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Chapter 16

Thematic Language-Stimulation Therapy

Shirley Morganstein and Marilyn abstract or theoretic models of language (Boyle & Coelho,
1995; Drew & Thompson, 1999) Schuell’s approach was
Certner-Smith conceived as a result of focused clinical observation and data
collection on large numbers of patients. This clinical
approach enabled her to see and record relevant behaviors,
OBJECTIVES postulate and evaluate the underlying mechanisms for that
behavior, and find ways into the wounded brain. Since the
1960s, many aphasia therapists have found an intelligent and
In this chapter, we provide a theoretic background for comfortable point of entry in Schuell’s work. It was from
Thematic Language Stimulation (TLS), an intervention tech- that place of comfort that TLS was born.
nique for aphasia; explain the rationale for TLS and delin- Since the original formulation of TLS in 1982, a variety
eate its various components; provide suggestions for clinical of different therapeutic approaches have developed in
and functional communication analysis as a precursor to the response to changes in the way that we, as a profession, per-
use of TLS; and provide a template for replication of TLS ceive aphasia, the concept of disability, and the therapeutic
modules and directives for implementation in aphasia milieu. Specifically, we are looking more closely at the person
therapy. with aphasia, rather than the disorder of aphasia, as did Schuell.
This is not to say that Schuell did not consider the interper-
sonal aspects of communication—quite the contrary. All of
her investigations and interventions sought to alleviate the
In the previous chapter, the reader will find an excellent
symptoms that interfered with normal communication. She
description and discussion of the work of Hildred Schuell.
did speak to the devastating effect of impaired communica-
Despite evolving knowledge gained in neurologic sub-
tion on the person with aphasia:
strates of speech and language function, Schuell’s model of
aphasia rehabilitation remains relevant. Schuell posited a Like anyone who, suddenly in the midst of the journey of his life
neurobiologic change with controlled stimulation, and so has found himself alone in a dark wood where the straight way is
lost, the aphasic patient knows despair. Surely anyone partially
do today’s researchers in “the community of brain repair.”1
paralyzed and unable to communicate must feel himself in a dark
Jenkins and colleagues (1990) found expansion of distal wood, indeed, and surely the straight road he took for the natural
digit representation in monkey brains after sensory training, way must seem lost to him.” (Schuell, 1964, p. 321)
suggesting that the brain can change with systematic motor
stimulation. Similarly, Kilgard and Merzenich (1998) reported Schuell would have greatly appreciated the work of indi-
changes in the organization of monkey auditory cortex after viduals currently involved in the social, environmental, and
exposure to a combination of sound and chemical neuro- life participation approaches. Today, many speech-language
transmitters. pathologists may feel a pull away from traditional interven-
Thematic Language Stimulation is firmly rooted in tions and into the more person-centered ones. Without
Schuell’s stimulation treatment model. Indeed, as a graduate question, we are learning from people with aphasia what the
student in the 1960s, the senior author was privileged to form and content of our therapy can be. The disability
have studied with Schuell during her tenure at the empowerment movement is having a strong, positive effect
University of Minnesota and the Minneapolis VA Hospital. on the work of the aphasia therapist, yet some new views
Some approaches to management of aphasia are based on about how we can intervene in the workings of the brain in
the person with aphasia also have appeared. Constraint-
induced therapy, for example (Maher et al., 2003;
Pulvermuller et al., 2001), is based on the neurophysiologi-
1
Leslie Gonzalez-Rothi, Speaking Out! 2004, Tampa, Florida. cal finding that “doing” actually changes structure within

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Chapter 16 ■ Thematic Language-Stimulation Therapy 451

the brain. Other recent studies are revisiting the notion that TLS THEORY
some specific drugs may have an enhancing effect on brain
function for communication (Greener, Enderby, & Whurr, Organizing Content and Delivery
2001). The organization of the language used for stimulation is
Perhaps more to the point is an examination not of central to TLS. This is accomplished in two ways: first, in
which intervention is appropriate but, perhaps, at what establishing a relevant, thematic “core vocabulary,” and sec-
point in the therapeutic process, in what order, and for which ond, in creating predictable, systematic linguistic stimuli for
persons with aphasia different intervention approaches may each presented task.
be useful. As we noted in our chapter in the fourth edition
of this text, a significant body of research that might help Thematic Content
us to reliably identify specific candidates and the most
beneficial timing for these specific techniques continues Wepman (1972), in his content-centered treatment approach,
to be absent. believed that treatment should focus on ideas. He advocated
The current version of TLS continues to reflect its origi- stimulation of thought to enhance verbal production during
nal stimulation roots. We also have found it to be helpful in conversation. In contrast, TLS requires more stringent con-
the metalinguistic exploration of symptoms and strategy trol of content and its manipulation within the session.
training and in the education of other speech-language Content themes heighten the saliency of the therapy and
pathologists and caregivers. We view TLS as one technique provide a context for both the stimulation and the subse-
in a growing professional armamentarium. None of these quent conversation. Meaningful content in natural contexts
techniques is mutually exclusive; indeed, some actually may strengthens the therapeutic effect. Rather than creating new
be enhanced by the inclusion of others at another point in ones, the TLS structure capitalizes on the organizational
time. systems already established within the brain.
Both Schuell (1964) and Wepman (1972) agreed that
treatment content should be personally relevant. At the
DEFINITION most basic level, people tend to have more to talk about
“Thematic language stimulation” is a systematic method of when the subject is connected to them (Wallace & Canter,
therapy for aphasia that employs thematically related 1985). In addition, Marshall (1994) noted that, for those
vocabulary in multimodality stimulation, targeting changes with fluent aphasia, personally relevant material is “com-
in language processing for functional communication. forting and helps to break the garbage in-garbage out
Specifically, it begins with a select group of words related cycle” (p. 444). Human beings are simply more at ease and
in meaning, places them in particular linguistic contexts, better equipped to talk about topics that interest them most.
uses them in tasks that employ both input and output Therefore, in choosing a TLS topic that is relevant for the
modes, and targets improvement of underlying language person with aphasia, we establish a heightened “perfor-
processes to impact on conversational success. The TLS mance edge” for therapy as well as a shared referent for sub-
hypothesis is that you are changing the way the brain is sequent exchanges. In addition, choosing material of high
working by “working the brain.” It extends concepts origi- personal relevance can reassure patients that we know more
nally presented by Schuell and colleagues (1964) and by of who they are than they are able to tell us. In this way, we
Wepman (1953, 1972). In addition, the authors have been foster an atmosphere of respect that affirms the present
influenced by the work of Edith Kaplan (1989) and of value of the patient in a therapeutic partnership.
Nancy Helm-Estabrooks and M. Albert (1991), who Thematic language stimulation themes may be fairly uni-
emphasize the process approach in evaluation and treat- versal, such as “cooking” or “sports.” Often, however, the
ment—that is, understanding the why as well as the what authors create units based on the unique backgrounds and
about aphasia. interests of the individuals with whom we work. For exam-
Like all stimulation approaches, TLS places the burden of ple, we once used a family interview and a few trade maga-
success on therapists, because they provide a possible neuro- zines to construct a TLS unit on the garbage industry for a
biologic link between what the person with aphasia knows particular client, and it proved to be a great success. In this
and what the person with aphasia can produce. Theoretically, way, we have learned a good deal about the world in which
restoration of language proficiency comes about by means of our clients live and work. It is frequently most interesting in
carefully controlled stimulation. Stimulation targets overall and of itself, but it also has practical value, in that we can
improved understanding, speaking, reading, and writing. sometimes use this information again in TLS sessions with
Observation of the person’s behavior during stimulation others.
reveals information about underlying processes. Awareness A TLS unit usually consists of 8 to 10 vocabulary words,
of these processes has value in the development of strategies primarily nouns and verbs, that are highly related to a topic.
for success in conversation. From this pool of core vocabulary items, we develop, for
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452 Section IV ■ Traditional Approaches to Language Intervention

