Speech and language vol 11 speech and language advances in basic research and practice

The author also addresses directions for future research and some unresolved issues in the study of all aspects of chil-dren's speech and language development as well as in the study of

Contributors to This Volume

Marcel P R van den Broecke

Rob C van Geel

SPEECH AND LANGUAGE Advances in Basic Research and Practice

VOLUME 11

Edited by NORMAN J LASS

Department of Speech Pathology and Audiology West Virginia University

Morgantown, West Virginia

1984

ACADEMIC PRESS, INC

(Harcourt Brace Jovanovich, Publishers)

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PRINTED IN THE UNITED STATES OF AMERICA

84 85 86 87 9 8 7 6 5 4 3 2 1

Contributors

Numbers in parentheses indicate the pages on which the authors' contributions begin

Antonie Cohen (197), Instituut voor Fonetiek, Rijksuniversiteit Utrecht, 3512

JK Utrecht, The Netherlands

Donald Fucci (249), School of Hearing and Speech Sciences, Ohio University, Athens, Ohio 45701

Sarah Hawkins (317), Haskins Laboratories, 270 Crown Street, New Haven, Connecticut 06510

Raymond D Kent (113), Department of Communicative Disorders, University

of Wisconsin-Madison, Madison, Wisconsin 53706

Linda Petrosino (249), School of Hearing and Speech Sciences, Ohio sity, Athens, Ohio 45701

Univer-Betty Jane Philips (113), Language and Learning Center, Boys Town National Institute for Communication Disorders in Children, Omaha, Nebraska

53226

Marcel P R van den Broecke (197), Instituut voor Fonetiek, Rijksuniversiteit Utrecht, 3512 JK Utrecht, The Netherlands

Rob C van Geel (197), Instituut voor Fonetiek, Rijksuniversiteit Utrecht, 3512

JK Utrecht, The Netherlands

vii

Preface

Volume 11 of Speech and Language: Advances in Basic Research and

Prac-tice contains six contributions on a wide variety of topics Tikofsky examines contemporary approaches to aphasia diagnostics from both a medical and non-medical perspective In addition to providing a detailed description of specific contemporary aphasia test batteries, he discusses the relationship of human neu-ropsychology and aphasia, neurological diagnosis and aphasia, as well as recent developments in neurologic diagnosis in relation to aphasia He concludes that,

The decades ahead will see a greater integration of behavioral and neurological aphasiology in diagnosis Much of the groundwork for such an integration has been established What is required now is an increased dedication to joint research efforts to increase the precision and utility in contemporary and future aphasia assessment

Acoustic-phonetic descriptions of speech production in speakers with cleft palate and other velopharyngeal disorders are presented by Philips and Kent, whose intent is to illustrate the potential application of this information in con-tributing to diagnostic evaluation and remedial programming The authors pro-vide a detailed discussion of velopharyngeal incompetence, linguistic and pho-netic considerations related to velopharyngeal function, speech motor control considerations related to velopharyngeal function, speech patterns associated with velopharyngeal incompetence, prespeech and early speech development in children with velopharyngeal incompetence, basic acoustic effects of nasaliza-tion, and spectrographic correlates of velopharyngeal incompetence

Smith addresses the role of infant vocalizations as they relate to subsequent speech and language development Specifically, he is concerned with whether it

is possible to determine from an infant's prelinguistic vocalizations if the infant will have a phonological disorder when he begins to produce meaningful speech Since the capability for such a diagnosis presently does not exist, the author assesses contemporary research to determine whether it suggests that the devel-opment of such a reliable screening system may eventually be possible The methods employed to study prelinguistic sound development are discussed in regard to their diagnostic potential for predicting future phonological disorders, including transcription-based observations, acoustic analysis, and meta-phonological observation of phonetic development The author addresses direc-tions for future research and concludes that "integration of a variety of tech-niques may provide the best method for early diagnosis of speech (and language) disorders."

Pitch phenomena and applications in electrolarynx speech are addressed by Cohen, van den Broecke, and van Geel Included is a discussion of linguistic and

ix

instrumental approaches to pitch, a model of sentence melody, intelligibility and naturalness in various forms of alaryngeal speech, a grammar of intonation, development of a prototype electrolarynx with semiautomatic pitch control, and

a training program for intonated electrolarynx speech The authors also provide

an evaluation of intonated versus monotonous electrolarynx speech as well as implications for further research and practical applications of intonated elec-trolarynx speech in various languages

Fucci and Petrosino present practical applications of neuroanatomy in an tempt to provide the speech-language pathologist with a basic understanding of the structure and function of the human nervous system as well as an appreciation

at-of the necessary assessment at-of the integrity at-of the nervous system After a detailed discussion of the structure and function of the human nervous system, including the central, peripheral, and autonomie nervous systems, they address neurological considerations for the speech-language pathologist Assessment of nervous system integrity, including a discussion of higher cortical function, the cranial nerves, the motor system, the sensory system, and reflexes, as well as the disorders associated with the nervous system assessment procedures, is provided

Hawkins employs studies of temporal coordination to understand the ment of motor control in speech and to provide a basis for testing theories on the development of speech as a motor skill Discussions include prosody in speech perception and speech production, the contribution of studies of temporal coordi-nation to understanding the development of motor control in speech, some basic assumptions about the development of speech, acoustic-phonetic and neu-romotor influences on the development of temporally coordinated speech, two strategies for learning to produce clusters of consonants fluently, and a theory of the developing motor control of speech The author also addresses directions for future research and some unresolved issues in the study of all aspects of chil-dren's speech and language development as well as in the study of the motor control of speech, whether in development, maturity, or disintegration

develop-It is our intention that the contents of this volume in particular, and of this serial publication in general, will result in increased discussion and, conse-quently, further investigation of a number of unresolved contemporary issues in speech and language processes and pathologies that will ultimately lead to their resolution

NORMAN J LASS

Contents of Previous Volumes

Jesse G Kennedy HI and James H Abbs

Acoustic Characteristics of Normal and Pathological Voices

Steven B Davis

Synergy: Toward a Model of Language

Carol A Pruning and Judy B Elliott

SUBJECT INDEX

Volume 2

Functional Articulation Disorders: Preliminaries to Treatment

Ralph L Shelton and Leija V McReynolds

The Early Lexicons of Normal and Language-Disordered Children: mental and Training Considerations

Develop-Laurence B Leonard and Marc E Fey

The Shaping Group: Habituating New Behaviors in the Stutterer

Conversational Speech Behaviors

Marjorie A Faircloth and Richard C Blasdell

Oral Vibrotactile Sensation and Perception: State of the Art

Donald Fucci and Michael A Crary

Phonology and Phonetics as Part of the Language Encoding/Decoding System

Sol Adler and lowana A Whitman Tims

Speech Perception: A Framework for Research and Theory

Dominic W Massaro and Gregg C Oden

Velopharyngeal Structure and Function: A Model for Biomechanical Analysis

David Ross Dickson and Wilma Maue-Dickson

Use of Feedback in Established and Developing Speech

Gloria J Borden

Delayed Auditory Feedback and Stuttering: Theoretical and Clinical Implications

William R Leith and Claudia C Chmiel

Biofeedback: Theory and Applications to Speech Pathology

Sylvia M Davis and Carl E Drichta

Speech Production Models as Related to the Concept of Apraxia of Speech

Anthony G Mlcoch and J Douglas Noll

Aspects of Speech and Orthognathic Surgery

A Critical Review of Developmental Apraxia of Speech

Thomas W Guyette and William M Diedrich

Relapse following Stuttering Therapy

Franklin H Silver man

Analysis and Measurement of Changes in Normal and Disordered Speech and Language Behavior

Merlin J Mecham

Physiological, Acoustic, and Perceptual Aspects of Coarticulation: Implications for the Remediation of Articulatory Disorders

Donald J Sharf and Ralph N Ohde

An Empirical Perspective on Language Development and Language Training

Scott F McLaughlin and Walter L Cullinan

Elements of Voice Quality: Perceptual, Acoustic, and Physiologic Aspects

Raymond H Colton and Jo A Estill

The Resolution of Disputed Communication Origins

Murray S Miron

INDEX

Volume 6

Auditory Discrimination: Evaluation and Intervention

Charlena M Seymour, Jane A Baran, and Ruth E Reaper

Evaluation and Treatment of Auditory Deficits in Adult Brain-Damaged Patients

Thomas E Prescott

A Pragmatic Approach to Phonological Systems of Deaf Speakers

D Kimbrough Oiler and Rebecca E Eilers

Speech and Language Characteristics of an Aging Population

Virginia G Walker, Carole J Hardiman, Dona Lea Hedrick, and Anthony Holbrook

Language and Cognitive Assessment of Black Children

Harry N Seymour and Dalton Miller-Jones

Effect of Aberrant Supralaryngeal Vocal Tracts on Transfer Function

Sally J Peterson-Falzone and Karen L Landahl

The Human Tongue: Normal Structure and Function and Associated Pathologies

Donald Fucci and Linda Petrosino

From an Acoustic Stream to a Phonological Representation: The Perception of Fluent Speech

Volume 7

To Hear Is Not to Understand: Auditory Processing Deficits and Factors encing Peformance in Aphasie Individuals

Influ-Cynthia M Shewan

Auditory Processes in Stutterers

Hugo H Gregory and James Mangan

A Review of Research on Speech Training Aids for the Deaf

Richard P Lippmann

A New Era in Language Assessment: Data or Evidence

John R Muma, Rosemary Lubinski, and Sharalee Pierce

Quantification of Language Abilities in Children

Rachel E Stark, Paula Tallal, and E David Mellits

Communication Behavior Assessment and Treatment with the Adult Retarded:

An Approach

Nathaniel O Owings and Thomas W Guyette

Distribution and Production Characteristics of /s/ in the Vocabulary and taneous Speech of Children

