SLPs doing cognitive rehab

[RxPsych]

Anyone have any experience with SLPs doing cognitive rehab? I'm looking through a patient's chart and the SLP plans to begin "cognitive treatment."

What does that look like from an SLP approach? Are they even qualified to do this? I remember this being an issue of scope creep during a TBI IPR practicum experience I had, but I didn't get a chance at the time to learn more about it. I just remember the SLPs and OTs advocating for doing more cognitive assessments, which my mentor at the time was not particularly fond of, especially since the OT at this place had a tenuous understanding of the definition of "percentile."

Is this scope creep? Or are SLP cognitive assessments/treatments much different from the ones we use?

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[WisNeuro]

They've been doing this for a loooonnnnggg time.

 

[RxPsych]

Is anyone privy to the extent of their training in cognitive assessment/intervention?

 

[AcronymAllergy]

Agreed, I've seen this in almost every large hospital I've worked in. I suspect their training in cognitive treatment varies from one SLP to the next.

As for scope creep, it depends. SLPs commonly use some of the same language measures we do (e.g., BNT), as well as some more unique to speech pathology. They also, less commonly but not uncommonly, administer cognitive testing (e.g., RBANS); I have yet to be impressed with any write-up of the latter, or even convinced that it was given and interpreted competently.

 

[PsyNeuro37]

Did a lot of my training in the neuro-rehab world. SLPs would very commonly do cog rehab. They would also do some cog assessment at intake, but more for intervention planing to identify deficits/strengths/cognitive targets, never anything diagnostic from what I was exposed to. The CLQT+ was the most common assessment I’ve seen administered by SLP. Plus the OLog/CogLog in acute brain injury. Some of it made sense from a logistic standpoint too. If on an inpatient unit we had 5 SLPs and 1 neuropsychologist, there just wasn’t enough time in the day for the neuropsychologist to give every patient 60min of cog rehab daily. The quality of the cog rehab varied greatly by SLP from what I experienced. Anything from just doing some worksheets over and over for “cognitive stimulation,” which is less than ideal, to very patient-centered approaches in their development internal and external compensatory strategies. The inpatient and outpatient settings where it tended to work best were ones that had a strong collaborative relationship between SLP and neuropsych.

 

[oliversacks4thewin]

During my schooling, I actually partnered with the SLP program at the school to research and write a few papers regarding cognitive rehab processes. Depending on the program focus, they receive a fair amount of education on the subject matter, which makes a lot of sense when you think about the specific conditions they specialize in treating (dysarthria, dysphagia, aphasia, etc.) which are often the result of some sort of brain/head injury.

 

[WisNeuro]

During my schooling, I actually partnered with the SLP program at the school to research and write a few papers regarding cognitive rehab processes. Depending on the program focus, they receive a fair amount of education on the subject matter, which makes a lot of sense when you think about the specific conditions they specialize in treating (dysarthria, dysphagia, aphasia, etc.) which are often the result of some sort of brain/head injury.

It's just too bad they have zero skepticism in mild TBI's leading to catastrophic disability, and have zero understanding of performance and symptom validity.

 

[oliversacks4thewin]

It's just too bad they have zero skepticism in mild TBI's leading to catastrophic disability, and have zero understanding of performance and symptom validity.

All fair points lol. I agree with AcronymAllergy, that some SLP's tend to overstep and think they know a lot about some of the cognitive measures that exist out there, and that's usually when they end up with some egg on their face, but the same can be said about some psychologists too. Admittedly, the group I worked with brought me into the fold of the research projects because they acknowledged their limited understanding of psychometric properties. I was lucky in how amenable they were to my "expertise" (C'mon, I was a student, what did I actually know? lol) and were willing to add in a few additional measures and screenings to ensure fidelity of diagnoses and symptoms, prior to use of established cognitive rehab activities. All of it was for grant-funded research though...so who knows how much of that translated to clinical practice?

