Clinical Relevance of Discourse Characteristics After ...

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Cherney, Drimmer, and Halper (1997). In contrast, no group differences were identified by Tompkins et al. (1993) in their study of discourse elicited through a ...

Clinical Relevance of Discourse Characteristics After Right Hemisphere Brain Damage Margaret Lehman Blake University of Houston, Houston, TX

Purpose: Discourse characteristics of adults with right hemisphere brain damage are similar to those reported for healthy older adults, prompting the question of whether changes are due to neurological lesions or normal aging processes. The clinical relevance of potential differences across groups was examined through ratings by speech-language pathologists. Method: A thinking-out-loud task was used to elicit discourse from 8 individuals with right brain damage and 8 healthy older adults. Speechlanguage pathologists rated discourse transcripts on content and quantity variables and then classified them as belonging to a participant with or without brain damage. Subjective ratings were validated against corroborating measures. Results: Discourse produced by adults with right brain damage was rated as more tangential


ne of the characteristics of communication commonly associated with right hemisphere brain damage (RHD) is inefficient discourse production. General descriptions of stereotypical RHD discourse include the presence of egocentric or overpersonalized responses, irrelevant comments and digressions from the topic, a focus on tangential or irrelevant details, disorganized thoughts, and responses that seem impulsive and not well thought-out (Chantrain, Joanette, & Ska, 1998; Glosser, 1993; Myers, 2001). Verbosity is frequently mentioned (e.g., Myers, 1999), although paucity of speech also can occur, and indeed one study reported that the characteristics were diagnosed nearly equally as often ( Lehman Blake, Duffy, Myers, & Tompkins, 2002). Most of these same “aberrant” discourse characteristics have also been reported to occur in healthy older adults and are attributed to the normal aging process (Arbuckle & Gold, 1993; Gold, Andres, Arbuckle, & Schwartzman, 1988; Gold, Andres, Arbuckle, & Zieren, 1993; North, Ulatowska, Macaluso-Haynes, & Bell, 1986; Shadden, 1995). Table 1 provides a summary of the discourse features reported in the literature for adults with RHD and adults without brain

and egocentric than that from healthy older adults. Extreme verbosity or paucity of speech was attributed to people with right brain damage. One third of the speech-language pathologists accurately classified discourse samples according to group, whereas the others displayed biases toward one group or the other. Conclusions: Tangentiality, egocentrism, and extremes of quantity are clinically relevant characteristics of discourse produced by adults with right brain damage. Speech-language pathologists must be aware of potential biases that influence their perception of “normal” discourse production. Key Words: stroke, language expression, discourse analysis

damage. The extensive overlap leads to the question of whether discourse changes should be considered a result of brain damage or simply a part of the aging process. If differences do exist between these populations, it is important to determine whether they are clinically relevant. The following review will describe discourse changes associated with normal aging and those attributed to RHD, as well as the limited information available about the clinical relevance of discourse characteristics. Additionally, the selection of discourse elicitation tasks will be reviewed, as it has been suggested that discourse performance may be directly influenced by demands of the task (e.g., Bower, 1997; Marini, Carlomagno, Caltagirone, & Nocentini, 2005; Tompkins, 1995; Ulatowska, Chapman, Highley, & Prince, 1998).

Discourse Changes in Normal Aging Although many studies do not specifically define “healthy older adults,” the participants in the literature generally are adults living independently with no known neurological deficits or serious medical conditions that may affect

American Journal of Speech-Language Pathology • Vol. 15 • 255–267 • August 2006 • A American Speech-Language-Hearing Association 1058-0360/06/1503-0255


TABLE 1. Discourse characteristics of healthy older adults and adults with right hemisphere brain damage (RHD). Healthy older adults Quality: content Fewer concepts Lack of specificity Inclusion of tangential or irrelevant information Inclusion of overpersonalized/ egocentric information Quality: clarity Reduced cohesion Quality: organization Reduced coherence (disorganization) Lack of integration Quantity Number of words (too many or too few)

Adults with RHD

• • •

• •

cognitive or language abilities. The research on this population has yielded results suggesting that a variety of changes in quality and quantity of discourse production occur as part of normal aging. Several factors influence the quality of discourse, including content, clarity, and organization. Discourse produced by healthy older adults can include anomalous content, information that is irrelevant to the stimulus, and/or personal information. The amount of accurate, relevant content can covary with quantity, such that discourse includes extensive content that is not clearly focused on a single topic. This “off-topic verbosity,” characterized by “a loosely connected series of utterances on diverse topics” (Arbuckle & Gold, 1993, p. P225), was identified in 18% of healthy older adults in a series of studies by Gold, Arbuckle, and colleagues (Arbuckle & Gold, 1993; Gold et al., 1988, 1993). In terms of clarity, older adults may display reduced cohesion, characterized by an increased number of ambiguous referents and production of empty speech (as reviewed in Shadden, 1995). North et al. (1986) obtained such findings using a variety of discourse elicitation tasks including story retelling, procedural discourse, and descriptions of personal experiences. Overall, the older adult group (mean age = 72 years) differed from the middle-aged group (mean age = 45 years) in that they generated more ambiguous pronouns and fewer propositions. The authors suggested that the results were in part due to the high demands on memory and the complex nature of the stimuli. Disorganization is a third characteristic of poor discourse quality. Lack of focus was a central component of the offtopic verbosity described by Arbuckle and Gold (1993) and Gold et al. (1988, 1993), and Shadden’s (1995) review suggested that older adults have difficulty organizing and summarizing information. In terms of quantity of speech, older adults generally are reported to produce longer discourse than younger adults. Off-topic verbosity is similar to, although more extensive than, simple talkativeness and is apparent in a minority of healthy

older adults. Off-topic verbosity was found to correlate with measures of disinhibition, lower nonverbal intelligence scores, and extroversion (Arbuckle & Gold, 1993; Gold et al., 1988, 1993).

