55 Word-Finding Strategies in Closed Head Injured Adults Juleen Kleiman, BA (Speech and Hearing Therapy) (Witwatersrand) Lesley Bucke, BA (Speech and Hearing Therapy) (Witwatersrand) Department of Speech Pathology and Audiology, University of Witwatersrand, Johannesburg ABSTRACT Word-finding difficulties are a common and prominent language deficit following closed head injury. The word-finding difficulties of three closed head injured patients were investigated within the framework of compensatory strategies using Teicher's Taxonomy of Word- Finding Strategies (Teicher, 1986). The word-finding difficulties were evaluated during procedural discourse and two confrontation nam- ing conditions. Each subject's communicative competence and language ability was determined. Results indicated that all subjects employed a wide range of strategies, particularly during confrontation naming, but with differential effectiveness. A relationship was noted between the strategy's effectiveness and the subject's pragmatic ability. The results are discussed in the light of the existing literature on head injury. The theoretical and clinical implications are considered. OPSOMMING Woordvindprobleme is 'n algemene en prominente taalverskynsel na geslote hoofbeserings. Woordvindprobleme van proefpersone met geslote hoofbeserings is geevalueer binne 'n raamwerk van kompensasiestrategiee deur gebruik te maak van Teicher se "Taxonomy of Word-Finding Strategies" (Teicher, 1986). Die woordvindprobleme is geevalueer tydens proseduregesprekke en twee konfrontasie- benoemingstake. Elke proefpersoon se kommunikasie- en taalvaardigheid is bepaal. Die resultate dui daarop dat al die proefpersone gebruik gemaak het van 'n wye reeks stategiee, veral tydens konfrontasiebenoeming, maar met variasie in effektiwiteit. 'n Ooreenkoms is opgemerk tussen die strategies wat gebruik is en die proefpersone se pragmatiese vermoens. Die resultate is bespreek in die lig van reeds bestaande literatuur in verband met geslote hoofbeserings en daar is verwys na teoretiese en kliniese implikasies. Closed Head Injury (CHI) has been termed "the invisible epidemic" (Holland, 1982) in view of the marked increase in the incidence of the disorder during this decade (Annegers, Grabouw, Kurland and Laws, 1980). The primary source of pathophysiology in CHI is that of blunt trauma to the skull which results in multiple diffuse damage to the brain, discontinuation of neural substance and shearing and straining of the axons in j the white brain matter occurs (Hagen, 1984). This results 'in a diversity of cognitive, memory and language deficits, based on the combination of pathophysiologic mechanisms and severity of the injury (Ylivisaker and Szekeres, 1986). The CHI patient therefore presents the speech-language pathologist with a "unique and complex diagnostic, prognostic and treatment challenge" (Hagen, 1984:245). The neurobehavioural and linguistic sequelae following CHI constitutes an area of much controversy. Different labels including "aphasia" (Luria, 1970), "subclinical aphasia" (Sarno, 1980) and "confused" language (Hagen, 1984) have been adopted to describe the linguistic symp- toms following CHI. The heterogeneity of this population is being increasingly well recognised. Despite this heteroge- neity, researchers are in agreement that anomia is a com- mon and prominent language deficit following CHI (Hagen, 1984; Heilman, Safron and Geschwind, 1971; Levin, Benton and Grossman, 1981). Anomia has been defined as poor access to lexical items (word retrieval) and as a failure to name on confrontation and during discourse (Goodglass, Kaplan, Weintraub and Ackerman, 1976). The primary cortical areas identified as being responsible for naming abilities include the parieto- temporo-occipital areas of the left dominant hemisphere (Luria, 1975; Benson, 1979). The CHI patient frequently presents with circumlocutions, paraphasias and reduced fluency which are typical of aphasia (Holland, 1982). In ad- dition, CHI patients reportedly exhibit "non-aphasic" nam- ing errors resulting from their impulsivity, perceptual dis- inhibition and lack of language boundness (Holland, 1982; Teicher, 1986). Within the past few years there has been a renewed focus on the importance of observing and assessing language and behaviour of the CHI within a compensatory strategy framework? (Kirchner and Skarakis-Doyle, 1983; Penn, 1985; Penn and Cleary, 1987; Teicher, 1986). When com- pensation follows a head injury we are observing the pa- tient's direct attempt to compensate for his primary deficits. This is in accord with Piaget's (1952) belief that the human organism constantly strives to maintain a balance and adapt to environmental demands. This process of equilibrium is determined in part by neurological and subject variables, and in part by ecologic variables (Penn and Cleary, 1987). Compensatory strategies, which may develop spontaneous- ly or which may be trained, have been defined as alternate methods of controlling and manipulating information (Kirchner and Skarakis-Doyle, 1983). The individual adopts these strategies to meet the communicative demands of the situation when he is unable to bring together all the necessary resources, as a result of brain damage (Penn, Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 35, 1988 © SASHA 1988 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 56 J u l e e n Kleiman and Lesley Bucke 1985). The degree to which a brain damaged patient will develop and utilise compensatory strategies will play a ma- jor role in determining the eventual outcome for the patient (Penn, 1985). Teicher (1986) examined the word-finding