The linguistic differences and similarities in the neurogenic communication disorders

The linguistic differences and similarities

in the neurogenic communication disorders

of Dementia, Traumatic Brain Injury and Stroke

And how can clearly be established

Επιστημονικό Περιοδικό ΣΚΕΨΥ

Τεύχος 4

Πατιού Ιωάννα

TEACCH

Το TEACCH (μεταφράζεται “Θεραπεία και Εκπαίδευση Παιδιών με Αυτισμό και Διαταραχές Επικοινωνίας”) αποτελεί ένα πρόγραμμα εναλλακτικής εκπαίδευσης, για παιδιά με διαταραχές του αυτιστικού φάσματος, που ενσωματώνει παρεμβάσεις σε περιβάλλον, ημερήσιο πρόγραμμα και αντικείμενο εργασίας, και επικοινωνία.

Το TEACCH (Treatment and Εducation of Autistic and Communication Handicapped Children) πρόκειται για ένα κρατικό πρόγραμμα, που υλοποιήθηκε το 1972 στην Ψυχιατρική Σχολή του Πανεπιστημίου της Βόρειας Καρολίνας των ΗΠΑ ως συνέχεια μίας ερευνητικής δουλειάς, που είχε αρχίσει από το 1966.

Τα βασικά στοιχεία του TEACCH είναι τέσσερα:

1) Η φυσική δόμηση του περιβάλλοντος

Αφορά στον τρόπο οργάνωσης του περιβάλλοντος. Δόμηση δεν σημαίνει κατά ανάγκη ομοιομορφία.

Όπως σε όλα τα σπίτια έτσι και οι σχολικές τάξεις δεν μπορεί να είναι παντελώς ίδιες, γιατί ασφαλώς κάθε τάξη θα έχει διαφορετικά έπιπλα, αντικείμενα κ.ο.κ..

Δομημένη τάξη είναι η τάξη εκείνη, που με την πρώτη ματιά γίνεται κατανοητό ποια δραστηριότητα φιλοξενεί και σε ποιο σημείο. Είναι ιδιαίτερα σημαντικό, να εκπαιδεύσουμε τα παιδιά με αυτισμό να μπορούν να παραμένουν για κάποιο χρονικό διάστημα σε ένα μέρος.

Στη δομημένη τάξη πρέπει να υπάρχει ένας χώρος για ομαδικές δραστηριότητες, όπως επίσης και ένας χώρος για ατομική απασχόληση ή εργασία. Για αυτό τον λόγο προϋπόθεση είναι το κατάλληλο μέγεθος του χώρου. Είναι αναγκαίο ο εκπαιδευτικός να έχει άμεση οπτική επαφή με τον χώρο εργασίας του μαθητή. Τοποθετώντας κατάλληλα έπιπλα βοηθάμε τα παιδιά να κατανοήσουν τον χώρο, όπου θα κάνουν μία δραστηριότητα, δημιουργώντας ταυτόχρονα συνθήκες εύκολης μετάβασης από τη μία δραστηριότητα σε άλλη.

Επιπλέον, από έναν δομημένο χώρο, το παιδί δεν μπορεί να φύγει παρά μόνο από ένα σημείο. Το γεγονός αυτό βοηθά τον εκπαιδευτικό να προλάβει το παιδί, αν προσπαθήσει να απομακρυνθεί πριν ολοκληρώσει τη εργασία του και επίσης να το προστατέψει.

Αν οι μαθητές δεν εκπαιδευτούν νωρίς να μπορούν να κάθονται σε ένα μέρος είναι πολύ δύσκολο να τους ελέγξει κανείς αργότερα π.χ. στην εφηβεία ή την ενήλικη ζωή, όταν η σωματική ανάπτυξη και η δύναμη δεν επιτρέπει στον εκπαιδευτικό να ελέγξει με ευκολία το άτομο.

Στη συνέχεια παρουσιάζονται οι περιοχές διδασκαλίας, οι χώροι δόμησης μιας τάξης. Κάθε χώρος έχει τη ιδιαίτερη σημασία του.

Η δομημένη τάξη:

– Περιοχή διδασκαλίας
– Περιοχή ανεξάρτητης εργασίας
– Περιοχή ελεύθερου παιχνιδιού
– Περιοχή δομημένου παιχνιδιού
– Περιοχή φαγητού
– Περιοχή ομαδικής εργασίας
– Περιοχή μεταβατική

2. Το ατομικό ημερήσιο πρόγραμμα

Βοηθά το παιδί να κατανοήσει τι δραστηριότητες θα κάνει κατά τη διάρκεια της ημέρας.

Το πρόγραμμα έχει διαφορετική μορφή ανάλογα με το παιδί και τις δυνατότητές του και είναι αυστηρά εξατομικευμένο.

Για τα παιδιά, που διαβάζουν, οι δραστηριότητες σημειώνονται γραπτά. Για τα παιδιά που δε διαβάζουν χρησιμοποιούνται φωτογραφίες, σκίτσα, σχήματα ή τα ίδια τα αντικείμενα.

