Do People With Apraxia of Speech and Aphasia Improve or Worsen Across Repeated Sequential Word Trials? 患有言語失用症和失語症的人在重複的順序單字試驗中是改善還是惡化？
Katarina L. Haley, ^((D) ){ }^{\text {(D) }} Adam Jacks, ^("a "){ }^{\text {a }} (D) Jessica D. Richardson, ^("b ")^((D)){ }^{\text {b }}{ }^{(D)} Tyson G. Harmon, ^("C "){ }^{\text {C }} (D) Elizabeth H. Lacey, ^("d "){ }^{\text {d }} (D) and Peter Turkeltaub ^(d)({ }^{\mathrm{d}}( (D) 卡塔琳娜·L·哈利， ^((D) ){ }^{\text {(D) }} 亞當傑克斯, ^("a "){ }^{\text {a }} (D) 傑西卡·D·理查森， ^("b ")^((D)){ }^{\text {b }}{ }^{(D)} 泰森·G·哈蒙， ^("C "){ }^{\text {C }} (D) 伊莉莎白·H·萊西， ^("d "){ }^{\text {d }} (D) 和彼得·特克爾陶布 ^(d)({ }^{\mathrm{d}}( (四)^(a){ }^{a} Division of Speech and Hearing Sciences, Department of Allied Health Sciences, The University of North Carolina at Chapel Hill ^(b){ }^{\mathrm{b}} Department of Speech and Hearing Sciences, The University of New Mexico, Albuquerque ^(c){ }^{c} Department of Communication Disorders, Brigham Young University, Provo, UT ^(d){ }^{\mathrm{d}} Department of Neurology, Georgetown University Medical Center, and MedStar National Rehabilitation Hospital, Washington, DC ^(a){ }^{a} 北卡羅來納大學教堂山分校聯合健康科學系言語與聽力科學系 ^(b){ }^{\mathrm{b}} 新墨西哥大學阿爾伯克基分校言語與聽力科學系 ^(c){ }^{c} 楊百翰大學溝通障礙系，猶他州普羅沃 ^(d){ }^{\mathrm{d}} 神經內科、喬治城大學醫學中心和 MedStar 國家復健醫院，華盛頓特區
ARTICLE INFO 文章訊息
Article History: 文章歷史：
Received July 25, 2022 2022 年 7 月 25 日收到
Revision received November 29, 2022 2022 年 11 月 29 日收到修訂
Accepted December 28, 2022 2022 年 12 月 28 日接受
Editor-in-Chief: Cara E. Stepp 主編：卡拉·E·斯特普
Editor: Nancy Pearl Solomon 編輯：南希·珀爾·所羅門 https://doi.org/10.1044/2022_JSLHR-22-00438
Abstract 抽象的
Purpose: During motor speech examinations for suspected apraxia of speech (AOS), clients are routinely asked to repeat words several times sequentially. The purpose of this study was to understand the task in terms of the relationship among consecutive attempts. We asked to what extent phonemic accuracy changes across trials and whether the change is predicted by AOS diagnosis and sound production severity. Method: One hundred thirty-three participants were assigned to four diagnostic groups based on quantitative metrics (aphasia plus AOS, aphasia-only, and aphasia with two borderline speech profiles). Each participant produced four multisyllabic words 5 times consecutively. These productions were audio-recorded and transcribed phonetically and then summarized as the proportion of target phonemes that was produced accurately. Nonparametric statistics were used to analyze percent change in accuracy from the first to the last production based on diagnostic group and a broad measure of speech sound accuracy. Results: Accuracy on the repeated words deteriorated across trials for all groups, showing reduced accuracy from the first to the last repetition for 62% of participants. Although diagnostic groups differed on the broad measure of speech sound accuracy, severity classification based on this measure did not determine degree of deterioration on the repeated words task. Discussion: Responding to a request to say multisyllabic words 5 times sequentially is challenging for people with aphasia with and without AOS, and as such, performance is prone to errors even with mild impairment. For most, the task does not encourage self-correction. Instead, it promotes errors, regardless of diagnosis, and is, therefore, useful for screening purposes. 