Knowledge and Skills Needed by Speech-Language Pathologists Providing Services to Individuals With Cognitive-Communication Disorders

Assumptions

1. Cognition and language are intrinsically and reciprocally related in both development and function. Thus, an impairment of language may disrupt one or more cognitive processes and similarly an impairment of one or more cognitive processes may disrupt language. Therefore, practitioners who serve individuals with cognitive-communication disorders require knowledge and skills in both areas, as delineated in this document.

2. Cognitive-communication disorders encompass difficulty with any aspect of communication that is affected by disruption of cognition. Communication may be verbal or nonverbal and includes listening, speaking, gesturing, reading, and writing in all domains of language (phonologic, morphologic, syntactic, semantic, and pragmatic). Cognition includes cognitive processes and systems (e.g., attention, perception, memory, organization, executive function). Areas of function affected by cognitive impairments include behavioral self-regulation, social interaction, activities of daily living, learning and academic performance, and vocational performance.

3. The roles of the speech-language pathologist (SLP) can be considered within the framework of the World Health Organization International Classification of Functioning, Disability and Health (WHO, 2001). The categories of this classification system, as defined in the ASHA position statement “Roles of Speech-Language Pathologists in the Identification, Diagnosis, and Treatment of Individuals With Cognitive-Communication Disorders” (ASHA, 2005), can be applied to cognitive-communication disorders as follows:

   • Body structure and function: Neuroanatomic structures and neurophysiological and neuropsychological functions supporting cognitive-communication processes.

   • Activity and participation: Execution of everyday tasks and involvement in social, academic, and vocational situations that may be affected by a cognitive-communication impairment. Activity/participation components are modified by the qualifiers of “capacity” (i.e., executing a task in a standardized or uniform environment) and “performance” (i.e., executing a task in a natural context).

   • Contextual factors: Environmental and personal factors that serve as facilitators or barriers to functioning and participation. Environmental factors related to cognitive-communication disorders might include the school curriculum, workplace demands, and interactive and support competencies of everyday communication partners as well as societal attitudes toward disability. Personal factors include such features as age, race/ethnicity, gender, educational background, cultural beliefs, and lifestyle that may contribute to intervention outcomes. Specifically related to outcomes for people with cognitive-communication disorders are awareness of and adjustment to disability, motivation, and acceptance of responsibility for change.

   • Therefore, assessment and intervention can focus at the level of body structure and function, also called “impairment-oriented,” and at the level of activity/participation. For both levels, contextual factors must be considered for assessment and intervention.

4. Although SLPs are autonomous professionals, successful intervention with children and adults with cognitive-communication disorders often requires the collaborative involvement of other professionals. SLPs work collaboratively with teachers and other professional colleagues, families, employers, and others who provide support to individuals with cognitive-communication disorders. SLPs (working within their scope of practice and individual level of competence) are uniquely qualified to assess, diagnose, and treat communication disorders associated with cognitive impairments.

The following knowledge and skills have been developed for SLPs working with children and adults with either congenital or acquired cognitive-communication disorders of varied etiologies. These knowledge and skills generally apply across populations with cognitive impairments, although the relative importance of each may vary with the specific roles and responsibilities.

As indicated in the accompanying ASHA position statement (ASHA, 2005), appropriate roles for SLPs working with individuals with cognitive-communication disorders include, but are not limited to the following:

1. Identification: Identifying individuals at risk for or presenting with cognitive-communication disorders.

2. Assessment:

   • Selecting and implementing clinically, culturally, and linguistically appropriate approaches to assessment and diagnosis, using both static and dynamic procedures.

   • Identifying contextual factors that contribute to or can be used to ameliorate cognitive-communication disorders

3. Intervention: Selecting and implementing clinically, culturally, and linguistically appropriate and evidence-based approaches to intervention (e.g., training discrete cognitive processes, teaching specific functional skills, developing compensatory strategies and support systems, providing caregiver training, and providing counseling and behavioral support services).

4. Counseling: Providing culturally and linguistically appropriate counseling for individuals and their significant others about cognitive-communication disorders and their impact.

5. Collaboration: Collaborating with the individual with a cognitive-communication disorder, family members, teachers and other professional colleagues, care providers, and others in developing and implementing assessment and intervention plans.

6. Case Management: Serving as case manager, service coordinator, or team leader by coordinating, monitoring, and ensuring the appropriate and timely delivery of a comprehensive management plan.

