NEUROPSYCHOLOGICAL REHABILITATION

2012, 22 (2), 295 –318

Decreasing cues for a dynamic list of noun and verb

naming targets: A case-series aphasia therapy study

Paul Conroy1 and Jade Scowcroft2

1
Neuroscience and Aphasia Research Unit (NARU), School of
Psychological Sciences, University of Manchester, Manchester, UK
2
Psychology Department, Durham University, Durham, UK

Errorless learning has had positive reports across both clinical and non-clinical
domains. Within aphasia therapy studies, decreasing cue methods have been
proposed as the optimal combination of low error and high effort. This study
aimed to evaluate a modification to the decreasing cue method in which the
set size of target nouns and verbs for training was extended dependant on par-
ticipant progress in naming therapy. Four participants with word retrieval
symptoms as part of their aphasia took part in a case-series study in which a
decreasing cue hierarchy was applied to a dynamic list of noun and verb
targets. An assessment probe at the start of each session determined how
many new items were to be taken on in therapy, dependant on participant
responsiveness to that point. All participants made significant improvements
in naming accuracy for treated items from baseline and compared to control
items. Two participants continued to take on new items which reflected consist-
ent trajectories of improving naming accuracy, while two participants reached
saturation points at which the frequency of errors in naming accuracy limited
their set sizes. The varying trajectories of the participants were evaluated in
relation to their baseline language and cognitive skills. Clinical implications
from the findings and themes for further research were also considered.

Keywords: Naming; Aphasia; Decreasing cues; Learning.

Correspondence should be addressed to Dr Paul Conroy, Neuroscience and Aphasia Research

Unit (NARU), School of Psychological Sciences (Zochonis Building), The University of Man-
chester, Oxford Road, Manchester M13 9PL. E-mail: paul.conroy@manchester.ac.uk
We are very grateful to the four participants and their families for their time, energy and
patience in taking part in this and other research studies.

# 2012 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/neurorehab http://dx.doi.org/10.1080/09602011.2011.641434
296 CONROY AND SCOWCROFT

INTRODUCTION
Errorless learning has had a history of successful application across both
clinical and non-clinical domains (Fillingham, Hodgson, Sage, & Lambon
Ralph, 2003). In the clinical domain, a substantial literature describing error-
less interventions for memory impairments has emerged (Baddeley & Wilson,
1993; Clare & Jones, 2008; Clare et al., 2000; Komatsu, Mimura, Kato,
Wakamatsu, & Kashima, 2000; Tailby & Haslam, 2003; Wilson, Baddeley,
Evans, & Shiel, 1994; Wilson & Evans, 1996). Typically, an advantage for
errorless learning with participants with amnesia has been explained with
reference to intact implicit learning mechanisms that cannot distinguish error-
ful from correct responses and, hence, both types of response are reinforced
(Page, Wilson, Shiel, Carter, & Norris, 2006); although competing expla-
nations have been proposed (e.g., Squires, Hunkin, & Parkin, 1997). In the
non-clinical domain, the computational neuroscience literature has conceptu-
alised learning and relearning in terms of Hebbian reinforcement, whereby
“neurons that fire together, wire together”. The formation of language-
related representations can be shown to be vulnerable to error production in
learning sequences in both computational models and neurologically intact
participants such as those learning a foreign language (McCandliss, Fiez,
Protopapas, Conway, & McClelland, 2002; McClelland, Thomas, McCan-
dliss, & Fiez, 1999).
Errorful (trial and error naming) therapies have been the mainstay of
anomia therapies within aphasia, typically utilising progressive phonological,
orthographic and/or semantic cues (see Nickels, 2002 for a review). Against
the background of both related clinical and basic neuroscientific evidence as
described, the hypothesis that people with aphasia may also be vulnerable to
error reinforcement related to depleted self-monitoring and executive-
attentional skills is very credible. The application of errorless learning
principles to the remediation of symptoms of aphasia has now spanned
several studies implemented over the last decade. The notion that minimising
errors in the therapy process may provide an optimally effective treatment
method in aphasia has been investigated in noun-naming studies which
found that errorless therapy was as effective as traditional hierarchical
cueing (errorful) therapy (Fillingham, Sage, & Lambon Ralph, 2005a,
2005b, 2006). Here, errorless therapy referred to word repetition in picture
naming in contrast to phonemic/orthographic cueing in an errorful/trial
and error therapy. Other contemporaneous studies found that errorful
therapy may be more effective in some cases (Abel, Schultz, Radermacher,
Willmes, & Huber, 2005). McKissock and Ward (2007) compared three treat-
ment conditions (errorless, errorful-with feedback, and errorful) for symp-
toms of anomia in aphasia. They found that the latter treatment (errorful
without feedback) in which participants were encouraged to guess at a
 DECREASING CUES FOR NAMING IN APHASIA 297

