobe lesions

Arvedson & McNeil, 1987; Martin & Saffran, 1992; Coslett, 1999; Ansaldo et al., 2004
Attentional Impairments and Aphasia

• Poorer phrase completion under focused attention

and divided attention conditions than in single task
condition
• Fewer well-formed utterances and significantly more
simple versus complex sentences in divided attention
conditions
• Slower central processing (phonological word-form
selection) for picture-naming

Murray et al., 1997, 1998; Murray, 2000; Hula, McNeil, & Sung, 2007
Attentional Impairments and RHD

• Acquired pragmatic disorders associated with hypo-

responsiveness, hyper-responsiveness, and interpersonal
interactions
• Impaired ability to appreciate visual and verbal cues within
communicative contexts
• Difficulty shifting attention during conversations
• Reduced ability to sustain attention to the communication
environment and to filter distractions
• Difficulties forming and maintaining inferences about the
meaning of verbal communications
• Irrelevant interpretations of, and responses to, the
communication environment

Blake et al., 2002; Myers & Blake, 2008

Attentional Impairments and AD

• Difficulty following simple conversations; amplified

when conversation involves multiple participants
and/or participants who move from one location to
another
• Inconsistent naming
• Increased phonemically-implausible spelling errors;
more errors for delayed vs. direct copying; more errors
for longer vs. shorter dictated words
• AD subgroup characterized by attention/concentration
impairments with severe language impairments

Alberoni et al., 1992; Kempler et al., 1995; Neils et al., 1995; Davidson et al., 2009
Attentional Impairments and TBI

• “Cardinal” deficits consisting of impairments in

lexical-semantic and sentential semantic skills, verbal
fluency, complex auditory comprehension, and
attentional operations
• Confused or disorganized language characterized by
deficient sentence and discourse planning
• Conversational difficulties characterized by problems
with maintaining or extending the topic of
discussion, using reference, and integrating relevant
information
• Incoherent and socially inappropriate expression
Hinchliffe et al., 1998; Ellis & Peach, 2009; Deschaine & Peach, 2008; Coelho, 2007; Stierwalt & Murray, 2002
Attention Interventions for Language Disorders

• Nonlinguistic tasks to treat sustained, selective, and

alternating attention (symbol cancellation, trail
making, repeated graphomotor patterns, auditory
continuous performance, and sorting)
• Treatment for spatial attention by increasing
patients’ orientation to left hemi-space during
picture naming
• Treatment for focused, alternating, selective, and
divided attention using a variety of linguistic stimuli
(numbers, letters, words) and tasks included in
Attention Process Training II
Helm-Estabrooks et al., 2000; Crosson et al., 2007; Coelho, 2005; Sinotte & Coelho, 2007; Murray, 2006
Specificity of Attention Interventions

• Outcomes associated to date with attentional

treatments for acquired language disorders have
been weak
• Most likely due to generalized or non-specific
approach taken with regard to attention intervention
• All approaches assume improved language will result
from increased attention to linguistic stimuli
• None are motivated by analysis of the ways specific
linguistic processes recruit select attentional
operations in the service of language

Rohling et al., 2009

Specificity of Attention Interventions

• Specific attention functions improve in patients with localized

vascular lesions only when specific training is received for that
function (e.g., training for intensity [alertness, vigilance]
versus selectivity [selective and divided attention] aspects of
attention)
• No evidence to support approaches (e.g., APT-II) that
incorporate direct training of distinct attentional components,
i.e., sustained, selective, divided, and alternating attention
• Attention treatments result in significant improvement when
focus is on:
– Learning or relearning of specific skills that are important to
desired outcomes
– Behaviors that have functional significance
Sturm et al., 1997; Park and colleagues, 1999, 2001, 2005
Specificity of Attention Interventions

• Treatment for language disorders due to attentional

impairments better served by addressing underlying
attentional deficits within context of specific
linguistic operations
• That treatment studies for language disorders
associated with attentional impairments have not
done so offers explanation for weak outcomes
• Appreciation of the ways language operates as an
attention director needed to address attentional
deficits through language treatment

Peach, 2012
Language and Attention

• Some accounts suggest that the language processor

attends to the referents that are being described
• Language processing focuses attention on the
relevant aspects of the real-world context
• Language processing can’t be separated from real-
world context onto which the language must be
mapped
• Fundamental relationships between language and
attention expressed in the related concepts of
grounding and windowing

