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Journal of Speech and Hearing Disorders, Volume 54, 113-124, February 1989
THE COMMUNICATIVE
EFFECTIVENESS
INDEX:
DEVELOPMENT
AND PSYCHOMETRIC EVALUATION OF A
FUNCTIONAL COMMUNICATION
MEASURE FOR ADULT
APHASIA
JONATHAN L O M A S
L A U R APICKARD
McMaster University, Hamilton, Ontario, Canada
STELLA BESTER
HEATHER ELBARD
Chedoke-McMaster Hospitals,
Hamilton, Ontario, Canada
ALAN FINLAYSON
Chedoke-McMaster Hospitals and
McMaster University, Hamilton, Ontario, Canada
CAROLYN ZOGHAIB
Chedoke-McMaster Hospitals,
Hamilton, Ontario, Canada
Groups of aphasic patients and their spouses generated a series of communication situations that they felt were important in
their day-to-day life. Using criteria to ensure that the situations were generalizable across people, times, and places, we reduced
the number of situations to 36 and constructed an index that allowed the significant others of 11 recovering and 11 stable aphasic
individuals to rate their partners' performance in the situations on two occasions 6 weeks apart. These data were then used to
evaluate the psychometric properties of the Communicative Effectiveness Index (CETI) as a measure of change in functional
communication ability. Further application of a generalization criterion reduced the final index to 16 situations. Results- showed
the CETI to be internally consistent and to have acceptable test-retest and interrater reliability. It was valid as a measure of
functional communication according to the pattern of correlations found with other measures (Western Aphasia Battery, Speech
Questionnaire, and global ratings). Finally, it was responsive to functionally important performance change between testings.
Further research with the CETI and its usefulness for clinicians and researchers are discussed.
Historically, the focus of aphasia assessment has been
on language abilities with general communicative abilities as only a secondary consideration. Furthermore,
assessment instruments have been validated with more
concern for their ability to discriminate aphasic from
nonaphasic performance or one aphasia type from another
than for their ability to detect change in the severity of the
aphasia over time. The development of an instrument
with the intent to measure change does not guarantee that
it will actually measure change (Kirshner & Guyatt, 1985;
MacKenzie, Charlson, DiGioia, & Kelly, 1986).
Despite these historic trends there has been increased
interest recently in measuring pragmatic communication
skills in aphasia and to do this in the context of withinpatient evaluation of change rather than between-patient
discrimination (Behrmann & Penn, 1984; Beukelman,
Yorkston, & Lossing, 1984; Holland, 1977; Houghton,
Pettit, & Towey, 1982; Milton, Prutting, & Binder, 1983).
We were particularly interested in a measure of functional communication that could document the evolution
in aphasic individuals of both language and nonlanguage
solutions to the communication problems encountered in
day-to-day living. The existing instruments developed to
measure this area of aphasic performance (Holland, 1980;
© 1989, American Speech-Language-Hearing Association
Lincoln, 1982; Sarno, 1969) are all unsatisfactory for one
or more of the following reasons: They are incomplete in
their documentation of psychometric properties (Skenes
& McCauley, 1985), correlate poorly with observation of
nonverbal communication (Behrmann & Penn, 1984), are
not easy for the assessor to either administer or score
(Houghton et al., 1982; Swisher, 1979), correlate so well
with existing language measures (Holland, 1980) that
they are probably not measuring any separate dimension
of communication, and have not been shown to be sensitive to functionally important change over time. Therefore, we developed a measure of functional communication for the adult with aphasia that could measure change
in performance over time--the Communicative Effectiveness Index (CETI).
Based on previous work in the area of disease-specific
quality of life measures (Guyatt, Bombardier, & Tugwell,
1986; Kirshner & Guyatt, 1985), we established a set of
properties that the instrument should possess. These
properties were relevant both to the development of
items and the structure of the index, as well as to the
evaluation of the index, During development we asked
ourselves the following questions:
113
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0022-4677/89/5401-0113501.00/0
114 Journal of Speech and Hearing Disorders
Are both verbal and nonverbal communication assessed?
Are patients' values reflected in the instrument?
Is performance in daily living assessed?
Is the instrument credible to users (face validity)?
Is the instrument simple and easy to administer?
For the evaluation of the index we answered the following questions:
Is there a quantitative measure of change?
Is the instrument reliable (i.e., is it reproducible across
time, people, and places)?
Is the instrument valid (i.e., does it really measure the
stated dimension of functional communication)?
Is the instrument responsive (i.e., does it measure
functionally important change even if this change is
small)?
These properties or criteria are quite similar to those
proposed by the American Psychological Association as
standards for test development (APA, 1974) and are used
by others in their critical appraisals of language assessment tools (McCauley & Swisher, 1984; Skenes & McCauley, 1985).
METHOD
lndex Structure
In deciding on the structure of the index we wished to
ensure that performance (not potential) of communication
in daily living was assessed. To do this one must directly
observe, or get reports of direct observation of, the aphasic individual in actual communication situations. Alternatively, one might role-play such situations with the
aphasic patient. Holland (1980), in her Communicative
Abilities in Daily Living, chose the role-playing option;
Sarno (1969), in her Functional Communication Profile,
assumed that the clinician-assessor would have some
direct observation experience of the aphasic patient's
performance. However, we wanted our instrument to be
simple and easy to administer and therefore rejected the
role-playing option. Furthermore, we were not confident
that clinician-assessors generally observe the aphasic
patient in daily-living situations; thus, they might confuse
potential with performance. Therefore, we rejected direct
observation by the clinician. We opted for reports from
direct observation made by the aphasic individual's significant other (i.e., spouse, relative, neighbor, or friend)
who spends enough time with him or her to make accurate judgments of communication performance.
