This article was downloaded by: [Universidad De Concepcion]

On: 14 August 2014, At: 17:23

Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office:
Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Aphasiology
Publication details, including instructions for authors and subscription
information:
http://www.tandfonline.com/loi/paph20

CAC classics
a b c
Craig W. Linebaugh , Rebecca J. Shisler & Leslie Lehner
a
The George Washington University , Washington , DC , USA
b
University of Georgia , Athens , GA , USA
c
Evanston , IL [no professional affiliation]
Published online: 11 Jun 2012.

To cite this article: Craig W. Linebaugh , Rebecca J. Shisler & Leslie Lehner (2005) CAC classics,
Aphasiology, 19:1, 77-92, DOI: 10.1080/02687030444000363

To link to this article: http://dx.doi.org/10.1080/02687030444000363

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the Content)
contained in the publications on our platform. However, Taylor & Francis, our agents, and our
licensors make no representations or warranties whatsoever as to the accuracy, completeness,
or suitability for any purpose of the Content. Any opinions and views expressed in this
publication are the opinions and views of the authors, and are not the views of or endorsed
by Taylor & Francis. The accuracy of the Content should not be relied upon and should be
independently verified with primary sources of information. Taylor and Francis shall not be liable
for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other
liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in
relation to or arising out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Any substantial
or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or
distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use
can be found at http://www.tandfonline.com/page/terms-and-conditions
 APHASIOLOGY, 2005, 19 (1), 7792

CAC Classics

Cueing hierarchies and word retrieval: A therapy program

Craig W. Linebaugh
The George Washington University, Washington, DC, USA
Rebecca J. Shisler
University of Georgia, Athens, GA, USA
Downloaded by [Universidad De Concepcion] at 17:24 14 August 2014

Leslie Lehner
Evanston, IL [no professional affiliation]

Background: Lexical retrieval impairments are pervasive among persons with aphasia, and a
great deal of effort has been expended to develop effective treatments for these impairments.
This study introduced the cueing hierarchy approach to treating impaired lexical retrieval.
Aims: The purpose of this study was to develop a new treatment approach in which cues of
increasing stimulus power were presented sequentially, contingent upon participant
responses and to provide preliminary evidence regarding the effectiveness of the cueing
hierarchy approach.
Methods & Procedures: Five single-subject experiments were conducted in which persons
with a significant lexical retrieval impairment participated in a treatment regimen involving
the systematic use of a cueing hierarchy comprised of both semantic and phonological cues.
Participants' performances were measured on both trained and untrained stimuli.
Outcomes & Results: Four of the five participants achieved improved naming performance
on trained stimuli and three also showed generalization to untrained stimuli.
Conclusions: Although the interpretation of the results is limited by what are now recognized
as significant flaws in the experimental design, the results were sufficiently robust and
promising to provoke many other investigators to examine the effectiveness of the cueing
hierarchy approach. Through the efforts of these investigators, cueing hierarchies employing
a variety of cues have been demonstrated to be an effective intervention for a number of
different aphasic lexical retrieval impairments.

Authors' commentary: Introduction

When this paper was first published in 1977, we asserted that more rehabilitative
effort might have been directed towards the word retrieval impairments of persons
with aphasia than towards any other aphasic impairment. More than 25 years later

Address correspondence to: Craig W. Linebaugh, Academic Planning and Development, Rice Hall, Suite
602, The George Washington University, Washington, DC 20052, USA. Email: cline@gwu.edu
Originally published in: Brookshire, R. H. (Ed.). (1977). Clinical Aphasiology Conference Proceedings (pp.
1931). Minneapolis, MN: BRK Publications.
The authors wish to thank the editors of Aphasiology for undertaking the republication and updating of
papers from early Clinical Aphasiology Conferences. We also wish to thank the clinical aphasiologists who have
helped to demonstrate the effectiveness of the cueing hierarchy treatment approach for a variety of aphasic
language impairments.

