MacDonald_2017_Introducing the model of cognitive communication competence.pdf

Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ibij20 Brain Injury ISSN: 0269-9052 (Print) 1362-301X (Online) Journal homepage: https://www.tandfonline.com/loi/ibij20 Introducing the model of cognitive-communication comp...

Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ibij20 Brain Injury ISSN: 0269-9052 (Print) 1362-301X (Online) Journal homepage: https://www.tandfonline.com/loi/ibij20 Introducing the model of cognitive-communication competence: A model to guide evidence-based communication interventions after brain injury Sheila MacDonald To cite this article: Sheila MacDonald (2017) Introducing the model of cognitive-communication competence: A model to guide evidence-based communication interventions after brain injury, Brain Injury, 31:13-14, 1760-1780, DOI: 10.1080/02699052.2017.1379613 To link to this article: https://doi.org/10.1080/02699052.2017.1379613 © 2017 The Author(s). Published by Taylor &Francis Group, LLC.Published online: 24 Oct 2017.Submit your article to this journal Article views: 29039View related articles View Crossmark dataCiting articles: 60 View citing articles Introducing the model of cognitive-communication competence: A model to guide evidence-based communication interventions after brain injury Sheila MacDonald a,b aAdjunct Lecturer, Department of Speech-Language Pathology, University of Toronto, Toronto, Ontario, Canada; bOwner, Sheila MacDonald & Associates, Guelph, Ontario, Canada ABSTRACT Primary objective : Communication impairments associated with acquired brain injury (ABI) are devastat- ing in their impact on family, community, social, academic, and vocational participation. Despite international evidence-based guidelines for communication interventions, evidence practice gaps include under identification of communication deficits, infrequent referrals, and inadequate treatment to realize functional communication outcomes. Evidence-informed communication intervention requires synthesis of abundant interdisciplinary research. This study describes the development of the model of cognitive-communication competence, a new model that summarizes a complex array of influences oncommunication to provide a holistic view of communication competence after ABI. Research design : A knowledge synthesis approach was employed to integrate interdisciplinary evidence relevant to communication competence. Methods and procedures : Development of the model included review of the incidence of communication impairments, practice guidelines, and factors relevant to communication competence guided by three key questions. This was followed by expert consultation with researchers, clinicians, and individuals with ABI. Main outcomes and results : The resulting model comprises 7 domains, 7 competencies, and 47 factors related to communication functioning and intervention. Conclusion : This model could bridge evidence to practice by promoting a comprehensive and consistent view of communication competence for evidence synthesis, clinical decision-making, outcome measure- ment, and interprofessional collaboration. KEYWORDSCognitive-communication; communication;communication competence; social communication; socialcognition; speech-languagepathology Introduction This paper presents the development of the model of cogni- tive-communication competence to assist in conceptualizing the full range of communication impairments after acquired brain injury (ABI), the influences on communication, and the analysis of evidence-based interventions. Such a model could be used not only to guide clinical decision-making but also to promote a shared understanding of communication deficits and interventions among health policy advisers, administra- tors, and funders who create the conditions for implementa- tion of practice guidelines. It is proposed that such a model could be used as a basis for education, identification, pro- gramme planning, assessment planning, and treatment design to facilitate implementation of existing practice guidelines and to identify opportunities for development of new ones. The paper ends with a summary of evidence-based best practices that can help to reduce the negative effects of communication disorders and improve the lives of those who experience them. Communication impairments after ABI are prevalent and devastating. The majority of individuals who sustain an ABI will experience some form of communication impairment with reported incidence rates commonly higher than 75% ( 1-4). Research indicates that even those with mild brain injury should be screened and evaluated for possible communication disorders ( 5–7). These communi- cation deficits disrupt family communications ( 8,9); social participation ( 10,11), independence in community interac- tions ( 12), academic success ( 13–17), and successful return to competitive employment ( 18–20). There is a growing body of evidence that speech-language pathology (SLP) interventions can be effective in improving cognitive and communication functioning and ultimately improving the lives of those with ABI ( 10,21–24). International standards and guidelines indicate that all indi- viduals with communication impairments after ABI should be provided with SLP intervention ( 24). Speech-language pathol- ogists have the knowledge and skills to address communica- tion impairment ( 24,25). Evidence supports SLP interventions to improve attention ( 26), memory ( 27,28), social communi- cation ( 10,29), reading comprehension ( 30), and executive function and metacognition ( 31). SLP assessments have been shown to be helpful in detecting subtle but debilitating deficits (2,6,32,33) and in guiding return to school ( 14,16,34) and return to work ( 19,20).Evidence supports SLP involvement for individuals with ABI in acute care ( 35–37), inpatient rehabilitation ( 38–40), and community-based interventions including several years post injury ( 8,41). CONTACT Sheila MacDonald [email protected] Sheila MacDonald & Associates, Suite 108; 5420 Hwy 6 North, Guelph, Ontario N1H 6J2, Canada Colour versions of one or more of the figures in the article can be found online at www.tandfonline.com/ibij . BRAIN INJURY2017, VOL. 31, NOS. 13 –14, 1760 –1780 https://doi.org/10.1080/02699052.2017.1379613 © 2017 The Author(s). Published by Taylor & Francis Group, LLC. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License ( http://creativecommons.org/Licenses/by-nc-nd/4.0/ ), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. Evidence to practice gaps in communication intervention A number of evidence to practice gaps for those with commu- nication impairment have been reported. First, while there are a range of evidence-based SLP interventions available, estimates indicate that fewer than 50% of individuals are in fact referred for SLP services ( 1,36,42). In a study of 11 226 adults receiving SLP services in outpatient rehabilitation programmes in the USA, more than 54.9% had not received SLP services before being admitted to an outpatient facili ty, some weeks to months after onset of brain injury ( 43). Blake and colleagues ( 1)reviewed national stroke data and reported that while 94% of individuals were diagnosed with a cognitive o r communication deficit, only 45% were referred for SLP services and more often those referrals were to address swallowing diffi culties (52%), rather than com- munication deficits in expressi on (22%), comprehension (23%), or pragmatics (5%) ( 43). In a Canadian stroke study, Salter and colleagues ( 44) noted that while 77.5% of those screened met the threshold for possible cognitive-communication impairment, only 3.7% were referred for a full SLP evaluation. An international survey by Morgan and Skeat ( 45) determined that only 12% of centres had routine procedures f or referral to SLP and few had set referral criteria or established referral protocols. Edwards and colleagues ( 42) reported the following percentage of missed com- munication and cognitive deficits when formal screening proce- dures were not employed: anomia (97%), hearing impairment (86%), aphasia (79%), and memory impairments (31%). Several reasons for lack of referral to SLP services have been postulated including lack of awareness of the full range of possible commu- nication deficits ( 13); lack of understanding of available SLP treatments ( 1); unclear identification, screening, and referral sys- tems ( 42,45); lack of physician awareness of SLP services ( 46); and a generalized underutilizati on of allied health expertise ( 47). Frequently, the more obvious communication impairments in motor speech, aphasia, fluency, or voice prompt referral for SLP intervention while the more prevalent, subtle, but equally debili- tating cognitive-communication disorders are overlooked, thus depriving individuals of access to evidence-based interventions (1,36). Although social communication deficits have been noted inthemajorityofseverelyinjuredadultswithABI( 48,49), referral rates to SLP for social or pragmatic treatment are as low as 3 –5% in large US national data collection samples ( 43). Fair and timely access to communication interventions requires evaluation methods that consider the multiple cogni- tive, emotional, and physical influences on real-world commu- nication performance, and that incorporate measures with sufficient sensitivity and ecological validity to detect these defi- cits ( 50–53). Communication deficits are underidentified due to use of screening and assessment measures that lack the sensitiv- ity to detect subtle but functionally significant communication deficits ( 7,14,54,55). Also, referral processes and care pathways tend to focus disproportionately on swallowing or motor speech deficits to the exclusion of other equally pressing communica- tion concerns ( 36,40,56) . In addition, clinicians require guidance in selecting the most accurate, comprehensive, relevant, and ecologically valid assessment tools from a growing range of standardized tests, ( 7,51,57), activity, and participation measures (7,10,50,52,53,58–61). Significant gaps in treatment service also have been noted including premature discharge from treatment or inadequate treatment to realize functional goals in social, academic, or workplace communications ( 14,19,31,43,62). Current practice guidelines recommend interventions be contextualized by including the communication demands of the individual ’s life, involving communication partners, and promoting self- coaching, self-regulatory, or metacognitive strategy instruc- tion and providing tailored supports for return to work, school, or social participation ( 23,24). Yet speech-language pathologists cite significant barriers to implementation of evidence guidelines such as lack of time (92.3%), lack of resources (81.7%), or lack of interest from others (58.2%) (63). The analysis, interpretation, and application of evidence relevant to communication interventions after ABI are increasingly onerous, requiring clinicians to synthesize over 8000 articles with more than 49 key search terms, and more than 70 clinical practice recommendations ( 22–24,64,65). Finally, use of outcome measures that do not reflect the full range of communication functioning, or the complex demands of real-world communication activities or participa- tion lead to under-reporting of communication problems, untimely discharge, and false indications of resolution of problems ( 32,52). Rationale for a new model of cognitive- communication competence Evidence-based intervention for individuals with ABI-related communication disorders could be improved through the development of a comprehensive and unifying model of com- munication competence. Models provide a guide or map for selection and evaluation of published data, integration of findings, clinical decision –making, and delineation of knowl- edge gaps and areas for future research. ( 66). A model of communication competence could provide some structure for evidence selection, synthesis, and application of the vast and varied evidence relevant to communication disorders. This is evidence that spans the fields of SLP, psychology, neuroscience, rehabilitation, and education and concerns the complex interplay between cognitive, communicative, emo- tional, and physical factors ( 1,13,18,24,40). Currently commu- nication disorders that occur due to underlying cognitive impairment are well defined within the field of SLP (24,67,68) but less well understood by the wider healthcare systems responsible for policy development, funding, and outcome measurement ( 5,13,36). A unified model could cre- ate a shared vision of the communication needs of those with ABI to improve their access to disability supports, commu- nity-based rehabilitation services, educational accommoda- tions, and insurance or healthcare funding to address communication challenges. In summary, a model of cogni- tive-communication competence could promote greater con- sistency in referral and assessment practices; guide treatment and application of evidence-based practice; and promote greater understanding of the full range of communication impairment for improved data collection, and planning of service needs. BRAIN INJURY 1761 The model of cognitive-communication competence The goal in developing the model of cognitive-communication competence was to develop an integrated, consistent, and unify- ing conceptual model of communication that allows us to map the key variables, synthesize findings of multiple lines of inquiry, and promote clinical application as well as continued growth of meaningful evidence for optimal communication intervention. This model was designed to meet the following objectives: (1) To highlight the central role of communication skills and processes in all interactions including commu- nity integration and societal participation, and to stimulate consideration of the importance of commu- nication sampling characteristics, communication complexity, and communication task demands in all research, rehabilitation, and real-world evaluations. (2) To depict communication as a complex, multifaceted construct with a range of individual, cognitive, com- municative, emotional, physical, self-regulatory, and contextual influences. (3) To synthesize existing evidence (i.e. practice standards, guidelines, evidence reviews) relevant to communica- tion disorders including International Guidelines for Cognitive-Communication Intervention ( 24) and evi- dence for cognitive-communication interventions gleaned from systematic reviews and meta-analyses (10,22,23,26,28,29,51,52,69,70). (4) To integrate interdisciplinary fields of inquiry in