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Nonlinguistic elements of communication
Prosody
Facial expression
Body language
Emotion
Math/Visuospatial Skills
Perception of depth, distance, shapes
Localizing targets in space
Identifying figure-ground relationships
4
4
Processing melody of music
Assembling small details for perception of a larger
picture
Macrostructure/gestalt
5
5
Group of deficits or changes that may occur following insult
to a person’s right cerebral hemisphere
Usually not involved with language-related deficits
Right hemisphere strokes may leave intact functional language
abilities if left hemisphere is untouched
6
6
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Any etiology that damages right hemisphere
Stroke
Disease
Trauma
Seizure disorders
Infection
Toxicity
Level of deficit or disorder depends on the location and
extent of damage
7
7
8
8
Insensitive to others, preoccupied with self
Oblivious to social conventions
Unaware of or inattentive to their physical and mental limitations
Verbose, tangential, and rambling speech
Insensitive to the meaning of abstract or implied material
Unable to grasp the overall significance or meaning of complex
events
9
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Some are behaviorally passive
Unresponsive to social or environmental stimuli
Use short utterances that lack emotional inflection
Have difficulty maintaining attention for more than a few seconds
10
Patient and Therapist
http://youtu.be/YgfSgn0Brmc
11
Two patients with RHD
http://youtu.be/d4FhZs-m7hA
12
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Manifest themselves in the realm of pragmatics
Areas of deficit which affect communication include:
Facial recognition
Comprehension of facial expressions
Production of facial expressions
Comprehension of prosody
Production of prosody
Inferencing
Discourse
13
13
Ability to process visual information of facial features and
spatial relationships is a refined skill that can be lost
Visual agnosia
Ability to recognize faces is important in discriminating
familiar/non-familiar faces
Prosopagnosia
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14
HTTP://YOUTU.BE/VWCRXOMPBTY
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Prosopagnosia is not due to difficulty with the eyes but with the
brain
Damage to visual association areas in occipital lobe that are used to
process/interpret visual info from the eyes
Individuals with prosopagnosia may not recognize others visually
by their face, but they may recognize them by voice, smell,
clothing, or other distinctive features
Individuals with prosopagnosia are able to recognize other
objects, just not faces
16
16
Right hemisphere allows us to evaluate facial expressions
Difficulty interpreting facial expressions and identifying
emotions conveyed on the faces of speakers
Facial expression may be used to reinforce or alter the
meaning of verbal utterances
Inability to process the emotions expressed by facial
expressions restricts individuals to a less informed and more
literal interpretation
17
17
Right hemisphere controls the left side of the face
More emotional expression is displayed on the left side of the face
than on the right side
Damage to right hemisphere limits expressivity on the left side of the
face
Individuals with right hemisphere deficits may present a flat affect
and reduced facial expression
Social interactions may be difficult
18
18
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PROSODIC DEFICITS
There are two components to speech:
Linguistic
Language
Prosodic
Pitch, stress, timbre, cadence, tempo:
Infuses words with emotion
Individuals with right hemisphere disorder may have difficulties
processing prosodic components of speech
May be unable to identify emotions associated with an utterance, constraining
these individuals to literal interpretations of verbal language
Misinterpretations of sarcasm and figurative language negatively impact
communication
19
19
PROSODIC
Aprosodia
• Difficulty interpreting prosodic and facial and situational cues that signal the
emotional content of the message.
Individuals with right hemisphere deficits may seem monotone and
emotionless, though they still possess the full range of emotions
May be experiencing higher levels of negative emotion due to right hemisphere
disorder, though may not be able to convey those emotions with prosody of speech
Difficulty using prosody to express emotion
20
20
Ability to take previous knowledge and experience and
apply it effectively to the interpretation of small details
Allows for perception of macrostructure (gestalt)
Inability to read facial expressions may be due to inability to
infer meaning of facial expression
Inappropriate perception of humor and sarcasm may be due
to inability to interpret nonliteral language and infer the true
meaning of language
21
21
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Tendency to lend a literal interpretation to figurative language,
Difficulty grasping figurative and implied meanings in narratives, humor
and in conversation, particularly with interpretation of idioms,
metaphors and figures of speech.
22
• Tend to respond only to the literal interpretation of what they see or
hear.
