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Neuropsychological Rehabilitation
The International Handbook
Barbara A. Wilson, Jill Winegardner, Caroline M. van Heugten, Tamara
Ownsworth

Rehabilitation of Language Disorders in Adults and Children

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Anastasia Raymer, Lyn Turkstra
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18
REHABILITATION OF
LANGUAGE DISORDERS IN
ADULTS AND CHILDREN
Anastasia Raymer and Lyn Turkstra

Definition of aphasia
Aphasia is an impairment in language comprehension and expression caused by acquired brain
damage (Papathanasiou and Coppens, 2013). Aphasia is not a disorder of intellect, although persons
with aphasia may also have cognitive impairments if neuropathology affects regions involved in
cognitive functions other than language. Aphasia also may have secondary effects on cognitive
functions that are language-dependent (e.g. verbal working memory), and individuals with aphasia
may perform poorly on cognitive tests as a result of language impairments. The onset of aphasia may
be acute (e.g. stroke, focal trauma) or progressive (degenerative diseases, tumour, epilepsy). In the
mid-twentieth century the term aphasia also was applied to children with developmental language
disorders (see Benton, 1964), but current use is limited to language disorders acquired after age two
years (Avila et al., 2010).
Aphasia is often described using the classic localisationist model of Wernicke and Lichtheim, who
described interconnected language ‘centers’ in the left hemisphere, with non-fluent aphasias
associated with anterior cortical lesions, and fluent aphasias with posterior lesions (Heilman, 2015).1
In modern times, strict localisation models have been challenged, and in some cases replaced, by
complex cognitive neuropsychological models (Thompson, Faroqi-Shah and Lee, 2015) and
computational models (Kiran et al., 2013). Discussion of these models is beyond the scope of this
chapter, however, and localisationist models continue to be the major influence on aphasia
classification and rehabilitation, so we will use general localisationist models here. Localisationist
models categorise aphasia according to patterns of language breakdown in three key areas: auditory
comprehension, repetition and fluency of verbal expression. The major distinction is between fluent
and non-fluent aphasias, as Wernicke and Lichtheim originally described (see Table 18.1).

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Table 18.1  Aphasia syndromes

Aphasia syndrome Fluency Repetition Auditory comprehension Typical naming errors

Broca’s non-fluent impaired relatively intact semantic paraphasia
Global non-fluent impaired impaired stereotypy
Transcortical motor non-fluent relatively intact relatively intact no response
Mixed transcortical non-fluent relatively intact impaired no response
Wernicke’s fluent impaired impaired neologisms
Conduction fluent impaired relatively intact phonemic paraphasia
Transcortical sensory fluent relatively intact impaired semantic paraphasia
Anomic fluent relatively intact intact circumlocution

Non-fluent aphasias
Non-fluent aphasias include Broca’s aphasia, global aphasia, transcortical motor aphasia, and mixed
transcortical aphasia. Individuals with Broca’s aphasia have non-fluent verbal expression and repetition
due to agrammatism, that is, omission of grammatical words (e.g. auxiliaries, articles) and word endings
(e.g. plurals, verb tense). They may also have flattened prosody, difficulty initiating and sequencing
articulatory movements, or apraxia of speech (Duffy, 2015), and word retrieval difficulties. Individuals
with Broca’s aphasia may have asyntactic comprehension leading to difficulty understanding
grammatically complex sentences (e.g. passives). Broca’s aphasia is typically associated with a large
left frontal-subcortical lesion (Kreisler et al., 2000).
Individuals with global aphasia are severely impaired in repetition, word retrieval and auditory
comprehension, with non-fluent verbal output often limited to automatisms (e.g. cursing, I don’t
know) and stereotypies (repeated use of a meaningless word: ‘wuntu, wuntu’) (Galletta and Barrett,
2015). Global aphasia is typically associated with extensive left pre- and post-Rolandic damage
extending to subcortical white matter (Naeser et al., 1990).
Two forms of non-fluent aphasia fall in the transcortical category in that, despite non-fluent
spontaneous verbal expression, repetition abilities are remarkably intact, yielding a parrot-like quality
or echolalia when asked to repeat sentences. In transcortical motor aphasia (TCMA), verbal expression
is non-fluent and word retrieval difficulty may arise due to impaired initiation of verbal output
(Crosson, Ford and Raymer, 2015). Auditory comprehension can be affected for grammatically
complex sentences. TCMA has been described acutely with left hemisphere lesions of the mesial
frontal cortex (supplementary motor area), dorsolateral frontal cortex, or thalamus (Kreisler et al.,
2000). In mixed transcortical aphasia, sometimes referred to as ‘isolation of the speech area’, repetition
is relatively spared, whereas other language domains are severely impaired. This infrequent syndrome
occurs with damage to left anterior and posterior cortical watershed regions that preserve left
perisylvian cortex (Baumgaertner, 2015).

