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Aphasiology
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Switching in adults with aphasia

a a
Hsinhuei S. Chiou & Mary R. T. Kennedy PhD
a
University of Minnesota , Minneapolis, MN, USA
Published online: 04 Dec 2010.

To cite this article: Hsinhuei S. Chiou & Mary R. T. Kennedy PhD (2009) Switching in adults with
aphasia , Aphasiology, 23:7-8, 1065-1075, DOI: 10.1080/02687030802642028

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 APHASIOLOGY, 2009, 23 (7–8), 1065–1075

Switching in adults with aphasia

Hsinhuei S. Chiou and Mary R. T. Kennedy
University of Minnesota, Minneapolis, MN, USA

Background: Clinicians report that many adults with aphasia have difficulty in switching
ideas and responses in a flexible manner. Switching requires the regulation of processes
from current and previous tasks, and the ability to resist interference from previous
tasks. Yet there is little research that documents switching after aphasia. Furthermore
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predicting, or knowing what is to come next, may facilitate flexible switching.

Aims: The purpose of this study was to compare the switching ability of adults with
aphasia to matched controls when the rules changed and when adults knew how the
change would occur (predicting).
Methods & Procedures: A total of 14 adults with mild or moderate aphasia and 14
matched healthy controls switched between Go/No-go (GNG) rules with minimised
linguistic and cognitive demands. To determine if adults with aphasia benefited from
knowing what to expect, predictable and unpredictable conditions were created. Switch
cost and number of omission and commission errors were the dependent variables.
Outcomes & Results: Adults with aphasia were slower, less accurate, and less likely to
disregard the previous rule when switching from one rule to another than controls.
Predictable and unpredictable switching influenced participants’ performance to some
extent.
Conclusions: These findings provide evidence of impaired reconfiguration and
interference when adults with aphasia switch rules. These underlying processing deficits
are discussed within a broader framework of cognitive flexibility. Future studies should
investigate switching processes and their relationship with functional communication.
Keywords: Switching; Reconfiguration; Interference; Go/No-go; Aphasia.

Aphasia has been characterised as both a linguistic and a cognitive impairment

(Chapey, 1994; Helm-Estabrooks, 2002). The ability to switch is indicative of
cognitive flexibility, and clinicians report that adults with aphasia experience
difficulty in switching. Unfortunately, few empirical studies have investigated
switching in adults with aphasia, even though some have proposed that this skill may

Address correspondence to: Mary R. T. Kennedy PhD, University of Minnesota, Department of

Speech-Language-Hearing Sciences, 115 Shevlin Hall, 164 Pillsbury Drive SE, Minneapolis, MN 55455,
USA. E-mail: kenne047@umn.edu
This research was supported by CLA PhD student dissertation award and Bryngleson funds from the
Department of Speech-Language-Hearing Sciences at the University of Minnesota. The authors thank
Minnesota Stroke Association, Fairview hospitals, Methodist hospital, North Memorial hospital, Julia M.
Davis Speech-Language-Hearing Center, Sister Kenney Institute, United hospital, Abbot Northwestern
hospital, Courage Center, Amherst H. Wilder Foundation, Lyngblomsten, Augustana Care, Yang Zhang,
Edward Carney, Ben Munson, Miriam Krause, and Pradeep Ramanathan who helped with participant
recruitment, stimuli recording, computer programs, and data analysis. Special thanks to stroke survivors and
to Cindy Busch, Kathleen Miller, Lynne Conley, Gail Lommen, Sharon Spencer, and Heather Cummings.

