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Asphasia - Language is critical for socialization. Discuss.

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“Communication is vital to both biological and social existence” (Hedge, 1991).  Language is critical for socialization. Language is welded to interaction and human experience. It carries a person’s share of social and personal experience so that they can have a warm relationship with others. However, people with aphasia which is a kind of communication disorders of neurological origin have impaired language ability. Their abilities of maintaining interpersonal relationships are reduced as they have impaired abilities to convey needs and wants. Therefore, it is necessary for the aphasic people to have treatment in order to improve their skills such as comprehending and producing language in order to communicate more effectively and to minimize the effect of aphasia in a person’s social participation (Chapey & Hallowell, 2001). The social approach and the cognitive neuropsychological approach are chosen to describe the assessment and intervention based on the communication impairment and its result in social participation.

Aphasia is a common communication disorder associated with brain damage (Chapey & Hallowell, 2001; Haynes, Pindzola & Emerick, 1992; Hedge, 1991). It is a multimodality problem which includes reading, writing, speaking and comprehension characterized by impairment in speaking and understanding of language particularly morphemes and large syntactic units, the accessibility to vocabulary is reduced, and impairment in syntactic rules and auditory retention span (Hedge, 1998).

        “Cognitive neuropsychology is that a cognitive process can be characterized as a set of sub-processes that are sequentially computed in the course of cognitive performance” (Basso, 2003, p.121).        Cognitive neuropsychology approach is aimed at understanding the details of individual’s behaviour from scientific modeling (Howard, 2000). It has developed a great diversity which included reading and cognitive disorders such as perception and semantic. It is an interest in investigating and understanding single subjects using explanation from information processing model rather than in explanations at neurological levels.

Models of word retrieval in cognitive neuropsychology were used to distinguish between a number of different stages in word finding. Word retrieval problems mean that a person knows and understands the word and has used it before, but he/she has difficulty retrieving such known word at time (Howard, 2000). It could be seen that the models of cognitive neuropsychology put more emphasis on improving cognitive processing. It focuses on the level of impairment and looks for the effective in changing language performance (Simmons-Mackie, 2001).

        Social model is an integration of psychosocial and communication. It states that the major goals for human beings are social affiliation and maintaining a healthy identity. People use communication to obtain a membership in a society. Aphasia is suggested to be an impairment of brain damage in formulation and reception of language which is often associated with decrease in social participation and fulfillment of desired social role. As Goodwin (1995) suggested that aphasia is not a lesion resided in the skull but also located outside the person in dynamic relationships in society. The social approach is aimed to help those people with aphasia to fulfill psychosocial needs through communication (Byng, Pound & Parr, 2000; LaPointe, 2003; Simons-Mackie, 2001).

The Life Participant approach to aphasia (LPPA) incorporates the social models into contemporary treatment with real life goals generated from the needs of each unique participant in intervention. It is a consumer-driven service delivery and seasonal approach that change in needs and goals of any person in the rehabilitation and recovery process. The aims for changing placed on the re-engagement and strengthening daily participation in activities of choice (LaPointe, 2003).

There are some differences between the goals of the two approaches. The cognitive neuropsychological approach is to develop normal language process based on the information processing models of specific language. As it is believed that language function can be retrained and restored or relearned through intervention and the target could directly to the impairment (Whitworth, Webster & Howard, 2005).It focuses on the transactional function of communication such as transferring information to patients while social approach focuses on interaction such as sharing ideas as social approach looks aphasia more than a linguistic or cognitive deficit. Rather, it looks at the problems of decrease in life participation and fulfillment of desired social role which are associated with the impairment. It focuses on the performance increased in daily activities and communication in use. It encompasses the quality of life and social participation (Simmons-Mackie, 2001).

Cognitive neuropsychological approach looks at the functional origin of impairment. The goals of this approach are to analyze the causes of the impairment using the information models of language processing as it contains the subsystems that are interconnected with functional impairment. It is focused on the understanding of client’s speech and language pattern with reference to the normal processing system to enable the development of target intervention (Whitworth, Webster & Howard, 2005). The final goal is to make prediction on success or failure of particular methods for specific deficit from treated patients to others (Howard, 2000).

However, the goal for social approach is to promote membership in a social community and participation in personally relevant activities for those affected by aphasia. There is no expectation that reduced impairment or improved functional skill will enhance participation automatically. The ultimate goal for this approach is to enhance the living of life with aphasia which is consistent with the philosophy of LPAA which places the emphasis on availability of services as it is necessary for all stages of life with aphasia. It is acknowledged that life consequences of varied overtime. Therefore, people with aphasia are feeling free to discontinue the intervention or re enter when they think they need to continue work on the goals (Simmons-Mackie, 2001; Elman, 2005).

