From the Desk of Ann Kummer
The ability to communicate is predicated on not just speech and language skills, but also on a myriad of underlying cognitive skills that allow the individual to think, learn, understand, and then communicate. There are many medical conditions that affect the development of cognition, and thus, the development of speech and language. There are also many diagnoses that can cause a deterioration of cognition, and thus, a deterioration of the ability to communicate. Because there are so many conditions that affect the function of the brain, compromised cognition can occur at any age…from infants to the elderly.
Because cognition is the basis for the ability to develop communication skills, it is important that speech-language pathologists in all settings understand how to recognize cognitive-communication disorders. In addition, SLPs should consider the underlying cognitive deficits that are affecting communication as they plan strategies for treatment.
I’m especially excited that Stephanie Volker has agreed to write this article on cognitive-communication disorders! I have known Stephanie for many years because we worked together at Cincinnati Children’s Hospital. She is incredibly knowledgeable on this topic as you will recognize when you read this article.
Here’s a little more about Stephanie:
Stephanie Mayer Volker is a speech-language pathologist who specializes in providing cognitive-communication rehabilitation to children and adolescents who have impairments due to acquired brain injury or chronic conditions. She received her Bachelor of Science in Education and Master of Science in Speech-Language Pathology at Miami University in 1994 and 1995 respectively and achieved AACBIS Certified Brain Injury Specialist Certification in 2005. She is currently employed at Cincinnati Children's, serving children and adolescents with acquired brain injury (ABI) as a clinician in the Division of Speech-Language Pathology. She was instrumental in creating and developing Cincinnati Children’s Outpatient Neurorehabilitation Team, a family-centered, collaborative, comprehensive outpatient rehabilitation program for children and adolescents who have sustained an ABI. She serves as an expert clinical leader and mentor to clinicians in the Division of Speech-Language Pathology and the Outpatient Neurorehabilitation Team at Cincinnati Children’s. Stephanie has lectured on a variety of topics related to ABI and cognitive-communication rehabilitation for the adult and pediatric populations at the local, state, and national levels.
Now…read on, learn, and enjoy!
Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q
20Q: Cognitive Communication Disorder - An Overview for SLPs
After this course, readers will be able to:
- define a cognitive-communication disorder (CCD) and appropriate settings for the provision of services
- list 2-3 causes of cognitive-communication disorder in children, adolescents, and adults
- describe evidence-based recommendations for assessment and intervention
1. What is a cognitive-communication disorder?
To fully understand and appreciate the impact of a cognitive-communication disorder (CCD), it is important to conceptualize communication as part of a broad framework; beyond speech, language, voice, fluency, and social-pragmatic skills. Communication is a complex process that relies on an intricate and efficient interaction between language skills and cognitive processes. The ability to communicate successfully relies not only on intact speech and language systems, but also on higher-order cognitive skills, such as attention, memory, processing, reasoning, and executive functions, which are recruited in the act of using speech and language skills to effectively communicate. In a CCD, the underlying deficit is impaired cognition, which negatively impacts communication, despite preserved speech and language skills (Ciccia, et al 2021). In simple terms, a communication breakdown can reflect problems a person is experiencing in their thinking.
The American Speech-Language-Hearing Association (ASHA) defines Cognitive-Communication Disorders (CCDs) as difficulty with any aspect of communication that is affected by disruption of cognition (ASHA, 2022). According to The College of Audiologists and Speech-Language Pathologists of Ontario (CASLPO), cognitive-communication impairments are defined as difficulties with listening, speaking, reading, written expression, or social interaction that occur due to underlying problems with cognitive skills such as attention, memory, organization, reasoning, social cognition, or executive functions (MacDonald & Shumway, 2002). The definitions from ASHA and CALSPO are based on the premise that, in a CCD, basic language functions such as syntax and semantics are intact, in contrast to disorders such as aphasia and developmental language impairments, in which impairments in basic language functions are the defining characteristic (Togher et al, 2014).
If the communication challenges resulting from impaired cognition primarily impact using language in social interactions, the diagnosis of a Social Communication Disorder, as opposed to a Cognitive-Communication Disorder, may be more appropriate. Both disorders are described in the literature as outcomes of ABI in both adults and children/adolescents (ASHA, n.d.; Ciccia et al, 2021; MacDonald, 2017; McDonald et al, 2013; Sohlberg et al, 2019) due to underlying deficits in cognition, as opposed to language. For more information on this differential diagnosis, readers are encouraged to seek further information on Social Communication Disorder in the articles referenced and in other presentations on SpeechPathology.com.
While The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5) does not include a description of a cognitive-communication disorder, cognitive-communication deficit is included as a medical diagnosis code in the International Statistical Classification of Diseases and Related Health Problems11th ed, ICD-11 (World Health Organization, 2019) and can be used by SLPs for diagnosis and billing purposes.