language practice, a variety of activities, all linked to the greatest degree of success to the more difficult. Here,
theme. (See Appendix 16-1 for an example of one such unit.) “more difficult” is relative; the TLS philosophy employs
Simultaneously, the functional communication segment an 80% to 90% success level for activities. Less success
uses extensions and elaborations on this theme. The reader than that simply affirms failure to both the client and
will note that, with some exceptions, the exercises employed the therapist—that is, failure to achieve an adequate
are highly familiar: repetition tasks, fill-ins, multiple-choice stimulus. Greater than 90% success suggests the activity
selection, and more. What is different about TLS is the way is not truly stimulating the brain but, instead, is riding
they are created, selected, ordered, delivered, extended, and the wave of current capabilities—rather enjoyable at
enhanced. times but, perhaps, not therapeutic. The degree to
which clients achieve high numbers of “correct”
Stimulation Delivery in TLS responses in therapy is dependent on the therapist’s
understanding of performance variables and how to
Chapter 15 (Duffy and Coelho) provided a comprehensive
influence them, the intensity of language stimulation
discussion about the principles of Schuell’s stimulation ther-
delivered and for which there is a response, and the
apy. Several of these are very important in the development
moment-to-moment adjustments made during sessions.
and execution of TLS and warrant further elaboration here:
This is probably more about what is frequently called
1. Stimulus Adequacy The adequate stimulus, by defini- “the art of aphasia therapy,” for which we believe there
tion, is one that has an intended result. Such stimuli is a definite learning process.
must be sufficiently intense, focused, and redundant to
create a neurobiologic effect—that is, a change in brain-
Functional Communication
mediated language performance. In TLS, stimuli can be
made adequate in several ways. First, the high degree of The stimulation of language in clinical exercises is not the
relevant content ensures saliency. Second, redundancy, only benefit of TLS; it also can be of value in the transition
in the form of repeated semantic and syntactic elements, from language used in structured activities to conversational
and the use of multiple input and output channels are exchanges in a shared topical context. The desire for func-
programmed into stimulus/response tasks that literally tional change is a powerful one and is shared by the clinician,
bombard the patient with linguistic stimuli. Third, the client, family members, and more recently, the sources of
hierarchical development of task sequences builds and therapeutic funding.
extends stimuli in familiar but varied contexts. Intervention in the functional domain has become central
2. Maximal Patient Response TLS supports this princi- in several models of therapy for aphasia. These social and
ple by providing many opportunities for the client to ecological models propose that the effectiveness of interven-
respond in all modalities. That is, between 10 and 15 tion be measured by functional communication success in
different multimodality exercises are presented for each natural environments and that therapeutic interventions
vocabulary item over the course of five to seven sessions. employ analysis and problem solving in that milieu (Boles,
In addition, therapists are encouraged to repeat activi- 1998).
ties with minor adaptations from session to session. Task In many therapeutic models, treatment includes a problem-
repetition, reordering, adaptation, and extension in solving component, in which the clinician tries various com-
meaningful context enable maximal response. Using a binations of cues and strategies to facilitate improved lan-
variety of tasks that can be rearranged and adapted for guage function (Chapey, 1994a; Holland, 1998; Kaplan, 1989;
use over a period of several sessions, therapists can Wepman, 1972). This process draws on the very essence of
broaden the stimulation base without shifting out of the our practice as speech-language pathologists: the ability to
theme. In addition, language can be extended further by observe symptoms and behavior and apply interventions
using environmental materials and objects, such as a real that help. In TLS, because we are keeping the treatment
restaurant menu for a unit on dining out or a trade mag- structure consistent, the process itself becomes more of a
azine on a specific chosen topic. focus. Freed of the necessity of constantly learning new
3. Systematic and Intense Presentation TLS activities directions and rules of therapy for new tasks, clients engage
are composed and delivered systematically to obtain the more easily in problem-solving activity and can concentrate
greatest number of accurate responses. The progression more on their own performance issues. This consistent
is from introductory topical conversational material to structure helps both the clinician and the client to develop
identification of theme vocabulary to manipulation of insights that assist in facilitating functional communication
language in carefully adapted and sequenced multi- behaviors.
modality tasks and a return to conversational format— We believe that TLS may provide a link from clinical to
all within one session. Within that structure, the order functional language stimulation by manipulation of the theme.
of presentation also is from those likely to result in the The daily segue from clinical task to relevant, theme-based
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Chapter 16 ■ Thematic Language-Stimulation Therapy 453