SLP, psychology, rehabilitation, and education, from a range of perspectives including instructional practices (71), metacognitive strategy instruction ( 31), social communication, pragmatics, discourse, communica- tion partner training ( 10,72,73), gist reasoning, social cognition, and executive functioning ( 13,21,58,70,74– 79). A model could help to interpret and integrate an array of published facts and map them onto a con- ceptual framework that gives them greater meaning and applicability ( 80). (5) To denote the importance of context in communica- tion competence, including situational, and commu- nication partner demands, by incorporating the tenets of the World Health Organization ’s International Classification of Functioning ( 81) which expands the scope beyond communication impairments to the activity limitation and participa- tion restrictions they entail ( 82). (6) To promote communication competence in real- world settings as the desired outcome of commu- nication intervention. Communication competence is a complex construct that has been variously defined within the linguistics, SLP and education literature ( 83–85). Communication competence involves multiple skills including the strategic selec- tion of both perceptive and expressive communica- tion behaviours from a diverse repertoire of possibilities, effective and appropriate employment of communication skills and strategies (i.e. content, form, and use of language), consideration of the communication partner ’s perspective, and strategic and dynamic adaptation of communication to var- ied contexts in order to achieve personal goals while considering those of others. ( 85–87). Ylvisaker and colleagues ( 88) stressed that the goal of communi- cation competence beyond ‘appropriateness ’is com- munication ‘success ’which includes the ability to affect the behaviour of others, gain acceptance by peers and family members, establish friendships, andmeetthedemandsofschool,work,andcom- munity. Finally, an updated definition of commu- nication competence must integrate the tenets of the World Health Organization ( 81) by referring to activity and participation levels of communica- tion health ( 87). Communication competence then is defined as the strategic and effective employment of communication perception and production skills, influenced by a multifaceted set of cognitive, lin- guistic, emotional, and self-regulatory abilities, within daily activities and dynamic interpersonal exchanges, to meet the individual ’s participation goals within family, community, social, work, aca- demic, and problem-solving contexts. It is proposed that a comprehensive model could convey the full range of communication impairments after ABI, provide a map for integrating disparate findings, and provide a structure for ongoing development of best practices for communication interventions. Method The steps followed in developing the model of cognitive- communication competence are presented in Figure 1 . Define, review, and quantify the full range of communication impairments after ABI This model was developed for those with ABIs that occur after birth and are non-progressive, including such diagnoses as stroke, traumatic brain injury (TBI), concussion, encephalitis, Lyme disease, meningitis, hypoxia, aneurysm, seizure disor- der, aneurysm, tumour, and right hemisphere disorder. It excludes progressive neurological disorders such as commu- nication disorders arising from dementia, multiple sclerosis, Parkinson`s disease, or Huntington`s disease. It excludes aetiologies that arise prior to or at birth such as cerebral palsy, autism spectrum disorder, or foetal alcohol syndrome. Communication deficits have been reported after most forms of ABI including TBI ( 21), right hemisphere disorder (1,2,40), concussion and mild brain injury ( 7,39,54), blast injury ( 25), stroke and aphasia ( 36,63), penetrating brain injury ( 89), hypoxic ischaemic brain injury ( 42,90), and ence- phalitis ( 29,91,92). The first step in developing the model was to review evidence regarding the incidence of the full range of commu- nication impairments after ABI. In order to obtain the most current and comprehensive estimates of communication 1762 S. MACDONALD impairment after ABI, a literature search was conducted using terms ‘communication impairment ’and ‘brain injury ’and ‘incidence ’limited to the years 2000 –2016 utilizing the follow- ing databases: MEDLINE, PsycINFO, and Embase and yield- ing 152 articles. Seminal textbooks in the field of cognitive- communication disorders were also searched for incidence and prevalence data. Estimates to follow are based on the best determination that can be made from the available literature. After ABI the most prevalent communication impairments are cognitive-communication disorders with incidence rates as high as 75 –100% depending on sampling characteristics (3,4,36,40,93–96). Cognitive-communication disorders are difficulties in communicative competence (listening, speaking, reading, writing, conversation, and social interaction) that result from underlying cognitive impairments (attention, memory, organization, information processing, problem sol- ving, and executive functions) ( 24,67,68). Cognitive-commu- nication disorders are now widely accepted as a diagnostic intervention category ( 24) . They have been established within the scope of SLP practice, guidelines, and standards internationally including in the USA ( 67), Canada ( 68), Scotland ( 97), and New Zealand ( 98). They are recognized as unique disorders which require individually tailored pro- grammes, and consideration of multiple influences on com- munication, and speech-language pathologists are uniquely trained to detect and remediate these disorders ( 24). Dysarthria and apraxia are motor speech disorders which occur in less than 35% of indi viduals with ABI, again, depending on population and sampling characteristics (97,99,100 ). Aphasia is a disturbance in specific language functioning that is characterized primarily by errors at the word and sentence level. It is common after stroke, but occurs in only 1 –2.5% of individuals with TBI ( 5,23,96), although it has been reported as high as 32%, again, depend- ing on sampling characteristics ( 3) . Stuttering or difficulties with speech fluency occur after ABI at a rate of less than 1% (5). Finally, voice disorders or changes in vocal quality, loudness, or pitch also occur at a rate of 0.6% ( 5). Referral, screening, and tracking systems should therefore prioritize the more prevalent and subtle cognitive-communication dis- orders ( 13,24). Review existing models of communication Various models of communication were examined follow- ing a search of MEDLINE, PsycINFO, and Embase using the key words ‘communication ’,‘social communication ’,or ‘discourse ’and ‘model ’and ‘brain injury ’.Thesemodels were reviewed to delineate the primary domains of influ- ence on communication functioning. These included global models of cognitive-communication functioning ( 84,101 ), pragmatics and social communication ( 73,102 –105 ), and social cognition ( 106 ). There are also specific models that detail the theoretical bases o f one specific type of commu- nication impairment including models for narrative dis- course production ( 89), motor speech ( 107 ), reading comprehension ( 17), and