# 2009 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/aphasiology DOI: 10.1080/02687030802642028
 1066 CHIOU AND KENNEDY

differentiate between those who use what they learn in therapy from those who do
not (Kraat, 1990). The purpose of this study was to investigate the switching abilities
of adults with aphasia.
Switching is critical for cognitive flexibility, as one adaptably shifts attention,
ideas, sets, and responses (Rende, 2000). It requires regulation of processes of
current and previous tasks with the ability to resist interference from previous tasks
(Rogers & Monsell, 1995). Switching is measured as the ‘‘cost’’ or the difference in
response times (RT) and in accuracy between tasks with and without switching. Two
types of endogenous control processes are critical to switching: reconfiguration and
interference (Meiran, Chorev, & Sapir, 2000; Monsell, Yeung, & Azuma, 2000).
Reconfiguration is defined as a self-initiated activation and modification of a new
rule when switching from a previous task to a new task (Dreher, Koechlin, Ali, &
Grafman, 2002). The second type of endogenous control process is interference.
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Since the switch cost cannot be completely eliminated by an increase in preparation

time or manipulation of foreknowledge of the next task (Monsell et al., 2000; Sohn &
Carlson, 2000), it is possible that at least part of the switch cost represents
interference from the previous task (Allport, Styles, & Hsieh, 1994).
Deficits of reconfiguration or interference can be identified by the kinds of errors
made while switching. People with reconfiguration deficits may have difficulty in
constructing processes required for a new rule or a new task, resulting in omitting a
response to a new or specified stimulus. People who experience interference may
have difficulty suppressing processes from a previous rule or task, resulting in
erroneous responses (commissions) to a new rule or a new task. According to
Norman and Shallice (1986), both reconfiguration and interference are present in a
supervisory activation system (SAS). When a novel task is introduced, the SAS
intervenes in the process of schema selection, overrides the habitual responses, and
reconfigures task sets to meet the demands of the changing environment.
It has been suggested that underlying cognitive deficits in adults with aphasia
explain impaired shifting. Adults with nonfluent aphasia were trained to use three
response modalities (verbal, gesture, and communication board) and continued to
encounter difficulty spontaneously switching between modes, especially from the
verbal mode to others (Purdy, Duffy, & Coelho, 1994). In the alternating symbol
task of the Cognitive Linguistic Quick Test (Helm-Estabrooks, 2001), Helm-
Estabrooks (2002) found that adults with mild aphasia had difficulty switching
between circles and triangles. In Chiou and Kennedy (2006), maintaining and
shifting sets were associated with the accuracy of confidence judgements about one’s
comprehension, all of which are a part of the supervisory system. However,
assessment options are limited for individuals with aphasia because of the language
load and involvement of multiple cognitive processes in many complex cognitive
tasks (Keil & Kaszniak, 2002). For example, suppression and activation of new
cognitive set rules are involved during the Wisconsin Card Sorting Test (WSCT;
Heaton, Thompson, & Gomez, 1999), but this task is long and complicated for
adults with aphasia. Simple Go/No-go (GNG) tasks (Drewe, 1975) avoid linguistic
and cognitive demands present in other executive functions tasks by requiring simple
responses. In a GNG task a response selection process is required between either
executing or inhibiting a response, triggered by a ‘‘go’’ stimulus or a ‘‘no-go’’
stimulus. Set shifting occurs when a previous response is suppressed while a new
response is activated. Various stimuli have been used in GNG tasks with healthy
adults, and Talati and Hirsch (2005) suggested that this variability across studies
 SWITCHING IN ADULTS WITH APHASIA 1067

