Cognitive-Communication Disorders
Roberta DePompei - rdepom1@uakron.edu
Barb Conrad - Manager - conrad@esclc.org
Peer Reviewed: K. Jillson and C. Lepi
Updated September, 2011

Introduction:

Cognitive communication is the ability to use language and underlying skills such as attention, memory self-awareness, organization and problem solving skills to communicate effectively. Cognitive communication combines thinking skills with language. Cognitive communication problems can occur across the lifespan and result from a number of etiologies such as autism, traumatic brain injury, acquired brain injury, stroke, or dementia. The focus for this information is placed on children and youths with acquired brain injuries. However, many of the assessment and intervention ideas can be applied to the other etiologies as well.

If there is an acquired brain injury, there can be a number of speech language or cognitive communicative related behaviors that will require attention by the speech-language pathologist.

Problems and examples of behaviors that can indicate difficulty with communication after ABI include:

Speech: A child may find it hard to form words if the muscles for speech have been affected. Drooling, difficulty swallowing, slurred words, hoarse voice, different rate of speech, apraxia or dysarthria can occur after an ABI.

Expressive Language: Using words and sentences to convey ideas can be an issue. Look for hyperverbal expressions, tangential language, word finding problems, poor development of new vocabulary, delayed language development and especially, inadequate social pragmatic language skills.

Receptive Language: Comprehension of what is said or written may be affected. Look for poor recognition of vocabulary, multiple requests for repeats of the same information, difficulty sequencing or inability to recall what was just said.

Cognitive Communication:
While all of the above are important, most of the techniques already employed in speech or language disorders can be applied to these difficulties after considering the cognitive-communicative challenges that are underlying the identified challenges. Since TBI is often under identified in the schools, it is the intent of this tutorial to provide information and materials that may help with proper identification and provision of adequate services for this population based solely on the cognitive-communicative challenges that can exist.
The first four sections are powerpoints and contain audio lectures embedded within the powerpoints. These include:
1. The causes and epidemiology of acquired brain injury
2. Behaviors that affect learning after ABI.
3. Assessment
4. Intervention

Section five is a case study that: 1. Provides a case with most of the important information; 2. Lists two websites that are to be used to search out information to answer a series of questions; and 3. Outlines sample responses to the questions. These responses are only provided as examples and many other responses could be provided when completing this case.

Section six provides Ohio resources and Section Seven provides additional references

Section 5: Case Study
The Case of Kenneth

Ken is 8 years old and is in the third grade. His teacher says he has immature speech and seems not to hear very well. Your classroom observations follow:

• he responds to what his teacher says and always does the last thing she tells him to do regardless of the length of the directions
• he is visually alert and follows the lead of 2 other students
• he is rarely in his seat
• he cannot work in full class situations but does well in small groups that are no longer than 5-10 minutes
• when you speak with him, you notice poor sentence structures and a lot of "you know" thrown into the conversation
• his teacher considers him disrespectful and punishes him for his repetition of questions to her
• his teacher believe he belongs "somewhere else" not in her classroom—special classes or tutoring is being suggested and a MFE is recommended
• he becomes agitated and strikes out either verbally or physically when verbal directions are given to the class
• his grades are a little less positive each year
• not many of the children like to sit near him or play with him on the playground

Your testing and observations confirm that Kenneth has normal hearing, is delayed in expressive vocabulary, especially related to new learning in the classroom. He can sequence 2 directions at a time and his ability to communicate deteriorates under the pressures of timed performances, completing assignments, keeping up with curricular requirements, and dealing with social pragmatic interactions.

You have listened to the 4 sections of this program. Now go to the two following websites and spend time looking through the information presented there. Then answer the following questions using this information as the basis for your response.

Websites:

• http://www.projectlearnet.org
• http://free.braininjurypartners.com

Answer the Following Questions

1. Identify two behaviors that concern you.
2. Do you think these behaviors are related to medical, cognitive, social or emotional problems?
3. If cognitive, name the underlying processes that the behaviors made you think could be a problem.
4. List the section of the website(s) that you would use to find information about the underlying concern/behavior.
5. Describe how the problem in question might have developed over time in light of the noted problems that you identified.
6. List several interventions or ideas for assessment that are suggested on the website(s) that you might try with this client and tell me why you selected them.
7. Given this child's abilities and challenges, what strategies and approaches could you use to adapt each child's curriculum and school day to improve their opportunities for success?
8. What would you suggest to the parents?
9. If you had parents who did not understand the school interaction process, what would you suggest from the websites?
10. If you had parents who had a "reputation" as "troublemakers" what would you suggest from the sites?
11. How would you qualify Ken for services in your Ohio school?

