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Operant conditioning and programmed instruction in aphasia rehabilitation.

Abstract

Behavior theory has fallen from favor as a foundation for aphasia rehabilitation. Once a robust basis for experimental and clinical examination of communication disorders in adults, behavior modification has been largely absent in the literature of the past 25 years. This paper advocates a return to the application of a behavioral framework for the treatment of aphasia, with particular attention to the principles of reinforcement, and punishment, including overcorrection. It also advocates a return to such programs of instruction as melodic intonation therapy and to the application of contemporary alternate augmentative communication systems (AAC). The language of sets provides an overall framework for approaching aphasia therapy.

Key Words: Programmed instruction, aphasia, rehabilitation, behavioral speech interventions

Introduction

Behavior theory presents a set of principles by which a person's performance can be observed, analyzed and modified to support the development of socially valued adaptive skills. These principles are rules or laws which describe behavior and its relationship to environmental consequences and motivating stimuli. It is important for speech-language pathologists (SLPs) to understand behavioral principles, because clinical treatment involves the modification of communicative behavior. When clinical treatment is effective, there is behavioral change.

Principles of behavior modification have been described as they relate to aphasia rehabilitation (Brookshire, 1969; Goldfarb, 1981; Holland, 1970; Holland & Harris, 1968). These principles refer to a Skinnerian or operant model, not a Pavlovian or reflexive model. Systematic reinforcement of operant behaviors can lead to new responses that expand a person's interactive repertoires communicatively, socially, and verbally. New reflexes cannot be learned, but operant procedures can be used to inhibit or shape infantile oral reflexes, such as suckling and biting, which may be exhibited following brain damage in adults.

While there was a flurry of activity in operant-based aphasia research more than 25 years ago (Albert, Sparks, & Helm, 1973; Brookshire, 1968; Goldfarb & Scharf, 1980; Keenan, 1966; Keith & Darley, 1967; Rosenberg & Edwards, 1965; Sarno, Silverman, & Sands, 1970; Tikofsky & Reynolds, 1962; 1963), there has been much less recent interest. One recent non-language study (Goldenberg, Hodges, Hershe, & Jinich, 1980) reported efficacy of operant conditioning in reducing fecal incontinence in 12 patients (ages 12-78 years) with medical and surgical conditions using biofeedback. An auditory language comprehension program for persons with severe aphasia (Bastiaanse, Nijboer, & Taconis, 1993) was applied in a case study involving a participant who learned to discriminate a target word from one, two, and then three distracters. Two other studies used filmed or videotaped programmed instruction to examine reading recognition and comprehension (Di Carlo, 1980) and comprehension of indirect requests such as "can" and "should" (Levey & Goldfarb, 2003) with participants who had aphasia. However, the generalizability of recent studies is limited due to the small number of subjects and low statistical power.

Consequences of Ignoring Behavioral Principles

SLPs with a limited understanding of applied behavior analysis (ABA) are at risk for attempting to modify maladaptive communicative behavior ineffectively. Consider the following vignette: Several adults with aphasia are seated in a small group during a speech-language therapy session. One of the adult clients points to the door and says, "Go, go." When this request is ignored by the SLP, the client repeats the gesture and the utterance with greater intensity. Without turning to the client, the SLP says, "Just a minute, I'm helping John now." The client then unlocks his wheelchair and rolls back and forth, ramming the chairs of other group members.

This continues until the SLP turns to the client, saying, "All right, I'm coming!" This vignette illustrates important limitations in the application of the principles of reinforcement. Specifically, the client demonstrates several forms of verbal and non-verbal behavior with the potential to gain social attention (e.g., pointing, vocalizing, chair-ramming). However, the SLP responds to the one form (chair- ramming) that is the least adaptive from a social-communicative perspective. Moreover, the SLP ignores (at least twice) two conventional forms (pointing, vocalizing) with the highest level of social acceptability. If the goal is to gain the SLP's attention, then the client learns two lessons from the interaction: (1) conventional social signals are not reinforced in this context, and (2) antisocial behavior (chair-ramming) leads to reinforcement. Under these conditions, we can expect an increase in the frequency of maladaptive behavior for communication purposes.