conversation moves the clinician and the person with aphasia Metalinguistic dialogue reinforces the collaborative rela-
back and forth between both environments. Capitalizing on tionship in problem-solving treatment outcomes. Because it
what may be improved access primed in the stimulation mode, encourages the person with aphasia to take on more respon-
the therapist skillfully shifts the environment of practice to sibility and independence in symptom and communication
functional conversation. Once there, both clinician and client management, it is a helpful tool for discovering those strate-
continue the problem-solving process, exploring successful gies that are most likely to actually be used with confidence
strategies, heightening awareness, and developing insights. both inside and outside the treatment session. An example of
a metalinguistic dialogue is as follows:
Metalinguistic Dialogue Therapist I noticed that when you had trouble saying some of
the words just now, you seemed to pause and think about it
Metalinguistic dialogue is used in conjunction with TLS to more in your head. What did you notice?
strengthen the clinical to functional link. A metalinguistic Patient Yes, I try to see the word.
act requires that an observation be made about the use of Therapist So you see the word written in your mind, and then
language. The observation could be about one’s own lan- you can say it easier?
guage or about another’s use of his or her language. Patient Yes, that’s right
Engaging in metalinguistic dialogue requires skill, but the Therapist Is that easier than trying to write it?
speech-language pathologist has the ability to describe and Patient Yes, and it’s faster.
codify the speech, language, and communication behaviors
that affect conversation. From the personal and experiential ASSESSMENT FOR TLS
perspective, the person with aphasia has valid observations
Regardless of the theoretic basis for provision of language
to contribute, and both perspectives are complementary.
treatment, clinicians need specific information about lan-
Conversation strategies that are personalized and congruent
guage function to develop a program. Schuell (cited in Byng,
with the individual’s ideas of what works or fits that individ-
Kay, Edmundson, & Scott, 1990) proposed that treatment
ual’s life, however, are more likely to be the strategies that
planning requires knowledge of which cerebral processes are
are actually used. Nina Simmons-Mackie (2001), in her
impaired, the level at which performance breaks down in
description of “enhanced compensatory strategy training,”
each modality, and the reason why performance breaks
notes that “the person with aphasia is considered a partner in
down when it does. For the present authors, this is a pre-
identifying and elaborating a strategy repertoire” (p. 254).
scription for a process-oriented examination of both func-
The metalinguistic dialogue can happen at any point in
tional performance and behaviors more typically elicited in a
the therapy session. We have found that it usually occurs
formal test milieu. Whereas formal aphasia tests can provide
quite naturally toward the end of the session, after the client
some information, clinicians would do well to heed the
and therapist have experienced the activities and the follow-
warning inherent in Edith Kaplan’s (1991) comment that
up functional conversation. The typical flow is from baseline
“batteries are for cars, not for people”.
conversation to TLS activities to functional conversation
Assessing aphasia is one of the most complex require-
and, then, to metalinguistic dialogue.
ments of speech-language pathologists. Competent evalua-
This metalinguistic dialogue often begins with the
tion requires astute observation of language behavior com-
speech-language pathologist sharing examples of positive
bined with a thorough knowledge concerning the range of
performance that are tied specifically to language and com-
possible symptoms and how they influence communication.
munication. Such observations or questions may assist those
The speech-language pathologist also must have the knowl-
with aphasia to explore and reflect on their own perfor-
edge and skill to manipulate the environment and explore all
mance. Beyond its usefulness to develop strategies, the
possible avenues of success. Thus, proper aphasia assess-
exchange may serve to increase the patients’ understanding
ment bridges both domains of science and art. When the
about the nature of aphasia and how it operates with their
therapist has a thorough understanding of the patient’s clin-
present brain function. Once such dialogues are integrated
ical and functional picture, the therapist can create an
into the session and the patients are “on board” with this
appropriate therapy program; specifically, the therapist can
component of treatment, the therapist offers more detailed
choose a particular approach or environment suited to the
observations about performance and asks the clients for
information provided by the evaluation. Moreover, end-
their discoveries. The dyadic exchange could include com-
point recommendations then are more individualized and
ments about performance during transaction, interaction,
helpful for communicative partners.
and eventually, to domains beyond language (e.g., metacog-
nition). Commenting and problem solving about the style of
Establishing Baseline Functional Conversation
various conversation partners in the social network that
either supports or exists as a barrier to conversational suc- At the onset of treatment, a baseline of functional communi-
cess may lead to productive solutions. cation is obtained. Although we have used some formal
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454 Section IV ■ Traditional Approaches to Language Intervention

instruments to measure functional communication in on. The value of these subtests is that they assist the clinician
research or for other purposes (Taylor, 1969; Yorkston & in the differential diagnosis of aphasia. They do not, how-
Beukelman, 1980), our approach for TLS usually is more ever, explain what to do once aphasia is confirmed.
informal. That is, we believe that the experienced clinician Therefore, the clinician must engage in further analysis,
usually can answer questions about functional communica- adding probes to explore cognition, behavior, and therapeu-
tion after a relatively short period of interaction with the tic style to determine both “what to do” and “where to begin”
client. in therapy.

How Well Do Patients Initiate and Sustain Formal Testing

Conversation?
1. Repetition Some people with aphasia can repeat well,
Assessment of the client’s overall level of participation in a and some cannot. Because TLS relies completely on the
conversational exchange establishes a baseline for measuring objective of “language in, language out,” therapists must
progress and helps the clinician to develop initial ideas about know whether repetition will be a primary stimulation
intervention. Therefore, the relative burden of information task, one to avoid completely, or one that will need to be
exchange as well as the degree to which information must be adapted but can still be used successfully. Any formal
inferred need to be determined. test of repetition can provide the level of breakdown
with respect to length and complexity of units, but fur-
How Well Do Patients Express Themselves ther observations are required to assist in therapeutic
Verbally and Nonverbally? decision making. For example, if repetition is better
Assessment focuses on content. Observations address the than spontaneous speech, the clinician has discovered a
patient’s relative use of alternatives to speech when they key aural-oral connection to modify speech output; if it
appear in the natural course of an exchange. This informa- is worse, the clinician must look elsewhere, most likely
tion about preferred modes, and relative ease of success in to the visual modality, for primary input. In addition, for
any mode, will assist in decisions about TLS activity selec- many individuals with aphasia, repetition is not a “can
tion and order. It also will guide the way in which we intro- do/can’t do” phenomenon. Many patients “can do” once
duce options for enhanced communication and how we train some structural stimulation requirements are met, such
the communicative partner. as slowing the rate of presentation or providing face-
to-face delivery (particularly for the patient with
apraxia). Such observations are critical to TLS planning,
How Well Do Patients Follow Conversation and
and success that can be achieved using this approach.
Directions? How Complex Can Auditory Demands
2. Sentence Construction Most formal aphasia batteries
Be Before Performance Breaks Down?
assess the ability of the patient to create sentences given
Information regarding comprehension informs decisions a one-, two- or three-word stimulus. Creation or expan-
about task selection and presentation and about adjustments sion of verbal utterances that are substantive and gram-
that need to be made in the therapist’s verbal behavior when matically correct is an objective of many treatment
introducing tasks, counseling the client, and engaging in approaches. Clinicians learn more about how best to
conversation. Skilled clinicians can derive a good deal of facilitate this for a particular patient when they know
information during conversational exchange about the (a) the required length and grammatical composition of
intermittency of auditory processing, regardless of whether stimuli, (b) the effect of vocabulary complexity, and (c)
patients are aware of a loss in understanding and how well how much and what type of verbal or visual cues are
they comprehend subtleties, humor, and/or sublinguistic needed to facilitate performance.
information. 3. Automatic Language For some people, automatic
language is far more preserved than propositional lan-
guage, and automatic language should be facilitated first
Assessing Clinical Performance on Tasks
if it will create a base of success. Knowing the ease with
Thematic language stimulation is strongly dependent on a which automatic language can be facilitated will help
process approach. Therefore, we continually ask “Why?” with therapeutic task selection and sequencing. For
when symptoms are revealed. It is only by understanding the example, fill-in tasks with multiple-choice response
“why” that we can determine “what” can be done about it in requirements are high in predictability and might be
treatment. Standard aphasia tests tell some of the “what” but considered to be a natural extension of automatic lan-
none of the “why.” In comparing the various standard apha- guage material.
sia instruments, a core group of subtests occur repeatedly: 4. Picture Description A pictorial cue can be powerful for
repetition, naming, answering yes/no to questions, and so some clients in eliciting a flow of ideas. When aural-oral
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Chapter 16 ■ Thematic Language-Stimulation Therapy 455