Οι αλλαγές, που για τα παιδιά με αυτισμό αποτελούν προβλήματα εξαιτίας της ανάγκης για ομοιομορφία, είναι αναπόφευκτες. Σε τέτοιες περιπτώσεις πρέπει να προειδοποιούμε το παιδί για την αλλαγή και είναι ιδιαίτερα βοηθητικό να αντικαθιστούμε οπτικά (με εικόνες) την αλλαγή της δραστηριότητας. Όταν το παιδί φτάνει το πρωί στο σχολείο βλέπει το πρόγραμμα του και ξέρει τι θα κάνει.

Ένα εξατομικευμένο πρόγραμμα μπορεί να περιλαμβάνει:

– Ελεύθερο παιχνίδι
– Δουλειά με τον δάσκαλο
– Δομημένο παιχνίδι (αξιοποιούμε τα ενδιαφέροντα του παιδιού)
– Ελεύθερο παιχνίδι (επανάληψη)
– Ατομική εργασία
– Τουαλέτα
– Φαγητό
– Εξωτερικές δραστηριότητες (στην αυλή)
– Ατομική εργασία
– Δουλειά με τον δάσκαλο (επανάληψη)
– Κολατσιό
– Τουαλέτα (επανάληψη)
– Σπίτι

3. Το σύστημα ατομικής εργασίας

Αποτελεί έναν τρόπο οργάνωσης μίας δραστηριότητας στο σχολείο ή στο σπίτι, ώστε το άτομο με αυτισμό να μπορεί να το εφαρμόσει.

Τα ερωτήματα στα οποία δίνει απάντηση το σύστημα ατομικής εργασίας είναι:

– Τι δουλειά θα κάνω;
– Πού και πότε θα την κάνω;
– Πόση θα κάνω;
– Πώς ξέρω ότι τελείωσα;
– Τι ακολουθεί και τι κάνω μετά;

4. Η οπτική παρουσίαση των δραστηριοτήτων

Αποτελεί ένα σύστημα επικοινωνίας για το παιδί που του επιτρέπει να κάνει μόνο του γνωστές τις ανάγκες του σε κάποιον άλλο.

Για να επιτευχθεί αυτό ακολουθούνται τα εξής 3 στάδια:

– Οπτική οργάνωση (τοποθέτηση των υλικών σε χωριστά κουτιά)
– Οπτικές οδηγίες (ο τρόπος που θα ασχοληθεί με τα υλικά)
– Οπτική σαφήνεια (σηματοδότηση σκοπού δραστηριότητας, π.χ. κωδικοποίηση με χρώματα, ετικέτες).

Παρουσιάζονται οπτικά ερεθίσματα, για να είναι σαφές το κάθε τι από το παιδί και για να δοθεί έμφαση στις σημαντικές πληροφορίες.

Στόχος του TEACCH

Το πρόγραμμα οργανώνεται σε 3 μέρη ανάλογα με την ηλικία:

1. Primary Stage / Προκαταρκτικό Στάδιο (5-10 ετών): Τα παιδιά περνούν τον περισσότερο χρόνο στη τάξη.

2. Middle Stage / Μεσαίο Στάδιο (10-15 ετών): Τα παιδιά περνούν περισσότερο χρόνο στο χώρο του σχολείου, όχι αναγκαία με παιδιά άλλων τάξεων.

3. High Stage / Υψηλό Στάδιο (15-21 ετών): Οι έφηβοι περνούν περισσότερο χρόνο στην κοινότητα και στο χώρο εργασίας).

Πηγή: http://www.noesi.gr/book/intervention/teacch

Γράφει για το NOESI.gr: ‘Αγγελος Κουτουμάνος  – κοινωνικός λειτουργός

Δυσκολίες Προφορικού Λόγου στην Προσχολική ηλικία

Δυσκολίες Προφορικού λόγου:

à(5% των νηπίων εμφανίζουν γλωσσικά προβλήματα). 

Ø      Φτωχό λεξιλόγιο και γενικά καθυστέρηση στην ομιλία (που επιμένουν παρά την πάροδο του χρόνου).

Ø      Αναγραμματισμοί, μπερδεύει την σειρά των γραμμάτων μέσα στη λέξη.

Ø      Μπερδεύει «ακουστικά» παρόμοιες λέξεις, π.χ. καράβι αντί καλάμι, φάρος αντί βάρος, δεσμός αντί θεσμός.

Η αδυναμία ακουστικής σύλληψης και διάκρισης των φθόγγων χαρακτηρίζεται με τον όρο «κωφότητα φθόγγων». Τα παιδιά δεν μπορούν να συλλάβουν και να διακρίνουν ακουστικά τις λεπτές εκείνες αποχρώσεις που υπάρχουν στους φθόγγους. Με άλλα λόγια υπάρχει έλλειψη ακουστικής διαφοροποίησης. Αυτό μπορεί να έχει αργότερα αρνητικές επιπτώσεις στην αναγνωστική ικανότητα του παιδιού.

Ø      Ανώριμες προφορικές εκφράσεις, συντακτικά και γραμματικά.

Ø      Αδυναμια διήγησης μιας ιστορίας με τη σωστή χρονολογική σειρά, ή να περιγραφή μιας εικόνας.

Ø      Δυσκολία συσχετισμού αντικειμένων του άμεσου περιβάλλοντος του με την ανάλογη «ονομασία» τους, π.χ. να συσχετίσει την εικόνα μιας πόρτας με την λέξη «πόρτα».

