Transcript Assessment of Social Communication Abilities following Traumatic

Filling in the Gaps:
The Importance and Challenges
of Measuring Social
Communication Abilities
following Traumatic Brain Injury.
Margaret A. Struchen, PhD
Baylor College of Medicine
TIRR (The Institute for Rehabilitation and Research)
Research Team
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Angelle M. Sander, Ph.D.
Charles F. Contant, Ph.D.
Laura Rosas, M.A.
Patty Terrell Smith, B.S.
Diana Kurtz, B.A.
Monique Mills, B.S.
Allison N. Clark, M.A.
Analida Hernandez Ingraham, B.S.
This work was supported by funds from the
National Institute on Disability and
Rehabilitation Research in the Office of Special
Education and Rehabilitative Services in the
U.S. Department of Education.
(Grant #:H133G010152)
Objectives
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Learners will become familiar with the impact of social
communication abilities on functional outcomes for
persons with traumatic brain injury and their families.
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Learners will understand the challenges inherent in
developing clinical useful assessment tools to measure
social communication abilities.
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Learners will be able to describe 3 tools that can be
used for measuring social communication abilities
following TBI.
Importance of Problem
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Estimated incidence TBI
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1.4 million persons each year. (Langlois et al., 2004)
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Disability related to TBI
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50, 000 die
235, 000 hospitalized
1.1 million treated and released from ED
5.3 million persons with traumatic brain injury have a longterm or lifelong need for help to perform activities of daily
living (Thurman et al., 2001)
About 40% of those hospitalized with TBI have at least one
unmet need for services one year post-injury. (Corrigan et
al., 2004)
Cost related to TBI
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Estimated direct and indirect costs totaled an estimated
$56.3 billion in the United States in 1995 (Thurman, 2001)
Importance of Problem
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Social isolation has been frequently
reported
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Social network size shown to
decrease with time, increased
reliance on family for emotional
support and leisure
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High rates of unemployment 1-10
years post-injury.
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Decreased productivity and social
isolation can have a negative impact
on quality of life and on emotional
functioning of persons with TBI
Importance of Problem
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Impairment in social skills is a common
occurrence following TBI
Contributes to both decreased productivity
and social isolation following TBI
Adequate assessment
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Important step to develop empirically-based
treatments
 Identification of areas of functional impairment
Social Communication
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Holland (1977) noted that individuals with
certain classic forms of aphasia
“communicate” better than they talk.
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Sohlberg & Mateer (1989) point out that the
converse might be said of individuals with
TBI: they talk better then they
communicate.
“If someone were to read uncritically,
he or she would get the impression
that social skills deficits are at the
core of a vast majority of behavioral
dysfunctions.”
Bellack, 1979
Terminology and Fields
Pragmatics (SLP/Linguistics)
 Discourse Processes (SLP/Linguistics)
 Functional Communication (SLP)
 Social Problem Solving (Beh/Clin Psych)
 Social Skills (Beh/Clin Psych)
 Communicative Competence (Communication)
 Social Communication Abilities
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Definition
Social skills are the abilities to:
“Express both positive and negative feelings in the
interpersonal context without suffering consequent lack
of social reinforcement. Such skill is demonstrated in a a
large variety of interpersonal contexts and involved the
coordinated delivery of appropriate verbal and nonverbal
responses. In addition, the socially skilled individual is
attuned to the realities of the situation and is aware
when he is likely to be reinforced for his efforts.”
Hersen & Bellack, 1977
What are we talking about?
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Social skills involve general
interpersonal competencies as well
as specific skills.
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Involves communication behaviors –
 Verbal
 Nonverbal
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Must be addressed in relation to
specific contexts and communication
partners.
Models of Social Communication
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McFall (1982) - Information processing model - included
3 stages:
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Decoding: reception, perception, interpretation
Decision: response search, response test, response selection,
repertoire search
Execution: execution, response, judgment
Wallace (1980) - Receiving-Processing-Sending
Ylvisaker et al. (1992) - 5-factor model of social skill:
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Communication
Cognition
Knowledge of self
Personal Appearance
Social Environment
Social Environment
Awareness/Self-Evaluation
Sensory
Input
Cognitive
Abilities
Social
Communication
Receptive
Processing
Expressive
Impact on Outcomes
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Emotional, social, and behavioral impairments
more predictive of participant restriction
following TBI than cognitive or physical
impairments.
