LISTENERS'ATTITUDES: SPEECH SUPPLEMENTA­ TION STRATEGIES FOR IMPROVING EFFECTIVE­ NESS OF SPEAKERS WITH MIXED DYSARTHRIA AS A RESULT OF MOTOR NEURON DISEASE Natalie Toy and Karin Joubert Department of Speech Pathology and Audiology, University of the Witwatersrand, South Africa Abstract This study examined unfamiliar and familiar listener attitudes towards the use of combined alphabet-topic cues and a control condition (habitual speech with no cues) associated with the speech of three individuals with severe mixed dysarthria. Two listenergroups (N=36) were shown experimentally imposed visual imag- esofthecombinedalphabet-topiccuestrategyinconjunction with recorded auditory presentationswiththe habitual speech of three individuals with mixed dysarthria. Using a 7-point Likert scale, listeners were asked toratehoweffectivetheythoughtthespeakerscommunicated;howcomfortabletheywerecommunicating with the speakers; and how persistent they were in trying to understand the speakers. The results revealed thattherewerenosignificantdifferencesintheattituderatingsoffamiliarlistenersascomparedtounfamiliar listeners. However, resultsrevealedthatratingofcommunicativeeffectiveness, comfort communicatingwith speakers and listener persistence were each more favourable when using the combined cue condition than purelyhabitualspeech.Theresultssuggestthataugmentativeandalternativecommunicationstrategiespro- viding frequent and specific cues regarding the content and constituent words of a message may enhance the attitudes of listeners. Keywords: Dysarthria, intelligibility, listener attitudes, speech supplementation, augmentative and alternative communication. S peech, one ,bf the pre-dominant forms o f com - suits from damage to the peripheral or central nerv- municatiori is used in every facet o f our lives, ous system and is characterized by slowness in co- whether for the purpose o f expressing our ba- ordination and imprecision o f the movement o f the sic needs, social j interaction or vocational purposes speech musculature. Reduced speech intelligibility (Light, M cNaughton, Gulens, Kresman, Williams is a hallmark characteristic o f most dysarthrias and 8c Cohen, 1999), The inability to communicate via has a significant impact on an individual’s ability to speech has significant psychosocial consequences on communicate, thus ultimately affecting an individu- an individual’s functioning and role in society, such as al’s quality o f life (Hustad 8c Beukelman, 2 0 0 1 ). It alterations in social and family roles, as well as family has been estimated that dysarthria accounts for up to interactions (Fox, Sohlberg 8c Fried-Oken, 1999). 54% o f all communication disorders associated with In addition, Britnell, Madill, Montgomerie and stroke, traumatic brain injury and progressive neuro- Stewin (1 9 9 2 ) found that individuals with a dis- logical disorders such as M N D , Parkinson’s disease ability reported decreased participation in occupa- and Multiple Sclerosis (Duffy, 2005). tional roles and recreational activities. Individuals M N D , also known as Lou Gehrigs disease or with M otor Neuron Disease (M N D ) reported that Amyotrophic Lateral Sclerosis, is a progressive neu- as a result o f a reduction in their motor abilities and rological disease, which usually results in severe phys- speech intelligibility, attitudes changed from kind- ical disability involving all four limbs, speech, swal- ness to awkwardness and avoidance (Mathy, Y o r k - _________________________________________________Ston 8c G u tm ann, 2 0 0 0 ), contributing to decreased Author Contact: Department o f Speech Pathology and Audiology participation in various social activities and eventu- Private Bag 3, ally isolation. I Wits, 2050, South Africa Dysarthria, a deficit o f speech production, re- E-mail: Karin.Joubert@wits.ac.za THE SOUTH AFRICAN JOURNAL OF C O M M U N IC ATIO N DISORDERS, VOL. 55 2008 | 63 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. ) mailto:Karin.Joubert@wits.ac.za NATALIE TOY A N D KARIN JOUBERT lowing and breathing (Young 8cMcNicoll, 1998).The cause o f M N D is unknown and is said to occur in 1.5 per 100,000 o f the population worldwide with the average age o f onset at 65 years and a greater incidence in males (Freed, 2000). Patients with M N D usually do not show any changes in cognitive abilities (Young 8cM cN icoll, 1998). The disorder is characterized by deficits in either the lower motor neuron or the upper motor neuron, but usually results from a com­ bination o f both (Freed, 2000). The type o f dysarthria that occurs in individuals with M N D depends on which motor neurons are affected. In the initial, mild stages, individuals with lower motor neuron in­ volvement will present with flaccid dysarthria, where as those with upper motor involvement present with spastic dysar­ thria. However, as the disease progresses to involve both the upper and lower motor neurons, patients will present with mixed dysarthria that will predominate throughout most o f the disorder (Freed, 2000). In a progressive neurological disorder such as M N D, ap­ proximately 75% o f the patients will reach a point where in­ telligible verbal communication is no longer possible (Freed, 2000). The rapid decline o f speech function in patients with M N D is common, but is not inevitable. Mathy et al. (2000) identified and documented the progression o f dysarthria in individuals with M N D (Appendix A). In the early stage (Stage 1), there are no obvious deficits noticed in an indi­ vidual’s speech, but as the disease progresses, the individu­ al’s speech intelligibility becomes more compromised until at the final 5th stage, individuals with M N D lose all speech function. Communication by nature requires the involvement of two communication partners who take turns playing the roles o f the listener and speaker throughout the course o f in­ teraction (Hustad &. Beukelman, 2002). Speech intelligibil­ ity can be defined as the extent to which a spoken utterance is understood by the listener (Yunusova, Weismer, Kent 8c Rusche, 2005) and is seen as a significant factor in deter­ mining whether an individual is an effective communicator within a conversation (DePaul 8c Kent, 2000). Intelligibil­ ity is therefore a central concept in the field o f speech-lan­ guage pathology, particularly for speakers with dysarthria, whose compromised intelligibility may impair their abili­ ty to communicate effectively in their daily lives (Hustad, Jones 8c Dailey, 2003). Sentence intelligibility measures are often used for clini­ cal purposes such as quantifying the severity o f dysarthria, measuring progress throughout the intervention process and in determining a speaker’s communicative effectiveness (Hustad 8c Cahill, 2003). In addition, intelligibility meas­ ures are also used for basing decisions on the implementa­ tion o f alternative and augmentative communication (AAC) strategies (DePaul 8c Kent, 2000). Speech intelligibility is an interactive process that fluc­ tuates for any given speaker and is dependent on a host of variables pertaining not only to the speaker, but also to var­ iables associated with the listener and the communicative context (Hustad 8c Cahill, 2003). Relatively few o f these variables that are thought to have an influence on intelli­ gibility, have been systematically studied. However, recent research is beginning to demonstrate the importance of “signal-independent information” extrinsic variables on in­ telligibility (Hustad 8c Cahill, 2003). These extrinsic vari­ ables are not dependent on the acoustic signal produced by the speaker, but focus on factors that influence intelligibility for the listener. There is a growing body o f experimental research sug­ gesting that AAC strategies designed to supplement dys- arthric speech can significantly increase speech intelligibil­ ity for individuals with dysarthria (Beukelman 8c Yorkston, 1977; Crow 8c Enderby, 1989; Hunter, Pring 8c