Thinking Before Speaking, Understanding the Meaning, and Reading Context Cues: An Update on Communication Interventions after ABI

By: Sheila MacDonald, M.Cl.Sc.SLP (C), Speech-Language Pathologist/Owner; Sheila MacDonald & Associates, Speech-Language Pathology Services

Communication, our most complex, and arguably most important human function, warrants  specialized approaches to assessment and treatment.    Individuals with acquired brain injuries (ABI) experience a vast array of communication impairments that present significant barriers to full participation in life [1]..  Disruptions in communication present challenges to community reintegration, family and social interactions, and academic and vocational success [2].  Analysis of the effectiveness of communication interventions is a complex undertaking with 11 categories of intervention, more than 25 relevant systematic reviews and over 72 practice recommendations to be integrated. [3,4,5]  A review of 20 systematic reviews relating to cognitive-communication interventions revealed that these interventions are generally evidence based [5]. Further delineation of the characteristics that make the intervention successful will require more specific analysis of communication participant profiles, treatment procedures, and real world outcome measures, including communication outcomes.  This paper summarizes the major themes in communication interventions after ABI and refers readers to the growing body of evidence to support them. 

Communication disorders resulting from ABI can be divided into three main groups:  1.Disruptions with speech production due to impairments in physiological functioning (i.e. dysarthria, apraxia, and voice disorders), 2. Disruptions with words due to impairments in the language system (i.e. aphasia), and, 3. Disruptions inunderstanding, expression, and social interaction due to impairments in underlying cognitive processes (i.e. cognitive-communication disorders).  Cognitive-communication disorders (CCD’s) are the most prevalent communication difficulties after ABI with reported incidences as high as 80-100% [6, 7]. Aphasia and dysarthria are less common with reported incidences in large group studies of less than 5% [8,9,10].  CCD’s encompass difficulty with any aspect of communication (listening, speaking, gesturing, reading, writing, conversational interaction) that is affected by disruption of cognition (attention, memory, organization, reasoning, executive function) and behavioural self regulation. [5]. A peer reviewed framework for consolidating cognitive-communication evidence after ABI was proposed by MacDonald & Wiseman-Hakes [5 ]. This discussion will follow that general framework of communication interventions.

Social Communication Interventions

Direct intervention for social communication skills  

Individuals with ABI may demonstrate difficulties with planning, initiating, organizing and modulating discourse to meet the needs of the communication partner and the context[1,2,4]. They may be seen as vague, verbose, tangential, off topic, inappropriate, withdrawn, or less interesting. Social communication or pragmatic interventions are designed to increase self regulation of conversational interaction through provision of direct instruction, modeling, cues, strategies, immediate feedback, self instructional techniques, and opportunities for communication practice. Targeted goals could include increasing communication behaviours such as greetings, conversational initiations, topic introductions, questions, background information or listener feedback responses or decreasing negative communication behaviours such as: off topic responses, or inappropriate comments.  Social communication interventions for individuals with ABI are generally supported by 5 systematic reviews, although there were methodological concerns with the quality of the studies prior to 2007 [11, 12, 13, 14, 15]

Recent research lends additional support to social communication interventions. A randomized controlled trial (RCT) by Dahlberg and colleagues [2] demonstrated the effectiveness of social communication interventions using a group program featuring individualized goal setting, videotaping, practice of communication targets in real world settings, and routine ratings using goal attainment scaling. Individuals with ABI usually have preserved knowledge of optimal social communications but have difficulty performing in social interaction due to challenges with self regulation (impulse control, emotional regulation, frustration tolerance) and self monitoring (self corrections, clarifications, adaptations to changes in context etc.). A systematic review of 65 behavioural intervention studies, including interventions targeting socially successful communication behaviours, concluded that intervention gains were most likely to transfer to real world interactions if interventions promoted self regulation [15].  

