iTechnology and Communicative Drawing for Individuals with
Aphasia Jennifer A. Ostergren, PhD, CCC-SLP Jennifer Raminick,
B.A.
Slide 2
Welcome Drawing on an iPad by an individual with aphasia
(Ostergren, 2012)
Slide 3
Thank You To our clients (our wonderful teachers) Thank you for
your inspiration and willingness to participate in our research To
my students (future SLPs) Thank you for your help in preparing this
presentation. In particular thank you Kristen Churney for her guest
appearance in describing the CDP
Slide 4
House Keeping A handout for this presentation, including links
to the technology discussed is available at: __________ (insert CD
page web address once loaded)
Slide 5
Agenda Multi-Modality Communication and Aphasia Correlations
with Neuroplasticity Drawing and Aphasia iTechnologies for
Communicative Drawing Examples of available iApps Features of
available iApps Recommendations for Selection Communicative Drawing
and iTechnology in a Clinical Setting New Directions and Future
Research Questions and Answers
Slide 6
Agenda Multi-Modality Communication and Aphasia Correlations
with Neuroplasticity Drawing and Aphasia iTechnologies for
Communicative Drawing Examples of available iApps Features of
available iApps Recommendations for Selection Communicative Drawing
and iTechnology in a Clinical Setting New Directions and Future
Research Questions and Answers
Slide 7
What is Multimodality Communication? Using different modes of
communication to meet the needs of the individual and to allow them
the opportunity to participate in their communities (ASHA, 2004)
Writing Gesturing Drawing AND Speech
Slide 8
Total Communication Use in PWA (Rautakoski, 2011) Many people
with aphasia (PWA) use nonverbal methods of communication
spontaneously, including: Pointing Gesturing Facial expressions
Pantomime Drawing Concrete signs Some PWA also use low-tech devices
Not used as much as the spontaneous nonverbal communication Some
PWA need special training in use of total communication
Slide 9
Key Elements to Multimodality Communication (Beukelman &
Mirenda, 2012) Co-Construction Partner Training Varied Approaches
Given: Partner Dependent Communicators Partner Independent
Communications Direct training and generalization to real- world
settings is KEY!
Slide 10
AS: Example of Multimodality Communication What did you do
yesterday? Drew a hamburger Said, Hamburger. Big Put up four
fingers Wrote : UCLA, DDS, 2 Viet, 1 Japan, and 2 white The client
had gone out to eat hamburgers with four of his friends from dental
school at UCLA; two friends were Vietnamese and two were Caucasian,
and the 1 Japan was referring to himself.
Slide 11
Neuroplasticity Rich body of research on neuroplasticity in the
past decade (Saur & Hartwigsen, 2012) Neuroplasticity is
defined as, ... functional reorganization/ compensation within
residual neural tissue, mediated by changes in neural circuitry
(Gonzalez Rothi, Musson, Rosenbeck, & Sapienza, 2008)
Slide 12
Educating Clients about Neuroplasticity Empowering Individuals
with Aphasia with Neuroplastic Principles: From Theory to Practice.
Birtler, E., Hayes, M., Kim, J., Sibby, K., Weltz, K., Navarro, A.,
& Ostergren, J. (2012). California Speech and Hearing
Association (CSHA) Magazine, 42 (1), July 2012.
Slide 13
Explaining Neuroplasticity to PWA WHAT YOUR BRAIN IS DOING FOR
YOU. Researchers have identified four strategies your brain uses to
compensate for damaged areas: 1. Homologous area adaptation 2.
Cross-modal reassignment 3. Map expansion 4. Compensatory
masquerade No matter how long since your stroke, your brain is
still working to get the job done! Grafman (2000). Conceptualizing
Neuroplasticity
Slide 14
Explaining Neuroplasticity to PWA WHAT YOU CAN DO FOR YOUR
BRAIN. Repeat, Repeat, Repeat o Why does your clinician make you
keep repeating the same thing over and over? Raymer et. al (2008).
Translational research in aphasia
Slide 15
Explaining Neuroplasticity to PWA Raymer et. al (2008).