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Such factors have been found to impact:
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Friendships and social integration
Vocational Outcome
Perceived caregiver stress/burden
Recurring Themes (Morton & Wehman, 1995)
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Reduction in friendships and social
support.
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Lack of social opportunities to make
new friendships.
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Reduction in leisure activities.
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Anxiety and depression found in large
number, remains for prolonged
period.
Social Skills & Social Integration
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Weddell et al. (1980):
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Sample: 31 men, 13 women with severe TBI > 2 yrs. post-injury
 Measure: Semi-structured interview (multiple constructs)
 Findings:
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Almost half had limited or no social contacts, few leisure interests 1yr post-injury
Those with “personality change” significantly less likely to return to
work, had fewer interests, more frequently bored, more dependent on
family
Also, quality of friendships changed to more casual acquaintances.
Lezak (1987):
Sample: 42 men with varying degrees of injury severity –
longitudinal study with 6 timepoints (every 6 months)
 Measure: Portland Adaptability Inventory
 Findings: Social dislocation and isolation continuing pattern over
time in spite of some emotional and personality improvements
(90% with problems with social contact at all timepoints)
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Social Skills & Social Integration
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Bergland & Thomas (1991):
 Sample:
12 adults with TBI (injury sustained in
adolescence)
 Measure: Global ratings via structured
interview
 Findings:
92% of family members and persons with TBI
reported that person with TBI had changes in
friendships
 75% reported difficulty with making new friends.
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Social Skills & Social Integration
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Snow et al. (1998):
 Sample:
 24 persons with severe TBI
 Assessed 3-6 months and at 2 years post-injury
 Measure:
Discourse analysis
 Findings: Discourse measures related to:
 Social integration as measured by CHART at follow-up.
 Executive functioning/verbal memory as measured by
FAS, Trails, and RAVLT.
Social Skills & Employment
Brooks et al. (1987):
 Sample:
 134 persons with TBI
 2-7 yrs. post-injury
 >6 hrs. coma and/or >48 hrs PTA
 Measure:
Responses of family members to structured
interview (communication composite - 10 items)
 Findings:
Conversational skills major predictor of
failure to return to work following severe TBI, in
addition to personality problems, behavioral
disorders, and cognitive status.
Social Skills & Employment
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Sale et al. (1991):
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Sample: 29 persons employed (M = 5.8
mos.) and then separated from job
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Measure: Qualitative approach
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Identification of reasons for separation
Sorting by “experts” into themes
Results: Most common cause of job
separation: interpersonal difficulties,
social cue misperception, inappropriate
verbalization.
Social Skills & Employment
 Wehman
et al. (1993):
 Sample:
39 persons with severe TBI referred to
supported employment program
 Measure:
Ratings by employment specialists using
Client Employment Screening Form
 Findings:
 Those difficult to employ and maintain jobs were those working
in positions that required frequent work-related interactions.
 Communication problems included: repeatedly asking for
assistance, responding inappropriately to nonverbal social cues,
and exhibiting unusual or inappropriate behaviors.
Social Skills & Employment
Godfrey et al. (1993):
 Sample:
66 severe TBI assessed 6 mos.-3 yrs. post
 Measures:
 Informant rating scale
 Behavioral measure of social skills functioning (behavioral
rating of videotaped social interaction).
 Findings:
 Persons with TBI that failed to return to work were rated by
informants as displaying significantly more adverse
personality changes
 Rated by trained judges to be significantly less socially
skilled.
Social Skills & Family Burden
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Thomsen (1974;1984):
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Sample: 50 adult severe TBI, 40 of that group at f/u
Measures: Structured interview
Findings:
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Brooks & Aughton (1979):
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Personality changes overshadowed cognitive and
neurophysical function as determinants of family burden.
Loneliness is greatest difficulty after TBI.
Sample: 35 adult TBI, 35 family members
Measures: Objective and Subjective Burden scales
Findings: Behavioral and emotional changes
outranked cognitive changes in contributing to family
burden.
Numerous studies replicate these findings.
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Communicative, behavioral, personality changes
assessed by questionnaire/interview
Social Skills & Family Burden
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Godfrey et al. (1991):
 Sample:
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18 community-dwelling persons with severe TBI
At least 8 months post-injury
Family member
 Measure:
Behavioral measurement of social skill
with videotaped interaction of person with TBI
and family member.