auditory comprehension (40,108 ). There are also models relevant to aspects of cog- nitive functioning that affect communication such as mod- els of working memory ( 109 ) and executive functioning (110 ). These models provide an important foundation for the multiple contributing factors to communication perfor- mance. Review of these models underscored the need to consider all components of communication, cognition, emotional influences, physical functioning, and individual and contextual influences in communication. It also indi- cated that while there are models of various aspects of communication there appears to be no overarching model that integrates all factors for consideration in communica- tion competence. There remains a need for a model with a central focus on communication that includes all aspects of communication (comprehension and expression; spoken and written, verbal and non-verbal, impairment and parti- cipation), that indicates the multifaceted influences on communication (i.e. cognitive, physical, emotional), and that can apply to all communication interventions by speech-language pathologis ts along the post-injury continuum. Figure 1. Development process for the model of cognitive-communication competence. BRAIN INJURY 1763 Select domains and factors relevant to communication competence The domains and factors within the model were selected from classifications presented in existing models, published standards and guidelines, and sy stematic reviews. An initial set of domains and factors were derived from the Cognitive-Communication Int ervention Review Framework presented in a knowledge translation paper that synthesized 20 systematic reviews ( 23). Next, guidelines for cognitive- communication intervention were reviewed including guidelines from the USA ( 67), Canada ( 68), Scotland ( 97), New Zealand ( 98), and the international guidelines called the INCOG guidelines ( 24).The7domainsand47factors are presented in the results section. Research of factors within the model The first author and a research assistant then conducted multiple literature searches from April 2016 to April 2017 to provide an overview of the evidence base for each factor and its relationship to communication competence. Search terms were developed for each factor within the model by reviewing previous models, guidelines, and professional databases ( 111 –113 )Thesesearch terms were applied to the following databases: MEDLINE, PsycINFO, and Embase using the key term within the model and ‘communication ’and ‘brain injury ’. The searches were limited to human studies in the English language in the years 2000 –2016. Studies were excluded if they did not refer to acquired, non-progressive brain injury (i.e. Parkinson ’s disease, multiple sclerosis, HIV, schizophrenia), did not relate to com- munication intervention, or did not relate to clinical practice (i.e. administrative practice). Initial searches in the cognitive domain yielded hundreds of studies by using the search formula ‘cogni- tion ’or ‘communication ’and ‘brain injury ’. These searches were then further limited by using the more communication focused search term ‘cognitive-communication ’. Using this method, the number of studies for the attention factor for example reduced from 842 to 18. Seminal textbooks in the field were also searched. This synthesis, construction, and refinement of the model was an iterative, cyclical process. Studies produced were then reviewed to answer the following three guiding questions relevant to the factor ’s inclusion in the model: (1) Has this factor been shown to significantly affect communication competence? (2) Has this factor been shown to be an essential compo- nent of assessment of communication deficits after ABI? (3) Is there evidence that treatment for this factor can improve communication competence? The goal was to provide a rationale for inclusion of each factor in the model rather than to list or evaluate all possible research within each domain. The resulting model of cogni- tive-communication competence and search findings are summarized in the next section. Expert consultation The model was then reviewed by an expert panel of six researche rs in SLP who are members of the TBI research writing team of the Academy of Neurological Communication Disorders (A NCDS). All members of the ANCDS group conduct research specific to evidence-based practice in cognitive-communi cation disorders after ABI. The names of each member and their fields of research are summarized in Table 1 . We discussed each of the model components in the context of its relevance to cogni- tive-communication competence in four conference calls from April 2016 to April 2017. Feedback on the factors of the model and suggested revisions were provided via email throughout this period. While consensus was reached quickly on most aspects of the model, much discussion ensued regarding the placement of items relating to execu- tive functioning, self-regulation, and metacognition. Resolution was reached by placing these items on the top of the model in a section called ‘control functions ’to illustrate their supervisory or regulatory function while also noting they are part of the cognitive domain. Three additional leading research scientists in cognitive-commu- nication disorders were invited to review the model. Their names and areas of expertise are also listed in Table 1 . These researchers provided additional guidance with respect to inclusion of factors relating to social cognition and provided seminal articles in the field for review. Six clinicians with 18 –36 years of experience in cognitive-com- munication disorders from acute care to community also reviewed the model. The names of these individuals are presented in Table 2 . These consultations occurred in email and telephone discussions from April 2016 to April 2017. The clinicians expressed that the model was clear and comprehensive and reflected the multiple influences on communication in their clinical practice. Their input led to an expansion of the list of cognitive-co mmunication competencies and the individual factors to be considered in intervention. The model was then shared with a group of 10 adults with mild to moderate ABI who were part of a social communica- tion group led by the author. These individuals stated that the model was a useful education tool and would help them to convey the multiple factors that affected their communication performance. They also indicated that the terminology within the model was comprehensible. The model of cognitive-communication competence The model of communication competence incorporates seven domains of functioning that contribute to commu- nication success in seven key areas of communication competence. Within each domain are several factors for consideration based on current evidence. The model is presented in Figure 2 . The rationale for inclusion of each domain and its component factors is presented below. 