Fluent aphasias
Fluent aphasia subtypes include Wernicke’s aphasia, conduction aphasia, transcortical sensory aphasia and
anomic aphasia. In general, these individuals can fluently produce utterances with many words, but
the utterance quality is abnormal. In Wernicke’s aphasia there is a press to speak or logorrhea
(Greenwald, 2015). Fluent spontaneous verbalisations, repetition and spoken naming are disrupted
by paraphasias (word selection errors) and neologisms (nonsense words). Auditory comprehension is
severely impaired, even for single words. These individuals often seem to be unaware of their verbal

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errors, and thus show signs of anosognosia. Wernicke’s aphasia is associated with lesions affecting the
posterior portion of the left superior temporal gyrus (Hillis et al., 2001).
Patients with conduction aphasia have inordinate difficulty with repetition relative to other
language abilities (Wilshire, 2015) and commonly produce phonemic paraphasias and conduit
d’approche (successive attempts to self-correct mispronunciations). Individuals with conduction
aphasia may fail to understand syntax, in part because of impairments in phonological short-term
memory. Lesions associated with conduction aphasia involve the left inferior parietal or superior
temporal cortex, sometimes including the arcuate fasciculus (Buchsbaum et al., 2011).
The last two forms of aphasia are characterised by fluent production and intact repetition.
Individuals with transcortical sensory aphasia (TSA) have fluent verbal expression and naming with
numerous paraphasias and impaired auditory comprehension (Reilly and Martin, 2015). Lesions
affect the left posterior temporal or parietal cortex, thus TSA may be associated with Gerstmann
syndrome. In anomic aphasia, word retrieval problems (anomia), which are common across aphasia
types, can occur as an isolated syndrome (Harnish, 2015). Word retrieval errors in conversation or
picture naming tasks may include circumlocutions, semantic paraphasias and response omissions.
Anomic aphasia may occur acutely with lesions in the left temporo-occipital junction or thalamus
(Race and Hillis, 2015).

Aphasia in children
The localisationist aphasia classification was developed from studies of adults, and behavioural
phenotypes may be quite different in children with aphasia. Children with left hemisphere strokes,
for example, often are mute in the initial period post-stroke (Benton, 1964), have milder deficits
than adolescents and adults who are injured after language has developed (Bates et al., 2001), and are
more likely to have non-fluent aphasia than fluent aphasia, although all types of aphasia are possible
in children (Chilosi et al., 2008). It was previously thought that children with unilateral left
hemispherectomy before age seven would have normal language development, as language could be
‘relocated’ to the right hemisphere (e.g. Benton, 1964; Lenneberg, 1967). However, there is robust
evidence of persistent language impairments in these children (e.g. Bates et al., 2001), and evidence
of subtle long-term language deficits even in children with very early focal lesions (Lauterbach et al.,
2010). As Chilosi and colleagues (2008) stated, ‘both hemispheres are involved in language acquisition
and the effects of brain injury differ depending on the specific stage of language development, on the
particular language component studied and on the site/side of the injury’ (p. 212). Thus, while
traditional aphasia syndromes may be present in children, the relation of site of lesion to clinical
profile is less predictable than in adults. As in adults, aphasia in children may have an acute onset, as
after stroke (Avila et al., 2010), or progressive, as in the case of degenerative disorders such as
Landau-Kleffner Syndrome (Deonna and Roulet-Perez, 2010).

