# The Italian Adaptation of the Treatment of Underlying Forms for Object Relatives in Agrammatic Aphasia: Training Efficacy, Generalization Patterns, and Cross-Linguistic Implications

Mauro Viganò, Elena Barbieri, Cynthia K Thompson, Chiara Vitali, Carlo Cecchetto

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Mauro Viganò, Elena Barbieri, Cynthia K Thompson, Chiara Vitali, Carlo Cecchetto. The Italian Adaptation of the Treatment of Underlying Forms for Object Relatives in Agrammatic Aphasia: Training Efficacy, Generalization Patterns, and Cross-Linguistic Implications. Journal of Speech, Language, and Hearing Research, In press, 10.1044/2025_JSLHR-24-00305. hal-05021736

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Viganò, M., Barbieri, E., Thompson, C.K., Vitali, C., & Cecchetto, C. (2025). The Italian adaptation of the Treatment of Underlying Forms for object relatives in agrammatic aphasia: training efficacy, generalization patterns and crosslinguistic implications. *Journal of Speech, Language, and Hearing Research*. DOI: 10.1044/2025_JSLHR-24-00305.

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*The Italian adaptation of the Treatment of Underlying Forms for object relatives in agrammatic aphasia: training efficacy, generalization patterns and crosslinguistic implications.*

Mauro Viganò¹, Elena Barbieri²,³, Cynthia K. Thompson⁴, Chiara Vitali⁵, & Carlo Cecchetto¹,⁶

¹UMR 7023 Structures Formelles du Langage, CNRS & Université Paris 8, Paris, France.

²Mesulam Center for Cognitive Neurology and Alzheimer's Disease, Northwestern University, Chicago, IL.

³Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL.

⁴Roxelyn and Richard Pepper Department of Communication Sciences and Disorders, Northwestern University, Evanston, IL.

⁵IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy.

⁶Department of Psychology, University of Milano-Bicocca, Milan, Italy.

**Corresponding author:**

Mauro Viganò

c/o UMR 7023 Structures Formelles du Langage

CNRS & Université Paris 8

59/61 rue de Pouchet, 75017 Paris

Email: [dott.mauro.vigano@gmail.com](mailto:dott.mauro.vigano@gmail.com)

**ORCiDs:**

Mauro Viganò: 0000-0003-3447-4792
Elena Barbieri: 0000-0002-7303-846X
Cynthia K. Thompson: 0000-0003-3197-3457
Chiara Vitali: 0000-0002-8245-4967
Carlo Cecchetto: 0000-0001-9985-7087

**CONFLICT OF INTEREST STATEMENT**

All authors declare that they have no conflicts of interest.
**ABSTRACT**

**Purpose.** Treatment of Underlying Form (TUF) is a training program grounded in linguistic theory and aiming to boost complex sentences production in people with agrammatism. Language treatment studies in aphasia confirmed TUF efficacy and led to the formulation of the Complexity Account of Treatment Efficacy (CATE). According to CATE, which relies on the primitive distinction between A- and A'-structures, training complex sentences induces an improvement on simpler structures, but no generalization occurs between different types of syntactic movement. This experiment provides the first adaptation of TUF in Italian and investigates the cross-linguistic validity of training efficacy and its generalization pattern.

**Method.** Using a single-subject experimental design, five participants with chronic post-stroke agrammatism underwent intensive training for object relatives. Performance on trained and untrained object relatives (A'-structures), object clefts (simpler A'-structures) and passive sentences (A-structures) was measured at multiple time points, i.e., pre- and post-treatment, during the training and at follow-up. A standardized assessment of aphasia was also administered pre- and post-treatment.

**Results.** The results reported a robust improvement in the production of trained and untrained object relatives in all five participants, a generalization to object clefts in four participants, and unexpectedly, a generalization to passives in three participants. All participants showed improved comprehension on all these structures. A general linguistic
improvement was also found in the standardized testing of aphasia, especially in
morphosyntactic abilities.

**Conclusion.** The findings confirmed the efficacy of the Italian adaptation of TUF for object relatives supporting its use in the clinical practice. To explain the generalization to passives in Italian but not in the English version of TUF, we propose an amendment of CATE, which takes as a primitive the syntactic operation of *Internal Merge* (keeping the A- vs. A'- distinction as a modulating factor).

KEYWORDS

Agrammatism; treatment efficacy; syntactic movement.
# 1. INTRODUCTION

Treatment of Underlying Forms (TUF) is a linguistic-based language intervention for production of complex sentences that entail syntactic movement (Chomsky, 1982). TUF (Thompson & Shapiro, 2005) was originally developed in English for people with stroke-induced agrammatism (see Thompson, 2019, for a review), who typically show profound morpho-syntactic impairments, including difficulties in production and comprehension of reversible, non-canonical sentences (Bastiaanse & van Zonneveld, 2005; Grodzinsky, 1995; Schwartz et al., 1994, 1987; Caramazza & Zurif, 1976; see Barbieri et al., 2024; Garraffa & Grillo, 2008; Luzzatti et al., 2001, for evidence from Italian-speaking participants).

Non-canonical sentences are structures in which noun phrases (NPs) are moved from the base-position where they receive their thematic role (e.g., patient/theme) to a higher projection in the syntactic tree and appear in a linear order that differs from the basic order of a particular language. For example, in SVO languages, the linear order of the NPs in non-canonical sentences does not follow the sequence agent followed by patient/theme. The syntactic movement operation required by these structures is defined as *Internal Merge* by the minimalist approaches (Chomsky, 1995) in the generative linguistic framework. The ability to process the movement dependency between the moved NP and its original position is necessary for meaning extraction, since thematic roles are assigned in the position that precedes movement. In non-canonical sentences, the full analysis of the dependencies is even
more crucial, since the comprehension of these structures cannot rely on heuristics based on
the linear order of the sentence constituents. A longstanding tradition within the generative
framework (Chomsky, 1982) has identified two main types of syntactic movement: A-
movement (e.g., the movement of an argument to satisfy case and agreement features or the
*Extended Projection Principle* — EPP) and A'-movement (e.g., the movement to a functional
projection in the left periphery, which satisfies discourse related features). A- and A'-
movement also display different properties in terms of locality (A-movement cannot cross
clause boundaries, while A'-movement can), binding (the phrase that undergoes A-movement
can bind anaphors that it could not previously bind, while this is not possible in A'-movement),
improper movement (the same phrase can undergo A-movement and then A'-movement, but
not vice versa). Examples of A-movement structures are passive sentences (1) and subject-
raising structures (2). Sentences characterized by A'-movement include object-extracted wh-
questions (3), object clefts (4) and object relatives (5).

In the following examples, we indicate by *t* (for “trace”) the position from which syntactic
movement has occurred.

(1) "The woman is carried *t* by the man"

(2) "The man seems *t* to lift the woman"

(3) "Who does the man lift *t*?"

(4) "It is the woman who the man lifts *t*"

(5) "John sees the woman who the man lifts *t*"

Studies on English-speaking individuals with agrammatism have used TUF to train several
sentence types, including argument- and adjunct-extracted *wh*-questions (Thompson et al.,
1993, 1996; Thompson & Shapiro, 1995; Wambaugh & Thompson, 1989), object clefts (Thompson et al., 1997, 1998, 2021), and object relatives (Thompson et al., 2003) for A'-movement, passives (Barbieri et al., 2019a; Thompson et al., 1997, 2021) and subject-raising constructions (Thompson et al., 1997) for A-movement. These studies have shown that TUF is an effective method for training complex sentences, characterized by either A- or A'-movement, in people with agrammatism both following focal brain lesions and in neurodegenerative conditions (i.e., Primary Progressive Aphasia, Thompson et al., 2021) (also see Swiderski et al., 2021 for results of a meta-analysis of TUF studies, attesting to its efficacy).

These findings also revealed specific regularities in treatment generalization patterns, and have led to the proposal of the *Complexity Account of Treatment Efficacy* – CATE (Thompson & Shapiro, 2007; Thompson et al., 2003). According to CATE, training complex sentences that entail a certain type of syntactic movement yields generalization to simpler instances of the same type of movement, but not to structures that entail a different type of movement, or to more complex sentences. For example, Thompson and colleagues (2003) demonstrated that training sentences with object-relative clauses (A'-movement) generalized to object-cleft and object-extracted wh-questions (A'-movement) but not to passives (A-movement). Moreover, treatment of the least complex A'-structure (i.e., object-extracted wh-questions) did not yield improvement on the more complex A'-structures (i.e., object relatives and clefts) or on A-structures (i.e., passives). In summary, two principles regulate CATE: (i) generalization goes from complex to simpler structures; (ii) no generalization occurs between different types of syntactic movement (hence, the distinction between A- and A'-structures is taken as a primitive). The hierarchy of complexity within our selected sentence types (see (1) through (5)) is based on their structural properties. Object relatives (5) are the most complex structures, since they are biclausal structures in which the A'-movement crosses the clausal
boundary. Within A'-structures, object wh-questions (3) are the simplest structures since they are monoclausal sentences in which the wh-item is moved to the left-periphery of the complementizer phrase (CP). It has been proposed (cf. Thompson et al., 2003) that object clefts (4) fall at an intermediate level of complexity, since the subject of the matrix clause is an expletive that does not receive a thematic role and does not have semantic content; rather, it is base generated in Spec,IP as a slot filler and is not part of the verb argument structure (cf. Haegemann, 1994 and Koopman & Sportiche, 1991).

The results of these studies on TUF also bring up the issue of cross-modal generalization between production and comprehension abilities. Although TUF includes training components for both production and comprehension, it is mainly focused on sentence production. While some studies (Thompson et al., 2003) reported relevant improvement in comprehension prompted by TUF, Barbieri and colleagues reported variable efficacy among participants, with only half of the participants showing medium to large effect sizes in comprehension of trained structures (Barbieri et al., 2019a). Therefore, the mixed evidence on this matter leaves the question open and is worth further investigation.

To the best of our knowledge, cross-linguistic adaptations of TUF have only been attempted for German (Schröder et al., 2015; Stadie et al., 2008). Findings from these studies validate the efficacy of TUF for German-speaking participants, and the generalization trend from complex to simpler sentences (namely from object relatives to object-extracted wh-questions), but not vice versa. However, in apparent contrast with CATE, Stadie et al. (2008) found an improvement in the performance on passives (A-structure) following a treatment for object relatives (A'-structure). The authors' explanation of their findings relied on the lower number of phrasal nodes entailed by passive sentences, compared to object relatives, which render the former more structurally simple than the latter. Generalization from
complex/higher to simpler/lower structures is predicted by the Tree Pruning Hypothesis for agrammatism (Friedmann, 2001; Friedmann & Grodzinsky, 1997), according to which production impairments may selectively affect higher projections of the tree. As proposed by Stadie and colleagues (2008), based on the Tree Pruning Hypothesis, generalization from object relatives to passives occurs because A'-movement in relatives activates higher nodes, while passive sentences are monoclausal structures characterized by a shorter A-movement. Regarding cross-modal generalization, Schröder and colleagues (2015) analyzed the results by Stadie et al. (2008) including participants' performance in comprehension tasks (that was not considered by in the first study). According to the authors, the findings support the existence of modality-specific syntactic representations for comprehension and production. Indeed, the one-way generalization from comprehension to production and the fact that only the participants with good comprehension abilities showed generalization in production from complex to simpler sentences led the authors to state that only comprehension can be supportive of production within cognitive models of sentence processing.

