By Katy James, Lead Speech and Language Therapist, Cognivate Rehabilitation
When an adult sustains an acquired brain injury (ABI) – whether traumatic or non-traumatic – the effects on communication can be subtle but far-reaching.
Many people are familiar with and may easily recognise when someone presents with dysarthria or aphasia, the motor speech and language impairments that often follow ABI. But less understood, and often less visible, is a cognitive-communication disorder (CCD) which can have a profound impact on a person’s everyday life.
Cognitive-communication disorders are defined as “difficulties in communicative competence (listening, speaking, reading, writing, conversation, and social interaction) that result from underlying cognitive impairments (attention, memory, organisation, information processing, problem solving, and executive functions)” (MacDonald , 2017). Current evidence suggests that around 70–75% of people with moderate to severe TBI experience some level of cognitive-communication difficulty (Togher et al., 2023; Grayson et al., 2020).
These are often described as the “hidden” effects of brain injury as they may not always be obvious. Many people’s communication after a brain injury may be perceived as ‘fine’ because their speech sounds clear, yet they may be experiencing a wide range of changes, including struggling to plan what they want to say, or to stay on track, or they may misread social cues and lack confidence in themselves.
Signs and symptoms of CCD vary and it can be useful to think of it as an umbrella term, and then describe the features that we see. After ABI, and particularly TBI, we see a range of CCD presentations from “impoverished communication through to excessive talkativeness” (Togher et al, 2023), both of which can lead to a change in turn taking skills and participation in communication activities. The person may appear limited in their interactions, with reduced facial expression, body language and gesture and they may appear ‘flat’. They may struggle to find their words and generate ideas of things to talk about, or think of questions to keep a conversation going. Attention difficulties and slower information processing can make it harder to keep up with conversation, particularly where it’s fast flowing, in a busy place, or in groups.
Conversely, others may be seen to dominate conversations, talking over others or not leaving space for others to speak. They may get fixated on topics, or be egocentric, talking only about themselves and appearing to lack interest in others’ topics or interests. Others’ contributions to conversations may be disorganised or they may jump from topic to topic, making it hard for the listener to follow.
Communication changes like these can disrupt family life, impact on friendships and relationships, make participation in community and leisure much harder and compromise a successful return to work.
Why involve Speech and Language Therapists in rehabilitation?
International guidelines (INCOG 2.0) indicate that anyone with communication difficulties after a brain injury should be offered assessment and treatment from a specialist Speech and Language Therapist (SLT). However, the communication difficulties that occur after ABI, particularly CCD, can be difficult to detect and describe consistently meaning people are not always referred to SLT. The freely available Cognitive-Communication Checklist for Acquired Brain Injury (CCCABI) aims to improve understanding and identification of the full range of communication difficulties associated with brain injury. Intended for use by healthcare professionals it is designed to help flag communication difficulties that require referral to SLT services and is a very helpful resource in the MDT’s toolkit.
SLTs are key members of the rehabilitation team because they understand how a person’s thinking skills and communication are linked. An SLT’s input can be wide-ranging but may include assessing subtle changes in attention, memory, or organisation that affect communication and highlighting any language impairment that in turn may be impacting a person’s ability to attend to and process information.
Working collaboratively with MDT colleagues, the SLT can help individuals and those around them make sense of how cognitive changes, and other influences, such as mood and confidence or physical factors, such as fatigue or pain may come together to affect day-to-day communication.
By focusing on functional, personally meaningful goals, SLTs help individuals and their conversation partners develop strategies that build confidence, communication competence, and support participation in all types of activities. This might include family conversations at the dinner table, making an order in a cafe, preparing for and taking part in meetings, managing messages, emails and phone calls, accessing social media, meeting new people or joining a new social club, to name just a few.
