Medical Speech Pathology

Curiosity, Dialogue, and Knowledge

Right Hemisphere Dysfunction

What Are the Typical Characteristics (Underlying Processes) Associated with RHD?

  1. Cognitive communication problems
  2. Left-sided neglect
  3. Anosognosia – denial of illness
  4. Attention
  5. Memory
  6. Organization
  7. Reasoning
  8. Problem solving
  9. Orientation
  10. Social judgment/pragmatics

What Specific Communication Impairments Are Associated with RHD?

  1. Diminished speech prosody
  2. Monotonous devoid of emotion
  3. Lose normal variability in vocal pitch and loudness
  4. Anomalous content and organization of connected speech
  5. Excessive confabulatory and sometimes inappropriate connected speech rambling, irrelevant, tangential
  6. Use more words but produce less information
  7. Insensitive to others preoccupied with self
  8. Oblivious to social conventions
  9. Verbose, tangential and rambling speech
  10. Insensitive to the meaning of abstract or implied materials
  11. Unable to grasp the overall significance or meaning of complex events

Test Protocols (MIRBI, RIPA, RICE) That Are Available for Assessing RHD

MIRBI (Mini Inventory of Right Brain Injury)

  • Evaluation of right brain injury
  • Evaluation of communication problems in right hemisphere


  • Visual processing
  • Signs of neglect
  • reading and writing
  • Language processing
  • Understanding and interpreting humorous statements and conversation; figurative language
  • Emotional and affect processing
  • Flat affect; ability to repeat a neutral sentence in a happy and sad voice

RIPA (Ross Information Processing Assessment)

  • Memory
  • Spatial orientation
  • Orientation to environments
  • General information recall
  • Problem solving/abstract reasoning
  • Organization
  • Auditory retention and processing

RICE-3 (RIC Evaluation of Communication Problems in Right Hemisphere Dysfunction 3)

  • General behavior patterns
  • Visual scanning and tracking
  • Assessment of writing errors
  • Assessment of pragmatic communication violations
  • Metaphorical language

How Can Each Process (Attention, Orientation, Neglect, Executive Function, Pragmatic Impairments, Discourse Deficits) Be Assessed.


Sustained attention – focusing on one thing for a long time

Selective attention – focusing on one thing when distractions are around

Alternating attention- switching between two things

Divided attention – attending to two things at the same time

Arousal, vigilance, and orienting

What are the effects on conversation?







Informal observation

Bumping into walls?

Eating from one side of the plate?

Failing to dress or groom one side of the body?

Writing samples

Formal test

Bilateral simultaneous stimulation tasks

Cancellation tasks

Scanning tasks

Line bisecting tasks

Draw or copy symmetrical objects such as:

Clock, a person

Executive Function

Setting goals

Self-regulating daily schedule

Synthesizing information from different sources

Tied to higher level attention processes

Pragmatic deficits

Pragmatic protocol

Discourse Deficits



A  Quick Look at RHD, LHD, and Dementia for Comparison

  RHD Left HD Dementia
Cognitive function problems
  • Executive function
  • Attention
  • Neglect
  • Organization
  • Reasoning
  • Problem solving
  • Orientation
  • Social judgment
  • Pragmatics


  • Verbal skills
  • Lexical retrieval


  • Orientation
  • Attention
  • Associating
Language problems
  • Prosody
  • Pragmatics
  • Verbal output
  • Comprehension
  • Word finding
  • Early: anomic
  • Middle: Wernicke
  • Late: global
Memory problems
  • Memory
  • Working memory
  • Span retention
  • Episodic memory
  • Working memory
  • Span retention

How Would You Treat (Both Facilitate and Compensate) Attentional Impairments? Be sure to include Sohlberg and Mateer’s hierarchy in your discussion.

Sohlberg and Mateer levels of attention

Sustained – performing one task over time

Selective – performing one task in presence of distraction

Alternating – alternating attention between two tasks one at a time

Divided – dividing attention between two tasks simultaneously

Behavioral intervention focused on Reaction time (RT) – Patient must respond as fast as possible to stimuli that is auditory or visual, these are computerized

Sustained Attention Tasks

The use of computerized tasks is preferred with easy ability to increase time between stimulus presentation and other variables while simultaneously tracking data.  Non computerized tasks are also viable and include: a series of yes/no questions, a series of simple addition problems, putting together a simple puzzle, and other such simple tasks – these reduce cognitive demands to focus treatment on ability to simply maintain attention over time.

Selective Attention Tasks

The patients must select target stimuli from a series of targets and foils which can be auditory or visual, i.e.- the patient taps their fingers every time a number is repeated in a series of numbers read by the clinician. This same task can be made into an alternating task by switching the number the patient is to tap on.

Alternating Attention Tasks

Have the patient sort playing cards by number, then stop and sort them by suit, then stop and sort by color, then stop and sort by face cards, etc.  Or use the above task from selective attention and you have an auditory task as well.

Divided Attention Tasks

Have the patient count out loud to 100 while completing a cancellation task.  Also, sort playing cards and answer questions at the same time. Combine other activities as appropriate to the patients intact perceptual skill sets.

