The meeting discusses cognitive-communication interventions for youth with traumatic brain injury

(TBI), focusing on individualized treatment approaches and the impact of various factors on recovery
and communication outcomes.
Cognitive-Communication Interventions for Pediatric TBI
This article reviews the importance of individualized cognitive-communication interventions for youth
with traumatic brain injury (TBI) to improve their long-term academic and social outcomes.
Individual Factors Affecting Treatment
Individual factors significantly influence the treatment planning for cognitive-communication disorders
in children with TBI.
Severity of TBI is predictive of cognitive-communication deficits, with children having moderate to
severe TBI showing reduced language production and poorer story recall.
Age at the time of injury impacts the development of skills, with early childhood TBIs affecting narrative
discourse and high-level language skills.
Contextual factors such as family stress and school supportiveness can improve therapeutic outcomes
when addressed in treatment planning.
Approaches to Intervention for TBI
Intervention strategies for cognitive-communication disorders are categorized into four main types:
restorative, compensatory, habilitative, and functional/contextual.
Restorative approaches aim to restore lost functions through direct therapy.
Compensatory approaches modify tasks to utilize retained abilities, including accommodations and
strategies.
Habilitative approaches focus on developing skills post-injury.
Functional/contextual approaches target meaningful goals that can be generalized to everyday activities.
Interventions Supporting Fundamental Cognitive Processes
Interventions targeting fundamental cognitive processes utilize a bottom-up approach to improve basic
cognitive skills.
Drill and practice methods are effective for strengthening neural pathways through repetition and
spaced practice.
Direct attention training (DAT) uses repetitive drills to enhance specific areas of attention, showing
significant improvements in global attention measures when combined with metacognitive strategies.
Errorless learning minimizes opportunities for errors, but evidence for its effectiveness in children with
TBI is mixed, with some studies showing advantages for specific age groups and severity levels.
Interventions Supporting Higher-Order Cognitive Processes
Higher-order cognitive interventions employ a top-down, strategy-based approach to enhance executive
functioning and learning processes.
Metacognitive skills training helps children regulate their behavior and manage tasks effectively, utilizing
strategies like goal setting and self-monitoring.
Strategic learning interventions, such as SMART, are designed to support new learning and academic
demands, particularly during key transitions in education.
Efficacy of SMART Training for TBI
The SMART training program has shown significant cognitive improvements in adolescents with
traumatic brain injury (TBI) compared to traditional memory strategies.
SMART training is a top-down approach that enhances cognitive strategies for evaluating and applying
information.
A randomized controlled study indicated significant gains in abstract thinking, detail recall, and
executive function measures for participants in the SMART group.
Control group participants using rote memorization showed no significant improvements.
Findings suggest that top-down processing can enhance bottom-up cognitive processes.
Importance of Strategic Learning
Strategic learning helps students synthesize information and manage cognitive overload, particularly for
those with TBI.
Research indicates that the brain excels at extracting central meanings rather than storing details.
Teaching students to focus on main ideas can prevent them from getting lost in details.
The first SMART strategy involves distinguishing between important and less relevant information.
Younger learners can benefit from activities that promote main idea identification over detail recall.
Modifying Communication Environments
Adjusting the communication environment can enhance cognitive-communication success for children
with TBI.
Observing a child's behavior helps identify underlying cognitive-communication impairments.
Communication partners should adapt their interaction styles to support the child's needs.
Clinicians can provide ongoing coaching to caregivers and teachers to improve teaching strategies.
External supports like visual cues and reduced distractions can facilitate better communication.
Dynamic Approach to Cognitive-Communication Intervention
A multifaceted and individualized approach is essential for supporting students with TBI in their recovery
and academic pursuits.
Clinicians should consider academic, motivational, situational, and personal factors in treatment
planning.
Engaging and empowering communication partners, such as family and teachers, is crucial.
A dynamic approach promotes global gains in cognitive-communication abilities.
Continuous adaptation to the child's evolving strengths and needs is necessary for effective intervention.

