Management of Discourse Deficits following Traumatic Brain Injury: Progress, Caveats, and Needs

ABSTRACT

Currently, there is substantial evidence to support the assessment of communication, following traumatic brain injury (TBI), beyond what is included in standardized aphasia or child language batteries. The sensitivity of discourse analyses for delineating subtle cognitive-communicative deficits is well established in the research literature. A variety of useful monologic and conversational discourse measures have been identified including productivity, efficiency, content accuracy and organization, story grammar and coherence, and topic management. Disruption of discourse may persist for years after TBI and appears to have a negative impact on quality of life. Although discourse analyses have great potential for clinical application for individuals with TBI, their widespread use has been limited by time and training constraints. A further limitation is that there is no empirical evidence to guide the treatment of discourse deficits. There is need for the development and investigation of theoretically based interventions.

KEYWORDS

Discourse - treatment - traumatic brain injury

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APPENDIX A

Samples of Monologic Discourse

The samples of monologic discourse that follow are narratives elicited in a story retelling task. The task was a portion of the experimental protocol from Phase III of the Vietnam Head Injury Study. All participants were 35 or more years after the onset of severe penetrating head wounds. Participants watched a picture story that had no soundtrack, Old MacDonald had an Apartment House,[46] presented on a 17-inch computer screen in a PowerPoint format. When the story was over, they were then asked to retell the story. Information regarding all of the analysis procedures described may be found in Cherney, Shadden, and Coelho.[19]

Sample 1. Relatively normal grammatical complexity (subordinate clauses/T-unit = 0.30)

• 1. The farmer and his wife just moved into an apartment building in the city

• 2. She was maintaining the house

• 3. and he was a gardener on the outside planting

• 4. and before too long he started doing the vegetables in the house

• 5. and doing the farm animals in the house

• 6. and the person who owned the building wasn't so pleased with his actions and his way of doing things

• 7. and plus the people in the neighborhood

• 8. but when he harvested the vegetables he began to sell them

• 9. and the person that owned the apartment house figured he can make money this way

• 10. so this is when he started to become happy

• 11. so he continued on doing this

• 12. and they were very happy

Sample 2. Decreased grammatical complexity (subordinate clauses/T-unit = 0.13)

• 1. Old McDonald and Mrs. McDonald had an apartment

• 2. and they had one room that was not rented

• 3. so they went to this room and grew plants on the table

• 4. and Mr. McDonald went out and cut the trees down

• 5. and they put a garden outside

• 6. and the other tenants didn't like this garden until this garden grew fresh fruit and everything

• 7. and they weren't real happy with it

• 8. so Mr. McDonald moved the dirt and everything inside

• 9. and they was growing the plants inside

• 10. and everything went well until the roots come through the ceiling of the apartment below

• 11. and this made the people awful mad

• 12. and cows come in and wanted the roots

• 13. they got the cows back out in the barn

• 14. and then Mr. McDonald built a building to sell and put the fresh fruit in this building to sell

• 15. and then the people were happy with this fresh fruit because they could have fresh fruit and vegetables for their meals

Sample 3. Reduced verbal productivity

• 1. well let's see a man and a woman was uh doing something

• 2. he was picking fruit

• 3. and she was looking at a flower

• 4. and later she had uh an orange tree

• 5. and then he went and picked some vegetables

Sample 4. Poor cohesive adequacy (cohesive adequacy = 0.55)

• Cohesive markers that were judged to be incomplete or errors appear in italics and bold type.

• 1. Once upon a time there was a lady who tried to grow a plant.

• 2. and uh while she was trying to grow a plant there was somebody chopping a tree down

• 3. then later uh the plant grew up during May and June

• 4. and as it grew the idea of growing things caught on in the community

• 5. Pretty soon there people were growing vegetables in every conceivable place

• 6. vegetables were getting so large that they had carrots coming through the roof

• 7. and while that was going on there was also animals

• 8. one scene showed a man leaning up against a multistory building with cows looking out of windows

• 9. later on there was a man who had built a building

• 10. and was putting up a sign saying fruits and vegetables

• 11. next scene showed people very happy ‘cuz they didn't have to go in this house with animals to get their vegetables

• 12. they could go to one place to buy their fruits and vegetables

• 13. earlier in the story when the lady was trying to grow her plant it was five o'clock in the afternoon

• 14. when the plant grew that was April

• 15. Then in May you could see the plant on the table growing and that was five o'clock

• 16. and the man cutting down the tree that was about one thirty on that day

Sample 5. Good cohesive adequacy (cohesive adequacy = 0.82)

• Cohesive markers judged to be incomplete or errors appear in italics and bold type.