Because the purpose of the CETI is to quantitatively
assess change in performance over time, the spouses' or
significant others' judgments were structured as ratings of
the aphasic person's performance in particular situations
on a 10-cm visual analogue scale (VAS). To emphasize
that we were interested in performance relative to premorbid ability of the individual, not relative to some
absolute standard, the anchor on one end of the scale was
not at all able and at the other end was as able as before
54
113-124
February 1989
the stroke. We selected the VAS (rather than a Likert-type
scale) because we believed it to be particularly sensitive
to changes in performance over time (Bond & Lader,
1974).
Because the focus of the CETI was on change in
performance rather than absolute level of performance,
significant others rated the aphasic partner on the communication situations on a series of different occasions.
The difference in ratings from one assessment to the next
(the change score) was the score of interest. On the basis
of recent research showing that the size of the change
score is unaffected but the variance around it is reduced
when raters are allowed to see their ratings from previous
occasions (Guyatt, Berman, Townsend, & Taylor, 1985),
we decided to adopt this strategy for the administration of
the CETI. Raters therefore saw on the VAS where they
had rated the performance of the aphasic person on their
previous assessments for each communication situation
(see Figure 1).
Index Content
To ensure that the communication situations that
would be rated were representative of patient values and
daily-living activities, we elicited situations from aphasic
individuals themselves. The procedures employed, and
the reliability or validity of the various judgments made
by experts during the process, have been described in
more detail elsewhere (Lomas, Pickard, & Mohide, 1987).
What follows is a brief description and summary of the
results.
Under the auspices of the local Stroke Recovery Association, we assembled for a 4-hr meeting a group of 9
I THE
COMMUNICATIVE
EFFECTIVENESS
INDEX I
Fiaum~ 1. Schematic of the use of the visual analogue scale for
rating at initial and repeat testing.
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LOMAS ET AL.: The C o m m u n i c a t i v e E f f e c t i v e n e s s I n d e x
stroke survivors who had been or still were aphasic; 7 of
them were accompanied by their spouse or significant
other. Using the nominal group process technique of
Delbecq, Van de Ven, and Gustafson (1975), we asked for
their responses to the question " I n which situations does
a stroke survivor have to be able to get his meaning across
and to understand what someone else means?" The
nominal group process allows each participant 10 min of
individual consideration of the question before responses
are elicited from members in turn--the aim is to provide
each participant with an equal opportunity to respond.
Responses are recorded in view of the entire group, and
the process continues until no m e m b e r has any further
responses to offer. As far as possible the exact wording of
the respondents is recorded. Following this the group
then judges redundancies between responses and rewords those that can be combined or that it feels need
improvement, thus arriving at a final list.
The process was repeated with a second group of 5
aphasic stroke survivors and their spouses who were
recruited from past patients of the speech pathology
service at Chedoke-McMaster Hospitals; this group provided a comparability check on the representativeness of
the situations generated by the first group.
Both groups had individuals with long-standing aphasia and a variety of severities, ranging from mild residual
anomia to persisting global aphasia. In the case of the few
individuals in the latter category it was, obviously, the
spouse or significant other who volunteered the wording
for responses.
To perform the comparability check, an expert panel of
eight (five speech-language pathologists and three neuropsychologists) independently applied explicit rules developed by us (see Appendix A) to each of the group's
lists after noncommunication situations had been removed. This was in order to (a) assign the communication
situations to one of the four categories of basic need, life
skill, social need, or health threat, thus comparing the
relative proportions in each category for each list; and (b)
use the first patient group's list as the "index set" and
match comparable situations from the second patient
group, thus dividing the latter into matched and unmatched situations.
The levels of agreement on categorization among the
eight raters are presented in Table 1. The large number of
TABLE 1. Levels of agreement between the eight raters on
categorization decisions.
%of
~of
No. of raters assigning item
to category
Patient
Group 1
items
Patient
Group 2
items
All 8 agreed on category
7 of 8 agreed on category
6 of 8 agreed on category
5 of 8 agreed on category
4 of 8 agreed on category
Less than 4 agreed on category
21.2
27.3
27.3
21.2
3.0
0
10.5
28.9
31.6
18.5
10.5
0
115
raters and possible categorizations precluded the use of
conventional measures of interrater reliability. However,
we could use the percentage of item categorization decisions falling into each of the possible levels of agreement.
In no case did fewer than four of the eight panelists agree
on a category assignment, and for the majority of the
assignments (70%-75%), six or more of the panelists were
in agreement.
The results of the comparability check are presented in
Table 2. After exclusion of noncommunication situations,
the number of situations generated by each group was
roughly comparable (33 and 38). The percentage in each
of the communication categories was not significantly
different between the two groups [×2(3) = 1.65, p = .65],
Finally, 52% of the communication situations from the
second patient group were completely matched to situations generated by the first patient group. We were
therefore satisfied that the patient groups were not generating unique and nongeneralizable communication situations.
The final pool of situations for initial evaluation of the
C E T I was arrived at in the following manner.
1. An initial pool was constructed from all communication situations generated by the first patient group plus
all the unmatched situations from the second patient
group.
2. The expert panel met as a group and judged each
situation, retaining only those that they felt satisfied three
criteria: not redundant with another situation on the list,
assessed performance rather than potential, and relevant
to both institutional and community environments. The
last of these criteria was important to ensure that the
C E T I would be applicable for aphasic persons living in
both community and institutional settings.
There were 51 situations in the initial pool of finalized
items--those from the first patient group plus unmatched
situations from the second patient group. After application of the three criteria by the expert panel, 36 situations
remained. These 36 situations, worded as closely as
possible to the actual wording used by the item-generaTABLE 2. Comparability of the communication situations generated by two patient groups.
Patient
Group
1
Number of situations generated
Number of noncommunication
situations generated
Number of communication situations
generated
Percentage in each communication
category:
Basic Need
Health Threat
Life Skill
Social Need
Percentage of situations matched
to Patient Group 1
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Patient
Group
2
40
44
7
6
33
38
16%
3%
37%
44%
20%
9%
36%
35%
-
52%
116 Journal of Speech and Hearing Disorders
tion groups, were structured as our initial CETI. It was
then administered to the significant others of two groups
of aphasic persons to evaluate its reliability, validity, and
sensitivity to change.