strategies employed by a group of CHI individuals during an instance of word-finding difficulty. The results revealed that by utilising a behavioural taxonomy to assess word-finding strategies, many of the strategies employed by the subjects could be identified, described and compared within and across subjects. Profiles of successful and unsuccessful stra- tegies and their pragmatic effectiveness were identified. Furthermore, the importance of evaluating naming ability during discourse, as well as confrontation naming was stressed. This study highlighted the potential value of the CHI population's word-finding difficulties within a compen- satory framework. According to Ylvisaker and Szekeres (1986:474) "Impaired social interaction is often the residual deficit most troubling for the patient's family and for the pa- tient himself." Assessment tools which therefore have as their basis a social interaction model of communication which incorporates linguistic, pragmatic, social and cognitive variables are invaluable (Penn and Cleary, 1987). The purpose of this study therefore is to examine the word- finding compensatory strategies being employed by three CHI subjects during discourse and confrontation naming and to determine the effectiveness of these strategies in communicative interaction. By evaluating CHI word- finding difficulties in terms of compensatory strategies a pattern of behaviour may emerge which may offer insight into the central nervous sytem (Marshall, 1976) as well as provide us with useful prognostic and diagnostic informa- tion. This will then assist us in designing more effective therapeutic strategies as the ultimate therapeutic goal, ac- cording to Penn (1985), is to teach positive strategies which will increase pragmatic competence and flexibility of style. METHOD Aims The aim of the present study was to identify, describe and compare the word-finding strategies employed by three CHI subjects during procedural discourse and confrontation naming tasks in an effort to adapt to their word-finding dif- ficulties. The study was further designed to determine whether a relationship exists between the nature and the ef- fectiveness of such strategies, and the individual's overall communicative effectiveness and language ability. Subjects (Ss) Three English speaking subjects who had sustained closed head injuries as a result of motor vehicle accidents (Ss 1 and 2) and assault (S3) were selected as subjects for this study. Ss 1 and 3 were males, S2 female and their age range was 27.1 years to 44.4 years (mean 33.3 years). Mean coma duration of the subjects was 4 weeks (range 2 — 6 weeks), thus indi- cating a severe head injury according to the criteria suggest- ed by Russell (1971). All subjects were neurologically stable at the time of testing with a mean post-injury time of 21 months (range 8 — 48 months). Subjects were all pretrauma- tically right-handed and had completed at least 11 years of schooling. Family reports indicated that subjects were of average intellectual capacity prior to the accident. No pre- vious history of sensory or motor deficit was reported nor was any history of drug or alcohol abuse noted. Hearing was within normal limits for all three subjects at the time of testing. Further relevant clinical and biographical details are included in table 1 below. Testing material As there are presently no language tests designed specifi- cally for the CHI population it was necessary to employ and Table 1: Relevant clinical and biographical detail for all subjects SUBJECT 1 SUBJECT 2 SUBJECT 3 Age 27.1 years 28.3 years 44.4 years , Sex Male Female Male J Educational Standard 9 Apprentice Matric Diploma Greenoaks Secretarial College Standard 8 j • 1 Premorbid laterality Right Right Right <' | Coma (weeks) 3 6 2 ! Time since injury to testing (months) 48 8 8 History of speech therapy Yes, until 1984 Presently receiving theraphy Yes, until 1987 Present motor problems L-arm hemiplegia L-hemiplegia. Previous L-side neglect resolved L-hemiplegia Occupation Supervising packing of medical supplies Unemployed Unemployed ** / Immediate post-trauma cat scan results Diffuse cerebral oedema with small parieto-temporal haemorrhage on left Diffuse cerebral oedema with parieto-occipital haemorrhage on right Intracerebral haemorrhage occupying most of right tem- poral lobe with right and left lateral ventricle involve- ment. Craniotomy to drain sub-dural haemotoma The South African Journal of Communication Disorders, Vol. 35, 1988 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Word-Finding Strategies in Closed Head Injured Adults 57 modify tests designed for other neurogenic groups such as aphasia. The following tests were administered: a. Western Aphasia Battery (WAB) (Kertesz, 1980) - the Aphasia Quotient (AQ) was only administered as it serves as a functional measure of spoken language impairment. It thus provided an overall language severity score in subjects and a basis for comparison between subjects. b. Prutting's Pragmatic Protocol (Prutting, 1982) — a strong relationship seems to exist between the CHI Ss' effective use of compensatory strategies and their overall commu- nicative competence (Cleary, 1985; Teicher, 1986). The general pragmatic communication abilities of the Ss were therefore assessed using Prutting's Pragmatic Protocol (Prutting, 1982). This provides a global measure of com- municative competence and places language in the con- text of socialisation. The data for the analysis consisted of a 10 minute inter- actional language sample which was simultaneously video- and audiotaped. Topics discussed in this sequence were: family structure, the