may explain some of the inconsistency of hemispheric involvement during this task
(Swainson et al., 2003). Clinical populations such as those with traumatic brain
injury have demonstrated difficulty in inhibiting responses using GNG tasks,
although these studies were not designed to differentiate between reconfiguration
and interference (e.g., Dockree et al., 2004). Although a relationship between
switching ability and frontal-parietal networks in typical adults has been proposed,
this study was the first to use GNG tasks to investigate these switching processes in
adults with aphasia.
Individuals with aphasia who have left hemisphere stroke appear to encounter
difficulty in response selection that results in reduced flexibility in selection of
appropriate responses to meet communicative needs. Rushworth, Nixon, Wade,
Renowden, and Passingham (1998) argued that left hemisphere deficits come from a
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network of brain regions that are important for response selection. Compared to
right hemisphere patients and neurologically typical controls, patients with left
hemisphere damage (LHD) were impaired in tasks that required selecting a motor
response. In Mecklinger, Cramon, Springer, and Cramon (1999), 7 of 11 participants
with LHD and language impairment demonstrated disproportionately high RT
switch costs when switching between two visual classification tasks—line-drawn
object and spatial pattern—compared to patients with right hemisphere damage. The
authors attributed these deficits to a less-efficient suppression of internal
interference, difficulty in reconfiguring cognitive processes, and language impair-
ment. Together these studies provide evidence that adults with aphasia may
encounter greater switch costs because of the inefficient reconfiguration and
interference from diminished suppression in switching tasks.
Many people perform better when they are able to predict what will happen next.
Sohn and Carlson (2000) emphasised that with foreknowledge in both repetitive and
switching trials, performance can be improved in healthy adults. Indeed, adults with
aphasia may be better prepared to switch if forewarned, i.e., when they can predict
what is coming. Therefore we were also interested in determining whether or not
adults with aphasia would use this foreknowledge as a strategy to enhance their
reconfiguration during switching tasks.
Two research questions were proposed in this study: First, are adults with aphasia
as fast as controls when switching between rules and will they benefit from knowing
what to expect next? Second, are adults with aphasia as accurate as controls when
switching between rules and will their accuracy improve from knowing what to
expect? It was expected that adults with aphasia would be slower and make more
errors switching between rules compared to controls. Switching difficulty in adults
with aphasia could be explained by difficulty in reconfiguration and/or resistance to
interference, investigated by omission and commission error patterns. It was
unknown if adults with aphasia would benefit from knowing what to expect,
although we expected controls to benefit from this forewarning.

METHOD
Participants
A total of 14 adults with mild or moderate chronic aphasia and 14 age- and
education-matched healthy controls were included in this study (Table 1). Severity
and type of aphasia were classified by an aphasia quotient (Western Aphasia
 1068 CHIOU AND KENNEDY

TABLE 1
Participants’ demographic information and test results

Aphasia mean¡SD Control mean¡SD

Age at testing (years) 63.85¡11.83 66.00¡12.29

Gender: Male/female 6/8 7/7
Years of education 15.07¡2.46 16.21¡2.05
Western Aphasia Battery
Aphasia quotient* 76.33¡11.48 99.70¡0.23
Cortical quotient* 77.97¡8.96 98.01¡2.15
Communicative Abilities of Daily Living* 90.71¡8.30 99.00¡0.00
Sorting Subtest
Confirmed correct sort* 7.79¡3.04 13.07¡1.90
Confirmed/unconfirmed target Sorts* 7.07¡3.32 12.50¡2.35
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Trail Making Subtest

Number-letter switching* 2.64¡3.05 11.14¡2.63
Design Fluency Subtest
Switching* 7.36¡2.31 12.14¡2.03
Total attempted designs* 7.50¡4.01 13.50¡3.08
Percent design accuracy* 5.50¡4.27 9.00¡2.75
TEA Visual Elevator Subtest
Raw accuracy scores* 6.00¡2.37 10.62¡3.36
Attentional switching timing* 2.23¡2.56 10.69¡4.63

*p , .05.

