Pragmatic performance and functional communication in adults with aphasia.
This study used linear regression to define the relationship between pragmatic performance and functional communication by 27 individuals with aphasia, including 14 with fluent aphasia and 13 with non-fluent aphasia. Pragmatic performance was measured with the Pragmatic Protocol. Functional communication was measured using the ASHA Functional Assessment of Communication Skills (ASHA FACS). Results provide support for the relationship between these variables and for their underlying link to linguistic competence. Nonetheless, standard language assessment (Western Aphasia Battery) appears insufficient for describing overall communicative competencies and for explaining differences between some participants' functional communication abilities. Implications for assessment and treatment of communicative effectiveness are discussed.
Keywords: Aphasia Pragmatics Functional Communication.
With any type of disorder, different assessment measures can be, and have been, constructed to assess different aspects of behavior. For example, numerous assessments for aphasia currently exist. Some assessments, such as the Western Aphasia Battery (WAB) (Kertesz, 1982) or the Boston Diagnostic Aphasia Examination (Goodglass & Kaplan, 1983) purport to assess type and severity of aphasia. Other assessment tools focus on different aspects of communication. The Pragmatic Protocol (Prutting & Kirchner, 1983), for example, examines communication from an entirely different perspective.
Pragmatics is the study of the relationship between language behavior and the contexts in which language is used (Prutting & Kirchner, 1983). It involves the acquisition and use of conversational knowledge and the semantic rules necessary to communicate intent. In addition, pragmatics involves the interactional aspects of communication, including sensitivity to social contexts (Chapey, 1992). Specific pragmatic aspects investigated in adults with aphasia include communication acts (Gurland, Chwat, & Wollner, 1982; Wambaugh, Thompson, Doyle, & Camarata, 1991), speech acts (Doyle, Thompson, Oleyar, Wambaugh, & Jackson, 1994; Prinz, 1980; Wilcox & Davis, 1977), discourse analysis (Armstrong, 1987, 1991; Bottenberg & Lemme, 1991; Guilford & O'Connor, 1982; Mentis & Prutting, 1987) and use of nonverbal communication (Behrmann & Penn, 1984; Cicone, Wapner, Foldi, Zurif, & Gardner, 1979; Glosser, Weiner, & Kaplan, 1986; May, David, & Thomas, 1988). Researchers have investigated pragmatic performance in individuals with aphasia (Avent & Wertz, 1996; Holland, 1982; Prutting & Kirchner, 1987; Wilcox & Davis, 1977), and data suggest that individuals with aphasia maintain a high level of pragmatic appropriateness despite their linguistic impairments (Avent & Wertz, 1996; Prutting & Kirchner, 1987).
Another area of assessment for aphasia has been referred to as "functional communication." Functional communication is defined as "the ability to receive or convey a message, regardless of the mode, to communicate effectively and independently in a given [natural] environment" (p.2)(ASHA, 1990). While profiling specific pragmatic strengths and weaknesses may assist in identifying the nature and processes involved in "communication," a functional communication assessment should help to outline the consequences of the communication deficit in an individuals' daily interactions. For example, when assessing pragmatic ability with an instrument such as the Pragmatic Protocol (Prutting & Kirchner, 1987), speech act usage, turn-taking ability, and lexical selection categories may be rated as appropriate or inappropriate. Using a functional communication measure, such as the American Speech Language-Hearing Association Functional Assessment of Communication Skills for Adults (ASHA FACS) (Frattali, Thompson, Holland, Wohl, & Ferketic, 1995), rather than profiling specific deficits, the overall quality of communication in "real-life" activities can be established, as well as the amount of assistance needed during these activities. Thus, ratings are made regarding specific daily activities such as "Participates in a group conversation," "Requests information of others," and "Initiates communication with other people."