subject's accident, daily acti- vities and interests. c. Discourse Tasks — this is a procedure for sampling and quantifying connective speech for CHI Ss who display social and vocational communicative deficits yet have difficulty on standardised aphasia tests (Milton, Prutting and Binder, 1984). Procedural discourse was employed as the mode of elicitation and it provides the tester with a moderate level of context control and has temporal con- straints (Ulatowska, North and Macaluso-Haynes, 1981). The task involved a complete discussion of three daily ac- tivities noted for their familiarity and relatively high fre- quency of occurrence for an adult (Ulatowska et al. 1981). Instructions given were: "I'd like you to tell me as completely as possible, how to make a sandwich; change / a bed; wash laundry." d. Confrontation naming tests — chosen to evaluate different aspects of confrontation naming. The Boston Naming Test (BNT) (Kaplan, Goodglass and Weintraub, 1976) was employed to evaluate object (noun) naming on confronta- tion, while the Action Naming Test (ANT) (Obler and Al- bert, 1986) was employed to evaluate action (verb) nam- ing on confrontation. Repetition and cueing were pro- vided if the subject did not respond after a 20 second delay. Behaviours associated with word-finding difficulties on the procedural discourse tasks, the BNT and the ANT, were described using Teicher's Behavioural Taxonomy of Word-Finding Strategies (Teicher, 1986), based on Penn's Taxonomy of Compensatory Strategies (1985). This qualitative analysis yields pertinent information about language use difficulties in CHI. Five broad strate- gy categories were derived and are displayed in table 2. An additional category for analysis "Repetition" was in- cluded in the taxonomy as Penn (1985) makes use of this strategy in her Taxonomy of Compensatory Strategies. Repetition facilitates processing and captures the listener's attention. A 'detailed description and example of each word-finding strategy is displayed in appendix I. Table 2: Teicher's taxonomy of word-finding strate- gies (Teicher, 1985) Elaboration Fluency Description Circumlocution Silent pause Filled pause Non-verbal/Paralinguistic Social Symbolic Noise Meaningless Gesture Iconic/Pantomime Facial Expression Deictic Comment Clause Self-correction Requests Help Other Any behaviour not includ- ed in the preceding catego- ries Testing procedure Testing was carried out individually and extended over a number of morning sessions in an attempt to eliminate fati- gue as a confounding variable. In order to reduce anxiety, rapport was established with each subject prior to his being tested. Analysis of data Standardised tests administered were scored according to the procedure laid down in the test manual. Non-standar- dised test results were analysed according to the methods described previously. The examiner and two reliability judges completed Prutting's Pragmatic Protocol (Prutting, 1982) independent- ly in order to measure reliability. Point-to-point inter-rater reliability was calculated separately for the three categories of the protocol. Reliability was 82%, with a range extending from 75,5% to 85,5%. Rating was thus reliable, based on Sil- verman's (1977:157) minimal acceptable inter-rater reliabili- ty of 0,75. Three raters rated each Ss' word-finding strategies using Teicher's Taxonomy of Word-Finding Strategies (Teicher, 1986). The raters involved one of the authors and two third year speech therapy students blind to the aims of the study. All raters had been trained in the use of the profile. Training sessions included familiarisation, discussion and explana- tion of each strategy listed on the taxonomy. Clinical video- tapes of CHI Ss engaged in conversation were chosen to il- lustrate and clarify certain strategies. Judges rated each interaction separately and independently on all three view- ings and completed the ratings according to their observa- tion of relevant dimensions. During the first viewing, raters were required to underline when a word-finding difficulty had occurred. During the se- cond viewing, the raters were required to comment if the word search was successful or unsuccessful. A successful word search was any attempt at word-finding which result- ed in the production of a specific lexical item. In an unsuc- cessful word search, the listener may not have known the desired word, but knew when the speaker had not reached the target word or when the search strategy was ineffective Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 35, 1988 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 58 J u l e e n Kleiman and Lesley Bucke (Teicher, 1986). Finally, the raters were required to catego- rise the behaviours accompanying the word-finding in- stances into Teicher's Behavioural Taxonomy (Teicher, 1986). Point to point inter-rater reliability was determined. Re- liability values ranged from 83.2% for S2 to 77.4% for SI. It can therefore be concluded that rating was reliable accord- ing to Silverman's (1977; 157) minimal acceptable inter- rater reliability value of 0.75. Duration of each word search for all Ss was analysed quanti- tatively by' computing the overall ratings of successful and unsuccessful searches. It was calculated from the moment of onset of the search to the moment of successful or unsuccessful achievement and then rounded to the nearest half second. Finally, the percen- tage of time each initial word-finding strategy and strategy sequence was employed successfully and unsuccessfully was computed for each subject. RESULTS AND DISCUSSION a. Western Aphasia Battery (Kertesz, 1980) Subject 1 obtained a WAB