cueing verbs : a treatment strategy for aphasic adults (cvt)ment protocol, "cueing verbs: a...

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Journal of Rehabilitation Researchand Development Vol . 25 No . 2Pages 47—60

Cueing verbs : A treatment strategy for aphasic adults(CVT)FELICE L . LOVERSO, Ph .D., THOMAS E . PRESCOTT, Ph .D., and MARILYN SELINGER, Ph .D.Harry S. Truman Memorial Veterans Hospital, Columbia, Missouri 65201, and Veterans AdministrationMedical Center, Denver, Colorado 80220

Abstract—This investigation demonstrated that the treat-ment protocol, "Cueing Verbs : A Treatment Strategy forAphasic Adults" (hereafter referred to as CVT), was aneffective rehabilitation technique . Specifically, this CVTwas shown to be beneficial with marked/moderate tomild fluent aphasic adults . Additionally, the study ad-dressed such issues as optimal treatment frequencies,treatment initiation and termination points, and criteriafor success and failure . Finally, the six-tier hierarchy oftreatment levels are presented with all variables operation-ally defined.

INTRODUCTION

The establishment of efficacious treatment proto-cols for aphasic adults is a complicated, time-consuming, and difficult endeavor . The need forreliable treatments for various types and degrees ofaphasia, with factors such as optimal treatmentfrequencies, continues to be in high demand formost clinicians treating this population of patients.The present study reports an early stage in anattempt to provide these health care professionalswith an effective treatment tool, "Cueing Verbs : ATreatment Strategy for Aphasic Adults (CVT),"based on sound theoretic and behavioral evidence.

Address all correspondence and reprint requests to : Felice L. Loverso,Ph .D ., Harry S . Truman Memorial Veterans Hospital, 800 HospitalDrive, Columbia, MO 65201.

Thomas E . Prescott, Ph .D ., and Marilyn Selinger, Ph .D ., VA MedicalCenter, 1055 Clermont, Denver, CO 80220

One language theory, quite common in the fieldsof cognitive psychology and generative semantics,proposes a case grammar in which the verb is thepredicate core of all simple sentences (6) . A predi-cate can be defined as a "general function thatspecifies the relationships that might exist amongsome set of concepts ." Utilizing the verb as thepropositional core of sentences has allowed severalresearchers (11,15,18,19) to postulate that languageand memory are in fact built around the verb . Mostcommonly, events of an individual's database(knowledge and memory) are represented by center-ing all language procedures around the action.Therefore, action, in our opinion, is the centralnode.

For an individual to utilize language, it is firstnecessary to identify the relationships of the lan-guage concept to the action being described . Togenerate the meaning of an event without dealingwith the ambiguities at the surface structure, theaction must first be identified . The verb is chosenbecause it is the only terminal element in thestructure; any change in the verb form wouldnecessarily change the meaning of the event (4).

Figure 1 depicts the system based on the verb asthe central node which specifies that: 1) the individ-ual or thing that carries out the action is the agent orinstrument ; 2) the person or thing that is affected bythe action is the object or recipient ; 3) any objectthat the actor uses is the instrument ; 4) the thingthat causes the action to take place is the purpose ; 5)the place where the action takes place is the

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Journal of Rehabilitation Research and Development Vol . 25 No. 2 Spring 1988

ACTOR

ACTION

OBJECT

CENTRAL NODE

who - RECIPIENT

" VERB"what - OBJECT

CONDITION

where - LOCATIONwhen - TIME

why - PURPOSE

how - INSTRUMENT

who - AGENT

what - INSTRUMENT

Figure 1.Language system based on the verb as the central node.

location; and, 6) the temporal aspects of when theaction took place is the time . Definition of constitu-ent elements into this actor-action-object form sim-plifies the grammatical complexities resulting fromtransformations, such as passive transformations.The actor-action-object framework further simpli-fies approaches to language in the manner discussedby Bever (2), who called this actor-action-objectframework the primary internal structure of asentence. Bever also found this form to guide theprocedure by which we perceptually segment sen-tence units . In other words, perceptual segmentationproceeds in terms of internal structural organizationinto sentences. Bever found that the segmentation ofcompound embedded sentences occurs in actor-action units.

