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Assessing functional communication in aphasia: Clinical utility and time

demands of three methods
Article in European journal of disorders of communication: the journal of the College of Speech and Language Therapists, London · February 1994
DOI: 10.3109/13682829409041490 · Source: PubMed
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European Journal of Disorders of Communication,29,165-182, 1994 165
0 College of Speech and Language Therapists, London
Assessing functional communication in aphasia:

clinical utility and time demands of three
methods
Int J Lang Commun Disord Downloaded from informahealthcare.com by Max-Planck-Gesellschaft on 06/14/13
Catherine Crockford" and Ruth Lesser

Department of Speech, University of Newcastle upon Tyne, UK
ABSTRACTS
A variety of methods has recently been used to assess everyday communication abilities in aphasic
adults. This study compares three such methods for their clinical utility and the amount of a thera-
pist's time they use. The three methods employed a standard rating schedule completed by relatives,
analysis of speech elicited through role-play and a partial analysis of everyday conversation sam-
ples. The utility of these assessments as a clinical tool was measured in terms of the therapist's time
needed, and the assessment's ability to show stability or change of communicative effectiveness on
For personal use only.
test-re-test measures and to illuminate areas for therapeutic intervention. Eight aphasic adults (five
acute and three chronic) were tested on all three assessments, then re-tested after a period of 3
months. The results suggested that, although more time-consuming, the partial conversational
analysis was a more sensitive measure of stability or change of communicative effectiveness over
time than the other two measures, and had the potential advantage for indirect intervention of
revealing conversational strategies used by the partner as well as those used by the aphasic individ-
ual.
Un certain nombre de methodes ont it6 utitise'esrtcemment pour tvaluer les capacite's communica-
tives quotidiennes des adultes aphasiques. La presente Ctude compare trois de ces me'thodes en fonc-
tion de leur utilite' clinique et du temps qu'elles prennent aux thtrapeutes. Ces trois me'thodes
utilisent une liste de questions dont les rtponses chiffrtes sont fournies par l'entourage du patient,
une analyse de langage suscitt par des jeux de rales et une analyse partielle d'extraits de conversa-
tions de la vie courante. L'utilite' de ces tvaluations en tant qu'outils cliniques a Ctt mesure'e en fonc-
tion du temps qu'elles prenaient au thtrapeute, en fonction de leur capacitt de diagnostiquer la
stabilite' ou le changement dans l'effkacite' communicative lorsque les tests sont re'pe'tts, et en fonc-
tion de leur possibilite' de mettre la lumidre sur les zones d'intervention the'rapeutiques possibles.
Huit adultes aphasiques (cinq cas aigus et trois chroniques) ont t t i teste's selon ces trois me'thodes,
puis un nouveau test a tte' fait au bout de trois mois. Les risultats suggdrent que, m&ne si elle prend
davantage de remps, l'analyse partielle de conversations est une mesure plus sensible de la stabilitt
ou de I'tvolution de l'eficacite' communicative dans le temps, et qu'elle a I'avantage potentiel de
re've'ler les strattgies en matiZre de conversation utilistes tant par l'aphasique que par I'interlocuteur,
ce qui peut permettre l'intervention directe.
Verschiedene Methoden sind in Eetzter Zeit eingesetzt worden, um das Kommunikationsvermogen
aphasischer Erwachsener im Alltag zu erfassen. In dieser Studie werden drei solche Methoden im
Hinblick auf ihren klinischen Nutzen sowie auf ihre zeitlichen Anforderungen an die Therapeutln-
nen verglichen. Die drei Methoden verwendeten einen standardmafigen Einstufungsplan, der von
Verwandten ausgefillt wurde, die Analyse von im Rollenspiel elizitierter Sprache und die partielle
Analyse von Gesprachsteilen aus dem Alltag. Der Nutzen dieser Bewertungsrnodi als klinische Mit-
tel wurde als Funktion einerseits der von den Therapeutlnnen geforderten Zeit, andererseits der
~ ~ ~
*Now at: Speech and Language Therapy Department, St Thomas' Hospital, London, UK.
166 CROCKFORD AND LESSER
Miiglichkeiten einer Methode, Stabilitat oder Veranderung der kommunikativen Wirksamkeit bei
Tesrwiederholung z i i zeigen, s o w i e Bereiche der moglichen therapeutischen Intervention
urcfzuzeigen. Acht aphasische Erwachsene (5 akut, 3 chronisch) wurden mit allen drei Rewer-
tiingsniodi getestet und nach drei Monaten wieder getestet. Die Ergebnisse zeigen, dab die partielle
Gesprachsanulyse, obgleich zeitintensiver ein sensitiveres MaJ f u r die iiber die Zeit stabile oder
1,eriitiderte Kommunikationsfahigkeit als die anderen beiden Methoden liefert. Sie hat auch den
weiteren potentiellen Vorteil f u r indirekte Intervention dadurch, dab sie die Koriver~~ationsstrategien
dcs Partners neben denen des Aphatikers zeigt.
Key words: aphasia, functional communication, conversational analysis.
The importance to aphasia therapists of assessing aphasic people’s success in