Aphasia Quotient of 74.8 while Ss 2 and 3 scored 92.6 and 64.0 respectively. None of the Ss therefore scored above 93.8 which is the suggested cut-off point for aphasia (Kertesz, 1980). This indicates an element of language form disturbance for all Ss, the nature of which was diffuse. This contradicts Milton, Prutting and Binder's (1984) opinion that CHI Ss do not present with a degree of aphasia. Word-finding difficulties were observed in all Ss in addition to problems in the areas of comprehension and repetition which correlates with Cleary's (1985) findings. Brooks (1984), Cleary (1985) and Groher (1977) have sug- gested that an underlying memory problem together with reduced attention and concentration span are contributory factors towards overall difficulties in these areas. Naming ability and verbal associative fluency have been shown to be the most effective predictors of injury (Levin et al. 1981) which corresponds with the findings. S3 presented with the most severe generalised cerebral dysfunction in addition to the most severe linguistic deficit. b. Prutting's Pragmatic Protocol (Prutting, 1982) All 3 Ss presented with a greater or lesser degree of pragma- tic difficulty. S2 experienced the least overall difficulty (15% inappropriate responses), SI presented with 22% inappro- priate responses while S3 experienced the most overall diffi- culty (66%). Similar findings were found on the WAB (Kertesz, 1980). This observation contributes towards Irvine and Behrmann's (1986) finding of a balance existing bet- ween language form and language use skills in CHI in- dividuals. Results indicate that overall appropriateness of subjects' responses occurred mainly in the Utterance Act and the Pro- positional Act categories while the least appropriate response occurred in the Ilocutionary/Perlocutionary Act. This is in agreement with Cleary (1985), Milton et al. (1984), and Teicher (1986) and it seems to imply that CHI indivi- duals function inadequately in their roles as discourse part- ners. The South African Journal of Communication Disorders, Vol. 35, 1988 Table 3: Subjects' performance on the procedural discourse tasks SI S2 S3 Number of word-finding difficulties 32 7 19 Percentage: Successful 69% 86% 74% Percentage: Unsuccessful 31% 14% 26% , Duration: Successful Mean Range 2.0 sec 0.5 — 5.0 sec 1.0 sec 0.5 — 1.0 sec 2.0 sec | 1.0 — 5.0 sec ' Duration: Unsuccessful Mean Range 3.5 sec 0.5 — 7.0 sec 2.0 sec 4.0 sec ; 2.0 - 5.0 sec j Number of different strategies used: ' Successful 7 2 ! Number of different strategies used: ' Unsuccessful 7 2 4 Number of different strategy sequences: Successful 5 0 3 Number of different strategy sequences: Unsuccessful 6 1 2 Most frequently used initial strategy: Successful Filled pause 37% Silent delay 86% Filled pause 58% Most frequently used initial strategy: Unsuccessful Filled pause 30% Repetition 30% Silent delay 100% Filled pause 100% Most frequently used stategy sequence: Successful Filled pause/ Repetition 23% / Filled pause/ Silent delay ' 2 1 % Most frequently used stategy sequence: Unsuccessful Filled pause/ Repetition 20% Filled pause/ Description 60% R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Word-Finding Strategies in Closed Head Injured Adults 59 c. Procedural discourse tasks While all 3 subjects presented with word-finding difficulties they all experienced relatively high levels of success for pro- duction of the desired lexical item following this difficulty. Table 3 describes the subjects' performance during the pro- cedural discourse tasks. Both the duration mean and range of word searches were calculated. All Ss presented with a longer duration when strategies were unsuccessful. For example S3's mean dura- tion of a successful word search was 2 seconds while that of an unsuccessful word search was 4 seconds, a difference of 2 seconds. A wide range of successful and unsuccessful in- itial word-finding strategies were employed, namely filled pause, silent delay and repetition, though a greater number and variation of strategies were used when success was not attained. This may relate to the Ss' attempts to compensate for increased instances of word-finding difficulty. Certain strategies occurred more frequently than others, particular- ly fluency strategies. Silent delay and filled pause were em- ployed 69% of the time during a successful word search and 75% during an unsuccessful word search. Repetition was the most facilitative initial strategy and was employed by Ss to maintain listener attention (Penn, 1985). Ss 1 and 3 employed word-finding strategy sequences, successfully and unsuccessfully, in an attempt to produce desired lexical items. Filled pause was the most frequently used initial stra- tegy in all sequences. Filled pause may be potentially dis- tracting if used too often (Cleary, 1985). This was particular- ly evident in Si's speech where it was the most frequently Table 4: Subjects' performance on the BNT used initial strategy and part of the most frequently used strategy sequence, both successfully and unsuccessfully. This may relate to the increased number of word-finding difficulties experienced by SI. d. Confrontation Naming Tests — Boston Naming Test (BNT) (Kaplan et al. 1976) All Ss experienced word-finding difficulties and, as a result, employed word-finding strategies to overcome this difficul- ty. Table 4 illustrates the Ss' performance on the BNT (Kaplan et al. 1976). The level of success for production of the desired lexical item was relatively low for all Ss — 16%, 20% and 42% for Ss 1, 2 and 3 respectively. The duration mean and range of word searches indicates that all Ss presented with