In order to tap the most useful and meaningfulaspects of language, it appears advantageous to usethe internal structure . Since transformations areoperations applied to the internal structure, theymay be superfluous in terms of language stimula-tion. The actor-action-object framework, by previ-ous definition, supercedes grammatical function,and therefore, transformations . As seen in Figure 1,the interrogatives who, what, when, where, why,and how are linguistically analogous to the con-structs discussed by Bever . Linguistically, the verband action appear equivalent.

Shafto (20) examined memory for simple sen-tences in 12 undergraduate students . He found thatmemory is a function of the predicate structures ofthe main verbs, rather than of the surface structuresor noun elements of the sentences . These resultsfurther support the notion that the internal structure

is the center point for language and that the verb isthe pivot point for language knowledge as well asfor memory. Further, researchers have developedcomputer languages (18) and language models(14,15,19) based on the verbs that have provided astructural framework wherein language concepts canbe fastened . Utilizing the verb as the central nodeallows for expansion into the subject-verb-objectframework via the strategies of wh-cueing.

The previous flexible, highly functional mode oflanguage representation appears to be applicable tothe field of aphasiology . Yet, investigations into thelinguistic deficits of aphasic patients have neglectedthe verb and its application to internal structure.Nouns, transformations, and morphology are amongthe most researched areas in aphasiology, while onlya few researchers have included the verb in theiranalysis of aphasic disorders . Wepman, Bock,Jones, and VanPelt (25) considered the disorder ofanomia . In addition to difficulty in noun naming,their aphasic subjects showed an absence of all butthe most frequent verbs and adjectives . BothHalpern (9) and Siegel (22) examined repetition ofnouns, verbs, and adjectives, and their findingsindicated that both verbs and adjectives were moreseverely disturbed than were nouns in their aphasicpatients . These results for verbs and nouns havebeen corroborated by Loverso and Craft (12).

In 1973, Goodglass (7) observed agrammaticpatients . The results of these observations may shedan interesting light on the preponderance of noun-centered approaches in aphasiology . Goodglassfound that his subjects tended to produce one-wordsentences, where all words, whether they represent

49

LOVERSO et al . : Cueing Verbs : A Treatment Strategy

nouns or verbs, were transformed to a nominalfunction . Nouns (or the nominal case) appear on thesurface to be what is least disturbed, and thereforeshould be an adequate stepping stone from which tobuild language rehabilitation . In fact, the oppositemay be true; perhaps it is the nature of the disorderto nominalize all language forms and thereforecause a dead end to further language facilitation.Most recently, cross-linguistic studies of aphasicpatients' comprehension strongly support the verbas the central unit for language/information process-ing (1).

It was the purpose of this investigation to examinethe applicability of the CVT to treatment forpatients exhibiting aphasia. Our aim is to provideinitial behavioral evidence about the effectiveness oftreatment in improving productive language skillsand the actual treatment approach utilized in thisstudy.

METHODS

SubjectsThe following selectional criteria were used to

establish candidacy for inclusion in this study:1. All subjects were at least 6 months past the

onset of aphasia.2. Each subject was at or above the 50th percen-

tile on the Porch Index of Communicative Ability(PICA) overall measure (16).

3. All subjects showed a stable baseline (plus orminus 5 percentile points) for the overall measure ofthe PICA over a 3-consecutive-month period.

4. Each subject was left-brain-damaged as con-firmed by 3 of the following 4 procedures : a)abnormal angiogram; b) abnormal motor signs ; c)abnormal CT scan ; or, d) abnormal brain scan.(Any subject who exhibited right hemispheric braindamage was excluded from the study .)

5. Each subject showed no more than 30dBhearing level as measured by a hearing screeningtest .

6. Each subject had sufficient visual acuity toperform the task as measured by a visual screeningprocedure.

Subject No . 1 was a 68-year-old right-handedmale who sustained a left temporal parietal infarct 8months prior to inclusion in the study . Initialspeech/language testing indicated a moderate apha-

sia. This patient had a high school education andwas a retired bricklayer.

Subject No . 2 was a 59-year-old right-handedmale who suffered a left temporal lobe infarct 7years prior to participation in this investigation.This patient's initial speech/language evaluation, 3months before beginning this treatment protocol,indicated that his performance was in the moderaterange of aphasia. This subject was divorced, livedalone, and had a college education.