Given the challenges posed to CATE by the only existing cross-linguistic adaptation of TUF, the present study intends to test the principles of generalization from complex to simpler structures, and of generalization from production to comprehension in a Romance language (Italian). To our knowledge, no attempts have been made to adapt TUF to Italian or Romance languages. Italian is a good candidate for exploring CATE and TUF cross-linguistically, for two reasons. On the one hand, syntactic derivation of passives, object relatives and object clefts occurs in a similar way as in English, thereby offering an excellent opportunity to test CATE predictions. On the other hand, English and Italian entail several morphological and syntactic differences: among these, the presence of rich inflectional morphology, as well as pro-drop and lack of do-support in questions and negation in Italian are all factors that may affect
treatment efficacy and generalization. For example, the question arises of whether a richer
morphology constitutes an additional difficulty for people with agrammatism or it is
beneficial, since it provides explicit cues to identify relevant morphosyntactic traits. As for the
difference concerning pro-drop, the availability of null subject is associated with a more
flexible word order in Italian. Since TUF heavily relies on differences in word order between
the target structures, this raises the issue of the treatment efficacy. Moreover, evidence in
favor of cross-linguistic validity of TUF is a fundamental step towards the introduction of TUF
in clinical practice with Italian-speaking individuals with agrammatism.

The aims of the present study are to 1) introduce an adaptation of TUF (focused on training
object relatives) to Italian, 2) evaluate its efficacy in improving production and comprehension
of trained structures in people with aphasia, and 3) investigate its generalization patterns. To
address the latter aim, we investigated both production and comprehension of untrained
sentences with the same syntactic structure but different lexical items (i.e., object relatives
with different verbs), of simpler structures entailing the same type of syntactic movement
(object clefts; A'-movement) and of simpler structures entailing a different type of movement
/passives, A-movement). We adopt this hierarchy of complexity, as explained above, based on
previous literature on TUF (cf. Thompson et al., 2003; see Thompson, 2019 for review), as the
derivations on these structures in Italian and English are similar in relevant respects (cf.
Cecchetto & Donati, 2015; Contemori & Belletti, 2014; Belletti, 2013). In view of the
similarities in syntactic derivation between English and Italian, we predict that TUF will be
effective in improving both production and comprehension of trained sentences, and that
generalization from complex to simpler sentence structures will follow the principles of CATE,
i.e., production and comprehension of object clefts (but not passive) will improve following
treatment of object relatives.
## 2. METHOD

### 2.1. Participants

Five monolingual, Italian-speaking right-handed adult individuals presenting with aphasia following stroke were included in the study. All participants were in the chronic phase (time post-onset > 12 months). Participants were recruited by examining medical records provided by the rehabilitation clinic where the study took place, and selecting individuals with a clinical diagnosis of nonfluent aphasia and agrammatism. Concurrent neurodegenerative diseases, nonlinguistic cognitive impairments and affective or psychiatric disorders were considered as exclusion criteria. All participants gave informed consent to take part in the study.

The research protocol was approved by the ethical committee of the neurorehabilitation clinic that hosted the project (Study ID: 03_29/06/2022; E.C. "IRCCS Fondazione Don Carlo Gnocchi", Milan, Italy).

### 2.2. Procedures

#### 2.2.1. *Standardized assessment*

Before and after treatment, each participant underwent standardized language assessment using the Italian version of a) the Aachen Aphasie Test (IT-AAT, Luzzatti et al., 1996, 2023) for a global assessment of aphasia, b) the Northwestern Assessment of Verbs and Sentences (IT-NAVS, Barbieri et al., 2019b, 2024) for a focus on grammatical competences, c) the Digit Span (forward and backward, Monaco et al., 2013) for phonological short-term and working memory, d) the Communicative Effectiveness Index (IT-CETI, Moretta et al., 2021) for a functional assessment (administered to the participants and their caregivers), and e) the analysis of spontaneous speech (via the description of a novel complex picture, see **Supplementary Figure 1**).
### 2.2.2. Experimental stimuli

The sentences used for evaluation (probes) and for treatment were developed using a set of 20 transitive verbs and animate nouns as arguments, obtaining 20 pairs of reversible sentences for each of the five structures considered (e.g., “The man carries the woman” and “The woman carries the man”). We considered four syntactic structures (actives, passives, object clefts, and object relatives; see (6) – (9) below) (following Thompson et al., 2003, in defining complexity within A and A' movement types). For untrained structures, all 20 verbs were used in 20 separate sentences; for the trained structures (object relatives), 10 verbs/sentences were constructed to be used for treatment and 10 verb/sentences were developed to test generalization.

(6) Active sentences: no syntactic movement involved.

e.g., *L'uomo porta la donna* – “The man carries the woman”

(7) Passive sentences: simple type of A-movement.

e.g., *La donna è portata dall'uomo* – “The woman is carried by the man”

(8) Object clefts: simple type of A'-movement.

e.g., *È la donna che l'uomo porta* – “It is the woman that the man carries”

(9) Object relatives: complex type of A'-movement:

e.g., *Gianni guarda la donna che l'uomo porta* – “John sees the woman that the man carries”

To summarize, we trained 10 object relatives and used 10 untrained object relatives only for assessment, while all the other sentence types were control structures (used only in the evaluation not in treatment). For each pair of sentences (e.g., the woman is carried by the
man), two pictures depicting the two semantically reversible counterparts (e.g., a man carrying a woman and a woman carrying a man) were selected among the training material of the English version of TUF (Thompson, 2016). All NPs described animate entities and were used in singular form. Possible gender mismatch between the two NPs of the sentences was not considered a factor since, in Italian, gender is not part of the featural composition of the clausal inflectional head and it has been shown that gender mismatch does not improve the comprehension of object relatives (cf. Belletti et al., 2012 for evidence in children and Biondo et al., 2023 for neurotypical adults). A complete list of sentences is presented in **Appendix A**.

For treatment, written labels for the NPs and the verb of all active sentences were developed.

Sentence constituent cards displaying additional morphemes (e.g., the relative complementizer *che* / "that") required for the surface form of object relatives were constructed as well.

### 2.2.3. *Experimental design*

A modified multiple baseline design across participants was used to evaluate treatment efficacy (Thompson, 2006; 2015), whereby all participants were tested during the baseline phase for comprehension and production of all sentence types over four probe sessions, administered on four consecutive days, followed by a six-week pre-treatment control period.

Treatment was initiated for all participants following this control period. Each day during the baseline phase, comprehension and production of all sentence types was assessed, providing a measure of the initial level of competence. Standardized language assessment was also administered during baseline and at the end of the treatment phase together with treatment probes administered in a single session. Maintenance of treatment gains was measured six weeks following cessation of treatment (see **Figure 1**). Treatment probes were readministered
in two sessions over two consecutive days, again evaluating comprehension and production
of all sentences.

INSERT FIGURE 1 HERE

Before each training session, participants were assessed using half of the probes,
alternating between comprehension and production. During all experimental procedures
participants did not receive any other treatment (linguistic/cognitive or physical). All
experimental procedures were administered by author MV, who is a licensed speech-language
therapist.

2.2.4. Probes

Comprehension and production probe sessions entailed testing of all sentence types.
Sentences (total n=80) were pseudorandomized by sentence type and assigned to 8 lists (4 for
comprehension and 4 for production), so that each sentence was never probed for both
comprehension and production in the same session and that each reversible form was probed
in different sessions for comprehension and production. For baseline, post-treatment and
follow up probes, 10 items per sentence type were probed for comprehension and 10 for
production. During the treatment phase, probes (5 items/sentence type) were administered
daily, prior to each treatment session, alternating between comprehension and production.
For both comprehension and production probes, a 10-s response time was allowed. No
feedback was provided to the participants.

**Comprehension probes.** A sentence-picture matching task was employed to test auditory comprehension of the four sentence types. Target sentences were presented auditorily, and participants were required to point to the target picture, with the foil being a picture showing the same participants and the same action, but with reversed thematic roles. Presentation
order of the two pictures was randomized. Responses (correct vs. incorrect) were recorded by
the examiner.

**Production probes.** Production of the four sentence types was elicited using a sentence production priming task (after Thompson, 2011). Participants were presented with a picture pair and asked to listen to a sentence describing the first picture. Then, participants were invited to produce a sentence describing the second picture and using the same structure.

Responses were considered as correct if they were instances of the target sentence type and if thematic roles were correctly assigned. Omissions of free morphology that was irrelevant for the target sentence structure (e.g., articles), as well as plausible lexical substitutions, were accepted. Production of different sentence types or of ill-formed sentences (e.g., omission of the verb or incomplete argument structure), thematic role inversion (i.e., repetition of the prime sentence), implausible lexical substitutions (e.g., production of inanimate arguments in lieu of an animate ones), lexical substitutions that prevented the interpretation of thematic role assignment (e.g., *L'uomo spia l'uomo* – “The man spies on the man” for *L'investigatore spia il ladro* – “The detective spies on the burglar”), and sentences with ungrammatical word order, were all considered as errors.

For passive targets, omission of copulas (i.e., the auxiliary “to be” – è) or of the preposition *da* (by), as well as incorrect gender agreement between the subject and the past participle (e.g., *La donna è sollevato dall'uomo* – “The woman-F.SG is lifted-M.SG by the man-M.SG” for *La donna è sollevata dall'uomo* – “The woman-F.SG is lifted-F.SG by the man-M.SG”), were scored as errors. This last choice differs from the norms used in the Italian version of the Sentence Production Priming Task of the IT-NAVS (Barbieri et al., 2024), where gender agreement is considered irrelevant for the production of the syntactic structure. Although errors in gender agreement can be considered a morphological paragrammatic phenomenon,
they may also hint at an erroneous derivation of the syntactic structure. Namely, such errors
may suggest that the participant incorrectly establishes agreement between the past
participle and the Agent (the by-phrase), rather than between the past participle and the
Patient (the grammatical subject). In such instances, it may be argued that the participant is
producing the agreement pattern of an active sentence despite the order of a passive
sentence, forcing us to doubt a purely morphological/paragrammatic interpretation. Omission
of the auxiliary è ("to be") in object cleft and of the complementizer che ("that") in object
clefts and relatives were also considered as errors. Errors were coded by type.

2.2.5. *Treatment*

Participants underwent six weeks of individual intensive training focused on object relatives. The eight-step procedure for object relative treatment described in Thompson et al., (2003) was adapted, with the number of items trained during each session recorded. All treatment sessions were 45-minutes in duration and were provided four times per week.

Step 1: Comprehension probe and feedback. The procedure is identical to the one described for the comprehension probes, randomly selecting a stimulus (within the object relatives sentence set with the 10 trained verbs). In case of incorrect response, the therapist repeats the target sentence and points out the agent and the theme of the action on the target picture. In case of correct answer, positive feedback is provided.

