Lesión cerebral

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Introducción del modelo de competencia

cognitivo-comunicacional: Un modelo para guiar
las intervenciones de comunicación basadas en la
evidencia después de una lesión cerebral

Sheila MacDonald

Para citar este artículo: Sheila MacDonald (2017) Presentamos el modelo de la comunicación cognitiva
competencia: Un modelo para guiar las intervenciones de comunicación basadas en la evidencia
después de una lesión cerebral,
Lesión cerebral, 31:13-14, 1760-1780, DOI: 10.1080/02699052.2017.1379613

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© 2017 El autor(es). Publicado por Publicado en línea: 24 Oct 2017.

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LESIÓN CEREBRAL
2017, VOL. 31, NOS. 13–14, 1760–1780
[Link]

Introducción del modelo de competencia cognitivo-comunicacional: Un modelo

para guiar las intervenciones de comunicación basadas en la evidencia después
de una lesión cerebral
Sheila MacDonalda,b
Profesor adjunto, Departamento de Patología del Habla y del Lenguaje, Universidad de Toronto, Toronto, Ontario, Canadá;
bOwner, Sheila MacDonald & Associates, Guelph, Ontario,
Canadá

ABSTRACTO PALABRAS CLAVE

Objetivo principal: Las deficiencias de comunicación asociadas con la lesión cerebral adquirida (ABI) Comunicación cognitiva;
tienen un impacto devastador en la participación familiar, comunitaria, social, académica y vocacional. A comunicación;
pesar de las directrices internacionales basadas en la evidencia para las intervenciones de competencia en
comunicación;
comunicación, las lagunas en la práctica de la evidencia incluyen la identificación de déficits de
comunicación social;
comunicación, remisiones infrecuentes y tratamiento inadecuado para lograr resultados de comunicación cognición social;
funcional. La intervención de comunicación basada en la evidencia requiere síntesis de abundante patología del habla
investigación interdisciplinaria. Este estudio describe el desarrollo del modelo de competencia cognitivo-
comunicacional, un nuevo modelo que resume una compleja gama de influencias en la comunicación
para proporcionar una visión holística de la competencia comunicativa después de la ABI.
Diseño de la investigación: Se utilizó un enfoque de síntesis del conocimiento para integrar
evidencia interdisciplinaria relevante para la competencia en comunicación.
Métodos y procedimientos: El desarrollo del modelo incluyó la revisión de la incidencia de los
impedimentos de comunicación, las guías de práctica y los factores relevantes para la competencia de
comunicación guiados por tres preguntas clave. Esto fue seguido por consultas de expertos con
investigadores, clínicos y personas con ABI.
Principales resultados y resultados: El modelo resultante comprende 7 dominios, 7 competencias y
47 factores relacionados con el funcionamiento e intervención de la comunicación.
Conclusión: Este modelo podría tender un puente entre la evidencia y la práctica mediante la
promoción de una visión integral y coherente de la competencia de comunicación para la síntesis
de la evidencia, la toma de decisiones clínicas, la medición de resultados y la colaboración
interprofesional.

Introducción
lesión cerebral leve debe ser examinada y evaluada para
Este artículo presenta el desarrollo del modelo de competencia posibles trastornos de comunicación (5-7). Estos déficits de
cognitivo-comunicacional para ayudar a conceptualizar toda la comunicación perturban las comunicaciones familiares (8,9);
gama de deficiencias de comunicación después de una lesión participación social (10,11), independencia en las
cerebral adquirida (ABI), las influencias en la comunicación y interacciones comunitarias (12), éxito académico (13-17), y
el análisis de las intervenciones basadas en la evidencia. Este retorno exitoso al empleo competitivo (18-20).
modelo podría ser utilizado no solo para guiar la toma de Cada vez hay más pruebas de que las intervenciones de
decisiones clínicas, sino también para promover una patología del habla y el lenguaje (SLP) pueden ser eficaces para
comprensión compartida de los déficits de comunicación y las mejorar el funcionamiento cognitivo y de la comunicación y, en
intervenciones entre los asesores de políticas de salud, última instancia, mejorar la vida de las personas con ABI (10,21-
administradores y financiadores que crean las condiciones 24). Las normas y directrices internacionales indican que todas
para la implementación de las directrices de práctica. Se las personas con problemas de comunicación después de la ABI
propone que ese modelo se utilice como base para la deben recibir una intervención de SLP (24). Los patólogos del
educación, la identificación, la planificación de programas, la habla y el lenguaje tienen los conocimientos y las habilidades
planificación de evaluaciones y el diseño de tratamientos a fin para abordar el deterioro de la comunicación (24,25). La
de facilitar la aplicación de las directrices prácticas existentes evidencia apoya las intervenciones de SLP para mejorar la
y determinar oportunidades para la elaboración de otras atención (26), la memoria (27,28), la comunicación social
nuevas. El documento termina con un resumen de las mejores (10,29), la comprensión lectora (30), y la función ejecutiva y la
prácticas basadas en la evidencia que pueden ayudar a reducir metacognición (31). Las evaluaciones de SLP han demostrado ser
los efectos negativos de los trastornos de comunicación y útiles para detectar déficits sutiles pero debilitantes (2,6,32,33) y
mejorar las vidas de quienes los experimentan. para guiar el regreso a la escuela (14,16,34) y el regreso al trabajo
Los problemas de comunicación después de la ABI son (19,20). La evidencia apoya la implicación de SLP para las
frecuentes y devastadores. La mayoría de los individuos que personas con ABI en la atención aguda (35-37), la rehabilitación
mantienen una ABI experimentarán algún tipo de deterioro de de pacientes hospitalizados (38-40) y las intervenciones basadas
la comunicación con tasas de incidencia reportadas en la comunidad, incluyendo varios años después de la lesión
comúnmente superiores al 75% (1-4). La investigación indica (8,41).
que incluso aquellos con
CONTACTSheila MacDonald sheilamacdonald@[Link] Sheila MacDonald & Associates, Suite 108; 5420 Hwy 6 North, Guelph,
Ontario N1H 6J2, Canadá Las versiones en color de una o más de las figuras del artículo se pueden encontrar en línea en
[Link]/ibij.
© 2017 El autor(es). Publicado por Taylor & Francis Group, LLC.
Este es un artículo de Acceso Abierto distribuido bajo los términos de la Licencia Creative Commons Attribution-NonCommercial-NoDerivatives
([Link] que permite la reutilización, distribución y reproducción no comercial en cualquier medio, siempre que la obra original se cite correctamente,
y no se altere, transforme o construya de ninguna manera.
 preocupaciones de comunicación igualmente apremiantes
(36,40,56). Además, los médicos requieren orientación para
Evidencia para practicar brechas en la seleccionar las herramientas de evaluación más precisas,
intervención de la comunicación completas, relevantes y ecológicamente válidas de una gama
creciente de pruebas estandarizadas (7,51,57), medidas de
Se ha informado de una serie de pruebas que indican lagunas en la
actividad y participación (7,10,50,52,53,58-61).
práctica para las personas con problemas de comunicación. En primer
lugar, si bien hay una serie de intervenciones disponibles basadas en
la evidencia, las estimaciones indican que menos del 50% de las
personas son de hecho remitidas para servicios de SLP (1,36,42). En
un estudio de 11 226 adultos que recibían servicios de SLP en
programas de rehabilitación ambulatoria en los Estados Unidos, más
del 54,9% no había recibido servicios de SLP antes de ser admitido
en un centro ambulatorio, algunas semanas o meses después del
inicio de la lesión cerebral (43). Blake y sus colegas (1) revisaron los
datos nacionales de derrame cerebral e informaron que mientras que
el 94% de las personas fueron diagnosticadas con un déficit cognitivo
o de comunicación, solo el 45% fueron remitidas para servicios de
SLP y más a menudo esas remisiones fueron para abordar
dificultades para tragar (52%), en lugar de déficits de comunicación
en la expresión (22%), comprensión (23%), o pragmática (5%) (43).
En un estudio de derrame cerebral realizado en Canadá, Salter y sus
colegas (44) observaron que mientras que el 77,5% de los
examinados cumplía el umbral de posible deterioro de la
comunicación cognitiva, solo el 3,7% fueron remitidos para una
evaluación completa de SLP. Una encuesta internacional realizada
por Morgan y Skeat (45) determinó que solo el 12% de los centros
tenían procedimientos rutinarios para remitir a la SLP y pocos habían
establecido criterios de remisión o protocolos de remisión. Edwards y
colegas (42) reportaron el siguiente porcentaje de comunicación
perdida y déficits cognitivos cuando no se emplearon procedimientos
formales de detección: anomia (97%), discapacidad auditiva (86%),
afasia (79%) y deterioro de la memoria (31%). Se han aducido varias
razones para no remitir a los servicios de SLP, entre ellas la falta de
conocimiento de toda la gama de posibles deficiencias de
comunicación (13); falta de comprensión de los tratamientos
disponibles de PCS (1); sistemas de identificación, detección y
remisión poco claros (42,45); falta de conocimiento médico de los
servicios de SLP (46); y una infrautilización generalizada de los
conocimientos sanitarios conexos (47). Con frecuencia, las
deficiencias de comunicación más obvias en el habla motora, afasia,
fluidez, o la referencia de voz rápida para la intervención SLP,
mientras que los trastornos cognitivos de comunicación más
frecuentes, sutiles, pero igualmente debilitantes se pasan por alto,
privando así a las personas del acceso a intervenciones basadas en
pruebas (1,36). Aunque se han observado déficits de comunicación
social en la mayoría de los adultos gravemente lesionados con ABI
(48,49), las tasas de derivación a SLP para el tratamiento social o
pragmático son tan bajas como 3-5% en las grandes muestras
nacionales de recolección de datos de Estados Unidos (43).