Spon-John V Irwin

Speech Processes in Reading

Charles A Perfetti and Deborah McCutchen

Structure and Mechanical Properties of the Vocal Fold

Minoru Hirano, Yuki Kakita, Koichi Ohmaru, and Shigejiro Kurita

Jitter and Shimmer in Sustained Phonation

Vicki L Heiberger and Yoshiyuki Horii

Boundary: Perceptual and Acoustic Properties and Syntactic and Statistical Determinants

The Development of Phonology in Unintelligible Speakers

Frederick F Weiner and Roberta Wacker

Determining Articulatory Automatization of Newly Learned Sounds

Walter H Manning and Edward A Shirkey

Conversational Turn-Taking: A Salient Dimension of Children's Language Learning

Louis J DeMaio

Ontogenetic Changes in Children's Speech-Sound Perception

Lynn E Bernstein

Speech Production Characteristics of the Hearing Impaired

Mary Joe Osberger and Nancy S McGarr

Anxiety in Stutterers: Rationale and Procedures for Management

K Dale Gronhovd and Anthony A Zenner

Critical Issues in the Linguistic Study of Aphasia

Laryngectomee Rehabilitation: Past and Present

Robert L Keith and James C Shanks

Sensory and Motor Changes during Development and Aging

Ann Palmer Curtis and Donald Fucci

The Phonetic Structure of Errors in the Perception of Fluent Speech

Z S Bond and Randall R Robey

Multiple Meanings of A'Phoneme" (Articulatory, Acoustic, Perceptual, eme) and Their Confusions

Apraxia of Speech: Articulatory and Perceptual Factors

Anthony G Mlcoch and Paula A Square

The Prevention of Communicative Disorders in Cleft Palate Infants

Kenneth R Bzoch, F Joseph Kemker, and Virginia L Dixon Wood

The Relationship between Normal Phonological Acquisition and Clinical Intervention

Categorical Perception: Issues, Methods, Findings

Bruno H Repp

Speech Perception as a Cognitive Process: The Interactive Activation Model

Jeffrey L Elman and James L McClelland

INDEX

Contemporary Aphasia

Diagnostics

RONALD S TIKOFSKY

Department of Speech Pathology and Audiology

School of Allied Health Professions

University of Wisconsin-Milwaukee

Milwaukee, Wisconsin and

Department of Radiology

Division of Nuclear Medicine

Medical College of Wisconsin

Milwaukee, Wisconsin

I Introduction 2

II Historical Background 3

A Diagnostic Issues prior to the 1940s 3

B Diagnostics from the 1940s to the 1960s 11 III Aphasia Testing Post-1960 15

A Language Modalities Test for Aphasia (LMTA) 15

B Minnesota Test for Differential Diagnosis of Aphasia (MTDDA) 19

C Porch Index of Communicative Ability (PICA) 22

D Boston Diagnostic Aphasia Examination (BDAE) 27

E Western Aphasia Battery (WAB) 33

F Communicative Activities in Daily Living (CADL) and Functional Communication Profile (FCP) 43

IV Where Have the Tests Taken Us? 50

A Has Diagnostic Precision Increased? 50

B Do Aphasia Tests Really Differ One from the Other? 52

C What Are We Diagnosing? 53

V Human Neuropsychology and Aphasia 59

A General Concepts of Human Clinical Neuropsychology 59

B Aphasia as Part of the Brain Damage Symptom Complex 61

VI Neurodiagnostics: Neurological Diagnosis and Aphasia 64

A Nonscanning Approaches 64

B Recent Developments in Neurologic Diagnosis in Relation

to Aphasia 74 VII Conclusions and Projections 100

References 101

1

SPEECH AND LANGUAGE: Advances in Basic Copyright © 1984 by Academic Press, Inc

Research and Practice, Vol 11 All rights of reproduction in any form reserved

ISBN 0-12-608611-7

I INTRODUCTION

Diagnosis and assessment hold a prominent place in historical and rary aphasiology Diagnostics provide the data base for clinicians and re-searchers Since Broca (1861) presented his paper almost a century and a quarter ago, aphasiologists have continued to seek answers to many of the questions he and his followers raised with respect to language and brain The passage of time and advances in psychometrics, linguistics, and medicine as well as computer technology have done much to clarify the issues raised by the early scholars These advances have led to new and perhaps even more difficult questions to challenge the contemporary aphasiologist

contempo-Aphasiologists have taken some liberties in their use of the term diagnosis

They have broadened the concept to one that encompasses matters relating pects of linguistic impairment to alterations in brain function and the determina-tion of the site of the lesion producing the impairment Approaches to diagnostics

as-in the study of aphasia are often determas-ined by the motivations and demands of the several disciplines that view aphasia and the aphasie as their province

In the period from World War II to the present, two primary trends in aphasia diagnostics emerged, one related to the development of neuroradiographic tech-niques as a means to establish the site of lesion and the other, from speech pathology-psychology, in the area of psychometric assessment of aphasia There has been increased effort to bring together the findings of contemporary neu-rology as it pertains to aphasia and those of speech pathology, psychology, and neurolinguistics to establish better understanding of the intriguing phenomenon presented to us by aphasia This article examines contemporary approaches to aphasia diagnostics from the nonmedical and medical perspectives

The physician must address the question of whether the symptom complex of which aphasia is but a part is the result of a completed or ongoing process A decision based on the clinical evidence including laboratory tests must be made

as to etiology It is at this point in time that the physician begins to probe in a general fashion the language behavior of the patient The goal is to determine locus of lesion and to make a general assessment of the medical status of the patient

The domain of questions reaches beyond the confines of localization,

howev-er Basic to the discussion are questions pertaining to the matter of what is really being localized Hughlings Jackson (1878) long ago recognized that to localize the site of a lesion producing a given language deficit is not the same thing as localizing normal language function Even the seminal work of Penfield and Roberts (1959) on cortical stimulation and that of current workers have not truly localized language They have been able to arrest language in already impaired brains, but there is no evidence to suggest that they evoked normal language behavior on the operating table

Techniques for assessing and determining the site of lesion-producing aphasie

symptoms with greater precision are certainly more powerful now than they were only a decade or two ago It is no longer necessary to wait for an autopsy to obtain a picture of the lesion, because of the use of brain scan techniques Advances in neuroradiology have made it possible to visualize with great ac-curacy the locus, size, and depth of an infarct producing aphasia This increase in precision allows the physician to ask questions relative to aspects of the lesion and its effects on behavior in a somewhat different fashion The possibility of testing hypotheses regarding the relation of change in structure and physiology to change in performance is closer to realization If such relations could be deter-mined by radiologie techniques, more powerful diagnostic tools would become available to the physician and speech-language pathologist

The role of the speech-language pathologist with respect to aphasia has gone a remarkable shift in the years since World War II When concerned with the structure and locus of the lesion, many aphasiologists focused on devising appropriate means by which to assess, classify, and describe the alterations in language function that arise as a consequence of physical change in the brain It should be obvious, therefore, that issues relative to the determination of the consequences of focal and diffuse brain lesions require the integration of the diagnostic tools of both physician and language pathologist

under-This article is devoted to an examination of several approaches to the question

of diagnostics and aphasia A brief historical perspective will be presented lowed by a glimpse into the future Psychometric and neurologic approaches to aphasia diagnostics will be examined in some detail

fol-II HISTORICAL BACKGROUND

A Diagnostic Issues prior to the 1940s

Early reports dealing with aphasia were based on data from one or two cases Determination of the symptom patterns presented by the aphasie patient were not based on precise and well-standardized tests Rather, descriptions of the symp-tom complex emerged from clinical examinations constructed by physicians As Benton (1967) noted, questions determining whether aphasia involved a deficit

in intelligence led not only to controversy but to the recognition of the need for special tests With Wernicke's (1874) description of sensory aphasia, the need to distinguish between general reductions in comprehension as might be observed with the dementias and specific descriptions of language comprehension was increasingly felt

Early discussions and debates focused on the description of the impaired behaviors, the underlying language mechanisms, and reasons why the damaged brain yields the observed symptoms Broca's (1861) essay goes into elaborate detail concerning the nature of articulate language and the mechanism of impair-

ment, which he called "aphemia." The other central focus in this early period was to establish the site of lesion This was achieved through postmortem and inference Early works attempted to establish centers that were correlated with specific language functions They also hypothesized the interrelations between and among the centers It was this approach that led Head (1926) to invoke the pejorative term "diagram makers" upon the efforts of these early scholars Emerging from the trend in localization was the concept of a "center." Thus, it was possible to argue on the basis of focal pathology and the attendant behavioral deficits that there were centers for various faculties of language such as auditory comprehension and articulate speech