2. Is this a newer diagnosis for the profession of speech-language pathology?
Yes and no. It was in the late 1980s when the American Speech-Language-Hearing Association (ASHA) first described the role of speech-language pathologists (SLPs) in the care of individuals with cognitive disorders affecting communicative abilities (ASHA, 1987) and then provided members with guidance in a position statement one year later (ASHA, 1988). As a result, SLPs stepped into an expanded role in serving more individuals who experienced neurological disorders. This was due to the inclusion of cognition as an underlying consideration for impaired communication, as opposed to considering only those who sustained brain lesions associated with traditional language areas which are responsible for listening, speaking, reading, and writing (ASHA, 1987, 1990). In 2002, evidence-based guidelines for the management of CCDs were described in a committee report to the Academy of Neurological Communication Disorders and Sciences (ANCDS) (Katz & Kennedy, 2002). Next, ASHA, in collaboration with colleagues in neuropsychology, published guidelines for referral of suspected CCDs in children and adults in 2003 (ASHA, 2003). In 2004, ASHA added assessment and treatment of cognitive-communication disorders to the preferred practice patterns document for the profession (ASHA, n.d).
According to Ciccia et al (2021), the use of the term CCD as a diagnosis or diagnostic category has increased steadily since 2004, based on both ASHA and PubMed searches of the term. Increased interest in research and clinical practice focusing on CCDs by multiple disciplines resulted in the creation of the International Cognitive-Communication Disorders Conference (ICCDC) first convened in 2017. The success of that conference led to additional meetings in 2020 and 2022.
In 2019, ASHA added a Cognitive-Communication Disorders track to the annual convention and a steady increase in research and clinical practice focused on CCDs continues in the field of speech-language pathology as well as in other allied health and educational professions.
3. Are cognitive-communication disorders common?
CCDs are much more common than many SLPs realize. They result from many medical and developmental conditions, due to a variety of clinical diagnoses, are present in children, adolescents, and adults, require assessment and intervention in most settings in which SLPs provide care, and are one of the largest and fastest-growing parts of the SLP’s scope of practice (Ciccia et al, 2021; Laane & Cook, 2020; Hinckley, 2014; MacDonald, 2021; Morrow et al, 2020; Ramsey & Blake, 2020; Riedeman & Turkstra, 2018; Shultz et al, 2010). SLPs who work in hospitals, rehabilitation centers, outpatient clinics, long-term care facilities, and or community-based programs for adults have almost certainly encountered a client/patient with CCD. Pediatric SLPs who work in early intervention, schools, community settings, as well as medical settings, could also provide services to youth with CCDs as part of their caseload. However, some SLPs who encountered individuals with a CCD may have provided a different diagnosis, may not have identified a CCD through their assessment, and/or may not have provided evidenced-based intervention specific to CCDs.
4. What causes a cognitive-communication disorder?
In adults, CCDs typically result from neurogenic conditions causing an acquired brain injury (ABI) such as a traumatic brain injury (TBI), right hemisphere damage (RHD), cerebral vascular accident (CVA), brain tumor, and dementia. In fact, the best available evidence suggests that cognitive-communication impairments are the most prevalent communication difficulties after ABI in adults, with a commonly reported incidence of more than 75% after moderate-to-severe injury (MacDonald, 2017).
CCDs are not limited to the adult population, they are also highly prevalent in children and adolescents due to both neurological and, what some may consider to be “developmental” conditions. While most SLPs are familiar with CCDs resulting from ABI in children such as TBI, CVA, meningitis, encephalitis, brain tumors, etc., the presence of a CCD has been used to apply to children with developmental disorders (Ciccia et al, 2021). Some may be surprised to learn that it can be cognitive deficits that underlie the communication impairments in youth with diagnoses such as attention deficit disorder (ADHD), intellectual disability, autism, and cerebral palsy (CP), and, thus, their presentation could fit the clinical definition of a CCD (Morrow et al, 2021).
In both adult and pediatric populations, the most common cause of a CCD is TBI. The high incidence of TBI in both populations, relative to other neurological diagnoses, contributes to TBI as the primary cause of CCDs. Furthermore, the hallmark deficits associated with TBI are CCDs resulting from disrupted cognitive processes (e.g., attention, memory, executive function) rather than a specific language disorder. Though language disorders, such as aphasia, and speech disorders, such as dysarthria, can result from TBI, CCDs are the most common clinical finding regarding communication due to TBI with reported incidence rates of CCDs as high as 80-100%. (Coelho, 2007; Togher et al., 2014; Turkstra et al 2015; Ylvisaker, 1993).
5. What are the communication symptoms of cognitive-communication disorders?
The clinical presentation of a CCD in adults, adolescents, and children is highly heterogeneous and is dependent on many factors including the underlying cause, severity, age of onset, time since onset, psychosocial factors, pre-existing abilities, and the profile of underlying strengths/weakness in the cognitive skills which cause the communication impairments. As stated in the definitions of a CCD, symptoms can appear in an individual’s ability to understand and process language in both verbal (auditory comprehension) and written form (reading comprehension), express thoughts, ideas, and knowledge verbally (verbal expression) and in writing (written expression) and use language appropriately and efficiently in social interactions (pragmatics, social communication, social competence) (ASHA, n.d.; MacDonald & Shumway, 2002).
To better understand the symptoms of CCD, remember that the communication challenges are due to impairment in cognitive skills such as attention, processing (speed and capacity), working memory, memory (encoding and retrieval), reasoning/problem solving, and executive function skills including initiation, flexible thinking, emotional regulation, self-monitoring, metacognitive awareness, organization, planning, etc. These communication deficits are present despite intact speech and language skills (ASHA, 2004; Ciccia et al, 2009; Ciccia et al, 2021; Ewing-Cobbs et al, 2002; MacDonald, 2017). Examples of this difference can include the following challenges.
