European Journal of Disorders of Communication,30,47S-491,1995 475

0 Royal College of Speech and Lunguage Therapists,London

NOTES AND DISCUSSION

Drawing to communicate: a case report of an

adult with global aphasia
Jeannene M. Ward-Lonergan
Bowling Green State University, Bowling Green, Ohio, USA
Marjorie Nicholas
Audiology and Speech Pathology Service, VA Medical Center, Boston, Massachusetts, USA

ABSTRACTS
Treatmentfor adults with global aphasia has typically involved the use of verbal treatment methods
or alternative communication techniques including communication boards, word lists and note-
books. However, many adults with aphasia are unable to communicate verbally and alternative
communication techniques can be limited, as a result of the restricted number and type of concepts
that can be adequately depicted and expressed. Another viable means of communicationfor the
globally aphasic adult is drawing. However, few individuals with severe aphasia initiate communi-
cation through this modality without specific training. I n this case report we present several success-
ful treatment methods that were used to train an adult with global aphasia to communicate more
effectivelythrough drawing. Several of his drawings are presented to illustrate the results of training
in the use of drawing as an alternative means of communication.
Le traitement des adultes souffrant d'aphasie globale fait typiquement appel d des planchettes de
communication, d des listes de mots et des cahiers. Cependant, bien des adultes aphasiques sont
incapables de communiquer verbalement et les techniques alternatives de communication peuvent
&re d'un secours limit6 d cause des restrictions en nombre et en type des concepts que l'on peut
dkrire et exprimer de facon adiquate. Un autre moyen possible de communicationpour l'adulte
aphasique est le dessin. Malgr6 tout, rares sont les personnes aphasiques graves quipeuvent se met-
tre a communiquer ainsi sans entrainement spicifique. Dans cette ktude de cas nous prisentons
plusieurs mithodes de traitement que l'on a utiliskes avec succ2spour entrainer un adulte aphasique
global d communiquer plus eficacement par l'intermtdiaire du dessin. Nous prhentons plusieurs
de ses dessins en guise d'illustration des risultats de son entrainement d communiquer.

Bei der Behandlung von Erwachsenen mit globaler Aphasie werden typischerweise verbale
Behandlungsmethoden oder alternative Kommunikationstechniken wie Kommunikationstafeln,
Wortlisten und Notizhefte eingesetzt. Aber viele Envachsene konnen nicht mehr verbal kommu-
nizieren, und die alternativen Techniken sind aufgrund der kleinen Anzahl und der Art von
darstellbaren und ausdriickbaren Begriffen stark begrenzt. Eine weitere mogliche Kommunikations-
art fiir den envachsenen Globalaphasiker sind Zeichnungen. Jedoch wenige Patienten mit schwerer
Aphasie benutzen diese Modalitiit von sich aus ohne spezielles Training. Es werden in dieser Fall-
studie mehrere Behandlungsmethoden vorgestellt, die beim Trainieren eines Erwachsenen mit
Globalaphasie, durch Zeichnen effektiver zu kommunizieren, erfolgreich venvendet wurden.
Einige Zeichnungen werden als Illustration der Ergebnisse des Trainings im Einsatz vom Zeich-
nungen als alternatives Kommunikationsmittelgezeigt.

Key words: global aphasia, drawing, communication.

