Great news! Resurgence patients can now manage appointments & billing online 24/7.

Wait, an SLP can help with thinking??

Since March is National Head Injury Awareness month, I wanted to talk about a common  secondary disability that happens with brain injury; cognitive deficits.  On the Resurgence Neuro Rehab facebook page, I put together a little video that talks about what the word “cognition” really means.  My hope for this post is to explain that, as well as explain a little bit about impairments in cognition, and how I can help with that.


Cognition is the act of thinking.  But, thinking involves several smaller processes.  So, let’s say we want to think about a phoenix; the beautiful mythical bird that is Resurgence Neuro Rehab’s logo.  Before we can think about anything, we have to be able to hold our attention to that thought; we have to pay attention to the phoenix to be able to talk about it.  We also use our memory to remember what we want to think about.  (If we cannot pay attention to it, it’s not likely that we will remember it.)  


Then, we have to be able to sequence our thought about the phoenix; perhaps we need to sequence the words so that when we express our thought verbally it makes sense to the person it is being expressed to.  (“think beautiful the I is phoenix” vs. “I think the phoenix is beautiful.”)  Or, perhaps we are giving a presentation and we need to logically sequence our points.  Then, we problem solve; that might be the ability to reorder our thoughts/words so that it makes logical sense, or recognizing an error when we expressed our thought and being able to correct our “mistake.”  


Which, brings me to the concept of error awareness; that’s part of cognition, too!  We have to be aware of our errors so that we can correct them,or modify our behavior/message to be better understood by our audience.  Additionally, we need to put our thoughts into a message, and deliver it effectively.  


The act of putting all those previously stated concepts together to perform a task is called “executive function.”  So, if we were giving a presentation on the phoenix, we would attend, remember, sequence, problem solve, and be aware of our errors, so that we can execute our task of presenting about the phoenix.  


There are other areas that relate to cognition that an SLP can address.  To highlight a lesser known talent, some of the more subtle deficits can affect communication as well, like inferencing.  


If I am having a conversation with a person talking about the phoenix, who has had a brain injury, and I roll my eyes when s/he starts talking, that person may not put the thoughts together that I’m rolling my eyes, therefore I might not want to talk about the phoenix.  That person may not have noticed I was having a deep conversation with my friend about a sick relative at the moment s/he came to tell me about their admiration of the phoenix.  So, brain injury can affect a person’s social language, as well.  


So, 2 people talking, with one person crying, probably means, I should not go up to them and randomly talk about a phoenix.  That’s making an inference.  And, a speech language pathologist can work on the ability to inference as part of cognitive therapy.


Maybe I wasn’t talking to my friend about anything, maybe I was sitting alone, looking sad, and s/he wanted to cheer me up.  And so rather than rolling my eyes, I smile and say, “Yeah, the phoenix is a truly beautiful bird.”  But the person with brain injury couldn’t take what I said and make sense out of it, and s/he doesn’t know how to respond, therefore introducing a different topic of conversation.  Topic maintenance is another lesser-known area an SLP can address.


There’s also the problem of conversation dominance. or turn-taking.  Some people like to hear themselves talk.  Sometimes, people are just excited to be talking to another person!  Sometimes, people dominate the conversation because they cannot make sense of what other people are saying.  They dominate the conversation to avoid showing they are having trouble with understanding.  Maybe it’s language processing, maybe it’s a hearing issue; An SLP can work on that, too!


Shew!  That’s several processes for just thinking!  And those aren’t really all…  there are several different types of attention and several different kinds of memory, to break it down further.  I’ll save all of that for another post.


Now, let’s talk about where thinking happens!  I think we take thinking for granted; it just happens for most of us. Using the above example, we have a thought about the phoenix.  Our brain sends a message to the language center to put that thought into words:  ‘I think the phoenix is beautiful” and our brain sends a message from the thought language center, to our lungs, lips, tongue, cheeks, teeth, velum, and larynx to express that same sentence, verbally.  The thought, “I think the phoenix is beautiful” then comes from our brain, out our mouth, to an audience.  The audience typically provides some type of feedback; our eyes see their body language, our ears hear their voice, our brain processes the language, forms a reaction and the whole process starts again!  Neurologically it is way more complicated than that, but for this post’s purpose, the rough synopsis will suffice. But the thought moves from one part of the brain to another part of the brain through a series of neurons & synapses.  


We have chemicals in our brains that are essential for all of this to happen.  Neurotransmitters.  Neurotransmitters are everything!  The right balance of neurotransmitters is key to our brain’s being able to send the messages through our entire nervous system. 

For example, dopamine is the neurotransmitter for motor movement.  Parkinson’s disease is marked by the death of dopamine cells in the brain; people with Parkinson’s disease have difficulty regulating the motor movement as evidenced by shuffling gait, rigid movements, decreased facial expression etc.  Conversely, people with schizophrenia have an excess of dopamine in their systems.  Too little dopamine = Parkinson’s disease, too much = schizophrenia.  


There are 7 major neurotransmitters in our bodies, each with specific tasks.  When 1 gets out of whack, for whatever reason, our brain and our body goes a little bit haywire.  


