Promoting Aphasics Communicative Effectiveness

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Promoting Aphasics Communicative Effectiveness

• By
• Khalila Ali
• Bethany Bucci
• Lindsay Friedman

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History of PACE

• Introduced by Wilcox and Davis
• At the ASHA convention in 1978
• Published procedure in 1981
• Way to reshape structured interactions between
  clinicians and clients into a more natural
  conversation form
• Believe that it is useful for all severities and
  types of aphasia

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Four Basic Principles

• 1. The clinician and the client participate
  equally as the sender and the receiver of
  information.
• 2. The interaction consists of an exchange of new
  information only.
• 3. The client is allowed to choose the
  communicative mode.
• 4. Feedback from the clinician is based on
  successful exchange of information and is
  characteristic of feedback from a natural
  environment.

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Equal Participation

• Accomplishes three important goals
• Gives client experience with topic and turn
  initiation as sender and receiver
• Allows the clinician to model as sender and
  receiver and model appropriate communicative
  channels
• Gives client experience with sustaining an
  interaction with several turns on the same topic

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The Aphasic Clientas Initiator

• Must develop an appropriate message
• Must consider context
• What is new information vs. what is already known
• Gain attention of listener
• Self-monitor and reformulate if a lack of
  understanding is relayed from listener

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The Aphasic Client as Respondent

• Decode the message (receptive)
• Evaluate comprehension of message
• Provide feedback to initiator (expressive)
• Response (I understand)
• Request for clarification (Im not sure what you
  mean)

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The Clinicianas Model

• Clinician may modify the clients behavior
• Enhance desired and diminish undesired
  communication techniques
• Clinician uses communication strategies that are
  desirable for the aphasic client to use when it
  is his/her turn
• Clinicians receiving/sending behavior has impact
  on the clients receiving/sending behavior

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The Aphasic ClientSustaining a Topic

• Turn taking within one topic
• May involve several mini-turns as sender and
  receiver
• Requires receptive and expressive behaviors
• Clinician still has ability to serve as model

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Example of Mini-Turn Sequence

• Client A womanpaper.
• Clinician A woman with the paper? contingent
  query, use of definite article to signal given
  information
• Client No, shes...(makes a writing gesture).
  Pronominalization, repair
• Clinician Oh, shes writing?
  pronominalization, contingent query
• Client Yes. confirmation
• Clinician Shes writing. confirmation

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New Information Exchanges

• The Model of a Pyramid of Information
• Base is shared knowledge
• Each level provides new information
• Opinions, feeling, informative statements
• Attempt is made to keep the information unknown
  to the receiver
• The initiator hides the card
• Large number of stimuli used
• Stimuli changed frequently
• Third party may choose the stimuli (friend,
  family)

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Free Choice of Communicative Channels

• Any available means to communicate by
• Speaking, Writing, Gesturing, Pointing, Drawing
• Combinations may be more effective
• Focuses more on effective message transmission
  vs. linguistic perfection
• Often, clients find existing abilities that help
  convey information as well as new abilities

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Free Choice of Communicative Channels

• Clinician should remember
• Not to directly instruct the client to use a
  certain channel
• Make available materials that may be necessary
  (pencils, paper, word lists, cards etc.)
• Always serving as a model to the client
• Model the channel you want the client to use
• Patients are more likely to continue to use
  strategies they developed themselves over
  strategies a clinician instructed them to use

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Feedback Based on Communicative Adequacy

• When clinician is serving as receiver, she
  provides feedback similar to those that occur in
  natural conversations
• Considered to have communicated successfully if
  the clinician comprehends the message (via any
  means)

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Davis and Wilcox Recommendations

• Clinician should provide guesses when the client
  sends an ambiguous message
• This helps direct the clients repair
• Clinician should respond using the same channel
  the client used to send the message
• Client is given opportunity to evaluate
  effectiveness of channel
• Clinician is serving as a model
• Clinician should not instruct repairs, but
  provide typical feedback similar to conversations

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Davis and Wilcox Recommendations

• Clinician should maintain objectivity, especially
  with clients they know particularly well
• Periodic use of a less familiar receiver, helps
  generalization of techniques
• Include family members in interactions as well
• Counseling client and family members may be
  necessary to help accept residual communication
  abilities

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• Important to combine the use of the 4 principles
  to provide the most effective treatment
• Create an atmosphere where the client understands
  that conveying the message accurately is the 1
  goal

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Adjusting PACE to Meet the Individual

• Conversational Stimuli
• Consider the general topic Stimuli topics should
  be interesting to client (i.e. work, family,
  hobbies, etc.)
• Consider the symbolic representation of the
  stimuli pictures (actual or drawn), written
  material, or a combination of the two.
• Generally, pictures are used with lower
  functioning aphasics written material with
  higher functioning aphasics.

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Adjusting PACE to Meet the Individual

• Consider the type of message that is represented
  
• clinician will decide whether messages will
  represent multiple or single concepts.
• (2)depending on clients level of aphasic
  impairment, clinician will determine whether
  message to be conveyed will be transmitted with a
  single word or gesture or more complex
  communicative behaviors.