Frameworks for rehabilitation

Aphasia rehabilitation is influenced by several major perspectives. The first is the localisationist
framework just described, which categorises treatments by aphasia subtype. This framework has had
a major influence on development of specific treatments, particularly treatments for non-fluent
aphasia, which will be described later in the chapter.
The second major framework is the World Health Organization Model of Functioning, Disability,
and Health (WHO ICF, 2001), which emphasises the influence of language dysfunction on the
individual’s ability to participate in personally relevant communication activities in everyday life.
Some treatment approaches are directed at the impairment level of the WHO ICF, and are devised
to restore language functions in a manner compatible with normal language functioning. Other

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intervention approaches use compensatory strategies or alternative means of communication to

achieve goals for activities and participation (e.g. using an alternative communication device). Some
approaches manipulate environmental factors to facilitate successful recovery of language functions,
such as training communication partners or modifying the environment (e.g. creating versions of
books for a book club that have simplified language). The WHO ICF framework can be viewed as
orthogonal to the localisation-based framework; for example, there are impairment-, activity- and
participation-based treatments for people with non-fluent and fluent aphasia.
The third perspective derives from principles of neuroscience (Raymer et al., 2008). The purpose
of interventions for aphasia is to initiate changes in neural functions, that is, neuroplasticity, whether
in peri-lesional regions within the language-dominant left hemisphere or in contralesional right
hemisphere cortex (Crosson et al., 2007b). Neuroscience has demonstrated several use-dependent
principles that have implications for how intervention is conducted to maximise treatment effects for
individuals with aphasia (Kleim and Jones, 2008; Turkstra, Holland and Bays, 2003):

• Neural change requires repeated language use, providing strong impetus for rehabilitation
methods such as constraint-induced language therapy (CILT; Pulvermuller et al., 2001), which
is based on high-intensity repetition of words and phrases.
• Enriching the language environment of individuals recovering from brain injury has the
potential to improve rehabilitation outcomes.
• Language targets in rehabilitation should be specified and salient or important to the individual.
• Intensity of rehabilitation should be carefully considered, as some outcomes can be amplified if
treatment is provided with many opportunities for repetition and intensively delivered
intervention (Cherney, Patterson and Raymer, 2011).

These principles were derived primarily from animal research, and how each plays out in human
language and communication continues to be the subject of investigation in many research studies
(Raymer et al., 2008). Nevertheless, discussion of these neuroplasticity principles has had a major
influence on treatment design in recent years, particularly the idea that brain change requires many,
many repetitions of a language behaviour, and that high-dose intervention for patients with acute-
onset aphasia might be best in the chronic stage post-injury.
A fourth framework that applies specifically to the rehabilitation of children is a developmental
framework. Whereas targets of adult rehabilitation are maximal independence and return to
premorbid function, a developmental framework recognises interdependence with key stakeholders,
such as parents and teachers, the influence of injury on the child’s developmental trajectory and the
child’s ability to meet language benchmarks at each age. Thus, a child’s intervention might be
embedded in classroom activities, with goals related to the academic curriculum and reassessment
over many years post-injury as language demands increase with age.

Aphasia assessment
The aim of language assessment is to identify language impairments, areas of strength or preserved
language functions, impact of language dysfunction on communication activities, life participation,
and quality of life, and intervention objectives (Murray and Coppens, 2013). At a minimum,
assessment should include a detailed clinical interview and informal observations of the patient. The
interview and observations can reveal not only language strengths and challenges, but also
communication strategies attempted and response of communication partners, who may need
training and support. While preference is given to interviewing patients themselves, it is also helpful
to query caregivers about the patient’s communication needs and challenges, and for children,
discussions with caregivers and other stakeholders are the cornerstone of assessment. McClung,