a longer duration when strategies were unsuccessful, for example 8 seconds versus 2 seconds for S3. The Ss' re- sults differed from each other for successful and unsuccess- ful initial word-finding strategies. However, for all Ss, an in- crease in the number and variation of different initial strate- gies and word-finding strategy sequences was evident when success was unattainable. All Ss employed word-finding strategy sequences, but the most frequently used successful and unsuccessful strategy sequences varied across and with- in Ss. S2, however, employed the same successful and un- successful strategy sequences, silent delay/description. This is hypothesised to relate to S2's careful self-monitoring. Ela- boration strategies (description and elimination), fluency SI S2 S3 Number of word-finding difficulties 49 30 19 Percentage: Successful 16% 20% 42% Percentage: Unsuccessful 84% 80% 58% / / / Percentage: Successful with cueing phonemic cues 34% 56% 57% / / / Percentage: Stimulus cues 0% 44% 0% Duration: Successful Mean Range 6.0 sec 1.0 - 20.5 sec 6.5 sec 2.0 - 10.0 sec 2.0 sec 0.5 - 3.5 sec Duration: Unsuccessful Mean Range 10.0 sec 2.5 - 19.0 sec 8.5 sec 2.5 - 14.5 sec 8.0 sec 2.5 - 11.5 sec . / , Successful 5 3 5 t iNumDer o r u m e r e n t s t r a t e g i e s u s e u . Unsuccessful 11 6 5 Successful 4 2 1 iNumDer o i u m e r e n t s t r a t e g y s e q u e n c e s . Unsuccessful 14 11 5 Most frequently used initial strategy: Successful Repetition 50% Silent delay 50% Repetition 63% Most frequently used initial strategy: Unsuccessful Description 50% Description 45% Description 73% Successful Repetition/ Description 25% Silent delay/ Description 33% Comment/ Filled pause 13% iviost irequentiy useu stategy sequence: 1 Unsuccessful Description/ Comment clause 13% Silent delay/ Description 30% Description/ Filled pause 28% Die Suid-Afrikaanse Tydskrif vir Kommunikasieawykings, Vol. 35, 1988 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 60 J u l e e n Kleiman and Lesley Bucke strategies (silent delay and filled pause) and social strategies (comment clause, self-correction and requests help) were the most frequently used initial strategies. All the Ss re- quired cues following the failure to name the desired lexical item. Phonemic cues were the most successful in facilitating retrieval of the specific lexical item for all Ss. — Action Naming Tests (ANT) (Obler and Albert, 1986) All 3 Ss experienced instances of word-finding difficulty on the ANT. They employed word-finding strategies to over- come their difficulty. Table 5 illustrates the Ss' performance on the ANT (Obler and Albert, 1986). Level of success for production of the desired lexical item was low for all Ss — 27%, 22% and 30% for Ss 1, 2 and 3 respectively. Results obtained correlate closely with those obtained on the Β NT (Kaplan et al. 1976). Ss presented with longer duration when strategies were un- successful in facilitating production of the specific lexical item. For all Ss an increase in the number of different initial strategies and strategy sequences was evident when success was not attained. S3, however, deviated from the trend. The number of different initial strategies employed during the BNT (Kaplan et al. 1976) and the ANT (Obler and Albert, 1986) for successful and unsuccessful word searches was equivalent. SI and S2 employed word-finding strategy se- quences while S3 failed to successfully employ strategy se- quences. This is hypothesised to relate to S3's inappropriate pragmatic behaviour and lack of self-monitoring. The most frequently used successful and unsuccessful strategy se- quences varied across and within Ss except S2 who em- ployed the same strategy sequence (silent delay — descrip- tion) successfully and unsuccessfully.' This was also evi- dent on the BNT (Kaplan et al. 1976). Fluency and elabora- tion strategies were the most frequently employed initial word-finding strategies. All Ss required cues following the failure to name the desired word, and phonemic cues were the most successful in facilitating retrieval of the specific lexical item. The superiority of phonemic cues over stimu- lus and verbal contextual cues is confirmed by the results on both confrontation naming tests and by the studies perform- ed by Pease and Goodglass (1978) and Williams (1983). e. Summary of results and discussion The results indicate that three different patterns of perfor- mance were identified with some commonality of word- finding strategies employed across Ss. The study indicates that a relationship exists between Ss' effective use of word- finding strategies during procedural discourse tasks and their overall communicative competence, as shown on Prut- ting's Pragmatic Protocol (Prutting, 1982) and the WAB. Viewed within a compensatory strategy framework, it is ad- vocated that the CHI Ss are self-monitoring more carefully in an attempt to compensate for their deficits; hence the use of word-finding strategies. This is in accord with Cleary Table 5: Subjects' performance on the ANT SI S2 S3 Number of word-finding difficulties 22 18 17 Percentage: Successful 27% 22% 30% Percentage: Unsuccessful 73% 78% 70% Successful with Percentage: cueing phonemic cues 61% 83% 53% Percentage: Verbal contextual cues 45% 56% 29% Successful Mean 5.0 sec 9.5 sec 3.0 sec Duration: Range 2.0 - 8.0 sec 4.5 - 13.0 sec 1.5 - 5.0 sec Duration: Unsuccessful Mean 11.0 sec 10.0 sec 6.5 sec Range 5.5 - 18.5 sec 4.5 - 18.0 sec 0.5 - 16.5 sec Number of different strategies used: Successful 4 3 3 Number of different strategies used: Unsuccessful 7 4 3 Number of different strategy sequences: Successful 3 2 0 Number of different