目的：在疑似言語失用症 (AOS) 的運動言語檢查中，客戶通常會被要求連續多次重複單字。本研究的目的是根據連續嘗試之間的關係來理解任務。我們詢問試驗中音素準確性的變化有多大，以及這種變化是否可以透過 AOS 診斷和聲音產生的嚴重程度來預測。方法：133 名參與者根據定量指標被分配到四個診斷組（失語症加 AOS、僅失語症和具有兩種邊緣言語特徵的失語症）。每位參與者連續說出 4 個多音節單字 5 次。這些作品被錄音並按語音轉錄，然後總結為準確產生的目標音素的比例。基於診斷組和語音準確性的廣泛測量，使用非參數統計來分析從第一次到最後一次產生的準確性百分比變化。結果：所有組別的重複單字準確性均有所下降，62% 的參與者從第一次重複到最後一次重複的準確性有所下降。儘管診斷組在語音準確性的廣泛測量上存在差異，但基於此測量的嚴重性分類並不能確定重複單字任務的惡化程度。討論：對於患有或不患有 AOS 的失語症患者來說，響應連續說 5 遍多音節單字的請求是一項挑戰，因此，即使有輕微的障礙，表現也很容易出錯。對大多數人來說，這項任務並不鼓勵自我糾正。相反，無論診斷如何，它都會導致錯誤，因此對於篩檢目的很有用。
Acquired apraxia of speech (AOS) is defined conceptually as a motor programming or planning disorder and behaviorally as a syndrome with a characteristic profile of abnormal speech sound and prosody production (Jacks & Haley, 2021; McNeil et al., 2009). The diagnosis is typically accompanied by aphasia, but occasionally, it presents with no or minimal language impairment. There 後天性言語失用症（AOS）在概念上被定義為一種運動程式設計或計劃障礙，在行為上被定義為一種以異常語音和韻律產生為特徵的綜合徵（Jacks & Haley，2021；McNeil等，2009）。診斷通常伴隨失語症，但有時也沒有或僅有輕微的語言障礙。那裡
is lingering uncertainty about exactly how the behavioral speech profile of AOS differs from that of aphasia with phonemic paraphasia, which is conceptualized as a linguistic/phonologic impairment. This study is part of a larger project aiming to delineate behavioral diagnostic boundaries where they exist and identify speech tasks that are informative for severity estimation and treatment planning. 對於 AOS 的言語行為特徵到底與伴隨音位性失語症的失語症有何不同，目前仍存在不確定性，後者被概念化為語言/語音障礙。這項研究是一個更大項目的一部分，旨在描繪行為診斷邊界，並識別可為嚴重程度估計和治療計劃提供資訊的語音任務。
The study focused on a traditional task within typical motor speech examinations for AOS: consecutive repetition of multisyllabic words. The original purpose of the 研究的重點是 AOS 典型運動言語檢查中的一項傳統任務：連續重複多音節單字。最初的目的
task appears to have been to evaluate stability across repeated attempts with the expectation that people with AOS would demonstrate limited consistency. In their seminal book, Wertz and colleagues explained: “Repeated trials on the same word may show inconsistent articulatory errors and a combination of correct and incorrect productions among the five attempts” (Wertz et al., 1984, p. 103). In more recent reviews, different authors argued instead that production consistency is relatively strong in AOS, particularly in comparison to aphasia with phonemic paraphasia (McNeil et al., 2009; Wambaugh et al., 2006). A debate ensued about whether the original or revised consistency criteria should be used when diagnosing AOS. In the following, we first summarize what is known about production consistency on the task and then shift our focus to changes in proportional accuracy across sequential repetitions that are either self-initiated or requested. 任務似乎是評估重複嘗試的穩定性，並期望 AOS 患者表現出有限的一致性。在他們的開創性著作中，Wertz 及其同事解釋道：「對同一個單字的重複嘗試可能會顯示出不一致的發音錯誤，以及五次嘗試中正確和不正確的輸出的組合」（Wertz 等人，1984 年，第103 頁）。在最近的評論中，不同的作者認為 AOS 的生產一致性相對較強，特別是與失語症合併音位性失語症相比（McNeil 等人，2009 年；Wambaugh 等人，2006 年）。隨後就診斷 AOS 時是否應使用原始一致性標準或修訂後的一致性標準展開了爭論。在下文中，我們首先總結了有關任務生產一致性的已知信息，然後將我們的重點轉移到自發或請求的順序重複中比例精度的變化。
Repeated Production to Reveal Inconsistency 重複生產發現不一致
