Right Hemisphere Damage


See ASHA's  Right Hemisphere Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective. See also ASHA’s Evidence Maps on Stroke and Traumatic Brain Injury for information related to right hemisphere damage in these populations.

Treatment for RHD is individualized to address areas of need identified in the assessment, taking into account the goals identified by the individual and his or her family.

Treatment occurs in the language(s) used by the individual with RHD—either by a bilingual SLP or with the use of trained interpreters, when necessary. See ASHA’s Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators.

Consistent with the WHO (2001) ICF framework, the goal of intervention is to help the individual with RHD achieve the highest level of independent function for participation in daily living.

Intervention is designed to

  • capitalize on strengths and address weaknesses related to underlying structures and functions that affect communication across partners, activities, and settings;
  • facilitate the individual’s activities and participation by teaching new skills and compensatory strategies to the individual with RHD and to his or her communication partner(s); and
  • modify contextual factors that serve as barriers and enhance those that facilitate successful communication and participation, including adjusting the environment; informing listeners about the individual’s cognitive/communication needs; and encouraging the speaker to use strategies in everyday interactions.

See the ASHA resource titled Person-Centered Focus on Function: Traumatic Brain Injury  [PDF] for an example of functional goals consistent with ICF.

Treatment Approaches

Treatment can be restorative (i.e., aimed at improving or restoring impaired function) and/or compensatory (i.e., aimed at compensating for deficits not amenable to retraining).

Treatment approaches—whether restorative or compensatory—can focus on specific functional skills (e.g., composing and sending emails) or underlying processes (e.g., attention, memory, executive function) that affect a range of skills.

Treatment Options and Techniques

Below are brief descriptions of treatment options for addressing RHD, grouped into broad categories. This list is not exhaustive, and the inclusion of any specific treatment does not imply endorsement from ASHA. The majority of the treatments below are based on theories of RHD and treatments designed for disorders caused by brain injury.

Treatment selection depends on the communication needs of the individual, the preferences of the individual and his or her family, and the presence of co-occurring conditions that might affect the individual’s insight into limitations or ability to implement some compensatory strategies.  

For a detailed discussion of treatment of RHD, see, for example, Blake (2018), Myers (1999), and Myers (2001).

Language

Treatment for language deficits associated with RHD typically focuses on narrative and conversational discourse, understanding and managing alternate meanings, and pragmatics.

Narrative and conversational discourse skills include the ability to make inferences and understand global meanings of discourse (e.g., topic, gist, big picture). Treatments that target these skills include the following:

  • Guided inference-generating tasks in which the individual labels items in scenes or stories, identifies the relevant or significant items, and explains the relationship among items in an effort to arrive at an inference.
  • Macrostructure tasks such as
    • identifying the “big picture” of news stories, picture scenes, or conversations by generating headlines for the news stories, titles for the pictures, or the gist of a conversation and
    • organizing printed sentences into a narrative, placing pictures into a logical sequence, or arranging pieces of a puzzle—sentences, pictures, and puzzles can vary in degree of complexity, explicitness, or amount of detail.

Understanding and managing alternate meanings involves the ability to understand lexical ambiguities, generate alternate meanings, and understand nonliteral language. Treatments that target these skills include

  • grouping words according to their connotative meaning (e.g., positive or negative associations);
  • providing multiple meanings for homographs (e.g., left = direction vs. left = went) or homophones (e.g., “son” vs. “sun”);
  • resolving lexical (word) ambiguities based on contextual cues;
  • interpreting figurative language such as metaphors and figures of speech (Lundgren, Brownell, Cayer-Meade, Milione, & Kearns, 2011);
  • generating alternative meanings to ambiguous sentences; and
  • adding a “next sentence” (after being given a sentence with several possible interpretations) to disambiguate the intended meaning.

Treatment for pragmatic deficits focuses on improving skills to support successful social communication in a variety of settings. Techniques used to practice these skills include coaching, one-on-one rehearsal, role play, group practice, visual and verbal feedback, and video modeling.

Some approaches focus specifically on conversational skills and include

  • increasing appropriate use of conversational conventions such as head nods (to indicate understanding or agreement) and eye contact (to indicate attention to and interest in content) and
  • decreasing use of barriers to successful conversation such as poor turn taking, interruptions, tangential comments, and abrupt beginnings and endings.