476 WARD-LONERGAN AND NICHOLAS

INTRODUCTION
Treatment for global aphasia has typically involved the use of verbal treatment
methods or alternative communication techniques such as communication
boards, word lists and notebooks. However, many patients with aphasia are
unable to communicate verbally, and some alternative communication tech-
niques are limited by the number and type of concepts that can be easily
depicted or expressed. In addition, the syndrome of global aphasia generally
precludes the comprehension and retrieval of linguistic symbols such as letters
and words. One alternative mode of communication for patients with severe
aphasia is a non-linguistic technique such as drawing. In this report we present
several treatment methods that were successful at improving communicative
drawing skills in a man with global aphasia.
Numerous investigators have examined the ability of people with aphasia to
process and/or produce drawings (Gainotti & Tiacci, 1970; Hecaen & Assal,
1970; Wapner, Judd & Gardner, 1978; Cohen & Kelter, 1979; Gardner & Win-
ner, 1981; Gardner, 1982; Gainotti, Silveri, Villa & Caltagirone, 1983; Larrabee
& Kane, 1983; Kimura & Faust, 1984; Dagge & Hartje, 1985; Zaidel, 1986;
Swindell, Holland, Fromm & Greenhouse, 1988). However, literature pertain-
ing to training patients with severe aphasia to use drawing as a means of func-
tional communication is sparse.
In 1974, Hatfield and Zangwill trained a ‘gross motor aphasic’ subject (i.e. a
person with non-fluent aphasia) to produce drawings depicting short stories
that were narrated to him, as well as events acted out by the clinician and
events occurring in his own life. They concluded that the capacity to draw in
patients with aphasia is indicative of ‘a relative integrity of ideational
processes’. Pillon, Signoret, van Eeckhout and L‘hermitte (1980) presented an
impressive case study of their patient Sabadel, who was a graphic illustrator
before the onset of right hemiplegia and global aphasia. Sabadel’s drawing
skills improved greatly as a result of a treatment programme focused on
improving his use of drawing to facilitate communication.
Trupe (1986) modified two published treatment protocols to teach 15
patients with severe aphasia to use drawing as a means of communication:

1. Visual Action Therapy (VAT) (Helm-Estabrooks, Fitzpatrick & Barresi,

1982).
2. Promoting Aphasics’ Communicative Effectiveness (PACE) (Davis &
Wilcox, 1981).

The modified VAT programme involved a progression from tracing to match-

ing tasks, to imitating and later independently producing drawings in response
to object presentation, and finally to requesting objects by drawing. In the
modified PACE approach, training progressed from depicting simple concepts
in simple drawings, to complex concepts in simple drawings, and finally to com-
plex concepts in complex drawings. All participants learned to represent con-
cepts effectively, but they did not all attain the same degree of complexity in
their drawings. Trupe concluded that ‘many severely aphasic patients are capa-
ble of learning symbolic communication through drawing when other modali-
ties of communication are unavailable to them’.
DRAWING TO COMMUNICATE 411

Lyon and Sims (1989) described a treatment programme that provides the
clinician with strategies for enhancing the functional drawing skills of people
with severe aphasia. Five aphasic adults participated in a 3-month ‘PACE-like’
drawing treatment programme, in which they were given salient visual contexts
to draw followed by verbal and graphical cueing. Reportedly, they all became
more proficient in their use of drawing to communicate following the training
programme.
Finally, Morgan and Helm-Estabrooks (1987) reported that two adults with
severe aphasia were able to improve their drawing skills substantially through
training in a systematic treatment approach known as ‘Back to the Drawing
Board’ (BDB) (also described in Helm-Estabrooks & Albert, 1991). Patients in
this study improved their ability to depict sequential events and details critical
to those events following treatment with BDB.
The purpose of the following case report is to present several treatment
approaches that proved successful in helping an adult with global aphasia to
communicate more effectively via drawing. Our treatment programme incor-
porated elements from several of the published treatment protocols mentioned
above. I t is our hope that this information will provide clinicians and
researchers with useful ideas for aiding individuals with severe aphasia to use
drawing as a means of expression. Although most of the individual treatment
approaches we used have been previously described, we believe this case
report deserves attention for several reasons. First, many drawing treatment
approaches have not specifically targeted individuals with global aphasia, but
rather people with non-fluent aphasia and good comprehension. Second, we
combined several methods in a particular sequence that may have been impor-
tant to the outcome. Finally, the baseline drawing skills of our case, Mr G, were
quite poor and, therefore, he was not an obvious candidate for treatment using
the drawing modality. This fact is of clinical importance with respect to the
selection of patients who may benefit from drawing treatment.

