RHD is most commonly caused by a stroke or other acquired brain injury (e.g., stroke, tumor) that impacts the right hemisphere of the brain. RHD is a constellation of changes in

• pragmatics—the ability to convey or comprehend meaning or intent of a message;
• discourse—the ability to understand or produce verbal and written language in units longer than single sentences; and
• cognitive-communication skills—the cognitive skills that are needed for effective, clear communication, including attention, memory, executive function, visual-perceptual skills, and/or awareness of deficits.

Communication deficits caused by brain injury often co-occur with other cognitive deficits. These include the following:

• Anosognosia—reduced awareness of neurological deficits and other changes following brain injury.
• Unilateral left neglect—reduced attention to and awareness of stimuli on the left side of an individual’s visual field, body, or environment.
  • Egocentric unilateral spatial neglect (i.e., reduced awareness of visual stimuli to one side of the individual’s midline) is the most common (Kleinman et al., 2007).
  • Neglect may involve visual, auditory, somatosensory, or kinetic modalities.
  • This may co-occur with neglect dyslexia—misreading or not detecting text on the left side of the page or on the left side of words (Siéroff, 2017).

Word retrieval, syntax, morphology, and phonological processing are not typically affected by injury to the right hemisphere. However, these deficits occur with right hemisphere stroke in a small percentage of patients. This phenomenon is called crossed aphasia. This condition may occur in people with language dominance in the right hemisphere at baseline. Most people are left hemisphere dominant for language, so crossed aphasia is rare.

Although the deficits associated with RHD may be subtle in highly structured contexts, they are often more apparent during dynamic and/or complex tasks such as conversation (Ferré et al., 2011). These deficits can significantly impact functional performance in social and vocational settings (Blake, 2006; Lehman & Tompkins, 2000).

Realizing the potential impact of RHD on daily functioning is particularly important, as the deficits experienced by people with acute RHD often go unrecognized and undiagnosed (Edwards et al., 2006). This may lead to reduced referrals for speech-language pathology or other rehabilitation services and prolonged, negative impacts for people with RHD. In addition, RHD can lead to disrupted social relationships (Hewetson et al., 2021) and difficulty maintaining jobs and other social activities (Tompkins, 2012).

Incidence is the number of new cases of a disorder or condition identified in a specific time period.

Prevalence is the number of individuals who are living with a disorder or condition in a given time period.

There are no population-level statistics on the incidence and prevalence of RHD. Therefore, the following estimates should be interpreted with caution. Statistics are most often reported within stroke populations because of the localized nature of RHD.

Hospital-based studies have reported that 42.3%–47.2% of people presenting with stroke have right hemisphere strokes (Deb-Chatterji et al., 2022; Hedna et al., 2013; Portegies et al., 2015). However, these statistics may be an underestimate. Patients may be less likely to seek medical attention with right hemisphere stroke due to diminished insight into their new deficits and the reduced recognizability of RHD symptoms (e.g., visual or cognitive-communication deficits) when compared to those of the left hemisphere (e.g., aphasia; Deb-Chatterji et al., 2022; Foerch et al., 2005).

The reported rates of disorders of the right hemisphere are as follows:

• Anosognosia is frequently present in individuals with traumatic brain injury; however, prevalence rates are not available for individuals with right hemisphere damage in isolation. Across multiple studies, 76.9%–97.1% of individuals with traumatic brain injury had limited awareness of deficits at discharge (Steward & Kretzmer, 2022). Persistent deficits were noted in 66.2%–87.5% of these individuals in the subacute stage, and 35%–60% of individuals continued to have reduced insight at 6–10 months post-injury (Steward & Kretzmer, 2022).
• Aprosodia is estimated to be present in 50%–70% of individuals with right hemisphere brain damage (Sheppard et al., 2020; Ukaegbe et al., 2022).
• Cognitive-communication deficits are estimated to occur in 50%–90% of all individuals with right hemisphere brain damage (Ferré & Joanette, 2016; Hewetson et al., 2017).
• Crossed aphasia (i.e., aphasia that results from right hemisphere brain damage) is rare. Historical reports have estimated that crossed aphasia occurs in under 3% of individuals with vascular etiologies (Lahiri et al., 2019). However, one recent study reported crossed aphasia in 6.73% of individuals with first-time strokes (Lahiri et al., 2019).
• Pragmatic deficits were reported in 16.3%–29.6% individuals with right hemisphere brain damage in two retrospective analyses of an inpatient rehabilitation unit (Blake et al., 2002, 2003). However, these numbers likely underestimate the prevalence of pragmatic deficits in this population due to reduced SLP referral and a general lack of comprehensive evaluation of pragmatic skills (Blake et al., 2002).
• Spatial neglect is estimated to occur in 33%–82% of individuals with right hemisphere stroke (Barrett, 2021). The overall prevalence of neglect dyslexia in individuals with RHD is not known. However, one study of 138 individuals with right hemisphere stroke found that 22.5% exhibited neglect dyslexia during the acute phase of their recovery (Lee et al., 2009).