El acceso justo y oportuno a las intervenciones de

comunicación requiere métodos de evaluación que consideren las
múltiples influencias cognitivas, emocionales y físicas en el
desempeño de la comunicación en el mundo real, y que
incorporen medidas con suficiente sensibilidad y validez
ecológica para detectar estos déficits (50-53). Los déficits de
comunicación están infraidentificados debido al uso de medidas
de detección y evaluación que carecen de sensibilidad para
detectar déficits de comunicación sutiles pero funcionalmente
significativos (7,14,54,55). Además, los procesos de referencia y
las vías de atención tienden a centrarse desproporcionadamente
en la deglución o los déficits del habla motora, excluyendo otras
 LESIÓN CEREBRAL cognitivo-comunicacional podría promover una mayor
1761
coherencia en las prácticas de remisión y evaluación; orientar
el tratamiento y la aplicación de la práctica basada en pruebas;
También se han observado deficiencias significativas en los y promover una mayor comprensión de toda la gama de
servicios de tratamiento, como el alta prematura o el problemas de comunicación para mejorar la recopilación de
tratamiento inadecuado para alcanzar los objetivos funcionales datos y la planificación de las necesidades de servicios.
en las comunicaciones sociales, académicas o en el lugar de
trabajo (14,19,31,43,62). Las pautas de práctica actuales
recomiendan que las intervenciones se contextualicen
incluyendo las demandas de comunicación de la vida del
individuo, involucrando a los compañeros de comunicación y
promoviendo el autocuidado, auto-regulación, o la instrucción
de estrategias metacognitivas y la prestación de apoyos
adaptados para el regreso al trabajo, la escuela o la
participación social (23,24). Sin embargo, los patólogos del
habla y el lenguaje citan barreras significativas a la
implementación de pautas de evidencia tales como falta de
tiempo (92.3%), falta de recursos (81.7%), o falta de interés de
otros (58.2%) (63). El análisis, la interpretación y la aplicación
de pruebas relevantes para las intervenciones de comunicación
después de la ABI son cada vez más onerosos, lo que requiere
que los médicos sinteticen más de 8000 artículos con más de
49 términos clave de búsqueda y más de 70 recomendaciones
de práctica clínica (22-24,64,65). Por último, el uso de
medidas de resultados que no reflejen toda la gama de
funciones de comunicación, o las complejas exigencias de las
actividades de comunicación o la participación en el mundo
real dan lugar a una información insuficiente de los problemas
de comunicación, la descarga prematura, y las indicaciones
falsas de la resolución de los problemas (32,52).

Fundamentos de un nuevo modelo de

competencia cognitivo-comunicativa
La intervención basada en la evidencia para las personas con
trastornos de comunicación relacionados con la ABI podría
mejorarse mediante el desarrollo de un modelo integral y
unificador de competencia en comunicación. Los modelos
proporcionan una guía o mapa para la selección y evaluación
de los datos publicados, la integración de los hallazgos, la
toma de decisiones clínicas y la delineación de las lagunas de
conocimiento y áreas para la investigación futura. (66). Un
modelo de competencia comunicativa podría proporcionar
alguna estructura para la selección, síntesis y aplicación de la
evidencia amplia y variada relevante para los trastornos de
comunicación. Esta es una evidencia que abarca los campos de
SLP, psicología, neurociencia, rehabilitación y educación y se
refiere a la compleja interacción entre los factores cognitivos,
comunicativos, emocionales y físicos (1,13,18,24,40).
Actualmente, los trastornos de la comunicación que se
producen debido al deterioro cognitivo subyacente están bien
definidos dentro del campo de la PSL (24,67,68), pero son
menos comprendidos por los sistemas sanitarios más amplios
responsables del desarrollo de políticas, financiación y
medición de resultados (5,13,36). Un modelo unificado podría
crear una visión compartida de las necesidades de
comunicación de aquellos con ABI para mejorar su acceso a
apoyos de discapacidad, servicios de rehabilitación basados en
la comunidad, acomodaciones educativas y financiamiento de
seguros o atención médica para abordar los desafíos de
comunicación. En resumen, un modelo de competencia
1762 S. MACDONALD

El modelo de competencia cognitivo-comunicacional la perspectiva del socio de comunicación, y la

