Aphasia Research Research Articles

Developing, Implementing, and Improving Assessment and Treatment Fidelity in Clinical Aphasia Research.

Purpose The purpose of this study was to describe the development and implementation of a fidelity program for an ongoing, multifacility, aphasia intervention study and to explain how initial fidelity measures are being used to improve study integrity. Method A Clinical Core team developed and incorporated a fidelity plan in this study. The aims of the Clinical Core team were to (a) supervise data collection and data management at each clinical site, (b) optimize and monitor assessment fidelity, and (c) optimize and monitor treatment fidelity. Preliminary data are being used to guide ongoing efforts to preserve and improve the fidelity of this intervention study. Results Preliminary results show that specific recruitment strategies help to improve appropriate referrals and that accommodations to participants and their families help to maintain excellent retention. A streamlined and centralized training program assures the reliability of assessors and raters for the study's assessment and treatment protocols. Ongoing monitoring of both assessment and treatment tasks helps to maintain study integrity. Less-than-optimal interrater reliability data for the raters of some of the discourse measures guided the Clinical Core team to address the training and coding inconsistencies in a timely manner. Conclusions The creation of a Clinical Core team is instrumental in developing and implementing a fidelity plan for improved assessment and treatment fidelity. Intentional planning and assignment of study staff to implement and monitor ongoing fidelity measures assures that clinical data are reliable and valid. Ongoing review of the plan shows areas of strengths and weaknesses for continuing adjustments and improvement of study fidelity.

WORD LEARNING IN APHASIA: TREATMENT IMPLICATIONS AND STRUCTURAL CONNECTIVITY ANALYSES.

Of current interest in aphasia research is the relevance of what we can learn from studying word learning ability in aphasia. In a preliminary study, we addressed two issues related to the novel word learning ability of individuals with aphasia. First, as word learning engages large-scale cognitive-linguistic systems (language skills, verbal short-term memory (STM), other memory and executive functions), we probed whether novel word learning practice in three people with aphasia could stimulate these language-related systems. Second, as lesion correlates affecting word learning in aphasia remain unclear, we examined whether the structural integrity of the left arcuate fasciculus (AF) in the same three individuals is related to outcomes of novel word learning practice. To stimulate word learning systems, our three participants practiced for 4 weeks with an explicit novel word - novel referent word learning task, adopted from the Ancient Farming Equipment learning paradigm (Laine & Salmelin, 2010). The participants' progress on receptive and expressive novel word learning was followed up, and their language and verbal STM abilities as well as single-session novel word learning (Learning to Name Aliens by Gupta, Martin, Abbs, Schwartz & Lipinski, 2006) were tested before and after the practice period. To address the second question, we analyzed the participants' structural MRI scans with respect to the integrity of the left AF and its overlap with the lesion areas. All participants showed some receptive word learning in the trained task, as well as improvements in verbal STM span at posttest. Two of the three participants also showed improved performance on some of the language outcome measures. One participant with partially spared left AF, especially temporo-parietal connections, exhibited better word learning performance than the other two who had larger damage and disconnection of the AF. While the present results are preliminary, they open the possibility that novel word learning practice in aphasia may stimulate remaining word learning mechanisms in aphasia, and thereby influence language and verbal STM abilities. These results also suggest that preservation of novel word learning ability in aphasia in part depends on the integrity of the left arcuate track.

A Taxonomy of Brain–Behavior Relationships After Stroke

Purpose Understanding the brain basis of language and cognitive outcomes is a major goal of aphasia research. Prior studies have not often considered the many ways that brain features can relate to behavioral outcomes or the mechanisms underlying these relationships. The purpose of this review article is to provide a new framework for understanding the ways that brain features may relate to language and cognitive outcomes from stroke. Method Brain-behavior relationships that may be important for aphasia outcomes are organized into a taxonomy, including features of the lesion and features of brain tissue spared by the lesion. Features of spared brain tissue are categorized into those that change after stroke and those that do not. Features that change are further subdivided, and multiple mechanisms of brain change after stroke are discussed. Results Features of the stroke, including size, location, and white matter damage, relate to many behavioral outcomes and likely account for most of the variance in outcomes. Features of the spared brain tissue that are unchanged by stroke, such as prior ischemic disease in the white matter, contribute to outcomes. Many different neurobiological and behavioral mechanisms may drive changes in the brain after stroke in association with behavioral recovery. Changes primarily driven by neurobiology are likely to occur in brain regions with a systematic relationship to the stroke distribution. Changes primarily driven by behavior are likely to occur in brain networks related to the behavior driving the change. Conclusions Organizing the various hypothesized brain-behavior relationships according to this framework and considering the mechanisms that drive these relationships may help investigators develop specific experimental designs and more complete statistical models to explain language and cognitive abilities after stroke. Eight main recommendations for future research are provided. Presentation Video https://doi.org/10.23641/asha.10257578.