Another context in whic h limited knowledge of behavioral principles can lead to inappropriate practices involves the use of punishment. In an alternative version of the above vignette, the SLP may have considered chair-ramming to be an inappropriate behavior and may have chosen to consequate this behavior with some form of punishment. If so, two problems could have resulted. First, research indicates that punishment alone has only a temporary effect (at best) on reducing the frequency of an inappropriate behavior (Goldfarb, 1981; Rosenberg & Edwards, 1965). In fact, a more likely explanation for its frequent use is that a clinician may be reinforced by an immediate change in a client's behavior. Secondly, if the SLP chose a punishment without first conducting a functional assessment of the maladaptive behavior, the consequence believed to be punishing may actually have been reinforcing. For example, in the absence of a functional assessment, the SLP might have decided to "punish" the client's chair-ramming behavior by using "time out" (i.e., removing the client from the room). However, if chair-ramming was motivated by the client's desire to "go" (i.e., to leave the group), then being removed from the room would actually have functioned as reinforcement rather than as punishment. Under these circumstances, an increase in chair-ramming could be expected. While an understanding of behavioral principles does not, alone, insure errorless clinical management, a failure to appreciate these basic principles can lead to counterproductive results. The above examples, illustrating ineffective use of reinforcement and punishment, are not atypical in situations where information about behavioral principles is not available to the clinician.

Operant Conditioning: Overcorrection

A contingency classified as punishment which may be useful with adults who have aphasia (Goldfarb, 1982) is overcorrection (Azrin & Foxx, 1971; Foxx & Azrin, 1972; 1973). This process is based on the assumptions that undesired behavior can be reduced or eliminated by requiring a person to (1) correct the environmental consequences of an inappropriate act (restitution) and to (2) practice overly correct forms of an appropriate related behavior (positive practice) (Foxx & Azrin,, 1972). The overcorrection procedure must be directly related to the undesired behavior or it may become arbitrary or punitive. It is also necessary that overcorrection be instituted immediately after the undesired behavior has occurred, thereby preventing its reinforcement. The overcorrection procedure should also be lengthy, preventing the client from engaging in other activities which may be reinforcing. Therefore, overcorrection may be considered a time-out period.

Azrin and Foxx (1971) successfully reduced incontinence in nine profoundly developmentally delayed adults by 90%, employing an intensive training program which included an overcorrection procedure. Whenever incontinence occurred, the patient was required to clean all traces of accidents, wash the soiled clothing, shower, and obtain fresh clothing.

Several procedures have been used in an attempt to eliminate self-stimulatory behavior in persons with developmental delay (DD) and autism spectrum disorders (ASD), but none has been successful in eliminating the behavior totally (Lovaas, Schaeffer, & Simmons, 1965; Mulhern & Baumeister, 1969). Foxx and Azrin (1973) compared overcorrection with 4 other procedures for eliminating the behavior of hand-mouthing. The other procedures included (1) physical punishment by a slap, (2) positive reinforcement for non-self-stimulatory behavior, (3) a distasteful solution painted on the hand, and (4) free reinforcement. Overcorrection was found to be the most effective method, reducing the frequency of hand-mouthing from over 100 per hour to zero per hour. A verbal warning was paired with the overcorrection procedure. When overcorrection was eliminated, the verbal warning alone was sufficient to maintain the desired behavior.

Overcorrection procedures have been used to reduce or eliminate stealing by institutionalized adults with developmental delay (Azrin & Wesolowski, 1974) and to reduce or eliminate drooling and tongue thrusting by children with language-impairment (Goldfarb & Guglielmo, 1977). Similar procedures have been used to increase eye contact by children with ASD and children with DD (Foxx, 1977). Generalization of overcorrection procedures has also been studied (Epstein, Doke, Salwaj, Sorrell, & Rimmer, 1974; Rusch, Close, Hops, & Agosta, 1976).