Conceptualization of centers within the cortex for specific psychological tions during the period from 1861 to the mid-1900s fit well with the then contemporary approaches to psychological theory It was during this period that concepts of faculty psychology and associationism were taking form Boring (1950) presents the work of Gall and the early localizationists in the light of an emerging physiological psychology The link between specific mental functions and correspondingly specific cortical sites was forged It was a linkage that was

func-to be challenged in the decades that followed Broca's attack on Flourens' concept

of "communal action" of the brain In Boring's view, Broca and Flourens brought the genesis of an experimental method to the study of aphasia It is in the context of an emerging clinical and experimental science that one must view early approaches to diagnosis As Benton (1967) points out, the use of psycho-metrically sound instruments as we understand them today was nonexistent in Broca's time Standardization and norms were not available This situation was not only true for aphasia but also for all mental functions Test batteries were in use, but data could not be compared easily from laboratory to laboratory Benton (1967) stated in regard to test construction in aphasia that "it is not inaccurate to say that we are today where intelligence testing was in 1900, i.e., the pre-Binet stage" (p 35) This is a strong assertion but Benton's evaluation of the tests available to assess the aphasie showed them to be psychometrically weak Weisenburg and McBride's (1935) attempt at development of a standardized battery led them to conclude that while the examination procedures should be standardized, "examinations for aphasia can never be routine procedures but the standard tests must sometimes be altered to throw more light on unusual difficulties" (1964 reprint, p 132) This view prevailed since it reflected the widespread belief that, as Eisenson (1954) put it, "Aphasie patients are charac-teristically too inconsistent in their responses to permit formal scoring standards

to be developed and meaningfully applied" (p 31) This was his position, when

he commented in the first edition of Examining for aphasia (Eisenson, 1946)

that, "the examiner will need to use the best approach he can devise for the

particular patient he is testing" (p 7) Eisenson's Examining for aphasia and the

Halstead-Wepman aphasia screening test (Halstead & Wepman, 1949) were the first two commercially produced aphasia tests These instruments, and many that

were developed during this period, remained close to the conception of aphasia

as a disorder of symbolic formulation (Head, 1926) and the classification system devised by Weisenburg and McBride (1935) No significant effort was made in this period to relate test findings to etiology or locus of lesion The one major exception was Luria's extensive investigation of traumatic aphasia first published

in Russian in 1947 and later translated to English (Luria, 1970) His central emphasis was on questions of the "topical diagnosis of aphasia" and analysis of different types of speech disorders that result from "focal brain damage." Although Boring (1950) suggests that Broca's report represented the begin-nings of an experimental science for human mental function, close examination

of the reports and commentaries of the time suggests that many of the odological requirements of such a science were lacking Unlike their counter-parts who worked with animals, the neurologists could not then and cannot now control the site of lesion Those working in the area of mind-brain or language-brain relations were dependent solely on the disease process to place the lesion for them Furthermore, in the period of Broca through the 1940s, the major method of determining site and depth of lesion was the postmortem examination

meth-of the brain Even in the case meth-of autopsy, the techniques for examining the brain

in detail (and in particular intrahemispheric connections) were severely limited

by the neuropathologist's available technology The only available in vivo

mate-rial was the patient who came to surgery with focal trauma or penetrating wounds

to the head In these cases it was possible to view the brain in a subject where the lesion was fresh Often, however, the precision of localization was blurred by fragmentation, uncertain trajectory, intracranial bleeding, etc Lacking also was any truly systematic approach to careful correlation of symptom analysis with focus of lesion or longitudinal studies of the course of the aphasia and changes in the lesion

It is interesting to note that in the preface to the second edition of On aphasia

published in 1890, Bateman (1890) commented on the status of the precision with which localization of function could be achieved When he completed the first edition of the work, he stated that "localization of cerebral function was in its infancy, and our knowledge of actual pathological changes occurring in nerve tissue was vague and unsatisfactory." Although Bateman felt that great strides in neuropathology were made between 1870 and 1880, he believed that the workers

of the time were still "on the threshold of the inquiry that much is still to be learnt, before we can speak with anything like mathematical precision, of certain functions of the wonderful piece of mechanism—the human brain." Bateman's discussion of etiology and differential diagnosis would not have been adequate even in the early twentieth century He does, however, address questions of differential diagnosis and cerebral pathology

Collins (1898), one of the first Americans to write a major treatise on aphasia, devoted chapters to diagnosis, etiology, and the morbid anatomy of aphasia Although not presenting any formal test, Collins outlines an approach to exam-

ination that has a strong contemporary ring to it He notes that "the constitution

of the speech faculty consists of two parts, the receptive and emissive" (p 324), noting that the symptoms may predominate in either dimension, "in true aphasia, that is, dependent upon a lesion of the speech centers, neither can

be the medium of manifestation of the spee h defects" (p 324) Collins, in his discussion of the morbid anatomy, makes a valiant effort to relate the various disease processes to the disturbance of cortical function He points to the necessi-

ty of studying morbid changes accompanying "motor aphasia" to separate it from "motor image aphasia" and to show that when disease is limited to Broca's area there is no secondary degeneration in projection tracts The discussion goes

on to raise questions concerning the extent of cortical and subcortical ment in the different diseases yielding aphasie symptoms Collins makes clear, even in this early work, the need for careful and exacting postmortem examina-tion of the brain to correlate disease, behavior, site, and extent of lesion The trend of a continual massing of data based on autopsy continues through the present time Two relatively modern sources that support classical localiza-tion theory are the studies by Henschen in the 1920s and Nielsen in 1936 and

involve-1948 According to Nielson, Henschen, who analyzed 1500 cases which had been reported in the literature, "discarded all psychologic factors and based his studies on localization entirely on autopsy material Anatomic localization was

carried to the nth degree" (Nielson, 1962 reprint, p 11) In his report of

Henschen's study, Nielson notes that the statistical procedures he used mine not only the rule for each function but also the exceptions." Furthermore,

"deter-he states "to establish any principle, t"deter-herefore, it is necessary to present a number of instances and to discover the generalizations which are valid" (Nielsen, 1962, pp 3 and 4) Nielsen pays more attention to pathology than behavior His approach to examination is not well documented or even sug-gestive of standardization

The workers cited above represent an approach to diagnosis that centers on determination of site of lesion to support hypotheses relating symptoms to lo-calization of function Their evidence for support was based solely on the postmortem examinations of brains of patients who demonstrated language im-pairment following disease which affected the cortex and subcortical pathways Another major source of data employed to corroborate the relationship of the different forms of aphasia to sites of damage comes from studies of patients who sustained gunshot wounds to the head Data on missile wounds to the head in relation to aphasia come from only a few sources Studies of patients from World War I are reported by Kleist (cf Russell and Espir, 1961), Head (1926), and Goldstein (1948) The second major source of data derives from the work carried out on patients from World War II Among the major contributors are Luria (1970), Goldstein (1948), and Conrad (1954) as well as Russell and Espir (1961) Head (1926, Vol 1, p 442) raises the question of being able to "discover

what relation the site of lesion, when it can be determined, bears to the clinical manifestations." He notes that material presented by gunshot wounds is not as valuable for establishing localization as in brains where there has been a full microscopic examination However, he goes on to say that such patients "are of infinitely greater scientific interest for determining the exact nature of the phe-nomenon during life, than those broken-down wrecks in whom disease is termi-nated by death" (p 442) Of course, the great advantage in using gunshot wound patients lay in the fact that many remained alive and there was resolution of the aphasie symptoms Thus, it was possible to obtain longitudinal data as to the course of recovery

In establishing the procedures to determine site of lesion, Head makes an important, but sometimes overlooked, diagnostically significant observation He asserts that the effects of diachasis must be taken into account to understand the change that occurs in the initial symptoms which are replaced by the permanent consequences of anatomical destruction Secondly, Head observes that a lesion which affects a small area of tissue can produce "profound and widespread defects" (p 476) if it is acute or progressive, whereas a large area of destruction

of old and slow onset may yield only minor disturbances of function

Head used his own terminological system to classify defective language and his serial tests to characterize impaired behavior While it is possible to argue over terminology, testing, and behavioral analysis, it is clear, even to Head (1926, Vol 1, p 476), who is considered as the archetype antilocalizationist, that "A lesion at some appropriate place on the surface of the brain can interrupt speech for a time " He does recognize that different forms of aphasia result from lesions in different parts of the brain The areas he identifies are essentially those which early workers such as Broca and Wernicke observed to be damaged What

is different in Head's approach is his belief that "No one part of this wide area on the surface of the brain is associated exclusively with the processes of speech" (Head, 1926, p 477) He asserts that there are no "centers" for the behaviors which constitute the activities of "normal language function" but he does accept the notion that there are areas of the brain "within which structural injury can produce disorders of symbolic formulation and expression" (Head, 1926, Vol

1, p 478) He also believed strongly that both "cortical and subcortical nisms participate in every act of language" (p 478) Such views have found their way into the thinking of Lashley (1951) in his attempt to characterize and integrate psychoneurologic concepts of brain function, as well as those of Gold-stein (1948) and Luria (1966, 1970, 1973) Possibilities of subcortical mecha-nisms generating aphasie symptoms such as suggested by Head have been con-firmed to some extent by Van Buren and Borke (1969), Van Buren (1975), and Ojemann and his co-workers (Ojemann, Fedio, & Van Buren, 1968; Ojemann, 1976)

mecha-Two important trends emerge from this relatively early work with respect to

diagnostics One stresses an evolution of a large number of clinical syndromes which could be related to relatively well-defined and small areas of cortical damage Thus, an accurate portrayal of the symptom or symptom complex should, if this concept were correct, lead to the diagnosis of a circumscribed area

of cortical damage producing the disturbed language function The second trend does not refute the central concept of clinical localization in its entirety Rather, the view taken is that one cannot with accuracy achieve a one-to-one correlation between disturbed language function and narrowly specified areas of cortical damage The relationship then is seen as one in which certain aspects of language impairment are more susceptible to disruption as a consequence of a lesion to broadly defined cortical or subcortical regions Those holding this view also take the stance that the destruction of cortical tissue produces a disruption of the general organizational activities of the brain, and that the behavioral symptom complexes are a reflection of the system's attempt at reorganization Accepting this position requires a dynamic conceptualization of both brain function and language behavior, one which posits interactions between cortical and subcor-tical regions that enable the organism to engage in linguistic behaviors Thus, the diagnostic issue here is less one of predicting specific site of lesion and more one

of suggesting how the effects of a particular lesion can account for the altered language

One can summarize this early period of scholarship as having laid the tions of the central issues relative to diagnostics in aphasia That the foundations were not well secured by statistically established data is not really relevant What emerges from analysis of these reports and theories of mind-language-brain relationships are the questions in diagnostics that have become the touchstone for contemporary students of aphasia

founda-One aspect of diagnostics continues to follow the tradition of the structuralists, that of a continuing search for verification that lesions of specific cortical areas produce specific alterations of language behavior The link between symptom, aphasia in its varied forms, lesion, and disease or trauma remains a valid arena for research

