Beeson, P., Rising, K., Volk, J. (2003). Writing Treatment for Severe Aphasia: Who Benefits? Journal of Speech, Language, and Hearing Research, 46, Issue 5, pp. 1038 – 1060.

This study involved the implementation of the copy and recall treatment (CART), which consists of repeated copying and recall of target words. Participants included 8 individuals, ages ranging from 65 to 79, diagnosed with severe aphasia. It was likely that all 8 participants were globally aphasic at earlier stages of recovery. However, at the time of this study, using the Western Aphasia Battery (WAB; Kertesz, 1982), aphasia types were determined to be: 1 with Wernicke’s aphasia and 7 with severe Broca’s aphasia. All participants were at least 2 years post-stroke. The purpose of the study was to determine the best candidates for the treatment.

Although most cases presenting severe aphasia have concomitant impairments of spoken and written language, there have been several case reports documenting better written than spoken naming (Basso, Taborelli, & Vignolo, 1978; Bub & Kertesz, 1982; Ellis, Miller, & Sin, 1983; Levine, Calvanio, & Popovics, 1982, as cited by Beeson et al).  These findings provide hope for speech-language pathologists in regards to utilizing alternate communication modalities for those individuals with severe aphasia whose spoken language do not improve with contemporary treatment. It is because “writing most closely approximates the specificity of spoken language” (p.1038) that Beeson et al. feel that writing may be an appropriate target for treatment.

Considering that those with severe aphasia typically have impaired phonological processes, leaving them to rely on damaged lexical-semantic processing, treatment could be directed towards strengthening lexical-semantic spelling processes. This may enable them to use single-word writing as an effective means of communication. This has positive implications when considering some case reports of those with severe aphasia indicate that orthographic representations are better preserved than speech, as well as motor control of the hand as compared to the speech mechanisms (Beeson et al. 2002).

All 8 participants presented severe aphasia as indicated by quotients less than 30 on the Western Aphasia Battery (WAB; Kertesz, 1982) and severity ratings of 1 on the Boston Diagnostic Examination for Aphasia-Third Edition (Goodglass & Kaplan, 2001). All participants presented limited speech production and were in need of additional means of communication. Participants had received previous treatment, but none directed at writing. In order to maximize conversational communication, all participants were included in weekly aphasia groups throughout the study.

Single-word processing abilities were assessed pre- and post-treatment using selected subtests from the Psycholinguistic Assessments of Language Processing in Aphasia (PALPA; Kay, Lesser, & Coltheart, 1992).  These allowed examination of single-word reading, auditory comprehension, verbal repetition, written naming, and writing to dictation. The picture version of the Pyramids and Palm Trees Test (Howard & Patterson, 1992) was also used to assess the ability to make semantic associations.  A case conversion task, in which participants were asked to transpose uppercase letters to lowercase, and vice versa, was used to assess peripheral writing processes. Tools used to assess nonverbal cognitive skills were the Coloured Progressive Matrices (CPM; Raven, Court, & Raven, 1990) and the Tapping Forward Subtest from the Wechsler Memory Scale-Revised (WMS-R; Wechsler, 1987). The oral language portions of the WAB (Kertesz, 1982) were readministered post-treatment to assess whether any changes occurred in other modalities, such as, auditory comprehension and/or verbal expression.

With the aid of family members, potential target words were compiled that reflected the individual interests and needs of each participant.  From these, 20 picturable words were selected based on functionality and personal relevance. Word lists consisted mainly of common nouns and proper names, ranging in length from 2 letters to 9 letters. Each word was represented by a picture or line drawing affixed to an index card. From each individualized list, 4 sets of target words, with five words per set, were created for each participant.

Once three pretreatment probes were completed, weekly sessions began with Set 1 using CART.  Each session was one hour long, and included 6 homework packets (for each day not in therapy) consisting of labeled pictures of currently targeted words and daily test pages for written naming of those pictures without a written model of the word. Once a participant was able to write at least four of five words in the set correctly over a minimum of two consecutive sessions, training could continue with the next set of targeted words. Mastered words from the previous set would then be included in the homework packets in order to provide maintenance of learned skills. The latter part of each session focused on the conversational use of these mastered written words as well.

In the event that criterion could not be met on a given set, training would discontinue for that set.  Training on the next set would be implemented in order to verify that failure to meet criterion was not a result of the particular words in the previous set. If treatment once again failed to show positive results, CART was discontinued. However, once the first three sets were successfully mastered, treatment sessions with the clinician ended and the participant was then given 4 weeks worth of homework on the mastered sets and the untrained Set 4.  A final probe would then be given to assess maintenance of Sets 1-3, and the ability to learn the target words of Set 4 independently.

Of the 8 participants in this study, 4 exhibited strong, positive responses to writing treatment, mastering 80% of 15 words over the course of 8 to 12 weekly sessions.  They also learned another 2 to 5 words during the month long period of independent homework. Some positive response to CART was also shown by 3 other participants, learning some of the targeted words, but failing to meet or maintain criterion. Only 1 participant exhibited a poor response to treatment.

Although more research needs to be done to identify prognostic indicators of those who may potentially benefit from CART, as well as for those who would not be ideal candidates, two types of factors found in this study seem to limit the likelihood of success: “cognitive-linguistic impairments and failure to complete CART homework” (p. 1054).Also, it appears that semantic impairment may limit the functional success of CART for the basic reason that “written words must be linked to their meaning in order to be useful”(p.1054). Other indicators suggest that a poor prognosis may be discerned within as few as one or two sessions. Overall, positive predictors may include the following factors; “(a) a relatively preserved semantic system, (b) adequate processing of visual information, and (c) the individual’s motivation and ability to accurately complete daily CART homework” (p. 1055).  To be most effective, individuals need to expand the quantity of available written words, as well as expand the use of those words in conversational communication. 

The positive response to CART exhibited by most participants in this study supports the possibility that those with severe aphasia, unable to recover spoken language, may benefit from writing as an alternate modality for communication. It also indicates that there is a need for further research aimed at meeting the communication needs of those who do not respond to CART.