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Adjusting PACE to Meet the Individual

• Sending Receiving Criteria
• Generally, fewer criteria concepts are used with
  lower functioning aphasics a larger number of
  criteria concepts with higher functioning
  aphasics.
• Specific concept criterion may influence the
  selection of the message types in the previous
  step (selection of conversational stimuli)
• 2 ways in which in which clinician can require 3
  concepts to be conveyed about each topic

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Adjusting PACE to Meet the Individual

• Inform client that you both will take turns
  letting each other know 3 things about each
  topic. Specifics depend on sender since the
  message stimuli only specifies general topic.
• (2)Present stimulus card w/ representations of
  three specific concepts. Inform client that you
  both will take turns letting each other know
  everything that is on the card.

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Adjusting PACE to Meet the Individual

• Depending on the level of the aphasic client,
  strategy 2 would seem easier in that the message
  conveyed is not left up to client, it is clearly
  portrayed on the stimulus card.
• Communicative Channel
• Due to previous formal informal testing,
  clinician should have initial impressions about
  appropriate communicative channels of client.
• Initial channels emphasized should have been
  identified as successful communicative strategies
  for the client.

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Adjusting PACE to Meet the Individual

• Clinician should also be aware of the fact that
  messages can be accurately conveyed using a
  combination of modalities should encourage this
  fact.
• Clinician Modeling
• Clinician should initiate the PACE process by
  modeling a variety of channels.
• Based on clients preferences, clinician should
  refine use of those channels.

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Adjusting PACE to Meet the Individual

• Modeling of non-preferred channels should occur
  when clients use of such channels would improve
  communication when client relies to heavily on
  a channel that may not always available.

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Observing Communicative Change in PACE

• In order to document clients effectiveness in
  transmitting each message, a rating scale is
  employed.
• One scale assigns numerical values to clients
  success in communicating message when acting as
  sender or receiver (focuses on global
  turn-taking).
• Another scale reflects the number of mini turns
  exchanged between clinician client before
  message comprehension.

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Efficacy of PACE

• According to Davis Wilcox (1985), pace is an
  effective treatment procedure in terms of
  improving aspects of clients communicative
  abilities.
• Although not extensive, the group single case
  study conducted by Davis Wilcox found that
  patients made improvements during PACE phases not
  observed during treatment phases involving direct
  stimulation.
• Improvements were noted in the role playing
  situations, and for some on the verbal subtests
  of the PICA.

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Efficacy of PACE

• Very few studies have investigated the efficacy
  of PACE
• According to Davis of the few studies that did
  address efficacy, most did not incorporate all of
  the main principles of PACE during examination.
• Ex) Some researchers did not use turn-taking as
  part of the therapy process

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Efficacy of PACE

• WHY have there been so few studies on the
  efficacy of PACE?
• PACE is a functional approach to aphasia therapy.
• It is possible that PACE is so readily accepted
  because its basic functional design is inherent
  to so many other methods of aphasia therapy.
• Ex) In Hollands Conversational Coaching method
  (1991) the goal is also to obtain the most
  effective communication outcome but utilizing any
  verbal or non-verbal modalities possible. As in
  PACE, family and friends can be easily involved
  in Conversational Coaching intervention.

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PACE

• The reason the efficacy of the complete PACE
  method has never been thoroughly evaluated is
  probably because
• PACE may be most fairly evaluated as a
  component of a treatment program, because the
  procedure is most likely to be deployed in this
  way. (Davis, 2004)

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Criticisms of PACE

• The principle of the PACE that does make the
  procedure very unique is the required exchange of
  novel information.
• In many other types of intervention the clinician
  would be privy to more information than the
  client.
• This may be the basis for one major criticism of
  PACE

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Criticisms (contd)

• Some do not view PACE to be representative of
  natural communication because the believe the
  client and clinician can never really be equal
  communication partners if the clinician is
  considered to have a base of professional
  knowledge of communication in general.
• However, one of the reasons PACE is so accepted
  is because the clinician as a communication
  partner can easily (and hopefully would) be
  replaced by a family member or friend.

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Criticisms (contd)

• PACE has also been criticized for discouraging
  verbal behavior in communication because the
  client is encouraged to use any communication
  modality as long as the message is effectively
  conveyed in the end.
• Davis (2004), responds to this by recalling that
  the ultimate goal in aphasia therapy is to
  increase the effectiveness of communicationusing
  any modality necessary to supplement language
  (not circumvent it).

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Criticisms (contd)

• Finally
• Some believe that because the client and
  clinician are equal communication partners, the
  clinician does not retain enough information to
  supply the client with any valuable feedback.
• However, in the spirit of natural conversation,
  the clinician is able to provide corrective
  feedback by modeling behaviors such as requesting
  clarification or more information
• If the clients chosen communication mode in
  ineffective in transmitting a message, the
  clinician is able to alert him to that fact and
  can in turn demonstrate repair methods during her
  turn to convey a message.

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REFERENCES

• Davis, G.A., Wilcox, M.J. (1981). Incorporating
  parameters of natural conversation in aphasia
  treatment. In R. Chapey (Ed.), Language
  intervention strategies in adult aphasia (pp.
  169-193). Baltimore Williams Wilkins.
• Davis, G. Albyn. 2004. Pace Revisited.
  Aphasiology. 18.