• Describe the common communication challenges of students with TBI;
• Outline some general assessment principles relating to TBI;
• Describe the scope of behaviors and cognitive processes that need to be assessed in students with TBI; and
• Provide practitioners with specific information relating to the assessment of cognitive-communication impairments through language sample analysis and administration of formal assessment measures.

• Speech difficulties
• Aphasia
• Cognitive-communication impairments

Muteness
Muteness is not atypical during the early stages of recovery following TBI.  A person in coma may be mute, may utter unintelligible words, or may say words that do not relate to the immediate environment and that indicate confusion.  As a person who has been mute emerges from coma, he/she may regain natural speech quite spontaneously and rapidly or may remain mute for an extended period.Several researchers have documented through case reports examples of TBI survivors who have recovered functional speech as many as three (Light, Beesley, & Collier, 1988), nine (Beukelman, 1998) or thirteen (Workinger & Netsell, 1984) years post-injury.

When an individual remains mute for an extended period of time following emergence from coma, the integrity of the motor system needs consideration.  Dongilli, Hakel, and Beukelman (1992) analyzed the recovery patterns of speech and cognition among persons with TBI who were nonspeaking at the time of their admission to inpatient rehabilitation and identified differences between functional and nonfunctional speakers in terms of motor speech abilities, primitive oral reflexes, and feeding status.  They found that:

• Over half of the survivors became functional speakers during inpatient rehabilitation
• All survivors who regained functional speech did so when they were either at Rancho Level V or Level VI
• No survivors became functional speakers while they demonstrated one or more primitive oral reflexes, although some had displayed primitive oral reflexes at an earlier stage of recovery

Dysarthria
Among the speech challenges that follow TBI, dysarthria is the most common.  According to Sarno (1980; Sarno, Buonaguro, & Levita, 1986), approximately two-thirds of survivors of severe TBI display some form of dysarthria.  Many types of dysarthria are associated with TBI (including spastic, flaccid, ataxic, and mixed), and the full spectrum of severity levels is possible. When speech intelligibility is poor, clinicians should not hesitate to introduce AAC strategies and devices.

Apraxia of speech
Apraxia of speech is not common following TBI, but it can occur.  Sometimes it is so mild that little or no functional consequence occurs other than to prevent the person from saying tongue twisters.  In other instances, apraxia of speech may appear as a form of "neurogenic stuttering" and impair the fluency with which the person utters words.  In rare instances, apraxia of speech following TBI may resemble that of stroke survivors.

APHASIA
Persistent aphasia occurs in approximately one-third of the cases of severe TBI (Sarno, 1980; Sarno et al., 1986); it is rare following moderate and mild injuries.  Persistent aphasia needs to be distinguished from a transitory form of aphasia that often appears during the early days or weeks following emergence from coma.  When persistent aphasia occurs, it is indicative of damage to the language-specific regions of the brain and should be managed in much the same fashion as aphasia resulting from strokes.  However, speech-language pathologists and educators need to be aware of the potential for aphasia to exist in conjunction with cognitive-communication impairments.

COGNITIVE-COMMUNICATION IMPAIRMENTS
Cognitive-communication impairments are exceedingly common following moderate and severe TBIs, but they may be masked by the presence of other speech or language impairments such as dysarthria or aphasia.

A cognitive-communication impairment occurs when there are deficits in one or more of the cognitive processes that underlie communicative functioning.  The broad scope of communication is of concern in cognitive-communication impairments, not specific or discrete speech or language skills.  Typically, individuals with cognitive-communication impairments speak fluently and produce grammatically correct sentences.  Their communication challenges are not readily apparent to untrained listeners during informal conversation.  However, these challenges have a direct and substantial impact on social, academic, behavioral, and vocational performance.

Cognitive deficits associated with cognitive-communication impairments include:

• Memory problems
• Attention problems
• Poor judgment
• Disorientation
• Concrete reasoning
• Rigidity of thought
• Perceptual deficits
• Decreased executive functioning
• Disinhibition

• Word retrieval deficits
• Poor organization of speech or writing
• Tangential speech or topic shading
• Poor integration and synthesis of written or auditory material
• Failure to comprehend abstract language (humor, proverbs, idioms, etc.)
• Poor eye contact
• Flat affect
• Inappropriate use of gestures and proxemics
• Poor topic maintenance
• Decreased awareness and comprehension of nonverbal cues
• Inappropriate use of prosody and register shifts

OBSERVATIONS ARE MORE IMPORTANT THAN SCORES
The lure of administering standardized assessment procedures is that you emerge with a score to compare with normative data.  Normative data does not currently exist for students with TBI, however, and, because of the tremendous variability among survivors, such data is unlikely to ever exist in a worthwhile form.  Instead, the value of administering assessment measures is in observing how the student approaches solving the problems presented.  Administering tests with which you are highly familiar and that you have given to many other students is helpful.  That way, you know what to expect from the "average" student of a given age and will more readily recognize deviations from normal performance patterns.

