Aphasia Assessments Explained: From the Western Aphasia Battery to Quality of Life

 Language assessments after stroke are not all the same, and the type of test a clinician chooses directly affects what gets measured and what gets missed. This episode breaks down the difference between impairment-based assessments like the Western Aphasia Battery and participation-based assessments like the Communication Activities of Daily Living, and explains why that distinction matters for survivors. Dr. Seles walks through how aphasia intersects with cognition and why quality-of-life assessments belong in every evaluation. Angie shares the real benefits and challenges of completing language assessments from the survivor's side of the table. Dr. Seles closes with three concrete tips for speech-language pathologists supporting survivors with low social support and reduced quality of life. For SLPs, students, survivors, and care partners who want to understand what gets tested, what gets missed, and what good assessment actually looks like. In this episode of Brain Friends, we discuss language assessments used in individuals with aphasia and acquired communication disorders. 
 
Angie shares the benefits and challenges in completing language assessments and which type of assessment is beneficial to recovery. 
 
Dr. Seles discusses the difference between impairment-based tests like the Western Aphasia Battery (WAB) and participation-based tests like the Communication Activities of Daily Living (CADL). 
 
Together we discuss the importance of quality-of-life assessments and how aphasia impacts cognition. Finally, Dr. Seles shares 3 tips for Speech-Language Pathologists (SLP) to help survivors navigate low social support and quality of life.

https://www.cognitiverecoverylab.com/seles

https://aphasia.org/stories/announcing-the-davetrina-seles-gadson-health-equity-grant-program/

Our beloved colleague, Dr. Davetrina Seles Gadson, passed away January 11, 2025. Dr. Gadson was an extraordinary speech-language pathologist and neuroscience researcher who devoted her energy to studying health disparities in aphasia recovery. She was a fierce advocate for improving services for individuals with aphasia, particularly Black Americans. Her research transformed our understanding of these health disparities and shed light on how we can address them. We were privileged to have Dr. Gadson as a cherished member of our lab community for four years, first as a postdoctoral fellow and then as an Instructor of Rehabilitation Medicine. She was still a close collaborator and friend to many of us at the time of her passing. Dr. Gadson was an incredible person—compassionate, inspiring, and full of life. Her dedication to advancing equity in aphasia recovery and her profound impact on our community will never be forgotten. We are committed to honoring her memory by continuing to push our field forward and fight for equitable services for all people with aphasia. 

Transcript

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SPEAKER_01 0:00

Welcome to Brain Friends, where two neuronerds talk all things aphasia, language recovery, culture, and community. I am Dr. Datrina Celeste Gatson, a clinical speech language pathologist and neuroscientist.

SPEAKER_00 0:13

And I am Angie Cawthorn, stroke survivor and aphasia advocate. Welcome to our show. Welcome to Brain Friends.

SPEAKER_01 0:24

We want to thank all of our listeners for downloading the podcast. We appreciate everyone listening. So please tell a friend to tell a friend that we are here. And we are. Okay, you ready? Go ahead. Okay, so here's the icebreaker. Okay. Name something, or is there anything that you ever really wanted to do, but Mother Nature stopped it? Mother Nature told you no. Oh goodness.

SPEAKER_00 0:54

I wanted I went to a wedding in Dinapolis for a friend of mine. And I wanted to come back home from this wedding. And it was the blizzard of 96 in Philadelphia. And it was like it the snow was uh really, really high. Like I couldn't find my car. Snow. Like it was crazy. And I was um in uh at my friend's wedding from college, and it was it was beautiful there. There's no problems there, but I'm watching the news. So Mother Nature was like, nah, you're gonna have to sleep in the train station because we were kids, right? So everybody's poor, we're all poor. And so they were on their honeymoon, right? So they had no place for me to stay to put me up. The other friends that they came in, we had all dispersed, and I ran out of money, and so I had to call to call a friend of mine, like, yo, I need you to wire me $50 because $50 was making all the difference in 1996. Wow, to get home, to get home and to have a little bite to eat on the train. It was bananas, so mother nature stopped me from going home. So, what about you? What has mother nature stopped you from doing what you needed to do?