Ø      Δυσκολίες στην απομνημόνευση ποιημάτων ή τραγουδιών με ομοιοκαταληξία ή ρίμα.

Ø      Τραυλισμός.

• BRIDGING THE GAP BETWEEN RECEPTIVE AND PRODUCTIVE DEVELOPMENT WITH MINIMALLY VIOLABLE CONSTRAINTS

• BRIDGING THE GAP BETWEEN RECEPTIVE AND PRODUCTIVE DEVELOPMENT WITH MINIMALLY VIOLABLE CONSTRAINTS

(A REVIEW ON THE PAPER) 

• PATIOU IOANNA

• UNIVERSITY OF ESSEX, DEPARTMENT OF LANGUAGE AND LINGUISTICS, GRADUATE PROGRAMME IN LANGUAGE DISORDERS

• COLCHESTER 2004
•  

                        The child’s phonological development is composed by two domains: the perception and the production. Researches in this section have shown that there are gaps between those two fields and that the acquisition of receptive ability is always followed by the acquisition of the productive ability. This claim that “perception generally precedes production was supported by Edwards, Menyuk and Anderson and Zlatin and Koenigsknecht”. (Yeni-Komshian G.H., Kavanagh J.F., Ferguson C.A. 1980, p 119).

        But apart from their differences they should be considered as parts of the child’s linguistic competence and phonological acquisition. Furthermore, reception and production present parallel ways in development and structure, because the same markedness constraints apply in both domains. The difference and the gap between these two fields emerges in case that the representations of perception is more marked than the representations of production. This could be explained according to the process of the perceptive faithfulness constraints. Generally, the Optimality theory is the key element which will offer an integrated explanation for this gap as it views “the Universal Grammar as a set of violable constraints”. (Archangeli D. & Langendoen D.T. 1998, p 11).

•  

•   
• The development of receptive ability

          During the process of phonological acquisition, it is logical for the child to have gaps between the perception and the production. Although, some linguists have different point of view. This issue will try to present that there are indeed some gaps during the process of perceptual and productive acquisition  and some structural constraints which are similar and occur first in perception and then in production. Generally, “the child’s perception of the phonological system is complete by the time the child begins to acquire productive control of phoneme contrasts”. (Yeni-Komshian G.H., Kavanagh J.F., Ferguson C.A. 1980, p 118)   

·        Segmental constraints in early perception :                             

           According to detailed researches, Barton cites that the form of sound or meaning pairing and the different sounds that are stored in memory are components of a phonological contrast. In his experiments he tried to prove that the “ability to distinguish various contrasts emerges in a relatively fixed sequence”. (Pater J. 2004, p 221) he reaches to the conclusion that the phonemic perception – “the ability to pair a segmental phonetic contrast with a meaning difference” (Pater J. 2004, p 221) – may be developed in stages and that the ability to distinguish minimal pairs is not necessary in order to perceive a contrast.         

           Another experiment which was held by Stager and Werker was based on the concept that the infants are “capable of detecting an acoustic change in repeated stimuli”. (Yeni-Komshian G.H., Kavanagh J.F., Ferguson C.A. 1980, p 148) They showed that the pairing: sound-meaning, may result in decrease of attention to the phonemic detail. The experiment was done in infants and it was focused on the habituation/dishabituation of the sound combined with the meaning. The infants had to watch to some colored objects that were moving on a video screen while they would hear a novel syllable. This was done many times until habituation was achieved. Then, the researchers compared the mean looking time where the pair sound-meaning was diverted from the habituation phase, with the mean looking time where the pair was the same. The outcomes revealed that in case that the articulation of the initial consonant of the syllable was the only difference, the looking time was quite the same in both trials. But in case that the differences in syllables where prominent, the result was that the looking time in the switch trials was higher.         

          In addition to this experiment, another one was held with a chequer-board pattern instead of the video pattern, in order to prove that the infants didn’t perceive the consonantal place distinction in the previous experiment. That was a genuine research which was testing the perception ability of the infants and demonstrated that they can perceive a contrast. It should also be referred that the dependent variable in these experiments is the looking time.        

        In general, the overall conclusion we can arrive at, is that the consonantal place distinction is not encode in the lexical representations of the infants, although it is present in the phonemic representation. “The lexical representations of speech perception come from the same stored lexicon that is used for speech production”. (Cole R.A. 1980, p 248) Moreover, the last experiment reveals that 14 month-olds are able to perceive the phonetic level while the first experiment shoed that they can’t perceive the lexical representations.         

          In disagreement with the results of the research made by Werker and Stager, is the study of Pater et al. He used the same methodology with Werker and Stager in 14 month-olds and found that the infants didn’t notice any difference between the sub-minimal status of bi and di pair, as Werker and Stager had reported. Pater also concluded that the14 month-olds didn’t realized any voice distinction in the lexical representations.        