RHD Discourse Characteristics Discourse impairments after RHD also affect both content and quantity of speech. Deficiencies in information content have been defined as the production of fewer target concepts (Uryase, Duffy, & Liles, 1991), propositions, or core information units (Joanette, Goulet, Ska, & Nespoulous, 1986). Lojek-Osiejuk (1996) used two scripts to obtain discourse samples from adults with RHD. The tasks included immediate story recall and free recall (among others). Model units were defined as propositions or concepts that were stated in the stories or produced by a control group without brain damage. Overall, Lojek-Osiejuk concluded that the RHD group generated fewer model units, although this was not consistent across all stimuli or tasks. Marini et al. (2005) reported that adults with RHD produced fewer thematic units than a control group in story generation tasks, although no group differences were found on a story-retelling task (which was purported to be an “easier” task because it did not require creating a story line). The production of fewer relevant or target concepts often co-occurs with the presence of digressions or tangential remarks. Often it appears as if adults with RHD include more tangential or extraneous pieces of information at the expense of core propositions (e.g., Joanette et al., 1986). This was illustrated by adults with RHD in a study by Mackenzie, Begg, Lees, and Brady (1999). As compared with a control group without brain damage, the participants with RHD produced less interpretive information but more irrelevant or extraneous information. The presence of the irrelevant comments created discourse that was much less concise and not as informative. Wapner, Hamby, and Gardner (1981) found “embellishments” in story retellings of 14 out of 15 participants with RHD. Similar findings of elaborations, redundancies, and irrelevant information were reported by Cherney, Drimmer, and Halper (1997). In contrast, no group differences were identified by Tompkins et al. (1993) in their study of discourse elicited through a picture description task. In addition to the tangential remarks, many adults with RHD include personal or egocentric information in discourse (Chantrain et al., 1998; Lojek-Osiejuk, 1996; Mackenzie et al., 1999; Myers & Brookshire, 1994; Tompkins et al., 1993; Wapner et al., 1981). Egocentric remarks have been loosely defined as those that are inappropriately personal or contain personal matter or opinion, or responses in which the speaker puts himself into the story. In many studies, they are considered a subset of tangential information, although in others (e.g., Tompkins et al., 1993), egocentric and tangential remarks are considered separately. Clarity of discourse produced by adults with RHD often is reduced due to poor use of referential cohesion. Studies suggest that adults with RHD tend to use an insufficient number of referents, or unclear referents, which leads to poor cohesion. Chantrain and colleagues (1998) obtained

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supporting data in a study of referential communication. The participants had to describe a series of complex visual pictures to a listener using a referential barrier task. Difficulties using consistent, appropriate referents were not pervasive across all participants with RHD but occurred more often in the RHD group than in a group of adults without brain damage. Another measure of cohesion is the number of complete and incomplete cohesive ties (e.g., personal reference, lexical, and elliptical cohesive markers). Uryase et al. (1991) reported a smaller number of complete ties and a greater number of incomplete ties produced by adults with RHD in comparison to adults without brain damage in a story-retelling task. Disorganization and lack of integration have been reported in several studies (Cherney et al., 1997; Myers, 1979; Wapner et al., 1981). Lojek- Osiejuk (1996) identified difficulties with hierarchical organization of information for some participants with RHD on some tasks. Results from Marini et al. (2005) also indicated that adults with RHD have difficulty with organization as defined by poor coherence in story generation tasks. Brady, Mackenzie, and Armstrong (2003) elicited discourse through a semistructured conversation and found that adults with RHD exhibited some difficulties with topic coherence, primarily with subdivisional levels. The participants tended to raise subtopics to the level of importance of main topics. The differences were fairly subtle, however, and did not clearly separate the RHD group from the healthy older adults. A similar absence of group differences was reported in an earlier study in which discourse by adults with RHD was equivalent to a control group in terms of topic maintenance and organization ( Mackenzie, Begg, & Brady, 1997). Quantity of speech produced by adults with RHD is variously reported to be excessive (i.e., verbose responses; Hillis Trupe & Hillis, 1985; Mackisack, Myers, & Duffy, 1987), deficient (i.e., paucity of speech; Mackenzie et al., 1997; Uryase et al., 1991), or equivalent to control groups of adults without brain damage (Joanette et al., 1986; Tompkins et al., 1993). These varying results have been obtained using a variety of standard discourse elicitation tasks and are not clearly tied to specific tasks or stimuli.

Clinical Relevance of Discourse Characteristics Studies of RHD discourse that use a control group of adults without brain damage suggest that the former group exhibits deficiencies in both quality and quantity of discourse. However, a critical question is whether these discourse characteristics of adults with RHD are clinically relevant. Two studies have addressed this issue, albeit in indirect ways. Both used a picture description task (the Cookie Theft picture from the Boston Diagnostic Aphasia Examination; Goodglass & Kaplan, 1983) to elicit discourse from adults with RHD. Hillis Trupe and Hillis (1985) reported that the vast majority (94%) of participants with RHD who demonstrated deficient speech production (a reduction in the amount of appropriate information conveyed or in the efficiency of production) were referred for speechlanguage therapy, while only one of the individuals with

speech production within the normal range received such a referral. While a direct correlation is not possible, it can be inferred that the inappropriate and/or inefficient discourse demonstrated by these individuals influenced the recommendations for speech-language services. Tompkins et al. (1993) assessed clinical relevance of discourse quality in a post hoc fashion. They asked 10 speechlanguage pathologists (SLPs) to read transcripts obtained through the picture description task and then classify each as belonging to a healthy older adult or a person with RHD. The SLPs were at chance level at identifying the healthy older adults. Those individuals who were incorrectly classified as having RHD tended to include excessive detail and/or overpersonalized remarks in their responses. The authors suggested caution in making judgments based on discourse content, as it might lead to misclassification of healthy older adults. The conclusions that can be drawn from these findings are limited, as accuracy data for classification of individuals with RHD group was not included, and the only descriptive information about the SLP raters was the number of years in the profession (which ranged from 1 to 20).