Social Perception Interventions

Individuals with ABI have reduced ability to perceive context cues, understand sarcasm, humour, and indirect requests, read the emotional cues of their conversation partner, and interpret another’s perspective, knowledge, or point of view. In a randomized controlled trial by Bornhoffen and McDonald [16] aspects of emotion perception were trained using a naturalistic format of video vignettes. Results indicated that participants significantly improved both in judging basic emotional stimuli and in making social inferences.

Discourse Interventions 

Individuals with ABI frequently have difficulties formulating messages to explain, instruct, inform, persuade, recount, or share information or ideas. Discourse interventions address difficulties with information transfer, organization, cohesion, and fluency of expression [17]. Speech-language pathologists conduct a discourse analysis to delineate the pattern of strengths and weaknesses within 5 types of discourse: procedural, narrative, expository, persuasive, and conversational. Recommended strategies include provision of organizational structures such as story grammar, self instructional or self questioning strategies, and scripting. [18,19]. Further research is required to analyze the benefits of particular discourse intervention approaches for this population [17]. However, evidence relating to use of discourse strategies with other populations (autism, language learning disabilities, right hemisphere deficits) may assist clinicians as we await further evidence [20].

Communication Partner Training

Communication interventions for many populations extend beyond direct training of the identified individual to training of communication partners .A systematic review of 31 studies supported the effectiveness of communication partner training for individuals with aphasia [21].  Communication partner training has also been found to be effective for individuals with ABI.  Togher and colleagues [22] demonstrated the effectiveness of communication partner training in an RCT  in which community members (police officers) were provided with strategies to assist  communications with individuals with ABI. In a study by Shelton and Shryock [23] speech-language pathologists provided communication strategies to healthcare staff within a neurological rehabilitation setting. Results indicated improved staff/patient interactions with the use of communication strategies.  Training of communication partners in the individual’s daily life can provide more frequent cueing, immediate naturalistic feedback, and opportunities for real world practice to compensate for challenges with new learning and self regulation [19]

Social Networks

Another direction in supporting individuals at risk for social isolation has been to promote the creation of social networks, social participation, meaningful routines, and peer mentoring Struchan and colleagues [24] conducted a pilot RCT in which trained social peer mentors were matched to individuals with TBI for telephone interactions and   joint participation in community events. Mentored participants had high satisfaction ratings and significant improvements in perceived social support.

Verbal Expression (Word Retrieval, Sentence Formulation)

Interventions for verbal expression include those addressing word retrieval, and sentence formulation  There is general evidence to support verbal expression interventions in adults although not sufficient evidence to recommend one form of language or word retrieval intervention over another [5]. A review of interventions for pediatric ABI showed a trend toward improvement with language interventions but there was insufficient evidence to form practice guidelines [25]. Evidence is also available for word retrieval and expressive language techniques in adults with aphasia [26] and children with developmental language impairments [27]. Research from other diagnostic groups may inform clinical practice for those who have similar communication presentations. A systematic review by Cherney and colleagues [28] analyzed the benefits of constraint induced language therapy (CILT) which combines forced use of compromised verbal language skills with massed practice for adults with aphasia. Modest evidence was found for the use of CILT and intensive intervention. Expressive language interventions involve numerous treatment targets (vocabulary items, grammatical forms, sentence structures) and numerous treatment techniques (semantic feature analysis, phonemic cueing, CILT, melodic intonation therapy etc.) It will therefore take considerable time before there are specific evidence based guidelines to support specific interventions for specific populations.  Clinical practice in ABI can be aided by analysis of research for other etiologies who share similar communication presentations.  There are useful websites which provide a means of searching according to communication intervention subtypes by age and population  [3, 29, 30 ].

