1. Lyn S. Turkstra, PhD, CCC-SLP, BC-ANCDS Department of Communicative Disorders University of Wisconsin-Madison

2. Overview  Many individuals with TBI have cognitive impairments that affect their ability to communicate in work, social, and family life. This webinar will present an overview of communication challenges for adults with traumatic brain injury (TBI), and offer strategies and solutions to support effective communication.

3. A caveat…  The problems we will be discussing occur mostly in individuals with moderate-to- severe injuries and those with milder injuries who have persistent, measurable cognitive impairments beyond distractibility and mental fatigue

4. Communication Basics Thoughts and feelings Language Speech, Sign, Gesture, Writing, Voice Hearing, Listening, Understanding

5. Common Problems After TBI Cognitive and Emotional Impairments Word-Finding Problems, Aphasia Dysarthria, Dysphonia, Weakness, Incoordination Hearing Loss, Distractibility, Impaired Comprehension, Slow Thinking

6. Common Cognitive Impairments after TBI  Memory  Executive function  Social Cognition

7. A Common Memory Profile  Strengths:  Simple short-term recall: Can repeat back information immediately after hearing or reading it  Implicit memory: Memory for habits or skills repeated over and over, without conscious awareness of learning; and memory for emotional associations – feelings about events and people, even if the event is forgotten

8. A Common Memory Profile  Limitations  Working Memory: the “computational” aspect of short-term memory, being able to manipulate information mentally – e.g., to follow a command that is out of order  Transfer of new explicit information (facts and events) to long-term storage  Conscious recall of facts and events

9. Executive Functions  EFs are the cognitive functions we use for  Control of thoughts and feelings: starting, stopping, and shifting thinking and behavior  Having a sense of time: having a feeling of what was yesterday vs. last year, sequencing information, and being able to estimate time  Abstract thinking: getting out of the moment to see the big picture, understanding non-literal language like sarcasm and humor, being metacognitive (awareness – thinking about your own thinking)

10. A Common EF Profile  Impairments in self-control  Lack of initiative (e.g., not enough talking) or disinhibition (e.g., “unfiltered” language, tangents and extra information), perseveration, lack of flexibility in solving problems  Impairments in time estimation and sequencing  Poor time estimation for completing tasks (e.g., talking for an hour and thinking it was 5 minutes), confusion about what happened when, difficulty prioritizing tasks  Impairments in abstract thinking  Concrete thinking and lack of “in-the-moment” awareness of limitations and their effects, impairments in understanding nonliteral language, lack of transfer of new learning to a different context

11. EFs are “Fatigable”  Self-regulation fatigue is a common problem in people with EF impairments  Running out of “thinking energy” part-way through the day  Having more behavior problems when tired, stressed, or multi-tasking  Consider that we all have SR fatigue at one time or another: what would it be like if you already had SR impairments?

12. Social Cognition  The cognitive functions we need to function successfully in social interactions  Includes Theory of Mind  Understanding that others have thoughts different from ours and that their thoughts influence their behaviors  Also includes emotion recognition  “Reading” emotions from others’ facial expression (affect) and voice

13. A Common Social Cognition Profile  Missing social cues such as disinterest or discomfort of the conversation partner  Family comments that the person is “egocentric,” or “talking at them” vs. “to them”  Missing jokes, sarcasm, and implicature  E.g., “This workplace has a dress code” = “You should dress according to the workplace dress code”

14. What can we do?  Step #1:  Understand the person’s strengths and limitations  Step #2:  Check the environment  Step #3:  Check yourself

15. Finally…  Listen to the person with TBI: many people will tell you exactly what their optimal workplace communication conditions are if you ask the right questions

16. Speaking of which…  Questions?

17. Resources  www.projectlearnet.org/  A resource originally designed for teachers and parents, with tutorials and guides for understanding and addressing behavior problems after TBI  http://www.biaw.org/online-library.htm  Wisconsin Department of Public Instruction webcast series on Traumatic Brain Injury and Challenging Behavior  Beautiful Minds: Guiding Individuals with TBI in Their Quest to Communicate Work and Learn