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Editorial Puttingcommunication disorders incontext after traumatic braininjurySkye McDonaldPublished online: 31 Aug 2010.

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aphasiology , 2000, vol. 14, no. 4, 339±347

Editorial

Putting communication disorders incontext after traumatic brain injury

SKYE McDONALD

School of Psychology, University of NSW, Sydney, Australia

Abstract

In this editorial, the importance of context in communication after traumaticbrain injury (TBI) is discussed. Context is de®ned in a number of waysincluding the socio-cultural background of the individual, the speci®c socialcontext of any given communicative setting and the cognitive context of theindividual including their prior knowledge and coexisting cognitive de®cits.Each of these is covered elsewhere in this special issue of Aphasiology andmentioned perfunctorily here. In addition, however, it is argued that socialperception, the ability to read social contextual cues, while critical to languagecompetence is an area that has received relatively little attention in the researchliterature. However there is evidence that TBI individuals have problemsunderstanding paralinguistic information (e.g. tone of voice), non-verbal cues(e.g. facial expression) and contextual information (e.g. relationship betweenspeakers). The potential role of cognitive disturbances in producing suchde®cits is brie¯y considered.

Introduction

Severe TBI frequently causes psychosocial impairments, communication dis-turbances and lowered levels of social skills. It is well documented that such de®citsreduce the capacity of the individual to return to their community successfully andlead to long-term social isolation (e.g. Thomsen 1975, Tate et al. 1989). The papersin this issue address important issues regarding the identi®cation and remediationof these disturbances.

The eåects of sociocultural context: Situation and personspeci®c

First, it is apparent that a `one size ®ts all ’ approach to language remediation isinappropriate and several papers in this issue cogently demonstrate this. Thepremorbid communication style and the socio-cultural context of the TBIindividual are important considerations in the formulation of remediation goalsand in the assessment of whether current communication and social skills areappropriate. This is critical within the adult population which encompasses a broadrange of social backgrounds, each bringing a distinctive constellation of social

Address correspondence to : Skye McDonald, School of Psychology, University of New SouthWales, Sydney, NSW 2052, Australia. E-mail : s.mcdonald ! unsw.edu.au

’ 2000 Psychology Press Ltdhttp:} } www.tandf.co.uk } journals } pp} 02687038.html

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mores and communicative styles (Ylvisaker and Freeney, this issue). It is nowheremore apparent than when translating assessment and therapy to adolescents whohave socio-cultural and developmental characteristics that set them apart from botheach other and the adult population (Turkstra, this issue). Furthermore, the contextin which language behaviour is observed can dramatically alter one’s perceptionsof a TBI individual’s communication competence, as evident from the studydescribed by Togher (this issue). In the right circumstances, a TBI speaker’scommunicative di¬culties can be ameliorated to the point of normalcy. Context, itwould seem, is everything when assessing and treating communication and socialskills. This important revolution in understanding TBI is exempli®ed amply bythese papers and also highlights how much is yet to be done in this area. If contextis everything, there are many contexts yet to explore. As a ®rst step, it is apparentthat we need a better understanding of how normal speakers from a range ofbackgrounds communicate in everyday settings. Turkstra’s careful observation ofnormal adolescent social behaviour reveals idiosyncrasies in this cohort that areeasily missed by focusing on TBI subjects in contrived contexts alone.