Another and equally important aspect of aphasia diagnostics emerged in the effort to understand better the nature of the language disturbance called aphasia Head's (1926) concept of aphasia as disorder of *'symbolic formulation and expression" based on Jackson's work (1878) held sway into the late 1950s As a corollary, the question of aphasia as being a ' 'disorder of basic mental function' ' (Weisenburg & McBride, 1964 reprint, p 39) arose Perhaps the most important influence on those who took this position derived from the influence of the

"Gestalt psychology" of the period Weisenburg and McBride (1964, p 39) summarize Goldstein, the leading proponent of this point of view, as stating that

"the various symptoms of aphasia are the manifestation of a single functional disorder, loss of the ability to grasp the essential nature of a process." They go

on to interpret Goldstein as believing that aphasia was not dependent upon a specific locus of lesion but rather on the disruption of a 4 'cortical function ' ' This concept is not necessarily incompatible with the view that lesions in relatively focal regions will determine the particular form which the behavioral disturbance will take This concept, which allows for both a holistic and a specifistic ap-proach to aphasia, is seen in the contemporary works of Luria and others In fact,

as will be shown later a reinterpretation of this concept in the light of cated neuropsychologic and neuroradiolographic techniques provides a clearer understanding of the diagnostic issues in aphasia

sophisti-The movement toward a neuropsychologic approach to aphasia diagnosis was

advanced by the publication of Aphasia: A clinical and psychological study

(Weisenburg & McBride, 1935) This work was the result of a 5-year study of

234 patients and served as the major reference work for American students of aphasia through the middle 1950s In the processes of developing their own battery of tests, Weisenburg and McBride reviewed in detail the then extant approaches and tests used to assess aphasia with particular attention to Head's well-known battery Their review of diagnostic testing following World War I reflected the growing influence of the ' 'mental testing" and "educational test-ing" approaches of the time They note "few tests of higher mental processes in the language field" (Weisenburg & McBride, 1964, p 85) were used with aphasies and observe that "nonlanguage intelligence tests" were developed after World War I As a result of their exhaustive review, Weisenburg and McBride

(1935) concluded that "what was needed most was a study of the actual nature of

the psychological changes occurring in aphasie conditions" (p 2) To fill this need they sought to attack the problem with four basic objectives to be accom-plished (Weisenburg & McBride, 1964, p 2):

1 The establishment of a battery of tests satisfactory for the determination and analysis of aphasie disorders

2 The study of psychological changes in aphasia

3 The classification of types of aphasia

4 The study of the nature and location of the lesions present in aphasia

It is interesting to note, in light of contemporary efforts to find short tests, that these authors caution that one could use less extensive batteries for ordinary diagnostic purposes "but this is not adequate if reeducation is contemplated

or if a research study is to be made." They make the point that "the greater the simplification, the less complete is the knowledge of the aphasie changes" (Weisenburg & McBride, 1964, p 3) Schuell (1965) reiterates this point in developing her battery

Thus, the Weisenburg and McBride (1964) study held great promise as a major step forward in establishing the methodological foundations for aphasia

diagnostics They presented a mass of data based on a test performance using the available test instruments No special tests of language function were developed for the battery In their effort to establish a coherent approach to diagnostic classification, they recognize, even after extensive but not statistical analysis, the complexity of classification based on test performance, independent of anatomic and physiologic issues, and that "it would be possible to make more than one classification on a purely psychological basis" (Weisenburg & McBride, 1964,

p 142) What emerged from their effort overcame the biases of traditional terminology Weisenburg and McBride pointed out that patients could be grouped or classified on the basis of symptom prominence Four major classes of symptoms were described: predominantly expressive, predominantly receptive, expressive-receptive, and amnesic To their credit, they recognized the inherent disadvantages of their simplification of the diversity of aphasie patterns Unfor-tunately, the disadvantages were not always kept in mind by those who adopted this classification system

Diagnostics in aphasia demand that anatomic and physiologic as well as havioral questions be addressed Although they did not carry out extensive and meticulous neurological evaluations of their subjects or have the benefit of large numbers of autopsied brains to support their inferences, Weisenburg and McBride tackled the problem of localization They agreed and gave full support

be-to the contention that "extent and nature of the aphasia varies with the site, the extent, and the nature of the pathological lesion but cannot be understood in these terms alone" (p 435) It is a view that compelled Weisenburg and McBride to take heed of Jackson's concept of positive and negative aspects of aphasie language behavior They raise the point in discussing physiological adaptation that can now be investigated using technologies that were not available when their findings were published However, the question of determining the dynam-ics of physiological response to pathology is an essential aspect of aphasia diagnostics They state "that in contrast to the negative or pathological aspects,

we are dealing with a dynamic or live physiological activity which it is ble to measure or define All we know is that it cannot produce normal language, but what it does produce is the result of the activity of the uninjured brain" (Weisenburg & McBride, 1964, p 477) Although these authors admit that their work contributed little to the problem of localization, they do note that rela-tionships between their grouping of patients and general regions of lesion could

impossi-be established Their results in this regard show that the predominantly pressive patients tend to have the primary site of lesion in the anterior cortex with some involvement of posterior regions In the receptive cases the reverse was true For the expressive-receptive group and amnesics no specific mention of locus is made They do however suggest that in the former classification group there is some evidence suggesting a greater and more permanent lesion to both anterior and posterior cortex with more involvement in anterior regions As for

ex-the amnesic, ex-they felt nothing definite with regard to localization could be established Given that most workers in the field now acknowledge that naming disorders occur with all other forms of aphasia, one would not expect to find a well-defined region yielding this type of problem Weisenburg and McBride's general assessment of the relation of type of aphasia to locus of lesion has its contemporary counterparts in the work of those who describe two general catego-ries of aphasia: nonfluent (Broca's) with anterior lesions, and fluent (Wer-nicke's) with posterior lesions However, few contemporary investigators would accept the conclusion reached by Weisenburg and McBride, that because of the physiological conditions imposed by cerebral insult "it is impossible to localize speech disturbances" (1964, p 468) They try to make the case that the residual language of the aphasie is the result of activity of uninjured brain which is "a live dynamic electrical function and cannot be measured" (p 468) This is no longer the case, and the means of measuring and assessing that activity, elec-trical, chemical, and circulatory, is near at hand

Further work on diagnostics was not to appear until the mid-1940s, which ushered in the beginnings of a new era in the study of aphasia Early efforts at diagnostics sought to establish the nature and forms of aphasia and to correlate such descriptions with site of lesion as a means of substantiating theories of cerebral localization In only a few instances was the matter of diagnostic testing related to predicting the course or possible resolution of the aphasie symptoms It was also the case that most investigators appeared to assume that the lesions generating the aphasie symptoms were relatively static and that whatever spon-taneous recovery took place occurred because adjacent areas or the right hemi-sphere took over such functions as best they could It was the advent of World War II that brought about a resurgent interest in aphasia Young men who sustained and survived gunshot wounds to the head producing aphasia required attention and rehabilitation It became the task of the psychologist-speech pa-thologist, in the military services and later in Veterans' Administration Hospi-tals, to devise appropriate diagnostic and rehabilitative techniques to deal with these patients At the same time the incidence of stroke was increasing, and with better medical care the survival rate also improved adding additional impetus to the rehabilitative aspects of diagnosis

B Diagnostics from the 1940s to the 1960s

This section examines the development of diagnostics from the early 1940s to the beginning of the 1960s This period serves as the prelude to the rapid expansion of current studies of aphasia

Although Chesher (1937), Robbins (1939), and Someberg and Ingram (1944) reported tests for aphasia, no standard diagnostic approach was accepted In

1945, the United States War Department, in a Technical Bulletin, attempted to

establish standardized diagnostic procedures to be used with aphasie patients in military hospitals This was a four-part battery and included the AGCT (Army General Classification Test) or Basic Battery I, Wechsler-Bellevue Intelligence Scale, Goldstein-Scheerer Cube Test, as well as a language test The bulletin urged that examiners make note of the frequency of "slips of the tongue," tendency to fatigue, and frustration level No data based on the use of the battery have ever been published, and it is clear that this battery was not satisfactory Two screening instruments resulted from this dissatisfaction One was part of a more general manual for conducting mental evaluations (Wells & Ruesch, 1945), and the other evolved into what became a commonly used instrument for screening based on a test developed by Sail and Wepman (1945) to aid military officers needing to make evaluations of brain-injured servicemen Halstead, an early worker in neuropsychology, published an aphasia test (Halstead, 1947) and later collaborated with Wepman to create the Halstead-Wepman Aphasia Screening Test (Halstead & Wepman, 1949) Recognizing the importance that the study of aphasia holds for generating evidence of "far-reaching neurological, psychological, and psychiatric significance," Halstead suggested establishing an international registry of all brain injured persons and special research centers