presentation and response is tenuous, a pictorial cue can correct errors that occur in this format. For some
also can provide a starting point for therapy. In addi- clients, visual stimuli are more salient. In addition, when
tion, the contrast between narrative and spontaneous the patient and clinician share a visual reference in the
expression can be explored with respect to the com- same context, this may reveal specific symptoms and
plexity of ideas and vocabulary generated as well as the procedures for modification.
degree of clinician-initiated cueing that is necessary for 9. Graphic Expression Writing adds to the sources of
a response. linguistic bombardment necessary to reach a threshold
5. Following Instructions Although it is desirable to for response. Integrated into the therapeutic program, it
minimize task instructions to the patient at each session, comes to be thought of as a welcome addition, adding to
it is important to determine each particular patient’s the patient’s repertoire of success. For the person with
need for such repetition of procedures. When we apply milder aphasia, one needs to know how much and what
process parameters to listening, the logical questions to kind of assistance is needed for the production of words,
be asked are (a) how complex and lengthy can directions phrases, sentences, or narratives and whether a self-
be, (b) will a visual cue be needed to support the verbal initiated written cue aids verbal performance. Therefore,
request, (c) how does the rate of presentation affect clinical and functional graphic abilities are explored
comprehension, and (d) is the auditory mode a strong or fully. The therapist investigates writing and drawing not
weak one for the individual? only as an augmentative communication tool but also as
6. Yes/No Reliability For the client with more severe a source of stimulation itself. By integrating writing at
aphasia, ability to respond readily and consistently in a an early stage of treatment, the clinician stimulates the
yes/no question format is an essential skill. Indeed, it is patient’s language system in yet another way. Many
a valuable task for auditory, verbal, and visual stimula- individuals with global aphasia can copy neatly and
tion of all clients. In addition, before construction of a accurately. In addition, after several such trials are com-
TLS unit, the parameters of length, complexity, ease, bined with repetition, they may even produce the target
and facilitation requirements should be noted via word verbally without struggle.
descriptive comments.
These formal test probes, combined with observation of
7. Reading Comprehension For many individuals with
performance, comprise our “minimal data set” for evaluative
aphasia, reading comprehension is a valid alternative to
exploration in both clinical and functional domains.
auditory comprehension. In this instance, treatment
first emphasizes presentation of information via the
visual modality rather than the more traditional audi- Cognitive and Behavioral Considerations
tory mode. The comparison of results on subtests that
Several non-language behaviors have an impact on the treat-
tap auditory processing of directions and commands
ment planning process. Additional knowledge about the per-
with those that examine silent reading of sentences and
son’s cognitive and behavioral strengths and weaknesses will
paragraphs allows the clinician to decide on a preferred
influence the treatment model or approach that is chosen. In
input mode. It also is important to compare scores
the case of TLS, such an analysis is necessary to customize
obtained during testing as well as the overall ease of per-
both the content and delivery of therapeutic materials. As in
formance in both modalities, because this information
the language analysis, certain behaviors are observed,
sometimes provides a clue about a client’s “hardwiring”
described, and noted for future reference.
for processing language. For example, if visuographic
expression is more preserved and preferred to the aural-
Patient Involvement
oral system, that will be the road that we follow. In addi-
tion, for some individuals, silent reading before verbal For some, the purpose of therapy is obvious, and they “get
performance has a priming effect; only when a detailed with the program” immediately, respond well to the treat-
process approach is applied to tasks are such important ment materials, and provide clinicians with evidence that
pieces of information learned. This information then they are on the right track. For others, however, lack of
can be applied not only to task and cue selection but also insight is as much an obstacle to recovery as their symptoms.
can be shared with those who have aphasia and with Naturally, TLS works best with insightful, motivated clients
their communicative partners. Thus, treatment deci- who “get it.” Therefore, very early in the period of evaluation
sions are made based on a balancing of the patient’s and during the initial phases of therapy, we note the patient’s
strengths and weaknesses (Holland, 1998). ability to connect with the disorder, comment on the patient’s
8. Oral Reading Oral reading is another avenue that pro- own internal processes or performance for such behavior on
vides an opportunity to get language “in and out.” task, and consider other types of metalinguistic analyses.
Therefore, the clinician needs to know if oral reading is Because of the way TLS is structured, however, it also is a
more preserved than speaking and whether the patient treatment approach that can facilitate improved insight and
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456 Section IV ■ Traditional Approaches to Language Intervention

