Filling in the Gaps: Filling in the Gaps:

Margaret A. Struchen, PhDBaylor College of Medicine

TIRR (The Institute for Rehabilitation and Research)

The Importance and Challenges The Importance and Challenges of Measuring Social of Measuring Social Communication Abilities Communication Abilities following Traumatic Brain Injury.following Traumatic Brain Injury.

Research TeamResearch Team

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)

ObjectivesObjectives

Learners will become familiar with the impact of social communication abilities on functional outcomes for persons with traumatic brain injury and their families.

Learners will understand the challenges inherent in developing clinical useful assessment tools to measure social communication abilities.

Learners will be able to describe 3 tools that can be used for measuring social communication abilities following TBI.

Importance of ProblemImportance of Problem Estimated incidence TBI

1.4 million persons each year. (Langlois et al., 2004) 50, 000 die 235, 000 hospitalized 1.1 million treated and released from ED

Disability related to TBI 5.3 million persons with traumatic brain injury have a long-

term 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 Estimated direct and indirect costs totaled an estimated

$56.3 billion in the United States in 1995 (Thurman, 2001)

Importance of ProblemImportance of Problem Social isolation has been frequently

reported

Social network size shown to decrease with time, increased reliance on family for emotional support and leisure

High rates of unemployment 1-10 years post-injury.

Decreased productivity and social isolation can have a negative impact on quality of life and on emotional functioning of persons with TBI

Impairment in social skills is a common occurrence following TBI

Contributes to both decreased productivity and social isolation following TBI

Adequate assessment Important step to develop empirically-based

treatments Identification of areas of functional impairment

Importance of ProblemImportance of Problem

Holland (1977) noted that individuals with certain classic forms of aphasia “communicate” better than they talk.

Sohlberg & Mateer (1989) point out that the converse might be said of individuals with TBI: they talk better then they communicate.

Social CommunicationSocial Communication

“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 FieldsTerminology 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

DefinitionDefinition

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?What are we talking about? Social skills involve general

interpersonal competencies as well as specific skills.

Involves communication behaviors – Verbal Nonverbal

Must be addressed in relation to specific contexts and communication partners.

Models of Social Communication Models of Social Communication McFall (1982) - Information processing model - included

3 stages:» 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:

» Communication Cognition Personal Appearance Knowledge of self Social Environment

Sensory Input

Cognitive Abilities

Social Environment

Social Communication

Receptive

Processing

Expressive

Awareness/Self-Evaluation

Impact on OutcomesImpact on Outcomes

Emotional, social, and behavioral impairments more predictive of participant restriction following TBI than cognitive or physical impairments.

Such factors have been found to impact:» Friendships and social integration» Vocational Outcome» Perceived caregiver stress/burden

Recurring Themes Recurring Themes (Morton & Wehman, 1995)(Morton & Wehman, 1995)

Reduction in friendships and social support.

Lack of social opportunities to make new friendships.

Reduction in leisure activities.

Anxiety and depression found in large number, remains for prolonged period.

Social Skills & Social IntegrationSocial Skills & Social Integration Weddell et al. (1980):

Sample: 31 men, 13 women with severe TBI > 2 yrs. post-injury Measure: Semi-structured interview (multiple constructs) Findings:

Almost half had limited or no social contacts, few leisure interests 1-yr 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)

Social Skills & Social IntegrationSocial Skills & Social Integration 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.

Social Skills & Social IntegrationSocial Skills & Social Integration

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 & EmploymentSocial Skills & EmploymentBrooks 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 & EmploymentSocial Skills & Employment Sale et al. (1991):

Sample: 29 persons employed (M = 5.8 mos.) and then separated from job

Measure: Qualitative approach Identification of reasons for separation Sorting by “experts” into themes

Results: Most common cause of job separation: interpersonal difficulties, social cue misperception, inappropriate verbalization.

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 & EmploymentSocial 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 & EmploymentSocial Skills & Employment

Social Skills & Family BurdenSocial Skills & Family Burden Thomsen (1974;1984):

Sample: 50 adult severe TBI, 40 of that group at f/u Measures: Structured interview Findings:

Personality changes overshadowed cognitive and neurophysical function as determinants of family burden.