Based on speech/language performance, threeindependent judges, all of whom hold doctorates inSpeech/Language Pathology, determined that boththe patients had fluent aphasia . Additionally, eachsubject had reached maximum benefit from treat-ment, as indicated by stable speech/language perfor-mance.

ScoringBoth graphic and verbal output for each patient

was scored . This scoring system was liberallyadapted from the multidimensional scoring systemfor the PICA . Criterion scores were PICA scores of13, 14, 15, and 16 . Any score falling below criterionrange was considered incorrect . Scores were talliedfor each session and the percentage correct wasgraphed. Scores of 90 percent for 3 consecutivesessions were considered criterion for moving on tothe next level . Patients were given scores for theirinitial response . Since this is a treatment technique,treatment interactions were initiated only after thefirst response was obtained and scored . See Table 1for a complete description of scoring methods.

Treatment frequency/durationSubjects were scheduled for 1-hour treatment

sessions at least 3 times weekly . Duration oftreatment was established by each subject's individ-ual performance at each treatment level . Treatmentcontinued at each level until 90 percent performancefor verbal and graphic scores was observed over 3consecutive trials or 20 sessions at any given levelwas recorded.

StimuliThe stimuli for this investigation were 30 verbs

(same) at each level . They were : give, learn, run,think, buy, feel, find, keep, call, write, read, want,have, like, eat, help, look, cut, live, speak, win, go,draw, play, start, grow, move, plant, make, and hit.

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Table 1.Summary of scoring descriptions.

Scoring : Scoring both verbal and graphic output x/o, x-verbal,o-graphic

A. Criterion for each level (PICA 13, 14, or 15)

1 . 15 = complete response2 . 14 = distorted but intelligible (graph or verbal)3 . 13 = complete with delay including self corrects .

B. Below Criterion (PICA 12 or under)

1 . 12 = syntactical error2 . 11 = syntactical error with delay3. 9 = repeat input if:

a. Patient asks for a repeat.b. There is no response for 30 seconds.c. Patient does not do task.

4. 8 = wh words such as who and what are repeated withthe verb after a repeat has occurred.

5 . 7 = spelling errors or related semantic errors.6. 6 = unrelated semantic errors, e .g ., patient given

who cue for subject and responds with aninanimate or nonhuman noun . An occupationhuman noun is acceptable for a what cue.

The linguistic stimuli were controlled with respectto frequency of occurrence (23), imagery (24), andconcreteness (16) . Additionally, the emotional con-tent of these verbs was specifically addressed . Nodifferences were noted between verbs of high emo-tional and low emotional content.

The wh-question cues utilized were : who, what,when, where, why, and how . All stimuli wererandomly presented to all subjects studied.

Baseline testingEach patient included in this investigation exhib-

ited a stable speech/language baseline (plus or minus5 percentile points) on the PICA overall measure for3 consecutive tests . These evaluations were adminis-tered in 1-month increments.

To establish an initial CVT treatment level com-mensurate with each patient's abilities, treatmenttask baselines were administered . As seen in Table 2,on the first day of treatment, a patient wasadministered overall Level I . If the patient wasunable to score at the 60th percentile or greater onthis initial session, he/she proceeded through allsub-levels of the first level of this program . The

same approach was utilized for Level II aftercompletion of Level I.

Treatment protocolIn this approach, verbs are presented as pivots

and wh-questions provided strategic cues to elicitsentences in an actor-action then actor-action-objectframework (for complete Verbing Manual see Ap-pendix 1) . There are six hierarchical levels to thistreatment with 30 verb stimuli at each level . All verbstimuli and wh-cues were randomly presented toeach patient.

Each CVT treatment level and the sequence ofstimuli presentation are provided below:

Level IA : As depicted in Figure 2, this treatmentlevel requires the patient to repeat and copy asubject-plus-verb combination . All stimuli are pro-vided by the clinician.

Level IB : Figure 3 illustrates the next treatmentlevel . At this level, the patient is provided with theverb, the wh-cue, and a choice of subjects . Based onthe wh-cues, the patient chooses the correct subject

Table 2.Verb program flow chart.