For auditory comprehension of spoken language, a child with a CCD can struggle with understanding the content of a conversation, not due to deficits in receptive vocabulary or decreased comprehension of complex syntactical structure (impaired language), but due to lapses in attention, decreased ability to hold the content of the conversation in working memory, poor ability to regulate emotions, and/or decreased ability to recall previous content relevant to the conversation.
Verbally, an adult may struggle to express himself/herself in conversations, despite intact speech and language skills, and demonstrate the following communication deficits: limited commenting due to slowed processing speed resulting in an inability to keep up with the pace of the conversation, lack of spontaneous comments due to poor initiation, frequent interrupting due to poor impulse control, tendency to make off-topic comments due to attention lapses, working memory, and/or self-monitoring deficits, and decreased cohesion and sequence in story-telling due to impaired organization, working memory, and/or attention.
When reading, an individual can struggle to comprehend due to poor ability to hold the information in working memory, lapses in attention necessitating the need to re-read frequently, poor memory leading to the inability to get the main idea or remember details, and decreased use of strategies to support comprehension due to poor metacognitive awareness and ability to judge one’s own level of comprehension/learning.
Producing written content can be a challenge due to decreased attention, poor working memory, decreased recall of important content, inability to reason or problem-solve for writing prompts such as cause/effect or compare/contrast, and/or ability to organize and plan. As a result, written content lacks cohesion and coherence - not due to underlying expressive or written language deficits, but due to impaired cognition.
Socially, an adolescent may struggle to interact appropriately with peers not due to lack of knowledge of social rules or decreased supralinguistic language ability, but rather due to challenges such as poor self-monitoring of his/her own’s interactions, decreased impulse control leading to interrupting, verbosity, or perseverative content, inability to recall details of conversation leading to misinterpretation of jokes or sarcasm, and/or decreased working memory or attention resulting in poor ability to make inferences. These social communication breakdowns are not a result of impaired language, but due to impaired cognition.
The preceding examples are not intended to fully describe all of the symptoms of a CCD and the descriptions of symptoms of CCDs in the literature, for both adults and children/adolescents, are highly varied across all communication domains (ASHA, n.d.; Blosser & Pompei, 2003; Catroppa et al, 2016; Ciccia et al 2021, Coelho, 2007; Corrigan et al, 2013; Haarbauer-Krupa et al 2019; Katz et al, 2002; Lundine et al 2019; MacDonald, 2017; Turkstra et al, 2005; Turkstra et al 2015).
6. What are potential outcomes of cognitive-communication disorders?
CCDs can result in poor psychosocial outcomes for individuals who present with this disorder, especially when the negative impact of the symptoms is not improved via access to evidence-based intervention by SLPs. Potential poor outcomes of CCDs and/or the conditions which cause CCDs include negative impacts on social participation, academic success, vocational success, family dynamics and relationships, and independent living.
The negative social outcomes of ABIs, and resulting CCDs, can be significant and devastating to the individuals impacted, as well as to their families. Social isolation, loneliness, loss of friends, and/or inability to make friends are frequently reported outcomes of the social impairments associated with CCDs (Finch et al, 2016; Toegher et al, 2014; Ylvisaker et al, 2007; Ylvisaker & Feeney, 2001).
CCDs following ABI can have long-term implications for academic outcomes as well (Laane & Cook, 2020). Longitudinal studies conducted during the K–12 school years have shown that problems associated with TBI tend to persist or worsen as children progress through school, culminating in poor academic outcomes for these students (Anderson et al, 2000; Ewing-Cobbs et al., 2004; Glang et al., 2008; Haarbauer-Krupa et al, 2019; Prasad et al., 2017). CCDs can negatively interfere with a student’s ability to access school curricula and access meaningful support from peers and teachers (Cameto et al., 2004; Prasad et al., 2017; Todis et al., 2011). ABI sustained in childhood, and resulting CCDs, can negatively impact the opportunity for adolescents to access and enroll in post-secondary education (Todis et al, 2011).
It has been reported that ABI in adults has a significant impact on successful return to work including decreased probability of employment, increased time to return to work, and decreased probability of returning to the same position (Temken et al, 2009). Persistent cognitive-communication deficits experienced by adults with TBI play a role in employment outcomes (Douglas et al, 2016). Even when the cause of a CCD does not occur in adulthood, the negative consequences can impact future employability of children and adolescents who sustain an ABI during their school years (Cameto et al, 2004).
Caregivers of individuals with CCDs report an increased burden to support their loved ones’ communication in a wide variety of situations, and family functioning can be negatively impacted following an ABI due to the presence of a CCD (Grayson et al, 2020). CCDs impact individuals’ ability to communicate in their roles as a parent, sibling, spouse, or child which can lead to family stress, marital breakdown, and fractured family relationships (MacDonald, 2017).
All of the above reported outcomes can ultimately impact an individual’s ability to live independently.
7. In what setting should cognitive-communication disorders be addressed?
While there is no one “optimal” setting in which adults and children with CCDs are provided services, it is important to realize that there is no one setting in which this population should NOT be served. As stated earlier, this population requires services in most settings in which SLPs provide care. Although the most common cause of CCDs is a medical condition, this is not a disorder that SLPs should consider to be addressed only in healthcare settings. SLPs who work along the entire continuum of care for children and adults with any diagnosis which results in a CCD should be providing intervention when needed (Lumba-Brown et al, 2018; Morrow et al, 2020; Riedeman & Turkstra, 2018).