 Findings:
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Less socially skilled person with TBI showed less
positive affect and required more effort from family
member
Interpreted as greater family burden.
Summary
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Body of literature provides basis for hypothesizing that
social communication functioning will account for a
significant portion of variance in functional outcome.
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Most studies with indirect evidence: measure emotional
functioning, personality functioning, behavioral functioning.
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For those which directly measure social
skills/communication, most have used assessment
instruments designed to measure a broad range of
symptoms following TBI.
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Self-report questionnaires with multiple physical, cognitive,
emotional, behavioral areas addressed.
Structured interview (often with social communication only a part)
Exception, work in New Zealand and Australia using
behavioral measures.
Gaps
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Systematic and comprehensive examination of social skills has not
been conducted in most research in TBI.
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Many studies examine “psychosocial status, communication skills,
emotional functioning, social skills, and related constructs” via a single
item or group of items contained on self- or other-report measures.
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Several studies have examined social communication skills by using
discourse analysis.
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Limitations global/micro measures for application to clinical setting.
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Clinically, many rely on behavioral observation without structured
rating scales, on clinical interview, and on self- or other-report
questionnaires.
How do you
measure social
communication?
Methods
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Aphasia Batteries or subtests
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Functional Communication Batteries
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Interview
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Self/Other-Report Questionnaire
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Behavioral Observation
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Discourse Analysis
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Role Play
Aphasia Batteries
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Studies of large TBI populations found classic
language disorders relatively rare
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Parallel interest in measuring /disability
handicap
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to focus on effects of cognitive and
psychosocial skills on outcomes
Functional Communication
Batteries
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Developed from 1960s onward
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Designed for use by speech language therapists, limited
use by other professionals.
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Inclusion of complex terminology (e.g., speech act pair
analysis, turn-taking contingency)
Examples:
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Functional Communication Profile (Sarno, 1969)
Pragmatics Profile of Early Communication Skills (Dewart &
Sumner, 1988)
Profile of Communicative Appropriateness (Penn, 1985)
Interview
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Despite lack of convincing evidence of reliability
or validity – interview is most frequently used
method of assessment.
Standard problem-oriented behavioral interview
(antecedents, behaviors, consequences):
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Frequency of social interaction
Person’s level of satisfaction with frequency
Quality of social interaction
Description of satisfactory/unsatisfactory occasions
Extent to which person believes their behavior contributed to
such outcomes
Description of own behaviors that were instrumental in
determining such outcomes.
Self/Other-Report Questionnaire
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Vast number of self-report questionnaires
developed for other populations are available.
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Social anxiety (e.g., Social Avoidance and Distress Scale)
Assertiveness (e.g., Assertion Inventory)
Interpersonal behaviors (e.g., Dating and Assertion
Questionnaire)
Questionnaires designed for use with TBI.
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Frontal Lobe Personality Scale (FLOPS)
Dysexecutive Questionnaire (BADS)
La Trobe Communication Questionnaire (Douglas et al., 2000)*
Behavioral Observation
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Gold Standard for psychological assessment.
Use of rating scales/coding systems in various
populations.
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Molar vs. Molecular
Intermediate level of analysis involved with behavioral
assessment:
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Heterosocial Skills Behavioral Checklist
Social Interaction Test
Provides depth of information to identify target behaviors
Provides format that is practical to administer in a clinical setting.
Despite these advantages, relatively few studies have
utilized such behavioral assessment.
Rating Scales
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Neurobehavioral Rating Scale (Levin et al., 1987): rating scale
assessing behavioral symptoms in persons with TBI
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Pragmatics Protocol (Prutting & Kirschner, 1983): measures 32
pragmatics skills rated in terms of appropriateness
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Communication Performance Scale (Erlich & Sipes, 1985):
adapted from Pragmatics Protocol and rates 13 behaviors;
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(Erlich & Barry, 1989) - 9-point ratings of 6 behaviors.