SLTs can also play an important role in interdisciplinary vocational rehabilitation, helping to prepare someone for their return to an existing role, educating employers about communication changes and how to best support the individual to fulfil their role with strategies and required adjustments and adaptations, or exploring alternative roles or opportunities such as voluntary work.
So what does good, real-world IDT SLT input actually look like?
At Cognivate, cognitive-communication difficulties are routinely considered within interdisciplinary neurorehabilitation, rather than viewed in isolation. SLT input is embedded within a wider team that includes neuropsychology, occupational therapy and physiotherapy, allowing communication, cognition, emotion and function to be understood together in the context of a person’s everyday life, relationships and goals.
The following case example illustrates how targeted SLT intervention, delivered as part of an interdisciplinary team, can support meaningful participation and identity after severe brain injury.
A 54-year-old father of three and grandfather, a senior manager and keen cyclist, was referred to Cognivate after sustaining a severe brain injury when he was hit by a car while out on his bike. He was left with significant cognitive impairment, executive function and cognitive-communication difficulties – including problems with attention, memory, organisation and planning, and managing his emotions. He was distractable, and had poor recall of information. His conversations had become verbose and tangential, and he used fewer facial expressions and gestures. He described difficulties with recognising his own emotions and those of others around him, and presented with heightened levels of anxiety.
The Cognivate IDT worked with him to explore his hopes and goals. A deeply meaningful and personally relevant goal was to deliver the father-of-the-bride speech at his daughter’s wedding and it was agreed that this was a key area for SLT to lead on.
Working closely with the interdisciplinary team, I began by helping him to organise his ideas – deciding what was most important to include and what could be left out to keep his speech an acceptable length,, relevant and engaging. Together, we developed cue cards and prompts to help him stay on track, rehearsing and refining these strategies using video feedback and confidence rating scales to support his self-evaluation and monitoring, and to increase awareness of the effectiveness of his non-verbal communication skills.
Emotional regulation strategies developed jointly with neuropsychology were introduced to help him manage his emotions in a way that would feel natural and non-intrusive while he delivered the speech.
In the lead up to the big day, he reported feeling more confident about his ability to give the speech and to get through to the end, something he had been uncertain he would achieve. Feedback from his daughter and the guests was overwhelmingly positive, they described an excellent and amusing speech filled with the right level of warmth and emotion. He described pride in being able to give his daughter the speech she deserved and described the occasion as a ‘big win’.
In summary
Cognitive-communication difficulties are a common yet often hidden consequence of acquired brain injury and are frequently overlooked, particularly when a person’s speech sounds clear and fluent. Despite this, underlying impairments in attention, memory, executive functioning, and emotional regulation can significantly disrupt communication, affecting relationships, social participation, and a successful return to work. Because these difficulties can be subtle and variable, many people are not identified or referred for support.
Speech and Language Therapists play a crucial role in recognising and addressing these complex changes. Interdisciplinary, community-based services such as Cognivate are well placed to identify and address cognitive-communication difficulties early, ensuring communication support is integrated into rehabilitation that is meaningful, functional and life-changing.
With the right support, people can rebuild communication confidence, re-engage in meaningful activities, reconnect with what matters most to them, and reclaim important personal, social, and vocational roles.
References and suggested further reading
Togher L. et al. (2023). INCOG 2.0 Guidelines for Cognitive Rehabilitation: Cognitive-Communication Disorders. Journal of Head Trauma Rehabilitation.
Grayson L. et al. (2020). A survey of cognitive-communication difficulties following traumatic brain injury: Are families receiving the support they need? Brain Injury.
MacDonald S. (2021). The Cognitive-Communication Checklist for Acquired Brain Injury (CCCABI). American Journal of Speech-Language Pathology.
Headway (UK). Cognitive-Communication Difficulties after Brain Injury. www.headway.org.uk
Howell S. et al, (2022) Stakeholder views on cognitive communication assessment and intervention for a person living independently in the community with severe traumatic brain injury. International Journal of Language and Communication Disorders