In addition to medical settings, adult providers who serve individuals with CCDs in community settings have a unique opportunity to address the significant and often debilitating impact that these deficits have on social and vocational outcomes. Regarding pediatric SLPs, the literature strongly supports assessment and treatment of CCDs in the school setting, even going so far as to state that the school is sometimes the optimal setting to provide this intervention. The school-based SLP has the advantage of being able to support cognitive-communication skills in the real-world functional setting where children spend most of their time. While these skills can be addressed in an outpatient rehabilitation setting, addressing these challenges in the school setting adds an evidence-based, relevant context to help a child or an adolescent transition new skills or strategies to everyday use (Sohlberg & Turkstra, 2011; Ylvisaker et al., 2007). School-based SLPs also have the advantage of being able to support educational personnel’s knowledge about CCDs and contribute ideas to the classroom to support the students’ progress (Mitchell et al., 2020).
8. Is telepractice an effective service delivery for individuals with cognitive-communication disorders?
Yes. Since the Covid-19 pandemic, telepractice has become a much more frequently used service-delivery method by many SLPs, including those who provide services to individuals with CCDs. ASHA defines telepractice as the delivery of services using telecommunication and internet technology to remotely connect clinicians to clients, other health care providers, and/or educational professionals for screening, assessment, intervention, consultation, and/or education. According to ASHA, telepractice is an appropriate model of service delivery for audiologists and speech-language pathologists, and may be the primary mode of service delivery or may supplement in-person services (known as hybrid service delivery) (ASHA, n.d.).
Telepractice service delivery can support meeting the needs of individuals with CCDs following ABI, as well as their families, due to a variety of factors. One important consideration is access to care. Many clients in rural or remote areas, especially those who have sustained an ABI, do not live near medical centers with access to SLPs who are able to provide this intervention. Even individuals who do not live in remote areas often report that they struggle to find SLPs who provide intervention for neurogenic CCDs, especially for children/adolescents (Coleman et al, 2015, Rietdijk et al., 2020).
Telepractice intervention can also increase ecological validity of both assessment and intervention (Coleman et al, 2015; McCarron et al 2019; Riegler et al, 2013; Wade, 2020). By allowing more direct access to the home environment, SLPs who utilize telepractice can tailor interventions to everyday communication needs. Telepractice offers clinicians an effective way of identifying and working towards individualized goals for the client, as well as their family members. This also supports involvement of the family, which is often essential to carryover and generalization of strategies in functional communication interactions (Rietdijk et al., 2020).
9. What are important considerations for SLPs who work with adults with cognitive-communication disorders?
One issue unique to serving adults with CCDs is return to work. The nature of impairment associated with CCDs after an ABI can significantly impact an adult’s ability to successfully return to work. This is often reported as a primary goal of adults’ status post ABI but is one of the most challenging to achieve. SLPs who serve adults should assess clients’ goals related to work and address CCDs in the context of those goals. SLPs can determine how the impairments associated with CCD affect job performance and target strategies to minimize the impact of the deficits in the work setting. SLPs can collaborate with employers, vocational rehabilitation counselors, job coaches, and counselors to help implement strategies and accommodations for successful return to work outcomes (Meulenbroek & Turkstra, 2016).
Individuals with TBI may be eligible for protection in the workplace under Section 504 of the Rehabilitation Act of 1973. This law protects a qualified individual from discrimination based on their disability. Section 504 prohibits employment discrimination against individuals who meet job requirements and can perform essential job duties with or without reasonable accommodations. It may also provide vocational training and employment services for eligible individuals. SLPs can give input about reasonable accommodations to minimize the effects of cognitive-communication deficits in vocational settings (ASHA Practice Portal).
Each state has an agency to help people with disabilities find work. These Vocational Rehabilitation Services (VR) have different names in different states and are funded by both the federal and state government. People who are disabled by brain injury are entitled to apply for vocational rehabilitation (Kowlakowsky-Hayner & Tyman, 2012).
10. What important issues should SLPs who work with children and adolescents consider?
Since ABI, more specifically traumatic brain injury TBI, is the leading cause of CCDs in children and adolescents, it is critical that SLPs understand the unique needs of this population. Although CCDs due to childhood ABI are well described in the literature, recognition of these problems and intervention, in clinical settings is a challenge (Turkstra et al, 2015). Children and adolescents with CCDs lack access to intervention by SLPs in the school setting due to barriers including: proper identification for special education; poor sensitivity to CCDs of assessments used in schools; poor understanding of the connection between ABIs sustained at a young age and later challenges caused by CCDs; assumption that CCDs should be addressed in a medical setting; and emphasis on developmental speech and language assessment and treatment (Cermak et al, 2019; Coelho et al, 2005, Ciccia et al, 2021; Ettel et al, 2016; Nagele et al, 2019).
It is a myth that children who sustain a brain injury at a young age recover better and will not have a long-lasting impact from their injury (Anderson et al, 2012; Haarbauer-Krupa et al, 2019; Turkstra et al, 2015). In fact, there is evidence to suggest that injuries sustained at a younger age are associated with poorer outcomes (Anderson et al, 2012). A pediatric brain injury is an injury to a “still developing brain” and the impact of that injury can have a significant impact on the future development of many skills including cognition and communication.
