A Cognitive Neuropsychological
A Cognitive NeuropsychologicalApproach to Assessment andIntervention in AphasiaThis book provides both a theoretical and practical reference to cognitiveneuropsychological approaches for speech and language therapists workingwith people with aphasia. Having evolved from the activity of a group ofclinicians working with people with aphasia, it is a highly practical guide thataims to interpret the theoretical literature as it relates to aphasia and link itdirectly to available assessment tools and therapy techniques.The opening section of the book provides an overview of the theoryunderpinning the approach and how it can be applied to the assessment andinterpretation of language-processing impairments. The second sectionoffers a working explanation of different components of language processing, outlining the deficits that may arise from impairment to each component.In addition, the clinician is guided to available assessments to test out clinicalhypotheses and offered interpretations of performance patterns. The finalsection provides a comprehensive overview of the therapy literature withsystematic summaries of the therapies undertaken and a synthesis of thefindings to date.This book has been written by clinicians with hands-on experience. It willbe an invaluable resource for clinicians and students of speech and languagetherapy and related disciplines.Anne Whitworth is Senior Lecturer on the Speech and Language Sciencesprogrammes at the University of Newcastle-upon-Tyne.Janet Webster is the Co-Director of the North East Aphasia Centre at theUniversity of Newcastle-upon-Tyne.David Howard is Research Professor at the University of Newcastle-uponTyne and is co-author of the Comprehensive Aphasia Test.
A CognitiveNeuropsychological Approach toAssessment and Interventionin AphasiaA clinician’s guideAnne Whitworth, Janet Webster andDavid Howard
First published 2005by Psychology Press27 Church Road, Hove, East Sussex, BN3 2FASimultaneously published in the USA and Canadaby Psychology Press Inc270 Madison Avenue, New York NY 10016This edition published in the Taylor & Francis e-Library, 2005.“To purchase your own copy of this or any of Taylor & Francis or Routledge’scollection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.”Psychology Press is part of the Taylor & Francis GroupCopyright 2005 Psychology PressAll rights reserved. No part of this book may be reprinted orreproduced or utilised in any form or by any electronic, mechanical orother means, now known or hereafter invented, including photocopyingand recording, or in any information storage or retrieval system,without permission in writing from the publishers.This publication has been produced with paper manufactured to strictenvironmental standards and with pulp derived from sustainableforests.British Library Cataloguing in Publication DataA catalogue record for this book is available from the British LibraryLibrary of Congress Cataloging in Publication DataWhitworth, Anne.A cognitive neuropsychological approach to assessment andintervention in aphasia : a clinician’s guide / Anne Whitworth,Janet Webster and David Howard. – 1st ed.p. cm.Includes biographical reference and index.ISBN 1-84169-345-6 (hard cover)1. Aphasia. 2. Cognitive neuroscience. 3. Neuropsychology.I. Webster, Janet, 1974– II. Howard, David, 1951– III. Title.RC425.W48 2005616.85′52–dc222004013474ISBN 0-203-49350-8 Master e-book ISBNISBN 0-203-59527-0 (Adobe eReader Format)ISBN 1-84169-345-6 (Print Edition)
No method of treatment is better than the principles on which it is based, andthe search for principles should concern us no less than the immediate clinicalsituation.(Zangwill, 1947, p. 7)
ContentsPrefaceIntroductionixxPART 1Theory and principles1 A cognitive neuropsychological approach: theoriesand models2 Identifying and characterising impairments: principlesand evidence1311PART 2Deficits and assessment233 Introduction to assessment254 Auditory comprehension of spoken words295 Spoken word production456 Written comprehension and reading597 Written word production798 Object and picture recognition97PART 3Therapy9 Introduction to therapy10 Therapy for auditory comprehension105107115
