Assessment in terms of motor speech function should cover a range of areas. In the CASE assessment, topics such as: Automatic speech, isolated syllables, words, words of increasing length, sentences, diadokinesis tasks, phonatory efficiency, oral reading, oral mechanism, and prosody are explored. This is based on the research of Darley et al., 1975 that noted dysarthria could affect phonation, resonance, articulation or prosody as the result of damage to the central or peripheral nervous system. When assessing motor speech functions, Wertz et al (1984) has also suggested that prosody is affected in patients with conditions such as apraxia. In an article titled Speech, Language, and Swallowing Disorders in the Older Adult, Ashley et al. (2006) discusses how individuals with apraxia can have fairly intact ‘automatic speech’, which makes it a key part of a motor speech assessment so clinicians are able to adequately differentially diagnose. Ardran and Kemp (1970) discuss oral-motor assessment, which was used a basis for the oral mechanism portion of the CASE oral motor subtest. Duffy (2005) also noted that the examination of speech and motor programming should include maximum phonation time, diadochokinetic rates, isolated sound and syllable production, words in simple and complex syllable structures, words of increasing length, automatic/frequent words or phrases and contextual speech. The National Institute for Deafness and Other Communication Disorders (2005) also supports using speech tasks that include repeating a set of words of increasing length or reading sentences of increasing length and complexity. Didokinesis norms were obtained from Fletcher, S.G. (1972) and phonatory efficiency norms were obtained from Hirano, Koike, & VonLeden (1968).
In 2009, the National Early Literacy Panel conducted a meta-analysis of over 500 research articles and determined: letter matching, phonological awareness, print awareness, decoding, reading comprehension, segmentation of words, naming objects rapidly, and even writing and spelling one’s name were all predictive of literacy achievement. Additionally, research by Bradley & Bryant, 1983; Bruck, 1992; Fletcher 1972, Lindamood, Bell, & Lindamood, 1992 support and underscore the importance of phonological awareness in the assessment and remedial instruction of disabled readers.
Pragmatics involves using language, changing language, and following rules as they relate to the social culture (Social Language Use (Pragmatics), 2014). The CASE assessment explores the topics of: Emotions, Situations, Humor, Sarcasm, Figurative Language, Social Conventions, and Conversational Skills. Emotions were covered based on a variety of research supporting deficits in this area due to brain injury. Patients with right hemisphere impairments may have difficulty understanding the emotion provided by the communication partner (Blonder et. al, 1995). Fainsilber and Ortony (1987) concluded that people use figurative language, such as metaphors, for describing intense emotions. Ortony (1975) explains that metaphors can evoke vibrant descriptions of the physical experience of emotion, while Gibbs et al. (2002) states that metaphors also convey more subtle shades of emotion. Individuals with impaired ability to understand and interpret emotions would then have difficulty with these aspects of pragmatic language. Individuals from different cultures may also have difficulty understanding nuances of pragmatics such as social conventions. Garcia (2004) discusses the importance of pragmatics on English language learners to understand and interpret a speaker’s intentions and feelings, and further, to respond appropriately. Bara et al. (2000), Leitman et al. (2006), Rajendran et. al. (2005), and Channon et al. (2005 & 2007) concur that patients with traumatic brain injury (TBI), schizophrenia, autism, and dementia have demonstrated deficits interpreting sarcasm from contextual cues. When this social language skill is compromised, the impaired individual may have difficulty understanding the implied criticism (McDonald, 1999) where the speaker’s comments are implied to be callous (Dews & Winner, 1995); however, the impaired individual may perceive their comments as polite (Jorgensen, 1996). Conversational skills in right hemisphere damage may be related to pragmatic functions such as: turn taking, topic maintenance (Van Lancker, 1997). Van Lancker also goes on to remark that understanding of humor, and non-literal meanings can also be impaired as a result of damage to the right hemisphere. Prosodic difficulties also arise in the form of monotonous speech (Pell, 2006), and an abnormal rate of speech (Blonder et. al, 1995).
CASE’s non-verbal section was designed to assist the therapist in determining the non-verbal patient’s ability level and guide the therapist towards a communication system that would best suit the patient. The first subtest is comprised of gesture imitation. Iverson and Thal (1998) describe gestures as “actions produced with the intent to communicate and are typically expressed using fingers, hands, and arms, but can also include facial features and body motions.” The CASE app assesses basic gestures (i.e. closing eyes on command shaking head, and holding up fingers). The Handbook of Augmentative and Alternative Communication (1997) states that it is important to assess current ability to use gestures “Nonverbal communication modalities serve to supplement the client’s use of verbal communication.” The patient will need to be able to point or gesture to the appropriate pictures or symbols for the next set of subtests as we move into receptive ID of objects. The handbook further suggests that it is imperative the patient is able to discriminate between picture symbols. Pictures in the CASE app come in a field size of 3 and 6. The minimum field size is 3 to rule out chance. As we move up to a field size of 6, the pictures become smaller. For patient’s who can read, the following subtests, also in a field of 3 and 6, will provide a basic understanding of the patient’s reading ability level. This was included in the non-verbal section as well so therapist’s can get a quick idea if pictures or words would be the best access method for the patient. For individuals who are non-verbal, but are not able to utilize gestures, the eye gaze subtest can provide a very basic starting point to determine if further investigation into a potential eye gaze device may be beneficial to the patient. It can also be used in conjunction with a head mounted laser pointer. This is in a field of 1 and 2. In the field of one, there is only one picture in the field with the rest of the boxes empty. This is to determine if the patient is able to hear a direction to look at an object and if the eyes go towards that part of the screen. When we increase the field size to two, the middle box remains empty so the patient will either need to look left or right. This next step is probed to determine if the patient can discriminate when there is a distractor image in the field. This is also tested with the pictures further away from one another.
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