CASE DESCRIPTION
Mr G is a 61-year-old, right-handed man who developed global aphasia after a
left hemisphere cerebrovascular accident. His aphasia diagnosis was made on
the basis of initial neurological and speechllanguage evaluations, and was con-
firmed during subsequent evaluations conducted at 6-month intervals for 2
years following his stroke. The scan on computed tomography showed a large
left hemisphere lesion that involved both the middle cerebral artery and ante-
rior cerebral artery distributions, affecting many important language areas.
Mr G is married and the father of three grown children. He received an
Associate’s degree in Civil Engineering, and had been employed as a civil engi-
neer for approximately 30 years. He had taken drafting courses, but had no
artistic training or interest according to his wife.
Mr G was initially evaluated at 10 weeks post-onset. He received an aphasia
severity rating of 0.5 on the Boston Diagnostic Aphasia Examination (Good-
glass & Kaplan, 1983), which indicated little or no usable speech or auditory
comprehension. He also received a total score of 27 (out of 61) on the Boston
Assessment of Severe Aphasia (BASA) (Helm-Estabrooks, Ramsberger, Mor-
gan & Nicholas, 1989), a performance in the 50th percentile for global aphasic
478 WARD-LONERGAN AND NICHOLAS

individuals. Mr G was unable to produce any meaningful words; spontaneous

speech consisted only of ‘ah ah’ utterances. No usable speech could be elicited
in any contexts, including singing, repetition or oral reading. In addition, Mr G
showed virtually no ability to communicate via writing or gesturing. He was
unable to write his name and was severely apraxic for both limb and bucco-
facial commands. His drawing of a man on the BASA was not recognisable as a
figure of a person.

TREATMENT PROGRAMME
Mr G began outpatient speech-language treatment at 11weeks post-onset. He
attended therapy twice a week for hour-long sessions for his entire treatment
programme. The prognosis for recovery of usable speech was poor, given the
total absence of change in spontaneous speech in the first two and a half
months, the impossibility of eliciting speech in any context and the location of
his lesion (Naeser, Palumbo, Helm-Estabrooks, Stiassny-Eder & Albert, 1989).
Therefore, Mr G and his family agreed that treatment should focus on non-ver-
bal methods of communication.
Early treatment focused on gestural communication using two approaches:

1. Limb Visual Action Therapy (Helm-Estabrooks et al., 1982).

2. Amer-Ind Gesture training (Skelly, 1979).

He received VAT from 11 to 14 weeks post-onset. VAT was chosen to over-

come limb apraxia as a prerequisite for learning a communicative gestural sys-
tem. In Mr G’s case, this method was discontinued as a result of persistent
visual memory difficulty. He received Amer-Ind Gesture training from 11to 31
weeks post-onset. By the end of this treatment, he was able to execute 20 ges-
tures given a picture stimulus, but no carry-over to functional contexts was
seen.
As a result of this limited response to gestural training, we turned to a differ-
ent non-verbal modality, drawing, as a means of communication for Mr G. His
treatment programme consisted of several techniques presented sequentially
that are elaborated below.

Back to the Drawing Board

BDB (Morgan & Helm-Estabrooks, 1987) was provided from 21 to 44 weeks
post-onset. This treatment approach was chosen to encourage the use of draw-
ing for the purpose of communication. After a pre-test in which the patient is
asked to draw simple scenes that are acted out by the clinician, the treatment
begins by having the patient copy a simple black and white one-panel cartoon.
The qualities of the drawing are discussed and suggestions for improvement,
including demonstrations of alternative ways to draw the picture, are made by
the clinician. Eventually, the patient draws the picture from memory and
advances to more complex cartoons of two and three panels (Figures 14). The
rationale for using cartoons as stimuli is discussed in Morgan and Helm-
Estabrooks (1987). In BDB, only simple black and white line drawing cartoons
are used. They are relatively easy to copy and to recall from memory, and they
are salient because they depict something with humour (Dagge & Hartje,
DRAWING TO COMMUNICATE 419

1985). BDB was chosen as the first element of the treatment programme
because it is highly structured and relies at first on copying skills. At no time
does the patient have to generate a novel image without a model. Mr G pro-
gressed from drawing the one-panel cartoons to the two-panel cartoons in eight
sessions and from the two-panel to the three-panel cartoons in another eight
sessions. He worked on the three-panel cartoons for 11sessions, completing the
entire programme in 27 sessions.

