BRAIN INJURY, 1992, VOL.
6, NO. 3, 283-292
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Communication disorders following closed head injury: new approaches to assessment and rehabilitation SKYE McDONALD Departmcnt of Ncuropsychology,Lidcombe Hospital, New South Wales, Australia
(Received 30 March 1993; accepted 7 M a y 1991) In this paper communication disorders following closed head injury are described and various forms of language assessment techniques are reviewed. The usefulness of conventional, pragmatic and cognitive approaches is considered. A ncw cognitive-pragmatic approach is then advocated which is an amalgam of the last two approaches. From the examples given it is argued that such an approach is practical in terms of: 1) incorporating knowledge of co-existing cognitive deficits; and 2) focusing on normal everyday communication practices. It is also suggested that the use of a cognitive-pragmatic framework has potential in refining remcdiation and management strategm with the closed-head-injured population.
The nature of the problem Aphasic disorders in closed head injury (CHI) occur relatively infrequently in the acute phase of recovery and are followed by a variable recovery course [l-31. None the less, it has been the impression of clinicians working with this population that there is often something wrong with a significant proportion of non-aphasic patients’ communication skills. Levin et af. [4],studying CHI patients one year post trauma, noted that many suffered inefficient filtering of extraneous material and that their conversation would frequently drift to irrelevant topics. Thomsen [ 5 ] , interviewing CHI victims years after their head injury, found that, despite the absence of aphasic symptoms, many patients were slow in their responses and required frequent repetition of questions. Their expressive speech was characterized by numerous pauses and a reliance on set expressions. They also tended to leave sentences unfinished. McKinlay et al. [6] reported that in a significant proportion of cases relatives complained of reduced fluency (44%) or excessive talking (26%) in the CHI patient. Prigatano et al. [7] described talkativeness, tangentiality, and the use of peculiar phraseology as characteristic of speech patterns after CHI. Milton and Wertz [8] also described many of the characteristics mentioned above, as well as problems assimilating and using contextual cues. The implications of persisting poor communication skills after CHI can be exemplified by Thomsen’s 10-15 year follow-up study of severely head-injured patients. She found Address correspondence to: Skye McDonald, Department of Neuropsychology, Lidcombe Hospital, Joseph Street, Lidcombe, 2141, New South Wales, Australia. 0269-9052/92 $340 0 1992 Taylor & Francis Ltd.
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that social isolation was the most serious handicap they faced [5]. A more recent study (91 found that even among severe CHI patients considered to have made a good recovery and to have attained ‘good’ reintegration, there were many that continued to suffer from social isolation and a drop in vocational status. As pointed out by Milton et al. [lo]: inappropriate management of communication exchanges by the head injured individual and the penalisation that follows often present a major barrier to social integration (p. 115).
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Longstanding communication disorders following CHI thus present a major challenge to rehabilitationists. Early identification and remediation of these disorders will be influential in maximizing the head-injured individual’s capacity to reintegrate into hidher social, vocational, and interpersonal worlds. Conventional approaches
Conventional language assessment models examine language production and reception in terms of phonological, semantic, and syntactical characteristics a t no greater complexity than the sentence. Most CHI patients will perform, overall, within normal limits on conventional aphasia batteries. They cannot therefore be considered aphasic on the basis of the batteries’ classification criteria. However their abilities on specific subtests are frequently below normal expectations. A significant proportion of severely head-injured non-aphasic patients have been found to have residual deficiencies in confrontation naming, word-finding or verbal associative tasks (4,11-15]. Subgroups of CHI patients have also been identified as performing poorly o n the Token Test, which is a structured test of comprehension (4,11-15]. These specific disturbances do not, however, reflect the nature of extent of clinically observed communication disorders. As an advance on this traditional mode of assessment, there is growing recognition that two additional factors are important to consider in functional language assessment following head injury: pragmatic language processes and coexisting cognitive impairments. Pragmatic approaches
The realm of pragmatics has steadily influenced the development of new techniques with which to assess communication disorders following brain injury. Pragmatic approaches enable a broader focus to be taken on the range of communication disorders seen and mirror similar research advances into understanding normal communication functions. Pragmatics, broadly speaking, is the study of language use 1161. The discipline is a divergent one encompassing dimensions such as the relationship of linguistic structure to function [17], the influence of non-linguistic contextual cues o n the conveyance of meaning and the resolution of ambiguity [16, 181 and the study of communication behaviour between speakers [19-251. Pragmatics is thus concerned with the ongoing interaction of language with the context in which it occurs. Because pragmatic theory focuses on dynamic aspects of communication, it is a valuable framework with which to assess everyday language use. For example, in a great deal of normal communication the meaning intended is not simply the literal one but rather a constellation of meanings conveyed by the interaction of the utterance with its context [19, 261. ‘Can you play tennis?’ will have different meanings depending on whether it is said in the vicinity of a tennis court as an invitation to play, or as a conversational remark in a living-room.
