Communication problems following a Traumatic Brain Injury

Although we know a lot about the communication problems that follow a TBI, our knowledge is incomplete and there is a lot of confusion about the terminology used.

The three most common communication problems to affect people who have sustained a TBI are

  • difficulties with the production of the sounds of speech  due to apraxia and/or dysarthria.

  • difficulties with understanding or using language (aphasia)

  • difficulties with a wide range of cognitive skills that underpin communication (cognitive-communication impairment)

1. Acquired apraxia (otherwise known as dyspraxia) following a traumatic head injury

Apraxia is the impaired ability to programme and sequence the movements required for speech production so the articulation of the speech sounds is impaired. Features of apraxia are as follows:

  • Involuntary speech is relatively preserved.

  • The recitation of common, over-learned phrases and sayings remains intact. Often, the person is able to say things like prayers or poems easily.

  • The person with apraxia can articulate  meaningful speech more easily than  nonsense speech.

  • Imitation of speech is very difficult for a person with apraxia. We also see the person with apraxia visibly searching, using groping movements of the articulators, and attempting numerous trials, and using false starts

  • Articulation errors increase as the complexity of the movements required increase. Vowels are easier to say than consonants; single consonants are easier to say than consonant clusters (e.g. s versus st; sp versus spl). Fricatives and affricates (e.g. j. ch, sh) are more difficult than all other sounds.  Sounds that are very common in a language are easier to say than unusual sounds.

  • Articulation errors  increase as the length of words increases. So it is more difficult to say "rosebush" than it is to say "rose".

  • Words that are made up of more than one syllable can be reduced to one syllable or the syllables can be swopped around.

  • Some errors are 'anticipatory', meaning that the person anticipates that they will have a problem saying a sound, and so they hesitate. These hesitations affect the rhythm (prosody ) of their speech and they sound non-fluent.

  • Some errors are 'perseveratory' - the same words are misarticulated every time they are said, but the errors themselves are inconsistent.  So, for example, "apricot" may be pronounced as "piyacopt" or "apertot" or "pacitotot" - each trial produces a different error.

  • The position of sounds in a word affects the person, and it is usually initial consonants that are the most difficult to get right

  • Articulation errors occur more often on words that carry a lot of psychological or linguistic weight - in other words, words that communicate ideas and feeling more than other words.

2. Dysarthria following a traumatic brain injury

 

If those parts of the brain or the nerves that control the muscles that are used to produce speech are damaged, then dysarthria results. There is no one type of dysarthria. It is a group of different kinds of problems that affect all levels of the speech production system, including respiration, voicing, resonance and articulation. Dysarthria can range from very mild to very severe.

  • Respiration: The forward flow of air out of the lungs can be weak; the person may not be able to control this flow of air for the special breathing for speech; the person may run out of air while speaking; the person can speak on residual air and sound like they are struggling.
     

  • Voice: The voice may be affected in terms of pitch, loudness or quality. Voice can be too loud, too soft, the pitch can be too high or too low; the voice quality can be strained or strangled. Sometimes, there are problems with iitiating voicing.
     

  • Resonance: The person may sound as if they have a cold; or sound as if the air is coming out of the nose instead of the mouth when speaking.
     

  • Articulation: the person may have difficulty with coordinating the movements for speech; the speech sounds may be distorted.

3. Aphasia: language problems following a traumatic brain injury

Aphasia is defined as the loss of language following damage to the brain. If those parts of the brain responsible for understanding language for expressing language are damaged, then aphasia results. Many people suggest that we use the word "aphasia" to refer only to the loss of language following focal damage to the language areas of the brain.

  • The symptoms of language problems following a TBI vary, depending on whether the damage was focal (in a defined area of the brain) or diffuse (more spread out through various areas of the brain).

  • It is not all that usual for people who have sustained a TBI to present with classic aphasia - the problems are usually more to do with impaired cognitive processes that underpin the communication (see below). On conventional tests of aphasia, people with TBI usually perform well or have minor problems but some people with TBI do present with problems with the form of language use or understanding.

  • Word finding problems: One of the most significant features of the language of people who have sustained a TBI is difficulties with word retrieval. Many people who have sustained a TBI cannot remember people's names, the names of things, and even the names of very common items. We see people hesitating, groping for words, using the incorrect word, or 'circumlocuting' - using a lot of words to express an idea when one or two words would do. So a 'balloon' may be described as, "It's the things that...you know... um... the thing that is round and goes up in the...um...the...heavens...um, the blue..um.. the sky".

  • High level language problems: We cannot be sure that high level language problems are experienced because of cognitive problems or some of the cognitive problems are a result of language difficulties, or if language and cognition interact. The jury is still out on these extremely complex notions.  Nevertheless, high level language problems are very often experienced by people who have sustained a TBI. Examples include:

    • Idioms (e.g. 'best thing since sliced bread'; 'costs an arms and a leg')

    • Metaphors (e.g. 'fishing in troubled waters'; 'bubbly personality'; 'apple of my eye')

    • Comparing and contrasting

    • Finding opposites

    • Telling and understanding jokes

    • Describing social contexts

    • Categorising ( e.g. 'all these things are for eating'; 'these things are all work related'; 'this one does not belong because...')

    • Verbal reasoning (e.g. 'the reason he said that is because...')

  • Problems with discourse: Language use breaks down at the level of discourse. As a result, we often see people who have sustained a TBI being socially isolated because they cannot engage with other easily. People who have sustained a TBI may have a lot of difficulty with aspects of discourse such as

    • identifying characters

    • telling a narrative in an organised, sequential way

    • making use of adequate language to accurately communicate ideas

    • introducing the narrative and terminating it

    • reading the social situation (including pragmatics)

    • conveying information in  a way that makes the communication partner want to listen, to interact and respond

4. Cognitive-communication problems following  a traumatic brain injury

Cognitive-communication problems are defined as communication problems that occur as a result of impairments with the cognitive skills that are required for communication.

