I participated in a very interesting Hands-On Lab at the ASHA Convention which taught how to assess pragmatic skills in adults with brain injury. In this lab, I learned 3 different conversation sampling tasks and how to score the conversation sample.
Free DIRECT download: 7 conversation tasks to assess pragmatics (cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
This post relies heavily on the lab, with permission from the primary author, Heidi Iwashita, MS, CCC-SLP. The other authors are McKay Moore Sohlberg, PhD, CCC-SLP, Jill Potratz, MS, CCC-SLP, Laurel Smith, BS, and Jennifer Sabo, BS. Read the 2019 study by Heidi and Dr. Sohlberg.
Outline:
- Why assess social communication (pragmatics)?
- Collecting standardized conversation samples.
- 3 conversation tasks.
- 4 additional conversation tasks.
- Assessing the conversation sample.
- Try these tools to gain insight into your patient.
- Related Eat, Speak, & Think posts.
Why assess social communication (pragmatics)?
Pragmatic deficits are common following a brain injury and include understanding and producing nonverbal communication, initiating conversation, turn-taking, maintaining the topic of conversation, and responding to social cues (Struchen, Pappadis, Sander, Burrows, & Myszka, 2011).
As speech-language pathologists (SLPs), we may assess pragmatic skills informally, since standardized language tests generally don’t directly assess these skills. Instead, we may rely on clinical judgment as to whether a person’s social communication skills appear “off”.
However, if we use informal assessments, we can’t reliably identify which specific skills are relatively intact and which are definitely impaired. Furthermore, best practice (and insurance) dictates that we use standardized assessment tools.
We need quick, standardized tools to assess social communication skills to document the presence of an impairment, characterize the nature of the impairment, provide information for treatment planning, and demonstrate progress over time.
Collecting standardized conversation samples
One approach to collecting a language sample is to simply talk to our patient. This approach is called “free conversation”, which allows us to assess many pragmatic skills such as topic maintenance, turn-taking, and responding to non-verbal cues.
However, free conversation isn’t standardized and can be influenced by a number of factors. It’s likely that the assessment will occur during our first meeting with our patient, before we’ve achieved a level of rapport. Our patient won’t likely talk to us in the same way they talk to their family. For instance, our patient might be deferential to us as a medical provider, or they may be upset by all they’ve been through.
Scientists have studied how to generate feelings of connectedness, or closeness between strangers, for a variety of reasons. For instance, this 1997 study by Arthur Aron and colleagues found that after discussing 36 questions of increasing depth, strangers felt closer to each other. It didn’t matter whether they agreed on viewpoints or believed the exercise would make them feel closer to a stranger. In fact, they reported feeling as close to these new acquaintances as they did to their close friends.
Aron et al’s 36 questions takes 45 minutes, which isn’t practical for clinical practice. While it’s widely accepted in the research community that free conversation isn’t the best way to collect a conversation sample, we don’t have a consensus on how best to collect a conversation sample.
The three conversation tasks I describe below are from the hands-on lab, but you’ll see four other conversation sampling tasks described under the Pragmatics Rating Scale section. You have the option of trying out different sampling methods and choosing the ones that you find most helpful.
3 conversation tasks
Relationship Closeness Induction Task
The Relationship Closeness Induction Task (RCIT) developed by Constantine Sedikides, PhD, and colleagues and published in 1999. The RCIT consists of three sets of questions and takes nine minutes to administer. These questions are reciprocal, meaning that we answer the same questions that we ask. Professor Sedikides and colleagues developed the questions for college students and suggested that they can be adapted for other populations.
Heidi Iwashita and colleagues used modified questions for the hands-on lab, which are listed below. These questions took six minutes to administer.
- List 1 (one minute):
- What is your first name?
- How old are you?
- Where are you from?
- Where else have you lived?
- Who else is in your family besides you?
- List 2 (two minutes):
- What are your hobbies?
- What is one of your favorite books? Why?
- If you could travel anywhere in the world, where would you go and why?
- What is one habit you would like to break?