1) Attention systems → getting in, staying in, and shifting conversations

What it is. Orienting, alerting, and executive control networks enable children to detect relevant cues,
sustain focus, and shift flexibly between speakers/topics (Posner & Rothbart, 2007).
Participation links.
Initiation & joint attention (orienting to name, gaze, or object) predict early language growth and later
discourse engagement (Mundy & Newell, 2007; Tomasello, 2008).
Sustained/selective attention supports following directions in group settings and turn-taking under
distraction (Stevens & Bavelier, 2012).
Flexible attention enables topic shifts and repair when contexts change.
Developmental notes. Rapid gains ages 3–7 in control/selection; classroom complexity stresses these
systems (Rueda et al., 2005).
OT levers. Visual anchors and “first/then,” noise/light management, brief chunks + clear turn cues;
coach teachers/parents to allow wait time and pre-cue topic shifts (AOTA, 2020; Sohlberg & Mateer,
2001).
2) Processing speed → keeping pace with conversational flow
What it is. Rate of perceiving + transforming information (Kail & Salthouse, 1994).
Participation links. Children with lower speed miss entries to turns, respond late, or abandon bids—
reducing perceived competence and peer inclusion (Miller et al., 2001).
Developmental notes. Continuous improvement through adolescence; heavy dual-task loads (listening
+ note-taking) widen gaps (Fry & Hale, 1996).
OT levers. Preview agendas/keywords, reduce simultaneous task demands, add visual scaffolds (icons,
note frames), and shape peer norms for extra wait time.
3) Working memory (WM) → following directions & building utterances
What it is. Holding and manipulating verbal/visuospatial info (Baddeley, 2003).
Participation links. WM predicts multi-step direction following, complex syntax, and narrative
coherence (Montgomery et al., 2010). Weak WM shows as lost steps, filler pauses, and topic drift.
Developmental notes. Big gains 5–10y; vulnerable in ADHD/DLD/ASD (Alloway et al., 2009; Bishop,
2017).
OT levers. Chunking steps, repeat-back, visual sequences, and checklists in natural routines; train
teachers to use “say-plan-do-review.”
4) Executive functions (EF) → planning messages, inhibiting, and shifting topics
What it is. Inhibition, shifting, updating, planning (Miyake et al., 2000; Diamond, 2013).
Participation links.
Inhibition reduces interrupting/blurting;
Shifting supports topic transitions and perspective switches;
Planning/organization underpins narratives, explanations, and group problem-solving (Ketelaars et al.,
2012).
Developmental notes. Rapid integration in preschool; protracted maturation through adolescence (Best
& Miller, 2010).
OT levers. Goal–Plan–Do–Check in authentic tasks; topic maps/story frames; “stop–think–speak”
scripts; visible agendas for group work (Toglia, 2018).
5) Language-related cognition → making meaning from context
What it is. Categorization, sequencing, inferencing, prediction, and semantic networks (Kintsch, 1998;
Bishop, 2017).
Participation links. Supports comprehending classroom discourse, making inferences in stories, and
responding to indirect requests/sarcasm.
Developmental notes. From concrete categories (early childhood) toward relational/abstract reasoning
(school age).
OT levers. Graphic organizers, “because/so” sentence frames, think-alouds to model inferencing during
routines.
6) Social cognition / pragmatics → reading minds, reading rooms
What it is. Theory of mind, emotion recognition, intention attribution (Adolphs, 2009).
Participation links. Turn-taking rules, humor, double meanings, and repair strategies (“Can you say that
another way?”) (ASHA, 2016).
Developmental notes. Early mental-state talk (3–5y) → nuanced perspective taking in middle childhood
(Wellman, 2014).
OT levers. Perspective maps, role-play in peer routines, emotion labeling, and co-created conversation
scripts embedded in play/class activities.
7) Self-regulation & arousal/interoception → readiness to communicate
What it is. Coordinating attention, emotion, and physiology to meet task demands (Blair & Raver, 2015).
Participation links. Dysregulated states → withdrawal or impulsivity; optimal arousal supports listening
stamina and prosody.
Developmental notes. Co-regulation with adults precedes independent strategies; state shifts impact
speech intelligibility and reciprocity.
OT levers. Sensory-environment tuning, movement/micro-breaks, breathing/rhythm routines; coach
parents/teachers in co-regulation.
8) Metacognition → monitoring and repairing communication
What it is. Awareness of one’s performance and strategies (Kennedy & Coelho, 2005).
Participation links. Detecting breakdowns, requesting clarification, and self-advocacy in groups.
Developmental notes. Emerges in middle childhood; gains with explicit modeling/feedback.
OT levers. Self-monitor checklists, video feedback, and GAS/COPM reflections tied to real routines.

Developmental “ladder” (quick view)

0–3y: Joint attention, gesture, imitation → early words (Kuhl, 2004; Tomasello, 2008).
3–6y: EF and WM surge → sentence complexity, story grammar, group routines (Rueda et al., 2005).
6–12y: Discourse skills, inferencing, classroom conversation, note-taking (Montgomery et al., 2010).
Adolescence: Abstract language, sarcasm, rapid turn-taking under load; higher EF/processing-speed
demands (Diamond, 2013).

OT assessment to capture participation, not just capacity

Context observation: circle time, small-group projects, playground; tally turns, repairs, steps followed
(AOTA, 2020).
Cognitive probes: brief WM/EF/attention tasks; pragmatic checklists (ASHA, 2016).
Participation measures: COPM for caregiver/child priorities; GAS for individualized outcomes (Law et
al., 2019).
Environment audit: noise, visual load, timing, cueing expectations (WHO, 2001).

OT intervention: link specific cognitive process → real

communicative task
Following 3-step classroom directions → WM/attention: visual sequence + repeat-back; measure %
steps completed.
Group discussion participation → EF/inhibition/shift: agenda + topic card + “stop-think-speak”;
measure turns kept and on-topic %.
Narrative sharing → planning/organization: story frame + graphic organizer; measure story grammar
elements.
Peer problem-solving → social cognition: role-play + perspective map + repair stems; tally successful
clarifications.
Morning transitions → self-regulation: sensory tune-ups + breathing script; track time-to-ready.