Step 2: Sentence production priming probe. The pair of pictures for the selected stimulus remains visible. The procedure is then identical to the one described for production probes.

In case of a correct answer, positive feedback is provided and a new stimulus is shown, starting from Step 1. Otherwise, training proceeds with the following steps.
Step 3: Verb and verb arguments comprehension. From this step on, the “parts” of the sentence are presented in written form on individual cards. The therapist displays these cards to form the two simple sentences corresponding to the two clauses of the target object relative. For example, [Gianni] [guarda] [la donna] (i.e., “John sees the woman”) and [l’uomo] [porta] [la donna] (i.e., “the man carries the woman”). The therapist then guides the participant in the analysis of the two sentences by providing the following instructions: “point to the action word”, “point to the doer of the action to see/carry”, and “point to the receiver of the action to see/carry”. Incorrect responses are corrected with reference to the target picture. Correct responses determined positive feedback.

Step 4: Verb and verb arguments production. Leaving the written cards in the same order, the therapist asks the participant to produce the verb and the verb arguments, one sentence at a time, with the following instructions: “name the action word”, “name the doer of the action to see/carry”, and “name the receiver of the action to see/carry”. Feedback is again provided and errors are corrected by modelling the target answer.

Step 5: Object relative construction. The therapist describes the objective of creating a new sentence that merges the two simple sentences. A new card with the complementizer [che] (i.e., “that”) is introduced as “linking word” between the two clauses. The therapist explains that [la donna]/“the woman” in the second sentence is the same as the one in the first sentence. Therefore, the corresponding card can be moved next to the first one and, since they are the same, it can be removed. The participant is instructed to read/repeat the sentence in the target form. In this step, the underlying syntactic movement is therefore physically enacted as in the example below.

<figure><img src="image_3.png" /></figure>
*Step 6:* Comprehension and production of the verbs and the verb arguments in the object relative structure. *Steps 3 and 4* are repeated using the same instructions to make the participant identify and produce the verbs and their arguments of the two clauses of the target structure. Feedback and modelling in case of error are provided.

*Step 7:* Autonomous execution of *Steps 4 to 6*. The cards are rearranged to form again the two active sentences (like in *Step 3 and 4*). The participant is asked to execute in autonomy *Step 4 to 6* and, by doing so, to enact the syntactic movement in order to generate the target object relative structure.

*Step 8:* Repetition of *Steps 1 and 2* for further reinforcement.

## 2.3. Statistical Analysis

Analyses followed the procedures adopted in previous studies on TUF (Thompson et al., 2003, 2021). Individual performance on the daily probe tasks (for both comprehension and production) were plotted over time to show acquisition curves for all trained (object relatives with the 10 verbs used during the treatment), untrained (object relatives with the 10 verbs *not* used during the treatment) and control (actives, passives and clefts with all the 20 verbs) items during all the phases of the study (baseline, treatment, and follow-up). Performance at baseline, pre- and post-treatment and follow-up was compared by calculating effect sizes for all the tested structures using Cohen's *h* (1988).

Baseline accuracy was computed as the average of the four baseline probes, after ensuring stable performance by comparing average accuracy on the first two sessions to the average accuracy of the last two sessions. Pre-treatment accuracy was computed as the average of the daily probes in the first week of treatment. For post-treatment accuracy, we used the scores
obtained on the post-treatment probes, while for the follow-up time point, we calculated the average of the two follow-up sessions.

Cohen's *h* was also used to compare the performances on the IT-NAVS between pre- and post-treatment evaluations. As for pre- vs. post-treatment AAT performances, significant differences were assessed according to the psychometric single case analysis procedure described in Luzzatti et al. (2023). For the IT-CETI, the cut-off of a 10mm increase in the self-reported score for each item was considered as indicative of significant improvement, according to the norms (Moretta et al., 2021).

In addition, we reported descriptive statistics for the characteristics of spontaneous speech pre- and post-treatment and for error analysis of the production probes at each time point (baseline, first week, post-treatment, and follow-up).

# 3. RESULTS

## 3.1. Participants' characteristics

Participants' characteristics are displayed in **Table 1**. All participants were right-handed and presented with a single extensive lesion in the left hemisphere (four out of five following an ischemic stroke, one following an AVM rupture). Neuroimaging data were not available. Standardized language assessment and analysis of spontaneous speech confirmed the presence of language deficits consistent with nonfluent aphasia and agrammatism in all participants (i.e., better production and comprehension of canonical sentences than non-canonical ones, reduced speech rate, production of short and simple sentences, fewer production of verbs in comparison to nouns, omission of free and bound morphemes; the relevant data are presented below in **Table 4 and 5** under pre-treatment).

INSERT TABLE 1 HERE
All participants completed the study, with the exception of LM, who was unable to take part in the fourth baseline evaluation and three training sessions during the fifth week due to health issues. Overall, the average number of trained items for each week increased during the training period, going from a range of 1.25-3.5 to a range of 4.5-13.75, with large variability among participants (see **Supplementary Table 1**).

**3.2. Production probes**

Individual performances on the production probes in each phase of the protocol are reported in **Table 2** and plotted in **Figure 2**.

INSERT TABLE 2 AND FIGURE 2 (from a. to d.) HERE

No difference was found among the multiple baseline evaluations or between the baseline and the first week of training for any of the participants. With respect to object relatives, no difference was found between the trained and the untrained items either at baseline or during treatment. For this reason, in the following analyses, accuracy on object relatives is reported as the average of trained and untrained items.

All participants displayed large treatment gains (large effect size according to Cohen's *h*) in production of object relatives (trained structures, A'-movement, high complexity) that were maintained at follow-up for all five participants (**Figure 2a**). Baseline accuracy across participants ranged between 0% and 6.3%, while post-treatment accuracy ranged between 75% and 100%. Accuracy at follow-up remained stable, at high levels, for PP, EB and LM (ranging from 87.5% to 95% accuracy), while it slightly decreased for SP and AG (55% and 47.5% respectively), but remained superior to baseline performance for both participants.

As for object clefts (untrained structures, A'-movement, lower complexity: expected generalization according to CATE), all participants reported large effect size treatment gains
according to Cohen's *h* (Figure 2b). Three out of five participants (PP, EB and SP) reached levels of accuracy comparable to that displayed for object relatives (100%, 80% and 90% respectively), whereas, LM reached a 60% post-treatment accuracy and AG only 20%. Treatment gains were maintained at follow-up for two individuals (PP: 90% and EB: 80%). All the others showed a decrease in the accuracy (ranging from 10% to 55%) that, however, remained higher than baseline performance.

Three out of five participants also reported a large improvement on passive sentences (untrained structures, A-movement: unexpected generalization according to CATE; Figure 2c). PP reached a high level of accuracy (80%) that remained stable at follow-up (85%). EB and SP showed a lower level of post-treatment accuracy (50%) with a moderate loss at follow-up (25% and 35% accuracy respectively). LM and AG showed no generalization to passive sentence production.

Baseline accuracy on simple active sentences (untrained; **Figure 2d**) was high in four (PP, EB, SP, LM) out of five individuals (ranging from 72.5% to 92.5%). AG showed a baseline accuracy of 40%. All were at ceiling-level performance (100% accuracy) at post-treatment, and performance remained stable at follow-up (ranging from 85% to 100%).

**Supplementary Tables 2 to 6** display a detailed analysis of the participants' errors on the production probes, separately for each sentence type. All participants exhibited a global shift from the production of ill-formed, incomplete and/or unstructured utterances (during the baseline and in the first week of the treatment) to the production of grammatical sentences different from the probed structure – e.g., production of a grammatical cleft in place of a relative (during post-treatment and follow-up evaluations). Examples of the first type or errors are verb omission, incomplete argument structure, ungrammatical word order, while for the second type of errors, participants often produced the target structure with the inversion of
the thematic roles (i.e., repeating the model offered by the examiner) or a structure different
from the target (e.g., subject clefts and relatives instead of object clefts and relatives; active
sentences instead of passives). PP and SP mostly exhibited errors of this second type with rare
omissions of free morphology. On the contrary, EB and LM showed frequent morphological
errors, such as omissions of the auxiliary è/"to be" in passives and clefts, of the preposition
da introducing the by-phrase in passives, and (less frequently) the complementizer che/"that"
in clefts and relatives. AG displayed errors of the first type (ill-formed productions) in post-
treatment and follow-up assessment as well, although with an overall reduction of the
number of items eliciting no response, interjections or stereotyped expressions.

**3.3. Comprehension probes**

Individual performances on the comprehension probes in each phase of the protocol are
reported in **Table 3** and **Figure 3**. In line with the production probes, no differences were found
among the multiple baseline probes or between baseline and the first week of training for any
of the participants. Similarly, no difference was found between trained and untrained object
relatives. Therefore, data are reported as an average of trained and untrained sentences.
Comprehension trajectories over time were more homogeneous across participants than
production trajectories for all sentence types.

INSERT TABLE 3 AND FIGURE 3 (from a. to d.) HERE

Comprehension of object relatives (trained structures, A'-movement, high complexity;
**Figure 3a**) was quite high at baseline for 2/5 participants (PP: 71.3% and EB: 76.3%). All
participants showed significant treatment gains (large effect size for PP, EB, SP and medium effect size for LM and AG) that were maintained at follow-up.

Accuracy on object clefts (untrained structures, A'-movement, lower complexity; **Figure 3b**) largely improved during the training period for all participants, with 3/5 (PP, EB, and SP) maintaining this gain at follow-up.

The same three participants showed significant improvement (large effect size for PP and EB; medium for SP) in comprehension of passive sentences (untrained structures, A-movement; **Figure 3c**) that was maintained at follow-up. More modest improvements were observed in LM and AG (medium and small effect size, respectively), with AG showing maintenance at follow-up.

Comprehension of simple active sentences (untrained, **Figure 3d**) was high at baseline across all participants, albeit lower for LM and AG than for the other three participants. Performance in these two participants was quite variable, and although accuracy improved during treatment in both, a decline was observed at follow-up.

Overall, all sentence types were associated with an improvement trend across the participants, although this gain was not strong or stable at follow-up for two participants (LM and AG).

**3.4. Standardized testing**

The results of the standardized neuropsychological assessment (IT-AAT, IT-NAVS, and Digit Span) are reported in **Table 4**, responses to the IT-CETI are shown in **Supplementary Table 7**, and the analysis of spontaneous speech is reported in **Table 5**.

INSERT TABLE 4 HERE
### 3.4.1. IT-AAT

The AAT overall score (AAT profile's height) significantly improved for 3/5 participants (PP, EB and SP), according to the AAT psychometric single-case diagnostic procedure (Luzzatti et al., 2023). While no changes were found in spontaneous speech or on the Token Test for any of the participants, improved accuracy was found for one participant (PP) on the Repetition test, and for 2/5 participants on the Written Language (EB and SP), Naming (SP and AG), and Comprehension (PP and EB) subtests.