Loneliness is greatest difficulty after TBI.

Brooks & Aughton (1979): 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. Communicative, behavioral, personality changes

assessed by questionnaire/interview

Social Skills & Family BurdenSocial Skills & Family Burden Godfrey et al. (1991):

Sample: 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: Less socially skilled person with TBI showed less

positive affect and required more effort from family member

Interpreted as greater family burden.

SummarySummary Body of literature provides basis for hypothesizing that

social communication functioning will account for a significant portion of variance in functional outcome.

Most studies with indirect evidence: measure emotional functioning, personality functioning, behavioral functioning.

For those which directly measure social skills/communication, most have used assessment instruments designed to measure a broad range of symptoms following TBI. 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.

Systematic and comprehensive examination of social skills has not been conducted in most research in TBI.

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.

Several studies have examined social communication skills by using discourse analysis.

Limitations global/micro measures for application to clinical setting.

Clinically, many rely on behavioral observation without structured rating scales, on clinical interview, and on self- or other-report questionnaires.

GapsGaps

How do you How do you measure social measure social

communication?communication?

MethodsMethods

Aphasia Batteries or subtests

Functional Communication Batteries

Interview

Self/Other-Report Questionnaire

Behavioral Observation

Discourse Analysis

Role Play

Aphasia BatteriesAphasia Batteries

Studies of large TBI populations found classic language disorders relatively rare

Parallel interest in measuring /disability handicap move to focus on effects of cognitive and

psychosocial skills on outcomes

Functional Communication Functional Communication BatteriesBatteries

Developed from 1960s onward

Designed for use by speech language therapists, limited use by other professionals.

Inclusion of complex terminology (e.g., speech act pair analysis, turn-taking contingency)

Examples: Functional Communication Profile (Sarno, 1969) Pragmatics Profile of Early Communication Skills (Dewart &

Sumner, 1988) Profile of Communicative Appropriateness (Penn, 1985)

InterviewInterview 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): 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 QuestionnaireSelf/Other-Report Questionnaire

Vast number of self-report questionnaires developed for other populations are available. 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. Frontal Lobe Personality Scale (FLOPS) Dysexecutive Questionnaire (BADS) La Trobe Communication Questionnaire (Douglas et al., 2000)*

Behavioral ObservationBehavioral Observation Gold Standard for psychological assessment. Use of rating scales/coding systems in various

populations. Heterosocial Skills Behavioral Checklist Social Interaction Test

Molar vs. Molecular Intermediate level of analysis involved with behavioral

assessment: 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 ScalesRating Scales Neurobehavioral Rating Scale (Levin et al., 1987): rating scale

assessing behavioral symptoms in persons with TBI Pragmatics Protocol (Prutting & Kirschner, 1983): measures 32

pragmatics skills rated in terms of appropriateness Communication Performance Scale (Erlich & Sipes, 1985):

adapted from Pragmatics Protocol and rates 13 behaviors; (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

Profile of Functional Impairments in Communication (PFIC): (Linscott, Knight, & Godfrey, 1996): Rating on 10 communication rules and specific behavior items.**

Discourse AnalysisDiscourse Analysis 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.

It focuses on how lexico-grammar and discourse systematically vary across social situations and at the same time help to define those situations.

Research in discourse analysis seeks to: 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 AssessmentsRole Play Assessments

Examples: Behavioral Assertion Test – Revised (Eisler et al., 1975)

Assessment of Interpersonal Problem-Solving Skills** (Donahoe et al., 1990)

Simulated Social Interaction Test (Curran et al., 1980; Curran, 1982)

Vary by Social Behaviors Assessed Assertiveness Social Skills description, solution generation, and

enactment Social Skill and anxiety

ChallengesChallenges

Definitional Issues Comprehensiveness Clinical Feasibility Variance in “Normal”

Population Contextual Issues

Definitional IssuesDefinitional Issues

Various disciplinesSLPLinguisticsPsychology

Different terminologiesClarity and collaboration

ComprehensivenessComprehensiveness Models of social communication

ReceptiveProcessingSending

Most measures utilized focus on expressive or sending aspects

How are we addressing receptive/processing social communication skills?