picture name but were not given the correct target word was not significantly
different to a no-treatment condition, in other words no help at all. At the
same time, errorless and errorful with feedback (where guesswork was fol-
lowed by correct naming being confirmed or the correct name being given)
were again as effective as one another in improving naming. However, the
value of error-production in aphasia therapy, given the requirement to
invest time and effort in trial and error therapy methods, remains unclear.
A positive feature of considering the role of wider learning factors in
relation to aphasia therapy may be the incorporation of insights from other
forms of neurorehabilitation. For example, Fridriksson, Holland, Beeson,
and Morrow (2005) have explored the effectiveness of “spaced retrieval”
(originally a memory intervention in dementia) as a treatment for aphasia
in which recall of names is extended over progressively longer intervals of
time within an errorless framework. Komatsu et al. (2000) evaluated if
there was a potential trade-off between low error and high effort in
memory rehabilitation in that both were likely to make a contribution to
the effectiveness of treatment. Komatsu et al. hypothesised that decreasing
cue therapy, which combined low error and high effort, would be the most
effective of the four treatment conditions, in that decreasing cues therapy rep-
resented the optimal trade-off between error and effort. However, Komatsu
et al. found an advantage for errorless learning that was not affected by the
degree of effort involved. In other words, the “pure” errorless condition
(low error and low effort) resulted in most correct recall of names, whilst
decreasing cues (low error and high effort) proved the next most effective.
Despite the value of insights from other aspects of neurorehabilitation, it
may be that the error and effort have distinctive and possibly more (or less)
significant effects within anomia, rather than amnesia, therapy.
Within the aphasia therapy literature, the role of error and effort was
addressed by Conroy, Sage, and Lambon Ralph (2009a) in a study which inves-
tigated whether decreasing cues would result in greater effects in terms of both
naming accuracy and speed relative to increasing cues. This study focused on
intervention effects on the retrieval of both nouns and verbs. Traditionally,
agrammatic (i.e., severely non-fluent) aphasia has been associated with rela-
tively poorer verb than noun production. The opposite pattern (noun , verb
production) has been associated with fluent aphasia sub-types such as
anomic and Wernicke’s aphasia. Hence, there has been a tendency in the
aphasiology literature for verb therapies to be directed to participants with
non-fluent aphasia and noun therapies to those with both fluent or non-fluent
aphasia (Conroy, Sage, & Lambon Ralph, 2006). However, relative perform-
ance in noun and verb naming corresponds only loosely with aphasia classifi-
cation (Luzzatti et al., 2001). As noun–verb dissociations are relative, verb
therapies may be needed for many people with aphasia, irrespective of classi-
fication (Conroy, Sage, & Lambon Ralph, 2009b). The verb therapy literature
298 CONROY AND SCOWCROFT

has been relatively limited compared to the number of studies that have focused
on noun retrieval (Conroy et al., 2006). This may reflect the higher linguistic
and cognitive processing demands of verb processing, which may point to a
role for errorless methods within aphasia therapy when the production target
is more challenging. The results of Conroy et al. (2009a) showed significant
therapy effects across both decreasing and increasing cue therapies, with
little or no change in naming of control sets. Noun naming was significantly
better across the case-series than verb naming at both post-intervention assess-
ment points. The therapies were similar in the degree to which participants
improved in naming accuracy and they yielded almost identical overall
speed of naming responses. This was somewhat surprising given that the error-
less therapy (decreasing cues) was both quicker to implement and had elicited
quicker naming responses during therapy tasks. Therefore, the decreasing cues
therapy was offering some element of added value to the outcomes of the two
therapies, in that it generated the same degree of naming accuracy as the trial
and error methods, within a therapy method which was quicker to implement.
Decreasing cues had also served to allow the participants to progress with a
high degree of success through therapy, relative to trial and error methods, in
a way which had sustained their effort, compared to “pure” errorless
methods such as whole word repetition.
One limitation of most errorless/decreasing cues studies in aphasia has
been that the experimental methods used may have constrained the range
of differences in performance across participants by limiting the number of
word targets used in therapy to a set list size. For example, in the Conroy
et al. study (2009a), set lists of 40 items for decreasing cue therapy and 40
items for increasing cue therapy were used. This was despite the finding
that participants with anomia can tolerate more items in therapy and that
the severity of anomia should not necessarily determine how many words
should be given in therapy (Snell, Sage, & Lambon Ralph, 2010).
The present study, therefore, aimed to evaluate a modification to the
decreasing cue method, which was intended to better reflect the learning
potential of each participant in therapy. This was to allow participants to pro-
gress at their own individual level in terms of the number of items they took
on in therapy. The decreasing cue method was applied to a dynamic list of
noun and verb targets which had the capacity to grow from a very limited
set size to a more extensive one, based purely on participant responsiveness
to therapy. This method was designed to avoid a ceiling being placed on
the progress in naming accuracy that some participants could make, or at
least raise the ceiling much higher and to tally set size and naming accuracy.
The study aimed to compare participant responsiveness to noun and verb
naming targets within this dynamic method. Lastly, the study aimed to con-
sider the participants’ responses to therapy with regard to whether inaccurate
responses during therapy were item-specific.
 DECREASING CUES FOR NAMING IN APHASIA 299

METHOD
A case-series design was utilised in which participants with different subtypes
and severity of aphasia underwent identical assessment and therapy pro-
cedures. This approach would allow comparison of data both within and
between participants. Assessment and therapy sessions were administered
by the same clinician (the first author), supported by the second author.
The sessions were digitally audio-recorded to allow for verification of pro-
cedures and results.

Participants
Four participants with chronic aphasia including word retrieval impairment
took part in the study. The participants were aphasic having sustained a
single left cerebrovascular accident (CVA), as confirmed by medical notes
and brain scan. Participants varied in their aphasia symptoms, severity and
time since CVA. All were monolingual English speakers. Following approval
of research ethics for this study, participants were recruited from the caseload
of the Shropshire Enablement Team, a multi-disciplinary rehabilitation team
in the West Midlands region of England.
Inclusion criteria were devised to ensure the decreasing cue therapy would
be viable and also to eliminate the likelihood of spontaneous recovery.
Participants had to be at least six months post-CVA, with no other history
of significant neurological illness such as, for example, dementia or multiple
sclerosis. Normal or corrected hearing and vision were required. With regard
to language skills, two factors were considered: degree of naming impairment
and word repetition skills. Evidence of naming impairment was a score below
the unimpaired control participant age-related range on the Boston Naming
Test (BNT; Kaplan, Goodglass, & Weintraub, 2001). On the word repetition
task, which consisted of the first 20 items in PALPA 9 (Kay, Lesser, &
Coltheart, 1992), participants were required to score at least 75% correct
(15/20 or more). This was in order to ensure that the decreasing cue
therapy, which required reliable word repetition skills, would be viable and
relatively error-free for all participants.
Table 1 shows participants’ age (on entry to the study), gender, handedness,
occupation, number of months since CVA and description of the CVA. Table 1
also details baseline naming scores according to results obtained from the BNT
and scores on the sub-part of PALPA 9 Word Repetition task (Kay et al.,
1992). The BNT was administered without its cueing system, purely as a
screen of anomia severity. The participants have been presented in Table 1
and all subsequent tables and figures in rank order of their degree of baseline
naming impairment severity, as indicated by the BNT score. Therefore, par-
ticipant DH is presented first on the left (most severely naming impaired),
 300
CONROY AND SCOWCROFT
TABLE 1
Participant details