### 3.4.2. IT-NAVS

Performance on the Verb Naming Task (VNT) improved in 3/5 participants (EB, LM and AG), with the other two (PP and SP) showing ceiling-level performance at baseline. Accuracy on the Verb Comprehension Task (VCT) was at ceiling for all participants on both pre- and post-treatment assessments. On the Argument Structure Production Task (ASPT), improved accuracy was seen in 2/5 participants (LM and AG); the remaining 3 participants showed high performance at baseline. Improved production of free morphology was observed in 3/5 participants (EB, SP, and LM). The Sentence Production Priming Task (SPPT) showed large improvements for 4/5 participants, and a small improvement for AG. With respect to sentence types, performance on subject and object relatives largely improved in 4/5 participants, with the remaining one (AG) showing improvement only on object relatives. Production of subject and object clefts largely improved in 3/5 participants (PP, EB, SP), whereas no improvement was found on passives for any of the participants. Production of actives improved in 3/5 participants (EB, LM and AG). On the Sentence Comprehension Task (SCT), smaller improvements were seen in all participants due to an overall higher baseline performance
than on the SPPT. Nevertheless, comprehension of object relatives and object clefts largely
improved in all participants, and 2/5 participants (PP and SP) also showed improved
comprehension of passive sentences.

3.4.3. Forward and backward Digit Span

No change in accuracy was found between pre- and post-treatment on Forward and
Backward Digit Span tests (see **Table 4**).

3.4.4. IT-CETI

**Supplementary Table 7** shows the self-reported agreement to the different statements regarding communication efficacy included in IT-CETI. Considering the cut-off for significant change (Moretta et al., 2021), all participants (except EB) reported a higher perceived improvement than their caregivers. Adding for each item of IT-CETI the number of participants and caregivers who reported an improvement, the statements associated with the highest gain are: "Getting involved in group conversations that are about him/her"; "Starting a conversation with people who are not close family"; Having coffee-time visits and conversations with friends and neighbors (around the bedsides or at home)"; Communicating physical problems such as aches and pains"; and "Describing or discussing something in depth".

3.4.5. Spontaneous speech

The analysis of the spontaneous speech (see **Table 5**) did not reveal any major change
across participants. A mild increase in the verbs to nouns ratio and in the production of
sentences with a complete argument structure was found for all participants. A higher number
of subordinate clauses on the post-treatment evaluation was observed in PP.
# 4. DISCUSSION

The present study used a modified multiple-baseline across participants design to investigate the efficacy and the generalization patterns of Treatment of Underlying Forms (TUF) in its Italian adaptation. Rather than staggering the length of the baseline phase across participants, all participants received four consecutive baseline probes, followed by a six-week period with no intervention, which was followed immediately by treatment. TUF was used to train sentences with object relative clauses in five people with nonfluent agrammatic aphasia following stroke in chronic phase. The results confirm that TUF is effective for treating Italian-speaking people with aphasia who evince impairments in sentence processing and that treatment effects generalize to untrained material and structures in keeping with the results of studies examining the effectiveness of TUF in English (Swiderski et al., 2021; Thompson, 2019).

## 4.1. Efficacy and generalization patterns in Italian TUF

The stable performance across the four baseline evaluations found in all participants indicates that the changes found in sentence production and comprehension across participants resulted from treatment and cannot be explained by mere exposure to the study materials. Moreover, the finding that performance remained stable during the six weeks between the end of the baseline evaluation and the beginning of the training demonstrates that the results cannot be attributed to general recovery from aphasia or to extraneous variables.
Results obtained from trained structures (object relatives) in comprehension and production support the efficacy of TUF, in line with previous studies on English (Thompson et al., 2003), as shown by the large improvements observed in all participants on both comprehension and production of object relatives, which were maintained at follow-up. In addition, the lack of differences in performance between trained and untrained items supports the ability of TUF to generalize to untrained items within the same trained sentence type.

As predicted by the Complexity Account of Treatment Efficacy (CATE, Thompson & Shapiro, 2007; Thompson et al., 2003) and in line with previous studies (Thompson et al., 2010a, 2010b, 2003), we found an improvement in production and comprehension of object clefts in all participants (with only AG showing a smaller degree of improvement). Object clefts are A'-structures, like object relatives, and they have been described as structurally simpler to relatives (see the Introduction). Therefore, this result supports the idea that generalization occurs from complex to simpler structures that share the same type of syntactic movement.

As for the generalization across structures characterized by different types of syntactic movement, we also found an improvement on passive sentences (i.e., A-structures) for some participants (3/5 in production and 4/5 in comprehension), albeit to a smaller extent. A possible explanation of this finding – which is consistent with evidence from a previous study in German (Stadie et al., 2008) – is provided in the following section (4.2).

Interestingly, we found that production and comprehension of simple active sentences largely improved in all participants, who showed an almost-at-ceiling level of accuracy at post-treatment. This result aligns with prior research on English simple active sentences (see Barbieri et al., 2019a; Thompson et al., 2003), suggesting that TUF effectively enhances the
ability to process the verb argument structure and thus further supports generalization from
complex to simpler syntactic structures.

As for generalization from production to comprehension (given the stronger focus of TUF
on training production), mixed evidence can be found in the literature. In this study, we found
consistent improvement on the comprehension probes and on the Sentence Comprehension
Task of the IT-NAVS. Our results are not in line with some previous studies on English (Jacobs
& Thompson, 2000) and German (Schröder et al., 2015), as participants in these studies did
not show improvements in sentence comprehension despite significant gains in production.
However, other studies using TUF (Barbieri et al., 2019a; Thompson et al., 2003, 2010a, 2010b,
2021) and Mapping Therapy (Schwartz et al., 1994; Jones, 1986) in English-speaking
individuals with aphasia provide evidence in favor of cross-modal generalization.
Generalization from production to comprehension relies on the centrality of thematic-
argument mapping to both modalities. The latter is emphasized in both TUF, in which several
training steps require the participant to analyze and identify the thematic roles in both
canonical and non-canonical forms, and Mapping Therapy. The focus of TUF on thematic-
argument mapping may have promoted the improvement of meaning extraction, thereby
boosting comprehension. A possible explanation for different results among the studies may
be related to small differences in training procedures: Schröder et al. (2015) and Jacobs &
Thompson (2000) adopted a training method in which there is no step involving a sentence-
to-picture matching via pointing. In this way, there is no direct training of comprehension, as
it is assessed in probes. On the contrary, in many studies on English TUF and in our study, the
training procedure (as described in Thompson et al., 2003) consists in a sentence-to-picture
matching via pointing for Step 1 and 8. In this way, even if TUF training is focused on
production, comprehension abilities are reinforced.
Clearly, different patterns of generalization across participants and across studies may stem
from inter-individual variability in individuals with agrammatism, who show variable
responses to treatment and different language profiles. Our data do not provide a definitive
answer to these questions. In this respect, in-depth characterization of lesion location with
neuroimaging is fundamental for pursuing this line of research.

Our results also indicate that TUF yields improvements on standardized assessments for
aphasia. Results on the IT-NAVS showed improved sentence production for all participants on
both canonical and non-canonical sentence structures. The IT-NAVS Argument Structure
Production subtest also showed improved production of free morphology at the group level.
These findings are in line with the reduced number of morpheme omissions/substitutions
observed on the probes following treatment. In addition, the error analysis showed a general
trend from production of incomplete and/or unstructured utterances (e.g., verb omission,
incomplete argument structure, ungrammatical word order) to production of well-formed but
non-target sentences (e.g., inversion of the thematic roles, production of a structure different
from the target one). Small improvements on the IT-AAT were also found in the three
participants who best responded to treatment, although on different subtests on different
participants. Taken together, these results indicate that TUF promotes a general improvement
of linguistic (especially morphosyntactic) abilities, even those that are not targeted by
treatment.

The performance on the Digit Span test did not change following treatment. This might
appear unexpected, since processing of complex noncanonical sentences, like object relatives,
has been linked to higher cognitive demands, namely to a higher phonological short-term
memory load (Papagno & Cecchetto, 2019; but see Caplan et al., 2007; Caplan & Waters,
1999). However, the Digit Span test relies on production abilities that might be impaired in
people with nonfluent aphasia (e.g., with impaired lexical access for digits, articulation deficit, and slow speech), impacting its validity as a measure of short-term and working memory in this population (cf. DeDe et al., 2014). Adopting a Digit Span task via pointing on a visual support, which does not require speech production, might provide a more reliable measure for verbal short-term and working memory (cf. Ryan et al., 2014 for the equivalence of oral and pointing Digit Span in the general population). An alternative procedure, which does not involve the repetition of sequences, is words and pseudowords recognition in a list (adopted by Miceli et al., 1994 for Italian). Such tasks could, therefore, clarify whether TUF is able to induce an improvement of phonological short-term and working memory.

Finally, the IT-CETI revealed a self-reported improvement in communicative efficacy, especially in the items regarding conversational function. These findings hint at a possible effect of TUF on functional communication. Yet, the analysis of spontaneous speech did not show relevant changes between the pre- and post-treatment evaluations, suggesting that the previous statement should be taken with caution. It should be noted that improved scores on the IT-CETI could also be induced by an acquaintance bias, since participants and caregivers were familiar with the researcher, who administered the questionnaire and served both as evaluator and therapist.

## 4.2. Generalization across movement types and revision of CATE

Although results obtained from English-speaking individuals with aphasia support the CATE assumption of no generalization from A' to A-movement (Thompson & Shapiro, 2005; Thompson et al. 2003), our study is not the first to report data that are not in full agreement with this principle. A generalization trend from object relatives to passives was found in German-speaking people with agrammatism trained with TUF (Stadie et al., 2008). As
described in the introduction, Stadie and colleagues (2008) proposed an explanation in line
with the Tree Pruning Hypothesis (Friedmann, 2001; Friedmann & Grodzinsky, 1997).
Generalization would occur from object relatives to passives since the latter structure activate
a lower number of phrasal nodes. Although this account could be valid for both Italian and
German results, it does not explain the lack of generalization from object relatives to passives
in English (Thompson & Shapiro, 2005; Thompson et al. 2003) and therefore lacks
crosslinguistic validity. Moreover, the Tree Pruning Hypothesis is highly debated as it presents
theoretical and empirical problems, that go beyond the purpose of the present study (cf.
Druks, 2014 for a review).

A possible explanation of the differences in the generalization patterns of TUF between
German and English may stem from differences in the syntactic structure of passives in the
two languages. Namely, Drai and Grodzinsky (2006) propose that the moved NP does not need
to cross the lexical verb in German passives. In addition, in the passive sentences studied by
Stadie et al. (2008), the internal argument moves to the initial position, which is identified as
Spec,CP in Verb Second languages like German (Haider, 1986). As Spec,CP is the position
targeted by A'-movement, including in relatives, the passives by Stadie have positional
properties that make them more similar to relatives, when compared to English and Italian
passives. Therefore, generalization from relatives to passives may occur due to shared
properties in both structures. It should be noted that this explanation does not apply to Italian,
where passives show the same derivation as English, including verb crossing and movement
of the internal argument to Spec,IP (as opposed to Spec,CP).

