Communication following TBI

8/19/2019 Communication following TBI

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c) University of Sydney, Prof. Leanne

Togher

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Communication treatment approaches

for people with ABIWelcome!

Leanne Togher Ph.D.

The University of Sydney

Australia


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Togher

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Background to TBI Express

Sociolinguistics

Systemic Functional Grammar (Halliday 2001)

Observation of interactions of people with TBI

Dr Mark Ylvisaker – Joint construction of narratives

- Collaboration and elaboration

Background to TBI Express development

Evidence based assessment measures of

discourse including conversation

Findings of the TBI Express clinical trial

Overview of the TBI Express training

Today


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Sensation andPerception

Language

Selective andFocused Attention

Executive Functions

Social Cognition

Explicit Long-termMemory

Implicit Long-termMemory

Motor Skills

PERCEPTION

Situation Listener

Self

GENERATING BEHAVIOUROPTIONS

DECISION-MAKINGBehaviour EvaluationBehaviour Selection

EXECUTION

Self-awareness ofstrengths and limitations

Awareness that there arebehaviour options

Awareness that there areconsequences of

behaviour

Knowledge of personaladaptive strategies

Strategy Use

Working Memory

SENSORY ANDCOGNITIVE

PREREQUISITES

METAPRAGMATICSKILLS

PRAGMATICELEMENTS

McDonald, S., Turkstra, L. & Togher, L. (2012). Pragmatic language impairment after brain injury:

social implications and treatment models. In: Developmental Social Neuroscience: Contributions toChildhood Brain Disorders, Anderson, V. & Beauchamp, M. (Eds.) pp 325-349, Guildford

Publications.

Systemic functional linguistics

(Halliday, 1994, Halliday & Matthiesen, 2004)

› Sociolinguistic theory

› Describes discourse in social terms

› Provides a way of examining the co-construction

of discourse between conversational partners

Context of situation

FIELD: What is happening

TENOR: Who is involved

MODE: Spoken vs. written


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Meeting a new friend at the pub

FIELD: casual conversation

TENOR: equal participants, unfamiliar

MODE: spoken

TENOR

STATUS: relative position of the interlocutors ina culture’s social hierarchy

CONTACT: degree of institutional involvementwith each other

AFFECT: degree of emotional charge in

the relationship between participants (Halliday, 1978)

STATUS

Reciprocity of choice

Equal status = similar kinds of choices whereas

unequal status means that they take up different

choices

Choices are usually made unconsciously and

therefore it is context and to a certain extent,

society, which makes these choices available

(Poynton, 1985)

Context of culture

Global context

Cultural rules

Choices are predetermined and reflected

directly in the language that is produced


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Language and its environment (Martin, 1992)

ideology

genre

semantics

wording

ideology

genre

semantics

wording

Exchange structure analysis

SYNOPTIC MOVES

Ask for or provide information or action

Necessary for the interaction to be

completed

Exchange structure analysis

DYNAMIC MOVES

Embedded in an exchange to negotiate meanings

Keep the interaction going during

communication breakdown or to facilitate

completion

Exchange structure example

K2 Have you been to the shops?rprq Pardon?

rrprq The shops

K1 Yes I got the groceries this

morning


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Exchange structure analysis example

K1 Shane: I think I’ll head off for a swim later

K2 Jane: Are you going to Bondi beach?

cfrq Shane: Where?

rcfrq Jane: Bondi

K1 Shane: Either there or over to Manly

K2 Shane: Would you like to come with me?

K1 Jane: That‘d be great

The teaching exchange

Asking for information that you already have

dK1 Therapist: What did we do yesterday?