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Other meanings are also constructed from the particular form the message takes; for example, while a family member may be tolerated if she asks ‘What time is it?’, this message may be considered an affiont to a stranger stopped on the street. In the latter case the same message would be normally constructed more formally and politely, such as ‘Excuse me, could you tell me the time please?’ In this example the form of the message is adapted to acknowledge the social relationship between the speakers 122, 271. Pragmaticists have also argued that the manner in which the utterance is constructed is important to enhance its clarity and avoid ambiguity. Grice [20, 211 identified four maxims of cooperative conversational practice that were normally adhered to by speakers. These incorporated the requirements that the speaker say as much as is necessary, no more and no less, say only what is relevant to the context, and speak truthfully in an organized and unambiguous manner. As a development of these principles of language structure it has been argued [17, 281 that normal conversation is organized in a manner that provides the given (old) information at the beginning of an utterance followed by the new information; for example, ‘the client who rang yesterday caNed back today’. By constructing utterances in t h s way speakers provide their listeners with a context to facilitate their comprehension of novel material. Not only is the language structure within a clause complex organized to enhance clarity, but linguists have demonstrated that lexical and grammatical devices operate throughout the entire length of any discourse to form chains of semantic continuity linking non-adjacent clauses and clause complexes. These non-structural components are necessary to enhance the cohesion and coherence of an extended discourse [17, 331. The nature and position of devices used by normal speakers depends heavily on the context and function of the communication act. Pragmatic theory thus assigns a complexity to even apparently simple, normal communications. Inability to appreciate pragmatic requirements when formulating an utterance or, alternatively, when interpreting an utterance, will lead to failed or clumsy communication. There have been a number of clinical researchers interested in pragmatic approaches to the assessment of developmental and acquired language disorders following brain damage. Prutting and Kirchner [29, 301 developed a ‘Pragmatic Protocol’ on the basis of an extensive review of the pragmatic literature and modified in response to clinical trials. The protocol, designed within a speech-act theory framework, was used to classify attributes of spontaneous conversation, including the interactional behaviour between speakers. Language was deemed appropriate or inappropriate to the context. Milton et al. [lo] applied this protocol to assessment of language in the CHI population and reported inadequacies in areas such as topic selection, topic maintenance, and turn-taking initiation. Snow et al. [31] described a checkhst devised by Damico [32] based on Grice’s cooperative principles of conversation. They applied this to a number of CHI patients across a variety of communication tasks. Their preliminary results using this procedure indicated that particular CHI patients had discourse impairments in areas such as topic maintenance, informational redundancy, insufficiency, and non-fluency. Finally, Mentis and Prutting 1331 examined narrative and procedural discourse of CHI patients in terms of linguistic cohesion [34] and reported differential reliance on particular lexico-grammatical cohesive devices by CHI patients compared with controls.
Cognitive approaches
A further consideration in the assessment of communication skills following CHI is the likely impact on communication of other cognitive impairments. Closed head injury,
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frequently a consequence of hgh-velocity motor-vehicle accidents, may result in a diverse range of cognitive deficits due to the multi-focal nature of the cerebral insult. Nevertheless there is a preponderance of frontal and temporal lobe pathology. While temporal lobe pathology is associated with disorders of memory and new learning, frontal lobe impairments frequently result in disorders of attention and concentration, slowed information processing, rigd, inflexible, stimulus-bound behaviour, an inability to assume the abstract attitude, and a general failure to deal with novel problemsolving situations adaptively [35]. Such deficits also disturb the head-injured victims’ ability to monitor and regulate their behaviour and may produce disorders of inhibition and impulse control [36]. The particular constellation of cognitive deficits experienced by any individual will only be discerned accurately by appropriate neuropsychologcal assessment. However, with the general understanding that these types of deficits are commonly seen following head injury, the implications of such impairments for communication ability must be considered. Cognitive impairments are likely to contribute to, or, indeed, in some cases underlie, communication disturbances following head injury [37]. In recognition of this, Hagan [38-401 has reported a cognitive approach to the assessment of language disorders following closed head injury. He developed categories with which to classifj both the patients’ behaviour and their functional communication level. These categories were developed from a cognitive perspective on language. Cognitive deficits in areas such as attention, sequencing, memory, categorization, and associative abilities were translated into characteristics of language disorganization. Apart from behavioural observation, direct assessment of language function was achieved via a range of existing intelligence and psycholinguistic tests. There is scope, however, to become more specific regarding the impact of different forms of cognitive impairment on communication. This can be facilitated by differentiating between types of communication acts and their specific pragmatic requirements. Cognitive-pragmatic approaches
Cognitive-pragmatic language tasks are those that require particular pragmatic processes which have been judged to be vulnerable to specific cognitive disturbance. They therefore represent an amalgam of the above two approaches. The advantage of this type of assessment procedure is two-fold. First, it differentiates between different communication contexts and their relative pragmatic demands. Second, it recognizes that particular cognitive deficits may be disruptive in one communication context but not another. Using a number of such tasks it is possible to document the influence of various cognitive impairments in producing different types of communication disorders. This greater accuracy in assessment should facilitate the identification of specific targets for remediation. In order to illustrate this approach, examples of cognitive-pragmatic tasks are set out in the following section. To date, these tasks have been designed to focus on frontal lobe deficits only. The impact of temporal or other pathology on communication awaits further study.
