Communication problems

Communication problems after brain injury are very common. The ability to communicate requires extremely complex skills, and many different parts of the brain are involved.

There are four main categories of the effects of brain injury. Any of these can cause communication problems:

• Physical - affecting how the body works

• Cognitive - affecting how the person thinks, learns and remembers

• Emotional - affecting how the person feels

• Behavioural - affecting how the person acts

Many people will experience more than one form of communication problem after brain injury, depending on the areas of the brain affected and the severity of the injury.

Any communication difficulty has the potential to affect the person’s everyday life and the lives of those around them. The problems can lead to reduced social contact and impaired ability to live independently and carry out previous activities (e.g. working and caring for family).

Support, rehabilitation and awareness can reduce these effects, and the information on this page should help you to increase your understanding of the difficulties.

Language difficulties (aphasia)

Injury to language centres of the brain leads to a condition called aphasia. There are different levels of impairment and the term dysphasia refers to partial loss of language. However, in practice, the terms are interchangeable and here we will simply use the term aphasia.

Wernicke’s area and Broca’s area are two regions of the brain that are important for understanding and using language. Injury to these areas leads to two main forms of aphasia: receptive aphasia and expressive aphasia.

Receptive aphasia

Receptive aphasia is an impairment of the understanding of language. This usually occurs because of damage to Wernicke’s area, so it is sometimes referred to as Wernicke’s aphasia.

In its most severe form, the person will not recognise spoken and/or written words. They will not be able to understand sentences or follow conversations. However, usually people will retain some understanding. For example, the person may recognise some but not all words, or simple but not complex sentences. It may be that familiar words still have meaning (e.g. pill), but that less frequently used words are no longer understood (e.g. medication).

The person with receptive aphasia may have better ability in one area than another (e.g. they may be able to recognise written words more readily than spoken ones, or vice versa). They may also have retained some non-verbal skills (e.g. they may recognise gestures or pictures).

People with receptive aphasia usually retain the ability to speak fluently and the term fluent aphasia is sometimes used. However, the content of speech is often jumbled or lacking meaning. People may speak in long chains of words that have limited meaning, use incorrect words, or unintentionally create made-up words.

The problem with understanding language means the person may be unaware of their errors and expect the listener to respond.

Problems with reading, when evident, may reflect the receptive spoken language issues. E.g. the person may:

• Be unable to recognise individual letters

• Be unable to recognise written words

• Read but not understand familiar words

• Be unable to fully understand simple written sentences

It is important to be aware that reading problems may also arise due to other difficulties, such as altered vision.

Tips for survivors with receptive aphasia

• Make sure the environment is quiet and free of distractions

• Communicate when you are relaxed and have plenty of time

• Write down key points you want to make ahead of the conversation - you could give the list to the person so they can prompt you

• Let the other person know when you have lost track

• Try to summarise what you have understood at key points in a conversation - you could try writing down (or asking the other person to write down) key points in a way you understand so you can refer to them later

• Don’t pretend to understand when you haven’t

• Ask for things to be rephrased or repeated when you don’t understand

• Ask people to use your preferred non-verbal methods, such as gestures, sketches, simple writing etc

Tips for people communicating with survivors with receptive aphasia such as carers

• Make sure the environment is quiet and free of distractions

• Understand that you will be primarily responsible for guiding the conversation

• Be patient and don’t expect immediate responses

• Try to make sure you are both relaxed and have plenty of time when communicating

• Make sure you have the person’s attention before speaking

• Think about your word choice - it may help to use simple words, such as ‘pills’ rather than ‘medication’

• Use simple sentence structures, but not as if talking to a child

• Speak clearly and pause normally at the ends of phrases and sentences

• Repeat or rephrase things when needed

• Avoid asking more than one question at a time

• Be aware of signs that the person is becoming overwhelmed or confused - signs may include lack of response, a vacant expression or obvious distraction

• Consider using non-verbal methods to aid the person’s understanding, e.g. gestures, pointing, pictures or sketches

• Consider writing down key words

• Encourage the person to summarise what they have understood before moving on or changing the subject - this helps you to be aware of and sort out any misunderstandings

• Make it clear through pauses, gestures, etc, when you are moving from one topic to another

• Don’t keep conversations going for longer than the person is comfortable

• Support the person in engaging in as broad a range of social activities as possible

Expressive aphasia

Expressive aphasia is an impairment of the ability to use and express language. This is caused by damage to Broca’s area, so the condition is sometimes referred to as Broca’s aphasia. In its most severe form, the affected person may be unable to produce any meaningful speech. More commonly, speech output may lack fluency with relatively few words used. The speaker will use short, simple sentences, broken up by frequent pauses. However, they may be able to understand language normally and be aware of their own difficulties.

