CCDs: Treatment and Therapy Options

Cognition is a fantastically complex process.  It includes the various systems we use to process information, like maintaining attention, determining what info is less important, (and then not focusing on it), storing information and retrieving it later.  In short, “cognition” refers to how we think.

Cognition has strong ties to communication.  Not only are cognitive and linguistic processes interwoven, (think about the language you use to do your thinking), but we use cognition to do things such as: pick up the verbal and non-verbal cues that others give us, navigate expectations for socially appropriate communication, maintain conversational topics, understand and retain information, and make judgments about the environment so we can use our speech and voice to effectively express ourselves.

Sometimes, things happen to disrupt cognition such as:

• Congenital disorders
• Prenatal neurological injuries
• Injuries sustained during childbirth
• Acquired brain injuries, (e.g., traumatic brain injury, stroke, tumors, meningitis, oxygen deprivation)
• Degenerative disorders (e.g., Alzheimer’s and other forms of dementia)

It follows that, when something happens to our cognitive system, it can affect the way we communicate.  ASHA describes cognitive-communication disorders (CCDs) as encompassing, “difficulty with any aspect of communication that is affected by disruption of cognition. Communication may be verbal or nonverbal and includes listening, speaking, gesturing, reading, and writing in all domains of language (phonologic, morphologic, syntactic, semantic, and pragmatic),” (ASHA, 2005).  Thus, rather than being one thing, cognitive-communication disorders are a spectrum of challenges that can occur when an individual experiences problems with cognition.  In other articles in this series we talk about some of those challenges like language, articulation, and fluency.   Therefore, in this article we are going to focus on some of the characteristics that are a little more unique to CCDs.

Individuals who experience cognitive-communication disorders may present with concerns such as:

• Executive Functioning: This includes skills like planning, organizing, strategizing, managing time and space.  Individuals with CCDs may have difficulty self-monitoring to follow social and other rules, as well as anticipating the consequences if they don’t.  They may struggle to follow schedules or plan daily routines.  Changes in those routines can be even more difficult to navigate.
• Memory:  This can include difficulties with long-term memory, (e.g. recounting an event from when they were younger).  However, working memory- which is associated with short-term memory- seems to be particularly affected in cognitive-communication disorders.  Working memory is like the “workbench” where we manipulate information to complete immediate tasks around us.    Sometimes, people with CCDs present with challenges recalling new information, following directions, or completing tasks.  They may also struggle with “word retrieval” or coming up with the correct label for something.
• Attention:  This is associated with both executive functioning and memory.  This is the ability to determine what information is the most relevant to a task, maintain that in working memory, and ignore thoughts or other input, (sound, sight, smell, etc.), that is not pertinent to that task.  Cognitive-communication impairments may result in difficulty maintain a topic during conversation.  Discussions might include rapid, disjointed topic shifts, or they could be unusually verbose and repetitive.  Individuals with CCDs may also have difficulty analyzing and elaborating on abstract information.
• Emotion:  Depending on the type of injury that was sustained, the individual may have difficulty managing emotions.  This can be due to physiological responses to changes in brain chemistry, damage to portions of the brain that regulate emotion, or reduced insight into emotional states.  Individuals with CCDs sometimes have difficulty reading non-verbal cues from others such as facial expressions or tone of voice.  They may also have increased struggles analyzing and responding to humor or non-literal language.

There are a variety of other challenges that individuals with cognitive-communication disorders face.  However, these examples provide a good representation of three things:  (1) The diverse nature of these impairments, (2) the overlap in clinical areas of need, (3) the variety of professional skillsets required to support rehabilitation.  For this reason, individuals with CCDs often respond best to a team approach to intervention.  The team benefits from physicians and neurologists to understand and address the underlying medical issues behind the disruption in cognition.  Psychiatrists and neuropsychologists can lend their expertise on the cognitive changes that occurred.  Social workers and case managers may be helpful in coordinating team efforts, addressing functional needs and supporting social/emotional issues with clients and families.  Speech-language pathologists are essential to monitor and address communicative aspects of CCDs, (ASHA & APA, 2007).  Strong teams will include members who understand and respect the various skills that other members contribute, and coordinate well to support the work each other is doing.

Likewise, intervention is frequently more effective when it take place across a variety of contexts.  Some of the memory and analysis deficits associated with cognitive-communication disorders can make generalization of skills to other environments more difficult.  Context-rich therapy can involve practice in different locations, (e.g., home, community, store), and with different communication partners, (like therapists, family members, friends, store clerk).