SPEAKER_01 2:36

So, one time, and this is still true to this day, I wanted to go skydiving. And the first two uh I tried three times, and each time, Mother Nature, it was some element of mother nature that stopped me. Like the first time it was raining, the second time the wind was too strong, and the third time we ran out of time before it became dark, so we wouldn't have had enough time to go up and down, and so that was something to where it was like, Well, I really want to go, but I feel like Mother Nature has stopped.

SPEAKER_00 3:16

I'm gonna say that's God, I'm gonna stop you right there, ma'am. Ma'am, ma'am, ma'am. I'm gonna stop you right there. Yeah, okay. That is God saying, boop, sit your butt down, baby. Sit your butt down. We're not doing this, right?

SPEAKER_01 3:29

Because then if I had an accident, it would have been like, I told you three times not to go. This is not Disney. This ain't no Disney when the third time things work out. This is not a Disney enemy. Three times, and each time there was a mother nature element that that was our father, yeah. So now I feel like maybe I'll just try the indoor skydiving.

SPEAKER_00 3:53

Yeah, do what you gotta do. Okay. Uh, first of all, I have Scott. Oh, did I go parachute? I did something, and I was like, Y'all can keep this money, y'all need to put me down. Yeah, when I got up there, I was like, Yeah, this is not for me. This was a terrible mistake, and y'all can actually just keep can y'all just drop me off anywhere. Can was it with a boat?

SPEAKER_01 4:15

Like paragliding, paragliding, or parachute, I guess is paragliding or parachuting. Like, I I know something.

SPEAKER_00 4:24

Angelique ain't had no business doing. Okay. I was like, put me down, put me down, please. And I mean, I did it because I'm a boss, but yeah, I was like, Yeah.

SPEAKER_01 4:35

Let's get into today what we're talking about. And I think that you kind of hinted at it because you said that you've been busy a lot doing things. So today I want us to kind of dive into and talk about assessments.

SPEAKER_02 4:50

Yes.

SPEAKER_00 4:51

So I do a lot of research um uh work. Like I take when studies come up to help researchers do stuff in Asia, I I raise my hand. I'm like, whatever I can do to help, and it's helped me tremendously. And but every time I go, I have to take a test. And I've taken the test quite frankly, at this point, so many times, I feel like I'm not a good candidate for that test anymore. You know, um, so they have um do they have other tests? I know there's the WAB, which is the what's it called?

SPEAKER_01 5:36

Western aphasia battery, and then there's the cattle, right? The cattle, which is the communication activities for daily living. Right now, the cattle is newer, is that right? Right, and it and it measures it measures something different, you know. The cattle is looking at your ability to use communication within uh activities of daily living, and so whether it's making a phone call or you know, doing something with scheduling, so it's gonna look at your ability to use communication within you know your environment versus the Western aphasia battery is looking more at the impairment level of your aphasia. So what body structures are impacted, what your ability to repeat is or to understand, versus your ability to like participate in something.

SPEAKER_00 6:40

So, like the cattle would be more of a LPAA model.

SPEAKER_01 6:46

Yeah, you could say that. Yeah, and LPAA looks at the life participation approach to aphasia, yes, because it's looking at the cattle, is looking at how you participate, how you're able to do activities. Um, but I kind of wanna you say that you're not good for the Western Aphasia battery. What why aren't you good for it?

SPEAKER_00 7:10

Well, because I there's parts of it at this point I'm actually aware of. Like I know they're gonna ask me to say um, you know, how many animals begin with the letter S. Like I know that's a question. If I already know that's a question, I'm primed to give a good answer.

SPEAKER_01 7:31

You've been at home practicing.