Session ILevel I60% Achieved

Yes

Proceed to Level IUntil Criterion isReached

Session ILevel II60% Achieved

Proceed to Level IIUntil Criterion isReached

Proceed to Level HAUntil Criterion is

Reached

Level IIB UntilCriterion is

Reached

No

NoYes

Proceed to Level IAUntil Criterion IsReached

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ACTION

LEVEL IA:REPEAT S-V COMBINATIONBOTH VRB . AND GPH.Figure 2.Level IA : Patient is to repeat and copy a subject-plus-verbcombination (stimuli provided by clinician).

and completes the subject-plus-verb combination.Level I : At this treatment level (Figure 4), the

patient self-generates a subject-plus-verb combina-tion . Only the verb and the wh-cue are provided.

Level IIA : As seen in Figure 5, this treatment levelis similar to the treatment in Level IA, with theexception that a recipient to the action is required.

Level IIB : Figure 6 depicts the sequence of stimulifor the next treatment level . Like treatment LevelIB, this level requires the patient, guided by awh-cue, to choose a subject from an array . At thislevel, however, the patient must also choose arecipient of the verb.

Level II : This treatment level (Figure 7) is de-signed to elicit a self-generated subject-plus-verb-plus-object combination . As seen in this figure, thepatient is provided with the verb, a subject cue, andan object cue.

ProceduresThe following procedures were utilized for each

subject . Once PICA baseline was accomplished,each patient was given CVT Level I to establishwhether or not all three initial CVT treatment levels

were indicated . If the patient scored 60 percent orgreater on this initial session, he/she remained atthis CVT Level I . If 60 percent was not reached onthis initial session, the patient proceeded through theprogram in the following manner : IA, IB, I. Thesame sequence was utilized for Level II.

After all baselining procedures were accom-plished, the patients were scheduled for treatment 3to 5 times weekly . All verb, subject, recipient, andwh-cue stimuli were randomly presented to eachpatient at each CVT level . Following the completionof any CVT treatment level, the PICA was againadministered to each patient . Patients were alsotested 1 month following completion of treatment.

RESULTS

To establish whether or not treatment effects wereobserved, all performances on the standardized tests(PICA) were compared and contrasted, using an

2

WH-CUE

i

1

LEVEL IB:

AFTER CHOOSING A CORRECT

S, STATE S — V COMBINATION

BOTH VRB . AND GPH.

Figure 3.Level IB: Based on wh-cues, patient chooses the correct subjectand completes the subject-plus-verb combination.

2

WH-CUE

4 3

AGENT

AGENTLOCATION

INSTRUMENTTIME

ACTION

52

Journal of Rehabilitation Research and Development Vol . 25 No . 2 Spring 1988

WH-CUE

ACTION

LEVEL I:GENERATE S, STATE S-V

COMBINATION BOTH VRB . AND GPH.

Figure 4.Level I : Patient self-generates a subject-plus-verb combination(only verb and wh-cue provided).

analysis of variance with repeated measures proce-dure (10) . Data for each subject was analyzedindividually over time and individual analyses werecomputed for the PICA overall, gestural, verbal,graphic, and isolated subtest scores . The locus ofthese differences was determined by computing the

WH-CUE

significant gap (26) for each mean comparison . Theresults for both subjects are summarized in Table 3.

Results for Subject No . 1 reveal statisticallysignificant (p< .05) differences for the overall PICAscores over time, as well as for graphic, verbal, andsub-test I and sub-test C performance . Figure 8illustrates this patient's overall speech/languagefunctioning as measured by the PICA from theinitial baselines through treatment levels I and IIand for the maintenance measure . As seen in thisFigure, Subject No . 1 received only the two overallCVT treatment levels, as initial treatment baselinesfor both Level I and II revealed greater than 60percent performance. As seen in Figure 9, SubjectNo . 1's verbal performance was statistically (p< .05)different from baseline to completion of overallLevel I . A similar pattern of performance wasobserved for graphic scores as seen in Figure 10.

Subject No . 2 demonstrated a statistically signifi-cant (p< .05) performance on the overall, graphic,verbal, and sub-test I, C, D, and VI measures.Initial treatment baselines indicated task perfor-mance below the 60th percentile . Therefore, SubjectNo . 2 received treatment levels IA, IB, and I.Subsequent baselining for treatment Level II re-vealed performance greater than 60 percent, result-ing in the patient receiving Level II without sub-levels IIA and IIB .