viii Contents11 Therapy for word retrieval and production13512 Therapy for reading18713 Therapy for writing227EpilogueGlossaryReferencesAuthor indexSubject index259265269283289
PrefaceThis volume evolved from the activity of a group of speech and languagetherapists in Newcastle-upon-Tyne, UK, who met, and still meet, regularly toevaluate new developments in aphasia, explore new assessment tools andapproaches, exchange views on management strategies, encourage clinicalresearch and generally swap stories of working with people with aphasia.Steeped within a strong cognitive neuropsychological tradition, we decided,several years ago, to tackle the frustration that arose from the lack of accessible literature in this area for the working clinician and try to draw togetherwhat it was that we did in our daily practice. Our project benefited us all andit seemed a logical next stage for some of us to extend this and make it morecomprehensive and accessible to a wider group of clinicians and studentsworking with people with aphasia. Members of the Newcastle Aphasia StudyGroup who contributed to this book’s antecedent are, in alphabetical order,Jennifer Bell, Helen Bird, Kirsty Bramley, Frauke Buerk, Ros Emerson, GillEverson, Jane Giles, Liz Green, Clare Headington, Rose Hilton, FionaHinshelwood, Lisa Hirst, David Howard, Louise Kelly, Anne-Marie Laverty,Lucy Skelton, Susan Stewart, Jill Summersall, Sonja Turner, Julia Wade, JanetWebster, Anne Whitworth and Sheila Wight. Our many thanks to the groupmembers for their efforts and support that allowed this book to see the lightof day, and their continued enthusiasm for discussing and evaluating theirwork with aphasia that permeates our lively meetings. In addition, we wouldlike to thank Lyndsey Nickels who has tirelessly read and commented onprevious drafts of this volume, along with Sue Franklin and Lisa Perkins whohave also given their time and wisdom to reshaping earlier ideas.Anne Whitworth, Janet Webster and David Howard
IntroductionWhile a cognitive neuropsychological approach is widely used in aphasiaclinics throughout the UK and other countries to assess and treat people withaphasia, there is relatively little published information that is accessible to thespeech and language therapist (or speech language pathologist) that exploresthe application of this approach. A small number of published assessmenttools, for example the Psycholinguistic Assessments of Language Processingin Aphasia (Kay, Lesser, & Coltheart, 1992) and the ADA ComprehensionBattery (Franklin, Turner, & Ellis, 1992), while widely used, are not supported by accessible literature to assist the working clinician in selecting theappropriate test to use, interpreting the results and identifying intact andimpaired processing systems. These are, we would argue, crucial steps indevising therapy that is, as Hatfield and Shewell (1983) put it, both rationaland specific; rational in the sense that it is based on a coherent account ofimpaired and intact processes, and specific in that it is targeted towards theeffects of the impairments for an individual.Therapeutic application of cognitive neuropsychology also remainsdifficult to digest. While there is a developing literature on therapy for peoplewith aphasia that uses therapy approaches grounded within a cognitiveneuropsychological perspective, these case reports are presented in variousforms that differ in their accessibility to clinicians and transparency with thetheoretical models used. This book aims to link theory and practice within acognitive neuropsychological framework, presenting the theoretical literatureand relating it directly to available assessment tools and reported therapytechniques. It is intended to provide both a theoretical and practical referencefor the working clinician. It does not aim to be prescriptive; it is anticipatedthat it will provide information that will help clinicians to use cognitiveneuropsychological knowledge in the assessment and treatment of peoplewith aphasia.As service provision to people with aphasia often occurs within the contextof healthcare systems, the terms ‘person with aphasia’ and ‘client’ are usedinterchangeably throughout the book.
