Article summary with Dynamic assessment in persons with severe aphasia by Paemeleire & Moerkerke - 2019

Aphasia refers to an impairment of language, affecting both the production or comprehension of speech and the ability to read or write.

Assessment of aphasia

Assessment of aphasia can serve several purposes:

1. To determine the underlying language disorder using a hypothesis-testing manner. 
2. To identify the functions in which any residual skills are observed, because these functions possess the highest probability of progression.
3. To determine a baseline for which the impact of severe aphasia on the different functioning levels of the ICF and on the quality of life is assessed.
4. To screen for the presence of non-linguistic disorders. Many persons with severe aphasia have comorbid non-linguistic disorders.
5. To look for prognostic factors. Next to the nature, localisation, and size of the injury, there are other factors important for predicting the outcome of recovery, such as whether executive functions are intact or not.  

According to the authors of this article, traditional assessment in persons with severe aphasia consists of a couple of important disadvantages: (1) is is frustrating for both parties; (2) it often is little informative, and; (3) it is not adapted to frequently occurring comorbid disorders. Traditional assessment almost always focuses on detecting disorders within a strongly controlled, non-interactive setting. Yet, we know from clinical practice that persons with severe aphasia often function better in a natural context. In sum, traditional assessment instruments yield problems regarding frustration, sensitivity, and validity. To overcome these issues, dynamic assessment is proposed. With dynamic assessment, the examiner is no longer an observer, but instead incorporates the role of supportive communication partner. In this article, the concept of dynamic assessment is illustrated using the workbook GLOBAMIX.

A static assessment instrument is characterised by a strict protocol regarding the administration and scoring rules. The examiner should play a neutral role. As the word already implies, a static assessment aims at assessing the static performance of the present functioning of an individual. 

In contrast, a dynamic assessment instrument is characterised by an interactive approach of assessment with an individual and experimental nature. The examiner is no longer an observer. Instead, the examiner changes to being an active participant. Active efforts are conducted to determine the effect of factors such as strategies, task adaptions, context factors, and contextual support on the outcomes. The learning potential of the participant and his or her maximum level of performance are under study. Dynamic assessment is in particular suitable for complex groups including people with severe and multiple disorders. 

GLOBAMIX is developed for the dynamic assessment of persons with both fluent and non-fluent aphasia. The ultimate goal is to identify residual skills and to explore perspectives for the treatment and guidance. Both linguistic and non-linguistic skills are assessed, as both play a role in the functional communication and the possibility of compensation (strategies and aids). In addition, some supportive and contextual factors are identified. It is important to know that GLOBAMIX is not a test, but a toolbox with material for holistic, dynamic assessment. It is not a replacement of existing assessment instruments, but an addition to yet existing material. GLOBAMIX is developed from the following four basic principles: 

1. Primum non nocere: first and foremost, do not harm. People with severe aphasia are very limited in their interactions and therefore need an examiner that is supportive and collects information with minimal frustration. 
2. Acknowledge competence and reveal competence. 
3. A bio psychological vision on assessment, aiming for a more holistic approach than is offered by the ICF.
4. It is both based on scientific evidence (evidence-based practice) and clinical experience (practice-based evidence).

Recommendations

Finally, some recommendations on how to implement the principles of dynamic assessment in assessment for persons with severe aphasia:

• Spread the tasks over several sessions.
• Provide enough practice items. 
• Provide enough difficulty levels.
• Look for discrepancies in functioning of the individual.
• Stop the task if there is too much frustration.
• Take input disorders into account.
• Support language comprehension by giving instructions.
• Ask as little as possible for verbal responses.
• Determine the most adequate yes/no response.
• Use labelled yes/no questions.
• Provide a pointing stick.
• Use manipulable stimuli.
• Provide cues for incomplete, wrong, or absent responses.
• Evaluate the effectiveness of given cues.
• Determine the learning potential of the individual.
• Conduct an elaborate qualitative analysis.

Conclusion

To conclude, assessment of persons with severe aphasia is challenging. We know from experience that elaborate dynamic assessment according to the above described principles can offer an important contribution to identify the residual skills and learning potential of the individual. This information is important for the treatment and guidance of both the person and his or her environment. Next to theoretical insight, the authors hope to provide practical material to the field by means of GLOBAMIX. Deficits are diagnostic and positive performance is prognostic.