Compensatory Strategies

  1. Managing fatigue – rest, diet, exercise
  2. Reducing noise- ear plugs
  3. Reducing visual clutter
  4. Post-its to increase task focus
  5. Countdown timers
  6. Assist with pacing
  7. Realistic expectations for productivity
  8. Strategic scheduling of difficult tasks

Describe the impact of neglect on communication. How would you treat (facilitate and compensate) issues with neglect?

Neglect causes a failure to respond to any stimuli on that side of the body (left for RHD). They can bump into things, not eat on the left side of their plate, not respond to someone talking to them from the left, and they will not read or comprehend anything on the left side.


  • Use external aids
  • Draw red lines
  • Use fingers to follow print
  • Sit to left and encourage the patient to turn towards you
  • Put the dinner plate to the right and gradually move mid-line


  • Using meaningful stimuli, the patient reads words and sentences and identifies objects that span the neglected and non-neglected areas
  • Paper and pencil cancellation tasks
  • Computerized scanning tasks
  • Right to left alternating tasks- Patient finds targets when they appear on the screen
  • Reading and writing tasks

Describe the impact of prosodic affective impairments on the communication. How would you treat these impairments.

  • Direct therapy is rare unless paired with dysarthria, if you have no prosody people can’t tell what your emotions are and they don’t understand other emotions.
  • Comprehension – prosodic interpretation skills
  • Non-verbal communication (eye contact, head nods) be targeted with explanation, monitoring, and self-instruction activities
  • Emotional expression problems – targeted by social skills training generally, therapy is indirect

Treatment of discourse deficits is broad and includes many types of impairments as well as treatment activities. Describe the problems someone with RHD might have as well as the treatment activities that you might use.

Social disconnection- reduce awareness of the social purpose served be communication and of the bonds that tie the self to people, events and objects in the environment.

RHD Patient may seem distant, remote, less engaged in communication interactions, less responsive to communicative context, have difficulty assessing listener needs, and make less use of conventions for conversation.


Conversational convention tasks:

1. Video tape conversations

2. Didactic phase – review tape with Patient, discuss targets

3. Recognition phase – Patient reviews tape for target behavior

4. Training phase – patient is given cues – at each instance of failure to use target behavior during taped conversation

5. Transition phase- conversations move to situations outside of therapy

Theory of mind task

Patient is presented with a paragraph length story followed by questions which test the patient’s ability to adopt the perspective of a story character

Treatment for discourse deficits addresses:

  • reduction of performance in inference generation
  • reduced level of informative content
  • reduced ability to manage alternate meanings and revisions

Inference tasks

1. Picture/story headlines

a. Patient generates titles for short stories, news, or pictured scenes

2. Story Continuations

a. Patient provides his/her own story ending or chooses an ending from a multiple choice format based on story context

3. Comprehension of individual inferences

a. Patient reads a simple story and answer questions about explicit and implicit information

Integration tasks

1. Sentence/picture arrangement

a. Patient orders a set of sentence or pictures into a meaningful arrangement to tell a story

b. Puzzle and object arrangements

i. Patient arranges simple puzzle pieces into a pattern according to a model or object

c. Recognizing commonalities

i. Patient arranges stimuli by a theme

Informational Content Tasks

Divergent Reasoning Level I: Increasing Informative Content

1. Patient states and supports an opinion in a brief monologue (less than a min) the clinician tapes and then provides a written transcript of the monologue which is then scored and discussed with Patient based on the targeted dimension

2. Divergent Reasoning II: increasing Efficiency

a. Repeat activity for divergent reasoning I, place particular emphasis on efficiency

3. Recognizing the dimensions of informative content

a. Patient reads a paragraph level informative or opinion piece on a given topic that contains errors in the dimensions of relevance, completeness, efficiency, and or relatedness. Choose error types consistent with those the patient makes.

4. Increasing tasks specificity

a. Patient tells personal stories about past events, clinician provides written transcript to patient and reviews them with the patient noting instances of unreferenced pronouns.

Managing Alternate Meanings

1. Word associations

a. The patient finds two out of three words that can be grouped together (e.g.- tramp, hike, and scamper are all ways to describe moving through the woods).

2. Resolving lexical ambiguities

a. The patient provides two meanings for ambiguous lexical entities (book titles with double meanings, or multiple meaning words with use in different sentence constructions)

3. Inference revision

a. The patient states the outcome or answers multiple choice questions about two sentence stories in which the first sentence is misleading.

4. Semantic relationships

a. Patient is presented with a sentence in which the final word has more than one meaning, Patient selcts the most closely related word from a list of words which vary in the degree in which they are related to the final word this should be done as rapidly as possible.

5. Sentence interpretation: explaining alternatives

a. Clinician reads a pair of pointed sentences aloud and the Patient selects appropriate interpretation from multiple choices. Patient explains inappropriateness of the other choices.


One comment on “Right Hemisphere Dysfunction

  1. Lisa K
    July 12, 2014

    Do you have any sample goals for discourse deficits? Also, I am looking for good therapy materials to address right hemisphere related cognitive and language deficits. THANKS!

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October 2022
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