Introduction xiThe person with aphasia and the broader clinical contextBefore embarking on our exploration of this approach, we wish, as clinicians,to state the obvious. Investigation and interpretation of communicationimpairments using this approach is only one facet in the holistic approach toworking with people with aphasia. This approach should, we believe, only beused within a total communication framework, with the person with aphasiabeing central and his or her personal circumstances and partners in communication being integral to the entire process. The importance of looking atareas other than deficits, of viewing the person with aphasia as an autonomous human being, of considering communication in context and of lookingoutside traditional modes of service delivery, are assumed to be obviouselements of any coherent holistic approach to working with people withaphasia.We do not, therefore, wish to imply that this approach should be used inisolation from the broader context of the person with aphasia’s real-life circumstances, but we do believe that a comprehensive analysis of his or herlanguage-processing system often forms a necessary and vital part in understanding the nature of the difficulties encountered by the person with aphasiaand in directing and informing subsequent management.Structure of the bookThis volume is divided into three discrete but interconnected sections. Part 1sets out the cognitive neuropsychological approach used within the currentmanagement of people with aphasia, placing it within both an historical andcontemporary framework.Part 2 provides a working explanation of the theoretical model, outliningthe deficits that may arise from impairment to each stage of the model anddiscussing assessment for each stage. The areas of spoken and written wordcomprehension, spoken and written word production, and object recognitionare explored. While strictly outside the domain of language, object andpicture recognition have been included because many assessments employpicture materials; as a result, these impairments may impact on performanceon language assessments. In the chapters of Part 2, we seek to provide anaccessible guide to the use of assessment tools in identifying underlyingimpairments. This is supported by brief case studies illustrating variouspatterns of impairment.Part 3 provides a selective review of the therapy literature, with detailedsummaries of the therapy used. Therapy studies have been systematicallyreviewed to provide information on the therapy procedures employed in eachstudy, including, for example, tasks, materials and feedback given to the client, alongside brief details of the client and the outcome of therapy. Asynthesis of the therapy literature is provided for auditory comprehension,naming, reading and writing, summarising what has been gained, to date,
xii Introductionfrom clinical research using a cognitive neuropsychological approach tomanage communication impairment in people with aphasia. The literaturereviewed here is not exhaustive, and the studies discussed are neither necessarily methodologically ideal nor are described taking the exact theoreticalposition of the authors of this volume. We believe, however, that they arerepresentative of the research in the area and allow us to shed light on theutility of the theoretical models many clinicians and researchers have beenapplying to the management of aphasia.
Part 1Theory and principles
1A cognitiveneuropsychological approachTheories and modelsAn historical perspectiveCognitive neuropsychology first emerged as a coherent discipline in the 1970sas a reaction to the then dominant approach in neuropsychology. This earlierapproach to neuropsychology (the ‘classical approach’) sought to characterise the performance of people with aphasia by defining them in terms of theirlocalisation of lesion (see Shallice, 1988, for further discussion of thisapproach). The aim here was to understand the psychological functions ofparts of the cortex by investigating the patterns of deficits shown by individuals with lesions in these areas, and identify syndromes defined in terms ofdeficits that frequently co-occurred. Over the last 20 years, in the UK at least,cognitive neuropsychology has expanded to become the dominant approachin neuropsychology. Part of the reason is that it moved neuropsychologyfrom being of interest only to those concerned with brain behaviour relationships to a major source of evidence on the nature of normal processing.Another reason is that good cognitive neuropsychology pays real attention toproviding accounts that address how individual people with brain lesionsbehave, often using sophisticated experimental methods to investigate thedeterminants of their performance.The origins of cognitive neuropsychology lay in two papers on people withreading disorders by Marshall and Newcombe (1966, 1973). There were twocritical features. First, Marshall and Newcombe realised that individualpeople with reading disorders could show qualitatively different patterns ofimpairment that would have been obscured by treating them as a group. Theydescribed two people who made semantic errors in single-word reading (e.g.NEPHEW ‘cousin’, CITY ‘town’; a difficulty described as ‘deepdyslexia’), two people who made regularisation errors (e.g. LISTEN ‘liston’, ISLAND ‘izland’; ‘surface dyslexia’), and two people who madeprimarily visually related errors (e.g. EASEL ‘aerial’, PAMPER ‘paper’;‘visual dyslexia’). The second feature was that the nature of the individual’sproblems could be understood in terms of an information-processing modeldeveloped to account for the performance of normal individuals, in this casethe ‘dual-route’ model of reading. Three of the essential features of cognitive
