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Script Training Treatment for Adults With Apraxia of Speech

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Outcomes of script training for individuals with apraxia of speech (AOS) and mild anomic aphasia were investigated. Script training is a functional treatment that has been successful for individuals with aphasia but has not been applied to individuals with AOS. Principles of motor learning were incorporated into training to promote long-term retention of scripts. Three individuals with AOS completed script training. A multiple-baseline, across-behaviors design examined acquisition of client-selected scripts. Errors and speaking rates were also analyzed. Random practice and delayed feedback were incorporated into training to promote motor learning. Probes for long-term retention were elicited up to 6 months after treatment. All clients successfully acquired their scripts, and probes demonstrated script retention 6 months after treatment. Errors generally decreased but remained variable even during maintenance and retention probes. Speaking rate increased for 2 clients but also remained variable. Script training was successful and functional for clients with AOS. Clients reported increased confidence, speaking ease, and speech naturalness. Although scripts did not become errorless, clients retained their scripts and reported using them frequently. Whether principles of motor learning may have promoted the long-term retention of scripts exhibited by participants must be determined through future research.
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Script Training Treatment for Adults
With Apraxia of Speech
Gina Youmans
Scott R. Youmans
Long Island University, Brooklyn, NY
Adrienne B. Hancock
George Washington University, Washington, DC
Purpose: Outcomes of script training for indi-
viduals with apraxia of speech (AOS) and mild
anomic aphasia were investigated. Script training
is a functional treatment that has been successful
for individuals with aphasia but has not been
applied to individuals with AOS. Principles of
motor learning were incorporated into training
to promote long-term retention of scripts.
Method: Three individuals with AOS completed
script training. A multiple-baseline, across-
behaviors design examined acquisition of client-
selected scripts. Errors and speaking rates were
also analyzed. Random practice and delayed
feedback were incorporated into training to pro-
mote motor learning. Probes for long-term reten-
tion were elicited up to 6 months after treatment.
Results: All clients successfully acquired their
scripts, and probes demonstrated script retention
6 months after treatment. Errors generally de-
creased but remained variable even during main-
tenance and retention probes. Speaking rate
increased for 2 clients but also remained variable.
Conclusions: Script training was successful
and functional for clients with AOS. Clients
reported increased confidence, speaking ease,
and speech naturalness. Although scripts did not
become errorless, clients retained their scripts
and reported using them frequently. Whether
principles of motor learning may have promoted
the long-term retention of scripts exhibited by
participants must be determined through future
research.
Key Words: script training, apraxia of speech,
motor learning
Script training is a relatively new, functional approach
to the treatment of neurogenic communication dis-
orders. Script training was initially developed by
Holland and colleagues (Holland, Milman, Munoz, & Bays,
2002) to facilitate verbal communication on client-selected
topics. As compared to a total communication approach to
therapy, script training focuses more narrowly on reinject-
ing islands of relatively fluent, automatic speech into the
conversation of individuals for whom speech production is
no longer automatic. Script training is intended for those
individuals who wish to speak relatively normally, within the
limited context of a few practiced, reautomatized phrases,
on a few personally important topics.
Youmans, Holland, Munoz, and Bourgeois (2005) inves-
tigated script acquisition and automatization in two individ-
uals with chronic, moderately severe, nonfluent aphasia.
Client-selected scripts were trained phrase-by-phrase in a
cumulative manner, using a cuing hierarchy that began with
in-unison production and ended with independent produc-
tion. A single-subject, multiple-baseline, across-behaviors
design was employed in this study. Each participant mastered
three scripts, and mastered script productions were judged
to be automatic as measured by stability of performance,
relatively errorless productions, speaking rate, and speech
naturalness. A 90% script acquisition criterion was used.
Treatment time ranged from 3 to 4 weeks of hour-long, twice
weekly sessions, and both clients reported using their scripts
frequently to communicate in daily situations. In addition,
social validity raters judged posttreatment speech produc-
tions to be significantly more natural and more informative
than baseline speech productions. Therefore, script training
was practical and functional for the two individuals with
nonfluent aphasia.
Script training was initially based on the instance theory
of automatization (Logan, 1988). Instance theory defines
automaticity as the retrieval from memory of complete,
context-bound, skilled performances. Each performance of
a task is stored in memory as an instancerepresentation,
and skills become more automatic as a learner shifts from
reliance on a general learning algorithm to reliance on recall
Research Article
American Journal of Speech-Language Pathology Vol. 20 2337 February 2011 AAmerican Speech-Language-Hearing Association 23
of past performances. Because instance theory supposes
recall of integrated performances, it predicts that to become
automatic, skills must be practiced in a holistic fashion rather
than in a dissected, component-based manner. In this view,
tasks are not broken down and practiced as component skills,
such as naming, grammatical rule use, and isolated sound
productions, because the development of automaticity does
not depend on improvement of such underlying processes;
automatization of a skill is item-based rather than process-
based. Following this theoretical paradigm, scripts in the
Youmans et al. (2005) study were practiced at the phrase
level rather than at the level of syllables or phonemes.
In addition, instance theory predicts that repetitive, spe-
cific practice is necessary to establish automatic, item-based
recall of past performances. Therefore, blocked practice of
targeted phrases was used, with more random practice intro-
duced only as completely mastered scripts were generalized
to conversational contexts. Also, feedback during script
training was given immediately and consistently, in an error-
less learning style, to promote rapid script acquisition, to
decrease learning of persistent errors, and to decrease client
frustration.
