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The residual word-finding deficit of traumatically head-injured children Hvozdanski, Marion Jeanette 1986

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THE RESIDUAL WORD-FINDING DEFICIT OF TRAUMATICALLY HEAD-INJURED CHILDREN By MARION JEANETTE HVOZDANSKI B.Sc., The U n i v e r s i t y of V i c t o r i a , 1984 } THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES School of Audiology and Speech S c i e n c e s We accept t h i s t h e s i s as corn-forming t o t h e r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA September 19B6 © Marion J e a n e t t e Hvozdanski I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h C o l u m b i a , I agree t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by t h e head o f my department o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f Audiofocfy, OSH! &p&JU>Jh, &JULUUL4 The U n i v e r s i t y o f B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date JojaJPsiAjU, H[ 1431* ABSTRACT The purpose of t h i s study was t o i n v e s t i g a t e the nature of the r e s i d u a l word-finding d e f i c i t a f t e r severe head-i n j u r y . Reach of f i v e s e v e r e l y head—injured s u b j e c t s , (2;0-8;0 p o s t - i n j u r y ) males, ranging i n age from 10;0—17;0 was compared with a C o n t r o l matched f o r age and sex. S u b j e c t s were t e s t e d with a number of s t a n d a r d i z e d and experimental language t e s t s . R e s u l t s were compared between s u b j e c t groups. R e s u l t s i n d i c a t e d t h a t naming s t i m u l u s and c o n d i t i o n a f f e c t e d the accuracy of the head—injured c h i l d r e n s ' responses. Photographs were e a s i e r t o name than l i n e drawings. V i s u a l c o n f r o n t a t i o n naming and sentence completion were e a s i e r t a s k s than naming t o a u d i t o r y d e s c r i p t i o n , which i n t u r n was e a s i e r than naming t o p a l p a t i o n . M e t a l i n g u i s t i c s k i l l s , e.g. antonyms and homonyms, were demonstrated t o be an area of d e f i c i t f o r the h e a d - i n j u r e d c h i l d r e n and warrant f u r t h e r r e s e a r c h . E x p o s i t o r y speech of the h e a d - i n j u r e d c h i l d r e n was marked by an o v e r a l l s i m p l i f i c a t i o n s s m a l l e r MLU, and r e d u c t i o n of s y n t a c t i c complexity when compared with the C o n t r o l group. The speech of the h e a d - i n j u r e d c h i l d r e n a l s o c o n t a i n e d more pauses which are i n d i c a t i v e of word-f i n d i n g d i f f i c u l t y . TABLE OF CONTENTS ABSTRACT i i LIST OF TABLES . i v LIST OF FIGURES v i i ACKNOWLEGDEMENT v i i i Chapter Page 1. INTRODUCTION 1 2. METHOD 6 3. PATIENT 1 14 4. PATIENT 2 26 5. PATIENT 3 38 6. PATIENT 4 51 7. PATIENT 5 63 8. GROUP RESULTS 72 9. DISCUSSION 88 REFERENCES 119 APPENDIX 124 i i i LIST OF TABLES Table Page 2- 1. Homonym T e s t : Examples o-f Stimulus S e t s 10 3— 1. F r u i t and Vegetable Naming: Summary of Raw Scores 22 3-2. Naming l i s Summary of Raw Scores 23 3-3. Homonym Te s t : Summary of Raw Scores 24 3- 4. Boston Cookie Theft D e s c r i p t i o n : Numerical Language Measures 26 4- 1. F r u i t and Vegetable Naming: Summary of Raw Scores 33 4-2. F r u i t and Vegetable Naming: Summary of Mean Response L a t e n c i e s 33 4—3. Naming I I : Summary of Raw Scores and Mean Response L a t e n c i e s 34 4—4. Homonym Te s t : Summary of Raw Scores 35 4- 5. Boston Cookie Theft D e s c r i p t i o n : Numerical Language Measures 37 5— 1. F r u i t and Vegetable Naming: Summary of Raw Scores » 46 5-2. F r u i t and Vegetable Naming: Summary of Mean Response L a t e n c i e s 47 5-3. Naming U s Summary of Raw Scores and Mean Response L a t e n c i e s 47 5-4. Homonym Te s t : Summary of Raw Scores 48 5- 5. Boston Cookie Theft D e s c r i p t i o n : Numerical Language Measures 50 6- 1. F r u i t and Vegetable Naming: Summary of Raw Scores 58 6-2. F r u i t and Vegetable Naming: Summary of Mean Response L a t e n c i e s 59 i v 6-3. Naming I I : Summary of Raw Scores and Mean Response L a t e n c i e s 59 6-4. Homonym Te s t : Summary o-f Raw Scores 61 6- 5. Boston Cookie The-ft D e s c r i p t i o n : Numerical Language Measures 62 7— 1. F r u i t and Vegetable Naming: Summary of Raw Scores 68 7-2. F r u i t and Vegetable Naming: Summary of Mean Response L a t e n c i e s 68 7-3. Naming U s Summary of Raw Scores and Mean Response L a t e n c i e s 69 7—4. Homonym Te s t : Summary of Raw Scores 70 7- 5. Boston Cookie T h e f t D e s c r i p t i o n : Numerical Language Measures 71 8- 1. The Word T e s t : S u b t e s t s Mean Standard Scores 73 8-2. BDAE S u b t e s t s : Mann-Whitney U Values 73 8—3. F r u i t and Vegetable Naming: Mann—Whitney U Values of Raw Scores 75 8-4. F r u i t and Vegetable Naming: Mann-Whitney U Values f o r Mean Response L a t e n c i e s 76 8-5. F r u i t and Vegetable Naming: Mean, Range, Standard D e v i a t i o n , and Variance of Raw Scores 77 8-6. Naming l i s Mann-Whitney U Values f o r each Naming C o n d i t i o n 78 8-7. Naming I I : Mann-Whitney U Values of Mean Response L a t e n c i e s f o r each Naming C o n d i t i o n 79 8-8. Naming l i s Mean, Range, Standard D e v i a t i o n , and V a r i a n c e of Raw Scores 80 8-9. Homonym T e s t : Mann-Whitney U Values f o r each C o n d i t i o n and each Subject 81 v 8—10. Homonym T e s t : Mean, Range Standard D e v i a t i o n , and V a r i a n c e o-f Raw Scores 82 8-11. Boston Cookie T h e f t D e s c r i p t i o n (ORAL): Mann—Whitney U Values; Experimental vs C o n t r o l 83 8-12. Boston Cookie Theft D e s c r i p t i o n (WRITTEN): Mann-Whitney U Values; Experimental vs Co n t r o l 84 8-13. Boston Cookie The-ft D e s c r i p t i o n : Mann-Whitney U Values f o r Experimental Group; Oral vs Wr i t t e n D e s c r i p t i o n 85 8—14. Boston Cookie The-ft D e s c r i p t i o n : Mann—Whitney U Values -for C o n t r o l Group; Oral vs W r i t t e n D e s c r i p t i o n 86 v i LIST OF FIGURES F i g u r e Page 9-1. Model o-f L e x i c a l / S e m a n t i c Storage 91 9-2. Word-finding Model 110 v i i ACKNOWLEDGEMENT I wish t o acknowledge the guidance, support, and a s s i s t a n c e of Dr. John G i l b e r t , Ms. Lynne Brown, and Ms. E l i z a b e t h Zook. I a l s o wish t o thank the C o n t r o l s u b j e c t s f o r t h e i r v a l u a b l e time. S p e c i a l thanks t o the head—injured c h i l d r e n and t h e i r f a m i l i e s f o r t h e i r c o o p e r a t i o n and candour. v i i i CHAPTER 1 INTRODUCTION The number of p u b l i s h e d r e s e a r c h s t u d i e s of c h i l d h o o d aphasia are w o e f u l l y few i n comparsion t o the l i t e r a t u r e of a d u l t aphasia (Satz and Bullard—Bates,1981; Denckla, 1979). De s p i t e the d i s p a r i t y i n r e s e a r c h of the two groups 1 i t has been proposed t h a t c h i l d h o o d aphasia i s a d i s t i n c t l y d i f f e r e n t d i s o r d e r from a d u l t a p h a s i a , i . e . d i f f e r i n g i n type, and pr o g n o s i s . It has been argued t h a t c h i l d r e n who are are head-i n j u r e d r e c o v e r more completely, and i n a s h o r t e r p e r i o d of time, than a d u l t s who have i n c u r r e d s i m i l a r i n j u r i e s ( A l a j o u a n i n e and L h e r m i t t e , 1965s Basser,1962; Denckla, 1979; Hecaen, 1976; Lenneberg, 1967; Woods and Teuber, 1978). T h i s argument i s based on the hy p o t h e s i s t h a t a young c h i l d ' s c e r e b r a l hemispheres are e q u i p o t e n t i a l i n t h e i r a b i l i t y t o re p r e s e n t language. Thus ( i t i s c l a i m e d ) , i f damage t o the l e f t hemisphere oc c u r s e a r l y i n l i f e , the r i g h t hemisphere i s capable of assuming the language f u n c t i o n s p r e v i o u s l y performed by the l e f t hemisphere. However, many of these r e s e a r c h e r s have a l s o 1 For the purpose of t h i s study we define childhood aphasia as the language disorder incurred through brain trauma as a r e s u l t of closed head-injury following a normal period of development. 1 r e p o r t e d that d e s p i t e apparent c l i n i c a l r e c o v e r y , c h i l d r e n s t i l l e x p e r i e n c e problems with language i n the school s e t t i n g ( A l a j o u a n i n e and L h e r m i t t e , 1965) and t h a t r e c o v e r y can take more than two years i n the worst cases (Woods and Tueber, 1978). Recent r e s e a r c h has attempted t o i l l u m i n a t e t h i s concept o-f more r a p i d and complete r e c o v e r y i n c h i l d r e n than i n a d u l t s (Woods and Carey, 1979; L e v i n , Grossman, Sarwar, and Meyers 1982; L e v i n and E i s e n b e r g , 1979; Chadwick et a l . , 1981). Using complex l i n g u i s t i c measures, and attempting t o improve the homogeneity o-f the s u b j e c t groups, i n v e s t i g a t o r s are beginning t o demonstrate t h a t the r e c o v e r y o-f these c h i l d r e n i s l e s s complete than p r e v i o u s l y supposed. T h i s schism i n r e s e a r c h -findings suggests t h a t one o-f the long—term q u e s t i o n s t h a t should be addressed i s : "Do c h i l d r e n r e c o v e r more completely and at a f a s t e r r a t e than a d u l t s a f t e r i n c u r r i n g s i m i l a r h e a d - i n j u r y ? " If the answer t o t h i s question i s "no", which seems l i k e l y g iven the t r e n d of the c u r r e n t r e s e a r c h f i n d i n g s , then the next q u e s t i o n s t o be addressed are: "What are the r e s i d u a l l o n g -term l i n g u i s t i c d e f i c i t s of h e a d — i n j u r y ? " and, "Are such d e f i c i t s d i f f e r e n t i n c h i l d r e n than i n a d u l t s ? " The r e c e n t l i t e r a t u r e concerning h e a d - i n j u r y has demonstrated one of the r e c u r r e n t language d e f i c i t s t o be word-finding d i f f i c u l t y ( L e v i n , Grossman, Sarwar, and 2 Meyers, 1981; Hecaen, 1983; Woods and Carey, 1979; Sarno 1980; Chadwick et a l . , 1981). Residual word—finding a b i l i t i e s then appear t o be a f r u i t f u l area t o i n v e s t i g a t e i n more d e t a i l t o a i d i n answering the long—term q u e s t i o n s we have posed. The purpose of t h i s study was t o i n v e s t i g a t e the nature of the word—finding problem e x h i b i t e d by c h i l d r e n ages 10;0—17;0 who have s u f f e r e d a severe h e a d - i n j u r y . The s p e c i f i c r e s e a r c h q u e s t i o n s which are being addressed over a f i v e — y e a r p e r i o d are s 1) What e f f e c t does the s t i m u l u s have on w o r d - f i n d i n g p r o c e s s e s ? Barton et a l . (1969) s t u d i e d the e f f e c t of s t i m u l u s context on word f i n d i n g i n aphasic a d u l t s . The r e s u l t s of t h e i r i n v e s t i g a t i o n demonstrated t h a t word-f i n d i n g accuracy was dependent on s t i m u l u s context. Sentence Completion was the e a s i e s t task f o l l o w e d by V i s u a l C o n f r o n t a t i o n naming, with naming t o D e s c r i p t i o n being the most d i f f i c u l t t a s k . Rudel, Denckla, Broman, and H i r s c h , (1980) repeated t h i s experiment with c h i l d r e n age 6;0—11;0. For c h i l d r e n 6;0 t o 10;0, Rudel et a l . found the same order of s t i m u l u s d i f f i c u l t y as Barton et a l . (1969) found f o r a d u l t a p h a s i c s . However, c h i l d r e n over 10;0 d i d not appear a f f e c t e d by s t i m u l u s c o n t e x t , and performed e q u a l l y well on a l l t a s k s . It t h e r e f o r e appears t h a t a d u l t a p h a s i c s demonstrate a p r i m i t i v i z a t i o n of language s k i l l s r a t h e r than t o t a l l y d e v i a n t language behavior. Given these •findings we hypothesized a p r e d i c t e d order of d i f f i c u l t y f o r our experiment; t h a t i s , V i s u a l C o n f r o n t a t i o n naming would be the most accurate c o n d i t i o n f o l l o w e d i n d e c r e a s i n g order by Sentence Completion, naming t o A u d i t o r y D e s c r i p t i o n , and T a c t i l e naming. 2) What e f f e c t does the type of p i c t o r i a l s t i m u l u s have on naming accuracy? In a case study of c a t e g o r y - s p e c i f i c naming d e f i c i t s , Hart, Sloan Berndt, and Caramazza <1985) used Black and White L i n e drawings, Coloured drawings, Photographs and Real O b j e c t s f o r e l i c i t i n g names of s t i m u l i . The r e s u l t s of these naming t e s t s i n d i c a t e d a h i e r a r c h y of d i f f i c u l t y f o r p i c t u r e type; t h a t i s , Real  O b j e c t s were the e a s i e s t t o name f o l l o w e d by Photographs. Cdloured l i n e drawings, and Black and White drawings. Based on these f i n d i n g s , we hypothesized t h a t the head-i n j u r e d c h i l d r e n would be a b l e t o name Photographs with g r e a t e r accuracy than e i t h e r Coloured or Black and White l i n e drawings. 3) Is the word—finding problem due t o a semantic d i s o r g a n i z a t i o n of the l e x i c o n , or a r e d u c t i o n of the l e x i c a l s t o c k , e i t h e r by impaired a c c e s s , or complete d e s t r u c t i o n ? Recent work by Brober (1984) on the breakdown of meaning i n aphasia suggests t h a t t h e r e i s semantic d i s o r g a n i z a t i o n of the l e x i c o n a f t e r b r a i n damage. We p r e d i c t e d t h a t the r e s u l t s of our t e s t i n g would a l s o demonstrate semantic d i s o r g a n i z a t i o n i n the l e x i c o n s of h e a d - i n j u r e d c h i l d r e n , which would then imply t h a t word-f i n d i n g problems are the r e s u l t of impaired a c c e s s , r a t h e r than complete d e s t r u c t i o n of the " l e x i c a l " s t o c k . 5 CHAPTER 2 METHOD Su b j e c t s F i v e t r a u m a t i c a l l y head—i n juredl c h i l d r e n were s e l e c t e d -from S u n n y h i l l H o s p i t a l f o r C h i l d r e n , Vancouver B.C. and the Surrey School Board, Surrey B.C. A l l of these c h i l d r e n had s u f f e r e d a severe c l o s e d h e a d — i n j u r y . A l l of the c h i l d e n had been i n v o l v e d i n a p r e v i o u s study of language d e f i c i t s of head—injured c h i l d r e n ( M i t c h e l l , 1985). S u b j e c t s were male, ranging i n age from 10;0 t o 17;O ye a r s . None of the s u b j e c t s had any h i s t o r y of hea r i n g impairment or l e a r n i n g d i f f i c u l t i e s . Developmental m i l e s t o n e s at the time of the a c c i d e n t were w i t h i n normal l i m i t s i n a l l cases. Each s u b j e c t (E) was c o n s i d e r e d a s i n g l e , e x p e r i m e n t a l , case study. The data c o l l e c t e d f o r each c h i l d were analyzed and compared with a normal C o n t r o l s u b j e c t (C) matched f o r age and sex. T e s t i n g S tandardized and experimental t e s t s were administered t o a l l s u b j e c t s . The t e s t s were given over two s e p a r a t e , one-hour s e s s i o n s . Standardized t e s t s were administered i n the f i r s t s e s s i o n . T h i s s e s s i o n was audiotaped t o permit subsequent t r a n s c r i p t i o n . Experimental t e s t s were administered i n the second s e s s i o n , which was videotaped f o r reasons s t a t e d above, and f o r a f u t u r e i n v e s t i g a t i o n of g e s t u r a l communication. 1) Standardized t e s t s S e l e c t e d s u b t e s t s from the f o l l o w i n g t e s t s were administered t o each s u b j e c t : a) Boston D i a g n o s t i c Aphasia Examination (BDAE).— The Responsive Naming. Sentence R e p e t i t i o n , and Word Fluencv s u b t e s t s of the BDAE (Goodglass and Kaplan, 1983). b) The Word Test - The Antonym. Synonym. D e f i n i t i o n . and M u l t i p l e D e f i n i t i o n s u b t e s t s of the Word Test (Jorgenson, B a r r e t t , Husingh, and Zachman, 1981). I t should be noted t h a t t h i s t e s t i s normed o n l y t o age 11;11. In cases where the s u b j e c t was o l d e r than 11;11, the Experimental and C o n t r o l s u b j e c t s were compared t o the 11;11 norms. c) The Boston Naming Test <BNT).— The BNT (Kaplan, Goodglass, Weintraub, and S e g a l , 1981). Test s c o r e s were compared t o norms, and average response l a t e n c i e s were c a l c u l a t e d . 7 The Feabody P i c t u r e Vocabulary Test; Revised (PPVT).-The E x p e r i m e n t a l s ' r e s u l t s on the PPVT (Dunn and Dunn, 1981) were compared with t h e i r 1985 r e s u l t s ( M i t c h e l l , 1985), and the s c o r e s of t h e i r C o n t r o l s . 2) Experimental t e s t s Three experimental t e s t s s e l e c t e d from r e c e n t aphasia l i t e r a t u r e were administered t o the Experimental and C o n t r o l s u b j e c t s . They are as f o l l o w s : a) F r u i t and veget a b l e naming - Adapting a procedure developed by Hart, Sloan Berndt, and Caramazza (1985), a l l s u b j e c t s were r e q u i r e d t o complete a v i s u a l c o n f r o n t a t i o n naming t a s k . The s t i m u l i c o n s i s t e d of 22 v e g e t a b l e s and f r u i t t h a t were represented by t h r e e d i f f e r e n t p i c t o r i a l s t i muli; 1) Black and White drawings 2) Coloured L i n e Drawings 3) Photographs There were 22 of each p i c t u r e type, g i v i n g a t o t a l of 66 s t i m u l i . The s t i m u l i were presented i n random order; response, and response l a t e n c y were recorded. b) Naming II — A naming t e s t developed by Denckla, Rudel, Broman, and H i r s c h (1980) was admin i s t e r e d . S i x t y nouns were chosen from the Thorhdike—Lorge word freqency l i s t (1944). Twenty words were chosen from each of the 8 c a t e g o r i e s f o u r and f i v e , and ten words each were chosen from c a t e g o r i e s s i x and seven. S e l e c t i o n s from c a t e g o r i e s s i x and seven were then combined t o form one category. Three words were chosen from each of the t h r e e c a t e g o r i e s t o c o n s t i t u t e a twelve—word l i s t . There were f o u r word l i s t s a l t o g e t h e r . The f i r s t two words of each l i s t were t r i a l items and not scored. The remaining ten words were the a c t u a l t e s t items. Each word l i s t was used t o c o n s t r u c t a separate naming s u b t e s t ; 1) V i s u a l C o n f r o n t a t i o n — each s u b j e c t was r e q u i r e d t o name a black and white l i n e drawing. 2) A u d i t o r y D e s c r i p t i o n - each s u b j e c t was r e q u i r e d t o p r o v i d e a word, given an a u d i t o r y d e s c r i p t i o n . e.g. What i s the name of a sour yellow f r u i t 7 (1emon) 3) Sentence Completion - each s u b j e c t was r e q u i r e d t o complete a sentence with the a p p r o p r i a t e word. e.g. A s p i d e r s p i n s a ? (web) 4) T a c t i l e Naming — each s u b j e c t was r e q u i r e d t o name an o b j e c t a f t e r o n l y being allowed t o p a l p a t e i t . The o b j e c t was not v i s i b l e t o the s u b j e c t . c) Homonym t e s t — T h i s procedure was developed by Grober (1984). S t i m u l i c o n s i s t e d of 12 homonyms i n which one meaning was dominant over the other a c c o r d i n g t o p u b l i s h e d norms ( P e r f e t t i , L i n d s a y , and Gordon, 1971). Nine words taken from the norms were presented with each 9 homonym; ( i ) t h r e e r e l a t e d t o the dominant meaning, ( i i ) t h r e e r e l a t e d t o the nondominant meaning, and ( i i i ) t h r e e u n r e l a t e d t o e i t h e r meaning. There were t h r e e o-f each type o-f homonym p a i r ; 1) dominant meaning r e - f e r e n t i a l concept, nondominant meaning p r e d i c a t i v e concept (N,V), 2) dominant meaning p r e d i c a t i v e concept, nondominant meaning r e f e r e n t i a l concept (V,N), and 3) both meanings r e f e r e n t i a l concepts (N,N). Table 2-1 g i v e s an example of these s t i m u l u s s e t s . TABLE 2-1 HOMONYM TESTs EXAMPLES OF STIMULUS SETS Homonym Domi nant meaning Nondomi nant meaning Un r e l a t e d meani ng bat (N,V) b a l l cave look basebal1 f l y alone c l u b animal b e s i d e count (V,N) add duke ban number duchess growl money r o y a l t y sound bank (N,N) money r i ver grammar sa v i n g s shore k i c k vaul t stream s t r i ng Each word was typed i n b o l d b l a c k l e t t e r s onto a 3" * 5" index c a r d . S t i m u l i were presented v i s u a l l y and o r a l l y at a subject—determined pace. Each t r i a l began 10 with the p r e s e n t a t i o n of the homonym. The s u b j e c t was then i n s t r u c t e d t o p l a c e a l l subsequently presented words i n t o one of two p i l e s ; the "YES" p i l e , which i n d i c a t e d the word was r e l a t e d t o the homonym, or the "NO" p i l e , which i n d i c a t e d t h a t the word was not r e l a t e d t o the homonym. A f t e r completing the i n i t i a l s o r t , the s u b j e c t was i n s t r u c t e d t o s o r t the "YES" p i l e i n t o the v a r i o u s meanings of the homonym. One p o i n t was awarded f o r each card c o r r e c t l y s o r t e d . There were t h r e e i n i t i a l p r a c t i c e t r i a l s f o l l o w e d by nine t e s t s o r t s . The s c o r e s f o r the t h r e e concept combinations were t a b u l a t e d . d) Language sample - A procedure developed by H i e r , Hagenenlocker, and S h i n d l e r (1985) was used t o analyze e x p r e s s i v e language. Each s u b j e c t was given s i x t y seconds t o d e s c r i b e "The Cookie T h e f t " p i c t u r e from the Boston D i a g n o s t i c Aphasia Examination (Goodglass and Kaplan, 1983). The d e s c r i p t i o n was taped and t r a n s c r i b e d . Each speech sample was analyzed u s i n g the f o l l o w i n g numerical language measures: ( i ) t o t a l number of words, ( i i ) number of unique words, ( i i i ) mean leng t h of u t t e r a n c e , ( i v ) number of p r e p o s i t i o n a l phrases, (v) number of su b o r d i n a t e c l a u s e s , (vi) number of p r e p o s i t i o n a l e r r o r s , ( v i i ) number of p e r s e v e r a t i o n s , ( v i i i ) number of empty words, e.g. "umm","er", t h i n g , e t c . , ( i x ) number of semantic p a r a p h a s i a s , (x) number of phonemic pa r a p h a s i a s , ( x i ) number o-f jargon words, ( x i i ) number o-f nouns, ( x i i i ) number of verbs, (xiv) number o-f p r e p o s i t i o n s , (xv) number of determiners, (xvi) number of c o n j u n c t i o n s , ( x v i i ) number of a d j e c t i v e s , ( x v i i i ) number of adverbs, (xix) number of determiners ommitted. A d d i t i o n a l l y , two i n d i c e s were c a l c u l a t e d : 1) Anomia index- d e f i n e d as I-C Nouns/(Nouns + Pronouns)3 because i t i s common i n anomia f o r t h e r e t o be an i n c r e a s e i n the use of pronouns at the expense of nouns (Wepman, Bock, Jones, and van P e l t , 1956). The l a r g e r the anomia index the g r e a t e r the anomia. 2) Conciseness index- d e f i n e d as 100 * C r e l e v a n t o b s e r v a t i o n s / t o t a l number of words used3. The g r e a t e r the index the more c o n c i s e the d e s c r i p t i o n . e) W r i t i n g - Procedures used t o analyze the language sample were repeated, except t h a t the s u b j e c t was r e q u i r e d t o w r i t e a d e s c r i p t i o n of "The Cookie T h e f t " p i c t u r e . The r e s u l t i n g w r i t t e n d e s c r i p t i o n was s u b j e c t e d t o the same a n a l y s i s as the v e r b a l sample with one added measures number of s p e l l i n g e r r o r s . S t a t i s t i c a l A nalyses R e s u l t s of the s t a n d a r d i z e d t e s t s were scored u s i n g t e s t norms. Scores of Experimental and C o n t r o l groups were t e s t e d f o r s t a t i s t i c a l s i g n i f i c a n c e . R e s u l t s o-f experimental t e s t s were t a b u l a t e d and and then analyzed u s i n g the Mann-Whitney U t e s t -for two independent groups (Shavelson, 1981). U v a l u e s were c a l c u l a t e d and t e s t e d f o r s i g n i f i c a n c e between groups, and between naming c o n d i t i o n s w i t h i n each group. Parent Interview The p a r e n t s of the hea d - i n j u r e d c h i l d r e n were in t e r v i e w e d t o i n v e s t i g a t e the f a m i l y ' s p e r c e p t i o n of the head—in j u r e d c h i l d ' s l e v e l of f u n c t i o n s i n c e the a c c i d e n t , and t o ga i n i n s i g h t i n t o the c h i l d ' s i n t e r a c t i o n i n h i s environment. These i n t e r v i e w s w i l l be used i n a l a t e r a n a l y s e s . 13 CHAPTER 3 PATIENT 1 Personal H i s t o r y P a t i e n t 1 was born January 20, 1970 and pl a c e d f o r adoption. Approximately two years l a t e r , h i s mother gave b i r t h t o the f i r s t of her two n a t u r a l c h i l d e n — a g i r l f o l l o w e d two years l a t e r by another boy. P a t i e n t 1 i s r i g h t handed, and h i s f i r s t and o n l y language i s E n g l i s h . P r i o r t o h i s a c c i d e n t , p a t i e n t 1 was e n r o l l e d i n r e g u l a r grade nine c l a s s e s . H i s academic performance at t h i s time was average t o above average. He p a r t i c u l a r l y e x c e l l e d i n drama c l a s s and acted i n a number of school p l a y s . Mr. 1 spends much of h i s spare time with P a t i e n t 1's s i s t e r who i s a c o m p e t i t i v e runner. Mr. 1 i s very i n v o l v e d i n the a d m i n i s t r a t i v e / c o a c h i n g s i d e of the s p o r t . P a t i e n t 1 i s u s u a l l y i n t e r e s t e d i n h i s s i s t e r ' s r e s u l t s but c l a i m s t o hate running. H i s r e l a t i o n s h i p with h i s younger brother i s t y p i c a l , i . e . they f i g h t . At the present time P a t i e n t 1 s t i l l e x p e r i e n c e s d i f f i c u l t y with word—finding, language comprehension, and making i n f e r e n c e s . P a t i e n t 1's pa r e n t s are s u p p o r t i v e of t h e i r son when he expe r i e n c e s d i f f i c u l t i e s but they are not always sure how they can help him compensate f o r h i s weaknesses. 14 I n j u r y On October 20, 1984 P a t i e n t 1 was r i d i n g h i s b i c y c l e when he was h i t by a car- On admission t o h o s p i t a l he was comatose and e x h i b i t e d b i l a t e r a l d ecerebrate p o s i t i o n i n g . A CT scan i n d i c a t e d a hematoma i n the l e f t f r o n t a l r e g i o n , with some compression of the l e f t l a t e r a l v e n t r i c l e . There was a l s o evidence of con t u s i o n i n the l e f t p a r i e t a l lobe i n c l o s e r e l a t i o n s h i p with a l i n e a r s k u l l f r a c t u r e , and a s s o c i a t e d c o n t u s i o n of the r i g h t f r o n t o - p a r i e t a l area. The head i n j u r y was diagnosed as severe. S e i z u r e a c t i v i t y was not evi d e n t but the p a t i e n t was r e p o r t e d t o be tremulous and s h i v e r y . T h i s c o n d i t i o n was t r e a t e d with v a l i urn. Recovery P a t i e n t 1 remained comatose f o r two weeks. On the f i f t h day p o s t — i n j u r y he was assessed at 5 on the Glasgow Coma s c a l e (James and Trauner, 1985). There was no eye—opening t o p a i n ; however t h e r e was b i l a t e r a l limb f l e x i o n . On the ele v e n t h day p o s t — i n j u r y , P a t i e n t 1 opened h i s eyes but was unable t o obey simple commands. P a t i e n t 1 was a b l e t o obey simple commands and attempted t o a r t i c u l a t e words and feed hims e l f on the ni n e t e e n t h day p o s t — i n j u r y . On the t w e n t y - t h i r d day p o s t - i n j u r y P a t i e n t 1 began t o v e r b a l i z e 15 but c o n v e r s a t i o n was i n a p p r o p r i a t e and h i s speech was "rambling", "compulsive", and " p e r s e v e r a t i v e " : i t was r e p o r t e d t h a t he was "having d i f f i c u l t y f i n d i n g words f o r what he wanted t o say". Paraphasias were noted i n e x p r e s s i v e language at one month p o s t - i n j u r y , e.g. " K i l l i p " f o r " P h i l l i p " . At t h r e e months p o s t - i n j u r y speech was i n n a p p r o p r i a t e . When asked t o p o i n t t o the c o l o u r grey P a t i e n t l ' s response was : G r e y , Match the Bismark, I'll give you grey now, the grey squirrel. L i t e r a l and v e r b a l paraphasias were fre q u e n t : e.g. You 're snoring my breath T h i s phrase was u t t e r e d when P a t i e n t 1 became bored with the task at hand. A u d i t o r y comprehension was reduced and naming a b i l i t y was f a i r . R e p e t i t i o n s k i l l s were good and r e a d i n g at the s i n g l e word l e v e l was adequate. Reading at the sentence l e v e l was p r o b l e m a t i c at t h i s time. W r i t i n g s k i l l s were moderately impaired. At t h r e e months p o s t -i n j u r y word-finding s t i l l caused P a t i e n t 1 d i f f i c u l t y . L i t e r a l and v e r b a l paraphasias were s t i l l e v i d e n t i n spontaneous speech. A u d i t o r y comprehension was s t i l l reduced with the p r o c e s s i n g of l i n g u i s t i c concepts being p a r t i c u l a r l y p r o b l e m a t i c . Reading and w r i t i n g s k i l l s were improving, but s h o r t term memory was weak. P a t i e n t 1 r e t u r n e d t o n i n t h grade c l a s s e s at s i x months p o s t - i n j u r y . Academic achievment was r e p o r t e d t o be well below h i s premorbid l e v e l and he r e q u i r e d l e a r n i n g a s s i s t a n c e i n a l l s u b j e c t s . Comprehension was adequate and paraphasias were reduced. Word-finding and the p r o c e s s i n g of a b s t r a c t i n f o r m a t i o n were s t i l l p r o b l e m a t i c . At t h i s time P a t i e n t 1 was s e l e c t e d t o p a r t i c i p a t e i n t h i s l o n g i t u d i n a l study of l i n g u i s t i c r e c o v e r y a f t e r traumatic h e a d - i n j u r y . M i t c h e l l (1985) t e s t e d P a t i e n t 1 with a number of r e c e p t i v e and e x p r e s s i v e language measures. R e s u l t s of the r e c e p t i v e language t e s t s were not s i g n i f i c a n t l y d i f f e r e n t from those of h i s c o n t r o l . E x p r e s s i v e language t e s t s i n d i c a t e d moderate word-finding problems, and impaired sentence r e p e t i t i o n due t o sequencing e r r o r s . At the present time, approximately one and one h a l f y e ars p o s t — i n j u r y , P a t i e n t 1 i s i n f u l l - t i m e attendance at high s c h o o l . He i s completing grade ten i n a l l c o u rses except Math and Typing, which he f a i l e d l a s t year. In a d d i t i o n t o t a k i n g r e g u l a r grade nine math, he i s a l s o t a k i n g a mo d i f i e d Consumer Math course at the grade ten l e v e l . P a t i e n t 1 c o n t i n u e s t o r e c e i v e l e a r n i n g a s s i s t a n c e i n a l l s u b j e c t s and i t i s p o s s i b l e t h a t t h i s year he w i l l f a i l S o c i a l S t u d i e s . 