Martin, 1991; Hustad 8c Beukelman, 2001). The use o f low technol­ ogy AAC strategies in progressive diseases such as M N D has received significant attention in recent years (Beliveau, Hodge 8c Hagler, 1995; Dongilli, 1994; Garcia 8c Cannito, 1996; Hustad 8cBeukelman, 2001).These strategies include alphabet supplementation, topic supplementation and com­ bined supplementation. The alphabet supplementation strategy involves the use o f an alphabet board that speakers point to, to indicate the first letter o f each word while simultaneously speaking it (Beukelman 8c Yorkston, 1977; Crow 8c Enderby, 1989; Hustad 8c Beukelman, 2001; Yorkston, Beukelman, Strand 8c Bell, 1999). This strategy aims to improve intelligibili­ ty by providing the listener with knowledge regarding the phonetic content o f a word. In alphabet cues, the listener receives first-letter-of-word orthographic information that serves to limit the number o f possible word choices and therefore improve the chances o f correct word identifica­ tion (Hustad, 2001a; Hustad 8c Beukelman, 2001; Hustad 8c Garcia, 2005). Several studies have demonstrated that al­ phabet supplementation can lead to sentence intelligibility scores that average approximately 35% higher than intelligi­ bility scores associated with habitual speech (Beukelman 8c Yorkston, 1977; Beukelman et al., 2000; Crow 8c Enderby, 1989; Hustad et al., 2003). W ith topic supplementation strategies, the use o f a com­ munication board containing key words or phrases that rep­ resent topics or contexts in the speaker’s life is used (Hustad, 2001a). Topics are represented orthographically or through the use o f picture symbols. The speaker would point to the topic o f his/her message before producing it verbally (Beuke­ lman et al., 2002; Hustad, 2001b). Hustad and Beukelman (2001,2002) suggest that this strategy assists the listener to narrow the expectations o f the semantic content o f the mes­ sage. The topic supplementation strategy has been shown;to produce sentence intelligibility scores ranging from 3%' to 16% higher than habitual speech (Beukelman 8c Yorkston, 1977; Beukelman et al., 2002; Crow 8c Enderby, 1989; Hus­ tad et al., 2003). The combined supplementation strategy involves the in­ tegration o f both alphabet and topic supplementation strat­ egies. In this scenario, the speaker first presents the listener with a topic cue followed by a first-letter cue for each word spoken. This strategy has been shown to provide the high­ est sentence intelligibility scores, yielding as much as 35% to 40% higher scores than habitual speech (Beukelman 8c Yorkston, 1977; Beukelman et al., 2000; Crow 8c Enderby, 1989; Hustad et al., 2003). The concept o f ‘attitude’ has important social implica­ tions for individuals who use speech supplementation strat­ 64 | DIE SUID-AFRIKAANSE TYDSKRIF VIR KOMMUNIKASIE-AFWYKINGS, VOL. 5 5 ,2 0 0 8 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. ) S T R A T E G I E S FOR IM P R O V I N G E F F E C T I V E N E S S OF S P E A K E R S WITH M IX ED D Y S A R T H R I A egies to enhance their intelligibility. Attitudes have been a topic o f interest within the disability literature for the past five decades (Hustad 8c Gearhart, 2 0 0 4 ).The widely accept­ ed notion o f the AAC acceptance model states that attitude is a concept made up o f three different components, namely affective, cognitive and behavioural components (Antonak 8c Livneh, 1988; Eiser, 1986; Greenwald, Brock 8c Ostrom, 1968; Lasker 8c Bedrosian, 2000; Triandis, Adamopoulos 8c Brinberg, 1984). The affective component o f attitude in­ volves emotional and physiological reactions to AAC such as comfort level or frustration. The behavioural component relates to the willingness to use AAC or to interact with someone using AAC, whilst the cognitive component o f at­ titude relates to both the speaker and partner’s perceptions o f communication skills (Hustad, 2001b). The attitudes o f potential communication partners may be influenced by factors such as rate, intelligibility, personali­ ty characteristics and their view on disability. These attitudes in turn, may impact on a speaker’s desire or motivation to adopt one o f the previously mentioned speech supplemen­ tation strategies and hence provides valuable information to support clinical decisions (Hustad 8c Gearhart, 2004). Hustad and Gearhart (2004) investigated 168 listeners’ attitudes towards 7 dysarthric speakers who implemented three different supplementation strategies (topic/subject cues, alphabet cues and combined topic-alphabet cues) by measuring ratings relating to cognitive, affective and behav­ ioural components o f attitude. The results showed that rat­ ings for the behavioural component were the highest for all but one speaker. The study concluded that there is strong evidence o f a positive relationship between intelligibility scores and attitude ratings, with attitude ratings increasing linearly with intelligibility scores. In addition the study yielded important clinical impli­ cations for individuals who supplement their speech with AAC strategies. The implementation o f combined cues or alphabet cues resulted in higher attitude ratings relative to topic cues and habitual speech. These strategies also resulted in the greatest intelligibility gains (Hustad et al., 2003). As listeners appeared to be more willing to communicate with speakers who implemented alphabet or the combined cues strategies, the use o f strategies aimed at enhancing intelli­ gibility will likely serve to particularly enhance the behav­ ioural attitude o f listeners. Also o f particular interest in recent studies is the means o f defining the optimal listener-speaker pair. Familiarity has been among one o f the many factors used in explaining variations in listener performance (DePaul 8c Kent, 2000). Familiarity is however a vague and abstract concept, and for research purposes needs to be usable and measurable based on definable characteristics.' In a longitudinal case study, DePaul and Kent (2000) studied the effect o f listener familiarity and proficiency on intelligibility judgements o f individuals with M N D . The results indicated better per­ formances for familiar listeners as opposed to unfamiliar lis­ teners. Familiar listeners were defined as individuals who had experience in communicating, on a daily basis with a person with a communication disorder. Unfamiliar listeners were defined as individuals that had no more than inciden­ tal experience listening to and communicating with persons having communication disorders. The results o f this study suggest that speech-language pathologists should use listen­ er training as part of their practice standards in dysarthria treatment. The components should include: (i) establish­ ing pre-treatment listener’s proficiency, (ii) training listen­ ers through familiarization techniques, and (iii) re-assessing intelligibility using these trained listeners. Additional research examining familiarity with dysar­ thric speech is required in order to obtain conclusive results regarding the influence o f familiarity on the speech intelli­ gibility o f individuals with dysarthria. This study is largely based on the previous work conduct­ ed by Hustad (2001b), which investigated 68 unfamiliar lis­ teners’ evaluation o f speech supplementation strategies used for severely dysarthric speech. As communication is dyad­ ic (Hustad 8c Beukelman, 2002), requiring interaction be­ tween the speaker and listener in communicative exchanges, speech intelligibility and listener attitude is a central con­ struct in the area o f AAC (Hustad, 2001a,b). It is there­ fore o f significance to determine listeners’ attitudes towards AAC and in particular speech supplementation strategies, as this can greatly influence the acceptance o f AAC systems and strategies by the user. Method Aim The primary aim o f the study was to compare unfamiliar and familiar listeners’ attitudes towards