Output may be a struggle, but sometimes an individual can provide accurate, if limited, information. Speech may be ‘telegraphic’, omitting small words such as ‘the’. So, ‘tomorrow I’m going to the pub with my wife for our anniversary’, may be expressed as ‘tomorrow...pub...wife...anniversary’. This requires the listener to accurately piece the message together.

The person may struggle to name objects or people, even when aware of what or who they are. This can be extremely frustrating and cues or reminders may not work if the brain is simply unable to produce the correct output.

Problems with writing, when evident, may reflect the expressive spoken language issues. For example, the person may:

• Be unable to write down a specific letter of the alphabet

• Write words with letters in the incorrect order

• Write down incorrect words, which are still connected to the intended ones, e.g. they may write ‘wife’ when they needed to write ‘daughter’

• Be unable to write simple sentences

Writing problems may also arise due to other difficulties, such as altered vision and/or reduced physical control of the pen or pencil.

Tips for survivors with expressive aphasia

• Avoid unnecessary background noise during conversations

• Try to make sure you are relaxed and not rushed when communicating

• Use non-verbal methods of communicating, such as pictures, gestures and drawings

• If your writing is better than your speech then consider using writing to support getting your message across successfully

• Identify simple key words and phrases that are easy to say and you can use often, e.g. “tea please!”

• Try not to force yourself to say a specific word or phrase if you are struggling - try a different way of expressing the idea

• Be positive and focus on your successes

Tips for people communicating with survivors with expressive aphasia such as carers

• Make sure the environment is quiet and free of distractions

• Try to have plenty of time for a conversation so you aren’t both rushed and stressed

• Try to make sure you are both relaxed when communicating

• Encourage the person to use non-verbal skills to convey their message e.g. gestures, pointing, pictures or sketches

• Agree signals or gestures for words or phrases the person uses often, such as ‘yes’ and ‘no’

• Do not pretend to understand when you have not

• Feed back parts of the message that you have understood so that the person knows what they need to repeat

• If you are both struggling, try to agree an ‘end point’ to reduce spiralling frustration

• Do not push the person for a level of accuracy that may not be achievable

• Support the person in engaging in as broad a range of social activity as possible

Speech difficulties

Sometimes brain injury causes communication difficulties by impairing the physical ability to speak, rather than the ability to understand and express language. The two main speech disorders are dysarthria and dyspraxia of speech.

Dysarthria

Dysarthria occurs when there is damage to parts of the nervous system involved in the control of muscles used for speech. It can also occur because of injury or weakness more directly affecting the muscles themselves. Dysarthria results in reduced control and clarity of speech.

When dysarthria occurs in isolation, a person’s ability to speak will be impaired, but their ability to understand language and construct sentences will be intact. However, in practise there are often elements of both aphasia and dysarthria present.

Features may include:

• Reduced movement (range or strength) of the lips, tongue and soft palate

• Problems controlling the flow of air from the lungs when speaking

• Difficult in producing varied and controlled changes in the volume of speech

• Difficulty in producing varied and controlled patterns in the tone of speech

• Slurring of speech

Tips for people with dysarthria

• Think about your posture - try to adopt as good a position as possible when speaking (as upright as possible, with your head in the midline is best)

• Try to ensure you have adequate time for important conversations, e.g. book double appointment slots

• Agree clear signals for ‘yes’ and ‘no’ and for words or phrases that you need to use regularly

• Feel confident to use strategies such as writing, spelling tricky words aloud, using gestures, etc.

• If you tend to run out of breath (or your voice becomes quieter) when you say a long sentence, take breaths with it

• Aim to ‘chunk’ sentences into smaller but grammatical sections, e.g. ‘the doctor // gave // me these // pills’

• Ask your listeners to let you know if they have not fully understood, e.g. “did you catch where I said I went last night?”

• Ask your listeners to check any words they may have missed so you can correct any misunderstanding

Tips for people communicating with survivors with dysarthria such as carers

• Avoid unnecessary background noise and interruption

• If the person’s understanding is impaired then don’t patronise them by simplifying your own speech

• Allow sufficient time for the person to get their message across

• Don’t rush to make assumptions about what the person is trying to say, but be willing to have a guess

• Position yourself so you can watch the person as they speak - you may pick up clues about the words attempted from their mouth shapes

• If you don’t understand a word, ask them to spell it or write it down

• Ask for repetition of any words you have missed, e.g. “where did you say you went last night?”