adaptación estratégica y dinámica de la comunicación
El objetivo al desarrollar el modelo de competencia cognitivo-
a diversos contextos con el fin de lograr objetivos
comunicacional fue desarrollar un modelo conceptual de
personales, teniendo en cuenta los de los demás. (85-
comunicación integrado, consistente y unificador que nos permita
87). Ylvisaker y colegas (88) subrayaron que el
mapear las variables clave, sintetizar hallazgos de múltiples líneas de
objetivo de la competencia comunicativa más allá de
investigación, y promover la aplicación clínica, así como el
la 'adecuación' es el 'éxito' comunicativo que incluye
crecimiento continuo de pruebas significativas para una intervención
la capacidad de afectar el comportamiento de los
de comunicación óptima. Este modelo fue diseñado para cumplir los
demás, ganar aceptación por los compañeros y
siguientes objetivos:
miembros de la familia, establecer amistades, y
satisfacer las demandas de la escuela, el trabajo y la
(1) Destacar el papel central de las habilidades y los comunidad. Por último, una definición actualizada de
procesos de comunicación en todas las interacciones, la competencia comunicativa debe integrar los
incluyendo la integración comunitaria y la participación principios de la Organización Mundial de la Salud
social, y estimular la consideración de la importancia de las (81) haciendo referencia a los niveles de actividad y
características de muestreo de la comunicación, la participación de la salud comunicativa (87). La
complejidad de la comunicación, y tareas de comunicación en competencia comunicativa se define entonces como el
todas las evaluaciones de investigación, rehabilitación y del empleo estratégico y eficaz de las habilidades de
mundo real. percepción y producción de la comunicación,
(2) Describir la comunicación como una construcción influenciado por un conjunto multifacético de
compleja y multifacética con una gama de influencias capacidades cognitivas, lingüísticas, emocionales y
individuales, cognitivas, comunicativas, emocionales, físicas, autorreguladoras, dentro de las actividades diarias y
autorreguladoras y contextuales. los intercambios interpersonales dinámicos, para
(3) Para sintetizar la evidencia existente (p.e. normas de cumplir con los objetivos de participación del
práctica, guías, revisiones de evidencia) relevante para los individuo dentro de la familia, la comunidad, lo
trastornos de comunicación, incluyendo las Guías Internacionales social, el trabajo, lo académico y los contextos de
para la Intervención en la Comunicación Cognitiva (24) y la resolución de problemas.
evidencia para laintervenciones de comunicación obtenidas de
revisiones sistemáticas y metanálisis
(10,22,23,26,28,29,51,52,69,70). Se propone que un modelo amplio podría transmitir toda la
gama de problemas de comunicación después de la ABI,
(4) Integrar campos interdisciplinarios de investigación
proporcionar un mapa para integrar los resultados dispares y
en SLP, psicología, rehabilitación y educación, desde una
proporcionar una estructura para el desarrollo continuo de las
gama de perspectivas que incluyen prácticas instructivas (71),
mejores prácticas para las intervenciones de comunicación.
instrucción de estrategias metacognitivas (31), comunicación
social, pragmática, discurso, capacitación de socios de
comunicación (10,72,73), razonamiento esencial, cognición Método
social y funcionamiento ejecutivo (13,21,58,70,74-79). Un
modelo podría ayudar a interpretar e integrar una serie de Los pasos seguidos en el desarrollo del modelo de
hechos publicados y mapearlos en un marco conceptual que competencia cognitivo-comunicacional se presentan en la
les dé mayor significado y aplicabilidad (80). Figura 1.
(5) Señalar la importancia del contexto en la competencia
comunicativa, incluidas las demandas situacionales y de los
Definir, revisar y cuantificar toda la gama de
asociados en la comunicación, incorporando los principios de
deficiencias de comunicación después de la
la Clasificación Internacional del Funcionamiento de la
ABI
Organización Mundial de la Salud (81) que amplía el alcance
más allá de los impedimentos de comunicación a las Este modelo fue desarrollado para aquellos con ABI que se
restricciones de limitación de actividad y participación que producen después del nacimiento y no son progresivos,
conllevan (82). incluyendo tales diagnósticos como accidente cerebrovascular,
(6) Promover la competencia comunicativa en entornos lesión cerebral traumática (TBI), conmoción cerebral, encefalitis,
reales como el resultado deseado de la intervención enfermedad de Lyme, meningitis, hipoxia, aneurisma, trastorno
comunicativa. La competencia comunicativa es un constructo convulsivo, aneurisma, tumor y trastorno del hemisferio derecho.
complejo que ha sido definido de diversas maneras dentro de Excluye los trastornos neurológicos progresivos como los
la literatura lingüística, SLP y educativa (83-85). La trastornos de la comunicación derivados de la demencia, la
competencia en materia de comunicación entraña múltiples esclerosis múltiple, la enfermedad de Parkinson o la enfermedad
aptitudes, incluida la selección estratégica de comportamientos de Huntington. It excludes aetiologies that arise prior to or at birth
de comunicación perceptivos y expresivos a partir de un such as cerebral palsy, autism spectrum disorder, or foetal alcohol
repertorio diverso de posibilidades, y el empleo eficaz y syndrome.
adecuado de aptitudes y estrategias de comunicación (p.e. Communication deficits have been reported after most
contenido, forma y uso del lenguaje), consideración de la 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
encephalitis (29,91,92).
The first step in developing the model was to review
evidence regarding the incidence of the full range of
communication impairments after ABI. In order to obtain the
most current and comprehensive estimates of communication
 BRAIN INJURY 1763

internationally including in the USA (67), Canada (68),

Scotland (97), and New Zealand (98). They are recognized as
unique disorders which require individually tailored
programmes, and consideration of multiple influences on
communication, 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 individuals 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, depending 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 disorders
(13,24).

Review existing models of communication

Various models of communication were examined following a
search of MEDLINE, PsycINFO, and Embase using the key
words ‘communication’, ‘social communication’, or
‘discourse’ and ‘model’ and ‘brain injury’. These models were
reviewed to delineate the primary domains of influence 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
Figure 1. Development process for the model of cognitive-
bases of one specific type of communication impairment
communication competence. including models for narrative discourse production (89),
motor speech (107), reading comprehension (17), and auditory
comprehension (40,108). There are also models relevant to
impairment after ABI, a literature search was conducted using aspects of cognitive functioning that affect communication
terms ‘communication impairment’ and ‘brain injury’ and such as models of working memory (109) and executive
‘incidence’ limited to the years 2000–2016 utilizing the functioning (110). These models provide an important
following databases: MEDLINE, PsycINFO, and Embase and foundation for the multiple contributing factors to
yielding 152 articles. Seminal textbooks in the field of communication performance. Review of these models
cognitive-communication disorders were also searched for underscored the need to consider all components of
incidence and prevalence data. Estimates to follow are based communication, cognition, emotional influences, physical
on the best determination that can be made from the available functioning, and individual and contextual influences in
literature. communication. It also indicated that while there are models
After ABI the most prevalent communication impairments are of various aspects of communication there appears to be no
cognitive-communication disorders with incidence rates as high overarching model that integrates all factors for consideration
as 75–100% depending on sampling characteristics in communication competence. There remains a need for a
(3,4,36,40,93–96). Cognitive-communication disorders are model with a central focus on communication that includes all
difficulties in communicative competence (listening, speaking, aspects of communication (comprehension and expression;
reading, writing, conversation, and social interaction) that result spoken and written, verbal and non-verbal, impairment and
from underlying cognitive impairments (attention, memory, participation), that indicates the multifaceted influences on
organization, information processing, problem solving, and communication (i.e. cognitive, physical, emotional), and that
executive functions) (24,67,68). Cognitive-communication can apply to all communication interventions by speech-
disorders are now widely accepted as a diagnostic intervention language pathologists along the post-injury continuum.
category (24) . They have been established within the scope of
SLP practice, guidelines, and standards
1764 S. MACDONALD