Clinical aphasiologists routinely observe client behaviors which may be reduced by overcorrection. Some of these behaviors involve speech. For example, swearing, or the use of deistic or taboo words and phrases is common in aphasia following stroke and left hemispherectomy (Van Lancker & Cummings, 1999). Also common are stereotypies, such as saying "I come over there" in response to any question or using the phrase, "I don't know" in the presence of word retrieval difficulty. Inappropriate responses are also observed while people with aphasia are reading. Specifically, visual half-field neglect (i.e., failure to read words on the right side of the page) often accompany right homonymous hemianopia. Further, inappropriate responses can be observed when people with aphasia are writing. Problems may occur in size, shape, and spacing of letters produced in non-dominant left-handed writing. Additionally, visual half-field neglect also occurs in writing. Finally, maladaptive behaviors may be produced secondary to emotional incontinence. For example, people with aphasia may wipe their eyes and nose on their sleeve. They may drool. They may experience dysphagia. They may demonstrate incomplete or inadequate grooming, toileting, or other self-care.

Positive practice extends time out from reinforcement, which is part of overcorrection. It may be used effectively in modifying an individual's requests for action or information. Impairments in naming and word finding are characteristic of virtually all types of aphasia. This symptom is called "anomia" and it should not be confused with the syndrome of anomic aphasia. It is characterized by the use of generic terms (e.g., "The thing with the stuff over there.") in place of substantive words (e.g., "the flower pot"). There are also phonemic paraphasias, where the word or phrase produced is similar in sound to the target (e.g., "corned beef and garbage"), and semantic paraphasias, where the word or phrase is similar in meaning to the target (e.g., using "driving range" to mean "parking lot"). A therapy goal for individuals with these problems may be to reduce the use of generic terms or paraphasias. Positive practice may require the individual with aphasia (IWA) to identify semantic features of form and function for the target word or phrase before the communication partner (CP) complies with the request. Consider the following exchange:

IWA: Paperskate.

CP: What do you do with it?

IWA: Write your name.

CP: What does it look like?

IWA: Ink. Pencil--pen.

CP: Here you are.

The positive practice repertoire may also include gesture and pantomime to reduce use of generic terms and paraphasias.

Programmed Instruction: Melodic Intonation Therapy

Evidence used to support the efficacy of treatment programs can be classified at three levels (U.S. Department of Health and Human Services, 1995). The first level of evidence (Level A) consists of the results of at least two randomized clinical trials (RCT), with good internal and external validity. The second level (Level B) involves evidence similar to Level A, but includes only a single RCT, or RCTs that only indirectly address the question of interest, or two or more non-randomized clinical trials. The third level (Level C), consists of data generated by a single non-RCT, by studies using historical controls, or by quasi-experimental controls such as pre- and post-treatment comparisons. It may also involve expert opinion in the form of a strong consensus (90% or more expert reviewers agree) or as simple consensus (75-89% of expert reviewers agree).

According to the U. S. Department of Health and Human Services (1995), the best evidence level of support for any aphasia therapy is Research Evidence Level C, with expert opinion = consensus. Included among these therapies are traditional stimulus-response modality-specific treatments and drills. Examples include (1) the Language Oriented Treatment (Shewan & Bandur, 1982) protocol, where the language behavior of individuals with non-fluent or Broca's aphasia is cued with the initial phoneme of the target word; (2) direct stimulus-response treatment (Wertz, Collins, Weiss, et al., 1981; Wertz, Weiss, Aten, et al., 1986), where individuals with aphasia are asked to complete a highly associative open-ended sentence about activities of daily living (e.g., "You wash your hands with soap and --"); and (3) Melodic Intonation Therapy (MIT) (Albert, Sparks, & Helm, 1973). MIT rests on Level C evidence (pre- and post-treatment comparisons) with simple consensus (75-89% of expert reviewers agree). Further research involving randomized clinical trials might improve the level of evidence supporting this treatment. Behavioral strategies lend themselves to evaluation at higher levels of evidence because of the data collection and the pre-/post-training evaluations that are necessary aspects of clinical procedures. They are also reinforcing for clinicians, who can examine schedules of reinforcement, criterion levels, and response data to determine whether or not treatment is effective. As a shaping and fading procedure, MIT qualifies as a behavioral approach.