More recently, Cherney, Halper, Holland, and Cole
(2008) investigated a computerized version of script train-
ing with three participants: one classified with nonfluent
Brocas aphasia and the other two with fluent anomic and
Wernickes type aphasias. As in the previous study by
Youmans et al. (2005), individualized scripts were selected
by the study participants and then practiced primarily at
the phrase level in blocked fashion, following tenets of
the instance theory of automatization. Script training was
relatively successful for all three participants. Analysis of
pre- and posttreatment script productions indicated marked
improvement on topic content, grammatical productivity,
and speaking rate for all scripts. In addition, clients and
families reported increased communication across a variety
of situations, increased confidence, and general satisfaction
with the computer-based script training approach to therapy.
Although positive script acquisition data have been
reported, studies have not yet systematically explored long-
term retention of acquired scripts. It also remains to be seen
whether blocked training and errorless learning techniques
are the most appropriate practice conditions for script train-
ing, and whether practice and feedback conditions should
be varied across different neurogenic populations. Because
initial applications of script training have been successful,
script training should be further explored with individuals
who exhibit a variety of aphasia profiles, as well as with
individuals who present with coexisting motor speech
disorders.
Acquired apraxia of speech (AOS) commonly occurs
concomitant with Brocas, anomic, or nonclassified aphasia
(Wertz, LaPointe, & Rosenbek, 1984). AOS is a disorder
of motor speech characterized by disruption of automatic
programming and sequencing of oral motor patters for
speech (Darley, Aronson, & Brown, 1975; Johns & LaPointe,
1976; Kent, 2000). This disruption of sensorimotor plans or
programs causes speech to be phonetically and prosodically
distorted because phonological representations of speech
are inadequately programmed and executed (Duffy, 2005).
Because AOS involves a fundamental loss of automaticity
of speech production, script training may be an appropriate
and functional approach to the treatment of this disorder in
isolation, or as it co-occurs with aphasia.
Motor learning theories emerged from studies of skilled
motor behaviors in normal individuals, often limb move-
ments for sports training (Schmidt, 1991). These theories
posit that the skill acquisition phase, which is the focus of
the instance theory and most other learning theories of auto-
maticity, may not best represent learning. Instead, long-term
retention and generalization are invoked as the true indices
of motor skill learning (Schmidt, 1975; Schmidt & Lee,
1999). Motor learning literature identifies specific practice
conditions that may enhance retention and transfer of acquired
motor skills, including random practice rather than blocked
practice (Knock, Ballard, Robin, & Schmidt, 2000) and
practice specific to the target, such as focusing on complete
actions instead of isolated muscles (Clark, 2003). Motor
learning theories also predict that certain feedback conditions
will facilitate motor learning, including delayed feedback
rather than immediate feedback, and summary feedback after
multiple trials rather than feedback following individual trials
(Adams, Page, & Jog, 2002; Wulf, Schmidt, & Deubel,
1993).
There is much empirical evidence supporting motor
learning theory in sports training and limb rehabilitation
(Buxbaum et al., 2008; Gilmore & Spaulding, 2001; Krakauer,
2006; Langhammer & Stanghelle, 2000; Platz, Denzler,
Kaden, & Mauritz, 1994; Smania et al., 2006), and relatively
recently researchers have suggested that the integration of
motor learning principles with existing treatment protocols
may be particularly beneficial for clients who present with
AOS (Knock et al., 2000; McNeil, Robin, & Schmidt, 1997).
However, because principles of motor learning are based
on novel skill acquisition in normal, healthy individuals, the
question arises as to how and to what degree these learning
principles apply to skill relearning in neurologically impaired
populations, and to speech relearning in particular. To this
end, researchers have begun to systematically apply princi-
ples of motor learning to the treatment of individuals with
AOS.
To date, only one study has compared practice condi-
tions based on motor learning to traditional practice condi-
tions during AOS treatment. Knock and colleagues (2000)
compared a traditional model of blocked practice to random
practice during Phonetic Placement Therapy (Van Riper &
Irwin, 1958) for two individuals with severe AOS and coexist-
ing aphasia. Using a single-subject, alternating-treatment
design, these authors determined that single syllables trained
during random practice were retained more robustly at
probes 4 weeks after the termination of treatment. In addi-
tion, these authors observed transfer to similar but untrained
stimuli for randomly practiced syllables for one of the two
individuals with AOS.
One study has also examined motor skill retention and
transfer under varying frequency and timing of feedback
conditions. Austermann-Hula, Robin, Maas, Ballard, and
Schmidt (2008) compared acquisition of nonsense, single-,
and multisyllabic productions during Phonetic Placement
Therapy for four individuals with AOS under a traditional
24 American Journal of Speech-Language Pathology Vol. 20 2337 February 2011
high-frequency feedback condition (feedback after each
trial) to a low-frequency feedback condition (60% of trials
received feedback) prescribed by motor learning theory. Two
of the four participants demonstrated stronger retention of
stimuli trained with low-frequency feedback, one at 4 weeks
after treatment and the other at 8 months posttreatment,
and one of the four participants demonstrated stronger
transfer to untrained items after low-frequency feedback.
Results were also mixed for the timing of feedback effects;
only one of the two participants clearly demonstrated greater
transfer and retention of syllables trained under delayed
feedback conditions.
In the current study, we investigated whether a script
training approach, to date only applied to individuals with
aphasia, might benefit individuals with a primary diagnosis
of AOS and co-occurring, mild aphasia. Because emerging
evidence suggests that well-established principles of motor
learning in normal individuals may apply to impaired motor
systems, we modified the script training approach to include
principles of motor learning in an effort to promote long-
term retention of acquired scripts.