I
I I I

Figure 1:(a) Back to the Drawing Board (BDB) one-panelcartoon stimulus; (b) Mr G’s ini-
tial attempt to memory; (c) Mr G’sfinal, acceptable attempt to memory.

Figure 2: (a) Mr G’spre-BDB pre-test drawing representing a person opening an umbrella;

(b) Mr G’spost-BDB post-test drawing representing the same scene.
480 WARD-LONERGAN AND NICHOLAS
DRAWING TO COMMUNICATE 48 1

Figure 4 (a) Mr G’spre-BDB pre-test drawing representing a person shufling cards and
then spilling them on the floor; (b) Mr G’spost-BDB post-test drawing representing the
same scene.

Drawing treatment using the PACE approach

This approach (Davis & Wilcox, 1981) was provided from 56 to 68 weeks post-
onset, after a 3-month break from treatment because of the patient’s request
(Figures 5-7). The primary goal of this approach is to maximise use of residual
communicative abilities in people with aphasia. It is based upon the belief that
‘any aphasic individual can communicate in some way’ and that patients should
be encouraged to use any one or a combination of modalities to express
intents. This approach also ‘reflects the aim and structure of natural communi-
cation’, by having the clinician and patient serve as both speakers and listeners
in their interactions (Davis & Wilcox, 1981). Mr G received three sessions
using pictured objects as treatment stimuli (Figure 5), five sessions using stick
figure action drawings as stimuli (Figure 6), followed by ten sessions using pho-
tographs as stimuli (Figure 7).
Unlike BDB, in each session of PACE drawing treatment, Mr G was
required to draw pictures to convey information that was unknown to the clini-
cian. This was a critical change from the earlier treatment programme. In BDB,
Mr G learned to produce communicative drawings that could convey sequen-
tial action information, but that information was always first presented as
drawings for him to copy. In the PACE phase of treatment, the stimuli were
more varied and he had to convey information that was not known to the clini-
cian. At the same time, he still had a model (line drawings or photographs) that
482 WARD-LONERGAN AND NICHOLAS

Figure 5: Mr G’s drawings of single objects fromthe PACE phase of treatment.

he could use as a basis for his own drawings. This phase therefore began to
approximate more naturalistic communication situations, without placing too
many demands on Mr G to generate his own images.

Functional Drawing Training

FDT (clinician-designed techniques) was provided from 68 to 169 weeks post-
onset (Figures 8-12). The purpose of this phase of treatment was to promote
more refined drawing skills to enhance functional communication, and to give
h4r G an opportunity to create his own images without any visual models. Gen-
erally, this involved the presentation of verbal and/or written prompts or ques-
tions to elicit a variety of drawings. These scenarios were often accompanied by
gesturing, writing or pantomimes by the clinician, to ensure that Mr G under-
stood what was requested. For example, Mr G was asked to communicate
information about recent events that had occurred in his life or about current
world events (e.g. ‘Show me what you did this weekend’, or ‘Show me what you
saw on the news last night’). He was also requested to draw about earlier per-
sonal experiences or historical events (e.g. ‘Show me something about your
wedding day’, or ‘Show me something about Kennedy’s assassination’). These
tasks were designed to resemble typical conversational interactions that might
occur between two people.
DRAWING TO COMMUNICATE 483

4
Figure 6: Mr Gs drawings of stick figures in action scenes from the PACE phase of treatment.

RESPONSE TO TREATMENT
Mr G made notable improvement in his communication skills over the course
of treatment. On formal testing with the BASA, his performance improved
from 27 (50th percentile for globally aphasic adults) when he was first evalu-
ated to 39 (95th percentile for globally aphasic adults) at one year post-onset,
at which point his formal test performance began to plateau. Subsequent re-
evaluation with the BASA over the second year showed no changes on this
standardised measure. No change was observed in spontaneous speech at any
point, but auditory comprehension and reading comprehension showed
improvements on the BASA within the first year.
484 WARD-LONERGAN AND NICHOLAS

2
,-

Figure 7: Mr G’s drawings of action scenesfrom photographsfrom the PACE phase of

treatment.

