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Kathryn M. Yorkston
Edythe A. Strand
Mary R.T. Kennedy
University of Washington, Seattle
This paper describes the concept of model of chronic disease as a factor in disability
comprehensibility and how it is an important affecting speech performance in physical and/or
construct in the assessment and treatment of social contexts. The literature related to
dysarthric speech. Intelligibility and comprehen- comprehensibility of dysarthric speech is
sibility are differentiated in terms of their reviewed. Clinical approaches to improving
definition, measurement, and approaches to comprehensibility, including issues of candi-
treatment. Specifically, comprehensibility is dacy, intervention planning, and treatment
defined within the World Health Organization approaches, are discussed.
T
he term comprehensibility has been applied to words or sentences. Second, the transmission system will
measurement of the adequacy of communication in impact intelligibility of the utterance. For example, live
a number of populations, including speakers of voice will often yield higher intelligibility scores than
English as a second language and individuals with hearing transcriptions of tape-recorded utterances. Finally, the
impairment. Barefoot and colleagues (Barefoot, Bochner, listener’s task will influence intelligibility scores. For
Johnson, & vom Eigen, 1993) suggest that comprehensibil- example, forced-choice word selection and sentence
ity can be defined as “the extent to which a listener completion will yield higher scores than orthographic
understands utterances produced by a speaker in a commu- transcription.
nication context” (p. 32). The notion of communicative The concepts of comprehensibility and intelligibility
context is not new. Miller and Selfridge (1950) suggest that may be distinguished by the fact that comprehensibility
total context includes the sum of all conditions surrounding incorporates signal-independent information such as
a communication event. It is the knowledge shared by the syntax, semantics, and physical context. Figures 1 and 2
communication partners about the time, place, topic, illustrate the distinction between speech intelligibility and
purpose, or any other feature of the setting in which the comprehensibility as applied to the area of dysarthria. A
utterance occurs. review of Figure 1 suggests that speech intelligibility is a
Those who conduct clinical research in dysarthria have measure of the adequacy of the acoustic signal. It is the
focused more on intelligibility than on comprehensibility. product of at least two components. The first component is
The term intelligibility refers to the degree to which the the impairment or the disordered speech production
acoustic signal (the utterance produced by the dysarthric mechanism. The second component represents compensa-
speaker) is understood by a listener. Intelligibility is tory strategies the speaker employs in response to the
typically measured by having listeners orthographically impairment. When intelligibility is measured in the clinical
transcribe words or sentences that the speaker reads. An setting, all other signal-independent information is held
intelligibility score is then computed by dividing the constant. For example, information such as semantic
number of words understood by the total number of words context provided in the natural communication environ-
spoken. Because many factors influence intelligibility, a ment is removed by using standard or randomly selected
number of aspects of measurement are typically controlled words and sentences. Measures of speech intelligibility
(Yorkston, Beukelman, & Traynor, 1984). First, the have been employed as a gauge of each of its compo-
speaker’s task is held constant because intelligibility scores nents—the impairment and the compensatory strategies
may differ depending on whether the speaker is producing employed by the speaker to improve speech production.
Definition Interruption or inter- Loss and/or abnorm- Restriction or lack of Inability or limitation in Restriction, attributable to
ference of normal ality of mental, emo- ability to perform an performing socially social policy or barriers
physiological and tional, physiological, action or activity in defined activities and (structural or attitudinal),
developmental pro- or anatomical struc- the manner or range roles within a social which limits fulfillment of
cesses or structures ture or function, inclu- considered normal and physical environ- roles or denies access to
ding secondary that results from ment as a result of services or opportunities
losses and pain impairment internal or external
factors and their
interplay
Level of deficit Cells and tissues Components of the Speech performance Speech performance Performance of roles by
speech production with full range, speed, in a physical and speakers in social context
process, including strength, & coordi- social context
respiration, phonation, nation
velopharyngeal func-
tion, and oral articula-
tory structures
Examples of Degeneration of upper Changes in respira- Speech intelligibility Comprehensibility Premature retirement
assessment & lower motor tory support
targets neurons through EMG
& clinical observation
Examples of No physiologic inter- Energy conservation Proper phrasing of • Reduction in noise Scaffolding to support work-
approaches vention is currently techniques to com- utterances to high- in the environment related activities
to intervention available for ALS pensate for poor light stress patterning • Partner signals
respiratory support when messages are
not understood so
that repair strategies
can be initiated
clinical observation of spasticity, fasciculations, and the environment during communicative exchanges.
