Syntactic Approaches for Improving Aphasia

Overview of Syntactic Treatment Approaches in Aphasia

• Syntactic approaches are impairment-based treatments specifically designed to reduce syntactic deficits in individuals with agrammatism, typically associated with Broca’s aphasia.
• While disorders other than aphasia may present with syntax challenges, the target population for these specific methods is people with aphasia.
• Theoretical debates regarding the nature of agrammatism inform these treatments:
  • Loss of representation: Some theorize patients lack the basic syntactic rules or access to those rules.
  • Mapping deficits: Others suggest difficulty mapping syntactic structures to thematic roles.
  • Cognitive factors: Agrammatism may be linked to deficits in short-term and working memory, which are not uniquely linguistic.
• Related Lexical Approaches: Verb Network Reinforcement Treatment (VNeST) and Verb as Core (reviewed in earlier chapters) are often considered syntactic because they involve using verbs within phrases and sentences.
• Key Approaches reviewed: Treatment of Underlying Forms (TUF), Mapping Therapy, and Sentence Production Program for Aphasia (SPPA).

Treatment of Underlying Forms (TUF)

• Definition: TUF is an approach designed to improve the comprehension and expression of sentence structures by focusing on the metalinguistic awareness of abstract linguistic properties.
• Target Population: Primarily individuals with Broca’s aphasia and agrammatism.
• Primary Principles:
  • It is rooted in government binding theory, a component of Chomsky’s derivational linguistic theory.
  • Argument Structure: Verbs carry lexical information that dictates the number and type of participants (arguments) in a sentence.
    • Agent: The entity performing the action (e.g., subject).
    • Theme/Patient/Object: The entity undergoing the action.
    • Goal: The entity toward which the action is directed.
  • Phrase Movement: This refers to changes in word order that create complex syntactic structures.
    • Canonical Sentences: Subject-Verb-Object (SVO) order in English (e.g., "Latisha planted nasturtiums").
    • Noncanonical Sentences: These involve movement, such as passive structures (OVS; "The nasturtiums were planted by Latisha") or sentences with embedded clauses (e.g., object relative: "I know who the cat scratched").
• Implementation Phases:
  • Phase 1: Metalinguistic Awareness (Thematic Role Training): The clinician uses word cards and pictures to teach the roles of the agent, theme, and verb. For passive sentences, the clinician arranges cards (e.g., "dog", "chased", "cat"), explains the roles, and then demonstrates noncanonical changes (e.g., "The cat was chased by the dog").
  • Phase 2: Creating Noncanonical Sentences (Sentence Building): The client practices building complex forms using word cards for specific images provided by the clinician.
  • Phase 3: Thematic Role Training Practice: The client practices these structures with new word combinations and models, such as subject relative sentences (e.g., "The boy who rode the bike crashed").
• Evidence-Based Practice Status:
  • Research demonstrates improvement in trained and untrained $wh$-structures and noun phrase movement.
  • Complexity Account of Treatment Efficacy (CATE): Findings suggest that training complex sentence forms leads to greater generalization toward simpler structures than a simple-to-complex hierarchy.
  • Neurological Correlates: fMRI data indicates increased activation in the right hemisphere area homologous to the left hemisphere Broca’s area following TUF.
  • Limitations: Most studies use single-case designs; outcomes may be limited by aphasia severity or cognitive deficits.

Mapping Therapy

• Definition: Mapping Therapy is a linguistically rooted treatment designed to address deficits in thematic role assignment, helping patients link semantic roles (who did what to whom) to syntactic positions.
• Primary Principles:
  • Focuses on the mapping between the thematic roles and the surface syntax of sentences.
  • The goal is to increase competence in producing and comprehending complex, noncanonical sentences by analyzing the grammatical roles of nouns and verbs.
• Implementation Steps:
  • Stimulus: The clinician presents a printed sentence which the client reads aloud.
  • Probe Questions: The clinician asks questions to identify the verb, agent, and patient/theme (e.g., "Which word is the agent?"). Questions are randomized.
  • Underlining: The client underlines critical components (e.g., the adjective in the subject position or the cleft object).
  • Feedback: Positive reinforcement for correct answers; for errors, the clinician provides the correct answer and encourages the client to analyze why it was an error.
  • Advanced Support: Some versions (Byng et al., 1994) use color and spatially coded templates for syntactic classes.
• Evidence-Based Practice Status:
  • Studies show improved production of semantically reversible, canonical sentences.
  • Comprehension improvements are less consistent, though some adaptations involving object manipulation and sentence-picture matching (Kiran et al., 2012) have shown better results.
  • Generalization is more likely when training complex structures first, supporting CATE.

Sentence Production Program for Aphasia (SPPA)

• Definition: A stimulation approach (updated from the Helm Elicited Language Program for Syntax Stimulation - HELPSS) designed to enhance sentence production through repeated stimulation of morphosyntactic forms.
• Primary Principles:
  • Based on the theory that patients have impaired access to grammatical knowledge rather than a total loss of that knowledge.
  • It does not rely on linguistic theory to the same extent as TUF or Mapping Therapy.
  • Primary Goal: Increase the variety and complexity of spoken utterances using sentence completion tasks.
• Sentence Types (Table 32–1):
  1. Imperative Intransitive
  2. Imperative Transitive
  3. $wh$-Interrogative—What and Who
  4. $wh$-Interrogative—Where and When
  5. Declarative Transitive
  6. Declarative Intransitive
  7. Comparative
  8. Yes-No Questions
• Implementation Process:
  • Level A (Repetition): The clinician tells a brief story with a picture and provides a target sentence for the client to repeat (e.g., "What does his mother say?" "Wake up!").
  • Level B (Completion): The clinician asks a question to elicit the target sentence without providing the direct model (e.g., "So what does his mother tell him?").
• Scoring System:
  • $1$: Fully correct response.
  • $0.5$: Partially correct (one word correct or produced in error).
  • $0$: Incorrect (two or more errors or omitted).
• Evidence-Based Practice Status:
  • Based largely on HELPSS data; studies show improvement in correct sentence construction and narrative morphology.
  • Recent research questions the efficacy of the simple-to-complex hierarchy used in SPPA in light of CATE. More research is needed regarding generalizeability to natural conversation.