Translational research in aphasia
Slide 16
Explaining Neuroplasticity to PWA Pulvermller & Berthier
(2008). Aphasia therapy on a neuroscience basis
Slide 17
Outcome of Education Clients and family members are very
receptive to information about neuroplasticity Visual aids and
reducing jargon critical Qualitative changes were noted
immediately: Increased motivation/participation More attempts to
verbalize More willingness to try alternative modalities Seeking
areas of change in their own environments EDUCATING CLIENTS ABOUT
DRAWING, as part of multimodality communication, is critical!
Slide 18
Agenda Multi-Modality Communication and Aphasia Correlations
with Neuroplasticity Drawing and Aphasia iTechnologies for
Communicative Drawing Examples of available iApps Features of
available iApps Recommendations for Selection Communicative Drawing
and iTechnology in a Clinical Setting New Directions and Future
Research Questions and Answers
Slide 19
Effects of Brain Damage on Drawing Left hemisphere lesions May
have difficulty depicting internal details of a target picture, but
little difficulty depicting external shape Some are unable to
generate a mental image of the target items Some may have
difficulty choosing the correct color for images Right hemisphere
lesions May retain ability to produce internal details but fail to
correct spatial relations or relative size May omit all or the left
half of external configuration May interfere with ability to
discriminate between colors (Helm-Estabrooks & Albert,
2004)
Slide 20
Left or Right Hemisphere Lesion? ?? Right hemisphereLeft
hemisphere (Helm-Estabrooks & Albert, 2004)
Slide 21
History of Drawing and Aphasia Long history in the research
literature (Lyons, 1995) Two primary areas of emphasis in the
research: Realm of AAC and improving functional communication
(Beeson & Ramage, 2000; Sacchett, 2002; Sacchett & Lindsay,
2007; Helm-Estabrook & Albert, 2004 ) For its impacts on verbal
output as a source of de- blocking and semantic access (Davis,
Farias, Baynes, 2005; Farias, Davis, Harrington, 2006)
Slide 22
Drawing and AAC Drawing can be used to compensate when a PWA is
not able to use written or verbal language (Lyons, 1995) Advantage
- no limitations caused by deficits in short-term memory and/or
sequential ability (Sacchett, 2002) A move toward interactive
(Sacchett, 2002) Supplementing Language Communication is enhanced
by the drawings, so the emphasis is on the exchange of information
and ideas Substituting Language Drawings are the communication, so
emphasis is on producing recognizable content units.
Slide 23
De-blocking, Semantic Access, and Drawing Drawing vs. writing
as a cue for verbal expression Drawing more effective in increasing
verbal naming (Davis, Farias, Baynes, 2005; Farias, Davis,
Harrington, 2006) Quality of the drawings has no impact on the
ability to access the semantic features of a word (Farias, Davis,
Harrington, 2006) Possible Explanation?
Slide 24
Communicative Drawing Program (CDP) The functional goal of the
CDP is for patients with aphasia who are unable to convey desired
messages through speech or writing to communicate instead through
drawing. (Helm-Estabrooks & Albert, 2004, pg. 273)
Slide 25
CDP Candidate Profile (Helm-Estabrooks & Albert, 2004)
Inability to communicate information through speech or writing
Ability to use a medium-point felt-tip pen to copy one dimensional
shapes Relatively intact visual memory Good visual attention skills
Alert, cooperative, and willing to pursue a drawing program to
improve functional communication Pre-morbid artistic skills are not
required, nor it is necessary to draw with the dominant hand
Slide 26
Overview of Steps 1.Basic semantic-conceptual knowledge
2.Knowledge of object color properties 3.Outlining pictures of
objects with distinct shape properties 4.Copying geometric shapes
5.Completing drawings with missing internal and external features
6.Drawing objects with characteristic shapes from memory 7.Drawing
objects to command from stored representations 8.Drawing objects
within superordinate categories 9.Generative drawing- animals and
modes of transportation 10.Drawing cartooned scenes
(Helm-Estabrooks & Albert, 2004)
Slide 27
Circle the objects that belong together. Criterion: 100%
identification of the 5 items in 5 different superordinate
categories Step 1 Basic Semantic-Conceptual Knowledge
Slide 28
Select the correct color (from 12 colored markers) and color
that item. Criterion: Correct color choices for all nine items.