Participant DH KW RC WE
Age on entry to study 39 49 57 69
Gender Female Male Female Female
Handedness Right Right Right Right
Occupation Home worker Self-employed builder Shop worker Teacher
Description of CVA Large left parietal Left MCA infarct due to left carotid artery Left parieto-temporal Left MCA infarct
infarct occlusion infarct
Months since CVA on entry to 8 51 10 99
study
BNT score (max ¼ 60; 10 17 24 37
cut-off ¼ 46#)
Word repetition† (max ¼ 20; 15 16 18 20
cut-off ¼ 15)
Aphasic symptoms in connected Non-fluent (severe) Anomic (severe) Anomic (moderate) Non-fluent (moderate)
speech

BNT, Boston Naming Test (Kaplan et al., 2001); cut-off ¼ 46#, Age-related cut-offs (Mean – 2 SDs) (Tombaugh & Hubiey, 1997); Word repetition†,
PALPA 9 (first 20 items) (Kay et al., 1992).
 DECREASING CUES FOR NAMING IN APHASIA 301

followed by KW, RC and lastly WE on the right (least severely naming

impaired). Baseline noun naming scores obtained in the BNT showed a
range of naming ability on a continuum from relatively severe word retrieval
impairment (i.e., DH ¼ 10/60, KW ¼ 17/60) to more moderate impairment
(RC ¼ 24/60, WE ¼ 37/60). Table 1 also contains a description of the par-
ticipants’ aphasic symptoms in connected speech, with further details pro-
vided below in a summary of language and cognitive assessment findings
for each participant.

Background assessment
Participants underwent comprehensive linguistic and cognitive assessment,
the results of which are shown in Figure 1 and Table 2, respectively.
The Comprehensive Aphasia Test (CAT; Swinburn, Porter, & Howard,
2004) is a standardised assessment which consists of a battery of sub-tests
which can be used to evaluate a wide range of linguistic skills. The language
sub-tests allow measurement of comprehension skills (spoken words, spoken
sentences, spoken paragraphs, written words, written sentences) and expres-
sive skills (repetition, naming of objects and actions, verbal and written com-
posite picture description, reading aloud). Most distinctively, the CAT
contains a self-report questionnaire which examines participants’ self-evalu-
ation of the extent of disability related to aphasia and the emotional conse-
quences of aphasia. As well as raw scores, the CAT provides T-scores
through which an individual participant’s performance can be judged
against people with aphasia as a whole. The range of possible T-scores on

Figure 1. T-scores on Comprehensive Aphasia Test (CAT; Swinburn et al., 2004).

302 CONROY AND SCOWCROFT

TABLE 2
Results of cognitive tests

DH KW RC WE

Raw %ile Raw %ile Raw %ile Raw %ile Max

score Score score score score score score score score
Camden Memory Tests
Picture Recognition 30 100 30 100 27 3.9 28 15.7 30
Subtest
Recognition Memory for 13 ,1.9 21 1.9 23 ,3.1 13 ,3.1 25
Words
Wisconsin Card Sorting
Test
Number of categories 2 2 –5 5 11–16 1 2 –5 3 .16 6
Items to end of first 23 2 –5 52 2–5 13 .16 30 2– 5 0
category
Rey Complex Figure
Test
Copy 26 ,1 32.5 11–16 17.5 ,/ ¼ 1 28 2– 5 36
Immediate Recall 5 ,1 14 8 2.5 ,/ ¼ 1 7 4 36
Delayed Recall 7 ,1 19 38 0 ,1 7 3 36

the CAT was 25–75. The CAT T-scores for the four participants are shown in
Figure 1. Description of the participant performances on the CAT are given
below.
Assessment of participants’ cognitive skills included measures in the
domains of memory and executive skills. The specific assessments were
selected on the basis of two criteria. Firstly, these assessments had previously
been sensitive in revealing a range of cognitive skills within participants with
varying degrees of aphasia (including global aphasia) and had shown correla-
tional relationships between test scores and naming therapy outcomes
(Lambon Ralph, Snell, Fillingham, Conroy, & Sage, 2010). Secondly, these
assessments are reasonably familiar and widely available amongst UK clini-
cians and researchers. The cognitive assessments used in the present study are
briefly described as follows and a summary of participant performance is then
provided.

Memory. The following tests were used to assess memory.

. The picture and written word subtests from the Camden Memory Tests
(Warrington, 1996). In the picture version, participants looked at a set of
composite scenes and decided whether each one had been taken by an
amateur or professional photographer. Participants then looked at a set
of three photographs and decided which one they had previously seen.
 DECREASING CUES FOR NAMING IN APHASIA 303

For the written word recognition task, participants read written words
appearing on a set of cards, one word per card. Participants then decided
which words they had already seen from sets of multiple word lists.
. Copy, immediate and delayed recall parts of the Rey Complex Figure
Test (Meyers & Meyers, 1995). This test required participants to copy
a complex geometric figure, then to draw this figure from memory 5
minutes later, and then again 30 minutes later.