SPEAKER_00 7:35

Right, right. And here's the problem. My innate um, my flex is I don't want to be wrong. Like it's I it's it's you know, so now it's my pride is in there. It's almost like I know the cheat sheet to the test of a test that I don't necessarily want to pass or fail. I just want to do it, but I don't want to throw off you guys' work, the researchers' work by already knowing the answers, but I've already taken the test a thousand times. So I don't know the answer, but I remember the answer. Do you eat a banana before you peel it? I don't know. Do I what? See, well, that's they don't ask me that, I don't think.

SPEAKER_01 8:23

Yes, that's sort of the auditory comprehension. Yes, no.

SPEAKER_00 8:28

Oh, do I peel and eat food before I eat it? I peel it before I eat it. Yes. Do you eat a banana before you peel it? I do not know. I don't know. I'm not getting what you're saying. So one of the assessments do I peel? Say it again.

SPEAKER_01 8:53

Do you eat a banana before you peel it? No, after. Yeah. So no would be that. Yeah. Ah. So okay. So maybe in some ways, that Western aphasia battery, depending on what the subtest is, there could still be some room. Right.

SPEAKER_00 9:18

Ah, well, now you're just trying to show, well, that I ain't as good as a lot of people. No, no, no.

SPEAKER_01 9:25

No, no, no, no. Because one of the things that you were explaining that I think is so important for everyone to hear is that how those tests, especially the Western aphasia battery, a lot of people use it because it's reliable, meaning that I can give it to you now, do therapy, give it to you later, and it's reliable enough to show your improvement. So that tests, retests, reliability is what we call it. But what you're explaining is happening is a testing effect, essentially, meaning that you've learned so many parts of the test that you know you know it because you know it, not necessarily because I know it.

SPEAKER_00 10:12

Right, right, right, right. I remember it. It's like there you go. I know I remember five times five is 25, but I no longer know the five times five. Like I remember because my father drilled that into my head. But, you know, or and they also made us learn tiny tables in that way. But you know, it's one thing to know something, and it's another thing to remember it. And I, you know, so I I found that very, you know, some of the parts like they have the story in it, and with they take the wob as it's um, because I have aphasia, but I also feel like I have cognitive impairment, and I don't know if the cognitive impairment is more than the aphasia, or is the aphasia the definition of my cognitive impairment?

SPEAKER_01 11:16

Mmm. Ooh, you're saying a lot of good stuff. So when you say that you have cognitive impairment, tell me what some of those cognitive challenges are.

SPEAKER_00 11:30

My reading, my short-term memory is my ability to understand a task and complete it. Um my follow-through is ridiculously not where I need it to be. And I realize I go in, I'm getting news now, where there's I might have been a time where I told you I'm feeling better, I feel so much better, I'm getting smarter, I feel it. And then a week later, I'm back where I was. And I'm so, and I don't know if that's just regular little depression kicking in, right? I feel like I'm the same, but you know what I mean? But yet I so I don't know if that's neuroplasticity kicking in, and things are are happening in my brain in a good way, and that's why I'm having this boost, and then I go back down to my baseline.

SPEAKER_01 12:25

You know what I'm saying? Go back down to your baseline when you're doing assessments or just in your day-to-day, just in my day-to-day.

SPEAKER_00 12:33

Day to day in my in cooking, you know. Um, it's still as much as I love baking, it's still not as a good flow as I know as it should be. For as much as I do it, I should have a much better cognitive, not cognitive, consistent, no, I should be better at it. And my flow should be better.

SPEAKER_01 12:59

Okay, so I'm in like full, I mean, we are talking about assessment, so the clinician in me is kind of kicking in a little bit. I love it. Come on, clinician, come on, SLP. The SLP in me. So when you say your flow, are you talking about the reading of the recipes, the sequencing of the steps?