• Repeat back so the person can then confirm either that you have understood them or correct any misunderstandings e.g. “did you say you went to the supermarket last night?”

• If they are able, encourage the person to slow down the pace of their speech - this gives them time to form the words as clearly as possible

• If they are able, encourage the person to ‘over-articulate’, aiming to be very accurate and not omitting any of the middle or end sounds, e.g. ‘hip-po-po-ta -mus’ not ‘hippomus’

• If they are able, encourage the person to split long words up into syllables, e.g. sup-er-mar-ket

• Prompt the person to use key words or short sentences

• Encourage the person to use natural aids to communication, e.g. gestures, pointing, writing words down

• Encourage the person to use any communication aid that has been provided

Dyspraxia of speech

Dyspraxia is a disorder of planned and co-ordinated movement. It occurs because of injury to areas of the brain responsible for conscious movement, mainly situated in the frontal lobes.

Dyspraxia of speech causes people to have difficulty saying what they consciously intend to say. However, some individuals may be able to speak perfectly normally when not thinking about it, for example, if someone asks them a question and they have to respond spontaneously. Long words tend to be more difficult to say than short words for some people with dyspraxia of speech.

The disorder can range from mild in some people to very severe in others.

Tips for people with dyspraxia

• Use short, simple words and sentences that you’re comfortable with

• If certain sounds or sound sequences are easier for you than others (e.g. ‘b’) make good use of them, e.g. ‘bed’ may be easier to say than ‘sleepy’ or ‘tired’

• Use non-verbal methods to get your message across, e.g. gestures, alphabet charts, pictures and objects

• Ask people to let you know if they haven’t fully understood

• Try to ensure you have adequate time for important conversations, e.g. book double appointment slots

• Agree clear signals for ‘yes’ and ‘no’ and for words or phrases that you need to use regularly

• Feel confident to use strategies such as writing, spelling, tricky words aloud, using gestures, etc.

Tips for people communicating with survivors with dyspraxia

• Do not pressurise the person to try to repeat any successful spontaneous words (this takes it from being spontaneous to a ‘planned’ movement, which may be far harder to achieve and thus lead to increased frustration)

• Respond to speech attempts that you have understood - focus on their success in having got their message across

• Encourage the person to select and use short, simple words and sentences

• Avoid unnecessary background noise and interruption

• If the person’s understanding is unimpaired then don’t patronise them by simplifying your own speech

• Allow enough time for the person to get their message across

• Don’t rush to make assumptions about what the person is trying to say, but be willing to have a guess at appropriate points

A speech and language therapist will be able to identify and assess dysarthria and dyspraxia of speech. Recovery and degree of difficulties will depend upon the severity of the initial brain injury. However, for a variety of reasons (e.g. presence of other difficulties), individuals may respond differently to therapy. Some people will make more progress than others, despite having had a similar injury.

In severe cases, those with speech difficulties may be unable to achieve recognisable speech. In such cases, they may benefit from the use of an Augmentative Aid to Communication (AAC).

Cognitive communication difficulties

Communication is a complex process, which involves many aspects of thinking and social skills. If brain injury impairs any of these skills then it can affect the ability to communicate successfully. ‘Cognitive communication difficulties’ is the term most often used for the resulting problems.

The frontal lobes are particularly important for cognitive communication skills because of their role in the brain’s executive functions, including planning, organisation, flexible thinking and social behaviour. However, many other parts of the brain interact to perform the skills and are also important, such as areas of the temporal and parietal lobes.

This type of communication difficulty reflects a range of potential cognitive changes, such as:

• Attention and concentration difficulties

• Memory problems

• Literal interpretation

• Reduced reasoning and problem-solving skills

• Cognitive fatigue

• Slowed speed of information processing

• Impaired social communication skills

• Reduced insight

Attention and concentration difficulties

Problems in this area can contribute to a range of communication difficulties. For example:

• The person may not be able to concentrate to watch a TV programme that they used to enjoy. They may begin to chat, thus affecting other people’s enjoyment of the programme.

• They may have difficulty concentrating on conversations. This could cause them to end conversations abruptly or avoid them altogether.

Failure to pay attention can lead to the person missing important information. This can cause them to say inappropriate and embarrassing things. For example, you may have told them that a friend’s pet has died but if they were unable to pay full attention, they might still ask the friend how their pet is.