Executive skills. The Wisconsin Card Sorting Test (Grant & Berg,
1993) was used to assess aspects of executive functioning such as cognitive
flexibility and problem-solving. This test examined participants’ ability to
formulate rules with which to match cards on the basis of shape, colour or
number, and then to shift to different rules as the test progressed. We looked
at two measures: number of items to first category which was the number of
guesses participants made before they had worked out the “rule” for matching
cards, and the number of categories, which was the number of times the
participant both worked out and maintained the application of a matching
rule. This latter measure can be particularly useful in detecting perseveration
where a participant has worked out one rule successfully but cannot shift from
this as required. Results for the four participants on these cognitive tests are
shown in Table 2.

Summary of language and cognitive assessment findings. DH showed

stronger performance in language comprehension tasks relative to expression
tasks (see Figure 1). The composite T-score of 53 and 58 for spoken and
written comprehension, respectively, reflected maximum possible scores for
single word spoken and written comprehension, and slightly lower but still
strong scores for sentence comprehension tasks (comprehension of spoken
sentences: 20/32; comprehension of written sentences: 26/32). While the
repetition T-score of 47 showed more marked impairment, this reflected
some success in word repetition (24/32), and poorer scores on complex
words, non-words and sentences (3/6, 4/10, 0/12, respectively). The
naming T-score of 46 was made up of a score of 16/48 for naming objects,
0/10 for naming actions and 0 for word fluency. Reading aloud was impaired
(T-score 45), while a stronger T-score for writing (53) reflected reliable
copying skills (27/27) and moderate impairment in writing picture names
(17/21) and writing to dictation (14/28). Strikingly, with a disability quotient
of T-score 61, DH evaluated the impact of her linguistic deficits on her every-
day functioning as relatively modest. In connected speech tasks at baseline,
e.g., composite picture description, DH was severely non-fluent, with effort-
ful production of single words or minimal combinations of words, but with
some reliability in producing morphological features such as number and
tense. On this basis, she was not agrammatic. Within the cognitive domain,
304 CONROY AND SCOWCROFT

while memory for picture recognition was at ceiling, recognition memory for
written words was below the second centile. Visual processing was impaired
at all stages of the Rey Complex Figure task, however, with performance at
below the first centile for copy and recall sub-tasks. Executive problem-
solving skills were at the lower end of the normal range for both number of
categories identified and number of trials to the first category on the Wiscon-
sin Card Sorting task (both 2nd–5th centile).
With the exception of naming and repetition, KW showed a generally more
impaired linguistic profile than DH. In particular, he was the only participant
below T-score 50 for receptive skills (both spoken and written comprehension:
T-score 46). This stemmed from mild impairments in single word comprehen-
sion tasks (spoken: 28/30, written: 22/30) and markedly impaired sentence
comprehension scores (spoken: 11/32, written: 12/32). Repetition was
KW’s strongest linguistic skill (T-score 52) which reflected some reliability
across all sub-tests: single word, complex words, non-words, sentences (28/
32, 6/6, 4/10, 6/12, respectively). The naming T-score of 48 was made up
of moderately impaired performance across the sub-tests (naming objects:
17/48, naming actions: 4/10, word fluency: 2). Reading aloud and writing
showed the most severe impairments (T-scores 44 and 34, respectively) and
these patterns stemmed from a similar degree of impairment across the
various sub-tasks (reading words: 3/48, complex words: 0/6, non-words: 0/
10, writing picture names: 0/21, writing to dictation: 0/28), although
copying words in writing was an intact skill (27/27). KW judged the impact
of his symptoms to be the most detrimental to his everyday functioning
amongst the four participants, with a disability quotient T-score of 35. In con-
nected speech, KW was fluent but with severe anomia leading to frequent
pauses and commentary on his marked difficulty with word retrieval. The cog-
nitive scores for KW suggested adequate memory skills (e.g., 11 –16th centile
for the Rey copy, and 38 for delayed recall) although recognition memory for
words was impaired (less than 2nd centile). Executive skills were at the lower
end of the normal range at 11 –16th centile for identifying several categories
and centile 2–5 for number of trials before completing the first category.
RC showed the most even trajectory of T-scores amongst the participants,
with the lowest T-score of 49 and highest of 57. Receptive skills were her
strongest, with spoken and written comprehension T-scores (55 and 57,
respectively) reflecting no errors in single word spoken comprehension
(30/30), and few errors in spoken sentence (score 20/32), spoken paragraphs
(score 3/4), and written sentence (26/32) comprehension. Repetition T-score
of 49 stemmed from reliable single word (30/32) and complex words (5/6)
repetition, and more frank impairment in repetition of non-words (5/10)
and sentences (1/12). A naming T-score of 51 suggested moderate impair-
ment, consisting of scores 31/48 for naming objects, 2/10 for actions,
and 5 items in word fluency. Reading aloud and writing were again
 DECREASING CUES FOR NAMING IN APHASIA 305