Behaviorally Referenced Rating System of Intermediate
Social Skills (BRISS) (Wallenger et al, 1985).: Intermediate level
coding of 11 specific behavioral components (5 verbal/6 nonverbal)
rated on 7-pt. Scale
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Profile of Functional Impairments in Communication
(PFIC): (Linscott, Knight, & Godfrey, 1996): Rating on 10
communication rules and specific behavior items.**
Discourse Analysis
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Discourse Analysis is concerned with how language
users produce and interpret language in situated
contexts and how these constructions relate to social
and cultural norms, preferences, and expectations.
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It focuses on how lexico-grammar and discourse
systematically vary across social situations and at the
same time help to define those situations.
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Research in discourse analysis seeks to:
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analyze the linguistic structures of different discourse genres
describe conversational sequences
examine speech activities
describe oral and literate registers
analyze stance
(UCLA Department of Applied Linguistics & TESL)
Role Play Assessments
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Examples:
Test – Revised (Eisler et al., 1975)
 Assessment of Interpersonal Problem-Solving Skills**
 Behavioral Assertion
(Donahoe et al., 1990)
 Simulated
Social Interaction Test (Curran et al., 1980;
Curran, 1982)
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Vary by Social Behaviors Assessed
 Assertiveness
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Social Skills description, solution generation, and
enactment
 Social Skill and anxiety
Challenges
Definitional Issues
 Comprehensiveness
 Clinical Feasibility
 Variance in “Normal”
Population
 Contextual Issues
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Definitional Issues
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Various disciplines
 SLP
 Linguistics
 Psychology
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Different terminologies
 Clarity
and collaboration
Comprehensiveness
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Models of social communication
 Receptive
 Processing
 Sending
Most measures utilized focus on
expressive or sending aspects
 How are we addressing
receptive/processing social
communication skills?
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Clinical Feasibility
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Instruments must be:
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User-friendly
 Reliable
 Timely
 Portable ?? (for context)
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Reliable
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Interrater
 Test-Retest
 Internally consistent
Variance in “Normal” Population
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Great challenge – enormous diversity of
“normal” performance.
 Community
 Context
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Insufficient normative data on virtually all
measures utilized.
Addressing Context
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Outpatient NP clinic setting - limited
flexibility to address context
 Role-play
 Varied
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communication samples
Rehabilitation setting or ongoing treatment
setting – can address with different
communication partners, settings, and
situations.
 Portability
of rating scales like PFIC are useful
RESEARCH PARTICIPANTS
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Participants with TBI:
123 adults with TBI recruited from participants in
TIRR TBI Model System study.
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Acute medical care at Level One Trauma Center (BTGH or
Hermann Hospital)
Inpatient rehabilitation at TIRR
Complicated Mild to Severe TBI
> 18 years of age
> 1 year post-injury
Informed consent and release of medical records to
document TBI.
RESEARCH PARTICIPANTS
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Exclusionary Criteria:
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Age < 18 years
Pre-existing neurological disorder affecting cognitive
functioning (e.g., stroke, dementia, etc.)
Pre-existing severe psychiatric disorder (e.g., schizophrenia,
bipolar disorder, etc.)
Controls:
 Matched
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by age, education, and gender
Family/Friend:
 LCQ
Other form; Q’aires on life satisfaction, stress,
caregiver appraisal
Measures of Social Communication:
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Receptive Aspects:
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Processing Aspects:
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ASSESSMENT OF INTERPERSONAL PROBLEM SOLVING
SKILLS (AIPSS)
Expressive Aspects:
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FLORIDA AFFECT BATTERY (FAB)
ASSESSMENT OF INTERPERSONAL PROBLEM SOLVING
SKILLS (AIPSS)
ASSESSMENT OF INTERPERSONAL PROBLEM SOLVING
SKILLS (AIPSS)
PROFILE OF FUNCTIONAL IMPAIRMENTS IN
COMMUNICATION (PFIC)
DICE GAME (DICE)
Questionnaire:
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LATROBE COMMUNICATION QUESTIONNAIRE (LCQ)
Receptive Aspects
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Florida Affect Battery (Bowers et al., 1991):
 Affect Discrimination
 Affect Selection
 Matching Affect
 Emotional Prosody Discrimination
 Conflicting Prosody
 Matching Prosody to Emotional Face
Assessment of Interpersonal Problem Solving
Skills:
 Problem Identification
Florida Affect Battery
(N=71)
***
35
30
25
20
***
***
***
***
TBI
Control
15
10
5
0
FAD
***p < .0001
SFA
MFA
EPD
CEP
MEP
Processing Aspects
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Assessment of Interpersonal Problem Solving Skills
(Donahoe et al., 1990):
 Generation of problem-solving solutions
Expressive Aspects
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Assessment of Interpersonal Problem Solving
Skills (Donahoe et al., 1990):
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Profile of Functional Impairments in
Communication (Linscott, Knight, & Godfrey, 1996):
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Quality of verbal skills
Quality of nonverbal skills
Overall quality of response
Rating on 10 communication rules and 85 specific behavior
items.