         Shvachkin also examined children’s ability to hear phonemic distinctions. In an extensive research with infants he reached to the conclusion that “the development phonemic perception was gradual and that it was consisted of six levels: distinction of vowels, distinction of presence of consonants, distinction of sonorants and voiced stops, distinction of palatalized and nonpalatalized consonants, distinction of sonorants and distinction of obstruents”. (Ingram D. 1976, p 23)         

            The main theme of research in this area is if the misperception is the basic reason of “some neutralizations of adult contrasts in children’s production”. (Pater J. 2004, p 224) The outcome of the experiments indicates that there are indeed lexical representations for distinctions which are lost in production and as far as it concerns the difficulty to perceive contrasts, the researchers refer that they are first being represented lexically and then being produced. Reaching to an end of this chapter, it should be cited that the lexical representations which children acquire are only segments of what they can perceive while at a later stage “when these lexical representations have been enriched, the productive representations need only to be elaborated”. (Pater J. 2004, p 225) This is in agreement with Waterson’s point of view, who proposes that “children tend to perceive utterances and reproduce the most salient features of the utterance”. (Yavas M.S. 1991, p 23)          

           Furthermore, Peizer and Olmsted and Salus and Salus support that the sounds should first be perceived in order to be pronounced correctly. And consequently, they refer that “sounds which are not pronounced later are also sounds that are perceived later”. (Ingram D. 1976, 24).

•             
• Prosodic constraints in early comprehension   
•  

         In order to explain the restrictions that occur in prosodic phonology of production it should be mentioned that some words in English are constrained by a single initially stressed disyllable, called trochaic foot which remain intact in comparison with the final stressed disyllables that lose their stressed initial syllable.

        The restrictions subjected to the trochaic foot, is being represented below for the word garbage:

      W

     F

΄σ        σ

As far as it concerns the production of the word garbage, it should be represented either with an iambic (right headed) foot:

       W               

      F          

σ        ΄σ  

or with the completion of the initial syllable to the W level:

    W

             F

 σ           ΄ σ

          Jusczyk’s researches have revealed that such constraints occur not only on children’s productive ability but also on their perceptive ability. According to his studies, where he tested 7,5 and 10 month-olds, he indicated that the first group listened far more time to passages which contained familiarized trochaic words, in comparison with the second group who listened longer to familiarized iambic words. Thus, the overall conclusion we arrive at from this experiment is that the trochaic pattern is acquired before the iambic. Extended this conclusion, we can also conjecture that there is indeed a gap between comprehension and production as it had been referred at the beginning. All these tests have clearly indicated that there are parallel restrictions occurring, in children’s perceptive and productive ability during the acquisition of phonological process.  

·        Minimal violation across perception and production                            

            One of the basic restrictions of truncation is the word size – “a word is made up of a single trochee” (Pater J. 2004, p 227) – . Another one is the violation of lexical structure – faithfulness [faithfulness constraints require the output to be identical to the input and its’ aim is to “prohibit deletion, insertions, feature changes or other changes in mapping from inputs to outputs” (Kager R., Pater J., Zonneveld W. 2004, p 20)] – called Max. More precisely Max means that “every segment of the input has an identical correspondent in the output”. (Archangeli D. & Langendoen D.T. 1998, p 63) The relationship between word size and Max constraints is the following: word size»Max: production. A rank like this would be optimal for a young learner in comparison with an adult where the rank would be reversed.         During the acquisition of receptive competence, the phonological grammar intervenes in order to regulate the structure – the complexity of the perceptive representations. That should be considered as a component of the learning process.        

             But with a strategy like this, constraints and violations restrict the lexical representations of the grammar. Thus, the grammar “intervenes between the incoming data and the stored representations, as well as taking its usual place between the stored representations and the concatenated utterance”. (Pater J. 2004, p 228) So the phonetic form of a word passes through the grammar, once in the perception and once in the production. Consequently, the input to the grammar is the perceived form and the output is the lexical form. Thus we have the same ranking in the perception, as we had in the production: word size»Max: perception.      

            Furthermore, it should be referred that the lexical representations are also subject to prosodic structure. According to the Optimality theory, the phonotactic  generalisations are the result of the interaction between the output of the markedness and the output of the faithfulness constraints.        

       Another interesting account, which is worth noticing, is that a constraint may be obeyed in a domain, but not in another. For example, the word size constraint is overcomed in perception but not in production. Prince called this phenomenon: nonuniformity, meaning that a markedness constraint may be violated only in one certain section. Nonuniformity is part of the Optimality theory. Faithfulness constraint is the responsible restriction that prevents a markedness constraint having uniformity.        

           As far as it concerns the faithfulness restrictions, they may apply either to the input-output faith or to the base/reduplicant faith. So, the structural limitations of the unmarked in reduplication applies to the following rank: faith (input-output) » markedness » faith (base/reduplicant). Taking all these into account, we reach to the conclusion that the nonuniformity’s rank is the following: faith»markedness»faith.        

           In order to be able to explain the differences in the complexity of the structures between the perception and the production, we should accept the fact that the faithfulness constraints may apply either the lexical – to the surface faith of production or the surface – to the lexical faith of perception. So there are two kinds of Max violation: the Max (LS), where “if the input is a lexical form, every segment of the input has a correspondent in the output” (Pater J. 2004, p 230) and the Max (SL) where “if the input is a surface form, every segment of the input has a correspondent in the output”. (Pater J. 2004, p 230) During the process of perceptual acquisition of the initial unstressed syllables the word size constraints exists between the Max (SL) and the Max (LS) restrictions. As far as it concerns the perception, the dominance of surface form is responsible for the representation of the initial unstressed syllable in the lexical form, in violation of word size, while in production the surface form is not dominant, resulting in an optimal truncation.        