# 2005 Psychology Press Ltd

http://www.tandf.co.uk/journals/pp/02687038.html DOI:10.1080/02687030444000363
 78 LINEBAUGH, SHISLER, LEHNER

this may still be the case (see Nickels & Best, 1996a, 1996b, for a review),
although wisely, clinical aphasiologists have directed a great deal of clinical and
research effort towards the functional communicative consequences of aphasia.
In 1977, programmed stimulation (LaPointe, 1977) was in its early stages of
evolution as an approach to aphasia rehabilitation. At that time, many clinicians
were developing task continuua in which patients progressed through a series of
treatment tasks based on their reaching an established criterion on each task.
Linebaugh and Lehner developed the cueing hierarchy approach as a means of
bringing a greater degree of control to the application of external facilitators in
aphasia therapy, and to bring greater efficiency to the language intervention pro-
cess. This paper was the first discussion of the cueing hierarchy approach to
aphasia rehabilitation conducted at a professional meeting.
Downloaded by [Universidad De Concepcion] at 17:24 14 August 2014

The dimension of aphasic impairment which has perhaps had more rehabilitative effort
directed toward it than any other is the near universal reduction in available vocabulary.
The clinical literature is replete with reports of therapeutic approaches which have been
successfully employed in reducing the word-finding difficulties of aphasic patients (e.g.,
Wiegel-Crump & Koenigsknecht, 1973; Croskey & Adams, 1969; Keenan, 1966), as well
as reports of strategies which these patients employ spontaneously in their efforts to
retrieve a desired word (Marshall, 1976). The present paper is a consideration of the
rationale and development of a treatment program which employs and seeks to expand on
the basic principles of the programmed stimulation approach to aphasia rehabilitation. In
addition, the program seeks to foster the use and generalization of the retrieval strategies
employed by our aphasic patients. Along with the description of the word-retrieval
program, the performance of five of our patients who have participated in it will be
discussed.

RATIONALE AND DEVELOPMENT

Two principles formed the basis and guided the development of the word-retrieval
program. The first principle is an extension of the generally accepted concept that the
essence of aphasia rehabilitation is the elicitation of a response. It is suggested that the
recovery process is best served by eliciting the desired response with a minimal cue.
Thus, in order to achieve maximum benefit from each stimulus presentation, we seek to
have our patients retrieve the desired word with no more external facilitation than is
essential.
In order to implement this principle, the concept of ``stimulus power'' as described by
Bollinger and Stout (1976) was incorporated. Factors such as the number of repetitions,
number of input modalities, contextual constraints, and the form in which these constraints
are provided (e.g., descriptive statement, sentence completion) were considered. In the
development of the program, cues were drawn from three areasverbal, gestural, and
articulo-phoneticand hierarchically arranged according to stimulus power (see below: A
Cueing Hierarchy). What is crucial to note here is that stimulus power is relative to each
individual patient; thus the cueing hierarchy that is appropriate for one patient may not be
appropriate for another. It is essential, therefore, in implementing this therapeutic
approach, that the stimulus power of a wide variety of cues be assessed for a particular
patient, and that the cueing hierarchy for each patient be individually structured.
The cueing hierarchy then becomes the means by which the first principle is imple-
mented, for it dictates the order in which successive cues are provided. The cue of lowest
 CUEING HIERARCHIES AND WORD RETRIEVAL 79

stimulus power is presented first, followed by increasingly powerful cues until the desired
response is elicited. Note that in this manner the retrieval of the desired word is achieved
by presentation of the least powerful cue capable of eliciting the response.
The second principle which was employed in developing the word-retrieval program is
a modification of the concept of stimulus fading. It was felt that the repeated elicitation of
the appropriate response with successively less powerful cues would not only provide a
highly salient positive reinforcement, but would also optimally stimulate the processes
underlying the recovery of the word retrieval process. Thus instead of fading the stimulus
over a number of sessions contingent upon reaching criterion at various levels of task
difficulty, we chose to fade the stimulus, i.e., reduce the stimulus power, immediately
upon elicitation of the appropriate response. As will be described in the next section, this
was accomplished by reversing the process of providing increasingly powerful cues after
the desired word had been elicited. Thus, once the clinician has worked down the hier-
Downloaded by [Universidad De Concepcion] at 17:24 14 August 2014

archy until the patient retrieves the appropriate word, the clinician then works back up
presenting cues of decreasing power with the patient producing the word at each level.
While a repetitive component to this task exists, it is felt that its effect is minimized by
not permitting the patient to respond until the complete stimulus has been given. Fur-
thermore, at levels 2 and 3 of the hierarchy presented below, the patient is required to
produce the stimulus as well as the response. It is suggested that similar levels be
included in all cueing hierarchies based on Marshall's (1976) description of the word
retrieval strategies employed by aphasic patients and the teaching of ``self-generated
cues'' by Berman and Peelle (1967). Indeed, the strategies individual patients are
observed to employ spontaneously may be incorporated into their hierarchies. In this
way, the use and generalization of such strategies may be fostered.