7. Education:

   • Developing curricula and educating, supervising, and mentoring future SLPs in assessment and treatment options and other issues related to cognitive-communication disorders.

   • Educating families, caregivers, and other professionals regarding the needs of individuals with cognitive-communication disorders.

8. Prevention: Educating the public on the prevention of factors contributing to cognitive-communication disorders.

9. Advocacy:

   • Advocating for services for individuals with cognitive-communication disorders.

   • Serving as an expert witness.

10. Research: Advancing the knowledge base on cognitive-communication disorders and their treatment through research activities.

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Knowledge

The specialized knowledge needed to perform the above roles can be summarized into the following categories:

1. Cognition and its relationship to language and communication in normal development and across the life span.

   • Knowledge of cognitive processes and systems (e.g., attention, perception, memory, organization, executive function).

   • Knowledge of language domains (i.e., phonologic, morphologic, syntactic, semantic, pragmatic) and their interrelatedness with cognition.

   • Knowledge of the neuroanatomical substrates of language, other cognitive processes, and communication.

   • Knowledge of the cognitive, linguistic, psychosocial, sensory, motor, and perceptual processes required for the performance of various communication tasks.

   • Knowledge of typical child and adult development of language, other cognitive processes, and communication—including factors that influence development in these domains.

   • Knowledge of the effects of changes in cognitive, linguistic, psychosocial, sensory, motor, and perceptual processes involved in communication across the life span.

   • Knowledge of environmental and personal factors that influence the development and performance of cognitive-communication activities, including cultural and linguistic factors.

2. Cognitive-communication disorders across the life span.

   • Knowledge of genetic, medical, and environmental conditions that place individuals at risk for developing cognitive-communication disorders.

   • Knowledge of pre-, peri-, and postnatal medical conditions associated with cognitive-communication disorders.

   • Knowledge of acquired etiologies of cognitive-communication disorders (e.g., traumatic brain injury, stroke, tumor, anoxic or toxic encephalopathy, dementia and other degenerative neurological disorders).

   • Knowledge of brain-behavior relationships and the effects of various etiologies and sites of lesion on language, other cognitive processes, and communication.

   • Knowledge of the natural course of various etiologies of cognitive-communication disorders.

   • Knowledge of personal and environmental factors (e.g., education, social and cultural background, psychological status, medications, motivation and support of communication partners, access to technology and other resources) that may affect language, and other cognitive-communication processes.

   • Knowledge of the effects of specific sensory, motor, and perceptual impairments on communication performance and improvement of cognitive-communication disorders.

3. Clinical tools and methods for assessing cognitive-communication disorders.

   • Knowledge of various purposes of assessment (e.g., diagnosis; qualification for services; planning intervention; measuring intervention outcomes; academic, social, and vocational accommodations) and tools and procedures relevant to each purpose.

   • Knowledge of standardized and nonstandardized, static and dynamic procedures for assessing language and other cognitive processes, including factors that influence ecological and cultural validity.

   • Knowledge of standardized and nonstandardized, static and dynamic procedures for assessing cognitive-communication performance at the activity/participation level.

   • Knowledge of standardized and nonstandardized, static and dynamic procedures for assessing contextual factors influencing cognitive-communication performance.

   • Knowledge of procedures for assessing interactive competencies and support behaviors of communication partners in a variety of environments.

   • Knowledge of the needs of culturally and linguistically diverse populations, including selection and/or adaptation of assessment procedures.

   • Knowledge of assessment approaches with augmentative and alternative communication systems (AAC).

4. Intervention approaches and methods for cognitive-communication disorders across the life span.

   • Knowledge of each individual's service needs (admission, types of service delivery, discharge, follow-up) based on the individual's characteristics, environment, and support systems.

   • Knowledge of models of intervention including impairment-oriented (e.g., training discrete cognitive processes) and activity/participation-oriented (e.g., teaching specific functional skills) approaches.

   • Knowledge of specific intervention strategies.

   • Knowledge of the impact of personal and environmental contextual factors on cognitive-communication performance.

   • Knowledge of the impact of the neuropharmacologic agents on cognitive-communication performance.

   • Knowledge of the cognitive, language, and speech characteristics of developmental and acquired communication disorders for the purpose of differential diagnosis.

   • Knowledge of the prognostic implications of specific diagnostic categories.

