Communication Challenges and How to Address Them

Cognitive-communication disorders

The communication challenges associated with brain injury are referred to as cognitive-communication disorders, because they are symptoms of underlying impairments in cognitive functions.

Cognitive-communication disorders are difficulties in:

• Listening
• Processing information
• Understanding
• Speaking and verbal expression (finding the right words and organizing sentences)
• Reading and writing
• Thinking

Underlying cognitive impairments that cause cognitive-communication disorders include impairments in:

• Attention: the ability to focus or maintain attention over time and, block out distractions such as noise, internal thoughts, pain etc.
• Memory: the ability to remember previous conversations, hold the current topic or goal of conversation in mind, difficulty remembering ideas, facts, details, appointments, etc.
• Information Processing: slow processing, reduced ability to process complex information and, reduced ability to process large amounts of information. Information processing is negatively affected by fatigue, which is common following brain injury.
• Reasoning and Problem Solving: difficulty understanding abstract information, making inferences, solving problems, especially when reasoning is required. This includes how to approach or behave in different social situations (such as a formal court setting), being unable to select the important details from the unimportant details, and being able to think 'outside the box'.
• Executive Functions:  planning, strategic thinking and action, goal directed behaviour, being able to self-monitor and inhibit behaviour (i.e. impulse control).

Some types of cognitive- communication disorders include:

Social Communication Disorders

Social communication disorders refer to difficulties with knowing the right thing to say, in the right (socially acceptable), way at the right time. It refers to the ability to adapt one’s conversational style, non-verbal communication and language according to the context and, relationship with the speaker. For example, being able to speak in a thoughtful, respectful manner with a judge or a police officer as compared to how one would speak to a friend where we can be less formal, make jokes and use different language. Many people with a brain injury also have difficulty understanding jokes, and with emotion recognition. They can’t always tell when another person is being truthful, is angry or teasing. As a result, they are at risk of being exploited and abused. (Byom et al., 2020, Wiseman-Hakes et al., 2019, 2020).

Social communication disorders are also heavily influenced by cognitive-communication disorders and executive functions. For example, difficulties with reasoning and executive functions can result in a person saying the wrong thing at the wrong time and not being able to control explosive emotions and impulsive responses. Social communication disorders can also be exacerbated by the mental health challenges and history of trauma experienced by many people with brain injury who intersect with the criminal justice system.

Among justice-involved persons with brain injury, cognitive-communication impairments are often exacerbated by;

Language and Literacy Impairments 

Many individuals who intersect with the criminal justice system come from socially disadvantaged families and communities (Clark et al., 2010), and are at risk for impoverished early language and emergent literacy experiences (Roy & Chiat, 2013; Spencer, Clegg, & Stackhouse, 2012). As a result, the cognitive-communication and social communication impairments associated with brain injury are superimposed on language and literacy impairments. (Snow et al., 2019, 2016, 2011; Davies et al., 2012).

Specific challenges in justice-involved populations include having a limited vocabulary, difficulty understanding the meaning of complex words and complex sentences, and poor reading and writing abilities. This puts the person at a distinct disadvantage in navigating the justice system and acting in their own interests, and further limits later employment and community integration.

Hearing and Auditory Processing Impairments

Many people with brain injury have auditory processing deficits (Atcherson et al., 2016, Vander Werf 2017), which are deficits in the brain’s ability to make sense of the rapid incoming auditory signals of speech (ASHA, SAC). People with brain injury also may be unable to block out sounds in the environment because of problems focusing auditory attention. Brain injury also can cause a hearing loss (a reduced ability to detect sounds), especially if they have a history of being hit repeatedly in the head and face. Hearing may sometimes be better in one ear than in the other. Complicating the effects of hearing loss is tinnitus, or ringing in the ears, which can be distracting in listening situations and also can negatively affect mental health. These hearing and auditory processing disorders are often undiagnosed.

Communication, Anger and Aggression

Some people with brain injury have significant challenges with anger management. They go from “0 – 100” with little warning and have difficulty controlling these extreme emotions. In addition to heightened emotion and lack of impulse control, this can also be a reflection of lack of emotional vocabulary and lack of the communication skills needed to express themselves in more appropriate ways. It is not uncommon for anger and aggression to be interpreted as anti-social behaviour. However, unidentified communication challenges are often a contributing factor. Research has shown that once other people are informed about the communication difficulties their perception of the ‘issues’ changed, to an understanding of unidentified and overlooked needs rather than previously understood ‘anti-social’ behaviours (Winstanley et al., 2018).