17 Parent Interview P a t i e n t i 's parents were both present -for i n t e r v i e w . H i s f a t h e r c o n s t a n t l y r e i t e r a t e d t h a t he found i t d i f f i c u l t t o t e l l whether P a t i e n t 1's c o g n i t i v e / l a n g u a g e problems were a r e s u l t of the a c c i d e n t or h i s son's l a z i n e s s . P a t i e n t 1's l a z i n e s s appears t o have been a bone of c o n t e n t i o n between f a t h e r and son b e f o r e the a c c i d e n t . The mother seemed more attuned t o the problems P a t i e n t 1 i s e x p e r i e n c i n g as the r e s u l t of the a c c i d e n t , as she was a b l e t o p r o v i d e s p e c i f i c examples t o i l l u s t r a t e h i s weaknesses. She s t a t e d t h a t she does not n o t i c e any changes i n P a t i e n t 1's comprehension when he becomes f a t i g u e d . However, she r e p o r t e d t h a t she always has P a t i e n t 1 repeat r e q u e s t s she makes of him t o ensure t h a t he has completely understood the message. A few of P a t i e n t I's t e a c h e r s have r e p o r t e d t h a t they f e e l t h a t he does not always completely understand what i s expected of him when questioned i n c l a s s . He e x p e r i e n c e s s i m i l a r d i f f i c u l t i e s with w r i t t e n i n s t r u c t i o n s which r e s u l t i n incomplete answers on t e s t s and i n w r i t t e n work. H i s parents r e p o r t t h a t P a t i e n t 1 has always loved to t a l k but s i n c e the a c c i d e n t h i s speech i s rambling and not always c l e a r . He has d i f f i c u l t y i d e n t i f y i n g and m a i n t a i n i n g the t o p i c of c o n v e r s a t i o n , with the r e s u l t t h a t he makes statements t h a t are not always a p p r o p r i a t e 18 t o a p a r t i c u l a r t o p i c . P a t i e n t 1 a l s o e x p e r i e n c e s d i f f i c u l t y m a i n t a i n i n g a task and "takes f o r e v e r t o get orga n i z e d " . However, he i s a b l e t o focus long enough t o p l a y simple v i d e o games and complete two-mile runs. Both p a r e n t s were s u r p r i s e d t h a t P a t i e n t 1 w i l l have nothing t o do with drama s i n c e the a c c i d e n t . He i s re p o r t e d t o have been q u i t e a good a c t o r who loved t o perform. H i s parents b e l i e v e t h a t he i s r e l u c t a n t t o resume a c t i n g because of h i s l a p s e s of memory and d i f f i c u l t i e s with speaking. Apparently, P a t i e n t 1 has, on h i s own i n i t i a t i v e , b e f r i e n d e d a handicapped boy from h i s l e a r n i n g a s s i s t a n c e c l a s s , who was being avoided by other s t u d e n t s . He takes t h i s boy t o h i s c l a s s e s and p l a y s checkers with him at lunchtime. T h i s f r i e n d s h i p has both s u r p r i s e d and pleased P a t i e n t l ' s parents. P a t i e n t 1 i s e a s i l y f r u s t r a t e d s i n c e the a c c i d e n t , although s i n c e Christmas 1985, h i s parents have n o t i c e d he does not get as upset as he d i d befor e . They a l s o r e p o r t t h a t he does not read as much as p r e v i o u s l y and th a t h i s s p e l l i n g i s much worse, i . e . now he tends t o s p e l l words p h o n e t i c a l l y . H i s memory con t i n u e s t o be impaired. 19 R e s u l t s 1) S t a n d a r i z e d t e s t s a) Peabody P i c t u r e Vocabulary T e s t . - On t h i s t e s t o-f r e c e p t i v e vocabulary, P a t i e n t 1 achieved a standard s c o r e o-f 90 (1985, 91) which i s low average f o r a c h i l d of h i s c h r o n o l o g i c a l age. The C o n t r o l ' s standard s c o r e was 124 which i s s i g n i f i c a n t l y higher than P a t i e n t 1's s c o r e although P a t i e n t l ' s s c o r e i s w i t h i n the average range of 100 +15. b) The Word T e s t . — On both the Synonym and Antonym s u b t e s t s P a t i e n t l ' s standard s c o r e was 52. T h i s s c o r e i s w i t h i n the average range of 50 + 5 . H i s C o n t r o l scored a 55 on the Antonym s u b t e s t which i s a l s o w i t h i n the average range and not s i g n i f i c a n t l y d i f f e r e n t from P a t i e n t i ' s s c o r e . H i s C o n t r o l ' s s c o r e f o r the Synonym su b t e s t was 56, which i s w i t h i n one standard d e v i a t i o n above the average ranges t h i s i s s i g n i f i c a n t l y higher than P a t i e n t i ' s s c o r e s f o r the same s u b t e s t . P a t i e n t 1 achieved a standard s c o r e of 49 on the D e f i n i t i o n s u b t e s t . T h i s s c o r e i s w i t h i n the average range when compared t o the 11; 11 norms but i s s i g n i f i c a n l y lower than h i s C o n t r o l ' s s c o r e of 57. On the M u l t i p l e D e f i n i t i o n s u b t e s t , P a t i e n t l ' s standard s c o r e was 35. T h i s score i s two standard d e v i a t i o n s below the mean. Hi s C o n t r o l ' s s c o r e was 55, which i s w i t h i n the 20 average range but s i g n i - f i c a n t l y higher than P a t i e n t i ' s s c o r e f o r the same t e s t . c) . The Boston Naming T e s t . — the mean raw s c o r e f o r a person with 12 years of s c h o o l i n g or l e s s i s 55.73 with a standard d e v i a t i o n of 4.42. Both P a t i e n t l ' s s c o r e of 51 and h i s C o n t r o l ' s s c o r e of 53 a r e w i t h i n the average range and not s i g n i f i c a n t l y d i f f e r e n t from each o t h e r . d) The Boston D i a g n o s t i c Aphasia Examination.- P a t i e n t 1 scored 7/8 (80 7.1 e) on both the low and high p r o b a b i l i t y s e c t i o n s of the Sentence R e p e t i t i o n s u b t e s t . H i s c o n t r o l scored 8/8 (100 % l e ) on both s e c t i o n s . On the Responsive Naming s u b t e s t , P a t i e n t 1 scored 24/30 (SO 7.1e) whi l e h i s c o n t r o l scored 30/30 (100 7.1 e) . P a t i e n t 1 named 19 animals i n one minute on the Word Fluency t e s t (.32/min). H i s c o n t r o l named 23 animals i n one minute on the same t e s t (.38/min). Both s c o r e s f a l l w i t h i n the 100 7.1 e. 2) Experimental t e s t s a) F r u i t and Vegetable Naming.- A summary of s c o r e s f o r P a t i e n t 1 and h i s Co n t r o l are given i n Table 3—1. The s c o r e s a re l i s t e d by the type of p i c t u r e used t o e l i c i t the word. U n f o r t u n a t e l y , due t o a malfunc t i o n of the vide o equipment, the c a l c u l a t i o n of response l a t e n c i e s was i m p o s s i b l e f o r P a t i e n t 1's experimental t e s t i n g . TABLE 3-1 FRUIT AND VEGETABLE NAMING: SUMMARY OF RAW SCORES P i c t u r e Type P a t i e n t 1 C o n t r o l Photographs 20/22 = 91% 20/22 = 91% Colored drawings 19/22 = 86% 18/22 = 86% B/W drawings 19/22 = 86% 17/22 = 77% There was v i r t u a l l y no d i f f e r e n c e between P a t i e n t l ' s s c o r e s and those of the C o n t r o l s u b j e c t . However, the reduced s c o r e of the C o n t r o l s u b j e c t on the Black and  White drawings might suggest t h a t Black and White drawings are more d i f f i c u l t t o name than the Coloured Drawings or the Photographs. b) Naming I I . — A summary of raw s c o r e s i s p r o v i d e d i n T a b l e 3-2. The s c o r e s are recorded under the s t i m u l u s c o n d i t i o n used t o e l i c i t the word. The C o n t r o l s u b j e c t ' s s c o r e s were i d e n t i c a l f o r a l l f o u r s t i m u l u s c o n d i t i o n s . P a t i e n t i ' s r e s u l t s suggest, however, t h a t i t i s e a s i e r t o r e t r i e v e a word i n c e r t a i n s i t u a t i o n s . I t appears t h a t V i s u a l C o n f r o n t a t i o n and Sentence Completion were the l e a s t d i f f i c u l t c o n d i t i o n s . A u d i t o r y D e s c r i p t i o n was more d i f f i c u l t than V i s u a l C o n f r o n t a t i o n or Sentence Completion, and T a c t i l e naming was the most d i f f i c u l t c o n d i t i o n . TABLE 3-2 NAMING I I : SUMMARY OR RAW SCORES Stimulus C o n d i t i o n P a t i e n t 1 Co n t r o l V i s u a l C o n f r o n t a t i o n 10/10 10/10 Sentence Completion 10/10 10/10 A u d i t o r y D e s c r i p t i o n 9/10 10/10 T a c t i l e 8/10 10/10 c) Homonym T e s t . - Table 3—3 p r o v i d e s the raw s c o r e s f o r each s u b j e c t , and each meaning c o n d i t i o n : 1) where the dominant meaning i s a r e f e r e n t i a l concept and the nondominant meaning i s a p r e d i c a t i v e concept (N,V), 2) where the dominant meaning i s a p r e d i c a t i v e concept and the nondominant meaning i s a r e f e r e n t i a l concept (V,N), 3) where both the dominant and the nondominant meanings are r e f e n t i a l concepts (N,N>. The d i f f e r e n c e between P a t i e n t l ' s s c o r e s and those of h i s C o n t r o l i s unremarkable. TABLE 3-3 HOMONYM TESTs SUMMARY OF RAW SCORES Meaning C o n d i t i o n P a t i e n t 1 Co n t r o l N V 26/27 = 96.37. 25/27 = 92.67. V N 26/27 = 96.37. 25/27 = 92.67. N N 25/27 = 92.67. 24/27 = 88.97. d) Boston Cookie The-ft P i c t u r e D e s c r i p t i o n . - Numerical language measures f o r the Boston Cookie T h e f t P i c t u r e D e s c r i p t i o n a re presented i n Tabl e 3-4. Data f o r both s u b j e c t s ; Experimental and C o n t r o l , and both c o n d i t i o n s , w r i t t e n and o r a l , are contained i n t h i s t a b l e . When P a t i e n t 1 's s c o r e s were compared with those of h i s C o n t r o l ' s t h e r e were a few no t a b l e d i s c r e p e n c i e s . P a t i e n t 1 used c o n s i d e r a b l y more words, 26, than the Con t r o l f o r both the o r a l , and w r i t t e n p i c t u r e d e s c r i p t i o n s . In a d d i t i o n , P a t i e n t 1's o r a l c o n c i s e n e s s  index was c o n s i d e r a b l y lower than h i s C o n t r o l ' s (The lower the index the l e s s c o n c i s e the d e s c r i p t i o n ) . U n l i k e h i s C o n t r o l , P a t i e n t l ' s o r a l d e s c r i p t i o n contained empty  words and a semantic paraphasia ("overdoing" f o r " o v e r f l o w i n g " ) . When MLU measures were compared, P a t i e n t l ' s MLU was almost h a l f t h a t of h i s C o n t r o l f o r both w r i t t e n and o r a l d e s c r i p t i o n s . TABLE 3-4 BOSTON COOKIE THEFT DESCRIPTIONS NUMERICAL LANGUAGE MEASURES P a t i e n t 1 C o n t r o l  Measures Oral Wri t t e n Oral Wri t t e n t o t a l words 97.0 52. 0 71.0 78. 0 unique words 58.0 15. 0 44.0 52. 0 MLU (words) 5. 1 12. 8 10.6 20. 8 prep phrases 1.0 4. 0 4.0 8. 0 subord c l a u s e s 2.0 1. 0 0.0 1. 0 anomia index* 0. 38 0. 13 0.25 0. 13 c o n c i s e index** 5.2 9. 6 11.3 12. 8 prep e r r o r s 0.0 0. 0 0.0 0. 0 pe r s e v e r a t i ons 0.0 0. 0 O.O O. O empty words 6.0 0. 0 0.0 0. 0 sem paraphasia 1.0 O. 0 0. 0 0. 0 phnm paraphasia 0.0 0. 0 0.0 o. 0 jargon O.O O. o 0.0 0. 0 s p e l l i n g e r r o r s n/a O. o n/a 1. O syntax e r r o r s 1.0 O. 0 O.O 1. 0 t o t a l nouns 15.0 13. 0 15.0 21. 0 t o t a l pronouns 9.0 2. o 5. O 3. O t o t a l verbs 20.0 12. 0 13. O 12. O t o t a l preps l.O 6. o 8.0 IO. 0 t o t a l det 10. O 11. 0 13.0 18. 0 t o t a l adj/adv 9.0 o 6.0 5. 0 t o t a l conj 3.0 2. 0 8.0 6. 0 det omitted 1.0 0. 0 O.O 0. O *Anomia index **Consiseness index = 1 — E N / ( N + Prn ) 1 = CioO * r e l e v a n t o b s / t o t a l words] Keys prep = p r e p o s i t i o n sem = semantic phnm = phonemic det = determiners conj = c o n j u n c t i o n s subord = subordinated MLU = mean len g t h of u t t e r a n c e CHAPTER 4 PATIENT 2 Personal H i s t o r y P a t i e n t 2, born May 4, 1972, was the second born c h i l d but the - f i r s t boy -for h i s parents. P a t i e n t 2's s i s t e r had been born two years e a r l i e r . In 1974 the -family moved t o A u s t r i a where they l i v e d u n t i l 1976. During t h i s time, P a t i e n t 2 was exposed t o the German language. A f t e r r e t u r n i n g t o Canada i n 1976, P a t i e n t 2 was e n r o l l e d i n k i n d e r g a r t e n where i t was r e p o r t e d t h a t h i s r i g h t hand was dominant and h i s E n g l i s h language s k i l l s were average t o above average. Mr. 2 was employed as a l a y m i n i s t e r f o r a s p l i n t e r church group. In 1977 the e n t i r e f a m i l y was i n v o l v e d i n a c a r a c c i d e n t . P a t i e n t 2 was s e r i o u s l y i n j u r e d and h i s mother was k i l l e d . Mr. 2 and the daughter were not s e r i o u s l y i n j u r e d . A f t e r P a t i e n t 2 was r e l e a s e d from h o s p i t a l , the f a m i l y moved t o B r i t i s h Columbia where P a t i e n t 2 was g r a d u a l l y i n t e g r a t e d i n t o the school system. Mr. 2 found employment as a nurses' a i d i n a r e s i d e n t i a l f a c i l i t y f o r the p h y s i c a l l y / m e n t a l l y handicapped. Mr. 2 r e m a r r i e d and had t h r e e more c h i l d r e n who are c u r r e n t l y a l l under f i v e y e a r s of age. Mr. 2's new w i f e i s r e p o r t e d t o be very s t r i c t ; t h i s has caused c o n s i d e r a b l e f r i c t i o n between her stepdaughter and h e r s e l f . Recently, the daughter ran away from home but i s now back l i v i n g with the f a m i l y . Mr. 2 appears t o be the main support f o r P a t i e n t 2 s i n c e he does not want t o "burden" h i s daughter with P a t i e n t 2. In j u r y In 1977 P a t i e n t 2, age 5, i n j u r e d i n a motor v e h i c l e a c c i d e n t , was admitted t o S i c k C h i l d r e n s ' H o s p i t a l i n Toronto where b r a i n trauma was diagnosed as severe. Recovery P a t i e n t 2 remained i n a coma f o r one month. Nine weeks p o s t — i n j u r y he was t r a n s f e r r e d t o The O n t a r i o C r i p p l e d C h i l d r e n s ' Centre where he remained f o r s i x months of r e h a b i l i t a t i o n . Because P a t i e n t 2 was h o s p i t a l i z e d i n O n t a r i o , i t has not been p o s s i b l e t o access acute medical, and r e c o v e r y i n f o r m a t i o n . Upon d i s c h a r g e from the r e h a b i l i t a t i o n h o s p i t a l , P a t i e n t 2 and f a m i l y moved t o B r i t i s h Columbia where the c h i l d was g r a d u a l l y i n t e g r a t e d i n t o the school system. He c o n t i n u e s t o r e q u i r e s p e c i a l c l a s s placement. P a t i e n t 2 i s d y s a r t h r i c and c o n f i n e d t o a wheelchair as a r e s u l t of the a c c i d e n t . At seven y e a r s f i v e months post i n j u r y F'atient 2 was 27 s e l e c t e d t o p a r t i c i p a t e i n t h i s l o n g i t u d i n a l study of l i n g u i s t i c r e c o v e r y a f t e r t r a u m a t i c h e a d - i n j u r y . M i t c h e l l (1985) t e s t e d P a t i e n t 2 with a number of r e c e p t i v e amd e x p r e s s i v e language measures. R e s u l t s of these t e s t s i n d i c a t e d t h a t he had a m i l d t o moderate word-finding d e f i c i t , and was a l s o e x p e r i e n c i n g some comprehension problems of complex sentences. At e i g h t years p o s t - i n j u r y , P a t i e n t 2 c o n t i n u e s t o r e q u i r e s p e c i a l c l a s s placement. H i s teacher r e p o r t s t h a t he i s r e a d i n g at a modified grade f o u r l e v e l . She a l s o r e p o r t s t h a t h i s r e c e p t i v e and e x p r e s s i v e language appears t o be r e s t r i c t e d t o simple a c t i v e sentences. Parent Interview P a t i e n t 2's f a t h e r was i n t e r v i e w e d and impressed us as a very knowledgeable and p e r c e p t i v e man. He was very aware of h i s son's areas of weakness and was a b l e t o p r o v i d e numerous e n l i g h t e n i n g examples. When questioned about P a t i e n t 2 's communication s k i l l s Mr. 2 s t a t e d : ( P a t i e n t 2) doesn't take the i n i t i a t i v e t o say much ... he needs encouragement t o use h i s speech ... u s u a l l y though he needs somebody s t a r t i n g a c o n v e r s a t i o n or asking q u e s t i o n s b e f o r e he w i l l answer. He went on t o say t h a t P a t i e n t 2 communicates mainly with speech and g e s t u r e s . 28 Mr. 2 a l s o d e s c r i b e d problems r e l a t e d t o h i s son's d y s a r t h r i a . The c l a r i t y o-f P a t i e n t 2's speech i s poor i-f he i s t i r e d , i . e . i n the mornings and evenings. He a l s o e x p e r i e n c e s problems s u s t a i n i n g h i s b r e a t h i n g t o accomodate longer u t t e r a n c e s ; he has a tendency t o droo l when he i s c o n c e n t r a t i n g on an a c t i v i t y -for any p e r i o d o-f t i me. When questioned about P a t i e n t 2's language comprehension a b i l i t i e s , Mr. 2 made the -following observations On the s u r f a c e l e v e l , yes, he would understand (language) a l l the time but again very o f t e n he p e r c e i v e s me t o say something or ge t s a message, somehow, t h a t I was not r e a l l y communicating. T h i s comment suggested t h a t P a t i e n t 2 experiences. d i f f i c u l t y i n t e r p r e t i n g complicated sentences. Mr. 2 went on t o p r o v i d e a very p e r c e p t i v e example of t h i s problems For i n s t a n c e , I t e l l him we are going t o see our f r i e n d , .... something t h a t i s f u r t h e r ahead ... he would probably move h i s wheelchair t o the wardrobe and t r y t o get h i s j a c k e t on .... he doesn't seem t o keep i n mind the context i n which something i s s a i d ... somewhere i n h i s p e r c e p t i o n t h i n g s get fragmented or they seem t o l a c k cohesion. According t o Mr. 2, these comprehension problems a l s o extend t o r e a d i n g . If P a t i e n t 2 reads a s t o r y he i s ab l e t o answer simple q u e s t i o n s about the s e t t i n g and the main c h a r a c t e r s , but confuses the sequence of events, e s p e c i a l l y what happens b e f o r e and what happens a f t e r . Mr. 2 has n o t i c e d t h a t h i s son i s p a r t i c u l a r l y poor at 29 judging time and has d i f f i c u l t y with s p a t i a l concepts causing problems i n math. Near the end of the i n t e r v i e w , Mr. 2 commented t h a t , i n many ways, P a t i e n t 2 i s j u s t l i k e a normal teenager and o f t e n w o r r i e s about what type of work he w i l l be a b l e t o do i n the f u t u r e . P a t i e n t 2 a l s o w o r r i e s about h i s dependence on h i s f a t h e r f o r personal c a r e , as was demonstrated by the f o l l o w i n g exchange t h a t o c c u r r e d between f a t h e r and son one Sunday mornings P a t i e n t 2s I don 't want t o go t o church today. Mr 2s Why? P a t i e n t 2s I'm too much work f o r you and you must not work on Sunday. It became obvious t h a t Mr. 2 i s the person p r i m a r i l y r e s p o n s i b l e f o r P a t i e n t 2 and t h a t f a t h e r and son have a s p e c i a l bond. Mr. 2 appears t o be a man of gre a t emotional s t r e n g t h . R e s u l t s 1) Standardized t e s t s . a) The Peabody P i c t u r e Vocabulary T e s t . - On t h i s t e s t of r e c e p t i v e vocabulary, P a t i e n t 2 achieved a standard s c o r e of 58, which i s an extremely low f o r a c h i l d of h i s age (average range i s 100 + 15). H i s Co n t r o l s c o r e d 130, which i s s i g n i f i c a n t l y above the average range and P a t i e n t 2's s c o r e . 30 b) The Word T e s t . - For the Synonym. Antonym. and D e f i n i t i o n s u b t e s t s P a t i e n t 2 achieved s c o r e s of 35, 36, and 35, r e s p e c t i v e l y . These s c o r e s are two standard d e v i a t i o n s below the mean and a r e s i g n i f i c a n t l y lower than h i s C o n t r o l ' s s c o r e s of 54, 55, and 56. P a t i e n t 2's standard s c o r e on the M u l t i p l e D e f i n i t i o n s u b t e s t was 16. H i s C o n t r o l ' s s c o r e on the same s u b t e s t was 49, which i s w i t h i n the average range; on the other hand P a t i e n t 2's s c o r e i s well below average, and c o n s i d e r a b l y lower than t h a t of h i s C o n t r o l . c) The Boston Naming T e s t . - The mean raw s c o r e f o r t h i s t e s t i s 55 with a standard d e v i a t i o n of + 4.42. P a t i e n t 2's s c o r e was 30 with a mean response l a t e n c y of 3.26 seconds. The C o n t r o l s u b j e c t scored 49 with a mean response l a t e n c y of .68 seconds. Both the C o n t r o l ' s raw s c o r e and response l a t e n c y were c o n s i d e r a b l y b e t t e r than P a t i e n t 2's. d) Boston D i a g n o s t i c Aphasia Examination. - P a t i e n t 2's s c o r e s f o r Sentence R e p e t i t i o n weres 8/8 (90 7.1e) f o r the high p r o b a b i l i t y sentences and 6/8 <90 7.1e) f o r the 1 ow p r o b a b i l i t y sentences. H i s C o n t r o l scored 8/8 (90%le) i n both cases. P a t i e n t 2 made one phonemic paraphasia ( " f l a n " f o r "fan") and omitted one word. P a t i e n t 2 scored 19/30 (60-70 7.1e) on the Responsive  Naming s u b t e s t . The mean response l a t e n c y was 4.89 seconds. P a t i e n t 2's s c o r e i s c o n s i d e r a b l y lower than h i s 31 C o n t r o l ' s s c o r e of 30/30 (100 >ile). The C o n t r o l s u b j e c t ' s mean response l a t e n c y was 1.32 seconds, which i s s i g n i f i c a n t l y l e s s than P a t i e n t 2's response l a t e n c y . For the Word Fluency s u b t e s t , P a t i e n t 2 was a b l e t o name nine animals i n one minute (90 Y.le) w h i l e h i s C o n t r o l named 28 (100 7.1e). I t i s d i f f i c u l t t o make a v a l i d comparison between these s c o r e s on t h i s s u b t e s t because of P a t i e n t 2's d y s a r t h i a . 2) Experimental t e s t s . a) F r u i t and Vegetable Naming.— A summary of raw s c o r e s f o r P a t i e n t 2 and h i s C o n t r o l s u b j e c t i s p r o v i d e d i n Table 4-1. The s c o r e s are l i s t e d by the type of p i c t u r e used t o e l i c i t the word. The d i f f e r e n c e between P a t i e n t 2's s c o r e s and those of h i s C o n t r o l s u b j e c t are s u b s t a n t i a l . The p a t t e r n of s c o r e s suggests a h i e r a r c h y of d i f f i c u l t y f o r the d i f f e r e n t p i c t u r e s t i m u l i . Naming accuracy f o r both s u b j e c t s was g r e a t e s t f o r photographs. Naming Photographs appeared t o be e a s i e r than naming Coloured L i n e Drawings, which i n t u r n appeared t o be e a s i e r t o name than Black and White  Drawings of the same o b j e c t s . Table 4-2 l i s t s the mean response l a t e n c i e s f o r each p i c t u r e type f o r each s u b j e c t . For both s u b j e c t s the p a t t e r n of response l a t e n c i e s suggested t h a t Photographs 32 were e a s i e r t o name than Coloured Drawings which i n t u r n were e a s i e r t o name than Black and White Drawings. TABLE 4-1 FRUIT AND VEGETABLE NAMING: SUMMARY OF RAW SCORES P i c t u r e Type P a t i e n t 2 Con t r o l Photographs Coloured drawings B/W drawings 13/22 = 59% 9/22 = 41% 10/22 = 46% 22/22 = 100% 21/21 = 95% 20/22 = 91% TABLE 4-2 FRUIT AND VEGETABLE NAMING: SUMMARY OF MEAN RESPONSE LATENCIES (SECS.) P i c t u r e Type P a t i e n t 2 C o n t r o l Photographs 6.35 s 1.29 s Coloured drawings 7.10 s .68 s B/W drawings 8.48 s .49 s fa) Naming I I . - A summary of raw s c o r e s i s p r o v i d e d i n Table 4-3. Scores a re recorded under the s t i m u l u s c o n d i t i o n used t o e l i c i t the word. Mean response l a t e n c i e s are shown i n b r a c k e t s f o l l o w i n g the raw s c o r e s . 33 TABLE 4-3 NAMING I I : SUMMARY OF RAW SCORES AND MEAN RESPONSE LATENCIES Stimulus C o n d i t i o n P a t i e n t 2 C o n t r o l V i s u a l C o n f r o n t a t i o n 9/10 <1.98 s) 10/10 (.58 s> Sentence Completion 8/10 <1.78 s) 10/10 (.56 s) A u d i t o r y D e s c r i p t i o n 5/10 (4.06 s) 9/10 (1.9 s) T a c t i l e 6/10 (16.0 s) 8/10 (7.7 s) P a t i e n t 2's s c o r e s were c o n s i d e r a b l y lower than h i s C o n t r o l ' s . The p a t t e r n of s c o r e s i n both cases seems t o suggest d i f f e r e n t l e v e l s of d i f f i c u l t y f o r the v a r i o u s s t i m u l u s c o n d i t i o n s . V i s u a l C o n f r o n t a t i o n and Sentence  Completion appeared t o be the most s u c c e s s f u l c o n d i t i o n s f o r word r e t r i e v a l . A u d i t o r y D e s c r i p t i o n was more d i f f i c u l t than the f i r s t two c o n d i t i o n s , and T a c t i 1 e naming appeared t o be the most d i f f i c u l t case of a l l . c) Homonym T e s t . — Table 4—4 p r o v i d e s the raw s c o r e s f o r each s u b j e c t , f o r each meaning c o n d i t i o n : 1) where the dominant meaning i s a r e f e r e n t i a l concept and the nondominant meaning i s a p r e d i c a t i v e concept (N,V), 2) where the dominant meaning i s a p r e d i c a t i v e concept and the nondominant meaning i s a r e f e r e n t i a l concept (V,N), 3) where both the dominant and nondominant meanings are r e f e r e n t i a l concepts (N,N). 34 TABLE 4-4 HOMONYM TEST: SUMMARY OF RAW SCORES Meaning C o n d i t i o n P a t i e n t 2 C o n t r o l N V 16/27 = 59.37. 24/27 = 88.97. V N 13/27 = 48.17. 25/27 = 92.67. N N 19/27 = 70.47. 25/27 = 92.67. The C o n t r o l ' s s c o r e s were much higher than F'atient 2's, f o r each homonym p a i r . The C o n t r o l d i d not appear t o f i n d one c o n d i t i o n more d i f f i c u l t than any other as h i s s c o r e s on the t h r e e c o n d i t i o n s were not s i g n i f i c a n t l y d i f f e r e n t from each other. The p a t t e r n of P a t i e n t 2's s c o r e s suggests a h i e r a r c h y of d i f f i c u l t y f o r the th r e e meaning c o n d i t i o n s . P a t i e n t 2 found the e a s i e s t p a i r s t o c l a s s i f y were the Noun-Noun p a i r s , f o l l o w e d by the Noun—Verb p a i r s , f o l l o w e d by the Verb—Noun p a i r s . d) Boston Cookie Theft P i c t u r e D e s c r i p t i o n . - The numerical language measures are presented i n Table 4-5. There i s no i n f o r m a t i o n f o r the w r i t t e n d e s c r i p t i o n as P a t i e n t 2 was unable t o produce a w r i t t e n sample due t o h i s p h y s i c a l l i m i t a t i o n s , i . e . s p a s t i c i t y . Data f o r both s u b j e c t s i s con t a i n e d i n t h i s t a b l e . There are a few t h i n g s worth n o t i n g when P a t i e n t 2's 35 r e s u l t s a re compared with h i s C o n t r o l ' s . The C o n t r o l s u b j e c t ' s MLU was almost double t h a t of P a t i e n t 2. The c o n c i s e n e s s index and the anomia index d i d not appear t o d i f f e r s u b s t a n t i a l l y between the two s u b j e c t s . In P a t i e n t 2's d e s c r i p t i o n every sentence was a simple a c t i v e ; h i s C o n t r o l i n c l u d e d s u b o r d i n a t i o n and use of the p a s s i v e v o i c e i n h i s d e s c r i p t i o n . 