In line with Stadie et al. (2008), our results follow the generalization from complex to
simpler structures predicted by CATE, but not with the assumed lack of generalization across
different types of syntactic movements (Thompson & Shapiro, 2007; Thompson et al., 2003).
A tentative explanation for our findings builds on a parallelism between language acquisition and acquired disorders of morphosyntax. Rich functional morphology is not a source of difficulty for language acquisition in children; rather, it facilitates the acquisition of both free and inflectional morphology and syntax. For example, Italian children display an early mastery of passives (Belletti & Guasti, 2015), articles (Belletti & Guasti, 2015), and finiteness (Phillips, 2010; Guasti, 1993), in comparison with English-speaking children. Passive morphology is richer in Italian than English, given that the past participle agrees in gender and number features with the subject NP. Richer morphology may support the processing of passives in Italian, because overt gender and number features could facilitate thematic roles assignment. This facilitating effect could also account for the overall better performance with passives in Italian-speaking (versus English-speaking) people with agrammatism (Drai and Grodzinsky, 2006) and for the differences in the generalization pattern between the present study and the literature (Thompson & Shapiro, 2005; Thompson et al. 2003). However, further studies are needed to confirm this hypothesis, given that the parallelisms between developmental and neurological populations are not straightforward. In this respect, future studies could examine whether a mismatch in morphologically marked grammatical features (e.g., number and gender) between the subject NP and the NP in the *by*-phrase can modulate the comprehension and the production of passives in Italian speakers with agrammatism.

To summarize, the generalization to passives, observed in Italian and German but not in English, could be due to different factors: the characteristics of syntactic movement in German (absence of verb crossing and/or A'-properties) and the morphological richness in Italian. This finding further supports the importance of investigating the crosslinguistic validity of CATE as different linguistic properties seem to impact on generalization pattern.
In conclusion, our findings point towards a revision of CATE. We propose that TUF is effective on the more general operation *Internal Merge*. The distinction between A- and A'-movement does not emerge as a primitive explaining the generalization trend but as a factor that modulates the effect of training. The more the structures are similar, the stronger is the generalization; however, other elements of complexity, such as the richness of the morphological system and crosslinguistic differences in the syntactic derivation of the target structures, may affect performance as well.

## 4.3 Limitation and future developments

A first limitation of this study is the unavailability of neuroimaging data, as this information would have allowed a better characterization of the participants, possibly providing an explanation for the interindividual differences in the results.

Moreover, it should be noted that the study presents a risk of bias, since the same researcher served as both examiner and therapist due to resource limitations.

Further studies should also consider a larger sample size, allowing group analyses and a more complex design (e.g., testing the generalization from simple to complex sentences, from A- to A'-structures) and possibly clustering the participants in significant subgroups (e.g., lesion site, level of impairment, presence vs. absence of a specific morphological deficit).

## 4.4. Conclusion

Our study demonstrated the cross-linguistic validity of Treatment of Underlying Forms (TUF) for object relatives in Italian-speaking individuals with agrammatism. The large improvement found in all participants in production and comprehension of trained structures and the noted generalization from trained to untrained syntactic structures or lesser syntactic
complexity support the adoption of TUF into clinical practice with Italian speakers with
agrammatism. The unexpected generalization from treated A'-structures to untreated A-
structures in some participant led us to propose a revision of the Complexity Account of
Treatment Efficacy (CATE). TUF improves processing of syntactic movement (Internal Merge)
in general, and movement type is a modulating factor along with other characteristic of the
language and the stimuli. In particular, the generalization from object relatives (A'-structure)
to passives (A-structure) in Italian-speakers (vs. English-speakers) might be explained in terms
of morphological richness (i.e., number and gender marking on the past participle in Italian
passives contributes cues that can facilitate syntactic processing and thematic roles
assignment). Future studies are needed to confirm these promising results for the treatment
of other syntactic structures and to further support our claims.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study and the supplementary materials are openly
available in OSF repository at:

<https://osf.io/sypaz/?view_only=1e71af7e1a734504a8b9dbd78efb98e8>

FUNDING STATEMENT

This study did not receive any specific funding.

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TABLES

<table><caption>**Table 1.** Demographic and clinical data of the participants.</caption><thead><tr><td>ID</td><td>Gender</td><td>Age Years</td><td>Education Years</td><td>Handedness</td><td>TPO Month</td><td>Etiology</td><td>Lesion site</td></tr></thead><tbody><tr><td>PP</td><td>M</td><td>22</td><td>13</td><td>R</td><td>41</td><td>Hemorrhagic AVM rupture</td><td>LH Fronto-temporal</td></tr><tr><td>EB</td><td>F</td><td>55</td><td>13</td><td>R</td><td>158</td><td>Ischemic MCA occlusion</td><td>LH Fronto-insular and nucleo-capsular</td></tr><tr><td>SP</td><td>M</td><td>51</td><td>18</td><td>R</td><td>23</td><td>Ischemic MCA occlusion</td><td>LH Cortical (Rolandic and prerolandic regions) and nucleo-capsular</td></tr><tr><td>LM</td><td>F</td><td>60</td><td>13</td><td>R</td><td>149</td><td>Ischemic MCA occlusion</td><td>LH Fronto-temporo-parietal</td></tr><tr><td>AG</td><td>M</td><td>40</td><td>13</td><td>R</td><td>14</td><td>Ischemic MCA occlusion</td><td>LH Fronto-parietal and frontal anterior</td></tr></tbody></table>

**Notes.** ID=Participant's identifier; F=Female; M=Male; R=Righthanded; TPO=Time Post Onset; AVM=ArterioVenous Malformation; MCA=Middle Cerebral Artery; LH=Left-hemispheric stroke.
<table><caption>**Table 2.** Average performance (percentage of correct answers) in production probes for each participant and each sentence type at baseline, post-treatment and follow-up evaluations. Differences in performance between time points are reported, together with a measure of effect size.</caption><thead><tr><th>Sentence Type</th><th>B</th><th>P</th><th>FU</th><th>Δ P-B</th><th>H P-B</th><th>Δ FU-B</th><th>H FU-B</th></tr></thead><tbody><tr><td><strong>ORS</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>PP</td><td>6.3%</td><td>95.0%</td><td>95.0%</td><td>88.8%</td><td>2.185</td><td>88.8%</td><td>2.185</td></tr><tr><td>EB</td><td>3.8%</td><td>75.0%</td><td>87.5%</td><td>71.3%</td><td>1.705</td><td>83.8%</td><td>2.029</td></tr><tr><td>SP</td><td>1.2%</td><td>90.0%</td><td>55.0%</td><td>88.8%</td><td>2.274</td><td>53.8%</td><td>1.447</td></tr><tr><td>LM</td><td>0.0%</td><td>100%</td><td>95.0%</td><td>100%</td><td>3.142</td><td>95.0%</td><td>2.691</td></tr><tr><td>AG</td><td>0.0%</td><td>75.0%</td><td>47.5%</td><td>75.0%</td><td>2.094</td><td>47.5%</td><td>1.521</td></tr><tr><td><strong>OCs</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>PP</td><td>10.0%</td><td>100%</td><td>90.0%</td><td>90.0%</td><td>2.498</td><td>80.0%</td><td>1.855</td></tr><tr><td>EB</td><td>0.0%</td><td>80.0%</td><td>80.0%</td><td>80.0%</td><td>2.214</td><td>80.0%</td><td>2.214</td></tr><tr><td>SP</td><td>0.0%</td><td>90.0%</td><td>55.0%</td><td>90.0%</td><td>2.498</td><td>55.0%</td><td>1.671</td></tr><tr><td>LM</td><td>0.0%</td><td>60.0%</td><td>40.0%</td><td>60.0%</td><td>1.772</td><td>40.0%</td><td>1.369</td></tr><tr><td>AG</td><td>0.0%</td><td>20.0%</td><td>10.0%</td><td>20.0%</td><td>0.927</td><td>10.0%</td><td>0.644</td></tr><tr><td><strong>Passives</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>PP</td><td>22.5%</td><td>80.0%</td><td>85.0%</td><td>57.5%</td><td>1.226</td><td>62.5%</td><td>1.358</td></tr><tr><td>EB</td><td>2.5%</td><td>50.0%</td><td>25.0%</td><td>47.5%</td><td>1.253</td><td>22.5%</td><td>0.730</td></tr><tr><td>SP</td><td>12.5%</td><td>50.0%</td><td>35.0%</td><td>37.5%</td><td>0.848</td><td>22.5%</td><td>0.543</td></tr><tr><td>LM</td><td>3.3%</td><td>0.0%</td><td>5.0%</td><td>-3.3%</td><td>-0.367</td><td>1.7%</td><td>0.084</td></tr><tr><td>AG</td><td>0.0%</td><td>0.0%</td><td>0.0%</td><td>0.0%</td><td>0.000</td><td>0.0%</td><td>0.000</td></tr><tr><td><strong>Actives</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>PP</td><td>92.5%</td><td>100%</td><td>100%</td><td>7.5%</td><td>0.555</td><td>7.5%</td><td>0.555</td></tr><tr><td>EB</td><td>72.5%</td><td>100%</td><td>85.0%</td><td>27.5%</td><td>1.104</td><td>12.5%</td><td>0.309</td></tr><tr><td>SP</td><td>82.5%</td><td>100%</td><td>100%</td><td>17.5%</td><td>0.863</td><td>17.5%</td><td>0.863</td></tr><tr><td>LM</td><td>83.3%</td><td>100%</td><td>95.0%</td><td>16.7%</td><td>0.841</td><td>11.7%</td><td>0.390</td></tr><tr><td>AG</td><td>40.0%</td><td>100%</td><td>95.0%</td><td>60.0%</td><td>1.772</td><td>55.0%</td><td>1.321</td></tr></tbody></table>