Although assumptions regarding communicative effectiveness have been based on pragmatic analyses of conversation (e.g., Wambaugh et al., 1991; Wilcox & Davis, 1977), there is little empirical research suggesting how pragmatic performance actually relates to functional communication. At first glance, the literature regarding pragmatic performance and functional communication in adults with aphasia appears to indicate that these concepts are one and the same. In fact, as Irwin, Wertz, and Avent (2002) so appropriately noted, these terms are often used interchangeably (Davis, 1993). However, as Murray and Chapey (2001) indicate, there are important distinctions between the two assessment approaches. Irwin, Wertz, and Avent (2002) concur, reporting that improvement on a pragmatic performance assessment is not significantly related to improvement on a functional communication assessment and that "these tests may measure different aspects of change in performance" (p.96). The authors report that both pragmatic performance and functional communication correlate well with language ability over time but that they do not correlate well with each other over time (i.e., pragmatics and functional communication do not correlate). Thus, these assessments seem to be measuring different underlying constructs. Although there are many overlapping variables within these components of communication, research has not fully demonstrated empirically how pragmatic performance relates to the ability of individuals with aphasia to communicate effectively and independently.
Breaking down aphasia performance into fluent versus non-fluent has not clarified these relationships. Holland (1980, 1982) reported that adults with non-fluent aphasia demonstrated a more 'normal' pattern of communication than adults with fluent aphasia. Busch, Brookshire, and Nicholas (1988) also found adults with non-fluent aphasia to be more efficient in communicating crucial information than adults with fluent aphasia. And, Behrmann and Penn (1984) reported more functional use of gestures in adults with non-fluent aphasia. These data suggest that we can at least feel comfortable stating that non-fluent aphasics are superior in terms of functional communication. On the other hand, standardization data for the ASHA FACS (Frattali et al., 1995), a functional communication measure, revealed that adults with fluent aphasia demonstrated a higher level of functional communication than adults with non-fluent aphasia. Some of the differences cited above would likely occur simply because different assessments of functional communication are employed. Still, concerns regarding the relationship between fluency and functional communication appear valid.
Prutting and Kirchner (1987) used the Pragmatic Protocol to develop profiles of deficits for individuals with fluent and non-fluent aphasia. Deficits identified were related to the linguistic constraints characteristic of each aphasia subtype. The majority of inappropriate behaviors for both groups were in the categories of specificity/accuracy, fluency, pause time in turn-taking, and quantity/conciseness. Participants with non-fluent aphasia had more difficulty with pause time in turn-taking and quantity/conciseness than the participants with fluent aphasia. Avent and Wertz (1996) reported no significant differences between adults with fluent aphasia and adults with non-fluent aphasia with regard to pragmatic performance, but did observe that adults with fluent aphasia performed slightly better than adults with non-fluent aphasia. Participants with fluent aphasia, however, entered therapy with a higher level of pragmatic performance.
If pragmatic performance is indicative of an individual with aphasia's functional communication, then similar ratings would be expected on both a pragmatic performance assessment and a functional communication assessment, regardless of fluency. Research has not addressed the interaction of these two variables. If, on the whole, individuals with non-fluent aphasia are considered to be better functional communicators and individuals with fluent aphasia are better or at least equal pragmatically, then an examination of the relationship between pragmatics and functional communication in relationship to language impairment is warranted. Pragmatic performance is often a target in treatment of aphasia. The relationship between one's ability to "understand" the rules of language (pragmatics) and implement the rules of language successfully (functionally communicate) speaks directly to appropriate treatment goals. If functional communication is independent of pragmatic performance, then treating pragmatics may not be the most valuable use of treatment time and dollars. The purpose of this study was to examine the relationship between pragmatic performance and functional communication in light of severity of language impairment and fluency. In doing so, the following questions were posed: 1) Is there a relationship between pragmatic performance and functional communication?; 2) How well do measures of functional communication and pragmatic performance predict type of aphasia (fluent vs. non-fluent)?; and 3) How well do measures of functional communication and pragmatic performance predict the severity of aphasia (mild-moderate or moderate-severe)?
Twenty-seven individuals with aphasia (14 fluent and 13 non-fluent), who had suffered a single, left-hemisphere stroke participated in this study. All participants met the following inclusion criteria: 1) English speaker; 2) at least two months post-onset to insure medical stability and to allow for adjustment to the aphasia; 3) no evidence of additional neurologic disorders (e.g., dementia, Parkinson's disease); 4) no evidence of psychiatric disorder (as reported by caregiver); and 5)completion of an audiometric screening.