Authors' commentary: Development and Rationale

The cueing hierarchy approach was developed based on the authors' model of word
retrieval in which a ``cognitive representation'' of the entity to be named, whether
evoked by an object or a picture, served as the input to a process of word retrieval;
that is, activation of a target semantic representation in the speaker's lexicon. The
lexical semantic representation, in turn, served as the input to a process in which a
phonological representation was either selected or generated (we chose not to cross
that bridge in 1977!). The critical assumption in development of the cueing hier-
archy approach was that processing at either the semantic or phonological level
could be influenced by external stimuli or cues.
Many, far more sophisticated, models of lexical retrieval have been articulated
since the publication of the original paper; however, most are consistent with the
rationale upon which the cueing hierarchy approach was developed. Both discrete
two-stage models (Levelt, 1992) and interactive models (e.g., Dell, 1986; Hum-
phreys, Riddoch, & Quinlan, 1988; Martin, Dell, Saffran, & Schwartz, 1994) posit
cognitive-linguistic processes that may be influenced by external stimuli or cues.
Thus, the cueing hierarchy approach, which seeks to ``inject'' facilitation at as
``high'' a level as possible in the model, i.e., as early as possible in the cognitive
processing involved in word retrieval, is compatible with more recent theories
regarding word retrieval. Moreover, within interactive models, the effects of cues
thought to influence processing at the phonological level (e.g., first phoneme,
rhyming word) may be expected to facilitate semantic-level processing as well.
 80 LINEBAUGH, SHISLER, LEHNER

A CUEING HIERARCHY

Table 1 lists the ten levels of the hierarchy. At level one, the patient is presented with a
line drawing of an item and asked ``What's this called?'' This cue is of minimal sti-
mulus power and serves only to orient the patient to the task. If the patient is unable to
respond, the patient is asked to state what one does with the item or to think about what
one does with it (level 2). Level 3 requests the patient to demonstrate the function. At
level 4, the clinician states the function of the object followed by the lead-in phrase
``It's a'' (e.g., You drink coffee from this. It's a . . .). At level 5, the clinician adds a
gesture to the function statement. The next four levels all involve sentence completion
with an increasing amount of information supplied at each level. Level 6 is an open-
ended statement (e.g., ``you eat soup with a . . .''). At level 7, the first phoneme of the
Downloaded by [Universidad De Concepcion] at 17:24 14 August 2014

target word is silently articulated by the clinician. If the patient is still not able to
produce the desired response, the first phoneme of the word is vocalized following the
sentence completion stimulus (level 8). At level 9, the sentence completion item plus
the first two phonemes of the word are produced. Level 10 requests the patient to
imitate the word.
Successive levels of the hierarchy are presented until the patient produces the desired
word. Once the appropriate response has been elicited, the order of stimulus presenta-
tion is reversed. Beginning with the level at which the word was elicited, the cues are
then presented in the order of successively decreasing stimulus power through level one.
If at any level the patient is unable to respond, the order of stimulus presentation is
again reversed and successively more powerful cues provided until the word is pro-
duced. Then the order is once more reversed. Experience to date suggests that most
patients can go up the hierarchy without requiring the second reversal. When it has been
necessary to go back down the hierarchy, a less powerful cue is generally required to
elicit the response. Rarely is it necessary to reverse the order of stimulus presentation
more than once.
Going up the hierarchy is considered an important aspect of the program in that it
permits the patient to respond to cues of decreasing stimulus power. At levels 2 (stating
the function) and 3 (gesturing the use of the object), many patients can be taught to use
these cues as a self-cueing device. It is not unusual for a patient to use a gesture to assist
himself in producing a word in subsequent sessions.

TABLE 1
A cueing hierarchy

1. ``What's this called?''

2. Directions to state the function of the item.
3. Directions to demonstrate the function.
4. Statement of the function by the clinician.
5. Statement and demonstration of the function by the clinician.
6. Sentence completion.
7. Sentence completion + the silently articulated first phoneme of the response.
8. Sentence completion + the vocalized first phoneme.
9. Sentence completion + the first two phonemes vocalized.
10. Say ``______.''
 CUEING HIERARCHIES AND WORD RETRIEVAL 81

PROCEDURE
Entrance criteria
Patients selected for the program met the following criteria: (1) no more than one literal
paraphasic error per word on imitation, (2) a Z score of 0 or below on the visual
confrontation naming subtest of the Boston Diagnostic Aphasia Examination (BDAE)
(Goodglass & Kaplan, 1972), (3) errors on at least 75% of the items presented on a pre-
probe, and (4) an average Z score not lower than 1 on the auditory comprehension
subtests of the BDAE. Additionally, all patients were at least one month post onset when
the program was initiated.