PERFORM "REAL WORLD" OBSERVATIONS
Often times, TBI survivors perform better on standardized tests than they do in real life.  This may reflect the benefit that students with TBI derive from the high degree of structure inherent in standardized testing situations and, as such, contributes an important piece of diagnostic information.  However, determining how a student performs in an actual classroom, social, or vocational situation is much more important.  Although performing "real world "observations is more difficult than administering standardized tests, such observations are imperative when assessing and developing reintegration programs for students with TBI.

RECOGNIZE THE IMPORTANCE OF PERSONAL HISTORY AND LIFE SCRIPTS
The TBI population as a whole does not represent a random sampling of the general population.  As a group, TBI survivors prior to injury tend to engage in risk-taking behaviors, have a history of speech and language challenges or learning disabilities, or be labeled as "under-achievers" or "at-risk" students more often than people who do not sustain TBIs.  This is not meant to imply that individuals are in some way responsible or to blame for their injuries, and certainly a large number of people who sustain TBIs are simply in the wrong place at the wrong time.  However, the behaviors and cognitive contributors to characteristics that raise the likelihood of someone sustaining a TBI are certainly not going to be improved by acquiring brain damage.  Hence, knowing the academic, social, and behavioral history of a student prior to injury is crucial and provides important information and clues about how he/she will perform following injury.

EXAMINE FAMILY DYNAMICS AND SOCIAL STRESSORS
TBI does not happen to individuals; it happens to families.  How various family members cope with the ongoing trauma and recovery process will have a direct impact on a student survivor's emotional status and reintegration into school and the community.  If the family as a whole is in crisis, the student survivor certainly will be in crisis as well and will not perform at a level commensurate with his/her ability.

EXPECT VARIABILITY
One of the hallmarks of TBI is variability.  Expect day-to-day and even hour-to-hour fluctuations in performance.  Be especially alert to decreases in communication performance as cognitive demands increase.  Speech-language pathologists and educators need to recognize that a student with TBI may be a functional communicator in informal conversation but not in other situations.

REJECT A "STANDARD BATTERY"
Do not expect one assessment tool to work for all students with TBI.  Using subtests from multiple sources is appropriate, as is using informal measures and developing individualized assessment tools.  Anyone who tells you that they always administer the same test battery to students with TBI does not understand the nature and variability of TBI consequences.

• School psychologist
• Special education teacher(s)
• Regular education teacher(s)
• Speech-language pathologist
• School nurse
• Physical therapist
• Occupational therapist
• School administrator

A comprehensive assessment should address the following potential concerns:

• Behavior control (including sexual and emotional disinhibition, impulsivity, and judgment)
• Sensory deficits (including vision, hearing, touch, taste, and smell)
• Memory (including encoding, storage, and retrieval)
• Attention and distractibility
• Visual-perceptual skills
• Motor functioning (including equilibrium and coordination of fine and gross movements)
• Communication
• Problem solving
• Speed of processing
• Recall of previously learned material (including general knowledge information and specific academic information)
• Ability to engage in new learning
• Emotional status and self-esteem (including anxiety level, depression, and suicidal tendencies)
• Awareness and acceptance of areas of challenge

Spoken language samples need to include opportunities for students to engage in informal conversation, language-based problem solving activities, verbal sequencing, narrative tasks, divergent thinking, and abstract language usage.  Always videotape the student and view the tape when performing the communication analysis!  Luckily, transcription of the language sample or performance of syntactic or morphologic analyses in unnecessary because people with cognitive-communication impairments do not typically have challenges with structural aspects of language.  Instead, view the videotape to determine the appropriateness of the following behaviors:

• Eye contact
• Physical contact
• Use of gestures and facial expressions
• Interpretation of nonverbal information
• Register shifts
• Appropriate topic selection
• Topic maintenance
• Use of nonspecific vocabulary
• Discourse organization

• Task initiation
• Over-attention to detail
• Immediate solution recognition
• Discrimination of salient versus irrelevant information
• Willingness to continue working despite frustration
• Integration and synthesis of information
• Inhibition of impulsivity
• Need for redirection to the task
• Processing delays
• Flexibility of thought

SO WHAT TESTS DO I ADMINISTER????
A single standardized tool to assess cognitive-communication impairments does not exist.  Instead, clinicians may find it helpful to use subtests from multiple assessment instruments to evaluate various aspects of cognitive-communication impairments. The following provides examples of how clinicians can use formal instruments to assess word finding, abstract language comprehension, and reasoning.

Word Finding
Standardized assessment tools are available for determining the presence and extent of challenges in word finding or retrieval.  One option is to administer a test designed for people with aphasia, such as the Boston Naming Test (Kaplan, Goodglass, & Weintraub, 1983).  Even individuals with relatively mild cognitive-communication challenges often struggle with retrieval of specific words and will perform below expectation for their age and educational level.