          So, the gap between perception and production can be considered as an instance of minimal constraint violation. (Tohkura Y., Vatikiotis-Baterson E., Sagisaka Y. 1992) The role of the word size constraint changes through the levels of development as a result of the position of faithfulness constraints.       

           Thus, when the word size constraint is fully satisfied in perception and production, we get: word size»Max (SL), Max (LS), when it is minimally violated in perception we get: Max (SL)»word size» Max (LS) and when it is violated in both domains we get: Max (SL), Max (LS)»word size. The final stage is the adult level, which children have to get through this ranking until they acquire it and understand the grammar. 

·        Further articulating the model      

        Jusczyk and Aslin’s research is in disagreement with the results of Stager and Werker’s research. The first ones find out that the infants are able to represent perfectly relatively phonological detail in memory. Stager and Werker, cite that the infants link the phonological form with the meaning, to the lexical representation level, in comparison with Jusczyk and Aslin who report that the surface phonological representation is meaning-free. (Pater J. 2004) So, what they suggest is the following rank of representations and faithfulness constraints:

•  “Acoustic representation                       Present at birth  
• Faith (AS=acoustic representation
• to surface representation)    
•    
• Surface representation                            6 – 9 months   
• Faith (SL)
• Lexical representation                            11-18 months   
• Faith (LS)
• Surface representation                           18-24 months”

• (Pater J. 2004, p 233)

          In the surface representation between 6-9 months, the faithfulness constraint, faith (AS) is promoted above the markedness constraint. In the next stage of lexical representation between 11-18 months the faithfulness constraint, faith (SL) is forced to dominate the markedness constraint. While in the last stage of 18-24 months the production of words with meaning results in the dominance of faith (LS) above the markedness constraint. This is the process of acquisition that infants follow from perception to production. 

·        Comparison with other approaches: 

·        Smolensky’s model:                    

           According to this approach, the choice of the lexical forms of the candidates was made on the basis of withdraw to faithfulness. Smolensky’s proposal will show that the truncation which has already been discussed previously is optimal and so we get: word size» faith. In production the word size violation is satisfied due to faithfulness violation. In comprehension, the word size will surely be violated in the surface form. This means that the markedness constraints – which are “the natural antagonists of faithfulness constraints because faithfulness may preserve the lexical properties while the markrdness may ban them at the surface” (Kager R., Pater J., Zonneveld W., 2004, p 20) – will create an iambic foot without taking into account the initial syllable.       

           Smolensky’s approach reveals that the comprehensive ability is advanced relative to the productive ability. But the lexical forms of comprehension should be perfectly phonological comprehensive. This is impossible to occur and it could be explained in terms of the infant’s comprehensive and productive ability which are subject to similar constraints.   

 ·        A mixed model  :              

             As it has been referred in a previous section, the comprehensive process of acquisition is influenced by the markedness constraints, since the lexical form is considered to be the output. But this proposal rejects the equivalence either between the lexical form and the input or the surface form and the output. The following approach of mixed model will try to explain and restore this equivalence. The basic element in this model is to accept that the acoustic-phonetic representation produces the phonological surface string. This could be done only by considering the acoustic-phonetic string as output to the grammar.

         Apart from this, the mixed model should also be combined with Smolensky’s view that “the surface strings must faithfully represent the phonetic form”. (Pater J. 2004, p 236) The three stages of development during the comprehensive acquisition are similar with the stages of Minimal violation across perception and production section. The only difference is that instead of faith (AS), here we will use faith (SL). So the process of acquisition is subject to the following stages:

• Stage 1: markedness » faith (AS), faith (LS)
• Stage 2: faith (AS) » markedness » faith (LS)

• Stage 3: faith (AS), faith (LS) » markedness

              The first stage represents reduced representations in both domains of comprehension and production, the second stage reveals faithful comprehension and reduced production and the last one shows faithful comprehension and production.         

           It should also be referred that during the acquisition of comprehension and production the words are restricted to a single trochaic foot. This limitation occurs because “the structural constraints apply to the surface phonological form constructed on the basis of the perceived acoustic-phonetic representation”. (Pater J.2004, p 236)         

             The significant point of this model is that it allows the: faith (AS) » word size » faith (LS) ranking happen, producing by this way, the gap between the perceptive and the productive ability. As far as it concerns the comprehension, the faith (AS) is satisfied by the markedness prosodic structure, while in production we have the unmarked structure as a result of the continuous supremacy of word size over faith (LS). Moreover, the general conclusion we arrive at from this model is that the restrictions in the structure, influence the perceptive outcome.          Furthermore, in order the input –output mapping to be equivalent with the lexical–surface representations, we should be based on the Optimality theory.  