atrophy. Currently, there is not intervention at this physi- Another example of intervention at the level of disability
ologic level. The impairment associated with dysarthria in might be teaching the communication partner to signal
ALS results from deficits in respiration, phonation, when messages have not been understood so that strategies
velopharyngeal function, and/or oral articulation. Ap- for repair can be initiated. The final level in this framework
proaches to the assessment and treatment of the impair- is societal limitation. This implies the restriction of a
ment have been described elsewhere (Rosenbek & speaker’s ability to perform societal roles because of the
LaPointe, 1985; Yorkston et al., 1988). Using the example dysarthria. With some recent exceptions (King, Ramig,
of dysarthria associated with ALS, the assessment target Stein, & Dereshiwsky, 1994), there are no structured
for understanding the contribution of reduced respiratory approaches for measurement of such limitations in
support to the speech impairment may include measure- dysarthria. Until better measures are available, we must
ment of vital capacity, sustained phonation time, and rely on activities such as interviews regarding recreation,
phrase length. Intervention at the level of the impairment home maintenance, or vocational roles. Intervention at the
might include training the use of energy conservation level of societal limitation may take the form of develop-
techniques to compensate for poor respiratory support. For ment of scaffolding to support work-related activities or
the parameter of functional limitation, the level of deficit educating employers about the removal of barriers to
refers to how well the dysarthric speaker can perform communication.
movements to produce the intended acoustic output. At this
point, measures such as speech intelligibility are targets of
assessment. An example of intervention at this level might
Studies of Comprehensibility
be encouraging the speaker to use proper phrasing in order in Dysarthria
to highlight stress patterning, thus improving speech There are many reports in the field of dysarthria that
intelligibility. focus on speech intelligibility. Studies of children (Kent,
If functional limitation is defined as performance of an Miolo, & Bloedel, 1994) and of adults (Yorkston, Dowden,
activity, the disability is the performance of that activity in & Beukelman, 1992) have been reviewed elsewhere. The
a natural setting or context. We are recommending that the focus of the following section will be on those studies that
term comprehensibility be used to indicate the adequacy of measure speech intelligibility in the context of some type
speech performance in a social context. An example of of signal-independent information. The term that we are
intervention at this level might be the reduction of noise in applying to this topic is comprehensibility.
Candidacy
What are the characteristics of speakers with dysarthria
who would likely benefit from an intervention focusing on
improved comprehensibility? Support for the importance
of severity of dysarthria as a factor in candidacy decisions
FIGURE 7. A schematic representation of approaches to intervention for individuals with severe dysarthria.
Appendix A
Techniques for Improving Comprehensibility: For the Communication Partners of the Dysarthric Speaker
Communication is a partnership. The following techniques may ❏ Avoid communication over long distances. Make sure to
make the communication process easier. The items that are always be in the same room when you initiate conversation. It is
checked may be the most appropriate for you. difficult for many speakers with dysarthria to speak loudly
enough to be heard in another room.
❏ Make sure you know the general topic of the conversation.
Knowing the topic of conversation makes a big difference in ❏ Make sure your hearing is as good as possible. It is
understanding speech that is distorted. Encourage speakers important that you hear well. If you suspect you have even a
with dysarthria to introduce topics. mild hearing loss, have your hearing tested. Properly fitted
hearing aids may make the speech of individuals with dysarthria
❏ Watch for turn-taking signals. Some speakers with dysarthria more understandable.
for whom speech is slow have difficulty getting a turn in a
conversation. Watch carefully for your partner’s signals or ❏ Decide on and incorporate strategies for resolving
decide in advance on some turn-taking signals. communication breakdowns. There may be times when you
will not be able to understand some or all of a message. It is
❏ Give your undivided attention. Speech is usually so easy to important to develop a plan of action to take if this happens.
understand that listeners can do other things and still under- Some people find the following steps helpful in preventing
stand what is being said. Speech that is slow and distorted is frustration:
more difficult to understand and therefore, requires our
• Signal as soon as you don’t understand. (Most people find
undivided attention. that a nonverbal signal is best because it does not disrupt
the flow of conversation).
❏ Picking the time and place for communication. Most of us
can talk all day without getting tired. Most of us can do many • Let the speaker know the parts of the message that you did
things while we talk. We can walk and talk, chew gum and talk, understand. (In this way, the speaker will not have to repeat
or eat and talk. Talking may be a very difficult task for a speaker the entire message.)
with dysarthria. Avoid important conversations when the • Let the speaker repeat the misunderstood words one time.
speaker is tired. Mealtimes may no longer be the best time for
conversation. • If you still don’t understand, ask the dysarthric speaker to go
to a predetermined “back up” plan that involves perhaps
❏ Watch the speaker. All of us get a considerable amount of rephrasing, verbal spelling, or writing.
information by watching a speaker. When speech is slow or
distorted, it is even more important to look at the speaker’s
❏ Establish some rules of the game. Speakers with dysarthria
may have some very definite preferences about what they
face. would like you to do and what they wish you would not do.