 

[bcliff]

FYI: Joint Committee on Interprofessional Relations Between the American Psychological Association (APA) and the American Speech-Language-Hearing Association (ASHA)

 

[RxPsych]

This is all very helpful, thanks everyone. It seems weird to me that SLPs would engage in cognitive assessments of domains such as EF, visuospatial, and memory and doing cognitive rehab. However, I recognize the proliferation of SLPs in hospital settings and the typical lack of neuropsychologists or even general psychologists, so it feels like *somebody* should do these assessments. However, I worry that they are not trained enough to know what they don't know, but again, I'm not privy to their training and I'm certainly making assumptions.

I would agree that it's concerning if they are providing psychoeducation re: TBI and doing evaluations without adequate performance and symptom validity.

 

[WisNeuro]

This is all very helpful, thanks everyone. It seems weird to me that SLPs would engage in cognitive assessments of domains such as EF, visuospatial, and memory and doing cognitive rehab. However, I recognize the proliferation of SLPs in hospital settings and the typical lack of neuropsychologists or even general psychologists, so it feels like *somebody* should do these assessments. However, I worry that they are not trained enough to know what they don't know, but again, I'm not privy to their training and I'm certainly making assumptions.

I would agree that it's concerning if they are providing psychoeducation re: TBI and doing evaluations without adequate performance and symptom validity.

Particularly in terms of mild TBI, poorly done evals by SLPs are far worse and damaging than no assessment at all. The level of iatrogenic damage here is incredibly high.

 

[Therapist4Chnge]

I deal with SLPs constantly doing trash evals for mTBI. Chiros love to use SLPs as part of their "plaintiff dream team". Just like 50+ sessions of PT & OT, they'll do a couple dozen "cog rehab" sessions. I work with a couple of SLPs who are good, but they seem to be the exception when it comes to mTBIs. It took me some time to educate them, but it was worth it. Admittedly, the bad SLPs make my legal work much easier.

 

[RxPsych]

The SLP administered a test called the CLQT and concluded "severe deficits in EF, visuospatial skills, and memory" and "moderate impairments in attention and language" consistent with their brain injury. This individual had a mild brain injury that isn't even the primary reason, or significant concern, of their hospital admission. It has resolved without surgical intervention.

Is this the norm for those of you that have worked in a hospital setting?

 

[WisNeuro]

The SLP administered a test called the CLQT and concluded "severe deficits in EF, visuospatial skills, and memory" and "moderate impairments in attention and language" consistent with their brain injury. This individual had a mild brain injury that isn't even the primary reason, or significant concern, of their hospital admission. It has resolved without surgical intervention.

Is this the norm for those of you that have worked in a hospital setting?

Yep, and they then send this patient to at last 1 year of in-house services with OT, SLP, neuroopth, and therapy, netting their healthcare system six figures of revenue from one patient. If that patient is now worse off than if they had no SLP eval at all? 🤷‍♂️

 

[PsyNeuro37]

The SLP administered a test called the CLQT and concluded "severe deficits in EF, visuospatial skills, and memory" and "moderate impairments in attention and language" consistent with their brain injury. This individual had a mild brain injury that isn't even the primary reason, or significant concern, of their hospital admission. It has resolved without surgical intervention.

Is this the norm for those of you that have worked in a hospital setting?

CLQT is kind of like a watered down RBANS with a pretty small normative sample from my understanding. It uses criterion cut scores where Score X/Y/Z = WNL/Mild/Moderate/Severe. There are obviously a lot of issues with that interpretative approach in general before even getting into those related to cog assessment in mTBI.

 

[WisNeuro]

CLQT is kind of like a watered down RBANS with a pretty small normative sample from my understanding. It uses criterion cut scores where Score X/Y/Z = WNL/Mild/Moderate/Severe. There are obviously a lot of issues with that interpretative approach in general before even getting into those related to cog assessment in mTBI.

