Introduction

The following exercise is a case study of a man (‘BB’) of 41 years of age who was studied by Jones (Reference Jones1986). In November 1978, BB suffered a left cerebral embolus that resulted in a right hemiplegia and Broca's type aphasia. Despite long-standing and intensive speech and language therapy, BB's single-word output had remained unchanged for six years. A new therapy programme was commenced in December 1984 which resulted in a significant improvement in BB's expressive language. The case study is presented in five sections: medical and communication history; assessment battery; assessment findings; language intervention; and language performance during therapy.

Medical and communication history

In November 1978, BB experienced a left cerebral embolus which resulted in a right hemiplegia and Broca's-type aphasia. Prior to his cerebrovascular accident, BB had been a wholesale greengrocer. A CAT scan revealed extensive damage in the territory of the left middle cerebral artery. This damage involved the frontal, temporal and parietal lobes and extended vertically to a depth of 6mm. Following his CVA, BB's comprehension of auditory and visual material was severely affected but superior to his expressive language. BB could only produce a few common words (e.g. ‘yes’, ‘no’, ‘hello’), which were awkwardly articulated. His articulatory difficulties were diagnosed as articulatory apraxia. BB's written output was limited to copying using the non-preferred left hand. For the next three years, BB received individual therapy three times a week and group therapy twice a week. Individual therapy was terminated when it was felt that BB had reached his maximum potential. At this stage, BB had improved auditory comprehension although his comprehension of visual material was still severely affected. Spoken output was limited to nouns and the occasional well-learnt phrase (e.g. ‘are you well?’). Twice weekly group therapy continued for another three years. This therapy was supervised by speech and language therapists but was conducted by volunteers. Volunteers also provided twice weekly therapy on a domiciliary basis when BB was the subject of a number of research studies. These studies examined his problems with reading (he was diagnosed as having deep dyslexia), writing (particularly spelling) and his severe word-finding difficulties.

The author of the study first met BB in November 1984. By that stage, BB had not received individual therapy for three years, with the exception of work on his spelling problems. Comprehension was functional in everyday situations. It was heavily reliant on pragmatic and contextual cues. BB could read simple written material but could not decode more complex and less redundant material. There had been almost no change in BB's spoken output in over three years. BB could still only produce single words (nouns) and had a severe word-finding deficit. No verb production was evident. Articulatory fluency varied, with well-learnt phrases produced fluently and with stereotyped prosody. BB was embarrassed about his communication problems and rarely initiated conversation. When he did attempt to communicate, there was an increased burden on his listener. Written output had improved in terms of spelling but, like spoken output, it was limited to the single-word level. In November 1984, BB's expressive language during picture description and narrative production appeared as below.

Assessment battery

Prior to embarking on a new therapy programme, the author of the study conducted a wide-ranging assessment of BB's expressive and receptive language skills. Several tests and tasks were used for this purpose. Alongside the cookie theft picture description and an account of his prior work (see above), BB's sentence production abilities were examined in other ways. BB was presented with 24 verb pictures, and was asked to describe the actions that people were performing. He was explicitly instructed to produce just a ‘doing’ word. BB was also asked to describe what was happening in 10 subject–verb–object-type pictures. The pictures depicted only animate actors and inanimate patients. The same 10 verbs that were depicted in these pictures were then given to BB in infinitive form. BB was asked to generate a sentence around each verb. To decrease his processing load and help him concentrate on sentence construction, BB was given access to the pictures if he requested them. During the Word Order Test (Jones, Reference Jones1984), BB was given a series of individual pictures. For each picture, the three elements of the target sentence depicted in the picture were given to BB on separate pieces of paper (e.g. the fireman/the policeman/follows). BB was required to place the elements in the order that matched the scene depicted in the picture.

To test receptive language, several tests and tasks were also used. The Test for Reception of Grammar (TROG; Bishop, Reference Bishop1983) was completed to obtain a comprehensive picture of BB's comprehension skills. In the picture selection comprehension task of the Word Order Test, BB was presented auditorily with a sentence which he was then required to match to one of three pictures. The sentences were simple active reversible declaratives which contained three types of verbs (non-motion verbs, non-directional-motion verbs, directional-motion verbs). The three pictures represented the target sentence, the same sentence with the arguments reversed, and the same noun arguments in the same order as the target sentence but with a different verb. In a test of recognition of sentence patterns, BB was presented with a number of written sentences which varied in complexity. He was asked to ‘block off’ words in the sentence which he believed ‘belonged together’. He was also asked to re-assemble the sentences using the ‘blocked off’ words that he had generated.

Assessment findings

When presented with verb pictures, and asked to produce a ‘doing’ word, BB achieved a score of 20/24. All ‘doing’ words were gerunds. When asked to describe 10 subject–verb–object pictures, the following responses were produced:

• The boy is kicking the ball: eh…um…push…push…no…ball…no

• The boy is riding the bike: girl…no boy…bike…well…um…boy…um

• The girl is writing a letter: writing…/r/…/r/…read…girl

• The boy is painting a picture: eh…boy…no girl?…um…don't know

• The boy is digging the garden: /g/…/g/…don't know…(cued 1st syllable) garden…boy…is…no

• The boy is reading a book: oh…/k/…/k/…/k/…don't know

• The girl is brushing her hair: eh…um…/k/…don't know

• The boy is eating an apple: boy…no (pointing to apple) drink?…no

• The boy is climbing a ladder: me! (indicating boy) no…boy /k/…climb up…yes!