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Rothi and Nadeau (2010) developed a checklist that may be useful in organising interviews and
observations into a list of barriers or facilitators of recovery that will be relevant in treatment.
If the individual is in the acute stage of recovery when behaviour is the most changeable,
observation and interview data may be the main source of assessment. It also may be helpful to give
standardised or informal screening tests (e.g. shortened forms of the Boston Diagnostic Aphasia
Examination [Goodglass, Kaplan and Barresi, 2001] or Western Aphasia Battery [Kertesz, 2007]). In
the chronic stage, formal, standardised language tests become more useful for characterising the
patient’s strengths and limitations. If the goal of assessment is to give an overall picture of the patient’s
language functioning – including reading, writing, auditory comprehension and spoken language –
the clinician may administer a comprehensive aphasia test battery (e.g. the Boston Diagnostic Aphasia
Examination or Aphasia Diagnostic Profiles). Scores across subtests of these comprehensive batteries
can classify the aphasia into one of the main syndromes defined above. Standardised aphasia test
batteries are normed only on adults, and there are no analogous tests for children. Some comprehensive
child language tests include individually standardised subtests, which allow comparison of performance
across language modalities commonly affected by aphasia (e.g. syntax comprehension vs. repetition),
but standard scores will be unreliable indicators of ability when the test model is developmental
rather than acquired language problems.
If it is of interest to examine a single aspect of language more closely, the clinician may administer
tests of specific language processes, such as naming and reading, or comprehension of connected
language, or tests that focus on different parts of speech (e.g. nouns vs. verbs), or semantic categories
(e.g. animals, fruits and vegetables). It also might be of interest to evaluate language use in non-test
contexts such as story-telling or conversations. Analysis of discourse can be highly informative, but
should be used with the caveat that, although probes and analysis methods for language samples may
be standardised, there are few sources of normative data against which to compare results (Coelho,
Ylvisaker and Turkstra, 2005).
Most standardised aphasia tests focus on the impairment level of the ICF. There are, however,
several tools that evaluate language use in typical communication activities, such as the Communication
Activities of Daily Living-2 (Holland, Frattali and Fromm, 1999), and also rating scales like the
Functional Assessment of Communication Skills (ASHA-FACS; Frattali et al., 1995) and
Communication Effectiveness Index (CETI; Lomas et al., 1989), which ask the patient, family
members or caregivers to gauge communication abilities in a variety of daily life scenarios. It is also
important to ask questions about the individual’s communication quality of life (Simmons-Mackie
and Kagan, 2007), which is challenging but possible using tools such as the Quality of Communication
Life Scale (Paul et al., 2005).

Rehabilitation of children with aphasia

The paediatric aphasia rehabilitation literature is sparse. A search of the Speech Pathology Database
for Best Interventions and Treatment Efficacy (SpeechBITE) revealed only one single case description
of treatment of aphasia in a child (Lee Oelschlaeger and Scarborough, 1976), and a search of PubMed,
PsychInfo and Google Scholar yielded only medical treatments. The absence of treatment studies is
most likely because aphasia is rare in children, which in turn is because common aetiologies of
aphasia, such as stroke, are rare in children; the incidence of stroke in children is 1 in 100,000 vs. 1
in 2300–5000 for perinatal stroke and 1 in 500 for stroke in adults (Tsze and Valente, 2011; Lynch,
2009; CDC.gov, 2016), although numbers may be higher in countries where stroke aetiologies such
as sickle cell disease are common (e.g. Toure et al., 2008). While low incidence may be the major
reason for the lack of paediatric aphasia treatment literature, other factors might include: (1) the
erroneous belief that children have better language outcomes than adults, and thus will recover
spontaneously (see critique by Dennis, 2010); (2) methodological challenges of differentiating

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treatment effects vs. spontaneous recovery vs. developmental changes; and (3) the multifactorial
nature of childhood rehabilitation, which includes parents, school, peers, hospital therapists and
school-based therapists, making it challenging to identify active and essential treatment ingredients.
In the absence of formal treatment guidelines, readers are referred to general rehabilitation principles
for acquired communication disorders in children, described in sources such as Allison, Byom and
Turkstra (2017) and Ylvisaker and Feeney (1998).

Rehabilitation of adults with aphasia

Several meta-analyses of aphasia treatment studies in adults indicate that treatment is beneficial for
improving language abilities beyond what would be anticipated from spontaneous recovery alone
(Brady et al., 2012; Robey, 1998; Wisenburn and Mahoney, 2009). The approach taken for an
individual with aphasia will depend on a number of medical, philosophical and psychosocial factors.
Foremost is the patient’s constellation of language dysfunctions. Treatment methods have been
devised to address impairment of auditory comprehension and verbal expression. Within each
modality, treatment methods vary depending upon level of breakdown in single-word lexical-
semantic and phonological processing versus sentence-level morpho-syntactic processing.