In addition, not a great deal is known about how normal (skilled) speakersmoderate their communication strategies to negotiate diåerent communicativesettings and where TBI speakers fall down. Godfrey and Shum (this issue) arguethat the ¯exible application of social skills to meet diåerent circumstances is one ofthe major problems that TBI individuals face. This may well be true and wouldbe, as they suggest, a major factor limiting the generalization of social skillsremediation. In such a case, an alternative approach to remediation would be tofocus on particular communicative contexts and provide speci®c training withinthese, with the expectation of improving communication skills in those contextsalone. This task is made simpler by focusing on some contexts that are importantfor the TBI population, speci®cally those that may prove to be critical hurdles tore-entry into the community. Making new friends and succeeding in job interviewsare examples of communication contexts that have particular salience. Sensitivityof methodologies such as exchange structure analysis (Togher, this issue) hasgreat potential for identifying how normal communication varies from onesuch setting to another. Preliminary work has begun to identify behaviours insuch settings that diminish the perceived social competence of interlocutors withTBI (Godfrey et al. 1989, Spence et al. 1993). Meanwhile, social skills approachescan potentially break down such social tasks into manageable components fortraining (Godfrey and Shum, this issue) and person-speci®c metaphors can increasethe relevance of such approaches to TBI individuals (Ylvisaker and Freeney,this issue). These are encouraging beginnings to a context-speci®c approach toassessment and remediation.

Methodologies that assess communication in context

A second important issue is how de®cits in communication and social skills arecharacterized. It is now well recognized that traditional notions of languagecompetence based on phonological, syntactic and semantic skills fail to address thetypes of communication disturbances that individuals with TBI experience.Aphasia is relatively infrequent in this population. On the other hand, many severe-TBI speakers fail to ful®l the social requirements of a given communicative setting.Their conversation may be self-focused and immature, they may abruptly switch

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Communication disorders in context 341

between topics or have prolonged ®xation on topics, be overly familiar withinappropriate levels of self-disclosure and yet show little interest in theirconversational partner (Milton and Wertz 1986, Prigatano 1986, Crossen 1987).

These kinds of communication disturbance require assessment of the social aswell as linguistic adequacy of the intercourse and a variety of emergingmethodologies are useful in this regard. The application of theoretical approachessuch as systemic functional grammar (Togher, this issue) and pragmatic theory(Dennis and Barnes, this issue) are representative of a general upsurgeof new, moresensitive methodologies (see McDonald et al. 1999). For example, exchangestructure analysis (Togher, this issue) characterizes language in terms of howspeakers manage the exchange of information between them which is moderated bythe purposes of the communication and their relationship to each other. Usingthis methodology, Togher has demonstrated how communicative competencein a TBI youth varies from one context to the next. Speech act analysis haslikewise proven a fruitful means of characterizing communicative competence, inparticular, the identi®cation of how de®cits in understanding social messages occur.Pragmatic theory, such as speech act theory, is concerned with inference and howcontextual features are necessary in order for communication to make sense.Invariably, the literal meaning of an utterance is insu¬ciently informative on itsown. What the hearer gleans from what is going on around them or what they knowof the world, ®lls in the gaps. Using a speech act perspective, Dennis and Barnes(this issue) demonstrated that, in severely injured TBI children, the ability tounderstand what sentences imply or presuppose can be impaired. Importantly, thisability was found to be linked to the capacity to produce eåective speech acts,whereas semantic word-®nding skills and general knowledge were not, i.e.adequate pragmatic comprehension and adequate expression were inter-related. Asa third approach, analysis of social skills enables communication to be seen in broadbehavioural terms explicitly addressing both verbal and non-verbal components(Ehrlich and Sipes 1985, Ehrlich and Barry 1989, Godfrey and Shum, this issue,Turkstra, this issue). This approach de®nes communication disorders in a broadersense than is possible using primarily language-based theory and also clearly relatesto over-arching psychosocial de®cits seen in this population which are notrestricted to particular modalities. This approach to communication will berevisited later.

The cognitive context of communication disorders

As a third critical aspect of understanding and treating communication there isincreasing recognition that communication disturbances need to be seen within thecontext of co-existing cognitive dysfunction. While basic language loss may re¯ectdisorders to primary language systems, communication de®ciencies need to be seenas an interaction between language and other cognitive processes. The charac-terization of communication di¬culties as a facet of broader cognitive disturbanceprovides direction for both assessing and remediating such problems. For example,Dennis and Barnes demonstrate a clear relationship between poor workingmemory and poor ability to comprehend and produce pragmatically appropriatelanguage in their research published here and elsewhere (Dennis and Barnes 1990).