of cognitive-pragmatic approaches to assessment fo meet the informational needs of the listener Examples
1 . Ability
The conversational maxim of manner described by Grice [20, 211, namely, that a speaker must be ordered and avoid ambiguity, has ramifications for the C H I individual who is
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concrete with impaired planning ability. Furthermore, a failure to adhere to this principle may be less important in casual conversation than when the discourse is task oriented; for example, providmg a listener with instructions. In order to assess this, a head-injured individual was selected who had predominantly frontal lobe impairments as assessed by neuropsychological assessment. His deficits were characterized by rigidity, perseveration, and poor planning and problem-solving skills. He was also considered to be quite impaired in terms of communication ability. He was asked to describe how to play a simple, yet novel game to a blindfolded listener. A group of non-brain-damaged subjects also performed this task for comparative purposes. The productions were transcribed and given to judges to rate in terms of their organization. Without knowing the identity of the subjects or the texts, the judges universally rated the head-injured text as extremely disorganized, confirming that the patient had difficulty adhering to Grice’s maxim of manner. An analysis was subsequently performed on the sequencing of the informational content in the texts expressed as propositions. The propositional analysis revealed that the CHI patient made specific errors in the sequence in which he described the procedure. He also focused on irrelevant propositions at crucial points in his explanation. Whereas the non-brain-damaged subjects’ explanations incorporated from 16 to 28 propositions in total, the CHI subject produced 54 propositions, 28 of which were repetitions. Furthermore, the sequence of these was revealing in terms of the specific difficulty the subject was having with perseveration. In the first 20 propositions he made 18 novel propositions and repeated himself twice. In the next 34 propositions he made a total of 8 new propositions and 26 repetitions. From the subject’s performance on this task several important features emerged. First, it was ascertained that frontal-lobe injury in this case had affected the head-injured subject’s ability to adhere to the maxim of manner. Second, it was revealed that, counter to expectations, this was not due to his inability to develop a plan for h s communication per se. He was sensitive to the d e n t information needed for an adequate explanation and incorporated this. O n the other hand, errors in sequencing and inclusion of irrelevant material were indicative that he had trouble monitoring his output and keeping ‘on track‘. It also revealed that perseveration was in fact a secondary problem which manifested only when his communication plan had run its course. Because he failed to monitor his production accurately, he failed to discern that his explanation had finished, and consequently continued on in a repetitive, disjointed, and unplanned manner. Having identified these particular areas of deficit, remediation strategies could be made quite specific.
2. Ability to negotiate requests Brown and Levinson [22J describe the systematic manner in which people phrase their utterances in order to avoid offending the listener, or, alternatively, to improve their own standing in the listener’s eyes. These strategies have been loosely termed politeness. The selection of particular polite devices depends on the social distance between listeners, the cultural imposition that their speech act entails and the power relationship between them. Appropriate selection thus requires dynamic appreciation of a number of contextual factors. Given that frontal lobe impairment can lead to rigid thought processes and loss of flexibility, there may be certain CHI patients who cannot produce effective, socially acceptable utterances. We explored this by focusing on two head-injured subjects with overlapping but different constellations of frontal lobe deficits as weII as demonstrable
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problems in everyday communication. One CHI subject was particularly concrete and perseverative. The other subject, while less impaired in terms of abstraction skills, had major deficits of impulse control. Matched control subjects also took part. The subjects were asked to formulate polite requests under a variety of circumstances (such as aslung a stranger the time, aslung a farmly member to turn the radio down). Despite the varying demands of each request, the two CHI subjects produced adaptive and effective responses. From this we surmised that, to a great extent, the formulation of simple conventional requests was an automatic or overlearned process unaffected by their frontal pathology. We then increased the demands of the task by insisting that requests were made in the form of hints. A common strategy used by the non-brain-damaged control subjects on thus task was to formulate their hints by referring to some logically prior condition that preceded the desire to make the request. For example, when required to hint that the listener should buy the speaker a drink, several normal speakers simply stated that they were thirsty. When requested to hint to a partner that the speaker wanted to go home, many normal speakers referred to the fact that they were tired. In contrast to this, neither CHI subject referred to contextual cues that were either logically or conceptually removed !?om the actual request. Nor could they refrain from developing their request to the point of stating their intention baldly, and were overall unable to make effective hints. As a consequence of this we concluded that fiontal lobe impairment, particularly loss of abstraction ability and disinhibition, as manifested in these two subjects, disrupted their ability to communicate non-conventional indirect meaning. Given that a great deal of communication in everyday social contexts relies on innuendo, inference, and indirectness, this has major ramifications for their communication skill. Furthermore, because this inability can be linked directly to their known cognitive deficits, the targets for rehabilitation are clear.
3 , Appreciation ofconversational implicature The preceding study revealed that frontal-lobe injury in the patients tested affected their ability to express themselves indirectly in novel situations. It was also of interest to determine whether the failure to produce indirect language was mirrored by a failure to understand it. A simple means to explore this was to focus on sarcasm. According to Grice, indirect conversational implicature such as irony is understood by: 1) processing the literal meaning; 2) deciding that it is inappropriate in the context; and 3) substituting it for another non-literal meaning which, in the case of sarcasm, is usually the opposite. Rigidity of thought processes after fiontal lobe damage should make this transition difficult. In order to explore this, a task was designed in which the two subjects who took part in the previous study were asked to interpret a pair of sentences. The first sentence acted as the context and the second was a response that was either literally consistent with the meaning of the first, e.g. Sentence 1. ‘What a huge meal’. Sentence 2. ‘You don’t have to eat it ail.’ or that conflicted with it, in which case one or other of the sentences could be interpreted as a sarcastic retort, e.g. Sentence 1. ‘What a huge meal.’ Sentence 2. ‘Don’t worry there’s more to come.’