RHD results in a collection of symptoms that vary in severity and in domains affected depending on the site and extent of injury. For a detailed discussion of signs and symptoms associated with RHD, see Blake (2018).

Below are examples of symptoms grouped by domain. Individuals may not present with all symptoms.

Apragmatism

Apragmatism is when a person has difficulty conveying or comprehending the meaning or intent of a message within a specific context. Contexts can include the conversational partner(s), environment, culture, or goals of the interaction. Apragmatism is a primary communication impairment in RHD (Minga et al., 2023).

Apragmatism can be divided into three areas: Linguistic, paralinguistic, and extralinguistic.

• Linguistic apragmatism—the inability to use contextually appropriate words to convey or understand meaning. A person with RHD may
  • have trouble using or recognizing sarcasm, jokes, figurative language, or information that can be interpreted in multiple ways (Lundren & Brownell, 2016);
  • have difficulty making inferences or understanding global meanings of discourse—such as the implied main idea or the overall gist of the story or discussion (Tompkins et al., 2004, 2008); and/or
  • be tangential or verbose and may interrupt—or may have reduced verbal output (Blake, 2006).

• Paralinguistic apragmatism—the inability to use changes in the intonation, pitch, amplitude, or stress of speech (i.e., prosody) to convey or understand meaning. A person with RHD may
  • have aprosodia—or the inability to understand and express meaning and emotion through the use of variations in pitch, loudness, intonation, and rhythm (Stockbridge et al., 2022).

• Extralinguistic apragmatism—the inability to use nonverbal aspects to convey meaning. A person with RHD may
  • have a reduced ability to use or interpret other nonverbal communication— such as
    • variations in facial expressions,
    • body language, and
    • the use of gestures or eye contact.

Cognitive Communication

RHD affects aspects of cognitive communication that impact how the person interacts with others and with their environment. Common areas of impairment include

• awareness of deficits;
• attention (all forms, including unilateral neglect);
• memory;
• executive functioning (e.g., working memory, inhibitory control, cognitive flexibility);
• problem solving;
• reasoning and judgment; and
• sequencing.

For more information about the executive functioning deficits that occur across brain injuries of varying etiologies, please see ASHA’s Practice Portal page on Executive Function Deficits.

Discourse

RHD also affects discourse—language units larger than a sentence that have a specific purpose and meaning together.

Discourse-level communication involves cognition and language—both of which are commonly impaired in RHD. As such, subtle deficits in cognition and/or language may be more apparent in discourse-level tasks than in discrete tasks.

Cognitive deficits in RHD may make efficient and appropriate discourse management challenging. However, healthy aging can also contribute to changes in discourse over time. Clinicians can determine if there are any baseline or age-related factors that may influence a patient’s discourse-level communication to understand the true impact of RHD.

Discourse-level changes may impact the following:

• Coherence—the ability to maintain a topic and to connect statements, ideas, and thoughts across a conversation.
  • May have difficulty identifying and including important information.
    • May include too little relevant information about stories and procedures.
    • May disproportionately exclude inferred content (vs. explicit content).
  • May have difficulty suppressing tangential or irrelevant information.
    • May have difficulty suppressing information about themselves or about a topic for which they feel strongly.
    • May struggle to present information sequentially.
• Cohesion—the ability to consistently refer to content the same way throughout a conversation (e.g., using the pronoun “she” to refer to a singular person unless a new person is introduced).
  • Requires functional attention and working memory to
    • track references from sentence to sentence,
    • plan and adapt to listener knowledge, and
    • monitor listener understanding.
  • May have difficulty with ambiguity, such as when to use “a” versus “the” to convey introduced content (Barker et al., 2017). They may vary the label when referring to the same subject, which can lead to confusion for their conversational partner (Stockbridge et al., 2022).
• Conversational or social skills—the ability to initiate conversation, ask questions (Minga et al., 2020), and take turns.
  • May have difficulty identifying instances of communication breakdown and misunderstanding or may have difficulty achieving effective conversational repair when they do identify a breakdown.