Discourse Elicitation Tasks Several researchers have noted that the specific elicitation task and stimulus can affect discourse production (Marini et al., 2005; Shadden, 1995; Ska & Joanette, 1996). In a review of studies of healthy adults, Bower (1997) described age-related reductions in syntactic complexity and organization of event structures in discourse obtained through interviews and story-retelling and picture description tasks. In contrast, age differences in complexity or structure do not often appear in studies of conversational discourse. Several studies of both adults with RHD and healthy older adults have reported deficits on one type of task or even one stimulus but not on others. For example, Davis, O’NeilPirozzi, and Coon (1997) and Diggs and Basili (1987) reported discourse deficits in adults with RHD only for certain tasks (e.g., story retelling or picture sequences) or certain stimuli. Marini et al. (2005) systematically studied the effect of complexity of elicitation task on discourse production by using three levels of difficulty: story retelling, story generation from picture sequences, and story generation from a set of randomly ordered pictures that the participant first had to sequence. The results indicated that discourse deficits after RHD were apparent only in the more complex story generation tasks. Similar conclusions regarding the effect of complexity have been reported by other researchers (North et al., 1986; Ulatowska et al., 1998). The extent of imposed structure also may play a role, as the proportion of irrelevant comments may be higher in discourse elicited through interviews than through more controlled tasks such as story retelling or picture descriptions (North et al., 1986). All of the typical discourse elicitation tasks rely on cognitive processes that may affect a person’s responses. For example, story-retelling tasks place demands on memory processes, picture description tasks involve visual attention (and may be particularly difficult for individuals with Lehman Blake: RHD Discourse


neglect), procedural narratives may require the knowledge and use of scripts and require good organizational abilities, and discourse elicited through conversation or interviews can be affected by pragmatic skills. Thinking-out-loud tasks are quite different from the traditional tasks used in previous discourse research. In a typical thinking-out-loud task, a participant is instructed to verbalize his thoughts while completing a task (such as a math problem or a logic puzzle, or while reading). The elicitation procedure was designed to illuminate thoughts associated with task completion while placing minimal demands on memory and other cognitive processes (Ericsson & Simon, 1980; Olson, Duffy, & Mack, 1984). In a reading task, a participant is instructed to read a story one sentence at a time, and after each sentence to verbalize his thoughts about the story. The nature of the thinking-out-loud task and imposed structure reduces the importance of several processes that may impact discourse production, including the following: memory, because the story is presented in written form and the participant can look back at the previous sentences; referential cohesion, because most thoughts refer to the justread sentence available to both the participant and the tester; organization, because the instructions are to speak aloud thoughts about the story, and not construct or retell a story; and pragmatics, because the task is not interactive. Lessening the importance or impact of these processes may allow a more direct analysis of the content of the discourse. The purpose of the current study was to explore whether experienced SLPs can accurately classify discourse produced by healthy older adults and adults with RHD. If SLPs link abnormal discourse characteristics to correct classification of participants, this would suggest that there are clinically relevant differences in content and /or quantity of discourse produced by adults with RHD. A thinking-out-loud discourse elicitation task was chosen to minimize the demands on memory, organization, and pragmatics that could negatively affect discourse production.

Method Participants Eight individuals with RHD due to stroke and 8 healthy older adults with no history of neurological damage participated in this study. All had participated in a previous study of inferencing and discourse comprehension ( Lehman Blake & Lesniewicz, 2005). Data from the 8 individuals with RHD were used in the current study. Eight individuals from the original group of 20 healthy older adults were selected to match the RHD group in terms of age and education, as there is some suggestion in the literature that these factors may influence discourse production in healthy older adults (e.g., Cooper, 1990; Mackenzie, 2000; Shewan & Henderson, 1988). The groups were not matched in terms of gender, as the available evidence is equivocal regarding the effect of gender on discourse production (Arbuckle & Gold, 1993; Gold et al., 1988, 1993; Mackenzie, 2000). Participants were recruited through newspaper advertisements, local stroke support groups (for RHD), and senior

centers (for healthy older adults). To be included, potential participants had to be right-handed, between the ages of 50 and 85 years, native speakers of American English (with no other language learned prior to school age), and with no selfreported history of drug or alcohol abuse. Additionally, individuals who reported any neurological condition ( besides stroke) were excluded. Participants with RHD were included on the basis of a lesion in the right hemisphere, not the presence of cognitive-communication disorders. For these individuals, location of the stroke was determined from medical records. Any potential participant with an identified lesion outside the right hemisphere was excluded from the study. To be included, healthy older adults had to demonstrate normal cognitive functioning based on age- and educationbased norms on the Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975; see also Crum, Anthony, Bassett, & Folstein, 1993). All participants had to pass hearing and vision screenings to participate in the study. Hearing thresholds (unaided) had to be at least 35 dB at 500 and 1000 Hz and 40 dB at 2000 Hz, tested in a quiet room with a portable audiometer. Vision was screened using a sentence-reading screening that was similar to the experimental stimuli. Potential participants were given a page that contained 10 sentences, printed in the same size and font as the experimental stories, which they read out loud. Anyone who made more than one uncorrected error was excluded. The sentences were designed to screen for left visuospatial neglect, as most began with a word or phrase that could be omitted and still leave a syntactically and semantically intact sentence (e.g., “Early one morning Bob went for a run in his neighborhood”). Additionally, all individuals with RHD had to score within the range of normal performance on the six conventional subtests of the Behavioural Inattention Test (Wilson, Cockburn, & Halligan, 1987) to exclude any individual with neglect who might not be able to process the complete text in the reading task. Select demographic and clinical data for the RHD and healthy older adult participants are provided in Table 2. Several ancillary tests were administered to help characterize the groups in terms of language and cognitive abilities that could potentially affect discourse production. The Discourse Comprehension Test (reading version; Brookshire & Nicholas, 1993) consists of five stories, each followed by eight yes–no questions. The questions probe main ideas and details that are either explicit or implied. The Peabody Picture Vocabulary Test—III ( Dunn & Dunn, 2000) was used as a measure of receptive vocabulary, which is strongly correlated with overall language ability. Finally, an auditory working memory task was administered ( Lehman & Tompkins, 1998; Tompkins, Bloise, Timko, & Baumgaertner, 1994) due to the reported links between working memory and comprehension (Daneman & Carpenter, 1980; Tompkins et al., 1994). The two participant groups did not differ on any of these measures.