Battery; Kertesz, 1982). Four were mildly anomic, four were moderately anomic, one
had a mild conduction, and five had mild Broca’s aphasia. The average time since
stroke was 3.09 years (SD52.59). Of the participants with aphasia, 12 had sustained
ischaemic strokes and 2 had sustained haemorrhagic strokes.
All participants were native English speakers, and were right-handed, without
history of neurological disease, substance abuse, or psychiatric disorder. All
participants had adequate corrected hearing and vision verified with standard
screenings. Additionally, participants had to remember sequences of three letters
presented visually on a note card after a 5-second delay, to ensure they were able to
hold visual information in memory.
Several neurocognitive tests were administered to assess cognitive flexibility and
switching skills. Results from the Trail Making, Design Fluency, and Sorting
subtests of the Delis-Kaplan Executive Function System (D-KEFS; Delis, Kaplan, &
Kramer, 2001) as well as the Visual Elevator test, a subtest of the Test of Everyday
Attention (TEA; Ridgeway, Robertson, & Ward, 1994) can be found in Table 1.
Overall, adults with aphasia had more difficulty switching numbers, letters, circles,
rules, and directions compared to healthy controls.

General procedures
All research procedures were approved by the University of Minnesota’s
Institutional Review Board for human participants. Participants were recruited
from local stroke support groups and flyers posted in an urban region of the upper
Midwest. All procedures were completed in one or two sessions. Sessions took place
in quiet rooms without distractions or interruptions.
 SWITCHING IN ADULTS WITH APHASIA 1069

Prior to the GNG tasks, a visual-auditory detection task served as a baseline

measure to confirm participants’ ability to detect stimuli over a period of time. Four
types of non-linguistic stimuli included two horizontal lines of two different lengths
(3 inches long and 1 inch long) and two auditory tones of two different fundamental
frequencies (500 Hz and 1000 Hz). These were presented in a random order for
500 ms each.

GNG task, stimuli, design, and specific procedures

GNG tasks were created and presented with ‘‘eevoke 2.0.0.2’’ (ANT Software BV,
2004), a program on a Dell laptop with a 15-inch colour screen. Two speakers were
placed beside the laptop and participants were able to adjust the sound level. The
word ‘‘READY’’ was presented visually (in the centre of the computer screen) and
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auditorily for 2 seconds to signal the start of the task. A range of interstimulus
intervals (2000¡1000 ms) was used to avoid establishment of a response pattern.
Stimuli were presented for 1000 ms followed by the next stimulus. Participants
responded to a ‘‘go’’ stimulus by pressing a button on a game pad with their left
index finger.
Two types of stimuli were used in the GNG tasks for both go stimuli and no-go
stimuli: capital orthographic letters presented visually (size 24 font) and audible
letter names presented to both ears at a comfortable loudness through two speakers.
Visual contours or phonemes that were similar to the no-go and go stimuli were
excluded. This study’s design consisted of between- and within-participant
conditions. Group (adults with aphasia, controls) was the between-participant
condition, whereas switching (with rules, without rules) and predictability
(predictable, unpredictable) were the within-participant conditions.
Two types of predictability were created. In the predictable condition auditory
(A) and visual (V) stimuli were alternated on every trial, i.e., AVAVAVAVAV.
Participants were forewarned of this modality sequence and were instructed to
ignore the no-go stimulus during the entire task. In the unpredictable condition the
modality sequence was uncertain, i.e., an auditory stimulus could be followed by an
auditory or visual stimulus. In other words, participants were unsure about the type
of stimulus they would hear or see next.
In the switching condition without rules, participants followed a simple rule, e.g.,
‘‘Do not respond to O’’ regardless of the modality. A total of 100 stimuli included 60
go stimuli (30 visual, 30 auditory) and 40 no-go stimuli (20 visual, 20 auditory). In
the switching condition with rules, each rule appeared on the computer screen and
was printed on a card, which remained in view. Participants were instructed not to
respond to a no-go stimulus in a given modality (letter or letter name). Since a
modality was specified for each rule, the no-go stimuli and the modality changed
when a rule changed. For example, if the first rule was ‘‘Do not respond when you
see F’’, then the next rule would be ‘‘Do not respond when you hear E’’. Prior to the
next rule, the word ‘‘wait’’ appeared on the screen for 10 seconds.
Stimuli for the GNG task in the switching condition with rules consisted of 80
stimuli (60 go, 20 no-go). There were five rule switches, with one after every 16
stimuli: 12 go stimuli, 4 no-go stimuli. There were three kinds of go stimuli (see
Figure 1): novel (letters and letter names not presented before, N-S, N-D), go stimuli
in a modality different from current no-go stimuli (G-D), and last no-go stimuli
(same or different from the last GNG rule, L-S, L-D). Half of each stimulus type
 1070 CHIOU AND KENNEDY
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Figure 1. Type of experimental stimuli for both predictable and unpredictable conditions with the number
of go and no-go opportunities by same and different modalities. Only no-go stimuli in the same modality
could result in commission errors, whereas all other go-stimuli could result in omission errors.