Dividing attention between two or more activities may be difficult. For example, the person may ignore what someone says when carrying out another activity at the same time. This may appear rude to people who do not understand.

Memory

A person with memory problems may find it hard to access information that they ‘know’. This can affect skills such as word recall and remembering people’s names, which are very important when communicating socially.

The failure to remember names or faces at a party, or information relevant to a conversation, can cause embarrassment and can lead to people avoiding social situations altogether.

Literal interpretation

Damage to the right side of the brain may lead to the person interpreting verbal information very concretely and taking things literally. They may have a reduced ability to grasp humour or sarcasm and may miss the subtle nuances of conversation.

This type of difficulty can result in the person taking things the wrong way. For example, a joking “What time do you call this to come home at night?!” could be taken seriously and lead to an argument.

Similarly, it can make it hard for the person to understand common expressions. For example, if you use an expression such as “I’ll just be a minute” they may take it literally and get upset if you take longer than one minute.

Reduced reasoning and problem-solving skills

Altered problem-solving ability can result in the person being unable to use language to think through and resolve a problem (e.g. how to get home having missed the last bus). This can cause them to make poor judgements or decisions (e.g. setting out to walk home alone in the dark, rather than a wider alternative such as ringing home for a lift).

Impaired reasoning and problem-solving skills can also lead to people experiencing difficulties in their conversational style. They may fail to understand the logic of someone’s point of view, and be inflexible in their own opinions.

Cognitive fatigue

Cognitive fatigue is a common long-term consequence of brain injury. Once fatigued, the person will often manage less well with their cognitive communication skills. Attention and concentration will be reduced, they will be less able to think clearly and they may become irritable and agitated.

Fatigue can also make other communication impairments worse, e.g. aphasia, dysarthria and dyspraxia of speech.

Impaired social communication skills

Social communication difficulties are particularly associated with injury to the frontal lobes of the brain. Difficulties in this area can mean the person does not recognise everyday social cues, both verbal and non-verbal. For example, they may not realise that someone is uncomfortable with the topic of conversation or that they are in a hurry to leave.

There are a number of widely accepted ‘norms’ of social behaviour within any culture. Brain injury may affect a person’s ability to recognise and adhere to these norms effectively. They may say the wrong thing at the wrong time and come across as rude or aggressive, e.g. saying “Look at her! Isn’t that coat horrible!” in a loud voice on the bus.

Other potential problems with social communication include:

• Altered turn-taking skills (e.g. the person either being overly talkative and taking over the conversation or not realising that it is their turn to speak).

• Interrupting someone else because they are afraid that otherwise they will forget what they want to say.

• Altered ability to talk around a shared topic (e.g. flitting from topic to topic, or having a reduced range of topics).

• Speaking only about themselves and fixating on certain subjects.

• Talking in a sexually explicit way or swearing at inappropriate times.

• Perseverating (getting stuck) on a favoured topic (e.g. wishing to leave hospital).

• Altered ability to give information in an orderly and organised way (e.g. assuming the other person shares knowledge about the topic when they don’t, or vice versa).

• Not using or ‘reading’ non-verbal cues accurately, such as facial expressions and body language.

Reduced insight

The person may lack or have limited insight into any or all of these problems. They may believe that they are acting ‘normally’ and exactly as they would have done before the injury.

This can be hard for those interacting with them. If the person lacks insight, it makes changing the problematic behaviours extremely difficult because it is hard for them to deal with a problem if they don’t know there is one.

Tips for people with cognitive communication difficulties

• Avoid rushing so you have enough time available for important conversations, e.g. ask for a double slot of appointments.

• Try to anticipate situations where communication may be difficult. Try to build up from easy to more difficult situations gradually (e.g. a coffee for two in a small café may be easier than attending a busy wedding reception).

• Try to use diaries, wallplanners, notepads, smartphones, voice records, Post-It notes, apps, or any other kind of reminder systems that suit you.

• Be prepared to ask for help to use such reminder systems to best effect.

• Aim to establish set places to keep important things in order to reduce demands on memory.

• Practise using your reminder systems as much as possible so they become second nature.

• Listen to feedback from others about your social interactions. Try to act on previous feedback when in similar situations again.

• Think about others when in a public environment.

• Try not to talk too loudly or swear, especially when with new or unfamiliar people.

• Be alert to other people changing the subject during a conversation. Try not to carry on talking about the previous topic.

• Try to rest and avoid stressful situations when you recognise signs of fatigue.

• Try to schedule demanding social situations (e.g. appointments) at times when you feel your most awake and alert.

• Try to do one thing at a time if possible.