• 1. The McDonald's were looking for a place to stay

• 2. they found a home

• 3. and she wanted to grow something in the house

• 4. so she planted some flowers inside her house

• 5. and she couldn't get them to grow there wasn't enough light

• 6. Mr. McDonald went outside

• 7. and he cut the trees blocking the sunlight coming through the window

• 8. well that grew pretty well

• 9. after that went out and planted more plants

• 10. but trouble didn't grow outside

• 11. but had a lot of plants growing inside

• 12. so they had so many plants growing that the gentleman who owned the house left and left them the house

• 13. then they had plants all over

• 14. they had plants upstairs downstairs through the floor through the wall

• 15. because they were growing like mad

• 16. and anybody came to see the plants they were pretty

• 17. then there was a cow sitting on top of this footstool

• 18. but in the end she's growing plants on top of her table again

Sample 6. Good story grammar as evidenced by two complete episodes.

• 1. so they brung dirt in the house and started making gardens in the house

• 2. they grew tomatoes and mushrooms and cabbage and carrots and had cows and chickens in there

• 3. the wife was trying to scare crow from getting the corn that was in the living room

• 4. and they had stuff in the bathroom

• 5. and they expanded

• 6. and the neighbors got mad at them

• 7. and this supervisor came and looked at the buttons where the names were supposed to be

• 8. and they had vegetables and that on it

• 9. he got mad and threw them out

In the story narrative above, the first episode appears in T-units 1-6. The Initiating Event is in T-unit 1, the Action is in T-units 2 and 4, and the Direct Consequence was in T-unit 6. For the second episode, the Initiating Event is in T-unit 7, the Action is in T-units 7 and 8, and the Direct Consequence was in T-unit 9.

Sample 7. Poor story grammar, no complete episodes.

• 1. Once upon a time there was a lady who tried to grow a plant.

• 2. and uh while she was trying to grow a plant there was somebody chopping a tree down

• 3. then later uh the plant grew up during May and June

• 4. and as it grew the idea of growing things caught on in the community

• 5. Pretty soon there people were growing vegetables in every conceivable place vegetables were getting so large that they had carrots coming through the roof

• 6. and while that was going on there was also animals

• 7. one scene showed a man leaning up against a multistory building with cows looking out of windows

• 8. later on there was a man who had built a building and was putting up a sign saying fruits and vegetables

• 9. next scene showed people very happy ‘cuz they didn't have to go in this house with animals to get their vegetables

In the narrative sample above, the participant begins several episodes (as in T-unit 1) but does not integrate subsequent actions into a logical sequence (T-unit 2) nor he is he able to bring in a Direct Consequence (as in T-unit 3). Some of the information that is provided is inaccurate (as in T-unit 4, the McDonalds grew the vegetables, not the people in the community) and some is added but not integrated (as in T-units 6 and 7).

The discourse sample that follows is a segment of a conversation between the author and an individual with a closed head injury.

Sample 8. Example of analysis of conversation.

• Codes: (1) Speaker Initiations-OB = Obliges, COM = Comments;

• (2) Response Adequacy-AD + = Adequate plus response, AD = Adequate response,

• INAD = Inadequate Response;

• (3) Topic Initiations-N = Novel Topic Initiation, SS = Subtle Shift of Topic, DS =

• Disruptive Shift.

• E = Examiner, P = Participant with TBI.

• N OB E: How long have you been a priest?

• AD P: About 15 years

• COM E: Uh-huh

• COM P: Yes

• N OB E: and you grew up in New York?

• AB P: yes

• N OB E: Uh-huh and where did you go to seminary?

• AD + P: I started off in Orange in Orange, Connecticut…did what is called a novitiate which is sort of a the basic for a spiritual like we learn how to pray and we learn the first person the first time we're introduced to the community life we live with others and we're also given the explanation of what life of a priest is like receive a few of our classes or else I have the opportunity for doing some work with some other people in one of the local parishes maybe teaching what we call CCD religious instruction and in finishing my novitiate I made my temporary vows of poverty, chastity, and obedience for a span of 3 years then I continued my studies going to Salamenca, Spain where I studied 2 years of what we call Humanities Liberal Arts studies Latin, Greek, Art, and Literature.

• SS OB E: Now where in Spain is that?

• AD P: Salamenca

• OB E: What part of Spain was that?

• AD + P: Sort of the center an hour outside of Madrid. Use to have the old reputation of being a higher seat of learning.

• SS OB E: Uh-huh now while you were in Spain did you have the opportunity to travel much?

• AD + P: well within Spain we'd go for vacations in the northern part and that's probably about it no I didn't really.

• SS OB E: Now the other individuals you were studying with did they all come from the state or were they from all over?

• AD + P: No they're from all over pretty much Mexico, Spain, a few of them Ireland, and a few from the United States.