functional (pragmatic) communication rather than only on formal linguistic

tests has frequently been emphasised (Holland, 1980; Lubinski, Duchan
& Weitzner-Lin, 1980; Green, 1984; Penn, 1985; Blomert, Koster, Van Mier &L
Kean, 1987; Hawkins, 1989; Lomas, Bester, Elbard, Finlayson, Pickard
bi. Zoghaib, 1989; Manochiopinig, Sheard & Reed, 1992).
This importance has resulted in the development, from a variety of orienta-
tions, of a range of measures for examining functional communication in apha-
sia. Manochiopinig et al. (1992) have described fifteen of the current pragmatic
assessments as falling into five categories:
1. Outcome ratings of efficiency of communication in specified situations.
2. Structured tests of communication in which real life situations are simu-
lated.
3. Assessments of communicative style in family interactions.
4. Composite assessments which include linguistic as well as pragmatic factors.
5. Structured observational profiles which sample pragmatic meanings (often
drawing on speech act theory).
I.Jnlike linguistic tests, which form a regular part of the aphasia therapist’s cus-
tomary examination and re-examination of patients, these pragmatic assess-
ments tend at present to be used more in research studies than as part of
routine clinical practice. This may be the result of reservations about the sub-
jective nature of some of them, arising from the dearth of tested theories
applied to aphasia in the field of pragmatics. A second reason may be that dif-
ferentiating patients for planning targeted intervention has not been as clearly
specified from pragmatic assessments as from linguistic assessments (see Lesser
& Milroy, 1993, for a current review); this may make the therapist reluctant to
spend a substantial amount of time on a pragmatic assessment, given the need
for accountability of time in a service constrained by economic factors. So far
little attention has been paid in the literature to the time-effectiveness of prag-
matic assessments, in spite of the importance of this to the practising therapist
with a large caseload. In the present study three methods of assessing func-
tional communication are examined from two perspectives. The first is the clin-
ical usefulness of the information obtained, both in respect of the intervention
to be planned and in respect of the potential evaluation of the completed inter-
vention (i.e. through test-re-test). The second perspective concerns the amount
of time each assessment requires.
‘The rating measure of communicative efficiency chosen was the Communica-
ASSESSING FUNCTIONAL COMMUNICATION IN APHASIA 167
tive Effectiveness Index (CETI) (Lomas et al., 1989). This uses a 16-point ques-
tionnaire, each question being concerned with an everyday situation and paired
with a visual analogue scale which the relative or other carer is asked to mark.
An example question is: ‘Does he intentionally let you know how he is feeling
rather than you “reading” his emotions?’ A template is used for converting
each mark to a 10-point scale, thus allowing for easy comparison of test-re-test
scores. The inter-rater reliability of CETI has been reported as being 0.73 (95%
confidence interval), and the authors suggest that clinicians can therefore feel
confident that a change in scores provides valid and reliable measures of the
patient’s progress in functionally communicating in everyday life situations.
The design of this measure should mean that it uses very little of therapists’
time. They need to explain the use of the scale to the carers on first presenta-
tion, but the amount of time used for calculating changes between presenta-
tions should be minimal. On the other hand, CETI’s potential for planning
appropriate intervention is also limited.
The structured test of simulated situations chosen was one that was in the
early stages of its refinement at the time of selection, the Amsterdam Nijmegen
Everyday Language Test (ANELT) (Blomert et al., 1987; Blomert, Koster.
Kean, Schaap, Von Stockert, Buslach & Junker, 1990). This test was chosen as
being considerably shorter than the other test which falls into this category in
Manchiopinig et a1.b classification, Communicative Abilities in Daily Living
(CADL) (Holland, 1980). It was therefore more likely to be frequently used by
practising therapists, as requiring less investment of time. In its 1987 version
ANELT uses 18 communicative situations which, it is claimed, the patient may

encounter in real life. The tester explains each to the patient with the use of
appropriate ‘props’; the patient then role-plays each with the tester as partner.
For example, the patient is asked to pretend to be a salesperson giving advice on
which of two corkscrews to buy. In contrast to CETI, it is the clinician who
effects judgement rather than an untrained carer, and the patient’s performance
is assessed against prescribed expectations, which are distinguished as being
necessary (N) or socially conventional (C) components of the communication.
ANELT is likely to produce more detailed information than CETI about the
patient’s capabilities, with some qualitative information about how communica-
tion is achieved, e.g. whether more N or C components are used (more N com-
ponents are predicted). It should also lend itself to test-re-test use, like CETI.
The third measure selected was analysis of real-life everyday conversations
in a domestic setting. Direct analysis of conversation between an aphasic per-
son and a familiar carer has potential for providing more specific detail about a
person’s communicative abilities. It is, however, a time-consuming process.
Even though the recordings may be made at home (for example, with a radio
microphone system) without the therapist’s presence being required, listening
to the tape, transcription of key extracts and their analysis can be demanding
on the therapist’s time and skills. Although grammatical analysis of children’s
tape-recorded speech is now well established as a clinically useful procedure
(Crystal, Fletcher & Garman, 19Sl), it has not yet been established whether a
similar investment of time on the pragmatic analysis of conversations with
aphasic adults would also pay dividends in providing information of both
diagnostic and therapeutic value. To satisfy the same purpose as the other two
functional assessments chosen for this study, conversational analysis would also
need to lend itself to test-re-test purposes. For this some quantification of
results is needed.
The quantitative analysis of conversation is a controversial area. Man-
chiopinig et al. (1992) have expressed reservations about using quantification
of conversational behaviours for test-re-test purposes in aphasia on the
grounds of potential variability in topics. Lesser and Milroy (1993) have also
expressed reservations because of the difficulty of incorporating sufficient
influence of the context in which each variable occurs and of the assumption of
homogeneity of classifications based on context-insensitive criteria. It was,
however, decided to attempt a limited amount of quantitative conversational
analysis in the present study in addition to a qualitative analysis. This would

serve the purpose of allowing a closer comparison with the other two measures
selected both in respect of test-re-test comparison and in respect of time taken
for analysis. There are precedents for the quantitative analysis of natural con-
versations between aphasic adults and their carers, e.g. in Gerber and Gur-
land’s (1989) recommendations for quantification of conversational repairs
through their Assessment Protocol of Pragmatic Linguistic Skills (APPLS).
The aspects of conversation selected for analysis in the present study are
described below.
QUANTIFICATION OF CONVERSATIONAL BEHAVIOURS