Both cognitive psychological approach and LPAA have similar ways of assessment, in the sense that both of them focus on the changes pre and post therapy.In cognitive psychological approach, there are analysis on the changes of client’s cognitive system and assessing the relationship of neurological damage and the outcome of therapy (Whitworth, Webster & Howard, 2005). Social approach measures the changes of documented life enhancement. It is suggested that the assessment of quality of life and the extent whether the aphasic people meet the goals are measured by outcomes (e.g. emotional well-being, satisfaction of the therapy) (LPAA Project Group, 2001; Elman, 2005).

The assessment of naming was used in the cognitive neuropsychological approach. The distinction between different word finding stages is motivated by experimental work with normal subjects and the models have drawn support from neuropsychological studied of brain damaged patients. It is hypothesized that each level of processing can be selectively impaired by acquired brain damage, and that the level of deficit can be identified on the basis of: (1) the performance of patient in different task; (2) the effects of psycholinguistic variables on patient’s performance; (3) the errors that a patient makes in word production and comprehension. The conjunction of above evidences can be used to determine the level of breakdown (Howard, 2000).

There are several levels of impairment in the naming model. The semantic impairment and post-lexical impairment n phonological assembly are more likely to be seen in people with aphasia. Patients with semantic impairments have difficulty in word comprehension and production. It affects lexical semantic representations that patients make semantically related errors in naming and their naming accuracy is affected by the concreteness, or imageability of the target name. Patients with post-lexical phonological assembly impairments have increasing rate of error with longer words as word length affects the opportunity for errors in phonological assembly (Howard, 2000). This indicated the mappings made between the levels of impairment and the features of aphasic word finding in terms of an information-processing model. The mapping deficit hypothesis suggested that the problem in naming model is not resting with functional level, but rather moving to positional level which is assigning relationships between constituents. It indicated that distinctions between processing levels capture important properties of the processes in word retrieval. The cognitive neuropsychological models are both a simplification and a partial description. This assessment schema gives important information to treatment by identifying both impaired and intact processing components which can (Howard, 2000).

The assessment for social approach provides insight into well-being, personal consequence lifestyle effects of aphasia. The measurements include professional judgments, communication effectiveness ratings etc. The communicative profiling system is suggested in social approach that all interviews, personal journals and observations are used to identify personal behaviours in social relationship.  It is suggested the client to gather the self ratings of life satisfaction. There are observational assessments to assess the success of adaptation over the course of treatment. Analyzing conversation to address natural social interactions and documenting life participation (Simmons-Mackie, 2001).

The cognitive psychological therapy approach is the study of efficacy of language, intervention based on sampling method. It focuses on the remediation of impaired cognitive processes or the compensation through the cognitive process or both. It involves consideration of the client’s performance of the assessment based on model of the cognitive processes and representation that underlie normal performance of the task.  There are six categories of approaches developed by Howard and Hatfield (1987) and Lesser and Milroy (1993): (1) To reactivate the access to impaired processing and language ability. (2) To relearn impaired language knowledge; (3) to reorganize the brain to take over the function of impaired language; (4) to find an alternative way to perform language function. (5) To adopt external prosthesis to promote communication. (6) To maximize using retained language and communication behaviours in order to compensate the impaired function (Whitworth, Webster & Howard, 2005).

It invites the idea of using a series of studies of treatment effect with individual patients to identify the optimal treatment strategy for the patient with particular impairment. This approach offers the possibility that treatment effectiveness will be related to level of breakdown and the possibility that treatment designed on the basis of knowledge of intact and impaired processes will be most effective (Howard, 2000).

         One approach is to understand the process of treatment is to study each single treatment events on patient’s ability to retrieve words. There is distinction between threekinds of effects while applying a technique. Prompting technique is when the effect measured as the difference in naming immediately after prompting. Effect measured as the difference in naming accuracy for treated items relative to untreated controls at later time is called facilitation which is a long term effect. Therapies are the use of multiple techniques and try to have a long-term change in a patient’s ability in retrieving words. Effect measured as accuracy in naming treated items relative to untreated controls after treatment (Howard, 2000).

Cognitive neuropsychology has developed the techniques for studying effects which can show quite conclusively that treatment is effective, using appropriate statistical techniques to analyze data. And the naming therapy has shown item-specific patterns of improvement which allocating items to treatment and control condition and comparing the post-therapy accuracy for the two conditions.

        Although treatment in social approach also works on improving or compensating for the language impairment and usage of language functional techniques, however, its ultimate goal still remains on increase communication skills and confidence as it has no expectation that reduced impairment will improve social participation.  