36 TABLE 4-5 BOSTON COOKIE THEFT DESCRIPTION: NUMERICAL LANGUAGE MEASURES P a t i e n t 2 C o n t r o l  Measures Oral W r i t t e n Oral W r i t t e n t o t a l words 35.0 . 52.0 unique words 22.0 36.0 MLU (words) 6.8 12.8 prep phrases 1.0 4.0 subord c l a u s e s O.O 1.0 anomia index* 0. 18 0.33 c o n c i s e index** 14.3 17.3 prep e r r o r s 1.0 0.0 p e r s e v e r a t i o n s 0.0 0.0 empty words 0.0 0.0 sem paraphasia 0.0 • O.O — -phmn paraphasia O.O O.O jargon 0.0 0.0 s p e l l i n g e r r o r s n/a n/a syntax e r r o r s O.O 0.0 t o t a l nouns 10.0 . 10.0 t o t a l pronouns 2.0 5.0 t o t a l verbs 11.0 16.0 t o t a l preps 2.0 4.0 t o t a l det 9.0 lO.O t o t a l adj/adv 0.0 4.0 t o t a l conj 0.0 • 3.0 det omitted O.O 0.0 — . — * Anomia index = 1 - C N / ( N + Prn ) 3 ** Conciseness index = C100 * r e l e v a n t o b s / t o t a l wordsJ KEY: prep = p r e p o s i t i o n sem = semantic phmn = phonemic det = determiners conj = c o n j u n c t i o n s subord = su b o r d i n a t e MLU = mean len g t h o-f u t t e r a n c e 37 CHAPTER 5 PATIENT 3 Personal H i s t o r y P a t i e n t 3, an o n l y c h i l d , was born J u l y IO, 1972. H i s mother i s a l e g a l s e c r e t a r y and h i s -father i s a mechanic. They d i v o r c e d s h o r t l y be-fore P a t i e n t 3's a c c i d e n t . At the time o-f the a c c i d e n t P a t i e n t 3 had completed grade 4 i n the r e g u l a r school system. H i s grades had been average. P a t i e n t 3 was, and con t i n u e s t o be, d e c i d e d l y le-ft handed as i s h i s -father's b r o t h e r . P a t i e n t 3 appears t o have an e x c e l l e n t r e l a t i o n s h i p with both h i s parents. He l i v e s with h i s mother but spends much time with h i s f a t h e r and they o f t e n go f i s h i n g . Both p a r e n t s are very s u p p o r t i v e and a c c e p t i n g of P a t i e n t 3's d i f f i c u l t i e s . I n j u r y On August 23, 1980, P a t i e n t 3, age lOsO, was i n v o l v e d i n a head—on c o l l i s i o n with a c a r while r i d i n g on a motorcycle. He was wearing a helmet, which came o f f du r i n g the a c c i d e n t . The a c c i d e n t l e f t him i n a coma f o r approximately s i x weeks. Upon admission t o h o s p i t a l , h i s head i n j u r y was 38 diagnosed as severe- The r e s u l t s of a r i g h t angiogram were unremarkable; the l e f t angiogram f a i l e d . A CT scan i n d i c a t e d l e f t f r o n t o - p a r i e t a l sub-dural hematoma, with no s h i f t of m i d l i n e s t r u c t u r e s . C o n v u l s i v e a c t i v i t y was not evident but an i n c r e a s e of i n t e r c r a n i a l p r e s s u r e was t r e a t e d with h y p o v e n t i l a t i o n . Recovery On the f i f t h day p o s t - i n j u r y , the Glasgow Coma S c a l e was 5.0. The unconscious s t a t e began t o l i g h t e n on the t w e n t y — f i r s t day p o s t — i n j u r y . P a t i e n t 3 demonstrated c o n s c i o u s r e s p o n s i t i v i t y and began o r a l f e e d i n g at f o r t y -f i v e days p o s t — i n j u r y . At two months post-trauma, P a t i e n t 3 was s t i l l unable t o v o c a l i z e but he was using a f i n g e r t a p p i n g system t o i n d i c a t e " yes " and " no ". P a t i e n t 3 began s e l f - f e e d i n g , and c o u l d stand with a s s i s t a n c e , at two and a h a l f months post—onset. At t h i s time speech c o n s i s t e d of whispered, single-word responses. By t h r e e months po s t - o n s e t , he was t a l k i n g i n complete sentences with a low i n t e n s i t y v o i c e . At f o u r months post—trauma, comprehension of l i n g u i s t i c a l l y complex commands was impaired. T e s t s of Receptive language y i e l d e d language ages t h r e e y e a r s below P a t i e n t 3's c h r o n o l o g i c a l age. E x p r e s s i v e language t e s t i n g y i e l d e d s c o r e s t h a t were approximately eighteen 39 months b e t t e r than the r e c e p t i v e language s c o r e s . Reading s k i l l s were good, but P a t i e n t 3 experienced d i f f i c u l t y when r e q u i r e d t o w r i t e h i s thoughts; r e s u l t i n g sentence s t r u c t u r e was poor. At f i v e months p o s t - i n j u r y , v o c a l i z a t i o n s continued t o be a t a reduced i n t e n s i t y l e v e l . Word-finding and r e c a l l / p r o c e s s i n g of a u d i t o r y cues were s e v e r e l y impaired. The a b i l i t y t o sequence and o r g a n i z e h i s thoughts was m i l d l y impaired. By s i x months p o s t - i n j u r y , P a t i e n t 3's r e a d i n g comprehension was at a l e v e l commensurate with h i s age. Math s k i l l s , however, were measured s i x months below age l e v e l . P a t i e n t 3 began t o attend a few r e g u l a r school c l a s s e s at e i g h t months p o s t - i n j u r y . He s t i l l had a r i g h t - s i d e d weakness with a hemiparesis of the r i g h t hand. Short—term memory and t h i n k i n g s k i l l s were poor. Word-finding continued t o be p r o b l e m a t i c . O v e r a l l i n t e l l e c t u a l f u n c t i o n i n g was r e p o r t e d t o be w i t h i n normal l i m i t s . L e arning a s s i s t a n c e was r e q u i r e d f o r a l l academic s u b j e c t s at n ine months p o s t - i n j u r y . A school r e p o r t s t a t e d t h a t , w h i l e P a t i e n t 3 was r e g a i n i n g h i s o l d v e r b a l / c o g n i t i v e s k i l l s , he was moderately t o s e v e r e l y impaired i n h i s a b i l i t y t o l e a r n and r e t a i n new v e r b a l m a t e r i a l . At two y e a r s ten months p o s t — i n j u r y , P a t i e n t 3 was s e l e c t e d t o p a r t i c i p a t e i n t h i s l o n g i t u d i n a l study of l i n g u i s t i c r e c o v e r y a f t e r t r a u m a t i c h e a d — i n j u r y . M i t c h e l l (1985) t e s t e d P a t i e n t 3 with a number of r e c e p t i v e and 40 e x p r e s s i v e language measures. The r e s u l t s o-f r e c e p t i v e language t e s t i n g were not s i g n i - f i c a n l t y d i f f e r e n t from P a t i e n t 3's C o n t r o l . The e x p r e s s i v e language t e s t i n d i c a t e d t h a t P a t i e n t 3 had a m i l d word-finding problem. At t h r e e years ten months post-trauma P a t i e n t 3 i s e n r o l l e d i n grade 8 at h i s l o c a l highschool but c o n t i n u e s t o r e c e i v e l e a r n i n g a s s i s t a n c e i n a l l academic s u b j e c t s . H i s grades are below average. Parent Interview P a t i e n t 3's f a t h e r was i n t e r v i e w e d . He was most i n s i g h t f u l about P a t i e n t 3's areas of weakness and was a b l e t o p r o v i d e i l l u s t r a t i v e examples. In g e n e r a l , P a t i e n t 3's f a t h e r i s very a c c e p t i n g of h i s son's c o g n i t i v e and l i n g u i s t i c d e f i c i t s . He appeared t o have very r e a l i s t i c e x p e c t a t i o n s of P a t i e n t 3. Such e x p e c t a t i o n s a i d P a t i e n t 3 i n m a i n t a i n i n g a p o s i t i v e o u tlook. When questioned about P a t i e n t 3's c o n c e n t r a t i o n a b i l i t i e s and a t t e n t i o n span, and how they vary with time of day, Mr. 3 provided the f o l l o w i n g example: He does i t [homework] qui c k e r i n the morning ... neater ... he doesn't have t h a t memory wander or a t t e n t i o n span, which i s very s h o r t . P a t i e n t 3 can work on homework i n the morning f o r approximately t h i r t y minutes, but can o n l y maintain h i s c o n c e n t r a t i o n on homework f o r f i f t e e n minutes i f he does 41 i t i n the evening. Because of t h i s , h i s parents have accomodated P a t i e n t 3 so t h a t he can do h i s homework i n the morning i n s t e a d of the evening. Although, P a t i e n t 3 w i l l read at home, he does not read as much as he d i d be f o r e the a c c i d e n t . P a t i e n t 3's f a t h e r r e p o r t e d : He w i l l read at home but you have t o push him ... Before the a c c i d e n t he 'd do i t on h i s on h i s own ... He used t o r e a l l y l i k e r e a d i n g . When P a t i e n t 3 reads, he uses a r u l e r or f o l l o w s h i s f i n g e r , a p r a c t i c e which he f o l l o w e d t o some extent b e f o r e the a c c i d e n t . Mr. 3 r e p o r t e d t h a t P a t i e n t 3 tends t o cramp l e t t e r s t ogether when he w r i t e s . He begins a l i n e with normal s p a c i n g , but approximately halfway a c r o s s the page, he s t a r t s t o compress l e t t e r s as i f he were attempting t o get every word i n the sentence on one l i n e , r a t h e r than extending the sentence t o two l i n e s . Placement of w r i t t e n work on a blank page i s r e p o r t e d l y normal. However, Mr. 3 mentioned t h a t , i f P a t i e n t 3 i s drawing a p i c t u r e , he tends t o p l a c e the p i c t u r e i n one corner of the page. U s u a l l y the bottom. Never over here Etop l e f t hand c o r n e r ] . P a t i e n t 3 J s s p e l l i n g i s r e p o r t e d l y q u i t e good; Mr. 3 has never n o t i c e d l e t t e r r e v e r s a l s . Word—finding d i f f i c u l t i e s a re evi d e n t i n P a t i e n t 3's speech and when he i s t i r e d the word-finding worsens. 42 Mr. 3 d e s c r i b e d the way P a t i e n t 3 r e a c t s when he has d i f f i c u l t y f i n d i n g a word: H e ' l l j u s t wait ... stop t a l k i n g and t h i n k about i t f o r a few seconds and c o n t i n u e . If he can't r e t r i e v e the word d u r i n g t h i s pause he w i l l : s u b s t i t u t e something ... He t w i s t s the sounds around ... That w i l l vary on how t i r e d he i s . D e s p i t e P a t i e n t 3's language weaknesses Mr. 3 made the f o l l o w i n g r e p l y when he was asked "What was P a t i e n t 3's best s u b j e c t ? " : Anything t o do with r e a d i n g or language ... He e x c e l I s at t h a t ... Mathematics i s a major weakness f o r P a t i e n t 3 Mr. 3 s a i d: Before the a c c i d e n t h i s math was p r e t t y good ... s i n c e [the accident} h i s math i s t e r r i b l e ... Cmath i s ] one of the t h i n g s that s u f f e r e d the most Cfrom the a c c i d e n t 1 . He j u s t doesn't Cto know] how t o o r g a n i z e i t . F u r t h e r q u e s t i o n i n g r e v e a l e d t h a t P a t i e n t 3 can o r g a n i z e an event t h a t o c c u r s d a i l y , but f a i l s i f the event i s novel or o n l y o c c u r s r a r e l y . T h i s o r g a n i z a t i o n a l problem d i s t r e s s e s P a t i e n t 3, a c c o r d i n g t o Mr. -3: He CPatient 33 has t r o u b l e j u s t o r g a n i z i n g t h i n g s ... t h i n g s you and I j u s t take f o r granted which i s d i f f i c u l t f o r him. T h i s problem i s exacerbated by time c o n s t r a i n t s . Thus P a t i e n t 3 becomes more d i s o r i e n t e d as the time a l l o t e d f o r a c e r t a i n a c t i v i t y i s reduced. 43 R e s u l t s 1) Standardized t e s t s . a) Feabody P i c t u r e Vocabulary T e s t . - P a t i e n t 3 achieved a standard s c o r e of 89, low average f o r a c h i l d of h i s c h r o n o l o g i c a l age. H i s C o n t r o l achieved a standard s c o r e of 110, which i s a high average s c o r e although not s i g n i f i c a n t l y higher than P a t i e n t 3's. The mean standard s c o r e f o r t h i s t e s t i s 100 + 15. b) The Word T e s t . - The mean standard s c o r e f o r t h i s t e s t i s 50 + 5. On the Synonym s u b t e s t P a t i e n t 3's standard s c o r e was 44. T h i s i s j u s t w i t h i n one standard d e v i a t i o n below the mean and i s s i g n i f i c a n t l y lower than h i s C o n t r o l ' s s c o r e of 51. P a t i e n t 3's standard s c o r e on the Antonym s u b t e s t was 52, which i s w i t h i n the average range, and i s not s i g n i f i c a n t l y d i f f e r e n t than h i s C o n t r o l ' s s c o r e of 54. On the D e f i n i t i o n s u b t e s t , P a t i e n t 3 r e c e i v e d a standard s c o r e of 39, which i s w i t h i n two standard d e v i a t i o n s below the mean, and i s s i g n i f i c a n t l y lower than h i s C o n t r o l ' s s c o r e of 54. P a t i e n t 3's s c o r e on the M u l t i p l e D e f i n i t i o n s u b t e s t was 21, which i s w i t h i n f i v e standard d e v i a t i o n s below the mean. H i s C o n t r o l ' s s c o r e of 50 was s i g n i f i c a n t l y higher than P a t i e n t 3's. 44 c) Boston Naming T e s t . - The mean raw s c o r e f o r a person with twelve years of s c h o o l i n g or l e s s i s 55.73 + 4.42. Both P a t i e n t 3*s s c o r e of 52 (mean l a t e n c y = 1.81 s) and h i s C o n t r o l ' s s c o r e of 54 (mean l a t e n c y = .59 s) a r e w i t h i n the average range and are not s i g n i f i c a n t l y d i f f e r e n t from each other. However, i f mean response l a t e n c i e s are compared, P a t i e n t 3's mean i s c o n s i d e r a b l y longer than h i s C o n t r o l ' s . d) Boston D i a g n o s t i c Aphasia Examination.- On the Sentence R e p e t i t i o n s u b t e s t P a t i e n t 3's s c o r e s were 8/8 (100 7.1 e) f o r the high p r o b a b i l i t y sentences and 5/8 (85 '/.le) f o r the low p r o b a b i l t y sentences. H i s C o n t r o l ' s s c o r e f o r both sentence types was 8/8 (100 7.1 e) . P a t i e n t 3's s c o r e on the Responsive Naming s u b t e s t was 30/30 (100 % l e ) with a mean response l a t e n c y of 1.67 s. H i s C o n t r o l had an i n d e n t i c a l s c o r e of 30/30 with a mean reponse l a t e n c y of .78 s. P a t i e n t 3's response l a t e n c y i s c o n s i d e r a b l y longer than h i s C o n t r o l ' s mean l a t e n c y . On the Word Fluency s u b t e s t , P a t i e n t 3 named nine animals i n one minute (90 % l e ) , while h i s C o n t r o l named 17 i n the same time (90—100 Xle) . The raw s c o r e s appear t o d i f f e r c o n s i d e r a b l y . 45 2) Experimental t e s t s . a) F r u i t and Vegetable Naming.- A summary of raw s c o r e s f o r P a t i e n t 3 and h i s Co n t r o l i s contained i n Table 5—1. The s c o r e s are l i s t e d by the type of p i c t u r e used t o e l i c i t the word. TABLE 5-1 FRUIT AND VEGETABLE NAMING: SUMMARY OF RAW SCORES P i c t u r e Type P a t i e n t 3 C o n t r o l Photographs 17/22 = 777. 22/22 = 1007. Coloured drawings 17/22 = 777. 21/22 = 957. B/W drawings 16/22 = 737. 20/22 = 917. The p a t t e r n of raw s c o r e s suggest t h a t Photographs and Coloured Drawings were e a s i e r t o name than Black and White  Drawings. P a t i e n t 3's raw s c o r e s f o r a l l t h r e e s t i m u l u s c o n d i t i o n s were c o n s i d e r a b l y lower than h i s C o n t r o l ' s . Table 5—2 g i v e s mean response l a t e n c i e s f o r each p i c t u r e type and f o r each s u b j e c t . The response l a t e n c i e s of P a t i e n t 3's C o n t r o l do not demonstrate a c l e a r p a t t e r n . However, P a t i e n t 3's response l a t e n c i e s suggest t h a t Photographs were e a s i e r t o name than Coloured L i n e  Drawings, which i n t u r n were e a s i e r t o name than Black and  White Drawings. 46 TABLE 5-2 FRUIT AND VEGETABLE NAMING: SUMMARY OF MEAN RESPONSE LATENCIES <SECS) P i c t u r e Type P a t i e n t 3 Co n t r o l Photographs 1.21 s .75 5 Coloured drawings 1.74 s .61 s B/W drawings 1.96 s .61 s b) Naming I I . — A summary of raw s c o r e s i s pr o v i d e d i n Table 5-3. The s c o r e s are recorded under the s t i m u l u s c o n d i t i o n used t o e l i c i t the word. The number i n b r a c k e t s f o l l o w i n g the raw sc o r e i s the mean response l a t e n c y . The raw s c o r e s do not i n d i c a t e a c l e a r p a t t e r n of behaviour w i t h i n each s u b j e c t and are n e g l i g i b l y d i f f e r e n t between s u b j e c t s . TABLE 5-3 NAMING I I : SUMMARY OF RAW SCORES AND MEAN RESPONSE LATENCIES <SECS) Stimulus C o n d i t i o n P a t i e n t 3 C o n t r o l V i s u a l C o n f r o n t a t i o n 9/10 (1. 1 s) 10/10 (.56 s) Sentence Completion 10/10 <1. 1 s) 10/10 (.53 s) A u d i t o r y D e s c r i p t i o n 9/10 (4. 2 s) 9/10 (1.6 s) T a c t i l e 8/10 <8. 3 s) 9/10 (6.0 s) 47 The mean reponse l a t e n c i e s -for both s u b j e c t s -follow a p a t t e r n which suggests t h a t V i s u a l C o n f r o n t a t i o n and Sentence Completion were e a s i e r than A u d i t o r y D e s c r i p t i o n , which i n t u r n was e a s i e r than T a c t i l e naming. I t i s important t o note t h a t d e s p i t e the o v e r a l l s i m i l a r i t y i n s c o r e s , f o r a l l c o n d i t i o n s P a t i e n t 3's mean response l a t e n c i e s were s u b s t a n t i a l l y longer than those of h i s C o n t r o l . c) Homonym T e s t . — Table 5-4 l i s t s raw s c o r e s f o r s u b j e c t and homonym c o n d i t i o n s : 1) where the dominant meaning i s a r e f e r e n t i a l concept, and the nondominant meaning i s a p r e d i c a t i v e concept (N,V), 2) where the dominant meaning i s a p r e d i c a t i v e concept, and the nondominant meaning i s a r e f e r e n t i a l concept (V,N), and 3) where both the dominant and nondominant meanings a re r e f e r e n t i a l concepts (N,N). TABLE 5-4 HOMONYM TEST: SUMMARY OF RAW SCORES Meaning C o n d i t i o n P a t i e n t 3 Cont r o l N V 19/27 = 70.47. 26/27 = 96.37. V N 23/27 = 85.27. 25/27 - 92.67. N , N 26/27 = 96.37. 27/27 = 100.7. 48 P a t i e n t 3 ' 5 s c o r e f o r the Noun-Noun c o n d i t i o n was not s u b s t a n t i a l l y d i f f e r e n t from t h a t of h i s C o n t r o l . However, f o r the two remaining c o n d i t i o n s P a t i e n t 3's s c o r e s were c o n s i d e r a b l y lower than h i s C o n t r o l ' s . U n l i k e h i s C o n t r o l , who found a l l c o n d i t i o n s t o be of approximately equal d i f f i c u l t y , P a t i e n t 3 found the Noun- Noun c o n d i t i o n e a s i e r than the Verb-Noun c o n d i t i o n , which i n t u r n was e a s i e r than the Noun-Verb c o n d i t i o n . d) The Boston Cookie Theft D e s c r i p t i o n . - The numerical language measures f o r the Boston Cookie T h e f t P i c t u r e D e s c r i p t i o n are presented i n Table 5-5. Data f o r both s u b j e c t s , Experimental and C o n t r o l , and both c o n d i t i o n s , w r i t t e n and o r a l , are l i s t e d . A comparison of the two s u b j e c t s ' o r a l d e s c r i p t i o n s y i e l d s o n l y one n o t a b l e d i f f e r e n c e s P a t i e n t 3's c o n c i s e n e s s index was c o n s i d e r a b l y lower than t h a t of h i s C o n t r o l . T h i s suggests t h a t P a t i e n t 3's d e s c r i p t i o n was l e s s c o n c i s e than h i s C o n t r o l ' s . The o n l y n o t a b l e d i f f e r e n c e between the two w r i t t e n d e s c r i p t i o n s i s t h a t P a t i e n t 3's MLU was much s h o r t e r than t h a t of h i s C o n t r o l . 49 TABLE 5-5 BOSTON COOKIE THEFT DESCRIPTION: NUMERICAL LANGUAGE MEASURES P a t i e n t 3 C o n t r o l Measures Oral W r i t t e n Oral W ritten t o t a l words 55.0 33.0 56.0 59.0 unique words 36.0 23.0 36. 0 37.0 MLU (words) 7.9 3.7 10.2 11.8 prep phrases 3.0 2.0 3. 0 4.0 subord c l a u s e s 1.0 0.0 3.0 2.0 anomia index* 0.27 0.06 0. 13 0.27 c o n c i s e index** 7.3 15.2 12.5 13.6 prep e r r o r s 0.0 0.0 0.0 0.0 p e r s e v e r t i ons 0.0 0.0 0.0 O.O empty words 5.0 0. 0 1.0 O. 0 sem par a p h a s i a 0.0 O.O 0.0 O.O phnm par a p h a s i a O.O O.O O.O O.O jargon 0. 0 0.0 0.0 O.O s p e l 1 i ng e r r o r s n/a O.O n/a 0.0 syntax e r r o r s O.O 1.0 0.0 O.O t o t a l nouns 8.0 16.0 13.0 13.0 t o t a l pronouns 3.0 l.O 2.0 5.0 t o t a l verbs 10.0 5.0 18.0 17.0 t o t a l preps 3.0 2.0 3.0 4.0 t o t a l det 7.0 2.0 lO.O 10.0 t o t a l adj/adv O. 0 0.0 1.0 3.0 t o t a l conj 4.0 3.0 2.0 l'.O det omitted 1.0 5.0 0.0 0.0 * Anomia index = 1 — C N / ( N + Prn ) ] ** Conciseness index = CdOO * r e l e v a n t o b s . ) / t o t a l words] Key : prep = p r e p o s i t i o n sem = semantic phnm = phonemic det = determiners conj = c o n j u n c t i o n s subord = su b o r d i n a t e MLU = mean le n g t h of u t t e r a n c e 50 CHAPTER 6 PATIENT 4 Personal H i s t o r y P a t i e n t 4 was born October 14, 1972. Three y e a r s l a t e r h i s o n l y s i b l i n g , a s i s t e r , was born. P a t i e n t 4's f a t h e r works f o r a u t i l i t y company and h i s mother runs a sewing b u s i n e s s out of the home. P a t i e n t 4 i s r i g h t handed and h i s f i r s t language i s E n g l i s h . Although the mother's n a t i v e tongue i s Dutch, P a t i e n t 4 does not speak t h i s language. P a t i e n t 4 and h i s s i s t e r are c o m p e t i t i v e f i g u r e s k a t e r s and s k a t e as a p a i r i n the dance event. Both parents are very i n v o l v e d i n the a d m i n i s t r a t i v e a s p e c t s of the s k a t i n g c l u b ; hence the f a m i l y spend a c o n s i d e r a b l e amount of time t o g e t h e r . In a d d i t i o n t o a t t e n d i n g s k a t i n g p r a c t i c e s t h r e e t o f i v e times per week throughout the year, P a t i e n t 4 a l s o belongs t o a Ukranian dance group and p l a y s organized hockey i n the winter. At the time of h i s a c c i d e n t P a t i e n t 4 was i n grade seven i n the r e g u l a r school system. He was a b l e t o maintain grades t h a t were average t o above average d e s p i t e h i s demanding schedule. A f t e r the a c c i d e n t , and throughout the re c o v e r y p e r i o d , P a t i e n t 4's pa r e n t s s t r o n g l y b e l i e v e d t h a t he would make a complete r e c o v e r y i f he worked hard i n therapy. P a t i e n t 4 seemed t o b e l i e v e t h i s as w e l l . In f a c t the day a f t e r he was d i s c h a r g e d from the r e h a b i l i t a t i o n h o s p i t a l he went downhill s k i i n g , much t o the c h a g r i n of h i s speech t h e r a p i s t whom he met on the s k i s l o p e t h a t day. At the present time P a t i e n t 4 and h i s p arents are r e l u c t a n t t o admit t h a t he ever e x p e r i e n c e s d i f f i c u l t y with language. However, when they are pressed f u r t h e r i t becomes obvious t h a t P a t i e n t 4 s t i l l e x p e r i e n c e s s u b t l e d i f f i c u l t i e s as a r e s u l t of the a c c i d e n t . When P a t i e n t 4 does encounter a problem h i s f a m i l y i s s u p p o r t i v e by p r o v i d i n g encouragement and at times d e v i s i n g games t h a t d r i l l those c o g n i t i v e / l a n g u a g e s k i l l s t h a t cause him problems. The p a r e n t s r e p o r t t h a t P a t i e n t 4's s i s t e r i s s u p p o r t i v e of her brother but o c c a s i o n a l l y j e a l o u s of the e x t r a a t t e n t i o n t h a t he r e c e i v e s . One and a h a l f years a f t e r h i s i n j u r y , P a t i e n t 4 i s again l e a d i n g the h e c t i c l i f e he d i d b e f o r e the a c c i d e n t . He has r e t u r n e d t o f i g u r e s k a t i n g , hockey, and dancing. I n j u r y On September 16, 1984, P a t i e n t 4, age 11; 11, was i n j u r e d i n a high speed motor v e h i c l e a c c i d e n t and became unconcious immediately. On admission t o h o s p i t a l , he was found t o have a f r a c t u r e of the r i g h t f r o n t a l — p a r i e t a l area extending t o the base of the s k u l l at the l e v e l of 52 the o r b i t a l r o o f . P a t i e n t 4's head i n j u r y was diagnosed as severe. A CT scan showed a s h i f t of the b r a i n from m i d l i n e t o the l e f t i n v o l v i n g the r i g h t l a t e r a l v e n t r i c l e s . A m i l d d i l a t i o n of the l e f t l a t e r a l v e n t r i c l e and a hematoma i n the r i g h t f r o n t a l p a r i e t a l area were a l s o e v i d e n t . Damage t o the o p t i c nerve r e s u l t e d i n a permanent l o s s of v i s i o n i n the r i g h t eye. Recovery P a t i e n t 4 remained unconcious f o r ten days. On the t e n t h day p o s t - i n j u r y he was a b l e t o obey simple commands. He attempted t o mouth words but f a i l e d t o a chieve phonation. He was a b l e t o w r i t e h i s own name. Re f l e x e s were i n t a c t but a l e f t - s i d e d weakness was p r e s e n t . At two weeks p o s t — i n j u r y P a t i e n t 4 communicated by: 1) nodding t o i n d i c a t e " yes ", and 2) p o i n t i n g t o the o b j e c t s he wanted. Comprehension was r a p i d l y improving. By the t h i r d week post—trauma he was a b l e t o answer simple q u e s t i o n s although h i s v o i c e was of low i n t e n s i t y . At one month p o s t — i n j u r y P a t i e n t 4's speech c o n s i s t e d of s h o r t sentences two t o t h r e e words i n l e n g t h . Speech was improving r a p i d l y but most u t t e r a n c e s were incomplete or p e r s e v e r a t i v e ; h i s v o i c e continued t o be of low i n t e n s i t y . W r i t t e n language c o n s i s t e d of s i n g l e words and 53 s h o r t sentences. A t t e n t i o n span and pe r c e p t u a l a b i l i t i e s were l i m i t e d . Short term memory was p a r t i c u l a r l y p r o b l e m a t i c . The r e s u l t s of language t e s t i n g at two months p o s t -i n j u r y were c l o s e t o premorbid l e v e l s . Word-finding proved a p a r t i c u l a r d i f f i c u l t y . C o g n i t i v e t e s t i n g i n d i c a t e d P a t i e n t 4's a b i l i t i e s were commensurate with age but he was e x p e r i e n c i n g d i f f i c u l t y with higher l e v e l f u n c t i o n s . P a t i e n t 4 began t o attend a few r e g u l a r school c l a s s e s . At t h r e e months p o s t — i n j u r y , P a t i e n t 4's r e c e p t i v e language s k i l l s were w i t h i n normal l i m i t s . E x p r e s s i v e language was s t i l l impaired. Word-finding problems were e v i d e n t i n c o n v e r s a t i o n a l s i t u a t i o n s . Spontaneous speech was c i r c u m l o c u t o r y and o f t e n s o c i a l l y i nappropri ate. At seven months p o s t — i n j u r y , P a t i e n t 4 was a t t e n d i n g r e g u l a r c l a s s e s f u l l t i m e but r e q u i r e d t u t o r i n g i n a l l s u b j e c t s , and memory l a p s e s were s t i l l a problem. At t h i s time, P a t i e n t 4 was s e l e c t e d t o p a r t i c i p a t e i n t h i s l o n g i t u d i n a l study of l i n g u i s t i c r e c o v e r y a f t e r t r a u m a t i c h e a d - i n j u r y . M i t c h e l l (1985) t e s t e d P a t i e n t 4 with a number of r e c e p t i v e and e x p r e s s i v e language measures. Test r e s u l t s y i e l d e d the f o l l o w i n g i n f o r m a t i o n . Receptive language — not s i g n i f i c a n t l y d i f f e r e n t than t h a t of h i s matched C o n t r o l . E x p r e s s i v e language — some areas of weakness. At t h i s 54 time P a t i e n t 4 was encountering mi l d word—finding di-f-fi c u l t i e s as i n d i c a t e d by h i s performance on a v i s u a l c o n f r o n t a t i o n naming task. During a sentence r e p e t i t i o n task he e x h i b i t e d common sequencing e r r o r s . At the present time, May 1986, approximately one and one h a l f years p o s t - i n j u r y , P a t i e n t 4 i s a t t e n d i n g high school f u l l - t i m e where he i s working at grade l e v e l i n a l l s u b j e c t s and no longer r e q u i r e s t u t o r i n g . H i s school r e p o r t s i n d i c a t e average t o above average academic achievment. P a t i e n t has r e c e n t l y been e x p e r i e n c i n g problems with math caused by h i s la c k of mastery of f r a c t i o n m a n i p u l a t i o n , p o s s i b l y as a r e s u l t of i n s t r u c t i o n i n f r a c t i o n s missed d u r i n g h i s h o s p i t a l i z a t i o n . Parent Interview During the course of the parent i n t e r v i e w , Mrs. 4 made a number of i n t e r e s t i n g statements. She s t a t e d t h a t P a t i e n t 4 has experienced a few memory l a p s e s s i n c e the a c c i d e n t . The most rec e n t episode occurred d u r i n g an attempt t o earn a f i g u r e s k a t i n g badge. P a t i e n t 4 co u l d not remember the p r o t o c o l f o r the t e s t even though he had performed numerous such t e s t s b e f o r e , and s i n c e , the a c c i d e n t . However, P a t i e n t 4 has not had problems remembering h i s c o m p e t i t i v e s k a t i n g or A.D.L. r o u t i n e s . Mrs. 4 r e p o r t e d t h a t her son's s p e l l i n g i s worse 55 s i n c e the a c c i d e n t . Her e x p l a n a t i o n f o r t h i s i s t h a t he "rushes too much" when he w r i t e s . He tends t o omit one l e t t e r , u s u a l l y at the end of the word. She a l s o c l a i m s t h a t he has never l i k e d r e a d i n g and t h a t he s t i l l does not read very o f t e n . She b e l i e v e s t h a t he i s c u r r e n t l y r e a d i n g below h i s age l e v e l . R e s u l t s 1) Standardized t e s t s . a) Peabody P i c t u r e Vocabulary T e s t . - On t h i s t e s t of r e c e p t i v e vocabulary, P a t i e n t 4 achieved a standard s c o r e of 112, which i s high average f o r a c h i l d of h i s age. H i s C o n t r o l achieved a s c o r e of 126. The C o n t r o l s u b j e c t ' s s c o r e i s w i t h i n one standard d e v i a t i o n above the average range. The mean standard s c o r e f o r t h i s t e s t i s 100 + 15. b) The Word T e s t . — The mean standard s c o r e f o r t h i s t e s t i s 50 + 5. For the Synonym and Antonym s u b t e s t s P a t i e n t 4 achieved standard s c o r e s of 54 and 52 r e s p e c t i v e l y . These are w i t h i n the average range when compared with the uppermost norms f o r t h i s t e s t , and were not s i g n i f i c a n t l y d i f f e r e n t from h i s C o n t r o l ' s s c o r e s of 54 and 55 f o r the same s u b t e s t s . P a t i e n t 4 achieved a standard s c o r e of 46 on the D e f i n i t i o n s u b t e s t . T h i s s c o r e i s w i t h i n the average range when compared t o the 11; 11 norms but i s s i g n i f i c a n t l y lower than the standard s c o r e of 56 t h a t P a t i e n t 4's C o n t r o l achieved- On the M u l t i p l e  D e f i n i t i o n s u b t e s t P a t i e n t 4's standard s c o r e was 41. T h i s i s w i t h i n one standard d e v i a t i o n below the mean f o r a c h i l d age 11; 11 and i s s i g n i f i c a n t l y lower than h i s C o n t r o l ' s s c o r e of 52. c) Boston Naming T e s t . — The mean raw s c o r e f o r a person with 12 y e a r s or l e s s of s c h o o l i n g i s 55.73 with a standard d e v i a t i o n of 4.42. Both P a t i e n t 4's s c o r e of 54 (mean l a t e n c y = .51 s ) , and h i s C o n t r o l ' s s c o r e of 58 (mean l a t e n c y = .99 s) are w i t h i n the average range. d) Boston D i a g n o s t i c Aphasia Examination.