The clinician considers the following factors that may have an impact on screening and comprehensive assessment:
- Language(s) spoken
- Concurrent motor speech impairment (e.g., dysarthria)
- Hearing loss and auditory agnosia (inability to recognize or differentiate between sounds; neurological inability of the brain to process sound meaning)
- Visual acuity deficits, visual agnosia, and visual field cuts
- Upper extremity hemiparesis (may affect ability to write)
- Presence of chronic pain from either preexisting or new conditions
- Endurance and fatigue (testing may need to be broken into shorter sessions)
- Potential impact of prescription drugs on the individual’s presentation and test performance (e.g., excessive drowsiness; exacerbation of cognitive problems secondary to polypharmacy)
- Poststroke depression
- Premorbid functional status (literacy, level of education, profession, cultural background, interests, family support, etc.)
- Anticipated/preferred discharge setting
If the individual with RHD wears prescription glasses and/or hearing aids, these should be worn during assessment.
If additional hearing and/or visual deficits resulted from the neurological event—and physical or environmental modifications (e.g., large-print material, attention to placement of test stimuli, modified lighting, amplification devices) are not sufficient to compensate for these changes—then the individual should be referred for complete audiologic and/or vision assessments prior to testing. If there are signs or reports of depression, then the individual should be referred for a psychological or psychiatric evaluation.
Screening does not provide a detailed description of the severity and characteristics associated with RHD but, rather, identifies the need for further assessment. Screening is conducted in the language(s) used by the person, with sensitivity to cultural and linguistic diversity.
Screenings may be completed by the SLP or another appropriately trained professional. Standardized and nonstandardized methods are used to screen oral motor functions, speech production skills, comprehension and production of spoken and written language, pragmatic language skills, and other cognitive skills (attention, memory, and executive function) as they relate to communication, swallowing, unilateral visual neglect, and hearing.
Screening often incorporates the use of targeted questionnaires with the individual and family members. Keep in mind, however, that changes post RHD are not always recognized by the individual or family members.
Screening may result in
- recommendation for comprehensive speech, language, swallowing, cognitive-communication assessments and/or
- referral for other examinations or services (e.g., complete audiologic assessment and/or vision testing; assessment by a psychiatrist or neuropsychologist).
Consistent with the World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2016b; WHO, 2001), comprehensive assessment is conducted to identify and describe
- impairments in body structure and function, including underlying weaknesses in spoken and written language that might affect communication performance;
- co-morbid deficits such as other health conditions and medications that can affect communication performance;
- the individual’s limitations in activity and participation, including changes in, and impact on, functional status in communication, vocation, and interpersonal interactions;
- contextual (environmental and personal) factors that serve as barriers to, or facilitators of, successful communication and life participation; and
- the impact of communication impairments on quality of life, functional limitations relative to the individual’s premorbid social roles, and the impact on his or her community.
See the ASHA resource titled
Person-Centered Focus on Function: Traumatic Brain Injury [PDF] for an example of assessment data consistent with ICF.
Assessment can be static (i.e., using procedures designed to describe current levels of functioning within relevant domains) and/or dynamic (i.e., an ongoing process using hypothesis-testing procedures to identify potentially successful interventions and supports).
Assessment protocols can include both standardized and nonstandardized tools and data sources. The choice of assessment tools and procedures is based on a variety of factors, including the needs of the person with RHD, the clinician’s professional judgment, the complexity of impairment, payer guidelines, and facility policy. See ASHA’s resource on
assessment tools, techniques, and data sources for additional information.
There are few standardized communication assessments for use with patients with RHD (see, e.g., Joanette et al., 2015) and few standardized assessments of cognition normed on individuals with RHD. Functional nonstandardized assessments are particularly valuable for individuals with RHD, whose performance on activities of daily living (ADLs) and more complex tasks may be disproportionately better or worse than their performance as predicted by standardized test scores.
Typical components of a comprehensive assessment of deficits associated with RHD include following:
- Relevant medical history (history of previous strokes or other neurological disorders)
- Patient interview (educational, social, and occupational history)
- Input from family members or others close to the patient, to identify changes
- Impact of deficits on ADLs and overall daily functioning
- Input from other medical professionals (e.g., physical and occupational therapists, neurologist, neuropsychologist, social worker, etc.)