54 113-124
February 1989
TABLE 3. Description of patient samples.
Characteristic
Number
Age
The Patient Sample
Sex
The C E T I was administered on two occasions, 6 weeks
apart, to 11 patients recovering from recent onset of
aphasia and 11 stable aphasic patients. Inclusion criteria
for both groups were: spoken and written knowledge of
English, a spouse or significant other was available who
had contact with the aphasic individual at least three
times a week, a score of less than 93.8 on the Western
Aphasia Battery [this score is the cutoff value for aphasic
vs. nonaphasic individuals (Kertesz, 1979)]. In addition,
for the recovering group, initial test administrations had
to be possible within 6--10 weeks postonset. For the
stable group, the initial administrations had to be 15
months or more postonset, the attending clinician had to
judge the patient as stable, and patients could not be
receiving formal language treatment. The attending clinicians used informal assessments to judge whether the
patients were stable. The aphasic patients involved in the
initial generation of communication situations were excluded from this portion of the study.
The patients were recruited from two regional referral
centers from admission log books (recovering group) or
from consecutive speech pathology department files going back from 15 months prior to the study start date
(stable group). The recovering group were all receiving
language treatment from the regional referral centers.
Table 3 describes the two patient groups. The slightly
greater age of the recovering sample (65.4 years vs. 57
years) represents a recent shift in the demographics of
stroke patients referred to the centers.
The majority of patients in both patient groups had
suffered a cerebral vascular accident (CVA). In the recovering group, 10 patients were suffering from their first
unilateral infarct and all but one of these were in the left
hemisphere; the other patient had a recent left hemisphere infarct after a previous right hemisphere lesion. At
initial testing the types of aphasia, according to t h e
classification system of Kertesz (Kertesz & Poole, 1974),
were: 4 global, 5 Broca, 1 Wernicke, and 1 transcortical
sensory. In the stable group, 9 patients had unilateral left
hemisphere lesions with no previous infarcts, and 2
patients had previous infarcts prior to the latest left
hemisphere lesion--one in the left and one in the right
hemisphere. The types of aphasia were: 7 Broca, 1 conduction, and 3 anomic.
Only one potential subject for the study was excluded
because of the unavailability of a significant other meeting the criterion of at least three contacts per week. Eight
of the significant others in the recovering group were
spouses, 2 were daughters, and 1 was a sister. All 11 were
spouses for the stable group.
The number of weeks postonset for initial assessment
fell within our desired ranges of 6--10 weeks for the
Etiology
Recovering
M
SD
M
F
CVAa
Aneurysm
Unknown
Time of initial testing
(weeks postonset)
Time between initial and
repeat testing (weeks)
Severity (WAB Aphasia
Quotient) b
Initial test
Repeat test
Description of significant
others
M
SD
M
SD
Range
M
SD
M
SD
Spouse
Child
Sibling
aCVA = cerebral vascular accident,
Battery (Kertesz, 1982).
11
65.4
8.3
8
3
11
0
0
7.2
2.4
7.1
1.3
5.7-9.7
28.1
21.3
33.7
33.7
8
2
1
Stable
11
57.0
14.2
10
1
8
2
1
163
61
8.2
1.1
6.0-9.5
60.0
26.4
59.0
29.8
11
0
0
bWAB = Western Aphasia
recovering group and greater than 65 weeks for the stable
group. Second assessments were completed at slightly
longer than our planned 6-week interval but were not
significantly different between the recovering (7.1 weeks)
and stable (8.2 weeks) groups, t(20) = 1.1, n.s.
The relative severity of the aphasia in the two groups,
as measured by the Aphasia Quotient (AQ) of the Western
Aphasia Battery, was as expected; at initial assessment
the value of the recovering group's AQ was about half that
of the stable group. Furthermore, the AQ did show
significant improvement in the recovering group between
first (M = 28.1) and second (M = 33.7) testing [t(10) =
3.16, p = .01], supporting the fact that they were recovering; the stable group's AQ showed little change (Ms =
60, 59).
Finally, the existence of a period of spontaneous recovery in aphasic patients (Culton, 1969; Lomas & Kertesz,
1978) enabled us to use the recent onset recovering group
to assess the C E T I ' s ability to detect functionally important change. I f the index was responsive to change, then
there would be a significant improvement in scores from
initial to second testing in recovering patients. The stable
group enabled us to assess the test-retest reliability of the
CETI. I f scores on the index were reproducible over
time, there would be a strong relationship between the
scores at initial and second testing in stable patients. Data
on both groups combined contributed to assessments of
the internal reliability and the validity of the index.
Test Administration
Tests were administered by a trained research assistant
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LOMAS ET
either at the centers or the aphasic patients' homes. In
addition to the CETI, a number of other assessments
were conducted. The Western Aphasia Battery (Kertesz,
1982) was administered to obtain a score on a traditional
"language" assessment tool. The Speech Questionnaire
(Lincoln, 1982) was used as an alternate measure of
functional communication that, although poorly documented as to its validity and significantly focused on
functional language, was easy and simple to administer.
This assessment was completed by the significant other
in the presence of the research assistant. The significant
others were also asked to complete a single global rating
scale that asked them to assess the partner's "overall
language and communication skill during the previous
week" (possible score of 1--extremely poor to 7--excellent). Finally, 11 aphasic patients had available at least
two eligible significant others. We had them both independently complete the C E T I to provide some information on the interrater reliability of the index.
The C E T I requires a brief training period with the
significant other to familiarize him/her with the use of the
VAS. In addition, raters were explicitly instructed to
think not only of verbal communication but also of all
other forms of communication and understanding when
rating the performance of the aphasic individual in the
specific communication situations. It was stressed that
the assessment was of the individual's overall ability to
get his/her meaning across or understand someone else's
meaning in daily-living situations, using any communi-
cation means at their disposal.