To be of practical use as a clinical tool only a few conversational behaviours

can be examined. These must be quick to extract from the data, and as repre-
sentative and context-sensitive as possible. They should also pinpoint areas
where therapeutic intervention could improve the effectiveness of communica-
tion between patient and carer. Several behaviours were considered and the
following three categories were decided upon for reasons that are discussed in
the following sections:
1. Editing elements produced by the aphasic adult.
2. Amount and type of collaborative repair.
3. Proportion of conversational load carried by each interlocutor in the dyad.
The first is the only one of these three categories that analyses speech behav-
iours of the aphasic individual relatively independently from those of the part-
ner, and which may be considered to include a measure of the patient’s
linguistic deficits as such.
Editing Elements
Editing elements, which function in part as indicators of troubles or time
stalling behaviours, are said to be a characteristic speech behaviour of many
aphasic individuals (Schlenk, Huber & Willmes, 1987). Schlenk et al. found
that aphasic subjects produced more editing elements than did subjects who
appeared from formal aphasia tests to have fully recovered from aphasia.
These latter subjects in turn produced more editing elements than subjects who
had not suffered brain damage. The aphasic subjects, like non-aphasic groups,
produced significantly more prepairs (searching behaviours) than identifiable
repairs. Against expectations Schlenk et al. found that Wernicke’s aphasic

subjects, in spite of their presumed difficulties in self-monitoring, did not pro-
duce significantly fewer repairs than Broca’s aphasic subjects. Their results,
therefore, suggest that the amount of trouble-indicating behaviour (as reflected
in the number of editing elements produced) is proportional to the severity of
the aphasia, whether of a fluent or non-fluent type. They also suggest that as
patients recover from aphasia the number of trouble-indicating behaviours
should decrease. Quantifying the number of editing elements used by the apha-
sic partner, therefore, may have the potential to be a sensitive measure of the
stability or change of one aspect of communicative effectiveness over time. The
present study classed the following behaviours as editing elements, all of them
interpretable as indicating troubles in the aphasic person’s contribution to the

conversation:
1. Unfilled pauses of at least 2 seconds, which were attributable to word-find-
ing difficulties rather than interpreted by the conversational partner as con-
veying the intent of a dispreferred response (see Lesser and Milroy, 1993,
pages 195-196).
2. Filled pauses of at least 2 seconds, e.g. ‘uh uh’.
3. Unsolicited repetition of an immediately preceding utterance.
4. One or several phonemic approximations to an identifiable target word.
5. Circumlocutions giving partial semantic information about an unretrieved
content word.
6. Comments, e.g. ‘what is it called again?’.
Unrepaired neologisms and unintelligible syllables were excluded from this

count, as not indicative of editing behaviour.
CallaborativeRepair
Lubinski et al. (1980) suggested that analysis of collaborative repair may be
used to diagnose conversational competence. They acknowledged, however,
that the number of breakdowns alone could not be an index of conversational
competence. Other factors must also be considered, such as the number of non-
actualised breakdowns, the length of the repair sequences, the cooperation
between the partners for sharing repair work, and the role of agenda, topic and
background knowledge. Barnsley (1987) investigated repair strategies apparent
during conversations between aphasic adults and their therapists. One of the
implications of her study is that repairs, as they become more frequently suc-
cessful (as assessed through the interlocutor’s reaction), may take fewer turns
to effect as the patient’s communicative abilities improve. A measure of the
number of turns used during such stretches of collaborative repairs may, there-
fore, also be a candidate for examining stability or change of communicative
effectiveness over time.
Conversational Loading
Dyadic conversation is a two-way interaction, in which the burden of commu-
nication is shared by both participants. It seems from previous studies that the
more severe the aphasia the less the aphasic person will be able to contribute a
balanced proportion of a conversation, but may contribute either too much
I70 CROCKFORD AND LESSER
(Ilawkins, 1989) or too little (Miller, 1989). Thus the conversational load
carried by a person may be a measure of linguistic competence and may be
sensitive to stability or change of communicative effectiveness over time. In the
present study conversational loading was quantified on two different aspects:
1. The number of turns of each participant which included initiation of infor-
mation, because this is a measure of contribution to the conversation (for
examples, see the Appendix).
2. The number of turns that were minimal responses (e.g. ‘uhm’, ‘yeah’),
because these place the conversational load on the other speaker.
METHOD
The three assessments, CETI, ANELT and quantification of conversational
behaviours (QCB), were used with two groups of aphasic subjects (and their
carers, where appropriate), on two occasions separated by a 3-month interval.
The subjects were also rated on each occasion by their speech and language
therapists on a commonly used clinical scale, the severity rating scale of the
Boston Diagnostic Aphasia Examination (BDAE) (Goodglass & Kaplan,
1983). Where the therapist had some uncertainty between two points on the
qcale, an intermediate point was recorded, thus permitting greater sensitivity to
change. Eight subjects were selected according to the following criteria:
1. Aphasic following a single completed cerebrovascular accident in the left
hemisphere.
2. Having a severity rating of over 1 on the BDAE scale.
3. Known to have a supportive partner and living at home with him or her.
The subjects were divided into two groups - acute and chronic; members of
the first group were expected to show changes on the assessments, whereas
members of the second group were expected to remain stable. Five of them
were allocated to the acute group, i.e. they were within 3 months of the stroke
and were therefore considered to be still within the period when some notice-
able communicative changes might still be occurring. Two of the acute group
(those rated as at severity level 2) were receiving speech and language therapy
once a week. Three patients were allocated to the chronic group, having
become aphasic at least a year before; of these one (RM) had a history of two
transient ischaemic attacks 10 months after the completed stroke. None of the
chronic patients was receiving speech and language therapy. A description of
the subjects i s given in Table 1.
PROCEDURE
As a result of potential ambiguities and cultural differences between their ori-
gins and the British population to which they were to be applied, minor modifi-
cations were made t o the published versions of the CETI and ANELT
assessments. In CETI questions 11 and 13 were reworded to improve clarity (in
the event question 11 remained problematic and was not used by any rater).
For ANELT a practice item was devised, local names and British English terms
were used (e.g. clothes shop instead of clothing store) and a dinner invitation
Table 1: Subjects
Acute
Initials PK FK FB WM SR
Age (years) 63 86 14 60 51
Sex F M M M M
Age at formal education end (years) 21 14 14 14 16
Years lived with partner (years) 40 51 13 44 51
Weeks since stroke 6 5 9 11 11
Type of aphasia Fluent Fluent Non-fluent Fluent Fluent
BDAE aphasia severity 4 3 2 2 3.5
Other effects of stroke - - - Right -
hemiplegia
D ysart hr ia
Receiving speech therapy - - Weekly Weekly -
Chronic
Initials JM EA RM
Age (years) 81 82 69
Sex M M F
Age at formal education end (years) 14 18 14
Years lived with partner 56 54 3
Years since stroke 2 4 1
Type of aphasia Non-fluent Fluent Fluent
BDAE aphasia severity 3 4 2
Other effects of stroke - - -
- -
Receiving speech therapy -
from the boss was substituted for a friend’s birthday party to reflect a social
obligation of equivalent strength to the Dutch. The amended test was piloted
on an aphasic subject outside the study.
All subjects were interviewed with their partners, in their homes, for about 2
hours. The same order of presentation was used for each subject. A case his-
tory was taken initially. Then the ANELT was administered and audio-
recorded using a Sony TCD-3 tape recorder. The partner was then given a brief
training period on CETI and asked to rate the questionnaire items. The
researcher was present and noted the time taken. Following this a conversation
between the subject and partner was tape-recorded for up to 10 minutes; the
topics were not prescribed, although if the conversation flagged the researcher
suggested the topic of holidays. The researcher was present in the room during
the conversation. The length of the conversations in this naturalistic situation
varied from 5 to 10 minutes.
A template was used for measuring the CETI ratings, which permitted each
question to be given up to 10 points with intervals of half a point (0.5). ANELT
responses were transcribed and scored as of type N (necessary elements of the
communication) or of type C (socially conventional but optional elements of
the communication), with a 0.5 score allocated when only part of the informa-
tion was produced and a request for further information was needed; for exam-
ple, when buying a train ticket, the subject might ask for a ticket but not specify
the destination. The time taken for these measures was noted.
The conventions used in the transcriptions of spontaneous conversation
were based on those used by Levinson (1983). The transcriptions were