For the purpose of this study, pragmatic performance was defined by an overall percentage of pragmatically "appropriate" parameters according to the Pragmatic Protocol (Prutting & Kirchner, 1987). The Pragmatic Protocol is a reliable measure and has been widely used to profile the pragmatic performance of adults with aphasia (Roberts & Wertz, 1993; Avent & Wertz, 1996). Functional communication was defined by overall quantitative and qualitative ratings from the ASHA FACS (Frattali et al., 1995). The Western Aphasia Battery (WAB) (Kertesz, 1982) was used to determine type and severity of aphasia. Descriptive information for individual participants is provided in Table 1. Descriptive data for participants classified by type of aphasia (fluent and non-fluent) are provided in Table 2; and descriptive data for participants classified by severity are provided in Table 3.
Participation involved one experimental session lasting approximately 1-11/2 hours and two additional observation sessions lasting approximately 1-11/2 hours each. The initial experimental sessions were conducted in the participants' homes and included administration of portions of the Western Aphasia Battery (Kertesz, 1982) necessary to obtain an aphasia quotient (AQ), a fluency classification, an audiometric screening, and an informal 15-20 minute conversation between the participant and principal investigator. Work history and illness were the targeted topics for conversation because they have been found to yield the most complex language (Glosser, Weiner, & Kaplan, 1988). Alternative conversational topics included recent activities, interests, recent life changes, education, and family. Open-ended requests (e.g., "Tell me about your family."), as opposed to yes-no questions, were employed (Terrell & Ripich, 1989). The principal investigator attempted to keep the topics and the form of the conversations similar for all participants; however, the exact content of the conversation depended largely on the participant. All experimental sessions were videotaped for data analysis.
Observational sessions of the participants during everyday activities allowed the principal investigator to observe a representative sample of the individual with aphasias' communicative abilities in typical interactions. Activities observed included attending church, therapy, grocery shopping, and swimming class. The additional observation sessions were necessary to complete the ASHA FACS and were not videotaped.
Pragmatic Performance: Pragmatic aspects of language were analyzed for each participant using the Pragmatic Protocol (Prutting & Kirchner, 1987). This protocol measures 30 pragmatic aspects of language use including verbal (e.g., speech act usage, turn-taking, topic maintenance/initiation), paralinguistic (e.g., prosody, vocal quality/intensity), and nonverbal (e.g., facial expression, eye gaze, gestural usage) parameters. Each of the pragmatic parameters was rated as "appropriate," "inappropriate," or "no opportunity to observe." Appropriate ratings were defined as behaviors that facilitated the communicative interaction. Inappropriate ratings were defined as behaviors that detracted from the communicative interaction and penalized the individual (Prutting & Kirchner, 1987). The percentage of appropriate parameters was then computed and used to determine overall pragmatic appropriateness.
Functional Communication: Functional communication abilities were analyzed using the American Speech-Language-Hearing Association Functional Assessment of Communication Skills for Adults (ASHA FACS) (Frattali et al., 1995). The ASHA FACS, which has undergone extensive research and standardization procedures, measures an individual's ability to receive and convey messages effectively and independently, regardless of the mode of communication, in natural contexts. This assessment evaluates how a deficit (e.g., aphasia) affects one's ability to communicate in daily life activities. Forty-three behaviors are assessed across four domains: Social Communication; Communication of Basic Needs; Reading, Writing, and Number Concepts; and Daily Planning. Within each domain, specific functional behaviors are rated both quantitatively and qualitatively. The 7-point quantitative scale measures functional communication performance along a continuum of independence relating to levels of assistance and/or prompting needed to communicate. The 5-point qualitative scale measures a range of response dimensions (i.e., adequacy, appropriateness, promptness, and communication sharing) that characterize the individual's communication abilities for each assessment domain addressed. The ASHA FACS employs an observation format in which ratings are based on either the clinician's direct observations or observations made by others who are familiar with the individual with aphasia. The observation allows the clinician to make judgments based on interactions that take place in the individual with aphasia's daily life rather than on artificial testing situations set up by the clinician.