The raters were also told to feel free not to rate a
particular communication situation if they felt that it was
not relevant or did not apply to their partner's situation.
This instruction was included to facilitate the final item
reduction by revealing which communication situations
were considered generally applicable across the variety
of settings and people to whom the C E T I would eventually be administered. Perhaps most important, it also
ensured that raters provided assessments only on items
describing situations in which they had actually observed
their partner's performance; raters were explicitly instructed to rate actual performance and not to infer
potential performance for unobserved situations.
The rating for each situation was converted into a score
by laying a template marked with l-ram divisions over the
10-cm VAS and reading off a value between i and 100. The
total C E T I score was converted to a 100-point maximum by
dividing the sum of the individual situation ratings by the
total number of situations. A high score indicated good
performance and a low score, poor performance.
AL.:
The Communicative Effectiveness Index
117
generalizability of each item was revealed by the number
of significant others who actually chose to rate their
partner on it (i.e., the number who had actually observed
performance of the behavior described in an item). To
guarantee that the final items were as generalizable as
possible, we adopted the stringent criterion that we
would include only those situations for which 21 of the
possible 22 significant others gave a rating at both initial
and repeat testings.
Application of the above criterion excluded 20 items to
leave a final set of 16 communication situations on the
C E T I (see Appendix B). Eight of the 16 items were rated
by all 22 significant others at both initial and repeat
testing, and 8 items by 21 of the 22 at both initial and
repeat testing. All remaining reliability and validity evaluations were carried out on these 16 items. For the
analyses that follow, the 8 missing values were imputed
using a program that took the patient's scores on all the
other items and weighted it by all other patients' scores
on that particular item.
DISTRIBUTION OF SCORES
Figure 2 displays the distribution of total scores on the
C E T I for both groups at the initial assessment. Table 4
provides the actual scores of the individuals in both
groups for the initial and repeat assessments.
The mean C E T I scores for the group reflected the
greater severity of the recovering group (44.8) compared
to the stable group (68.0). This shows that, although the
C E T I was not developed for use on the absolute scores
(the focus is on the change in score over time), the
absolute scores may have some validity as indicators of
the severity of an aphasic individual's problems. Of
course, on an individual patient basis, some of the recov-
RECOVERING SAMPLE (N=11)
# OF
PAT I ENTS
MEAN
I/
:
I,
44.8
S,D, = 12,7
STABLE SAMPLE (N=11)
# OF
PATIENTS
RESULTS
FINAL ITEM REDUCTION
0-10 '11-20'21-30 "31-40
MEAN = 68.0
The 36 communication situations were initially selected to be generalizable across people and settings on
the basis of the expert panel's judgments. The true
'81-9
J
91-1
S.D, = 16,8
CETI TOTAL SCORE
FIGURE 2. Distribution of total scores on the Communicative
Effectiveness Index at initial testing.
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118 Journal o f Speech and Hearing Disorders
54
TABLE 4. Scores on the Communicative Effectiveness Index
(CETI) (max. = 100) and change scores on the Western Aphasia
Battery (WAB; Kertesz, 1982) (max. = 10O) and the Speech
Questionnaire (SQ; Lincoln, 1982) (max. = 18).
Patient
Recovering group
1
2
3
4
5
6
7
8
9
10
11
M
SD
Stable group
1
2
3
4
5
6
7
8
9
10
11
M
SD
Initial
test score
CETI
Repeat
test score
Change score
CETI
CETI WAB SQ
57
47
31
46
64
48
24
53
47
25
48
65
65
49
66
72
54
28
59
62
44
51
8
18
18
20
8
6
4
6
15
19
3
44.8
12.7
55.9
12.6
11.4
6.6
57
62
75
51
79
73
77
98
84
41
52
64
63
75
51
80
74
88
89
85
40
40
68.0
16.8
68.1
18.0
7
1
0
0
1
1
11
-9
1
-1
-12
0
6.3
8
13
-3
21
4
17
0
9
0
8
2
7.2
7.6
10
4
-14
-2
2
7
5
5
-9
-5
-4
-0.1
7.4
4
-2
0
2
0
2
4
1
5
3
5
2.2
2.3
1
2
0
-4
-1
0
0
0
0
-1
1
-0.2
1.5
e r i n g group still had absolute scores h i g h e r than the
stable group.
T h e scores approximate a normal distribution with evid e n c e that significant others were using all or most of the
VAS w h e n doing their ratings with enough room left at the
top and bottom of the scale for both deterioration and
i m p r o v e m e n t in performance to b e d e t e c t e d (MacKenzie &
Charlson, 1986).
Because the i n t e n t of the C E T I is not to d i s c r i m i n a t e
b e t w e e n a p h a s i a types, no a t t e m p t was m a d e to relate
these total scores to the nature of the aphasic patient's
deficits.
T a b l e 4 also p r o v i d e s the change scores from the AQ of
the W e s t e r n A p h a s i a Battery (WAB) and from the S p e e c h
Questionnaire. 1 It is i n t e r e s t i n g to note that in the recove r i n g group, with the exception o f 2 patients (6 a n d 8), the
C E T I reveals t h e same or larger i m p r o v e m e n t s in perform a n c e than the WAB. Also, in the stable group, with the
F e b r u a r y 1989
e x c e p t i o n of 3 patients (7, 8, a n d 11), the C E T I shows
s m a l l e r changes in p e r f o r m a n c e than the WAB for this
clinically d e t e r m i n e d stable p o p u l a t i o n who are not rec e i v i n g s p e e c h therapy. I n d e e d , 7 of the 11 patients have
change scores of zero or one on the C E T I , w h e r e a s none
have such small c h a n g e scores on t h e WAB. T h e greater
t e n d e n c y for the WAB to show changes in performance,
in this stable p o p u l a t i o n , m a y reflect its r e l i a n c e on
a s s e s s m e n t of p e r f o r m a n c e on a specific occasion (when
patients m a y or m a y not b e "'at t h e i r best"); as o p p o s e d to
the C E T I ' s r e q u e s t for ratings of p e r f o r m a n c e at the
general t i m e i m m e d i a t e l y p r e c e d i n g the a s s e s s m e n t session (thus a v e r a g i n g the " g o o d " and " b a d " days).