the use o f speech supplementation strategies (combined topic and alphabet cues) by speakers with mixed dysarthria. Three sub-aims delineate the means by which the primary aim o f the study was realised: • To describe the effects o f speech supplementation strate­ gies on listeners ’perception o f communication effectiveness. • To describe the effects o f speech supplementation strate­ gies on listeners’ "willingness to interact with speakers. • To describe the effects o f speech supplementation strat­ egies on listeners’ ratings o f persistence in trying to under­ stand speakers. Research Hypotheses As the research investigated the influence o f two factors (familiarity and cues vs. no cues) on listener attitudes to­ wards speakers with dysarthric speech, two hypotheses were formulated. Firstly, familiar listeners will have significant­ ly higher ratings pertaining to their attitudes towards com­ municating with dysarthric speakers on the cognitive, af­ fective and behavioural components o f attitude. Secondly, it is hypothesized that the use o f speech supplementation strategies will yield higher ratings on the cognitive, affec­ tive and behavioural components o f attitude, than the use o f no cues. Research Design A comparative research design was employed for the study (Schiavetti 8c Metz, 2006). This design was selected as it was appropriate to investigate the differences between the attitudes o f the two groups o f listener participants (fa­ miliar vs. unfamiliar) towards speakers with mixed dysar­ thria who use speech supplementation strategies. Participants The study involved the use o f two participant groups. THE SOUTH AFRICAN JOURNAL OF C O M M U N IC ATIO N DISORDERS, VOL. 55 2008 | 65 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. ) NATALIE TOY A N D KARIN JOUBERT The speakers were individuals with M N D that presented with mixed dysarthria who produced speech samples. The second participant group included listeners that were either familiar or unfamiliar with communicating with a person with communication disorders. Speakers with dysarthria Three individuals with M N D that presented with mixed dysarthria participated in the study. Using a non-probabil­ ity, purposive sampling strategy (Schiavetti 8c Metz, 2006), speakers that met the following selection criteria were re­ cruited with the assistance from the Motor Neuron Disease Association (Gauteng): (i) diagnosis o f M N D made by a certified neurologist; (ii) used speech as their primary mode o f communication; (iii) English first language speaker; (iv) reading ability at or above the 5 th grade level; (v) presented with mixed dysarthria and in the 3rd or 4th stage o f dysarthria (Mathy et al., 2000) (Appendix A); (vi) speech intelligibility scores between 30 - 70% as measured by the Sentence In ­ telligibility Test (S IT ) (Yorkston, Beukelman 8cTice, 1996), and; (vi) able to produce at least eight consecutive words in connected speech. See Table 1 for detailed information re­ garding each speaker. Table 1. D em ographic inform ation f o r the speakers •with dysarthria Vanable Speaker SIT B SIT SIT judge Judge 2 judge Judge 2 judge ____ 1 1 1 Judge 2 Age (years) Gender Medical diagnosis Primary mode of communication Staging of dysarthria SIT score (%) Rate of speech (wpm)* 68 Male MND Speech Stage 3 51 Male MND Speech Stage 3 52 Male MND Speech Stage 4 62.73% 61.75% 67.27% 68.21% 30.91% 31.96% 67.92 79.46 55.68 wpm = words per minute Listener Participant Group The primary participants in this study were the listen­ ers. A total o f 36 participants were recruited for the study. A non-probability sampling strategy, ‘purposive sampling’ was employed to recruit the 18 familiar listeners (FL), and ‘convenience sampling’ to recruit the 18 unfamiliar listen­ ers (UL). The listener participant groups met the following criteria: (i) aged 30 - 75 years; (ii) English first language speaker; (iii) no self-reported hearing loss; (iv) no identi­ fied language, learning, cognitive or visual disabilities per ‘self report. Familiar listeners were defined as individuals (family member/friend/care worker) who had experience in communicating, on a daily basis with a person with a com­ munication disorder (Hustad, 2001a,b). Unfamiliar listen­ ers were defined as individuals that had no more than in­ cidental experience listening to and communicating with persons having communication disorders. The two listener groups were matched for gender and mean age. The unfa­ miliar listener group comprised o f 18 participants (14 fe­ male, 4 male). Their average age was 58.0 years (range 32 to 75; SD=10.3). The familiar listener group recruited through the Parkinson’s disease Association support group o f South Africa, comprised o f 18 listeners (14 female, 4 male). Their average age was 50.7 years (range 32 to 79; SD=14.8). D e­ mographic information regarding listeners assigned to each listener group is provided in Table 2. T able 2 . D em ographic in fo rm a tio n fo r the listen er groups G roup participant Fam iliar Listener Unfam iliar - Listener- I Ages G ender Age gender 1 56 Fem ale 53 Female 2 56 Fem ale 73 Fem ale 3 58 Fem ale 55 Female 4 66 Fem ale 42 Fem ale 5 65 Fem ale 40 Male 6 71 Fem ale 69 Female 7 62 Fem ale 71 Female 8 38 Fem ale 62 Female 9 57 Fem ale 38 Fem ale 10 54 Fem ale 79 Fem ale 11 56 Fem ale 37 Fem ale 12 32 Fem ale 61 Fem ale 13 58 Male 42 Fem ale 14 68 F em ale 32 Male 15 55 Male 38 Female 16 57 Male 36 Male 17 60 Fem ale 44 Female 18 75 Male 42 Male Materials Speech Stimuli Four narrative passages, each consisting o f 10 sentences were employed as speech stimuli. Narratives (Appendix B) representing situational information common to first lan­ guage English speakers were developed based on linguis­ tic characteristics specified in a study conducted by Hustad (2001b). The length and content o f the stimulus material were equalised across the following linguistic parameters: (i) sentences per narrative; (ii) topic per narrative; (iii) words per narrative; (iv) number o f words per sentence; and (v) reading level. Summary statistics for stimulus material are presented in Table 3. , Table 3. Linguistic characteristics o f narratives __________ Characteristic___________ Number Sentences per narrative 10 Topics per narrative 1 W ords per narrative 65 5-word sentences per narrative 2 6 word sentences per narrative 3 7 word sentences per narrative 3 8 word sentences per narrative 2 Reading level for each narrative 5 66 Questionnaire A questionnaire (Appendix G) to measure the primary dependant variables was developed, and included demo­ graphic information and three statements probing listener DIE SUID-AFRIKAANSETYDSKRIF VIR KOMMUNIKASIE-AFWYKINGS, VOL. 5 5 ,2 0 0 8 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. ) S T R A T E G I E S FOR IM P R O V I N G E F F E C T I V E N E S S OF S P E A K E R S WITH M IX ED D Y S A R T H R I A attitudes in the cognitive, behavioural and affective domains. These statements were selected as they directly address the three components o f attitude and were the same as those employed in the other studies (Hustad, 2001b; Hustad 8c Gearhart, 2004). Each o f the three variables were measured using a 7-point ordinal Likert scale, with 1 = strongly disa­ gree and 7 = strongly agree. Listeners were required to circle the number which most closely represented their perception o f each speaker. The statements were: (i) I think this person is an effective communicator using this strategy; (ii) I would feel comfortable communicating with this person in a class or at work if s/he used this strategy; and (iii) I would be will­ ing to communicate with this person in a class or at work if s/he used this strategy. In addition a qualitative question (“W hat feelings would you experience i f you were to com­ municate with the speakers?”) was included to obtain infor­ mation regarding the listener’s feelings/emotions towards the speaker after hearing the