strategy sequences: Unsuccessful 7 8 1 Successful Filled pause 38% Description 50% Self-correct 40% Filled pause Most frequently used initial strategy: 40% Most frequently used initial strategy: Unsuccessful Silent delay 38% Description 57% Description 50% Most frequently used stategy sequence: Successful Repetition/ Pantomime 33% Silent delay/ Description 40% Most frequently used stategy sequence: Unsuccessful Filled pause/ Description 32% Silent delay/ Description 35% Description/ Filled pause 16% The South African Journal of Communication Disorders, Vol. 35, 1988 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Word-Finding Strategies in Closed Head Injured Adults 61 (1985) and Teicher (1986). In terms of word-finding difficulty, a confrontation naming task was found to be more difficult for CHI Ss than a pro- cedural discourse task. While procedural discourse max- imally challenges the CHI individual's communicative abili- ty, it may facilitate naming as found in non-brain damaged individuals (Clark and Clark, 1977). The semantic, syntactic and temporal constraints characteristic of procedural dis- course (Ulatowska et al. 1981) seemed to assist Ss 2 and 3 in the recall and production of the desired lexical items as the "lost" word seemed to be closer to the "tip of the tongue". Within the confrontation naming task, naming of objects (nouns) appeared to be more difficult than the naming of ac- tions (verbs). This finding is consistent with the findings of Goodglass et al.'s (1966) study and Irvine and Behrmann's (1986) study. Mean length of response time for successful and unsuccess- ful searches during the procedural discourse tasks was less than during the confrontation naming condition for all 3 Ss. This is hypothesised to relate to the nature of the discourse task which may have facilitated naming. This finding is con- firmed by Newcombe et al. (1965, cited by Berko-Gleason, Goodglass, Obler, Greene, Hyde and Weintraub, 1980) and Teicher (1986). SI presented with a longer successful mean latency for object naming versus action naming whereas the converse was found for Ss2 and 3. Furthermore individual patterns exist for unsuccessful mean latencies for object and action naming. It is evident from the data that no one pat- tern of performance is generated, confirming the notion of heterogeneity within the CHI population (Hagen, 1984; Ir- vine and Behrmann, 1986). In contrast to this diverse pic- ture, all Ss presented with a longer duration for unsuccess- ful word-finding strategies during procedural discourse and confrontation naming. Pausing to reconsider and reattempt when not experiencing success is speculated to contribute to this longer duration as CHI Ss experience significant diffi- culty processing complex information (Hagen, 1984). I i AlKSs displayed an increase in the number of different in- itial strategies and different strategy sequences when suc- cess was not attained. It appears that in an attempt to over- come the unsuccessful attempt, additional and varied strate- gies are employed. This appears to confirm a breakdown in Luria's (1975) 'rule of forcej theory where strong and weak stimuli evoke similar responses so that no selective organi- sation of the relevant associational process is possible. An analysis of the entire sequence of strategies employed reveals much variability across and within Ss. The same initial strategies were used successfully and un- successfully by all the Ss during the procedural discourse tasks and occasionally during the confrontation naming tasks, namely fluency strategies. This finding correlates with Cleary's (1985) and Teicher's (1986) results. Ulatowska et al. (1981) state that in discourse, message transmission in any form is the goal. Therefore the CHI Ss, in an attempt to maintain the conversational flow and transmit the message, predominantly adopted fluency strategies. Other strategies employed which were not accounted for by Teicher's Behavioural Taxonomy of Word-Finding Strate- gies (1986) were the use of unfinished words, Okay', and humour. These strategies have implications in the develop- ment of assessment tools for CHI and in their treatment. In summary, word-finding strategies were employed by all the subjects in an attempt to overcome their word-finding difficulty, but to differential effect. There are several possi- ble explanations for the performance variation noted. Coma duration and neurological dynamics may account for the differences. Other variables which may play a role are age range, the time-since-injury and non-medical variables such as personality and motivation since affective disorders are a well-recognised by-product of CHI (Hagen, 1984). In addition, the increasingly well accepted fact that the CHI group is a heterogeneous group is a further important consi- deration. Individual patterns, rather than a single group pat- tern, characterise this population (Irvine and Behrmann, 1986), a finding supported by this data. CONCLUSION It is clear from this study that CHI Ss are generally using word-finding strategies frequently and effectively to over- come their word-finding difficulties. This is in agreement with the results of Teicher's (1986) study. This may indicate that CHI Ss are, in fact, effective commu- nicators who learn useful compensatory strategies if given the opportunity to do so (Cleary, 1985; Teicher, 1986). The implications of this finding for remediation are many. In view of the heterogeneity of the CHI population, it is essen- tial that the clinician assesses each closed head injured pa- tient individually without relying on the predicted findings from the literature. The