WH-CUE

AGENT

ACTION

RECIPIENT

LEVEL IIA : REPEAT S-V-O COMBINATION BOTH VRB . AND GPM.

Figure 5.Level IIA: Patient is to repeat and copy a subject-plus-verb combination (recipient to the action required) .

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Table 3.Results of analysis of variance procedures.

Subject # 1 Subject # 2

Overall P < .05 Overall P< .01Graphic P < .01 Graphic P < .01Verbal P< .05 Verbal P< .01Subtest # I P< .01 Subtest # I P < .01Subtest # C P < .05 Subtest # C P < .05

Subtest # D P< .05Subtest # VI P< .05

Figure 11 illustrates Subject No . 2's overallspeech/language performance . Like Subject No. 1,Subject No. 2 demonstrated stable baseline perfor-mance with overall speech/language treatment ef-fects noted through the treatment phase of thisstudy. Maintenance of overall speech/language func-tioning was observed . Figure 12 and Figure 13 showthis patient's verbal and graphic performance respec-tively, as measured by the PICA . Treatment effectsagain can be seen, as well as maintenance ofperformance, following treatment from a stablebaseline for each output modality.

In addition to the overall speech/language andverbal and graphic modality measures, each patientdemonstrated statistically significant (p< .05) differ-

2

WH-CUE

AGENTLOCATION

INSTRUMENTTIME

ent performance on sub-tests I and C . Performanceon sub-test I, which is designed to assess spontane-ous speech in response to describing the function ofcommon objects, for both subjects were similar totheir performance on the verbal modality measures.Performance on sub-test C, which requires thepatient to write names of common objects todictation, was quite different for each subject.Subject No . 1 improved his abilities on this task andmaintained those gains following treatment . SubjectNo. 2, on the other hand, reverted to the originalsub-test C level following treatment . Additionally,Subject No . 2's performance on sub-test D (writingnames of common objects after being spelled by theexaminer) and VI (pointing to objects named) wassimilar to those previously described, in that treat-ment results were observed, as well as maintenanceof those behaviors following treatment.

CONCLUSIONS

Darley (5) suggests that instead of asking thequestion, "Does treatment work?", clinicians woulddo well to ask the questions : 1) For whom does itwork? 2) What does the treatment consist of? 3)When should treatment begin and end? and, 4) How

4

WH-CUE

TIMERECIPIENTLOCATION

CAUSALITYACTION

I I I

LEVEL IIB : AFTER CHOOSING A CORRECT S . & O .,

STATE S-V-O COMBINATION BOTH VRB . AND GPH.

Figure 6.Level IIB : Guided by wh-cues, patient chooses a subject from an array and a recipient of the verb.

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frequently should treatment be provided? While thepresent investigation demonstrates that CVT, asapplied to our subjects, was worthwhile in terms ofstatistically significant improvement in speech/language functioning, the research also attempts toanswer the basic Darley questions . Responses tothose questions should provide clinicians with theinformation needed to apply treatment techniques inan optimal fashion . It is hoped that this would resultin more timely, efficacious treatment directed at thetarget population for whom the technique wasdesigned.

CVT was designed for marked/moderate, moder-ate, and mild fluent aphasic adults . These severitylevels were targeted because the technique itselfrequires abilities that allow the patient to followbasic instructions and to possess output skills thatare variably accurate and appropriate . This tech-nique builds on the input skills of auditory andvisual processing and enhances verbal and graphicoutput abilities . It also appears that fluent aphasicadults may fare much better with CVT than do thenonfluent aphasic adults . The findings reportedhere, as well as data from patients presently receiv-ing this treatment, suggest that the difficulties fluentaphasic patients experience are directly related to the

WH-CUE

very direction of this treatment technique . Forexample, Shewan (21) pointed out that aphasicpatients make more errors on verb phrases thannoun phrases . Our treatment protocol attacks a verbphrase and its structural sequence . It is also ourbelief that a linguistic technique such as this may notbe robust enough, by itself, to combat the motor-programming deficits present in most nonfluentaphasic persons.