Another option when evaluating word finding is to use a test of word fluency.  Perhaps the best known of these is a test commonly referred to as the FAS test.  Actually, it is a subtest of the Neurosensory Center Comprehensive Examination for Aphasia (Spreen & Benton, 1977).  The individual simply names in one minute as many words as he/she can that begin with the letter "F."  The procedure is repeated with the letters "A" and "S."  Normative information is available for individuals with aphasia, individuals with brain damage but no aphasia, and individuals with no brain damage.  Another version of a word fluency test appears as a subtest of the Boston Diagnostic Aphasia Examination (Goodglass & Kaplan, 1983) and requires individuals to name as many animals as possible within a one minute time period.  Although less normative data is available for this word fluency measure, clinicians can gain valuable information by observing the strategies survivors employ to perform the task.  For example, does the individual have sufficient flexibility of thought to shift from naming farm animals to jungle animals; or, does the individual use a strategy such as progressing alphabetically to trigger additional responses.  Frequent repetition of the same responses may also provide clinicians with an initial indication of memory status, although specific memory testing should also be performed.

Sometimes, word finding problems are not apparent unless the individual is in a stressful or high-pressure situation.  This is easily simulated during assessment sessions by first verifying that a survivor can name all of the pictures in a set and then instructing him/her to name the pictures as quickly as possible.  Slapping the cards on the desk to reveal each subsequent picture is an effective way of implying time pressure even though the actual rate of presentation is entirely dependent on the client's response speed.  Any dramatic decrease in response speed between the first and second rounds of naming the pictures suggests a word finding problem.

Abstract Language Comprehension
Clinicians may also find the evaluation of abstract language comprehension aided through administration of formal assessment measures.  For this purpose, tests of right hemisphere dysfunction following strokes may be helpful.  Specifically, two instruments are available that include a subtest requiring interpretation of proverbs and idioms:  the Rehabilitation Institute of Chicago Evaluation of Communication Problems in Right Hemisphere Dysfunction (RICE) (Burns, Halper, & Mogil, 1985) and the Mini Inventory of Right Brain Injury (Pimental & Kingsbury, 1989).  The RICE is not standardized but it does provide information that can be used for pre-test/post-test comparisons.

Reasoning
Four subtests of the Ross Test of Higher Cognitive Processes (Ross & Ross, 1976) are good for assessing verbal reasoning skills:  the Deductive Reasoning subtest, the Missing Premises subtest, the Questioning Strategies subtest, and the Analysis of Relevant and Irrelevant Information subtest.  The Deductive Reasoning subtest requires students to apply principles of logic to written statements to determine whether the given conclusions follow.  The Missing Premises subtest requires students to determine what information is missing to draw a given conclusion.  The Questioning Strategies subtest resembles a "twenty questions" game with a limited response set.  The student reads a set of five words and three groups of yes/no questions and answers.  By reading the questions and answers, the student must first determine which of the five words matches the yes/no questions; then, he/she must determine which of the three groups of questions provided the best information for determining the word to select.  The Analysis of Relevant and Irrelevant Information subtest requires students to determine whether they have too little, too much, or exactly enough information to solve a problem.

The Ross Test of Higher Cognitive Processes is intended for regular education students in upper elementary grades.  Normative data is provided only for this group of students.  However, the information obtained from administering the test to a TBI survivor with cognitive-communication impairments can be very helpful when trying to determine how a student will handle academic tasks.  Students must have regained reading skills to perform the subtests, although accommodations and changes in the administration procedures are certainly appropriate when assessing students with TBI.

    Burns, M. S., Halper, A. S., & Mogil, S. I.  (1985).  Rehabilitation Institute of Chicago Evaluation of Communication Problems in Right Hemisphere Dysfunction.  Gaithersburg, MD:  Aspen Publishers, Inc.

    Dongilli, P. A., Hakel, M. E., & Beukelman, D. R. (1992).  Recovery of functional speech following traumatic brain injury.  Journal of Head Trauma Rehabilitation, 7, 91-101.

    Goodglass, H., & Kaplan, E.  (1983).  The Assessment of Aphasia and Related Language Disorders.  Malvern, PA:  Lea & Febiger.

    Kaplan, E., Goodglass, H., & Weintraub, S.  (1983).  Boston Naming Test.  Malvern, PA:  Lea & Febiger.

    Light, J. B., Beesley, M., & Collier, B.  (1988).  Transition through multiple augmentative communication systems:  A three-year case study of a head injured adolescent.  Augmentative and Alternative Communication, 4, 2-14.

    Pimental, P. A., & Kingsbury, N. A.  (1989).  Mini Inventory of Right Brain Injury.  Austin, TX:  Pro-Ed.

    Ross, J. D., & Ross, C. M.  (1976).  Ross Test of Higher Cognitive Processes.  Novato, CA:  Academic Therapy Publications.

   Sarno, M. T. (1980).  The nature of verbal impairment after closed head injury. Journal of Mental and Nervous Disease, 168, 685-692.

    Sarno, M. T., Buonaguro, A., & Levita, E.  (1986).  Characteristic of verbal impairment in closed head injured patients. Archives of Physical Medicine and Rehabilitation, 67, 400-405.

    Spreen, O., & Benton, A. L.  (1977).  Neurosensory Center Comprehensive Examination for Aphasia, 1977 Revision.  Victoria, B.C.: University of Victoria Neuropsychology Laboratory.

    Workinger, M.S., & Netsell, R. (February 1984).  Restoration of speech production thirteen years post-trauma.  Paper presented at the Second Biennial Clinical Dysarthria Conference, Tucson, AZ.
 

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