Method
Participants
Three participants whose primary diagnoses were AOS
were included in this investigation. Evaluation and diagnosis
of all participants was completed by speech-language pa-
thologists with extensive experience in motor speech dis-
orders. Participant 1 (P1) was 81 years old, right-handed,
and female; 15 months earlier she had experienced a left
cerebrovascular accident (CVA). Her scores on the Western
Aphasia Battery (WAB; Kertesz, 1988) indicated that she
had Brocas aphasia (Aphasia Quotient [AQ] = 50.3). How-
ever, most of her errors occurred on tasks that required a
verbal response, such as spontaneous speech, repetition,
and object naming, and most of these errors were judged as
secondary to AOS rather than aphasia. She demonstrated
comparably good word finding, accurately producing eight
of 10 items and approximating the spelling of the remaining
two, when she was allowed to write her responses and did not
need to struggle for speech productions. As she did not
exhibit grammatical difficulties typical of Brocas aphasia,
P1 was diagnosed with a mild anomic aphasia. The Apraxia
Battery for Adults (ABA; Dabul, 1979) was administered,
resulting in a diagnosis of moderate to severe AOS. Dur-
ing conversation and testing, this participant presented with
five out of five speech characteristics identified by McNeil
et al. (1997) as cardinal features of AOS. For the testing
profile of P1, please refer to Table 1.
Participant 2 ( P2) was a 40-year-old, right-handed
woman who 3 years earlier had experienced a left CVA.
The WAB was administered, resulting in an AQ of 75.6;
in accordance with the WAB profile, P2 was diagnosed
with mild anomic aphasia. This participant had a mild word-
finding impairment and an occasional difficulty with letter
transpositions in her writing, in the absence of other aphasic
errors. Her speech and writing were free of the syntactic/
morphological errors that would suggest an underlying lan-
guage formulation difficulty. The ABA was given, resulting
in a designation of mild to moderate AOS. P2 exhibited
each of the five cardinal speech characteristics of AOS from
McNeil and colleagues (1997), although she exhibited one
of these, an abnormally slow speaking rate, somewhat
inconsistently. This was most likely due to her less involved,
mild to moderate AOS impairment level. This participants
communication errors were primarily attributable to AOS.
Table 1 contains testing profile information for P2.
Participant 3 ( P3) was a 51-year-old, right-handed man
who had experienced a left CVA six years earlier. WAB
results indicated an AQ of 62 and a classification of Brocas
TABLE 1. Evaluation results for each of the participants.
Test /checklist Subtest
Participants
123
WAB Spontaneous Speech 9/20 18/20 13/20
Information Content 5/10 9/10 9/10
Fluency 4/10 9/10 4/10
Auditory Comprehension 9.05/10 9.1/10 7/10
Repetition 2.4/10 8.3/10 3.3/10
Naming/ Word Finding 4.7/10 9.5/10 7.8/10
Aphasia Quotient 50.3 75.6 62
ABA Diadochokinetic Rate Mildmod. Mildmod. Severeprof.
2 Syllable Average Severeprof. Mildmod. Severeprof.
Limb and Oral Apraxia Mildmod. Mildmod. Mildmod.
Utterance Time Severeprof. Mildmod. Mildmod.
McNeil checklist Slow rate Present Inconsistent Present
Prolonged segment/intersegment durations Present Present Present
Distortions/distorted sound substitutions Present Present Present
Errors consistent in type Present Present Present
Prosodic abnormalities Present Present Present
Note. WAB = Western Aphasia Battery (Kertesz, 1988); ABA = Apraxia Battery for Adults (Dabul, 1979); mod. = moderate;
prof. = profound.
Youmans et al.: Script Training and Apraxia of Speech 25
aphasia, and the participant was clinically diagnosed with
anomic aphasia when apraxic errors were taken into account.
P3 exhibited mild word-finding difficulties, as well as mild
auditory comprehension errors, and did not exhibit errors
indicative of an underlying difficulty with grammatical
formulation of language. This participant presented with all
five of the cardinal features of AOS (McNeil et al., 1997).
The ABA was administered, and the patient was diagnosed
with moderate to severe AOS. As with the first two partic-
ipants, most of P3s communication errors were secondary to
AOS. Please see Table 1 for the testing profile of P3.
Procedures
Prior to the initiation of this study, approval for all
procedures was granted by the institutional review boards
associated with the authorsuniversity affiliations. All
sessions took place in well-lit, quiet, distraction-free settings.
Two of the participants were seen by the same speech-
language pathologist, and the third participant was seen
by a different speech-language pathologist. Both speech-
language pathologists had experience working with adults
with acquired motor speech disorders. All procedures were
consistent for all of the clients with few exceptions; the
exceptions will be highlighted.
Prior to data collection, topics and scripts were created.
The participants were asked to decide on three functional
topics. Suggestions and feedback were given to the par-
ticipants about their choices; however, the participants were
encouraged to generate ideas that were personally relevant.
Scripts were then constructed collaboratively to reflect what
participants wanted to say in their own wording. The scripts
are presented in the Appendix.
Treatment session structure. Each participant was seen
individually for two or three 60-min sessions each week.
Treatment sessions were structured to allow at least three
10-min episodes of concentrated script training practice,
interspersed with approximately four brief periods of relaxed,
open conversation. At the beginning of each session, the
participants were audio-recorded while speaking on each of
their three chosen script topics. The participants were not
cued or given feedback during this data collection, with the
exception of P3, who required first word cuing on three
occasions during training. (This will be further discussed
in the Results section.) As scripts became mastered and
entered a random practice phase (see below), treatment ses-
sions ended with approximately 10 min of script conversa-
tion practice to promote flexible use of scripts. Additionally,
home practice sessions were prescribed twice daily for 15 min,
during which the participants practiced their scripts via a
tape recorder and written cue cards. Participants reported
consistency of home practice weekly.