Quick red flags (screen for deeper evaluation)

Needs directions repeated >2×; loses track after step 1–2.
Late/absent responses in groups; difficulty entering conversations.
Interrupts or perseverates; struggles to switch topics.
Misses sarcasm/indirect requests; limited repair attempts.
Breakdowns when noise/visual load increases.

A) OT assessment in natural routines (function-first)

Goal: Link capacity (attention/EF) to participation (how the child communicates and follows routines)
and to environmental loads (noise, visual complexity, timing). (AOTA, 2020; Sohlberg & Mateer, 2001)
1) 10–15 minute observation template (classroom, therapy room, or home routine)
Task chosen: circle time / small-group work / morning instruction / homework start.
Record for 5 minutes:
Turns attended (n), on-topic responses (%), prompts needed (verbal/visual/gestural), latency to
respond (s).
Breakdowns: missed instructions, overlaps/interruptions, topic loss, sensory distress signs.
Environment snapshot:
Noise: continuous speech/music? intermittent clangs? (note source; aim for steady ≤ 50–60 dBA
classroom range).
Visual field: boards/screens/posters within the child’s gaze; count major competing surfaces (e.g., >3
busy boards = high load).
Timing load: long monologues (>1 min without chunking), rapid topic shifts, dual-task demands (listen +
write).
2) Quick probes (2–5 minutes each)
Working memory & selective attention: 2– and 3-step direction probes (e.g., “Get your math book,
circle the date, then sit by the window”). Score steps completed and prompts required.
Shifting/inhibition: give a “go/stop” or “odd/even” sorting switch for 60 s; count correct after switches.
Pragmatics in action: tally use of repair stems (e.g., “Can you repeat that?”) and topic maintenance over
3 conversational exchanges.
3) Informant quick-check (2 minutes)
Ask teacher/caregiver:
“What breaks down first? noise, visuals, speed, or task complexity?”
“What already helps? visuals, repeats, movement, smaller chunks?”
4) Set outcomes you can see
Performance: % multi-step directions followed; average response latency; turns on topic.
Participation: # of voluntary contributions per group task; independence level with routine.
Goal scaling (GAS): define −2 to +2 anchor behaviors (e.g., −2 needs 3 prompts; 0 needs 1 prompt; +2
independent).

B) Levers you can pull tomorrow (with “how-to” + micro-data)

These map to environmental supports and strategy training emphasized in AOTA (2020) and classic
cognitive rehab principles (Sohlberg & Mateer, 2001): external supports → internalized strategies.
1) Visual anchors
What: Stable visuals that “hold” the topic/steps so attention doesn’t have to.
How:
Agenda strip (icons or 1–5 words): place at eye level, left of the main work area.
Step frame (max 3–4 steps): each step with an icon; child checks off with dry-erase.
Topic card on desk: “We’re talking about… [photosynthesis]”.
Coach script (teacher/parent):
“First, point to the agenda. Tell me step 1. Great—do it, then check it off.”
Micro-data: steps completed without verbal repeat; # of self-references to the visual per task.
2) “First/Then” contingencies
What: Simple contingency to reduce uncertainty and load.
How: Card with two boxes (“FIRST math page 1 / THEN lego 3 min”). Use visuals.
Fade: Move to “First/Then/Next” as tolerance grows.
Micro-data: time to task start; # redirections needed to complete “FIRST.”
3) Noise & light management
What: Shape sensory inputs to match the task.
How:
Noise: close door/windows if possible; seat away from HVAC/projectors; use soft floor spots or tennis
balls on chair legs; offer non-occluding ear defenders only for high-load moments.
Light/visuals: turn off unneeded screens; use matte surfaces; reduce wall clutter in the child’s sightline
during instruction.
Placement: seat with back to busy areas; face the teacher/board.
Micro-data: % of instructions followed before vs. after changes; observed restlessness ↓/↑.
4) Brief chunks + clear turn cues
What: Make input digestible and signal the floor for speaking.
How:
Chunking rule: 30–60 s talking → pause → check understanding (“Tell me step 1”).
Turn cues: hand token, visual “Your turn / My turn” card, or name cue followed by a 3-count wait.
Dual-task control: don’t require note-taking during novel instructions—preview key words first.
Micro-data: response latency (s); # of successful entries into conversation; # of repeats required.
5) Wait time (3–5 seconds)
What: Extra processing time improves accuracy and participation.
How: Teach staff to count silently to three after asking a question; maintain open posture and eye gaze
without repeating the question.
Pre–post: track correct responses and reduced prompting.
Micro-data: correct responses ↑; interruptions ↓.
6) Pre-cue topic shifts
What: Signal changes before they happen to aid shifting and reduce perseveration.
How:
Verbal+visual cue: “In one minute, we’ll switch from reading to sharing.” Show a timer; place the next
topic card on the desk.
Bridge phrase: “We’re closing reading with one keyword… now switching to sharing.”
Micro-data: seconds to re-engage on new topic; # of off-topic comments during first minute after
switch.
7) Caregiver/teacher coaching (in vivo)
Cycle (3–5 min at a time): Goal → Plan → Try → Reflect.
Goal: “Follow 3-step routines with ≤1 prompt.”
Plan: add agenda strip + 3-s wait time.
Try: coach live for one routine; model the wait and pre-cue.
Reflect: “Which cue made it easier?” Decide 1 change to keep all week.
Fidelity check (tiny): yes/no for (a) visual posted, (b) wait time used, (c) chunking used.

