Situation-Specific Therapy Addressing Functional Reading: A Case Study

*Currently Affiliated with Mercy Medical Center-North Iowa

Address correspondence to:

Angela N. Burda, Ph.D.
Department of Communicative Disorders
University of Northern Iowa
230 Communication Arts Center
Cedar Falls, IA 50614-0356
angela.burda@uni.edu

Abstract

This paper presents a case study in which an 18 year old male with non-fluent aphasia following a gunshot wound learned how to perform a functional reading task utilizing situation-specific therapy. Situation-specific therapy is an approach in which patients are taught a small set of specific responses related to a functional situation (Hopper & Holland, 1998). In this study, the participant learned to locate businesses in the yellow pages and dial the corresponding phone number. Initially, the participant was unable to complete the task, but following 10 treatment sessions, he accurately completed the target tasks. He maintained the capacity to perform the task for one month following the conclusion of treatment. Situation-specific therapy can be an additional tool for speech-language pathologists wanting to address communication in particular contexts.

Situation-Specific Therapy Addressing Functional Reading: A Case Study

Recent trends in health care, such as a reduction in Medicare and other third party payer benefits as well as the implementation of a prospective payment system (Estes et al., 1993; Hackler, 1994) have greatly impacted the provision of speech-language therapy. These trends have resulted in shorter stays and fewer therapy sessions being approved for reimbursement, requiring speech-language pathologists (SLPs) to explore time efficient treatment models. For example, therapy approaches may need to target functional communicative skills that will generalize to patients' daily living situation and do so in an efficient manner. As Kearns (1989) notes, carryover of improvements in individuals' functional communicative skills is the primary goal of speech pathology intervention.

In order to meet this increasing challenge, researchers have studied the functional communication approach as a means to target inefficient or ineffective language use in natural communication contexts (Horner, Loverso, & Rothi, 1994). More specifically, functional communication treatment seeks to improve specific communication skills in order to conduct daily activities, interact socially, and express physical and psychological needs (Aten, 1994). For example, Hillis (1989) trained two aphasic persons' written naming skills to improve overall writing in a number of functional communication situations. Both individuals demonstrated acquisition and maintenance for written naming, but only one showed generalization to untrained stimuli. In another example, Lowell, Beeson, & Holland (1995) used a general naming strategy that could potentially be used in any functional situation. Three individuals with aphasia participated, and two out of the three showed improved naming performance with generalization to untrained items. One of the participants did not show significant improvement. A logical extension of functional communication therapy is situation-specific therapy. In this approach, patients are taught a small set of specific responses related to a functional situation (Hopper & Holland, 1998). Generalization occurs only to items similar to those that are specifically trained.

Hopper and Holland (1998) conducted one of the first studies to evaluate the efficacy of a situation-specific treatment to improve patient communication in an emergency. Two individuals with Broca's aphasia were trained to communicate over the phone in emergency situations. A set of ten photographs depicting emergencies (e.g., drowning in a pool, choking) were used, with six of the photographs used in training, and the remaining four used to assess generalization. During training, each patient was asked to describe the emergency in terms of who was in it, what was happening, and where it was happening. Treatment followed a cueing hierarchy and used role-playing. Training continued until the participant received a score of 83% accuracy (5/6 correct) on picture identifications over two consecutive probe sessions, or until ten treatment sessions were completed. Following the completion of treatment, generalization was assessed by the patient's performance on the remaining four photographs. One participant achieved criterion (83%) on the trained items but both participants generalized their performance to the untrained items and maintained this performance at one month post treatment. Therefore, Hopper and Holland's (1998) study suggested that this treatment program was effective in improving the participants' ability to verbally express emergencies over the telephone.

The use of situation specific therapy is consistent with the American Speech-Language-Hearing Association's (ASHA) Scope of Practice (2001) which notes the objective of speech-language pathology is to optimize individuals' abilities to communicate successfully in natural environments, thereby improving their quality of life. ASHA's Scope of Practice uses the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) (WHO, 2001) as a framework for examining rehabilitation activities. For example, the Activity/Participation portion of the ICF includes many aspects of functional behavior, including communication (Threats, 2001). Speech-language pathologists can utilize the ICF framework and collaborate with the patient to select an appropriate treatment target. Intervention is designed based on individual patient's needs and with each patient's input. To illustrate, a clinician might have two patients with nonfluent aphasia at similar levels of severity but who want to be able to do different activities in the course of their daily lives. Using the ICF collaborative model, the therapist and client A might decide that intervention needs to target verbal expression so that the patient can telephone his grandchildren and say "Happy Birthday." Patient B, on the other hand, might want to be able to formulate grammatical responses while writing letters to relatives but has little interest in verbal activities. Thus, uniquely designed intervention approaches occur with each protocol including the patients' selection of functional activities within the Environmental and Personal Factors framework in the ICF. Based on their desired outcome tasks, both patients would benefit from situation-specific therapy, which allows specific tasks in specific contexts to be addressed in a systematic, intensive manner. Intervention can be matched to the immediate needs of the patient.

Since few investigations exist for situation-specific therapy, more research is needed to outline potential treatment plans and to investigate their potential benefits. The purpose of this project was to determine whether or not situation-specific treatment improved an individual's ability to access and act on information in the yellow pages, a task considered to be a functional activity (Worrall, 1995). This study sought answers to the following research questions: (1) Did the participant benefit from the treatment? (i.e., did W. G. learn to use the yellow pages to call businesses within 10 sessions?); (2) Did the participant generalize learning to untrained items? (3) Was the learning maintained following the completion of treatment?