• If you have missed part of a conversation, be honest and ask people to repeat themselves. Most people will be perfectly understanding about this when they know that concentration can be difficult for you.

• Try not to dwell on social mistakes and don’t let them put you off social situations. Other people will usually be understanding and will often just forget about it anyway.

Tips for people communicating with survivors with cognitive communication difficulties

• Ensure the person’s attention is on you before giving information or instructions.

• Where possible, make things more predictable by developing a consistent routine.

• Decrease distractions, aiming for a quiet and relaxed setting.

• Break down instructions and information into small steps.

• Give the person time to process what you have said.

• Look out for signs of fatigue. Let the person ‘opt out’ for a while rather than expect them to continue fully in the conversation.

• If the person has some level of insight into their problems, discuss how and when they would like you to give feedback, e.g. on any success or difficulty they have had in conversing.

• Support the person in having varied communication opportunities to prevent social isolation.

• Encourage the person to let you know if they are finding a social setting difficult.

• Encourage them to move away from a difficult situation in order to reduce the chance of them becoming overwhelmed or angry.

• Ask questions and use reminders to help the person stay on topic.

• Make it clear when you are moving to a new topic.

• Avoid sarcasm, and use of non-literal expressions.

• Encourage the person to make eye contact when talking, as long as they don’t find it too stressful.

• Support the person in the use of diaries, wallplanners, notepads, smartphones, voice recorders, Post-It notes, apps or any other reminder systems that suit them.

• Be aware of any related cognitive problems that may affect the person’s independent use of strategies.

• Make it clear when their behaviour is socially unacceptable or offensive. Try to do this discreetly and in private.

Rehabilitation – speech and language therapy

Speech and language therapists (SLTs) specialise in the management of speech, language, communication and swallowing disorders. They may work alone, or as part of a multidisciplinary team consisting of physiotherapists, psychologists, occupational therapists, nurses and others.

SLTs usually work in local hospitals, rehabilitation units and community brain injury teams, while some work in private practice. Referrals can come from the hospital or GP. A directory of professionals in private practice is available from the Association of Speech and Language Therapists in Private Practice.

Assessments are conducted in order to find out how communication skills are affected. The SLT will want to meet with the person and their family in order to gain a full picture of the person’s life before the injury. This will include taking a case history to find out about their personality, work and leisure preferences. This information is important as it helps to identify:

• How the person’s lifestyle has changed since the injury

• How the injury may affect future plans, e.g. work, independence, social life

The SLT will assess speech and language skills in order to identify changes in any of the areas outlined in this publication. They will then devise a therapy programme based on the assessment findings. Due to the close interplay with other cognitive skills, an assessment also involving others in a multidisciplinary team will give the fullest information.

The SLT’s key role is to help the person communicate as successfully as possible. This may involve providing therapy, information and strategies to help the person and their carers to address the problems. While some individuals may progress sufficiently to resume some or all prior activities (e.g. work), this level of recovery is not always a realistic goal.

While SLTs are an invaluable source of help, sadly in many cases appointments may be restricted in number or unavailable. Fortunately, there are things that you can do to help even without professional input.

Communication aids

The speech and language therapist (SLT) may suggest that an Augmentative Aid to Communication (AAC), also known as a communication aid, may be of benefit. Sometimes this is a short-term need (e.g. an alphabet chart for someone who has a tracheostomy), while people with persisting problems may have a long-term requirement. For some individuals, learning alternative forms of communication (such as sign language) may be helpful.

There are many types of communication aids, including:

• Low-tech options such as alphabet boards and picture charts

• High-tech aids such as dedicated communication devices, computer-based systems and amplifiers

The type of aid selected must be suited to the overall needs of the individual. The following factors are important:

• Any physical difficulty which could affect the person’s ability to use aids

• Positioning of the communication aid

• Required level of portability of the aid, e.g. does the person need to be able to take it out with them, or use it only in the house?

• Any visual difficulty (which would affect the size and number of images used on the aid)

• Cognitive skills (which could affect the difficulty of learning to use the aid)

• Psychological factors – for example, if the person is very distressed it may affect their ability to concentrate, remember and learn effectively

• Preference and motivation (the person needs to believe that the aid provides them with something that spoken language alone doesn’t)

Many modern aids are able to accommodate variable levels of ability and need, ranging from making simple yes/no decisions through to complex uses of language (e.g. people have written whole books using simple eye-pointing alphabet charts).

You can find further information about communication aids and about choosing and funding them from a SLT.

This information was last reviewed in 2017.