screened for the three aspects chosen for quantitative analysis, i.e. editing ele-
ments, collaborative repair and the weight of conversational loading of each
partner in terms of patient-carer ratios of initiations and minimal responses.
The time samples were exactly matched for each patient across the two occa-
sions. The time spent on transcription of the texts and analysis of the samples
was noted, although, because of the difference in time samples across patients
(see Table 3), only average group data on time are reported in the results. The
McNemar test was used to test for the significance of changes on each assess-
ment between the two occasions.
RESULTS
The quantitative results on the two occasions are summarised in Table 2 in
respect of CETI and ANELT (with BDAE ratings).
As question 11 of CETI was not rated by any carer, the maximum possible
score from the remaining 15 questions was 150. Three raters also omitted from
one to four further questions; a note on Table 2 indicates the maximum possi-
ble score for each patient where this occurred.
Table 2: Results of CETI, ANELTand BDAE ratings

__
Acute patients Chronic patients
-
PK FK FB WM SR JM EA RM
CETI results
1st occasion
(max.=150) 94* 150 87; 90 105.51 104 104 123
(Yo 1 85 100 58 64 70 69 69 82
2nd occasion
(max.=l50) lOY* 150 76.5 YYi 82.5 YO 92.5 123
(Yo) 99 100 55 66 55 60 62 82
ANELT results
1st occasion
Total score 36 20 12.5 6.5 27 8 18 44
N score 20 12 9.5 5.5 13 8 12 22
C score 16 8 3 1 14 0 6 22
2nd occasion
Total score 54 12 15 12 27 6 21 35
N score 24 8 13 8 16 5 13 20
C score 30i 4 2 4 11 1 8 15
BDAE ratings
1st occasion 4 3 2 2 3.5 2 3 4
2nd occasion 5 3.5 2 2 4 2 3 4
T Out of 110. t Out of 140 (see text).

Significantly different from 1st occasion,p < 0.05.
None of the changes on CETI in either the acute or chronic group reached
statistical significance; this outcome had been predicted for the chronic group,
but CETI had been expected to reveal positive changes in the acute group. The
two acute subjects, FB and WM, who were receiving a small amount of direct
therapy (one session a week), however, remained at the same BDAE severity
level of 2, and it would appear, therefore, that any changes in their aphasia may
indeed have been minimal. Nevertheless CETI did not detect the changes in
the other three acute patients implied by the improvements in the BDAE
severity ratings. It is notable that, although FK’s CETI scores by his wife were
at ceiling on both occasions, his BDAE severity rating from the therapist
implied a much geater impairment, being initally only 3 (improving to 3.5). The
apparent conflict between another patient’s (SR’s) improvement on the BDAE

scale and deterioration on CETI is explicable by the fact that his wife was
unwilling to complete the second CETI assessment as a result of being upset
about their relationship, and the second CETI ratings were given by his sister;
CETI’s authors make claims for inter-rater reliability and this result was unex-
pected (see later comment).
ANELT scores (see Table 2) picked up only one signiflcant improvement in
an acute patient; PK produced significantly more C-elements (socially conven-
tional additions) on the second occasion. Neither SR’s nor FK’s ANELT scores
reflected the improvement recorded on the BDAE scale. All but three of the
patients across both groups on both occasions showed the consistently better
production of N-elements than C-elements predicted by Blomert et al. (1987).
In respect of the three conversational behaviours selected for QCB, conver-

sational analysis appeared to be more sensitive to change than the other two
assessments of functional communication, in that it picked out significant
changes in one o r two out of the three behaviours measured in four of the five
acute patients (Table 3). FB showed a significant reduction in the number of
editing elements used; closer inspection showed that this was the result of a sig-
nificant decrease in phonemic searching. With their partners, two acute sub-
jects (PK and FK) showed a significant decrease in the number of turns spent
on collaborative repair sequences. In PK’s case, this reflected the general
improvement shown also on other measures. Her significant increase in contri-
bution to the conversational load could be attributed to a greater use of initia-
tions rather than to a decrease in minimal responses. In the case of another
acute patient, WM, the significant change was an increase, rather than a
decrease, in the percentage of all turns spent on collaborative sequences, and
this result will be referred to later in the discussion.
There were also significant changes in the conversations of two of the
chronic patients. Although identical time samples were used, the analysis
showed that significantly fewer total turns were used on the second occasion in
the conversations in which JM and RM participated. In RM’s case this was
associated with a significant reduction in the amount of the sample spent in col-
laborative repair sequences; a qualitative account of this will also be given in
the discussion.
As regards consistency across all the five experimental measures employed
(i.e. CETI, ANELT and the three conversational dimensions), for one acute
subject (PK) three of the five measures were consistent in showing significant
Tabie 3: Conversarionai anaiysis