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Poor cohesion of discourse has likewise been associated with poor workingmemory (Hartley and Jensen 1991). The suggestion that poor working memoryundermines eåective discourse processing provides a direction for therapy basedon basic cognitive remediation research. Executive dysfunction, i.e. the loss ofregulatory control over problem solving and goal directed behaviour, has also beenimplicated in disorders of communication by several empirical studies (Marsh andKnight 1991, McDonald and van Sommers 1993, McDonald and Pearce, 1996,1998, Pearce et al. 1998) and the role of such de®cits in producing impairments inconversational competence has also been explored in this issue (Godfrey andShum). The role of cognitive de®cits in producing communication disorders isimportant, not simply to provide post hoc explanation of the kinds of de®cits seen,but because conceptualization of communication disorders in this frameworkprovides a valuable heuristic device to shape psycholinguistic accounts ofcommunicative competence and to guide assessment and treatment approaches(Godfrey and Shum, this issue).

Social perception after TBI: Reading contextual cues

Discourse approaches to language assessment as exempli®ed by Togher (this issue)and Dennis and Barnes (this issue) implicitly acknowledge the role of contextualin¯uences on communicative performance. Dennis and Barnes go further andevaluate access to general knowledge as an in¯uence on the production ofpragmatically appropriate speech acts in TBI children. However, in general, suchapproaches are primarily focused on language as the medium for communicationand do not directly investigate how well TBI speakers are able to register, interpretand utilize the diåerent types of contextual information that are implicitlyrecognized as integral to discourse. Approaches that focus more broadly on socialskills, such as detailed by Godfrey and Shum (this issue), explicitly address bothverbal and non-verbal facets of communication and provide a basis for consideringhow communication disturbances may re¯ect problems in social perception morebroadly de®ned.

As is apparent from Godfrey and Shum’s review, social skills approaches havetraditionally focused on the availability and application of skilled behaviour, bothverbal and non-verbal (eye contact, body orientation etc.). Yet there is growingawareness that social competence relies equally on accurate social perception(Argyle 1986). The ability to interpret, integrate and use paralinguistic features(e.g. intonation), non-verbal cues (e.g. facial expression, eye gaze, gesture) andcontextual in¯uences (e.g. type of social relationships, con¯ict of goals betweenspeakers) are all integral to socially skilled behaviour (Morrison and Bellack 1981,Boice 1983). The assessment of social perception is vital to remediation strategiesbecause the training of particular skills can be counterproductive if they are usedindiscriminately (Trower 1980). In keeping with this, in 1994 our group ran acarefully controlled social skills treatment programme for six chronic TBI subjects,focusing on the improvement of their social responses (Flanagan et al. 1995).Although we were able to claim some success, it became apparent that the failureof several of the participants to improve their social responsiveness lay in theirincapacity to understand the cues that were available in the social context and to use

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Communication disorders in context 343

these appropriately. Similarly, low sensitivity to contextual cues has been linked topoor social skills in a number of studies of non-brain-injured groups (e.g. Kahn1970, Kagan 1984).

The possibility that socially inadequate communication after TBI re¯ects afailure to make inferences from available information has already been introducedby the work of Dennis and Barnes (1990, this issue). My own group (McDonald1992, McDonald and Pearce 1996, Pearce et al. 1998), has reported similar evidence,®nding that a proportion of TBI adults misinterpret conversational inferencesgenerated by discrete speech acts. Given that linguistic performance is relativelynormal in these subjects, the default interpretation is that they have di¬cultyutilizing the contextual information necessary to generate these inferences.However, the nature of the contextual cues involved and whether any particularsources of contextual cues are more poorly processed is not well understood.