Blocked practice. As script practice began, scripts were
trained one phrase at a time, using a blocked practice ap-
proach to promote acquisition. For this blocked practice, the
cuing hierarchy used previously for script training (Cherney
et al., 2008; Youmans et al., 2005) was followedthat is,
clinician modeling of the target phrase, clinician and partic-
ipant productions of the phrase in unison, clinician and par-
ticipant productions of the phrase in unison with clinician
fading participation, independent productions by the partic-
ipant with written cue cards, and independent productions
with no cuing. All cues and supports provided by the clin-
icians for independent phrase productions during this blocked
practice were delayed, and participants were allowed to
produce errors and/or struggle for 5 to 10 s before support
was provided. This allowance for active error correction
differed from the silent, reflective feedback interval that is
often incorporated into motor learning studies. Feedback
on articulator placement/positioning and on speech sound
accuracy was provided after each independent production
to promote successful acquisition of script phrases. Practice
tapes were recorded with successive, single phrase blocks, to
allow blocked practice at home.
Random practice. When three phrases of a script were
produced independentlywithout cuing or supportwith
90% accuracy, random practice of the script was initiated for
these acquired phrases, with additional phrases added into
random practice as they were successfully acquired. This
successive addition of phrases into random practice entailed
a blocked/random transitional period in which the first
practice episode consisted of initial acquisition, through
blocked practice, of a new script phrase, whereas the rest of
the session focused on random practice of acquired phrases.
Random practice was divided into two treatment tasks,
which both occurred during each session. First, the clinician
randomly selected and pointed to the cue cards used to train
the phrases. Participants were expected to produce each
phrase in the order in which it was indicated. Participants
were instructed to attempt each phrase only once before
moving on to the next phrase, regardless of the accuracy of
their production. This task was completed two to three times
per session in 510-min practice episodes, each including
a minimum of five trials of each phrase. Intertrial intervals
were not timed; rather, as soon as the client produced an
attempt at a target, the clinician indicated the next target.
This was to eliminate repeated self-practice, which tended
to occur when an intertrial interval was imposed and which,
as a type of blocked practice, could interfere with random
practice. Feedback on the accuracy of speech sound produc-
tion and articulator placement/positioning was provided in a
summary fashion after each episode of random practice. In
the second random practice taskwhich usually occurred
at least once, at the end of a sessionthe clinician and the
participant engaged in a structured conversation in which
the client was expected to produce, in a random order, the
phrases of the script being practiced in order to meet various
changing conversational demands. Summary feedback on
speech production accuracy was provided after each conver-
sation. In addition, during this random practice phase, home
practice tapes were rerecorded in a fixed random rather
than blocked order.
Dependent Measures
The data were collected via digital recorder at the begin-
ning of each session and later transcribed orthographically. A
second transcriber reviewed the transcripts to ensure accu-
racy. A third transcriber reviewed and resolved any transcript
differences between the first two transcribers. The transcripts
26 American Journal of Speech-Language Pathology Vol. 20 2337 February 2011
were then analyzed, and the dependent variables of percent-
age of script words produced correctly ( PSC), errors, and
speaking rate (defined below) were measured for each of
the scripts at the beginning of each of the sessions. A data
point for each of the dependent variables was plotted on each
graph for every session for visual inspection.
PSC was measured by dividing the total number of words
in the script that the participant produced correctly by the total
number of words in the script and multiplying the quotient
by 100. PSC was a measure of each participants accuracy of
script production and as such was the primary behavior of
interest. Accuracy for PSC for purposes of initial scoring and
reliability scoring was defined as script word productions
having no more thanone obvious sound production error (sub-
stitution, distortion, addition, or omission). In addition, if the
one error changed the meaning or distorted the production
so that it was judged unintelligible by the rater, the utterance
was considered an error rather than a script correct utterance.
Error production was also a variable of interest. Errors
were defined as word or phrase repetitions that were deemed
as noncommunicative, pauses greater than 3 s, unintelligible
utterances, and interjections. Errors were viewed as a reflec-
tion of how much the participant struggled while attempting to
produce scripts. The error count was not simply an inverse
of words correct. A client could produce many errors (pauses,
repetitions, etc.) or no errors, within any given script produc-
tion attempt.
Speaking rate in words per minute was calculated for
each of the scripts during each session. Speaking rate was
calculated by summing the number of nonerror, communi-
cative words produced during the script attempt, whether
part of the script or not. This count was then divided by
the number of minutes of the production attempt.
Experimental Design
A single-subject, multiple-baseline, across-behaviors ex-
perimental design was employed to determine the efficacy of
script training for each participant. The examiner monitored the
data for stable baselines before initiating treatment and for
visually evident changes in the primary behavior of interest,
PSC, once treatment was initiated. For the second and third
scripts, treatment was initiated after mastery of the preceding
script was demonstrated. Script mastery was defined as an
independent production of at least 90% of the entire script for a
given topic across a minimum of two consecutive sessions.
Mastered scripts were then placed in the maintenance
phase. The maintenance phase consisted of data collection at
the beginning of sessions but no direct therapeutic inter-
vention from the clinician. Additionally, long-term mainte-
nance probes for P1 and P3 were collected at 2 weeks, 2 months,
4 months, and 6 months after the cessation of treatment, fol-
lowing the same data collection procedures used in the pre-
vious phases of this study. Script 3 maintenance probes were
not collected for P2 due to attrition: She relocated to a different
country.
Reliability
Interjudge reliability was calculated to ensure reliability
of the measurements. Following the data analysis of the
primary judge, a second judge was trained to measure the
dependent variables until he reached 90% level of agreement
with the first judge. The second judge then reanalyzed 30%
of the data. Bivariate correlations were then calculated to
determine the relations between the ratings of the two judges
for each of the variables. The results indicated a strong cor-
relation between the raters on PSC (r= .99, p< .001), errors
(r=.99,p< .001), and words (r=.99,p< .001), thus
indicating robust interjudge reliability.