A Systematically Conducted Scoping Review of the Evidence and Fidelity of Treatments for Verb Deficits in Aphasia: Verb-in-Isolation Treatments.

Purpose Aphasia research demonstrates increasing interest in the treatment of verb retrieval deficits. This systematically conducted scoping review reports on the level and fidelity of the current evidence for verb treatments; on its effectiveness regarding the production of trained and untrained verbs, functional communication, sentences, and discourse; and on the potential active ingredients. Recommendations to guide clinical decision making and future research are made. Method The computerized database search included studies from January 1980 to September 2018. The level of evidence of each study was documented, as was fidelity in terms of treatment delivery, enactment, and receipt. Studies were also categorized according to the treatment methods used. Results Thirty-seven studies were accepted into the review, and all but 1 constituted a low level of evidence. Thirty-three studies (89%) described treatment in sufficient detail to allow replication, dosage was poorly reported, and the fidelity of treatment was rarely assessed. The most commonly reported treatment techniques were phonological and semantic cueing in 25 (67.5%) and 20 (54%) studies, respectively. Retrieval of trained verbs improved for 80% of participants, and improvements generalized to untrained verbs for 15% of participants. There was not sufficient detail to evaluate the impact of treatment on sentence production, functional communication, and discourse. Conclusions The evidence for verb treatments is predominantly of a low level. There are encouraging findings in terms of treatments being replicable; however, this is tempered by poor monitoring of treatment fidelity. The quality of verb treatment research would be improved by researchers reaching consensus regarding outcome measures (including generalization to, e.g., sentences and discourse) by manualizing treatment to facilitate implementation and exploring the opinions of participants. Finally, while treatment is largely effective in improving production of trained verbs, lack of generalization to untrained items leads to the recommendation that personally relevant verbs are prioritized.

The benefits of abstract word training on productive vocabulary knowledge among second language learners

AbstractThis study investigates the effect of an abstract word training paradigm initially developed to treat lexical retrieval deficits in patients with aphasia on second language (L2) vocabulary acquisition. Three English–Spanish L2 learners (Experiment 1) and 10 Spanish–English L2 learners (Experiment 3) were trained on 15 abstract words within a context-category (e.g., restaurant) using a five-step training paradigm based on semantic feature analysis. In addition, 7 English–Spanish L2 learners were trained on either abstract or concrete words within a context-category (Experiment 2). Across all experiments, the majority of participants trained on abstract words showed improved production of the trained abstract words, as measured by a word generation task, as well as improvement on untrained concrete words within the same context-category (i.e., generalization). Participants trained on concrete words (Experiment 2) exhibited much smaller word production gains and no generalization to abstract words. These results parallel previous findings from aphasia research and suggest that this training paradigm can successfully be extended to L2 learning contexts, where it has the potential to be a useful tool in vocabulary instruction. We discuss the findings in terms of models of spreading activation and the underlying conceptual representations of abstract and concrete words in the L2 lexicon.

Rating experience of ICT-delivered aphasia rehabilitation: co-design of a feedback questionnaire