The second Darley question, "What does thetreatment consist of?", can be summarized asfollows . CVT emphasizes the verb or action versusthe traditional noun-centered approaches used inaphasia rehabilitation . The cueing strategies imple-mented from the verb or pivot allow the patient tobuild on his/her language skills rather than beingcornered with one-word noun phrases . It appearsthat, by using this approach, one can enhance thepotential for resultant functional communication byaphasic adults . It is our belief, and one that wasconfirmed by family-member reports, that func-tional communicative abilities are aided because useof the verb in this pivot role results in the direct,systematic application of strategies (wh-questions)by the aphasic patient . In addition, by specifyingfunction, the patient is able to narrow the semantic

WH-CUE

ACTION

LEVEL II : GENERATE S . & O ., STATE S-V-O

COMBINATION BOTH VRB . AND GPH.

Figure 7.Level II : Provided with the verb, subject cue, and object cue, patient self-generates the subject-plus-verb-plus-object combination .

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BASELINE

TREATMENT MAINTENANCE

100 -

100 -

95 -

95 -

90 -

90

85

• 80•

75

70

65

01

MONTHS POST ONSET

SUBJECT #1 : O.A . PICA DATA x BASELINE,TREATMENT & MAINTENANCEPHASES.

Figure 8.Subject No . 1 : Overall speech/language functioning.

field referring to the ideas he/she wishes to commu-nicate. Consequently, there is an increase in thechance of eliciting utterances appropriate to thecommunicative situation. McNeil and Kozminsky(13) have urged clinicians working with aphasicadults to direct their rehabilitation efforts towardestablishing a number of strategies the patient canutilize to maximize his/her language use . Thepresent study attempts just that . Based on soundtheoretical and clinical models, CVT is constructedon the structure of language while reinforcing andteaching self-cueing strategies.

Establishing a beginning and ending point for anyeffective treatment program requires the clinician todefine the behaviors to be elicited in a consistentmanner . CVT uses a six-tier hierarchy of taskcontinuum from repetition of two-word utterancesto self-generation of subject-verb-object combina-tions . By utilizing the initial probe technique previ-ously described, a clinician can zero in on the targetperformance. This should allow the clinician andpatient to begin at a level of complexity appropriatefor that individual patient . Sixty percent perfor-mance criteria was used to establish a treatmentinitiation point . As Brookshire (3) suggests, clini-cians should attempt to provide aphasic patientswith treatment tasks at a level where performancebegins to break down and correct responses outnum-ber incorrect responses . This investigation attempted

BASELINE

TREATMENT MAINTENANCE

85

10

11

12

14

15

O

a.70

65 -

60 -

55-

08

9

10

11

12

14

15

MONTHS POST ONSET

SUBJECT #1 : VERBAL PICA % x BASELINE,TREATMENT & MAINTENANCEPHASES.

Figure 9.Subject No . 1 : Verbal performance.

BASEUNE

TREATMENT MAINTENANCE100

95

90

85

so -

8 9

10

11

12

14

MONTHS POST ONSET

70

85

60

55

01'1s

SUBJECT #1 : GRAPHIC PICA % x BASELINE,TREATMENT & MAINTENANCEPHASES.

Figure 10.Subject No . 1 : Graphic scores .

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75 -

70 -

4.0

4.8

7 .0

7 .1

7 .3

7 .3

7 .4

7 1.5

YEARS.MONTHS POST ONSET

SUBJECT *2: O .A . PICA DATA x BASELINE,TREATMENT & MAINTENANCEPHASES.

100

95

90

85-+

65 -

0 1

BASELINE MAINTENANCETREATMENTBASELINE

TREATMENT

MAINTENANCE100

95

90

85

80

O 75Y.

70

65 -

60 -

55

014 .0

4 .8

7 .0

7 .1

7 .3

7 .3

7.4

7.5

YEARS .MONTHS POST ONSET

Figure 11.Subject No . 2 : Overall speech/language functioning.

YEARS.MONTHS POST ONSET

SUBJECT *2 : GRAPHIC PICA % x BASELINE,TREATMENT & MAINTENANCEPHASES.

Figure 13.Subject No . 2 : Graphic scores .