A standard multiple linear regression analysis was used to answer the research questions. Unless there is a reason to suppose that experimental variables are related in a nonlinear fashion, it is common practice to use linear regression as a tool to determine whether the variables are statistically related. Linear regression relates a single dependent variable, such as a fluency rating, to one or more independent variables, such as pragmatic performance and functional communication ability. It is assumed that a constant difference in an independent variable is associated with a constant difference in the dependent variable. Therefore, linear regression can indicate which variables are significantly related to one another as well as the relative sizes of the effects. The .05 level of significance was used for all tests. Bonferroni corrections were used to control the experiment-wise error rate in correlation matrices. Normal quantile quantile plots were used to verify that the variables used in correlations and the regression residuals were normally distributed.
Intra- and Inter-judge Agreement
Intra- and inter-judge agreements were determined for both the Pragmatic Protocol and the ASHA FACS. Intra-judge agreement was determined by having the principal investigator re-score the Pragmatic Protocol and the ASHA FACS for five randomly selected participants. The principal investigator viewed the videotapes of the conversation samples and completed a second Pragmatic Protocol without access to the original ratings. Percent agreement between the principal investigator's first and second ratings was 95.5%. The principal investigator completed a second ASHA FACS within two weeks of the original rating. Percent agreement between the principal investigator's first and second ratings was 95.7%.
Inter-judge agreement for the Pragmatic Protocol and the ASHA FACS was determined for 6 of the 27 participants. These 6 participants were selected randomly. The second judge was a graduate student in speech-language pathology with experience working with individuals with aphasia prior to and throughout her graduate training. The second judge trained to criterion for all measures prior to the initiation of the study. She viewed the videotapes of all six samples and completed an independent Pragmatic Protocol for each. Comparisons were then made between these ratings and the original ratings made by the principal investigator. Inter-judge percent agreement for the Pragmatic Protocol was 92.1%. The second judge also observed the six participants during the three scheduled sessions in order to complete the ASHA FACS. Inter-judge percent agreement for the ASHA FACS was 92.4%.
Pragmatics and Functional Communication
The answer to the first research question, "Is there a relationship between pragmatic performance and functional communication?" is yes. The correlations calculated for the regression model were examined. The variables included were the percentage of appropriate pragmatic parameters calculated for the Pragmatic Protocol (Prutting & Kirchner, 1987) and both of the overall ratings (qualitative and quantitative) provided by the ASHA FACS (Frattali et al., 1995). Results are presented in Table 4. A Bonferroni correction was applied to the alpha level and all three correlations were significant at the .05/3=.017 level, indicating a strong relationship (r = .838 to .916) between pragmatics and functional communication, at least as they are defined by the Pragmatic Protocol and ASHA FACS.
To answer the second question, "How well do measures of functional communication and pragmatic performance predict type of aphasia (fluent vs. non-fluent)?", standard linear regression analysis was used to examine the relationship between fluency type, as measured by the fluency subscale of the WAB, the two functional communication ratings, and pragmatic performance. To control for the fact that two regressions were performed (fluency and severity), a .05/2 or .025 level of significance was used. For both models, the influence diagnostics Cook's D and DFBETA were examined and no participants were found to have undue influence on the model. Residuals were examined and found to be normally distributed.
For fluency, the overall model was significant F(3,23)=5.212, p=.007 and explained 40.5% of the variance. However, the partial t-tests for the quantitative and qualitative measures of the ASHA FACS were not significant, indicating that they provided redundant information. This was not surprising since they were highly correlated. Strong correlations between independent variables (i.e., Pragmatic Protocol and ASHA FACS) often indicate multicollinearity. Since the quantitative measure of the ASHA FACS was the least significant, it was dropped from the equation. The resulting model still explained a significant 39.7% of the variance in fluency F (2,24)=7.898, p=.002. Partial t-tests showed a significant result for the Pragmatic Protocol rating, t=3.49, p=.002 and a marginally useful level for the qualitative measure of the ASHA FACS, t=1.89, p=.070. Since dropping the qualitative measure resulted in a drop in variance of 9%, it was left in the model. The final regression equation was fluency=-.276+.158(Pragmatic Protocol)1.819(qualitative) (see Table 5). Thus, the Pragmatic Protocol explained most of the variability in fluency while the ASHA FACS was found to only provide redundant information.