Altmann, 1996
Language and Attention: Grounding

• Meanings of specific utterances sharing similar

lexical items depend on which “thing” is identified or
which process is described with respect to the
ground (speech event, participants, interaction, and
circumstances)
• Interpretations are based on speaker-hearer
interaction in current discourse context
• Grounding refers to a speaker’s use of linguistic
elements to direct a hearer’s attention to a particular
meaning within the discourse

Langacker, 2008; Taube-Schiff & Segalowitz, 2005

Through nominal grounding (e.g., the, this, that, some, a,
each, every, no, any), the speaker directs the hearer’s
attention to the intended discourse referent, which may
or may not correspond to an actual individual. Clausal
grounding (e.g., -s, -ed, may, should, will) situates the
profiled relationship with respect to the speaker’s current
conception of reality

(Langacker, 2008, p. 259)

Individually and together, the speaker and hearer function as the subject of conception and figure, at
least minimally, in the meaning of every utterance. An important aspect of the subject’s activity is the
focusing of attention. Within the full scope of awareness for the content of an utterance, the subject
attends to a certain region (Langacker’s “onstage” region) and further singles out some onstage
linguistic or grammaticized element as the focus of attention. This is the object of conception which
can be either a thing or a relationship. As the focused object of conception, it is interpreted most
clearly with respect to the context and the listener. For example, the demonstrative this indicates that
the nominal it points to is close to the speaker but it does not refer to the speaker explicitly.
Language and Attention: Grounding

• Participants demonstrate greater demands for

attentional control when judging spatial (above-
below) or temporal (past-present) function words
embedded in phrases
• Greater shift costs observed in a grammatically
dissimilar condition (participants required to shift
between spatial and temporal function words) versus
a grammatically similar condition (participants
required to shift between spatial words describing a
vertical dimension, i.e., above-below, or a proximal
condition, i.e., near-far).
Taube-Schiff & Segalowitz, 2005
Language and Attention: Grounding

• Spatial language (e.g., The bottle is over the glass) directs

attention to a visual scene
• Two views for how this might occur:
– Directs hearer’s attention to a reference object in the array being
described and then specifies how attention should be switched to the
object to be located
– Sentence activates knowledge that includes the placement of the
objects according to the way objects typically interact
• Evidence suggests that spatial language comprehension is
associated with a situational representation of how objects
usually function
• Spatial language thought to direct attention to objects not
mentioned in the heard sentence

Coventry, Lynott, Cangelosi, Monrouxe, Joyce, & Richardson, 2010

Language and Attention: Windowing

• Language can be used to direct one’s attention over a referent

scene in a certain pattern, with the greatest attention being
placed in one or more windows of a scene
• Such referent situations are referred to as event frames, sets
of conceptual elements and interrelationships that are evoked
together.
• Those elements or interrelationships that are conceived as
central identifying core of a particular event are said to be
windowed (foregrounded) while those that are conceived as
peripheral or incidental are said to be gapped (backgrounded)

Coventry, Lynott, Cangelosi, Monrouxe, Joyce, & Richardson, 2010

Peach, 2012
Open Path Windowing

• Maximal windowing: The crate that was in the aircraft’s cargo bay fell out
of the plane through the air into the ocean.
• Medial gapping: The crate that was in the aircraft’s cargo bay fell out of
the plane into the ocean.
• Initial gapping: The crate that was in the aircraft’s cargo bay fell through
the air into the ocean.
• Final gapping: The crate that was in the aircraft’s cargo bay fell out of the
plane through the air.
• Initial windowing: The crate that was in the aircraft’s cargo bay fell out of
the plane.
• Medial windowing: The crate that was in the aircraft’s cargo bay fell
through the air.
• Final windowing: The crate that was in the aircraft’s cargo bay fell into the
ocean.

Talmy, 2003
Peach, 2012
Phase Windowing

• Departure phase windowing:

– The pen kept falling off the table.
• Return phase windowing:
– I kept putting the pen back on the table.
• Departure phase plus return phase
windowing:
– The pen kept falling off the table and I kept
putting it back.