Select domains and factors relevant to communication Expert consultation

competence
The model was then reviewed by an expert panel of six
The domains and factors within the model were selected from researchers in SLP who are members of the TBI research
classifications presented in existing models, published writing team of the Academy of Neurological Communication
standards and guidelines, and systematic reviews. An initial Disorders (ANCDS). All members of the ANCDS group
set of domains and factors were derived from the Cognitive- conduct research specific to evidence-based practice in
Communication Intervention Review Framework presented in cognitive-communication disorders after ABI. The names of
a knowledge translation paper that synthesized each member and their fields of research are summarized in
20 systematic reviews (23). Next, guidelines for cognitive- Table 1. We discussed each of the model components in the
communication intervention were reviewed including context of its relevance to cognitive-communication
guidelines from the USA (67), Canada (68), Scotland (97), competence in four conference calls from April 2016 to April
New Zealand (98), and the international guidelines called the 2017. Feedback on the factors of the model and suggested
INCOG guidelines (24) . The 7 domains and 47 factors are revisions were provided via email throughout this period.
presented in the results section. While consensus was reached quickly on most aspects of the
model, much discussion ensued regarding the placement of
items relating to executive functioning, self-regulation, and
Research of factors within the model metacognition. Resolution was reached by placing these items
The first author and a research assistant then conducted multiple on the top of the model in a section called ‘control functions’
literature searches from April 2016 to April 2017 to provide an to illustrate their supervisory or regulatory function while also
overview of the evidence base for each factor and its relationship noting they are part of the cognitive domain. Three additional
to communication competence. Search terms were developed for leading research scientists in cognitive-communication
each factor within the model by reviewing previous models, disorders were invited to review the model. Their names and
guidelines, and professional databases (111–113) These search areas of expertise are also listed in Table 1. These researchers
terms were applied to the following databases: MEDLINE, provided additional guidance with respect to inclusion of
PsycINFO, and Embase using the key term within the model and factors relating to social cognition and provided seminal
‘communication’ and ‘brain injury’ . The searches were limited to articles in the field for review. Six clinicians with 18–36 years
human studies in the English language in the years 2000–2016. of experience in cognitive-communication disorders from
Studies were excluded if they did not refer to acquired, non- acute care to community also reviewed the model. The names
progressive brain injury (i.e. Parkinson’s disease, multiple of these individuals are presented in Table 2. These
sclerosis, HIV, schizophrenia), did not relate to communication consultations occurred in email and telephone discussions
intervention, or did not relate to clinical practice (i.e. from April 2016 to April 2017. The clinicians expressed that
administrative practice). Initial searches in the cognitive domain the model was clear and comprehensive and reflected the
yielded hundreds of studies by using the search formula multiple influences on communication in their clinical
‘cognition’ or ‘communication’ and ‘brain injury’. These searches practice. Their input led to an expansion of the list of
were then further limited by using the more communication cognitive-communication competencies and the individual
focused search term ‘cognitive-communication’. Using this factors to be considered in intervention.
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 The model was then shared with a group of 10 adults with
model was an iterative, cyclical process. Studies produced were mild to moderate ABI who were part of a social
then reviewed to answer the following three guiding questions communication group led by the author. These individuals
relevant to the factor’s inclusion in the model: stated that the model was a useful education tool and would
help them to convey the multiple factors that affected their
(1) Has this factor been shown to significantly affect communication performance. They also indicated that the
communication competence? terminology within the model was comprehensible.
(2) Has this factor been shown to be an essential
component of assessment of communication deficits after
ABI? The model of cognitive-communication competence
(3) Is there evidence that treatment for this factor can The model of communication competence incorporates seven
improve communication competence? domains of functioning that contribute to communication
success in seven key areas of communication competence.
The goal was to provide a rationale for inclusion of each Within each domain are several factors for consideration
factor in the model rather than to list or evaluate all possible based on current evidence. The model is presented in Figure 2.
research within each domain. The resulting model of The rationale for inclusion of each domain and its component
cognitive-communication competence and search findings are factors is presented below.
summarized in the next section.
 BRAIN INJURY 1765

Table 1. Expert Consultation: Research reviewers.

Research reviewers
Reviewer Affiliations Areas of research
Lindsey Byom Advanced Fellow in Women’s Health Geriatric Education Cognitive-communication
Ph.D., CF-SLP and Clinical Center William S. Middleton Memorial Veterans Discourse
Hospital,Madison, WI, USA Social communication after TBI
ANCDS TBI Scientific Writing Team
Rik Lemoncello Associate Professor, Cognitive-communication
PhD, CCC/SLP Pacific University, School of Communication Sciences & Disorders, Assistive technologies for cognition
Forest Grove, Oregon,USA Memory rehabilitation
ANCDS TBI Scientific Writing Team Evidence-based practice
Peter Meulenbroek Assistant Professor, University of College of Health Sciences, Cognitive-communication
PhD., CCC-SLP Division of CommunicationSciences and Disorders University of Kentucky Social communication disorders
Lexington, Kentucky, USA Workplace communication disorders
ANCDS TBI Scientific Writing Team Executive function
Traumatic brain injury
McKay Moore Sohlberg University of Oregon Cognitive-communication
PhD., CCC-SLP HEDCO Professor & Director, Communication Cognitive rehabilitation
Disorders & Sciences, University of Oregon,Eugene Oregon, Systematic instruction
USAANCDS TBI Scientific Writing Team Assistive technology for cognition
Brain injury rehabilitation
Brian Ness Associate Professor, Cognitive-communication
PhD., CCC-SLP Communication Sciences and Disorders, California Baptist University, Self-regulation
Riverside, California, USA
ANCDS TBI Scientific Writing Team
Therese M. O’Neil- Pirozzi Associate Professor, Cognitive-communication cognition
ScD., CCC-SLP Northeastern University; Boston, Massachusetts, USA Neuroplasticity Neuroscience
Associate Project Director, Spaulding/Harvard TBI Model System
ANCDS TBI Scientific Writing Team
Leanne Togher Professor, Faculty of Health Sciences The University of Sydney, Cognitive-communication
PhD. Sydney, Australia Social communication/social cognition
National Health & Medical Research Council Communication partner training
Community communication
Discourse, aphasia, eHealth
Lyn Turkstra Assistant Dean, Cognitive-communication
PhD., CCC-SLP Speech-Language Pathology Program & Professor, Cognitive rehabilitation
School of Rehabilitation Science, Adolescent communication & development
McMaster University,Ontario, Canada Social communication/social cognition
Academic & workplace communication
Catherine Wiseman-Hakes University of Toronto, Rehabilitation Science Institute and Cognitive-communication outcomes of TBI
PhD. Dpt. Of Speech-Language Pathology Hospital for Sick Children, Social communication in vulnerable populations with
Research Institute: Neurosciences & Mental Health, Toronto, TBI (girls and young women, survivors of violence, Penal
Ontario, Canada system, refugees, victims of war and displacement)
Sleep and fatigue and cognitive-communication

Components of the model of cognitive- individual’s unique characteristics, needs, life contexts, goals, and
communication competence skills (24). Pre-injury factors that have been found to influence
communication outcome include age and stage of neurological
Individual domain
and cognitive development (114–117); education, learning skills,
International standards for cognitive-communication intervention learning disability (118), sex (118–120); mental health concerns,
recommend that rehabilitation of individuals with cognitive- previous brain injury, or substance abuse (118,121–124). Injury-
communication disorders be grounded in analysis of an related factors that influence

Table 2. Expert Consultation: Clinician reviewers.