SPEAKER_00 13:23

The sequencing of the steps, the reading of the recipe, the knowing I already know the recipe. First of all, why am I looking at a recipe? It's not that deep. You know what I mean? Like, you should already, you should, as much as I just made some sticky buns to two days ago, they were bangers. Um, yes, they were, but I'm still looking at my recipe. Like, I've I don't know, I feel like at before the stroke, I didn't need the recipe. Yeah, and that's so that's to me, that's my baseline, right? And now, seven years later, even though I'm much better, I can't get anything done without looking at it 20 times. And my flow and my sequencing is not as, and every once in a while it'll feel like I got this, and that's when I'm like, Dr. Celeste, I'm feeling so much better. Look at me.

SPEAKER_02 14:21

Yeah, and then I'm like, get the sound effects out.

SPEAKER_01 14:28

Well, this is so good. I'm glad that you're sharing because you're right. When you're looking at the sequencing aspect of it, that is cognition. So that's your executive function, your ability to organize and sequence steps versus your reading part of the recipe can be linked to your aphasia given where the damage is. And so, one thing that I would challenge you to do to help with your neuroplasticity is maybe try to do it without the recipe or say to yourself, you know what? Okay, I'm cooking, I'm only gonna look at this recipe five times, or set a certain number for yourself, and then practice the cognition piece would be practicing, remembering whatever it is, whether it's the ingredients or which step is next. And you might mess up one, but the more you do that, that can help build the neuroplasticity and get you stronger and being able to not use the recipe if that's a goal.

SPEAKER_00 15:34

Here's the issue. Here's my personality uh flaw. I don't have the patience for it not to be right. Oh well. I just I it it it would it would bother me more that it's not right. And um yeah, yeah, I get what you're saying, and but I don't have patience for it not to be right.

SPEAKER_01 15:58

Like so that means you need to give yourself grace then for using the recipe because that is what gives you more peace.

SPEAKER_00 16:11

You're right, no, you're right, and I should give myself more grace and give myself more grace, you're right. No, you're absolutely right on that, and that's that's that's good stuff. That's good stuff.

SPEAKER_01 16:23

Okay, all right. Yeah. Now, just curious, out of the another test besides the Western aphasia battery, have you ever done the Boston Diagnostic Aphasia exam?

SPEAKER_00 16:38

That sounds familiar. What does that one look like?

SPEAKER_01 16:41

So it's the it's it's the same in the sense of it looks at the impairment of aphasia versus your participation or how you use communication. So sometimes people might use the Western aphasia battery, sometimes people might use the Boston Diagnostic Aphasia exam. And there are some other ones that are coming into play because of the, I don't want to say overuse, especially because if the web wants to sponsor us, hey, we're here.

SPEAKER_00 17:20

But the hall I didn't know that was a thing. I love the WAB.

SPEAKER_01 17:25

It's a thing. But the hallmark, you know, you know, and I've said this in one of the manuscripts that we've published, which is that the West the WAB, the Western aphasia battery is often used as a hallmark exam. And I don't know if this is public knowledge, but aren't you doing some things with it to help minimize the potential assessment bias related to the um WAB because it hasn't really been normed in a diverse group?

SPEAKER_00 18:02

I am actually working on a uh a project that's coming up, and their aphasia team is working on uh trying to fix some of the inherent biases of the WAB. Um, and because some of those pictures, uh, first of all, not only are they terribly drawn, okay, like, but they are really don't depict uh the cultural differences that are seen in American life. And to test American life, but you're not testing the full spectrum, right, is an inherent bias of the tests, and so they might think we don't communicate well, or they might score slower uh based off of a cultural difference of the person that's given the test. Right. So we're trying to eliminate some of that.

SPEAKER_01 18:52

I think that's so awesome. That's one of the things that we said in a manuscript that we published where we found that the Western aphasia battery um had a by a baseline um bias. It wasn't statistically significant as far as the raw numbers, but one of the reasons why we saw a difference between the groups, we looked at black and white, was that potentially um that when you give these picture description tasks that aren't necessarily relevant to different cultures, then with individuals with aphasia, you can be you can make it more of like a code switching or vocab semantic recall versus actual the individual pulling words from the vocabulary that they know. They're thinking, like, oh, well, what was that? I've seen that before. What was that called? Right, right. I'm like, uh-huh, okay. Let me no, don't say uh-huh, because if you don't get it, then somebody else ain't.