__ -~ ~ - -
PK FK FB WM SR JM EA RM
Sample time (min) 10 x 10 8 9 5 6.5
1st occasion
No. of patient’s editing elements 47 38 86 9 108 34 25
Total no. of all turns 179 95 151 137 120 161 123
No. of turns spent in collaborative
repair sequences 56 10 76 53 11 50 26
(Percentage in collaborative repair) (31) (11) (50) (39) (9) (31) (21)
Conversational loading
Patientipartner ratio of minimal
responses in all turns 40:13 12:7 23:s 18:3 14:14 59:9 7:7
(patient’s %) (73) (63) (82) (86) (50) (87) (50)
Patient/partner ratio of initiations in
turns other than collaborative repair 24:65 2530 1454 26:63 34:38 562 41:47
(patient’s %) (27) (45) (20) (29) (47) (7) (47)
2nd occasion
No. of patient’s editing elements 35 33 58* 7 107 30 31
Total no. of all turns 164 113 112 151 105 108** so**
No. of turns spent in collaborative
repair sequences 3** O* 60 88* 5 25 3
(Percentage in collaborative repair) m** (0)* (54) (W* (5) (24) (6)**
Con versational loading
Patient/partner ratio of minimal
responses in all turns 21:19 7:9 9:4 25:2 135 34:O 8:4
(patient’s %) (53) (44) (69) (93) (68) (100) (67)
Patient/partner ratio of initiations in
turns other than collaborative repair 45:43 30:39 14:24 2857 25:37 254 16:18
(patient’s %) (51)** (43) (37) (33) (40) (4) (47)
Significant difference from first occasion: * p < 0.05; ** p < 0.01.
improvement; the two exceptions for PK were CETI, which gave no signiflcant
results throughout, and editing elements, although her scores on both of these
did agree with the trend for improvement which was reflected in the BDAE
ratings. There was consistency in all the results of one of the chronic patients
(EA), all of the measures showing the predicted lack of significant change.
Four subjects (RM, JM, FB and WM) showed no significant changes on the
CETI, ANELT or BDAE ratings, though they each changed signiflcantly on at
least one aspect of the conversational analysis.
As Table 4 indicates, the times taken for CETI and ANELT varied. CETI
took an average of 20 minutes to administer and 10 minutes to score on the
first occasion, i.e. a total expenditure of therapist time per patient of 30 min-
utes, although this could be reduced if the therapist were not present while the
carer performed the ratings. There was a small reduction of time on the second
occasion.
The ANELT took an average of nearly 30 minutes to administer, and nearly
71 minutes to transcribe and score, i.e. about 100 minutes of therapist time per
patient. It is necessary for the therapist to explain and administer this test, so
no saving of time on first administration is possible. On the second occasion,
there was a saving of about 5 minutes on administration and 11 minutes on
analysis, reducing the therapist time to about 83 minutes per patient.
The conversational analysis procedure took the least time to administer,
because only a maximum of 10 minutes of conversation was required. The con-
versations took the longest time, however, to analyse. Transcription of each 5
Table 4: Individual times taken to administer and score CETI and ANELT

PK FK FB WM SR JM EA RM Mean
CETI results
1st occasion
Total time 20 26 40 27 25 30 50 25 30
Administration 10 16 30 17 15 20 40 15
Scoring 10 10 10 10 10 10 10 10
2nd occasion
Total time 21 22 35 26 30 27 45 23 29
Administration 11 12 25 16 20 17 35 13
Scoring 10 10 10 10 10 10 10 10
ANEL T results
1st occasion
Total time 63 92 155 126 109 120 80 58 100
Administration 18 27 45 41 34 35 20 18
Analysis 45 65 110 85 75 85 60 40
2nd occasion
Total time 56 66 104 115 73 115 62 I5 83
Administration 16 21 24 35 23 35 17 25
Analysis 40 45 80 80 50 80 45 50
minutes of conversation took 60 minutes, with scoring of editing elements and

collaborative repairs each taking an average of 10 minutes and conversational
loading 20 minutes. An average of 15 minutes was then needed to draw conclu-
sions. The total amount of therapist time needed for the conversational analysis
was therefore from 120 up to 185 minutes.
DISCUSSION
The results are discussed against the aims of the study, first in respect of the
clinical utility of each assessment for planning therapy and for test-re-test, and
then comparatively in respect of the therapist’s time. The limitations of the pre-
sent study will then be commented on.
Clinical Utility: CETI