So how does this relate to telepractice service delivery?   First, let’s go back and address the language issues that we haven’t spent a lot of time on yet, and what the research tells us.  Brennan et al. (2004) evaluated the story-telling skills of individuals with Traumatic Brain Injury (TBI) in telepractice and face-to-face conditions.  Their research indicated that there was not a significant difference between how patients responded in the two conditions.  They did note that participants in a related study, (Georgadis, 2004), who experienced stroke had a stronger performance than their TBI counterparts in the telepractice condition.  The authors suggested that this could have been due to attention issues that were more of a concern for the TBI patients.  They also noted high participant satisfaction, suggesting that they were comfortable receiving services through this medium.  It is important to note that these studies looked specifically at assessment, that participants were adults, and that they experienced cognitive-communication disorders from a specific etiology (TBI).  So there is definitely more we need to know about intervention, other medical causes of CCDs, and different age levels.  We also need to know more about how attention deficits affect telepractice services.  However, this does point to some strong potential for language services to individuals with CCDs through telepractice.

Turning attention back to remarks about the need for various team members and contexts: Unfortunately, there is nothing in the literature right now to guide us in the best way to address this.  Success is likely to depend on the flexibility and creativity of the telepractitioner, other professionals and of concerned family members.  That said, experienced telepractitioners typically learn how to coordinate with various individuals and get “buy-in” from team members whom they never see face-to-face.  The individual who is coordinating care and the telepractice clinician should be especially proactive about educating others regarding the dynamics of telepractice and also systematic about facilitating communication between each team member.  It is important to have a plan in place for the various components of an interdisciplinary approach, including:

• Educating one another on the various professional domains of brain-behavior relations
• Using that information to make decisions about responsibility for specific intervention goals. This will help maximize efficiency of the treatment process and prevent gaps in addressing areas of need.
• Deciding in which areas there may be some professional overlap and how those will be managed
• Determining a system for measuring outcomes. Preparing to modify service methods or goals based on information from other team members
• Developing a unified approach to advocating for the client in the community, with third-party payers, and with other decision-makers

(ASHA & ATA, 2007)

Success will also probably depend on the technology that is available to everyone.  When we think of teletherapy, we typically envision sitting down in front of the computer for 30 – 60 minutes.  In this situation, a creative and proactive SLP can change the environment by bringing other speaking partners into the interaction.  Imagine taking advantage of multi-user video conferencing to target staying on a conversational topic while talking with grandparents in another state or family members serving in the military abroad.  Interactions like this have the potential to be incredibly meaningful.

Likewise, mobile technology can bring the therapist along into a variety of functional and purposeful contexts – perhaps even more than would be possible in traditional face-to-face intervention.  Say a client is working on attention, word selection, and organizing tasks in appropriate order.  These are skills needed in a restaurant, and what could be more motivating than doing this at their favorite place to go?  With some preparation, a flexible caretaker, a tablet, and any number of videoconferencing apps, a therapist can virtually tag along with the client to the restaurant the family visits every week.  The telepractitioner can prep the client for skills they will need, observe how the client employs them, and provide feedback in real-time- all in a relatively inconspicuous manner.  Interactions like these may be more likely to generalize into daily activities than practicing them in a session room and asking the client to transfer them into other environments.

As with other practice areas, the profession has a lot more to learn about the potential of telepractice for serving their clients with cognitive-communication disorders.  We do know the importance of context when providing treatment to individuals with CCDs.  In the hands of inventive, flexible clinicians and caretakers, telepractice and mobile technology can provide some unique tools and maybe even some advantages in making services more contextual.

If you’re a therapist looking for a better way to work, check out our VocoVision Telepractice Services here!

Works Cited

American Speech-Language-Hearing Association. (2005). Roles of speech-language pathologists in the identification, diagnosis, and treatment of individuals with cognitive-communication disorders: position statement [Position Statement]. Available from www.asha.org/policy.

Brennan, D. M., Georgeadis, A. C., Baron, C. R., Barker, L. M. (2004). The effect of videoconference-based telerehabilitation on story retelling performance by brain-injured subjects and its implications for remote speech-language therapy. Telemedicine Journal and e-Health, 10, 147– 154.

Georgeadis, A., Brennan, D., Barker, L. M., Baron, C. ( 2004). Telerehabilitation and its effect on story retelling by adults with neurogenic communication disorders. Aphasiology, 18, 639– 652

Joint Committee on Interprofessional Relations Between the American Speech-Language-Hearing Association and Division 40 (Clinical Neuropsychology) of the American Psychological Association. (2007). Structure and Function of an Interdisciplinary Team for Persons With Acquired Brain Injury. Available from www.asha.org/policy.