Possible Responses to the Questions

These answers are intended to stimulate thinking about the process and are not the only responses. Many other solutions for competent interventions are possible. Please note: to read the responses accurately. The behaviors that were identified are numbered one and two. In the following responses after the first, the numbers one and two: 1. refers to the first behavior (lack of response to directions); and 2 refers to the second identified behavior (children unwilling to play with him as a result of poor pragmatic language skills).

5. Ohio Resources (laws, connections, contacts)
Definition in Ohio for services under TBI (Eligibility Category in Ohio)

The definition for TBI services is found in the definitions of disability in the Operating Standards for Ohio's Schools Serving Children with Disabilities, 2008. They are found on the website: http://www.edresourcesohio.org/

Operating Standards, a button on the left side of the page.

The citation is OAC 3301-51-01(B)(10)(d)(xii) and it reads:

"Traumatic brain injury" means an acquired injury to the brain caused by an external physical force or by other medical conditions, including but not limited to stroke, anoxia, infectious disease, aneurysm, brain tumors and neurological insults resulting from medical or surgical treatments. The injury results in total or partial functional disability or psychosocial impairment or both, that adversely affects a child's educational performance. The term applies to open or closed head injuries, as well as to other medical conditions that result in acquired brain injuries. The injuries result in impairments in one or more areas such as cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motor abilities; psychosocial behavior; physical functions; information processing; and speech. The term does not apply to brain injuries that are congenital or degenerative, or to brain injuries induced by birth trauma. This definition replaces the definition of traumatic brain injury in 34 C.F.R. 300.8(c)(12) (October 13, 2006) and shall be used instead whenever the federal regulations at 34 C.F.R. Part 300 (October 13, 2006), state statutes at Chapter 3323. of the Revised Code, or the state rules in Chapter 3301-51 of the Administrative Code refer to traumatic brain injury.

See Whose IDEA is This for additional information to qualify students for service as TBI- http://www.edresourcesohio.org/

Guidance Regarding TBI Educational Identification
Written by: Ann Guinan
Assistant Director, Procedural Safeguards
Office for Exceptional Children

May 2010

1. What documentation is required to support an identification of TBI?
• Is a parent's report of a fall sufficient? No, no one item can make a child eligible or not eligible. This information would be one piece of information that would be included with all of the other information that would be gathered concerning this student and their educational performance.
• Is an emergency room visit report sufficient if the diagnosis is concussion? No. The key is "how has the concussion affected educational performance" and has it significantly affected performance to the point where the child needs special education and related services to be successful.
2. Is a neuropsychological required? No, the team must determine what information they need to make a determination as to whether or not the child meets the definition of the category. This means that in some cases this assessment may be required. In other instances it would not be necessary.
3. If a neuropsychological is done and the results are consistent with TBI, but there is no medical record of a head injury--an adoption or foster child from another state, etc.), is that sufficient? Only if the child's educational performance is significantly impaired to the point where the child needs special education and related services. Also there would have to be evidence of either an external or internal head injury as that is part of the definition of TBI.
4. Is it the school's responsibility to pursue a neuropsychological if the records show a medical report of a prior head injury? Only if the IEP or evaluation team determines that they need one to determine eligibility. This is an IEP team decision that is made when they are planning the evaluation and determining what information they need to determine if the child meets the definition for the category.
5. If a student is identified as LD, but the team learns of the previous head injury, should a change of educational identification be made? Not necessarily. Once a child is identified the district must provide FAPE regardless of the category the child is identified under. Therefore, there would be no need to change the category unless the child meets the definition of the category of TBI and the team determines that this category better captures the child's disability and educational need.

Ohio Center for Autism and Low Incidence (OCALI)
Contact: Donna Owens,
Family and Adult Services Administrator
470 Glenmont Ave
Columbus OH 43214
Phone: 614.410.0381
e-mail: donna_owens@ocali.org

Donna Owens works for the Ohio Center for Autism and Low Incidence (OCALI) whose primary funding comes from a contract with the Ohio Department of Education, Office for Exceptional Children. Donna facilitates a Statewide TBI Education Network that includes representatives from education, higher education, neuropsychologists, and community support representatives from the Brain Injury Association of Ohio. The purpose of this network is to increase educator's awareness of TBI and its impact, increase training opportunities on TBI for educators and families, and to improve services and supports available for families of children and youth with TBI.