RELIABILITY
Internal Reliability
I f the items w i t h i n the a s s e s s m e n t tool are all measuring the same d i m e n s i o n (in this case, c o m m u n i c a t i o n
effectiveness), t h e r e s h o u l d b e a strong r e l a t i o n s h i p both
a m o n g t h e m and b e t w e e n each one a n d the total score
(i.e., the tool s h o u l d b e i n t e r n a l l y consistent). O f course,
this r e l a t i o n s h i p s h o u l d not b e perfect; o t h e r w i s e t h e r e
w o u l d b e no justification for h a v i n g m o r e than one item in
the index.
Two m e a s u r e s of internal c o n s i s t e n c y w e r e u n d e r t a k e n
on the scores of b o t h groups c o m b i n e d (N = 22). T h e s e
results, and the results of the o t h e r r e l i a b i l i t y assessments, are p r e s e n t e d in T a b l e 5. First, w e c a l c u l a t e d the
correlations b e t w e e n the score o b t a i n e d on each i n d i v i d ual item a n d the total score (item-total correlations).
Second, w e c a l c u l a t e d the C r o n b a c h a l p h a statistic
(Cronbach, 1951), w h i c h c o n c e p t u a l l y c o m p u t e s the composite correlation from all the correlations of split-half
comparisons of all the item scores.
T h e overall t r e n d in t h e item-total correlations is
toward high values (11 of the 16 items c o r r e l a t e d at .50 or
greater with the total), i n d i c a t i n g that scores on the
TABLE 5. Reliability assessments of the Communicative Effectiveness Index.
1. Internal reliability (calculated on initial scores of both
patient samples, N = 22)
a) Item-total correlation
#items
>.75
4
.5-.75
7
.25-.50
3
<.2,5
2
b) Cronbach's alpha: .90
Total 16
2. Test-retest reliability (calculated on stable group only,
(n =
1Although Lincoln (1982) advises against pooling the scores on
the Speaking and Understanding scales of the Speech Questionnaire, we have done so in this report of change scores for
simplicity of presentation. When used in the validity analysis
later in the paper, the scores on the two scales are kept separate.
113-124
i1)
Intraclass correlation = .94
95% confidence limits = .87-.99
3. Interrater reliability (calculated on change scores of eligible
from both patient samples, n = 1I)
Intraclass correlation = .73
95% confidence limits = .62-.81
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LOMAS ET AL.: The Communicative Effectiveness Index
individual items are strongly related to, but not totally
coincident with, the total score. The Cronbach alpha of
.90 is high and supports the good internal reliability of the
index.
119
correlation is acceptable, espeeially given the fairly subjective nature of the rating judgments that were required
of the significant others, and suggests that the change
scores obtained from one rater are generalizable to others.
Test-Retest Reliability
VALIDITY
Just as it is important to demonstrate that an instrument
can detect change when real change in performance has
occurred (see Validity section), it is equally important to
be able to show that it does not detect any change over
time when performance has stabilized (i.e., test-retest
reliability).
We calculated test-retest reliability using the stable
group of patients, which, given our inclusion criteria for
the group, should not show any change in mean performance on the C E T I between the two testings (see Table
5). We did indeed find this to be the case with a mean
score at first testing of 68.0 (SD = 16.8) and at second
testing of 68.1 (SD = 18.1). The standard error of this
mean difference of 0.1 between first and second testing
was estimated to be 5.87.~ The intraclass correlation (rho)
was .94, with a confidence interval of .87 to .99.
The individual patient scores shown in Table 4 indicate that this test-retest reliability was a group effect, with
the scores of some aphasic patients in the stable group
changing by up to 12 points. It is not clear whether the
changes in these patients' scores reflect measurement
error or the variability in clinicians' judgments about
what constituted a "stable patient." Clarification of the
meaning of these individual patient score changes will
have to await further study of the properties of the CETI.
Either way, we were most interested in the group effect,
which clearly demonstrated test-retest reliability.
Interrater Reliability
In addition to being reproducible across time, the
ratings made of one individual's performance should also
be reproducible across different raters at the same point
in time (interrater reliability). With two significant others
available for 11 of our 22 patients (6 recovering and 5
stable), we were able to calculate the interrater reliability
of the CETI. Because the focus of the instrument is on the
change in score from one assessment to the next, we
calculated the intraclass correlation coefficient (rho) on
the change score produced by the 11 pairs of raters (see
Table 5). For these 11 patients the mean change score of
the first raters was 6.4 (SD = 6.5) and of the second raters
8.3 (SD = 9.4); the intraclass correlation, adjusted to
represent the population of potential raters (Berk, 1979),
was .73 with 95% confidence limits of .62 to .81. This
2This estimate of the standard error is based on the estimated
variance of the difference score, derived from the pooled variance of the scores on first and second testing, corrected for test
reliability using the formula SE = SDV~T~-~
Face Validity
Face validity pertains to the degree to which an instrument appears to be measuring what it was designed for.
As such it relates significantly to our criterion of "credible
to users." The extensive involvement of the aphasic
patients themselves in generating the items used on the
C E T I should ensure that the index has high face validity.
Furthermore, the item reduction process involved clinicians, the aphasic individuals, and their significant others
in culling from an initial pool of 51 items the 16 that were
most representative of communicative effectiveness in
the aphasic patient. Thus, clinicians familiar with the
deficits encountered in aphasia should find the items
listed in Appendix B credible as measures of functional
communication.