I
I

Figure 8: (a) Mr G’s drawing of President Kennedy’s assassination; (b) Mr G’s drawing of
Oswald’s shooting.
DRAWING TO COMMUNICATE

Figure 9 Mr G’s drawing of a current event in the news (art theft by two men masquerading
as policemen at the Isabella Stewart Gardner Museum in Boston, MA).

Figure 10:Mr G’s spontaneous drawing produced at home indicating that a neighbour’s car
headlight needed repair.
486 WARD-LONERGAN AND NICHOLAS

I
I_:
c
Figure 12:Mr G’s drawing of a golfer teeing offat a golf course.
DRAWING TO COMMUNICATE 487

Unfortunately, there are no standardised measures available to assess com-

municative drawing skills in aphasia. However, substantial improvement was
noted in Mr G’s ability to use drawing as a means of effective communication.
During structured treatment sessions, he progressed through the following
hierarchy of treatment tasks: copying and drawing from memory one- to three-
panel cartoons; drawing pictured objects; drawing action scenes of stick figure
stimulus pictures; drawing simple agent-action scenes in photographic stimuli;
drawing events and scenes from memory after watching them acted out by his
therapists; creating drawings to depict various holidays, locations, family fig-
ures and famous people when given verbal and/or visual prompts; and drawing
recent and remote events from memory.
Response to treatment on BDB was measured by comparing drawings from
the pre-test to an identical test given immediately after completion of BDB. At
44 weeks post-onset, after approximately 5 months of therapy, Mr G’s post-
treatment drawings were rated as much more recognisable by a naive judge
(see Figures 2 and 4 for examples of pre- and post-BDB drawings). Mr G’s pre-
treatment drawings were often sketchy and lacking essential details. Many of
these drawings were unrecognisable to the naive judge. The quality of his draw-
ings produced during treatment improved dramatically. Specific improvements
included elaboration of detail in people’s facial and physical features, elabora-
tion of detail in scenic information, improved use of drawing to represent facial
expressions and mood, and improved use of spatial orientation. All of these
changes facilitated the communicative partner’s interpretation of Mr G’s
intents. These improvements are reflected in the drawings produced by Mr G
on the formal post-test (see Figure 4). Although some of the areas that showed
improvement were directly targeted in treatment (e.g. general elaboration of
detail), others emerged spontaneously (e.g. attention to drawing facial expres-
sions).
Similarly, Mr G showed consistent improvement of drawing skills within the
second phase of treatment using the PACE approach. One area that showed
improvement was Mr G’s ability to modify his drawings in response to his com-
municative partner’s need for more information. During treatment Mr G was
introduced to the technique of enlarging portions of previous drawings that
were not clearly recognisable to viewers. This technique was suggested by Lyon
and Sims (1989) in their drawing programme. Enlargement for the purposes of
clarification is evident in Figure 7 in the first picture of a woman sipping
through a straw and in the fourth picture of a man filing his nails.
Improvements were also noted within the final phase of Mr G’s drawing pro-
gramme (Functional Drawing Training). At first, specific scenarios were pro-
vided (e.g. ‘Draw something about the Kennedy assassination’). Figure 8a
illustrates Mr G’s ability to depict such an event and also illustrates his use of
enlargement to clarlfy information, in this case, about the assassin. After com-
pleting this drawing, Mr G was asked, ‘What happened to him?’ as the clinician
pointed to the man with the gun. Figure 8b was Mr G’s response. This drawing
is similar t o the famous photograph of Jack Ruby shooting Lee Harvey
Oswald. Clearly, Mr G’s drawing reflected a visual memory for that famous
photograph. Later in this phase of treatment, more open-ended scenarios were
presented (e.g. ‘Draw something that happened in the news’). Figure 9 shows
488 WARD-LONERGAN AND NICHOLAS