"with adequate facilities for the application of diverse methodologies and niques for investigation" (1947, pp 89 and 90) At the same time, Eisenson (1946, 1954) published a more extensive aphasia test battery Both these tests served as the major diagnostic instruments for evaluating adult aphasies until the mid 1960s

tech-The tests were intended to serve as diagnostic tools for speech pathologists Their authors did not intend them as devices by which to test theories of aphasia

or cerebral localization Rather, they seemed to provide examiners with atic approaches by which to explore various aspects of communicative function which could be impaired by brain damage The authors of the tests relied on the classification model developed by Weisenburg and McBride (1935) and Head's (1926) conceptual framework of aphasia as a disorder of symbolic formulation and expression as well as the psychological analysis of behavioral change associ-ated with aphasia developed by Goldstein (1948) Thus, for the working speech pathologist in the late 1940s and early 1950s a systematic means for assessing aphasia and the related problems of agnosia and apraxia was at hand Although these tests were quickly accepted and used, they however lacked a firm psycho-metric foundation The authors presented little data to support their selection of items, standards by which to determine placement into diagnostic categories, or criteria for establishing degree of impairment Their data base was careful obser-vation of large numbers of aphasies, and although the tests may "possess great clinical utility" (Benton, 1967, p 36), they did not achieve the levels of reliabil-ity, validity, and standardization that were the criteria by which other psycholog-ical tests were measured

system-An alternate approach to aphasia diagnostics had its genesis in a paper

pub-lished by Brown and Schuell in 1950 Four levels of performance were

evalu-ated: (1) primary associations, (2) symbol associations, (3) elaboration, and (4)

conceptual processes Although Brown and Schuell (1950) presented little

statis-tical confirmation as to the validity of their test, they did measure reliability and

found it to be satisfactory In addition, they reported that evaluations based on

their tests correlated with clinical evaluations made by others who had evaluated

clinically the patients who served as subjects

Schuell continued her work to develop an effective diagnostic instrument until

her death in 1970 A second stage in the development of her test, "The

Min-nesota Test for Differential Diagnosis of Aphasia" (MTDDA), came in 1953

(Schuell, 1953) She reported on tests designed to determine the aphasies' ability

to understand spoken language Using items that ranged from understanding of

single words through complex information, she tested 138 patients

She established four prognostic groups based primarily on degree of difficulty

in understanding single words plus difficulty in other areas tested The group

having the best potential for recovery had no difficulty in understanding single

words and little or no impairment in other areas, whereas all subjects who had

great difficulty in this and other areas had no recovery of functional speech The

four prognostic groups that she reported served as the forerunners of the

diag-nostic categories on the current revision of the MTDDA (Schuell, 1973)

Con-tinuing in her efforts to establish a comprehensive diagnostic instrument, Schuell

(1955) published results obtained on a broader battery of tests She suggested

that aphasia symptoms be considered in relation to three language processes:

auditory, visual, and sensory-motor, and four language modalities:

comprehen-sion of auditory material, reading, speaking, and writing Schuell was careful to

caution that these results were preliminary and the test items were in the

develop-mental stage The MTDDA had been conceived in the Brown and Schuell (1950)

paper and in the mid-1950s was undergoing its birth pangs The test was made

available for experimental use in 1955 In 1957 Schuell published the "Short

Examination for Aphasia" (Schuell, 1957), which was designed as "a clinical

tool and not a standardized test" (Schuell, 1966, p 137) The purpose was to

provide the neurologist with a tool for assessing aphasia symptoms as part of the

routine neurological examination This shortened version of the then

experimen-tal MTDDA became popular and was used so widely by speech pathologists that

Schuell (1966) wrote a paper reevaluating the test because of her concern for

sources of reliability of the original version, suggesting alternate procedures

when using the Short Examination This paper appeared a year after the formal

publication of the MTDDA (Schuell, 1965)

Schuell's approach to diagnostics emphasized only the behavioral aspects of

aphasia She did little to relate her findings to the underlying neurological basis

of the aphasie symptoms Thus, Schuell followed in the tradition established by

Weisenburg and McBride that created a division in the study of aphasia That division led to a trend whereby psychologists and speech pathologists directed their attention to the behavioral aspects of aphasia, while neurologists continued

to seek clues as to the localization of the various forms of aphasia

The major sources of data for neurologists in the early 1950s came from studies of patients with gunshot wounds during World War II Two major works

in English appeared dealing with these patients (Conrad, 1954; Russell and Espir, 1961) Although the latter work did not appear until 1961, it is based on material collected from World War II casualties Both works, while having somewhat differing orientations as to the dynamics of aphasia, developed in-teresting approaches to determining site of lesion Unfortunately, little or no formal or uniform systematic behavioral testing of patients was carried out so that correlational studies could be executed It is interesting to note that in both studies the areas producing aphasie symptoms are the familar anterior and pos-terior regions described by many of the early scholars Russell and Espir (1961) did note in their conclusions that "the physiological activity of the speech territory must depend on its connections with the pulvinar of the thalamus" (p 171) This hypothesis predated current work on aphasia subsequent to thalamic stimulation and lesions

One method for establishing the focus of disrupted cortical function is the electroencephalogram (EEG) Marinesco, Sager, and Kreindler (1938) studied eight aphasies using EEG techniques They found a reduction of alpha waves in the left hemisphere Although not showing a specific locus of change, they found that the activity for both Broca's and Wernicke's aphasia presented waves be-tween 4 and 6 Hz on the left with 9 Hz on the right for the former type and approximately the same for the latter type of aphasia Other studies such as that

of Strauss and Greenstein (1948) and Jones and Bagchi (1951) suggested that it should be possible to consistently lateralize and frequently localize the pathology

by EEG techniques These reports as well as others (Weinstein, Kahn, & Strauss, 1950; Kerschman, Conde, & Gibson, 1949; Fabrot, 1953) did not include behavioral measures

Tikofsky (1957) attempted to relate measures of language impairment as mined by administration of the Halstead-Wepman Aphasia Screening Test and Eisenson's Examining for Aphasia Test with presence and locus of lesion as determined by EEG analyses Fifty-three aphasies were evaluated, and the data obtained were subjected to factor analysis Results of the analysis suggested that behavioral tests seemed to measure general mental ability rather than language function Furthermore, it was determined that the behavioral tests and the EEG did not measure the same attributes of cerebral activity and that it was not possible to relate aphasie patterns to changes in EEG patterns Thus, from this study it appeared that the EEG did not hold much promise as a diagnostic tool in

deter-aphasia However, a follow-up study by Tikofsky, Kooi, and Thomas (1960) showed that the EEG had the potential to serve as a predictor of recovery

III APHASIA TESTING POST-1960

Diagnostic testing of aphasies through the early 1950s developed without recourse to either a strong theoretical framework or attention to evolving princi-ples of psychological test construction standards Most workers felt that stan-dardization of tests for aphasies was not possible This view was based on an assumption that the patients were too inconsistent in their responses and too idiosyncratic to permit ''formal scoring standards to be developed and mean-ingfully applied" (Eisenson, 1954, p 1) Thus, the approach to diagnosis was to establish a description of the patient's performance or deficit from quasi-quan-titative data in addition to qualitative analyses derived from the clinician's expe-rience and intuition

As the decade of the 1950s ended, a marked shift in approach to diagnostic testing began to emerge There was growing recognition that testing was going to have to become more formalized Standardization of administration, scoring, and interpretation of responses would become necessary if treatment were to be subjected to critical evaluation Aphasia tests developed since the early 1960s increasingly reflect this trend

In the following sections several of these tests will be examined The approach will be to provide the reader with the background which led to the development and direction taken by the authors of the instruments as well as an examination of the instruments themselves

In addition to growing recognition of the need to take into account accepted test construction principles, several other factors began to emerge One was a reexamination of the approach to classification and another was recognition of psycholinguistic principles as applied to the interpretation of aphasie language Another and important trend was the growing influence of neuropsychological theory and research

A Language Modalities Test for Aphasia (LMTA)

The Language Modalities Test for Aphasia (LMTA) (Wepman & Jones, 1961) was developed by Wepman and his colleagues at the University of Chicago Work on the test began in 1955 with the intent of creating a useful instrument for the clinician and researcher It was Wepman and Jones' (1961) view that the then available tests did not provide an adequate means to differentiate between "defi-ciencies of language comprehension and symbol formulation and the deficiencies

of the reception and expression of language" (p 1) Furthermore, they argued that most tests did not yield sufficient information with respect to the disruptions

of input and output modalities and their intentions as well as their impact on spontaneous language

While drawing on the existing literature, Wepman and Jones began to develop

a new conceptual approach to aphasia This approach took cognizance of opments in linguistics and psycholinguistics Wepman's philosophy of diag-nostics and its underlying theoretical base is expressed best in several important papers (Wepman, Jones, Bock, & Van Pelt, 1960; Wepman & Van Pelt, 1955; Wepman & Jones, 1964a; Jones & Wepman, 1961)

devel-The test is constructed around the concept that one could probe the patient's performance with respect to transmission deficits at either the input or output levels (agnosia and apraxia) or at the level of integration and symbol formulation (aphasia) Within the transmission levels it was also possible to determine which modality was most impaired (e.g., visual, oral, etc.) The patient's efforts at spontaneous language, the integrative aspect of symbolic formulation, could be subjected to analysis to allow for a classification based on linguistic parameters Unlike Schuell, Wepman did not accept a view of aphasia as a unitary disorder but felt that one could determine the deficits in terms of modalities

In light of this theoretical bias, the LMTA was designed to elicit samples of spontaneous language as well as behaviors in the several input and output do-mains Analysis of data obtained on over 200 adult aphasies evaluated on pilot versions of the test led to the creation of the form published in 1961 The final version of the LMTA consists of two forms to permit test-retest evaluation as well as two complete cycles of test items within a form (split-half) Test items within forms and across forms were equated for difficulty Twenty-three stim-ulus items were presented in each form as well as a brief screening test identical

in both forms Five types of responses were elicited: (1) oral: some form of overt oral response such as naming, repetition, and reading aloud; (2) graphic: copy-ing, writing to dictation, and writing names of objects, and three types of match-ing tasks; (3) matching (type 1): the subject finds the name of a pictured stimulus from among four visually present alternatives, or attempts to select a picture from among four alternatives which best represents a word, number, or sentence presented visually or auditorily; (4) matching (type 2): when presented with a spoken stimulus the subject selects the appropriate item from one of four possible alternatives; (5) matching (type 3): the subject, when presented with a pictured stimulus (e.g., form, picture, or word), must select from among four alternatives

an identical representation of the stimulus It is important to note that the above set of response categories was not used in the analysis of responses to pictures requiring that the subject produce a story The categories described focused on the transmissive capabilities of the subject rather than linguistic ones To this

point in time no serious effort had been made to establish this distinction in a formal way nor were there tests that included measures of spontaneous language