understanding about the therapeutic process. Even at the Visual Perception

lowest level of function for this type of reflection, we offer
Because TLS relies heavily on multimodality stimulation,
many opportunities and indicate to the person that such
any visual problems that affect task presentation, such as the
concerns are not only worthwhile but also essential to
presence of hemianopsia or the need for altered print size,
recovery. We share our observations with the patient, and
should be known in advance. For some, it may simply be a
we encourage the patient to do the same. This process is
matter of modifying the aural-oral elements and adapting
important, because recovery does not happen via neurobio-
visual materials. For others with severe accompanying visual
logic stimulation alone but, rather, via the insights that peo-
impairments, TLS may not be effective.
ple with aphasia derive from their own process. Therefore,
we continually ask “why” of our clients, and sometimes, they
can give us an answer. TREATMENT DELIVERY
After completing an assessment of conversational proficiency,
Specific Symptom Awareness language, and cognitive/behavioral status, the clinician is
Clients are asked to modify their symptoms as part of the ready to incorporate this information into an organized treat-
therapeutic process. Some modifications result from the ment delivery plan. Before therapy can begin, however, one
clinician’s direct intervention; others result from the per- more set of questions needs to be answered:
son’s own insight regarding a specific symptom and the 1. Is this person a good candidate for TLS? Candidacy
patient’s resultant, focused response to it. To us, clients with for TLS is best determined in one or two sessions of trial
specific symptom awareness seem to achieve greater therapy; however, certain rules of thumb seem to be of
progress and do better overall. Indeed, such awareness has a help in deciding which clients have the potential for suc-
significant impact on how we structure material in tasks and cess. Good candidates generally are those with no
how we cue or strategize for success. We all have memories marked perseveration or semantic confusion in task per-
of such moments in our therapy sessions. For example, one formance and with good ability to understand the pur-
author recalls a person with conduction aphasia who taught pose of therapy, stable emotional status, and some
her clinician the value of graphomotor association by amount of visual language preservation. Level of severity
producing a dictionary of words beginning with target may vary, but patients with moderate to severe difficulties
sounds and then using that list to aid pronunciation of words appear to profit most. Although preliminary research
in general. findings suggest otherwise, we feel the technique is of
value to people with either fluent or nonfluent aphasia.
Task Orientation and Retention 2. How should tasks be chosen and sequenced? Our
When clients have good task orientation and retention of analysis during assessment has told us very specifically
treatment set, directions need not be repeated from day to which modalities and tasks are the strongest and which are
day. Subsequently, a natural flow occurs from one task to the the weakest. Therefore, to adhere to the principle of stim-
next and from one day to the next. In addition, because of its ulus adequacy, we begin there. In addition, because it will
organization, TLS can assist even the person with severe prime the session for all subsequent task presentations and
aphasia to prepare himself cognitively for the tasks at hand. adaptations, the first task should be one that provides a
In turn, this sometimes engenders feelings of competence in high probability of success. If it is known, for example, that
the “knowing” of what to do. Therefore, keeping structure the patient does not repeat well but that he can read words
constant and changing the items within it, rather than the and phrases both silently and orally with good success,
constant shifting of exercises that sometimes is seen in then the TLS exercises chosen first should require this
more traditional language therapy, is valuable. patient to do just that. Because treatment is multimodal,
the next task might begin to include aural-oral require-
ments, such as answering questions using the material just
Perseveration
practiced visually. This might be followed by a writing task
For some people with aphasia, perseveration is a highly at a level compatible with demonstrated skills in this
problematic and unwelcome intrusion for communication. modality; for example, the client might be able to copy or
In our experience, the semantic relatedness of TLS can write the target words as the clinician dictates them.
make perseveration even worse for these clients. Typically, 3. What cues are most beneficial to achieve maximal
this tendency is discovered once treatment is underway and success in treatment? Because successful language
the clinician observes that the client’s responses, rather than stimulation should neither involve too much struggle
demonstrating the advances in vocabulary retrieval and sen- nor be so “easy” that it does not provide a neurobiologic
tence use, contain recycled errors in word choice that are effect, an 80% to 90% success rate is targeted in TLS
not evolving into something better. For such an individual, therapy. To achieve this level of success, considerable
TLS is not an appropriate treatment approach. experimentation regarding facilitatory cueing takes
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Chapter 16 ■ Thematic Language-Stimulation Therapy 457

place; however, our assessment analysis has provided milieu, single-subject design studies are accomplished more
clues about the likelihood that they will or will not suc- easily than group studies, therapists, according to Siegel (1987)
ceed. Therefore, the clinician answers questions such as as well as Siegel and Spradlin (1985), often find it difficult to
the following: (a) Are visual cues more powerful than integrate them into a typical service delivery model. In 1993,
auditory ones? (b) How much spontaneous writing is we completed one such clinically based, single-subject study
possible with and without input from dictation? (c) with TLS.
When can I fade out a verbal, auditory, or visual cue and
still maintain an accurate response?
Defining Success
When we determine cueing that works at baseline, we
also determine the beginning of a cueing hierarchy. In the early stages of our clinical work with TLS, we were rel-
These hierarchies are individualized and will change over atively comfortable with clinical evidence that the approach
time as the client progresses and needs to be challenged was making language more available during the execution of
further. Maintaining a high level of success throughout tasks. As sessions progressed, performance seemed to improve
treatment, however, should be a constant goal. during each session and from session to session. If TLS or, for
4. How do I select theme and vocabulary? As men- that matter, any restorative technique is to be judged effica-
tioned earlier, theme selection is based on each client’s cious, however, it must be held to the ultimate standard—that
interests; personal relevance generates ideas and themes is, improvement in conversational speech. We found immedi-
that provide a shared reference point for all subsequent ate difficulties in selecting functional conversation as the
interaction. The inclusion of material based on client improvement measure, because few quantifiable options from
input reflects respect for the client’s personal contribu- which to choose were available and those that were available
tion to the decision about treatment needs. Themes that seemed to be insensitive to discriminating what would
are more concrete—or even able to be pictured—are undoubtedly be very small changes. For that reason, we
easier to conceptualize. It is entirely possible, however, declined to use the CADL (Communication Activities of
to select complex themes and create vocabulary and Daily Living) (Holland, 1980), the CETI (Communicative
tasks that can be modified to levels consistent with nor- Effectiveness Index) (Lomas et al., 1989), and the FCP
mal language complexity. A minimum of 6 and maxi- (Functional Communication Profile) (Taylor, 1969). We
mum of 10 words are recommended. found support, however, in our frustration:
A closed set of core vocabulary permits manipulations Clinicians and investigators who wish to quantify changes in
that fulfill some of the content and delivery principles the informativeness of the connected speech of adults with
aphasia in response to manipulation of experimental variables
described earlier: redundancy, multimodality presentation,
have been hampered by the scarcity of standard measures for
and predictable task inventory. The majority of words are characterizing this aspect of connected speech. (Nicholas &
nouns; however, an occasional verb or adjective also is desir- Brookshire, 1993, p. 338).
able. For example, if the theme is “restaurant,” appropriate
vocabulary words might be waitress, tip, table, menu, appetizer, At the time we embarked on our study, the only published
water, check, chef, and order. system for measuring small improvements in discourse
The actual tasks that we have employed in our TLS work appeared to be that proposed by Yorkston and Beukelman in
are familiar to any experienced aphasia clinician. What is 1980. In their system, the individual’s response to the cookie
different is the constancy of theme that connects them all theft picture from the Boston Diagnostic Aphasia Examination
and the systematic way in which they are employed. A com- (Goodglass & Kaplan, 1983) is analyzed for the number of
plete TLS unit (“Books”) is provided for your use in content units produced and for a measure of communicative
Appendix 16-1. efficiency, which is determined by the ratio of content units
per minute of discourse. Content units, or groupings of
information expressed by normal speakers in response to the
PRELIMINARY RESEARCH WITH TLS cookie theft picture, are finite and offer a clear index of rel-
ative performance in response to this specific picture stimu-
According to Darley in 1972 (as cited in Howard, 1986, p. 89), lus. Concerns regarding the differences between connected
“If speech pathologists are to have a role in the management of speech elicited in this manner and that elicited in a conver-
aphasic patients, it must depend not on wishful thinking, but sational exchange remained, but a content unit analysis
on unequivocal demonstration of effectiveness in significantly seemed to be our best method of defining success—that is,
altering, in a favorable way, the course of recovery.” In the communication of information in discourse.
1980s, this was referred to as “evaluating efficacy.” In 2005,
American Speech-Language-Hearing Association adopted the
Design Choice
term “evidence-based practice” and created a position state-
ment reinforcing the need for evidentiary support for clinical In general, single-subject studies investigating the efficacy of
interventions. Although in the typical speech therapy clinical a particular approach to aphasia intervention employ either
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458 Section IV ■ Traditional Approaches to Language Intervention