Other approaches target the skills that underlie and support all social communication. These skills include the ability to

  • communicate one’s thoughts effectively and in an organized manner;
  • be assertive when necessary;
  • actively listen to communication partners;
  • use and interpret nonverbal communication cues;
  • regulate one’s own emotions;
  • respect social boundaries; and
  • adopt a theory of mind by
    • understanding other peoples’ beliefs, attitudes, and emotions and using that understanding to navigate social situations;
    • understanding that one’s own beliefs may differ from the beliefs of others; and
    • inhibiting one’s own beliefs in order to understand the beliefs of others.

Pragmatic and social norms (e.g., eye contact, turn taking, nonverbal cues, etc.) vary from culture to culture. It is important to consider the individual’s background and cultural needs when determining deficits and addressing goals related to pragmatics. See ASHA’s Practice Portal page on Cultural Competence for more information. See also ASHA’s Practice Portal page on Social Communication Disorder.

Prosody

Treatment for prosodic deficits focuses on variations in pitch, loudness, and rhythm—the suprasegmental features of communication that convey meaning. Treatment may address expressive deficits (i.e., difficulty using prosody to express feelings, emotion, and tone) or receptive deficits (i.e., difficulty interpreting prosodic features in the speech of others). See, for example, Leon et al. (2005), Rosenbek et al. (2004), and Rosenbek et al. (2006).

Direct treatment approaches to improve prosody include

  • prosodic production drills to improve conscious control of prosody such as
    • asking the person to imitate or read printed sentences and vary prosodic contours to convey different emotions (e.g., happiness, sadness, surprise) and
    • using contrastive stress tasks to practice manipulating prosodic features to alter meaning—the person is asked to repeat a sentence multiple times, each time in answer to a question that requires a different stress pattern; 
  • imitation/modeling tasks using a hierarchical approach that begins with in-unison production of a target, then repetition (imitation) of the target, and, finally, production of the target with cues but no model; and
  • tasks to improve the person’s ability to recognize prosodic features of spoken targets such as
    • listening to sentences with prosodic contours that convey different emotions (e.g., anger, surprise, sadness) and then identifying the emotion and
    • judging whether two target items (e.g., words, phrases, or sentences) differ from one another in pitch, loudness, and/or pattern of stress.

Treatment can also involve the use of compensatory strategies, including

  • identifying cues other than prosody that convey emotions (e.g., word choice, facial expression, body language, verbal cues);
  • asking communication partners to explicitly state their emotions at the beginning of a conversation to help avoid misinterpretation (e.g., “I’ve been really upset today.”); and
  • encouraging the person with RHD to explicitly state his or her emotional state or intent at the beginning of a conversation.

Attention, Memory, and Executive Function

Treatment for cognitive deficits that have an impact on language following a right hemisphere injury focuses on attentionmemory, and executive functioning (see, e.g., Tompkins, 2012).

SLPs engage in professional practice in all areas that impact communication, including cognition (ASHA, 2016b). The cognitive treatments listed in this section utilize language-based materials and tasks and focus on the ultimate goal of improving communication.

Attention

Direct approaches are aimed at improving one or more types of attention (sustained, selective, alternating, and divided). These approaches include

  • computerized attention training programs (e.g., monitoring a computer screen for a target that appears in one of four quadrants);
  • cancellation tasks that require the person to selectively attend to one or more target type within an array of targets; and
  • cancellation tasks that switch targets one or more times during the completion of the task requiring an alternate response each time the target changes.

Metacognitive and compensatory strategies help the person sustain attention to a task or goal until it is completed. They include

  • using systems, tools or strategies (e.g., graphic organizers or charts) that facilitate successful completion of a goal, such as breaking the goal into smaller steps, developing a timeline to complete each step, self-monitoring (often with use of an external timer), and evaluating performance at regular intervals; and
  • writing down thoughts and ideas that can potentially distract from the task at hand—then returning to the list after the task is completed.    

Environmental modifications are changes to the environment aimed at minimizing distraction. They include

  • avoiding or modifying problematic or distracting settings (e.g., turning off or moving away from the TV; avoiding noisy restaurants); 
  • choosing the best time of day to complete important tasks (e.g., early in the day when the person is least tired); and
  • organizing work space and removing items that are distracting.    
Memory

Treatment for memory deficits typically are compensatory in nature. They include the use of external reminders and internal strategies.