On face value, a speaker who is asked to say difficult words multiple times should produce incorrectly some proportion of speech sounds, and any inconsistency among these errors would be evident to an attentive listener, assuming the errors themselves are perceptible. Indeed, diagnosticians have found the task useful in eliciting errors and have verified that word productions often do vary from attempt to attempt. The original clinical observations that production difficulties in AOS are inconsistent have stood the test of time for clinical diagnosticians (Molloy & Jagoe, 2019). 從表面上看，如果說話者被要求多次說出困難的單詞，那麼他應該會錯誤地發出一定比例的語音，並且假設這些錯誤本身是可察覺的，那麼這些錯誤之間的任何不一致對於細心的聽眾來說都是顯而易見的。事實上，診斷學家發現這項任務在引發錯誤方面很有用，並且已經證實單字的產生經常因嘗試而異。 AOS 產生困難不一致的初步臨床觀察結果經受住了臨床診斷人員時間的考驗（Molloy & Jagoe，2019）。
The reason that confusion emerged about production consistency in AOS is not found in clinical gestalt observation, but rather in how behavior has been measured, compared, and interpreted in research studies-all of which have been conducted with small sample sizes (ranging from four to 20 participants with AOS plus-in some cases-an approximately equally sized control group of people with aphasia and no AOS). When measuring error consistency, it is important to remember that it-like most behaviors-can be either consistent or inconsistent, depending on one’s definition (Shuster & Wambaugh, 2008). On the one hand, error frequency and error patterns tend to be consistent in AOS (Mauszycki et al, 2010), allowing for reliable documentation of severity and a rationale for sound-based treatments. On the other hand, uncertainty remains regarding exactly how a challenging word will be produced (Haley & Martin, 2011), and variability increases with the unit of analysis as the field of potential variants increases from sounds to syllables to words (Haley et al., 2018). AOS 中生產一致性出現混亂的原因並不是在臨床格式塔觀察中發現的，而是在研究中如何測量、比較和解釋行為的，所有這些都是以小樣本量（從4 到4 到10 個樣本）進行的。在測量錯誤一致性時，重要的是要記住，它與大多數行為一樣，可以是一致的，也可以是不一致的，這取決於一個人的定義（Shuster & Wambaugh，2008）。一方面，AOS 中的錯誤頻率和錯誤模式往往是一致的（Mauszycki 等，2010），從而可以可靠地記錄嚴重性和基於聲音的治療的基本原理。另一方面，關於如何產生具有挑戰性的單字仍然存在不確定性（Haley & Martin，2011），隨著潛在變體領域從聲音到音節再到單字的增加，變異性隨著分析單位的增加而增加（Haley 等，2011）。
Importantly, inconsistency of word retrieval and deficits in other linguistic behaviors and domainsincluding phonology-is also characteristic of aphasia (Goodglass, 1993). This means that differences in sound production consistency vis-a-vis AOS would, at a minimum, need to be expressed quantitatively and ideally relative to normative data. Because most people with stroke-induced AOS also have aphasia and because both linguistic and motor processes shape the speech output, it is an unavoidable reality that the relative contributions of linguistic and motor networks cannot be parsed during behavioral assessment. Consequently, one must ask the question whether the presence of AOS would alter production consistency beyond a baseline inconsistency of phonological origin-a question that would require a large and representative participant sample. To complicate matters further, it has been difficult to integrate results cross research groups for virtually all clinical research on AOS because diagnostic criteria have varied and diagnostic validity remains unverifiable due to reliance on clinical impression (Haley et al., 2012; Wambaugh et al., 2006). 重要的是，單字檢索的不一致以及其他語言行為和領域（包括語音學）的缺陷也是失語症的特徵（Goodglass，1993）。這意味著聲音生產一致性與 AOS 之間的差異至少需要相對於規範數據進行定量和理想的表達。由於大多數患有中風誘發的 AOS 的人也患有失語症，並且語言和運動過程都會影響語音輸出，因此在行為評估過程中無法解析語言和運動網絡的相對貢獻是不可避免的現實。因此，我們必須問這樣一個問題：AOS 的存在是否會改變生產的一致性，超越語音起源的基線不一致——這個問題需要大量且具代表性的參與者樣本。更複雜的是，幾乎所有AOS 臨床研究的跨研究小組的結果很難整合，因為診斷標準各不相同，並且由於依賴臨床印象，診斷有效性仍然無法驗證（Haley 等，2012；Wambaugh 等，2012） 。
