Disclaimer: this resource is intended for speech and language therapists and students of this profession. If you require therapy for aphasia please contact a speech and language therapist.
Copy and Recall Treatment (CART)
Summary: Copy and Recall Treatment (CART) (Beeson, 1999; Beeson, Rising, & Volk; 2003) seeks to improve single word writing ability. Clients first copy target written words before being asked to write these from memory. Targeted words are typically functional. CART bears some similarities to Anagram and Copy Treatment (ACT) and some clinicians have combined these approaches (Beeson, Hirsch, &, Rewega, 2002; Helm-Estabrooks & Albert, 2004).
Example:
1) The client is provided the spoken form and a picture of the target word.
2) The client is asked to write the target word.
3) If the client is successful the therapist gives feedback and moves on to the next target.
4) If the client has difficulty writing the target, the therapist provides a written model and the client is asked to copy this at least 3 times.
5) The client’s written attempts to copy the target are removed from view. The client is again provided the spoken form and a picture of the target word and asked to write the target word.
5a) The therapist may wish to ease the client into this recall stage by leaving the written form of the word within view and covering part of the word. The client is then asked to write the target word (e.g. recalling the first two letters, which are not visible, and copying the remaining letters). This is repeated, with the letters being progressively covered, until the client is able to recall the full word.
6) If the client is successful the therapist gives feedback and moves on to the next target.
7) If the client continues to experience difficulty writing the target, repeat steps 4-5. The therapist should monitor the client’s level of frustration and move on to the next target as necessary.
The client may find the following prompts support retrieval of the target written form:
Encourage the client to visualise the written form of the word
Ask the client to first focus on writing the first letter of the target word (offer a phonological cue)
If necessary, the task can be made more challenging by introducing a delay between copying of the model and recall (e.g. short discussion or attempting other target words).
Adapted from Beeson et al. (2003), & Raymer, Cudworth, & Haley (2003).
1) The client is provided the spoken form and a picture of the target word.
2) The client is asked to write the target word.
3) If the client is successful the therapist gives feedback and moves on to the next target.
4) If the client has difficulty writing the target, the therapist provides a written model and the client is asked to copy this at least 3 times.
5) The client’s written attempts to copy the target are removed from view. The client is again provided the spoken form and a picture of the target word and asked to write the target word.
5a) The therapist may wish to ease the client into this recall stage by leaving the written form of the word within view and covering part of the word. The client is then asked to write the target word (e.g. recalling the first two letters, which are not visible, and copying the remaining letters). This is repeated, with the letters being progressively covered, until the client is able to recall the full word.
6) If the client is successful the therapist gives feedback and moves on to the next target.
7) If the client continues to experience difficulty writing the target, repeat steps 4-5. The therapist should monitor the client’s level of frustration and move on to the next target as necessary.
The client may find the following prompts support retrieval of the target written form:
Encourage the client to visualise the written form of the word
Ask the client to first focus on writing the first letter of the target word (offer a phonological cue)
If necessary, the task can be made more challenging by introducing a delay between copying of the model and recall (e.g. short discussion or attempting other target words).
Adapted from Beeson et al. (2003), & Raymer, Cudworth, & Haley (2003).
Evidence Base: Beeson et al. (2002) report 2 case studies where Anagram and Copy Treatment (ACT) was delivered alongside a CART homework programme and a further 2 case studies where a CART homework programme was carried out. All subjects had significant aphasia and severe agraphia. Positive item-specific results were reported for all subjects. Beeson et al. observe that a CART homework programme alone can result in similar positive outcomes to ACT delivered alongside a CART homework programme. They note, however, that each approach has features that will suit different clients. For example, ACT involves a supportive cueing heirarchy while CART may be carried out predominantly at home with less clinical support.
Beeson et al. (2003) delivered CART to eight participants with severe aphasia (7 with Broca’s, 1 with Wernicke’s) during a 10-12 week direct therapy and homework programme (direct therapy was delivered once per week during this period) followed by an additional 4 week homework programme. Up to 20 written words were targeted during this period. Results show that 4 participants exhibited a strong positive response to CART, i.e. mastering at least 80% of words targeted during direct therapy and mastering additional words during the following 4 week homework period. Of the remaining participants, 3 demonstrated some level of positive response and 1 showed a poor response to therapy. Factors associated with successful outcomes were: accurate/consistent homework completion, an ability to distinguish words from nonwords, a relatively preserved semantic system, and adequate nonverbal visual problem-solving abilities. Little generalisation was observed to untrained words.