Step 2 Knowledge of Object Color Properties
Slide 29
Select the correct color (from 12 colored markers) and color
that item. Criterion: Correct color choices for all nine items.
Step 2 Knowledge of Object Color Properties
Slide 30
Take this pen and draw an outline around each object without
touching the lines of the pictures Criterion: Each object outline
conforms to shape and does not touch or trace the lines of printed
stimuli Step 3 Outlining Pictures of Objects with Distinct Shape
Properties
Slide 31
Take this pen and copy each figure. Your drawings should not
touch the examples. Criterion: For each shape, all lines are
present, in correct proportion and in proper relation to one
another Step 4 Copying Geometric Shapes
Slide 32
Show me what is missing in this pictureOkay, now take this pen
and fill in the missing part. Criterion: All completions are
successfully rendered, complete, and conceptually reasonable Step 5
Completing Drawings with Missing External and Internal
Features
Slide 33
Look at this object. (Present single card.) Remember what it
looks like, because Im going to ask you to draw it. Okay, are you
ready? Take this pen and draw the object here. Criterion: For each
shape, all lines are present, in correct proportion and in proper
relation to one another Step 6 Drawing Objects with Characteristic
Shapes from Memory
Slide 34
Step 7 Drawing Objects to Command from Stored Representations
Look at this word. It says____ Can you draw____right here? ice
cream Criterion: Drawings of each object can be correctly
identified by a nave judge who is not shown the target words
Slide 35
Step 8 Drawing Objects Within Superordinate Categories See this
word? It says ___. I want you to think of a _____ and draw it right
here. tool Criterion: All responses belong to the named
superordinate category and can be identified correctly by a nave
judge not provided with the target words.
Slide 36
Step 9 Generative Drawing: Animals and Modes of Transporting
People On this page, I want you to draw as many types of
animals/modes of transportation as you can. Make your drawings
clear enough so that anyone could name the animals/modes of
transportation that you draw. Criterion: All responses are correct
exemplars of the superordinate categories and are correctly
identified by a nave judge.
Slide 37
Step 10 Drawing Cartooned Scenes Show me what is funny about
this pictureNow study the picture well because Im going to ask you
to draw it from memory. Criterion: Each panel should be accurate
enough for a nave judge to identify all elements necessary for
understanding and stating the message (joke) of each cartoon.
Slide 38
CDP: Case Study (A.S) 45-yr-old male Status post left basal
ganglia intracranial hemorrhagic CVA 10/03/2008 Dentist Bilingual
in English (primary) and Japanese Mixed, non-fluent aphasia -
Verbal expression characterized by: - 1-word utterances - verbal
apraxia - decreased loudness and pitch range - confrontational
naming relatively intact - Written expression characterized by
1-word phrases - Severe auditory and reading comprehension deficits
(1-2 word phrases) - Used writing and gestures to supplement verbal
expression
Slide 39
Sample CDP Goals (A.S.) Goal: To improve multimodality
communication, the client will draw three-panel drawings from
memory with enough detail so that a naive judge can identify the
message. Objective 1: In the clinical setting, when given the name
of an object with distinct visual features (i.e., ice cream cone,
palm tree, etc), the client will draw the object with enough detail
so that a naive judge can identify the object with 100% accuracy in
a minimum of 10 trials. Objective 2: In the clinical setting, when
given a superordinate category (e.g., tool, animals, vehicle, etc.)
and no prompts, the client will draw at least one object within the
specified category with enough detail so that a naive judge can
identify the object with 100% accuracy in a minimum of 10 trials.
Objective 3: In the clinical setting, when given a three-panel
cartooned story, the client will draw the story from memory with
enough detail so that a naive judge can identify the message of the
cartoon in 2 out of 3 trials.
