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For those who have lost the ability to speak after a stroke, writing can offer another avenue for communication. However,aphasiaoften impacts both spoken and written language, so impaired writing (agraphia) requires specialized treatment to improve.
The Treatment
Anagram, Copy, and Recall Treatment (ACRT), a combination of Anagram and Copy Treatment (ACT) and Copy and Recall Therapy (CART), is an evidence-based lexical treatment for writing single words for people with severe aphasia and agraphia. This treatment requires lots of repetition, so motivation to improve and determination to practice are essential. While time-intensive, this practice can largely be done at home with simple tools and a helper, or independently with apps.
Choosing Words
Pick functional words when verbal expression isn’t effective for communicating basic needs in more severe aphasia. Family names, common requests, and recurring topics are good targets to train. Select a set of words (25-40) that the person with aphasia wants to practice. Get family or caregiver input on the list, then run them by the person with aphasia to make sure they approve.
For example: A 65 year-old man with aphasia may wish to write his name (Bob), his wife’s name (Cheryl), the names of his children (Dan and Karen), his grandchildren (Mackenzie and Noah), the town where he lives (Westfield), the places where his children live (Ohio and Florida), his favorite sport and team (football, Colts), his most requested items (iPad, Netflix, coffee, sandwich), his past career (engineer), and the issues he likes to talk about (fishing, election, movies, BMW). Now he can use those words to tell people about himself and his family, to let his wife know what he wants, and to bring up topics of conversation he enjoys.
Alternately, when verbal expression is recovering nicely, it may be written skills that need attention. In this case, make a list of simple or familiar words that start with each sound. Train this set of words using the method below. These words will become thekeywordsused in the next step of writing therapy,phonological treatment.
For example, “top” may be a good key word for the sound /t/. Once the person can reliably write “top” and words beginning with all the other sounds, they may be ready for sound-based treatment. In this more advanced therapy, they can learn to associate the letter T in “top” with the sound /t/ to begin sounding out words. Key words and the phonological treatment are part of ourAdvanced Writing Therapyapp, the next step in agraphia treatment.
How To Do Anagram, Copy, and Recall Treatment
Once you have generated a word list, organize it with the shortest and most regularly spelled words first to ensure early success. Divide the words into sets of 5-10 to work on at a given time. After the first set has been mastered, move to the next set.
You’ll need pictures of the words, letter tiles (Scrabble®or Banangrams®tiles work well), paper, pencil or marker, and a helper. Or, you can independently use theWriting Therapy appwith just pen and paper (see below).
Step 1 – Test
Show a picture of the word – a dog, for example. Say “write the word for this” or “can you writedog?”If they can, provide positive feedback (“that’s right!”) and move to the next word. If not, move to Step 2.
Step 2 – Anagram
Provide the letter tiles used in the word in random order (O – D – G). “Put the letters in order.”If they can’t get the letters in the right order, arrange the letters for them.
Step 3 – Copy
With the correct spelling visible, prompt to “copy the word 3 times.”
Step 4 – Recall
Remove the paper and letters, show the picture again, and say “write this word” on a new piece of paper.
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ACRTUsing the Writing Therapy App
Not everyone has a therapist or partner around to help with therapy. Even if there is someone nearby, you may be without the letter tiles or pictures you need to practice. Using theWriting Therapyapp on your iOS or Android device, you can work independently orwithout extra supplies.
Setup
Open theWriting Therapyapp and touch the third activity: Spell What You See. On the Settings tab, set the Difficulty to Easy.
After you select your categories and press Start, touch theSettingsgear icon in the upper right corner and turn offAuto-Advance so the app won’t move on until you’re ready.
Pro Tip: If you want to practice only certain words,setNumber of TrialstoAllon the Settings tab and touchAdvanced Settings. PressChoosenext toCustomize Word List. Select only the words you want to practice.If using your own pictures and words, go to theCategoriestab and pressAdd/Edit Customto add a photo and sound. Select all categories on the Categories tab once you’ve edited your word list to ensure all your words will show up. You only need to set up your word list once.
Anagram
On the screen you’ll see the picture and all the letters in the word. Put the letter tiles in the correct order, then pressCheckto see if you’re right. If you’re wrong, use theHintbutton or trial and error until you get it right.Touch the picture to hear the word at any time.
Copy
Now write the word on a piece of paper. Copy it 3 more times.
Recall
Turn the paper over and use it to cover the word on the bottom of the screen. Write the word again on a new piece of paper.
Changing Difficulty
Step Up
To make the task harder, you can add more letters to the mix in Step 2 (chooseMediumorHardon theSettingstab), or increase how long you wait before doing Step 4. Try the same words inSpell What You Hearfor extra practice.
Step Down
To make the task easier, use theFill-in-the-BlankorCopyactivities in the app.
Remember: You don’t have to stick strictly to the protocol. There are lots of variations of anagramming, copying, recalling, and repeating that can work. The key ingredients seem to be intensive practice, focusing on just a handful of words at a time, and choosing words the person with aphasia is motivated to learn and use.
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Setting Goals for Anagram, Copy, and Recall Treatment
Short-term goals for this therapy approach should focus on increasing the accuracy of writing the words from the treatment list. Start with writing in response to picture stimuli, then move up to writing to dictation, and finally, writing in response to questions designed to elicit the treated words.
Long-term functional goals may include communicating novel information or making requests via writing. If not observed during therapy sessions, this can be measured by family report from conversational interactions at home. The client may have specific goals related to writing notes, taking messages, making lists, or electronic correspondence.
Resources for Anagram, Copy, and Recall Treatment
Most of the research on ACRT has been led by Pélagie M. Beeson, Ph.D. and her lab at the University of Arizona. Many helpful protocols, references, and examples of writing assessments and treatments are freely available on theAphasia Research Project website. Trainkeywords if you plan to advance to phonological therapy.
Keywords are incorporated into theAdvanced Writing Therapyapp, part ofAdvanced Language Therapy 4-in-1. Try Advanced Language Therapy Lite for FREE to sample all 4 apps to take speech therapy to the next level.
An entire chapter is dedicated to ACRT in theManual of Aphasia and Aphasia Therapy – 3rdEdition.This valuable reference adds an extra step of anagramming with 2 extra letters and copying again three times after Step 3. There’s also a useful 6-point scoring system to help track progress.
There’s a detailedoverview of ACT and CART treatment and the evidence for theseapproaches on theCommunication Therapies for Adults blog.
A 2013 study looked at using one-handed typing on the keyboard on a mobile phone to practice sending text messages. T-CART is a modified protocol for texting, but could be used for any typing practice as so much of our modern communication is now digital.
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Megan S. Sutton, MS, CCC-SLP is a speech-language pathologist and co-founder of Tactus Therapy. She is an international speaker, writer, and educator on the use of technology in adult medical speech therapy. Megan believes that technology plays a critical role in improving aphasia outcomes and humanizing clinical services.