1764 S. MACDONALD Components of the model of cognitive- communication competence Individual domain International standards for cognitive-communication interven- tion recommend that rehabilitation of individuals with cogni- tive-communication disorders be grounded in analysis of an individual ’s unique characteristics, needs, life contexts, goals, and skills ( 24). Pre-injury factors that have been found to influ- ence communication outcome include age and stage of neuro- logical and cognitive development ( 114 –117 ); education, learning skills, learning disability ( 118 ), sex ( 118 –120 ); mental health concerns, previous brain injury, or substance abuse (118 ,121 –124 ). Injury-related factors that influence Table 1. Expert Consultation: Research reviewers. Research reviewers Reviewer Affiliations Areas of research Lindsey ByomPh.D., CF-SLP Advanced Fellow in Women ’s Health Geriatric Education and Clinical Center William S. Middleton Memorial Veterans Hospital,Madison, WI, USA ANCDS TBI Scientific Writing Team Cognitive-communicationDiscourse Social communication after TBI Rik LemoncelloPhD, CCC/SLP Associate Professor, Pacific University, School of Communication Sciences & Disorders,Forest Grove, Oregon,USAANCDS TBI Scientific Writing Team Cognitive-communicationAssistive technologies for cognitionMemory rehabilitationEvidence-based practice Peter MeulenbroekPhD., CCC-SLP Assistant Professor, University of College of Health Sciences,Division of CommunicationSciences and Disorders University of Kentucky Lexington, Kentucky, USA ANCDS TBI Scientific Writing Team Cognitive-communicationSocial communication disorders Workplace communication disorders Executive functionTraumatic brain injury McKay Moore SohlbergPhD., CCC-SLP University of OregonHEDCO Professor & Director, CommunicationDisorders & Sciences, University of Oregon,Eugene Oregon, USAANCDS TBI Scientific Writing Team Cognitive-communication Cognitive rehabilitationSystematic instruction Assistive technology for cognition Brain injury rehabilitation Brian NessPhD., CCC-SLP Associate Professor, Communication Sciences and Disorders, California Baptist University, Riverside, California, USAANCDS TBI Scientific Writing Team Cognitive-communication Self-regulation Therese M. O ’Neil- Pirozzi ScD., CCC-SLP Associate Professor, Northeastern University; Boston, Massachusetts, USAAssociate Project Director, Spaulding/Harvard TBI Model System ANCDS TBI Scientific Writing Team Cognitive-communication cognition Neuroplasticity Neuroscience Leanne TogherPhD. Professor, Faculty of Health Sciences The University of Sydney, Sydney, Australia National Health & Medical Research Council Cognitive-communication Social communication/social cognition Communication partner trainingCommunity communicationDiscourse, aphasia, eHealth Lyn TurkstraPhD., CCC-SLP Assistant Dean,Speech-Language Pathology Program & Professor, School of Rehabilitation Science, McMaster University,Ontario, Canada Cognitive-communicationCognitive rehabilitation Adolescent communication & development Social communication/social cognitionAcademic & workplace communication Catherine Wiseman-HakesPhD. University of Toronto, Rehabilitation Science Institute andDpt. Of Speech-Language Pathology Hospital for Sick Children,Research Institute: Neurosciences & Mental Health, Toronto,Ontario, Canada Cognitive-communication outcomes of TBISocial communication in vulnerable populations withTBI (girls and young women, survivors of violence, Penalsystem, refugees, victims of war and displacement) Sleep and fatigue and cognitive-communication Table 2. Expert Consultation: Clinician reviewers. Clinician reviewers Clinician Years in ABI Clinical Practice Clinical experience Michelle Cohen 36 Inpatient and outpatient rehab, return to community, social, work, school Leah Davidson 18 Inpatient and outpatient rehab, return to community, social, work, school Brenda D ’Allessandro 27 Inpatient and outpatient rehab, return to community, social, work, school Lisa Jadd 32 Intensive and acute care, inpatient rehab, community based rehab, private practice and clinic; return to community, social, work, school Joanne Ruediger 36 Acute care, inpatient rehabilitation, community-based and private practice; return to community, social, work, school Elyse Shumway 35 Acute care, rehabilitation, community private practice (return to work, school, social) and long-term care Dierdre Sperry 27 Inpatient, outpatient, community private practice (return community, social, work, school) BRAIN INJURY 1765 communication include aetiology, severity, and location or extent of neurological impairment, and time since injury or onset of condition ( 114 ,125 –127 ). Individual differences in psy- chological response to trauma that warrant consideration include resilience, motivation, or adjustment ( 128 ,129 ). Communication outcomes can be influenced by a complex interaction between these pre- and post-injury individual char- acteristics as well as contextual and environmental factors ( 130 ). Contextual or environmental domain The contextual domain is placed in an arc at the top of the model to emphasize the overarching need to consider the communication demands of the individual ’s life, to involve communication partners, and to evaluate, support, and sti- mulate communication in communication contexts that are as similar as possible to the contexts of the individual ’s life ( 24). Many aspects of communication context have been found to influence communication competence including communica- tion partner characteristics (relationship, familiarity, age, roles, authority differential, cues, and skills) ( 131 –137 ) and communication tasks demands (i.e. environment, interrup- tions, predictability, load on working memory, response requirements, stimulus characteristics, etc.) ( 94,132 ,137 ,138 ). Communication partners (family, peers, etc.) can contribute critical screening and assessment information ( 18,52,139 ) and training of communication partners has been found to improve communication competence in paid carers (134 ,136 ,140 ), community members ( 12), and family members ( 135 ,141 ). Communication interventions must incorporate the tenets of the World Health Organization ’s International Classification of Functioning, Disability and Health, by considering the interaction between an individual ’s health condition, life contexts (roles, activities, participation), and their goals and preferences ( 87,142 ). Cognitive domain There are multiple cognitive processes that influence commu- nication competence. Communication and cognition are highly interdependent constructs and there are multiple cog- nitive processes that influence communication competence (28,143 ). Cognitive factors selected for inclusion in the model were based on the analysis of previously described practice guidelines ( 24,68,144 ) models of cognitive-commu- nication functioning and systematic reviews of cognitive interventions to improve communication functioning ( 23). Control functions Control functions refer to a set of cognitive processes that regulate thinking, behaviour, and communication (75,110 ,145 ). These functions are part of the cognitive domain but are illustrated separately at the top of the model to high- light their superordinate role in coordinating, integrating, or regulating cognitive and communication processes (29,75,103 ,110 ,145 ,146 ). Converging evidence indicates that these higher-order functions are frequently impaired after ABI and can influence communication competence with Figure 2. A model of cognitive-communication competence. 