In order to answer the third research question, "How well do measures of functional communication and pragmatic performance predict the severity of aphasia (mild-moderate or moderatesevere)?", the same type of regression was employed--this time examining the relationship between the same independent variables and severity of impairment (as measured by the WAB). The overall model for severity of impairment (WAB AQ) was significant F(3,23)=24.56, p<.001 and explained 76% of the variance in severity. Again, the partial t-tests for the quantitative and qualitative measures failed to reach statistical significance, thus indicating that they provided redundant information. Since the quantitative measure of the ASHA FACS was the least significant, it was dropped from the equation first. In the resulting model, the qualitative measure of the ASHA FACS was still not significant so it too was dropped from the equation. The final regression equation contained only the Pragmatic Protocol and explained a significant 75% of the variance in severity, F (1,25)=73.39, p<.001. The equation itself was Severity (WAB) =-42.86+1.25(Pragmatic Protocol) (see Table 6). Thus, the Pragmatic Protocol explained most of the variability in severity while the ASHA FACS was found to only provide redundant information.
The purpose of the present study was to investigate the relationship between pragmatic performance and functional communication. To do this with any relevance, this study also had to examine how well measures of pragmatic performance and functional communication ability predict the type (fluent or non-fluent) and severity of aphasia.
Pragmatic performance, as measured by the Pragmatic Protocol (Prutting & Kirchner, 1987), was found to have a strong, positive correlation with functional communication, as measured by the ASHA FACS (Frattali et al., 1995). The most obvious common denominator between pragmatic performance and functional communication, based on our results, appears to be severity of oral expressive language. In most instances, the higher the WAB aphasia quotient (i.e., severity of language impairment), the better the pragmatic performance and functional communication ratings. This is consistent with strong correlations. Other investigations have also reported that communicative performance (i.e., Pragmatic Protocol, ASHA FACS) correlates well with traditional language measures (Avent et al., 1998; Frattali et al., 1995; Irwin et al., 2002),). And while some investigations (Goldblum, 1985; Guilford & O'Connor, 1982; Penn, 1988) have demonstrated preserved pragmatic abilities with little correlation between traditional language measures and communicative performance, interpretation of pragmatic performance independent of oral-expressive language in this sample would be difficult. The number of pragmatic problems was clearly more abundant in the moderate-severe group than in the mild-moderate group. Moreover, the majority of the pragmatic problems recorded related to behaviors classified as "verbal aspects" in the Pragmatic Protocol.
Severity of impairment was found to be a stronger indicator of both pragmatic performance and functional communication than type of aphasia (fluent or non-fluent) in this study. However, severity of impairment within our sample could be a factor in that result, as well. Avent and Wertz (1996) reported that adults with fluent aphasia in their sample demonstrated a slightly higher level of pragmatic appropriateness than did adults with non-fluent aphasia. Although the differences in participants with fluent and non-fluent aphasia were minimal and no differences were observed between more specific types of aphasia, it is interesting to compare their observations to those of Holland (1980, 1982), who reported that adults with non-fluent aphasia demonstrated the most "normal" pattern of communication and were believed to be the most functionally communicative. Results from the current investigation revealed significant differences between fluent and non-fluent groups for pragmatic performance; but the fluent group, as a whole, was less severely impaired than the non-fluent group. Examining individual performance, differences were minimal in the number and type of inappropriate pragmatic behaviors displayed between the fluent and non-fluent subjects within each severity level.
Does this mean that pragmatic performance and functional communication are synonymous (Davis, 1993) and that any differences are based entirely on severity of aphasia? No. Our results demonstrate that pragmatic performance is very predictive of severity of aphasia and type of aphasia. Functional communication, however--at least as it is defined by the ASHA FACS--did not contribute to or explain any of the variability in type or severity of aphasia. Thus, despite its strong correlation with pragmatic performance, differences must exist in what measures of functional communication actually assess. This supports the findings of Irvin, Wertz, and Avent (2002) that assessments of pragmatic performance and functional communication measure different underlying constructs. They observed more variances in the two measures over time than in initial assessments of individuals with aphasia.