Melodic Intonation Therapy (MIT) can increase the expressive abilities of some aphasic patients for whom other clinical approaches have failed (Sparks & Holland, 1976), particularly those with moderate non-fluent (Broca's) aphasia, whose level of language comprehension exceeds their level of language production. It is a programmed approach, originally designed with two levels of increasing difficulty, each level consisting of several steps (Albert, et al., 1973.) Short phrases or sentences are embedded in simple melody patterns that are not recognized as songs. As patients progress through the program the melodic aspect is faded. First, the target utterance is intoned, so that "I am hungry," a four-syllable phrase with emphasis on the third syllable (/h??/), is sung in musical notes as low, low, high, low. Next, the patient is instructed to employ speech-song or sprechgesang, similar to the "hammy" delivery of a bad Shakespearean actor, so that "I am hungry," while not sung, will have longer vowel durations, greater amplitude displacements, and more pitch variation than normal speech. Finally, the phrase is trained, in several steps, to be produced with normal speech prosody. The technique was based on common observation of the ability of aphasic patients to sing the lyrics of well-known songs learned premorbidly.

Following extended clinical trials, MIT was expanded to include three levels of increasing difficulty (Sparks & Holland, 1976). This three-level treatment was designed to be administered intensively, with daily therapy in individual and group settings for at least three months. Goldfarb and Bader (1979) proposed that MIT might also be successful when used as a combined clinic and home training program.

In Level I, all sentences are intoned. The clinician holds the patient's left hand, presumably recruiting the prosodic abilities in the unimpaired right hemisphere of the patient's brain, and provides assisted hand-tapping to accompany each production of a target utterance. Level II introduces a series of back-ups for the five steps learned in Level I, as well as instituting 6-second delays between stimulus and response at Steps 4 and 5. In Level III, melodic intonation is gradually faded through sprechgesang to normal speech prosody, while hand-tapping is discontinued. As in Level II, the back-up and delay strategies apply.

The Language of Sets" A Model for Treatment

In mathematics, the intersection of two sets consists of the elements the sets have in common. Santo Pietro and Goldfarb (1995) used this concept to help plan treatment for adults with aphasia. The concept may be applied in both general and specific ways. As a specific example, assume that Patient A and the patient's Clinician B are asked, independently, to list five goals of language rehabilitation most important for Patient A. Patient A identifies these goals as improving the ability to: (1) recite hymns and prayers in church; (2) state bids while playing bridge games; (3) retrieve names and relationships of family members; (4) verbalize activities of daily living; and (5) speak and understand conversational speech on the telephone. Clinician B identifies appropriate goals as improving the ability to: (3) retrieve names and relationships of family members; (4) verbalize activities of daily living; (5) speak and understand conversational speech on the telephone; (6) read and understand the newspaper; and (7) write legibly with the left hand. Clinician B can make more appropriate choices by examining these two sets of goals arithmetically. As presented above, Set A = {1,2,3,4,5} and Set B = {3,4,5,6,7}. The intersection of these two sets of goals is {3,4,5} or Set C. Expressed in words, the intersection of Set A and Set B is Set C. The symbol for intersection is n , read "cap." In symbols, A n B = C, or {1,2,3,4,5} n {3,4,5,6,7} = {3,4,5}. These three goals, {3,4,5} might be expected to elicit maximum motivation and cooperation between Patient A and Clinician B.