Response Elicitation Verbal transcripts were obtained from the participants using a thinking-out-loud procedure as part of a separate research study of predictive inferences (see Lehman Blake &

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TABLE 2. Characteristics of two groups of participants. Characteristic Sex Age M SD Range Education M SD Range Discourse Comprehension Test percentage correcta M SD Range Receptive vocabulary standard scoresb M SD Range Working memory recall errorsc M SD Range (maximum = 42)



69.4 6.5 57–76



14.0 2.8 12–20

14.3 2.9 12–20



88% 0.11 70%–100%

89% 0.06 78%–100%



111.3 13.8 98–130

103.3 20.7 83–147



12.0 4.5 2–16

13.7 5.6 7–21



Healthy older adults

Adults with RHD

6 female, 2 male

3 female, 5 male

69.3 8.1 55–78

Months postonset M SD Range Lesion sited

60.4 36.3 10–119 1 primarily anterior, 2 primarily posterior, 1 anterior + posterior, 1 subcortical only, 3 normal CT scane


Discourse Comprehension Test (Brookshire & Nicholas, 1993). Peabody Picture Vocabulary Test—III (Dunn & Dunn, 2000). c Auditory working memory (Lehman & Tompkins, 1998; Tompkins et al., 1994). d Anterior/posterior to the central sulcus (sulcus of Rolando), based on medical records. e Diagnosis of right hemisphere stroke based on physical deficits (i.e., left-sided hemiparesis). b

Lesniewicz, 2005, for details). The experimental stories (based on stimuli provided by Klin, Murray, Levine, & Guzman, 1999) were each approximately 10 sentences long and were written so that they suggested one specific event (the target predictive inference) would occur. Responses were elicited in the following manner: Individuals were given stories printed in 14-point font in black ink on white paper. Several blank lines appeared between each sentence of the story, and the participants were given a sheet of colored paper to cover up all sentences below the one they were currently reading. Participants were asked to read the stories out loud, and after each sentence to verbalize their thoughts about the story, particularly any predictions of what might happen. Responses were tape-recorded and later orthographically transcribed, including all errors, fillers, and disfluencies. In the larger study, participants completed several sets of stories over three testing sessions. For the current purposes, two of those stories were selected. The selection was based on inferencing data from the larger study. Responses elicited from the two stories indicated that the majority of participants in both the RHD

and healthy older adult groups generated a target inference, suggesting that the stories clearly conveyed a specific outcome. As most participants generated the target predictive inference, it was assumed that the inferencing demands of the task might not interfere with other discourse processes. A sample story and responses are provided in Appendix A. Two individuals collected and transcribed the thinkingout-loud protocols. To measure reliability, each tester retranscribed the responses from 25% of the participants (2 RHD and 2 healthy older adults each). Reliability was measured by counting the number of words (including interjections and fillers) that differed between the two transcriptions. Interrater reliability was 93% (range = 88%–96%), and intrarater reliability was 95% (range = 91%–97%).

Raters Twenty SLPs with at least 5 years of experience in the profession (range = 6–34 years) were recruited to rate the Lehman Blake: RHD Discourse


TABLE 3. Characteristics of raters. Characteristic




Number of years 18.0 8.9 6–34 as a speech-language pathologist Number of years 15.1 7.0 3–28 working in neurogenics Number of RHD patients 1.85 2.3 0–8 seen per month Level of familiarity with RHD 4.45 0.69 3–5 communication disorders (1 = slightly familiar; 5 = very familiar) Work setting: acute care and rehabilitation (1), acute care hospital (2), research center (2), rehabilitation (in /outpatient or long-term care; 4), university clinic (5), university faculty (6)

verbal transcripts. The SLPs volunteered in response to a message posted on the e-mail list of the American SpeechLanguage-Hearing Association’s Special Interest Division for Neurophysiology and Neurogenic Speech and Language Disorders. Raters worked in a variety of settings and had a range of experience with adults with RHD (see Table 3). All reported that they were at least “somewhat familiar” with deficits associated with RHD, as rated on a 5-point scale with the mid- and endpoints labeled as follows: 1 = I know a little bit about RHD disorders, 3 = I’m somewhat familiar with RHD disorders, and 5 = I’m very familiar with RHD disorders.