Treatments for specific language functions

Auditory comprehension treatments

Restorative treatments for auditory comprehension focus either on lexical or grammatical processes,
as indicated in evaluation of an individual with aphasia. The premise that systematic auditory
stimulation will facilitate recovery from aphasia was the basic tenet of rehabilitation for decades
(Coelho, Sinotte and Duffy, 2008). Auditory comprehension training studies driven by cognitive
neuropsychological perspectives of lexical processing often emphasise phonological or semantic
attributes of words (Morris and Franklin, 2013). Repeated practice with auditory-verbal tasks, such
as answering questions, manipulating objects and pointing to command, are completed as clinicians
manipulate characteristics of the words (e.g. semantic category, phonological attributes, grammatical
category), paralinguistic aspects of the auditory-verbal signal (e.g. rate, pauses, intonation), and task
conditions (e.g. number of response choices, length of auditory input, relatedness of foils) to
systematically increase the level of difficulty of auditory processing over time. Positive results of
auditory stimulation training have been reported in single case studies (Jacobs, 2001) and as part of
group studies of aphasia therapy (Wertz et al., 1986). Computerised training programmes are
particularly amenable to auditory stimulation practice (Raymer et al., 2006).
Restorative sentence comprehension treatments often incorporate a linguistic approach to
training. For example, a number of studies have examined effects of mapping therapy, a technique
that uses written sentences in training as individuals with aphasia are taught to translate from
grammatical word order (e.g. subject noun, verb, object noun) to the semantic roles (e.g. agent,
action, object) played by words in the sentence (Marshall, 2015). Repeated practice with syntactically
complex sentences may lead to improved comprehension abilities, with some generalisation to
untrained sentence structures.
When effects of restorative auditory comprehension treatments are limited, other methods are
often attempted to circumvent the impairment by summoning compensatory input modalities to
enhance comprehension. Individuals with aphasia can be encouraged to use intact visual modalities
(e.g. lip-reading, word reading or gestural input) to support comprehension through the impaired
auditory modality in individuals with aphasia (Raymer and Rothi, 2008).

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Word retrieval treatments

Because word retrieval impairments are so common across all forms of aphasia, many techniques
have been investigated to remediate this problem (Raymer, 2011). Several approaches incorporate
systematic use of cues and linguistically rich stimulation in the context of picture naming tasks to
facilitate progress in word retrieval treatment. For example, clinicians may provide phonological
(initial phoneme, rhyming words, repetition) and semantic (category, phrase completion) cues, pair
word comprehension and word production tasks, or provide a grid of semantic features to facilitate
retrieval of words. Several principles that increase benefits of word retrieval training include training
with atypical exemplars of a semantic category (Kiran, 2007), training in an errorless format
(Fillingham et al., 2005), and training at a higher dose (e.g. number of words, Mason et al., 2011)
and at a higher dose frequency (sessions per week, Raymer, Kohen and Saffell, 2006; Sage, Snell and
Lambon Ralph, 2011). A meta-analysis of the word retrieval treatment literature showed that training
that centres on phonological attributes of words maximises treatment effects (Wisenburn and
Mahoney, 2009).
Gestural pantomimes are an alternative means to facilitate word retrieval through what Luria
(1970) called intersystemic reorganisation. A systematic review of studies of pantomime treatments
for word retrieval showed that combining pantomimes with spoken words in treatment led to
improvements in word retrieval for trained nouns and verbs (Rose et al., 2013). Crosson and
colleagues (2007a) reported the benefits of word retrieval training with non-symbolic (non-
meaningful) limb movements (e.g. reaching or circular motions with the left hand in left space)
paired with spoken production of words. The advantage in non-symbolic limb movements is that
they can be implemented with all types of words, regardless of the meaning, and they are less
vulnerable to disruption by limb apraxia. On the other hand, a benefit of pantomime training is that
when word retrieval abilities do not improve, general communication abilities often are enhanced
through the use of pantomimes.