Mr G’s response to such a request; it depicts a robbery that occurred at the

Gardner Museum in Boston, Massachusetts.
Towards the end of his treatment programme, Mr G also began to use some
spontaneous gestures in conjunction with his drawings. He also supplemented
some drawings with limited writing, including first letters of place names and
people’s names, dates and other numerical information. We also began to
observe some generalisation of drawing to his home environment. In one
instance, Mr G tried to indicate that the neighbour’s car headlight needed
repair (see Figure 10). In the drawing on the left, he was trying to show that the
left front headlight was out. When his son did not understand this drawing, he
then drew the side view of the car shown on the right. In Figure 11, Mr G was
trying to express what he wanted for lunch - a sandwich on pumpernickel
bread with potato chips. Again, Mr G demonstrated his ability to draw from
two perspectives. The upper drawing is a top view and the bottom drawing is a
side view of the sandwich.

DISCUSSION
The success achieved by Mr G in using drawing to communicate was probably
related to several factors. One of these factors is the overall organisation and
sequence of his treatment plan that began with a highly structured method
(BDB), progressed to a less structured conversational approach (PACE), and
finally concluded with an unstructured, interactive approach (Functional
Drawing Training). The progression of methods began with less demanding
tasks (copying from a model) and progressed to more difficult tasks (generat-
ing drawings without any visual model). The pragmatic demands of the com-
munication situation also progressed from very few demands in BDB, where
Mr G only had to copy a cartoon and then produce from memory, to situations
where he had to think of an appropriate way to communicate new information,
via drawing, that was unknown to the clinician.
Mr G was able to draw action scenes in all phases of treatment. This finding
is consistent with the notion that one’s daily life experiences are organised
around familiar situational schemata, as opposed to isolated configurations
(Zaidel, 1986). Based on the results of an investigation related to memory for
pictorial scenes in stroke patients, Zaidel suggested that familiar visual situa-
tional schemata may have bilateral representation. This hypothesis is sup-
ported by the fact that Mr G exhibited good recall for real life events and
scenes despite his large left-hemisphere lesion. We also suspect that his ability
to depict figures in action in the PACE approach tasks and in less structured
drawing tasks may have been enhanced by first completing the BDB pro-
gramme.
In general, Mr G s drawings show features that are typical for drawings of
patients with left-hemisphere damage. In contrast to drawings produced by
patients with right-hemisphere damage, which often show a lack of overall con-
tour or gestalt, drawings of left-hemisphere patients often retain correct config-
urational information (Swindell e t al., 1988). Mr G’s drawings were
characterised by good representation of configurational information, spatial
orientation, symmetry and attention to detail. These aspects became increas-
ingly evident as he refined his skills over the course of the treatment pro-
DRAWING TO COMMUNICATE 489