**Notes.** ORs=Object Relatives; OCs=Object Clefts; B=Average of baseline assessment (percentage of correct answers); P=Post-treatment assessment; FU=Average of the follow-up assessment; Δ=Difference between the performances; H=Cohen's *h* between the two proportions of correct answers.
<table><caption>**Table 3.** Average performance (percentage of correct answers) on comprehension probes for each participant and each sentence type at baseline, post-treatment and follow-up evaluations. Differences in performance between time points are reported, together with a measure of effect size.</caption><thead><tr><th>Sentence Type</th><th>B</th><th>P</th><th>FU</th><th>Δ P-B</th><th>H P-B</th><th>Δ FU-B</th><th>H FU-B</th></tr></thead><tbody><tr><td><strong>ORS</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>PP</td><td>71.3%</td><td>100%</td><td>92.5%</td><td>28.8%</td><td>1.132</td><td>21.3%</td><td>0.577</td></tr><tr><td>EB</td><td>76.3%</td><td>100%</td><td>97.5%</td><td>23.8%</td><td>1.018</td><td>21.3%</td><td>0.701</td></tr><tr><td>SP</td><td>46.3%</td><td>95.0%</td><td>85.0%</td><td>48.8%</td><td>1.195</td><td>38.8%</td><td>0.850</td></tr><tr><td>LM</td><td>33.3%</td><td>70.0%</td><td>67.5%</td><td>36.7%</td><td>0.751</td><td>34.2%</td><td>0.697</td></tr><tr><td>AG</td><td>41.3%</td><td>75.0%</td><td>70.0%</td><td>33.8%</td><td>0.700</td><td>28.8%</td><td>0.587</td></tr><tr><td><strong>OCs</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>PP</td><td>62.5%</td><td>90.0%</td><td>95.0%</td><td>27.5%</td><td>0.675</td><td>32.5%</td><td>0.867</td></tr><tr><td>EB</td><td>65.0%</td><td>100%</td><td>95.0%</td><td>35.0%</td><td>1.266</td><td>30.0%</td><td>0.815</td></tr><tr><td>SP</td><td>45.0%</td><td>80.0%</td><td>75.0%</td><td>35.0%</td><td>0.744</td><td>30.0%</td><td>0.624</td></tr><tr><td>LM</td><td>40.0%</td><td>80.0%</td><td>55.0%</td><td>40.0%</td><td>0.845</td><td>15.0%</td><td>0.302</td></tr><tr><td>AG</td><td>37.5%</td><td>80.0%</td><td>65.0%</td><td>42.5%</td><td>0.896</td><td>27.5%</td><td>0.557</td></tr><tr><td><strong>Passives</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>PP</td><td>75.0%</td><td>90.0%</td><td>95.0%</td><td>15.0%</td><td>0.404</td><td>20.0%</td><td>0.596</td></tr><tr><td>EB</td><td>77.5%</td><td>100%</td><td>95.0%</td><td>22.5%</td><td>0.988</td><td>17.5%</td><td>0.537</td></tr><tr><td>SP</td><td>50.0%</td><td>80.0%</td><td>85.0%</td><td>30.0%</td><td>0.644</td><td>35.0%</td><td>0.775</td></tr><tr><td>LM</td><td>40.0%</td><td>70.0%</td><td>50.0%</td><td>30.0%</td><td>0.613</td><td>10.0%</td><td>0.201</td></tr><tr><td>AG</td><td>50.0%</td><td>60.0%</td><td>70.0%</td><td>10.0%</td><td>0.201</td><td>20.0%</td><td>0.412</td></tr><tr><td><strong>Actives</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>PP</td><td>90.0%</td><td>100%</td><td>100%</td><td>10.0%</td><td>0.644</td><td>10.0%</td><td>0.644</td></tr><tr><td>EB</td><td>97.5%</td><td>100%</td><td>100%</td><td>2.5%</td><td>0.318</td><td>2.5%</td><td>0.318</td></tr><tr><td>SP</td><td>90.0%</td><td>90.0%</td><td>95.0%</td><td>0.0%</td><td>0.000</td><td>5.0%</td><td>0.192</td></tr><tr><td>LM</td><td>70.0%</td><td>80.0%</td><td>80.0%</td><td>10.0%</td><td>0.232</td><td>10.0%</td><td>0.232</td></tr><tr><td>AG</td><td>75.0%</td><td>100%</td><td>85.0%</td><td>25.0%</td><td>1.047</td><td>10.0%</td><td>0.252</td></tr></tbody></table>

**Notes.** ORs=Object Relatives; OCs=Object Clefts; B=Average of baseline assessment (percentage of correct answers); P=Post-treatment assessment; FU=Average of the follow-up assessment; Δ=Difference between the performances; H=Cohen's *h* between the two proportions of correct answers.
<table><caption>**Table 4.** Pre- and post-treatment performance on standardized language assessments for each participant. Differences in performance between time points are reported, together with a measure of effect size.</caption><thead><tr><th rowspan="2">ID<br>Test</th><th colspan="4">PP</th><th colspan="4">EB</th><th colspan="4">SP</th><th colspan="4">LM</th><th colspan="4">AG</th></tr><tr><th>Pre</th><th>Post</th><th>Δ</th><th>Sign/H</th><th>Pre</th><th>Post</th><th>Δ</th><th>Sign/H</th><th>Pre</th><th>Post</th><th>Δ</th><th>Sign/H</th><th>Pre</th><th>Post</th><th>Δ</th><th>Sign/H</th><th>Pre</th><th>Post</th><th>Δ</th><th>Sign/H</th></tr></thead><tbody><tr><td>AAT COM</td><td>2</td><td>3</td><td></td><td></td><td>2</td><td>2</td><td></td><td></td><td>2</td><td>2</td><td></td><td></td><td>2</td><td>2</td><td></td><td></td><td>1</td><td>1</td><td></td><td></td></tr><tr><td>AAT ART</td><td>3</td><td>3</td><td></td><td></td><td>2</td><td>2</td><td></td><td></td><td>3</td><td>3</td><td></td><td></td><td>2</td><td>2</td><td></td><td></td><td>1</td><td>1</td><td></td><td></td></tr><tr><td>AAT AUT</td><td>4</td><td>4</td><td></td><td></td><td>3</td><td>3</td><td></td><td></td><td>4</td><td>4</td><td></td><td></td><td>3</td><td>3</td><td></td><td></td><td>3</td><td>3</td><td></td><td></td></tr><tr><td>AAT SEM</td><td>4</td><td>4</td><td></td><td></td><td>4</td><td>4</td><td></td><td></td><td>4</td><td>4</td><td></td><td></td><td>3</td><td>4</td><td></td><td></td><td>3</td><td>4</td><td></td><td></td></tr><tr><td>AAT PHO</td><td>4</td><td>4</td><td></td><td></td><td>4</td><td>4</td><td></td><td></td><td>4</td><td>4</td><td></td><td></td><td>4</td><td>4</td><td></td><td></td><td>4</td><td>4</td><td></td><td></td></tr><tr><td>AAT SYN</td><td>2</td><td>2</td><td></td><td></td><td>1</td><td>1</td><td></td><td></td><td>1</td><td>1</td><td></td><td></td><td>1</td><td>1</td><td></td><td></td><td>1</td><td>1</td><td></td><td></td></tr><tr><td>AAT TT</td><td>66</td><td>66</td><td>0</td><td>0</td><td>57</td><td>60</td><td>3.05</td><td>0</td><td>55</td><td>57</td><td>2.04</td><td>0</td><td>48</td><td>48</td><td>0</td><td>0</td><td>50</td><td>50</td><td>0</td><td>0</td></tr><tr><td>AAT REP</td><td>51</td><td>56</td><td>5.04</td><td>1</td><td>49</td><td>51</td><td>2.02</td><td>0</td><td>56</td><td>57</td><td>1.01</td><td>0</td><td>50</td><td>53</td><td>3.02</td><td>0</td><td>50</td><td>51</td><td>1.01</td><td>0</td></tr><tr><td>AAT WRIT</td><td>50</td><td>52</td><td>2.02</td><td>0</td><td>48</td><td>53</td><td>5.05</td><td>1</td><td>60</td><td>66</td><td>6.06</td><td>1</td><td>57</td><td>52</td><td>-5.05</td><td>0</td><td>45</td><td>44</td><td>-1.01</td><td>0</td></tr><tr><td>AAT WRIT 1</td><td>57</td><td>58</td><td>1.02</td><td>0</td><td>57</td><td>65</td><td>8.15</td><td>1</td><td>65</td><td>71</td><td>6.11</td><td>1</td><td>71</td><td>71</td><td>0</td><td>0</td><td>46</td><td>49</td><td>3.06</td><td>0</td></tr><tr><td>AAT WRIT 2</td><td>47</td><td>51</td><td>4.07</td><td>1</td><td>47</td><td>52</td><td>5.09</td><td>1</td><td>52</td><td>57</td><td>5.09</td><td>1</td><td>54</td><td>56</td><td>2.04</td><td>0</td><td>46</td><td>-36</td><td>-10.18</td><td>0</td></tr><tr><td>AAT WRIT 3</td><td>48</td><td>49</td><td>1.02</td><td>0</td><td>43</td><td>48</td><td>5.1</td><td>1</td><td>66</td><td>70</td><td>4.08</td><td>1</td><td>52</td><td>36</td><td>-16.33</td><td>0</td><td>36</td><td>36</td><td>0</td><td>0</td></tr><tr><td>AAT NAM</td><td>70</td><td>72</td><td>2.03</td><td>0</td><td>52</td><td>55</td><td>3.04</td><td>0</td><td>61</td><td>70</td><td>9.11</td><td>1</td><td>52</td><td>56</td><td>4.05</td><td>0</td><td>48</td><td>53</td><td>5.06</td><td>1</td></tr><tr><td>AAT COMP</td><td>63</td><td>73</td><td>10.39</td><td>1</td><td>55</td><td>64</td><td>9.35</td><td>1</td><td>58</td><td>64</td><td>6.24</td><td>0</td><td>55</td><td>61</td><td>6.24</td><td>0</td><td>51</td><td>58</td><td>7.27</td><td>0</td></tr><tr><td>AAT COMP 1-2</td><td>74</td><td>78</td><td>4.51</td><td>0</td><td>56</td><td>66</td><td>11.27</td><td>1</td><td>52</td><td>66</td><td>15.77</td><td>1</td><td>60</td><td>62</td><td>2.25</td><td>0</td><td>50</td><td>60</td><td>11.27</td><td>1</td></tr><tr><td>AAT COMP 3-4</td><td>55</td><td>66</td><td>11.44</td><td>1</td><td>54</td><td>60</td><td>6.24</td><td>1</td><td>62</td><td>60</td><td>-2.08</td><td>0</td><td>51</td><td>59</td><td>8.32</td><td>1</td><td>51</td><td>55</td><td>4.16</td><td>0</td></tr><tr><td>AAT H. Profile</td><td>57.7</td><td>61.02</td><td>3.31</td><td>1</td><td>50.94</td><td>54.53</td><td>3.51</td><td>1</td><td>58.08</td><td>62.47</td><td>4.38</td><td>1</td><td>52.18</td><td>53.22</td><td>1.04</td><td>0</td><td>48.42</td><td>50.03</td><td>1.61</td><td>0</td></tr><tr><td>NAVS VNT</td><td>100</td><td>100</td><td>0</td><td>0.000</td><td>55</td><td>81.82</td><td>26.82</td><td>0.590</td><td>86.36</td><td>95.45</td><td>9.09</td><td>0.327</td><td>59.09</td><td>63.64</td><td>4.55</td><td>0.093</td><td>31.82</td><td>81.82</td><td>50</td><td>1.062</td></tr><tr><td>NAVS VCT</td><td>100</td><td>100</td><td>0</td><td>0.000</td><td>95</td><td>100</td><td>5</td><td>0.451</td><td>95.45</td><td>100</td><td>4.55</td><td>0.430</td><td>95.45</td><td>100</td><td>4.55</td><td>0.430</td><td>95.45</td><td>100</td><td>4.55</td><td>0.430</td></tr><tr><td>NAVS ASPT A</td><td>96.88</td><td>100</td><td>3.12</td><td>0.355</td><td>90.63</td><td>96.88</td><td>6.25</td><td>0.267</td><td>78.13</td><td>87.5</td><td>9.37</td><td>0.251</td><td>40.63</td><td>65.63</td><td>25</td><td>0.506</td><td>37.50</td><td>53.13</td><td>15.63</td><td>0.315</td></tr><tr><td>NAVS ASPT W</td><td>96.88</td><td>100</td><td>3.12</td><td>0.355</td><td>9.38</td><td>50</td><td>40.62</td><td>0.948</td><td>34.44</td><td>62.5</td><td>28.06</td><td>0.569</td><td>9.38</td><td>43.75</td><td>34.37</td><td>0.823</td><td>9.38</td><td>25</td><td>15.62</td><td>0.425</td></tr><tr><td>NAVS SPPT Actives</td><td>100</td><td>100</td><td>0</td><td>0.000</td><td>80</td><td>100</td><td>20</td><td>0.927</td><td>100</td><td>100</td><td>0</td><td>0.000</td><td>60</td><td>100</td><td>40</td><td>1.369</td><td>40</td><td>100</td><td>60</td><td>1.772</td></tr><tr><td>NAVS SPPT Passives</td><td>20</td><td>40</td><td>20</td><td>0.442</td><td>0</td><td>0</td><td>0</td><td>0.000</td><td>0</td><td>20</td><td>20</td><td>0.927</td><td>0</td><td>0</td><td>0</td><td>0.000</td><td>0</td><td>0</td><td>0</td><td>0.000</td></tr><tr><td>NAVS SPPT SCs</td><td>40</td><td>100</td><td>60</td><td>1.772</td><td>0</td><td>60</td><td>60</td><td>1.772</td><td>0</td><td>100</td><td>100</td><td>3.142</td><td>0</td><td>20</td><td>20</td><td>0.927</td><td>0</td><td>20</td><td>20</td><td>0.927</td></tr><tr><td>NAVS SPPT OCs</td><td>0</td><td>80</td><td>80</td><td>2.214</td><td>0</td><td>60</td><td>60</td><td>1.772</td><td>0</td><td>100</td><td>100</td><td>3.142</td><td>0</td><td>0</td><td>0</td><td>0.000</td><td>0</td><td>0</td><td>0</td><td>0.000</td></tr><tr><td>NAVS SPPT SRs</td><td>80</td><td>100</td><td>20</td><td>0.927</td><td>0</td><td>60</td><td>60</td><td>1.772</td><td>0</td><td>100</td><td>100</td><td>3.142</td><td>0</td><td>60</td><td>60</td><td>1.772</td><td>0</td><td>0</td><td>0</td><td>0.000</td></tr><tr><td>NAVS SPPT ORs</td><td>20</td><td>80</td><td>60</td><td>1.287</td><td>0</td><td>80</td><td>80</td><td>2.214</td><td>0</td><td>80</td><td>80</td><td>2.214</td><td>0</td><td>60</td><td>60</td><td>1.772</td><td>0</td><td>40</td><td>40</td><td>1.369</td></tr><tr><td>NAVS SPPT Total</td><td>43.33</td><td>83.33</td><td>40</td><td>0.863</td><td>13.33</td><td>60</td><td>46.67</td><td>1.025</td><td>16.67</td><td>83.33</td><td>66.67</td><td>1.459</td><td>10</td><td>40</td><td>30</td><td>0.726</td><td>6.67</td><td>26.67</td><td>20</td><td>0.563</td></tr><tr><td>NAVS SCT Actives</td><td>100</td><td>100</td><td>0</td><td>0.000</td><td>100</td><td>100</td><td>0</td><td>0.000</td><td>100</td><td>0</td><td>0</td><td>0.000</td><td>100</td><td>100</td><td>0</td><td>0.000</td><td>80</td><td>100</td><td>20</td><td>0.927</td></tr><tr><td>NAVS SCT Passives</td><td>80</td><td>100</td><td>20</td><td>0.927</td><td>80</td><td>80</td><td>0</td><td>0.000</td><td>60</td><td>100</td><td>40</td><td>1.369</td><td>40</td><td>40</td><td>0</td><td>0.000</td><td>40</td><td>60</td><td>20</td><td>0.403</td></tr><tr><td>NAVS SCT SCs</td><td>100</td><td>80</td><td>-20</td><td>-0.927</td><td>100</td><td>100</td><td>0</td><td>0.000</td><td>100</td><td>100</td><td>0</td><td>0.000</td><td>80</td><td>100</td><td>20</td><td>0.927</td><td>100</td><td>100</td><td>0</td><td>0.000</td></tr><tr><td>NAVS SCT Ocs</td><td>20</td><td>100</td><td>80</td><td>2.214</td><td>100</td><td>100</td><td>0</td><td>0.000</td><td>40</td><td>80</td><td>40</td><td>0.845</td><td>40</td><td>80</td><td>40</td><td>0.845</td><td>60</td><td>100</td><td>40</td><td>1.369</td></tr><tr><td>NAVS SCT SRs</td><td>80</td><td>100</td><td>20</td><td>0.927</td><td>100</td><td>100</td><td>0</td><td>0.000</td><td>100</td><td>100</td><td>0</td><td>0.000</td><td>40</td><td>100</td><td>60</td><td>1.772</td><td>100</td><td>100</td><td>0</td><td>0.000</td></tr><tr><td>NAVS SCT Ors</td><td>60</td><td>100</td><td>40</td><td>1.369</td><td>60</td><td>100</td><td>40</td><td>1.369</td><td>40</td><td>100</td><td>60</td><td>1.772</td><td>20</td><td>80</td><td>60</td><td>1.287</td><td>20</td><td>100</td><td>80</td><td>2.214</td></tr><tr><td>NAVS SCT Total</td><td>73.33</td><td>96.67</td><td>23.33</td><td>0.718</td><td>80</td><td>96.67</td><td>16.67</td><td>0.560</td><td>73.33</td><td>96.67</td><td>23.33</td><td>0.718</td><td>53.33</td><td>83.33</td><td>30.00</td><td>0.663</td><td>66.67</td><td>93.33</td><td>26.67</td><td>0.709</td></tr><tr><td>DS Forward</td><td>3.39</td><td>3.39</td><td></td><td>0</td><td>3.83</td><td>3.83</td><td></td><td>0</td><td>2.6</td><td>2.6</td><td></td><td>0</td><td>2.92</td><td>2.92</td><td></td><td>0</td><td>2.55</td><td>2.55</td><td></td><td>0</td></tr><tr><td>DS Backward</td><td>2</td><td>2.38</td><td></td><td>0</td><td>2.79</td><td>2.79</td><td></td><td>0</td><td>2</td><td>2</td><td></td><td>0</td><td>2</td><td>2</td><td></td><td>0</td><td>2</td><td>2</td><td></td><td>0</td></tr></tbody></table>