Construct Validity
The construct validity of an instrument is a measure of
the extent to which it actually measures what it was
designed for. This is assessed by comparing the scores on
the instrument to scores obtained from other measures of
the same individual's performance. We had three concurrent measures available for comparison with the CETI.
First, we used the Western Aphasia Battery (WAB), a
traditional measure of language ability that has b e e n
validated as being able to reliably discriminate among
aphasic types and between individuals who do or do not
have aphasia (Shewan & Kertesz, 1980). However, although the WAB has been used, it has not been evaluated
as a measure of change in aphasic performance over time.
We used the Aphasia Quotient (AQ) as the WAB score of
interest (maximum score = 100). The second measure
was the Speech Questionnaire (SQ), a brief self-administered instrument designed as a measure of functional
language ability in aphasia, which has b e e n shown to be
internally reliable using Guttman scaling and to have
good test-retest reliability (Lincoln, 1982) but has not
been assessed for its validity against other measures or for
its ability to measure change over time. We used the
scores from the Speaking (maximum = 13) and Understanding (maximum = 5) subscales separately because
Lincoln reports that they cannot be combined. Finally,
we had the single global ratings done by each of the
significant others to evaluate the overall ability of their
partner in both language and communication (maximum
score = 7). Performance was rated as excellent, good,
fairly good, fair, not too good, poor, or extremely poor.
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120 Journal of Speech and Hearing Disorders
54 113-124
Each of these measures was obtained at both the initial
testing and the repeat testing.
Commensurate with our a priori hypothesis that functional communication is a separate but overlapping dimension to language, we made a series of predictions
about the relationship between the scores on the C E T I
and scores on these other measures. We predicted that
the strongest associations would be seen between the
C E T I and the global ratings by the significant others;
although because these global ratings included more
assessment of language ability than the C E T I (communication and language were assessed by the global ratings),
we did not expect the correlations to be extremely high.
Shewan and Kertesz (1980) claim that the WAB has some
components that measure functional communication, but
the focus of the WAB on language assessment led us to
expect only a moderate but nevertheless significant correlation with the CETI. Finally, the correlation of both
the Speaking and Understanding subseales of the SQ
with the C E T I was not expected to be very different from
that between the C E T I and the WAB, despite the supposed focus of the SQ on functional language ability. This
a priori hypothesis was based on scrutiny of the items in
the SQ; they exclusively concerned language issues (e.g.,
"Does he/she say phrases spontaneously?") rather than
communication performance in different daily-living situations.
The Spearman rank correlation coefficients between
the C E T I and the three measures for initial and repeat
testings were calculated on all 22 of the aphasic individuals from both groups (except for some of the global
ratings where ratings for fewer than 22 patients were
available) (Table 6). We did indeed find that the highest
correlations were with the global ratings by significant
others at initial and repeat testing. The WAB had the next
highest correlations and the SQ similar but slightly lower
correlations. All the correlations between the C E T I and
the other measurements at initial and repeat testing were
significant at at least the .05 level.
Our belief that the SQ, despite its stated objective, was
measuring language rather than communication found
some support from the fact that it correlated highly with
the WAB: .89 at initial testing and .87 at repeat testing.
However, correlations involving the SQ should be treated
TABLE 6. Correlations between the Communicative Effective-
ness Index and three other measures of aphasic performance.
Global ratings by significant others
Western Aphasia Battery b
Speech
Questionnaire °
Speaking
Understanding
N
Initial
test
Repeat
test
a
22
.79**
.61"*
.62**
.52**
22
22
.46*
.47*
.43*
.56*
~The number of raters at initial testing was 19 and at repeat
testing was 21. bKertesz, 1982. °Lincoln, 1982.
*p < .05. **p < .01.
February 1989
cautiously insofar as the other instruments combine measurement of speaking and understanding, whereas the SQ
measures them separately.
The pattern of correlations found between the C E T I
and these other measures suggests that it possibly measures a separate but overlapping dimension to the traditional language assessment instrument.
Sensitivity to Change in Performance
Because the principal objective of the C E T I is to assess
changes in performance over time (i.e., evaluate progress), it was particularly important to demonstrate that it
was sensitive to and able to measure functionally important change. It was for this reason that we selected
patients for a "recovering group"; spontaneous recovery
assured us of a patient sample in which functionally
important change would likely occur. I f the C E T I failed
to show significantly improved scores for this group
between the initial and repeat testing, then it would
clearly not be sensitive to or able to measure this functionally important change.
Therefore, using only the 11 aphasic patients from the
recovering group, we did a repeated measures analysis of
variance on their initial and repeat test scores on the
CETI. The mean total score at initial testing was 44.8 (SD
= 12.7) and at repeat testing was 55.9 (SD = 12.6). The
difference between these mean scores was significant,
F(1, 10) = 32.4, p < .002. No such significant difference
was found for the stable patients, where the mean total
score at initial testing (68.0) was not significantly different
from that at repeat testing (68.1).
The mean change score for the recovering group was
11.4, with a standard deviation of 6.6 and a range of 3-19.
This change, however, was not significantly correlated
with the group's change in AQ scores on the Western
Aphasia Battery; the Spearman rank correlation coefficient was only .36 (df = 11, p > .D.
DISCUSSION
This study used aphasic patients to generate items for a
functional communication measure and patients' significant others to rate performance on these items. On the
basis of psychometric evaluation of 11 recovering and 11
stable aphasic patients, the resulting 16-item Communicative Effectiveness Index appears to be reliable and
valid.
Both the inclusion/exclusion criteria and the scores on
traditional language measures indicate that one group
was indeed recovering function, whereas the other was
stable. Although some individuals in each group may not
have shown recovering or stable scores, the two groups
were selected to have the potential to recover or to have
a high probability of being stable. Obviously, this did not
guarantee that all group members would recover or be
stable, but it did result in group means that clearly
represent recovering and stable samples. The stable pa-
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LOMAS ET AL.: The Communicative Effectiveness Index
tients were used to assess test-retest reliability, and the
recovering patients contributed to the assessment of the
CETI's sensitivity to change in performance. The remaining aspects of instrument evaluation combined both
groups of patients for analysis.