Limitations in language superimposed on brain injury-related cognitive-communication impairments are also exacerbated by the mental health challenges often experienced by those with brain injury. (Wiseman-Hakes et al., 2020).  Not surprisingly, more than one in five people who access mental health and/or addictions services (MHA) have a history of brain injury. (Hwang et al., 2008)

Stress and Self Confidence

Most individuals with brain injury are aware of their challenges in a general sense, even if they do not recognize their specific limitations. They recognize that when they are under stress, their ability to communicate is even more challenged (as is true for everyone). People with brain injury also, however, feel the stigma of labels (Ponsford et al.,2014) and worry that others will perceive them as ‘stupid’. The distinction between specific cognitive and communication challenges and overall intelligence is very important to acknowledge, because having a brain injury does not necessarily mean a person is less intelligent. A brain injury can cause a person to be slower at listening, understanding, thinking and responding; however, with support, rehabilitation, education, environmental modifications, and communication partner training, people with brain injury can live successful and meaningful lives and contribute to their communities and society.

Why are Communication Impairments Important in the Context of Criminal Justice? 

These communication problems can have major negative consequences for individuals with brain injury at all stages of the criminal justice procedures and beyond (e.g., in recidivism rates).. ‘Every stage of criminal justice involvement involves complex social interactions that typically require high-level and fast-paced processing of information, understanding, and responding - from interactions with police, front-line workers, and probation and parole officers; to formal proceedings such as hearings and trials; to participation in extrajudicial programs. (Wszalek & Turkstra, 2015)

Communication problems associated with brain injury are barriers to participation in the criminal justice system. For example, adults with moderate-severe brain injury are significantly less accurate and slower in their understanding of written legal language when compared to adults without brain injury. (Wszalek & Turkstra 2019)

Communication problems such as;

• Slowed thinking
• Difficulty concentrating and following what is being said, especially when there are multiple speakers
• Difficulty understanding complex and abstract language
• Difficulty responding in conversation

• Understanding written language
• Limited vocabulary
• Difficulty talking about an event
• Poor memory of spoken language

Can be barriers to understanding legal terms such as:

• Pre-trial detention
• Judicial interim release
• Substantial likelihood
• Custodial sentence
• Extrajudicial measures
• Proceedings
• Entitled
• Plea bargain
• Remorse
• Understanding the conditions of bail

Moreover, social communication challenges such as these:

• Difficulty reading emotions from others’ facial expressions, voices, and body language
• Difficulty “reading the minds” of others to understand others’ intentions and actions
• Difficulty adjusting language and behaviour to the context (people, places, events)
• Knowing the right thing to do, but not recognizing when to do it or stop doing the wrong thing
• Poor impulse control, for language and behaviour

Are often misinterpreted as:

• Non compliance
• Rudeness/lack of respect
• Defiance
• Poor motivation
• Disengagement
• Intentional inattention
• “Bad attitude”
• Carelessness
• Apparent insensitivity or lack of consideration for others
• Negative behaviours, from passivity to aggression

(Snow & Powell 2012)

Strategies for Communication and Literacy 

What can legal professionals do to support individuals with brain injury? 

First and foremost, it every person’s legal right to have support for any communication disability under:

• The Accessible Canada Act, which stipulates full accessibility in the area of Communication; including “providing barrier free services and spaces for persons with communication disabilities”
• The Accessibility for Ontarians with Disabilities ACT (AODA) under ‘Information and Communications’ speciality which also includes ‘Rephrasing in clear language’ if the person does not understand.

The following strategies can be employed to support and facilitate communication:

• Where possible, use shorter sentences and speak a bit more slowly than you might normally (but not in a way that is patronizing to the individual). This is a ‘fine balance’; think about what it’s like learning another language and how it helps when the communication partner speaks slowly and in shorter sentences.

• Do not ask the person ‘Do you understand’? Most often, the person will say yes, or nod in assent, but this does NOT mean they did understand.  Instead, ask the person to tell you what they understand.

• Wherever possible, work with clients in a quiet room with limited distractions. If they are bothered by bright lights, turn the lights down.

• Recognize that the person may be working very hard to listen, follow and understand, but may just lose their attention or focus. They may also be fatigued. If so, see if they need a break (where possible; recognizing this is not often an option in the context of the legal system).

• Ask if they have any hearing challenges and if so, if one ear is better than the other? If the individual reports any concerns about their hearing, ringing in the ears (tinnitus) or listening (the ability to quickly make sense of the rapid incoming auditory signals of speech), then a referral for hearing testing is indicated. (Note: a hearing test is covered by OHIP if it is ordered by a physician).

• Pause in between topics (or complex sentences) and give the person time to process. Ask if there’s anything they’d like you to explain again.

• Let clients know this is a safe space and they can ask for repetition or clarification any time.

• Avoid legalese (where possible) and explain complicated words the person might not understand.

• Provide a brief summary of the main points after each section of the conversation and ask your client to tell you what they understand.