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A normal control group also performed this task. As predicted, the two CHI subjects could interpret the meaning of the literally consistent sentence pairs but, in contrast to the controls, were completely unable to resolve the disparity between the inconsistent sentence pairs and at no time recognized that the interaction was a sarcastic one. From their performance on this task, it appears that not only are they unable to make nonconventional indirect references, but they also cannot understand them.
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Future directionsfor cognitive-pragmatic assessment$
The above examples demonstrate the usefulness of applying pragmatic theory to an understanding of cognitive function in order to elucidate the communication disturbance. The studies described represent only initial steps along this path. There is scope to explore the relative contributions of other frontal lobe impairments such as inertia and attentional disorders on select pragmatic tasks. There is also a need to elucidate the role of different cognitive processes, in particular, memory function, in the maintenance of effective Finally, the realm of pragmatics offers a wide variety of speech communication SMS. contexts to choose from in order to explore further the impact of particular frontal lobe processes on different speech acts. For example, it would be interesting to explore whether the two subjects described in the last two studies had greater or less difficulty formulating complaints in common situations (such as returning a faulty item to a retad outlet) compared with their inabdity to formulate indirect requests. It is anticipated that the patient who experienced differentially poor frustration tolerance and impdse control would find thls task particularly difficult compared with the CHI subject with problems of inertia and perseveration. By designing tasks systematically to test these hypotheses, a rich body of assessment materials can be amassed to further our knowledge in this area. Implications for therapy The assessment of cognitive-pragmatic language skills is not only a useful means to delineate accurately the type of communication hsorder seen following closed head injury, but it also has applications to the rehabltation of closed-head-injured patients. Rehabilitation of communication has tradtionally focused on three levels; retraining of the deficit slulls, usually by repetitive exposure; training of dternative strategies to overcome impairments; and management of the patient’s environment so as to ameliorate the impact of hidher deficits on hidher Ue. The usefulness of direct retraining in other language disorders, such as aphasia, is a controversial issue. Direct retraining of communication hsorders that may be a result of frontal pathology is patently unlikely to succeed. The frontal lobes are mainly involved in detection and adaptation to novel situations. The idea of retraining ths capacity by repetitive exposure is therefore paradoxical. Consistent with this position, fkontal lobe hnctions, such as executive control and conceptual abilities, have been reportedy resistant to direct therapeutic intervention [41j. Development of alternative strategies to overcome impaired frontal processes may prove a more fruitful avenue. Ylvisaker and Szekeres [42] have described a variety of interventions designed to improve self-monitoring and self-evaluation in communication. These incIude the use of progressive feedback from the therapist to help orient the patient to h d h e r strengths and weaknesses. They also advocated the use of external feedback such as graphs and charts and the development of self-questioning strategies to improve monitoring. Other researchers have reported the use of groups to improve awareness of
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communication practices. Gajar et al. [43] utilized either therapist-controlled or groupcontrolled feedback in the form of light signals to improve group conversational skills. Ehrlich and Sipes 1441 have advocated the use of role models and role plays to provide strategies and feedback. So a variety of techniques are being developed to address remediation of communication skills afier CHI. These techniques are also aimed at improving skills within a social context. Detection of communication incompetencies and feedback on therapy in all cases described was reliant on listener intuition, although observations made by Gajar et al. [43] and Ehrlich and Sipes [44] were guided by discourse theory. While obviously this is an ecologically valid approach, there is also room for further specification of the communication behaviours observed. The communication pattern can be evaluated more accurately using a pragmaticcognitive approach, that is 1) specifying the particular cognitive impairment the patient is suffering; 2) specifying the particular pragmatic demands of communication tasks he/she is faced with; and 3) anticipating how the cognitive impairment will be manifested in the patient’s communication output. Once these parameters have been defined, a new source of potential feedback to the patient becomes available to provide an external source of monitoring. A pragmatic analysis of each communication task attempted will also provide explicit information for the development of effective communication strategies. The third direction of rehabilitation involves the re-integration of the patient into h s / her social environment. As part of this process counselling and educational input to the family of the head-injured patient is integral [45]. The implications of cognitive-pragmatic disorders for communication breakdown between family members and the C H I individual are clear. Constellations of frontal lobe deficits may lead to failure of the C H I patient to detect nuance, implicature, hints, and so on, and may simultaneously result in a blunt and ineffective communication style. By educating the family specifically about such deficits, potential misunderstandings can be minimized and the family’s use of overly complex or subtle communication strateges avoided. Once again a specific knowledge of the patient’s strengths and weaknesses across different social contexts as provided by cognitivepragmatic assessment will facilitate this process.
Conclusion The studies described represent only the beginning stages of this field of enquiry. There is a great deal of scope to explore the impact of a variety of cognitive deficits on communication skills in a broad realm of contexts. By pursuing a cognitive-pragmatic approach to language assessment and rehabilitation following closed head injury, the emphasis will remain practical and relevant, while incorporating an understanding of co-existing cognitive deficits. Not only will such investigations be informative regarding the conlmunication difficulties head-injured patients experience, but they will also further our understanding of the nature of normal communication practices.
Acknowledgements The research described in t h s paper was funded by the Commonwealth Department of Health and Community Services (RADGAC) and Lidcombe Hospital. The author would like to thank Associate Professor Peter van Sommers and Professor Max Coltheart for advice on methodological issues and Dr Robyn Tate and Dr Shane Darke for their helpful comments regarding the manuscript.
