Filling in the Gaps:

1
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)

2
Research 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.

3

• 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)

4
Objectives

• 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.

5
Importance 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)

6
Importance 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

7
Importance of Problem

• 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

8
Social Communication

• 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.

9
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
10
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

11
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
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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.

13
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

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Social Environment
Awareness/Self-Evaluation
Sensory Input
Cognitive Abilities
Social Communication Receptive Processing Expressi
ve
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Impact 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

16
Recurring Themes (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.

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Social Skills Social Integration

• Weddell et al. (1980)
• Sample 31 men, 13 women with severe TBI gt 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)

18
Social 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.

19
Social 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.

20
Social Skills Employment

• Brooks et al. (1987)
• Sample
• 134 persons with TBI
• 2-7 yrs. post-injury
• gt6 hrs. coma and/or gt48 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.

21
Social 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.

22
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.

23
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.

24
Social Skills Family Burden

• Thomsen (19741984)
• 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

25
Social 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.

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Summary

• 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.

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Gaps

• 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.

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How do you measure social communication?
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Methods

• Aphasia Batteries or subtests
• Functional Communication Batteries
• Interview
• Self/Other-Report Questionnaire
• Behavioral Observation
• Discourse Analysis
• Role Play

30
Aphasia 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

31
Functional Communication Batteries

• 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)

32
Interview

• 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
• Persons 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.

33
Self/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)

34
Behavioral 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.

35
Rating 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.

36
Discourse 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)

37
Role 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

38
Challenges

• Definitional Issues
• Comprehensiveness
• Clinical Feasibility
• Variance in Normal Population
• Contextual Issues

39
Definitional Issues

• Various disciplines
• SLP
• Linguistics
• Psychology
• Different terminologies
• Clarity and collaboration

40
Comprehensiveness

• 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?

41
Clinical Feasibility

• Instruments must be
• User-friendly
• Reliable
• Timely
• Portable ?? (for context)
• Reliable
• Interrater
• Test-Retest
• Internally consistent

42
Variance in Normal Population

• Great challenge enormous diversity of normal
  performance.
• Community
• Context
• Insufficient normative data on virtually all
  measures utilized.

43
Addressing Context

• Outpatient NP clinic setting - limited
  flexibility to address context
• Role-play
• Varied 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

44
RESEARCH 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
• gt 18 years of age
• gt 1 year post-injury
• Informed consent and release of medical records
  to document TBI.

45
RESEARCH PARTICIPANTS

• Exclusionary Criteria
• Age lt 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 Qaires on life satisfaction,
  stress, caregiver appraisal

46
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)

47
Receptive 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

48
Florida Affect Battery(N71)





p lt .0001
49
Processing Aspects

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

50
Expressive 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

51
Social CommunicationSelf/Other-Ratings

• LaTrobe Communication Questionnaire
• (Douglas, OFlaherty, 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

52
La Trobe Communication Questionnaire(N71)



p lt 0.05, p lt 0.01
53
Questions?
54
References

• 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.
• Bowers, D, Blonder, LX, Heilman, KM, (1991). The
  Florida Affect Battery. Center for
  Neuropsychological Studies University of
  Florida.
• Brooks DN, Aughton ME. (1979). Psychological
  consequences of blunt head injury. Journal of
  Rehabilitation Medicine, 1, 160-165.
• Brooks, DN, McKinlay, A, Symington, C, et al.
  (1987). Return to work within the first seven
  years of severe head injury. Brain Injury, 1,
  5-19.
• Corrigan JD, Whiteneck G, Mellick, D. (2004).
  Perceived needs following traumatic brain injury.
  Journal of Head Trauma Rehabilitation, 19(3),
  205-216.
• Donahoe CP, Carter MJ, Bloem WD, Hirsch GL, Laasi
  N, Wallace CJ. (1990). Assessment of
  interpersonal problem solving skills. Psychiatry,
  53(4),329-39.
• Douglas JM, OFlaherty CA, Snow PC. (2000).
  Measuring perception of communicative ability
  The development and evaluation of the La Trobe
  Communication Questionnaire. Aphasiology, 14,
  251-268.

55
References (cont.)

• 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 emotional
  dysfunction following closed head injury. Journal
  of Clinical and Experimental Neuropsychology, 15,
  503-515.
• Holland AL. (1977). Comment on "spouses
  understanding of the communication disabilities
  of aphasic patients". Journal of Speech Hearing
  Disorders. 42(2), 307-310.
• Langlois JA, Rutland-Brown, Thomas KE. (2004).
  Traumatic brain injury in the United States
  Emergency department visits, hospitalizations,
  and deaths. Atlanta (GA) Centers for Disease
  Control and Prevention, National Center for
  Injury Prevention and Control.
• Lezak M. (1987). Relationships between
  personality disorders, social disturbances, and
  physical disability following traumatic brain
  injury. Journal of Head Trauma Rehabilitation,
  2(1), 57-69.
• Linscott RJ, Knight RG, Godfrey HPD. (1996). The
  Profile of Functional Impairemtn in Communication
  (PFIC) A measure of comunication impairment for
  clinical use. Brain Injury, 10, 111-123.

56
References (cont.)

• McDonald S, Pierce S. (1995) The dice game A new
  test of pragmatic skills after closed head
  injury. Brain Injury, 9(3), 255-271.
• McFall RM. (1982). A review and reformulation of
  the concept of social skills. Behavioral
  Assessment, 4, 1-33.
• Morton MV, Wehman P. (1995). Psychosocial and
  emotional sequelae of individuals with traumatic
  brain injury A literature review and some
  recommendations. Brain Injury, 9, 81-92.
• Sale P, West M, Sherron P, et al. (1991).
  Exploratory analysis of job separations from
  supported employment for persons with traumatic
  brain injury. Journal of Head Trauma
  Rehabilitation, 6(3), 1-11.
• Snow PC, Douglas J, Ponsford J. (1998).
  Conversational discourse abilities following
  severe traumatic brain injury A follow-up study.
  Brain Injury, 12, 911-935.
• Sohlberg MM, Mateer, CA. (1989). Introduction to
  Cognitive Rehabilitation. New York Guilford
  Press, p. 214.
• Thomsen, IV. (1974). The patient with severe head
  injury and his family. Scandinavian Journal of
  Rehabilitation Medicine, 6, 180-183.
• 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.

57
References (cont.)

• 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 States A
  public health perspective. Journal of Head Trauma
  Rehabilitation, 14(6 ), 602-615.
• 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 two-year
  follow-up of patients with severe head injury.
  Psychological Medicine, 10, 257-263.
• 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.

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www.tbicommunity.org

• Margaret A. Struchen, Ph.D.
• Brain Injury Research Center/TIRR
• 2455 S. Braeswood
• Houston, TX 77030
• [phone]
• struchen_at_bcm.edu
• strucm_at_tirr.tmc.edu