Cognition is our ability to take in information and process it. This includes thinking, remembering, communicating and using reason to make decisions/conclusions [1].
We use these skills 24/7, mostly without actively realizing it. After a brain injury, it’s normal for there to be changes to these skills–and it’s normal to need to use different supports and tools to help with day-to-day activities. To find the right supports and tools, it’s helpful to understand the cognitive effects of brain injury.
Let’s talk about:
Attention & concentration
Attention and concentration is the ability to focus on something. You may have been told several times growing up to ‘pay attention’ to something going on (like a teacher talking). Or you may have spent a lot of time concentrating on a video game or book you’re enjoying.
There are a few different types of attention.
This is your ability to focus on one thing and ignore internal/external distractions.
An internal distraction is something happening in your mind/body. For example: You’re doing homework, but all you can think about is how hungry or thirsty you are right now. Or you have a really itchy spot on your arm. Or your shirt is bunched up behind your back. You can’t think about anything else.
An external distraction is something that’s happening around you that’s taking your attention away from what you’re supposed to be focusing on. For example: Someone is talking to you and you’re supposed to be focusing on what they’re saying. But there’s a ticking noise coming from the lights at school that you can’t block out, and your friend’s shirt has some text on it that you’re trying to read at the same time, all while other kids in the hallway are laughing and talking themselves.
This is how long you can concentrate on something. Let’s use homework as an example again. Before your brain injury, you may have been able to keep your attention on math problems or an essay as long as you needed. Now you may find it hard to stay focused for more than a couple of minutes. Sustained attention depends on factors including how much you like the activity you’re doing, how tired you are, or what’s going on around you in your environment.
This is your ability to be aware of specific locations in your environment. When you’re looking at a room, your spatial (spay-shul) attention can take in the room as a whole or pick out things more specifically (like a clock on your night stand) [2]. If you struggle with spatial attention, you might have a hard time finding patterns or processing what is happening in a space you’re looking at.
Alternating attention lets you switch from one task to another without losing track of what you’re doing. Basically, it means you can keep track of several things at once–this is also called multi-tasking.
If you’re struggling with alternating attention, you may find it challenging to switch between assignments, chores, social interactions, and more
This is how much information you can take in and use at once without getting overwhelmed. For example, you may be able to pay attention in class, but not remember what was said just a few minutes later because the teacher went too fast or provided you with too much information at once. It’s harder to hold onto the information you’re paying attention to.
This is the ability to plan, keep, and act on an idea.
For example: if you need to do your homework, you need to take out your notebook, do the assignment, put it in your backpack, and hand it in. These multiple steps can become more challenging to remember after brain injury
In these examples, you can see how changes in attention can make it harder to do things every day. And in the early stages of your recovery, you might not fully realize that attention is something you’re struggling with. You might chalk it up just to being tired – and while it’s harder to pay attention when you’re tired, that may not be the only reason. It may be directly tied to your brain injury.
Tips to help with concentration and attention
Attention is an important part of acting independently and being able to do things that are important to you – so it can be really frustrating if you just can’t seem to focus. It might even make you feel sad because you can’t engage in activities or conversations the way you used to.
If you’re struggling with attention, it’s best to talk to a doctor or someone on your health care team with any specific questions you have. There are some things you can try on your own to help you with your focus and attention, including:
- Asking people to repeat the things they say to you and break it up into small bits of conversation. This will help you absorb the information.
- Break tasks into small steps. Instead of ‘do homework’, start with ‘get out my notebook’.
- Create a checklist of things to do (and again, keep the steps small) so that you have a guide and don’t have to keep all the information in your head.
- Do things throughout your day that you enjoy and are stress-free ways for you to both relax and practice your concentration. It’s always easier to pay attention to something we really like. Card games, puzzles, listening to music, video games and reading are examples of activities that can help develop concentration and are entertaining at the same time.
- Make sure the environment you’re in works for you. If there’s too much going on (like lots of loud noises, bright lights or too many people), it might make it harder for you to focus. Don’t be afraid to ask people you’re talking to if you can go somewhere more quiet or ask for a quiet place to work on homework if that’s what you need.
- Take away timers if you find that puts too much pressure on you. Don’t rush through a task or expect it to be done perfectly–just focus on working towards completing it.
- Take breaks as you need to. If you’re tired, it gets harder to pay attention.
- Use tools to help you with your attention. These could be checklists, ear protection, timers, or even someone else helping you. There are lots of different things you can try to support concentration. You can ask someone on your health care team for advice.
Judgement & problem-solving
Judgement is our ability to take in information and then make decisions/solve problems. Every day we’re making lots of small decisions about what we do.