ABSTRACT Background: Speech and language therapy can provide beneficial outcomes in post-stroke aphasia rehabilitation, and intensity is a key component of a successful programme. Information and communication technologies (ICT) may offer an option for the provision of intensive rehabilitation but the views of those undertaking this mode of rehabilitation must be considered to ensure motivation and adherence with self-administered rehabilitation. There is no consensus measure for recording feedback from people with aphasia on user experience of ICT-delivered aphasia rehabilitation. This paper reports on the collaborative development of a feedback questionnaire with people with aphasia for people with aphasia. Aims: There are three research aims (i) to develop a questionnaire to facilitate feedback on ICT-delivered aphasia rehabilitation by collaboratively working with people with aphasia in the design process, (ii) to describe the development process and the co-design techniques employed, and (iii) to explore the experiences of co-designers in the development process. Methods & Procedures: Using public patient involvement (PPI) in health research, a co-design process was employed throughout 6 group workshops. Six people with aphasia (43 to 76 years of age) with a range of aphasia severities (Western Aphasia Battery Aphasia Quotient range 24.4–83) engaged in the co-design process. The final product, an online user feedback questionnaire, was developed. Individual exit interviews were carried out with the co-designers after the workshops, and a thematic analysis of the interview data was completed. Outcomes & Results: The final questionnaire provides an outcome measure that investigates: cognitive workload, satisfaction, programme functionality and ease of use, and the level of assistance required when engaging in ICT-delivered aphasia rehabilitation. It is presented as an online survey in an aphasia-accessible format. Following the co-design experience, four themes were identified within the exit interviews: Group Dynamics, Balance of Complexity of Tasks, Reflection on Abilities and Positive Experience. The co-design process provided opportunities for social interaction with other people with aphasia and allowed co-designers to reflect on their own abilities. The workshops were considered accessible and facilitated their engagement in the co-design process. The process was inclusive and the co-designers reported feeling comfortable about contributing in the workshops and this was also noted in their feedback in the individual exit interviews. Conclusion: People with aphasia can, and should, be included in all stages of the aphasia research process and especially in the development and design of evaluation measures for use by people with aphasia.

A multimodal analysis of enactment in everyday interaction in people with aphasia

ABSTRACTBackground: “Multimodal communication” is a relatively common term in aphasia research. However, the scope of studies on multimodal interaction in aphasia is generally restricted to one or two multimodal resources, and the type of discourse analysed is often not representative of authentic interaction. Finally, the interpersonal (versus referential) functions of multimodal resources are frequently overlooked.Aims: The purpose of this study was to explore the multimodal realisation of enactments by people with aphasia in everyday interaction.Methods & Procedures: Authentic interactions of six people with aphasia interacting with communication partners of their choice were systematically analysed. Frameworks originating from non-brain-damaged studies were applied to examine the characteristics and functions of linguistic, multimodal, and stance-taking resources used to realise enactments.Outcomes & Results: Even though the participants used the same multimodal resources as non-brain-damaged communicators, the frequencies and characteristics were different. The relationship between multimodal resources and interpersonal functions was different as well.Conclusions: People with aphasia use the same multimodal resources as non-brain-damaged communicators, indicating their retained strengths. However, their higher use of intonation, gesture, and – to a lesser extent – facial expression indicates that these may be important “meaning making” resources for them, which could be utilised more in therapeutic endeavours.

CSD Program Makes College Possible After Brain Injury

CSD Program Makes College Possible After Brain Injury

A comparison of drawing and writing on facilitating word retrieval in individuals with aphasia

ABSTRACTBackground: Drawing has long been a focus in aphasia research as a compensatory strategy for improving functional communication in individuals with aphasia, but fewer studies have addressed drawing as a facilitative tool to improve their verbal output.Aims: The purpose of the current study was to investigate differences in naming accuracy in individuals with aphasia during a drawing versus a writing condition. Two research questions were formed to examine the role of drawing in facilitating naming: 1) Will participants perform better when naming with drawing compared to confrontation naming only or when naming with writing? and 2) Is the quality of the picture drawn related to the naming accuracy?Methods & Procedures: Across three separate one-hour sessions, fifteen individuals with aphasia (n = 15) aged 44–81 years (M = 61.47, SD = 13.27) were evaluated using two standardized language assessments, the Western Aphasia Battery-Revised and Pyramid and Palm Tree Test, and three naming tasks designed to assess the effect of writing and drawing on naming performance. The three naming conditions consisted of confrontation naming only, naming with drawing, and naming with writing.Outcomes & Results: A one-way, repeated measures analysis of variance (ANOVA) was computed to analyze the impact of naming conditions on the participants’ naming accuracy. The main effect of naming conditions was statistically significant, F (1, 14) = 5.87, p < 0.05, and Bonferroni correction revealed that the participants performed significantly better in the naming with drawing condition than with writing condition. In addition, no correlation between the quality of the pictures drawn and the participants’ naming performance was found which suggested that the quality of drawing did not affect the accuracy of naming.Conclusions: When attempting to name a picture along with drawing its representation, the act of drawing may facilitate word retrieval by stimulating the semantic network associated with the word and involving the right cerebral hemisphere in the word retrieval process. Through drawing, these semantic features of the target word are more strongly activated than other related words. When the semantic features are more strongly activated, the probabilities of retrieving the target word may increase. In contrast, writing heavily relies on the left hemisphere and linguistic systems. Thus, naming when attempting to write the associated word may be a more cognitively and linguistically demanding task for individuals with aphasia.