Rating Procedures Raters were blind to group inclusion (i.e., whether a discourse sample was from an individual with RHD or a healthy older adult). Raters read discourse samples from each participant and rated them in terms of tangentiality/off-topic content, egocentrism, and amount of speech produced (verbosity vs. paucity of speech). Definitions were not provided, as one purpose of the study was to determine whether experienced SLPs could correctly classify patients using their own clinical expertise. Providing definitions may have shifted raters’ attention to trying to match the protocols to the authors’ definitions and could potentially have interfered with their clinical impressions. Participants’ age, level of education, and gender were provided on each transcript. This information was included in part to prevent questions from the raters. Also, it was possible that these variables might influence raters’ perceptions, even though they have not been clearly linked to performance (e.g., Cooper, 1990; Mackenzie, 2000). Raters received packets containing 32 transcripts (2 from each of the 8 RHD and 8 healthy older adult participants), which were randomly ordered and presented in the same random order to all raters. The SLPs independently completed the rating task in the following way: Each rater read 1 transcript from 1 participant and rated it in terms of tangentiality, egocentrism, and quantity of speech. All rating scales were 5-point Likert-type scales with the end- and midpoints labeled (see rating scales in Appendix B). The scales for tangentiality and egocentrism ranged from a score

of 1 being abnormal to a score of 5 indicating normal discourse. Because both excessive speech and paucity of speech are considered abnormal, the scale for quantity differed, with a 1 indicating verbosity, a 3 representing a normal amount of speech, and a 5 representing paucity of speech. For all scales, raters had to choose a whole number. After a rater made judgments on the three factors for the first story, she or he then read the second sample from the same participant and made judgments on the same variables. After reading and rating the two samples, the SLP then classified the transcripts as belonging to either a healthy older adult or an adult with RHD. The rater then indicated how confident she or he was with the classification on a 5-point Likert-type scale (see Appendix B). A score of 1 represented not at all certain; could not decide, 3 indicated fairly certain, and 5 represented very certain. Raters also were given the opportunity to write comments for each transcript. The amount of time needed to complete all ratings was approximately 90 min. To test the reliability of the ratings, five of the SLPs were randomly selected to rerate a subset of transcripts. Each rater was assigned 4 participants in consecutive order (i.e., Raters 1 and 5 reread Participants 1–4, Rater 2 reread Participants 5–8, and so on). The sample of raters represented a range of years in the profession (7–34 years) and years working with neurogenic communication disorders (7–28 years). Two raters held university faculty positions, one worked in a research center, one in a university clinic, and one in a hospital setting. The reliability ratings took place approximately 6 months after the initial ratings. The raters used the same rating scales but did not have access to their original responses. Three of the five raters were 100% reliable in their classification of the participants as RHD or healthy older adult. One rater agreed with three out of four of her previous classifications (75% reliability), and the fifth changed the classification of two of four (50% reliability). Reliability of the content and quantity ratings ranged from 58% (14/24) to 79% (19/24). All but 7 of the 39 discrepancies differed by only 1 point on the 5-point scales; the remaining 7 differed by 2 points (e.g., a score of 5 the first time and 3 the second). The average ratings for the three variables in the initial rating did not differ significantly from the reratings, as measured by two-tailed matched-pairs t tests: tangentiality, t (4) = –0.006, p = .99; egocentrism, t(4) = 2.43, p = .07; quantity, t (4) = 0.46, p = .67.

Objective/Corroborating Measures Objective and/or corroborating measures were sought to help establish the validity of the subjective ratings. These comparisons were conducted on a post hoc basis. There are no established objective measures of tangentiality or egocentrism, so definitions were constructed from the literature and used to classify the content of the transcripts. Tangential information was defined as statements that were irrelevant, off-topic, or incorrect; centered on isolated details; did not match the content of the story; or were digressions (a turn away from the main topic or subject; Chantrain et al., 1998; Cherney et al., 1997; Lojek-Osiejuk,

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1996; Mackenzie et al., 1999; Marini et al., 2005). Egocentrism was defined as the participant integrating himself or herself into the story or the inclusion of personal information (Arbuckle & Gold, 1993; Gold et al., 1993; Tompkins et al., 1993). This included self-assessments of performance (e.g., “I didn’t get that one right ”). The author and a research assistant (hereafter referred to as “readers”) first discussed the definitions and practiced identifying tangential and egocentric content on two sample stories. Interrater reliability on these samples was over 90%. The readers then independently scored transcripts from the 16 participants. Egocentrism was evaluated first, so that those comments would not also be identified as tangential. The number of instances of each type of abnormal content was tallied and averaged across the two readers for each participant. Number of words was the objective measure of quantity. The number of words (including interjections and fillers) produced by each participant was counted for each story, using the Word Count tool in Microsoft Word. The numbers were then pooled across the two stories to obtain a total number of words produced for each participant.

Results To rule out any potential effects of learning or fatigue on the ratings, Spearman correlation coefficients were calculated between the order of presentation and average quality and quantity ratings. No meaningful relationships were found (all rs < .2, p > .10). For the major analyses reported below, effect sizes, calculated as Cohen’s d (Cohen, 1988), are reported for each t-test contrast. For correlations, effect sizes were based on the calculated coefficient using Cohen’s (1988) suggestions: small effect size r = .1, medium r = .3, and large r = .5. The accuracy of classification pooled across all participants and raters was 73% (range = 54%–88%). Results from a paired t test indicated that raters were (statistically) equally accurate at classifying samples from healthy older adults (M = 68%, range = 38%–88%) and individuals with RHD (M = 77%, range = 50%–100%), t(19) = 1.7, p = .10, d = .44. The extreme ranges obscured the accuracy of individual raters, so raters were split into groups based on their accuracy of classification. Seventy percent was chosen as the cutoff for high versus low accuracy. Six raters demonstrated high accuracy of classification of all participants ( healthy older adults = 81%; RHD = 87%). Another six were quite accurate with healthy older adult participants (79%) but were poor at correctly identifying participants with RHD (61%). This group showed a bias toward classifying most individuals as healthy older adults. A third group of seven raters demonstrated a bias toward RHD, with high accuracy of classification of individuals with RHD (87%), but they were at chance level for correctly identifying healthy older adults (51%). One rater was essentially at chance level for classification of participants in either group (50% accuracy for healthy older adults, 57% accuracy RHD). This last SLP had 23 years of experience in the profession, 10 of which were spent working with neurogenic communication disorders. She worked in a rehabilitation facility, seeing