Clinician reviewers
Years in ABI Clinical
Clinician 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)
1766 S. MACDONALD

Figure 2. A model of cognitive-communication competence.

communication include aetiology, severity, and location or extent members (135,141). Communication interventions must
of neurological impairment, and time since injury or onset of incorporate the tenets of the World Health Organization’s
condition (114,125–127). Individual differences in psychological International Classification of Functioning, Disability and
response to trauma that warrant consideration include resilience, Health, by considering the interaction between an individual’s
motivation, or adjustment (128,129). Communication outcomes health condition, life contexts (roles, activities, participation),
can be influenced by a complex interaction between these pre- and their goals and preferences (87,142).
and post-injury individual characteristics as well as contextual
and environmental factors (130).
Cognitive domain
There are multiple cognitive processes that influence
Contextual or environmental domain communication competence. Communication and cognition
The contextual domain is placed in an arc at the top of the model are highly interdependent constructs and there are multiple
to emphasize the overarching need to consider the communication cognitive processes that influence communication competence
demands of the individual’s life, to involve communication (28,143). Cognitive factors selected for inclusion in the model
partners, and to evaluate, support, and stimulate communication were based on the analysis of previously described practice
in communication contexts that are as similar as possible to the guidelines (24,68,144) models of cognitive-communication
contexts of the individual’s life (24). Many aspects of functioning and systematic reviews of cognitive interventions
communication context have been found to influence to improve communication functioning (23) .
communication competence including communication partner
characteristics (relationship, familiarity, age, roles, authority Control functions
differential, cues, and skills) (131–137) and communication tasks Control functions refer to a set of cognitive processes that
demands (i.e. environment, interruptions, predictability, load on regulate thinking, behaviour, and communication
working memory, response requirements, stimulus characteristics, (75,110,145). These functions are part of the cognitive domain
etc.) (94,132,137,138). Communication partners (family, peers, but are illustrated separately at the top of the model to
etc.) can contribute critical screening and assessment information highlight their superordinate role in coordinating, integrating,
(18,52,139) and training of communication partners has been or regulating cognitive and communication processes
found to improve communication competence in paid carers (29,75,103,110,145,146). Converging evidence indicates that
(134,136,140), community members (12), and family these higher-order functions are frequently impaired after ABI
and can influence communication competence with
 BRAIN INJURY 1767

respect to energization (initiation of conversation or social linked to attentional control and executive functioning in that
interaction); behavioural and emotional self-regulation it involves inhibition or suppression of interfering distractions,
(inhibition of undesired responses, profanity, personal mental set shifting, self-monitoring, and updating. (165,166).
disclosure; modulation of emotion, impulse control; Working memory plays an important role in communication
flexibility, adaptation); executive functions (goal-directed for such things as tracking what has been said, what we are
communication, topic maintenance, task monitoring); and about to say, what we read, or what we are planning to write.
metacognition (self-appraisal, awareness, conversational Working memory deficits after ABI have been implicated in
repair, strategy application, adaptation to the needs of the communication impairments including problems with auditory
conversational partner) (75,103,110,145–149). The separate comprehension of inferential or ambiguous material
depiction of these control functions at the top of the model is (94,167,168), discourse comprehension (78,169), discourse
justified by evidence of their overarching influence on production (170), social communication (103), reading
communication and social participation comprehension (17), and written expression (16).
(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 Memory
evidence (29,75,151). Therefore control functions, though part Memory functions have a place in the model because memory is
of the cognitive domain, are depicted separately at the top of critical to language processing and production (171). Memory
the model to highlight the supervisory or regulatory functions impairments are common after ABI with reported incidence rates
that work in concert to direct functional communication. from 20% to 79% depending on aetiology, severity, and time post
injury (172). They may involve episodic, declarative, or
Speed of processing prospective memory and have been found to affect
Speed of processing is frequently impaired following ABI and communication functions such as auditory comprehension,
has been found to adversely affect many aspects of reading comprehension, verbal expression and discourse, written
communication including social communication expression, or social communication (76,78,89,154,170,173,174).
(103,152,153), reading comprehension (154), and discourse Evidence supports the use of the following memory intervention
(18). Speed of processing is critical to the ability to process approaches for speech-language pathologists: use of external
complex social interaction, facial expressions, conversational memory aids (22,28), internal memory strategies (27), spaced
hints, interjections, and contextual influences, not only to keep retrieval (175), instructional practices such as systematic
pace with the complex processing of social situations instruction and errorless learning (92,176), and prospective
(103,154,155) but also to inhibit unwanted behaviours in a memory training (177). Therefore memory is depicted in the
timely fashion (152). Slower processing after ABI has also model to prompt consideration of its contribution to
been well documented during completion of complex communication competence and the development of optimal
communication tasks that simulate the tasks of work, school, therapeutic instruction.
or community interaction (19,32,33). Speed of processing is
included in the model to convey the need to evaluate Social cognition
cognitive-communication performance using timed tests, to Social communication is a dynamic process in which one
evaluate real-world communication demands in terms of speed makes decisions based on social knowledge, perceptions of
and efficiency in addition to accuracy, and to address emotional and situational cues, and inferences about the
efficiency of communication through provision of supports conversational partner’s perspective while adapting their
and accommodations when required. communication to the situation (79). These abilities are
frequently disrupted after ABI due to social cognition
Attention and working memory impairments in Theory of Mind (understanding of others’
The ability to direct, sustain, shift, suppress, and regulate mental states, thoughts, beliefs, desires, intentions),
attention underlies many aspects of communication perspective taking and cognitive empathy, emotional
(2,26,103,156). Challenges with attention after brain injury have perception (interpretation of non-verbal, facial, or vocal cues),
been implicated in communication impairments in auditory and social inference (interpretation of sarcasm, lies, irony,
comprehension (157,158), discourse production (147,159), social certain types of humour) (77,79,103,106,178). Individuals
communication (103), reading comprehension (16,154), and with brain injury may be unable to understand or describe
written expression (16). Assessment of communication after ABI their own emotions (i.e. alexithymia), or to empathize or to
requires evaluation of the potential influences of sustained respond adequately to another’s display of emotion
attention, selective attention, divided attention, and working (106,179,180). Social cognition’s inclusion in the model
memory (7,13,28,39,158,160). Evidence supports attention reflects the need to evaluate these skills and to include
interventions to promote functional gains in communication, with participation in dynamic, interactive, and even emotive
direct attention training and metacognitive strategy instruction conversational contexts in both intervention and research.
garnering the most evidence to date (26,39,160–164).
Reasoning and problem solving
Working memory is a limited capacity system for storage and Reasoning involves the analysis or synthesis of facts in order
manipulation of information (109) that helps us to maintain and to draw a conclusion or make a decision. It is involved in
update information held in mind (79). It is closely communication acts such as explaining, discussing, listening
1768 S. MACDONALD