Sentence production treatments

Some individuals with aphasia, particularly those with non-fluent forms of aphasia, need training that
focuses on improving the use of fluent, grammatical sentences. As in sentence comprehension
treatments, the premise of some restorative sentence production treatments is to practise sentences
varying in grammatical complexity. Clinicians model and expand target sentences and individuals
then rehearse sentences to facilitate correct production. The methods vary in the context used for
sentence practice, including picture description, story completion activities (e.g. Helm-Estabrooks
and Nicholas, 2000), or sentence reading (e.g. Thompson and Shapiro 2008). With repeated practice,
some individuals improve use of complete, grammatical sentences. Mapping therapy, described
earlier for sentence comprehension training, is an approach to expanding sentence production in
aphasia (Marshall, 2015). Interestingly, some sentence production training studies have shown that
practice with grammatically more complex sentence types (e.g. object relative clauses) can generalise
to less complex sentence structures (e.g. who-questions) in some individuals with aphasia (Thompson,
2001; Thompson and Shapiro, 2008).
Melodic Intonation Therapy is a reorganisation treatment designed to invoke the right
hemisphere’s intonational capacity to support sentence production (Helm-Estabrooks and Albert,
2000). In this systematic programme, patients produce sentences while tapping rhythmically and
using highly intoned speech. Over time the melody is reduced to a more natural prosody, and the
tapping discontinues. The method has been deemed effective for improving sentence production,
particularly in patients with Broca’s aphasia (van der Meulen, van de Sandt-Koenderman and
Ribbers, 2012).

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Finally, a great deal of interest has centred on a treatment approach for verbal expression inspired
by use-dependent principles of neuroplasticity, constraint-induced language therapy (CILT). This
technique encompasses two principles, forced use of verbal production over compensatory strategies,
and intensive massed practice (Pulvermuller et al., 2001). A systematic review of the literature
indicated that the effects of CILT surpass the effects of comparison treatments for measures of
language impairment and communication activities (Cherney et al., 2008b, 2011). Whether this
effect has to do with forced use of verbal production or the intensive treatment schedule has yet to
be determined.

Treatments for communication activities and participation

Some approaches to aphasia treatment, sometimes termed ‘functional’ treatments, incorporate any
strategies, verbal and non-verbal, to improve communication with conversational partners.
Individuals with aphasia are often instructed to use writing or drawing to convey ideas. Some
individuals with severe aphasia establish basic yes and no (head nods, thumbs up) signals and
pantomimes to enhance communication. Promoting Aphasics’ Communication Effectiveness
(PACE) is a training technique wherein individuals with aphasia participate in a communication
activity with cards and provide any verbal or non-verbal cues to convey the concept on the picture
card (Davis, 2014). Alternatively, script training is a technique in which individuals with aphasia
prepare, practise and role-play scripts for real-life contexts (Cherney et al., 2008a). An efficient
setting in which to apply functional language strategies is group aphasia therapy (Elman, 2006). In
group aphasia treatment, a small number of individuals with aphasia interact in language activities
designed to promote use of communication strategies in discussions about daily living activities,
current events, hobbies and other interests. Participation in group aphasia treatment emphasising use
of communication strategies has been reported to lead to significant improvements on some language
and communication measures (Elman and Bernstein-Ellis, 1999; Simmons-Mackie, 2008).

Facilitating the communication environment

A number of intervention strategies influence the communication environment for individuals with
acquired language disorders. Environmental treatments are designed to facilitate language and
communication abilities using external sources and to remove barriers to successful communication.

Communication partner training

Not all communication partners naturally engage in techniques to promote communication and
overlook unsuccessful communication events. Several dozen studies have examined communication
partner training (CPT) for family members or caregivers and medical professionals, such as those
describing Supported Conversation for Adults with Aphasia (Kagan et al., 2001). A number of
strategies that can be implemented by communication partners are provided in Table 18.2. Some
options are designed to enhance auditory comprehension, whereas others are meant to promote
resolution of verbal production breakdown by the speaker with aphasia. A systematic review of the
CPT literature showed that, whereas language changes are limited in individuals with aphasia,
improvements in communication outcomes for individuals with aphasia and their partners are
evident (Simmons-Mackie et al., 2010).

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Table 18.2  Partner strategies to facilitate or reduce barriers in the aphasic communication dyad
To facilitate auditory comprehension:
• Gain eye contact and speak directly to the individual.
• Use short, grammatically simple sentences.
• Speak at a slower rate while maintaining a natural prosody.
• Speak at an appropriate loudness level (not louder).
• Repeat sentences and then revise the utterance as necessary.
• Talk about familiar topics.
• Signal when the topic changes.
• Embellish messages with alternative communication channels (writing, drawing, gestures, facial expression).