**Notes.** AAT=Italian Aachen Aphasia Test (all scores are reported as normalized T scores). AAT analysis of the spontaneous speech: COM=Communicative behavior; ART=Articulation and prosody; AUT=Formulaic automated language; SEM=Lexical and Semantic structure; PHO=Phonemic structure; SYN=Syntactic structure. AAT Tests: TT=Token Test; REP=Repetition; WRIT=Written Language (subtests: 1=reading, 2=diction by composing from graphemes/morphemes, 3=diction by handwriting); NAM=Naming; COMP=Comprehension (subtests: 1-2=auditory comprehension of words and sentences, 3-4=reading comprehension of words and sentences); H. Profile=averaged level of performance according to the T scores in all the tests. NAVS=Italian Northwestern Assessment of Verbs and Sentences (all the scores are reported as percentages of correct answers). Tests: VNT=Verb Naming Task; VCT=Verb
Comprehension Task; ASPT=Argument Structure Production Task (A=sentences with a correct/complete argument structure, W=sentences with non paragrammatic phenomena); SPPT=Sentence Production Priming Task; SCT=Sentence Comprehension Task; SCs=Subject Clefts; OCs=Object Clefts; SRs=Subject Relatives; ORs=Object Relatives. DS=Digit Span test; Δ=Difference between the performances; Sign=Significant difference; H=Cohen's *h* between the two proportions of correct answers.

<figure><img src="image_4.png" /></figure>
<table><caption>**Table 5.** Characteristics of spontaneous speech pre- and post-treatment for each participant.</caption><thead><tr><th rowspan="2"></th><th colspan="2">PP</th><th colspan="2">EB</th><th colspan="2">SP</th><th colspan="2">LM</th><th colspan="2">AG</th></tr><tr><th>Pre</th><th>Post</th><th>Pre</th><th>Post</th><th>Pre</th><th>Post</th><th>Pre</th><th>Post</th><th>Pre</th><th>Post</th></tr></thead><tbody><tr><td>N° words (token)</td><td>95</td><td>91</td><td>24</td><td>37</td><td>26</td><td>55</td><td>44</td><td>43</td><td>18</td><td>33</td></tr><tr><td>Duration</td><td>3'22"</td><td>3'02"</td><td>1'05"</td><td>1'55"</td><td>1'44"</td><td>3'09"</td><td>1'45"</td><td>3'45"</td><td>2'43"</td><td>2'34"</td></tr><tr><td>N° words/min</td><td>28.19</td><td>30.03</td><td>22.22</td><td>19.27</td><td>15.02</td><td>16.83</td><td>25.14</td><td>11.47</td><td>6.62</td><td>12.84</td></tr><tr><td>N° words (type)</td><td>47</td><td>52</td><td>20</td><td>31</td><td>21</td><td>34</td><td>22</td><td>26</td><td>16</td><td>26</td></tr><tr><td>Types/tokens ratio</td><td>0.49</td><td>0.57</td><td>0.83</td><td>0.83</td><td>0.81</td><td>0.62</td><td>0.5</td><td>0.6</td><td>0.89</td><td>0.79</td></tr><tr><td>N° nouns (token)</td><td>27</td><td>26</td><td>15</td><td>21</td><td>15</td><td>22</td><td>19</td><td>22</td><td>11</td><td>17</td></tr><tr><td>N° verbs (token)</td><td>12</td><td>19</td><td>3</td><td>6</td><td>3</td><td>6</td><td>7</td><td>6</td><td>4</td><td>7</td></tr><tr><td>Verbs:nouns ratio</td><td>0.44</td><td>0.73</td><td>0.2</td><td>0.29</td><td>0.21</td><td>0.27</td><td>0.37</td><td>0.27</td><td>0.36</td><td>0.41</td></tr><tr><td>N° closed-class words (token)</td><td>53</td><td>46</td><td>5</td><td>9</td><td>7</td><td>26</td><td>18</td><td>14</td><td>1</td><td>7</td></tr><tr><td>Closed:open-class words ratio</td><td>1.26</td><td>1.02</td><td>0.26</td><td>0.33</td><td>0.37</td><td>0.89</td><td>0.69</td><td>0.48</td><td>0.05</td><td>0.27</td></tr><tr><td>N° sentences*</td><td>6</td><td>14</td><td>1</td><td>4</td><td>3</td><td>4</td><td>4</td><td>5</td><td>0</td><td>2</td></tr><tr><td>N° subordinate sentences</td><td>1</td><td>4</td><td>0</td><td>0</td><td>0</td><td>1</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>N° omissions of functional words</td><td>1</td><td>0</td><td>13</td><td>14</td><td>10</td><td>5</td><td>3</td><td>11</td><td>14</td><td>10</td></tr><tr><td>N° paragrammatism</td><td>1</td><td>0</td><td>1</td><td>1</td><td>1</td><td>0</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td>N° paraphasias</td><td>0</td><td>0</td><td>1</td><td>3</td><td>1</td><td>0</td><td>2</td><td>2</td><td>0</td><td>2</td></tr></tbody></table>