For example
It’s time to eat, but your friends want to go hang out. You use your judgement to ask yourself “what will happen if I don’t eat?” and “what will happen if I’m late to meet my friends?” You decide that you would rather eat and be late to meet your friends than skip dinner and be hungry and cranky.
After a brain injury, you may have trouble:
- Judging a situation
- Understanding possible future consequences of a decision
- Thinking through your decisions
- Taking in all the information you need
- Considering different points of view and new information
You may make decisions based on your first thought, and not change your mind easily.
Being able to problem-solve and rely on your judgement are essential skills for moving through the world safely while being respectful of yourself and others. They are also important skills for independent living in the future. After a brain injury, you may need to devote time and patience to develop these skills.
Tips for judgment and problem-solving
- Ask for feedback on your decisions. You can ask a parent/guardian(s), friend, sibling, or a health care provider for their recommendations on the situation, your decision, and how you can develop a decision-making process for the future.
- Before making a decision, consider the possible reactions from the people that would be affected by it. For example: if I did this, how would my sibling feel? (if your sibling is involved in the situation).
- When it comes time to make a decision, make a list of choices or ask your parents or loved ones to give you choices if that helps you. For example, have a parent ask if you want to go for a walk, play a game, or watch TV instead of asking you an open-ended question where you have to come up with suggestions.
- Reduce distractions that could affect your decision-making process.
- Take extra time to clearly think about your decision.
- Try planning by talking out loud to help you make your decisions.
- Write down the important things to think about when making a decision. This gives you a guide to use during the process.
- Write down problems or situations from the past. These can be a guide for decision-making in the future.
Language & communication
You may not have thought a lot about the way you communicated before your brain injury. You probably just did it. But for a lot of people, brain injury can impact:
- Talking
- Reading
- Writing (including texting)
- Understanding information/what is being said
This might be something that’s happening for you. After a brain injury, you may have:
- A hard time expressing yourself
- A hard time finding words
- A hard time organizing what you want to say or what you hear
- A hard time understanding others
- Trouble with conversation
- Trouble with facial expressions or tone
- Trouble responding appropriately
These challenges can last for a short time or a long time (depending on your brain injury). They can be caused by physical issues with control over your tongue, mouth, and throat muscles. They can also come from damage to the parts of the brain that control and understand language.
This can be confusing and frustrating, because communication is something we need to do every day.
There are different names of the different types of communication challenges people experience. If you want to dive into more detail, you can ask your health care team or visit the communication page on braininjurycanada.ca.
Tips for improving & supporting communication
There are lots of different ways to communicate, which means there are also lots of supports that may help you. We haven’t listed every possible tip/tool here, and not every option listed may work for you. You will have to spend some time figuring out what works best for you.
A speech-language pathologist (SLP) is a health care professional that helps people with language, speech, communication and swallowing difficulties. A speech-language pathologist will assess your needs and use that to develop a plan for treatment/support.
Some things a speech-language pathologist might help you with (or suggest for you) can include:
- Teaching your muscles to move correctly
- Practicing sounds
- Learning new ways of communicating (using pictures, gestures, or writing)
- Increasing the size of text on a screen
- Choosing a large-print book
- Reading slowly
- Reviewing what you’ve read
- Using a line guide(which is a dark line you can put under words or where you want to write)
It’s important to remember that recovery is different for everyone. While communication skills can improve over time, there may still be some challenges you experience [3].
Augmentative and alternative communication (AAC) is a term that’s used to describe the tools and technology that can help people communicate. If you have trouble with your eyesight or hearing, these kinds of tools may be helpful for you.
You can use apps for computers, tablets, and smartphones that generate sentences, translate text to speech, and more. Speech-language pathologists (SLPs) and occupational therapists on the recovery team will be able to determine if a device is appropriate for you and make recommendations for one that best suits your needs.
It’s frustrating to struggle with communication, especially if you haven’t had problems in the past. Communication skills often improve over time and you can also learn adaptive strategies to make it easier and more natural, but it takes time and effort. Be patient and kind to yourself.
Multi-tasking can be tiring and it can divide your concentration. When you want to read, write, or speak with someone, try reducing distractions and focus on one task at a time.
The more you practice a skill, the stronger it gets. While it may sound a little odd to practice talking, writing, or reading, it can help! Ask your friends, teachers, and family to help you practice. You can also join social groups or ask your health care team about resources that could help you develop your communication skills.
Memory
Memory is something commonly affected by brain injury, in a variety of ways. This can include:
- Short-term memory loss: this means you can’t remember things that just happened, which can be made worse if you struggle with focus and attention.
- Amnesia: this most commonly refers to loss of declarative memory after damage to specific areas of your brain’s memory system. Amnesia can be divided into anterograde and retrograde.
- Anterograde amnesia refers to the inability to form new memories after the time of injury and is often the result of short-term memory loss.