speaker. Data collection procedures Ethical considerations Various ethical considerations were implemented throughout the research study. The researcher obtained ethi­ cal clearance from the Human Research Ethics Committee (medical) of the University o f the Witwatersrand before this research study was implemented. Written informed consent was obtained from the M N D Association, Parkinson’s dis­ ease Association and all participants, using established and approved methods. All participants in the study were fully informed o f the nature o f the study and were assured o f an­ onymity and confidentiality. Each participant was required to sign a consent form, providing proof o f his/her willing­ ness to partake in the study and had the right to withdraw from the study at any time, without suffering any negative consequences. Data collection from the speakers with dysarthria: Re­ cording speech samples The recording o f narrative samples took place in a qui­ et room in the speakers’ homes, and were obtained using a Sony M ini-Disc Walkman (M Z -R 900) digital audio re­ corder and a head mounted Sennheiser microphone to limit disturbance noises during the recording as a result o f micro­ phone movement. jThe head mounted microphone helped to maintain a constant distance from the speaker’s mouth so as to obtain correct! sound levels during the recording. Each speaker was instructed to read all four narrative passages, printed in font size 20 and presented directly in front o f the speaker, as naturally as possible to emulate a typical communication situation. The rate and prosody o f the speakers was not controlled. Constructing the stimuli (audio-visual footage) The recorded speech samples were transferred digitally to a Toshiba Satellite (A100-519) laptop via the onboard sound card. The recordings were edited using digital audio editing software (Acoustica v4.0).The speech samples were edited to remove extraneous comments, and the amplitude o f all the samples normalized to a -5 dB setting using the sound editing software to ensure that all the speech samples were at a similar volume level. The edited speech samples were then combined with vis­ ual information to implement the combined topic-alphabet cue strategy using Windows Movie Maker software (version 6, Windows Vista OS). The visual orthographic information took the form of a text presentation on the screen showing the narrative topic cue, and the display o f the first alphabet letter o f each word spoken during the narrative. The display o f the alphabet cue visuals was synchronized to the actual speech sample, so that as the speaker produced each word, the first letter was displayed simultaneously in real-time. For the stimuli where no cues were used, a blank screen was dis­ played in the background whilst the audio speech sample was played. Presentation of stimuli to the listeners The final step involved the presentation of the compiled stimuli to the unfamiliar (UL) and familiar (FL) groups. The audio-visual recordings containing the narrative samples of the three speakers associated with the combined cue con­ dition and the no cues condition were presented to the 36 listeners. All 36 listeners viewed the audio-visual footage in a quiet room at their place o f residence. All the listeners were seat­ ed during the viewing with the laptop positioned directly (0.5m) in front o f them. The volume was normalized at the maximum output o f the laptop for each listener, so that all the listeners listened to the stimuli at the same sound level. Listeners were instructed that they would hear two speakers each reading a narrative, one purely auditory with­ out any supplementation cues and the other with the com­ bined alphabet and topic cue. The listener was briefed prior to the presentation on how the combined supplementation strategy worked and how it would appear on the screen. Following the completion o f the listening task, all partic­ ipants were requested to independently complete the ques­ tionnaires after receiving verbal and written instructions on the requirements o f the questionnaire. Randomization To prevent the possibility o f order and learning effect of cue conditions during the presenting o f the narrative audio­ visual stimuli to the listeners, the sequence o f the cue/no cue narratives shown to each listener was alternated. Different sequences and combinations o f possible presentation orders for cues condition, speakers (3 speakers) and narratives (4 narratives) was used in the study. Each listener in the unfa­ miliar listener group was matched to one o f the 18 in the fa­ miliar listener group. Therefore 18 sequences were displayed in total, ensuring that no two listeners were exposed to the same speaker, narrative, and cue combination. Data Analysis The values obtained from the Likert-type scales were re­ corded and collated for statistical analysis. Descriptive sta­ tistics were utilized to summarize and organize the data col­ lected. A two-way repeated measure Analysis of Variance (ANOVA) design was used (one-factor repetition) to de­ termine the effect o f the two experimental (‘familiarity’ and ‘cue/no cue’) factors on the listeners’ attitudes. The design used a within-subjects repeated measure for the ‘cues/no cues’ factor in the design, since the listener at­ titude rating measurements for both the cues and no-cues condition were obtained from the same listener participants. Two different sample groups for the familiar and non-fa­ miliar listeners were used, and therefore repeated-measures THE SOUTH AFRICAN JOURNAL OF C O M M U N IC ATIO N DISORDERS, VOL. 55 2008 | 67 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. ) NATALIE TOY A N D KARIN JOUBERT were not used for the ‘familiarity’ factor o f the listeners in the research design. The research design was employed for each o f the three listener attitude components measured in the study. The three dependant variables were the listener ratings o f com­ munication effectiveness (cognitive); listener feelings and emotions (affective); and willingness/persistence to com­ municate and understand the speaker (behavioural). Results and Discussion The results o f the study will be described and discussed in this section in relation to the aims o f the research. The results from the research data indicated mean listener at­ titude ratings across all listener and cue conditions (com­ bined cues and no-cue strategy) o f M = 3.241(SD = 1.852) for the cognitive component; M = 3.612(SD = 1.936) for the af­ fective component; and M = 4.00(SD = 1.933) for the behav­ ioural component. Listener Attitude Ratings Communicative effectiveness The mean attitude ratings for the communicative effec­ tiveness o f listener attitude are shown in Figure 1 below. The figure shows a difference in the cognitive attitude rat- ^ & / O N o Visual Cues 13 C o m b in e d C u e s S t r a t e g y F a m ilia r L iste n e rs ( F t ) U n fa m ilia r l i s t e n e r s ( U l ) UstenerGroups F igu re 1. M ean Attitude (cognitive component) ratings f o r the listener groups (Familiar, Unfamiliar) with Combined ings (mean) for the familiar listener group (Combined cues: M =4.77, S D = 1.47;N o Cues:M =2.88, SD =1.52) and the un­ familiar listener group ( Combined Cues: M =3.42, SD =1.55; No Cues: M - 1 .5 7 , S D -1 .5 0 ). The difference exists for both □ N o V isual Cues B C o m b in ed Cues Stra te g y F a m ilia r lis te n e r s ( F l) U nfa m ilia r L isteners ( U l) UstenerGroups the combined cues and no cues condition. Listener emotions and feelings (affective) The mean attitude ratings for the affective attitude com­ ponent (see Figure 2) show similar results to those observed for communication effectiveness, with a slight difference observed in the ratings between the familiar listener ( Com­ bined Cues: M = 5.00 SD =1.47; No Cues: M = 2.88 SD=1.52) and unfamiliar listener group ( Combined Cues: M =4.21 SD = 1.55; No Cues: M = 2.143 SD =1.50). Again this differ­ ence is observed for both the cue conditions. Listener willingness and persistence to communicate (behavioural) The results for the behavioural component (Figure 3) o f the listener attitudes showed slightly higher mean ratings than the other attitude components. As observed in the pre- F igu re 2. Mean Attitude (affective component) ratings f o r the listener groups (Familiar, Unfamiliar) with Combined Cues, No Cues condition 68 | DIE SUID-AFRIKAANSE TYDSKRIF VIR KOMMUNIKASIE-AFWYKINGS, VOL. 5 5 ,2 0 0 8 F ig u re 3. Mean Attitude (behavioral component) ratings f o r the listener groups (Familiar, Unfamiliar) with Combined Cues, No Cues condition vious attitude component results, the behavioural attitude results show a slight difference between the familiar lis­ tener ( Combined Cues: M =5.3 8 SD =1.47; No Cues: M = 3.056 SD =1.52) and unfamiliar listener groups ( Combined Cues: M = 4 .5 SD =1.55; No Cues:M =2.85 SD=1.50). A two-way repeated measure Analysis o f Variance (ANOVA) test with one factor repetition for the ‘cues/no cues’treatment was performed for each o f the three depend­ ant measures. The test assumes that the treatment factors have equal variances (this assumption was confirmed for each set o f dependent measure data by performing an equal variance test). The results o f the test are described for each treatment factor (‘Familiarity’ and ‘Cues condition) in the following section. Listener Familiarity Hypothesis 1 stated that familiar listeners will have significantly higher ratings than unfamiliar listeners, per­ taining to their attitudes towards the speech o f dysarthric speakers, measured for the cognitive, affective and behav­ ioural components o f attitude. The results o f this hypothesis, when tested using a two-way repeated measure ANOVA to compare the mean difference on the attitude ratings for F L as compared to U L is presented in Table 4. Results o f testing hypothesis 1 The two-way repeated measure ANOVA tests applied to all 3 dependent measures (Table 4) indicates that the differ­ ences observed in mean values for the ‘listener familiarity’ 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. ) S T R A T E G I E S F OR IM P R O V IN G E F F E C T I V E N E S S OF S P E A K E R S WITH M IX ED D Y S A R T H R I A Table 4. Two way repeated measure A N O VA (One Factor Repetition) results f o r Listener Attitude (Cognitive, Affective & Behavioral components) Dependent Variable Listener Attitude(C ognitive) - C om m unicative Effectiveness ( Equal Variance Test: Passed (P = 0.596) Source of VsnatioS SS F P Power/ Test Sensitivity Familiarity 0.374 0.121 0.730 0.050 Cue/No Cue 68.881 29.796 < 0.001 1.000 Fam iliarity x Cue/No Cue 0.00620 0.00268 0.959 0.050 dom o a riso n s fcir fa cto r^ * (Overall sianificance level = 0.05) Difference of Means Unadjusted P C ritical Level S ig nificant FL vs. UL 0.444 0.730 0.050 NO Com bined Cues vs. No Cues 2.091 0.0169 0.050 YES Listener Attitude(Affective) - Listener's C om fort, em otions Equal Variance Test: Source.of Variation Passed (P = 0.757) SS F P Power/ Test Sensitivity Fam iliarity 0.211 0.0761 0.785 0.050 Cue/No Cue 55.254 30.278 < 0.001 1.000 Fam iliarity x Cue/No Cue 0.00397 0.00217 0.963 0.050 (io m b a riso ns for fa c to ri * (Overall sianificance level = 0.05) Difference o f Means Unadjusted P Critical Level S ig nificant FL vs. UL 0.333 0.785 0.050 NO C om bined Cues vs. No Cues 1.673 0.0161 0.050 YES ¥ ' Listener Attitude(Behavioral)-Listener's willingness to communicate Equal Variance Test: Passed (P =1.000) Source o f Variation" SS F P Power/ Test Sensitivity Familiarity 0.988 0.294 0.592 0.050 Cue/No Cue 100.829 27.624 < 0.001 1.000 Fam iliarity x Cue/No Cue 62.252 0.833 0.369 0.050 fcomoarisons for factors' * (Overall sianificance level = 0.05) Difference o f Means Unadjusted P C ritical Level S ig nificant FL vs. UL 0.722 0.592 0.050 NO Com bined Cues vs. I■Jo Cues 1.988 0.0210 0.050 YES Type I, a = 0.050 * Pair wise Multiple Comparison Procedures (Holm-Sidak method): factor is not sufficiently.large to exclude the possibility that the difference is due to random sampling variance, when the effects o f the other factor (combined cues versus no cues strategy) is taken into account. Comparison o f the F L and U L groups yielded mean differences between the groups of 0 .4 4 4 for the cognitive component (P=0.7 3 0 ); 0 .3 3 3 for the affective component (P=0.785); and 0 .7 2 2 for the behav­ ioural component (P=0.592). Therefore there is no statisti­ cally significant difference in the scores o f the F L sample group as compared to the U L sample group, across all 3 lis­ tener attitudes. The study results therefore conclude that the hypothesis stating that ‘familiarity’ plays an influencing factor on the attitude ratings (all three components) o f listeners is not valid. The effect o f familiarization o f the listener in influenc­ ing their attitudes towards dysarthric speakers would there­ in contrast to the results indi­ cated by the longitudinal study carried out by De Paul and Kent (2000), which concluded that a familiar listener had superior performance over unfamiliar lis­ teners. According to their study, the performance was significant­ ly improved especially during the individuals’ second year o f pro­ gression o f M N D when their speech intelligibility decreased markedly. Several factors may have con­ tributed to the current results. The familiar listener participant group was defined as listeners who had experience in commu­ nicating on a daily basis with persons with a communication disorder. However, it did not specify the degree o f the dysar­ thria o f the person that these fa­ miliar listener individuals com­ municated with or had contact with. In this study, the familiar listener participants were ‘fa­ miliar’ with individuals who had Parkinson’s disease. It was noted that many o f the familiar listen­ ers communicated with individ­ uals in the early stages o f Parkin­ son’s disease, where their speech was only mildly impaired. These ‘familiar’ listener participants would therefore not have any substantial experience in com­ municating with speakers who had severe dysarthria. In this study the duration o f interaction between the famil­ iar listener and speaker was not specified and this variability of exposure was not taken into ac­ count. The familiar listener may have interacted with the in­ dividual for a month or a few years. This is in contrast to the longitudinal case study done by De Paul and Kent (2000). Therefore, the researchers’ selection criteria had to be stricter in specifying the frequency and length o f exposure to an in­ dividual with dysarthria, as well as the severity of dysarthria. However the researchers were unable to define the selection criteria to include exposure and stricter familiarity require­ ments for the study due to the nature and time limitations o f the research. Speech Supplementation Strategy (Combined cues vs. No cues) Hypothesis 2: The use o f a speech supplementation strategy, in this case the combined topic and alphabet cues will yield higher ratings, than the use o f no cues pertain­ ing to listeners’ attitudes towards the speech o f dysarthricfore appear to play no significant role. This result is however THE SOUTH AFRICAN JOURNAL OF COMMUNICATION DISORDERS, VOL. 55 2008 69 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. ) NATALIE TOY A N D KARIN JOUBERT speakers. Results o f testing hypothesis 2 The results o f the two-way repeated measure ANOVA (one factor repetition) analysis are presented in Table 4 in the previous section. This analysis compared the mean dif­ ference on the listener attitude ratings for the use o f the combined topic and alphabet cue, as compared to the use o f no cues pertaining to their attitudes towards the speech o f dysarthric speakers. Three components o f attitude were measured namely, cognitive, affective and behavioural. C om m unicative effectiven ess (cogn itive); The