Dice Game (McDonald & Pierce, 1995):
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Inclusion of essential propositions
Efficiency of procedural sample
Social Communication
Self/Other-Ratings:
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LaTrobe Communication Questionnaire
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»
When talking to others, do you (does your family
member)…
•
•
•
•
»
(Douglas, O’Flaherty, Snow, 2000)
Leave out important details?
Say or do things others might consider
rude or embarrassing?
Hesitate, pause, or repeat self?
Have difficulty getting the conversation
started?
Rating:
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»
»
»
Never or rarely
Sometimes
Often
Usually or always
La Trobe Communication
Questionnaire
(N=71)
60
*
50
40
30
**
20
*
10
0
LCQ Tot
* p < 0.05, ** p < 0.01
LCQ Avg
LCQ _ INC
TBI
Control
Questions?
References
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Bellack, AS. (1979). A critical appraisal of strategies for assessing social skills.
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Bergland MM, Thomas KR. (1991). Psychosocial issues following severe head injury
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Bowers, D, Blonder, LX, Heilman, KM, (1991). The Florida Affect Battery. Center for
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Brooks DN, Aughton ME. (1979). Psychological consequences of blunt head injury.
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Douglas JM, O’Flaherty CA, Snow PC. (2000). Measuring perception of
communicative ability: The development and evaluation of the La Trobe
Communication Questionnaire. Aphasiology, 14, 251-268.
References (cont.)
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Godfrey HPD, Knight RG, Bishara SN. (1991). The relationship between social skill
and family problem-solving following very severe closed head injury. Brain Injury, 5,
207-211.
Godfrey HPD, Partridge FM, Knight RG, et al. (1993). Course of insight disorder and
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Lezak M. (1987). Relationships between personality disorders, social disturbances,
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Linscott RJ, Knight RG, Godfrey HPD. (1996). The Profile of Functional Impairemtn in
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References (cont.)
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McDonald S, Pierce S. (1995) The dice game: A new test of pragmatic skills after
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McFall RM. (1982). A review and reformulation of the concept of social skills.
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Sale P, West M, Sherron P, et al. (1991). Exploratory analysis of job separations from
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Snow PC, Douglas J, Ponsford J. (1998). Conversational discourse abilities following
severe traumatic brain injury: A follow-up study. Brain Injury, 12, 911-935.
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Thomsen, IV. (1984). Late outcome of very severe blunt trauma: a 10-15 year second
follow-up. Journal of Neurology, Neurosurgery, and Psychiatry, 47, 260-268.
References (cont.)
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Thurman D. (2001). The epidemiology and economics of head trauma. In: Miller L,
Hayes R (Eds.) Head Truama: Basic, Preclinical, and Clinical Directions. New York:
Wiley & Sons.
Thurman D, Alverson C, Dunn K, et al. (1999). Traumatic brain injury in the United
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Wallace CJ, Nelson CJ, Liberman RP, et al. (1980). A review and critique of social
skills training with schizophrenic patients. Schizophrenia Bulletin, 6, 42-63.
Weddell R, Oddy M, Jenkins D. (1980). Social adjustment after rehabilitation: A twoyear follow-up of patients with severe head injury. Psychological Medicine, 10, 257263.
Wehman P, Kregel J, Sherron P, et al. (1993). Critical factors associated with the
successful supported employment placement of patients with severe traumatic brain
injury. Brain Injury, 7(1), 31-44.
Ylvisaker M, Urbanczyk B, Feeney, TJ. (1992). Social skills following traumatic brain
injury. Seminars in Speech and Language, 13(4), 308-322.
www.tbicommunity.org
Margaret A. Struchen, Ph.D.
Brain Injury Research Center/TIRR
2455 S. Braeswood
Houston, TX 77030
(713) 666-9550
[email protected]
[email protected]