To circumvent the complexity of interacting impairments at linguistic and motor levels, some researchers restricted their sampling to stroke survivors who have AOS and no more than minimal aphasia. In addition to severely limiting the feasible sample size, an unfortunate trade-off was that generalization of results became restricted to a presentation that is highly unusual. McNeil and colleagues compared sound error consistency for four people with relatively isolated AOS to four people with aphasia and phonemic paraphasia (McNeil et al., 1995). The analysis was based on three consecutive repetitions of 10 multisyllabic target words. On average, those with relatively isolated AOS produced more consistent errors than those with phonemic paraphasia. Based on the argument that cases of isolated AOS are diagnostically more informative than studies of AOS with coexisting aphasia, this study prompted a recommendation to alter existing diagnostic criteria from stating that sound errors in AOS are inconsistent to stating instead that AOS is characterized by sound errors that are relatively “consistent in terms of location and invariable in terms of type” (McNeil et al., 2009; Wambaugh et al., 2006). 為了避免語言和運動層面上相互作用障礙的複雜性，一些研究人員將樣本限制在患有 AOS 且不超過輕度失語症的中風倖存者中。除了嚴格限制可行的樣本量之外，一個不幸的權衡是結果的概括僅限於非常不尋常的演示。 McNeil 及其同事將四個患有相對孤立的 AOS 的人與四個患有失語症和音位性失語症的人進行了聲音錯誤一致性的比較（McNeil 等人，1995）。分析基於 10 個多音節目標字的連續 3 次重複。平均而言，AOS 相對孤立的患者比音位性失語症患者產生更一致的錯誤。基於孤立 AOS 病例比共存失語症 AOS 的研究在診斷上更具資訊性這一論點，本研究建議改變現有的診斷標準，從陳述 AOS 中的聲音錯誤不一致改為陳述 AOS 的特點是聲音錯誤相對「位置一致，類型不變」（McNeil 等，2009；Wambaugh 等，2006）。
Researchers continued to study sound production consistency in more diverse samples of left hemisphere stroke survivors with aphasia, and results challenged the altered diagnostic criterion (Bislick et al., 2017; Haley et al., 2013; Scholl et al., 2017; Staiger & Ziegler, 2008). In fact, where a difference existed, it suggested lower, rather than higher, consistency in AOS compared to aphasia and there were indications that consistency magnitude could be explained by impairment severity. In our group’s 研究人員繼續研究更多不同樣本的左半球中風倖存者失語症的發聲一致性，結果對改變的診斷標準提出了挑戰（Bislick 等人，2017 年；Haley 等人，2013 年；Scholl 等人，2017年；Staiger 和齊格勒，2008）。事實上，如果存在差異，則表明與失語症相比，AOS 的一致性較低而不是較高，並且有跡象表明一致性程度可以透過損傷嚴重程度來解釋。在我們組的
most recent study, speech and error consistency were examined in 137 participants with left hemisphere lesions due to stroke or trauma (Haley, Cunningham, Jacks, et al., 2021). Instead of diagnostic impression, objective measures were used to form four comparison groups. One group exhibited both slow multisyllabic word production and high sound distortion frequency and was considered to meet core diagnostic criteria for AOS; one group showed fast/normal multisyllabic word production and low sound distortion frequency and was considered to meet diagnostic criteria for aphasia only; two “borderline” groups had values that were intermediate between these profiles. Study results showed that all four groups produced multisyllabic words with varying degrees of inconsistency when asked to say them 5 times consecutively and that consistency measures, like previous smaller studies, were either similar or lower in the AOS group compared to the aphasia-only group. High speech sound error frequency