Example mini-plans by routine

Morning instruction (classroom)
Setup: post 3-step visual on desk; seat away from noise; topic card on corner.
Teacher script: “First look at your steps. Then do step 1.” (pause 3 s)
Data: steps independently completed; repeats needed; latency to start.
Small-group discussion
Setup: turn token + agenda of 3 prompts; timer visible.
Coach: “Name, it’s your turn (show card).” (wait 3 s) “Who’s next?”
Data: turns taken, on-topic %, repair stems used.
Homework start (home)
Setup: “First/Then” card + ear-savers during instructions; lamp positioned to minimize glare.
Parent script: “First read the 2 bullets; then timer 5 min lego.”
Data: time to start; # prompts.

Tracking change (2 lines on a chart)

Performance line: % steps followed (daily).
Participation line: # turns on topic (per session).
Add weekly note if a lever changed (e.g., “added wait time”).

Safety & fit notes

Use ear defenders strategically (not full-day); watch for social isolation.
Avoid over-reliance on visuals; fade to brief verbal anchors as skills grow.
Ensure cultural/linguistic relevance of icons/phrases.
Coordinate with SLP to align pragmatic goals and cueing language.
A) Assessment (fast, functional, and
mappable to participation)
1) Red-flag scan (what you observe)
Loses step 2–3 of directions; needs frequent re-asks.
“Um/uh” filler pauses, abandons sentences mid-way.
Topic drift in conversation/narratives; forgets what they intended to say.
Struggles when listening and writing/drawing at the same time.
2) Rapid functional probes (2–5 min each)
2–4-step Direction Probe (verbal → action).
Example: “Get your math book, circle the date, then sit by the window.”
Score: steps correct (0–4), # prompts, latency. Increase to 5–6 steps only after 80% success.
Dual-channel Probe (verbal + visual).
Say three steps while showing a picture strip; remove it and ask child to execute. Compare with
visual left in view—quantifies external support effect.
Sentence Build / Narrative Micro-task (verbal WM → utterances).
Give 3 content words (e.g., dog–garden–fell) → child creates a sentence or 2-sentence mini-
story; rate completeness and coherence (0–2 each).
Backward number/word span (quick index).
Ages 6+: try 2–4 digits backward. Stop after two misses at a span.
3) Contexted observation (10 minutes)
In the target routine (circle time/small-group/homework start):
Performance: % multi-step directions followed; average response latency.
Participation: # on-topic contributions; independence level.
Load audit: simultaneous demands (listening+writing), noise, visual clutter.
4) Map capacity ↔ participation
If WM improves notably with external visuals or reduced dual-tasking, plan environmental
levers first; then teach internal strategies.

B) Intervention (build supports → train

strategies → generalize)
1) Environmental scaffolds (immediate wins)
Chunking: deliver 1–3 steps max; pause between chunks.
Visual sequences: step cards or icons left in view; child checks off as they go.
Reduce dual-tasking: during novel instructions, no note-taking; preview key words first.
Time supports: add wait time (3–5 s) before expecting a response.
2) Strategy training (internalize WM supports)
Repeat-back (“say it back”).
Script: “Your plan?” → child repeats steps or key words before acting.
Chunk–Label–Do.
Teach the child to group steps and give each group a label (“get ready / do / finish”).
Note frames / visual coding.
Provide a small box template with 3 slots (Step 1–3) or simple icons the child can point to as
they speak/act.
“Say–Plan–Do–Review.”
30-sec loop: say the steps → point to visual → do → quick review (“Which step was hardest?”).
3) Language-to-WM bridges (building utterances)
Semantic scaffolds: word banks and because/so sentence frames to hold ideas.
Story frames: Beginning–Middle–End or 5-part story map; child points then speaks.
Paused planning: 5-second “think box” before speaking to load the plan into WM.
4) Dosage & progression
Start daily in 1–2 target routines (5–10 min bursts).
Progress n of steps (2→3→4), delay to action (immediate → 5 s), and supports (full visual →
keywords → none).
Fade adult prompts to self-prompt (“What’s step 2? Check your strip.”).
5) Caregiver/teacher micro-scripts
“First tell me the plan, then do it.”
“Point to step 1… do… check it off.”
“We’ll do listen–say back–do.”
“Hold that thought—use the because/so frame.”