Of the three types of functional assessments examined in this study, CETI
appears to be the least useful. It was not expected to provide diagnostic infor-
mation of value to planning therapy, but was expected to be useful for test-re-
test purposes to help in the evaluation of therapy and the investigation of
whether linguistically oriented intervention had generalised to everyday com-
munication. From the present limited study, however, its value for this must be
questioned. In the first place some carers found it difficult to respond to up to 5
of the 16 items in the questionnaire; but these may have been more relevant to
patients with greater degrees of severity than in the present small sample, and
it would not be appropriate to question the inclusion of these items from this
limited evidence.
Two factors not discussed by Lomas et al. (1989) may have influenced the
results and therefore require more consideration. One is that ratings appeared
to be influenced by the subjects’ or partners’ mood levels at the particular
times rather than only reflecting the subjects’ communicative abilities, the
extreme case being the refusal of one wife to complete the questionnaire
because of tensions with her husband. It appeared that patients who were
showing signs of depression postmorbidly were given low ratings on all ques-
tions which involved communicating with friends and strangers, regardless of
their communicative ability. The second factor noticed is that carers were
prone to give ratings with only an isolated incident in mind. Market research
questionnaires frequently use the technique of drawing attention to specific
periods or specific points of time to focus attention; however useful this tech-
nique may be in commercial research, it seems to be more difficult for carers to
give a balanced overview of general communicative abilities when recent
events are still salient. What would appear at first to be an advantage for this
type of pragmatic assessment - its ability to provide a general overview repre-
sentative of an extended period - may therefore in practice be almost as much
subject to specific biases as are briefer samples of communication taken by the
therapist. The ceiling scores given to one patient may also reflect another sub-
jectivity in carers, i.e. the need to appear motivating and positive to encourage
the spouse. The assessment also seems to require that the same individual must
provide the ratings on both occasions, judging from the discrepant ratings
of SR’s wife and sister. The present study, therefore, did not find evidence to
support CETI’s claimed reliability as a re-test instrument. Nevertheless CETI

has the incidental utility of drawing aspects of communication to the carers’
attention which they may not previously have considered. This may serve to
help the therapist in the advice given to carers as part of indirect intervention.
Clinical Utility: A NEL T

The ANELT showed a little more scope for revealing change, as well as provid-
ing some qualitative information about the type of responses made under these
circumstances (minimally whether C- or N-elements were used). In spite of
Blomert et al.’s (1987) claims that aphasic patients have no difficulty in playing
along with imaginary scenarios, however, this did seem to be an influence on
the sample of patients studied here. For example, those who did not have adult
daughters found it difficult to give any information regarding ‘arranging a din-
ner for a wedding’. Davis and Wilcox (1985) have suggested that role-playing
tasks, being somewhat abstract, may tap cognitive rather than communicative
abilities. This may exacerbate the frequently described gap in aphasia between
the automatically accessed use of speech and speech under voluntary control.
The tests, however, do supply speech examples for linguistic analysis under
structured situations from which implications for direct therapy can be drawn,
and these situations can be repeated later as a re-test. The value of ANELT as
a measure of progress in pragmatic rather than linguistic abilities may, how-
ever, be questionable.
Clinical Utility: QCB

The Quantification of Conversational Behaviours used here showed itself more
sensitive than either of the other two measures in its potential for picking up
the changes which the BDAE scales indicated had occurred, and may therefore
have some potential for detecting changes for test-re-test purposes. Variability
in topics across the two occasions did not prove to be a problem; for these
familiar dyads in the same home setting topics remained similar, e.g. plans for
going out, the language difficulties, visitors. All three of the aspects considered,
i.e. editing elements, collaborative repairs and conversational loading, seem to
be possible candidates for examining further for their test-re-test utility; within
conversational loading it would appear to be the ratio of initiations that is
likely to prove more informative than the ratio of minimal reponses.
Contrary to Schlenk et al.’s (1987) finding, however, the quantification of
editing elements revealed some differences between patients. One fluent
patient, WM, produced far fewer editing elements (7 and 9) than the other
patients (between 25 and 108). A qualitative inspection of the data led to the
hypothesis of his having poor self-monitoring skills. This result, however, runs
contrary to the proposal made earlier in this study that the number of editing
elements would be proportional to communicative effectiveness. Nevertheless
change or stability in the number of editing elements produced by any individ-
ual patient across evaluation periods may be relevant to therapeutic interven-
tion.
It is important, however, to stress the vulnerability to distortion through
quantification of all these measures, and in particular of the two which involve
both partners most obviously. With RM, there were differences in the conver-
sations on the two occasions, reflected in the significant difference in the total
numbers of turns (from 123 to 50). This affects the interpretation of the signifi-
cant reduction in the number of turns devoted to collaborative repair (from 26
to 3) within trouble-spot episodes. The researcher used three prompts to
encourage the flow of conversation on the first occasion, but none was needed
on the second occasion, with R M and her husband having a more animated
conversation on the one theme of her stroke club, both taking more extensive
turns and with less need for collaborative repairs. In the first conversation the
data on turns during collaborative repair sequences were derived from nine
trouble spots, five of them related to word-finding difficulties and four to prob-
lems typical of normal conversations, such as overlap. The only trouble-spot
which occurred in the second conversation was caused by overlap. There is a

further point to note in the interpretation of RM’s results. This was the patient
who had had two transient ischaemic attacks 2 months before the study began.
These had not affected her aphasia in any obvious way, and had not been con-
sidered to affect her status as a ‘chronic patient’ for purposes of the present
study. Her rating of 4 on the BDAE scale remained unchanged, and the consis-
tency of her scores on CETI and ANELT would appear to have supported this
conclusion. As discussed above, however, the conversation analysis revealed
significant changes between the two assessments in respect of collaborative
repairs, indicating its greater sensitivity; the changes noted would be inter-
pretable as improvements rather than as suggesting any subtle deterioration
from any further effects of transient ischaemic attacks.
Scanning of the results showed clearly that the partners of WM and FB had
altered their communicative strategies. With WM there was a significant
increase in the number of turns used during collaborative repairs, which could
be misread as a deterioration in WM’s abilities. In fact, instead of effecting
repairs in the quickest possible way, as in the initial assessment, the wife had
now adopted the strategy of giving her husband a series of hints, with the aim
of his effecting the repair himself. This caused extensive repair sequences, one
of them lasting €or 27 turns, thus distorting the quantitative results.
Similarly with FB, the number of his editing elements had significantly
decreased, suggesting that his speech had become more fluent. A more
detailed look at the transcription, however, showed that his wife was in fact
giving him less chance to speak than previously, by frequently attempting to
complete his sentences for him; she interrupted 34% of his turns in the second
conversation compared to 16% on the first occasion.
It is clear, then, that the qualitative information provided by these limited
aspects of conversational analysis is potentially of more value than the quanti-
tative, and that in any case quantitative summaries must be interpreted with
caution. The main clinical utility of conversational analysis is therefore likely to
prove to be in planning intervention, rather than for test-re-test purposes. The
information derived from such qualitative analyses is potentially useful, partic-
ularly for conversational management mediated through the carers; it can be
used to develop the partners’ strategies, depending on whether they prove con-
structive or destructive to the aphasic person’s communication. At present rec-
ommendations to carers for improving patients’ communication rest largely on
general advice (e.g. Green, 1984); conversation analysis offers the opportunity
to examine communication at a micro as well as at a macro level, and to apply