·        The dual-lexicon model  :                     

       The general concepts of the dual-lexicon or two-lexicon model are the separate representations for production and perception and the different faithfulness constraints that occur in every domain. The markedness constraints result in difference in the ranking of faithfulness limitations and in restriction to the extention of diverge. Although, another more significant difference emerges: when a knowledge has been acquired from the receptive ranking of markedness constraints, it is transferred immediately to the production grammar and so it doesn’t need to be relearned.         Bringing this chapter to a close, we should refer that the Optimality theory gives the answer to the process of child’s output representations: the output limitations interact with the lexicon with the help of the faithfulness constraints and this leads the child to the creation of his output representations. For example the word: fish: “its’ perceived form is entered first in the input lexicon. Then the reduction rules, constraints, of child’s phonology, turns this form into one underlying production. I and S are stored in the output lexicon as an unordered pair of vowel and fricative which must be ordered by the production rules”. (Kager R., Pater J., Zonneveld W. 2004, p 13) Then it is subjected to the output constraints that fricatives are not allowed to be positioned in onsets. So when a new phonological rule is being acquired by a child, the existing pronunciations may persist, “as if output forms serve as independent lexical items”. (Menn and Matthei 1992, p 213 in Kager R., Pater J., Zonneveld W.2004, p 14)  

·        Conclusion:                      

            Smolensky proposed to use Optimality theory in order children to acquire the receptive and productive phonology with a single grammar. The differences that emerge are the constraints in the early comprehension and production, where the receptive phonology is acquired perfectly from the beginning.          

          This issue also revealed that the receptive ability is being developing in a similar, parallel way to the development of productive ability.         

            Although, a series of structural limitations ranked over faithfulness constraints, apply to both domains production/reception and surface form/lexical form. So children acquire the reception by “the promotion of comprehension specific faithfulness constraints” (Pater J.2004, p 239) while they get their productive competence later, by the acquisition of lower rank of the production specific faithfulness constraints.         

           The overall conclusion we can arrive at is that the markedness constraints in perception, intervene between the listening signal and the lexical representation. In addition to this, researches have shown that the phonotactic limitations play also an important role in adult’s speech perception.        

            Bringing this essay to a close, we should cite that it was a worthy attempt to present in a simple and well-structured way the process of phonological acquisition and offer a detailed explanation for the gap between perception/production. Generally, this issue is an integrated paper which presented new researches and shed new light upon the subject of bridging the gap between reception/production.                         

HOW REHABILITATION MODELS SHOULD ADDRESS THE PSYCHOSOCIAL IMPACT OF APHASIA

·        HOW REHABILITATION MODELS SHOULD ADDRESS THE PSYCHOSOCIAL IMPACT OF APHASIA

• IOANNA PATIOU

• UNIVERSITY OF ESSEX, DEPARTMENT OF LANGUAGE AND LINGUISTICS, GRADUATE PROGRAMME IN LANGUAGE DISORDERS

• COLCHESTER 2004

           Aphasia is an acquired language disorder which affects the language (reading, writing, comprehension, expression) and the speech. Apart from these fields it also has an impact on the patients’ everyday lives, their relationships with the other people, their family, their work, their cultural values and their social interactions. So aphasia should be considered as a “multi-facet disorder which demands a flexible and integrated therapy and support”. (Pound C., Parr S., Lindsay J. & Woolf C., 2002, p 1) The choice of the rehabilitation model is being done according to the aims of the intervention and the patients’ response to the treatment method. Different kinds of rehabilitation have different impact on the patients’ impairment and degree of change. Rehabilitation refers to “services concerned with: education, physical functioning, psychological adjustment, social adaptation, vocational capacities or recreational activities”. (Sussman M.B. 1965, p 1) This essay will be focused on the psychosocial change that can be achieved with the appropriate rehabilitation models.    

·        The psychosocial impact of aphasia     

          Aphasia is also characterized as a social problem which affects the patients’ daily activities and interactions, resulting in serious social and psychological ramifications. Increased attention has been paid nowadays to the psychosocial effects of aphasia and the emotional needs of the patients as it has been realized that they play a significant role in the rehabilitation and the treatment. Many aphasic patients face great difficulties in coping with their lives because of their impairment. Lewis and Rosenberg cite that these patients experience “two main psychological disturbances: anxiety and problems with identity and self-esteem”. (Brumfitt S. 2002, p 20) Depression, low self esteem, behavioral alternations and changes may also be present. The emotional dimensions of aphasia can affect all the aspects of the patients’ social and daily lives, as the loss of normal communication and linguistic impairment can lead to a different life style with isolated activities. Most of the aphasic patients express “feelings of isolation, loneliness, sensitivity, psychological impoverishment that caused them to avoid and reject people, in fear of rejection”. (Sarno M.T. 1991, p 500) Moreover, they suffer from hopelessness, grief, discouragement, denial, embarrassment because of their inability, futility, despair, anger and they use to have regressive, aggressive and anti-social behavior because they cannot adapt themselves to their new life. So, we reach to the conclusion that the emotional devastation, the frustration, the panic and the gray period of aphasia are the main characteristics of the behavioral changes in the psychology of the aphasic patient. (Howard D. & Hatfield F.M. 1987)      

         All these feelings are the result of the changes that have taken place in their lives so suddenly. These patients lose the accustomed roles they used to have before, in their home, their job, their community, their company. Many of them lose their jobs, with consequent financial problems, they may also lose the role they used to have in their family and in the society and sometimes they lose their physical health and capacity. (Perkins W.H. 1977) For example, in case of hemiplegia, the psysical difficulties can affect the sexual interest and the relationship between the patient and his/her partner, as many aphasics suffer from fear that sex can cause harm. Thus, it is very difficult and hard for them to face the reality from another point of view, which they cannot accept, as they have lost their favor of the life. Such feelings of depression and emotional disturbances may have as a result catastrophic reactions e.g.: denial to eat, poor motivation to participate in the therapy plan, suicide attempts, weight change, delusional behavior, psychical destructiveness, panic attacks, violence. (Myers R. “Notes from the lesson”, 2004)      

          Furthermore, aphasia affects the relationship between the aphasic patients and their spouses. Many of them experience “ a variety of negative reactions including shock, guilt, bitterness, depression, loneliness and irritability. The spouses of the aphasic patients have to face role changes and altered social lives”. (Sarno M.T. 1991, p 511) So the lives of the aphasics and their family members are completely changed.       