Noradrenaline,  or norepinephrine, is responsible for alertness, attention, focus, and memory storage.  Scientists have associated damage to this neurotransmitter with Alzheimer’s type dementia.  


Dopamine, serotonin, and acetylcholine play an important role in our cognitive abilities.  Additionally, histamines play an important role in our wake/sleep cycle, as they control our hormones, heart rate, & metabolism.  If you can’t stay awake, you can’t think, communicate, or safely swallow.  


Let’s talk about those reasons our brain/our thinking might go haywire.  Well, head injury, medications (SLP’s have a list of medications that affect cognition and a list that affects swallowing), illness, medical events (like a stroke), prolonged depression, Post Traumatic Stress Disorder, and neurologic disease, to name a few, can change the balance of neurotransmitters in our system.  Our neurotransmitters decrease by 50% as we age.


Let me quickly summarize:  Our brain has several areas within it, that contribute to our ability to think.  In addition, the brain requires a balance of neurotransmitters to think efficiently and clearly.  There are inside and outside factors that contribute to the health of our brain and the balance of neurotransmitters, which impact our ability to think.


Now that we have all that down, let’s talk about head injury.  Head injury can be traumatic (like being hit in the head, concussion, a vehicle accident, sports injury…) or non-traumatic (a medical event; stroke, encephalopathy, metabolic disorders, meningitis…)


Either type may affect a person’s ability to think!  Sometimes that difficulty comes out as a language deficit, sometimes it comes out as a speech clarity problem, sometimes it can present as a coordination issue, like having problems coordinating breathing and speaking or breathing and swallowing.  Sometimes it can show up as a comprehension deficit; difficulty understanding speech, body language, or spoken or written language.  And that is a speech language pathologist’s area of expertise!  


As a speech language pathologist, I have the privilege of working with cognitive disorders because they usually affect communication and swallowing.  And, what a privilege it is to watch the transformation before our very eyes, of someone who relied on a caregiver to complete basic daily tasks for them to be able to complete that task independently or with a little assistance.  Man, there’s nothing in the world like it!  


I sit here and recall a beautiful transformation of a former client who suffered a brain injury from illness; required 100% assistance to complete basic grooming tasks at the start of therapy.  I co-treated with the OT, who worked on the physical ability to complete the task, while I worked on the cognitive piece.  After some time (and a lot of pep-talks) the client was able to complete all bathing/grooming tasks safely and independently to return home.  Everyone was so happy!  That person was depressed, too.  A major medical event like that, not only impacts memory, it affects state of mind!  


It is not uncommon to find people with cognitive issues to also have mood disorders.  Which came first?  It can be difficult to discern.  But, when you think about neurotransmitters, it makes sense that people with cognitive difficulties may also have depression, and that people with depression may also have cognitive issues.


In a very interesting study, Wang et. al (2018) found a link between antidepressant use and dementia; in their study, people who used antidepressants were at a significantly higher risk for dementia than people who did not take antidepressants.  In a class I took with Peter Johnson, an SLP with expertise in cognitive disorders, he stated that people with more than 10 years of depression are 2x more likely to develop Alzheimer’s disease.  


We know that PTSD creates a change in the brain that increases the fight or flight response, thus increasing adrenaline (so we can fight or flight).  When we are either fighting or flighting, we aren’t thinking; we are reacting to stay alive, therefore we don’t have much attention, memory, sequencing, or effective problem solving; we are solely in survival mode.  The very cool, yet not-so-good thing about the brain is that, what we repeat, we continue, and then our brain can lose an ability that we are not repeating.  So, if a person is stuck in fight or flight mode for an extended period of time, the brain can lose its ability to use attention, memory, sequencing problem solving, and/or error awareness, without skilled intervention.  Guess who can provide skilled intervention?  If you said, “an SLP,” you’re right!  


Cognitive abilities are necessary for our daily function.  When we brush our teeth, we use our cognitive abilities.  When we go to work and do our jobs, we use our cognitive abilities.  Even when you don’t think you’re thinking, you are, and you’re using your cognitive abilities.  

In fact, just the act of thinking about thinking has a special label:  meta-cognition.  I use meta-cognitive approaches in my cognitive therapy approaches!  It’s quite effective!  This bring me to the most fascinating, mind-blowing concept of neuro-plasticity.  I talk about it a lot.  Like, a LOT!!  Not just because it blows my mind, but because I like to prove to people that you are never too old to learn something new.  


Your brain is never too old to learn a new habit.  NEVER!  All you have to do is think about thinking or the task you are trying to complete.  Your brain has the ability and the power to create new pathways, therefore create new behaviors, habits, and abilities.  


So, if you happen to have difficulty thinking, remembering, or performing cognitive tasks that used to be easier, please call me.  704-264-0528.  I may be able to help!  I have evaluation materials that will show me which part of the thinking process you are having trouble with, so that I can immediately begin helping you retrain your brain!  


I hope you found this post informative and as always, if you have any questions or suggestions for upcoming topics, please email me!



Michelle Hill MS CCC-SLP is a speech language pathologist and Owner/Founder/CEO of Resurgence Neuro Rehab.

Great news! Resurgence patients can now manage appointments & billing online 24/7.