middle-ranking in terms of T-scores (51 and 49, respectively), with intact

skills for written copying (27/27) but evidence of some impairment across
all other sub-tasks (reading words: 34/48, reading complex words: 2/6,
reading non-words: 4/10, written picture naming: 9/21, and writing to dicta-
tion: 8/28). RC was the only participant for whom the self-evaluation of the
impact of her symptoms was numerically proportionate to her linguistic
scores, with a disability quotient T-score of 51. In connected speech tasks,
RC was fluent but moderately anomic with occasional pauses for word
searches and some emptiness of speech with, for example, the use of pro-
forms (e.g., he, she, this, etc.) without prior referents. Cognitively, RC
scored at the low end of the normal range for picture recognition memory
and recognition memory for words (both 3rd centile), and for executive
skills. All of her Rey Complex Figures scores showed impaired performance,
at around the first centile for copy, immediate and delayed recall.
WE was distinctive in having all T-scores on the CAT above 50, placing her
in the upper clinical range for all linguistic skills. This was most marked for her
expressive skills, with repetition scores (T-score: 64) close to/at ceiling (word
repetition: 30/32, complex words: 6/6, non-words: 8/10, sentences: 12/12),
and reading aloud (T-score: 66) – reading words, complex words and function
words at ceiling (48/48, 6/6, 6/6, respectively), and only reading non-words
below ceiling (8/10). Receptive skills were the most impaired (spoken com-
prehension T-score: 52, written comprehension T-score: 56) with reliable
single word comprehension (spoken and written, both: 29/30) and a more
marked sentence comprehension deficit (spoken: 19/32, written: 21/32).
Naming was relatively impaired for WE, with a T-score of 61, which reflected
individual scores for naming objects (46/48), naming actions (8/10), and
word fluency (10 items). The Disability Quotient for WE was T-score: 51:
she still reported considerable impact from the linguistic symptoms. In con-
nected speech tasks, WE was moderately non-fluent, with evidence of pro-
duction errors, hesitancy, many single words or, more typically, minimal
combinations of words, but she was not agrammatic. Cognitively, WE
scored at the lower end of the normal range for all skills tested (see Table 2).

Therapy targets
The primary outcome measure in the study was naming accuracy of nouns
and verbs. Appropriate noun and verb naming targets were obtained using
the Object and Action Naming Battery (Druks & Masterson, 2000) which
provides details of the psycholinguistic properties of the target words.
Items that participants had failed to name on two presentations were selected
for therapy. This testing was carried out in parallel with the formal linguistic
and cognitive assessment within a one month time frame before the com-
mencement of therapy.
306 CONROY AND SCOWCROFT

Detail of therapy method: Dynamic list

The therapy method was dynamic in that a top-up approach to increasing the
number of target words was used across 10 weekly therapy sessions. Ten
target words were introduced in the first session (5 nouns, 5 verbs), trained
within the session and left for homework practice. At the start of session 2,
if a participant was 100% accurate in naming these initial 10 targets, then a
further 10 targets were trained within session 2. The homework practice
was thus increased to 20 items. If success at this optimal level continued,
then a participant would take on 10 items in each session, totalling 100
items (50 nouns, 50 verbs) overall by the end of 10 sessions.
A flow-chart demonstrating some ways which participants might pro-
gress through the dynamic therapy is shown in Figure 2. An assessment
probe (unsupported picture naming of all items introduced) was carried
out at the start of each session from session 2 onwards. Items which
were correctly named in the assessment probe were described to the partici-
pants as “banked”, i.e., taken as accurate and stable (for the time being),
while incorrect items were for “recycling”, i.e., returned into the practice
set of 10 items for training within the session and over the next week.
Therefore, if at the start of session 2, 9 items were produced correctly
and 1 incorrectly on the assessment probe, then the 9 correct items were
“banked”, and the 1 incorrect was “recycled” and added to 9 new items
to make a total set of 10 items for training within the session. This set of
10 items trained in that session were added to the previously banked 9

Figure 2. Flowchart to illustrate some options for progressing through therapy.

 DECREASING CUES FOR NAMING IN APHASIA 307

items and left as a set of 19 items for home practice over the next week. If
at the start of session 2, 5 items were correct and 5 incorrect, the 5 incorrect
items were recycled and added to 5 new items to make a total set of 10
items for training within the session. These 10 items trained in the
session were then added to the previously banked 5 items to make up the
set of 15 items for home practice.

Detail of therapy method: Decreasing cues

A decreasing cues method was used to facilitate naming accuracy for the
dynamic list of target nouns and verbs. Taking the example of the first 10
items introduced in session 1, on the first presentation, production was cued
using whole word repetition – participants were asked to listen to the thera-
pist’s production of the target word and then attempt their own production
three times. Based on the broadly reliable single word repetition skills of
the participants according to the inclusion criteria (see Table 1), it was antici-
pated this whole word cueing would generally result in accurate target word
production. On the second picture presentation in a session, a CV (initial con-
sonant + vowel) phonological and orthographic cue was provided: the initial
consonant and vowel of a one-syllable word was offered by the therapist as a
cue to the participant producing the whole target word (where target words
had more than one syllable, the whole first syllable was offered). Again,
the participant was asked to produce the target word three times. If a partici-
pant struggled to produce a target to this cue in this second picture presen-
tation, then the therapist immediately reverted to the initial whole word
cue. On the third (final) picture presentation within a session, the participant
was initially requested to attempt naming of the 10 targets without therapist
support (i.e., uncued naming). Where naming was successful, it was requested
that the participant repeat the correct production a further three times (10 total
naming attempts in a session). If any attempts at production were not correct,
then the CV cue was offered. If the CV cue was not successful, then the whole
word cue was again provided.
In sum, this quite precise method was utilised in order to ensure that it
resulted in an error-reducing therapy. This was largely based on decreasing
cues, e.g., proceeding from a whole word cue to a part word cue to no cue
within a session. However, the method could more precisely be described
as a staircase one, in which cues typically decreased, but on occasion
increased (i.e., where a participant has produced an error in production). It
was anticipated that approximately 80% of naming attempts would be very
likely to be correct (errorless), in that there were only two specific points
within the 10 naming attempts at which participants would be most likely
to generate an error: at the two points where the cue was reduced. The
method was also designed to ensure participants experienced ease of
308 CONROY AND SCOWCROFT

engagement within the therapy tasks, matched with sustained effort over the
course of the 30–40 minutes required.