Other Deficits

Other deficits that may be associated with RHD include

• pseudobulbar affect, which can cause lability (e.g., crying or inappropriate laughing); difficulty interpreting and conveying emotions;
• reduced empathy;
• egocentrism, or the use of language that is excessively self-focused and preoccupied with the person’s own thoughts, feelings, and needs;
• dysphagia;
• dysarthria; and
• hemiparesis/hemiplegia.

See ASHA’s Practice Portal pages on Adult Dysphagia and Dysarthria in Adults.

RHD may result from a variety of changes in the structure or function of the right hemisphere of the brain. These can range in severity and may result in chronic or acute deficits. Changes in the brain include tumors, surgery, infection, stroke, seizure, neurodegenerative conditions, and traumatic brain injury.

Please see the following Practice Portal pages for further information: Head and Neck Cancer and Traumatic Brain Injury in Adults.

SLPs play a central role in the screening, assessment, diagnosis, and treatment of persons with RHD. The professional roles and activities in speech-language pathology include

• clinical/educational services (diagnosis, assessment, planning, and treatment);
• prevention, counseling, and advocacy; and
• education, administration, and research.

See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).

Appropriate roles for SLPs include, but are not limited to, the following:

Assessment

• Screening individuals with a history of right hemisphere brain injury, and determining the need for further assessment and/or referral for other services.
• Conducting a culturally and linguistically relevant, comprehensive assessment of language, communication, and cognition.
• Diagnosing cognitive and communication disorders, the characteristics of these disorders, and their functional impact.

Counseling and Education

• Educating and counseling people with RHD and their care partners on cognitive and communication-related issues, and facilitating participation across contexts (i.e., family, vocational, and community).
• Providing prevention information to individuals and groups known to be at risk for conditions associated with RHD (e.g., stroke and traumatic brain injury).
• Educating other professionals on the needs of persons with RHD and the role of SLPs in diagnosing and managing deficits associated with this disorder.

Treatment

• Making decisions about the management of disorders related to RHD in collaboration with the patient, family, and interprofessional treatment team. See ASHA’s resources on interprofessional education/interprofessional practice (IPE/IPP) and focusing care on individuals and their care partners.
• Developing person-centered treatment plans, providing intervention and support services, documenting progress, and determining appropriate dismissal criteria.

Other

• Consulting and collaborating with other professionals to facilitate program development and to provide supervision, evaluation, and/or expert testimony, as appropriate.
• Advocating for individuals with RHD and their families at the local, state, and national levels.
• Remaining informed of research in the area of RHD and helping advance the knowledge base related to the nature and treatment of RHD.

As indicated in the ASHA Code of Ethics (ASHA, 2023), individuals who hold the Certificate of Clinical Competence shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience.

The clinician considers the following factors that may have an impact on screening and comprehensive assessment:

• language(s) used
• concurrent motor speech impairment (e.g., dysarthria)
• hearing loss and auditory agnosia—the inability to recognize or differentiate between sounds or the brain’s neurological inability to process sound meaning
• visual acuity deficits, visual field cuts, and visual agnosia—the inability to recognize or interpret visual stimuli (e.g., objects, faces)
• upper extremity hemiparesis (may affect the ability to write, sign, or gesture or to access augmentative and alternative communication devices)
• presence of chronic pain (from either preexisting or new conditions) and/or acute pain
• 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)
• emotional and psychological status (e.g., poststroke depression)
• premorbid functional status and social determinants of health
• anticipated/preferred discharge setting (may indicate the level of supervision and independence that would be required to succeed)

If the individual with RHD wears prescription glasses and/or hearing aids, then they should wear these items 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. The individual should be referred to psychology, psychiatry, and/or neuropsychiatry if there are signs or reports of depression, emotional lability, or other psychological issues.