Talmy, 2003
Language and Attention: Windowing

• The creation of a linguistic window over portions of a

conceptual complex links the attentional system with the
corresponding parts of the cognitive system processing that
complex
• Referred to as “the windowing of attention” when language
includes explicit linguistic material for the portions to be
foregrounded (windowed) and the exclusion of any linguistic
material for the portions to be backgrounded (gapped)
• In this way, the language system can direct the limited
cognitive resources of the attentional system to the
information that the user establishes as the most relevant
based on larger concerns or goals

Talmy, 2003
Word Processing

• Some aspects of word production (lemma selection

and phonological word-form selection) are subject to
a central bottleneck (require privileged use of
resources) while other aspects (phoneme selection)
operate independently of a central bottleneck
• Domain-general central processing mechanisms
required for determiner as well as noun production;
findings suggest that determiner form retrieval
cannot rely on automatic, language-dedicated
mechanisms for closed-class word retrieval

Ferreira & Pashler, 2002; Ayora, Janssen, Dell'Acqua, & Alario, 2009
Sentence Processing

• Speakers use devices like accent or topicalisation (placing

of a topic at the beginning of a sentence) to direct
listeners’ attention to the focus of the sentence
Blue, the hat was, that the man on the corner was
wearing)
• Greater attention is required to resolve referential
ambiguity raised by the use of anaphora when a longer
distance occurs between a referent and its antecedent
Mary told John during the party about the woman he
was going to meet

Cutler & Fodor, 1979; Myachykov & Posner, 2005

Sentence Processing

• When subjects are asked to describe a stimulus in which

attention is cued to one or the other sides of an array (e.g., a
heart and a star), the choice of syntactic subject will vary
according to the cue (i.e., the heart is to the left of the star
versus the star is to the right of the heart)

Myachykov & Posner, 2005

Sentence Processing

• Similarly, when subjects are asked to describe an unfolding

event (e.g., the eating of a dark fish by a light fish), the choice
of syntactic subject is also determined by the cue (i.e., the
dark fish was eaten by the light fish versus the light fish ate
the dark fish)

Myachykov & Posner, 2005

Considerations for Intervention

• Language processing is dependent upon adequate attentional

functioning in the service of language
• Language disruption may represent
– A failure of an impaired language mechanism to sufficiently direct attention to
critical linguistic constituents necessary for the processing of meaning
– A failure of language processing secondary to inadequate recruitment of
attentional resources that are essential for the interpretation of linguistic cues
– A failure of language processing due to reduced capacity or allocation of
attentional resources that support language processing
– Some combination of all of the above
• In all instances, the focus of the intervention for improved language
functioning should be on the use of attention-directing language
tasks

Peach, 2012
Attention Assessment For Acquired Language Disorders

• Current practice consists of determining the extent to which a

variety of attentional domains are impaired without recourse
to their direct influence on language functioning
• Tests of the effects of attentional impairments on language
processing must use language stimuli to establish the
influences of one on the other; problems arise when
attempting to determine the source of the language
disturbance, i.e., attentional vs. linguistic
• Dual-task assessment should be included to index
interference during language processing when listeners/
speakers control and coordinate allocation of attentional
resources for semantic, syntactic, and phonologic processes
Attention Assessment For Acquired Language Disorders

• Assess language performance:

– General language
– Oral naming/Word meaning
– Higher-level language
– Functional language
• Assess attentional impairments for:
– Attention Control: Focused, sustained, divided, and higher-
order (executive) attention
– Speed of information processing
• Attention allocation (dual-task performance)
• Ecological outcomes
vanZomeran & Spikman, 2005; McNeil, Hula, & Sung, 2011
Peach, 2012
Peach, 2012
Treatment: Lexical Processing

• Attention Manipulation: Spatial Attention

– Picture stimuli are presented in ipsilesional hemispace for
naming and gradually moved to the center of visual space
– Accuracy of naming for trained and untrained items assessed to
evaluate improvement
• Attention Manipulation: Attention Allocation
– Patient listens to word lists and raises hand when target word
heard while simultaneously completing card sorting task
– Accuracy measured for target word identification and card
sorting responses

Peach, 2012
Treatment: Sentence Processing

• Attention Manipulation: Focused Attention

– Patient describes a dynamic event with semantically-reversible
objects using external cues to determine the syntactic subject
– Events are presented using pictures and/or object manipulations

Event: A brown bear kissing a black bear

Cue: Brown bear
Response: The brown bear is kissing the black bear
Cue: Black bear
Response: The black bear was kissed by the brown bear

Event: A black bear giving a donkey to a brown bear

Cue: Black bear
Response: The black bear is giving the donkey to the brown bear
Cue: Brown bear
Response: The brown bear was given the donkey by the black bear.
Peach, 2012
Treatment: Sentence Processing

• Attention Manipulation: Focused Attention

– Place embedded topics at the beginnings of sentences to
improve attention to, and comprehension for, sentences
– Subsequently withdraw topicalisation of target words

Topicalized sentence (Cutler & Fodor, 1979):

Candid, the story was, that the reporter with the daily newspaper was responsible
for.
Which reporter was responsible for the story?
Which story was the reporter responsible for?
Sentence without topicalisation:
The opening of the concert was spoiled by the director’s outburst.
Which opening was spoiled by the director’s outburst?
Whose outburst spoiled the opening?