As exempli®ed by Dennis and Barnes (this issue), some contextual informationis provided by general knowledge of the world, which enriches the literal meaningof the utterance. In other cases, inferences are generated by context-speci®cinformation, i.e. an understanding of what else is going on in the situation in thewhich the utterance occurs. Such contextual in¯uences can profoundly alter themeaning intended in any communicative act. For example, sometimes a verbalmessage is intended to mean the opposite to that asserted (as in sarcasm) or toallude to a topic in only the most indirect terms (a hint). In such cases the literalmeaning of the utterance bears little relationship to the meaning intended and thecontext in which the utterance is made contains important clues to help theutterance make sense. Empirical studies have demonstrated that TBI subjects havedi¬culty understanding both such speech acts (McDonald 1992, McDonald andvan Sommers 1993, McDonald and Pearce 1996).

Other contextual information that can be vital includes information about whatthe speaker knows and believes because this, too, can radically aåect the meaningof the message. For example, a comment such as `Oh no. Rosie didn’t scribble onmy book’ may be sarcastic (meaning the opposite) if all parties are aware of the truestate of aåairs. The same comment may well be a lie if the speaker believes thelistener is not aware of the true state of aåairs (Sullivan et al. 1995, Winner et al.1998). Thus, listeners need to be able to put themselves `in the speaker’s shoes’(hold `a theory of mind’) which they glean from available facts and observationsin order to fully appreciate the speaker’s intended meaning and this may beproblematic for some TBI individuals. Egocentricity and poor sensitivity to othersare common problems ascribed to TBI individuals and a few empirical studiesprovide further support for this observation. For example, a proportion ofmoderate to severe TBI subjects have been reported to be impaired in their abilityto appreciate the perspectives of diåerent protagonists within stories of con¯ict(Levine et al. 1993, Santoro and Spiers 1994, Van Horn et al. 1992) and deceit (Baraet al. 1997). They also have more di¬culty than matched controls when answeringpersonality questionnaires `as if they were someone else ’ (Spiers et al. 1994).

Similarly, contextual information may help determine what the speaker isintending to do with their utterance, to lie, to joke, to criticize, etc., since the sameutterance, e.g. `No ! You haven’t put on weight ! ’ may well be intended in a variety ofways. The ability to attribute speaker intention to speci®c utterances has beenexamined in right hemisphere damaged subjects (Kaplan et al. 1990) but this hasnot been explicitly reported in the TBI population.

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344 S. McDonald

In sum, there are a broad range of contextual cuesÐsome related to knowledgeof the world and others speci®c to the situationÐthat must be processed in orderto interpret the implications behind any given utterance appropriately. In additionsome of the context itself must be inferred (e.g. speaker knowledge and intentions).There are a variety of sources of contextual cues which are available to the listenerto help make sense of what they hear. Some, like world knowledge, may beepistemic, but situation speci®c, e.g. knowledge of the speci®c circumstancesleading up to the communicative act, such as shared knowledge of past eventswhich have relevance for the present communicative setting (Sperber and Wilson1986). Alternatively, contextual cues may be directly perceived in the com-municative context such as paralinguistic information, the demeanour of theprotagonists, facial expression and so forth. Sensitivity to the latter class of cues isclearly measurable and yet few studies have focused on such skills in TBI, althoughthose that have are quite telling. For example, it has been established that TBIindividuals have di¬culty recognizing emotion from photographs (Prigatano andPribram 1982), tone of voice (McDonald and Pearce 1996), and videoed portrayal(Flanagan et al. 1999). Interestingly, certain emotions appear to be more di¬cultthan others. For example, happy and angry emotions appear to be recognized moreeasily than fear, sadness, and disgust (Prigatano and Pribram 1982, Flanagan et al.1999). In addition, children with TBI have trouble conceiving how facialexpressions may mask true emotional feelings in order to meet externalcircumstances (Dennis et al. 1998). Finally, TBI individuals have been shown tohave di¬culty comprehending sarcasm when the only cues to the sarcasticintention of the speaker was in their visible demeanour and tone of voice (Flanaganet al. 1999).