 

In the old days, the communication problems that people with a TBI have were referred to as 'anomic aphasia' or 'sub-clinical aphasia' (and a few other terms were used as well). Today, we have a better understanding of the root of the problems and we now use the term "cognitive communication impairments" to describe the problems with the non-linguistic cognitive processes that support language and communication, as well as problems with language use that influence cognition or thinking.

What are the cognitive processes that underlie or are influenced by language?

Examples of cognitive processes include:

  • sequencing

  • memory

  • organization

  • orientation

  • mood

  • flexibility and adjusting

  • inhibition

  • initiation

  • planning

  • problem solving

  • resolving

  • terminating

  • comparing and contrasting

What are the features of the communication of people following a TBI?

  • Prosody, or the rhythm of language may be affected: the person may be non-fluent, hesitate, use pausing incorrectly, have difficulty sequencing phrases.

  • Affect: the person may not express with words or with tone of voice the emotional content of what is being said. So, we may not know that the person is being angry, or that what s/he is expressing is funny.

  • Topic selection: the person may not be able to select an appropriate topic to talk about in a particular setting, or may have difficulty selecting a topic in a group setting. Comments may be inappropriate.

  • Topic maintenance: a person may not be able to stick to the topic and is easily distracted and forgets what is being spoken about. The person may interrupt, start talking about something else, or seem distracted.

  • Turn taking: the person may not be able to take turns in a conversation, interrupting others, dominating a conversation, or not responding when s/he should.

  • Quantity/conciseness: the person may talk too much or too little; the person may use too many words to describe something that could be said much more concisely. Explanations can be rambling.

  • Memory: the person may not remember what is being discussed; s/he may not remember a topic that was discussed the night before; s/he may not remember information that was familiar to him/her in the past. S/he may not remember instructions that have been given, no matter how simple.

  • Attention: the person may have difficulty attending to a conversation.

  • Distractibility: the person may be easily distracted by lights or noises.

  • Slow auditory information processing: the person may take a long time to process what is said and appears to not understand. Multiple repetitions may be necessary.

  • Disinhibition: the person may engage in non-stop rapid talking and cannot control this behaviour. Some behaviours and topics may be inappropriate.

  • Confabulation (lying): the person may make up stories and may seem to be telling lies. This form of 'lying' is not purposefully manipulative  -  instead we think it is a result of disturbed memories and the person really thinks that what s/he is saying is true.

  • More difficulty with expressing or understanding longer sentences.

  • Perseveration: saying the same thing (word, sentence, sound, topic) repeatedly with no awareness of this behaviour.

     

Speech therapy after a traumatic brain injury in adults
Speech therapists work with clients who have sustained a traumatic brain injury on their cognitive-communication skills; their speech production; their reintegration into society; and their use of AAC.
Cognitive-Communication Therapy
In our therapy with our clients, we have 2 main goals
1. to restore functions such as memory, executive skills, language functions and so on
2. to compensate for lost functions
  • Restoring functions
Sometimes we work on the underlying skills, such as memory training; sometimes we work on specific functions (e.g. filling in forms; negotiating the way through going to a meeting e.g introducing oneself; taking notes; asking questions and responding).
  • Compensatory Strategy Training:
The goal of compensation therapy is to use whatever skills the person has to compensate for the problems OR to adapt the environment and the people in it.
 
We work, for example, on getting the people in the environment to know how to have conversations with the person so that as little breakdown as possible happens; we sometimes get the person to work in a quieter environment with fewer distractions.
 
We may make use of memory aides e.g. cell phones, tablets, reminder books, diaries. We may use strategies such as mnemonics, imagery, and associations to provide the person with different ways to help him or her to remember.
 
We may teach our clients ways to manage time, maintain attention, ask for clarification. There are many, many possibilities.
We may make use of technology such as computers rather than writing; recording conversations; tasking photographs as memory aides.

Speech production therapy

Th aim of speech therapy with people who have impaired speech is to work on the systems (e.g. respiration, articulation), OR to work on compensation. There are many theories about speech production and many approaches to rehabilitation.

AAC

We often use AAC (Augmentative and alternative Communication) to supplement (augment) or replace oral speech (Please see my page on AAC here).

Reintegration in society

We work with our clients to help them to go back into the roles that they played in society - as husbands, wives, workers, friends, breadwinners, and any other roles. Where people are not able to go back into their roles, we help clients and their families to adapt to new roles, and to adjust to new ways of living. We often work with psychologists and social workers as well as family members.

Going back to school

When children have sustained a TBI, their return to school can be difficult if the long-lasting effects of the TBI are not dealt with well. Often children who have sustained a TBI go back too early, or are placed in schools that do not serve them well. Unfortunately in places like South Africa, often children who have sustained a TBI cannot be accommodated in local schools and so they do not go back to school at all. Sometimes children are placed in specialised schools such as remedial schools and are treated as if they are learning disabled children. This is an unfortunate consequence and few teachers - and some speech therapists, OTs and physios - have a really good knowledge of TBI.

Children with TBI live with very different problems as compared to children with learning difficulties. They experience more of the cognitive communication problems that underpin their learning and classroom learning and socialization.

If you are not comfortable with the return to school, speak to your speech therapist who will help to guide you and the teachers. If you do not have access to a speech therapist, please feel free to contact me by e mail and I will try to find some information and guidance for you.