- For a l l s u b t e s t s administered t h e r e was v i r t u a l l y no d i f f e r e n c e between P a t i e n t 4's s c o r e s and those of h i s C o n t r o l . Both P a t i e n t 4 and h i s C o n t r o l , achieved s c o r e s of 100% on the Responsive Naming and the Sentence R e p e t i t i o n s u b t e s t s . Mean response l a t e n c y f o r P a t i e n t 4 on the Responsive Naming subt e s t was 1.41 s. H i s C o n t r o l ' s mean response l a t e n c y f o r the same s u b t e s t was 1.12 s. The d i f f e r e n c e between the two mean reponse l a t e n c i e s appears n e g l i g b l e . On the Word Fluency task P a t i e n t 4 named 25 animals i n one minute while h i s C o n t r o l was a b l e t o name 18 animals i n the same time. Both s c o r e s are w i t h i n normal 1i mits. 57 2) Experimental t e s t s . a) F r u i t and Vegetable Naming.- A summary o-f raw s c o r e s f o r P a t i e n t 4 and h i s C o n t r o l are given i n Table 6-1. Scores are l i s t e d by the type o-f p i c t u r e used t o e l i c i t the response. TABLE 6-1 FRUIT AND VEGETABLE NAMING: SUMMARY OF RAW SCORES P i c t u r e Type P a t i e n t 5 C o n t r o l Photographs 20/22 = 91.0% 21/22 = 95.0% Colour drawings 21/22 = 94.5% 19/22 = 86.0% B/W drawings 18/22 = 82.0% 18/22 = 82.0% Table 6-2 l i s t s the mean response l a t e n c i e s -for each p i c t u r e type, f o r each s u b j e c t . There was e s s e n t i a l l y no d i f f e r e n c e between the raw s c o r e s of P a t i e n t 4 and h i s C o n t r o l , w i t h i n each s t i m u l u s c o n d i t i o n . However, P a t i e n t 4's mean response l a t e n c i e s were c o n s i d e r a b l y longer than those recorded f o r h i s Co n t r o l s u b j e c t . 58 TABLE 6-2 FRUIT AND VEGETABLE NAMING: SUMMARY OF MEAN RESPONSE LATENCIES (SECS) P i c t u r e Type P a t i e n t 4 C o n t r o l Photographs 1.07 s 0.43 s Colour drawings 0.96 s 0.40 s B/W drawings 1.04 s 0.46 s Naming II — A summary o-f s c a r e s i s provided i n Table 6-3. The s c o r e s are recorded under the s t i m u l u s c o n d i t i o n used t o e l i c i t the word. The number i n b r a c k e t s f o l l o w i n g the raw score i s mean response l a t e n c y . TABLE 6-3 NAMING I I : SUMMARY OF RAW SCORES AND MEAN RESPONSE LATENCIES (SECS) Stimulus C o n d i t i o n P a t i e n t 4 C o n t r o l V i s u a l C o n f r o n t a t i o n 10/10 (O.SSs) 9/10 (0.50s) Sentence Completion 10/10 (0.66s) 10/10 (0.45s) A u d i t o r y D e s c r i p t i o n 9/10 (1.04s) 10/10 (0.64s) T a c t i l e 10/10 (3.95s) 9/10 (4.04s) Examination of the raw s c o r e s appears t o show no 59 d i f f e r e n c e between the s u b j e c t s or the s t i m u l u s c o n d i t i o n s ; response l a t e n c i e s do, however, appear t o show a d i f f e r e n c e between the s u b j e c t s and the s t i m u l u s c o n d i t i o n s - P a t i e n t 4's mean response l a t e n c i e s f o r the Sentence Completion and A u d i t o r y D e s c r i p t i o n c o n d i t i o n s are d i f f e r e n t enough from h i s C o n t r o l ' s t h a t they suggest P a t i e n t 4 does experience d i f f i c u l t i e s with these cues. In a d d i t i o n , i f d i f f e r e n c e s between the mean response l a t e n c i e s f o r the d i f f e r e n t s t i m u l u s c o n d i t i o n s a re compared, a d i f f i c u l t y h i e r a r c h y f o r the s t i m u l u s c o n d i t i o n s appears t o emerge. For both s u b j e c t s , the V i s u a l C o n f r o n t a t i o n naming c o n d i t i o n was equal i n d i f f i c u l t y t o Sentence Completion. In both c a s e s , A u d i t o r y  D e s c r i p t i o n appeared t o be the next l e v e l of d i f f i c u l t y , with T a c t i l e naming being the most d i f f i c u l t case f o r both s u b j e c t s . c) Homonym T e s t • — Table 6—4 p r o v i d e s the raw s c o r e s f o r each s u b j e c t , f o r each meaning c o n d i t i o n s 1) the dominant meaning i s a r e f e r e n t i a l concept, and the nondominant meaning i s a p r e d i c a t i v e concept <N,V), 2) the dominant meaning i s a p r e d i c a t i v e concept and the nondominant i s a r e f e r e n t i a l concept (V,N), 3) both meanings are r e f e r n t i a l concepts (N,N). P a t i e n t 4's s o r t of the Noun—Verb. and Verb-Noun p a i r s was c o n s i d e r a b l y l e s s a c c u r a t e than h i s C o n t r o l . The d i f f e r e n c e i n accuracy of the Noun-Noun s o r t was 60 n e g l i g i b l e between the two s u b j e c t s . These r e s u l t s i n d i c a t e t h a t P a t i e n t 4 experienced d i - f - f i c u l t y performing the Homonym Test when one of the meanings was a p r e d i c a t i v e concept, while the accuracy of h i s C o n t r o l ' s s o r t was u n a f f e c t e d by meaning c o n d i t i o n . TABLE 6-4 HOMONYM TEST: SUMMARY OF RAW SCORES Meaning C o n d i t i o n P a t i e n t 4 C o n t r o l  N , V 20/27 = 74.1% 27/27 = 100.07. V , N 20/27 = 74.17. 25/27 = 92.67. N , N 26/27 = 96.37. 27/27 = 100.07. d) Boston Cookie Theft P i c t u r e D e s c r i p t i o n . — Numerical language measures f o r the Boston Cookie T h e f t D e s c r i p t i o n are presented i n Table 6-5. Data f o r both the s u b j e c t s , Experimental and C o n t r o l , and both c o n d i t i o n s , w r i t t e n and o r a l , are cont a i n e d i n Table 6-5. Comparisons between P a t i e n t 4 and h i s C o n t r o l are unremarkable f o r a l l measures i n both w r i t t e n and o r a l modes. 61 TABLE 6-5 BOSTON COOKIE THEFT DESCRIPTION: NUMERICAL LANGUAGE MEASURES P a t i e n t 4 C o n t r o l  Measures Oral W r i t t e n Oral Written t o t a l words 37.0 49. 0 28.0 32.0 unique words 26.0 28. 0 19.0 24.0 MLU (words) 6.8 8. 0 8.7 10.6 prep phrases 3.0 4. 0 1.0 2.0 subord c l a u s e s 0.0 1. 0 O.O 1.0 anomia index* 0.08 0. 0 0. 11 0. 18 c o n c i s e index** 18.9 12. 2 14.3 15.6 prep e r r o r s O.O 0. 0 0.0 0.0 p e r s e v e r a t i ons O.O O. 0 0.0 O.O empty words 1.0 0. 0 2.0 0.0 sem paraphasia 0.0 O. 0 0.0 O.O phnm paraphasi a 0.0 O. O 0. O 0.0 jargon O.O O. 0 O.O O.O s p e l l i n g e r r o r s n/a *-* X - * 0 n/a 0.0 syntax e r r o r s O.O 0. 0 O.O l.O t o t a l nouns 12.O 12. 0 8.0 9.0 t o t a l pronouns 1.0 O. O 1.0 2.0 t o t a l verbs. 6.0 16. 0 8.0 8.0 t o t a l prep 4.0 4. 0 2.0 4.0 t o t a l det 6.0 11. 0 6.0 6.0 t o t a l adj/adv 2.0 1. o O.O O.O t o t a l conj O.O 2. 0 3.0 1.0 det. omitted 2.0 O. 0 1.0 0.0 * Anomia Index = 1 - C N / ( N + Prn ) ] ** Conciseness Index = C 100 * r e l e v a n t obs / Tot. words] KEY: prep = p r e p o s i t i o n s sem = semantic phnm = phonemic det = determiners conj = c o n j u n c t i o n subord = su b o r d i n a t e MLU = mean len g t h o-f u t t e r a n c e 62 CHAPTER 7 PATIENT 5 Personal H i s t o r y P a t i e n t 5 was born June 3, 1975, a -First c h i l d . A s i s t e r was born -five y e a rs l a t e r . P a t i e n t 5's mother l i v e s , i n t e r m i t t e n t l y , with her boy-friend. She r e c e i v e s wel-fare and he works, or l i v e s on unemployment in s u r a n c e . Both are n a t i v e Indians. The b o y f r i e n d i s r e p o r t e d t o be the main support f o r the c h i l d r e n . He meets with P a t i e n t 5's t e a c h e r , something P a t i e n t 5's mother o n l y does i n f r e q u e n t l y . The teacher has r e p e a t e d l y made appointments t o meet with P a t i e n t 5's mother o n l y t o have Ms. 5 " f o r g e t " t o show up at the appointed time. The teacher r e p o r t e d t h a t Ms. 5 cannot be depended on t o b r i n g her son t o h i s appointments. At the time of the a c c i d e n t P a t i e n t 5 was i n k i n d e r g a r t e n . A f t e r h i s r e l e a s e from h o s p i t a l , P a t i e n t 5 was i n t e g r a t e d i n t o the r e g u l a r school system but r e q u i r e d s p e c i a l c l a s s placement. I n j u r y A p r i l 9, 1982, P a t i e n t 5 was i n a motor v e h i c l e a c c i d e n t i n which he was s t r u c k on the r i g h t s i d e of h i s 63 head and rendered unconscious. The r e s u l t i n g h e a d — i n j u r y was severe. A CT scan i n d i c a t e d c e r e b r a l edema and a r i g h t i n t r a c r a n i a l hemmorage. There was no shi-ft of m i d l i n e s t r u c t u r e s . Recovery P a t i e n t 5 remained i n i n t e n s i v e c a r e f o r f o r t y days. I n i t i a l l y he was mute, confused, and d i d not r e c o g n i z e h i s f a m i l y or h i s f r i e n d s . At one month p o s t - i n j u r y he was a b l e t o speak i n s i n g l e words. By two months p o s t - i n j u r y P a t i e n t 5 was c o n v e r s i n g i n s h o r t sentences. Memory was impaired. At ten months p o s t - i n j u r y r e c e p t i v e language was measured t o be at a 5;9 l e v e l . Speech was i n t e l l i g i b l e d e s p i t e a s l i g h t " s l u r " . P a t i e n t 5 r e p o r t e d l y experienced problems with verb tense. Three years p o s t - i n j u r y , P a t i e n t 5 continued t o r e q u i r e s p e c i a l c l a s s placement. At h i s time he was s e l e c t e d t o p a r t i c i p a t e i n t h i s l o n g i t u d i n a l study of l i n g u i s t i c r e c o v e r y a f t e r t raumatic h e a d — i n j u r y . M i t c h e l l (1985) t e s t e d P a t i e n t 5 with a number of e x p r e s s i v e and r e c e p t i v e language t e s t s . The r e s u l t s of t h i s t e s t i n g i n d i c a t e d t h a t P a t i e n t 5 was e x p e r i e n c i n g moderate t o severe word-finding problems and language comprehension was impaired. In 1986, f o u r years p o s t — i n j u r y , P a t i e n t 5 c o n t i n u e s t o 64 r e q u i r e s p e c i a l c l a s s placement. Due t o muscle damage i n c u r r e d i n the a c c i d e n t h i s g a i t remains impaired and r e q u i r e s physiotherapy. Parent Interview I t was not p o s s i b l e t o o b t a i n an i n t e r v i e w with P a t i e n t 5's mother. She f a i l e d t o keep her appointment and r e f u s e d t o be i n t e r v i e w e d i n her home. R e s u l t s 1) Standardized t e s t s . a) Peabody P i c t u r e Vocabulary T e s t . - On t h i s t e s t of r e c e p t i v e v o c a b u l a r y , P a t i e n t 5's standard s c o r e was 70, which i s below the average range and s i g n i f i c a n t l y lower than h i s C o n t r o l s u b j e c t ' s s c o r e of 121. I t i s s i g n i f i c a n t t h a t P a t i e n t 5's standard s c o r e on t h i s t e s t i n 1985 was 91. T h i s i s a marked drop i n s c o r e s , given t h a t the mean standard s c o r e i s 1O0 + of 15. b) The Word T e s t . — P a t i e n t 5's standard s c o r e on the Synonym s u b t e s t was 38, which i s w i t h i n two standard d e v i a t i o n s below the mean. H i s C o n t r o l achieved a standard s c o r e of 54, which i s w i t h i n the average range of 50 + 5. On the Antonym and D e f i n i t i o n s u b t e s t s P a t i e n t 5's 65 standard s c o r e s were 40 i n both cases. These s c o r e s a re one standard d e v i a t i o n below the mean. H i s C o n t r o l ' s s c o r e s were 57 and 52 r e s p e c t i v e l y , which are both w i t h i n the average range. P a t i e n t 5 achieved a standard s c o r e o-f 34 on the M u l t i p l e D e f i n i t i o n s u b t e s t . T h i s i s w i t h i n t h r e e standard d e v i a t i o n s below the mean. The C o n t r o l s u b j e c t ' s s c o r e was 53, which i s w i t h i n the average range and t h e r e f o r e s i g n i f i c a n t l y higher than P a t i e n t 5's sc o r e . c) The Boston Naming T e s t . - P a t i e n t 5's raw s c o r e 32/60 i s below the average range of 43 + 4.07, and s i g n i f i c a n t l y lower than h i s C o n t r o l ' s s c o r e of 51/60. P a t i e n t 5's mean response l a t e n c y was 1.01 s, which i s c o n s i d e r a b l y longer than h i s C o n t r o l ' s mean response l a t e n c y of .698 s . d> The Boston D i a g n o s t i c Aphasia Examination.- On the Sentence R e p e t i t i o n s u b t e s t , P a t i e n t 5 scored 6/8 (75 % l e ) on the high p r o b a b i l i t y sentences, and 2/8 (25 7.1 e) on the 1 ow p r o b a b i l i t y sentences; h i s C o n t r o l scored 8/8 (100 % l e ) i n both i n s t a n c e s . P a t i e n t 5's s c o r e s , e s p e c i a l l y on the high p r o b a b i l i t y sentences, a re c o n s i d e r a b l y l e s s than the s c o r e s of h i s C o n t r o l . On the Responsive Naming s u b t e s t , P a t i e n t 5's s c o r e was 21/30 (70 7.1e) with a mean response l a t e n c y of 1.36 s. The C o n t r o l ' s s c o r e was 26/30 (90 7.1 e) with a mean response l a t e n c y of .66 s; P a t i e n t 5's response l a t e n c y was c o n s i d e r a b l y longer than h i s C o n t r o l ' s . On the Word Fluency s u b t e s t , P a t i e n t 5 named o n l y t h r e e animals i n one minute (60 7.1 e) 66 while h i s C o n t r o l was a b l e t o name 23 animals (100 % l e ) i n the same time p e r i o d . P a t i e n t 5's s c o r e s on the Reponsive Naming and Word Fluency naming s u b t e s t s were c o n s i d e r a b l y lower than the s c o r e s o-f h i s C o n t r o l the same t e s t s . 2) Experimental t e s t s . a) F r u i t and Vegetable Naming.- A summary of raw s c o r e s f o r P a t i e n t 5 and h i s C o n t r o l i s given i n Table 7—1. The s c o r e s are l i s t e d by the type of p i c t u r e used t o e l i c i t the word. P a t i e n t 5 named Photographs with g r e a t e r accuracy than Black and White Drawings which i n t u r n were e a s i e r f o r him t o name than were the Coloured Drawings. H i s C o n t r o l s u b j e c t d i d not seem t o p r e f e r a c e r t a i n type of s t i m u l i over any another as the c o n s i s t e n c y of h i s s c o r e s demonstrates. I t should a l s o be noted t h a t P a t i e n t 5's s c o r e s were much lower than those of h i s C o n t r o l . Table 7-2 p r o v i d e s the mean reponse l a t e n c i e s f o r each p i c t u r e type f o r each s u b j e c t . P a t i e n t 5's response l a t e n c i e s were c o n s i d e r a b l y longer than h i s C o n t r o l ' s . 67 TABLE 7-1 FRUIT AND VEGETABLE NAMING: SUMMARY OF RAW SCORES P i c t u r e Type P a t i e n t 5 Con t r o l Photographs Coloured drawings B/W drawings 13/22 = 59 "/. 8/22 = 36 7. 12/22 = 55 "/. 21/22 = 95 7. 22/22 = 100 7. 20/22 = 91 7. TABLE 7-2 FRUIT AND VEGETABLE NAMING: SUMMARY OF MEAN RESPONSE LATENCIES <SECS) P i c t u r e Type P a t i e n t 5 C o n t r o l Photographs 1-78 s .46 s Coloured drawings 1.09 s .48 s B/W drawings 1.68 s .54 s b) Naming I I . — A summary of raw s c o r e s i s provided i n Table 7-3. The s c o r e s a re recorded under the s t i m u l u s c o n d i t i o n used t o e l i c i t the word. Numbers i n b r a c k e t s i n d i c a t e mean response l a t e n c i e s . The p a t t e r n of s c o r e s suggests t h a t V i s u a l C o n f r o n t a t i o n and Sentence Completion were e a s i e r naming c o n d i t i o n s than A u d i t o r y D e s c r i p t i o n , which i n t u r n appeared t o be e a s i e r than T a c t i l e naming. 68 TABLE 7-3 NAMING l i s SUMMARY OF RAW SCORES AND MEAN RESPONSE LATENCIES (SECS) Stimulus C o n d i t i o n P a t i e n t 5 C o n t r o l V i s u a l C o n f r o n t a t i o n 8/10 (1. 14 s> 10/10 54 s) Sentence Completion 10/10 (1. 11 5) 9/10 < . 51 s) A u d i t o r y D e s c r i p t i o n 6/10 (1. 52 s) 8/10 (1. 27 s) T a c t i l e 4/10 (4. 56 s) 8/10 (5. 87 s) c) Homonym T e s t . — Table 7—4 p r o v i d e s the raw s c o r e s f o r each s u b j e c t , and each meaning c o n d i t o n : 1) where the dominant meaning i s a r e f e r e n t i a l concept, and the nondominant meaning i s a p r e d i c a t i v e concept (N,V), 2) the dominant meaning i s a p r e d i c a t i v e concept, and the nondominant meaning i s a r e f e r e n t i a l concept (V,N), 3) both meanings are r e f e r e n t i a l concepts <N,N). P a t i e n t 5's s c a r e s were c o n s i d e r a b l y lower than those of h i s C o n t r o l . For P a t i e n t 5 the Verb—Noun p a i r s appeared t o be e a s i e r t o s o r t than the other two p a i r c o n d i t i o n s . The Co n t r o l s u b j e c t d i d not appear t o f i n d any one c o n d i t i o n e a s i e r than any ot h e r . 69 TABLE 7-4 HOMONYM TEST: SUMMARY OF RAW SCORES Meaning C o n d i t i o n P a t i e n t 5 Co n t r o l N V 13/27 = 48.1% 24/27 = 88.9% V N 18/27 = 66.7% 25/27 = 92.6% N N 15/27 = 55.6% 26/27 = 96.3% d) Boston Cookie Theft P i c t u r e D e s c r i p t i o n . - The numerical language measures f o r the p i c t u r e d e s c r i p t i o n are presented i n Table 7-5. Data f o r both s u b j e c t s , P a t i e n t 5, and C o n t r o l , and both c o n d i t i o n s , w r i t t e n and o r a l , a re con t a i n e d i n t h i s t a b l e . A comparison of the two o r a l d e s c r i p t i o n s i n d i c a t e s i n t e r e s t i n g d i f f e r e n c e s between the two s u b j e c t s . P a t i e n t 5's t o t a l number of words (and MLU) were much l e s s than those of h i s C o n t r o l . In a d d i t i o n , anomia and c o n c i s e n e s s i n d i c e s were markedly d i f f e r e n t . Comparison between the two w r i t t e n d e s c r i p t i o n s c o u l d not be made s i n c e P a t i e n t 5 was unable t o complete the task. When P a t i e n t 5 was i n s t r u c t e d t o w r i t e e v e r y t h i n g he saw happening i n the p i c t u r e , he was on l y a b l e t o w r i t e the word " w r i t e " ( s p e l l e d < r i t > ), a d e c i d e d l y abnormal response. 70 TABLE 7-5 BOSTON COOKIE THEFT DESCRIPTION: NUMERICAL LANGUAGE MEASURES P a t i e n t 5 C o n t r o l Measures Oral W r i t t e n Oral W ritten t o t a l words 48.0 1.0 68.0 50.0 unique words 24.0 1.0 35.0 33.0 MLU (words) 4.2 1.0 7.3 10.0 prep phrases 0.0 0.0 4.0 3.0 subord c l a u s e s 0.0 0.0 2.0 2.0 anomia index* 0.33 CNC*** 0.07 0.07 c o n c i s e index** 12.5 CNC 16.2 16.0 prep e r r o r s 1.0 0.0 0.0 0.0 p e r s e v e r a t i o n s 1.0 0.0 0.0 0.0 empty words 1.0 0. 0 0.0 0.0 sem paraphasia 1.0 0. 0 0.0 0.0 phnm par a p h a s i a O.O 0.0 0.0 0.0 jargon O.O 0.0 0.0 O.O s p e l l i n g e r r o r s n/a l.O n/a l.O syntax e r r o r s 0.0 O.O O.O O.O t o t a l nouns 8.0 O.O 13.0 13.0 t o t a l pronouns 4.0 O.O l.O 1.0 t o t a l verbs 15.0 1.0 15.0 14.0 t o t a l preps 0.0 0.0 4.0 3.0 t o t a l det 10.0 O.O 10.0 l l . O t o t a l adj/adv 0.0 O.O 4.0 2.0 t o t a l conj 8.0 0.0 1.0 1.0 det omitted O.O 1.0 O.O O.O * Anomia index = C N / (N + Prn) 1 ** Conciseness index = C(100 * r e l e v a n t o b s ) / t o t a l words] *** c o u l d no c a l c u l a t e due t o l a c k of i n f o r m a t i o n KEY: prep = p r e p o s i t i o n s sem = semantic phnm = phonemic det — determiner conj = c o n j u n c t i o n subord = s u b o r d i n a t e MLU = mean le n g t h of u t t e r a n c e 71 CHAPTER 8 GROUP RESULTS Standardized T e s t s 1) Peabody P i c t u r e Vocabulary Test (PPVT) The mean standard s c o r e -for the Experimental group was 83.5. T h i s s c o r e i s w i t h i n one standard d e v i a t i o n below the mean f o r t h i s t e s t . The mean standard s c o r e f o r the Co n t r o l group was 122.2 which i s s i g n i f i c a n t l y higher than t h a t of the Experimental group, and w i t h i n one standard d e v i a t i o n above the mean f o r the t e s t . 2) The Word Test Table 8-1 l i s t s the mean s c o r e s f o r each s u b t e s t and each group. In a l l cases, the s c o r e s of the C o n t r o l group a r e s i g n i f i c a n t l y l a r g e r than those of the Experimental group. The Experimental group's mean s c o r e f o r the Synonym and D e f i n i t i o n s u b t e s t s a re one standard d e v i a t i o n below the mean f o r the t e s t . The M u l t i p l e D e f i n i t i o n s u b t e s t mean f o r the Experimental group i s th r e e standard d e v i a t i o n s below the mean. The Antonym s u b t e s t i s the o n l y s u b t e s t mean f o r the Experimental group t h a t i s w i t h i n normal l i m i t s . 72 TABLE B - l THE WORD TEST: SUBTESTS MEAN STANDARD SCORES Subtest Experimental Group C o n t r o l Group Synonym 44.6 53.8 Antonym 46.4 55.2 D e f i n i t i o n 41.8 55.0 M u l t i p l e D e f i n i t i o n 29.4 51.8 3) The Boston D i a g n o s t i c Aphasia Examination (BDAE) Raw s c o r e s were analyzed u s i n g the Mann—Whitney U Test. Table 8—2 l i s t s t he U v a l u e s f o r each s u b t e s t . TABLE 8-2 BDAE SUBTESTS: MANN-WHITNEY U VALUES Subtest U v a l ue Responsive Naming 6. 0 Sentence R e p e t i t i o n (L) 2. 5 * Sentence R e p e t i t i o n (H) 7. 5 Word Fluency 6. 0 KEY: L = low p r o b a b i l i t y sentences H = high p r o b a b i l t y sentences * = s i g n i f i c a n t at p — 0.05 73 The C o n t r o l group scored s i g n i f i c a n t l y b e t t e r than the Experimental group on the low p r o b a b i l i t y sentences of the Sentence R e p e t i t i o n s u b t e s t ; t h e r e was no s i g n i f i c a n t d i f f e r e n c e between other s u b t e s t s . 4) The Boston Naming Test <BNT) The mean raw sc o r e f o r the C o n t r o l group was 53.8, which i s s i g n i f i c a n t l y higher than the Experimental groups ' mean s c o r e of 43.8. The response l a t e n c i e s f o r the BNT were analyzed with The Mann-Whitney U Te s t . The r e s u l t s of t h i s a n a l y s i s i n d i c a t e d t h a t response l a t e n c i e s were not s i g n i f i c a n t l y d i f f e r e n t between the two groups. Experimental T e s t s 1) F r u i t and Vegetable Naming The raw s c o r e s of t h i s t e s t f o r each group were analyzed with the Mann-Whitney U Test. The r e s u l t s of t h i s a n a l y s e s a re l i s t e d i n Table 8-3. Three r e s u l t s a re s i g n i f i c a n t l y d i f f e r e n t . The C o n t r o l group's s c o r e s on the Photographs. and Black and White Drawings are s i g n i f i c a n t l y higher than s c o r e s of the Experimental group under the same c o n d i t i o n s . In a d d i t i o n , f o r the Co n t r o l group, Photographs were s i g n i f i c a n t l y e a s i e r t o name than 74 Black and White Drawings. TABLE 8-3 FRUIT AND VEGETABLE NAMING: MANN-WHITNEY U VALUES OF RAW SCORES T e s t s Value of U photo <C vs E) 1.0 * c o l o u r (C vs E) 4.5 B/W (C vs E) 3.5 ** photo vs c o l o u r (E) 10.5 c o l o u r vs B/W (E) 12.5 photo vs B/W CE) 8.0 photo vs c o l o u r (C) 8.0 c o l o u r vs B/W (C) 9.0 photo vs B/W (C) 1.5 ** KEY : photo = photographs c o l o u r = c o l o u r e d l i n e drawings B/W = black and white drawings E = experimental group C = c o n t r o l group * = s i g n i f i c a n t at p = 0.01 ** = s i g n i f i c a n t at p - 0.05 The mean response l a t e n c i e s f o r the F r u i t and Vegetable  Naming Test were a l s o analyzed with the Mann—Whitney U t e s t . U v a l u e s a re given i n Table 8—4. Repsonse l a t e n c i e s f o r the C o n t r o l s u b j e c t s ' c o r r e c t answers are s i g n i f i c a n t l y s h o r t e r than those of Experimental s u b j e c t s f o r the Coloured and Black and White p i c t u r e s . 75 TABLE 8-4 FRUIT AND VEGETABLE NAMING: MANN-WHITNEY U VALUES FOR MEAN RESPONSE LATENCIES T e s t s Value of U photo (C vs E) 2. 0 c o l o u r (C vs E) 0. 0 * B/W (C vs E) 0. 0 * photo vs c o l o u r (E> 7. 0 c o l o u r vs B/W <E) 6. O photo vs B/W (E) 7. 0 photo vs c o l o u r (C) 6. 0 c o l o u r vs B/W (C) 7. 5 photo vs B/W (C) 8. 0 KEY : C = c o n t r o l group E = experimental group photo = photographs c o l o u r = c o l o u r e d drawings B/W = black and white drawings * = s i g n i f i c a n t at p ^ 0.01 Table 8—5 p r o v i d e s the means and v a r i a n c e of t h e raw sc o r e s on the F r u i t and Vegetable Naming T e s t . The v a r i a n c e of s c o r e s i s g r e a t e r f o r the Experimental s u b j e c t s i n a l l naming c o n d i t i o n s when compared with t h e i r C o n t r o l s u b j e c t s . The g r e a t e s t v a r i a n c e of s c o r e s f o r Experimental s u b j e c t s i s i n the Coloured Drawing c o n d i t i o n . The v a r i a n c e of the Experimentals' raw sco r e s on the Photograph. and Black and White Drawing, c o n d i t i o n s do not seem t o be markedly d i f f e r e n t from each other. The C o n t r o l s ' v a r i a n c e of raw s c o r e s i s approximately the same i n a l l t h r e e naming c o n d i t i o n s . The Experimentals' means 76 were c o n s i d e r a b l y s m a l l e r than t h e i r C o n t r o l s ' TABLE 8-5 FRUIT AND VEGETABLE NAMING: MEAN, RANGE, STANDARD DEVIATION, AND VARIANCE OF RAW SCORES P i c t u r e Type Experimental C o n t r o l  _ 2 2 X R S.D. S X R S.D. S photographs 16.6 7 3.51 12.3 21.2 2 0.84 0.71 co l o u r e d 14.8 13 5.23 35.2 20.4 4 1.64 2.69 B/W 15.0 8 3.87 15.0 19.0 3 1.41 1.99 2) Naming I I . The raw s c o r e s -for each s u b t e s t were s u b j e c t e d t o the Mann—Whitney U t e s t . The U v a l u e s are l i s t e d i n Table 8-6. For the Experimental group the s c o r e s f o r the Sentence  Completion c o n d i t i o n a re s i g n i f i c a n t l y higher than t h e i r s c o r e s on e i t h e r the A u d i t o r y D e s c r i p t i o n or T a c t i l e  Naming c o n d i t i o n s . The U va l u e s f o r the Co n t r o l Group show t h a t t h e i r s c o r e s are s i g n i f i c a n t l y higher on V i s u a l  Nami ng than on T a c t i l e Naming, and s i g n i f i c a n t l y higher on Sentence Completion than on T a c t i l e Naming. 