In addition, Donna facilitates a research project being conducted by the Teaching Research Institute of the University of Western Oregon. Ohio is one of three states that is participating in this research project. The focus of the project is to research the impact of improved communication between hospitals and schools when a student is hospitalized for a head injury. If parent agree to participate in the project, they are offered information and training. In addition, the child's school is contacted and provided with information about TBI and offered assistance if further training is needed. Ohio has identified a TBI point person in each of the 16 State Support Team regions to make resources on TBI available to educators when assistance is needed.

Ohio Legal Rights
Contact: Kristin Hildebrant
Supervising Attorney
Ohio Legal Rights Service
50 W. Broad St., Suite 1400
Columbus, Ohio 43215-5923
Phone: 614-466-7264 ext.109; 614-644-1888 fax
e-mail: khildebrant@olrs.state.oh.us

The Ohio Legal Rights Service (LRS) is an independent agency of the State of Ohio. LRS is designated under federal law as the system to protect and advocate the rights of people with disabilities. The mission of LRS is to protect and advocate, in partnership with people with disabilities, for their human, civil and legal rights. LRS provides legal advocacy and rights protection to a wide range of people with disabilities. This includes assisting individuals with problems such as abuse, neglect, discrimination, access to assistive technology, special education, housing, employment, community integration, voting and rights protection issues with the juvenile and criminal justice systems.

LRS administers the Protection and Advocacy for Individuals with Traumatic Brain Injury (PATBI) program which is designed to improve access to health and other services for all individuals with brain injury and their families. PATBI serves to protect the rights of adults with TBI and ensures access to services for students with TBI. Through the PATBI program, staff at LRS has worked to help implement a TBI screening and awareness project in Columbus City Schools, partnered with the Ohio Department of Education, the Ohio Center for Autism and Low Incidence (OCALI) and the Brain Injury Association of Ohio to develop a statewide TBI Education Network and participated in the Ohio Brain Injury Advisory Committee. LRS advocates on behalf of students with TBI and provides assistance with special education issues, including providing information and technical assistance to families, attending IEP meetings, negotiating with schools and representation in due process hearings and court.

Publications about special education available on the LRS website include: "Students with TBI - Thriving Beyond Injury" a guide for parents and schools working together to improve special education services for students with traumatic brain injury (TBI), "Negotiation Skills For Parents: How To Get The Special Education Your Child With Disabilities Needs" and a series of special education FAQs.

For more information go to www.olrs.ohio.gov. Publications are located in the Resource Center.
Or contact LRS directly at:
Ohio Legal Rights Service
50 W. Broad St., Suite 1400
Columbus, Ohio 43215-5923
614-466-7264 or 800-282-9181
(TTY) 614-728-2553 or 800-858-3542

TBI Statewide Educator Network
Contact: Sara Timms, Ed.S., School Psychologist
Columbus City Schools
2571 Neil Ave.
Columbus, OH 43202
Phone:614-365-5220
e-mail: stimms2576@columbus.k12.oh.us

The Columbus City Schools partnered with Ohio Legal Rights Service to better identify and serve children with TBI. The pilot began in 2006-2007 school year. The object was to educate school personnel about TBI and to increase number of children identified as TBI. A full power point presentation can be seen here. ( link to powerpoint 5*) Please note there is no audio on this powerpoint.

Some key suggestions and ideas from this ongoing project include:
How to identify students:

• There must be documentation of adverse effect on student's educational functioning
• Injury results in total or partial functional disability or psychosocial impairment, or both
• Impact must be substantial
• Sometimes the effects of the TBI are not evident until years later, especially when the demands of school increase.
• Student can still qualify for TBI years after sustaining the TBI.
• Do thorough parent interview
• Ask about significant differences before/ after TBI- what changes did parents see after TBI
• Ask about medical treatment, follow-up appointments, therapies…
• Ask what departments, doctors, therapists…the child was seen in or by after the TBI
• Obtain release of information for past medical records; neuropsychological reports; psychological reports related to TBI.
• ER visit and follow-up by physicians is acceptable as long as TBI is referenced and/or diagnosed
• Send release directly to the department or doctors that treated child after TBI or at least name them on release – usually obtain records faster than sending them, but…
• If TBI was several years later, may have to go through medical records dept.
• Include date or year of TBI if known- helps hospital retrieve records faster
• Review school record/ file. Look for differences (academic, behavioral) before/ after the TBI.
Why identify a student TBI instead of another disability such as SLD, ED, or OHI?
• May lead to their educational needs not being met
• Student may exhibit unpredictable behaviors/ performance in school, not explained by SLD, ED, or OHI
• More specific explanation of child's needs and/or reason for difficulty (i.e.: ED= mental health condition over long period of time/marked degree, SLD= psychological processing disorder, OHI= chronic or acute health problems…)
• Students with TBI may have an unusual profile of abilities and needs, not always identified through standard battery of tests.
• Their needs may change quickly and often as they go through recovery. As they heal, they may require less intensive service; therefore they should be re-evaluated often.
• Certain types of injuries have delayed consequences