In fact, as we shall see, the diagnosis (i.e., classification of type of aphasia) in the LMTA is based almost exclusively on the scoring of responses to the four story-eliciting pictures contained in each form of the test A ''six-point scale" was developed for scoring "tell-a-story" test items The term scale is inap-propriate in the classical sense of scaling technique Rather, Wepman and Jones established a six-category classification system Responses to each of the tell-a-story pictures are analyzed in terms of the overall language pattern generated by the subject General criteria are given to provide the diagnostician with guide-lines for assigning the subject's performance to a category (Wepman & Jones, 1961)

The six categories, normal, syntactic, semantic, pragmatic, jargon, and global, reflect Wepman and Jones' efforts to examine the linguistic charac-teristics of aphasie language as it might be derived from views of scholars such as Morris (1938) and Jakobson and Halle (1956) Wepman and Jones provide operational criteria for defining the linguistic aspects of aphasie language behav-ior Their approach to classification represented a significant break with that developed by Weisenburg and McBride (1964) Given the model of commu-nicative function developed by Wepman and his co-workers (Wepman & Van

Pelt, 1955; Wepman, 1953; Wepman et al., 1960; Jones & Wepman, 1961), it

was possible to separate "transmissive" disorders such as agnosia and apraxia from linguistic ones, the aphasias

Scoring responses to items in the transmissive categories also reflected man and Jones' attempt to focus on elements of language performance In their

Wep-paper Dimensions of language performance in aphasia (Jones & Wepman,

1961), other types or characteristics in response to such items are described These scoring categories were refined and reduced to six in the LMTA scoring system: (1) correct response, (2) phonemic errors, (3) grammatical errors, (4) semantic errors, (5) jargon (unintelligible or illegible), and (6) no response or an unrelated response While qualitative from the point of view of examiner in-terpretation, these categories were well defined and when taken with those for analyses of tell-a-story responses provided insight as to the dimensions of lan-guage performance retained and impaired Research findings to demonstrate the psychometric properties of the LMTA are presented in the manual and Jones and Wepman (1961)

Although subjected to a wide variety of statistical analyses, the approach to scoring and classifying subjects was not based on numerically derived scores, such as is the case with more recently published tests Geschwind, discussing the Wepman and Jones (1964b) paper on psycholinguistic methods in the study of aphasia, recognized the importance of their attempts at classification and tried to

show how the categories used in the LMTA related to other systems of tion It should be noted that Wepman did not accept Geschwind's view that pragmatic aphasia was the same as Wernicke's aphasia (Wepman & Jones, 1964b) Wepman and Jones (1960) argued that although traditional approaches

classifica-to describing disordered language processes which served as a base for therapy

"led to static classification systems useful for nosological categorization, they have proven less useful in understanding the language process itself (p 331) The LMTA was seen by its authors as providing a means to establish a "modern concept of aphasia which explores the dynamic nature of language" (p 331) The LMTA does not offer a formal means by which to establish degree of impairment However, Wepman and Jones (1961) noted that although each of the five categories of aphasia are relatively independent, each is seen as repre-senting different degrees of impairment and reflecting differing degrees of cor-tical integration Thus, one might consider the syntactic aphasie of Wepman and Jones as being the least and the global as the most severely impaired However, this approach to delimiting severity of language, or better still communicative function [which was also based on Wepman's theory of language regression in aphasia (Wepman, 1964a)], did not permit an estimate of range of performance ability within types of aphasia While reflecting that the types of aphasia repre-sented different levels of cortical integration, the authors of the LMTA made little effort to relate these to site of lesion They accepted a view that "while specialized areas of the brain could be said to subserve specific functions, the language process was better conceived as the product of overall integration"

(Wepman et al., 1960, p 324) The diagnostic focus of the LMTA was to

establish a reliable method for describing in psycholinguistic terms the major forms of aphasie impairment for the purpose of developing appropriate therapeu-tic strategies

Given the rapidly developing interest in aphasia as a psycholinguistic nomenon, it is interesting to note that the LMTA was not more widely used in aphasia research Although described briefly in texts (Darley, 1979a, 1982; Eisenson, 1973; Kertesz, 1979; Sarno & Höök, 1980), there are only two studies which used the instrument as a part of a research protocol (Archibald, Wepman,

phe-& Jones, 1967; Carson, Carson, phe-& Tikofsky, 1968) The test did not receive wide acceptance in most clinical settings It seems that the principal drawback to its achieving popularity as a viable diagnostic instrument lay not in difficulties in scoring or theoretical constructs but rather in the apparatus and film strips neces-sary for test administration For those who used the LMTA, it was a valuable diagnostic and research tool In fact, if it were to be redesigned in light of modern technology, it could achieve the potential that Wepman and Jones envi-sioned for it when they undertook the task of creating an instrument which would look at the characteristics of language breakdown as a basis for therapy

B Minnesota Test for Differential Diagnosis of

Aphasia (MTDDA)

In the middle and late 1950s, Hildred Schuell, working at the Minneapolis Veterans Administration Hospital, was assembling an experimental form of the present MTDDA Formal presentation of the test for general use occurred in

1965 (Schuell, 1965) The underlying rationale for the instrument and tion of the data for the test appeared a year earlier (Schuell, Jenkins, & Jiménez-Pabon, 1964) Since that time both the test and book have been revised (Schuell, 1973; Jenkins, Jiménez-Pabon, Shaw, & Sefer, 1975) Development of the MTDDA and the research base to support the diagnostic approach taken by Schuell and her colleagues occurred at the same time that Wepman and his group were creating the LMTA (Wepman & Jones, 1961) This parallel development of diagnostic instruments produced spirited debate in the speech pathology liter-ature as to the nature of aphasia, and one's view of the disorder influenced test development and interpretation of performance The basic lines of argument are

elabora-to be found in a series of papers that appeared between 1959 and 1962 (Schuell & Jenkins, 1959, 1961; Jones & Wepman, 1961; Schuell, Jenkins, & Carroll, 1962) An understanding of the fundamental difference between the two is crit-ical to an appreciation of their different approaches to diagnosis Both Jones and

Wepman (1961) and Schuell et al (1962) use factor analysis-derived data to

support their theories Jones and Wepman, on the basis of their analysis, cluded that several factors served as the underlying basis of the performance of the aphasie and thus rejected the view that aphasia could be viewed as a " unitary general disorder." Schuell and her colleagues took the opposite stance

con-In their now classic paper The nature of the language deficit in aphasia

Schuell and Jenkins (1959) presented the conceptual framework to support the view that aphasia reflects a general language deficit which crosses all modalities Schuell believed that the central and unifying characteristic in aphasia was relat-

ed to the patients' difficulties in comprehending spoken language

In order to appreciate Schuell's approach to diagnostic classification, it is necessary to take into account her definition of aphasia as a "reduction of available language that crosses all modalities and may or may not be complicated

by perceptual or sensorimotor involvement, by various forms of dysarthria, or by other sequelae of brain damage" (Schuell, 1973, p 4) She further noted that it

is the overall pattern of involvement one observes from patient to patient that is the basis for differential diagnoses It was her contention that all aphasies demon-strated some degree of impairment of auditory processes ' 'because language learned by ear, remains dependent upon discrimination, recognition, and recall

of learned auditory patterns, and upon auditory feedback processes" (Schuell,

1973, p 5) Thus, all the diagnostic categories derived from an analysis of performance begin with the inclusion of 4'simple aphasia," "reduction of avail-

able language in all modalities with no specific perceptual or sensorimotor pairment and no dysarthria" (Schuell, 1973, p 6)

im-By way of contrast, the MTDDA is considerably longer than the Eisenson Examining for Aphasia or LMTA or Halstead-Wepman Aphasia Screening Test Schuell (1966) felt strongly that a short test for aphasia could never really be satisfactory She asserted that for an adequate differential diagnosis all language modalities had to be tested or else the examiner might overlook essential aspects

of the aphasia She stated that "If any dimension of aphasie impairment is neglected misdiagnosis and corresponding errors of prediction may result" (Schuell, 1966, p 277) Prediction of recovery was in fact one of the central motivations in her approach to diagnosis and dominated her interpretation of the ways in which behavior is evaluated She believed that "an adequate diagnostic test must sample relevant kinds of behavior in all language modalities over the entire range of aphasie deficit" (Schuell, 1966, p 278) Length, she points out,

is of singular importance if a fine differential diagnosis is required

The published version of the test Schuell began to construct in 1948 was Form

8, but the basic instrument had in fact been completed with Form 6 in 1958 Schuell felt that the changes made in this final form represented an instrument with more sensitivity and more information for the clinician From its conception

to birth, four guiding principles governed subtest selection and format These principles also represented Schuell's approach to understanding the central task

of differential diagnosis, that of detailed observation to permit a careful analysis

of the behavioral response in order to achieve prediction of recovery The ples are (1) differences in the behavior of nonaphasics and aphasies should be explored in all language modalities; (2) within each modality the tests should be graduated in difficulty to allow comparison over successive testing with the same patient; (3) a variety of nonlanguage tasks should be included (her motivation to include such tasks was that "there are complex processes underlying language events that cannot be directly observed but must be inferred from relevant kinds

princi-of discriminatory behavior") (Schuell, 1973, p 20); and (4) the test should be sufficiently comprehensive and detailed so as to allow differentiation of the diversity of clinical symptoms occurring as a consequence of brain lesions The MTDDA is divided into five major divisions to examine disturbances of (1) auditory, (2) visual and reading, (3) speech and language, (4) visuomotor and graphic, and (5) numerical and arithmetic functions Within each division there are a series of subtests to explore the functions being assessed The number of subtests in each division and the number of items composing a given subtest vary Scoring the test is based on an analysis of the items passed and failed on a given subtest While this involves a plus-minus system of scoring, Schuell and

her associates were keenly aware of the pitfalls of the approach They (Schuell et

al., 1964; Jenkins et al., 1975) attempt to rationalize this approach to scoring

However, in addition, they established a four-point diagnostic scale ranging from