Training and generalization lists

Downloaded by [Universidad De Concepcion] at 17:24 14 August 2014

The words employed in the program included 20 with a frequency of occurrence of 50

times per million and 20 with a frequency of less than 50 times per million (Thorndike &
Lorge, 1944). Additionally, words were selected which were presented in a pre-probe,
during which the cues were presented in order of decreasing stimulus power to determine
the level at which the patient was able to respond.
Following the pre-probe, a training list consisting of five high frequency words and
five low frequency words was selected. During each session, the 10 items were presented
with the cueing hierarchy employed in the manner described above. The high and low
frequency words were alternately presented.
A second list composed of 10 high and 10 low frequency words was also selected.
These words were not part of the training list and were presented after every five therapy
sessions in order to assess generalization.

Program termination criteria

The program was terminated when either of the following conditions occurred: (1) the
patient demonstrated no improvement for three consecutive generalizations or (2)
accurate responses were elicited at levels 1, 2, or 3 on 80% of the generalization items for
three consecutive generalizations.

Modification of the training list

The training list was modified when accurate responses were elicited at levels 1, 2, or 3
on the same five of the ten training words for five consecutive sessions. When this
occurred, three of the five words were replaced with words in the same range of fre-
quency of occurrence.

Authors' commentary: Procedure

The cueing hierarchy

The cueing hierarchy employed in the original study contains perhaps the largest
number of levels reported in the literature. The large number of levels (10) was the
result of including a variety of cues that had been observed in clinical practice to
facilitate word retrieval by persons with aphasia.
Levels 25 of the cueing hierarchy were aimed at evoking semantic features of
the target word and thereby facilitating activation of its lexical semantic
 82 LINEBAUGH, SHISLER, LEHNER

representation. Semantic information has been shown to facilitate word retrieval

(Howard, Patterson, Franklin, Orchard-Lisle, & Morton, 1985) and to be an
effective agent in aphasia rehabilitation (Boyle & Coehlo, 1996; Drew &
Thompson, 1999). Levels 2 and 3 were also included to leverage both the facil-
itative (Berman & Peelle, 1967) and communicative (Tompkins & Marshall, 1982)
value of self-generated cues. Levels 69 incorporated the well-demonstrated
facilitative effects of sentence completion cues (Barton, Maruszewski, & Urrea,
1969; Goodglass & Stuss, 1979), while levels 8 and 9 invoked the high stimulus
power of phonological cues (Pease & Goodglass, 1978).
In recent years, investigators have employed cueing hierarchies that include
semantic or phonological cues, but not both. Wambaugh and colleagues (Wam-
baugh, 2003;. Wambaugh, Doyle, Linebaugh, Spencer, & Kalinyak-Fliszar, 1999;
Wambaugh, Linebaugh, Doyle, Martinez, Kalinyak-Fliszar, & Spencer, 2001) have
Downloaded by [Universidad De Concepcion] at 17:24 14 August 2014

examined the relative effectiveness of semantic and phonological hierarchies for

patients whose aphasic impairments were primarily at either the semantic or
phonological processing level. In general, the two types of hierarchies have proven
effective for both types of patients.
It is interesting to note that much of the discussion that followed presentation of
the original paper at the 1977 Clinical Aphasiology Conference focused on
development of the 10-level hierarchy. The authors asserted then, and have con-
tinued to assert (Linebaugh, 1997), that cueing hierarchies should be individualised
according to patients' patterns of impairment and responsiveness to different cues.
Several investigators (Hillis, 1989, 1998; McNeil, Doyle, Spencer, Jackson, Flores,
& Small, 1998; Raymer, Thompson, Jacobs, & le Grand, 1993) have employed
hierarchies designed to address specific patient characteristics. All of these studies
reported improved performance for trained words, and several reported general-
ization to untrained words.