   • Knowledge of the accepted formats for documenting and reporting assessment results in various health care and education settings.

   • Knowledge of the impact of context and other factors (e.g., medical treatments) on the application of intervention strategies.

   • Knowledge of applicable laws regarding least restrictive environment and possible negative effects of placement in an overly (or insufficiently) restrictive setting.

   • Knowledge of the criteria for evaluating the evidence supporting intervention strategies.

   • Knowledge of the components of the comprehensive treatment plan, including goal selection and prioritization, goal-attack strategies, objectives, procedures, activities, and coordination with other services and agencies.

   • Knowledge of characteristics and application of available treatment materials

   • Knowledge of procedures for improving interactive competencies and support behaviors of communication partners in a variety of environments (e.g., home, school, work, and social settings).

   • Knowledge of characteristics and application of available technologies (e.g., memory and organization aids, computer-assisted intervention, AAC systems).

   • Knowledge of principles of behavior management and behavior modification.

   • Knowledge of service-delivery models (e.g., classroom-, home-, and workplace-based; pull-out, collaborative-consultation; individual and group intervention).

   • Knowledge of group dynamics and techniques for conducting intervention in groups.

   • Knowledge of theories and principles of learning and generalization/transfer.

   • Knowledge of methods for facilitating and measuring generalization and maintenance of treatment effects, and of procedures for follow-up.

   • Knowledge of procedures for facilitating effective transitions (e.g., hospital to community; school to work).

   • Knowledge of methods for measuring treatment efficacy, effectiveness, and outcomes for individuals and programs.

   • Knowledge of the impact a disability may have on the individual, family, and others; knowledge of family systems theory.

   • Knowledge of counseling principles and techniques, and criteria for referral to other professionals.

   • Knowledge of current reimbursement policies and practices.

5. Collaboration, education, advocacy, and research principles.

   • Knowledge of the roles, responsibilities, and specialized expertise of other individuals providing services and supports to children and adults with cognitive-communication disorders.

   • Knowledge of current models and methods of collaborative intervention.

   • Knowledge of ways to conduct family education and support activities.

   • Knowledge of the broad spectrum of services that families and others may require.

   • Knowledge of factors (e.g., sociocultural, educational, emotional) that affect the content and delivery of information to individuals from diverse backgrounds.

   • Knowledge of ways to effectively communicate information to referral sources, administrators, payers and other decision-makers.

   • Knowledge of available resources for individuals with cognitive-communication disorders, family members, and others.

   • Knowledge of curricular content and adult teaching/learning strategies for clinical education, mentoring, and supervision.

   • Knowledge of local, state, and federal legislation and regulations related to service provision for children and adults with cognitive-communication disorders.

   • Knowledge of research principles and methods of conducting clinical research to address questions related to cognitive-communication disorders and interventions

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Skills

1. Identification: Identification skills include the ability to:

   • Recognize genetic, medical, and environmental conditions that place individuals at risk for developing cognitive-communication disorders.

   • Recognize pre-, peri-, and postnatal medical conditions associated with cognitive-communication disorders.

   • Recognize acquired etiologies of cognitive-communication disorders (e.g., traumatic brain injury, stroke, tumor, anoxic or toxic encephalopathy, dementia and other degenerative neurological disorders).

   • Recognize symptoms of cognitive-communication disorders.

   • Educate others to recognize symptoms of cognitive-communication disorders.

2. Assessment: Assessment skills include the ability to:

   • Review medical charts and other documentation for relevant case history information.

   • Interview the individual and family members to obtain relevant case history information.

   • Obtain relevant information from and coordinate with other disciplines involved in the management of the individual being assessed.

   • Identify the purpose of the assessment and tools relevant to that purpose.

   • Select and administer standardized and nonstandardized, static and dynamic procedures for assessing language and other cognitive processes.

   • Select and administer standardized and nonstandardized, static and dynamic procedures for assessing cognitive-communication performance at the activity/participation level.

   • Select and administer standardized and nonstandardized, static and dynamic procedures for assessing contextual factors influencing cognitive-communication performance.

   • Assess interactive competencies and support behaviors of communication partners (e.g., caregivers, spouses, teachers, employers, peers) in a variety of environments.

   • Select and adapt assessment procedures for the needs of culturally and linguistically diverse populations.

   • Select and implement appropriate AAC systems as needed.