1766 S. MACDONALD respect to energization (initiation of conversation or social interaction); behavioural and emotional self-regulation (inhi- bition of undesired responses, profanity, personal disclosure; modulation of emotion, impulse control; flexibility, adapta- tion); executive functions (goal-directed communication, topic maintenance, task monitoring); and metacognition (self-appraisal, awareness, conversational repair, strategy application, adaptation to the needs of the conversational partner) ( 75,103 ,110 ,145 –149 ). The separate depiction of these control functions at the top of the model is justified by evidence of their overarching influence on communication and social participation ( 16,21,22,31,34,40,65,75,150 ). Metacognitive strategy instruction and self-regulatory or self-coaching approaches to communication interventions are well supported by the evidence ( 29,75,151 ). Therefore control functions, though part of the cognitive domain, are depicted separately at the top of the model to highlight the supervisory or regulatory functions that work in concert to direct functional communication. Speed of processing Speed of processing is frequently impaired following ABI and has been found to adversely affect many aspects of communication including social communication (103 ,152 ,153 ), reading comprehension ( 154 ), and discourse (18). Speed of processing is critical to the ability to process complex social interaction, facial expressions, conversational hints, interjections, and contextual influences, not only to keep pace with the complex processing of social situations (103 ,154 ,155 ) but also to inhibit unwanted behaviours in a timely fashion ( 152 ). Slower processing after ABI has also been well documented during completion of complex com- munication tasks that simulate the tasks of work, school, or community interaction ( 19,32,33). Speed of processing is includedinthemodeltoconveytheneedtoevaluate cognitive-communication performance using timed tests, to evaluate real-world communication demands in terms of speed and efficiency in addition to accuracy, and to address efficiency of communication through provision of supports and accommodations when required. Attention and working memory The ability to direct, sustain, shift, suppress, and regulate attention underlies many aspects of communication (2,26,103 ,156 ). Challenges with attention after brain injury have been implicated in communication impairments in audi- tory comprehension ( 157 ,158 ), discourse production (147 ,159 ), social communication ( 103 ), reading comprehen- sion ( 16,154 ), and written expression ( 16). Assessment of communication after ABI requires evaluation of the potential influences of sustained attention, selective attention, divided attention, and working memory ( 7,13,28,39,158 ,160 ). Evidence supports attention interventions to promote func- tional gains in communication, with direct attention training and metacognitive strategy instruction garnering the most evidence to date ( 26,39,160 –164 ). Working memory is a limited capacity system for storage and manipulation of information ( 109 ) that helps us to main- tain and update information held in mind ( 79). It is closely linked to attentional control and executive functioning in that it involves inhibition or suppression of interfering distrac- tions, mental set shifting, self-monitoring, and updating. (165 ,166 ). Working memory plays an important role in com- munication for such things as tracking what has been said, what we are about to say, what we read, or what we are planning to write. Working memory deficits after ABI have been implicated in communication impairments including problems with auditory comprehension of inferential or ambiguous material ( 94,167 ,168 ), discourse comprehension (78,169 ), discourse production ( 170 ), social communication (103 ), reading comprehension ( 17), and written expres- sion ( 16). Memory Memory functions have a place in the model because memory is critical to language processing and production ( 171 ). Memory impairments are common after ABI with reported incidence rates from 20% to 79% depending on aetiology, severity, and time post injury ( 172 ). They may involve episo- dic, declarative, or prospective memory and have been found to affect communication functions such as auditory compre- hension, reading comprehension, verbal expression and dis- course, written expression, or social communication (76,78,89,154 ,170 ,173 ,174 ). Evidence supports the use of the following memory intervention approaches for speech-lan- guage pathologists: use of external memory aids ( 22,28), inter- nal memory strategies ( 27), spaced retrieval ( 175 ), instructional practices such as systematic instruction and errorless learning ( 92,176 ), and prospective memory training (177 ). Therefore memory is depicted in the model to prompt consideration of its contribution to communication compe- tence and the development of optimal therapeutic instruction. Social cognition Social communication is a dynamic process in which one makes decisions based on social knowledge, perceptions of emotional and situational cues, and inferences about the con- versational partner ’s perspective while adapting their commu- nication to the situation ( 79). These abilities are frequently disrupted after ABI due to social cognition impairments in Theory of Mind (understanding of others ’mental states, thoughts, beliefs, desires, intentions), perspective taking and cognitive empathy, emotional perception (interpretation of non-verbal, facial, or vocal cues), and social inference (inter- pretation of sarcasm, lies, irony, certain types of humour) (77,79,103 ,106 ,178 ). Individuals with brain injury may be unable to understand or describe their own emotions (i.e. alexithymia), or to empathize or to respond adequately to another ’s display of emotion ( 106 ,179 ,180 ). Social cognition ’s inclusion in the model reflects the need to evaluate these skills and to include participation in dynamic, interactive, and even emotive conversational contexts in both intervention and research. Reasoning and problem solving Reasoning involves the analysis or synthesis of facts in order to draw a conclusion or make a decision. It is involved in communication acts such as explaining, discussing, listening BRAIN INJURY 1767 to a lecture, providing a comparison, reading for new infor- mation, expository or essay writing, persuading or negotiat- ing, summarizing, expressing a preference, or participating in a social debate ( 9,181 –185 ). Verbal reasoning is mediated by specific areas of the prefrontal cortex ( 183 ) and involves contributions from other cognitive processes such as working memory, attention and inhibitory control. Reported reasoning deficits after ABI include reduced ability to do the following: extract the ‘gist ’or the pertinent information, eliminate irre- levant information, weigh the facts, flexibly revise based on new information, generate alternatives, or predict conse- quences ( 19,20,32,33,74). Problem solving incorporates rea- soning and decision-making and also includes the ability to identify the problem, to plan and implement solutions, and to monitor, evaluate, refine, and revise. During problem solving individuals with ABI may have difficulties with efficiency, inferential thinking, analogous thinking, interpretation of abstract ideas, flexibility, generation of options, interpretation or anticipation