• Tend to focus on irrelevant or insignificant details and fail to
synthesize information in discourse, whether in narrative or
conversation.
23
• There is an impaired ability to understand humor or sarcasm is a
hallmark of right-hemisphere damage.
• https://youtu.be/KzCIRWUGgVs
24
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• Some adults react to cartoons with unrestrained hilarity
• Humor production observed to be, at times, disinhibited, crude,
suggestive or otherwise inappropriate in some adults with RHD.
25
The exchange of communicative information from speaker to
listener
Most common discourse deficits in those with right hemisphere
deficits include:
Lack of sensitivity to shared knowledge
Difficulties with turn-taking
Difficulties with topic maintenance
26
26
• Difficulties when discourse contains ambiguous or conflicting
elements that make multiple interpretations possible.
• Consistent deficits in discourse:
Diminished informational content
Difficulty telling a coherent story
Excessive detail and over personalization have been reported
27
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Prutting & Kitchner, 1987 Tompkins (1995)
Proxemics • Impulsive
Gesture • Talk excessively
Question formulation • Interject irrelevant and inappropriate
comments
Topic change
• Generate impulsive responses
Appropriate topic
selection and • Difficulty with turn-taking
maintenance
• Topic maintenance
Repairing
misunderstandings
through turn-taking • Maintaining eye contact
28
• Ulatowska, Oleas Santos, Reyes, Garst, & Davis (2013)
Procedural Discourse in Adults with Aphasia and Right Hemisphere
Disorder
29
• Pragmatic Deficits cont…
A tendency to over personalize external events
A reduced sensitivity to the communicative situation or to the pragmatic
aspects of communication
Difficulty understanding and producing indirect requests ("Can you
pass the salt?")
A decreased sensitivity to listener needs and situations
30
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Simultagnosia
Cerebral achromatopsia
31
31
Inability to visually perceive multiple details at one
time, often due to lesion at parietal-occipital area
32
32
Rare loss of color vision due to trauma or damage to the cortex
Individual only sees the world in shades of gray
33
33
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Neglect
Sustained and selective attention deficits
34
34
Inability to attend to sensory stimuli from
one side of their body (body neglect)
environment (hemispatial neglect)
Side unattended to or unrecognized is the side of the
body/environment that is contralateral to lesioned
hemisphere
Most commonly neglected side of body/space is the left
side due to right hemisphere lesion
35
35
• Neglect is a perceptual disorder following right parietal
lesions.
• Patients may
Have impaired use of margins and punctuation in writing
Fail to attend to the left side of space
Have impaired localization skills
Fail to look to the left side of a page while reading and omit the left
when drawing or copying a figure
36
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Somatophrenia or body-centered neglect
The individual is unable to perceive their own body parts as
being part of themselves
Neglected body parts often display hemiparesis
Motor function may remain intact for neglected limbs
though the limbs may remain unutilized
Motor neglect is diminished use of a neglected limb despite
being motorically intact
37
37
Mild cases of hemispatial neglect may be known as
extinction
Individuals may be able to attend to neglected side with prompting
38
38
Lady with Left Neglect
http://youtu.be/ymKvS0XsM4w
39
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• Poor performance when
drawing or copying geometric designs
creating designs with colored blocks
copying two-dimensional stick figures
reproducing three-dimensional constructions using wooden blocks.
40
Jeong, 2016 Bogen, 1969
41
41
Necessary for attending, processing, and understanding
language, important social cues, and social interactions
Deficits in selective and sustained attention may cause
individuals with right hemisphere lesions to
miss relevant information,
be distracted by irrelevant stimuli, and
further lose track of what is being spoken of
42
42
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Disorders of Visual Relationship Site of Lesion
Processing to Language
Disorders of gaze stability Causes problems Frontal lobe eye fields
in reading
Disorders of visuospatial Alexia Hemialexia can results from lesions to the
processing splenium of the corpus collosum. Visuospatial
alexia can occur from lesions in the right
occipital cortex or from subcortical
disconnenctions.
Agraphia Visuospatial agraphia results from lesions to
the frontoparietal or tempoparieto-occipital
areas.