• The boy is drinking orange: /b/…boy…ah!…boy is…/i/…eat…no…um

When given the infinitive form of verbs and asked to generate a sentence around each verb, the following responses were produced:

• Kick: /k/…kick…no…football…don't know

• Ride: ride a…ride a…um…no

• Write: write…eh…pen…um…letter

• Paint: paintbrush!…paint…oh…brush house…Good!

• Dig: dig…garden…yes!

• Read: read…letter…um…write…no…read…no!

• Brush: brush…um…yes…hair?…no…comb

• Eat: eat…food!…me!…eat…eh…Barbara (his wife)…no

• Climb: /k/…climb up…eh…climb?…don't know

• Drink: beer!…drinking…no

When asked to rearrange sentence elements in the Word Order Test, BB produced a total of 29/60 (48%) errors. His errors primarily took the form of object–verb–subject constructions. However, there were also a number of verb–subject–object and verb–object–subject constructions.

On the TROG, BB passed 12/20 blocks in the auditory version and 8/20 blocks in the visual (reading) version. Items which produced errors in both versions were singular/plural, simple active reversible, comparatives, monosyllabic prepositions and postmodified subjects. When presented with a spoken sentence and asked to match it to one of three pictures, the total number of errors produced was 36/60 (60%). For all three types of verbs included in these sentences, the errors were the same – BB chose the picture in which the arguments were reversed. When asked to ‘block off’ elements within sentences, BB displayed intact performance. However, when he was given the same elements that he had ‘blocked off’ and was asked to form sentences, he had considerable difficulty. Several of his attempts at this task were:

• For a new spanner/£2/paid/John.

• Sarah and Tom/in Bath/lived/in a house.

• His dinner/Tom/ate.

• Ann/a new red bike/got/for her birthday.

Language intervention

Given BB's lack of progress after several years of therapy, it was decided that a new approach to therapy was needed. This was instituted in December 1984 when BB started to receive therapy three times a week. Intervention followed seven stages:

1. (1) BB was required to ‘block off’ elements within written sentences. The verb was the focus of attention. BB was required to label the verb, and there was discussion of its role in signalling the state or activity undertaken in the sentence. Although the use of correct inflections of the verb was not the aim of this stage, several different verb forms were used but not discussed.

2. (2) The concept of the actor was introduced in this stage. It was explained that the actor answers to the question ‘who’ or ‘what’ undertakes the activity expressed by the verb. Initially, verbs were used which take a human subject to convey ‘who’, and an animal or inanimate subject to convey ‘what’. Verbs were also chosen for their intransitive structure and high imageability.

3. (3) The concept of the theme (or object) argument was introduced. Verbs were used which have an obligatory theme. The question words ‘who’ and ‘what’ were used again. To avoid confusion with the use of these same question words in relation to the actor, verbs were chosen which had an obligatory human actor and an inanimate theme, or a non-human animate actor and an inanimate theme.

4. (4) Verbs were introduced which have an obligatory argument that answers to the question ‘where’ in a prepositional phrase (e.g. put). The prepositional phrase was presented in both initial and final positions in the sentence. Some verbs were also used where the prepositional phrase could be used in the absence of a theme (e.g. ‘He ate in the kitchen’).

5. (5) Further sentence elements were introduced which answered to the questions ‘when’, ‘why’ and ‘how’. The need for these elements was discussed in terms of how much information the listener wants to be given. BB was given a chart of all the question words which had been introduced and their relationship to verbs in sentences.

6. (6) At this stage, BB performed tasks which were intended to reinforce the skills acquired to date. Written sentences were presented in which obligatory arguments occurred in the wrong location and BB was required to judge their acceptability. In other sentences, obligatory arguments were omitted and BB was required to supply them, along with the relevant question word. BB was also presented auditorily with an actor and a transitive verb and was required to supply the question word that would achieve completion of the sentence.

7. (7) Passive voice sentences were introduced at this stage. To ease their introduction, irreversible sentences such as ‘The ball was kicked by the boy’ were first to be used. Embedded and subordinate clauses were then introduced. To ease their introduction, the same actor was used of both verbs, with the second use taking the form of a pronoun (e.g. ‘Bob ate the bun because he was hungry’). It was also emphasised to BB that the subordinate clause in sentences of this type answered to the question ‘why’. Two different actors were then introduced in sentences that contained subordinate clauses. BB struggled with embedded clauses in reversible sentences, but had little difficulty with embedded clauses in irreversible sentences. To overcome these difficulties, it was emphasised to BB that in sentences such as ‘The cat chasing the dog is black’, ‘the dog’ is the argument of ‘chase’ and not ‘is’.

Language performance during therapy

In March 1985, three months into the new therapy program, BB underwent further assessment. He repeated the cookie theft picture description and the narrative production task in which he was asked to describe his previous work. The language that was elicited in these tasks is shown below.