were in the same modality (S, NG) as the no-go stimuli and the other half were
different (D, G-D); thus the similarity of the modality was also an independent
variable, but only when switching occurred. It is important to point out that NG (see
Figure 1) were the only no-go stimuli.
The arrangement of these stimuli allowed for the investigation of both omission
and commission errors while switching rules (Rogers & Monsell, 1995). The presence
of novel or no-go errors would indicate difficulty in reconfiguration of a new rule.
Last no-go errors would occur when participants perseverate on the last GNG rule
and do not respond to L-S or L-D (go stimuli for current GNG rule). The presence
of last no-go errors would support interference.

RESULTS
Speed
The dependent variable for switch cost was the difference between mean RT (for
accurate go responses) when switching without rule changes and mean RT when
switching with rule changes. A group (adults with aphasia, controls)6predictability
(predictable, unpredictable) analysis of variance (ANOVA) revealed that adults with
aphasia had higher switch costs (M5184.40, SD581.73) than controls (M5151.95,
SD571.93) F(1, 26)56.11, p5.02, gp25.19. Main effects of predictability and the
interaction were non-significant. Thus, in answer to the first question, adults with
aphasia were slower than healthy controls in self-initiated control when required to
switch according to modality rules. Contrary to our expectation, however, neither
group benefited from being forewarned about what to expect next.
 SWITCHING IN ADULTS WITH APHASIA 1071

Accuracy
To answer the second question, ‘‘Are adults with aphasia as accurate as controls
when switching between rules and would their accuracy improve from knowing what
to expect?’’, two kinds of errors were investigated. An error of omission occurs when
the participant fails to respond to a go stimulus. This omission can occur during an
ongoing go stimulus or after a rule switch. An error of commission occurs when the
participant responds to a no-go stimulus. Because the design required that there be a
different number of opportunities for omission and commission errors when
switching rules and when not switching, separate ANOVAs had to be calculated.