Disorders of visuosymbolic Acalculia Left or right hemispheres,anywhere
processing
43
It is important to understand and recognize disorders which
may present alongside and interact with deficits and disorders
that more highly concern SLPs
Anosognosia
Depression
Capgras delusion
Fregoli delusion
Visual hallucinations
Paranoid hallucinations
44
44
An individual’s inability to recognize/realize they have
deficits
These patients usually are calm and assured that if there
is a problem it does not have anything to do with them
45
45
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• Difficulty expressing emotions through the use of the prosodic feature of speech
• Lack of inappropriate intonation to convey happiness, sadness, surprise, anger, or
disappointment
• Flat affect and monotone speech
• May appear to be clinically depressed
• Problems with comprehension of prosodic variations
(particularly in those with temporoparietal lesions
46
Common in any population following disease, surgery, stroke, or
trauma
May go unnoticed or masked by other deficits in those with
right hemisphere disorders
If depression is suspected, SLP must refer to appropriate mental
health authorities
47
47
• Hypoarousal
Decreased movement, speaking, or initiation of behaviors
Abulia
A profound passivity and indifference to their environment
48
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Belief that loved ones, significant others, or family members have been
replaced by imposters who look and sound like the original person
May present in those with epilepsy, TBI, stroke, or acute lesion to right
hemisphere
Current explanation involves disconnection of the area of the brain
responsible for processing faces and the area of the brain responsible for
producing normal emotional response in reaction to seeing the face
49
49
HTTP://YOUTU.BE/ENCCAHIOLBC
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50
FREGOLI
The delusional belief that a familiar person is able to take on the
guise of another person, at times many other people, and assume
their exact appearance
Often accompanied by a degree of paranoia
51
51
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When an individual is perceiving something visually that does
not exist
Due to lesions or seizure activity usually in posterior right
hemisphere among visual processing areas
Nature of hallucinations vary widely and unpredictably among
individuals
52
52
Visual and/or auditory
Perceived as threatening, ominous, or foreboding
53
53
54
54
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Informal testing
Formal testing
55
55
Present pictures of family members, friends, or famous
individuals the patient would have knowledge of and ask the
patient to name the individuals in the photos
56
56
Comprehension
SLP makes faces or presents photos of faces denoting certain
emotions and asks the patient to name the emotions being
conveyed by the faces
Expression
Asking patient to produce facial expression to match a certain
emotion
57
57
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Comprehension
Taking a phrase and varying the
meaning of the phrase by altering
intonation and then asking the patient
for interpretation of emotion being
conveyed
Production
Listening to connected speech of
individual to check for abnormal level
of monotone
Ask patient to vary prosody to convey
different emotional meanings Yorkston et al, 2011
58
58
Presenting simple inferencing tasks such as
“It is snowing; the kids are wearing heavy coats. What
season is it?”
Or a Norman Rockwell painting
59
59
Observing and recording the patient as they communicate with
others
Engaging the patient directly in conversation for an extended period
of time and noting any abnormalities in discourse
60
60
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Cancellation Tasks
Patient must circle or cross out certain stimuli on a page
Line bisection
Patient puts a mark in the center of a long horizontal line
Copying line drawings
Patient copies drawing of house, flower, clock, tree
61
61
Baking pan task
Patients must evenly distribute blocks within a baking pan
Observe and search for signs of neglect in activities of daily
living
Shaving, eating, putting on makeup, walking, navigating
62
62
Card sorting tasks
Sustained attention:
e.g., sort cards into suits or color without competing stimuli
Selective attention:
e.g., sort cards into suits or color with radio as competing stimuli
63
63
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Card sorting
Alternating attention:
e.g., sort cards by suit and when given a cue, shift to sort cards by color
or number and then back to sort by suit
Divided attention:
e.g., sort cards in a certain way while simultaneously attending to a
short story and answer questions as the sorting is completed
64
64
• Auditory comprehension of complex material
• Word finding, word fluency, and body part naming
• Oral sentence reading
• Writing problems, such as, grapheme substitutions and omissions
• .
65
65
66
66
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Good for assessing aspects of language not
typically addressed in aphasia tests
Right hemisphere tests usually assess humor,
metaphor, sarcasm, facial expression, and
prosody
Right Hemisphere Language Battery (2nd
ed)
Mini Inventory of Right Brain Injury (2nd
ed)
Communication Activities of Daily Living
(2nd ed)
Arizona Battery for Communication
Disorders of Dementia
Ross Information Processing Assessment
(2nd ed)
67
67
Voice
Aprosodia Battery (Ross, Thompson, & Yenkosky, 1997)
Assesses repetition of affective prosody, identification of affective prosody, and
discrimination between two sentences spoken in different prosodic tones.