Brain Injury Association of Ohio
Contact: Suzanne Minnich, Executive Director
855 Grandview Ave., Suite 225
Columbus, OH 43215-1123
phone: 1-800-444-6443.
Web site: www.biaoh.org

The Brain Injury Association of Ohio (BIAOH) is the state-wide education and advocacy organization for children and adults living with disabilities due to brain injury. A state affiliate of the Brain Injury Association of American (BIAA), it was started in the early 1980s by parents, medical and rehabilitation professionals. It remains constituent-directed, and has been fortified over the years through the growing involvement of individuals living with BI. BIAOH's major funding stems from contracts awarded through the Ohio Rehabilitation Services Commission (RSC)and the Ohio Department of Job and Family Services with supplemental income provided through fund-raising, conferences, and membership fees.

BIAOH's mission is to promote prevention, research, education & advocacy. Key among BIAOH's programs are those designed to increase access to appropriate services and supports. These include assistance available through its state-wide, toll-free Helpline 1-800-444-6443, and its staffed Community Support Network system (regional field offices). In addition to service linkage, Community Support Network (CSN) Coordinators provide training, assist with support groups, and prevention initiatives within their multi-county areas. Occasionally, at parents' request they attend school-convened Individual Education Plan meetings and trainings for students. Central to BIAOH's educational initiatives is its Annual Conference which includes a track for educators. Its 29th Annual Conference, Building Community: Recognition, Response, Resilence, is scheduled for Nov. 1 & 2, 2010 at the DoubleTree Columbus-Worthington, and will offer continuing education credits in various disciplines. BIAOH succeeds in generating awareness and changing public policy largely through collaborative initiatives. Key partnerships include those with Ohio's Brain Injury Advisory Committee administered through RSC; Ohio's TBI Model Systems Program (the Ohio Valley Center for Brain Injury Prevention and Rehabilitations), Ohio's Injury Prevention Partnership administered through the Ohio Department of Health; the Ohio National Guard's OHIOCARES program, and more recently Ohio's Family and Children First system. For additional information go to www.biaoh.org or call 1-800-444-6443.

Resources

Web sites:

http://www.asha.org
http://www.lapublishing.com
http://www.thebrainproject.org
http://www.cdc.gov
http://www.tndisability.org/brain/cd/ProjectBrain/mediaframeset.html
http://www.free.braininjurypartners.com
http://www.projectlearnet.org
http://www.cdc.gov/ncipc/tbi/physicians_tool_kit.htm
http://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm
http://www.helpingkidsbrains.com/
http://www.cdc.gov/ncipc/tbi/FactSheets/VictimizationTBI_FactSheet4FriendFam.htm
http://www.dvbic.org
http://www.state.oh.us/olrs
http://www.biaoh.org
http://www.ncepmaps.org
** This is ASHA's new maps for evidence based practice and there are maps for autism, adult and child TBI included at the present time.

Materials:
Available from: www.lapublishing.com:

Learning and Cognitive Communication Challenges: Developing Educational Programs for Students with Brain Injuries
Roberta DePompei and Janet Tyler

Billy Butterfly Tries
Cindy Koneczny

ELVIN The Elephant Who Forgets
Heather Snyder and Susan Beebe, illustrator
All About Me!
Roberta DePompei, Ph.D. and Bob Cluett, A.D.

All About Me! My Life as a Teenager
Roberta DePompei

Students with Brain Injury: Challenges for Identification, Learning and Behavior in the Classroom
Katherine Kimes, Ed.D., Marilyn Lash, M.S.W. and Ron Savage, Ed.D.

Signs and Strategies for Educating Students with Brain Injuries
Marilyn Lash, M.S.W., Gary Wolcott, M.Ed., and Sue Pearson, M.A.

Parents and Educators as Partners: A workbook on helping your child after brain injury
Marilyn Lash, M.S.W. and Bob Cluett, A.D.