To facilitate verbal expression of the speaker with aphasia:

• Gently provide missing words or multiple choice options.
• Encourage circumlocution and use non-verbal channel to communicate messages.
• Reiterate messages so speaker can confirm messages were understood as intended.
• Encourage speaker to disregard simple errors when intent of messages is not disrupted.
• Write down ideas when breakdown occurs and return to them later.

Technological aids to communication

Expanding technologies have advanced opportunities for individuals with aphasia of all ages to
communicate through verbal and non-verbal means with assistive technologies (Lasker, 2013).
Beyond inexpensive low-tech picture pointing boards or notebooks, there are numerous software
programs and mobile applications that can promote compensatory communication approaches.
Specialised augmentative and alternative communication devices or computers outfitted with
appropriate software allow some individuals with aphasia to express themselves using spelling, mouse
clicks, touch screens or speech generating devices. Some studies have demonstrated that individuals
with severe aphasia can learn to use computer-assisted communication programmes, such as
Lingraphica (Aftonomos, Appelbaum and Steele, 1999) or Sentence Shaper (Linebarger et al., 2008).
These assistive technologies have high cognitive demands, particularly on executive functions and
working memory, and may not be effective for all individuals with aphasia (Lasker, 2013).

Pharmacological intervention in aphasia

Because aphasia results from disruption of neural substrates of language, clinicians have explored
pharmacological methods to replace neurotransmitters, maximise plasticity and promote recovery of
language functions (Shisler, Baylis and Frank, 2000). For example, bromocriptine, examined in
several unblinded studies of individuals with frontal lobe damage and aphasia, may improve verbal
fluency as measured in the reduction of pausing and improved word retrieval in selected patients
(e.g. Gold, VanDam and Stillman, 2000). Treatment with dextroamphetamine has been associated
with improved aphasia recovery in one double-blind placebo controlled investigation (Walker-
Batson et al., 2001). The overall evidence from high quality research studies is limited (Greener,
Enderby and Whurr, 2001). Also problematic is that studies have conflated pharmacological and
behavioural interventions and the relative contributions of these two distinct elements of treatment
are not clearly established (Barbancho et al., 2015).
Pharmacological interventions in children primarily address the medical condition leading to
aphasia. For example, the most published cause of childhood aphasia is Landau-Kleffner Syndrome,
which is treated by managing seizures surgically or with drugs such as steroids and anticonvulsants
(Gallagher et al., 2006).

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Conclusions
Rehabilitation of children and adults with aphasia is guided by the WHO ICF, models of brain–
behaviour relations, and principles of neuroplasticity and neurodevelopment. Rehabilitation begins
with evaluation of language in contexts that are important to that individual, to document language
impairments as well as personal and environmental influences on language use in everyday life and
impact on quality of life. Intervention methods include treatments that aim to restore language
functions, use alternative cognitive systems and neural regions to mediate language functions, use
strategies to compensate for language problems, and modify environmental and personal factors to
support successful language use in everyday life. Meta-analyses have produced strong evidence of the
efficacy of aphasia therapy in adults, and there are continued efforts to devise novel methods of
behavioural, pharmacological and neuromodulatory intervention methods, such as transcranial
magnetic stimulation (TMS) or tDCS (transcranial direct current stimulation). There is a gap in the
literature on rehabilitation of acquired aphasia in children and adolescents, as there is in all paediatric
rehabilitation. Nevertheless, the future of treatment research is promising, and individuals with
aphasia are likely to benefit in substantial ways in the years ahead.

Acknowledgements
The second author’s work on this manuscript was supported in part by the Walker Fund.

Notes
1 Note that verbal fluency in aphasia refers to the ease with which an individual produces fully elaborated
conversational sentences, not the number of different words that can be produced on a word association task, as
in neuropsychology, or disruption in the smooth, forward-flow of speech as in stuttering. Verbal fluency in
aphasia is influenced by the integrity of grammatical, articulatory, and prosodic elements of language, and
initiation and elaboration of utterances. A serious disturbance of any one of these aspects of verbal expression
may limit the overall number of words expressed and render the impression of non-fluent verbal production.

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