Participant Self-Ratings
Participants rated their confidence, speech naturalness,
and speech production ease while speaking on their chosen
script topics. Participants were instructed to mark a 23-cm
unscaled line that had descriptive adjectives (such as easy
and hard) at either end and a question about their speech
production (such as How hard is it to say what you want?)
printed above it. The distance from the leftmost point of the
line to the participants mark was then measured and con-
verted to a percentage of the total line length. High percent-
ages indicated ratings of high confidence, speech production
ease, and speech naturalness. P1 and P2 completed pre- and
posttreatment ratings; however, P3 did not complete these
ratings.
Results
Script Acquisition and Retention
All of the participants had a marked increase in their PSC
for each of their scripts when they moved from the base-
line to the treatment phase per visual inspection of the graphs
(see Figures 1, 2, and 3). All of the participants reached
the mastery criterion for each of their scripts, set at produc-
tion of 90% of the script correct across at least two consecu-
tive sessions.
The training time required for script mastery varied for
each of the participants. P1 required 44 sessions to master all
threescripts.P2required22sessions,andP3required31ses-
sions. P1 acquired her three individual scripts in 19 sessions,
15 sessions, and 10 sessions, respectively. P2 acquired her
scripts in eight sessions, eight sessions, and six sessions,
respectively. P3 mastered his scripts in 14 sessions, eight
sessions, and nine sessions, respectively. Throughout treat-
ment, all participants reported consistent home practice for
the prescribed time: P1 reported that she practiced twice daily
without fail, P2 failed to practice only for a 2-day interval
during acquisition of Script 3, and P3 reported that he prac-
ticed every day throughout treatment, although the time of
day and time devoted to practice varied for this participant.
All of the participants maintained script production accu-
racy, as measured by PSC, on all scripts for which mainte-
nance data were collected (the exception being P2s third
script). Some fluctuations of PSC in maintenance occurred
during acquisition of succeeding scripts, but the fluctuations
generally stabilized. For P1 and P3, retention on all long-
term probes (at 2 weeks, 2 months, 4 months, and 6 months)
was robust, with PSC ranging from 72% to 100%. At
6 months, P1 produced her three scripts with 100%, 92%,
and 100% PSC, respectively, and P3 produced his three
Youmans et al.: Script Training and Apraxia of Speech 27
FIGURE 1. Percentage of script words produced correctly (PSC) and error for Participant 1 (P1) on each topic.
The solid line indicates PSC. The dashed line indicates errors. The gray vertical lines indicate phase changes
(baseline, treatment, maintenance, and probe). For P1, the four probes indicate data collected at 2 weeks,
2 months, 4 months, and 6 months.
28 American Journal of Speech-Language Pathology Vol. 20 2337 February 2011
FIGURE 2. PSC and error for Participant 2 (P2) on each topic. The solid line indicates PSC. The dashed line
indicates errors. The gray vertical lines indicate phase changes (baseline, treatment, and maintenance). No
probes were elicited from P2.
Youmans et al.: Script Training and Apraxia of Speech 29
FIGURE 3. PSC and error for Participant 3 (P3) on each topic. The solid line indicates PSC. The dashed line
indicates errors. The gray vertical lines indicate phase changes (baseline, treatment, maintenance, and probe).
For P3, the two probes indicate data collected at 2 weeks, 2 months, and 4 months.
30 American Journal of Speech-Language Pathology Vol. 20 2337 February 2011
scripts with 100%, 100%, and 72% accuracy, respectively.
P2 demonstrated maintenance phase production accuracy as
measured by PSC for 12 weeks for Script 1 and for 6 weeks
for Script 2; Script 3 maintenance data and long-term probe
data were not available due to attrition.
On three different instances during treatment, P3 had
significant difficulty initiating one of his three scripts during
data collection, and on these three occasions a first word
prompt was provided by the clinician. P3 required these
first word prompts for Script 1 on Treatment Days 8 and
11 (first word would) and for Script 3 on Treatment Day
28 (first word I). Following these initial prompts, P3 pro-
duced significant portions of his scripts correctly, without
further assistance, and data from these script productions that
followed the initial cue are provided herein.
Error Productions
The error data were also plotted for each of the partici-
pants (see Figures 1, 2, and 3). As a general observation, as
scripts were in the baseline and treatment phases, more errors
were produced. Conversely, in the maintenance and long-
term probe phases, errors were generally more stable, and
fewer than in the preceding phases with few exceptions.
These exceptions include the maintenance phase of Script 2
for both P1 and P2, for which errors were still moderately
variable. Additionally, P3 demonstrated spikesin errors
intermittently during the later part of the maintenance phase
and the probes for Script 1.
Speaking Rate
Speaking rate results were highly variable between and
within participants (see Figures 4, 5, and 6). P1s speaking
rate remained variable across all of the phases for each script,
but she demonstrated a general increase in words per minute
over time. An exception was observed during the probe
phase of Script 2 in which her speaking rate declined slightly
(see Figure 4). On her first script, P2 demonstrated a gradual
increase in speaking rate from her baseline to her treatment
phase, a generally stable speaking rate across her treatment
phase, and an increase in speaking rate following script mas-
tery into her maintenance phase. P2s Script 2 was variable
during baseline, and this was followed by a gradual decrease
during the treatment phase and a gradual increase during
the maintenance phase. P2s speaking rate for Script 3 was
highly variable across sessions (see Figure 5). P3 demon-
strated slow baseline and treatment speaking rates with low
variability for Script 1, with a significant increase in speaking
rate and variability upon script mastery; however, a decrease
in speaking rate was observed during probes. Script 2 fol-
lowed a similar pattern: The baseline speaking rate was slow
with low variability, with increased speaking rate and varia-
bility upon script mastery; as opposed to Script 1, Script 2
probe phases demonstrated a fast speaking rate and low var-
iability. Speaking rate for Script 3 showed greater variability
across baseline, treatment, and probe phases than during pre-
vious scripts; only a slight trend of increased speaking rate
existed across time with high variability (see Figure 6). Even
when rates increased, P1 and P3 continued to produce their
scripts below the average in words per minute for normal
speakers in conversation (M= 174.6, SD = 33.4; Walker,
1988). P3 also produced most of his scripts at a slower than
normal speaking rate but did speak at the low end of this
distribution for a few script productions on each topic across
treatment phases.