of multiple perspectives, organization, persis- tence, self-monitoring, and self-regulation ( 9,32,33,94,182 ). Clinically those with ABI may present with difficulty follow- ing discussions, understanding team meetings, expressing a choice, or interpreting education or counselling sessions. Deficits in verbal reasoning and decision-making have been shown to compromise communication competence in aca- demic ( 181 ), workplace ( 20), and family contexts ( 9). There is evidence to support interventions for verbal reasoning and problem solving to improve communication competence (31,186 ,187 ). Communication domain Communication is our most complex human function and warrants specific examination in research, clinical practice, and outcome measurement after brain injury ( 21,23). In the model of cognitive-communication competence communica- tion is viewed as the primary domain of focus within a com- plex interplay of cognitive, linguistic, emotional, physical, personal, and contextual factors. Communication is the inter- personal exchange of ideas, information, needs, and perspec- tives that can be intentional or unintentional. Brain injury can impair any modality of communication (e.g. listening, speak- ing, reading, written expression, non-verbal expression), any aspect of the language system within that modality (e.g. pho- nology, semantics, syntax, pragmatics), or any aspect of non- verbal communication (i.e. facial expression, tone of voice) (21,40). The model is intended to demonstrate the full range of communication functions and the complex interplay of factors that form an individual ’s constellation of strengths and weaknesses ( 21). Auditory comprehension Auditory comprehension is included in the model as a key component of communication competence and a complex area of functioning requiring close examination of contribut- ing linguistic, cognitive, and perceptual demands of a given listening task or context. Comprehension after ABI can be affected at a variety of levels including the lexical, syntactic, semantic, supralinguistic, or pragmatic levels ( 188 ) as well as the literal, interpretive, critical, and metacognitive levels ( 84). Reported auditory comprehension deficits after ABI include difficulties with accurate or efficient processing of complex vocabulary ( 14), sarcasm and irony ( 189 ), implied informa- tion or inference ( 94,190 ), hints ( 155 ); non-literal or figurative language (metaphor, proverbs, idioms) ( 14,94,168 ,191 ), indir- ect requests ( 158 ), ambiguous sentences ( 167 ), and complex semantic or syntactic relationships ( 14,51,54,78,145 ,192 ). Cognitive factors have been shown to play a key role in comprehension deficits including impairments in working memory, attention, speed of processing, organization, reason- ing, social cognition or theory of mind, and executive func- tioning and self-regulation ( 77,94,114 ,167 ,169 ,190 ,191 ,193 ). A variety of task demands can affect comprehension including syntactic complexity, predictability of stimulus material, amount of contextual support, and the speaking rate of the conversation partner ( 158 ,190 ,193 ). Both verbal and non-ver- bal aspects of comprehension need to be incorporated in screening tools, referral criteria, and outcome measures (84,194 ). Several approaches to auditory comprehension intervention are supported in the literature including gist reasoning training ( 78,187 ), metaphor training ( 168 ), infer- ence training ( 40), and metacognitive strategy instruc- tion ( 150 ). Verbal expression and discourse Difficulties with expressive communication after ABI include errors and delays in word retrieval and disruption of verbal fluency ( 6,54,194 ,195 ) and problems with production of timely, meaningful, and organized discourse with sufficient regulation of quality, topic selection, or listener-oriented behaviours (Le et al, 2011; ( 14,50,52,79,102 ,196 ). Discourse may be sparse, vague, or impoverished or excessively detailed, and tangential (21,50,170 ). Difficulties after ABI may occur in procedural dis- course such as providing instructions or directions ( 197 ), in narrative discourse or story telling ( 198 ,199 ), in persuasive dis- course or the ability to persuade, sell, negotiate, or argue (200 ,201 ), in expository discourse or the ability to explain or provide a rationale ( 32,33); or in conversational discourse (52,53,147 ,202 ). These difficulties may arise from underlying problems with working memory, organization, executive func- tions, or self-regulation ( 50,78,89,105 ,143 ,145 ,196 ,198 ,203 ,204 ). The model depicts these interactions with arrows between the communication and cognitive domains and the control or self- regulatory domains. The model illustrates the interaction between the communica- tion and context domains because facility with discourse can vary as a function of task, sampling technique, discourse analysis, conversation partner characteristics, or amount of contextual support ( 52,53,132 ,137 ). Research supports assessment and treat- ment using a range of discourse tasks, contexts, communication partners, and opportunities for practice and feedback in commu- nication contexts that are similar to the individual's daily life (52,205 ,206 ). Discourse measures tha t have been found to differ- entiate performance of those with and without brain injury include measures related to story completeness, productivity, efficiency, content accuracy, co herence, and organization or story grammar ( 89,207 ). Evidence-based interventions for dis- course include communication groups, organizational strategies, 1768 S. MACDONALD communication coping strategies and communication partner training ( 12,141 ,208 –210 ). Pragmatics and social interaction In developing the model, consideration was given to varied terms used to categorize aspects of social communication competence. Pragmatics refers to the ability to use language in context ( 73). The term ‘pragmatics ’has historically been used in SLP ( 211 ,212 ) to refer to aspects of communication competence such as the ability to use language to accomplish social goals, to manage turns and topics in conversation, and to express appropriate degrees of politeness, awareness of social roles, and recognition of others ’conversational needs (213 ). Prutting and Kirchener ’s( 214 ) taxonomy of pragmatic behaviours includes such verbal behaviours as topic selection, maintenance and change, turn taking, lexical selection, cohe- sion; vocal intensity, prosody, fluency, and non-verbal aspects such as facial expression, eye gaze, and body movements. Turkstra and colleagues ’review of pragmatic theory, develop- ment, and interventions indicates that pragmatic communica- tion is a multifaceted construct that incorporates aspects of communication development, social cognition, and con- text ( 73). Social communication is an overlapping term that refers to the ability to express meanings and intents and understand those conveyed by others through use of verbal and non- verbal skills and knowledge of social conventions within var- ied environments, and with varied communication partners (10). Whereas the term pragmatics is often used to refer to the skills of the individual, social communication is used as a broader term that includes the effectiveness of the exchange between communication partners