Understanding Social and Pragmatic Communication Following a Brain Injury

By Rebecca D. Eberle, M.A., CCC-SLP, BC-ANCDS, FACRM, Clinical Professor, Speech, Language and Hearing Sciences, Indiana University

We all demonstrate social and pragmatic communication skills that are uniquely ours. This may be illustrated by our use of humor, sarcasm, play on words, facial expressions, and gestures, among other characteristics. These communication behaviors ultimately become synonymous with our personality and general character; for example, “she is a good listener” or “he shows me he really cares!” After a brain injury, it is common to experience alterations in social and pragmatic communication. This can impact a person’s ability to maintain relationships and develop new ones. It can also impede positive vocational and community re-entry success.

Communication is an umbrella term that encompasses many subskills such as speech, language, and comprehension. Social and pragmatic communication, however, should not be confused with speech or language. Speech refers to the motor aspect of making speech sounds and producing words or sentences. Language is the ability to both express our ideas in words and sentences as well as understand the words and sentences spoken by others. This comprehension component of communication is not related to “hearing” the sounds, but rather understanding the words and the word order.

Social communication is a dynamic process that includes receiving and interpreting simple and complex messages from others and sending messages to others that convey intent. These messages can be verbal, including actual written or spoken words, or nonverbal. This may include changes in tone, vocal volume, word stress, gestures and facial expressions, proximity, and body postures. How a message is communicated can be more powerful and communicative than the words produced. We can say a simple sentence for which the meaning can vary greatly based on a person’s use of facial expressions, volume, or tone. For example, the simple sentence, “I have a new neighbor,” can carry the intent that I am excited, unhappy, or that I don’t care, based on the associated use of tone and body language. The inability to understand emotional spoken tone and facial expressions is called emotion perception impairment. A person with brain injury may see and hear these non-verbal aspects of communication, but not interpret them correctly.

Impairments of pragmatic communication may include disruptions in staying on topic, organizing thoughts when speaking, and taking turns in conversation, among other difficulties. Pragmatic communication impairments may also be secondary to other cognitive impairments. Attention deficits, for example, may affect one’s ability to listen to others’ messages. Executive dysfunction may lead to impairments of self-awareness and self-regulation, resulting in the loss of a social filter and causing an individual to over-share feelings or thoughts inappropriately. These impairments typically result in problems with social relationships, fewer employment opportunities, poorer quality of life, and reduced community integration due to social isolation.

Fortunately, understanding and treating these impairments after brain injury has been an area of aggressive research over the past decade. As a result, we have more viable assessment and intervention options. Specific measurement tools have been developed that assist with identification of the nature of the social challenges. Effective intervention can only be achieved after a thorough assessment, which helps identify the specific skill disruptions leading to functional communication problems. After this detailed detective work, clinicians can collaborate with clients and their families to choose appropriate interventions.

Researchers have published several systematic reviews of the available interventions for social communication and pragmatic impairments, providing recommendations for therapists. The research indicates that specific, scientifically proven interventions result in positive changes in social communication, pragmatic conversation skills, and enhanced emotion perception skills. Like other aspects of cognitive rehabilitation, therapy interventions are most effective when contextual factors such as individual work history and personal aspirations, cultural and personal beliefs, and support systems are included in the treatment planning and implementation. Family education about the nature of the impairments and family participation in the treatments enhances the outcomes. Treatment models are available for family and caregiver training, and these models have proven to assist with both positive functional outcomes and generalization into salient environments.

In summary, we now have unequivocal evidence at the highest level for social communication treatment. Assessment tools and outcome measures are available to assist the diagnostician and therapist define areas of impairment and focus therapy. Lastly, we understand that impairments of social communication and pragmatic skills can serve as a significant barrier to long-term outcomes if not addressed; therefore, it is necessary to include these treatments in the overall rehabilitation treatment plan.

References

1. Cicerone, K. D., Goldin, Y., Ganci, K, et al. (2019). Evidence-Based Cognitive Rehabilitation: Systematic Review of the Literature from 2009 Through 2014. Archives of Physical Medicine and Rehabilitation, 100(8), 1515-1533.
2. Neumann, D., Zupan, B. & Eberle, R. (2019). Social communication. In J. M. Silver, T. W. McAllister, & D. B. Arciniegas (Eds.), Textbook of Traumatic Brain Injury (3rd ed., pp. 281-297). American Psychiatric Association.
3. Togher, L., McDonald, S., Tate, R., Power, E., & Riediijk, R. (2013). Training communication partners of people with severe traumatic brain injury improves everyday conversations: A multicenter single blind clinical trial. Journal of Rehabilitation Medicine, 45, 637-645.
4. Togher, L., Wiseman-Hakes, C., Douglas, J., et. al. (2014). INCOG recommendations for management of cognition following traumatic brain injury, part IV: Cognitive communication. The Journal of Head Trauma Rehabilitation, 29:4, 353-368
5. Ylvisaker, M., Turkstra, L., & Coelho, C. (2005) Behavioral and social interventions for individuals with traumatic brain injury: A summary of the research with clinical implications. Seminars in Speech and Language, 26:4, 256-267.

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This article originally appeared in Volume 15, Issue 1 of THE Challenge! published in 2021.