SUBJECT *2 : VERBAL PICA % x BASELINE,TREATMENT & MAINTENANCEPHASES.

Figure 12.Subject No . 2 : Verbal performance.

to direct treatment activities at levels that wereinitially taxing, yet not impossible or frustrating forthe patients to endure . On the other end of thecontinuum, treatment was terminated when thepatient performed with 90 percent accuracy for threeconsecutive trials . This traditional approach, usedby most clinicians dealing with treatment of aphasicadults, has been observed to demonstrate compe-tency of the behaviors desired . Based on the datapresented for both the treatment and maintenancephases of this study, termination-of-treatment crite-ria seemed appropriate, because each patient wasable to maintain performance after reaching crite-rion performance during treatment.

Finally, Darley asked the question regardingfrequency of treatment . In this investigation, weattempted to study the treatment approach in apractical, traditional environment . We scheduledpatients at least three times weekly, which was feltto be representative of what most clinicians do inrehabilitative settings . This, too, appeared effective,because both patients met overall treatment goals onthat treatment schedule . We are presently exploringthe effects of scheduling fewer than, and more than,three sessions weekly.

In summary, this investigation has demonstratedthat CVT is an effective rehabilitation program for

BASELINE TREATMENT MAINTENANCE100

95

90

85

80 -I

70

65

60

55

014 .0

4.8

7 .0

7 .1

7.3

7 .3

7.4

7.5

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aphasic adults. Specifically, the authors believe thatfluent aphasic patients in the marked-to-moderate,moderate, and mild severity levels of aphasia mightdo well with the use of the verb-as-pivot andwh-question cueing strategies as applied in thisinvestigation .

Continuation of this study with increased num-bers of aphasic persons is presently underway in ourclinics . The authors are also looking at specifictreatment media such as the microcomputer, andtheir capabilities of discharging CVT to aphasicadults.

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A

revision

of theconcept of anomia . J Speech Hear Dis 21 :468-477, 1956.

13 :192-199, 1982 . 26 . Winer BJ : Statistical Principles in Experimental Design,13 . McNeil MR, Kozminsky L : The efficiency of five self-

generated strategies for facilitating auditory processing.In : Clinical Aphasiology Proceedings,

Brookshire RH(Ed .) .

Minneapolis,

MN :

BRK Publishers

11 :268-274,

2d Ed., New York, NY : McGraw-Hill, 1971 .

1980.

58


APPENDIX IVerbing Manual

Materials:

A. 30 verbs (4 x 6 cards)

B. 6 wh-question cards (4 x 6) / who, what,where, when, why, how

C. Subject and object cards (4 x 6)

D. Subject and object choice cards (4 x 6)

II . Scoring: Scoring both verbal and graphic outputx/o, x-verbal, o-graphic.

A. Criterion for each level (PICA 13, 14, or 15)

1. 15 = complete response2 .

14 = distorted but intelligible (graph orverbal)

3 . 13 = complete with delay including self-corrects.

B. Below Criterion (PICA 12 or under)

= syntactical error= syntactical error with delay= repeat input if:

Patients asks for a repeat.There is no response for 30 seconds.Patient does not do task.

= wh words such as who and what arerepeated with the verb after a repeathas occurred.

= spelling errors or related semanticerrors.

= unrelated semantic errors, e .g ., pa-tient given who cue for subject andresponds with an inanimate ornonhuman noun . An occupation hu-man noun is acceptable for a whatcue.

C . Overall Criterion for each level

1 . Three consecutive trials with 90 percentaccuracy.

D . Patient is given scores for initial output . Sincethis is a treatment technique, treatment isinitiated only after a response has been madeand has been scored .

IV. Verbing Level Selection:

A. If the patient scores below 60 percent on initialtrial, proceed to level "A" and advancethrough total sequence, e .g ., Level A, Level B,Level I.

1 . Do not begin treatment at a "B" level.