Detail of therapy method: Weekly therapy and homework

practice
Weekly sessions were planned as these were deemed most practical by both
participants and the authors. Furthermore, recent evidence has suggested that
non-intensive naming therapy may result in longer lasting effects (Sage,
Snell, & Lambon Ralph, 2011). However, a potential drawback of relatively
non-intensive therapy, e.g., once weekly, can be the diminishing of learning
effects between sessions. In order to minimise this risk, and also to refine the
decreasing cue method as one with real-world clinical plausibility, a home-
work component was introduced into the present study. Participants and
carers were given simple written instructions accompanied by visual
prompts which detailed the practice task as follows: for all the target words
introduced in therapy, look at the picture, read the word underneath the
picture and read this word aloud slowly and carefully three times. Participants
were asked to record the number of such homework sessions and their dur-
ation in minutes between weekly therapy sessions.

Post-therapy assessments
Following completion of session 10, a control set of words which totalled the
same number of items as the treated set, had the same baseline accuracy as
treated items, and were matched for key psycholinguistic properties (word
class – noun or verb, word frequency, word length, word imageability) was
collated for each participant. Naming accuracy for the treated and control
sets was assessed one week after the final therapy session. This was then
repeated eight weeks later in order to allow comparison of any immediate
changes in naming with longer term follow-up changes in naming.

RESULTS
Accuracy scores for treated versus control nouns and verbs at both post-
therapy assessment points are shown in Figure 3.
These data show that participants progressed to varying degrees in naming
accuracy through therapy. At the higher end of the results obtained, WE
scored 80 (47 nouns + 33 verbs) and 81 (48 nouns + 33 verbs) at the two
assessment points at the higher end of accuracy, while at the lower end,
DH achieved scores of 27 (16 nouns + 11 verbs) and 22 (13 nouns + 9
verbs) at the respective assessment points.
 DECREASING CUES FOR NAMING IN APHASIA 309

Figure 3. Accuracy scores for treated versus control nouns and verbs at both post-therapy assessment
points. The error bars represent the standard error of the mean.

The individual participant results were analysed as follows: overall therapy

effects for treated and untreated words at both post-therapy assessment points;
results for verb versus noun naming accuracy; and lastly, patterns of progress
through therapy.
Non-parametric analyses of individual participants’ accuracy scores indi-
cated that each participant made statistically significant improvement to
their naming skills for the treated items, when baseline scores (at zero)
were compared both to immediate post-therapy assessment and to follow-
up assessment (all McNemar 1 tailed, p , .001).
Between the two post-therapy assessment points, there was no significant
change in naming accuracy for the treated items for two participants (KW:
McNemar 1 tailed, p ¼ .314; WE: McNemar 1 tailed, p ¼ .5). There were
more substantial drop-offs in accuracy between the two post-therapy assess-
ment points for the other two participants; for DH, this approached statistical
significance (McNemar 1 tailed, p ¼ .06), while for RC, this was very signifi-
cant (McNemar 1 tailed, p ¼ .006).
Accuracy levels for treated versus non-treated (control) items were ana-
lysed using chi square comparisons within each participant at each post-
therapy assessment point. There was a consistent statistically significant
advantage for treated sets (both nouns and verbs) over control sets (all: x2 .
5, df ¼ 1, p , .02).
Individual participant analyses of the accuracy scores of nouns versus
verbs revealed no difference for 3 out of 4 participants (KW, DH, RC: x2
310 CONROY AND SCOWCROFT

, 0.7, df ¼ 1, p . .4), despite a numerical trend for noun accuracy greater

than verb accuracy.
For participant WE, however, there was a statistically significant differ-
ence between total noun versus verb accuracy scores (i.e., treated and
control nouns . treated and control verbs: x2 ¼ 4.867, df ¼ 1, p , .026).
While this difference was borderline significant in WE’s control items
alone (i.e., untreated control nouns versus control verbs: x2 ¼ 3.69, df ¼ 1,
p , .055), it was a more marked significant difference between treated
nouns and treated verbs for WE (x2 ¼ 12.61, df ¼ 1, p , .001).
Progress through the therapy sessions, evaluated through assessment
probes at the start of each session, is depicted in Figure 4 which compared
the optimal performance (10 new items successfully trained over 10 weekly
sessions) against the performance of the four participants.
Figure 4 shows a narrow range of response to therapy up to session 5, at
which point, it was possible for participants to have extended the target list
of items to 50. The actual range was 31 (DH) to 47 (WE). Relative perform-
ance at this point (session 5) was predictive of relative performance by the end
of session 10 (i.e., participant ranking at session 5 was identical at session 10).
The range of items in therapy across participants widened substantially,
however, between sessions 6 and 10. At session 10, DH had a final set of
36 therapy items and WE a final set of 84. DH showed a flattening profile
between sessions 5 and 10 where the total of items only grew from 31 to
36. There was a similar plateau in RC’s total items (50) between sessions 8
and 10. The remaining participants, WE and KW, continued to take on new
items in each session (with the exception of session 10 for KW), which
reflected more even and consistent trajectories of improving naming accuracy

Figure 4. Progress through therapy.

