Authors: A.J.W.Ter Mors, M. Reijbroek-Delisse
Brain injury due to different causes is common and can have severe functional impact. Meerhof et al. 1997  reported an incidence of head and brain injury of 836/100,000 in 1997 in the Maastricht-region in the Netherlands. And data from the LMR (Landelijke Medische Registratie) showed 118,927 hospital admissions in 2002, due to acquired brain injury, in the Netherlands. (Incidence 793/100,000)
Stroke is a frequent cause of brain injury. Struijs et al., 2005  and Bots, 2006  report between 34.000 and 41.000 cases each year, in the Netherlands. Due to aging of the population the number of stroke patients will increase with 27% in the year 2020 (Struijs et al., 2005) . Stroke has a high disease burden, both for the patients and for their significant others. One year after stroke, 35% of the patients are functionally dependent, which makes stroke a leading cause of disability .
Cognitive and communication impairments are common, if the right cerebral hemisphere is involved. Tompkins (2012)  refers to these problems as cognitive-communication disorders. She defines communication and cognition as follows:
Communication is the interpersonal exchange of ideas, information, needs, mutual understanding and the like. Communication does not need to involve language, it may occur via facial expression or tone of voice.
Cognition is the “collection of mental processes and activities used in perceiving, remembering, and thinking, and the act of using those processes”.
Benton et al 1996  estimate impairment in at least 1 aspect of communication in 50% of patients with right hemispheric damage (RHD). Ferré et al, 2009  report a prevalence of 78%.
Blake et al (2002,2003) recorded aprosodia in at least 25% of cases.
Cognitive impairment (attention, neglect, perception, learning and memory, and reasoning and problem-solving) is seen in 50%  to 68%  of patients.
Tompkins 2012  gives an overview of the literature on the effect of interventions aimed at the disorders in communication and cognition. Preliminary results show some effects in the treatment environment, but generalisation outside the treatment condition and effect on activities and participation is not established.
For years speech therapists in the Netherlands mainly focussed on the language problems due to left cerebral hemispheric damage. In RHD patients the focus was on dysphagia and dysarthria. Only recently the awareness of RHD communication problems is growing. (See Table 1)
As part of the GGZ Oost Brabant, a mental health institution in the Netherlands, we run a specialised brain injury facility, the Acquired Brain Injury department Huize Padua. This is a rehabilitation facility specialised in assessment and treatment of challenging behaviour due to acquired brain injury.
In this context we see a lot of patient with RHD and aggression. Tateno et al, 2003  mentioned aggression and agitation in 33% of brain injury patients, six months post injury, more often associated with frontal lobe injury as measured by the Overt Aggression Scale . Azouvy et al, (1999)  found aggressive behaviour in 20% of patients five years post injury especially these behavioural consequences have a severe impact on the patient  and their significant others .
We are not aware of literature on the prevalence of aggression/agitation in RHD patients or on the combination of aggression and communication impairments due to RHD. Pryor  discussed several potential staff variables that may be associated with aggression of patients with ABI, including staff having inadequate communication styles (for example, talking too loud or asking too many questions). It is plausible that the association is even stronger when these communication styles are used in the interaction with RHD patients.
From our experience with the combination of behavioural problems and cognitive-communication disorders we hypothesize that misunderstandings and burn out due to these cognitive-communication disorders can lead to behavioural problems.
So in the treatment of these behavioural problems we focus on the underlying cognitive-communication problem, instead of targeting the behavioural problem directly. This case report illustrates this.
This case report illustrates how language problems can affect communication and cause behavioural problems. Especially the subtle right hemispheric communication problems after brain injury can lead to misunderstandings not recognised by the patient or the family or even the professionals involved. These misunderstandings combined with other neuro-cognitive deficits can lead to too much pressure on the patient, without him or her being able to cope with it, due to the disabilities and impairments. And thus can lead to behavioural problems.
We will demonstrate with this case report how attending to the underlying language/communication problem, can dissolve behavioural problems, severely impacting the life of the patient and her family.(By targeting the presenting behaviour instead of the underlying language problem things might take a turn for the worse.)
We present the case of a 46-year-old divorcé with two children (12 and 18), Mrs C. She suffered a brain infarction in the basal ganglia of the right hemisphere. With left sided hemi-paralysis, cognitive impairments and substantial but subtle right hemispheric language problems.
She prematurely aborted the treatment in the rehabilitation-centre to live at home, against medical advice, though her ADL (Activities of Daily Living) dependence and difficulties bringing up her youngest child, required specialized care at home.
C was verbally and physically aggressive, had emotional outbursts and denied her problems, which lead to her dismissing all the people around her, leading to social isolation and withdrawing from health services, causing her to be at risk of losing custody over her youngest, who had to be put into care.
Interventions to reduce her aggression focussed on her presenting behaviour. But her behaviour deteriorated.
