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An errorless learning approach to treating dysnomia
Brain and Language 91 (2004) 177–178 www.elsevier.com/locate/b&l
An errorless learning approach to treating dysnomia Carol Frattali*, Yun Kyeong Kang Speech-Language Pathology Section, Rehabilitation Medicine Department, W.G. Magnuson Clinical Center, National Institutes of Health, Building 10, Rm. 6S235, MSC 1604, Bethesda, MD 20892-1604, USA
Abstract Few errorless learning approaches to dysnomia treatment are found in the aphasia literature; none are found when paired with effortful rather than effortless learning (Fillingham, Hodgson, Sage, & Lambon Ralph, 2003). Grounded in Hebbian plasticity (Hebb, 1961), errorless learning occurs with increases in synaptic strength. Therefore, if a stimulus elicits an errorless response, Hebbian learning will strengthen the tendency to activate the same pattern of response on subsequent occasions. Our interest was in developing and piloting a treatment method of errorless and effortful learning cast in an ecologically valid framework of interactive discourse. Ó 2004 Published by Elsevier Inc.
Procedures
Materials
Subjects
Forty photo stimuli were used for active treatment, including 20 objects (For Subject #1: 10 living; 10 non-living; for Subject #2: 20 living) and 20 actions (for Subject #1: 10 biological motion; 10 tool use; for Subject #2, 20 tool use). For Subject #3, 30 object and 30 action stimuli included, for each category, 10 1-, 2-, and 3-syllable words. A set of 40 photo stimuli (20 objects; 20 actions) for untreated items was used to determine generalization effects. All stimuli were balanced by frequency (Francis & Kucera, 1982), imageability (Gilhooly & Logie, 1980), and syllabic length. An ABA multiple baseline design was used, with 3–4 treatment sessions constituting Phase A1 (noun training, generalization to untrained verbs), 3–4 sessions in Phase B (verb training, generalization to untrained verbs, maintenance of performance for trained nouns), and 3–4 sessions in Phase A2 (noun training, generalization to untrained verbs, and maintenance of performance for trained verbs). A 6-month follow-up determined maintenance of gain in treatment-induced changes.
We treated three patients with persistent or progressive aphasia, one resulting from left temporal-variant frontotemporal dementia (Subject #1: age = 66 years, education = 22 years, time post-onset = 12 months) and two resulting from left-hemisphere cortical stroke, Subject #2: age = 57 years, education = 18 years, time postonset = 10 months; Subject #3: age = 73 years, education = 16 years, time post-onset = 4 months). Methods Using Levelt’s model of lexical access (Levelt, Roelofs, & Meyer, 1999) and based on results of a comprehensive battery of standardized language/naming tests, we identified level of salient breakdown in lexical retrieval at the conceptual-semantic (Subject #1), lemma (Subject #2), and lexeme level (Subject #3), respectively. Each patient underwent an individualized experimental treatment in 2-h sessions for a total of 9–12 sessions over a 2–3 month period. An errorless and effortful learning approach was designed to allow participation in a conversational paradigm during which both examiner and patient were engaged actively in analyses of conceptual, semantic or phonological information, but with focus directed away from the task of confrontation naming. This approach was anticipated to result in successes at the level of targeted word retrieval due to the priming effect of the treatment, but as a byproduct of the treatment method applied. The approach was described as errorless in its avoidance of errorful naming upon presentation of stimuli, and effortful in its recruitment of higherorder cognitive functions that served to prime target words. *
Corresponding author. Fax: 1-301-480-9895. E-mail address: carol [email protected] (C. Frattali).
0093-934X/$ - see front matter Ó 2004 Published by Elsevier Inc. doi:10.1016/j.bandl.2004.06.091
Treatment approach Patients were told to avoid naming the object or action upon stimuli presentation, but were engage in facilitated conversational interchange focused in fine-grained analysis of its conceptual, semantic, and/or phonological features (e.g., comparative analysis, associative skills, spatial and temporal analysis, and analogical reasoning). Analyses Accuracy of naming was recorded after the period of direct treatment for each set of stimuli concluded. The McNemar test was used to compare paired proportions of correct responses during baseline per-
178
Abstract / Brain and Language 91 (2004) 177–178
formance with Phase A or B performance as well as for generalization and maintenance effects (p < .05).
month follow-up, Subject #3 maintained and exceeded gain for naming nouns (p < .0001).