K2 Patient: We worked on staying on topic

K1 Therapist: That’s right

TBI Subject S1

32 years

Severe TBI 4 years post-injury PTA = 6 months LOC = 8 weeks

CT scan: frontal haemorrhages/contusions

Cognitive-communication disorder: poor topic

management, impaired social judgment,

overfamiliarity & poor self monitoring

Five interactions

INFORMATION REQUESTING

Mother

Therapist

Bus timetable service

Police

INFORMATION GIVING

Community education re driver safety to school students


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Exchange structure data - S1

Mother condition - TBI subject S1

10 rchall S: If you could just tell me a few things I did

11 dK1 M: You tell me a few things you did

12 dK1 M: What days did you go?

13 K2 S: Monday, Wednesday

14 K1 M: Yes

15 dK1 M: And what did you do on Mondays?

16 K2 S: Wasn’t that the day, that afternoon we went to the

swimming pool?

17 K1 M: Yes…that’s right

18 K2 S: And there was speech group in the morning

19 K1-Fg M: Yes and they did

20 dK1 M: what else did they do?

21 K2 S: I can’t recall

22 chall M: Of course you can23 chall M: Think of some of the things you did there

24 K2 S: Aerobics class

25 K1 M: That’s right

Mother condition - Control subject C1

4 K2 C: Yeah can you tell me what sort of thingsR. was doing at the ADP?

5 K1-Fg M: Well

6 clrq C: Is that right?7 clrq C: Adult Development Program?

8 rclrq M: What at Headway?

9 rclrq C: Ah10 rclrq M: Yeah that’d be it

11 cf C: [Yeah that’d be it

12 K1 M: Oh he used to go a couple of days a week13 K1 M: Um they did exercises and

14 clrq C: Physical?

15 rclrq M: Yeah some physical and mental things16 K1 M: and played games

Results

People with TBI were given less information whencompared with the brothers

People with TBI asked more questions, but were stillgiven less information

People with TBI had fewer opportunities to giveinformation than their brothers, particularly withtherapists and their mothers

(Togher, Hand & Code, 1996, 1997a, 1997b, Togher & Hand, 1998)


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Some implications

› People with TBI have a problem developing and sustainingsocial relationships – maybe some of the problem is how

partners are interacting with them

› Suggestion that we can teach communication partners the

structure of a range of interactions and with this awareness

they can use conversational strategies to foster appropriate

interaction

Joint construction of narratives

Jorgensen, M. & Togher, L. (2009). Narrative after traumatic brain injury: a

comparison of monologic and jointly-produced discourse, Brain Injury, 23 (9), 727-

740.

Narrative

› Abstract

› Orientation

› Complication

› Evaluation

› Resolution

› Coda

Why assess jointly-produced narrative?

Narrative does not typically exist as a monologue in

everyday interactions

Advances in measurement tools (Coelho, 2007;

Togher et al., 2006; Turkstra, Brehm & Montg omery, 2006)

Varied communication partners: researcher/ therapist vs.

everyday communication partners

People with TBI differed in language use across

communication partners (Togher, Hand & Code, 1997, Guo &Togher, 2007)


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To study the effects of a familiar

partner on the production of

narrative after TBI

Aim

Questions

1. Are participants with TBI as able to jointly-

produce a narrative as control participants?

2. Does a familiar partner facilitate the productionof narrative in those with TBI?

10 participants with severe TBI with a friend

Inclusion criteria for TBI participants: Severe TBI according to PTA

Cognitive communication disorder on the Scales of Cognitive

Ability following TBI (SCATBI)(Adamovich & Henderson, 1992)

Social communication disorder on the Pragmatic Protocol

(Prutting & Kirchner, 1987)

Recruited through brain injury rehabilitation units in

Sydney, Australia

10 matched control participants (age, sex and education)with a friend

Participants Participants (n=20)

TBI PARTICIPANTS

Age: Mean= 39.4 years (27 – 67)

Length of PTA: Mean = 17.8weeks, (range = 1.5 days to 40weeks)

Time since injury: Mean = 13.05years (range = 4 - 28)

SCATBI severity scores: Mean=10.1 1.60 (range = 8-12)