gramme. Larrabee and Kane (1983) reported that drawings of people with left-
hemisphere damage were often symmetrical, but their drawings also were over-
simplified and reduced in size. Swindell et al. (1988) and Gainotti and Tiacci
(1970) found similar qualities in the drawings of their subjects with left-hemi-
sphere damage. In general, Mr G’s drawings show features that are consistent
with these findings.
One feature of Mr G’s drawing that may be unique to him is his excellent
ability to draw from a ‘bird’s eye’ perspective (i.e. aerial view), although he was
never directly asked to draw from this perspective (see Figure 12). This ten-
dency may have been related to his prior training in drafting as an engineer, or
to some general preservation of topographical/geographical knowledge. For
example, adults with global aphasia often show relative preservation of com-
prehension for geographical place names when they have to locate them on a
map (Wapner & Gardner, 1979). Mr G’s response to treatment also supports
the notion that previous artistic training is not a prerequisite for successful use
of drawing for communication (Gardner & Winner, 1981), because Mr G never
had any artistic training or even artistic inclinations before his stroke.
Although we believe that the training programme was a major factor in
improving the quality of Mr G’s drawings, other factors may also have been
important. These include spontaneous recovery, motivation level, persever-
ance, extent of family involvement and emotional state. The ultimate test of
any treatment method designed to improve communication skills is, however,
whether the patient will use these skills in situations outside the therapy room.
In Mr G’s case, he did not often initiate the use of drawing to communicate on
his own, just as he did not initiate communication in other modalities such as
gesturing. We suspect that this lack of initiation might be related, in part, to the
extent of his lesion in the supplementary motor area of the frontal lobe. There
is evidence to suggest that this area is involved in the initiation of communica-
tion as well as of other activities (Penfield & Roberts, 1959; Jurgens, 1984;
Goldberg, 1985), and that it may affect the ability to use non-verbal as well as
verbal means of expression.
However, despite some difficulty with the spontaneous initiation of drawing,
Mr G was able to communicate through drawing when given even limited
encouragement such as offering him a pad of paper and a pen. For patients like
Mr G, who have difficulty initiating communication in any modality, finding a
means of expression such as drawing that they can use to answer questions and
to respond to the communications of others is a worthwhile goal in treatment.
Even when initiation is not an issue, the clinician needs to devise ways to
facilitate carry-over to non-therapy situations. Including the patient’s family
members or other communicative partners in the treatment sessions may be an
important first step. Lyon and Sims (1989) have delineated appropriate ques-
tion formats for communicative partners to use that promote efficient interpre-
tation of unclear drawings. We have found that it is helpful to use drawing
interactively, so that the clinician also uses drawings to ask questions, establish
the context, etc. This is particularly useful for patients like Mr G who may have
severe auditory comprehension impairments and may not be able to under-
stand the questions others ask about their drawings. As with the implementa-
tion of any augmentative communication system, carry-over would probably be
490 WARD-LONERGAN AND NICHOLAS

furthered by systematic extension of the therapy to other locations, to interac-

tions with other people, and to new topics of conversation.
Although the prognosis for recovery of global aphasia is generally consid-
ered to be poor, we believe that this case supports the notion that some indi-
viduals with severe aphasia can improve communication skills with training in
the use of alternative modalities such as drawing. One cannot fail to be
impressed by the drawing ability demonstrated by Mr G, despite his persistent
global aphasia. In 1981 Gardner and Winner concluded that ‘graphic skills can
function independently of linguistic and other left hemisphere skills’. It is our
hope that this case report will inspire future research aimed at identifying sys-
tematic techniques to assist adults with severe aphasia to communicate more
effectively via drawing.

ACKNOWLEDGEMENTS
This paper is partially based on a presentation at the Spaulding Rehabilitation Hospital National
Stroke Rehabilitation Conference, Cambridge, MA, April 1991. We wish to express our apprecia-
tion to Robert J. Duffy, PhD, University of Connecticut, and Angela M. M d a l l a , Bowling Green
State University, for their valuable editorial comments and suggestions.