- List 3 (three minutes):
- If you could have one wish granted, what would that be?
- What is one thing about yourself that most people would consider surprising?
- Is it difficult or easy for you to meet people? Why?
- What is one recent accomplishment that you are proud of?
- What is one of your happiest early childhood memories?
Purposeful Conversation Task
The Purposeful Conversation Task asks your patient and a family member to engage in a deeper conversation on a specified topic. For the hands-on lab, Iwashita and colleagues slightly adapted the language used in Togher et al’s 2010 article “Measuring the social interactions of people with traumatic brain injury and their communication partners: The adapted Kagan scales.” Dr. Togher generously gave permission for the article to be included here. The clinic-ready adapted Kagan scales can be found in the appendix.
Here are the adapted scripts:
- Working together, come up with a list of situations you’re expecting to face over the next month where communication is important to you both. It might be something routine like a family dinner or a social event. Discuss these situations together and why they are important.
- Imagine that we’re collecting information about TBI for people with TBI and their families, friends, and caregivers. We’d like you and your communication partner to discuss what you think might be helpful for a person with TBI in their recovery. This may be information about: therapy, ways of dealing with stress, depression, practical ideas, how to deal with your family, how to deal with the medical system, financial or legal matters, or anything that patients might wish to know after a head injury.
Ideally, you would ask your patient to discuss this with a family member or friend during your session. But you can still use this task if it’s just you and your patient, as it would provide a different context for a conversation sample.
Joint Problem-Solving Task
The Problem-Solving Task comes from an interesting paper by Kilov, Togher, & Grant (2009): “Problem solving with friends: Discourse participation and performance of individuals with and without traumatic brain injury.” Kilov et al gave an unusual household object to a person with TBI and one of their friends and asked them to work together to figure out what it was. The objects were a tap turner and a belliclamp, which will be familiar to Occupational Therapists.
The pair were given one clue and five minutes to try to determine what the mystery object was. If they weren’t successful, they were given another clue and another two minutes to discuss. This continued for a maximum of four clues and 11 minutes.
Engaging in a joint problem solving task is more challenging than describing a picture or explaining how to make coffee. While engaging with socially-accepted verbal and nonverbal behaviors, the person with an acquired brain injury must:
- Attend to the task and their partner.
- Discuss the task with their partner.
- Notice the features of the object.
- Organize and express their thoughts.
- Generate possible solutions.
- Agree or disagree in socially appropriate ways.
- Come to a resolution
In the hands-on lab at ASHA, we worked as “clinician” and “patient” to figure out what one or more unusual household objects were. I remember one was the plastic ring left after the tape has been used, and another was a knitting needle gauge.
For my practice, I’ll bring three or four small items and ask my patient if they know what any are. I’ll pick one they don’t know and ask them to figure it out with their family member. (I work in home health, and there’s virtually always family or a friend there). This way I can assess my patient’s social communication skills with someone from their life.
4 additional conversation tasks
Donald MacLennan and colleagues developed the Pragmatics Rating Scale. For their research, they used four conversation tasks which are different from the tasks above. Since we don’t have a consensus on which types of conversation sampling is most helpful in capturing pragmatic impairments, I’d like to include these tasks for your consideration.
- Unstructured free conversation – five minutes.
- Structured conversation – watch a short video clip (four minutes) and discuss (five minutes).
- Narrative discourse – “Tell me what you usually do on Sundays.”
- Procedural discourse – one of two tasks.
- “Tell me how you go about doing dishes by hand.”
- Clinician teaches the patient a simple dice game, and the patient describes how to teach someone else the game.
I’m especially interested in watching and discussing a video clip and asking my patient how they would teach someone else a simple game I just taught them. I think these tasks would provide some interesting insight into my patient’s cognitive-linguistic skills.
Assessing the conversation sample
The Pragmatics Rating Scale
Donald L. MacLennan, MA, CCC-SLP generously gave permission for me to include both the Pragmatics Rating Scale and a conference handout describing the background and the results of a study. The Pragmatics Rating Scale was developed for the Defense & Veterans Head Injury Program. It was specifically designed to provide a comprehensive assessment of social communication skills in a short period of time.