• Write some notes to give to the client if they think it would be helpful.

• Set up realistic reminder strategies (see example below regarding bail conditions).

• If you have any significant concerns about a person’s ability to understand and express themselves in court, consider bringing in a Communication Intermediary. (See below for further details).

•  Ensure that formal paperwork, restrictions and stipulations are written clearly and concisely. (These documents are often lengthy and use complex language that likely will not be understood by the client. This makes them vulnerable to breaching their conditions, thus precipitating the cycle).

• Have a discussion with your client to make sure they fully understand conditions of bail etc. As above, don’t ask them if they understand; ask them to tell you what they understand. Correct any misinterpretations and support them to create a strategy or plan as to how they will meet their conditions. For example, if a client has memory problems, how can you help them plan to remember their bail hearings? Consider helping to put it in their calendar on their phone or device, and plan how they will get to the hearing.

• Consider advocating for the client to have appropriate rehabilitation for any spoken and written communication challenges and or social communication challenges as part of their conditions of probation, parole, or, as an alternative to sentencing.

The following Strategies can be employed to support individuals with Literacy difficulties

Questions to ask your client to determine if literacy is an issue:

1. What is your level of education?
2. Did you require an IEP (Individual Education Plan) in school or extra support?
3. How do you best learn information? Visual, auditory, pictures or words?
4. How do you keep organized?
5. Do you require support to understand the documentation?
6. How can I support you in this?
7. Do you require information to be written, recorded or broken down further?
8. Would you like a support person to attend meetings with you?  Is there someone I can ask or I can refer you to an agency?

If Literacy Challenges are present:

Support Strategies for Literacy Challenges

• Focus on “need-to-know” and “need- to do”.  Provide specific and simple instructions and tasks and review out loud
• Ask the client to repeat back information discussed in their own words to ensure they understand
• Ask clients to summarize information they have read, in their own words to demonstrate they understand written documentation
• Use diagrams, draw pictures
• Use clearly written and simple directions and review written directions with your client to ensure they understand
• Repeat and summarize information frequently
• Use concrete examples and not abstract or general statements
• Create photograph lists of important documents for visual cues
• Allow clients to voice record prompts or conversations as needed
• Help set up reminders or calendars on phone with voice prompts

Free and Easy Apps to assist with document reading

Apple Store app: seeing ai

Android Google Play Store: @voice Aloud Reader

Communication Intermediaries

A Communication Intermediary supports victims, witnesses and accused people who have speech, language and communication disabilities, to understand information questions and to communicate their messages as accurately, authentically and completely as possible when communicating with police, legal or justice professionals.

In Canada, the term Communication Intermediary is a qualified Speech-Language Pathologist who has additional training from Communication Disabilities Access Canada (CDAC) to support people communicating in justice situations.

Communication Intermediaries work in a similar way to sign language interpreters however, they use different techniques to support people who have communication disabilities due to cerebral palsy, autism spectrum disorder, cognitive disabilities, fetal alcohol syndrome, acquired and traumatic brain injury, learning disability, stroke, dementia, ALS, Parkinson’s Disease and other disabilities that can affect communication.

Similar to other accessibility services, such as sign language interpreting, communication intermediary support is an essential accessibility service that falls under the duty to accommodate legislation in Human Rights Codes, provincial and federal accessibility acts and the United Nations Convention on the Rights of Persons with Disabilities.  As an accessibility accommodation, communication intermediary services are sourced and paid for by police, legal or justice services to ensure that victims, witnesses and accused can effectively communicate when using their services.

A Communication Intermediary conducts a communication assessment to determine what the person needs to understand questions and to communicate his or her responses; writes a report on the person’s communication abilities and documents any required communication aids and supports; explains the person’s communication needs to police, legal and justice professionals and provides direct communication support within all stages of the justice process.

To find a communication intermediary, go to CDAC national database or contact The Ministry of the Attorney General’s Diversity, Inclusion and Accessibility Office.

For more information on communication intermediaries, please visit the CDAC Resource Page here.

For information on CDAC and issues relating to communication access, legal capacity and social justice for people with disabilities that can affect communication visit the CDAC website.

References

American Speech-Language- Hearing association (ASHA). Central Auditory Processing Disorder.

Atcherson SR, Steele CL. (2016). Auditory Processing Deficits Following Sport-Related or Motor Vehicle Accident Injuries. Brain Disorders & Therapy, 5:1

Byom L, O’Neil-Pirrozi, Lemoncello R, MacDonald S, Meulenbroek P, Ness B, Moore-Sohlberg M. (2020) Social communication following adult traumatic brain injury: A scoping review of theoretical models. American J of Speech Language Pathology. Early online June 23.