Participant Self-Ratings
P1 rated (a) her confidence speaking on her chosen topics
as increasing from 0% prior to treatment to 46% after treat-
ment, (b) her speech production ease as increasing from
2.5% to 97%, and (c) her speaking naturalness as increasing
from 0% to 48%. P2 rated (a) her confidence as increasing
from 57% to 98%, (b) her production ease as increasing from
27% to 95%, and (c) her speech naturalness as increasing
from 48% to 96%.
Discussion
Script Acquisition and Retention
This study investigated the effectiveness of script training
for individuals with a primary diagnosis of AOS and coexist-
ing mild aphasia. Script training, previously applied only
to individuals with a primary diagnosis of aphasia, appears to
be a promising treatment option for individuals diagnosed
with primary AOS and coexisting mild aphasia, based on our
findings. Script training was successful, functional, and prac-
tical for these participants. Time for script mastery varied
from six to 19 sessions, depending on the severity of AOS
and the order in which scripts were trained. These numbers
are comparable to those of Youmans et al. (2005) in which
participants with nonfluent aphasia mastered their individual
scripts in between five and 11 sessions. The exception to this
is P1, who required 19 sessions to master her initial script
and 15 sessions to master her second script. For P1 and P3 in
particular, markedly fewer treatment sessions were required
for acquisition of their second and third scripts. This same
acquisition pattern was noted for both participants in the pre-
vious study by Youmans and colleagues (2005) and may in-
dicate an increased level of efficiency and/or confidence in
the script training process itself as script training progresses.
Error Productions
Unlike the participants with nonfluent aphasia in the pre-
vious study by Youmans and colleagues (2005) whose script
performances became relatively errorless, these participants
with AOS continued to produce errors throughout mainte-
nance phases and probes. Many researchers consider greater
than normal variability in coarticulation, rate, articulatory
accuracy, and force as a hallmark of AOS(Duffy, 2005,
p. 324). With that in mind, mastered scripts were produced
relatively fluidly, with notably less struggle and generally
fewer errors as training progressed into maintenance phases.
For mastered scripts, error productions usually occurred as
a struggle to initiate a script; once initiated, mastered script
phrases were generally produced in a relatively fluid, error-
less manner. This error pattern was in contrast to the syllable-
by-syllable struggles that typified initial script acquisition
for all three participants. The source of the initiation difficul-
ties in these participants was unclear, but it was most likely
Youmans et al.: Script Training and Apraxia of Speech 31
FIGURE 4. Speaking rate for P1 on each topic. The gray vertical lines indicate phase changes (baseline,
treatment, maintenance, and probe).
32 American Journal of Speech-Language Pathology Vol. 20 2337 February 2011
FIGURE 5. Speaking rate for P2 on each topic. The gray vertical lines indicate phase changes (baseline,
treatment, and maintenance).
Youmans et al.: Script Training and Apraxia of Speech 33
FIGURE 6. Speaking rate for P3 on each topic. The gray vertical lines indicate phase changes (baseline,
treatment, maintenance, and probe).
34 American Journal of Speech-Language Pathology Vol. 20 2337 February 2011
due to motor planning problems, given that this continuing
struggle to initiate mastered scripts was not observed in par-
ticipants with nonfluent aphasia without significant apraxia
(Youmans et al., 2005). In addition, when asked to differ-
entiate between trying to make your mouth move the right
wayand trying to think of /remember which word you want
to say,the current participants clearly and consistently in-
dicated a motoric rather than cognitive-linguistic difficulty.
Speaking Rate
Although speaking rate did increase from baseline to main-
tenance for P1 and inconsistently for P2 and P3, speaking rates
did not consistently increase from baseline to maintenance,
as they did for participants with nonfluent aphasia who partic-
ipated in script training (Youmans et al., 2005). However, a
marked session-to-session variability in speaking rate, such as
that observed in the current investigation, was also present for
individuals in this prior study.
Because inconsistent difficulty with script initiation per-
sisted for all clients, mastered script productions did not
become automatic, as measured by stability of performance
across productions, relatively errorless productions, speaking
rate, and speech naturalness. This is in contrast to individuals
with nonfluent aphasia (Youmans et al., 2005) who frequently
produced their mastered scripts errorlessly and without con-
scious effort. However, as with the individuals in that in-
vestigation, these participants with a primary diagnosis of
AOS repeatedly produced their mastered scripts flexibly, in
conversation with multiple partners, and also reported fre-
quent, successful use of their script phrases outside of the
therapy environment. The objective of script training is to
create islands of relatively errorless, relatively fluent speech,
which allow individuals with speech fluency difficulties to
communicate verbally on topics of personal importance. This
objective was met for all three participants.
Participant Self-Rating
Additionally, the self-rating forms completed by P1 and P2
indicated a positive change in their perceptions of their speech
following therapy. The differences in their pre- to posttreat-
ment ratings indicated that they both perceived the greatest
gain to be the ease in which they produced speech. Both par-
ticipants also indicated improvement in the naturalness of
their speech and in confidence while speaking on their script
topics. Although P1 indicated relatively low perceptions of
confidence after therapy, she demonstrated an improvement
from her ratings of 0% confidence at the initiation of therapy.