            Apart from these problems, aphasics also suffer from fears, phobias and embarrassment because of their inability to speak properly and communicate. This is so important because speech is one of the most vital and significant functions of the human beings. The impairment they have with their speech, their memory, their comprehension influences their whole lives as they have difficulties with ordinary activities such as: making calculations, answering the telephone, go for shopping, etc. (Ender by P. & Emerson J. 1996) In addition to this, they are unable to do the hobbies they enjoyed or do something independently. Consequently they withdraw from their friends, their social and leisure activities, and their jobs and live a pessimistic, hopeless, lonely and miserable daily routine.    

·        Rehabilitation models

           Regarding the personality and the emotional and psychosocial disturbances, the rehabilitation should start as soon as possible, since the therapeutic plan can lead to positive outcomes and improve the patients’ condition. But, although there are three separately approaches to the treatment of aphasia: the medical, the behaviorist and the holistic model of rehabilitation, effective management can be achieved by the interaction and the participation of medicine, psychology, counseling, psysical and social intervention. The choice of the appropriate method should be done according to the needs and the adaptation of the individual patient.        

          The main goals of the therapeutic models are: “the enhancement of communication, the identification and dismantling barriers of social participation, the adaptation of identity and the promotion of a healthy psychological state”. (Pound C., Parr S., Lindsay J., Woolf C. 2002, p 19).

·        Medical model

        The medical model reinforces the traditional approach of aphasias’ rehabilitation. Historically, medicine was the prior method they used for the patients’ treatment and the recovery. The medical model is focused on “the functional inabilities and limitations of the individual patient”. (Pound C., Parr S., Lindsay J., Woolf C., 2002, p 4) As far as it concerns the role of medicine in the psychosocial rehabilitation of aphasia, it is very valuable. The medical model is based on the concept that the patients’ problems and depression are the result of the brain injury. Its’ aim is to diminish the aphasics’ difficulties and emotional disturbances (depression, anxiety, fear, pessimism, denial, etc) and restore his independence and self esteem with the appropriate medication. For example, “the use of drugs, anti-depressants and muscle relaxants has shown a significant improvement for walking and activities of daily life”. (Enderby P. & Emerson J. 1996, p 25)                     The medical model provides “a well organized setting in which all services are mobilized for the patient with aphasia”. (Sarno M.T. 1991, p 558) So, the patients are able to live a more normal life and overcome many difficulties of their impairment. But, nowadays this model is used in cases that “the interaction between the patient and the therapist is not possible”. (Sarno M.T. 1991, p 516)   

·        Holistic model

          The development of a carefully designed and effective therapy plan for the patients’ future is very important and prominent. Many aphasic patients cannot realize their problem and so they don’t accept their impairment. Thus their denial of the illness or the therapy plan should be examined in terms of the psychological impact as it delays the rehabilitation and results in deep depression. The holistic model can contribute satisfactory in the improvement of this situation.

         The holistic model is more involved with the socio-cultural, psysical and bio conditions of the society and the human problems. “The holistic concept stresses an organic and functional relationship, a continuity interaction and a fundamental interdependence among the traditionally defined parts or areas of human behavior”. (Sussman M.B. 1965, p 31) The human environment, the social impact and interaction with groups and the cultural effect, play a significant role in the holistic rehabilitation.   Its’ purpose is to restore the abnormalities and the troubles that are related to the patients’ personality, feelings, way of thinking and acting, as “it is focused on the consequences of the impairment, on social and intellectual domains”. (Crystal D. & Varley R. 1998, p 18) Thus, the psychotherapy, the family support, the group therapy and the counseling are all considered to be components of the holistic model.

·        Psychotherapy

         The main characteristic of psychotherapy (or “talking cure” Brumfitt S. 2002, p 26) is that it helps the aphasic patient “to express distress and direct his attention on the preserved abilities in order to make a connection with the past and present self. Also it allows time for the patient to mourn the lost self before a new one can emerge”. (Brumfitt S. 2002, p 20) So the aim of this approach is to help the patient go through the destructive feelings of depression and anxiety, reduce his confusion and panic and finally get rid of them. The imaginary psychotherapy, the drama therapy, the art therapy and the dream therapy are being used for such purposes and are considered as helpful rehabilitation methods because they give the chance to the aphasic to experience all his senses and reveal all his unexpressed feelings. (Brumfitt S. 2002, p 27)                      For these reasons, the role of the therapist is considered to be very important and essential for the patients’ recovery. But in order psychotherapy to be effective the relationship between the therapist and the patient should be friendly and trustworthy so as the aphasic to feel safe and comfortable to express his inner world and his emotional pain. The patient will be willing to do the psychotherapy if he realizes that the therapist is the one who can help him relieve his distress and improve his communicational skills.      