As a general concept, aphasia treatments (Santo Pietro & Goldfarb, 1995) may be grouped according to the intersections in the Venn diagram illustrated in Figure 1, below:

[FIGURE 1 OMITTED]

The diagram represents a person with language impairment (P) communicating with a communication partner (CP) within an environment (E). None of the component sets should be treated independently of the others. The clinician who treats to deficit, or chooses to rebuild skills lost as a result of the neurological impairment, notes that the set representing impairment {I} is contained completely within the set of the patient {P}, who is contained completely within an environment ({E}. The set {I} also intersects the communication {C} between the patient {P} and the communication partner {CP} as well as the communication partner him/herself. Rebuilding language skills will affect the patient, the patient's communication partner, the communication between them, and their shared environment. Similarly, {P}, {CP}, {C}, and {E} will have a direct effect on the level of impairment {I} as a function of treatment. Aphasia rehabilitation should not be confined to the circle representing {I}; it must address all the other intersections in the diagram. For example, it should treat to strength or that section of {C} which is unimpaired; repair communicative acts between patients and their communication partners; educate and support the partners; repair the communication-impaired environment to provide opportunities for communication; and treat the whole person to reduce psychosocial handicap.

Goals based on the model of sets described above are best realized using operant conditioning and programmed instruction techniques. In programmed instruction there is a built-in system of individualized training. Small training steps permit individuals to move from one clinical task to another at different rates. The clinician programs treatment so that communicative responsibility is increasingly assigned to the client (Bollinger & Stout, 1976; Stocker & Goldfarb, 1995).

New Directions: Alternative-Augmentative Communication

Members of our research group (Lavi, Goldfarb, & Arroyo, 2005) are currently engaged in an intensive study of a case of possible in-utero CVA. The child, a female now age 4, presents with problems similar to some observed in adults who have suffered CVA. For example, the child's stroke affected auditory comprehension areas of the brain, leading to an early misdiagnosis of deafness. She does show evidence of hearing loss, but the problem seems to be more central than peripheral. Similarly, both auditory comprehension deficits and hearing loss co-exist in many older adults with thromboembolic strokes.

Operant audiometry continues to be the focus of research in testing hearing of young children through localization (Primus, 1987) and visual reinforcement strategies (Thompson, et al., 1989). Speech-language pathologists and audiologists need to interact to facilitate conditioning of the aphasic patient for a complete audiological evaluation, as well as to determine which aspects of the disorder respond to amplification or language intervention. The child in our study did not have vocal language, but had been trained to use some American Sign Language symbols. Her frustration with limited communicative ability was evidenced by frequent tantrums. Giving her a communicative strategy through a Picture Exchange Communication System (PECS) (Bondy & Frost, 1998; Charlop-Christy, et al., 2002) permitted non-vocal language production. She progressed to learning alternative-augmentative communication (AAC) with DynaMyte (DynaVox Systems, Inc., Pittsburgh, PA, U.S.A.), a portable ele ctronic communication device. (Note that the product name has changed to Dyna-Mo, as sales representatives were not allowed to board airplanes carrying DynaMyte.)

The current focus of therapy is to use AAC to facilitate development of vocal language. There are many new communication board sets and such communication software as Boardmaker (Assistive Technology, Inc., Dedham, MA, U.S.A.), which are useful to supplement and substitute for vocal language efforts of aphasic adults. They are telephone- and modem-ready, using Windows XP Home Edition as an operating system. Recent research suggests efficacy of AAC devices, such as the word-based TalksBac system for adults with non-fluent aphasia (Waller, et al., 1998) and using aided and unaided AAC for adults with severe aphasia (Jacobs, et al., 2004). Ideally, AAC devices will be employed by clinicians well versed in theories and applications of operant conditioning and programmed instruction principles.

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