- Retrograde amnesia means you’ve forgotten things that happened before your brain injury.
You may also struggle with what is called nondeclarative memory loss. Nondeclarative memory is the term used to describe our abilities to do things without actively thinking about it–including our body’s natural responses to situations. Examples of this can include riding a bike, walking, or even something like brushing your teeth.
On rare occasions, a person with memory loss may remember things that did not happen or twist details. This is called confabulation. When someone is doing this, they often don’t realize it–they’re not doing it on purpose.
Problems with memory can affect daily living, relationships, and rehabilitation. Memory recovery is often slow and in some cases, a person may never fully recover. This can be upsetting for you and the people in your life. It’s important to be kind to yourself if memory is hard for you–there are tools you can use to help you remember things.
Tips to help with memory
The following tips are some basic introductory tools to help support your memory:
- Ask people to repeat themselves if necessary.
- Choose activities that are familiar to you. This will help you form memories and create enjoyable experiences.
- Create routines for events that are repeated every day, like when you have meals or do your homework.
- Try to use one calendar system for keeping track of events rather than several different systems. This could be a school agenda, an app on your phone, or a calendar in your room.
- Use any calendar or routine you put in place consistently. Consistency helps make habits and avoids confusion.
- It’s a good general rule to write things down if you need to remember them. Have paper and a pen/pencil with you so that you can write down important points. You can also ask the person with whom you’re speaking with to write down what they want you to remember.
Planning skills
Planning can become challenging for some people after a brain injury. This could affect you in different ways:
- You may not be able to think ahead to what needs to be done, or you find it hard to finish things.
- Your thinking may also be disorganized and incomplete. This may show up as repetitive movements or comments.
- You might act impulsively by doing something quickly without thinking.
- You may need a lot of time to understand information and respond to it.
Planning is an important part of doing things on your own. For example: you need clean clothes to wear, which means that you need to be able to do laundry. This means you need to:
- Plan when to put your clothes in the washer
- Add soap
- Set your washing cycle
- Switch from the washer to the dryer
- Set your drying cycle
- Hang up your clothes that can’t go in a dryer
- Folded/hang your clothes after they’re dry
- Put them away
This kind of step by step process is needed for homework, cooking, and lots of other parts of daily living–and this may be challenging for you. But by setting goals and working with rehabilitation specialists, you can develop your planning skills.
Tips to help with planning
The following tools can help you develop planning skills:
- Break down the task into small steps. For example, ‘do your homework’ becomes ‘take out your notebook, get a pen, read the instructions’, etc.
- Have a parent, friend or someone else clearly explain the activity before you start.
- Read instructions or have directions read to you slowly so you have time to understand and respond.
- Reduce distractions, and give yourself extra time to problem-solve.
- Set routines and schedules to help make things more predictable.
- Use a checklist so that you can check off each step of a task as you do it.
- Use a calendar or whiteboard to provide visual cues and reminders.
- When possible, help with household chores (as much as you can do). Things like setting the table, washing dishes, or preparing a salad need planning–but may be familiar enough that you can do them easily. These kinds of activities will help you practice step-by-step planning.
Self-awareness
Self-awareness is noticing how you think and feel about yourself–including your wants, beliefs, desires and innermost thoughts. It’s common after a brain injury for a person not to be as self-aware as they were before. For example, you might not be aware of the changes in yourself. You may feel pressure to go back to school or other activities without understanding what your abilities are at the time.
This is when you need the help of therapists, family, and friends. Your support team will help you figure out the best ways to receive feedback and identify ways to improve self-awareness. For example, perhaps you’re more likely to listen to a sibling vs. a parent, or a doctor over a family member when receiving feedback. And maybe journaling is a good way for you to connect with how you’re feeling.
Cognitive rehabilitation and recovery
Every person is unique and so is each brain injury. For that reason, it is impossible to predict what cognitive changes you will experience and how rehabilitation will impact you. Cognitive rehabilitation is a collection of treatments that can help support and improve the things we’ve talked about on this page. A variety of different professionals are involved, and sometimes therapy is delivered by a person called a “cognitive rehabilitation therapist” (CRT).
Cognitive rehabilitation can be helpful even years after injury. It’s never too late to seek support and address challenges you may be facing. Remember, these challenges don’t take away your intelligence. And with time, patience, and practice you can regain and learn new skills.
Information for this page sourced in part from My Health Alberta and the ABI Partnership Project
Language and communication sourced in part from msktc.org.
[1] https://www.merriam-webster.com/dictionary/cognitive
[2] https://jov.arvojournals.org/article.aspx?articleid=2770249
[3] https://sac-oac.ca/public/what-do-speech-language-pathologists-do.