Screening

Screening is a procedure for identifying the need for further assessment and does not provide a detailed description of the severity and nature of the deficits associated with RHD. Screening is conducted in the language(s) used by the person, with sensitivity to cultural and linguistic diversity. Screening 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 neglect, and hearing. Deficits in these skills may be related to RHD.

Screening often incorporates the use of targeted questionnaires with the individual and family members. Keep in mind that changes after RHD are not always recognized by the individual or family members.

Screening may result in

• a recommendation for comprehensive speech, language, swallowing, and cognitive-communication assessments and/or
• a referral for other examinations or services (e.g., complete audiologic assessment and/or vision testing as well as assessment by a psychiatrist or neuropsychologist).

Comprehensive Assessment

Effective RHD assessment relies on patient and care partner interviews to establish baseline communication function and to highlight behavioral changes. Assessment also considers normal age-related changes in cognitive-communication skills when gauging baseline function.

There are few standardized assessments for use with patients with RHD (see, e.g., Joanette et al., 2015). Functional assessment may more accurately predict performance on activities of daily living than standardized assessment and is particularly valuable for individuals with RHD. Assessment considers the impact of RHD on a patient’s quality of life. Appropriate treatment goals target the patient’s cognitive-communication deficits in an effort to restore that person to their maximum functional capacity and quality of life.

Typical components of a comprehensive assessment of deficits associated with RHD include the following:

Case History

• Relevant medical history (history of previous strokes or other neurological disorders).
• Patient interview (educational, social, and occupational history).
• Input from care partners or others close to the patient to identify changes from baseline.
• Impact of deficits on activities of daily living and overall daily functioning.
• Input from other medical professionals (e.g., physical and occupational therapists, neurologist, neuropsychologist, social worker).
• Cultural and linguistic backgrounds, including languages used across different contexts.
• Social determinants of health.

Individual and Care Partner Report

• Functional communication and cognitive-communication struggles and successes.
• Communication difficulties and impact on individual and their family/care partners.
• Contexts in which the individual has difficulty engaging (e.g., social interactions, work activities).
• Goals and preferences of the individual and their care partners.

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. Consider using nonlinguistic tasks to differentially diagnosis motor speech limitations from apragmatism.

Language Assessment, Including Discourse

• Discourse assessment in adults may include picture/picture series description, storytelling, and conversational sampling (Coelho et al., 2022). The SLP can use computerized discourse analysis tools (e.g., Computerized Language Analysis [CLAN]) to compare discourse abilities to the norm.
• Functional language use and quality-of-life self-report measures, including proxy measures, can help capture differences between communication challenges that occur in different environments (e.g., work vs. home).
• Reading decoding and comprehension—specifically at the paragraph level or longer—including looking for evidence of neglect dyslexia.
• Language comprehension and production in a variety of contexts (e.g., conversation, storytelling). See the RHDBank protocol for guidance.
• Discourse analysis to assess the strengths and challenges of various forms of discourse and to help identify treatment targets. This includes global coherence (Leaman & Edmonds, 2021; Wright & Capilouto, 2012), main concept analysis (Dalton & Richardson, 2019), and story grammar (Greenslade et al., 2020).

Pragmatics Assessment

• Linguistic Pragmatics—use of language that is appropriate to the context and is able to clearly communicate intended meanings or interpreting and expressing meaning through the use of word selection and grammar.
• Paralinguistic Pragmatics—use of prosody to understand and express feelings, emotion, tone, and implied information.
• Extralinguistic Pragmatics—the use, recognition, and interpretation of nonverbal cues (e.g., facial expression, eye contact, gesture) for communication.
• Social Participation Pragmatics—the use of pragmatic skills in community settings (e.g., work, family) and how pragmatic skills shape social engagement. This includes
  • social participation restrictions and
  • satisfaction with social participation across multiple settings.

See Minga et al. (2023) for further information.

Cognitive-Communication Assessment

Areas that are assessed in terms of cognitive communication include the following:

• attention
• awareness of deficits
• metacognition, cognitive flexibility, and theory of mind
• impulsivity
• judgment and safety awareness
• memory (verbal and nonverbal; short-term, episodic, and working)
• problem solving and reasoning
• visuospatial awareness in one’s environment (e.g., navigating, finding items on the person’s left side)

Feeding and Swallowing Assessment

Deficits that frequently occur with RHD impact feeding and swallowing. These deficits include

• visuospatial deficits;
• hemispatial neglect; and
• related neurobehavioral impairments, such as
  • level of arousal and cognitive status,
  • poor initiation (e.g., having food in front of them and not eating),
  • impulsivity (e.g., pocketing food, eating quickly and choking),
  • impaired awareness of deficits (e.g., not following diet recommendations), and
  • reduced attention (e.g., difficulty using swallowing strategies).