Notes: *N° of sentences with complete argument structures.
FIGURES

<table><caption>Figure 1. Design of the study.</caption><thead><tr><th></th><th></th><th></th><th></th><th></th></tr></thead><tbody><tr><td>BASELINE</td><td>NO TREATMENT</td><td>TREATMENT</td><td>NO TREATMENT</td><td>FOLLOW-UP</td></tr><tr><td>4 days<br>(4 evaluations)</td><td>6 weeks</td><td>6 weeks<br>(24 sessions)</td><td>6 weeks</td><td>2 days<br>(2 evaluations)</td></tr><tr><td>10 comprehension +<br>10 production probes<br>for each type of<br>sentence in each<br>evaluation</td><td></td><td>5 probes for each type of<br>sentence before each<br>treatment session:<br>comprehension and production<br>probes in alternate days</td><td></td><td>10 comprehension +<br>10 production<br>probes for each type<br>of sentence in each<br>evaluation</td></tr></tbody></table>

<caption>FIGURE 1</caption>
**Figure 2.** Proportion correct response on the production probes for each participant and for each sentence type: (a) Object Relatives; (b) Object Clefts; (c) Passives; (d) Actives.

**Notes.** B=Baseline evaluations; W=Weekly evaluations during the treatment; P=Post-treatment evaluation; FU=Average of the follow-up evaluations.

(a)

<figure><img src="image_5.png" /><figcaption>FIGURE 2A</figcaption></figure>
(b)

<figure><img src="image_6.png" /><figcaption>FIGURE2B</figcaption></figure>
(c)

<figure><img src="image_7.png" /><figcaption>FIGURE2C</figcaption></figure>
(d)

<figure><img src="image_8.png" /><figcaption>FIGURE 2D</figcaption></figure>
**Figure 3.** Proportion correct responses on the comprehension probes for each participant and for each sentence type: (a) Object Relatives; (b) Object Clefts; (c) Passives; (d) Actives.

**Notes.** B=Baseline evaluations; W=Weekly evaluations during the treatment; P=Post-treatment evaluation; FU=Average of the follow-up evaluations.

(a)

<figure><img src="image_9.png" /><figcaption>FIGURE 3A</figcaption></figure>
(b)

<figure><img src="image_10.png" /><figcaption>FIGURE3B</figcaption></figure>
(c)

<figure><img src="image_11.png" /><figcaption>FIGURE3C</figcaption></figure>
(d)

<figure><img src="image_12.png" /><figcaption>FIGURE 3D</figcaption></figure>
# APPENDIX

## Appendix A. List of stimuli

### Active sentences

1a) La donna porta l'uomo
The-F.SG woman-F.SG carry-IND.PRES.3P.SG the-M.SG man-M.SG
*The woman carries the man*

1b) L'uomo porta la donna

2a) L'uomo bacia la donna

2b) La donna bacia l'uomo

3a) Il sarto misura la cliente

3b) La cliente misura il sarto

4a) Il clown colora la bambina

4b) La bambina colora il clown

5a) Il giocatore tocca l'arbitro

5b) L'arbitro tocca il giocatore

6a) La pittrice fotografa il turista

6b) Il turista fotografa la pittrice

7a) Il cane salva il padrone

7b) Il padrone salva il cane

8a) Il fratello spinge la sorella

8b) La sorella spinge il fratello

9a) L'investigatore spia il ladro

9b) Il ladro spia l'investigatore

10a) Il dottore pesa l'infermiera

10b) L'infermiera pesa il dottore

11a) Il vescovo benedice il prete

11b) Il prete benedice il vescovo

12a) L'uomo copre la donna

12b) La donna copre l'uomo

13a) La bambina veste la signora

13b) La signora veste la bambina

14a) Il nonno abbraccia il nipote

14b) Il nipote abbraccia il nonno

15a) Il signore libera la ragazza

15b) La ragazza libera il signore

16a) La bambina pettina la signora

16b) La signora pettina la bambina

17a) L'uomo solleva la ragazza

17b) La ragazza solleva l'uomo

18a) La ragazza tira il bambino

18b) Il bambino tira la ragazza

19a) L'ufficiale saluta il soldato

19b) Il soldato saluta l'ufficiale

20a) Il ragazzo stringe il serpente

20b) Il serpente stringe il ragazzo
## Passive sentences

1a) L'uomo è portato dalla donna
   The man is carried by the woman

1b) La donna è portata dall'uomo

2a) La donna è baciata dall'uomo

2b) L'uomo è baciato dalla donna

3a) La cliente è misurata dal sarto

3b) Il sarto è misurato dalla cliente

4a) La bambina è colorata dal clown

4b) Il clown è colorato dalla bambina

5a) L'arbitro è toccato dal giocatore

5b) Il giocatore è toccato dall'arbitro

6a) Il turista è fotografato dalla pittrice

6b) La pittrice è fotografata dal turista

7a) Il padrone è salvato dal cane

7b) Il cane è salvato dal padrone

8a) La sorella è spinta dal fratello

8b) Il fratello è spinto dalla sorella

9a) Il ladro è spiato dall'investigatore

9b) L'investigatore è spiato dal ladro

10a) L'infermiera è pesata dal dottore

10b) Il dottore è pesato dall'infermiera

11a) Il prete è benedetto dal vescovo

11b) Il vescovo è benedetto dal prete

12a) La donna è coperta dall'uomo

12b) L'uomo è coperto dalla donna

13a) La signora è vestita dalla bambina

13b) La bambina è vestita dalla signora

14a) Il nipote è abbracciato dal nonno

14b) Il nonno è abbracciato dal nipote

15a) La ragazza è liberata dal signore

15b) Il signore è liberato dalla ragazza

16a) La signora è pettinata dalla bambina

16b) La bambina è pettinata dalla signora

17a) La ragazza è sollevata dal ragazzo

17b) L'uomo è sollevato dalla ragazza

18a) Il bambino è tirato dalla ragazza

18b) La ragazza è tirata dal bambino

19a) Il soldato è salutato dall'ufficiale

19b) L'ufficiale è salutato dal soldato

20a) Il serpente è stretto dal ragazzo

20b) Il ragazzo è stretto dal serpente
## Object clefts

1a) È l'uomo che la donna porta
Be-PRES.IND.3P.SG the-M.SG man-M.SG that the-F.SG woman-F.SG carry-IND.PRES.3P.SG

*It's the man that the woman carries*

1b) È la donna che l'uomo porta

2a) È la donna che l'uomo bacia

2b) È l'uomo che la donna bacia

3a) È la cliente he il sarto misura

3b) È il sarto che la cliente misura

4a) È la bambina che il clown colora

4b) È il clown che la bambina colora

5a) È l'arbitro che il giocatore tocca

5b) È il giocatore che l'arbitro tocca

6a) È il turista che la pittrice fotografa

6b) È la pittrice che il turista fotografa

7a) È il padrone che il cane salva

7b) È il cane che il padrone salva

8a) È la sorella che il fratello spinge

8b) È il fratello che la sorella spinge

9a) È il ladro che l'investigatore spia

9b) È l'investigatore che il ladro spia

10a) È l'infermiera che il dottore pesa

10b) È il dottore che l'infermiera pesa

11a) È il prete che il vescovo benedice

11b) È il vescovo che il prete benedice

12a) È la donna che l'uomo copre

12b) È l'uomo che la donna copre

13a) È la signora che la bambina veste

13b) È la bambina che la signora veste

14a) È il nipote che il nonno abbraccia

14b) È il nonno che il nipote abbraccia

15a) È la ragazza che il signore libera

15b) È il signore che la ragazza libera

16a) È la signora che la bambina pettina

16b) È la bambina che la signora pettina

17a) È la ragazza che l'uomo solleva

17b) È l'uomo che la ragazza solleva

18a) È il bambino che la ragazza tira

18b) È la ragazza che il bambino tira

19a) È il soldato che l'ufficiale saluta

19b) È l'ufficiale che il soldato saluta

20a) È il serpente che il ragazzo stringe

20b) È il ragazzo che il serpente stringe
## Sentences with object relative clauses (object relatives)

1a) Gianni guarda l'uomo che la donna porta

Gianni-M.SG look-IND.PRES.3P.SG the-M.SG man.M.SG that the-F.SG woman-F.SG
carry_IND.PRES.3P.SG

*John looks at the man that the woman carries*

1b) Gianni guarda la donna che l'uomo porta

2a) Gianni guarda la donna che l'uomo bacia

2b) Gianni guarda l'uomo che la donna bacia

3a) Gianni guarda la cliente che il sarto misura

3b) Gianni guarda il sarto che la cliente misura

4a) Gianni guarda la bambina che il clown colora

4b) Gianni guarda il clown che la bambina colora

5a) Gianni guarda l'arbitro che il giocatore tocca

5b) Gianni guarda il giocatore che l'arbitro tocca

6a) Gianni guarda il turista che la pittrice fotografa

6b) Gianni guarda la pittrice che il turista fotografa

7a) Gianni guarda il padrone che il cane salva

7b) Gianni guarda il cane che il padrone salva

8a) Gianni guarda la sorella che il fratello spinge

8b) Gianni guarda il fratello che la sorella spinge

9a) Gianni guarda il ladro che l'investigatore spia

9b) Gianni guarda l'investigatore che il ladro spia

10a) Gianni guarda l'infermiera che il dottore pesa

10b) Gianni guarda il dottore che l'infermiera pesa

11a) Gianni guarda il prete che il vescovo benedice

11b) Gianni guarda il vescovo che il prete benedice

12a) Gianni guarda la donna che l'uomo copre

12b) Gianni guarda l'uomo che la donna copre

13a) Gianni guarda la signora che la bambina veste

13b) Gianni guarda la bambina che la signora veste

14a) Gianni guarda il nipote che il nonno abbraccia

14b) Gianni guarda il nonno che il nipote abbraccia

15a) Gianni guarda la ragazza che il signore libera

15b) Gianni guarda il signore che la ragazza libera

16a) Gianni guarda la signora che la bambina pettina

16b) Gianni guarda la bambina che la signora pettina

17a) Gianni guarda la ragazza che l'uomo solleva

17b) Gianni guarda l'uomo che la ragazza solleva

18a) Gianni guarda il bambino che la ragazza tira

18b) Gianni guarda la ragazza che il bambino tira

19a) Gianni guarda il soldato che l'ufficiale saluta

19b) Gianni guarda l'ufficiale che il soldato saluta

20a) Gianni guarda il serpente che il ragazzo stringe

20b) Gianni guarda il ragazzo che il serpente stringe