a reversal/withdrawal or multiple-baseline design (Pring, so, we avoided any linking of materials with conversational
1986). Our desire was to determine whether TLS was more topics. It may be argued that we did not provide the best pos-
effective than a “traditional” approach, and we therefore sible non-TLS modules because of our bias; however, we are
chose a reversal design in which TLS and non-TLS modules accustomed to delivering other kinds of therapy to those for
would alternate with each other for 3 weeks after a baseline whom TLS is not appropriate and attempted to do that for
determination of communicative efficiency. Modules 1 and 2 this study. Our hope is that, in future studies, we will be able
(i.e., TLS and non-TLS, respectively) were ordered such to employ other therapists so as to eliminate any possible bias
that subjects would receive either one first for a 3-week in this regard.
period. This served to control for the number of times that
each was received. The same content unit analysis obtained
Subject Selection
at baseline was performed between each of the modules.
The decision regarding the content of the non-TLS mod- The individuals who participated in the study completed a
ule was of great concern, because many differing approaches 3-week course of treatment while at an inpatient acute reha-
to therapy for aphasia are available. Our personal journey bilitation facility, and they were selected without regard to
involved exploration of many of these approaches, and we age, type of aphasia, etiology, duration of symptoms, or any
would—and will—employ many of them therapeutically other particular characteristic. All were screened for ade-
when we felt it to be an appropriate choice for a specific indi- quate vision and hearing, and all received traditional aphasia
vidual. Our choice of non-TLS therapy for Module 2, how- testing before inclusion in the study.
ever, was derived from what seemed to be “the norm” for
many speech-language pathologists—that is, a “general lan-
Procedures
guage stimulation” approach employing a variety of exercises
for word retrieval, comprehension, reading, and writing but Before beginning the first module, in between modules, and
without controlled content and delivery around thematic again at the end of the last module, the responses of each
structure and Schuellian principles. patient to the cookie theft picture were audiotaped and video-
Therefore, Module 2 employed activities from the many taped. Written transcripts of these descriptions were obtained
easily accessible aphasia workbooks frequently used by clini- and analyzed according to the procedure of Yorkston and
cians. These activities were administered by us subsequent Beukelman (1980). Each therapy session was videotaped as
to completion of the same evaluative procedures described well. All subjects received 30-minute sessions of therapy 5 days
above. In other words, we attempted to treat the patient with per week for each of the three consecutive weeks.
traditional speech and language tasks selected for the individ-
ual’s level of performance in each modality but without
Results
regard to semantic uniformity across modalities. We did not
hesitate to assist patients in achieving success on these tasks Pring (1986) offers some encouragement for the analysis of
within the session, and we provided whatever degree of stim- data in a visual rather than a statistical manner when changes
ulation and support was required for specific activities. Even are likely to be small. Thus, as can be seen in Figure 16–1, two

14
JS
RE
12 LS
Communicative efficiency

10

8
Figure 16–1. Treatment effects of thematic lan-
guage stimulation. JS, RE, and LS refer to indi-
6 vidual patients.

0
Test 1 Test 2 Test 3 Test 4
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Chapter 16 ■ Thematic Language-Stimulation Therapy 459

of the three subjects (both people with fluent aphasia) demon- edgeable and comfortable with partnership to be supportive
strated treatment effects with TLS. That is, the communica- and effective.
tive efficiency score (number of content units divided by rate) Training aimed at understanding aphasia and how to be
increased after TLS modules, and decreased after non-TLS of help needs to be addressed early and frequently through-
modules, relative to baseline. No treatment effect was out the course of treatment. Although communicative part-
observed for patient JS; in fact, her scores appear to be poorer ners generally cannot provide TLS therapy, they learn, by
with both treatment approaches relative to baseline. observing sessions and talking with us, about how those with
aphasia organizes their language, employ appropriate strate-
gies, and requires in the way of priming input or providing
Discussion
support to do their best. These lessons can be learned from
Because of the very small number of subjects in our study, many different approaches; because of its strong dependence
little about the efficacy of TLS can be confirmed. Certainly, on structure, TLS may simply be a more organized observa-
we would need to test many more individuals before draw- tional environment for shared insights and opportunities
ing any conclusions. What seems safe to assume, however, is regarding problem solving.
that the use of a content unit analysis as a measure of dis- Thematic Language Stimulation is an intervention that
course for revealing small, quantifiable changes in perfor- bridges treating the language deficit and facilitating function
mance is a good idea. We found it interesting, however, that via the conversation focus. In recent years, addition of the
our best results were obtained when treating individuals metalinguistic component to complement the TLS format
with fluent, rather than nonfluent, aphasia given our clinical has reinforced the role of problem solving by the patient,
impression that people with nonfluent aphasia respond quite family, and other supporters. Success in conversation often
well. Even so, we observed that patient JS, the subject with is a prerequisite to success in chosen activities and participa-
nonfluent aphasia, lacked a sense of treatment purpose tion goals. Being skilled to problem solve and advocate for
despite a good degree of cooperativeness regarding therapy. life’s goals beyond the duration of the speech therapy inter-
Our impression is that this person would have had difficulty vention is of great value for the ultimate outcome.
with any intervention because of her inability to interact Lastly, our training needs to involve the community. For
with the concept of treatment in general. Further explo- the person with aphasia to participate successfully in chosen
ration of TLS intervention is warranted with a greater num- activities, we must assist the community with learning to
ber of subjects, individuals of varying aphasic syndromes, recognize aphasia and to respond effectively. After all, the
and consideration of the timing of implementation during ultimate goal is for people with aphasia to succeed.
the recovery phase.