SPEAKER_00 20:06

Well, see, this is what I'd be trying to tell you. I am slower than I present. Like people tell me all the time, like I say, about my reading, and I discussed this with you before as well. Like, I can read, but the words don't really make it in. So they say, Well, so listen to a book, do an audio book. It still doesn't make it in, it's my comprehension. I can read the words, I can read the words in somewhat of a sentence. I can get that, it's fine, but they the whole story doesn't come. The whole movie doesn't come, the whole book, even if I'm listening to it, doesn't come on the first or second time. I can be watching a TV show, I have no idea who these characters are, or if they're not the same person, or like so, you know, don't let it be a cool movie where people are doing stuff and then somebody else and they do a flashback. Oh, I'm done. I have no idea what's going on. Oh, because I can't cognitively, that has I don't know that has nothing to do with aphasia, that's just brain damage, right?

SPEAKER_01 21:14

Yeah, you know, I think that that's one of the challenges with some aphasia research that looks at cognition is because some of these things are related to cognition, but if an individual is unable to say it like how you just communicated it, then it's hard for me to one understand that that's the issue. You get what I'm saying? So the like for an example. Okay, you got it. Okay. So an example would be sometimes when you ask, like in the earlier assessments, if you ask somebody in the hospital, you know, orientation questions like Where are you? Why are you here? You have to be mindful that their ability to answer it is based on their aphasia versus their cognition of it, meaning like being able to remember. Right. Because they could possibly know where they are, the cognitive part, they know where they are, but they're not able to say it.

SPEAKER_00 22:26

And we are not judged by what we know. We are choosed by we are judged by what we can prove we know. Right. And if I can't say it, I don't know it. Right. And that's just that's just the way this, that's just the way this part of the game is played. So I'm judged on, you know, that cognitive part that can be gone, or is it my phasia, or do we just box it all up and call it aphasia because it has to have a name? Because if it's mild cognitive impairment, that sounds like a road to dementia.

SPEAKER_01 23:02

Well, that sounds like a new episode. Come through a new episode. That sounds like a new episode. But I think the thing is, is you know, we've talked about this before where you where people say it's not a loss of intellect, it's a loss of the ability to say the word.

SPEAKER_02 23:17

Yeah.

SPEAKER_01 23:17

And I know you have pushback on that. And so we could definitely talk about that when we talk about malcognitive impairment. But I think where the disconnect is, is that sometimes it is cognition and not just the point that you can't say what you want to say. But the hallmark sign of aphasia is that you know what you want to say, you just can't produce it because of the verbal or the expression piece of it, which that production piece is what really is the differentiating factor of aphasia versus because someone with cog cognition, they might not, they they might not even be able to remember or know what they want to say. So it's not that the word, it's not that they can't produce the word, the word's not even there.

SPEAKER_00 24:13

That sounds legit too, but I mean there is a part of I it's that tip of the tongue feeling, or you know, sometimes like if a person is playing like a trivia game and you know the answer, like um a music, what song is that? And you have that I know the song, I just hold on, I can't, it's I know the song. You live in that I know what I want to say with aphasia all the time. But the cognition part of it of the memory and how things are just messed up in your brain, it it can't. I I'm sorry, I'm getting off uh thought. I'm sorry. Sorry.

SPEAKER_01 24:57

That's okay.

SPEAKER_00 24:58

I don't know how to fix that.

SPEAKER_01 25:01

Well, I think that this has been a great time to talk about assessments and the need to diversify assessments, especially the impairment-based ones. Just a follow-up question out of those two, the Western Aphasia battery and the cattle. Um, another one that I like a lot is the ALA, which is the um assessment for living with aphasia. It also looks at participation. I was gonna ask you, out of those two, the cattle and the western aphasia battery, did you like one more than the other? The cattle. Why?