See the Assessment section of ASHA’s Practice Portal page on Adult Dysphagia.

Audiologic Assessment

Hearing and vestibular testing may be indicated, depending on the individual’s presenting needs. SLPs make referrals to audiologists as appropriate. For details, see the Assessment sections of ASHA’s Practice Portal pages on Hearing Loss in Adults, Balance System Disorders, and Tinnitus and Hyperacusis.

Assessment Results

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.
• Statement regarding prognosis for improvement.
• 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).

Cultural and Linguistic Considerations

Pragmatic and social norms (e.g., eye contact, turn-taking, nonverbal cues) vary among different cultures. Cultural differences should not be interpreted as pragmatic deficits. See ASHA’s Practice Portal page on Cultural Responsiveness for more information.

When selecting the language of assessment, it is important to consider the patient’s preference, language(s) 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 by the client and their care partners to determine the degree of impact.

Prompts and cues used in assessment may not carry the same meaning for individuals from one culture to another. Any accommodations and/or modifications to the testing process to reconcile cultural and linguistic variations should be documented. Scores from standardized tests should be interpreted and reported with caution in these cases. See ASHA’s Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology; Collaborating With Interpreters, Transliterators, and Translators; and Cultural Responsiveness.

Treatment for RHD is individualized to address areas of need identified in the assessment, considering the goals identified by the individual and their care partners.

Treatment is provided in the language(s) used by the individual with RHD. Services may be provided either by a multilingual SLP or in collaboration with trained interpreters. See ASHA’s Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators.

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

Treatment approaches can be restorative, compensatory, or a combination of the two.

• Restorative—goal is to improve the underlying impairment.
• Compensatory—goal is to use strategies to increase success despite existing impairments.

People with RHD often have limited insight into their deficits. This can decrease participation in either therapeutic approach and can limit an individual’s ability to generalize compensatory strategies taught in treatment sessions.

Treatment selection depends on the person’s communication and activity participation needs, the preferences of the person and their care partners, and the presence of co-occurring conditions. See ASHA’s Practice Portal page on Cultural Responsiveness for more information.

Below are descriptions of treatment options for addressing RHD, although there are few published treatment approaches available.

Apragmatism and Discourse

Treatment for apragmatism and discourse focus on improving communication skills across a variety of settings. Treatment often involves making implicit communication practices explicit. SLPs typically work to increase the individual’s awareness of their pragmatic deficits when compared to social norms. The clinician asks questions to better understand the person’s norms and premorbid communication behaviors. Techniques used to practice these skills include coaching, one-on-one rehearsal, role play, group practice, visual and verbal feedback, and video modeling. There are four aspects of apragmatism and discourse:

• linguistic apragmatism
• paralinguistic apragmatism
• extralinguistic apragmatism
• cognitive-communication skills

Each of these four aspects is discussed in the subsections below.

Linguistic Apragmatism

Treatment considers the person’s language use including appropriateness to context, if they can clearly communicate, and if they can correctly interpret the meaning of others’ language. This includes (a) using conversational skills, (b) applying inference and using global meanings of discourse, and (c) understanding and using alternate meanings.

Conversational Skills

Treatment considers the person’s premorbid behaviors and cultural norms and includes explicit instruction on how to use and monitor strategies for successful conversation—for example:

• improved turn-taking
• reduced interruptions
• reduced tangential comments
• less abrupt beginnings and endings
• context-appropriate social boundaries
• improved question asking

Conversational skills may also be supported by providing direct instruction on theory of mind—which is the ability to understand the mental states of others and how their mental states may differ from your own. It includes

• considering others’ beliefs, attitudes, emotions, and intentions in social situations, and
• understanding that one’s own beliefs may differ from other people’s beliefs.

Inference and Global Meanings of Discourse (Topic, Gist, Big Picture)

People with RHD may have difficulty understanding the key points or the core message or topic of conversation.