Knowing these preferences may reduce frustration. For
❏ Piecing together the cues. Some people describe the task of example, does the speaker with dysarthria want you to guess or
understanding slow and distorted speech as a process of not? want you to finish sentences or not?
piecing together a series of cues. Some of the cues, of course,
come from speech. Other cues may come from the gestures
that the speaker may use or from the physical surroundings.
❏ Facilitating communication with others. Communicating with
people who are unfamiliar to them is difficult for many dysarthric
Take advantage of whatever cues are available to you. speakers. You may be of assistance as a translator in some
situations. Again, it is useful to have some predetermined
❏ Make the environment work for you. Maximize your ability to guidelines. Does the dysarthric speaker want you to translate
understand the speaker with dysarthria by making sure you misunderstood parts of the message? to provide long or
have enough light; that the light is on the speaker’s face; and elaborate responses to questions when you know what the
that all extraneous noise is eliminated or reduced. answers are? to order food in a restaurant?
(Adapted from Vogel and Miller, 1991; and Yorkston, Strand, and difficulty expressing subtle changes in meaning with your
Miller, in press). intonation, you’ll need to express sarcasm or humor in other
ways.
The following techniques may be useful for individuals whose
natural speech may at times be difficult to understand. The items ❏ Rephrase your message. If listeners have not understood you
that are checked may be the most appropriate for you. These even after you’ve repeated the message, try communicating the
techniques enhance the understandability of your speech by thought using different words. But use a signal to let them
providing your communication partner some extra cues: know.
❏ Provide your communication partner context for what you ❏ Accompany speech with simple gestures when appropri-
are saying. Knowing the topic of conversation makes a big ate. At times, speech may be supplemented by simple
difference in understanding speech that is distorted. If your gestures. For example the palm extended in a halting motion,
speech is difficult to understand, provide the context by writing then a circular motion with index finger may accompany the
or spelling the topic of your message. message, “Stop and turn around where you are.”
❏ Don’t shift topics abruptly. If your speech is difficult to ❏ Take advantage of situational cues. Your surroundings may
understand, your partners may get lost if you change from one help you give a listener extra cues. For example, you might
topic to another without a transition. Let people know that you point to objects in the room in order to introduce a topic.
are changing topic and what the new topic is.
❏ Make the environment as “friendly” as possible. Some
❏ Turn-taking signals. Conversations tend to go very quickly. If communication environments are more difficult than others.
your speech is slow, you may need to use clear signals that you Avoid carrying out important conversations in noisy places or in
want a turn. These signals may take the form of an eye gaze, a places where your communication partner cannot watch you as
breathing pattern, a body movement, a gesture, or verbal you speak, for example, in dimly lit rooms or in situations where
interjection. Choose one or two that work for you and make your listener is a long distance from you.
sure listeners are aware of them.
❏ Avoid communication over long distances. Trying to speak
❏ Get your listener’s attention. It is impossible for any listener with someone who is across the room or in another room is
to understand unless he or she is paying attention. If your difficult. If you need to call attention to yourself, a buzzer,
speech is difficult to understand, it is even more important that beeper, or baby monitor may be useful.
listeners are paying attention. Before you begin a message,
alert your communication partner by saying his or her name. ❏ Alphabet board supplementation. If your speech is very
difficult to understand, you may want to point to the first letter of
❏ Use complete sentences. Grammatically complete sentences each word as you say it. This reduces your speaking rate,
are usually easier for listeners to understand. Avoid telegraphic allowing weakened muscles more time to formulate the precise
sentences or those in which the “little” grammatical words are movements of the speech sounds. It also provides the listener
deleted. with information about the word being spoken. If a word is not
understood even when the first letter of the word has been
❏ Use predictable types of sentences. Simple, grammatically identified, you can resolve the misunderstanding by spelling out
predictable sentences are generally easier to understand than the word in its entirety.
longer grammatically complicated sentences.
❏ Communicating emotional messages. Take care to commu-
❏ Use predictable wording. There are many ways to communi- nicate “emotionally loaded” messages when you are not tired
cate a single idea. If your speech is difficult to understand, and when there is plenty of time.
avoid unusual idioms or slang expressions. Be direct. For
example, “Close the window, please,” may be easier to ❏ Have a handy backup system. Have a highly understandable
understand than, “I wouldn’t mind if you would close the communication system handy in case of difficulty. This may be
window.” as simple as a pad of paper and pencil to write cue words.
Generally, we advise speakers with dysarthria not to let their
❏ Watch the tone of your voice. We communicate much listener get absolutely lost. Understanding little or nothing of a
information by changing the tone of voice. For example, the message can be very frustrating to a listener. If you see that
phrase “You really look terrific” may mean two completely someone is not understanding you, stop and make sure that he
different things depending on how you say it. If you have or she understands before you continue.
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