- Cultural and linguistic backgrounds
- Functional communication struggles and successes
- Communication difficulties and impact on individual and his or her family/caregivers
- Contexts of concern (e.g., social interactions, work activities)
- Language(s) used in contexts of concern
- Goals and preferences of the individual
Oral Mechanism Evaluation
- Strength, speed, and range of motion of components of the oral–motor system
- Sequential/alternating movement repetitions (i.e., diadochokinetic rates)
- Steadiness, tone, and accuracy of movements for speech and nonspeech tasks
- Motor speech abilities (see the Assessment section of ASHA’s Practice Portal page on
Dysarthria in Adults)
- Phonation, including pitch and volume
- Language comprehension and production—specifically in discourse-level tasks
- Reading decoding and comprehension—specifically at the paragraph level or longer
- Use of prosody to express feelings, emotion, and tone
- Interpreting prosodic features in the speech of others
- Social communication/pragmatics (see the Assessment section of ASHA’s Practice Portal page on
Social Communication Disorder)
Assessment of Other Cognitive Skills (in the Context of Communication)
The focus of the cognitive assessment is to determine the impact of cognitive deficits on communication (e.g., Blake, 2018). SLPs may conduct these assessments in collaboration with neuropsychologists. Areas assessed include the following:
- Attention (selective, sustained, divided, and alternating; Lezak, Howieson, & Loring, 2004)
- Memory (verbal and nonverbal; short-term, episodic, and working)
- Problem solving and reasoning
- Judgment and safety awareness
- Executive functioning
- Visuospatial awareness in one’s environment (e.g., navigating, finding items on left side; Azouvi et al., 2002)
- Awareness of deficits
- Facial recognition
Feeding and Swallowing Assessment
See assessment section of ASHA’s Practice Portal page on
Factors affecting the assessment of neurogenic dysphagia following RHD include
- level of arousal and cognitive status;
- impairments in trunk positioning and motor control that may impact swallowing;
- visuospatial deficits;
- respiratory status, including presence of tracheostomy and/or use of mechanical ventilation;
- ability to follow commands;
- level of motivation; and
- related neurobehavioral impairments (e.g., perseveration, poor initiation, impulsivity, impaired sequencing, impaired awareness of deficits, reduced self-awareness, reduced attention, confusion).
If the RHD is a result of TBI, then hearing and vestibular testing may be indicated, depending on the individual’s presenting needs. Referral to an audiologist is made, as appropriate. For details, see the Assessment sections of ASHA’s Practice Portal pages on
Hearing Loss – Beyond Early Childhood,
Balance System Disorders, and
Tinnitus and Hyperacusis.
Assessment may result in one or more of the following:
- Diagnosis of a cognitive-communication disorder and other deficits associated with RHD
- Description of the characteristics, severity, and functional impact of the disorder
- Prognosis for improvement (in the individual and in relevant contexts)
- Recommendations for intervention, support, and community resources
- Referral for other assessments or services (e.g., neuropsychologist, physical therapist, occupational therapist, vocational counselor, neuro-ophthalmologist, audiologist)
When selecting the language of assessment for individuals who speak more than one language, it is important to consider the languages spoken, age of acquisition of each language, premorbid use of each language, and language(s) needed for return to daily activities. Clinicians should gather data in all languages used in order to determine degree of impact.
Pragmatic and social norms (e.g., eye contact, turn taking, nonverbal cues, etc.) vary from culture to culture. Cultural differences should not be interpreted as pragmatic deficits. See ASHA’s Practice Portal page on
Cultural Competence for more information.
Appropriate accommodations and modifications can be made to the testing process to reconcile cultural and linguistic variations. Documentation should include descriptions of these accommodations and modifications. Scores from standardized tests should be interpreted and reported with caution in these cases. See ASHA’s Practice Portal pages on
Bilingual Service Delivery;
Collaborating With Interpreters, Transliterators, and Translators; and