SPEAKER_00 25:45

Um I found it to be more um more of a challenge. Ooh, I found it to be more of a challenge. Um and uh now that you explained to me what they are and the differences, I can and I just took them like two days ago, and I took them both. I see what you're saying about one being assessment and one asking me, like, how do you get to the bank? Or this is going to be on TV, find this on the you know, um, you know, versus um, you know, whatever's on the wob with the picture of the tree and the fireman coming to get the little the man out the tree because the little girl ain't in the tree. He went up there to get the cat. Again, if I know that three days later, it's not really a test. Right. If I remember, even though I don't know nothing about peeling no banana and when I'll eat it.

SPEAKER_01 26:47

Now you case now you came through, Dr. Okay, Dr. Celeste. No, I mean that just goes to show how that test is used so much, like to the point where I can I've given that test so many times to where I can just say them. I can like just the questions live in my mind. Rent free. Definitely rent-free. Um, last question what about quality of life tests? So um outcomes that ask you about how you feel, how you're able to, you know, navigate like the your perception of how aphasia has impacted your life. Did you take any of those types of assessments?

SPEAKER_00 27:36

There was a one test where she asked me um, like if you needed somebody to look after you, do you have someone to look after you? And it was a scale of one to five.

SPEAKER_01 27:47

Okay, sounds like a social support.

SPEAKER_00 27:50

Yeah, and I remember I answered five on all of them. And uh she was like, Wow, that's amazing that you have answered the five to everything.

SPEAKER_01 28:01

Yeah. Did you like that type of test?

SPEAKER_00 28:04

Yeah, well, because I'm answering five, uh I mean, so yeah, it was great for me, but a person that's answering one or two to all the questions, it's that's just that's not making them feel good at the end of that test. I felt I came out feeling amazing because it just reaffirmed that I have somebody to look after me and I have friends, and I have a purpose of being. Yes. But if a person doesn't, we just put in their face for a good five minutes, tell me everything that's wrong in your life, that social assessment, like uh you know what I mean? So it's yeah, it was great for me, right?

SPEAKER_01 28:46

Well, I don't, I know it's I know we're out of time, but it's so I'm so grateful to hear that you did that type of assessment too, because as someone who is really about those types of tasks, the social support, I feel like if you were a person that answered two and one in some of the lower numbers, as a therapist, that would tell me that we need to try to structure your therapy and communication in a context that helps you participate with people or not be as isolated because then you can get depression and all these other things if you don't have a sense of purpose or you do feel like you don't have the social support.

SPEAKER_00 29:36

Yeah, yeah. It's um I wouldn't even know how would you as a as a therapist, how does that even, you know, if you find out that somebody is, and I know I'm pretty sure you guys would be like, man, dated reporters, but how would you even know if somebody's giving you ones and twos and you're like, uh oh, this is this person is you know in a darker place than I thought, and you only have eight weeks anyway, you haven't even given the cattle yet. How do you juggle that as a practitioner?

SPEAKER_01 30:15

Well, I would do it in a couple of ways. One way would be to of course asking the patient first before you're, you know, going and doing these things, but reaching out to social workers to see if they're able to kind of like help support some way in that, um, whether it's through community service programs or just any additional advice that they can give. I would definitely do a neuropsychology consult to make sure that that individual has the mental support that's necessary navigating something like this individually. And then as a therapist, besides those two things, I would really just try to get the person involved in groups or see if there was an opportunity to instead of just doing individual therapy sessions, if we could do a group therapy session like once a week, if they're coming twice a week to kind of give that level of camaraderie and just um that the person wasn't going to give them.

SPEAKER_00 31:25

Yeah, that is good stuff. Thank you, Dr. Celeste. This has been so good. Yes, thanks, Angie. Bye. Appreciate it.

SPEAKER_01 31:59

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