Treatment includes

• labeling items in scenes or stories,
• identifying the relevant or significant items,
• explaining the relationship among the words and concepts, and
• organizing printed sentences into a narrative or placing pictures into a logical sequence.

Understanding and Using Alternate Meanings

People with RHD may have trouble understanding ambiguities and nonliteral language as well as recognizing multiple meanings of words.

Treatment includes

• grouping words according to their connotative meaning (i.e., alternate or secondary meaning);
• providing multiple meanings for homographs (e.g., “left” = the direction vs. “left” = the verb meaning “went”) or homophones (e.g., “son” vs. “sun”); and
• using context to
  • understand ambiguities (at the word and sentence levels),
  • interpret figurative language such as metaphors and figures of speech (Lundgren et al., 2011), and
  • generate alternative meanings to ambiguous sentences.

Paralinguistic Apragmatism (Prosody)

Paralinguistic apragmatism, or prosody, is the set of variations in the suprasegmental aspects of language (e.g., rate, pitch or intonation, and intensity).

Prosody can convey linguistic content such as rising intonation for a yes/no question or part of speech (e.g., “PREsent” vs. “present”). Prosody also can convey emotional or affective information (e.g., anger, happiness). Deficits in prosody (aprosodia) can be expressive and/or receptive.

For examples of prosodic treatments, see Leon et al. (2005), Rosenbek et al. (2004, 2006), and Durfee et al. (2021).

Restorative treatment of prosody may include the following:

• Explicit instruction in the features of prosody and their role in supporting meaning (Durfee et al., 2021).
• Cognitive–linguistic approach—wherein people with RHD explicitly define the intended emotion and its features and then practice producing those features, with gradually fading cues (Rosenbek et al., 2004).
• Imitative approach—wherein people with RHD imitate clinician productions of target prosodic variations, with gradually fading cues.
• Expressive activities such as
  • manipulating and varying prosodic features during imitation, reading tasks, or conversation to match a target meaning or emotion and
  • using contrastive stress tasks to practice manipulating prosodic features to alter the meaning of a response to a repeated question, such as in the following:
    • Client: Tom went to a football game.
    • Clinician: Tom went to a basketball game?
    • Client: No, Tom went to a football game. 
    • Clinician: Marissa went to the football game?
    • Client: No, Tom went to the football game.
  • Receptive activities such as
    • identifying the emotion(s) conveyed by speakers within the context of audio or video clips;
    • engaging in role-playing exercises;
    • participating in natural conversation with the clinician or other communication partners; and
    • identifying differences and similarities in the prosodic features between multiple audio, video, or spoken samples (e.g., words, phrases, or sentences).

Treatment can also use compensatory strategies, including

• identifying nonprosodic elements that convey emotion (e.g., word choice, facial expressions, body language);
• asking communication partners to state their emotions at the beginning of a conversation to help avoid miscommunication (e.g., “I’m really upset right now”); and
• encouraging or prompting the person with RHD to verbalize their emotional state or intent at the beginning of the conversation.

Prosodic features—and how people use them to convey meaning—vary across languages, and goals may need to be language specific. See ASHA’s page on Phonemic Inventories and Cultural and Linguistic Information Across Languages for more information.

Extralinguistic Apragmatism

Treatment for extralinguistic apragmatism considers the person’s premorbid behaviors and cultural norms and includes explicit instruction on how to use and monitor the following behaviors:

• body language of the person and their conversational partners—for example,
  • changing facial expressions based on the tone of the message
  • using specific gestures to emphasize meaning
• active listening strategies—for example,
  • nodding to indicate understanding as a listener
  • turning toward the person who is talking
• strategies for successful conversation—for example,
  • improved turn-taking
  • reduced interruptions
  • reduced tangential comments
  • less abrupt beginnings and endings
  • context-appropriate social boundaries
  • improved question asking
• theory of mind—the ability to understand the mental states of others and how their mental state may differ from your own. This includes
  • considering the other person’s beliefs, attitudes, emotions, and intentions in social situations and
  • understanding that one’s own beliefs may differ from those of others.

Cognitive-Communication Skills

Attention, memory, and executive functions (discussed in the subsections below) are common targets for treatment in people with RHD (see, e.g., Tompkins, 2012). These skills influence the dynamic aspects of communication and functional independence.