Omission errors. To examine omission errors without rule switching, a group6

predictability analysis of covariance (ANCOVA) was generated with omission errors
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from the detection task as the covariate. Main effects for group and predictability
were non-significant (p,.05), as were interaction effects. Thus the two groups were
similar when making omission errors, and being forewarned about the kinds of input
did not change this.
Reconfiguring a new rule was examined by the pattern of novel omission errors
(N-S, N-D) and omission errors when responding to N-G (Figure 1), whereas last
no-go errors would be evidence of interference (L-S, L-D). To examine omission
errors during rule switching, a group6predictability6error type (novel, last no-go)
6similarity (S, D) ANCOVA was generated with omission errors from the detection
task as the covariate. Adults with aphasia made more omission errors than controls,
revealed in a significant main effect for group, F(1, 25)520.65, p5.0001, gp25.45
(Table 2). Main effects of error type, predictability, and similarity were non-
significant (p..05). Several interactions were significant: group6error type, F(1,
2557.02, p5.01, gp25.22, group6predictability6error type, F(1, 2555.66, p5.03,
gp25.19, error type6similarity, F(1, 25)55.334, p5.029, gp25.18, and group6error
type6similarity, F(1, 25)58.454, p5.008, gp25.25.
To investigate how error patterns reflected endogenous control processes in the
above interactions, individual comparisons were conducted to interpret the two 3-
way interactions. Four 1-way comparisons of predictability for error type and group
were conducted using a Dunn-Bonferroni adjustment of the alpha level (p5.0125).
The aphasia group exhibited a trend for predictability on novel errors, F(1,
13)57.12, p5.019, gp25.35, but not on last no-go errors, F(1, 13)50.16, p5.69, i.e.,
adults with aphasia tended to make more errors of omission on stimuli that were
new, but only when there was no forewarning about the modality (letter or name of
letter) (M52.64, SD52.06), than when they were forewarned (M51.14, SD50.66),
demonstrating difficulty with reconfiguration. Adults with aphasia did not benefit
from being forewarned about what to expect next when they missed a response to
last no-go stimuli. This is evidence of deficits in reconfiguration for adults with
aphasia. Controls did not exhibit a predictability effect for novel errors, F(1,
13)51.72, p5.21, or last no-go errors, F(1, 13)50.65, p5.44.
Comparisons of the similarity for each omission error type and group were also
conducted (p5.0125). For adults with aphasia there were no differences in number of
omission errors based on similarity of novel stimuli, F(1, 13)52.32, p5.15, with a
trend towards more omission errors on last no-go stimuli, F(1, 13)54.50, p5.05
(Figure 2). Thus adults with aphasia were negatively affected by previous rule sets;
they omitted more responses to the last no-go stimuli when it was the same modality
 1072 CHIOU AND KENNEDY

TABLE 2
Errors

Aphasia group (n514) Control group (n514)

Predictable Unpredictable Predictable Unpredictable

Number of errors
Novel (omission) Same 0.29¡0.47 1.21¡1.31 0.36¡0.93 0.14¡0.36
(omission) Different 0.86¡0.77 1.43¡1.09 0.21¡0.58 0.00¡0.00
No-go (commission) Same 4.86¡3.70 5.07¡3.10 1.21¡1.25 0.93¡0.92
(omission) Different 7.00¡5.51 6.29¡4.71 0.50¡1.16 0.29¡0.61
Last no-go (omission) Same 1.21¡1.19 1.21¡1.31 0.07¡0.27 0.14¡0.36
(omission) Different 0.64¡0.84 0.93¡1.14 0.00¡0.00 0.07¡0.27
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Means and SD of omission and commission errors for each group by predictability, error type, and
similarity of the Go/No-go tasks with rule switching.

as the no-go stimulus (M52.43, SD51.65) than when it was a different modality
(M51.57, SD51.60), demonstrating some evidence of interference. However,
performance among adults with aphasia was highly variable. Controls did not
exhibit a similarity effect for novel omission errors, F(1, 13)51.68, p5.22, or last no-
go omission errors, F(1, 13)52.17, p5.17.

Commission errors. The presence of a commission error, where the individual

responded to a no-go stimulus when indeed they should have inhibited their response,
would be evidence of difficulty with reconfiguration. To examine commission errors
without rule switching, a group6predictability ANOVA1 revealed a significant main
effect for group, F(1, 26)55.86, p5.02, gp25.18. Adults with aphasia made more
commission errors (M52.64, SD53.47) than controls (M50.61, SD50.96) when
following a simple rule but without any switching. A trend towards a predictability
effect was also found, F(1, 26)53.80, p5.06; both groups tended to make more
commission errors when they were not forewarned about what was to come next, than
when they were forewarned. The interaction effect was non-significant.
To examine commission errors during rule switching, a group6predictability6
similarity ANOVA was generated (see Figure 1, NG). A significant main effect for
group revealed that adults with aphasia made more commission errors (M523.21,
SD513.53) than controls (M52.93, SD52.37) when switching rules, F(1, 26)530.53,
p5.00001, gp25.54. Main effects of predictability and similarity and interaction effects
were non-significant. Thus, adults with aphasia were more likely to respond to a no-go
stimulus than controls, regardless of whether they were forewarned about what was to
come next or whether the modality was the same or different from the last no-go rule.
This finding provides evidence of their difficulty with reconfiguration.

