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Modifying the Communicative Abilities of Daily Living (CADL-2) for Use with Illiterate Persons with Aphasia: Preliminary Results

Modifying the Communicative Abilities of Daily Living (CADL-2) for Use with Illiterate Persons with Aphasia: Preliminary Results
Nidhi Mahendra, PhD, CCC-SLP
November 22, 2004

Postdoctoral Fellow
Department of Speech Language and Hearing Sciences
University of Arizona


Illiterate individuals with aphasia comprise a unique and little studied population. Researchers have demonstrated substantial differences in performance of literate and illiterate individuals on linguistic tests (Lecours, Mehler, Parente, & Caldeira, 1987, 1988) and have suggested that diagnostic tools need to be modified for this population. However, there remains a dearth of appropriate language assessment tools for use with these people.

The primary focus of this study was to translate the CADL-2 (Holland, Frattali, & Fromm, 1998) into Hindi and modify it for use with illiterate aphasic persons residing in India. Preliminary data are presented from fifteen individuals, highlighting the effects of cultural and linguistic variables on test performance. Clinical implications of these data are discussed.


Appropriate assessment and management of language deficits in illiterate individuals with aphasia has long posed a challenge to speech-language pathologists. This challenge is especially significant in developing countries like Mexico and India where large percentages of the population live in rural areas and illiteracy is common. In India, 80% of the country's population lives in rural areas and there is a high prevalence of illiteracy, with approximately 27% of adults being illiterate. However, illiteracy is not a problem confined only to developing countries. For instance, in the 1991 report of the United States Census Bureau, some 22 million illiterate American adults (Kahn & Kelly, 1991) were reported.

There are few appropriate language tests to assess the performance of illiterate aphasic individuals (Castro-Caldas, Reis, & Guerreiro, 1997). Researchers have found substantial differences in performance of literate and illiterate individuals on linguistic tests and psychometric measures (Lecours et al., 1987; Lecours et al., 1988). Therefore, assessment measures and tests should be modified for illiterate people with cognitive and communicative deficits.

However, when developing measures of functional communication, or modifying existing tools for use with illiterate persons with communication disorders, an important issue is the perception of what is considered 'functional communication' by literate versus illiterate persons.

Functional communication has been defined as communication skills used in everyday living situations. This paper represents the first attempt to characterize functional communication in individuals with aphasia, who were premorbidly unable to read or write.

The first goal of this study was to conduct a literal translation of the CADL-2 (Holland et al., 1998) to change the language from English to Hindi, and modify it for use with a population of illiterate individuals with aphasia. The second goal was to explore the need for a cultural translation i.e., changing or modifying test stimuli or response scoring guidelines, to evaluate aphasia among illiterate persons residing in India. This application is significantly different from that for which the CADL-2 was originally developed.

Nidhi Mahendra, PhD, CCC-SLP

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