C) Goals, data, and fidelity

Sample SMART goals
Following directions: “During morning instruction, with a 3-step visual, child will repeat back
and complete all 3 steps with ≤1 prompt in 4/5 trials.”
Utterance building: “Given a 3-word prompt, child will produce a 2-sentence coherent mini-
story including because/so in 80% of opportunities.”
GAS anchors (example)
−2: Needs ≥3 prompts; completes ≤1 step.
−1: Needs 2 prompts; completes 2 steps.
0 (expected): Needs ≤1 prompt; completes all steps with visuals.
+1: Independent with visuals.
+2: Independent without visuals.
Tiny data (per session)
Steps correct /3 or /4; prompts n; latency s; visual references n; story coherence 0–2.
Fidelity (yes/no)
Visual posted? □ Chunked input? □ Repeat-back used? □ Dual-task reduced? □

D) Differentiation & teamwork

ADHD: WM drops with distraction—maximize environmental levers first.
DLD: WM + language load—coordinate with SLP; keep linguistic complexity matched to WM
supports.
ASD: Pair WM with predictable visual routines; embed interests to sustain load.

Materials you can print today

3-step direction strip with check boxes.
First/Then/Next card.
3-slot note frame (“Step 1–2–3”).
Because/So sentence frame and B–M–E mini story map.

A) Assessment (fast, functional, and tied to

participation)
1) Red-flag scan (what you see in real routines)
Inhibition: blurts answers; talks over peers; grabs materials; difficulty waiting for a turn.
Shifting: can’t move from one activity/topic to the next; perseverates on preferred ideas; rigid
rules in play.
Planning/organization: disorganized stories; missing beginnings/endings; loses key points in
explanations; weak group-work roles.
Updating (working EF): forgets the new rule; repeats outdated info.
2) 10–15-minute naturalistic observation (class, clinic, or
home)
Choose one real routine (circle time, small-group discussion, morning instruction, homework
start).
Performance metrics (5–10 min sample):
Turns on-topic (# / total); interruptions/overlaps (#); topic shifts achieved (#/attempts).
Narrative organization (0–2 each for setting, sequence, causal link, closing).
Response latency (s) after a question; prompts (# verbal/visual/gestural).
Load audit: noise source(s); visual clutter in the child’s sightline; dual-task demands (e.g., listen
+ write).
3) Quick EF probes (2–5 minutes each)
Inhibition / Stop–Go: Clap when you hear animals, stay quiet for non-animals (or “Go/No-
Go”). Track correct responses and false alarms (impulses).
Cognitive Flexibility / Rule Switch: Sort by color for 30 s, then switch to sorting by shape.
Record correct after the first 5 switched trials.
Planning for expression / Micro-narrative: Give 3 picture prompts → child plans with a story
frame (B-M-E) then tells it. Score story grammar (0–2 each) and need for cues.
Topic shift practice: Provide a “bridge phrase” card (“Now I’m moving to…”) and ask the
child to change topics once; tally success and cues.
(Use formal EF tests when needed for depth; the above link EF capacity to communicative
participation directly.)
4) Informant mini-interview (2 minutes)
“What breaks down first? blurting, transitions, or message organization?”
“What already helps? visual agenda, wait time, sentence frames, turn tokens?”
“One routine we can target daily?”
5) Outcomes you can see
Performance: interruptions per 10 min; successful topic shifts; story-elements present.
Participation: # of appropriate contributions in group work; independence with assigned role.
GAS anchors (−2 to +2) tied to prompts and independence (see examples below).

B) Intervention (environment → strategy →

generalization)
1) Environmental scaffolds (immediate relief)
Visible agenda & timing: post a 3-step agenda with icons; use timers for transitions.
Turn-taking signals: physical token or “Your turn / My turn” cards; teacher uses name cue + 3-
s wait.
Visual topic map: title card (“We’re talking about…”) with 2–3 sub-points.
Reduce competing load: minimize background talk/visual clutter during new tasks; avoid listen
+ write simultaneously for new material.
2) Strategy training (internalize EF supports)
Goal–Plan–Do–Check (GPDC) (Toglia) in communicative tasks
Goal: “Explain how plants grow to my group.”
Plan: “3 points: sunlight–water–soil; use the diagram; keep turns short.”
Do: deliver with token and agenda visible.
Check: “Did I cover 3 points? Did I wait my turn?”
Stop–Think–Speak script (inhibition)
Palm card with icons: ✋ Stop → 👀 Think (What’s the question? Is it my turn?) → 🗣 Speak (one
point).
Pair with a whisper-rehearsal: child quietly rehearses one sentence before speaking.
Bridge phrases (shifting)
Teach sentence starters: “Now I’ll switch to…,” “The next part is…,” “Another idea is…”.
Practice with a timer and a visual “topic card” swap.
Story frames & graphic organizers (planning/organization)
B-M-E for K–2; “Somebody–Wanted–But–So–Then” or 5-finger retell for older kids.
Use because/so connectors to build causal links (“…because…”, “…so…”).
Updating & monitoring (metacognitive tie-in)
“New rule” icon (🔁). Child states the current rule before acting (“We’re sorting by shape now”).
Self-monitor checklist: □ waited turn □ used bridge phrase □ covered 3 points.
3) Practice design (dose & fading)
Daily, 5–10 minutes in 1–2 target routines (small group discussion; morning share).
Fade supports: token → verbal cue → self-cue; full story map → keywords → none.
Increase complexity: 1 → 2 planned topic shifts; 2 → 3 story elements; single-rule → rule-
switch.
4) Coaching teachers/parents (in vivo, 3–5 minutes)
Plan: “This week we use token + 3-s wait + bridge phrases in science groups.”
Model & prompt: therapist models the count-to-three and hands token; adult mirrors.
Reflect: “Which cue reduced blurting most?” Keep one successful cue all week (PDSA).