The Pragmatics Rating Scale offers a five-point scale to assess:
- Non-verbal aspects of communication (intelligibility, prosody, eye contact, etc).
- Propositional aspects of communication (cohesion, relevance, etc).
- Interactional aspects of communication (topic management, turn-taking, etc).
MacLennan et al point out that we don’t have normative data for pragmatic behaviors in normal adults, but there is likely overlap on the continuum between impaired and intact social communication skills. They chose a score of three or less to represent an impairment.
The Modified Pragmatics Rating Scale
Heidi Iwashita and McKay Moore Sohlberg published “Measuring conversations after acquired brain injury in 30 minutes or less: a comparison of two pragmatic rating scales” in June 2019.
Their study demonstrates that the Pragmatics Rating Scale is valid, reliable, and clinically-feasible. See the appendix for a Modified Pragmatics Rating Scale for ABI. Stay tuned for further developments (Instagram)!
The Adapted Kagan Scales
Leanne Togher, PhD, FSPAA, CPSP (speech pathologist) and colleagues adapted two of Kagan’s scales to assess how well a familiar communication partner supports a person with a brain injury in conversation. Dr. Togher generously gave me permission to include the research paper where you’ll find the Adapted Kagan Scales included in the appendix. (This is the same article mentioned in the Purposeful Conversation Task section.)
Dr. Togher and colleagues collected two conversation samples from each participant: a five-minute free conversation sample and a five-minute purposeful conversation sample (described above). In each case, the conversation was between a person with a brain injury and a family member, friend, or paid cargiver.
The adapted scales are the adapted Measure of Support in Conversation (MSC) and the Measure of Participation in Conversation (MPC). You can use the adapted MSC to assess the familiar communication partner, whereas the MPC is used to assess the person with brain injury.
The adapted MSC assesses the familiar conversation partner’s ability to acknowledge the competence of the person with a brain injury, as well as their ability to reveal competence. The MPC assess how well the person with brain injury interacts verbally and non-verbally, and how well they convey information.
Try these tools to gain insight into your patient
Free conversation and informal assessment of pragmatic skills can only take us so far in helping our patients. Pragmatic impairments can be devastating after a brain injury, and the first step is to document our patient’s profile of strengths and weaknesses, as well as assess the supportive abilities of their typical communication partners.
I’m really excited to have seven different conversation sampling tasks to choose from and three assessment tools (the Pragmatics Rating Scale and the two Adapted Kagan Scales).
I’ve already used the Pragmatics Rating Scale to document pragmatic impairments in a patient who is clearly impaired but who tested normal on the battery of language and cognitive assessments I gave. I found it very easy to use, and I’m sure I’ll use it for all of my patients who have an acquired brain injury. I’m also looking forward to trying the two Adapted Kagan Scales.
Please give share this article with your colleagues. Give them a try and let us know what you think in the comments below.
Related Eat, Speak, & Think posts
- Easy discourse measures to demonstrate improvement.
- Single-use cognitive evaluation folders.
- Single-use communication evaluation folders.
- 18 free cognitive assessment tools.
- 3 versions of the Clock Drawing Test for cognition.
Free DIRECT download: 7 conversation tasks to assess pragmatics (cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Photo by rawpixel on Unsplash.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
Thank you so much for this, what a great article! The lab you attended sounds really interesting. I might be being silly, but I can’t find the appendix for the post anywhere?
Thanks, Vicky. What do you mean by “appendix”?
Hi Vicky – I couldn’t find the appendix either to locate the assessments.
Thank you for providing a little more detail! I wasn’t sure what Vicky was asking about.
The appendix for the Relationship Closeness Induction Task starts on page 3 of the PDF.
The appendix for the adapted Kagan Scales starts on page 12 of that PDF.
Links to the PDFs are in the post above, where each is discussed.
If that’s still not what you’re looking for, please be a little more specific and I’ll try to help!
Lisa