While one may on the surface see that correlations exist (albeit some stronger than others) between linguistic severity, pragmatics, and functional communication, examining differences between participants on a more individual level can provide, perhaps, a more pragmatic endpoint. Traditional language testing (e.g., WAB) did not capture all of the communicative competencies observed. For the most part, participants with better linguistic skills performed better pragmatically. However, in participants with similar linguistic ability or severity of impairment (i.e., similar WAB aphasia quotient), variances in pragmatic performance appeared to correlate better with variances in functional communication. For example, Participants #1 and #24 presented with similar aphasia quotients (45.3 and 45 respectively). However, participant #1 received a rating of pragmatically appropriate behaviors that was 23 percentage points higher on the Pragmatic Protocol, and he received much higher ratings on the quantitative and qualitative portions of the ASHA FACS. His superior ability to convey intentions and attitudes may influence his communicative effectiveness and independence in the absence of superior linguistic competence. This is what Holland (1977) meant when she stated that "aphasics probably communicate better than they talk" (p. 173). Thus, evaluation with the WAB alone would provide a much worse prognosis for that individual than would be provided by an assessment of pragmatic performance and functional communication.
Other participants with moderate to severe impairments also performed much better than expected based on their linguistic deficits. Although no single factor was significant for producing variability, different factors could produce changes in communicative competence for different individuals without showing statistical significance. For example, although time-post onset was not significantly correlated with pragmatic performance or functional communication, it is important to note that Participant #1 was approximately eight years and five months further post-onset than Participant #24. Thus, individuals with aphasia may continue to show improvement in pragmatic abilities and acquire strategies necessary for successful functional communication despite relatively little improvement in linguistic skills over time. This is consistent with the results of Avent et al. (1998), who also reported that even though there is a relationship between language impairment and pragmatic behavior, improvement in pragmatic performance is not necessarily related to improvement in language ability. Further research is necessary to examine the influence of time-post onset on linguistic competence, pragmatic performance, and functional communication.
The close alignment of pragmatics and functional communication in the absence of linguistic competence could also be influenced by several other factors including: a) age, b) communicative environment, and c) ability to read and write. For example, Participant #13 presented with an aphasia quotient that was clinically similar to Participant #20, but performed much worse on the Pragmatic Protocol and the ASHA FACS. Upon further examination of the data, several potential factors were identified that could enhance Participant #20's communication abilities. First, Participant #20 was 22 years younger than Participant #13. Although no significant correlations were found between age and the measures employed, age has been previously identified as a variable affecting prognosis (Davis, 1993). Secondly, Participant #13 was essentially confined to bed due to physical limitations, whereas Participant #20 was able to drive a car (with modifications) and do some light shopping on her own. Thus, Participant #20 had the opportunity to engage in a variety of communicative interactions, whereas Participant #13's communicative environment was limited to two aides that stayed with her in her home. Finally, Participant #20's reading and writing skills were far superior to Participant #13's, allowing her to use a communication notebook independently.
While functional communication and pragmatic performance correlate in many patients despite linguistic severity, there are also patients in whom none of the measures seem to align. Some researchers have stressed the importance of situational context (the physical environment, communication partners, sociolinguistic considerations, etc.) (Ferguson, 1994; Holland, 1991; Lyon, 1992) and it does appear to be relevant to the previous example. However, for other participants in this study (#16 and #18), good environments for promoting communication (i.e., strong family support, ongoing language therapy, opportunities for varied communicative experiences) were not sufficient to overcome severe linguistic deficits. In these participants pragmatic performance was much better than linguistic skill, but their functional communication remained severely limited; thus, the need for "evaluation in natural contexts" (Ferguson, 1994; Holland, 1982) and using measures such as the Pragmatic Protocol and the ASHA FACS to assess quality of communication, as well as traditional measures of linguistic severity.
While this investigation focused on assessment of pragmatic performance and functional communication, implications for treatment should be considered. While pragmatics appears to have a relationship to functional communication, much of the relationship is tied to linguistic competence, especially when time post-onset is relatively short. Thus, early on, evaluating patients with traditional language measures, such as the WAB or the BDAE may be most appropriate. Such examinations provide information on linguistic severity and, especially with the BDAE, provide information on where to initiate treatment of auditory comprehension and verbal expression. Improving linguistic competence during the period of spontaneous recovery may be most beneficial, since pragmatics and functional communication are both related to linguistic competence and may continue to emerge.