Results
Conclusions
For Subject #1, from baseline to completion of Phase A1, significant improvement in naming nouns occurred (p = .016), but with no generalization to untrained nouns. During Phase B, the subject showed significant improvement in naming verbs (p = .004) with a loss of improvement from baseline in naming nouns, and no generalization to untrained verbs. During Phase A2, Subject #1 showed significant improvement in naming nouns (p = .012), with maintenance of gain in trained verbs (p = .016). No generalization occurred for untrained nouns or verbs. At 6 months follow-up, the subject had lost all gain. For Subject #2, from baseline to completion of Phase A1, significant improvement in nouns occurred (p = .001), but with no generalization to untrained verbs. During Phase B, the subject showed no improvement in naming verbs, but with maintenance of gain for trained nouns (p < .0001). During Phase A2 , the subject again showed significant improvement in naming nouns (p = .001) and with maintenance of gain for trained verbs (p = .016). No generalization occurred for untrained nouns or verbs. At 6 months follow-up, the subject had lost all gain. For Subject #3, from baseline to completion of Phase A1, significant improvement in naming nouns occurred (p < .0001), but with no generalization to untrained verbs. During Phase B, Subject #3 showed no improvement in naming verbs, but with maintenance of gain for improvement in naming nouns (p < .0001). During Phase A2, Subject #3 again showed significant improvement in naming nouns (p < .0001) with generalization to untrained nouns (p = .003). There was no generalization to untrained verbs. At 6-
Results suggest the potential of short-term individualized (focused at point of breakdown in the lexical access system) treatment using an errorless and effortful approach; treatment, in all cases, resulted in improvement during its active course. At 6-month follow-up, Subject #3 showed continual improvement without treatment. Results have implications for dysnomia feature analysis and classification as precursor to individualizing treatment. Results also suggest the value of Hebbian learning to treatment effect in its active phases.
References Fillingham, J. K., Hodgson, C., Sage, K., & Lambon Ralph, M. A. (2003). The application of errorless learning to aphasic disorders: A review of theory and practice. Neuropsychological Rehabilitation, 13(3), 337–363. Francis, W. N. & Kucera, H. (1982). Frequency Analysis of English Usage. Boston: Houghton Mifflin Company. Gilhooly, K. J. & Logie, R. H. (1980). Age of acquisition, imagery, concreteness, familiarity and ambiguity measures for 1944 words. Behaviour Research Methods and Instrumentation, 12, 395–427. Hebb, D. O. (1961). The organization of behavior: A neuropsychological theory. Stimulus and response—and what occurs in the brain in the interval between them. New York: Science Editions, Inc. Levelt, W. J. M., Roelofs, A., & Meyer, A. S. (1999). A theory of lexical access in speech production, Behavioral and Brain Sciences, 22, 1–75.
An errorless learning approach to treating dysnomia Carol Frattali*, Yun Kyeong Kang Speech-Language Pathology Section, Rehabilitation Medicine Department, W.G. Magnuson Clinical Center, National Institutes of Health, Building 10, Rm. 6S235, MSC 1604, Bethesda, MD 20892-1604, USA
Abstract Few errorless learning approaches to dysnomia treatment are found in the aphasia literature; none are found when paired with effortful rather than effortless learning (Fillingham, Hodgson, Sage, & Lambon Ralph, 2003). Grounded in Hebbian plasticity (Hebb, 1961), errorless learning occurs with increases in synaptic strength. Therefore, if a stimulus elicits an errorless response, Hebbian learning will strengthen the tendency to activate the same pattern of response on subsequent occasions. Our interest was in developing and piloting a treatment method of errorless and effortful learning cast in an ecologically valid framework of interactive discourse. Ó 2004 Published by Elsevier Inc.
Procedures
Materials
Subjects
Forty photo stimuli were used for active treatment, including 20 objects (For Subject #1: 10 living; 10 non-living; for Subject #2: 20 living) and 20 actions (for Subject #1: 10 biological motion; 10 tool use; for Subject #2, 20 tool use). For Subject #3, 30 object and 30 action stimuli included, for each category, 10 1-, 2-, and 3-syllable words. A set of 40 photo stimuli (20 objects; 20 actions) for untreated items was used to determine generalization effects. All stimuli were balanced by frequency (Francis & Kucera, 1982), imageability (Gilhooly & Logie, 1980), and syllabic length. An ABA multiple baseline design was used, with 3–4 treatment sessions constituting Phase A1 (noun training, generalization to untrained verbs), 3–4 sessions in Phase B (verb training, generalization to untrained verbs, maintenance of performance for trained nouns), and 3–4 sessions in Phase A2 (noun training, generalization to untrained verbs, and maintenance of performance for trained verbs). A 6-month follow-up determined maintenance of gain in treatment-induced changes.