Experimental control

The investigators in the 1977 study sought to maintain some degree of

experimental control by conducting regular probes (every fifth session) on a
list of untreated items and by seeking to replicate their findings across partici-
pants. A degree of control was maintained for participants BH and CS who
showed improvement for trained stimuli, but only minimal gains on untrained
stimuli. Participants MS and KH showed substantial gains on both trained and
untrained stimuli, while participant TT showed substantial improvement on the
untrained, generalisation stimuli but essentially no change on trained stimuli.
As a result, experimental control was maintained for only two of the five
participants.
The study also suffers from a lack of certain important controls now expected in
single-subject experiments. Most notably, the investigators conducted only a single
pre-treatment probe, rather than establishing a stable baseline of pre-treatment
performance on both the training and generalisation words. Other important aspects
of treatment efficacy studies that might have been employed in this study include
measures of performance maintenance and measures of generalisation to more
complex linguistic structures and to functional communication tasks. Inclusion of a
set of ``exposure control'' stimuli to which the participants are exposed as
 CUEING HIERARCHIES AND WORD RETRIEVAL 83

frequently as the treatment stimuli, but without direct intervention to facilitate

accurate responses, would also have added an important element of experimental
control (Linebaugh, Baron, & Corcoran, 1998).

RESULTS
Individual patients
Patient MS is a 70-year-old man, who suffered the onset of aphasia in April, 1974. At the
onset of the treatment program, he had a raw score of 33 (Z = .75) on the visual
confrontation naming subtest of the BDAE and correctly identified only three of the 40
items on the pre-probe. As shown in Figures 1 and 2, respectively, MS showed an
Downloaded by [Universidad De Concepcion] at 17:24 14 August 2014

improvement of approximately two levels on both the training and generalization items
over 25 therapy sessions. In addition, the number of items correctly identified at level l
increased steadily. Finally, it should be noted that during the course of the program, MS's
ability to employ gestures improved and he adopted the strategy of restructuring ques-
tions into a sentence completion form for self-cueing. Although MS demonstrated
improvement, his performance became stable over three generalizations and the program
was discontinued.
Patient BH is a 72-year-old woman who has had aphasia since September, 1975. Prior
to the initiation of the word retrieval program, she had a raw score of 27 (Z = .9) on the
visual confrontation naming subtest of the BDAE and was able to identify two of the pre-
probe items. Over 20 sessions, BH has shown an improvement of approximately two
levels on the training words (Figure 3) and one level on the generalization list (Figure 4).
The self-cueing strategy which she employs most effectively is gesture.

Figure 1. Patient MS's performances on high and low frequency training words.
Downloaded by [Universidad De Concepcion] at 17:24 14 August 2014

Figure 2. Patient MS's performances on high and low frequency generalization words.

Figure 3. Patient BH's performances on high and low frequency training words.
84
 CUEING HIERARCHIES AND WORD RETRIEVAL 85
Downloaded by [Universidad De Concepcion] at 17:24 14 August 2014

Figure 4. Patient BH's performances on high and low frequency generalization words.

Patient CS is a 52-year-old male, who has been aphasic since December, 1975. At the
beginning of the treatment program, he had a raw score of 0 on the visual confrontation
naming subtest of the BDAE and correctly identified only one of the items on the pre-
probe. Figure 5 shows that his performance on the training items improved by
approximately one level over fifteen sessions. Figure 6, which charts his generalization
scores, reveals a modest gain over the first ten sessions. His poor performance on the
generalization following session 15 may be attributed to any of a wide range of factors.
Patient TT is a 67-year-old male who has been aphasic since March of 1977. At one
month post onset, TT scored 27 (Z = .1) on the visual confrontation naming subtest of
the BDAE and named 10 of the items on the pre-probe. As shown in Figure 7, TT's
performance on the training items was highly variable. Figure 8 shows that he has
improved nearly 4 levels on the generalization list. TT continues to participate in the
therapy program and more frequently uses gestures and function cues to assist himself
with word retrieval.
KH is a 46-year-old female, who first developed aphasia in January, 1977. Because
she became easily frustrated during formal testing, we did not administer the visual
confrontation naming subtest. Her score on the responsive naming subtest of the BDAE
was 9 of a possible 30, and she correctly identified 4 of the items on the pre-probe. Figure
9 is a display of KH's performance on the training items over five sessions. As shown,
she steadily improved over the five sessions, changing her mean score by three levels on
the training items. Figure 10 shows her performance from the initial pre-probe to the first
generalization, approximately one month later. On this generalization, she responded
accurately on l5 of the items. KH's substantial improvement during the one month in
which she participated in the program is striking. Perhaps the highly structured nature of
the program contributed to the reorganization of her language skills. During the initial
Downloaded by [Universidad De Concepcion] at 17:24 14 August 2014

Figure 5. Patient CS's performances on high and low frequency training words.

