Some people with RHD may experience a rather confusing phenomenon known as unilateral (one-sided) neglect or left neglect in which they appear not to see the left side of their world. In fact, what is happening is that they have difficulty paying attention to objects and/or people on their left. Because of the damage to the right side of their brain, they have difficulty directing their attention to the left side of their environment. In severe cases, it is almost as if the left side of the world has ceased to exist! Fortunately, for many people with RHD, this problem can improve significantly in the early days after their brain injury. But, for a large minority, the problem can persist and can cause great difficulty in safely navigating their environment.
It is useful to think about neglect in three separate categories. A people with RHD can experience some or all of these types of neglect.
Personal neglect – This is where the people with RHD has trouble attending to the left side of their own body. This can cause them to shave only the right side of their face, brush only their right teeth, or dress only the right side of their body. They may even do things that put them at risk of injury, such as letting their left arm dangle down into their wheelchair wheel or bumping into objects or doorframes on the left side.
Peripersonal neglect – In this case, the people with RHD has difficulty paying attention to items close to them on the left side (i.e., within arm’s reach). Thus, the person may only eat food on the right side of their plate or only look at the right page of an open book.
Extrapersonal neglect – This form of neglect affects the person’s ability to attend to and locate items in the left side of their environment, beyond arm’s reach. They may not look at someone who is sitting on their left side or they may not turn toward a sound or voice on their left. They may not look out the window if it is to their left or look at the TV.
When neglect affects reading and writing, it can be called neglect dyslexia and neglect dysgraphia. Neglect dyslexia is an impairment of reading due to difficulty attending to the left side of words, sentences or paragraphs. As a result, the person may not read the left page of an open book. But, even more than that, each line of print has a left side, so the person may not read several of the words on the left side of each line. Even each word has a left side, so the person may neglect those, as well. For example, the word “peanut” may be read as “nut” or the word “pancake” may be read as “cake”. Making sense of printed material can, therefore, be extremely challenging for people with RHD. Similarly, neglect dysgraphia affects writing. The people with RHD may write only on the right side of the page, may angle their writing on the page and may omit or repeat letters.
In all forms of neglect, it is useful to remember that it is not a problem with the person’s eyes or vision; rather, it is a problem of attention resulting from the damage to their brain. They now have difficulty aiming their attention to the left side to perform daily tasks. This is a challenging problem to tackle if it doesn’t improve on its own in the early days after the injury or stroke. It is often complicated even more by anosognosia, or reduced awareness of the neglect; people with RHD may not be aware that they are missing things. Unilateral neglect can also seem to wax and wane depending on the person’s fatigue, how difficult a task is, or how many things are in the environment.
The person with RHD’s entire rehabilitation team will work on this issue and will help identify strategies that can help. Some examples might be to sit on the person’s left and place important items on their left to encourage their brain to direct attention to that side. Reminders to look to turn their head and scan the environment to the left can also help. Most importantly, ensuring the people with RHD’s safety is critical. Help them avoid running into obstacles, falling, burning or otherwise injuring themselves on the left side.