The evaluations of reliability produced clearly acceptable values for use of the CETI in group studies and
adequate values for use with individual patients. However, further studies would be useful to clarify the CETI's
reliability for use with the latter. The most contentious
question is whether the results support the validity of the
CETI as a measure of functional communication. There
are two aspects to this question. First, there is the question of whether significant others are unbiased reporters
of aphasic patient performance. Second, there is the issue
of whether the relationship of scores on the CETI and
scores on the other measures supports the hypothesis of a
dimension of functional communication that is separate
from but overlapping with the language dimension.
Spouses (or significant others) have been shown to have
a good level of agreement with aphasic patients on the
presence or absence of particular communication problems, as well as on the severity of the problem (Shewan &
Cameron, 1984). Of particular interest for the CETI is that
when there is disagreement between the spouse and the
aphasic patient on the precise level of severity, spouses
are equally likely to underestimate (31% of problems) as
to overestimate (27%) severity as judged by the patients
themselves (Shewan & Cameron, 1984). In contrast, some
studies have shown that, relative to clinicians (not relative to the aphasic patient), spouses overestimate performance (e.g, Helmiek, Watamori, & Palmer, 1976). However, because we were looking for validation of spouse
assessments as proxies for the aphasic patients, we did
not consider as relevant those studies that contrasted
spouse and clinician assessments.
Furthermore, the validity of clinicians' assessments of
as subjective an area as functional communication in the
aphasic patient is potentially problematic because of their
limited opportunity to view the patient when he or she is
actively engaged in functional "real-life" behaviors. Indeed, we have shown elsewhere (Lomas et al., 1987) that
the types of communication situations that are considered
important for functional behavior in aphasia are significantly different for clinicians and aphasic patients. This
finding also reinforced our decision to go directly to the
patients and their partners for item generation for the
CETI. It also calls into question the widespread use of
clinicians' views as the basis for constructing items for
any "quality of life" assessment instrument.
Thus, for the purpose of rating performance, we believe
that spouses are reasonable proxy respondents for the
aphasic patient, with no apparent bias toward overestimating ability. Furthermore, for the CETI it would not
even matter if spouses did overestimate ability because of
the focus of the index on the change score. As long as
ability was overestimated an equivalent amount at each
testing, then the validity of the change score would
remain intact.
121
Assessment of construct validity presents a particular
problem for the development of instruments in new areas
because of the absence of an alternative measure of the
dimension under consideration with which to compare
the new measure. For aphasia assessment tools that focus
on discriminating among types of aphasia and relating
this to localization of the damaged areas of the brain (e.g.,
the Western Aphasia Battery or the Boston Diagnostic
Aphasia Examination) such a "gold standard" for comparison (and, therefore, validation) is available from CT
scans or other "hard" evidence of the actual location of
damage. However, what can be considered the "gold
standard" of functional communication against which the
CETI can be validated? One of the reasons to develop
such a measure is the belief that existing aphasia assessment instruments do not, or do not fully, assess functional
communication and would not, therefore, correlate particularly highly with the CETI.
We adopted the approach of specifying, a priori, the
relationship we would expect to see between the CETI
and three other measures (WAB, Speech Questionnaire,
and global ratings) if the CETI was measuring a separate
dimension of functional communication (Cronbach &
Meehl, 1955). The actual correlations we obtained were
consistent with these specifications. Further evidence for
the recovery of functional communication separately from
the recovery of language ability came from the observation that the recovering group's change scores on the
CETI did not correlate significantly with their change
scores on the WAB. This result is not inconsistent with
our hypothesis of a separate dimension of functional
communication, with a separate recovery course from
language, and that this dimension is being measured by
the CETI but not by traditional instruments. A similar
argument has been made by Sarno in discussing the
relationship between the Functional Communication
Profile and the Neurosensory Centre Comprehensive
Examination for Aphasia (Sarno, Sarno, & Levita, 1971).
It might be argued that validation should involve correlations of the CETI scores with direct observations of
actual communication behavior. This approach was used
by Holland in validation of the Communicative Abilities
in Daily Living (Holland, 1980). However, such a validation strategy for the CETI would have been redundant
and, if the observations were rated or scored by clinicians, potentially misleading. It would have been redundant because the structure of the index was such that
spouses were already rating the functional communication ability of their aphasic partners based on observations of their actual communication behavior. Our acceptable levels of interrater reliability attest to the stability of
this rating.
If the ratings of actual communication behavior were
performed by clinicians, then they would be, to some
extent, subjective, and we have no reason to believe that
they would be any more valid as a measure of a particular
patient's functional communication ability than ratings
done by the spouse. In fact, we have reason to believe
that they would be less valid compared to a spouse-there is only limited exposure of the clinician to the
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122
Journal of Speech and Hearing Disorders
particular communication foibles of a particular patient.
The existing evidence comparing clinician and spouse
judgments demonstrated that they do not coincide (Helmick et al., 1976; Lomas et al., 1987). Therefore, in the
area of functional communication measurement, it would
not appear to be a reasonable premise that ability can be
more objectively defined by expert clinicians than by
individuals such as spouses who have significantly
greater exposure to the aphasic patients' behavior.
Obviously, the small number of patients involved in
the evaluation of the C E T I means that further validation
and reliability assessments should be undertaken. Future
work can profitably explore the relationship between
changes on the C E T I and other language and communication measures; this will assist in specifying more
clearly the degree to which functional communication is
separate from other aspects of aphasic patients' difficulties. The higher scores of the stable group compared to
the recovering group suggest that, although not designed
for this purpose, the C E T I could be useful in measuring
absolute severity of, and not just change over time in,
functional communication deficits. Studies in other patient groups would clarify this potential use of the index.