Figure 6. Patient CS's performances on high and low frequency generalization words.
86
Downloaded by [Universidad De Concepcion] at 17:24 14 August 2014

Figure 7. Patient TT's performances on high and low frequency training words.

Figure 8. Patient TT's performances on high and low frequency generalization words.
87
Downloaded by [Universidad De Concepcion] at 17:24 14 August 2014

Figure 9. Patient KH's performances on high and low frequency training words.

Figure 10. Patient KH's performances on high and low frequency generalization words.
88
 CUEING HIERARCHIES AND WORD RETRIEVAL 89

therapy session, she was frustrated by the hierarchy, apparently because she rarely suc-
ceeded until several cues had been presented. However, as she worked back up the
hierarchy, KH experienced success and learned to use sentence completion cues as a self-
cueing device. Unfortunately, the patient moved following the first generalization and
was unavailable for additional follow-up.

Training vs. generalization words

Three of the five patients (MS, TT, KH) showed substantial improvement on the gen-
eralization words. Indeed, KH and TT showed substantially greater improvement on the
generalization words than on the training words. In addition, nearly all of our patients
have shown greater improvement on low frequency as opposed to high frequency words.
We interpret these findings as an indication that the program facilitates the word retrieval
Downloaded by [Universidad De Concepcion] at 17:24 14 August 2014

process as a whole rather than merely facilitating the recall of those specific words which
are worked on in therapy.

Authors' commentary: Results

The results of the original study revealed that the participants' responses to the
treatment were generally positive, though varied. Three participants (BH, CS, KH)
improved approximately two levels on the cueing hierarchy for trained high-fre-
quency words. Two of these same participants (BH, KH), plus a third (MS)
improved at least two levels for trained low-frequency words. Participant TT's
responses on the trained stimuli were equivocal. Three of the participants (MS, TT,
KH) also showed improvement on both high- and low-frequency generalisation
words, while two participants (BH, CS) showed minimal change on the general-
isation probes. While improved performance on the untrained generalisation sti-
muli negates a level of experimental control as noted above, it does attest to the
potential effectiveness of the treatment approach to facilitate word retrieval as a
process, rather than merely improving performance on specific trained words. The
most puzzling result was provided by TT, who showed no stable change on the
training words, yet displayed substantial improvement on the generalisation words.
An important factor in interpreting the participants' performances on the
untrained stimuli is the manner in which the generalisation probes were conducted.
The probes were conducted using the cueing hierarchy, with the cues presented
sequentially until the participant produced an accurate response as in the treatment
portion of the study, but the cues were not presented in order of decreasing stimulus
power after production of an accurate response. At the time, the investigators were
interested in determining if the participants would produce accurate responses to
less powerful cues on untrained stimuli, and did not believe that presentation of the
cues every fifth session to assess performance on the untrained stimuli would
directly improve retrieval of these words. Contrary to this belief, the results of
more recent studies that employed ``one-way'' hierarchies (Raymer et al., 1993;
Thompson & Kearns, 1981) suggest that use of the cueing hierarchy during the
probes may have influenced performance on the untrained stimuli. In retrospect, an
unadorned visual confrontation naming task might have constituted a more
appropriate probe task.
Improved performance on the training stimuli was replicated across four of the
five subjects. Fortunately, these results proved sufficiently promising to provoke a
 90 LINEBAUGH, SHISLER, LEHNER

number of other clinical aphasiologists to undertake studies employing cueing

hierarchies. Many of these studies have shown cueing hierarchies to be effective in
improving word retrieval (see Patterson, 2001, for a review).

FUTURE DIRECTIONS
In addition to applying the word retrieval program as it is presently constituted to a larger
number of patients, we plan to investigate the efficacy of a number of variations. A wider
assortment of cues (e.g., partial and complete graphic representations, paired associa-
tions) will be employed along with different procedures for stimulus fading. From this we
hope to develop more comprehensive guidelines for the utilization of cueing hierarchies
and increase the overall efficiency of the program. In addition, we are currently exploring
Downloaded by [Universidad De Concepcion] at 17:24 14 August 2014

the use of cueing hierarchies for areas of deficit other than word retrieval.