Therefore, it is important to consider childhood TBI as a chronic condition, as opposed to an “event” from which a child will recover (Corrigan & Hammond, 2013). Even children who demonstrate a good recovery soon after injury are at risk to demonstrate a “neurocognitive stall” (Chapman, 2006). As they grow up, children continue to develop neurologically and the results of an earlier injury may not become apparent until that child has reached certain developmental milestones, at which point his or her challenges are more apparent. Children are at risk of “growing into symptoms” as the demands on their cognitive-communication skills become greater and they fail to demonstrate the ability to develop those skills at the same rate as their peers. However, these later appearing deficits may not be correctly attributed to a CCD result from an earlier ABI.
As a result, many children and adolescents who have sustained a brain injury often “fall through the cracks” and do not receive the appropriate services, especially in the school system. Few SLPs employed in schools report having students with TBI on their caseloads (ASHA, 2018), despite estimates that there are approximately 2.5 million students with TBI in the U.S. public education system annually (Schutz et al., 2010). It has been reported that 98-99% of children with TBI are not appropriately identified within the US education system and therefore, are not receiving the appropriate services (Lundine & Hall, 2020). The National Collaborative on Children’s Brain Injury (NCCBI) found that only 32% of students with moderate-severe TBI, who would be predicted to need special education services, are identified nationally under the Special Education TBI category. Possible reasons for this discrepancy include lack of awareness about TBI as a disability, lack of communication between hospital and school, under-reporting of injuries by parents, and students with TBI receiving services under alternate disability categories (Nagele et al, 2019).
Any ABI to the developing brain can have significant long-term consequences, including the presence of a CCD, thus necessitating a continuum of care, including appropriate identification, assessment, treatment, and ongoing monitoring in all settings in which children and adolescents are served by SLPs.
11. What is the ICF and how does it apply to the care of individuals with cognitive-communication disorders?
The World Health Organization's (WHO) International Classification of Functioning, Disability, and Health (ICF) is a tool that was developed to improve the functional health of the world's people by changing the way we view disability (WHO, 2007).
Most of the research and clinical practice recommendations for CCDs directly reference, or consider, the ICF and recommend application of this framework in assessment and intervention. There is evidence in the literature regarding the benefit of applying the ICF to a variety of speech and language disorders, including CCDs (Larkins, 2007; MacDonald & Shumway, 2002; McCormack & Worrall, 2008, Threats, 2010). Larkins (2007) reports that the use of the ICF leads to more relevant and meaningful therapy interventions for the individual with TBI and resulting CCDs because it can provide a structure to assess and intervene beyond the impairment level such as capacity versus performance, and to investigate context such as the environmental and personal factors that influence the client’s ability to undertake the activities.
MacDonald & Shumway (2002) provide an excellent example of framing cognitive-communication disorders within the ICF:
- Impairment (body structures/function): Specific cognitive impairments which may affect language: decreased attention, inflexibility, impulsivity, inefficient processing of information (rate, amount, complexity), poor memory
- Activity/Participation: Limitations and restrictions: difficulty in conversations, limited expression of ideas, opinions, wants/needs, social isolation, dependence on others for functional communication
- Contextual Environmental Factors: Difficulties imposed by environment: lack of family/friend support, reduced social acceptance, financial constraints, lack of function necessary for employment or family responsibilities, inflexible work, or academic environment
- Contextual Personal Factors: Individual factors: race, gender, age, lifestyle, habits, upbringing, coping style, social background, education, profession, past experiences, character style
When using the ICF framework, clinicians can elevate the client’s Activities and Participation (functional, real-world outcomes) to be equally as important as communication impairments related to Body Functions and Structures (diagnosis and deficits) to develop patient-centered, functional goals and achieve successful, meaningful outcomes for children, adolescents, and adults with CCDs (Larkins, 2007).
On its Practice Portal, ASHA recommends application of the ICF for comprehensive assessment and intervention of individuals with CCDs and with TBI (ASHA, n.d.). An example of the application of the ICF to CCDs is the ASHA resource titled Person-Centered Focus on Function: Traumatic Brain Injury (ASHA, n.d).
12. What are the evidence-based recommendations for assessment of cognitive-communication disorders?
ASHA’s 2004, “Preferred Practice Patterns for the Profession of Speech-Language Pathology” provides recommendations for the assessment of CCDs by SLPs.
Per ASHA, assessment of CCDs can be static (i.e., using procedures designed to describe structures, functions, and environmental demands and supports in relevant domains at a given point in time) or dynamic (i.e., using hypothesis testing procedures to identify potential for change and elements of successful interventions and supports). Evaluation should include standardized and/or nonstandardized methods which are selected with consideration for ecological validity. An assessment of CCDs should identify and describe underlying strengths and weaknesses related to cognitive abilities like memory and attention, an individual’s executive, or self-regulatory control over cognitive, language, and social skills functioning, and linguistic factors, including social skills that affect communication performance. Assessment of CCDs should also explore the effects of cognitive-communication impairments on the individual's activities (capacity and performance in everyday communication contexts) and participation. Finally, an assessment should evaluate contextual factors that serve as barriers to or facilitators of successful communication and participation for individuals with cognitive-communication impairment (ASHA, n.d.).
A comprehensive assessment of cognitive-communication skills should go well beyond the impairment level. Application of the ICF framework (WHO, 2007) to the evaluation of CCDs suggests four main approaches: traditional assessment using structured linguistic tasks, assessment via social skills, assessment via language analysis, and assessment of CCDs by exploring everyday communication activities in the context within which they occur (Larkins, 2007).