Eventually she committed to treatment to try to retain custody over her youngest child.
(Premorbidly she had received mental health care for borderline personality disorder)
We aimed at helping this patient to live successfully with her youngest child admitting into her life the necessary help to function and take care of her child properly.
Firstly a communication diagnosis was established. Based on the examination findings education was given to the patient and basic and specific communication guidelines were issued to the team, the family and community mental health care workers. (See table 2) These were implemented during her stay on the inpatient ward.After discharge home our community mental health nurse took over and transferred the implementation to her home.
To understand the behaviour presented we needed to understand the communication during daily life activities. Observation by the team focussed on the subtle communication problems, not on the aggressive behaviour.
To gain insight in the subtle communication problems the speech therapist did her examination; field observation and video analyses were performed.
Advanced speech therapy screening:
- Aken Aphasia Test, Graets P, Bleser de R, Willmes K,
- Amsterdam - Nijmegen Test for daily communication skills, Blommert L, Koster Ch, Kean M.
- The Dutch Aphasia Foundation: language test for auditive and oral language skills
- Examination of the right hemisphere (language test), Wijmen M, Boxtel-Randewijk K.
Main outcome parameters/endpoint
Living in on her own successfully.
Accepting help and admitting health care workers
Retaining custody over her child.
We hypothesize that cognitive-communication impairments due to RHD often are not recognized.Due to cognitive, communicational and physical impairments the RH patient is impaired in daily life functioning. Often one of the impairments is lack of awareness of or insight in impairments (anosognosia). Because of the functional problems professional and non-professional carers tend to try to offer help in any way. Often the help is delivered via verbal intervention. The anosognosia leads to an argumentative increase in communication and this in turn together with the under recognized communication problems will lead to misunderstandings, with emotions running high. Combined with emotional lability or disinhibition either due to the brain injury or to premorbid personality, as in this case, aggression can occur, with carers withdrawing especially when the issue concerned is emotionally charged as in this case (child custody). From this hypothesis it follows that preventing miscommunication by structured guidelines to patient and significant others, this outcome of aggression and dislodging relationships can be undone.
Applying specific guidelines of communication will reduce behavioural problems and thus enable Mrs. C. to live on her own with her child.
Education of the patient and video feedback were undertaken. Guidelines were issued to the team, the family and community health care workers involved.
During a conversation it is important to use the fundamentals of communication, such as respect autonomy, gain trust, respond neutrally and take enough time.
Specific guidelines were issued, based on the examination findings (see Table 2).
Table 2: Specific Guidelines
Mrs. C was discharged home successfully. She admitted health care workers and retained custody over her child.
This outcome has been consistent over the last 2 years.
This case report shows the importance of acknowledging subtle cognitive-communication impairments in RHD brain injury. Lack of understanding the underlying problems can lead to behavioural problems and be detrimental to activities and societal participation.
This case report is not a scientific experiment, but it carries an implication that a systematic education of the patient and significant others, issuing guidelines on how to optimally compensate for the cognitive-communication impairments of a patient with RH brain injury can reduce behavioural problems and can be beneficial to activities and societal participation.
The design of this study, being naturalistic, has its limitations as to internal validity. The design did not control for other events or interventions possibly influencing the outcome.
Furthermore it is a case report (N=1).
Also aggression was not an outcome measurement though the hypothesis involved the link between cognitive-communication problems and aggression.
So in future studies we will apply an experimental AB design together with a multiple baseline design across subjects.
We will use aggression and participation as outcome measurements.
And we will perform a series of studies for direct, systematic and clinical replication. 
As stated in the introduction the research into the effect of interventions aimed at restoring function by training the skills involved, as yet shows no effect on activities and participation. 
Because of the results in this case, supported by our clinical experience we propose that education and providing guidelines to the patient and significant others to compensate optimally for impairments could be more effective than skills training.
- By attending to the underlying communication problem in a patient with RHD, behavioural problems changed for the better, significantly improving the quality of life of the patient and her family, and the participation of the patient.
- Focussing on the presenting behaviour instead of the underlying communication problem could cause deterioration of the behavioural problems.
- Family and professionals should be aware of subtle communication problems with righthemispheric lesions as the underlying problem in a presenting behavioural problem.
- Further research is needed to establish efficacy of the presented interventions to compensate for the impairments (psycho education).
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GGZ Oost Brabant
Brain Injury Department, Huize Padua
5427 ZG Boekel
Tel + 31(0)492-846422
Editor’s note: The views and opinions expressed in the articles contained in the International NeuroTrauma Letter are those of the authors and contributors alone and do not necessarily reflect the views, policy or position of the International Brain Injury Association or all members of the INTL Editorial Board. The INTL is provided solely as an informational resource and the inclusion of any particular article does not establish or imply IBIA’s endorsement of its contents.