Slide 40
CDP Training/Tasks (A.S.) Began with Step 3 of the CDP During
Step 7 1.Modeled adding more detail to unrecognizable drawings
2.Client began to spontaneously add more detail 3.Clinician
provided the client with a puzzled look whenever his drawings were
not recognizable Homework given for Steps 8-9 CDP supplemented by
multimodality communication Barrier tasks encouraged all
modalities
Slide 41
CDP Outcome Measure The client will draw one-, two-, and
three-panel cartooned stories from memory. Panel should be accurate
enough for a nave judge to identify all elements necessary for
understanding and stating the message (joke) of each cartoon.
(Helm-Estabrooks & Albert, 2004)
Slide 42
1-Panel Model Copyright 2003. Helm-Estabrooks, N. Communicative
Drawing Program Cartoons
Slide 43
Post-Therapy Pre-Therapy
Slide 44
2-Panel Model Copyright 2003. Helm-Estabrooks, N. Communicative
Drawing Program Cartoons
Slide 45
Post-Therapy Pre-Therapy
Slide 46
3-Panel Model Copyright 2003. Helm-Estabrooks, N. Communicative
Drawing Program Cartoons
Slide 47
Post-Therapy Pre-Therapy
Slide 48
Maintenance/Generalization Data Copyright 2003.
Helm-Estabrooks, N. Communicative Drawing Program Cartoons
Slide 49
Maintenance/Generalization Data Caregiver interview and the
Communicative Effectiveness Index (CETI) indicate that A.S.
primarily communicates via verbal and written expression and
drawing 1 2 3
Slide 50
Potential Supplemental Practice - Game Apps Draw Something
Social drawing and guessing game Whiteboard Collaborative drawing
app
Slide 51
Agenda Multi-Modality Communication and Aphasia Correlations
with Neuroplasticity Drawing and Aphasia iTechnologies for
Communicative Drawing Examples of available iApps Features of
available iApps Recommendations for Selection Communicative Drawing
and iTechnology in a Clinical Setting New Directions and Future
Research Questions and Answers
Slide 52
New Frontier The role of new technologies in multimodal
communication, including drawing. More questions than answers Is
new technology applicable for drawing purposes? What technology is
best? Any hidden pitfalls? Any potential advantages? Where to
begin??????
Slide 53
Technology for PWA Most often technology is used in speech
therapy for: stimulus material, data tracking, and AAC (ASHA, 2011)
Technology-aided therapy effective, due to the increased intensity
of treatment (van de Sandt- Koenderman, 2011) Likely due to
potential for use with multiple communication partners and use
across multiple settings
Slide 54
What is a Smartphone? Smartphone is a mobile phone that
includes software that a user is able to modify and update. The
user controlled software must be able to transfer information to
and from external systems (Toyysy & Helenius, 2006, p.
110).
Slide 55
Windows Phone $400-$500 Android $300-$400 Blackberry $250-$500
Smartphone Options
Slide 56
iPhone $400-$600 HP Palm $400-$600 Nokia $400-$600
What is an App? Apps is an abbreviation for application Piece
of software that can run on the Internet, on a computer, on a phone
or other electronic devices Variety of available on different
smartphones Some require internet connectivity, while others do run
off-line
Slide 60
What is iTechnology? Technology manufactured by Apple,
collectively referred to as: iTechnology or iDevices For example:
iPads iPod Touch iPhones
Slide 61
Potential Benefits of Drawing Apps Unlimited numbers of pages
accessible without erasing Save and organize drawings created for
future access/modification Enhance drawings with colors, stored
symbols, and backgrounds. Incorporate real photographs Possibility?
GPS Picture Prediction (e.g., Locabulary for picture) Export and
send drawings via email Some apps include keyboard function to
augment drawing with typed letters, words, or phrases. Possibility?
Text-to-speech Possibility? Interactive Alphabet Board/Phoneme
cue
Slide 62
iTechnology: A Pilot Study Methods 4 PWA Ages 20 80 years old
Non-fluent forms of aphasia Participants were evaluated on their
ability to: Access and navigate within a drawing app (NotesPlus)
Intelligibility of their drawings (as compared to traditional paper
and pencil methods) Ostergren, J., & Raminick, J. (n.d.)
