Cognitive communication disorder: the central role of the SLT   

Dr Susan Howell, Clinical Researcher and SLT at University College London, shares a case study following a person-centred approach to cognitive communication disorder following traumatic brain injury.  

A traumatic brain injury (TBI) has complex, life-changing impacts and the effect on communication competence can be profound, but these effects are often overlooked because the person can talk.   

Cognitive communication disorder (CCD) following brain injury refers to any aspect of communication that is affected by disordered cognition and a loss of behavioural control following injury (ASHA, 2005). CCDs are most keenly observed at the level of discourse and social interaction.  

As one person with CCD explained: “Communication is everything. It’s about how you interpret the world, how you deal with the hidden little intricate bits like other people’s facial expressions, reading between the lines and how you explain stuff. And if other people interrupt me or ask me to elaborate, I think to myself, ‘I cannot articulate my way around this.’ It’s a head bake.” 

The long-term consequences of a CCD following TBI are well-documented and may undermine the person’s ability to independently manage the communication and interaction demands of everyday life. Best practice and evidence-based recommendations for the assessment and management of CCD were first published in 2014 (Togher et al, 2014). These include: 

• assessment and treatment by a specialist SLT 
• collaborative working within a multidisciplinary team (MDT) of experts 
• person-centred treatment interventions and strategies 
• training for all involved stakeholders 
• communication partner training to maximise capability in everyday contexts 
• evaluation of outcomes from participation in real-world activity. 

These guidelines were reviewed and supplemented with new evidence for the management of both CCDs and disorders of social cognition following TBI (Togher et al, 2023). The guidelines set out the current evidence, treatment approaches and available decision-making tools to guide clinical decision making.  

However, and despite the strengthening of the evidence underpinning these treatment recommendations, there are barriers to their implementation. These include gaps in professional awareness and recognition of the disorder, an underappreciation of the adverse impact of the disorder in everyday life, and gaps in professional awareness of the SLT scope of practice (MacDonald, 2017; MacDonald, 2021). Barriers also include SLT confidence in managing the complexities of the disorder with variable use of best evidence in clinical practice (Riedeman and Turkstra, 2018). 

Case study – The pivotal role of speech and language therapy expertise

In order to learn more about the impact of this evidence-to-practice gap on the person with CCD, their family and the healthcare and legal professionals supporting them, our research team at University College London conducted an investigation into the views of a diverse group of stakeholders each involved in a single case of a community dwelling individual.   

BB, a pedestrian who sustained a severe traumatic brain injury, was discharged after 10 months of acute and post-acute rehabilitation without his cognitive communication disorder being identified, resulting in no onward referral for speech and language therapy. His communication difficulties, initially misinterpreted as behavioural issues, were later recognised by a care expert, leading to the involvement of a new multidisciplinary team including SLTs, for assessment and intervention. Using semi-structured interviews with healthcare and legal professionals, data was analysed through a thematic framework, revealing four key themes: 

1. SLTs were viewed as central to the MDT, supporting other professionals by facilitating information sharing, managing complex interactions and developing communication strategies.  
2. SLT input led to significant changes in professional understanding and practice, with staff adapting their language, tone, and methods of communication. Tools like scripts, structured messages and phrasebooks proved especially useful in supporting BB.  
3. SLT intervention improved BB’s quality of life, relationships, decision-making capacity and autonomy.  
4. Finally, the case exposed barriers to accessing CCD expertise, including poor awareness of CCD in rehabilitation settings and inconsistencies in SLT training. This case underscores the need for earlier identification of CCD, improved professional training and better application of evidence-based practices across services. 

Going forward, raising awareness of CCD amongst professional groups providing rehabilitation services for people with TBI is a priority. This case has investigated the knowledge and training needs of these groups and shown the dependence of non-clinical professionals on clinical expertise for diagnosis and referral. Findings from our research can be used by other stakeholder groups to promote awareness of cognitive communication disorder and the SLT role within the multidisciplinary team. 

The full version of this article was first published in the spring 2024 issue of Bulletin (pages 44-46). 

The RCSLT is currently developing new online guidance on Cognitive Communications Disorders (CCD) and as part of our consultation phase we are now looking for feedback on the current drafts. Review the guidance and share your views by Tuesday 23 September 2025 at 12pm.