DISCUSSION
Adults with mild or moderate aphasia demonstrated reduced ability to switch
flexibly between rules compared to healthy controls. When switching between rules

1
There was no covariate because there were no opportunities for commission errors in the detection
task.
 SWITCHING IN ADULTS WITH APHASIA 1073
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Figure 2. Mean of number of novel and last no-go omission errors by group and similarity when switching
rules.

they were slower than controls and thus demonstrated a greater ‘‘cost’’. In the
presence of this cost, adults with aphasia also exhibited more errors, indicating their
difficulty in formulating and constructing a new rule set and their adherence to the
previous rule set. Healthy controls flexibly formulated and adapted to new rules and
efficiently inhibited previous response sets. This finding of diminished endogenous
controlled processes (reconfiguration, interference) by adults with aphasia supports
and expands the results of the Mecklinger et al. (1999) study which found that adults
with LHD and language difficulties exhibited high switch costs when switching
between two visual graphic tasks. They attributed these deficits to less-efficient
suppression of interference and difficulty in reconfiguring cognitive processes.
The predictable presentation of perceptual inputs was designed to provide
participants with the expectations of what would occur next. Healthy controls were
very capable of making rapid and correct responses in both the predictable and
unpredictable conditions, leaving one to wonder if these tasks challenged them
sufficiently. The aphasia group made more novel errors when they were not
forewarned about what to expect than when they were forewarned. It is likely these
errors occurred because novel stimuli had not been primed like no-go stimuli
presented in the instructions for the rule, or last no-go presented earlier in the last
rule set.
One possible explanation for the lack of a predictability effect was that the
predictable and unpredictable presentations might not have been sufficiently
different to render significant differences in performance, even though participants
reported that the predictable condition was easier than the unpredictable condition.
Rule changes and participants’ heightened attention could also have resulted in a
reduced predictability effect. This finding supports Sohn and Carlson (2000), who
suggested that although foreknowledge allows preparation in repetitive and
switching tasks, repeating the same task may have benefits over task switching,
regardless of foreknowledge.
 1074 CHIOU AND KENNEDY

Most studies of executive functions in adults with aphasia have used standardised
tests to describe cognitive flexibility, and most of these tests are fairly complex,
recruiting numerous simultaneous processes. The results from this study provide
evidence of the presence of simple, underlying processes, and that these processes of
reconfiguration and resistance to interference are impaired in adults with aphasia.
These findings also expand on the notion of difficulties in switching between
communication modes (Purdy et al., 1994; Yoshihata, Watamori, Chujo, &
Masuyama, 1998) by providing evidence of specific processing difficulties.
Limitations of this study include the diverse aetiology and locations of stroke in
this sample of adults with aphasia; future studies with a larger sample size should
consider subgroups based on aetiology and lesion location. Although the current
study provides evidence that GNG tasks are appropriate for adults with mild or
moderate aphasia, this task may be too difficult for adults with more severe
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comprehension and cognitive impairments. Future studies should investigate

patterns of aphasic symptoms and specific cognitive processing deficits involved in
communication.
Individuals with intact cognitive flexibility and switching ability are able to think
flexibly, generate different ideas to solve problems, shift from one topic to another,
and use a variety of strategies (e.g., verbal, gestures, facial expressions, pictures) to
communicate. It is possible that the impaired reconfiguration and interference during
switching identified in this study may be similar to processes shared in constructing,
controlling, monitoring, and inhibiting thoughts, ideas, and behaviours (Chiou &
Kennedy, 2006). Adults with aphasia who show difficulty with reconfiguration and
interference may also have trouble shifting conversational topics appropriately, may
exhibit topic perseveration, and may not use gestures or verbal rephrasing when their
message is misunderstood. Additional research is clearly warranted.

Manuscript received 24 July 2008

Manuscript accepted 20 November 2008
First published online 24 March 2009

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