Motor Learning Principles
This was an investigation of the effectiveness of script
training for individuals with AOS, not a comparison of script
training with motor learning principles to script training with-
out those principles, nor a comparison of motor learning
theory to traditional training approaches or general learn-
ing theories. We incorporated recent research on motor learn-
ing principles in an attempt to most effectively tailor script
training to individuals with AOS. To promote motor learning
as measured by long-term retention, blocked practice was
used during initial acquisition to provide early success, and
then random practice was introduced as individual script
phrases reached mastery level, and summary feedback fol-
lowed this random practice. In addition, delayed feedback
was provided during the blocked practice portion of the study,
allowing space for participants to actively evaluate their pro-
ductions and to attempt to correct their errors. Summary
feedback, also indicated by motor learning theory, was pro-
vided during random practice of script productions. All three
participants performed well during maintenance phases. In
addition, the two participants available for follow-up produced
their scripts with very high levels of PSC accuracy consistently
for 6 months after training.
Because this was not a controlled, comparative study, we
cannot ascribe this long-term retention to the incorporation
of motor learning principles. Past research that has incorpo-
rated motor learning principles into AOS treatment has probed
and demonstrated long-term retention at 4 weeks posttreat-
ment for two participants (Knock et al., 2000) and at 4 weeks
for one participant and 8 months for a second participant
(Austermann-Hula et al., 2008). The scheduled 6-month long
retention probes taken in the current study compare favorably
with those included in these past investigations.
In addition, these extant studies that apply motor learning
principles to AOS treatment have trained primarily at the
syllable or single nonword level with individuals whose
AOS severity ranged from mild to severe (Austermann-Hula
et al., 2008; Knock et al., 2000). The current study expands
the inclusion of motor learning principles to the training
of functional, phrase-level utterances for individuals with a
comparable level of motor speech impairment (mild to mod-
erate to moderately severe AOS).
Future Research
Future research should continue to investigate the efficacy
of script training for individuals with various types of neu-
rogenic disorders and various levels of impairment. Script
training has been successful and functional for all participat-
ing individuals to date: two individuals with moderately
severe nonfluent aphasia (Youmans et al., 2005); one indi-
vidual with moderately severe nonfluent aphasia, one with
moderate fluent aphasia, and one with moderate anomic
aphasia (Cherney et al., 2008); and the two individuals with
moderate to severe AOS and one with mild to moderate AOS
who participated in the present study. Script therapy contin-
ues to be prescribed for individuals who are at least several
months post-CVA and who have participated in broader treat-
ments to facilitate recovery and functional communication.
The question remains whether principles of motor
learning, primarily based on data from normally functioning
individuals, are appropriate for individuals with neurologi-
cally impaired motor systems. Although principles of motor
learning were included in our protocol rather than system-
atically investigated, the incorporation of more demanding
training principles such as random practice did not prohibit
successful script acquisition treatment outcomes. We were
initially concerned that participants would be overly frus-
trated by increased training demands, and therefore we de-
layed random practice and summary feedback until individual
Youmans et al.: Script Training and Apraxia of Speech 35
phrases were produced at mastery levels. The extent to which
principles of motor learning may be responsible for the robust
retention exhibited by these participants remains to be deter-
mined through future research.
Finally, future research might explore different practice
and feedback conditions to determine which result in the
greatest long-term retention and generalization for clients
with different impairment profiles. Currently we used a
motor learning approach, allowing blocked practice earlier in
treatment and introducing random practice as clients mastered
individual script phrases. This random/blocked practice
order has been proposed as the optimal motor learning sched-
ule for individuals with neurogenic impairment (Rosenbek,
Lemme, Ahern, Harris, & Wertz, 1973), and even for normal
learners (Lai, Shea, Wulf, & Wright, 2000). However, this
has yet to be systematically investigated. It remains possible
that more difficult practice conditions such as random prac-
tice and variable feedback should be applied from the be-
ginning of treatment to produce the most robust effects.
Alternatively, it is possible that more traditional approaches
such as blocked practice and errorless learning may be more
successful for some individuals.
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Received September 3, 2009
Revision received March 19, 2010
Accepted August 19, 2010
DOI: 10.1044/1058-0360(2010/09-0085)
Contact author: Gina Youmans, Long Island University,
Department of Communication Sciences and Disorders,
1 University Plaza, Brooklyn, NY 11210.
E-mail: gina.youmans@liu.edu.
36 American Journal of Speech-Language Pathology Vol. 20 2337 February 2011
Appendix
Participant Script Examples
Participant 1
Script 1: Conversation starters/maintainers
How are your grandchildren?
Good morning.
Ill see you later.
Whats new?
Script 2: Atlantic City
Did you go to Atlantic City?
Maybe Ill win today.
Im never going again!
Script 3: Information about stroke
I had a stroke.
Speaking is hard.
But I can understand you.
Participant 2
Script 1: Answering interview questions
I am organized and a hard worker.
Also, Im a good listener.
I let people talk and try to understand them.
After I got my degree, I worked as a personal assistant.
Most recently I worked as an office manager.
I enjoyed it, but I had to leave for health reasons.
Script 2: Requesting accommodations
If possible, I would like to start by working half days.
Also, I will need a left-handed computer set up.
Multitasking is difficult for me.
I need to take my time.
But I am very accurate.
Script 3: Asking questions at an interview
What are the responsibilities of this job?
What are you looking for in an employee?
What is the next step in this interview process?
Participant 3
Script 1: Inquiry at a bookstore
I need your help.