0, indicating no impairment, to 3, indicating severe impairment, "almost

com-plete disruption of performance." This scale is used to summarize the findings

across all subtests In the words of the authors, it "presents an overall view of

the pattern of impairment observed in each patient" (Jenkins et al., 1975, p

141) An elaborate rationale is given to show how one can go from a plus-minus

system of scoring to the scale just described The rating is derived from an

analysis of ratings on 12 functional categories It is important to recognize that

while the "diagnostic scale designates the nature of the impairment that is

observed, diagnostic rating does not necessarily reflect the level of function in a

given language modality" (Jenkins et al., 1975, p 144) In addition to the

diagnostic scale, a severity scale was also developed This scale was designed to

estimate residual capability in each language modality examined and the level of

performance breakdown The authors claim that the scale is sensitive to

dif-ferences in performance that occur over time, thus permitting an evaluation of

the effectiveness of treatment Test-retest data on 75 patients support these

contentions In addition, correlations between severity ratings and number of

errors generated by 157 patients were high and significant for 5 of the 6

catego-ries so rated The 5 rated categocatego-ries are (1) auditory comprehension, (2) reading,

(3) spoken language, (4) written language, and (5) dysarthria A seven-point

scale is used but although 0 always refers to "no observable impairment," the

criteria for assigning a given rating of (1) through (6) vary with the nature of the

category being evaluated

While Schuell did not present specific data with respect to questions of validity

and reliability, the development of the diagnostic severity scales and approach to

classification were based on a large sample of aphasie patients Reports of

research on test construction and analysis are to be found in three major works by

Schuell and her collaborators (Schuell et al., 1964; Schuell, 1973; Jenkins et al.,

1975) This instrument was also subjected to a factor analysis (Schuell et al.,

1962) in part as a reply to the Wepman and Jones critique of Schuell's

hypoth-eses that aphasia was not multidimensional but unitary in character In discussing

their analyses, the authors take note of the fact that they did not test for specific

syntactic or transformational abilities They felt that data on such issues as

reported by Goodglass and Hunt (1958) and Goodglass and Berko (1960) would

not substantially alter their approach, stating that "impaired structural usage,

like vocabulary, is an aspect of language impairment that can be identified and

studied in aphasia" (Schuell et al., 1962, pp 364-365) If such tests were

included, it was felt they would load heavily on their first factor, "language

behavior." The basic contention of Schuell and her colleagues was that

tradi-tional divisions of aphasia into sensory or motor dichotomies and so-called pure

types were in error They asserted that aphasia represents a general language

deficit that crosses all modalities, but that just the assessment of this aspect of

aphasia is insufficient to describe adequately the aphasie patient (Schuell &

Jenkins, 1961) This position remains a central theme in all of the followup work that has been done using the MTDDA as a diagnostic instrument In the updated

version of Aphasia in adults (Jenkins et al., 1975) an attempt is made to relate the various diagnostic categories to neurological deficit Jenkins et al (1975)

remarked that "We conclude that these data support the hypotheses that ferences between aphasie subjects in the major diagnostic categories reported are true differences, related to locus and extent of brain damage and evidence of complicating neurophysiological conditions, as well as to obtained patterns of aphasie impairment" (p 168)

dif-The MTDDA broke with tradition and established a new quantitative and qualitative approach to differential diagnosis and classification It is an instru-ment which has won relatively wide acceptance by many practicing speech-language pathologists, even those who do not accept Schuell's basic assumptions concerning the nature of aphasia or who are unaware of them Time will tell if the MTDDA will remain a major diagnostic tool in the face of some of the newer tests, and in particular those which are now employed in conjunction with neu-roradiographic studies

C Porch Index of Communicative Ability (PICA)

If the MTDDA broke with tradition in terms of classification schemes, then Porch's development of the PICA went well beyond that point with respect to scoring and classification Since its introduction in 1967, PICA has become one

of the most popular aphasia tests despite the requirement of special training at some considerable cost to the trainee Those who use the instrument regularly are devoted to it and often will not consider the possibility of using other instru-ments

Porch was motivated to construct his test because, as he puts it, "No test existed with which one could sensitively and reliably quantify aphasie behavior' ' (Porch, 1967, p iii) For Porch the central concern was not what label could be attached to the observed behavior, but rather the degree to which one could evaluate responses in a manner that would permit quantification He recognized,

as did Benton (1967), this glaring lack in the diagnostic instruments available at the time It is interesting to note that at the time PICA was emerging the MTDDA was also coming into rather popular usage The latter instrument included scaling procedures for interpretation of responses in terms of diagnosis and severity However, Schuell did not emphasize the quantitative aspects of scoring to the degree proposed by Porch Thus, Porch accepted a challenge that had been raised over several decades, namely the need to establish an acceptable psychometric approach to testing aphasies (Yates, 1954; Bay, 1964)

In developing a strategy for test construction, Porch tried to take into account a variety of factors which might mask aphasie performance and to take an adequate

sample of communicative skills He also recognized the need for standardization

of procedures as well as control of relevant variables While efforts to deal with these issues were being made by other workers in the field (Wepman & Jones, 1961; Schuell, 1965), they, in fact, represented only a portion of Porch's concern with test construction For him the critical issue was to resolve the problem of establishing an efficient means for scoring responses

It was Porch's belief that the major problem in designing a scoring system was

to establish a method which permitted a description of how the patient responded

to the task, and "to do so with high reliability and with the confidence that small changes in responses were being accurately detected and described" (1967, p 37) He went on to argue that no matter what the task and how standardized the administration procedures, "the effectiveness of their application would be lim-ited by the sensitivity of the scoring method" (1967, p 3) Before proposing his own approach to scoring, he reviewed the scoring procedures that were current in

1967 In his test manual, he devotes several pages to this critique and in the end finds all the systems wanting (Porch, 1967, pp 4-10) He summarizes his analysis by saying "The problem of constructing such a battery is not so much one of selecting valid tests, since these have been fairly well agreed upon The problem involves the necessity for insuring that the scores derived from the use

of the battery specify sensitively the nature and degree of communicative ability in terms of several dimensions, and that the results can be interpreted or repeated by other investigators" (Porch, 1967, p 10) Thus was born the con-cept of a multidimensional scoring system for analyzing aphasie responses to test items Such an approach, especially since it was a quantitative one, flew in the face of a tradition that had argued that aphasies were too idiosyncratic and inconsistent in performance to permit stable and reliable numbers to be assigned

dis-to performance Furthermore, Porch's scoring method was not easily associated with traditional taxonomic approaches to evaluation and diagnosis Thus, it is not surprising that the introduction of the multidimensional scoring system aroused a continuing controversy in the field of aphasia diagnostics, with a strong division between adherents and opponents of the Porch system There is no doubt that PICA has achieved acceptance; in fact, as Porch pointed out recently (Porch, 1981; Porch & Porec, 1977), PICA is the only test of aphasia which has won acceptance by the legal profession

Construction of the PICA did not begin with any theoretical model of aphasia, taxonomic orientation, or effort to establish locus of lesion Rather, emphasis was on the design of a scoring system that would describe the patient's response

in terms of a variety of dimensions Porch built his multidimensional scoring system around five dimensions: (1) accuracy, (2) responsiveness, (3) com-pleteness, (4) promptness, and (5) efficiency These dimensions are the basis for the final 16 categories listed in Table I (Porch, 1967) Each category, as can be seen in the table, is assigned a score, which is then used to evaluate performance

Table I. The PICA Categories for Scoring Responses 0

Accurate, responsive, incomplete, delayed Accurate, self-corrected

Accurate, after instructions are repeated Accurate, after cue is given

Inaccurate, almost accurate Inaccurate attempt at the task item Comprehensive but not an attempt at the task item Incomprehensible but differentiated

Incomprehensible and undifferentiated

No response, but patient attends to the tester

No response, no awareness of task

« From Porch (1967)

on each item for each subtest There are 18 subtests using the same 10 test stimuli Of the 18 tests, 4 require a verbal (oral) response, 8 a gestural response (pointing, silent reading, matching), and 6 some form of graphic response (writ-ing or copying)

Administration of the test must be carried out under standard conditions as described in the manual (Porch, 1967, 1971a) A training period of approx-imately 40 hours is required to learn to administer and score the PICA in a standard and reliable fashion The exact procedures for administration and scor-ing are given in the manuals

In his first publication of the PICA, Porch (1967) goes to great pains to provide a data base to support his scoring system He obtained good examiner reliability for scoring and high statistical reliability He relates his findings to results obtained by Wepman and Jones (1961) for the LMTA From a narrowly conceived psychometric standpoint, Porch achieved his stated goal of being able

to quantify responses of aphasie subjects with high reliability The statistical basis of the multidimensional scoring system is described in Porch (1971a) He claims that there are at least three major benefits to be derived from his multidi-mensional scoring system: (1) it permits a very precise description of the nature

of the patient's response; (2) to use the system properly, that is, to decide quickly which of the 16 categories to assign to a response, the clinician must be a sharp observer of response differences; and (3) high interscorer reliability, which Porch

asserts is most important He concludes that "It is a system in which clinical standards are far more stringent than psychometric standards" (Porch, 1971a, p 791)