After spontaneous recovery has slowed and individuals are unable to make substantive gains in linguistic competence, improvements may still be made in treatment by targeting "functional communication," or communication in natural contexts. Gains may be more likely when training someone to specifically function within their own communicative environment, a task which may be too difficult to undertake in the constraints of acute care or rehab. But teaching strategies to establish communicative intent and to "get the point across" in the context of daily activities may move a patient's skills beyond the limitations of linguistic competency. While many "pragmatic" behaviors are tied to verbal or linguistic competence, working in the realm of the more non-verbal areas of pragmatics (i.e., eye contact, turn taking, body language) may be very functional in getting across one's message.
Though common sense may suggest that pragmatic performance and functional communication are related to each other and to linguistic competence, different assessments are designed and marketed to test each separately. This investigation examined these relationships and the results provide empirical support for the different types of assessment. Based on the current data, it appears that linguistic competence is an underlying factor influencing the relationship between pragmatic performance and functional communication. Communication includes both linguistic competence and pragmatic competence, and, in most cases, linguistic competence appears to be inseparable from the ability to communicate functionally and in a pragmatically appropriate way. Despite the strong relationship among these communicative parameters, tests designed to examine severity of linguistic impairment (i.e., WAB), while valuable, provide an incomplete description of the individual with aphasia's communication ability. Observations made in natural communicative environments were important for identifying communicative strengths. This is evidenced by a number of participants whose pragmatic performance and functional communication abilities were different despite having similar WAB aphasia quotients, especially those who were further post-onset and had different opportunities for communication.
Continued research is needed to determine how specific aspects of pragmatic behavior influence specific domains of functional communication. Further investigation is also needed to determine whether tools such as the Pragmatic Protocol and the ASHA FACS are more sensitive to changes over time in communication skills than traditional standardized measures (e.g., WAB). Avent and Wertz (1996) reported that pragmatic performance does improve. Functional communication measures such as the ASHA FACS can do more than measure impairment and function. They can provide the clinician with a view of aphasia from the patient's perspective, a means of appreciating the person's daily struggle in adapting to a new life that has been imposed upon them. They can be used to assist in developing meaningful goals, assessing the outcomes of rehabilitation, and in documenting multidimensional benefits of therapy. It is yet to be determined if individuals with aphasia can be taught to utilize preserved pragmatic performance to improve functional communication or whether time and/or environment may, alone, be the true therapists.
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Author contact information:
Gary H. McCullough, Ph.D.
Department of Speech-Language Pathology
University of Central Arkansas
201 Donaghey Avenue
Conway, AR 72035-0001
Phone: (501) 852-7886
Email : firstname.lastname@example.org
Jacki L. Ruark
Department of Speech-Language Pathology
University of Central Arkansas
201 Donaghey Avenue
Conway, AR 72035-0001
Phone: (501) 450-3310
Email : JackiR@uca.edu
Jacqueline Rainey, Dr. PH