Length of friendships: Mean =14.1 14.2 years

CONTROL

PARTICIPANTS

Age: Mean= 39.50

11.57 years (29 to 67years)

Length of friendships:

Mean= 16.45 12.84years


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Monologic narrative

Control and TBI participants on their own

Story generation picture sequence

‘The Flowerpot Incident’

Procedure

Jointly-produced narrative

Participants and friends together

Story retell task

Holidays/home improvement video

Procedure

Productivity – total C-units, words/C-unit

Cohesion – % cohesive ties

Content – story grammar, essential units

Exchange structure analysis – % K1 moves

Analysis


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TBI vs. control in monologic narrative

Statistical differences in all measures

More C-units but fewer words per C-unit

Less cohesive

Fewer story grammar elements

Less essential content

Consistent with Hartley & Jensen 1992,

Coelho et al. 1991, Biddle et al. 1996, Snow etal., 1999

TBI vs. control in jointly-produced narrative

No significant difference between groupsacross all measures

Empowered to participate and produce narrative

Consistent with equal participation in problem-

solving task with friends (Kilov, Togher & Grant, 2009, Aphasiology )

Implications

Friends can fill supportive and therapeuticroles in treatment

Use of everyday partners in therapy Training parents of children with TBI (Ylvisaker et al. 2003)

Supporting Partners of People with Aphasia inRelationships and conversation (SPPARC) (Lock et al.2001)

Police officer training for people with TBI (Togher, McDonald,Code & Grant, 2004)

Discourse assessmentLa Trobe Communication Questionnaire

Talkbank – TBI Bank

Adapted Kagan rating scales


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Self report scale for TBI

Other report scale for communication partner

30 items, 22 based on Grice’s maxims and 8 ontypical communication problems following TBI

30 = No/ rare perceived communicationdifficulty

120 = Always / greater perceivedcommunication difficulty

› (Douglas, O’Flaherty & Snow, 2000)

La Trobe Communication Questionnaire (LCQ)

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www.talkbank.org

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TBI Bank


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Aphasia Bank Talk Bank

• Operated from Carnegie Mellon University, Pittsburgh – Brian MacWhinney

• Web accessible multimedia databases for humancommunication

• Powerful analytic tools

• Community for collaborative commentary (crossdisciplinary)

• Displays transcript and video simultaneously

• CHILDES, PhonBANK, Aphasia BANK and now TBIBank

• Can be used for teaching purposes

TBI Bank Protocol

Monologic Discourse Tasks

›I. Free Speech Samples (Brain Injury Story & Important

Event)›II. Picture Descriptions (Broken Window; Refused Umbrella &

Cat Rescue)

›III. Story Narrative (Cinderella)

›IV. Procedural Discourse (Peanut Butter & Jelly Sandwich or

similar )

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A. BRAIN INJURY STORY and COPING

1. “I’m going to be asking you to do some talking. How do you think your

speech is these days?”

If no response in approximately 10 seconds, prompt:

“How's your talking?” Listen, encourage full response. If no response, use Troubleshooting questions.

2. Tell me what you remember about when you had your head injury.


“What other things have people told you about when you had your head

injury?”

Listen, encourage full response.

At a natural juncture add:

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Brain injury story and coping cont’d

3. "Tell me about your recovery. What kinds of things have you doneto try to get better since your head injury?”


“Tell me about any changes you’ve needed to make in your daily life.”

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Example: Picture descriptions

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Results

Inter-rater reliability scores for both the Adapted MPC and

the MSC scales were excellent

(MPC: ICC = 0.84-0.89; MSC: ICC = 0.85-0.97). Over 90% of

ratings scored within 0.5 on a 9 point scale

Intra-rater agreement was also strong

(MPC: ICC = 0.81-0.92; MSC: ICC = 0.80-0.90)

Over 90% of ratings scored within 0.5 on a 9 point scale

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Communication following TBI

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