77 TABLE 8-6 NAMING l i s MANN-WHITNEY U VALUES FDR EACH NAMING CONDITION Naming C o n d i t i o n Value o-f U V.N. (E vs C) 7.0 S.C. (E vs C) 11.0 A.D. (E vs C) 6.0 T.N. (E vs C) 6.5 V.N. vs S.C. (E) 8.5 V.N. vs A.D. (E) 6.0 V.N. V 5 T.N. <E) 5.0 S.C. V S A.D. (E) 3.0 * S.C. vs T.N (E) 4.0 * A.D. vs T.N. <E) 10.5 V.N. vs S.C (C) 4.5 V.N. vs A.D. (C) 7.0 V.N. vs T.N. <C> 4.0 * S.C. vs A.D. (C) 7.0 S.C. vs T.N. (C) 4.0 * A.D. vs T.N. (C) 9.0 K'EYs C = c o n t r o l group E = experimental group V.N. = v i s u a l c o n f r o n t a t i o n naming S.C. = sentence completion A.D. = a u d i t o r y d e s c r i p t i o n T.N. = t a c t i l e naming * * s i g n i f i c a n t at p= 0.05 The mean response l a t e n c i e s f o r the c o r r e c t answers i n each c o n d i t i o n were a l s o analyzed; r e s u l t s are presented i n Table 8-7. These r e s u l t s i n d i c a t e t h a t response l a t e n c i e s f o r the Experimental Group are s i g n i f i c a n t l y longer than those of the C o n t r o l Group i n both the V i s u a l  Nami ng and Sentence Completion c o n d i t i o n s . Comparisons between c o n d i t i o n s show th a t f o r the Experimental Group, response l a t e n c i e s a re s i g n i f i c a n t l y longer on V i s u a l 78 Naming Naming and Sentence Completion c o n d i t i o n s than on T a c t i l e c o n d i t i o n . TABLE 8-7 NAMING I I : MANN-WHITNEY U VALUES OF MEAN RESPONSE LATENCIES FOR EACH NAMING CONDITION Naming C o n d i t i o n Value of U V.N. (E vs C) 0.5 ** S.C. (E vs C) 0.0 * A.D. <E vs C) 5.0 T.N. (E vs C) 7.0 V.N. vs S.C. (E) 8.0 V.N. vs A.D. (E) 4.0 V.N. vs T.N. (E) O. 0 * S.C. vs A.D. (E) 4.0 S.C. vs T.N. <E> O.O * A.D. vs T.N. (E) 2.0 V.N. vs S.C. (C) 4.5 V.N. vs A.D. (C) 0.0 * V.N. vs T.N. (C) O.O * S.C. vs A.D. (C) 0.0 * S.C. vs T.N. <C) O.O * A.D. vs T.N. (C) 0.0 # KEY : E = experimental group C = c o n t r o l group V.N. = v i s u a l c o n f r o n t a t i o n naming A.D. = a u d i t o r y d e s c r i p t i o n naming S.C. = sentence completion naming T.N. = t a c t i l e naming * = s i g n i f i c a n t at p — 0.01 ** = s i g n i f i c a n t at p - 0.05 For the Co n t r o l Group, the response l a t e n c i e s f o r the V i s u a l Naming c o n d i t i o n a re s i g n i f i c a n t l y longer than f o r both the A u d i t o r y D e s c r i p t i o n , and T a c t i l e Naming. The 79 Sentence Completion l a t e n c i e s a re s i g n i f i c a n t l y longer than l a t e n c i e s -for A u d i t o r y D e s c r i p t i o n and T a c t i l e  Naming. Response l a t e n c i e s on A u d i t o r y D e s c r i p t i o n were s i g n i f i c a n t l y longer than l a t e n c i e s on T a c t i l e Naming. Table 8-8 g i v e s the mean and v a r i a n c e of the raw s c o r e s f o r each naming c o n d i t i o n and f o r each group. TABLE 8-8 NAMING I I : MEAN, RANGE, STANDARD DEVIATION, AND VARIANCE OF RAW SCORES Condi t i o n Experimental C o n t r o l  2 2 X R S.D. S X R S.D. S V. C. 9.2 2 0.84 0. 70 9.8 1 0.70 O. 49 s . c . 9.6 0.74 0. 55 9.8 1 0.47 0. 22 A. c . 7.6 4 1.95 3. 80 9.2 2 0.84 O. 70 T. c . 7.2 6 2.29 5. 20 8.8 J C 0.84 0. 70 KEY: V.C. = v i s u a l c o n f r o n t a t i o n S.C. = sentence completion A.D. = a u d i t o r y d e s c r i p t i o n T.N. = t a c t i l e naming In a l l naming c o n d i t i o n s , the v a r i a n c e of s c o r e s i s g r e a t e r f o r Experimental s u b j e c t s than i t i s f o r Con t r o l s u b j e c t s . A comparison between c o n d i t i o n s f o r the Experimental s u b j e c t s shows t h a t the v a r i a n c e i s g r e a t e s t f o r the T a c t i l e Naming c o n d i t i o n f o l l o w e d by the A u d i t o r y  D e s c r i p t i o n c o n d i t i o n ; the V i s u a l C o n f r o n t a t i o n and 80 Sentence Completion c o n d i t i o n s do not appear t o be markedly d i f f e r e n t . However, both of these c o n d i t i o n s show a v a r i a n c e t h a t i s much l e s s than t h a t f o r e i t h e r the Au d i t o r y D e s c r i p t i o n or T a c t i l e Naming. Va r i a n c e f o r s c o r e s of the C o n t r o l group do not appear t o d i f f e r s i g n i f i c a n t l y between naming c o n d i t i o n s . 3) Homonym Test Raw s c o r e s f o r each s u b j e c t group, and each c o n d i t i o n , were analyzed with the Mann—Whitney U t e s t . Table 8—9 l i s t s the Mann-Whitney U v a l u e s . TABLE 8-9 HOMONYM TEST: MANN-WHITNEY U VALUES FOR EACH CONDITION AND EACH SUBJECT GROUP Homonym C o n d i t i o n Value of U N,V <C vs E) 3.0** V,N (C vs E) 5. 0* N,N <C vs E) 6.0 N,V vs V,N (E) 10.0 N,V vs N,N (E) 8. 0 V,N vs N,N (E) 9.0 N,V vs V,N (C) 12. O N,V vs N,N (C) 9.0 V,N vs N,N (C) 10.0 KEY: N,N = Noun-Noun N,V = Noun—Verb V,N = Verb-Noun ** = s i g n i f i c a n t at p ^ 0.05 * = s i g n i f i c a n t at p — 0.075 81 The o n l y r e s u l t s r e a c h i n g s i g n i f i c a n c e are f o r the sc o r e s of the C o n t r o l s u b j e c t s on the Noun-Verb and Verb-Noun meaning c o n d i t i o n s , which are s i g n i f i c a n t l y h i g h e r than the s c o r e s f o r Experimental s u b j e c t s . However, an examination of the v a r i a n c e of raw s c o r e s f o r each meaning c o n d i t i o n shows t h a t i n a l l cases the C o n t r o l s u b j e c t s perform the homonym s o r t with l e s s v a r i a n c e than the Experimental s u b j e c t s . Table 8-10 l i s t s the v a r i a n c e of raw s c o r e s f o r the homonym t e s t . TABLE 8-10 HOMONYM TEST: MEAN, RANGE, STANDARD DEVIATION, AND VARIANCE OF RAW SCORES FOR EACH MEANING CONDITION C o n d i t i o n Experimental C o n t r o l X R S. D. 2 S X R S.D. 2 S N,V 18.8 13 4. 87 23.72 25.2 3 1.23 1.51 V,N 20.0 13 4. 95 24.50 25.0 O 0.00 0.00 N,N 22.2 11 4. 97 24.70 25.8 3 1.30 1.69 For a l l meaning p a i r s the v a r i a n c e of the Experimental group's raw s c o r e s i s much g r e a t e r , and the mean much s m a l l e r than t h a t of the C o n t r o l group. 82 4) Boston Cookie Theft P i c t u r e D e s c r i p t i o n Numerical language measures c a l c u l a t e d f o r the Oral and Wri t t e n d e s c r i p t i o n s were analyzed with the liann—Whi tney U t e s t . U v a l u e s f o r the Oral D e s c r i p t i o n are presented i n Table 8-11. BOSTON COOKIE THEFT DESCRIPTION (ORAL): MANN-WHITNEY TABLE 8-11 U VALUES; EXPERIMENTAL vs CONTROL Language Measures Value of U t o t a l # words # of uni que words M.L.U. (words) # of p r e p o s i t i o n a l phrases # s u b o r d i n a t e c l a u s e s anomia index c o n c i s e n e s s index # p r e p o s i t i o n e r r o r s p e r s e v e r a t i ons empty words # semantic paraphasias # phonemic paraphasias jargon syntax e r r o r s t o t a l nouns t o t a l pronouns t o t a l verbs t o t a l p r e p o s i t i o n s t o t a l determiners t o t a l adj/adv t o t a l c o n j u n c t i o n s # det. omitted 13. O 11.0 5.0 7.5 9.0 7.5 lO.O 4.5 7.5 12.5 12.5 12.0 7.0 10.5 9.5 5.0 7.5 8.5 1.5 7.0 1.0 * 4.0 ** * s i g n i f i c a n t at p - 0.01 ** s i g n i f i c a n t at p ^ 0.05 83 There were two s i g n i f i c a n t r e s u l t s . F i r s t , M.L.U.s f o r the Con t r o l group are s i g n i f i c a n t l y l a r g e r than those of the Experimental group. Second, the C o n t r o l group used s i g n i f i c a n t l y more p r e p o s i t i o n a l phrases than the Experimental group. Values of U f o r the Written D e s c r i p t i o n are presented i n Table 8-12. TABLE 8-12 BOSTON COOKIE THEFT DESCRIPTION (WRITTEN): MANN-WHITNEY U VALUES Language Measures Value of U t o t a l # word t o t a l uni que words M.L.U. (words) # p r e p o s i t i o n a l phrases # s u b o r d i n a t e c l a u s e s anomia index c o n c i s e n e s s index # p r e p o s i t o n e r r o r s p e r s e v e r a t i ons empty words # semantic paraphasias # phonemic paraphasias jargon s p e l 1 i ng e r r o r s t o t a l nouns t o t a l pronouns t o t a l verbs t o t a l p r e p o s i t i o n s t o t a l determiners t o t a l adj/adv t o t a l c o n j u n c t i o n s determiners omitted 4.0 3.0 4.5 5.5 2.0 7.0 7.0 7.0 7.0 7.0 7.0 7.0 6.0 2.0 5.5 5.0 5.0 4.5 9.0 2.0 4.0 1.0 * ** s i g n i f i c a n t at p = 0.05 84 The C o n t r o l group used s i g n i f i c a n t l y more p r e p o s i t i o n a l phrases than the Experimental group; t h i s was the onl y s i g n i f i c a n t d i f f e r e n c e . U v a l u e s f o r comparison of the Experimental group's W r i t t e n D e s c r i p t i o n s with t h e i r Oral D e s c r i p t i o n s , are presented i n Table 8-13. BOSTON COOKIE THEFT DESCRIPTIONS MANN-WHITNEY U VALUES FOR EXPERIMENTAL GROUP; ORAL vs WRITTEN DESCRIPTION TABLE 8-13 Language Measures Value of U t o t a l # words # uni que words M.L.U. (words) # p r e p o s i t i o n a l phrases subord i nate c1auses anomia index c o n c i s e n e s s index # p r e p o s i t i o n a l e r r o r s p e r s e v e r a t i ons empty words # semantic paraphasias # phonemic paraphasias jargon syntax e r r o r s t o t a l nouns t o t a l pronouns t o t a l verbs t o t a l p r e p o s i t i o n s t o t a l determiners t o t a l adj/adv t o t a l c o n j u n c t i o n s determiners omitted 6. 0 4.0 lO.O 8.5 4.5 6.0 8.0 6.0 8.0 7.0 7.5 lO.O 10.0 6.0 10.0 6.0 10.0 10.0 9.5 7.5 2.0 * 2.0 * # s i g n i f i c a n t at p ^ 0.05 85 There were two s i g n i f i c a n t r e s u l t s from t h i s comparison: (1) Oral D e s c r i p t i o n s contained more empty words than the Wri t t e n D e s c r i p t i o n s , and <2)there were s i g n i f i c a n t l y more pronouns i n the Oral D e s c r i p t i o n s than i n the Wr i t t e n  D e s c r i p t i o n s . Mann—Whitney U v a l u e s f o r the comparison of the C o n t r o l group's Written D e s c r i p t i o n with t h e i r Oral D e s c r i p t i o n , are given i n Table 8—14. BOSTON COOKIE THEFT DESCRIPTION: MANN-WHITNEY U VALUES FOR CONTROL GROUP; WRITTEN vs ORAL DESCRIPTION TABLE 8-14 Language Measures Value of U t o t a l # of words # of unique words M.L.U. (words) # p r e p o s i t i o n a l phrases s u b o r d i n a t e c l a u s e s anomia index c o n c i s e n e s s index # p r e p o s i t i o n a l e r r o r s p e r s e v e r a t i on empty words # semantic paraphasias # phonemic paraphasias jargon syntax e r r o r s t o t a l nouns t o t a l pronouns t o t a l verbs t o t a l p r e p o s i t i o n s t o t a l determiners t o t a l adj/adv t o t a l c o n j u n c t i o n s . determiners omitted 6.0 9.0 9.5 9.0 8.0 10.O 10.0 lO.O 10.0 7.5 10.O 10.O 10.0 10.0 S.O 9.5 7.5 7.5 8.5 8.5 5.5 8.0 86 There are no s i g n i f i c a n t d i f f e r e n c e s between the Oral and W r i t t e n D e s c r i p t i o n s of the C o n t r o l s u b j e c t s . 87 CHAPTER 9 DISCUSSION Standardized T e s t s 1) PPVT. The PPVT w i l l be a u s e f u l t e s t t o measure long-term r e c o v e r y of r e c e p t i v e vocabulary. Comparison of the Experimental group's (E) 1985 s c o r e s with t h e i r 1986 s c o r e s showed a s t a r t l i n g o v e r a l l d e c l i n e ; thus, s c o r e s f o r E2 and E5 dropped s i g n i f i c a n t l y ; the s c o r e f o r E3 dropped one standard s c o r e shy of a s i g n i f i c a n t drop. E l maintained h i s s c o r e from 1985; o n l y E4 scored h i g h e r i n 1986 than he d i d i n 1985. It would be reasonable t o assume t h a t at a year f u r t h e r removed from t h e i r a c c i d e n t s , each E should have improved. If each E had maintained h i s s c o r e from the p r e v i o u s year, i t c o u l d be argued t h a t they were not a c q u i r i n g new knowledge at the same r a t e as they had b e f o r e the a c c i d e n t . Such an argument i s supported by Thqmsen (1977) who demonstrated t h a t the v e r b a l l e a r n i n g c a p a c i t y of a d u l t s was impaired a f t e r severe h e a d - i n j u r y . The c o n s i d e r a b l e drop i n s c o r e s of t h r e e of the f i v e E's i s d i f f i c u l t t o e x p l a i n . The s c o r e s may have dropped because, f o r example, the t e s t was administered by two d i f f e r e n t examiners; s i n c e the PPVT i s not d i f f i c u l t t o 88 a d m i n i s t e r and i s well s t a n d a r d i z e d , t e s t s c o r e s should not, however, be s i g n i f i c a n t l y a f f e c t e d by d i f f e r e n t a d m i n i s t r a t o r s . An a l t e r n a t i v e e x p l a n a t i o n f o r a decrement i n PPVT s c o r e s may be t h a t Es' r e c e p t i v e vocabulary i s i n f a c t degenerating over time, r a t h e r than showing improvement. T h i s might be a t t r i b u t a b l e t o delayed degeneration of c o r t i c a l / s u b - c o r t i c a l matter. T e s t i n g i n 1987 should p r o v i d e f u r t h e r i n s i g h t i n t o t h i s problem. If s c o r e s continue t o d e c l i n e , t h i s may lend support t o a h y p o t h e s i s of delayed degeneration. Should s c o r e s improve, t h i s may support the "impairment of v e r b a l l e a r n i n g " h y p o t h e s i s , which would i n t u r n lend v a l i d i t y t o s i m i l a r f i n d i n g s i n a d u l t s a f t e r c l o s e d h e a d - i n j u r y (Thomsen 1977). It i s i n t e r e s t i n g t o note t h a t the t h r e e E's who showed a drop i n PPVT s c o r e s were a l l ten years o l d or younger at the time of t h e i r a c c i d e n t . T h i s w i l l be d i s c u s s e d i n g r e a t e r d e t a i l l a t e r i n terns of the r e l a t i o n s h i p between age and extent of r e c o v e r y , when compared with a d u l t s . 2) The Word T e s t . The r e s u l t s of the Word Test suggest an order of d i f f i c u l t y f o r the f o u r s u b t e s t s f o r the E's. The Antonym s u b t e s t seemed t o be the e a s i e s t c o n d i t i o n f o l l o w e d , i n order of i n c r e a s i n g d i f f i c u l t y , by the Synonym. D e f i n i t i o n . and 89 M u l t i p l e D e f i n i t i o n s u b t e s t s . T h i s order seems l o g i c a l i f the l e v e l of a b s t r a c t i o n / l e x i c a l s t o r a g e r e q u i r e d t o complete th e s e , t a s k s i s c o n s i d e r e d . F i g u r e 7-1 p r o v i d e s a model f o r l e x i c a l / s e m a n t i c s t o r a g e modified from C l a r k (1973). T h i s model suggests t h a t we s t o r e words by a common concept; f o r example, i f the concept i s CheightD i t i s suggested t h a t we s t o r e words (bin) f o r one end of the continuum such as s m a l l , t i n y , s h o r t , and an a l t e r n a t e l i s t of words (bin) f o r the o p p o s i t e end of the continuum such as l a r g e , t a l l , e t c . Using t h i s model, i t i s p o s s i b l e t o suggest an e x p l a n a t i o n f o r the h i e r a r c h y of d i f f i c u l t y f o r the t a s k s i n the Word t e s t . Thus, the Antonym s u b t e s t would be e a s i e s t because the minimum s t o r a g e space r e q u i r e d would be two b i n s . For example, i f the c h i l d i s asked t o generate an antonym f o r the word " s m a l l " , he would r e q u i r e t h a t one s t o r a g e b i n be a l l o t t e d f o r the word " s m a l l " and another s t o r a g e b i n at the o p p o s i t e end of the continuum f o r a word l i k e " b i g " , f o r c o n t r a s t i v e comparison. If E i s r e q u i r e d t o generate a synonym, t h i s w i l l r e q u i r e a t h r e e step search of the s t o r a g e b i n s : one search f o r the word used as a s t i m u l u s , e.g. " s m a l l " ; a second search f o r c o n t r a s t i v e comparison at the other end of the continuum e.g.,"big", and a t h i r d search w i t h i n the same b i n as " s m a l l " , f o r a response. S i n c e f i n d i n g a synonym r e q u i r e s one more step than i s neccessary f o r f i n d i n g an antonym, i t 90 FIGURE 9-is MODEL OF LEXICAL/SEMANTIC STORAGE SEMANTIC CONCEPT e.g. H e i g h t / s i z e Negative SMALL LITTLE SHORT ( mod i f i e d from C l a r k (1973) ) 91 should be a more d i - f - f i c u l t task -for a c h i l d whose l e x i c a l s t o r a g e / r e t r i e v a l system i s impaired as a r e s u l t o-f a head-i n j u r y . I t can be hypothesized t h a t the D e f i n i t i o n s u b t e s t should be more d i f f i c u l t than the Antonym or Synonym s u b t e s t s , because i t r e q u i r e s f i r s t , s e a r c h i n g i n the synonym mode, and second, f o r m a t t i n g the r e s u l t s of the se a r c h i n t o a sentence, or sentences. It may a l s o be the case t h a t the E must have synonym type s t o r a g e space f o r the concepts of the d e f i n i n g a t t r i b u t e s of the word which i s t o be d e f i n e d . Thus E must a l s o have access t o a s t o r e of concepts t h a t exemplify the form, f u n c t i o n , e t c . , of the word t o be d e f i n e d i n order t o g i v e a complete d e f i n i t i o n . The M u l t i p l e D e f i n i t i o n i s p o s s i b l y l o g a r i t h m i c a l l y more d i f f i c u l t than the D e f i n i t i o n task because i t r e q u i r e s at l e a s t double a c c e s s i n g and double s t o r a g e . The M u l t i p l e D e f i n i t i o n s u b t e s t may a c t u a l l y be more complex than t h i s e x p l a n a t i o n can account f o r , because the M u l t i p l e D e f i n i t i o n i s r e a l l y a homonym d e f i n i t i o n t a s k . To generate d e f i n i t i o n s , E has t o have s t o r e d , and be a b l e t o acc e s s , the i n f o r m a t i o n f o r a meaning c o n t r a s t and a phonetic i d e n t i t y . The complexity of such a task most c e r t a i n l y causes the head—injured c h i l d r e n great d i f f i c u l t y . The C o n t r o l group (C) d i d not f i n d one p a r t i c u l a r s u b t e s t e a s i e r than any o t h e r , with the e x c e p t i o n of the M u l t i p l e D e f i n i t i o n task which they found c o n s i d e r a b l y more 92 d i f f i c u l t than the other t h r e e s u b t e s t s . Thus even f o r c h i l d r e n who have not s u f f e r e d a h e a d — i n j u r y , the complexity of the task causes problems i n response. F u r t h e r r e s e a r c h on the development of m u l t i p l e meanings i s needed i n order t o understand the development of t h i s s k i l l and t o know at what p o i n t the c h i l d may be expected t o have reached an a d u l t s k i l l l e v e l of homonym d e f i n i t i o n . I t i s p o s s i b l e t h a t many a d u l t s never a c h i e v e an " a d u l t " l e v e l of homonym d e f i n i t i o n , s i n c e the a b i l i t y t o g i v e such d e f i n i t i o n s may be dependent on l e v e l of l i t e r a c y . 3) The Boston D i a g n o s t i c Aphasia Examination (BDAE). The Experimental group scored s i g n i f i c a n t l y lower than the C o n t r o l group o n l y on the Low P r o b a b i l i t y Sentence R e p e t i t i o n s u b t e s t . T h i s d i f f e r e n c e i s understandable s i n c e low p r o b a b i l i t y sentences have a "lower degree t o which s u c c e s s i v e words are' p r e d i c t a b l e from the preceeding words" (Goodglass and Kaplan 1976). T h e r e f o r e , they r e q u i r e a g r e a t e r degree of " p r o c e s s i n g " than do sentences t h a t are more p r e d i c t a b l e . E r r o r s i n c l u d e d word omissions, one r e f u s a l and a l l t h r e e types of paraphasia. There were i n t o t a l seven semantic p a r a p h a s i a s , e.g. "asked" s u b s t i t u t e d f o r "convinced",four phonemic p a r a p h a s i a s , e.g. " r a r e " was pronounced as " f a i r " , and f o u r n e o l o g i s t i c e r r o r s , e.g. " f l e d " became / g j r e t / . Goodglass and Kaplan (1976) s t a t e : R e p e t i t i o n i n aphasia may be d i s t u r b e d at t h r e e p o i n t s i n the process. F i r s t , the p a t i e n t may f a i l at the l e v e l of r e c o g n i t i o n . He may f a i l t o grasp the sounds as words and, consequently, r e f u s e t o attempt t o repeat them, or he may capture o n l y c e r t a i n fragments of the spoken model. Second, he. may f a i l at the l e v e l of a r t i c u l a t i o n i n s p i t e of h i s a b i l i t y t o demonstrate t h a t he knows the meaning of the t e s t words or sentence. F i n a l l y , h e may f a i l because of a s e l e c t i v e d i s s o c i a t i o n between a u d i t o r y input and the speech-output systems. The l a t t e r group of p a t i e n t s may demonstrate f a i r l y f l u e n t speech and n e a r - p e r f e c t comprehension, yet have e x t r a o r d i n a r y d i f f i c u l t y i n r e p e a t i n g what they have heard, (p. 7) In g e n e r a l , the Experimental group d i d not experience " e x t r a o r d i n a r y d i f f i c u l t y " r e p e a t i n g the sentences, but t h e i r e r r o r s i n d i c a t e t h a t they were breaking down at a l l t h r e e l e v e l s of r e p e t i t i o n d e s c r i b e d by Goodglass and Kaplan (1976). I t i s extremely d i f f i c u l t t o i s o l a t e at which p a r t i c u l a r l e v e l most breakdowns oc c u r r e d . However, i t i s c l e a r t h a t when memory load i s i n c r e a s e d t h e r e i s more l i k e l y t o be a mismatch between the hypothesized semantic and phonetic templates which c o n s t i t u t e the word—finding p r o c e s s . 4) The Boston Naming Test (BNT). When compared with t h e i r 1985 BNT r e s u l t s a l l s u b j e c t s made small g a i n s on t h i s t e s t ; however, o v e r a l l t h e i r s c o r e s were s t i l l below normal. Two of the E's (#3 and #5) had 94 moderate t o severe word f i n d i n g problems as i n d i c a t e d by t h e i r BMT s c o r e s and t h e i r numerous paraphasias. Some examples of E5's paraphasias were: s t i m u l u s : p i c t u r e of a pyramid response : " a d i f f e r e n t kind of i g l o o " s t i m u l u s s p i c t u r e of a p r o t r a c t e r response : "/temis/" Two of E4's par a p h a s i a s were: s t i m u l u s : p i c t u r e of pyramid response : " r o o f " s t i m u l u s : p i c t u r e of a compass response : " p e n c i l h o l d e r " The remaining t h r e e E's a l s o made paraphasic e r r o r s although t h e i r s c o r e s were w i t h i n the average range. Some of these e r r o r s were: s t i m u l u s : p i c t u r e of i c e tongs E l response : " i c e p i c k e r s , claws" s t i m u l u s : p i c t u r e of Sphynx E2 response : "King Tut's pet" s t i m u l u s : p i c t u r e of Sphynx E4 response : " / s p l j j k s / " None of the C o n t r o l s u b j e c t s made paraphasic e r r o r s . Although, E's #1, #2 and, #3 had s c o r e s w i t h i n the average range on the BNT t h e i r spontaneous speech c o u l d not be c o n s i d e r e d normal. A l l t h r e e s u b j e c t s had spontaneous speech t h a t c o n t a i n e d numerous i n s t a n c e s of c i r c u m l o c u t o r y speech, word-finding pauses, and predominantly semantic paraphasias. 95 In g e n e r a l , semantic cues d i d not ex p e d i t e word—finding. I-f a semantic cue was pr o v i d e d , a t y p i c a l response from the E was " Yes, I know !". On many o c c a s i o n s E's provided themselves with a semantic cue. For example, when E3 was shown a p i c t u r e of a " t r i p o d " he immediately responded " I t ' s a high p l a c e where you put a camera". T h i s example, i n a d d i t i o n t o many o t h e r s , c l e a r l y i n d i c a t e d t h a t E knew the meaning of the word but was e x p e r i e n c i n g d i f f i c u l t y a c c e s s i n g the phonemic template t h a t matched the meaning. For most of the s u b j e c t s the phonemic cue t r i g g e r e d a r e l i e v e d "oh yah !!" f o l l o w e d immediately by the t a r g e t word. E5 was the o n l y s u b j e c t who d i d not appear t o b e n e f i t c o n s i s t e n t l y from a phonemic cue, except f o r the s t i m u l u s p i c t u r e s t h a t have a higher f u n c t i o n a l y i e l d i n E n g l i s h . However, as the words decreased i n t h e i r f u n c t i o n a l frequency, E5 would t r y t o t u r n the cue i n t o a word t h a t r e s u l t e d i n e i t h e r a n e o l o g i s t i c p a r a p h a s i a , or a word t h a t f i t the phonemic cue but was i n no way r e l a t e d t o the s t i m u l u s p i c t u r e . For E5 i t appears t h a t a number of the words are impaired at the semantic l e v e l e i t h e r i n s t o r a g e , or i n r e t r i e v a l . I t i s c u r i o u s t o note t h a t , o v e r a l l , the response l a t e n c i e s were not s i g n i f i c a n t l y longer than those of the Co n t r o l group: t h i s may be due t o the l i m i t a t i o n s i n the s t a t i s t i c a l a n a l y s e s , or t o the r e l a t i v e l a c k of complexity r e q u i r e d t o name a l i n e drawing. T h i s o b s e r v a t i o n w i l l be 96 d i s c u s s e d l a t e r . Experimental T e s t s 1) F r u i t and Vegetable Naming. Comparing raw s c o r e s and response l a t e n c i e s o-f the two groups showed t h a t the C o n t r o l group performed s i g n i f i c a n t l y b e t t e r than the Experimental group on a l l t h r e e p i c t u r e naming t a s k s . Comparing mean response l a t e n c i e s and raw s c o r e s between p i c t u r e c o n d i t i o n s y i e l d e d o n l y one s i g n i f i c a n t d i f f e r e n c e . For C o n t r o l s , Photographs were named s i g n i f i c a n t l y f a s t e r than Black and White Drawings; thus t h e r e was no s t a t i s t i c a l support f o r the h y p o t h e s i s t h a t Photographs would be e a s i e r t o name than Coloured L i n e Drawings, which i n t u r n would be e a s i e r t o name than Black and White Drawings. However, t h i s l a c k of group s i g n i f i c a n c e may be due t o l i m i t a t i o n s of the parametric t e s t used t o analyze the data s i n c e d i f f e r e n c e s between i n d i v i d u a l s c o r e s f o r the naming c o n d i t i o n s and the s u b j e c t s , would c e r t a i n l y be s i g n i f i c a n t l y d i f f e r e n t i f an a p p r o p r i a t e parametric s t a t i s t i c a l t e s t e x i s t e d . To answer t h i s q u e s t i o n , these t e s t s w i l l be repeated i n a y e a r ' s time. Because of l i m i t a t i o n s i n s t a t i s t i c a l a n a l y s e s , i t i s u s e f u l t o compare v a r i a n c e s and means f o r the s c o r e s on the v a r i o u s c o n d i t i o n s . The v a r i a n c e and means between p i c t u r e 9 7 types f o r the Experimental group suggest t h a t the order of d i f f i c u l t y , from easy t o hard, of the t h r e e c o n d i t i o n s i s Photographs ,Black and White Drawings, and Coloured L i n e  Drawings. The obvious question r a i s e d by t h i s r e s u l t i s "Why are the Black and White Drawings e a s i e r t o name than the Coloured L i n e Drawings ?" I t would be reasonable t o b e l i e v e t h a t the added dimension of c o l o u r would make the Coloured  L i n e Drawing e a s i e r t o name than a Black and White L i n e  Drawing. Perhaps the added dimension of c o l o u r a c t u a l l y d u l l s the p r o c e s s e s of acc e s s and r e t r i e v a l because i t i s one a d d i t i o n a l p i e c e of i n f o r m a t i o n t h a t must be processed as a word i s being accessed and r e t r i e v e d . However, a case study by Hart et a l . <1985) us i n g s i m i l a r p i c t o r i a l s t i m u l i d i d f i n d our p r e d i c t e d order of p i c t u r e naming d i f f i c u l t y . I t may be t h a t our s u b j e c t group was too small t o demonstrate such a h i e r a r c h y , or t h a t t h e r e are i n d i v i d u a l d i f f e r e n c e s i n p i c t u r e naming p r e f e r e n c e or other reasons not immediately t r a n s p a r e n t . Lack of agreement between the h y p o t h e s i s and the r e s u l t s may a l s o be due t o l i m i t a t i o n s of s t a t i s t i c a l a n a l y s e s . F u r t h e r r e s e a r c h on a l a r g e r s c a l e i s r e q u i r e d t o adequately e x p l a i n presesnt r e s u l t s . 