The International Classification of Functioning Disability and Health (ICF) framework combine the ideas of the medical and social model (WHO, 2001). There are two parts in the model. The first part is body functions and structure, activities and participation and the second part is personal and environment factors which might be barriers or facilitators to individual’s function.  As social approach is focused on the environmental and physical factors, though aphasia is a disorder at body functions and structure levels, people with similar impairments in language might have different participation and activity. If the personal and environmental factors are more likely to be facilitators rather barriers to function, people with aphasia are more likely to participate more with an improvement of quality of life (Elman, 2005). Therefore, clinicians try to work on anything that showing aphasia is a barrier to life participation. There is conversation therapy which is aimed to enhance conversational interaction as conversation is used to exchange information and fulfill social needs. This therapy focuses on message exchange and social communication skills appropriate to specific communicative events. Clients can gain self-esteem and confidence and build social interaction skills (Simmons-Mackie, 2001).

The enhanced compensatory strategy training in social approach gives priorities to generativity and interactivity. Instead of training corpus gesture, client generates the idea via gesture in dynamic interchange (Simmons-Mackie, 2001). The group therapy is also applied in social approach to practice conversational skills within group format. It focuses on interaction rather discrete skills unlike the naming approach which could facilitate participation.

To conclude, aphasia is a kind of disorder which has impairment in communication which has adverse effect for social participation. Cognitive neuropsychological has provided the theoretical and practical tools for identifying the level of impairment in word finding for a subject. However, it needs prospective case series studies which can examine how different types of patient respond to a treatment, so that clinicians can compare one treatment across subjects. The contribution of cognitive neuropsychology to studies of aphasic treatment is then “in bringing greater sophistication to the proper design of the studies and in considering the processes involved in treatment tasks and how this might be effective” (Howard, 2000, p.97). The variety of case studies have shown that specific treatments can be effective, however, more researches are still needed to work on it. The contribution of social approach is that it has modified the structure and the content of service. It focuses on the development of health identities with aphasia rather than the level of impairment in therapy (Simmons-Mackie, 2001). It helps to increase communicative confidence by practicing in a more interactive environment.

References

Basso, A. (2003). Therapy for lexical disorders. In Papathanasiou, I. and Bleser,            

The sciences of aphasia: from therapy to theory. Boston: Pergamon

Byng, S., Pound, C. and Parr, S. (2000). Living with aphasia: a framework for therapy

Interventions. In Papathanasiou, I.Acquired neurogenic communication disorders: a clinical perspective. London: Whurr

Chapey, R. & Hallowell, B. (2001). Intorduction to language intervention strategies in

adult aphasia. In Chapey, R. (4th Ed.), Language intervention strategies in aphasia and related neurogenic communication disorders.Philadelphia : Lippincott Williams & Wilkins.

Elman, R.J. (2005). Social and life participation approaches to aphasia intervention. In

LaPointe, L.L. (3rd Ed.), Aphasia and related neurogenic language disorders. New York: Thieme.

Haynes, W.O., Pindzola, R.H. & Emerick, L.L. (1992). Diagnosis and Evaluation in

Speech Pathology. Englewood Cliffs: Prentice Hall.

Hedge, M. N. (1991). Introduction to communicative disorders. Texas: Pro-Ed, Inc.

Hedge, M.N. (1998). A coursebook on aphasia and other neurogenic language disorders.

San Diego: Singular Pub. Group.

Howard, D. (2000). Cognitive neuropsychology and aphasia therapy: the case of word

retrieval. In Papathanasiou, I.Acquired neurogenic communication disorders: a clinical perspective. London: Whurr

LaPointe, L.L. (2003). Functional and pragmatic directions in aphasia therapy. In

Papathanasiou,I. and Bleser, The sciences of aphasia : from therapy to theory. Boston: Pergamon

LPAA Project Group (2001). Life participation approach to aphasia: A statement of

values for the future. In Chapey, R. (4th Ed.), Language intervention strategies in aphasia and related neurogenic communication disorders.Philadelphia : Lippincott Williams & Wilkins.

National Aphasia Association (1999). Aphasia: The Facts. Retrieved April 27, 2006,

from http://www.aphasia.org/facts.php

Simmons-Mackie, N. (2001). Functional, pragmatic & psychological social approaches to

aphasia interventions. In Chapey, R. (4th Ed.), Language intervention strategies in aphasia and related neurogenic communication disorders.Philadelphia : Lippincott Williams & Wilkins.

Whitworth,A., Webster,J. &Howard,D. (2005). A cognitive neuropsychological approach

to assessment and intervention aphasia: A clinician’s guide. New York: Psychology Press

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