approximately two patients with RHD per month. She indicated that she was “very familiar” with deficits associated with RHD, and her overall confidence in her ratings was 3.83 on the 5-point scale. Kruskal-Wallis tests were conducted to examine whether specific characteristics could differentiate between the three groups of raters (high accuracy overall, high healthy older adult accuracy, and high RHD accuracy). The one rater with poor accuracy was excluded from this set of analyses. No meaningful relationships were identified between accuracy and (a) number of years in the profession, ( b) number of years working with neurogenic communication disorders, (c) self-reported familiarity with RHD disorders, or (d) number of patients with RHD seen in a typical month (all c2 < .5, p > .05). A variety of work settings were represented in each subgroup of raters. Raters reported a range of certainty of their classifications (M = 3.3, range = 1.94–4.6). Certainty was not meaningfully correlated with accuracy (Spearman’s rs = .02, p = .46), although it was related to the raters’ self-reported level of familiarity with RHD (rs = .60, p = .003). Data for the three discourse variables were submitted to nonparametric correlational analyses to evaluate whether they were independent of each other and thus could be further analyzed individually. Egocentrism and tangentiality were not meaningfully related (rs = .10, p = .7). There was a trend toward significance for quantity and egocentrism (rs = .41, p = .07), and also quantity and tangentiality (rs = .39, p = .09), although neither reached the standard significance level of p < .05. Distributions of the rating data are presented in Figure 1. Results from Wilcoxon signed-ranks tests indicated that transcripts from the individuals with RHD were rated significantly more tangential (M = 3.63, SD = 0.55) and egocentric (M = 3.64, SD = 0.42) than those from healthy older adults (tangentiality: M = 4.44, SD = 0.41; egocentrism: M = 4.48, SD = 0.29; both Z = –3.9, p < .001). Large effect sizes (Cohen, 1988) were obtained for both contrasts (tangentiality = 1.68; egocentrism = 2.31), indicating that the magnitude of the differences was substantial. To test the validity of the SLPs’ ratings, Spearman correlation coefficients were computed between the average number of tangential /egocentric ideas identified by the readers using definitions from the literature and the average ratings from the SLPs. Moderate to strong negative correlations were obtained for both contrasts (tangentiality rs = –.59, p = .02; egocentrism rs = –.88, p < .001). High ratings, indicating more “normal” discourse, corresponded to fewer instances of tangentiality or egocentrism identified by the readers. The large effect sizes suggest that the raters’ perceptions of these content variables were closely related to common definitions found in the literature. The average ratings for quantity of speech were the same for both groups ( RHD: M = 3.44, SD = 0.23; healthy older adults: M = 3.44, SD = 0.34). However, individuals with the highest two and lowest two average quantity scores were correctly classified as having RHD by the majority of the raters. Inspection of the data (see Figure 1) suggested there was broad overlap between the groups, which led to the Lehman Blake: RHD Discourse


FIGURE 1. Average ratings for tangentiality, egocentrism, and quantity for two participant groups. Circles indicate outlying values; asterisks indicate significant group differences ( p < .01).

nonsignificant result. The objective measure of quantity, total number of words, was compared across groups. Results of an independent, two-tailed t test indicated no difference between the groups, t(14) = 0.41, p = .7, d = .07. Additionally, a correlational analysis between the objective word count and subjective SLP ratings was computed to assess the validity of the ratings. A strong negative Spearman correlation coefficient (rs = –.90, p < .001) indicated that subjective quantity ratings were closely related to objective word counts (i.e., lower ratings, meaning greater verbosity, were related to more words). Characteristics of discourse produced by participants who were most commonly misclassified (overall accuracy less than 65%) were examined to see whether there were patterns that might distinguish these participants’ discourse productions. The 2 individuals with RHD who were classified as normal both had ratings of tangentiality and egocentrism that were close to the average for the healthy older adults. Of the 3 without brain damage who were classified as RHD, 1 had discourse rated as tangential, egocentric, and verbose. This individual possibly could be considered to have off-topic verbosity (Arbuckle & Gold, 1993; Gold et al., 1988, 1993). The second was rated as having paucity of speech, and several raters indicated that it was hard to classify the discourse due to the limited responses. The third individual had ratings of tangentiality and egocentrism that were near the average for the healthy older adult group, but he had 20 years of education. Several raters commented that his discourse did not seem commensurate with his level of education.

Given reports in the literature of differential performance across stimuli, the ratings of the three variables were analyzed separately for Story 1 and Story 2. A series of matched pairs t tests indicated that for the RHD group, ratings of egocentrism were higher for Story 2 than Story 1, t(19) = 4.7, p < .001, d = .498, but no significant differences were found for tangentiality or quantity ( both t < 1.7, p > .10). For the healthy older adult group, the only significant difference was a higher verbosity rating for Story 1 versus Story 2, t(19) = 2.23, p = .04, d = .16. The small effect size suggests that although statistically significant, the difference probably is not meaningful.