Drawing and iTechnology: A pilot study in the use of a drawing iApp
by individuals with aphasia (n.d.). Unpublished manuscript.
Slide 63
CDP Cartoon Copyright 2003. Helm-Estabrooks, N. Communicative
Drawing Program Cartoons
Slide 64
Paper/Pencil vs. iPad Intelligible to a naive judge using pen
and paper Intelligible to a naive judge using the iPad PT1 HPR
One-PanelYes Two-PanelYes Three-PanelNo PT2 One-PanelYes
Two-PanelNo Three-PanelNo PT3 One-PanelNo Two-PanelYes
Three-PanelYes PT4 HPL One-PanelNo Two-PanelYesNo
Three-PanelYesNo
Slide 65
Example (PT 1): Paper/Pencil vs. iPad
Slide 66
App Use: Ease of Use After Training
Slide 67
PT 4: Words of Caution Still obstacles to over-come
Non-dominant hand use/Limited control Registering drawing contact
(false starts) No different in stylus vs. finger-tip Difficulty and
frustration with touch screen use (with and without stylus) No
previous touch screen use Lower levels of use and confidence with
computers and technology in general
Slide 68
Finding the Right App: Recommended Feature Analysis - ASHA
defines feature matching as: devices are selected based on
relationships between an individual's strengths capabilities and
communication needs in relation to various features of a device
(ASHA, 2004, page 9).
Slide 69
Best predictor of long-term success with AT is careful
selection of aids to ensure they are well- matched to the user and
the environment (Scherer et al., 2007)
Slide 70
Which Apps to Use: App Analysis Ostergren, J. & Gastelum,
M. (n.d.). An Exploration iTechnology Drawing Apps for Individuals
with Aphasia. Unpublished manuscript. Evaluation of Drawing and
Writing apps for communicative drawing purposes, given: Phase 1
Phase 2 Phase 3
Slide 71
Phase 1 App Identification (Part A) METHODS Search Terms: Apps
with drawing or handwriting in search terms Consumer Ratings: Apps
highly rated by users on the Apple Market place as a 4 or higher
stars Device Mode: Apps that could be utilized on an iPad.
Category: Productivity apps RESULTS 22 drawing apps 112 writing
apps identified TOTAL = 134 apps
Slide 72
Phase 1 App Identification (Part B) METHODS Line Sizes. Apps
with at least 8 line size options Color Choices. Apps with at least
8 color options Background Choices. Apps with the ability to modify
the background in some fashion beyond strictly a white canvas were
selected. Saving Capacity. Apps with the ability to save drawings
for future retrieval and easily modification. Ability to Email.
Apps with an email function. RESULTS 5 drawing apps 9 writing apps
identified TOTAL = 14 apps
Slide 73
Phase 3 App Evaluation METHODS Apps from Phase 2 rated using 5
point scale, as follows Ease of Navigation: 1 = Complex navigation5
= Minimal/Easy Navigation Visual Distraction 1 = Maximal
Distraction....................5 = Minimal Distraction Workspace: 1
= Small Icons/Workspace..5 = Large Icons/Workspace Iconicity: 1 =
Opaque Icons5 = Transparent Icons
Slide 74
Drawing Apps
Slide 75
Writing Apps
Slide 76
Looking Deeper: Additional Trends Uncovered Options for setting
hand use (right vs. left) Moveable palm rests Icon knowledge
required Layers in saving Less is more Remote access/additional
accounts (e.g., EverNote) Start position important Access knowledge
required Tapping, swiping, and finger expansion
Recent Replication: Pilot Study 13 additional PWA Varying forms
of aphasia (fluent and non-fluent) Varying ages All in chronic
stage of recovery from a CVA All receiving services at CSULB for
communication impairments Asked to draw a 1-panel CDP cartoon using
paper and pen and one (1) of the following apps: Sketch Time Jotter
Absolute Board Noteshelf
Slide 83
Sketch Time Intelligible to a naive judge using pen/paper
Intelligible to a naive judge using the iPad PT 1YesNo PT 2 HPL No
PT 3No
Slide 84
Jotter Intelligible to a naive judge using pen/paper
Intelligible to a naive judge using the iPad PT 1No PT 2 HPL YesNo*
PT 3 HPL No
Slide 85
Absolute Board Intelligible to a naive judge using pen/paper
Intelligible to a naive judge using the iPad PT 1YesNo PT 2 HPR