to pragmatics the same principle of differential diagnosis of the disorder as has
proved productive in its application to the linguistic behaviours of aphasic
people. In this way specific recommendations about pragmatics can be made,
tailored to the needs of the specific dyad (R. Lesser, L. Algar & R. Chastney
unpublished data). Like ANELT, the data collected for conversational analysis
also provide material for linguistic analysis as a preliminary to direct linguistic
therapy.
Therapist’s Time
In respect of the second purpose of this study, the measurement of therapist’s
time needed for these functional assessments, the results indicated that CETI
took the least time per patient (about 30 minutes), ANELT more (about 100
minutes) and QCB the most (from 120 to 185 minutes). Both ANELT and con-
versational analysis, therefore, make considerable demands on time; this can
only be justified in routine clinical practice if they make significant contribu-
tions to understanding the patient’s condition and intervention.
It may prove possible to reduce the amount of therapist time involved in the
application of conversation analysis. Use of a radio microphone at home by the
patient and carer could reduce the therapist’s time spent on obtaining the sam-
ple, and improve its spontaneity. But much of the therapist’s time is spent on
the actual transcription and is therefore unlikely to be significantly reducible
with present technological resources. This may be one facet of assessment
which could be delegated to trained therapy assistants, given that broad-based

orthographic transcriptions are adequate for this type of pragmatic assessment.
This would reduce the skilled therapist’s time to that required for feature iden-
tification from the transcript and interpretation of the data. Judging by the
results of the present study, this could reduce the therapist’s time to about 55
minutes per patient for QCB, an investment of time which the results of the
present study indicate could be more productive for QCB than for CETI or
ANELT. It would also compare favourably with the amount of time required
for conducting, and interpreting, the results of a standard clinical aphasia bat-
tery, although its motivations are clearly different.
Limitations
There are, however, limitations in the present study which make its conclusions
tentative in respect of test-re-test changes. One factor is the definition of sub-
jects as ‘acute’ when they are between 5 and 11 weeks’ post-stroke. This period
had been chosen as still being within the period of spontaneous recovery as
defined by many authorities (e.g. Basso, 1989). The paucity of significant differ-
ences between the acute and chronic groups, particularly in respect of CETI
and ANELT is, however, more in keeping with Holland, Greenhouse, Fromm
and Swindell’s (1989) report of maximum recovery occurring during the first
4 weeks or so after a stroke. The one patient who showed improvement across
methods (PK) was one of the two to be first examined within 6 weeks of
the stroke. With the possible exception of ANELT, none of the chosen func-
tional asssessments would lend themselves readily to use while a patient was
still hospitalised, and they are therefore not likely to be of clinical use while the
patient is still at this acute stage. Another limitation in the present study is that
the relatively short span of 3 months between the two occasions of assessment
imay have minimised the opportunity of revealing changes. Furthermore the
number of cases was small, and there was variability within the groups particu-
larly in respect of time post-onset in the chronic group (14 years) and number
of years the patients and partners had lived together (3-57). These caveats,
however, limit the reliability of the study only in respect of the conclusions that
‘can be drawn about test-re-test reliability, and are unlikely to have influenced
the results in respect of therapist’s time.
CONCLUSION
‘This study indicates that it is worth investigating further the potential clinical
usefulness of therapists investing time on conversational analysis, in spite of the
,greater investment needed than for the other two functional assessments exam-
ined here. Within the limits acknowledged above, this study suggests that quan-
titative measures of conversation may even have more potential for examining
test-re-test changes than the two other instruments used (provided that quali-
tative aspects are taken into consideration), in spite of the claims of the latter
that this is one of their main functions.
It is likely, however, that the real value of conversational analysis will prove
to be in its provision of in-depth information about the patients’ communica-
tive behaviours, and in highlighting the carers’ individual communication
strategies as well as the patients’. Provided that the investment of skilled thera-
pists’ time can be managed as suggested, conversational analysis has a clinically
viable potential for improving communication by providing carers and patients
with insights into specific collaborative strategies appropriate for individual
dyads. Such pragmatic indirect therapy for aphasia has not yet used an individ-
ualised case study approach to any extent, although this approach has become
a powerful influence on the psycholinguistically based direct therapy which has
followed the development of cognitive neuropsychological models. In the
future, offering global advice about functional communication, without
analysing the different needs and different practices of individuals, may prove
to be as ingenuous as offering the same undifferentiated psycholinguistic ther-
apy to every aphasic person.
In spite of the additional time required for conversational analysis as a mea-
sure of functional communication, it would seem to promise advantages over
the other two measures used in the present study, in its potential clinical use
both for planning intervention and for examining change.
ACKNOWLEDGEMENT
This research was supported by a Nuffield Foundation Undergraduate Bursary used by the first
author.
APPENDIX
tnitiation was deflned as the provision of new information such that the con-
versation could develop. The examples below are from different parts of the
data from PK and her husband MK.
1. M: Tilly should be back in London now shouldn’t she