FUTURE TRENDS
KEY POINTS
The World Health Organization’s model for classification of
functioning and disability differentiates deficit, activity, and 1. Thematic language stimulation is a neurobiologic
participation as points of reference in the individual’s health approach to speech and language therapy, based on
perspective. To treat individuals for their deficit or brain the theory of aphasia treatment first postulated by
impairment in isolation is to ignore other critical features of Hildred Schuell in the mid-twentieth century.
their recovery. Improved language function that stays in the 2. Success in implementation of TLS may depend on
therapy room without application to functional activities several factors, including the ability of the therapist
and participation goals also reflects inadequate therapy. to provide adequate stimulation and the abilities of
With a driving force to make life better for people with the client to understand and respond to the aphasic
aphasia and those who matter most to them, our therapy symptoms.
needs to be authentic, flexible, and congruent at each of the 3. Therapists who employ TLS must use the client’s
various points in recovery. To meet these criteria, the interests and talents to tap into the best possible sub-
speech-language pathologist needs to direct less, listen ject matter for a successful outcome.
more, and support the direction described by patients and 4. Thematic language stimulation extends out of the
their chosen partners to assist in achieving a satisfactory basic Stimulus-Response formats into the natural
recovery. flow of speaking and listening in a conversation.
Our role as educators and trainers will continue to 5. The ability of both therapist and client to examine
expand. If people are to be successful outside of the therapy language and cognitive abilities and make decisions
room, they must be knowledgeable and empowered to prob- about how to integrate treatment is key to the use of
lem solve and make choices. Similarly, families and others in TLS.
the social network of those with aphasia need to be knowl-
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460 Section IV ■ Traditional Approaches to Language Intervention

ACTIVITIES FOR REFLECTION AND DISCUSSION Holland, A. (1980). Communicative abilities in daily living. Baltimore,
MD: University Park Press.
Holland, A. (1998). A strategy for improving oral naming in an
1. Create your own “mini” TLS unit by following these individual with a phonological access impairment. In N. Helm-
steps: Estabrooks & A. Holland (Eds.), Approaches to the treatment of
a. Select four vocabulary items on a topic of choice. aphasia (pp. 39–67). San Diego: Singular.
Include nouns and verbs. Howard, D (1986). British Journal of Disorders of Communication, 21,
b. Using the examples given in Appendix 16-1, place 89–102.
each vocabulary item: Jenkins, W. M., Merzenich, M. M., Ochs, M. T., Allard, T., & Guic-
i. In a word-phrase-sentence format. Robles, E. (1990, January). Functional reorganization of pri-
ii. In an open-ended sentence for a fill-in. mary somatosensory cortex in adult owl monkeys after behav-
iii. In a multiple choice reading format. iorally controlled tactile stimulation. Journal of Neurophysiology,
63(1), 82–104.
iv. In a question designed to elicit discussion.
Kaplan, E. (1989). A process approach to neuropsychological assess-
c. What other exercises NOT in Appendix 16-1 might
ment. In T. Boll (Ed.), Clinical neuropsychology and brain function:
be used with the same four vocabulary items? Research, measurement, and practice. Washington, DC: APA.
2. Create a “cueing hierarchy” for someone who might not Kaplan, E. (1991). Neuropsychological assessment & language treat-
be able to succeed with item b.iii above. How would you ment: A process-based approach. Seminar June 7–8 in Alexandria,
adapt and change the presentation or task requirements VA, sponsored by Education Resources, Inc, Medfield MA and
to enable success? the Boston Neurobehavioral Institute, Boston, MA.
Kilgard, M. P., & Merzenich, M. M. (1998). Cortical map reorga-
nization enabled by nucleus basalis activity. Science, 270,
1714–1718.
Lomas, J., Pickard, L., Bester, S., Elbard, H., Finlayson, A., &
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APPENDIX 16.1
Thematic Language Stimulation (TLS) Unit on Books
with Instructions for Creating TLS Units.

How to Create a TLS Unit First, randomize core vocabulary items in a list of roughly twice its
size. Use foils (i.e., other words) that are varied in the degree to
Select between 8 and 10 words that have a close association to your which they may be related, visually or semantically, to the targets.
chosen theme. These words will become your core vocabulary, which The semantic closeness of the foils will determine the difficulty of
will be used in each exercise. Use nouns primarily, but verbs and the task.
adjectives are fine as well.

Exercise 5: Sentence Fill-Ins, Multiple Choice

Twelve Exercises
These are fill-in sentences for which the target word is one of the
Exercise 1: Repetition choices. For each fill-in sentence, three choices are offered. Semantic
This is controlled repetition practice, in which the stimuli gradu- closeness of the foils determines the complexity of the task.
ally increase in length and complexity. Use each core vocabulary
item, and create a phrase and sentence sequence for them in which Exercise 6: Yes/No Questions
the target word is in the final position, whenever reasonable.
Questions are formulated with target vocabulary, and the task is to
provide a yes/no response.
Exercise 2: Speech Stimulation/Production

This is a grouping of three statements and one question, which Exercise 7: Answering Questions, Multiple Choice
evolves for each core vocabulary item from repetition to open-
ended fill-ins to generation of novel utterances. Begin with a state- Questions are developed for which correct answers are randomly
ment for the client to repeat in which the core vocabulary item is ordered in a vocabulary grouping of four or five items. Place these
the last word. Create the next statement using the exact language of choices above four or five questions. The client must choose and
the first, but with the last word as a fill-in. Create a question requir- write the correct word.
ing the target word as an answer. End with a question relevant to
the content just practiced, but designed to elicit a novel response. Exercise 8: Sentence Arrangement

The client is provided with a scrambled sentence for each core

Exercise 3: Copying
vocabulary item. Create out-of-order sentences of varied complex-
Provide opportunity for the client to copy each target item at least ity, but within the mild to moderate range for each vocabulary item.
three times, and attempt to write from memory.
Exercise 9: Sentence Construction
Exercise 4: Categorization
Pairs of words are provided with which to create sentences. Create
This task is for identification of the core vocabulary in a list of two columns. On the left, list the core vocabulary first, followed by
words that vary in their semantic closeness to the target items. a verb. In the next column, list a noun phrase.
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462 Section IV ■ Traditional Approaches to Language Intervention

Exercise 10: Sentence Correction

The client is provided with sentences containing two errors of

either word choice, grammar, or spelling, which the client must
identify and correct.

Exercise 11: Paragraph Reading, Multiple Choice Questions

A paragraph is created in which all (or most) of the vocabulary has

been used. The client must then answer some multiple-choice
questions about the paragraph. When possible, use humor or
idiomatic expressions to improve processing. Create three or four
questions with multiple-choice answers for practice in processing
factual and implied information.

Exercise 12: Conversational Questions

This is A list of questions on the topic designed to elicit conver-

sation.

Vocabulary Unit: Books

Exercise 1: Repetition/Oral Reading

Directions: Repeat or read aloud these words, phrases, and sentence.

fiction read
enjoy fiction read my book
I always enjoy fiction. Tonight I will read my book.
print library
large print at the library
The book comes in large print. See you at the library.
glasses characters
reading glasses many characters
I’ve lost my reading glasses. The novel has many characters.
writer mystery
great writer solve the mystery
She is a great writer. Did you solve the mystery?

Exercise 2: Speech Stimulation/Production

Directions: Listen, fill in, and answer the questions.

1. I prefer to read fiction. 3. She is a famous writer.

I prefer to read _______________. She is a famous _______________.
What do I prefer to read? _______________ What is she? _______________
What do you prefer to read? Name a famous writer.

2. The story is a mystery. 4. The book comes in large print.

The story is a _______________. The book comes in large _______________.
What is the story? _______________ How is the book printed? _______________
Why are mysteries fun to read? How is large print helpful?
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Chapter 16 ■ Thematic Language-Stimulation Therapy 463

5. I wear reading glasses 7. The book has three main characters.
I wear reading _______________. The book has three main _______________.
What do I wear? _______________ What were there three of _______________?
Where do you buy reading glasses? How many characters are too many?