   • Assess the impact of personal and environmental contextual factors on cognitive-communication performance.

   • Differentially diagnose developmental and acquired cognitive-communication disorders.

   • Weigh prognostic factors to formulate prognoses for potential changes in cognitive-communication competence and performance.

   • Convey diagnostic information in a way that is culturally and linguistically appropriate for individuals, families, and others.

   • Weigh prognostic factors for potential changes in the home, educational, vocational, and social environments.

   • Document and report assessment results using accepted formats for various health care and education settings

3. Intervention: Intervention skills include the ability to:

   • Apply appropriate admission, discharge, follow-up criteria in clinical decision-making.

   • Select and implement appropriate treatment approaches for specific individuals and clinical populations, including impairment-oriented (e.g., training discrete cognitive processes) and activity/participation-oriented (e.g., teaching specific functional skills) approaches.

   • Evaluate and select appropriate treatment programs and materials.

   • Recognize the impact of context on the application of intervention strategies and modify the tasks, environments, and support behaviors of others in relevant settings.

   • Evaluate the evidence supporting intervention strategies.

   • Develop a comprehensive treatment plan, including selection and prioritization of goals, goal-attack strategies, objectives, procedures, activities, and coordination with other services and agencies.

   • Evaluate and apply available treatment materials and develop new materials as needed.

   • Improve interactive competencies and support behaviors of communication partners in a variety of environments (e.g., home, school, work, and social settings).

   • Apply appropriate technologies (e.g., memory and organization aids, computer-assisted intervention, AAC systems).

   • Apply principles of applied behavior analysis and behavior modification.

   • Select appropriate service-delivery model(s) (e.g., classroom-, home-, and workplace-based; pull-out, collaborative-consultation; individual and group intervention) and modify as needed.

   • Select appropriate service setting consistent with the requirement for providing services in the least-restrictive environment based on individual needs (e.g., inclusive classroom and workplace).

   • Deliver effective group intervention.

   • Facilitate and measure generalization and maintenance of treatment effects.

   • Document treatment results and assess the efficacy and effectiveness of treatment for impairment-oriented and activity/participation goals and objectives across a variety of contexts.

   • Conduct program evaluation.

   • Provide effective follow-up services for individuals who have been discharged.

   • Provide services to individuals to ensure seamless transitions across settings (e.g., hospital to community, school to work).

   • Train family members, teachers, caregivers, employers, and other frequent communication partners in techniques for facilitating functional communication and successful performance of everyday activities.

   • Counsel individuals, family members, and others in domains related to cognitive-communication intervention and make referrals as needed.

   • Apply current reimbursement policies, procedures, and formats.

4. Collaboration and Case Management: Skills for collaboration and case management include the ability to:

   • Coordinate and implement management plans that are integrated with other services and individuals.

   • Work effectively within a variety of collaborative teams.

   • Communicate effectively with referral sources, administrators, payers, and other decision-makers.

   • Coordinate and use available resources judiciously on the basis of immediate and long-term needs of individuals with cognitive-communication disorders, family members, and others.

5. Counseling, Education, Advocacy, and Prevention: Counseling, education, advocacy, and prevention efforts require the ability to:

   • Design and conduct effective and culturally and linguistically appropriate counseling; teacher, employer, family education; and support activities.

   • Inform families and others of available services.

   • Design and implement effective education, mentoring, and supervision programs.

   • Inform others about local, state, and federal legislation and regulations related to service provision for children and adults with cognitive-communication disorders.

   • Advocate for adequate provision of services and supports for children and adults with cognitive-communication disorders.

   • Design and conduct effective programs for prevention of cognitive-communication disorders via primary (e.g., using helmets, monitoring prenatal maternal health, smoking cessation) and secondary (e.g., providing supports that prevent exacerbation) measures.

6. Research: Skill in research requires the ability to:

   • Read and critically evaluate the research literature in cognitive-communication disorders.

   • Design and implement single-subject experiments to address questions related to cognitive-communication disorders and interventions.

   • Design and implement group studies to address questions related to cognitive-communication disorders and interventions.

   • Participate in research to add to the knowledge base of cognitive-communication disorders.

   • Develop and evaluate new methods, materials, and technologies to improve assessment and intervention practices in the area of cognitive-communication disorders.

   • Report and disseminate results of clinical research tailored to a variety of audiences (clinicians, other professionals, consumers, employers, administrators, policy makers, and others).