Attention

Restorative approaches are aimed at improving one or more types of attention (e.g., sustained, selective, alternating, divided). Restorative approaches include tasks that require the person to keep a target action or response in mind in the presence of confounding variables—variables such as competing distractors, dual-task training, and task shifting. Treatment options include

• computerized attention training programs (e.g., monitoring a computer screen for a target that appears in one of four quadrants),
• cancellation tasks, and
• recognizing targets or patterns in auditory or visual information.

Task complexity can be varied by the amount of material presented, the rate of presentation, the number of targets, or the relationship between targets (e.g., “Tell me if the next number in the sequence is higher than the one before it”).

Compensatory and metacognitive approaches help the person attend to a task until they complete it. These approaches include the following:

• Using visual systems, tools, or strategies before, during, and after tasks.
  • Before:
    • listing small steps and the expected timeline for each step
    • identifying potential distractions and ways to overcome them
    • predicting performance before the activity
  • During:
    • self-monitoring (e.g., identifying episodes of reduced attention and potential causes)
    • using strategies (e.g., reading aloud, self-talk, timed breaks) throughout, as needed
  • After:
    • comparing expected performance on an activity with actual performance
    • evaluating the value of the strategies used
    • generating new strategies
• Modifying the environment to minimize external distractions, such as
  • avoiding or reducing competing auditory or visual stimuli (e.g., turning off the TV during conversation or other tasks, avoiding noisy restaurants);
  • identifying the best time of day to complete important tasks (e.g., after a nap, before a physical therapy appointment); and
  • organizing the workspace and removing distracting items.

People with RHD may experience three types of attention disorders: unilateral neglect, left-sided neglect, and neglect dyslexia.

Unilateral Neglect

Unilateral neglect is an attention disorder that frequently occurs with anosognosia—reduced insight into one’s own deficits. People with RHD may experience the neglect of visual, auditory, and/or tactile stimuli from one side of their body and/or the environment. This includes proprioceptive feedback—or information sent to the brain that allows an individual to know where their body is in space.

Left-Sided Neglect

Left-sided neglect, is common in people with RHD. This section focuses on one particular subtype—called left visual neglect—particularly as it affects communication and functional independence.

It is important to understand the person’s visual acuity (i.e., how sharp someone's vision is at a distance), and the presence of a visual field cut (i.e., missing a part of the area a person can typically see) before selecting treatment strategies. Clinicians may consult with or refer to neuro-optometry or neuro-ophthalmology as appropriate.

Treatment approaches include the following:

• Implementing and/or teaching task-specific strategies that emphasize the left side for visual scanning. These can be taught to an individual, their caregiver, or both.
  • e.g., highlighting the left edge of a screen/paper or placing high-priority items to the person’s left.
• Selecting stimuli that inherently encourage left scanning.
  • e.g., presenting the person with written sentences in paragraph form, which requires the person to read text in the entire paragraph—including the neglected space—to understand the sentence.
• Using situations that require three-dimensional navigation of the environment.
  • e.g., engaging in route-finding tasks, reading aisle signs while grocery shopping, interacting with unfamiliar partners in the community.

Neglect Dyslexia

Neglect dyslexia is a reading impairment that can occur in people with RHD wherein they omit or misread text on the left side of the page or on the left side of individual words. Treatment can include compensatory strategies designed to draw attention to the left side of the text (e.g., a bold, red line down the left side of the page). Other treatment approaches have been trialed, although there is no consensus as to the best method for treating this disorder (see, e.g., Gordon et al., 1985; Reinhart et al., 2011).

Memory

Compensatory treatment is often used to address memory deficits in people with RHD. This includes the use of external aids and internal strategies.

External aids include

• alarms, timers, and electronic reminders about upcoming tasks or events (e.g., medication reminders, upcoming appointments);
• calendars to track appointments and important events;
• journals to document details of events or activities;
• labels (e.g., on cabinets and drawers) to indicate content;
• note-taking (e.g., during phone calls or meetings);
• photographs and other visual supports (e.g., representing a sequence of steps in a task); and
• to-do lists.

Internal strategies include

• mnemonics—creating an acronym or a phrase using the first letter of each item in a list;
• a rehearsal of information (e.g., a grocery list or phone number) by
  • internal repetition or
  • visualization of a task being performed and completed repeatedly; and
• semantic elaboration—identifying and describing salient features of the information to be remembered, and then linking these features with preexisting knowledge.