Project BRIDGE: Building Research Initiatives by Developing Group Effort

Project BRIDGE: Building Research Initiatives by Developing Group Effort

Effects of executive attention on garden path processing in Broca’s aphasia

Effects of executive attention on garden path processing in Broca’s aphasia

Zur zerebralen Organisation von Sprach

The article is devoted to the cerebral organisation of language. This work is intended as a state-of-the-art paper describing current research and theory in some subfields of cognitive neuroscience that may be of importance for the glottodidactics. Part 1 focuses on the issue of lateralization of language. Part 2 provides information on evaluation procedures in brain and points out that language, cognition and emotion can't be viewed as separate elements of mental processing. An attempt has been made to elucidate the role of epigenetic determinations in learning process. In part 3 experimental aspects of neurolinguistics are emphasized, such as aphasia research, advanced brain mapping techniques as essential steps toward better understanding the neural correlates of language functions, and a review how event-related potentials (ERPs) have been used to reflect semantic and syntactic processing in normal adults and children.

A core outcome set for aphasia treatment research: The ROMA consensus statement.

A core outcome set (COS; an agreed, minimum set of outcomes) was needed to address the heterogeneous measurement of outcomes in aphasia treatment research and to facilitate the production of transparent, meaningful, and efficient outcome data. The Research Outcome Measurement in Aphasia (ROMA) consensus statement provides evidence-based recommendations for the measurement of outcomes for adults with post-stroke aphasia within phases I-IV aphasia treatment studies. This statement was informed by a four-year program of research, which comprised investigation of stakeholder-important outcomes using consensus processes, a scoping review of aphasia outcome measurement instruments, and an international consensus meeting. This paper provides an overview of this process and presents the results and recommendations arising from the international consensus meeting. Five essential outcome constructs were identified: Language, communication, patient-reported satisfaction with treatment and impact of treatment, emotional wellbeing, and quality of life. Consensus was reached for the following measurement instruments: Language: The Western Aphasia Battery Revised (WAB-R) (74% consensus); emotional wellbeing: General Health Questionnaire (GHQ)-12 (83% consensus); quality of life: Stroke and Aphasia Quality of Life Scale (SAQOL-39) (96% consensus). Consensus was unable to be reached for measures of communication (where multiple measures exist) or patient-reported satisfaction with treatment or impact of treatment (where no measures exist). Harmonization of the ROMA COS with other core outcome initiatives in stroke rehabilitation is discussed. Ongoing research and consensus processes are outlined. The WAB-R, GHQ-12, and SAQOL-39 are recommended to be routinely included within phases I-IV aphasia treatment studies. This consensus statement has been endorsed by the Collaboration of Aphasia Trialists, the British Aphasiology Society, the German Society for Aphasia Research and Therapy, and the Royal College of Speech Language Therapists.

Who participates in aphasia research? An analysis of the REhabilitation and recovery of peopLE with Aphasia after StrokE (RELEASE) data set

Background: People with aphasia present with different of demographic, language, stroke, and impairment profiles. A Cochrane review found that two-thirds of included trials had comparison data on p...

Tidier descriptions of speech and language therapy interventions for people with aphasia; consensus from the RELEASE Collaboration