to a lecture, providing a comparison, reading for new information, the literal, interpretive, critical, and metacognitive levels (84).
expository or essay writing, persuading or negotiating, Reported auditory comprehension deficits after ABI include
summarizing, expressing a preference, or participating in difficulties with accurate or efficient processing of complex
a social debate (9,181–185). Verbal reasoning is mediated by vocabulary (14), sarcasm and irony (189), implied information
specific areas of the prefrontal cortex (183) and involves or inference (94,190), hints (155); non-literal or figurative
contributions from other cognitive processes such as working language (metaphor, proverbs, idioms) (14,94,168,191),
memory, attention and inhibitory control. Reported reasoning indirect requests (158), ambiguous sentences (167), and
deficits after ABI include reduced ability to do the following: complex semantic or syntactic relationships
extract the ‘gist’ or the pertinent information, eliminate (14,51,54,78,145,192). Cognitive factors have been shown to
irrelevant information, weigh the facts, flexibly revise based play a key role in comprehension deficits including
on new information, generate alternatives, or predict impairments in working memory, attention, speed of
consequences (19,20,32,33,74). Problem solving incorporates processing, organization, reasoning, social cognition or theory
reasoning and decision-making and also includes the ability to of mind, and executive functioning and self-regulation
identify the problem, to plan and implement solutions, and to (77,94,114,167,169,190,191,193). A variety of task demands
monitor, evaluate, refine, and revise. During problem solving can affect comprehension including syntactic complexity,
individuals with ABI may have difficulties with efficiency, predictability of stimulus material, amount of contextual
inferential thinking, analogous thinking, interpretation of support, and the speaking rate of the conversation partner
abstract ideas, flexibility, generation of options, interpretation (158,190,193). Both verbal and non-verbal aspects of
or anticipation of multiple perspectives, organization, comprehension need to be incorporated in screening tools,
persistence, self-monitoring, and self-regulation referral criteria, and outcome measures (84,194). Several
(9,32,33,94,182). Clinically those with ABI may present with approaches to auditory comprehension intervention are
difficulty following discussions, understanding team meetings, supported in the literature including gist reasoning training
expressing a choice, or interpreting education or counselling (78,187), metaphor training (168), inference training (40), and
sessions. Deficits in verbal reasoning and decision-making metacognitive strategy instruction (150).
have been shown to compromise communication competence
in academic (181), workplace (20), and family contexts (9). Verbal expression and discourse
There is evidence to support interventions for verbal reasoning Difficulties with expressive communication after ABI include
and problem solving to improve communication competence errors and delays in word retrieval and disruption of verbal
(31,186,187). 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
Communication domain
behaviours (Le et al, 2011; (14,50,52,79,102,196). Discourse
Communication is our most complex human function and may be sparse, vague, or impoverished or excessively detailed,
warrants specific examination in research, clinical practice, and tangential (21,50,170). Difficulties after ABI may occur in
and outcome measurement after brain injury (21,23). In the procedural discourse such as providing instructions or
model of cognitive-communication competence directions (197), in narrative discourse or story telling
communication is viewed as the primary domain of focus (198,199), in persuasive discourse or the ability to persuade,
within a complex interplay of cognitive, linguistic, emotional, sell, negotiate, or argue (200,201), in expository discourse or
physical, personal, and contextual factors. Communication is the ability to explain or provide a rationale (32,33); or in
the interpersonal exchange of ideas, information, needs, and conversational discourse (52,53,147,202). These difficulties
perspectives that can be intentional or unintentional. Brain may arise from underlying problems with working memory,
injury can impair any modality of communication (e.g. organization, executive functions, or self-regulation
listening, speaking, reading, written expression, non-verbal (50,78,89,105,143,145,196,198,203,204). The model depicts
expression), any aspect of the language system within that these interactions with arrows between the communication and
modality (e.g. phonology, semantics, syntax, pragmatics), or cognitive domains and the control or self-regulatory domains.
any aspect of non-verbal communication (i.e. facial The model illustrates the interaction between the communication
expression, tone of voice) (21,40). The model is intended to and context domains because facility with discourse can vary as a
demonstrate the full range of communication functions and the function of task, sampling technique, discourse analysis, conversation
complex interplay of factors that form an individual’s partner characteristics, or amount of contextual support
constellation of strengths and weaknesses (21). (52,53,132,137). Research supports assessment and treatment using a
range of discourse tasks, contexts, communication partners, and
Auditory comprehension opportunities for practice and feedback in communication contexts
Auditory comprehension is included in the model as a key that are similar to the individual's daily life (52,205,206). Discourse
component of communication competence and a complex area measures that have been found to differentiate performance of those
of functioning requiring close examination of contributing with and without brain injury include measures related to story
linguistic, cognitive, and perceptual demands of a given completeness, productivity, efficiency, content accuracy, coherence,
listening task or context. Comprehension after ABI can be and organization or story grammar (89,207). Evidence-based
affected at a variety of levels including the lexical, syntactic, interventions for discourse include communication groups,
semantic, supralinguistic, or pragmatic levels (188) as well as organizational strategies,
 BRAIN INJURY 1769

communication coping strategies and communication partner communication is dynamic and interactive and should be
training (12,141,208–210). evaluated and treated within the targeted context to whatever
extent possible (10). Evidence supports SLP treatment for
Pragmatics and social interaction social communication deficits (10) including context-sensitive
In developing the model, consideration was given to varied approaches (10,22,23,216), communication partner training
terms used to categorize aspects of social communication (12,134,136), group interventions (8,209,220,221) peer
competence. Pragmatics refers to the ability to use language in mentoring (11), social cognition approaches (222), and
context (73). The term ‘pragmatics’ has historically been used behavioural interventions (88).
in SLP (211,212) to refer to aspects of communication
competence such as the ability to use language to accomplish Reading comprehension
social goals, to manage turns and topics in conversation, and Reading comprehension is included in the model because
to express appropriate degrees of politeness, awareness of deficits are prevalent after ABI and have implications for
social roles, and recognition of others’ conversational needs community independence, social, academic, and vocational
(213). Prutting and Kirchener’s (214) taxonomy of pragmatic competence (16,69). Reading comprehension involves a
behaviours includes such verbal behaviours as topic selection, complex array of visual, perceptual, and cognitive skills
maintenance and change, turn taking, lexical selection, (attention, memory, working memory, executive functions) as
cohesion; vocal intensity, prosody, fluency, and non-verbal well as linguistic or communication skills (word
aspects such as facial expression, eye gaze, and body comprehension, sentence processing, discourse
movements. Turkstra and colleagues’ review of pragmatic comprehension) (16,69). Reading difficulties after ABI are
theory, development, and interventions indicates that varied and may include problems with oral reading, decoding,
pragmatic communication is a multifaceted construct that tracking, speed, or stamina for reading over time (16,17,69).
incorporates aspects of communication development, social Most commonly individuals with ABI have difficulties at the
cognition, and context (73). level of text or discourse comprehension (16,69) including
Social communication is an overlapping term that refers to problems understanding inference or implied information (94);
the ability to express meanings and intents and understand understanding the inherent organization of a text or story
those conveyed by others through use of verbal and non-verbal grammar (223), recalling details (14,187); or difficulty
skills and knowledge of social conventions within varied understanding the main point or gist or moral of a story (224).
environments, and with varied communication partners (10). Evidence supports reading assessment of text length materials
Whereas the term pragmatics is often used to refer to the skills with sufficient cognitive and linguistic challenge and
of the individual, social communication is used as a broader ecological validity to simulate the individual’s academic,
term that includes the effectiveness of the exchange between vocational, or daily life reading requirements (14,16,223).
communication partners in context. Both terms, pragmatics Reading for academic or vocational purposes involves goal-
and social communication, are used interchangeably in the directed processes that place demands on executive
SLP literature (10). After some discussion with members of functioning including the ability to understand task demands,
the consultation team it was decided to include both the terms attend selectively to important materials, ignore less relevant
‘pragmatics’ and ‘social interaction’ in the list of factors details, monitor, and make corrections while reading (16).
within the communication domain to delineate the Assessment should consider the characteristics of reading
communication skill set an individual possesses. The term materials such as degree of predictability, analysis and synthesis,
‘social communication’ was placed on the right of the model amount of organizational structure, amount of inference, speed
as one of the target communication competence outcomes, the and stamina over time, and requirements to analyse, synthesize,
effective use of social communication in context. and summarize materials (16,30). Assessment should also
Social communication success is determined by the goals, consider the cognitive demands placed on the reader such as to
conventions, boundaries, or expectations of that particular determine the goal or purpose of the reading task; maintain or
context and can be enhanced or inhibited by the skills of the shift goals fluidly across task requirements; make inferences
communication partner (72,133). Social communication about task expectations (e.g. what the teacher or employer wants
impairments after ABI include difficulties with such skills as or needs); read large volumes of material efficiently; make
conversational initiation, fluency (speed, efficiency, revisions, connections among the ideas presented in the text, make
mazes, false starts, repetitions), topic management predications, develop coherent interpretations, or provide
(maintenance, turn taking, shift), listener-oriented behaviours explanations and summaries (16). There is evidence to support
or perspective taking, self-regulation (of topics, comments, SLP intervention for reading comprehension (22,43,69) including
tone, interjections), and adaptation to changing circumstances the use of gist reasoning training, organizational training,
or distractions in the environment (visual, auditory, compensatory strategies, and metacognitive strategies, and oral
interruptions) (29,50,72,114,215–217). These deficits can reading approaches (16,17,69,187).
arise as a result of cognitive, communication, emotional, and
physical factors including deficient attention, organization, Written expression
working memory, or executive functions (114,143,159). They
Individuals with ABI may have written expression difficulties
can place individuals at increased risk of social isolation,
due to problems with motor control, word retrieval, sentence
marital breakdown, and limitations in academic and vocational
formulation, generation or discourse planning. Written
success (209,218,219). Social
expression difficulties are frequently related to underlying
1770 S. MACDONALD