Restorative treatment is also used to treat memory deficits. Treatment may include

• recalling information during unrelated tasks,
• computer-assisted training,
• spaced retrieval tasks, and
• working memory tasks.

Please see ASHA’s Practice Portal page on Traumatic Brain Injury for further information.

Executive Functions

Executive functions are also common treatment targets for people with RHD. Please see ASHA’s Practice Portal page on Executive Function Deficits for further information.

Awareness of Deficits

Treatment to increase awareness of deficits and their functional impact include the following:

• discussing and predicting how deficits might affect day-to-day function, and identifying ways to minimize negative consequences
• planning and predicting task performance (e.g., using a graphic organizer or chart), and then comparing predicted and actual performance
• providing feedback either during or after a task, reviewing performance, and generating strategies for improvement
• considering and discussing the core skills needed to complete complex tasks, and identifying the person’s current level of independence for each skill (e.g., to drive independently, people have to be able to see signs and oncoming traffic, remember where they are going, and use dashboard information)
• emphasizing safety and risk avoidance (e.g., being aware of cognitive deficits and their impact on successfully navigating environments and complex tasks)
• incorporating family, friends, and care partners, when appropriate, to provide a personal perspective and insight into changes from trusted sources

The goal of treatments that address anosognosia and that involve increasing one’s awareness is to teach an individual how to use metacognitive skills to reflect on their own performance, challenges, and safety. This can drive the use of compensatory strategies, encourage participation in therapy, and limit risk (e.g., fall risk).

Service Delivery

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). Group treatment for people with RHD provides opportunities to target the dynamic aspects of communication and receive peer feedback.
• Provider—person providing the treatment (e.g., speech-language pathologist, multidisciplinary team, trained volunteer, care partner).
• Dosage—frequency, intensity, and duration of service.
• Timing—timing of intervention relative to the onset of RHD.
• Setting— location of treatment (e.g., hospitals, outpatient facilities, skilled nursing facilities, home, community-based settings). Telepractice may provide an opportunity to introduce multiple settings but may be impacted by the presence and severity of unilateral neglect and other cognitive-communication deficits.

ASHA Resources

• Clinician’s Guide to Cognitive Rehabilitation in Mild Traumatic Brain Injury: Application for Military Service Members and Veterans [PDF]
• Evaluating and Treating Communication and Cognitive Disorders: Approaches to Referral and Collaboration for Speech-Language Pathology and Clinical Neuropsychology
• Focusing Care on Individuals and Their Care Partners
• Interprofessional Education/Interprofessional Practice (IPE/IPP)
• Person-Centered Focus on Function: Traumatic Brain Injury [PDF]
• Right Hemisphere Brain Damage (RHD) [Consumer Information]
• Traumatic Brain Injury (TBI) [Consumer Information]
• Traumatic Brain Injury: A Primer for Professionals

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• American Stroke Association
• Brain Injury Association of America (BIAA)
• RHDBank (for student and video links: User Name = student; Password = access)
• Right Hemisphere Brain Damage
• Right Hemisphere Stroke
• Social Communication and TBI: A Guide for Professionals

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Acknowledgments

Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject-matter expert input and review. ASHA extends its gratitude to the following subject-matter experts who were involved in the development of the Right Hemisphere Disorder page:

• Christine R. Baron, MA, CCC-SLP
• Margaret L. Blake, PhD, CCC-SLP
• Perrine Ferré, MA
• Melissa Johnson, MA, CCC-SLP
• Yves Joanette, PhD
• Kristine M. Lundgren, ScD, CCC-SLP
• Jamila M. Minga, PhD, CCC-SLP
• Ilana F. Oliff, MA, CCC-SLP
• Amy D. Rodriguez, PhD, CCC-SLP
• Victoria L. Scharp, PhD, CCC-SLP
• Shannon Sheppard, PhD, CCC-SLP
• Melissa Stockbridge, PhD, CCC-SLP

ASHA seeks input from subject matter experts representing differing perspectives and backgrounds. At times a subject matter expert may request to have their name removed from our acknowledgment. We continue to appreciate their work.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Right hemisphere Disorder [Practice portal]. https://www.asha.org/Practice-Portal/Clinical-Topics/Right-Hemisphere-Disorder/