Background: Speech and language therapy (SLT) interventions for people with aphasia are complex – for example, interventions vary by delivery model (face-to-face, tele-rehabilitation), dynamic (group, 1-to-1) and provider. Therapists tailor the functional relevance and intervention difficulty to the individual’s needs. Therapy regimes are planned at a specific intensity (hours per week), frequency (number of weekly sessions), duration (time from start to end of therapy intervention) and dose (total number of therapy hours). Detailed and transparent description of interventions for people with aphasia facilitates replication in clinic, between-study comparisons and data-syntheses. Incomplete intervention reporting and inconsisten-cies in the use of terminology have been observed (RELEASE: REhabilitation and recovery of peopLE with Aphasia after StrokE Collaborators, 2015-2018; Brady, Kelly, Godwin, Enderby, & Campbell, 2016; Pierce, O’Halloran, Togher, & Rose, in press). Even when similar terms are used there may be little agreement on their use (Pierce et al., in press). Our RELEASE Collaboration includes 72 multidisciplinary, multilingual aphasia researchers from 28 countries. In preparation for planned meta-analyses (HSD (Hoffmann et al., 2014). The TIDieR checklist supports transparent reporting, data extraction and synthesis in aphasia research. It has facilitated an exploration of the contribution specific parameters (for example intensity) may make to the effectiveness of (or tolerance to) an intervention (Brady et al., 2016). However, while the variables described above are readily summarised, other aspects of therapeutic interventions such as the theoretical approach, the materials used and the procedures employed (the “Why” and “What” within TIDieR) are more challenging to summarise in manner supporting data synthesis and meta-analyses. The World Health Organisation’s (“International Classification of Health Interventions (ICHI),”) also seeks a framework which supports the synthesis and statistical analysis of healthcare interventions based on (a) the treatment target, (b) the intended action to the target and (c) the processes and methods required to carry out the action (ICHI, 2018). However a framework which complements these initiatives and which supports greater consistency in the description of SLT interventions for aphasia is required. Aims: We sought to develop international consensus on a framework to support the description of SLT interventions for people with aphasia. Methods and procedures: Two researchers independently extracted information about the SLT interventions in our RELEASE database (Hoffmann et al., 2014). Information on therapy approaches, materials and procedures were extracted, where possible, as direct quotes from published reports. Using the narrative descriptions, similar approaches were grouped and assigned to one or more category labels by an experienced speech and language therapist. These preliminary groupings were shared with RELEASE Collaborators for review. Each reviewed interventions included within up to four category labels and responses via email were requested. There followed an opportunity for group discussion on the proposed categorisation via videoconference. Outcomes and results: Therapy interventions were categorised based on three per-spectives (a) the role of the intervention within the study design e.g., usual care as a comparison control (b) the intervention target e.g., rehabilitation of spoken language production and (c) the theoretical approach e.g., semantic therapy. We identified 15 SLT approaches. Categories were not mutually exclusive; rather they represented different ways of categorising a complex intervention. Inadequate reporting of therapy interven-tions, procedures and materials hampered some classifications. The Collaboration facilitated knowledge sharing relating to emerging treatment category definitions such as multimodal treatment (Pierce et al., in press) which reflected interventions aimed to utilise a range of learning mechanisms and neural networks to facilitate language recovery. Conclusions: Our collaboration agreed on a framework which supports transparent description, data synthesis and meta-analyses of SLT interventions for people with aphasia after stroke.

Research and clinical services in Chinese aphasia: a recent update

Background: Chinese is the most widely spoken language in the world, with a total of approximately 1.2 billion native speakers worldwide. Living with aphasia negatively affects one’s quality of lif...

Report from ROMA: an update on the development of a core outcome set for aphasia research

(2018). Report from ROMA: an update on the development of a core outcome set for aphasia research. Aphasiology: Vol. 32, International Aphasia Rehabilitation Conference (IARC) September 2018, pp. 241-242.

Implementation of discourse analysis in aphasia: investigating the feasibility of a Knowledge-to-Action intervention

ABSTRACTBackground: Linguistic discourse analysis is frequently used in aphasia research but is met with frequent calls for greater clinical application by speech pathologists and discussion of barriers and facilitators to clinical use. When examined in the clinical context, applications of linguistic discourse analysis were reportedly limited by knowledge and time-based barriers. Implementation science was used to guide the development of an intervention to overcome these barriers and bridge a Knowledge-to-Action gap.Aims: This study aimed to examine whether speech pathologists were able to translate knowledge and skills acquired during an implementation intervention to the assessment of a person with aphasia. The content of the intervention and the feasibility of the implementation strategy were also investigated. Transcription-based and transcription-less approaches to linguistic discourse analysis were compared.Methods & Procedures: Twenty-nine students in their final year of Australian speech pathology university degrees participated in a preliminary Knowledge-to-Action Intervention. Four intervention conditions targeted different evidence-based modes of discourse analysis: one transcription-less approach (judgement-based analysis) and three transcription-based approaches (manual, computer-assisted, and automated analysis). Participants completed evaluations at pre- and post-intervention and a six-month follow-up examining the knowledge acquisition, application, and implementation to practice. Outcomes were subject to content and statistical analysis to examine changes across time-points.Outcomes & Results: Following the intervention, participants set significantly more goals within contexts of discourse production and described significantly more discourse-based therapy approaches. Knowledge and skills acquired during the intervention were adapted by participants, with moderate maintenance observed at follow-up. Participants reported a lack of opportunity to implement their newly acquired skills to clinical practice.Conclusions & Implications: Specific training in the use of discourse analysis led to significant changes in assessment outcomes across all discourse analysis conditions. However, training alone did not remove the challenges involved in implementation. Participant feedback will help guide a more comprehensive intervention strategy with refined content to better facilitate the implementation of linguistic discourse analysis research in speech pathology practice.