cognitive deficits in attention, working memory, organization, tolerance for transportation, fatigue, cognitive drain, or social
social cognition, executive function and self-regulation withdrawal (235). Visual perceptual impairments may occur in
(14,16,225). Many standardized tests assess writing skills that 54–74% of individuals with ABI (236) and include problems
have matured by adolescents and there is a need to evaluate with visual acuity, visual fields, peripheral vision, diplo-pia,
higher-level written expression skills (14). Sufficiently photophobia, visual perception, and a range of binocular
sensitive written expression tasks are those that require the vision impairments relating to accommodation and
individual to analyse, synthesize, and formulate written convergence (236–238). Overall, the physical domain in the
communications that are similar to their academic, social, or model highlights the importance not only of communication
vocational demands in writing activities such as homework deficits that have a physical basis, but also of additional
assignments, peer conversations, daily scheduling, letters, physical factors that can influence communication
summaries, and written explanations (14,16,19,20,32,33,226). performance and require SLP collaboration with other
Difficulties with written expository and persuasive discourse disciplines (i.e. physicians, physiotherapists, optometrists,
have been noted in complex assessment tasks that simulate the audiologists, occupational therapists).
writing requirements of work or school (19,32). Intervention
research to date favours use of individualized approaches, Emotional/psychosocial domain
compensatory strategies, technology (i.e. voice to text),
organizational frameworks, graphic organizers, self-regulated The emotional domain in the model represents the dynamic and
strategy development, explicit instruction of specific writing complex relationship among emotional, physical, cognitive, and
conventions and genres, and metacognitive strategy instruction communication factors in determining communication
embedded in functional academic or vocational contexts competence for full life participation. ABI can result in a number
(16,225–227). It is hoped that the inclusion of written of emotional or psychological challenges that are important
expression in the communication domain of the model could considerations for cognitive-communication competence and
draw attention to its importance as a functional require SLP collaboration with psychologists and physicians.
communication skill for future intervention research. These include anxiety, (239,240), depression (241–244), and
post-traumatic stress disorder (240,245,246). They have been
associated with cognitive impairments in attention, working
Physical/sensory domain memory, information processing, executive functions, and
Communication is affected by a range of co-occurring or processing speed and can have implications for communication
comorbid physical factors that must be considered in competence (240,247,248) and can also have cognitive-
assessment and treatment planning. Sleep disorders are communication competence. In addition to these psychological
common after ABI and have been shown to adversely affect diagnoses, individuals may endure problems with emotional
cognitive-communication performance (156,228). Persisting regulation leading to excesses in irritability, aggression or quick
fatigue is the hallmark of ABI and can affect communication temperedness, or emotional reductions in arousal, motivation, or
performance as well as the individual’s ability to participate in drive (249). Brain injury itself leads to increased stress related to
communication interventions (229,230). Education regarding the emotional consequences of trauma, loss and mourning,
pacing and fatigue has become an integral part of SLP change in life circumstances, restrictions on activities and
intervention. Hearing difficulties after ABI are also common individual freedoms (i.e. inability to drive or work); difficulties
and consultation with an audiologist is important not only in with decision-making, reduced choice and autonomy, changes in
ruling out hearing impairment but also in developing identity and self-confidence, and a host of stressors related to
intervention plans for tinnitus and other neurologically marital, legal, and financial changes (9,219). An individual’s
induced hearing sensitivities (231). The presence of motor emotional regulation may also be affected by physical changes in
speech disorders such as dysarthria and apraxia may require sleep hygiene, medications, and pain (9,219). Individuals with
SLP evaluation of articulation, respiration, phonation, ABI are at high risk for significant decrease in friendships and
social supports and have reduced opportunity to engage in
resonance, strength, coordination, and speed of movements
vocational and avocational or leisure activities in order to
(232,233). Voice disorders which are less common in ABI (5)
establish new friendships and this can lead to a downward spiral
involve changes in the vocal quality, loudness, or pitch of
into stress and depression (142).
voice due to changes in vocal cord movement or respiratory
The integral nature of cognitive, communication, and emotional
support for voice. Prosody disorders are also possible,
skills in the model underscores the clinical imperative to prioritize,
particularly after right hemisphere brain damage (1,40,94).
streamline, and stage interventions according to the individual’s
Stuttering or difficulties with speech fluency can occur due to
specific needs. While such conditions may require a primary focus of
neurological impairment after ABI (234) with reported
mental health intervention from mental health professionals, speech-
incidence of less than 1% in a large sample (5).
language pathologists may collaborate to provide cognitive-
Comorbid physical impairments must be considered by
communication strategies that ease communication distress and
speech-language pathologists and require informed
increase overall sense of well-being (208,247). Communication
collaboration with colleagues in the disciplines responsible for
interventions have been shown to increase measures of well-being
managing them. Deficits in balance, dizziness, or vestibular
and decrease indications of post-traumatic stress, anxiety, and
disorders are common even after mild TBI and can impede
depression. (39,208,209,247). Douglas (208) demonstrated that
participation in conversation, rehabilitation, social, vocational,
speech-language pathologists can train more
or academic activities due to resulting problems with driving,
 BRAIN INJURY 1771