REFERENCES
Cohen R, Kelter S (1979). Cognitive impairment of aphasics in a color-to-picture matching task Cortex
15: 23545.
Dagge M, Hartje W (1985). Influence of contextual complexity on the processing of cartoons by patients
with unilateral lesions. Cortex 21: 607-16.
Davis GA, Wilcox MJ (1981). Incorporating parameters of natural conversation in aphasia treatment. In:
R Chapey (Ed.), Language Intervention Strategies in Adult Aphasia, pp. 169-93. Baltimore, MA:
Williams & Wilkins.
Gainotti G, Silveri C, Villa G, Caltagirone C (1983). Drawing objects from memory in aphasia. Brain
106: 613-22.
Gainotti G, Tiacci C (1970). Patterns of drawing disability in right and left hemispheric patients. Neuro-
psychologia 8: 379-84.
Gardner H (1982). Art, Mind, and Brain: A Cognitive Approach to Creativity. New York: Basic Books.
Gardner H, Winner E (1981). Artistry and aphasia. In: M Taylor Sarno (Ed.), Acquired Aphasia, pp.
361-84. New York Academic Press.
Goldberg G (1985). Supplementary motor area structure and function: Review and hypothesis. Behav-
ioral and Brain Sciences 8: 567-615.
Goodglass H, Kaplan E (1983). Boston Diagnostic Aphasia Examination, 2nd edn. Philadelphia: Lea &
Febiger.
Hatfield FM, Zangwill OL (1974). Ideation in aphasia: The picture-story method. Neuropsychologia 1 2
389-93.
Hecaen H, Assal G (1970). A comparison of constructive deficits following right and left hemispheric
lesions. Neuropsychologia 8: 289-303.
Helm-Estabrooks N, Albert ML (1991). A Manual of Aphasia Therapy. Chicago: Riverside.
Helm-Estabmoks N, Fitzpatrick PMM, Barresi B (1982). Visual action therapy for global aphasia. Jour-
nal of Speech and Hearing Disorders 4 7 385-9.
Helm-Estabmoks N, Ramsberger G, Morgan AR,Nicholas M (1989). Boston Assessment of Severe Apha-
sia. Chicago: Riverside.
Jurgens U (1984). The efferent and afferent connections of the supplementary motor area. Brain Research
Amsterdam 300: 63-81.
Kimura D, Faust R (1984). ‘Ihe association of aphasidapraxia with drawing disability. Paper presented at
the Academy of Aphasia, Los Angeles, October.
Larrabee GJ, Kane RL (1983). Differential drawing size associated with unilateral brain damage. Neu-
ropsychologia 21: 173-7.
Lyon JG, Sims E (1989). Drawing: Its use as a communicative aid with aphasic and normal adults. In: TE
DRAWING TO COMMUNICATE 491

Prescott (Ed.), Clinical Aphaswlogy: Conference Proceedings, vol. 18, pp. 339-55.Boston: Col-
lege-Hill.
Morgan ALR, Helm-Estabrooks N (1987).Back to the drawing board: A treatment program for nonver-
bal aphasic patients. In: RH Brookshire (Ed.), Clinical Aphasiology: Conference Proceedings, vol.
17,pp. 64-72.Minneapolis: BRK Publishers.
Naeser MA, Palumbo CL, Helm-Estabroob N, Stiassny-Eder D, Albert ML (1989).Severe non-fluency
in aphasia: Role of the medial subcallosal fasciculus plus other white matter pathways in recovery
of spontaneous speech. Brain 112 1-38.
Penfield W, Roberts L (1959).Speech and Brain-mechanisms. Princeton, NJ: Princeton University Press.
Pillon B, Signoret JL, van Eeckhout P, L'hermitte F (1980).Le dessin chez un aphasique: Incidence pos-
sible sur le language et sa &ducation. [Drawing for the aphasic: The possible impact of language
and its reeducation.] Revue Neurologique 136:699-710.
Skelly M (1979).Amer-Ind gestural code based on universal American hand-talk. New York Elsevier.
Swindell CS, Holland AL, F r o m D, Greenhouse JB (1988).Characteristics of recovery of drawing abil-
ity in left and right hand brain damaged patients. Brain and Cognition 7: 16-30.
Tmpe EH (1986).Training severely aphasic patients to communicate by drawing. Paper presented at the
annual convention of the American Speech-Language-Hearhg Association, Detroit, MI, Novem-
ber.
Wapner W, Gardner H (1979).A note on patterns of comprehension and recovery in global aphasia.
Journal of Speech and Hearing Research 22 765-72.
Wapner W, Judd T, Gardner H (1978).Visual agnosia in an artist. Cortex 14 343-64.
Zaidel DW (1986).Memory for scenes in stroke patients. Brain 109:547-60.

Address correspondence to Jeannene M. Ward-Lonergan, Bowling Green State University, Bowling

Green, Ohio,USA.

Received January 1994; revised version accepted January 1995.