"Original CLQT One pilot (n=13) and three studies (n=92, 154, and 119, respectively) established the reliability and validity of the CLQT. Criterion cut scores, domain scores, and severity ratings were developed from these data sets along with the author’s clinical expertise. Aphasia sample (CLQT+) One clinical study including 76 individuals diagnosed with aphasia associated with left hemisphere strokes were given the Aphasia Administration version of the CLQT+. Consistent with the original CLQT data, scores have been provided for two age groups: ages 18–69 and ages 70–89. In general, as expected, average task scores are lower for the aphasia sample compared to the non-clinical sample"

 

[R. Matey]

CLQT is kind of like a watered down RBANS with a pretty small normative sample from my understanding. It uses criterion cut scores where Score X/Y/Z = WNL/Mild/Moderate/Severe. There are obviously a lot of issues with that interpretative approach in general before even getting into those related to cog assessment in mTBI.

Yet another reason why people administering psychological tests need to have a robust background in psychometrics.

 

[Therapist4Chnge]

My favorite (paraphrased) SLP interpretation, which I’ve seen numerous times in legal cases:

“On RBANS Picture Naming…the claimant successfully name 7 out of 10 items (70%)”

It can be and often is….that bad.

 

[WisNeuro]

My favorite (paraphrased) SLP interpretation, which I’ve seen numerous times in legal cases:

“On RBANS Picture Naming…the claimant successfully name 7 out of 10 items (70%)”

It can be and often is….that bad.

I mean, 70% is like a C, right? So they did average?

 

[borne_before]

SLPs do have cognitive rehabilitation within their scope of practice, particularly as it relates to cognitive-communication-swallowing disorders. What this typically looks like from an SLP approach:

• Cognitive-linguistic therapy focusing on attention, memory, executive functions, and problem-solving as they relate to communication
• Treatment of cognitive-communication deficits following TBI, stroke, or other neurological conditions
• Addressing functional communication skills that have cognitive components

Personally, I'm related to two SLPs My father was actually a professor who earned his doctorate in audiology before the field split from speech pathology. His research specialized in strokes and swallowing/communication disorders, particularly aphasia. As an aside, my dad actually did a ton of CBT-like interventions with stutterers. In the early 70's he actually got a grant to administer cannabis to stutterers. When I was an anxious youngster, he would have me listen to a progressive muscle relaxation tape he published. My mother has a master's in rehab counseling, which was similar back then. They did a ton of hospital contracting when I was kiddo, but my mom eventually worked in a Headstart/school district.

I currently work with about 8 SLPs at my clinic, so I've seen the full spectrum of the profession up close! My dad (who basically started a speech department in the mid-70s that was top ASHA ranked) had a rather colorful take on the profession. He used to say that "speech paths are often teachers' pets who are good at homework."

Personally, am I the only one who can see how SLP's sometimes have a chip on their shoulder (because becoming an SLP is genuinely difficult) while people still call them "speech teachers" or "speechies" - which, as you can imagine, doesn't go over well after completing a rigorous master's program!

They also have this kind of demanding type A personality. It's hard to describe, but I count them amongst my closest colleagues here.

I think you're right that language is central to much of cognitive rehabilitation as practiced by SLPs. The cognitive-linguistic connection is fundamental to their approach. While I'm not entirely familiar with all aspects of cognitive rehab from the SLP perspective, I know their expertise in swallowing disorders (dysphagia) is also remarkable and shows their broad clinical skill set.

Really, I'm just replying to see if you all find speechies to be a little high strung?

 

[oliversacks4thewin]

SLPs do have cognitive rehabilitation within their scope of practice, particularly as it relates to cognitive-communication-swallowing disorders. What this typically looks like from an SLP approach:

• Cognitive-linguistic therapy focusing on attention, memory, executive functions, and problem-solving as they relate to communication
• Treatment of cognitive-communication deficits following TBI, stroke, or other neurological conditions
• Addressing functional communication skills that have cognitive components

Personally, I'm related to two SLPs My father was actually a professor who earned his doctorate in audiology before the field split from speech pathology. His research specialized in strokes and swallowing/communication disorders, particularly aphasia. As an aside, my dad actually did a ton of CBT-like interventions with stutterers. In the early 70's he actually got a grant to administer cannabis to stutterers. When I was an anxious youngster, he would have me listen to a progressive muscle relaxation tape he published. My mother has a master's in rehab counseling, which was similar back then. They did a ton of hospital contracting when I was kiddo, but my mom eventually worked in a Headstart/school district.