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Subject review
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Communication disorders following closed head injury: new approaches to assessment and rehabilitation SKYE McDONALD Departmcnt of Ncuropsychology,Lidcombe Hospital, New South Wales, Australia
(Received 30 March 1993; accepted 7 M a y 1991) In this paper communication disorders following closed head injury are described and various forms of language assessment techniques are reviewed. The usefulness of conventional, pragmatic and cognitive approaches is considered. A ncw cognitive-pragmatic approach is then advocated which is an amalgam of the last two approaches. From the examples given it is argued that such an approach is practical in terms of: 1) incorporating knowledge of co-existing cognitive deficits; and 2) focusing on normal everyday communication practices. It is also suggested that the use of a cognitive-pragmatic framework has potential in refining remcdiation and management strategm with the closed-head-injured population.
The nature of the problem Aphasic disorders in closed head injury (CHI) occur relatively infrequently in the acute phase of recovery and are followed by a variable recovery course [l-31. None the less, it has been the impression of clinicians working with this population that there is often something wrong with a significant proportion of non-aphasic patients’ communication skills. Levin et af. [4],studying CHI patients one year post trauma, noted that many suffered inefficient filtering of extraneous material and that their conversation would frequently drift to irrelevant topics. Thomsen [ 5 ] , interviewing CHI victims years after their head injury, found that, despite the absence of aphasic symptoms, many patients were slow in their responses and required frequent repetition of questions. Their expressive speech was characterized by numerous pauses and a reliance on set expressions. They also tended to leave sentences unfinished. McKinlay et al. [6] reported that in a significant proportion of cases relatives complained of reduced fluency (44%) or excessive talking (26%) in the CHI patient. Prigatano et al. [7] described talkativeness, tangentiality, and the use of peculiar phraseology as characteristic of speech patterns after CHI. Milton and Wertz [8] also described many of the characteristics mentioned above, as well as problems assimilating and using contextual cues. The implications of persisting poor communication skills after CHI can be exemplified by Thomsen’s 10-15 year follow-up study of severely head-injured patients. She found Address correspondence to: Skye McDonald, Department of Neuropsychology, Lidcombe Hospital, Joseph Street, Lidcombe, 2141, New South Wales, Australia. 0269-9052/92 $340 0 1992 Taylor & Francis Ltd.
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that social isolation was the most serious handicap they faced [5]. A more recent study (91 found that even among severe CHI patients considered to have made a good recovery and to have attained ‘good’ reintegration, there were many that continued to suffer from social isolation and a drop in vocational status. As pointed out by Milton et al. [lo]: inappropriate management of communication exchanges by the head injured individual and the penalisation that follows often present a major barrier to social integration (p. 115).
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Longstanding communication disorders following CHI thus present a major challenge to rehabilitationists. Early identification and remediation of these disorders will be influential in maximizing the head-injured individual’s capacity to reintegrate into hidher social, vocational, and interpersonal worlds. Conventional approaches
Conventional language assessment models examine language production and reception in terms of phonological, semantic, and syntactical characteristics a t no greater complexity than the sentence. Most CHI patients will perform, overall, within normal limits on conventional aphasia batteries. They cannot therefore be considered aphasic on the basis of the batteries’ classification criteria. However their abilities on specific subtests are frequently below normal expectations. A significant proportion of severely head-injured non-aphasic patients have been found to have residual deficiencies in confrontation naming, word-finding or verbal associative tasks (4,11-15]. Subgroups of CHI patients have also been identified as performing poorly o n the Token Test, which is a structured test of comprehension (4,11-15]. These specific disturbances do not, however, reflect the nature of extent of clinically observed communication disorders. As an advance on this traditional mode of assessment, there is growing recognition that two additional factors are important to consider in functional language assessment following head injury: pragmatic language processes and coexisting cognitive impairments. Pragmatic approaches
The realm of pragmatics has steadily influenced the development of new techniques with which to assess communication disorders following brain injury. Pragmatic approaches enable a broader focus to be taken on the range of communication disorders seen and mirror similar research advances into understanding normal communication functions. Pragmatics, broadly speaking, is the study of language use 1161. The discipline is a divergent one encompassing dimensions such as the relationship of linguistic structure to function [17], the influence of non-linguistic contextual cues o n the conveyance of meaning and the resolution of ambiguity [16, 181 and the study of communication behaviour between speakers [19-251. Pragmatics is thus concerned with the ongoing interaction of language with the context in which it occurs. Because pragmatic theory focuses on dynamic aspects of communication, it is a valuable framework with which to assess everyday language use. For example, in a great deal of normal communication the meaning intended is not simply the literal one but rather a constellation of meanings conveyed by the interaction of the utterance with its context [19, 261. ‘Can you play tennis?’ will have different meanings depending on whether it is said in the vicinity of a tennis court as an invitation to play, or as a conversational remark in a living-room.