Peach, 2012
Treatment: Sentence Processing

• Attention Manipulation: Focused Attention

Present sentences with anaphoric pronouns that require a
cognitive search for the antecedent

Anaphoric sentences:
Kevin left after he found the envelope.
Who found the envelope?

Mary told John during the party about the woman he was going to meet.
Who was going to meet the woman?

The man who investigated Charley over the previous three years told the woman
how much he hates him.
Who does the man hate?

Peach, 2012
Treatment: Sentence Processing

• Attention Manipulation: Focused Attention

Present sentences that use nominal grounding elements
Articles (a, the):
The girl in the class likes a boy.
Do we know which girl likes the boy?
Do we know which boy the girl likes?
Demonstratives (this, that, these, those):
This evidence should satisfy those detectives.
Is the evidence close at hand?
Are the detectives close at hand?
Quantifiers (all, most, some, every, each, any):
All of the buildings were badly damaged but most of the animals escaped.
Did any of the buildings escape damage?
Did any of the animals escape harm?

Peach, 2012
Treatment: Sentence Processing

• Attention Manipulation: Focused Attention

Present sentences that use clausal grounding elements

Tense:

Jim says that he is injured.

Jim says that he was injured.

Jim said that he is injured.

Jim said that he was injured.

Is Jim saying that he is injured now?

Is Jim saying now that he is injured?

Peach, 2012
Treatment: Sentence Processing

• Attention Manipulation: Focused Attention

Present sentences that use clausal grounding elements

Modals (may, can, will, shall, must):

You might help me shovel the snow for a change.

You must help me shovel the snow for a change.

Is there a chance you won’t help me with the snow?

Are you required to help me shovel the snow?

Peach, 2012
Peach, 2012
Treatment: Sentence Processing

• Attention Manipulation: Focused Attention

Identify core elements of a sentence using windowing
Path windowing (The example is for open path windowing):
The ball that was hit by the pitcher sailed like a rocket on a line drive to the
outfield wall.
Initial windowing:
How was the ball hit?
The ball that was hit by the pitcher sailed like a rocket
Medial windowing:
What kind of a hit was it?
The ball that was hit by the pitcher sailed on a line drive.
Final windowing:
Where did the hit go?
The ball that was hit by the pitcher sailed to the outfield wall.
Peach, 2012
Peach, 2012
Treatment: Sentence Processing

• Attention Manipulation: Focused Attention

Identify core elements of a sentence using windowing

Phase windowing:
The car battery continued to die and I kept recharging it.

Departure phase windowing:

What did the car battery do?
The car battery continued to die

Return phase windowing:

What did I do?
I kept recharging the battery.

Peach, 2012
Treatment: Sentence Processing

• Attention Manipulation: Focused Attention

Identify core elements of a sentence using windowing
Factuality windowing:
I wasn’t in the meeting last week.
Comparison frame:
What would be the opposite of this event?
I was in the meeting last week.
I went to the meeting last week because I was scheduled to speak.
Comparison frame:
What would you have done if you were not scheduled to speak at the
meeting last week?
I would not have gone to the meeting because I was not scheduled to
speak.

Peach, 2012
Treatment: Sentence Processing

• Attention Manipulation: Attention Allocation

– Patients memorize a string of 2-6 digits presented visually,
judge the grammaticality of a sentence presented
auditorily, and then verify whether another string of digits
matches the preceding string
– Accuracy scores are calculated for the grammaticality
judgments with and without the strings of digits
– Sentence stimuli include errors of auxiliary and determiner
omission, agreement, and transposition in early and late
positions (see Blackwell & Bates, 1995 for list of sentences)

Peach, 2012
 Selected References

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and L.P. Shapiro (Eds.), Cognition and acquired language disorders: An information
processing approach (pp. 61-93). St. Louis, MO: Mosby.

Coslett, H.B. (1999). Spatial influences on motor and language function.

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Peach, R.K. (2012). Management of acquired language disorders associated with

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