C) Goals, GAS, and tiny data

Sample SMART goals
Inhibition/turn-taking (class): “During 10-min group discussion with a turn token, student will
wait for cue and contribute ≤2 interruptions while producing 3 on-topic turns in 4/5 sessions.”
Shifting (transitions): “Given a visual pre-cue and bridge phrase, student will shift topics
within 10 s of the cue with ≤1 prompt in 80% of opportunities.”
Planning/organization (narrative): “Using a story map, student will produce a 4-element
narrative (setting, sequence, cause, closing) in 3/4 trials.”
GAS anchors (example: inhibition/turn-taking)
−2: >6 interruptions; needs frequent adult stop cues.
−1: 3–5 interruptions; needs 2–3 prompts.
0 (expected): ≤2 interruptions; ≤1 prompt with token.
+1: 0–1 interruption; independent with token.
+2: 0 interruptions; independent without token.
Tiny data (per session—2 lines max)
Interruptions (#) • On-topic turns (#) • Topic shift success (%) • Narrative elements (0–4).

D) Differentiation & teaming

ADHD: emphasize external controls first (token, agenda, wait-time), then internal scripts; keep
tasks brief and salient.
ASD: pair EF strategies with predictable visuals and clear social rules; rehearse bridge phrases
within special interest topics to increase flexibility.
DLD/Language needs: align with SLP—use simpler syntax in scripts and visuals; teach
connectors explicitly.
Anxiety: preview agenda and roles; use checklists to reduce uncertainty before group speaking.

Ready-to-print tools (quick wins)

Turn token card (“My turn/Your turn”).
Bridge phrase strip (3–5 starters).
Story map (B-M-E or SWBST).
GPDC cue card with check boxes.
Self-monitor mini-checklist (waited, bridged, covered 3 points).
What is cognitive communication deficit (CCD)?
When we communicate, we use both verbal and nonverbal communication.
Verbal communication is the words that we say out loud. Nonverbal
communication is everything else that we do when we communicate, like
using our body language, facial expressions, and tone of voice. Most people
use a combination of both verbal and nonverbal communication when they
talk to others. But sometimes, people have trouble with one or both types of
communication.
Meanwhile, cognition is the mental process that we use to think, learn, and
remember information. It includes things like attention, memory, and problem-
solving. Since communication is the process of exchanging information
between two people, a cognitive communication deficit occurs when someone
has trouble with one or more cognitive processes involved in communication.

Why does cognition play a great role in communication?

Cognition is a key part of communication. In fact, many experts believe that
cognition plays an even bigger role in communication than language ability.
That’s because we use cognitive skills to understand and remember
information as well as to plan and organize our thoughts before we speak.

Need help with cognitive

communication deficit?
 There are several potential areas where deficits may occur:
 Pragmatics: Rules of verbal and non-verbal social communication
(pragmatics) are difficult to follow for some people. This includes
understanding jokes, gauging changes in tone, or knowing when it is
appropriate to speak.
 Reasoning: Inability to think of and implement solutions to challenges. It's
also possible that you can't come up with many answers or indicate which
option is best.
 Attention: It's difficult for them to focus or concentrate on a task, especially
when it's noisy or when multiple things are happening at the same time, such
as talking on the phone while watching TV.
 Memory: Forgetting someone's name after meeting them, or an important
date, may be caused by forgetfulness. It might also include difficulties in
absorbing new information such as names, locations, situations, and
commands.
 Organization/Planning: Having trouble with organization, thinking through a
sequence of events, or telling a story in the right order.
 Insight/Awareness: It's difficult to recognize when something is amiss in the
environment or with oneself. Even after education, the client may not realize
they have thought disorders, for example.
Who can be affected by CCD?
If you think children are the only group of people that can suffer from
cognitive-communication deficits, then you are wrong. In fact, even adults can
have trouble with cognition and communication. For example, research shows
that adults with schizophrenia often have trouble with cognitive processes
involved in communication, such as attention and memory. And adults who
have had a stroke often have trouble with cognition and communication, too.

What causes cognitive-communication deficits?