98 2) Naming I I . A comparison of response l a t e n c i e s and raw s c o r e s f o r the naming c o n d i t i ons supports the p r e d i c t e d order of d i f f i c u l t y h y p o t h e s i s . V i s u a l C o n f r o n t a t i o n and Sentence Completion were the e a s i e s t naming t a s k s , f o l l o w e d by A u d i t o r y D e s c r i p t i o n , which i n t u r n was an e a s i e r task than T a c t i l e Naming. An e x p l a n a t i o n f o r these r e s u l t s may l i e i n the r e l a t i v e complexity of the v a r i o u s t a s k s . I t i s reasonable t o assume t h a t V i s u a l C o n f r o n t a t i o n naming would be one of the s i m p l e r c o n d i t i o n s because t h a t task i s seemingly not very complex. The s u b j e c t "only" has t o r e c o g n i z e the p i c t u r e and access one l e x i c a l item. He does not have t o analyze a l i n g u i s t i c u n i t . By comparison, Sentence Completion should a l s o be an "easy" c o n d i t i o n because, although i t uses a l i n g u i s t i c s t i m u l u s <the se n t e n c e ) , the l e v e l of a n a l y s i s r e q u i r e d i s l i m i t e d s i n c e the sentence o c c u r s so f r e q u e n t l y with the word, and the s t i m u l u s i t s e l f i s not very long. S i n c e sentence c o n s t i t u e n t s are l i m i t e d , the l e x i c a l item r e q u i r e d t o complete the sentence i s h i g h l y p r e d i c t a b l e . I t i s p a s s i b l e t h a t these f r e q u e n t l y o c c u r r i n g sentences are i n some way s t o r e d as one u n i t with the word w i t h i n the mental d i c t i o n a r y . Naming t o A u d i t o r y D e s c r i p t i o n should be more d i f f i c u l t because the s u b j e c t has t o p r o c e s s , and h o l d i n memory a long 99 l i n g u i s t i c element b e f o r e a c c e s s i n g the t a r g e t word. The reason t h a t T a c t i l e Naming was so much more d i f f i c u l t than the other t h r e e c o n d i t i o n s f o r both s u b j e c t groups might be a t t r i b u t a b l e t o experience. U n l e s s the s u b j e c t i s b l i n d , everyday l i f e does not p l a c e much demand on the a b i l i t y t o name an o b j e c t by p a l p a t i o n alone. If we were t o have a number of b l i n d s u b j e c t s complete the T a c t i l e -Sentence  Completion and A u d i t o r y D e s c r i p t i o n t e s t s and compared t h e i r r e s u l t s with the normal and h e a d - i n j u r e d c h i l d r e n i t might support the h y p o t h e s i s t h a t e x p e r i e n c e p l a y s a l a r g e p a r t i n t a c t i l e naming a b i l i t y . Between groups, the C o n t r o l s performed s i g n i f i c a n t l y b e t t e r than the Experimentals on V i s u a l C o n f r o n t a t i o n and Sentence Completion. For T a c t i l e and A u d i t o r y D e s c r i p t i o n c o n d i t i o n s t h e r e was no s i g n i f i c a n t d i f f e r e n c e between the two groups. T h i s f i n d i n g may be due t o l i m i t a t i o n s i n s t a t i s t i c a l a n a l y s e s . Variance of s c o r e s f o r the Experimental group was c o n s i d e r a b l y l a r g e r than f o r the C o n t r o l group.This would suggest t h a t the Experimental s u b j e c t s experienced more d i f f i c u l t y with t h e s e c o n d i t i o n s than d i d the C o n t r o l s . 3) Homonym Te s t . The C o n t r o l group performed s i g n i f i c a n t l y b e t t e r on Noun- Verb and Verb-Noun p a i r s o r t s than d i d the Experimental group. There was no s i g n i f i c a n t d i f f e r e n c e between the groups 100 on the Noun-Noun s o r t . These r e s u l t s would appear t o i n d i c a t e t h a t p r e d i c a t i v e concepts are l e s s r e s i s t a n t t o the d e l e t e r i o u s e f f e c t s of b r a i n damage than r e f e r e n t i a l concepts. A p o s s i b l e e x p l a n a t i o n f o r the s e l e c t i v e d i s r u p t i o n of the u n d e r l y i n g semantic r e p r e s e n t a t i o n of p r e d i c a t i v e concepts c o u l d be t h a t verbs are c o g n i t i v e l y more complex than nouns. I t has been demonstrated t h a t nouns are more common than verbs (Myerson and Goodglass 1972, Fi l l e n b a u m 1961) which may a l s o account f o r s e l e c t i v e impairment of verbs. However, i n v e s t i g a t o r s have provided evidence t o support the n o t i o n t h a t verbs a re c o g n i t i v e l y more complex than nouns.(Genter 1981 and 1982, Thorndyke 1975, K i n t s c h 1974). Genter (1981) p o s t u l a t e d t h a t the u n d e r l y i n g semantic r e p r e s e n t a t i o n of nouns i s d i f f e r e n t from verbs. He argued; the c o n f l a t i o n of f e a t u r e s which r e p r e s e n t the meanings of nouns are more s t r o n g l y i n t e r r e l a t e d than the c o n f l a t i o n of f e a t u r e s which r e p r e s e n t the meaning of verbs. ( i n Grober, 1984. p. 563) If Genter's s u p p o s i t i o n i s a c c u r a t e , then nouns would be l e s s v u l n e r a b l e t o the e f f e c t s of h e a d - i n j u r y than verbs. Another p o s s i b l e e x p l a n a t i o n f o r the s p a r i n g of r e f e r e n t i a l concepts may be th a t t h e r e i s a s p e c i f i c verb p r o c e s s i n g d e f i c i t t h a t i m p a i r s the m e t a l i n g u i s t i c judgment r e q u i r e d t o complete the homonym meaning s o r t t a s k . Experimental support f o r the n o t i o n of a verb p r o c e s s i n g d e f i c i t i s provided by Goodglass et a l . (1968) and Gardener (1973). 101 Grober'5 (1984) j u s t i f i c a t i o n f o r using the homonym s o r t i n g task t o i n v e s t i g a t e the e f f e c t of b r a i n damage on r e f e r e n t i a l and p r e d i c a t i v e concepts was as f o l l o w s : S i n c e the d e c i s i o n s were made without s y n t a c t i c cues p r o v i d e d by sentences, any d i f f e r e n c e s t h a t emerge between the p r e d i c a t i v e and r e f e r e n t i a l senses of the homonyms must r e f l e c t the p r e — e x i s t i n g r e p r e s e n t a t i o n a l d i s t i n c t i o n s . ( p.558 ) However, i n the present study we found a s e r i o u s flaw i n the homonym meaning s o r t . There were great i n d i v i d u a l d i f f e r e n c e s i n response s t r a t e g i e s which made i n t e r p r e t a t i o n of the r e s u l t s d i f f i c u l t and o c c a s i o n a l l y m i s l e a d i n g . For example, C o n t r o l s u b j e c t s would o f t e n " s t r e t c h " an u n r e l a t e d word so t h a t i t c o u l d p l a u s i b l y be r e l a t e d t o the s t i m u l u s word. Such responses were d i f f i c u l t t o c a t e g o r i z e s i n c e , although they were not c o r r e c t , at the same time they were not completely i n c o r r e c t . The Experimentals d i d not tend t o " s t r e t c h " u n r e l a t e d words, tending r a t h e r towards i d e n t i f y i n g the dominant meaning of the word, p l a c i n g the words a s s o c i a t e d with the nondominant meaning i n the " u n r e l a t e d " p i l e . T h e r e f o r e , although not n e c e s s a r i l y q u a n t i t a t i v e l y d i f f e r e n t from C o n t r o l s t h e r e was a d e f i n i t e q u a l i t a t i v e d i f f e r e n c e between the groups with C o n t r o l s e x h i b i t i n g an ap p a r e n t l y g r e a t e r c o g n i t i v e f l e x i b i l i t y . There i s an a d d i t i o n a l problem with the homonym task. Recent r e s e a r c h (Blockberger 1982) i n d i c a t e s t h a t the dominant meanings of m u l t i p l e meaning words are d i f f e r e n t f o r c h i l d r e n than f o r a d u l t s . T h e r e f o r e , using an a d u l t normed 102 l i s t of m u l i t p l e meanings, such as the P e r f e t t i norms, w i l l f u r t h e r c o m p l i c a t e the i n t e r p r e t a t i o n of our r e s u l t s . 4) Boston Cookie T h e f t P i c t u r e D e s c r i p t i o n . a) Oral d e s c r i p t i o n - Comparison between the groups y i e l d e d two s i g n i f i c a n t r e s u l t s t h a t are a t t r i b u t a b l e t o the d e f i c i t s r e s u l t i n g from the h e a d - i n j u r y i n c u r r e d by the Experimental s u b j e c t s . The C o n t r o l group had a mean MLU (words) t h a t was s i g n i f i c a n t l y h i g h e r than the Experimental group's mean MLU. T h i s r e s u l t i s c o n s i s t e n t with r e s u l t s of the PPVT• I t may be argued t h a t i f r e c e p t i v e vocabulary i s reduced then e x p r e s s i v e vocabulary w i l l a l s o be l i m i t e d , an o b s e r v a t i o n r e f l e c t e d i n the lower MLU f o r Experimentals. The s m a l l e r MLU may a l s o be a r e f l e c t i o n of the Experimental group's use of sim p l e r syntax than the C o n t r o l group's. T h i s n o t i o n i s supported by the o b s e r v a t i o n t h a t the C o n t r o l group used s i g n i f i c a n t l y more p r e p o s i t i o n a l phrases than the Experimental group. An e x p l a n a t i o n f o r the Experimental group's use of simple syntax may be t h a t the a c c e s s / s t o r a g e of t h e i r mental grammars has been damaged as a r e s u l t of the h e a d - i n j u r y . b) W r i t t e n D e s c r i p t i o n — The o n l y s i g n i f i c a n t r e s u l t was t h a t the C o n t r o l group used s i g n i f i c a n t l y more unique words than the Experimental group. T h i s r e s u l t can a l s o be 103 e x p l a i n e d by the -fact t h a t the Experimental group's r e c e p t i v e vocabulary was s i g n i f i c a n t l y reduced, hence, i t s c o r o l l a r y , t h a t e x p r e s s i v e vocabulary would a l s o be reduced. c) Oral vs W r i t t e n D e s c r i p t i o n - The Experimental group used s i g n i f i c a n t l y more empty words, e.gi "umm" i n the o r a l d e s c r i p t i o n s . T h i s i s r e a d i l y e x p l a i n e d by the d i f f e r e n c e s between the m o d a l i t i e s . When we pause d u r i n g a n a r r a t i v e we o f t e n f i l l the s i l e n c e with an "umm" or an " e r " . However, when we pause d u r i n g w r i t i n g , our pen j u s t s t o p s - we never w r i t e i n an "empty word" t o f i l l t h i s pause. S i n c e the C o n t r o l group d i d not use s i g n i f i c a n t l y more empty words i n t h e i r o r a l d e s c r i p t i o n , i t i s reasonable t o suggest t h a t the empty words i n the speech of the Experimental group a c t u a l l y epresent word—finding a c t i v i t y . The Experimental group a l s o used more pronouns i n t h e i r o r a l d e s c r i p t i o n than i n the w r i t t e n d e s c r i p t i o n . One p o s s i b l e e x p l a n a t i o n f o r t h i s behaviour may be t h a t , when the Experimental s u b j e c t d e s c r i b e s the p i c t u r e t o the examiner ( o r a l c o n d i t i o n ) , the s u b j e c t presumes the shared r e f e r e n t (the p i c t u r e ) and t h e r e f o r e does not f e e l compelled t o use the proper name i n a l l cases. However, when Experimentals are w r i t i n g t h e i r d e s c r i p t i o n s , they are not " t a l k i n g " t o a s p e c i f i c person so they do not assume a shared r e f e r e n t ; they t h e r e f o r e use fewer pronouns f o r c l a r i t y . I t would be i n t e r e s t i n g t o have s u b j e c t s d e s c r i b e a p i c t u r e which cannot 104 be seen by the examiner; i f they used fewer pronouns, t h i s would lend support t o the p r e s u p p o s i t i o n a l argument. Recovery We now address the q u e s t i o n , "What do these r e s u l t s suggest concerning long-term r e c o v e r y of l i n g u i s t i c f u n c t i o n i n g of c h i l d r e n when they a re compared t o a d u l t s having a s i m i l a r h e a d — i n j u r y ? " The t e s t r e s u l t s i n d i c a t e t h a t none of the c h l d r e n has achieved complete r e c o v e r y of language f u n c t i o n , d e s p i t e the f a c t t h a t they a re from two t o e i g h t y ears p o s t - i n j u r y . Four of the f i v e p a t i e n t s c ontinue t o r e q u i r e s p e c i a l or mod i f i e d academic placement. E4 i s a b l e t o maintain average grades i n a r e g u l a r c u r r i c u l u m but admits t h a t these are harder t o achieve than b e f o r e the a c c i d e n t . Our f i n d i n g s of incomplete r e c o v e r y f o r t h i s small group of c h i l d r e n cause us t o question the hyp o t h e s i s t h a t , the younger the c h i l d at the time of h e a d — i n j u r y , the more r a p i d and complete h i s / h e r r e c o v e r y , as suggested by Lennenberg (1967), and Seron (1979). In f a c t i t appears t h a t , f o r our f i v e s u b j e c t s , the younger they were at the time of the i n j u r y the l e s s well they have recovered. Our r e s u l t s appear t o suggest t h a t i t takes as long , i f not l o n g e r , f o r a c h i l d t o recover from a c l o s e d h e a d — i n j u r y than an a d u l t , and t h a t t h e i r r e s i d u a l d e f i c i t s may i n e f f e c t 105 be more severe(Woods and Teuber 1978, Hecaen 1983). Woods and Carey (1979) t e s t e d 27 c h i l d r e n with l e f t hemisphere i n j u r i e s on a number of r e c e p t i v e and e x p r e s s i v e language t e s t s and compared the r e s u l t s with a p p r o p r i a t e c o n t r o l s . They found t h a t c h i l d r e n i n j u r e d a f t e r one year of age s u f f e r e d a " s i g n i f i c a n t r e s i d u a l impairment" on a v a r i e t y of language t e s t s . L e v i n et a l . (1982) reviewed a l l p e r t i n e n t r e s e a r c h l i t e r a t u r e and concluded t h a t t h e r e was no support f o r the b e l i e f t h a t c h i l d r e n are spared r e s i d u a l language d e f i c i t s (of the v a r i e t y experienced by a d u l t head—injured p a t i e n t s ) a f t e r i n c u r r i n g s evere h e a d — i n j u r y . They a l s o concluded t h a t younger c h i l d r e n were a c t u a l l y more prone t o e x h i b i t r e s i d u a l language problems than o l d e r c h i l d r e n . These f i n d i n g s appear t o suggest t h a t , s i n c e younger c h i l d r e n s u f f e r g r e a t e r impairment than o l d e r c h i l d r e n , then the c e r e b r a l o r g a n i z a t i o n of language f u n c t i o n s i s in n a t e . What such language functons might be s p e c i f i c a l l y remain t o be seen. There are a number of f a c t o r s which make the i n t e r p r e t a t i o n and d e f i n i t i o n of "recovery" e s p e c i a l l y d i f f i c u l t with c h i l d r e n . F i r s t i s the developmental f a c t o r . At p r e s e n t , we are unable t o make a d e f i n i t i v e statement of when a normal c h i l d might be s a i d t o have f u l l y a c q u i r e d a language system. I t seems reasonable t o assume t h a t , i f a c h i l d has not f u l l y a c q u i r e d h i s language system at the time of i n j u r y , then 106 he/she w i l l -fare worse than a c h i l d who had a complete and f l e x i b l e system p r i o r t o the a c c i d e n t . In the l a t t e r case, i s i t a c c u r a t e t o assume t h a t we do indeed have a c h i l d , s i n c e we might reasonably suppose t h a t i n terms of language we are now o b s e r v i n g an a d u l t ? Second. at what p o i n t can we say a p a t i e n t has "recovered" and i n what sense? What b a t t e r y of t e s t s w i l l i n d i c a t e t h a t r e c o v e r y has taken p l a c e ? These que s t i o n s are d i f f i c u l t t o answer at present because a) many of the s t a n d a r d i z e d t e s t a r e too broad t o i d e n t i f y the r e s i d u a l d e f i c i t s i n q u e s t i o n , and b) the m e t a l i n g u i s t i c t a s k s t h a t can tap these d e f i c i t s a r e s t r i c t l y e x p e r i m e n t a l . I n v e s t i g a t o r s need t o d i r e c t t h e i r e f f o r t s towards a thorough i n v e s t i g a t i o n of m e t a c o g n i t i v e and m e t a l i n g u i s t i c s k i l l s , an undoubtedly p r o b l e m a t i c area f o r h e a d - i n j u r e d p a t i e n t s , as a number of r e s e a r c h e r s have a l r e a d y shown (Thomsen 1977, Grober 1984). Fu r t h e r evidence which q u e s t i o n s the h y p o t h e s i s t h a t c h i l d r e n r e c o v e r more f u l l y than a d u l t s i s provided by Hecaen (1983). He reviewed h i s p r e v i o u s r e s e a r c h i n a d d i t i o n t o h i s subsequent s t u d i e s on h e a d - i n j u r y and r e p o r t e d : We found a g r e a t e r frequency of language d i s o r d e r s i n the c h i l d r e n with l e f t - s i d e d l e s i o n than i n a d u l t s , t h i s tendency became even g r e a t e r f o r the group of c h i l d r e n under 10 yr of age.(The d i f f e r e n c e s do not reach a l e v e l of s t a t i s t i c a l s i g n i f i c a n c e because of the small number of c h i l d r e n , but the d i r e c t i o n of the tendency i s c l e a r . ) These f i n d i n g s suggest the p o s s i b i l i t y of a l e s s e r degree of f o c a l i z a t i o n of the anatomic s u b s t r a t e f o r the 107 r e p r e s e n t a t i o n o-f language i n the le-ft hemisphere i n the e a r l i e s t years o-f l i f e . ( p. 586 ) If t h i s i s t r u e i t c o u l d account f o r the f a c t t h a t r e s e a r c h e r s / c l i n i c i a n s r a r e l y c l a s s i f y head—injured c h i l d r e n a c c o r d i n g t o aphasic terminology. If the b r a i n i s l e s s " f o c a l i z e d " f o r language i n the e a r l y years then c h i l d r e n would not f i t n e a t l y i n t o the l o c a l i z a t i o n c a t e g o r i e s used i n a p h a s i o l o g y , the v a l i d i t y of which has r e c e n t l y been questioned by Caplan (1986). I t may well be the case t h a t the language t a s k s which have been used t o t e s t l i n g u i s t i c impairment are simply too g r o s s t o uncover the commona1ites of language d e f i c i t , r e g a r d l e s s of age of the p a t i e n t . Present f i n d i n g s would appear t o suggest t h a t the younger the c h i l d at the time of the i n j u r y , the l e s s chance t h e r e i s f o r f u l l r e c o v e r y . T h i s may be because t h e r e are c e r t a i n language f u n c t i o n s which had not been ac q u i r e d p r i o r t o the a c c i d e n t , and which, because of the d i s t u r b a n c e caused by the a c c i d e n t , can no longer be a c q u i r e d . Hence, the c h i l d can o n l y recover up t o t h a t stage of a c q u i s i t i o n a v a i l a b l e p r i o r t o the a c c i d e n t but i s unable t o go beyond t h i s . Such an e x p l a n a t i o n c a l l s i n t o q u e s t i o n the h y p o t h e s i s t h a t c h i l d r e n have e q u i p o t e n t i a l hemispheric o r g a n i z a t i o n of language du r i n g the e a r l y y e a r s . Rather, i t lends support t o the h y p o t h e s i s t h a t t h e r e i s an i n n a t e and e a r l y s p e c i a l i z a t i o n of language w i t h i n the l e f t hemisphere. However, i t may be t h a t the development of language r u l e s i s o c c u r r i n g a c r o s s at 108 l e a s t the f i r s t e i g h t years. T h i s then l e a v e s the young c h i l d v u l n e r a b l e t o more e x t e n s i v e impairment of language f u n c t i o n i f the h e a d - i n j u r y o c c u r s e a r l y i n l i f e , s i n c e we might assume t h a t such r u l e s are m u l t i p l i c a t i v e . Word-finding D i f f i c u l t i e s In an attempt t o e x p l a i n at what p o i n t i n the word—finding p r o c e s s breakdown o c c u r s , a modified v e r s i o n of a t h r e e step word-finding model p o s i t e d by Wolf (1980) i s presented i n F i g u r e 9-2. I t i s by no means complete, s i n c e we are unsure about the o r g a n i z a t i o n of the l e x i c o n w i t h i n each stage. D e s p i t e i t s l i m i t a t i o n s i t appears t o be one of the more l o g i c a l and e m p i r i c a l l y motivated models a v a i l a b l e f o r t h i s d i s c u s s i o n . The input s t i m u l u s can be e i t h e r t a c t i l e , v i s u a l or a u d i t o r y / l i n g u i s t i c . It i s neccessary t o note t h a t although a word may be w i t h i n a speaker's l e x i c o n i t i s not e q u a l l y a c c e s s i b l e through a l l m o d a l i t i e s ; t h a t i s one modality may have a s t r o n g e r " l i n k " with the r e t r i e v a l p r o c e s s . The " s t r e n g t h " of these l i n k s may be a f f e c t e d by age, b r a i n damage, or experience. T h i s i s t r u e of normal (Wiegel-Crump and Dennis 1986, Denckla, Rudel, Broman, and H i r s c h 1980) and b r a i n — i n j u r e d s u b j e c t s (Barton et a l . 1967). A d d i t i o n a l l y , w i t h i n the l i n g u i s t i c m odality t h e r e i s a h i e r a r c h y of d i f f i c u l t y f o r the s t i m u l u s c o n d i t i o n s used t o e l i c i t the word (Denckla, Rudel, Broman, and H i r s c h 1980). 109 FIGURE 9-2s WORD-FINDING MODEL INFUT; TACTILE VISUAL AUDITORY (1 i n g u i s t i c ) STEP 1: RECC GNITION/SE MANTIC AROU -i SAL STEP 2: RET RIEVAL r OF "WO RD" STEP 3: GRAPHEMI C RULES PHON f OLOG ICAL RULES \ OUTPUT; GESTURE WRITTEN ORAL <after Wolf 1980) 110 In t h i s model, the word—finding process roughly i n v o l v e s t h r e e s t e p s . F i r s t . the input s t i m u l a t i o n evokes a r e c o g n i t i o n and semantic a r o u s a l l i n k e d with the s t i m u l u s . A breakdown at t h i s p o i n t may manifest i t s e l f as a neologism. Such neologisms are f r e q u e n t l y found i n the speech of many head- i n j u r e d p a t i e n t s . It may a l s o be t h a t at t h i s p o i n t t h e r e i s a d i r e c t r o u t e from the r e c o g n i t i o n of the in p u t t o g e s t u r a l output. T h i s might account f o r the a b i l i t y of some p a t i e n t s t o g e s t u r e , w h i l s t unable t o v o c a l i z e the a p p r o p r i a t e word. If a p a t i e n t i s unable t o advance t o the second step of the word—finding p r o c e s s , then he/she may be a b l e t o by—pass s t e p s two and t h r e e and d i r e c t l y generate output i n a g e s t u r a l form. For those p a t i e n t s who f i n d g e s t u r e a f a c i l i t a t o r f o r the word—finding p r o c e s s , i t may be t h a t g e s t u r e i s enough t o r e t r o a c t i v e l y s t i m u l a t e r e c o g n i t i o n so that the remaining s t e p s of the word-finding process are a c c e s s i b l e . If a speaker s u c c e s s f u l l y completes the f i r s t s t e p , he/she would then proceed t o r e t r i e v e the s t o r e d "word" i n some raw phonemic form. T h i s stage of the process may be impaired due t o d i s r u p t e d access t o , or d i s o r g a n i z a t i o n o f , the l e x i c o n . T h i s impairment may manifest i t s e l f i n semantic paraphasias. Once step two i s complete the next step i s t o convert the "word" i n t o an a p p r o p r i a t e output which can take a v a r i e t y of forms, i . e . g e s t u r a l , w r i t t e n , or spoken form. I l l If the output i s t o be spoken, then the t h i r d s t e p i n v o l v e s a p p l y i n g p h o n o l o g i c a l and a r t i c u l a t o r y - m o t o r r u l e s of the language t o tr a n s f o r m the word i n t o i t s spoken form. If output i s t o be w r i t t e n , then the graphemic and d i g i t a l — manipulatory motor commands are a p p l i e d t o convert the word t o i t s w r i t t e n form. As with input m o d a l i t i e s , output m o d a l i t i e s may be d i f f e r e n t i a l l y a f f e c t e d due t o brain-damage or l a c k of experie n c e (e.g. l i t e r a c y s k i l l s ) . For a l l f i v e s u b j e c t s , i t appeared t h a t the word—finding p r o c e s s breaks down at the p o i n t where the semantic component of the word i s coded i n t o i t s p h o n e t i c component. T h i s appears t o be the case because when the Experimentals were e x p e r i e n c i n g word—finding d i f f i c u l t i e s they d i d not u s u a l l y b e n e f i t from a semantic cue. When provided with the semantic cue, they u s u a l l y responded© "I know t h a t , I j u s t can't t h i n k of the word." It was a l s o q u i t e common f o r an Experimental s u b j e c t t o p r o v i d e h i m s e l f with a semantic cue, i n an e f f o r t t o r e t r i e v e the word. An example of t h i s o c c u r r e d with E3. He was asked t o name a p i c t u r e of a t r i p o d and immediately responded: "A high p l a c e t o put a camera on". When an Experimental was pro v i d e d with the phonemic cue, the t a r g e t word was almost i n s t a n t a n e o u s l y produced. It would appear t h a t the naming pr o c e s s breaks down at th a t l e v e l where meaning i s converted t o phonetic output by a s e r i e s of motor commands. There would appear t o be a gap 112 between the semantic and phonemic systems t h a t i s somehow br i d g e d by the phonemic cue. T h i s i s well captured by a d e s c r i p t i o n of word-finding d i f f i c u l t i e s g iven by W i l l i a m James (1893)s Suppose we t r y t o r e c a l l a f o r g o t t e n name. The s t a t e of our consciousness i s p e c u l i a r . There i s a gap t h e r e i n , but no mere gap. I t i s a gap t h a t i s i n t e n s e l y a c t i v e . A s o r t of wra i t h of the name t h a t i s i n i t ; beckoning us i n a giv e n d i r e c t i o n , making us at moments t i n g l e with a sense of c l o s e n e s s and then l e t t i n g us si n k back without the longed f o r term. If wrong names are proposed t o us, t h i s s i n g u l a r l y d e f i n i t e gap a c t s immediately so as t o negate them. They do not f i t i n t o the mould and the gap of one word does not f e e l l i k e the gap of another, a l l empty of content as both seem n e c e s s a r i l y , when d e s c r i b e d as gaps.(p.647) Word-finding might be viewed as analogous t o f i t t i n g a semantic key i n t o a phonemic l o c k . One key does not f i t s e v e r a l l o c k s and some l o c k s a re immovable due t o damage or la c k of use. The phonemic cue c o u l d be m e t a p h o r i c a l l y the o i l t h a t h e l p s ease the lock open. Some l o c k s w i l l need more o i l than o t h e r s and some may be permanently broken. L i m i t a t i o n s and Problems When st u d y i n g the hea d - i n j u r e d c h i l d t h e r e e x i s t s a confounding v a r i a b l e t h a t i s not u s u a l l y a s s o c i a t e d with the hea d - i n j u r e d a d u l t . T h i s v a r i a b l e i s age. Due t o the emergent nature of the e n t i r e language system, c h i l d r e n of d i f f e r e n t ages may be viewed as working with c o n s i d e r a b l y d i f f e r e n t language systems. A d u l t s , on the other hand, can be 113 assumed t o be working with a completely developed language system. T h i s age v a r i a b l e e f f e c t s r e c o v e r y , therapy, and r e s e a r c h r e s u l t s and makes the i n t e r p r e t a t i v e comparisons with h e a d — i n j u r e d a d u l t s of q u e s t i o n a b l e v a l i d i t y . S i n c e the word-finding process has been demonstrated t o bi a developmental language s k i l l , the age and hence l e v e l of language development at the time of the i n j u r y w i l l n e c e s s a r i l y a f f e c t the u l t i m a t e r e c o v e r y of language s k i l l s , and have c o n s i d e r a b l e b e a r i n g on the i n t e r p r e t a t i o n of r e s e a r c h f i n d i n g s . Wiegel—Crump and Dennis (1986) s t u d i e d development of the word f i n d i n g p r o c e s s i n 50 normal c h i l d e r e n age 6;0 —14:0. They found t h a t as c h i l d r e n grow o l d e r , t h e i r naming accurac i n c r e a s e s w h i l e response l a t e n c y decreases. They a l s o found t h a t the types of e r r o r s t h a t c h i l d r e n made changed over time. The c h i l d r e n ' s e r r o r s were u s u a l l y semantic paraphasias. However, Wiegel—Crump and Dennis s t a t e d : The o l d e r the c h i l d , the c l o s e r was the e r r o r t o the t a r g e t and i n the o l d e s t c h i l d r e n , the e r r o r and t a r g e t r e p r e s e n t e d a minimal c o n t r a s t i v e s e t . ( p . l ) Another of t h e i r f i n d i n g s concerned the d i f f e r e n t i a l e f f e c t of the naming c o n d i t i o n on accuracy. In t h e i r experiment they used t h r e e d i f f e r e n t naming c o n d i t o n s : 1) v i s u a l c o n f r o n t a t i o n naming, 2) naming t o d e f i n i t i o n , 3) naming t o a rhyming word. Using these c o n d i t i o n s they found t h a t naming r e s u l t s f o r the f i r s t two c o n d i t i o n s i n c r e a s e with age, p l a t e a u i n g at age 10. The t h i r d c o n d i t i o n 114 rhyming, c o n t i n u e s t o improve with age. Denckla, Rudel, Broman, and H i r s c h (1980) a l s o -found a developmental d i f f e r e n c e i n word f i n d i n g a b i l i t y as a f u n c t i o n of s t i m u l u s context. T h e i r experiment used t h r e e c o n d i t i o n s : 1) v i s u a l c o n f r o n t a t i o n naming, 2), naming t o d e f i n i t i o n , and 3) sentence completion. T h e i r r e s u l t s showed t h a t f o r c h i l d r e n 6;0-10;0 sentence completion was e a s i e s t , f o l l o w e d by v i s u a l c o n f r o n t a t i o n , with naming t o a d e f i n i t i o n being the most d i f f i c u l t . T h i s h i e r a r c h y of naming c o n d i t i o n s has a l s o been demonstrated with a d u l t a p h a s i c s (Barton et a l . 1967). For c h i l d r e n over 10;0 naming accuracy was not a f f e c t e d by s t i m u l u s c o n d i t i o n . These f i n d i n g s , i n combination with the nonparametric s t a t i s t i c used f o r our a n a l y s i s , a f f e c t at l e a s t two of the v a r i a b l e s under i n v e s t i g a t i o n i n t h i s study. The f i r s t v a r i a b l e a f f e c t e d i s response l a t e n c y . Response l a t e n c y alone should have been s u f f i c i e n t t o d i f f e r e n t i a t e between Experimental and C o n t r o l groups. However, t h i s was not the case. As p r e v i o u s l y mentioned, response l a t e n c y decreases as a c h i l d g e t s older.