Authors' commentary: Future directions

In the years since 1977, a number of investigators have taken up the suggestion to
employ a wider assortment of cues. First letters (Best, Howard, Bruce, & Gate-
house, 1997), anagrams (Hillis, 1998) and non-word rhymes (Wambaugh et al.,
2001) have all been used in cueing hierarchies that enhanced word retrieval.
Some successful extensions of the cueing hierarchy approach have also been
introduced. Building on work that examined the relative effectiveness of active and
passive prestimulation on word retrieval (Varholak & Linebaugh, 1995), Line-
baugh et al. (1998) combined active prestimulation with a cueing hierarchy to treat
word retrieval impairments. Wambaugh and colleagues (Wambaugh, 2003;
Wambaugh et al., 1999, 2001) combined active prestimulation with cueing hier-
archies that focused on either semantic or phonologic impairments. McNeil, Small,
Masterson, and Fossett (1995) combined cueing hierarchy intervention with
pharmacological intervention in treating a patient with primary progressive apha-
sia. All of these studies reported positive results using the cueing hierarchy
approach.
So what of ``future'' future directions? The cueing hierarchy approach will
benefit from the same types of investigation as will most other approaches to
aphasia rehabilitation. In particular, additional research directed towards identi-
fying those persons whose language impairments are most amenable to cueing
hierarchy intervention will contribute significantly to providing the most effective
treatment to specific patients. The optimal timing post-onset for employing cueing
hierarchy based treatment as opposed to other types of intervention also will
contribute to the efficacy of rehabilitation efforts. Finally, exploring the neural
responses to cueing hierarchy intervention using brain imaging or electro-
physiological techniques may guide further refinements in the application of this
treatment approach.

REFERENCES FOR THE 1977 PAPER

Berman, M., & Peelle, L. M. (1967). Self-generated cues: A method for aiding aphasic and apractic patients.
Journal of Speech and Hearing Disorders, 32, 372376.
Bollinger, R. L., & Stout, C. E. (1976). Response-contingent small-step treatment: Performance based com-
munication intervention. Journal of Speech and Hearing Disorders, 41, 4049.
 CUEING HIERARCHIES AND WORD RETRIEVAL 91

Croskey, C. S., & Adams, M. R. (1969). A rationale and clinical methodology for selecting vocabulary stimulus
material for individual aphasic patients. Journal of Communication Disorders, 2, 340343.
Goodglass, H., & Kaplan, E. (1972). The assessment of aphasia and related disorders. Philadelphia: Lea &
Febiger.
Keenan, J. S. (1966). A method for eliciting naming behavior from aphasic patients. Journal of Speech and
Hearing Disorders, 31, 261266.
Marshall, R. C. (1976). Word retrieval behavior of aphasic adults. Journal of Speech and Hearing Disorders, 41,
444451.
Thorndike, E. L., & Lorge I. (1944). A teacher's word book of 30,000 words. New York: Columbia University
Press.
Wiegel-Crump, C., & Koenigsknecht, R. A. (1973). Tapping the lexical store of the adult aphasic: Analysis of
the improvement made in word retrieval skill. Cortex, 9, 410417.

COMMENTARY REFERENCES
Downloaded by [Universidad De Concepcion] at 17:24 14 August 2014