Raymer et al. (2003) explored whether words learned using CART would generalise to similar untrained words. In this single case study of a subject with severe agraphia CART was delivered during twice-weekly 90 minute therapy sessions and daily homework tasks over 3 months. In addition to improved spelling of targeted words, findings showed an improvement in spelling of untrained words - particularly words with similarities to words targeted during therapy. For example, Raymer et al. note that following CART training of the target ‘puddle’ the subject showed improved ability to write the corresponding letter sequences in the untrained words ‘pudding’ and ‘cradle’.
Ball et al. (2011) delivered a modified form of ACT and CART incorporating spoken repetition to 3 participants with severe aphasia and apraxia of speech. Following a 3 month programme, all participants showed positive results in their ability to write words targeted in treatment. However, no improvements were found in spoken naming of these targets.
Beeson et al. (2003) delivered CART to eight participants with severe aphasia (7 with Broca’s, 1 with Wernicke’s) during a 10-12 week direct therapy and homework programme (direct therapy was delivered once per week during this period) followed by an additional 4 week homework programme. Up to 20 written words were targeted during this period. Results show that 4 participants exhibited a strong positive response to CART, i.e. mastering at least 80% of words targeted during direct therapy and mastering additional words during the following 4 week homework period. Of the remaining participants, 3 demonstrated some level of positive response and 1 showed a poor response to therapy. Factors associated with successful outcomes were: accurate/consistent homework completion, an ability to distinguish words from nonwords, a relatively preserved semantic system, and adequate nonverbal visual problem-solving abilities. Little generalisation was observed to untrained words.
Raymer et al. (2003) explored whether words learned using CART would generalise to similar untrained words. In this single case study of a subject with severe agraphia CART was delivered during twice-weekly 90 minute therapy sessions and daily homework tasks over 3 months. In addition to improved spelling of targeted words, findings showed an improvement in spelling of untrained words - particularly words with similarities to words targeted during therapy. For example, Raymer et al. note that following CART training of the target ‘puddle’ the subject showed improved ability to write the corresponding letter sequences in the untrained words ‘pudding’ and ‘cradle’.
Ball et al. (2011) delivered a modified form of ACT and CART incorporating spoken repetition to 3 participants with severe aphasia and apraxia of speech. Following a 3 month programme, all participants showed positive results in their ability to write words targeted in treatment. However, no improvements were found in spoken naming of these targets.
References
Ball, A.L., de Riesthal, M., Breeding, V.E., & Mendoza, D.E., 2011. Modified ACT and CART in severe aphasia. Aphasiology, 25(6-7), 836-848
Beeson, P.M., 1999. Treating acquired writing impairments: Strengthening graphemic representations. Aphasiology, 13(9-11), 767-785
Beeson, P.M., Hirsch, F.M., & Rewega, M.A., 2002. Successful single-word writing treatment: Experimental analyses of four cases. Aphasiology, 14(4-6), 473-491
Beeson, P.M., Rising, K., & Volk, J., 2003. Writing treatment for severe aphasia: Who benefits? Journal of Speech, Language, and Hearing Research, 46(5), 1038-1060
Helm-Estabrooks, N. & Albert, M.L., 2004. Manual of aphasia therapy. Austin, TX: PRO-ED
Raymer, A., Cudworth, C., & Haley, M., 2003. Spelling treatment for an individual with dysgraphia: Analysis of generalisation to untrained words, Aphasiology, 17(6-7), 607-624
Ball, A.L., de Riesthal, M., Breeding, V.E., & Mendoza, D.E., 2011. Modified ACT and CART in severe aphasia. Aphasiology, 25(6-7), 836-848
Beeson, P.M., 1999. Treating acquired writing impairments: Strengthening graphemic representations. Aphasiology, 13(9-11), 767-785
Beeson, P.M., Hirsch, F.M., & Rewega, M.A., 2002. Successful single-word writing treatment: Experimental analyses of four cases. Aphasiology, 14(4-6), 473-491
Beeson, P.M., Rising, K., & Volk, J., 2003. Writing treatment for severe aphasia: Who benefits? Journal of Speech, Language, and Hearing Research, 46(5), 1038-1060
Helm-Estabrooks, N. & Albert, M.L., 2004. Manual of aphasia therapy. Austin, TX: PRO-ED
Raymer, A., Cudworth, C., & Haley, M., 2003. Spelling treatment for an individual with dysgraphia: Analysis of generalisation to untrained words, Aphasiology, 17(6-7), 607-624