need for sensitive assessment measures aimed at evaluating communicative efficiency in CHI is stressed. Measures such as Teicher's Taxonomy (1986) may be employed to present a profile of compensato- ry strategies. The speech-language pathologist may then structure an effective treatment programme as "... treat- ment serves to challenge and channel spontaneous recovery, maximise residual function, and compensate for lost abilities." (Hagen, 1984:275.) REFERENCES Annegers, J.F., Grabouw, J.D., Kurland, L.T. and Laws, E.R. The incidence, causes and secural trends of head trauma in Olmsted Country, Minnesota. Neurology, 30, 912—919, 1980. Benson, D.F. Neurological correlates of anomia. In H. Whitaker and H. Whitaker (Eds.) Studies in Neurolinguistics. New York: Academic Press, 1979. Berko-Gleason, K., Goodglass, H., Obler, L., Greene, E., Hyde, M.R., and Weintraub, S. Narrative strategies of aphasic and normal speaking subjects. Journal of Speech and Hearing Research, 23, 3 7 0 - 3 8 2 , 1980. Brooks, N. Cognitive deficits after head injury. In N. Brooks (Ed.) Closed Head Injury — Psychological, Social and Family Conse- quences. New York: Oxford University Press, 1984. Clark, H. and Clark, E. Psychology and Language: An Introduction to Psycholinguistics. New York: Harcourt Brace Jovanovich, 1977. Cleary, J. Compensatory Strategies in Closed Head Injury. Undergra- duate research report, Department of Speech Pathology and Audiology, University of the Witwatersrand, 1985. Goodglass, H., Kaplan, E., Weintraub, S. and Ackerman, N. The "Tip-of-the-tongue" phenomenon in aphasia. Cortex, 12, 1 4 5 - 1 5 3 , 1976. Groher, M. Language and memory disorders following closed head trauma. Journal of Speech and Hearing Research, 20, 2 1 2 - 2 2 3 , 1977. Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 35, 1988 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 62 Juleen Kleiman and Lesley Bucke Hagen, C. Language disorders in head trauma. In A. Holland (Ed.) Language Disorders in Adults. San Diego: College-Hill Press, 1984. Heilman, K., Safron, A. and Geschwind, N. Closed head trauma and aphasia. Journal of Neurology, Neurosurgery and Psy- chiatry, 34, 2 6 5 - 2 6 9 , 1971. Holland, A. When is aphasia aphasia? The problem of closed head in- jury. Paper presented at the Clinical Aphasiology Con- ference, Oshkosh, Wisconsin, 1982. Irvine, L. and Behrmann, M. The communicative and cognitive deficits following closed head injury. South African Journal of Communication Disorders, 33, 49—54, 1986. Kaplan, E., Goodglass, H. and Weintraub, S. The Boston Naming Test. Unpublished test, Boston, M.A. : Veterans Hospital, 1976. Kertesz, A. Western Aphasia Battery. London, Ontario, Canada: Uni- versity of Western Ontario, 1980. Kirchner, D. and Skarakis-Doyle, E. Developmental language dis- orders: a theoretical perspective. In T. Gallagher and C. Prutting (Eds.) Pragmatic Assessment and Intervention Issues in Language. San Diego: College-Hill Press, 1983 Levin, H.S., Benton, A.L. and Grossman, R.G. Neurobehavioural Consequences of Closed Head Injury. New York: Oxford Univer- sity Press, 1981. Luria, A.R. Traumatic Aphasia: Its Syndromes, Psychology and Treat- ment. The Hague: Mouton, 1970. Luria, A.R. Basic problems of language in the light of psychology and neurolinguistics. In E. Lennenberg and E. Lennenberg (Eds.) Foundations of Language Development. New York: Academic Press, 1975. Marshall, R.C. Word retrieval of aphasic adults. Journal of Speech and Hearing Disorders, 61, 444—451, 1976. Milton, S.B., Prutting, C.A. and Binder, G.M. Appraisal of communi- cative competence in head injured adults. Paper presented at the Clinical Aphasiology Conference, Seabrook Island, Cali- fornia, 1984. Obler, L.K. and Albert, M.L. The Action Naming Test, 1986. Pease, D. and Goodglass, H. The effects of cueing on picture nam- ing in aphasia. Cortex, 14, 178—189, 1978. Penn, C. Compensatory strategies in aphasia: behavioural and neurological correlates. In K.M. Grieve and D. Griesel (Eds.) Neuropsychology. University of South Africa Press, Muckle- neuk, Pretoria, 1985. Penn, C. and Cleary, J. Compensatory strategies in the language of closed head injured patients. Unpublished paper, University of the Witwatersrand, Johannesburg, 1987. Piaget, J. The Origin of Intelligence in Children. New York: Basic Books, 1952. Prutting, C.A. Pragmatics as social competence. Journal of Speech and Hearing Disorders. 47, 123—134, 1982. Russell, W.R. The Traumatic Amnesias. London: Oxford University Press, 1971. Sarno, M.T. The nature of verbal impairment after closed head injury. Journal of Nervous and Mental Disorders, 1968, 6 8 5 - 6 9 2 , 1980. Silverman, S. Research Design in Speech Pathology and Audiology, Engelwood Cliffs, New Jersey : Prentice Hall Inc., 1977. Teicher, S.H. Word-finding Strategies in Closed Head Injured Adults. Masters dissertation, University of California, Santa Bar- bara, 1986. Ulatowska, H., North, Α., Macaluso-Haynes, S. Production of nar- rative and procedural discourse in aphasia. Brain and Langauge, 13, 3 4 5 - 3 7 1 , 1981. Williams, S. Factors influencing naming performance in aphasia: A review of the literature. Journal of Communication Dis- orders, 16, 357—372, 1983. Ylivisaker, M. and Szekeres, S.F. Management of the patient with closed head injury. In R. Chapey (Ed.) Language Intervention Strategy in Adult Aphasia (2nd Ed). Williams and Wilkins, Bal- timore: 1986. The South African Journal of Communication Disorders, Vol. 35, 1988 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Word-Finding Strategies in Closed Head Injured Adults 6 3 APPENDIX 1 Description of Teicher's (1986) taxonomy of