Clark, T., Smoth, J., Raphael, D., Jackson, C., Denny, S., Fleming, T., … Crengle, S. (2010). Kicked out of school and suffering: The health needs of alternative education youth in New Zealand. Youth Studies Australia, 29, 10–17.

Davies RC, Williams WH, Hinder D, Burgess CN, Mounce LT. (2012). Self-reported traumatic brain injury and postconcussion symptoms in incarcerated youth. J Head Trauma Rehabil.,27(3):E21-E27.

Hwang SW, Colantonio A, Chiu S, Tolomiczenko G, Kiss  A, Cowan L, Levinson W. (2008). The effect of traumatic brain injury on the health of homeless people. Canadian Medical Association Journal, 179(8):779–784.

MacDonald S. (2017). Introducing the model of cognitive-communication competence. Brain injury. 31(13-14):1760-1780.

Ponsford, J., Kelly, A., & Couchman, G. (2014). Self-concept and self-esteem after acquired brain injury: A control group comparison. Brain injury, 28(2), 146–154.

Pamela C. Snow, Linda J. Graham, Emina J. Mclean & Tanya A. Serry (2019): The oral language and reading comprehension skills of adolescents in flexible learning programmes. International Journal of Speech-Language Pathology. Early Online: 1–10.

Roy, P., & Chiat, S. (2013). Teasing apart disadvantage from disorder. The case of poor language. In C.R. Marshall (Ed.), Current issues in developmental disorders (pp. 125–150).

London: Psychology Press.

Snow PC, Graham LJ, Mclean EJ, Serry TA (2019): The oral language and reading comprehension skills of adolescents in flexible learning programmes.  International Journal of Speech-Language Pathology.

Snow, P. C., Woodward, M., Mathis, M., & Powell, M. B. (2016). Language functioning, mental health and alexithymia in incarcerated young offenders. International Journal of Speech-Language Pathology, 18(1), 20–31.

Snow, P. C., & Powell, M. B. (2011). Oral language competence in incarcerated young offenders: Links with offending severity. International Journal of Speech-Language Pathology, 13(6), 480–489.

Speech and Audiology Canada (SAC) (2012). Canadian Guidelines on Auditory Processing Disorders in Children and Adults.  https://www.sac-oac.ca/sites/default/files/resources/Canadian-Guidelines-on-Auditory-Processing-Disorder-in-Children-and-Adults-English-2012.pdf

Spencer, S., Clegg, J., & Stackhouse, J. (2012). Language and social disadvantage: A comparison of the language abilities of adolescents from two different socio-economic areas. International Journal of Language and Communication Disorders, 47, 274–284.

Vander Werff KR, Rieger B. (2017) Ear Hear. Brainstem evoked potential indices of subcortical auditory processing after mild traumatic brain injury. Jul/Aug;38(4):e200-e214.

Wszalek JA, & Turkstra LS. (2015). Language impairments in youths with traumatic brain injury: Implications for participation in criminal proceedings. Journal of Head Trauma Rehabilitation, 30(2), 86–93.

Wszalek, J. A., & Turkstra, L. S. (2019). Comprehension of social–legal exchanges in adults with and without traumatic brain injury. Neuropsychology, 33(7), 934–946.

Winstanley M, Webb RT, Conti-Ramsden G. (2018). More or less likely to offend? Young adults with a history of identified developmental language disorders^. International J of Communication Disorders. 53(2), 256-270. 

Wiseman-Hakes C, Colantonio A, Ryu H et al. (2020). Research to Integrate Services for Individuals with Traumatic Brain injury, Mental Health, and Addictions: Proceedings of a Multidisciplinary Workshop. Canadian Journal of Community Mental Health, Published on the web 12 May 2020

Wiseman-Hakes C, Kakonge L, Dougherty M, Beauchamp M. (2020) A Conceptual Framework of Social Communication: Clinical Applications to Pediatric Traumatic Brain injury Seminars in Speech and Language 41(2).

Wiseman-Hakes C., Ryu H., Lightfoot D., Kukreja G., Colantonio A., Matheson FI. (2020). Examining the Efficacy of Communication Partner Training for Improving Communication Interactions and Outcomes for Individuals with Traumatic Brain injury: A Systematic Review. Archives of Rehabilitation Research and Clinical Translation. 2(1). P1-21.  

Wiseman-Hakes C. Saleem M., Poulin, V., Nalder, E., Balachandran P., Gan, C., Colantonio, A. (2019). The development of intimate relationships in adolescent girls and women with Traumatic Brain injury: a framework to guide Gender Specific Rehabilitation and enhance positive social outcomes.  Disability and Rehabilitation early online April 17, 2019. 

Yuhasz, J. E. (2013). Misconceptions about traumatic brain injury among correctional health care professionals. Journal of Correctional Health Care, 19(2), 135–143.