6. I borrow books from the library. 8. I’ve always liked to read.

I borrow books from the _______________. I’ve always liked to _______________.
Where do I borrow books? _______________ What have I liked to do? _______________.
How long can you borrow books? What kind of books do you read?

Exercise 3: Copying

Directions: Write each word three times. Then, cover it up, and try to write it from memory:

Name: ____________________________________________________________________________

Date: ____________________________

read print
_____________________________________ _____________________________________
_____________________________________ _____________________________________
_____________________________________ _____________________________________
_____________________________________ _____________________________________

library glasses
_____________________________________ _____________________________________
_____________________________________ _____________________________________
_____________________________________ _____________________________________
_____________________________________ _____________________________________

writer mystery
_____________________________________ _____________________________________
_____________________________________ _____________________________________
_____________________________________ _____________________________________
_____________________________________ _____________________________________

fiction characters
_____________________________________ _____________________________________
_____________________________________ _____________________________________
_____________________________________ _____________________________________
_____________________________________ _____________________________________
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464 Section IV ■ Traditional Approaches to Language Intervention

Exercise 4: Categorization

Directions: Circle the words that belong in the category “Books.” If you prefer, you can cut these out, mix them
up with another set of words from this book, and sort them into two categories.

fiction butter

print read

banana salami

pill rain

library writer

spoil weather

glasses splash

inkling characters

mystery insult
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Chapter 16 ■ Thematic Language-Stimulation Therapy 465

Exercise 5: Sentence Fill-ins, Multiple Choice

Directions: Read the sentence, circle the correct word, and then write it.

night print perfect

1. The book is no longer in ________________________________________________________.

mystery show petal

2. A “whodunnit” is a _____________________________________________________________.

ocean travel library

3. Borrow the books from the ______________________________________________________.

puppet muffler writer

4. Stephen King is a popular _______________________________________________________.

glasses ears advice

5. To read better, I need my ________________________________________________________.

filling fiction syrup

6. That type of book is ____________________________________________________________.

wash read order

7. My cousin likes to ______________________________________________________________.

characters tumbles services

8. The book has too many _________________________________________________________.

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466 Section IV ■ Traditional Approaches to Language Intervention

Exercise 6: Yes/No Questions

Directions: Read the question, and circle “yes” or “no.”

1. Do you read only paperbacks? Yes No
2. Is fiction about real events? Yes No
3. Are all writers good? Yes No
4. Are most libraries quiet? Yes No
5. Are characters a key part of a book? Yes No
6. Do you wear glasses on your nose? Yes No
7. Does large print help some people? Yes No
8. Does a mystery keep you guessing? Yes No

Exercise 7: Answering Questions, Multiple Choice

Directions: Use each word to answer the questions that follow:

fiction print characters writer

1. Who are the people in a novel? ___________________________

2. What are the words on a page? ___________________________
3. What is a story not based in fact? _________________________
4. Who creates a story? ___________________________________

read library glasses mystery

5. Where can you borrow books? ___________________________

6. What do you do with a book? ____________________________
7. What do you wear to help you read? ______________________
8. What is a book about a crime? ___________________________

Exercise 8: Sentence Arrangement

Directions: Rearrange these words to make a correct sentence. Write that sentence on the line.

1. I asked if the book: in came print large

_____________________________________________________________________________________________

2. Our library: new has a wing

_____________________________________________________________________________________________

3. My book: characters many has too

_____________________________________________________________________________________________

4. I bought a new: reading pair glasses of

_____________________________________________________________________________________________
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Chapter 16 ■ Thematic Language-Stimulation Therapy 467

5. Stephen King: writer is a popular

_____________________________________________________________________________________________

6. The ending of the mystery: was total surprise a

_____________________________________________________________________________________________

7. I like: book to read reviews

_____________________________________________________________________________________________

8. Her brother: fiction will only read

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Exercise 9: Sentence Construction

Directions: Create sentences with these word pairs.

1. fiction-prefer fiction shelf
2. print-see large print
3. library-borrow new library
4. characters-admire twelve characters
5. glasses-broke reading glasses
6. writer-produced well-known writer
7. mystery-confusing clever mystery
8. read biography never read

Exercise 10: Sentence Correction

Directions: There are two errors in each sentence below. Find the errors, circle them, and rewrite the sentence.

1. The print is two small for me to feed.

_____________________________________________________________________________________________

2. Someone found my library cargo in them bathroom.

_____________________________________________________________________________________________

3. She is famous for solvent the mystery before she funishes the book.

_____________________________________________________________________________________________

4. Eye need a strongest prescription for my glasses.

_____________________________________________________________________________________________

5. Do yous prefer function or nonfiction?

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468 Section IV ■ Traditional Approaches to Language Intervention

6. I like to read the newspaper ever mourning.

_____________________________________________________________________________________________

7. I cold easily identification with the lead character.

_____________________________________________________________________________________________

8. The writer has writen nearly thirty books in his careen.

_____________________________________________________________________________________________

Exercise 11: Paragraph Reading, Multiple-Choice Questions

Directions: Read the paragraph, and then answer the questions.

Once a month, Ellen goes to the public library to attend a book club. This month’s selection was a mystery by
Agatha Christie. Ellen asked her friend Laurie to read the book and try the club. At the meeting, Laurie was par-
ticularly annoying and negative. She had forgotten her glasses and could not read the print. She disliked the
writer’s style; said there were too many characters to keep straight, and she guessed the ending. When it was
time to go, Laurie announced she would like to join the group, but insisted the next selection be contemporary
fiction. Ellen reacted quickly and suggested another Agatha Christie book and that the group read only myster-
ies for the rest of the season.

1. The writer of book was:

a. Stephen King c. Ernest Hemmingway
b. Agatha Christie d. Angela Lansbury
2. Laurie didn’t like the book because:
a. too many characters c. it wasn’t funny
b. too many pages d. the print was in color
3. What did Laurie suggest that the club read next time?
a. contemporary fiction c. a biography
b. another mystery d. poetry
4. Ellen suggested they read more Agatha Christy because:
a. she likes repetition c. she wants Laurie to try harder
b. she wants Laurie to drop out d. she is a mystery buff

Exercise 12: Conversational Questions

Directions: Answer these conversational questions on the topic.

1. Why are books easier to read in large print for some people?
2. How has your library changed in the way you can borrow books?
3. Do you prefer fiction or nonfiction? Why?
4. What do you like or dislike about mysteries?
5. Why do drug stores now stock reading glasses?
6. Besides books, what else do you like to read?
7. What makes a character in a book memorable?
8. Why are the benefits of a writer holding a book signing?