in context. Both terms, pragmatics and social communication, are used interchange- ably in the SLP literature ( 10). After some discussion with members of the consultation team it was decided to include both the terms ‘pragmatics ’and ‘social interaction ’in the list of factors within the communication domain to delineate the communication skill set an individual possesses. The term ‘social communication ’was placed on the right of the model as one of the target communication competence outcomes, the effective use of social communication in context. Social communication success is determined by the goals, conventions, boundaries, or expectations of that particular context and can be enhanced or inhibited by the skills of the communication partner ( 72,133 ). Social communication impairments after ABI include difficulties with such skills as conversational initiation, fluency (speed, efficiency, revi- sions, mazes, false starts, repetitions), topic management (maintenance, turn taking, shift), listener-oriented beha- viours or perspective taking, self-regulation (of topics, com- ments, tone, interjections), and adaptation to changing circumstances or distractions in the environment (visual, auditory, interruptions) ( 29,50,72,114 ,215 –217 ). These defi- cits can arise as a result of cognitive, communication, emo- tional, and physical factors including deficient attention, organization, working memory, or executive functions (114 ,143 ,159 ). They can place individuals at increased risk of social isolation, marital breakdown, and limitations in academic and vocational success ( 209 ,218 ,219 ). Social communication is dynamic and interactive and should be evaluated and treated within the targeted context to what- ever extent possible ( 10). Evidence supports SLP treatment for social communication deficits ( 10) including context- sensitive approaches ( 10,22,23,216 ), communication partner training ( 12,134 ,136 ), group interventions ( 8,209 ,220 ,221 ) peer mentoring ( 11), social cognition approaches ( 222 ), and behavioural interventions ( 88). Reading comprehension Reading comprehension is included in the model because deficits are prevalent after ABI and have implications for community independence, social, academic, and vocational competence ( 16,69). Reading comprehension involves a com- plex array of visual, perceptual, and cognitive skills (attention, memory, working memory, executive functions) as well as linguistic or communication skills (word comprehension, sen- tence processing, discourse comprehension) ( 16,69). Reading difficulties after ABI are varied and may include problems with oral reading, decoding, tracking, speed, or stamina for reading over time ( 16,17,69). Most commonly individuals with ABI have difficulties at the level of text or discourse comprehension ( 16,69) including problems understanding inference or implied information ( 94); understanding the inherent organization of a text or story grammar ( 223 ), recal- ling details ( 14,187 ); or difficulty understanding the main point or gist or moral of a story ( 224 ). Evidence supports reading assessment of text length materials with sufficient cognitive and linguistic challenge and ecological validity to simulate the individual ’s academic, vocational, or daily life reading requirements ( 14,16,223 ). Reading for academic or vocational purposes involves goal-directed processes that place demands on executive functioning including the ability to understand task demands, attend selectively to important materials, ignore less relevant details, monitor, and make corrections while reading ( 16). Assessment should consider the characteristics of reading materials such as degree of predictability, analysis and synthesis, amount of organizational structure, amount of inference, speed and stamina over time, and requirements to analyse, synthesize, and summarize materials ( 16,30). Assessment should also con- sider the cognitive demands placed on the reader such as to determine the goal or purpose of the reading task; maintain or shift goals fluidly across task requirements; make inferences about task expectations (e.g. what the teacher or employer wants or needs); read large volumes of material efficiently; make connections among the ideas presented in the text, make predications, develop coherent interpretations, or provide expla- nations and summaries ( 16). There is evidence to support SLP intervention for reading comprehension ( 22,43,69) including the use of gist reasoning training, organizational training, compen- satory strategies, and metacognitive strategies, and oral reading approaches ( 16,17,69,187 ). Written expression Individuals with ABI may have written expression difficulties due to problems with motor control, word retrieval, sentence formulation, generation or discourse planning. Written expression difficulties are frequently related to underlying BRAIN INJURY 1769 cognitive deficits in attention, working memory, organization, social cognition, executive function and self-regulation (14,16,225 ). Many standardized tests assess writing skills that have matured by adolescents and there is a need to evaluate higher-level written expression skills ( 14). Sufficiently sensi- tive written expression tasks are those that require the indivi- dual to analyse, synthesize, and formulate written communications that are similar to their academic, social, or vocational demands in writing activities such as homework assignments, peer conversations, daily scheduling, letters, summaries, and written explanations ( 14,16,19,20,32,33,226 ). Difficulties with written expository and persuasive discourse have been noted in complex assessment tasks that simulate the writing requirements of work or school ( 19,32). Intervention research to date favours use of individualized approaches, compensatory strategies, technology (i.e. voice to text), organizational frameworks, graphic organizers, self- regulated strategy development, explicit instruction of specific writing conventions and genres, and metacognitive strategy instruction embedded in functional academic or vocational contexts ( 16,225 –227 ). It is hoped that the inclusion of written expression in the communication domain of the model could draw attention to its importance as a functional communica- tion skill for future intervention research. Physical/sensory domain Communication is affected by a range of co-occurring or comorbid physical factors that must be considered in assess- ment and treatment planning. Sleep disorders are common after ABI and have been shown to adversely affect cognitive- communication performance ( 156 ,228 ). Persisting fatigue is the hallmark of ABI and can affect communication perfor- mance as well as the individual ’s ability to participate in communication interventions ( 229 ,230 ). Education regarding pacing and fatigue has become an integral part of SLP inter- vention. Hearing difficulties after ABI are also common and consultation with an audiologist is important not only in ruling out hearing impairment but also in developing inter- vention plans for tinnitus and other neurologically induced hearing sensitivities ( 231 ). The presence of motor speech disorders such as dysarthria and apraxia may require SLP evaluation of articulation, respiration, phonation, resonance, strength, coordinati