two-way repeated measure ANOVA. determined that there was a statistically significant difference (P=<0.001) in the mean values among the different levels o f cues. The difference in the mean values among the different levels o f cues is greater than would be expected by chance after allowing for the ef­ fects o f differences in familiarity. The two-way repeated measure revealed ratings o f effec­ tiveness that were significantly higher for combined cues than for the no cue condition. All the statistical findings for ratings o f communication effectiveness in this study are consistent with intelligibility data obtained in previous studies (Hustad, 2003; Hustad &Beukelman, 2003; Hustad et al., 2003). The indication is that the combined topic and alphabet cue results in more favourable ratings o f effective­ ness and intelligibility than the no cue condition. According to Hustad (2001b), a reason for the positive effect o f the combined cue on effectiveness rating may be that all the listeners recognized attempts to enhance speech via the strategy presentation and they equated the use of the multiple supplementation strategies as trying “harder” to compensate to a greater extent for the communication difficulties. L isten er com fort an d em otion (affectiv e): Similarly, the two-way repeated measure ANOVA determined that there was a statistically significant difference (P=< 0.001) in the mean values among the different levels o f cues. As was the case for listener effectiveness combined cues yielded more favourable affective attitude ratings than the no cue con­ ditions. The results suggest that the more information the listener has about a topic the more comfortable they would be to interact with the speakers. Participants stated that be­ cause they were provided with the topic o f the narrative, as well as the alphabet cues, they were able to anticipate and understand more o f what the speaker was saying. L isten er persisten ce (behaviou ral): Again, the two-way repeated measure ANOVA determined that there was a sta­ tistically significant difference (P= <0.001) in the mean be­ havioural rating. Listeners are therefore more persistent to interact with speakers that employed the combined topic and alphabet cue supplementation strategy in conjunction with their habitual speech, as compared to the no cue con­ dition. The overall results o f the present study showed that the U L and F L sample groups were from the same population group and therefore listener familiarity was not a favourable indicator o f increased intelligibility and listener attitude rat­ ings. However, the present study did show that the com­ bined alphabet and combined cue supplementation strategy used in conjunction with habitual speech, resulted in sig­ nificantly higher ratings o f listeners’perceptions o f the com­ munication o f speakers with dysarthria ranging from 33% - 67% intelligibility. It is however important to consider these findings in light o f the limitations o f the research. The study employed a traditional experimental paradigm which differs significant­ ly from naturalistic, real life communication situations. As the speakers and listeners did not converse and interact with one another in communicative exchanges, extra-linguistic factors such as gesture, body language and facial expression used in conjunction with verbal communication were omit­ ted. The listeners were also not able to directly interject and ask for clarification from the speaker. The content, form and use o f messages produced by the speaker were also scripted, and the environment in which the listeners heard the audio recordings was manipulated for an ideal listening and viewing condition. The audio-visual material presented to the listeners for viewing and listen­ ing was digitally enhanced, so that all the cues used were clearly and readily visible. In a real life situation and im­ plementation o f these supplementation strategies, the com­ municative partner does not have the advantage o f this type o f digital enhancement. The communicative partner would have to deal with the effects o f lighting, distance from the speaker and the angle at which the partner is facing towards the speaker. In addition the speech patterns o f the speaker may have been different if they were directly implementing the supplementation strategy, for example slowing down of their speech rate as they point to the various alphabet cues, thus affecting their overall speech intelligibility as perceived by the listener. These factors need to be considered in light o f the current research. The sample size o f the study involved only 3 speakers with dysarthria and 36 listener participants; therefore this relatively small sample size may have an influence on the reliability and validity o f the study. In addition the partici­ pants in the study were restricted to a specified age range. The results indicated by the study may not be fully repre­ sentative o f the general population. ' In this study, only three Likert-type questions were used to gather information regarding listener attitudes. Although the construct o f attitude and its constituent components (cognitive, affective and behavioural) are well grounded in literature (Hustad 8c Gearhart, 2004), measurement of these constituents in a research study is more complex. The measurement o f listener attitudes based on three questions cannot fully account for the many different facets o f a listen­ er’s attitude and it is suggested that future research should aim to adapt or develop a more comprehensive instrument with well-described psychometric properties to explore lis­ tener attitudes. The results o f the qualitative question: “W hat feelings would you experience if you were to communicate with the ■■ speakers?”indicated a few general trends across all 36 listen­ ers’emotional reactions towards the 3 speakers. The majority o f listeners felt a great sense o f empathy and awkwardness towards the speakers because they acknowledge the speak­ ers’ intent to communicate, but still struggled to understand them. Listeners stated a great sense o f awkwardness in not knowing what the speaker is saying and not being able to re­ 7 0 | DIE SUID-AFRIKAANSETYDSKRIF VIR KOMMUNIKASIE-AFWYKINGS, VOL. 55, 2008 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. ) S T R A T E G I E S FOR IM PR O V IN G E F F E C T I V E N E S S OF S P E A K E R S WITH M IX E D D Y S A R T H R I A spond appropriately during a communicative exchange. Listeners also stated becoming highly frustrated with the speakers and frequently becoming quite impatient. Most of the participants stated that it would have been easier to un­ derstand what the speaker was saying, if they were face-to- face with the speaker in comparison to only being able to listen to a recording o f their speech. The majority o f the participants did indicate that they found the cues beneficial in helping them to understand the speaker. However, a few listener participants did state that they found the visual cues misleading, stating they had difficulty in focusing on the cues and integrating the visual and auditory stimuli (this was particularly evident when the speaker spoke at a fast rate). Conclusion The overall aim o f the study was to determine the influ­ ence o f familiarity on a listener’s attitude towards speakers with mixed dysarthria. The findings of this study concluded that familiarity has no statistically significant influence on their attitudes towards speakers with mixed dysarthria. The results, however did suggest that speakers whose speech intelligibility is severely reduced may benefit mark­ edly from using a combined topic-alphabet cue strategy, as within this experimental research paradigm, the combined cue strategy resulted in more favourable listener attitudes. In addition, listeners appeared to be more comfortable and persistent in communicating with speakers who implement­ ed the combined cues. Although many