PICA has been used to discriminate aphasies from among other populations with neuropathologies affecting speech and language, e.g., apraxia, language of confusion, and right versus left hemisphere lesions as well as recovery (Porch, 1971b; Porch, Wertz, & Collins, 1974; cf Johns, 1978; Wertz, 1977, 1978; Wertz, Rosenbeck, & Collins, 1976) Two as yet unpublished studies (Barnes, 1975; cf McNeil, 1979; Shirley, 1979) use the PICA as a tool in localizing lesions producing aphasia These studies attest to Porch's comment that "the PICA scores and profiles have important implications both for the clinical man-agement of the aphasie patient and for our theoretical views of brain functions" (1971b, p ix)

Porch placed great emphasis on the adequacy of PICA'S psychometric ties McNeil (1979) raises questions concerning the PICA scoring scheme These center on the nature of the scaling procedure Silverman (1974) raises the issue of using the mean of a patient's scores on a particular subtest He argued that such a score would not reflect the patient's most frequent response to the items in the subtest and suggested the use of the mode instead, "since the PICA scoring system apparently only has been demonstrated to have ordinal properties" (Sil-verman, 1974, p 226) Silverman tries to make the case that the mean is only an appropriate measure of central tendency if the scale being used is interval or ratio Porch (1974) replied that the use of the mean was defensible and that since

proper-it was almost impossible to develop "pure" interval or ratio scales in measuring behavior, using less powerful statistical procedures would weaken the data He felt, therefore, that it was more fruitful to view PICA as an interval scale, thus permitting use of the more powerful statistic Van Denmark (1974), citing Hays (1963), supports the use of the mean as the appropriate measure of central tendency on PICA subtests However, she points out the potential danger in using subtest means, thus challenging Porch's (1971b) claims Van Denmark (1974) did not accept Porch's claim that the "mean does in fact, represent quantities or magnitudes of communication adequacy" (p 511) She argued that the mean is "not a level of behavior" (Van Denmark, 1974, p 511) and should not be interpreted in such a fashion Van Denmark believed that PICA has scoring mechanisms for making relevant behavioral observations that can be referred directly to the scoring scales, but that subtest and overall means have a different function, namely "as averages or ratings which are applicable in intra-and intersubtest comparisons and or prognostic statements" (p 511) It is her strong opinion that this distinction is critical for interpreting the test results The issue of the appropriateness relative to interpretation of Porch's scales is questioned by McNeil, Prescott, and Chang (1975) These authors addressed the issue of the rationale for the hierarchical ordering of the 16 categories of the

PICA and its effect on interpretation of results Essentially the question raised was whether or not the "numerical PICA values correspond hierarchically to the ordered perceptions of behaviors associated with those numerical values"

(McNeil et al, 1975, p 114) They showed that "the ordinal relationship of

behaviors associated with the 16 PICA categories has been demonstrated by aphasiologists This ordinality, however, differs significantly from that hier-

archically rated by judges for communication" (McNeil et al., 1975, p 117)

They claim this difference would affect the validity of PICA interpretation in terms of performance outside the clinical setting and indicate that their work does not discredit PICA, but only shows how one type of information relative to the scale may contribute to the validity and clinical usefulness of the instrument Lincoln, Pickersgill, and Valentine (1981) also examined PICA scales and found that they were not equal interval They suggest the possibility of developing a weighting system to overcome the problem of unequal intervals between catego-ries Porch has not replied to these critiques in the literature, which for the most part suggest refinements or alternate statistical approaches In the years since its introduction, PICA has become an increasingly popular diagnostic instrument This author feels that most users of the PICA have been satisfied with Porch's defense of his scoring system However, his work has come under attack by Martin (1977) and Boone (1972)

Boone's (1972) critique was directed at PICA's lack of direct testing of

audito-ry verbal functions He believes that it is not possible to use the test to establish where the breakdown of auditory verbal ability occurs with respect to "param-eters as length of instruction, complexity of linguistic instruction, auditory verbal memory lengths, auditory sequencing complexity, etc." (pp 1354 and 1355) These are factors which most workers in the field have considered crucial aspects

of an aphasia evaluation Porch's approach-to testing can be construed as narrow and superficial, but then he created a scoring system independent of an explicit conceptual or theoretical framework of the aphasie process It is really to this that Martin's harsh analysis is directed Every aspect of the PICA comes under attack The claims that Porch makes as the basis for the test, namely specificity

of response, control of relevant variables, elimination of subjectivity and biases, etc., and most particularly the multidimensional scoring system, are found to be seriously flawed by Martin The claim that PICA corrects for lacks in other diagnostic tests of aphasia is vigorously rejected Martin argues "that PICA does none of these things and the multidimensional scoring system as applied in PICA

is invalid" (Martin, 1977, p 547) Martin's case is established not by the force

of data or experiment but by careful examination of Porch's claims and assertions

in the light of other diagnostic procedures and conceptualization of aphasia, as well as his statistics Martin recognizes and brings out in a forceful fashion the seductive power of quantification, arguing that to a great extent the drive toward quantification ignores the complexity of the factors that make up the symptom

complex of aphasia To some extent this view is echoed by McNeil (1979) who remarks that "Because of the quantifiable nature of the PICA it is highly suscep-tible to misuse and misinterpretation" (p 233) In Martin's view "tests such as the PICA may give us a sense of precision, an appearance of being exact, but the sense or appearance is not the fact It is difficult to question that which gives us professional comfort, but it is a scientific necessity" (Martin, 1977, p 560) Studies using PICA have demonstrated its potential for discriminating aphasies from other language-disordered populations It has even proven useful

as a predictor of site and size of the lesion producing aphasia (Shirley, 1979) Shirley claims that her results support Porch's model for localizing brain impair-ment (J G Shirley, personal communication) It is undoubtedly true that the PICA will continue to enjoy popularity, and perhaps even more so now that it is

an accepted forensic instrument However, it is also the case that the test samples little of what one would consider communicative behavior PICA provides the examiner with insight as to how the patient performs in response to a set of rigidly established stimulus-response tasks Aphasies do respond differently from each other, and there are patterns that are common to groups of patients Ignoring the issue of the statistical adequacy of the scoring system, the test has little to say about aphasia itself Administration and interpretation of PICA will provide few insights into the dynamics of the linguistic and communicative dimensions of the patients' language capacities PICA gives us a system for examining responses, a system which might be applied to any other test of aphasia and to nonlanguage behavior as well It is necessary, therefore, in using this instrument as a diagnostic tool that one should be aware of its limitations when interpreting the patients' presenting symptoms

D Boston Diagnostic Aphasia

Examination (BDAE)

The BDAE (Goodglass & Kaplan, 1972) was published shortly after Vol 2 of

the PICA administration and scoring manual appeared (Porch, 1971b) A

revi-sion of the test was published in 1983 (Goodglass & Kaplan, 1983) However, the "Boston" was in the making for almost 10 years prior to its formal publica-tion It represents the culmination of clinical, experimental, and theoretical re-search efforts of the Boston Veterans' Administration Aphasia Research Group

In an attempt to justify yet another test for aphasia, Goodglass and Kaplan (1972) observed that their test would offer features to the examiner which would yield insight into the patients' functions and "serve as a bridge relating test scores to the common aphasie syndromes recognized by neurologists" (p v) Their ap-proach to analysis of aphasie syndromes as seen in interpretation of findings and item construction reflect an interdisciplinary interaction among and between

psychologists, speech-language pathologists, and neurologists committed to a return to classical approaches to classification and localization

Goodglass summarized the work on the development of the BDAE prior to its publication in a 1970 progress report of the Boston University Aphasia Research Center (Goodglass, 1970) He states that the goal was to develop a test which would reflect the current conceptions of the nature of aphasia while at the same time meeting "the various demands made on an aphasia examination" (Good-glass, 1970, p 16) Although he recognized that the demands would vary with examiner and circumstance, he felt that an examination must provide

1 A thorough inventory of language and language-related functions which makes explicit all the variables contributing to cerebral localization, diagnostic classification, and neuro- psychological functions

2 A survey of functional efficiency in each of the areas related to aphasia therapy, to serve as a basis for treatment planning

3 A quantified examination with sufficiently large samples of type of performance, covering a wide range of disability, so as to provide reliable baseline and test-retest com- parisons over the full range of severity of aphasies (Goodglass, 1970, p 16)

These "demands" relate to the general aims of aphasia examinations put forward by Goodglass and Kaplan (1972) in developing the background for the BDAE They contend that the BDAE meets the three applications of (1) deter-mining presence and form of aphasia to permit inferences with reference to cerebral localization; (2) assessing level of performance over a wide range of ability, for initial assessment and change over time; and finally (3) "comprehen-sive assessment of assets and liabilities of the patient in all language areas as a guide to therapy" (Goodglass & Kaplan, 1972, p 1)

The principles underlying the "Boston" differ markedly from those of Schuell

et al. (1964), who argue that variations in performance on subtests relate to a reduction in general language capacities They differ also from Wepman and Jones (1961) in their rejection of a "stimulus-response" system view of lan-guage Goodglass and Kaplan (1972) recognize that in aphasia the several com-ponents of language are differentially impaired It is, in their view, this differen-tial and selectivity of impairment which provides insight into the ways in which language is organized in the brain, the locus of the lesion producing the aphasia, and "the functional interaction (e.g., inhibitory, regulatory, selective) of various parts of the language system" (p 2) In developing their rationale for the BDAE they point out many problems in establishing evidence for "underlying indepen-dence of components in language" (p 2) Chief among these is the difficulty of devising tasks which can be "passed or failed through only one process" (p 2)

In the manual they do make explicit arguments in support of their approach to testing Unlike Porch, they seek not to scale but rather to create "windows" by which to peer into the process by which the patient responds to the demands