·        Family therapy

         The family therapy is also another alternative way of aphasias’ rehabilitation. Its’ purpose is to release the patients and the family members from some bad experiences. It also targets to the emotional needs of the aphasics in order to understand what makes them suffer, so as to help them organize and programme their new lifestyle in a better way. The role of the therapist is to give information and direct the feelings of the patients and their family. (Lebrun Y. & Hoops R. 1976) It is very important the family members not to be overprotected or extremely anxious about the current condition of the aphasic because this may have a bad effect and outcome in his recovery. Encouragement and hope are the basic components of the linguistic and psychological rehabilitation. The family therapy is one of the most effective methods “to stimulate and support the patient through the various stages of recovery”. (Sarno M.T. 1991, p 559) The positive and encouraging side of the family members can contribute to the improvement of the patients’ depressed and isolated feelings. In terms of the family therapy, it is suggested that the spouses and the other members of the family should treat the patient as before the injury.   

·        Group therapy

        The group therapy is the method that is used most in the recovery of the brain-injured patients. It is focused on making the patient feel better by the support of the group therapists. The aphasic has the opportunity to express all his anger, his anxiety, his violence and hostility in order to feel released and so to develop and built a new stronger and independent self. Moreover in a psychotherapy group the aphasic patient can talk about his experience and his emotional needs in a positively environment where he has time to think and express his views. In a therapy group like this, the patient can feel that he is understood and safe with result to become more open to the physical and psychological healing. (Murdoch B. E. 1990, p 94-97) Thus, this approach is considered to be very valuable and helpful in many ways because it helps the aphasic “break down some of the barriers which had been built up since the aphasia had occurred and also because it allows the exploration of conflicts in a controlled setting with professionals available to give appropriate support”. (Code C. & Muller D. 2002, p 23) Apart from this, self worth and restoration of self-esteem is regained from the conversations, the verbal interactions and mutual understanding from the other members of the group.        Great attention should also be paid to the skills of the group leader as he has to be experienced and capable in order to be able to operate effectively the emotional, behavioral and perceptual deficits of the patient. (Lebrun Y. & Hoops R. 1976)                      Although the fact that the group therapy may be a very useful intervening method for the psychological rehabilitation of the aphasics, it can also be significant and necessary for their wives of the patients and their family members. As it has been referred previously, the social and the sexual life of the couple after the stroke or the TBI incident, changes completely. The spouses of the patients may also feel stress, isolation, frustration and anxiety. (Lebrun Y. & Hoops R. 1978) The group therapy gives them the chance to get rid of all these pessimistic feelings, make them feel better and improve their relationships with their partner.     

·        Counseling

        Counseling is one of the most substantial parts of the holistic model and it can be a really effective mean of treatment when it is combined with other rehabilitation approaches. Counseling is not only beneficial for the aphasic patient but also for their family members and relatives. The therapist is aiming to improve the quality of life, the relationships and the linguistic ability of the aphasic. The supportive behavior and environment which the therapist creates, can change the patients perception and emotional grief. The counselor can change the patients’ discouraging feelings of disbelief, anger, hopeless, through a complex process. In the beginning, “he allows the patient to grieve and share with him his pain and afterwards he tries to install new emotions that help the aphasic accept the current situation and cope with his loss”. (Repper J. & Perkins R. 2003) The therapeutic process of counseling can repair the psychological damage and help the patient discover his self in order to built a confident and strong identity.        Moreover the counselor helps the patients face the reality and understand their problem, as many aphasics have the tendency to overestimate their abilities because they cannot realize the severity of their condition.      

·        Behaviorist Model

        The behaviorist model is another aspect of the psychosocial therapy of aphasia. It is based on the Skinner’s theory of  “behavior modification through the operant conditioning, which stresses the importance of reinforcement in producing a certain behavior, useful for the rehabilitation”. (Code C. & Muller D. 2002, p 191) The therapists use this rehabilitation model in order to manipulate the patients’ behavior. So they change the depressed and anxious behavior of the aphasic with the help of a specific stimulus. This way of treatment is considered to be “ a programmed instructional approach, an educational process which applies to operant conditioning methods”. (Sarno M.T. 1991, p 551) The behaviorist model is very effective for the aphasic as the providing feedback from the therapist can change the patients’ psychosocial problems and the emotional disturbances. Furthermore, it gives the opportunity to the aphasic to retrieve information about him. In summary, it shows the patient the strategy, the way in order to modify his response –negative emotions- when another similar occasion happens.  

·        Conclusion

        The overall conclusion we arrive at is that the aphasic patient exhibit neuropsychosocial deficits apart from the linguistic impairment. Aphasia is deemed responsible for psychological, social, familial and professional changes in the patients’ daily life. For these reasons, great emphasis has been put on the importance of rehabilitation to the social and emotional functioning. “Current trends in the concept of rehabilitation and in related forces of social change suggest that in the future, rehabilitation of the disabled will be cast in a broader social frame reference”. (Sussman M. 1965, p 34) So, this field needs further and deeper investigation in order new techniques or improvement of the current psychosocial approaches and methods of treatment to be developed.      

          Living with aphasia is a difficult and painful experience.  In this dark trip the aphasic patient needs encouragement, hope and support from the therapist, the family members and relatives. The good psychology and positive thinking may be the most efficacious rehabilitation method.