External reminders include

  • to-do lists;
  • note-taking (e.g., during phone calls or meetings);
  • calendars to keep track of appointments and important events;
  • alarms and timers that can serve as medication reminders or that signal an upcoming appointment;
  • journals to document details of events or activities;
  • labels (e.g., on cabinets and drawers) to indicate content; and
  • photographs (e.g., representing a sequence of steps in a tasks).

Internal strategies include

  • mnemonics (e.g. creating an acronym or phrase using the first letter of each item in a list);
  • visualization and rehearsal (e.g., repeatedly visualizing a task being performed and completed);
  • repetition and rehearsal of information (e.g., a grocery list or phone number); and
  • semantic elaboration (e.g., identifying and describing as many salient features as possible of the information to be remembered; associating/linking the information with preexisting knowledge).
Executive Function

Treatments for executive functioning deficits are functional in nature and typically focus on skills like solving problems, thinking flexibly, setting and completing goals, staying on task, and keeping organized. They include the use of metacognitive and compensatory strategies (see, e.g., Sohlberg & Turkstra, 2011) and environmental modification.  

Metacognitive and compensatory strategies include

  • problem-solving systems (e.g., identifying and describing a problem; brainstorming solutions and possible outcomes; choosing and trying the best solution; evaluating the outcome; and selecting an alternate solution, if necessary);
  • systems to set and accomplish goals (e.g., breaking goal into smaller steps, developing a timeline to complete each step, evaluating progress at regular intervals); and
  • devices to serve as reminders to stay on task or return to task (e.g., timers set to take a break or return to work from a break).

Environmental modifications to facilitate organization include

  • making sure that items and materials are stored near where they will be used (e.g., paper is near printer; pens and pencils are on desk);
  • labeling boxes, drawers, cabinets, and so forth, to indicate content; and
  • color-coding tabs in a file drawer to identify categories (e.g., medical records or bills).

Other

Unilateral Neglect

Unilateral neglect is considered to be an attention disorder, and it frequently occurs with anosagnosia. Unilateral neglect can affect visual, auditory, tactile, and olfactory modalities as well as movement. This treatment section focuses on left visual neglect, particularly as it affects language processing and communication.

Treatments include

  • completing tasks that require scanning across the entire visual field emphasizing the left side (e.g., reading text passages, describing a picture, and locating and picking up objects in the environment, given verbal instructions); 
  • providing verbal or physical cues (e.g., “start at the red line” or “look to the left”) to encourage leftward gazing or scanning when reading;
  • completing tasks that encourage leftward scanning by virtue of the stimulus itself—for example, presenting a sentence or paragraph that spans both the neglected and the non-neglected space and that requires the person to read the words in the neglected space in order to understand the sentence; and   
  • engaging in virtual reality experiences using computer programs that allow the person to practice three-dimensional navigation of an environment (e.g., interacting with a group of people during a meeting; noticing and reading signs while driving, crossing the street, or taking a walk in a crowded city).
Awareness

Treatments to increase awareness and consequences of deficits include

  • providing feedback (e.g., verbal and visual) when an error occurs during completion of a task and reviewing performance before proceeding with the task;
  • providing verbal and visual feedback after completion of a task (e.g., by video recording the performance and then reviewing the recording afterward);
  • asking the person to plan how to complete a specific task (e.g., using a graphic organizer or chart), predict how well they will perform the task, and then evaluate their performance by comparing it to the earlier prediction;
  • increasing awareness by discussing deficits with the person, having him or her predict how these deficits might affect day-to-day functioning, and then talking about ways to minimize any negative consequences;
  • increasing awareness as it relates to safe swallowing (e.g., being aware of residual food in oral cavity); and
  • incorporating family members, loved ones, co-workers, and employers, when appropriate, into treatment to reinforce changes and increase awareness.

Service Delivery

See ASHA's Right Hemisphere Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective. See also ASHA’s Evidence Maps on Stroke and Traumatic Brain Injury for information related to right hemisphere damage in these populations.

In addition to determining the optimal treatment approach for individuals with RHD, other factors include the availability of specific types of services in a particular region, insurance coverage, pattern of recovery, potential for returning to school or work, and service delivery options, including the following:

  • Format—structure of the treatment session (e.g., group vs. individual)
  • Provider—person providing the treatment (e.g., SLP, multidisciplinary team, trained volunteer, caregiver)
  • Dosage—frequency, intensity, and duration of service
  • Timing—timing of intervention relative to the onset of RHD
  • Setting—location of treatment (e.g., inpatient or outpatient hospital units, skilled nursing facilities, home, or community-based settings)

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.