Can you look up a magazine?
I like things about guitar, history, and computers.
Please show me where to go.
Script 2: Requesting a date
Would you like to have dinner together?
How about Friday?
What time?
Lets meet at the Alpine Grill in Lincoln.
Great! See you then.
Script 3: Ordering at a restaurant
I want a large burrito bowl please.
Rice, black beans, and steak.
Tomatoes, corn, sour cream, hot sauce.
And only a little lettuce.
Youmans et al.: Script Training and Apraxia of Speech 37
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... Script training in aphasia typically involves the repeated practice of words, phrases, and sentences embedded within a monolog or dialogue that is individualized to the person with aphasia (3). People with aphasia (PWA) engage in repeated script practice using a fading of cues protocol until they can speak the script automatically and use it in everyday communication situations (4,5). Script training is based on the Instance Theory of Automatization (6), which posits that automaticity of skills is achieved by retrieving intact, context-dependent information (in this case, scripts of language) from long-term memory. ...
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... E17 supporting verbal expression. These strategies included targeting word retrieval strategies (using object function and feature descriptors, and writing) and use of traditional script training (Youmans et al., 2011) and video-implemented script training for aphasia (Henry et al., 2018) to enhance AC's ability to communicate with her siblings and extended family members. Individual therapy was steadily supported by homework tasks designed to practice components of therapy tasks. ...
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Nonfluent primary progressive aphasia (nfvPPA) is an established language-led dementia and a known variant of frontotemporal degeneration. The purpose of this article is to report the trajectory of a single case, AC, diagnosed with nfvPPA. We describe a range of interventions offered to AC over 3 years that aimed to support her communicative function, social participation, sense of identity, and emotional well-being. We offer reflections on how these interventions align with palliative care principles, highlighting their value for guiding communication and life participation interventions for persons with nfvPPA. This study used a longitudinal analysis of impairment progression, traditional outcome measures, patient-reported outcome measures, and narrative description to report on patient and family response to interventions. Individual and group interventions are critical for addressing the progressive communication impairments and life participation restrictions for persons affected by nfvPPA. Palliative care principles have intuitive appeal for informing the selection of intervention approaches while focusing on managing symptoms, upholding patient autonomy and dignity, and enhancing quality of life throughout the course of rapidly progressive conditions like primary progressive aphasia. Speech–language pathologist-led interventions, grounded in palliative care principles, can optimize communicative function and quality of life for persons with nfvPPA.
Chapter
Primary progressive aphasia (PPA) is a rare neurological condition that affects an individual’s ability to communicate. PPA is a syndrome characterized by a ‘progressive worsening of language with preservation of the activities of daily living and evidence of relatively normal non-verbal abilities on neuropsychological testing’. It commonly appears initially as a disorder of speaking (an articulatory problem) progressing to nearly total inability to speak in its most severe stage, while comprehension remains relatively preserved. This chapter provides an overview of the characteristic features of PPA, its classification, assessment, and rehabilitation options.
Chapter
Primary progressive aphasia (PPA) is a neurodegenerative syndrome characterized by a gradual loss of communication ability. Due to the centrality of communication deficits, speech-language pathologists play a prominent role in the provision of care for individuals with PPA. In this chapter, we outline a person-centered approach to the management of PPA that aims to preserve independence for as long as possible while anticipating future decline in communication and other domains. A growing evidence base supports the utility of speech-language treatment approaches in PPA, including restitutive, compensatory, and communication partner-focused techniques. Restitutive interventions aim to rebuild lost communication skills, such as naming or fluent speech production. Compensatory approaches include training with high- and low-tech augmentative and alternative communication systems that provide complementary means of communication beyond speech. Communication partner interventions focus on education and strategy training in order to equip conversation partners as skilled communication facilitators. Throughout intervention, clinicians should aim to provide treatment that impacts functional communication and promotes social engagement. Given the documented benefits of speech-language intervention in PPA, we are optimistic that such treatment will become the standard of care and that additional research will continue to improve the quality and accessibility of behavioral interventions.
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Full-text available
This study examined the effects of two summary feedback practice schedules on the acquisition and retention of a novel speech motor skill in a group of 18 subjects with Parkinson's disease (aged 55 to 73 years; 14 men). Subjects practiced producing the phrase 'Buy Bobby a poppy' within a 2,400-millisecond time period (approximately two times slower speech rate than normal). Subjects produced 50 practice trials and received knowledge of results feedback about performance using a visual display. The absolute error between the target and actual utterance duration was used to measure performance accuracy and estimate motor acquisition. Subjects received a 20-trial retention test at ten minutes and two days following the practice session. The 18 subjects were randomized to two practice conditions. The 9 subjects who received summary feedback after every five trials were found to have significantly better 2-day retention scores than the 9 subjects who received summary feedback after every trial. These results are consistent with previous limb motor learning studies. It appears that there may be common motor learning principles involved in the acquisition and retention of novel speech and limb motor skills in normal subjects and in subjects with Parkinson's.
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Full-text available
The present study was designed to examine whether applying principles of motor learning to a commonly used treatment approach for acquired apraxia of speech (AOS) would enhance relearning of speech production skills. In particular, we examined one main principle, random practice, and compared it to blocked practice. Of importance is the fact that many speech treatments utilize blocked practice, but the literature on motor learning clearly shows that blocked practice facilitates acquisition of target behaviours, but not retention and transfer. The latter two are considered true indices of learning. In two subjects with severe AOS, results showed that random practice facilitated retention whereas blocked practice did not. The present study provides preliminary evidence that these principles may have a similar effect on learning of skilled speech motor acts as they do on learning of limb movements. The results reported here are encouraging and provide justification and focus for further investigation.
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Full-text available
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