Anagram and Copy Therapy (ACT) & Copy and Recall Therapy (CART)

Rationale

Component lettersBoth Copy and Recall Therapy (CART) and Anagram and Copy Therapy (ACT) are methods employed that aim to facilitate improvements in writing of single words for clients with aphasia. Both CART and ACT, aim to associate meaning with written word forms via the process of eliciting a written response from a picture with the long-term aim of facilitating spontaneous production of written words. In CART, clients are required to copy a written word from a model provided, while in ACT clients are required to write the target word using letters presented in an array which may or may not include distractors (i.e. letters that are not required in order to spell the target word).

Who is it used with?

These approaches are frequently reported in clients with severe impairments in spoken expression where writing is seen as proving an additional modality in which to convey information. Such clients will also have impairments to writing processes, in particular in their ability to write single words.

A modified protocol for both CART and ACT has been reported where clients were additionally required to offer spoken responses (either spontaneously or via repetition) in an attempt to improve both writing and spoken output, however no improvements were observed in spoken output (see Ball et al, 2011). Therefore, while CART and ACT may both involve exposure to and practice of spoken words, its inclusion may not guarantee improvements beyond writing.

Basic task structure

Both CART and ACT have similar structures although they differ in terms of the level of starting difficulty. However, task difficulty and appropriateness of task may be dependent on the nature of the client’s impairment.

CART

  1. Client is presented with a picture. Clinician provides a spoken prompt to elicit writing (e.g. ‘Coffee, Can you write the word coffee?’)
  2. If client is able to successfully write the target, then clinician should provide reinforcing feedback and move onto the next target
  3. If client is unable to successfully write the target, then the clinician should provide a written model of the target for the client to copy at least three times.
  4. Remove client’s previous written responses (i.e. those given in step 3) and once again present the picture and ask the client to write the target word.
  5. If client is successful, then clinician should offer feedback before moving to next item
  6. If client is unsuccessful, go back to step 3.
  7. If client is repeatedly unsuccessful on a particular item, move to next item before frustration develops

 Adapted from Beeson, Rising & Volk (2003)

Beeson et al (2003) Example of CART attempts

Beeson et al (2003) Example of CART attempts

ACT

  1. Client is presented with a picture. Clinician provides a spoken prompt to elicit writing (e.g. ‘Can you write money’?).
  2. If client is able to successfully write the target, then clinician should provide reinforcing feedback and move onto the next target
  3. If client is unable to successfully write the target, then the clinic should present the component letters in a random order (e.g. through letters cards, Scrabble tiles) and the client should be encouraged to use these letters to assist with writing of the target word.
  4. If client is successful, then they should be encouraged to copy the completed word three more times.
  5. If client is unsuccessful, then the clinician should arrange the letters in the correct order while providing feedback.
  6. Client should then be encouraged to write the target word and then copy this three times
  7. Remove client’s previous written responses (i.e. those given in step 4 or 6) and once again present the picture and ask the client to write the target word.

 Adapted from Beeson, Hirsch & Rewega (2002)

Beeson (1999) ACT protocol

Beeson (1999) ACT protocol

Step-downs

  • Some clients may find writing is facilitated if they are asked to mentally imagine what the word looks like.
  • Some clients may appear phased when asked to write the whole word. Clinician may attempt to facilitate production of the word by first explicitly encouraging writing of the first letter. This may also be facilitated with a phonological cue.

 Step-ups

  • If a client is successful in copying and recall (i.e. writing the target when previous attempts have been removed), the delay between copy and recall can be increased, possibly with a short conversation or intervening trials.
  • If a client is successful solving the anagrams in ACT, then additional letters may be included with the array to act as distractors. The distractibility of the additional letters may be manipulated in relation to visual similarity to other letters (e.g. if a client has impairment in early visual processing of letters), or in relation to phonological similarity (e.g. if writing is sometimes mediated via phonology i.e. sounding out the letters, or if there are additional phonological level impairments.

What does the research say?

In general:

  • Both CART and ACT have been associated with improved writing ability
  • Improvements are mostly item-specific although participants may also improve in their spelling of parts of untreated words if their spelling overlaps with treated words
  • Such therapy protocols rely on high amounts of practice which are generally carried out as homework activities

Beeson (1999) presented initial evidence that such therapy tasks can be effective in leading to the improvement of writing whole words within a single case study of a participant described as presenting with severe Wernicke’s type aphasia. This was followed by the reporting of a further four case studies where two participants completed ACT and two completed CART (see Beeson, Hirsch & Rewega, 2002). Here, all four participants were reported to show positive effects of treatment.