Finally, studies on larger numbers may clarify the reliability of the C E T I for use with individual patients.
Future work with the C E T I would also help to answer
some important questions that were not addressed by the
current evaluation. For instance, the high proportion of
men in both our patient groups (18 out of 22) raises the
question of whether the index is truly generalizable
across the sexes. With more women would different
results have been obtained or would different communication situations have been included as items? However,
it should be r e m e m b e r e d that more males than females
generally become aphasic (McGlone, 1980). Nevertheless, the items on the C E T I appear, and were constructed
to be, generalizable across the sexes (as well as across
places and time). It is interesting to note that of the 16
final items on the index, 8 were from the category of
Social Need, 3 from Life Skill, 4 from Basic Need, and
only 1 from the Health Threat category (see Appendix A).
The major value of this instrument is as a measure of
change in communicative effectiveness, thus enabling
clinicians to evaluate individual patients' progress in
therapy and researchers to evaluate recovery of communication ability in group studies of the effectiveness of
therapy. The C E T I does not purport to be a comprehensive aphasia assessment instrument; it does not substitute
for the traditional language assessments. It has not been
designed (nor has it been validated) as a tool to discriminate among aphasic types or between those with aphasia
and those without aphasia, although it does appear to
potentially reflect levels of severity in an aphasic population. It should not be used to predict responsiveness to
therapy unless future work is able to validate it for such a
use. In its present form and at the present stage of
evaluation, clinicians and researchers should feel confident using the change scores obtained from one testing to
the next as valid and reliable measures of an aphasic
54 113--124 February 1989
patient's progress at functionally communicating in everyday life situations.
The critical value for the C E T I ' s change scores, above
which individual aphasic patients can be d e e m e d to have
made a clinically important improvement, can be estimated by two methods. If one assumes that the combined
treatment effect and spontaneous recovery of the recovering group is equivalent to clinically important improvement, then the difference between the mean initial and
repeat scores of this group (11.4) represents the critical
value--scores at or above this level signify improvement.
Alternatively, one may consider that the critical value is
the change score that would exclude all patients in the
stable group from having exhibited clinically important
improvement [i.e., the largest change score in the stable
group (12.0)]. Both methods yield a change score of
approximately 12 over a 6--8 week period as the initial
estimate of the critical value. Of course, if some of the
recovering patients were not in fact recovering, or if some
of the stable patients were not in fact stable, this will be
an overestimate of the critical value. Corroboration or
revision of this initial estimate will have to await further
development work with the CETI.
One final characteristic of the C E T I worth mentioning
is its reliance on assessments made by significant others.
This not only gives, in a structured fashion, first-hand
evidence on communication performance to the clinician, but it also involves an often motivated and concerned spouse in assessment of progress and orients him
or her to the full repertoire of potential communication
behaviors available to his or her partner. Given that the
clinician can only be in contact with the aphasic individual for a few hours a week, increased involvement of
those who live with or spend large amounts of time with
him/her may lead to improved results in therapy outcomes. The Communicative Effectiveness Index is an
attempt to make available an instrument that will be able
to measure some of these more functional changes that,
though occurring during the aphasic patient's recovery
process, have so far eluded measurement.
ACKNOWLEDGMENTS
We wish to thank the following for their assistance during the
study: the Hamilton-Wentworth Stroke Recovery Association;
Allan Kroll and the staffof Niagara Region Rehabilitation Center;
and Drs. Geoffrey Norman, Gordon Guyatt, Cindy Shewan, and
Judith Trotter.
This study was supported by grants from the Ontario Ministry
of Health (#01265) and Bauer Funds from the Health Sciences
Gerontological Research Group, McMaster University. The first
author is supported as a career scientist by the Ontario Ministry
of Health (#0135).
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APPENDIX
A
The following definitions were provided to the expert panel:
Communication Categories
1. Basic Need--Communication is required to meet basic
needs (e.g., toileting, eating, grooming, positioning).
2. Health Threat--Physical well-being or health is dependent
on effective communication (e.g., calling for help after falling,
giving or receiving information about one's medical condition).
3. Life Skill--Giving or receiving information that is necessary to accomplish everyday living (e.g., shopping, home maintenance, use of telephone, understanding traffic symbols).
4. Social Need--Communication that is primarily social in
nature (i.e., communication with others as an end in and of itself
such as dinner table conversation, playing cards, writing a letter
to a friend).
Matching
Situations should be considered matched if the inclusion of
both of the situations in a communication assessment scale
would provide no extra information beyond the inclusion of only
one of the situations.
APPENDIX
B
F i n a l 16 Items of the C o m m u n i c a t i v e Effectiveness
Index (CETI)
Please R a t e
's ability a t . . .
1, Getting somebody's attention.
2, Getting involved in group conversations that are about him/
her.
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124
Journal of Speech and Hearing Disorders
3. Giving yes and no answers appropriately.
4. Communicating his/her emotions.
5. Indicating that he/she understands what is being said to him/
her.
6. Having coffee-time visits and conversations with friends and
neighbors (around the bedside or at home).
7. Having a one-to-one conversation with you.
8. Saying the name of someone whose face is in front of him/
her.
9. Communicating physical problems such as aches and pains.
54
113-124
F e b r u a r y 1989
10. Having a spontaneous conversation (i.e., starting the conversation and/or changing the subject).
i i . Responding to or communicating anything (including yes
or no) without words.
12. Starting a conversation with people who are not close family.
13. Understanding writing.
14. Being part of a conversation when it is fast and there are a
number of people involved.
15. Participating in a conversation with strangers,
16. Describing or discussing something in depth.
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The Communicative Effectiveness Index: Development and Psychometric Evaluation
of a Functional Communication Measure for Adult Aphasia
Jonathan Lomas, Laura Pickard, Stella Bester, Heather Elbard, Alan Finlayson, and
Carolyn Zoghaib
J Speech Hear Disord 1989;54;113-124
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