It can be challenging for SLPs to fully assess the presence of CCDs, but best practice recommendations include standardized assessments that are already familiar to SLPs. Comprehensive, standardized language assessment should be completed and paired with measures of cognitive performance. In a clinical tutorial for SLPs to support students with TBI, Coreno & Ciccia (2020) mention the Behavior Rating Inventory of Executive Function-2 (BRIEF-2) (Gioia et al, 2015), The Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES) (MacDonald, 2005), and Student Functional Assessment of Verbal Reasoning and Executive Strategies (Student FAVRES) (MacDonald, 2016) as options for standardized assessment.
A review of the literature shows that there are many different options for evidence-based nonstandardized assessment which can detect CCDs. Checklists, observations, questionnaires, client or caregiver interviews, and rating scales are reported as options for nonstandardized assessment of CCDs for use with adults (MacDonald & Shumway, 2002, Sohlberg et al, 2019). Nonstandardized assessment options for evaluation of cognitive-communication skills following pediatric TBI include “paper-pencil tasks”, observation, questionnaires, and checklists. Specific options include Task Analysis, Dynamic Assessment, Functional Behavior Assessment, Criterion-referenced Assessment, Curriculum Based Assessment, Discourse Analysis, Systematic Observation of an IADL, Virtual Reality Tasks, Structured Cognitive Tasks, and Functional Rating Scales (Chevignard et al, 2012; Hall et al, 2021; Lundine & Hall, 2020; Lundine, 2020).
Since CCDs reflect underlying cognitive impairments, it also is important to have a neuropsychological assessment carried out by an appropriately qualified professional (ASHA, 2003, Turkstra et al, 2015).
13. What are the advantages of using standardized tests to assess cognitive-communication disorders?
Standardized testing is used quite frequently for assessment purposes by SLPs. The advantages of using standardized tests to evaluate CCDs are similar to the advantages for use with other speech and language diagnoses. Standardized tests can be convenient and easy to use given the fact that they have clearly defined procedures for administration. The results of standardized tests can support identification and qualification for services in both medical and school settings. Standardized tests (should) have good reliability for administration across evaluators, settings, and over repeated administrations. Standardized tests have clear descriptions of normative data as well as the purposes and intended use of the test (Turkstra et al, 2005). And, according to ASHA as well as many experts in the field of CCDs and TBI, standardized assessment can be a key component of a comprehensive evaluation of CCDs (ASHA, n.d.). A review of the literature reveals that there are some standardized measures to evaluate the presence and severity of cognitive-communication impairment in both children and adults (Frith et al., 2014; Hardin & Kelly, 2019; MacDonald & Johnson, 2005; Sohlberg et al., 2019; Turkstra et al., 2005).
14. What are the disadvantages of using standardized tests to assess cognitive-communication disorders?
Unfortunately, there are a considerable number of disadvantages to using standardized tests in the evaluation of CCDs, especially if this is the only tool used for a comprehensive assessment.
The most important consideration is that the hallmark deficits of individuals with CCDs, which significantly and negatively impact their lives, often do not “show up” on standardized testing, and test scores alone do not accurately identify, diagnose, or describe CCDs disorders (Cermak et al., 2019; Coelho et al., 2005; Steel & Togher, 2019). This lack of sensitivity to CCDs is due to several factors.
First, most standardized assessments are not normed on the population in which CCDs most frequently occur, individuals with acquired brain injuries. Second, tests of language, for both children and adults, focus predominantly on form and content and are not designed to assess higher-level cognitive-communication skills, especially those which are impacted by an ABI (Coelho et al., 2005; Turkstra,1999). Furthermore, by nature, standardized tests often suppress the impact of CCDs because of the artificial conditions which are part of the standardized testing method, and an individual’s performance on a test may not reflect what their performance looks like in “real life”. These artificial conditions include high structure, visual supports, a quiet 1:1 environment, allowance for repetition, slowed rate of presentation, and the limited nature of skill sampling (Blosser & DePompei, 2003; Ciccia et al, 2009; Coelho et al, 2005; Larkin, 2007; Turkstra, 1999; Turkstra et al, 2015). Standardized tests are designed to assess individuals’ ability to demonstrate a specific skill, but they are not designed to assess or predict success or failure in a real-world context. In other words, standardized assessments test what you should do, not what you would do (Lundine & Hall, 2020). Finally, communication performance also varies in response to changing communication demands, and standardized tests do not assess the context-dependent factors which impact communication such as demands of the environment, communication partners, physical factors such as fatigue/headache, or cultural considerations (Douglas, 2010).
In summary, standardized tests often lack ecological validity, sensitivity, and predictive value for assessment of CCDs.
15. What are the advantages of using nonstandardized measures to assess cognitive-communication disorders?
Nonstandardized assessments are defined as systematic clinical procedures that allow for observation of skill performance in functional contexts with and without clinician support. Functional nonstandardized assessments are particularly valuable because individuals with CCDs often perform disproportionately better or worse in activities of daily living compared with abilities predicted by standardized test scores (ASHA, n.d.).