predicted low error consistency at the word level (consistency of error type and production, due to more incorrect word variants) and high consistency in terms of what target segments were produced incorrectly (consistency of error location because more errors translate to more incorrect sound locations, regardless of the nature of the errors). The evidence showed strongly that relative consistencies of sound error location and type are not valid diagnostic criteria for differentiating between AOS and aphasia with phonemic paraphasia. 最近的研究對 137 名因中風或創傷而左半球病變的參與者進行了言語和錯誤一致性檢查（Haley、Cunningham、Jacks 等，2021）。使用客觀測量來形成四個對照組，而不是診斷印象。一組表現出緩慢的多音節單字產生和高聲音失真頻率，被認為符合 AOS 的核心診斷標準；一組表現出快速/正常的多音節單字生成和低聲音失真頻率，被認為僅滿足失語症的診斷標準；兩個「邊緣」群體的價值觀介於這些概況之間。研究結果表明，當被要求連續說出5 次時，所有四個組別都會產生不同程度不一致的多音節單詞，並且與之前的小型研究一樣，與僅失語症組相比，AOS 組的一致性測量結果相似或較低。高語音錯誤頻率預示著單字層級的低錯誤一致性（錯誤類型和產生的一致性，由於更多不正確的單字變體）以及錯誤產生的目標片段的高一致性（錯誤位置的一致性，因為更多的錯誤轉化為更多不正確的聲音位置，無論錯誤的性質如何）。證據有力地表明，聲音錯誤位置和類型的相對一致性並不是區分 AOS 和失語症與音位性失語症的有效診斷標準。
Having demonstrated that consistency metrics are of limited diagnostic use, the question remains whether the challenge of repeating words multiple times might help differential diagnosis in other ways. One previously considered possibility is that the task provides information about a speaker’s ability to self-correct and that this ability could potentially inform diagnosis. 在證明一致性指標的診斷用途有限之後，問題仍然是多次重複單字的挑戰是否可能有助於以其他方式進行鑑別診斷。先前考慮的一種可能性是，該任務提供了有關說話者自我糾正能力的信息，並且這種能力可能有助於診斷。
Sound-Level Self-Corrections in AOS and Aphasia AOS 和失語症的聲級自我校正
Self-corrections are common in AOS (Bailey et al., 2017; Harmon et al., 2019). Sometimes, they are heard as successive attempts referred to as “groping,” a term that also encompasses inaudible articulatory posturing (Darley, 1968). Self-corrections are referenced in traditional accounts, stating that AOS involves “effortful, trial and error, groping articulatory movements and attempts at selfcorrection” (Wertz et al., 1984, p. 81). Darley and colleagues observed: “The apraxic patient effortfully gropes to find the correct articulatory postures and sequences of them. He often behaves as though uncertain of where his tongue is or how to move it in a given direction or to a given position” (Darley et al., 1975, p. 263). These 自我修正在 AOS 中很常見（Bailey 等人，2017 年；Harmon 等人，2019 年）。有時，它們被視為連續的嘗試，被稱為“摸索”，這個術語也包含聽不見的發音姿勢（Darley，1968）。傳統的敘述中提到了自我糾正，指出 AOS 涉及「努力、反覆試驗、摸索發音運動和自我糾正的嘗試」（Wertz 等人，1984 年，第 81 頁）。達利和同事觀察到：「失語症患者會努力摸索以找到正確的發音姿勢和順序。他常常表現得好像不確定自己的舌頭在哪裡，或如何將其向給定方向或給定位置移動」（Darley et al., 1975, p. 263）。這些
speaker-initiated successive attempts are referred to as false starts, revisions, re-approaches, or struggles (Johns & Darley, 1970; Liss, 1998; Odell et al., 1991). Although accuracy sometimes does increase across repeated attempts, improvement cannot be taken for granted (Johns & Darley, 1970). In his presentation at the 1968 ASHA convention, Darley explained “The patient is often aware of his error but is frequently unable to correct it.” As an example, when repeating the word “thickening,” one of our participants in the AOS group (who had minimal aphasia) said, “sl…sli…sli…uh…slickening.” Self-correction strings are sometimes more diverse, involving both lexical and phonemic/phonetic levels (Goodglass, 1993; Joanette et al., 1980; Marshall & Tompkins, 1982; Lee et al., 2000), as exemplified by another study participant who had AOS with moderate Broca’s aphasia and produced the following response when the examiner held up a screwdriver and asked what it is called: “hamber, or…ru…hamber or ru… need to… rrr…fru… I… I know but…sss…skewdiver… screw. . .screw.” 