•The ages of our c h i l d r e n range from 10;0—16;0. T h e r e f o r e , the response l a t e n c i e s a p p r o p r i a t e f o r t h e i r age should a l s o d i f f e r . S i n c e the s t a t i s t i c a l t e s t used f o r our experiment r e l i e s on rank o r d e r i n g of l a t e n c i e s , when the v a r y i n g C o n t r o l group s c o r e s are combined with the v a r y i n g Experimental Group s c o r e s i t would appear t h a t the response l a t e n c y w i l l not be a s i g n i f i c a n t d i f f e r e n t i a t i n g f a c t o r because of the developmental nature of t h i s v a r i a b l e . The response l a t e n c y alone would probably d i f f e r e n t i a t e a head-injured c h i l d from a normal c h i l d i f a l l s u b j e c t s i n both groups were the same age. T h i s problem i s not encountered i n a sample of a d u l t h e a d - i n j u r e d p a t i e n t s s i n c e i t i s s a f e t o assume t h a t , by adultood , response l a t e n c y f o r naming has reached asymptotic l e v e l s . Summary and C l i n i c a l I m p l i c a t i o n s Given the r e s u l t s of t h i s study, an attempt w i l l be made t o r e l a t e our f i n d i n g s t o the c l i n i c a l s e t t i n g . Our i n v e s t i g a t i o n of the e f f e c t of the p i c t u r e s t i m u l u s on naming accuracy i n d i c a t e s t h a t c o l o u r photographs are e a s i e r t o name than l i n e drawings. T h e r e f o r e , when working with a head-i n j u r e d p a t i e n t s , the next step a f t e r a c h i e v i n g a hig h l e v e l of naming accuracy of photographs would t o be t o pro g r e s s t o l i n e drawings. We a l s o need t o c o n s i d e r s t i m u l u s c o n d i t i o n s when we plan a h i e r a r c h y of t a s k s f o r therapy. For b r a i n -damaged p a t i e n t s and normal c h i l d r e n under 10s0, v i s u a l c o n f r o n t a t i o n naming and sentence completion t a s k s a re e a s i e r than naming t o a d e f i n i t i o n . Keeping the d i f f i c u l t y of the task and the frequency of occurrence of the t a r g e t word i n mind, we should be a b l e t o implement a s u c c e s s i o n of i n c r e a s i n g l y d i f f i c u l t therapy t a s k s t o s t i m u l a t e the p a t i e n t ' s r e c o v e r y . A d d i t i o n a l l y we need t o keep i n mind t h a t p h o n o l o g i c a l cues are more s u c c e s s f u l i n a i d i n g word—finding d i f f i c u l t i e s than semantic cues. T h i s i s a l s o t r u e of normal c h i l d r e n . We have a l s o shown t h a t m e t a l i n g u i s t i c t a s k , e.g. antonyms, homonyms, e t c . , are a robust area of d e f i c i t f o r these c h i l d r e n as a r e s u l t of the h e a d - i n j u r y . F u t u r e r e s e a r c h i s needed t o i n v e s t i g a t e , i n d e t a i l , the r e l a t i v e d i f f i c u l t y and developmental course of these v a r i o u s m e t a l i n g u i s t i c s k i l l s t o a i d the t h e r a p i s t i n p l a n n i n g e m p i r i c a l l y motivated therapy. E x s p o s i t o r y speech i n the h e a d - i n j u r e d c h i l d i s s i m i l a r t o the speech of a h e a d - i n j u r e d a d u l t . There appears t o be an o v e r a l l s i m p l i f i c a t i o n of language t h a t i s r e f l e c t e d i n the reduced MLU and s y n t a c t i c complexity of t h e i r e x p r e s s i v e language, when t h i s i s compared with the language of normal s u b j e c t s . Head—injured p a t i e n t s a l s o use more pauses i n t h e i r e x p r e s s i v e language than do normal s u b j e c t s . These pauses have been i n t e r p r e t e d t o i n d i c a t e word—finding d i f f i c u l t i e s (Butterworth 1979). The most important c o n c l u s i o n t o be drawn from t h i s study i s t h a t i t i s necessary t o t e s t word-finding under a v a r i e t y of c o n d i t i o n s , with a number of d i f f e r e n t t a s k s , i n order t o d e t e c t r e s i d u a l word-finding d e f i c i t s . I t i s q u i t e common f o r a p a t i e n t t o perform w i t h i n the normal range on a standard naming t e s t e.g. Boston Naming T e s t , yet s t i l l p resent with a 117 naming d e f i c i t i n c o n v e r s a t i o n a l speech t h a t may be s u b t l y d i s g u i s e d as longer than normal h e s i t a t i o n s . I t i s important t o a s s e s s the head—injured p a t i e n t under as many c o n d i t i o n s as p o s s i b l e t o e s t a b l i s h the boundaries of t h e i r 1 i n g u i s t i c / m e t a l i n g u i s t i c d e f i c i t . Most p r e v i o u s r e s e a r c h on h e a d - i n j u r y has f a i l e d i n t h i s r e s p e c t because the measures used have been too broad t o q u a n t i f y the r e s i d u a l language d e f i c i t s . Sarno (1981) questioned t h i s p r a c t i c e s The boundaries which u s u a l l y help i d e n t i f y and c l a s s i f y p a t i e n t s with l i n g u i s t i c d e f i c i t s a f t e r b r a i n damage do not seem t o h o l d t o the same degree f o r the head trauma p a t i e n t as they do i n the s t r o k e p o p u l a t i o n . <p. 629) Sarno f e l t t h a t i t would be more u s e f u l t o f o c u s on the q u a l i t a t i v e r a t h e r than q u a n t i t a t i v e s c o r e d i f f e r e n c e s i n order t o d i s t i n g u i s h the ve r b a l impairment of the head-i n j u r e d p a t i e n t from other p a t i e n t s e x h i b i t i n g a v e r b a l d e f i c i t . 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Children's Language, V o l . 3. New York: Gardener Press. Woods, B., and Carey, S. 1979. Language d e f i c i t s a f t e r apparent c l i n i c a l r e c o v e r y from c h i l d h o o d aphasia. Annals of Neurology, 6, 405-409. Woods, B., and Teuber, H.L. 1978. Changing p a t t e r n s of ch i l d h o o d aphasia. Annals o-f Neurology, 3 , 273—280. 123 APPENDIX 1 (Examiner's speech i s i n i t a l i c print. P a t i e n t ' s speech i s i n bold p r i n t . Three dots i n d i c a t e s a pause i n the p a t i e n t ' s speech but i n d i c a t e s the omission of unecessary wording i n the examiner's speech.) P a t i e n t 1; T r a n s c r i p t of Standardized T e s t i n g tell me a word that means the same ... if I said small you could say l i t t l e oh ... the same something that means the same ... same as "chef" cook ... repair umm ... that's a good one ... repair huh . . . f i x .- - bashful shy donate give enormous large imaginary f i c t i o n a l locate mmm ... locate ... umm f i n d remain stay 124 journey travel assist help bever age softdrink that's your -favourite kind? Umm 7-up mixed with Sprite mixed with Gingerale ... sounds grim It's lovely ...same as quarrel •fight ... humourous very large very large...ok vacant vacant ... mmm ... uh... oh... hmmp ... open space I guess ...col 1ide crash abandon 1 eave Do you -find that hard? No ...only some of them ...you did fine ...That was good ...O.K. They don't make any sense whatsoever They don't make any sense? some of the words yah 125 Do you -find some of the words just don't mean anything to you? Yah, that's b a s i c a l l y i t Hmmm They never did ... Have you heard them before? Oh yah i t ' s very hard to imagine them though Ohf hard to imagine them So I never pay any attention to them This time, instead of giving me something that means the same opposites Right, opposites. I'm very good at that Oh you are ... If I said big you'd say? smal 1 right ... strong weak question answer pull push sharp d u l l entrance entrance mmmm... what's the opposite of entrance ?...exit innocent 126 g u i l t y succeed b a n k r u p t bankrupt.....O.K. cheap expensive distant close narrow wide lead lead? lead, the opposite o-f lead? As in the f i r s t person leading the w a y ? Uh ...What's the guy at the back called? ...I don't know back-up or something ... dangerous safe opposite of dry wet sorry ...the opposite of moist dry I gave it away there ...reckless. safe (introduction to d e f i n i t i o n subtest)... t e l l me what the word means Oh come on t h i s i s l i k e school Nell some of it is ....tell me what dog means, you could say 127 Its a -Four legged mutt! or a four legged animal ... animal that has hair and i t barks. Tell me what disturb means to d i s t r a c t someone from or something from i t s present occupation or something l i k e that ... famous Uh someone who has been p u b l i c l y known and i s world uh world uh wo .. world wide household name at times. ... stadium ... a place where games of uh physical or non-physical sports are played . . . curious a person or a thing who has an interest i n something but they don't know what i t i s they want to f i n d out more ... elevator a uh place where you lose your stomach half the time HON about seriously? that's i t that's a l l you can t e l l me about i t ? well i t does go up and down anything else? i t ' s compact um small ... bad a i r ... unaware means Uh a person or thing not uh r e a l i z i n g something i s something i s happening around him or i t ... struggle means a c o n f l i c t between two or more persons or things ... ai r c o n d i t i o n e r . . . a great place to be in front of during the summer 128 Wow about seriously? umm something that provides cool a i r thats i t flashlight umm a portable l i g h t uh to use i n the dark . . . invent to create something new, d i f f e r e n t and uh possibly ex c i t i n g ... eager ... The opposite of me! Umm O . K . eager huh. Umm someone with alot of ambitions, energy just waiting to be shot out of him. ... advance umm to uh go for t h uh to explore f i n d out d i f f e r e n t things, new things. ... pure umm no substitutes, no preservatives, uhmm hasn't been frozen or anything l i k e that Uhmm has a l l the natural q u a l i t i e s that i t i s sposed to have ... predict ... umm to take a uh so c a l l e d mental guess at what w i l l happen i n the future Do you do alot of these at school? no ... your'e really good at it No, I'm just bored, I'm tryin g to get t h i s over with ...(introduction to multiple meanings subtest ) ... block a block eh ... uh ...a small uh piece of wood another meaning ... someone preventing you to going ... to go forward t h e i r blocking you 129 ... duck a animal ... a bi r d I should say ... another meaning ... to watch i t ... uh to -flatten yourself i f something very fa s t i s coming towards you rock music! ... another meaning... umm a material ... a s o l i d material, a stone ... pound a pound mmm a weight uh of something another meaning ... umm ...mmm ... what you do to beef to get veal beef t o get veal beef? yah! To get veal beef you got to pound i t (gestured pounding) s p l i t i t apart Mhat's that (gesture) called? I don't know I never do i t hitting? You could say that but with a mallet I don't know ... train a t r a i n ? i t i s where you teach someone something ... another meaning ... a locomotive ... iron Iron? It's a metal... the opposite of steel or c l o s e l y r e l a t e at least 130 . another meaning -for it Iron? mmm that's good ... ummm ... there's another meaning •for iron ... oh yah vitamins, c e r t a i n vitamins . . . bark Oh what a dog does at times another meaning i t comes off trees ...tip a t i p ? uh ... uh ... some advice you uh give to another person ... another meaning the end of something ... yard umm eh uh distance ... measurement in distance another meaning yard, yard, yard, a a place of area or a small a small uh area l i k e a back yard or something l i k e that ... change What you get back after you paid ...tell me more you put i n f i v e bucks for something thats three nine nine ... l e t me make sure that's r i g h t (started to ca l c u l a t e in the air) you should get .80$ back, that's change ... another meaning ummm ... to transform into something d i f f e r e n t ... chest a chest ... uh that's a part of the body below the head and above the gut ... another meaning a very good game o-f strategy -file a f i l e ? a place where you can put papers, a book, whatever into i t . . „ another meaning ... uh something you use to uh on wood or steel note a note i s a uh l i t t l e l e t t e r passed back and fo r t h i n clas s at times ... another ...meaning to take down things off a board tell me more about that sure! Social studies, Science, Biology, English,... what else ? Math felt f e l t oh to touch something ...another meaning ... a cert a i n type of pen with a very soft end ... uh .. a coloured pen. Are we finished? ...some more to do I'm stuck -„. quick a we can It doesn't bother me that much good I'm just getting bored just got here That's the idea ... say what I say 132 as good as I p o s s i b l y can ... You know how You know how The vat leaks The vat l e a k s Down to earth Down t o e a r t h limes are sour l i m e s are sour ... who s a i d ! I got home from work I got home from work The spy fled to Greece The spy f l e d t o uh Greece You should not tell her You should not t e l l her P r y the tin lid off Pry the t i n l i d o f f Go ahead and do it if possible Go ahead and do i t i f p o s s i b l e The Chinese fan had a rare emerald The Chinese f a n had a r a r e /em^ral/ Near the table in the dining room Near the t a b l e on Yech! Near the t a b l e on the d i n i n g room (He knew he had made a mistake and t r i e d t o c o r r e c t i t made an e r r o r , a g a i n , r e a l i z e d i t but d i d n ' t t r y t o c o r r e c t i t a second time ) The barn swallow captured plump worm 133 The barn swallow captured a plump worm They heard him speak on the radio last night They heard him speak on the radio l a s t night The lawyers closing argument convinced him The lawyers closing argument convinced him I stopped at his front door and rang the bell I stopped at h i s -front door and rang the b e l l The phantom soared across the foggy heath The phantom soared across the -foggy heath Anything special you do for those? ... Are they difficult at all? No they just got longer, and longer, and longer Mhat did you do when they got longer? nothing You didn't do anything special ? (he appeared to be having trouble so I was probing -for any strategies he might have been using) Not at a l l ... tell me the answer... Mhat do we tell time with? a clock, a watch, or anything e l s e Mhat do you do with a razor? You can cut things b a s i c a l l y , your ... uh...uh mustache or whatever Mhat do you do with soap ? You wash yourself Mhat do you do with a pencil? You write things Mhat do we cut paper with? 134 s c i ssors What colour is grass? green What do we light a cigarette with? A match Hon many things in a dozen? 12 Hhat colour is coal? Black Uhere do we go to buy medicine? Pharmasave ... name as many animals as you can ....you could start with dog cat, mouse, r a t , hamster, -flea, spider, scorpion, snake, cobra, Lets see what else we got here, we're missing something... Oh Yah ! tarantula, black widow uhmm one o-f them regular household snakes, python, uhh I already said hamster, What els e we got? OH! falcon, eagle, uh bluejay, robin, uh blackbird, There's got to be something else here ... I'm missing one... badger, cougar, l i o n , manx ... I said cat That's fine ... I'll show you a picture and you tell me the name o f i t O.K. that's a bed and underneath that's a tree (he could see through the top picture to the one underneath. He was directed just to name the top picture. Testing continued.) penci1 house Oh t h i s one's going to be tough ... whistle s c i s s o r s comb f1ower 135 saw toothbrush chopper Give me the f u l l name chopp ... uh helicopter broom octopus that's mushroom coathanger wheelchair camel face another name for that? mask pretzel bench racquet ... tennis racquet snai 1 volcano seahorse d a r t canoe glo ... Uh ... globe wreath beaver harmonica 136 acorn igloo s t i l t s dominoes cactus uh ... escalators harp uh ... What are those things c a l l e d ? ... hammocks door ... uh .. doorknocker pelican stethoscope pyramid muzzle unicorn Oh what are those things c a l l e d again? I don't know you, pour things through i t MUM Hmm it's a / f d / / f u z z e l / a funnel Geeze I hate these di-f-ferent instruments that don't deal with rock. What i s t h i s ? That could be used in rock. I'll tell you Mho after you tell me the name of it. I don't believe i t ! tihats that called? harmonica? WO, I'll 137 organ! No, I ' l l give you a hint It's close! It's an /BV-k/ academic? /•31kor/ acornea? accordian, Mhat about "tieird Al Yankovik"? I never l i s t e n to him! I don't either but he uses an accordian hangman's lynch Tell we another name for that Yah, knots, rope ...another name rope another name? uh I t ' s a /nu/ New Hampshire! No I t ' s a /nu/ new, new, new, It's a new name -for me! Uhmm ... new, new, new ... Noose. Does that sound fami1iar? Uhmm sort o-f an old mistake branch Actually, i t ' s not. Look again 138 O.K. P r i c k l e s ! No ... weed I t ' s something you eat I've never eaten that! I ' l l give you a hint. I t ' s /ans/ asparagus compass lock tripod scrol 1 icepickers another name -for it claws ... I ' l l give you a hintf /ta/ Tomahawks No, They're tongs Tongs, sounds l i k e Chinese Sphinx, one of the wonders of the world yoke Something weeds grow on Uhat's it called? I don't know. It's made of wood, n a i l s ... I t ' s a / t r Z l / t r e l l a t r e l l i s 139 Never heard of him p a i n t The thing the paints are on? Mmm Oh boy... p a i n t b r u s h e s , p a i n t , and t h i n g t h a t h o l d s p a i n t . . . t h a t ' s d i f f e r e n t that's the thing that holds the paint called? Hmm ... don't know not i n t o a r t . . . i t ' s a /pal/ palama ... a palette How I hate how people come up with a l l these b i g words Nhafs that? Oh ... umm ... Uh ... what was t h a t ? I saw i t today... I kicke d i t . . . No i t can't be t h a t . . . not compass... O . K . i t ' s a h a l f c i r c l e , I know t h a t ... I t ' s used -for measuring angles Yah ... Oh! what i s t h a t word?! Word, word,word, I need t o know the word... t h e r e ' s a cou n t i n g board under t h a t ( r e f e r r i n g t o the abacus i n the next p i c t u r e ) I t ' s a /pro/ p r o t r a c t e r ! l i k e I s a i d , a counting board Uhat's that? something t h a t you count on Oh/ that's what your c a l l i n g the counting board. There's another name for i t ... T i c Tac Toe ? Nof the Chinese used i t to count with 140 Oh! i t ' s the weirdest Chinese checkerboard I've ever seen! It's an /aLb/ As.btu/? an abacus 141 P a t i e n t 2: T r a n s c r i p t o-f Standardized T e s t i n g ( I n t r o d u c t i o n t o synoynm s u b t e s t of Word Test) ...give we a fiord that means the same a 'chef' worker ... - repair that's another word that means the same as 'repair'? make bashful harmful ... donate g i v e enormous l a r g e . imaginary Hhat's a word that means the same as imaginary? No (meaning he co u l d n ' t t h i n k of one) i ( I n t r o d u c t i o n t o antonym s u b t e s ) , . . big ... t i n y strong weak question answer pull 142 did you say h a l l ? Nof ... Nhat's the opposite of pull? reach sharp Nhat ' s the opposite of 'sharp'? round . ... entrance? m m m . . . en trance? m m m Can you think of it? No. ( i n t r o d u c t i o n t o d e f i n i t i o n s u b t e s t ) . , , Nhat does 'disturb' mean? disturb? Mmmm Mmmm Nhat does disturb mean? to d i s t r a c t Can you tell me anything more? take away the time take away the time? ya Nhat does famous mean? famous? Umm Mmmm It means 143 'famous' nhat does it mean? the greatest ... anything else? No ..- Hhat's a stadium? a stadium i s l i k e the gym . . . . anything else? Inside the stadium your voice echoes ( i n t r o d u c t i o n t o m u l t i p l e meanings subtest) Hhat's a block? piece of wood anything else? a block ... Hhat's another meaning for block? Can you think of one? No ... duck animal that swims i n the water and another meaning i s you duck your head (he gestured the action) . . . . rock rock Hhat's rock? a big hard stone ..- another meaning ... the piece of wood that's hard the piece of mood that's hard 144 the p i e c e o-f wood t h a t ' s rock hard ( i n t r o d u c t i o n t o Boston naming t e s t ) bed t r e e p e n c i l house w h i s t l e s c i s s o r s comb f 1 ower saw toothbrush h e l i c o p t e r No you use it for cleaning a • • • It's a /brW/ broom shrimp ( p i c t u r e of Octopus) Hmmm ( i n d i c a t i n g I d i d n ' t hear him) crab Wo .... it 's an /akt/ o s t r i c h Wo ... octopus mushroom hanger 145 wheelchair camel mask • • • * ... it's something to eat • • • a it's a /prZ/ pretzel pretzel Have you heard of that before'? Yaaa Vou just couldn't think of the name Yaaa bench bat its a /raUc/ mmmm raquet Oh yaa sn a i l volcano It's an ocean animal .,, It's a sea 146 sea-f i sh sea-fish ... seahorse. Have you heard o-f that be-fore? Yaa • * • You throw it No - - . it's a /dar/ m m m dart Oh yaa . -. heard o-f those be-fore? Yaa boat ... there's another name -for it ... it's a special kind of boat. Its a /ks/ m m m m canoe Oh yaa You knew what it was but you couldn't get the name right Yaa globe wreath woodchuck 147 ...... name o-f it beaver harmonica rhinoceros peanut it's a special kind o-f nut chestnut ... it's an /e/ acorn a house .. - it's a special kind o-f house... igloo s t i l t s blocks ... a game a • • a they're /da/ dominoes i t grows in a hot place (picture of a cactus) ... can you give me it's name? No It's a /kcSL/ cactus Oh yaa elevator 148 ,.. You go up on it e s c a l a t o r harp a • • • You l i e on it ( p i c t u r e of a hammock) a bed it's a //>ae-/ /hae/, /ha«7, /hat/ hammock Oh yaa • • • • i r ' s o n r/»e door i t l o o k s l i k e a b e l l , it's a door /na/ door knocker flamingo ( p i c t u r e of p e l i c a n ) ... another kind of bird goose It's a /pel/ No ... pelican C p i c t u r e of stethoscope. P a t i e n t 2 stuck h i s f i n g e r s i n h i s ears) used by doctors No - . . it's a /st£./ 149 stethoscope roof Hmmm'? roof ( p i c t u r e of pyramid) it's found in Egypt house ... I'll give you a hint ( a house made of sand it's a /plr/ pyramid Oh yaa It's not a dog ( p i c t u r e of muzzle on dog) - - - - on the dog it's a /m^/ muzzle horse ( p i c t u r e of a unicorn) it's a special kind of horse a trained horse it's a mythical animal . pegasus .., it's a /yu/ fyunl/ ...... unicorn 150 a strainer it's used for pouring • • » a it's a /f^/ •funnel harmonica ....it's a musical instrument harp it's an /ae-k/ accordian rope rope .... special kind ..... used -for hanging i t ' s a hangrope ... it's a /nu/ No No noose Oh it's something to eat •food it's /As/ asparagus. Nave you ever had asparagus? 151 Yes pencil holder ... it's for draining it's a /ka/ .... a /ksm/ compass lock .....another name -for it No . . . a latch high place where you put a camera ... special name for it? No a /trai/ tripod s c r o l l . paper ......... used to pick up ice called /ta/ ... tongs a goddess it's found in Egypt it's called the /sfl/ 152 sphynx •h ( i n r e c o g n i t i o n ) harness .... special kind .... used on farm animals • a • • it's a /yo/ yo yoke..... a vine what's the vine growing on ladder it's a /tr&l/ / t r e l / t r e l l i s •h ( i n r e c o g n i t i o n ) paints ... what are the paints on? artists use it its a /pal/ pal a palette it's used to measure angles 153 to show how hot things are ..„ i t ' s used to measure angles Oh ... i t ' s a /pro/ Oh ..pro... protracter Oh • • • • i t ' s used -for counting number1ine i t ' s an /&./ adjective ... abacus ( i n t r o d u c t i o n t o BDAE sentence r e p e t i t i o n ) You know how You know how The vat leaks The vat leaks down to earth down to earth limes are sour 1 i mes are sour I got home -from work I got home from work The spy fled to Greece The spy f l e d to Greece 154 You should not tell her You should not t e l l her Pry the tin lid off Pry the t i n l i d off Go ahead and do it if possible Go ahead and do i t i f possible The Chinese fan had arare emerald The Chinese f l a n had a rare emerald Near the table in the dining room Near the table i n the dining room The barn swallow captured the plump worm The barn swallow captured the plump worm They heard him speak on the radio last night They heard him speak on he radio l a s t night The lawyers closing argument conv inced him The lawyers again The lawyers closing ar gument conv inced him The lawyers clo s i n g argument convinced him I stopped at his front door and rang the bell I stopped at h i s front door and rang the b e l l The phantom soared across the foggy heath The phantom soared across the heath Do you find that difficult? sometimes Nhen they get longer is it harder? Yaa 155 Mhat do you do when you have problems remember ing something like this? I stop and ask you t o say i t again ( i n t r o d u c t i o n t o the the BDAE r e s p o n s i v e naming subtest) Mhat do we tell time with? a c l o c k Mhat do you do with a razor? shave someones head .... Mhat do you do with soap? wash myself Mhat do you do with a pencil? w r i t e down whatever you have t o w r i t e down Mhat do we cut paper with? the s c i s s o r s Mhat colour is grass? green Mhat do we light a cigarette with? f i r e How many things in a dozen? 7 ... Mhat colour is coal? b l a c k Mhere do you go to buy medicine? the s t o r e ( i n t r o d u c t i o n t o BDAE animal f l u e n c y s u b t e s t ) ... start with the word "dog" dog, c a t , zebr a , chimpanzee, a l l i g a t o r , r a t t l e s n a k e , p o l a r 156 bear, ant, ant, ( r e p e a t i n g t o c l a r i f y f o r examiner), ant t h a t c r a w l s on the ground, bear, zebra. 