There are many advantages to using nonstandardized measures to assess cognitive-communication skills. First, they allow clinicians to evaluate skills in real-world contexts while also assessing the use of, or potential benefit from, compensatory strategies which may support improved function (ASHA, 2019; Ciccia et al., 2009; Coelho et al., 2005; Hall et al, 2021; Steel & Togher, 2019). Nonstandardized assessments are consistent with the ICF framework since they encourage a focus on activities, participation, and context rather than just specific body, structure, and function (Coelho et al., 2005; WHO, 2007) and can be more predictive of outcomes in social, academic, and/or vocational settings than standardized test scores (LeBlanc et al., 2000). Finally, if done well, nonstandardized assessments can support the development of relevant, functional treatment plans which are based on the individuals’ goals in his/her own environment (Chevignard et al., 2012).
16. What are the disadvantages of using nonstandardized measures to assess cognitive-communication disorders?
Although highly recommended for use in the evaluation of CCDs, use of nonstandardized measures can present challenges for use by SLPs. Nonstandardized measures can place a higher clinical burden on an SLP due to the learning curve associated with administering them (there is often no manual or protocol to follow easily), the time involved in administration/assessment (sometimes including observation in a “real world” context), a need to “think outside the box” and consider the relevant factors to include in the assessment, and the documentation of results to support recommendations/qualification for services (Lundine, 2020). Nonstandardized assessments do not provide a norm-referenced comparison and some SLPs may receive pushback from payor sources or school administrators who value standardized test scores above other clinical data relevant to functional communication (Lundine, 2020). Finally, it can be challenging to develop systematic, reliable, and valid nonstandardized assessment measures (Hall et al 2021).
17. What are the recommended, evidence-based interventions for cognitive-communication disorders?
According to Toegher et al, (2014) the “ultimate goal of cognitive-communication intervention is to help the individual achieve the highest level of participation in everyday communication life." Intervention should be designed to contribute to the individual’s social, vocational, educational, and independent living success (Ylvisaker et al, 2007).
Recommended interventions reported in the literature have common elements including consideration of premorbid communication status and other personal factors, individualized goals that are important to participants, instructional methods that match participants’ learning ability, activities for planned generalization, intervention embedded in the communication environments of the individual’s everyday life, i.e. in natural contexts, education and psychosocial support, inclusion and training of important communication partners, promotion of self-advocacy, and measurement of outcomes beyond the therapy room (Ciccerone et al, 2011, 2019; Finch et al, 2016; MacDonald & Shumway, 2002; Resch et al, 2018; Sohlberg & Mateer, 2001; Toegher et al, 2014, Wade, 2020).
Intervention for CCDs should address the communication domains (auditory comprehension, verbal expression, reading comprehension, written expression, and pragmatics/social communication) and the cognitive deficits (processing speed, memory, attention, reasoning/problem-solving, and/or executive function skills) which cause the communication impairment (Laane & Cook, 2020). Targeting the underlying cognitive deficits which contribute to impaired communication can be done using the basic principles of cognitive rehabilitation (Sohlberg & Turkstra, 2011).
ASHA categorizes treatment approaches for CCDs into 4 types: restorative, compensatory, habilitative, and functional/contextual (ASHA, n.d.). Interventions have also been categorized as targeting fundamental processes from a bottom-up skills approach or targeting higher-order processes from a top-down strategy-based approach (Laane & Cook, 2020).
Restorative interventions are intended to regain skills that were impacted following the onset of injury (ASHA, n.d.). Evidence suggests that restorative approaches hold less promise in the chronic stage of recovery from ABI (Resch et al, 2018). Restorative interventions mentioned in the literature include Drill and Practice, Direct Attention Training, and Errorless Learning (Sohlberg and Mateer, 2001; Sohlberg & Turkstra, 2011).
Compensatory approaches focus on capitalizing on strengths and implementing strategies to reduce the negative impact of skill deficits. This approach equips the individual with tools that can be employed repeatedly across dynamic task demands and real-life contexts to perform daily communication tasks more effectively (Laane & Cook, 2020). It is important to consider that significant progress and successful outcomes can be achieved when implementing compensatory approaches, even when the prognosis for further gains in skills is limited. Compensatory approaches can include strategies used by the individual with a CCD, used with prompts by the individual, or provided to or for the individual, like accommodations or modifications (ASHA, n.d.). Compensatory interventions mentioned in the literature include External Aids, Assistive Technology, Internal Aids, Metacognitive Skills Training, Strategic Learning Intervention, and Communication Partner Training (Ciccerone, et al, 2019; Sohlberg et al, 2007; Toegher et al, 2014). Communication partner training has been found to be a significant benefit to individuals with CCDs as well as to their families (Finch et al, 2016; Rietdijk et al, 2020).
Habilitative interventions for children and adolescents focus on improving and retaining skills that are in the process of developing post-injury. Habilitative interventions help children learn, keep, or improve skills and functional abilities, rather than restore skills that they had mastered prior to injury (ASHA, n.d.).
Functional/contextualized approaches target personal, meaningful goals that can be generalized to everyday activities (ASHA, n.d.). Although ASHA considers this a separate intervention category, many other experts apply this concept to best practices for any successful intervention method for CCDs (Ciccerone et al, 2019, Finch et al, 2016; Laane & Cook, 2020; MacDonald & Wiseman-Hakes, 2009; Rietdijk et al, 2020).