Auditory comprehension, attention, memory, and information processing

Comprehension difficulties after ABI may result from any combination of the following factors: impaired attention, memory deficits, slowed information processing, specific language impairments (syntax, semantics) and difficulties interpreting non-literal language (expressions, idioms, sarcasm, humor, inferring) as well as difficulties interpreting emotional cues. Each of these sources of difficulty has a corresponding field of research, models of intervention, and evidence base. This discussion will be limited to a few themes for intervention. One approach is to remediate underlying cognitive deficits such as attention to improve comprehension. SR’s of attention training have generally supported its use in the post acute phase, in individualized treatments that incorporate meta-.cognitive training (feedback, self monitoring, strategy training, self reflective logs, and anticipation/prediction activities) [31].  Studies that measure the impact of attention training on functional communication are required.  Reviews of attention and memory interventions favor treatments in natural contexts over de-contextualized drill and practice or repetitive computer tasks [5].  This is true in reviews of treatments for developmental language impairment as well [27].  Compensatory memory strategies are well supported in available systematic reviews [32].  Also supported are a number of instructional practices to facilitate improved processing and retention of new information or therapy targets [33].  These include such strategies as errorless learning, spaced retrieval, and cumulative review.   Finally, interventions to improve comprehension through direct language training have been supported for other populations [27]. There may be benefit to evaluating comprehension interventions by grouping participants according to comprehension deficits rather than by etiology or neurological diagnosis [20].

Organization, Reasoning, Executive Functions, & Problem Solving

Communication difficulties attributed to underlying impairments in organization, reasoning, and problem solving are typically addressed through interventions in these areas. Kennedy and colleagues [34] conducted a meta-analysis reviewing executive functions and problem solving  interventions and recommended meta-cognitive strategy instruction as a practice standard  One means of incorporating meta-cognitive strategy instruction and self regulation is Ylvisaker’s self coaching approach [19] which employs self instructional scripts, self selected/negotiated feedback,  real world communications,  and supports from everyday communication partners.   Such an approach may promote improved executive functioning and problem solving while addressing cognitive-communication challenges.  

Speech production, basic communication & augmentative communication

Speech production interventions have been researched with multiple populations and not specifically with ABI. The Academy of Neurological Communication Disorders (ANCDS) produced systematic reviews of interventions for dysarthria including participants with ABI. As part of these reviews Yorkston and colleagues [ 35,36]  analyzed specific communication characteristics (type, severity of dysarthria, respiratory, articulation, phonation features) in addition to more general characteristics of medical diagnosis, age, and demonstrated support for the use of the Lee Silverman Voice Program, and biofeedback to improve speech production. Augmentative and alternative communication (AAC) approaches such as voice output devices assist those with severely impaired speech production. These approaches were supported in a meta-analysis of 20 years of AAC interventions with several populations [37].   A randomized controlled trial by Barecca and colleagues [38] demonstrated the effectiveness of training yes/no communication systems for individuals who were nonverbal after severe ABI.

Community, work, and school re-integration

Activity or participation level interventions may target such areas as communication for parenting (teaching, reading, homework assistance, explaining, disciplining, praising), work (job interview, instructing coworkers, understanding meetings) and school (assignments, note taking, studying, test writing etc.). There are studies to support community based interventions and interventions that promote re-integration to work or school [39, 40, 41].   Some of these studies include speech-language pathology interventions as part of the multidisciplinary protocol. A review of the specific interventions and outcomes in these contexts would be beneficial and would require separate reporting of communication intervention baselines, protocols, and outcomes.

Conclusions

Evidence supports a variety of communications interventions for individuals with ABI including those related to: social communication, verbal expression, attention training, instructional practices, compensatory memory strategies, executive functions, and  speech production.  It is generally recognized that further research is required to draw specific conclusions for specific interventions and subpopulations. Analysis of interventions for school and vocational re-integration requires more of a focus on communication. Other areas require a more specific focus on ABI.  As we await definitive studies, some important themes of clinical relevance are emerging. Research to date suggests the following qualities of effective interventions:  individualized goal setting, contextualized goal setting with real world communication practice, self regulation strategies, specific feedback, videotaping, self coaching or self instruction, meta-cognitive strategies, errorless learning, direct instruction, spaced retrieval, massed practice, communication partner training, and use of real world outcome measures [5].  

Acknowledgements

I would like to express my appreciation to Catherine Wiseman-Hakes and Elyse Shumway who provided editorial comments on this paper.

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