Texts and articles

1. Babikian T, Asarnow R. Neurocognitive outcomes and recovery after pediatric TBI: Meta-analysis of the literature. Neuropsychology 2009; 23(3):283–296.
2. Blosser JL, DePompei R. (2003) Pediatric Traumatic Brain Injury: Proactive Intervention. New York: Delmar.
3. Braga L, Da Paz J, Ylvisaker MJ. Direct clinician-delivered versus indirect family-supported rehabilitation of children with traumatic brain injury: A randomized controlled trial. Brain Injury. 2005; 19(10):819–831.
4. Brian Injury Association of America. A call to action for children and adolescents with Traumatic Brain Injury. TBI Challenge. Washington, DC: BIAA. 2008; 2–4:17.
5. Chapman SB, Gamino JF, Cook LG, et al Impaired discourse gist and working memory in children after brain injury. Brain and Language. 2009; 97: 178-188.
6. Chapman SB, Nasits J, Challas JD, Billinger AP. Long-term recovery in pediatric head injury: Overcoming the hurdles. Advances in Speech Language Pathology. 1999; 191: 19–30.
7. Chapman SB, Nasits J, Challas JD, Billinger AP. Long-term recovery in pediatric head injury: Overcoming the hurdles. Advances in Speech Language Pathology. 1999; 191: 19–30.
8. Chapman SB. Neurocognitive stall: A paradox in long term recovery from pediatric brain injury. Brain Injury Professional. 2006; 3(4):10–13.
9. DePompei, R., & Blosser, J. (2003). Communication: How communication changes over time. Wake Forrest, NC: LA Publishing/Training.
10. Durgin. C., & Gioia, G. (2010). Consulting to Support Children and Youth with Acquired Brain Injuries: Ten Principles for Consideration. Journal of Behavioral and Neuroscience Research Vo1. 8(1), 49-59
11. Gamino JF, Chapman SB, Cook LG. Strategic learning in youth with traumatic brain injury: Evidence for stall in higher-order cognition. Top in Lang Disorders. 2009; 24 (3): 1-12.
12. Gerard-Morris H, Taylor HG, Yeates KO, et al. Cognitive development after traumatic brain injury in young children. Journal of International Neuropsychological Society. 2009:1-12.
13. Glang A, Tyler J, Pearson S, Todis B, Morvant M. Improving educational services for students with TBI through statewide resource teams. NeuroRehabilitation. 2004; 19(3):219–231.
14. Hawley C, Ward AB, Magnay A, et al. Return to school after brain injury. Archives Disorders in Children. 2004; 89:136–142.
15. Kirkwood MW, Yeates KO, Taylor GH, et al. Management of pediatric mild traumatic brain injury: A neuropsychological review from injury through recovery. The Clinical Neuropsychologist. 2008; 22(5):769–800.
16. Turkstra L, McDonald S, DePompei R. Social information processing in adolescents: Data from normally developing adolescents and preliminary data from their peers with traumatic brain injury. Journal of Head Trauma Rehabilitation.2001:16(5): 469-483.
17. Turkstra LS, Williams WH, Tonks J, Frampton I Measuring social cognition in adolescents: Implications for students with TBI returning to school. NeuroRehabilitation. 2008; 23 (6): 501-509.
18. Turkstra LS, Williams WH, Tonks J, Frampton I Measuring social cognition in adolescents: Implications for students with TBI returning to school. NeuroRehabilitation. 2008; 23 (6): 501-509.
19. Wade S, Walz, NC. Family, school and community: their role in the rehabilitation of children. (In Frank RG, Rosenthal M , Caplan B, eds) Handbook of Rehabilitation Psychology ( Second Edition).Washington, DC: American Psychological Association; 2009.
20. Yeates KO, Taylor GH. Behavior problems in school and their educational correlates among children with traumatic brain injury. Exceptionalit. 2006; 14(3):141–154.
21. Yeates KO, Taylor GH. Behavior problems in school and their educational correlates among children with traumatic brain injury. Exceptionalit. 2006; 14(3):141–154.
22. Ylvisaker M, Adelson D, Braga, LW, et al. Rehabilitation and ongoing support after pediatric TBI: twenty years of progress. Journal of Head Trauma Rehabilitation. 2005; 20(1):95–109.
23. Ylvisaker M, Todis B, Glang A, et al. Educating students with ABI: Themes and recommendations. Journal of Head Trauma Rehabilitation. 2001; 16(1):76–93.