 DECREASING CUES FOR NAMING IN APHASIA 311

during therapy, relative to DH and RC. DH and RC, in contrast, reached sat-
uration points at which the frequency of errors in naming accuracy limited
their set sizes.
Quantitative analysis of inaccurate naming responses during therapy sup-
ported this saturation hypothesis, rather than the other possibility that some
participants individually had difficulties on a small number of specific
items repeatedly. All items introduced to each participant were produced suc-
cessfully in an assessment probe on at least one occasion, which indicated that
the words were feasible therapy targets. Relatively few items were the source
of consistently inaccurate naming attempts, in the sense that the same word
was produced inaccurately at least three times or more during therapy.
Figure 5 shows the relative proportion of words which generated consistently
inaccurate productions (i.e., three or more instances of inaccurate productions
on these specific words) against inconsistently inaccurate productions (accu-
racy errors once or twice on a specific word).
At the mean level across the participants, Figure 5 shows that there were
approximately twice as many instances of inconsistent as opposed to consist-
ent error production (inaccuracy on the same words repeatedly).
A final analysis was total post-therapy accuracy scores against the total list
sizes at the end of the last session of therapy. Figure 6 shows the post-therapy
accuracy scores across conditions, word classes, assessments and participants,
as percentages of the total therapy lists by session 10. The percentage accu-
racy scores for treated items ranged from 67% to 79% of total items in
therapy with a mean of 73%. For the control items, this range was 20% to

Figure 5. Consistency of inaccurate production on word targets in therapy.

312 CONROY AND SCOWCROFT

Figure 6. Accurate items post-therapy as a percentage of trained items.

30% with a mean of 25% accuracy of total items. There was a range of accu-
racy percentages between participants. While WE averaged 93% accuracy
across her treated sets, the remaining participants achieved 64% (KW),
68% (DH), and 61% (RC). This suggested the flattening trajectories of the
accumulation of items during therapy (Figure 4) for DH, RC and to a lesser
extent for KW, pointed to the saturation of their learning and eventual
strong but not flawless accuracy levels post-therapy.

DISCUSSION
This study aimed to evaluate a modification to the decreasing cue method to
better reflect the learning potential of each participant in therapy. There has
been a considerable degree of consensus in the aphasiology literature that
errorless (including decreasing cues) and errorful (trial and error) therapy
methods have been similarly effective as means of improving naming
accuracy (Abel et al., 2005; Conroy et al., 2009b; Fillingham et al., 2005a;
McKissock & Ward, 2007). Conroy et al. (2009a), however, noted that par-
ticipants found the combination of low error rate and sustained effort inherent
within decreasing cue therapy an optimal method in that it was both engaging
(compared to “pure” errorless methods) and easy but becoming incrementally
more challenging (relative to trial and error naming). Furthermore, Conroy
et al. (2009a) had found the time investment within therapy for decreasing
cues to be less compared with increasing/trial and error cues; in other
 DECREASING CUES FOR NAMING IN APHASIA 313

words, the same degree of progress was achieved with a method which caused
less frustration, and was easier and quicker.
The present study sought to build on the efficiency of the decreasing cue
method and modify it away from being predominantly an experimental
method to one with more real-world applicability. The central idea was to
allow participants to progress at their own individual level in terms of the
number of items they took on in therapy, whilst maintaining accuracy of
items already in the treatment set. Hence, the decreasing cues method was
applied to a dynamic list of noun and verb targets which had the capacity
to grow from a very limited set size to a more extensive one, based purely
on participant responsiveness to therapy. In this way, the method would
avoid a ceiling being placed on the progress in naming accuracy that some
participants could make, or at least raise the ceiling much higher. Also, as
the therapy design was a relatively errorless one (decreasing cue method),
the aim had been to utilise this accessible therapy method such that the train-
ing set size and total accuracy scores were, ideally, a perfect match in number,
but certainly relatively close.
The method was effective in allowing participants to show more substan-
tial differences in accuracy than may have been apparent with shorter, fixed
target lists. At the same time, the errorless nature of the decreasing cue
method (reinforced by errorless homework tasks) did close the gap between
the total numbers of trained items per participant and post-therapy accuracy
scores. The mean percentage accuracy score was 73% (range 61–93%)
which meant that almost three of every four trained items was accurate
after therapy.
The study also aimed to compare participants’ responses to therapy for
nouns and verbs. In a comparable study, which compared decreasing and
increasing cues for noun and verb naming, Conroy et al. (2009a) had found
a noun-naming advantage in accuracy post-therapy across participants with
both mild and severe degrees of baseline naming impairment. In this study,
analyses of individual accuracy scores of nouns versus verbs revealed no sig-
nificant difference for three out of four participants. For participant WE,
however, there was a statistically significant difference between total noun
versus verb accuracy scores (greater accuracy for nouns over verbs) which
was borderline significant in WE’s control items alone and significant
between treated nouns and treated verbs. The borderline difference between
noun and verb control items reflected WE’s baseline accuracy skills across
these word classes: i.e., there was a tendency for her to be more accurate in
noun versus verb retrieval. That this difference became larger in magnitude
for the treated items, suggested that there was also a related but additional
factor which was WE’s relatively poorer skills in progressing through
therapy for verbs compared to nouns. The contrast between WE and the
other participants here may have related to a floor effect for the other
314 CONROY AND SCOWCROFT