P: yes thats (.) I suppose so
M: train got in about (.) quarter past one
2. M: George’lI want to hear all about you and what you’re doing
P: oh I don’t know about that no (.) I think it’ll be more about urn what thev
are doing
In example (1)M initiates, P responds and M initiates again. In example (2) M

initiates, P responds and then initiates (underlined).
REFERENCES
BARNSLEY, G. (1987). Repair strategies used by aphasics and their conversational partners. BSc disserta-
tion, Department of Speech, Newcastle University.
BASSO, A. (1989). Spontaneous recovery and language rehabilitation. In X. Seron & G. Deloche (Eds),
Cognitive Approaches in Neuopsychological Rehabilitation. Hillsdale, NJ: Lawrence Erlbaum
Associates.
BLOMERT, L., KOSTER, C., KEAN, M-L., SCHAAP, T., VON STOCKERT, T., BUSLACH, D. & JUNKER, D. (1990). The
Amsterdam-Nijmegen Everyday Language Test: standardised Dutch version and a preliminary
study of a German adaptation. Paper presented at the Eighth European Workshop on Cognitive
Neuropsychology, Bressanone.
BLOMERT, L., KOSTER, c., VAN MIER, H. & KEAN, M-L..(1987) Verbal communication abilities of aphasic
patients; the everyday language test. Aphasiology 1,463-474.
CRYSTAL,D., FLETCHER, P. & GARMAN, M. (1981). The Grammatical Analysis of Language Disability. Lon-
don: Edward Arnold.
DAVIS, G.A. & WILcox, ~ ~ ( 1 9 8 5Adult
) . Aphasia Rehabilitation. Applied Pragmatics. Windsor: NFER-
Nelson.
GERBER, S. & GURLAND, G.B. (1989). Applied pragmatics in the assessment of aphasia. Seminars in Speech
and Language 10,263-28 1.
GOODGLASS, H. & KAPLAN, E. (1983). The Assessment of Aphasia and Related Disorders. Philadelphia: Lee
& Febiger.
GREEN, G . (1984). Communication in aphasia therapy: some of the procedures and issues involved. British
Journal of Disorders of Communication 19,3546.
HAWKINS, P. (1989). Discourse aphasia. In P. Grunwell & A. James (Eds), The Functional Evaluation of
Language Disorders. London: Croom Helm.
HOLLAND, A. (1980). Communicative Abilities in Daily Living. Baltimore: University Park Press.
HOLLAND, A,, GREENHOUSE, I.B., FROMM, D. & SWINDELL, C.S. (1989). Predictors of language resititution fol-
lowing stroke: a multivariate analysis. Journal of Speech and Hearing Research 32,232-238.
LESSER, R. & MJLROY, L. (1993). Linguistics and Aphasia: Psycholinguistic and Pragmatic Aspects of
Intervention. London: Longman.
LEVINSON, S.C. (1983). Pragmatics. Cambridge: Cambridge University Press.
LOMAS, I., PICKARD, L., BESTER, s., ELBARD, H., FINLAYSON, A. & ZOGHAIB, c. (1989). The communicative
effectiveness index: development and psychometric evaluation of a functional communication mea-
sure for adult aphasia. Journal of Speech and Hearing Disorders 54,113-124.
LUBINSKI, R., DUCHAN, D. & WEITZNER-LIN, B. (1980). Analysis of breakdowns and repairs in aphasic adult
conversation. In R. Brookshire (Ed.), Clinical Aphasiology Conference Proceedings. Minneapolis:
BRK Publishers.
MANOCHIOPINIG, s., SHEARD, c . & REED, V.A. (1992). Pragmatic assessment in adult aphasia: a clinical
review. Aphasiology 6, 519-533.
MILLER, N. (1989). Strategies of language use in assessment and therapy for acquired dysphasia. In P.
Grunwell & A. James (Eds), Functional Evaluation of Language Disorders. London: Croom Helm.
PENN,c, (1985). The profile of communicative appropriateness: ii clinical tool for the assessment of prag-
matics. The South African Journal of Communication Disorders 32, 18-23.
SCHIENK, K.J., H U B E K , ~ .& WILIMES, K. (1987). Prepairs and repairs: different monitoring functions in
aphasic language production. Brain and Language 30,226-244.
Address correspondence to Ruth Lesser, Department of Speech, Newcastle University, Newcastle upon
Tyne NEI 7RU, UK.
Received June 1993; revised version accepted December 1993

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Assessing functional communication in aphasia: Clinical utility and time

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Assessing functional communication in aphasia:

Catherine Crockford" and Ruth Lesser

The importance to aphasia therapists of assessing aphasic people’s success in

functional (pragmatic) communication rather than only on formal linguistic

ANELT uses 18 communicative situations which, it is claimed, the patient may

analysis in the present study in addition to a qualitative analysis. This would

QUANTIFICATION OF CONVERSATIONAL BEHAVIOURS

To be of practical use as a clinical tool only a few conversational behaviours

repairs. Against expectations Schlenk et al. found that Wernicke’s aphasic

interpretable as indicating troubles in the aphasic person’s contribution to the

Unrepaired neologisms and unintelligible syllables were excluded from this

Receiving speech therapy -

were based on those used by Levinson (1983). The transcriptions were

Table 2: Results of CETI, ANELTand BDAE ratings

T Out of 110. t Out of 140 (see text).

apparent conflict between another patient’s (SR’s) improvement on the BDAE

In respect of the three conversational behaviours selected for QCB, conver-

Tabie 3: Conversarionai anaiysis

Acute patients Chronic patients

minutes of conversation took 60 minutes, with scoring of editing elements and

sent study will then be commented on.

Clinical Utility: CETI

support CETI’s claimed reliability as a re-test instrument. Nevertheless CETI

Clinical Utility: A NEL T

Clinical Utility: QCB

which occurred in the second conversation was caused by overlap. There is a

to examine communication at a micro as well as at a macro level, and to apply

which could be delegated to trained therapy assistants, given that broad-based

data from PK and her husband MK.

1. M: Tilly should be back in London now shouldn’t she

In example (1)M initiates, P responds and M initiates again. In example (2) M

initiates, P responds and then initiates (underlined).

Received June 1993; revised version accepted December 1993

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