word-finding strategies STRATEGY TYPE DEFINITION EXAMPLES ELABORATION — Description — Circumlocution — Elimination FLUENCY — Silent delay — Filled pause SOCIAL — Comment clause — Self-correction — Requests help NON-VERBAL/ PARALINGUISTIC — Symbolic noise Meaningless gesture Iconic gesture/ Pantomime — Facial expression — Deictic OTHER — Incorrect lexical choice Expansion or elaboration of the message to ensure effec- tive transmission. Description of the appearance or function of what is being spoken about. Production of general words or "empty words" (Heilman et al. 1971) in place of the desired word. Elimination of a series of words which may be semanti- cally related to the desired word. Used to hold the place in conversation. An unfilled pause. Pause filled with some sound indicating ongoing lexical search. Devices reflecting sensitivity to the needs of the inter- locuter. Any metalanguage about the desired word search used to maintain a speaking turn. Correction of phonetic or semantic errors without cues from the listener. Direct request or a non-verbal cue for help. Vocal and/or gestural behaviours which supplement or substitute for the verbal message. ί Sound effects made in conjunction with or in place of the intended word to ensure effective transmission. Meaningless, natural gesture, lacking structure. Clearly, discernible gesture representing a particular word, object or its use. Facial configuration in conjunction with or in place of the intended lexical item. Pointing to an object or in a general direction. Any behaviour unclassifiable in the preceding taxonomy Synonym or any acceptable alternative for the desired lexical item. ' Ί have one at home — it's white and you dry yourself with it." (Towel) "You get a free whatschimacallit." "It's not January, it's February." "We use the uh, uhm the book." "You know" or "Oh, what are those things?" "He hit the bat, I mean the ball." "I'll know if you give me the first sound", or use of gesture. The use of a high pitched, glottalised screech made to represent a car's brakes. An upward and outward hand move- ment. Left hand in a cupped position as if hold- ing a jar and the right hand moving in a circular motion above the left as if open- ing a jar. Widening of eyes and opening of mouth to indicate surprise. "Over there" or "that one". "Digging" for "Pushing". Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 35, 1988 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Furnquip Manufacturing and Wholesale Suppliers (Pty) Limited Registration No. 61/02456/07 t / a FURNQUP MEDICAL GROUP YOUR YELLOW PAGES OF MEDICAL EQUIPMENT HEAD OFFICE CORRESPONDENCE ONLY TO: P.O. BOX 84416 GREENSIDE 2034 SOUTH AFRICA TEL. A D D . FURNQUIP TEL: (011) 787-5733/4, 787-5768/9 HEAD OFFICE: "GREENBRIARS" 75 CONRAD DRIVE, BLAIRGOWRIE 2194, SOUTH AFRICA TELEX 4-28072 SA. FAX (2711) 787-5716 ASSOCIATED COMPANIES Deliveries Store Only Furnquip Medical Natal (Pty) Ltd Furnquip Medical Transkei Medical Industries c / o Dolphins Transport P.O. Box 1999, Bophuthatswana (Pty) Ltd (Pty) Ltd Joe Arnison Str., Durban 4000 P.O. Box 84416, P.O. Box 9030 Madeira Str., Labore Tel. 031-309-2313/4 Greenside 2034 Umtata 5100 Brakpan Telex 6-22133 Tel. (011) 787-5717 Tel. 0471-24221 ELECTRONIC ARTIFICIAL LARYNX A N D COMPLETE SPEECH THERAPY AIDS FQ/JM001 — Barts Artificial Larynx Mark II This has been improved and although an old design, is still very useful as a back-up larynx or as a teaching aid. FQ/JM005, 006, 007, 008 These are the different microphones that are available for use with the De Luxe Speech Amplifier (010) and continue in production unchanged. FQ/JM010 - De Luxe Speech Amplifier M k II This has been completely redesigned. Output has been increased by approximately one third and a new loudspeaker used which gives a much clearer and more crisp tone. FQ/JM011 — M a r k II Electronic Artificial Larynx This unit has been improved and now has a separate ON/OFF isolator switch to prevent accidental use in one's pocket etc. The output is increased and if the optional high power battery is used very great volume can be achieved. This unit is supplied with one battery and charger. FQ/JM015 - Pausaid This is supplied complete with a microphone and battery. Pausaid has a throat microphone which will detect when phonation is continuous and will therefore prompt the patient auditorially to make regular stops in speech. FQ/JM016 — Vocal Loudness Indicator The VLI is a compact battery operated device intended to display relative levels of vocal loudness. The VLI consists of a series of eight numbered lights, each lighting up at a different loudness level. FQ/JM017 — Companion Intra Oral Larynx 1 Introduced early 1987, this has proved extremely sue- j cessful as an intra-oral larynx for post operative use and For further information please fill in the following in some cases for permanent use by laryngectomies and return: where a throat larynx is not liked or acceptable. ! Surname: FQ/JM018 - S u m m i t Amplifier ' This is an amplifier in the same housing as the Mark II First Names: 010 amplifier. Address: FQ/JM019 Headset or throat microphone for the new type - amplifier 018. FQ/JM020 - Pocket Audiometer ^ This unit is designed as a front line free field screening Telephone No: audiometer capable of quickly and easily checking whether or not a patient has a hearing problem. V ^ S ^ f K DIRECTORS: G.L.L. HARDING (GROUP MANAGING) J.L. M c F A R L A N D (RN. DIP. NURS. SCI) CONSULTANT NATIONAL (BRITISH) m EVERYTHING FOR HOSPITALS AND INSTITUTIONS UNDER ONE ROOF ^f^s^ "THE ORIGINAL TURNKEY PROJECT SPECIALISTS" R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2)