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Other meanings are also constructed from the particular form the message takes; for example, while a family member may be tolerated if she asks ‘What time is it?’, this message may be considered an affiont to a stranger stopped on the street. In the latter case the same message would be normally constructed more formally and politely, such as ‘Excuse me, could you tell me the time please?’ In this example the form of the message is adapted to acknowledge the social relationship between the speakers 122, 271. Pragmaticists have also argued that the manner in which the utterance is constructed is important to enhance its clarity and avoid ambiguity. Grice [20, 211 identified four maxims of cooperative conversational practice that were normally adhered to by speakers. These incorporated the requirements that the speaker say as much as is necessary, no more and no less, say only what is relevant to the context, and speak truthfully in an organized and unambiguous manner. As a development of these principles of language structure it has been argued [17, 281 that normal conversation is organized in a manner that provides the given (old) information at the beginning of an utterance followed by the new information; for example, ‘the client who rang yesterday caNed back today’. By constructing utterances in t h s way speakers provide their listeners with a context to facilitate their comprehension of novel material. Not only is the language structure within a clause complex organized to enhance clarity, but linguists have demonstrated that lexical and grammatical devices operate throughout the entire length of any discourse to form chains of semantic continuity linking non-adjacent clauses and clause complexes. These non-structural components are necessary to enhance the cohesion and coherence of an extended discourse [17, 331. The nature and position of devices used by normal speakers depends heavily on the context and function of the communication act. Pragmatic theory thus assigns a complexity to even apparently simple, normal communications. Inability to appreciate pragmatic requirements when formulating an utterance or, alternatively, when interpreting an utterance, will lead to failed or clumsy communication. There have been a number of clinical researchers interested in pragmatic approaches to the assessment of developmental and acquired language disorders following brain damage. Prutting and Kirchner [29, 301 developed a ‘Pragmatic Protocol’ on the basis of an extensive review of the pragmatic literature and modified in response to clinical trials. The protocol, designed within a speech-act theory framework, was used to classify attributes of spontaneous conversation, including the interactional behaviour between speakers. Language was deemed appropriate or inappropriate to the context. Milton et al. [lo] applied this protocol to assessment of language in the CHI population and reported inadequacies in areas such as topic selection, topic maintenance, and turn-taking initiation. Snow et al. [31] described a checkhst devised by Damico [32] based on Grice’s cooperative principles of conversation. They applied this to a number of CHI patients across a variety of communication tasks. Their preliminary results using this procedure indicated that particular CHI patients had discourse impairments in areas such as topic maintenance, informational redundancy, insufficiency, and non-fluency. Finally, Mentis and Prutting 1331 examined narrative and procedural discourse of CHI patients in terms of linguistic cohesion [34] and reported differential reliance on particular lexico-grammatical cohesive devices by CHI patients compared with controls.
Cognitive approaches
A further consideration in the assessment of communication skills following CHI is the likely impact on communication of other cognitive impairments. Closed head injury,
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frequently a consequence of hgh-velocity motor-vehicle accidents, may result in a diverse range of cognitive deficits due to the multi-focal nature of the cerebral insult. Nevertheless there is a preponderance of frontal and temporal lobe pathology. While temporal lobe pathology is associated with disorders of memory and new learning, frontal lobe impairments frequently result in disorders of attention and concentration, slowed information processing, rigd, inflexible, stimulus-bound behaviour, an inability to assume the abstract attitude, and a general failure to deal with novel problemsolving situations adaptively [35]. Such deficits also disturb the head-injured victims’ ability to monitor and regulate their behaviour and may produce disorders of inhibition and impulse control [36]. The particular constellation of cognitive deficits experienced by any individual will only be discerned accurately by appropriate neuropsychologcal assessment. However, with the general understanding that these types of deficits are commonly seen following head injury, the implications of such impairments for communication ability must be considered. Cognitive impairments are likely to contribute to, or, indeed, in some cases underlie, communication disturbances following head injury [37]. In recognition of this, Hagan [38-401 has reported a cognitive approach to the assessment of language disorders following closed head injury. He developed categories with which to classifj both the patients’ behaviour and their functional communication level. These categories were developed from a cognitive perspective on language. Cognitive deficits in areas such as attention, sequencing, memory, categorization, and associative abilities were translated into characteristics of language disorganization. Apart from behavioural observation, direct assessment of language function was achieved via a range of existing intelligence and psycholinguistic tests. There is scope, however, to become more specific regarding the impact of different forms of cognitive impairment on communication. This can be facilitated by differentiating between types of communication acts and their specific pragmatic requirements. Cognitive-pragmatic approaches
Cognitive-pragmatic language tasks are those that require particular pragmatic processes which have been judged to be vulnerable to specific cognitive disturbance. They therefore represent an amalgam of the above two approaches. The advantage of this type of assessment procedure is two-fold. First, it differentiates between different communication contexts and their relative pragmatic demands. Second, it recognizes that particular cognitive deficits may be disruptive in one communication context but not another. Using a number of such tasks it is possible to document the influence of various cognitive impairments in producing different types of communication disorders. This greater accuracy in assessment should facilitate the identification of specific targets for remediation. In order to illustrate this approach, examples of cognitive-pragmatic tasks are set out in the following section. To date, these tasks have been designed to focus on frontal lobe deficits only. The impact of temporal or other pathology on communication awaits further study.