NoYes PT 3 HPL No PT 4YesNo
Slide 86
Noteshelf Intelligible to a naive judge using pen/paper
Intelligible to a naive judge using the iPad PT 1 HPL No PT 2 HPR
No PT 3 No
Slide 87
RESULTS 5/17 PWA had intelligible drawings in the paper and
pencil mode (29%) Two (2) had equally intelligible app drawings
(Notesplus) Three (3) had less intelligible app drawings (Jotter,
Absolute Board, and Sketch-Time)*
Slide 88
Ad Hoc and Qualitative Motor control and app use: 9/17
individuals had hemiparesis (52%) 3 of these individuals had
intelligible drawings in one mode (33%) 1 = equally intelligible
drawings in both modes 1 = less intelligible app drawing 1 = less
intelligible paper/pencil Most individuals in our study with
hemiparesis had unintelligible drawings in both modes (6/9,
67%)
Slide 89
Conclusion Interpret with CAUTION small sample! For some
individuals, drawing using an app was less intelligible, with some
apps But
Slide 90
The Devils in the Details Aim for Total Communication
Slide 91
Slide 92
Slide 93
Slide 94
Pointed to spot highlighted and said: Water and Hot. Also,
gestured drinking.
Slide 95
Big Picture: Lessons Learned Aim for communication, not
perfection in drawing. Incorporate within multimodality system
(e.g., speech, writing, gestures, AND drawing) Provide education in
neuroplasticity and the positive impact of drawing on verbal
expression Consider pre-morbid technology use and comfort Increase
acceptance by minimizing client frustration
Slide 96
Additional Lessons Learned: Experiment/Match to Client Compare
Drawings on Different Apps Explore Palm Rest/Hand Use Settings
Evaluate Stylus vs. Finger-tip Individual preference a factor
Assess with different pen settings on the app (fine vs. large)
Assess Case Withstand pressure from resting palm while drawing
Adjust to different positions
Slide 97
Additional Lessons Learned: Therapy Tips Incorporate within
Multimodality/Total Communication Training Speaking Gestures
Drawing Writing Use Barrier Tasks Train Partners Use CDP to Enhance
Details (Internal/External Features) Assess with Referential
Communication Tasks
Slide 98
Referential Communication Task Based on Purdy and VanDyke
(2009) CSULB Modifications: 15 real color photographs of common
everyday activities Unfamiliar listener: Instructions: A PWA is
going to be describing to you pictures shown to them. You will not
be able to see these pictures. The PWA may speak, write, draw,
gesture (or use a variety of methods) in describing these pictures
to you. Please write down what you think the picture
represents.
Slide 99
Agenda Multi-Modality Communication and Aphasia Correlations
with Neuroplasticity Drawing and Aphasia iTechnologies for
Communicative Drawing Examples of available iApps Features of
available iApps Recommendations for Selection Communicative Drawing
and iTechnology in a Clinical Setting New Directions and Future
Research Questions and Answers
Slide 100
Future Research: Information Needed Develop and test frameworks
for effectively and efficiently evaluating apps Explore
communicative drawing and technology Influence of technology in
communication dynamics Collect actual efficacy data Just because it
is new, doesnt make it better. Move toward dedicate apps for PWA
that allow for fluidity in modalities PWA input critical
Slide 101
Agenda Multi-Modality Communication and Aphasia Correlations
with Neuroplasticity Drawing and Aphasia iTechnologies for
Communicative Drawing Examples of available iApps Features of
available iApps Recommendations for Selection Communicative Drawing
and iTechnology in a Clinical Setting New Directions and Future
Research Questions and Answers
Slide 102
Q & A For additional information about this presentation
contact: Dr. Jennifer A. Ostergren Assistant Professor California
State University, Long Beach Department of Communicative Disorders
[email protected]
Slide 103
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Reference Pulvermller, F., & Berthier, M. L. (2008).
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