There are many different causes of cognitive communication deficits. Some
common causes include:
 Autism spectrum disorder: Autism is a brain development disorder that affects
communication and social interaction. People with autism often have difficulty
with verbal and nonverbal communication. They may also have difficulty
understanding social cues or picking up on the emotions of others.
 Attention-deficit/hyperactivity disorder (ADHD): ADHD is a condition that
causes problems with focus, hyperactivity, and impulsivity. People with ADHD
may have difficulty paying attention to conversations, or following along if
there is more than one person talking. They may also have trouble staying on
task or keeping their thoughts organized.
 Traumatic brain injury (TBI): A TBI is a type of brain injury that can occur after
a blow to the head. TBI can cause a wide range of cognitive and
communication problems, depending on the severity of the injury.
 Brain tumor: Brain tumors can cause cognitive and communication problems
depending on the location of the tumor. If it is in an area of the brain that
 controls language, a person may have difficulty understanding or producing
speech.
 Dementia: Dementia is a general term for a decline in mental ability. It can
cause problems with memory, thinking, and communication over time.
 Stroke: A stroke is a medical emergency that occurs when the blood supply to
the brain is cut off. This can cause problems with movement, speech, and
thinking.

Types of cognitive communication deficit

There are many different types of cognitive communication deficits. Some
common examples include:

Difficulty functioning independently due to:

 uninterested or unaware of others around them
 no speech that conveys meaning
 can only open eyes, suck, and/or yawn in response to stimuli
 attention and memory problems along with impulsive behavior
 difficulty saying their name or responding when someone else says it
 having trouble expressing needs using basic words and gestures (for
example, yes/no, head nod)
 Limited social skills, such as greeting others or using facial expressions.
 Trouble counting to ten and expressing needs effectively.
 Easily agitated when goals are not met.
 Lack of eye contact or very limited communication abilities
 difficulty paying attention while speaking (i.e., does not complete sentences or
take turns speaking during conversation)
 can't react appropriately to the other person's message (i.e., delayed,
perseverative, or off-topic replies, with inappropriate words)
Difficulty functioning independently due to:
 inability to anticipate the results of one's own actions
 lack of organizational skills
 limited problem-solving and judgment abilities
 poor awareness of the scale of issues
 socially inappropriate behavior demonstrated
 difficulty with word selection and recollection of names
 forgetful or uninformed about current events and/or personal history
 talks too much repeat themselves or goes off-topic
 elaborates provided information in conversation
 struggle to switch gears, start a new topic, or end the discussion
 missing or misunderstanding humor
 difficulty understanding nonverbal communication (i.e., facial expressions
and/or body language)
 difficulty understanding abstract information
Difficulty managing home or maintaining a job or business due to:
 difficulties in planning and executing basic daily activities difficulties
 following instructions problems
 interpreting or applying abstract written material difficulties
 comprehending or applying abstract written information difficulties
 recognizing and implementing solutions to personal and/or business issues
that are difficult to process, assess, and resolve
 Having difficulty managing several things at once
 Struggling to keep emotions (especially anxiety, frustration, or anger) under
control when faced with performance issues
 Having trouble making, following through on, and/or changing plans as
necessary
 Difficulty comprehending and taking care of personal legal or financial affairs
(i.e., taxes file management property law etc.)
 difficulty effectively communicating with colleagues and/or customers,
especially initiating effective responses, interpreting combined verbal and
nonverbal responses during conversations to determine strategic
communication action; modifying responses when feedback indicates it has
not been successful
How are cognitive-communication deficits
diagnosed?
If you suspect that your child has a cognitive communication deficit, the first
step is to talk to your child’s doctor. Your doctor will likely ask about your
child’s medical history and any development concerns that you have. They
may also recommend that your child see a speech-language pathologist
(SLP) for an evaluation.

An SLP is a healthcare professional who specializes in diagnosing and

treating communication disorders. During an evaluation, the SLP will likely ask
you questions about your child’s communication skills and development. They
may also observe your child’s communication in different situations. The SLP
will use this information to make a diagnosis and develop a treatment plan.

How are cognitive-communication deficits

treated?
There is no one-size-fits-all approach to treating cognitive-communication
deficits. Cognitive speech therapy can look different for everyone. Treatment
will depend on the specific diagnosis, as well as the severity of the deficit. In
some cases, medication may be recommended to treat underlying conditions,
such as ADHD or dementia. However, speech and language therapy is often
the main form of treatment for cognitive-communication deficits.
Speech therapy can help people with cognitive communication deficits
improve their ability to communicate effectively. It can also help them develop
strategies to compensate for any difficulties they have. For example, an SLP
may teach a person with ADHD how to use a notebook to keep track of
conversations. This can help the person stay focused and remember what
was said.

What can Speech Therapy do?