variables are likely to influence listener attitudes, there is strong evidence to sug­ gest that listener attitudes are closely linked to intelligibility (Hustad 8c Gearhart, 2004). The findings o f the influence o f familiarity on the listener attitudes may possibly have been affected by the time con­ straints imposed on the study and an insufficient definition o f the familiar listener. It is suggested that the definition o f a familiar listener include specific detail on the duration and frequency o f interaction with the person with dysarthria as well as the severity o f the reduction in the speaker’s intelli­ gibility. Other studies (DePaul 8c Kent, 2000) indicated that familiarity does lead to significant performances on speech intelligibility and therefore listener attitudes. It further in­ dicated that an advantage o f familiarity evolved over time and reached a maximum level when the speech impairment was significantly reduced in intelligibility (DePaul 8c Kent, 2000). The results o f the study should be interpreted in light of the experimental nature o f the study where the listeners did not communicate in a real communicative exchange and it therefore does not permit generalisation to ecologically val­ id communication situations. This study however has important implications in the clinical management o f individuals with motor speech dis­ orders, such as dysarthria. The implementation o f speech supplementation strategies such as the use o f combined al- phabet-topic cues can improve the communicative effective­ ness and lead to more favourable interactions with listeners. Future research should address the attitudes o f unfamil­ iar and familiar listeners towards individuals with different severity levels and speech characteristics, using more natu­ ralistic speech samples. It is important that future research should take intra-rater reliability into account by repeating a small proportion o f speech samples. In addition, a quali­ tative approach could be employed to investigate how AAC strategies affect listener attitudes to provide information re­ garding what listeners think, feel and believe when faced with speakers using AAC. References Antonak, R., 8c Livneh, H . (1988). The measurement o f atti­ tudes towards people with disabilities. Charles C. Thomas: Springfield, IL . Beliveau, C., Hodge, M ., 8c Hagler, P. (1995). Effects of supplemental linguistic cues on the intelligibility o f se­ verely dysarthric speakers. Augmentative and Alternative Communications, 1 1 , 176-186. Beukelman, D. R., Yorkston, M ., 8c Reichle, J. (2000). A ug­ mentative and alternative communication fo r adults with acquired neurological disorders. Brooks Publishing Co.: Baltimore. Beukelman, D ., 8c Yorkston, K. (1977). A communication system for the severely dysarthric speaker with an intact language system .Journal o f Speech and Hearing Disorders, 4 2 , 265-270. Britnell, E. S., Madill, H. M ., Montgomerie,T. C., 8c Stew- in, L. L. (1992). Work and family after injury: Do female and male client perspectives differ? Career development quarterly, 4 1 , 145-160. Crow, E ., 8c Enderby, P. (1989). The effects o f an alphabet chart on the speaking rate and intelligibility o f speakers with dysarthria. In K. Yorkston, 8c D. Beukelman (Eds), Recent advances in clinical dysarthria (pp. 99-108). P R O - E D : Austin, T X . DePaul, R., 8c Kent, R. D. (2000). A longitudinal case study o f A L S: effects o f listener familiarity and proficiency on intelligibility judgements. American JounalofSpeech-Lan- guage Pathology, 9 (3), 230-240. Dongilli, P. (1994). Semantic context and speech intelligibil­ ity. In J. Till, K. Yorkston, 8c D. Beukelman (Eds), Motor Speech Disorders: Advances in assessment and treatment (pp. 175-191). Paul H. Brookes Publishing Co.: Baltimore. Duffy, J. R. (2005). Motor speech disorders: substrates, differen­ tial diagnosis and management. Mosby: St. Louis. Eiser, J. R. (1986). Social Psychology: Attitudes Cognition and Social Behaviour. Cambridge University Press: Cam­ bridge, UK. Fox, L., Sohlberg, M . M ., 8c Fried-Oken, M . (1999). E f­ fects o f conversational topic self selection on augmenta­ tive communication intervention for adults with apha­ sia. Paper presented at the Clinical Aphasiology Conference. Keywest, FL. Freed, D. (2000). Motor Speech Disorders: Diagnosis and treat­ ment. Singular Publishing Co.: San Diego. Garcia, J., 8c Cannito, M . (1996). Influence o f verbal and non-verbal contexts on the sentence intelligibility of a speaker with dysarthria./owrwa/ o f Speech and Hearing Re­ search , 3 9 , 750-760. Greenwald, A. G., Brock, T. C., 8c Ostrom, T. M . (1968). Psychological foundations o f attitudes. Academic Press: T H E SOUTH AFRICAN JOURNAL OF C O M M U N IC ATIO N DISORDERS, VOL. 55 2008 | 71 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. ) NATALIE TOY AND KARIN JOUBERT NY. Hunter, L., Pring, T., 8c Martin, S. (1991). The use o f strat­ egies to increase speech intelligibility in cerebral palsy: An experimental evaluation. British Journal o f Disorders o f Communication, 2 6 , 163-174. Hustad, K. C. (2001a). Effects o f linguistic cues and stim­ ulus cohesion on intelligibility o f severely dysarthric speech. Journal o f Speech, Language and Hearing Research, 4 4 (3), 497-510. Hustad, K. C. (2001b). Unfamiliar listeners’ evaluation of speech supplementation strategies for improving the ef­ fectiveness o f severely dysarthric speech. Augmentative and Alternative Communication , 1 7 (4), 213-220. Hustad, K. C. (2003). Effects o f presentation mode and repeated familiarization on intelligibility o f dysarthric speech. American Journal o f Speech-Language Pathology, 1 2 (2), 198-208. Hustad, K. C., 8c Beukelman, D . R. (2001). Effects o f lin­ guistic cues and stimulus cohesion on intelligibility o f se­ verely dysarthric speech. Journal o f Speech, Language and Hearing Research, 4 4 (3), 407-510. Hustad, K. C., 8c Beukelman, D. R. (2002). Listener com­ prehension o f severely dysarthric speech: Effects o f lin­ guistic cues and stimulus cohesion .Journal o f Speech, L an­ guage and Hearing Research, 4 5 (3), 545-558. Hustad, K. C., 8c Cahill, M . A. (2003). Unfamiliar listen­ ers’ evaluation o f speech supplementation strategies for improving the effectiveness o f severely dysarthric speech. Augmentative and Alternative Communication , 4 , 213- 220. Hustad, K. C., 8c Garcia, J. M . (2005). Aided and unaid­ ed speech supplementation strategies: Effect o f alphabet cues and iconic hand gesture on dysarthric speech. Jour­ nal ofSpeech, Language and Hearing Research , 4 8 ( 5 ) , 996- 1012. Hustad, K. C., 8c Gearhart, K. J. (2004). Listener attitudes towards individuals with cerebral palsy who use speech supplementation strategies. American Journal o f Speech- Language Pathology, 13 (2), 168-181. Hustad, K. C ., Jones, T., 8c Dailey, S. (2003). Implementing speech supplementation strategies: Effects on intelligi­ bility and speech rate o f individuals with chronic severe dysarthria. Journal o f Speech, Language and Hearing Re­ search , 4 6 (2), 462-474. Lasker, J. P., 8c Bedrosian, J. L. (2000). Acceptance o f AAC by adults with acquired disorders. In D. Beukelman, K. Yorkston, 8c J. Reichle (Eds), Augmentative Communica­ tion f o r adults with acquired neurologic disorders (pp. 107- 136). Paul H. Brookes: Baltimore. Light, J. A., McNaughton, D ., Gulens, M ., Kresman, C., Williams, M ., 8c Cohen, K. (1999). The mentor pro­ gramme for individuals who use AAC. Unpublished man­ uscript. Pennsylvania State University. Mathy, P., Yorkston, K. M ., 8c Gutmann, M . L. (2000). A ug­ mentative and alternative communication f o r adults with acquired neurologic disorders. Brookes Publishing Co.: Baltimore, Maryland. McMillan, J. H., 8c Schumacher, S. (2001). Research in edu­ cation: A conceptual introduction (5th ed.). Addison Wesley Longman Inc.: New York. Schiavetti, N., 8c Metz, D. E. (2006). Evaluatng research in communicative disorders (5th ed.). Allyn and Bacon: Bos­ ton. Triandis, H. C., Adamopoulos, J., 8c Brinberg, D. (1984). Perspective and issues in the study o f attitudes. In R. L. Jones (E d ), Attitudes and Attitude change: Theory and prac­ tice. Council for Exceptional Children: Reston, VA. Yorkston, K. M ., Beukelman, D. R., Strand, E. A., 8c Bell, K. R. (1999). Management o f motor speech disorders in children and adults. P R O -E D .: Austin, T X . Yorkston, K., Beukelman, D ., 8cTice, R. (1996). Sentence I n ­ telligibility Test f o r Macintosh. Lincoln, NE. Young, J. M ., 8cMcNicoll, P. (1998). Against all odds: Posi­ tive life experiences o f people with advanced amyotroph ic lateral sclerosis. Health and Social Work, 2 3 (1), 35-43. Yunusova, Y., Weismer, G ., Kent, R. D., 8c Rusche, N. M . (2005). Breath-group intelligibiity in dysarthria: Charac­ teristics and underlying correlates.Journal o f Speech, L an ­ guage and Hearing Research, 4 8 (6), 1294-1310. 