Discussion Classification Accuracy SLPs who were knowledgeable about cognitivecommunication deficits associated with RHD as a group varied in their ability to accurately classify discourse as being produced by adults with RHD or healthy older adults, although as individuals they were relatively consistent over time. Currently there are no standardized measures with which to evaluate discourse. Thus, SLPs must rely on their subjective, clinical impressions. If they have a very broad view of what is considered normal discourse for older adults (as did one third of the raters in this study), they may attribute some discourse characteristics to normal aging and fail to

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provide therapy to remediate the problems. On the other hand, if they have a restricted view of “normal,” they may spend valuable therapy time working on discourse characteristics that may be appropriate for the patient’s age. It is unclear what factors influence classification bias. Accuracy was not meaningfully related to how much experience the raters had in the field of speech-language pathology, past experience or current exposure to adults with RHD, their work setting, or their certainty of classification. Mackenzie (2000), lamenting about the limited information about discourse in adults older than 75 years, stated that “detection of deficit is commonly dependent on the assessor’s opinion as to what constitutes normal performance” (p. 269). This sentiment can be extended to the discourse of adults with RHD. It is possible that raters’ classifications were based on personal beliefs about “normal” discourse parameters, which may be difficult to explain or objectively measure. These beliefs may be influenced by one’s ethnocultural background, attitudes toward aging, and/or experience with or knowledge of healthy/normal aging processes.

Content and Quantity Variables The content ratings of tangentiality and egocentrism differentiated adults with RHD from those without brain damage. The large effect sizes obtained suggest that the differences were substantial and clinically useful. It is possible that the presence of a lesion in the right hemisphere exacerbates the normal changes in discourse production that occur as part of the aging process. Corroborating measures indicate that tangentiality and egocentrism ratings from experienced SLPs were valid, compared with counts based on set definitions. It is unclear why, given the robustness of these variables for distinguishing RHD from normal aging, the raters were not more accurate in their classification. One potential explanation is that the raters based their decisions on variables other than the three specified here. This possibility is supported by the comments obtained from the raters. Some indicated that the three target variables did not always capture the essence of the discourse, and their classifications were based on other factors such as “ bizarre” quality, “responses [were] not reflective of the character’s motives,” or “responses [were] related only to the previous sentence and not the theme of the story.” Quantity of speech did not differ between the two groups for either the subjective quantity ratings or the objective word count measure. This finding was not completely unexpected, as some previous studies have failed to find differences between RHD and healthy older adult groups using objective quantity measures (Joanette et al., 1986; Marini et al., 2005), and abnormal quantity can be either excessive or restricted. The limited range available for ratings of abnormal quantity probably was not the cause of the negative results, because the objective word count variable (with a much larger range of data) also did not distinguish between the groups. Despite the lack of significant group differences, the individuals who were rated as most verbose or producing a paucity of speech were correctly identified as having brain damage. Additionally, the third most extreme high and low

scores belonged to healthy older adults who were misclassified as RHD. Thus, individuals who were rated at the extremes of quantity were classified as having RHD. These results support previous findings that verbosity or paucity of speech are associated with RHD. The thinking-out-loud task limited the influence of certain language and other cognitive variables on discourse production (cohesion, memory, organization, and pragmatics). When these variables were omitted, or at least reduced in importance, differences between groups were still apparent. This suggests that abnormal content and quantity do not appear only when the task is complex or demanding enough to tax an individual’s abilities. The individuals with RHD who participated in the current study had relatively chronic lesions and were quite mildly impaired. Indeed, they did not differ from the group without brain damage in terms of discourse comprehension, receptive vocabulary, or even working memory. Additionally, individuals with visuospatial neglect were not included in the study. Given the well-established finding that the presence of neglect is related to poorer performance on a variety of language tasks (e.g., Cherney et al., 1997; Myers & Brookshire, 1994; Tompkins, 1995), excluding this portion of the RHD population may result in a group of participants with less-severe language disorders. Similar to the findings of Marini et al. (2005), differences in the discourse content were identified even though the groups did not differ on a set of language and cognitive measures. Especially when combined with the structured task used, the results indicate that tangentiality and egocentrism are robust characteristics that differentiate even mildly impaired adults with RHD from adults without brain damage.

Limitations and Future Directions Several limitations of this study should be addressed. First, the participant groups were quite small, and the individuals with RHD were not representative of the larger population. Future studies should include larger groups made up of individuals with a range of severity of language and cognitive impairments to enable generalization of the findings to the broader population of adults with RHD. Second, despite the significant differences between groups in ratings of content, it is not clear why raters were not more accurate at classifying the participants. Future studies might ask raters specifically to describe the rationale for their classification without restricting them to a few select variables. Analysis of these reasons might help identify salient characteristics of discourse that either help or hinder raters’ successful classifications. Finally, the demographic and background information collected from the raters failed to differentiate between subgroups of raters based on their classification biases. The measures of experience and familiarity used in this study were based on years in the profession and self-report of knowledge. It is possible that a composite variable that integrates these factors as well as working environment (e.g., academic vs. clinical) and number of patients seen could provide a composite measure of professional experience that might be related to accuracy of classification. Another Lehman Blake: RHD Discourse


component that may be important is the nature of the raters’ knowledge of RHD, and whether they frequently seek out new information about this population (e.g., through continuing education activities or by reading recent research). The ethnocultural background of both participants and raters should be identified in future studies to assess how that factor may influence both production and perception of discourse.

Clinical Implications SLPs harbor biases about what “normal” discourse should sound like in older adults. They also seem to be overconfident in their ability to identify discourse produced by adults with RHD based on how familiar they are with the population. The inclusion of tangential and egocentric information in discourse as well as extreme verbosity or paucity of speech are clinically relevant indicators of RHD that appear even in constrained tasks and in adults with only mild cognitive/communicative deficits. These findings suggest that SLPs can use these factors to aid their diagnosis of discourse impairments.

Acknowledgments This study was funded by grants from the American SpeechLanguage-Hearing Foundation, the National Institutes of Health (Grant 1R03-DC005563-01A1), and the Pattye Sue Stephens Lebel and Jesse Loran Lebel Communication Disorders Faculty Fellowship Endowment. Thanks to Kimberly Lesniewicz for her assistance with the transcriptions and analyses.