We treated three patients with persistent or progressive aphasia, one resulting from left temporal-variant frontotemporal dementia (Subject #1: age = 66 years, education = 22 years, time post-onset = 12 months) and two resulting from left-hemisphere cortical stroke, Subject #2: age = 57 years, education = 18 years, time postonset = 10 months; Subject #3: age = 73 years, education = 16 years, time post-onset = 4 months). Methods Using Levelt’s model of lexical access (Levelt, Roelofs, & Meyer, 1999) and based on results of a comprehensive battery of standardized language/naming tests, we identified level of salient breakdown in lexical retrieval at the conceptual-semantic (Subject #1), lemma (Subject #2), and lexeme level (Subject #3), respectively. Each patient underwent an individualized experimental treatment in 2-h sessions for a total of 9–12 sessions over a 2–3 month period. An errorless and effortful learning approach was designed to allow participation in a conversational paradigm during which both examiner and patient were engaged actively in analyses of conceptual, semantic or phonological information, but with focus directed away from the task of confrontation naming. This approach was anticipated to result in successes at the level of targeted word retrieval due to the priming effect of the treatment, but as a byproduct of the treatment method applied. The approach was described as errorless in its avoidance of errorful naming upon presentation of stimuli, and effortful in its recruitment of higherorder cognitive functions that served to prime target words. *
Corresponding author. Fax: 1-301-480-9895. E-mail address: carol [email protected] (C. Frattali).
0093-934X/$ - see front matter Ó 2004 Published by Elsevier Inc. doi:10.1016/j.bandl.2004.06.091
Treatment approach Patients were told to avoid naming the object or action upon stimuli presentation, but were engage in facilitated conversational interchange focused in fine-grained analysis of its conceptual, semantic, and/or phonological features (e.g., comparative analysis, associative skills, spatial and temporal analysis, and analogical reasoning). Analyses Accuracy of naming was recorded after the period of direct treatment for each set of stimuli concluded. The McNemar test was used to compare paired proportions of correct responses during baseline per-
178
Abstract / Brain and Language 91 (2004) 177–178
formance with Phase A or B performance as well as for generalization and maintenance effects (p < .05).
month follow-up, Subject #3 maintained and exceeded gain for naming nouns (p < .0001).
Results
Conclusions
For Subject #1, from baseline to completion of Phase A1, significant improvement in naming nouns occurred (p = .016), but with no generalization to untrained nouns. During Phase B, the subject showed significant improvement in naming verbs (p = .004) with a loss of improvement from baseline in naming nouns, and no generalization to untrained verbs. During Phase A2, Subject #1 showed significant improvement in naming nouns (p = .012), with maintenance of gain in trained verbs (p = .016). No generalization occurred for untrained nouns or verbs. At 6 months follow-up, the subject had lost all gain. For Subject #2, from baseline to completion of Phase A1, significant improvement in nouns occurred (p = .001), but with no generalization to untrained verbs. During Phase B, the subject showed no improvement in naming verbs, but with maintenance of gain for trained nouns (p < .0001). During Phase A2 , the subject again showed significant improvement in naming nouns (p = .001) and with maintenance of gain for trained verbs (p = .016). No generalization occurred for untrained nouns or verbs. At 6 months follow-up, the subject had lost all gain. For Subject #3, from baseline to completion of Phase A1, significant improvement in naming nouns occurred (p < .0001), but with no generalization to untrained verbs. During Phase B, Subject #3 showed no improvement in naming verbs, but with maintenance of gain for improvement in naming nouns (p < .0001). During Phase A2, Subject #3 again showed significant improvement in naming nouns (p < .0001) with generalization to untrained nouns (p = .003). There was no generalization to untrained verbs. At 6-
Results suggest the potential of short-term individualized (focused at point of breakdown in the lexical access system) treatment using an errorless and effortful approach; treatment, in all cases, resulted in improvement during its active course. At 6-month follow-up, Subject #3 showed continual improvement without treatment. Results have implications for dysnomia feature analysis and classification as precursor to individualizing treatment. Results also suggest the value of Hebbian learning to treatment effect in its active phases.
References Fillingham, J. K., Hodgson, C., Sage, K., & Lambon Ralph, M. A. (2003). The application of errorless learning to aphasic disorders: A review of theory and practice. Neuropsychological Rehabilitation, 13(3), 337–363. Francis, W. N. & Kucera, H. (1982). Frequency Analysis of English Usage. Boston: Houghton Mifflin Company. Gilhooly, K. J. & Logie, R. H. (1980). Age of acquisition, imagery, concreteness, familiarity and ambiguity measures for 1944 words. Behaviour Research Methods and Instrumentation, 12, 395–427. Hebb, D. O. (1961). The organization of behavior: A neuropsychological theory. Stimulus and response—and what occurs in the brain in the interval between them. New York: Science Editions, Inc. Levelt, W. J. M., Roelofs, A., & Meyer, A. S. (1999). A theory of lexical access in speech production, Behavioral and Brain Sciences, 22, 1–75.