The relationship between such social perceptual de®cits and cognitive impair-ments seen in TBI is an area open for further research. Hypothetically, certainconstellations of cognitive de®cits that are frequently seen after TBI haveconsequences for social perception. A small proportion of severe TBI patientssuåer de®cits in the basic neuropsychological functions of language and perception(Tate et al. 1991). Such impairments, while not particularly prevalent after TBI, willcontribute to poor social comprehension in that those experience them. Slowedinformation processing is more frequently reported after TBI (Tate et al. 1991) asa result of diåuse axonal injury (van Zomeren and Brouwer 1987). This reducesboth the rate and amount of information that can be absorbed, limiting the capacityof the individual to monitor complex environments such as provided by manysocial settings. Damage to executive functions secondary to damage to theprefrontal lobes of the brain or their connections is also common after TBI and amodel of executive dysfunction and the potential eåects this has on producingsocially eåective behaviour has been described in detail by Godfrey and Shum (thisissue). In addition, however, executive dysfunction can disrupt the comprehension ofsocial information. Patients may be unable to analyse and synthesize information,to see abstract and inferred relationships, to consider alternative solutions toambiguous situations and to problem solve eåectively (Lezak 1995).

Impaired information-processing speed and problem-solving ability have beenclearly linked to poor comprehension of verbally mediated inference (Dennisand Barnes 1990, McDonald and Pearce 1996, Perkins et al. 1999). In addition,emotional discrimination does not appear to be a simple perceptual process andmay also be aåected by these more pervasive cognitive de®cits. There is no such

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Communication disorders in context 345

thing as a `pure’ emotional expression, each normal expression represents a hybridof a family of overlapping feelings (Russell 1994) and may be ¯eeting, mixed ordisguised in the service of social appropriateness. Thus, the identi®cation ofemotion requires attention (i.e. good information-processing capacity) and ismoderated by contextual information (Carroll and Russell 1996) presumablyrelying on problem-solving skill (i.e. executive abilities). In support of this wefound that the proportion of our socially unskilled TBI subjects who failed torecognize emotions when these were depicted dynamically (as in video or audiopresentations) exceeded that expected from the general incidence of perceptualde®cits in this population (McDonald and Pearce 1996, Flanagan et al. 1999).

The notion that certain neuropsychological de®cits underlie impairments insocial perception does not imply a simple direct relationship between the two.Impaired problem-solving ability, for example, does not re¯ect impairment tosimple, irreducible neuropsychological function. Problem solving encompasses arange of processes such as working memory, ¯exibility, planning and inhibitorycontrol (Milner 1963, Shallice 1982, also see Godfrey and Shum, this issue). It mayaåect verbal and non-verbal tasks diåerentially (Milner 1964, Benton 1968) and isin¯uenced by task di¬culty (Shallice and Burgess 1991). Furthermore, not only dosuch patients manifest signi®cant individual diåerences on standard tests ofneuropsychological function but they are variable on tests of social perception. Forexample, some subjects have demonstrated clear de®cits in the recognition ofverbal inference and yet normal abilities in the recognition of emotional state,whereas others have demonstrated the reverse (McDonald and Pearce 1996).Clearly, problem-solving de®cits vary and impact diåerentially upon socialperception. The problems that TBI individuals experience in social perceptualability and their cognitive underpinnings remain an area of fertile research.

Conclusions

In conclusion, communication disorders after TBI must be seen in contextÐin thecontext of the person’s socio-cultural background and experiences, in the contextor speci®c communicative contexts that the individual is likely to encounter and inthe context of all available information that can and should be utilized for accuratereading of the social situation. The cognitive de®cits that the TBI individualexperiences are also important backgroundfactors that provide clues and directionsfor characterization of communication disturbances. In this special issue ofAphasiology several methodologies and theoretical approaches are used to attemptto grapple with these issues and in this editorial some directions for future researchhave been explored, speci®cally, the need to analyse speci®c communicationcontexts for training and for greater focus on the ability of the TBI individual toread social cues.

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