Assesses ability to understand gestures associated with emotional states.
Prosody-Voice Screening Profile (PVSP; Shriberg, Kwaitowski, & Rasmussen,
1990)
Assesses prosodic and vocal characteristics of the speaker. Measures vocal quality,
pitch, loudness, phrasing, and rate.
68
68
The Pragmatic Protocol (Prutting & Kirchner, 1987)
Permits assessment of conversational behaviors that are likely to be affected by right-
hemisphere injury
Communication Activities in Daily Living—Second Edition (CADL-2; Holland,
Frattali, & Fromm, 1998)
Designed to assess functional language in individuals with aphasia, but may be used to
assess communicative effectiveness of adults with right hemisphere brain injury
69
69
23
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70
70
Expression
Teach patients to produce facial expressions reflecting their true
emotional state
Do not use with severely affected patients or those with an
emotional disorder such as depression
71
71
72
72
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Expression
Educate patients on the use of prosody and teach to explicitly
communicate their emotional state to their family
Read a short story and then be cued to produce the final quote by
a character with appropriate emotional prosody
Comprehension
Discriminate changes in pitch or prosody by listening to SLP
produce the same utterance multiple times with varied (or not
varied) prosody
When patient can discriminate, the patient verbally models the
utterances and the differences back to SLP
73
73
Use of Norman Rockwell illustrations to
put together appropriate clues and
details to reduce inferencing deficits and
improve use of inferencing during
discourse
Present short stories or pictures and
have the patient generate appropriate
titles for the stories or pictures
74
74
Increase the patient’s awareness of listener’s
needs, social conventions and expectations, and
increasing theory of mind.
75
75
25
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Teach overt rules of social interactions
Ask the patient to view and analyze the prerecorded
actions among individuals
Individual must then apply those social skills to their own
interactions to detect and repair problems they may have
socially
76
76
Visual Scanning Therapy (VST)
Give task that requires shift of
attention toward/into neglected
space for completion
Shift attention far enough left
to find edge of book
Relies on heavy verbal cueing
Poor generalization to activities
of daily living due to cueing
77
77
Edgeness
Flat container with raised edges (baking pan) and small
blocks are used for patient to find blocks spread across the
pan
Difficulty level can be altered
Does not rely on heavy verbal cueing from clinician and
therefore has better generalization
78
78
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Sorting tasks
Patient must maintain attention long enough to successfully
complete the task
Trailmaking tasks
A paper and pencil task where the patient must connect randomly
printed stimuli in sequential order
79
79
1 5
9
2
3
11
8 7
6
10
4
80
80
1 C
5
A
2
3
4
D
B E
81
81
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Auditory drills
SLP recites strings of names, letters, or numbers, with
the patient instructed to respond to only
predesignated target stimuli
Simple card and board games with set rules
Tic-tac-toe, checkers, etc.
82
82
Tasks that add competing/distractor stimuli to a sustained attention
task
Tasks that require the suppression of distractor for correct
completion
Stroop task
Green Red Blue Purple
83
83
Speak clearly to patient
Speak to the patient one person at a time
Speak in short and easy-to-follow sentences while giving
repetitions and frequent breaks
84
84
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Activities that require multi-tasking
85
85
SLP can reduce distractions in the environment
Close blinds
Shut off television
Instruct/educate the family to
Speak clearly to patient
Speak to the patient one person at a time
Speak in short and easy-to-follow sentences while giving repetitions and
frequent breaks
86
86
Counseling and coaxing individual to recognize and
take ownership of deficits
87
87
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Mr. Williams came to the hospital following a stroke in the right hemisphere.
Nursing reports his communication is fine and the physician only refers him for a
swallowing eval and excludes language/cognition. During the swallow eval, you
begin notice…….
As the SLP, what would be our first assumption about Mr. Williams in terms of
communication?
You decide to do a screening. What would you do first?
Your screening leads to a referral for a speech evaluation. What areas would you
assess and what would you use?
Provide an activity to address a linguistic or nonlinguistic characteristic of RHD.
88
88
30
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