College of Health and Behavioral Sciences
University of Central Arkansas
Doyne Health Science Center 104
Conway, AR 72035-0001
Phone: (501) 450-5509
Table 1 Descriptive Data for Individual Participants Subject Gender Age Education 1 M 76 16 2 F 65 16 3 M 60 16 4 F 78 12 5 M 46 12 6 M 69 14 7 F 39 13 8 F 38 12 9 M 76 12 10 M 54 12 11 F 70 15 12 F 79 12 13 F 79 12 14 M 66 8 15 F 65 6 16 M 68 16 17 F 83 18 18 M 64 9 19 F 70 12 20 F 57 18 21 M 77 14 22 M 65 12 23 F 74 13 24 M 60 9 25 M 70 11 26 F 56 16 27 M 48 12 Subject MPO AQ Fluency 1 114.0 45.3 NF 2 202.0 73.4 NF 3 3.0 82.4 F 4 2.0 64.6 F 5 59.0 68.5 F 6 7.0 88.5 F 7 131.0 88.9 F 8 120.0 67.7 NF 9 6.0 78.7 F 10 108.0 15.3 NF 11 91.0 57.6 NF 12 3.0 35.6 F 13 15.0 27.4 NF 14 8.0 16.6 F 15 10.0 12.4 NF 16 60.0 7.7 NF 17 24.0 58.9 F 18 9.0 10.4 NF 19 2.0 20.3 NF 20 87.0 20.6 NF 21 7.0 89.3 F 22 23.0 72.9 F 23 72.0 39.4 F 24 7.0 45 F 25 2.0 81.1 F 26 26.0 61.4 NF 27 4.0 69.0 NF Subject PP CIDS CQDS 1 68.96 4.28 3.13 2 93.00 6.70 4.38 3 93.00 6.49 4.56 4 80.00 3.98 2.50 5 86.00 5.73 3.80 6 100.00 6.27 4.56 7 96.00 6.60 4.56 8 86.00 5.78 3.98 9 89.00 6.21 4.40 10 55.60 4.88 4.06 11 82.80 6.54 4.44 12 68.90 3.37 2.38 13 41.38 2.97 2.94 14 41.38 2.67 1.73 15 48.20 2.98 2.63 16 48.27 2.70 2.56 17 86.20 5.21 3.88 18 51.70 2.55 2.13 19 69.00 3.82 3.06 20 75.70 5.92 3.44 21 100.00 6.91 4.88 22 86.20 5.85 4.00 23 89.65 5.64 3.69 24 45.00 2.90 2.40 25 93.00 6.56 4.50 26 79.30 5.10 3.69 27 86.00 6.10 4.33 Age and Education are reported in years. MPO = months post onset AQ = aphasia quotient (based on administration of the Western Aphasia Battery F = fluent aphasia, NF = non-fluent aphasia PP = pragmatic protocol CIDS = quantitative score of ASHA FACS QDSC = qualitative score of ASHA FACS Table 2. Descriptive Data for participants classified by type of aphasia Variable Fluent Aphasia Non-Fluent (N=14) Aphasia (N=13) Age (years) Mean 67.5 62.3 Standard deviation 12.7 11.43 Range 39.0 to 83.0 38.0 to 79.0 MPO (months) Mean 25.4 65.3 Standard deviation 37.4 61.3 Range 2.5 to 131.1 2.5 to 202.0 WAB AQ Mean 64.64 37.57 Standard deviation 22.51 25.26 Range 16.6 to 89.3 7.7 to 73.4 MPO = months post onset WBA AQ = Aphasia quotient based on the Western Aphasia Battery Table 3. Descriptive Data for participants classified by severity of impairment Variable Fluent Aphasia (N=14) Non-Fluent Aphasia (N=13) Age (years) Mean 62.8 67.5 Standard deviation 14.5 8.2 Range 38 ti 83 54 to 79 MPO (months) Mean 47.2 41.3 Standard deviation 61.3 43.8 Range 2.5 to 202 2.5 to 114 WAB AQ Mean 73.5 24.2 Standard deviation 10.8 13.2 Range 57.6 to 89.3 7.70 to 45.3 MPO = months post onset WBA AQ = Aphasia quotient based on the Western Aphasia Battery Table 4. Correlation results for Pragmatic Protocol and ASHA FACS PP CIDS QDSC PP Pearson Correlation 1.000 .916 .838 Sig. (2-tailed) <.001 <.001 N 27 27 27 CIDS Pearson Correlation 0.916 1 0.948 Sig. (2-tailed) <.001 * <.001 N 27 27 27 QDSC Pearson Correlation 0.838 0.948 1.000 Sig. (2-tailed) <.001 <.001 * N 27 27 27 PP = Pragmatic Protocol CIDS = Quantitative score of ASHA FACS QDSC = Qualitative score of ASHA FACS Correlations are significant at the 0.017 level (2-tailed) Table 5. Summary of multiple linear regression analysis for variables predicting fluency. Variables V SE B [beta] Pragmatic Protocol 0.158 0.045 1.016 QDSC -1.819 0.96 -0.551 N=27 [R.sup.2]= .397 QDSC = Qualitative score of ASHA FACS Table 6. Summary of multiple linear regression analysis for variables predicting severity Variables B SE B [beta] Pragmatic Protocol 1.249 0.146 0.864 N = 27 [R.sup.2] = .746
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|Author:||McCullough, Kimberly C.; McCullough, Gary H.; Ruark, Jacki L.; Rainey, Jacqueline|
|Publication:||The Journal of Speech-Language Pathology and Applied Behavior Analysis|
|Date:||Jun 22, 2006|
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