說話者發起的連續嘗試被稱為錯誤的開始、修正、重新接近或掙扎（Johns & Darley, 1970; Liss, 1998; Odell et al., 1991）。儘管重複嘗試有時準確度確實會提高，但不能認為改進是理所當然的（Johns & Darley，1970）。達利在 1968 年 ASHA 大會上的演講中解釋道：“患者常常意識到自己的錯誤，但常常無法糾正。”舉個例子，當重複“thickening”這個詞時，AOS 組的一位參與者（患有輕微失語症）說：“sl…sli…sli…呃…slickening。”自校正字串有時更加多樣化，涉及詞彙和音素/語音層次（Goodglass，1993；Joanette 等人，1980；Marshall 和Tompkins，1982；Lee 等人，2000），另一位研究參與者舉例說明了這一點患有中度布羅卡失語症的AOS，當檢查者舉起一把螺絲刀並詢問它叫什麼時，產生以下反應：「hamber，或…ru…hamber 或ru…需要…rrr…fru…我…我知道但是…sss …skewdiver…螺絲。 。 。
Self-corrections of speech sound errors are not unique to AOS. Many people with aphasia and phonemic paraphasia also attempt to correct their errors. Specific to conduction aphasia, the French term conduit d’approche expresses self-correction toward increasing phonologic accuracy (Joanette et al., 1980; Kohn, 1984; Marshall & Tompkins, 1982; Valdois et al., 1989). One of our participants with conduction aphasia struggled with the word “eraser”: “es…ester, easer, easer, eiser, hazer, azer, h-a-s-e-r, hasser, easer, hasier, eraser, eraser, pencil eraser.” Again, though there may be gradual approximation in the direction of greater accuracy (Gandour et al., 1994; Joanette et al., 1980; Valdois et al., 1989), success is not certain (Farmer et al., 1978; Gandour et al., 1994; Joanette et al., 1980; Kohn, 1989). Of note, the extent to which selfcorrections are successful appears to be inversely related to impairment severity (Farmer et al., 1978; Marshall & Tompkins, 1982). 語音錯誤的自我修正並不是 AOS 所獨有的。許多患有失語症和音位性失語症的人也試圖糾正他們的錯誤。針對傳導性失語症，法語術語「conduit d'approche」表達了提高語音準確性的自我糾正（Joanette et al., 1980；Kohn, 1984；Marshall & Tompkins, 1982；Valdois et al., 1989）。我們的一位患有傳導性失語症的參與者對「橡皮擦」這個詞感到困惑：「es…ester，easer，easer，eiser，hazer，azer，haser，hasser，easer，hasier，橡皮擦，橡皮擦，鉛筆橡皮擦。同樣，儘管可能會朝著更高精度的方向逐漸逼近（Gandour 等人，1994 年；Joanette 等人，1980 年；Valdois 等人，1989 年），但成功並不確定（Farmer 等人，1978 年； Gandour）等人，1994；喬內特等人，1980；Kohn，1989）。值得注意的是，自我修正的成功程度似乎與傷害嚴重程度成反比（Farmer et al., 1978; Marshall & Tompkins, 1982）。
Repeated Production to Self-Correct 重複生產自我修正
The task of repeating words several times consecutively does present at least a theoretical opportunity to self-correct. Small studies and informal observations have examined the accuracy of sequential repetition in AOS, with varied findings. Johns and Darley (1970) asked 10 people with aphasia and AOS to repeat monosyllabic words 3 times successively and reported that the: “…apraxic subjects often seemed to adjust themselves to the task, progressing from incorrect to correct production” (p. 569). In contrast, LaPointe and Horner asked seven other people with aphasia and AOS to repeat multisyllabic 連續多次重複單字的任務確實至少提供了一個理論上的自我修正機會。小型研究和非正式觀察檢驗了 AOS 中順序重複的準確性，但得出了不同的結果。 Johns 和Darley（1970）要求10 名患有失語症和AOS 的人連續重複單音節單字3 次，並報告說：「......失語症的受試者似乎經常調整自己以適應任務，從不正確的發音進展到正確的發音」（第569 頁） 。相比之下，拉普安特和霍納要求另外七名患有失語症和 AOS 的人重複多音節
Correspondence to Katarina L. Haley: Katarina_Haley@med.unc. edu. Disclosure: The authors have declared that no competing financial or nonfinancial interests existed at the time of publication. 通訊作者：Katarina L. Haley：Katarina_Haley@med.unc。教育。揭露：作者聲明，在出版時不存在競爭的財務或非財務利益。