I currently work with about 8 SLPs at my clinic, so I've seen the full spectrum of the profession up close! My dad (who basically started a speech department in the mid-70s that was top ASHA ranked) had a rather colorful take on the profession. He used to say that "speech paths are often teachers' pets who are good at homework."

Personally, am I the only one who can see how SLP's sometimes have a chip on their shoulder (because becoming an SLP is genuinely difficult) while people still call them "speech teachers" or "speechies" - which, as you can imagine, doesn't go over well after completing a rigorous master's program!

They also have this kind of demanding type A personality. It's hard to describe, but I count them amongst my closest colleagues here.

I think you're right that language is central to much of cognitive rehabilitation as practiced by SLPs. The cognitive-linguistic connection is fundamental to their approach. While I'm not entirely familiar with all aspects of cognitive rehab from the SLP perspective, I know their expertise in swallowing disorders (dysphagia) is also remarkable and shows their broad clinical skill set.

Really, I'm just replying to see if you all find speechies to be a little high strung?

In my experience, the SLP's I have worked with were very much "type A" but I have to wonder if this just normative variation, as the individuals I worked with were conducting research or part of an AMC institution, which pulls for driven, motivated, type A individuals.

 

[smalltownpsych]

I just reviewed “ADHD testing” from SLPs at a nearby ADHD pill mill and it was a travesty. I don’t know how much the family paid for it but it basically read to me as this patient has reported problems consistent with severe emotional distress so they have ADHD. No mention of the impaired range of cognitive ability as measured by a test I wasn’t familiar with and forget the name right now. The organization that did the testing is run by a SLP and that is who all the employees are except for the two psychiatrists and two NPs who are there to dole out the meds. Just reviewing their website made my blood boil. I am glad the family has come to us because they were getting worse after the “evaluation” diagnosis and treatment.

 

[borne_before]

I just reviewed “ADHD testing” from SLPs at a nearby ADHD pill mill and it was a travesty. I don’t know how much the family paid for it but it basically read to me as this patient has reported problems consistent with severe emotional distress so they have ADHD. No mention of the impaired range of cognitive ability as measured by a test I wasn’t familiar with and forget the name right now. The organization that did the testing is run by a SLP and that is who all the employees are except for the two psychiatrists and two NPs who are there to dole out the meds. Just reviewing their website made my blood boil. I am glad the family has come to us because they were getting worse after the “evaluation” diagnosis and treatment.

See, that seems like overreach.

 

[Grenth]

Not completely related to the topic at hand but I took my autistic kid to a SLP for help with some receptive language delays. When the SLP learned he was receiving ABA therapy she told me she "didn't believe in ABA because of positive reinforcement which treats children like dogs." I basically had to bite my tongue off to not ask her if she worked for a paycheck or if she didn't believe in it because it would be treating her like a dog.

Then she gave me kid a sticker at the end of successful sessions. She was the worst by far but my kid has seen a number of SLPs for language and feeding delays and they all seem to do a little unlicensed psychological evaluation and treatment.

 

[borne_before]

Not completely related to the topic at hand but I took my autistic kid to a SLP for help with some receptive language delays. When the SLP learned he was receiving ABA therapy she told me she "didn't believe in ABA because of positive reinforcement which treats children like dogs." I basically had to bite my tongue off to not ask her if she worked for a paycheck or if she didn't believe in it because it would be treating her like a dog.

Then she gave me kid a sticker at the end of successful sessions. She was the worst by far but my kid has seen a number of SLPs for language and feeding delays and they all seem to do a little unlicensed psychological evaluation and treatment.

I think OTs and SLPs have an almost reflexive yuck towards ABA because it simply gets better results than them in autism. They view ABA as this relative newcomer. OTs especially love less-than-validated treatments. SLPs are just mad because behaviorism is better at teaching kiddos language when there isn't an articulation concern in the way.