Beeson, Rising & Volk (2003) further investigated the effectiveness of CART in eight participants with aphasia. Four of these participants were described as having significantly positive responses to treatment, while three showed some improvement but these were restricted to only a subset of treated words, whereas the other showed no effect of treatment. From a post-hoc analysis, several factors were highlighted that may have individually, or in combination have influenced treatment outcomes: 1) ‘consistent and accurate completion of homework activities’; 2) a relatively preserved semantic system; 3) a retained ability to discriminate real words from non-words; and 4) adequate non-verbal problem-solving abilities. Such factors suggest that while CART (and ACT) may be suitable for clients with severe aphasia, there are some caveats in terms of which aspects of language need to be retained.

The factors above also demonstrate the importance of client motivation in continuing therapy in their own time through the completion of homework. Indeed, many of the reports of CART and ACT report the inclusion of homework in addition to the face-to-face therapy protocol and in some reports; more or less the entirety of the therapy is conducted away from the clinician. Regardless of whether therapy is carried out at home, a key contributor in success of writing treatments will be the practice amount – improvements will generally only be evidence after significant amounts of practice (which homework naturally affords).  For example, Both Beeson, Hirsch & Rewega (2002), and Beeson, Rising & Volk (2003), requested that participants copy each target word 20 times per day (where participants were working on fives words at any one time) where therapy lasted from anywhere between 8 and 37 weeks.

Raymer et al (2003) If you practice writng 'hammer', you may also be able to write the 'hamm' of 'hammock'

Raymer et al (2003) If you practice writng ‘hammer’, you may also be able to write the ‘hamm’ of ‘hammock’

Evidence for generalization of improvements is fairly thin with most studies reporting item-specific improvements (i.e. improvements only to words practiced as part of therapy). However, Raymer, Cudworth & Haley (2003), report a single case study that employed CART where they reported that the client did show signs of generalization in that he improved in his ability to correctly spell (from dictation) parts of untrained words that shared similarities in spelling with trained words.

One issue to consider in relation to the improvements observed in the majority of such studies is how they measure treatment effectiveness. In the vast majority of cases, participants are generally only ever working on small item sets at a time (e.g. sets of five to seven words). This means that ‘improvement’ is often judged against fairly small numerical gains. However, the functional importance of gaining even a small number of words that can be written and used for communicative purposes should not be underestimated when it comes to considering ‘clinical significance’. While some participants have indeed improved in small sets of items, a number of clients have also shown that they retain the ability to write these words even when daily practice moves onto a new set of words. Therefore, the maintenance of improvements is also equally important to consider when assessing the effectiveness of therapy.

Beeson et al (2002) Examples of functional word sets

Beeson et al (2002) Examples of functional word sets

The combined finding that improvements require fairly extensive practice and that effects appear to be mostly restricted to treated words, suggests that treated items need to be selected carefully on an individual basis, i.e. that treated items should be functional and useful in real-life contexts for the client. This means that clinicians should have a good understanding of how the client may benefit from using writing communicatively. This is on the assumption that writing is encouraged as a method to either replace or supplement spoken communication and information from other modalities (e.g. gesture) and that writing will often be completed in single words.

Possible further research questions

  • Do improvements in writing associated with CART and ACT translate into real life communication changes (i.e. do clients use their newly acquired words communicatively)?
  • How long does it actually take for a word to be acquired to the point where it will be maintained (i.e. how many times does it need to be written/copied before it sticks)?
  • How many words can be worked on simultaneously before there is a drop-off in ability to maintain improvements?

References

Ball, A. L., de Riesthal, M., Breeding, V. E., & Mendoza, D. E. (2011). Modified ACT and CART in severe aphasia. Aphasiology, 25(6-7), 836-848.

Beeson, P. M. (1999). Treating acquired writing impairments: Strengthening graphemic representations. Aphasiology, 13, 767-785.

Beeson, P. M., Hirsch, F. M., & Rewega, M. A. (2002). Successful single-word writing treatment: Experimental analyses of four cases. Aphasiology, 14(4-6), 473-491.

Beeson, P. M., Rising, K., & Volk, J. (2003). Writing treatment for severe aphasia: Who benefits? Journal of Speech, Language, and Hearing Research, 46, 1038-1060.

Raymer, A., Cudworth, C., & Haley, M. (2003). Spelling treatment for an individual with dysgraphia: Analysis of generlaisation to untrained words. Aphasiology, 17(6-7), 607-624.

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