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Tompkins, C. A. (1995). Right hemisphere communication disorders: Theory and management. San Diego, CA: Singular. Tompkins, C. A., Bloise, C. G. R., Timko, M. L., & Baumgaertner, A. (1994). Working memory and inference revision in brain-damaged and normally aging adults. Journal of Speech and Hearing Research, 37, 896–912. Tompkins, C. A., Boada, R., McGarry, K., Jones, J., Rahn, A. E., & Ranier, S. (1993). Connected speech characteristics of right-hemisphere-damaged adults: A re-examination. In M. Lemme (Ed.), Clinical aphasiology (Vol. 21, pp. 113–122). Austin, TX: Pro-Ed. Ulatowska, H. K., Chapman, S. B., Highley, A. P., & Prince, J. (1998). Discourse in healthy old-elderly adults: A longitudinal study. Aphasiology, 12, 619–633. Uryase, D., Duffy, R. J., & Liles, B. Z. (1991). Analysis and description of narrative discourse in right-hemisphere-damaged adults: A comparison with neurologically normal and lefthemisphere-damaged aphasic adults. Clinical Aphasiology, 19, 125–138. Wapner, W., Hamby, S., & Gardner, H. (1981). The role of the right hemisphere in the apprehension of complex linguistic materials. Brain and Language, 14, 15–33. Wilson, B., Cockburn, J., & Halligan, P. (1987). Behavioural Inattention Test. Bury Saint Edmunds, England: Thames Valley Test. Received April 11, 2005 Revision received August 10, 2005 Accepted March 1, 2006 DOI: 10.1044/1058-0360(2006/024) Contact author: Margaret Lehman Blake, Department of Communication Disorders, University of Houston, 4505 Cullen Blvd., 100 Clinical Research Center, Houston, TX 77204-6018. E-mail: [email protected]

Lehman Blake: RHD Discourse


Appendix A Sample Story and Responses From 2 Participants The text of the story is printed in bold. Responses from a healthy older adult appear in the left column and an adult with right hemisphere brain damage (RHD) in the right column. Participant 1a

Participant 8b Carol was frustrated with her job waiting on tables.

This is common with waitresses at times. Sometimes they really like their job.

All three of my daughters have done that and they’ve all been frustrated. Okay, this might indicate that Carol is ready to look for another job, or look for a, first we have to know what the sources of frustration are, it’s possible she might be able to overcome them in her current job.

Customers were rude, and the chef was impossibly demanding. Makes a bad day for the waitress because she still has to be nice to the customersI

Okay, this may narrow down her choice to leaving and finding another job, preferably finding another job first and then leaving this job because um, I don’t think you’re going to solve either one of these problems. You can’t teach the customer good manners, and the chef is probably set in his ways.

After a long and hard day, a man complained that the spaghetti she had just served was cold. This happens quite often. The best way to handle this is to take it back to the kitchen and have them warm it up in the microwave.

Well, uh, this is probably, possibly one of the reasons, even though it’s a um, certainly a very logical thing to complain about, one of the possible reasons that she feels that some of the customers are rude. Um, and, points to the fact that uh, perhaps it’s not the customers, perhaps it’s the restaurant that is not doing uh, maybe the chef, or maybe the dish work waits a little too long before it’s served. Maybe that’s the reason the customers are unhappy, rather than um, merely the fact that um, they have a rude nature.

As he became louder and nastier, she lost control. More difficult. Sometimes it is tough to keep your temper. She is just having a hard day.

Um, well, you don’t do that when you’re waiting on people. You um, you try to um, muster self-control and um, try to calm them down and um, try to solve their problem.

Carol didn’t stop to think about the consequences. This is true whenever you get frustrated too much. She could be fired if the man complained to management.

Uh, another indication that she’s lost control.

She angrily lifted up the plate of spaghetti. Maybe nothing will happen. There is a chance that she could spill the plate on the customer.

Uh, which uh.

She took the food back to the kitchen. What she should do. Have the food warmed up and take it back to the customer.

Okay, this isn’t as bad as I thought she was going to do (laughing). I thought she might throw it at the guy, or dump it on the table. So uh, but she should not have shown anger, she should have shown sympathy to calm the man down.

She sighed, realizing her shift was almost over. Happy about that because it had been a very frustrating day for her. Maybe tomorrow might be a lot better. Look at the bright side.

So uh, another indication that um, she is eager to go home to get out of this environment that she’s unhappy with the job, but she did retain, even though it says she lost control, it doesn’t indicate any um, undue consequences as a result.

Carol regained her composure and brought out a hot plate of spaghetti for the customer. Will the customer thank her for doing this?


Which is of course, the best thing to do, so, even though it says that she lost control, uh, and she angrily lifted the plate of spaghetti, she shouldn’t have shown anger, but she did the right thing in um, bringing out a hot plate of spaghetti.

100% agreement by raters that participant was a healthy older adult. 95% agreement by raters that participant had RHD.


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Appendix B Rating Scales for Discourse Variables and Confidence Ratings Tangentiality 1 Very tangential; excessive off-topic information


3 Somewhat tangential


5 Not tangential; all information was on-topic

Egocentrism 1 Extremely egocentric; excessive overpersonalization


1 Verbose; excessively long responses


3 Somewhat egocentric


5 Not egocentric; no references to personal experience


5 Paucity of speech; very few— or very short— responses given

Quantity ( Verbosity/ Paucity) 3 Appropriate length of response

Confidence Ratings How certain are you of your answer? 1 Uncertain; I could not decide which one was correct


3 Fairly certain


5 Very certain my classification is correct

Lehman Blake: RHD Discourse