157 P a t i e n t 3s T r a n s c r i p t of Standardized T e s t i n g ( I n t r o d u c t i o n t o synonym sub t e s t ) ...If 1 said small I'd say big «... actually something like ... No, oppposite ...You want something that's the same. If I said small you'd say? t i n y , l i t t l e ... exactly. So i f I say "chef" you say uh cook repair f i x bashful Uh shy donate Uh kinda l i k e uh give enormous enormous ... large imaginary uh fake locate uh f i n d remain uh stay journey 158 uh journey ... explore assist uh help beverage Uh you can't just say beverage huh no drink quarrel uh ... kinda l i k e a rock or something mold rock or what? rock or mold humorous •funny vacant uh taken col 1ide uh smash abandon 1 eave ... ("introduction t o antonym s u b t e s t ) If I saud small you say? 1 arge Hhat's the opposite of strong? weak question uh answer 159 pull P u l l ? uh p u l l .... extract sharp uh d u l l entrance ...exit innocent-uh innocent ... g u i l t y succeed 1 ose cheap expensive d i s t a n t uh ... close and near narrow uh wide lead lead ... follow dangerous uh safe moist uh dry reckless reckless uh careful (Introduction to d e f i n i t i o n subtest)...disturb uh to bug ... annoy l<bO •famous uh popular ... usually means r i c h l i k e Kenny Rogers famous owns a these mansions that 1/4 b i l l i o n no prob. stadium kinda l i k e dome anything else uh and uh you can usually get food there l i k e at B.C. Place you can get food and go to the can whatever you want .... large ... cur ious uh kinda l i k e eager kind of a go getter or something eager. Eager to do t h i s l i k e jumpy. Jumpy to get going .. elevator a thing that goes up and down anything else well i t ' s usually worked by a winch and a cable. Like they have one at the hosp i t a l . Winch, cable. They got two act u a l l y , in Sunnyhill. One's slow and one's f a s t . There 's only two f l o o r s . ... unaware well unexpected l i k e you don't expect anything, unaware. I guess I'd have to give the meaning of aware which i s a l e r t and i f your unaware your not a l e r t . ... struggle too bad t h i s doesn't have two parts (laughs) struggle, kinda l i k e struggle to break free. Like i f some guy's got you , you struggle to break free. Whatever you do you punch him i n the face or whatever. air conditioner a i r conditioner, uh a i r conditoner. Dad 's. Dad and Mom in th e i r truck and car. That's l i k e i t uses fuel of some sort. MM MM mm 161 a uh gives you -fresh clean a i r -from the outside, l i k e uh i t brings outside a i r and i t goes through a cooler and i t s nice cold a i r for a hot day. anything else? wel1 no -flashlight well f l a s h l i g h t i t ' s usually operated on ba t t e r i e s and i t ' s a l i g h t i t ' s a hand l i g h t l i k e I have one i n my room. .invent you just think of something l i k e Thomas Be l l .... Graham B e l l . Graham Bell invented the phone and who's that Thomas guy? Thomas ... / £ / Edison he invented a whole bunch of things eager eager uh eager uh didn't we already have that? Ho. ... you used "eager " in one of your definitions ....Hhat does eager mean? l i k e a go getter or whatever just eager to get going excited to get going. advance advance means to go ahead ... follow... Like go ahead... Like my teacher asks me 'do you wanna advance i n t h i s book?' and whatever, I go 'sure', 'no I don't' or whatever ,. pure pure, well l i k e a F l o r i d a orange j u i c e , pure, pure orange ju i c e from concentrate, pure, natural predict predict, uh well i f you predict something you guess at something and your usually r i g h t ... (introduction to multiple meanings subtest) ... block 162 block, kinda l i k e brick and brick or building blocks, Lego or Lego and building blacks and Duplo and whatever . .. another meaning? Some peoples names are Block l i k e I know a guy named Jason Block and a block ... our -fireplace i s made o-f rectangular blocks mmm rectangular blocks bricks a c t u a l l y duck duck ... an animal can you tell more? Uh ya you usually shoot them down ... another meaning duck ... to duck (gestured ducking) and uh that's a l l I know ... rock a rock, a boulder i s kind o-f a rock ... a rock i s something natural that the ... the earth had at the time o-f dinosaurs ... another mean ing? volcanic stu-f-f when i t dr ... l i k e molten lava comes out and that's melted rock ... hot ...pound Where the dog goes another mean in g? pound ... l i k e i-f you get a steak and i t ' s so many pounds. I'm so many pounds 'cept that's not changed to into metric train t r a i n ... something that goes along tracks in the Frazer Canyon 163 another meaning something that has more l i k e i f you t i e a couple o-f cars together then the leading one i s apparently the engine and the one behind at the very back i s the caboose iron uh iron do we have any iron that's aluminum those hinges... Iron another meaning iron uh ... I don't know bark something that comes off trees another meaning a dog barks tip t i p uh ... well the t i p of the pen i s the stuff that contains the ink y a r d a yard's got three feet or something another meaning a yard l i k e where the house i s and from to the sidewalk to the a l l e y that's your yard ... from one part of the fence to the other part that's your yard . .» change change, change from a d o l l a r b i l l another mean ing Change ... change your clothes chest chest, that's t h i s thing (gestured to h i s chest) another meaning 164 Chest ... can't get too rude or anything, r i g h t ? . .. another mean ing. Chest... chest, l i k e ya lock money away in a chest sometimes f i l e - f i l e . . . t h i s should be an easy one...my mom has a f i l e cabinet where she keeps a l l her f i l e s f i l e f i l e you l i n e up i n single f i l e ... note note, uh note i s just quick write down of something ... another meaning note uh ... leave parents a note, to take note of something i n your head f e l t f e l t uh I f e l t the velvet or f e l t i s a kind of pen (introduction to sentence r e p e t i t i o n subtest) ... You know hON You know how The vat leaks The what leaks The vat leaks The vat leaks down to earth down to earth limes are sour 1imes are sour I got home from work 165 I got home from work The spy fled to Greece The spy f l e d to Greece you should not tell her you should not t e l l her pry the tin lid off pry the t i n l i d off go ahead and do it if possible go ahead and do i t i f possible The Chinese fan had rare emerald The Chinese fan had a f a i r emerald Near the table in the dining room Near the table in the dining room The barn swallow captured a plump worm The barn swallow catched ... caught a plump worm They heard him speak on the radio last night They heard him speak on the radio l a s t night The lawyer's closing ar gument convinced him The lawyer's closing argument convinced him I stopped at his front door and rang the bell I stopped at h i s front door and rang the b e l l The phantom soared across the foggy heath The phantom soared across the foggy heath (introduction to responsive naming ) Nhat do we t e l l time with? a watch, clock 166 Mhat do you do with a razor? You u s u a l l y shave with a r a z o r Mhat do you do with soap? You u s u a l l y wash y o u r s e l f with soap Mhat do you do with a p e n c i l you w r i t e with a p e n c i l Mhat do we cut paper with? s c i s s o r s Mhat colour is grass? green, u s u a l l y green Mhat do we light a cigarette with? Uh t h a t ' s a bad h a b i t , anyway a l i g h t e r , I know cause mom and dad smoke How many things in a dozen? 1 2 Mhat colour is coal? U s u a l l y black Where do you go to buy medicine? d r u g s t o r e ( i n t r o d u c t i o n t o animal naming su b t e s t ) you could start with the word "dog" dog, c a t , mouse, f i s h , uh p i g , pig» cow, horse, uh horse and uh ... d i d I ... name ... uh house p e t s , No, named them a l l ... oceans, sharks, uh sharks and uh whales, uh snakes, uh ... uh O.K. that's it ( i n t r o d u c t i o n t o Boston naming t e s t ) bed 167 tree penci1 house whistle s c i s s o r s comb •f 1 ower saw toothbrush helicopter broom octopus mushroom coathanger wheelchair hammer mask pretzel bench tennis raquet uh snai1 volcano uh seahorse dart canoe globe wreath uh beaver harmonica hi ppopotamus ... actually it's not ... Can you give me another name? i s i t a dinosaur? Wo . . . I'll give you a hint ... It's a /rai/ rhinoceros acorn igloo s t i l t s and eh uh dominoes cactus uh escalators uh what's that called? A harp, and eh uh hammer door ... or no that thing right there knocker kinda and uh pelican pyramid muzzle unicorn uh -funnel uh What's that called? uh accordian 169 and uh noose uh ... asparagus uh what's that called? Compass uh latch or lock uh ... Mom! What's that thing c a l l e d with three arms? ... You've got to get i t yourself ...photographers use i t stand? your getting closer stand or uh it's a /trai/ I don't know I've never heard o-f that a tripod I've never heard of i t It's a ... What i s that? uh geez it's a document Is that the name of i t ? No, I'm giving you a hint Document uh ... beats me It's a /skro/ Why are you giving me so many hints? Because I want to see if you can get i t with the hints ... It's a scroll scrol 1 uh, uh, what ar these called? We have them at our school uh ... tongs! tongs King Tut or King Tut's pet or something It's c a l l e d the / s f l ^ ) / 170 / s f i n / ? Sphynx eh uh i t ' s c a l l e d eh uh ... b u l l s wear i t .... b u l l s wear i t but I don't know what i t ' s c a l l e d ! ...it's a /yo/ yodel? a yoke uh i t ' s used to keep plants growing s t r a i g h t l y Exactly, it's called a ... Don't ask me what i t ' s c a l l e d ! a / t r e i / Never heard of i t t r e l l i s Never heard of i t painters use i t ... Uh I don't know I never paid attention in art ... a /pal/ Palestine? ... a palette. eh uh that's part of geometry r ight i s n ' t that good enough? No ...... it's a /pro/ proton? ... a protracter protracter abacus! 171 P a t i e n t 4s T r a n s c r i p t o-f Standardized T e s t i n g (•introduction t o synonym s u b t e s t of word)... you give me a fiord that means the same thing, synonym .... give me another word for "chef" cook repair f i x bashful shy donate g i v e enormous b i g imaginary f a k e locate f i n d remain s t a y journey voyage assist help beverage 172 •food q u a r r e l •fight humorous •funny vacant empty col lide crash abandon leave ("introduction t o antonym subtest) " s t r o n g " weak quest ion answer pull l e t go sharp d u l l en trance e x i t innocent g u i l t y succeed •failure the o p p o s i t e o-f 173 cheap expensive d i s t a n t c l o s e narrow wide lead f o l low dan gerous I don't know moist dry reckless c a r e f u l ^ i n t r o d u c t i o n t o d e f i n i t i o n s u b t e s t ) ... t e l l me the meaning of the word " d i s t u r b " t o awake famous t o be wel1 known stadium a l a r g e p l a c e where s p o r t s events are h e l d curious t o want t o f i n d out t h i n g s elevator a box t o r i d e up i n anything else? 174 No unaware not ready for something struggle to f i g h t to get loose air conditioner a system that keeps you cool flashlight a tool to give you l i g h t ... that gives you l i g h t anything else? No invent to f i n d something out that i s new eager to want to learn anything else? No advance to want to go one step further pure something that has no a r t i f i c i a l things in i t predict to say ... to give an answer before you f i n d out the question anything else? No 175 (introduction to multiple meanings subtest) ... Hhat's a block? to stand in front of someone ... another meaning a square piece of wood or some material duck to bend down to get out of the way of something another meaning animal fowl rock a type of music ... another a s o l i d material pound to h i t somebody r e a l l y hard another one a weight t r a i n a vehicle that runs on two tracks and to teach someone iron a strong material anything else No I can't think of another one bark the substance on he outside of a tree and the noise a dog makes t i p 176 to l i g h t l y tap someone on the shoulder or h i t him on the shoulder another meaning to give someone some information to help them yard a measurement another and the f i e l d behind your house i s c a l l e d your yard c h a n g e money ... s i l v e r money ... coins and to become a new person chest a game another I won't give the name that my P.E. teacher uses O.K. I t ' s the name for your muscles, the front part of your body O.K. f i l e a tool you use to wear down your n a i l s another meaning a l i t t l e envelope that you put i n a f i l e cabinet note a piece of paper given to people to t e l l them something and to jot down some information felt a pen, coloured pen used to write and a material O.K. that's all for that one. Do you find that hard? 177 Ya sometimes some words you don't know what they mean you just have to guess at them 1 find sometimes giving definitions is hard There's so many d i f f e r e n t ways you can give the d e f i n i t i o n Yah that's right i t ' s hard to know ... remember at school your English teacher gives you one d e f i n i t i o n of a word and then your Social teacher wants the other d e f i n i t i o n That's right ... I say a sentence and you say it after me. "You know how" You know how The vat leaks The vat leaks Down to earth Down to earth Limes are sour Limes are sour I got home from work I got home from work The spy fled to Greece The spy f l e d to Greece You should not tell her You should not t e l l her pry the tin lid off pry the t i n l i d off go ahead and do it if possible go ahead and do i t i f possible The Chinese fan had a rare emerald 178 The Chinese f a n had a r a r e emerald Near the table in the dining room Near the t a b l e i n the d i n i n g room the barn swallow captured a plump worm the barn swallow captured a plump worm they hear him speak on the radio last night they heard him speak on the r a d i o l a s t n i g h t the lawyer's closing argument convinced him the lawyer 's c l o s i n g argument convinced him I stopped at his -front door and rang the bell I stopped at h i s f r o n t door and rang the b e l l The phantom soared across the -foggy heath The phantom soared a c r o s s the foggy heath Is there anything special you do to remember those or do you -find them difficult? Well I s o r t of repeat the one as your going through i t good or I go o f f of i t That's a good thing to do t h e r e ' s a l o t of fragments i n t h e r e you find if you don't do that you sometimes miss things ya you f o r g e t out a word and t h a t puts you r i g h t o f f and that confuses the whole thing. Do you find sometimes in school that you have to do that too? ya l i k e when one of the /tlt^zrs/ ... / t i t j ^ a f - s / d i c t a t e t o us they always go too f a s t . You t r y t o w r i t e down your s c r i b b l i n g . They make you do i t over again. They do notebook checks. I t ' s got t o be neat and dated. 179 I ask you a question about something and you give me the word...Nhat do we tell time with? a watch Nhat do you do with a razor? shave Mhat do you do with soap wash yourelf Nhat do you do with a pencil? You write with i t Nhat do we cut paper with? s c i s s o r s Nhat colour is grass? green Nhat do you light a cigarette with? a l i g h t e r or a match How many things in a dozen? 12 Nhat colour is coal? black Where do we go to buy medicine? the drugstore or the pharmacy I want to see how many animals you can name in a minute......you could start with "dog" dog, cat, monkey, parrot, b i r d , horse, c a t t l e , sheep, chicken, ducks, cats, Oh I said that, snakes, spiders, grasshoppers, f l i e s , bees, wasps, worms, umm bears, rabbits, deers, elk, moose, umm frogs, l i z a r d s , snakes, r e p t i l e s . 180 ... Mhat sort of things do you use to help you to think of them? I look around my room and I have teddy bears... a frog up there ... a l i z a r d up there <Introduction to Boston Naming Test) whistle s c i s s o r s comb f1ower saw toothbrush helicopter broom octopus mushroom hanger wheelchair camel mask pretzel bench tennis raquet s n a i l volcano seahorse dart canoe 181 globe wreath beaver harmonica rhinoceros acorn igloo s t i l t s domi noes cactus escalator harp /ham^k/ doorknocker pelican stethoscope pyramid muzzle unicorn •funnel squeezebox Is there another name for that? squeezebox or .... I heard i t on T.V. l a s t night . mom's frie n d plays i t . Sqeeze box that's what the h i l l b i l l i e s c a l l e d them. Yah they did I can't think of the other name 182 It's an /3L/ •hhh ... quite a -few people play them /3ik/ accordian noose asparagus compass lock Is the another name -for that? doorbolt O.K. compass Mmmtlmm (no) it's a /trai/ tripod scrol 1 tongs sphynx Ohh I had trouble with t h i s l a s t time (picture o-f a yoke) It's used -for -farm animals r i g h t there (pointed to oxen i n picture) I know i t ' s used on farm animals I just can't think of the name It's a /yo/ yoke yoke You don't hear of those very often oh my dad b u i l t one outside It's used in the garden 183 I know my dad b u i l t one It's a / r r e l / t r e l l i s t r e l l i s oh my P.E. uses these They do? Ya ... oh not my P.E. teacher my Art teacher. Michelangelo used one. It's a /poa/ palette rorora mmm (positive) ( p i c t u r e of p r o t r a c t e r ) You use them to measure ri g h t angles MMmmm mmm ... it's a /pro/ protracter abacus... I know the hard ones, but these ones I just can't get 184 P a t i e n t 5; T r a n s c r i p t of Standardized T e s t i n g (introduction t o synonym s u b t e s t of Word Test) like if I say 'small' you could say ... high? no, you could say l i t t l e . l i t t l e ? You want something that means the same. If I said big you could say ... smal1! no, you could say large large? right... Yah So give me a word that means the same as 'chef barber O.K. give me a word that means the same as 'repair ' /k^mplndyr/ ... give me a word that means the same as 'bashful' I don't know that one ... ( i n t r o d u c t i o n t o antonym su b t e s t ) so i f I said 'big' you could say smal 1 Right/ If I said l i t t l e ' you could say? big Right / ..... opposite of 'strong' weak 185 ... opposite o-f 'question" < no response ) Mhat ' s the opposite o-f 'question'? c o r r e c t ? pull go ... sharp d u l l .-. entrance I don't know t h a t one You don't know that one? Mmm Mmm (negative) . opposite of 'innocent' I don't know! You don't know that one? no ... ( I n t r o d u c t i o n t o d e f i n i t i o n s u b t e s t ) .... you tell me what that word means Again !? ..., If I said dog you could say ...? c a t Wo- Listen carefully #5 ... Mhen I give you a word you tell me what it means. So if I say the word 'dog'r you could say 'its an animal, 'its got four legs, and a tail'. O.K. ? O . K . ... 'disturb' mean? (no response) 186 Do you have any idea? No O.K. nhat does 'famous' mean ? I don't know Can you take a guess? c a r p e n t e r ? Hhat's a stadium' ? I t s ... t h a t you ... t h a t you., ummm p l a y on and t h a t ya make shows with and ya do ... do t h i n g s l i k e ya a c t on them. Mmmm 'kay now? ( h e wanted t o know i f i t was time t o t u r n o f f the tape r e c o r d e r ) Not yet . . . Your trying really hard/ and you know what? Nhat #5 I d i d Nhat? I speaked on a um on a on a um one of those tape r e c o r d e r s and they ... and i t has a long t h i n g (gestured something l i k e a cord) and t h e r e ' s a microphone Mmmm this one has a microphone built in right here and I and and then ya p r e s s t h a t No, You don't w a n t to press that or else it won't work and then ... then i t c o u l d i t speaks It does ? Oh I know what one your talking about . You can talk over the radio. ( nodded head ) 187 yeah that's right.... now there's a new thing we're going to do. O.K. ... ( i n t r o d u c t i o n t o m u l t i p l e meaning subtest) ... Hhat's a block? I t ' s square and i t umm and you c o u l d umm b u i l d t h i n g s Hhat's anther kind of block'? Um ya make ya make a chimney with i t ? Hhat's a 'duck? i t s a animal and and i t has two, t h r e e , and l e g and i t goes quack quack (made a quacking sound i n s t e a d of sa y i n g quack, quack) ....Hhat's another weaning for the word 'duck'?.... You c o u l d eat i t ... do you know any other weanings no O.K.... rock ... I t 's hard and ya umm and i t s round... you c o u l d make a l i t t l e h o l e i n i t and look through i t . . . a n o t h e r meaning ...? No ( I n t r o d u c t i o n t o Sentence R e p e t i t i o n ) ... you say the same thing I do O.K. O.K. Listen carefully first yah and when I f i n i s h you say what I s a i d O.K. You know how 188 You know how The vat leaks The vat l e a k s Down to earth Down t o e a r t h Limes are sour Limes are sour I got home from work I got /om/ from work The spy fled to Greece The spy / g a r e t / the l e a s e . How come ya can't tape i t r i g h t now? (He was r e f e r r i n g t o the f a c t t h a t I was a l s o w r i t i n g down h i s responses) I am taping. I'm just making a couple of notes while your saying it. O.K. ... You should not tell her You should not t e l l her O.K good ... Pry the tin lid off P r i v a t e t i n l i t t l e Go ahead and do it if possible go i n head and do i t i f p o s s i b l e The Chinese fan had a rare emerald The Chinese f a n had a r a r e /£mar€najd/ Near the table in the dining room Near the t a b l e i n the d i n i n g room The barn swallow captured the plump worm What!? O.K. one more time. The barn swallow captured a plump worm 189 I can't answer that one ... say back nhat I said I can't ... I heard him speak on the radio l a s t night They heard him speak on the radio l a s t night The lawyer's c l o s i n g arguement convinced him The ... What ! ? «,, The lawyer's c l o s i n g arguement convinced him. The closed arguement asked him ... I stopped at his front door and rang the bell I stopped at h i s -front door and rang h i s doorbell ... The phantom soared across the foggy heath The phantom crossed the -front huffing Good. O.K. Now do i t ? (turn off the tape recorder) Not yet. Ne s t i l l have ... a few more things to do (heavy sigh) O.K. #5 You said ... No ... that one was the l a s t one of t h i s thing ("gestured to test) we s t i l l have a few more things to do Oh » ... Nhat do we t e l l time with? What do we t e l l time with? No. This time I ' l l ask you and you t e l l me. So if I said a clock 190 Mhat do you do with a razor? Ya ... (gestured shaving) Mmm Mmm Do you know what that's called? No O.K. good, Mhat do you do with soap? wash ... and and dry with the towel MMmm Mmm Mhat do you do with a pencil? draw Mhat do we cut paper with? s c i s s o r s Mhat colour is grass? green Mhat do we light a cigarette with? l i g h t e r ... or a match. . .. How many things in a dozen? I can't answer t h a t one ... Mhat colour is coal? black ... Mhere do we go to buy medicine? d o c t o r s do you know another place? h o s p i t a l s .... ("Introduction t o animal naming su b t e s t ) name as many animals as possible. You could start with 'dog' dog, c a t , duck, anim ... c a r ... no one of those /tr<9/ ... one of those ... ummm swan, ug l y d u c k l i n g , swan, ahh urn, I don't know 191 Think of some other animals swan t h a t swims and i t s p l a s t i c You said that one a swan t h a t ' s p l a s t i c any other animals you can tell me about? no ...Can you write for me #5? w r i t e ? Do you know how to write? Yah, a l i t t l e b i t ... I 'm going to show you a picture. I want you to look at the picture and tell me everything you can about it, but I want you to write it down. You write down everything thats w r i t e ? ! ! ! or print ... can you do that for me? I . . . I . . . I . . . do messy p r i n t i n g that's O.K. I can't You can t? I don't know how you don't know how to spell ... word? I c o u l d s p e l l but not t h a t many words (The w r i t t e n form of the Boston c o o k i e t h e f t p i c t u r e was administered see t e s t booklet f o r r e s u l t s ) O.K. ... one test left to do and then your done O.K. c o u l d I p l a y t h a t one? You know how ? (pointed t o a toy piano) 192 Uellr when we're -finished you can have your choice ... What i s that? ... I'll show you a picture and you tell me the name o-f i t bed . . . next one? tree next one? penci1 next one? house whistle s c i ssors comb f1ower saw toothbrush helicopter broom octopus mushroom hanger wheelchair camel a l i t t l e bit louder so I can hear you... next one? mask 193 / p t f r t s l l / ... / p r e t s l l / that's that one? bench rock ( p i c t u r e of t e n n i s racquet) Sorry.... Mhat was this one again? r o c k e t O.K. next one Umm what's t h i s one again? ( p i c t u r e of s n a i l ) Uhat's this one? c a r t ... animal Which one do you want? It' s an animal I don't know It' s a /sne/ s n a i 1 Uhat s that? volcano Uhat's that one? seahorse d a r t boat It's a special kind of boat . . . do you know the name for it? No It's a /kS/ canoe Right/ Mhat's that? 194 globe Nhat's that? wreath Hhat's that? Uhh ... <slammed f i s t on the t a b l e i n f r u s t r a t i o n ) You knout it but you can't think of the word,.. r i g h t I t ' s an animal beaver O.K /hay ... /harmanlk .3 / ... next one? r h i n o Do you know the big name for it? It's a /rain / r h i n o c e r o s nut Nhat kind of nut? It's a special kind of nut I don't know It comes from a tree ummm It's an /e/ /ekna/ ... acorn r ight i g 1 oo s t i l t s b l o c k s ( p i c t u r e of dominoes) 195 Those are special kind of blocks. Do you know what those are called? / p ^ r t s l l / ... it's a game game b l o c k s „ - - they're /da/ /damollnz/ ... / d a m l l l n z / ... they're /da/... dominoes dominoes? c a c t u s s t a i r They're a special kind of stairs. Do you know what they're called? no You go up on it it's an . e s c a l a t o r ... God again You got it again Ohhhhh! ( i n exasperation) You know that one too ... No I don't It's a musical instrument I know i t i s It's a /ha/ homonym ... it's a /har/ 196 /har/...heart . . . a harp harp . . . this one? a bed - . . i t ' s a special kind of bed. Do you know what i t ' s called? No Vou l i e on i t . . . and i t s a /hzeJ hand I t ' s a /h^m/ ham hammock hammock 11 Mmm Hmmm a hammock door . . . right, but what's this on the door? Right here ( p i c t u r e o-f doorknocker) f i r e ... and a can d l e , . - i t 's a /na/ knob Not a knob. I t ' s a /na . . . . . . . y r / knocker? Yep •h I got th a t one wrong! i t ' s O.K. b i r d 197 It's a special kind of bird I don't know it's a /pel/ / p e l Ik/ a pelican... Ohhhh. Nhat 's this one? No Oh no! I don't even know that one! You can't think of the name Mmm limm (negative response) ... though you've seen it before I know The doctor uses it I know It's a /stz/ / s t t f / it's a /stzQ/ /st^&3mada/ a stethoscope stethoscope? right ..... Next one? i g l o o not quite No i t ' s one o-f those ... i t ' s a igloo Wo A d i f f e r e n t kind of a igloo 198 That's right a different kind of igloo ... It's found in Egypt ... it's a /pir/ pyramid - - good Uh I don't even .... Ohhh! i t ' s one of those doggies MMM but what's on the doggies face?.... right here I don't know Uhat's that called I don't know It's used on dogs to keep them quiet I know .., It's a /mg/ mutt not a muttf It's a /m^z/ /mQz/ muzzle /m zu/? muzzle O.K. ... uhhh Uhat's that one called? r-hernicorn not a hernicorn it's a /yu/ unicorn right 199 t e l e s c o p e ...not quite. It's used for pouring things Arrgh ... ( s t a r t e d t o pant) . . . #5 look at me I ' l l never get t h i s these are harder at the end . . . . so don't worry O.K. . . Hhat's this thing called? scooper kind of a scooper i t ' s called a /f^/ •funnel good . . . that's right Ohhhh! I ' l l get t h i s wrong I know i t ! take your best guess t e l l e r not a teller a /muzer/ ( he then whispered "musical instrument") , . . It's a musical instrument I know I t s an /3Hk/ /aek/ that's a hint accordian a c c o r d i a n Have you heard that word before? no 200 You seemed to know what that was uh oh! ... you hang people by the neck -from them that's right t h a t s c a r e s me ... do you know what it's called no It 's called a /nu/ /nurar/ ... it's a noose a noose? a noose What i n the world i s a noose? You told me what it was ... It's used to hang people with Uhat's this? a branch ... it's something you eat I don't know it's /$sp/ (NR) asparagus asparagus? Have you ever had asparagus? No I wouldn't think so never Hhafs this called? 201 Its ... my mom has one and I don't even know ... you turn t h i s MUM Hmm that's right ... you use it for drawing I know mm in My mom used to have i t I'll give you a hint it's a /to/ /ksp/.../ks-f/... /k-sfes/ almost, it's a compass lock ...door lock That's right ... what's that? compass -.. it looks like it, but this is something that photographers use ... or surveyors Oh a surveyor ! Hhat's this called? Do you know? No It's a /trai/ / t r a i g s/ Ho .. it's a /traip/ / t r a i p s s / . .. a tripod tripod? ... that's right Oh! Oh! here's a l e t t e r it's a special kind of letter that's .. that the kings used to have 202 That's r i g h t .... Do you know what i t ' s c a l l e d ? No ... it ' s a /skr/ /skrap/ ... / s k r l p t / Hot a /skrlp/ / s k r l p / ? it's a scroll S c r o l l ? Ohhh Hhat are those? t h a t s a p i c k b l a c k s up and ya ahhh on top that's right. It's a utensil / t i n s e l / ? It's a utensil ..... They are /ta/ /tlnzal/ Ho /ta/ t a r they're tongs tongue tongs Oh tongs That's right T h i s i s a b l o c k s Actually 1 think those are supposed to be icecubes oh People use them to pick up icecubes so they don't get their hands cold 203 Oh Hhat's that called? a H H H H H (in mock f e a r ) l i o n . ,. kind of looks like a lion... It's found in Egypt near the pyramids I don't know It's a /sp/ spear no... not a spear its s p i r i t the sphynx sphynx Ne've got 5 pictures left to do MMM Uhat's this one called? doorknocker ... It 's used on animals noose ..... I'll give you a hint Ohhh i t ' s an animal cart ... it's for the animal cart..... uhat's it called No it's a /yo/ yoyo not a yoyo it's a yoke yoke? 204 ... what's this called? •f 1 owerpot not quite... the thing the -flowers are growing up on a vase .... it's a /trt-1/ / t r e l / t r e l l i s t r e l l i s ? I almost got i t ... three more paints ... Hhat's this thing called that the paints are on? I don't know Artists use it A r t i s t s use it's a /po\l/ palace Almost. It's a palette palette? MMH Ohh! ( i n r e c o g n i t i o n ) two more/ Hhat's this one called? two more no /ttmls/ a what? /t£mls/ 205 No ... i t ' s used to measure angles i t ' s a /pro/ program no .... it's a protracter protracter? yup. it goes with the compass. ....What's this one called? I have i t at home ...Do you remember it's name? No... I don't even know what i t i s ... i t ' s tuh, i t ' s tuh tuh, tuh, draw things with? Wot his one. This one is to count things with count? MHMmm Not t h i s one the other one Oh that one, that 's right. But what's this one called? You use it to count with. counters ... I'll give you another hint.... it's an /SL/ /«mls/ Almost, it's an abacus abacus? MmmMmm an abacus 206 

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