positive communication-specific coping skills to ease immediate relationships in all contexts and pivotal to successful reintegration
distress in instances of communication breakdown. It is within the at home, community, work, and school (11). Social isolation has
speech pathology scope of practice to evaluate and develop an also been reported as a frequent consequence of social
optimal plan of intervention for individuals with communication communication impairments (11,29,142).
impairment of any origin, including those related to emotional, Challenges with academically related cognitive-
behavioural, or mental health conditions or those at risk of mental communication functions include problems with understanding
health conditions due to their injuries (68,250). Speech-language course instruction, memory and new learning, reading,
pathologists assess and diagnose communication deficits and integrating, summarizing, completing written assignments,
collaborate with those with mental health expertise on such issues as participation in class discussions and presentations, engagement
intervention, stressors, priorities, substance abuse, and behavioural in social communication for group work, peer problem solving,
dysregulation. Clinically there has been some controversy regarding and extracurricular activities, and organization, task management,
the order of interventions with some clinicians advocating the need to time management, and self-regulation (15,226,227,255). The
address psychological diagnoses first before engaging in cognitive or needs of students with persisting cognitive-communication
communication therapies. However, evidence is building for difficulties subsequent to ABI are often not identified or
combined approaches addressing emotional/psychological therapies accounted for across the developmental and academic continuum
and cognitive/communicative approaches simultaneously and where students may be challenged to keep pace with
warrants further study (247,251–253). Finally, cognitive- increasing cognitive-communication demands
communication skills need to be considered and supported by health (14,24,227,255). Therefore the term ‘academic
professionals in the context of counselling or other psychological communications’ is incorporated in the model of cognitive-
interventions (254) communication competence as a key outcome indicator to
The speech-language pathologist must weigh the operating promote awareness of academic support and achievement as a
factors in collaboration with other service providers in order to determining factor in competence.
determine current priorities, the individual’s ability to Communication impairments subsequent to ABI have been
participate in cognitive-communication intervention, their shown to be a significant barrier to workplace reentry and job
tolerance for participation in multiple interventions, optimal maintenance (18–20,209,256). Research has identified key
methods of pacing and prioritizing therapy, positive influences communication skills associated with employment success
on emotions and behaviours, and methods of maximizing (139,257). Cognitive-communication assessment measures
communication success within their rehabilitation and with sufficient sensitivity and ecological validity are able to
community reintegration settings. differentiate individuals with ABI who did and did not
successfully return to competitive employment (18–20).
Communication competence is the goal
Information management refers to the ability to organize
The model of cognitive-communication competence illustrates process, recall, and convey information relevant to one’s daily life
that the goal of communication intervention is competence in and includes independent management of health, financial, legal,
the following areas of outcome: family communications, and household information. Problem-solving communications are
community communications, social communications, depicted as a separate outcome target for cognitive-
workplace communications, academic communications and communication competence in the model. Many individuals with
information management, and problem-solving mild or resolving cognitive-communication deficits have
communications. The impact of cognitive-communication persisting difficulties with higher-level reasoning and problem
impairments on family functioning is well documented solving despite strengths in other areas of communication
including increased communication burden for family functioning. These cognitive-communication challenges in
members, decreased meaningful engagement in conversation, reasoning and problem solving have been demonstrated in a
increased conflict and expression of anger, decreased empathy number of studies (19,20,32,33). These deficits often go
and consideration for others, and increased reliance on others undetected in clinical settings yet can have significant impact on
for decision-making (9,208). These difficulties can undermine the individual’s autonomy and family functioning (9).
the individual’s ability to communicate in their roles as a Focusing on outcomes in these seven key areas of
parent (e.g. provision of advice, encouragement, play, communication competence highlights the importance of using
discipline), as a sibling (e.g. perspective taking, conversation, context sensitive, ecologically valid, activity and participation
making plans, using tact and diplomacy), or as a spouse (e.g. level techniques for assessment, treatment planning,
sharing, discussing, expressing feelings, problem solving, and outcome measurement (11,18,31,216,226).
expressing calmly) leading to family stress, marital Communication competence relies on the integration,
breakdown, and disintegra- coordination, and regulation of multiple skills for successful
tion of family relationships (9,208,218,250). Communication participation in multiple contexts (31). It is at this level of
deficits have also been shown to produce barriers to dynamic integration of skills within real-life contexts that
community independence in areas such as interactive with communication is most likely to be compromised (103,258).
stores, services, landlords, neighbours, and support personnel Thus the model conveys that the goal of communication
(12). In the model these are illustrated as “community intervention is to improve an individual’s success in
communications”. Social communication competence is vital communicating in the contexts of their daily lives; the goal is
to establishing and maintaining communication competence.
1772 S. MACDONALD

How the model of cognitive-communication provision and serve as an educational tool for interprofes-
competence could be applied sional collaboration. The model’s central focus on
communication could encourage healthcare professionals to
Fair and timely access to communication intervention
consider their role as key communication partners who can
services
support and enhance communication competence in healthcare
The model could be used to promote fair and timely access to interactions including those related to goal setting,
communication interventions while reducing barriers that counselling, discharge planning, decision-making, and
individuals currently face (1,13,36). Fair access to academic and vocational re-integration
communication interventions requires clear navigation to services (24,103,134,136,208,250,259). The model could promote an
in the form of consistent referral criteria, sensitive screening increased focus on measurement of communication health and
protocols, care pathways, guidelines, and education of referral outcomes which are rarely measured separately, and usually
sources (1,6,13,45). It is hoped that the model could be used to not at the level of activity and participation (1,10,69).
guide development of evidence-based referral tools and pathways
and to educate others (i.e. administrators, policymakers, funding
Classification, identification, and tracking of
sources, referral sources, the general public) to be mindful of the
communication deficits
full range of communication impairments and needs.
It is hoped that the model of cognitive-communication
competence could provide a platform for development of
Evidence-based assessment identification and tracking systems to better evaluate the full
The model could promote evidence-based assessment by scope of communication problems across the continuum of
conveying the multifactorial nature of communication impairment care. Currently there is a lack of system-wide understanding of
and the need to consider the broad range of cognitive, emotional, the need for communication intervention and lack of data to
physical, and contextual influences on communication. It could drive attention to the problem. Greater specificity of
guide clinicians to think beyond the employment of a single communication impairment is required in large-scale tracking
communication test towards a broader assessment process that of health outcomes (260–263). The largest incidence study to
includes self-evaluation, clinical observation, real-world date examined records of 44 000 US military service members
evaluation, communication partner evaluation, hypothesis testing, with TBI following blast injury but the national data collection
behavioural sampling under a range of conditions, and system did not allow for collection of information regarding
contributing information from multidisciplinary colleagues cognitive-communication disorders (5). Data collection
(51,52). The model may encourage evaluation beyond impairment systems should be based on evidence of the full range of
level testing to include dynamic interaction with communication communication disorders possible (1,13,36) such as the
partners, analysis of communication demands and environments, American Speech and Hearing Association’s National
and goal setting in the seven areas of communication competence: Outcome Measure System (43). Use of such system-wide
family, social, community, workplace, academic, information methods of identifying, classifying, and tracking
management, and problem solving communications (12,52,139). communication impairments is required in order to determine
the range of needs, entry points to the system, staffing
allocation, and evaluation of outcomes. The model of
Evidence-based treatment cognitive-communication competence could be one such tool
to convey the need for data to quantify the vast range of
The model of cognitive-communication competence can serve communication impairments, the multifaceted influences on
as a coherent framework to guide evidence searches through a communication competence, and the functional impact of even
range of treatment options while integrating findings from subtle communication challenges on the quality of life of
multiple fields of study. It may broaden understanding of the
individuals who experience them.
range of interventions available and inspire clinicians to turn
to guidelines relevant to a wider range of cognitive and
communication interventions. For example, if targeting social Limitations
communication, the clinician may consider interventions in
This paper presents initial steps in development of a
the domains of communication (discourse planning), cognition
comprehensive model of communication competence to guide
(executive functions), context (communication partner
interventions for individuals with ABI. It included expert
training, social networking, peer mentoring), control factors
review with researchers, clinicians, and individuals with brain
(metacognitive strategy instruction), as well as emotional
injury as well as literature search and syntheses. More
influences (communication specific coping).
comprehensive analysis within each of these steps is required
with larger samples of clinicians and researchers on the expert
Education, interprofessional collaboration, and research teams and more steps to ensure objectivity, diversity, and
international input. Additional analysis is required to
The model of communication competence could assist in determine the level of reliability in assigning evidence to each
creating shared perspectives across interprofessional and of the categories within the model. Future research will also be
international boundaries. It could promote the importance of necessary to examine the model’s utility in achieving the
communication as an integral part of health service proposed goals and its effectiveness as an educational tool
 BRAIN INJURY 1773

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Assessment of Verbal Reasoning and Executive Strategies. This measure is
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