B. If the patient scores above 60 percent on initialtrial, proceed to the overall level, e .g ., Levels Ior II.

V . Individualized verbing level procedures : (See Figures2 through 7)

A. Level # IA

1 . Task: The patient will repeat a syntacti-cally correct sentence consisting of asubject-plus-verb after the clinicianpresents the verb, the cue and subject bothgraphically and verbally.

a. Input: The patient is presented with:

1. The verb (graphic and verbal)2. The wh-cue (graphic and verbal)3. An appropriate subject (graphic

and verbal)4. The complete grammatical sen-

tence (graphic and verbal)

b . Output : The patient is required to:

1. Repeat the verb2. Repeat the subject cue3. Repeat the subject4. Repeat the subject + verb combi-

nation and is given a verbal score5. Copy S + V combination from

the cards and is given a graphicscore

B. Level # IB

1 . Task: The patient will generate a subject-plus-verb sentence, given the verb bothgraphically and verbally and choose thecorrect subject.


1 . 122 . 143 . 9

4 .

a.b.c.

8

5 . 7

6 . 6

III . Treatment Frequency : 1 . The verb (graphic and verbal)

A . Minimally 3 times weekly and maximally 5 2 . The wh cue (graphic and verbal)

times weekly 3 . The subject choice card (graphic)

59

LOVERSO et al : Cueing Verbs : A Treatment Strategy

b. Output: The patient is required to:

1 . Repeat the verb2. Repeat the wh cue3. Choose a correct subject4. Generate the S + verb combina-

tion verbally and is then given averbal score

5. Copy the S + V combinationfrom the cards and is given agraphic score

1 . Task: The patient will compose a S + Vcombination using the verb both graphi-cally and verbally . The patient is cued withwho or what cues.


1. The verb (graphic and verbal)2. The wh cue (graphic and verbal)

b. Output : The patient is required to:

1. Respond verbally with an appro-priate subject after the wh-cue isgiven

2. Generate verbally the S+ V com-bination and then is given averbal score

3. Generate a graphic responsewhich should reflect exactly theverbal utterance and is then givena graphic score

3a. The written cues are removedas the patient writes the sub-ject of the sentence.

1 . Task: The patient will repeat a syntacti-cally correct sentence consisting of a S +V + 0 after the clinician presents theverb, the subject cue, the subject, theobject cue and the object both graphicallyand verbally .

6 . The complete sentence (graphicand verbal)

b. Output: The patient is required to:

1. Repeat the verb2. Repeat the subject cue3. Repeat the subject4. Repeat the object cue5. Repeat the object6. Repeat the full utterance and is

given a verbal score7. Copy the S + V + 0 sentence

from the cards and is then givena graphic score

1 . Task: The patient will generate a S + V+ 0 sentence after the clinician presentsthe verb, the subject cue and the objectcue both graphically and verbally andchoose the correct subject and object.

a. Input : The patient is presented with:

1. The verb (graphic and verbal)2. The subject cue (graphic and ver-

bal)3. Subject choice card (graphic only)4. Object cue (graphic and verbal)5. Object choice card (graphic only)

b . Output: The patient is required to:

1. Repeat the verb2. Repeat the subject cue3. Choose a correct subject4. Repeat the object cue5. Choose correct object6. Generate the S + V + 0 combi-

nation verbally and is given averbal score

7. Copy the S + V + 0 combina-tion from the cards and is thengiven a graphic score

C. Level # I

D. Level # IIA

E. Level # IIB

a . Input : The patient is presented with :

F . Level # II

1 . The verb (graphic and verbal) 1 . Task : The

patient

will

compose

a2 . The subject cue (graphic and ver-

bal)S + V + 0 combination both verballyand graphically . The patient is cued with

3 . The subject (graphic and verbal) wh-questions.4 . The object cue (graphic and ver-

bal)a .

Input : The patient is presented with:

5 . The object (graphic and verbal) 1 .

The verb (graphic and verbal)

60


F. Level # II (continued)

2. The subject cue (graphic and ver-bal)

3. The object cue (graphic andverbal)

b . Output : The patient is required to:

1. Respond verbally with an appro-priate subject after the subjectcue has been given

2. Respond verbally with an appro-priate object after the object cuehas been given

3. Generate verbally the full gram-matical utterance and is thengiven a verbal score

4. Generate a graphic responsewhich should reflect exactly theverbal utterance and is then givena graphic score

4a. The written cues are removedas the patient begins writingthe subject of the sentence asin Level # I .

cueing verbs : a treatment strategy for aphasic adults (cvt)ment protocol, "cueing verbs: a...

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