72 | DIE SUID-AFRIKAANSETYDSKRIF VIR KOMMUNIKASIE-AFWYKINGS, VOL. 5 5 ,2 0 0 8 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. ) APPENDIX A Stages of Dysarthria (Mathy, Yorkston, & Gutmann, 2000) S T R A T E G I E S FOR IM P R O V IN G E F F E C T I V E N E S S OF S P E A K E R S WITH M IX E D D Y S A R T H R I A Stage 1: No detectable speech disorder __ _______________________________________ • Speech of individuals with a spinal presentation of ALS sounds normal. • Speaker notices a change in function. • Listeners note no changes in speaking rate, precision or loudness.____________________________ Stage 2: O bvious speech disorder w ith intelligible speech_______________________________________ • Changes in speech are apparent. • Changes may be more apparent with stress or fatigue. Most speakers compensate unconsciously for articulator or respiratory impairment by decreasing their speaking rate and the length of their breath groups. Speech at this stage remains easy to understand, although voice quality maybe harsh or breathy ______ or mild articulator problems may be present._________________________________________________ Stage 3: Reduction in speech in te llig ib ility__________________________ ___________________________ • Speaking rate, articulation and resonance are impaired and may make speech difficult to understand, depending on the communication environment. • Helpful strategies include maintaining a slower speaking rate, conserving energy, increasing the precision of speech production and developing strategies to resolve communication breakdowns. Individuals can do with modifying their speech production (Kennedy, Strand, & Yorkston, 1994). • Some speakers begin to use AAC techniques to resolve breakdowns. When speaking rate is 50% or less, AAC assessment and intervention should be initiated. • Helpful strategies include maintaining a slow speaking rate, conserving energy, increasing ______ precision of speech production, and developing strategies to resolve communication breakdown. Stage 4: Natural speech supplemented w ith augmentative com m unication_______________________ Speech must be combined with AAC approaches (Kazandijan, 1997). • Natural speech may be limited to highly predictable messages, such as responses to questions and greetings. • The speaker must supplement natural speech by writing key words or pointing to the first letter of each word he or she speaks. • Intervention for speakers at this stage may include alphabet supplementation, changing communication modes for different situations, an alerting signal for gaining attention, augmented ______ telephone communication, and portable writing systems (Hustad, 1999)_______________________ Stage 5: No useful speech_____________________________________________________________________ • Speakers with advanced bulbar ALS lose speech function. Some individuals at this stage may vocalize for emotional expression or with extreme effort but do not produce understandable speech. ■ Intervention for speakers at this stage may include establishing reliable yes/no system, eye-gaze systems and communication systems for speaker’s dependant on ventilators, and integrated ______ multipurpose AAC systems________________________________________________________________ THE SOUTH AFRICAN JOURNAL OF C O M M U N IC ATIO N DISORDERS, V O L 55 2008 73 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. ) APPENDIX B NATALIE TOY A N D KARIN JOUBERT Narrative Stimuli Narrative 1: A holiday It was an amazing holiday (5). We gathered shells on the beach (6). We also saw dolphins swimming in the sea (8). We spent hours lying in the warm sun (8). One day we hiked up Table Mountain (7). The view was so magnificent and peaceful (7).lt was the best experience ever (6). We have a beautiful country (5).The week had come to an end (7). My fun holiday had officially ended (6). Narrative 2: A sporting event The two Batsmen walked onto the cricket field (8). The crowd was cheering wildly (5). Everyone was standing and clapping their hands (7). The sun was shining directly overhead (6). The Umpires briefly spoke to each other (7). They asked the players to begin the match (8). Each player went to their position (6). The crowd started a Mexican wave (6). It went round and round the stadium (7). It was a great game (5). Narrative 3: My wedding day The special day had arrived (5). Finally, my eldest daughter was leaving home (7). It was an exciting day (5). The church hall was decorated with red roses (8). The bridesmaids wore pink satin dresses 6). The groom and his best man wore white tuxedo’s (8). A silver limo arrived at twelve o’ clock (7). The wedding music started to play (6). We walked together down the aisle(6). Then my daughter looked at me and smiled (7). Narrative 4: The Trip To The Doctor I woke up with a fever and headache (8). I could barely sit up (5). I was in such pain and discomfort (7). The whole night I could not sleep (7). My grandmother took me to the doctor’s office (8). I waited there for 40 minutes (6). My grandmother was angry and frustrated (6). Finally, I went into the doctor’s office (7). I hated going to the doctor (6). I went home and slept (5). 74 | DIE SUID-AFRIKAANSE TYDSKRIF VIR KOMMUNIKASIE-AFWYKINGS, V O L 55, 2008 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. ) Date: A PP EN D IX C Attitude Questionnaire Code: ____ S T R A T E G I E S FOR IM P R O V IN G E F F E C T I V E N E S S OF S P E A K E R S WITH M IX ED D Y S A R T H R I A Highest level of education: Date of birth: _________________________________ Sex: Male/ female Age: _________________________ ;________________ First language:_________________________________ Relationship to the person with Parkinson’s disease: Spouse/ parent/ caregiver/ family friend/other If OTHER, please describe:____________________________ Do you have any hearing problems? If YES, please describe:_________________________________ Do you have any language, learning or cognitive problems? If YES, please describe:_________________________________ THE SOUTH AFRICAN JOURNAL OF C O M M U N IC ATIO N DISORDERS, V O L 55 2008 | 75 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. ) NATALIE TOY AND KARIN JOUBERT APPENDIX C (Continued) I th in k this person is an effective com m unicator using this strategy Disagree Agree Strongly Strongly ■ J. w ould fee[ com fortable com m unicating w ith this person in a cjass or at w ork if he/she used this strategy 1 2 3 4 5 6 7 Disagree Agree Strongly Strongly I w ould be w illing to com m unicate w ith this person in a class or at w ork if he/she used this strategy. 1 2 3 4 5 6 7 ; Disagree Agree ! Strongly Strongly ; SECTION B Please com plete the follow ing questions tru th fu lly and to the best o f your knowledge: What feelings would you experience if you were com m unicating to the tw o previous speak- 76 | DIE SUID-AFRIKAANSETYDSKRIF VIR KOMMUNIKASIE-AFWYKINGS,VOL. 5 5 ,2 0 0 8 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. )