For those who have lost the ability to speak after a stroke, writing can offer another avenue for communication. However, aphasia often impacts both spoken and written language, so impaired writing (agraphia) requires specialized treatment to improve.
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.
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 the key words used 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.
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 the Writing Therapy app with 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 write dog?” 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.
ACRT Using 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 the Writing Therapy app on your iOS or Android device, you can work independently or without extra supplies.
Step 1 – Setup: Open the Writing Therapy app. Go to the Settings and next to Customize Word List, press Choose. Select only the words you want to practice. Set Number of Trials to All and turn off Auto-Advance. If using your own pictures and words, go to the Choose Your Categories screen and press Add/Edit Custom to add a photo and sound. You only need to set up your word list once.
To start, go to the Home screen, be sure the difficulty is set to Easy, then press Spell What You See.
Step 2 – Anagram: On the screen you’ll see the picture and all the letters in the word. Touch the picture to hear the word. Drag and drop the letter tiles into the correct order, then press Check to see if you’re right. If you’re wrong, use the Hint button or trial and error until you get it right.
Step 3 – Copy: Now write the word on the paper. Copy it 3 more times.
Step 4 – 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.
- Step Up: To make the task harder, you can add more letters to the mix in Step 2 (choose Medium or Hard on the Home screen), or increase how long you wait before doing Step 4. Try the same words in Spell What You Hear for extra practice.
- Step Down: To make the task easier, use the Fill-in-the-Blank or Copy modes of the app on the Home screen.
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.
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 the Aphasia Research Project website. Use the key words from this list if you plan to advance to phonological therapy.
An entire chapter is dedicated to ACRT in the Manual of Aphasia and Aphasia Therapy – 3rd Edition. 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 detailed overview of ACT and CART treatment and the evidence for these approaches on the Communication Therapies for Adults blog. Ozark Speech Pathologist offers a practical way to organize your homemade letter cards in a tackle box for therapists who frequently do anagram, copy, and recall treatment with their clients.
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