A novel eye tracking paradigm for assessing semantic and phonologic activation in aphasia

A novel eye tracking paradigm for assessing semantic and phonologic activation in aphasia

Verbal fluency performance in Bengali-English bilingual aphasia

Event Abstract Back to Event Verbal fluency performance in Bengali-English bilingual aphasia Abhijeet Patra1 and Arpita Bose1* 1 University of Reading, School of Psychology and Clinical Language Sciences, United Kingdom Introduction: Research has shown that impairments in executive control may influence word production abilities in aphasia[1,2]. However, studies investigating the contribution of lexical retrieval and executive control processes during word production are mostly limited to monolingual aphasia[3,4]. Very little is known about bilinguals with aphasia (BWA). A better approach to understand the relationship between lexical retrieval and executive control processes might be to use a task that simultaneously draw upon these processes. In a verbal fluency task, lexical and executive contribution for semantic and letter fluency conditions are different; semantic fluency largely depends on lexical retrieval abilities, whilst letter fluency largely depends on executive control abilities. Characterisation of verbal fluency performance beyond number of correct responses (CR) (e.g., Fluency Difference Score FDS; cluster size; number of switches; temporal measures such as within- and between-cluster pauses), have enabled researchers to specifically speculate the components of performance that depends on lexical retrieval vs. executive control processes[5,6,7]. Previous research has shown that in semantic fluency, BWA produced fewer CR, smaller cluster sizes, and fewer number of switches compared to bilingual healthy adults (BHA)[5,6]. These studies have emphasised the greater role of lexical processes in performance differences between BWA and BHA. However, in absence of comparison to letter fluency, it remains inconclusive if it is only the lexical processes that are compromised in BWA. We compared semantic and letter fluency conditions between Bengali-English BWA and BHA to determine: a) if poor performance in aphasia is due to lexical retrieval and/or executive control difficulties; b) are the differences more exaggerated on measures which depend heavily on the executive control processes. Bengali is a South-Asian language spoken by 180.5 million speakers in the world[8]. Despite that aphasia research reporting Bengali speakers remain under-presented (only one study)[9]. We attempt to fill this gap in the literature. Methods & Procedure: Semantic (animals, fruits and vegetables) and letter fluency (/p/, /k/, /m/) 60-seconds trails were collected from eight non-fluent Bengali-English BWA and eight Bengali-English BHA in their dominant language (Bengali). The groups were matched for age, gender, years of education, and bilingualism measures (language proficiency, usage, dominance). We measured: CR, FDS ((CR.semantic fluency - CR.letter fluency)/CR.semantic fluency), cluster size, number of switches, within-and between-cluster pause. Results and Discussion: Table 1 presents results summary. Overall, on both fluency conditions, compared to BHA, BWA produced fewer number of CR, had higher FDS, made fewer switches, and had longer between-cluster pauses. These results are indicative of difficulty in the executive control component of the verbal fluency task in addition to their lexical difficulties[4,7]. Both groups performed similarly on cluster size and within-cluster pauses. Fewer number of CR, and fewer switches for BWA are consistent with the literature[5,6]. No difference in cluster size and within-cluster pause suggest similar search strategies used by BWA and BHA while accessing the mental lexicon. Our results demonstrate that inclusion of letter fluency and a full range of verbal fluency measures are necessary to understand the effect of lexical and executive control processes in verbal fluency performance. Acknowledgements We would like to thank all our participants for their time and effort. We also would like to acknowledge Felix trust, UK for the PhD fellowship.