participants, in that WE scored at 80% accuracy after therapy for the total
possible 100 words, whereas KW, DH and RC ranged between approximately
25% and 45% accuracy post-therapy. Effectively, the relative doubling of the
number of items in therapy for WE may have allowed her to show greater sen-
sitivity to the more challenging psycholinguistic variables associated with
verbs over nouns, particularly lower imageability, in contrast to the other
participants.
The method also offered some insights into the process of extending the list
size in therapy. Despite the errorless design, participants did make some pro-
duction errors in therapy, especially as the list sizes grew. Typically, however,
these were inconsistent production errors. In other words, there was an unpre-
dictable, somewhat random, quality to error production; e.g., for targets A, B
and C, if A and B were accurate but C inaccurate in session 5, then B and C
were accurate in session 6 but not A, etc. This suggested that when participant
progress did begin to stall, it reflected the general learning load in therapy.
Overall, the error production data pointed to some participants struggling to
keep a grip on the progress in naming accuracy that they had made as evi-
denced by somewhat erratic lapses in accuracy, rather than errors consistent
to specific words. Only one participant displayed item-consistency with
regard to inaccurate production attempts in therapy (DH), for whom consist-
ent errors (i.e., errors of inaccurate production made on the same words three
or more times) were almost three times more frequent than inconsistent
errors. On entry to the study, DH had presented with the more impaired
naming and word repetition skills compared with the other participants,
e.g., see CAT scores within Method and Figure 1. A cut-off for repeated
errors on specific words (e.g., three fails means a word is removed from
the training list) might in future avoid the potential confound of item-specific
difficulty (rather than general learning) dictating therapy progress.
What can account for the varying trajectories of progress through therapy
for these four participants? Lambon Ralph et al. (2010) had found both a cog-
nitive and a phonological factor to be predictive of immediate and longer-
term anomia therapy gains. The small participant number of four in the
present study precludes meaningful statistical analysis of the relationship
between the therapy outcomes and the baseline language and cognitive
measures. However, certain baseline scores can be highlighted in terms of
the rank order of participants in comparison with the therapy outcomes.
The cognitive factor in Lambon Ralph et al. (2010) had comprised aspects
of three cognitive elements (attention, executive functioning and visuo-
spatial memory). Executive functioning and visuo-spatial memory had been
assessed at baseline in the present study with the Wisconsin Card Sorting
Test and the Rey Complex Figure Test. The centile ranking for the number
of category scores for the Wisconsin did broadly reflect the therapy outcomes
(WE . KW . RC ¼ DH). The number of trials to the first complete
 DECREASING CUES FOR NAMING IN APHASIA 315

category, however, showed a similarly low level of performance across the

participants. Neither the Rey Complex Figure nor Camden Memory Scores
showed any convincingly differentiated underlying skills with which to
make sense of the varying therapy outcomes.
The phonological factor which Lambon Ralph et al. had found to be pre-
dictive of immediate and longer-term anomia therapy gains consisted of
word repetition and word reading (aloud). There was a narrow range of
scores across the four participants in relation to word repetition skills in the
CAT data (24–31/32 for word repetition), although the participant ranking
reflected participant progress for accuracy in that DH scored lowest here
(24/32) and WE highest (31/32). Word reading scores, however, did not
appear to map onto participant progress. Lambon Ralph et al. (2010) had
found that the Boston Naming Test had been the most predictive individual
language measure. According to this measure, WE had been the least
impaired participant at word retrieval and yet had also made the most striking
progress in naming therapy.
Individual participant factors which may exert a more subtle but equally
crucial role in determining therapy outcomes include motivation and engage-
ment. The method had intended to capture some indication of motivation and
engagement through recording homework activity frequency. While there
was evidence that homework was carried out by each participant, no partici-
pant recorded the frequency of this activity with sufficient consistency across
the therapy phase to allow any clear picture to be drawn. This was a limitation
of the present study which highlights the dilemma in attempting to make
therapy methods more clinically plausible through, for example, harnessing
participant motivation for independent practice, whilst allowing extraneous
variables to enter the data. Further research could usefully address this
theme of the role of independent time-investment in therapy, especially
with the expanding role offered by the use of therapy software packages
(see Fink, Brecher, Sobel, & Schwartz, 2005).
Therapy gains can also be considered in the context of the psycholinguistic
properties of the words undergoing training. Recent evidence has suggested
that words which were accurately cued at baseline with minimal phonemic
cues and with higher imageability scores were the items most likely to be
named accurately after naming therapy across a large data set from 22 partici-
pants with aphasia (Conroy, Snell, Sage, & Lambon Ralph, 2011). The
accumulation of words across the dynamic set of therapy items in the
present study can also be viewed as the gradual incremental increasing of
the psycholinguistic load on participants. This is similar to the phenomenon
within connectionist modelling (computations of neural elements connected
to one another to mimic cognitive behaviours such as learning and unlearn-
ing) known as catastrophic interference (Ellis & Lambon Ralph, 2000).
Here, where a model has been trained on set of items A, and then receives
316 CONROY AND SCOWCROFT

training on set B, the information about set A may be gradually lost as the new
(set B) items are learnt. However, if training on set A continues alongside set
B, then catastrophic interference can be avoided by the model incorporating
set B while maintaining set A. This observation led Ellis and Lambon Ralph
(2000) to conclude that: “human vocabulary acquisition does not involve
learning one set of words for a period of time and then suddenly adding a
second set; rather, natural vocabulary acquisition involves the gradual
accumulation of words with constant interleaving of old with new items”
(pp.1106–1107). This was clearly what the present study had intended to
achieve. However, the data from just 10 therapy sessions suggested that inter-
ference of mild to moderate degrees of “catastrophe” did impede optimal pro-
gress and that this impedance might remain or even increase with ongoing
therapy sessions. Further connectionist experiments which mimic learning
in damaged and hence depleted systems, such as word retrieval in aphasia,
could clarify whether this “saturation” interference is a fixed and universal
feature of progress in naming therapy.
No wider connected speech and functional communication measures were
collated within this study which would have indicated whether participants
had made gains in broader communication skills (which is, after all, the
purpose of therapy). Further related research could usefully incorporate
such measures, and also investigate whether improvements in word retrieval
in connected speech (e.g., a greater range of types and tokens of nouns and
verbs) correlate with high therapy set size and post-intervention accuracy
scores.
To return to the theme in the Introduction of taking insights from other
strands of neurorehabilitation and considering their usefulness within apha-
siology, the errorless paradigm within memory rehabilitation has sought to
both identify optimal training methods and to gauge some sense of the
limits of these methods in terms of the potential of rehabilitation (Jansari,
McGibbon, Haslam, & Anderson, 2009). In combination with computational
modelling research, further empirical studies into the application of efficient,
defined and replicable intervention methods such as decreasing cues for an
open-ended dynamic list of word targets could serve the same purposes in
aphasiology.

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