Clinical FeasibilityClinical Feasibility

Instruments must be: User-friendly Reliable Timely Portable ?? (for context)

Reliable Interrater Test-Retest Internally consistent

Variance in “Normal” PopulationVariance in “Normal” Population

Great challenge – enormous diversity of “normal” performance.CommunityContext

Insufficient normative data on virtually all measures utilized.

Addressing ContextAddressing Context

Outpatient NP clinic setting - limited flexibility to address contextRole-playVaried 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 PARTICIPANTSRESEARCH PARTICIPANTS Participants with TBI: 123 adults with TBI recruited from participants in

TIRR TBI Model System study.» 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.

Exclusionary Criteria:» 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 by age, education, and gender

Family/Friend: LCQ Other form; Q’aires on life satisfaction, stress,

caregiver appraisal

RESEARCH PARTICIPANTSRESEARCH PARTICIPANTS

Measures of Social Communication:Measures of Social Communication: Receptive Aspects:

» FLORIDA AFFECT BATTERY (FAB)» ASSESSMENT OF INTERPERSONAL PROBLEM SOLVING

SKILLS (AIPSS)

Processing Aspects:» ASSESSMENT OF INTERPERSONAL PROBLEM SOLVING

SKILLS (AIPSS)

Expressive Aspects:» ASSESSMENT OF INTERPERSONAL PROBLEM SOLVING

SKILLS (AIPSS)» PROFILE OF FUNCTIONAL IMPAIRMENTS IN

COMMUNICATION (PFIC)» DICE GAME (DICE)

Questionnaire:» LATROBE COMMUNICATION QUESTIONNAIRE (LCQ)

Receptive AspectsReceptive Aspects 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 BatteryFlorida Affect Battery(N=71)(N=71)

0

5

10

15

20

25

30

35

FAD SFA MFA EPD CEP MEP

TBI

Control

******

***

******

***p < .0001

Processing AspectsProcessing Aspects

Assessment of Interpersonal Problem Solving Skills (Donahoe et al., 1990): Generation of problem-solving solutions

Expressive AspectsExpressive Aspects Assessment of Interpersonal Problem Solving

Skills (Donahoe et al., 1990): Quality of verbal skills Quality of nonverbal skills Overall quality of response

Profile of Functional Impairments in Communication (Linscott, Knight, & Godfrey, 1996): Rating on 10 communication rules and 85 specific behavior

items.

Dice Game (McDonald & Pierce, 1995): Inclusion of essential propositions Efficiency of procedural sample

Social CommunicationSocial CommunicationSelf/Other-Ratings:Self/Other-Ratings:

LaTrobe Communication Questionnaire (Douglas, O’Flaherty, Snow, 2000)

» When talking to others, do you (does your family member)…

• 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:

» Never or rarely » Sometimes

» Often

» Usually or always

La Trobe Communication La Trobe Communication QuestionnaireQuestionnaire

(N=71)(N=71)

0

10

20

30

40

50

60

LCQ Tot LCQ Avg LCQ _ INC

TBI

Control

*

*

**

* p < 0.05, ** p < 0.01

Questions?Questions?

ReferencesReferences Bellack, AS. (1979). A critical appraisal of strategies for assessing social skills.

Behavioral Assessment, 1, 157-176. Bergland MM, Thomas KR. (1991). Psychosocial issues following severe head injury

in adolescence: Individual and family perceptions. Rehabilitation Counseling Bulletin, 35(1), 5-22.

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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 References (cont.)(cont.) Godfrey HPD, Knight RG, Bishara SN. (1991). The relationship between social skill

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Margaret A. Struchen, Ph.D.Brain Injury Research Center/TIRR2455 S. BraeswoodHouston, TX 77030(713) 666-9550struchen@bcm.edustrucm@tirr.tmc.edu

www.tbicommunity.orgwww.tbicommunity.org