of cognitive-pragmatic approaches to assessment fo meet the informational needs of the listener Examples
1 . Ability
The conversational maxim of manner described by Grice [20, 211, namely, that a speaker must be ordered and avoid ambiguity, has ramifications for the C H I individual who is
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concrete with impaired planning ability. Furthermore, a failure to adhere to this principle may be less important in casual conversation than when the discourse is task oriented; for example, providmg a listener with instructions. In order to assess this, a head-injured individual was selected who had predominantly frontal lobe impairments as assessed by neuropsychological assessment. His deficits were characterized by rigidity, perseveration, and poor planning and problem-solving skills. He was also considered to be quite impaired in terms of communication ability. He was asked to describe how to play a simple, yet novel game to a blindfolded listener. A group of non-brain-damaged subjects also performed this task for comparative purposes. The productions were transcribed and given to judges to rate in terms of their organization. Without knowing the identity of the subjects or the texts, the judges universally rated the head-injured text as extremely disorganized, confirming that the patient had difficulty adhering to Grice’s maxim of manner. An analysis was subsequently performed on the sequencing of the informational content in the texts expressed as propositions. The propositional analysis revealed that the CHI patient made specific errors in the sequence in which he described the procedure. He also focused on irrelevant propositions at crucial points in his explanation. Whereas the non-brain-damaged subjects’ explanations incorporated from 16 to 28 propositions in total, the CHI subject produced 54 propositions, 28 of which were repetitions. Furthermore, the sequence of these was revealing in terms of the specific difficulty the subject was having with perseveration. In the first 20 propositions he made 18 novel propositions and repeated himself twice. In the next 34 propositions he made a total of 8 new propositions and 26 repetitions. From the subject’s performance on this task several important features emerged. First, it was ascertained that frontal-lobe injury in this case had affected the head-injured subject’s ability to adhere to the maxim of manner. Second, it was revealed that, counter to expectations, this was not due to his inability to develop a plan for h s communication per se. He was sensitive to the d e n t information needed for an adequate explanation and incorporated this. O n the other hand, errors in sequencing and inclusion of irrelevant material were indicative that he had trouble monitoring his output and keeping ‘on track‘. It also revealed that perseveration was in fact a secondary problem which manifested only when his communication plan had run its course. Because he failed to monitor his production accurately, he failed to discern that his explanation had finished, and consequently continued on in a repetitive, disjointed, and unplanned manner. Having identified these particular areas of deficit, remediation strategies could be made quite specific.
2. Ability to negotiate requests Brown and Levinson [22J describe the systematic manner in which people phrase their utterances in order to avoid offending the listener, or, alternatively, to improve their own standing in the listener’s eyes. These strategies have been loosely termed politeness. The selection of particular polite devices depends on the social distance between listeners, the cultural imposition that their speech act entails and the power relationship between them. Appropriate selection thus requires dynamic appreciation of a number of contextual factors. Given that frontal lobe impairment can lead to rigid thought processes and loss of flexibility, there may be certain CHI patients who cannot produce effective, socially acceptable utterances. We explored this by focusing on two head-injured subjects with overlapping but different constellations of frontal lobe deficits as weII as demonstrable
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problems in everyday communication. One CHI subject was particularly concrete and perseverative. The other subject, while less impaired in terms of abstraction skills, had major deficits of impulse control. Matched control subjects also took part. The subjects were asked to formulate polite requests under a variety of circumstances (such as aslung a stranger the time, aslung a farmly member to turn the radio down). Despite the varying demands of each request, the two CHI subjects produced adaptive and effective responses. From this we surmised that, to a great extent, the formulation of simple conventional requests was an automatic or overlearned process unaffected by their frontal pathology. We then increased the demands of the task by insisting that requests were made in the form of hints. A common strategy used by the non-brain-damaged control subjects on thus task was to formulate their hints by referring to some logically prior condition that preceded the desire to make the request. For example, when required to hint that the listener should buy the speaker a drink, several normal speakers simply stated that they were thirsty. When requested to hint to a partner that the speaker wanted to go home, many normal speakers referred to the fact that they were tired. In contrast to this, neither CHI subject referred to contextual cues that were either logically or conceptually removed !?om the actual request. Nor could they refrain from developing their request to the point of stating their intention baldly, and were overall unable to make effective hints. As a consequence of this we concluded that fiontal lobe impairment, particularly loss of abstraction ability and disinhibition, as manifested in these two subjects, disrupted their ability to communicate non-conventional indirect meaning. Given that a great deal of communication in everyday social contexts relies on innuendo, inference, and indirectness, this has major ramifications for their communication skill. Furthermore, because this inability can be linked directly to their known cognitive deficits, the targets for rehabilitation are clear.
3 , Appreciation ofconversational implicature The preceding study revealed that frontal-lobe injury in the patients tested affected their ability to express themselves indirectly in novel situations. It was also of interest to determine whether the failure to produce indirect language was mirrored by a failure to understand it. A simple means to explore this was to focus on sarcasm. According to Grice, indirect conversational implicature such as irony is understood by: 1) processing the literal meaning; 2) deciding that it is inappropriate in the context; and 3) substituting it for another non-literal meaning which, in the case of sarcasm, is usually the opposite. Rigidity of thought processes after fiontal lobe damage should make this transition difficult. In order to explore this, a task was designed in which the two subjects who took part in the previous study were asked to interpret a pair of sentences. The first sentence acted as the context and the second was a response that was either literally consistent with the meaning of the first, e.g. Sentence 1. ‘What a huge meal’. Sentence 2. ‘You don’t have to eat it ail.’ or that conflicted with it, in which case one or other of the sentences could be interpreted as a sarcastic retort, e.g. Sentence 1. ‘What a huge meal.’ Sentence 2. ‘Don’t worry there’s more to come.’