4Theory and principlesneuropsychology that were to define the approach were evident here: (1) therealisation that the performance of the individual, not the average of a group,was the important evidence; (2) that the nature of errors was informative; and(3) that the explanations of individuals’ performance were to be couched interms of information models of normal language processing and not in termsof brain lesions.The approach developed from an initial focus on reading disorders toencompass a variety of other domains. These include, in a vaguely chronological order, spelling disorders, memory impairments (including both longand short-term memory), semantic disorders, disorders of word retrieval,disorders of object and picture recognition, word-comprehension impairments, disorders of action, executive disorders, sentence-processing impairments, number processing, and calculation. The initial focus, in terms of thepeople whose disorders were investigated, was on adults with acquired brainlesions, typically following stroke, head injury or, more rarely, brain infectionssuch as herpes simplex encephalitis. The focus has now broadened toencompass developmental disorders, and those disorders found in progressivebrain diseases, most prominently the dementias.Methods have also shown a gradual change. While the early studies werein-depth investigations of single individuals, there has been an increasing useof case series designs where a series of people are investigated using the sameset of tasks. The data are not, however, analysed in terms of groups, butrather the focus is on accounting for the patterns of performance of a groupof people analysed individually. Here, both differences and similaritiesbetween individuals constitute the relevant evidence. Theoretical models havealso evolved. While box and arrow models of cognitive architecture remain amajor source of explanatory concepts, there has been increasing use of computational models, usually confined to specific domains such as reading, wordretrieval or comprehension.Finally, there has been a resurgence of interest in localisation of cognitivefunctions in the brain. This has been fuelled by the development of imagingmethods such as positron emission tomography and functional magnetic resonance imaging that can be used to measure changes in regional blood flow(reflecting local synaptic activity) in the brain while people are engaged incognitive tasks. These methods have allowed people to explore how andwhere the information-processing modules are represented in the brain (e.g.Price, 2001; Price et al., 2003).Cognitive neuropsychology as a working theoretical modelWith the abandonment of theories that drew direct links between localisinglesions in the brain and characterising deficits in speech and language, thereplacement model drew on the components involved in processing information and the interconnections between such components. These were firstillustrated in Morton and Patterson’s (1980) version of the logogen model.
Theories and models 5Morton and Patterson (1980) revised and articulated earlier versions of thelogogen model (which date back to Morton, 1969) to account for both thetypes of errors and the factors influencing reading performance (e.g. wordimageability; part of speech) in people with deep dyslexia. This model was aquintessential ‘box and arrow’ processing diagram that specified a number ofcomponent processes (the boxes) and how they interrelate (the arrows). Themodel referred to in this book is illustrated in Figure 1.1 and is (loosely) basedon Patterson and Shewell’s (1987) adaptation of the earlier logogen models.While a model of this kind may appear complex, each of these componentsappears to be necessary to account for the processing of single words. AsColtheart, Rastle, Perry, Langdon and Ziegler (2001) argued: ‘All thecomplexities of the model are motivated. If any box or arrow were deletedFigure 1.1 Language-processing model for single words, based on Patterson andShewell’s (1987) logogen model.
6Theory and principlesfrom it, the result would be a system that would fail in at least one languageprocessing task at which humans succeed’ (p. 211).If different modules and connections (boxes and arrows) in this model can beindependently impaired, a very large number of possible patterns of performance may result from a lesion. Given this large number, one clearly cannotassume that any two people will necessarily have the same pattern of performance. The idea, therefore, that aphasia can be grouped into a limited number ofidentifiable and homogeneous ‘syndromes’ must necessarily fail. This does not,of course, mean that there will not be resemblances between the performancesof different people with aphasia; to the extent that they have the same components damaged, this is precisely what we would predict. Nor does it meanthat some combinations of symptoms do not appear more frequently thanothers. It simply means that one cannot group data from people with aphasiatogether as the differences between individuals are important (Shallice, 1988).Analysis of data from single individuals is the necessary consequence.Using this kind of model to explain patterns of performance with peoplewith aphasia involves making several assumptions, described and defended indetail by, among others, Caramazza (1986), Shallice (1988) and Coltheart(2001). Coltheart (2001) describes four assumptions:1234Functional modularity. Some, at least, of the components of the cognitivesystem are modular, meaning that they operate independently, orrelatively independently, of other components.Anatomical modularity. Some, at least, of the modules of the cognitivesystem are localised in different parts of the brain. As a result
Introduction While a cognitive neuropsychological approach is widely used in aphasia clinics throughout the UK and other countries to assess and treat people with . Cognitive neuropsychology first emerged as a coherent discipline in the 1970s as a reaction to the then dominant approach in neuropsychology. This earlier
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