Barton, M. I., Maruszewski, M., & Urrea, D. (1969). Variation of stimulus context and its effect on word-finding
ability in aphasics. Cortex, 5, 351365.
Berman, M., & Peelle, L. M. (1967). Self-generated cues: A method for aiding aphasic and apractic patients.
Journal of Speech and Hearing Disorders, 32, 372376.
Best, W., Howard, D., Bruce, C., & Gatehouse, C. (1997). Cueing the words: A single case study of treatments
for anomia. Neuropsychological Rehabilitation, 7, 105141.
Boyle, M., & Coehlo, C.A. (1996). Application of semantic feature analysis as a treatment for aphasic dysnomia.
American Journal of Speech-Language Pathology, 4, 9498.
Dell, G. S. (1986). A spreading activation theory of retrieval in language production. Psychological Review, 93,
283321.
Drew, R. L., & Thompson, C. K. (1999). Model-based semantic treatment for naming deficits in aphasia.
Journal of Speech, Language, and Hearing Research, 42, 972989.
Goodglass, H., & Stuss, D. T. (1979). Naming to picture versus description in three aphasic subgroups. Cortex,
15, 199211.
Hillis, A. E. (1989). Efficacy and generalization of treatment for aphasic naming errors. Archives of Physical
Medicine and Rehabilitation, 70, 632636.
Hillis, A. E. (1998). Treatment of naming disorders: New issues regarding old therapies. Journal of the
International Neuropsychological Society, 4, 648660.
Howard, D., Patterson, K., Franklin, S., Orchard-Lisle, V., & Morton, J. (1985). The facilitation of picture
naming in aphasia. Cognitive Neuropsychology, 2, 4980.
Humphreys, G. W., Riddoch, M. J., & Quinlan, P. T. (1988). Cascade processes in picture identification.
Cognitive Neuropsychology, 5, 67103.
LaPointe, L. L. (1977). Base-10 programmed stimulation: Task specification, scoring, and plotting performance
in aphasia therapy. Journal of Speech and Hearing Disorders, 42, 90105.
Levelt, W. J. M. (1992). Accessing words in speech production: Stages, processes and representations. Cog-
nition, 42, 122.
Linebaugh, C. W. (1997). Lexical retrieval problems: Anomia. In L. L. LaPointe (Ed.), Aphasia and related
neurogenic language disorders (2nd ed., pp. 112132). New York: Thieme.
Linebaugh, C. W., Baron, C. R., & Corcoran, K. J. (1998). Assessing treatment efficacy in acute aphasia:
Paradoxes, presumptions, problems and principles. Aphasiology, 12, 519536.
Martin, N., Dell, G. S., Saffran, E. M., & Schwartz, M. F. (1994). Origins of paraphasias in deep dysphasia:
Testing the consequences of a decay impairment to an interactive spreading activation model of language.
Brain and Language, 47, 609660.
McNeil, M. R., Doyle, P. J., Spencer, K., Jackson, G., Flores, D., & Small, S. L. (1998). Effects of training
multiple form classes on acquisition, generalization and maintenance of word retrieval in a single subject.
Aphasiology, 12, 575585.
McNeil, M. R., Small, S. L., Masterson, R. J., & Fossett, T. R. D. (1995). Behavioral and pharmacological
treatment of lexical-semantic deficits in a single patient with primary progressive aphasia. American Journal
of Speech-Language Pathology, 4, 7687.
Nickels, L., & Best, W. (1996a). Therapy for naming disorders (Part I): Principles, puzzles, and progress.
Aphasiology, 10, 2147.
Nickels, L., & Best, W. (1996b). Therapy for naming disorders (Part II): Specifics, surprises, and suggestions.
Aphasiology, 10, 109136.
 92 LINEBAUGH, SHISLER, LEHNER

Patterson, J. (2001). The effectiveness of cueing hierarchies as a treatment for word retrieval impairment. ASHA
Special Interest Division-2 Newsletter, 11(2), 1117.
Pease, D. M., & Goodglass, H. (1978). The effects of cueing on picture naming in aphasia. Cortex, 14, 178189.
Raymer, A. M., Thompson, C. K., Jacobs, B., & le Grand, H. R. (1993). Phonological treatment of naming
deficits in aphasia: Model-based generalization analysis. Aphasiology, 7, 2753.
Thompson, C. K., & Kearns, K. P. (1981). An experimental analysis of acquisition, generalization, and
maintenance of naming behavior in a patient with anomia. In R. H. Brookshire (Ed.), Clinical Aphasiology
Conference Proceedings (pp. 3545). Minneapolis: BRK Publishers.
Tompkins, C. A., & Marshall, R. M. (1982). Communicative value of self-cues in aphasia. In R. H. Brookshire
(Ed.), Clinical Aphasiology Conference Proceedings (pp. 7582). Minneapolis: BRK Publishers.
Varholak, S. E., & Linebaugh, C. W. (1995). Comparison of active versus passive prestimulation in the
treatment of anomia. Clinical Aphasiology, 23, 253266.
Wambaugh, J. L. (2003). A comparison of the relative effects of phonologic and semantic cueing treatments.
Aphasiology, 17, 433441.
Wambaugh, J. L., Doyle, P. J., Linebaugh, C. W., Spencer, K. A., & Kalinyak-Fliszar, M. (1999). Effects of
Downloaded by [Universidad De Concepcion] at 17:24 14 August 2014

deficit-oriented treatments on lexical retrieval in a patient with semantic and phonological deficits. Brain
and Language, 69, 446450.
Wambaugh, J. L., Linebaugh, C. W., Doyle, P. J., Martinez, A. L., Kalinyak-Fliszar, M., & Spencer, K. A.
(2001). Effects of two cueing treatments on lexical retrieval in aphasic speakers with different levels of
deficit. Aphasiology, 15, 933950.