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A normal control group also performed this task. As predicted, the two CHI subjects could interpret the meaning of the literally consistent sentence pairs but, in contrast to the controls, were completely unable to resolve the disparity between the inconsistent sentence pairs and at no time recognized that the interaction was a sarcastic one. From their performance on this task, it appears that not only are they unable to make nonconventional indirect references, but they also cannot understand them.
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Future directionsfor cognitive-pragmatic assessment$
The above examples demonstrate the usefulness of applying pragmatic theory to an understanding of cognitive function in order to elucidate the communication disturbance. The studies described represent only initial steps along this path. There is scope to explore the relative contributions of other frontal lobe impairments such as inertia and attentional disorders on select pragmatic tasks. There is also a need to elucidate the role of different cognitive processes, in particular, memory function, in the maintenance of effective Finally, the realm of pragmatics offers a wide variety of speech communication SMS. contexts to choose from in order to explore further the impact of particular frontal lobe processes on different speech acts. For example, it would be interesting to explore whether the two subjects described in the last two studies had greater or less difficulty formulating complaints in common situations (such as returning a faulty item to a retad outlet) compared with their inabdity to formulate indirect requests. It is anticipated that the patient who experienced differentially poor frustration tolerance and impdse control would find thls task particularly difficult compared with the CHI subject with problems of inertia and perseveration. By designing tasks systematically to test these hypotheses, a rich body of assessment materials can be amassed to further our knowledge in this area. Implications for therapy The assessment of cognitive-pragmatic language skills is not only a useful means to delineate accurately the type of communication hsorder seen following closed head injury, but it also has applications to the rehabltation of closed-head-injured patients. Rehabilitation of communication has tradtionally focused on three levels; retraining of the deficit slulls, usually by repetitive exposure; training of dternative strategies to overcome impairments; and management of the patient’s environment so as to ameliorate the impact of hidher deficits on hidher Ue. The usefulness of direct retraining in other language disorders, such as aphasia, is a controversial issue. Direct retraining of communication hsorders that may be a result of frontal pathology is patently unlikely to succeed. The frontal lobes are mainly involved in detection and adaptation to novel situations. The idea of retraining ths capacity by repetitive exposure is therefore paradoxical. Consistent with this position, fkontal lobe hnctions, such as executive control and conceptual abilities, have been reportedy resistant to direct therapeutic intervention [41j. Development of alternative strategies to overcome impaired frontal processes may prove a more fruitful avenue. Ylvisaker and Szekeres [42] have described a variety of interventions designed to improve self-monitoring and self-evaluation in communication. These incIude the use of progressive feedback from the therapist to help orient the patient to h d h e r strengths and weaknesses. They also advocated the use of external feedback such as graphs and charts and the development of self-questioning strategies to improve monitoring. Other researchers have reported the use of groups to improve awareness of
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communication practices. Gajar et al. [43] utilized either therapist-controlled or groupcontrolled feedback in the form of light signals to improve group conversational skills. Ehrlich and Sipes 1441 have advocated the use of role models and role plays to provide strategies and feedback. So a variety of techniques are being developed to address remediation of communication skills afier CHI. These techniques are also aimed at improving skills within a social context. Detection of communication incompetencies and feedback on therapy in all cases described was reliant on listener intuition, although observations made by Gajar et al. [43] and Ehrlich and Sipes [44] were guided by discourse theory. While obviously this is an ecologically valid approach, there is also room for further specification of the communication behaviours observed. The communication pattern can be evaluated more accurately using a pragmaticcognitive approach, that is 1) specifying the particular cognitive impairment the patient is suffering; 2) specifying the particular pragmatic demands of communication tasks he/she is faced with; and 3) anticipating how the cognitive impairment will be manifested in the patient’s communication output. Once these parameters have been defined, a new source of potential feedback to the patient becomes available to provide an external source of monitoring. A pragmatic analysis of each communication task attempted will also provide explicit information for the development of effective communication strategies. The third direction of rehabilitation involves the re-integration of the patient into h s / her social environment. As part of this process counselling and educational input to the family of the head-injured patient is integral [45]. The implications of cognitive-pragmatic disorders for communication breakdown between family members and the C H I individual are clear. Constellations of frontal lobe deficits may lead to failure of the C H I patient to detect nuance, implicature, hints, and so on, and may simultaneously result in a blunt and ineffective communication style. By educating the family specifically about such deficits, potential misunderstandings can be minimized and the family’s use of overly complex or subtle communication strateges avoided. Once again a specific knowledge of the patient’s strengths and weaknesses across different social contexts as provided by cognitivepragmatic assessment will facilitate this process.
Conclusion The studies described represent only the beginning stages of this field of enquiry. There is a great deal of scope to explore the impact of a variety of cognitive deficits on communication skills in a broad realm of contexts. By pursuing a cognitive-pragmatic approach to language assessment and rehabilitation following closed head injury, the emphasis will remain practical and relevant, while incorporating an understanding of co-existing cognitive deficits. Not only will such investigations be informative regarding the conlmunication difficulties head-injured patients experience, but they will also further our understanding of the nature of normal communication practices.
Acknowledgements The research described in t h s paper was funded by the Commonwealth Department of Health and Community Services (RADGAC) and Lidcombe Hospital. The author would like to thank Associate Professor Peter van Sommers and Professor Max Coltheart for advice on methodological issues and Dr Robyn Tate and Dr Shane Darke for their helpful comments regarding the manuscript.
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