Introduction

The following exercise is a case study of a man (‘Roy’) with agrammatic aphasia who was studied by Beeke et al. (Reference Beeke, Wilkinson and Maxim2007). Seven years prior to this study, Roy sustained a left-hemisphere cerebrovascular accident (CVA). Among other problems, his CVA caused Broca's-type aphasia. The principal language feature of his aphasia was a severe, chronic agrammatism. Aphasia is a common sequela of stroke-induced brain damage. Godefroy et al. (Reference Godefroy, Dubois, Debachy, Leclerc and Kreisler2002) reported aphasia in 207 (67.2%) of 308 patients admitted to a stroke unit. Some aphasia subtypes are more common than others. Non-fluent aphasia – of which Broca's aphasia is one type – is less common than fluent aphasia, accounting for 34.2% and 65.8% of cases in one clinical sample (Laska et al., Reference Laska, Hellblom, Murray, Kahan and Van Arbin2001). The case study is presented in five sections: history and communication status; assessment battery; focus on agrammatism; discourse production; and conversational data.

History and communication status

At the time of study, Roy was in his mid-to-late forties – his exact age was unknown. Seven years earlier, he sustained a left-hemisphere cerebrovascular accident while waterskiing. Also unknown are the aetiology, size and location of the lesion in this CVA. Roy is fully mobile. However, his CVA caused a dense hemiplegia that affected his right arm, and he has little useful movement of this limb. His hearing and vision are normal. Roy lives with his wife. He is an active member of his local stroke group and attends an exercise group.

Roy's CVA caused Broca's-type aphasia. He also has a mild articulatory dyspraxia and mild-to-moderate word-finding difficulties. He has severe agrammatism and non-fluent spoken output. His spoken language contains few identifiable syntactic structures and few, if any, verbs. There is a high frequency of adverbs, nouns and phrases such as I think and you know. Pronouns, articles and prepositions are largely absent. These language features are evident in the description that Roy gives of events around his stroke below. Notwithstanding his severe expressive difficulties, Roy's comprehension of language in conversational situations appears very good. Roy reported having speech and language therapy (SLT) both as an in- and out-patient in the months following his stroke. However, he has not had any SLT for some years. The content and duration of earlier SLT are unknown.

Assessment battery

Roy's language and communication skills underwent a wide-ranging assessment by a speech and language therapist. The assessments were intended to elicit quantitative and qualitative data at the word, sentence and narrative levels. The Psycholinguistic Assessments of Language Processing in Aphasia (PALPA; Kay et al., Reference Kay, Lesser and Coltheart1992) contains 60 subtests that assess all components of language structure such as orthography and phonology, word and picture semantics, and morphology and syntax. Spoken and written input and output modalities are assessed through tasks that require subjects to make lexical decisions, and undertake repetition and picture naming. One PALPA subtest in particular – Spoken Picture Naming – was used to assess Roy's naming abilities. An assessment known as Thematic Roles in Production (TRIP; Whitworth, Reference Whitworth1996) was used to assess Roy's retrieval of the same item in single word and sentence contexts. A series of 80 picture cards is used to explore words that are assigned different thematic roles in sentences of varying argument structure. The examiner models all target responses at the outset of the test as the subject views the picture stimuli. Like PALPA, TRIP draws on the cognitive neuropsychological literature for its theoretical base. The Verb and Sentence Test (VAST; Bastiaanse et al., Reference Bastiaanse, Edwards and Rispens2002) assesses the production and comprehension of verbs and sentences. The test is theoretically motivated and can be used as a basis for treatment. Subjects are required to undertake a series of tasks with a single practice item rehearsed at the outset of each task. The tasks are: verb comprehension; sentence comprehension; grammaticality judgement; action naming; filling in finite verbs and infinitives in sentences; sentence construction; sentence anagrams with pictures; sentence anagrams without pictures; and wh-anagrams. The cookie theft picture description (Goodglass and Kaplan, Reference Goodglass and Kaplan1983a) was also part of the assessment battery. In this picture, a woman is standing at the kitchen sink drying a plate, while the sink is overflowing with water. Meanwhile, a boy (presumably, the woman's son) has climbed a stool which is rocking precariously and is taking cookies from a jar in the cupboard. A girl (presumably, the boy's sister) has her hand raised upwards to receive the cookies that her brother is taking. A cartoon description task, adapted from Fletcher and Birt (Reference Fletcher and Birt1983) and featuring a dinner party, was also included in the assessment battery. Narrative production was examined through ‘Cinderella’ storytelling. Finally, a video-recorded sample of conversation between Roy and his daughter Di was also collected and analysed. The sample was 23 minutes in duration and was recorded at home.

Focus on agrammatism

The results of the assessment battery reveal the nature and extent of Roy's agrammatism. On the subtest of the PALPA that examines spoken picture naming, Roy named 33 of 40 items correctly. Of the seven errors produced, five were similar in nature to the following: ‘water’ for glass and ‘giraffe’ for elephant. Roy's production of verbs of varying argument structure was impaired. His production of one-, two- and three-argument verbs on the TRIP was 80%, 30% and 0%, respectively. At sentence level on the TRIP, Roy produced a sentence for 47% of constructions with a one-argument verb and 15% of constructions with a two-argument verb. Examples of his productions are shown below. Level and falling intonation are indicated by a comma and full stop, respectively:

• The girl is skipping.

• ‘Girl, (2.8) she, (4.2) skipping’

• The girl is kicking the snake.

• ‘um right (1.7) girl, (3.4) girl, (11.6) kick, (1.7) snake’

No sentences were produced that contained a three-argument verb. None of Roy's sentences were structurally or morphologically well formed. Determiners and verb tense morphology were omitted. The progressive –ing ending was used on 72% of all verbs, while the remaining 28% of verbs were uninflected. On the VAST, Roy produced only 8 of 40 verbs correctly as single words. When asked to produce verbs within a sentence, Roy used single words for 16 of 40 items and produced no response at all for the remaining 24 items. The single words were mostly isolated verbs. However, if a verb proved difficult to produce, he named an object in the picture (30% of his responses were nouns). Of all verbs elicited, 71% contained the progressive –ing form, 9% were uninflected, and 20% were indistinguishable from nouns because of the lack of sentence structure.

Discourse production

Roy's impaired sentence production during language testing deteriorates yet further on the picture description and storytelling tasks. Roy produces only two phrases and one sentence, all within the dinner party cartoon strip description. These phrases and sentence were ‘large trout’, ‘four people’ and ‘man washing up’. However, Roy still manages to achieve communicative success through the use of a number of strategies that compensate for the absence of verbs and arguments. These strategies are illustrated by the discourse data shown below.

Conversational data

An examination of Roy's communication skills during conversation with his daughter Di reveals other strategies that he uses to address his agrammatic output. Also, conversation analysis exposes how Di has successfully accommodated to her father's severe impairment of expressive language in conversation. Several extracts from the conversational exchange between Roy and Di are presented below.