18. Are speech-language pathologists meeting the needs of individuals with cognitive-communication disorders?
As a profession, SLPs are uniquely trained and qualified to diagnose and treat individuals with CCDs due to their essential clinical knowledge regarding the interaction between cognition and communication (Katz et al, 2002). This is recognized and recommended by our own professional organization as well as by research and practice guidelines within the fields of other allied health professions. International guidelines for cognitive-communication interventions recommend that individuals with communication disorders after brain injury be offered an appropriate treatment program by a speech-language pathologist (Togher et al, 2014) and evidence-based practice recommendations and guidelines for management of the impact of cognitive-communication disorders include description of assessment and intervention methods for SLPs (ASHA, n.d.)
Although there is a consensus that SLPs should diagnose and treat individuals with cognitive-communication impairments, evidence-practice gaps include:
- Infrequent referrals to SLP even though speech-language pathologists are more likely to diagnose an individual with communication and social deficits than neurologists, neuropsychologists, and occupational therapists (MacDonald, 2021).
- Under identification of cognitive-communication deficits for adults (MacDonald, 2017).
- No systematic continuum of care for children who sustain an ABI at a young age (Haarbauer-Krupa et al, 2018).
- Under identification and decreased treatment of children and adolescents who have a cognitive-communication disorder following ABI or TBI, especially in the school environment (ASHA, 2018; DePompei & Glang, 2018; Fuentes et al, 2017; Lundine & Hall, 2020; Haarbauer-Krupa et al., 2017; Schultz et al, 2010).
- Low frequency of speech-language pathology intervention for both children and adults with cognitive-communication disorders (ASHA, 2011).
- Relatives of individuals with cognitive-communication difficulties following TBI report speech-language therapy services are not meeting their needs (Grayson et al, 2020).
19. Are there barriers to serving individuals with cognitive-communication disorders? What are they?
There are many factors that prove to be barriers to the recommended best practices for serving individuals with CCDs by SLPs. These barriers are varied and include issues related to research, education/training within our own profession, and interprofessional relationships.
Research drives practice and current research in our field may be considered a barrier to treatment of CCDs. Although there is a growing body of research investigating CCDs, there is significantly less research by SLPs in this area as compared to research by other professions (neuropsychology for example), or research on other disorders within the scope of speech-language pathology (aphasia, fluency, specific language disorder, apraxia, etc.) and the body of literature on assessment and treatment of CCD is still evolving (Cermak et al, 2019; Ciccia et al, 2021; Hall et al, 2021, Laatch et al, 2019, Toegher et al, 2014).
A significant barrier to serving this population relates to education and training within our own profession. There have been numerous studies that have documented that SLPs in both medical and school settings report decreased clinical knowledge and confidence in providing services for CCDs and may not view themselves as experts on CCDs (Duff & Stuck, 2015; Morrow et al, 2020; Riedeman & Turkstra, 2018). These studies point to inadequate academic training at the graduate level as well as decreased opportunities for direct experience and training in working with this population. According to Morrow et al (2020), covering cognitive-communication in the necessary breadth and depth to yield well-prepared and confident clinicians is a significant challenge in the current diagnosis-based model of graduate-level coursework. The education and training provided in graduate school is often insufficient to leave a student feeling prepared and confident to work with these individuals upon graduation. In addition, the opportunities for continuing education in CCDs is limited and disproportionate when compared to CEU opportunities in lower incidence disorders like aphasia (Ramsey & Blake, 2020). This is especially true in terms of opportunities for continuing education in pediatric CCDs.
To provide services to individuals with CCDs in many settings, SLPs must rely on referrals from other medical professionals. Referral rates to SLPs for CCDs have been estimated to be lower than 50% (Ciccia et al, 2016). Barriers to SLPs receiving these referrals include: low detection rates of cognitive-communication impairment, lack of emphasis on these skills in screening tools, lack of appreciation of the significant functional impact of even subtle cognitive-communication deficits, lack of clear referral pathways to speech-language pathology, prioritization of referrals for physical impairments, lack of knowledge of evidence-based cognitive and communication interventions, and an overly narrow understanding of the scope of practice for SLPs (e.g., primarily treating speech or swallowing) even when these deficits have been identified through the assessment process of other providers (Ciccia et al, 2021).
The good news is that experts within our field are taking on the challenges noted above. Research to support evidence-based assessment and intervention for CCDs is growing and CCD is recognized by ASHA as an important area of clinical practice. Morrow et al (2021) provided recommendations to improve graduate education models for SLPs as part of the 2020 International Conference on Cognitive-Communication Disorders (ICCDC), and MacDonald (2021) developed the Cognitive-Communication Checklist for Acquired Brain Injury (CCCABI) to support screening and identification of CCDs and facilitate referrals to SLPs for further assessment.
20. What is cognitive-communication competence?
It is hoped that the reader has gained a better understanding of CCDs as well as an appreciation of the complex nature of this disorder. Cognitive-communication ability, any impairment of these skills, and resulting deficits which are then considered a CCD, should be viewed within the broader context of an individual’s unique everyday communication needs. To support best practices in the identification, assessment, and intervention of this complex disorder, MacDonald (2017) proposed a model of cognitive-communication competence that summarizes the complex array of influences on communication to provide a holistic view of communication competence after ABI. This model can support SLPs in providing care to individuals with CCDs by advancing research, developing interventions, and promoting a shared understanding of communication across professions with the hope of increasing access to care by SLPs. The model supports SLPs in the identification, assessment, and intervention of CCDs and is shared here with permission.
Figure 1. Model of cognitive-communication competence.
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