During treatment, speech therapists will often:

Assess the individual’s strengths and weaknesses

 When you suspect a person with a cognitive communication deficit, the first
step is always to consult with a medical doctor. After that, the speech therapist
will assess the individual’s strengths and weaknesses to get a better
understanding of the problem. An assessment may consist of multiple
components, including:
 Montreal Cognitive Assessment (MoCA)
 Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI)
 Cognitive Linguistic Quick Test (CLQT)
 Functional Assessment of Verbal Reasoning and Executive Strategies
(FAVRES)
 Assessment of Language-Related Functional Activities (ALFA)
These tests will help identify the areas of cognitive communication that are
most affected. From there, the therapist can develop a treatment plan that
targets those specific areas.

Design a treatment plan

After the assessment, the speech therapist will work with the individual to
design a treatment plan. The treatment plan will be based on the individual’s
specific needs and goals.

Provide therapy
The speech therapist will provide therapy to help the individual improve their
communication skills. Therapy may be provided in a group or individual
setting, depending on the needs of the individual. In speech therapy, the three
primary objectives are to restore function, make up for deficits, and teach the
client and their family about the disorder and its management.

Monitor progress
The speech therapist will monitor the individual’s progress and make
adjustments to the treatment plan as needed. They will also provide support
and guidance to the individual and their family members.

The goal of speech therapy is to help the individual develop the skills they
need to communicate effectively. With time and practice, most people with
cognitive-communication deficits can make significant improvements in their
ability to communicate.

Cognitive-communication deficits can have a big impact on a person’s life.

However, with early diagnosis and treatment, many people are able to live
fulfilling lives. If you think your child may have a cognitive-communication
deficit, talk to their doctor. An evaluation by an SLP can help confirm the
diagnosis and develop a treatment plan.

Tips you can do at home to support

If you think your child receiving speech therapy is enough, you are sadly
mistaken. Just like anything else, if you don’t practice, you will not improve. It
is important that you provide opportunities at home for your child to practice
their skills. Here are some things you can do:

Read books together

This is a great way to work on many different skills at once. Reading books
can help with vocabulary, understanding complex sentences, and following a
story. It also improves their attention span and listening skills. Thus, it
improves both their cognitive and communication skills.
In adults, reading the newspaper or articles about their pastime hobbies can
also keep them engaged and updated on the world around them. Even if they
are no longer able to participate in that activity, it is important to keep their
mental state active.

Have conversations
Talk about your day, tell stories, discuss current events, ask questions… just
chat! The more opportunities your child has to practice communication, the
better. You can also model proper communication skills for them to imitate.

For adult patients, it is important to always ask them how they are and what is
new with them. A lot of times, they may not want to talk because they feel like
no one cares. Showing that you care and want to know what is going on in
their life will help them feel supported and may encourage them to
communicate more.

Play games
Games are not only fun, but they are also great for learning. There are many
games that work on communication skills, such as charades, guess the word,
and story cubes. These games can help with turn-taking, following directions,
and vocabulary, to name a few.

Playing a memory game with adults can also help sharpen their cognitive
skills. This will help with mental stimulation and keep their mind active.
Encourage them to be social
Invite friends and family over, go to the park, join a sports team… Just get out
there and interact with others! Social activities are essential for
communication development. They provide opportunities to practice skills in a
natural setting.

Going to support groups or social gatherings specifically for people with

cognitive-communication deficits can also be beneficial. These groups provide
a safe and supportive environment where people can interact with others who
understand their challenges.
Give them ample time to respond
It can take a person with a cognitive-communication deficit longer to process
information and formulate a response. It is important to be patient and give
them the time they need. Rushing them will only make the situation worse.

If you are talking to an adult patient, it is important to not finish their sentences
for them. This can be frustrating and will only discourage them from
communicating. It is better to let them take their time and finish their thoughts
at their own pace.

Speak slowly and clearly

When you are talking to your child, slow down and enunciate your words. This
will help them process the information more easily. It is also important to use
simple sentences and vocabulary.
With adults, it is important to not talk down to them or use baby talk. This will
only make them feel patronized and less likely to communicate. Instead,
speak to them in a normal tone and use words they will understand.

Be positive and encourage effort

Children with cognitive-communication deficits can get frustrated easily. It is
important to be patient and encourage their efforts. Remember, progress is
often slow but it is possible with time and practice.
Adults may also get discouraged, especially if they are having difficulty
communicating. It is important to be supportive and let them know that you are
there for them. A positive attitude can go a long way.
Provide visual aids
Visual aids can be very helpful for children with cognitive-communication
deficits. Use pictures, diagrams, charts, or any other type of visual aid to help
explain things. You can also write down key points to help them remember.

Adults may also benefit from visual aids. For example, you can provide them
with a list of topics to choose from if they are having trouble coming up with
something to say. You can also use pictures or other visual aids to help jog
their memory if they are having trouble recalling a certain word or event.

Cognitive-communication deficits can be challenging, but with the right

support, you or your child can make significant progress. Just remember to be
patient, encourage their efforts, and provide opportunities for practice. With
time and effort, your child will develop the skills they need to communicate
effectively.
At Better Speech, we offer online speech therapy services convenient for you
and tailored to your child's individual needs. Our services are affordable and
effective - get Better Speech now.